**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents of which two were reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interview, the facility failed to ensure pressure-reducing devices functioned correctly to prevent the worsening of pressure ulcer/injury for Resident (R) 20's coccyx (area at the base of the spine) wound. This placed the resident at risk for delayed healing or worsening of an existing pressure ulcer. Findings included: - The Electronic Medical Record (EMR) documented R20 had diagnoses of unspecified symptoms and signs involving cognitive functions and awareness, tremors, anorexia (lack or loss of appetite), urinary incontinence, and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R20 had severe cognitive impairment and rejection of care behavior for one to three days during the observation period. R20 was independent with eating and required supervision with lower body dressing, and personal hygiene. R20 was independent with rolling side to side in bed, transferring from chair to bed and bed to chair, and required supervision and touch assistance with toilet transfers. R20 had occasional incontinence of urine and frequent incontinence of bowel. The MDS further documented that R20 had occasional moderate pain which affected sleep and interfered with therapy and day-to-day activities. R20 had weight loss and received a therapeutic diet. R20 had two Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcers/injuries. R20 had a pressure-reducing device for the chair and bed and received pressure ulcer care, application of nonsurgical dressings and ointment/medication, and nutritional/hydration interventions to manage skin issues. R20's Pressure Ulcer Care Area Assessment (CAA), dated 03/07/24, documented R20 had a new Stage 1 (pressure wound which appears reddened, does not blanche, and may be painful but is not open) and Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) pressure ulcers. R20 spent a great deal of time in his recliner and refused position changes. The CAA further documented a new onset of urinary incontinence. R20's Care Plan, dated 03/12/24, documented R20 spent a great deal of time in the recliner, refused position changes, and slept through the night in his recliner at times. R20 had an air mattress on the bed and staff was directed to encourage R20 to offload pressure to his coccyx. The care plan further directed staff to identify and document potential causative factors and eliminate and resolve them when possible. The Physician Order, dated 09/06/24, directed staff to use wound cleanser to cleanse the wound, pat dry, and cover it every three days. The Wound-Weekly Observation Tool dated 09/12/24 documented a Stage 2 coccyx wound (acquired on 04/05/24) which measured eight millimeters (mm) in length and eight (mm) in width. R20 had a ROHO cushion (pressure relief cushion that is made of soft, flexible air cells) in the wheelchair and recliner. R20 needed position changes, and dressing changes every three days and as needed, and received Prostat (a concentrated protein drink). The Progress Note dated 09/17/24 documented R20 still had two small open areas on his bottom. On 09/17/24 at 08:55 AM, observation revealed R20 sat in his recliner with his feet elevated. R20 reported he had a sore on his bottom about the size of a pencil eraser. R20 reported staff had provided a cushion for his recliner and wheelchair. The resident verified he slept in his recliner, due to laying in bed was uncomfortable for him. R20 stated the staff had instructed him to change positions to help the pressure sore heal and said he had dressing changes to the area. On 09/18/24 at 10:44 AM, observation revealed Licensed Nurse (LN) G provided a dressing change to R20's coccyx area. R20 had a ROHO-type cushion in the seat of the recliner that had lost air and gone flat. LN G verified the cushion went flat when pressure was applied and said that therapy had provided the cushion and LN G would contact the therapy staff to check the function of the cushion. On 09/18/24 at 10:54 AM, Administrative Nurse D reported therapy services provided the pressure relieving cushions for R20, but the nursing staff was responsible for checking the cushion for proper inflation. Administrative Nurse D stated he would educate staff on how to ensure this was done. The facility's Wound Management policy, dated 01/26/24, documented the facility is committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being and to minimize the development of in-house acquired pressure ulcers unless the individual's clinical condition demonstrates they are unavoidable. A commitment to the Wound Management Program is demonstrated by the implementation of processes founded on accepted standards of practice, research-driven clinical guidelines, and interdisciplinary involvement. Wound management principles include and are not limited to the control or elimination of causation factors such as pressure, shear, friction, moisture, and circulatory impairment. The facility failed to ensure that R20's pressure-reducing cushion functioned correctly. This placed R20 at risk for delayed healing or worsening of an existing pressure ulcer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported that staff failed to follow the physician's orders to administer insulin (controls the amount of sugar in the blood by moving into cells) and medications to treat Parkinson's disease (a slowly progressive neurological disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). This placed the resident at risk for physical decline and an ineffective medication regimen. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of Parkinson's disease, diabetes mellitus type two (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had intact cognition. R2 required setup assistance with eating, dressing, and personal hygiene, and was independent with toileting, mobility, and transfers. The assessment revealed R2 received insulin during the observation period. The Annual MDS, dated 08/01/24, documented R2 had moderately impaired cognition. R2 required setup assistance with eating, dressing, and personal hygiene, and was independent with toileting, mobility, and transfers. The assessment revealed R2 received insulin. R2's Care Plan, dated 8/05/24 and initiated on 01/16/21, directed staff to administer medications as ordered and to monitor and document side effects and effectiveness. The update, dated 03/18/22, directed staff to obtain Accu-checks (blood glucose monitoring test), administer insulin per the physician's order, and update the physician per request related to blood glucose readings. The Physician's Order, dated 11/25/19, directed staff to administer Sinemet (medication used to treat Parkinson's disease), 25-100 milligrams (mg). two tablets, by mouth, every eight hours, for Parkinson's disease. R2's Medication Administration Record dated July 2024 lacked documentation that staff administered the Sinemet medication on the following days: 07/11/24 at 06:00 AM 07/23/24 at 06:00 AM R2's Medication Administration Record dated August 2024 lacked documentation that staff administered the Sinemet medication on the following days: 08/04/24 at 06:00 AM R2's Medication Administration Record dated September 2024 lacked documentation that staff administered the Sinemet medication on the following days: 09/02/24 at 10:00 PM The Physician's Order, dated 05/13/24, directed staff to administer Novolog (a fast-acting insulin), 15 units, subcutaneous (under the skin), three times per day, for diabetes mellitus type two. R2's Treatment Administration Record dated July 2024 lacked documentation the insulin was administered on the following days: 07/10/24 in the evening 07/29/24 in the evening The Physician's Order, dated 07/22/24, directed staff to administer insulin glargine (a long-acting insulin), 35 units, subcutaneous, twice per day, for diabetes mellitus type two. R2's Treatment Administration Record dated August 2024 lacked documentation the insulin was administered on the following days: 08/17/24 at 07:00 PM 08/21/24 at 07:00 PM. R2's Treatment Administration Record dated September 2024 lacked documentation the insulin was administered on the following days: 09/14/24 at 07:00 PM. The Medication Regimen Review for the months of July, August, and September 2024 lacked evidence the CP identified and reported R2 had not been administered the ordered medication and insulin. On 09/17/24 at 12:25 PM, observation revealed Licensed Nurse (LN) G washed her hands, obtained gloves, wiped R2's finger with alcohol, obtained his blood sugar, and told him he did not need his insulin. On 09/18/24 at 11:13 AM, Administrative Nurse D stated he had not been made aware by the CP that R2 had not received the as-ordered medication and insulin. The facility's Consultant Pharmacist Services Provider Requirements policy, dated 09/18/24, documented that the consultant pharmacist provided pharmaceutical care services and reviewed the medication regimen of each elder in the health center at least monthly incorporating federally mandated standards of care in addition to other applicable professional standards, and documenting the review and finding in the elder's clinical record. The CP communicates potential or actual problems related to medication therapy orders to the responsible physician and the Director of Nursing and reviews medication administration records, physician orders, and administration of the medications to the elders. The CP also monitors to ensure the appropriate review is documented in the elder's clinical record. The facility failed to ensure the CP identified and reported that staff failed to follow the physician's orders to administer insulin and medications to treat Parkinson's disease. This placed the resident at risk for physical decline and an ineffective medication regimen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 31 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observations, record review, and interview, the facility failed to administer medication as ordered by the physician for one resident, Resident (R) 2, who received insulin (controls the amount of sugar in the blood by moving into the cells) and medications to treat Parkinson's disease (a slowly progressive neurological disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). This placed the resident at risk for unnecessary medication side effects and an ineffective medication regimen. Findings included: - The Electronic Medical Record (EMR) for R2 documented diagnoses of Parkinson's disease, diabetes mellitus type two (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), dementia (a progressive mental disorder characterized by failing memory and confusion), hypertension (high blood pressure), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R2 had intact cognition. R2 required setup assistance with eating, dressing, and personal hygiene, and was independent with toileting, mobility, and transfers. The assessment revealed R2 received insulin during the observation period. The Annual MDS, dated 08/01/24, documented R2 had moderately impaired cognition. R2 required setup assistance with eating, dressing, and personal hygiene, and was independent with toileting, mobility, and transfers. The assessment revealed R2 received insulin. R2's Care Plan, dated 8/05/24 and initiated on 01/16/21, directed staff to administer medications as ordered and to monitor and document side effects and effectiveness. The update, dated 03/18/22, directed staff to obtain Accu-checks (blood glucose monitoring test), administer insulin per the physician's order, and update the physician per request related to blood glucose readings. The Physician's Order, dated 11/25/19, directed staff to administer Sinemet (medication used to treat Parkinson's disease), 25-100 milligrams (mg), two tablets, by mouth, every eight hours, for Parkinson's disease. R2's Medication Administration Record dated July 2024 lacked documentation that staff administered the Sinemet medication on the following days: 07/11/24 at 06:00 AM 07/23/24 at 06:00 AM R2's Medication Administration Record dated August 2024 lacked documentation that staff administered the Sinemet medication on the following days: 08/04/24 at 06:00 AM R2's Medication Administration Record dated September 2024 lacked documentation that staff administered the Sinemet medication on the following days: 09/02/24 at 10:00 PM The Physician's Order, dated 05/13/24, directed staff to administer Novolog (a fast-acting insulin), 15 units, subcutaneous (under the skin), three times per day, for diabetes mellitus type two. R2's Treatment Administration Record dated July 2024 lacked documentation the insulin was administered on the following days: 07/10/24 in the evening 07/29/24 in the evening The Physician's Order, dated 07/22/24, directed staff to administer insulin glargine (a long-acting insulin), 35 units, subcutaneous, twice per day, for diabetes mellitus type two. R2's Treatment Administration Record dated August 2024 lacked documentation the insulin was administered on the following days: 08/17/24 at 07:00 PM 08/21/24 at 07:00 PM. R2's Treatment Administration Record dated September 2024 lacked documentation the insulin was administered on the following days: 09/14/24 at 07:00 PM. On 09/17/24 at 12:25 PM, observation revealed Licensed Nurse (LN) G washed her hands, obtained gloves, wiped R2's finger with alcohol, obtained his blood sugar, and told him he did not need his insulin. On 09/17/24 at 03:19 PM, LN G stated R2 required three different insulins and stated that after the insulin was administered, it was documented in the medical record. On 09/18/24 at 11:13 AM, Administrative Nurse D stated if R2 had not received his insulin, staff were to document in the medical record the reason why it was not administered. The facility's Administering Medications Using Electronic Medication Administration Record policy, dated 09/16/24, documented the facility administered medications in a safe manner and completed accurate and timely real-time documentation of all medication administration using the Electronic Medical Record (eMAR) system utilized in the facility. All medications would be administered to every resident as ordered by a physician in a safe and sanitary manner. If the resident or representative refused medication or the resident was unable to take medication as scheduled, click the appropriate box on the eMar as not done and provide a documented explanation. The facility failed to administer medications as ordered by the physician for R2, who received insulin and Parkinson's disease medication. This placed the resident at risk for unnecessary medication side effects and an ineffective medication regimen.

The facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) were used for Resident (R) 20 who had an ongoing pressure ulcer and dressing change. The deficient practice placed the resident at risk of infectious disease processes. Findings included: - On 09/17/24 at 08:55 AM, observation revealed R20's door had an EBP sign and supply tote with personal protective equipment (PPE) of gloves, gowns, and eye protection shields next to the door. R20 sat in his recliner with his feet elevated. R20 reported he had a sore on his bottom about the size of a pencil eraser. R20 said he had dressing changes to the area. On 09/18/24 at 10:44 AM, observation revealed Licensed Nurse (LN) G provided a dressing change to R20's coccyx area. LN G washed her hands, placed disposable gloves on, and proceeded to assist R20 into the bathroom. LN G removed the dressing from R20's coccyx area and cleansed it with wound cleanser. LN G reported she had forgotten to bring a dressing for the wound and left the room. Upon returning to the room, LN G placed gloves on and dressed the wound. LN G had not donned a gown while assisting R20 in the bathroom or during the dressing change. On 09/18/24 at 10:48 AM LN G verified she had not worn a gown and should have during R20's care and dressing change. On 09/18/24 at 10:54 AM, Administrative Nurse D verified LN G should have worn a gown during R20's care and dressing change. The facility's Enhanced Barrier Precautions (EBP) policy, dated 05/04/24, documented the facility follows recommendations and guidance from the Centers for Disease Control in order to keep all residents safe from Healthcare Acquired Infections (HAI). On the recommendation and approval of the facility's Infection Preventionist in collaboration with the facility's Medical Director, Enhanced Barrier Precautions are implemented as one intervention this facility uses to reduce transmission of resistant organisms that employ targeted PPE use during high-contact resident care activities. The facility failed to ensure staff used EBP while caring for R20, who had an ongoing pressure ulcer and dressing change. The deficient practice placed the resident at risk for facility-acquired infections.

