Every finding on record at Astoria Health & Rehab Center

Based on record review, staff interview and facility policy review the facility failed to notify the physician when medications were not administered. The affected one resident, (Resident #41) of three reviewed for medication administration. The facility census was 40. Findings Include:Review of Resident #41's medical record revealed an admission date of 03/05/26 and a discharge date of 04/01/26. Resident was admitted with diagnoses of rhabdomyolysis, chronic obstructive pulmonary disease, post-traumatic stress disorder, parkinsonism, anxiety disorder, essential (primary) hypertension, pain in unspecified shoulder, low back pain, fibromyalgia, and chest pain.Review of the 5- Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident 41 had moderate cognitive impairment. Resident required supervision assistance with eating and oral hygiene, required partial assistance with personal hygiene, bed mobility, ambulation, and wheelchair mobility, and required substantial assistance with toileting hygiene, bathing, dressing, and transfers. Resident was on two high-risk drug classes, antipsychotic and antianxiety medications.Review of the physician orders revealed an order dated 03/05/26 for Xanax (alprazolam) (antianxiety) 0.5 milligram (mg) tablet every four (4) hours for anxiety disorder.Review of the March 2026 Medication Administration Record (MAR) revealed Xanax (alprazolam) 0.5 mg tablet was held every 2:00 A.M. from 03/06/26 through 03/31/26 except on 03/10/26, 03/28/26, 03/29/26, and 03/30/26. Resident's controlled drug record also had no documentation the 6:00P.M. dose was provided on 03/28/26. Further review of the March 2026 MAR revealed no documentation was present indicating the reason the Xanax (alprazolam) 0.5 mg tablet was held.Review of the progress notes from 03/06/26 through 03/31/26 revealed no documentation of the physician being notified of the medications not being administered every 2:00 A.M. from 03/06/26 through 03/31/26 except on 03/10/26, 03/28/26, 03/29/26, and 03/30/26. Interview on 08/19/26 at 3:17 P.M. with the Director of Nursing confirmed the Xanax (alprazolam) 0.5 mg tablet every 2:00 A.M. was held from 03/06/26 through 03/31/26 except on 03/10/26, 03/28/26, 03/29/26, and 03/30/26. Interview also confirmed there was no documentation of the physician being notified of the Xanax being held or not administered. Interview confirmed that the physician should be notified when a medication is held. Interview also confirmed she spoke with one of the nurses today, who was responsible for some of the Xanax being held and she did not notify the physician of the Xanax being held.Review of the General Dose Preparation and Medication Administration policy dated 11/15/24 revealed staff should document when medication is refused.This deficiency represents non-compliance investigated under Complaint Number 3132622.

Based on record review, observation, review of facility policy, resident interview, and staff interview, the facility failed to ensure bed linens were applied to the beds of residents using an air mattress. This affected three (#27, #13, and #11) out of ten residents reviewed for linen use on beds. This also affected six residents (#2, #60, #33, #36, #15, and #40) identified by the facility to be using an air mattress on the bed and cognitively impaired. Additionally, the facility failed to have an adequate number of clean towels and washcloths on hand for resident care. This had the potential to affect all residents. The total census was 45.Findings include-1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease and type two diabetes mellitus. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #27 had moderately impaired cognition and required assistance to roll left and right in bed. Review of the provider orders dated 06/17/25 revealed an air mattress ordered for use to Resident #27's bed.Observation on 04/15/26 at 9:13 A.M. revealed Certified Nursing Assistant (CNA) #48 completing care for Resident #27. There was no flat sheet on the resident's bed covering the air mattresses. Interview at this time with CNA #48 confirmed they only use chux pads (incontinence pads) under residents with air mattresses and no sheet is used to cover the mattress.Facility identified Resident #27 has a Drive Air Mattress. Review of the Drive Air Mattress Owner's Manual, undated, revealed Drive air mattress support surfaces are designed to be used with appropriate linens. Deep pocketed fitted or flat sheets are recommended. 2. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE]. Diagnoses included occlusion and stenosis of bilateral carotid arteries, muscle weakness, neuralgia and neuritis, and age related physical debility.Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #13 had severe impaired cognition and required substantial assistance with rolling left and rolling right. Observation 04/15/26 at 9:25 A.M. revealed Resident #13 did not have a flat sheet between her and the air mattress.The facility identified that Resident #13 has a Drive Air Mattress. Interview on 04/15/26 at 9:35 A.M. with Clinical Support #4 revealed no flat sheets are used when residents have air mattresses, they only use chux pads.3. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction.Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #18 had moderately impaired cognition and required substantial assistance with personal care.Observation on 04/15/26 at 10:07 A.M. revealed Resident #18 was in the bed. Resident #18 had no sheet between him and the mattress, only a chux pad was observed in place.Facility identified that Resident #18 has a Drive Air Mattress.Interview on 04/15/26 at 10:37 A.M. with Clinical Support #4 confirmed no bottom sheet are used when residents have an air mattress, but some CNAs use just chux pads and some use a bottom flat sheet.Interview on 04/15/26 at 10:43 A.M. with Assistant Director of Nursing (ADON) #29 revealed when residents with an air mattress are on hospice, they do not use a bottom or flat sheet, only the chux pads. ADON #29 also stated it depends on the resident whether they should have a bottom sheet or not. ADON #19 could not answer how a CNA would know what residents were to use a bottom sheet. Interview on 04/15/26 at 10:56 A.M. with Licensed Practical Nurse (LPN) #19 revealed they only use the chux with residents who have air mattresses. No sheet or anything else is used between residents and the mattresses. Interview on 04/15/26 at 12:29 P.M. with CNA #14 revealed only use a chux pad with residents who have air mattresses. No sheet or anything else is used between residents and the mattresses. Interview on 04/15/26 at 1:40 P.M. with the Director of Nursing (DON) revealed if the resident wants a flat sheet under them then the staff will put one on. The DON also stated if a resident is cognitively impaired then they would not place a flat sheet under the resident.Interview on 04/16/26 at 8:14 A.M. with the ADON #29 confirmed that sheets should be used between residents and the air mattresses. ADON #29 confirmed the use of air mattresses manufacturers Span, Drive and Proactive Protek. The facility identified nine residents (#2, #11, #13, #15, #27, #33, #36, #40 and #60) who were cognitively impaired and use an air mattress. 4. Observation on 04/14/26 at 9:29 A.M, with Director of Maintenance (DOM) #20 and Housekeeper #18 in the only linen room revealed 14 towels and approximately 50 washcloths. There were 15-20 pieces of blankets cut into wash cloth size, with raggedy frayed edges, strings all over them and stains with the regular washcloths on the shelf ready for use. Interview at this time with Housekeeper #18 confirmed the cut up wash cloths have been put out for use with the regular wash cloths for a couple of weeks because the facility does not have enough wash cloths. Interview on 04/14/26 at 12:56 P.M. with the DOM #20 confirmed the cut up washcloths and stained washcloths were removed from the shelf.Interview on 04/14/26 at 1:02 P.M. with DOM #50 revealed 100 towels should be in the linen room and 150 washcloths should be in the linen room. The DOM #50 confirmed the facility has had a linen shortage of washcloths and towels due to staff possibly disposing of them after use. The DOM# 50 stated the Administrator orders them when needed. The DOM #50 also stated that on occasion, night shift staff would cut up blankets for washcloths when they ran out. DOM #50 confirmed blankets should not be cut up and used as washcloths.Observation and interview on 04/14/26 at 1:36 P.M. with Clinical Support #4 in the linen closet confirmed 38 cut up blankets for washcloths and four stained washcloths present. Interview on 04/15/26 at 10:56 A.M. with LPN #19 revealed they have ran out of washcloths and towels for residents.Interview on 04/15/26 at 12:29 PM with CNA #14 revealed they have ran out of washcloths and towels for bathing residents and don't have anything else to use. CNA #14 stated they will use towels as washcloths if no washcloths are available. CNA #14 stated washcloths that are cut up from a blanket are used if no washcloths or towels are available.Interview on 04/15/26 at 12:29 PM CNA #14 stated they have run out of towels and washcloths often in the last three months and feels can't give appropriate resident care. CNA #14 also stated cut up washcloths from blankets are sometimes on the shelves and will use them as a last resort. Interview on 04/15/26 at 1:40 P.M. the DON stated staff have come to her with concerns regarding running low on towels and washcloths. The DON stated this issue has been added to the Quality Assurance Performance Improvement (QAPI). The DON stated she was aware of the cut up blankets on the shelf with the other washcloths last week and threw them away. The DON was unaware of who was cutting them up. Review of the facility concern log dated 04/02/26 revealed Resident #56 reported no wash cloths were available. The result was to order 20 dozen more. Review of the admission Agreement dated 09/09/20, the facility will provide basic services as required by law to the resident including washcloths and towels.Review of the policy titled Laundering Processing of Linens, dated 04/2026, revealed linens will be laundered and processed in a manner which results in a clean and visually acceptable end product. This deficiency represents non-compliance investigated under Complaint Number 2726616.

