Every finding on record at Apostolic Christian Home

The facility identified a census of 58 residents and one kitchen. Based on record review and interviews, the facility failed to provide the services of a full-time certified dietary manager for the 58 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 12/16/24 at 07:26 AM, during the initial tour of the kitchen, Dietary Staff BB stated she had started the certified dietary manager course three years ago. Dietary Staff BB stated she had completed three months of the course before staffing shortages at the facility required her to return full-time in dietary. Dietary Staff BB stated the Registered Dietician (RD) came to the facility monthly. On 12/18/24 at 01:10 PM, Administrative Staff A stated he was aware Dietary Staff BB was not certified. Administrative Staff A stated that was something that he would investigate. The Facility's Dietitian policy revised November 2024 documented that a qualified, competent, and skilled dietitian would help oversee the food and nutrition services in the facility. The facility failed to employ a full-time certified dietary manager to evaluate residents' nutritional concerns and oversee the ordering, preparing, and storage of food for the 58 residents in the facility, placing the residents at risk for inadequate nutrition.

The facility identified a census of 58 residents. The sample included 15 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. This failure affected all 58 residents residing in the facility. Findings Included: - On 12/18/24 an inspection of the Facility Assessment was completed. The assessment was revised on 06/28/2024. A review of the evaluation revealed the following: The assessment identified the average daily staffing required for the facility but failed to identify the specific staffing levels needed and the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse's Aides (CNA) needed for each unit, shift, and per census. The assessment lacked staffing levels required for each shift, including evenings and weekends. On 12/18/24 at 12:45 AM, Administrative Staff A stated the facility assessment was just revised. He stated he worked with Administrative Nurse A to complete the assessment based on the resident population, acuity, census, and needs of each resident to provide staffing. He stated the assessment was completed yearly based on the required guidelines. The facility's Facility Assessment policy revised October 2024 indicated the facility would complete an annual assessment to determine and update the capacity to meet the needs and competency of each resident. The facility failed to conduct a thorough, updated facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations and emergencies. This failure affected all 88 residents residing in the facility.

The facility had a census of 58 residents. The sample included 15 residents with five reviewed for accommodation of needs. Based on observation, record review, and interview, the facility failed to ensure the residents were provided foot pedals during wheelchair transports for Resident (R) 23, R36, R46, R34, R40, and R33. This placed the residents at risk for preventable accidents and injuries due to unmet care needs. Findings Included: - On 12/16/24 at 08:16 AM, R23, a severely cognitively impaired resident, sat upright in his Broda chair (specialized wheelchair with the ability to tilt and recline). R23 had socks on both feet. Certified Nurse Aide (CNA) O pushed R23 in his Broda chair and R23's feet slid along the floor before he lifted his legs. On 12/17/24 at 07:18 AM, Staff pushed R36 in her wheelchair with no foot pedals. Staff repeatedly told R36 to keep her feet up. On 12/17/24 at 07:20 AM, Staff pushed R46, a cognitively impaired resident, in her wheelchair with no foot pedals. Staff repeatedly asked R46 to keep her feet up. On 12/17/24 at 09:47 AM, R23 sat upright in his Broda chair as Licensed Nurse (LN) J pushed his chair. R23's feet bumped up and down. R23 picked his feet up and held them out after LN J asked him to pick them up as she pushed him to the dining room. On 12/17/24 at 11:00 AM, R34, a severely cognitively impaired resident, sat upright in her Broda chair in the hallway outside the TV room with socks on her feet and no heel protectors in place. Certified Nurse Aide (CNA) N pushed R34 in the Broda chair to the dining room with R34's feet sliding on the floor. On 12/17/24 at 11:13 AM, R23 sat upright in his Broda chair as CNA O pushed him from the dining room down the hallway. R23's feet slid along the floor. R23 wore only socks on his feet. On 12/18/24 at 08:08 AM, R40, a severely cognitively impaired resident, was wheeled to the main dining room by Licensed Nurse (LN) G without any foot pedals. R40 had socks on as her feet slid on the floor as she was pushed to the back dining room table. On 12/18/24 at 08:14 AM, R33, a severely cognitively impaired resident with lower extremity limitation, sat in his Broda chair at the dining room table next to the piano. LN H wheeled R33 from his dining room table to the front window. R33's right foot was not on a foot pedal and slid on the ground as he was pushed to the window. On 12/18/24 at 11:37 AM, CNA M stated that all the residents had foot pedals for their wheelchairs, but staff would only apply them for residents who could not lift their legs up. She stated that the resident's legs should never slide or touch the ground while being pushed. She stated that staff would ask the residents if they could hold their legs up and apply them if needed. She stated that foot pedals would only be applied if they were needed. On 12/18/24 at 11:45 AM, Licensed Nurse (LN) H stated staff know which residents can hold their feet up. She stated the foot pedals were left off the wheelchairs to promote independence. She stated staff should never allow the resident's feet to slide on the floor as they push them. On 12/18/24 at 12:34 PM, Administrative Nurse D stated staff should always apply wheelchair foot pedals for high fall risk residents. She stated staff were expected to apply the pedals when pushing the residents long distances. The facility's Assistive Devices and Equipment policy revised 01/2024 indicated the facility will supervise the use of assistive devices including grab bars, walkers, canes, and foot pedals. The policy indicated staff will ensure the safe use of all assistive devices. The facility failed to utilize and ensure foot pedals were provided and used during wheelchair transports for R23, R36, R46, R34, R40, and R33. This placed the residents at risk for preventable accidents and injuries due to unmet care needs.

The facility reported a census of 58 residents. The sample included 15 with five residents reviewed for drug regimen review. Based on interviews, observations, and record review, the facility failed to ensure the Consulting Pharmacist (CP) identified and made recommendations related to Residents (R) 55, R8, R52, and R32's indications for their antipsychotic medications (a class of medications used to treat major mental conditions that cause a break from reality). This placed the residents at risk for unnecessary psychotropic (alters mood or thoughts) medications and related complications. Findings Included: - The Diagnosis tab within R55's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), fatigue, and pain. R55's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of eleven indicating moderate cognitive impairment. The MDS documented she was independent with meals, oral hygiene, toileting, bathing, dressing, transfers, and bed mobility. The MDS documented no behaviors were exhibited during the observed period. The MDS documented she took antipsychotic medication. The MDS documented a gradual dose reduction (GDR) was not completed and documented as clinically contraindicated on 09/06/24. R55's Psychotropic Drug Use Area Assessment (CAA) completed 08/05/24 documented she took antipsychotics and was at risk for adverse effects related to her Seroquel medication (an antipsychotic medication). R55's Care Plan initiated on 09/11/24 documented she was at risk for a cognitive decline due to her medical diagnosis. The plan documented she was independent when completing her activities of daily living (ADLs). The plan documented she was at risk for adverse reactions related to her medications; and took medications with Black Box Warnings (BBW- the highest safety-related warning that medications can be assigned by the Food and Drug Administration). The plan instructed staff to monitor for changes and notify her medical provider. R55's plan lacked documentation showing she had behaviors and non-pharmacological interventions to address those behaviors. The plan lacked documentation related to her antipsychotic medication. R55's EMR under the Orders tab indicated an order for staff to administer 50 milligrams (mg) of Seroquel three times a day for behavioral disturbances and paranoia related to dementia. The EMR revealed she had the medication upon her admission on 07/31/24. A review of R25's EMR revealed no documented rationale for the indicated use of Seroquel for dementia-related behaviors. A review of the facility's Monthly Medication Reviews (MMR) from 08/2024 to 12/2024 revealed no recommendations noting the inappropriate indication of use related to R55's Seroquel medication. On 12/18/24 at 07:30 AM, Licensed Nurse (LN) G administered R55's morning medications. R55 received her morning dose of Seroquel without behaviors or refusals. R55 reported she felt fine and had no concerns. On 12/18/24 at 12:23 PM, Administrative Nurse D stated the pharmacist did not recognize or report issues related to medication indications. Administrative Nurse D stated she would meet with them to ensure they did in the future. The facility's Medication Regimen Reviews policy last revised May 2024 documented the Consultant Pharmacist reviewed the medication regimen of each resident at least monthly. Medication regimen reviews (MRR) are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated. The policy documented that the Consulting Pharmacist would identify, and report medication irregularities found during the monthly review. The facility failed to ensure the CP identified and made recommendations related to R55's inappropriate indication for her Seroquel medication. This placed R55 at risk for unnecessary psychotropic medications and related complications.a 41037 - R8's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented R8 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, antidepressant (a class of medications used to treat mood disorders) medication, diuretic (a medication to promote the formation and excretion of urine) medication, and opioid (a class of controlled drugs used to treat pain) medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 14 which indicated intact cognition. The MDS documented that R8 had received antianxiety (a class of medications that calm and relax people) medication, antipsychotic medication, opioid medication, and antidepressant medication during the observation period. R8's Psychotropic Drug Use Care Area Assessment (CAA) dated 07/05/24 documented she had received multiple psychotropic and opioid medications. The nursing staff continued to monitor for effectiveness and side effects every shift. R8's Care Plan dated 08/25/24 documented the nursing staff would monitor R8 for possible signs and symptoms of side effects of her medications. The plan lacked documentation related to her antipsychotic medication. R8's EMR under the Orders tab revealed the following physician orders: Quetiapine fumarate (antipsychotic) oral tablet extended release 24 hour (Seroquel) 150 milligram (mg) give one tablet by mouth at bedtime related to major depressive disorder dated 07/12/24. Review of R8's EMR lacked documentation of non-pharmaceutical interventions tried and failed prior to the antipsychotic medication. The EMR lacked evidence of documentation related to informed consent for the use of antipsychotic medication. R8's Monthly Medication Review (MMR) reviewed from May 2024 through December 2024 lacked evidence the CP identified and reported R8's antipsychotic medication did not have a physician-documented rationale or risk versus benefit for continued use of an antipsychotic without a CMS-approved indication. On 12/17/24 at 07:17 AM, R8 lay asleep on her bed. R8's oxygen cannula was in her nostrils; she was covered with a blanket and the head of her bed was elevated. On 12/18/24 at 12:23 PM, Administrative Nurse D stated the pharmacist did not recognize or report issues related to medication indications. Administrative Nurse D stated she would meet with them to ensure they did in the future. The Medication Regimen Reviews policy last revised May 2024 documented the Consultant Pharmacist reviewed the medication regimen of each resident at least monthly. Medication regimen reviews (MRR) are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated. The goal of the MRR was to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. An irregularity refers to the use of medication that was inconsistent with accepted pharmaceutical services standards of practice; was not supported by medical evidence; and/or impedes or interferes with achieving the intended outcomes of pharmaceutical services. It may also include the use of medication without indication, without adequate monitoring, in excessive doses, and or in the presence of adverse consequences. If the identified irregularity represents a risk to a person's life, health, or safety; the consultant pharmacist contacts the physician immediately (within one hour) to report the information to the physician verbally and document the notification. The facility failed to ensure the CP had identified and reported irregularities with R8's antipsychotic medication. This deficient practice placed R8 at risk for unnecessary medication administration, ineffective benefits of the medication, and possible adverse side effects. 49634 - The Diagnosis tab of R52's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), aphasia (condition with disordered or absent language function), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) affecting right dominant side, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dysphagia (swallowing difficulty), hypertension (high blood pressure), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Quarterly Minimum Data Set (MDS) dated [DATE], documented a Brief Interview of Mental Status (BIMS) score of four which indicated severely impaired cognition. The MDS documented R52 had an impairment on one side of her body. The MDS documented R52 needed partial to moderated assistance with dressing, toileting, and setting up for eating. The MDS documented R52 received an antidepressant (a class of medications used to treat mood disorders) and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) during the observation period. R52's Psychotropic Drug Use Care Area Assessment (CAA) dated 05/16/24 documented R52 admitted to the facility with a psychotropic medication and the physician would monitor R52's medication routinely. The MDS documented staff would monitor the side effects of medication for R52. R52's Care Plan dated 08/05/2024 documented R52 had impaired cognitive function, dementia, or impaired thought processes related to dementia. R52 would be able to communicate basic needs daily. R52's plan of care documented staff would administer medications as ordered and monitor and document for side effects and effectiveness. Staff were to keep the R52's routine consistent and try to provide consistent caregivers as much as possible to decrease confusion. R52's EMR under the Orders tab documented the following physician's order: Quetiapine fumarate (antipsychotic) 25 milligrams (mg) oral tablet give 0.5 tablet by mouth one time a day for behavioral disorders associated with dementia dated 07/17/24. R52's EMR revealed no physician-documented rationale for the continued use of quetiapine fumarate for dementia-related behaviors. A review of the CP's Monthly Medication Reviews (MMR) from 08/2024 to 12/2024 revealed no recommendations noting the inappropriate indication of use related to R52's quetiapine fumarate medication. On 12/16/24 at 07:32 AM R52 sat at the dining room table eating her breakfast. On 12/18/24 at 12:23 PM Administrative Nurse D stated the pharmacist did not recognize or report issues related to medication indications, but she stated she would meet with them to ensure they did in the future. The facility's Medication Regimen Reviews policy last revised May 2024 documented the Consultant Pharmacist reviewed the medication regimen of each resident at least monthly. Medication regimen reviews (MRR) are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated. The policy documented the Consulting Pharmacist would identify and report medication irregularities found during the monthly review. The facility failed to ensure the CP identified and made recommendations related to R52's inappropriate indication for her quetiapine fumarate medication. This placed R52 at risk for unnecessary psychotropic medications and related complications. - The Diagnosis tab of R32's Electronic Medical Record (EMR) documented diagnoses of anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), dementia (a progressive mental disorder characterized by failing memory and confusion), protein-calorie malnutrition, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), chronic pain, hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), insomnia (inability to sleep), chronic pain, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and dysuria (painful urination), The Annual 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 R32 required substantial to maximum assistance for eating, bathing, and dressing, and was dependent on staff for oral hygiene. The MDS documented R32 received antipsychotics during the observation period. R32's Psychotropic Drug Use Care Area Assessment (CAA) dated 12/09/24 documented R32 triggered secondary to the use of psychotropic medication to manage psychiatric illness and conditions. A licensed nurse monitored for side effects every shift, and the physician was to be notified of any abnormal findings. A pharmacist consultant would review medications monthly, and the physician would review medications with each visit. Contributing factors included current history of depression, anxiety, and bipolar disease. Risk factors included increased falls, impaired balance, and a potential for adverse effects of medication. The care plan would be reviewed to monitor the effectiveness of psychotropic medication and any adverse effects of medication. R32's Care Plan revised 12/13/24 documented R32 received psychotropic medications related to bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), depression, and anxiety. R32 would be free of psychotropic drug-related complications including movement disorder, discomfort, hypotension, gait disturbance, constipation, or cognitive and behavioral impairment. Nursing staff were to administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness every shift. Nurses were to consult with the pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly. Nursing staff were to monitor and record the occurrence of target behavior symptoms every shift. R32's EMR under the Orders tab documented the following physician's order: Risperidone (antipsychotic) oral tablet 0.5 milligrams (mg) give one tablet by mouth two times a day for delusions dated 07/24/24. R32's EMR revealed no physician-documented rationale for the continued use of risperidone for delusions. A review of the CP's Monthly Medication Reviews (MMR) from 08/2024 to 12/2024 revealed no recommendations noting the inappropriate indication of use related to R32's risperidone medication. On 12/16/24 at 07:15 AM, R32 lay on the couch in the Northeast hallway. R32 had a blanket and pillow. On 12/18/24 at 12:23 PM, Administrative Nurse D stated the pharmacist did not recognize or report issues related to medication indications, but she stated she would meet with them to ensure they did in the future. The facility's Medication Regimen Reviews policy last revised 05/2024 documented the consultant pharmacist reviews the medication regimen of each resident at least monthly. Medication regimen reviews (MRR) are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated. The policy documented the Consulting Pharmacist would identify and report medication irregularities found during the monthly review. The facility failed to ensure the CP identified and made recommendations related to R32's inappropriate indication for her risperidone medication. This placed R32 at risk for unnecessary psychotropic medications and related complications.

The facility reported a census of 58 residents. The sample included 15 with five residents reviewed for unnecessary medications. Based on interviews, observations, and record review, the facility failed to ensure an appropriate indication or documented physician rationale for Resident (R) 55, R8, R32, and R52s' antipsychotic medications (a class of medications used to treat major mental conditions that cause a break from reality). This placed the residents at risk for unnecessary psychotropic (alters mood or thoughts) medications and related complications. Findings Included: - The Diagnosis tab within R55's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), fatigue, and pain. R55's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of eleven indicating moderate cognitive impairment. The MDS documented she was independent with meals, oral hygiene, toileting, bathing, dressing, transfers, and bed mobility. The MDS documented no behaviors were exhibited during the observed period. The MDS documented she took antipsychotic medication. The MDS documented a gradual dose reduction (GDR) was not completed and documented as clinically contraindicated on 09/06/24. R55's Psychotropic Drug Use Area Assessment (CAA) completed 08/05/24 documented she took antipsychotics and was at risk for adverse effects related to her Seroquel (antipsychotic medication). R55's Care Plan initiated on 09/11/24 documented she was at risk for a cognitive decline due to her medical diagnosis. The plan documented she was independent with her activities of daily living (ADLs). The plan documented she was at risk for adverse reactions related to her medications and took medications with Black Box Warnings (BBW- the highest safety-related warning that medications can be assigned by the Food and Drug Administration). The plan instructed staff to monitor for changes and notify her medical provider. R55's plan lacked documentation showing she had behaviors and non-pharmacological interventions to address those behaviors. The plan lacked documentation related to her antipsychotic medication. R55's EMR under the Orders tab documented an order for staff to administer 50 milligrams (mg) of Seroquel three times a day for behavioral disturbances and paranoia related to dementia. The EMR revealed she had the medication upon her admission on 07/31/24. A review of R25's EMR revealed no documented rationale for the documented use of Seroquel for dementia-related behaviors. On 12/18/24 at 07:30 AM, Licensed Nurse (LN) G administered R55's morning medications. R55 received her morning dose of Seroquel without behaviors or refusals. R55 stated she felt fine and had no concerns. On 12/18/24 at 11:54 AM, LN H stated the appropriate indication for antipsychotic medication did not include dementia-related indications unless the resident had schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), Huntington's disease (a rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder), or Tourette's syndrome (condition of the nervous syndrome causing uncontrollable repetitive movements or unwanted sounds). On 12/18/24 at 12:23 PM, Administrative Nurse D stated only CMS-approved indications should be used for antipsychotic medications. She stated that dementia was not an appropriate indication for Seroquel. The facility's Psychotropic Drug Use policy revised July 2024 documented residents would not receive medications that were not clinically documented to treat specific conditions. The policy documented monthly medication reviews would be completed to show psychotropic monitoring to ensure appropriate indication, effectiveness, and the need for a gradual dose reduction. The facility failed to ensure an appropriate indication or a documented physician rationale for R55's Seroquel medication. This placed R55 at risk for unnecessary psychotropic medications and related complications. 41037 - R8's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of diabetes mellitus (DM - when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which documented intact cognition. The MDS documented R8 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication, antidepressant (a class of medications used to treat mood disorders) medication, diuretic (a medication to promote the formation and excretion of urine) medication, and opioid (a class of controlled drugs used to treat pain) medication during the observation period. The Quarterly MDS dated [DATE] documented a BIMS score of 14 which documented intact cognition. The MDS documented that R8 had received antianxiety (a class of medications that calm and relax people) medication, antipsychotic medication, opioid medication, and antidepressant medication during the observation period. R8s Psychotropic Drug Use Care Area Assessment (CAA) dated 07/05/24 documented she had received multiple psychotropic and opioid medications. The nursing staff continued to monitor for effectiveness and side effects every shift. R8's Care Plan dated 08/25/24 documented nursing staff would monitor R8 for possible signs and symptoms of side effects of her medications. The plan lacked documentation related to her antipsychotic medication. R8's EMR under the Orders tab revealed the following physician orders: Quetiapine fumarate (antipsychotic) oral tablet extended release 24 hour (Seroquel) 150 milligram (mg) give one tablet by mouth at bedtime related to major depressive disorder dated 07/12/24. Review of R8's EMR lacked documentation of non-pharmaceutical interventions tried and failed prior to the administration of antipsychotic medication. The EMR lacked evidence of documentation related to informed consent for the use of antipsychotic medication. On 12/17/24 at 07:17 AM, R8 lay asleep on her bed. R8's oxygen cannula was in her nostrils; she was covered with a blanket and the head of her bed was elevated. On 12/18/24 at 11:54 AM, LN H stated the appropriate indication for antipsychotic medication did not include dementia-related indications unless the resident had schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), Huntington's disease (a rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder), or Tourette's syndrome (condition of the nervous syndrome causing uncontrollable repetitive movements or unwanted sounds). On 12/18/24 at 12:23 PM, Administrative Nurse D stated only CMS-approved indications should be used for antipsychotic medications. She stated that dementia was not an appropriate indication for Seroquel. The facility's Psychotropic Drug Use policy revised July 2024 documented residents would not receive medications that were not clinically documented to treat a specific condition Residents, families, and/or the representative were involved in the medication management process. Residents who had not used psychotropic medications were not prescribed or given those medications unless the medication was determined to be necessary to treat a specific condition that was diagnosed and documented in the medical record. Medications not classified as anti-psychotic, anti-depressant, anti-anxiety, and hypnotic medication were not prescribed or administered as a substitution for another psychotropic medication unless there was a documented clinical indication consistent with clinical standard of practice. Consideration of the use of any psychotropic medication was based on a comprehensive review of the resident. That included an evaluation of the resident's signs and symptoms to identify underlying causes. The facility failed to ensure an appropriate indication or a documented physician rationale for R8's Seroquel medication. This placed R8 at risk for unnecessary psychotropic medications and related complications. 49634 - The Diagnosis tab of R32's Electronic Medical Record (EMR) documented diagnoses of anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), dementia (a progressive mental disorder characterized by failing memory and confusion), protein-calorie malnutrition, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), chronic pain, hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), insomnia (inability to sleep), chronic pain, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and dysuria (painful urination), The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which documented severely impaired cognition. The MDS documented R32 required substantial to maximum assistance for eating, bathing, and dressing, and was dependent on staff for oral hygiene. The MDS documented R32 received antipsychotics during the observation period. R32's Psychotropic Drug Use Care Area Assessment (CAA) dated 12/09/24 documented R32 triggered secondary to the use of psychotropic medication to manage psychiatric illness and conditions. A licensed nurse monitored for side effects every shift, and the physician was to be notified of any abnormal findings. A pharmacist consultant would review medications monthly, and the physician would review medications with each visit. Contributing factors included current history of depression, anxiety, and bipolar disease. Risk factors included increased falls, impaired balance, and a potential for adverse effects of medication. The care plan would be reviewed to monitor the effectiveness of psychotropic medication and any adverse effects of medication. R32's Care Plan revised 12/13/24 documented R32 received psychotropic medications related to bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), depression, and anxiety. R32 would be free of psychotropic drug-related complications including movement disorder, discomfort, hypotension, gait disturbance, constipation, or cognitive and behavioral impairment. Nursing staff were to administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness every shift. Nurses were to consult with the pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly, Nursing staff were to monitor and record the occurrence of target behavior symptoms every shift. R32's EMR under the Orders tab documented the following physician's order: Risperidone (antipsychotic) oral tablet 0.5 milligrams (mg) give one tablet by mouth two times a day for delusions dated 07/24/24. A review of R32's EMR revealed no physician-documented rationale for the continued use of risperidone for delusions. On 12/16/24 at 07:15 AM, R32 lay on the couch in the Northeast hallway. R32 had a blanket and pillow. On 12/18/24 at 11:54 AM, LN H stated the appropriate indication for antipsychotic medication did not include dementia-related indications unless the resident had schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), Huntington's disease (a rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder), or Tourette's syndrome (condition of the nervous syndrome causing uncontrollable repetitive movements or unwanted sounds). On 12/18/24 at 12:23 PM, Administrative Nurse D stated only CMS-approved indications should be used for antipsychotic medications. She stated delusions were not an appropriate indication for risperidone. The facility's Psychotropic Drug Use policy revised July 2024 documented residents would not receive medications that were not clinically documented to treat a specific condition Residents, families, and/or the representative were involved in the medication management process. Residents who had not used psychotropic medications were not prescribed or given those medications unless the medication was determined to be necessary to treat a specific condition that was diagnosed and documented in the medical record. Medications not classified as anti-psychotic, anti-depressant, anti-anxiety, and hypnotic medication were not prescribed or administered as a substitution for another psychotropic medication unless there was a documented clinical indication consistent with clinical standard of practice. Consideration of the use of any psychotropic medication was based on a comprehensive review of the resident. This included evaluation of the resident's signs and symptoms to identify underlying causes. The facility failed to ensure an appropriate indication or a documented physician rationale for R32's risperidone fumarate medication. This placed R32 at risk for unnecessary psychotropic medications and related complications. - The Diagnosis tab of R52's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), aphasia (condition with disordered or absent language function), hemiparesis/hemiplegia (weakness and paralysis on one side of the body) affecting right dominant side, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), dysphagia (swallowing difficulty), hypertension (high blood pressure), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), and major depressive disorder (major mood disorder that causes persistent feelings of sadness). The Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of four which documented severely impaired cognition. The MDS documented R52 had an impairment on one side of her body. The MDS documented R52 needed partial to moderated assistance with dressing, toileting, and set up for eating. The MDS documented R52 received an antidepressant (a class of medications used to treat mood disorders) and antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) during the observation period. R52's Psychotropic Drug Use Care Area Assessment (CAA) dated 05/16/24 documented R52 was admitted to the facility with a psychotropic medication and the physician would monitor R52's medication routinely. The MDS documented staff would monitor side effects of the medication for R52. R52's Care Plan dated 08/05/2024 documented R52 had impaired cognitive function, dementia, or impaired thought processes related to dementia. R52 would be able to communicate basic needs daily. R52's plan of care documented staff would administer medications as ordered and monitor and document for side effects and effectiveness. Staff were to keep the R52's routine consistent and tried to provide consistent caregivers as much as possible to decrease confusion. R52's EMR under the Orders tab documented the following physician's order: Quetiapine fumarate (antipsychotic) 25 milligrams (mg) oral tablet give 0.5 tablet by mouth one time a day for behavioral disorders associated with dementia dated 07/17/24. A review of R52's EMR revealed no physician-documented rationale for the continued use of quetiapine fumarate for behavior disorders with dementia. On 12/16/24 at 07:32 AM, R52 sat at the dining room table eating her breakfast. On 12/18/24 at 11:54 AM, Licensed Nurse (LN) H stated the appropriate indication for antipsychotic medication did not include dementia-related indications unless the resident had schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), Huntington's disease (a rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder), or Tourette's syndrome (condition of the nervous syndrome causing uncontrollable repetitive movements or unwanted sounds). On 12/18/24 at 12:23 PM, Administrative Nurse D stated only CMS-approved indications should be used for antipsychotic medications. She stated that dementia was not an appropriate indication for quetiapine. The facility's Psychotropic Drug Use policy revised July 2024 documented residents would not receive medications that were not clinically documented to treat a specific condition Residents, families, and/or the representative were involved in the medication management process. Residents who had not used psychotropic medications were not prescribed or given those medications unless the medication was determined to be necessary to treat a specific condition that was diagnosed and documented in the medical record. Medications not classified as anti-psychotic, anti-depressant, anti-anxiety, and/or hypnotic medication were not prescribed or administered as a substitution for another psychotropic medication unless there was a documented clinical indication consistent with the clinical standard of practice. Consideration of the use of any psychotropic medication was based on a comprehensive review of the resident. This included evaluation of the resident's signs and symptoms to identify underlying causes. The facility failed to ensure an appropriate indication or a documented physician rationale for R52's quetiapine fumarate medication. This placed R52 at risk for unnecessary psychotropic medications and related complications.

