Every finding on record at Willow Point Rehabilitation and Nursing Center

The facility identified a census of 29 residents. The facility had one main kitchen and one main dining area. Based on observation, record review, and interview the facility failed to ensure the director of food and nutrition services had the required qualifications of a certified dietary manager (CDM). This placed residents at risk for unmet dietary and nutritional needs. Findings included: - On 10/22/24 at 07:20 AM Dietary BB stated she had not taken her test to get her dietary manager certification but was scheduled to take it on 11/16/24. Dietary BB stated that the registered dietician was available to call anytime but only came to the facility twice a month to review the residents' diet. The facility did not provide a policy regarding the CDM. The facility failed to ensure the director of food and nutrition services had the required qualifications of a CDM. This placed residents at risk for unmet dietary and nutritional needs.

The facility identified a census of 29 residents. The facility had one main kitchen. Based on observation, and interview, the facility failed to ensure staff stored food items by the professional standards for food service safety. This placed residents at risk of foodborne illness and cross-contamination (the transfer of harmful substances to food). Findings included: - Upon entry of the kitchen on 10/22/24 at 07:11 AM, observation revealed the coffee station table and the area had a dry, brown-tinged towel in front of the coffee maker. In the dishwasher area, there were two trays with dishes left from the night before that had not been washed. The dishwashing area had a musty odor. In the drink refrigerator, a pitcher of some sort of juice or drink was not labeled or dated. The pitcher of Kool-Aid lacked a label or date. There was a tray with 12 clear plastic drinking glasses filled with juice and three clear plastic drinking glasses filled with milk that lacked a cover, label, or date. The condiment refrigerator had a covered and labeled salad with a date of 10/18/24. Two covered fruit cups lacked a label or date. Two bowls of applesauce and peaches lacked a label or date. On 10/22/24 at 07:20 AM Dietary BB stated she had not had the chance yet to go through the refrigerators and freezers this morning to look for any items that had not been labeled or dated. Dietary BB stated she expected all food items to be dated and labeled when opened or placed into a new container or sealed bag. Dietary BB stated that juice and milk glasses should have a plastic wrap cover when stored in the refrigerator as well as a date on them. The facility did not provide a policy on food storage. The facility failed to ensure staff stored food items by the professional standards for food service safety. This placed residents at risk of foodborne illness and cross-contamination.

The facility identified a census of 29 residents. Based on interviews and record review, the facility failed to implement a policy that prohibited hiring employees found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law when the facility failed to conduct background screening on two employees. This deficient practice placed the affected residents at risk for abuse, neglect, misappropriation, or mistreatment. Findings included: - On 10/23/24 at 09:00 AM a review of staffing for license verification, in-service training, and background checks was completed. An employee review of Licensed Nurse (LN) G revealed a hire date of 08/30/23. The facility was unable to provide evidence a criminal background check had been completed by the facility for LN G. An employee review of Housekeeping U revealed a hire date of 06/06/24. The facility was unable to provide evidence a criminal background check had been completed by the facility for her. On 10/23/24 at 10:45 AM Administrative Staff A stated he was not sure why the employees were missing background checks in their files but would make sure all other employee's files were reviewed. On 10/23/24 at 11:45 AM Administrative Staff A provided a receipt dated 10/23/24 for background checks for both LN G and Housekeeping U. The facility's Abuse, Neglect, and Exploitation policy revised 09/2023 indicated the facility will provide staff that are knowledgeable in identifying potential for abuse. The policy indicated the facility will screen all employees to identify previous concerns of abuse, exploitation, and neglect. The policy indicated all employees will have criminal background checks upon hire, transfer, or re-hire. The facility failed to conduct a criminal background check as required for two employees. The employees were allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This deficient practice placed the affected residents at risk for abuse, neglect, misappropriation, or mistreatment.

The facility identified a census of 29 residents. The sample included 13 with two reviewed for accidents. Based on observation, record review, and interview the facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area, and out of reach of seven cognitively impaired, independently mobile residents. This placed the affected residents at risk for preventable accidents and injuries. Findings Included: - On 10/22/24 at 07:04 AM an inspection of the 100-hall revealed the restorative room was left unlocked and unsupervised. An inspection of the sink area of the room revealed several types of multiple-purpose cleaners in an unlocked cabinet underneath the sink. The bottles contained the warning, Keep out of reach of children, hazardous to humans can cause eye irritation, harmful if swallowed. On 10/22/24 at 07:14 AM Certified Nurse's Aide (CNA) stated the chemicals under the sink should be secured under the sink or the door should be closed. She stated chemicals should not be within reach of the residents. On 10/24/24 at 12:15 PM Administrative Nurse D stated potentially hazardous cleaning products should be locked up in closets and inaccessible to the residents. The facility's Accidents and Fall Management policy revised 12/2017 indicated each resident will be assessed based on each resident's individual identified risks. The policy noted staff will ensure a safe care environment to include transfer equipment, spills, clutter, and potential room hazards. The facility failed to secure potentially hazardous cleaning chemicals in a safe, locked area, and out of reach of seven cognitively impaired independently mobile residents. This placed the affected residents at risk for preventable accidents and injuries.

The facility identified a census of 29 residents. The sample included 13 residents with two residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to ensure that Resident (R)24's bed rails were removed as indicated per her most current side rail assessment. The facility additionally failed to ensure that R5, R12, and R17 had safety assessments for the use of side rails that acknowledged the risks from their low air-loss mattresses, risk for entrapment, consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed the residents at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. Findings Included: - The Medical Diagnosis section within R24's Electronic Medical Records (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (difficulty swallowing), insomnia (difficulty sleeping), encephalopathy (a broad term for any brain disease that alters brain function or structure), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). R24's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS indicated she had a history of delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue). The MDS indicated she had bilateral upper and lower extremity impairments. The MDS indicated she required substantial to maximal assistance from staff for dressing, bed mobility, transfers, bathing, and toileting. The MDs indicated she had no falls since her admission. The MDS indicated she was at risk for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) with a history of Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcer. The MDS indicated she had pressure-reducing devices for her wheelchair and bed. The MDS indicated she had no bed rails. R24's Functional Abilities Care Area Assessment (CAA) completed 01/31/24 indicated she required substantial to maximal assistance with her activities of daily living (ADLs). The CAA instructed staff to give verbal cues to and allow her to participate in the care process. R24 Care Plan initiated 03/14/23 indicated she was at risk for falls, pressure injuries, and a decline in her ADLs related to her medical diagnoses and limited mobility. The plan indicated she required extensive assistance from staff for bed mobility, transfers, dressing, bathing, toileting, and ambulation in her wheelchair. The plan noted she was at risk for pressure injuries and had a low air-loss mattress on her bed. The plan noted she had assist bars installed on her bed. The plan indicated she used them for repositioning. R24's EMR revealed a Clinical Health Review completed on 08/16/24 noting an assessment was completed for side rails and restraints. The assessment indicated R24 was able to get into and out of bed with or without assistance. The assessment indicated she had impaired memory, cognition, or decision-making functioning. The assessment indicated side rails, grab bars, or transfer bars will not be utilized at this time due to the assessment findings. The evaluation did not acknowledge the use of R24's low air-loss mattress. A review of the low air-loss mattress manufacturer's operation (Drive Model #14048 Series) manual indicated the usage of bed rails with the air mattress system should be assessed based on the risk of entrapment. R24's EMR lacked a safety assessment for the use of her bed cane which addressed the risk of entrapment between the device and the mattress, a consent for the use, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the bed canes. The facility was unable to provide this documentation as requested on 10/24/24. On 10/22/24 at 10:17 AM R24 watched television in her bed. Her bed was in a low position and had bilateral side rails at the head of her bed. She had a bariatric (associated with obesity) low air-loss mattress system. On 10/24/24 at 08:55 AM Licensed Nurse (LN) G entered the room and confirmed that R24 had grab bars (side rails) to assist with repositioning and transfers. He stated staff should check the side rails to ensure no gaps or entrapment hazards were created by the bed or bars. He stated he was not sure if the side rail assessments included the risks associated with the low air-loss mattresses. On 10/24/24 at 12:15 PM Administrative Nurse D stated the side rails assessments were part of the clinical assessment completed quarterly. She stated the assessment should include risks associated with the railing, bed, and environment. The facility did not provide a bed rail policy. The facility failed to ensure that R24's bed rails were removed as indicated per her most current side rail assessment and further failed to ensure safety assessments acknowledged the risks when used with a low air loss mattress. This placed the R24 at risk for impaired safety related to the risks associated with the use of side rails. - The Medical Diagnosis section within R5's Electronic Medical Records (EMR) noted diagnoses of Alzheimer's Disease (progressive mental deterioration characterized by confusion and memory failure), dysphagia (difficulty swallowing), seizures (violent involuntary series of contractions of a group of muscles), epilepsy (brain disorder characterized by repeated seizures), left-sided hemiparesis (muscular weakness of one half of the body) and major depressive disorder (major mood disorder). R5's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of eight indicating moderate cognitive impairment. The MDS indicated he had bilateral upper and lower extremity impairments. The MDS indicated he required substantial to maximal assistance from staff for dressing, bed mobility, transfers, bathing, and toileting. The MDS indicated he had no falls since his admission. The MDS indicated he had no bed rails. R5's Functional Abilities Care Area Assessment (CAA) completed 10/20/23 indicated he required substantial to maximal assistance from staff for all his activities of daily living (ADLs). The CAA noted staff was to support R5 with all transfers and needs due to his decline. R5's Care Plan initiated on 10/15/15 indicated he required assistance with his ADLs related to his physical limitations and medical diagnoses. The plan noted he required assistance from two staff for bed mobility, transfers, dressing, grooming, and toileting. The plan noted he required a Hoyer lift (full-body mechanical lift) for all transfers. The plan noted he had assist bars on his bed. The plan noted that R5 used the bars during assisted repositioning and turning (12/05/22). R5's EMR revealed a Clinical Health Review completed on 09/29/24 noting an assessment was completed for side rails and restraints. The assessment noted he was not ambulatory, not able to get out of bed with assistance from staff, not able to turn unassisted, had poor balance and trunk control, and had impaired memory, cognition, and decision-making function. The assessment indicated side rails were utilized for bed mobility and repositioning. The evaluation did not acknowledge the use of R5's low air-loss mattress. R5's EMR lacked a safety assessment for the use of his bed cane which addressed the risk of entrapment between the device and the mattress, a consent for the use, and lacked evidence the resident and/or responsible party were advised of the risks and/or benefits of the use of the bed canes. The facility was unable to provide this documentation as requested on 10/24/24. A review of the low air-loss mattress manufacturer's operation (Drive Model #14048 Series) manual indicated the usage of bed rails with the air mattress system should be assessed based on the risk of entrapment. On 10/23/24 at 08:45 AM R5 sat up in his bed and ate his breakfast. His bed was in the medium to higher position. His low air-loss mattress was set to his current weight at 250 pounds (lbs.) and he had bilateral side rails mounted at the head of his bed. On 10/24/24 at 09:00 AM Licensed Nurse (LN) G stated side rail assessments were completed quarterly by Administrative Nurse D. He stated staff should check the sidebars to ensure no gaps or entrapment hazards were created by the bed or bars. He stated he was not sure if the side rail assessments included the risks associated with the low air-loss mattresses. On 10/24/24 at 11:45 AM Certified Nurse's Aide (CNA) M stated staff were expected to check each resident's bed, mattress, and railing to ensure safety. On 10/24/24 at 12:15 PM Administrative Nurse D stated the side rails assessments were part of the clinical assessment completed quarterly. She stated the assessment should include risks associated with the railing, bed, and environment. The facility did not provide a bed rail policy. The facility failed to ensure that R5 had a safety assessment for the use of side rails that acknowledged the risks from use with the low air-loss mattress, consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed R5 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. 41713 - R17's Medical Diagnosis tab of the Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), and hemiplegia and hemiparesis (weakness and paralysis on one side of the body). R17's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 99 indicating he could not recall or answer the interview questions. R17 had both long and short-term memory deficits. R17 had impairment on one side of both his upper and lower extremities. R17 required partial assistance from staff for transfers. R17 required substantial assistance from staff for showering. R17 was dependent on staff for toileting and lower body dressing. R17 required a wheelchair for mobility. The MDS indicated R17 had no side rails. R17's Cognition Care Area Assessment (CAA) dated 08/14/24 documented his BIMS score was 99 due to the resident being unable to verbalize words. The resident could communicate through yes and no words only. R17 was able to write his needs and wants on paper but was sometimes unclear. R17's Care Plan revised on 07/15/24 directed staff that R17 had a left-side bed cane (side rail device attached to bed to improve bed mobility) added to his bed for mobility, so he could turn in bed and sit on the edge of the bed without assistance. R17 felt the bed cane enhanced his ability to rise independently and safely. R17's EMR under Physician Orders lacked documentation related to his bed cane. R17's Clinical Health Review dated 10/23/24 documented R17 was able to get in or out of bed without assistance. R17 was able to turn side to side in bed unassisted. R17 had impaired memory and had conditions that required medications which required increased safety measures. R17 used a side rail, grab, or transfer bar for positioning, support, or mobility. Based on the assessment, side rails, grab or transfer bars would be utilized on one or both sides of the bed to promote increased independence, participation in bed mobility, and positioning. R17's EMR on 1023/24 lacked a documented safety assessment for the use of side rails which addressed entrapment, and consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. On 10/22/24 at 07:42 AM observation revealed R17's bed had a side rail attached to the left side of his bed. On 10/24/24 at 12:06 PM, Licensed Nurse (LN) G stated that bed rails were not really used much in the facility. LN G stated some of the residents did have bed canes. LN G stated he was not sure if a specific bed cane assessment was done that would include the risks of using the bed cane. On 10/24/24 at 12:12 PM Administrative Nurse D stated residents were assessed quarterly if they used a bed cane. Administrative Nurse D stated when the bed cane was attached to the bed the rail was pulled in as close to the bed as it could be. Administrative Nurse D stated she was not certain if the bed rail assessment included or listed the risks of using them. Administrative Nurse D stated the facility did not have a specific policy that addressed bed cane or side rail use but instead, followed the standards of practice. The facility did not provide a bedrail policy. The facility failed to ensure that R17 had a safety assessment for the use of side rails that acknowledged the risk of entrapment, and consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the [NAME] ails. This placed R17 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails. - R12's Medical Diagnosis tab of the Electronic Medical Record (EMR) documented diagnoses of peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), acquired absence of left and right leg above the knee, and quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord). R12's Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R12 had impairment of both upper and lower extremities on both sides. R12 used a wheelchair for mobility. R12 required substantial assistance to being dependent on staff for his functional abilities. R12 was on hospice services. The MDS indicated he had no side rails. R12's Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. R12 had impairment of both upper and lower extremities on both sides. R12 used a wheelchair for mobility. R12 required substantial assistance to being dependent on staff for his functional abilities. R12 was on hospice services. The MDS indicated he had no side rails. R12's Care Plan directed staff that he used a trapeze bar (a short horizontal bar that hangs from the ceiling or pole used to assist in repositioning while in bed). R12's care plan lacked staff direction for his use of his bed cane (side rail device attached to the bed to improve bed mobility). Staff was directed to check the low air loss pump and pressure one time per shift, to ensure that the pump was set for body weight. Staff was directed the current setting for weight was at a level four but no higher than a five. Staff was directed that R12 had been choosing to have staff turn the pump setting to nine. Staff was directed to continue to educate R12 on the use of the low air loss mattress and the risks related to not using the device as recommended. R12's EMR under Physician Orders lacked documentation related to his bed cane bed rail. R12's Clinical Health Review dated 10/04/24 documented R12 was not able to get in or out of bed without assistance. R12 was not able to get in and out of bed with the use of a side rail, grab or transfer bar, with or without assistance. R12 was able to turn side to side in bed unassisted. R12 was able to turn side to side in bed with the use of a side rail, grab, or transfer bar, with or without assistance. R12 used a side rail, grab, or transfer bar for positioning, support, or mobility. Based on the assessment, side rails, grab or transfer bars would be utilized on one or both sides of the bed to promote increased independence, participation in bed mobility, and positioning. R17's EMR on 10/23/24 lacked an assessment for the safe use of side rails which acknowledged risks from low air loss mattress and entrapment, consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. A review of the low air-loss mattress manufacturer's operation (Drive Model #14027) manual indicated the usage of bed rails with the air mattress system should be assessed based on the risk of entrapment. On 10/22/24 at 07:43 AM an inspection of R12's room revealed a bordered mattress and bed cane side rail on both sides of his bed. R12's bed had a Drive Model low air-loss mattress system set at 350. On 10/24/24 at 12:06 PM, Licensed Nurse (LN) G stated that bed rails were not used much in the facility. LN G stated some of the residents did have bed canes. LN G stated he was not sure if a specific bed cane assessment was done that would include the risks of using the bed cane. On 10/24/24 at 12:12 PM Administrative Nurse D stated residents were assessed quarterly if they used a bed cane. Administrative Nurse D stated when the bed cane was attached to the bed the rail was pulled in as close to the bed as it could be. Administrative Nurse D stated she was not certain if the bed rail assessment included or listed the risks of using them. On 10/24/24 at 12:30 PM Administrative Staff A stated the facility followed the standards of practice regarding bed rails. The facility did not provide a bed rail policy. The facility failed to ensure that R12 had a safety assessment for the use of side rails that acknowledged the risks from the low air-loss mattress, consent for the use of the side rails, and failed to ensure the resident and/or responsible party were advised of the risks and/or benefits of the use of the side rails. This placed R12 at risk for uninformed decisions and impaired safety related to the risks associated with the use of side rails.

The facility identified a census of 29 residents. The sample included 13 residents. One resident was sampled for reasonable accommodations of needs. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 4 had foot pedals on her wheelchair while being pushed. This deficient practice left R4 vulnerable to accidents and injuries due to unmet care needs. Findings included: - R4's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN-elevated blood pressure), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) following 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) affecting right dominant side, major depressive disorder (major mood disorder that causes persistent feelings of sadness), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented R4 was impaired on one side of her body. The MDS documented R4 needed supervision or touching assistance from staff once seated in her wheelchair. R4's Cognitive Loss Care Area Assessment (CAA) dated 06/06/24 documented R4's BIMS last review was a 12 indicating moderate impairment, and R4's BIMS was currently a seven. R4's Care Plan dated 01/29/24 documented R4 required staff assistance with activities of daily living (ADLs) related to physical limitations. R4's plan of care documented R4 used a wheelchair for transportation and locomotion. R4's plan of care documented she was able to wheel herself about her home in her wheelchair and needed to wear appropriate shoes and non-slip footwear. On 10/22/24 at 08:14 AM Certified Nurse Aide (CNA) O pushed R4 up the 300 hall into the dining room in a wheelchair with no foot pedals. R4's feet repeatedly bounced on the floor, and CNA O repeatedly asked R4 to pick up her feet. On 10/24/24 at 08:19 AM CNA N pushed R4 from the commons area into the dining room; R4 had no foot pedals on her wheelchair. On 10/24/24 at 11:58 AM, CNA M stated residents should always have foot pedals if the resident was being pushed by a staff member. On 10/24/24 at 12:14 PM Licensed Nurse (LN) G stated all residents should have foot pedals if being pushed by staff. On 10/24/24 at 12:14 PM Administrative Nurse D stated residents should not be pushed by staff unless they have foot pedals on their wheelchairs. The facility did not provide a policy on accommodation of needs. The facility failed to provide foot pedals for R4's wheelchair. This deficient practice left R4 vulnerable to preventable accidents and injuries due to unmet care needs.

The facility identified a census of 29 residents. The sample included 13 residents with one sampled for activities of daily living (ADL). Based on observations, interviews, and record review, the facility failed to ensure Resident (R) 18 received supportive care and services to promote and maintain his quality of life when the facility did not implement strategies to allow and promote R18, who had a primary language other than English to communicate his wants, needs, or feelings and promote socialization. This deficient practice placed the resident at risk for decreased quality of life, isolation, and impaired dignity. Findings included: - R18's Electronic Medical Record (EMR) from the Diagnoses tab documented 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), hypertension (HTN-elevated blood pressure), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), cognitive-communication deficit, hemiplegia (paralysis of one side of the body), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), expressive language disorder, and protein-calorie malnutrition. R18's Quarterly 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 R18 needed minimal to partial assistance from staff for toileting, hygiene, and bathing. The MDS documented R18 often had social isolation. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/04/22 documented that a TV program in R18's native language was established, and music was provided by R18's family. R18 had an improvement in his BIMS score from the previous assessment. The Communication CAA dated 01/04/24 documented R18 does not speak a lot of English and was able to use a few words and gestures. Staff repeated information when communication was difficult. Staff restated things or used gestures. R18's communication was unchanged at this time. R18's Care Plan reviewed 10/16/23 documented R18 could not share emotions and communicate related to impaired verbal communication related to speaking [non-English language]. R18's plan of care documented R18 was able to communicate thoughts, feelings, and preferences through an interpreter. R18's Care Plan directed staff to turn on R18's radio or his TV which had the native language subtitles when R18 was in his room. On 10/22/24 at 08:46 AM R18 sat at the dining room table eating his breakfast. Staff placed R18's divided tray in front of him, but staff did not communicate with R18 during the meal. On 10/22/24 at 12:15 PM R18 sat in his wheelchair in his room, with his head down. Staff did not turn R18's TV or his radio. On 10/22/24 at 02:10 PM staff pushed R18 out of his room into the commons area. The TV in the commons area was on a Western channel and in English. There were no subtitles in R18's native language. R18 put his head down. On 10/23/24 at 09:17 AM staff pushed R18 into the commons area. The TV in the commons area was on a Western channel, not in R18's preferred language, and with no subtitles. On 10/24/24 at 09:17 AM staff took R18 to his room. Staff did not turn on the TV or turn on the radio in R18's preferred language. R18 sat in his room, awake but with his head down. On 10/24/24 at 11:26 AM Certified Nurse Aide (CNA) M stated R18 pointed at things or gestured. CNA M stated R18 liked to watch TV in his room in his native language. She stated staff had a communication book; the book had pictures to help understand R18's wants. CNA M stated they also had access to an interpreter, and there was always someone in the facility who knew R18. On 10/24/24 at 12:05 PM Licensed Nurse (LN) G stated there was always staff in the facility that had worked in the facility a long time, that knew R18 well. He stated staff were able to understand a lot of what R18 was saying by pointing and gestures. On 10/24/24 at 12:14 Administrative Nurse D stated R18 can understand a lot of what the staff were saying. She stated the facility has an interpreter available 24 hours a day. Administrative Nurse D stated the facility could also call R18's family. The facility did not provide a policy related to maintaining communication and other ADLs. The facility failed to implement strategies to facilitate person-centered communication and socialization for R18. This placed the resident at risk for decreased quality of life and isolation.

The facility identified a census of 29 residents. The sample included 13 residents with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R)24's low air-loss mattress was set to the appropriate weight settings per her physician's order and current weight. This deficient practice placed R24 at risk for complications related to skin breakdown and pressure ulcers. Findings included: - The Medical Diagnosis section within R24's Electronic Medical Records (EMR) noted diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), dysphagia (difficulty swallowing), insomnia (difficulty sleeping), encephalopathy (a broad term for any brain disease that alters brain function or structure), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). R24's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of zero indicating severe cognitive impairment. The MDS indicated she had bilateral upper and lower extremity impairments. The MDS indicated she required substantial to maximal assistance from staff for dressing, bed mobility, transfers, bathing, and toileting. The MDS indicated she was at risk for pressure ulcers with a history of Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcers. The MDS indicated she had pressure-reducing devices for her wheelchair and bed. The MDS indicated she weighed 154 pounds (lbs.). R24's Functional Abilities Care Area Assessment (CAA) completed 01/31/24 indicated she required substantial to maximal assistance with her activities of daily living (ADLs). The CAA instructed staff to give verbal cues to and allow her to participate in the care process. R24's Pressure Injuries CAA completed 01/31/24 indicated she was at risk for pressure injuries and skin breakdown related to her previously healed pressure injuries, incontinence, and limited mobility. The CAA instructed staff to provide wound and incontinence care, repositioning, and a low air-loss mattress for her bed. R24 Care Plan initiated 03/14/23 indicated she was at risk for falls, pressure injuries, and a decline in her ADLs related to her medical diagnoses and limited mobility. The plan indicated she required extensive assistance from staff for bed mobility, transfers, dressing, bathing, toileting, and ambulation in her wheelchair. The plan noted she had a pre-existing Stage 3 pressure ulcer located on her sacrum (large triangular bone/area between the two hip bones). The plan indicated staff were to complete preventative wound care to her sacrum. The plan indicated her low air-loss mattress was to be set on the less than (<) 250 lbs. mark. R24's EMR under Physician's Orders revealed an order for her low air-loss mattress dated 04/11/24. The order instructed staff to set her mattress's weight at <250 lbs. A review of the manual of low air-loss mattress manufacturers' operation (Drive Model #14048) indicated that the mattress system was intended to reduce the incidence of pressure ulcers while optimizing comfort. The manual indicated the mattress pump's pressure levels and firmness were preset based on the weight range and comfort settings. The manual indicated an optimal bed system assessment should be conducted on each patient by a qualified clinician or medical provider to ensure maximum safety. On 10/22/24 at 10:17 AM R24 watched television in her bed. Her bed was in a low position and had bilateral grab bars at the head of her bed. She had a bariatric (associated with obesity) low air-loss mattress system. Her mattress control panel was set to 500 lbs. On 10/24/24 at 08:55 AM R24's low air-loss mattress control panel weight was set to 550 lbs. Licensed Nurse (LN) G entered the room and confirmed the bed should be set per the resident's weight. He verified the bed was set to 550 lbs. but did not know why the setting was so high. He stated staff were to check the settings each shift. On 10/24/24 at 12:15 PM Administrative Nurse D stated the mattresses should be by the resident's current weight and inspected each time staff enter the room. She stated someone may have bumped R24's control panel to cause the weight pressure to increase. The facility was unable to provide a policy related to the prevention of pressure ulcers as requested on 10/24/24. The facility failed to ensure R24's low air-loss mattress was set to the appropriate weight settings per her physician's order and current weight. This deficient practice placed R24 at risk for complications related to skin breakdown and pressure ulcers.

The facility identified a census of 29 residents. The sample included 13 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 ensure consistent communication between the facility and Resident (R) 15's dialysis center. This deficient practice placed R15 at risk of potential adverse outcomes and physical complications related to dialysis. Findings included: - R15's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), obesity, dialysis (a procedure where impurities or wastes are removed from the blood), hypertension (HTN-elevated blood pressure), and abnormalities of the 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 R15 had impairment on one side of his body. The MDS documented R15 was independent for toileting, eating, and bathing. The MDS documented R15 required dialysis during the observation period. R15 Nutritional Status Care Area Assessment (CAA) dated 07/30/24 documented R15 was alert and oriented. He was able to make his own food choices, often declined meals and alternate menus, and purchased snacks. R15's weight was followed by his physician and dialysis. R15's Care Plan dated 07/20/19 documented that R15 received dialysis and had a shunt (tube or device implanted in the body to redirect a body fluid from one cavity to another) in his left arm. Staff were to monitor the dialysis shunt daily and change dressing as ordered by the dialysis center, and physician. R15's EMR under the Orders tab revealed the following physician's order: Monitor the dialysis site every shift for bleeding, infection, thrill (a fine vibration felt that reflects the blood flow by a dialysis resident's shunt), and bruit (blowing or swishing sound heard when blood flows through a shunt), every shift related to dialysis dated 09/14/21. A review of R15's clinical record including the facility dialysis communication forms lacked evidence of post-hemodialysis assessment for the dialysis dates of 04/10/24, 05/15/24, 06/14/24, 06/26/24, 08/21/24, 08/23/24, and 09/18/24. On 10/23/24 at 09:10 AM R15 stood at the nurse's station waiting for the bus, for an out-of-facility appointment. On 10/24/24 at 12:05 PM Licensed Nurse (LN) G stated it was the nurse's responsibility to ensure a communication sheet was sent to dialysis with the resident and to ensure a signed communication sheet was returned with the resident. On 10/24/24 at 12:14 PM Administrative Nurse D said the facility expects to get all dialysis communications sheets returned with the resident. She stated if the communication sheet was not returned or not signed when the sheet was returned, the nurse should call the dialysis center and fax the sheet to the dialysis center for any orders and a signature. The facility's Dialysis Management Guideline policy dated 04/15 documented the facility was to have an agreement, or arrangement with the dialysis center. The facility was to maintain communication and coordinate care with the dialysis center before and after dialysis, including transportation services. Dialysis care and services are to be included in the resident's plan of care. The resident's dialysis access site was to be assessed on a routine basis. Emergency care and contracts are to be maintained in the resident's clinical record. The resident's nutritional status and needs are to be reviewed on a routine basis by a registered dietitian. Social and mental health services are to be available for residents receiving dialysis. The facility failed to ensure consistent communication between the facility and R15's dialysis center. This deficient practice placed R15 at risk of potential adverse outcomes and physical complications related to dialysis.

