Every finding on record at Anderson County Hospital Ltcu

The facility identified a census of 27 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to provide direct, interactive activities based on resident preferences for the residents on weekends. This deficient practice placed the affected residents at risk for decreased psychosocial well-being, boredom, and isolation. Findings Included: - A review of the facility's Activity Calendars for December 2024, January 2025, and February 2025 was completed. The calendars revealed religious services provided at 09:00 AM and 03:15 PM for Saturdays but lacked staff-led activities. The calendars revealed a devotional group was held at 09:00 AM on Sundays. The calendar revealed the residents were provided music and coloring pages on Sundays but lacked staff-led activity groups. The council reported the weekends were sometimes slow without activities. On 02/11/25 at 10:30 AM, the facility provided manicures for the residents. On 02/12/25 at 11:40 AM, the facility's Resident Counsel reported that staff-led activities rarely occurred on weekends. The council reported that the facility's previous Activity Coordinator (AC) quit in December 2024. The council reported that the facility provided religious activities on Saturdays and Sundays but lacked staff-led activities. On 02/13/25 at 12:01 PM, the Certified Nurse's Aide (CNA) M stated that the facility staff completed activities on weekdays but was not sure what activities were available on weekends outside of church services. She stated that the facility provided coloring pages, board games, and puzzles that the residents could complete on their own but was not sure of any staff-led activities. On 02/13/25 at 12:16 PM, Licensed Nurse (LN) G stated the facility provided puzzles and games for the residents on the weekends. On 02/13/25 at 12:30 PM, Administrative Nurse D stated the facility provided religious services on weekends. She stated the residents could play board games, puzzles, and self-led activities. She stated she was not sure of any staff-led activities outside of church services on the weekends. The facility's Activities Evaluation policy (undated) indicated the facility would provide ongoing individualized and group activities that promote goals, strengths, and social, and emotional support for each resident. The facility failed to provide consistent activities on the weekends which reflected the residents' interests and preferences. This deficient practice placed the affected residents at risk for boredom, isolation, and decreased quality of life.

The facility had a census of 27 residents. The sample included 12 residents, with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure 15 pressurized medical oxygen tanks in a safe, locked area, and out of reach of the nine cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries. Findings Included: - On 02/11/25 at 07:20 AM, an inspection of the facility's oxygen storage room revealed that the door was not secured. An inspection of the room revealed 15 full supplemental oxygen cylinders in the storage rack. The door closed and locked upon exit. On 02/13/25 at 08:22 AM the facility identified it had nine cognitively impaired independently mobile residents. On 02/13/25 at 12:01 PM, Certified Nurse's Aide (CNA) M stated the room was to be locked at all times due to the oxygen tanks. She stated the door had an electronic lock and staff were to ensure the door was fully closed and locked upon exiting the room. On 02/13/25 at 12:30 PM, Administrative Nurse D stated staff were expected to ensure the door was locked upon entering and exiting the room. The facility's Medical Gas Usage and Storage policy revised 02/2025 stated all pressurized containers and potentially hazardous medical equipment will be locked within a secure temperature-controlled room. The facility failed to secure 15 pressurized medical oxygen tanks in a safe, locked area, and out of reach of the nine cognitively impaired independently mobile residents. This deficient practice placed the residents at risk for preventable accidents and injuries.

The facility identified a census of 27 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure the Consultant Pharmacist (CP) recommendations were acknowledged and/or acted upon for Resident (R) 2, R20, and R25. The facility failed to ensure the CP identified and reported the non-approved indication for R10's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. These deficient practices placed the residents at risk for unnecessary medication use and physical complications. Findings included: - R2's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and confusion), and short-term memory loss. The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R2 had received an antidepressant (a class of medications used to treat mood disorders) medication, a diuretic (a medication to promote the formation and excretion of urine), and an opioid (a class of controlled drugs used to treat pain). The MDS lacked indication of physician documentation that a gradual dose reduction was clinically contraindicated for R2. The MDS lacked documentation a drug regimen review was completed during the observation period for R2. The Quarterly MDS dated [DATE] documented a BIMS score of 99 which indicated severely impaired cognition. The MDS documented that R2 had received an antidepressant medication, an antianxiety (a class of medications that calm and relax people) medication, a diuretic, and an opioid. The MDS lacked indication of physician documentation that a gradual dose reduction was clinically contraindicated for R2. The MDS lacked documentation a drug regimen review was completed during the observation period for R2. R2's Psychotropic Drug Use Care Area Assessment (CAA) dated 04/23/24 documented she currently took Zoloft (antidepressant) 50 milligrams (mg) daily. R2's Care Plan dated 10/28/24 documented she would not experience adverse effects related to medications. R2's EMR under the Orders tab revealed the following physician orders: Sertraline (Zoloft) tablet 100 mg, one tablet, daily for anxiety with depression dated 09/19/24. Review of R2's EMR under the Notes tab revealed a Pharmacy Review note dated 03/28/24 at 01:32 PM documented the recommendation pending. The facility provided an unaddressed and unsigned Monthly Medication Review (MMR) dated 03/28/24 upon request. On 02/11/25 at 03:30 PM, R2 walked with her walker in the hallway to the common area by the front entrance door. On 02/13/25 at 12:04 PM, Licensed Nurse (LN) G stated she made changes for any new medication orders on the MRRs when they were returned from the physician's office. On 02/13/25 at 12:26 PM, Administrative Nurse D stated the CP would email the MMRs to her, and she printed them from the email. Administrative Nurse D stated she would fax the MMRs to the resident's physician for a response. Administrative Nurse D stated if the physician failed to respond to the MMRs, the facility's medical director was responsible for following up on the unaddressed MMR. Administrative Nurse D stated if there was no response from the physician or medical director, she was not sure what the next plan of action was. The facility's Medication Regimen Review policy last revised 02/01/24 documented the purpose of this policy was to minimize or prevent adverse consequences by identifying irregularities including syndromes potentially related to medication therapy, emerging or existing adverse medication consequences, as well as the potential for adverse drug reactions, and medication errors. Medication Regimen Review (MRR) consists of the pharmacist reviewing each resident's medication regimen including psychotropic drugs and review of the resident's medical chart at least once a month in order to identify irregularities; and to identify clinically significant risks and/or adverse consequences resulting from or associated with medications. It may be necessary for the pharmacist to conduct the MRR more frequently, for example weekly, depending on the resident's condition and the risks for adverse consequences related to current medications. Findings and recommendations are reported to the Director of Nursing and the attending physician. The facility failed to ensure the physician reviewed and addressed the CP recommendations for R2. This deficient practice placed R2 at risk for unnecessary medication use, side effects, and physical complications. - R20's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), cognitive impairment, and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R20 had received a hyperglycemic (medication that raises blood sugar levels) medication, an opioid (a class of controlled drugs used to treat pain) medication, a diuretic (a medication to promote the formation and excretion of urine) medication, an anticoagulant (a class of medications sued to prevent the blood from clotting) medication, an antidepressant (a class of medications used to treat mood disorders) medication, and an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. The MDS lacked indication of physician documentation that a gradual dose reduction was clinically contraindicated for R20. The MDS lacked documentation a drug regimen review was completed during the observation period for R20. R20's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/31/24 documented she had a diagnosis of Alzheimer's disease and a recent functional decline following a fall at home. R20's Care Plan dated 01/01/25 documented she would refuse her medication at times. The plan of care documented R20 would pocket her medication in her mouth at times. R20's EMR under the Orders tab revealed the following physician orders: Quetiapine (antipsychotic) (Seroquel) tablet 25 milligrams (mg) give one tablet by mouth daily for generalized anxiety dated 12/18/24. Review of R20's EMR under the Notes tab revealed a Pharmacy Review note dated 05/24/24 at 12:14 PM documented the recommendation pending. The facility provided an unaddressed and unsigned Monthly Medication Review (MMR) dated 05/24/24 upon request. On 02/12/25 at 03:09 PM, R20 sat at the dining room table and had her fingernails painted by the nursing staff. On 02/13/25 at 12:04 PM, Licensed Nurse (LN) G stated she made changes for any new medication orders on the MRRs when they were returned from the physician's office. On 02/13/25 at 12:26 PM, Administrative Nurse D stated the CP would email the MMRs to her, and she printed them from the email. Administrative Nurse D stated she would fax the MMRs to the resident's physician for a response. Administrative Nurse D stated if the physician failed to respond to the MMRs, the facility's medical director was responsible for following up on the unaddressed MMR. Administrative Nurse D stated if there was no response from the physician or medical director, she was not sure what the next plan of action was. The facility's Medication Regimen Review policy last revised 02/01/24 documented the purpose of this policy was to minimize or prevent adverse consequences by identifying irregularities including syndromes potentially related to medication therapy, emerging or existing adverse medication consequences, as well as the potential for adverse drug reactions, and medication errors. Medication Regimen Review (MRR) consists of the pharmacist reviewing each resident's medication regimen including psychotropic drugs and review of the resident's medical chart at least once a month in order to identify irregularities; and to identify clinically significant risks and/or adverse consequences resulting from or associated with medications. It may be necessary for the pharmacist to conduct the MRR more frequently, for example weekly, depending on the resident's condition and the risks for adverse consequences related to current medications. Findings and recommendations are reported to the Director of Nursing and the attending physician. The facility failed to ensure the physician reviewed and addressed the CP recommendations for R2. This deficient practice placed R2 at risk for unnecessary medication use, side effects, and physical complications. 49634 - R25's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), seizure (violent involuntary series of contractions of a group of muscles), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R25 was independent with oral hygiene and eating but required supervision or touching assistance for bathing, dressing, and toileting The MDS documented R25 exhibited no behaviors. The MDS documented R25 took an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The Admissions MDS dated [DATE] documented a BIMS of three which indicated severely impaired cognition. The MDS documented R25 was independent with eating and required supervision or touching for oral hygiene and dressing. The MDS documented R25 took an antianxiety (a class of medications that calm and relax people) medication during the look back period. R25's Behavioral Symptoms Care Area Assessment (CAA) dated 05/08/24 documented R25's was admitted to long term care on 5/6/24. R25 had a diagnosis of dementia and currently took Namenda (dementia medication). R25 also had a diagnosis of anxiety and had orders for Xanax (antianxiety medication) as needed (PRN). R25 had been tearful and sad at times since her admission. She scored a one on her MDS mood interview as she voiced, she was just occasionally (2-6 days) sad during the lookback period. R25's Care Plan dated 05/08/24 documented she had a Black Box Warning (BBW - highest safety-related warning that medications can have assigned by the Food and Drug Administration), R25 took an antipsychotic, and her first appointment with the physician would be the week after her admission. R25's EMR under the Orders tab documented: Seroquel (antipsychotic medication) 25 milligrams (mg) give 0.5mg tablet by mouth nightly for anxiety disorder dated 05/10/24. R25's Consultant Pharmacist Recommendation to Physician dated 11/27/24 documented the physician to assess R25's Seroquel (Quetiapine) for a potential gradual dose reduction (GDR). R25's Physician/Prescriber response dated 12/11/24 documented the physician agreed and would assess a dose reduction at R25's next appointment. R25's medical record lacked documentation that the physician had addressed R25's Quetiapine. On 02/12/25 at 09:33 AM, R25 sat at the breakfast table, talking to peers. On 02/13/25 at 09:24 AM, R25 sat in the day room, looking at the puzzle pieces. On 02/13/25 at 12:04 PM, Licensed Nurse (LN) G stated she made changes for any new medication orders on the MRRs when they returned from the physician's office. On 02/13/25 at 12:26 PM, Administrative Nurse D stated the Consult Pharmacist (CP) would email the MMRs to her, and she printed them from the email. Administrative Nurse D stated she would fax the MMRs to the resident's physician for a response. Administrative Nurse D stated if the physician did not respond to the MMRs, the facility's medical director was responsible for following up on the unaddressed MMR. Administrative Nurse D stated if there was no response from the physician or medical director, she was not sure what was the next plan of action. The facility's Medication Regimen Review policy last revised 02/01/24 documented the purpose of this policy was to minimize or prevent adverse consequences by identifying irregularities including syndromes potentially related to medication therapy, emerging or existing adverse medication consequences, as well as the potential for adverse drug reactions, and medication errors. Medication Regimen Review (MRR) consists of the pharmacist reviewing each resident's medication regimen including psychotropic drugs and review of the resident's medical chart at least once a month to identify irregularities; and to identify clinically significant risks and/or adverse consequences resulting from or associated with medications. It may be necessary for the pharmacist to conduct the MRR more frequently, for example weekly, depending on the resident's condition and the risks for adverse consequences related to current medications. Findings and recommendations are reported to the Director of Nursing and the attending physician. The facility failed to ensure the physician addressed the CP recommendations for R25. This deficient practice placed R25 at risk for unnecessary medication use, side effects, and physical complications. 45668 - The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of Parkinson's Disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), generalized weakness, dementia (a progressive mental disorder characterized by failing memory and confusion), chronic heart failure, hypertension (high blood pressure), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) in both knees. R10's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven. The score indicated severe cognitive impairment. The MDS indicated he required substantial staff assistance for dressing, personal hygiene, bathing, bed mobility, toileting, and transfers. The MDS noted she took an antipsychotic medication (a class of medications used to treat major mental conditions that cause a break from reality) on a routine basis. R10's Psychotropic (alters mood or thought) Medication Care Area Assessment (CAA) completed 06/18/24 revealed he was at risk for adverse side effects and complications related to his psychotropic medication. The CAA noted he took antipsychotic medications. The CAA noted a care plan was developed to minimize his risks. R10's Care Plan initiated 05/29/23 revealed he took antipsychotic medications. The plan noted his medications had a Black Box Warning (BBW - high-risk medications with potential adverse effects). R10's EMR under Physician's Orders revealed an active order (dated 12/23/24) for staff to administer 2.5 milligrams (mg) of Olanzapine (an antipsychotic medication) by mouth daily with dinner. The order revealed the antipsychotic medication was given for dementia. R10's EMR indicated he had been on Olanzapine since 02/28/24. A review of R10's Monthly Medication Reviews (MMR) from 02/01/24 through 02/01/25 revealed no recommendations from the Consulting Pharmacist (CP) to review the appropriate indication for the use of R10's antipsychotic medication. On 02/13/25 at 07:45 AM, R10 took his morning medications without behaviors or issues. On 02/13/25 at 12:16 AM, Licensed Nurse (LN) G stated antipsychotic medications were to be used for potentially violent residents or aggressive behaviors. She stated they were not to be used for dementia-related behaviors. She stated dementia was not an accepted indication for Olanzapine. She stated the pharmacy reviewed each resident's orders and should have made recommendations. On 02/13/25 at 12:30 PM, Administrative Nurse D stated she was not sure if antipsychotics were used for dementia but stated the facility would use the medication for aggressive behaviors. She stated the medical director was responsible for reviewing the monthly pharmacy recommendations. The facility's Medication Regimen Review policy revised 02/2024 indicated the consulting pharmacist was to complete monthly medication reviews to identify irregularities to minimize the risks of medication errors and adverse drug reactions. The policy revealed the consulting pharmacist would make recommendations to the facility's medical provider and director of nursing. The facility's CP failed to identify and report an inappropriate indication for R10's Olanzapine medication. This placed R10 s at risk for unnecessary psychotropic medications and related complications.