The facility had a census of 58 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to keep Resident (R) 112's protected health information (PHI) private on a medication cart parked in the main dining room. This placed R112 at risk for impaired privacy. Findings included: - On 12/17/24 at 07:37 AM, an observation revealed a medication cart parked in the main dining room with a laptop computer sitting on the top, Licensed Nurse (LN) G walked away from the medication cart and into the dining room. LN G left the computer screen unlocked and open and R112's PHI was on the screen, visible to all who passed by the medication cart. The information visualized included R112's medications, date of birth, allergy information, and code status. On 12/18/24 at 11:55 AM, Licensed Nurse (LN) H stated the medication cart should be double locked, the computer screen should be closed, or the PHI should be hidden from view. On 12/18/24 at 12:20 PM, Administrative Nurse D stated she expected the nursing staff to close the computer screen before walking away from the medication cart. Administrative Nurse D stated the resident's PHI should never be left on the computer screen for unintended viewing. The facility's Confidentiality of Information and Personal Privacy policy last reviewed 08/2024 documented that the facility would protect and safeguard resident confidentiality and personal privacy. The facility failed to keep and maintain R112's privacy regarding PHI. This placed the resident at risk for impaired privacy.

The facility reported a census of 58 residents. The sample included 15 residents with 15 reviewed for care plan revisions. Based on interviews, observations, and record reviews, the facility failed to revise Resident (R) 33's Care Plan to reflect his increased behavioral episodes. The facility additionally failed to revise R32's Care Plan to reflect her sleeping preferences. This deficient practice placed both residents at risk for impaired care due to uncommunicated care needs. Findings Included: - The Diagnosis section within R33's Electronic Medical Records (EMR) included diagnoses of epilepsy (brain disorder characterized by repeated seizures), seizures (violent involuntary series of contractions of a group of muscles), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), insomnia (difficulty sleeping), aphasia (difficulty speaking), major depressive disorder (major mood disorder), and cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). R33's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. The MDS documented episodes of wandering behaviors one to three days during observation. The MDS documented upper and lower extremity impairments on one side of his body. The MDS documented he was dependent on staff assistance for oral hygiene, toileting, transfers, bed mobility, dressing, and bathing. R33's Cognitive Loss Area Assessment (CAA) completed 03/07/24 documented he had poor memory and recall. The CAA documented poor decision-making thought processes. The CAA documented he had impaired hearing requiring the use of sign language and electronic adaptive equipment. R33 was not triggered for behavioral CAA. R33's Care Plan initiated on 11/04/24 documented he was at risk for falls, cognitive decline, and activities of daily living (ADLs) deficit. The plan documented he required moderate to maximal assistance for his bed mobility, toileting, dressing, eating, personal hygiene, and bathing. The plan documented he required a sit-to-stand mechanical lift and staff assistance with transfers. The plan documented he was unable to ambulate in his Broda chair (specialized wheelchair with the ability to tilt and recline) without staff assistance. The plan documented he had a history of wandering but had no exit-seeking behaviors. The plan instructed staff to keep his routine consistent to prevent confusion. R33's EMR under Progress Notes revealed a note on 11/22/24. The note documented that R33 became physically aggressive while staff attempted to transfer him from his Broda chair to the shower chair. The note documented he was resistant to care and hitting staff. R33's EMR under Progress Notes revealed a note on 11/27/24. The note documented that R33 was resistive towards care. The note documented he began to hit, slap, and kick staff. The note documented that staff made several attempts to perform care with no success. The note documented that R33's representative was notified and requested to be called each time he refused care or became aggressive. R33's EMR under Progress Notes revealed a note on 12/07/24. The note documented staff attempted to get R33 up for the day and he became physically aggressive. The note documented that R33 began to hit, kick, and twist staff members' arms. The note documented that R33's representative was notified. R33's representative requested his neurologist be notified of his behaviors. R33's EMR under Progress Notes revealed a note on 12/08/24. The note documented that R33 was hitting, punching, and grabbing staff when they attempted to get him up for the morning. The note documented staff gave him more time and he eventually allowed them to assist him. On 12/17/24 at 08:20 AM, R33 sat in his Broda chair in the dining room. R33 was assisted by staff during his breakfast. On 12/18/24 at 11:37 AM, Certified Nurse's Aide (CNA) M stated R33 could get aggressive during care and transfers. She stated he could be resistant to care and had decreased awareness due to his cognitive impairment and inability to hear. She stated staff should explain what was going to happen to him before treatment or care and allow him to express his opinions. She stated that usually, his refusal is in the morning time. She stated staff contacted his representative to assist during behaviors. On 12/18/24 at 11:54 AM, Licensed Nurse (LN) H stated R33 sometimes had behaviors. She stated staff were to communicate clearly with him at eye level. She stated that staff should give him time to process and explain what would happen to him, before attempting to move him. She stated he could be aggressive, and staff should give R33 time and reapproach him at a later time if he was agitated. She stated that staff should offer him choices and listen to his frustrations. She stated he has been known to be physically aggressive and the care plan should reflect interventions and triggers related to his behaviors. On 12/18/24 at 12:23 PM, Administrative Nurse D stated R33 behaviors were not frequent and more sporadic. She stated he occasionally had behaviors, but staff were usually able to calm him down and get the care completed. She stated the care plan should reflect behavioral interventions and possible triggers to assist with behaviors. The facility's Care Plans policy revised 03/2024 documented a comprehensive assessment would be completed to identify treatment goals and interventions based on the assessment findings. The policy documented that each resident's care plan would reflect the resident's current conditions and changes toward their care goals. The facility failed to revise R33's Care Plan to reflect increased behavioral concerns and interventions. This deficient practice placed R33 at risk for impaired care due to uncommunicated care needs. 49634 - The Diagnosis tab of R32's Electronic Medical Record (EMR) documented diagnoses of anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), dementia (a progressive mental disorder characterized by failing memory and confusion), protein-calorie malnutrition, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), chronic pain, hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), insomnia (inability to sleep), chronic pain, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and dysuria (painful urination). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which documented severely impaired cognition. The MDS documented R32 required substantial to maximum assistance for eating, bathing, and dressing; R32 was dependent on staff for oral hygiene. The Cognitive Loss/Dementia Care Assessment Area (CAA) dated 12/09/24 triggered secondary to R32's BIMs score. Contributing factors included dementia. Risk factors included self-care deficits, falls and injuries, incontinence, decreased socialization, skin breakdown, and weight loss. The care plan would be reviewed to maintain cognitive status, activities of daily living (ADLs) status, continence status, mobility, encourage activity participation, maintain communication, decrease fall, pressure ulcer risk, and maintain weight. R32's Care Plan revised 12/13/24 documented she had a psychosocial well-being problem related to lack of motivation. R32 would verbalize feelings related to emotional state. Staff was to allow R32 time to answer questions and to verbalize feelings perceptions and fears as needed. Staff were to encourage participation from the resident, who depended on others to make own decisions. Nursing staff were to monitor R32's feelings relative to unhappiness, anxiousness, and crying, and provide opportunities for the resident and family to participate in care. Staff were to remove the resident to a calm safe environment and allow R32 to vent and share feelings. R32's Care Plan lacked preferences or indications for sleeping and napping on the couches in areas other than R32's room and when R32 yelled out for help. On 12/16/24 at 07:15 AM, R32 lay on the couch in the Northeast hallway. R32 had a blanket and pillow. R32 was yelling out help me. On 12/16/24 at 01:12 PM, R32 lay on the couch in the Northeast hallway. R32 had a blanket and was reaching out her hand and asking for help. On 12/16/24 at 11:33 AM, R32 lay on the couch in the hallway next to the dining room. R32 had her eyes shut and was covered with a blanket. On 12/18/24 at 11:37 AM, Certified Nurses Aid (CNA) M stated she did not have access to the Kardex (a nursing tool that gives a brief overview of the care needs of each resident). CNA M stated the nurse in charge keeps all the CNAs updated on any changes with each resident. CNA M stated all the nursing staff know R32 likes to sleep on the couches, and at times yells for help. CNA M said staff could check on R32 to ensure she did not need help. CNA M stated she was unsure if R32's preferences were on her care plan. On 12/18/24 at 11:55 AM, Licensed Nurse (LN) H stated all nursing staff have access to the care plan and said the care plan identifies resident-specific information. LN H stated that R32 liked to take naps on couches and would occasionally yell out. She stated she did not believe R32's preferences were part of her care plan. On 12/18/24 at 12:18 PM, Administrative Nurse D stated the care plans were updated by the MDS coordinator; she stated the core group of administrative staff discussed what should be placed on the care plans. She stated she saw R32 sleeping on the couch at times and yelling for help. Administrative Nurse D stated she did not believe R32's preference of sleeping on the couch or yelling was care planned. The facility's Comprehensive Care Plan policy revised March 2024 documented a comprehensive, person-centered care plan that includes objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The facility failed to revise R32's Care Plan with preferred preferences for napping on the couches in common areas or for the behavior of yelling out for help. This deficient practice placed R32 at risk for impaired care due to uncommunicated care needs.

The facility identified a census of 58 residents. The sample included 15 residents with two residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing heel protectors or boots were in place for Resident (R) 34 who had a pressure-related injury on her left heel. These deficient practices placed R34 at risk for complications related to further skin breakdown and worsening of pressure ulcers. Findings included: - R34's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of a pressure ulcer of the left heel, dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of three which indicated severely impaired cognition. The MDS documented R34 was at risk of developing pressure ulcers and currently had an unhealed pressure ulcer. The MDS documented R34 had a pressure-reducing device on her bed, nutritional or hydration interventions in place to manage skin problems, and pressure ulcer care in place. R34's Pressure Ulcer Care Area Assessment (CAA) dated 11/08/24 documented R34 had developed a new pressure ulcer related to mobility impairment. R34's Care Plan dated 11/04/24 documented staff would apply bilateral heel protectors to R34's feet when she was out of bed. The plan of care also documented staff would apply bilateral Thera-boots when she was in bed. R34's EMR under the Orders tab revealed the following physician orders: Ensure R34 was wearing bilateral heel protectors during the day and bilateral Thera-boots at night, dated 11/08/24. On 12/17/24 at 11:00 AM, R34 sat upright in her Broda chair (specialized wheelchair with the ability to tilt and recline) in the hallway outside the TV room with socks on her feet and no heel protectors in place. Certified Nurse Aide (CNA) N pushed her in the Broda chair with her feet sliding on the floor to the dining room. On 12/17/24 at 04:07 PM, R34 lay awake on her bed. She was not wearing Thera-boots and her heels laid directly on the bed. A pressure-reducing boot laid on the floor of her open closet. On 12/18/24 at 11:37 AM, CNA M stated she would know which residents were to have pressure-reducing measures in place by the Kardex (a nursing tool that gives a brief overview of the care needs of each resident), the charge nurse information, and if the heel protectors were in the room. On 12/18/24 at 11:55 AM, Licensed Nurse (LN) H stated the pressure-reducing devices were listed on the Treatment Administration Record (TAR) and staff would sign off every shift that the items were in place. LN H said usually the CNAs would apply the heel protectors or boots. On 12/18/24 at 12:20 PM, Administrative Nurse D stated she expected R34's heel protectors and boots to be in place. Administrative Nurse D stated she expected the nurse to ensure the pressure-reducing devices were in place as ordered. The facility's Support Surface Guidelines policy last revised September 2024 documented that the purpose of this procedure was to provide guidelines for the assessment of appropriate pressure-reducing and relieving devices for residents at risk of skin breakdown. The facility failed to ensure pressure-reducing heel protectors and boots were in place for R34 who had a pressure injury on her left heel. This deficient practice placed R34 at risk for complications related to skin breakdown and worsening pressure ulcers.

The facility reported a census of 58 residents. The sample included 15 residents with five reviewed for accidents. Based on interviews, observations, and record review, the facility failed to ensure a safe care environment related to the use of Resident (R)35's fall prevention interventions for his wheelchair. This deficient practice placed R35 at risk for preventable falls and injuries. Findings included: - The Diagnosis tab within R35's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) restlessness, agitation, major depressive disorder (major mood disorder), muscle spasms, muscle weakness, and repeated falls. R35's Quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. The MDS documented he required partial to moderate assistance with dressing, transfers, bed mobility, bathing, personal hygiene, and personal hygiene. The MDS documented he could independently use his wheelchair. The MDs documented two or more non-injury falls since his last assessment. R35's Falls Care Area Assessment (CAA) completed 05/01/24 documented he had a significant history of falls and required assistance. The CAA documented he did not always comply with asking for assistance. The CAA documented he had difficulty maintaining a standing position, even with a mobility aid or personal assistance. The CAA documented a care plan will be implemented to address his fall risks and provide interventions. R35's Care Plan initiated 07/23/24 documented he was at risk for a decline in his activities of daily living (ADLs) and falls related to his medical diagnoses. The plan documented he required touch assistance and supervision when transferring between surfaces. The plan documented he could not safely transfer himself without staff assistance, and chair alarms were put into place. The plan documented he used a wheelchair for mobility. The plan instructed staff to ensure a Dycem (non-slip mat used for stabilization and gripping to prevent slipping) was placed in his recliner and wheelchair to prevent slips and falls. On 12/17/24 at 10:20 AM, R35 sat in his room in the recliner. His fall alarm was in place in the chair and was functioning. His recliner had a Dycem mat directly underneath him. An inspection of his wheelchair revealed a pressure relieving mat but lacked a Dycem mat. On 12/17/24 at 01:25 PM, R35 sat in his wheelchair in the small dining area next to the main dining room eating his meal. R35's wheelchair had his pressure mat but lacked a Dycem mat. On 12/18/24 at 12:03 PM, R35 sat in his room in his wheelchair. R35 removed the blanket and Dycem mat from his recliner. He stated he was going to lunch. R35 folded the Dycem mat and placed it on his bed. An inspection of his wheelchair revealed no Dycem mat in place under him. On 12/18/24 at 11:37 AM, Certified Nurse's Aide (CNA) N stated R35 was impulsive and would often transfer himself without staff knowing. She stated he was a fall risk due to his cognitive impairment and limited mobility. She stated he could wheel himself but needed assistance with transfers. She stated he should have a Dycem mat in his recliner but was not sure about his wheelchair. She was not sure if he had one for each or if it was moved every time he transferred. On 12/18/24 at 12:23 PM, Administrative Nurse D stated she was not sure if R35 had two Dycem mats but stated staff were expected to ensure the Dycem mats were in place every time he transferred or moved. The facility's Assessing Falls policy revised August 2024 documented the facility would assess each resident's functional abilities and identify pertinent interventions to prevent subsequent falls. The policy documented the facility would provide ongoing monitoring and assessment of individuals at risk for falls. The facility failed to ensure R35's care-planned fall inventions were in place, related to his wheelchair's Dycem mat. This deficient practice placed R35 at risk for preventable falls and injuries.

The facility identified a census of 58 residents. The facility identified one resident on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure the blood pressure cuff, pulse monitor, and oxygen saturation equipment were sanitized after each resident's use. This deficient practice placed the residents at risk for infectious diseases. Findings included: - On 12/16/24 at 07:47 AM, License Nurse (LN) I obtained a resident's blood pressure and pulse in the main dining room. LN I did not sanitize the pulse monitor or blood pressure cuff before or after resident use. On 12/17/24 at 07:18 AM, LN G obtained a resident's blood pressure, oxygen saturation, and pulse in the main dining room. LN G did not sanitize the blood pressure cuff, oxygen saturation monitor, or pulse monitor before or after resident use. On 12/18/24 at 07:42 AM, LN G obtained the resident's blood pressure and pulse monitoring in the main dining room. LN G did not sanitize the blood pressure cuff or the pulse monitor before and after resident use. On 12/18/24 at 11:55 AM, LN H stated all shared equipment was to be sanitized between resident use. LN H stated the facility had a sanitizer spray all staff could use. On 12/18/24 at 12:18 PM, Administrative Nurse D stated it was the facility's expectation was all nursing staff sanitize shared equipment after each resident's use. The facility's Sanitizing Shared Equipment dated September 2024 documented Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC. Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Semi-critical items consist of items that may encounter mucous membranes or non-intact. Non-critical items are those that encounter intact skin but not mucous membranes. Non-critical items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions. The facility failed to ensure the blood pressure cuff, pulse monitor, and oxygen saturation equipment was sanitized after each resident's use. These deficient practices placed the residents at risk for infectious diseases.

The facility identified a census of 58 residents. The sample included 15 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer and administer or obtain informed declinations for the Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial pneumonia infections) vaccination for Resident (R) 32 and R52. This placed the residents at increased risk for complications related to pneumonia. Findings included: - Review of R32's clinical record revealed the PCV13 was administered on 11/30/17, and the PSV23 was administered on 08/30/13. R31's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician-documented contraindication. Review of R53's clinical record revealed the PCV13 was administered on 09/27/18, and the PSV23 was administered on 09/02/19. R53's clinical record lacked documentation the PCV20 was offered or declined and lacked documentation of a historical administration or a physician-documented contraindication. On 12/18/24 at 12:18 PM, Administrative Nurse D stated the facility relied on WEB IZ (database-driven immunization registry system) to prompt the facility when an immunization needed to be given. She stated the facility did not offer the PCV20 if a resident had the PCV13 and PCV23. Administrative Nurse D stated R32 and R53 were not offered the PCV20. The facility did not provide an immunization policy. The facility failed to offer the PCV20 or obtain informed declinations for R32 and R53. This placed the residents at increased risk for complications related to pneumonia.