The facility identified a census of 29 residents. The sample included 13 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to follow physicians' ordered parameters related to blood glucose monitoring for Resident (R)10 and R15. This deficient practice placed R10 and R15 at risk for delayed treatment of hyperglycemia (greater than the normal amount of glucose in the blood, hypoglycemia (abnormally low blood glucose), and unnecessary medication complications. Findings included: - R10's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of sleep apnea (a disorder of sleep characterized by periods without respirations), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), dysplasia (abnormal development of tissues and organs), major depressive disorder (major mood disorder that causes persistent feelings of sadness), cognitive communication deficit, muscle weakness, dementia (a progressive mental disorder characterized by failing memory and confusion), delusional disorder (a type of mental health condition in which a person can't tell what's real from what's imagined), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and hypertension (HTN-elevated blood pressure). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine which indicated moderately impaired cognition. The MDS documented R10 needed partial to moderate assistance with toileting. The MDS documented R0 had DM. The MDS documented R10 received insulin (a hormone that lowers the level of glucose in the blood) during the observation period. R10's Nutritional Status Care Area Assessment (CAA) dated 10/03/24 documented that R10 had a recent hospital stay. R10 had surgery to repair bowel adhesions that were increasing the risk of obstruction. The CAA documented R10 had a decline in nutrition related to not being hungry and reported occasional nausea. R10 returned to the facility on a mechanical soft diet. The facility anticipates R10's appetite, intake, and weight to improve as the healing process occurs. The dietitian would oversee R10's regimen and chart for any additional needs. R10's diet will be care planned; staff was to cue R10 to consume the meals served. R10's EMR under Orders revealed the following physicians' orders: Glargine insulin (long-acting insulin) subcutaneous (beneath the skin), solution pen-injector 100 units per milliliter (ml) inject 15 units subcutaneously at bedtime, notify the physician of blood glucose less than 60 ml per deciliter (dl) or greater than 400 ml/dl for 30 days for 09/25/24. Novolog Flex-Pen (short-acting insulin) subcutaneous solution pen-injector 100 units per ml inject 10 units subcutaneously three times a day, notify provider for blood glucose less than 60 ml/dl or higher than 400 ml/dl related to DM, hold if blood glucose was lower than 110 ml/dl dated 02/08/24. R10's EMR under the Treatment Administration Record (TAR) recorded the following blood glucose levels under 110 ml/dl that lacked evidence R10's insulin was held per physician's order. 08/09/24 AM 82 ml/dl 09/07/24 PM 104 ml/dl 09/12/24 AM 106 ml/dl 09/17/24 PM 106 ml/dl 10/04/24 AM 84 ml/dl 10/14/24 AM 108 ml/dl 10/14/24 PM 99 ml/dl 10/15/24 AM 105 ml/dl On 10/22/24 at 07:33 AM R10 sat in the dining room with his walker next to him. He was drinking coffee. On 10/24/24 at 12:05 PM, Licensed Nurse (LN) G stated the TAR shows the nurse staff the resident's parameters when the nurses document the blood sugar. LN G stated nurse staff would verify and then give insulin or hold insulin. LN G stated it was the nurses' responsibility to verify blood sugar and insulin. On 10/24/24 at 12:14 PM Administrative Nurse D stated verifying blood sugars was the nurse's responsibility. She stated the nurse takes the blood sugar, verifies with the TAR, and either gives insulin, holds insulin, or calls the physician. The facility did not provide a policy for unnecessary medication or medication monitoring. The facility failed to hold R10's insulin for blood glucose levels outside the ordered parameters. This deficient practice placed R10 at risk for complications related to hypoglycemia and unnecessary medications. - R15's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), obesity, dialysis (a procedure where impurities or wastes are removed from the blood), hypertension (HTN-elevated blood pressure), 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 R15 had impairment on one side of his body. The MDS documented R15 was independent in toileting, eating, and bathing. The MDS documented R15 had DM. R15 Nutritional Status Care Area Assessment (CAA) dated 07/30/24 documented R15 was alert and oriented. He was able to make his own food choices, often declined meals and alternate menus, and purchased snacks. R15's weight was followed by his physician and dialysis. R15's Care Plan revised 10/21/24 documented R15 was at risk for hyperglycemia and hypoglycemia related to his diabetes and use of insulin to manage his blood sugars. R15's plan of care documented he would have no unmonitored hyperglycemia or hypoglycemia. R15's plan of care documented he needed to have insulin administered per his physicians' orders; staff were to take his blood sugar and give the ordered amount of insulin. R15's EMR under Orders revealed the following physicians' orders: Aspart insulin (short-acting insulin) solution Pen-injector 100 units per millimeter (ml) inject seven units subcutaneously (beneath the skin) three times a day related to DM. Hold for finger stick blood sugar below 110 milliliters per deciliter (ml/dl) and call the physician if blood sugar reading was less than 70 ml/dl or over 400 ml/dl dated 01/24/24. Lantus Solostar (long-acting insulin) insulin solution Pen-injector insulin 100 units per ml inject 20 units subcutaneously at bedtime related to DM. Notify physician of blood sugar less than 70 ml/dl or greater than 400 ml/dl dated 01/24/24. R15's EMR under the Treatment Administration Record (TAR) recorded the following blood glucose levels below 110 ml/dl that lacked evidence R15's insulin was held per physician's order. 08/29/24 AM 107 ml/dl 09/10/24 PM 107 ml/dl 09/16/24 AM 106 ml/dl 09/17/24 PM 105 ml/dl 09/26/24 AM 108 ml/dl 09/14/24 AM 94 ml/dl 10/01/24 PM 104 ml/dl 10/20/24 AM 106 ml/dl On 10/22/24 at 08:13 AM R15 sat at the dining room table visiting with peers. On 10/24/24 at 12:05 PM, Licensed Nurse (LN) G stated the TAR shows the nurse staff the resident's parameters when the nurses document the blood sugar. LN G stated nurse staff would verify and then give insulin or hold insulin. LN G stated it was the nurses' responsibility to verify blood sugar and insulin. On 10/24/24 at 12:14 PM Administrative Nurse D stated verifying blood sugars was the nurse's responsibility. She stated the nurse takes the blood sugar, verifies with the TAR, and either gives insulin, holds insulin, or calls the physician. The facility did not provide a policy for unnecessary medication or medication monitoring. The facility failed to follow physicians' ordered parameters related to blood glucose monitoring for R15. This placed the resident at risk for complications related to medications.

The facility identified a census of 31 residents. The sample included three residents with one resident reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on record review and interviews, the facility failed to provide dementia care and services for Resident (R) 1 when the facility failed to assess, identify, record, respond to, and reassess R1's specific behaviors and triggers to promote an environment which supported R1's individualized care needs. This deficient practice created an environment that affected R1's ability to maintain his highest practicable level of physical, mental, and psychosocial well-being. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented R1 had diagnoses of schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia [psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought]) and dementia with other behavioral disturbances. The Significant Change Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. R1 hallucinated (sensing things while awake that appear to be real, but the mind created). R1 had wandering behavior one to three days in the assessment period. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of nine which indicated moderate cognitive impairment. R1 had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). R1 had verbal behavioral symptoms directed towards others four to six days and other behavioral symptoms not directed towards others one to three days in the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/11/23, documented R1 triggered for cognitive loss related to low BIMS and wandering. The Behavioral Symptoms CAA dated 10/12/23, documented R1 triggered for behavior symptoms and problems. R1's Care Plan dated 04/06/20 and revised 06/04/21, documented R1 had difficulty keeping his hands to himself at times. The plan documented an intervention, dated 04/06/20, that directed if reasonable, staff discussed R1's behavior and explained why the behavior was inappropriate and/or unacceptable. An intervention, dated 01/05/24, directed R1 had an increase in verbal and physical approaches to staff and staff cued R1 regarding appropriate requests to staff for needs given. An intervention, dated 03/07/24, directed staff made sure R1 had their attention before starting cares with him as he did not like to be approached abruptly. An intervention, dated 03/07/24, directed staff encouraged R1 to verbally express what he was thinking or feeling instead of grabbing or hitting. An intervention, dated 03/07/24, directed if R1 grabbed people or made other physical contact, staff firmly and clearly told R1 that behavior was not acceptable and was not tolerated. R1's Care Plan revised 08/31/23, documented R1 was at risk for verbal and physical touch towards others. The plan documented an intervention, dated 03/15/24, that documented on 03/01/24, R1 was moving about in the lobby and nurse desk area when he approached a female resident [R2] who was standing at the desk; R1 reached out and poked or touched her on her belly area on her left side. Staff assisted R1 out of the area and there was no further interaction with R1 and R2. R1's Care Plan dated 01/31/22, documented R1 had cognitive loss that affected his memory. The plan documented staff gave R1 his medications per physician orders and helped him establish a regular daily schedule. R1 needed tasks divided into several steps to assist him so staff explained any activity or care procedure prior to beginning with R1. Staff reminded R1 who they were when providing cares, staff gave R1 one instruction at a time. Staff provided R1 cueing and prompting but allowed him as much independence as possible. Staff repeated instructions as needed in a calm tone and staff gave R1 choices when possible. R1's Care Plan lacked evidence of resident specific triggers related to behaviors for R1. The Notes tab of R1's EMR revealed the following: A Nurse's Note, on 02/04/24 at 07:11 PM, documented around 06:15 PM, R1 started grabbing the arms of staff walking nearby. R1 was assisted to his room and Haldol (antipsychotic medication used to treat major mental conditions which cause a break from reality) was given which was ineffective. A message was left for the doctor and R1's representative. A Behavior Note, on 02/06/24 at 10:11 AM, documented a Certified Medication Aide (CMA) explained to the nurse that R1 grabbed her between her legs. The other nurse attempted to talk to R1 about grabbing other people and staff members. R1 responded by saying he wanted cocaine. The nurse witnessed R1 wheel himself down the hall and attempt to go into a female resident's room. The nurse explained to R1 that was not his room and redirected R1 to his room. R1 appeared less agitated while in his room. The doctor and R1's representative were notified. A Nurse's Note, on 03/01/24 at 01:41 AM, documented R1 attempted to grab staff late in the evening and staff redirected R1. R1 went to his room and slept. A Nurse's Note, on 03/05/24 at 11:53 AM, documented R1 attempted to grab the writer that morning and staff provided redirection in which R1 was compliant. R1 went by the front door and the alarm sounded, he stated he wanted to go to the store. R1 was redirected and given snack items to eat. A Nurse's Note, on 03/14/24 at 08:00 PM, documented R1 pinched the buttocks of a female resident that was standing at the nursing station. Staff redirected R1 and immediately separated him and female resident. R1 placed on 15-minute checks. A Nurse's Note, on 03/15/24 at 06:33 AM, documented R1 was up and down majority of the night asking for honey buns and coffee. Staff redirected R1 to his room multiple times during the course of the night and he went to bed for short periods of time. A Nurse's Note, on 03/15/24 at 10:41 AM, documented R1's behaviors continued throughout the morning and R1 yelled in the hallways asking for honey buns. Staff redirected to his room with snacks given. A RISK Progress Note, on 03/15/24 at 11:54 AM, documented R1 poked a female peer on her left belly area on 03/01/24 and staff assisted him away from the lobby area. Staff continued ongoing observation for risk of R1 returning or interacting with female resident to provide immediate redirection as needed. In the facility's investigation report, dated 03/20/24, Administrative Staff A stated he was notified on 3/14/24 at 08:02 PM that at 08:00 PM, R1 wheeled up to R2 and pinched her buttocks. R1 was trying to get the attention of the nurse and R2 appeared to be a nurse as she stood around the nurses' station daily. This was witnessed by Certified Nurse Aide (CNA) M, who immediately separated the two. Administrative Staff A stated R1's representative and physicians were notified as well as Administrative Staff A and Administrative Nurse D. R1 was placed on 15-minute checks to ensure safety of the other residents. R2 was moved from 200-hall to the 100-hall to help protect her from R1 as he was on the 200 hall. A referral packet for R1 was sent to the hospital for psychiatric evaluation and treatment on 3/18/24 and R1 was admitted to the hospital on 3/20/24. On 04/10/24 at 12:03 PM, Licensed Nurse (LN) G stated when R1 had behaviors, staff used distraction and provided activities and with any difficult behaviors, staff removed R1 from the area and did things to keep his mind off of what upset him. On 04/10/24 at 12:05 PM, LN H stated if R1 had behaviors, staff tried to remove him from the incident. She stated R1 had inappropriate verbal behaviors directed towards staff mostly and staff tried to watch R1. On 04/10/24 at 12:09 PM, CMA R stated when R1 had behaviors, staff usually redirected him. She stated staff kept R1 away from R2 and told R1 to keep his hands to himself and that he cannot touch ladies. CMA R stated R1 liked to grab and hold onto others, mostly staff depending on his mood. She stated if she saw R1 having a behavior, she de-escalated him, got him into activities, and provided redirection. She stated R1's behaviors seemed to be getting worse the older he gets. On 04/10/24 at 12:33 PM, Administrative Nurse D stated before the 03/14/24 incident between R1 and R2, staff kept R1 and R2 separated or in areas where they were not around each other. She stated staff tried to redirect R1 as best as they could, used food as a redirection, and provided one-on-one supervision depending on the situation. Administrative Nurse D stated some days R1 was easy to redirect by talking with staff and sometimes staff gave him a honey bun as a redirection; it depended on the day which redirection strategy staff used. She stated prior to R1 transferred to the hospital, staff monitored him, made sure they knew where he was at all times, made sure R1 was not in R2's area, and offered interventions depending on the behaviors he had in that moment. Administrative Nurse D stated prior to the 03/14/24 incident, R1 yelled a lot and yelled out throughout the facility. On 04/10/24 at 12:43 PM, Administrative Staff A stated he was notified on 03/14/24 that R1 pinched R2 at the nurse's station when he was looking for a honey bun and he thought she was a nurse. He stated he reviewed the camera and said what he saw was a poke. On 04/10/24 at 01:56 PM, LN G stated one of R1's triggers was wanting something and not getting it. She stated somebody would walk by R1 and he would grab them, or he saw staff and next thing they knew, he was propelling up to them. LN G stated redirection helped at first with R1's behaviors but the last couple of weeks before he was transferred to the hospital, his behaviors were beyond that point. On 04/10/24 at 02:10 PM, CMA R stated a few of R1's triggers included if he could not get coffee when he wanted or when he could not get food he wanted since he was on a pureed (mechanically altered diet) diet. She stated she had received dementia and behavioral training in the last year. On 04/10/24 at 02:22 PM, CNA N stated R1's usually behaviors were he liked to eat snacks and go to the vending machine. She stated he did not have any triggers that she knew of but if there were any triggers, they were found on the care plan. She stated she had not received any behavioral health or dementia training. On 04/10/24 at 02:39 PM, Administrative Nurse D stated Relias (online training platform) was the main source for behavioral health and dementia training. She stated R1 did not necessarily have any triggers and from day-to-day, staff did not know what a trigger might be for him. Administrative Nurse D stated every day, staff tried to exhaust all leads to suit R1 and she did not know if his behaviors were because of his dementia so she did not know what triggered his behaviors. She stated the care plan had behaviors, behavioral interventions, and any known triggers for behaviors. Administrative Nurse D stated she expected staff to monitor residents for any behavior triggers to update the care plan. On 04/10/24 at 02:52 PM, Administrative Staff A stated he saw on Relias that some staff were assigned behavioral health and dementia training while others were not. He stated he believed all staff should be trained on how to interact with dementia residents. The facility's Behavior Management and Psychotropic (medication that alters mood or thought) Medications policy, last revised December 2022, directed the plan of care addressed individualized focus, goals, and interventions directed towards managing the resident's target behaviors, non-pharmacological interventions, psychotropic medication use, and gradual dose reductions and/or supporting documentation for continued use. The policy directed residents with psychosocial and/or history of traumatic events were identified in the care plan with triggers, de-escalations, personnel preferences, and interventions. The facility failed to provide dementia care and services for R1 when the facility failed to assess, identify, record, respond to, and reassess R1's specific behaviors and triggers to promote an environment which supported R1's individualized care needs. This deficient practice created an environment that affected R1's ability to maintain his highest practicable level of physical, mental, and psychosocial well-being.

The facility identified a census of 33 residents. The sample included three residents. Based on observation, record review, and interviews, the facility failed to report an allegation of resident-to-resident abuse between R1 and R2 to the State Agency (SA) within the mandated timeframe. This deficient practice placed R2 at risk for unresolved and ongoing abuse. Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of schizoaffective disorder (a mental disorder in which a person experiences a combination of symptoms of schizophrenia [psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought] and dementia progressive mental disorder characterized by failing memory, confusion) with other behavioral disturbance. The Significant Change Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of nine which indicated moderate cognitive impairment. R1 had hallucinations (sensing things while awake that appear to be real, but the mind created) and wandering behavior for one to three days in the assessment period. The Quarterly MDS dated [DATE], documented R1 had hallucinations and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue) and had physical behaviors directed towards others one to three days in the assessment period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/11/23, documented R1 triggered for cognitive loss related to low BIMS and wandering. The Behavioral Symptoms CAA dated 10/12/23, documented R1 triggered for behavioral symptoms. R1's Care Plan, last revised 06/04/21, documented R1 had difficulty keeping his hands to himself at times and documented an intervention, dated 01/05/24, that directed R1 had an increase in verbal and physical approaches to staff and staff were to cue R1 regarding appropriate requests to staff for needs given. In a Report of Concern dated 03/01/24, Certified Nurse Aide (CNA) M reported R1 was touching other residents sexually and inappropriately. The report alleged R1 was rubbing R2's private areas on 03/01/24 at 08:50 PM. CNA M's Witness Statement dated 03/06/24 documented that on 03/01/24, CNA M sat in a chair across from the nurse's station and at about 08:45 PM, R1 kept trying to get behind the nurse's station to CNA N and Licensed Nurse (LN) G. CNA M stated she stopped R1 from going behind the nurses station. At approximately 08:50 PM, R1 went around the nurse's station and over to R2. R1 started to touch R2's private areas and R2 told R1 to stop. CNA M stated she pushed R1 away. CNA N's undated Witness Statement, stated on 03/01/24, CNA N saw R1 sitting by R2. CNA N did not see R1 touch R2 but another staff member said R1 touched R2. CNA N stated she told R1 not to touch R2 and R1 moved away from R2. LN G's undated Witness Statement, stated on 03/01/24, she was working as the nurse in charge on the night shift. She was notified of a potential resident-to-resident incident that occurred that day but she was not notified by any working staff member that shift. LN G stated to her knowledge, there were no known incidents. On 03/11/24 at 12:23 PM, R1 sat in his wheelchair at the dining table and ate lunch. On 03/11/24 at 11:54 AM, LN H stated she had not seen R1 being sexually inappropriate with any other residents. She stated if she saw any abuse or it was reported to her, she reported it immediately to Administrative Staff A or Administrative Nurse D. On 03/11/24 at 11:56 AM, LN I stated she had not seen R1 being sexually inappropriate with any other residents. She stated if she saw any abuse, she would intervene and then notify Administrative Staff A and Administrative Nurse D immediately. She stated the facility reported to the SA within 24 hours. On 03/11/24 at 11:59 AM, Administrative Staff A stated he was gone on 03/04/24 and 03/05/24 so when he came back on 03/06/24, he found the Report of Concern from CNA M. He stated it was already past five days, so he did not report the allegation to the SA. He stated he planned to complete the investigation and then report it to the SA. Administrative Staff A stated he reviewed the cameras and R1 was observed poking R2 twice on the outside of her hip and never touched her genitals. He stated once he received the Report of Concern, he started the investigation and got witness statements. Administrative Staff A stated CNA N and LN G did not see the incident. He stated CNA M called him on 03/02/24 to report she had issues with R1 herself but did not mention any incident with R1 and R2. Administrative Staff A stated he did not report the allegation because it was way out of the reportable window. He stated he expected if staff saw something, they would call him or Administrative Nurse D and he would report it to the SA and then investigate. Administrative Staff A stated he educated staff that a Report of Concern was not a timely report of an allegation and that staff had access to his phone number to call him directly. The facility's Abuse, Neglect, and Exploitation policy, revised October 2022, directed all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately to the administrator and/or their designated representative, the SA, and when applicable, law enforcement. Allegations were reported not later than two hours after the allegation was made if the allegation involved abuse or resulted in serious bodily injury or not later than 24 hours if the allegation did not involve abuse and did not result in serious bodily injury. The facility failed to report an allegation of abuse between R1 and R2 to the SA within the mandated timeframe. This deficient practice placed R2 at risk for unresolved and ongoing abuse.

The facility identified a census of 36 residents with three residents reviewed for abuse and neglect. Based on record review, observation, and interview the facility failed to ensure staff identified and reported an allegation of physical abuse immediately to the Administrator as required. On 02/09/24 between 10:30 PM to 11:00 PM, Certified Nurse Aide (CNA) N and CNA M provided peri-care to Resident (R)1, a severely cognitively impaired resident who was dependent on staff for assistance with activities of daily living (ADL). As staff rolled R1 towards CNA M, R1 hit CNA M. CNA M allegedly became upset and smacked R1 on the hand. CNA N attempted to report the abuse to Licensed Nurse (LN) G, but CNA M approached, so CNA N ended the conversation and walked away. CNA N mentioned it later to another CNA on shift but did not report it to the Administrator. On 02/12/24, over three days later, CNA N wrote a Report of Concern and left it in Administrative Staff A's box. On 02/13/24 at 07:45 AM, Administrative Staff A received the Report of Concern and was informed of the allegation of abuse. The facility failed to ensure staff identified a situation of physical abuse and/or mistreatment and reported it immediately to the Administrator. CNA M worked in the facility again on 02/12/24. This placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab recorded diagnoses of dysphagia (swallowing difficulty), abnormal posture, and hemiplegia (paralysis of one side of the body) affecting the left nondominant side. The Significant Change Minimum Data Set (MDS) dated [DATE] documented per staff interview that R1 had short and long-term memory problems but was able to recall staff names and faces. The Cognitive Loss Care Area Assessment (CAA) dated 02/01/24 documented R1 used gestures and noise to make needs known to staff. Staff anticipated R1's routine and understood R1's wants when R1 pointed or made gestures. The Communication CAA dated 02/01/24 documented R1 was deaf but communicated with gestures and noises and focused on staff facial areas. R1 understood information by reading the staff's lips. The Behavioral CAA dated 02/01/24 documented R1 was non-verbal and deaf, but communicated her likes and dislikes through slapping, pinching, and verbal noises. R1's Care Plan dated 12/07/22 directed staff to tell R1 before starting a task of what was going to happen and to look at R1's facial expressions and eye movements and observe what R1 pointed at during interactions. R1's Care Plan directed staff to report any changes noted in R1's behaviors, or cognitive status. Interventions dated 07/10/23 directed staff to make eye contact and explained what was going to be done to R1 before beginning care. Interventions dated 01/19/24 documented R1 communicated mostly with hand gestures, facial expressions, hitting, scratching, or pinching and directed staff to approach slowly, smiling, gently, and calmly. The Report of Concern dated 02/12/24 documented CNA N arrived at work early on 02/09/24 and proceeded to take over R1's hall. CNA N documented she checked on R1 with CNA M. R1 hit CNA M and CNA M popped R1 on the hand. CNA N's undated Witness Statement, documented on 02/09/24 CNA N came in early and rounded with CNA M. CNA N entered R1's room to help CNA M with care. CNA N stood on one side of the bed, with CNA M on the other side. They rolled R1 towards CNA M and R1 started to hit CNA M. CNA M got upset and smacked R1's hand. CNA N started to report the incident to LN G, but CNA M walked up, so CNA N stopped talking and walked away. CNA N documented she also mentioned it to CNA O. CNA O told CNA N she needed to report it. LN G's undated Witness Statement, documented on 02/09/24, no incidents were reported to him. CNA O's undated Witness Statement, documented on 02/09/24 CNA O worked on R1's hall but did not witness abuse. The Nurse's Note dated 02/14/24 at 12:49 PM documented R1 had a skin assessment completed related to a staff-to-resident interaction. R1 showed no anxiety or unwanted behaviors towards current staff. R1's EMR lacked further documentation of the event which included any follow-up assessments to monitor R1's ongoing psychosocial wellbeing after the alleged abuse. A review of the facility's Investigation dated 02/19/24 documented Administrative Staff A was informed on 02/13/24 at 07:45 AM by a Report of Concern written by CNA N that CNA M hit R1 on the hand after R1 hit CNA M. The incident occurred on 02/09/24 between the hours of 10:30 PM and 11:00 PM. CNA N claimed she informed CNA O and LN G, but the witness statements written by CNA O and LN G documented they did not know about the event. CNA M was suspended pending investigation, and CNA N received a write-up for not reporting timely. The Investigation documented cognitive residents on R1's hall would be interviewed to rule out other possible abuse, neglect, or exploitation, and immediate abuse, neglect, and exploitation training for staff which would be completed by the end of day on 02/19/24. The Investigation lacked evidence the facility attempted to obtain a statement of events from the alleged perpetrator, CNA M. CNA O's notarized Witness Statement dated 02/20/24 documented CNA M offered to change R1's incontinence brief on the evening of 02/09/24. CNA O documented she was doing other rounds (providing care to other residents) at 10:00 PM when CNA M offered to help with R1. On 02/20/24 at 11:10 AM R1 laid in bed on her left side with a blanket pulled up to her chest. Her leg was out with her right hand cupping her right thigh although, in that position, visualization of the resident's hands for bruising was not possible. R1 did not respond to her name being called and her eyes were barely open. On 02/20/24 at 11:15 AM CNA P stated if she witnessed abuse towards any resident, she would report the concern as quickly as possible to Administrative Staff A and/or Administrative Nurse D. CNA P stated she would keep the resident safe. On 02/20/24 at 11:25 AM LN H stated if he saw or heard of any abuse, he would immediately report the abuse and remove the individual who was the source of the abuse. On 02/20/24 at 02:15 PM Administrative Staff A stated he arrived at work on 02/13/24 and found the Report of Concern from CNA N in the box by his office door. On 02/20/24 at 02:18 PM, CNA M said CNA N came in for the overnight shift and CNA M gave her report on what tasks were already completed on the assigned hall and that was all. CNA M went on to say she rarely worked on R1's hall and would not be the main person over there. CNA M stated she never gave a witness statement regarding the event and the facility never asked her to. CNA M stated the facility called her and told her she was suspended while the facility investigated an abuse allegation and once it was completed CNA M would be contacted and told if CNA M could come back to work. CNA M stated on 02/09/24 she was not assigned to R1's hall and went on to say she could not remember when she last worked with R1. CNA M said Administrative Staff A was aware on 02/09/24 but would not say who had reported something had happened. CNA M stated she worked with CNA N before 02/09/24 and she felt CNA N did not like her. CNA M talked about a night she had a headache and went home early and went on to say that CNA N went and reported to Administration about everything. CNA M said she knew staff were double briefing the residents and she told CNA N not to do that. CNA M said she never had to be physical with R1. CNA M stated other staff said that R1 hit and bit people, but R1 was never mean to her. CNA M stated she received a text from Administrative Staff A that stated she was cleared and scheduled to come back to work on 02/17/24. CNA M said she told Administrative Staff A that she already made plans and could not work on 02/17/24. On 02/20/23 at 02:23 PM CNA N was unavailable for interview. On 02/20/24 at 02:43 PM Administrative Nurse D stated she received text messages from CNA N on 02/09/24 throughout CNA N's shift, but CNA N never reported any concerns with R1 or abuse. On 02/20/24 at 04:18 PM Administrative Staff A stated he wondered about the delay in reporting being a concern because it was several days. The facility's policy Abuse, Neglect and Exploitation revised 10/22 documented the resident has the right to be free from verbal, sexual, physical, and mental abuse and involuntary seclusion. The policy directed that there were steps to be followed to ensure that all staff were knowledgeable in identifying other residents and staff who have the situational, recognized the potential to be abusive; as well as what to do should an incident occur. Training included reporting of suspected abuse, neglect, mistreatment of residents, and/or misappropriation of personal property. What to report and who to report to, and to report immediately to the administrator and/or their designated representative. The facility failed to ensure staff identified a situation of physical abuse and/or mistreatment and reported immediately to the Administrator. This placed R1 in immediate jeopardy. The facility completed the following corrective actions by 02/19/24: CNA M was suspended via text message on 02/13/24 at 12:29 PM. All staff received Abuse, Neglect, and Exploitation training that started on 02/13/24, completed on 02/19/24. CNA N's employment was terminated on 02/19/24. The corrective actions were completed before the onsite survey therefore the citation was issued as past noncompliance at the scope and severity of J.