Based on closed medical record review and staff interview, the facility failed to provide bed hold information to residents when hospitalized . This affected one Resident (#46) of one resident reviewed for hospitalization s. The facility census was 44. Findings include: Review of the closed medical record revealed Resident #46 was admitted on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had adequate hearing, clear speech, vision impairment, a Brief Interview for Mental Status (BIMS) score of 13 out of 15, signs of [MEDICAL CONDITION], and fluctuating periods and severity of inattention and disorganized thinking. The assessment further indicated the resident required extensive assist to total dependence for activities of daily living (ADLs). A review of the medical record revealed the resident was transferred to an acute care hospital emergency roiagnom on [DATE] after an acute change in condition. The medical record contained no evidence that bed hold information was provided to the resident or the resident's representative at the time of the hospitalization . Interview with Business Office Manager (BOM) #90 on 03/28/18 at 2:37 P.M. verified no bed hold notice was provided at the time of the hospitalization . BOM #90 further reported a bed hold notice was not warranted because the resident was discharged . Interview with Social Service Director (SSD) #50 on 03/28/18 at 3:41 P.M. revealed the resident's representative was planning to have the resident discharged to a different long term care facility, but the discharge had not occurred prior to the resident's hospitalization . SSD #50 verified the resident was hosptalized on [DATE] and not yet discharged . Review of a Bed Hold Notice provided by the facility documented, This notice is to be provided to the resident and his/her representative at the time of the transfer. In the case of an emergency, the paperwork should be provide within 24 hours.

Based on resident record review and staff interview, the facility failed to accurately complete minimum data set (MDS) assessments. This affected three Resident's (#34,#27 and #43) of 14 reviewed. The facility census was 44. Findings include: 1. Review of the medical record for Resident #34 revealed the resident was initially admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the document titled, Evaluation of Oral/Dental Status dated 04/03/17, revealed the resident had no teeth. Continued review of the medical record for Resident #34 revealed the resident was assessed by the dentist on 01/30/18. Dental assessment documentation revealed the resident was edentulous. Review of Resident #34's admission minimum data set (MDS) assessment dated [DATE], section L specific to dental, section B. No natural teeth or tooth fragments (edentulous) was documented no. Interview on 03/28/18 at 1:57 P.M. with Registered Nurse (RN) #100 verified the admission MDS assessment dated [DATE], section L specific to dental status was incorrect. RN #100 verified Resident #34 was edentulous. 2. Review of the medical record for Resident #27 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the document titled, Foley Catheter Justification dated 02/21/18, revealed Resident #27 had a urinary catheter in place to assist in healing of a perineal wound. Review of the admission MDS assessment dated [DATE], section H specific to bowel and bladder revealed no documentation of the indwelling catheter utilized by Resident #27. Observation on 03/27/18 at 9:39 A.M. of Resident #27 revealed a indwelling urinary catheter was in place. Interview on 03/27/18 at 9:40 A.M. with Resident #27 revealed the indwelling catheter was placed prior to admission to the facility. Resident #27 revealed the catheter was being used to assist with the healing of a pressure wound. Interview on 03/28/18 at 1:54 P.M. with RN #100 revealed Resident #27 had an indwelling catheter in place when the resident was admitted to the facility. RN #100 verified section H of the admission MDS assessment dated [DATE], for Resident #27 did not identify the use of an indwelling catheter. 3. Review of the medical record revealed Resident #43 was admitted on [DATE]. A review of the admission physician order [REDACTED]. The facility completed a comprehensive admission Minimum Data Set (MDS) assessment dated [DATE]. Section I of the assessment, which pertained to active diagnoses, contained no documentation of the resident's active [DIAGNOSES REDACTED]. Interview on 03/29/18 at 2:11 P.M. with Registered Nurse (RN) #100 verified the order sheet contained [DIAGNOSES REDACTED].

Based on medical record review, review of Minimum Data Set (MDS) assessments and staff interview the facility failed to have resident's re-screened for pre-admission screening and resident review (PASARR) level II services. This affected one Resident (#20) of two reviewed for PASARR II services. The facility census was 44. Findings include: Review of Resident #20's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review revealed the [DIAGNOSES REDACTED]. Review of a pre-admission screen (PAS) dated 06/16/15 revealed under section D (indications of serious mental illness) Resident #20 was documented as not having any of the mental disorders listed. Resident #20 was marked as being not applicable for PASARR II screening/services. Review of a significant change MDS assessment dated [DATE] revealed anxiety disorder, depression and [MEDICAL CONDITION] were checked as active diagnoses. Resident #20 did not have active [DIAGNOSES REDACTED]. Resident #20's brief interview for mental status (BIMS) score on this assessment was 15, cognitively intact. During further review of Resident #20's medical record no further PAS/PASARR screenings were found. During an interview on 03/28/18 at 4:52 P.M. Social Services Director (SSD) #50 confirmed Resident #20 was not be re-screened for PASARR level II services determination after the addition of major [MEDICAL CONDITION], panic disorder and [MEDICAL CONDITION] to her [DIAGNOSES REDACTED].

Based on medical record review, staff and resident interview, and review of facility policy, the facility failed to document the resident's participation in developing the care plan. This affected one Resident (#33) of one reviewed for care planning. The facility census was 44. Findings include: Resident #33 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had adequate hearing and vision, usually made self understood and understood others, had a Brief Interview for Mental Status (BIMS) score of three out of 15, had no potential indicators of [MEDICAL CONDITION], and required supervision for activities of daily living (ADLs). A Care Plan Conference Summary dated 03/06/18 revealed a care plan conference was attended by members of the interdisciplinary team and the resident's representative attended via telephone. The medical record contained no evidence the care plan was discussed with the resident or that it was not practicable for the resident to attend the care plan meeting. During an interview on 03/27/18 at 10:28 A.M., Resident #33 denied being invited to a meeting to discuss a care plan. Interview on 03/28/18 at 9:32 A.M. with Social Service Director (SSD) #50 revealed Resident #33 did not attend the care plan meeting because of the resident's cognition. SSD #50 verified the medical record contained no evidence that the resident was invited to or participated in the care plan meeting, or that it was not feasible for the resident to attend. Review of the Care Conference facility policy with revision date of 8/2015 revealed the facility would hold regular interdisciplinary care conferences for the purpose of providing resident, family, and team communication in planning and developing an individualized plan of care. The policy further indicated, Each resident shall be invited to participate in their conference. At the resident's discretion, the family shall be invited to participate also. The coordination of the care conference and documentation is the responsibility of the MDS Coordinator or his/her designee.

Based on record review and staff interview, the facility failed to timely schedule diagnostic services. This affected one (#34) of six residents reviewed for ancillary services. The census was 44. Findings include: Review of the medical record for Resident #34 revealed the resident was initially admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of neurological consultation documentation dated 01/19/18, revealed Resident #34 was scheduled for magnetic resonance imaging (MRI) of the cervical spine on 01/30/18. Review of the progress note dated 01/29/18 at 2:11 P.M. revealed the MRI scheduled on 01/30/18 for Resident #34 was canceled due to payer source. Further review of the progress note dated 02/23/18 at 2:58 P.M. revealed the MRI for Resident #34 was rescheduled for 02/26/18. The medical record contained no documentation of the facility attempting to reschedule the appointment prior to 02/23/18. Interview on 03/29/18 at 2:00 P.M. with the Director of Nursing verified the medical record for Resident #34 contained no documentation of the facility attempting to reschedule the MRI until 26 days after the appointment was canceled.