The facility had a census of 31 residents. The sample included 12 residents, with five reviewed for immunizations to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interview, the facility failed to follow the latest guidance from the Centers for Disease Control and Prevention (CDC) when they failed to offer and administer or obtain an informed declination, or a physician-documented contraindication for Resident (R)3, R6, R20, R21, and R22, pneumococcal PCV20 vaccination. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease. Findings included: - Review of R3, R6, R20, R21, and R22's clinical medical records lacked evidence the facility or the resident representative received or signed consent or informed declination for the current pneumococcal vaccine PCV20. The records lacked evidence of a physician-documented contraindication. On 09/17/24 at 01:15 PM, Administrative Nurse E stated the facility only offered the PVC20 to new residents but did not have documentation that it was ever offered and declined. The facility's Flu/Pneumonia Vaccine policy, dated 01/31/24, documented influenza and pneumonia vaccines would be administered by appropriately qualified personnel who are following facility procedures, without the need for an individual physician evaluation or order other than the signed standing orders. Each person offered the vaccine(s) would be provided with current information from the CDC and Federal Drug Administration regarding the benefits and risks of the vaccine. Every year, a log documenting how many people (residents, staff, and volunteers) receive influenza and Pneumovax vaccine, as well as the number who refused and did not receive the vaccination. The resident's clinical record would document that the resident and/or surrogate decision-maker was provided education regarding the benefits and potential side effects of the vaccines. The documentation would include whether the resident received the vaccines or refused to receive the immunizations due to medical contraindications or refusal. The facility failed to offer the pneumococcal PCV20 vaccinations per CDC recommendations. This deficient practice placed the residents at risk of acquiring, spreading, and experiencing complications from pneumococcal disease.

The facility had a census of 31 residents and one kitchen. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to employ a full-time Certified Dietary Manager for the 31 residents who reside in the facility and received their meals from the kitchen. This placed the residents at risk of not receiving adequate nutrition. Findings included: - On 09/16/24 at 08:10 AM, observation revealed the kitchen staff finishing the morning meal and preparing the midday meal. Dietary Staff CC stated the Dietary Manager had the day off and planned on returning within the survey period. On 09/18/24 at 08:30 AM, Dietary Staff BB reported he is in the process of obtaining a certified dietary manager course. The facility's Organizational Plan and Roles of Key Staff policy, dated 2020, documented in states without an established minimum standard, the following qualifications of the Dining Service Manager should be considered: Certified Dietary Manager credential. The facility failed to employ a full-time Certified Dietary Manager for 31 residents who reside in the facility, which placed the residents at risk of inadequate nutrition.

The facility had a census of 31 residents. Based on observation, interview, and record review the facility failed to submit complete and accurate staffing information through Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Service (CMS) for Fiscal Year (YR) 2023 Quarter (Q) 4, FY 2024 Q1, Q2, and Q3 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days. (FY 2023 Quarter 4: 11 dates and FY 2024 Quarter 1: 5 days, Quarter 2:25 days and Quarter 3: 5 days). A review of the facility's licensed nurse data or the dates listed on the PBJ revealed a licensed nurse on duty 24 hours a day seven days a week. On 09/18/24 at 10:00 AM, observation revealed a licensed nurse on duty in the facility. On 09/18/24 at 11:51 AM Administrative Staff A reported the facility sent the payroll information to a corporate office and it was submitted to the PBJ from there. She stated there was a nurse on duty at all times, and the information submitted was not accurate. The facility's Mandatory Submission of Uniform Format Staffing Information (PBJ-Payroll Based Journal) policy, dated 09/18/24, documented the facility will electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by Centers for Medicare and Medicaid Services. The facility failed to submit accurate PBJ data which placed the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 31 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to ensure the staff person designated as the Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP) completed the specialized training in infection prevention and control. This placed the 31 residents in the facility at risk for lack of identification and treatment of infections. Findings included: - On 09/17/24 at 01:15 PM, Administrative Nurse E stated she was responsible for the IPCP and was in the process of taking the class. Administrative Nurse E confirmed she was not certified. The facility's Infection Control Policy, dated 03/13/23 documented the IP was responsible for overseeing the Infection Control program and was required to have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related fields, and be qualified by education, training, experience, or certification. The policy documented that the IP was required to work at least part-time at the facility, have completed specialized infection prevention and control training, and participate in the Quality Assurance Performance Improvement (QAA) committee regularly. The facility failed to ensure the staff person designated as the IP possessed the required certification, placing the residents at increased risk for infections.

The facility identified a census of 34 residents with three residents reviewed for care and treatment of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). Based on record review, observation, and interview, the facility failed to ensure Resident (R) 2 received treatment and care in accordance with professional standards of practice related to CHF. This deficient practice placed R2 at risk for complications from congestive heart failure that included weight gain, edema (swelling), and difficulty breathing. Findings included: - R2's Electronic Medical Record (EMR) documented R1 had diagnoses of acute on chronic diastolic congestive heart failure, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and atrial fibrillation (rapid, irregular heartbeat). The Quarterly Minimum Data Set (MDS), dated 01/25/24, documented R2 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated intact cognition. The MDS documented R2 weighed 193 pounds and had a five percent weight gain in the last month; R2 was not on a physician-prescribed weight gain regimen. The MDS recorded R2 received a diuretic (medication to promote the formation and excretion of urine). The Activity of Daily Living (ADL)/Rehabilitation Potential Care Area Assessment (CAA), dated 10/25/23, documented R2 required substantial assistance with ADL care, toileting, and mobility both with walking and wheelchair propulsion. The Pressure Ulcer/Injury CAA, dated 10/25/23, documented R2 was at risk for pressure ulcer due to immobility and incontinence. Staff monitored R2's skin when they provided care. R1's Care Plan, dated 01/26/24, documented R2 required maximum assistance from staff for bathing, bed mobility, dressing, personal hygiene, toilet use, and transfer. The plan directed staff to monitor, document, and report any signs and symptoms of CHF: dependent edema of legs and feet, periorbital (around the eyes) edema, shortness of breath upon exertion, weakness, weight gain, crackles, and wheezes upon auscultation (listening) of the lungs, and weakness or fatigue. The Weights and Vitals, dated 01/01/24 documented R2 weighed 179.8 pounds. The Weights and Vitals, dated 02/06/24, documented R2 weighed 193.1 pounds which indicated a 13.3 pound weight gain. R2's clinical record lacked evidence staff notified R2's primary care physician. The Health Status Note, dated 02/10/24, documented R2 had audible expiratory wheezing at intervals. The Health Status Note, dated 02/12/24, documented R2 complained to a certified nurse aide (CNA) that he had a hard time breathing. When the nurse approached R2, he stated he was much better at that point. The note documented R2 had bilateral (both sides) lower extremity edema. The Alert Note, dated 02/13/24, documented a CNA notified the nurse R2 presented with new onset edema in his bilateral thighs going up to his hips. R2 had a baseline of chronic edema to his bilateral lower extremities due to CHF. The CNA notified the nurse R2 was wheezing while lying down in bed. R2's lung sounds were clear but diminished. R2 voiced pain, a 10 on a zero to ten scale (pain scale where zero equals no pain and 10 the worst pain imaginable) that felt like a stabbing ice pick to his right lateral (towards the side) abdomen. Staff administered R2 his as-needed albuterol (medication used to clear airways) inhaler for dyspnea (difficulty breathing). The note documented that staff would pass on to the day shift staff to notify R2's primary care physician of the 13.3-pound weight gain over a time period of one month, new onset edema to bilateral thighs, bilateral hips, and distention to the right lateral abdomen. The Health Status Note, dated 02/13/24, documented that R2's primary care physician was notified of his change in condition. The Health Status Note, dated 02/13/24, documented the facility received new orders to increase R2's Lasix (diuretic medication) to 40 milligrams (mg) twice a day for five days and give potassium 20 milliequivalents (mq) for five days. Staff were to obtain daily weights, and a Basic Metabolic Panel (BMP-laboratory blood test) on 02/19/24; and monitor for increased edema. The Health Status Note, dated 02/14/24, documented R2 had 2+ pitting edema (swelling resulting from an excessive accumulation of fluid in the body tissue demonstrated by the application of pressure to the swollen area with a finger which causes an indentation) to his left lower extremity and 3+ pitting edema to his right lower extremity. R2's right hip contained fluid pockets. R2's skin was tight and shiny in appearance. R2's lung sounds were clear but the left lobe was diminished. R2's respirations were even and unlabored. A review of R2's clinical record revealed the facility failed to follow R2's primary care physician's orders to obtain a BMP on 02/19/24. The facility obtained the BMP on 02/21/24 and received the results on 02/26/24. The results of the BMP showed R2's potassium level was 3.8 millimoles per liter (mmol/L) and R2's sodium level was 140 milliequivalents per liter (mEq/L). On 02/26/24 at 11:45 AM, observation revealed R2 sat in a chair in his room. R2's pajama pant legs were pulled up revealing his lower extremities. R2's had obvious edema to both legs with the right greater than the left. R2's right lower leg was taut and shiny. R2 rubbed his right lower leg. On 02/26/24 at 11:45 AM, R2 stated his right leg was really swollen and it hurt. R2 stated no one had obtained his weight yet that day. On 02/26/24 at 01:00 PM, Administrative Nurse E verified the lab was drawn on 02/21/24, not 02/19/24 as the doctor ordered it to be drawn. Administrative Nurse E verified she just received the results of the BMP back. On 02/27/24 at 10:00 AM, Administrative Nurse D verified the staff had not identified R2's 13.3-pound weight gain and verified the staff did not notify R2's primary care physician. The facility's undated Quality Assurance Performance Improvement Policy, documented the facility would ensure that all staff will consistently develop processes and systems to provide safe, effective, and optimal care and services to each resident residing at or receiving services from the facility. The governing body of this facility understands and supports processes and systems of care that are coordinated and collaborative with the mission of continuously improving performance involving every department and discipline for every resident served. The facility lacked a Quality Care Policy. The facility failed to ensure R2 received treatment and care in accordance with professional standards of practice related to CHF. This deficient practice placed R2 at risk for complications from congestive heart failure which placed him at risk for weight gain, edema, and difficulty breathing.