The facility identified a census of 44 residents. The sample included three residents with one sampled for abuse and neglect. Based on record review and interviews, the facility failed to ensure Resident (R) 1 remained free from neglect when on 06/01/23, Transportation D dropped off R1 at the bus stop, per R1's request, after explicit instructions from Administrative Staff A to take R1 to the bank, but to keep R1 under constant staff supervision. R1 had moderate cognitive impairment, was at risk or falls, and required supervision from staff with activities of daily living (ADLs) and smoking. R1 left the facility via facility transportation to the bank at 01:19 PM on 06/01/23, accompanied by Transportation D. R1 made a statement to Transportation D regarding an idea that R1 might not return to the facility. Transportation D returned to the facility, without R1, at 02:01 PM, as verified on camera. At 03:20 PM, Administrative Staff B approached Administrative Staff A to report Transportation D dropped R1 off at a bus stop after R1 withdrew $3000.00 in cash. Administrative Staff A called Transportation D who reported he took R1 to the bank and R1 asked for a ride to a friend's house. Transportation D stated he had a personal appointment and could not take R1 to the friend's house so R1 then asked Transportation D to drop him off at the bus stop. Transportation D complied and left R1, with no staff supervision, at the bus stop. At approximately 03:35 PM, three staff members left the facility to look for R1 and found him approximately five miles away, at 03:50 PM. R1 was drinking a pop and smoking a cigarette. R1 arrived back to the facility with staff at 04:17 PM. The facility failed to ensure staff provided the appropriate cares and supervision required for R1, who was cognitively impaired. This neglect placed R1 in immediate jeopardy. Findings included: - R1 admitted to the facility on [DATE]. The Diagnoses Tab of R1's Electronic Medical Record (EMR) documented diagnoses of cognitive communication deficit, difficulty in walking, need for assistance with personal care, shortness of breath, and chronic respiratory failure. The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. R9 was independent with most ADLs but needed supervision with setup help for personal hygiene. He had no falls since admission. The Quarterly MDS dated [DATE], documented R1 had a BIMS score of nine, which indicated moderately impaired cognition. R1 was independent with setup help for bed mobility, transfers, and walking; supervision with setup help for locomotion and eating; supervision with one staff for toileting; limited assistance with one staff for dressing; and extensive assistance with one staff for personal hygiene. R1 had two or more noninjury falls since last assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 03/25/23, documented R1 had short- and long-term memory deficits related to a BIMS score of nine. The ADL Functional/Rehabilitation Potential CAA dated 03/26/23, documented R1 was at risk for changes in ADL status/needs related to a BIMS score of nine and supervision with cares. The Care Plan dated 03/16/23, documented R1 was unable to independently perform ADL and directed he had episodes of urinary incontinence (lack of voluntary control over urination), and staff to check and change, as needed. The Care Plan dated 04/25/23, documented R1 was at risk for falls and directed staff encouraged him to change positions slowly. The Care Plan dated 05/17/23, documented R1 chose to smoke even though it was an identified health risk. R1 was educated on the policy and regulations regarding smoking. R1 made a choice to keep a travel pack of cigarettes with him and not to turn them into the nurses at the end of the day. The Assessments tab of R1's EMR revealed the following: A Clinical Health Review, dated 03/10/23, documented R1 required supervision with smoking. A Fall Risk Assessment, dated 04/25/23, documented R1 had a fall risk score of eight, which indicated a moderate risk for falls. A Smoking Assessment, dated 05/17/23, documented the facility maintained R1's smoking materials when not in use. In a Witness Statement on 06/01/23, Administrative Staff B stated on 06/01/23 at approximately 03:40 PM, she and Social Services X were in Social Services X's office talking about R1 leaving to the bank and asked if he needed to be changed in the system. Administrative Staff B then went to Administrative Nurse D's office to see what she thought should be done with his census. Administrative Staff B overhead LN G tell Administrative Nurse D that R1 went to the bank with Transportation D and Transportation D had dropped R1 off at a bus stop so he could go see some friends. Administrative Staff B then went to Administrative Staff A's office to let her know what was going on. Administrative Staff A made a phone call and told Administrative Staff B and Social Services X what bus stop R1 was dropped off at. At approximately 03:50 PM, Administrative Staff B and Social Services X left the building to find R1. Staff found R1 sitting on a bench, smoking a cigarette, and drinking a pop. Administrative Staff B stated she got out of the car and approached R1, who offered her money to give him a ride to his buddy's house. Social Services X pulled the car around and R1 got into the car, then stated he was tired of living in the facility. Once they returned to the facility, a Wanderguard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) was placed on R1's left wrist. In a Witness Statement on 06/01/23, Social Services X stated she left the facility at 03:50 PM to look for R1. They drove down the street he was dropped off at and found R1 sitting on a bench, drinking a soda, and smoking a cigarette. Social Services X and Administrative Staff B placed R1 in the car and brought him back to the facility. In a Witness Statement on 06/01/23, LN G stated sometime after 01:00 PM, Transportation D asked about R1 wanting to go to the bank and potentially being dropped off at another location. She stated she instructed him to speak with Administrative Staff A for direction. Staff explained the situation to Administrative Staff A as she walked up the hall. She asked what his current BIMS score was, LN G looked it up, and it was nine. Administrative Staff A told Transportation D not to leave him alone or drop him off anywhere under any circumstance. Transportation D said ok and went outside to the van with R1. He returned inside and stated R1 was asking to be dropped off at the bus stop. LN G instructed Transportation A to talk to Administrative Staff A again for guidance. LN G stated at about 02:05 PM, Transportation D returned to the facility and stated he dropped R1 off at the bus stop by a fast-food restaurant and R1 had pulled about $3,000 out of the bank. LN G sent Transportation D back to Administrative Staff A since LN G was unaware of their prior conversation and the instructions that were given. In a Witness Statement on 06/02/23, Administrative Staff A stated at approximately 01:07 PM, Transportation D approached her and informed her R1 wanted to be taken to his local bank, but he had made a statement to Transportation D that he might not come back. She stated she requested LN G to look up his BIMS score which was nine. Administrative Staff A stated she told Transportation D, in front of LN G, to not let R1 out of his sight, do not even let him out of the van, and to call her if he had any problems with R1. Transportation D acknowledged her direction and left the facility with R1 at approximately 01:19 PM. Administrative Staff A stated at 02:01 PM, Transportation D arrived back to the facility without R1, as verified by camera footage. At approximately 03:20 PM, Administrative Staff B approached Administrative Staff A and said R1 had been dropped off at a bus stop after pulling $3,000 out in cash from the bank and she asked if Administrative Staff A was aware. Administrative Staff A immediately called Transportation D on his personal cellphone, as he had left the facility. Transportation D stated he was about to call Administrative Staff A and reported he had taken R1 to the bank as requested, but then R1 asked to be dropped off at a friend's house. Transportation D told R1 he had a personal appointment to get to, so he could not do that. R1 then asked Transportation D to drop him off at the bus stop and he complied. Administrative Staff A stated she immediately told Transportation D to get back to the bus stop and find R1 and that she specifically told him not to let R1 out of his sight and asked Transportation D why would he drop R1 off at a bus stop. Transportation D stated R1 was a grown man, and he could see if he left a little kid at a bus stop, but R1 was a grown man. He stated he knew he should not have taken R1 anywhere because he knew he would get in trouble. Administrative Staff A stated at approximately 03:35 PM, three staff members went to locate R1 and found him. R1 reported to Administrative Staff B that he rode the bus and that he was going to see his friends. Administrative Staff A stated at 04:09 PM, she called Transportation D back and terminated him effective immediately. R1 arrived back to the facility at 04:17 PM, accompanied by staff, and was placed on one-to-one with a Wanderguard placed on his left wrist. According to the Kansas State University Historical Weather website, the temperature on 06/01/23 at 01:00 PM was 84.5 degrees Fahrenheit (F), the temperature at 02:00 PM was 85.0 degrees F, the temperature at 03:00 PM was 84.8 degrees F, and the temperature at 04:00 PM was 86.2 degrees F. On 06/12/23 at 09:10 PM, observation of the street where staff dropped R1 off revealed the street was very busy with a posted speed limit of 40 miles per hour (mph). According to Google Maps, the distance from where staff dropped R1 off at the bus stop to where staff found R1 measured approximately five miles. On 06/12/23 at 12:48 PM, Administrative Staff B stated R1 signed out and went with Transportation D. Administrative Staff B stated she heard LN G, Social Services X, and Administrative Nurse D talking about how R1 went to the bank, withdrew money, then got onto a bus. She asked if Administrative Staff A knew about it and went to notify her. Administrative Staff B stated Administrative Staff A called Transportation D who reported he took R1 to the bank then dropped him off at the bus stop per his wishes. Consultant GG walked into the office at that time and said he was going to look for R1 while Administrative Staff B and Social Services X were going to look the other direction on the street where R1 was dropped off. Administrative Staff B stated she and Social Services X found R1 sitting on a bench, and she got out of the car and approached R1. R1 told Administrative Staff B he would give her money to give him a ride. R1 got into the car and realized who they were and stated he was not going back to the facility. Administrative Staff B stated she told R1 to go back to the facility so they could complete the proper documentation for him to leave. On 06/12/23 at 12:57 PM, Social Services X stated she was in Administrative Staff A's office discussing where to look for R1 at and Consultant GG stated he would go to the area of the bus stop. Social Services X and Administrative Staff B drove in the opposite direction of Consultant GG on the street where R1 was dropped off at. She stated while they were driving, she looked over and saw R1 sitting on a bench. Administrative Staff B ran across the street while Social Services X pulled the car around. She stated R1 was not happy when he found out they were with the facility. On 06/12/23 at 01:40 PM, Administrative Staff A stated around 01:00 PM, Transportation D approached her and stated R1 wanted to go to the bank and had mentioned he did not know if he was going to come back to the facility. She stated she asked LN G what R1's BIMS was, and it was nine. Administrative Staff A stated she directed Transportation D to not let R1 out of his sight, take him to the bank, and call her if he had any issues to which he said ok. She stated at approximately 03:20 PM, Administrative Staff B asked her if she knew Transportation D dropped R1 off at a bus stop. She stated she immediately called Transportation D who reported that R1 wanted to be dropped off at a bus stop by the fast-food restaurant. Administrative Staff A stated she told Transportation D he needed to go back and pick R1 up. She stated Consultant GG drove one direction while Social Services X and Administrative Staff B drove the other direction. Social Services X called Administrative Nurse D to report they found R1. Administrative Staff A terminated Transportation D. R1 returned to the facility and a Wanderguard was placed on R1, which he was not happy about. She stated he was placed on one-to-one supervision and his care plan was updated. Administrative Staff A stated staff were educated on abuse, neglect, and exploitation (ANE) and transportation procedures, an emergency Quality Assurance and Performance Improvement (QAPI) meeting was held, and the door codes were changed. On 06/15/23 at 10:03 PM, Transportation D stated he was taking R1 outside in a wheelchair when R1 stood up and stated he was leaving. He stated he told R1 if he left then Transportation D would get into trouble. Transportation D went inside to talk to Administrative Staff A and told her R1 was getting ready to leave and he did not want to take R1 anywhere. Transportation D stated he went back outside and R1 continued to state he was leaving so he went back inside to tell Administrative Staff A to talk to R1. He stated Administrative Staff A told him to take R1 through the drive through at the bank and he told her R1 had to go inside the bank and was able to walk so he could not stop him from getting out of the van. Transportation D stated he took him to the bank and when they got to the stop light by the fast-food restaurant, R1 got out of the van. He stated he asked R1 if he was going to come back and R1 stated he would call at 06:00 PM. Transportation D stated he did not call the facility when R1 got out of the van because he was running late for his doctor's appointment and was frustrated and did not know what to do. He stated he had told the facility R1 was trying to leave, but nobody did anything and/or the facility failed to send extra staff with him to the bank. The facility's Abuse, Neglect, and Exploitation policy, last revised October 2022, directed neglect was defined as the failure to provide the goods and services necessary to avoid physical harm and occurred on an individual basis when a resident received lack of care in one or more areas. The policy defined willful as the individual acted deliberately. The policy directed it was the policy of the facility to treat each resident with respect, kindness, dignity, and care, and to keep them free from abuse and neglect. The facility failed to ensure R1 remained free from neglect when on 06/01/23, Transportation D dropped R1 at the bus stop per R1's request, after explicit instructions from Administrative Staff A to take R1 to the bank but to keep him under constant staff supervision. R1 had moderate cognitive impairment, was at risk for falls, and required supervision with ADLs and smoking. R1 was found by staff five miles away, sitting on a bench, drinking a soda, and smoking a cigarette. The facility failed to ensure staff provided the appropriate care and supervision required for R1, who was cognitively impaired. This neglect placed R1 in immediate jeopardy. The facility completed the following corrections by 06/02/23: Transportation D was terminated on 06/01/23. A Wanderguard (device which alerts staff is resident attempts to leave through guarded doors) was placed on R1's left wrist on 06/01/23. R1's care plan was updated on 06/01/23. An emergency QAPI meeting was completed on 06/01/23. Staff education on ANE and transportation procedures was completed on 06/01/23. Maintenance changed the door codes on 06/02/23. All corrective actions were completed prior to the surveyor entrance, therefore the deficient practice was cited as past non-compliance and existed at a J scope and severity.

The facility identified a census of 45 residents. The facility identified 22 COVID-19 (an acute respiratory illness capable of producing severe symptoms and in some cases death) positive residents on 05/02/23. Based on observations, record review, and interviews, the facility failed to ensure staff exercised appropriate infection control techniques to prevent the transmission of COVID-19 within the facility. The facility failed to disinfect shared equipment used on COVID-19 positive negative residents. The facility failed to accurately identify COVID-19 positive resident rooms, inform staff of COVID-19 positive test results, and implement the required isolation, with the appropriate signage and personal protective equipment (PPE- gloves, gowns, face shields and/or eyeglasses/goggles) designation for those positive residents. The facility further failed to ensure positive COVID-19 residents did not share a room with residents who tested negative. The facility failed to ensure staff used the appropriate PPE required when caring for COVID-19 positive residents; failed to use standards of practice related to the use of PPE including appropriate use of source control, respirators, gowns; and proper removal and disposal of soiled PPE when exiting the infectious room/area. The facility failed to post the appropriate signage announcing the COVID-19 outbreak status and ensuring all who entered the facility received education and information related to COVID-19 and related risks. The cumulation of these failures placed all residents in the facility in immediate jeopardy. Findings included: - On 05/01/2023 at 07:00 AM an inspection of the facility's main entrance revealed no signage alerting employees, vendors, residents, and visitors of the COVID-19 exposure risk due to current outbreak, or education related to signs/symptoms associated with COVID-19 and guidance on visitation with known COVID-19 exposure, positive COVID-19 test results or symptoms. On 05/01/23 at 07:09 AM, observation revealed an uncovered trash barrel with used PPE in the 200 hallways where COVID-19 positive and negative residents resided. On 05/01/23 at 07:49 AM, an unidentified female staff member walked down the 200-hallway with her shirt pulled up over her mouth; she did not wear a facemask. On 05/01/23 at 08:13 AM, an unidentified staff wore a face mask below her nose and frequently touched her mask without performing hand hygiene before or after touching their mask. On 05/01/23 at 08:52 AM, observation revealed Certified Nurse Aide (CNA) M had her face mask pulled down to her [NAME] exposing her mouth and nose. On 05/02/23 at 07:20 AM, staff moved the full-body mechanical lift into Resident (R)44's room from the hallway. The lift was not disinfected before transferring R44 into his wheelchair using the lift and sling. After use, staff moved the lift to the hallway across from R44's room without disinfecting the lift. The lift was then moved to another area and positioned with the lift arm over a trashcan. The trash can lid was partially open. On 05/02/23 at 07:34 AM an inspection of the 300 Hall revealed an uncovered clean linen cart left unattended in the middle of 300 hall in front of R47's (who tested COVID-19 positive on 05/04/23) room. The cart contained unused bed linen and pillowcases. On 05/02/23 at 07:40 AM, the facility's sit-to-stand (mechanical assistive lift) was moved from the designated COVID-19 hallway and positioned outside R7's room, who was COVID-19 negative. The lift was then moved into R7's room without being disinfected and positioned in front of R7's bed. Staff completed an assisted transfer of R7 using the lift. Staff moved the lift back out into the hall across from R7's room without cleaning it and continued to assist R7 with dressing. Staff then took the lift back to the COVID-19 unit and posted it next to the medication cart. On 05/02/23 at 08:11 AM Social Service X walked from R99's room (who tested positive for COVID-19 on 04/24/23) with an isolation gown on. Social Service X walked from the 200-hallway down the 300 hallways with the isolation gown on, and then down the 100 hallways to R99's previous room. Social Service X pushed a wheelchair retrieved from R99's previous room, down the 100 hallways as she wore the isolation gown. She stopped to talk to with an unidentified resident in the100 hallway. Social Service X left the empty wheelchair from R99's previous room in the hallway and pushed an unidentified resident into the dining room as she wore the isolation gown. Social Service X returned to the 100 hallway and retrieved the empty wheelchair and pushed the wheelchair down the 200 hallways to R99's current room. Social Service X exited R99's isolation room still wearing the isolation gown and went down the hallway to the nurse's station. Social Service X then walked back down the 200 hallway and removed the isolation gown but did not perform hand hygiene afterwards. On 05/02/23 at 11:07 AM, an unidentified female staff wore her face mask below her nose. She pulled the mask down to her [NAME] without performing hand hygiene before or after touching the mask. On 05/02/23 at 02:45 PM, CNA P assisted R41 to walk across the television room and sit on the couch. R41 used a walker and CNA P walked right next to her. CNA P wore a KN-95 (higher level respirator mask) but wore it inappropriately, without it covering her nose. On 05/04/23 at 07:05 AM, an uncovered linen cart containing unused towels and bed linen was observed in the 100-hallway across from a COVID-19 positive isolation room. On 05/04/23 at 08:30 AM, CNA Q spoke to a resident in the resident's room on the 100-hallway. CNA Q opened the door, and doffed (removed) gloves and isolation booties then exited the room without performing hand hygiene. CNA Q entered the shower room and closed the door. On 05/04/23 at 08:42 AM, CNA MM adjusted her face mask multiple times but did not wash her hands before proceeding to the kitchen to wait for room trays. On 05/04/23 at 08:45 AM, Certified Medication Aide (CMA) R loaded breakfast room trays with her hair hanging down her back. She adjusted her face mask and did not wash her hands before continuing to get the room trays ready. On 05/04/23 at 08:47 AM, an unidentified dietary staff was noted to have her face mask handing on her right ear with her mouth exposed while she prepared breakfast plates. On 05/04/23 at 08:49 AM, CNA PP entered a room on 100-hall and did not sanitize her hands upon entering. CNA PP greeted residents, then exited the room to put on gloves without performing hand hygiene. On 05/04/23 at 09:04 AM, CNA NN donned (put on) gloves without performing hand hygiene. He donned an isolation gown, did not tie the gown, then proceeded into a COVID-19 positive room with room tray. CNA NN then exited the room, doffed gown, and gloves, did not perform hand hygiene, then donned new gloves and gown and entered another COVID-19 positive room. He exited that room, doffed gown, and gloves, but did not perform hand hygiene before he grabbed a room tray and entered another COVID-19 negative room. CNA NN exited the COVID-19 negative room and did not perform hand hygiene. He donned gloves and gown to enter a COVID-19 positive room to deliver a room tray, doffed gown, and gloves before exiting, but did not perform hand hygiene. CNA NN delivered a room tray to a COVID-19 negative room and did not perform hand hygiene. He donned gloves and gown to deliver a room tray to a COVID-19 positive room; he exited the room and doffed gloves and gown without performing hand hygiene afterwards. CNA NN donned gloves and gown and entered another COVID-19 positive room. On 05/02/23, R2's, R31's and R99 (who shared a room with R26)) were in isolation lacked signage outside the room to direct staff on the type of isolation and PPE required. The facility had five residents (R16, R29, R44, R30, and R49) who were negative for COVID-19 but shared a room with COVID-19 positive residents. On 05/04/23 at 10:50 AM R18 laid on his back on the bed. Licensed Nurse (LN) I and Administrative Nurse E used hand sanitizer and doffed gloves to provide wound care for R18. Wound care items were placed on a barrier. Administrative Nurse E removed R18's soiled dressings from his buttocks and Administrative Nurse E then placed a barrier between R18's buttocks and the bed. R18 was incontinent of stool, Administrative Nurse E removed disposable wipes from R18's dresser and provided peri care. Administrative Nurse E doffed her gloves and did not perform hand hygiene prior to donning new gloves. Administrative Nurse E asked LN I if she was to remove the threes soiled dressing from R18's left foot. Administrative Nurse E pulled on the trash bag and then returned to assist with holding R18's left leg. LN I doffed soiled gloves, hand sanitized and donned new gloves. LN I used a new dry gauze dressing to dry to wound bed, applied skin prep to peri-wound, then used the tip to apply prescribed ointment to wound bed. LN I applied ointment to island dressing before she applied the dressing to pressure ulcer. LN I doffed soiled gloves, hand sanitized and donned new pair of gloves. Administrative Nurse E touched her facial mask with her gloved hand, then placed the same gloved hand onto R18's bed. Administrative Nurse E with the same gloves she placed gauze dressing into plastic medication cup with normal saline, opened border dressing and placed prescribed ointment into plastic medication cup. LN I cleansed third pressure wound on R18's left foot. LN I doffed soiled gloves, failed to hand sanitize prior to donning new gloves. LN I doffed soiled gloves; hand sanitized prior to donning a new pair of gloves. Administrative Nurse E removed the treatment barrier and placed onto the overflowing trash bag, then placed soiled incontinence brief into the trash can. Administrative Nurse E doffed soiled gloves hand sanitized prior to donning a new pair of gloves, removed soiled dressing from left ankle. On 05/02/23 at 02:45 PM, Administrative Nurse D stated the facility was currently in outbreak testing for COVID-19 which started with an employee testing positive at work. She stated the facility immediately went into outbreak testing and started testing each resident. Administrative Nurse D stated the facility staff were wearing face masks before the outbreak but switched to N-95 masks (higher level respirator mask) once the outbreak occurred. She stated the facility put positive residents in isolation and signage was posted on the door to alert staff and visitors. She stated all visitors were encouraged to wear masks due to the outbreak but not sure why signage was not currently posted on the entry doors to alert entrants of the facility about the outbreak. She stated the facility was currently transitioning COVID-19 positive residents to the 200-Hall, but all COVID-19 positive residents should have transmission precaution signage posted outside their rooms to indicate the PPE requirements. At 02:45PM Administrative Nurse D stated all equipment should be disinfected before use in between residents. She stated equipment should not be shared between infected and non-infected residents but if required the equipment should be thoroughly disinfected before and after use. On 05/04/23 at 08:37 AM, CNA P stated she did not wash her hands when she exited the room. On 05/04/23 at 11:35 AM LN I stated she should have hand sanitized between doffing and donning new gloves. LN I stated she realized she forgot to hand sanitize when she applied the border dressing. On 05/04/23 at 11:36 AM Administrative Nurse E stated hand hygiene should be performed between donning and doffing gloves. Administrative Nurse E stated she should have changed her gloves and hand sanitized after touching the trash can and before she touched R18 again. Administrative Nurse E stated she had only touched the outside of the trash can. On 05/04/23 at 03:32 PM CNA N stated staff should wash hands or hands sanitize between donning and doffing gloves when providing resident care. CNA N stated shared equipment should always be sanitized between each use and not shared between COVID-19 positive residents and non-positive residents. CNA N stated the facility just had an in-service this week to review hand hygiene and PPE use. On 05/04/23 at 04:26 PM Administrative Nurse D stated staff should wash, or hand sanitize hands between donning and doffing of gloves when providing care or treatments. Administrative Nurse D stated the last in-service for hand hygiene and PPE was in 08/2022 and again this week they had an in-service with the staff. The facility's Hand Hygiene policy dated 05/2017 documented hand hygiene would be completed by staff between glove changes during care or procedures. The facility's Infection Management Process policy dated 12/1019 documented staff would be educated on proper use of PPE when handling soiled clothing and linen s. PPE includes gowns, gloves, mask, and eye shields. Posting to notify employees, visitors and volunteers would be implemented to identify isolation precautions to be utilized including the correct PPE to be used. Residents requiring room isolation may be cohorted with another resident with the same condition. The facility's Checklist for Controlling COVID-19 in LTC [long term care] Facility policy dated 05/21/20 documented dedicate equipment was to remain in the resident room for duration of isolation (blood pressure cuff, stethoscope, glucometer, mechanical lift, sling). It may become necessary to rent equipment. The facility failed to ensure staff exercised appropriate infection control techniques to prevent the transmission of COVID-19 within the facility. The cumulation of these failures placed all residents in the facility in immediate jeopardy. The facility completed the following corrective actions to remove the immediacy: 1.Resident care equipment was disinfected immediately. 2.COVID-19 signage was posted at both entrance doors to the facility at 05:35 PM on 05/02/23. 3.Centers for Disease Control (CDC) Actions to Protect Yourself and Others was posted at all entrances to the facility at 06:00 PM on 05/02/23. 4.The facility cohorted residents who were positive for COVID-19 in the same room and away from COVID-19 negative residents on 05/02/23. 5.PPE was made available outside each COVID-19 positive room and each COVID-19 positive room received a droplet precaution posting on the door on 05/02/23. 6. Staff were educated on equipment disinfection between use on residents, donning and doffing of PPE when entering and exiting an isolation room and the appropriate PPE required for droplet precautions, and hand hygiene practices on 05/02/23 at 11:59 pm. The above corrective actions removing the immediacy were verified on 05/03/23 though the deficient practice remained at a scope and severity of F.