The facility identified a census of 27 residents. The facility identified four residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to implement adequate hand hygiene. This deficient practice placed the residents at risk for infectious diseases. Findings included: - On 02/11/25 at 08:33 AM, Certified Nurse Aide (CMA) R failed to perform hand hygiene and donned a pair of gloves, CMA R removed R10's hearing aids from the medication cart. CMA R changed the battery in one hearing aid. CMA R placed R10's hearing aids in each ear at the dining room table. CMA R doffed her gloves and failed to perform hand hygiene. CMA R pushed R10 into an area across from the dining room. CMA R failed to perform hand hygiene and donned a pair of gloves from her uniform pocket. CMA R then administered R10's inhalation medication by assisting R10 with one puff into each nostril. CMA R failed to perform hand hygiene or change gloves. CMA R then instilled R10's eye drops, she held R10's eye open and then instilled one eye drop into each eye. On 02/13/24 at 12:29 PM, Administrated Nurse D stated staff were expected to complete hand hygiene before, during, and after touching the residents. She stated staff were expected to complete hand hygiene in between glove changes and changing personal protective equipment (PPE). The Infection Prevention and Control policy revised 02/12/2025 documented the facility's health system shall establish and maintain an infection prevention and control plan including the appropriate policies and procedures for surveillance, prevention, and control of infection that reflect the hospital's mission statement. The facility was dedicated to minimizing infection risks to prevent infections in patients, personnel, volunteers, and visitors. The facility would ensure the infection prevention and control program was managed effectively: represents relevant components and functions with the hospital to implement the infection prevention and control programs to reduce, eliminate, or prevent healthcare-acquired infections and ensure that hospital leaders allocate adequate resources for the implantation and education of the infection prevention program. The facility failed to implement adequate hand hygiene. This deficient practice placed the residents at risk for infectious diseases.

The facility identified a census of 27 residents. The sample included 12 residents, with one reviewed for dementia (a progressive mental disorder characterized by failing memory, and confusion) care. Based on interviews, record reviews, and observations, the facility failed to provide dementia-related care services for Resident (R) 10 to promote the resident's highest practicable level of well-being. This deficient practice placed R10 at risk for decreased quality of life, isolation, and impaired dignity. Findings Included: - The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of Parkinson's Disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), generalized weakness, dementia, chronic heart failure, hypertension (high blood pressure), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) in both knees. R10's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven. The score indicated severe cognitive impairment. The MDS indicated he required substantial staff assistance for dressing, personal hygiene, bathing, bed mobility, toileting, and transfers. The MDS noted he was frequently incontinent of bowel and bladder. R10's Functional Abilities Care Area Assessment (CAA) completed 06/13/24 revealed he required assistance from staff to complete his activities of daily living (ADL). The CAA indicated he required two staff and a Sit-to-Stand lift for all transfers. The CAA noted a care plan was developed to minimize his risks. R10's Dementia CAA completed 06/13/24 revealed he was at risk for cognitive loss due to his medical diagnoses. The plan instructed staff to allow him time to communicate his needs and process his thoughts. R10's Care Plan initiated 05/29/23 revealed he had required assistance and supervision with his ADLs. The plan noted he used a manual wheelchair and could propel himself. The plan noted he had dementia and Parkinson's disease but was alert and oriented and could make his needs known. The plan noted he had difficulty hearing and wore hearing aids. The plan instructed staff to give him time to process his thoughts. The plan noted he had a history of falls. The plan noted he had difficulty during mealtimes and required a plate guard for meals. The plan noted he did not like scrambled eggs but preferred hard-fried eggs. The plan lacked interventions related to his wandering and sun-downing (a condition where a person tends to become confused or disoriented toward the end of the day) behaviors. On 02/12/25 at 02:45 PM, R10 sat in his wheelchair in the dining room. R10 was confused and kept repeating Where's the visitor parking lot as he wheeled himself around the dining and television area. R10 continually circled the room asking other residents and staff Where's the visitor's lot and stated, he needed to leave. R10 was not offered activities or interventions for his sun-downing behaviors. Staff only pointed to the parking lot and did not attempt to reorient him during this episode. On 02/13/25 at 08:40 AM, R10 sat for breakfast at the dining room table. R10's plate had a large amount of scrambled eggs. R10's plate had no plate guard on it, but his silverware had adapted silverware for easy gripping. R10 received no assistance during his meals and continually yelled out Down we go as he looked at his food. At 10:10 AM, R10 remained in the same spot at the dining room table. The dining room was empty. His food remained un-eaten, and his water glass was spilled over the right side of his wheelchair onto the floor. R10's scrambled eggs remained untouched. R10 attempted multiple times to reposition his wheelchair to leave the table but his wheelchair was stuck on the table's leg. R10 indicated he did not like scrambled eggs when asked about his breakfast. At 10:28 AM, staff came into the dining room from the nurse's station and repositioned his wheelchair so he could move. R10 wheeled himself towards the center hall and sat. R10 fell asleep in his wheelchair until lunch service. On 02/13/25 at 11:20 AM, R10 was moved back to his dining room spot. R10 provided his lunch meal with no plate guard in place. R10 was given adaptive silverware. On 02/13/25 at 12:01 PM, the Certified Nurse's Aide (CNA) M stated that R10 enjoyed watching television. She stated his family provided him with a television streaming service device on his room's television. She stated that R10 has not had wandering or sundowning behaviors recently. She stated staff should attempt to reorient him and provide activities for him to prevent behaviors or disruptions. She stated staff were to help during meals and check in with him to see if he needed anything. She stated that R10 was able to wheel himself around the facility. On 02/13/25 at 12:16 PM, Licensed Nurse (LN) G stated staff was expected to provide activities for him, take him on walks, and visit with him. She stated that R10 should not be left alone during mealtimes or allowed to exhibit sundowning behaviors without staff attempting to assist him. On 02/13/25 at 12:30 PM, Administrative Nurse D stated that R10 had not displayed sundowning behaviors in a while. She stated staff were expected to engage in conversation and activities with him. She stated staff should reorient him to his surroundings and prevent behaviors from occurring. The facility's Person-Centered Dementia Care policy (undated) revealed the facility was to provide dementia-related services designed to focus on the resident's abilities and provide memory enhancement. The policy noted each resident would be provided specialized activities, nutrition, and environmental modifications. The facility failed to provide dementia-related care services for R10 to promote the resident's highest practicable level of well-being. This deficient practice placed R10 at risk for decreased quality of life, isolation, and impaired dignity.

The facility identified a census of 27 residents. The sample included 12 residents, with two residents reviewed for hospice. Based on observation, record review, and interviews, the facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for Resident (R) 22. This placed the resident at risk for inappropriate end-of-life care. Finding Included: - R22's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of assistance with personal needs, urinary retention, diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), sinus tachycardia(normal rhythm, heart beating too fast), dysphagia (swallowing difficulty), and anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Significant Change in Status Minimum Data Set (MDS) for R22 dated 11/26/24 recorded a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The MDS documented R22 was independent in oral hygiene, and eating, and needed staff touching or verbal cues for bathing and toileting. The MDS documented R43 received hospice services during the observation period. The Admission MDS for R22 dated 02/16/24 documented a BIMS of eight which indicated a modernly impaired cognition. The MDS documented R22 required substantial to maximum assistance for toileting, bathing, and oral hygiene. The MDS documented R22 was continent during the lookback period. R22's Activities of Daily Living (ADLs) - Functional status/Rehabilitation Potential Care Area Assessment (CAA) dated 11/26/24 documented R22 was admitted to long-term care from the local hospital for generalized weakness. R22 needed the assistance of one for transfers, ambulation, and daily care. The CAA documented R22 received Physical and occupational therapy due to generalized weakness. R22's Care Plan dated 11/19/24 documented R22 had a do not resuscitate code status and was receiving hospice services. R22's plan of care documented if R22 needed any specific supplies, the facility should reach out to hospice. R22's plan of care documented hospice would assist with R22's pain management and communicate with R22's physician. A review of the hospice-provided communication binder revealed R22 was admitted to hospice services on 10/31/24. On 02/11/24 at 11:44 AM, R22 sat at the dining room table visiting with peers. On 12/12/24 at 02:42 AM, R22 sat at the dining room table visiting with peers. On 02/13/24 at 11:53 AM, Certified Nursing Aide (CNA) M stated all staff had access to the resident's care plans. CNA M stated she was unsure if all supplies should be put in the resident's care plan, she stated hospice had everything the residents were receiving and when the aides and nurses came in to provide services in the hospice care plan. CNA M stated all staff could always look in the hospice binder. On 02/13/24 at 12:04 PM, Licensed Nurse (LN) G stated all residents on hospice services have a binder. LN G stated if she could not find the information in the resident's care plan, she could look in the resident's hospice binder. LN G stated oxygen and wheelchairs should be care planned. On 02/13/24 at 12:29 PM, Administrated Nurse D stated the resident's care plan should state what was provided by hospice, what equipment, what supplies, and when the hospice staff would be in the building. Administrative Nurse D stated all the supplies and equipment provided could be found in the hospice's binder. The facility failed to provide a policy related to hospice services as requested on 02/13/25. The facility failed to ensure a coordinated plan of care, which coordinated care and services provided by the facility with the care and services provided by hospice, was developed and available for R22. This deficient practice placed the resident at risk for inappropriate end-of-life care.