The facility identified a census of 31 residents with three residents reviewed for resident rights. Based on record review, observation, and interview, the facility failed to protect Resident (R) 1's right to dignity. This deficient practice placed R1 at risk for impaired psychosocial wellbeing. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of early on-set Alzheimer's (progressive mental deterioration characterized by confusion and memory failure), convulsions (involuntary series of contractions of a group of muscles), and extrapyramidal (movement disorders as a result of taking certain medications) and movement disorder. The Annual Minimum Data Set (MDS), dated 07/14/23, documented the Brief Interview for Mental Status (BIMS) could not be completed because R1 was rarely understood. Per staff interview, R1 had short term memory problems and long-term memory problems. The MDS documented R1 required extensive assistance of one to two staff for all activities of daily living (ADL) except eating for which R1 was totally dependent on one staff. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 07/14/23, documented R1 was severely impaired for making decisions regarding tasks of daily life. R1 displayed inattention which fluctuated in severity and R1 wandered four to six days during the observation period. The Psychosocial Well Being CAA, dated 07/14/23, documented R1 had little pleasure or interest in doing things. R1's Care Plan, revised 07/27/23, documented R1 had impaired communication related to Alzheimer's disease. The care plan documented R1 would be able to communicate basic needs. The care plan directed staff to use R1's preferred name, staff were to identify themselves to R1 with each interaction and make eye contact with R1. The plan directed staff to reduce distractions, use consistent simple directive sentences, provide R1 with necessary cues, and stop and return if R1 was agitated. The Facility Grievance Form, dated 10/02/23, documented Certified Nurse Aide (CNA) O had been informed by one of R1's representatives that CNA M was telling people that when CNA M put R1 to bed the previous night, or the night before that, R1 grabbed CNA M by her neck and forced CNA M to make out with R1. CNA M's undated Witness Statement, documented CNA M was assigned to work on the hallway where R1 resided. CNA M noticed R1 was starting to get antsy while seated in a recliner. CNA M went over to R1 as R1 was attempting to stand up by herself. CNA M assisted R1 to stand. CNA M stated R1 leaned over and kissed CNA M on the side of the neck and placed a hand on CNA M's lower buttock. CNA M stated she leaned away from R1 and told R1 they were going to go for a walk and moved R1's hand from her buttock. Licensed Nurse (LN) G came over to assist CNA M with ambulating R1 in the hallway and then back to the recliner. CNA M stated she did not tell any other staff member of the event. CNA P's Witness Statement, dated 10/02/23, documented CNA P said another CNA told her that R1 had grabbed CNA M's buttock and made out with CNA M's neck. CNA P stated she had never witnessed the behavior from R1. CNA N's Witness Statement, dated 10/02/23, documented CNA M told CNA N that R1 groped her and made out with her. The other staff that were working had already heard about it. CNA N noted an agency CNA then came and told CNA N the same story. CNA N stated she accidentally told R1's representative about the rumor. CNA N stated she realized telling the rumor to R1's representative was wrong. CNA Q's Witness Statement, dated 10/03/23, documented CNA Q stated CNA M was transferring R1 to a reclining chair. CNA M had her arms around R1 to stabilize her and R1 gave CNA M a kiss on the cheek. Later in the day, CNA M stated multiple times R1 had groped her and tried to make out with her. CNA MM's Witness Statement, dated 10/03/23, documented CNA MM stated CNA M came to her and told her that R1 had groped her and kissed her neck. CNA NN's Witness Statement, dated 10/03/23, documented CNA M made statements to CNA NN That R1 had groped her and was making out with CNA M's neck. CNA M talked about R1 in an inappropriate manner. CNA NN stated CNA M had made these comments in front of other staff. Licensed Nurse (LN) G's Witness Statement, dated 10/04/23, documented LN G was on the memory unit when R1 started to get restless. CNA M assisted R1 to her feet with a gait belt. R1 leaned her head on CNA M's shoulder. CNA M laughed and said, Oh, [R1] you're so nice. LN G stated she went over to assist CNA M with ambulating R1. R1 leaned into CNA M again and gave CNA M a quick kiss on the jaw line. LN G, CNA M, and R1 laughed. CNA M stated, Well let's keep walking. R1 leaned into CNA M for a few steps, and then continued to walk down the hallway. The Facility Incident Report, dated 10/10/23, documented on 09/25/23 at around 04:23 PM CNA M and LN G walked with R1. R1 leaned heavily on CNA M as R1 had difficulty with her balance. R1 kissed CNA M on the neck twice and grabbed the back of CNA M's shirt to help steady herself. CNA M and LN G walked R1 from the memory care living room down the hallway and back to the living room recliner. According to multiple staff witness statements, CNA M told staff R1 groped CNA M and made out with her neck. R1's representative wanted a complete investigation by the facility to prove that nothing else had happened. The facility interviewed all of the staff that were there during this time period. All witness statements showed CNA M made statements exaggerating the kiss and the pulling of back of her shirt. The facility reviewed video footage and identified CNA M had not put R1 to bed without another staff member with her. From the investigation, witness statements, and video footage, the facility deducted that CNA M exaggerated inappropriately about an innocent kiss. The investigation included employee training and/or in-service which covered the prevention and reporting of abuse, neglect, and exploitation as well as protection of privacy and procedure for reporting to family completed on 10/02/23. On 10/10/23 at 10:30 AM, observation revealed R1 laid in bed listing to music. On 10/10/23 at 10:35 AM, CNA NN stated that R1 was completely dependent on staff for all her cares, even eating. CNA NN stated that R1 would kiss staff on the cheek or hand in appreciation of her cares. CNA NN stated R1 was completely non-verbal, and that was how she demonstrated her gratitude and affections for the staff caring for her. On 10/10/23 at 10:45 AM, CNA PP stated that she never misunderstood R1's affection for sexual behavior or action and said that anyone that did was not thinking right. CNA PP stated R1 would give quick pecks on the cheek or neck in appreciation for cares due to being non-verbal and having early onset Alzheimer's. CNA PP stated that she had heard the rumors that CNA M had said about R1, and she did not think it was nice. On 10/10/23 at 11:30 AM, Administrative Staff A stated CNA M had been dismissed from working at the facility following the investigation. Administrative Staff A stated CNA M denied ever spreading rumors about R1. Administrative Staff A stated the witness statements from other CNAs all had the same story. Administrative Staff A stated CNA N should have never disclosed the rumors to R1's representative and CNA N was educated on all communication with the family needed to go through the nurse. Administrative Staff A stated R1's representative was upset with the facility that this had occurred and wanted a complete investigation into the situation and stated that he was going to turn the incident into the police for investigation. Administrative Staff A stated CNA M should not have spread rumors or discussed the resident's cares in a negative or unnecessary manner. Administrative Staff A stated CNA N should not have reported the rumors to R1's family members. On 10/10/23 at 02:45 PM, R1's representative stated they were upset that staff spread rumors about their loved one. R1's representative said the facility should take care of R1 and not allow anything bad to happen to her. The Resident Rights Policy, dated 10/01/23, documented each resident residing in the facility has the right and will be afforded the right to a dignified existence, self-determination, and communication with and access to person and services inside and outside the facility without interference, coercion, discrimination or reprisal. No staff member or contracted provider will hamper, compel, treat differently or retaliate against a resident for exercising Resident Rights. It is the responsibility of all who work at the facility to advocate and protect the rights of each resident. All staff members are trained on this Resident Right Policy at the time of employment, before providing care to residents and at least annually to ensure full understanding and competency. The facility failed to protect R1's right to dignity. This deficient practice placed R1 at risk for impaired dignity and decreased psychosocial wellbeing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to report to the state agency an unwitnessed fall which resulted in a fracture for Resident (R) 3, and an injury of unknown origin for R5, who had a laceration over her left eye. This placed the residents at risk for further injury and unidentified abuse or mistreatment. Findings included: - R3's Electronic Medical Record (EMR) recorded diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), transient ischemic attack (TIA-a temporary disruption in the blood supply to part of the brain), and incontinence (lack of voluntary control over urination). R3's Quarterly Minimum Data Set (MDS), dated [DATE], documented moderately impaired cognition and indicated R3 required supervision and set up assistance with toileting, dressing, personal hygiene, and independent with ambulation in her room, bed mobility, and transfers. The MDS further documented R3 had unsteady balance, no functional impairment, and had no falls. R3's Annual MDS, dated 02/02/23, documented R3 had moderately impaired cognition and required extensive assistance of one staff for transfers, toileting, ambulation in her room, and limited assistance of one staff for ambulation in corridors, personal hygiene, and dressing. The MDS further documented R3 had unsteady balance, occasional incontinence, no functional impairment, and had one non-injury fall. The Fall Care Area Assessment [CAA], dated 02/02/23, documented R3 had moderately impaired cognition, and ambulated with a walker. R3, at times, would not accept assistance from staff for toileting and dressing. The CAA further documented R3 was alert and oriented, and her mood changed frequently. R3 had episodes of refusing to allow evaluations or assistance and participated in activities of her choice. The Fall Assessments, dated 04/18/22, 07/27/22, and 02/02/23, all documented R3 was a high risk for falls. The Fall Investigation, dated 02/21/22, documented at 08:00 AM, R3 stated she tried to get out of bed to go to the bathroom, was unable to stand, and slid to the floor. The investigation further documented R3 did not have on any socks at the time of the fall, and nonskid socks were applied. The investigation noted R3 did not receive any injury. The Nurse's Note, dated 02/21/23 at 04:29 PM, documented R3 reported right breast pain and stated that earlier in the day she heard a pop and started to have severe pain. The note further documented R3 stated she often had acid reflux and refused to go to the emergency room for evaluation. The note documented the nurse administered antacid medication (used to treat heartburn) and pain medication. The Nurse's Note, dated 02/22/23 at 09:17 AM, documented R3 complained of pain under her right breast and continued to refuse to go to the emergency room for an x-ray (a photograph or digital image of the internal composition of part of the body) or to have the physician evaluate her. The note further documented R3 requested medication for her heart burn and requested to stay in her bed because she was sore. The Nurse's Note, dated 02/22/23 at 12:39 PM, documented the nurse contacted the physician due to R3 had extreme discomfort under her right breast. The note further documented R3 did not have any swelling or redness in the area, continued to decline transfer to the emergency room, and did not want the physician notified. The noted documented R3 continued to have heart burn and the physician ordered a scheduled antacid. The Nurse's Note, dated 02/25/23 at 08:40 AM, documented R3 complained of severe pain under her right breast that was rated as a 10 out of 10 (a 0 to 10 pain scale with zero as no pain and 10 representing the worst pain imaginable). The nurse assessed the area under the resident's right breast and did not see any swelling, redness, or bruising. The area was symmetrical (made up of exactly similar parts facing each other) upon palpation on each side of her chest. The note documented R3 winced in pain with each movement. The nurse contacted the emergency room, who suggested R3 be sent to the walk-in clinic. The note documented R3 agreed to go to the clinic for evaluation. The Physician Orders, dated 02/25/23, directed staff to administer Aleve (over the counter pain medication), 220 milligrams (mg), by mouth, every eight hours for pain; and Tylenol (medication for minor aches and pains), 650 mg, by mouth, every four hours for five days, for pain. The order further directed staff to apply a heat pack every two hours alternating with an ice pack every two hours as needed. The order directed staff to encourage R3 to deep breath and use an incentive spirometer (a handheld device used to help improve the functioning of lungs) every two hours while awake. The order directed staff to have R3 hold a pillow to her chest when coughing due to R3 had fracture of ribs 3, 4, and 5. The Nurse's Note, dated 02/27/23 at 02:38 PM, documented R3 had increased pain and agitation and the current pain medication was not effective for reducing pain. The Physician Order's, dated 02/27/23, directed staff to hold the resident's Tylenol and administer Norco (narcotic medication for moderate to severe pain), 5/325 mg, by mouth every four hours as needed for pain, and a Salanpas (pain patch), to the right chest, every 12 hours, as needed for pain. On 03/28/23 at 09:08 AM, observation revealed R3 had gripper socks on while in bed but Certified Nurse Aide (CNA) R had to adjust them and put one of them back onto her foot. Further observation revealed CNA R assisted R3 to sit on the side of her bed, placed a gait belt around the resident's waist, and CNA R and CNA S had the resident stand up. R3 required extra assistance to stand, she slowly grabbed her walker and slowly walked with staff down the hall to the shower room with just the gripper socks on her feet. On 03/27/23 at 11:20 AM, CNA R stated R3 had fallen many times due to not calling for assistance. CNA R further stated R3 used to walk without assistance. CNA R stated even though staff remind R3, R3 gets up before staff get to her to assist her. On 03/28/23 at 10:09 AM, Administrative Nurse E stated R3 refused assistance and would get up on her own because she felt she could still take care of herself. Administrative Nurse E stated after a fall, the team would meet to discuss the fall and would try to come up with new interventions and verified she would not get the new intervention into the computer right away. On 03/28/23 at 12:00 PM, Licensed Nurse (LN) G stated R3 was alert and orient and did not feel R3 had cognitive impairment, just behaviors. LN G stated R3 does not like to call for assistance even though they remind her often because she still thinks she can get up on her own. On 03/28/23 at 01:35 PM, Administrative Staff A stated she did not call in the fall because she did not think she had to if the resident's care had not changed. The facility's Abuse, Neglect, Exploitation Prevention policy, undated, documented The Director of Nursing, Administrator or other designated investigating individual would begin their own internal investigation and notify the State of Kansas agency within twenty-four (24) hours of identifying the concern of possible abuse, neglect, or exportation and will fully cooperate with the