The facility identified a census of 45 residents. The sample included 13 residents. Based on observation, record review, and interviews, the facility failed to ensure cognitively impaired, dependent Resident (R) 38 remained free from abuse when the facility failed to prevent an episode of staff to resident physical abuse. On 05/01/23 at 07:55 AM Certified Nurse Aide (CNA) M brought R38 to the common area in a Broda (special wheelchair with tilt abilities) chair. CNA M then forcefully grabbed R38 by R38's right wrist/forearm multiple times while attempting to adjust R38's shirt and hair, despite the fact the resident raised her right arm in objection to the provision of cares. CNA M held R38's right arm tightly against R38's body and restricted R38's movement while R38 struggled against CNA M's grip. R38, who already had an older-appearing dime sized dark brown bruise on her inner right wrist, did not appear to have any physical injuries immediately after the interaction but became physically agitated with increased combativeness towards staff afterwards. The facility failure to prevent the incident of physical abuse placed R38 in immediate jeopardy. Findings Included: - The Medical Diagnosis section within R38's Electronic Medical Records (EMR) included diagnoses of intracerebral hemorrhage (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), hemiplegia (paralysis of one side of the body), aphasia (condition with disordered or absent language function), fracture of left humerus (broken bone of the left upper arm), need for assistance with personal cares, and dysphagia (swallowing difficulty). A review of R38's Admission Minimum Data Set (MDS) completed 12/15/22 indicated a Brief Interview for Mental Status (BIMS) was not completed. The MDS noted she had hearing and visual impairments with no speech. The MDS noted she usually would make herself understood if prompted or given time and would sometimes understand others. The MDS noted she required total assistance from one to two staff for transfers, locomotion, toileting, dressing, personal hygiene, and bathing. The MDS indicated no noted behaviors. A review of R38's Quarterly MDS completed 03/09/23 indicated a BIMS assessment could not be completed. The MDS indicated R38 had no behaviors. The MDS noted she required total assistance from one to two staff for transfers, locomotion, toileting, dressing, personal hygiene, and bathing. The MDS indicated she had function limitations of range of motion (ROM) to both upper and lower extremities and required extensive physical assistance from one staff for bed mobility. The MDS noted she had hearing and visual impairments with no speech. The MDS noted she usually would make herself understood if prompted or given time and would sometimes understand others. A review of R38's Communication Care Area Assessment completed 12/20/22 indicated she had communication deficit related to her hearing impairment, aphasia, difficulty understanding and communicating her needs. The CAA noted staff should learn and be aware of R38's gestures and personal sign language to assist her. The CAA noted a BIMS assessment was not completed due to hearing and language barriers. R38's Activities of Daily Living (ADLs) CAA completed 12/20/22 indicated she required total staff assistance for all daily care needs. The CAA indicated she was at risk for skin breakdown related to her bowel and bladder incontinence, communication deficit, limited ROM, and medical diagnoses. A review of R38's Care Plan initiated 12/07/22 indicated she had a deficit in cognitive function characterized by deficits with memory, judgment, decision making, and thought processes related to cognitive changes. The plan noted she had aphasia and staff should encourage her to communicate her needs in a slow/calm manner. The plan indicated staff should explain to her before beginning care or tasks (12/07/22). The plan indicated R38 had hearing impaired and used gestures and personal sign language to make staff aware of her needs (12/20/22). The plan instructed staff to reach out to her family to learn about her specific gestures and sign language. The care plan lacked documentation related to refusal of cares provided and aggressive behaviors. The plan indicated she had limitation to her left side and staff should place all items on her right side (12/12/22). A review of R38's Care Plan indicated staff identified a yellowish bruise of unknown origin on her left upper arm on 03/26/23. The plan noted an x-ray was completed of her arm and revealed to be a humeral fracture. The plan noted the facility continued pain management, shoulder immobilization, and scheduled orthopedic appointments. On 05/01/23 at 07:50AM observation revealed Certified Nurse Aided (CNA) M transported R38 from the 300 Hall to the dining area in her Broda chair. R38's left arm was immobilized, and she only had range of motion in her right arm. R38 was agitated during transport and began grabbing at CNA M with her right arm. R38 was positioned in front of the television. CNA M attempted to adjust R38's shirt with R38 still agitated. R38 pushed CNA M's hands away as CNA M attempted to adjust R38's shirt around her stomach. CNA M forcefully grabbed R38's right arm and continued to adjust her shirt. CNA M stepped back and directly behind the chair. R38 calmed down. CNA M brushed her hand through R38's hair. CNA M patted down R38's hair with her hands and R38 swung her right arm upward in protest. CNA M grabbed R38's right upper arm and forearm manipulating it against R38's body. CNA M did not communicate with R38 during this interaction. R38 remained agitated and was moved to the dining area for breakfast. R38 grabbed a fork and made stabbing motions with the fork as staff walked past her in the dining area. An inspection of R38's right arm revealed two older dime-sized brown bruised areas under her upper arm and lower forearm. These bruises were not documented in R38's EMR. In an interview of 05/01/23 at 08:35AM, CNA M reported she was trying to pull R38's shirt down as R38 was being combative towards staff. CNA M reported she had received some information related to R38's care needs but nothing about preventing behaviors or caring for her. CNA M stated that it was her first day working with R38 and she was just assisting another staff with moving R38 to the television area. She reported she was agency staff and had no previous training on abuse. She stated all staff had access to the Kardex (condensed document containing care planned information) and can ask the nurses if any question arise. On 05/01/23 at 08:45 AM, Licensed Nurse (LN) H reported most of the staff in the facility were agency with one to two days experience with the residents. She stated if a resident was agitated, or aggressive, staff should give that resident time and space to calm down and reapproach at another time. She stated R38 can be aggressive, but staff should not have grabbed the resident physically. She stated she felt staff had to wing it because staff received little direction from the facility's management. On 05/01/23 at 09:00 AM, Administrative Staff A stated CNA M would be removed from the facility immediately and the situation would be investigated. She stated all agency staff received training that include abuse, neglect, and exploitation. She reported the facility was in crisis staffing due to having a COVID-19 (highly contagious, potentially life-threatening viral infection) outbreak. She stated she was, at that time, unable to leave the 200 Hall (designated Covid area). A review of the facility's Abuse, Neglect, and Exploitation revised 10/2022 indicated all residents have the right to be free from verbal, sexual physical, and mental abuse. The policy indicated all employees will be trained during orientation and at least annually in the prevention of abuse. The policy indicated the facility will identify and intervene potential abuse situations. The policy indicated the facility will ensure staff are knowledgeable of each individual's care needs. The facility failed to ensure cognitively impaired, dependent R38 remained free from abuse when the facility failed to prevent an episode of staff to resident physical abuse. The abuse and mistreatment of R38, who was totally dependent upon staff and nonverbal, placed R38 in immediate jeopardy. The facility implemented the following corrective actions to address the immediacy related to the abuse: 1. CNA M was suspended immediately and escorted out of the building. 2. R38 was assessed for injury immediately. 3. The facility provided staff education on prevention of abuse, neglect and exploitation. 4. R38's responsible party and physician were notified. 5. Law enforcement was notified. 6. Other Residents were interviewed to assess for others affected by abuse. The above corrections removing immediacy were verified on 05/02/23. The deficient practice remained at a scope and severity of a G to represent actual harm determined by the visual agitation of the resident after the event as well as using the reasonable person concept based on the fact R38 was unable to verbalize or express the psychosocial impact of the abuse.

The facility identified a census of 45 residents. The sample included 13 residents with three residents reviewed for falls. Based on observation, record review, and interviews, facility failed to identify toileting as a causal factor for falls and implement toileting interventions after R40 experienced falls related to incontinence which resulted in an orbital socket (set of bones that surround the eye) injury. As a result, R40 had another toileting related fall in which she sustained a femur (large bone of upper leg) fracture. Findings Included: - The Medical Diagnosis section within R40's Electronic Medical Records (EMR) included diagnoses of muscle weakness, history of falls, dementia (progressive mental disorder characterized by failing memory, confusion), reduced mobility, cognitive communication deficit, anxiety (progressive mental disorder characterized by failing memory, confusion), and left femur fracture (broken bone in left upper leg). Review of R40' s Discharge Minimum Data Set (MDS) completed 05/08/22 revealed a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderate cognitive impairment. She required extensive assistance for transfers and limited assistance with toileting. The MDS further indicated she had one injury fall since her admission. The MDS documented R40 as frequently incontinent of bowel and bladder and was not on a toileting program. A review of R40's Significant Change MDS completed 02/16/23 revealed a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderate cognitive impairment. The MDS documented she required limited assistance from staff for transfers, bed mobility, dressing, toileting, personal hygiene, and bathing. R40 was frequently incontinent of bladder and occasionally incontinent of bowel and a trial toileting program was not attempted. A review of R40's Urinary Incontinence Care Area Assessment (CAA) completed 02/20/23 indicated she was frequently incontinent. The CAA instructed staff to encourage her for toileting and assist as needed. The CAA noted she was at risk for urinary tract infections and skin breakdown. The CAA instructed staff to encourage resident participation during cares to promote independence. A review of R40's Fall CAA completed 02/20/23 revealed she was at risk for falls related to her fall history, cognitive impairment, and medical diagnoses. The CAA instructed staff to remind her to call for assistance for bathroom use. A review of R40's Care Plan (initiated 04/12/22) revealed she required assistance from one staff for transfers. The care plan indicated once R40 transferred to her wheelchair she could independently propel herself throughout the facility. R40's care plan lacked documentation of interventions related to her bowel and bladder incontinence, assistance needed for toileting, and skin care after incontinence episodes. R40's Care Plan revealed she was at risk for falls. The care plan instructed staff to keep all commonly used items within reach (04/12/22), wear appropriate footwear (04/12/22), encourage position changes slowly (04/12/22), apply nonskid strips to her floor at bed side (11/04/22), and nonskid strips in front of her bathroom sink (02/03/23). R40's Care Plan noted she fell on [DATE] attempting to go to the bathroom. The plan documented she injured her left orbital (eye) socket resulting in a minor injury. The entry noted she was sent to an acute care facility and later returned. A review of the Fall Investigation dated 05/08/22 indicated toileting as an identified predisposing factor. The care plan and fall investigation lacked documented interventions for the fall. The fall investigation lacked identification of causal factor for the fall. R40's Care Plan revealed she had a major injury fall on 02/03/23 resulting in a left femur fracture. A review of the Fall Investigation for the 02/03/23 fall indicated R40 attempted to leave her bathroom and fell out of her wheelchair. The report indicated R40 had a skin tear on her left arm but no signs of other injuries. The report documented predisposing factors for the fall included confusion, impaired memory, and needing assistance with ambulation. The investigation lacked identification of causal factor for the fall. A review of R40's Progress Note dated 02/03/23 indicated R40 complained about discomfort in her left leg. The note indicated a completed x-ray revealed a left femur fracture. The note indicated she was sent out to an acute care facility for treatment. R40's EMR indicated she was hospitalized from 02/03/23 through 02/07/23 for a left femur fracture. A review of R40's EMR revealed no Bowel and Bladder assessments since she admitted on [DATE]. (Refer to F690) On 05/02/23 at 09:15 AM R40 reported she was not sure if the facility provided a toileting program but did report she had incontinence, and falls related to her incontinence. She stated staff came around and asked her for bathroom assistance, but she was not sure how often. She reported she fell before going to the bathroom and broke her hip in the facility. On 05/04/23 at 03:30 PM Certified Nurse Aide (CNA) N stated R40 could independently wander the facility safely but still needed assistance with transfers, cares, and toileting. She stated R40 was incontinent but not sure if she recently had a bowel and bladder assessment or toileting program. She stated she did not know if R40 had any recent falls but R40 had fall strips in her room and bathroom. She stated all CNA staff had access to view the care plans on the residents. She stated R40 often attempted to transfer without alerting staff. She stated R40 was not currently being assisted for restorative cares related to toileting. On 05/04/23 at 04:01 PM Administrative Nurse D stated all residents in the facility would receive bowel and bladder assessments upon admission, quarterly, annually, and with significant changes. She stated every time an accident or fall occurred the facility investigated and provided interventions to prevent further occurrences. A review of the facility's Fall Management policy revised 12/2017 indicated the facility will identify risk related to falls/accidents to allow interventions to be implemented. The policy noted a plan of care will address the individualized focus, goal, and interventions directed towards reducing the resident's risk of injury and potential reoccurrences of falls. The facility failed to identify toileting as a causal factor for falls and implement toileting interventions after R40 experienced falls related to incontinence which resulted in an orbital socket injury. As a result, R40 had another toileting related fall in which she sustained a femur fracture.

The facility identified a census of 45 residents. The sample included 13 residents with three reviewed for nutrition. Based on observation, record review, and interviews, the facility failed to identify and implement appropriate, culturally aware, resident-centered interventions to address decreased intake for cognitively impaired Resident (R) 38, who was at risk for weight loss. This deficient practice resulted in a significant, unintended loss of 21.74 percent (%) in four months (between 01/01/23 through 05/04/23) . Findings Included: - The Medical Diagnosis section within R38's Electronic Medical Records (EMR) included diagnoses of intracerebral hemorrhage (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), hemiplegia (paralysis of one side of the body), aphasia (condition with disordered or absent language function), fracture of left humerus (broken bone of the left upper arm), need for assistance with personal cares, and dysphagia (swallowing difficulty). A review of R38's Admission Minimum Data Set (MDS) completed 12/15/22 indicated a Brief Interview for Mental Status (BIMS) was not completed. The MDS identified R38 had short-term and long-term memory problems, no memory recall ability, and moderately impaired decision-making abilities. The MDS noted R38 weighed 140 pounds (lbs.) with no weight loss and R38 was not indicated to be on physician ordered program. The MDS indicated no swallowing concerns noted. The MDS noted she had hearing and visual impairments with no speech. The MDS noted she usually would make herself understood if prompted or given time and would sometimes understand others. The MDS noted she required limited assistance from one staff for meals. A review of R38's Quarterly MDS completed 03/09/23 indicated a Brief Interview for Mental Status (BIMS) assessment could not be completed. The MDS identified R38 had short-term and long-term memory problems, no memory recall ability, and moderately impaired decision-making abilities. The MDS indicated R38 had no behaviors. The MDS noted she required extensive assistance for eating her meals. The MDS noted R38 weighed 118 pounds (lbs.) but noted she had no recent weight loss and was not on a physician ordered weight loss program. The MDS noted she had hearing and visual impairments with no speech. The MDS noted she usually would make herself understood if prompted or given time and would sometimes understand others. A review of R38's Communication Care Area Assessment completed 12/20/22 indicated she had a communication deficit related to her hearing impairment, aphasia, and difficulty understanding and communicating her needs. The CAA noted staff should learn and be aware of R38's gestures and personal sign language to assist her. R38's Activities of Daily Living (ADL) CAA completed 12/20/22 indicated she required total staff assistance for all daily care needs. R38's Nutrition CAA completed 12/20/23 noted she was at risk for weight loss related to her dysphagia, communication deficit, and need for assistance related to meal intake. The CAA indicated staff were to provide assistance with meals and promote adequate hydration. A review of R38's Physician's Order revealed an order dated 12/05/22 indicating she admitted on a regular diet with mechanically soft texture. On 12/14/23 R38's diet changed to a regular diet with pureed textures. R38's Care Plan, initiated 12/15/22, noted for staff to weigh her as ordered (12/15/22), provide her diet as ordered by physician (12/15/22), provide pureed diet (12/15/22), provide a dietary consult, and promote fluids to prevent dehydration (12/20/23). The plan failed to address refusals related to aggression and/or behaviors. A review of R38's Dietary Assessment completed 12/22/22 indicated R38 could feed herself but needed assistance and encouragement during meal services. The note indicated nutritional intake varied during meals and R38 had a feeding tube (tube for introducing high calorie fluids into the stomach) removed before her admission to the facility. The assessment instructed staff to monitor her weight weekly and report changes On 12/27/22 a physician order was added to encourage R38 to consume fluids, due to low sodium levels. R38's Weight History revealed on 01/01/23 R38's weight was 139.6 lbs. On 01/18/23, R38's weight decreased to 127 lbs. R38's Physician's Orders indicated an order started 01/18/23 for her to receive Mighty Shakes with meals. An order for R38 to start Boost was added to her EMR on 01/18/23. On 02/13/23 R38's weight decreased to 122 lbs. On 02/20/23 R38's Mighty Shake the order was changed to be given three times daily for weight loss. A Dietician Note dated 02/28/23 indicated R38's weight decreased to 125.5 lbs. (loss of 10%) within the last 30 days. The note indicated she was on a pureed with thin liquids. The note indicated she received mighty shakes (nutritional supplement shake) three times a day (TID) and had a Boost (nutritional supplement shake) at bedtime. The note indicated her oral intake was poor. The note indicated no new interventions would be added, due to her not eating and refusing her scheduled medications. A review of R38's Dietary assessment completed 03/06/23 indicated she weighed 118 lbs. and noted a 10% weight change since 12/06/23. The assessment indicated she required extensive assistance with meals. The assessment noted she required a divided plate and a two handled sip cup for meals. The assessment did not address R38's ongoing refusals for medication, supplements, and meals. The assessment did not indicate R38's dietary or cultural preferences. A Dietician Note completed 03/12/23 indicated R38's weight was 118lbs. and the resident was on a pureed diet. The note indicated her oral intake was poor. The note indicated R38 refused cares and medications. The note indicated she received mighty shakes TID and a Boost supplement at bedtime. A review of R38's Medication Administration Report (MAR) for April 2023 revealed she refused her Boost supplement 18 out of the 30 days offered at bedtime. R38's MAR for April 2023 revealed she refused her Mighty Shake on 20 occasions. A Progress Note dated 03/05/23 indicated R38 continued to refuse her foods most of the time. A Progress Note dated 03/29/23 indicated R38 ate very little and continued to refuse her mighty shake. An Dietician's Assessment completed 04/13/23 indicated R38's weighed 109 lbs. The Registered Dietician (RD) recommended R38 receive fortified foods, multivitamins, and weekly weights, related to her continued weight loss. The assessment did not indicate R38's dietary or cultural preferences. On 04/13/23 R38's Care Plan noted she recently was a weight loss concern due to eating less. The plan noted family had been bringing in food and assisting R38 with meals. On 04/17/23 R38's plan added recommendations for fortified foods, multivitamins, and continued observations of her weight. The plan indicated R38 could feed herself but may require staff assistance and was a nutritional risk. The plan failed to address refusals related to aggression and/or behaviors. The Care Plan lacked new nutrition related interventions between 12/20/22 through 04/13/23. R38's plan of care did not address R38's need for a divided plate and two handled sip cup per dietary assessment on 3/06/23. R38's EMR revealed an order was started for a multivitamin on 04/17/23. A Progress Note dated 05/01/23 indicated R38 became physically aggressive during dinner service. The note indicated staff attempted to feed her when R38 started throwing her drink everywhere and clawed her direct care staff's arm. The note indicated staff left her alone to calm down. R38's Weight History revealed on 05/04/22 R38 weighed 108 lbs. On 05/04/23 at 12:14 PM R38 sat in dining room. R38 had a divided plate with a pureed meal. R38 consumed some of the main portion with staff assistance. R38 had a two handled sip cup with water. On 05/04/23 at 03:30 PM Certified Nurse Aide (CNA) N stated staff weighed the residents based on a list provide by the nurses. She stated if a resident had weight loss the charge nurse would be notified. She stated residents at risk for weight loss were tracked by the RD. She stated that RD comes in monthly to review each resident's changes. She stated she weighs all the residents and provided restorative services for the residents. She stated she was not aware of R38 having a significant weight loss. On 05/04/23 at 04:01 PM Administrative Nurse D stated the facility attempted to provide dietary supplements and shakes with noted weight loss beyond the last thirty days. Administrative Nurse D reported she was unaware of the cause of the weight loss but did report to the dietician. She reported R38's eating habits change from day to day, and sometimes the person assisting her. She reported it depended on the staff taking care of her. On 05/09/2023 at 10:30AM Consultant HH stated R38 was difficult to prevent weight loss due to the language barrier and not knowing what foods she really preferred. She stated R38 was placed on puree diet due to issues swallowing but seemed to respond better to non-pureed foods brought in by her daughter. She stated due to R38 using her own variation of sign language staff may not be able to effectively know her needs and could cause behavioral episodes and refusal of meals. She stated the language barrier made it difficult to know how to address R38's weight loss. A review of the Facility's Nutrition Policy (undated) indicated the facility will continually assess and monitor each resident's weight, diet, and hydration levels to prevent avoidable weight loss and malnutrition. The policy noted the facility will provide an interdisciplinary approach with involvement of the registered dietician, nursing, and medical provider. The facility failed to identify and implement appropriate, culturally aware, resident-centered interventions to address decreased intake for cognitively impaired R38, who was at risk for weight loss. This deficient practice resulted in a significant, unintended loss of 21.74 percent (%) in four months (between 01/01/23 through 05/04/23).

The facility identified a census of 45 residents. The facility had one main kitchen. Based on observations, record review, and interviews, the facility failed to properly label and store food, failed to store clean dishes inverted, failed to prevent cross-contamination during puree (mechanically altered diet) and mechanical soft (mechanically altered diet) diet preparation, and failed to ensure staff wore hair nets appropriately in the kitchen. This deficient practice had the risk to spread foodborne illness to all affected residents. Findings included: - On [DATE] at 07:17 AM, the refrigerator revealed two uncovered pudding cups and an Italian dressing bottle with the lid partially on and dressing crusted around the opening. Plates were stored at the end of the steam table, not inverted, or covered to prevent contamination. On [DATE] at 07:19 AM, the freezers revealed a bag of strawberries that leaked to the shelf below it and a bag of unidentified meat patties, opened and not dated. On [DATE] at 07:19 AM, the dry storage revealed a bag of beans, opened and not dated; a bag of cake mixes, opened and not dated; a bag of macaroni noodles, opened and not dated; and a bag of flour tortilla shells, opened and not dated. On [DATE] at 11:07 AM, Dietary CC was preparing the puree diet lunch and used gloves when preparing the first batch. When she prepared the second batch, she touched the chicken without gloves and placed it in the food processor. Dietary CC then prepared the mechanical soft diet lunch and wore gloves. She touched the food processor lid then grabbed the chicken with her gloved hands without using utensils. On [DATE] at 11:16 AM, plates were stored at the end of the steam table, not inverted or covered to prevent contamination. Dietary DD and Dietary EE wore their hairnets on top of their head with their hair hanging out of the bottom of the hair net. On [DATE] at approximately 10:00 AM, Dietary BB stated she was training to become the certified dietary manager (CDM) and stated that she oversaw the kitchen. She stated she was responsible for handling food preferences for the residents. On [DATE] at 04:30 PM, Dietary BB was unavailable for interview. On [DATE] at 10:37 AM, Consultant HH stated she did spot inspections and consulted with Dietary BB about the findings. She stated she noticed some expired foods and improperly kept items in storage. The facility's undated Food Storage policy documented that all foods held longer than 24 hours are to be labeled and that the label must include the name of the food and the date by which it should be sold, consumed, or discarded. The facility failed to properly label and store food, failed to store clean dishes inverted, failed to prevent cross-contamination during puree and mechanical soft diet preparation, and failed to ensure staff wore hair nets appropriately in the kitchen, This deficient practice had the risk to spread foodborne illness to all affected residents.

The facility identified a census of 45 residents. The sample included 13 residents with six residents reviewed for activities of daily living (ADL) cares. Based on observation, record review, and interviews, the facility failed to ensure bathing was provided for four residents who required assistance from staff to complete the care. This deficient practice placed resident (R)103, R29, R4 and R18 at risk for potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices. Findings included: - R103's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of failure to thrive and major depressive disorder (major mood disorder). The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99, with a staff interview which revealed R103 had modified independence with cognitive skills, with some difficulty in new situations. The MDS documented R103 was independent with set up assistance for ADL. The MDS documented bathing activity did not occur for R103 during the look back period. R103's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 02/15/23 documented he required supervision to limited assistance from staff depending on ADL. R103's Baseline Care Plan lacked documentation of ADL care. Review of the EMR under Reports: Documentation Survey Report (POC) under daily charting look back report for R103 reviewed from 02/02/23 to 03/10/23 (37 days) and from 04/26/23 to 05/02/23 (7 days) revealed no documentation of bathing. The clinical record lacked documentation of R103 refused a shower/bath. On 05/03/23 at 02:34 PM R103 stood at the nurse's station, stated he had scheduled a shower for today, an unidentified staff was overheard telling R103 today was not his shower/bath day. R103 stated he had not had a bath for two weeks he had a foul body odor and food in his beard. Another nursing staff had approached R103 and offered a shower. On 05/04/23 at 12:34 PM R103 walked with a front wheeled walker into the 100 hallways, with no shoes only socks. R103 stated he felt better after his shower yesterday, no body odor. On 05/04/23 at 03;32 PM Certified Nurse Aide (CNA) N stated at the time of admission a resident was offered the morning or evening for their bath. CNA N stated staff check the Kardex (a medical information system used by nursing staff to communicate important information on their patients. It is a quick summary of individual patient needs that is updated at every shift change) daily for the residents due for a bath/shower that day. CNA N stated if a resident would refuse a shower/bath, staff would offer several more times and report refusal to the nurse. CNA N stated document in POC the bathing or refusals. On 05/04/23 at 04:09 PM Agency Licensed Nurse (LN) G stated if a resident was to refuse their bath/shower, the CNAs would offer several more times and offer alternative bathing, then report the refusal to the nurse. LN G stated the nurse would approach the resident and if continued to refuse the nurse would notify the director of nursing and the resident's family. LN G stated the refusal would be charted in the POC. On 05/04/23 at 04:26 PM Administrative Nurse D stated at the time of admission each resident was asked their preference of days or evenings and frequency. Administrative Nurse D stated the dayshift nurse or her would update the Kardex with the residents' preferences. Administrative Nurse D stated alternative bathing was offered, along with a as needed bathing would be offered, and refusals are documented in the POC. The facility was unable to provide a policy related to bathing. The facility failed to ensure a shower/bath was provided for R103, who required assistance with ADL's, which had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial wellbeing. - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99, a staff interview documented a severely impaired cognition. The MDS documented that R29 required limited assistance of one staff member for activities of daily living (ADLs). The MDS documented R29 required limited assistance of one staff member for transfer only for bathing activity during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 99, a staff interview documented a moderately impaired cognition. The MDS documented that R29 required limited assistance of one staff member for ADLs. The MDS documented R29 was dependent on one staff member for bathing during the look back period. R29's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 02/21/23 documented the care plan would be reviewed to maintain current ADL status and reduce risk for falls and pressure ulcer risk. R29's Care Plan dated 11/04/22 documented R29 preferred a bath/shower two times a week and at times would choose to only bath one time a week. Review of the EMR under Report: Documentation Survey Report tab (POC) under daily charting looks back report for R29 reviewed from 02/01/23 to 05/02/23 (91 days) revealed shower/bath were given on the following (7) dates 02/07/23, 02/14/23, 02/24/23, 03/03/23, 03/07/23, 04/11/23, and 04/25/23. Resident was not available (RA) on 04/21/23. Resident refused (RR) one time on 03/31/23. On 05/01/23 at 02:50 PM R29 slept on his bed. On 05/04/23 at 03:32 PM, Certified Nurse Aide (CNA) N stated at the time of admission a resident was offered the morning or evening for their bath. CNA N stated staff checked the Kardex (a medical information system used by nursing staff to communicate important information on their patients. It is a quick summary of individual patient needs that is updated at every shift change) daily for the residents due for a bath/shower that day. CNA N stated if a resident would refuse a shower/bath, staff would offer several more times and report refusals to the nurse. CNA N stated they document in POC the bathing or refusals. CNA N stated R29 did not refuse very often to take his bath/shower. On 05/04/23 at 04:09 PM, Licensed Nurse (LN) G stated if a resident was to refuse their bath/shower, the CNAs would offer several more times and offer alternative bathing, then report the refusal to the nurse. LN G stated the nurse would approach the resident and if continued to refuse the nurse would notify the director of nursing and the resident's family. LN G stated the refusal would be charted in the POC. On 05/04/23 at 04:26 PM, Administrative Nurse D stated at the time of admission each resident was asked their preference of days or evenings and frequency. Administrative Nurse D stated the dayshift nurse or her would update the Kardex with the residents' preferences. Administrative Nurse D stated alternative bathing was offered, along with a as needed bathing would be offered, and refusals are documented in the POC. The facility was unable to provide a policy related to bathing. The facility failed to ensure a shower/bath was provided for R29, who required assistance with ADL's, this had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial wellbeing. - R4's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), major depressive disorder (major mood disorder), and diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS documented that R4 required extensive assistance of one staff member for activities of daily living (ADLs). The MDS documented R4 required physical assistance of one staff member for bathing during look back period. The Quarterly MDS dated [DATE] documented a BIMS score of four which indicated severely impaired cognition. The MDS documented that R4 required extensive assistance of one staff member for ADLs. The MDS documented bathing did not occur during the look back period for R4. R4's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 01/06/23 documented R4 was at risk of ADL decline related to the need for assistance with ADLs. R4's Care Plan dated 04/24/19 documented staff would provide supervision and set up assistance for bath/shower. The Care Plan dated 08/26/21 R4 would refuse at times to take a shower, but staff would attempt to redirect R4 into the bath/shower. Review of the EMR under Report: Documentation Survey Report tab (POC) under daily charting looks back report for R4 reviewed from 02/01/23 to 05/04/23 (93 days) revealed shower/bath were given on the following dates 02/17/23, 04/28/23, and 05/03/23. Two partial baths documented on following dates 02/03/23 and 03/06/23. Resident refused five times on the following dates 03/08/23, 03/15/23, 03/22/23, 03/24/23, and 03/29/23. Not applicable was documented on 03/10/23 and 03/27/23. On 05/02/23 at 01:42 PM, R4 laid on right side on the bed asleep, covered with a blanket. On 05/04/23 at 03:32 PM, Certified Nurse Aide (CNA) N stated at the time of admission a resident was offered the morning or evening for their bath. CNA N stated staff check the Kardex (a medical information system used by nursing staff to communicate important information on their patients. It is a quick summary of individual patient needs that is updated at every shift change) daily for the residents due for a bath/shower that day. CNA N stated if a resident would refuse a shower/bath, staff would offer several more times and report refusal to the nurse. CNA N stated document in POC the bathing or refusals. CNA N stated R4 did not refuse very often to take his bath/shower. On 05/04/23 at 04:09 PM, Licensed Nurse (LN) G stated if a resident was to refuse their bath/shower, the CNAs would offer several more times and offer alternative bathing, then report the refusal to the nurse. LN G stated the nurse would approach the resident and if continued to refuse the nurse would notify the director of nursing and the resident's family. LN G stated the refusal would be charted in the POC. On 05/04/23 at 04:26 PM, Administrative Nurse D stated at the time of admission each resident was asked their preference of days or evenings and frequency. Administrative Nurse D stated the dayshift nurse or her would update the Kardex with the residents' preferences. Administrative Nurse D stated alternative bathing was offered, along with a as needed bathing would be offered, and refusals are documented in the POC. The facility was unable to provide a policy related to bathing. The facility failed to ensure a shower/bath was provided for R4, who required assistance with ADLs, this had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial wellbeing. 47834 - R18's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of major depressive disorder (major mood disorder), need for assistance with personal care, open wound to right foot, pressure ulcer of left heel, pressure ulcer of sacral region (large triangular bone between the two hip bones), stage four (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling), malnutrition, and quadriplegia (paralysis of the arms, legs and trunk of the body below the level of an associated injury to the spinal cord). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS documented R18 was dependent on two staff members assistance for activities of daily living (ADLs). The MDS documented R18 as at risk for development of pressure related injuries, R18 had one or more unhealed pressure ulcers, and R18 was totally dependent on one staff member for bathing during the look back period. The Quarterly MDS dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The MDS documented R18 was dependent on two staff members assistance for ADLs. The MDS documented R18 was at risk for development pressure related injuries and had one or more unhealed pressure ulcers. The MDS further documented R18 required extensive assistance of one staff member for personal hygiene and noted bathing did not occur during the look back period. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 01/02/23, documented R18 was triggered for ADL function related to staff support for cares and needs. The CAA further documented R18 as dependent on staff for transfers, bathing, dressing, and daily care needs related to quadriplegia. The CAA directed staff to continue to provide cares so that no needs went unmet. The Care Plan dated 09/28/20, documented R18 required staff assistance with ADLs related to physical limitations. The Care Plan updated on 11/08/22, documented R18 preferred to be showered twice a week and there was a bathing cot available for that process. Review of the EMR under Report: Documentation Survey Report tab (POC) under the daily charting look back report for R18 reviewed from 02/01/23 to 05/02/23 (91 days) revealed shower/bath were given on the following (3) dates 03/02/23, 03/15/23, and 04/26/23. It documented R18 refused (RR) one time on 03/29/23. On 05/03/23 at 08:37 AM R18 was sleeping in his bed. On 05/04/23 at 11:40 AM R18 was laying in bed in his room. R18 stated he did not get showers very often. He stated staff often told him they would see about it or try to give him a shower when he would ask; however, he stated they rarely gave him one. He stated that it made him feel like staff did not care. Observations revealed R18's beard and hair were unkept, and his fingernails were approximately half of an inch to one inch long and dirty. R18 stated that staff would not help him trim his fingernails or shave/trim his hair or beard. On 05/04/23 at 03:32 PM Certified Nurse Aide (CNA) N stated at the time of admission a resident was offered the morning or evening for their bath. CNA N stated staff checked the Kardex (a medical information system used by nursing staff to communicate important information on their patients. It is a quick summary of individual patient needs that is updated at every shift change) daily for the residents due for a bath/shower that day. CNA N stated if a resident would refuse a shower/bath, staff would offer several more times and report refusal to the nurse. CNA N stated document in POC the bathing or refusals. On 05/04/23 at 04:09 PM Agency Licensed Nurse (LN) G stated if a resident was to refuse their bath/shower, the CNAs would offer several more times and offer alternative bathing, then report the refusal to the nurse. LN G stated the nurse would approach the resident and if the resident continued to refuse the nurse would notify the director of nursing and the resident's family. LN G stated the refusal would be charted in the POC. On 05/04/23 at 04:26 PM Administrative Nurse D stated at the time of admission each resident was asked their preference of days or evenings and frequency. Administrative Nurse D stated the dayshift nurse or her would update the Kardex with the residents' preferences. Administrative Nurse D stated alternative bathing was offered, along with a as needed bathing would be offered, and refusals were documented in the POC. The facility was unable to provide a policy related to bathing. The facility failed to ensure a shower/bath was provided for R18, who required assistance with ADLs, which had the potential to cause skin breakdown and/or skin complications due to poor personal hygiene and impaired psychosocial wellbeing.

