Every finding on record at Westview of Derby Rehabilitation & Health Care Cen

The facility reported a census of 62 residents; the sample included six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to implement an intervention to prevent further falls after a fall with serious injury for Resident (R) 1. Findings included:- R1's Electronic Medical Records (EMR), documented diagnoses which included unspecified symptoms and signs involving cognitive functions and awareness (various disorders that affect an individual's intellectual capabilities and conscious perception of their surroundings), displaced intertrochanteric fracture of right femur with nonunion (a break in the right thigh bone, specifically in the area between the greater and lesser trochanters, where the bone fragments have shifted out of alignment and have failed to heal after a prolonged period, even after treatment), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), muscle weakness, and a history of falling. R1's 07/25/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The MDS documented R1 had two or more noninjury falls, two or more falls with an injury that was not severe, and one fall with a major injury.R1's 07/25/25 Falls Care Area Assessment (CAA) documented R1 required the assistance of two staff and a mechanical lift for transfers and required a wheelchair for mobility. R1's Care Plan, dated 12/20/24, documented R1 was at high risk for falls, had numerous falls since admission, and was expected to have ongoing falls due to impulsivity and poor safety awareness. An intervention, dated 12/20/24, stated the facility was to provide non-skid footwear to R1. An intervention dated 02/13/25 stated the facility was to lower R1's bed to the lowest position and use a floor mat. An intervention dated 03/26/25 directed staff to ensure R1 had a call light and not to leave in the bathroom unattended; R1 required a bolstered mattress. An intervention, dated 06/18/25, stated that staff will get R1 up and bring him out to the living room area if he is awake in bed. An intervention dated 07/10/25 stated R1 sometimes puts himself on the fall mat beside his bed. R1's Fall Investigation Report, written on 07/14/25, documented on 07/08/25 at 04:00 PM, staff left R1 unattended in the dining room. R1 stood up and fell. The intervention stated that the facility was to send R1 to the hospital for a femur fracture. The report lacked any intervention to prevent further falls. On 09/16/25 at 12:58 PM, R1 lay in bed at the lowest position with a fall mat on the floor beside his bed. R1 reported he had had many falls, rubbed his arm and leg, and stated he had gotten hurt. On 09/16/25 at 1:58 PM, Certified Medication Aide (CMA) R stated R1 had a lot of falls. Staff put his bed low, with a fall mat, and would sometimes sit with R1. CMA R said R1 was dependent on two staff members for assistance with care. CMA R reported if someone fell, the nurse would be called to assess them, get vital signs, and assist the resident up if safe to do so. CMA R stated staff were not involved in choosing the interventions for the falls and said the chosen interventions were not good. On 09/16/25 at 04:22 PM, Licensed Nurse (LN) G stated that when a resident fell, the staff would call the nurse and assess for range of motion, vital signs, any signs of injury, and initiate neurological checks. The nurse created an intervention, and the Director of Nursing (DON), MDS Coordinator, and Assistant DON would review the intervention and change it if needed. On 09/16/25 at 04:43 PM, Administrative Nurse D stated the previous DON had recently quit and oversaw the investigations for falls. Administrative Nurse D stated she was unable to find most of the investigations for the previous falls. Administrative Nurse D stated it was her expectation that the nurse on duty would put an intervention in the computer at the time of a fall; then a team of nurses would review the falls on the next working day to create an appropriate intervention and put the intervention into the computer. Administrative Nurse D stated staff just started doing fall huddles to discuss the fall at the time and started putting the intervention on the communication board.The facility's policy Skilled Fall Policy dated 05/2025, documented the community shall ensure that the Fall Program is maintained to reduce the occurrence of falls, reduce the risk of injury, and promote independence and safety. After each fall, an occurrence report will be completed, the root cause will be determined, and interventions will be implemented.

The facility reported a census of 62 residents; the sample included six residents reviewed for bowel movements and related monitoring. Based on observation, interview, and record review revealed the facility failed to monitor and respond to Resident (R)1 for lack of bowel movements. Findings included:- R1's Electronic Medical Records (EMR) documented diagnoses that included unspecified symptoms and signs involving cognitive functions and awareness (various disorders that affect an individual's intellectual capabilities and conscious perception of their surroundings), and constipation (difficulty passing stools).R1's 07/25/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of four, indicating severe cognitive impairment. The MDS noted R1 was always incontinent of bladder, but bowels were unrated on the assessment; R1 did not have a toileting program, and/or constipation.R1's Urinary Continence and Indwelling Catheter Care Area Assessment (CAA), dated 07/25/25, documented R1 was incontinent of bladder and bowel. Staff assisted him with peri-care check and changes with the assistance of two staff members.R1's Care Plan dated 9/06/25, documented R1 was incontinent of bowels and directed staff to take R1 to the toilet at the same time each day and provide peri-care for each incontinent episode. R1's Care Plan dated 02/18/25, documented R1 took pain medication and instructed staff to monitor for constipation. R1's Physician Orders in the EMR documented an order for Milk of Magnesia (laxative) 400 milligrams (mg)/5 milliliters (ml); give 15ml by mouth as needed for constipation, give at bedtime if no bowel movement in three days; ordered on 07/11/25. R1's Physician Orders in the EMR documented an order for sennosides (laxative) 8.6 mg by mouth every night for constipation; ordered on 07/12/25.Review of R1's bowel movement frequency in the EMR dated 08/24/25 through 9/16/25 revealed the resident exceeded three days/72 hours without a bowel movement and/or treatment from 08/24/25 at 03:52 PM through 09/02/25 at 09:13 PM (nine consecutive days) with no medication given for constipation and no assessment documented.The EMR for the same timeframe listed above also revealed the resident exceeded three days/72 hours without a bowel movement and/or treatment from 09/06/25 at 09:59 PM through 09/14/25 at 08:17 PM (eight consecutive days). On 09/12/25 (after six consecutive days with no bowel movement), R1 received Milk of Magnesia. The follow-up from the Milk of Magnesia was documented as unknown, with no additional explanation documented in the nurses' notes. No additional documentation concerning constipation was provided, and no assessment was documented. R1's Tasks documented a bowel movement on 09/14/25 at 08:17 PM.On 09/16/25 at 12:58 PM, R1 lay in bed. The bed was in the lowest position with a fall mat on the floor beside his bed. R1 reported he has had falls with broken bones. On 09/16/25 at 1:58 PM, Certified Medication Aide (CMA) R stated R1 was dependent on two staff members to take him to the toilet; R1 sometimes told staff when he had to go. CMA R said staff documented when residents had bowel movements. CMA R said she was not aware of R1 receiving medications for constipation, as she had not given him any. On 09/16/25 at 04:22 PM, Licensed Nurse (LN) G stated that staff monitor bowel movements and if there was no bowel movement in three days, the nurse would notify the provider. LN g said the nurse would listen to bowel sounds and would follow the standing orders. LN G said staff would definitely investigate and assess the resident and document it in the EMR if the resident went three to four days with no bowel movement.On 09/16/25 at 04:43 PM, Administrative Nurse D stated that the staff monitors the bowel movements, and the Certified Nurse Aides (CNA) were supposed to document bowel movements in the EMR, but it has not always been done. Administrative Nurse D said the nurse was supposed to monitor the EMR dashboard for alerts, as the EMR would alert staff if a bowel movement was not documented in three days. Administrative Nurse D said it was not always being followed up on, and she was working on getting staff to follow up on alerts. The facility did not provide a policy to address the monitoring of residents to prevent constipation.

The facility identified a census of 69 residents. The facility had one main kitchen and one dining area. The facility failed to ensure that staff members properly tested and recorded the dish machine temperatures. This deficient practice placed residents at risk for contamination and food-borne illness. Findings included: - The initial tour of the facility on 03/03/25 at 07:29 AM review of the Dish Machine Log from 02/01/25 to 02/28/25 revealed 34 undocumented dish machine water temperature opportunities out 84 opportunities. The dish machine lacked a Dish Machine Log for 03/2025 was eight undocumented dish machine water temperatures. On 03/03/25 at 07:30 AM, Dietary Aide CC stated the dish machine water temperature was checked all the time. Dietary Staff CC stated the Dish Machine Log for 03/2025 was in the Certified Dietary Manager's office. On 03/04/25 at 12:06 PM, Dietary Staff BB stated the dish machine water temperature should be checked at least daily. Dietary Staff BB stated he had not posted the Dish Machine Log 03/2025. The facility's undated Food Storage policy did not cover the water temperatures for the dish machine. The facility failed to ensure that staff members properly tested and recorded the dish machine temperatures. This deficient practice placed residents at risk for contamination and food-borne illness.

The facility identified a census of 69 residents. The sample included 18 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. This failure affected all 69 residents residing in the facility. Findings Included: - On 03/03/25 Administrative Nurse D provided a Facility Assessment updated 08/12/24. A review of the assessment revealed the following: The assessment failed to identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, patient acuity, and census. The assessment lacked staffing levels required for each shift to include evenings and weekends. The assessment failed to identify the means of input gathered from the residents and their representatives when formulating the assessment data. The assessment lacked informed contingency plans for events that do not require activation of the facility's emergency plan but have the potential to impact resident care. On 03/05/25 at 01:34 PM Administrative Staff A stated he updated the assessment annually based on the changes that were put out by the Centers for Medicaid and Medicare Services (CMS). The facility's Facility Assessment Quick Reference Guide dated 08/2024 indicated the facility assessment was to be individualized to the community needs and developed utilizing evidence-based data-driven methods. The facility failed to conduct a thorough, updated facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and emergencies. This failure affected all 69 residents residing in the facility.

The facility identified a census of 69 residents. The sample included 18 residents, with one medication room and three medication carts. Based on observation, record review, and interviews, the facility failed to ensure controlled substances were accounted for and reconciled between shifts. This placed the residents at risk for misappropriation and/or diversion of controlled substances. Findings included: - On 03/04/25 at 07:12 AM a review of the January, February, and March of 2025 Shift Change Controlled Substance Inventory Count Sheet on the 100 and 200, halls revealed a missing signature for the On Nurse were 02/14, 02/15, 02/16, 02/17, 02/18, 02/ 20, 02/22, 02/23, 03/01, and 03/02. On 03/04/25 at 07:12 AM a review of January, February, and March of 2025 Shift Change Controlled Substance Inventory Count Sheet on the 100 and 200 halls revealed a missing signature for the Off Nurse. The missing signatures for 02/02, 02/05, 02/18, 02/20, 02/22, and 02/28. On 03/04/25 at 07:12 AM, Certified Medication Aide (CMA) S stated all CMAs or Nurses were to count the medication cards, and pills, and sign the count sheet. She stated she did not know what the process was if the count sheet was not signed. On 03/05/25 at 12:52 AM, Licensed Nurse (LN) G stated the CMAs were to count all cards and then count all narcotics per pill. The CMA with a nurse or another CMA was to count at the end of every shift with the incoming and outgoing nurse or CMA. On 03/05/25 at 01:16 PM, Administrative Nurse D said it was the policy to count cards, and pills, and sign each shift. She stated if the narcotic count was not signed, the CMA should take the sheet to the charge nurse or to the director of nursing to reconcile medication. The facility's Controlled Substance policy dated 12/24 documented that controlled substances were subject to special handling storage, disposal, and record-keeping requirements. The facility would maintain compliance with these special provisions. All controlled substances are to be counted every shift The count was to be performed by the oncoming LN or CMA where applicable and the off-going LN or CMT where applicable. The oncoming nurse or CMA would be responsible for viewing the controlled substance proof of use record to verify the amount on the record at the time of the count both nurse or CMA would sign the Narcotic sign in and out sheet. The facility failed to ensure an accurate reconciliation of controlled medications was completed. This placed residents at risk of medication misappropriation and diversion.

The facility had a census of 69 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to keep Resident (R) 38's protected health information (PHI) private on a medication cart parked in the main dining room. This deficient practice placed R38 at risk for impaired privacy. Findings included: - On 03/04/25 at 10:02 AM, an observation revealed a medication cart parked in the 400 hallway with a laptop computer sitting on the top, the computer screen was unlocked and open, and R38's PHI was on the screen visible to all who passed by the medication cart. The information visualized included R38's medications, date of birth, allergy information, and code status. No nursing staff were in view of the medication cart. Certified Medication Aide (CMA) R agency exited another room into the hallway. On 03/04/25 at 10:05 AM, CMA R stated she had just walked away from the medication cart for just a minute. CMA R stated she should not leave the computer open and R38's PHI. On 03/05/25 at 12:50 PM, Licensed Nurse (LN) G stated the laptop should be closed. On 03/05/25 at 01:17 PM, Administrative Nurse D stated she expected the laptop on the medication cart to be locked or closed. On Administrative Nurse D stated the resident's PHI should not be available to just anyone. The facility's Electronic Medical Records policy dated 12/2025 documented electronic records are an acceptable form of medical record management. Only authorized persons who have been issued a password and user ID code would be permitted access to the electronic medical records system. The facility would make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of the use or disclosure. The facility failed to maintain R38's privacy regarding PHI. This deficient practice placed the resident at risk for impaired privacy.

The facility identified a census of 69 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to provide resident directed, interactive activities based on resident preferences for the residents on the weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings Included: - A review of the facility's Activity Calendars for December 2024, January 2025, and February 2025 was completed. The calendars revealed the residents were provided church related services via television or internet on Sundays. The calendar revealed movies were played for the residents at 02:30 PM and the evening news at 06:00 PM on Sundays. The calendars lacked engaging staff-led activities for Sundays. On 03/04/25 at 10:30 AM, the facility provided music and exercise group for the residents in the dining hall area. On 03/04/25 at 11:00 AM, the facility's Resident Council reported the facility rarely provided activities on weekends. The council reported very little occurred on Sundays. The council reported staff would put on a movie for the residents to watch but would not provide engaging activities. The council reported activities were inconsistent on Saturdays. The council reported sometimes outings occurred on Saturdays, but not all residents could go out due to the limited space in transportation. The council reported if you had to sign up and hope you could get a spot to go. The council reported the facility did not provide an alternative activity for residents who could not go on the outing. The council reported that weekends were often boring due to the lack of engaging activities. On 03/05/25 at 11:12 AM, Certified Medication Aide (CMA) R stated staff were expected to complete the activities on weekends. She stated the facility had outings and religious services come in on Sundays. She stated staff could also provide coloring pages for the residents to turn in to win a prize. On 03/05/25 at 12:47 PM, Activity Staff Z stated staff were expected to complete the scheduled activities on weekends. She stated the activities were not assigned staff to hold the activities, but staff would provide the scheduled activities. She stated the facility did not document what activities were provided or which residents attended. She stated the facility also had an activity basket for the weekends with puzzles, coloring pages, and games. She stated staff could give them to the residents. The facility failed to provide a policy related to activities as requested on 03/05/25. The facility failed to provide consistent activities on the weekends which reflected the residents' interests, and preferences. This placed the affected residents at risk for boredom, isolation, and decreased quality of life.

The facility identified a census of 69 residents. The sample included 18 residents with seven residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the physician reviewed and addressed the Consultant Pharmacist (CP) recommendations for Resident (R) 60's as needed antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality). The facility also failed to ensure the CP identified and reported irregularities regarding the lack of dosing instructions for Voltaren (topical pain reliever medication) gel for R4. The facility also failed to ensure the physician reviewed and addressed the CP's recommendations for reeducation of R14's analgesics (pain relief) dosage. The facility also failed to ensure the physician had reviewed and addressed the CP's recommendation for R26's antidepressant (a class of medications used to treat mood disorders) medication. These deficient practices placed these residents at risk for adverse medication effects and unnecessary medications. Findings included: - R60's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R60 had received antipsychotic medication, antianxiety (a class of medications that calm and relax people) medication, antidepressant (a class of medications used to treat mood disorders), and insulin (medication to regulate blood sugar) during the observation period. The MDS documented R60 had not completed a gradual dose reeducation (GDR) and the physician had not documented a GDR was clinically contraindicated. R11's MDS lacked documentation a medication regimen review was completed during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of eight which indicated moderately impaired cognition. The MDS documented that R60 had received insulin, antipsychotic medication, and antidepressant medication during the observation period. The MDS documented R60 had not completed a gradual dose reeducation (GDR) and the physician had not documented a GDR was clinically contraindicated. R11's MDS lacked documentation a medication regimen review was completed during the observation period. R60's Psychotropic Drug Use Care Area Assessment (CAA) dated 10/21/24 documented a pharmacist would review and attempt a GDR as needed. R60's Care Plan dated 10/29/24 documented staff would administer her medication as ordered. The plan of care documented the CP would review her medication monthly per protocol. The plan of care documented the nursing staff would monitor for side effects from her psychotropic medication. R60's EMR under the Progress Notes tab revealed a Consulting Pharmacy Note dated 10/27/24 at 07:19 PM Medication Regimen Review (MRR) documented please see pharmacy recommendations in the report. Review of the Monthly Medication Review (MMRs) from October 2024 to February 2025 provided by the facility revealed an MMR dated 10/28/24 that was reviewed and signed by the physician on 03/05/25. The MMR had indicated a 14-day stop date was required for any as-needed antipsychotic medication. On 03/04/25 at 10:05 AM, R60 laid asleep on her bed. R11 was covered with a blanket and her call light was pinned next to her on the bed. On 03/04/25 at 11:16 AM, Administrative Nurse E stated the facility was unable to provide June and July of 2024. Administrative Nurse E stated the pharmacy was unable to locate the MMRs. On 03/05/25 at 12:53 PM, Licensed Nurse (LN) G stated he did not take care of MMRs. On 03/05/25 at 01:16 PM, Administrative Nurse D stated she had only been in the facility since November 2024 and the pharmacy reviews may have been from the previous nursing administration. Administrative Nurse D stated the CP would email the MMRs to her and Administrative Nurse E. Administrative Nurse D Stated Administrative Nurse E would print the MMRs, and then have the attending physicians address the CP recommendations. Administrative Nurse D stated the facility had realized part of the process for addressing the MMR was missing and had not been completed as required. The facility's Medication Regimen Review (MMR) (undated) indicated the CP would complete monthly medication reviews for each resident and report irregularities identified within the review. The policy indicated the CP will communicate their recommendations with the medical provider and Director of Nursing (DON). The facility failed to ensure the physician reviewed and addressed the CP recommendations for R60's antipsychotic medication. This deficient practice placed R60 at risk for unnecessary medication use, side effects, and physical complications. 45668 - The Medical Diagnosis section within R4's Electronic Medical Records (EMR) included 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), muscle weakness, aphasia (difficulty speaking), chronic kidney disease, and heart failure. R4's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS indicated she required substantial to maximal assistance with transfers, bed mobility, dressing, toileting, bathing, and personal hygiene. The MDS noted no pain reported during the assessment. The MDS noted she took opioid (a class of controlled drugs used to treat pain) medication. R4's Psychotropic Drug Use Area Assessment (CAA) completed 09/03/24 indicated she took antidepressants (a class of medications used to treat mood disorders). The plan instructed staff to observe for side effects. The CAA noted a care plan was implemented to address the risks of her medications. R4's Care Plan initiated on 04/27/24 indicated she was at risk for pain related to her medical diagnoses. The plan instructed staff to monitor for signs/symptoms of pain and provide treatment. The plan noted she took medications with Black Box Warnings (BBW - the highest safety-related warning that medications can be assigned by the Food and Drug Administration). R4's EMR under Physician's Orders revealed an order dated 10/01/24. The order instructed staff to administer Diclofenac Sodium External Gel topically (topical ointment used to treat pain) three times daily to affected areas for pain. The order lacked a dosage for administration. A review of R4's Monthly Medication Review for 11/2024 revealed the Consultant Pharmacist (CP) identified R4's Diclofenac order lacked a dosage and site of application. The CP recommended clarifying the dosage amount and location of administration. The facility provided no documented response to the CP's recommendation. On 03/04/25 at 07:30 AM, R4 sat in her wheelchair in her room. R4 was administered her medication but did not want her Diclofenac medication applied. On 03/05/25 at 12:53 PM, Licensed Nurse (LN) G stated all valid medication orders were to include the amount to be administered and the location of the application. He stated the facility was to take the pharmacy's recommendations and update the orders. On 03/05/25 at 01:16 PM, Administrative Nurse D stated all medication orders should have an accurate dosage amount to be given. She stated Diclofenac should be measured before administration to ensure the correct amount was given. She stated she had only been in the facility since November 2024 and the pharmacy reviews may have been from the previous nursing administration. The facility's Medication Regimen Review (MMR) (undated) indicated the CP would complete monthly medication reviews for each resident and report irregularities identified within the review. The policy indicated the CP would communicate their recommendations with the medical provider and Director of Nursing (DON). The facility failed to follow the CP's recommendations related to R4's Diclofenac medication. This placed R4 at risk for unnecessary medications and potential side effects. 49634 - The Diagnosis tab of R14's Electronic Medical Record (EMR) documented diagnoses of obesity (excessive body fat), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hemiplegia (paralysis of one side of the body), affecting left nondominant side, muscle weakness, hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), lack of coordination, need for assistance with personal care, cellulitis (bacterial infection of the skin and underlying tissues), and abnormalities of gait and mobility. The Quarterly Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R14 required substantial to maximum assistance for bathing and dressing, and was dependent on staff for toileting. The MDS documented R14 received antidepressants (a class of medications used to treat mood disorders) during the observation period. The Annual MDS dated [DATE] documented a BIMS of 15 which indicated intact cognition. The MDS documented R14 had impairment of one side of her body. The MDS documented R14 needed substantial to maximum assistance for bathing and dressing. R14 was dependent on staff for toileting. The MDS documented R14 received antidepressants during the look-back period. R14's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/12/24 documented R14 takes medication for depression daily, and Licensed staff would monitor for symptoms of adverse reaction daily and document them. The pharmacist would review her medication quarterly and attempt to reduce it as needed. R14's Care Plan dated 05/1023 documented R14 had depression and took an antidepressant. R14 would remain free of signs and symptoms of distress, symptoms of depression, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), or sad mood. Nursing staff were to monitor, document, and report to the physician any ongoing signs and symptoms of depression. Nursing staff were to administer medications as ordered and monitor and document any side effects and effectiveness. R14's EMR under Progress Notes dated 06/26/24 documented see note regarding psychotropic gradual dose reduction (GDR) per pharmacy. The facility was unable to provide upon request evidence of the Monthly Regiment Review (MRR) and that the physician had addressed the consulting pharmacist (CP) recommendation. R14's EMR under Orders documented the following physician's order: Trazadone (antidepressant medication) oral tablet, give 50 milligrams (mg), give 1.5 tablets by mouth at bedtime for difficulty sleeping. Acetaminophen (APAP - analgesics) Tylenol Tablet Give 650 mg by mouth one time a day for pain Do Not Exceed 3 gm APAP/24 hours (hrs) Start Date of 02/20/24 - discontinue (D/C) date of 11/26/24. Acetaminophen Tablet 325 MG Give two tablets by mouth every four hours as needed for pain Not To Exceed 3 gm/24 hrs -Start Date of 06/30/22 - D/C Date of 11/26/24. On 03/05/25 at 12:53 PM, Licensed Nurse (LN) G stated he did not review the MRR's from the CP. On 03/05/25 at 01:16 PM, Administrative Nurse D stated she realized a process had been broken when she was hired at the facility. She stated the facility was unable to produce the CP's recommendations for June and July of 2024. Administrative Nurse D stated the physician was unable to address and make recommendations for June and July of 2024. The facility's Psychotropic Medication Use revised 12/24 documented the residents would only receive antipsychotic medication when necessary to treat specific conditions, for which were indicated. The facility failed to ensure the CP identified and made recommendations related to R14's antidepressant medication, and analgesics. This placed R14 at risk for unnecessary psychotropic medications and possible toxicity-related complications. - The Diagnosis tab of R26's Electronic Medical Record (EMR) documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body), following a 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) non-dominant side, attention and concentration deficit, dysphagia (swallowing difficulty), memory deficit, muscle weakness, need for assistance with person care, difficulty in walking, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R26 required set up or touching for eating. and was dependent of staff for oral hygiene bathing, and dressing. The MDS documented R26 received antidepressant (a class of medications used to treat mood disorders), and antianxiety (a class of medications that calm and relax people), during the observation period. The Annual MDS dated [DATE] documented a BIMS score of four which indicated severely impaired cognition. The MSD documented R26 set up or touching for eating, and was dependent of staff for oral hygiene bathing, and dressing. The MDS documented R26 received antidepressant and antianxiety medication during the observation period. R26's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/09/24 documented R26 takes medication for depression and anxiety and staff would observe daily for adverse effects and document as needed. The CAA documented R26 would have a licensed pharmacist review and make recommendations for gradual dose reduction (GDR) as needed would be addressed in her care plan. R26's Care Plan Date 02/05/2024 documented R26 had depression and took medication to assist with the management of signs and symptoms. R26 takes an antidepressant (a class of medications used to treat mood disorders) daily and tends to isolate herself in her room. Staff were to administer her medication as ordered by the physician and documented any side effects. R26's EMR under Orders documented the following physician's order: Sertraline HCL (antidepressant medication) 50 milligram (mg) give one tablet by mouth in the morning for depression dated 05/22/24. A review of R26's EMR under progress revealed the following note under Progress Notes dated 06/26/20 documented see consulting pharmacy note regarding psychotropic gradual dose reduction (GDR). The facility was unable to provide upon request evidence of the Monthly Regiment Review (MRR), and that the physician had addressed the consulting pharmacist (CP) recommendation. On 03/03/25 at 07:19 AM, R26 laid on her bed asleep. On 03/04/25 at 08:24 AM, R26 was sitting in her Broda chair (specialized wheelchair with the ability to tilt and recline), in the dining room. 0n 03/04/25 at 10:05 AM Administrative Nurse E stated the facility was unable to find all of the CP's recommendation for residents done in June and July of 2024. She stated the facility was unable to obtain the records due to transferring pharmacist. On 03/05/25 at 12:53 PM, Licensed Nurse (LN) G stated he did not review the MRR's from the CP. On 03/05/25 at 01:16 PM, Administrative Nurse D stated she realized a process had been broken when she was hired at the facility. She stated the facility was unable to produce the CP's recommendations for the months of June and July of 2024. She stated the physician was unable to address and make recommendations for the months of June and July of 2024. The facility's Psychotropic Medication Use revised 12/24 documented residents would only receive antipsychotic medication when necessary to treat specific conditions, for which they were indicated. The facility failed to ensure the CP identified and made recommendations related to R26's Sertraline. This placed R26 at risk for unnecessary psychotropic medications and related complications.