investigating agency. The risk management committee and Quality Assurance Performance Improvement Committee will analyze occurrences to determine changes to policies and procedures to prevent further occurrences. The facility failed to report R3's unwitnessed event which resulted in a significant injury to the State Agency. This placed the resident at risk for further injury and unidentified abuse or mistreatment. - The Electronic Medical Record (EMR) documented R5 had diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), epilepsy (brain disorder characterized by repeated seizures), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R5 had severely impaired cognition and required limited assistance of two staff for bed mobility, transfers, toileting and locomotion. The MDS further documented R5 had unsteady balance, occasional bladder incontinence, no functional impairment, and had two or more non-injury falls. R5's Quarterly MDS, dated 01/23/23, documented R5 had severely impaired cognition and required extensive assistance with bed mobility, transfers, locomotion, toileting, and personal hygiene. The MDS further documented R5 had unsteady balance, frequent bowel and bladder incontinence, no functional impairment, and had two or more falls. The Fall Care Area Assessment [CAA], dated 07/22/22, documented R5 required a wheelchair for mobility due to increased weakness, increased confusion and instability. The Fall Risk Assessments, dated 0/23/22, 10/18/22, 11/05/22, 01/16/23, documented the resident was a high risk for falls. The Fall Care Plan, dated 11/03/20, documented R5 would have on appropriate footwear and/or nonskid socks during transfers. The update, dated 06/03/22, documented new shoes were ordered for the resident. The update, dated 07/30/22, documented a motion sensor was placed in her room. The update, dated 08/19/22, documented R5 had a high/low bed to be kept in the lowest position. The update, dated, 08/21/22, directed staff to utilize as needed medication when the resident had increased anxiety. The update, dated 12/29/22, directed staff to place a second motion sensor in her room. The update, dated 01/05/23, documented anti-roll back brakes were installed on her wheelchair. The update, dated 03/10/23, directed staff to not leave the resident unattended in her room while she was in her wheelchair. The Nurse's Note, dated 06/28/22 at 10:31 AM, documented R5 had a small laceration over her left eye and stated she fell but had not called for assistance. The note further stated the laceration started bleeding after her shower and the nurse applied steri-strips due to the location of the wound. The EMR lacked further documentation regarding the laceration or a related fall. On 03/21/23 at 11:20 AM, observation revealed Certified Nurse Aide (CNA) R placed a gait belt around R5's waist, CNA R and CNA S took ahold of the gait belt and assisted the resident to stand up, pivot and sit down on the bed. Further observation revealed CNA R took off the resident's shoes and swung her legs onto the bed, took off R5's glasses, covered her up and attached the call light the R5's blanket. CNA R lowered R5's bed, placed a fall mat next to the bed, placed a motion sensor on the mat, and turned on another motion sensor that was on the wall by the resident's door before leaving the room. On 03/28/23 at 01:30 PM, Administrative Nurse D stated she had not started working at the facility until September and could not find documentation that the laceration was investigated or reported. The facility's Abuse, Neglect, Exploitation Prevention policy, undated, documented The Director of Nursing, Administrator or other designated investigating individual would begin their own internal investigation and notify the State of Kansas agency within twenty-four (24) hours of identifying the concern of possible abuse, neglect, or exportation and will fully cooperate with the investigating agency. The risk management committee and Quality Assurance Performance Improvement Committee will analyze occurrences to determine changes to policies and procedures to prevent further occurrences. The facility failed to ensure staff reported an injury of unknown origin to administration for cognitively impaired R5, placing her at risk for further injury and unidentified abuse or mistreatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to investigate an injury of unknown origin for one sampled resident, Resident (R) 5, who had a laceration over her left eye. This placed the resident at risk for further injury and unidentified abuse or mistreatment. Findings Included: - The Electronic Medical Record (EMR) documented R5 had diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), epilepsy (brain disorder characterized by repeated seizures), and dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R5 had severely impaired cognition and required limited assistance of two staff for bed mobility, transfers, toileting, and locomotion. The MDS further documented R5 had unsteady balance, occasional bladder incontinence, no functional impairment, and had two or more non-injury falls. R5's Quarterly MDS, dated 01/23/23, documented R5 had severely impaired cognition and required extensive assistance with bed mobility, transfers, locomotion, toileting, and personal hygiene. The MDS further documented R5 had unsteady balance, frequent bowel and bladder incontinence, no functional impairment, and had two or more falls. The Fall Care Area Assessment [CAA], dated 07/22/22, documented R5 required a wheelchair for mobility due to increased weakness, increased confusion, and instability. The Fall Risk Assessments, dated 0/23/22, 10/18/22, 11/05/22, 01/16/23, documented the resident was a high risk for falls. The Fall Care Plan, dated 11/03/20, documented R5 would have on appropriate footwear and/or nonskid socks during transfers. The update, dated 06/03/22, documented new shoes were ordered for the resident. The update, dated 07/30/22, documented a motion sensor was placed in her room. The update, dated 08/19/22, documented R5 had a high/low bed to be kept in the lowest position. The update, dated, 08/21/22, directed staff to utilize as needed medication when the resident had increased anxiety. The update, dated 12/29/22, directed staff to place a second motion sensor in her room. The update, dated 01/05/23, documented anti-roll back brakes were installed on her wheelchair. The update, dated 03/10/23, directed staff to not leave the resident unattended in her room while she was in her wheelchair. The EMR documented falls on these dates: 06/17/22, 06/19/22, 06/28/22, 08/07/22, 08/21/22, 08/26/22, 11/07/22, 11/26/22, 12/29/22, 01/20/23, and 03/01/23. R5's clinical record lacked evidence of resident centered interventions placed after each fall to prevent future falls. The clinical record lacked evidence the facility performed a thorough root cause analysis to attempt to identify R5's needs or reasons she continued to fall. On 03/21/23 at 11:20 AM, observation revealed Certified Nurse Aide (CNA) R placed a gait belt around R5's waist, CNA R and CNA S took ahold of the gait belt and assisted the resident to stand up, pivot and sit down on the bed. Further observation revealed CNA R took off the resident's shoes and swung her legs onto the bed, took off R5's glasses, covered her up and attached the call light the R5's blanket. CNA R lowered R5's bed, placed a fall mat next to the bed, placed a motion sensor on the mat, and turned on another motion sensor that was on the wall by the resident's door before leaving the room. On 03/21/23 at 11:30 AM, CNA R stated R5 had the double motion sensor and fall mat because of R5's many falls. CNA R stated R5 was very quick and would try to transfer herself and would fall. On 03/28/23 at 10:09 AM, Administrative Nurse E stated R5 would get up on her own and had a lot of falls and when the team got together, if they did not feel the interventions needed changed, they would keep them the same and it was difficult to always come up with a new intervention. Administrative Nurse E stated after a fall, the team would meet to discuss the fall and would try to come up with new interventions and verified she would not get the new intervention into the computer right away. On 03/28/23 at 12:00 PM, Licensed Nurse (LN) G stated the motion detector had been placed in R5's room within the last three months because of all her falls; staff watched her closely because she is quick and when they did not get to her in time, she would fall. On 03/28/23 at 01:30 PM, Administrative Nurse D stated the resident had a lot of falls and interventions were implemented by the team and nurse's did not update the care plan at this time but may try and work to that at some point. On 03/28/23 at 01:30 PM, Administrative Nurse D stated she had not started working at the facility until September and could not find documentation that the laceration was investigated or reported. The facility's Abuse, Neglect, Exploitation Prevention policy, undated, documented The Director of Nursing, Administrator or other designated investigating individual would begin their own internal investigation and notify the State of Kansas agency within twenty-four (24) hours of identifying the concern of possible abuse, neglect, or exportation and will fully cooperate with the investigating agency. The risk management committee and Quality Assurance Performance Improvement Committee will analyze occurrences to determine changes to policies and procedures to prevent further occurrences. The facility failed to investigate an injury of unknown origin for cognitively impaired R5, who had a laceration over her left eye. This placed the resident at risk for further injury and unidentified abuse or mistreatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with person-centered interventions for inappropriate sexual behavior for one sample resident, Resident (R) 2, and failed to revise and implement person- centered interventions to prevent falls for R3 and R5, who had multiple falls. This placed the resident at risk for uncommunicated and/or unmet care needs. Findings Included: - The Electronic Medical Record (EMR) documented R2 had diagnoses of dementia with behavioral disturbances (progressive mental disorder characterized by failing memory, confusion), inappropriate sexual behaviors, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), date 03/02/23, documented R2 had moderately impaired cognition and required extensive assistance for transfers, toileting, limited assistance of one staff for bed mobility, and personal hygiene. The MDS further documented R2 had disorganized thinking, inattention, physical behaviors one to three days, and other behaviors one to three days. The Behavior/Verbal Aggression Care Plan, dated 02/15/23, documented R2 used inappropriate language, was verbally aggressive, and quick tempered due to poor impulse control, dementia, and his traumatic brain injury (tTBI). The care plan directed staff to administer medication as ordered, analyze key times, triggers, circumstances and what de-escalated behaviors and document. The care plan directed staff to redirect R2's verbal aggression with music, singing, puzzles, group activities, and intervene before behavior escalated. The care plan documented R2 participated in individualized psychotherapy session twice a month with a telemed psychiatric service and to point out signs of positive progress or change in reactions to others when he was upset. The care plan lack direction regarding R2's inappropriate sexual behavior. The Mood Care Plan, dated 02/15/23, directed staff to encourage and provide opportunities for activities and encourage him to express feelings appropriately through 1:1 talks, and discuss any concerns, fears, issues regarding health and other subjects as often as he desires. The plan directed staff to monitor and document any anxious, negative statements, or health related complaints, and mental health medication oversight and talk therapy provided by psychiatric services. The Anxiety Care Plan, dated 02/15/23, directed staff to remove R2 to a calm environment and allow to vent and share his feelings, encourage participation in daily care, and honor his requests as much as safely possible. The Physician Order, dated 04/23/22, directed staff to administer Cymbalta (an antidepressant medication), 30 milligrams (mg), 1 caplet, by mouth, in the evening and administer Cymbalta, 60 mg, 1 caplet, by mouth in the evening for depression. The Nurse's Note, dated 07/13/22 at 04:58 AM, documented R2 was very inappropriate toward staff and stated that he would like to have an underage staff member home with him. The note recorded R2 made comments about younger staff members and how they looked. The Nurse's Note, dated 10/19/22 at 08:07 PM, documented R2 told a Certified Medication Aide (CMA) that he wanted to take her to the bathroom and show her a good time. The resident was told that it was very inappropriate to talk to her that way and he needed to apologize. The note further documented R2 was angry at staff and would wheel up behind them and touch staffs' buttocks to get their attention. The Nurse's Note, dated 11/19/22 at 11:26 AM, documented R2 sexually touched a CMA's buttocks and he started to laugh when she told him it was not appropriate and to not touch her. The note further documented R2 called the nurses and CMA derogatory names. The Nurse's Note, dated 02/06/23 at 11:25 AM, documented R2 sat in his wheelchair behind a CMA staring at her buttocks with a grin on his face. The nurse told him that it was not appropriate and to move along and do something else. The resident laughed and said he was reading something on her pants. The note further documented the nurse told R2 that there was no lettering where he was looking and to finding something else to do. The Nurse's Note, dated 02/14/23 at 07:19 PM, documented R2 touched Certified Nurse Aide (CNA)'s buttocks and the nurse told the resident there are consequences for touching others inappropriately. The Nurse's Note, dated 02/16/23 at 04:17 PM, documented the psych services recommended adding medroxyprogesterone (hormone medication), 5 mg, by mouth, daily for sexual behaviors. The Nurse's Note, dated 02/16/23 at 09:23 PM, documented R2 commented to the CMA that the buttocks of one of the younger CNA's was nice to look at and stated that when he heard her voice, he had dreams of sleeping with her. The note further documented the CNA told staff that she felt very uncomfortable to provide care to the resident and was advised to not provide cares to the resident alone. R2's clinical record lacked evidence the facility followed up with R2 regarding the sexual behaviors and lacked evidence of ongoing behavioral support services in order to identify triggers and effective redirection methods. On 03/28/23 at 04:00 PM, observation revealed R2 seated at a table putting a puzzle together. On 02/27/23 at 11:30 AM, CNA R stated he had a lot of behaviors some toward resident's and some towards staff. CNA R stated he has one resident he likes to get upset and they try to keep them separate. CNA R stated he has inappropriate sexual behaviors with staff. On 03/28/23 at 10:09 AM, Administrative Nurse E stated verified there was not a care plan for his inappropriate sexual behaviors and didn't think they could put that in his care plan. On 03/28/23 at 01:30 PM, Administrative Nurse D stated they work as a team on care plans and right now the nurse's don't put interventions in the care plans and stated the care plan would be updated. The facility's Care Plan Revision undated policy documented the care plan would be revised whenever the behavior or cognition of a resident changed with either a deterioration or an improvement. Any change in the problem, goals, or specific interventions or reasonable time frames would be revised on the resident's plan of care. The facility failed to revise R2's care plan with interventions when for his inappropriate sexual behavior. - R3's Electronic Medical Record (EMR) recorded diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), transient ischemic attack (TIA-a temporary disruption in the blood supply to part of the brain), and incontinence (lack of voluntary control over