The facility identified a census of 27 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated by the physician with a supporting rationale for risk versus benefit for Resident (R) 20 and R25's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. The facility also failed to ensure R10's antipsychotic medication had a Centers for Medicare and Medicaid (CMS) approved indication or the required risk versus benefit physician documentation. These deficient practices placed these residents at risk for unnecessary medications and adverse side effects. Findings included: - R20's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), cognitive impairment, and diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of six which indicated severely impaired cognition. The MDS documented R20 had received hyperglycemic (medication that raises blood sugar levels) medication, opioid (a class of controlled drugs used to treat pain) medication, diuretic (a medication to promote the formation and excretion of urine) medication, anticoagulant (a class of medications sued to prevent the blood from clotting) medication, antidepressant (a class of medications used to treat mood disorders) medication, and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication. The MDS lacked indication of physician documentation of a gradual dose reduction was clinically contraindicated for R20. The MDS lacked documentation a drug regimen review was completed during the observation period for R20. R20's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 12/31/24 documented she had a diagnosis of Alzheimer's disease and a recent functional decline following a fall at home. R20's Care Plan dated 01/01/25 documented she refused her medication at times. The plan of care documented R20 would pocket her medication in her mouth at times. R20's EMR under the Orders tab revealed the following physician orders: Quetiapine (antipsychotic) (Seroquel) tablet 25 milligrams (mg) give one tablet by mouth daily for generalized anxiety dated 12/18/24. R20's clinical record lacked physician documentation of a rationale for the continued use of the antipsychotic medication, Seroquel, with no gradual dose reduction or documentation of risk versus benefit rationale. The facility was unable to provide evidence of the above physician documentation. On 02/12/25 at 03:09 PM, R20 sat at the dining room table and had her fingernails painted by the nursing staff. On 02/13/25 at 12:16 AM, Licensed Nurse (LN) G stated antipsychotic medications were to be used for potentially violent residents or aggressive behaviors. She stated they were not to be used for dementia-related behaviors. She stated dementia was not an accepted indication for Seroquel. LN G stated Administrative Nurse D would ensure there was the correct documentation for the use of antipsychotic medications. On 02/13/25 at 12:30 PM, Administrative Nurse D stated she was not sure if antipsychotics were used for dementia but stated the facility would use the medication for aggressive behaviors. Administrative Nurse D stated the facility would rely on the physician for the documentation for the rationale of the risk versus benefit of antipsychotic medication. The facility's undated Psychotropic Medication Use policy documented that psycho-pharmacologic medications are drugs that affect brain activities associated with mental processes and behavior. These drugs are also called psychoactive or psychotherapeutic medications. Psychotropic medications are divided into four broad categories: anti-psychotic, antidepressant, anti-anxiety (a class of medications that calm and relax people), antihistamine (a medication that prevents or reduces the effects of histamine, anti-convulsant (a medication that prevents or treats seizures and convulsions), all mood-altering drugs, and hypnotic (a class of medications used to induce sleep) mediations. Centers for Medicare & Medicaid Services (CMS) regulations state that each resident's drug regimen must be free from unnecessary drugs and define what was considered an unnecessary drug. In addition, CMS regulations state that residents who have not previously used anti-psychotic drugs should not be given these drugs unless anti-psychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. Further, the regulation mandates that residents who use anti-psychotic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, to discontinue these drugs. The resident's need for the psychotropic medication would be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose can be lowered or discontinued. Both the Physician and the nursing staff would evaluate the effectiveness of an as-needed order for psychotropic drugs to manage behavior. The facility failed to ensure a GDR was attempted or documented as contraindicated by the physician with a supporting rationale with risk versus benefit for antipsychotic medication Seroquel for R20. These deficient practices placed R20 at risk for unnecessary medications and adverse side effects.- The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of Parkinson's Disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), generalized weakness, dementia (a progressive mental disorder characterized by failing memory and confusion), chronic heart failure, hypertension (high blood pressure), and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) in both knees. R10's Quarterly Minimum Data Set (MDS) dated 12/06/24 documented a Brief Interview for Mental Status (BIMS) score of seven. The score indicated severe cognitive impairment. The MDS indicated he required substantial staff assistance for dressing, personal hygiene, bathing, bed mobility, toileting, and transfers. The MDS noted she took antipsychotic medications (a class of medications used to treat major mental conditions that cause a break from reality) on a routine basis. R10's Psychotropic (alters mood or thought) Medication Care Area Assessment (CAA) completed 06/18/24 revealed he was at risk for adverse side effects and complications related to his psychotropic medication. The CAA noted he took antipsychotic medications. The CAA noted a care plan was developed to minimize his risks. R10's Care Plan initiated 05/29/23 revealed he took antipsychotic medications. The plan noted his medications had a Black Box Warning (BBW - high-risk medications with potential adverse effects). R10's EMR under Physician's Orders revealed an active order (dated 12/23/24) for staff to administer 2.5 milligrams (mg) of Olanzapine (an antipsychotic medication) by mouth daily with dinner. The order revealed the antipsychotic medication was given for dementia. R10's EMR indicated he had been on Olanzapine since 02/28/24. On 02/13/25 at 07:45 AM, R10 took his morning medications without behaviors or issues. On 02/13/25 at 12:16 AM, Licensed Nurse (LN) G stated antipsychotic medications were to be used for potentially violent residents or aggressive behaviors. She stated they were not to be used for dementia-related behaviors. She stated dementia was not an accepted indication for Olanzapine. On 02/13/25 at 12:30 PM, Administrative Nurse D stated she was not sure if antipsychotics were used for dementia, but stated the facility would use the medication for aggressive behaviors. The facility's Psychotropic Medications revised (undated) indicated antipsychotic medication was only to be used to treat specific diagnosed conditions and documented in the clinical record. The policy indicated antipsychotic medications were to be continually monitored and not used to treat crying, memory impairment, poor self-care, indifference to the surroundings, wandering, restlessness, and uncooperative behaviors. The facility failed to ensure an appropriate indication or a documented physician rationale for R10's Olanzapine medication. This placed R10 s at risk for unnecessary psychotropic medication use and related complications. - R25's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of hypertension (high blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), seizure (violent involuntary series of contractions of a group of muscles), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and hypothyroidism (a condition characterized by decreased activity of the thyroid gland). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R25 was independent with oral hygiene and eating, and needed supervision or touching assistance for bathing, dressing, and toileting. The MDS documented R25 exhibited no behaviors. The MDS documented R25 took an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication during the observation period. The Admissions MDS dated 05/08/24 documented a BIMS of three which indicated severely impaired cognition. The MDS documented R25 was independent with eating and needed supervision or touching for oral hygiene and dressing. The MDS documented R25 took an antianxiety (a class of medications that calm and relax people) medication during the look-back period. R25's Behavioral Symptoms Care Area Assessment (CAA) dated 05/08/24 documented R25's was admitted to long-term care on 5/6/24. R25 had a diagnosis of dementia and was currently taking Namenda (dementia medication). R25 also had a diagnosis of anxiety and had orders for Xanax (antianxiety medication) as needed (PRN). R25 had been tearful and sad at times since her admission. She scored a one on her MDS mood interview as she voiced, she was just occasionally (2-6 days) sad during the lookback period. R25's Care Plan dated 05/08/24 documented R25 had a Black Box Warning (BBW - highest safety-related warning that medications can have assigned by the Food and Drug Administration), R25 took an antipsychotic, and her first appointment with the physician would be the week after her admission. R25's EMR under the Orders tab documented: Seroquel (antipsychotic medication) 25 milligrams (mg) give 0.5mg tablet by mouth nightly for anxiety disorder dated 05/10/24. A review of R25's EMR revealed no physician-documented rationale for the continued use of Seroquel for anxiety disorder, or a risk vs benefit. On 02/12/25 at 09:33 AM, R25 sat at the breakfast table, talking to peers. On 02/13/25 at 09:24 AM, R25 sat in the day room, looking at the puzzle pieces. On 02/13/25 at 12:16 AM, Licensed Nurse (LN) G stated antipsychotic medications were to be used for potentially violent residents or aggressive behaviors. She stated they were not to be used for dementia-related behaviors. She stated dementia was not an accepted indication for Seroquel. On 02/13/25 at 12:30 PM, Administrative Nurse D stated she was not sure if antipsychotics were used for dementia but stated the facility would use the medication for aggressive behaviors. On 02/13/25 at 12:26 PM, Administrative Nurse D stated the Consult Pharmacist (CP) would email the MMRs to her, and she printed them from the email. Administrative Nurse D stated she would fax the MMRs to the resident's physician for a response. Administrative Nurse D stated if the physician did not respond to the MMRs, the facility's medical director was responsible for following up on the unaddressed MMR. Administrative Nurse D stated if there was no response from the physician or medical director, she was not sure what the next plan of action was. The facility's Psychotropic Medication Use policy documented psycho-pharmacologic medications are drugs that affect brain activities associated with mental processes and behavior. These drugs are also called psychoactive or psychotherapeutic medications. Psychotropic medications are divided into four broad categories: antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antidepressant (a class of medications used to treat mood disorders), antianxiety (a class of medications that calm and relax people), antihistamine (drug used in the treatment of allergies, and anti-convulsant (drug to prevent seizures, all mood-altering drugs, and hypnotic mediations(drugs to suppress the central nervous system). Centers for Medicare & Medicaid Services (CMS) regulations state that each resident's drug regimen must be free from unnecessary drugs and define what was considered an unnecessary drug. In addition, CMS regulations state that residents who have not previously used anti-psychotic drugs should not be given these drugs unless anti-psychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. Further, the regulation mandates that residents who use anti-psychotic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, to discontinue these drugs. The resident's need for the psychotropic medication would be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose can be lowered or discontinued. Both the Physician and the nursing staff would evaluate the effectiveness of as-needed orders for psychotropic drugs to manage behavior. The facility failed to ensure an appropriate indication or a documented physician rationale for R25's Seroquel medication, or a risk vs benefit. This placed R25 s at risk for unnecessary psychotropic medications and related complications.