Based on medical record review, observation, interviews and review of an Admission Log the facility failed to inform residents of receiving new roommates. This involved two Residents (#12 and #25) of 23 residents interviewed. The census was 41. Findings include : 1. Record Review for Resident #12 revealed [DIAGNOSES REDACTED]. The most recent annual Minimum Data Set (MDS) dated on 01/08/16 revealed the resident had a BIMS score (a test to determine cognition) of 10 which was moderately impaired. Observation of Resident #12 on 04/05/16 at 9:00 A.M. revealed the resident was up in his wheel chair in the lobby . The resident was alert and oriented to self and place. During an interview on 04/04/16 at 2:18 P.M. with Resident #12, he revealed on 10/28/15 a new resident was admitted to the facility in was assigned to his room. Resident #12 stated he was not told of the new admission moving into his room. 2. Record Review for Resident # 25 revealed [DIAGNOSES REDACTED]. The most quarterly MDS dated on 12/31/15 revealed the resident had no cognitive deficient. Review of the Social Service notes revealed no entry of notifying the resident prior to receiving a roommate. Observation of Resident #25 on 04/05/16 at 11:00 A.M. revealed the resident was up in her wheel chair reading a book. The Resident was alert and oriented. During an interview on 04/04/16 at 5:12 P.M. with Resident #25, she revealed a new roommate was moved into her room and she was not informed. During a second interview on 04/07/16 at 10:00 A.M., Resident #25 indicated it would have been nice if staff had informed her. Interview with Social Service employee #200 on 04/07/16 at 11:00 A.M. revealed a notation was made in the charts after she talked with the residents. At this time she verified there was no notation in either residents chart that they were informed of new roommates. Review of the Admission log revealed from 10/2015 until 04/2016 revealed Resident #12 received a roommate on 10/28/15 and Resident #25 received a new roommate on 02/22/16.

Based on medical record review, staff interview and review of policy and procedure the facility failed to document narcotic medication administration on the Medication Administration Record (MAR). This affected two Residents (#1 and #43) of five residents reviewed for unnecessary medication. Facility Census was 41. Findings include: 1. Review of Resident #1's medical record was revealed the resident was admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Controlled Drug Record for Resident #1 revealed [MEDICATION NAME] (a narcotic pain medication) was signed off on the controlled drug record on 04/02/16 at 8:00 P.M. Review of the 04/2016 MAR revealed no documentation the [MEDICATION NAME] was administered to the resident on the above date and time. Further review of the Controlled Drug Record for Resident #1 revealed [MEDICATION NAME] (a narcotic anti-anxiety medications) was signed off on the controlled drug record on 04/02/16 at 8:00 P.M. and on 04/03/26 at 2:00 A.M. Review of the 04/2016 MAR for 04/2016 revealed no documentation the [MEDICATION NAME] was administered to the resident on the above dates and times. 2. Review of Resident #43's medical record was revealed the resident was admitted to the facility on [DATE] with pertinent [DIAGNOSES REDACTED]. Review of the Controlled Drug Record for Resident #43 revealed [MEDICATION NAME] (a narcotic pain medication) was signed off on the controlled drug record on 04/01/16 at 6:00 A.M., 6:00 P.M., and 10:00 P.M., on 04/02/16 at 6:00 A.M. and 04/03/16 at 11:30 P.M. Review of the 04/2016 MAR revealed no documentation the [MEDICATION NAME] was administered to the resident on the above dates and times. Further review of the Controlled Drug Record revealed [MEDICATION NAME] (a narcotic anti-anxiety medication) was signed off on the controlled drug record on 04/01/16 at 7:30 P.M., 04/02/16 at 10:00 P.M. and on 04/03/16 at 10:15 P.M. Further review of the 04/2016 MAR reveled no documentation the [MEDICATION NAME] was administered to the resident on the above dates and times. Interview with Licensed Practical Nurse (LPN) # 201 on 04/06/16 at 12:22 P.M. revealed he process for signing out a controlled substance included removal of the medication from the narcotic box, signing the controlled drug log, documenting the medication administration on the MAR after the resident had taken the medication and documenting the medication on the appropriate flow sheet, either the behavior tracking form or the pain flow sheet. LPN #201 further revealed the nurse is to chart the effectiveness of the medication on the MAR and on the appropriate tracking form as well. During an interview conducted on 06/16/16 at 2:40 P.M. with the Director of Nursing, she verified the missing documentation of the narcotics on the MAR for Resident #1 and #43. Review of the form titled LTC facility's Pharmacy Services and Procedures Manual Policy 6.0 General Dose Preparation and Medication Administration revealed the Staff should document administration of controlled substances in accordance with applicable law, and document necessary medication administration/treatment information including but not limited to when medications are given.