The facility had a census of 69 residents. The sample included 18 residents, with five residents reviewed for accidents and/or hazards. Based on observation, record review, and interview, the facility failed to secure areas containing hazardous materials out of reach of seven cognitively impaired /independently mobile residents in the secured unit. The facility further failed to implement interventions related to Resident (R)28's falls. This deficient practice placed the affected residents at risk for preventable injuries and accidents. Findings Included: - The facility identified that Residents (R) 5, R16, R22, R30, R42, R53, and R60 were cognitively impaired and independently mobile within the facility. On 03/03/25 at 07:03 AM, a walkthrough of the facility was completed. Upon inspection of the facility's supplemental oxygen storage room revealed the entry door was unlocked. An inspection of the room revealed 46 fully charged supplemental oxygen cylinder tanks. At 07:05 AM Licensed Nurse (LN) G secured the oxygen room door and stated the room should have been locked. He stated staff may have forgotten to check the door before exiting the room. He stated the residents should not have access to areas with potential hazards. On 03/03/25 at 07:10 AM, an inspection of the 400 hall revealed the shower room was propped open. The shower contained unsecured two containers of Micro-kill bleach wipes and a spray bottle of disinfectant. The products contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 03/03/25 at 07:14 AM, an inspection of an unsecured closet next to the maintenance office revealed a one-gallon carton of floor cleaner on the floor. The product contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 03/03/25 at 07:15 AM, an unlocked utility closet next to R4's room revealed an unlocked electrical panel. The panel contained the warning, high voltage - the danger of electric shock. On 03/03/25 at 07:17 AM, an unlocked utility closet next to R60's room revealed an unlocked electrical panel. The panel contained the warning, high voltage - the danger of electric shock. On 03/05/25 at 01:16 PM, Administrative Nurse D stated all areas within the facility that contained potential hazards for the residents should remain locked and staff were expected to check the doors to ensure they were secured. The facility was unable to provide a policy related to environmental safety as requested on 03/05/25. The facility failed to secure areas containing hazardous materials out of reach of seven cognitively impaired /independently mobile residents in the secured unit. This deficient practice placed the affected residents at risk for preventable injuries and accidents. 41037 - R28's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of muscle weakness, chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and hypertension (HTN - elevated blood pressure). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R28 required substantial to maximum staff assistance for transfers. The MDS documented R28 had one non-injury during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of three which indicated severely impaired cognition. The MDS documented that R28 required substantial to maximum staff assistance for transfers. The MDS documented R28 had one non-injury during the observation period. R28's Fall Care Area Assessment (CAA) dated 03/18/24 documented he had a history of falls. R28's Care Plan dated 10/15/22 documented he was found on the floor. The plan of care documented nursing staff would ensure R28 was wearing gripper socks when up for the day and not the pressure-reducing boots only when in bed. The plan of care dated 10/25/22 documented nursing staff would ensure R28's call light was within reach. The plan of care dated 03/06/23 documented nursing staff would ensure R28's items were within his reach when in bed. The plan of care dated 09/17/23 documented nursing staff would remind R28 to ask for assistance with toileting or wanting to walk and staff would assist R28 to the bathroom every two hours. The plan of care dated 11/20/23 documented staff would cue R28 during transfers to assist with pivoting. The plan of care dated 01/11/24 documented R28 had a witnessed fall when staff lowered him to the floor. The plan of care documented staff would ensure R28 had the appropriate footwear (non-skid socks or shoes) and gripper strips on the floor next to his bed. The plan of care dated 02/16/24 documented staff would educate R28 to ask for assistance with care. The plan of care dated 04/08/24 documented staff instructed R28 to call for assistance when he wanted to serve popcorn. The plan of care dated 07/19/24 documented staff increased R28's monitoring when in the dining room and would encourage him to sit in the common area following meals. The plan of care dated 02/18/25 documented when R28 became restless after meals, staff was to assist him to a chair in the common area as tolerated or offered to be laid down in the bed. The plan of care lacked staff direction for fall prevention for the following dates 11/20/24 and 11/21/24. R28's EMR under the Progress Notes tab documented an Incident Note dated 01/11/24 at 07:55 AM during a staff-assisted transfer R28's legs buckled, and he fell to the ground with staff assistance. R28 received a skin tear on his left forearm. R28 was wearing only his socks and no shoes. On 02/16/24 at 07:40 PM, a Situation, Background, Assessment, and Recommendation (SBAR- communication tool) documented R28 was found on the floor in the dining room. On 04/08/24 at 04:15 PM a Health Status Note documented dietary staff found R28 on the floor in the dining room. R28 was instructed not to get up without assistance. On 04/08/24 at 06:29 PM a Health Status Note documented dietary staff found R28 on the floor in the dining room. R28 was instructed not to get up without assistance. On 07/19/24 at 07:30 PM a Health Status Note that documented R28 attempted to transfer himself from his wheelchair and fell to the floor. On 11/20/24 at 06:06 PM a Health Status Note documented R28 attempted to stand up from his wheelchair, fell to the floor, and received a skin tear on his right elbow. On 11/21/24 at 07:30 PM a Health Status Note documented R28 was found on the floor in the hallway. R28 had an incontinent episode. A fall intervention was put into place to assist R28 to bed after supper mealtime as R28 preferred to lie down after dinner. On 02/13/25 at 08:35 PM a Health Status Note documented R28 was found on the floor in the common area. R28 had bruising, redness, and swelling on the right side of his forehead and a skin tear on his right elbow. On 03/05/25 09:51 AM, R28 sat in his wheelchair in the dining room. R28 had eggs and other food on his lap and there was not a plate or any fluids on the table in front of him. No nursing staff was noted in the dining room. On 03/05/25 09:55 AM, no gripper strips were on the floor in front of R28's bed. On 03/05/25 at 12:25 PM, Certified Nurse Aide (CNA) M stated R28 was a high fall risk. CNA M stated that R28 had a fall mat next to his bed when he was in bed. On 03/05/25 at 12:50 PM, Licensed Nurse (LN) G stated that everyone had access to the resident's care plan. LN G stated that R28's fall interventions should be on his care plan and the staff could review the interventions from the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). LN G stated the charge nurse would try to come up with a new fall intervention. On 03/05/25 at 01:17 PM, Administrative Nurse D stated that R28 was now a high fall risk. Administrative Nurse D stated the management team would review the fall and the fall intervention. Administrative Nurse D stated she was not sure who would ensure past interventions were in place for the resident. The facility's undated Fall Assessment policy documented the purpose of the Fall Management Program, which was to develop, implement, monitor, and evaluate an interdisciplinary team fall prevention approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promoted the safety, prevention, and education of both staff and residents. The facility failed to ensure the gripper strips were in place in front of R28's bed. This deficient practice placed R28 at risk of falls and possible injuries.

- The Medical Diagnosis section within R57's Electronic Medical Records (EMR) included diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R57's admission Minimum Data Set (MDS) dated 12/19/24 noted a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS noted he required substantial to maximal assistance with transfers, toileting, bed mobility, bathing, and personal hygiene. The MDS noted he took anxiolytic medication. R57's Psychotropic Drug Use Area Assessment (CAA) completed 12/28/24 indicated he was on hospice services and took antianxiety medication. The CAA instructed staff to monitor him for side effects. The CAA noted the consultant pharmacist (CO) would recommend a gradual dose reduction (GDR) as needed and a care plan was completed. R57's Care Plan initiated on 12/28/24 indicated he had a terminal illness of Parkinson's disease. The plan noted he was at risk for depression, anxiety, loss of interest in activities, and a decline in functioning. The plan instructed staff to administer his medications as ordered and monitor for side effects. The plan instructed staff to report changes in behavior or a decline in his daily functioning. R57's EMR under Physician's Orders revealed an order started on 01/31/25. The order instructed staff to administer 0.5 milliliters of Lorazepam Oral Concentrate (medication used to treat anxiety) by mouth every four hours as needed (PRN) for anxiety. The order lacked a stop date or intended duration. R57's EMR lacked documented rationale for the medication's extended use. On 03/04/25 at 11:21 PM, R57 rested in his bed. R57 reported no concerns related to the medication regimen. On 03/05/25 at 12:53 PM, Licensed Nurse (LN) G stated all PRN psychotropic medications should have a stop date. He stated nursing staff should review the orders each day to ensure the medications were administered appropriately. On 03/05/25 at 01:16 PM, Administrative Nurse D was not aware that R57's PRN Lorazepam medication required a stop date. The facility's Psychotropic Medication Use revised 12/24 indicated the facility will ensure all PRN psychotropic medications were limited to 14 days unless a longer timeframe was deemed appropriate. The facility failed to implement a 14-day stop date on R57's PRN Lorazepam order or provide documentation showing the clinical necessity to continue the medication. This deficient practice placed R57 at risk for unnecessary medications and side effects.The facility identified a census of 69 residents. The sample included 18 residents with seven reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to provide a 14-day stop-date on as-needed (PRN) anxiolytic (a class of medications that calm and relax people) medication or documented rationale of continued use for Residents (R) 57 and R60. The facility additionally failed to complete gradual dose reductions (GDR) for R14 and R26's antidepressant (a class of medications used to treat mood disorders) medications. This deficient practice placed the residents at risk for unnecessary psychotropic (alters mood or thought) medications and side effects. Findings Included: - The Medical Diagnosis section within R57's Electronic Medical Records (EMR) included diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R57's admission Minimum Data Set (MDS) dated 12/19/24 noted a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The MDS noted he required substantial to maximal assistance with transfers, toileting, bed mobility, bathing, and personal hygiene. The MDS noted he took anxiolytic medication. R57's Psychotropic Drug Use Area Assessment (CAA) completed 12/28/24 indicated he was on hospice services and took antianxiety medication. The CAA instructed staff to monitor him for side effects. The CAA noted the consultant pharmacist (CO) would recommend a gradual dose reduction (GDR) as needed and a care plan was completed. R57's Care Plan initiated on 12/28/24 indicated he had a terminal illness of Parkinson's disease. The plan noted he was at risk for depression, anxiety, loss of interest in activities, and a decline in functioning. The plan instructed staff to administer his medications as ordered and monitor for side effects. The plan instructed staff to report changes in behavior or a decline in his daily functioning. R57's EMR under Physician's Orders revealed an order started on 01/31/25. The order instructed staff to administer 0.5 milliliters of Lorazepam Oral Concentrate (medication used to treat anxiety) by mouth every four hours as needed (PRN) for anxiety. The order lacked a stop date or intended duration. R57's EMR lacked documented rationale for the medication's extended use. On 03/04/25 at 11:21 PM, R57 rested in his bed. R57 reported no concerns related to the medication regimen. On 03/05/25 at 12:53 PM, Licensed Nurse (LN) G stated all PRN psychotropic medications should have a stop date. He stated nursing staff should review the orders each day to ensure the medications were administered appropriately. On 03/05/25 at 01:16 PM, Administrative Nurse D was not aware that R57's PRN Lorazepam medication required a stop date. The facility's Psychotropic Medication Use revised 12/24 indicated the facility will ensure all PRN psychotropic medications were limited to 14 days unless a longer timeframe was deemed appropriate. The facility failed to implement a 14-day stop date on R57's PRN Lorazepam order or provide documentation showing the clinical necessity to continue the medication. This deficient practice placed R57 at risk for unnecessary medications and side effects.- The Diagnosis tab of R14's Electronic Medical Record (EMR) documented diagnoses of obesity (excessive body fat), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hemiplegia (paralysis of one side of the body), affecting left nondominant side, muscle weakness, hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), lack of coordination, need for assistance with personal care, cellulitis (bacterial infection of the skin and underlying tissues), and abnormalities of gait and mobility. The Quarterly Minimum Data Set (MDS) dated 01/12/25, documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R14 required substantial to maximum assistance for bathing, and dressing, and was dependent on staff for toileting. The MDS documented R14 received antidepressants (a class of medications used to treat mood disorders) during the observation period. The Annual MDS dated 07/12/24 documented a BIMS of 15 which indicated intact cognition. The MDS documented R14 had impairment of one side of her body. The MDS documented R14 needed substantial to maximum assistance for bathing and dressing. R14 was dependent on staff for toileting. The MDS documented R14 received antidepressants during the look-back period. R14's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/12/24 documented R14 takes medication for depression daily, and a Licensed staff would monitor for symptoms of adverse reaction daily and document. The pharmacist would review her medication quarterly and attempt to reduce it as needed. R14's Care Plan dated 05/1023 documented R14 had depression and took an antidepressant. R14 would remain free of signs and symptoms of distress, symptoms of depression and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), or sad mood. Nursing staff were to monitor, document, and report to the physician any ongoing signs and symptoms of depression Nursing staff were to administer medications as ordered and monitor and document any side effects and effectiveness. R14's EMR under Progress Notes dated 06/26/24 documented see note regarding psychotropic gradual dose reduction (GDR) per pharmacy. The facility failed to provide upon request evidence of the Monthly Regiment Review (MRR), and that the physician had addressed the consulting pharmacist (CP) recommendation. R14's EMR under Orders documented the following physician's order: Trazadone (antidepressant medication) oral tablet, give 50 milligrams (mg), give 1.5 tablets by mouth at bedtime for difficulty sleeping. On 03/05/25 at 12:53 PM, Licensed Nurse (LN) G stated he did not review the MRR's from the CP. On 03/05/25 at 01:16 PM Administrative Nurse D stated she realized a process had been broken when she was hired at the facility. She stated the facility was unable to produce the CP's recommendations for June and July of 2024. She stated the physician was unable to address and make recommendations for June and July of 2024. The facility's Psychotropic Medication Use revised 12/24 documented residents would only receive antipsychotic medication when necessary to treat specific conditions, for which they are indicated. The facility failed to ensure the physician reviewed and addressed the CP recommendations for R14. This deficient practice placed R14 at risk for unnecessary medication use, side effects, and physical complications. - The Diagnosis tab of R26's Electronic Medical Record (EMR) documented diagnoses of hemiparesis/hemiplegia (weakness and paralysis on one side of the body), following a 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) non-dominant side, attention and concentration deficit, dysphagia (swallowing difficulty), memory deficit, muscle weakness, need for assistance with person care, difficulty in walking, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypothyroidism (a condition characterized by decreased activity of the thyroid gland), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS) dated 10/31/24, documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R26 required set up or touching for eating, and was dependent on staff for oral hygiene bathing, and dressing. The MDS documented R26 received antidepressants (a class of medications used to treat mood disorders), and antianxiety (a class of medications that calm and relax people), during the observation period. The Annual MDS dated 01/29/25 documented a BIMS score of four which indicated severely impaired cognition. The MSD documented R26 set up or touching for eating, and was dependent on staff for oral hygiene bathing, and dressing. The MDS documented R26 received antidepressant and antianxiety medication during the observation period. R26's Psychotropic Drug Use Care Area Assessment (CAA) dated 01/09/24 documented R26 takes medication for depression and anxiety and staff would observe daily for adverse effects and document as needed. The CAA documented R26 would have a licensed pharmacist review and make recommendations for gradual dose reduction (GDR) as needed would be addressed in her care plan. R26's Care Plan Date 02/05/2024 documented R26 had depression and took medication to assist with the management of signs and symptoms. R26 takes an antidepressant daily and tends to isolate herself in her room. Staff were to administer her medication as ordered by the physician and documented any side effects. R26's EMR under Orders documented the following physician's order: Lorazepam (antianxiety medication) oral concentrate two milligrams/milliliter (mg/ml) give 0.25 ml by mouth every four hours as needed (PRN) for anxiety and restlessness for 12 months starting on 09/06/24, ending on 09/06/25. Sertraline HCL (antidepressant medication)50 milligram (mg) give one tablet by mouth in the morning for depression dated 05/22/24. A review of R26's EMR under progress revealed the following note under Progress Notes dated 06/26/20 documented see consulting pharmacy note see note regarding psychotropic gradual dose reduction (GDR). The facility was unable to provide upon request evidence of the Monthly Regiment Review (MRR), and that the physician had addressed the consulting pharmacist (CP) recommendation. On 03/03/25 at 07:19 AM, R26 laid on her bed asleep. On 03/04/25 at 08:24 AM, R26 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline) in the dining room. On 03/05/25 at 12:53 PM, Licensed Nurse (LN) G stated he did not review the MRR's from the CP. On 03/05/25 at 01:16 PM, Administrative Nurse D stated she realized a process had been broken when she was hired at the facility. She stated the facility was unable to produce the CP's recommendations for June and July of 2024. She stated the physician was unable to address and make recommendations for June and July of 2024. The facility's Psychotropic Medication Use revised 12/24 documented residents would only receive antipsychotic medication when necessary to treat specific conditions, for which they are indicated. The facility failed to ensure the physician reviewed and addressed the CP recommendations for R26. This deficient practice placed R26 at risk for unnecessary medication use, side effects, and physical complications.

The facility identified a census of 69 residents. The facility identified nine residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to store oxygen saturation equipment and nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) tubing in a sanitary manner and further failed to ensure the required personal protective equipment (PPE) was worn while doing tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted) care. This deficient practice placed the residents at risk for infectious diseases. Findings included: - On 03/03/25 at 07:08 AM, during the walk-through of the facility, Resident (R) 225's oxygen tubing and cannula were wrapped over her walker and her nebulizer tubing was on her side table, the tubing for R225 was not stored in a sanitary manner. On 03/04/25 at 01:26 PM, Licensed Nurse (LN) G performed tracheostomy (opening through the neck into the trachea through which an indwelling tube may be inserted) care for R38 who was on enhanced barrier precautions. LN G donned sterile gloves to perform tracheostomy care but did not don a gown or mask to provide R38's care. On 03/04/25 at 01:26 PM, LN G stated he was not aware he should have worn anything for PPE except gloves. On 03/05/25 at 01:19 PM, Administrative Nurse D stated respiratory equipment not in use should be placed in a bag. She stated the assistant director of nursing has done training for staff; she was unsure if the staff had been trained on EHB. The Administrative Nurse D stated there are signs placed on doors for residents who are placed on EHB, for staff to follow. The facility's Infection Prevention and Control Program policy documented the primary mission was to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility failed to store oxygen saturation equipment and nebulizer tubing in a sanitary manner and further failed to ensure that required PPE was worn while doing tracheostomy care. This deficient practice placed the residents at risk for infectious diseases.

The facility identified a census of 69 residents. The sample included 18 residents, with eight residents reviewed for activities of daily living (ADL) for dependent residents. Based on observation, record review, and interviews, the facility failed to ensure a shower/bath was provided for Resident (R) 11, R34, R14, and R15 who were dependent on staff assistance with ADLs. This deficient practice had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial well-being. Findings included: - R11's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of muscle weakness, need for assistance with personal care, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R11 was dependent on staff assistance for transfers and required substantial assistance from staff for showering/bathing. The Quarterly MDS dated [DATE] documented a BIMS score of 14 which indicated intact cognition. The MDS documented that R11 had limited range of motion (ROM - the full movement potential of a joint, usually its range of flexion and extension) on her upper extremity on one side. The MDS documented R11 required substantial to maximum staff assistance for bathing and was dependent on staff assistance for transfers during the observation period. R11's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 11/30/24 documented she required one staff member's assistance with her ADLs. R11's Care Plan dated 03/17/24 documented she preferred to be offered showers or bed baths twice weekly and as needed. The plan of care documented R11 occasionally refused her showers. R11's EMR under the Reports tab and Bathing task was reviewed for the following dates 01/01/25 to 03/03/25 (61 days). The EMR documented one Shower (SH) or Baths (B) on 01/11/25 and one Resident Refused (98 resident refused) on 01/01/25. R11's clinical record lacked evidence she was offered or refused care during the 61 days reviewed. The facility had reported there were bath sheets that were not part of R11's medical record. The facility did not provide the bath sheets for R11. On 03/05/25 at 10:26 AM, R11 laid on her bed with the head of her bed elevated. R11's hair appeared oily and uncombed. R11 had reported she had not received a bath/shower yet this week. R11 stated she felt dirty and neglected when she did not receive her scheduled bath. R11 stated the facility still charged her full price for care. On 03/05/24 at 12:24 PM, Certified Nursing Aide (CNA)M stated residents pick the days of the week they prefer bathing. She stated if the facility staff was unable to give bathing due to staffing, the resident would be scheduled the following day. CNA M stated if a resident refuses the shower, the CNA should ask a second time, and report the refusal to the nurse. CNA M stated staff would offer a bed bath or sponge bath. CNA M stated the bath aide documents bathing on a bath sheet, which is given to the director of nursing after the bath sheet was filled out. On 03/05/25 at 12:52 PM, Licensed Nurse (LN) G stated bathing was done by a bath aide twice a week. LN G stated if a resident refused the CNA would let the nurse know. The LN would visit with the resident and offer a sponge bath or bed bath. LN G stated bathing was documented in the residents' EMR. On 03/05/25 at 01:16 PM, Administrative Nurse D stated residents were offered two showers a week. She stated if a resident did not get their scheduled shower on the day the shower was scheduled, the nurse would visit with the resident and set up a time on a different day. Administrative Nurse D stated if a resident had not received a shower for multiple days or refused bathing consistently that information would be directed to the director of nursing. Administrative Nurse D stated the bath aide fills out a bath sheet, the sheets are given to the director of nursing to review. She stated nursing was to chart refusals. The CNA would chart showers given and refusals in the residents' EMR. Administrative Nurse D stated she was aware of a few residents' showers not being given due to refusals. The facility's Activities of Daily Living policy undated documented the facility provides each resident with care, treatment, and services according to the resident's individualized care plan. Based on the individual resident's comprehensive assessment, facility staff would ensure each resident's abilities in activities of daily living to not diminish unless circumstances of the resident clinical condition demonstrate that the decline was unavoidable, including bathing, dressing grooming transferring, locomotion, ambulation, toileting, eating, and communication. The facility failed to provide consistent bathing for R11. This deficient practice had the risk of poor hygiene and decreased self-esteem and dignity. 45668 - The Medical Diagnosis section within R15's Electronic Medical Records (EMR) included diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), morbid obesity (excessive body fat), and type two diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R15's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she required substantial to maximal assistance with toileting, transfers, bed mobility, dressing, and bathing. The MDS noted she was frequently incontinent of the bladder and always incontinent of the bowel. The MDS noted she had moisture-associated skin damage (MASD). R15's Functional Abilities Care Area Assessment (CAA) completed 04/03/24 indicated she was dependent on two staff for assistance with her activities of daily living (ADL). The plan noted she would work with therapy to improve her strength and transfer abilities. R15's Urinary Incontinence CAA completed 04/03/24 indicated she was at risk for impaired skin and pressure injuries related to her immobility and incontinence. The plan noted that the staff was to provide peri-care after each incontinent episode. R15's Care Plan initiated 07/21/22 indicated she had an ADLs deficiency related to her medical diagnoses. The plan noted she was dependent on staff assistance for bathing, toileting, dressing, personal hygiene, bed mobility, and transfers (07/21/22). The plan noted she refused all her treatments, therapies, and care (11/08/22). The plan noted that R15 had chronic moisture-associated skin damage due to her immobility and medical diagnoses (12/19/24). R15's Documentation Survey Report revealed her last documented bathing opportunity occurred on 02/01/25. R15's EMR under Tasks revealed no bathing opportunities occurred within the last 30 days reviewed. R15's Progress Notes under Alert Note revealed a note dated 01/24/25. The note revealed she was provided a bed bath by two staff members. No other progress notes revealed bathing. On 03/03/25 at 09:00 AM, R15 lay in her bed. Her bed was in the low position with her bedside table pulled to her left side. R15's hair and skwere greasy. Her hair uncombed. Her room smelled of body odor. R15 reported she felt dirty and unclean due to the facility not providing her bathing for the last month. She stated staff would provide peri-care but would not get her up for showering or bathing. She stated she had no current skin issues but has in the past due to not being bathed properly. On 03/05/24 at 12:24 PM, Certified Nursing Aide (CNA) M stated residents pick the days of the week they prefer bathing. She stated if the facility staff were unable to complete bathing due to staffing, the resident would be scheduled the following day. CNA M stated if a resident refused the shower, the CNA should ask a second time, and report the refusal to the nurse. CNA M stated staff would offer a bed bath or sponge bath. CAN M stated the bath aide documents bathing on a bath sheet, which was given to the director of nursing after the bath sheet was filled out. On 03/05/25 at 12:52 PM, Licensed Nurse (LN) G stated bathing was done by a bath aide twice a week. LN G stated if a resident refused the CNA would let the nurse know. The LN would visit with the resident and offer a sponge bath or bed bath. LN G stated bathing was documented in the resident's EMR. On 03/05/25 at 01:16 PM, Administrative Nurse D stated residents were offered showers twice a week. She stated if a resident had not gotten their scheduled shower on the day the shower was scheduled, the nurse would visit with the resident and set up a time on a different day. Administrative Nurse D stated if a resident does not receive a shower for multiple days or refuses bathing consistently that information would be directed to the director of nursing. Administrative Nurse D stated the bath aide fills out a bath sheet, the sheets are given to the director of nursing to review. She stated nursing was to chart refusals. The CNA would chart showers given and refusals in the residents' EMR. Administrative Nurse D stated she was aware of a few residents' showers not being given due to refusals. The facility's Activities of Daily Living policy (undated) documented the facility provides each resident with care, treatment, and services according to the resident's individualized care plan. Based on the individual resident's comprehensive assessment, facility staff would ensure each resident's abilities in activities of daily living do not diminish unless circumstances of the resident clinical condition demonstrate that the decline was unavoidable, including bathing, dressing grooming transferring, locomotion, ambulation, toileting, eating, and communication. The facility failed to provide consistent bathing opportunities for R15. This deficient practice placed R15 at risk for impaired psycho-social well-being and skin breakdown. 49634 - The Diagnosis tab of R14's Electronic Medical Record (EMR) documented diagnoses of obesity (excessive body fat), diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hemiplegia (paralysis of one side of the body), affecting left nondominant side, muscle weakness, hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), lack of coordination, need for assistance with personal care, cellulitis (bacterial infection of the skin and underlying tissues), and abnormalities of gait and mobility. The Quarterly Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R14 required substantial to maximum assistance for bathing and dressing; and was dependent of staff for toileting. The Annual MDS dated [DATE] documented a BIMS of 15 which indicated intact cognition. The MDS documented R14 had impairment of one side of her body. The MDS documented R14 needed substantial to maximum assistance for bathing and dressing. R14's Care Plan revised on 11/17/24 documented R14 had an activity of daily living (ALD) self-care deficit. R14's plan of care documented she was totally dependent on staff to provide bathing. R14 preferred to receive two showers per week in the daytime, and R14 required one to two staff assistance with her bath. R14's medical record documented R14 did not consistently receive bathing twice weekly from 01/16/25 to 3/2/25 per her choice. On 03/03/25 at 09:24 AM, R14 laid in her bed on her back, with the head of bed raised. R14's room had a distinct urine odor. On 03/03/25 at 09:24 AM, R14 stated she had not gotten a shower for 15 days and was supposed to get a shower on 03/03/25. R14 stated she knew she knew she smelt of urine, and not getting a shower made her feel bad. R14 stated showers get cut when staff was short. On 03/03/25 at 09:24 AM, R14 laid in her bed on her back, with the head of bed raised. R14's room had a distinct urine odor. On 03/05/24 at 12:24 PM, Certified Nursing Aide (CNA) M stated residents pick the days of the week they prefer bathing. She stated if the facility staff was unable to give bathing due to staffing, the resident would be scheduled the following day. CNA M stated if a resident refuses the shower, the CNA should ask a second time, and report the refusal to the nurse. CNA M stated staff would offer a bed bath or sponge bath. CNA M stated the bath aide documents bathing on a bath sheet, which is given to the director of nursing after the bath sheet was filled out. On 03/05/25 at 12:52 PM, Licensed Nurse (LN) G stated bathing was done by a bath aide twice a week. LN G stated if a resident refused the CNA would let the nurse know. The LN would visit with the resident and offer a sponge bath or bed bath. LN G stated bathing was documented in the residents EMR. On 03/05/25 at 01:16 PM Administrative Nurse D stated residents were offered two showers a week. She stated if a resident did not get their scheduled shower, on their shower day, the nurse would visit with the resident and set up a time on a different day. Administrative Nurse D stated if a resident does not receive or shower for multiple days or refuses bathing consistently that information would be directed to the director of nursing. Administrative Nurse D stated the bath aide feels out a bath sheet, the sheets are given to the director of nursing to review. She stated nursing was to chart refusals, and the CNA would chart showers given and refusals in the resident's EMR. The facility's Activities of Daily Living policy undated documented the facility provides each resident with care, treatment, and services according to the resident's individualized care plan. Based on the individual resident's comprehensive assessment, facility staff would ensure each resident's abilities in activities of daily living to not diminish unless circumstances of the resident clinical condition demonstrate that the decline was unavoidable, including bathing, dressing grooming transferring, locomotion, ambulation, toileting, eating, and communication. The facility failed to provide consistent bathing for R14 who required assistance with bathing. This deficient practice placed R14 at risk for complications related to poor hygiene and impaired dignity. - R34's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), mood disorder (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), major depressive disorder (major mood disorder that causes persistent feelings of sadness), hypertension (high blood pressure), muscle weakness, abnormalities of gait and mobility, weakness, 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), and dysphagia (swallowing difficulty). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R34 required substantial to maximum assistance from staff for oral hygiene, toileting, dressing, and showers. The MDS documented R34 required staff touching and cueing for eating. The Admission MDS dated [DATE] documented a BIMS score of one which indicated severely impaired cognition. The MDS documented R34 needed substantial to maximum assistance from staff for bathing and toileting and was independent with eating. R34's Cognitive and Dementia Care Area Assessment (CAA) dated 04/15/24 for R34 had a BIMS score of one, due to a diagnosis of vascular dementia. R34 requires assistance with ADLs and transfers. R34 had a poor appetite. R34's Care Plan dated 04/02/24 documented R34 required the assistance of one staff for participation with bathing. Staff were to offer R34 a shower two times a week and as needed in the evening. R34's plan of care documented she refuses showers occasionally, and bed baths could be offered as an alternative to showers. R34's medical record lacked documentation of any shower given from 01/07/25 to 03/03/25. R34's medical record documented not applicable or refusals for all bathing days from 01/0725 to 03/03/25. On 03/03/25 at 08:28 AM R34 sat in her armed chair. R34 hair was matted on the left side of her head, and ungroomed. On 03/03/25 at 8:55 AM, R34 sat in her armed chair. R34's hair was ungroomed and appeared tangled on the back of her head. On 03/05/24 at 12:24 PM, Certified Nursing Aide (CNA) M stated residents pick the days of the week they prefer bathing. She stated if the facility staff was unable to give bathing due to staffing, the resident would be scheduled the following day. CNA M stated if a resident refuses the shower, the CNA should ask a second time, and report the refusal to the nurse. CNA M stated staff would offer a bed bath or sponge bath. CAN M stated the bath aide documents bathing on a bath sheet, which is given to the director of nursing after the bath sheet was filled out. On 03/05/25 at 12:52 PM, Licensed Nurse (LN) G stated bathing was done by a bath aide twice a week. LN G stated if a resident refused the CNA would let the nurse know, and the LN would visit with the resident and offer a sponge bath or bed bath. LN G stated bathing was documented in the residents ' EMR. On 03/05/25 at 01:16 PM, Administrative Nurse D stated residents were offered two showers a week. She stated if a resident did not get their scheduled shower on the day the shower was scheduled, the nurse would visit with the resident and set up a time on a different day. Administrative Nurse D stated if a resident does not receive a shower for multiple days or refuses bathing consistently that information would be directed to the director of nursing. Administrative Nurse D stated the bath aide fills out a bath sheet, the sheets are given to the director of nursing to review. She stated nursing was to chart refusals. The CNA would chart showers given and refusals in the residents ' EMR. Administrative Nurse D stated she was aware of a few residents ' showers not being given due to refusals. The facility ' s Activities of Daily Living policy undated documented the facility provides each resident with care, treatment, and services according to the resident's individualized care plan. Based on the individual resident ' s comprehensive assessment, facility staff would ensure each resident's abilities in activities of daily living to not diminish unless circumstances of the resident clinical condition demonstrate that the decline was unavoidable, including bathing, dressing grooming transferring, locomotion, ambulation, toileting, eating, and communication. The facility failed to provide bathing and grooming for R34, who required assistance with bathing and grooming. This deficient practice placed R14 at risk for complications related to poor hygiene and impaired dignity.

