Every finding on record at Ambassador Healthcare at College Park

Based on observation, review of facility policy and procedure and staff interview, the facility failed to store food in a sanitary manner, failed to maintain the kitchen and equipment in a sanitary manner, and failed to ensure staff washed their hands appropriately when handling sanitized dishes. These failures have the potential to cause food borne illness in residents receiving an oral diet.The findings included:Review of the facility policy and procedure for Equipment revised 9/2017 revealed, All foodservice equipment will be clean, sanitary and in proper working order. Procedures. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials . All food contact equipment will be cleaned and sanitized after every use . All non-food contact equipment will be clean and free of debris.Review of the facility policy and procedure for Ice, revised 9/2017 revealed, Ice will be prepared and distributed in a safe and sanitary manner. The Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed, or according to manufacturer guidelines. The exterior of the ice machine will be cleaned weekly.Review of the facility policy for Warewashing 9/2027 revealed, All dishware, serviceware, and utensils will be cleaned and sanitized after each use. Procedures. The Dining Services staff will be knowledgeable in the proper technique for processing dirty dishware through the dish machine, and proper handling of sanitized dishware . All dishware will be air dried and properly stored.On 4/12/26 at 9:10 a.m., during an initial tour of the kitchen the following was observed:A sandwich with no date in the reach in refrigerator, and 18 covered food cups containing pudding and fruit without a date. Photographic evidence obtained.Two open bags of pasta with no date on them in the dry pantry room. Photographic evidence obtained.A mixing bowl with brown liquid at the bottom on a shelf in the kitchen. Photographic evidence obtained.Wet nesting (stacking wet pans creating moisture that fosters rapid bacteria and mold growth) of uncovered sheet pans on a rack by the stove. Photographic evidence obtained.Five open packages of rolls without an open date or expiration tab. Photographic evidence obtained.In the dry food storage area, a large white bin of flour was observed. The outside of the container had brown ingrained material. A dead bug was observed on top of the flour. Photographic evidence obtained.Dietary Aide Staff D was observed using the high temp dishwasher. Staff D used a dirty rack of dishware to push a clean rack of dishware out of the dishwasher. Dietary Aide Staff D was observed loading soiled dishware in the machine and removing sanitized dishes from the dishwasher, using the same gloves.The shelving unit for the clean dishware had a buildup of white substance. Food particles were observed on the shelves. Photographic evidence obtained.The front of the ice machine front was coated with white slime. A dead bug was observed between the inside and outside lids. The vents were dusty and had a white slime coating and had a dead bug where the lid on the inside meets the outside lid to close. The vents were dusty and had ingrained dirt. Photographic evidence obtained.The floor of the walk-in freezer was dirty with trash, debris, and dirt. The Certified Dietary Manager (CDM) verified the floor had dirt and debris and said she was looking for someone to clean the floor. Photographic evidence obtained.An opened undated bag of ravioli was observed in the freezer. Photographic evidence obtained.The spouts of eyewash station were coated with dust. A brown film was observed in the sink of the eyewash station.The hot temp beverage log had not been completed for the evening shift of 4/11/26 or the day shift on 4/12/26. Photographic evidence obtained.The sanitizer concentration log for the 3-compartment sink was prefilled for the lunch meal of 4/12/26. Photographic evidence obtained.Brown dirt was observed on the wall and pipes behind the food preparation area and stove. Photographic evidence obtained.On 4/12/26 at 9:40 a.m., in an interview, the Certified Dietary Manager provided a blank cleaning schedule form. She said that she had been off for a few weeks and could not locate documentation verifying the dietary staff completed the scheduled cleaning.On 4/12/26 at 9:55 a.m., Dietary Aide Staff D was observed using the high temp dishwasher. Staff D loaded dirty dishes in the high temp machine. She walked to the other side of the machine and removed the sanitized dishes without changing her gloves or washing her hands.The Certified Dietary Manager verified the observation and instructed Dietary Aide Staff D to remove her gloves, wash her hands and rewash the dishes. On 4/13/26 at 3:07 p.m., in an interview, the Dietary District Manager said that the ice machine had to be gutted and cleaned.

Based on observation, record reviews, residents and staff interviews, the facility failed to follow the planned menu to meet the needs and preferences of 11 (Residents #75, #4, #31, #55, #23, #7, #58, #63, #33, #54, and #76) of 37 residents reviewed. The findings included: On 4/13/26 at 12:37 p.m., Resident #75 was observed having lunch. The meal ticket noted 3/8 cup of spicy pork tips, 1/2 cup of pinto beans, 1/2 cup of seasoned okra, 1 square of corn bread, 1 margarine, 1 snickerdoodle cookie, 6 ounces of tea of choice and peach parfait was subbed for doubled chocolate brownie. Observation of the meal revealed Resident #75 received an unidentified ground meat with gravy, mashed potatoes with gravy, a vegetable medley that included carrots and green beans.In an interview, Resident #75 stated that he did not like that type of food and requested that his meal tray be removed without eating any food item on the plate.On 4/14/26 at 11:30 a.m. through 12:45 p.m., observation of tray line for the lunch meal revealed the planned menu was not followed to meet the needs and preference of residents. A sample of meal tickets observed during tray line revealed:Residents #4, #31, #55, and #23's received regular mashed potatoes instead of the fortified mashed potatoes per the meal tickets.Residents #7, #58, and #63 received regular mashed potatoes, instead of the potato wedges indicated on the meal tickets.Residents #33, #54, and #76 received fruit punch on their trays, instead of lemonade as noted in their meal tickets.On 4/14/26 at 2:00 p.m., in an interview, the Dietary Manager and the Regional Dietary Manager verified that the planned menu was not followed, lemonade was not available, many food items were substituted and the residents did not receive the food listed on the menu and per the residents' preferences.

Based on record review, resident and staff interviews, review of facility policy and procedure, the facility failed to provide assistance with showers and personal hygiene as outlined in the resident's care plan and according to residents' preferences for 4 (Residents #88, # 5, #49, and #65) of 5 dependent residents reviewed.The findings included:Review of the clinical record revealed Resident #88 was admitted on [DATE] and discharged on 3/24/26. The resident's diagnoses included: Cognitive impairment, and bowel and bladder incontinence. Review of the certified nursing assistant (CNA) documentation revealed Resident #88 was dependent for all care. Review of the CNA documentation for February 2026 revealed Resident #88 was scheduled for showers on the 3:00 p.m. to 11:00 p.m., shift on Tuesdays and Fridays. The documentation revealed on 2/20/26 and 2/24/26 Resident #88 did not receive his scheduled showers. On 2/27/27 the documentation showed he refused his shower. The documentation revealed no hygiene care was provided on 2/21/26, 2/22/26 and 2/28/26 on the 11:00 p.m., to 7:00 a.m., shift. Review of the March 2026 CNA documentation revealed Resident #88 did not receive scheduled showers on 3/3/26, on 3/6/16 he received a partial bed bath, on 3/10/26 he received a bed bath, on 3/13/25 he refused, on 3/17/26 resident had a bed bath, on 3/20/26 the activity did not occur. The documentation revealed he refused hygiene care on the evening shift on 3/2/26, 3/4/26, 3/5/26, 3/15/26, N/A was documented on 3/14/26, 3/17/26, 3/23/24 and on 3/22/26 the documentation was not completed. On the 11-7 shift on 3/3/26, and 3/14/26 the record was blank. On 3/5/26, 3/8/26, 3/10/26, 3/12/26, 3/13/26, 3/16/26 3/17/26, 3/18/36, 3/19/26, 3/20/26, 3/21/26, 3/21/26 N/A was documented. Review of the clinical record revealed Resident #5 was admitted to the facility 1/20/23. Diagnosis included polyneuropathy, unspecified, other acute osteomyelitis, left ankle and foot, local infection of the skin and subcutaneous tissue, unspecified, type 2 diabetes mellitus without complications, moderate protein calorie malnutrition, venous insufficiency (chronic) (peripheral), peripheral vascular disease, unspecified Review of the Minimum Data Set (MDS) 5-Day admission Assessment with a reference date 2/20/26 documented the resident is dependent on staff for Activities of Daily Living (ADLs). The MDS documented the resident's cognitive status was intact. Review of the certified nursing assistant (CNA) documentation revealed Resident #88 was dependent for all care. Review of the certified nursing assistant (CNA) documentation for February 2026 revealed Resident #5 was scheduled for showers on the 3:00 p.m. to 11:00 p.m. shift on Wednesdays and Saturdays. The documentation revealed on 2/4/26, 2/11/26 and 2/14/26 the resident did not receive a shower. The documentation revealed no hygiene care was provided on 2/9/26 on the 7:00 a.m. to 3:00 p.m. shift, the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. On 2/10/26, 2/11/26, 2/12/26, 2/13/26, 2/14/26 and 2/15/26 there is no documentation for the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 p.m. shift. On 2/16/26 and 2/17/26 there is no documentation for the 7:00 a.m. to 3:00 p.m. and the 11:00 to 7:00 a.m. shift. Review of the March 2026 CNA documentation revealed Resident #5 did not receive a scheduled shower on 3/14/26. The documentation revealed no hygiene care was provided on 3/17/26 on the 7:00 a.m. to 3:00 p.m. shift, the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. On 3/14/26 there is no documentation for the 7:00 a.m. to 3:00 p.m. shift or the 3:00 p.m. to 11:00 p.m. shift. On 3/20/26 there is no documentation for the 7:00 a.m. to 3:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. On 3/27/26 there is no documentation for the 7:00 a.m. to 3:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. On 3/29/29 there is no documentation for the 7:00 a.m. to 3:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. Review of the April 2026 CNA documentation revealed Resident #5 did not receive a scheduled shower on 4/1/26. On 4/1/26, 4/3/26, 4/10/26, 4/12/26, and 4/13/26 there was no documentation that personal hygiene was provided on the 7:00 a.m. to 3:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift. Review of the medical record for Resident #49 showed that the resident was admitted to the facility 10/29/25 with diagnoses of COPD (Chronic Obstructive Pulmonary Disease), atrial fibrillation, vertebral compression fractures, moderate protein-calorie malnutrition and advanced neuropsychiatric disease including dementia and bipolar disorder. A review of the Residents care plan initiated 10/30/25 and revised 2/16/26 showed that Resident 49 was at risk for an Activities of Daily Living (ADL's) self-care performance deficit related to impaired gait/balance, weakness, deconditioning, decreased mobility, cognitive impairment, hearing impairment, narcotic and psychotropic medication use, malnutrition, depression, bipolar, mood disorder, poor pulmonary function, foley catheter, incontinence, pain, poor safety awareness, history of falls with fracture prior to admission and increased assistance needed with ADL's. The interventions included providing a sponge bath when a full bath or shower cannot be tolerated. Bathing or showering required assistance by 1 staff, dressing required assistance by 1 staff, personal hygiene and oral care required assistance by 1 staff and toilet use required assistance by 1 staff. A review of the Physician Note for Resident #49 dated 10/29/25 revealed, the resident remained with ongoing dependence for all activities of daily living and limited mobility due to generalized weakness and chronic vertebral fractures. Review of the Certified Nursing Assistant (CNA) documentation for January 2026 revealed Resident #49 was scheduled for showers on the 3:00 p.m. to 11:00 p.m. shift on Wednesdays and Saturdays and hygiene was to be performed every shift. The documentation revealed on 1/10/26 Resident #49 did not receive her scheduled shower. The documentation revealed no hygiene care was provided on 1/1/26, 1/5/26, 1/15/26 and 1/20/26 on the 11:00 p.m., to 7:00 a.m., shift. No hygiene care was provided on 1/13/26 and 1/20/26 on the 7:00 a.m. to 11:00 a.m. shift. No hygiene care was performed on 1/10/26, and 1/11/26 on the 3:00 p.m. to 11:00 p.m. shift. Review of the CNA documentation for February 2026 revealed Resident #49 was scheduled for hygiene every shift. The Resident was not provided with hygiene care on 2/8/26 and 2/9/26, on the 11:00 p.m., to 7:00 a.m. shift and no hygiene care was performed on 2/1/26, 2/17/26, 2/23/26 and 2/26/26 on the 7:00 a.m. to 11:00 a.m. shift. Review of the CNA documentation for March 2026 revealed Resident #49 was scheduled for showers on the 3:00 p.m. to 11:00 p.m. shift on Wednesdays and Saturdays and hygiene every shift. The documentation revealed on 3/14/26 and 3/28/26, Resident #49 did not receive her scheduled shower. The documentation revealed no hygiene care was provided on 3/5/26, 3/8/26, 3/12/26, 3/20/26, and 3/30/26 on the 11:00 p.m., to 7:00 a.m., shift. No hygiene care was provided on 3/3/26 3/5/26, 3/8/26, 3/10/26, 3/12/26, 3/14/26, 3/15/26, 3/16/26, 3/20/26,3/22/26,3/25/26,3/27/26, 3/28/26, 3/30/26 and 3/31/26 on the 7:00 a.m. to 11:00 a.m. shift. No hygiene care was performed on 3/14/26, on the 3:00 p.m. to 11:00 p.m. shift. On 3/17/26, 3/23/26, 3/24/26 and 3/29/26 the hygiene documentation record was blank. Review of the CNA documentation for April 2026 revealed Resident #49 was scheduled for showers on the 3:00 p.m. to 11:00 p.m. shift on Wednesdays and Saturdays and hygiene every shift. The documentation revealed on 4/4/26 and 4/11/26, Resident #49 did not receive her scheduled shower. The documentation revealed no hygiene care was provided on 4/3/26, 4/5/26, 4/6/26, 4/7/26, and 4/10/26 on the 11:00 p.m., to 7:00 a.m., shift. No hygiene care was provided on 4/4/26, 4/5/26, 4/7/26, 4/10/26, 4/11/26, and 4/13/26 on the 7:00 a.m. to 11:00 a.m. shift. No hygiene care was performed on 4/2/26, 4/3/26, 4/4/26 and 4/6/26 on the 3:00 p.m. to 11:00 p.m. shift. On 4/1/26 and 4/12/26 the hygiene documentation record was blank. Observation on 4/13/26 at 12:04 p.m. showed the resident lying in bed still in her pajamas. Her hair appeared to be unbrushed. On 4/13/26 at 12:04 p.m., the resident said she has not gotten washed up and dressed yet and is still waiting for someone to come. On 4/12/26 at 11:18 a.m., during an interview with the Resident's family member, she said she thinks the Facility is short staffed. She said yesterday, it took over 2 hours for a brief change. She said she was at home talking on the phone to the resident, and the resident had to be changed. She said she called the front desk at 12:00 p.m. and the resident was not changed until 2:30 p.m. On 4/14/2026 at 11:36 a.m., during an interview with CNA Staff F, she said that she gets the resident up after lunch when she is too busy to get her up earlier. She said that when staff call out, they work short. On 4/12/26 at 11:10 a.m., Resident #65 was observed in his bed wearing a hospital gown. Resident #65 said since his admission to the facility, no one had assisted him in cleaning his upper and lower dentures. He said due to his arthritis in both hands he was unable to take out his dentures to be clean. He also said the facility had not provided a denture cup or the cleaning tablets so his dentures could soak and be sanitized overnight, so they could be clean in the morning before putting them back into his mouth. Review of Resident #65's medical record revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to muscle wasting and atrophy, need for assistance with personal care, and aged related physical debility. A plan of care for Resident #65 was to wear upper and lower dentures with a potential of oral/denture health problems. Resident #65 would be free of infection, pain or bleeding in the oral cavity and Resident #65 would comply with mouth care at least daily-dated 3/10/26. Interventions include providing mouth care as per ADL personal hygiene procedures. Review of Resident #65's KARDEX used by the Certified Nursing Assistant (CNA) to know their residents' level/plan of care, did not state Resident #65 had upper and lower dentures which needed to be cleaned and stored in a labeled container on a daily basis. On 4/14/26 at 12:26 p.m., in an interview with Staff I CNA, she said she had been Resident #65's CNA since his admission to the facility in February 2026. She said if a resident had denture(s) they were required to remove the denture(s) daily, clean the denture(s), and store the denture(s) when not in use in a labeled denture container. She said if a resident had denture(s) they would be noted on the resident's KARDEX used by the CNA as the level/plan of care for the resident. Staff I said she was unaware Resident #65 had a full set of upper and lower dentures and confirmed none of the staff had removed Resident #65's upper and lower dentures on a daily basis, cleaned them with the required denture cleaning product, and stored them in a labeled denture container when not in use. On 4/14/26 at 12:48 p.m., in an interview with the MDS (Minimum Data Set) Licensed Practical Nurse (LPN), she said Resident #65 was admitted to the facility on [DATE] with a full set of upper and lower dentures. She said Resident #65 was care planned for ADL self-care performance deficit related to significant functional decline and pain on 1/12/26, with interventions to include personal hygiene requiring assistance of 1 staff member for oral/denture care and personal hygiene/grooming. She said the nursing staff were required to perform daily mouth care, to include daily denture care even if it was not documented on the resident's KARDEX. On 4/14/26 at 3:48 p.m., in an interview with the Director of Nursing (DON) and Regional Nurse Consultant (RNC), they confirmed Resident #65 was admitted to the facility on [DATE] with upper and lower dentures. They confirmed the nursing staff had not removed and cleaned Resident #65's dentures as per the facility's policy. They said they would complete a facility wide audit to ensure residents with dentures had the required denture cleaning products and would complete reeducation with the nursing staff about the facility's policy and procedure for Oral Care/Hygiene – Denture and Partial Denture Care. The Clinical Activities of Daily Living (ADL's) policy and procedure effective 4/1/22, stated the purpose was to ensure the resident's needs were met in a manner that promoted their quality of life, resident rights, preferences, and independence. The facility should provide care and services for the following activities of daily living as needed based on the individual care plan of each resident not limited to bathing, dressing, grooming and oral care. The Oral Care/Hygiene – Denture and Partial Denture Care policy stated the facility staff would assist residents with denture care as needed based on their assessed level of independence. Dentures and partial dentures would be cleaned daily using appropriate denture-cleaning products, rinsed thoroughly, and stored in a labeled denture container when not in use.

Based on observation, residents, resident's family members and staff interviews, the facility failed to provide housekeeping and maintenance services to ensure a safe, clean and comfortable environment in 5 (Rooms 121, 207, 209, 214 and 215) of 60 residents rooms observed. The findings included:On 4/12/26 at 8:30 a.m., observation during an initial tour revealed: room [ROOM NUMBER]: The floor planks in front of the air-conditioner were loose and lifting from the floor. A hole was observed to the right lower side of bed 207 A's footboard. room [ROOM NUMBER]: Several floor planks were taped down. room [ROOM NUMBER] A: The laminate of the bedside table was chipping, exposing the material underneath. The bedside table legs had a brown film and were soiled with dried up food residue. A telephone was hanging from the light fixture on the wall above the resident's bed. room [ROOM NUMBER] A: A wheelchair was observed with a stained wheelchair cushion. Food crumbs were observed on and underneath the cushion. On 4/14/26 at 11:27 a.m., observation of room [ROOM NUMBER] revealed a door and a bottom drawer were missing from the dresser. On 4/15/2026 at 8:35 a.m., in an interview the Maintenance Director said the planking in room [ROOM NUMBER] was re-glued and taped to keep it in place and prevent water from getting under the planks. He said that the nurses and Certified Nursing Assistants place work orders for needed repairs in the electronic record. He reviews the concerns during his monthly rounds. The Maintenance Director said that bedside tables are replaced when the laminate starts to come off. On 4/15/26 at 11:54 a.m., in an interview, the Maintenance Director said that he wasn't aware of the broken dresser in Resident #49's room. door and drawer in the resident's room. He said that staff have access to a work order application to report area in need of repairs and a work order is generated. In an interview, the Maintenance Director said the facility had no policy addressing repairs, We just do them.

Based on observations, record review and staff interviews, the facility failed to follow the physician's orders for fluid restriction for 1 (Resident #75) of 2 residents reviewed for nutritional status.The findings included:Review of the clinical record for Resident #75 revealed an admission date of 2/23/26. Diagnoses included Acute Pulmonary Edema (excess fluid buildup in the lungs), heart failure.Review of the 5 Day Minimum Data Set (MDS) assessment with an assessment reference date of 3/2/26 revealed Resident #75 scored 8 of 15 on the Brief Interview for Mental Status, indicating moderate cognitive impairment. The resident required set up assistance with eating.The physician's orders dated 2/23/26 included to encourage the resident to comply with a fluid restriction of 1500 milliliters (ml) per day. Daily total from dietary 900 ml and 600 ml total from nursing.The baseline care plan dated 2/23/26 and the comprehensive care plan dated 2/23/26 did not include a focus, goal or interventions related to the fluid restriction.The Nutritional assessment dated [DATE] did not include the fluid restriction.On 4/13/26 at 11:01 a.m., a large Styrofoam cup filled with ice and water was observed on the resident's bedside table within his reach.On 4/13/26 at 12:40 p.m., Resident #75 was observed having lunch. A 1/2 full large Styrofoam cup was observed on the resident's over-the-bed table. A 6 ounce glass of juice was observed on the resident's meal tray.The meal ticket on the meal tray did not include the fluid restriction.On 4/13/26 at 2:55 p.m., in an interview, Licensed Practical Nurse (LPN), Unit Manager Staff C stated that she wasn't sure if Resident #75 was on a fluid restriction and didn't know how fluid restrictions were tracked. On 4/13/26 at 3:05 p.m., in an interview the Dietary District Manager said that residents on fluid restrictions show up in the dietary menu program and the amount of fluid allowed for each meal is listed on the meal ticket. The Dietary Manager who was present during the interview accessed the dietary menu program and said that the fluid restriction was not listed for Resident #75. She said that Resident #75 received more fluid than allowed on his breakfast tray.The District Manager said that the fluid restriction order should have pulled automatically from the electronic medical record into the dietary menu program.On 4/14/26 at 3:30 p.m., in an interview, the Registered Dietitian said that she was not aware that Resident #75 was on a fluid restriction. She said that several months ago, the facility began to move away from fluid restrictions, but there were some residents on dialysis who continue to have fluid restrictions.