Based on medical record review, observation, family, staff and witness interviews and review of facility policy, the facility failed to provide adequate supervision to prevent the elopement of a cognitively impaired resident. This resulted in Immediate Jeopardy for one (#47) of three residents identified by the facility as being at risk for elopement. Additionally, the facility failed to ensure two (#19 and #32) of three residents identified as being at risk for falls had fall prevention interventions in place that was not immediate jeopardy. The facility census was 39. On 08/30/13 at 2:40 P.M., the Administrator, Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) #60 were notified that Immediate Jeopardy began on 08/24/13 at 5:30 P.M. when Resident #47 exited the South Hall door which did alarm but was not equipped with a wanderguard device (electronic system utilized by the facility to monitor, alarm and lock exit doors). Staff present did not immediately respond to the door alarm and Resident #47 was subsequently found 0.1 miles away from the facility by family members and an off-duty police officer unsupervised near a soccer field and residential area. The Immediate Jeopardy was removed on 08/30/13 at 4:35 P.M., when the facility placed Resident #47 on one-on-one supervision and the facility implemented the following corrective actions: ? On 08/28/13, the facility initiated an investigation of the elopement of Resident #47 and both nurses (RN #40 and LPN #19) present during the time of elopement were placed on administrative leave. ? On 08/28/13, the DON and RDCS #60 began in-servicing all staff on the definition of elopement, the elopement policy and procedure and the monitoring tool utilized for one-on-one and 15 minute check monitoring. ? On 08/28/13, nursing staff re-assessed all residents for elopement risk and identified three residents (#47, #49 and #53) at risk for elopement. ? On 08/30/13, Resident #47 was placed on one-on-one-supervision and Residents #49 and #53 were placed on 15 minute checks. ? On 08/30/13 at 4:30 P.M., review of the Resident Observation/Monitoring Tool revealed 15 minute documentation of the one-on-one supervision for Resident #47, 15 minute documentation of checks for Resident #49 and 15 minute documentation checks, beginning at 6:15 P.M., upon readmission of Resident #53 to the facility, all continuing through 09/03/13 and on-going. ? On 09/02/13, the physician re-assessed Resident #47 and the facility began looking for bed availability in a secured unit. ? On 09/03/13, the DON and RDCS #60 completed in-service training. The facility left messages for all staff that were unavailable. The facility initiated a plan that all staff not in-serviced in person or over the phone will not be able to work until they receive the in-service. ? On 09/03/13, interviews conducted between 7:10 A.M. and 1:25 P.M. with STNAs #41, #5, and #38, LPN #29 and #10 and Activities Director #26 regarding the facility's elopement policy and residents at risk of elopement verified all were knowledgeable and able to verbalize the policy and residents correctly. ? On 09/03/13, the survey team verified the wander guards were in place for all three residents identified as high risk of elopement and the facility's monitoring was being documented. ? On 09/03/13, a review of all quarterly elopement drills for 2013 revealed a drill each shift each quarter was conducted regarding resident elopement. Review of the door alarm and wander guard alarm checks from 07/22/13 through 09/03/13 revealed no issues with either the door alarms or the wander guard locking mechanisms. Although the Immediate Jeopardy was removed when the facility established a system to ensure adequate supervision for residents at risk of elopement, the facility remained out of compliance at Severity Level 2 (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) because the facility failed to implement fall prevention devices for Resident #19 and #32 placing them at risk for potential harm from falls. Findings include: 1. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the admission assessment dated [DATE] revealed Resident #47 was identified at high risk for elopement due to being mobile, being cognitively impaired with poor decision making skills, having a history of attempted or actual elopement or unsafe wandering, demonstrating exit seeking behaviors, and wandering in and out of other resident's rooms. It was noted that when residing at home, the resident's spouse had to lock the doors to prevent unsafe wandering. A wander guard was placed on Resident #47 at the time of this assessment. Review of the elopement risk plan of care dated 01/18/13 and reviewed on 04/18/13, revealed the resident was at risk of elopement due to aimless wandering that significantly intrudes on the privacy and activities of others and a history of attempts to leave the facility unattended. Interventions included distracting the resident from wandering by offering pleasant diversions or structured activities, redirecting as needed, and implementing a wander device. Review of the Care Plan Conference Summary, dated 04/03/13, revealed Resident #47 wanders and sleeps in others beds, has long and short term memory deficits, has a history of exit seeking behaviors, and wears a wander guard. The Care Plan Conference Summary dated 07/18/13 revealed long and short term memory deficits, that the resident wanders in others rooms, and cannot always be found. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/16/13, revealed a Brief Interview of Mental Status (BIMS) score of 3 indicating the resident had severe cognitive impairment and wandering behavior that occurred daily. Review of the nurse's notes dated 08/24/13 revealed no documentation of Resident #47's elopement. Review of Nurse's Notes dated 08/25/13 at 9:15 A. M revealed Resident #47 made multiple attempts to exit the building during that shift, was redirected, and a new order for 15 minute checks for 24 hours was obtained. Review of the Resident Observation/Monitoring Tool revealed 15 minute checks on Resident #47 began on 08/25/13 at 9:30 A.M., ended on 08/26/13 at 6:15 A.M., began again on 08/26/13 at 3:00 P.M. until 08/26/13 at 11:45 P.M. On 08/27/13 at 2:44 P.M., an observation of the East Hall revealed Resident #47 standing at the exit door, looking outside. Staff members verbally redirected Resident #47 away from the door. On 08/27/13 at 5:20 P.M., a family interview revealed that Resident #47 had been seen by other family members unsupervised on 08/24/13 at approximately 5:30 P.M. away from the facility, wandering towards the wooded area near the facility and soccer fields, which are adjacent to a park. During subsequent interviews conducted from 08/27/13 through 08/30/13 with facility staff and an off-duty police officer that witnessed the elopement, revealed Resident #47 eloped from the facility on 08/24/13 and was unsupervised for approximately 30 minutes, wandering to an adjacent park area close to a residential neighborhood. Staff heard the door alarm sound but did not immediately check the doors or the residents and only located Resident #47 after being notified by a witness. On 08/27/13 at 6:17 P.M., interview with the Administrator and the DON revealed there was no issue on 08/24/13 that they were aware of and they were not notified of any incidents involving Resident #47 being away from the facility unsupervised. No nursing staff on duty on Saturday 08/24/13 had notified either the Administrator or the DON of Resident #47's elopement. The Administrator stated the wander guards are checked monthly by maintenance and also every shift for placement and functionality by nursing. On 08/27/13 at 6:32 P.M., interview with Maintenance Supervisor #1 revealed there are two to three residents in the facility with wander guard devices and the front entrance to the facility is the only door equipped with a wander guard locking mechanism. The hallway exit doors were equipped with alarms that sound when opened. At 6:44 P.M., Resident #47's wander guard was checked for functionality at the facility's front entrance and the South Hall exit door was checked for alarm functionality. Both the wander guard and the door alarm were functional. On 08/28/13 at 11:50 A.M., an observation revealed Resident #47 was not in his room or in the main hallways. Staff was asked to locate the resident and one State tested Nursing Assistant (STNA) and two Licensed Practical Nurses (LPNs) began to look for Resident #47. These staff members were unsure of the last time they had seen Resident #47. At 11:58 A.M., Resident #47 was located in another resident's bathroom. On 08/29/13 at 10:46 A.M., interview with the Administrator revealed the facility investigation was still ongoing and at that time no incident was believed to have occurred. All residents had been reassessed for elopement and staff in-servicing regarding elopement had begun. On 08/29/13 at 11:35 A.M., interview with LPN #20 revealed she worked both 08/24/13 and 08/25/13 from 7:00 A.M. to 3:00 P.M. LPN #20 stated that on 08/24/13 no abnormal behaviors were noted with Resident #47 but on 08/25/13 he showed exit seeking behaviors, such as pushing on the exit doors, so she notified Resident #47's physician and Power of Attorney (POA) and began 15 minute checks to ensure the resident's safety. LPN #20 was not notified during shift change report on 08/25/13 from the night shift nurse of any incident involving Resident #47's elopement on 08/24/13. On 08/29/13 at 2:50 P.M., an interview with LPN #19 revealed on 08/24/13 she was eating lunch in the break room and heard the South Hall door alarm activate. LPN #19 stated when she went to check the exit door another nurse was already outside with Resident #47. LPN #19 stated Resident #47 does try to exit the facility at times and wanders into other resident rooms on a daily basis. On 08/30/13 at 9:23 A.M., interview with a family member of Resident #47 revealed the family was not notified by the facility on 08/24/13 of the elopement of Resident #47. The family member was informed by spectators that were at a soccer game who had seen Resident #47 wandering unsupervised in a field behind the facility. The family identified an off-duty police officer as a witness. On 08/30/13 at 10:19 A.M., interview with a local police officer, who was off-duty at the time of the incident, revealed on 08/24/13 at approximately 5:30 P.M. he was sitting to the southeast of the facility watching his daughter's soccer game. He noticed a "little old man walking along the tall grass behind the facility near the woods" which leads to a residential neighborhood. He heard another soccer player's family refer to the man as "Uncle" and they ran over to get Resident #47 before he reached the path through the trees into the neighborhood. The officer went to talk to Resident #47 who told the officer he was "headed home". The officer estimated Resident #47 was out of the facility for about 30 minutes. The officer, the family member and Resident #47 were walking along the outside edge of the soccer field when a nurse came running out of the facility's South Hall door and came out to meet them. After they were almost back to the facility, another nurse, identified by the officer as LPN #19, came out of the facility and told the officer that two of the alarms were turned off and Resident #47 was the only resident missing. On 08/30/13 at 10:50 A.M., interview with STNA #27 revealed she was working at the time of Resident #47's elopement. At the time the South Hall exit door alarmed, STNA #27 was in another resident's room providing resident care. When she came out of the other residents room she noticed Registered Nurse (RN) #40 exiting the South Hall door where she turned to the left. She stated she could not see Resident #47 and reported she heard he walked pretty far to the left of the building. STNA #27 stated when Resident #47 returned he was very combative. STNA #27 stated Resident #47 was wearing a blue sweater and light denim pants. STNA #27 stated the staff was working one aide short on the shift when the elopement occurred. On 08/30/13 at 10:52 A.M., interview with Maintenance Supervisor #1 revealed the door alarms cannot be turned off all at once but they can be silenced one at a time. No door alarm malfunctions were reported to him from 08/24/13. On 08/30/13 at 10:57 A.M., interview with STNA #55 revealed she worked 08/24/13 during the time of Resident #47's elopement. STNA #55 was in a resident's room on the West Hall providing care and did not hear the alarm sound. When she came out of the room she noticed RN #40 was out of breath. RN #40 told her Resident #47 had gotten out of the facility and she had to get him back. STNA #55 did not see Resident #47 outside or see staff bring him back. She stated the following day, 08/25/13, Resident #47 was more agitated and tried to exit the facility a number of times. STNA #55 confirmed that staff were working with one less aide than they normally do at the time of Resident #47's elopement. On 08/30/13 at 11:03 A.M., an interview with RN #40 revealed she was the nurse supervisor working on 08/24/13 at the time of Resident #47's elopement. RN #40 stated she was in a resident's room passing [DEVICE] medications around 5:30 P.M. when she heard the door alarm sound. She finished providing care to the resident and when she exited the resident room, she did not see anyone at the nurse's station or doors. RN #40 stated when she inspected the alarm panel behind the nurse's station, she noted the South Hall door alarm had gone off. She then walked to the South Hall door and went outside. At that time, RN #40 stated she did not see any residents but was approached by a gentleman who asked her if she was missing a resident. This gentleman pointed down field to Resident #47 who was walking with another man back toward the facility. RN #40 stated at that time Resident #47 was on the sideline of the soccer field not all the way to the tree line but walking along the tall grass. She recalled Resident #47 was wearing a t-shirt, jeans and carrying a jacket or sweater, was not agitated and was drinking bottled water provided by a parent from the soccer game as it was very warm outside that day. RN #40 revealed she was joined outside by LPN #19 who was assigned to Resident #47 that day. RN #40 stated she did not notify the Administrator, DON, physician or family and did not fill out an incident report until called in by the Administrator on 08/28/13 because she assumed LPN #19 did those things. RN #40 verified that only two aides were working, as opposed to the scheduled three, at the time of Resident #47's elopement. On 08/30/13 at 12:38 P.M., the Administrator, DON and RDCS #60 revealed their investigation into the incident with Resident #47 on 08/24/13 had confirmed it was an elopement. The facility provided documentation of their investigation which verified Resident #47 did elope from the facility on 08/24/13, no notification was made to administration, the DON, physician or family upon elopement of Resident #47, no interventions were put into place to assure Resident #47 did not elope again and no distinct timeline could be ascertained from facility staff regarding how long Resident #47 was unsupervised out of the facility. On 09/03/13, observations of Resident #47 were made. At 7:25 A.M., Resident #47 was observed in the dining room with one-on-one STNA supervision. At 8:30 A.M., observation revealed Resident #47 leaving the dining room with one-on-one STNA supervision. At 11:45 P.M., Resident #47 was observed leaving his room for lunch with one-on-one LPN supervision. At 1:26 P.M., observations revealed Resident #47 sleeping in his room with one-on-one LPN supervision and at 2:27 P.M. Resident #47 was still sleeping in his room again with one-on-one LPN supervision. At 3:22 P.M., an observation revealed Resident #47 in bed in his room with one-on-one STNA supervision. Review of the facility policy entitled "Elopement", dated September 2008 and reviewed January 2013, revealed the policy includes assessing all residents for risk of elopement and all residents identified as such will have interventions put into place to prevent elopement. All residents identified as an elopement risk will be reviewed during weekly Behavior, Elopement, AMA, Discharge and Drug Panel (BEAD) meetings. On 09/03/13 at 3:08 P.M., interview with the DON revealed that the BEAD documentation was part of the quality assurance committee and the committee met last on 08/23/13 and did discuss Resident #47 and reviewed current interventions. Review of the facility procedure for elopement includes calling a "Code Green" when a resident is identified as missing from the facility, notifying the Administrator and DON, maintaining time-specific documentation in the resident's medical record and assessing the resident including a complete body assessment. The charge nurse must then notify the attending physician and the family. The procedure includes updating the plan of care and instituting a 15 minute monitoring schedule on which the resident will remain until the resident is no longer at risk of eminent elopement and the interventions initiated are evaluated by an interdisciplinary team. The nurse also initiates the Unusual Occurrence Report and Quick Response form. Review of Resident #47's medical record revealed no evidence of any documentation regarding the elopement or "Code Green", no evidence of documentation of notification of the Administrator, DON, physician or family, no time-specific documentation or assessment of the resident after elopement, no update of the care plan or initiation of the 15 minute checks upon return to the facility and no evidence of the Unusual Occurrence Report and Quick Response forms. 2. Review of Resident #19's medical record revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/09/13, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of three out of 15, demonstrating a significant cognitive impairment. Resident #19 was also assessed as requiring limited assist of one person with bed mobility, transfers, ambulation in the room and personal hygiene and extensive assist of one person with toilet use. The MDS revealed Resident #19 was not steady when moving from sitting to standing or when moving on and off the toilet, but can stabilize herself without human assistance. Review of the self-care deficit plan of care, dated 01/29/13 and last reviewed 08/15/13, revealed interventions including toileting with the assistance of one person. Review of the fall plan of care dated 1/28/13 and last reviewed 08/15/13 revealed Resident #19 to be at risk for falls related to medications and a balance problem, with interventions including maintaining a safe environment and to instruct on appropriate safety measures. Review of the Fall Risk Evaluation dated 05/09/13 revealed Resident #19 received a score of nine which indicated high risk of falls. On this assessment, Resident #19 was noted to have steady balance and maintains position as required, which was in contradiction to the MDS completed the same day and the plan of care. Review of the undated Resident Care Card revealed Resident #19 required supervision while toileting, which was defined on the card as "staff provides oversight, encouragement, or cueing throughout activity". Also noted on the card was a personal tab alarm to the bathroom door. Review of the physician order sheet for August 2013 revealed an order for [REDACTED]. Review of the Certified Nursing Assistant-Activities of Daily Living Tracking Form for August 2013 revealed Resident #19 was mostly independent with no physical help from staff in regards to toileting on the 7:00 A.M. to 7:00 P.M. shift, and required supervision with set up help only from the 7:00 P.M. to 7:00 A.M. shift. On 08/28/13 at 8:30 A.M., an observation of Resident #19's room revealed a personal tab alarm was present on the door frame for the bathroom door, but was not hooked up to the actual door. On 08/28/13 at 10:55 A.M., an observation revealed Resident #19's wheelchair was outside the bathroom door, the personal tab alarm was not hooked up, and Resident #19 was in the bathroom, unsupervised. On 08/28/13 at 1:33 P.M., 2:11 P.M. and 3:00 P.M. observations revealed the personal tab alarm for the bathroom door was not hooked up appropriately. On 08/28/13 at 10:59 A.M., a staff interview with Licensed Practical Nurse (LPN) #10 verified Resident #19 was in the bathroom at that time unattended and that the alarm had not sounded. LPN #10 revealed that Resident #19 can unhook the alarm by herself and ambulate into the bathroom without assistance. The alarm was hooked up by LPN #10 at that time and tested . The alarm was not functional when tested . On 08/29/13 at 9:25 A.M., a staff interview with STNA #25 revealed that Resident #19 was thought to be independent in the bathroom, although she does require assistance with personal hygiene occasionally. STNA #25 did not refer to the personal tab alarm as a way to know when Resident #19 needs assistance in the bathroom. On 08/29/13 at 10:02 A.M., a staff interview with LPN #20 revealed that the purpose of the personal tab alarm for Resident #19 was to alert staff when she goes into the bathroom, as she has a history of behaviors that put her at risk for accidents while in the bathroom alone. She verified at this time that the personal tab alarm had still not been fixed and was not functional. 3. Review of Resident #32's medical record revealed [DIAGNOSES REDACTED]. Review of August 2013 physician's orders revealed orders for a low bed, a mat on the floor, infrared alarm while in bed, wheelchair with self-releasing seat belt, personal alarm in the wheelchair with Dycem. The resident was documented with a fall on 06/23/13 from the bed with bruising to the head. Her fall risk assessment dated [DATE] identified the resident as a high risk for falls. Review of the plan of care for falls included interventions to utilize a low bed with a mat on the floor, infrared alarm in bed. The plan of care revealed the over the bed table interfered with the function of the infrared alarm and the alarm was to be turned off when the resident was eating in bed. On 09/03/13 at 9:20 A.M., the resident was observed in bed with her eyes closed. The alarming mat was on the floor next to the bed. Observation of the infrared monitor attached to the footboard revealed the switch was on the off position. At the time of the observation, Nurse #100 verified the alarm was not on. The green light flashed when the alarm was turned on by the nurse. Interview with STNA #10 at 9:30 A.M., verified the resident ate breakfast in her bed and the alarm had not been turned on after she ate. On 09/03/13 at 2:20 P.M., the resident was observed awake in the bed. Her call light was hung on the wall, and not within reach. This was verified by STNA #10 at the time of the observation. Interview with the DON and the STNA#10 revealed the resident is capable of using her call light, and she does utilize her call alarm when she needs assistance.