The facility identified a census of 69 residents. The sample included 18 residents, three medication carts, and one medication room. Based on observation, record review, and interviews, the facility failed to properly label medication in one of the three medication carts. This placed the residents at risk for adverse outcomes or ineffective medication regimens. Findings included: - On 03/05/25 at 09:06 AM the licensed nurse medication cart on the 400 hallway contained one opened, undated insulin (a hormone that lowers the level of glucose in the blood) pen. On 03/05/25 at 09:06 AM, Licensed Nurse (LN) G stated all insulin pens should be labeled once they are removed from the refrigerator and placed into the medication cart. On 03/05/25 at 01:17 PM, Administrative Nurse D stated she expected all insulin pens to be dated and labeled once the pens were opened. The facility failed to provide a policy related to medication storage. The facility failed to properly label medications. This deficient practice could potentially cause adverse consequences or ineffective treatment to the affected residents.

The facility identified a census of 69 residents. The sample included 18 residents, with seven reviewed for unnecessary medications. Based on record review, observations, and interviews, the facility failed to ensure R4's Diclofenac (topical medicated ointment used to treat pain) medication had a dosage administration amount. This deficient practice placed both residents at risk for unnecessary medications and potential side effects. Findings Included: - The Medical Diagnosis section within R4's Electronic Medical Records (EMR) included 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), muscle weakness, aphasia (difficulty speaking), chronic kidney disease, and heart failure. R4's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS indicated she required substantial to maximal assistance with transfers, bed mobility, dressing, toileting, bathing, and personal hygiene. The MDS noted no pain reported during the assessment. The MDS noted she took opioid (a class of controlled drugs used to treat pain) medication. R4's Psychotropic Drug Use Area Assessment (CAA) completed 09/03/24 indicated she took antidepressants (a class of medications used to treat mood disorders). The plan instructed staff to observe for side effects. The CAA noted a care plan was implemented to address the risks of her medications. R4's Care Plan initiated on 04/27/24 indicated she was at risk for pain related to her medical diagnoses. The plan instructed staff to monitor for signs/symptoms of pain and provide treatment. The plan noted she took medications with Black Box Warnings (BBW - the highest safety-related warning that medications can be assigned by the Food and Drug Administration). R4's EMR under Physician's Orders revealed an order dated 10/01/24. The order instructed staff to administer Diclofenac Sodium External Gel topically three times daily to affected areas for pain. The order lacked a dosage for administration. A review of R4's Monthly Medication Review for 11/2024 revealed the Consultant Pharmacist (CP) identified R4's Diclofenac order lacked a dosage and site of application. The CP recommended the facility clarify the dosage amount and location of administration. The facility provided no documented response to the CP's recommendation. On 03/04/25 at 07:30 AM, R4 sat in her wheelchair in her room. R4 was administered her medication but did not want her Diclofenac medication applied. On 03/05/25 at 12:53 PM, Licensed Nurse (LN) G stated all valid medication orders were to include the amount to be administered and the location of the application. On 03/05/25 at 01:16 PM, Administrative Nurse D stated all medication orders should have an accurate dosage amount to be given. She stated Diclofenac should be measured before administration to ensure the correct amount was given. The facility failed to provide a policy related to physician's orders as requested on 03/0625. The facility failed to ensure R4's Diclofenac's order contained a dosage amount to be administered. This placed R4 at risk for unnecessary medications and potential side effects.

The facility identified a census of 69 residents. The sample included 18 residents, with one resident reviewed for hemodialysis (a procedure using a machine to remove excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally). Based on observation, record review, and interviews, the facility failed to consistently monitor and document Resident (R) 54's dialysis (a procedure where impurities or wastes were removed from the blood), shunt for bruit (blowing or swishing sound heard when blood flows through a shunt), thrill (a fine vibration felt that reflects the blood flow by a dialysis resident's shunt), and dressing. This deficient practice placed R54 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R54's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), dialysis hypertension (HTN - elevated blood pressure), unsteadiness on his feet, muscle weakness, need for personal assistance, hearing loss, and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Significant Change Minimum Data Set (MDS) for R54 dated 01/16/24 recorded a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R54 required dialysis during the observation period. R54's Functional Abilities Care Area Assessment (CAA) dated 01/16/24 documented R54 Functional abilities will be addressed in the care plan. R54 required the assistance of one with activities of daily living (ADL) and two persons with transfers due to a fractured shoulder. R54's Care Plan dated 12/10/24 documented R54 required hemodialysis related to end-stage renal disease (a severe and irreversible condition where the kidneys lose their ability to function properly). R54 would have no signs and symptoms of complications from dialysis. Nurses would monitor thrill and bruit to the right upper extremity and obtain vital signs before and after dialysis. R54 would go to dialysis on Mondays, Wednesdays, and Fridays from 10:30 AM to 03:00 PM each dialysis day. Nursing staff were to encourage R54 to go to the scheduled dialysis appointments. R54's EMR under the Orders tab dated 08/04/23 revealed the following physician's order: Dialysis Monday, Wednesday, and Friday at 08:45, check thrill and bruit to right lower extremity, and obtain vital signs (VS) before and after dialysis in the afternoon, every Monday, Wednesday, and Friday for dialysis, dated 12/27/24. R54's EMR lacked documentation or direction for nursing staff to check R54's dressing, bruit, and thrill daily. On 03/03/25 at 07:28 AM, R54 sat in her wheelchair waiting to go to breakfast. R54 was able to communicate with visitors, by using a maker board. On 03/04/25 at 08:00 AM, R54 sat in the dining room waiting for her breakfast with peers. On 03/05/25 at 12:52 PM, Licensed Nurse (LN) G stated nurses do not have a place to document daily monitoring of R54's dressing, bruit, and thrill. He stated he monitored the bruit and thrill daily. LN G stated the bruit and thrill should be monitored daily, and nursing should document the bruit and thrill were monitored daily. On 03/05/25 at 01:16 PM, Administrative Nurse D stated she thought the dressing, bruit, and thrill were monitored before and after dialysis days, and that information was documented on the dialysis communication sheet. Administrative Nurse D was unsure if the bruit and thrill were monitored or documented on the days R54 did not go to dialysis. She stated that information would be documented on the Treatment Administration Record (TAR). The facility's dialysis communication policy failed to cover the access site monitoring. The facility failed to consistently monitor and document R54's dialysis shunt for bruit, thrill, and dressing. This deficient practice placed R54 at risk of potential adverse outcomes and physical complications related to dialysis.

The facility identified a census of 69 residents. The sample included 18 residents, with three residents reviewed for treatment/services to prevent/heal pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 24's heels were offloading, heel protectors were applied to both heels and further failed to monitor R24's low air loss mattress. This placed R24 at increased risk for developing pressure ulcers. Findings Included: - R24's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of heart failure (a condition with low heart output), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a 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), effecting the left no-dominant side, muscle weakness hypertension (high blood pressure), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of one which indicated severely impaired cognition. The MDS documented R24 was not at risk for developing pressure ulcers. The MDS documented R24 had a pressure-reducing device in her chair, a pressure-reducing device in her bed, nutritional and hydration interventions to manage skin problems, moisture-associated skin damage, and application of ointment or dressing to feet. The Significant MDS dated [DATE] documented a BIMS score of one which indicated severely impaired cognition. The MDS documented R24 was not at risk for developing pressure ulcers. The MDS documented R24 had a pressure-reducing device in her chair, a pressure-reducing device in her bed, nutritional and hydration interventions to manage skin problems, moisture-associated skin damage, and application of ointment or dressing to feet. R24's Pressure Ulcer/ Injury Care Area assessment dated [DATE] documented R24 had a risk for pressure due to impaired mobility, needing assistance to reposition has a Foley catheter (a tube inserted into the bladder to drain urine into a collection bag), pain, depression, dementia, and end of life care. R24's pressure injury would be addressed in the care plan. R24's Care Plan revised 02/08/21 documented R24 had potential impairment to skin integrity. Staff were to monitor and document the location, size, and treatment of skin injury, and report abnormalities of skin. R24's plan of care lacked documentation for staff to monitor R24's low air loss mattress. R24's Braden Scale for Prediction Pressure Sore Risk dated 02/23/25 documented a score of 13 indicating a moderate risk for pressure ulcers. R24's EMR under the Vitals and Weights tab documented a weight of 116.00 on 02/01/25. R24's low air loss mattress Drive manufactures recommendation indications document low air mattress should be set at person's weight. R24's Weekly Wound assessment dated [DATE] documented R24 had no skin issues. R24's physician's orders under the Orders tab revealed the following orders: Barrier cream to bottom areas every shift for preventative care dated 01/06/25. Left lateral malleolus (and expanded projection at the distal end of the fibula or tibia at the level of the ankle) apply Skin-prep (liquid skin protectant) twice daily related to redness and preventative 11/13/12. Heel protectors worn to bilateral feet while in bed daily as tolerated every shift while in bed 11/05/24. Offload heels daily while in bed every shift while in bed for redness dated 11/05/24. On 03/03/25 at 07:25 AM, R24 laid on her bed, R24's Low air loss mattress was set at 350 pounds. R24's heels laid directly on the mattress. R24's heels were not floated, and she did not have heel protectors. On 03/05/25 at 12:25 PM, Certified Nurse's Aide (CNA) M stated it would be all nursing duties to ensure residents' heels are floated or boots applied to heels. She stated staff ensured the mattress was plugged in. CNA M stated she was unsure what the mattress dial should be set on. On 03/05/25 at 12:52 PM, Licensed Nurse (LN) G stated all nursing staff check to ensure the mattresses are plugged in. LN G stated he does not monitor the mattress and was unsure what the mattress should be set at. He stated when the mattresses were put in place, the mattress was set, and nursing staff ensured the mattress was working. LN G stated nurses ensured residents had their heels floated. On 03/05/24 at 01:16 PM Administrative Nurse D stated she was unsure how low air loss mattresses were set. Administrative Nurse D stated it was all nursing staff's responsibility to ensure residents' heels are floated. She stated heels to be floated should be on the care plan, and orders should be on the Treatment Administration Record (TAR). The facility's Pressure Injury Prevention policy revised 02/22 documented the facility would implement and develop a plan to meet the needs of each resident. The facility would include the consideration of mechanical support surfaces, nutrition, hydration, positioning, mobility continence, skin condition, and overall clinical condition of the resident. The goal would be for the resident to be free of preventable pressure ulcers and injuries. The facility failed to ensure R24's heels were offloading, and heel protectors were applied to both heels and further failed to monitor R24's low air loss mattress. This placed R24 at increased risk for developing pressure ulcers.

The facility identified a census of 69 with 18 residents included in the sample. The facility identified 12 residents who were discharged from Medicare Part A services. Based on interview and record review the facility failed to issue CMS (Center for Medicare/Medicaid Services) Skilled Nursing Facility Advance Beneficiary Notification (SNF ABN) form 10055 (the form used to notify Medicare A participants of potential financial liability when a Medicare Part A episode ends) for Resident (R) 63. This failure placed the residents at risk for decreased autonomy and impaired decision-making. Findings included: - Review of R63's Electronic Medical Record (EMR) documented that the Medicare Part A episode began on 11/13/24 and ended on 012/06/24. R12 remained in the facility for custodial care. The facility was unable to provide evidence that staff issued the SNF ABN 10055. On 03/02/25 at 11:25 AM, Social Service X stated she had never given an SNF ABN for residents ending Medicare part that were staying in the facility. She stated she was not trained to give SNF ABN. The facility's Skilled Nursing Facility Advanced Beneficiary Notice undated policy documented The SNF ABN provides information to the patient to enable the patient to decide whether to get that care that may not be paid for by Medicare and assume financial responsibility. The facility failed to ensure the forms provided at the end of skilled services contained the required information for the residents to make informed choices and appeal the non-coverage decisions. This failure placed the residents at risk for decreased autonomy and impaired decision-making.

The facility reported a census of 69 residents. The sample included 18 residents, with one reviewed for personal funds. Based on record review, interviews, and observations, the facility failed to prevent unnecessary charges to Resident (R) 218 bank account resulting in multiple charges to his bank account. This deficient practice placed R218 at risk for misappropriation of funds. Findings Included: - The Medical Diagnosis section within R57's Electronic Medical Records (EMR) included diagnoses of Chronic obstructive pulmonary disorder (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), senile degeneration of the brain, and dementia (a progressive mental disorder characterized by failing memory and confusion). R218's EMR indicated he was admitted to the facility on [DATE]. R218's Admission Minimum Data Set (MDS) completed 09/19/24 noted a Brief Interview for Mental Status (BIMS) score of seven indicating severe cognitive impairment. The MDS noted he was admitted to the facility for hospice services. R218's Dementia Care Area Assessment (CAA) completed 09/22/24 indicated he had severe cognitive impairments and communication issues. The CAA noted a care plan will be implemented to address his needs. R218's EMR indicated he was discharged from the facility on 09/25/25. R218's Care Plan initiated on 09/12/24 indicated he was admitted to the facility and wished to remain in the long-term care unit. R218's EMR under Census revealed his payor source was private pay. R218's EMR under Miscellaneous revealed R218's Admission Agreement indicated that the facility was aware he received Medicaid/Medicare services. A review of the facility's Service Invoice (dated 09/30/24) for R218's services revealed his bank account was successfully charged $1850.00 on 09/09/24 for his services in September 2025. A review of the facility's Service Invoice (dated 11/30/24) for R218's services revealed his bank account was billed $2,494.73.00 for his services in September 2024. A review of the facility's Service Invoice (dated 12/15/24) for R218's services revealed his bank account was billed $215.27 for his services in September 2024. A review of the facility's Service Invoice (dated 02/28/25) for R218's services revealed his bank account was charged $2,279.46 on 02/10/25 but was declined due to insufficient funds. On 03/04/25 at 10:01 AM, R218's representative reported the facility charged his personal account $1650.00 in September 2024. She reported the facility then attempted to withdraw $2400.00 but the transaction was declined due to insufficient funds. She reported the facility debited $293.00 in December 2024. She reported the facility attempted to debit his account $2200.00 in January 2024 but the transaction was declined due to insufficient funds. R218's representative stated she reported the transactions to the state agency in February 2025. R218 representative stated she informed the facility. R218 was admitted to the facility on Medicaid under hospice services. She stated the services should have been covered under Medicaid/Medicare services. She stated she provided the facility with a copy of his Medicaid/Medicare eligibility. On 03/05/25 at 10:22 AM, Administrative Staff B stated that R218's billing code was set up incorrectly which resulted in the inappropriate charging of his bank account. She stated the facility would reimburse R218's accounts for the error. On 03/05/25 at 01:34 PM, Administrative Staff A stated R218 was admitted on both hospice pay and private pay at the facility. Administrative Staff A stated that may have caused him to be billed incorrectly. The facility failed to provide a policy related to resident personal funds as requested on 03/05/25. The facility failed to prevent unnecessary charges to the R218 bank account resulting in multiple charges to his bank account. This deficient practice placed R218 at risk for misappropriation of funds.

The facility identified a census of 69 residents. The sample included 18 residents, with two residents sampled for reasonable accommodations of needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 24's call light was within her reach and further failed to provide foot pedals for R25 while pushing her in the hall. This deficient practice left R24 vulnerable to unmet care needs due to the inability to call for staff assistance and placed R25 at an increased risk for preventable falls and injuries. Findings Included: - R24's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of heart failure (a condition with low heart output), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following a cerebral infarction (stroke - the 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), effecting the left nondominant side, muscle weakness hypertension (high blood pressure), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and dementia (a progressive mental disorder characterized by failing memory and confusion). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of one which indicated severely impaired cognition. The MDS documented R24 was dependent on staff for bathing and toileting. The MDS documented R24 had not had a fall during the observation period. The Significant MDS dated [DATE] documented a BIMS score of one which indicated severely impaired cognition. The MDS documented R24 was dependent on staff for bathing and toileting. The MDS documented R24 had a non-injury fall during the look-back period. R24's Falls Care Area Assessment (CAA) dated 05/24/24 documented R24 was at risk for falls and was dependent on staff for activities of daily living (ADL) and transfers. R24 CAA documented she had weakness due to hemiparesis/hemiplegia, was incontinent of bowel, had a Foley catheter, and had confusion. R24's Care Plan dated 03/05/21 documented R24 was at risk for falls, staff were to place a Dycem (non-slip mat used for stabilization and gripping to prevent slipping) in her recliner and wheelchair to help prevent slipping. R24's plan of care dated 12/26/24 documented staff were to ensure that R24 was positioned away from the edge of the bed and staff were to ensure her call light was within reach and encourage the resident to use it for assistance as needed. On 03/03/25 at 07:25 AM, R24 laid on her bed asleep. R24's call light was placed at the back of her legs; the call light was out of her reach. On 03/05/25 at 12:25 PM, Certified Nurse's Aide (CNA) M stated call lights should always be placed on a resident's side, clipped to their clothing, and always within their reach. On 03/05/25 at 12:52 PM, Licensed Nurse (LN) G stated all nursing staff checked to ensure residents' call lights were within the residents' reach. He stated some of the residents had specific places they liked the light placed. On 03/05/24 at 01:16 PM, Administrative Nurse D stated call lights should be within the resident's reach. The facility failed to provide an accommodations of needs policy. The facility failed to ensure R24's call light was within her reach. This deficient practice left R24 vulnerable to unmet care needs due to the inability to call for staff assistance. 45668 - The Medical Diagnosis section within R25's Electronic Medical Records (EMR) included diagnoses of acute respiratory failure, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), need for assistance with personal cares, unsteadiness of feet, and catatonic disorder (rare mental disorder that caused immobility, inability to communicate, and abnormal movements). R4's Admission Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of two indicating severe cognitive impairment. The MDS indicated she required substantial to maximal assistance from staff for toileting, bathing, dressing, bed mobility, and bathing. The MDS was unable to determine if she had a history of falls. R4's Falls Care Area Assessment (CAA) completed 12/03/24 indicated she was at risk for falsl related to her impaired gait and cognitive impairment. The CAA noted she used a wheelchair but could ambulate without assistance. The CAA noted a care plan was implemented to address her risks. R4's Care Plan initiated 12/15/24 indicated she was at risk for falls related to her impaired balance and poor safety awareness. The plan noted she required staff assistance with transfers, dressing, bed mobility, bathing, and toileting. The plan noted she had limited mobility and weakness. The plan noted she used a wheelchair for mobility but required staff assistance while walking. The plan noted she had one non-injury fall related to her being dizzy. On 03/03/25 at 08:10 AM, R4 sat in her wheelchair in the hallway next to her room. R4 wheelchair had no foot pedals. R4 had tan rubber-soled shoes on her feet. At 08:11 AM unidentified staff pushed R4 from the hallway to the dining hall table next to the kitchen's drink station. R4's feet slid on the floor as staff pushed her. On 03/03/25 09:30 AM, R4 was moved away from the dining room to her room for toileting assistance. R4's feet slid on the floor as staff pushed her to her room. On 03/05/25 at 11:30 AM, Certified Medication Aide (CMA) R stated some of the residents preferred not to have foot pedals on their wheelchairs, but their feet should never touch the ground while being pushed. She stated cognitively impaired resident must have foot pedals on to prevent falls during motion. On 03/05/25 at 01:16 PM, Administrative Nurse D stated staff were expected to put the foot pedals on before pushing the residents. The facility's Fall Prevention policy (undated) indicated the facility was to implement and provide preventative interventions to prevent potential accidents. The policy indicated the facility was to promote a safe environment to ensure resident safety. The facility failed to ensure the use of wheelchair foot pedals for R4 while being pushed in her wheelchair. This placed the resident at risk for preventable accidents and injuries.

The facility reported a census of 43 residents with three residents reviewed for accidents. Based on observations, interviews, and record reviews, the facility failed to ensure one resident remained free of accident hazards related to mechanical lift transfers when Resident (R) 1 obtained an injury on 11/15/24 at approximately 07:00 PM when an unknown staff member failed to safely operate the mechanical lift and transferred the resident without another staff member present. This deficient practice resulted in a fracture (broken bone) of R1's left patella (kneecap). Findings included: - Review of the Electronic Health Record (EHR) for R1 included diagnoses of cerebral palsy (a progressive disorder of movement, muscle tone or posture caused by injury or abnormal development in the immature brain, most often before birth), diabetes mellitus type two (DM2 - when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), blindness, and restless leg syndrome (RLS - a disorder that causes an overwhelming urge to move one's legs). The Annual Minimum Data Set (MDS), dated [DATE] documented a Brief Interview of Mental Status score of 14, which indicated intact cognition. The assessment documented the resident utilized a wheelchair for locomotion and was dependent on staff for transfers. The Activity of Daily Living (ADL) Functional / Rehabilitation Potential Care Area Assessment [CAA], dated 06/16/24 triggered for further development/review, but was not completed. The Quarterly MDS, dated [DATE] documented a Brief Interview of Mental Status score of 14, which indicated intact cognition. The assessment documented the resident utilized a wheelchair for locomotion and was dependent on staff for transfers. The 12/29/24 Care Plan documented on 06/13/19 R1 had an ADL deficit related to diagnoses of cerebral palsy and blindness and documented R1 required a mechanical lift with two-person assistance for transfers. The Care Plan lacked documentation or intervention related to the injury obtained on 11/15/24. The Progress Notes documented: On 11/15/24 at 08:15 PM, R1 complained of pain to both knees and the left was more painful than the right. The writer documented that R1's knees popped when R1 was being transferred with a mechanical lift. R1 requested to be sent to the Emergency Department (ED) for further evaluation and was transferred to the hospital via Emergency Medical Services (EMS). On 11/16/24 at 01:50 PM, the facility received notification from the ED where R1 was sent that R1 had sustained a non-displaced fracture of the left patella, and the facility notified the resident and the resident's physician. During an interview on 01/08/25 at 12:23 PM, R1 revealed on 11/15/24 at approximately 07:00 PM, one unknown staff member assisted her with the use of a mechanical lift. R1 revealed the unknown staff member was impatient and did not want to wait for a second staff member to assist. R1 stated during the lift procedure her legs hit an unknown metal object, she felt a pop, and immediately felt pain. R1 revealed after the lift procedure was completed, she was evaluated by the nurse and requested to go to the ED for further evaluation and treatment. R1 reported the ED initially diagnosed her knee injury as a sprain but called the next day to report a fracture of the left patella. During an interview on 01/08/25 at 01:39 PM, Certified Nurse Aide (CNA) D revealed staff should always utilize two staff members when operating a mechanical lift, one to operate the controls, and the other to ensure the resident remained safe. During an interview on 01/08/25 at 01:55 PM, CNA E revealed staff should always utilize two staff members when operating a mechanical lift and that no exceptions existed where one staff member could safely operate the lift without a second staff member present for safety reasons. During an interview on 01/08/25 at 01:57 PM, Licensed Nurse (LN) F revealed for safety reasons, staff should always utilize two staff members when operating a mechanical lift. LN F revealed that if one CNA had a resident hooked up to the mechanical lift and a second staff member was unavailable, that the staff member should contact the nurse on duty who would assist with the transfer. During an interview on 01/08/25 at 01:59 AM, Administrative Nurse C revealed the expectation was for two staff members to be present to complete mechanical lift transfers, one to operate the controls and the other to ensure resident safety as documented in R1's care plan. The facility's Safe Lifting and Movement of Residents policy, dated 12/2024, documented that staff responsible for direct resident care would be trained in the use of mechanical lifting devices. The policy lacked direction regarding the safe/appropriate use of mechanical lifting devices. The facility failed to ensure R1 remained free of accident hazards related to mechanical lift transfers when R1 obtained an injury on 11/15/24 at approximately 07:00 PM when an unknown staff member failed to safely operate the mechanical lift. This deficient practice resulted in a fracture of R1's left patella and had the potential to negatively affect the physical and psychosocial well-being of the resident.