urination). R3's Quarterly Minimum Data Set (MDS), dated [DATE], documented moderately impaired cognition and indicated R3 required supervision and set up assistance with toileting, dressing, personal hygiene, and independent with ambulation in her room, bed mobility, and transfers. The MDS further documented R3 had unsteady balance, no functional impairment, and had no falls. R3's Annual MDS, dated 02/02/23, documented R3 had moderately impaired cognition and required extensive assistance of one staff for transfers, toileting, ambulation in her room, and limited assistance of one staff for ambulation in corridors, personal hygiene, and dressing. The MDS further documented R3 had unsteady balance, occasional incontinence, no functional impairment, and had one non-injury fall. The Fall Care Area Assessment [CAA], dated 02/02/23, documented R3 had moderately impaired cognition, and ambulated with a walker. R3, at times, would not accept assistance from staff for toileting and dressing. The CAA further documented R3 was alert and oriented, and her mood changed frequently. R3 had episodes of refusing to allow evaluations or assistance and participated in activities of her choice. The Fall Assessments, dated 04/18/22, 07/27/22, and 02/02/23, all documented R3 was a high risk for falls. The Fall Care Plan, dated 03/31/22, directed staff to ensure R3's call light was within reach and to call for assistance; encourage R3 to participate in activities that promoted exercise, and have therapy evaluate and treat as needed. An update, dated 04/19/22, documented R3 required one staff for assistance with toileting, set up assistance of one staff for dressing, and directed staff to ensure R3 wore appropriate footwear with nonskid soles when she ambulated. An update, dated 08/10/22, directed staff to ensure R3 wore shoes or gripper socks when she ambulated and provide reminders if R3 did not wear shoes. An update, dated 02/21/23, directed staff to ensure R3 wore nonskid slipper socks to bed. The Fall Investigation, dated 08/10/22, documented at 03:48 PM, R3 slipped and fell in her room. The investigation documented the fall was unwitnessed, R3 had gait imbalance, and ambulated without staff assistance. The investigation recorded R3 had improper footwear on, and she obtained an abrasion (scrape) to her left elbow. The Fall Investigation, dated 10/24/22, documented at 03:25 PM, R3 slipped and fell in her room. The investigation documented the fall was unwitnessed, R3 had gait imbalance, and did not receive any injury. The Fall Investigation, dated 02/20/23, documented at 12:42 AM R3 slipped when she lost her balance and scooted to the door to call for assistance. The investigation documented R3 had gait imbalance and improper footwear. The Fall Investigation, dated 02/21/22, documented at 08:00 AM, R3 stated she tried to get out of bed to go to the bathroom, was unable to stand, and slid to the floor. The investigation further documented R3 did not have on any socks at the time of the fall, and nonskid socks were applied. The investigation noted R3 did not receive any injury. The Nurse's Note, dated 02/21/23 at 04:29 PM, documented R3 reported right breast pain and stated that earlier in the day she heard a pop and started to have severe pain. The note further documented R3 stated she often had acid reflux and refused to go to the emergency room for evaluation. The note documented the nurse administered antacid medication (used to treat heartburn) and pain medication. The Nurse's Note, dated 02/22/23 at 09:17 AM, documented R3 complained of pain under her right breast and continued to refuse to go to the emergency room for an x-ray (a photograph or digital image of the internal composition of part of the body) or to have the physician evaluate her. The note further documented R3 requested medication for her heart burn and requested to stay in her bed because she was sore. The Nurse's Note, dated 02/22/23 at 12:39 PM, documented the nurse contacted the physician due to R3 had extreme discomfort under her right breast. The note further documented R3 did not have any swelling or redness in the area, continued to decline transfer to the emergency room, and did not want the physician notified. The noted documented R3 continued to have heart burn and the physician ordered a scheduled antacid. The Nurse's Note, dated 02/25/23 at 08:40 AM, documented R3 complained of severe pain under her right breast that was rated as a 10 out of 10 (a 0 to 10 pain scale with zero as no pain and 10 representing the worst pain imaginable). The nurse assessed the area under the resident's right breast and did not see any swelling, redness, or bruising. The area was symmetrical (made up of exactly similar parts facing each other) upon palpation on each side of her chest. The note documented R3 winced in pain with each movement. The nurse contacted the emergency room, who suggested R3 be sent to the walk-in clinic. The note documented R3 agreed to go to the clinic for evaluation. The Physician Orders, dated 02/25/23, directed staff to administer Aleve (over the counter pain medication), 220 milligrams (mg), by mouth, every eight hours for pain; and Tylenol (medication for minor aches and pains), 650 mg, by mouth, every four hours for five days, for pain. The order further directed staff to apply a heat pack every two hours alternating with an ice pack every two hours as needed. The order directed staff to encourage R3 to deep breath and use an incentive spirometer (a handheld device used to help improve the functioning of lungs) every two hours while awake. The order directed staff to have R3 hold a pillow to her chest when coughing due to R3 had fracture of ribs 3, 4, and 5. The Nurse's Note, dated 02/27/23 at 02:38 PM, documented R3 had increased pain and agitation and the current pain medication was not effective for reducing pain. The Physician Order's, dated 02/27/23, directed staff to hold the resident's Tylenol and administer Norco (narcotic medication for moderate to severe pain), 5/325 mg, by mouth every four hours as needed for pain, and a Salanpas (pain patch), to the right chest, every 12 hours, as needed for pain. On 03/28/23 at 09:08 AM, observation revealed R3 had gripper socks on while in bed but Certified Nurse Aide (CNA) R had to adjust them and put one of them back onto her foot. Further observation revealed CNA R assisted R3 to sit on the side of her bed, placed a gait belt around the resident's waist, and CNA R and CNA S had the resident stand up. R3 required extra assistance to stand, she slowly grabbed her walker and slowly walked with staff down the hall to the shower room with just the gripper socks on her feet. On 03/27/23 at 11:20 AM, CNA R stated R3 had fallen many times due to not calling for assistance. CNA R further stated R3 used to walk without assistance. CNA R stated even though staff remind R3, R3 gets up before staff get to her to assist her. On 03/28/23 at 10:09 AM, Administrative Nurse E stated R3 refused assistance and would get up on her own because she felt she could still take care of herself. Administrative Nurse E stated after a fall, the team would meet to discuss the fall and would try to come up with new interventions and verified she would not get the new intervention into the computer right away. On 03/28/23 at 12:00 PM, Licensed Nurse (LN) G stated R3 was alert and orient and did not feel R3 had cognitive impairment, just behaviors. LN G stated R3 does not like to call for assistance even though they remind her often because she still thinks she can get up on her own. On 03/28/23 at 1:30 PM, Administrative Nurse D stated the staff tried multiple times to get the resident to go to the emergency room when she fell but she refused. The facility's Care Plan Revisions undated policy documented the care plan would be revised after every fall to include specific instruction to staff based on the causal factors identified at the time of the occurrence and during the fall investigation process to prevent or reduce the possibility fro reoccurrence of falls. The facility failed to revise R3's care plan with meaningful, resident centered interventions who had falls, placing the resident at risk for further falls. - The Electronic Medical Record (EMR) documented R5 had diagnoses of Parkinson's disease (slowly progressive neurological disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), epilepsy (brain disorder characterized by repeated seizures), dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), and diabetes mellitus type 2. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R5 had severely impaired cognition and required limited assistance of two staff for bed mobility, transfers, toileting, and locomotion. The MDS further documented R5 had unsteady balance, occasional bladder incontinence, no functional impairment, and had 2 or more non-injury falls. R5's Quarterly MDS, dated 01/23/23, documented R5 had severely impaired cognition and required extensive assistance with bed mobility, transfers, locomotion, toileting, and personal hygiene. The MDS further documented R5 had unsteady balance, frequent bowel and bladder incontinence, no functional impairment, and had two or more falls. The Fall Care Area Assessment [CAA], dated 07/22/22, documented R5 required a wheelchair for mobility due to increased weakness, increased confusion and instability. The Fall Risk Assessments, dated 0/23/22, 10/18/22, 11/05/22, 01/16/23, documented the resident was a high risk for falls. The Fall Care Plan, dated 11/03/20, documented R5 would have on appropriate footwear and/or nonskid socks during transfers. The update, dated 06/03/22, documented new shoes were ordered for the resident. The update, dated 07/30/22, documented a motion sensor was placed in her room. The update, dated 08/19/22, documented R5 had a high/low bed to be kept in the lowest position. The update, dated, 08/21/22, directed staff to utilize as needed medication when the resident had increased anxiety. The update, dated 12/29/22, directed staff to place a second motion sensor in her room. The update, dated 01/05/23, documented anti-roll back brakes were installed on her wheelchair. The update, dated 03/10/23, directed staff to not leave the resident unattended in her room while she was in her wheelchair. The EMR documented falls on these dates: 06/17/22, 06/19/22, 06/28/22, 08/07/22, 08/21/22, 08/26/22, 11/07/22, 11/26/22, 12/29/22, 01/20/23, and 03/01/23. R5's clinical record lacked evidence of resident centered interventions placed after each fall to prevent future falls. The clinical record lacked evidence the facility performed a thorough root cause analysis to attempt to identify R5's needs or reasons she continued to fall. On 03/21/23 at 11:20 AM, observation revealed Certified Nurse Aide (CNA) R placed a gait belt around R5's waist, CNA R and CNA S took ahold of the gait belt and assisted the resident to stand up, pivot and sit down on the bed. Further observation revealed CNA R took off the resident's shoes and swung her legs onto the bed, took off R5's glasses, covered her up and attached the call light the R5's blanket. CNA R lowered R5's bed, placed a fall mat next to the bed, placed a motion sensor on the mat, and w turned on another motion sensor that was on the wall by the resident's door before leaving the room. On 03/21/23 at 11:30 AM, CNA R stated they have the double motion sensor and fall mat because of R5's many falls. CNA R stated R5 was very quick and would try to transfer herself and would fall, On 03/28/23 at 10:09 AM, Administrative Nurse E stated R5 would get up on her own and had a lot of falls and when the team got together, if they did not feel the interventions needed changed, they would keep them the same and it was difficult to always come up with a new intervention. Administrative Nurse E stated after a fall, the team would meet to discuss the fall and would try to come up with new interventions and verified she would not get the new intervention into the computer right away. On 03/28/23 at 12:00 PM, Licensed Nurse (LN) G stated the motion detector had been placed in her room within the last 3 months because of all her falls, staff watch her closely because she is quick and when they did not get to her in time, she would fall. On 03/28/23 at 01:30 PM, Administrative Nurse D stated the resident had a lot of falls and interventions were implemented by the team and nurse's do not update the care plan at this time but may try and work to that at some point. The facility's Care Plan Revisions undated policy documented the care plan would be revised after every fall to include specific instruction to staff based on the causal factors identified at the time of the occurrence and during the fall investigation process to prevent or reduce the possibility for reoccurrence of falls. The facility failed to revise R5's care plan with meaningful, resident centered interventions who had falls, placing the resident at risk for further falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 30 residents. The sample included 13 residents. Based on record review and interview, the facility failed to develop a discharge plan to support and accommodate Resident (R) 29's goal of returning to the community. This placed R29 at risk for unmet care needs. Findings included: - R29's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE], with diagnoses of systemic lupus erythematosus (autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs.), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), muscle weakness, difficulty in walking, history of falls and need for assistance with personal care. The admission Minimum Data Set (MDS), dated [DATE], documented R29 had intact cognition, required set up help, supervision and limited assistance with activities of daily living (ADLD). R29 was not steady but able to stabilize without staff assistance, used a wheelchair or walker for mobility. R29 was always continent of urine and bowel. The MDS further documented R29 expected to be discharged to the community and no active discharge planning had occurred for the resident to return to the community. The Return to Community Referral Care Area Assessment (CAA), dated 01/26/23, documented R29 required stand by assistance and supervision to complete ADL, had a history of falls, reported adequate pain control, intact skin, and received physical therapy. The CAA further documented R29 planned to return to home. The Baseline Care Plan, dated 01/10/23, documented R29's discharge goals were unknown at that time, no discharge plan was initiated, and physical, occupational, and speech therapy screens were to be completed. The Comprehensive Care Plan, dated 02/06/23, lacked a discharge care plan focus. The admission Assessment, dated 01/10/23, documented R29 had intact cognition, wanted to try to complete personal hygiene independently, and planned to discharge to home. The Progress Note, dated 01/15/23 at 02:39 PM, documented R29 stated I wonder when I can get out of here. I want to be able to walk without that walker. The Progress Note, dated 01/30/23 at 10:53 AM, documented R29 returned to the facility. R29 stayed home over the weekend and tolerated the stay well with no noted complications. R29 stated it was nice to be home. The Progress Note, dated 02/09/23 at 03:27 PM, documented R29 left the facility in wheelchair in the company of a family member and all discharge documentation completed. On 03/28/23 at 08:51 AM, Social Services X stated she was responsible for discharge planning and care planning for R29's discharge. Social Services X verified the lack of a discharge care plan. The facility's Resident Discharge policy, dated 03/28/23, documented the facility will provide sufficient preparation an orientation to resident and/or surrogate decision makers to ensure safe and orderly transfer or discharge from the facility based on the resident's assessed the needs and ability to this facility to meet those needs. The facility failed to develop a comprehensive discharge plan that supported R29's discharge to the community placing the resident at risk for unmet care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 30 residents. The sample included 13 residents. Based on record review and