Based on surveyor observation, record review and interview, the facility failed to ensure a resident received verbal cues to reposition herself in her wheelchair. This affected one (#16) of two residents reviewed for positioning. Facility census was 39. Findings include: Review of Resident #16's medical record revealed an admission date of [DATE], revealed [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment, dated 07/01/13, revealed Resident #16 was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 3 out of 15 and requires extensive assist with transfers and mobility of one person. Review of the Occupational Therapy (OT) notes from 01/29/13 through 03/20/13 revealed a therapy goal to increase unsupported sitting balance and to reposition self when cued, with a discharge noted that Resident #16 requires minimal assistance and maximum verbal and tactile cues to maintain proper sitting balance. Review of the Physical Therapy (PT) notes from 02/06/13 through 04/17/13 revealed that Resident #16 has a posterior lean. Review of the Activities of Daily Living plan of care, dated 04/03/13, revealed no positioning interventions but did identify Resident #16 needed extensive assist with transferring and mobility. Review of the altered cognitive function plan of care, dated 06/07/13, revealed no interventions related to positioning, but included interventions to offer verbal reminders and cues as necessary for Resident #16. Observations made throughout the day on 08/27/13, revealed Resident #16 asleep in her wheelchair, leaning to the right side and slightly forward, with her head bent forward. Observation on 08/29/13 at 9:12 A.M., revealed Resident #16 asleep in her wheelchair in her room, head bent forward. Observation on 08/29/13 at 1:02 P.M., revealed Resident #16 asleep in her wheelchair near the nurses station, leaning forward with her head bent down. During this observation, several staff members were noted in the area, none offering verbal or tactile cues to remind Resident #16 to sit with proper positioning. On 08/29/13 at 2:18 P.M., an observation revealed Resident #16 asleep in her wheelchair in her room, leaning to the right and head bent forward. Interview on 08/29/13 at 9:25 A.M., with State tested Nurse Aide (STNA) #25 revealed Resident #16 often leans forward or to one side when asleep. STNA #25 voiced no knowledge of the need to cue Resident #16 at those times when her positioning is not correct. Interview on 08/29/13 at 11:22 A.M., with Occupational Therapy Assistant (OTA) #11 revealed that Resident #16 requires cues to maintain an upright sitting position and that staff had been educated regarding providing such cues. She also revealed that no additional interventions had been attempted in regards to Resident #16's positioning.