Based on observation, record review and staff interview, the facility failed to ensure 1 (Resident #76) of 2 residents reviewed received necessary treatment and services to promote healing and prevent worsening of a pressure ulcer.The findings included:Review of the clinical record for Resident #76 revealed an admission date of 4/26/26.Review of the physician progress note dated 3/27/26 revealed that Resident #76 was treated during the hospital stay on 3/21/26 for a right buttock pressure ulcer.Review of the Nursing admission Evaluation completed on 3/26/26 and signed on 3/27/26 revealed documentation that no skin impairment was noted.Review of the wound report dated 4/12/26 revealed that Resident #76 had a facility acquired pressure wound to the sacrum measuring 4 centimeters in length by 2 centimeters in width. The form noted that the date acquired was 4/12/26.Review of the physician's orders dated 4/12/26 revealed to clean the right buttock wound every day shift with normal saline, apply calcium alginate (highly absorbent dressing which aids in faster healing) and cover with dry dressing.Review of the Treatment Administration Record (TAR) revealed that the last wound care was signed as completed on 4/13/26 at 7:00 a.m.On 4/14/26 at 9:27 a.m., in an interview Licensed Practical Nurse (LPN) Staff A stated that Resident #76 had daily dressing changes for the wounds on both feet. LPN Staff A stated that Resident #76 did not have any other wounds.On 4/14/26 at 3:03 p.m., in an interview, Resident #76 stated that she has had a wound on her bottom since prior to her admission to the facility. The resident's daughter also stated that Resident #76 has had a wound to her buttock since prior to her admission to the facility in March 2026.On 4/14/26 at 3:10 p.m., with the resident's permission, her buttocks were observed. LPN Staff A and Certified Nursing Assistant (CNA) Staff B rolled the resident to reveal a dressing on the Resident's right buttock dated 4/12/26. LPN Staff A removed the dressing to reveal an open wound measuring approximately 5.0 centimeters in length by 5.0 centimeters in width. The wound bed was pink. LPN Staff A said he was not aware prior to now that the resident had a wound to her buttock.

Based on observation, review of facility's policies and procedures, clinical record review, resident representative and staff interviews, the facility administration failed to provide effective oversight and implement processes to ensure the safety of residents, including unsafe wandering and elopement of 1 (Resident #900) of 3 cognitively impaired and confused residents reviewed.On 11/28/25 at approximately 9:45 a.m., Resident #900 who was cognitively impaired, ambulatory, confused and had poor safety awareness walked past the unattended front desk of the facility and exited the building through the unlocked front door.Resident #900 crossed a two lane road and walked 0.5 mile to the dorm of a State College through uneven terrain and near water ponds. The college staff found Resident #900 wandering in the dorm, confused, unsteady and shaking. The college staff called EMS (Emergency Medical Services) and Resident #900 was transferred to a local emergency room (ER).The facility staff were not aware of the resident's exit until 11/28/25 at approximately 10:35 a.m., when the college campus officer notified the facility of the resident's transfer to a local emergency room via EMS.The facility administration did not consider Resident #900's unsafe wandering incident an elopement, did not document the incident and measures implemented to prevent further incidents of unsafe wandering in Resident #900's clinical record. The facility implemented a new process to sign residents in and out of the facility but failed to have documentation that staff were educated on the new process.The facility administration failure to have processes in place to ensure adequate supervision created a likelihood of avoidable accidents for Resident #900 and other cognitively impaired and confused residents from unsafe wandering and elopement, which could result in serious harm, serious injury, impairment or death of the residents.This failure resulted in the determination of Immediate Jeopardy.On 2/12/26, after verification of an acceptable removal plan, the immediate Jeopardy was removed as of 2/12/26. The scope and severity for F835 was reduced to D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.The findings included:Cross reference F689Review of the job description signed and dated 10/5/2025 by the Director of Nursing revealed the primary purpose of the position was to plan, organize, develop and direct the overall operation of the nursing services department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility and as directed by the Administrator and the Medical Director to ensure the highest degree of quality of care is always maintained.Duties and responsibilities included to, Participate in risk management and safety committees to mitigate risk factors for residents . Ensure the resident environment remains as free of accident hazards as much as possible and residents receives [sic] adequate supervision and assistive devices to prevent accidents.Review of the job description signed and dated 3/26/2025 by the Administrator revealed the primary purpose of the job description was to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to the residents at all times.Duties and responsibilities included to, Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Facility . Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice.Review of the clinical record revealed Resident #900 had a date of admission of 11/5/25. Diagnoses included adult failure to thrive, malignant neoplasm (cancer) of the esophagus, major depressive disorder, muscle wasting and atrophy.Review of the admission Minimal Data Set (MDS) with an assessment reference date of 11/12/25 revealed Resident #900 scored 12 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition. The MDS noted Resident #900 required partial to moderate assistance with ambulation of 50 feet, transfers, personal hygiene and bathing.Review of the admission elopement assessment dated [DATE] documented a score of 00, indicating the resident was not at risk for elopement. The clinical record contained no additional elopement assessments.Review of the Speech Language Pathology Evaluation and Plan of Treatment dated 11/6/26 revealed that Resident #900, Presents with moderate cognitive-communication deficit at this time with primary deficits and short term memory, problem solving and executive functioning skills .The Care Plan initiated 11/13/25 and revised 12/9/25 documented Resident #900 had impaired cognitive function or impaired thought processes related to disease processes.On 11/14/25 an Advanced Practice Registered Nurse (APRN) progress note documented, Patient was noted to be intermittently confused and repeatedly pulling at his IV (Intravenous) tubing, requiring redirection and reinforcement of safety measures . Acute Confusion with IV Interference . Observed intermittent confusion leading to pulling at IV tubing, placing patient at risk for injury and catheter complications. Reinforce safety measures and monitor mental status.On 11/16/25 at 2:41 a.m., a nursing alert note documented, PT (patient) ripped out IV. When Pt was asked Pt stated I didn't do that, I'm ready to go to Vietnam. Pt is confused, AO X1 (Alert, Oriented to Person). No evidence of learning.On 11/17/26, a physician progress note documented, Cognitive impairment with treatment-interfering behaviors . Confusion leading to repeated removal of IV lines, refusal of replacement at times. Requires close supervision and safety monitoring. Ensure orientation cues and minimize environmental triggers.On 11/18/25, a Speech Language Pathology discharge summary noted that on 11/18/26 Resident #900 achieved 65 to 70% accuracy for the Short Term Goal of, The patient will demonstrate functional problem solving and safety awareness in 70% of opportunities given min-mod verbal cues in order to promote safety withing current/home environment and to enhance decision making skills.On 11/19/25, the Psychiatry Advanced Practice Registered Nurse (APRN) documented in a progress note in Resident #900's clinical record, In my opinion, this patient lacks the capacity to make decisions related to his/her need for healthcare, or long-term placement. Due to cognitive impairment, the patient is unable to understand the nature, extent or probable consequences of not receiving medical care. In addition, the patient is unable to make a rational evaluation of the burden, risks, and benefits of treatments. In my opinion, the patient can benefit from a guardian or POA (Power of Attorney).On 11/25/25 a Physical Therapy encounter note documented, Pt reported that he needed to go to the bathroom. However, he was walking out of the room into someone else room. The [sic] was redirected to his room to use the bathroom. Pt appears to be confused to today. The DOR (Director of Rehab) notify.On 11/26/25, an APRN progress note documented Resident #900 had mild confusion fluctuates per history.On 11/28/25 at 6:00 p.m., a nursing progress note documented that Resident #900's level of consciousness was, noted as oriented to person oriented to place. Behavioral problems are not noted.The next nursing progress note was dated 11/30/25 at 12:25 p.m., and noted, Level of consciousness was noted as oriented to person to place restless .On 2/9/26 at 10:12 a.m., in a telephone interview, Resident #900's family member said that on 11/28/25 the resident left the facility unsupervised and they were very upset that the facility did not notify them of the incident until 24 hours later. The family member said, What if he had made it to the main road and got hit by a car or laid down somewhere and could not get back up?.On 2/9/26 at 1:57 p.m., an interview was conducted with the Director of Nursing (DON) and the Administrator to discuss Resident #900's elopement and facility processes to prevent unsafe wandering and elopement of cognitively impaired and confused residents.The DON said, I want to change the topic and not call it an elopement.The Administrator said that on 11/28/25 Resident #900 went out for a walk and forgot to sign himself out. The people who found him saw the PICC (Peripherally Inserted Central Catheter) line out, they freaked out. They called EMS and sent him to the Emergency Room. She said the resident was cognitively intact and had a BIMS of 13 on 11/28/25 when he returned to the facility. The Administrator reiterated that Resident #900 did not elope. He did not follow the leave of absence (LOA) policy. He went out and was just too tired to return on his own. She verified no one saw Resident #900 leave the facility and did not know where he was until the college campus security notified them at approximately 10:30 a.m. The Administrator said the resident would have come back to the facility, his intention was to get some sunshine not to leave the facility. The Administrator said that in December 2025, they initiated a new process to sign residents in and out of the facility. Residents are assigned a blue sign out sheet or a white sign out sheet. Residents with a white sign out sheet are able to leave the facility unsupervised. Residents with a blue sign out sheet need to have someone with them to leave the facility.On 2/9/26 at 4:39 p.m., in an interview the Administrator said she only educated the front desk staff and management staff on the new process. She said it was not important for all staff to be educated on the new process but educated the staff on the facility's elopement policy. She said, I did not write anything down on paper that I educated the staff.On 2/10/26 at 12:05 p.m., in an interview, Unit Manager Licensed Practical Nurse (LPN) Staff B verified that on 11/28/25 Resident #900 left the facility unsupervised. She said that a new elopement risk evaluation was not completed when the resident came back from the Emergency Room. She verified the lack of documentation in the clinical record that on 11/28/25 Resident #900 left the facility unsupervised. She said, I was told not to document anything, that the Administrator and DON would take care of that. She said Resident #900 was at baseline, always confused. On 2/10/26 at 12:10 p.m., an interview was held with the Administrator and DON to discuss facility practices for documentation, and elopement prevention.The DON said she wasn't at the facility on 11/28/25 but reviewed Resident #900's clinical record the following Monday when she came back to work. She verified the incident was not documented in the resident's record and said they should have probably been a note in the resident's clinical record when he returned to the facility. She said she saw there was no documentation and did not want to put a late entry in because the Administrator did the investigation. She said, I did not have anything to write in there. Sometimes I have the staff make late entries, sometimes. The DON said that a new elopement evaluation is done where there is a big change. If yesterday the resident had no desire to leave but today the resident wants to go out and does not make sense, then, they would reevaluate. She said after reviewing everything, she concluded that the resident wanted to go for a walk. The door opened and he walked out. Anybody coming in the building was able to push a button to open the door but that was no longer the case. The DON said she would allow cognitively impaired residents who do not have an incapacity statement to leave the facility and sit outside unsupervised. The DON said the root cause of the incident was that the resident wanted to go for a walk and he did not sign out.The Administrator said that they had a few issues with people coming into the building. The push button was replaced in December for safety concerns but it was not installed directly in response to the incident of Resident #900 leaving the facility without supervision on 11/28/25. She said when the resident came back to the facility, she interviewed him. He said he just wanted to take a walk. He then realized he probably needed some help to come back. He walked into the building to ask for a ride and the next thing he knew, EMS was there. She said Resident #900 was very apologetic for not signing out. The Administrator said she personally did the resident's BIMS upon his return and he scored 13. The Unit Manager was there to witness it. She said if a resident was cognitively impaired but did not have an incapacity statement, she would allow them to leave the facility unsupervised.The Administrator said on 11/28/25 they started to in-service staff on the facility's elopement prevention policy.On 2/10/26 at 1:30 p.m., in a telephone interview the psychiatric Advanced Practice Registered Nurse verified that she assessed Resident #900 on 11/19/26 at the request of the resident's attending physician and wrote the incapacity statement. She said Resident #900 scored very poorly on the SLUMS (St. Louis University Mental Status) exam. She said the resident scored 12 on the test. A score below 20 indicates dementia. She said if the resident is deemed incapacitated, he is not able to leave the facility on his own.On 2/10/26 at 3:23 p.m., in a telephone interview Resident #900's physician said the resident went out for a walk. He said he called his Nurse Practitioner and also reviewed the resident's clinical record. The physician said the resident was receiving Piperacillin (an antibiotic medication to treat infections), his mental status was clear. The resident's cognition was going in and out, Piperacillin can cause that. He went for a walk. He said, This guy was frail and he had cancer, he knew what was going on and he was aware of his condition. He was end-stage but clear and articulated all the time that he wanted out of here and was trying to leave. He wanted to go home. Then he would say okay and he would wait for his son. Reaffirmed with the physician that the resident constantly said he wanted to get out of the facility and go home. The physician replied, Yes. Review of the facility provided Brief Interview for Mental Status form dated 11/28/25 at 2:25 p.m., completed upon Resident #900's return from the ER revealed 13 was entered for BIMS Total Score (0-15). The form was not signed by the evaluator.The Administrator provided the facility's policy used to in-service the staff and the list of staff that were educated.Review of the facility provided policy titled, Nursing-Elopement Prevention with an effective date of 04/01/2022, and no revision date revealed, It is the policy of this facility to provide a safe environment for all residents and to eliminate and/or control elopement behavior of incapacitated residents. Definition: Elopement occurs when an incapacitated resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave or absence) and/or any necessary supervision to do so. Examples of wandering or elopement behaviors include but are not limited to: a history of wandering behavior or elopement or elopement attempts, oblivious to needs/safety, attempting to leave unescorted, exit seeking, without or without rational purpose, verbalization of plans to leave the facility whether or not authorized, or if resident has shown a repeated disregard for facility policy regarding passes previously granted . When an incapacitated resident not known to have or identified to have wandering/elopement behaviors wanders into an unsafe area or attempts to or actually leaves the building, an electronic monitoring device shall be applied, an Elopement Risk Assessment shall be completed, and a care plan initiated.Review of the facility provided policy and procedure for Medical Records-Documentation with an effective date of 04/01/22 and a revision date of 11/25/2025 revealed the purpose was, To ensure compliance with required medical record documentation per regulatory guidelines for both the paper and electronic medical record (EMR).Nurse's notes shall be written on each resident by licensed/qualified nursing personnel and shall address the resident's conditions. Frequency of entries shall be dependent on individual residents' needs and any pertinent change in condition. Documentation of observations should be specific and objective . Document normal behavior, progressive signs, attitudes, and moods as well as abnormalities and pathological signs .On 2/13/26, the Immediate Actions implemented by the facility and verified by the survey team included:Resident #900 was successfully discharged home as planned on 12/6/25.On 2/13/26, the survey team verified through record review and interview with the Administrator that on 12/6/25, Resident #900 was discharged home.From 11/28/25-12/3/25 the Administrator/Designee completed staff re-education on Missing Resident Drill and Elopement with 154/154 staff members to include following the policy with emphasis on: Responding to door alarms, using the elopement binder, performing a resident headcount and Administrator and DON notification.On 2/13/26 the survey team verified through review of the education and interview with Registered Nurse Staff F, Certified Nursing Assistant (CNA) Staff G, CNA Staff H, CNA Staff C, Licensed Practical Nurse (LPN) Staff I, LPN Staff B, LPN Staff J, and the DON.The Administrator/Designee completed a Missing Resident Drill on 11/28/25, 11/29/25 (2), and 11/30/25 at varying times with 44 staff members participating collectively from each department.On 2/13/26, the survey team verified through review of documentation of the Missing Resident Drills and interview with 1 RN, 2 CNAs and 3 LPNs. All staff were able to verbalize the facility process for missing residents.On 12/1/25, the Administrator modified the receptionist's process for resident's exiting the facility and added this to the education for newly hired staff. The new process education included: The newly created binder with blue or white sheets for each resident. The blue sheet indicates residents require supervision for LOA (Leave of Absence). The white sheets indicate the resident is safe for unsupervised LOA. The determination of supervision for LOA's is made by the clinical team. Residents must sign in and out for LOA each time they leave the center. The front door is opened by the remote or keypad.On 2/13/26, the survey team verified through review of the new process, education provided and interview with the receptionist, the Administrator, the DON, Unit Manager Staff B, and LPN Staff J.On 12/3/25, the facility's contracted vendor removed the automatic open option on the front double doors, allowing the doors to remain locked with access by staff remote or key-pad entry/exit only.On 2/13/26, the survey team verified through review of the bill for service that a contracted vendor removed the automatic open option on the front double doors. Observation of the front double doors showed the door remained locked at all times and the doors open by staff remote or key-pad entry. Interview with CNA Staff H, CNA Staff C, LPN Staff I, the DON and the Administrator.On 2/12/26 the facility extended the receptionist's hours from 7:00 a.m.-9:00 p.m., 7 days a week. The front desk coverage process was updated to include the extended receptionist hours. This process establishes coverage for the front desk when the receptionist is on break or needs to step away as well as the process between the hours of 9:00 p.m.-7:00 a.m., for assisting residents with LOA and/or visitors entering and exiting the facility.On 2/13/26, the survey team verified through review of the new receptionist schedule, and interview with the Administrator, the DON, Receptionist Staff E, and Receptionist Staff K. In interviews RN Staff F, CNA Staff G, CNA Staff H, and CNA Staff C said they worked the evening or night shift and had been educated on the new process for assisting residents entering and leaving the facility. On 2/12/26 the Chief Nursing Officer re-educated the facility Administrator and Director of Nursing on the Center for Medicare and Medicaid Services (CMS) definition of elopement, their individual roles to ensure the safety of residents under their care and the expectation of completing a risk management report for resident elopement events.On 2/13/26, the survey team verified through review of the education provided and interview with the DON and Administrator. In an interview, the Chief Nursing Officer (CNO) said the facility had changed their elopement policy to reflect CMS's definition of an elopement.On 2/12/26, the members of the interdisciplinary team were re-educated on reporting and documenting resident incidents in the clinical record, the alleged deficient practice outlined on the immediate jeopardy template, and federal regulation F835 by the Chief Nursing Officer with an emphasis on ensuring the facility policies and procedures are followed related to medical record documentation.On 2/13/26, the survey team verified through review of the education provided and interview with the Administrator, the DON, RN Staff F, LPN Staff I, LPN Unit Manager Staff B, and LPN Unit Manager Staff J.On 2/12/26, 32/32 current residents admitted in the last 30 days were re-evaluated for accuracy of new admission assessments and documentation related to cognitive status and elopement risk by the Director of Nursing/Designee. No new like residents were identified to be at risk.On 2/13/26, the survey team verified through interview with the DON and review of the facility provided evaluations of new admission assessments, documentation related to cognitive status and elopement risk.On 2/12/26, the receptionist on duty for the 11/28/25 event was re-educated by the Administrator/Designee on ensuring residents exiting the facility were approved by the clinical staff prior to allowing the resident to exit.The newly created binder with blue or white sheets for each resident. The blue sheet indicates residents require supervision for LOA. The white sheets indicate the resident is safe for unsupervised LOA. The determination of supervision for LOA's is made by the clinical team. Residents must sign in and out for LOA each time they leave the center.The front door is opened by the remote or keypad.On 2/13/26, the survey team verified through review of the LOA binder, the blue and white sign-in sheets and interview with the receptionist, RN Staff F, CNA Staff G, CNA Staff H, CNA Staff C, LPN Staff I, LPN Staff B, LPN Staff J, and the DON.On 2/12/26, the Director of Nursing/Designee completed a new elopement risk assessment on 103/103 current residents in the electronic medical record system. No new residents were identified as potentially being at risk for elopement.On 2/13/26, the survey team verified through review of the new elopement risk assessment for 20 randomly selected residents, interview with the DON and Unit Manager LPN Staff B. On 2/12/26, 31/31 current licensed nurses were educated by the Director of Nursing/Designee on communicating when a physician changes a residents' capacity to notify the Director of Nursing and/or the Administrator at the time of the determination to ensure timely re-evaluation of resident risk for elopement.On 2/13/26, the survey team verified through review of the education and interview with RN Staff F, LPN Staff I, LPN Staff B, LPN Staff J, and the DON.The Director of Nursing/Designee completed staff re-education regarding the CMS definition of elopement, the updated facility elopement policy, documentation of resident incidents in the clinical record, and the new receptionist process for resident's exiting the facility to include the newly created binder with blue or white sheets for each resident, the determination of supervision for LOA's is made by the clinical team, residents must sign in and out for LOA each time they leave the center and the front door is opened by the remote or keypad conducted on the following dates: 2/10/26 with 103/142 staff members. 2/11/26 with 32/142 staff members. 2/12/2026 with 7/142 staff members.In total 142/142 current employees were educated. The facility does not use any agency staffing.On 2/13/26, the survey team verified through review of the content of the education provided and interviews with RN Staff F, CNA Staff G, CNA Staff H, CNA Staff C, Licensed LPN Staff I, LPN Staff B, LPN Staff J, and the DON.An ADHOC (unplanned) Quality Assurance meeting was held with the facility medical director in attendance via phone on 2/12/26. The facility completed QA Meetings on 12/10/25 and 1/14/26 to include review of the new receptionist process for residents exiting the facility. The following team members were in attendance: Facility Administrator, Director of Nursing, Assistant Director of Nursing, and Maintenance Director. The ADHOC QAPI (Quality Assurance and Performance Improvement) Committee approved of the recommendations.On 2/13/26, the survey team verified through review of the ADHOC QAPI meeting and interview with the Administrator, and the DON.