The facility identified a census of 51 residents. The sample included three residents reviewed for elopement (when a cognitive impaired resident or resident with poor safety awareness exits the facility without staff knowledge). Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent an elopement for Resident (R) 1, who was cognitively impaired, at risk for elopement, and had previous elopement attempts. On 03/24/23 at approximately 12:41 PM R1 exited the facility from the North door that led out to the resident smoking area. R1 wore a Wander Guard bracelet (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort), but the North door was not linked into the Wander guard alarm system so no alarm sounded. Approximately four and a half hours later, and four miles from the facility, R1 was taken into custody by law enforcement and transported by EMS to the local hospital. The local hospital notified Administrative Staff A and facility staff, who were unaware R1 was missing, that R1 was at the hospital The hospital assessed R1 and recorded R1 had no injuries except for leg cramps. The facility failed to provide the required supervision to prevent R1 from leaving the facility without staff knowledge or supervision. The facility further failed to provide consistent checks and oversight which resulted in the facility's failure to identify R1's absence until notified by the hospital and law enforcement. This deficient practice placed R1 in Immediate Jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under Diagnoses tab recorded diagnoses of abnormalities of gait and mobility, cognitive communication deficit, dementia (progressive mental disorder characterized by failing memory, confusion), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), delusional (untrue persistent belief or perception held by a person although evidence shows it was untrue) disorder, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven, which indicated moderately impaired cognition. R1 required no supervision for activities of daily living (ADL), except for set up assistance with meals. The MDS documented R1 did not wander, but had a wander/elopement alarm used daily. The Cognitive loss Care Area Assessment (CAA) dated 11/03/22 documented R1 wandered in the environment and frequently stated he needed to leave to go to work. The Quarterly MDS dated [DATE] documented a BIMS score of 11 which indicated moderately impaired cognition. R1 required no supervision for ADLs. The MDS documented R1 did not wander but had a wander/elopement alarm used daily. The Elopement Risk Care Plan initiated 12/23/19 directed staff to report when R1 had increased wandering or pacing. R1 had a history of trailing behind other residents/visitors when they were entering or leaving the facility. Nursing staff should be mindful of leaving doors ajar and should ensure R1 was not following. An intervention initiated 11/08/22 documented R1 left out the front door alongside an agency worker who was leaving; unidentified facility staff followed, assisted R1 on a walk and then returned him back inside without adverse problems. The Risk for Falls Care Plan revised 08/24/20 directed staff to assure R1 had appropriate shoes and non-slip footwear. The Wander Care Plan initiated 10/18/22 directed staff if R1 exhibited exit seeking behaviors to evaluate R1 by completing the elopement assessment. The care plan further directed staff that if R1 exhibited exit seeking behaviors (packing, sitting close to door, packing his belongings, talking about taking a trip etc.) to place R1 on safety checks. The Clinical Health Review: Elopement Risk dated 11/28/22 documented a score of eight, which indicated a moderate risk for wandering/elopement. The Clinical Health Review: Elopement Risk dated 01/20/23 documented a score of 11, which indicated a moderate risk for wandering/elopement. The Orders tab revised 05/25/22 recorded a physician order to check Wander Guard for appropriate function, to R1's right wrist. Review of the Task: Monitor-Behavior Symptoms dated 02/28/23 to 03/29/23 documented R1 wandered on 03/06/23, 03/10/23, 03/12/23, 03/14/23, and 03/22/23. The Assessment Note dated 11/28/22 at 06:44 AM documented R1 was alert to himself with some memory loss and impaired judgement. R1 had a history of depression, delusions, anxiety, and dementia. R1 continued to ambulate around the building most of the day. The Nurse's Note dated 03/24/23 at 06:53 PM documented unidentified staff was notified that R1 was missing at approximately 04:30 PM to 05:00 PM. Facility staff immediately started looking throughout the building and performed a headcount on all residents. All residents were accounted for except R1. Administrative Staff A reported R1 was at the hospital and had been dropped off there by the police. R1 clinical record lacked any further documentation of R1's elopement incident. The Notarized Witness Statement dated 03/24/23 by Licensed Nurse (LN) J documented that around 12:00 PM LN J saw R1 eating lunch in the dining room. After passing medications to the residents present in the dining area, LN J proceeded down 100 hall to finish passing medications at approximately 12:50 PM. The Notarized Witness Statement dated 03/24/23 by R3 documented he went outside, pushed the code for the door and R1 was hiding behind him. R3 did not see R1 until R1 walked around him outside. R3 told R1 that he would go get someone, because R1 was not supposed to be outside but R1 just walked away. R3 documented he did not go get anyone. Administrative Staff A's Notarized Witness Statement dated 03/29/23 documented on 03/24/23 at 05:27 PM Administrative Staff A received a call from the hospital physician who stated that R1 was brought in by emergency medical services because R1 was found wandering in the community. R1 had no injuries and wore long pants, shoes and socks, a shirt, long sleeve jacked, a ball cap and a Wander Guard bracelet. Administrative Staff A documented that the facility started a head count on all other residents at the facility and all residents were accounted for, except R1. Administrative Staff A reviewed camera footage and learned R1 exited the 200-hall exit door behind R3, an alert and oriented resident, at 12:41 PM. R1 wore the same clothing that was noted at the emergency room . Administrative Staff A picked up R1 from the emergency room at approximately 07:45 PM. Observation on 03/29/23 at 10:40 AM revealed R1 laid in his bed with the blankets pulled up over his shoulders. R1 was on his right side with his eyes closed. On 03/29/23 at 10:50 AM Certified Medication Aide (CMA) S stated R1 wandered around a lot and the wandering had worsened since R1 admitted to the facility. CMA S stated R1 frequently asked CMA S to take R1 home. On 03/29/23 at 12:30 PM LN I stated R1 always tried to leave the facility and R1 was known to ask to go to his mom's house. LN I said R1 followed other residents that smoked out the door at the end of 200 hall. LN I revealed that when LN I worked, she made it a point to check on R1 because of the elopement risk. On 03/29/23 at 02:35 PM Certified Nurse Aide (CNA) M stated at dinner on 03/24/23, CNA M was passing out food and noted that R1 was not in the dining room. CNA M went to get R1 from his room and R1 was not here. CNA M notified LN H that R1 was not located in his room. On 03/29/23 at 02:47 PM LN H stated R1 was walked up and down the halls repeatedly. LN H stated residents who smoked were educated to not go out and open the doors for any other residents. LM H said R1 usually slept in his room for hours and R1 would go to bed in between meals. LN H recalled CNA M asked if LN H saw R1 between 04:00 PM and 05:00 PM on 03/24/23. On 03/29/23 at 03:29 PM Administrative Nurse D stated she expected staff to lay eyes on elopement risk residents every couple of hours to an hour depending on what the residents' behaviors or choice was. Administrative Nurse D stated R1 had stepped out once or twice to have a cigarette and R1 usually laid back down after he ate his lunch. Administrative Nurse D stated she expected staff to notice that R1 was missing sooner than four and a half hours. The Facility's Resident Elopement Policy & Procedure revised 12/22 documented the facility strived to promote a safe and secure environment to help minimize risk of residents leaving the premises or a safe area without the necessary supervision or authorization to do so. The facility failed to provide the required supervision to prevent R1 from leaving the facility without staff knowledge or supervision. The facility further failed to provide consistent checks and oversight which resulted in the facility's failure to identify R1's absence until notified by the hospital and law enforcement. This deficient practice placed R1 in Immediate Jeopardy. On 03/27/23 the facility completed the following corrective actions: 1.R1 was assessed by a nurse without injury upon return from the hospital. 2.R1's primary physician and responsible party was notified. 3.R1 was placed on 1:1 status immediately upon return to the facility until 03/27/23. On 3/27/23, the monitoring and supervision of the resident was changed to 15-minute checks for continued safety, until alternative memory care/secure unit placement can be obtained per responsible party request. 4.An elopement assessment was completed on R1 with the care plan updated on 3/25/23. 5.Elopement training completed with staff on 3/24/23. 6.Education on Wander Guard checks every shift with staff was completed. 7.The Wander Guard door system was tested and functioning on 03/24/25. 8.On 3/27/23, door alarm checks were completed on all doors to verify functionality and codes changed. 9.On 3/24/23, Quality Assurance Performance Improvement meeting was held with the medical director regarding the event 10.Resident council held to discuss not allowing other residents to exit the facility when exiting the facility and reporting issues immediately to facility staff on 03/27/23. The above corrective actions were completed prior to the survey event therefore the deficient practice was cited as past noncompliance.

The facility identified a census of 55 residents. The sample included three residents reviewed for abuse, neglect, and/or exploitation. Based on record review, observation, and interview the facility failed to prevent exploitation of cognitively impaired Resident (R) 1. On 11/09/21 at approximately 05:00 PM facility staff released R1 with his personal belongings, which included a television, to the care of an estranged family member with a history of exploiting R1 despite R1's plan of care specifically directed staff R1 was not to leave the facility with anyone except his legal Durable Power of Attorney (DPOA). R1 was gone from the facility with whereabouts unknown to the facility and his DPOA for ten days. R1 returned to the facility on [DATE] at 07:15 PM after a local hospital contacted the DPOA to let her know R1 was in the hospital. The facility's deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status score of 10, which indicated moderately impaired cognition. The MDS documented R1 had wandering behaviors. The MDS documented R1 was independent with most activities of daily living (ADL's), ambulated without the use of assistive devices, and received anti-psychotic medication (medication used to control documented mental illnesses). The 09/03/21 Cognition Care Area Assessment (CAA) recorded R1 was oriented to himself but confused at times regarding time and place. He had short and long-term memory problems and recall deficits. The Care Plan revised on 11/23/21 documented an intervention initiated on 9/30/19 that R1 was not to leave the building with the specific estranged family member, as directed by the resident's DPOA. Review of R1's paper chart included R1's signed Power of Attorney which indicated his legal DPOA. Review of a Complaint Intake received by the state agency documented the facility informed R1's DPOA on 11/12/21 that R1 was on leave from the facility. The intake documented Administrative Nurse D allowed the estranged family member to take R1, with his medications and clothing, from the facility sometime around 11/10/21. Administrative Nurse D told R1's DPOA she was new to the facility and did not know R1 was not supposed to leave with the estranged family member despite written instructions provided to the facility. A Nurses Progress Note dated 11/09/21 at 05:34 PM recorded R1's DPOA (later clarified to be the estranged family member with false legal documents) took R1 out of facility on leave until 11/29/21. The note further recorded the DPOA just showed up with no notice. The note documented the facility accommodated the request, prepared R1, and sent R1's medications with him in the pharmacy packaging. The note recorded the facility informed the DPOA that R1 only received a limited amount of leave days. A Nurses Progress Note dated 11/12/21 at 01:35 PM recorded R1's remaining belongings left in the facility were placed in safe storage and the facility sent all returnable medications back to the pharmacy. A Nurses Progress Note dated 11/19/21 at 08:34 PM recorded R1 returned to the facility with his legal DPOA at 0:7:15 PM. R1's EMR lacked documentation of any discussions between the facility and his legal DPOA regarding leave from the facility. The EMR further lacked documentation of an assessment of R1 upon R1 upon his return to the facility and/or what belongings and/or medications he returned with. On 11/23/21 at 11:12 AM R1 rested in bed, dressed, and in a relaxed manner. R1 described his relationship of the estranged family member and stated We just said hello and I asked how the children were doing. We did not go anywhere, and I said we better go back. R1 did not remember how long he was gone from facility and/or any visit to the hospital. Interviewed on 11/23/21 at 11:45 AM, Administrative Nurse D stated she began employment at the facility in September 2021. Administrative Nurse D stated on 11/09/21 R1's estranged family member informed her that the family member was R1's DPOA. The estranged family member presented Administrative Nurse D with Power of Attorney paperwork. Administrative Nurse D stated the estranged family member, along with an unidentified male companion, took R1 on leave and informed the facility R1 would return to the facility on [DATE]. When they left with R1, they took all of his clothes and his television with them. Administrative Nurse D said she was later informed by an unidentified staff member the family member was not R1's legal DPOA. Administrative Nurse D stated she then called R1's actual legal DPOA the next day to inform the DPOA of the error. Administrative Nurse D said the legal DPOA was very upset by the situation. Administrative Nurse D called the family member R1 who removed R1 from the facility and left a message saying R1 had to be returned to the facility by 11/12/21 due to lack of having paid leave days. Administrative Nurse D said R1's legal DPOA called on 11/19/21 to alert she learned R1 was at a local hospital. Per Administrative Nurse D, R1 returned to the facility on [DATE] with R1's legal DPOA. Administrative Nurse D stated she did not check R1's paper chart or EMR prior to allowing the estranged family member to take the resident from the facility. In an interview by telephone on 11/23/21 at 12:28 AM, R1's DPOA confirmed the information recorded in the complaint intake and acknowledged she also filed a police report for the situation as a kidnapping. She stated she was R1's legal DPOA for many years. She reported she was unsure how the estranged family member was able to produce DPOA paperwork. She further stated the estranged family member had a known history of taking advantage of R1's decreased cognition. She stated the estranged family member had used devious methods, which exploited R1's dementia, to obtain property of substantial value from R1 who was unable to understand the transaction. R1's DPOA stated the estranged family member had not returned R1's personal items which included clothing and his television to the facility. Interviewed on 11/23/21 at 1:00 PM, Administrative Staff A stated the facility did not consider the occurrence as a potential for abuse, neglect or exploitation. Administrative Staff A declined to provide any additional information to explain R1's release from the facility with a non-authorized person(s). Review of the facilities Abuse, Neglect and Exploitation policy revised September 2017 recorded the resident has the right to be free from verbal, sexual, physical and mental abuse and involuntary seclusion. It documented it was the policy of the facility to treat each resident with respect, kindness, dignity, and care to keep them free from abuse and neglect. It recorded the facility would take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. The facility failed to prevent exploitation of a vulnerable cognitively impaired resident when facility staff allowed an estranged family member to take R1 from the facility, with R1's personal property, despite the directives from R1's plan of care and legal DPOA. R1 remained out of the facility, in an unknown location with the estranged family member for 10 days, which placed R1 in immediate jeopardy.

The facility identified a census of 55 residents. The sample included three residents reviewed for abuse, neglect, and/or exploitation. Based on record review, observation, and interview the facility failed to provide the necessary protective oversight to prevent ongoing exploitation of cognitively impaired Resident (R) 1. On 11/09/21 at approximately 05:00 PM facility staff released R1 with his personal belongings, which included a television, to the care of an estranged family member with a history of exploiting R1 despite R1's plan of care specifically directed staff R1 was not to leave the facility with anyone except his legal Durable Power of Attorney (DPOA). R1 was gone from the facility with whereabouts unknown to the facility and his DPOA for ten days. The facility failed to implement protective measures when the facility realized the situation. The facility's deficient practice placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR), under the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status score of 10, which indicated moderately impaired cognition. The MDS documented R1 had wandering behaviors. The MDS documented R1 was independent with most activities of daily living (ADLs), ambulated without the use of assistive devices, and received anti-psychotic medication (medication used to control documented mental illnesses). The 09/03/21 Cognition Care Area Assessment (CAA) recorded R1 was oriented to himself, but confused at times regarding time and place. He had short and long-term memory problems and recall deficits. The Care Plan revised on 11/23/21 documented an intervention initiated on 9/30/19 that R1 was not to leave the building with the specific estranged family member, as directed by the resident's DPOA. Review of R1's paper chart included R1's signed Power of Attorney which indicated his legal DPOA. Review of a Complaint Intake received by the state agency documented the facility informed R1's DPOA on 11/12/21 that R1 was on leave from the facility. The intake documented Administrative Nurse D allowed the estranged family member to take R1, with his medications and clothing, from the facility sometime around 11/10/21. Administrative Nurse D told R1's DPOA she was new to the facility and did not know R1 was not supposed to leave with the estranged family member despite written instructions provided to the facility. A Nurses Progress Note dated 11/09/21 at 05:34 PM recorded R1's DPOA (later clarified to be the estranged family member with false legal documents) took R1 out of facility on leave until 11/29/21. The note further recorded the DPOA just showed up with no notice. The note documented the facility accommodated the request, prepared R1, and sent R1's medications with him in the pharmacy packaging. The note recorded the facility informed the DPOA that R1 only received a limited amount of leave days. A Nurses Progress Note dated 11/12/21 at 01:35 PM recorded R1's remaining belongings left in the facility were placed in safe storage and the facility sent all returnable medications back to the pharmacy. A Nurses Progress Note dated 11/19/21 at 08:34 PM recorded R1 returned to the facility with his legal DPOA at 07:15 PM. R1's EMR lacked documentation of any discussions between the facility and his legal DPOA regarding leave from the facility. The EMR further lacked documentation of an assessment of R1 upon his return to the facility and/or what belongings and/or medications he returned with. Upon request, the facility was unable to provide an investigation, or any documentation related to the facility's response to the incident. The facility was unable to provide an intake number to evidentiate facility self -report to the state agency and was unable to provide a law enforcement case number as well. On 11/23/21 at 11:12 AM R1 rested in bed, dressed, and in a relaxed manner. R1 described his relationship of the estranged family member and stated We just said hello and I asked how the children were doing. We did not go anywhere, and I said we better go back. R1 did not remember how long he was gone from facility and/or any visit to the hospital. Interviewed on 11/23/21 at 11:45 AM, Administrative Nurse D stated she began employment at the facility in September 2021. Administrative Nurse D stated on 11/09/21 R1's estranged family member informed her that the family member was R1's DPOA. The estranged family member presented Administrative Nurse D with Power of Attorney paperwork. Administrative Nurse D stated the estranged family member, along with an unidentified male companion, took R1 on leave and informed the facility R1 would return to the facility on [DATE]. When they left with R1, they took all of his clothes and his television with them. Administrative Nurse D said she was later informed by an unidentified staff member the family member was not R1's legal DPOA. Administrative Nurse D stated she then called R1's actual legal DPOA the next day to inform the DPOA of the error. Administrative Nurse D said the legal DPOA was very upset by the situation. Administrative Nurse D called the family member R1 who removed R1 from the facility and left a message saying R1 had to be returned to the facility by 11/12/21 due to lack of having paid leave days. Administrative Nurse D said R1's legal DPOA called on 11/19/21 to alert she learned R1 was at a local hospital. Per Administrative Nurse D, R1 returned to the facility on [DATE] with R1's legal DPOA. Administrative Nurse D stated she did not check R1's paper chart or EMR prior to allowing the estranged family member to take the resident from the facility. Administrative Nurse D said she did not feel the occurrence represented any potential for abuse and/or neglect and stated I did not look at it that way, or I would have reported it, it's not that we were trying to hide anything, we have reported things before. In an interview by telephone on 11/23/21 at 12:28 AM, R1's DPOA confirmed the information recorded in the complaint intake and acknowledged she also filed a police report for the situation as a kidnapping. She stated she was R1's legal DPOA for many years. She reported she was unsure how the estranged family member was able to produce DPOA paperwork. She further stated the estranged family member had a known history of taking advantage of R1's decreased cognition. She stated the estranged family member had used devious methods, which exploited R1's dementia, to obtain property of substantial value from R1 who was unable to understand the transaction. R1's DPOA stated the estranged family member had not returned R1's personal items, which included clothing and his television to the facility. R1's DPOA stated she was able to locate R1 only because the estranged family member took R1 to the local veterans' hospital to inquire about his available benefits. The hospital had R1's DPOA on record and notified her that R1 was there in the hospital with the estranged family member. Interviewed on 11/23/21 at 1:00 PM, Administrative Staff A stated the facility did not consider the occurrence as a potential for abuse, neglect or exploitation. Administrative Staff A declined to provide any additional information to explain R1's release from the facility with a non-authorized person(s). Review of the facilities Abuse, Neglect and Exploitation policy revised September 2017 recorded the resident has the right to be free from verbal, sexual, physical and mental abuse and involuntary seclusion. It documented it was the policy of the facility to treat each resident with respect, kindness, dignity, and care to keep them free from abuse and neglect. It recorded the facility would take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. The facility failed to provide the necessary protective oversight to prevent ongoing exploitation of a vulnerable cognitively impaired resident when facility staff allowed an estranged family member to take R1 from the facility, with R1's personal property, despite the directives from R1's plan of care and legal DPOA. R1 remained out of the facility, in an unknown location with the estranged family member for 10 days. The facility further failed to implement protective measures or investigate the occurrence of exploitation, which placed R1 in immediate jeopardy.