Based on medical record review, staff interview and review of facility policy and staff interview, the facility failed to obtain consent for or refusal of the pneumococcal vaccines for four residents and failed to obtain consent for or refusal of the influenza vaccine for a resident. This affected four (#4, #11, #26, #38) of five resident records were reviewed for pneumococcal and influenza vaccines. The facility census was 39. Findings include: 1. Review of Resident #4's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the comprehensive minimum data set (MDS) assessment dated [DATE] indicated Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no memory impairments. Resident #4's medical record did not contain information about pneumococcal vaccination being offered. 2. Review of Resident #11's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] indicated Resident #11 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no memory impairments. Resident #11's medical record did not contain information about pneumococcal vaccination being offered. 3. Review of Resident #26's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] Resident #26 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no memory impairments. Resident #26's medical record did not contain information about pneumococcal and influenza vaccination being offered. 4. Review of Resident #38's medial record revealed an admission date of [DATE] with [DIAGNOSES REDACTED].#38 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no memory impairments. Resident #38's medical record did not contain information about pneumococcal or influenza vaccination being offered. Interview on 08/29/13 at 4:18 P.M., with the Administrator and Medical Records Staff (MRS) #56 indicated that they could not find consents for or refusal of the pneumococcal vaccine for residents #4, #11, #26, and #38. During the same interview, the Administrator and MRS #56 indicated that they could not find consent for or refusal of the influenza vaccine for resident #38. The Administrator and MRS #56 denied knowledge of the reason the consents were not available. Review of the facility policy entitled "Infection Control Pneumococcal Vaccine", dated September 2008, indicated consent for the pneumococcal vaccine was supposed to be obtained at the time of the resident's admission and that the completed consent was supposed to be placed in the resident's chart. Review of the facility policy entitled "Infection Control Influenza Vaccine", dated September 2008, indicated consent for the influenza vaccine was supposed to be obtained at the time of the resident's admission and that the completed consent was supposed to be placed in the resident's chart.

Based on record review and staff interview, the facility failed to provide notice to a resdient of pending Medicare Non-Coverage for skilled services. This affected one (#20) of three residents reviewed for liability notices and beneficiary appeal. The facility census was 39. Findings include: Review of Resident #20's medial record revealed and admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the medical record revealed Resident #20 had a Brief Interview of Mental Status (BIMS) score of 13 which indicated no memory impairments. Review of Centers for Medicaid and Medicare Services (CMS) form # , Notice of Medicare Non-Coverage, revealed Resident #20's skilled services were scheduled to end 05/20/13. The CMS form # , Notice of Medicare Non-Coverage, was not signed by Resident #20. Interview with the Administrator on 09/03/13 verified Resident #20 did not receive advanced notice that Medicare covered skilled services were scheduled to end. The Administrator indicated the facility's previous social services designee was responsible for notifying residents of Medicare Non Coverage and was unable to explain why Resident #20 was not notified that skilled services were scheduled to end.

Based on record review, staff and family interview and facility policy review, the facility failed to notify the physician and family when Resident #47 eloped from the facility. This affected one (#47) of 23 residents reviewed in Stage II of the survey. Facility census was 39. Findings include: Review of Resident #47's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/16/13, revealed a Brief Interview of Mental Status (BIMS) score of 3, showing severe cognitive impairment, and wandering behavior that occurred daily. Review of the Nurse's Notes from 08/24/13 through 08/29/13 revealed no notification of Resident #47's elopement to the family or physician. Interview on 08/27/13 at 5:20 P.M., with Resident #47's family member revealed Resident #47 had eloped from the facility, as witnessed by another family and an off-duty police officer on 08/24/13. The family member revealed that the facility did not notify her of the elopement. Interview on 08/30/13 at 11:03 A.M., with Registered Nurse (RN) #40 revealed that she was the nurse supervisor working at the time of Resident #47's elopement. She verified neither the family nor the physician was notified regarding the elopement. Review of the facility's policy entitled "Change in Resident Condition", dated 01/27/11 and last revised 11/8/11, revealed that the physician and family should be notified any time there is an incident with a resident. Review of the facility's policy entitled "Elopement", dated 09/08, reviewed last on 01/13, revealed that the physician and family should be notified when an elopement occurs.

Based on surveyor observation, record review and staff interview, the facility failed to develop care plans for positioning for Resident #16 and care plan for medications for Resident #5 and #13. This affected three (#16, #13 and #5) of 23 residents reviewed during Stage II. Facility census was 39. Findings include: 1. Review Resident #16's medical record revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS), dated [DATE], revealed Resident #16 was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 3 out of 15, and required extensive assist of one person with transfers and mobility. Review of the Occupational Therapy (OT) notes from 01/29/13 through 03/20/13 revealed a therapy goal to increase unsupported sitting balance and to reposition self when cued, with a discharge note that Resident #16 requires minimal assistance and maximum verbal and tactile cues to maintain proper sitting balance. Review of the Physical Therapy (PT) notes from 02/06/13 through 04/17/13 noted Resident #16 had a posterior lean. Review of the Activities of Daily Living plan of care, dated 04/03/13, revealed no positioning interventions but did identify Resident #16 needed extensive assist with transferring and mobility. Review of the altered cognitive function plan of care, dated 06/07/13, revealed no interventions related to positioning, but included interventions to offer verbal reminders and cues as necessary for Resident #16. Observations made throughout the day on 08/27/13, revealed Resident #16 asleep in her wheelchair, leaning to the right side and slightly forward, with her head bent forward. Observation on 08/29/13 at 9:12 A.M., revealed Resident #16 asleep in her wheelchair in her room, head bent forward. Observation on 08/29/13 at 1:02 P.M., revealed Resident #16 asleep in her wheelchair near the nurses station, leaning forward with her head bent down. During this observation, several staff members were noted in the area, none offering verbal or tactile cues to remind Resident #16 to sit with proper positioning. On 08/29/13 at 2:18 P.M., an observation revealed Resident #16 asleep in her wheelchair in her room, leaning to the right and head bent forward. On 08/29/13 at 11:22 A.M., an interview with Occupational Therapy Assistant (OTA) #11 revealed that Resident #16 requires cues to maintain an upright sitting position and she confirmed the absence of a positioning plan of care. 2. Review of Resident #5's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed Resident #5 was unable to self administer medications. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The clinical record did not contain a care plan related to [MEDICATION NAME]administration for Resident #5. During interview on 08/29/13, Licensed Practical Nurse (LPN) #20 confirmed Resident #5 did not have a care plan related to the use of [MEDICATION NAME]and also confirmed [MEDICATION NAME]was not normally prescribed based on a sliding scale. LPN #20 was unable to explain the reason Resident #5's [MEDICATION NAME]was administered based on the results of blood glucose testing performed twice daily. 3. Review of Resident #13's medial record revealed [DIAGNOSES REDACTED]. Her medications included [MEDICATION NAME] and [MEDICATION NAME] for anxiety. Documentation from the Psychiatric Center dated 06/18/13 identified the resident as positive for anxiety/panic attacks, use of anti-depressants, nervous problems, speech changes, stress, dementia and psychiatric illness. Review of the residents identified behaviors for the use of [MEDICATION NAME] included pacing, and for the use of [MEDICATION NAME] included stuttering. Review of her plan of care for the use of [MEDICAL CONDITION] medications did not include the behaviors the facility had assessed the resident with and exhibited by her. Interview with the Director of Nursing on 08/29/13 at 1:30 P.M., verified that the facility failed to include the specific behaviors on the [MEDICAL CONDITION] medication care plan that Resident #13 was assessed as exhibiting.