Based on observation, clinical record review, review of facility's policies and procedures, resident representative and staff interviews, the facility failed to adequately supervise 1 (Resident #900) of 3 sampled residents with cognitive impairment, confusion and poor safety awareness to prevent unsafe wandering and elopement.On 11/28/25 at approximately 9:45 a.m., Resident #900 who was cognitively impaired, ambulatory, confused and had poor safety awareness walked past the unattended front desk of the facility and exited the building through the unlocked front door.Resident #900 crossed a two lane road and walked 0.5 mile to the dorm of a State College through uneven terrain and near water ponds. The college staff found Resident #900 wandering in the dorm, confused, unsteady and shaking. The college staff called EMS (Emergency Medical Services) and Resident #900 was transferred to a local Emergency Room.The facility staff were not aware of the resident's exit until 11/28/25 at approximately 10:35 a.m., when the college campus officer notified the facility of the resident's transfer to a local emergency room via EMS.The facility failure to ensure adequate supervision to prevent unsafe wandering and elopement of cognitively impaired, and confused residents created a likelihood of avoidable accidents for Resident #900 and other cognitively impaired and confused residents which could result in serious harm, serious injury, serious impairment or death of the residents.This failure resulted in the determination of Immediate Jeopardy.On 2/12/26, after verification of an acceptable removal plan, the immediate Jeopardy was removed as of 2/12/26. The scope and severity for F689 was reduced to D, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy.The findings included:Cross Reference to F835.On 2/9/26 at 10:12 a.m., in a telephone interview, Resident #900's family member said that on 11/28/25 the resident left the facility unsupervised and they were very upset that the facility did not notify them of the incident until 24 hours later. The family member said, What if he had made it to the main road and got hit by a car or laid down somewhere and could not get back up?.On 2/9/26 at 1:57 p.m., an interview was conducted with the Director of Nursing (DON) and the Administrator. The DON verified that on 11/28/25 Resident #900 exited the facility without staff knowledge and supervision. A request was made to see the investigation for Resident #900's elopement.The DON said, I want to change the topic and not call it an elopement.The Administrator said that on 11/28/25 Resident #900 went out for a walk and forgot to sign himself out. He was found on the cameras at the college at 9:54 a.m. The people who found him saw the PICC (Peripherally Inserted Central Catheter) line out, they freaked out. They called EMS and sent him to the Emergency Room. The facility staff knew he was missing at 10:30 a.m. The campus security came over and said that Resident #900 walked into a dormitory and was looking for a way back. The Administrator reiterated that no one saw Resident #900 leave the facility but he did not elope. He went out and he was just too tired to come back. She said the resident was cognitively intact and had a BIMS of 13 when he returned to the facility.The Administrator said they have initiated a new leave of absence (LOA) process to sign residents in and out of the facility. The front desk now has a book with blue sign out sheets and white sign out sheets. Residents with a blue sign-out sheet are not allowed to leave the facility unattended. The Administrator said she only educated the front desk staff and managers on the new process for the white and blue sign out sheets. She said she did not think it was important for all the staff to be educated on the new process but educated the staff on the facility's elopement policy.Review of the clinical record for Resident #900 revealed an admission date of 11/5/25. Diagnoses included malignant neoplasm (cancer) of the esophagus, severe protein-calorie malnutrition, adult failure to thrive and history of immunosuppression therapy.Review of the Elopement Risk Evaluation with an effective date of 11/6/25 revealed Resident #900 was determined not to be at risk for elopement based on the potential risk factors listed. Unit Manager (UM) Staff B completed the Elopement Risk Evaluation and answered No to the questions, Is the resident cognitively impaired, Does the resident have poor decision-making skills, Has the resident demonstrated exit seeking behaviors? , Does the resident wander oblivious to safety needs? and Does the resident have a history of elopement?. UM Staff B answered yes to questions, Is the resident independently mobile (ambulatory or wheelchair)? and Does the resident have the ability to exit the facility?.Review of the Physical Therapy Evaluation and Plan of Treatment dated 11/6/25 revealed Resident #900 required Partial/moderate assistance to walk 150 feet. The evaluation noted that Resident #900, Presents with decreased insight, decreased functional capacity . gross motor coordination deficits, strength impairment, postural alignment/control, deficits in judgment and decreased safety awareness.Review of the care plan initiated on 11/6/25 revealed that Resident #900 was at risk for falls related to little energy, impaired balance, pain due to severe protein-calorie malnutrition, chemotherapy and anemia.Review of the Speech Language Pathology Evaluation and Plan of Treatment dated 11/6/25 revealed that Resident #900, Presents with moderate cognitive-communication deficit at this time with primary deficits and short term memory, problem solving and executive functioning skills . The goals included for the resident to demonstrate functional problem solving and safety awareness in 70% of opportunities given minimum-moderate verbal cues in order to promote safety within current/home environment and to enhance decision making skills and increase ability to function safely without additional assistance/supervision due to cognitive deficits to 76-90% of the time in order to demonstrate improved problem solving/cognition skills. The Speech Language Pathologist documented Resident #900 scored 16/30 on the SLUMS (St. Louis University Mental Status) assessment, indicating moderate cognitive impairment.Review of the admission Minimum Data Set (MDS) with an assessment reference date of 11/12/25 revealed Resident #900 scored 12 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. The triggered care areas addressed in the resident's care plan included cognitive loss/dementia and activities of daily living functional /rehabilitation Potential.On 11/12/25 at 6:00 p.m., a nursing alert note documented, Resident pulled out his PIC (Peripherally Inserted Catheter) line (Catheter inserted into a peripheral vein and threaded into a large central vein to administer long term intravenous therapy) and was holding it in his hand. He is confused and did not know what he was doing. Palliative consult was ordered earlier today for change in mental status and advanced cancer.The care plan initiated on 11/13/25 revealed that Resident #900 had impaired cognitive function or impaired thought process related to disease process. Resident #900 scored 12 on the BIMS assessment. The goal included for the resident to be able to communicate basic needs on a daily basis and maintain current level of cognitive function.On 11/14/25 an Advanced Practice Registered Nurse (APRN) progress note documented, Patient was noted to intermittently confused and repeatedly pulling at his IV tubing, requiring redirection and reinforcement of safety measures . Acute Confusion with IV Interference . Observed intermittent confusion leading to pulling at IV tubing, placing patient at risk for injury and catheter complications. Reinforce safety measures and monitor mental status. Consulted and collaborated closely with the palliative care APRN and pain management team given global decline and comfort-oriented goals of care.On 11/14/25 at 7:07 p.m., a nursing progress note documented, Level of consciousness noted as oriented to person, restless.On 11/16/25 at 2:41 a.m., a nursing alert note documented, PT (patient) ripped out IV. When Pt was asked Pt stated I didn't do that, I'm ready to go to Vietnam. Pt is confused, AO X1 (Alert, Oriented to person). No evidence of learning.On 11/17/25, a physician progress note documented, Cognitive impairment with treatment-interfering behaviors . Confusion leading to repeated removal of IV lines, refusal of replacement at times. Requires close supervision and safety monitoring. Ensure orientation cues and minimize environmental triggers.On 11/17/25, an APRN note documented, Neurologic: Intermittent confusion; no focal deficits.On 11/18/25, a Speech Language Pathology discharge summary noted that on 11/18/26 Resident #900 achieved 65 to 70% accuracy for the Short Term Goal of, The patient will demonstrate functional problem solving and safety awareness in 70% of opportunities given min-mod verbal cues in order to promote safety within current/home environment and to enhance decision making skills.On 11/19/25, the Psychiatry Advanced Practice Registered Nurse (APRN) documented in a progress note that Resident #900 was seen at the request of his primary care physician to follow-up and evaluate for capacity. The APRN documented, In my opinion, this patient lacks the capacity to make decisions related to his/her need for healthcare, or long-term placement. Due to cognitive impairment, the patient is unable to understand the nature, extent or probable consequences of not receiving medical care. In addition, the patient is unable to make a rational evaluation of the burden, risks, and benefits of treatments. In my opinion, the patient can benefit from a guardian or POA (Power of Attorney). The patient's Primary care provider is to sign off the final Capacity Determination Form.On 11/19/25 an APRN progress note documented, Psychiatric APRN evaluated him (Resident #900) for decision-making capacity today, and after collaboration with her, she reported he was very confused, unable to answer orientation questions, such as year or president . The progress note documented that Resident #900 remained profoundly frail and fluctuating mental status.The progress note documented, Cognitive Impairment/Confusion. Confusion worsening. Psych APRN capacity evaluation completed today; she found significant disorientation and inability to answer orientation questions. I collaborated with her regarding these findings; detailed note pending. Risk of delirium, unsafe behaviors, and poor medical decision reliability .On 11/20/25, a nursing progress note documented Resident #900 was oriented to person, oriented to place, restless and not sure of the name of the facility. Resident #900's had verbal behaviors of screaming, cursing etc.On 11/24/25, a physician's progress note documented that Resident #900 was noted to be intermittently confused and repeatedly pulling at his IV (intravenous) tubing, requiring redirection and reinforcement of safety measures.On 11/25/25 a Physical Therapy encounter note documented, Pt reported that he needed to go to the bathroom. However, he was walking out of the room into someone else room. The [sic] was redirected to his room to use the bathroom. Pt appears to be confused to today. The DOR (Director of Rehab) notify.On 11/26/25, an APRN progress note documented Resident #900 had mild confusion fluctuates per history.On 11/28/25 at 6:00 p.m., a nursing progress note documented that Resident #900's level of consciousness was, noted as oriented to person oriented to place. Behavioral problems are not noted.The next nursing progress note was dated 11/30/25 at 12:25 p.m., and noted, Level of consciousness was noted as oriented to person to place restless .On 12/2/25 at 2:34 p.m., a Social Service Progress note documented, I provided the resident's son and daughter in law with the Health Care Surrogate form requested and instructed him to complete and return it to the facility.The clinical record noted that Resident #900 was discharged home on [DATE].There was no documentation in the clinical record that on 11/28/25 Resident #900 exited the facility without staff knowledge and supervision.Review of the facility provided typewritten timeline of event for Resident #900 revealed:11/28/25 at 9:00 a.m., Licensed Practical Nurse (LPN) Staff A administered morning medications. The resident was in a good mood, voiced no concerns.11/28/25, 9:00 a.m.- 9:30 a.m., therapy treats resident in the room.11/28/25 at 9:45 a.m., LPN Staff A and Certified Nursing Assistant (CNA) Staff C see resident standing at B wing nursing station. When asked if he needed anything, he said, no. CNA Staff D exits supply room and sees resident at nursing station.11/28/25 at 9:45 a.m., EMS leaves via front door with another resident. LPN/Unit Manager Staff B is at front door and ensures doors close, locks and no one follows EMS out[KM5.1][VB5.2].11/28/25 at 9:47 a.m., Front Desk goes to kitchen to take meal tickets.11/28/25 at 9:54 a.m., the resident appears on cameras walking on the college campus.11/28/25 at 9:59 a.m., College security is dispatched to the dormitory front desk to assist resident who is standing at the desk. Calls EMS once he notes IV port.11/28/25 at 10:34 a.m., Campus security officer arrives at facility to inquire if Resident #900 resides at Ambassador and speaks with the Assistant Director of Nursing (ADON).11/28/25 at 10:50 a.m., Resident is transported to a local ER (Emergency Room) Clinic.11/28/25 at 11:30 a.m., the ADON travels to ER Clinic to see resident. Upon arrival he is in no distress and is able to state that he went out the front door to go for a walk and describes how he opened front gate, also confirms that he went to ask to use the phone to get someone to assist him as he was tired of walking.11/28/25 at 2:20 p.m., Resident returned to the facility with no new orders.11/28/25 at 2:25 p.m., BIMs conducted, BIMs 13. Resident statement also taken and he states he didn't realize he couldn't go for a walk because he checked himself in and should be able to check himself out. Resident describes going out the front door as it was open and how he opened the gate. He states that he was looking for a phone for a ride when the officer assisted him. Resident was reeducated on the Leave of absence (LOA) process and verbalized understanding.Review of the facility provided witness statements for Resident #900 revealed:On 11/28/25 Receptionist Staff E signed a typewritten witness statement that read, 9:45 a.m. EMS left with (Resident name) and the doors were closed. 9:50 a.m.-9:55 a.m.- I took (name) the orientee, with me to the kitchen to drop off the meal changes. 10:15 a.m. I left the front desk to go pick up the LOA books from the nursing stations. I left (name) alone at the front desk while I was gone.On 11/28/25, LPN Staff A signed a typewritten witness statement that she saw Resident #900 around 9:00 a.m., he was eating his breakfast when she passed his medicines. He was in a good mood and had no concerns. She was going to help CNA Staff C with another resident around 9:45 a.m.-10:00 a.m. and Resident #900 was standing at the nursing station. She asked him if he needed anything and he said, No. Resident #900 never mentioned that he wanted to leave or was in distress.On 11/28/25 the ADON signed a typewritten statement that at approximately 10:34 a.m., she saw the campus police at the front desk. He informed her that they had found Resident #900 over by the campus dormitories. She asked the officer how Resident #900 got over there. The officer said the resident came to the desk and told the dormitory resident aide that he was tired and wanted to use the phone. The officer informed her that he had called EMS. The ADON statement documented, We then did a full head count of residents in house and began our interviewing process.On 2/9/26 at 3:55 p.m., in an interview the Speech Therapist said Resident #900 was cognitively impaired and was not safe to leave the facility without supervision. She said she was working with the resident on cognition. He had cognitive loss, no safety awareness and reduced memory awareness. The Speech Therapist said she did not receive education on the facility's leave of absence policy and did not know about the difference between the blue and white signing in and out sheets.On 2/10/26 at 9:15 a.m., observation of the route Resident #900 would have traveled to get to the college campus dorm revealed the resident crossed a 2 lane road with no sidewalk on either side. Uneven terrain was noted along the route and in the college parking lot. Multiple retention ponds were observed along the route with bridges over the ponds. The facility is located approximately 100 yards from a busy 6 lane road with a speed limit of 45 miles per hour.On 2/10/25 at 10:15 a.m., an interview was conducted with the Sergeant of Security training at the college where Resident #900 was found. He reviewed the incident forms but said he could not provide a copy to the survey team. He said that Resident #900 wandered to the (name) Dorm. The receptionist said he was confused, disoriented, unsteady and shaking. She contacted the campus police who noted the resident was disheveled and had no clue where he was. Resident #900 said he had come from a hospital in [NAME] but had no idea of where he was. Campus police contacted EMS. The Sergeant of Security Training reviewed the security camera video. He said that the campus police arrived at 9:59 a.m., Resident #900 was disheveled, disoriented, unsteady and shaking. He said, most definitely unsteady. He said they run marathons through the campus and was certain that the dorm where Resident #900 was found was half a mile from the facility. He said as soon as EMS arrived, campus police went to the facility to informed them of what had occurred with Resident #900.Review of the EMS Patient Care Record dated 11/28/25 for Resident #900 revealed EMS was called on 11/28/25 at 10:14 a.m., and was on scene at 10:20 a.m. The EMS Patient Care Record documented, EMS arrived on scene to find a man sitting in the back of a police car with the door open talking with the . State police officer. Patient seemed very nervous and scared but was able to identify that he had been walking and that he walked up to a building that he thought would have a phone. He did not remember any phone numbers . Patient had no medical complaints, only stating that he had been walking this morning and believed he was in [NAME], but he then realized he was in Fort [NAME]. Patient stated that it was very cold, and that he did not remember where he was supposed to be at. The EMS Patient Care Record documented on 11/28/25 at 10:47 a.m., Mental Status: Normal mentation for pt (patient), per facility via phone. Mental Status. Oriented-Person and the college police was notified of a potential escaped patient.On 2/10/26 at 12:05 p.m., in an interview Unit Manager Staff B verified that on 11/28/25 Resident #900 left the facility without staff knowledge and supervision. She said no other elopement evaluation was done for the resident after the initial elopement evaluation of 11/6/25. When asked about the lack of documentation of the resident's elopement in the clinical record, Unit Manager Staff B said she was told not to document anything about the incident, that the DON and Administrator would take care of that. She said as far as she was concerned, Resident #900 was at baseline, always confused.On 2/10/26 at 12:10 p.m., an interview was held with the DON and Administrator. The Administrator said that on the day Resident #900 went out for a walk, Receptionist Staff E left the front desk unattended but had the clicker to open the door in her pocket. When the resident came back from the ER, Unit Manager Staff B watched her personally doing a BIMS test for Resident #900. He scored a 13 indicating intact cognition. The Administrator said that if a resident was cognitively impaired but did not have an incapacity statement, she would allow them to leave the facility[KM10.1][VB10.2] unsupervised. She said she was not aware that on 11/19/25 the Psych APRN had evaluated Resident #900 for capacity and determined the resident was incapacitated. She said in December 2025, they changed the front door lock. The door does not open unless the receptionist uses the clicker to unlock the door. The change was unrelated to Resident #900 exit from the facility. It was already planned. They initiated a new process to sign residents in and out of the facility. Residents who cannot leave the facility unattended are identified with a blue sign in sheet. Residents who can leave the facility without supervision have a white sign in sheet. The Administrator said she educated the receptionists and management staff on the new process. She was not able to provide documentation of the training. She said all staff were educated on the elopement policy and given an elopement posttest to validate their understanding.Review of the Elopement Post test signed and dated by Receptionist Staff E on 11/28/25 showed the multiple choice questions were not answered. The posttest was blank.The Director of Nursing said that she was on leave on Friday 11/28/25 when Resident #900 left the facility. She came back that Monday and reviewed the clinical record. She verified that the incident was not documented in the clinical record and she did not ask the staff to make a late entry and document what had happened. She said sometimes she asks staff to go back and make a late entry but did not for Resident #900. The DON also verified that they did not reevaluate Resident #900's risk for elopement or update the care plan with interventions to prevent further incidents of elopement. She said Resident #900 was alert and oriented and there was no need to reevaluate him. The DON said they do a new elopement evaluation when there is a big change. She explained that if a resident did not express the desire to leave the day before and now they did, and the resident did not make sense, then they would reevaluate.On 2/10/26 at 1:10 p.m., in an interview, Receptionist Staff E said she was working at the front desk on 11/28/25 when Resident #900 left the facility. She said she was training someone. The trainee asked to see where the kitchen was. They went to the kitchen and left the front desk unattended around 9:50 a.m. She said that was probably when Resident #900 left the facility. She said a visitor must have come in, opened the front door and Resident #900 left the facility.On 2/10/26 at 1:30 p.m., in a telephone interview the psychiatric APRN said that on 11/19/25, at the request of the resident's physician, assessed Resident #900 for capacity. She found that Resident #900 lacked capacity to make decisions related to his healthcare needs. He scored very poorly on the SLUMS test, he scored 12. She explained that a score below 20 indicates dementia. The psychiatric APRN said that if Resident #900 was deemed incapacitated, he was not able to go out on his own.On 2/10/16 at 1:45 p.m., in an interview, Unit Manager Staff B said Resident #900 was always confused. He thought he was home. He would frequently come to the nurse's station looking for someone, a family member that wasn't there. The Unit Manager said she did not know if Resident #900 ever went to sit outside. She said on 11/28/25 upon the resident's return, they placed him on one on one supervision but did not recall for how long. She reiterated that she was told not to document anything about the resident leaving the facility on 11/28/25, that the DON and Administrator would take care of it.On 2/10/26 at 3:23 p.m., in a telephone interview, Resident #900's physician said that Resident #900 went out for a walk. He called his Nurse Practitioner and also reviewed the resident's clinical record. The physician said the resident was receiving Piperacillin (antibiotic), his mental status was clear. The resident's cognition was going in and out, Piperacillin can cause that. The physician said, This guy was frail and he had cancer, he knew what was going on and he was aware of his condition. He was end-stage but clear and articulated all the time that he wanted out of here and was trying to leave. He wanted to go home. Then he would say okay and he would wait for his son. Reaffirmed with the physician that the resident constantly said he wanted to get out of the facility and go home. The physician replied, Yes.Review of the Medication Administration Record for November 2025 revealed Resident #900 received Piperacillin 4.5 Grams intravenously every 6 hours from November 6, 2025, through November 30, 2025. On 2/11/26 at 4:25 p.m., in an interview the Administrator said that during a welcome meeting with new residents, they determine if the resident required supervision to leave the facility. When asked if the facility used a tool upon admission and as needed to facilitate the decision to use a blue sheet or white sheet, she said, No. The Administrator said she would type up something.On 2/13/26, the immediate actions implemented by the facility and verified by the survey team included:Resident #900 no longer resides at the facility and was successfully discharged home as planned on 12/6/25.On 2/13/26, the survey team verified through clinical record review and interview with the Administrator that on 12/6/25, Resident #900 was discharged home.On 11/28/25 Resident #900 was immediately placed on 1:1 staff observation. A licensed nurse performed a complete skin inspection with no new skin concerns identified. The resident's cognitive status was re-evaluated using the BIMS assessment with a score of 13/15 indicating resident #900 was cognitively intact.On 2/13/26, the survey team verified through documentation and interview with the Administrator, and Unit Manager LPN Staff B that Resident #900 was placed on 1:1 staff observation and a skin assessment was completed on 11/28/25.From 11/28/25-12/3/25 the Administrator/Designee completed staff re-education on Missing Resident Drill and Elopement with 154/154 staff members to include following the policy with emphasis on: Responding to door alarms, using the elopement binder, performing a resident headcount and Administrator and DON notification.On 2/13/26 the survey team verified through review of the education and interview with Registered Nurse Staff F, Certified Nursing Assistant (CNA) Staff G, CNA Staff H, CNA Staff C, Licensed Practical Nurse (LPN) Staff I, LPN Staff B, LPN Staff J, and the DON.On 12/1/25, the Administrator modified the receptionist's process for resident's exiting the facility and added this to the education for newly hired staff. The new process education included: The newly created binder with blue or white sheets for each resident. The blue sheet indicates residents require supervision for LOA. The white sheets indicate the resident is safe for unsupervised LOA. The determination of supervision for LOA's is made by the clinical team. Residents must sign in and out for LOA each time they leave the center. The front door is opened by the remote or keypad. On 12/3/25, the facility's contracted vendor removed the automatic open option on the front double doors, allowing the doors to remain locked with access by staff remote or key-pad entry/exit only.On 2/13/26, the survey team verified through review of the receptionist's process for residents exiting the facility, interview with the receptionist, review of the newly created binder. Observation of the front door of the facility showed the door remains locked and can only be opened with a remote or by entering a code on the keypad.On 2/12/26 the facility extended the receptionist's hours from 7:00 a.m. -9:00 p.m., 7 days a week. The front desk coverage process was updated to include the extended receptionist hours. This process establishes coverage for the front desk when the receptionist is on break or needs to step away as well as the process between the hours of 9:00 p.m. -7:00 a.m., for assisting residents with LOA and/or visitors entering and exiting the facility.On 2/13/26, the survey team verified through review of the new receptionist schedule, and interview with the Administrator, the DON, Receptionist Staff E, and Receptionist Staff K. In interviews RN Staff F, CNA Staff G, CNA Staff H, and CNA Staff C said they worked the evening or night shift and had been educated on the new process for assisting residents entering and leaving the facility. On 2/12/26, 32/32 current residents admitted in the last 30 days were re-evaluated for accuracy of new admission assessments and documentation related to cognitive status and elopement risk by the Director of Nursing/Designee. No new like residents were identified to be at risk.On 2/13/26, the survey team verified through interview with the DON and review of the facility provided evaluations of new admission assessments, documentation related to cognitive status and elopement risk.On 2/12/26, the Administrator confirmed the LOA process is included in the new admission packet.On 2/13/26, the survey team verified through review of the admission packet and interview with the Administrator.On 2/12/26, the Director of Nursing/Designee completed a new elopement risk assessment on 103/103 current residents in the electronic medical record system. No new residents were identified as potentially being at risk for elopement.On 2/13/26, the survey team verified through review of the new elopement risk assessment for 20 randomly selected residents, interview with the DON and Unit Manager LPN Staff B.On 2/12/26, the receptionist on duty for the 11/28/25 event was re-educated by the Administrator/Designee on ensuring residents exiting the facility were approved by the clinical staff prior to allowing the resident to exit. The newly created binder with blue or white sheets for each resident. The blue sheet indicates residents require supervision for LOA. The white sheets indicate the resident is safe for unsupervised LOA. The determination of supervision for LOA's is made by the clinical team. Residents must sign in and out for LOA each time they leave the center. The front door is opened by the remote or keypad.On 2/13/26, the survey team verified through review of the education provided, interview with the receptionist, review of the newly created binder. Interview with the DON, Unit Manager Staff A, and Unit Manager Staff B verified the determination of supervision for LOA is made by the clinical team.The Director of Nursing/Designee completed staff re-education regarding federal regulation F689, specifically the Center for Medicare and Medicaid Services (CMS) definition of elopement, the updated facility elopement policy, documentation of resident incidents in the clinical record, and the new receptionist process for resident's exiting the facility to include the newly created binder with blue or white sheets for each resident, the determination of supervision for LOA's is made by the clinical team, residents must sign in and out for LOA each time they leave the center and the front door is opened by the remote or keypad conducted on the following dates: 2/10/2026 with 103/142 staff members. 2/11/2026 with 32/142 staff members. 2/12/2026 with 7/142 staff members. In total 142/142 current employees were educated. The facility does not use any agency staffing.On 2/13/26, the survey team verified through review of the education provided and interviews with RN Staff F, CNA Staff G, CNA Staff H, CNA Staff C, LPN Staff I, LPN Staff B, LPN Staff J, and the DON.On 2/12/26, 31/31 current licensed nurses were educated by the Director of Nursing/Designee on communicating when a physician changes a residents' capacity to notify the Director of Nursing and/or the Administrator at the time of the determination to ensure timely re-evaluation of resident risk for elopement.On 2/13/26, the survey team verified through review of the content of the education, and interview with RN Staff F, LPN Staff I, LPN Staff B, LPN Staff J, and the DON.An ADHOC (unplanned) Quality Assurance (QA) meeting was held with the facility Medical Director in attendance via phone on 2/12/26. The facility completed QA Meetings on 12/10/2025 and 1/14/[TRUNCATED]