The facility reported a census of 65 with three of residents selected for reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to ensure a safe and secure environment to prevent the elopement of cognitively impaired R1, identified at risk for elopement. On 05/07/24 at 09:40 AM a CNA M let R1 out the front doors of the building. CNA M thought R1 had an appointment and was leaving to get on the facility transport vehicle. When R1 went out the doors his WanderGuard caused an alarm to activate, and CNA M did not check which resident caused the alarm. The facility did not know R1 was not in the building until almost 15 minutes later when a staff member driving by the facility saw the resident outside, unsupervised, and notified the facility. Staff found the resident approximately 90 feet from the facility, heading toward a highly trafficked, 4 lane road. These failures placed R1 in immediate jeopardy. Findings included: - Review of the resident's Electronic Health Record (EHR) revealed Resident (R)1 had diagnoses which included paraplegia, (paralysis characterized by motor or sensory loss in the lower extremities), cognitive communication deficit (an impairment in organization, sequencing, attention, memory planning, problem-solving, and safety awareness), reduced mobility (difficulty with movement), and chronic pain syndrome (pain that last over three months). Review of R1's Quarterly Minimum Data Set (MDS) dated [DATE], revealed R1 had a Brief Interview for Mental Status score of 10, which indicated moderately impaired cognition. The resident did not wander and had no falls during the look back period. R1 required assistance with bathing, transfers, and dressing. Review of R1's Care Plan dated 05/28/23, with a revision date of 09/13/23, revealed R 1 had an elopement risk, wandered, had attempted to leave the facility, and voiced desire to leave. R1 required frequent monitoring by staff. The care plan stated R1 had impaired cognitive function/dementia or impaired thought process. The care plan further revealed the resident had limited physical mobility and used a wheelchair for locomotion and the resident could go outside with staff supervision only. On 09/23/2023 the care plan informed staff that R1 had attempted to get out of the door in his wheelchair when he sat in front of the door and waited for it to open and occasionally voiced a desire to leave the facility. R1's WanderGuard was replaced on his wheelchair on 02/19/24. Review of the Elopement assessment dated [DATE], identified the resident as cognitively impaired, but not independently mobile. Review of the Nurse's Note dated 05/07/24, revealed at 09:40 AM, Certified Nurse Aide (CNA) M let R1 out the front door (of the facility). At 09:45 AM, Administrative Staff C and Dietary Aide BB reported they saw the resident sitting outside of the front door at a table. At 09:55 AM, an unidentified facility staff member no longer saw the resident sitting at the table. CNA N called the facility and talked to CNA O to let her know the resident was wheeling down the street in front of the facility toward the 4-lane street that runs along the side of the facility. CNA O brought the resident back into the facility. Review of the undated facility Incident and Investigation revealed R1 exited the community and wheeled himself down the sidewalk. A staff member saw him and called another staff member at the facility to go get him. The resident was located at the corner of the facility. The investigation further revealed CNA M let R1 out of the front door of the facility as she thought he was going on the transportation vehicle parked in the front of the building. The investigation verified the resident's WanderGuard sounded when triggered at the door of the facility. Review of the 05/07/24 at 10:00 AM Nurse's Note revealed the facility completed an assessment of the resident with no injuries noted. Observation of the resident on 05/15/24 at 09:00 AM, revealed the resident sat in bed with the head of the bed up and watching TV. No wandering behaviors were observed at that time. Observation of the resident on 05/15/24 at 02:10 PM, revealed the resident continued to lay in bed in his room with no behaviors noted. Observation of the area around the facility where the resident left the facility, unsupervised, revealed the resident mobilized toward a busy 4-lane road with speed limits posted at 30 miles per hour. During an interview with R1 on 05/15/24 at 11:21 AM, the resident stated that when he would get to close to the front door, an alarm would go off. The resident stated he had family that lived in another town and that he planned to move to be closer to family. The resident reported he did not remember the day he left the facility and stated his days run together. During an interview on 05/15/24 at 12:08 PM with CNA O, she reported when the resident was outside of the facility, she was in the shower room with another resident. CNA N called CNA O and reported R1 was on the sidewalk heading toward the 4-lane road on the side of the building. CNA N stated she was on break and was driving so she could not stop to get the resident. CNA O went outside and found R1 about 10 feet away from the crosswalk beside the facility. During an interview on 05/15/24 at 12:17 PM with Administrative Nurse D, revealed her expectation was for the staff to know who the residents were that had a risk for elopement. Administrative Nurse D further expected staff to know which residents had a WanderGuard, the location of the elopement book/policy, and if the alarm went off to look for the resident that caused the alarm to sound. Review of the Wunderground.com/accuweather.com report for 05/07/24 at 09:55 AM revealed an outside temperature at the time the resident left the facility and returned to the facility measured 68 degrees Fahrenheit. Review of the 05/23 Elopement Policy revealed it is the policy of the facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. The facility failed to ensure a safe and secure environment to prevent the elopement of cognitively impaired R1, identified at risk for elopement, when on 05/07/24 at 09:40 AM, CNA M let R1 out the front doors of the building, unsupervised. The resident remained out of the building without staff knowledge or supervision for approximately 15 minutes and was found headed toward a busy 4-lane road. On 05/15/24 at 03:31 PM, a copy of the immediate jeopardy (IJ) template was provided to Administrative Staff A and Administrative Nurse D and E for the failure to ensure the safety of R1 when he left the facility, unsupervised, and without staff knowledge. The deficient practice was cited as past non-compliance as the facility implemented the following corrective actions beginning on 05/07/24: 1. The facility located R1 and brought him back to the building. A skin assessment was performed by the Director of Nursing, with no issues found. A WanderGuard was found in place and functioning at the time of the event. R1's Physician and Durable Power of Attorney were notified of the event. Elopement evaluation completed and care plan reviewed. 2. A headcount of all residents was performed. 3. Community review of all residents at risk for elopement was completed on 05/07/24 by the Director of Nursing and Assistant Director of Nursing. Residents identified as having the potential to be affected were evaluated for elopement risk by the Assistant Director of Nursing. 4. Care plan review of residents identified as having the potential to be affected was completed on 05/07/24 by the Assistant Director of Nursing to verify prevention interventions were in place as indicated. 5. Current associates were re-educated by the Assistant Director of Nursing and/or designee on the community Elopement Policy and the community Elopement Evaluation process on 05/07/24. Associates who had not completed the required education on 05/07/24 were required to complete education prior to working their next scheduled shift. 6. An ADHOC QAPI meeting was completed with the community interdisciplinary team on 05/07/24. 7. The facility Medical Director was notified of elopement on 05/07/24 and further notified of the facility compliance plan. 8. Exit doors were evaluated and noted to be functioning without discrepancy. Front door code changed and communicated to the staff. 9. Residents identified with a new risk for elopement or change in elopement risk will be reviewed by clinical/interdisciplinary team during routine clinical huddle to verify elopement risk assessment accuracy, provider notification, and preventative measures. Due to the corrective measures implemented by the facility prior to the onsite complaint investigation on 05/15/24 and 05/16/24, the deficient practice was deemed past non-compliance. The deficient practice remained at a J scope and severity.

The facility reported a census of 64 residents with three residents identified and reviewed for elopement. Based on interview, observation, and record review the facility failed to provide adequate supervision to prevent cognitively impaired Resident (R)1, with a known history of elopement, from leaving the facility unsupervised and without staff knowledge on 12/31/23 at approximately 06:30 AM. The facility staff did not know R1 was not in the facility until the oncoming nurse, Licensed Nurse (LN) D, asked a Certified Nurse Aide (CNA) G to locate R1. The facility staff could not locate R1 on 12/31/23 at 06:30 AM and LN D started the elopement process. At 07:30 AM, CNA G found R1 outside, at the back of the facility, at the bottom of the concrete stairs. R1 exited the facility through a known malfunctioning exit door in the dark, followed the sidewalk around the building, and attempted to walk down 12 unlit concrete steps, at which time R1 fell and hit his head. When R1 left the facility, the temperature measured approximately 30 degrees Fahrenheit (F) with a wind chill of 20 degrees F. R1 was outside, with his location unknown to staff for approximately 60 minutes in the cold weather. This deficient practice placed R1 in immediate jeopardy. Findings included: - Resident (R) 1's Physician Orders dated 01/03/22 revealed a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The Modification of Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of two, indicating severely impaired cognition, and identified behavior of wandering that occurred daily. R1 was independent with Activities of Daily Living (ADLs). The Quarterly MDS dated [DATE] revealed a BIMS score of three, indicating severely impaired cognition. R1's behavior of wandering was not exhibited on the assessment. The Care Plan indicated R1 was at risk for elopement/wandering, wore a WanderGuard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort), and staff were to check placement and monitor its functioning every shift. Interventions updated on 12/31/23 instructed staff to include R1's picture and information in the elopement book. The Elopement assessment dated [DATE] indicated R1 was cognitively impaired, independently mobile, and had a history of elopement. R1 desired to leave the facility, was exit seeking with a purpose, had a diagnosis of Alzheimer's disease or dementia, and wore a WanderGuard. The Nurses Notes dated 12/31/23 revealed at 06:30 AM Licensed Nurse (LN) D asked Certified Nurse Aide (CNA) G to locate R1. The staff member could not locate R1 and notified LN D. LN D then started the elopement process with a resident head count and LN D instructed the other staff members to walk around the outside of the building to look for R1. LN D then notified Law Enforcement, the director of nursing, and family. At 07:30 AM, CNA G found R1 who fell down 12 concrete stairs at the back of the building. LN D assessed R1, applied a C-collar, and assisted R1 up the stairs to a gurney, where Emergency Medical Service (EMS) transported R1 to the hospital for evaluation and further treatment. The Nurses Note dated 12/31/23 at 11:30 AM, documented R1 returned to the facility from the hospital visit. LN D observed 11 staples at the top of R1's scalp, and abrasions to R1's third, fourth, and fifth knuckles on the right hand. An outside observation on 01/08/24 at 09:25 AM, of the 12 concrete steps in the back of the building where R1 fell on [DATE], revealed the second step from the bottom had gray colored hair attached to the step, which was left from R1's head wound (8 days prior). Observation on 01/08/24 at 11:34 AM, revealed R1 sat in the dining room visiting with family, and R1 had 11 staples on the top of his head. R1's abrasions on his right hand were in the healing process. R1's family member stated R1 had been a wanderer for a long time, and further stated R1 was always an exit seeker. Interview with Administrative Nurse B on 01/08/24 at 10:55 AM revealed the staff checked the WanderGuard system daily to make sure it was functioning properly. Interview with Administrative Staff A on 01/08/24 at 11:00 AM revealed the door at the end of the 200 Hall had been malfunctioning for the last month. Administrative Staff A explained the door did latch properly, but at times the door would bounce off of the door frame and the mag lock would not secure the door closed completely. Interview with CNA G on 01/08/24 at 11:50 AM revealed when she came into work on 12/31/23 at 06:00 AM the charge nurse asked her to locate R1. When she could not locate R1, the charge nurse started the elopement procedure with a head count completed, then CNA G and other staff members started looking for R1. She decided to look around back of the facility and about 07:30 AM she found R1 outside at the bottom of the concrete stairs to the basement. Interview with LN D on 01/08/24 at 12:30 PM revealed during the morning report R1 usually wandered around the facility and was not wandering around at that time, so LN D asked CNA G to locate R1. When staff could not locate R1, the elopement procedure was started and staff completed a head count, notified law enforcement, director of nursing, and R1's family. The other staff members in the facility attempted to help locate R1. CNA G found R1 at the bottom of the basement steps behind the facility. R1 received an injury to the top of his head, which required 11 staples. The facilities Elopement Policy dated 2002 revealed all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified with have these issues addressed in their individual care plans. The Purpose of this policy missing residents shall be defined to mean a resident who has left the facility grounds without signing him/herself out of the facility. Resident who are at risk for elopement shall be provided at least one of the following safety precautions by the facility. Door alarm on facility exit and or a personal safety device that will alert facility staff when the resident has left the building without supervision and or staff supervision. Maintenance will check all door alarms for proper function on a weekly basis. The facility failed to provide adequate supervision to prevent cognitively impaired R1 with a history of elopement from leaving the facility unsupervised and without staff knowledge. R1 exited the facility unsupervised, in the dark, and fell down 12 concrete steps causing a laceration to the head, which required 11 staples to close. This failure placed R1 in immediate jeopardy. On 01/08/24 at 05:01 PM Administrative Staff A and Administrative Nurse B were provided the Immediate Jeopardy Template. The facility identified and implemented the following corrective action on 12/31/23 which included: 1. On 12/31/23 at 07:40 AM, all staff received re-education regarding the facility elopement policy and elopement evaluation. The facility completed training on 01/01/24 at 02:30 PM. 2. The facility identified residents at risk for elopement and an assessment was completed on those residents. 3. A QAPI meeting was completed with the community interdisciplinary team on 12/31/23 at 10:30 AM. 4. Medical director notified of the event on 12/31/23 at 10:00 A 5. Exit doors were evaluated on 12/31/23 and safeguards were placed for staff supervision at the 200 Hall exit door to verify function of door and resident safety on 12/31/23. On 01/01/24 at 10:00 AM the facility had the Mag locking system to secure the 200 hall exit door evaluated. 6. The WanderGuard system and alarms were checked and validated for proper function on 12/31/23 at 09:30 AM with no discrepancies identified. 7. Routine elopement drill's will be scheduled per community policy on varying shifts to confirm staff competency, 8. Quality Assurance plan to monitor facility compliance Director of Nursing will report trends identified with routine reviews to the community QAPI committee for 3 months. Then the QAPI committee will re-evaluate the need for continued monitoring. The surveyor verified the facility implemented the above corrective actions prior to the onsite survey. Therefore, the deficient practice was deemed past noncompliance at a scope and severity of J.

The facility reported a census of 57 residents with three sampled for elopement. Based on observation, interview, and record review, the facility failed to ensure staff provided a safe and secure environment for cognitively impaired Resident (R)1. On [DATE] at approximately 07:05 AM, Licensed Nurse (LN) I walked in the front doors of the facility to report for her shift while R1 walked out of the front doors. LN I assumed R1 was a visitor or employee. The facility staff did not realize R1 was missing until 07:45 AM (40 minutes later), at which time the facility staff began searching for R1. Around 10:00 AM the family notified the facility R1 was found deceased by the train tracks at approximately 08:30 AM, after being struck by a train. R1 had walked approximately eight city blocks away, crossed a busy four lane street/highway with speed limits of 30 miles per hour, and onto heavily trafficked train tracks. This deficient practice placed R1 in immediate jeopardy. Findings included: - Review of R1's Electronic Medical Record (EMR) revealed a diagnosis of small cell lung carcinoma (cancer) with metastases (when cancer had spread to other parts of the body from the original location) to the brain. The Entry Minimum Data Set (MDS), dated [DATE], documented the resident admitted to the facility on [DATE] from an acute care hospital. The Care Plan for cognition, dated [DATE], documented the resident had impaired cognition due to metastatic brain cancer. The Care Plan for behaviors, dated [DATE], instructed staff the resident would occasionally pace in the halls and had difficulty sleeping at times. The Care Plan dated [DATE], lacked staff instruction for monitoring the resident for an elopement risk. Review of the resident's EMR revealed an Elopement assessment, completed [DATE], which indicated the resident was not at risk for elopement. Review of the resident's EMR revealed an incomplete Brief Interview for Mental Status (BIMS-a screening tool used to assess cognition) assessment, dated [DATE]. Review of the resident's EMR and information provided by the facility revealed the following: On [DATE] at 07:05 AM, Licensed Nurse (LN) I reported to work at the facility. As LN I approached the front door of the facility, she witnessed the resident walking out of the building, unaccompanied. During shift report on [DATE] at 07:45 AM, LN I and LN R were in the nurse's station when it was determined the resident had possibly eloped (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness, leaves the facility without the knowledge of staff). LN I and LN R immediately notified all staff, who then conducted a head count of all the residents and searched the premises inside and out for R1. LN I and LN R got into their cars and searched a one-mile radius in opposite directions searching for the resident with no success. On [DATE] at 07:47 AM, LN I notified Administrative Nurse D of the possible elopement. Administrative Nurse D requested the facility call the police department to notify them of the possible elopement. On [DATE] at 07:50 AM, the facility notified the resident's family and durable power of attorney (DPOA) the resident could not be located, and the facility had contacted/notified the authorities. On [DATE] at 08:00 AM, the local police department arrived at the facility and were provided with a printed picture and a detailed description of the resident. The facility staff continued their search for missing resident, R1. On [DATE] at 10:00 AM, the resident's family notified the facility the resident R1 was found deceased . The resident walked down paved, populated streets in a residential area and across a busy four lane highway in which the speed limited was posted at 30 miles per hour, to gain access to the highly trafficked train tracks, about eight blocks away. On [DATE] at 12:18 PM, Activity staff Z stated the resident had confusion. She could walk on her own and was independent. Activity staff Z stated she had never seen the resident attempt to exit the facility on her own, but stated she would not have been able to leave the facility unassisted, due to her confusion. On [DATE] at 12:37 PM, Social Service staff X stated she was responsible for completing the BIMS assessments with residents. When she attempted to complete the assessment with the resident on [DATE], the resident was unable to focus her attention to answer the questions of the assessment. On [DATE] at 01:00 PM, Certified Nurse Aide (CNA) M stated the resident had confusion due to having brain cancer. There had been a few times when the resident stood by the door and looked outside, but no one thought the resident would try to elope. The resident was not considered to be an elopement risk and did not have a wander guard (a device often worn as a bracelet resident's wear which alerts staff when a resident wanders too far or breaches a perimeter). On [DATE] at 01:12 PM, CNA N stated she had not seen the resident the morning of the elopement. CNA N stated the resident was confused but did not have a wander guard. On [DATE] at 10:23 AM, Administrative Nurse E stated the resident was intermittingly confused. Administrative Nurse E stated the door code would need to be entered for someone to open the door to go outside. On [DATE] at 12:28 PM, LN G stated the resident was confused. Her family visited her often and would take her outside to sit. LN G confirmed that staff should be the only ones who know the code to the front door. On [DATE] at 01:34 PM, LN H stated the resident had lung cancer which had metastasized to her brain. The resident was very confused and forgot things quickly. She was able to ambulate around the facility on her own. LN H stated she considered the resident to be at risk for elopement due to her confusion and being able to ambulate independently. LN H stated she had not done an elopement risk assessment with the resident and confirmed the resident did not wear a wander guard at the time of her elopement. On [DATE] at 02:14 PM, LN I stated she reported to work at the facility on [DATE] at 07:05 AM and as she approached the front door, a woman walked out of the door wearing a decorative surgical cap and they exchanged pleasantries. LN I stated she believed the woman was a staff member going outside for a break. LN I did not recognize the woman as a resident as she had not worked at the facility since the resident admitted on [DATE]. While receiving report at 07:45 AM, LN R described the newly admitted resident to LN I. LN I stated it was at that time, she realized the woman who had walked out of the door when she entered, was a resident. LN I stated they immediately did a head count of the residents in the building and then began the search for the resident. LN I stated there was no one in the lobby by the front door who could have opened the door for the resident, and LN I was unsure of how the resident knew the code. LN I stated the facility changed the door code frequently. On [DATE] at 03:02 PM, Administrative Nurse D confirmed the resident had confusion but the elopement risk assessment, completed on [DATE], found her to not be at risk for elopement. Administrative Nurse D stated at approximately 08:30 AM, someone informed them a body had been discovered by the train tracks, but they did not receive confirmation until 10:00 AM from the resident's family. Administrative Nurse D stated the facility began their corrective measures immediately on [DATE] and would complete the education on [DATE]. No staff members were allowed to work until the elopement education was completed. The facility reviewed all of the residents elopement assessments, to ensure accuracy. The facility policy for Elopements, reviewed ,d+[DATE], included: It is the policy of the facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. All residents so identified will have these issues addressed in their individual care plans. The facility failed to ensure staff provided a safe and secure environment for cognitively impaired Resident (R)1. On [DATE] at approximately 07:05 AM, R1 walked out the front door of the facility as LN I arrived for work. The facility staff did not realize R1 was missing for 45 minutes. R1 walked approximately eight city blocks, crossed a busy four lane street/highway with speed limits of 30 miles per hour, and onto heavily trafficked train tracks. Around 10:00 AM R1's family notified the facility she had been found deceased by the train tracks at approximately 8:30 AM. This deficient practice placed R1 in immediate jeopardy. On [DATE] at 04:30 PM Administrative Staff A was provided a copy of the immediate jeopardy (IJ) template and informed of the IJ for failure to ensure the safety of R1 when she left the facility, unsupervised, and without staff knowledge. The deficient practice was cited as past non-compliance as the facility implemented the following corrective actions beginning on [DATE]: 1. The facility reviewed all residents in the facility at risk for elopement to verify preventative interventions were in place, as indicated. 2. Current facility staff were re-educated by Administrative Nurse D/or designee regarding the facility's Elopement policy and Elopement Evaluation process. Staff were required to complete the education prior to working their next scheduled shift. 3. A Quality Assurance Improvement Plan (QAPI) meeting was completed with the interdisciplinary team where the corrective plan was developed on [DATE]. 4. The facility's medical director was notified of the incident on [DATE] at 07:56 AM. 5. The exit doors were evaluated and noted to be functioning without discrepancy. The numerical code to the front door was changed and communicated to the community staff. 6. Any resident identified with a new risk for elopement or change in elopement risk will be reviewed by the clinical interdisciplinary team to verify elopement risk assessment accuracy. The resident's physician will be notified, and preventative interventions will be put into place, as indicated. If discrepancies are identified immediate correction will be completed and one on one education will be completed as indicated. 7. Any resident identified with a change in elopement risk or who have had an elopement attempt will be reviewed during the routine risk meeting by clinical interdisciplinary team. 8. Routine elopement drills will be scheduled periodically on varying shifts to confirm staff competency. Findings of elopement drills will be reported to the facility administrator and reviewed at the following morning meeting. If discrepancies are identified, immediate correction will be completed and one on one education will be provided, as indicated. Due to the correction measures implemented by the facility prior to the onsite complaint investigation on [DATE], the deficient practice was deemed past non-compliance. The deficient practice remained at a J scope and severity.