The facility identified a census of 60 residents. The sample included three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to provide a safe environment, free from preventable accidents for Resident (R) 1. On 05/29/24 at 12:15 PM, Transportation FF strapped R1's wheelchair into the facility's transportation van but did not place the seatbelt around R1. When Transportation FF braked before making a turn, R1 slid out of her wheelchair onto the van floor. R1 was taken to the hospital for evaluation where she was found to have left tibia (bone in the lower leg) and fibula (bone in the lower leg) fractures as a result of the accident. This failure placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of pain, fibromyalgia (condition of musculoskeletal pain, spasms, stiffness, fatigue, and severe sleep disturbance), and weakness. The Admission Minimum Data Set (MDS) dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of 15. R1 had impairment on both sides in upper and lower extremities and she used a wheelchair. R1 did not have any falls since admission. The Activities of Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 04/22/24, documented R1 had chronic pain and needed assistance with most ADLs. The Falls CAA dated 04/22/24, documented R1 used a sit-to-stand (mechanical lift) lift for transfers as she was not strong enough to bear weight while transferring with staff. R1's Care Plan dated 04/10/24 and discontinued 05/29/24, documented R1 could not complete her care on her own because she had physical challenges and required two helpers providing more than half the effort to transfer with the stand-up lift. R1's Care Plan dated 05/30/24, documented R1 had the potential to fall down and hurt herself and directed an Occupational Therapy (OT) evaluation was ordered for a Broda (specialized wheelchair with the ability to tilt and recline) chair for all transports outside of the facility as of 05/29/24. R1's Care Plan dated 06/03/24, documented R1 could not complete care on her own because of physical challenges; she transferred with two helpers providing more than half the effort with a full body lift. The facility's investigative report, dated 06/04/24, documented on 05/29/24 at 01:10 PM, Administrative Nurse E, and Administrative Nurse F notified Administrative Nurse D that there had been an accident with a possible injury in the facility's van involving R1. Transportation FF was driving the facility's van when he pushed the van brake to turn into a parking lot. Upon pushing on the brake, R1 slid out of her wheelchair. Transportation FF pulled over to assist R1 and R1's friend called 911. The ambulance arrived and transported R1 to the emergency room (ER) for evaluation. At 02:45 PM, Administrative Nurse E received a call from R1's representative stating that R1 had tibia and fibula fractures. In a notarized Witness Statement on 05/29/24, Transportation FF stated he took R1 to the hospital on 05/29/24. He tied the front and rear straps to R1's wheelchair which he always did. He stated he was asked to stop at a fast-food restaurant and when they approached the business, he had to stop quickly. Transportation FF stated the next thing he knew, R1 was sliding out of the wheelchair onto the floor. He stated he stopped and assisted R1 but R1's friend was sure there were broken bones. He stated the ambulance came and took R1 out of the van and to the hospital. In a notarized Witness Statement on 05/29/24, Transportation EE stated on 05/29/24 at 12:15 PM, Administrative Nurse E went to her office and asked if she had heard from Transportation FF. She stated that R1's representative had called the facility regarding an accident. Transportation EE stated she called Transportation FF, but he did not answer so she called R1's friend. She stated that R1's friend reported that R1 slipped out of her wheelchair when Transportation FF put on the brakes and the ambulance was called. The Computed Tomography (CT- scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) Ankle Left without Intravenous (into a vein) Contrast report, dated 05/29/24, documented R1 had comminuted (fracture that occurs in at least two places) fractures in the distal (away from the farthest point of origin or attachment) fibula, comminuted fractures in the posterior (back) distal tibia, comminuted fractures in the anterior (front) distal tibia, and comminuted fractures in the central and superior (toward the head end of the body) medial malleolus (bony projection that extends downward from the medial surface of the lower end of the tibia). On 06/10/24 at 01:17 PM, R1 lay in her bed and watched television. She stated on 05/29/24, her wheelchair was strapped to the floor, but a strap was not placed across her lap or body. R1 stated the driver hit the brakes of the van fast and she slid clear out of her wheelchair and her left ankle was twisted underneath her. She stated it was very painful and she could feel something was wrong immediately. On 06/10/24 at 12:38 PM, Transportation FF stated on 05/29/24, he took R1 and her friend to an appointment and afterward, they asked to go through a drive-through for food. He stated he had to stop quickly and the next thing he knew, R1 was out of her wheelchair and onto the floor. Transportation FF stated he stopped the van and was going to lift her up but could not lift her then her friend called for an ambulance. He stated that day, he had strapped R1's wheelchair down on the front and the back and locked the wheelchair brakes but he did not use a seatbelt because she was large, and he did not know if he could get the seatbelt around her. Transportation FF stated they were not going very far so he did not think too much about a seatbelt. He stated there should be a seatbelt on if in a wheelchair or in a van seat. On 06/10/24 at 12:51 PM, Transportation EE stated on 05/29/24, she called R1's friend who told her the facility van was turning into the fast-food restaurant when R1 was suddenly on the floor. She stated the four hooks under the wheelchair were fastened and the resident should have been buckled in. She stated residents were expected to be buckled in if they were not in a wheelchair. Transportation EE stated she had not received training that it was necessary to buckle the resident in if they were in a wheelchair before the incident but said she had received this training since the incident. She stated residents in wheelchairs were buckled in with four straps on the wheelchair and a lap belt across the resident. On 06/10/24 at 01:00 PM, Administrative Nurse D stated on 05/29/24, she was informed the seatbelt was not on R1, but the wheelchair was buckled in. She stated when a resident in a wheelchair was loaded onto the facility's van, the wheelchair's wheels were locked and the wheelchair was locked into the van then a seatbelt went across the resident. Administrative Nurse D stated she expected the seatbelt to be buckled. On 06/10/24 at 01:44 PM, Administrative Staff A stated he expected laws and regulations to be followed and seatbelts to be worn and properly secured. He further stated he expected the wheelchairs to be properly secured and the seat belt used. The facility's Transportation Van or Bus Policy, dated April 2024, directed the facility to complete transportation van/bus competency training for all employees or volunteers who transport or secure the elder's mobility device in the facility van or bus. The policy directed the driver to obey all laws, rules, and regulations. On 06/10/24 at 02:49 PM Administrative Staff A received a copy of the Immediate Jeopardy Template and was informed the facility's failure to provide a safe environment, free from preventable accidents for R1 placed R1 in immediate jeopardy. The facility completed the following corrective actions by 05/30/24: An OT evaluation for R1 was ordered on 05/29/24. All facility transportation was suspended on 05/29/24 until training and competencies were completed by transportation staff. R1's Care Plan was updated on 05/30/24. Transportation EE and Transportation FF completed transportation competencies on 05/30/24. Due to the corrective measures implemented and completed prior to the onsite survey, this deficient practice was cited as past noncompliance. The scope and severity remained at a J.

The facility had a census of 66 residents. The sample included 18 residents, with 10 reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure staff provided Resident (R)52 with his call light when he went to bed, resulting in a fall in which R52 obtained a right trimalleolar ankle fracture (a break in the lower leg section that form your ankle joint). The facility further failed to assess residents for safe lift chair use, after falls out of a lift recliner for R52 and R36. The facility failed to follow R36 and R46's plan of care which resulted in falls and failed to implement meaningful, resident centered interventions for R14 and R57. This placed the residents at risk for further falls and avoidable injuries. Findings included: - The Electronic Medical Record (EMR) for R52 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), neurocognitive disorder with Lewy bodies (a type of progressive dementia that leads to a decline in thinking, reasoning, and independent function), tremors (an involuntary quivering movement), and Parkinson's disease (a disorder of the central nervous system that affects movement). The Admission Minimum Data Set (MDS), dated [DATE], documented R52 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, ambulation, wheelchair mobility, toileting, and personal hygiene. The MDS further documented R52 had unsteady balance, no functional impairments, and had no falls. The Annual MDS, dated [DATE], documented R52 had moderately impaired cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, and toileting. The MDS further documented R52 had unsteady balance, no functional impairment, and had two or more non-injury falls. The Fall Care Area Assessment [CAA], dated 05/15/23, documented R52 wore non-skid shoes during the day and had a large landing mat in front of his recliner. The Fall Assessments, dated 07/14/22 and 05/15/23, document R52 at risk for falls. The Fall Care Plan, dated 05/19/23, initiated on 07/14/22, directed staff to remind him to ask for help, report changes in his abilities to the nurse, monitor his safety during activities. An update, dated 08/02/22, directed staff to ensure the skid strips were in place on the floor in front of R52's recliner. An update, dated 11/18/22, directed staff to ensure R52 wore non-skid shoes during the day. An update, dated 11/21/22, directed staff to ensure there was a landing mat in front of R52's recliner when he was in it. An update, dated 05/22/23, directed staff to monitor R52 every 30 minutes and make sure his bed was in low position. The Fall Investigation, dated 08/02/22 at 12:25 PM, documented R52 slid out of his recliner and was on the floor in front of the recliner, with his legs out in front of him. The investigation further documented the fall was unwitnessed and R52 slid onto the floor when he raised his lift recliner into an upright position. It directed staff to place skid strips in front of the recliner. Review of the EMR lacked documentation an assessment was completed to determine R52's safe use of a lift chair. The Fall Investigation, dated 09/03/22 at 04:42 PM, documented R52 slid out of his recliner and obtained a laceration (cut) to the bridge of his nose and his forehead. The investigation documented staff reviewed safety measures with R52 and instructed him to call for assistance and directed him not to elevate his chair. The investigation documented staff felt it was doubtful R52 would retain the information they provided. The EMR lacked documentation an assessment was completed to determine R52's safe use of a lift chair. The Fall Investigation, dated 11/19/22 at 10:43 PM, documented R52 slid out of his recliner and staff observed him lying on the floor on his back. The investigation further documented the lift chair remote was clearly marked with up and down arrows on it. The investigation documented staff encouraged R52 to call for assistance prior to raising the chair up, but with R52's moderate impaired cognition, he may not always remember to call for assistance. The investigation directed staff to place a landing pad in front of R52's lift chair. The Fall Investigation, dated 05/20/23 at 07:45 AM, documented R52 was found lying on his back on the left side of the bed with his head slightly up on a bedside table and his legs straight out in front of him. The investigation further documented R52 had an abrasion (scrape) to the outer right ankle which measured 4.0 centimeters (cm) by 2.0 cm, and an abrasion to the right side of his head with a small amount of bleeding present, which measured 9.0 cm by 4.0 cm. The investigation documented R52 complained of right ankle pain; there was swelling but no deformity noted. R52 stated he was getting up to get his call light, that was still in his recliner, to call for assistance and fell . The investigation documented R52's call light should always be in reach. The investigation further documented the facility sent R52 to the emergency room for evaluation and he returned at 12:00 PM with non-weight bearing orders, a splint, and orders to see an orthopedic doctor for surgical repair, as he had a right trimalleolar ankle fracture. The Witness Statement, dated 05/20/23 documented Certified Nurse Aide (CNA) M reported R52 used his call light to tell staff he was ready to go to bed. CNA M documented she was training another CNA and together, they assisted R52 from the recliner to his bed. CMA M stated staff forgot to give R52 his call light. CNA M further documented he did not check on R52 after placing him in bed because it was almost at the end of the shift. The Physician's Order, dated 05/25/23, directed staff to ensure strict elevation of R52's right foot/ankle, non-weight bearing of his right lower extremity, keep splint in place, and plan for a surgical fixation on 05/31/23. On 06/21/23 at 03:00 PM, observation revealed R52 sat in his recliner with his feet elevated, and a call light at his side. There was a fall mat in front of the recliner. Further observation revealed R52 had a fracture boot on his right leg. R52's representative was in the room and stated R52 broke his leg because he did not have his call light, when he was in bed. On 06/26/23 at 12:30 PM, observation revealed CMA R and CNA N attached the sling underneath R52 to the full body lift. CNA M stood behind R52 to maneuver him to the recliner as CMA R used the lift controls to raise him up and take him to his recliner. Further observation revealed CMA R lowered R52 into his recliner, elevated his feet, gave him his call light, and put the fall mat in front of the recliner. On 06/26/23 at 12:30 PM, CNA M stated R52 broke his leg trying to get to his call light when he was in bed. CNA M stated staff check on R52 every 30 minutes since the fall. CNA M further stated R52 had other falls out of his recliner when he would elevate the chair, but not since he broke his leg. On 06/26/23 at 03:30 PM, Licensed Nurse (LN) G stated R52 had falls out of his recliner and staff tried to put a chair alarm in the recliner but as R52 elevated the recliner, the alarm pad would fall out, so staff took his alarm away. LN G further stated R52 had a fall with a fracture and the interventions after the fall were a low bed, 30-minute checks, and a fall mat in front of the recliner. LN G said staff made sure R52 had his call light and staff documented that, every shift, in the Medication Administration Record. On 06/27/23 at 09:45 AM, Administrative Nurse D stated staff did not follow R52's care plan and did not give R52 his call light, resulting in a fall where R52 broke his leg. Administrative Nurse D further stated staff tried different interventions to prevent falls for R52 when he was in his recliner. Administrative Nurse D verified the facility had not completed an assessment for the safe use of lift chairs. The facility's undated Falls and Fall Risk Assessment policy documented staff would document risk factors for falls in the resident's record and the physician would identify medical conditions affecting fall risks. The staff would evaluate, and document falls that occur while the individual was in the facility, identify them as witnessed or unwitnessed, and attempt to define possible causes of the fall. Based on the assessments, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If underlying causes could not be readily identified or corrected, staff would try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason was identified for its continuation. The staff would monitor and document the individual's response to interventions intended to reduce falls or the consequences of falling. If interventions have been successful in preventing falling, the staff would continue with current approaches or reconsider whether these measures were still needed if the problem that required the interventions had resolved. If the resident continued to fall, the staff and physician would re-evaluate the situation and consider other possible reasons for the resident's falls and would reevaluate the continued relevance of current interventions. The facility failed to provide a safe environment for R52 when staff failed to place his call light within reach. As a result, R52 attempted to get his call light and subsequently fell and broke his leg. The facility further failed to assess R52's ability to safely use a lift chair after multiple lift chair related falls. - The Electronic Medical Record (EMR) for R36 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (a disruption of blood flow to the brain due to problems with the blood vessels that supply it), major depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R36 had severely impaired cognition and required extensive assistance of two staff for bed mobility, toileting, and extensive assistance of one staff for transfers, ambulation, dressing, and personal hygiene. The assessment further documented R36 had unsteady balance, upper and lower functional impairment on one side, and had two or more non-injury falls. The Quarterly MDS, dated [DATE], documented R36 had severely impaired cognition and required extensive assistance of two staff for bed mobility, toileting, and extensive assistance of one staff for transfers, ambulation, mobility in his wheelchair, dressing, and personal hygiene. The MDS further documented had unsteady balance, upper and lower functional impairment on one side, and one non-injury fall. The Fall Assessments, dated 11/25/22 and 05/02/23, documented R36 was at risk for falls. The Fall Care Plan, dated 05/02/23, initiated on 07/25/22, directed staff to request a therapy screen if needed, use a bed alarm, stay with the resident during toileting, make sure his important items were within reach, assist R36 with transfers or when he walked, remind R36 to ask for help, and place a mat on the floor beside the bed in case he rolled out. The update, dated 01/16/23, directed staff to visualize R36 in the mornings at shift change. The update, dated 01/26/23, directed staff to use an alarm on his chair. The Fall Investigation, dated 01/26/23 at 07:45 PM, documented staff heard someone yelling for help and was R36 was discovered on the floor holding on to the footrest of the recliner, which was slightly open. The note further documented Social Services X and a Certified Nurse Aide (CNA) got R36 up and took him into the bathroom before a nurse could assess him for injuries. The investigation documented, due to R36's cognition, he did not always comprehend what was safe and had attempted to get up on his own without calling for assistance after his guest left. The Fall Investigation, dated 04/29/23 at 07:00 PM, documented R36 slid out of his recliner and education was provided to staff to make sure R36's chair alarm was under him when he is in his recliner. The investigation further documented R36 had severely impaired cognition and did not comprehend what was safe. The Fall Investigation, dated 05/28/23 at 09:30 PM, documented R36 was found on the floor in his room with the recliner controller in his hand; the chair was elevated in an up position. R36's drinks were spilled all over the floor, and he was still covered with a blanket he had on while in his recliner. The intervention directed to keep the remote for the recliner out of the resident's reach. The investigation further documented, R36 had severely impaired cognition and did not comprehend what was safe; it was felt by administration that keeping the recliner controller out of reach was not the appropriate intervention for this resident. R36's EMR lacked evidence the facility assessed for safe use of a lift chair. On 06/22/23 at 11:50 AM, observation revealed CNA O and CNA MM attached the sit to stand lift sling around the resident and hooked the sling to the lift. R36 HELD onto the handles and STAFF stood him up to transfer him to the toilet. On 06/22/23 at 11:55 AM, CNA O stated R36 used to sit in his room but since he had falls, staff kept him in the living room area unless his family was visiting. CNA O stated R36 had falls out of his recliner; he would elevate the recliner and slide out. On 06/26/23 at 12:22 PM, Licensed Nurse (LN) H stated R36's falls were out of his recliner, so now R36 stayed out in the living room area. On 06/27/23 at 09:45 AM, Administrative Nurse D stated R36 had falls from his recliner and the facility had looked into doing the lift chair/recliner assessments. She said staff keep R36 in the living room area unless his family was with him in his room. The facility's undated Falls and Fall Risk Assessment policy documented staff would document risk factors for falls in the resident's record and the physician would identify medical conditions affecting fall risks. The staff would evaluate, and document falls that occur while the individual was in the facility, identify them as witnessed or unwitnessed, and attempt to define possible causes of the fall. Based on the assessments, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If underlying causes could not be readily identified or corrected, staff would try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason was identified for its continuation. The staff would monitor and document the individual's response to interventions intended to reduce falls or the consequences of falling. If interventions have been successful in preventing falling, the staff would continue with current approaches or reconsider whether these measures were still needed if the problem that required the interventions had resolved. If the resident continued to fall, the staff and physician would re-evaluate the situation and consider other possible reasons for the resident's falls and would reevaluate the continued relevance of current interventions. The facility failed to assess cognitively impaired R36 for safe lift chair use and failed to follow his plan of care which resulted in falls. This placed the resident at risk for further falls and injury. - The Electronic Medical Record (EMR) for R46 documented diagnoses of dementia without behavioral disturbances (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and seizures (violent involuntary series of contractions of a group of muscles). The Annual Minimum Data Set (MDS), dated [DATE], documented R46 had severely impaired cognition and required extensive assistance of two staff for transfers, dressing, toileting, and extensive assistance of one staff for bed mobility, ambulation, and personal hygiene. The assessment further documented R46 had unsteady balance, no functional impairment, had one fall with injury, and used a bed, chair, and wander alarm daily. The Quarterly MDS, dated [DATE], documented R46 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and extensive assistance of one staff for mobility in her wheelchair, dressing and personal hygiene. The assessment further documented R46 had unsteady balance, no functional impairment, two or more non injury falls, and used a bed alarm daily. The Fall Assessments, dated 10/13/22 and 05/22/23 documented R46 at risk for falls. The Care Plan, dated 05/23/23, initiated 07/27/22, directed staff to request a therapy screen if needed, monitor her toileting program, make sure important items are within reach, keep room well lit, use a bed and chair alarm, use a standard walker and use agait belt with one staff assistance. The update, dated 01/23/23, directed staff to not leave R46 unattended in the dining and activity room. The Fall Investigation, dated 10/08/22 at 04:45 PM, documented R46 was in the bathroom with staff and as the Certified Nurse Aide (CNA) pulled down R46's pants, R46 fell forward, landed on her knees, and sustained an abrasion (scrape) to her right knee. The investigation further documented R46's walker was in the southwest corner of the restroom away from the resident and when the nurse asked where the walker was positioned at the time of the fall, the CNA stated it was where it was located when the nurse entered the room. The nurse asked the CNA why it was not in front of the resident with the brakes locked, the CNA could not give an answer. The investigation documented the CNA was educated to have the resident's walker in front of her and the brakes locked when she was standing. The Fall Investigation, dated 06/01/23 at 06:05 PM, documented R46 was in the activity room in her wheelchair. Staff walked out of the room and when they returned, R46 scooted out of the wheelchair and was seated on the wheelchair pedals. The investigation documented R46 had severely impaired cognition and did not comprehend what was safe and staff were educated to follow R46's care plan. On 06/22/23 at 12:25 PM, observation revealed CNA O and CNA MM placed the sling of the sit to stand lift around the resident, attached it to the lift, and told R46 to hold onto the handles of the lift. Further observation revealed CNA O had to assist R46 by taking her hands and putting them on the lift handles to hold on. Continued observation revealed CNA MM stood R46 up and transferred her onto the toilet. On 06/22/23 at 12:25 PM, CNA O stated R46 used to ambulate with her walker but can no longer do so and now used a Broda chair (positioning chair) for mobility. CNA O further stated R46 continued to try to self-transfer as she did not understand why she cannot do things on her own; staff were not to leave her anywhere unattended. On 06/26/23 at 02:16 PM, Licensed Nurse (LN) H stated R46 would fall out of her wheelchair prior to having the Broda chair and staff were to be with her at all times during activities and not leave her in a room unattended. On 06/27/23 at 09:45 AM, Administrative Nurse D verified staff had not followed the care plan and R46 had falls. The facility's undated Falls and Fall Risk Assessment policy documented staff would document risk factors for falls in the resident's record and the physician would identify medical conditions affecting fall risks. The staff would evaluate, and document falls that occur while the individual was in the facility, identify them as witnessed or unwitnessed, and attempt to define possible causes of the fall. Based on the assessments, the staff and physician would identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. If underlying causes could not be readily identified or corrected, staff would try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason was identified for its continuation. The staff would monitor and document the individual's response to interventions intended to reduce falls or the consequences of falling. If interventions have been successful in preventing falling, the staff would continue with current approaches or reconsider whether these measures were still needed if the problem that required the interventions had resolved. If the resident continued to fall, the staff and physician would re-evaluate the situation and consider other possible reasons for the resident's falls and would reevaluate the continued relevance of current interventions. The facility failed to follow R46's plan of care which resulted in falls. This placed the resident at risk for further falls and injury. 37450 - The Medical Diagnosis section in R14's Electronic Medical Record (EMR) included diagnoses of dorsalgia (back pain), scoliosis (curvature of the spine), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, fatigue, kyphosis (outward curvature of the spine), cervicalgia (neck pain), fracture of left clavicle (collarbone), shortness of breath, and panic disorder. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R14 had intact cognition, and required extensive assistance of one staff for activities of daily living (ADL). The MDS recorded R14 was not steady and was only able to stabilize with human assistance. R14had occasional incontinence of urine, received scheduled and as needed pain medication, and was short of breath with exertion. The MDS further documented R14 had one fall with no injury and one fall with injury. The Activity of Daily Living Care Area Assessment (CAA), dated 01/16/23, documented R14's family chose comfort care due to R14's decline. R14 needed extensive assistance with most of her ADL, and was failing to thrive. R14 had falls on 08/15/22 and 10/14/22. The CAA further documented R14 took two antidepressants (class of medications used to treat mood disorders), a Fentanyl (narcotic pain medication) patch, and had as needed pain and antianxiety (class of medications that calm and relax people) medications The Quarterly MDS, dated [DATE], documented R14 had moderately impaired cognition. The Quarterly MDS, dated [DATE], documented R14 had severe cognitive impairment, had other behavioral symptoms not directed toward others, and required extensive assistance of one staff for ADL. R14, received scheduled, as needed, and non-medication interventions for pain, and had a fall with major injury. The Care Plan, dated 10/27/22, documented R14 had the potential to fall down and hurt herself because of fatigue. The nurses needed to request a therapy screen for R14 if needed, and the nurse aides were to keep R14's room well lit when she was up and to remind her to get up slowly. On 04/16/23 the care plan added intervention to stay with R14 during toileting. On 04/24/23 the care plan further documented R14 had not met her goal of avoiding major injury due to a clavicle fracture. The Fall Note on 08/15/22 at 02:11 AM, documented the nurse heard a noise and R14 calling out for help. The nurse went to investigate and found R14 lying on her back in the bathroom with her head resting against the door frame. R14 had a hematoma to the right side of her head the size of a golf ball. R14 complained of pain in her head and buttocks. R14 was unable to tell the nurse what caused the fall. The note recorded R14 was independent, and had appropriate lighting and footwear on; her floor was clean and dry, and an assistive device (walker) was with the resident. The fall note further documented no new interventions at that time. The Fall Note, on 10/14/22 at 08:21 PM, documented R14 was getting ready for bed,and getting clothes to her closet, when she became unsteady and fell . R14 was sitting on her bottom with her head resting against the bed and her hand on her chest. R14 was very short of breath. Staff provided teaching on the use of the call light if R14 felt unsteady. The note documented no new interventions at that time, and stated the care plan was followed. The Fall Note on 04/21/23 at 11:30 PM, documented the nurse heard R14 scream and went to investigate. The nurse found R14 lying on her left side with her left arm behind her. Her oxygen tubing was off, and there was candy scattered on the floor. R14 reported pain to her left arm and was unable to move her left arm without pain. R14 went to the emergency room . The note documented no interventions at that time. R14 returned from the hospital with a left clavicle fracture. On 06/26/23 at 09:18 AM, R14 sat in her room, in a recliner. She wore oxygen via nasal cannula. R14 reported she no longer had shoulder pain from the fractured clavicle. She stated it was healed On 06/26/23 at 12:14 PM observation revealed Certified Nurse Aide (CNA) O assisted R14 to the bathroom. CNA O assisted R14 to a wheelchair and wheeled the resident into the bathroom. CNA O assisted R14 with toileting needs and then returned the resident to her recliner. CNA O reported R14 was usually continent, and used her call light, but recently had been calling out for assistance. On 06/27/23 at 09:40 AM, Administrative Nurse D stated the care plan had not been updated following the fall for R14 which resulted in a clavicle fracture. Administrative Nurse D and verified no new interventions were implemented to prevent further falls. Administrative Nurse D reported she had not reported the fall to the state agency because she thought if the care plan was followed, a report did not have to be made. The facility's undated Falls and Fall Risk, Managing policy documented based on previous evaluations and current data, the staff will identify interventions related to resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The facility failed to identify and implement interventions to prevent R14 from falling resulting in a major injury and placed the resident at risk of further falls. - R57's Electronic Medical Record (EMR) recorded diagnoses of atrial fibrillation (rapid, irregular heartbeat), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (elevated blood pressure), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), pain, sleep disorder, and dystonia ( movement disorder that cause slow repetitive movements). The Quarterly Minimum Data Set, (MDS) dated [DATE], documented R57 had intact cognition, rejection of care behavior one to three days during the look back period, required extensive assistance with activities of daily living, was not steady and only able to stabilize with staff assistance, and used a walker. The MDS further documented R57 was frequently incontinent of urine, received an antidepressant (medication used to treat mood disorder) and hypnotic (medication used to induce sleep) on a routine basis. R57 used bed and chair alarms. The Fall Care Area Assessment (CAA), dated 03/21/23, documented R57 had a history of multiple falls, impaired balance, impulsivity, anxiety disorder and depression (mood disorder). R57 had multiple falls from self-transferring and walking without assistance. R57 had a chair and bed alarm to alert staff when he was moving about and to stay with him during toileting. The Care Plan dated 12/22/22, documented R57 needed assistance because of having physical challenges, and frequent falls. R57 had trouble making decisions. The care plan directed staff to transfer R57 with a gait belt, walk using a four wheeled walker; R57 wore a Wanderguard device (personal alarm which alerts staff when close to alarmed exits) on his left ankle. The care plan further documented R57 had the potential to fall and hurt himself because of Parkinson's disease. The care plan further directed staff to keep an eye on his behaviors, make sure the call light was within reach, establish an activity of daily living program, to stay with R57 during toileting, make sure glasses are within reach, encourage R57 to use assistance, and to report pain and behaviors to nurse. R57's Care Plan documented an intervention dated 12/29/22which directed R57 used an alarm on his bed, chair and floor. On 01/20/23 the plan documented R57 was to use gripper socks at bedtime. On 02/16/23 the plan was updated to direct R57 had the potential to fall and hurt himself due to Parkinson's disease and dementia/Alzheimer's disease. An intervention dated 06/20/23 directed R57 used a self-locking wheelchair. The Fall Note, dated 01/20/23 at 01:48 AM, documented R57 had just been assisted by a Certified Nurse Aide (CNA) with getting ready for bed, and he was sitting in his recliner watching television. The CNA then went to assist R57's roommate. The CNA reported hearing a thud and R57 was sitting on the floor in front of his recliner. The fall note documented no actions were needed and direct staff to continue to observe resident. The care plan was updated for R57 to wear slipper socks at bedtime and to give R57 frequent reminders to call for assistance when getting up. The Fall Note dated 01/20/23 at 10:34 PM documented staff checked on R57 because the room door was shut. R57 was sitting in his chair with blood on the floor and his left knee. R57's walker was folded and turned on its side. R57 informed staff he did fall. The pad alarm was on his table and unplugged enough not to alarm the pagers. R57 had previous skin issues to his left knee from a previous fall and had acquired new skin tears and abrasions to just below the left knee, left upper arm, left ankle and upper buttocks. The note documented R57 received education to use the call light and not to remove pad alarm from the chair. The Fall Note dated at 02/02/23 at 05:10 AM documented staff were notified by the alarm and found R57 sitting on the floor in his room. R57 had an abrasion to his left knee, which was cleansed, and a dressing applied. The note documented action taken was to observe, teach use of call light, and safe use of devices. The intervention listed to adjust toileting schedule and staff to frequently remind R57 to use his call light for assistance for his safety. The Fall Note dated 03/02/23 at 11:33 PM documented R57 was assisted to the bathroom with his walker and gait belt. R57 lost his balance and fell partially on the couch, landing on his left knee sustaining injury to left knee and first aid was immediately applied. The fall note documented no interventions at that time. The Fall Note dated 03/28/23 at 12:49 PM documented staff observed R57 starting to stand up from his recliner when he fell on his left knee. Staff were not able to get to the

The facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to prepare pureed foods (a texture-modified diet in which all foods have a soft, pudding-like consistency) by methods that conserve nutritive value, flavor, and appearance for nine residents who received pureed diets placing the residents at risk for inadequate nutrition. Findings included: - On 06/22/23 at 08:35 AM, observation revealed Dietary Staff (DS) CC prepare pureed meal for nine residents. DS CC placed nine plus servings of refrigerated meatloaf into a blender, then added milk from a gallon jug, blending the mixture until desired consistency. DS CC placed the blended meat into serving pans placing additional milk on top of the mixture before placing in the oven for heating. On 06/26/23 at 02:16 PM DS BB stated DS CC should have used beef broth to puree the meat. DS BB stated the facility was getting used to using the recipes obtained recently from a consulting diet source. The pureed meat recipe instructions directed to combine beef base and water to make a broth, place portions in a sanitized food processor and to add bread and broth and to blend until smooth. The facility's Pureed policy, dated 2022, documented the actual processing of pureed food is a simple task when the right equipment and proper techniques are used. It is important to follow the recipe or any community policy/procedure regarding pureeing foods. The facility failed to prepare foods by methods that conserve palatable and nutritive value for nine residents who received a pureed diet, placing the residents at risk for inadequate nutrition.

The facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to report to the state agency Resident (R)16's injuries of unknown origin and failed to report to the state agency R14's unwitnessed fall resulting in fracture. This placed the residents at risk for unidentified and ongoing abuse or neglect. Findings included: - The Electronic Medical Record (EMR) for R16 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and edema (swelling). The Annual Minimum Data Set (MDS), dated [DATE], documented R16 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting and extensive assistance of one staff for dressing, eating and personal hygiene. The MDS further documented R16 had no skin issues. The Quarterly MDS, dated [DATE], documented R16 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and extensive assistance of two staff for dressing, eating and personal hygiene. The MDS further documented R16 had skin tears. The Care Plan, dated 05/05/23, initiated on 04/27/22, documented R16 would lose her balance, fall, or bumped into things, and could not remember. The care plan directed staff to check her skin weekly, use a pressure distribution device air mattress, and ensure that R16 had a foot cradle on her bed to prevent the sheets from rubbing on her feet. The update, dated 05/22/23, directed staff to apply sleeve protectors during the day and take them off at night. The Investigation, dated 03/03/23 at 03:17 PM, documented R16 had a skin tear to her right forearm that staff had noticed while getting her ready for bed. The investigation further documented R16 had severely impaired cognition, was unable to state when or how the skin tear happened and education was given to staff. The Investigation, dated 04/19/23 at 03:04 AM, documented R16 had a skin tear on her left forearm which measured 1.5 centimeters (cm) x 1.2 cm and had a V shape. The area was cleansed with normal saline, adhesive closures were applied, covered with a non stick dressing and wrapped with gauze. The investigation documented, staff did not know if the skin tear happened when changing her clothes, and due to R16's severely impaired cognition, she was unable to state when or how the skin tear happened; education was given to staff. The Investigation, dated 04/28/23 at 07:10 PM, documented R16 had a skin tear on her right arm which measured 0.1 cm x 2.5 cm. The area was cleansed with normal saline, skin approximated, and two closure strips were applied. The investigation further documented staff were unsure when it happened. The Investigation, dated 05/22/23 at 11:24 AM, documented staff found a skin tear to R16's right forearm which measured 4.7 cm x 0.1 cm, during her shower, and staff were unsure how the skin tear was obtained. On 06/26/23 at 08:57 AM, observation revealed R16 had sleeve protectors on her arms. On 06/22/23 at 12:30 PM, Certified Nurse Aide (CNA) O stated R16 had to have sleeve protectors on her arms at all times because of skin tears. On 06/26/23 at 02:17 PM, Licensed Nurse (LN) H stated when staff tell her there is a skin tear or bruise, she will complete an investigation by talking with the staff, the resident, and will look at the resident's environment to see if she can figure out what happened. LN H further stated R16 had to wear the sleeve protectors or wear long sleeve to protect her skin because it was so fragile. On 06/27/23 at 09:45 AM, Administrative Nurse D stated she was unaware she was required to report any injuries of unknown origins. The facility's Resident Abuse, Neglect, Exploitation, and Mistreatment policy, dated 06/2022, documented the facility administration shall be cooperative with the state Health Department officials in accordance with Kansas's law to protect the rights and safety of the resident. The time period for reporting a serious bodily injury is a two hour limit, if the event that causes the reasonable suspicion result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but no later than two hours after forming the suspicion. All others within 24 hours if the events that caused the reasonable suspicion do not result in serious bodily injury to the resident, the covered individual shall report the suspicion not later than 24 hours after forming the suspicion, and if a crime has been committed law enforcement will also be advised. The facility failed to report to the state agency R16's skin tears of unknown origin. This placed the resident at risk for unidentified and ongoing abuse or neglect. 37450 - The Medical Diagnosis section in R14's Electronic Medical Record (EMR) included diagnoses of dorsalgia (back pain), scoliosis (curvature of the spine), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, fatigue, kyphosis (outward curvature of the spine), cervicalgia (neck pain), fracture of left clavicle (collarbone), shortness of breath, and panic disorder. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R14 had intact cognition, and required extensive assistance of one staff for activities of daily living (ADL). The MDS recorded R14 was not steady and was only able to stabilize with human assistance. R14had occasional incontinence of urine, received scheduled and as needed pain medication, and was short of breath with exertion. The MDS further documented R14 had one fall with no injury and one fall with injury. The Activity of Daily Living Care Area Assessment (CAA), dated 01/16/23, documented R14's family chose comfort care due to R14's decline. R14 needed extensive assistance with most of her ADL and was failing to thrive. R14 had falls on 08/15/22 and 10/14/22. The CAA further documented R14 took two antidepressants (class of medications used to treat mood disorders), a Fentanyl (narcotic pain medication) patch, and had as needed pain and antianxiety (class of medications that calm and relax people) medications The Quarterly MDS, dated [DATE], documented R14 had moderately impaired cognition. The Quarterly MDS, dated [DATE], documented R14 had severe cognitive impairment, had other behavioral symptoms not directed toward others, and required extensive assistance of one staff for ADL. R14, received scheduled, as needed, and non-medication interventions for pain, and had a fall with major injury. The Care Plan, dated 10/27/22, documented R14 had the potential to fall down and hurt herself because of fatigue. The nurses needed to request a therapy screen for R14 if needed, and the nurse aides were to keep R14's room well-lit when she was up and to remind her to get up slowly. On 04/16/23 the care plan added intervention to stay with R14 during toileting. On 04/24/23 the care plan further documented R14 had not met her goal of avoiding major injury due to a clavicle fracture. The Fall Note on 08/15/22 at 02:11 AM, documented the nurse heard a noise and R14 calling out for help. The nurse went to investigate and found R14 lying on her back in the bathroom with her head resting against the door frame. R14 had a hematoma to the right side of her head the size of a golf ball. R14 complained of pain in her head and buttocks. R14 was unable to tell the nurse what caused the fall. The note recorded R14 was independent and had appropriate lighting and footwear on; her floor was clean and dry, and an assistive device (walker) was with the resident. The fall note further documented no new interventions at that time. The Fall Note, on 10/14/22 at 08:21 PM, documented R14 was getting ready for bed, and getting clothes to her closet, when she became unsteady and fell . R14 was sitting on her bottom with her head resting against the bed and her hand on her chest. R14 was very short of breath. Staff provided teaching on the use of the call light if R14 felt unsteady. The note documented no new interventions at that time and stated the care plan was followed. The Fall Note on 04/21/23 at 11:30 PM, documented the nurse heard R14 scream and went to investigate. The nurse found R14 lying on her left side with her left arm behind her. Her oxygen tubing was off, and there was candy scattered on the floor. R14 reported pain to her left arm and was unable to move her left arm without pain. R14 went to the emergency room . The note documented no interventions at that time. R14 returned from the hospital with a left clavicle fracture. On 06/26/23 at 09:18 AM, R14 sat in her room, in a recliner. She wore oxygen via nasal cannula. R14 reported she no longer had shoulder pain from the fractured clavicle. She stated it was healed On 06/26/23 at 12:14 PM observation revealed Certified Nurse Aide (CNA) O assisted R14 to the bathroom. CNA O assisted R14 to a wheelchair and wheeled the resident into the bathroom. CNA O assisted R14 with toileting needs and then returned the resident to her recliner. CNA O reported R14 was usually continent, and used her call light, but recently had been calling out for assistance. On 06/27/23 at 09:40 AM, Administrative Nurse D stated the care plan had not been updated following the fall for R14 which resulted in a clavicle fracture. Administrative Nurse D and verified no new interventions were implemented to prevent further falls. Administrative Nurse D reported she had not reported the fall to the state agency because she thought if the care plan was followed, a report did not have to be made. The facility's Resident Abuse, Neglect, Exploitation, and Mistreatment policy, dated 06/2022, documented the facility administration shall be cooperative with the state Health Department officials in accordance with Kansas's law to protect the rights and safety of the resident. The time period for reporting a serious bodily injury is a two hour limit, if the event that causes the reasonable suspicion result in serious bodily injury to a resident, the covered individual shall report the suspicion immediately, but no later than two hours after forming the suspicion. All others within 24 hours if the events that caused the reasonable suspicion do not result in serious bodily injury to the resident, the covered individual shall report the suspicion not later than 24 hours after forming the suspicion, and if a crime has been committed law enforcement will also be advised The facility failed to report to the state agency R14's fractured clavicle from an unwitnessed fall which placed the resident at risk for unidentified and ongoing abuse or neglect.

The facility had a census of 66 residents. The sample included 18 residents, with one reviewed for post-traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for PTSD for one sampled resident, Resident (R) 36, to provide direction to staff to ensure R36 received care to eliminate or mitigate triggers that may cause re-traumatization of the resident. This placed the resident at risk for unmet needs. Findings included: - The Electronic Medical Record (EMR) for R36 documented diagnoses of PTSD, dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (a disruption of blood flow to the brain due to problems with the blood vessels that supply it), and major depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Quarterly MDS, dated [DATE], documented R36 had severely impaired cognition and required extensive assistance of two staff for bed mobility, toileting, and extensive assistance of one staff for transfers, ambulation, mobility in his wheelchair, dressing, and personal hygiene. The MDS further documented R36 had no behaviors and received antidepressant (medication that is used to treat mood disorders and relieve symptoms of depression) medication. The EMR lacked documentation a Trauma Informed Care Assessment was completed for R36. The Care Plan, dated 05/02/23, imitated on 12/01/22, documented R36 was unaware of safety risks and directed staff to keep an eye on his behaviors. The EMR lacked documentation a care plan for R36's PTSD was developed. The Physician's Order, dated 11/25/22, directed staff to administer donepezil (cognition-enhancing medication), 10 milligrams (mg), by mouth, daily in the morning for dementia and directed staff to administer Celexa (an antidepressant medication), 20 mg, by mouth, daily in the evening for depression. The Nurse's Note, dated 05/26/23 at 03:16 PM, documented R36 became agitated with his morning cares. The Nurse's Note, dated 06/14/23 at 04:11 PM, documented R36 was aggressive with staff during cares, hit and grabbed at staff several times during the shift. The note further documented staff explained what they were doing and out of nowhere, R36 started to hit and grab their arms. The Nurse's Notes, dated 06/22/23 at 04:32 PM, documented at lunch, R36 grabbed a staff members braid and pulled down on it. The noted further documented, staff were able to get the resident to let go by removing his hand from her braid. On 06/26/23 at 12:22 PM, observation revealed staff pushed R36's wheelchair into the living room area in front of the television; R36 had no behaviors. On 06/22/23 at -9:30 AM, Administrative Nurse E verified she had not developed a care plan for R36's PTSD and verified a trauma informed care assessment was not completed. On 06/22/23 at 11:50 AM, Certified Nurse Aide (CNA) O stated R36 could be resistive of cares at times and staff tried to redirect him. On 06/26/23 at 02:17 PM, Licensed Nurse (LN) H stated R36 had times of aggression, swung at staff and pulled hair. LN H further stated staff redirected him LN H said she was unaware of R36's PTSD diagnosis, and stated R36 did not receive mental health services. On 06/26/23 at 03:36 PM, Social Services X stated she had discussed R36's PTSD with his representative and had spent time with the resident but due to transporting residents to their appointments, she had not completed any assessments or been involved with the care plan team to develop a care plan for direction to staff on what would trigger his PTSD. On 06/27/23 at 09:45 AM, Administrative Nurse D stated, the facility would complete Trauma Informed Care Assessment on residents with the diagnosis of PTSD and stated a care plan for R36's PTSD was now completed. The facility's Care Plan policy, undated, documented, a care plan would be developed for each resident using the results of the comprehensive assessment and would include measurable objectives and timetables to meet all resident needs. The facility failed to develop a comprehensive care plan for R36, who had a diagnosis of PTSD. This placed the resident at risk for unmet needs.