Based on record review, review of facility's policy and procedure and staff interviews, the facility failed to maintain a medical record on 1 (Resident #900) of 3 residents reviewed that was completely and accurately documented.The findings included:Review of the facility's policy and procedure titled, Medical Records - Documentation with an effective date of 04/01/22 and a revision date of 11/25/2025 revealed, Nurse's notes shall be written on each resident by licensed/qualified nursing personnel and shall address the resident's conditions. Frequency of entries shall be dependent on individual residents' needs and any pertinent change in condition. Documentation of observations should be specific and objective. Each entry will be signed with the writer's name and credentials .Review of the clinical record for Resident #900 revealed an admission date of 11/5/25 and a discharge date of 12/6/25.Review of the admission Minimal Data Set (MDS) with an assessment reference date of 11/12/25 revealed Resident #900 scored 12 on the Brief Interview for Mental Status (BIMS), indicating moderately impaired cognition.On 11/28/25 at 6:00 p.m., a nursing progress note documented that Resident #900's level of consciousness was, noted as oriented to person oriented to place. Behavioral problems are not noted.The next nursing progress note was dated 11/30/25 at 12:25 p.m., and noted, Level of consciousness was noted as oriented to person to place restless .On 2/9/26 at 10:12 a.m., in a telephone interview, Resident #900's family member said that on 11/28/25 the resident left the facility unsupervised, and they were very upset that the facility did not notify them of the incident until 24 hours later. The family member said, What if he had made it to the main road and got hit by a car or laid down somewhere and could not get back up?.On 2/9/26 at 1:57 p.m., in an interview the Director of Nursing (DON) and Administrator verified that on 11/25/25, Resident #900 exited the facility without staff knowledge and supervision. The Administrator said Resident #900 walked into the dormitory of a nearby state college campus. The people who found him called EMS (Emergency Medical Services) and sent Resident #900 to the Emergency Room. She said the facility staff knew that the resident was missing at 10:30 a.m. The campus security came over and said that the resident walked into a dormitory and was looking for a way back.On 2/10/25 at 10:15 a.m., in an interview, the Sergeant of Security training at the college where Resident #900 was found said that on 11/28/25 Resident #900 wandered to a college campus dorm that is half a mile from the facility. The receptionist at the dorm said the resident was confused, disoriented, unsteady and shaking and she called the campus police who called EMS. EMS transported Resident #900 to a local emergency room Clinic.Review of the EMS Patient Care Record dated 11/28/25 revealed that EMS was on scene at 10:20 a.m., departed at 10:44 a.m., arrived at destination at 10:51 a.m. and transferred the resident at 11:05 a.m.On 2/10/25 at 12:05 p.m., in an interview, Unit Manager Staff B verified that on 11/28/25 Resident #900 left the facility without staff knowledge or supervision. When asked about the lack of documentation of the resident's elopement in the clinical record, Unit Manager Staff B said that she was told not to document anything about the incident in the resident's clinical record, that the DON and Administrator would take care of that.On 2/10/26 at 12:10 p.m., in an interview was held with the DON and Administrator to discuss the lack of documentation of Resident #900's elopement, emergency room visit and return to the facility in the clinical record.The DON verified that on 11/28/25 Resident #900 exited the facility without staff knowledge and supervision. She verified that the incident was not documented in the resident's clinical record and said sometimes she asks staff to go back and make a late entry, but she did not for Resident #900.The Administrator said that on 11/28/25 Resident #900 went out for a walk. She said the resident was found in the dorm of a nearby state college. They called EMS and sent the resident to a local Emergency Room. She said upon Resident #900's return to the facility, Unit Manager Staff B watched her personally administer a BIMS (Brief Interview for Mental Status) test to Resident #900. He scored 13 on the BIMS test, indicating intact cognition.The facility provided BIMS test for Resident #900 was dated 11/28/25 at 2:25 p.m. The form was not signed with the writer's name and credentials.On 2/10/16 at 1:45 p.m., in an interview, Unit Manager Staff B said that upon Resident #900's return on 11/28/25, he was placed on one-on-one supervision but could not recall for how long. She reiterated that she was told not to document anything in the clinical record about the resident leaving the facility on 11/28/25 without staff knowledge or supervision.

Based on record review, review of facility's policies and procedures and staff interviews, the facility failed to provide care as specified in the care plan resulting in an avoidable fall with injury for 1 Resident #1) of 3 dependent residents reviewed. The findings included: Review of facility Policy titled Nursing - Activities of Daily Living (ADL's), effective date 4/01/22 revealed its primary goal is to ensure all resident's needs are met in a manner that promotes their quality of life and preference. (3) A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of medical records revealed Resident #1 was admitted to the facility on [DATE] with diagnosis including Alzheimer's Disease (a progressive neurodegenerative disorder that primary affects the brain, causing a gradual decline in memory, symptoms affecting memory, thinking and social abilities), anxiety disorder (feeling of fear, dread or uneasiness), and major depressive disorder (persistent feelings of sadness or hopelessness). The Admission Minimum Data Set (MDS) with a target date of 4/23/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition. Review of Care Plan dated 3/8/23 revealed Resident #1 has an ADL self-care performance deficit related to Alzheimer's Disease. Resident #1 was weak with impaired balance and mobility. Interventions included Resident #1 was dependent on staff for ADL's and required substantial/maximum assistance of two staff with bed mobility (changing positions while in bed). Review of Kardex (an electronic system used to summarize resident information) revealed Resident #1 required substantial/maximum assistance of two staff with bed mobility. Review of incident note dated 4/6/25 revealed that Certified Nursing Assistant (CNA) Staff A was providing care to Resident #1 and Resident #1 experienced a fall out of the bed. Review of a progress note dated 4/6/25 revealed Resident #1 was observed lying on her right side on the floor next to her bed and in between her tray table. Resident #1 was visibly upset and crying. Resident #1 was bleeding from the left side of her forehead above her eyebrow. Review of Change in Condition Form dated 4/6/25 revealed during ADL care Resident #1 fell from the bed during ADL care resulting in an injury to Resident #1's forehead. Review of medical record revealed Resident #1 was transferred to the hospital and required seven sutures to the forehead injury related to the fall reported. On 4/29/25 at 9:10 a.m., observed Resident #1 in bed with visible healing pink scar on forehead. On 4/29/25 at 3:13 p.m., in an interview Certified Nursing Assistant (CNA) Staff A said she was doing a linen change for Resident #1 alone. Staff A said she rolled Resident #1 toward her and the resident fell out of bed. Staff A said she was not told Resident #1 was a fall risk or a two person assist. Staff A said she has had Resident #1 multiple times and always did Resident #1's care by herself. Staff A said she received a call later that day from the Director of Nursing (DON) explaining Resident #1 was a two person assist with bed mobility. Staff A said the fall and injury was neglect because the care she provided was not done properly since Resident #1 required two people and she was doing care alone. On 4/29/25 at 3:53 p.m., in an interview Licensed Practical Nurse (LPN) Staff B said CNA Staff A came to get her because the resident fell off the bed. Staff B said Staff A told her she was changing Resident #1, put her on the side and Resident #1 fell off the bed. Staff B said staff use the Kardex to know each resident's individual needs and they are supposed to be trained on the Kardex in orientation. Staff B said neglect would include performing care alone when the resident requires two staff members for care. On 4/30/25 at 10:33 a.m., the DON said she was called about Resident #1 going to the hospital and that Resident #1 had a gash on her forehead. The DON confirmed she reviewed the staff witness statements and Resident #1 Kardex and concluded the staff did not follow the plan of care. The DON said Staff A told her she has been doing care for Resident #1 by herself all along and that she did not know about the Kardex. The DON said at that point we realized there was a breakdown in the system. The DON said Staff A was not in-serviced on the Kardex and did not receive Kardex training during orientation. The DON said not following the resident's plan of care is neglect. On 4/30/25 at 11:23 a.m., Licensed Nursing Home Administrator (LNHA)said she worked with the DON on the investigation for Resident #1's fall together. The LNHA said they found out Staff A had not followed the Kardex plan of care when she was providing care for Resident #1. The LNHA said her investigation revealed CNA, Staff A while providing care alone, turned Resident #1 towards her and the resident ended up falling out of bed. The LNHA said the conclusion of the investigation was Staff A was not following the Kardex and the plan of care for Resident #1 which is neglect. She said the facility substantiated neglect and confirmed Neglect is a never event.

Based on record review, review of facility's policies and procedures and staff interviews, the facility failed to protect the resident's rights to be free from neglect by failing to follow safety precautions specified in the care plan to prevent avoidable accident with injury for 1 (Resident #1) of 3 dependent residents reviewed. The findings included: Review of facility Policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment, Injury of unknown source and Investigations, effective date 4/01/22 revealed neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of facility Policy titled Nursing - Activities of Daily Living (ADL's), effective date 4/01/22 revealed its primary goal is to ensure all resident's needs are met in a manner that promotes their quality of life and preference. (3) A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of medical records revealed Resident #1 was admitted to the facility on [DATE] with diagnosis including Alzheimer's Disease (a progressive neurodegenerative disorder that primary affects the brain, causing a gradual decline in memory, symptoms affecting memory, thinking and social abilities), anxiety disorder (feeling of fear, dread or uneasiness), and major depressive disorder (persistent feelings of sadness or hopelessness). The Admission Minimum Data Set (MDS) with a target date of 4/23/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition. Review of Care Plan dated 3/8/23 revealed Resident #1 has an ADL self-care performance deficit related to Alzheimer's Disease. Resident #1 was weak with impaired balance and mobility. Interventions included Resident #1 was dependent on staff for ADL's and required substantial/maximum assistance of two staff with bed mobility (changing positions while in bed). Review of Kardex (an electronic system used to summarize resident information) revealed Resident #1 required substantial/maximum assistance of two staff with bed mobility. Review of incident note dated 4/6/25 revealed that Certified Nursing Assistant (CNA) Staff A was providing care to Resident #1 and Resident #1 experienced a fall out of the bed. Review of a progress note dated 4/6/25 revealed Resident #1 was observed lying on her right side on the floor next to her bed and in between her tray table. Resident #1 was visibly upset and crying. Resident #1 was bleeding from the left side of her forehead above her eyebrow. Review of Change in Condition Form dated 4/6/25 revealed during ADL care Resident #1 fell from the bed during ADL care resulting in an injury to Resident #1's forehead. Review of medical record revealed Resident #1 was transferred to the hospital and required seven sutures to the forehead injury related to the fall reported. On 4/29/25 at 3:13 p.m., in an interview Certified Nursing Assistant (CNA) Staff A said she was doing a linen change for Resident #1 alone. Staff A said she rolled Resident #1 toward her and the resident fell out of bed. Staff A said she was not told Resident #1 was a fall risk or a two person assist. Staff A said she has had Resident #1 multiple times and always did Resident #1's care by herself. Staff A said she received a call later that day from the Director of Nursing (DON) explaining Resident #1 was a two person assist with bed mobility. Staff A said the fall and injury was neglect because the care she provided was not done properly since Resident #1 required two people and she was doing care alone. On 4/29/25 at 3:53 p.m., in an interview Licensed Practical Nurse (LPN) Staff B said CNA Staff A came to get her because the resident fell off the bed. Staff B said Staff A told her she was changing Resident #1, put her on the side and Resident #1 fell off the bed. Staff B said staff use the Kardex to know each resident's individual needs and they are supposed to be trained on the Kardex in orientation. Staff B said neglect would include performing care alone when the resident requires two staff members for care. On 4/30/25 at 10:33 a.m., the DON said she was called about Resident #1 going to the hospital and that Resident #1 had a gash on her forehead. The DON confirmed she reviewed the staff witness statements and Resident #1 Kardex and concluded the staff did not follow the plan of care. The DON said Staff A told her she has been doing care for Resident #1 by herself all along and that she did not know about the Kardex. The DON said at that point we realized there was a breakdown in the system. The DON said Staff A was not in-serviced on the Kardex and did not receive Kardex training during orientation. The DON said not following the resident's plan of care is neglect. On 4/30/25 at 11:23 a.m., Licensed Nursing Home Administrator (LNHA)said she worked with the DON on the investigation for Resident #1's fall together. The LNHA said they found out Staff A had not followed the Kardex plan of care when she was providing care for Resident #1. The LNHA said her investigation revealed CNA, Staff A while providing care alone, turned Resident #1 towards her and the resident ended up falling out of bed. The LNHA said the conclusion of the investigation was Staff A was not following the Kardex and the plan of care for Resident #1 which is neglect. She said the facility substantiated neglect and confirmed Neglect is a never event.

Based on observation, record review, residents and staff interviews, the facility failed to provide timely assistance with dining for 2 (Residents #2 and #3) of 3 sampled dependent residents reviewed for dining services. The findings included: Review of the clinical record for Resident #2 revealed an admitted [DATE]. Diagnoses included Parkinson's Disease (a disorder of the central nervous system that affects movement). The Admission Minimum Data Set (MDS) assessment with a target date of 5/29/24 noted Resident #2 required partial to moderate assistance to go from a lying to sitting position and supervision or touching assistance with eating (The helper provides verbal cues or touching/steadying assistance as the resident completes the activity). Resident #2's cognition was intact with a Brief Interview for Mental Status score of 13. On 7/8/2024 at 8:15 a.m., Resident #2 was observed lying supine in a low bed, eyes closed. A breakfast tray was observed on an over the bed table to the right side of the bed. The over the bed table was in a high position and not within reach of the resident. Review of the clinical record for Resident #3 revealed an admitted [DATE] with a diagnosis of malignant neoplasm (cancer). The Admission Minimum Data Set (MDS) assessment with a target date of 6/4/2024 noted Resident #3's cognition was intact with a Brief Interview for Mental Status score of 15. Resident #3 required partial to moderate assistance from lying to sitting on the side of the bed, and setup or clean up assistance with eating (Helper sets up or cleans up). On 7/8/24 at 8:15 a.m., Resident #3 was observed lying supine in bed on a low bed. A breakfast tray was observed on the over the bed table to the side of the resident's bed. The over the bed table and breakfast tray were not within reach of the resident. Resident #3 asked for the orange juice on the tray. On 7/8/2024 at 8:24 a.m., Certified Nursing Assistant (CNA) Staff C was observed going in Resident #3's room. In an interview, Staff C verified the breakfast tray was not within Resident #3's reach. She said she delivers all the meal trays to the rooms, then comes back to assist the residents who need set up or feeding assistance. She stated, I leave it on the over bed table and leave it out of reach until I come back in to feed her. I need to pass all the other trays first. On 7/8/2024 at 8:30 a.m., in an interview Registered Nurse (RN) Staff B said he had to get the CNAs so they would assist and feed Residents #2 and #3. RN Staff B said that Resident #2 can feed herself some days. They need to wake her and set up her tray and see if she would feed herself or if she needs assistance. Resident #3 can feed herself if they position her and set up her tray. On 7/8/24 at 10:25 a.m., in an interview Unit Manager Staff E said staff are to deliver the trays of the residents requiring assistance last. When the tray is delivered, they wake the resident, ask if they need help and leave the tray within reach of the resident. On 7/8/24 at 10:35 a.m., an interview was conducted with the Director of Nursing and the Regional Nurse Consultant. Both said when a tray is brought into the room staff set the resident upright and offer help cutting the food or opening milk cartons. Trays are not to be dropped off in the room without setting up and waking the resident. Meal tray of residents who need assistance with feeding should be delivered last. It is in the Kardex (provides instructions for care), and the nurse should be telling CNAs in report. On 7/8/24 at 3:28 p.m., in an interview Resident #3 said she cannot remember if she received assistance with her meals. On 7/8/24 at 3:32 p.m., in an interview Resident #2 said she needs assistance with her meals. She said staff leave her tray at the bedside all the time without setting it up immediately. They come back and set it up for her later.

Based on observation, staff interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in a safe and sanitary manner. The findings included: Policy 027 dated 5/2014 with a revision date of 2017 for Equipment stated All food service equipment will be clean, sanitary, and in proper working order. All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials; All staff members will be properly trained in the cleaning and maintenance of all equipment; All food contact equipment will be cleaned and sanitized after every use; All non-food contact equipment will be clean and free of debris; The dining services director will submit requests for maintenance or repair to the Administrator and or Maintenance Director as needed; Copies of service repairs and preventative maintenance reports will be submitted monthly. On 1/8/24 at 9:15 a.m., the Initial kitchen tour was conducted with the Certified Dietary Manager (CDM). Small appliances were dirty. Panini press had caked on food. Photographic evidence obtained. The CDM said it did't work and needed to be disposed of. Toaster over had caked on debris also. The CDM said it is scheduled to be cleaned every day. Iced tea machine also appeared dirty. *Photographic evidence obtained. The clean dish rack contained dirty appearing dishes and the dish rack was dirty. Photographic evidence obtained. The floor had a lot of debris and dust. Photographic evidence obtained. Cooking area observed. Old appearing dried pureed bread per CDM sitting by steamer and stovetop. Appliances dirty with caked on grease and grime. A Pot with butter sitting on stovetop appeared full of debris. Dirty ragged oven mitts sat on shelf by the oven. The stove and flat top were dirty with caked on food. The oven appeared dirty. Photographic evidence obtained. The ceiling tiles, sprinkler heads, lights, and vents over steam table were dusty, and had black biogrowth and debris. Photographic evidence obtained. The fans in the walk in refrigerator had black biogrowth. Photographic evidence obtained. On 1/10/2024 at 10:25 a.m., in an interview with the Maintenance Director he said the maintenance department and the kitchen share the duties of cleaning the ceiling tiles. The kitchen puts in a work order for cleaning vents, sprinklers, etc. He said the kitchen ceiling was cleaned yesterday. He said maintenance had a monthly cleaning schedule. On 1/10/2023 at 10:45 a.m., during a follow up kitchen tour the CDM said the kitchen staff were not responsible to clean the ceiling. she could not remember the last time the ceiling was cleaned. She said she usually tells the Maintenance Director but does not keep any documentation. She said a couple of kitchen had not been doing their part to maintain the cleanliness in the kitchen. On 1/11/2024 at 9:30 a.m., in an interview the Administrator said the kitchen was subcontracted. He said he makes rounds through the kitchen every Monday and Keeps a monthly walk-through log that he discusses with the CDM. After reviewing the photographice evidence obtained, the Administrator said, 'The kitchen needs cleaning.

Based on observation, interview and record review, the facility failed to provide beverages according to preferences for 3 (Residents #86, #19, and #17) of 11 sampled residents. The findings included: On 1/8/24 at 12:28 p.m., during an observation of the noon meal in room tray pass the following was observed: There was a hydration cart provided that contained hot coffee, tea, and juices. Resident #86 received no liquids provided with the meal. The meal ticket specified 8 ounces (oz) of lemonade and 2 servings of the house shake (supplement provided for weight management). Registered Nurse Staff S verified the resident did not receive the liquids as specified on the meal ticket. Resident #19 received no liquids with the meal. The meal ticket specified 1 house shake, 4 oz of apple juice, and 6 oz of hot tea. Resident #17 received no liquids with her meal. The meal ticket specified 8 oz of chocolate milk 8 oz and 8 oz of iced tea. Resident #17 said I never get chocolate milk. The Unit Manager Staff A verified no liquids were provided for Resident # 17 and Resident #19. Staff A provided the liquids and went to the kitchen for the chocolate milk. Staff A returned and said there was no chocolate milk or house shakes available. Staff A was observed providing on the spot education to the Certified Nursing Assistants (CNAS) to read the meal tickets and provide the liquids specified. On 1/9/24 at 8:59 a.m., during an observation of the breakfast tray for Resident #17, did not have chocolate milk and the ticket was changed to milk 8 oz. Resident #17 said, I only drink chocolate milk. The meal ticket specified 4 oz of orange juice and 6 oz of coffee but the liquids were not on the tray. On 1/9/24 at 9:00 a.m., Resident #19 had 6 oz of hot tea on his tray. The meal ticket indicated he was to receive 4 oz orange juice and 4 oz of cranberry juice. On 1/9/24 Staff A confirmed the liquids specified for Residents #17 and #19 were not provided as specified on the meal tickets. Review of the Grievance log showed Resident #17 filed a grievance on 8/8/23, and 8/21/23 related to her dietary concerns. On 1/10/24 at 11:21 a.m., in an interview CNA Staff D said at meals if we are serving the trays, the CNA is responsible to read the ticket and put the liquids on the tray before you serve the residents in their rooms. On 1/10/24 at 12:00 p.m., in an interview with the Certified Dietary Manager, said the dietary staff were responsible for putting the supplements on the meal trays. They were to read the tickets and put the supplements on the tray. The kitchen provided fluid carts and the Certified Nursing Assistants were responsible to place the drinks on the trays. The CDM said the kitchen has been out of chocolate milk for about two weeks and could not provide any chocolate milk for Resident #17.