The facility reported a census of 55 residents with 11 selected for review including three reviewed for risk of elopement (an incident in which a cognitively impaired resident with poor or impaired decision-making ability/safety awareness leaves the facility without the knowledge of staff). Based on observation, record review, and interview, the facility failed to ensure a safe environment for cognitively impaired and independently mobile Resident (R)2, who was identified as at risk of elopement, had a history of elopement, and the facility discontinued her elopement risk interventions. On 09/23/22, R2 exited the facility without staff awareness or supervision and crossed a heavily traveled four lane street. The staff who were outside of the facility on break, observed her and assisted her back to the building. This deficient practice placed the resident in immediate jeopardy. Additionally, the facility identified R8 as an elopement risk and failed to complete 15 minute checks, and identified R9 as an elopement risk and failed to check the wander alarm bracelet (bracelet that sets off an alarm when resident wearing one nears or attempts to exit facility without an escort) for placement and function. Furthermore, upon review of three residents for accident hazards, the facility failed to implement appropriate interventions following falls and failed to investigate all falls for R4. The facility failed to implement new interventions following falls for R3 and failed to investigate all falls, failed to implement fall interventions, and failed to transfer R3 in a safe manner. Findings included: - The Medical Diagnosis tab for R2 included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), muscle weakness, anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), restlessness, and agitation. The Quarterly Minimum Data Set (MDS) dated [DATE], assessed R2 with a Brief Interview of Mental Status Score (BIMS) of two, indicating severe cognitive impairment, and noted R2 did not wander. R2 required supervision and setup help for walking and used a wander/elopement alarm daily. The Annual MDS dated [DATE], assessed R2 with a BIMS score of six, indicating severe cognitive impairment. The MDS noted R2 continued not to wander, was independent with walking, and used a wander/elopement alarm daily. The Activities of Daily Living [ADL] Care Area Assessment (CAA) dated 12/31/22 revealed R2 ambulated throughout the facility independently. The Elopement Assessment -V3 dated 06/21/22 revealed R2 was cognitively impaired and independently mobile and had a history of elopement. Since those items were answered on the assessment, the assessment indicated the resident was at risk for elopement and to proceed with interventions and elopement risk care plan. The assessment revealed discontinued off elopement risk because she acclimated to facility and is no longer exit seeking. The Care Plan dated 12/03/22 revealed R2 ambulated through the facility with no assistive device, was a risk for elopement or to wander, a wander alert device was added on 09/23/22, and the staff added her picture to the elopement book due to her elopement/wandering risk. The care plan history revealed the facility discontinued her elopement risk problem on 08/10/22. The Progress Note dated 09/23/22 at 11:29 AM revealed the staff informed R2's DPOA (Durable Power of Attorney) she left the building this morning after following a visitor out. The staff observed R2 walking down the sidewalk. The staff placed a wander alarm bracelet on her for her safety. The facility Incident Information dated 09/26/22 revealed on 09/23/22 at approximately 09:45 AM the housekeeping staff who were outside on break, discovered R2 walking across the street from the facility, headed towards a park (located across the heavily traveled four lane street). When the staff approached her, R2 stated she was going for a walk and when asked how she got out, R2 stated the lady let me out. The staff brought her back to the facility at 09:50 AM. R2 had been last seen at 09:30 AM holding some clothes and hangers sitting in the common area, which were later discovered on her bed. The facility concluded R2 was let out by a visitor while she was sitting close to the main entrance. The Witness Statement dated 09/23/22 by Administrative Nurse F revealed staff saw R2 walking about in the dining room and the common area about 09:30 AM with clothes hanging over her arm, with the hangers still attached, and R2 spoke to other residents and staff. The Witness Statement dated 09/23/22 by Housekeeping/Maintenance Staff U revealed while outside on break in the back parking lot talking to two other housekeepers, one of the housekeepers asked if that was R2. When the staff looked up, Housekeeping/Maintenance Staff U saw R2 stumble and they ran to R2, who was on the other side of street, south of the facility. R2 told Housekeeping/Maintenance Staff U she was going on a walk and a lady let her out. When brought back inside, the staff applied a wander alarm bracelet to R2. On 01/04/23 at 03:02 PM, observed R2 sitting in the dining room for a facility activity, a she wore a wander alarm bracelet on her left ankle. On 01/04/23 at 03:47 PM observed, with Administrative Staff A, the area the facility staff saw R2 on 09/23/22, when she exited. The street was a four-lane road with a speed limit of 30 miles per hour and heavily traveled. The location R2 crossed lacked a stop sign or traffic light for the four-lane traffic traveling alongside the north of the facility grounds. The park was located across the busy street. On 01/04/23 at 03:50 PM, Administrative Staff A stated a visitor let R2 out but the facility did not know who it was and the facility has a sign posted about not letting anyone out without checking with the staff. On 01/04/23 at 05:03 PM, Administrative Nurse D stated when the staff completed the elopement risk assessment in June 2022, R2 was at risk and to discontinue the elopement interventions was probably not the correct intervention. On 01/05/23 at 09:44 AM, Administrative Staff A stated R2 sat by the front doors before the morning meeting and R2 said she followed a visitor out, so that was how the facility knew R2 went out one the front doors (on 09/23/22). On 01/05/23 at 09:58 AM Housekeeping/Maintenance Staff U stated she was outside on break when she noticed R2 walking across the street, so she ran to get R2. R2 was walking on one street then crossed to the other street and was stumbling trying to step up on the curb. R2 was on the sidewalk when Housekeeping/Maintenance Staff U got to her. R2 went back to the facility with Housekeeping/Maintenance Staff U. R2 had said a lady let her out however, she could not describe her and did not know who she was. Housekeeping/Maintenance Staff U stated as R2 crossed the street there was not any traffic traveling on one road, but there was on their way back to the facility and she had to stop the traffic for her and R2 to cross the street. The facility Elopement Policy undated, revealed using the MDS assessment schedule, all residents are reviewed for safety concerns and precautions. Any residents that are at risk for elopement should be identified and interventions placed in their individual plan of care. Residents at risk for elopement shall be placed in an elopement book located at the reception desk and nurse's stations. This will be updated whenever new resident safety issues are identified. The facility failed to continue with elopement risk interventions for R2, who had severe cognitive impairment and was independently ambulatory, when assessed at risk on the elopement assessment on 06/21/22 and eloped on 09/23/22. This placed R2 at risk for immediate jeopardy. On 01/05/23 at 01:43 PM, Administrative Staff A was informed that they were in immediate jeopardy status and provided the Immediate Jeopardy Template for failure to continue with elopement risk interventions when R2 was at risk per the elopement assessment completed on 06/21/22. R2 eloped from the facility on 09/23/22. The facility completed implementation of the following corrective measures on 09/23/22 at 09:00 PM: 1. Wander alarm initiated to her left ankle. 2. Picture and resident information added to the elopement book. 3. Staff re-educated on elopement policy immediately following the resident's return back to the building, further education provided to staff before the beginning of their shifts. The majority, of staff, received education on 09/23/22. 4. All resident elopement assessments reviewed and updated. 5. R2's care plan reviewed and updated. 6. Maintenance director conducted wander alarm door inspection to all exit doors. The deficient practice with elopement was deemed past non-compliance due to the implemented corrective actions and existed at a J scope and severity. - The Medical Diagnosis tab for R9 included diagnoses of anxiety (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), encephalopathy (the functioning of the brain is affected by some agent or condition such as a viral infection or toxins in the blood), muscle weakness, and abnormalities of gait and mobility. The Admission Minimum Data Set (MDS) dated [DATE] assessed R9 with a Brief Interview of Mental Status (BIMS) score of eight, indicating moderate cognitive impairment, rejected care one to three days, and wandered one to three days. R9 walked in/out of room with supervision and did not require setup assistance from staff, used a walker for mobility and she required a wander/elopement alarm to be used daily. The Activities of Daily Living [ADL] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 10/18/22 revealed R9 ambulated with a walker and the staff supervised as needed. The Care Plan dated 12/03/22 revealed R9 had been seen several times within the area lost and not knowing where she lived or where she was going and had come to the facility for long term care and was finding adjusting difficult. R9 was at risk for elopement and lacked a wander alarm was in place. Staff were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and a book. The Elopement Assessment V-3 dated 09/29/22 revealed R9 was cognitively impaired and independently mobile, had a desire to leave the facility, was exit seeking with a purpose, and had wandering activity. This indicated R9 was at risk for elopement. The Orders tab for R9 lacked instructions for the staff to check for placement and functioning of a wander/alarm bracelet. The Task tab lacked instructions for the Certified Nurse Aides (CNA's) to check for wander alarm placement and functioning. On 01/04/23 at 03:15 PM observed R9 in her room with a wander alarm bracelet in place to her right ankle. On 01/05/23 at 08:46 AM observed R9 ambulating down the hallway on her own using a walker, wander alarm bracelet was in place to her right ankle. On 01/10/23 at 01:57 PM CNA N stated R9 was at risk for elopement and that she had a wander alarm bracelet in place, she has helped put her hose on so knows she has one. CNA N stated the CNA's do not document anything about wander alarms and believed management checks them. CNA N stated R9 wanted to get out of the facility when she first came I but had not witnessed her exit seeking or talking about leaving. On 01/11/23 at 08:53 AM Administrative Nurse D stated each nurse's cart had a device to check the wander alarm bracelet each 12-hour shift and would document the check on the Treatment Administration Record (TAR). Administrative Nurse D stated if a resident had a wander alarm in place it would be on the TAR to check for placement and function, and the wander alarm would be on the care plan. On 01/11/23 at 09:15 AM, Administrative Nurse D stated R9 did not have the wander alarm in place on the TAR to instruct the staff to check for placement and functioning. On 01/11/23 at 09:35 AM, CNA P stated R9 was at risk for elopement and had a wander alarm bracelet in place to her ankle. On 01/11/23 at 02:12 PM, Licensed Nurse (LN) G stated if a resident was an elopement risk, she would let Administrative Nurse A know, get an order from the doctor for a wander alarm bracelet, and would do checks to see if wander alarm was in place and working. When the order comes from the doctor it would be placed on the TAR for the nurses to check every shift or placement and if it is working with the device the facility has to check the wander alarm with. The facility Elopement Policy undated, lacked instructions for checking for placement and function of the wander alarm bracelet. The facility failed to perform checks of the wander alarm bracelet for placement and functioning, which increased the risk of R9, who had moderate cognitive impairment, to exit the facility without staff awareness. - The Medical Diagnosis tab for R8 included a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) with psychotic disturbance (serious illness affecting how one thinks and perceives reality). The Annual Minimum Data Set (MDS) dated [DATE] for R8 assessed him with a Brief Interview of Mental Status (BIMS) score of six, indicating moderate cognitive impairment and did not exhibit wandering. R8 required supervision and setup for walking in/out of the room and used a wheelchair and walker for mobility. R8 did not require a wander/elopement alarm. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 09/26/22 revealed R8 had cognitive loss due to head trauma. The Activities of Daily Living [ADL] CAA dated 09/26/22 revealed R8 was independent with most ADL's but may need assistance of one person with some. The Quarterly MDS dated [DATE], assessed R8 with a BIMS score of seven, indicating severe cognitive impairment, rejected care one to three days, and did not require a wander/elopement alarm. The Care Plan dated 12/03/22 revealed the facility identified R8 as a risk for elopement on 08/31/22. He attempted elopement on 10/27/22 when upset that the staff had not taken him to Walmart. R8 observed the staff leave the facility and thought they were not going to take him, so he decided to go himself. The care plan revealed the staff were to communicate the time they would take him and talk to him if the time needed to be changed. The staff placed R8's picture and resident information in the elopement book. The care plan included on 11/08/22 R8 removed two wander alarm bracelets and would not keep them on and would not allow a third to be placed on his person. The staff were to monitor and document his location in the facility, the nurses every two hours and the aides were to document hourly. The care plan revealed R8 ambulated independently, with or without a device, and would use a wheelchair for mobility or he would walk. The Elopement Assessment V-3 dated 09/23/22 revealed R8 was cognitively impaired and independently mobile and had a desire to leave the facility. This placed the resident at risk for elopement and the staff were to proceed with interventions and an elopement risk care plan. The Task tab instructed staff to Monitor - every one-hour check and revealed from 12/27/22 through 01/16/23 the staff failed to perform hourly checks on 01/04/23, 01/08/23, 01/10/23, and 01/15/23. Each day from 12/27/22 through 01/16/23 revealed hours of the day the staff failed to complete the instructed hourly checks. The Progress Note dated 10/31/22 at 06:36 PM, revealed R8 refused a wander alarm and stated, I decided to stay. Another staff attempted to place a wander alarm and he refused and became agitated. The Progress Note dated 11/08/22 at 04:35 AM, revealed the staff placed a wander alarm on R8 and he removed it stating he would stay there and not try to leave again. On 01/04/23 at 01:50 PM, observed R8 without a wander alarm in place. R8 was in his room resting on his bed. On 01/04/23 at 05:08 PM, Administrative Nurse A stated R8 is not supposed to have a wander alarm bracelet on, he had removed two and refused the third to be placed. The nursing staff was to check him every two hours and instructed them to do so on the Treatment Administration Record. Administrative Nurse A stated R8 walked independently, however, he stayed in his room or close to the nurse's station. On 01/05/23 at 08:20 AM, observed R8 sitting in a wheelchair in the dining room eating breakfast. On 01/10/23 at 01:00 PM, Certified Nurse Aide (CNA) M stated R8 usually eats breakfast in the dining room and has lunch and supper in his room. He will come out of his room if he wants to use the phone and will use the wheelchair to come out of his room but walk on his own in the room. CNA M stated R8 was an elopement risk, and they were to do hourly checks on him and document. CNA M stated she was pretty sure he had a wander alarm bracelet on his ankle. On 01/11/23 at 08:30 AM, observed R8 move himself away from the table in the dining room, move the foot pedals on his wheelchair down, place his feet on the pedals, and propel himself to his room. On 01/11/23 at 08:53 AM, Administrative Nurse A stated she expected the CNA's to complete hourly checks. The facility policy Elopement Policy undated, revealed any residents that are at risk for elopement should be identified and interventions placed in their individual plan of care. The facility failed to follow the care plan by lack of completion of hourly checks for R8, with severe cognitive impairment and assessed at risk for elopement, placing him at increased risk to exit the facility without staff awareness. - The Medical Diagnosis tab for R4 included diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebrovascular disease (reduction of blood flow to your brain or bleeding in part of the brain) affecting right dominant side, tremor, muscle weakness, and abnormalities of gait and mobility. The Admission Minimum Data Set (MDS) dated [DATE] for R4 assessed him with a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. He required limited assist of one for transfers and walking in/out of the room. R4's balance was not steady and required staff assistance to stabilize and he had limitations to one side of his upper and lower extremities. He used a walker and a wheelchair for mobility. R4 was always continent of bladder and occasionally incontinent of bowel. R4 had falls in the last six months prior to entry and had no falls since admission, on 02/25/22. The Admission MDS dated [DATE] for R4 assessed him with a BIMS score of three indicating severe cognitive impairment and required extensive assist of one staff for transfers. R4 did not ambulate and continued to require staff to stabilize his balance. There were not changes to his upper and lower extremity range of motion and continued to use a walker and wheelchair for mobility. R4 was frequently incontinent of urine and always incontinent of bowel. He had falls in the last month and last two to six months prior to reentry, and no falls since reentry on 05/12/22. The Falls Care Area assessment dated [DATE] revealed R4 had right sided weakness and was a fall risk. He walked with a walker and had unsteady gait. The staff were to observe him with ambulation and provide one person assist as needed. The Quarterly MDS dated [DATE] assessed R4 with a BIMS score of three, indicating severe cognitive impairment and was totally dependent of two or more staff for transfers. He did not ambulate. His balance during transitions and walking did not occur and there were no changes to his range of motion. R4 used a wheelchair for mobility and was always incontinent of bowel and bladder. Resident had no falls since the prior assessment on 08/26/22. The Care Plan dated 12/03/22 revealed R4 was a high risk for falls, and included these fall interventions: 1. On 02/25/22, the staff were to make sure his call light was within reach and to encourage him to use it for assistance as needed. 2. On 03/18/22, the staff educated R4 to ask for assistance when ready to stand up in the shower. 3. On 03/20/22, the staff placed a Call don't fall sign. 4. On 04/02/22, the Certified Nurse Aides (CNA's) were to offer him to be one of the first residents assisted to meals. 5. On 04/14/22, R4's room changed to one with a more open floor plan to better enable him to get in and out of the bathroom. 6. On 04/23/22, the staff were to assist R4 to the bathroom after meals as needed. 7. On 05/03/22, the staff were to place R4's bed in a low position. 8. On 05/05/22, the staff were to place a floor mat on the floor beside the bed when R4 was in bed. 9. On 06/11/22, the staff were to offer to assist R4 to the recliner or bed after meals. 10. On 06/13/22, the staff were to encourage him to watch something other than ghost/haunted shows at bedtime. 11. On 06/25/22, the staff were to offer reposition, fluids, snack, and/or bathroom during rounds. 12. On 07/17/22, the staff were educated/reminded that R4's bed was to be in the low position and the floor mat next to his bed when napping. 13. On 08/20/22, the staff educated R4 to use the call light and to use safety when trying to reach items. The Fall Risk Data Collection 1019 - V 2 dated 02/25/22 for R4 revealed a score of 29, indicating high risk for falls. intervention was for call light within reach and encourage him to use it for assistance as needed. The Electronic Medical Record (EMR) and facility documentation revealed R4 had 14 falls between 03/18/22 through 08/20/22. The Progress Note dated 03/18/22 at 07:30 PM revealed R4 was lying on the floor on his back in the shower room. He did not respond at first then was slow responding and a small lump was on the back of his head. R4 could not recall falling. The intervention for the fall was education to ask for assistance when ready to stand up in the shower. The facility failed to implement an appropriate intervention as his BIMS score was 10, indicating moderate cognitive impairment. The Progress Note dated 05/03/22 at 06:03 PM revealed R4 was found on his knees in front of the bed, the wheelchair brakes were not locked, had regular socks on his feet, the room was dark, and he was incontinent at the time of the fall. R4 had a scabbed over skin tear to his left forearm from a previous fall that re-opened. R4 stated he was trying to walk to his closet to get pants to change into and lost his balance and fell in front of the closet then scooted on his knees back to his bed. The intervention was to place the bed in the low position. The facility failed to implement an appropriate intervention relating to the cause of the fall. The Progress Note dated 05/05/22 at 06:30 AM revealed R4 was found in his room lying on his back on the floor next to the wheelchair and recliner. The facility lacked a post fall investigation to determine the root cause analysis of the fall. The facility implemented an intervention to place a floor mat on the floor beside the bed when he was in bed. The Progress Note dated 05/27/22 at 10:30 AM revealed R4 had a fall this shift. The facility Risk Watch report dated 05/27/22 revealed R4 was self-transferring from bed to wheelchair and could not find the call light in the bedding. The facility failed to implement a new intervention to prevent further falls. The facility Witness Statement dated 06/02/22 revealed at 10:30 AM while delivering clean linen, R4 was found faced down on the floor by his bed. The facility has no documentation of this event, unknown if it was a new fall or regarding the fall on 05/27/22. The care plan lacked a fall intervention for 05/27/22 and 06/02/22. The Progress Notes dated 07/18/22 at 03:48 AM revealed R4 was on the floor of his room sitting facing his bed with legs folded under him, his left arm was across the bed and right arm hanging at side, and the wheelchair was directly behind him. R4 stated he was leaning across the bed and slipped out of bed landing on knees. The intervention was the staff educated R4 to use the call light and use safety when trying to reach items. The intervention was not appropriate, as R4's BIMS score was three, indicating severe cognitive impairment. On 01/10/23 at 09:58 AM, observed R4 resting in bed in a semi-private room, bed in low position, mat on floor next to bed, and call light across the blanket covering him. On 01/11/23 at 09:19 AM, observed R4 sitting up in his wheelchair in his room, next to and facing the bed, lights off in the room, and the call light activated. On 01/11/23 at 09:24 AM, CNA NN and CNA P responded to the call light and R4 told them he was ready to lay down. CNA NN and CNA P transferred R4 using the lift from his wheelchair to his bed, bed placed in low position, mat placed on floor beside him on the left side of the bed. CNA NN asked if he was dry and R4 responded yes. The CNAs did not offer toileting to R4 at the time. On 01/11/23 at 09:35 AM, CNA P stated she was made aware of falls and the new interventions by a teachable moment board in the nurses' station, which is on a clipboard which informs the staff if there was a care plan change, and the board is looked at before shift starts. CNA P stated R4 was a fall risk, he was to have a fall mat beside the bed and his bed was to be lowered to the floor, make sure his call light was in reach, and explained that he was not on a toileting program. On 01/11/23 at 02:12 PM, Licensed Nurse (LN) G stated when a resident has a fall, she does an assessment, asks questions, has the CNA's write statements, completes the facility fall packet, and can add an intervention to the care plan from the electronic assessment. The family, medical provider and Administrative Staff D would be notified of the fall and documented in the progress note or the Risk Watch report. New interventions would be documented on the fall assessment and the floor staff educated. On 01/24/23 at 01:16 PM, Administrative Staff A stated each fall should have a new intervention implemented, each fall should be investigated to determine the root cause of the fall, the staff should follow the care plan, and education to a resident when their BIMS score was below 13 was not an appropriate intervention. The facility Fall Policy dated 09/17/19 revealed following any falls, the facility staff completes an Occurrence Report. Details of the fall would be recorded, and potential causative factors identified and investigated. Interventions would be implemented, and the care plan updated. The Occurrence Reports would be reviewed at clinical meetings to ensure completeness. The facility failed to implement new and appropriate interventions for the above falls and failed to investigate falls to determine the root cause, placing him at risk for further falls and injury. - The Medical Diagnosis tab for R3 included diagnoses of vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), muscle weakness, and abnormalities of gait and mobility. The Annual Minimum Data Set (MDS) dated [DATE] assessed R3 with a Brief Interview of Mental Status (BIMS) score of three indicating severe cognitive impairment and required two assist or more for transfers and walking in/out of her room. Her balance during transitions and walking was not steady and required staff assistance to stabilize. R3 had no impairments to her range of motion and used a walker and a wheelchair for mobility. She had two or more non-injury falls since the prior assessment on 03/31/22. The Falls Care Area assessment dated [DATE] revealed R3 was a fall risk, had vascular dementia, and impaired standing and walking balance. The resident required assistance with activities of daily living (ADL's). She was incontinent of bowel and bladder and had fall interventions in place. The Quarterly MDS dated [DATE] assessed R3 with the same BIMS score and transfer status. She required extensive assist of one person for walking in the room and two or more when walking in the corridor. There were no changes in her balance or range of motion, and she used a wheelchair only for mobility. R3 had one non-injury fall since the last assessment on 04/11/22. The Quarterly MDS dated [DATE] assessed R3 with the same BIMS score as the prior assessment. She required extensive assistance of two or more staff for transfers and did not ambulate in or out of her room. Her walking balance assessment did not occur, and she continued to need staff to stabilize her when moving from seated to standing. There were no changes to her range of motion and continued to use the wheelchair for mobility. R3 had two or more non-injury falls since the prior assessment. The Care Plan dated 12/03/22 for R3 revealed she was at risk for falls related to her dementia, impaired mobility, and decreased safety awareness and included these interventions: 1. On 04/02/21, the staff were to make sure her call light was in reach and encourage her to use if for assistance as needed, revised on 06/02/21. 2. On 04/07/21, R3 will get down and crawl on the floor when she sees something she wants to get. The staff were to ensure her personal items were within reach. 3. On 04/07/21, R3's bed was to be in the low position when she was in bed, revised on 12/27/22. 4. On 04/08/21 R3 was to have gripper socks. Intervention revised 08/26/22. 5. On 04/09/21, mat on floor beside bed when resident is in bed. 6. On 04/20/21, Dycem (non-slip material) to be under the wheelchair cushion and on top of the cushion. 7. On 04/21/21, grip strips in font of recliner. 8. On 05/05/21, anti-roll back brakes on wheelchair, revised on 08/26/22. 9. On 05/07/21, Dycem to the armchair seat, revised on 08/26/22. 10. On 06/01/21, the staff were to make sure the recliner was in the right position before the grip strips. 11. On 06/23/21, Dycem to be on top of pad in recliner (replaced 02/01/22 related to a non-injury fall). 12. On 03/07/22, the staff replaced the sign family had placed on the door to say R3 was a fall risk and please peek in on me I may be on the floor thank you and the family wants the sign left up. 13. On 08/09/22, R3 was found on the floor, and she has a history of putting herself on the floor, suspected she did this on this day however not witnessed, monitor her as able when in the wheelchair. 14. On 08/17/22 and 08/20/22 R3 slid out from wheelchair when trying to transfer herself, anti-roll brakes were not put on this new chair and maintenance had applied them now. 15. On 09/02/22, the staff were to offer her snacks, toileting, nap, or activity to discourage behavior of sitting herself on the floor to get attention. 16. On 09/07/22, R3 found on floor, continue all previous interventions. R3 crawls to the floor when she has incontinence and wants changed, this was a behavior with her and cannot be stopped. The Fall Risk Data Collection 1019 - V2 assessed her for high risk for falls on 02/14/22, 08/20/22, 09/07/22, and 10/09/22. The Progress Notes revealed R3 fell five times between 08/09/22 and 12/26/22, not including times the staff believed she placed herself on the floor. The Progress Note dated 08/09/22 at 04:49 PM, revealed R3 was sitting on the floor of her room in the doorway and the wheelchair was behind her, R3 unable to state how she fell and stated she sat on the floor. The fa [TRUNCATED]

The facility had a census of 36 residents, with three residents selected for sample. Based on observation, interview, and record review the facility failed to provide the necessary care and services (monitoring of bowel movements and/or implementation of the physician ordered bowel program when the resident failed to have bowel movements) to maintain normal bowel function for two of three sampled residents. (Resident (R) 1, R2) R2 failed to have a bowel movement (BM) for four days and the facility failed to follow the physician prescribed regimen for treatment of [REDACTED]. According to the KUB results, R2 experienced severe constipation as a result of failure to have a BM for four days. Findings included: - Resident (R) 2's Quarterly Minimum Data Set ((MDS) dated [DATE] identified the resident with severe cognitive impairment (Brief Interview for Mental Status score of 4), total dependence on staff for toileting, and frequent bowel incontinence. The 08/21/19 Care Plan lacked measurable goals and individualized interventions related to R2's bowel incontinence, history of severe constipation, and the bowel regimen followed to prevent a recurrence of constipation. physician's orders [REDACTED].>1) Milk of Magnesia (MOM), a medication used to treat constipation, 30 milliliters (ml) as needed for constipation. (MONTH) administer one time if no bowel movement in 3 days. (01/29/19 order) 2) [MEDICATION NAME] Sodium (laxative used to treat constipation) 100 milligrams (mg) - two capsules one time a day for constipation. (01/30/19 order) 3) [MEDICATION NAME] Powder (laxative) 17 grams (gm) daily for constipation (01/30/19 order) Review of the bowel movement documentation and Medication Administration Records (MARs) included: 1) (MONTH) 2019: a. There were no BMs recorded in the eight day time period from 07/07/19 - 07/15/19. According to the MARs, staff administered MOM 30 ml on (MONTH) 10th and (MONTH) 11th, 2019 with no results. The record lacked evidence staff implemented additional measures to relieve constipation when two doses of MOM failed to produce results. According to the MAR, staff administered an additional dose of MOM on 07/15/19 and obtained results. b. There were no BMs recorded in the six day time period from 07/19/19 - 07/25/19. According to the MARs, staff failed to administer any medications to relieve constipation until 07/24/19, five days after the resident was known to have had a BM and one day after the resident experienced nausea and vomiting and was diagnosed with [REDACTED]. Review of the Progress Notes included the following: 07/23/19 at 11:05 AM: Described R2's complaints of not feeling well. According to the note, the resident was dry heaving (repeated, involuntary retching) and felt as if she would vomit. The note described decreased bowel sounds (rumbling, growling or gurgling sounds noises produced by movement of contents through the stomach and bowel). The note also referenced the resident's lack of a bowel movement (BM) since 07/19/19, a time period of four days. The physician ordered a radiological exam of the kidney, ureter and bladder (KUB) due to R2's symptoms. 07/23/19 at 12:11 PM: Described the results of the KUB which showed severe constipation. 07/23/19 at 05:06 PM: Described orders to increase laxatives and recheck the KUB on 07/24/19. 07/24/19 at 10:03 AM: Described an order for [REDACTED].>07/24/19 at 05:17 PM: Described the results of the KUB performed earlier that morning as an improvement in constipation with no new abnormalities. 2) (MONTH) 2019: a. There were no BMs recorded in the four day time period from 08/27/19 - 08/31/19. According to the MARs, staff failed to provide any medication to promote a bowel movement during that four day time period. During an observation on 09/17/19 at 11:30 AM R2 was alert and could answer simple questions. The resident required assistance of two staff for transfers. During an interview on 09/18/19 at 09:00 AM Administrative Nurse D reported Our bowel program isn't working. According to Administrative Nurse D staff printed off BM records daily and gave those to the charge nurse. Administrative Nurse D said the charge nurse should then make sure the residents with no BMs in the past 3 days received medication to promote a BM and should also follow up to ensure the medication produced results. Administrative Nurse D confirmed awareness of R2's (MONTH) 2019 [DIAGNOSES REDACTED]. When asked to provide the facility's policy and/or bowel protocol, Administrative Staff A reported the facility did not have a policy. The facility failed to provide the necessary care and services (monitoring of bowel movements and/or implementation of the physician ordered bowel program when the resident failed to have bowel movements) to maintain normal bowel function for R2. R2 failed to have a bowel movement (BM) for four days and the facility failed to follow the physician prescribed regimen for treatment of [REDACTED]. According to the KUB results, R2 experienced severe constipation as a result of failure to have a BM for four days. - Resident (R) 1's clinical record included a comprehensive [DIAGNOSES REDACTED]. The 06/18/19 Quarterly Minimum Data Set (MDS) identified R1 with moderate cognitive impairment (Brief Interview for Mental Status score of 9), total dependence on staff for assistance with toileting, and total bowel incontinence. The undated Care Plan lacked measurable goals and resident specific interventions related to bowel incontinence and the bowel regimen followed to prevent constipation. Review of the physician's orders [REDACTED].>1) An 01/29/19 order for Milk of Magnesia (MOM), a medication used to treat constipation, 30 milliliters (ml) as needed for constipation. (MONTH) administer one time of no bowel movement in three days. 2) An 01/29/19 order for [MEDICATION NAME] (laxative medication) suppository inserted rectally as needed for constipation. Administer one time of no results from MOM. Review of the bowel movement documentation and Medication Administration Records (MARs) included: 1) (MONTH) 2019: There were no BMs recorded in the six day time periods from 07/08/19 - 07/14/19 and again from 07/16/19 - 07/22/19. According to the MARs, staff failed to administer medications during those six day time periods to promote bowel movements and prevent constipation. 2) (MONTH) 2019: There were no BMs recorded in the four day time period from 08/21/19 - 08/25/19. According to the MAR, staff failed to administer medications during that four day time period to promote a bowel movement. There were also no BMs recorded in the four day time period from 08/27/19 - 08/31/19. According to the MAR, staff administered MOM 30 ml on 08/30/19 at 09:15 AM and then failed to follow up when there were no results. 3) (MONTH) 2019: There were no BMs recorded in the five day time period from 09/05/19 - 09/10/19. According to the MAR, staff failed to administer medications during that five day time period to promote a bowel movement and prevent constipation. During an observation on 09/17/19 at 10:10 AM, R1 required assistance of two staff for bed repositioning. The resident had severe physical limitations of the lower extremities and wore an incontinence brief. During an interview on 09/18/19 at 09:00 AM, Administrative Nurse D reported Our bowel program isn't working. According to Administrative Nurse D the staff printed off BM records daily and gave those to the charge nurse. Administrative Nurse D said the charge nurse should then make sure the residents with no BMs in the past 3 days receive medication to promote a BM and should also follow up to ensure the medication produced results. When asked to provide the facility's policy and/or bowel protocol, Administrative Staff A reported the facility did not have a policy. The facility failed to provide the necessary care and services (monitoring of bowel movements and/or implementation of the physician ordered bowel program when the resident failed to have bowel movements) to maintain normal bowel function for R1.

The facility had a census of 37 residents with 5 residents selected for sample. Based on observation, interview, and record review, the facility failed to ensure 1 of 5 residents (resident #1) remained free of significant medication errors when staff failed to appropriately process a physician's orders [REDACTED]. After 35 days without [MEDICATION NAME], the resident experienced a [MEDICAL CONDITION] which lasted approximately 20 minutes which necessitated transfer and admission to the hospital. The facility's failure to administer medication as ordered by the physician resulted in a significant medication error which placed resident #1 in immediate jeopardy. Findings included: - Resident #1's clinical record included a comprehensive [DIAGNOSES REDACTED]. The 3/18/19 Quarterly MDS (Minimum Data Set) identified the resident with moderate cognitive impairment (Brief Interview for Mental Status score of 8) and total dependence on staff for ADLs (activities of daily living) such as bed mobility and transfers. The 3/15/19 Care Plan noted the resident's [MEDICAL CONDITION] disorder (violent involuntary series of contractions of a group of muscles) and directed staff to give medications as ordered. The care plan also directed staff to monitor/document the effectiveness of the medication, monitor labs, and report any sub-therapeutic or toxic results to the physician. Physician orders [REDACTED]. [MEDICATION NAME] is a medication used to control/prevent [MEDICAL CONDITION]. The resident also had an order for [REDACTED].>laboratory results dated [DATE] indicated a critical high [MEDICATION NAME] level of 33 mcg/ml (micrograms per milliliter) (normal range 10-20). In response to the critical high [MEDICATION NAME] level, the physician directed staff to discontinue the evening dose of 200 mg of [MEDICATION NAME] and recheck the [MEDICATION NAME] level in 2 weeks. MARs (medication administration records) for (MONTH) 2019 showed staff held the 8:00 a.m. doses of [MEDICATION NAME] 200 mg on 4/18/19 and 4/19/19. The clinical record lacked a physician's orders [REDACTED]. laboratory results dated [DATE] indicated a continuing high [MEDICATION NAME] level of 28. The clinical record lacked evidence of physician response to the 4/19/19 high [MEDICATION NAME] level, but the facility produced a screen shot of a text message from Licensed Nurse C's personal cell phone on 4/19/19 at 8:12 p.m. which showed a text exchange between the Physician D and Nurse C. According to the text exchange, the physician wanted to change resident #1's [MEDICATION NAME] order by decreasing the daily dose to 100 mg daily at 5:00 p.m. Review of the clinical record revealed no evidence staff processed or implemented that order. A follow up lab test done on 4/24/19 indicated the resident's [MEDICATION NAME] level was now 13 and within desirable limits. The clinical record lacked evidence staff notified the physician of the 4/24/19 [MEDICATION NAME] level results. According to a 5/23/19 notarized statement written by Physician D, resident #1's primary care provider, facility staff failed to notify him/her of the results of the 4/24/19 [MEDICATION NAME] level and failed to request orders related to [MEDICATION NAME]. In the statement, Physician D reported staff faxed the 4/24/19 [MEDICATION NAME] level results to the clinic's medical billing office rather than to the appropriate location and facility staff failed to provide the on-call provider with updates. A notarized witness statement written by Licensed Nurse C on 5/24/19 described a text exchange with resident #1's physician on 4/19/19 related to a critical high [MEDICATION NAME] level and subsequent receipt of an order to decrease the daily [MEDICATION NAME] dosage to 100 mg daily in the evening and recheck the [MEDICATION NAME] level in 4 days. According to the statement, Licensed Nurse C had difficulty entering the new order into the computer system and was unsuccessful each time. Nurse C recalled he/she communicated the new orders to the oncoming nurse at the end of the shift and included, I was sure I had put a note in the progress notes. MARs (medication administration records) for (MONTH) 2019 and (MONTH) 2019 showed resident #1 received no [MEDICATION NAME] in the time period from 4/17/19 - 5/22/19, a time period of 35 days. Progress Notes dated 5/22/19 at 12:26 p.m. described a prolonged [MEDICAL CONDITION] experienced by resident #1 which was unrelieved by intramuscular injection of [MEDICATION NAME], an antianxiety medication. The progress noted described the duration of the [MEDICAL CONDITION] activity as 5+ minutes prior to transfer to the hospital via ambulance. According to the previously mentioned notarized witness statement written by Physician D on 5/23/19, the [MEDICAL CONDITION] experienced by resident #1 on 5/22/19 was a generalized tonic/clonic [MEDICAL CONDITION] (a generalized [MEDICAL CONDITION] that produces muscle contractions on both sides of the body) which lasted 20 minutes. The 5/22/19 Hospital Admission Note for resident #1 noted the resident's low [MEDICATION NAME] level of 0.5 mcg/ml at the time of admission, with a desired therapeutic range of 10-20 mcg/ml. Admission [DIAGNOSES REDACTED].[MEDICATION NAME] level is low on admission. During an observation on 6/4/19 at 11:10 a.m., resident #1 lay in bed watching television. The resident had limited movement of his/her right arm/hand and had the capacity to respond appropriately to questions. According to the resident, he/she had a [MEDICAL CONDITION] problem all his/her life and takes medications to control the condition. The resident reported he/she required hospitalization a week ago because of a [MEDICAL CONDITION], but is doing better now. During an interview on 6/4/19 at 8:40 a.m., Administrative Nurse B confirmed Licensed Nurse C failed to enter the 4/19/19 physician's orders [REDACTED]. As a result of that failure, staff failed to administer [MEDICATION NAME] to the resident in the time period from 4/17/19 - 5/22/19, a time period of 35 days. Administrative Nurse B also confirmed staff failed to use the appropriate process to notify resident #1's physician of the normal [MEDICATION NAME] level on 4/24/19 so that the physician could then review current [MEDICATION NAME] orders and determine the dosage required to maintain the resident's [MEDICATION NAME] level in normal ranges. Although requested, the facility did not provide a policy related to the proper processing/implementation of physician orders. The facility failed to appropriately process a physician's orders [REDACTED].#1 which resulted in staff failure to administer [MEDICATION NAME] for a time period of 35 days. After 35 days without [MEDICATION NAME], the resident experienced a [MEDICAL CONDITION] which lasted approximately 20 minutes which necessitated transfer and admission to the hospital. Facility failure to administer medication as ordered by the physician resulted in a significant medication error which placed resident #1 in immediate jeopardy. The facility removed the immediate jeopardy on 6/4/19 at 1:00 p.m. by implementing the following measures: Notification to the facility Medical Director of the incident on 5/22/19 1) Education of 100% of nursing staff on 5/23/19 as follows: Expectations/facility policy related to processing of physician orders. Physician and family notification of lab results and documentation of the notification in the progress notes Requirement to call the physician rather than text him/her Placement of all new MEDICATION ORDERS FOR [REDACTED] Requirement to write the current medication orders on all drug related lab results prior to sending the lab results to the physician 2) Identification of 4 other facility residents who currently received anti-[MEDICAL CONDITION] medication to ensure all laboratory results were current and had been communicated to the physician, and ensured all four residents currently received anti-[MEDICAL CONDITION] medication as ordered by the physician. Staff completed this task on 6/4/19 at 1:00 p.m. After removal, the deficient practice remained at a scope/severity of G.