interview, the facility failed to develop a discharge summary for one resident reviewed for discharge that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay for Resident (R) 29. This placed the resident at risk for unmet care needs. Findings included: - R29's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE], with diagnoses of systemic lupus erythematosus (autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs.), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), muscle weakness, difficulty in walking, history of falls and need for assistance with personal care. The admission Minimum Data Set (MDS), dated [DATE], documented R29 had intact cognition, required set up help, supervision and limited assistance with activities of daily living (ADL). R29 was not steady but able to stabilize without staff assistance, used a wheelchair or walker for mobility. R29 was always continent of urine and bowel. The MDS further documented R29 expected to be discharged to the community and no active discharge planning had occurred for the resident to return to the community. The Progress Note dated 01/15/23 at 02:39 PM, documented R29 stated I wonder when I can get out of here. I want to be able to walk without that walker. The Progress Note dated 01/30/23 at 10:53 AM, documented R29 returned to the facility. R29 stayed home over the weekend and tolerated the stay well with no noted complications. R29 stated it was nice to be home The Progress Note dated 02/09/23 at 03:27 PM, documented R29 left the facility in wheelchair in the company of a family member and all discharge documentation completed. The Progress Note, dated 02/23/23 at 01:02 PM, documented Social Services X spoke with R29's family member about discharge to home on [DATE]. R29's EMR lacked a recapitulation of R29's stay. On 03/28/23 at 09:14 AM, Social Services X and Administrative Staff A reported they were unaware of the requirement for a recapitulation of R29's stay. The facility's Resident Discharge policy, dated 03/28/23, documented the facility would complete a Nursing Discharge Summary and Recapitulation and medication reconciliation will be completed in full and placed in clinical record. The facility failed to develop a discharge summary that included a recapitulation of the resident's stay for R29. This placed the resident at risk for unmet care needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 30 residents. The sample included 13 residents, with eight reviewed for behaviors. Based on observation, record review, and interview, the facility failed to consistently monitor Resident (R) 3, who had a physician order for hourly suicide checks. This placed the resident at risk for self-injury and death. Findings included: - The Electronic Medical Record (EMR) for R3 recorded diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), transient ischemic attack (TIA-a temporary disruption in the blood supply to part of the brain), and incontinence (lack of voluntary control over urination). The Annual Minimum Data Set (MDS), dated [DATE], documented R3 had moderately impaired cognition and required extensive assistance of one staff for transfers, toileting, ambulation in her room, and limited assistance of one staff for ambulation in corridors, personal hygiene, and dressing. The MDS further documented R3 had little pleasure doing things 12-14 days, felt down and depressed 12-14 days, had thoughts she would be better off dead or hurting self never or one day, and had rejection of care one to three days. The Behavior Care Plan, dated 02/02/23, documented R3 had verbal aggression related to inappropriate coping skills and directed staff to administer medications as ordered and monitor for effectiveness. The care plan further directed staff to analyze key times, triggers, circumstances and what de-escalates behaviors and document, assess coping skills and support systems. The Depression Care Plan, dated 02/02/23, documented R3 had a history of difficult relationships and loss of independence and directed staff to administer medication as ordered, discuss with R3 any concerns, fears or issues regarding health. The care plan further documented R3 needed time to talk when she was upset and directed staff to encourage her to express her feelings and provide validation. The update, dated 02/14/23, documented R3 refused telemed psychiatric talk therapy and medications. The Physician Order, dated 08/24/22, directed staff to administer Celexa (antidepressant medication), 40 milligrams (mg), by mouth, daily. The order directed staff to place the resident on suicide precautions until she was not suicidal and did not have a plan. The order was discontinued on 09/06/22. The Physician Order, dated 08/24/22, directed staff to place the resident on one hour suicide checks, be as unobtrusive as possible every hour for suicidal ideation. The order was discontinued on 09/06/22. The Treatment Administration Record, dated August 2022 lacked documentation staff observed R3 hourly on the following days and times: 08/27/22 05:00 AM 08/27/22 06:00 AM 08/28/22 06:00 AM 08/29/22 06:00 AM 08/30/22 12:00 AM through 06:00 AM 08/31/22 12:00 AM through 06:00 AM The Treatment Administration Record, dated September 2022 lacked documentation staff observed R3 hourly on the following days and times: 09/01/22 06:00 PM 09/02/22 06:00 AM and 11:00 PM 09/03/22 04:00 AM, 05:00 AM, 06:00 AM, 03:00 PM, 04:00 PM, 05:00 PM, and 06:00 PM 09/04/22 05:00 AM and 06:00 AM The Physician Order, dated 02/22/23, directed staff to administer Celexa, 20 mg, by mouth, daily for depression with psychotic features for 2 weeks. The Celexa was discontinued on 03/08/23. The Physician Order, dated 02/22/23, directed staff to administer Effexor (antidepressant medication), 75 mg, by mouth, daily, for depression and discontinue in two weeks. The medication was discontinued on 03/08/23. The Physician Order, dated, 03/08/23, directed staff to administer Effexor ER (extended release), 75 mg, by mouth, daily, for depression. The Nurse's Note, dated 08/24/22 at 06:53 PM, documented R3 stated she was tired of living and just wanted to die. The note further documented she wanted assistance with dying and told the nurse that she was looking around the room for something to hang herself with. The Nurse's Note, dated 08/25/22 at 11:29 AM, documented the facility spoke with R3's family regarding the resident and family stated they knew she had bad days, was trying to find was to take the resident out of the facility more often, and instructed the facility to engage her in more activities and mealtimes to help with the adjustment. The Nurse's Note, dated 09/05/22 at 04:02 PM, documented the resident continued to express a wish to die but was not describing how she would do it or stating she had any plan to commit suicide. The Nurse's Note, dated 09/08/22 at 04:37 PM, documented R3's family in to visit and the resident stated she was in good spirits. The Nurse's Note, dated 02/21/23 at 11:10 AM, documented R3 stated death was beautiful and staff asked her if she had a plan. R3 stated she did not have anything to hang herself with. The note further documented staff contacted the physician for further instructions. The Nurse's Note, dated 02/21/23 at 11:31 AM, documented R3 stated she felt down and did not have a plan to hurt herself or any desires to commit suicide at this time. The note further documented staff told the resident they had called the physician to report her symptoms of depression and further orders. R3's clinical record lacked evidence of social service support provided to the resident. On 03/22/23 at 09:30 AM, observation revealed R3 sat in her recliner, stated she was having a good day. On 03/27/23 at 11:20 AM, Certified Nurse Aide (CNA) R stated R3 had been on suicide watch many times and she usually got depressed when her family was not coming to visit her. CNA R further stated if R3 ever told her she wanted to harm herself, she would go tell the nurse. On 03/28/23 at 12:00 PM, Licensed Nurse (LN) G stated R3 had verbalized she wanted to harm herself and LN G contacted the Director of Nursing (DON) as well as R3's physician. LN G further stated after he had told the DON, R3 changed her mind but the physician changed her medications. On 03/28/23 at 01:30 PM, Administrative Nurse D stated she was not working at the facility at the time of the suicide watch but felt they probably looked in on R3 but just did not document. The facility's Suicide Precautions undated policy, documented once suicide precautions are implemented and ordered, the specific precautions woul be added to the physician order sheet and the individualized comprehensive care plan and the specific orders would be communicated to all staff members. The policy further documented, constant direct observation for suicide precautions may be implemented in any neighborhood or area of this facility and would remain in place until discontinued by the psychiatrist or physician or ordered the precautions. The facility failed to consistently monitor R3, who had physician ordered hourly suicide checks. This placed the resident at risk for injury or death.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 30 residents. The sample included 13 residents. Based on observation, record review, and interview, the facility failed to identify and provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for three sampled residents, Resident (R) 2, who had inappropriate sexual behaviors; R3, who had stated she wanted to harm herself twice in the last six months; and R5, who had behaviors. This placed the residents at risk for further decline of their emotional and mental well-being, Findings included: - The Electronic Medical Record (EMR) documented R2 had diagnoses of dementia with behavioral disturbances (progressive mental disorder characterized by failing memory, confusion), inappropriate sexual behaviors, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), date 03/02/23, documented R2 had moderately impaired cognition and required extensive assistance for transfers, toileting, limited assistance of one staff for bed mobility, and personal hygiene. The MDS further documented R2 had disorganized thinking, inattention, physical behaviors one to three days, and other behaviors one to three days. The Behavior/Verbal Aggression Care Plan, dated 02/15/23, documented R2 used inappropriate language, was verbally aggressive, and quick tempered due to poor impulse control, dementia, and his traumatic brain injury (TBI). The care plan directed staff to administer medication as ordered, analyze key times, triggers, circumstances and what de-escalated behaviors and document. The care plan directed staff to redirect R2's verbal aggression with music, singing, puzzles, group activities, and intervene before behavior escalated. The care plan documented R2 participated in individualized psychotherapy session twice a month with a telemed psychiatric service and directed staff to point out signs of positive progress or change in reactions to others when R2 was upset. The care plan lack direction or interventions regarding R2's inappropriate sexual behavior. R2's Mood Care Plan, dated 02/15/23, directed staff to encourage and provide opportunities for activities and encourage him to express feelings appropriately through 1:1 talks, and discuss any concerns, fears, issues regarding health and other subjects as often as he desired. The plan directed staff to monitor and document any anxious, negative statements, or health related complaints, and mental health medication oversight and talk therapy provided by psychiatric services. The Anxiety Care Plan, dated 02/15/23, directed staff to remove R2 to a calm environment and allow him to vent and share his feelings, encourage participation in daily care, and honor his requests as much as safely possible. The Physician Order, dated 04/23/22, directed staff to administer Cymbalta (an antidepressant medication), 30 milligrams (mg), 1 caplet, by mouth, in the evening and administer Cymbalta, 60 mg, 1 caplet, by mouth in the evening for depression. The Nurse's Note, dated 07/13/22 at 04:58 AM, documented R2 was very inappropriate toward staff and stated that he would like to have an underage staff member home with him. The note recorded R2 made comments about younger staff members and how they looked. The Nurse's Note, dated 10/19/22 at 08:07 PM, documented R2 told a Certified Medication Aide (CMA) that he wanted to take her to the bathroom and show her a good time. Staff infomred the resident that it was very inappropriate to talk to the CMA that way and he needed to apologize. The note further documented R2 was angry at staff and wheeled up behind them and touched staffs' buttocks to get their attention. The Nurse's Note, dated 11/19/22 at 11:26 AM, documented R2 sexually touched a CMA's buttocks and he started to laugh when she told him it was not appropriate and asked him not to not touch her. The note further documented R2 called the nurses and the CMA derogatory names. The Nurse's Note, dated 02/06/23 at 11:25 AM, documented R2 sat in his wheelchair behind a CMA staring at her buttocks with a grin on his face. The nurse told him that it was not appropriate and to move along and do something else. The resident laughed and said he was reading something on her pants. The note further documented the nurse told R2 that there was no lettering where he was looking and to finding something else to do. The Nurse's Note, dated 02/14/23 at 07:19 PM, documented R2 touched a Certified Nurse Aide (CNA)'s buttocks and the nurse told the resident there are consequences for touching others inappropriately. The Nurse's Note, dated 02/16/23 at 04:17 PM, documented the psychiatric services recommended adding medroxyprogesterone (hormone medication), 5 mg, by mouth, daily for sexual behaviors. The Nurse's Note, dated 02/16/23 at 09:23 PM, documented R2 commented to the CMA that the buttocks of one of the younger CNA's was nice to look at and stated that when he heard her voice, he had dreams of sleeping with her. The note further documented the CNA told staff that she felt very uncomfortable to provide care to the resident and was advised to not provide cares to the resident alone. R2's clinical record lacked evidence the facility followed up with R2 regarding the sexual behaviors and lacked evidence of ongoing behavioral support services in order to identify triggers and effective redirection methods. On 03/28/23 at 04:00 PM, observation revealed R2 sat at a table putting a puzzle together. On 02/27/23 at 11:30 AM, CNA R stated R2 had a lot of behaviors, some toward residents and some towards staff. CNA R stated R2 had one resident he got upset with so staff tried to keep them separated. CNA R stated R2 had inappropriate sexual behaviors with staff. On 03/28/23 at 08:22 AM, Social Services X stated she talked to the resident all the time about his inappropriate behaviors and often brought him into her office where he was able to express his feelings but stated she did not document all her interactions with the resident. Social Services X further stated R2 received psychiatric services monthly for his behavior. Social Services X stated she had trained herself for her position; she tried to reach out to other social services designees for knowledge but has not had a lot of luck. She stated she does not have a licensed social worker helping her. On 03/28/23 at 01:30 PM, Administrative Nurse D stated R2 received services for his behaviors and agreed there should be more documentation related to any interaction with the resident and as extra support for the resident. The facility's Social Services policy, undated, documented social service staff would provide social services or obtain needed services from outside entities with expressions or indications of distress that affect the resident's mental and psychosocial wellbeing resulting from depression, chronic disease, Alzheimer's or other dementia related diseases, difficulty with personal interaction, socialization skills and resident to resident interactions. The social service staff would help with difficulty coping with change or loss and a need for emotional support. The facility failed to identify and provided medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for R2, who has inappropriate sexual behaviors. - R3's Electronic Medical Record (EMR) recorded diagnoses of depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), transient ischemic attack (TIAa temporary disruption in the blood supply to part of the brain), and incontinence (lack of voluntary control over urination). The Annual Minimum Data Set (MDS), dated [DATE], documented R3 had moderately impaired cognition and required extensive assistance of one staff for transfers, toileting, ambulation in her room, and limited assistance of one staff for ambulation in corridors, personal hygiene, and dressing. The MDS further documented R3 had little pleasure doing things 12-14 days, felt down and depressed 12-14 days, had thoughts she would be better off dead or hurting self never or one day, and had rejection of care one to three days. The Behavior Care Plan, dated 02/02/23, documented R3 had verbal aggression related to inappropriate coping skills and directed staff to administer medications as ordered and monitor for effectiveness. The care plan further directed staff to analyze key times, triggers, circumstances and what de-escalates behaviors and document, assess coping skills and support systems. The Depression Care Plan, dated 02/02/23, documented R3 had a history of difficult relationships and loss of independence and directed staff to administer medication as ordered, discuss with R3 any concerns, fears or issues regarding health. The care plan further documented R3 needed time to talk when she was upset and directed staff to encourage her to express her feelings and provide validation. The update, dated 02/14/23, documented R3 refused telemed psychiatric talk therapy and medications. The Physician Order, dated 08/24/22, directed staff to administer Celexa (antidepressant medication), 40 milligrams (mg), by mouth, daily. The order directed staff to place the resident on suicide precautions until she was not suicidal and did not have a plan. The order was discontinued on 09/06/22. The Physician Order, dated 08/24/22, directed staff to place the resident on one hour suicide checks, be as unobtrusive as possible every hour for suicidal ideation. The order was discontinued on 09/06/22. The Treatment Administration Record, dated August 2022 lacked documentation staff observed R3 hourly on the following days and times: 08/27/22 05:00 AM 08/27/22 06:00 AM 08/28/22 06:00 AM 08/29/22 06:00 AM 08/30/22 12:00 AM through 06:00 AM 08/31/22 12:00 AM through 06:00 AM The Treatment Administration Record, dated September 2022 lacked documentation staff observed R3 hourly on the following days and times: 09/01/22 06:00 PM 09/02/22 06:00 AM and 11:00 PM 09/03/22 04:00 AM, 05:00 AM, 06:00 AM, 03:00 PM, 04:00 PM, 05:00 PM, and 06:00 PM 09/04/22 05:00 AM and 06:00 AM The Physician Order, dated 02/22/23, directed staff to administer Celexa, 20 mg, by mouth, daily for depression with psychotic features for 2 weeks. The Celexa was discontinued on 03/08/23. The Physician Order, dated 02/22/23, directed staff to administer Effexor (antidepressant medication), 75 mg, by mouth, daily, for depression and discontinue in two weeks. The medication was discontinued on 03/08/23. The Physician Order, dated, 03/08/23, directed staff to administer Effexor ER (extended release), 75 mg, by mouth, daily, for depression. The Nurse's Note, dated 08/24/22 at 06:53 PM, documented R3 stated she was tired of living and just wanted to die. The note further documented she wanted assistance with dying and told the nurse that she was looking around the room for something to hang herself with. The Nurse's Note, dated 08/25/22 at 11:29 AM, documented the facility spoke with R3's family regarding the resident and family stated they knew she had bad days and were trying to find a way to take the resident out of the facility more often. The note recorded the facility should engage R3 in more activities and mealtimes to help with the adjustment. The Nurse's Note, dated 09/05/22 at 04:02 PM, documented R3 continued to express a wish to die but was not describing how she would do it or stating she had any plan to commit suicide. The Nurse's Note, dated 09/08/22 at 04:37 PM, documented R3's family was in to visit and the resident stated she was in good spirits. The Nurse's Note, dated 02/21/23 at 11:10 AM, documented R3 stated death was beautiful and staff asked her if she had a plan. R3 stated she did not have anything to hang herself with. The note further documented staff contacted the physician for further instructions. The Nurse's Note, dated 02/21/23 at 11:31 AM, documented R3 stated she felt down and did not have a plan to hurt herself or any desires to commit suicide at this time. The note further documented staff told the resident they had called the physician to report her symptoms of depression and further orders. R3's clinical record lacked evidence of social service support provided to the resident. On 03/22/23 at 09:30 AM, observation revealed R3 sat in her recliner, and stated she was having a good day. On 03/27/23 at 11:20 AM, Certified Nurse Aide (CNA) R stated R3 had been on suicide watch many times and she usually got depressed when her family was not coming to visit her. CNA R further stated if R3 ever told her she wanted to harm herself, she would go tell the nurse. On 03/28/23 at 08:23 AM, Social Services X stated R3 did not want any therapy but she would try to visit with the resident regularly and verified she had not documented the conversations. Social Services X stated she had trained herself for her position; she tried to reach out to other social services designees for knowledge but has not had a lot of luck. She stated she does not have a licensed social worker helping her. On 03/28/23 at 12:00 PM, Licensed Nurse (LN) G stated R3 verbalized she wanted to harm herself and LN G contacted the Director of Nursing (DON) as well as R3's physician. LN G further stated after he had told the DON, R3 changed her mind but the physician changed her medications. On 03/28/23 at 01:30 PM, Administrative Nurse D stated there should be better documentation by staff regarding interactions they had with R3 and how R3 was feeling. The facility's Social Services policy, undated, documented social service staff would provide social services or obtain needed services from outside entities with expressions or indications of distress that affect the resident's mental and psychosocial wellbeing resulting from depression, chronic disease, Alzheimer's or other dementia related diseases, difficulty with personal interaction, socialization skills and resident to resident interactions. The social service staff would help with difficulty coping with change or loss and a need for emotional support. The facility failed to identify and provided medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for R3, who stated she wanted to harm herself twice within a six-month period. This placed the resident at risk for further decline of her emotional and mental well-being. - R5's Electronic Medical Record (EMR) recorded diagnoses of hallucinations (sensing things while awake that appear to be real, but the mind created), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), adjustment disorder with anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and dementia (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had severe cognitive impairment, had inattention and disorganized behavior which fluctuated, required extensive assistance of one or two staff for activities of daily living, had inattention and disorganized thinking, and no behaviors. The MDS further documented R5 received daily antianxiety, antidepressant (medication used to treat depression), and diuretic (medication to promote the formation and excretion of urine). The Behavior Care Plan, dated 02/01/23, documented R5 was verbally aggressive and made inappropriate comments to staff and other residents. The care plan directed staff to administer medication as orders, analyze key times, triggers, circumstances and what de-escalates behaviors and document., educated R5 on therapeutic breathing, offer active listening, validation of thoughts and feelings, and educate R5 on socially acceptable behaviors and ask her to refrain from vulgar speech directed at others. The care plan directed staff to offer listening to music, play bingo, animal and pet therapy, drink coffee with friends, and offer activities. The Anxiety Care Plan, dated 02/01/23, documented R5 had an actual psychosocial well-being problem related to anxiety and lack of acceptance to her current condition. The care plan directed staff to acknowledge R5's anxiety, maintain a calm demeanor while interacting with her, allow R5 time to answer questions she may have without compromising the privacy of others, and to verbalize feelings perceptions, and fears as her anxiety levels fluctuate throughout the day. The care plan directed staff to take R5 to one of the administration offices when appropriate to decrease anxiety. The Physician Order, dated 12/05/22, directed staff to administer lorazepam (antianxiety medication), 1 milligram (mg), py mouth, twice a day, for anxiety and agitation. The Physician Order, dated 12/06/22, directed staff to administer fluoxetine (antidepressant medication), 20 mg, by mouth, daily, for depression with severe psychotic symptoms. The Physician Order dated 01/09/23, directed staff to administer lorazepam 2 milligrams (mg)/1 milliliter (ml) to give 0.5 mg by mouth every one hour as needed for agitation, give 0.25 ml-0.5 ml. The order lacked a stop date. The Nurse's Note, dated 01/16/23 at 10:14 AM, documented R5 became agitated and called everyone vulgar names and used foul language. The Nurse's Note, dated 01/18/23 at 01:18 PM, documented R5 used foul language and called nursing staff and residents a vulgar name. The Nurse's Note, dated 01/23/23 at 08:34 AM, documented R5 wandered up and down the halls, used foul language and yelled at residents. The Nurse's Note, dated 02/22/23 at 04:39 PM, documented R5 was very restless and anxious throughout the shift and used foul language and called residents and staff vulgar names. The note further documented R5 wandered in and out of other resident's rooms; staff attempted to intervene with music and puzzles but R5 hollered and told them to get away and called them a vulgar name. The Nurse's Note, dated 03/04/23 at 09:58 AM, documented R5 roamed the facility in a wheelchair, cursed at others and turned the ice machine and flooded the counter and floor. Staff took R5 to the dementia unit for observation. R5's clinical record lacked evidence of social service support provided to the resident. On 03/20/23 at 03:17 PM, observation revealed R5 told a male resident to go home and proceeded to call him a vulgar name. Further observation revealed the male resident called R5 a vulgar name as he went by her. On 03/25/23 at 11:30 AM, Certified Nurse Aide (CNA) R reported R5 had a lot of behaviors, was very verbal to residents, and staff tried giving R5 her baby doll to help when she had behaviors. On 03/28/23 at 08:23 AM, Social Services X stated she did try to visit with the resident and often got the R5's baby doll for her when she was agitated. Social Services X verified she does not document her interactions with the resident. She stated R5 used to receive psychiatric services but R5 was on hospice now and the services stopped. Social Services X stated she had trained herself for her position; she tried to reach out to other social services designees for knowledge but has not had a lot of luck. She stated she does not have a licensed social worker helping her. On 03/28/23 at 12:00 PM, Licensed Nurse (LN) G reported R5 had behaviors with another resident and did not know about the stop date for the as needed lorazepam order. On 03/28/23 at 01:30 PM, Administrative Nurse D stated staff try to redirect the resident and administration staff take her into their offices when R5 gets agitated. The facility's Social Services policy, undated, documented social service staff would provide social services or obtain needed services from outside entities with expressions or indications of distress that affect the resident's mental and psychosocial wellbeing resulting from depression, chronic disease, Alzheimer's or other dementia related diseases, difficulty with personal interaction, socialization skills and resident to resident interactions. The social service staff would help with difficulty coping with change or loss and a need for emotional support. The facility failed to identify and provided medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for R5, who had behaviors. This placed the resident at risk for further decline of her emotional and mental well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 30 residents. The sample included 13 residents with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R)5's as needed (PRN) lorazepam (antianxiety medication) had a stop date as required, placing the resident at risk for adverse side effects related to psychotropic (altering mood and mind) medication use. Findings included: - R5's Electronic Medical Record (EMR) recorded diagnoses of hallucinations (sensing things while awake that appear to be real, but the mind created), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), adjustment disorder with anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), and dementia(progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R5 had severe cognitive impairment, had inattention and disorganized behavior which fluctuated. R5 required extensive assistance of one or two staff for activities of daily living, and had two or more non-injury falls. The MDS further documented R5 received daily antianxiety, antidepressant (medication used to treat depression), and diuretic (medication to promote the formation and excretion of urine). The Anxiety Care Plan, dated 02/01/23, documented R5 had an actual psychosocial well-being problem related to anxiety and lack of acceptance to her current condition. The care plan directed staff to acknowledge R5's anxiety, maintain a calm demeanor while interacting with her, allow R5 time to answer questions she may have without compromising the privacy of others, and to verbalize feelings perceptions, and fears as her anxiety levels fluctuate throughout the day. The Physician Order dated 01/09/23, directed staff to administer lorazepam 2 milligrams (mg)/1 milliliter (ml) to give 0.5 mgs by mouth every one hour as needed for agitation, give 0.25 ml-0.5 ml. The order lacked a stop date. The Electronic Medication Administration Record (EMAR), documented R5 received the PRN lorazepam on 02/16/23, twice on 02/17/23, 03/10/23, 03/17/23 and 03/21/23. The Progress Note, dated 03/04/23 at 09:58 AM, documented R5 roamed the facility in a wheelchair, cursed at others, turned the ice machine and flooded the counter and floor. Staff took R5 to the dementia unit for observation. On 03/25/23 at 11:30 AM, Certified Nurse Aide (CNA) R reported R5 had a lot of behaviors, was very verbal to residents. CNA R said staff tried giving R5 her baby doll to help when she has behaviors. On 03/28/23 at 12:00 PM, Licensed Nurse (LN) G reported R5 had behaviors with another resident and did not know about the stop date for the as needed lorazepam order. On 03/28/23 at 01:30 PM, Administrative Nurse D verified the as needed lorazepam did not have a stop date and said she fixed the order with a stop date. The facility's Psychotropic Medication Monitoring policy, documented orders for as needed psychotropic medication will be limited to fourteen (14) days or less and only for specific clearly documented circumstances. An antianxiety medication order on as needed bases for mood stabilization may be reordered at the end of 14 days after the ordering practitioner has evaluated the resident for continued need and the provide a rationale for continuation of the as needed medication rational and risk/benefit statement with a specific duration for the continuation of the order not to exceed six months. The facility failed to ensure R5's as needed psychotropic medication had the required stop date placing the resident at risk for adverse side effects.