Based on observations and staff and resident interviews, the facility failed to provide food that was palatable, attractive, and at an appetizing temperature as determined by the type of food to ensure resident's satisfaction for 8 of 22 residents reviewed, (Resident #76, #20, #34, #61,#53, #49, #353 and #77). The findings included: On 1/8/2024 at 12:00 p.m., in an interview with Resident #76, she said she had been a resident at the facility for approximately one year. She said the food was terrible and she never gets a Renal Diet. On 1/8/2024 at 12:45 p.m., in an interview with Resident #20, she said the food is so bad here she cancelled lunch and dinner service and provides her own food. On 1/9/2024 at 11:45 a.m., in an interview with Resident #34 and Resident #61who are roommates together, said the food is always cold and doesn't taste good except for once in a while. Resident #61 said she has been to the food committee meetings, but it seems like the complaints are not addressed. They are just told there is nothing they can do about it. On 1/9/2024 at 1:00 p.m., observed the lunch meal on the 200 hall. The Lunch meal consisted of three small Swedish meatballs on top of pasta noodles and a little sauce with carrots on the side. Most of the pasta noodles looked plain with no sauce. The food was served on a white plate and did not appear appetizing. On 1/9/2024 at 1:30 p.m., in an interview with Resident #53 who has been a resident for approximately three years, she said her food tastes average and is usually cold. She said it sits out on the corner in the cart for sometimes 20 minutes before the trays are distributed and that's one of the reasons the food is always cold. On 1/10/2024 at 10:45 a.m., in an interview with the Certified Dietary Manager (CDM), she said she attends the Food Committee meeting twice monthly. She provided the log for review. She said she and the Dietician sometimes complete audits for food temperature when delivered to floor. She admitted that food temperature had been an issue, but the food was hot when it leaves the kitchen. She said the reason the food gets cold is because it takes the Certified Nursing Aides (CNA) a long time to deliver the trays. She said she gives the completed audits to the Social Services Director. On 1/10/2024 at 11:45 a.m., in an interview with Resident #53, she said her hallway is the last to be served lunch trays and that 80% of the time the food is cold. She said the food just sits on the carts because the CNAs are too busy to deliver them. She also said that no one gets drinks until after all the trays are served. She said that the trays don't come with drinks and the staff have a drink cart to deliver drinks after all the trays are served. On 1/11/2024 at 11:20 a.m., in an interview with Resident #76, she said she does not eat the food from here at all anymore. She eats cereal or has family bring her food from home because the food tastes so bad. On 1/11/2024 at 11:40 a.m., in an interview with Resident #20, she said she always has food she buys at the supermarket because the food here is so bad. She said they still send her a tray but she usually will only eat the fruit or snacks off of it. On 1/11/2024 at 12:00 p.m. in an interview with the Social Services Director, she said she gets the completed audits from the CDM but does not compile any information from it. She said she just adds the information to the grievance that was filed. The Food committee minutes were reviewed as provided from June 1, 2023, through October 20, 2023. The minutes documented attendees and issues the issues discussed. The issues discussed were vague with no implementation or documentation of resolutions. The facility grievance log was reviewed. Audits were completed for complaints of cold food on 8/20/2023, 9/13/2023, 9/22/2023, 9/26/2023, 10/5/2023 and 11/8/2023. On 1/11/2024 at 9:30 a.m., in an interview the Administrator said the kitchen is subcontracted. He said he had been aware of the cold food complaints but thought it was taken care of since they purchased new heated bases for the plates in September. He said the CDM had been performing audits of trays to determine temperatures based on grievances. 38570 During an interview on 1/08/24 at 10:53 a.m., Resident #49 stated that the food delivered to her room is always cold. She said in the morning the eggs and pancakes are terrible when they are cold. She said she can barely eat them. She said that it happened every meal and she said they will heat it up but then it is rubbery. During an interview on 1/09/24 at 9:14 am, Resident #49 was observed during breakfast. She stated her eggs were not warm again. During an interview on 1/09/24 at 8:50 Resident #353 stated that the food was not good, it lacked flavor and was often cold when it arrived to her room. 49527 On 1/8/24 at 10:40 a.m., in an interview Resident #77 said the food was institutional food did not taste good and was served cold. On 1/9/24 at 8:40 a.m., reviewed breakfast meal ticket with Resident #77. She said the western scrambled eggs did not taste good.

Based on observations, staff and resident interviews and record review the facility failed to safely store medication in the facility for 6 (Resident #20, #40, #53, #84, #86, and #353) of 6 residents who had medication at bedside. The findings included: 1. Review of the clinical record revealed Resident #353 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Chronic Diastolic Congestive Heart Failure (CHF). The Admission Minimum Data Set (MDS) with a target date of 12/29/23 revealed Resident #353 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The physician's orders included Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-5-25 micrograms (mcg) one puff orally one time a day, and Ventolin HFA inhalation Aerosol Solution 108(90 base) mcg/act (albuterol sulfate) two puffs orally twice a day related to chronic obstructive pulmonary disease. On 1/9/24 at 3:10 p.m., two inhalers stored in a plastic container were observed at the resident's bedside. Resident #353 stated in an interview that she kept her inhalers at the bedside because she needed them. She stated she has COPD and CHF. When she asks the nurses for the inhalers they might not have them, so she keeps them at her bedside. On 1/11/24 at 1:34 p.m., Licensed Practical Nurse (LPN) Staff I stated the resident was alert and oriented and was able to administer her own inhalers since she did it at home. She stated she brings the inhalers to the resident who self-administers the medications. On 1/11/24 at 1:39 p.m., in an interview Registered Nurse Staff P stated the inhalers should be stored in a locked box. 41155 2. On 1/9/24 at 8:52 a.m., Resident #86 was in bed and bed side table was out of reach against the wall. There was a pill cup on the table containing 6 unidentified medications. The resident did not answer questions. Photographic evidence obtained. On 1/9/23 at 8:55 a.m., in an interview Registered Nurse Staff R confirmed the pills were left at the bedside and said, I recognize these as his night time medications. 44307 3. On 1/8/24 at 10:00 a.m., observed at bedside of Resident #40 two respiratory inhalers, Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol 160 mcg/ 4.5 mcg. In an interview, Resident #40 said, I have two, one is mine and one is from the facility. I take it 2 or 3 times a day. On 1/8/24 at1:30 p.m., observed Resident #40 respiratory inhalers continue on bedside table unsecured. On 1/9/24 at 915 a.m., observed Resident #40 medication inhalers continue on bedside table unsecured. On 1/9/24 at 3:45 p.m., Unit Manager Licensed Practical Nurse Staff A verified Resident #40 had two unsecured inhalers at the bedside. She said the resident should not have them. 4. On 1/9/24 12:17 p.m., rounded with Resident #84 who said he has been waiting to see the dermatologist for a couple of months. Resident #84 said the Physician Assistant (PA) gave him some cream and he is going through a tube a day. Observed hydrocortisone 1% cream at bedside. The resident said they gave him the cream and he puts it all over his chest. On 1/9/24 at 3:15 p.m., during an interview Registered Nurse (RN) Staff L, assigned to Resident #84 verified Resident #84 had hydrocortisone 1% at the bedside. On 1/9/24 at 3:45 p.m., Unit Manager LPN Staff A verified the tube of Hydrocortisone 1% was unsecured at the resident's bedside. She said the resident should not have medications at the bedside. On 1/10/24 at 3:00 p.m., in an interview the Director of Nursing (DON) said Residents #40 and #84 should not have had the medications at their bedsides. Staff should have noticed them, and it is not acceptable. 44824 5. On 1/8/2024 at 12:45 p.m., during an interview with Resident #20, she was observed to have multiple medications on the table at her bedside. She said they were her medications that the nurses gave her to use as needed. Included in the medications were: Diclofenac Sodium Topical gel which is a medication to treat arthritis pain. Vitamin D Tablets. [NAME] Oil 500mg Dietary Supplement. Osteo Bi-Flex joint health Glucosamine & Chondroitin is taken to improve joint care. Brimonidine tartrate eye drops. 6. On 1/9/24 at 12:30 p.m., in an interview with Resident #53, she said she takes Albuterol as needed for shortness of breath. She said the staff let her keep it at bedside, so she has it when she needs it. A cannister/inhaler of Albuterol Sulfate was observed on Resident #53 bedside table. On 1/10/ 24 at 11:35 a.m., in an interview Resident #53 said she put the Albuterol Sulfate in a locked box the day before after staff came in running in yesterday and told me to. On 1/11/2024 at 11:40 a.m., in an interview Resident #20 said the staff came in and took all the medications out of her room and put them in the medication cart. The bottle of (brand name) eye drops were still on the windowsill. She said, they must not have seen those. On 1/11/2024 at 3:00 p.m., in an interview the DON said she was made aware Residents #20 and #53 had unsecured medications at the bedside. She removed the medications from Resident #20's room and instructed Resident #53 to use a locked box. Facility policy for Medication Storage states Medications will be stored in a manner that maintains the integrity of the product and ensures the safety of the residents and is in accordance with Florida Department of Health guidelines; With the exception of Emergency Drug Kits, all medications will be stored in a locked cabinet, cart or medication room that is accessible only to authorized personnel, as defined by facility policy.

Based on record review, and staff interview, the facility failed to complete a performance review of 6 (Certified Nursing Assistants Staff W, X, Y, Z, AA, and BB) of 8 Certified Nursing Assistants (CNAs) employed at the facility greater than 12 months. The findings included: Review of the facility Performance Review Policy effective 4/1/22 revealed It is the policy of the facility to complete annual performance reviews for all employees who work in the facility. If an employee is performing below average and has ongoing performance issues, then a performance improvement plan is put in place. On 1/9/24, Review of the employee files failed to reveal documentation of a performance review and in-service education based on the outcome of the review for: CNA Staff BB, date of hire (DOH) of 8/16/22, CNA Staff AA DOH of 9/13/22, CNA Staff W DOH of 6/14/22, CNA Staff X DOH of 6/7/22, CNA Staff Y DOH of 9/20/22, and CNA Staff Z DOH of 7/19/22. On 1/9/24 at 3:43 p.m., the Human Resources Coordinator confirmed there were no annual performance reviews for the CNAs.

Based on observation, record review, review of policies and procedures, staff and residents interview, the facility failed to provide services to restore bladder function and prevent urinary tract infections to the extent possible for 3 (Residents #92, #254, and #11) of 3 residents reviewed for bladder function. The findings included: 1. Review of the clinical record revealed Resident #92 was admitted to the facility on [DATE]. Review of the Admission Minimum Data Set (MDS) assessment with a target date of 12/12/23 noted the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 13. Resident #92 had an indwelling catheter (catheter inserted in the bladder to drain urine). The care plan initiated on 12/5/23 noted the resident had an indwelling catheter related to urinary retention. The Certified Nursing Assistant Kardex (provides instructions for care) noted the resident was not toileted. Staff was to empty the catheter drainage bag and perform catheter care per policy. Review of the physician's orders revealed the orders related to the resident's urinary catheter were discontinued on 12/19/23. The care plan and the Kardex were not updated when the catheter was removed. On 1/8/24 at 10:30 a.m., in an interview Resident #92 said she had a urinary catheter which was removed in December. She said she has been wearing incontinent briefs since her admission and staff did not always answer the call light to assist her to the bathroom. Resident #92 said she was aware of the need to urinate, but it often took three hours for staff to answer the call light and she was not able to hold her urine for that long. On 1/10/24 at 10:22 a.m., in an interview Resident #92 said the previous night when she turned on the call light, the girl came, turned it off and said she would be back. She put the light on again after 15 minutes. It took an hour for staff to answer the call light. On 1/11/24 at 9:10 a.m., Resident #92 said she never wore incontinent briefs at home. She could always hold her urine and then go to the bathroom. She said she has been timing her urine and she wets the brief every 3 hours. She said the urologist told her the facility should offer toileting every 3 hours, but they do not, and then she wets herself. Resident #92 said when she puts the call light on, staff comes in, turn off the light and say they'll be right back. They do not come back until one to three hours later. By that time, it's too late and she wets the brief. On 1/11/24 at 9:17 a.m., CNA Staff J said she came on duty at 7:00 a.m. and was assigned to Resident #92. She said Resident #92 had an indwelling catheter therefore she did not need to offer toileting. CNA Staff J said she got her information from the Kardex. Review of the potential for bowel and bladder retraining program with an effective date of 12/8/23 and signed on 12/19/23 by Unit Manager Licensed Practical Nurse (LPN) Staff H noted Resident #92 always voided correctly without incontinence and was usually mentally aware of toileting needs. Unit Manager Staff H checked no to proceed with personalized toileting schedule and retraining program. Review of the Bowel and Bladder Report from 12/19/23 through 1/11/24 revealed multiple CNA entries noting the resident was incontinent of urine. On 1/11/24 at 9:26 a.m., Unit Manager, LPN Staff H said he obtained the information to complete the potential for bowel and bladder retraining program from the CNAs who told him the resident was continent of urine. He verified the lack of bladder assessment to restore or improve Resident #92's bladder function to the extent possible after the indwelling catheter was removed. On 1/11/24 at 9:38 a.m., MDS coordinator LPN Staff X verified the care plan and Kardex were not updated on 12/19/23 when the indwelling catheter was removed. On 1/11/23 at 10:05 a.m., the Director of Nursing said there was no process in place to assess continence status when an indwelling catheter is removed to restore bladder function. 2. Review of the facility policy on Urinary Catheter Care with a revision date of 2/21/23 indicated the purpose of this procedure was to prevent catheter-associated urinary tract infections. The policy specified to be sure the catheter tubing and drainage bag are kept off the floor for infection control. Review of the clinical record revealed Resident #254 was admitted to the facility on [DATE]. The Admission MDS assessment with a target date of 12/24/23 noted the resident had an indwelling catheter. The care plan initiated on 12/19/23 noted the goal was for the resident to show no signs or symptoms of urinary infection. On 1/8/24 at 3:34 p.m., observed Resident #254 in the wheelchair wheeling himself down the hallway. The urinary catheter drainage bag was on the floor and being dragged under the wheelchair. Several staff stopped to talk with the resident, including a Certified Nursing Assistant (CNA), but none moved the drainage bag off the floor. On 1/8/24 at 4:10 p.m., Licensed Practical Nurse (LPN) Unit Manager Staff H confirmed the indwelling catheter bag was on the floor. Staff H said the drainage bag should not be on the floor for infection prevention. Staff H repositioned the bag so it was not touching the floor. On 1/9/24 at 8:35 a.m., Resident #254 was observed in bed. The urinary catheter drainage bag was stored on the floor. Registered Nurse (RN) Staff P verified the drainage bag was on the floor. Staff P repositioned the drainage bag, so it was not touching the floor. On 1/9/24 at 3:28 p.m., CNA Staff Q said she was providing care to Resident #254 and did not make sure the drainage bag was off the floor. She said was aware the drainage bag should never be stored on the floor. On 1/10/24 1:48 p.m., the Director of Nursing (DON) said the catheter drainage bag should never come in contact with the floor. The DON said staff should have changed the drainage bag after it was found on the floor the previous day, but they didn't. 38570 3. Review of the clinical record for Resident #11 revealed an admitted [DATE]. Diagnoses included Alzheimer's disease, and a history of urinary tract infections. The Quarterly Minimum Data Set (MDS) assessment with a target date of 10/20/23 noted Resident #11 scored 05 on the Brief Interview for Mental Status, indicative of severely impaired cognition. Resident #11 was always incontinent of bladder and was dependent on staff for toileting and incontinence care. Resident #11's Care Plan revised on 3/19/2023 revealed the resident was a risk for self-care deficit related to dementia. The resident needed to be checked for incontinence on routine rounds and provided incontinence care per facility protocol. On 1/8/24 at 9:19 a.m., observed Resident #11 sitting in a Broda chair in her room. Resident was awake but did not respond when asked questions. Resident #11 was wearing an incontinent brief. The room had a strong odor of urine. On 1/8/24 at 10:00 a.m., and 10:55 a.m., Resident #11 remained sitting in the same position in the Broda chair in the room. The resident appeared to be sleeping. The room remained with a very strong urine odor. On 1/8/24 at 12:00 p.m., Resident #11 remained in the same position in the Broda chair. The room remained with a strong urine odor. Resident #11 was awake but did not reply to questions. Staff was not observed providing incontinent care to the resident up to this point. On 1/8/24 at 2:51 p.m., Resident #11 remained in the same position in the Broda chair. CNA staff J was observed entering the resident's room. She pushed the resident in the Broda chair to the dining room. The resident had a strong odor of urine. Staff was not observed changing the resident before taking her to the dining room for lunch. On 1/8/24 at 3:11 p.m., a strong smell of urine was noted in the dining room. Multiple residents were participating in an activity in the dining area. A large wet spot was observed on the floor. On 1/8/24 at 3:12 p.m., the Activities Assistant said Resident #11 was incontinent and the urine drained off the chair onto the floor. She said staff took the resident out of the dining room after lunch and brought her back within minutes for the scheduled activity. On 1/11/24 at 12:24 p.m., LPN Staff I verified Resident #11 had an incontinent episode in the dining room after lunch on 1/8/24. She said residents who are incontinent should be checked and changed every two hours and as needed. On 1/11/24 at 1:17 p.m., CNA Staff K said he was assigned to Resident #11 on 1/8/24. He said he had not changed the resident's brief that morning. He said before lunch he only looked at the brief. He did not notice it to be wet, so he did not change the resident before she went to the dining room. A review of facility policy titled Nursing - Activities of Daily Living (ADLS) Reveals that the purpose of the policy is to ensure all resident's needs are met in a manner that promotes their quality of life and preferences. Procedure: 1. The facility shall ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. 2. The facility shall provide care and services for the following activities of daily living as needed, based on the individual care plan of each resident. And that would include. Number C toileting. 3. A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain. Good nutrition, grooming, and personal. And oral hygiene. On 1/11/24 at 1:03 p.m., the DON stated that the policy for ADLs should be followed. Residents who are incontinent should be checked and changed every couple of hours and as needed.

Based on observation, resident and staff interviews, record review and review of facility policies and procedures, the facility of failed to provide the necessary care and services to maintain grooming and hygiene for 4 (Resident #8, #19, #38, and #60) of 8 residents reviewed for assistance with activities of daily living. The findings included: The facility policy and procedures, Nursing- Activities of Daily Living (ADLS) effective 4/1/22 documented To ensure all residents needs are met in a manner that promotes their quality of life and preferences . A resident who is unable to carry out activities of daily living shall receive the necessary services to maintain good nutrition, grooming and personal hygiene . 1. Review of the clinical record revealed Resident #8 had an admitted [DATE] with diagnoses including hemiplegia and hemiparesis (weakness or inability to move on one side of the body) of the right side. The plan of care initiated on 1/16/23 and revised on 1/5/24 noted Resident #8 required substantial assistance with personal hygiene and grooming. On 1/8/24 at 1:51 p.m., during an observation and interview, Resident #8 said he had a stroke and was not able to use his right hand or arm. The resident's right hand fingers were curled in a fist. He demonstrated how he used his left hand to open to move the right hand's fingers. Upon observation the fingernails on the right hand extended over 1/4 inch from the nail beds with a brown and black substance under the nail beds. He said the staff were supposed to cut and clean his nails, but they did not always do it. On 1/9/24 at 9:03 a.m., Resident #8 was in his room in a wheelchair, with the bedside table in front of him awaiting breakfast. A urinal half filled with urine was on the bedside table in front of the resident. Certified Nursing Assistant (CNA) Staff C entered the room, placed the breakfast tray on the bedside table next to the urinal and turned to exit the room. The resident said he was used to eat his meals with the urinal, because staff did not always empty it. On 1/9/24 at 2:37 p.m., in an interview CNA Staff C said there was a shower list at the nurse's desk and the staff follow it. Staff C said there were shower sheets at the desk and each CNA completes it when you give a shower or bed bath. The CNA explained you circle the sheet when a was shower given. The Resident Shower Sheet tasks listed cleaning and trimming fingernails. Staff C said you complete the form and sign it and then you give it to the nurse and the nurse signs it. We do nails, shave everything when you give the shower. On 1/10/24, review of the shower sheets for Resident #8 revealed the CNA noted on 1/6/24 and 1/10/24 the resident's fingernails had been cleaned and trimmed during the day shift. On 1/10/24 at 3:12 p.m., Resident #8 was observed exercising his right hand, using the left hand. The right hand fingernails remained untrimmed with a brown and black substance under the nails. The resident's hand had a foul odor. On 1/11/24 at 11:45 a.m., the resident's right hand nails remained untrimmed with an accumulation of black and brown substance under the nails. Unit Manager Staff A confirmed the observation of Resident #8's right hand. Staff A said she would have the CNA wash and soak the residents right hand and trim the fingernails. 2. On 1/8/24 at 11:39 a.m., Resident #19 was sitting on the side of his bed. His feet were blue and dark purple in color from the toes to approximately four inches above his ankles. He said he had a heart attack several years ago but did not know why his feet were discolored. Review of Resident #19's clinical record revealed an admitted [DATE] with diagnoses including acute ischemic heart disease, peripheral vascular disease, and type 2 diabetes mellitus. Review of the physician order dated 8/11/23 included to apply compression stockings (worn to reduce blood clots and promote blood flow) to bilateral legs. The stockings were to be applied in the morning and removed at bedtime. On 1/9/24 at 8:58 a.m., Resident #19 was observed seated on the side of the bed and did not have the compression stockings on. Resident #19's wife said, the staff are supposed to put the white stockings on him every day, but they are never on him. On 1/9/24 at 2:50 p.m., Resident #19 was lying in his bed and did not have the compression stockings on as ordered. On 1/9/24 at 2:58 p.m., during a joint observation with the Director of Nursing (DON), she confirmed Resident #19 was not wearing the compression stockings as ordered by the physician. On 1/10/24 at 11:21 a.m., in an interview CNA Staff D said the CNA's were to apply the compression stockings. Staff D said, the CNA's put the stockings on and we get the information from the care plan or CNA care Kardex, it will tell you what each resident needs. 3. Review of the clinical record revealed Resident #38 had an admitted [DATE] with diagnoses including anxiety disorder, histrionic personality disorder, mood disorder and depression. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) dated 12/14/23 documented Resident #38 was dependent on staff for bathing. The MDS noted Resident #38 scored 03 on the Brief Interview for Mental Status, indicative of severely impaired cognitive skills for daily decision making. The plan of care for Resident #38 initiated 2/16/23 noted the resident required total assistance of one staff for bathing and showers. The care plan of care specified to provide a sponge bath when a full bath or shower cannot be tolerated. On 1/8/24 at 1:36 p.m., Resident #38 was observed sitting on the side of his bed. The resident's hair was uncombed and greasy, and he was disheveled. Resident #38 did not respond appropriately to questions. On 1/9/24 at 8:41 a.m., Resident # 38 was observed in bed with the covers over his head. He did not respond when spoken to. On 1/9/24 at 9:42 a.m., in an interview CNA Staff C said the resident has no balance, he shakes, and you hold his hand, and he walks to the bathroom and back. He does not refuse care or hit you. We have a shower schedule, and it is by room and days of the week. We complete the shower sheet sign it and give it to the nurse. On 1/9/24 at 10:30 a.m., Resident #38 was observed in his bed, and smiled when greeted. He was dressed in his own clothing. His hair remained uncombed and greasy. He had a strong body odor. Review of the shower schedule documented Resident #38 was scheduled for showers on 7:00 a.m., to 3:00 p.m., shift on Mondays and Thursdays. Review of the CNA documentation for showers documented Resident #38 received a shower on 1/4/24 and his hair was washed. On 1/8/24 (Monday) the CNA documentation showed the resident received a bed bath. There was no documentation Resident #38 refused his scheduled shower which included hair washing. On 1/10/24 at 9:09 a.m., in an interview Unit Manager Staff A said Resident #38 did not like to get out of bed. She said she had not observed the resident refusing care, hit anyone, yell or be combative. 4. Review of Resident #60's clinical record revealed an admitted [DATE] with diagnoses including dementia and major depression. The Quarterly MDS dated [DATE] documented the resident was dependent on staff for bathing and hygiene. The MDS noted Resident #60's cognitive abilities for daily decision making were severely impaired with a BIMS score of 04. The plan of care for Resident #60 documented the resident was dependent on one to two staff for bathing, needed substantial assistance for dressing the upper body and was dependent on staff for dressing the lower body. Staff was to make sure the resident was safe if he became combative and attempt again another time. On 1/8/24 at 9:49 a.m., and 12:13 p.m., Resident #60 was observed in bed. The resident's fingernails extended approximately half inch from the fingertips and had an accumulation of brown substance under the nails. Resident #60 was not able to answer most questions. He was dressed in a green T-shirt and had an incontinent brief on. On 1/9/24 at 8:30 a.m., and 10:30 a.m., Resident #60 was observed in bed wearing the same green T-shirt as the previous day. On 1/10/24 at 9:10 a.m., Resident #60 was observed in bed with a neon green T-shirt on and a brief. On 1/11/24 at 10:32 a.m., Resident #60 was observed in bed wearing the same bright neon green T-Shirt. Review of the shower schedule revealed Resident #60 was scheduled for showers on the 7:00 a.m., to 3:00 p.m., shift on Tuesdays and Fridays. Review of the CNA documentation for December 2023 and January 2024 failed to reveal documentation Resident #60 received the scheduled showers from 12/30/23 through 1/10/24. On 1/6/24 the CNA documented on the shower sheet she gave a bed bath. There was no documentation that the resident refused the shower. On 1/11/24 at 10:36 a.m., in an interview CNA Staff E said they received an in-service approximately two months earlier. The Unit Manager told staff they needed to change the residents' clothes when they get up and when they go to bed. On 1/11/24 at 11:10 a.m., Unit Manager LPN Staff A reviewed the shower sheets for Resident #60 and said she realized there was a problem with staff giving showers on the unit.