The facility identified a census of 27 residents. The sample included 12 residents, with two residents sampled for discharge. Based on observation, record review, and interview, the facility failed to provide a written notice of transfer as soon as practicable to Resident (R) 13 and their representative. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R13. Findings Included: - The electronic medical record (EMR) for R13 documented diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), confusion, adult failure to thrive (includes not doing well, feeling poorly, weight loss, and poor self-care that could be seen in elderly individuals), weakness, hyperkalemia (greater than normal amount of potassium in the blood), hypokalemia (low level of potassium in the blood), and dementia (a progressive mental disorder characterized by failing memory and confusion). The admission Minimum Data Set (MDS) dated 11/06/24 documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. MDS indicated R13 was independent for eating and toileting. The MDS documented R13 needed supervision and touching for bathing. R13's Falls Care Area Assessment (CAA) dated 11/06/24 documented R13 had one fall prior to admission to long-term care. The CAA documented R13 had not had a fall since admission to long-term care. R13's CAA documented R13 required one staff assistance for transfers. The Discharge MDS dated 11 /29/24 for R13 documented an unplanned discharge to an acute hospital with an anticipated return to the facility. R13's Entry MDS dated 12/06/24 documented a reentry to the facility from an acute hospital. The Discharge MDS dated 01 /01/25 for R13 documented an unplanned discharge to an acute hospital with an anticipated return to the facility. R13's Entry MDS dated 01/09/25 documented a reentry to the facility from an acute hospital. R13's Care Plan dated 10/31/24 documented R13 had no plans to be discharged from the facility and planned to stay at the facility. A Nursing Note dated 11/29/24 documented that R13 had critical lab values and the physician requested R13 to be sent to the Emergency Department. R13 was sent by wheelchair, and R13's daughter was notified. A Nursing Note dated 01/01/25 documented that R13 was sent to the emergency room per physician, by wheelchair with staff for shortness of breath, audible wheezes, and crackles. A call was made to R13's daughter, but she did not answer, the nurse spoke to R13's son. The facility failed to provide a copy of any signed Written Notification of Transfer or Discharge for the time in the hospital from [DATE] to 03/15/24 and 01/01/25 to 01/09/25. On 02/12/25 at 12:12 PM, R13 sat at the dining room table visiting with peers. On 02/13/25 at 12:04 PM, Licensed Nurse (LN) G stated the nurse on duty calls the family with admissions and discharges, or any other pertinent information. LN G stated she did not send out a written notification of discharge. LN G stated she was unaware if anyone would send out a written notification of discharge. On 02/13/25 at 12:29 PM, Administrative Staff D stated they do not have the notification of transfer, administrative staff D stated that R13's daughter was notified when she was transferred and given an update on her condition. Administrative Nurse D stated we do not send written notifications. The facility's Admission, Transfer, and Discharge policy revised 02/13/25 documented that persons seeking to move into the facility would be provided with written and verbal information to assist the resident and or their family in deciding whether lining in the facility was appropriate for the resident's needs. All communication, written, and verbal, would be provided in a manner tailored to the resident's language and ability to understand. The information would include a description of the care and services provided by the community and the rights and obligations of persons who choose to live in the facility. The information would also include information about all changes for which the resident would be responsible. In the event there was not an opening in the facility, the person's name would be placed on a waiting list and would be notified by social service when an opening becomes available. The facility failed to provide a written notice of transfer as soon as practicable to R13 and their representative. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunities for healthcare service for R13.

The facility identified a census of 27 residents. The sample included 12 residents with two residents sampled for discharge. Based on observation, record review, and interview, the facility failed to provide a bed hold with the required information to Resident (R) 13 or their family representative when R13 transferred to the hospital. This deficient practice placed R13 at risk for impaired ability to return to the facility or his same room. Finding include: - The electronic medical record (EMR) for R13 documented a diagnoses of congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), hypertension (high blood pressure), confusion, adult failure to thrive (includes not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals), weakness, hyperkalemia (greater than normal amount of potassium in the blood), hypokalemia (low level of potassium in the blood), and dementia (a progressive mental disorder characterized by failing memory and confusion). The admission Minimum Data Set (MDS) dated 11/06/24 documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. MDS indicated R13 was independent for eating and toileting. The MDS documented R13 needed supervision and touching for bathing. R13's Falls Care Area Assessment (CAA) dated 11/06/24 documented R13 had one fall before admission to long-term care. The CAA documented R13 had not had a fall since admission to long-term care. R13's CAA documented R13 required one staff assistance for transfers. The Discharge MDS dated 11 /29/24 for R13 documented an unplanned discharge to an acute hospital with an anticipated return to the facility. R13's Entry MDS dated 12/06/24 documented a reentry to the facility from an acute hospital. The Discharge MDS dated 01/01/25 for R13 documented an unplanned discharge to an acute hospital with an anticipated return to the facility. R13's Entry MDS dated 01/09/25 documented a reentry to the facility from an acute hospital. R13's Care Plan dated 10/31/24 documented R13 had no plans to be discharged from the facility and planned to stay at the facility. A Nursing Note dated 11/29/24 documented that R13 had critical lab values, physician requested R13 to be sent to the Emergency Department. R13 was sent by wheelchair, and R13's daughter was notified. A Nursing Note dated 01/01/25 documented that R13 was sent to the emergency room per the physician's order via wheelchair. R13 was accompanied by staff for shortness of breath, and audible wheezes and crackles. A call was made to R13's daughter, but she did not answer, the nurse spoke to R13's son. The facility failed to provide evidence a bed hold notification was provided to the legal representative when R13 transferred to the hospital from [DATE] to 12/06/24 and 1/1/25 to 1/09/25. On 02/12/25 at 12:12 PM, R13 sat at the dining room table visiting with peers. On 02/13/25 at 12:04 PM, licensed Nurse (LN) G stated the nurse on duty was responsible for having the resident or residents repetitively sign a bed hold. On 02/13/25 at 12:29 PM, Administrative Nurse D stated the nursing staff was responsible for notifying the family and having the resident or family representative sign the facility's bed hold. The facility's Bed Hold and Permitting Resident to Return to Facility policy revised 02/13/25 documented the facility would allow the resident whose hospitalization or therapeutic leave exceeds the bed-hold policy under the state plan to return to the facility to resident's previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident requires the services provided by the facility and was eligible for Medicaid nursing facility service or pays privately for services. If the facility determined the resident who was transferred with an expectation of returning to the facility cannot return to the facility, the facility would comply with all requirements of regulations related to transferring and discharging a resident. All information provided to a resident and or representative required a signature or receipt of the policy by the resident and or representative including bed hold information provided at the time of discharge/transfer related to hospitalization and or therapeutic leave. The bed hold policy was provided at the time of admission and bed hold information was provided at the time of discharge/transfer related to hospitalization and or therapeutic leave. The facility failed to provide a bed hold with the required information to R13 and his family representative when R13 transferred to the hospital. This deficient practice placed R13 at risk for impaired ability to return to the facility or his same room.

The facility reported a census of 25 residents. The sample included one resident reviewed for elopement. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent the elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) of cognitively impaired Resident (R)1, who had a history of falls. On 01/30/24, Certified Nurse Aide (CNA) M heard the facility doorbell ring and used her access badge to let the visitor out of the facility but failed to ensure only the visitor exited. R1 followed the visitor out and exited the facility unsupervised on 01/30/24 at 10:26 AM. R1 ambulated with her walker on the sidewalk on the west side of the parking lot for approximately 100 feet, then across the parking lot for approximately 147 feet, and then toward the north side of the building for approximately 164 feet before CNA N saw R1 ambulating outside the facility, unattended. Two staff brought R1 back to the facility with a wheelchair. The facility failed to assess R1 for an elopement risk. This placed R1 into immediate jeopardy (IJ). Findings include: - R1's Physician Order Sheet (POS) dated 12/12/23, documented diagnoses which included: late onset of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), dementia (progressive mental disorder characterized by failing memory, confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 01/19/24 Annual Minimum Data Set (MDS), documented the resident had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severely impaired cognition. She required a walker and wheelchair for mobility devices. She required supervision with toileting, bed mobility, and ambulation. It was very important for R1 to go outside to get fresh air when the weather is good. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 02/01/24, documented the resident had a diagnosis of late onset of Alzheimer's disease and required 24-hour nursing supervision. The ADL Functional/Rehabilitation Potential CAA, dated 02/01/24, documented the resident preferred to ambulate independently with her walker. The Falls CAA, dated 02/01/24, documented the resident had a history of falls. R1's fall risk assessment scored 18, which indicated a high risk for falls. R1's Fall Care Plan, dated 12/20/22, instructed staff that R1 had a history of falls. R1's family reported falls usually occurred outside on uneven surfaces. The facility lacked an elopement risk assessment. Review of a Nursing Note on 01/30/24 at 11:48 AM documented R1 left the facility through the front door and noted the door was open, due to a visitor leaving. The resident had her walker with her. Staff used a wheelchair to bring the resident back into the facility and noted no injuries to R1. Review of a Nursing Note on 01/30/24 at 11:48 AM, documented the family were notified of the resident elopement. However, the electronic records (EHR) lacked documentation that staff notified R1's provider of the elopement. On 01/30/24 at 10:26 AM the facility's investigation documented staff found the resident outside. She was outside for approximately 10 minutes. She was ambulating with her walker and did not sustain any injury. The nursing staff brought R1 back inside the facility via wheelchair. Review of the facility's video surveillance on 01/30/24, revealed at 10:26 AM an unidentified visitor and R1 exited the first exit door into the foyer and then continued through the exit door of the facility into the parking lot. The resident ambulated with her walker south on the sidewalk. At the end of the sidewalk, R1 turned east and crossed the parking lot. The facility did not have video surveillance until the resident was on the north side of the facility where she was seen by staff members through the window in the activity room. On 01/30/24 at 10:36 AM, Licensed Nurse (LN) G and CNA M brought R1 back into the facility. On 01/30/24 at 10:26 AM, in the video surveillance it was unclear who opened the first exit door that required an exit code or staff identification access badge. Consultant GG reviewed staffing badge access security system and verified CNA M used her identification badge on 01/30/24 at 10:26 AM to open the front exit door for the unidentified visitor to exit the facility. The weatherunderground.com revealed on 01/30/24 at 10:26 AM, the temperature was 49 degrees Fahrenheit, sunny, with 10 miles per hour (MPH) wind. Observation on 02/12/24 at 11:48 AM, revealed the resident ambulated with her walker to the dining room. Observation on 02/12/24 at 03:00 PM, revealed R1 ambulated with use of a walker, in the hallway. On at 02/12/24 at 09:11 AM, R1 reported she enjoyed going outside on sunny, beautiful days. She enjoyed going on walks outside. On 02/12/24 at 12:38 PM, CNA N reported she was in the activities room when she observed R1 ambulating her with her walker on the sidewalk next to the fence and the courtyard. CNA N notified Administrative Nurse D. R1 frequently sat on the couch next to the front exit doors, or at the round table by the front door playing games or working on a puzzle with peers. On 02/12/24 at 01:00 PM, Maintenance U reported on 01/30/24 at approximately 01:40 PM, he was informed to decrease the automatic locking mechanism from 10 seconds to stay unlocked, to 5.5 seconds before the door would automatically lock. On 02/12/24 at 04:16 PM, interview with CNA M reported the doorbell for the front exit door sounded and she used her access badge to let the unidentified visitor out of the facility. CNA M reported she then walked away from the door. She reported she was not aware she should wait until the door closed and/or verified closure and said she did not wait for the door to close. CNA M said R1 liked to sit on the couch next to the door. R1 had not shown signs of exit seeking, prior to her elopement. On 02/13/24 at 09:12 AM Administrative Nurse D reported CMA M was in the activities room and observed R1 outside unattended. LN G and CNA M immediately took a wheelchair outside and returned the resident into the facility. The nursing staff failed to notify the residents physician related to the resident exiting the facility unsupervised. Administrative Nurse D reported that the facility had not had an elopement in the facility and do not have residents at risk for elopement. R1 had been the first resident to exit the facility unsupervised and had not shown signs of exit seeking behaviors prior to incident. The facility's Elopement Policy, undated, documented the facility should ensure the safety of the resident who were identified as being at risk for elopement, and staff would take precautions to ensure the residents safety and well-being. The facility failed to provide adequate supervision to prevent the elopement of cognitively impaired R1, who had a history of falls and used a walker for ambulation. CNA M failed ensure the safety of R1, when she used her badge to let a visitor out of the facility but did not verify the door closed without residents exiting the facility unsupervised. The facility had also not assessed the elopement risk of R1. This deficient practice placed R1 in immediate jeopardy. The facility provided the following corrective actions implemented immediately in response to the elopement of R1, completed 02/04/24: Staff education provided to staff on 01/30/24 at 11:30 AM through 02/04/24 at 06:30 AM regarding staff to stay at the door when someone arrives and/or exits, until the door closes to ensure the safety of all residents. The facility placed an exit notification sign placed on both sides of the front door alerting staff/visitors to ensure the door closes behind them prior to leaving, completed on 01/30/24 at 12:51 PM. The facility updated R1's care plan related to being at risk for elopement, on 01/30/24. The facility decreased the time the main door remained open after badge or keypad number entry, to ensure quicker locking time. Due to the corrective actions verified as implemented and completed prior to the onsite visit, the deficient practice was deemed past noncompliant at a J scope and severity.