The facility had a census of 66 residents. The sample included 18 residents of which 18 were reviewed for care planning. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent falls for Resident (R) 14, 57, and 21. This deficient practice placed the residents at risk for injuries to uncommunicated care needs. Findings included: - The Medical Diagnosis section in R14's Electronic Medical Record (EMR) included diagnoses of dorsalgia (back pain), scoliosis (curvature of the spine), major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, fatigue, kyphosis (outward curvature of the spine), cervicalgia (neck pain), fracture of left clavicle (collarbone), shortness of breath, and panic disorder. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R14 had intact cognition, and required extensive assistance of one staff for activities of daily living (ADL). The MDS recorded R14 was not steady and was only able to stabilize with human assistance. R14had occasional incontinence of urine, received scheduled and as needed pain medication, and was short of breath with exertion. The MDS further documented R14 had one fall with no injury and one fall with injury. The Activity of Daily Living Care Area Assessment (CAA), dated 01/16/23, documented R14's family chose comfort care due to R14's decline. R14 needed extensive assistance with most of her ADL and was failing to thrive. R14 had falls on 08/15/22 and 10/14/22. The CAA further documented R14 took two antidepressants (class of medications used to treat mood disorders), a Fentanyl (narcotic pain medication) patch, and had as needed pain and antianxiety (class of medications that calm and relax people) medications The Quarterly MDS, dated [DATE], documented R14 had moderately impaired cognition. The Quarterly MDS, dated [DATE], documented R14 had severe cognitive impairment, had other behavioral symptoms not directed toward others, and required extensive assistance of one staff for ADL. R14, received scheduled, as needed, and non-medication interventions for pain, and had a fall with major injury. The Care Plan, dated 10/27/22, documented R14 had the potential to fall down and hurt herself because of fatigue. The nurses needed to request a therapy screen for R14 if needed, and the nurse aides were to keep R14's room well-lit when she was up and to remind her to get up slowly. On 04/16/23 the care plan added intervention to stay with R14 during toileting. On 04/24/23 the care plan further documented R14 had not met her goal of avoiding major injury due to a clavicle fracture. The Fall Note on 08/15/22 at 02:11 AM, documented the nurse heard a noise and R14 calling out for help. The nurse went to investigate and found R14 lying on her back in the bathroom with her head resting against the door frame. R14 had a hematoma to the right side of her head the size of a golf ball. R14 complained of pain in her head and buttocks. R14 was unable to tell the nurse what caused the fall. The note recorded R14 was independent and had appropriate lighting and footwear on; her floor was clean and dry, and an assistive device (walker) was with the resident. The fall note further documented no new interventions at that time. The Fall Note, on 10/14/22 at 08:21 PM, documented R14 was getting ready for bed, and getting clothes to her closet, when she became unsteady and fell . R14 was sitting on her bottom with her head resting against the bed and her hand on her chest. R14 was very short of breath. Staff provided teaching on the use of the call light if R14 felt unsteady. The note documented no new interventions at that time and stated the care plan was followed. The Fall Note on 04/21/23 at 11:30 PM, documented the nurse heard R14 scream and went to investigate. The nurse found R14 lying on her left side with her left arm behind her. Her oxygen tubing was off, and there was candy scattered on the floor. R14 reported pain to her left arm and was unable to move her left arm without pain. R14 went to the emergency room . The note documented no interventions at that time. R14 returned from the hospital with a left clavicle fracture. On 06/26/23 at 09:18 AM, R14 sat in her room, in a recliner. She wore oxygen via nasal cannula. R14 reported she no longer had shoulder pain from the fractured clavicle. She stated it was healed On 06/26/23 at 12:14 PM observation revealed Certified Nurse Aide (CNA) O assisted R14 to the bathroom. CNA O assisted R14 to a wheelchair and wheeled the resident into the bathroom. CNA O assisted R14 with toileting needs and then returned the resident to her recliner. CNA O reported R14 was usually continent, and used her call light, but recently had been calling out for assistance. On 06/27/23 at 09:40 AM, Administrative Nurse D stated the care plan had not been updated following the fall for R14 which resulted in a clavicle fracture. Administrative Nurse D and verified no new interventions were implemented to prevent further falls. Administrative Nurse D reported she had not reported the fall to the state agency because she thought if the care plan was followed, a report did not have to be made. The facility's undated Care Plan policy, documented a care plan will be developed for each resident using the results of the comprehensive assessment. Each care plan will include measurable objectives and timetables to meet all resident needs identified in the comprehensive assessment. The care plan describes services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Care plans will be reviewed and revised on a quarterly basis by the interdisciplinary care plan team and also as needed when changes occur. The facility failed to identify and implement interventions to the care plan to prevent R14 from falling resulting in a major injury and placed the resident at risk of further falls and uncommunicated care needs. - R57's Electronic Medical Record (EMR) recorded diagnoses of atrial fibrillation (rapid, irregular heartbeat), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), hypertension (elevated blood pressure), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness), pain, sleep disorder, and dystonia (movement disorder that cause slow repetitive movements). The Quarterly Minimum Data Set, (MDS) dated [DATE], documented R57 had intact cognition, rejection of care behavior one to three days during the look back period, required extensive assistance with activities of daily living, was not steady and only able to stabilize with staff assistance, and used a walker. The MDS further documented R57 was frequently incontinent of urine, received an antidepressant (medication used to treat mood disorder) and hypnotic (medication used to induce sleep) on a routine basis. R57 used bed and chair alarms. The Fall Care Area Assessment (CAA), dated 03/21/23, documented R57 had a history of multiple falls, impaired balance, impulsivity, anxiety disorder and depression (mood disorder). R57 had multiple falls from self-transferring and walking without assistance. R57 had a chair and bed alarm to alert staff when he was moving about and to stay with him during toileting. The Care Plan dated 12/22/22, documented R57 needed assistance because of having physical challenges, and frequent falls. R57 had trouble making decisions. The care plan directed staff to transfer R57 with a gait belt, walk using a four wheeled walker; R57 wore a Wanderguard device (personal alarm which alerts staff when close to alarmed exits) on his left ankle. The care plan further documented R57 had the potential to fall and hurt himself because of Parkinson's disease. The care plan further directed staff to keep an eye on his behaviors, make sure the call light was within reach, establish an activity of daily living program, to stay with R57 during toileting, make sure glasses are within reach, encourage R57 to use assistance, and to report pain and behaviors to nurse. R57's Care Plan documented an intervention dated 12/29/22 which directed R57 used an alarm on his bed, chair and floor. On 01/20/23 the plan documented R57 was to use gripper socks at bedtime. On 02/16/23 the plan was updated to direct R57 had the potential to fall and hurt himself due to Parkinson's disease and dementia/Alzheimer's disease. An intervention dated 06/20/23 directed R57 used a self-locking wheelchair. The Fall Note dated 01/20/23 at 01:48 AM, documented R57 had just been assisted by a Certified Nurse Aide (CNA) with getting ready for bed, and he was sitting in his recliner watching television. The CNA then went to assist R57's roommate. The CNA reported hearing a thud and R57 was sitting on the floor in front of his recliner. The fall note documented no actions were needed and direct staff to continue to observe resident. The care plan was updated for R57 to wear slipper socks at bedtime and to give R57 frequent reminders to call for assistance when getting up. The Fall Note dated 01/20/23 at 10:34 PM, documented staff checked on R57 because the room door was shut. R57 was sitting in his chair with blood on the floor and his left knee. R57's walker was folded and turned on its side. R57 informed staff he did fall. The pad alarm was on his table and unplugged enough not to alarm the pagers. R57 had previous skin issues to his left knee from a previous fall and had acquired new skin tears and abrasions to just below the left knee, left upper arm, left ankle and upper buttocks. The note documented R57 received education to use the call light and not to remove pad alarm from the chair. The Fall Note dated at 02/02/23 at 05:10 AM documented staff were notified by the alarm and found R57 sitting on the floor in his room. R57 had an abrasion to his left knee, which was cleansed, and a dressing applied. The note documented action taken was to observe, teach use of call light, and safe use of devices. The intervention listed to adjust toileting schedule and staff to frequently remind R57 to use his call light for assistance for his safety. The Fall Note dated 03/02/23 at 11:33 PM documented R57 was assisted to the bathroom with his walker and gait belt. R57 lost his balance and fell partially on the couch, landing on his left knee sustaining injury to left knee and first aid was immediately applied. The fall note documented no interventions at that time. The Fall Note dated 03/28/23 at 12:49 PM documented staff observed R57 starting to stand up from his recliner when he fell on his left knee. Staff were not able to get to the resident before the fall. The nurse found R57 sitting on his couch. R57 reported he wanted to see what laundry had put in his closet. The fall note further documented staff educated R57 on the importance of using the call light; R57 had a bed alarm and chair alarm. He often attempted to ambulate in his room without calling for assistance and to give frequent reminders to use the call light to call and wait for assistance. No interventions at that time. The Fall Note dated 04/25/23 at 04:24 PM documented R57 was on his left knee in front of his bed. R57 reported he was trying to get into his wheelchair for supper and stated his call light was attached to his recliner and he should have used it. The chair alarm was working and answered promptly. The fall note further documented staff visited with R57 on the importance of using the call light to call staff for assistance and waiting for staff to get there to assist him. Resident verbalized understanding. No intervention was documented. On 06/26/23 at 03:38 PM observation revealed R57 sitting in his recliner watching television. R57 stated he had been admitted to the facility because of falling. He reported he was taking a sleeping pill and staff reported he had been walking around at night, but he does not remember this happening. R57 stated the facility wanted him to remain seated as the intervention to keep him from falling and when the alarms go off, they come running. He did report the staff remind him to use the call light and wait for assistance. R57 also reported he wanted to return home at the end of summer. On 06/27/23 at 09:45 AM. Administrative Nurse D stated due to R57's intact cognition the facility had not implemented new interventions to prevent his falls. The facility's undated Care Plan policy, documented a care plan will be developed for each resident using the results of the comprehensive assessment. Each care plan will include measurable objectives and timetables to meet all resident needs identified in the comprehensive assessment. The care plan describes services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Care plans will be reviewed and revised on a quarterly basis by the interdisciplinary care plan team and also as needed when changes occur. The facility failed to identify and implement interventions to the care plan to prevent R57 from falling resulting in a major injury and placed the resident at risk of further falls and uncommunicated care needs. 32360 - The Electronic Medical Record for R21 recorded diagnoses of dementia, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), other symptoms and signs involving cognitive functions and awareness, and Alzheimer's disease (progressive mental disorder characterized by failing memory, confusion). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R21 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and extensive assistance of one staff for mobility, dressing, and personal hygiene. The MDS further documented R21 had no behaviors and received antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) medication seven days of the look back period. The Care Plan, dated 05/12/23, initiated on 05/19/22, documented R21 had the inability to remember things that happened a short time ago, and the inability to make decisions. R21 had poor safety awareness, and the plan directed staff to watch to see if R21's behavior changed. The update, dated 08/12/22 directed staff to evaluate R21 for situational stressors, evaluate effectiveness of her medication and monitor her for adverse effects of the medications. It directed to record R21's behaviors, encourage her to participate in activities, and offer comfort and support. The care plan lacked documentation of R21's behaviors and lacked person centered approached to address behaviors. The Physician's Order, dated 06/08/21, directed staff to monitor for side effects of Cymbalta (antidepressant medication) and monitor for behaviors. The Physician's Order, dated 06/12/23, directed staff to administer Cymbalta, 20 milligrams (mg), 1 capsule, by mouth, for the diagnosis of anxiety. The Nurse's Note, dated 08/30/22 at 04:19 PM, documented R21 kicked towards another resident, though no contact was made. Staff told her it was inappropriate to kick towards people. The Nurse's Note, dated 10/21/22 at 02:02 PM, documented R21 kicked at another resident's wheelchair frame and staff told her that it was inappropriate and to not do it again. The Nurse's Note, dated 10/23/22 at 03:34 PM, documented R21 took papers off the desk at the nurse's station and attempted to look at them. The note further documented staff retrieved the papers and R21 attempted to take papers and food off the medication cart. The note documented staff took R21 to her room and told her not to take things off other people's places. At 04:34 PM, the note documented R21 left her room and another resident was in the hallway and R21 kicked at the other resident's wheelchair. The Nurse's Note, dated 02/24/23 at 03:02 PM, documented R21 was whistling and disturbing other resident's and staff took her to her room. The Nurse's Note, dated 02/26/23 at 02:25 PM, documented R21 was whistling in the dining room upsetting other residents, staff asked her to stop but she continued to whistle. The note further documented R21 was taken to her room, her call light given, and staff explained that it hurt other resident's ears and she replied, I don't care. The Nurse's Note, dated 03/02/23 at 02:37 PM, documented R21 was whistling and it disturbed other resident's, and she was taken to her room. The Nurse's Note, dated 03/05/23 at 01:36 PM, documented R21 whistled despite nursing staff asked her to quit. The note documented at 04:36 PM, R21 was asked by staff and residents to stop whistling, she refused, and staff took her to her room, and gave her call light and a magazine. The note further documented the intervention only lasted a short time and R21 began to whistle again until her family came in the afternoon to visit. The note documented, later in the dining room, R21 began to holler and progressively got louder. Staff asked R21 if she needed anything and she stated No. The Nurse's Note, dated 03/14/23 at 12:11 PM, documented R21 whistled while in the dining room, other residents had already voiced that it was agitating to them, especially those with hearing aids. The note documented staff asked her multiple times to stop and she was taken back to her room, given her call light, lunch tray, and she stopped whistling. The Nurse's Note, dated 03/26/23 at 01:05 PM, documented R21 whistled in the common area, was asked to stop by staff because other residents complained of this behavior. The note further documented staff took R21 to her room, gave her a call light and a magazine. The Nurse's Note, dated 04/06/23 at 09:19 PM, documented R21 whistled in the hallway after dinner, was asked to stop by two staff members due to it hurt other resident's ears. The note documented staff told R21 that if she wished to keep whistling, she needed to do it in her room. R21 stated she did not want to go to her room and would stop whistling. The note documented, R21 stopped whistling until the nurse walked away, and then she continued to whistle. The Nurse's Note, dated 04/09/23, documented R21 was observed kicking the bird cage; she was asked to sit and watch them, and not kick the cage. The note further documented R21 continued to kick the glass, and staff took her to her room. The Nurse's Note, dated 04/26/23 at 03:42 PM, documented R21 whistled even after she was asked to stop. R21 started crying, and stated she never did anything right. The Nurse's Note, dated 05/06/23 at 03:08 AM, documented on the previous evening, R21 was in another resident's room and was assisted out by staff. The note further documented R21 went back into the other resident's room, and again was taken out by staff. The note documented, after R21 was taken out of the room, and while out in the hallway, she pulled on another resident's hair. The Nurse's Note, dated 05/11/23 at 03:44 PM, documented R21 was rude to another resident during breakfast and staff moved her to another table. The Nurse's Note, dated 05/14/23 at 10:55 AM, documented at 09:30 AM, R21 wheeled herself in front of another resident; staff asked her to move away from the other resident, in which she did not move away but wheeled closer and leaned toward the other resident's face and said, move out of my way. Staff intervened and moved R21 away. The note documented R21 began to whistle and upset other residents and staff took her to her room. The Nurse's Note, dated 06/06/23 at 04:02 PM, documented R21 whistled in the hallway, other residents complained and asked her to stop. The further documented R21 refused and staff told her that if she did not stop she would need to go to her room. The note documented R21 got into the nurse's face and whistled loudly, and staff took her to her room. On 06/22/23 at 12:04 PM, observation revealed R21 sat in her wheelchair in the living room area and had no behaviors at that time. On 06/22/23 at 12:40 PM, Certified Nurse Aide (CNA) O stated R21 liked to whistle, and it often disturbed other residents. CNA O said R21 had no other behaviors, and staff take R21 to her room when she has behaviors. On 06/26/23 at 02:18 PM, Licensed Nurse (LN) H stated R21 liked to whistle and it disturbed other residents. LN H said sometimes R21 would get into other residents' faces and whistle. LN H said most of the time R21 would stop when asked to stop but when she did not, staff took her to her room. On 06/26/23 at 03:31 PM, Social Services X stated when R21 had behaviors, she stepped in and helped staff redirect . Social services X said provided 1:1 with R21. Social Services X stated R21 did not receive any mental health services. On 06/27/23 at 09:45 AM, Administrative Nurse D stated R21 whistled and upset other residents. Administrative Nurse D said staff would work on other interventions for R21's behavior and verified R21 did not receive any mental health services. The facility Care Plans policy, undated, documented residents had personalized plan that stated specific cares needed and would be reviewed and revised on a quarterly basis by the care team and also when changes occur. The facility failed to revise the care plan for R21 with person centered interventions which addressed dementia related behaviors. This placed the resident at risk for uncommunicated and/or unmet needs.

The facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review and interview the facility failed to prevent medication administration errors for Resident (R) 10's when staff crushed and mixed the medications and placed them in R10's food. The services the facility provided R10 did not meet professional standards of quality. This deficient practice placed R10 at risk for adverse reactions by not receiving the appropriate amount of medications prescribed. Findings included: - R10's Electronic Medical Record (EMR), documented diagnoses of epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), bipolar disorder (a disorder with episodes of mood swings ranging from depressive lows to manic highs), and anxiety disorder (mental health disorder with feelings of worry, anxiety, or fear that interferes with daily activities). The Quarterly Minimum Date Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of seven indicating severely impaired cognition. The MDS documented R10 required extensive assistance with transfers and locomotion and rejected care one to three days of the look back period. The revised Safety Care Plan, dated 06/03/23, instructed staff to keep the resident safe if a seizure occured and to provide seizure medication as ordered. The Physician Orders, dated 06/01/23, documented to administer the following medications: Keppra (an anticonvulsant medication to prevent seizures) 500 milligrams (mg) by mouth (PO) two times a day (BID) Docusate Sodium (stool softener medication)100mg PO BID Risperidone (antipsychotic medication) 2.5 mg PO BID Depakote (seizure medication) 125 mg capsule delayed release PO BID, Tylenol (pain medication) 500 mg PO in the evening, Zoloft ( an antidepressant medication) 100mg PO in the evening, R10's EMR lacked an order to crush and mix medications. The Nurses Note dated 06/19/23 at 07:55PM, documented R10's evening medications were crushed and mixed in his meat sandwich during the supper meal. The note recorded R10 ate half of the sandwich therefore half of R10's medications were received. The Nurses Note, dated 06/21/23 at 07:22PM, documented R10's evening medications were crushed and mixed in the tartar sauce and placed on his fish sandwich. The note further documented R10 ate half of the fish sandwich therefore he technically received half of his medication. According to the Food and Drug Administration for the medications Keppra, Risperidone and Depakote. Crushing the medications was discouraged. Review of R10's Medication Administration Record (MAR) revealed documentation on 06/19/23 and 06/21/23 that R10 received half of his evening medication. On 06/27/23 at 08:00AM, observation revealed R10 seated in his wheelchair at a dining table. On 06/22/23 at 08:15AM, Licensed Nurse (LN) G stated, depending on R10's mood, R10's medications were sometimes crushed and placed in his food. On 06/27/23 at 09:15AM, Administrative Nurse D verified the documentation on 06/19/23 and 06/21/23, regarding R10's medications being crushed and placed in his meals. Administrative Nurse D verified this practice of medication administration was inappropriate. The undated facility policy, Medication Administration, stated medications are to be administered as prescribed by the resident's physician. All medication errors should be reported. The facility failed to administer R10's medications in an appropriate manner, by crushing the medications and placing in his food. These services the facility provided R10 did not meet professional standards of quality for medication administration, placing R10 at risk for not receiving the appropriate doses of the medications.

The facility had a census of 66 residents. The sample included 18 residents with one reviewed for discharge. Based on record review and interview, the facility failed to develop a discharge summary that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay for Resident (R)67. This placed the resident at risk for unmet care needs. Findings included: - R67's Electronic Medical Record (EMR) revealed the resident admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS), dated [DATE], documented R67 had intact cognition, delusions, and no behavioral symptoms. The MDS further documented R67 required supervision with activities of daily living, had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag), received an antidepressant (class of medications used to treat mood disorders) and an antibiotic (medication to treat infections), had no therapy services and did not have an active discharge planning already occurring. The Psychosocial Well-Being Care Area assessment dated [DATE], documented R67 verbally stated embarrassment being in the facility. R67 had a desire to please others and was concerned about not doing things right. The CAA further documented the facility would continue to facilitate mental health and primary care doctor appointments. The Care Plan, dated 03/21/23, documented R67 needed to determine if it was safe to return to home because R67 wanted or expected to go home in the future. The care plan directed staff to talk about discharge, goals, and explore discharge options. The Nurses Note, dated 04/26/23 at 12:35 PM, documented communication to the physician, R67 plans to return home the following Monday, and requested R67's medication prescriptions sent to the pharmacy so they could be picked up on the Monday of discharge. R67's EMR lacked evidence a discharge summary which included a recapitulation was developed. On 06/27/23 at 09:44 AM, Administrative Nurse D verified the facility used a discharge summary, which did not include a complete recapitulation of R67's stay. The facility's undated Discharge Summary policy, documented it was the policy of this facility that residents who have a planned discharge from the facility will have a completed discharge plan and recapitulation of stay completed to facilitate continuity of care after discharge. A comprehensive discharge summary will describe for the next provider the resident's course of stay, medical conditions and diagnose, the results of relevant laboratory and other diagnostic testing completed I the facility, consultations completed in the facility and medications prescribed at discharge. The facility failed to develop a discharge summary that included a recapitulation of the resident's stay for R67. This placed the resident at risk for unmet care needs.

The facility had a census of 66 residents. The sample included 18 residents, with two reviewed for skin conditions not pressure related. Based on observation, record review, and interview, the facility failed to implement interventions to prevent skin tears for one sampled resident, Resident (R) 16, and the facility failed to protect skin to prevent bruises during a transfer for R65. This placed the residents at risk for further injury. Findings included: - The Electronic Medical Record (EMR) for R16 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and edema (swelling). The Annual Minimum Data Set (MDS), dated [DATE], documented R16 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting and extensive assistance of one staff for dressing, eating and personal hygiene. The MDS further documented R16 had no skin issues. The Quarterly MDS, dated [DATE], documented R16 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and extensive assistance of two staff for dressing, eating and personal hygiene. The MDS further documented R16 had skin tears. The Care Plan, dated 05/05/23, initiated on 04/27/22, documented R16 would lose her balance, fall, or bumped into things, and could not remember. The care plan directed staff to check her skin weekly, use a pressure distribution device air mattress, and ensure that R16 had a foot cradle on her bed to prevent the sheets from rubbing on her feet. The update, dated 05/22/23, directed staff to apply sleeve protectors during the day and take them off at night. The Investigation, dated 03/03/23 at 03:17 PM, documented R16 had a skin tear to her right forearm that staff had noticed while getting her ready for bed. The investigation further documented R16 had severely impaired cognition, was unable to state when or how the skin tear happened and education was given to staff. The Investigation, dated 04/19/23 at 03:04 AM, documented R16 had a skin tear on her left forearm which measured 1.5 centimeters (cm) x 1.2 cm and had a V shape. The area was cleansed with normal saline, adhesive closures were applied, covered with a non stick dressing and wrapped with gauze. The investigation documented, staff did not know if the skin tear happened when changing her clothes, and due to R16's severely impaired cognition, she was unable to state when or how the skin tear happened; education was given to staff. The Investigation, dated 04/28/23 at 07:10 PM, documented R16 had a skin tear on her right arm which measured 0.1 cm x 2.5 cm. The area was cleansed with normal saline, skin approximated, and two closure strips were applied. The investigation further documented staff were unsure when it happened. The Investigation, dated 05/22/23 at 11:24 AM, documented staff found a skin tear to R16's right forearm which measured 4.7 cm x 0.1 cm, during her shower, and staff were unsure how the skin tear was obtained. On 06/26/23 at 08:57 AM, observation revealed R16 had sleeve protectors on her arms. On 06/22/23 at 12:30 PM, Certified Nurse Aide (CNA) O stated R16 had to have sleeve protectors on her arms at all times because of skin tears. On 06/26/23 at 02:17 PM, Licensed Nurse (LN) H stated when staff tell her there is a skin tear or bruise, she will complete an investigation by talking with the staff, the resident, and will look at the resident's environment to see if she can figure out what happened. LN H further stated R16 had to wear the sleeve protectors or wear long sleeve to protect her skin because it was so fragile. On 06/27/23 at 09:45 AM, Administrative Nurse D stated staff should have implemented interventions to protect R16's skin. The facility's Prevention of Pressure Ulcers/Injuries policy, undated, directed staff to review the resident's care plan and identify the risk factors as well as interventions designed to reduce or eliminate those considered modifiable, inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living, evaluate, report, and document potential changes in the skin, and review the interventions and strategies for effectiveness on an ongoing basis. The facility failed to idenifty and implement interventions to prevent skin tears for R16 until multiple skin tears were sustained over the course of several months. This placed the resident at risk for further injuries. - The Electronic Medical Record (ER) for R65 documented diagnoses of compression fracture (when forced together bone surfaces caused a bone to break), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), interferer disc disorder (a breakdown of one or more of the discs that separate the bones of the spine), and inflammatory spindly (when the immune system attacks the spine an sometimes the joints of the arms and legs). The Admission Minimum Data Set (MD'S), dated 06/13/23, documented R65 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS further documented R65 had no skin issues. The Care Plan, dated 06/05/23, documented R65 had the potential for skin injury and directed staff to check her skin weekly, use one staff, a gait belt, and a front wheeled walker for transfers, and keep skin healthy and intact. The Investigation, dated 06/21/23 at 06:50 AM, documented the bath aide found four bruises on the resident's upper inner arm and notified the charge nurse. The investigation further documented the bruises on the left upper arm which measured 5.0 centimeter (cm) x 3.0 cm, was dark purple in color, the next bruise measured 2.0 cm x 0.5 cm and was a medium shade of purple, the next bruise was 3.0 cm in diameter, and the next bruise down was 2.0 cm in diameter and was dark purple. Staff interviewed R65 who stated she thought it happened when an evening shift staff helped her to stand up. The investigation documented the family and physician were notified and told to monitor the bruises. Staff were educated on how to transfer residents, and no abuse or neglect was suspected. On 06/22/23 at 08:30 AM, observation revealed R65 in her recliner with family at her side. The resident had four purple bruises on her upper left arm. When asked by this surveyor what happened to her arm, she stated, No one beat on me, if that's what you are worried about! and laughed. R65 stated the nurse had measured the bruises and took pictures, and stated, she bruised easily and thought it could have been from the blood pressure cuff or when assisted with a transfer. On 06/26/23 at 02:43 PM, Certified Nurse Aide (CNA) M stated R65 had a lot of anxiety and did not like to have a lot of staff in her room around her. CNA M stated R65 came from the hospital with fractures in her back, was a one person transfer with a gait belt, walker, and staff should not to pull on the resident's arms. On 06/26/23 at 02:40 PM, Licensed Nurse (LN) I stated R65 had bruises from a younger staff person who had put the gait belt on the resident but did not use it when she was assisting her in a transfer. LN I further stated, R65 had a lot of anxiety and stated she did not want to get the staff member in trouble that had transferred her. On 06/27/23 at 09:45 AM, Administrative Nurse D stated staff were educated on proper transfer techniques and a mandatory meeting was scheduled in which transfers were part of the agenda. The facility's Prevention of Pressure Ulcers/Injuries policy, undated, directed staff to review the resident's care plan and identify the risk factors as well as interventions designed to reduce or eliminate those considered modifiable, inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living, evaluate, report, and document potential changes in the skin, and review the interventions and strategies for effectiveness on an ongoing basis. The facility failed to prevent bruises on R65's arm during a transfer, this placed the resident at risk for further bruising and injury.