Based on observation, record review, review of policies and procedures, resident and staff interview the facility failed to evaluate and determine the resident's ability to safely self-administer medications for 2 (Resident #353, and #40) of 6 residents observed with unsecured medications at the bedside. The findings included: 1. Review of a facility policy titled, Self-administration medication program dated 4/1/2022, specified, under procedure: The facility should allow the resident to self-administer drugs if the interdisciplinary team, has determined that this practice is safe. The nurse or designee should complete a self-administration of medication Evaluation and report the findings to the unit manager or designee. The medication should be stored at the resident bedside, a lockbox or locked drawer must be used to store the medication. Review of the clinical record revealed Resident #353 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Chronic Diastolic Congestive Heart Failure (CHF). The Admission Minimum Data Set (MDS) with a target date of 12/29/23 revealed Resident #353 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The physician's orders included Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-5-25 micrograms (mcg) one puff orally one time a day, and Ventolin HFA inhalation Aerosol Solution 108(90 base) mcg/act (albuterol sulfate) two puffs orally twice a day related to chronic obstructive pulmonary disease. On 1/9/24 at 3:10 p.m., two inhalers stored in a plastic container were observed at the resident's bedside. Resident #353 stated in an interview that she kept her inhalers at the bedside because she needed them. She stated she has COPD and CHF. When she asks the nurses for the inhalers they might not have them, so she keeps them at her bedside. On 1/11/24 at 1:34 p.m., Licensed Practical Nurse (LPN) Staff I stated the resident was alert and oriented and was able to administer her own inhalers since she did it at home. She stated she brings the inhalers to the resident who self-administers the medications. Staff I stated she did not know if the resident has been evaluated for self-administration. On 1/11/24 at 1:39 p.m., in an interview Registered Nurse Staff P stated Resident #353's was not evaluated to determine if she could safely self-administer the inhalers. He also said the inhalers should be stored in a locked box. 44307 2. On 1/8/24 at 10:00 a.m., observed at bedside of Resident #40 two respiratory inhalers, Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol 160 mcg/ 4.5 mcg. In an interview, Resident #40 said, I have two, one is mine and one is from the facility. I take it 2 or 3 times a day. On 1/8/24 at1:30 p.m., observed Resident #40 respiratory inhalers continue on bedside table unsecured. On 1/9/24 at 915 a.m., observed Resident #40 medication inhalers continue on bedside table unsecured. On 1/9/24 at 3:15 p.m., RN Staff L reviewed the resident's clinical record and verified Resident #40 was not evaluated to determine if the resident was able to safely self-administer the inhalers. RN Staff L said he administered the inhalers to the resident in the morning but was not able to locate the inhalers in the medication cart.

Based on interview and record review the facility failed to implement adequate interventions and supervision to prevent incidents two incidents of joint dislocation for 1 (Resident #182) of 1 resident surveyed for injury of unknown origin. The findings included: Resident #182 is a [AGE] year old female admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) dated [DATE] showed the resident's Brief Interview for Mental Status (used to determine cognition level) was a 4, indicative of severe cognitive impairment. The resident required a two-person extensive assist with bed mobility and transfers. The resident also required extensive assistance with dressing and toileting. Review of the clinical record showed Unit Manager Staff I documented on 3/11/22 at 9:27 a.m. for 3/10/22 an Xray of the pelvis completed for Resident #182 showed a dislocation. The physician was notified a gave an order to send the resident to the hospital. Review of the hospital history and physical dated 3/10/22 showed Resident #182 presented to the emergency room with complaint of acute right hip pain. The right hip prosthesis was dislocated and confirmed by imaging. The ED (Emergency Department) was unable to manually realign. The hospital records showed on 3/11/22 Resident #182 was taken to surgery and the right hip was successfully realigned. The hospital records dated 3/14/22 showed a Physician's Assistant (PA) progress note that read, . Patient still contracting her hip we have abductor brace in between she is going with the abductor brace to skilled nursing facility today . The PA wrote, Patient will need to wear the abductor pillow (special pillow used to prevent the hip from moving out of the joint) at night even at the skilled nursing facility most likely for the next 2 weeks may be longer. In the next two weeks the patient is at a high propensity to dislocate the hip again. Total healing will be 6 to 8 weeks . No crossing of the legs no abductor lift greater than 60 degrees . Resident #182 returned to the facility on [DATE]. Review of the facility's progress note dated 3/14/22 showed Resident #182 arrived from the hospital after a close reduction of the right hip. Licensed Practical Nurse Staff X documented Resident #182 was to wear a hip abductor in the wheelchair. The care plan did not list the use of the abductor pillow. The facility physician's orders did not include an order to use an abductor pillow. The clinical record lacked documentation staff used the abductor pillow to prevent recurrence of hip dislocation. On 3/22/22 at 6:50 p.m., in a progress note the Director of Nursing (DON) documented, . A new Xray of right hip had been ordered due to resident non compliant with the abductor pillow and continuously is pulling it out . Resident would not tolerate the abductor pillow . Further review of the clinical record showed on 3/22/22 Resident #182 was transferred to the hospital for the second time for treatment of a right hip dislocation. Review of the hospital record revealed a physician's progress note dated 3/23/22 that read Resident #182, .is known to our practice for a failed total hip arthroplasty secondary to dislocation. She has previously been treated . for dislocated hip with a close reduction procedure. Unfortunately in a short period of time she has had a repeat dislocation. Her dislocation mechanisms seem to be positional she consistently sits in the fetal position with her legs flexed and internally rotated. This is her second dislocation in a very short period of time . On 4/5/22 at approximately 3:00 p.m. the DON verified the abductor pillow was not added to the care plan when Resident #182 returned from the hospital on 3/14/22. She also verified the Resident was sent back to the hospital on 3/22/22 for the second time for dislocation of her right hip. On 4/5/22 at 4:29 p.m., the Director of Nursing said she did not complete an incident report or investigate the two incidents of dislocation since she did not believe Resident #182 had a fall. On 4/6/22 at approximately 5:00 p.m., the Medical Director said she was not made aware Resident #182 needed to use an abductor pillow to prevent dislocation of her right hip when she returned from the hospital on 3/14/22. The physician said she would have written an order for the use of the abduction pillow.

Based on record review and interview, the facility failed to honor advanced directives and administered cardiopulmonary resuscitation to 1 (#2) of 3 residents sampled against the resident's expressed wishes. The facility Cardiopulmonary Resuscitation (CPR) policy does not provide for withdrawal of CPR when a valid Do Not Resuscitate Order (DNRO) is located after CPR is initiated. These actions resulted in Immediate Jeopardy that started on [DATE] when one (Resident #2) of 3 residents receiving cardiopulmonary resuscitation against the resident's expressed wishes. The facility's actions deprived Resident #2 of a natural death. RN Staff E involved in the incident had 10 assigned residents with a DNR status. There were a 40 residents total in the facility with DNROs. On [DATE] at 4:00 p.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the Immediate Jeopardy template. The Immediate Jeopardy ended on [DATE] at 2:15 p.m. after the removal plan was verified by review of policy and procedure revision, verification of staff training, and practice drills to verify staff competency. The scope and severity of the citation was reduced to D. The findings included: Review of the facility Cardiopulmonary Resuscitation policy effective [DATE] included Guideline: Emergency Procedure- Cardiopulmonary Resuscitation Item 1d. which read, Check the medical record for advance directive status. Item #4 read, If circumstances are such that CPR is initiated on a resident, then code status is clarified to indicate there is a current order not to initiate CPR in the event of death. A call is made to the physician to determine if CPR can be discontinued or the team continues CPR until EMS (Emergency Medical Service) arrives. Review of the resident record revealed Resident #2 was admitted to the facility on [DATE]. Review of the attending physician's progress note dated [DATE] revealed Resident #2 was a [AGE] years old female. She was admitted to the facility after hospitalization to continue care and rehabilitation due to increased weakness, fall. Resident #2 had a history of [REDACTED]. Review of the psych evaluation dated [DATE] revealed Resident #2 was AAO X3 (Alert, Awake, and Oriented to person, place and time). The Practitioner documented, Chief complaint . Of course I understand what a DNR means so bring it to me and I'll sign it . We discussed advanced care planning concepts in detail, and she is well aware if her (sic) should stop beating that she does not want any CPR. In fact, she demanded to sign the form as soon as this assessment was finished, and per staff, immediately signed the DNR form to state her firm decision . Assessment and Plan . Do not resuscitate. Honor advanced directives: NO CPR . Good insight into DNR status request . On [DATE] Resident #2's physician signed a Do Not Resuscitate Order that read I, the undersigned physician licensed pursuant to Chapter 458 or 459, F.S. (Florida Statutes) am the physician of the patient named above. I hereby direct the withholding or withdrawing of cardiopulmonary resuscitation (artificial ventilation, cardiac compression, endotracheal intubation and defibrillation) from the patient in the event of the patient's cardiac or respiratory arrest. The medical record face sheet was updated to reflect the DNR status as of [DATE]. On [DATE] at 17:00 a nurse's note by Registered Nurse (RN) Staff E indicated Around 1025 (10:25 a.m.) CNA (Certified Nursing Assistant) notified writer that resident was unresponsive. Upon assessment resident confirmed to be without pulse or respirations. Nurse initiated chest compressions while code status verified. DNR confirmed. EMTs (Emergency Medical Technicians) arrived and assumed care of resident. All supportive measures stopped . Review of the Emergency Medical Services (EMT) run sheet dated [DATE] at 10:38 a.m. revealed, . upon entering patient's room staff performing CPR, valid DNR handed it to EMS . 10:39 . EMS was presented with a valid DNR, staff advice (sic) to discontinue CPR and death was confirmed . On [DATE] at 10:08 a.m., in an interview, RN Staff A said she was going by the nurse's station and heard CNA Staff C yelling help. RN Staff A checked Resident #2 vitals and Licensed Practical Nurse (LPN) Staff B was following her. RN Staff A said Resident #2 didn't have a pulse. RN Staff A went to the desk to check Resident #2's code status. She said she met with RN Staff E on her way and said she (Resident #2) is a DNR. RN Staff E said they started CPR. RN Staff E said they could not stop CPR until a physician said so or EMS arrived and took over care. RN Staff A said CPR was going on when she returned to the room. RN Staff A showed EMS the DNRO, and EMS stopped the CPR. She didn't know how long it was. LPN Staff B and the Assistant Director of Nursing (ADON) were doing CPR. On [DATE] at 1:00 p.m., in an interview, the Director of Nursing said CPR should have been discontinued once the DNRO was verified. The current facility policy does not reflect this. She acknowledged the staff should have checked code status prior to initiating CPR. On [DATE] at 3:29 p.m., in an interview, RN Staff H said she was doing wound rounds and heard page overhead, she grabbed the crash cart. Upon arrival at the room CPR was in progress by LPN Staff B so she assisted with chest compressions, while RN Staff A was performing respirations. RN Staff H heard the resident was a DNR but told staff they already started CPR so they couldn't stop. CPR is to continue until EMS, or a physician says to stop. [DATE] 12:30 p.m., in an interview, RN Staff E said she was present during resuscitation. She said the physician was called after EMS arrived. On [DATE] at 3:10 p.m., in an interview, the Facility Administrator confirmed the CPR policy allows for continuation of resuscitation until physician stops or wait EMS arrives even in the presence of a valid DNRO. He acknowledged the staff should have checked code status prior to initiating CPR. On [DATE] a review of the facility's Immediate Jeopardy removal plan showed the facility's policy and procedure for cardiopulmonary resuscitation was revised on [DATE]. The facility conducted mocked drills on [DATE], [DATE], [DATE]. On [DATE] the facility began educating staff on new policy and a mock drill was conducted.

Based on record review and staff interview the facility failed to utilize its resources effectively to ensure each resident's resuscitation wishes were honored. The facility administration failed to develop and implement written policies and procedures to ensure residents' wishes for advanced directives were honored. The facility failed to self-identify the deficient practice with a likelihood of negative outcome. The facility's failure to honor residents' wishes not to be resuscitated would likely result in the resident experiencing major physical trauma including broken ribs, lung bruising, internal bleeding, damage to the airway and internal organs, and deprivation of a natural death. There were a 40 residents total in the facility with wishes not to be resuscitated. These actions resulted in Immediate Jeopardy that started on [DATE] when one (Resident #2) of 3 residents receiving cardiopulmonary resuscitation against the resident's expressed wishes. On [DATE] at 4:00 p.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the Immediate Jeopardy template. The Immediate Jeopardy ended on [DATE] at 2:15 p.m. after the removal plan was verified by review of policy and procedure revision, verification of staff training, and practice drills to verify staff competency. The scope and severity of the citation was reduced to D. The findings included: The Administrator's job description which he signed on [DATE] read Summary: Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents. The Director of Nursing job description which she signed on [DATE] included .Verify that medical and nursing care is administered in accordance with the resident's wishes, including the implementation of advance directives . Review of the facility Cardiopulmonary Resuscitation policy with a revision date of [DATE] included Guideline: Emergency Procedure- Cardiopulmonary Resuscitation Item 1d. which read, Check the medical record for advance directive status. Item #4 read, If circumstances are such that CPR is initiated on a resident, then code status is clarified to indicate there is a current order not to initiate CPR in the event of death. A call is made to the physician to determine if CPR can be discontinued or the team continues CPR until EMS (Emergency Medical Service) arrives. Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE]. Review of the psychiatric evaluation dated [DATE] revealed Resident #2 was AAO X3 (Alert, Awake and Oriented to person, place and time). The Practitioner documented Chief complaint . Of course I understand what a DNR means so bring it to me and I'll sign it . We discussed advanced care planning concepts in detail, and she is well aware if her (sic) should stop beating that she does not want any CPR. In fact, she demanded to sign the form as soon as this assessment was finished, and per staff, immediately signed the DNR form to state her firm decision . Assessment and Plan . Do not resuscitate. Honor advanced directives: NO CPR . Good insight into DNR status request . Review of the DNR order dated [DATE] revealed Resident #2 signed a statement that read, Based upon informed consent, I, the undersigned, hereby direct that CPR be withheld or withdrawn. The physician signed the DNR form on [DATE]. On [DATE] at 17:00 a nurse's note by Registered Nurse (RN) Staff E indicated Around 1025 (10:25 a.m.) CNA (Certified Nursing Assistant) notified writer that resident was unresponsive. Upon assessment resident confirmed to be without pulse or respirations. Nurse initiated chest compressions while code status verified. DNR confirmed. EMTs (Emergency Medical Technicians) arrived and assumed care of resident. All supportive measures stopped . On [DATE] at 12:45 p.m., in an interview Licensed Practical Nurse (LPN) Staff D said if a DNRO is found after CPR is started CPR will continue until told to stop by the physician or emergency medical services (EMS). On [DATE] at 3:29 p.m., in an interview RN Staff H said she heard Resident #2 was a DNR but told staff they already started CPR so they couldn't stop. CPR is to continue until EMS, or a physician says to stop. On [DATE] at 1:00 p.m. The Director of Nursing said CPR should have been discontinued once the DNRO was verified. She verified the current facility policy for CPR (Last revised: [DATE]) did not allow for withdrawal of CPR and read, If circumstances are such that CPR is initiated on a resident, then the code status is clarified to indicate there is a current order to not initiate CPR in the event of death. A call is made to the physician to determine if CPR can be discontinued or the team continues CPR until EMS arrives. She acknowledged the staff should have checked code status prior to initiating CPR. On [DATE] at 3:10 p.m., the Facility Administrator confirmed the CPR policy directs for continuation of resuscitation until physician stops or wait for EMS to arrive even in the presence of a valid DNRO. He acknowledged the staff should have checked code status prior to initiating CPR. The Administrator said the facility conducted audits on code status on [DATE] and [DATE]. They also performed mocked code blue drills on [DATE], [DATE] and [DATE] but did not revise their policy and procedure to ensure residents' resuscitation wishes were honored. On [DATE] at 12:00 p.m., in an interview, the Administrator said the vice president of clinical operation educated the administrative staff on the new policy. He said the corporate attorney and corporate compliance officer worked with the administrative team until the new policy was satisfactory. The facility's Immediate Jeopardy Removal Plan reviewed on [DATE] at 2:15 p.m., included documentation the governing board of the facility adopted the revised policy and procedure for cardiopulmonary resuscitation. On [DATE], 25 direct care nurses including 7 nurse managers, 19 certified nursing assistants and 10 therapists were educated on the new policy and procedure. 11 nurses and 3 nurse managers participated in code blue drills. The facility also conducted random audits to verify staff understanding of the new policy and procedure.

Based on staff interview, record review, and observation, the facility failed to provide consistent oxygen therapy for 1 (Resident #99) out of 5 residents reviewed who required continuous oxygen therapy. This resulted in Resident #99 requiring transfer to a higher level of care. The findings included: On 9/24/18 review of records revealed Resident #99 was admitted to the facility 8/19/14 with [DIAGNOSES REDACTED]. physician's orders [REDACTED].#99 included oxygen at 2 liters per minute via nasal cannula, order date 10/15/14. A review of the Comprehensive Care Plan for Resident #99 revealed a goal which shows the resident will maintain his respiratory baseline with a patent airway and unlabored respirations. Approaches included monitoring of heart and lung sounds, and to administer oxygen as ordered. Documentation of the assessment and monitoring of the resident's respiratory condition including response to therapy provided, and any changes in the respiratory condition. Documentation should also include: vital signs, respiratory rate, chest movement, respiratory effort, and the identification of abnormal breath sounds. Signs of dyspnea, cyanosis, coughing, whether position affects breathing, and presence of behavioral changes that may reflect [MEDICAL CONDITION] including anxiety, apprehension, and level of consciousness which is in keeping with the Professional Standards of Practice. The American Association of Respiratory Care guideline titled Respiratory Care (August 2007, Vol. 1) included Clinical Practice Guidelines: oxygen therapy should be administered in accordance with the physician prescription. In an interview on 10/16/18 at 12:10 a.m., the Assistant Director of Nursing (ADON) said the nurse has to switch from the concentrator to the portable tank when the resident goes out of their room. In an interview on 9/24/18 at 11:02 a.m., Registered Nurse (RN) Staff C said the nurse is responsible to make sure the oxygen tank is full. On 10/16/18 at 12:35 p.m. in a phone interview, Licensed Practical Nurse (LPN) Staff F said Resident #99 was in the dining room eating and started breathing abnormally. LPN Staff F was headed out the door when it was called to his attention that Resident #99 was having trouble breathing and he was called back inside the building. In an interview on 10/16/18 at 12:25 p.m., LPN Staff H said he was coming in for the day shift and was at the nurses' station when Resident #99 was brought from the dining room in his wheel chair by Certified Nursing Assistant (CNA) Staff I. LPN Staff H said his oxygen tank was empty, he was pale, and having trouble breathing. LPN Staff H took the resident to his room, put him in his bed, put head of bed up, put him on his concentrated air, and gave him a breathing treatment. LPN Staff H said Resident #99's oxygen saturation was still dropping so the LPN had the nurses at the desk call 9-1-1. In an interview on 10/16/18 at 12:44 p.m., CNA Staff I said that on 9/12/18 Resident #99's nails were blue and he could not talk. He was having trouble breathing, so I took him to the nurses' station. Review of the Health Status Notes for Resident #99 included on 9/12/18 Resident was found to be in distress while having breakfast. SPO2 (oxygen level) at 4 liter to be taken 68%. At 7:25 a.m. has pulse ox (level of oxygen in the blood) of 68%. He is on 4 liters (per minute) and nebulizer treatment is started. At 7:28 a.m. pulse ox remains at 68%. (Advanced Registered Nurse Practitioner) was called she ordered (resident) be sent to ER for [MEDICAL CONDITION] (low oxygen). At 7:50 a.m. (resident) left facility to be transferred to (local hospital). On 10/16/18, review of hospital records for Resident #99's treatment in the Emergency Department (ED) on 9/12/18. The [MEDICAL CONDITION] consult noted Patient presents with cyanosis (blue coloration of the skin) finger tips. The consult described presented to the ED with complains(sic) of shortness of breath. He resides in (the facility). He uses 2 l(iters) of oxygen. His oxygen tank was empty to one hour. He became lethargic and finger tips are blue . Modifying factors noted: Empty oxygen tank, history of [MEDICAL CONDITION]. The hospital record showed the resident was admitted [DATE] and discharged [DATE]. In an interview on 10/16/18 at 2:15 p.m. the Director of Nursing said she was not aware the Resident #99 was taken to the dining room, she stated, I was told he ate breakfast in his room when he started having trouble breathing. She confirmed the nurses charting does not show a good picture of the incident and she is unsure of who gave report prior to transport from the facility to the ED. She confirmed it does not matter if a resident is off of oxygen for an hour or 3-5 minutes; it is not acceptable.