The facility identified a census of 66 residents. The sample included eleven residents reviewed for misappropriation of resident property. Based on record review, observation, and interview the facility failed to prevent misappropriation of resident property for Resident (R)9, R1, R2, R3, R4 and R8. Findings included: - Resident (R) 9's Electronic Medical Record (EMR) documented [DIAGNOSES REDACTED]. The 5 Day Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BI[CONDITION]) score of 15 which indicated intact cognition. The Care Area Assessment (CAA) was not completed. The Care Plan for Activities of Daily Living (ADL) directed staff to assist with ADL's related to physical limitations. The Care Plan lacked directives for R9s' finances prior to discharge. The Profile tab documented R9 was his own responsible party. Review of the EMR lacked evidence of written or verbal authorization from R9 for any facility staff member to get into his wallet and use his debit card. The Progress Notes tab of the EMR dated 03/02/20 at 10:31 AM recorded R9's sister called to report money missing from his checking account on 02/27/20. The sister provided a printout of the transactions and facility notified the police on 02/28/20. Review of the bank transactions revealed the following transactions: 0[DATE] Doordash * McDonalds $12.04 0[DATE] Doordash * Church $17.47 0[DATE] Doordash * McDonalds $10.[AGE] 0[DATE] Lyft * Pending $15.71 0[DATE] Doordash * McDonalds $18.30 0[DATE] Doordash * [ENTITY] $50.[AGE] 0[DATE] Doordash * McDonalds $12.[AGE] 0[DATE] Doordash * [ENTITY] $37.34 0[DATE] Doordash * McDonalds $10.[AGE] 0[DATE] Doordash * McDonalds $13.09 02/23/20 Lyft * Pending $9.40 02/23/20 Lyft * Pending $10.47 02/23/20 Doordash * Sonic $31.38 02/24/20 Doordash * McDonald $18.35 02/24/20 Doordash * Fast Fre $34.99 02/25/20 Lyft * Pending $8.69 02/25/20 Lyft * Pending $23.[AGE] 02/25/20 Lyft * Pending $23.24 02/25/20 Doordash * McDonalds $17.51 02/25/20 Doordash * McDonalds $17.[AGE] 02/25/20 Doordash * Wendy's $20.02 02/25/20 Doordash * [ENTITY] $31.05 02/26/20 Doordash * McDonalds $45.15 02/26/20 Boost Mobile $34.00 02/26/20 [LOCATION] BPU $100.00 02/26/20 [LOCATION] BPU $100.00 02/26/20 [LOCATION] BPU $50.00 02/26/20 Lyft * Pending $14.51 02/26/20 MetroPCS Tel $43.00 02/26/20 [LOCATION] BPU $100.00 The bank transactions supplied lacked documentation for the remaining $300.[AGE]. R9 requested $13.68 be included for the cost of the card replacement from the bank. Certified Nurse Aid (CNA) M refused to give a Witness Statement of the events. Review of CNA M's personnel file noted background check completed 12/02/19 with no documentation of criminal history and documented Abuse, Neglect, and Exploitation training on 12/03/19. Review of the facility Grievance Log Report of Concern dated 02/27/20 documented R9's sister called the facility to report he was missing about $700 dollars form his checking account over several transactions, including a Board of Public Utilities (BPU) bill. R9 reported he would provide the facility a printout of the transactions. During the investigation R9 recalled one employee used his debit card during his stay. The facility Grievance Log Report of Concern lacked identification of employee recalled by R9. Review of the Facility Investigation documented R9 gave his debit card to CNA M to get him a pop and it took over three hours to get his pop and debit card back from CNA M. R9 reported it to Social Services X and she went to look into this concern. When located, CNA M reported she was pulled away to a task and forgot she still had R9's debit card. When Social Services X followed up with R9 he had his debit card back. It was determined upon review of R9's transaction history the total of fraudulent charges was $1,089.55. The facility's policy Abuse, Neglect, and Exploitation dated September 2017 directed the facility would identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property was more likely to occur. It further stated that the resident involved shall be assured of protection from further harm and monitored closely with both medical and social service intervention as indicated. The facility failed to prevent misappropriation of property of R9 by CNA M, when she obtained and used R9's debit card information. - R1's Electronic Medical Record (EMR) documented [DIAGNOSES REDACTED]. (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), and [MEDICAL CONDITION] (paralysis characterized by motor or sensory loss in the lower limbs and trunk). The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BI[CONDITION]) score of 12 which indicated intact cognition. The Care Area Assessment (CAA) dated [DATE] for Cognitive loss documented R1 had disorganized thinking. The Care Plan for cognition dated [DATE] directed staff to cue and prompt R1 to assist in making his own attempt with participation in daily cares. The Care Plan lacked directives for R1's finances prior to 0[DATE]. The Profile tab of the EMR documented R1 had a legal guardian. The EMR lacked evidence of written or verbal authorization from R1 or his legal guardian for any facility staff member to use his debit card. Review of a facility Witness Statement dated 02/18/20 given by Licensed Nurse (LN) G documented R1 asked him on different occasions to use R1s's debit card to purchase cigarettes and food. LN G refused each time and informed the resident that staff cannot take money from residents. Review of a facility Witness Statement dated 0[DATE] given by Housekeeping/Maintenance Staff V documented R1 asked him to take his debit card and purchase things. He stated he always told him no. He further stated that R1 had his personal identification number (PIN) number written down. The Housekeeping/Maintenance V Witness Statement lacked clarification as to how he was aware R1 had the PIN number written down. Review of a facility Witness Statement dated 02/20/20 given by Certified Nurse Aid (CNA) O documented he/she witnessed CNA M leaving the facility to go to the Automated Teller Machine (ATM). Certified Nurse Aid (CNA) M refused to give a Witness Statement of the events. Certified Nurse Aid (CNA) N refused to give a Witness Statement of the events. Review of CNA M's personnel file noted a background check completed 12/02/19 with no documentation of criminal history and documented Abuse, Neglect, and Exploitation training on 12/03/19. Review of CNA N's personnel file noted a background check completed 10/25/19 with no documentation of criminal history and documented Abuse, Neglect, and Exploitation training on 10/23/19. Review of facility Grievance Log Report of Concern dated 02/20/20 documented R1 reported to Social Services X he was missing $[AGE]0.00 dollars. When asked if he gave his card and PIN number out, R1 stated he gave it to a staff member but could not recall the staff member's name. On 02/20/20 the facility notified the police department about the missing money and the police assigned a case number. On 02/26/20 at 01:15 PM Social Services X stated Administrative Staff A interviewed the residents who had their own debit cards. R1 was good about telling staff if there was money missing. It was determined to be CNA M who took the money. On 02/26/20 at 02:20 PM Administrative Nurse D stated CNA M withdrew money at an ATM related to the bank statement dates, times, and location of transactions. Administrative Nurse D further stated she reviewed the statement of R1's' card and noted the money being withdrawn from R1s' account corresponded to the date reported that CNA M left to withdraw money. On 02/27/20 at 08:45 AM Administrative Staff B stated that R1 was his own person for finances. The facility's policy Abuse, Neglect, and Exploitation dated September 2017 directed the facility would identify, correct, and intervene in situations in which abuse, neglect and /or misappropriation of resident property was more likely to occur. It further stated the resident involved shall be assured of protection from further harm and monitored closely with both medical and social service intervention as indicated. The facility failed to prevent misappropriation of property of R1 by a staff member, when facility staff used R1's debit card to withdraw money from an ATM without R1's consent. - R2's Electronic Medical Record (EMR) documented [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BI[CONDITION]) score of 15 which indicated intact cognition. The Quarterly MDS dated [DATE] documented a BI[CONDITION] score of 15 which indicated intact cognition. The Care Area Assessment (CAA) dated 09/06/19 for Psychosocial Well Being documented R2 admitted to some depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness) due to his current situation. The Care Plan lacked directives for R2's finances and belongings prior to 09/18/20. The Profile tab of the EMR documented R2 was his own responsible party. Review of the EMR lacked evidence of written or verbal authorization from R2 for any facility staff member to use his debit card or his personal belongings. The Progress Note tab in the EMR dated 02/18/20 at 05:45 PM recorded R2 reported to Administrative Staff A, he was missing a single white gold ring with diamonds valued at $100 dollars, a silver ring valued at $45 dollars, Electronic Benefit Transfer (EBT) card with a $19 dollar balance, and a single $5 dollar bill. Review of a facility Witness Statement dated 0[DATE] given by Housekeeping/Maintenance U documented she assisted R2 out to smoke, brought him back to his room, and noted Certified Nurse Aid (CNA) M coming out of R2's room. R2's lock box was on his nightstand, and he kept the lock box in his drawer. Certified Nurse Aid (CNA) M refused to give a Witness Statement of the events. Review of CNA M's personnel file noted a background check completed 12/02/19 with no documentation of criminal history and documented Abuse, Neglect, and Exploitation training on 12/03/19. Review of facility Grievance Log Report of Concern dated 02/18/20 documented R2 reported he was missing one white gold ring with three diamonds valued at approximately $100 dollars, one silver optic shaped ring valued at approximately $45 dollars, one EBT card with $19 dollars on it, and one five dollar bill. R2 reported CNA M came out of R2'sroom. On 02/18/20 the facility notified the police department about the missing money and police assigned a case number. On 02/26/20 at 12:23 PM R2 sat in his wheelchair next to his bed. He was well groomed and appeared clean. On 02/26/20 at 12:25 PM R2 stated when he came back from going out for a smoke on Tuesday last week, he noted the door to his room was closed. Upon entering the room R2 noticed his lock box was not where it was prior to him leaving his room to go outside to smoke. R2 further stated once he noted he was missing things he told Administrative Staff A. R2 revealed he does not feel staff at the facility can be trusted. On 02/26/20 at 01:15 PM Social Services X stated Administrative Staff A interviewed the residents who had their own debit cards. She revealed R2 was good about telling her or Administrative Staff A if there was anything missing. It was determined to be CNA M who had taken money from R2. On 02/26/20 at 2:20 PM Administrative Nurse D stated CNA M was immediately suspended pending investigation. When Administrative Nurse D reached out to CNA M about the missing belongings CNA M did not respond. The facility's policy Abuse, Neglect, and Exploitation dated September 2017 directed the facility would identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property was more likely to occur. It further stated, the resident involved shall be assured of protection from further harm and monitored closely with both medical and social service intervention as indicated. The facility failed to prevent misappropriation of property of R2 by facility staff, when facility staff took his two rings, EBT card and cash out of his room without R2's consent. - R3's Electronic Medical Record (EMR) documented [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BI[CONDITION]) score of 14 which indicated intact cognition. The Care Area Assessment (CAA) for Cognitive Loss did not trigger. The Care Plan for independent with R3's personal care dated 01/06/20 directed staff to assist with Activities of Daily Living (ADL) as needed and encourage independence. The Care Plan lacked directives for R3's finances prior to 02/26/20. The Profile tab of the EMR documented R3 was his own responsible party for medical decisions but had a Durable Power of Attorney (DPOA) for finances. Review of the EMR lacked evidence of written or verbal authorization from R3 or his DPOA for any facility staff member to use his debit card. The Progress Note tab of the EMR dated 02/26/20 at 10:52 AM recorded R3's guardian notified the facility of a concern with R3's bank account charges. The guardian provided a copy of R3's bank statement to the facility. The progress note documented the facility initiated an investigation on 02/25/20 around 09:30 AM. The facility called the police department and a message was left to update an open report. Certified Nurse Aid (CNA) M refused to give a Witness Statement of the events. Certified Nurse Aid (CNA) N refused to give a Witness Statement of the events. Review of CNA Ms' personnel file noted a background check completed 12/02/19 with no documentation of criminal history and documented Abuse, Neglect, and Exploitation training on 12/03/19. Review of CNA N's personnel file noted a background check completed 10/25/19 with no documentation of criminal history and documented Abuse, Neglect, and Exploitation training on 10/23/19. On 02/26/20 at 12:03 PM R3 stood in the doorway to his room. He was well groomed, dressed appropriately, and clean. On 02/26/20 at 12:05 PM R3 stated his debit card and cash in his wallet were left in his room when he went out to the hospital. R3 revealed both the debit card and cash went missing from his room. R3 stated he had $40 dollars in cash in his wallet along with the debit card. R3 stated his DPOA was working on it and she would take care of it to recover his money. On 02/26/20 at 02:20 Administrative Nurse D stated R3's DPOA had noted fraudulent charges on R3's bank account. R3 was in the hospital from 02/12/20 through 0[DATE]. Administrative Nurse D reported she watched the video cameras and noted CNA M was at the vending machines in the hallway by the nurses station using a debit card to purchase food, which corresponded to the expenses noted on R3's bank statement. Administrative Nurse D further stated she was calling the police department again so an officer would come out for this event. On 02/27/20 at 08:45 AM Administrative Staff B stated R3 did have a DPOA. R3's DPOA monitored his accounts, paid his bills, but R3 kept his debit card on his person while at the facility. The facility's policy Abuse, Neglect, and Exploitation dated September 2017 directed the facility would identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property was more likely to occur. It further stated that the resident involved shall be assured of protection from further harm and monitored closely with both medical and social service intervention as indicated. The facility failed to prevent misappropriation of property by a staff member, when facility staff used R3's debit card to purchase food from the vending machine without R3's consent. - R4's Electronic Medical Record (EMR) documented [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BI[CONDITION]) score of eight which indicated mildly impaired cognition. The Care Area Assessment (CAA) for Cognitive Loss dated 12/29/19 documented R3 had non-compliance with care and participation with activities. The Care Plan for Activities of Daily Living (ADL) dated 12/31/19 directed staff to assist R4 with dressing and personal cares. The Care Plan lacked directives for R4's finances prior to 0[DATE]. The Profile tab of the EMR documented R4 was his own responsible party. Review of the EMR lacked evidence of written or verbal authorization from R4 for any facility staff member to use his debit card. The Progress Note tab of the EMR dated 0[DATE] at 02:41 PM recorded R4 reported to Administrative Staff A on 02/20/20 around 11:30 AM his debit card and driver's license were missing. The facility initiated an investigation at that time, starting with a search of R4's room per his permission and laundry facilities were searched. The facility notified the police of R4's missing items. R4 called his bank with Administrative Staff A to request recent transactions. The bank stated they would reimburse R4's account for all fraudulent charges. R4 was updated on outcome of the investigation. Review of the receipts located with R4's roommate's belongings with the last four numbers of R4s' debit card revealed the following: [DATE] Dollar General Store $12.05 [DATE] [ENTITY] $98.18 Review of the Commerce Bank transaction dates for R4s' bank account revealed the following: 02/18/20 Door Dash McDonalds $12.59 0[DATE] Shell $40.00 0[DATE] BP # 32 $16.[AGE] 0[DATE] [ENTITY] $6.46 0[DATE] Pizza Hut Store # 4[AGE]2 $20.51 Certified Nurse Aid (CNA) M refused to give a Witness Statement of the events. Certified Nurse Aid (CNA) N refused to give a Witness Statement of the events. Review of CNA M's personnel file noted a background check completed 12/02/19 with no documentation of criminal history and documented Abuse, Neglect, and Exploitation training on 12/03/19. Review of CNA N's personnel file noted a background check completed 10/25/19 with no documentation of criminal history and documented Abuse, Neglect, and Exploitation training on 10/23/19. Review of facility Grievance Log Report of Concern dated 0[DATE] documented R4 went to Social Services X and reported his driver's license and debit card were missing. On 02/26/20 at 11:53 AM R4 sat in a wheelchair in his room. He appeared well groomed and clean. On 02/26/20 at 11:55 AM R4 stated his bank card and drivers' license had not been found. He further stated no one had come to follow up with him since Administrative Staff A left for vacation the week prior. R4 stated he did not feel safe with the staff because his items were stolen. On 02/26/20 at 02:20 PM Administrative Nurse D stated R4 was missing his debit card and driver's license and staff did search for it in the facility with his permission but were unable to locate it. The facility's policy Abuse, Neglect, and Exploitation dated September 2017 directed the facility would identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property was more likely to occur. It further stated that the resident involved shall be assured of protection from further harm and monitored closely with both medical and social service intervention as indicated. The facility failed to prevent misappropriation of property by facility staff when R4s' debit card and drivers' license were confirmed to be missing. - Resident (R) 8's Electronic Medical Record (EMR) documented [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BI[CONDITION]) score of 10 which indicated mildly impaired cognition. The Annual MDS dated [DATE] documented a BI[CONDITION] score of 10 which indicated mildly impaired cognition. The Care Area Assessment (CAA) for Cognitive Loss dated 01/04/20 documented to focus on maintaining current level of cognitive function and monitor for declines. The Care Plan related to R8s's stroke dated 07/14/19 directed staff to allow R8 time to make decisions. The Care Plan lacked directives for R8's finances prior to 02/26/20. The Profile tab of the EMR documented R8 was his own responsible party. Review of the EMR lacked evidence of written or verbal authorization from R8 for any facility staff member to get into his wallet and use his cash. The Progress Note tab of the EMR dated 03/02/30 at 10:41 AM recorded Administrative Nurse D followed up with R8 regarding the report of missing money. R8 validated he did make recent cash withdrawals from his resident trust and had $[AGE] dollars in his wallet on 0[DATE]. The money was unable to be accounted for as of 02/27/20. Resident was notified on 02/28/20 that he would be reimbursed by the facility for the $[AGE] dollars. Review of R8's Trust Transaction History for February 2020 revealed: [DATE] Monthly Spending $62.00 02/18/20 Vending Machine money $5.00 Certified Medication Aide (CMA) S Witness Statement dated 02/28/20 documented on Thursday February 13th, R8 approached CMA S to count his money for him and separate the money into three different sections of his wallet. R8 had a total of $[AGE] dollars (three $20 dollar bills, one $10 dollar bill, and five one dollar bills). CMA S documented on Tuesday February 18th, 2020, R8 came back to her to be reminded of how much money he had and to check his wallet for him. CMA S noted all his money was missing. Certified Nurse Aid (CNA) M refused to give a Witness Statement of the events. Certified Nurse Aid (CNA) N refused to give a Witness Statement of the events. Review of CNA M's personnel file noted a background check completed 12/02/19 with no documentation of criminal history and documented Abuse, Neglect, and Exploitation training on 12/03/19. Review of CNA N's personnel file noted a background check completed 10/25/19 with no documentation of criminal history and documented Abuse, Neglect, and Exploitation training on 10/23/19. Review of Resident Questions completed during the facility investigation on 02/18/20 documented R8 reported he had cash missing. Review of facility Grievance Log Report of Concern dated 02/27/20 documented R8 reported Certified Medication Aide (CMA) S helped R8 count his money on 0[DATE] and set up his wallet. There was $[AGE] dollars total in his wallet. R8 asked CMA S if she recalled the amount of money, he had on 02/18/20. CMA S verified the money was gone from R8's wallet. The report further documented CMA S reported this event on 02/18/20. The corrective action taken revealed staff interviewed R8 on 02/18/20, 02/20/20, 02/27/20, and 02/28/20 regarding his concern about his missing money. On 03/02/20 at 01:05 PM R8 sat in his wheelchair near the nurse's station. Administrative Nurse D asked the resident if he was missing anything else like belongings in addition to the money he was missing. R8 was overheard stating his boom box was missing. Administrative Nurse D stated it would be replaced for him. On 03/02/20 at 01:20 PM R8 stated he had cash taken out of his wallet and he also had a boom box missing. R8 revealed he reported the occurrence when it happened over a week ago. He stated no staff member followed up with him about the investigation. On 03/02/20 at 05:00 PM Administrative Staff A stated if someone said they were missing money he expected a grievance form to be filled out so it could be investigated. On 03/03/20 at 09:24 AM CMA S stated R8 talked to her on the 18th of February about the missing money and she reported it to Administrative Staff A the same day. The facility's policy Abuse, Neglect, and Exploitation dated September 2017 directed the facility would identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property was more likely to occur. It further stated that the resident involved shall be assured of protection from further harm and monitored closely with both medical and social service intervention as indicated. The facility failed to prevent misappropriation of property of R8 by facility staff, when facility staff took money out of R8s' wallet and removed his boom box from his room.

The facility reported a census of 62 residents. The facility identified 6 residents at risk for elopement (when a cognitive impaired resident with little or poor safety awareness exits the facility without staff knowledge.) The sample included 3 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received adequate supervision and appropriate interventions to prevent an elopement. R1 who was identified at risk for elopement eloped from the facility on 12/23/19. Review of facility camera footage revealed R1 exited the facility at 04:48 PM and was found by his family member walking down the road two blocks from the facility at 05:10 PM. The resident exited through an unsecured door on the post-acute unit, unwitnessed by staff. The door alarms sounded, but staff were unable to hear the alarm at their assigned station. The resident was walking on the side of the road which had four lanes of moving traffic at 35 miles per hour and changing slopes/surfaces. This deficient practice placed R1 in immediate jeopardy. Findings included: - R1's (MONTH) 2019 Electronic Medical Record (EMR) documented [DIAGNOSES REDACTED]. The main feature of this disorder is the presence of delusions, unshakable beliefs in something untrue or not based on reality). The 10/4/19 Admission Minimum Data Set (MDS) documented staff assessed the resident with a Brief Interview for Mental Status score of four which indicated severely impaired cognition and poor safety awareness. The MDS documented the resident had a depression score of four (average depression) and no delusions during the seven-day assessment period. He was independent with his activities of daily living (ADL's) and walked independently without use of a rolling walker and/or wheelchair. The MDS recorded the resident was at risk for falls but had no wandering behavior during the assessment period. The Cognitive Loss Care Area Assessment (CAA) dated 10/4/19 documented the resident had inattention when spoken to, had wandering behaviors, and required frequent redirection as he liked to wander the halls and enter others rooms. R1 was easily redirected, wore a WanderGuard (a signaling device to alert staff a confused resident was near a facility exit), usually understood what was being said, but at times had a lack of carry over and/or inattention when being talked to. He had a short attention span. Staff were directed to limit lengthy conversations, keep conversations simple, limit distractions when speaking to resident, and provide redirection as needed. The Behavioral Symptoms CAA dated 10/4/19 triggered due to wandering. He payed close attention to visitors coming and going and tried to follow behind them. Staff were directed to monitor the Wander Guard for placement and functioning, complete elopement assessments as needed, and in case of a situation arising or increased wandering, place him on 15-minute checks. The resident's EMR documented an Elopement Risk assessment dated [DATE] with a score of nine which indicated he was at risk for elopement. After he left the faciity on [DATE] the elopement risk assessment recorded a score of 24, which indicated high risk. The resident's care plan dated 11/17/19 directed staff to have a schedule/calendar positioned where it is easily visible and to remind the resident to look at it regularly. Staff should observe and report any changes in cognitive status, provide cueing/prompting, but allow as much independence as possible.The care plan documented R 1 could walk and ambulate in the hall without assistance. At times the resident's gait was un-steady and he required assistance to regain a steady gait. The resident's care plan for elopement dated 11/17/17 recorded at times R1 wandered and might attempt to leave the building on his own. The care plan further documented R1 enjoyed sitting outside; and staff were directed to sit outside with resident if requesting to go. Include R1 in the supervised smoking times to go outside and sit. Activities was directed to offer additional times throughout the day. If R1 exhibited exit seeking behavior, evaluate him by completing an elopement assessment in Point Click Care and initiate 15 min checks. Ask R1 why he was wandering. Sometimes he may want something that staff could help with or assure and/or redirect him from exit seeking behavior such as he may be in pain, may be hungry, may need to go to the bathroom etcetera. Please report to the nurse if R1 had increased wandering or pacing. Review his behavior to determine triggers for exit seeking behavior. Talk with R1 and offer one to one time when available. R1 wears a WanderGuard on his left wrist. The Nurse's Notes dated 12/18/2019 at 03:58 PM read, The interdisciplinary team (IDT) met and noted (R1) continued to pace back and forth looking for a job to do. He received [MEDICATION NAME] (antipsychotic medication ) for management of his delusional disorder diagnosis. The nurses' notes lacked documentation the resident was exit seeking prior to the 12/20/19. A Nurses Note dated 12/23/2019 at 07:47 PM read, R1 returned to the facility with Certified Medication Aide (CMA) T. Staff assessed the resident and had no injury. Staff notified the physician with no new orders. Staff notified the resident's family member and stated she would come visit the resident the next day. Staff placed the resident on one on one supervision for exit seeking behavior and at this time he slept in his room. The Facility Investigation dated 12/23/19 at 05:00 PM revealed R1 was found by a facility staff member ambulating outside the facility about two blocks from the facility. Investigation revealed R1 exited the facility by pushing through locked sliding doors on the Post-Acute side of the facility which was not in use for resident care, other than for therapy who had left for the day. R1 ambulated down the 300 hall opened the double doors leading to Post Acute and pushed his way out of the locked sliding interior and exterior doors. The elopement alarm to the Post-Acute sliding glass doors sounded. The alarm could not be heard in the front of the facility with (inner) double doors shut. R1 usually ambulated about the facility near the 100/200 nurses station, main dining room, and living room. CMA T notified Administrator A that while driving down the road, CMA T saw R1 walking toward the next street on the north side of the roadway. CMA T assisted him to the car and back to the facility. Upon notification Administrator A notified Administrative Nurse D and began reviewing camera footage to determine how R1 exited the facility. Licensed Nurse (LN) G and LN H tested exit doors for proper functioning and found the WanderGuard alarm sounding on the Post-Acute side of the facility. This side of the building was not in used except for therapy and staff meetings. The Post-Acute interior sliding glass door remained locked, in the off function, and had been forced open. R1 was seen walking through the double doors to Post-Acute that are kept shut at 04:48 PM. He was found by CMA T at 05:10 PM (approximately 22 minutes later) and returned to the facility. A skin assessment was negative for injury and/or bruising. Staff notified his family member and placed him on one to one supervision. Staff secured the double doors with a cable lock, the elopement policy and procedure, Kardex, drill demonstration and in-service were immediately initiated for all staff. The resident was placed on one on one supervision and remained on one to one supervision until 12/24/19 at 03:00 PM. At this time R1 was placed on continuous 15-minute checks until 12/25/19 at 12:30 PM after lunch when staff initiated behavior charting every shift. Observation on 12/26/19 at 09:00 AM of the area the resident was found revealed: RI exited the facility on the northeast side of the building, walked approximately 200 feet around the building to the south and another 1000 feet toward a four-lane urban city street with 35 mile per hour speed limit, changing lanes of traffic, changing slopes, curbing, blacktop highway, grassy areas, residence areas, business's and concrete walkways. On 12/26/19 at 11:30 PM R1 was in the dining room seated upright holding a glass of fruit drink. The resident was later observed to rise from his chair with ease and ambulate freely to other areas inside the facility. Interviewed on 12/26/19 at 11:30 AM RI gave one- word answers and responded no to remembering exiting the facility. A 12/23/19 Notarized Witness Statement from CNA Q documented, at the start of my shift R1 was following me around the halls, I told him to wait for me by the front and I will see him when I am done. This happened around 03:30 PM last time I saw him. A 12/23/19 Notarized Witness Statement from CNA O documented at around 04:00 PM R1 was walking down the hallway. A 12/31/19 notarized Witness Statement from CMA R documented I last saw the resident about 03:45 Pm. I then went to pass medications. A 12/31/19 notarized Witness Statement from CMA O documented: she left the facility around 05:00 PM and noticed R1 walking east on the roadway heading toward the next cross street. She pulled her car next to him and told him to get in the car. She drove back to the facility and called the facility. Spoke with LN G and explained R1 was found next to the roadway and she was bringing him back. A 12/31/19 notarized Witness Statement from LN G documented: R1 had been at the 300/400 hall nurses station most of the day on 12/23/19. Around 04:00 PM R1 tried to give LN G snacks off the snack tray and was redirected to the dining room. Around 04:30 PM while LN G was administering a tube feeding to another resident, R1 was standing in the doorway of the resident room with a brownie in his hand. He was again redirected to the dining room to ready for dinner. LN G began to prep for dinner doing diabetic resident blood sugar checks and did not notice the resident back at the 300/400 nurses' station. Once returning to the nurses station around 05:15 PM, LN G received a phone call from CMA O and was informed that R1 was found by the roadway and CMA O was bringing him back to the facility. LN G went to the 100/200 nurses station to wait and this is when notified administrator [NAME] Once R1 and CMA O arrived a skin assessment was performed, and no injuries noted, and LN G began to notify all parties. On 12/26/19 at 01:37 PM Administrative Nurse D stated this was the first elopement for R1. He usually just walked aimlessly and looked for work as he thought he was at work. R1 did not normally walk toward the Post-Acute area and was usually near the 100-200 hall units. Staff notified his physician as well as the resident's responsible party. The physician had no new orders and placed him on one to one monitoring. The problem was the alarm could not be heard at the time. The facility placed a staff person at the door today as physical therapy was moving their offices off the unit. Interviewed on 12/26/19 at 02:00 PM Administrative staff A stated the facility immediately secured the doors on the Post-Acute care unit and contacted the alarm company to wire the door so it could be heard on all nursing units. The facility's Elopement policy revised 12/2018 documented: The facility strives to promote a safe and secure environment to help minimize the risk of residents leaving the premises or a safe area without the necessary supervision or authorization to do so. Elopement occurs when a resident leaves the premises or a safe area without the necessary supervision or authorization to do so. Risk for elopement should be identified for each resident and an individualized care plan developed based on their risk. Staff should investigate and report instances of potential elopement. The facility should have a process to monitor security of the premises on a routine basis. The facility failed to ensure this resident, who staff identified at risk for elopement received adequate supervision and appropriate interventions to prevent an elopement. R1 exited the facility on 12/23/19 without staff knowledge, was found outside of the facility two blocks away and approximately 22 minutes later in an unsafe location. This deficient practice placed R1 in immediate jeopardy. The immediate jeopardy was determined to be Past Non-Compliance when on 12/24/19 at 03:00 PM when the facility implemented the following: All Exit doors checked for proper function. Secured double doors to Post Acute Side of Facility. Elopement assessment completed on all residents. Elopement book updated. Care plans for all residents who triggered risk for elopement updated. WanderGuard Placement and functioning verified on all residents in the Elopement book. One to one supervision initiated with R1, backed down to 15-minute checks, then to behavior charting every shift. Elopement Policy and Procedure Kardex was reviewed with all staff. Elopement drill demonstration in-service initiated on 12/23/19 at 05:30 PM and completed on 12/24/19 at 01:00 PM. Alarm to double door being wired to sound on 100-200 Nurses Station.