The facility identified a census of 23 residents. The sample included three residents identified as at risk for falls. Based on record review, observation, and interview, the facility failed to ensure Resident (R)1 received adequate supervision and assistance to prevent a serious injury accident. On 11/14/23 at approximately 08:14 AM during an assisted transfer, staff failed to ensure R1's wheelchair brakes were locked. R1 slid to the floor, complained of right hip pain, and was transferred to a local hospital for evaluation and treatment. An x-ray revealed R1 sustained a proximal right femur (long bone in the leg and closer to the hip joint) fracture. R1 was subsequently transferred to a metropolitan hospital for an orthopedic (medical specialty specializing in bones) consult and surgical repair of the hip fracture. R1 sustained post-surgical complications and ultimately returned to the facility on [DATE]. This deficient practice also placed R1 at risk for increased pain, decreased mobility, and impaired quality of life. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of chronic obstructive pulmonary disease (COPD a chronic inflammatory lung disease that causes obstructed airflow from the lungs); stage three chronic kidney disease (moderate loss of kidney function); iron deficient anemia (a condition in which blood lacks adequate healthy red blood cells); and closed fracture of the right hip (a break that occurs in the upper part of the femur). The Annual Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of 11 which indicated moderate cognitive impairment. The MDS documented R1 required partial to moderate assistance with toileting, bed mobility, sitting-to-standing position changes, and walking. The MDS documented R1 had one non-injury fall since the previous assessment. The Activities of Daily Living [ADL] Care Area Assessment [CAA] dated 07/08/23 recorded R1 had pneumonia (inflammation of the lungs) and required staff assistance. The CAA noted R1 was able to notify staff of the need for assistance. R1 had one non-injury fall in June with a staff member present when R1 lost balance getting off the toilet. The Falls CAA dated 07/08/23, documented R1 was at high risk for falls due to R1's medical diagnosis, medication use, occasional urinary incontinence, and other factors. The CAA recorded R1 had one non-injury fall in the last six months and a care plan would be developed to address R1's fall risk. A Significant Change Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status score of three which indicated severe cognitive impairment. The MDS documented R1 required substantial to maximum assistance with toileting, bed mobility, and sitting-to-standing; walking did not occur. The MDS documented R1 had a fall with a fracture since the previous assessment. This same MDS lacked documentation that ADLs and falls triggered for review. The Cognitive Loss/Dementia undated CAA from the MDS dated [DATE] recorded R1's BIMS was previously eight but was three at that time. The CAA recorded R1's fall in the shower, on 11/14/24, which resulted in a diagnosis of a right femur fracture and surgical repair. The CAA recorded R1 suffered post-operative anemia and required one transfusion. On 11/21/23, R1 was transferred back to the local hospital for therapy. R1's family requested outpatient therapy and on 11/28/23, R1 returned to the long-term care unit. On 12/07/23, R1 was re-hospitalized due to the development of cellulitis (skin infection caused by bacteria) in the right lower leg. She was readmitted to the long-term care unit on 12/11/23. and on 12/13/23 a computed tomography (CT scan- a test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) scan of R1's chest indicated pneumonia. The resident was treated with antibiotics. The CAA recorded R1's scheduled pain medication was subsequently discontinued on 12/12/23. A Fall Risk Assessment, dated 06/22/23, documented R1 had a fall risk score of 17, which indicated R1 was at high risk for falls. A Fall Risk Assessment, dated 09/20/23, also documented R1 was a high fall risk with a score of 17. An updated Fall Risk Assessment, dated 11/14/23, documented R1 had a decreased fall risk score of 10, which indicated R1 was at moderate risk for falls. R1's Care Plan for falls dated 07/08/23 documented R1 did not get up on her own; she pushed the call light and waited for staff assistance. R1's Care Plan directed staff to make sure staff stayed with her and provided her reassurance when she ambulated. R1's ADL Care Plan dated 10/17/23 recorded R1 required assistance of one to two staff members with a gait belt for transfers. R1ambulated to the bathroom with the use of a rolling walker, gait belt, and one-person assistance. R1's Care plan further recorded R1 used a wheelchair to go to meals in the dining room. R1's revised ADL Care Plan dated 12/12/23 recorded R1 continued to require the assistance of one to two staff members with a gait belt for transfers. The plan added R1 was not ambulating at that time. The plan directed that after breaking her hip, R1 required the sit-to-stand lift with two-person assistance but R1 had to be able to bear weight and R1 was working with physical and occupational therapies. R1's Care Plan further noted R1 had increased incontinence since her fall and requested the use of a flex brief which was more comfortable on R1's skin. A Nurses Progress Note dated 11/14/23 at 11:25 AM documented R1 was transferring from the bath chair to a wheelchair, after bath on that day. A Certified Nurse Aide (CNA) assisted the resident, but R1's wheelchair brakes were not completely locked, and the wheelchair moved away from the resident during the transfer. R1 fell to the floor at that time. Upon assessment, R1 complained of right leg and hip pain. R1's vital signs were within normal limits, and she denied hitting her head. R1's primary care physician was notified and ordered R1 to transfer to the emergency department (ED) for further evaluation. The facility's Incident Investigation Report documented the responding nurse found R1 seated on the floor slightly tilted to the right with R1's right leg tucked behind the left leg. The report documented R1 expressed a sharp, throbbing, shooting, unbearable pain rated a 10 on a 0 to 10 numerical scale (where zero equals no pain and 10 equals the worst pain imaginable). The Hospital Emergency Report Note dated 11/14/23 at 10:11 AM recorded R1 presented to the emergency room after a fall. R1 had a shortened, internally rotated right hip and complained of pain on the right side. The Communication/Visit with Physician Note, dated 11/14/23 at 02:13 PM documented the hospitalist recorded an X-ray of the right hip, which revealed a right femur fracture. R1 was transferred to a larger hospital for an orthopedic evaluation. CNA M's Witness Statement documented at 08:13 AM on 11/14/23 CNA M finished giving R1 a whirlpool bath and helped R1 dress and dry off. As R1 stood up, she reached for the wheelchair and fell . CNA M noted she thought she had locked the chair. CNA M called for CNA O to come and help. CNA O's undated Witness Statement documented she was with another resident when she got a call from CNA M because R1 was on the floor. CNA O noted when she arrived at R1's room, she called for Administrative Nurse D to come to assess and help get R1 off the floor. CNA P's undated Witness Statement documented CNA P was at her medication cart when CNA O told CNA P she was needed in the spa. CNA P followed CNA O into the spa where R1 sat on the floor. Administrative Nurse D was doing an assessment. When asked, CNA P assisted Administrative Nurse D, CNA M, and CNA O to transfer R1 to her wheelchair and then obtain a full set of vital signs. Administrative Nurse D's undated Witness Statement documented she was called to assist in the bathing suite with R1. CNA M and R1 both reported that R1 was transferring from the bath chair to R1's wheelchair and when R1 reached for the wheelchair, it moved away from R1; it was discovered that R1's wheelchair brakes were not locked. Administrative Nurse D noted R1 reported she landed on her right hip, R1 denied hitting her head and staff obtained her vital signs. Staff notified the primary care physician and family and sent R1 to the emergency room . On 01/24/24 at 10:00 AM, R1 sat in her room in a recliner with her legs elevated. She had a blanket covering her lap. Interviewed on 01/24/24 at 10:00 AM R1 remembered she fell and broke a bone, but she was unable to recall how she fell . R1 stated she did not have much pain in her leg at that time, and acknowledged she received therapy. R1 said her right leg was healed. R1 acknowledged staff assisted her with transfers. Interviewed on 01/23/24 at 09:59 AM Licensed Nurse (LN) G stated that before the fall, R1 ambulated to and from the bathroom with staff assistance. R1 used a wheelchair to go to the dining room and wheeled herself or with staff assistance. LN G said that now, after the fall, R1 did not walk and was assisted with a wheelchair. Interviewed on 01/23/24 at 12:45 PM CMA R stated R1 used to come to the dining room for breakfast but now R1 took most meals in her room. Interviewed on 01/23/24 at 01:20 PM, Administrative Nurse D stated R1 received a whirlpool tub bath, was dressed, and had a gait belt on during the attempt to transfer her from the bath chair to her wheelchair, Administrative Nurse D stated R1 was a one-person assist with stand-and-pivot transfers, at that time, so R1 stood and pivoted to the wheelchair. Administrative Nurse D stated staff reported R1 had shoes on but sat on the edge of the wheelchair and since the wheelchair brakes were not locked, R1 slid off the chair. R1 complained of pain right away three to four staff members assisted R1 into the wheelchair and R1 was sent to the emergency room . Administrative Nurse D said R1 used a front-wheeled walker before her fall but required one to two staff assistance with transfers. Administrative Nurse D and Administrative Nurse F stated the investigation concluded the root cause for the fall was the staff's failure to ensure the wheelchair brakes were set/locked. Administrative Nurse D stated staff education began immediately, and staff were not permitted to return to work until completion of the required training and education. The facility's Fall Risk Assessment and Prevention policy revised 07/21/23, documented that nursing staff will complete a fall risk assessment to identify residents at risk for falls, and implement specific interventions to prevent falls and injuries associated with falls. The facility failed to ensure an environment free from preventable accidents when staff failed to lock the brakes on R1's wheelchair before a transfer. As a result of the deficient practice, R1 fell and required emergency services and surgical repair of a hip fracture. This deficient practice also placed R1 at risk for increased pain, decreased mobility, and impaired quality of life. On 11/28/23 the facility identified and completed the following corrective actions: Staff were educated on transfer training and progression, with attention to every detail such as preparation and implementation of equipment used and the different types of transfers (i.e., stand and pivot, slide board). Emphasis was noted in the written handouts on locking the wheelchair brakes. All actions were completed before the onsite survey therefore the deficient practice was deemed past noncompliance and remained at a G scope and severity.

The facility reported a census of 20 residents and identified 12 of those residents with controlled medications stored in the medication cart. Based on interview and record review, the facility failed to perform an accurate system for the count of the number of controlled medications (medications that can cause physical and mental dependence) in the medication cart, increasing the risk for diversion of the medications. Findings included: - On 09/16/21 at 03:50 PM, the record used for the shift to shift count of controlled medications lacked a place for the staff to document the number of controlled medications in the medication cart. On 09/16/21 at 03:52 PM, Licensed Nurse (LN) G stated that all controlled medications were stored in the medication cart and a count was done with the off going/on coming staff that was taking over the medication cart. During the count process the staff counted the number of pills in the cards or amount of liquid in a bottle. LN G stated that the number of controlled medications in the cart were not counted during the count process. On 09/16/21 at 04:11 PM, Administrative Nurse D stated that the staff have been counting the number of pills in the card of the controlled medications but have not been counting the number of controlled medications stored in the cart and probably should. The facility policy Controlled Substance Policy, dated 08/04/20, indicated controlled substances must be validated at least weekly by two licensed individuals. The facility failed to perform an accurate count of the number of controlled medications (medications that can cause physical and mental dependence) in the medication cart, increasing the risk for diversion of the 12 residents' narcotic medications.