Based on observations, record reviews, interviews and review of fall investigation reports, the facility failed to maintain an effective quality assurance committee in which it monitored, investigated, and developed action plans to prevent ongoing noncompliance with F441 cited on 7/31/15 and recited during this survey; and significant fall related injuries to residents. This failure to contributed to 1 (Resident #1) of 4 sampled resident's fall with a fracture as a result of improper transfer techniques by certified nursing assistants (CNA). The Quality Assurance (QA) Committee was not aware of issues regarding falls related to what the rehabilitation department was teaching staff; failed to communicate and collaborate with nursing education techniques for transfer to develop care plan's specific to transfer needs required by the resident. The facility also failed to identify a resident with repeated falls (Resident #2), and did not have documentation in the record about the falls; evidence of an investigation for the root analysis of the resident's falls, and from the analysis develop a plan to prevent future falls. The findings included: 1. Resident #1's clinical record contained a Minimum Data Set 3.0 (MDS) assessment dated [DATE]. The MDS indicated on the Brief Interview for Mental Status (BIMS) the resident had scored a 14 out of possible score of 15 (cognitively intact). Under functional status, the resident was coded as requiring the extensive assistance of two staff for transfers. A Care Area Assessment (CAA) summary completed on 8/25/15, had documented the resident was admitted with weakness, had a [DIAGNOSES REDACTED]. The summary noted to proceed to care plan with preventative measures and interventions to minimize risk. A fall risk evaluation was completed on 8/12/15 and indicated the resident had a score of 16 (a score of 10 or higher is at risk). On 11/19/15 the residents care plan dated 8/12/15 was reviewed. Under the section of at risk for fall related injury related to weakness and decreased mobility, the approaches included staff to assist with transfers as needed. In a Physical Therapy (PT) treatment note dated 10/13/15, Licensed Physical Therapist (LPT) Staff F documented a 2 person transfer for Resident #1 was demonstrated and performed with a CNA. Staff F noted the resident had good response and this was done with 100% safety. In a PT treatment note dated 10/16/15, Physical Therapist Assistant (PTA) Staff H documented CNA staff training for transfers with Resident #1. Staff H noted the resident had 2 good return demonstrations however on the 3rd attempt the resident's knees buckled and she required maximum assist to prevent her from falling. Staff were encouraged to use 2 people when transferring the resident. On 11/19/15 at 3:30 p.m., Resident #1 said she had been progressing pretty well with rehabilitation and was able to take steps using a walker and a person on each side of her. The resident said she had not been getting up at all without therapy assisting her. She said there was no one from rehabilitation here on the weekend and they wanted me to get up and said it was not good for me to be lying in bed. The resident said one CNA, may have been Staff G that came in to get her up with no one helping. The CNA sat her on the side of the bed and she was helping her stand up and move to the wheelchair. The resident said she told the CNA My legs are getting weak and I'm falling and then fell . The resident said the CNA was not able to keep her up. The resident said the wheelchair was relativity close but would have to take a step or 2 to sit there. She did not have a walker. The resident said in rehabilitation usually when going to take the steps she would stand with the walker then move the walker then take a couple of steps with a therapist on each side. The resident said she fell in a prayer type position on her knees and was yelling my leg, my leg. The CNA yelled for someone to give her a hand and someone came in. They pulled her right leg out and believed they lifted her up into the wheelchair and then lifted her back in bed. On 10/19/15 the therapist came in to look at it and said it was swollen and bruised. That night they got an x-ray and found her right ankle was broken. A physician's progress note dated 10/19/15 indicated the resident was complaining of pain in her right knee and ankle and ordered an x-ray to be done. A radiology report dated 10/20/15, noted the resident had a non-displaced oblique [MEDICAL CONDITION] fibula (ankle). On 11/20/15 at 8:24 a.m., CNA Staff G said when she first started caring for Resident #1, the resident was only being transferred by therapy. The resident was starting to get a little better and she was trained how to transfer the resident by Staff H and Staff F. She said the training was done in the resident's room and no other CNA was present. Staff G said she just watched them do it; then they watched her transfer the resident by herself. Staff G said the resident's care plan that was kept in a book on the unit was where she got the information on how to care for the resident. Staff G said if she was not familiar with a resident she would also check with nurse for more information. Staff G said after being trained by rehabilitation she started transferring the resident by herself. Staff G said since her fracture rehabilitation got her up and put her back to bed. She said was on 10/18/15 the resident wanted to get up for a while. Staff G had her sit on the side of the bed and had positioned the wheelchair next to bed so the resident could stand, turn and sit. Staff G said she did have a gait a belt on the resident. Staff G said she went to pivot the resident and her knees buckled and she lowered the resident down to the floor. One of the resident's legs was turned from where her legs buckled and believed it was her right leg. The resident was saying her legs just gave out. Did not voice that she was in any pain. Staff G said she went to door and called to Registered Nurse (RN) Staff K who came in and she told him what happened. He was checking her while she was still sitting on the floor. Staff G and Staff K both stood her up and sat her on the bed. The resident did say her ankle hurts. Staff G said she did put an ice pack on it per Staff K's instructions. Staff G said she was off the next day and when returned to work was told the resident had a small fracture. Staff G said other than talking to Staff K about how it occurred, no one else has talked to her about the incident. Staff G said since the incident she has not received any in-service training about transfers but will not be transferring anyone by herself again. On 11/20/15 at 8:45 a.m., and 9:09 a.m., PTA Staff H said on 10/16/15 he instructed both Staff G and Staff J on how to transfer Resident #1. He denied telling Staff G that she could transfer the resident by herself. He said this had always been for 2 people to transfer the resident. Staff H confirmed there was no in-service sheet to show the training he conducted with Staff G and Staff J. Per Staff H he did document the resident was a high fall risk the majority of time. He said he did show the 2 CNA's how to safely transfer with one person minimal assist with contact guard but still wanted 2 people as resident had a risk for her knees to buckle. Staff H said he did stress for 2 people to do the transfer. He confirmed he did not have those instructions documented anywhere. On 11/20/15 at 9:00 a.m., LPT Staff F confirmed on 10/13/15 she did a transfer training with Staff G. She said Resident #1 was not too confident to have a 2 person transfer (by CNA staff) so had Staff G trained for feet placement. Staff F said it was not very safe for a 1 person transfer and did not instruct Staff G she could do the transfer by herself. Staff F said there was no staff training in-service sheet filled out with those instructions. On 11/20/15 at 9:29 a.m., CNA Staff J said she did restorative range of motion to Resident #1's upper and lower extremities prior to her most recent hospitalization . Staff J said she and Staff G were educated on 10/16/15 by PTA Staff H on how to transfer Resident #1 from the bed to her wheelchair and back. Staff J said they did it 3 times. The first time she did pretty good; the second time the resident was trying to move too fast and did not go well as she was trying to throw herself onto the bed improperly and her knees buckled. She and Staff H held onto the gait belt to keep her from falling. Staff J said she and Staff G were told by Staff H the resident was a 2 person transfer. Staff J said she obtained resident care information as to whether they can ambulate or need a lift, from the resident's care plan. If the information was not in the care plan she will ask the nurse. There was no other form of information for them to use. Staff J said no one else had asked her any questions about the transfer training that she and Staff G attended. On 11/23/15 at 8:47 a.m., RN Staff K, said on the day of Resident #1's fall, the Director of Nursing (DON) was here and helping. He said around 12:00 p.m., Staff G came up to him at the nurses' station and said Resident #1 was on the floor. Staff G reported the resident's knees buckled and had set her on the floor. Staff K said he got up from the desk and walked to the room where he saw the resident sitting down on the floor on her buttocks. Staff K said the resident was not saying anything just sitting there. She did complain of discomfort to her right hip area. The resident told him Staff G was trying to get her up and she stood up but could not stand up any more and since Staff G was alone she started going down. Staff K said he examined the resident while she was on the floor and there were no apparent injuries. He said the resident did complain of her hip but did not see any shortening of the leg. Staff K said they rolled some bed sheets under her and after getting some help lifted her back in the chair or the bed; however, was not sure which. Staff K said he did another assessment when she was in bed as she was still complaining about the hip. Staff K did give her something for pain. Staff K said the resident's vital signs (blood pressure, pulse, and temperature) were taken; did not do any first aid as there were no skin tears; and he told the resident to get some rest. Staff K said he left the room and notified the resident's physician. Staff K said the resident must have called her family as they called him. Staff K said he wrote a progress note about the fall around 6:00 p.m., but confirmed did not document the time of the incident. Staff K said he was more worried about the hip that she had complained of and reported to the next shift. Staff K said he did not get off duty until 7:00 p.m., and did go back and check resident but did not document it anywhere. Staff K said he asked Staff G if the resident was a 1 or 2 person assist for transfers but does not remember what she said. Staff K said he usually had seen PT transferring the resident with 2 staff. Staff K said he did not report Staff G had transferred the resident by herself to the DON. Therapy communicated with CNA staff and would let them know if someone needed 1 or 2 staff assist. Staff K said CNA's got their resident care information from the care plan. On 11/20/15 at 10:10 a.m., the DON said she was on duty the weekend Resident #1 fell and worked on the B wing. She said there was another nurse on the wing with Staff K doing desk work. The DON said she was not made aware at the time when the resident fell . She said it happened around 12:00 p.m., but was not sure what time she was notified. The DON said it was reported the resident's knees gave out and she was lowered to the ground. The fall was witnessed and no apparent injuries were noticed at the time. The DON said she did not recall asking Staff K any questions when he notified her of the fall. She said she did not go assess or interview the resident about the fall. The DON said she was called at home on 10/20/15 to let her know the resident had a fracture. The DON said she made sure the resident's physician was notified and she contacted her Administrator (ADM). She said she did go in to see the resident on 10/21/15. She said the resident was to have a cast put on in the morning and she talked to her about her treatment plan. She said she did ask the resident what happened and cannot recall exactly what she said. The DON said she did not have any documentation of her interview with the resident. The DON confirmed she was the facility's Risk Manager and said she did look into the fall by reading the incident report. She did interview Staff K, and his written interview was the incident report itself. The DON did not interview the CNA Staff G, who was involved. The DON said she did review the resident's care plan, chart, and rehabilitation notes to see where her transfer status was at the time. The DON acknowledged she had not reviewed the treating therapist notes on 10/13/15 or 10/16/15 for training with 2 staff assist transfers and did not know if Staff G had been part of those training's. There was no written communication to nursing as to what the CNA's are being instructed to follow in regards to Resident #1's transfers. The DON acknowledged the residents care plan did not specify the level of assistance the resident required for safe transfers. 2. Resident #2's clinical record indicated the resident was admitted on [DATE] and had a [DIAGNOSES REDACTED]. A MDS 3.0 admission assessment dated [DATE] indicated the resident had scored a 3 on the BIMS (a score of 0-7 indicates the individual has severe cognitive impairment). Under the section for functional status, the resident was coded as requiring extensive assistance of 2 staff for transfers. The CAA's dated 10/2/15, listed falls as a potential problem for the resident and to proceed to care plan this area. physician's orders [REDACTED]. A change of condition review form was sent to the facility's pharmacist on 9/23/15 to review the resident's medications after a fall. A request for therapy evaluation dated 9/23/15, indicated the resident needed assistance for ambulation, transfers or bed mobility, had a gait problem, and recent fall. A physician's progress noted dated 9/28/15, indicted the resident had an increase in right hip pain status [REDACTED]. The radiology report dated 9/28/15 indicated no definite acute fracture or dislocation. However, prominent bone trabeculae are seen and possibility of non-displaced stress fracture is not entirely excluded. On 11/19/15 at 1:26 p.m., PT Staff F said on approximately 9/28/15, around the time the resident's physician ordered a CT scan, she saw the resident lying flat on her face on the floor. She said the resident was conscious when they found her. Staff F said she called the charge nurse who checked the resident and completed an incident report. There was no incident report or further documentation about the fall that occurred around 9/23/15, or of any fall that had occurred around 9/28/15. There was no documentation to show an investigation into the cause of the fall or follow up assessment of the resident after the fall or falls. The resident's care plan dated 9/29/15, under the section of at risk for fall related injury, related to weakness, with attempts to place herself down on floor, was updated to reflect the resident had a fall on 10/14/15, 11/8/15, and 11/16/15. The goal was resident will minimize risk for related injury by utilizing fall precautions through next review. The approaches included staff to assist with transfers as needed, bed and chair alarms, floor mats as ordered. On 10/15/15, approaches were added for Dycem (non-slip material) to wheelchair; and for a pelvic x-ray. On 11/8/15 the approach was added to educate the resident to ask for assistance with transfers (the resident has severe cognitive impairment), and side rails as enablers. On 11/16/15 the approach for therapy to evaluate and treat was added. 3. Incident and accident reports for Resident #2 were requested and reviewed. The first report dated 10/14/15, indicated the resident had an unwitnessed fall and was observed in the hallway sitting on the floor. The resident complained of pain in her pelvic region. The report indicated the resident required supervision and had an alarm in place at the time of the fall. The interventions implemented were Dycem to the resident's chair. A second report dated 11/8/15, indicated the resident was wheeled to hallway from the dining room, the resident slid down the wheelchair and onto the leg rests. The question of was there any interventions in place at the time of the fall, was answered No, and did not indicate the non-skid material Dycem, put in place at time of last fall, was in the resident's chair. The question of any new interventions implemented was answered, No. A third report dated 11/16/15, indicated the resident was sitting in her wheelchair at the dining room table when she slid herself to the floor. The report indicated there were CNA's present in the dining room. The interventions in place were Dycem and alarms. New nursing interventions to be implemented were for the resident to lay down after meals, and PT to evaluate. On 11/19/2015 at 9:15 a.m., CNA Staff O said the resident did not like to sit up in a chair; so when she was in the wheelchair, she slipped down quickly to the floor. Staff O said even with the alarm going off, she slid down quickly. A fall care plan note, dated 10/16/15, noted the resident was at the desk and placed herself on the floor. There was no other information about the fall or when this fall actually occurred. The resident's record contained no further documentation of the resident's falls. There was no documentation of any further interventions for staff to use that were not already in place, after 10/15/15. The care plan did not identify the amount of assistance the resident required with transfers or the new intervention of the resident to lie down after meals listed on the 11/16/15 incident report. The resident had incident reports for 2 subsequent falls on 11/8/15 and 11/16/15 but there was no documentation in the resident's record about these falls or if there was any increase in supervision of the resident when she was up in the chair. 4. On 11/23/15 at 1:19 p.m., the DON and ADM (Administrator) said there seems to be a variance of fall types amongst the residents in the facility. They said starting this week they would reevaluate the falls and look at the whole process of falls and fall investigations. The ADM said they do a trending report of falls, to include the time of day, the types of falls, and whether there are any similarities of falls. They look at the time of day falls occur as well as the day of the week. Neither the DON nor the ADM commented why there was no investigation into the fall of Resident #1 which resulted in an ankle fracture. The ADM said when he came to the facility 90 days ago, the QA committee wasn't even documenting QA minutes.

Based on record reviews, interviews, and review of facility policies and procedures related to falls, the facility failed to provide care in a manner to prevent accidents/falls for 2 (Residents #1, #2) of 4 sampled residents. Resident #1 required extensive assist of 2 staff members for transfers and when transferred by only 1 staff assisting, fell to the floor and sustained a fractured ankle. The facility failed to ensure Resident #2, with a known history of falls received increased supervision to prevent additional falls with injury. The findings included: The facility's policy for fall said It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk for falls and fall related injuries. Under guidelines the policy read, A comprehensive care plan will be implemented based on fall risk evaluation score with an individual goal and interventions specific to each resident. The care plan will be reviewed following each fall . and Interventions are to be revised as indicated by the assessment. 1. A fall risk evaluation was completed on 8/12/15 and indicated Resident#1 had a score of 16 (10 or higher is at high risk). The residents care plan dated 8/12/15 was reviewed on 11/19/15. Under the problem of at risk for fall related injury related to weakness and decreased mobility, the approaches included staff to assist with transfers as needed. Resident #1's clinical record contained a Minimum Data Set 3.0 (MDS) assessment dated [DATE]. The MDS indicated on the Brief Interview for Mental Status (BIMS), the resident had scored a 14 of a possible score of 15 (the individual is cognitively intact). Under the section for functional status, the resident was coded as requiring the extensive assistance of two staff for transfers. A Care Area Assessment (CAA) summary completed on 8/25/15, had documentation the resident was admitted with weakness, a [DIAGNOSES REDACTED]. The summary noted to proceed to care plan with preventative measures and interventions to minimize risk. In a physical therapy (PT) treatment note dated 10/13/15, Staff F, Licensed Physical Therapist (LPT), documented a 2 person transfer for Resident #1 was demonstrated and performed with a Certified Nursing Assistant (CNA). Staff F noted the resident had good response and this was done with 100% safety. In a PT treatment note dated 10/16/15, Physical Therapy Assistant (PTA) Staff H documented CNA staff training for transfers with Resident #1. Staff H noted the resident had 2 good return demonstrations however on the 3rd attempt the resident's knees buckled and she required maximum assist to prevent her from falling. CNA staff were encouraged to use 2 people when transferring the resident. On 11/19/15 at 3:30 p.m., Resident #1 said she had been progressing pretty well with rehabilitation and was able to take steps using a walker and a person on each side of her. The resident said she had not been getting up at all without therapy assisting her. She said there was no one here from rehabilitation on the weekend and they wanted me to get up and said it was not good for me to be lying in bed. The resident said one CNA, may have been Staff G, and came in to get her up with no one helping. The CNA sat her on the side of the bed and she was helping her stand up and move to the wheelchair. The resident said she told the CNA My legs are getting weak and I'm falling and then fell . The resident said the CNA was not able to keep her up. The resident said the wheelchair was relatively close but would have to take a step or 2 to sit there. Resident #1 said she did not have a walker. The resident said in rehabilitation she would take a couple of steps using a walker, with a therapist on each side of her. The resident said she fell in a prayer type position on her knees and was yelling my leg, my leg. The CNA yelled for someone to give her a hand and someone came in. They pulled her right leg out and believed they lifted her up into the wheelchair and then lifted her back in bed. On Monday, the therapist came in to look at it and said it was swollen and bruised. Finally that night they got the x-ray and her right ankle was broken. On 11/20/15 at 8:24 a.m., CNA Staff G said when she first started caring for Resident #1, the resident was only being transferred by therapy. The resident was starting to get a little better and she was trained how to transfer the resident by Staff H and Staff F. She said the training was done in the resident's room and no other CNA was present. Staff G said she just watched them do it, and then they watched her transfer the resident by herself. Staff G said the resident's care plan was kept in a book on the unit and was where she got the information on how to care for the resident. CNA Staff G said if she was not familiar with a resident she would also check with nurse for more information. Staff G said after being trained by rehabilitation she started transferring the resident by herself. She said it was on a Sunday (10/18/15) and the resident wanted to get up for a while. She had her sitting on the side of the bed and had positioned the wheelchair next to the bed so the resident could stand, turn, and sit. Staff G said she did have a gait a belt on the resident. Staff G said she went to pivot the resident and her knees buckled and she lowered the resident down to the floor. One of the resident's legs was turned from where her legs buckled and believed it was the right leg. The resident was saying her legs just gave out. The resident did not voice that she was in any pain. Staff G said she went to door and called Registered Nurse (RN) Staff K who came in and was told what happened. Staff K checked the resident while she was still sitting on the floor. CNA Staff G and RN Staff K both stood her up and sat her on the bed. The resident said her ankle hurt. Staff G said she did put an ice pack on it per Staff K's instructions. Staff G said she was off the next day and when returned to work was told the resident had a small fracture. Staff G said other than talking to Staff K about how it occurred, no one else had talked to her about the incident. Staff G said since the incident, she has not received any in-service training about transfers but will not be transferring anyone by herself again. Does make her own sheet for a place to document her resident care information as there was no other place to do that. On 11/20/15 at 8:45 a.m. and 9:09 a.m., PTA Staff H said on 10/16/15 he instructed both CNA Staff G and CNA Staff J on how to transfer Resident #1. He denied telling Staff G that she could transfer the resident by herself. He said this had always been for 2 people to transfer the resident. Staff H confirmed there was no in-service sheet to show the training he conducted with Staff G and Staff J. PTA Staff H said he documented the resident was a high fall risk the majority of time. He said he did show the 2 CNA's how to safely transfer with one person minimal assist with contact guard but still wanted 2 people as she had a risk for her knees to buckle. Staff H said he did stress for 2 people to assist with transfer. He confirmed he does not have those instructions documented anywhere. On 11/20/15 at 9:00 a.m., LPT Staff F confirmed on 10/13/15 she did a transfer training with Staff G. She said Resident #1 was not too confident to have a 2 person transfer (by CNA staff) so had Staff G trained for feet placement. Staff F said Resident #1 was not very safe for a 1 person transfer and did not instruct Staff G that she could do the transfer by herself. Staff F said there was no staff training in-service sheet filled out with those instructions. On 11/20/15 at 9:29 a.m., CNA Staff J said she did restorative range of motion to Resident #1's upper and lower extremities prior to her most recent hospitalization . CNA Staff J said she and CNA Staff G were educated on 10/16/15 by PTA Staff H on how to transfer Resident #1 from the bed to her wheelchair and back. CNA Staff J said they did it 3 times. The first time she did pretty good; the second time the resident was trying to move too fast and did not go well as she was trying to throw herself onto the bed improperly and her knees buckled. She and Staff H held onto the gait belt to keep her from falling. Staff J said she and Staff G were told by Staff H the resident is a 2 person transfer. Staff J said she obtained resident care information as to whether they can ambulate or need a lift etc. from the resident's care plan. There was no other form of information for them to use. On 11/23/15 at 8:47 a.m., RN Staff K said on the day of Resident #1's fall, the Director of Nursing (DON) was here and helping us. He said around 12:00 p.m., Staff G came up to him at the nurses' station and said Resident #1 was on the floor. Staff G reported the resident's knees buckled and had set her on the floor. Staff K said he got up from the desk and walked to the room where he saw the resident was sitting down on the floor on her buttocks. Staff K said the resident was not saying anything just sitting there. She did complain of discomfort to her right hip area. The resident told him Staff G was trying to get her up and she stood up but could not stand up any more and since Staff G was alone she started going down. Staff K said he examined the resident while she was on the floor and there were no apparent injuries. He said the resident did complain of her hip but did not see any shortening of the leg. Staff K said they rolled some bed sheets under her and after getting some help lifted her back in the chair or the bed; however was not sure which. Staff K said he did another assessment when she was in bed as she was still complaining about her hip. Staff K said he did give her something for pain. Staff K said the resident's vital signs (blood pressure, pulse, and temperature) were taken and he told the resident to get some rest. Staff K said he left the room and notified the resident's physician. Staff K said the resident must have called her family as they called him. Staff K said he wrote a progress note about the fall around 6:00 p.m., and confirmed he did not document the time of the incident. Staff K said he was more worried about the hip that she had complained of and reported to the next shift. Staff K said he did not get off duty until 7:00 p.m., but did go back and check the resident and did not document that anywhere. Staff K said he asked Staff G if the resident was a 1 or 2 person assist for transfers but did not remember what she said. Staff K said he usually seen PT transferring the resident with 2 staff. Staff K said he did not report Staff G had transferred the resident by herself to the DON. Therapy communicates with CNA staff and will let them know if someone needed a 1 or 2 person assist. Staff K said CNA's get their resident care information from the care plan. On 11/20/15 at 10:10 a.m., the DON said she was on duty the weekend Resident #1 fell and was working on the B wing. She said there was another nurse on the wing, RN Staff K, who was doing the desk work. The DON said she was not made aware at the time the resident fell . She said it happened around 12:00 noon but was not sure what time she was notified. The DON said it was reported the resident's knees gave out and she was lowered to the ground. The fall was witnessed and there were no apparent injuries at the time. The DON said she did not recall asking RN Staff K any questions when he notified her of the fall. She said she did not go assess or interview the resident about the fall. The DON said she was called at home on 10/20/15 to let her know the resident had a fracture. The DON said she made sure the resident's physician was notified and she contacted her administrator. She said she did go in to see the resident on 10/21/15. She said the resident was to have a cast put on in the morning and she talked to her about her treatment plan. She said she did ask the resident what happened and could not recall exactly what she said. The DON said she did not have any documentation of her interview with the resident. The DON confirmed she was the facility's risk manager and said she did look into the fall by reading the incident report. She did interview Staff K and his written interview was the incident report itself. The DON said she did not interview the CNA, Staff G who was involved. The DON acknowledged she had not reviewed the treating therapists' notes on 10/13/15 and 10/16/15 about training staff for 2 assist transfers and did not know Staff G had been part of those training's. There was no written communication to nursing from therapy as to what the CNA's are being instructed to follow in regards to Resident #1's transfers. The DON acknowledged the residents care plan did not specify the level of assistance the resident required for a safe transfer. A physician's progress note dated 10/19/15 indicated the resident was complaining of pain in her right knee and ankle and ordered an x-ray to be done. A radiology report dated 10/20/15, noted the resident had a non-displaced oblique fracture of the distal fibula (ankle). 2. Resident #2's clinical record indicated the resident was admitted on [DATE] and had a [DIAGNOSES REDACTED]. A MDS 3.0 admission assessment dated [DATE] indicated the resident had scored a 3 out of a possible score of 15 on the BIMS (severe cognitive impairment). Under functional status, the resident was coded as requiring extensive assistance of two staff for transfers. The CAA dated 10/2/15, listed falls as a potential problem for the resident and to proceed to care plan this area. physician's orders [REDACTED]. A change of condition review form was sent to the facility's pharmacist on 9/23/15 to review the resident's medications after a fall. A request for therapy evaluation dated 9/23/15, indicated the resident needed assistance for ambulation, transfers or bed mobility, had a gait problem, and recent fall. A physician's progress noted dated 9/28/15, indicted the resident had an increase in right hip pain status [REDACTED]. The radiology report dated 9/28/15 indicated no definite acute fracture or dislocation. However, prominent bone trabeculae (end of long bone, common injury site) are seen and possibility of non-displaced stress fracture is not entirely excluded. On 11/19/15 at 1:26 p.m., PT Staff F said on approximately 9/28/15, around the time the resident's physician ordered a CT scan, she saw the resident lying flat on her face on the floor. She said the resident was conscious when they found her. Staff F said she called the charge nurse who checked the resident and completed an incident report. There was no incident report or further documentation about the fall that occurred around 9/23/15, or of any fall that had occurred around 9/28/15. There was no documentation to show an investigation into the cause of the fall or follow up assessment of the resident after the fall or falls. The resident's care plan dated 9/29/15, under the problem of at risk for fall related injury, related to weakness, with attempts to place herself down on floor, was updated to reflect the resident had a fall on 10/14/15, 11/8/15, and 11/16/15. The goal was resident will minimize risk for related injury by utilizing fall precautions through next review. The approach included staff to assist with transfers as needed, bed and chair alarms, floor mats as ordered. On 10/15/15, approaches were added for Dycem (non-slip material) to wheelchair; and for a pelvic x-ray. On 11/8/15 the approach was added to educate the resident to ask for assistance with transfers (the resident has severe cognitive impairment), and side rails as enablers. On 11/16/15 the approach for therapy to evaluate and treat was added. Incident and accident reports for Resident #2 were requested and reviewed. The first report dated 10/14/15, indicated the resident had an unwitnessed fall and was observed in the hallway sitting on the floor. The resident complained of pain in her pelvic region. The report indicated the resident required supervision and had an alarm in place at the time of the fall. The interventions implemented were Dycem to the resident's chair. A second report dated 11/8/15, indicated as the resident was wheeled to hallway from the dining room, the resident slid down the wheelchair and onto the leg rests. The question of was there any interventions in place at the time of the fall, was answered No. and did not indicate the non-skid material Dycem, put in place at time of last fall, was in the resident's chair. The question of any new interventions implemented was answered, No. A third report dated 11/16/15, indicated the resident was sitting in her wheelchair at the dining room table when she slid herself to the floor. The report indicated there were CNA's present in the dining room and the interventions in place were Dycem and alarms. New nursing interventions to be implemented were for the resident to lay down after meals, and PT to evaluate. In an interview on 11/19/2015 at 9:15 a.m., CNA Staff O said the resident did not like to sit up in a chair; so when she was in the wheelchair, she slipped down quickly to the floor. CNA Staff O said even with the alarm going off, she slid down quickly. A fall care plan note, dated 10/16/15, noted the resident was at the desk and placed herself on the floor. There was no other information about the fall or when this fall actually occurred. The resident's record contained no further documentation of the Resident #2's falls. There was no documentation of any further interventions for staff to use that were not already in place, after 10/15/15. The care plan did not identify the amount of assistance the resident required with transfers or the new intervention of the resident to lie down after meals listed on the 11/16/15 incident report. The resident had incident reports for 2 subsequent falls on 11/8/15 and 11/16/15 but there was no documentation in the resident's record about these falls or if there was any increase in supervision of the resident when she was up in the chair.