The facility reported a census of 86 residents. The sample included three residents reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 received adequate supervision and appropriate interventions to prevent a fall with injuries. On 5/23/19 at approximately 5:00 PM R1 exited the facility through an alarmed door in her wheelchair, attempted to stand and fell to the ground. As a result of the fall, she sustained a right eye laceration and orbital (eye socket) bruising, right and left arm bruising, abrasions, and three broken fingers on her left hand. Findings included: - R1's Electronic Medical Record (EMR) documented [DIAGNOSES REDACTED]. The Annual Minimum Data Set ((MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of three which indicated severe cognitive impairment. She required extensive assistance of one person for all Activities of Daily Living (ADLs) except eating. The MDS recorded R1 had one non injury fall since the last assessment. The Quarterly MDS dated [DATE] documented the resident with a BIMS score of three, which indicated she had severely impaired cognition, and poor safety awareness. The resident used a wheelchair for mobility and occasionally a rolling walker with staff assistance. This MDS recorded the resident was at risk for falls but had none since the previous assessment. The Care Area Assessment (CAA) for cognition dated 4/29/19 documented the resident continued with confusion much of the time, was able to make her needs known, and often needed redirection. She had no change in cognitive ability since last assessment, and the plan of care remained appropriate. The CAA for falls recorded the resident was at risk for falls and had at least one fall attempting to toilet self since the previous assessment. The CAA recorded she needed to rock her body and push off the arms of the chair when she attempted to stand. She had impaired balance during transfers and required staff assistance. The CAA documented the care plan would be developed to prevent falls with injury. The care plan, last revised on 10/31/19, for Fall Risk recorded the resident primarily used her wheelchair for mobility. The care plan directed staff to provide self-directed activities, continue with therapy, ensure the call light was within reach and encourage use. The care plan directed staff to keep R1's bed in the lowest position, and ensure she was wearing appropriate footwear when ambulating. The care plan, last revised on 12/23/19, for ADL's documented R1 required assistance to complete her ADL's and directed staff to help her bear weight, and to transfer her with use of a front wheeled walker and gait belt. It further directed staff to provide a self-locking wheelchair. The care plan recorded R1 was unable to walk without help. The updated care plan for Falls dated 12/23/19 lacked documentation of any new interventions implemented after the fall, including the application of a watchmate (a signaling device alerting staff a confused resident is near a facility exit). Review of the Incident Report in the EMR dated 12/20/19 at 4:43 PM recorded R1 was observed outside the physical therapy department door, on the ground, lying on her right side by her wheelchair with normal mentation (thought process). The report documented the possible cause as the resident fell out of her wheelchair and the resident hit her head. It documented that neurological checks were initiated and immediate first aid was given. A skin check was performed and revealed the following injuries: a 1-centimeter (cm) laceration in the corner of her right eye, 10 cm x 7.5 cm x 5 cm bruising to her anterior left hand, and a 4 cm in diameter purple round bruise to the right forearm near the right wrist and a reddish-purple bruise to her right forearm. The physician and family were notified on 12/23/19 at 11:36 AM. The entry indicated Licensed Nurse (LN) R was interviewed and stated the alarm to the physical therapy door going outside was sounding, staff responded immediately, and the resident was found. A radiology report for R1 dated 12/21/19 at 10:56 AM recorded acute nondisplaced fractures of the proximal phalanx (bone) of the 2nd, 3rd, and 4th fingers. On 12/23/19 at 10:00 [NAME]M. observation revealed two doors which had keyed locks that entered the Physical Therapy department off the 100 hall. Inside the physical therapy, another door was observed. That door was an alarmed fire door with a panic bar and 15 second delay. The door led outside of the facility. On 12/23/19 at 2:37 PM R1 sat in her wheelchair at the nurse's station with notable bruising to her right eye, right and left arms. Her left hand and fingers were swollen. Interviewed on 12/23/19 at 2:37 PM, R1 had noted confusion, word search difficulty, and reported she did not remember falling. R1 looked at the couch and stated, I would like to lay down on it. I'm just always tired, and then said, does the hand sometimes start to get better? The following witness statements were obtained on 12/23/19 at 2:00 PM: A notarized Witness Statement from Administrative Staff F read: I was notified by the (Administrative Staff C} at 4:45 PM per phone call that a watchmate bracelet was being placed on (R1's) left ankle due to her going out the physical therapy door. She had gotten into the physical therapy room by an inner door that was unlocked. I was not aware at that time that a fall or any injury had occurred. I then notified (Certified Physical Therapy Assistant (CPTA) N) at 5:20 PM that the therapy room door was found unlocked. On 12/21/19 I was notified at 7:50 AM per telephone from (LN J) as she wanted to clarify that an administrative nurse was notified of a fall with injury that occurred yesterday. I then spoke with Administrative Nurse [NAME] and she stated that she was aware of the fall with injuries. I arrived at the facility and assessed the resident and spoke with the family again and physician regarding her injuries. I took (R1) to (hospital) for x- rays and to have a cast placed on left hand due to three broken fingers on her left hand I then updated the family again, I also completed a new elopement assessment to reflect her need for a watchmate bracelet, checked all the physical therapy doors at that time to ensure they were locked. A notarized Witness Statement from CPTA N read: I left work (Physical Therapy Department) at 12:40 PM. Prior to leaving therapy department, I checked to ensure the whirlpool bath door was locked, the door that enters therapy department from nursing home was locked, the file cabinet was locked, and I exited through the door that leads to the North Village Apartments and I locked that door with a key. At 5:20 PM I received a text from (Administrative Nurse F) reporting that (R1) had gotten outside through the therapy department that, the door was not locked. I was informed that the resident was found by (Maintenance Staff X). A notarized Witness Statement from LN H read: In report, the night shift nurse reported that (R1) had fallen outside by the dumpster and that she had gotten out the exit door in the physical therapy room. She got into the physical therapy room by the door on the facilities side that was unlocked. The nurse also told me her injuries and to apply ice to her hand for twenty minutes three times a day. Interviewed on 12/23/19 at 11:00 AM CPTA N stated she remembered locking all the doors before she left the faciity on [DATE], but was told when R1 was found on the ground, the door was unlocked. She remembered locking the whirlpool room door and both doors to the therapy department when she left. CPTA N stated there is a duplicate key in a mail slot at the nurses station in case the nurses need to review a file. Interviewed on 12/23/19 at 3:00 AM Administrator A Stated it is unknown how the physical therapy department door was unlocked. He stated the facility was conducting interviews regarding the situation. On 1/2/2020 at 9:24 [NAME]M. The facility emailed additional information, however a requested facility policy related to accident prevention was not received. The facility failed to ensure this cognitively impaired independently mobile resident with a high fall risk received adequate supervision and appropriate interventions to prevent her from wandering to an outside locations, falling, and sustaining injuries related to that fall.

The facility reported a census of 86 residents. The sample included 20 residents, with 3 residents reviewed for falls. Based on record review, observation, and interview, the facility failed to ensure 1 resident (#1) received adequate supervision and assistance devices to prevent a fall, which resulted in a scalp laceration (a cut) that required treatment with staples. Findings included: - The electronic medical record (EMR) documented resident #1 had [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident required extensive assistance of one staff member with most activities of daily living (ADLs) such as bed mobility and transfers. The resident had no history of recent falls. The quarterly MDS dated [DATE] recorded no cognitive and/or functional changes in the resident's status. The MDS recorded no falls since the previous assessment. The care area assessments (CAA) dated 7/31/17 for ADLs documented the resident was unsteady on his/her feet, wore incontinent products and required frequent toileting. The CAA for falls recorded the resident had no recent falls, however, remained at a risk for falls, due to his/her dependence on staff for transfers, poor balance and periods of confusion. The CAA noted a care plan would be developed to prevent falls. The fall risk assessment dated [DATE] recorded the resident had a history of [REDACTED]. The resident's care plan, revised 1/10/18, directed staff to transfer the resident with one-person assistance and the use of a gait belt and walker. A nurse's note dated 3/11/18 at 10:47 P.M. documented the resident fell (while being assisted to transfer) in his/her room on 3/11/18 at 9:40 P.M., sustained a scalp wound and was transferred to the hospital at 9:45 P.M. The facility's investigation documented the resident fell on [DATE] at 9:40 P.M. Direct care staff S assisted the resident. Direct care staff S assisted the resident to stand and transfer from the wheelchair to the recliner with a walker. The investigation documented direct care staff S stepped toward the resident's bed to obtain the resident's night clothes. At this time, the resident lost his/her balance, fell backward to the ground, and hit his/her head on the bedside table. The facility's investigation concluded direct care staff S did not use a gait belt when he/she transferred the resident. A hospital emergency department's report dated 3/11/18 documented the resident sustained [REDACTED]. Direct care staff S's notarized witness statement dated 3/15/18 recorded he/she assisted the resident to his/her wheelchair. Staff S turned to get the resident's night clothes and the resident lost his/her balance and fell . Licensed nurse K's notarized witness statement dated 3/14/18 recorded on 3/11/18 at 9:40 P.M., staff notified him/her the resident fell . Upon examination, staff K noticed the resident did not have a gait belt on. Direct care staff R's notarized witness statement dated 3/15/18 recorded on 3/11/18, he/she assisted the resident's roommate. It documented direct care staff S stepped behind resident #1 to obtain the resident's night clothes. Direct care staff R heard a loud noise and looked up to see resident #1 fall. It further documented the resident hit his/her head on the bedside table. On 4/2/18 at 2:56 P.M. the resident sat in a recliner in his/her room. The laceration to the resident's scalp was healing. On 4/2/18 at 2:56 P.M. the resident stated he/she fell about three weeks ago, went to the hospital and received stitches (staples) in the back of his/her head. He/she stated direct care staff O let go of him/her to retrieve something from the bed. The resident stated he/she fell to floor and landed on his/her back, the resident further stated direct care staff S did not use a gait belt. On 4/5/18 at 4:00 P.M. direct care staff R stated direct care staff S did not use a gait belt with the resident during the transfer on 3/15/18. On 4/5/18 at 4:15 P.M. direct care staff S was not available for interview. On 4/9/18 at 4:40 P.M. administrative licensed nurse D stated, he/she expected staff to use a gait belt with all transfers and the facility conducted an all staff in-service on the use of gait belts for resident transfers.

The facility reported a census of 83 residents. The sample included 3 residents reviewed for elopement. Based on observation, record review, and interview, the facility failed to ensure 1 resident (#1) received adequate supervision and appropriate interventions to prevent elopement after staff identified the resident at risk for elopement. Resident #1 exited the facility on 2/13/16 without staff knowledge and walked at least 110 feet. Staff found the resident outside of the facility, 15 to 20 feet from the building, approximately 5 hours after the resident was last seen, in 24 degree wind chill temperature wearing only pajamas, lying on his/her back, next to the sidewalk. This deficient practice placed resident #1 in immediate jeopardy. Findings included: - The February 2017 physician's orders [REDACTED].#1 included [DIAGNOSES REDACTED]. The significant change Minimum Data Set ((MDS) dated [DATE] documented staff assessed the resident with severely impaired cognition, poor safety awareness, and rejection of cares with physical behaviors such as wandering, which placed him/her at significant risk to wander to a dangerous place. He/she walked with one staff member assistance and used a rolling walker. The MDS recorded the resident was at risk for falls and had two non-injury falls since the previous assessment on 10/30/16. He/she received insulin (injectable medication used to control blood sugar levels), anti-depressants (medication used to relieve feelings of sadness) and diuretic medications (medication used to remove excess fluid from the body). The Care Area Assessment (CAA) dated 12/21/16 for cognition recorded the resident admitted with failing cognition which had slowly worsened. He/she was determined and did not receive instruction easily, and often decided he/she would do something different or not at all, and was quite difficult to divert from that. The facility allowed him/her to direct his/her care as long as it was not dangerous to him/her. The elopement risk assessments dated 11/19/16 and 2/1/17 documented the resident was at high risk for elopement. The care plan dated 12/22/16 documented the resident wandered and was at risk for elopement, and directed staff to check his/her wander guard (a bracelet worn signaling device, that alerted staff when at risk residents neared a facility exit) to ensure its function. The care plan directed staff to check the resident every hour at night, assist the resident to toilet at night during the first and third rounds, and check sensor pad alarm (a signaling pad placed under the resident when in the bed or in the chair to detect movement) twice a day to ensure the alarm worked. Review of the facility nurse's notes dated 2/14/17 at 6:25 A.M. recorded at 3:50 A.M., staff observed the resident on the ground on the south side of the building in the grass next to the sidewalk laying on his/her back. The resident's feet bled, and he/she had darkness to his/her heels. When staff asked the resident about pain, the resident stated he/she had pain to his/her lower back of the head. Assessment revealed no signs of impact on his/her head. The resident could not state when he/she exited the facility, or how long he/she was outside. Direct care staff O assisted the resident to the wheelchair and took the resident inside. The resident's temperature was 93.4 degrees Fahrenheit (normal body temperature was between 97.3 and 99.1 degrees Fahrenheit). He/she responded to his/her name and was able to carry out simple commands. Staff called for an ambulance. This same nurses note dated 2/14/17 at 6:25 A.M. recorded licensed nursing staff H last saw the resident on 2/13/16 at 10:30 P.M. Direct care staff P last saw the resident on 2/13/16 at 11:00 p.m., when he/she assisted the resident to bed. After investigating the resident's room, the plug for the sensor alarm remained connected to the chair pad alarm and not the bed alarm. The bed alarm did not alarm because of this. The nurse's note dated 2/14/17 at 1:10 P.M. documented staff advised administrative nursing staff D of the resident's elopement with a fall. Staff found the resident on the sidewalk outside the nurses' office exit door, and the length of time outside was unknown. The resident had scrapes on his/her toes and, due to a concern of hypothermia (body temperature that was below normal), staff called for an ambulance. According to the facility investigation dated 2/14/17 at 1:10 P.M., staff reported they did not see, hear, or respond to the resident's bed sensor alarm or the door alarm alert on the pagers; however, the pagers worked well, along with the visual lights at the nurses' station. Licensed nurse H stated he/she reset the visual alarm without checking the nursing office door, because he/she thought it was for a different door where he/she observed an assisted living resident exit. When direct care staff O was in the resident's room on the first rounds of the night, he/she assumed the resident was asleep, and did not look behind the curtain to check on him/her. Review of the facility pager logs dated 2/13/17 at 10:37 P.M. to 2/13/17 at 11:45 P.M. documented on 2/13/17 at 10:46 P.M.; the resident's sensor pad alarm alerted the staff pagers (direct staff P confirmed this was when he/she assisted the resident to bed). The log documented the pagers received an alert at 11:01 P.M., which indicated the nursing office door had been opened. The log did not record an alert from the resident's sensor alarm after 10:46 P.M According to wunderground.com, the outside temperature on 2/14/17 at 3:53 A.M. was 30.9 degrees Fahrenheit with a clear sky. Winds were from the west at 6.9 miles per hour, and the wind chill factor was 24.3 degrees Fahrenheit. The hospital discharge Final Report dated 2/14/16 at 5:57 A.M. documented emergency medical services (EMS) brought the resident to the emergency room after the facility staff found him/her outside without shoes on or a coat. Facility staff last checked on the resident at 11:00 P.M. on 2/13/17. Facility staff discovered the resident outside at 3:30 A.M. on 2/14/17. EMS brought the resident to the hospital due to he/she shivered, appeared very cold, and had a temperature of 93.4 degrees Fahrenheit. Hospital staff warmed the resident at the time of the exam. He/she had a skin tear to his/her right elbow and scattered abrasions to both of his/her feet. The wounds were cleaned and dressed per nursing staff. The physician diagnosed the resident with hypothermia due to prolonged outside exposure. On 2/16/16 at 9:45 A.M. the resident's room was approximately 65 feet from the nurses' office exit door. The exit door had a panic bar which easily opened and led to a wheelchair ramp and sidewalk alongside the facility. On 2/16//17 at 10:05 A.M., the resident laid in bed with his/her head elevated, alert and responsive. On 2/16/17 at 10:25 A.M., the resident's family member stated the resident eloped from the facility 5 times before and always through the same exit door. On 2/16/16 at 9:45 A.M., administrative nursing staff E stated the door alarms, sensor pad alarms, wanderguard alarms, and call lights sent signals to staff pagers. Licensed nurse E stated the nurses' office exit door did not have a wander guard system (alert signal device for the wander guard bracelets). The door could be opened from the inside without a delay, but could not be opened from the outside. On 2/16/16 at 3:25 P.M., licensed nurse H stated he/she last saw the resident at 10:45 P.M. on 2/13/16, seated upright in his/her recliner and watched a basketball game. Staff H further stated he/she checked the sensor pad under the chair to ensure it was connected, which it was. On 2/16/17 at 3:43 P.M., direct care staff P stated the resident was known to wander and, at times, he/she forgot to take his/her walker with him/her. Staff P further stated when he/she transferred the resident from the recliner to the bed, the alarm in the recliner alerted the pager, and the alarm in the bed alerted as the resident sat down. (The alarm log dated 10/13/16 recorded the resident's pad sensor alarms signaled the pagers at 10:46 P.M. and 10:47 P.M.) The facility's undated Resident Elopement policy documented residents who were identified at risk would be noted with a history of elopement and the ability to be mobile. The admission note or change of condition note would document at risk residents and if a resident was at risk for elopement, the issue would be care planned and appropriate interventions implemented. The facility failed to ensure this resident, who staff identified as an elopement risk, received adequate supervision and appropriate interventions to prevent an elopement. Resident #1 exited the facility on 2/13/17 without staff knowledge, and was found outside of the facility approximately 5 hours later, in cold temperatures, and required immediate hospitalization for hypothermia and abrasions to his/her feet. This deficient practice placed resident #1 in immediate jeopardy. The facility abated the immediate jeopardy on 2/17/17 at 3:00 PM by implementing the following: The sensor alarm plugs were changed so both alarms can be plugged in at the same time. Elopement risk residents and interventions were added to the direct care staff's flowsheet, and were highlighted. The nurse signed off on the treatment assessment record (TAR). Staff education occurred 2/14/17 and 2/15/17. The resident's visual checks were increased to every thirty minutes. Nursing staff discussed interventions in their report to direct care staff every shift effective 2/16/17. Administrative nurses will interview nurses and direct care staff daily for 2 weeks, weekly for 4 weeks, then monthly indefinitely to ensure hourly checks have been completed. Staff education occurred immediately and again on 2/17/17 during in-service. A new nurse orientation sheet including the door alarms and pager system was implemented on 2/14/17 at 9:00 A.M A bar was installed on the nursing office exit door with a 15 second delay on 2/15/17at 2:30 P.M. Maintenance will check all door alarms weekly. Administrator will verify weekly with maintenance these checks were being completed. Quality Assurance will spot check pad alarms, door alarms and interview random staff members daily for 2 weeks, then weekly for 4 weeks, then monthly to ensure policies were being followed. This information will be reviewed in QA meetings indefinitely. The deficiency remained at a scope and severity of a G.