Based on record review, and staff interview, the facility failed to revise a care plan for Resident #47's potential elopement risk, a care plan for Resident #19's assistance in bathroom, and a care plan for Resident #25's vascular ulcer with interventions to promote healing. This affected three (#47, #19, #25) of 23 residents reviewed for care plans during Stage II. Facility census was 39. Findings include: 1. Review of the clinical record for Resident #47, admitted [DATE], revealed [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 3, showing severe cognitive impairment, and wandering behavior that occurred daily. Review of the elopement risk plan of care dated 01/18/13, reviewed last on 04/18/13, revealed that the resident was at risk of elopement due to aimless wandering that significantly intrudes on the privacy and activities of others and a history of attempts to leave the facility unattended. Interventions included distracting the resident from wandering by offering pleasant diversions or structured activities, redirecting as needed, and implementing a wander device. This plan of care was updated to include 15 minute checks on 08/25/13 for a period of 24 hours. It was not updated to reflect the elopement that occurred on 08/24/13. Interview on 08/29/13 at 10:46 A.M., with the Administrator revealed that no new interventions were put in place for Resident #47 after he eloped and the elopement was not reflected on his care plan. 2. Review of Resident #19's medical record revealed an admission date of [DATE], revealed [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/09/13, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of three out of 15, demonstrating a significant cognitive impairment, and was requiring a limited assist of one person with bed mobility, transfers, ambulation in the room and personal hygiene and extensive assist of one person with toilet use. This MDS revealed Resident #19 was not steady when moving from sitting to standing or when moving on and off the toilet, but can stabilize herself without human assistance. Review of the physician order [REDACTED].#19 enters the bathroom unsupervised. Review of the Resident Care Card revealed a personal tab alarm was to be applied to the bathroom door. Review of the self care deficit plan of care, dated 01/29/13, last reviewed 08/15/13, revealed no interventions including the personal tab alarm to the bathroom door. Interview with Licensed Practical Nurse (LPN) # 20 on 08/29/13 at 10:02 A.M., verified the care plan was not revised to include the personal tab alarm. 3. Review of Resident #25's medical record revealed [DIAGNOSES REDACTED]. The resident was assessed on the comprehensive assessment as total assist of one for bed mobility. Review of the facility plan of care dated 06/21/13 identified the resident was at risk for developing pressure ulcers or potential for pressure ulcer development. The interventions did not include to float the resident's heels to reduce pressure The plan of care did not identify that the resident was at risk for vascular wounds. Review of the medical record revealed on 08/09/13 the resident was identified with an area on the right inner heel. The wound nurse's initial progress note identified the area as a deep tissue injury (DTI) as the stage and type of wound as vascular. The treatment was to apply skin prep. On 08/30/13 at 11:15 A.M., the resident was observed with the wound management team. During the observations the wound nurse stated the intervention to promote healing would be the same for a pressure wound to include: float the heel, pad the wheelchair foot pedals and keep pressure of the heels by floating them. She further indicated these interventions should be on the plan of care. She did not know why the facility had not updated the care plan with these specific interventions.

Based on observation, record review, and interview, the facility failed to ensure a resident was provided assistance with dressing and oral care per his comprehensive assessment and plans of care. This affected one (#41) of three sampled residents reviewed for assistance with activities of daily living. The facility census was 39. Findings included: Review of Resident #41's medical record revealed [DIAGNOSES REDACTED]. The resident was assessed to utilize a wheelchair for mobility, and was incontinent of urine at times. The most recent comprehensive assessment dated [DATE] revealed the resident was assessed as needing limited assist of one staff for dressing, extensive assist of one for toileting, supervision with personal hygiene Review of the residents plan of care for self care identified the resident as needing limited assist with some activities of life (ADL). Interventions included to assist with oral care daily and as needed, personal hygiene/oral care: the resident requires assist of one staff with personal hygiene and oral care, dressing: allow the resident sufficient time for dressing and undressing, assist the resident to choose simple comfortable clothing that maximizes his ability to dress self, the resident requires assist of one staff to button shirts. His monthly weekly summary identified the resident needs assistance with incontinence, and assistance with oral hygiene. Review of the Certified Nursing Assistance-Activities of Daily Living tracking sheet for August 2013 documented the resident as supervision/limited assist for dressing, and independent for toileting. Review of his most recent comprehensive assessment revealed the resident had been evaluated with a decline in dressing and toileting. On 08/28/13 at 9:30 A.M. the resident was interviewed in his room. When asked if the staff assisted him in dressing this morning, he said no. He then said that he sleeps in his clothes at night and doesn't need help in the morning. He said his biggest problem is putting on his shoes and socks, and he needs some help with tying his shoe. It was noted the resident had on the same shirt and pants from the previous day. He said he always slept in his clothes when he lived at home. He denied staff offering to help him change his clothes in the morning when he gets up. The resident said he has a problem with urinating and sometimes requires assistance in the bathroom. He said they will come when he turns on the call light and help him change his brief if necessary. The resident denied staff offering to assist with his oral hygiene, prompting him, or setting up his toothbrush with toothpaste for him to brush his teeth. He said he is pretty "lax" about doing his teeth, and always has been. He said his toothbrush was somewhere, and pointed down to the basin in the cabinet. The toothbrush and toothpaste appeared unused. He said he has a broken tooth and sometimes it hurts. Interview on 08/28/13 at 11:30 A.M., State tested Nursing Assistant (STNA) #10 revealed the resident needed supervision for his ADL's and a little assistance. She indicated he is able to transfer and toilet himself, and puts on the light for assistance. She said he is able to dress himself, and needs help with his buttons at times. She said he is independent with brushing his teeth. The STNA was asked if she was aware he slept in his clothes at night, she said no. The STNA said he was already up when she arrived at work, and she was not told that information by the night shift. She denied offering or assisting him with changing his clothes this morning and did not offer to assist him with any oral care . Review of his plan of care for oral health revised on 08/18/13 revealed the resident had several cavities.

Based on surveyor observation, review of medical record and staff interview, the facility failed to ensure a resident received assistance with dressing. This affected one (#47) of three residents reviewed for activities of daily living. Facility census was 39. Findings include: Review of Resident #47's medical record revealed an admission date of [DATE],with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS)assessment, dated 07/16/13, revealed a Brief Interview of Mental Status (BIMS) score of 3, showing severe cognitive impairment, and Resident #47 required extensive assist of one person for dressing. Review of the self care deficit plan of care, dated 01/30/13, last reviewed 07/22/13, revealed a deficit related to a [DIAGNOSES REDACTED]. Review of the Resident Care Card, which the aides use to identify the care needs of each resident, revealed Resident #47 required extensive assist with dressing. Review of the Certified Nursing Assistant - Activities of Daily Living (CNA-ADL) Tracking Form for August 2013 revealed that State tested Nurse Aides (STNAs) charted that Resident #47 required extensive assistance with one person to dress, which was charted on as having been done 08/27/13 and 08/28/13 on the 7:00 A.M. to 7:00 P.M. shift and as not having occurred on the 7:00 P.M. to 7:00 A.M. shift. Observation on 08/27/13 at 5:35 P.M., revealed Resident #47 wearing a light blue T-shirt covered by a thin gray sweater with a heavy plaid shirt/jacket over top. He was wearing black athletic pants with a white stripe down each side. On 08/28/13 during the breakfast meal, at 11:58 A.M., and during the dinner meal, Resident #47 was wearing the same clothing as on 08/27/13. On 08/29/13, an observation of the breakfast meal revealed Resident #47 wearing the same clothing as the previous two days. Interview on 08/29/13 at 9:25 A.M., with STNA #25 revealed that Resident #16 requires assistance of one aide when getting dressed and it is the aide's responsibility to change the resident's clothing if they require assistance. Interview on 08/29/13 at 10:06 A.M., with Licensed Practical Nurse (LPN) #20 revealed that night shift STNAs should have Resident #47 up and dressed for breakfast. She revealed he has more than one outfit available to wear and that he does not generally sleep in his clothing, but changes into different clothes to sleep. LPN #20 verified that Resident #47 was in the same clothes as the prior day. Interview on 08/29/13 at 12:41 P.M., with Occupational Therapy Assistant (OTA) #11 revealed that Resident #47 is unable to independently perform activities of daily living such as dressing. He required assistance because his dementia is advanced and safety is an issue and he needs maximum cueing for dressing.