The facility reported a census of 36 residents with 3 residents reviewed for resident to resident sexual allegations. Based on observation, interview, and record review the facility failed to protect the residents in the facility from potential resident to resident sexual abuse when the facility knew of resident #1's history of [MEDICAL CONDITION] and a prior sexual allegation from female resident #3 in (MONTH) of (YEAR) and the facility did not implement care plan interventions to prevent another occurrence. In (MONTH) (YEAR) resident #1 sexually abused cognitively impaired resident # 2, who was unable to provide sexual consent and displayed withdrawn behaviors after the allegation. The lack of protection had the potential to affect 23 opposite gender residents in the facility and placed them in immediate jeopardy. Findings included: - Review of resident #1's [DIAGNOSES REDACTED]. Review of the 8/18/18 significant change minimum data set (MDS) revealed resident #1 had a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The resident exhibited symptoms of [MEDICAL CONDITION] which included hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). The resident required limited assistance of one staff with walking in room and corridor, locomotion on unit, and was independent with locomotion off unit. The resident used a walker and a wheelchair for mobility. The resident received daily antipsychotic, antianxiety, and antidepressant medications. Review of the 11/23/18 quarterly MDS revealed resident #1 had a BIMS score of 15. The resident did not exhibit behaviors or [MEDICAL CONDITION] and his/her behaviors had remained the same since the previous assessment. The resident required limited assistance of one staff with walking in room and corridor and required supervision of one staff with locomotion on and off the unit. The resident used a wheelchair for mobility and antipsychotic and antidepressant medications. Review of the 8/18/18 activities of daily living (ADL) care area assessment (CAA) revealed the resident preferred staff to perform his/her care and required encouragement to participate with his/her care. Review of the 8/18/18 [MEDICAL CONDITION] medication CAA revealed the resident received an antipsychotic medication and had been an inpatient at the behavioral health unit. Review of the informed consent for psychoactive medications (undated) revealed the following less restrictive non-drug approaches had proven to be ineffective for resident #1: one-on-one, distraction, redirection, relaxation, and massage. The medication intervention recommendation was [MEDICATION NAME] (antianxiety medication) and [MEDICATION NAME] (antipsychotic medication). The purpose of the psychoactive medication was indicated for a list of targeted symptoms/behaviors written as: refusal to get out of bed, inappropriate sexual behavior and fixation on his/her own genitalia. Review of the facility reported incident investigation form signed 7/6/18 revealed a sexual abuse allegation between resident #1 and resident #3. Resident #1 had a BIMS of 15, which indicated the resident had intact cognition. Resident #3 had a BIMS of 9, which indicated the resident had moderately impaired cognition. The form indicated an allegation of sexual abuse. The report described the incident as second-hand (unidentified housekeeping staff) information reported resident #1 and #3 had a sexual relationship and resident #3 did not have the cognition for consent. The signed investigation reported the incident occurred approximately 2 weeks prior. The corrective action taken by the facility in response to the incident revealed both parties were interviewed. Staff interviewed residents on the same hall as resident #1. The facility moved resident #1 to another hall. The facility placed resident #1 and #3 on 30-minute visual checks. The facility made a report to the local police department. The facilities plan for on-going monitoring for effectiveness was to send resident #1 to a behavioral health unit at a local hospital to monitor and possible adjustment [MEDICAL CONDITION] medications. Review of the signed, unnotarized witness statement from licensed nursing staff C dated 7/6/18 revealed direct care staff D saw resident #1 in resident #3's room sitting on the bed. Review of the notarized witness statement dated 7/6/18 by social service staff E revealed he/she was in the department head meeting with the director of nursing (DON) stated he/she had received a text back from physician F stating he/she had received a text about resident #1 having sexual relations. The DON then asked if staff E knew anything and staff E stated no. Then the unidentified housekeeping staff stated that resident #3 and resident #1 were having sexual relations. Upon hearing this staff E and activities staff H talked to resident #3, who stated he/she and resident #1 were friends and then resident #1 tried getting too close and wanted to go further but resident #3 didn't want to. Resident #3 had not been around resident #1 for a couple of weeks now. Then staff E and Staff H went and talked to resident #1. Resident #1 denied everything and stated he/she never had anyone in his/her room and stayed to him/herself. Staff E contacted family member of resident #1 to inform resident #1 would be moved to a different room. The investigation lacked any signed witness statement from the unidentified housekeeping staff who reported the residents having a sexual relationship. Review of the medical chart revealed 30-minute visual checks for resident #1 dated 7/7/18 from 6:00 p.m. through 7/9/18 at 4:00 p.m., however documentation was missing on 7/8/18 at 6:00 p.m. through 9:30 p.m. (3.5 hours of missing 30-minute visual checks). Review of the care plan for resident #1 lacked new interventions added to his/her care plan after the 7/6/18 incident. Review of the facility reported investigation form revealed an incident, which occurred on 12/6/18 at 3:00 p.m. Resident #1 asked direct care staff I to get 3 items out of his/her room. Staff I handed the items to resident #1 and resident #1 reported he/she needed to go make a phone call. At 6:00 p.m., after supper Resident #1 and Resident #2 were witnessed sitting in the commons area of the facility visiting together. At 6:30 p.m. the two residents were witnessed dancing in resident #2's room by an unidentified direct care staff certified to administer medications. At 6:30 p.m. licensed nursing staff J observed resident #1 going back to his/her room in his/her wheelchair. Staff J stated that resident #1 did not come out of his/her room the remainder of the night. On (MONTH) 6, (YEAR) at 9:25 p.m. resident #2 was found looking out of his/her room and staff J stopped to visit with the resident, at that time resident #2 voiced concern that there was a situation that he/she was uncomfortable with. Resident #2 reported to Staff J that resident #1 came into his/her room and brought 3 gifts for which he/she was grateful for. However, resident #2 later believed that resident #1 implied that resident #2 owed resident #1 sex for the gifts and resident #2 was uncomfortable with this. Resident #2 was worried about how to tell resident #1 that he/she was uncomfortable with the situation. The three items that resident #1 took to resident #2's room were removed by staff and taken to the nurse's station and later returned to resident #1's room. On (MONTH) 6, (YEAR) at 10:00 p.m. staff J notified the administrative nursing staff B and administrative staff A and they discussed the following interventions to be immediately placed into effect for the remainder of the night and next morning. The facility placed the following new interventions: 1:1 monitoring to ensure resident #1 did not return to resident #2's room that night or the following day. Resident #1 was notified he/she was only allowed to interact with resident #2 in public areas. Resident #2 would be supported, and active listening was initiated. Safety would be provided as resident #1 would not be allowed to be in the presence of resident #2 privately, any longer. Provide as needed (PRN) medications as ordered for anxiety for resident #1. Skin assessments were provided by hospice and the director of nursing for resident #2. On (MONTH) 7th between 8 a.m. and 9 a.m. resident #2 told direct care staff K that he/she did not want to take a shower or leave his/her room to eat. Resident #2 stated he/she did not want to get anyone in trouble, but he/she was touched up there and lower. Resident #2 expressed concern that this was his/her fault. Staff K reassured the resident that this was not his/her fault and that no one was mad at him/her. The information was immediately shared with the charge nurse on duty. On (MONTH) 7, (YEAR) between 8 a.m. and 9 a.m., licensed nursing staff L was informed of the statement made by resident #2. Staff L went to visit with resident #2 and the resident stated, something happened last night and explained that resident #1 came back into resident #2's room. Resident #2 stated that resident #1 made sexual contact by touching his/her chest area and down there indicating the pelvic area. Resident #2 repeated he/she did not want to cause any trouble. Staff L immediately contacted the administrative nursing staff B. Staff B then contacted administrative staff A. Both staff E and Staff H conducted interviews with resident #1 and resident #2. Immediate new care planned interventions included resident #1 to remain in the company of only same gender residents in the facility. Resident #1 was not to be in the company of resident #2 and was to be monitored when out of his/her room so that resident #1 did not have any contact with opposite gender residents. Resident #1 and resident #2 would be seen by consultant staff M. The facility looked at potential placement in a same gender facility for resident #1. Resident #1 denied any sexual advances and stated he/she never did anything that was not consensual. Resident #2 reported that resident #1 made sexual advances toward him/her. Resident #2 was descriptive in that resident #1 put his/her hand under resident #2's shirt and felt his/her chest area. Resident #2 stated resident #1 asked if he/she could kiss resident #2's genital area and resident #2 stated no. On (MONTH) 7, (YEAR) at 10:00 a.m. the facility contacted local law enforcement. Resident #2 shared with the officers that resident #1 came back into his/her room and that was when the situation occurred. At that time nursing staff were able to report that resident #1 did not return to resident #2's room after he/she left around 6:30 p.m. (The facility lacked 1:1 documentation to support evidence that resident #1 did not go back into resident #2's room and per interview with Staff B on 12/11/18 - see below-the facility could not guarantee resident #1 did not go back into resident #2's room or another room occupied by an opposite gendered resident.) On (MONTH) 7th at 10:00 a.m. the facility notified physician F of all current events and current investigation by local law enforcement. Physician F suggested admission for resident #1 to a local behavioral health unit (BHU). On (MONTH) 7, (YEAR) at 1:00 p.m. the facility conducted a self-report to adult protective services of alleged sexual abuse by resident #1. Staff B reported that at that time the local law enforcement and internal investigation had been unable to substantiate sexual abuse. However, nursing care-plans were in place to protect resident #2, as well as all same gendered residents as resident #2, in the facility as the investigation continued. The staff informed the hospice company for resident #2 and the DPOA for resident #2, who stated that resident #2 had a past history of rape and that his/her past memories of past events often were mixed into current experiences. At 2:00 p.m. the facility concluded that due to inability by local law enforcement to substantiate the allegation, the internal investigation was unable to substantiate resident reports of sexual exploit. However, care planned interventions remained in place for the safety of resident #2 and the other same gendered residents as resident #2. (The facility did not update resident #1's care plan with interventions mentioned in the investigation) On (MONTH) 8, (YEAR) Nursing documentation recorded there were no further interactions between resident #1 and resident #2. Nursing documentation indicated the residents did not have any concerns and did not voice any fears and no reports of being scared were verbalized. On (MONTH) 10, (YEAR), resident #1 asked if he/she could visit with the administrative staff A. During the visit with the administrator resident #1 admitted to touching resident #2's chest and asked resident #2 to touch resident #1's genitalia so resident #1 could masturbate. At approximate 11:30 a.m. the facility received a call from APS following up on the original call. At 11:45 a.m. the facility called the local law enforcement with the new information and on (MONTH) 10th at 2:30 p.m. resident #1 admitted to the BHU. Review of the undated temporary care plan in-service form for resident #1 revealed a new intervention written: the resident was not to be in the company of resident #2. The resident was to be monitored when out of his/her room so that he/she did not enter any opposite gender resident rooms. The form was signed by 13 staff members, the DON and Administrator, but was undated and not located in the resident's medical chart. Review of the facility provided information and medical chart of resident #1 revealed the only monitoring documentation located were 4 nurses notes as follows: Nurse's note dated 12/8/18 at 12:18 a.m. revealed the resident continued on follow up he/she has been in his/her room throughout this shift --will continue to monitor. Nurse's note 12/8/18 at 9:03 a.m. (almost 6 hours later) revealed the resident was doing his/her normal routine today and showed no ill effects for the incident. Nurse's note dated 12/8/18 at 10:23 p.m. (over 12 hours later) revealed the resident remained in his/her room throughout the shift, with no complaints of distress and no signs of anxiety-- will continue to monitor. Nurse's note dated 12/9/18 at 10:57 a.m. (over 12 hours later) revealed the resident had no reports of fear or danger and was up and about per his/her normal. Nurse's note dated 12/9/18 at 11:07 a.m. revealed the resident had remained in his/her room since before 6pm. Observation on (MONTH) 11, (YEAR) at 10:30 a.m. revealed resident #1 was in a behavioral health unit. Interview with direct care staff K on 12/11/18 at 11:59 a.m. revealed the nurse documented the behaviors of residents. Staff K had provided ADL care for resident #1 and stated the resident did have behaviors that were verbally inappropriate. Staff K reported resident #1 masturbated in his/her room and stated resident #1's curtain was usually pulled. Staff K stated resident #1 had an incident with resident #3 in (MONTH) or (MONTH) of (YEAR)-and stated they were caught doing something, unsure of what, and the facility moved resident #1 to a different room. Interview with direct care staff N on 12/11/18 at approximately 10:45 a.m. revealed resident #1 would get in a mood and act inappropriate and became angry very quickly. Staff N stated resident #2 asked during cares on Thursday or Friday if the person (resident #1) was going to sue him/her and continued to act scared of everything and refused to eat or leave his/her room. Interview with administrative staff A on 12/11/18 at 2:59 p.m. revealed resident #1 had a prior allegation with resident #3 and stated the facility in-serviced staff after that allegation to not allow resident #1 in opposite gender resident rooms and not to be in common areas with opposite gender residents and stated resident #1. Staff A stated he/she would have expected interventions to have been on the care plan regarding each incident with resident #1. Staff A stated resident #1 admitted to the allegations from 12/6/18 on the morning of 12/10/18. Staff A stated the facility put resident #1 on one-on-one after the dancing Thursday night. Staff A stated the facility did not have documentation of 15-minute checks but had kept a direct care staff outside of his/her room at all times but monitoring ended at 6:00 a.m. on Friday 12/7/18, but stated the staff did monitor resident #1 anytime he/she left the room and monitored resident #1 with resident #2 as that was where the allegation was. Staff A stated once the facility found out there was more to the allegation, the facility kept resident #1 and resident #2 separated. (The facility did not have supporting documentation to verify the 1:1 monitoring) Interview with administrative nursing staff B on 12/11/18 at 5:14 p.m. revealed the facility was not sure the allegation was valid. Staff B reported no one specific staff member was designated to keep an eye on resident #1. Staff B reported he/she did not know for sure resident #1 did not get into another resident's room or go back to the room of resident #2. Staff B just received assurance from the direct care staff who said resident #1 did not go into other resident's room's that night. (The facility lacked documentation to support consistent monitoring as referenced). Staff B stated he/she did know resident #1 had a history of [REDACTED]. Staff B stated the facility did not have adequate care plan interventions in place to guide staff to respond in such situations as this one. Staff B stated at this time there was no one in the facility that would pose this type of threat, but when staff B looked back on it now, staff B would not have considered resident #1 a threat, either. Staff B stated he/she did not know resident #1 had forced himself onto resident #3, prior (incident reported on 7/6/2018). Review of the Abuse, Prevention and Prohibition Policy revised 11/2018 revealed each resident had the right to be free from abuse. Residents must not be subjected to abuse by other residents. The facility prohibited mistreatment, neglect and/or abuse of residents. The facility would reassess care planned interventions on a regular basis, intervention strategies based on resident screenings would be implemented to prevent occurrences of abuse. The facility would identify residents whose personal history rendered them at risk for abusing other residents through a prescreening process. The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or his designated agent. When another resident was the alleged perpetrator of the abuse, a licensed professional would immediately evaluate the resident's physical and mental status, care plan, monitor behaviors and notify the physician for a determination regarding treatment and/or discharge options. Residents would be referred for behavior management when indicated. Changes in room assignments and seating arrangements would be recommended as needed. The safety of other residents of the facility would be of primary concern. The facility failed to protect the residents in the facility from potential resident-to-resident sexual abuse from resident #1, with an established history of hypersexualized behaviors and an allegation of sexual abuse with resident #3 and the facility did not implement protective measures to prevent another occurrence of sexual abuse between resident #1 and resident #2. This deficient practice placed 23 opposite gender residents in immediate jeopardy. The facility abated the immediate jeopardy on 12/13/18 at 4:50 p.m. when the facility staff conducted a 100% audit of all care plans in the facility. The facility identified all residents with behaviors and developed a care plan which included identifying the behavior and interventions for staff to follow. The facility further added behavior monitoring to each resident identified for tracking of behaviors, for further updates and additional interventions for the resident's care plan. The facility indicated further monitoring would be completed per the Behavior Policy if indicated and staff would notify the physician for further evaluation and the interdisciplinary team would evaluate new or changing behavioral symptoms to identify underlying causes and address any modifiable factor that may have contributed. The facility director of nursing initialed training with all nursing staff on the abuse policy, which included notification of the abuse coordinator if staff suspected abuse, the behavior policy which included assessment, cause, management and monitoring; the care planning process of identifying problem areas, their causes and developed interventions that were targeted and meaningful to the resident, and included the need for staff to follow the care plan for each resident. The facility would educate all new hired nursing staff during orientation of the abuse, neglect, and exploitation policy, including behavior policy, and establishing/following care plans. The facility would question staff on appropriate action if a resident experienced behavior and appropriate interventions followed per the care plan. The facility administrator would randomly question at least three staff members a week on the appropriate action if staff observed a resident exhibit behavior and the proper interventions per the care plan. The facility administrator and director of nursing would randomly review residents with new behaviors daily to ensure staff followed the behavior policy and care planned interventions were in place. The facility would continue to utilize the behavior policy for residents with behaviors to ensure staff appropriately used the interventions in place. The Quality Assurance (QA) plan of action ensured staff were aware of the behavior policy and safety of other residents. The facility would implement corrective actions immediately if a concern was identified and revise the plan as needed-the plan would be reviewed weekly in the Compliance QA meeting. The deficient practice remained at a scope and severity of an E.