The facility had a census of 86 residents. The sample included 17 residents. Based upon record review, observation and interview the facility failed to provide adequate treatment and services to prevent pressure ulcers for 1 (#87) of 1 sampled resident. Findings included: - Resident #87's Physician order [REDACTED]. stenosis (narrrowing of the spinal column in the neck). The POS also included staff applied and changed a polymen dressing to the resident's Stage 2 pressure ulcers on the back of the resident's left lower leg and heel. The resident's admission Minimum Data Set ((MDS) dated [DATE] identified the resident scored 00 (severely impaired cognition) on the Brief Interview for Mental Status (BIMS) and had behaviors. The MDS identified the resident required extensive staff assistance with bed mobility, transfers, walking in the corridor, dressing, eating, was totally dependent upon staff for personal hygiene, toilet use, and locomotion on/off the unit. The MDS included the resident was at risk for the development of pressure ulcers and did not have unhealed pressure ulcers. The resident's significant change assessment dated [DATE] identified the resident scored 04 (severely impaired cognition) on the BIMS, had behaviors, required extensive staff assistance with bed mobility, transfers, the activity of walking in the room/corridor did not occur, was totally dependent upon staff for locomotion on/off the unit, dressing, toilet use and personal hygiene. The MDS identified the resident was at the risk for the development of pressure ulcers, had (1) Stage 2 pressure ulcer present upon admission/reentry and the date of the oldest pressure ulcer was 7/25/14. The MDS identified the resident had an open lesion on his/her foot, utilized a pressure relieving device for his/her bed and chair, and was not on a turning/repositioning program. The resident's Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 8/26/14 included the resident required extensive staff assistance with ADLs, was unable to do by himself/herself and was not aware of his/her needs and safety. The resident's pressure ulcer CAA dated 8/26/14 documented the resident had a pressure ulcer on the outer aspect of his/her left foot. The physician debrided the area and the resident was at risk for more breakdown. The resident's care plan last reviewed/revised on 11/7/14 included the resident required the assistance of 1 staff with ADLs. An entry dated 9/16/14 included the resident had an impairment in skin integrity, the resident had a pressure ulcer on his/her left heel, stasis ulcers present times 3 on his/her left calf. Staff assessed the resident's condition daily and documented any changes and staff measured the areas twice a week. Staff minimized pressure on the resident's bony prominences, the resident slept in a recliner so an air mattress was not appropriate. An entry dated 9/21/14 included staff applied a Roho cushion (pressure relieving device) under both of the resident's lower legs when the resident sat in the recliner and ensured the resident's heels dangled over the edge of the ROHO cushion. The care plan did not address the resident was on a turning/repositioning program. The resident's laboratory report dated 7/23/14 included the resident's [MEDICATION NAME] level was low at 3.2 grams/deciliter (normal refrence range 3.4 to 5.0 grams/deciliter). The resident's Skin/Foot condition reports dated 7/22/24 included the resident had a bunion like area on the outer aspect of his/her left foot, the area was reddened and painful and the resident wore no shoes that day. The resident's Skin/Foot condition report dated 7/25/14 included the resident had a Stage 2 pressure ulcer on the posterior aspect of his/her left foot near the great toe joint. The depth was unknown due to a scab formation, the bunion area was approximately the size of a quarter with an open area in the center that measured approximately 0.2 centimeters (cm) and staff applied a bunion pad over the area. The resident wore TED hose, recently had severe [MEDICAL CONDITION] and the [MEDICAL CONDITION] combined with the TED hose caused pressure and the resident's family was looking into purchasing the resident diabetic shoes. The resident's Skin/Foot condition report dated 8/5/14 included the resident had a Stage 2 pressure ulcer on his/her left outer foot that measured 0.2 cm in diameter, the resident wore a slipper sock only on that foot. The resident's Skin/Foot condition report dated 8/27/14 documented the resident had a Stage 2 pressure ulcer on the outer aspect of his/her left foot. The record lacked documentation regarding the area after that date. Observation on 11/13/14 at 10:25 A.M. revealed the resident did not have unhealed pressure ulcer on the outer aspect of his/her left foot. The resident's Skin/Foot condition report dated 9/16/14 documented the resident had a Stage 2 fluid filled blister pressure ulcer on his/her left heel. A Stage 2 pressure ulcer on his/her left leg directly toward the bottom of his/her left calf that measured 1.3 cm by 1.3 cm with an unknown depth due to a dark colored scab. The report also included the resident had a Stage 2 on his/her left lower calf that measured 1.7 cm by 1.3 cm with a depth of 0.1 cm. The report included the resident had a Stage 2 pressure ulcer on his/her left leg right above the heel area that measured 2.5 cm by 1.7 cm with a depth of 0.2 cm and a dark thin scab was present in the wound bed. The facility received a physician's orders [REDACTED]. The resident's skin condition report dated 9/23/14 documented the Stage 2 pressure ulcer directly above the resident's left heel measured 2.8 cm by 1 cm and the pressure ulcer was brown. The Stage 2 pressure ulcer on the bottom half of the the resident's left calf measured 0.6 cm by 0.7 cm with an unknown depth due to a brown colored scab. The Stage 2 pressure ulcer on the resident's left lower calf measured 0.7 cm in diameter and had a depth of less than 0.1 cm. The Stage 2 pressure ulcer on the resident's left leg directly above the heel area measured 1 cm by 2 cm with a depth of 0.1 cm, the area contained 60 percent (5) pink tissue and 40% tan tissue. Documentation included staff placed a Roho cushion (pressure relieving device) under the resident's legs when the resident sat in the recliner. According to the skin condition report the Stage 2 pressure ulcer on the bottom half of the resident's left calf healed on 9/30/14. The Stage 2 pressure ulcer on the resident's lower calf measured 0.2 cm in diameter and the Stage 2 pressure ulcer on the resident's left heel measured 3 cm by 1.7, the area was no longer fluid filled, the skin was brown in color and intact. The Stage 2 pressure ulcer on the resident's left leg directly above the heel measured 2.5 cm by 1.4 cm and had a yellowed colored center. Staff applied Santyl (a [MEDICATION NAME] ointment) with a [MEDICATION NAME] dressing and wrapped the area. According to the resident's skin condition report the pressure ulcer on the resident's left lower calf resolved on 10/17/14. The Stage 2 pressure ulcer on the resident's left heel measured 2.5 cm by 1.0 cm and was tan in color. The The Stage 2 pressure ulcer directly above the resident's left heel measured had a depth of 0.1 cm and measured 1.5 cm by 0.9 cm. According to the resident's skin condition report the Stage 2 pressure ulcer on the resident's left heel resolved on 10/24/14. The Stage 2 pressure ulcer on the resident's left leg directly above the heel measured 1.5 cm by 0.4 cm with serous drainage. The resident's skin condition report dated 11/11/14 documented the Stage 2 pressure ulcer directly above the resident's left heel measured 1.2 cm by 0.3 cm was tan in color and had an unknown depth due to a scab formation. A Physical Therapist note dated 9/23/14 included staff moisturized the resident's skin twice a week on bath days, but not between the resident's toes. Staff applied a short stretch compression wrap to the resident's foot and leg on in the A.M. and off in the P.M. and rewrapped during the day as needed. Staff performed a daily dressing change with Santyl and [MEDICATION NAME] and applied a gauze top dressing. Staff continued to offload the resident's heel and ankle with the Roho cushion. A PT note dated 10/7/14 documented the wounds were healing well. The resident continued to have [MEDICATION NAME] covering the wound bed of the largest wound and all other wounds are closed. Nursing staff continued Santyl, and compression for 1 week, then discontinue the Santyl and use a foam dressing and changed it twice a week after baths and to continue with the short stretch compression wrap until healed. The resident's clinical record lacked evidence to support the facility thoroughly assessed the resident's position when the resident sat in the recliner to ensure pressure was not applied to the resident's bony prominences when the resident sat in the recliner. The resident's clinical record lacked evidence to support staff offloaded the resident's heels/legs prior to the development of the pressure ulcers. On 11/13/14 at 7:10 A.M. staff propelled the resident toward the dining room. Observation revealed the resident's wheelchair had a pressure relieving device. On 11/13/14 at 7:25 A.M. the resident ate his/her breakfast meal which consisted of a bowl of cream of wheat, biscuit and gravy, bacon, apple juice, coffee and water. The resident had consumed 50 percent (%) of the cream of wheat, 75% of the biscuit and gravy and all of the bacon. Observaiton revealed the resident ate independently. On 11/13/14 at 7:35 A.M. the resident had consumed all of the food and liquids. On 11/13/14 at 12:20 P.M. the resident sat in his/her wheelchair at a dining room table and ate the lunch meal which consisted of chicken pie, broccoli salad, slice of pear pie, water and coffee. On 11/13/14 at 12:30 P.M. the resident had consumed 25% of the chicken pie and brocoli salad and was eating the slice of pear pie. The resident stated the food hurt his/her cavities and therfore he/she was not going to eat it. On 11/13/14 at 12:35 P.M. the resident conumed all of the pie and 25% of the food as noted. There was no evidence to support staff offered the resident an alternative to the meal. On 11/14/14 at 10:25 A.M. licensed nurse M performed the dressing on the pressure ulcer directly above the resident's heel on the resident's left foot. Observation revealed the pressure ulcer measured approximately 1.0 cm by 0.25 cm and licensed nurse M described the pressure ulcer as tan in color and a dark colored scab in the center of the wound bed. Observation confirmed the description of the pressure ulcer as described by licensed nurse M. Licensed nurse M stated the resident originally had 3 pressure ulcers on his/her left foot/leg due to the resident's legs/feet rubbed against the foot rest of the recliner. Licensed nurse M stated after the development of the areas staff placed the Roho cushion under the resident's legs/feet when he/she sat in the recliner. Licensed nurse M stated the resident had slept in the recliner since a week after the resident's admission to the facility. Licensed nurse M stated the facility did not offload the resident's feet/legs when the resident sat in the recliner until after the development of the pressure ulcers. On 11/13/14 tat 1:00 P.M. and 2:00 P.M. the resident sat in the wheelchair. On 11/17/14 at 7:10 A.M. the resident sat in a Broda chair. On 11/17/14 at 10:30 A.M. the resident sat in a recliner, the foot rest of the recliner was elevated and a Roho cushion was under the resident's legs/feet. On 11/17/14 at 10:45 A.M. direct care staff T stated the resident slept in the recliner. Direct care T stated staff was not on a turning/repositioning program because staff toileted the resident at least every 2 hours. On 11/17/14 at 2:31 P.M. licensed nurse L stated the resident had slept in the recliner since a week or so after admission. Licensed nurse L stated prior to the development of the pressure ulcer on the resident's left heel/calf staff did not offload the resident's legs/feet. Licensed nurse L stated the facility as well as the physical therapist identified the areas as pressure ulcers. On 11/17/14 administrative nursing staff stated the resident developed the open areas while in the facility. Administrative nursing staff D stated he/she was not sure if the areas were considered pressure or stasis ulcers. Administrative nursing staff D stated staff did not offload the resident's legs/feet until after the development of the open areas. On 11/19/14 at 9:13 A.M. physical therapy staff consultant II stated the areas on the resident's left calf and heel would be labeled as pressure ulcers although the areas were not on a bony prominence. Physical therapy consultant II stated not all pressure ulcers are on bony promnences. Physicial therapy staff II stated the pressure ulcers were most likely caused from the resident's legs resting against the foot rest of the recliner. The facility failed to offload this resident's legs/feet when he/she sat in the recliner and also failed to deveop a turning/repositiong program for this resident assessed to be at risk for the development of pressure ulcers. According to the resident's skin condition reports this resident developed (3) facility acquired pressure ulcers and the pressure ulcer above the resident's left heel was an unstageable pressure ulcer.

- Resident #34 's Physician order [REDACTED]. The resident's significant change Minimum Data Set ((MDS) dated [DATE] included the resident scored 03 (severely cognitively impaired) on the Brief Interview for Mental Status, required extensive staff assistance with bed mobility, transfers, locomotion off unit, dressing, toilet use and personal hygiene and walking in the corridor, the activity of walking in room did not occur and required limited staff assistance with locomotion on the unit. The MDS identified the resident was not steady and was only able to stabilize with human assistance when moved from seated to standing position, walking, turning around and facing the opposite direction while walking and surface to surface transfers, had a functional impairment on one side of his/her upper and lower extremity, utilized a walker and a wheelchair. The MDS coded the resident was frequently incontinent of urine, was on a toileting program, and had 2 or more injury except major falls and 2 or more major injury falls since the prior assessment. The resident's ADL Care Area Assessment (CAA)dated 10/27/14 included the resident had recent falls and fractures and was unable to safely ambulate independently, required lots of reminders to ask and wait for help and staff would not leave the resident alone in his/her room. The CAA documented the resident's fibula (lower leg) and right wrist were fractured and the resident's right wrist was in a cast. The resident's Fall CAA dated 10/27/14 included staff toileted the resident every hour during the night and frequently reminded the resident the staff was there to assist him/her and the resident often forgot that he/she required staff assistance. The resident's Fall assessment dated [DATE] identified the resident scored 13. The resident's Fall assessment dated [DATE] identified the resident scored 21. According to the legend a score of 10 and higher represented the resident was at high risk for falls. The resident's care plan last reviewed/revised on 11/4/14 included the resident was at a potential for injury related to a decline in his/her cognitive, the resident fell or nearly fell in the past 180 days, staff encouraged the resident to ask for assistance, instructed him/her on safety, and required frequent reminders. Staff reported all unsafe conditions and situations, ensured the resident's call light was within reach, toileted the resident before and after meals, and before activities and every hour from midnight to 6:00 A.M. every day. The resident required staff assistance of 1 with ADLs including transfers related to Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) and staff never left the resident unattended in his/her room. Staff performed 30 minute checks, had a low bed, a self locking wheelchair, a pad alarm on his/her bed that was connected to the call system. A fall and occurrence note dated 10/8/13 and timed 11:21 P.M. documented that at 5:20 P.M. the resident was on floor. Interventions included staff spoke with resident about not walking so fast as the resident had the habit of going at full throttle and kept his/her feet too close together and staff encouraged the resident to use his/her walker. Investigation interviewed staff, Resident stated tripped self when began to walk with walker, staff thought was steady on her feet after giving her the walker, almost had herself up by the time staff nurse got down the hall. There was no evidence to support the facility reassessed the resident for the causal factor of the fall. A fall and occurrence note dated 9/16/14 and timed 11:58 A.M. documented that at 10:30 P.M. the resident was on the floor. The resident ambulated without his/her safety device and urine was on the floor from the resident's bed to his/her bathroom. Interventions included staff toileted the resident before and after meals and before and after activities. There was no evidence to support the facility reassessed the resident for the causal factor of the fall. An X-ray report dated 9/17/14 included the resident had pain after a fall. The impression of the x-ray included the resident had a minimally displaced fracture in the region of the head of the left fibula. A fall and occurrence note dated 9/19/14 and timed 6:44 A.M. included at 4:30 A.M. the resident was on the floor in his/her room and had a right scalp laceration. The note included staff entered the resident's room and told the resident to get up and go to the bathroom. The staff then went next door while the resident got up. Staff heard the resident hit the floor, entered the resident's room and the resident laid at the foot of his/her bed with blood coming from his/her scalp. Staff assisted the resident into the bed and instructed the resident to hold a "rag" over his/her forehead while he/she located the nurse. Prior to the beginning of the shift, the staff was informed the resident fell two days ago and the resident should be assisted to the bathroom and the staff stated he/she forgot. Intervention included staff assisted the resident with all ambulation. There was no evidence to support the facility reassessed the resident for the causal factor of the fall. A fall and occurrence note dated 9/23/14 and timed 11:41 P.M. included at 9:05 P.M. the resident was on the floor in his/her room. The investigation note included staff toileted the resident after supper, the resident then spent the evening in activities playing bingo. When the activity was over, the resident went back to his/her room, apparently stood and fell from his/her wheelchair hitting his/her right arm against the sink. The resident complained of right wrist pain and the resident's right wrist immediately swelled. Interventions included staff performed 30 minute checks on the resident. There was no evidence to support the facility reassessed the resident for the causal factor of the fall. A hospital's discharge instruction form dated 9/23/14 and timed 10:40 P.M. included the resident had a fracture radius and ulna. A fall occurrence note dated 9/27/14 and timed 2:08 P.M. documented at 12:55 P.M. staff observed the resident on the floor in his/her room. The note included the resident attempted to ambulate independently to the bathroom. Interventions included a self locking wheelchair was already in place and staff initiated a low bed. There was no evidence to support the facility reassessed the resident for the causal factor of the fall. A fall occurrence note dated 10/21/14 and timed 11:07 P.M. included at 7:45 P.M. staff observed the resident on the floor and the resident's upper back scratched. The note included the resident sat on the side of his/her bed, slid down to floor, the bed was in the lowest position, the resident had taken off his/her shoes and in stocking feet. Intervention included the facility placed a mat bedside the resident's bed. There was no evidence to support the facility reassessed the resident for the causal factor of the fall. A fall occurrence note dated 10/23/14 and timed 3:22 A.M. documented at 3:00 A.M. the resident was on the floor in his/her room and the left side of the resident's back had an abrasion. The resident's bed alarm activated but staff could not get there fast enough. Intervention included staff performed 30 minute checks. There was no evidence to support the facility reassessed the resident for the causal factor of the fall. On 11/12/14 at 3:00 P.M. the resident laid in bed. Observation revealed the resident's bed in a low position, and a bed alarm in place. On 11/13/14 at 8:00 A.M. the resident sat in a wheelchair at the dining room table. On 11/17/14 at 12:30 P.M. direct care staff T transferred the resident from the wheelchair to the toilet via a gait belt. On 11/17/14 at 11:30 A.M. direct care staff T stated the resident was at risk for falls. Staff toileted the resident before and after meals, the resident had a low bed and no fall mat. Direct care staff T stated the fall mat presented more of a hazard the facility discontinued the use of the mat. Direct care staff T stated the resident required staff assistance with transfers and did not ambulate independently. On 11/17/14 at 2:36 P.M. administrative nursing staff D stated the resident was at risk for falls, fell and sustained 2 fractures during the month of September 2014. Administrative nursing staff stated the resident utilized a low bed, self locking wheelchair and a bed pad alarm. The facility failed to place timely and effective interventions and to reassess the resident to determine casual factors of the falls for this severely cognitively impaired resident with a history of falls who sustained a right wrist fracture and a left fibia fracture. - Resident #87's admission Minimum Data Set ((MDS) dated [DATE] identified the resident scored 00 (severely impaired cognition) on the Brief Interview for Mental Status (BIMS) and had behaviors. The MDS identified the resident required extensive staff assistance with bed mobility, transfers, walking in the corridor, dressing, eating, was totally dependent upon staff for personal hygiene, toilet use, and locomotion on/off the unit. The resident was not steady and was only able to stabilize with staff assistance when moving from seating to standing position, walking, moving on/off the toilet, surface to surface transfers, had a functional limitation on both sides of his/her upper extremity and on one side of his/her lower extremity and utilized a walker and a wheelchair. The resident fell within the last month, the last 2 to 6 months prior to admission, had a fracture related to a fall in the 6 months prior to admission and had not fallen since admission. The resident's significant change assessment dated [DATE] identified the resident scored 04 (severely impaired cognition) on the BIMS, had behaviors, required extensive staff assistance with bed mobility, transfers, the activity of walking in the room/corridor did not occur, was totally dependent upon staff for locomotion on/off the unit, dressing, toilet use and personal hygiene. The resident was not steady and was only able to stabilize with human assistance when moving from seated to standing, moving on/off the toilet, surface to surface transfers and the activity of walking did not occur, and had functional limitations on both sides of his/her lower extremities and utilized a wheelchair. The MDS identified the resident had not fallen since admission or the prior assessment. The resident's Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 5/8/14 included the resident required staff assistance with all ADLs, wanted to do things on his/her own but was unable and still thought he/she could at times. The resident was at risk for falls, needed constant monitoring, was independent prior to his/her hip fracture (prior to admission) and was able to do his/her own cares. The resident's ADL CAA dated 8/26/14 included the resident required extensive staff assistance with ADLs, was unable to do by himself/herself and was not aware of his/her needs and safety. anymore. The resident's Fall CAA dated 5/8/14 documented to see the resident's fall assessment and balance test. The resident's Fall CAA dated 8/26/14 included the resident was at risk for falls, was non weight bearing on his/her left leg, did not remember that, and needed many reminders and interventions. The resident's Fall assessment dated [DATE] identified the resident scored 22 (a score of 10 or higher represented the resident was at risk for falls). The resident's care plan last reviewed/revised on 11/7/14 included the resident had a self care deficit and required staff assistance of 1 with ADLs, staff toileted the resident before and after meals, at bedtime and as needed per his/her request, and staff ensured the resident's call light was within reach. The care plan addressed the resident had impaired physical mobility related to a history of falls and a hip fracture. Staff monitored the resident's mobility, the resident utilized a self-locking wheelchair and staff frequently reminded the resident to ask and wait for help. Staff monitored the resident closely and anticipated the resident's fall times. The facility had interventions in place to prevent the resident from standing alone and falling. The resident did not sleep in a bed, preferred to sleep in a recliner in the sitting area by the nurse's station. Due to his/her sleeping preference a pad alarm and monitor was not able to be used and with the position of the recliner staff was able to constantly observe the resident. Staff did not leave thee resident unattended when toileting, unless the sit to stand lift was in a locked position. A fall occurrence note dated 6/4/14 and timed 8:49 A.M. included at 6:15 A.M. the resident was on the floor. The note included the resident was in the recliner, attempted to transfer himself/herself and fell . The resident stated he/she needed to go to the bathroom and attempted to transfer self. The note included the facility reviewed the resident's toileting program in relationship to the fall. Staff toileted the resident before and after meals, before bed and as requested by the resident. Intervention included the facility would ensure the resident wore properly fitting shoes versus slipper socks. There was no evidence to support the facility reassessed the resident to determine the causal factors of the fall. A hospital's History and Physical dated 6/4/14 included the resident fell at the nursing facility and fractured his/her left hip. The note included the resident had a past surgical history that included an Open Reduction and Internal Fixation (ORIF-a type of surgery used to repair broken bones) on his/her right hip on 4/26/14 (prior to the resident's admission to the facility). An Operative report dated 6/4/14 included the date of the operation was 6/4/14, Preoperative and Postoperative [DIAGNOSES REDACTED]. A fall occurrence note dated 7/12/14 and timed 10:37 A.M. documented at 8:10 A.M. the resident fell in another resident's bathroom. The resident was incontinent of urine and bowel. Intervention included included staff would toilet the resident immediately after breakfast. There was no evidence to support the facility reassessed the resident to determine the causal factors of the fall. An X-Ray report dated 7/26/14 and timed 10:10 A.M. documented at 7:45 A.M. the resident attempted to transfer by himself/herself and fell . Interventions included staff applied moisturizer each morning during care and continued to toilet the resident before and after meals. An X-Ray report dated 8/8/14 included the resident fell 2 weeks ago, was having severe pain, could not bear weight, had a recent hip pinning on 6/4/14 and no definite acute abnormality observed.. A Physician's progress note dated 10/2/14 included the resident's left hip fracture was not healing quickly. A fall occurrence note dated 10/22/14 timed 5:21 A.M. documented at 4:00 A.M. the resident slid out of the recliner. Intervention included if the resident was awake in the middle of the night, especially during rounds, staff transferred the resident to the wheelchair so he/she could move himself/herself about. There was no evidence to support the facility reassessed the resident to determine the causal factors of the fall. A nurse's note dated 11/14/14 and timed 8:15 P.M. documented the resident fell at 4:00 P.M. The resident partially stood up, leaned to his/her left and fell . The resident stated he/she did not need to use the bathroom, stated he/she was not going anywhere, he/she just wanted to see if he/she could stand. The note included the resident received a 1 centimeter (cm) skin tear at the base of his/her right thumb, a 1 cm scrape on his/her right middle finger, a 1 cm skin tear on hi/her left index finger, a 6 cm scrape on his/her left forehead, a 3 cm scrape on his/her left upper cheek bone and a 2 cm skin tear on his/her left upper cheekbone. The note included the facility would do a trial period with a Broda chair. The note included no interventions were implemented. There was no evidence to support the facility reassessed the resident to determine the causal factors of the fall. On 11/13/14 at 7:47 A.M. the resident propelled his/her wheelchair from the dining room down the hallway. On 11/13/14 at 12:00 P.M. direct care staff LL transferred the resident from the wheelchair to the toilet via the sit to stand lift. Direct care staff LL stated the resident did not need to toilet at 8:00 A.M. (after breakfast) and he/she toileted the resident between 9:30 A.M. and 10:00 A.M. Direct care staff LL stated staff toileted the resident every 2 hours or as requested. On 11/17/14 at 7:10 A.M. the resident sat in a Broda chair in a reclined position. Observation revealed the resident had red colored abrasions on his/her left forehead and left cheek bone. On 11/17/14 at 2:31 P.M. licensed nurse L stated the resident was at risk for falls. The resident fell out of his/her wheelchair on 11/14/14 and sustained the areas on his/her forehead and cheekbone. Licensed nurse staff L stated prior to Friday's fall the resident utilized a self-locking wheelchair and staff frequently toileted the resident. Licensed nurse L stated a week after the resident's admission the resident would not sleep in his/her room or his/her bed and since then slept in the recliner by the west nursing station. Licensed nurse L stated the resident fell and sustained a hip fracture since admission. On 11/17/14 at administrative nursing staff D stated the resident was at risk for falls, staff frequently checked on the resident, the resident slept in a recliner by the nurse's station, and during the day sat in his/her wheelchair by the nurse's station, therefore the resident was usually within staff's eyesight. Administrative nursing staff D stated prior to the resident's fall on Friday the resident utilized a self-locking wheelchair. Administrative nursing staff D stated one of the resident's falls resulted in a hip fracture. The facility failed to implement timely and effective interventions and also failed to reassess the resident for the causal factors of the falls for this resident with a history of falls and one of falls resulted in a hip fracture. - Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] included the resident scored 15 (cognition intact) on the Brief Interview for Mental Status, had no behaviors, required extensive staff assistance with bed mobility, transfers, dressing and personal hygiene. The MDS included the resident was totally dependent upon staff with toilet use, locomotion on/off the unit and the activity of walking on/off unit did not occur. The resident was not steady and was only able to stabilize with human assistance when moving from seated to standing position, moving on/off the toilet and surface to surface transfers. The resident had no functional limitation in range of motion, utilized a walker and wheelchair, was frequently incontinent of urine and was on a toileting program. The MDS identified the resident had 2 or more no injury falls since the prior assessment. The resident's Activity of Daily Living (ADL) Care Area Assessment (CAA) dated 5/22/14 included the resident had a history of [REDACTED]. The resident's Fall CAA dated 5/22/14 included the resident had difficulty maintaining a standing position and had an impaired balance. The resident's care plan last revised on 11/4/14 addressed the resident had an alteration in thought processes due to an intellectual disability (a disability characterized by significant limitations in both intellectual functioning and in adaptive behavior), had a self care deficit related to a muscular skeletal impairment, required staff assistance of 1 with transfers via the sit to stand lift and utilized (2) ? rails at the head of his/her bed to promote bed mobility. The resident had difficulty with decision making, when staff reminded the resident of his/her safety issues the resident displayed anger and resisted assistance when needed. The resident had a potential for falls due to a decrease in muscle strength, and had a history of [REDACTED]., and frequently reminded the resident to stay in the Broda chair and to attempt to stand without staff assistance. An entry dated 8/14/14 included staff frequently reminded the resident to get close to things in his/her room and to not attempt to reach out and fall out of his/her Broda chair, staff kept the resident's closet door shut when not in use. An entry dated 9/21/14 included the resident utilized a Broda chair with foot pedals and staff ensured the Broda chair was lowered from the upright position after meals. A fall and occurrence note dated 10/26/13 and timed 3:34 P.M. included at 2:39 P.M. the resident was in the central bathroom, had already used the bathroom, stood up and tried to bend down to pick up a paper towel he/she had dropped and lost his/her balance. The resident had an abrasion on his/her right knee that measured 1.0 centimeters (cm) in diameter. Interventions included the resident would no longer use that bathroom, was told of the interventions but the resident may not follow the interventions. Staff notified the activities and kitchen departments as staff sometimes wheeled the resident to the central bathroom upon the resident's request. A fall and occurrence note dated 12/5/13 and timed 5:55 A.M. documented on 12/4/13 at approximately 6:30 P.M. the resident reported to the off going charge nurse that he/she fell and the resident complained on left shoulder pain. Interventions included a possible high rise toilet, toilet support grab bars and non skid strips on the floor. The resident stated he/she had to use the toilet, was in a standing position in his/her bathroom facing toward his/her room, was just standing, fell and hit his/her shoulder on the toilet. A fall and occurrence note dated 1/24/14 and timed 10:06 A.M. documented at 9:16 A.M. staff observed the resident on the floor in his/her bathroom. The resident stated he/she was getting off of the toilet, lost his/her balance and fell . Staff suggested the resident allowed staff to assist him/her with toilet use and the resident became upset with the idea. The resident at the time of the fall was using the toilet in his/her room and not in the public restroom which was an issue in the past. The clinical record lacked evidence the facility did a roo cause analysis to determine the cause fo the fall. A fall and occurrence note dated 5/2/14 and timed 5:14 P.M. documented staff observed the resident on the floor in his/her room. The resident stated he/she stood up to shut his/her door, lost his/her balance and landed on his/her bottom. Interventions included staff reminded the resident that he/she required staff assistance due to numbness in his/her right leg. The clinical record lacked evidence the facility did a roo cause analysis to determine the cause fo the fall. A fall and occurrence note dated 5/13/14 and timed 3:15 P.M. documented staff observed the resident on the floor in the central bathroom. The resident stated he/she stood up to spit in the sink, lost his/her balance and fell . Interventions included staff provided the resident a cup for the resident to spit in and reminded the resident he/she was not to stand without staff assistance. The clinical record lacked evidence the facility did a roo cause analysis to determine the cause fo the fall. A fall and occurrence note dated 5/16/14 and timed 1:06 A.M. documented at 10:15 P.M. staff observed the resident on the floor in his/her room. Direct care staff asked the resident to wait for him/ her to assist him/her to get dressed for bed. The direct care staff went to finish his/her previous duties and upon his/her return found the resident on his/her knees in front of his/her bed and the resident had an abrasion on his/her right knee. Dycem was in the resident's wheelchair and when staff assisted the resident back into his/her wheelchair the resident reached for something and almost fell out of the wheelchair. Interventions included staff consulted with physical therapy about a Broda chair, staff reminded the resident constantly to ask for staff assistance and to not bend down and reach for things on the floor. The resident had several falls, had recently slid from the wheelchair and refused help from staff. The resident now utilized a Broda chair and dycem was placed in the chair to help keep the resident from sliding. A fall and occurrence note dated 8/1/14 and timed 5:08 A.M. documented on 7/31/14 at 5:30 P.M. staff observed the resident on the floor. The resident attempted to stand up on his/her own. Interventions included staff encouraged the resident to not attempt to get up by himself/herself and the resident's call light was not within reach. The facility educated direct care to not leave the resident alone in his/her room without a call light within reach because the resident was unable to move his/her chair freely around the room. The facility educated staff when the resident sat on the edge of the chair, do not just tell the resident to slide back but to also ask the resident if he/she needed anything to prevent the resident from having a reason to get up by himself/herself. The facility encouraged staff to propel the resident down to the dining room before staff assisted other residents. A fall and occurrence note dated 8/13/14 and timed 5:29 A.M. documented on 8/12/14 at 10:45 P.M. staff observed the resident on the floor in his/her room. The resident attempted to stand without staff assistance and without an assistive device. Interventions included the facility educated staff on the need to keep the resident's closet door shut and to ensure the resident's room was picked up and neat and staff encouraged the resident to utilize the call light. . A fall note dated 9/19/14 and timed 12:26 A.M. documented on 9/18/14 at 8:00 P.M. staff observed the resident was on the floor in his/her room. The resident stated he/she slid out of the Broda chair and staff reminded the resident to not lean forward in his/her chair because the resident easily lost his/her balance and reminded the resident to ask for assistance when necessary. The Broda chair was not in a low position and the resident sat upright and the facility educated staff that the Broda chair must be returned to a low position after meals and activities. On 11/13/14 at 8:15 A.M. the resident sat in the Broda chair at a dining room table. On 11/13/14 at 4:50 P.M. the resident sat in the Broda chair and staff propelled the resident up the hallway. Observation revealed the Broda chair had foot pedals in place and the Broda chair was in a reclined position. On 11/17/14 at 7:20 A.M. the resident sat in the Broda chair in his/her room. Observation revealed no foot pedals in place, the resident sat forward in the chair, and attempted to propel the chair with difficulty. The resident stated he/she utilized the Broda chair because he/she had fallen and could not walk. The resident also stated he/she could not maneuver the Broda chair. On 11/17/14 at 11:40 A.M. the resident sat in the Broda chair and staff propelled the resident. Observation revealed no foot pedals in place and the Broda chair was in a reclined position. On 11/17/14 at 2:25 P.M. licensed staff L stated the resident was at risk for falls and utilized a Broda chair to minimize falls. Licensed nurse L stated staff reminded the resident to ask for staff assistance and to reach for things on the floor and staff ensured the resident's closet door was closed and ensured the resident's bed was in a low position. On 11/17/14 at 3:43 P.M. administrative nursing staff D stated the resident was at risk for falls, staff ensured the resident's bed was in a low position and utilized a Broda chair for positioning to prevent falls. On 11/17/14 at 11:44 A.M. direct care staff T stated the resident was at risk for falls and staff toileted the resident before and after meals. Direct care staff T stated the resident utilized a Broda chair and a low bed to minimize falls and staff reminded the resident to ask for staff assistance for transfers. The facility failed to do a root cause analysis and failed to place timely and effective fall interventions in place for this resident with an intellectual disability and a history of falls. - On 11/10/14 from 2:35 P.M. to 3:16 P.M. water temperatures were taken on all halls of the facility. The temperature of the water temperatures were as follows: Observation revealed the water temperature in 3 rooms on the SouthWest hallway were 127.9 degress Fahrenheit (F), 128.1 degrees F, 127.7 degrees F. Two resident's rooms water temperature on the NorthWest Hallway measured 127.9 degrees F and 117.5 degrees F. Seven resident's rooms water temperature on the NorthEast Hall measured 126.5 degrees F, 123.9 degrees F, 125.9 degrees F, and 124.8 degrees F, 126.1 degrees F, 126.8 degrees F, 126.5 degrees F and 127.4 degrees F. A resident's room on the SouthEast hall water temperature measured 126.6 degrees F. During interview with maintenance staff X on 11/13/14 at 3:15 P.M. the staff stated he/she adjusted the temperature of the water heater which increased the temperature of the water. Maintenance staff X accommpained the surveyors to 2 of the resident's rooms and confirmed the water measured at 127.9 and 128.1 degrees F. Review of the facility water temperature logs from 8/14 to 11/9/14 revealed the facility measured the water temperatue in 4 residents rooms on a weekly basis (different rooms). Further review revealed the temperatures ranged from 108 degrees F to 116 degrees F. The facility's undated Water Temperature Monitoring Policy and Procedure included the facility maintained a hot water distribution system with temperatures that are safe for residents and staff in the normal range of 98 degrees F to 120 degrees F. The facility failed to ensure water temperatures in resident's rooms were maintained at a safe level. - On 11/10/14 during Stage 1 of the survey observation revealed a melon sized hole in the bathroom floor with a pipe in the center of the hole. Further observation revealed the hole covered with a moveable trash can. Observation revealed resident #70 who resided in the room ambulated independently and was identified as having moderately impaired cognition. Observation also revealed several residents with wandering tendencies on the west hall. During interview with administrative staff A on 11/10/14 at 4:15 P.M. he/she stated the room had a water leak in the shower area of the resident's room. The facility failed to ensure the resident's room was as free from accident hazards as possible. The facility had a census of 86 residents. The sample included 17 residents. Based upon record review, observation, and interview, the facility failed to provide fall interventions for one resident #44, timely interventions and reassessment of root cause analysis for 2 residents with falls, (#34, #1), failed to maintain safe hot water temperatures, and failed to ensure resident rooms were free of accident hazzards. Findings included: - The quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] for resident #44 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. He/she displayed signs and symptoms of delirium (sudden severe confusion, disorientation and restlessness) as evidence by