The facility reported a census of 20 residents with 12 selected for review, including five residents reviewed for influenza vaccinations. Based on interview and record review, the facility failed to provide consent forms to allow the resident or the resident's representative the opportunity to refuse the influenza immunization for the five residents, Resident (R)1, R5, R8, R11, and R19. Findings included: - The electronic medical record (EMR), indicated that Resident (R)19 received an influenza vaccine on 09/17/20. The other four reviewed residents' EMRs, indicated that R1, R5, R8, and R11 received an influenza vaccine on 10/14/20. The EMRs all lacked consent forms for the influenza vaccination for these five residents. On 09/21/21 at 11:48 AM, Administrative Nurse F stated that the nurse providing the vaccine would supply the vaccine information sheet and have the consent filled out. On 09/21/21 at 03:50 PM, Administrative Nurse D stated the facility does a blanket consent for treatment that the resident/representative signs and there was not a consent form provided before vaccination for the influenza vaccine. Administrative Nurse D confirmed that the Consent and Agreement of Health Care Services does not include specifically in the agreement, consent for the influenza vaccine. The facility policy Post-Acute Vaccination of Residents, dated 07/27/20, indicated that prior to offering the influenza vaccine each resident and/or representative will receive current education regarding the benefits and potential side effects of the immunization. Informed consent in the form of a discussion regarding risks, benefits, and potential side effects of vaccination will occur prior to vaccination. In the case of residents, this may be with their representative when appropriate. Residents have the right to refuse vaccinations. The facility failed to provide consent forms to allow the resident or the resident's representative the opportunity to refuse influenza immunization for the five residents.

The facility reported a census of 20 residents with twelve selected for review, including one Resident (R)5, reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to change R5's oxygen tubing in a timely manner. This practice increased the risk of Resident (R)5 developing a respiratory infection. Findings included: - The Problem List, located in the electronic medical record (EMR), for Resident (R)5, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], assessed R5 with a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. He did not experience shortness of breath with exertion, lying flat, or at rest, and did require oxygen. The Annual MDS, dated [DATE], did not reveal any changes to R5's BIMS score, oxygen use, or shortness of breath. The Care Plan, dated 03/09/21, revealed that R5 required continuous oxygen at three liters and the staff could titrate the oxygen up to four liters with exertion to keep his oxygen saturation levels above 88%. R5 had an oxygen concentrator in his room and a portable tank on his wheelchair for ambulation. The oxygen connected to the continuous positive airway pressure ([CONDITION(S)]) Mid-machine (used to deliver air through a mask and tube into the airways) while sleeping. The Nursing Assessments, located under the active orders tag, located under the summary tab of the EMR, included an order, dated 07/22/21, for oxygen at three liters continuously, for [CONDITION(S)] (inadequate supply of oxygen), titrate up to four liters with exertion, to maintain oxygen saturations above 88%. On 09/15/21 at 03:12 PM, R5 was resting in his recliner in his room with oxygen in place per a nasal cannula connected to an oxygen concentrator. The green extension tubing connected to the concentrator had a date labeled 07/29/21, the nasal cannula connected to the green extension tubing had a date labeled 08/24/21. The nasal cannula, connected to the portable oxygen tank, had a date labeled 08/06/21. The humidifier bottle, connected to the oxygen concentrator, lacked a date. On 09/16/21 at 08:16 AM, R5 was sitting in the dining room with oxygen in place per a nasal cannula, connected to a portable oxygen tank. On 09/16/21 at 08:23 AM, R5's green extension tubing, connected to the oxygen concentrator, had a date of 07/29/21, and the nasal cannula connected to it had a date of 09/15/21. The humidifier bottle, connected to the oxygen concentrator, lacked a date. On 09/16/29 at 12:09 PM, Certified Nurse Aide (CNA) O, was changing out the portable oxygen tank, and confirmed that the date on the nasal cannula tubing connected to it was 08/06/21. On 09/20/21 at 09:56 AM, the nasal cannula connected to the portable oxygen tank, continued to have a date of 08/06/21. The green extension tubing, connected to the oxygen concentrator, had a date of 09/15/21 and the humidifier bottle, connected to the oxygen concentrator, lacked a date. On 09/20/21 at 03:35 PM, Licensed Nurse (LN) H stated that either a nurse or a Certified Medication Aide (CMA) changed the oxygen tubing every 30 days, including the extension tubing, and wrote the date and their initials on tape to indicate the date changed. The humidifier bottles were changed every 30 days with the oxygen tubing. On 09/20/21 at 03:49 PM, Administrative Nurse D stated the oxygen tubing, including the extension tubing, and the humidifier bottles, were to be changed monthly. The items should be dated when changed. Administrative Nurse D stated that R5's tubing was due to be changed on 09/15/21. The facility policy Storage and Labeling of Nasal Cannula/Mask Tubing, dated 12/15/17, indicated that residents who receive oxygen will have their tubing/mask changed monthly on the 17th and the tubing will be marked with the date of change. The policy lacked instruction on changing and dating of the humidifier bottle. The facility failed to change R5's oxygen tubing in a timely manner. This practice increased the risk of Resident (R)5 developing a respiratory infection.

The facility reported a census of 20 residents. The sample contained 12 residents, with two residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure safe mobility to prevent accidents when the facility failed to provide foot pedals to the wheelchair, while transporting one of the two sampled residents, dependent Resident (R) 9. Findings included: - The signed Physician Order Sheet (POS), dated 07/28/21, documented R9 had a diagnosis of bilateral (affecting both sides) [CONDITION(S)] ([CONDITION(S)] changes to one or many joints characterized by swelling and pain) of the knee. An annual Minimum Data Set (MDS), dated [DATE], documented R9's Brief Interview for Mental Status (BIMS) score was 11, indicating moderate cognitive impairment. R9 required limited assistance with locomotion on the unit. A Cognitive Loss Care Area Assessment (CAA), dated 03/17/21, documented R9's primary language was Japanese and confusion resulted when she did not understand. An Identified Risks care plan, dated 03/08/21, documented R9 used a wheelchair at times. The care plan lacked instruction regarding use of foot pedals on the wheelchair when staff propelled the resident in the wheelchair. On 09/16/21 at 09:47 AM, Certified Nursing Assistant (CNA) N propelled R9 in her wheelchair, without foot pedals, from the dining room to her room. R9's toes skimmed along on the floor throughout the travel, a distance of approximately 35 feet. On 09/16/21 at 10:02 AM, CNA M propelled R9 in her wheelchair, without foot pedals, from her room to the television lounge. R9's toes skimmed the floor throughout travel, a distance of approximately 40 feet. On 09/16/21 at 10:13 AM, Licensed Nurse (LN) G propelled R9 in her wheelchair, without foot pedals, from the television lounge to her room. R9's heels skimmed the floor for the duration of travel, a distance of approximately 40 feet. On 09/20/21 at 03:08 PM, CNA N propelled R9 in her wheelchair, without foot pedals, from the front lounge to her room. R9's heels skimmed along on the floor throughout travel, a distance of approximately 25 feet. On 09/20/21 at 03:38 PM, CNA N stated some of the residents have foot pedals on their wheelchairs. Staff use foot pedals when it is in the resident's care plan. She would ask the nurse before making any changes, but a resident's feet should not drag along the floor when staff propel them in a wheelchair. On 09/21/21 at 09:52 AM, Certified Nursing Assistant (CMA) S stated R9's knees bothered her, so she did not propel herself for long distances. When staff propel residents, they should use foot pedals because if the resident dropped their feet, they could fall out. R9 had bad knees, which could make it hard for her to keep her feet up. On 09/21/21 at 03:09 PM, LN H stated R9 had something wrong with her knees. She had a tendency to be up walking and just drop, because her knees gave out. When possible, residents using wheelchairs should propel themselves. But if staff were pushing a resident, they should use foot pedals. On 09/21/21 at 03:55 PM, Administrative Nurse D stated R9 should have foot pedals on the wheelchair when staff propel her. The facility was unable to provide a policy regarding the use of wheelchair foot pedals. The facility failed to ensure safe mobility for this resident when pushing her in her wheelchair, placing her at risk for accidental injury when staff propelled her without foot pedals, allowing her toes or heels to skim along the floor.

The facility reported a census of 20 residents. The sample contained 12 residents, with one resident reviewed for limited range of motion. Based on observation, interview, and record review, the facility failed to provide interventions to promote maintenance of range of motion and prevent decline in the right hand, for the one sampled resident, Resident (R) 8. Findings included: - The signed Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An annual Minimum Data Set (MDS), dated [DATE], documented staff assessed R8 as having memory problems. She required total assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. She required extensive assistance for eating and had functional limitation in range of motion in one upper extremity, and in both lower extremities. The care plan lacked intervention to maintain range of motion ability of the right hand. On 09/15/21 at 10:13 AM, R8 sat in her Broda chair (a specialized highbacked wheelchair) in the dining room. Her right hand remained tightly in a fist. On 09/15/21 12:14 PM, R8 sat in her Broda chair in dining. The resident did not use the right hand at all during the meal as it remained in her lap. On 09/15/21 at 02:20 PM, R8's right hand remained tightly in a fist. The resident's hand lacked any type of device to open her fingers from the palm of her hand. On 09/16/21 at 10:08 AM, R8 sat in her Broda chair in the lounge. She pulled briefly at her oxygen tubing using finger/thumb grasp of her curled right hand. This action dislodged the oxygen tubing from her right ear. Her right hand then returned to the fist position. On 9/21/21 at 08:40 AM, R8 sat in her Broda chair in the dining room. Throughout her breakfast, her arms remained under the blanket. On 09/15/21 at 02:20 PM, a family member reported R8 lost the use of her left arm after her stroke. R8's right hand looked like it stayed more in the position of a fist, but she could still move it. R8 has progressive dementia, so she may need interventions to maintain movement ability in her right hand. On 09/20/21 at 02:25 PM, Certified Nursing Assistant (CNA) N stated we help her get up in the morning, we feed her and reposition her. She doesn't use the left arm, and staff put a pillow under it. CNA N did not know of anything that the staff did for the resident's right hand. She doesn't use the right hand very much, but she can move it around. The staff do not do any range of motion with her right hand. On 09/21/21 at 08:42 AM, Administrative Nurse E acknowledged that the resident's right hand was usually in a fist, but R8 was able to move it. She does not have functional use of her left side, or her right leg. On 09/21/21 at 02:54 PM, Licensed Nurse (LN) H stated R8 has dementia and has good days where she tried to reach for the spoon with the fist that was tight. The staff are not currently doing anything to keep movement in her hand. Without adequate movement the hand could stay in a fist. Something could be done now before that happened. LN H reported they could notify the doctor and ask occupational therapy for recommendations. On 09/21/21 at 02:25 PM, CNA M stated she did not provide range of motion or perform restorative exercise with residents. Someone came up from therapy to do restorative with some of the residents, but no restorative services were done by staff with R8. On 09/21/21 at 04:19 PM, Administrative Nurse D stated some intervention should be in place to keep the resident's hand from remaining in a fist position and verified there was not currently any intervention in place. Occupational therapy looked at her for the Broda chair, but they did not evaluate her right hand at that time. The facility failed to provide interventions to promote maintenance or prevent decline of range of motion in the resident's right hand.