The facility had a census 30 residents. Based on record review and interview, the facility failed to provide Registered Nurse (RN) coverage eight consecutive hours a day, seven days a week placing all resident who reside in the facility at risk of lack of assessments and inappropriate care. Findings included: - Upon review of the Payroll Based Journal (PBJ- a required detailed information submitted by nursing homes of staffing required from the Centers of Medicare and Medicaid Service), the facilty lacked RN eight-hour coverage on 02/12/22, 03/28/22, 05/07/22, 05/08/22, and 05/29/22. On 03/27/23 at 09:00 AM, Social Worker X, who assisted with facility nursing staff with scheduling, verified the lack of RN coverage on the above five days. On 03/28/23 at 04:00 PM, Administrative Nurse D stated she was not employed by the facility at the time of the missing dates of RN coverage and said she was currently in the process of hiring more RN. The facility's Sufficient Nursing Staff policy, dated 03/28/23, documented a RN will be available in the health center for at least eight/twelve hours each day seven days a week. The facility failed to provide RN coverage eight consecutive hours a day, seven days a week placing the residents who resided in the facility at risk of lack of assessment and inappropriate care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 30 residents. The sample included four residents; one resident reviewed for abuse. Based on observations, record review, and interviews, the facility failed to ensure staff identified and reported an allegation of abuse for Resident (R) 1 to facility administration in a timely manner. This deficient practice placed R1 at risk for unidentified and ongoing abuse. Findings included: - R1 was admitted to the facility on [DATE]. The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) and enterocolitis (inflammation of both the small and large intestine) due to clostridium difficile (bacteria that can cause infection of the large intestine). The Annual Minimum Data Set (MDS) dated 10/22/22, documented a Brief Interview for Mental Status (BIMS) was not conducted due to rarely/never understood. R1 required limited assistance with two staff for bed mobility; total dependence with two staff for transfers, dressing, and personal hygiene; total dependence with one staff for locomotion; and supervision with setup help with eating. R1 was always incontinent of urine and feces. The Quarterly MDS dated 01/31/23, documented a BIMS was not conducted due to rarely/never understood. R1 required total dependence with two staff for bed mobility, transfers, dressing, and personal hygiene; total dependence with one staff for locomotion; and was independent with setup help only with eating. R1 was always incontinent of urine and feces. The Activities of Daily Living (ADLs) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 11/05/22, documented R1 required assistance of one to two staff for all ADLs. R1 was incontinent of both urine and feces. The ADLs/Mobility Care Plan dated 10/30/21, directed R1 had an ADL self-care performance deficit and required one to two staff assistance to turn and reposition in bed. The facility's Investigation dated 02/10/23, documented on 02/08/23 at 01:30 PM Dietary BB reported to Social Services X and Administrative Nurse E that Certified Medication Aide (CMA) R took a picture of R1's backside with bowel movement on him and showed it to her. Dietary BB stated the incident occurred in mid-January. Social Services X and Administrative Nurse E reported it to Administrative Staff A at 01:35 PM. An investigation was completed to find out who took the picture and who it was shown to. It was discovered that while on a smoke break, CMA R had shown the picture to Dietary BB. CMA R was terminated from facility employment on 02/08/23. In a Witness Statement, not dated, Administrative Staff A stated CMA R was asked to provide a statement on more than one occasion. CMA R voiced to Administrative Staff A that he did not take a picture of R1 at all. In a Witness Statement on 02/08/23, Dietary BB stated she and CMA R went to her car on a smoke break and she asked him how R1 was doing and if he was keeping food down. Dietary BB stated CMA R responded with no, R1 was having a lot of blow outs [slang for large bowel incontinence episode] then CMA R showed her a picture of R1's backside covered in fecal matter. In a Witness Statement on 02/09/23, Social Services X stated during a care plan conference, Dietary BB stated CMA R showed her a picture of R1's back side covered in bowel movement. Social Services X stated she notified Administrative Staff A as soon as possible. In a Witness Statement on 02/09/23, Administrative Nurse E stated during a care plan meeting, it was stated by Dietary BB that she was shown a picture of R1 covered in bowel movement. She stated CMA R had shown her the picture while on break. On 02/13/23 at 01:40 PM, R1 sat in his recliner with his eyes closed, he appeared to be resting comfortably. On 02/13/23 at 12:42 PM, Dietary BB stated on the day of the incident, she and CMA R went out to smoke and she asked him how R1 was doing, if R1 was eating all of his food and retaining his food. CMA R stated R1 was having major blow outs then showed her a picture on his phone. Dietary BB stated she did not think anything of it at that time then during the care plan meeting on 02/08/23, she asked the same questions about R1 then mentioned CMA R showed her a picture of one of R1's blow outs. Dietary BB stated the incident happened the second to last week of January and at the time, she did not know it was wrong to have a picture of it. She stated if it happened again, she would report it to Administrative Staff A or Administrative Nurse D. On 02/13/23 at 01:02 PM, Dietary BB stated she knew the picture was of R1 because CMA R stated it was. She stated the picture was of a mid-back to lower thighs covered in bowel movement and she could not tell who the resident was in the picture. On 02/13/23 at 01:57 PM, Certified Nurse Aide (CNA) M stated if there was an allegation, she reported it to the head nurse who was to report it to Administrative Nurse D but if she felt like it was not going up the chain of command, she reported it to Administrative Nurse D. CNA M stated it was considered exploitation to take pictures of residents and any incident was reported immediately. On 02/13/23 at 02:02 PM, Licensed Nurse (LN) G stated any abuse allegation was reported to Administrative Staff A and included exploitation from taking pictures of residents. She stated if she was shown any inappropriate pictures of residents, she would report it to Administrative Nurse D and Administrative Staff A immediately. On 02/13/23 at 02:13 PM, Administrative Nurse D stated she was notified CMA R showed Dietary BB a picture of R1's bottom while on a smoke break. CMA R was terminated and as far as she was aware, only Dietary BB had seen the picture. She stated she did not know why the incident was not reported immediately but it should have been as inappropriate pictures was considered abuse, neglect, and exploitation. On 02/13/23 at 02:30 PM, Administrative Staff A stated during a care plan meeting on 02/08/23 with Dietary BB, Social Services X, and Administrative Nurse E when Dietary BB stated there was a picture of R1 that CMA R had shown her. Administrative Staff A stated she had never seen any picture but when Dietary BB was shown the picture, she should have reported it to Administrative Staff A immediately. On 02/14/23 at 10:48 AM, CMA R stated he was terminated for pictures that he did not take and was not asked to make a statement until after he was terminated. The facility's Abuse, Neglect, and Exploitation Policy, dated 07/28/22, directed all facility employees were educated that all alleged or suspected violations involving mistreatment, neglect, abuse, or exploitation were reported immediately to the Administrator but not later than two hours after the alleged incident. The facility failed to ensure staff identified and reported an allegation of abuse for R1 to facility administration in a timely manner. This deficient practice placed R1 at risk for unidentified and ongoing abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 21 residents. The sample included 12 residents, with four reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide scheduled bathing or bathing alternatives for one of four sampled residents, Resident (R) 16. Findings included: - R16's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition with delusions, verbal behaviors, and frequently rejected cares. The MDS documented the resident was incontinent of urine, and bathing did not occur during the seven day evaluation period. R16's ADL Care Plan, dated 07/19/21, directed staff to assist the resident with bathing, and documented R16 requested to shower once a week. The facility's undated Bathing Schedule, directed staff to shower R16 on Monday and Thursday during the day. R16's June 2021 Bathing Report documented staff did not provide any bathing for R16 and the resident refused seven times. R16's medical record lacked documentation staff reapproached or encouraged the resident to bathe or attempted to reschedule R16's bathing. R16's July 2021 Bathing Report documented staff bathed R16 one time and the resident refused seven times. R16's medical record lacked documentation staff reapproached or encouraged the resident to bathe or attempted to reschedule R16's bathing. R16's August 2021 Bathing Report documented staff bathed R16 one time and the resident refused five times. R16's medical record lacked documentation staff reapproached or encouraged the resident to bathe or attempted to reschedule R16's bathing. On 09/07/21 at 08:06 AM, observation revealed R16 sat in the dining room, and made rude comments directed at other residents. Continued observation revealed staff provided one on one interaction to redirect R16's verbal behaviors. On 09/07/21 at 02:21 PM, Certified Nurse Aide (CNA) M stated residents should receive scheduled bathing, and if a resident refused bathing, staff reported to the charge nurse to reschedule the resident's bathing. On 09/07/21 at 03:42 PM, Licensed Nurse (LN) G stated staff should provide resident bathing as scheduled, and if a resident refused, staff should report to the charge nurse to reapproach the resident, or reschedule the resident's bathing. LN G stated R16 had frequent behaviors, and the resident usually refused bathing. On 09/08/21 at 10:21 AM, Administrative Nurse D stated R16 frequently refused bathing, and staff should report the refusals to the charge nurse to reapproach R16 about bathing or reschedule the resident's bathing. Administrative Nurse D stated nursing staff should document attempts to encourage/educate R16 to bathe, and/or document to reschedule R16's bathing. The facility's undated Bathing policy directed staff to provide residents' bathing per preference and schedule, and to report refusals to the charge nurse to address. The facility failed to provide R16's bathing as scheduled or bathing alternatives, placing the resident at risk for poor hygiene and impaired skin integrity.

The facility had a census of 21 residents. Based on observation, record review, and interview, the facility failed to secure hazardous chemicals for nine cognitively impaired, independently mobile residents who resided in the facility. Findings included: - On 09/01/21 at 09:15 AM, observation revealed one janitorial closet door unlocked. The closet contained the following items: One bottle approximately half full of One Step Disinfectant Cleaner. The label on the bottle read Keep out of reach of children. Harmful if swallowed. One container approximately half full of Super Sorb Cleaner. The label on the bottle read Keep out of reach of children. Harmful if swallowed. One bottle approximately half full of Maxi Gloss Restorer Floor Cleaner. The label on the bottle read Keep out of reach of children. One clear spray bottle, approximately half full, labeled as bleach water. The label on the bottle read Causes severe skin burns and eye damage. Causes serious eye damage. One bottle approximately half full of Xtract Carpet and Upholstery Cleaner. The label on the bottle read Can cause serious eye damage. One bottle approximately half full of Lime B Gone Cleaner. The label on the bottle read Causes severe skin burns and eye damage. On 09/01/21 at 09:15 AM, Housekeeping Staff (HS) U stated all the janitorial doors should be kept locked at all times and that it was not locked. On 09/08/21 at 02:00 PM, Administrative Nurse D stated she expected all janitorial doors to be locked due to the caustic (able to burn organic tissue by chemical action) substances kept in them. The facility's undated Control of Hazardous Chemicals policy, documented all substances with warning labels, including but not limited to Keep out of reach of children will be locked and inaccessible at all times. All hazardous chemicals are to be locked at all times to avoid accessibility of any elder in the facility. The facility failed to secure hazardous chemicals for nine cognitively impaired, independently mobile residents who resided in the facility, placing the residents at risk for injury.