The facility identified a census of 85 residents. The sample included 14 residents. Based on observation, interview and record review the facility failed to provide appropriate interventions to prevent falls for 1 of 3 residents sampled for accidents, (#48) identified to be at high risk for falls. Findings included: - Resident #48's electronic [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) 3.0 dated 12/17/12 documented the resident with a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severely impaired cognition. He/she required supervision with bed mobility, extensive assistance with transfers, walking and dressing and limited assistance with toileting. The resident was not steady moving from a seated to standing position, walking, turning around, moving on and off the toilet and with surface to surface transfers. The resident had impaired upper extremity range of motion on one side and was frequently incontinent of urine and always incontinent of bowel. There was a toileting program used to manage the resident's urinary continence. The resident had a fall in the last month prior to admission. He/she had a fracture related to a fall in the last 6 months prior to the admission. The Care Area Assessment (CAA) for incontinence dated 12/19/12 documented the resident had a long history of incontinence. He/she was able to recognize the time and place to void, wore pull ups and needed assistance to change the incontinent product. The resident reported he/she did not always make it to the toilet in time. The CAA for falls dated 12/19/12 documented the resident had a history of [REDACTED]. Since admitted to the facility he/she needed assistance to ambulate and was aware of how to use the call light. The resident's room was near the nurse's station. The quarterly Minimum Data Set 3.0 dated 7/29/13 documented the resident required extensive assistance for bed mobility, transfers, ambulation, dressing and toileting. He/she fell twice since the prior assessment. The Fall Risk assessment dated [DATE] documented the resident with a fall score of 18, which indicated the resident was high risk for falls. The fall score totals provided by the facility indicated a score higher than 10 represented a resident was high risk for falls. Review of the Voiding Diary dated 12/14/12 revealed staff did not check the resident hourly for incontinence and complete the assessment to establish a voiding pattern indicated on the form. The care plan for activities of daily living dated 2/14/12 directed staff to provide 1 person assistance with transfers, dressing, grooming and scheduled toileting. The resident had neuromuscular impairment with Parkinson's Disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, forward flexion of the trunk, loss of postural reflexes and muscle rigidity and weakness) and profound scoliosis (lateral curvature of the spine) and leaned to the left. The facility provided a physical therapy referral to assess his/her gait. Staff reviewed/updated the care plan on 2/11/13 and added self locking wheel chair brakes. On 2/25/13 up dated the care plan to reflect the resident was 50 percent weight bearing on the left leg. On 5/10/13 staff added new interventions for staff to keep the call light in reach, administer medications and observe for side effects. The resident had decreased functioning due to a right hip fracture. Staff toilet the resident before and after meals, at bed time and as needed and he/she wore pull ups. Review of the nurse's notes revealed staff documented the following: On 11/11/12 at 5:48 P.M. staff documented the resident was confused and in the living room with lights off and pants to his/her knees. No new interventions were added to the care plan to prevent the resident from falling. On 11/17/12 at 2:43 A.M. staff documented the resident was confused and thought there was water on the floor when there was not. On 11/27/12 at 9:10 A.M. staff documented the resident was very slow to comprehend things and required assistance to dress. On 12/09/12 at 2:00 A.M. staff documented the resident fell walking and tripped over a humidifier and sustained a skin tear to his/her right elbow and scrape on his/her right knee. Staff instructed the resident to turn on the lamp before getting up, but did not initiate any other fall interventions. On 12/12/12 at 4:43 A.M. staff documented the resident fell in the bathroom. Staff needed to check the resident more often, but did not specify how often and did not initiate any new fall interventions. On 2/10/13 at 6:30 P.M. staff documented the resident fell in his/her room and received a skin tear while attempting to transfer to the wheelchair. Staff initiated the intervention for self locking brakes on the wheelchair. On 2/12/13 at 4:15 A.M. staff observed the resident on the floor by his/her bed. The resident told staff his/her legs went out and caused the fall. Staff assessed the resident and assisted him/her to the bed. Staff found no injuries at that time. At 10:27 A.M. the resident complained of left thigh, knee and ankle pain. Staff were unclear of exactly what was hurting the resident. The physician was notified and an order was received to X-ray the resident. Further review of the resident's clinical record revealed the resident was admitted to an acute care hospital for a fractured right hip and returned to the facility on [DATE] at 1:30 P.M. with an order to be 50 percent weight bearing on the right leg. Review of the nurse's notes after the resident returned from the hospital with the broken hip revealed staff documented the following: On 3/2/13 at 10:37 A.M. staff documented the resident frequently attempted to transfer independently and had hallucinations. The record lacked evidence of new interventions to the care plan. On 3/6/13 at 4:00 A.M. staff documented the resident fell in his/her room while walking and suffered an abrasion to the top of the right foot. The resident was observed on the floor in front of the recliner. The call light was in place on the bed within reach. Staff assisted the resident up to the toilet and then transferred him/her back to bed. Staff turned the night light on in the room. No new interventions were added to the care plan. On 3/27/13 at 9:30 P.M. staff documented the resident fell in his/her room while attempting to transfer without staff assistance and fell on the floor in front of the wheelchair which resulted in a skin tear to his/her left forearm. Staff did not add fall interventions to the resident's care plan. On 4/18/13 at 6:30 A.M. staff documented the resident fell in the hallway while walking and lost his/her balance. The resident told staff he/she ambulated in the hall alone to see how long it would take staff to yell at him/her. Staff did not add any new fall interventions to the care plan. On 4/28/13 at 1:12 P.M. staff documented the resident fell in his/her room while walking and received a bruise to his/her right elbow. Staff documented the severely impaired resident was noncompliant with asking staff for assistance. Staff instructed the resident to use the call light. No new interventions were added to the care plan to prevent further falls. On 7/8/13 at 8:56 P.M. staff documented the resident fell in his/her room walking without staff assistance and the resident reported the fall was caused by a loss of balance. Staff reminded the resident to wait for assistance and use the call light. Staff did not add any new interventions to the care plan to prevent further falls. On 7/14/13 at 5:15 P.M. staff documented the resident fell while attempting to toilet himself/herself. The resident fell in the bathroom. Staff re-educated the resident to call for help and no new interventions were added to the care plan. Staff did not assess the resident's voiding pattern to establish the need for a new scheduled toileting plan. On 7/24/13 at 8:00 P.M. staff documented the resident fell in the bathroom attempting to toilet himself/herself and suffered a nickel sized bump on the back of his/her head. Staff observed the resident on the bathroom floor under the sink with his/her pants pulled partially down and bowel movement on the ground were the resident sat. Staff emphasized to the cognitively impaired resident the importance of using the call light for assistance. Staff did not assess the resident's bowel and bladder voiding pattern or add any new interventions to the care plan to prevent further falls. Observation on 8/8/13 at 12:07 P.M. revealed the resident sat in the recliner in his/her room. Observation on 8/8/13 at 12:08 P.M. of the nurse's desk revealed a small monitor with a picture of the resident's empty bed. The monitor did not display a picture of the resident who sat in the recliner. Observation on 8/8/13 at 12:44 P.M. revealed the resident sat in the wheelchair in his/her room. Direct care staff T asked the resident if he/she needed to use the toilet. The resident told staff he/she was elderly and did not always know when he/she needed to use the toilet and asked when the next opportunity to toilet would be. Staff informed the resident they would offer to toilet him/her before the next meal. Staff did not offer anymore encouragement to toilet the resident, but instead placed the gait belt around the resident and transferred the resident using extensive assistance and frequent cues to move his/her feet and sit down on the bed. Staff lowered the bed down to the floor. Staff did not place a fall mat by the resident's bed on the floor. During interview on 8/8/13 at 11:34 A.M. direct care staff U reported the resident was unsteady on his/her feet, leaned to one side and liked to do things on his/her own without calling staff for help. The video camera monitor at the nurse's desk was used by staff at night to see the resident while in bed. Staff kept the wheelchair away from the resident so he/she would be less eager to get up without staff assistance. When the resident was in bed, staff lower the bed down to the floor. The resident had self locking brakes on the wheelchair. During interview on 8/8/13 at 11:45 A.M. licensed nurse I reported the resident was high risk for falls, had balance issues, leaned to the left side and was not aware of safety and frequently tried to transfer independently which caused falls. When a resident fell the nurse assessed the resident and filled out an incident report in the computer and the system made staff put a fall intervention in place before the computer allowed the nurse out of the program. The resident had hallucinations in the past and was confused. The resident had a pad alarm which staff discontinued back in December 2012. Staff utilized fall interventions such as they lowered the bed all the way to the floor, the resident's room was as close as they could get it to the nurse's station the video monitor at night and toileting assistance. Staff reported the resident was frequently incontinent and did fall attempting to toilet independently. He/she acknowledged the voiding diary was incomplete and staff did not thoroughly assess the resident's incontinence to establish a voiding pattern. During interview on 8/8/13 at 12:44 P.M. direct care staff T reported the resident was at risk for falls and staff provided extensive assistance for transfers, toileting the resident before and after meals, and the resident would call to toilet at other times or independently climb out of bed and try to get to the toilet. During interview on 8/8/13 at 3:23 P.M. administrative nursing staff D reported the facility had tried to get rid of body alarms and there were only 2 pad alarms in the entire facility now. This resident had alarms which staff thought caused the resident more confusion so they discontinued them. Soon they planned to do a trial alarm with the resident that was not audible, but alerted staff to the pagers when the resident tried to get up. The facility did not have that alarm yet, but it was on order. Right now staff should lower the bed, use a landing strip mat by the bed and use the monitor/camera at night. Staff needed to put an appropriate intervention in place after each fall. Administrative staff D expected staff to attempt to educate the resident, but should have put more appropriate interventions in place after each time the resident fell and the care plan needed updated when the resident fell going to the toilet and was incontinent. The facility did not institute routine voiding diary use after a fall to determine a voiding pattern. Staff should complete a voiding diary upon the resident's admission, yearly and with significant changes. Staff should take the monitor with them during the night, but not during the day when the resident was out of bed. The care plan updated 5/10/13 lacked interventions for the monitoring of a fall landing mat. On 8/12/13 at 10:16 A.M. an interview was attempted with consultant physician II, however the physician was not available for interview. The facility provided a policy without a date entitled Fall Risk Assessment which directed staff to institute interventions for residents found to be at risk for falls. The facility failed to initiate timely and effective new interventions following this cognitively impaired resident's falls to prevent further falls resulting in a fracture and failed to utilize fall interventions as planned.