The facility reported a census of 36 residents with 3 residents reviewed for resident to resident sexual allegations. Based on observation, interview, and record review the facility failed to prevent the sexual abuse of resident #2, when the facility knew of resident #1's history of [MEDICAL CONDITION] and a prior sexual allegation from female resident #3 in (MONTH) of (YEAR) and the facility did not implement care plan interventions to prevent another occurrence. In (MONTH) (YEAR) resident #1 sexually abused cognitively impaired resident # 2, who was unable to provide sexual consent and displayed withdrawn behaviors and fear after the allegation. Findings included: - Review of resident #1's [DIAGNOSES REDACTED]. Review of the 8/18/18 significant change minimum data set (MDS) revealed resident #1 had a brief interview for mental status (BIMS) score of 15, indicating intact cognition. The resident exhibited symptoms of [MEDICAL CONDITION] which included hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). The resident required limited assistance of one staff with walking in room and corridor, locomotion on unit, and was independent with locomotion off unit. The resident used a walker and a wheelchair for mobility. The resident received daily antipsychotic, antianxiety, and antidepressant medications. Review of the 11/23/18 quarterly MDS revealed resident #1 had a BIMS score of 15. The resident did not exhibit behaviors or [MEDICAL CONDITION] and his/her behaviors had remained the same since the previous assessment. The resident required limited assistance of one staff with walking in room and corridor and required supervision of one staff with locomotion on and off the unit. The resident used a wheelchair for mobility and antipsychotic and antidepressant medications. Review of the 8/18/18 activities of daily living (ADL) care area assessment (CAA) revealed the resident preferred staff to perform his/her care and required encouragement to participate with his/her care. Review of the 8/18/18 [MEDICAL CONDITION] medication CAA revealed the resident received an antipsychotic medication and was an inpatient at the behavioral health unit. Review of the informed consent for psychoactive medications (undated) revealed the following less restrictive non-drug approaches had proven to be ineffective for resident #1: one-on-one, distraction, redirection, relaxation, and massage. The medication intervention recommendation was [MEDICATION NAME] (antianxiety medication) and [MEDICATION NAME] (antipsychotic medication). The purpose of the psychoactive medication was indicated for a list of targeted symptoms/behaviors written as: refusal to get out of bed, inappropriate sexual behavior and fixation on his/her own genitalia. Review of the facility investigation form signed 7/6/18 described a sexual abuse allegation between resident #1 and resident #3. Resident #1 had a BIMS of 15, which indicated the resident had intact cognition. Resident #3 had a BIMS of 9, which indicated the resident had moderately impaired cognition. The form indicated an allegation of sexual abuse. The report described the incident as second-hand (unidentified housekeeping staff) information reported resident #1 and #3 had a sexual relationship and resident #3 did not have the cognition for consent. The signed investigation reported the incident occurred approximately 2 weeks prior. The corrective action taken by the facility in response to the incident revealed both parties were interviewed. Staff interviewed residents on the same hall as resident #1. The facility moved resident #1 to another hall. The facility placed resident #1 and #3 on 30-minute visual checks. The facility made a report to the local police department. The facility's plan for on-going monitoring for effectiveness was to send resident #1 to a behavioral health unit at a local hospital to monitor and possible adjustment to [MEDICAL CONDITION] medications. Review of the care plan for resident #1 lacked new interventions added to his/her care plan after the 7/6/18 incident. Review of resident #2's signed physician orders [REDACTED]. Review resident #2's admission assessment dated [DATE] reveled the resident had a BIMS score of 5, which indicated severely impaired cognition. The resident had inattention behavior continuously present, which did not fluctuate and disorganized thinking present, which fluctuated. The resident had no further behaviors identified on the assessment. The resident required extensive assistance of two staff for bed mobility and transfers. The resident did not walk between locations in his/her room or corridor. Review of resident #2's care plan printed 12/4/18 revealed: 10/30/18 - Review of the activity problem revealed the resident was not good at expressing his/her interests/preferences. 12/24/18 - Staff would re-direct and reassure the resident as needed. 10/24/18 - Staff would monitor and redirect the resident for behaviors to determine the cause and trigger of the behaviors. 10/24/18 - Staff would provide me with care in a calm and unhurried manner. 10/24/18 - Provide, redirect, reassure, encourage activities for distraction. Review of the resident's physician order [REDACTED]. Review of the facility reported investigation form revealed an incident, which occurred on 12/6/18 at 3:00 p.m. Resident #1 asked direct care staff I to get 3 items out of his/her room. Staff I handed the items to resident #1 and resident #1 reported he/she needed to go make a phone call. At 6:00 p.m., after supper Resident #1 and Resident #2 sat in the commons area of the facility visiting together. At 6:30 p.m. the two residents were witnessed dancing in resident #2's room by an unidentified direct care staff certified to administer medications. At 6:30 p.m. licensed nursing staff J observed resident #1 going back to his/her room in his/her wheelchair. Staff J stated that resident #1 did not come out of his/her room the remainder of the night. On (MONTH) 6, (YEAR) at 9:25 p.m. resident #2 was found looking out of his/her room and staff J stopped to visit with the resident, at that time resident #2 voiced concern that there was a situation that made him/her uncomfortable. Resident #2 reported to Staff J that resident #1 came into his/her room and brought 3 gifts for which he/she was grateful. However, resident #2 later believed that resident #1 implied that resident #2 owed resident #1 sex for the gifts and resident #2 was uncomfortable with this. Resident #2 was worried about how to tell resident #1 that he/she was uncomfortable with the situation. The three items that resident #1 took to resident #2's room were removed by staff and taken to the nurse's station and later returned to resident #1's room. On (MONTH) 6, (YEAR) at 10:00 p.m. staff J notified the administrative nursing staff B and administrative staff A and they discussed the following interventions to be immediately placed into effect for the remainder of the night and next morning. The facility placed the following new interventions: 1:1 monitoring to ensure resident #1 did not return to resident #2's room that night or the following day. Resident #1 was notified he/she was only allowed to interact with resident #2 in public areas. Resident #2 would be supported, and active listening was initiated. Safety would be provided as resident #1 would not be allowed to be in the presence of resident #2 privately. Provide as needed (PRN) medications as ordered for anxiety for resident #1. Skin assessments were provided by hospice and the director of nursing for resident #2. On (MONTH) 7th between 8 a.m. and 9 a.m. resident #2 told direct care staff K that he/she did not want to take a shower or leave his/her room to eat. Resident #2 stated he/she did not want to get anyone in trouble, but he/she was touched up there and lower. Resident #2 expressed concern that this was his/her fault. Staff K reassured the resident that this was not his/her fault and that no one was mad at him/her. The information was immediately shared with the charge nurse on duty. On (MONTH) 7, (YEAR) between 8 a.m. and 9 a.m., licensed nursing staff L was informed of the statement made by resident #2. Staff L went to visit with resident #2 and the resident stated, something happened last night and explained that resident #1 came back into resident #2's room. Resident #2 stated that resident #1 made sexual contact by touching his/her chest area and down there indicating the pelvic area. Resident #2 repeated he/she did not want to cause any trouble. Staff L immediately contacted the administrative nursing staff B. Staff B then contacted administrative staff A. Both staff E and Staff H conducted interviews with resident #1 and resident #2. Immediate new care planned interventions included resident #1 to remain in the company of only same gender residents in the facility. Resident #1 was not to be in the company of resident #2 and was to be monitored when out of his/her room so that resident #1 did not have any contact with opposite gender residents. Resident #1 and resident #2 would be seen by consultant staff M. The facility looked at potential placement in a same gender facility for resident #1. Resident #1 denied any sexual advances and stated he/she never did anything that was not consensual. Resident #2 reported that resident #1 made sexual advances toward him/her. Resident #2 was descriptive in that resident #1 put his/her hand under resident #2's shirt and felt his/her chest area. Resident #2 stated resident #1 asked if he/she could kiss resident #2's genital area and resident #2 stated no. On (MONTH) 7, (YEAR) at 10:00 a.m. the facility contacted local law enforcement. Resident #2 shared with the officers that resident #1 came back into his/her room and that was when the situation occurred. At that time nursing staff were able to report that resident #1 did not return to resident #2's room after he/she left around 6:30 p.m. (The facility lacked 1:1 documentation to support evidence that resident #1 did not go back into resident #2's room and per interview with Staff B on 12/11/18 - see below-the facility could not guarantee resident #1 did not go back into resident #2's room or another room occupied by an opposite gendered resident.) On (MONTH) 7th at 10:00 a.m. the facility notified physician F of all current events and current investigation by local law enforcement. Physician F suggested admission for resident #1 to a local behavioral health unit (BHU). On (MONTH) 7, (YEAR) at 1:00 p.m. the facility conducted a self-report to adult protective services of alleged sexual abuse by resident #1. Staff B reported that at that time the local law enforcement and internal investigation had been unable to substantiate sexual abuse. However, nursing care-plans were in place to protect resident #2, as well as all same gendered residents as resident #2, in the facility as the investigation continued. The staff informed the hospice company for resident #2 and the DPOA for resident #2, who stated that resident #2 had a past history of rape and that his/her past memories of past events often were mixed into current experiences. At 2:00 p.m. the facility concluded that due to inability by local law enforcement to substantiate the allegation, the internal investigation was unable to substantiate resident reports of sexual exploitation. However, care planned interventions remained in place for the safety of resident #2 and the other same gendered residents as resident #2. (The facility did not update resident #1's care plan with interventions mentioned in the investigation.) On (MONTH) 8, (YEAR) Nursing documentation recorded there were no further interactions between resident #1 and resident #2. Nursing documentation indicated the residents did not have any concerns and did not voice any fears and no reports of being scared were verbalized. On (MONTH) 10, (YEAR), resident #1 asked if he/she could visit with the administrative staff A. During the visit with the administrator resident #1 admitted to touching resident #2's chest and asked resident #2 to touch resident #1's genitalia so resident #1 could masturbate. At approximate 11:30 a.m. the facility received a call from APS following up on the original call. At 11:45 a.m. the facility called the local law enforcement with the new information and on (MONTH) 10th at 2:30 p.m. resident #1 admitted to the BHU. Review of the 12/7/18 comprehensive certified nurse aide shower review for resident #2 revealed the resident had an old healing bruise on the inner thigh which measured 0.5 centimeters (CM) by 1.5 CM. Review of the notarized witness statement from direct care staff K dated 12/7/18 revealed on the morning 12/7/18 resident #2 refused to take a shower, eat or come out of his/her room. Staff K asked resident #2 why he/she did not want to come out of his/her room and resident #2 stated he/she was scared to come out of his/her room and did not want to get anyone in trouble. Resident #2 told staff K that someone touched up here (as he/she grabbed his/her chest) and lower. Resident #2 asked if everyone was mad at him/her for causing trouble. Staff K stated he/she reassured resident #2 nothing was his/her fault, and no one was mad at him/her. Review of the notarized witness statement from licensed nurse J dated 12/7/18 revealed he/she was in and out of resident #2's room throughout the night, which included extended periods between approximately 9:15 p.m. and 10:00 p.m. Staff J stated resident #2 came to the nurse's station at approximately 3:00 a.m. until 4:30 a.m. to talk and apologize for causing so much trouble. The statement lacked evidence resident #1remained on one-on-one observation 12/6/18 and 12/7/18. Review of the notarized witness statement from licensed nursing staff L dated 12/7/18 revealed resident #2 refused to eat or shower the morning of 12/7/18. Staff L said the resident stated, I'm causing trouble and scared to come out of my room. Staff L asked resident #2 to tell him/her what was bothering him/her and resident #2 stated something happened last night. Resident #2 stated what happened the night prior was his/her fault because he/she did not say no. Resident #2 stated resident #1 made sexual contact by touching his/her chest and pelvic area. The resident stated he/she did not want to cause any trouble. Review of the undated temporary care plan in-service form for resident #1 revealed a new intervention written: resident #1 was not to be in the company of resident #2. The resident was to be monitored when out of his/her room so that he/she did not enter any opposite gender resident rooms. The form was signed by 13 staff members, the DON and Administrator, but was undated and not located in the resident's medical chart. Review of the undated temporary care plan/in-service form revealed a new intervention for resident #2, which directed staff to re-assure and provide active listening. Provide a safe environment in the company of same gender residents. The form included 14 signatures and the director of nursing's signature at the bottom of the page. Review of resident #2's nurse's note dated 12/7/18 at 8:30 a.m. revealed the resident reported that another resident (resident #1) had sexual contact with him/her on the evening of 12/6/18. The resident reported a resident of the opposite gender came back into his/her room during the evening/night and had touched him/her. The note reported no injuries. The intervention identified in the note revealed staff provided reassurance and protection from the unnamed resident of the opposite gender and all other residents of the opposite gender as well. Staff provided care in the security of his/her room and provided active listening/reassurance. Staff initiated contact with law enforcement and an investigation. Review of resident #2's nurse's note dated 12/9/18 at 10:55 a.m. revealed the resident alert and able to make needs known. The resident had some delusions and thought staff, residents and his/her family were making foul comments about him/her when he/she went to the dining room. He/she asked if he/she could get a room change to stop people from talking about him/her. The resident had no reports of fear or feelings of danger. Review of resident #2's nurse's notes dated 12/9/18 at 11:06 p.m. revealed the resident's family talked to the nurse writer and reported the resident had 2 other rape incidents in his/her past and they were not sure he/she had not mixed past experiences with the current situation. The resident had not said anything about the situation to nursing staff that shift. Review of resident #2's nurse's note dated 12/11/18 at 2:12 AM revealed the resident requested as needed anxiety medication. Observation of the resident on 12/11/18 at 11:45 a.m. revealed resident #2 sleeping and awoke easily. The resident stated he/she was sleepy and had no signs of distress. Observation on (MONTH) 11, (YEAR) at 10:30 a.m. revealed resident #1 was in a behavioral health unit. Interview on 12/11/18 at 11:59 a.m. with direct care staff K revealed resident #2 had been melancholy lately and had been more so, since the events with resident #1. Staff K stated the day after it happened resident #2 did not want to go take a shower, was agitated, and secluded him/herself. Staff K said the staff reassured resident #2 she was safe, but resident #2 was upset and scared and needed reassurance. Staff K provided ADL care for resident #1 and stated the resident did have behaviors that were verbally inappropriate. Staff K reported resident #1 masturbated in his/her room and stated resident #1's curtain was usually pulled. Staff K stated resident #1 had an incident with resident #3 in (MONTH) or (MONTH) of (YEAR)-and stated they were caught doing something, unsure of what, and the facility moved resident #1 to a different room. Interview with direct care staff N on 12/11/18 at approximately 10:45 a.m. revealed resident #1 would get in a mood and act inappropriate and became angry very quickly. Staff N stated resident #2 asked during cares on Thursday or Friday if the person (resident #1) was going to sue him/her and continued to act scared of everything and refused to eat or leave his/her room. Interview with administrative staff A on 12/11/18 at 2:59 p.m. revealed resident #1 had a prior allegation with resident #3 and stated the facility in-serviced staff after that allegation to not allow resident #1 in opposite gender resident rooms and not to be in common areas with opposite gender residents. Staff A stated he/she expected interventions to have been on the care plan regarding each incident with resident #1. Staff A stated resident #1 admitted to the allegations from 12/6/18 on the morning of 12/10/18. Staff A stated the facility put resident #1 on one-on-one after the dancing Thursday night. Staff A stated the facility did not have documentation of 15-minute checks but kept a direct care staff outside of his/her room at all times. Monitoring ended at 6:00 a.m. on Friday 12/7/18, but stated the staff did monitor resident #1 anytime he/she left the room and monitored resident #1 with resident #2 as that was where the allegation occurred. Staff A stated once the facility found out there was more to the allegation, the facility kept resident #1 and resident #2 separated. (The facility did not have supporting documentation to verify the 1:1 monitoring.) Interview with administrative nursing staff B on 12/11/18 at 5:14 p.m. revealed the facility care plans were less than adequate and stated nothing was added to the care plan for either resident, but the facility did a mini in-service with one sheet for all staff to share (kept at the nurses station and not in either resident's chart) and got as many staff to sign as possible. When asked about the prior incident in (MONTH) (YEAR) which involved resident #1, staff B reported he/she did not know much about it but stated he/she did know resident #1 had a history of [REDACTED]. Staff B stated the facility did not have adequate care plan interventions in place to guide staff to respond in such situations as this one. Staff B stated he/she did not know resident #1 forced him/herself onto resident #3, prior (incident reported on 7/6/2018). Review of the Abuse, Prevention and Prohibition Policy revised 11/2018 revealed each resident had the right to be free from abuse. Residents must not be subjected to abuse by other residents. The facility prohibited mistreatment, neglect and/or abuse of residents. The facility would reassess care planned interventions on a regular basis, intervention strategies based on resident screenings would be implemented to prevent occurrences of abuse. The facility would identify residents whose personal history rendered them at risk for abusing other residents through a prescreening process. The facility employee or agent, who becomes aware of abuse or neglect, including injuries of unknown origin or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator or his designated agent. When another resident was the alleged perpetrator of the abuse, a licensed professional would immediately evaluate the resident's physical and mental status, care plan, monitor behaviors and notify the physician for a determination regarding treatment and/or discharge options. Residents would be referred for behavior management when indicated. Changes in room assignments and seating arrangements would be recommended as needed. The safety of other residents of the facility would be of primary concern. The facility failed to prevent an occurrence of resident-to-resident sexual abuse when the facility knew resident #1 had a history of [REDACTED].#3 and the facility did not implement interventions or care plan updated to prevent another occurrence of sexual abuse between resident #1 and resident #2. This deficient practice placed resident #2 in immediate jeopardy. The facility abated the immediate jeopardy on 12/13/18 at 4:50 p.m. when the facility staff conducted a 100% audit of all care plans in the facility. The facility identified all residents with behaviors and developed a care plan which included identifying the behavior and interventions for staff to follow. The facility further added behavior monitoring to each resident identified for tracking of behaviors, for further updates and additional interventions for the resident's care plan. The facility indicated further monitoring would be completed per the Behavior Policy if indicated and staff would notify the physician for further evaluation and the interdisciplinary team would evaluate new or changing behavioral symptoms to identify underlying causes and address any modifiable factor that may have contributed. The facility director of nursing initialed training with all nursing staff on the abuse policy, which included notification of the abuse coordinator if staff suspected abuse, the behavior policy which included assessment, cause, management and monitoring; the care planning process of identifying problem areas, their causes and developed interventions that were targeted and meaningful to the resident, and included the need for staff to follow the care plan for each resident. The facility would educate all new hired nursing staff during orientation of the abuse, neglect, and exploitation policy, including behavior policy, and establishing/following care plans. The facility would question staff on appropriate action if a resident experienced behavior and appropriate interventions followed per the care plan. The facility administrator would randomly question at least three staff members a week on the appropriate action if staff observed a resident exhibit behavior and the proper interventions per the care plan. The facility administrator and director of nursing would randomly review residents with new behaviors daily to ensure staff followed the behavior policy and care planned interventions were in place. The facility would continue to utilize the behavior policy for residents with behaviors to ensure staff appropriately used the interventions in place. The Quality Assurance (QA) plan of action ensured staff were aware of the behavior policy and safety of other residents. The facility would implement corrective actions immediately if a concern was identified and revise the plan as needed-the plan would be reviewed weekly in the Compliance QA meeting. The deficient practice remained at a scope and severity of a G.

The facility had a census of 52 residents. Thirty-five of the 52 residents used side rails on one or both sides of their beds. The sample included 3 residents who utilized side rails on their beds. Based on observation, interview and record review, the facility failed to provide 3 of 3 residents with adequate supervision and assistive devices to prevent accidents (assessment of side rail safety prior to use of side rails, assessment for safety after the addition of a pressure reduction air mattress to beds with side rails, use of side rails with gaps of 16 ¾ inches within the rails). Resident #1 used side rails on both sides of his/her bed and also had an air mattress on the bed. Staff failed to complete a side rail safety assessment prior to use of the side rails and then re-evaluate side rail safety after placement of an air mattress. On [DATE], staff found resident #1, deceased , on the floor next to the bed. The resident's buttocks rested on the floor with the knees bent at a 90 degree angle and the lower legs rested on the floor. The resident's head was caught behind the raised side rail on the left hand side of the bed. The facility's failure to assess for side rail safety prior to using them, failure to consider the potential hazardous combination of air mattress usage on a bed with side rails, failure to develop/implement new interventions to address risk when staff found resident #1 on more than one occasion with his/her lower body partially off the bed while the upper body remained behind the side rail placed resident #1 and 35 current residents who used side rails at risk for immediate jeopardy. Findings included: - Resident #1's clinical record included a signed physician order [REDACTED]. The [DATE] Annual MDS(Minimum Data Set) identified resident #1 with long and short-term memory problems, moderately impaired decision making abilities, the need for extensive assistance of one staff for bed mobility, total dependence on staff for transfers, an inability to ambulate, and no functional limitations in range of motion of the upper or lower extremities. Undated CAAs (Care Area Assessments) completed after the [DATE] Annual MDS included: Cognitive loss/dementia: Alert to self, place and situation. Had a [DIAGNOSES REDACTED]. ADLs (activities of daily living): Had a decline in ADL status .required extensive assist of two for transfers and bed mobility. The CAAs did not include any assessments/comments related to side rail use. Resident #1's care plan included: [DATE]: Described resident #1's preference to remain in bed all the time, ability to turn in bed with the assistance of side rails, and risk for falls. The care plan did not include goals/interventions related to use of side rails and/or an air mattress. A [DATE] Side Rail Assessment included three sections which had places for nurse assessment, therapist assessment, and then a section which listed all the documentation/action required if the assessment indicated to use side rails. The Nurse section of the [DATE] assessment identified resident #1 as ambulatory even though the [DATE] Annual MDS identified the resident as unable to ambulate. The Nurse section did not mark the area of forgetful or confused even though the MDS identified him/her with long and short-term memory problems and moderately impaired decision making abilities. The Therapist section of the assessment remained entirely blank. The third section of the form also remained entirely blank. A licensed nurse signed the form. The line for a therapist signature remained blank. Progress Notes included: [DATE] at 11:21 a.m.: Described resident #1's death at 8:15 a.m. and notification of the family and physician. The progress note did not include details about the resident's death. The facility initiated an in-depth investigation into the incident after surveyor arrival on [DATE], (12 days after the incident) Documents submitted by the facility as part of their investigation included: [DATE] notarized statement from Direct Care Staff G which included, .There was a skin tear on the top of (his/her) left hand and on (his/her) neck, along the jawline the skin was slightly purple and the skin looked torn [DATE] notarized statement from Licensed Nurse H which described the presence of a light blue discoloration on left jaw from chin back toward jaw 3 cm (centimeters) in length [DATE] notarized statement from Licensed Nurse D which described the position he/she found resident #1 on [DATE] as head was resting on the lower part of the side rail with left side of jaw close to chin with head facing up, arms down to sides, knees bent with legs resting on floor .unresponsive pulse and respirations absent During observations on [DATE] beginning at 5:30 p.m., 35 of 52 resident beds had side rails mounted to one or both sides of the beds. During an interview on [DATE] at 5:00 p.m., Administrative Staff A confirmed resident #1 expired on [DATE]. According to Staff A, a licensed nurse entered the resident's room to deliver a breakfast tray and found the resident seated on the floor next to the bed with his/her head resting on top of the rail (side rail/bed rail). Administrative Staff A reported he/she interviewed the nurse who found the resident as well as other staff and determined the resident most likely expired and then slipped from the bed onto the floor. Although requested, Administrative Staff A could not provide any evidence to support that theory. During an interview on [DATE] at 7:40 p.m., Licensed Nurse D reported he/she went to resident #1's room to take a breakfast tray on [DATE] and found the resident seated on the floor on the left side of the bed with his/her head behind the raised left side rail. Nurse D recalled he/she checked for a pulse and did not find one, and then called for assistance of other staff. Nurse D stated he/she had to use my hands to move (his/her) head out from behind the rail when we picked (him/her) up to put (him/her) in bed. Nurse D reported the resident had a mark on his/her chin/cheek/jawbone area from the side rail. Licensed Nurse D recalled resident #1 always had both side rails raised on his/her bed and always was real close to the left side of the bed for some reason. As requested, Licensed Nurse D accompanied survey staff to the room previously occupied by resident #1. The room contained the bed used by the resident. The bed had an air mattress in place as well as side rails on each side of the bed. The head of the bed remained raised approximately 30 degrees. Nurse D demonstrated the position he/she found resident #1 in upon entrance to the room on [DATE]. According to Nurse D's demonstration, resident #1 had his/her buttocks on the floor, both knees bent at a 90 degree angle with the lower legs resting on the floor, and his/her head behind the raised left side rail with the chin/lower cheek in contact with the side rail. Nurse D demonstrated how he/she stood over the resident, placed his/her hands on both sides of the resident's head, and then pulled the head out from behind the rail in order to lay the resident down. On [DATE] at 4:25 p.m., Licensed Nurse D again demonstrated the position in which he/she found resident #1 to survey staff and Administrative Nurse B. Nurse D again demonstrated how the resident's jawline rested on the lower portion of the side rail. At the time of the observation, Nurse D said the resident's chin/jawbone was caught on the lower part of the rail at the time staff found him/her. During an interview on [DATE] at 4:25 p.m., Licensed Nurse D reported he/she found resident #1 multiple times with his/her body too close to the left side of the bed and with the knees bent and extended over the edge of the mattress on the left side of the bed. When that happened, Nurse D reported he/she got assistance from other staff and they repositioned the resident in bed to get him/her further away from the edge of the mattress. During an interview on [DATE] at 9:00 a.m., Licensed Nurse E reported nurses completed the side rail assessment forms as assigned to them. According to Nurse E, therapists never complete the Therapist section of the form. Nurse E also reported resident #1 lacked the ability to ambulate and was alert but confused at times. Licensed Nurse E also reported resident #1 moved around in the bed and had a tendency to scoot toward the left hand side of the bed. During an interview on [DATE] at 10:05 a.m., Administrative Nurse B reported the nurses completed the Therapist section of the side rail assessment forms. During an interview on [DATE] at 2:10 p.m., Direct Care Staff G reported he/she worked in the facility the morning of [DATE] when resident #1 expired. According to Staff G, Licensed Nurse D stepped out of the resident's room and told him/her to go get the other nurse right away. Staff G reported he/she ran to find the other nurse and then went to resident #1's room to assist as needed. Upon entering the room, Staff G recalled Licensed Nurse D said he/she found the resident hanging from the rail and had to pull the resident off the rail to lay him/her down. Direct Care Staff G assisted Nurse D to lift the resident from the floor onto the bed, and saw a light purple bruise to the area of resident #1's face below the jawline. During an interview on [DATE] at 4:30 p.m., Direct Care Staff F reported he/she found resident #1 partially off the bed on two occasions prior to [DATE], and each time staff repositioned the resident to a different position on the bed. During an interview on [DATE] at 9:30 a.m., Licensed Nurse H reported he/she worked the day shift on [DATE] and assisted Licensed Nurse D after staff found resident #1 on the floor next to the bed. According to Nurse H, staff had already moved the resident from a sitting to a lying position on the floor next to the bed by the time he/she entered the room. Nurse H recalled that Licensed Nurse C initially said he/she found the resident hanging there from the bed. Nurse H reported the resident had a small blue place on (his/her) chin that was new after staff moved the resident from the floor to the bed. Licensed Nurse H reported he/she saw the resident in bed one time with the rails raised, the air mattress in place, and his/her feet off the mattress and the rest of the body still on the bed. According to Nurse H, that was not unusual because the resident always hovered toward the left side of the bed. Nurse H could not recall implementation of new interventions to address the resident's bed positioning for safety after staff repeatedly found the resident partially off the bed on multiple occasions. During an interview on [DATE] at 10:01 a.m., Direct Care Staff I reported resident #1 always laid too far over on the left side of the mattress. Staff I reported that concerned him/her because the resident had a slick air mattress on the bed and could fall off the bed. According to Direct Care Staff I, he/she found resident #1's feet completely off the bed on several occasions, and said The only thing that kept (him/her) from slipping off the bed was the bed rail. Staff I reported he/she always told the charge nurses when he/she found the resident in that position and added, Nothing ever changed. They kept that air mattress on the bed anyway. During an interview on [DATE] at 10:15 a.m., Direct Care Staff J reported resident #1 always was way, way over on that left side of the bed and staff had to reposition him/her frequently, as the resident allowed, returning him/her to the middle portion of the bed. Although requested, the facility did not provide a policy related to side rail safety which was in effect at the time of the [DATE] incident with resident #1. According to the FDA (Food and Drug Administration) reference, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE], .Additional caution should be taken when using pressure reduction products .We recommend that steps are taken to ensure that the therapeutic benefit outweighs the risk of entrapment . The facility's undated Abuse, Neglect and Misappropriation of Funds policy listed multiple incidents considered as neglect. The list included, Failure to take precautionary measures, such as the use of bed rails, as ordered, to protect the health and safety of resident. The policy also directed staff to report allegations of abuse, neglect or misappropriation of property to the State agency within 24 hours. The facility failed to provide resident #1 with adequate supervision (assessment of side rail safety prior to use of side rails, assessment of continued use of side rails after placement of an air mattress on the bed, development/implementation of new interventions to ensure safety after staff repeatedly found the resident partially off the bed or positioned too close to the edge of the bed) to prevent accidents. Staff found resident #1 deceased , positioned in a seated position on the floor, with his/her head behind the raised bed side rail. The facility abated the IJ (Immediate Jeopardy) on [DATE] at 6:30 p.m. when they implemented the following: * Reviewed the facility Side Rail Assessment form and then developed/implemented a new assessment form. * Assessed all current residents with side rails for safety which included the necessity of side rails. * Evaluated all residents with air/pressure reduction mattresses who also used side rails to ensure resident safety. *Removed side rails with large gaps (in excess of 4 ¾ inches) from the beds of both residents who had those types of rails. * Developed/implemented a Side Rail Safety policy. * Provided education to all staff on forms/policies related to side rails. The deficient practice remained at a scope/severity of G after abatement. - Resident #2's clinical record included an [DATE] Admission MDS (Minimum Data Set) that identified the resident with no cognitive impairment, the need for extensive assistance of two staff for transfers and bed mobility, an inability to ambulate, and functional limitations in range of motion (ROM) on both sides of the lower extremities. The [DATE] Quarterly MDS identified the resident with long and short-term memory problems, moderately impaired decision making abilities, the need for extensive staff assistance for bed mobility and transfers, an inability to ambulate, and functional limitations in ROM on both sides of the lower extremities. Undated CAAs (Care Area Assessments) completed after the [DATE] Admission MDS included: ADLs (activities of daily living): The resident required extensive assistance of staff for all ADLs and transfers. Falls: The resident had a history of [REDACTED]. The CAAs did not include additional assessments related to the need for or use of side rails. Resident #2's care plan included: [DATE]: Described a medical [DIAGNOSES REDACTED]. As of [DATE], resident #2's care plan lacked goals/interventions related to use of side rails. A [DATE] Side Rail Assessment included three sections which had places for nurse assessment, therapist assessment, and then a section which listed all the documentation/action required if the determination was made to use side rails. The Therapist section of the assessment included responses to all areas but a therapist did not sign the assessment form. The third section of the form described side rails as indicated at the time of the assessment but did not include evidence staff completed the documentation required for use of side rails in the MDS, care plan, nurses notes, and attainment of a signed consent for side rail use from resident and/or legal surrogate. A licensed nurse signed the form. During an observation on [DATE] at 5:00 p.m., resident #2's beds had raised side rails on both sides of the bed. The rails were of an older style, with rounded off edges and vertical bars within the frame of the rail itself. Gaps within each section of the vertical bars measured 4 ,[DATE] inches wide X 16 ,[DATE] inches long. During an interview on [DATE] at 6:00 p.m., Licensed Nurse E reported the family owned the rails on resident #2's bed. Nurse E reported he/she never paid attention to the large gaps within the rails prior to this observation. During an interview on [DATE] at 9:00 a.m., Licensed Nurse E reported nurses completed side rail assessments as assigned to them, and the nurses completed the Therapist section as well as the Nurse section. During an interview on [DATE] at 10:05 a.m., Administrative Nurse B reported the nurses completed the Therapist section of the side rail assessment forms A Nurses Note dated [DATE] at 4:17 p.m. included, Resident has been assessed and reviewed for side-rail usage and is determined side rails are not indicated. Resident does require staff assistance for bed mobility, bed lowest position with floor mats. Family aware and in agreement, will reassess when needed/quarterly. On [DATE] at 9:00 a.m., resident #2's bed no longer had side rails attached to the bed frame. The resident had a low bed with a mat on the floor next to the bed. According to the FDA (Food and Drug Administration) reference, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE], Zone 1, the area within the side rail, should not contain gaps of greater than 4 ,[DATE] inches in order to reduce the potential for entrapment within the rail. The facility failed to ensure the environment remained free of potential hazards (use of side rails without adequate assessment for safety, side rails with large gaps within the rails) for resident #2. - Resident #3's clinical record included a [DATE] Annual MDS (Minimum Data Set) that identified the resident with no memory problems, moderately impaired decision making abilities, the need for extensive assistance of one staff for bed mobility and two staff for transfers, an inability to ambulate, functional limitations in range of motion (ROM) of both lower extremities, and use of a wheelchair for locomotion. The [DATE] Quarterly MDS identified the resident with long and short term memory problems, severely impaired decision making abilities, the need for extensive assistance of two staff for bed mobility and transfers, an inability to ambulate, and functional limitations in ROM on both sides of the lower extremities. Undated CAAs (Care Area Assessments) completed after the [DATE] Annual MDS included: ADLs (activities of daily living): Described the need for extensive staff assistance with ADLs and the ability to help at times with bed mobility. The CAA did not include additional assessments related to the need for or use of side rails. The care plan included: [DATE]: Described the resident's independence with bed mobility to make adjustments to position and use of side rails to assist with turning side to side. A [DATE] Side Rail Assessment included three sections which had places for nurse assessment, therapist assessment, and then a section which listed all the documentation/action required if the determination was made to use side rails. The Nurse section described resident #3 as ambulatory even though the MDS assessments noted the resident's inability to ambulate. The Nurse section also failed to identify the resident as forgetful or confused even though the most recent MDS assessment identified the resident with long and short term memory problems and severely impaired decision making abilities. The Therapist section of the assessment included responses to all areas but a therapist did not sign the assessment form. The third section of the form described side rails as indicated at the time of the assessment but did not include evidence staff completed the documentation required for use of side rails in the MDS, care plan, nurses notes, and attainment of a signed consent for side rail use from resident and/or legal surrogate. A licensed nurse signed the form. During an observation on [DATE] at 5:00 p.m., resident #3 lay in bed with two raised side rails. The resident had an air mattress/pressure reduction mattress on the bed. The rails were of an older style, with rounded off edges and vertical bars within the frame of the rail itself. Gaps within each section of the vertical bars measured 4 ,[DATE] inches wide X 16 ,[DATE] inches long. During an interview on [DATE] at 6:00 p.m., Licensed Nurse E reported the family owned the rails on resident #3's bed. Nurse E reported he/she never paid attention to the large gaps within the rails prior to this observation. During an interview on [DATE] at 9:00 a.m., Licensed Nurse E reported nurses completed side rail assessments as assigned to them, and the nurses completed the Therapist section as well as the Nurse section. During an interview on [DATE] at 10:05 a.m., Administrative Nurse B reported the nurses completed the Therapist section of the side rail assessment forms Nurses Notes dated [DATE] at 3:38 p.m. included, Resident has been assessed and reviewed for side rail usage and is determined side rails will be removed. Will continue use of air mattress with high low bed with floor mats During an observation on [DATE] at 7:35 a.m., resident #3 lay in a low bed with a mat on the floor next to the bed. The bed did not have side rails attached to the frame. According to the FDA (Food and Drug Administration) reference, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE], Zone 1, the area within the side rail, should not contain gaps of greater than 4 ,[DATE] inches in order to reduce the potential for entrapment within the rail. The document also addressed use of pressure reduction devices on bed with side rails which included, .Additional caution should be taken when using pressure reduction products .We recommend that steps are taken to ensure that the therapeutic benefit outweighs the risk of entrapment . The facility failed to ensure the environment remained free of potential hazards (use of side rails without adequate assessment for safety, side rails with large gaps within the rails, the use of a pressure reduction mattress on a bed with side rails) for resident #3. - Observation of residents on all hallways where residents lived on [DATE] at 5:00 p.m. revealed a total of 35 resident beds with side rails on either one side or both sides of the bed. The rails were of a variety of types, with most located on the upper ½ to ¼ of the bed. As requested, the facility provided evidence of completion of assessments of side rail safety for all 35 residents who used side rails. Upon review of the 35 documents, 0 were complete. The Side Rail Assessment form used by the facility included a section for assessment by a therapist . 0 of 35 side rail assessment forms contained signatures of a therapist and no indication a therapist participated in the side rail assessment. One section of the assessment form included a list of all documentation/action required if staff determined the need for side rails. Of the 35 forms, 0 included evidence staff completed all the action/documentation required even though the residents currently utilized side rails on their beds. During an interview on [DATE] at 9:00 a.m., Licensed Nurse E reported nurses completed the side rail assessments assigned to them. According to Nurse E, therapists never completed the Therapist section of the form. During an interview on [DATE] at 10:05 a.m., Administrative Nurse B reported nurses completed the Therapist section of the side rail assessment forms rather than a therapist. The facility failed to adequately assess for side rail safety prior to use of side-rails for 35 residents.