Based on observations, record reviews, interviews, and review of facility policies and procedures related to care plans, the facility failed to revise the plan of care for 2 (Residents #1, and #2) of 4 sampled residents. The facility failed to update Resident #1's care plan to reflect the amount of transfer assistance required by the resident. Due to this failure, Resident #1 fell and sustained a fractured right ankle. The facility failed to update the plan of care related to Resident #1's unstable blood sugars and ensure her plan of care related to a highly contagious infection including specific interventions to prevent the transmission of the disease. The facility failed to revise the plan of care for Resident #2 in an effort to prevent additional falls and injury. The findings included: The facility's policy for falls stated, It is the intent of this facility to provide residents with assistance and supervision in an effort to minimize the risk for falls and fall related injuries. Under the guidelines, the policy read, A comprehensive care plan will be implemented based on fall risk evaluation score with an individual goal and interventions specific to each resident. The care plan will be reviewed following each fall . and Interventions are to be revised as indicated by the assessment. 1. A fall risk evaluation for Resident #1 was completed on 8/12/15 and indicated the resident had a score of 16 (10 or higher is high risk). On 11/19/15, the resident's care plan dated 8/12/15 was reviewed. Under the problem of at risk for fall related injury related to weakness and decreased mobility, the approaches included staff to assist with transfers as needed. Resident #1's clinical record contained a Minimum Data Set 3.0 (MDS) assessment dated [DATE]. The MDS indicated the resident had scored a 14 on the Brief Interview for Mental Status (BIMS) (a score of 13-15 indicates the individual is cognitively intact). Under the section for functional status, the resident was coded as requiring the extensive assistance of two staff for transfers. A Care Area Assessment (CAA) summary completed on 8/25/15, had documentation the resident was admitted with weakness, had a [DIAGNOSES REDACTED]. The summary noted to proceed to care plan with preventative measures and interventions to minimize risk. In a physical therapy (PT) treatment note dated 10/13/15, Licensed Physical Therapist (LPT) Staff F, documented a 2-person transfer for Resident #1 was demonstrated and performed with a certified nursing assistant (CNA). LPT Staff F noted the resident had good response and this was done with 100% safety. In a PT treatment note dated 10/16/15, Physical Therapy Assistant (PTA) Staff H documented CNA staff training for transfers with Resident #1. PTA Staff H noted the resident had 2 good return demonstrations however on the 3rd attempt the resident's knees buckled and she required maximum assist to prevent her from falling. Staff were encouraged to use 2 people when transferring the resident. On 11/19/15 in an interview at 3:30 p.m., Resident #1 said she had been progressing pretty well with rehabilitation and was able to take steps using a walker and a person on each side of her. The resident said she had not been getting up at all without therapy assisting her. She said there was no one from rehabilitation here on the weekend and they wanted me to get up and said it was not good for me to be lying in bed. The resident said one CNA, who may have been Staff G, came in to get her up with no one else helping. The CNA sat her on the side of the bed and she was helping her stand up and move to the wheelchair. The resident said she told the CNA My legs are getting weak and I'm falling and then fell . The resident said the CNA was not able to keep her up. The resident said the wheelchair was relatively close but would have to take a step or 2 to sit there. Resident #1 said she did not have a walker. The resident said in rehabilitation she will use a walker and take a couple of steps with a therapist on each side of her. The resident said she fell in a prayer type position on her knees and was yelling my leg, my leg. The CNA yelled for someone to give her a hand and someone came in. They pulled her right leg out and lifted her up into the wheelchair and then lifted her back in to bed. On 11/20/15 at 8:24 a.m., CNA Staff G said when she first started caring for Resident #1, the resident was only being transferred by therapy. The resident was starting to get a little better and she was trained how to transfer the resident by PTA Staff H, and LPT Staff F. She said the training was done in the resident's room and no other CNA was present. Staff G said she just watched them do it; then they watched her transfer the resident by herself. Staff G said the resident's care plan was kept in a book on the unit and was where she got the information on how to care for the resident. Staff G said if she was not familiar with a resident she would also check with the nurse for more information. Staff G said after being trained by rehabilitation she started transferring the resident by herself. She said it was on a Sunday (10/18/15) and the resident wanted to get up for a while. Had her sitting on the side of the bed and had positioned the wheelchair next to bed so the resident could stand, turn, and sit. Staff G said she went to pivot the resident and her knees buckled and she lowered the resident down to the floor. One of the resident's legs was turned from where her legs buckled and believes was the right leg. The resident was saying her legs just gave out and did not say she was in any pain. Staff G said she went to door and called to Registered Nurse (RN) Staff K who came in and she reported to him what happened. Staff G said she was off the next day and when returned to work was told the resident had a small fracture. On 11/20/15 at 8:45 a.m. and 9:09 a.m., PTA Staff H said on 10/16/15 he instructed both Staff G and Staff J on how to transfer Resident #1. He denied telling Staff G she could transfer the resident by herself. He said this had always been for 2 people to transfer the resident. Staff H confirmed there was no in-service sheet to show the training he conducted with Staff G and Staff J. Per Staff H he did document the resident was a high fall risk the majority of time. He said he did show the 2 CNA's how to safely transfer with one person minimal assist with contact guard but still wanted 2 people as there was a risk for her knees to buckle. Staff H did stress for 2 people to do the transfer. He confirmed he did not have those instructions documented anywhere. On 11/20/15 at 9:00 a.m., LPT Staff F confirmed on 10/13/15 she did a transfer training with Staff G. She said Resident #1 was not too confident to have a 2 person transfer (by CNA staff) so had Staff G trained for feet placement. Staff F said it was not safe for a 1 person transfer and did not instruct Staff G she could do the transfer by herself. Staff F said there was no staff training in-service sheet filled out with those instructions. In an interview on 11/20/15 at 9:29 a.m., CNA Staff J said she did restorative range of motion to Resident #1's upper and lower extremities prior to her most recent hospitalization . CNA Staff J said she and CNA Staff G were educated on 10/16/15 by PTA Staff H on how to transfer Resident #1 from the bed to her wheelchair and back. Staff J said they did it 3 times. The first time she did pretty good; the second time the resident was trying to move too fast and did not go well as she was trying to throw herself onto the bed improperly and her knees buckled. She and PTA Staff H held onto the gait belt to keep her from falling. CNA Staff J said she and CNA Staff G were told by PTA Staff H the resident is a 2-person transfer. CNA Staff J said she obtained resident care information as to whether they can ambulate or need a lift etc. from the resident's care plan. If the information was not in the care plan she will ask the nurse. There was no other form of information for them to use. On 11/23/15 at 8:47 a.m., RN Staff K said on the day of Resident #1's fall, the Director of Nursing (DON) was here and helping us. He said around 12:00 p.m., Staff G came up to him at the nurses' station and said Resident #1 was on the floor. Staff G reported the resident's knees buckled and had set her on the floor. RN Staff K said he got up from the desk and walked to the room where he saw the resident was sitting down on the floor on her buttocks. RN Staff K said the resident was not saying anything, just sitting there. She did complain of discomfort to her right hip area. The resident told him Staff G was trying to get her up and she stood up but could not stand up any more and since Staff G was alone she started going down. RN Staff K said he examined the resident while she was on the floor and there were no apparent injuries. He said the resident did complain of her hip, but he did not seen any shortening of her leg. RN Staff K said they rolled some bed sheets under her and after getting some help lifted her back up and into a chair or bed; however, was not sure which. RN Staff K said he did another assessment when she was in bed as she was still complaining about the hip and gave her something for pain. RN Staff K said he left the room and notified the resident's physician. RN Staff K said he asked CNA Staff G if the resident was a 1 or 2-person assist for transfers but did not remember what she said. RN Staff K said he usually sees PT transferring the resident with 2 staff. Staff K said he did not report Staff G had transferred the resident by herself to the DON. Therapy communicated with CNA staff and would let them know if someone was in need of 1 or 2 assist. RN Staff K said CNA's get their resident care information from the care plan. On 11/20/15 at 10:10 a.m., the DON was on duty the weekend Resident #1 fell and working on the B wing. The DON confirmed it was reported by RN Staff K on 10/18/15, the resident's knees gave out and she was lowered to the ground. The fall was witnessed and there were no apparent injuries at the time. The DON said she was called at home on 10/20/15 to let her know the resident had a fracture. The DON said she was the facility's Risk Manager and she did review the resident's care plan, chart, and rehabilitation notes to see where her transfer status was at the time. She reviewed the PT treatment plan and in therapy she was as a standby contact guard assist using a 2 wheeled walker as of 10/13/15. The DON acknowledged she had not reviewed the treating therapist notes on 10/13/15 and 10/16/15 about training staff for 2 assist transfers and did not know Staff G had been part of those trainings. Reviewed with the DON and there was no written communication to nursing as to what the CNA's were being instructed to follow in regards to Resident #1's transfers. Reviewed CNA staff were getting their information from the resident's care plan as to how much assistance a resident needed for transfers. The DON acknowledged the residents care plan did not specify how much assistance the resident required with transfers. On 11/19/15 at 3:30 p.m., Resident #1 said on 10/19/15 the therapist came in to look at her ankle and said it was swollen and bruised. Resident #1 said that night they got the x-ray and her right ankle was broken. A physician's progress note dated 10/19/15 indicated the resident was complaining of pain in her right knee and ankle and ordered an x-ray to be done. A radiology report dated 10/20/15, noted the resident had a non-displaced oblique [MEDICAL CONDITION] fibula (ankle). 2. Resident #1's clinical record revealed a [DIAGNOSES REDACTED]. A review of the laboratory reports indicated on 9/22/15 the resident's blood glucose was elevated at 138 (normal range 70-105). On 10/6/15, the resident's blood glucose was under 40. On a lab report dated 10/8/15, the resident's blood glucose was 83. A nurse's note dated 10/22/15 revealed the resident was noted to have altered mental status and was sent to the hospital. The nurse documented the resident was lethargic, flaccid, nonverbal, but was only able to nod her head yes or no. The resident was noted to have a decline after dinner and had complained during the shift of feeling foggy. A hospital history and physical dated 10/23/15 indicated the resident was hypoglycemic with a blood glucose of 32. The resident's blood sugar was 35 in the emergency room . The resident was admitted to the hospital and did not return to the facility until 10/30/15. On 11/19/15 at 3:30 p.m., Resident #1 said she was a diabetic and had an episode where her arms wouldn't work, was unable to push herself up, couldn't speak, and had saliva around her mouth. A CNA came in to check on her and kept asking her what's wrong and the next thing she knew the Physician's Assistant was in to see her. Resident #1 stated They asked if I wanted them to call 911 and I shook my head yes. When the paramedics got there one of them checked her blood sugar and said no wonder, her sugar is 32. The resident said she couldn't swallow the liquid glucose and the paramedics said let's get her out of here. The resident's care plan dated 8/12/15, under the problem of at risk for complications associated with hyper/[DIAGNOSES REDACTED] (high/low blood sugar), had not been updated to reflect the resident having unstable blood sugars and the resident became hypoglycemic with a blood sugar of 32. The care plan did not list any specific signs and symptoms staff should be monitoring for (such as the resident complaining of feeling foggy) the resident had exhibited when she became hypoglycemic. On 11/23/15 at 10:52 a.m., the DON acknowledged the residents care plan had not been updated in regards to her [DIAGNOSES REDACTED] and lacked resident specific interventions. 3. Resident #2's clinical record indicated the resident was admitted on [DATE] and had a [DIAGNOSES REDACTED]. A MDS 3.0 admission assessment dated [DATE] indicated the resident had scored a 3 out of a possible maximum score of 15 on the Brief Interview for Mental Status (severe cognitive impairment). Under the section for functional status, the resident was coded as requiring the extensive assistance of two staff for transfers. The CAA's dated 10/2/15, listed falls as a potential problem for the resident and to proceed to care plan this area. physician's orders [REDACTED]. A change of condition review form was sent to the facility's pharmacist on 9/23/15 to review the resident's medications after a fall. A request for therapy evaluation dated 9/23/15, indicated the resident needs assistance for ambulation, transfers or bed mobility, had a gait problem and recent fall. A physician's progress note dated 9/28/15, indicted the resident had an increase in right hip pain status after an unwitnessed fall. The radiology report dated 9/28/15 indicated no definite acute fracture or dislocation. However, prominent bone trabeculae (the end of a long bone, common area of injury) are seen and possibility of non-displaced stress fracture is not entirely excluded. On 11/19/15 at 1:26 p.m., PT Staff F said on approximately 9/28/15, around the time the resident's physician ordered a CT scan, she saw the resident lying flat on her face on the floor. She said the resident was conscious when they found her. Staff F said she called the charge nurse who checked the resident and completed an incident report. The resident's care plan dated 9/29/15 under the problem of at risk for fall related injury, related to weakness, with attempts to place herself down on floor, had been updated to indicate the resident had falls on 10/14/15, 11/8/15, and 11/16/15. The goal was resident will minimize risk for related injury by utilizing fall precautions through next review. The approaches included Staff to assist with transfers as needed, bed and chair alarms, floor mats as ordered. On 10/3/15, pressure alarm to bed and wheelchair to alert staff of unassisted transfer due to poor safety awareness; on 10/3/15 floor mat at bedside; on 10/15/15 Dycem (nonskid material) to wheelchair for safety precaution. On 10/15/15, approaches were added for Dycem (non-slip material) to wheelchair; and for a pelvic x-ray. On 11/8/15 the approach was added to educate the resident to ask for assistance with transfers (the resident had severe cognitive impairment), and side rails as enablers. On 11/16/15 the approach for therapy to evaluate and treat was added. An incident/accident report dated 11/8/15, indicated as the resident was wheeled to hallway from the dining room, the resident slid down the wheelchair and onto the leg rests. The question of was there any interventions in place at the time of the fall, was answered No, and did not indicate the non-skid material Dycem, put in place at time of last fall, was in the resident's chair. The question of any new interventions implemented was answered, No. An incident/accident report dated 11/16/15, indicated the resident was sitting in her wheelchair at the dining room table when she slid herself to the floor. The report indicated there were CNA's present in the dining room. The interventions in place were Dycem and alarms. New nursing interventions to be implemented are for the resident to lay down after meals, and PT to evaluate (but was not included in the care plan). On 11/19/2015 at 9:15 a.m., CNA Staff O said the resident did not like to sit up in a chair; so when she was in the wheelchair, she slipped down quickly to the floor. Staff O said even with the alarm going off, she slid down quickly. A fall care plan note, dated 10/16/15, noted the resident was at the desk and placed herself on the floor. There was no other information as to when this fall actually occurred. The resident's record contained no further documentation of the resident's falls. There was no documentation of any further interventions for staff to use not already in place, after 10/15/15. The care plan did not identify the amount of assistance the resident required with transfers. The new intervention of the resident to lie down after meals listed on the 11/16/15 incident report was not added. The amount of supervision the resident required when she was up in the chair was not identified. 4. In an interview on 11/19/15 at 3:02 p.m., Resident #1 said during her stay at the facility, she began having loose stools and was told she contracted [MEDICAL CONDITIONS]. Resident #1 said she was in a private room during the time of the infection. Resident #1 said no one was wearing special clothing while taking care of her when she had the infection and were only wearing gloves when assisting her to the toilet. ([MEDICAL CONDITION] is a highly contagious bacteria causing diarrhea and more serious intestinal conditions such as [MEDICAL CONDITION]-inflammation of the colon.) On 11/19/15 at 3:47 p.m., CNA Staff A said she remembered Resident #1 having [MEDICAL CONDITION]. Staff A was not sure how long contact precautions were maintained. Review of the clinical record documented Resident #1 was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/8/15, physician's orders [REDACTED]. Review of the MDS assessments with of 8/19/15 and 11/6/15 documented Resident #1 with a BIMS score of 15 (a high score reflects a high level of cognitive functioning.) Review of the comprehensive care plan showed a plan of care which indicated Resident #1 with an active [MEDICAL CONDITION] infection. Interventions included: .Personal Protective Equipment if indicated .obtain labs/cultures and notify results to physician as ordered . The care plan was not revised to reflect the specific precautions to use for a resident with a transmittable infection. The care plan did not specify what type of personal protective equipment should be used. On 11/20/15 at 12:45 p.m., the DON said Resident #1 tested positive for [MEDICAL CONDITION] and was placed on contact precautions. The DON admitted Resident #1's care plan should've been updated to reflect specific approaches in treating the infection as the care plan was what the nurses and CNA's used to provide care to the residents. She admitted the care plan had not been updated to reflect contact precautions and was unaware Resident #1 said no one was following precautions.