The facility reported a census of 96 residents. There were 21 residents in the sample. Based on observation, interview, and record review the facility failed to reassess pain using a physician ordered pain scale and provide non medication interventions for 1 of 4 residents sampled for pain (#51), treat pain for 1 of 4 resident's sampled for pain (#85), consistently assess vital signs and [MEDICAL TREATMENT] shunt (an access device used to remove poisons from the blood) for 1 of 1 resident sampled for [MEDICAL TREATMENT] (#103), and failed to assess and provide the necessary oxygen and [MEDICAL CONDITION] (a bi-level positive airflow pressure system, which helped people breathe easier) care for 1 of 1 resident sampled for special needs who required hospitalization (#125). Findings Included: - Review of resident #85's signed physician order [REDACTED]. Review of the admission MDS (Minimum Data Set) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 3, which indicated severe cognitive impairment. The resident required extensive assistance of one staff with bed mobility and toileting and required limited assistance of one staff with transfers. The resident had a condition or chronic disease, which resulted in a life expectancy of less than 6 months and he/she received hospice care. The resident reported pain, which he/she rated a 10, on a scale of ,[DATE] with 0 being no pain and 10 being the worst pain imagined. The resident reported pain made it difficult for him/her to sleep at night and limited his/her day to day activities. The resident received scheduled and as needed pain medications during the 5 day observation period. Review of the Cognitive Loss CAA (Care Area Assessment) dated [DATE] documented the resident was alert, oriented, and able to voice his/her wants and needs. Review of the Pain CAA (Care Area Assessment) dated [DATE] reported the resident's pain level was a 10 on a scale of ,[DATE]. The resident stated the pain was almost constant and usually an ,[DATE] prior to receiving medication. The physician ordered pain medications and he/she received hospice care for comfort. Review of a pain assessment dated [DATE] at 12:08 A.M. documented the resident experienced occasional aching pain. He/she reported medication improved his/her pain and an acceptable level of pain for him/her was 0 on a scale of ,[DATE]. Review of the care plan dated [DATE] documented the resident required increased assistance with ADL's when he/she experienced pain. The care plan directed staff to administer pain medications as ordered, record pain rating, monitor for medication effectiveness, monitor use of as needed pain medications and refer to the physician for changes in pain medication regimen to best manage pain, and monitor for non-verbal signs of pain. Review of physician orders [REDACTED]. Check pain every shift using pain scales, effective [DATE] [MEDICATION NAME] Release (a narcotic medication used to treat pain) 15 milligrams (mg) by mouth twice daily for pain, effective [DATE] [MEDICATION NAME] (a narcotic medication used to treat pain) 20 mg/ml, give 0.25 ml by mouth once daily for mild to moderate pain, [DATE] The physician discontinued the following as needed pain medications on [DATE]: [MEDICATION NAME] 20 mg/ml (milligrams per milliliter) give 0.25 ml for shortness of air and mild pain every one hour as needed, 0.5 ml by mouth every 1 hour as needed for shortness of air or moderate pain, 0.75 ml by mouth every one hour as needed for shortness of air and moderate to severe pain, and 1 ml by mouth every 1 hour as needed for and shortness of air and severe pain [MEDICATION NAME] (a narcotic medication used to treat pain) 5 mg by mouth every 4 hours as needed for pain Review of an [DATE] MAR (medication administration record) documented the resident's pain as follows using a pain scale of ,[DATE] with 0 being no pain and 10 being worst pain: Day shift: rated a 6 on ,[DATE], rated a 7 on ,[DATE], ,[DATE], ,[DATE], and ,[DATE], rated an 8 on ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE]. Evening shift:rated a 2 on ,[DATE], ,[DATE], and no rating documented on ,[DATE], rated a 4 on ,[DATE], rated a 5 on ,[DATE] and ,[DATE], rated a 6 on ,[DATE], and [DATE] Night shift: rated a zero on all shift. During an interview on [DATE] at 2:32 P.M. the resident's family member said the resident was dying [MEDICAL CONDITION], had pain, and staff did not move him/her gently. During an interview on [DATE] at 2:54 P.M. the resident's family member said the resident experienced unmanaged pain. During an interview on [DATE] at 1:58 P.M. direct care staff R said he/she notified the charge nurse if a resident complained of pain and pain interventions were in the care plan. Staff said he/she did not recall the resident. During an interview on [DATE] at 4:51 P.M. direct care staff U said he/she notified the nurse if a resident experienced pain and charted pain in the electronic record. Staff did not recall the resident. During an interview on [DATE] at 5:58 P.M. licensed nursing staff G said he/she documented pain assessments every shift on the MAR (medication administration record) and if a resident required an as needed pain medication follow up should occur within ,[DATE] minutes to include a numerical rating of pain. Staff G confirmed the pain assessment dated [DATE] documented an acceptable level of pain as 0 on a scale of ,[DATE] for this resident. During an interview on [DATE] at 11:05 A.M. licensed nursing staff N said residents were monitored for pain every shift using a numerical pain scale and staff documented the results on the MAR. Staff N said if a resident reported pain, the nurse checked to see if an as needed pain medication was available and if he/she tried non- medication interventions or called the physician for orders. Staff N said the resident experienced pain throughout his/her stay, was not aware of the resident's tolerable pain level, and he/she received hospice care for [MEDICAL CONDITION]. Staff N confirmed the resident reported pain after the discontinuation of as needed pain medications on [DATE], had no as needed pain medications ordered from [DATE] to the resident's date of death on [DATE], and confirmed the medical record lacked documentation of pain assessments and effectiveness of routine pain medications. Review of the facility's Pain Management policy dated ,[DATE] documented staff would implement individualized interventions when a resident experienced pain and staff would notify the physician of the need to change pain management interventions when indicated. The facility failed to implement pain management interventions for this resident who experienced end of life pain. - Review of resident #125's signed physician order [REDACTED]. Review of the admission MDS (Minimum Data Set) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. The resident required extensive assistance of 2 staff with bed mobility and dressing and extensive assistance of 1 staff with transfers and toileting. The resident refused cares ,[DATE] days during the 7 day observation period. The resident received oxygen therapy. The resident discharged from the facility prior to the due date for completion of the Care Area Assessments (CAA). Review of the care plan dated [DATE] documented the resident used 3 liters of oxygen continuously. Staff revised the care plan on [DATE] and documented the resident needed oxygen at all times and used a [MEDICAL CONDITION] (bi-level positive airflow pressure, which helped people breathe easier) during his/her sleep. The care plan directed staff to invite the resident to wear his/her, oxygen, use his/her [MEDICAL CONDITION] every night during sleep and keep the head of his/her the bed elevated to assist him/her with breathing. Review of nursing progress notes documented the following: On [DATE] at 6:36 P.M. the resident admitted from the hospital with no orders for a [MEDICAL CONDITION] or [MEDICAL CONDITION] (continuous positive airflow pressure machine, which helped users breathe easier). The resident reported he/she used a [MEDICAL CONDITION] during his/her hospitalization and had his/her own [MEDICAL CONDITION] at home, which he/she packed for moving. Facility staff phoned the hospital and was told the resident did not need a [MEDICAL CONDITION], had not been using one all the time, and said the resident should use 3 liters of oxygen and keep his/her head of the bed elevated. Facility staff informed the resident he/she would not use his/her [MEDICAL CONDITION] in the facility and the resident stated, I'll be fine. On [DATE] the physician discontinued the [MEDICAL CONDITION] and ordered use of a [MEDICAL CONDITION]. On [DATE] at 1:55 A.M. the facility received a [MEDICAL CONDITION], per a physician order, with no mask or tubing. Facility staff phoned the equipment company who informed the facility the necessary equipment would arrive in the following morning. The physician wrote an order for [REDACTED]. On [DATE] at 6:00 P.M. staff assisted the resident to bed. At 7:30 P.M. the resident reported he/she was short of breath and his/her upper mid chest felt like he/she had heartburn. Staff observed the resident's oxygen concentrator was off. Staff turned the oxygen concentrator on and gave a breathing treatment. At 10:00 P.M. the resident used his/her [MEDICAL CONDITION] for 30 minutes and then he/she removed the [MEDICAL CONDITION], stating the [MEDICAL CONDITION] did not feel comfortable. Facility staff phoned the equipment company and they said they would send a replacement on [DATE]. The record lacked a physical assessment or education by the nurse. On [DATE] at 4:22 A.M. the resident said he/she could not breathe and refused to wear his/her [MEDICAL CONDITION]. The record lacked education by the nurse. On [DATE] at 12:25 A.M. the resident slept all shift until staff disturbed him/her continuously at 7:00 P.M. to administer medications and encourage him/her to eat. The resident was lethargic (sluggish), complained of dizziness and and did not feel right. The resident complained of pain, did not ask for as needed pain medications, and asked for a sleeping pill during shift change. Staff applied the resident's [MEDICAL CONDITION], adjusted the mask for comfort, and administered sleep medication. On [DATE] at 3:00 A.M. the resident requested to remove his/her [MEDICAL CONDITION] and staff removed the [MEDICAL CONDITION]. The record lacked a physical assessment or education by the nurse. On [DATE] at 4:00 P.M. the resident's blood pressure and pulse changed rapidly throughout the shift and he/she complained of dizziness, headache, weakness, and did not feel right; staff paged the physician. The resident's blood pressure at 4:00 P.M. was ,[DATE] and heart rate was 104 and at 7:00 P.M. the resident's blood pressure was ,[DATE] and heart rate was 113. Staff sent a second page to the physician at 7:00 P.M. due to no response. The physician returned the page and directed staff to ask the resident if he/she wanted to go to the hospital. The resident stated he/she wanted to wait and see how he/she felt through the night and morning. The physician directed staff there was no further need to contact him/her and if the resident's condition worsened or the resident wanted to go to the hospital, staff could send the resident to the hospital for an evaluation and treatment. On [DATE] at 12:29 A.M. staff reported the resident's blood pressure stabilized at 9:50 P.M. and the resident said he/she felt better. The resident requested narcotic pain medication and narcotic sleep medication. Staff told the resident he/she could have either the pain medication or sleep medication, but not both due to the difficulties the resident had throughout the day and evening shift with blood pressure and pulse. Staff told the resident he/she would inform the night nurse of the situation and if he/she remained stable, staff could administer additional medication at a later time. The resident chose pain medication and staff informed the night nurse of his/her decision. [DATE] at 7:00 P.M. the resident reported difficulty taking in deep breaths after returning from the bathroom. Staff reported the resident was not distressed, sweaty, had non labored breathing, and held a conversation with staff. Staff discussed cough syrup would not be effective in bringing up mucous and staff encouraged the resident to sit on the edge of the bed and cough. The resident declined. Staff gave the resident 3 options: 1) phone physician for [MEDICATION NAME], 2) sit up and cough or, 3) try antianxiety (a medication to reduce feelings of anxiousness) medication. The resident chose an antianxiety medication and his/her breathing had improved. On [DATE] at 12:30 A.M. the resident cried and said he/she did not feel well. The resident's oxygen saturation (level of oxygen in the blood) was 90 percent with the [MEDICAL CONDITION] Staff asked the resident if he/she wanted to go to the hospital and the resident said no and went back to sleep. The record lacked a follow up physical assessment until 7:30 A.M. at which time the resident's oxygen saturation was 75 percent (%). On [DATE] at 7:30 A.M. facility staff paged the physician. The physician did not return the page and staff left a voice message for the physician at 10:48 A.M. A CNA (certified nursing assistant) informed the nurse the resident was short of breath, did not have his/her oxygen on, and he/she applied the oxygen for the resident. The staff nurse documented the resident was alert with confusion and stated he/she did not feel well. The resident's oxygen saturation was 75 percent at 7:30 A.M. Staff increased the oxygen from 3 liters to 4 liters and his/her oxygen saturation was 81% at 8:15 A.M. At 8:30 A.M. the resident's oxygen saturation was 85%. The resident remained confused and transferred to the hospital by EMS (emergency medical system). On [DATE] at 12:30 P.M. staff report the resident admitted to the hospital for CO2 (carbon [MEDICATION NAME]) narcosis (a decreased ability to breathe due to gas build up in the lungs) and acidosis (a build up of acid in the blood), which caused personality changes, confusion, and coma due to increased carbon [MEDICATION NAME] content in the blood. This may occur during oxygen therapy of patients with [MEDICAL CONDITION] or in patients who received inadequate levels of artificial respiration ([MEDICAL CONDITION]). On [DATE] at 12:23 P.M. hospital staff informed the facility the resident discharged from the hospital to another facility on a ventilator (a machine used to move air in and out of the lungs) and a tracheotomy (a surgical opening made in the neck to allow air flow). Review of the physician orders [REDACTED]. Oxygen at 3 liters per nasal canula (a tube used to deliver oxygen through the nose) every shift for obstructive chronic [MEDICAL CONDITION] with exacerbation, effective [DATE] [MEDICAL CONDITION] at bedtime, effective [DATE] [MEDICATION NAME] (a narcotic pain medication) 10 mg (milligrams) by mouth every 4 hours as needed, use sparingly and do not give if drowsy or sedated, effective [DATE]. [MEDICATION NAME] (a medication used to treat anxiety with sedating effects) 2 mg, give ,[DATE] tablet mouth twice a day as needed for anxiety, effective [DATE] [MEDICATION NAME] (a medication to induce sleep) 30 mg by mouth at bedtime as needed, effective [DATE] Oxygen at 3 L (liters) not signed as administered on the day or night shift of [DATE] day shift or night shift and signed as administered on [DATE] for night shift. The resident discharged to the hospital on [DATE] at 9:00 A.M. Review of the February 2015 MAR indicated [REDACTED] [MEDICATION NAME] 10 mg by mouth on the following dates: [DATE] at 8:30 P.M. [DATE] at 0400 A.M., 11:00 A.M., 3:30 P.M. [DATE] at 8:00 A.M. [DATE] at 03:50 A.M., 9:50 P.M. [DATE] at an unreadable time. [DATE] at 8:00 A.M., 9:00 P.M. [DATE] no medication was given on this day. [DATE] no medication was given on this day. [MEDICATION NAME] 30 mg by mouth on the following dates: [DATE] was marked through with an error. [DATE] at 12:30 A.M. [DATE] at midnight [DATE] at 11:00 P.M. [DATE] at midnight [MEDICATION NAME] 2 mg by mouth on the following dates: [DATE] at 9:00 P.M. [DATE] at 8:00 A.M. [DATE] at 7:00 P.M. Review of an unsigned transfer/discharge report dated [DATE] documented the resident left the facility by EMS at 9:00 A.M. Oxygen at 3 L (liters) not signed as administered on the day or night shift of [DATE] day shift or night shift and signed as administered on [DATE] for night shift. The resident discharged to the hospital on [DATE] at 9:00 A.M. During an interview on [DATE] at 4:45 P.M. direct care staff U said he/she knew a resident was on oxygen by review of the care plan. Staff U said he/she notified the nurse if a resident refused his/her oxygen and documented the refusal in the electronic. Staff U did not recall the resident. During an interview on [DATE] at 5:42 P.M. licensed nursing staff G said he/she was not aware how long the oxygen concentrator was off on [DATE]. Staff G said he/she did not notify the physician of the resident's difficulty with wearing the [MEDICAL CONDITION] and he/she did not complete a physical assessment when staff found the resident's oxygen off. Staff G said the resident did not refuse to use oxygen and did refuse to wear his/her [MEDICAL CONDITION] at times due to a poor fit. During an interview on [DATE] at 10:45 A.M. licensed nursing staff N said he/she first assessed the resident on [DATE] around 7:15 A.M. Staff N said the CNA reported to him/her the resident was short of air, did not have his/her oxygen on and needed to be assessed. Staff N said the resident required continuous oxygen due to acute and chronic [MEDICAL CONDITION]. Staff N said the resident did not refuse to wear his/her oxygen. Staff N said when he/she assessed the resident, he/she was confused, which was new for the resident. Staff N was not aware how long the oxygen was off and his/her oxygen saturation was 75%. Staff N increased the oxygen to from 3 liters to 4 liters and the resident's oxygen saturation increased to 85%. Staff N said he/she paged the physician at 7:30 A.M. and did not receive a return call. Staff N said he/she decided to send the resident to the hospital by EMS and he/she phoned the hospital at 12:30 P.M. and the emergency room nurse told him/her the resident admitted for CO2 narcosis and acidosis. Staff N could not recall the time the resident left the facility. Staff N said he/she expected the physician to return a page within 20 minutes and if no response the nurse should repage. Staff N said the policy was to contact the medical director if staff was not able to reach the attending physician. He/she said the facility staff did not make an attempt to contact the medical director. During an interview on [DATE] at 8:40 A.M. social service staff JJ said the resident did not refuse his/her oxygen treatment. During an interview on [DATE] at 4:07 P.M. administrative nursing staff D said he/she expected the nurse to repage the physician within 5 minutes if a resident experienced respiratory distress with an oxygen saturation of 75% and he/she expected staff to call 911 if the physician did not return the call within 5 minutes. Staff D said he/she expected nursing staff to phone the equipment company and/or pharmacy for needed respiratory equipment the same day and to notify the physician if unable to obtain equipment and/or the resident refused ordered treatment. Staff D said he/she expected nursing staff to request an order clarification on use of [MEDICATION NAME] sparingly. Staff D said he/she expected the nurse to provide the resident education regarding the use of his/her [MEDICAL CONDITION] and to monitor and assess as needed. Staff D said he/she expected the the facility to send the resident to the hospital before a 1 hour and 45 minute time lapse. During an interview on [DATE] at 12:48 P.M. physician consultant II said he/she expected a physician to return a page as soon as he/she received the page and if no response would expect the nurse to phone 911 and send the resident to the emergency room . Staff II said he/she expected the facility to send a resident with low oxygen saturation to the hospital within ,[DATE] minutes. Staff II said he/she expected nursing staff to notify the physician if a resident did not tolerate or refused equipment and the nurse should assess, educate, and document. Staff II said it could take a few days to a week to get a comfortable fit for a [MEDICAL CONDITION] and the staff should educate the resident on this. Staff II stated he/she preferred to use a lower dose of [MEDICATION NAME] because the medication was long acting and [MEDICATION NAME] was long acting too. Staff II said nursing homes were not able to monitor CO2 levels and an increase in oxygen dose could cause increased CO2 levels in some people. During an interview on [DATE] at 12:40 P.M. pharmacy consultant KK said the physician ordered medications to include; [MEDICATION NAME], and [MEDICATION NAME] were respiratory sedating medications and he/she expected staff to clarify the order with the physician regarding using the [MEDICATION NAME] sparingly. Review of the facility's oxygen policy dated [DATE] documented staff were to follow physician orders [REDACTED]. The facility failed to ensure the resident wore physician ordered oxygen at all times, to educate the resident on the use of [MEDICAL CONDITION] equipment, assess and monitor the resident's respiratory condition, and failed to adequately monitor the use of sedating medication for this resident with a significant compromised respiratory system who would transfer to the hospital with respiratory issues. - Review of resident #103's signed physician order [REDACTED]. Review of the annual MDS (Minimum Data Set) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. He/she did not refuse cares and required limited to extensive assistance of 1 staff with ADL's (Activities of Daily Living). Review of the ADL CAA (Care Area Assessment) dated [DATE] documented the resident required limited to extensive assistance of 1 staff with ADL's. Review of the care plan dated [DATE] documented the resident received [MEDICAL TREATMENT] on Mondays, Wednesdays and Fridays. The care plan directed staff to assess the resident's left upper arm AV shunt (arterio-venous device for [MEDICAL TREATMENT] access) for bruit or thrill (turbulence felt under the skin at the site),oxygen level and pain daily every shift, monitor vital signs and AV shunt for bleeding before and after [MEDICAL TREATMENT]. Review of the signed physician orders [REDACTED]. Check left upper arm AV shunt daily every shift. Check vital signs and shunt site before and after [MEDICAL TREATMENT] on Monday, Wednesday and Friday. Check pain level and oxygen saturation daily every shift. Review of the MAR (medication administration record) dated [DATE] to [DATE] lacked pain assessment and documentation on the following dates: [DATE] and [DATE], night shift. Review of the TAR (treatment administration record) dated [DATE] to [DATE] lacked assessment and documentation of the resident's AV shunt on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] night shift [DATE] and [DATE] evening and night shift [DATE], [DATE], [DATE],[DATE], ,[DATE], and [DATE] day shift [DATE], [DATE], [DATE], [DATE], and [DATE] evening shift Review of the TAR dated [DATE] to [DATE] lacked assessment and documentation of the resident's vital signs, pain and AV shunt before [MEDICAL TREATMENT] on the following dates: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the TAR dated [DATE] to [DATE] lacked assessment and documentation of the resident's vital signs, pain and AV shunt before and after [MEDICAL TREATMENT] on the following dates: [DATE], [DATE], [DATE], and [DATE]. Review of the TAR dated [DATE] to [DATE] lacked assessment and documentation of the resident's oxygen saturation level on the following dates: [DATE], [DATE],[DATE] and [DATE] evening and night shift [DATE], [DATE] [DATE], [DATE] and [DATE] night shift [DATE], [DATE], [DATE], [DATE] and [DATE] day shift [DATE] evening shift During an observation on [DATE] at 2:50 P.M. the resident returned from [MEDICAL TREATMENT]. During an observation on [DATE] at 2:52 P.M. the resident sat in his/her wheelchair at dining room table. He/she ate lunch independently. There was no drainage observed to the resident's left upper arm dressing. Observed licensed nursing staff H obtain a [MEDICAL TREATMENT] communication sheet from the resident which he/she filed in the resident's medical record. Staff H did not assess the resident's vital signs or AV shunt site during the observation period from 2:52 to 3:30 P.M. During an observation on [DATE] from 3:30 P.M. to 4:23 P.M. no licensed staff assessed the resident's vital signs or AV shunt. During an interview on [DATE] at 3:30 P.M. the resident sat in his/her wheelchair watching television. During an interview on [DATE] at 2:57 P.M. direct care staff O said he/she observed for symptoms to report to the nurse to include bleeding from his/her left upper arm. During an interview on [DATE] at 4:14 P.M. direct care staff P said he/she knew the resident should have blood pressure checks done on his/her right arm and he/she reported to the nurse if the resident's left arm AV shunt bled. During an interview on [DATE] at 3:02 P.M. licensed nursing staff H said he/she routinely checked vital signs, oxygen level and AV shunt site before and after [MEDICAL TREATMENT] and documented his/her findings in the electronic medical record. Staff H confirmed he/she failed to complete an assessment following resident's [MEDICAL TREATMENT] today. During an interview on [DATE] at 2:15 P.M. licensed nursing staff I said he/she assessed the resident's AV shunt, vital signs, oxygen level, and pain every shift. During an interview on [DATE] at 4:03 P.M. administrative nursing staff D said he/she expected a nurse to assess the resident within 30 minutes after returning from [MEDICAL TREATMENT]. Staff D said he/she expected the nurse to include the following in the his/her assessment; vital signs, AV shunt site, oxygen and pain level and expected staff to document results of the assessment in the TAR. Review of the facility's [MEDICAL TREATMENT] Management policy dated ,[DATE] documented staff assessed a resident's [MEDICAL TREATMENT] (AV shunt) every shift for bleeding, signs and symptoms of infection, and presence of thrill/bruit and staff documented the results of the assessment on the TAR every shift. The facility failed to monitor and document physician ordered vital signs, oxygen levels, pain and AV shunt assessments for this resident who required [MEDICAL TREATMENT]. - Review of the resident #51 signed physician order [REDACTED]. Review of the significant change MDS (Minimum Data Set) dated [DATE] documented a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. The resident required extensive assistance of one staff with bed mobility, locomotion off of the unit, transfers, dressing, and toileting; limited assistance of one staff with locomotion on the unit and personal hygiene; and set up and supervision with walking. The resident received scheduled, as needed, and non-medication interventions for pain and had pain almost constantly. The resident rated his/her pain a 9 on a scale of ,[DATE] (0 meant no pain and 10 meant the worst pain imagined) and reported the pain affected his/her sleep and participation in day to day activities. Review of the quarterly MDS (Minimum Data Set) dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The resident required limited assistance of one staff with bed mobility, transfers, walking in the corridor, dressing, toileting, and personal hygiene; extensive assistance of one staff for locomotion on and off the unit; and supervision of one staff when walking in his/her room. The resident received scheduled, as needed, and non-medication interventions for frequent pain. The resident rated his/her pain a 9 on a scale of ,[DATE], and reported pain made it hard for the resident to sleep at night and did not interfere with his/her day-to-day activities. Review of the ADL (activities of daily living) CAA (Care Area Assessment) dated [DATE] documented the resident declined in walking and experienced increased pain. He/she required extensive assistance with ADLs and had balance problems. Review of the Pain CAA dated [DATE] documented the resident walked less, rated his/her pain a 9 out of 10, and reported pain interfered with sleep and activities. The resident received scheduled and as needed pain medication and staff were to monitor pain levels. Review of the care plan dated [DATE] documented the resident's pain would resolve within one hour following a pain intervention. Staff were directed to use alternative methods of pain management, document the results, administer pain medications as ordered, document effectiveness, and listen to the resident's concerns and acknowledge the presence of pain. Review of the [DATE] MAR (medication administration record) recorded staff administered as needed [MEDICATION NAME] 59 times. Follow up documentation consistently lacked the resident's pain using the ,[DATE] scale. Review of the [DATE] MAR (medication administration record) recorded staff administered as needed [MEDICATION NAME] 37 times. Follow up documentation consistently lacked the resident's pain using the ,[DATE] scale. Review of the [DATE] MAR (medication administration record) recorded staff administered as needed [MEDICATION NAME] 40 times. Follow up documentation consistently lacked the resident's pain using the ,[DATE] scale. Review of the resident's medical record dated [DATE]-[DATE] lacked documentation of non-medication interventions used to manage the residents. Review of a Clinical Health assessment dated [DATE] recorded the resident's acceptable level of pain was a 0 on a scale of ,[DATE]. A review of a physician order [REDACTED]. Duri

The facility census totaled 99 residents with 3 resident sampled. Based on observation, record review and interviews, the facility failed to transfer a resident as planned which resulted in a fall and fractured knee for 1 (#1) of 3 residents sampled for falls. Findings included: - Resident #1's significant change Minimum Data Set assessment ((MDS) dated [DATE] documented the Brief Interview for Mental Status (BIMS) score of 1 which indicated severe cognitive impairment. The MDS further documented the resident required total dependence of 2 staff members for transfers, dressing, toileting and personal hygiene and total dependence of 1 staff member with bed mobility. The MDS documented the resident had no falls. The quarterly MDS dated [DATE] documented the BIMS score of 5 which indicated severe cognitive impairment. The MDS further documented the resident required total dependence of 2 staff members for transfers, dressing, and toileting. The MDS documented the resident had one fall since the prior assessment with major injury. The fall Care Area Assessment (CAA) dated 1/13/15 documented the resident required total dependence on staff for transfers with a mechanical lift. He/she was unable to come to a standing position without staff assistance. He/she was chair bound. The resident had several falls over the last year which occurred in his/her room while being unattended. He/she had several falls from the bed to the fall mat on the floor. The resident had a hi/low bed which was in the lowest position when he/she was in the bed. He/she had fall mats placed on both sides of the bed for safety. He/she had a reclining wheelchair with a wedge cushion and footrests to prevent him/her from sliding. The resident was at risk for falls and injuries related to his/her history of falls. The 5/8/15 revised fall care plan documented the resident required 2 staff members to transfer via a Hoyer lift (a total body lift used to transfer residents), total assist with bed mobility, a tilt back wheelchair with anti-lock brakes, a pommel cushion (cushion with elevated area on the front side to prevent sliding) for the prevention of falls, and an extra mattress on the floor on right side of bed. Review of the clinical record documented on 3/22/15 the resident was at a high risk for falls, required total dependence from the staff for ambulation and transfers, and used a total mechanical lift. The nurse's note dated 5/10/15 at 5:24 P.M. documented staff called the nurse to the resident's room. The resident was in bed with his/her legs crossed, and complained of knee pain to both knees. Direct care staff O stated the resident had slid out of the Hoyer lift and hit both of his/her knees on the floor. Licensed nursing staff H assessed the resident and found his/her left knee was swollen and slightly red. The resident complained his/her right knee hurt the worst. The right knee had no swelling, bruising, or discoloration noted. The doctor was called and ordered an x-ray of both knees. The x-ray report transmitted on 5/10/15 at 8:05 P.M. documented the resident had a fracture (broken bone) of the right knee. The nurse's note dated 5/11/15 at 10:55 A.M. upon discussion with the nursing staff the x-ray report had not been called to the doctor: The nurse immediately faxed the results to the doctor and also paged at 11:00 A.M. with a call from the doctor. The doctor ordered the resident sent to the emergency room for evaluation. The ambulance arrived at the facility and the resident was transferred to the hospital at 11:50 A.M. The notarized witness statement dated 5/11/15 noted direct care staff O dressed the resident, looked down the hall for another staff member, did not see one and attempted to use the Hoyer lift with the resident alone. The resident flipped forward and fell out of the Hoyer lift onto his/her knees. Direct care staff O picked up the resident, sat him/her on the edge of the bed, laid the resident down, and called for help. The licensed nursing staff H came to the room and assessed the resident. The notarized witness statement dated 5/11/15 noted staff called licensed nursing staff H to the resident's room, found the resident in his/her bed with his/her legs crossed, and complained of pain in both knees. The direct care staff O reported the resident slid out of the Hoyer lift sling and hit his/her knees on the floor. The resident's left knee was swollen and red and the resident complained of pain. On 6/24/15 at 8:50 A.M. the resident sat in the dining room in a high back wheelchair with a full body sling under him/her with no complaints of pain. Interview on 6/24/15 at 8:12 A.M. with direct care staff P stated the resident required a Hoyer lift for transfers and nursing staff were to always have 2 staff members with any lift transfers. Interview on 6/24/15 at 8:14 A.M. with licensed nursing staff I stated staff transferred the resident with a Hoyer lift and 2 staff members should always be there with the transfer. The resident used a full body lift sheet with the Hoyer lift. Licensed nursing staff I stated when a resident had a fall, the resident should not be moved until assessed by a nurse. Interview on 6/30/15 at 10:54 A.M. with direct care staff Q stated the resident required a Hoyer lift with transfer, the resident could not stand, and did not bear weight. Nursing staff are to use 2 staff members at all times when transferring a resident using a Hoyer lift . Interview on 6/30/15 at 11:02 A.M. with direct care staff R stated the staff used a medium sized full body sling and 2 staff members at all times for transfers with the Hoyer lift. Interview on 7/7/15 at 10:08 A.M. with licensed nursing staff J stated the resident required 2 nursing staff with a Hoyer lift for transfers. Licensed nursing staff J stated a resident should be left where found with a fall until assessed by a nurse. Interview on 7/7/15 at 10:33 A.M. with direct care staff S stated the resident required 2 staff members with a Hoyer lift for transfers. Direct care staff S stated the staff were not move a resident if found on the floor or after a fall, until the nurse did an assessment. Interview on 7/7/15 at 10:57 A.M. with administrative nursing staff D stated 2 staff were required to use a Hoyer lift. There was no excuse to use one staff with a Hoyer lift. Direct care staff were not to move a resident after a fall. They should put on the call light and wait for a nurse to do an assessment. The 1/2015 facility policy Falls Management stated the plan of care was to address the individualized resident's focus, goals, and interventions directed towards reducing the resident's risk of injury and potential reoccurrence of falls. The facility failed to ensure the staff followed this dependent resident's care plan related to transfers which instructed the direct care staff to use 2 staff members which caused a fall and a fractured right knee.