The facility census totaled 62 residents and 28 were included in the sample. The sample included 6 residents for review of care and services related to pressure ulcers or repositioning to prevent pressure ulcer development. Based on observation, interview and record review the facility failed to ensure a shearing redness area on resident #31's coccyx healed rather than progress to a stage 2 (open) pressure ulcer by a failure to monitor and provide needed care and service to promote healing. The facility failed to ensure direct care staff provided assistance with repositioning to prevent pressure ulcer development for 2 of 6 sampled residents at risk for pressure ulcer development. (#31 and #51) Findings Included: - The facility's face sheet for resident #31 included an admission date of [DATE]. The signed physician's orders [REDACTED]. The admission MDS (Minimum Data Set 3.0, a required assessment) with an ARD (Assessment Reference Date) of 9/26/11 identified the resident with severe cognitive impairment per staff assessment. The MDS indicated the resident required extensive assistance with all ADLs (Activity of Daily Living) except personal hygiene which required total assistance. The MDS identified the resident as always incontinent of bowel and bladder. The MDS identified the resident with 1 stage 1 pressure ulcer, 1 stage 2 pressure ulcer and 1 stage 3 pressure ulcer present on admission. The National Pressure Ulcer Advisor Panel (NPUAP), 2007 defined a pressure ulcer as 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. NPUAP defined pressure ulcers with the following staging; Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. The area may also present as an intact or open/ruptured serum-filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. The area may include undermining and tunneling. The admission MDS with ARD of 9/26/11 also identified the resident with an infection of the foot and listed the following preventative measures; pressure reducing device for chair and bed, turning/reposition program, nutrition or hydration interventions, ulcer care, application of non-surgical dressings and ointments/medications other than to the feet. The CAA (Care Area Assessment, a further required assessment) for pressure ulcer dated 9/26/11 identified the resident with risk for pressure ulcer development and admitted with pressure ulcers on the right heel, foot, inner knee and buttocks. The CAA identified the resident as incontinent of bowel and bladder and required extensive assist of 1-2 staff with bed mobility. The care plan dated 10/19/11 included the following guidance to staff; "I was admitted with a pressure ulcer and redness to my buttocks. These areas have been assessed by a wound nurse and treatment protocols are in place." The care plan directed staff to place a pressure reducing device on the resident's bed and in the wheelchair to help minimize skin issues. The plan directed staff to ensure that the resident's position changed frequently at least every 2 hours. The plan directed staff to keep the resident's skin clean and dry with a pillow between the resident's legs and "EZ" boots (pressure relieving) to the resident's feet. The daily skilled nurse's note dated 9/19/11 identified the following pressure ulcers present on admission; shearing to the coccyx area, an area on the right heel, an area on the right top of the foot and a blister on the top of the right foot. The note included measurements for the right heel, right top of foot and the blister but failed to include the size of the shearing on the coccyx area. The circled area of the body diagram encompassed the ankle area as well. The wound evaluation flow sheets dated 9/22/11 only identified areas to the right heel, the right anterior foot and right ankle without staging. The record lacked a wound evaluation flow sheet for the sheared area on the coccyx and therefore, no measurements at the time of admission were available for review. Record review revealed a physician's telephone order dated 9/19/11 to apply [MEDICATION NAME] (moisture barrier topically to buttocks twice a day. The first wound evaluation flow sheet that identified the coccyx pressure ulcer was dated 10/21/11 and identified the coccyx area as open with serosanguineous (containing or consisting of both blood and serous fluid) drainage and a yellow wound bed. The wound measured 2.5 cm (centimeters) x 3.0 cm. On 11/17/11 at 1:55 p.m. a discussion took place with Administrative nursing staff H about the concern with the pressure ulcers for this resident and the lack of wound report sheets or evidence of monitoring. The discussion included a request for the facility to provide additional information. Later that day at 5:30 p.m., an interview with Administrative nursing staff H about further evidence of monitoring of the pressures ulcers for this resident resulted in no additional information provided. On 11/21/11 a fax from the facility included a wound evaluation report dated 10/21/11 that changed the area identified as left buttock to coccyx and no other documentation about the coccyx pressure ulcer. On 11/21/11 at 11:30 a.m. a discussion with Administrative staff Z took place about the lack of measurement or monitoring of the coccyx pressure ulcer. On 11/22/11 at 11:47 a.m. the facility faxed 3 wound evaluation report sheets. The sheet dated 10/21/11 included a line through the words left buttocks and written to the side was coccyx and included the description above. The sheet provided the recommendations to change the treatment to clean with normal saline or wound cleanser, apply calcium alginate on wound bed and cover with a dry dressing every day and as needed. The sheet dated 10/28/11 included measurements of 2.5 x 2.5 cm 70% red granulation and 30% yellow slough with serosanguineous drainage and the same treatment. The 11/11/11 wound evaluation report identified the area with no drainage, no slough and measured 2.0 x 1.0 cm. Observation on 11/14/11 at 1:30 p.m. revealed the resident rested in bed; propped on his/her right side with a pillow to his/her back. Observation at 1:30 p.m., 2:30 p.m., 3:20 p.m. and 4:00 p.m. revealed the resident remained in the same position on his/her right side with a pillow to his/her back. The resident remained in the same position without a change for greater than 2 and 1/2 hours. Observation on 11/16/11 at 8:46 a.m. revealed the resident rested in bed on his/her right side with a pillow to his/her back. Observation at 9:20 a.m., 10:00 a.m., 11:00 a.m. and 11:30 a.m. revealed the resident remained in the same position on his/her right side with the pillow in the same position against his/her back. The resident remained in the same position for greater than 2 hours and 45 minutes. Observation at 11:45 a.m. revealed the resident in his/her wheelchair in the dining room. Observation on 11/17/11 at 8:48 a.m. revealed Licensed nursing staff J and Administrative nursing staff K performed dressing changes for this resident which included 3 areas. Licensed nursing staff J gathered supplies from the treatment cart (items all in factory sealed packages), entered the resident's room and placed the packages on the top of a bedside table without a barrier. Licensed nursing staff J washed his/her hands and opened the packages 1 by 1. As the nurse opened each package he/she removed the contents with his/her bare hands and placed the contents on the exterior part of the package which was previously handled with bare hands. Licensed nursing staff J then removed a pair of scissors from his/her uniform pocket (an area considered to be dirty) and used the scissors to cut a portion of the dressing. The nurse returned the scissors to his/her pocket and placed the cut portion of the dressing on the exterior surface of the package. Administrative nursing staff K requested to use the scissors to cut away the gauze wrap holding the dressing in place on the resident's right ankle. Licensed nursing staff J removed the scissors from his/her pocket and placed them directly on the bed. Administrative nursing staff K used the scissors to cut away the gauze wrap and then placed the scissors on the mattress and Licensed nurse J placed the scissors back in his/her pocket. Observation revealed the bandage stuck to the wound with dried red drainage. Licensed nursing staff J applied clean gloves to his/her hands and used normal saline to moisten the dressing while he/she gently pulled the dressing away from the wound. Licensed nursing staff J, without removing the now soiled gloves, and washing his/her hands, removed the scissors from his/her pocket to cut another piece of the wound dressing for the right ankle while holding the entire wound dressing with the soiled gloves. Licensed nursing staff J held the resident's lower leg with 1 hand while still wearing the same soiled gloves. Licensed nursing staff J then removed the soiled scissors from his/her pocket to cut a new wound dressing for the right heel wound. Licensed nursing staff J began to wrap the dressing with a gauze strip "Kerlix". Administrative nursing staff K assisted with the wrapping of the resident's right ankle and foot. The Kerlix brushed on the bed and came in contact then with the wound dressing. Both nurses removed his/her gloves and washed his/her hands before donning new gloves to treat the third area. Licensed nursing staff J removed the soiled dressing from the coccyx wound and without changing his/her gloves or washing his/her hands used normal saline to clean the wound and again removed the scissors from his/her pocket to cut a piece of wound dressing while wearing gloves soiled by the handling of the soiled dressing. Licensed nurse J and Administrative nurse K completed all the dressing changes, placed the "EZ" boots to the resident's feet and a pillow between the resident's knees. At that time, Administrative nursing staff K unfastened the resident's incontinent brief, confirmed the resident was incontinent of urine and placed the wet brief back over the clean dressing and turned on the call light and reported to Licensed nurse J that he/she had summoned an aide to change the resident. Observation of the coccyx wound during the dressing change on 11/17/11 which began at 8:48 a.m. revealed an open area the approximate length of a quarter (2.4 centimeters). The edges of the wound gapped open with white edges and pink wound bed without drainage. The facility's policy titled, "Dressings Dry/Clean" taken from the Infection Control Policy and Procedure Manual revised August 2007, directed staff to do the following: 8. Put on clean gloves, Loosen tape and remove soiled dressing. 9. Pull glove over dressing and discard into plastic or biohazard bag. 10. Wash and dry your hands thoroughly...14. Put on clean gloves...16. Cleanse the wound...18. Apply the ordered dressing and secure with tape...20. Remove disposable gloves and discard in designated container. Wash and dry your hands thoroughly. The facility's policy titled, "Handwashing/Hand Hygiene" taken from the Infection Control Policy and Procedure Manual revised August 2007, listed the objective as "To prevent and to control the spread of infectious diseases". The policy directed staff to 1. Appropriate 10 to 15 second handwashing with antimicrobial or non-antimicrobial soap and water must be performed under the following conditions: c. After contact with blood, body fluids, secretions, mucous membranes or non-intact skin; d. After removing gloves; e. After handling items potentially contaminated with blood, body fluids or secretions...3. The use of gloves does not replace handwashing. On 11/17/11 at 1:55 p.m. during a review of the infection control program Administrative nurse H reported an expectation for staff to clean the scissors before and after use, that the pocket is considered dirty and that staff should change gloves and wash hands between removal of the soiled dressing and application of a clean dressing. The facility failed to ensure a shearing redness area on this resident's coccyx healed rather than progress to a stage 2 (open) pressure ulcer by a failure to monitor and provide needed care and service to promote healing. The facility failed to ensure direct care staff provided assistance with repositioning to prevent pressure ulcer development for this resident with a history of multiple pressure ulcers and at risk for development of pressure ulcers. - The facility face sheet for resident #51 included an admission date of [DATE]. The signed physician's orders [REDACTED]. The quarterly MDS (Minimum Data Set 3.0, a required assessment) with an assessment reference date of 10/11/11 identified the resident with severe cognitive impairment based on staff assessment and totally dependent on 2 staff for bed mobility, transfers, toileting and personal hygiene. The MDS identified the resident as totally incontinent of urine and bowel. The care plan dated 10/12/11 directed staff to assist the resident with 2 people for bed mobility and reposition frequently, at least every 2 hours, and identified the resident as at risk for pressure ulcer development. The plan directed staff to check the resident for incontinence and change the incontinent brief/soiled brief every 2 hours. Observation on 11/16/11 at 8:46 a.m. revealed the resident rested in bed on his/her left side with a pillow to his/her back. Observations at 9:20 a.m., 10:00 a.m., 11:00 a.m. and 11:30 a.m. revealed the resident remained in the same position on his/her left side with a pillow in the same position against his/her back. The resident remained in the same position for greater than 2 hours and 45 minutes. Observation at 11:37 a.m. revealed direct care staff F and G prepared to get the resident up for lunch, and after the transfer to the wheelchair, direct care staff F wheeled the resident to the dining room. Interview at that time, with both direct care staff F and G confirmed neither direct care staff had provided care for the resident since putting him/her to bed after breakfast and they were assigned to the resident's care. The facility failed to ensure direct care staff provided planned care and services related to repositioning for prevention of pressure ulcers for this resident assessed at risk for the development of pressure ulcers.

The facility census totaled 62 residents with 28 included in the sample. The sample included the review of 6 residents for accidents and or falls. Based on observation, interview and record review, the facility failed to promptly develop interventions to ensure the environment remained as free of accident hazards as possible for 1 of 6 residents at risk for falls (#87). Resident (#87) fell and sustained a head injury that required staples to close a head laceration at a local hospital. The facility failed to investigate the causal factors for bruising of unknown origin to ensure the environment remained as free of accident hazards as possible for 1 sampled resident (#73) at risk for falls. The facility identified 6 residents as at risk for elopement (leaving the facility without staffs' knowledge) and the facility failed to ensure the 6 residents' environment remained as free of accident hazards as possible by a failure to ensure all exit doors remained locked to prevent the accidental exit of wandering, confused residents at risk for elopement. Findings included: - Review of the recapitulation of orders dated 10/5/11 identified resident #87 with the [DIAGNOSES REDACTED]. According to the closed record, the resident admitted to the facility on [DATE]. Review of the undated initial care plan revealed the following: "Fall risk: Orientate to room, provide verbal cueing for safety, keep call light in reach of resident/bed, toilet schedule q (every) 2 hours, ensure hose(stockings or socks)/slippers/clothes fit, side rail assessment, educate resident on calling for assistance, mat to floor by bed (written in, undated), anti-tippers placed on w/c (wheelchair) and auto lock brakes on wheelchair---(written in, undated)." Review of the physical therapy evaluation dated 10/6/11 assessed the resident as "Pt (patient) A&O (alert and oriented) to self only, very impulsive and decreased safety awareness. When pt is ready to sit down, pt attempts to sit even without chair behind pt. Pt amb (ambulated) x 20 feet with min (minimal) assist and FWW (front-wheeled walker). Pt demo (demonstrated) impulsiveness and would try to sit down with no warning without chair behind pt. Pt demo poor endurance during eval (evaluation) and treatment. Fatigues easily and appears very lethargic." Review of the nurse's notes revealed on 10/7/11 at 10:35 p.m., the staff found the resident walking in his/her room, and sustained a skin tear on his/her left knee. The staff notified the family and the physician. Review of a nurse's note, dated 10/8/11 but not timed, identified the resident "Stands up at times by self without difficulty. But difficult to transfer with assist." The note also identified the staff gave the resident phenobarbital by mouth for restlessness/agitation. On 10/9/11 at 11:30 a.m. staff identified the resident self-propelled a wheelchair in the living room, stood up independently, lost his/her balance and hit the back of his/her head on the end table, then fell to floor onto his/her right hip. Staff noted a laceration to the back of the resident's head that bled profusely. Family arrived 5 minutes later and requested staff to send the resident to the emergency room for evaluation. The staff called the physician and obtained an order to send the resident, who returned later that day with 7 staples to close the laceration. Review of the initial care plan revealed that after the fall with the head injury on 10/9/11, staff added the intervention of a personal body alarm to the wheelchair to alert staff when the resident became restless and started to attempt to stand independently. Staff knew the resident became restless and attempted to stand independently from the wheelchair, but failed to implement an intervention to keep the resident as safe as possible until after the resident had a fall with a head injury. Interview on 11/17/11 at 12:53 p.m. with licensed nursing staff J revealed he/she helped to care for the resident. Staff J said that the resident had lived in another facility prior to coming to this facility. When the resident first came here staff J stated the resident had a history of [REDACTED]. I mean tall and large. And, with his/her size, when he/she fell , he/she fell hard." Staff J confirmed the resident experienced falls during his/her time at the facility. "In fact, one of them he/she needed either staples or stitches in his/her head." The facility failed to promptly develop and implement interventions to keep a resident at risk for falls safe when the resident started to exhibit restlessness and attempted unsafe maneuvers, such as attempts to stand independently. This failure allowed for the resident to fall and sustain a head injury with a laceration that required 7 staples to close at a local hospital. - Review of the signed recapitulation of physician's orders [REDACTED]. Review of the admission MDS (Minimum Data Set-a required assessment) with an ARD (Assessment Reference Date) of 6/16/11 identified the resident with moderately impaired cognition, required extensive assistance from 1 staff with bed mobility, extensive assistance from two staff with transfers, limited range of motion on one side for both the upper and the lower extremities, not steady with surface-to-surface transfers, only able to stabilize with human assistance, with a fall history upon admission, no falls in the 2-6 months prior to admission, and no falls since the resident admitted to the facility. Review of the Fall CAA (Care Area Assessment) dated 6/16/11 identified the following: "I am very unstable when transferring and standing. I am weak on my right side and need human assistance to steady. "I forget to call for help. I am taking antidepressant medications. I fell prior to admission. I have neuropathy in both my legs that decrease my sensation." Review of the quarterly MDS, with an ARD of 9/3/11, identified the resident with severely impaired cognition, required extensive assistance from two staff with bed mobility, transfers, limited range of motion on one side with the upper and lower extremities, not steady with surface-to-surface transfers only able to stabilize with human assistance, with falls since admission, and with 2 or more falls with injuries (except major injuries) since admission. Review of the care plan, last revised on 11/7/11, identified the following: "I have a history of falls. I fell on [DATE] and fractured my right wrist trying to transfer myself from the bed to the wheelchair. I am still at high risk for future falls because of my decreased safety awareness, dementia, and right-sided weakness. I believe I can still do things I can't and sometimes will not use my call light to ask for assistance. These falls can be minimized through PT/OT (Physical therapy/Occupational therapy) programs to increase my strength, ROM (range of motion), and safety awareness. Keep frequently used items within easy reach. Maintain regular toileting at set intervals and/or a continence program. Refer to B&B (bowel and bladder) section for my toileting plan. Use a low-rise bed that measures 14 inches from floor " On 8/29/11, staff added the following information: "lowered to floor - monitor placement of foot during transfer." Review of the facility's fall investigation, dated 10/28/11 (for the fall on 10/28/11) identified the following: "(Family member) came to nurse and said '(Parent) fell ' When we (staff) got into room res (resident) had been made comfortable with pillows under his/her head and to his/her back. No one saw the actual fall or how he/she landed - an empty trash can was near res but no one thought anything of it. (Family member) revisited at 11:00 p.m. and noticed that trash can was cracked so it was thrown away - Several days later a large bruise to inner right thigh was noted. The investigation revealed the family member attempted to transfer the resident independently from the wheelchair to the resident's bed when the resident's legs gave way and the resident fell to the floor. Staff in-serviced the family to always ask for help. The investigation identified "no injuries other than bruise noted to right hip." Review of a fall investigation dated 11/6/11 identified at 3:45 a.m., an aide heard someone calling for help. The aide walked into the resident's room and found the resident had slid out of bed onto the floor. The aide got the nurse, who assessed the resident, determined there were no injuries, and 3 staff then helped the resident back into bed. After the fall on 11/6/11, the staff updated the resident's care plan to include the following interventions: "11/6/11 Mat to Rt (right) side of bed for safety. 11/6/11 I had fall bruise noted. 11/7/11 please monitor bruise for changes." Review of the nurse's notes revealed that on 11/7/11 staff documented they called the resident's Durable Power of Attorney (DPOA) and notified him/her of bruising on the right inner thigh. Review of an unusual skin report, dated 11/12/11, revealed a night shift aide documented "Bruise to right inner thigh gotten bigger. At 4:00 a.m. I went to change (resident) and I noticed when I went to pull up his/her pull-up that the bruise on his/her inner thigh seemed much bigger from a few nights ago when I last worked so I went to (charge nurse) and told him/her I thought it looked bigger. I also told (another aide) and asked him/her if he/she would come look because he/she is the one I reported it to when I first noticed the bruise on November 7, 2011. He/she agreed it was much larger and so later (charge nurse) and I went back in to measure it.' The charge nurse documented the size of the bruise had increased, "Bruise to the right inner thigh 26 cm (centimeters) x 25 cm was 18 cm x 17 cm when first measured 5 days ago. Continues with bruise from falls, 11-12-11 physician notified and updated." The nurse's notes, dated 11/12/11 at 4:00 a.m. identified the resident "resting quietly in bed, turned and repositioned, bruising to the right inner thigh measured and compared to the previous measurement, 26 cm x 25 cm now and 18 cm and 17 cm when measured on 11/7/11, pain management per MAR (Medication Administration Record), another bruise to the left inner thigh measuring 11 cm x 6 cm. bed in low position, landing strip on, call light within reach, will continue to monitor." The note first identified the bruise on the inner left thigh, almost 2 weeks after the resident's fall from the family member transfer on 10/28/11. Observation on 11/16/11 at 7:21 a.m. revealed direct care staff N and F assisted the resident from the bed to the wheelchair. Observation revealed the staff used a gait belt and helped the resident to stand and pivot prior to sitting in the wheelchair. Observation of the resident's legs revealed the resident had a diffuse, large discoloration/bruise on the right leg and discoloration on the left leg. The discoloration on both legs varied in color from small sections of dark purple to light yellow/green. The resident, when asked, identified the bruises did not hurt, and said they just "woke up one morning and there they were." In an interview on 11/17/11 at 12:53 p.m., Licensed nursing staff J identified the resident had several falls because he/she forgot that he/she can not stand, and would try to stand up out of a wheelchair or out of bed. As far as those bruises, (a family member) actually tried to help him/her to bed and (the resident) had a fall and that is what caused the bruising on the inner thighs. When asked how it happened to both thighs, Staff J said "I'm not sure." On 11/17/11 at 2:11 p.m., direct care staff X stated that he/she was aware of the resident's bruises, and said they happened as a result of a fall when the family tried to transfer him/her. On 11/17/11 at 5:10 p.m., Administrative Nurse H identified that when a resident developed a new bruise, staff were to measure it and then an investigation occurs to determine what caused it, if at all possible. When asked if Staff H was aware of the resident's bruises to the inner thighs, Nurse H stated that he/she was aware and said those were caused from a fall that happened when a family member tried to transfer the resident independently and the resident fell . When asked for the investigation into the development of the bruises, Staff H provided an investigation into the bruise on the right inner thigh, but failed to provide an investigation into the bruise on the left inner thigh. The facility failed to investigate for the cause of a bruise of unknown origin on the inner thigh of a resident to ensure the resident's environment remained as free of accident hazards as possible and prevent additional occurrences of bruising. - During initial tour of the facility on 11/14/11, observation at 10:05 A.M. revealed an exit door on Sweetwater Creek hall (rooms 101-118) opened without entering a pass code and without alarming. Outside, observation revealed a busy public road with cars driving by, approximately 15 yards away. At 10:08 A.M. on 11/14/11, Direct care staff Y reported he/she did not think the door opened without a code, and confirmed the facility had a lot of "wanderers". At 10:09 A.M., Administrative nursing staff K reported the door had a fire emergency system but reported he/she was not sure how the door worked. Staff K confirmed the door had a wander guard system, and would alarm if residents passed through the sensor. At 10:14 A.M. that same day, Maintenance staff C reported when the door stayed open longer than 3 seconds, an alarm sounded. Staff C also reported if a resident with a wander guard (a bracelet system to ensure confused and wandering residents did not accidentally leave the facility) came within a certain distance of the doors, the doors would automatically lock and no one could go in or out of the door. At 10:21 A.M. on 11/14/11 Nursing staff B opened the door without pushing a code to unalarm/unlock it, held the door open for approximately 10 seconds and reported he/she did not "know it did that." Staff B confirmed it should need to have a code entered to open the door, and confirmed a busy street was right outside the door. Staff B walked away, and then at 10:24 A.M., reported he/she would go stand by the door for safety. On 11/14/11 at 10:34 A.M., Maintenance staff C reported he/she checked the door daily, except for weekends, to ensure it worked properly, but confirmed the door opened without a code and created access to the busy street outside. Staff C reported Maintenance staff L checked the door the previous Friday. At 10:41 A.M. on 11/14/11, observation revealed Maintenance staff L worked with the door. Staff L raised his/her arm and felt along the magnetic strip at the top, then pulled down a 2-3 inch piece of weather/fire stripping. Staff L then closed the door. Observation revealed, Staff L had to enter a code on the key pad next to the door prior to it opening again. On 11/14/11 at 10:45 A.M. Maintenance staff L provided the daily maintenance log which revealed a box where staff marked when they checked the doors, reporting he/she made sure the doors were locked, the door closed when let go, and the key pad next to the door worked properly. The record revealed the door had not been checked since 11/10/11, 3 days prior. Staff L also reported maintenance staff completed Exterior Grounds and Facility checks weekly, and confirmed the doors were checked from the outside then. Staff L reported the maintenance staff needed to check out how the doors looked, check for anything that needed to be replaced, and looked at hinges and hardware. Staff L also reported maintenance staff checked the weather stripping at the beginning of each month because it sometimes became loose or went bad, and provided a weather stripping maintenance log. Review of the Monthly Inspection Report, under "General Building Construction" revealed "Weather Stripping and Seals" with an "F" written next to it on 11/8/11. Staff L reported the "F" meant fair. Staff L reported things in "fair" condition went on a list, and needed to be fixed, but were not a priority. At 11:07 A.M. on 11/14/11 Maintenance staff C reported, when doing the Exterior Grounds and Facility checks, he/she only checked to ensure the doors did not open from the outside, and then opened the door using the keep pad. Staff C also reported maintenance staff attempted to fix the "F" items on the "General Building Construction" within the month. On 11/15/11 at 7:15 A.M., Maintenance staff L reported the exit doors were always locked, and when a resident wearing an ankle bracelet came within a certain distance of the door, an alarm at the door chirped for 90 seconds and the door locked down to prevent anyone leaving or coming in from that exit door. During that interview, Administrative staff Z confirmed the door's wander guard locking function would not have engaged because the door already did not lock related to a piece of weather stripping causing the door not to latch. Review of that same "General Building Construction" log revealed the "Weather Stripping and Seals" were in fair condition during the 10/12/11 check, 9/12/11 check, and 8/17/11 check. At 11:09 A.M. Maintenance staff C stated, "I think the whole building needs to be redone, so I just do what I can do." Staff C reported he/she spot checked doors and windows for their stripping, but did not have a place to write down what he/she had fixed or when. Staff C also reported he/she checked the functioning of the facility's wander guard system (including the bracelets worn by the residents) weekly on Fridays, with the last check on 11/11/11. At 11:56 A.M. on 11/14/11, Administrative nursing staff H provided a list identifying 8 cognitively impaired, independently mobile residents. Staff H identified 6 of the residents (including resident #66) had wander guards applied because they were considered elopement risks. Review of the 11/11/11 log revealed only 4 residents currently in the facility with wander guards. The log was used by maintenance staff to identify the wanderguards they were to check and to document the functioning of wander guards. On 11/15/11 at 8:10 A.M. Maintenance staff C reported he/she checked the wander guard system by scanning the bracelets to ensure they would lock the doors and sound an alarm if the resident attempted to leave. Administrative nursing staff K or Administrative nursing staff H notified staff C if a resident had a wander guard. Staff C reported resident #66 had been placed on the list "yesterday". During an interview on 11/15/11 at 8:20 A.M., Administrative nursing staff H reported nursing needed to notify maintenance when a resident had wander guards applied. Staff H reported resident #66 had a wander guard in place on 8/24/11, and the other resident not on the wander guard maintenance list had a bracelet placed on 3/16/11 as noted in the resident's care plan. Staff H reported nursing also monitored the wander guard bracelets, mainly checking for placement. Staff H looked at the TAR (Treatment Administration Record) for both residents not on the maintenance wander guard log and confirmed neither resident's TAR had any note directing staff to monitor for functioning of the wander guards. Observation at 5:10 p.m. on 11/17/11 revealed resident #66, who lived down Meadowlark Lane, at the end of Cedar Brook hall pushing up and down on the door handle of an exit door leading to outside. Review of the facility's undated "Resident Wander guard Tracking" policy revealed, "All residents who are assigned a wander guard tag will need to be tracked on the wander guard log. The Maintenance director will test the tags on a regular basis (not to exceed weekly). The tag has a 3-5 year life." The facility failed to ensure that all exit doors remained locked to prevent the accidental exit of a wandering, confused resident at risk for elopement.