The facility reported a census of 25 residents. Based on observation, interview, and record review, the facility failed to follow the Center for Medicare and Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prevent transmission of COVID-19. The facility failed to ensure that all staff that entered the facility had a mask in place. Furthermore, the facility failed to ensure that all staff performed a self-screening prior to entry into the facility. Record review revealed lack of self-screening on three occasions that occurred from 03/14/20 to 05/19/20. The failure to have a mask in place and complete self-screening increased the risk of transmission of the pandemic COVID-19 virus to the vulnerable residents of the facility, placing them in immediate jeopardy. Findings included: - On 06/16/20 at 01:34 PM, Certified Nurse Aide (CNA) M revealed that after she takes her temperature and logs it, she enters the doors to the facility and goes to the nurse's station to get the masks that she needs. Most of the time they are out of masks at the screening station, and she did that today when she arrived at the facility. On 06/16/20 at 01:55 PM, CNA N revealed that when coming in at 06:30 AM for her shift, she checks her temperature, logs in on the self-screening sheet, goes to the breakroom to put away her purse and get protective safety eye glasses, and then she gets her masks behind the nurse's station. Furthermore, she reported usually they are out of masks on the screening table. On 06/16/20 at 01:59 PM, observation of the employee screening station did not reveal masks on the table, but a box of masks was in a holder attached to the hand sanitizer stand next to the table. On 06/16/20 at 06:34 PM, CNA O arrived at the employee screening station and checked her temperature, then entered the facility without a mask in place and went thru the door that leads to the breakroom area. The resident dining room was across the corridor form the door she entered that leads to the breakroom. On 06/16/20 at 06:43 PM, Administrative Nurse D confirmed that staff should have a mask on before coming through the doors to enter the facility from the employee screening station. On 06/16/20 at 07:10 PM, CNA O confirmed that she took her mask off when arriving to the screening station, she forgot to put it back on before entering the doors to the facility, and that a mask should have been in place. On 06/17/20 at 10:34 AM, Administrative Nurse E, responsible for Infection Control, revealed that the expectation of staff was to don masks before entering the facility, which was available before entering. On 06/17/20 at 01:22 PM, CNA M confirmed she enters the facility past the employee screening station and goes to the nurse's station without a mask in place. Furthermore, she reported that it was probably not okay to enter the facility through the doors without a mask in place, but the nursing staff does in the morning when they get there. On 06/17/20 at 01:44 PM, CNA N, confirmed that she enters the facility at the screening station, goes to the nurse's station without a mask in place sometimes, and pretty much everybody has no mask on when they go to the nurse's station. Furthermore, no mask is in place because there is no screener or masks at the entry way of the adjoining facility, and that the entrance to the facility at the employee screening station lacked masks. Per observation, the employee screening station was at a corridor on the other side of a set of double doors that adjoined the facility to another level of the care facility. Once staff passed through the double doors, there was a kitchen on the left, then a dining room that extended to the length of that corridor. To the right of that corridor included a door that entered another area that had the breakroom, staff bathroom, and two administrative nurse offices. Past that area to the right were medication carts located along the wall of that corridor, then there was an entry way to the right into the quiet living room. At the end of the corridor, straight ahead was the lobby area and adjoining it to the right is the nurse's station area, which is on the opposite side of the hallway of another entry into the quiet living room. Review of a staff email, sent out on 04/17/20 at 05:19 PM, included information that all staff that enter the facility should follow the Post-Acute Guidelines for Yellow level PPE (personal protective equipment). The yellow level required a level three mask, level one mask over, gloves, and eye protection. The yellow level PPE must be followed in any patient care areas. Areas to be considered patient care areas included any location where any staff may come within six feet of a resident who is not wearing a level one mask. A resident may be encountered in the dining room, walking down a hallway, or at the nurse's station. Masks and face shields are located at the nurse's station. In addition, on 06/16/20 at 08:57 AM Licensed Nurse (LN) G reported that the employee screening station was on the other side of hall doors near the dining room and that employees do their own screening. On 06/16/20 at 06:43 PM Administrative Nurse D confirmed that employees are to verify they do not have any of the CDC recommended symptoms, take their temperature, and fill out their screening form before entering the facility. If they have traveled or been exposed to someone that was positive for COVID-19 they shouldn't even show up for work. Review of Voalte message (a communication method seen by the staff when they login at the beginning of their shift) sent to staff, dated 03/13/20 at 11:53 PM, directed the employees to clock in and proceed to the (Facility name/Facility Name) door where there are logs where staff will record their temperature prior to entering. If temperature is greater than 100 degrees Fahrenheit (F), if you have traveled or been exposed to COVID-19, haven't been cleared by employee health, then you may not enter. Review of the nursing schedules and the employee temperature/screening logs, dated 03/14/20 to 06/15/20, revealed three CNA's failed to complete self-screening when arriving to the facility. On 03/14/20 CNA Q lacked a self-screening log, on 04/10/20 CNA P lacked a self-screening log, and on 05/19/20 CNA O lacked a self-screening log. On 06/17/20 at 02:15 PM, Administrative Nurse D confirmed that CNA Q, CNA P, and CNA O, failed to perform their screening. The facility policy COVID-19 Senior Living, dated 03/01/20, instructed to prevent the spread of respiratory germs in your facility that employees at least prior to starting their shift will be monitored for fever or respiratory symptoms. Staff are required to take their temperature at the start of each shift. An update to the policy on 04/20/20 contained the same instructions. The facility failed to ensure that all staff that entered the facility had a mask in place. Furthermore, the facility failed to ensure that all staff performed a self-screening prior to entry into the facility. The failure for staff to have a mask in place and complete self-screening increased the risk of transmission of the pandemic COVID-19 virus to the vulnerable residents of the facility. On 06/17/20 at 05:10 PM, Administrative staff D and E were informed that they were in immediate jeopardy status and provided the Immediate Jeopardy Template for failure to ensure that all staff that entered the facility had a mask in place and completed the self-screening to decrease the risk of transmission of the pandemic COVID-19 virus to the vulnerable residents of the facility. The facility provided an acceptable plan of removal of the immediate jeopardy on 06.18.2020 at 4:30 PM which included: 1. Staff are not allowed to enter the LTC (long term care) without being screened. 2. Creation of a new screening log to track symptoms of COVID-19 on 06/18/20. 3. Staff are not allowed to enter the LTC without properly donning a mask and performing hand hygeine. 4. The majority of staff were inserviced on 06/18/2020 from 12:00 PM thru 8:05 PM and all other staff will be inserviced on 06/19/20. 5. Update of the Daily Huddle form to include any PPE concerns and who to contact for additional PPE on 06/18/20 at 9:45 AM. 6. QAPI (Quality Assurance and Performance Improvement meeting held on 06/18/2020 at 4:30 pm with medical director. The survey team validated the immediate jeopardy removal on 06/22/2020 at 1:05 pm following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at the scope and severity of an F.

The facility reported a census of 27 residents. The sample included three residents. Based on record review and interview the facility quality assessment and assurance committee failed to implement appropriate plans of action to correct identified quality deficiencies. One of the three residents, Resident (R) 1, with a history (on 12/04/19) of inappropriate touching of R2, was on line of sight observations when out of his room. On 01/15/2020, the facility removed the line of sight supervision when he was out of his room without keeping R1 from further inappropriate touching of R2. As a result of this deficient practice, R1 inappropriately touched R2 on 02/16/2020, a month later. Findings included: - Resident (R) 1, had a history (on 12/04/19) of inappropriate touching of R2. The facility R1 at that time to be on staff's line of sight observations when out of his room to protect R2 from R1's inappropriate touching. Nurses' Notes (NN), dated 12/30/19 at 06:12 PM, documented the resident continued to attend activities and staff kept him in line of sight when out of his room. The resident did understand that the staff were keeping an eye on him and he had no inappropriate behavior noted. NN, dated 01/01/2020 at 01:37 PM, documented the staff checked and charted on the resident's location every hour and he had been in the line of sight of staff at all times when out of his room. NN, dated 01/06/2020 at 06:09 PM, documented the staff took the resident for a ride and he really enjoyed riding around seeing the sights. The staff continued to keep in line of vision when he is out of his room and he had no inappropriate behaviors. Interdisciplinary Team Notes (IDT,) dated 01/07/2020, documented under risky Behaviors, (a staff member) would audit the chart and the resident went on one to one visits and outings. NN, dated 01/10/2020 at 03:03 PM, documented the staff spoke with the resident to check and see how everything was going with the new interventions to help with his behaviors. The resident stated he was really liking the rides out of the building and it was really helping. He said he was really enjoying the one on one's that he was having daily. The staff member asked if he had been having any thoughts of doing something that he should not be doing, and he said no he thought he was doing good as far as he knew. NN, dated 01/13/2020 at 07:11 PM, documented the last NN that reported the staff continued to check and charted on R1's location every hour and he had been in the line of sight of staff at all times when out of his room. IDT Notes, dated 01/14/2020, under Risky Behaviors, documented, Audit- three activities on 10 th, van and Chaplin 6th van ride. IDT Notes, dated 01/21/1010, documented under Risky Behaviors,' the staff discontinued the resident's line of sight observations on 01/15/2020. The resident was having refusal of therapies at that time. NN, dated 02/16/2020 at 02:55 PM, documented at approximately (1345) 01:45 PM, a staff member noticed that R1 was fondling a female resident over her pants (R2) near the nursing station for a brief moment and then he stopped. Both residents were separated and a staff member was immediately placed with R1 for one to one supervision at all times. This was communicated to all staff members, in person and via voalte message. The care plan was updated with the one on one supervision intervention. The staff notified the physician who asked the staff to have the director of nursing contact him the next day to discuss treatment options. On 02/21/2020 at 02:30 PM, interview with Administrative Nurse B, revealed the facility staff following the inappropriate touching of R2 on 12/04/19, implemented R1 with locations checks every hour logged, the staff to keep R1 in continued line of sight supervision when he was out of his room, to talk to a male staff, to attend more activities, to go on outings, and also with the physician order [REDACTED]. The team decided to discontinue the in line of sight supervision on 01/15/2020 because the resident was doing so well. The team did not make any other changes at that time to protect R2 from R1's inappropriate touching. On 02/25/2020 at 01:00 PM, interview with Licensed Nurse (LN) C, verified she was the nurse the the nurses desk when R1 inappropriately touched R2. LN C verified she did not have R1 in line of sight vision because he had been taken off of that intervention awhile back. However, she further explained that she was still to have kept R2 in line of sight vision, since the same incident occurred 12/04/19. LN C said she was at the desk with R2 off to the right side and she could see her, but at the time of this incident, she had turned back to the computer and missed R1 come up and inappropriately touch R2. She explained that a Certified Nurse Aide came to her at the desk and reported she had seen the incident when coming back up a hallway. LN C explained that she immediately placed R1 on one on one with a staff for supervision and put it on his care plan for the other staff members. The facility's quality assessment and assurance committee failed to implement appropriate plans of action to correct identified quality deficiencies. Resident (R) 1, with a history on 12/04/19) of inappropriate touching of R2, was on line of sight observations when out of his room. On 01/15/2020, the facility removed the line of sight supervision when he was out of his room without keeping R1 from further inappropriate touching of R2. As a result of this deficient practice, R1 inappropriately touched R2 on 02/16/2020, a month later.