The facility identified a census of 96 residents. The sample included 3 residents. Based on observation, interview and record review the facility failed to prevent accidents for 1 of 3 residents (#1) identified at risk for elopement from leaving the facility unsupervised. Facility staff found the resident approximately 0.3 miles from the facility near a four lane heavily traveled road. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #1's physician's orders [REDACTED]. The Quarterly Minimum Data Set 3.0 with an assessment reference date of 11/01/11 recorded a Brief Interview of Mental Status score of 6, which indicated the resident had severe cognitive impairment. The resident had delusions and wandered 1-3 days during that observation period. He/She required supervision with walking, transfers, bed mobility, locomotion on the unit and limited assistance with locomotion off the unit. The resident fell since admission or prior assessment. The resident had 2 falls without injury. The Care Area Assessment for cognition dated 8/02/11 recorded the resident was alert and oriented with confusion related to a dementia diagnosis. The resident shared a room with his/her spouse who moved there at the same time. The resident became anxious when his/her spouse was not present. The resident said he/she and spouse were going back to their house in a little while and he/she would drive were they needed to go. Assessment for elopement dated 10/06/11 recorded the resident with a [DIAGNOSES REDACTED]. The resident made verbal threats of elopement, had short and long term memory deficit and moved without use of a mechanical device. The resident was able to open the front door and was a high risk for elopement. The clinical record contained a Fall Risk assessment dated [DATE] that documented the resident had a history of [REDACTED]. The fall score was 10 which indicated the resident was a moderate risk for falls. Nurse's Notes dated 10/06/11 at 7:37 P.M. documented at 4:30 P.M. the resident was walking on the unit very fast and went out the 100 hall back door. Therapy staff saw the resident getting off the ground outside where he/she fell . Staff brought the resident back into the facility. Vital signs and neurological checks were completed. The resident yelled at his/her spouse to get his/her stuff and they would go home. The resident continued to pace up and down the unit looking for a way out. Staff gave the resident scheduled Ativan. The resident continued several attempts to find a way out, but was redirected by staff. The clinical record lacked evidence the staff updated the care plan after the resident eloped from the facility. Nurse's Notes dated 11/05/11 at 12:29 P.M. documented the resident was confused and occasionally aggressive. The resident resisted cares, ambulated independently, refused to leave the wander guard on and removed it even from his/her leg. Staff found the wander guard under the resident's bed. Nurse's Notes dated 12/14/11 at 8:35 A.M. documented at 12:05 A.M. the door alarm sounded and the nurse responded by looking for any missed residents and performed room checks. Staff noted this resident was not in his/her room or any place in the facility. The Director of Nursing was notified and the elopement protocol was initiated. Staff looked outside of the compound and another nurse drove the surrounding area and saw the resident walking on Parallel Street. Staff took the resident back to the facility. Vital signs were as follows: blood pressure 150/85, pulse 88, temperature 96.5 degrees Farenheit, oxygen 96 percent and in no distress. There were no abnormal findings for the neurological checks. Nurse's Notes dated 12/16/11 at 11:18 A.M. recorded staff discussed with the resident's family the need to start looking for a lock down facility for the resident. Review of the Treatment Administration Record (TAR) and Medication Administration Record revealed staff did not document wander guard checks for this resident prior to 12/14/11. The TAR dated December 2011 documented staff should check the resident's wander guard for placement beginning 12/14/11 on every shift. Further review of the TAR on 1/26/12 revealed staff failed to check the resident ' s wander guard on 7 shifts. The Care Plan dated 8/15/11 for activities of daily living directed staff to provide 1 person assistance with dressing, bathing and grooming and supervision for transfers into and out of bed. The care plan contained new intervention dated 9/02/11 which identified the resident had a wander guard. At times he/she would take the wander guard off. Staff should monitor for the wander guard being on the resident. Staff did not add any new interventions to keep the resident safe from elopement until 1/18/12 when a new intervention was added to the care plan to inform staff regarding the resident took off the wander guard at times using his/her spouse's scissors. Staff should keep the spouse's scissors at the nurse's station. On 1/18/12 the care plan indicated staff moved both this resident and his/her spouse's room closer to the nurse's desk. Observation on 1/26/12 at 1:57 P.M. revealed the resident walked out of his/her room, down the hall and to the common area near the nurse's desk independently and without any assistive device. The resident told maintenance staff he/she was looking for their spouse. The resident had a wander guard on his/her ankle. During interview on 1/26/12 at 8:06 A.M. licensed nursing staff B reported on 12/14/11 at the end of his/her shift sometime after 11:00 P.M. he/she made rounds with the oncoming nurse for the 400 hall where they worked. Resident #1's room was not on the 400 hall, therefore he/she did not take care of the resident during his/her shift. Staff informed licensed nursing staff B that they could not locate resident #1 in the facility and believed he/she left the facility without being seen by staff from the 100 hall door where an alarm sounded. This staff exited the facility through the 100 hall exit door and looked for the resident. Several other staff outside looked for the missing resident. After not locating the missing resident, staff went back into the facility. Staff B drove his/her vehicle off of the facility property. While driving west on Parallel Street licensed nurse B observed the resident walking in the dark grassy field toward Parallel Street approximately 150 feet away. Staff stopped the car in the street and got out of the car and approached the resident. The resident told staff he/she was going to visit his/her sister. The resident was wearing a golf type short sleeved shirt with a t-shirt under and "Docker" type pants and shoes. He/She was not wearing a coat and did not have a wander guard on. Observation on 1/26/12 at 8:22 A.M. of the location where licensed nursing staff B observed the resident walking toward Parallel Street revealed a four lane road with a posted speed limit of 40 miles per hour. The temperature on 12/14/11 at 12:40 A.M. was 48.2 degrees Fahrenheit according to weather website wunderground.com for the history at Kansas City, Kansas. During interview on 1/26/12 at 2:10 P.M. licensed nurse C reported on 12/14/11 sometime near the beginning of the night shift around 11:00 P.M. this resident while dressed in his/her normal day time clothes wandered "not purposeful and disoriented and confused" in the areas of the television room and the nurse's desk. Staff redirected the resident back to his/her room, but he/she walked back out to that same area again. Licensed nurse C reported that was the last time he/she observed the resident prior to the elopement. While staff C was in another resident's room the 100 hall exit door alarm sounded. Licensed nurse C looked outside, but it was dark and he/she did not see any residents outside. Staff looked outside and inside the facility for resident #1, but did not locate the resident. Licensed nurse B drove his/her car around and returned back to the facility with the resident. When the resident returned to the facility he/she was in the same thinking state as before, confused and disoriented. The resident did not have any injuries. During interview on 1/26/12 at 9:49 A.M. administrative nursing staff A reported he/she was aware of the resident's prior episode of leaving the building through the 100 hall door on 10/06/11 which was witnessed by the therapy staff, however staff did not make him/her aware of that incident until approximately 1 month after the incident had occurred. He/She said staff failed to follow through with any investigation or paper work or further interventions to prevent the incident from happening again. During interview on 1/26/12 at 4:42 P.M. administrative nurse A acknowledged staff failed to document wander guard checks for this resident prior to the elopement on 12/14/11, failed to develop and implement interventions after the attempted elopement on 10/06/11 and reported the front door and the west side sliding glass doors would be manned by staff until they could be alarmed. The facility failed to provide necessary supervision to keep this resident safe. On 1/31/12 at 2:00 P.M. the facility abated the immediate jeopardy when administrative staff: Trained the facility on elopement procedure and alarm system. Completed Elopement Drills on every shift. In serviced the staff on Emergency Services Disaster Plan - Missing Residents. Immediate supervision on the front and back entrance door until 7:30 P.M. at which time the building is locked and alarmed. All residents currently wearing a wander guard were placed on 15 minute checks. All residents will be assessed for a risk for elopement on admission and continued monitoring through the Resident Assessment Instrument process. This deficient practice remained at a scope and severity of a D.

The facility identified a census of 94 residents. The sample included 3 residents and the facility identified 5 residents with Wanderguards, (an electronic bracelet which alarmed at an exit door used for safety when a resident was identified as having wandering behavior, and applied to a resident's extremity or wheelchair). Based on observation, interview and record review, the facility failed to have a system in place to ensure the residents Wanderguards functioned properly for 5 residents at risk for wandering (#10, #11, #12) and 2 un-sampled residents. Findings included: - Resident #10's physician's orders [REDACTED]. The admission Minimum Data Set (MDS) 3.0 with an Assessment Reference Date (ARD) date of 1/27/12 recorded the Brief Interview for Mental Status (BIMS) score was 9, which indicated the resident was moderately cognitively impaired, required supervision for bed mobility, transfers, walking in the room, required limited assistance for walking in the corridor, locomotion and off the unit, and personal hygiene, and was independent for dressing, eating, and toilet use. The MDS recorded the resident had wandering behavior which occurred daily. The cognitive Care Area Assessment (CAA) dated 1/27/12 recorded the resident had Alzheimer's dementia, had forgetfulness and confusion, walked frequently throughout the facility, got lost and unable to find room, and staff placed a Wanderguard on the resident for safety. The wandering care plan dated 2/16/12 directed the resident had a Wanderguard and staff monitored his/her whereabouts, resident exhibited exit seeking behavior, staff should evaluate by completing the elopement assessment, encourage activities for the resident, meet the resident's needs which may contribute to wandering behavior, redirect, and the resident had made no attempt or verbalization to exit the building. The care plan lacked information to direct staff to monitor the placement and functioning of the Wanderguard or the location of placement on the resident's body. The Elopement assessment dated [DATE] recorded the resident had impaired judgment and safety awareness, enough to prove dangerous to themselves or others, and included the comment, "Resident ambulates independently throughout facility with (his/her) walker. Has talked of going home but has made no attempt to exit facility. Resident has difficulty remembering the location of (his/her) room and dining room. Wanderguard to left wrist placed 1/27/12. Staff re-direct (him/her) if (he/she) appears lost." The Treatment Administration Record (TAR) recorded the order, Wanderguard to right ankle, check placement every shift, started 1/27/12. Observation on 2/28/12 AT 9:52 A.M. revealed the resident walked to nurse's station with his/her walker. During an interview on 2/28/12 at 9:56 A.M. licensed nurse D stated he/she checked the placement of the Wanderguards on the residents, but did not check if the Wanderguards functioned. During an interview on 2/28/12 at 10:58 A.M., licensed nurse F stated he/she documented on the TAR that he/she checked the placement of the residents Wanderguards, and checked the function of the Wanderguard by taking the resident to the door and knew it was functioning if the alarm went off. During an interview on 2/28/12 at 11:02 A.M. licensed nurse G stated he/she documented in the TAR when he/she checked residents Wanderguards, but did not check the function of the Wanderguards and thought staff did that on another shift. During an interview on 2/28/12 at 11:05 A.M. licensed nurse C stated he/she checked Wanderguards on morning rounds to see if they were in place, and he/she took the residents with Wanderguards by the door 1 time a week to check the function because the batteries ran down on the Wanderguards and they had to be checked, but he/she did not document the function information. During an interview on 2/28/12 at 12:43 P.M. licensed nurse E stated he/she checked the placement of residents Wanderguards and documented this in the TAR, but did not check the function of the Wanderguards. During an interview on 2/28/12 at 3:30 P.M., licensed nurse K stated he/she looked for the Wanderguard and verified it was in place, but did not check the function of the Wanderguards. During an interview on 2/28/12 at 3:40 P.M., licensed nurse H stated he/she visually checked the Wanderguard was in place but did not check the function of the Wanderguard. During an interview on 2/28/82 at 3:41 P.M., licensed nurse I stated he/she checked the placement of the residents Wanderguard but did not check the function of the Wanderguard. During an interview on 2/28/12 at 3:48 P.M., licensed nurse L stated he/she checked the placement of residents Wanderguard, did not check the function, but when the resident went near the door the alarm went off, so he/she thought the Wanderguard worked. During an interview on 2/28/12 at 3:53 P.M., licensed nurse J stated he/she checked the residents Wanderguard placement, but did not check the function. During an interview on 2/28/12 at 4:05 P.M., administrative nursing staff B stated he/she expected licensed nurses to visually check the Wanderguard was in place and document that in the TAR, but did not expect staff to take all residents to the door every shift to verify the function of the Wanderguards, and the facility did not have a Wanderguard tester to verify the Wanderguard worked. During an interview on 2/28/12 at 4:12 P.M., licensed nurse M stated he/she checked the function of all Wanderguards before staff placed them on the resident, but did not continue to monitor the function of the Wanderguards. The facility lacked a policy that included Wanderguard monitoring. The facility failed to ensure the Wanderguards functioned properly for this resident at risk for wandering. - Resident #11's Physician order [REDACTED]. The significant change Minimum Data Set (MDS) 3.0 with an Assessment Reference Date of 2/23/12 recorded the Brief Interview for Mental Status score was 0, which indicated severe cognitive impairment, and the resident required extensive assistance for bed mobility transfers, locomotion on the unit, dressing, eating, toilet use, and personal hygiene, and total dependence for locomotion off the unit, and walking in the room and corridor only occurred once or twice during the assessment period. The resident ' s behavior recorded on the MDS included verbal behavior toward others, 1-3 days which significantly disrupted care or living environment, and no wandering behavior. The behavior Care Area assessment dated [DATE] recorded the resident had behavioral problems related to Alzheimer's dementia, was very aggressive toward staff, confused and had exit seeking behavior. The elopement care plan dated 2/27/12 recorded, follow elopement protocol and notify administrative staff and family, document any elopements or attempted elopements with any sustained injuries and situation leading up to the event, apply alarm bracelet-check placement every shift and as needed, if the resident had agitation and was not redirect able, contact family member and ask them to come to facility and sit with him/her, or help the resident speak to his/her spouse on the phone, redirect the resident's attention with activities, reality orientation, etc., monitor for mental status changes (agitation, anger, emotional distress, hallucinations, delusions), staff to sit and talk with resident, offer drinks of fluid, something to eat when resident is exit seeking, remind the resident of potential dangers of leaving facility without escort, monitor the resident's whereabouts frequently every 30 minutes to 1 hour if exit seeking, staff to follow fall protocol measures if elopement occurs. The care plan lacked information to direct staff to monitor the functioning of the Wanderguard or the location of placement on the resident's body. The Elopement assessment dated [DATE] recorded the resident had wandering behavior and impaired judgment and safety awareness, and scored the resident high risk for elopement, and included the comment, "Resident confused can self-propel wheelchair, not knowing where (he/she) is going. Could only get out a door if someone held the door open for (him/her). Resident has a Wanderguard on and staff to check for placement every shift." The TAR recorded, Wanderguard check every shift, started 1/19/12, with the hand written comment, "right ankle". Observation on 2/28/12 at 10:21 A.M., the resident sat in his/her wheelchair with a Wanderguard bracelet on his/her right ankle. During an interview on 2/28/12 at 9:56 A.M. licensed nurse D stated he/she checked the placement of the Wanderguard on the residents, but did not check if the Wanderguard functioned. During an interview on 2/28/12 at 10:58 A.M., licensed nurse F stated he/she documented on the TAR that he/she checked the placement of the residents Wanderguards, and checked the function of the Wanderguard by taking the resident to the door and knew it was functioning if the alarm went off. During an interview on 2/28/12 at 11:02 A.M. licensed nurse G stated he/she documented in the TAR when he/she checked residents Wanderguards, but did not check the function of the Wanderguards and thought staff did that on another shift. During an interview on 2/28/12 at 11:05 A.M. licensed nurse C stated he/she checked Wanderguards on morning rounds to see if they were in place, and he/she took the residents with Wanderguards by the door 1 time a week to check the function because the batteries ran down on the Wanderguards and they had to be checked, but he/she did not document the function information. During an interview on 2/28/12 at 12:43 P.M. licensed nurse E stated he/she checked the placement of residents Wanderguards and documented this in the TAR, but did not check the function of the Wanderguards. During an interview on 2/28/12 at 3:30 P.M., licensed nurse K stated he/she looked for the Wanderguard and verified it was in place, but did not check the function of the Wanderguards. During an interview on 2/28/12 at 3:40 P.M., licensed nurse H stated he/she visually checked the Wanderguard was in place but did not check the function of the Wanderguard. During an interview on 2/28/82 at 3:41 P.M., licensed nurse I stated he/she checked the placement of the residents Wanderguards but did not check the function of the Wanderguards. During an interview on 2/28/12 at 3:48 P.M., licensed nurse L stated he/she checked the placement of resident's Wanderguard, did not check the function, but when the resident went near the door the alarm went off, so he/she thought the Wanderguard worked. During an interview on 2/28/12 at 3:53 P.M., licensed nurse J stated he/she checked the resident's Wanderguard placement, but did not check the function. During an interview on 2/28/12 at 4:05 P.M., administrative nursing staff B stated he/she expected licensed nurses to visually check the Wanderguard was in place and document that in the TAR, but did not expect staff to take all residents to the door every shift to verify the function of the Wanderguards, and the facility did not have a Wanderguard tester to verify the Wanderguard worked. During an interview on 2/28/12 at 4:12 P.M., licensed nurse M stated he/she checked the function of all Wanderguards before staff placed them on the resident, but did not continue to monitor the function of the Wanderguards. The facility lacked a policy that included Wanderguard monitoring. The facility failed to ensure the Wanderguards functioned properly for this resident at risk for wandering. - Resident #12's Physician order [REDACTED]. The significant change Minimum Data Set (MDS) 3.0 with an Assessment Reference Dated (ARD) date of 1/7/12 recorded the resident's Brief Interview for Mental Status (BIMS) score was 2, which indicated severe cognitive impairment, and required total dependence on staff for transfers, locomotion off the unit, toilet use and personal hygiene, extensive assistance for bed mobility, locomotion on the unit and dressing, and required limited assistance for eating, and the resident did not walk during the assessment period, and the resident had delusions, and wandering behavior that occurred daily. The behavior Care area Assessment (CAA) dated 1/7/12 recorded the resident had some behavioral problems, was confused, got upset at times, got physically aggressive toward staff and tried to get out of the door to go home to get (his/her) children. The wandering care plan dated 2/27/12 directed, Wanderguard applied to help monitor whereabouts, staff to check for placement every shift, evaluate the resident if exhibiting exit seeking behavior on the elopement assessment, if exit seeking, place on safety checks, staff would start with 15 minute checks and advance as behavior improves, if indicated, assist with alternate living arrangements, ask why wandering, provide for needs or assure and redirect from exit seeking, often looking for his/her children or grandchildren, encourage to attend activities to keep busy, if resident packed belongings (a sign the resident thought about leaving), room close to a busy and provide staff oversight location in the building, offer a "busy box" filled with items that resident enjoyed, offer distraction, offer medication as needed, review behavior to determine triggers for exit seeking behavior, talk with resident and offer 1 to 1 time when available, talk with the resident's family, they may know what has helped to decrease the wandering in the past, when resident wandered help make a phone call to family member, staff to call resident's family member, that usually helps her calm down. The care plan lacked information to direct staff to monitor the functioning of the Wanderguard or the location of placement on the resident's body. The dementia with agitation care plan dated 1/11/12 recorded the resident had a Wanderguard on left side of his/her wheelchair. The Elopement assessment dated [DATE] recorded the resident had impaired judgment and safety awareness, and made verbal threats of elopement, and included the comment, "Resident asks to be taken to the door daily so that (he/she) can leave, resident is confused, disoriented at all times. Resident memory is in the past, (he/she) thinks that (his/her) children are all still young." The TAR recorded the order, Check Wanderguard every shift, started 12/14/11, and no location for the Wanderguard indicated. Observation on 2/28/12 at 10:06 A.M. revealed the resident sat in his/her wheelchair in his/her room and had a Wanderguard on the left side of the wheelchair. During an interview on 2/28/12 at 9:56 A.M. licensed nurse D stated he/she checked the placement of the Wanderguards on the residents, but did not check if the Wanderguards functioned. During an interview on 2/28/12 at 10:58 A.M., licensed nurse F stated he/she documented on the TAR that he/she checked the placement of the resident's Wanderguards, and checked the function of the Wanderguard by taking the resident to the door and knew it was functioning if the alarm went off. During an interview on 2/28/12 at 11:02 A.M. licensed nurse G stated he/she documented in the TAR when he/she checked residents Wanderguards, but did not check the function of the Wanderguards and thought staff did that on another shift. During an interview on 2/28/12 at 11:05 A.M. licensed nurse C stated he/she checked Wanderguards on morning rounds to see if they were in place, and he/she took the residents with Wanderguards by the door 1 time a week to check the function because the batteries ran down on the Wanderguards and they had to be checked, but he/she did not document the function information. During an interview on 2/28/12 at 12:43 P.M. licensed nurse E stated he/she checked the placement of resident's Wanderguards and documented this in the TAR, but did not check the function of the Wanderguards. During an interview on 2/28/12 at 3:30 P.M., licensed nurse K stated he/she looked for the Wanderguard and verified it was in place, but did not check the function of the Wanderguards. During an interview on 2/28/12 at 3:40 P.M., licensed nurse H stated he/she visually checked the Wanderguard was in place but did not check the function of the Wanderguard. During an interview on 2/28/12 at 3:41 P.M., licensed nurse I stated he/she checked the placement of the residents Wanderguard but did not check the function of the Wanderguard. During an interview on 2/28/12 at 3:48 P.M., licensed nurse L stated he/she checked the placement of resident's Wanderguard, did not check the function, but when the resident went near the door the alarm went off, so he/she thought the Wanderguard worked. During an interview on 2/28/12 at 3:53 P.M., licensed nurse J stated he/she checked the resident's Wanderguard placement, but did not check the function. During an interview on 2/28/12 at 4:05 P.M., administrative nursing staff B stated he/she expected licensed nurses to visually check the Wanderguard was in place and document that in the TAR, but did not expect staff to take all residents to the door every shift to verify the function of the Wanderguards, and the facility did not have a Wanderguard tester to verify the Wanderguard worked. During an interview on 2/28/12 at 4:12 P.M., licensed nurse M stated he/she checked the function of all Wanderguards before staff placed them on the resident, but did not continue to monitor the function of the Wanderguards. The facility lacked a policy that included Wanderguard monitoring. The facility failed to ensure the Wanderguards functioned properly for this resident at risk for wandering.

The facility identified a census of 85 residents. The sample included 7 residents. Based on observation, interview and medical record review, the facility failed to prevent the development of 2 avoidable pressure ulcers for 1 of 3 sampled residents. (#59) Findings included: - Resident #59 ' s [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) 2.0 assessment dated [DATE] recorded the facility unable to determine the resident ' s short and long-term memory due to impairment. The MDS recorded the resident with severely impaired cognition. The MDS also recorded the resident required total assistance of all activities of daily living (ADL ' s), incontinent of bowel and bladder, received total nutrition through a gastrostomy tube, on a turning and repositioning schedule, had a pressure relieving device on the bed and chair, and did not have any type of ulcers including pressure ulcers. The medical record also documented the payor source for the resident as Medicaid per diem. The Resident Assessment Protocol summary (RAPs) dated 5-7-10 recorded the resident at risk for pressure ulcers due to impaired mobility, insulin dependence for diabetes, incontinence of bowel and bladder, depression, and [MEDICAL CONDITION] and did not have any breaks in his/her skin at this time. The 7-29-10 care plan recorded the resident with potential for ulceration of the skin caused by prolonged pressure related to his/her immobility, cognitive impairment, and status [REDACTED]. The care plan also identified the resident with an " actual " wound on his/her left side of head and blisters on his/her right and left heels. Interventions directed staff to assess for pain, provide medication as indicated, monitor for adequate protein in the diet, follow the physician treatment orders, monitor labs as ordered, follow recommendations of the registered dietician, and observe surrounding skin on heel for redness or bogginess. The Braden Scale Assessment (a scale to determine the risk of a resident to develop a pressure ulcer by assigning a score) dated 7-29-10 recorded the resident with a score of 11 indicating the resident at high risk of developing a pressure ulcer. During medical record review, the nurse ' s notes dated 9-9-10 at 9:35 A.M., recorded the resident with a " slight blister " on the right heel and one " coming up " on the left heel. The POS recorded an order at that time for the use of " skin prep " (a protective film applied to skin for protection) to the right and left heels twice daily until healed. Review of the dietary notes dated 3-23-10, recorded a Pre-[MEDICATION NAME] (a test to determine protein-calorie [MEDICAL CONDITION]) level of 18, which was in normal range, and recommended discontinuation of Prostat (a protein supplement). Review of the " Skin Report " form in the Treatment Administration Record (TAR) recorded on 9-9-10 the resident with stage 1 wounds on the right, left heels, and had 1 measurement of 0.4 centimeters (cm) length x 0.3 cm width with no depth, drainage or odor. Further measurements included: 9-15-10 left heel stage 1, 0.4cm x 0.3 cm closed. 9-15-10 right heel stage 1, 0.3 cm x 0.2 cm closed. 9-29-10 left heel healed. 9-29-10 right heel stage 1, 0.3 x 0.3 closed (The measurements did not depict length or width on any of the entries) Observation on 10-4-10 at 10:48 A.M., revealed the resident in bed, laying on his/her back with thick whitish mucous around his/her lips, and no elevation of the heels off the mattress. On 10-4-10 at 11:16 A.M., observation revealed the resident lying on his/her back, whitish mucous around his/her lips and with boots on both feet that were made of sheepskin without any type of pressure relief on the heels, extended to the calf area and lying directly on the mattress. Licensed nurse A removed the " Rookie " boots and observation of the right foot revealed an unstageable dark blue, black pressure area approximately 4.0 cm circumference on the right lateral heel. Observation of the left heel revealed 3 unstageable small black areas approximately 0.3-0.5 cm ' s diameter along a scarred area of the heel. Licensed nurse A re-applied the boots and both heels remained directly on the mattress. On 10-4-10 at 12:10 P.M., observation revealed the resident remained on his/her back with the " Rookie " boots in place and directly on the mattress. Direct care staff A and licensed nurse A checked the resident for incontinence and provided perineal care and positioned the resident back in the same position with his/her heels directly on the mattress. Observation of the wound on the resident ' s left side of head by his/her ear revealed the area closed, however at that time observation revealed a small amount of bloody drainage at the inner aspect between the left ear and scalp. Licensed nurse A stated it was probably due to the oxygen tubing and that he/she would treat it. On 10-4-10 at 1:34 P.M., observation revealed the resident in the same position, laid on his/her back and both feet directly on the mattress for a total of 2 hours and 46 minutes of continuous observation. Licensed nurse B measured the pressure areas. The left heel with multiple small blue, black pressure areas and stated he/she would measure the widest area and the longest area and it measured 0.5 cm length and width. Licensed nurse B stated the areas were from dry skin and began picking the skin away. He/she stated he/she would notify staff to lotion the areas well. The pressure ulcer on the right heel measured 4.1 cm length and 3.9 cm width. Licensed nurse B stated the areas were from blisters the resident developed because of " profound " [MEDICAL CONDITION] not caused from pressure because the resident had an " Aid Dyne special mattress " that did not cause any pressure to the skin and that the resident did not have to be turned. He/she also stated the boots were not pressure relieving, but were for circulation because they kept his/her feet and legs warm, which improved his/her circulation. Further observation of the left ear wound previously observed, revealed a " skin tag " type lesion on the scalp overlapping to the top of the inner ear adjacent to the scalp, open with serosanginous drainage. During record review with licensed nurse B, he/she acknowledged the nurse ' s note dated 9-9-10 documenting the blisters noted on both heels and the inaccurate nursing assessment dated [DATE] lacked documentation of the blisters. He/she stated it was an oversight. During review of the measurements on the TAR, he she acknowledged the measurements and stated the nurse did document the areas and measured them weekly. He/she acknowledged what the measurements on the TAR recorded and the increase in size of the pressure ulcers measured at this time. He/she again stated it was because of [MEDICAL CONDITION] and not pressure. During review of the care plan, he/she acknowledged the care plan lacked a date of when staff found the blisters on the heels and he/she dated it 9-9-10 and dated the intervention of checking the heel for redness and bogginess with the same date at that time. He/she continued to review the medical record, and stated he/she made rounds with the physician and wrote a nurse ' s note that documented the resident had profound [MEDICAL CONDITION] of both legs and that is what caused the area on the right heel. He/she stated that he/she wrote the nurse ' s note dated 10-1-10 for 9-30-10 after making rounds with the physician on 9-30-10. Further review of the medical record lacked evidence the resident had [MEDICAL CONDITION] of the feet and legs prior to the note on 9-30-10 and he/she confirmed. He/she stated the Physician saw the resident on 9-30-10 and wrote in the progress note that the resident had a blister on his/her heel from [MEDICAL CONDITION] and increased the resident ' s [MEDICATION NAME] medication. On 10-4-10 at 3:05 P.M., licensed nurse B stated he/she and another nurse examined the resident ' s left heel and felt the areas were from bruising. On 10-4-10 at 3:15 P.M., direct care staff B stated they reposition the resident every 2 hours for comfort. On 10-4-10 at 3:16 P.M., licensed nurse C stated the blistered areas on the resident ' s heels improved and stated staff turn the resident every 2 hours for comfort although they do not have to because the resident had a special mattress that was pressure relieving and did not have to be turned. The National Pressure Ulcer Advisory Panel (NPUAP) 2009 Quick Reference Guide for Pressure Ulcers documented repositioning for all at-risk individuals and done to reduce the duration and magnitude of pressure over vulnerable areas of the body. The Reference Guide also documented the frequency of repositioning was determined by the individual ' s tissue tolerance, his/her level of activity and mobility, his/her general medical condition, overall treatment objectives and assessments of the individual ' s skin condition. The Guide further direct health professionals to ensure the heels are free of the surface of the bed and use a pillow under the calves so that the heels are elevated (i.e. floating). The facility failed to accurately assess this dependent resident with unstageable pressure ulcers on both heels and foot, failed to prevent the pressure ulcers from increasing in size, failed to float the heels to relieve all pressure from the heels and failed to reposition the resident frequently to prevent the development of avoidable pressure ulcers on his/her heels.