The facility reported a census of 27 residents. The sample included three residents reviewed for behaviors. Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent an incident of inappropriate touching, between two of the three residents reviewed, Resident (R) 1 and R2. The facility failed to protect R2 from potential inappropriate touching by R1, when licensed nursing staff C remained seated behind the nurses' desk on the computer, within 10 feet, and R1 quickly approached R2, near the bird cage. As a result of this deficient practice, male R1 inappropriately touched female R2. Findings included: - The electronic medical record evidenced the facility admitted Resident (R) 1, on 12/14/18. The primary care physician listed [MEDICAL CONDITION] (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), as his diagnosis. On the admission Minimum Data Set (MDS), assessment dated [DATE], revealed the Brief Interview for Mental Status, (BIMS) indicated severe cognitive impairment. The Care Area Assessment (CAA), dated 12/30/19 for cognition included, he was frequently forgetful and at times had trouble understanding what was being said to him. He was not always able to make himself clearly understood. He had a history of [REDACTED]. The annual MDS, dated [DATE], revealed a BIMS score of nine, which revealed the resident with moderate cognitive impairment. The assessment also verified the resident was independent with transfers and ambulation and required limited assist with all other activities of daily living (ADLs), including dressing, toilet use and personal hygiene. The current care plan (CP), included an additional intervention on 08/29/19, instructing that staff would keep R1 in line of sight supervision at all times when R1 was out of his room and with hourly location checks. Provide behavior management activities to include looking at photo albums, reading the daily chronicles, riding the exercise bike, regular 1:1 visits with staff/ chaplain, regular outings and consistent staff. A behavior management plan, for R1, sent to the physician and all staff, on 02/16/20 at 02:43 PM, informed the physician, as well as staff, that R1 was seen by staff to attempt sexually inappropriate touching behaviors towards another resident (R2) who was not cognitively able to consent. (R2's significant change in condition MDS, dated [DATE], documented R1 with severely impaired cognition and she required extensive assistance to transfer, using a wheelchair to self-propel about the facility.) The staff had caught R1 inappropriately touching R2 leaning over her wheelchair, touching her inappropriately, although she was fully clothed including an adult brief and slacks. The facility initiated immediate 1:1 staff at all times even while the resident was in his room. If he starts to invade someone's personal space, staff were to redirect him to a quiet location, such as the patio or family room. An interview with Administrative nurse B, on 02/19/20 at 11:00 AM, revealed R1 on 02/16/20 at 01:45 PM, inappropriately touched R2's private area with his hand. Administrative Nurse B further explained that R2 was fully clothed including an adult brief under her slacks. Licensed Nurse (LN) C was present at the time approximately 10 feet away at the nurse's desk. The residents were near the bird cage facing in opposite directions. As Certified Nurse Aide (CNA) D approached the area from the hall, she visualized R1 to inappropriately reach and touch R2's clothed private area. R1 walked away immediately when CNA D approached him. Administrative nurse B verified R1 had sought R2's attention at times and liked to sit beside her during activity groups. This was R1's second episode of inappropriate touching of R2. The male R1 had never paid any attention to any other female resident on the unit. Administrative nurse B reported R2 did not react to the inappropriate touching by R1. On 02/19/20 at 01:10 PM, during the investigation, R1 appeared somewhat paranoid saying, What the hell is going on. He stood and walked independently with his walker. Throughout the day, when out of his room he was constantly in sight of a facility staff member. The staff kept R1 close, whenever he was out of his room at all times during the investigation in the facility. On 02/19/20 at 11:00 AM, R2 entered the dining room area in her wheelchair. She sat most of the time with her left leg crossed over the right. She moved the wheelchair about ad lib with her right foot. She did not speak and did not interact with other residents or with the staff. On 02/25/2020 at 01:00 PM, interview with Licensed Nurse (LN) C, verified she was the nurse the the nurses desk when R1 inappropriately touched R2. LN C verified she did not have R1 in line of sight vision because he had been taken off of that intervention awhile back. However, she further explained that she was still to have kept R2 in line of sight vision, since the same incident occurred 12/04/19. LN C said she was at the desk with R2 off to the right side and she could see her, but at the time of this incident, she had turned back to the computer and missed R1 come up and inappropriately touch R2. She explained that a Certified Nurse Aide came to her at the desk and reported she had seen the incident when coming back up a hallway. LN C explained that she immediately placed R1 on one on one with a staff for supervision and put it on his care plan for the other staff members. The facility failed to ensure adequate supervision as planned to protect R2 from inappropriate touching by R1, when the licensed nurse sat behind the nurses' desk on the computer 10 feet away and failed to immediately identify and intervene when R1 approached R2 and touched her inappropriately.

The facility reported a census of 29 residents. The sample included three residents reviewed for abuse. Based on observation, interview and record review, the facility failed to prevent inappropriate touching, which included two of the three sampled residents, Resident (R) 1 and R2. The facility failed to ensure adequate supervision as planned to protect R2 from potential inappropriate touching by R1, when the staff monitoring R1's whereabouts, failed to protect R2, when she turned to talk to a family member and let R1 out of her sight. As a result of this deficient practice, male resident R1 inappropriately touched female R2. Findings included: - The electronic medical record evidenced the facility admitted Resident (R) 1, on 12/14/18. The primary care physician listed [MEDICAL CONDITION] (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), as his diagnosis. On the admission Minimum Data Set (MDS), assessment dated [DATE], the resident scored three on the Brief Interview for Mental Status, (BIMS) which indicated severe cognitive impairment. The Care Area Assessment (CAA), dated 12/27/18 for cognition included, I have severely impaired cognition and delayed response when asked questions. The quarterly MDS, dated [DATE], revealed a BIMS score of five, which continued to score the resident with severe cognitive impairment. The assessment also verified the resident required supervision with all activities of daily living (ADLs), including transfers and ambulation with a wheeled walker. The current Care Plan (CP), included an additional intervention on 08/29/19, for the resident will be in line of sight supervision, at all times when out of his room and hourly location checks. When he invades someone's personal space, please redirect him to a quiet location. On 12/20/19 at 01:45 PM, additional information provided by Administrative Nurse B, included a behavior management plan, for R1, sent to the physician on 08/21/19 at 12:24 PM. This informed the physician that the resident had been suspected of potentially sexually inappropriate behaviors towards another resident who was not cognitively able to consent. The staff had caught R1 trying to take R2 into his room and recently caught him leaning over her wheelchair, apparently touching her inappropriately, although staff couldn't see his hands and she was fully clothed. The facility initiated location checks for the other resident, but received another report since then. The facility developed a behavior management plan for R1 including the primary care physician in its development and potentially a psych evaluation if the physician felt it was indicated for behavior management interventions. This is a new behavior for R1. The facility started location checks for R1 and line of sight supervision anytime he was not in his room immediately. R2's significant change in condition MDS, dated [DATE], documented the resident as unable to complete the BIMS with severe cognitive impairment. The resident required extensive assistance of two staff for transfers/bed mobility and used a wheelchair to self propel in the facility. The resident was unable to walk. An interview with Administrative nurse B, on 12/10/19 at 09:00 [NAME]M., revealed R1 on 12/04/19 at 02:05 PM, inappropriately touched female R2's private area with his hand rubbing back and forth. Administrative Nurse B further explained that R2 was fully clothed including an adult brief under her slacks. Licensed Nurse (LN) C was present at the end of the hallway when a family member walked up to her and LN C turned to visit with the family member. Certified Nurse Aide (CNA) D then entered the hallway and noted the inappropriate touch of R2's private area. R1 walked away immediately when CNA D stated, Hey guys, what's going on. Administrative nurse B verified the two residents had grown up together and went to the same school. He had sought her attention at times and liked to sit beside her during activity groups. It was unknown if they had a previous relationship when they were younger. The male resident had never paid any attention to any other female resident on the unit. Administrative nurse B reported female R2 failed did not react to the inappropriate touching by R1. On 12/10/19 at 10:20 AM, during the investigation, R1 talked about his Navy career but could not recall what he had for breakfast. He stood and walked independently with his walker. Throughout the day, when out of his room he was constantly in sight of a facility staff member. The staff kept R1 in view when out of his room at all times during the investigation in the facility. On 12/10/19 at 11:00 AM, CNA D and F placed R2 into a wheelchair. She moved the wheelchair about ad lib with her feet. She did not speak and did not interact with other residents or with the staff. The facility failed to ensure adequate supervision as planned to protect R2 from potential inappropriate touching by R1, when the staff monitoring R1's whereabouts turned to talk to a family member and let R1 out of her sight.

The facility reported a census of 27 residents with three residents sampled and reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure a safe transfer for one of the three sampled residents, Resident (R) 1, when the facility staff failed to use a gait belt during transfer as planned. The resident fell and experienced three fractures of the right ankle. Findings included: - Resident (R) 1's admission record, dated 07/16/19, included [DIAGNOSES REDACTED]. The 07/23/19 admission Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The resident did not walk and required extensive assistance of two for transfers and toileting. The resident had no falls since admission. The Fall Care Area Assessment (CAA), dated 07/23/19, revealed the resident with a fall risk score indicating he was at an increased risk for falls. He required two staff assistance for all transfers as he was unsteady without assistance. Interventions would be put in place to help ensure that R1 remained free of falls. The care plan, dated 07/17/29, included the resident required one to two staff assistance for transfers and a gait belt. He needed staff assistance to complete his cares. The 07/16/19, Fall Risk Assessment, documented a score of 11 with over 10 indicating an increased risk for falls. Nurses' Note, dated 07/31/19 at 07:26 PM, documented that the resident had an injury fall that afternoon when being toileted by two nurse aides. His right ankle was purple and he complained of pain. The staff sent the resident to the emergency room (ER) for further assessment and he returned to the facility that evening with a [DIAGNOSES REDACTED]. An x-ray report of the resident's right ankle, dated 07/31/19, documented the resident experienced a fractured distal tibia (long bone in the shin), a fractured distal fibula (thin bone next to the tibia in the shin), and a fracture in the medial malleolus (bone/bump inner ankle where the tibia/fibula bones join). A Post Fall Huddle form, dated 07/31/19 at 02:00 PM, documented 2 certified nurse aides assisting the resident to transfer in the bathroom, when his legs gave out and the resident fell to the floor. The staff members present failed to utilize a gait belt around the resident during the transfer. On 09/05/19 at 12:15 PM, R1 sat on the side of the bed eating the noon meal. He explained that he fell on his bottom trying to hurry to the bathroom and his feet got tangled up. He verified that two staff were with him but R1 could not remember if they had a gait belt on him or not at the time of the fall. On 09/05/19 at 04:00 PM, Certified Nurse Aide (CNA) N reported she worked at the time of the resident's fall. When CNA N entered the room to assist the resident CNA M was already in the room and helping the resident to the bathroom without a gait belt around the resident. The two CNAs assisted the resident to walk on to the bathroom but the resident was a fall risk and was care planned to have a gait belt on. The resident wanted to sit a little while. When the resident was done, CNA M stood him up, but he was not standing all the way up, so the two staff tried to lower him back down onto the toilet, but his feet started to slip. Next thing CNA N knew they heard a crunching sound after they lowered him to the floor. On 09/06/19 at 02:00 PM, CNA M explained the day of the resident's accident, R1 was in such a hurry to get to the bathroom she did not have time to get a gait belt on him. She did verify the staff were to use a gait belt on the resident with transfers. CNA M explained following the resident toileting he stood up for a quick second and told the staff his legs could not do it and were giving out, so the staff lowered him to the floor. In the process his leg somehow got twisted and she heard a pop in his ankle area. On 09/08/19 at 11:35 AM, Administrative Nurse [NAME] reported working when the resident fractured his ankle. She met with each of the two aides that were with the resident at the time and educated them about following the care plan and using the gait belt. She further explained that the staff doing the transfer failed to use a gait belt, and that the care plan instructed them to use a gait belt. The facility's undated policy, for How to Transfer an Individual Using a Gait Belt included a purpose: To provide safety and protection from possible injury during transfer and ambulation . Action: . 4.) Make sure the belt is applied tightly enough to prevent it from riding up or down on the individual's body, but loosely enough so you can grasp it firmly and comfortably . 6.) If the individual has a weak side, make sure his or her stronger side is facing the destination . Notes: .If the individual is particularly heavy or has difficulty supporting own weight, consider using a lift transfer device . The facility failed to ensure a safe transfer for the resident, when facility staff failed to use a gait belt for transfer as planned, the resident's legs became weak and he fell to the floor and experienced 3 fractures of the right ankle.