Based on record review, observation, and interview, the facility failed to monitor the evening meal intake for a resident identified as having a weight loss over a two month period (60 days). This affected one (#25) of three residents reviewed for a weight loss. The facility census was 39. Findings include: Review of Resident #25's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. On admission the resident was identified with chewing and swallowing problems, with an upper plate and no lower dentures. The admitting diet order was ground textured consistency with honey thick fluids. The plan of care dated 06/10/13 for chewing and swallowing included to monitor his intake during meals. Resident #25 speech therapy evaluation dated 06/05/13 revealed the resident had been demonstrating significant difficulties at meals since admission per staff. The diet was changed to a pureed consistency. The admission nutrition assessment dated [DATE] documented an admission weight of 206 pounds and a BMI of 30-35 with an ideal body weight of 160 to 206. He was not on any routine supplements or snacks. Review of the resident's weights included an admission weight of 207 on 06/04/13, a weight of 201 on 06/17/13 (decrease of 2.9%, 6 lbs), a weight of 198 (decrease of 4.3%, 9 lbs) for July 2013, and a weight 60 days after admission on 08/02/13 of 193 lbs (decrease of 8%, 14 lbs). His 07/08/13 dietary quarterly note revealed the resident's diet had been downgraded and he required more help with meals. On 08/28/13 at 12:30 P.M. the resident was observed in the dining room. He was holding his cup at times with supervision and assistance, and being fed by staff. Review of his Certified Nursing Assistant-Activities of Daily Living (CNA/ADL) tracking for meals revealed the resident's intake for his evening meal was not being documented. This was verified by State tested Nursing Assistant (STNA) #25 on 08/28/13 at 2:30 P.M. and also by the Director of Nursing (DON). Interview with the interim Registered Licensed Dietician # 61 on 08/29/13 at 8:40 A.M., revealed in order to correctly evaluate his nutritional needs the residents meal intakes for all three meals would be needed to determine if his nutritional needs were being met. Interview with STNA # 58 on 08/29/13 at 9:00 A.M., revealed the STNA's work from 7:00 A.M. to 7:00 P.M. He said the evening meal intake information is written on the meal ticket and left at the nursing station for the next shift (7:00 P.M. to 7:00 A.M.) to write in on the ADL tracking form.

Based on record review, review of [MEDICATION NAME]'s manufactures guidelines and staff interview, the facility failed to ensure medications administrated had supporting [DIAGNOSES REDACTED]. This affected two (#5 and #2) of five residents reviewed for unnecessary medication. The facility census was 39. Findings include: 1. Review of Resident 32's medical record revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed resident #2 had a Brief Interview of Mental Status (BIMS) score of 15 which indicated no memory impairments. Review of the self administration of medication assessment revealed Resident #2 was unable to self administer her medications. physician's orders [REDACTED]. physician's orders [REDACTED]. Review of the monthly physician orders [REDACTED]. Interview on 08/30/13 at 8:00 A.M., Licensed Practical Nurse (LPN) #20 verified Resident #2's record did not identify a purpose for the use of [MEDICATION NAME] and did not contain the correct [DIAGNOSES REDACTED]. 2. Review of Resident #5's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record revealed Resident #5 was unable to self administer medications. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Interview on 08/28/13, Licensed Practical Nurse (LPN) #20 indicated the administration instructions for the [MEDICATION NAME]? insulin was "not normal". LPN #20 explained [MEDICATION NAME]was a long acting insulin that affected blood glucose levels steadily over a 24 hour period and was usually administered at a set amount each day. LPN #20 continued to explain that [MEDICATION NAME]was not usually administered on a sliding scale (in a fluctuating amount based on blood glucose levels obtained immediately prior to administration). LPN #20 stated she had asked the previous Director of Nursing (DON) to have the order clarified, but she never received clarification. Interview on 08/28/13 at 3:30 P.M., with Registered Pharmacist (RhP) #65 verified Resident #5's [MEDICATION NAME]order needed clarified because the administration instructions appeared to be for a rapid acting insulin instead of a basal insulin. RhP #65 stated Resident #5's [MEDICATION NAME]should not have been dispensed to the facility until clarified and should have been identified as "an irregularity". RhP #65 provided information from Clinical Pharmacology, gold standard for insulin administration, that confirmed [MEDICATION NAME] is not to be administered based on a sliding scale. Review of the manufacturer's instruction package insert for [MEDICATION NAME]revealed administration should not be based on a sliding scale.

Based on record review and staff interview, the facility failed to ensure residents identified at high risk for falls were provided adequate supervision to prevent falls with injuries. This affected one (#32) of three sampled residents when the resident fell from her wheelchair while in her room unsupervised and sustained a laceration to her forehead requiring sutures. Findings include: Review of the medical record of Resident #32 revealed the physician's orders [REDACTED]. Fall assessments dated 05/31/12 and 08/20/12 revealed the resident was assessed at risk for falls due to having a history of falls, behavioral status, poor cognition, needing assistance with continence, needing assistance with ambulation, not being able to balance without assistance, age, health conditions and medications. Review of the most recent annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired and had disorganized thinking. The assessment stated the resident had behavioral symptoms which put her at significant risk of physical injury and identified her as unable to walk and as requiring extensive assistance with bed mobility, transfers, locomotion, toilet use, and personal hygiene. The assessment stated the resident used a wheelchair for mobility. According to the resident's current plan of care with an initiation date of 08/07/12 the resident had impaired cognition and behavioral problems such as resisting care, being verbally and physically abusive towards staff and others due to anxiety and dementia. Care planned problems initiated on 08/06/12 stated the resident had an impaired ability to make herself understood and to understand others and that she had limited mobility due to Alzheimer's and contractures of the hand and legs. The plan of care stated she required extensive assistance of one for mobility. Review of the nurses' notes dated back to 04/01/12 and interview with the Director of Nursing (DON) on 08/25/12 at 12:50 P.M. revealed Resident #32 experienced falls from bed on 04/16/12, 05/06/12, 07/12/12 and 08/03/12 and falls from the wheelchair on 04/18/12, 05/23/12 and 08/18/12. Further review of the nurses' notes and interview with Assessment Nurse #2 and the DON #1 on 08/25/12 at 12:50 P.M., revealed on 08/18/12 at 8:25 A.M. Registered Nurse (RN) #3 responded to a call from the nurse aide and upon entering the room found Resident #32 lying on the floor with a small to moderate amount of blood to the forehead. According to the note, RN #3 found the resident had a 0.5 centimeter (cm) by 0.5 cm laceration to the forehead. The note stated 911 was called and the resident was sent to the hospital. According to the hospital report, Resident #32 received three sutures in her forehead. The hospital report stated the resident did not tolerate the procedure well due to her dementia and limited understanding. She was discharged from the hospital the same day with [DIAGNOSES REDACTED]. During interview on 08/25/12 at 3:20 P.M., RN #3 stated at the time of the incident she was getting report from third shift staff and was not aware the laboratory technician had taken Resident #32 to her room and left the resident alone in her room unsupervised. RN #3 stated the only time the resident was left alone in her room unsupervised was when she was in bed because of her risk of falling. She stated at the time of the fall the resident was up in the wheelchair and had a half tray on her wheelchair that lifted up and a personal tabs alarm. Further review of the resident's fall plan of care revealed no interventions of the 1/2 tray, not leaving the resident alone in her room when up in the wheelchair, or the personal alarm to the wheelchair listed on the plan of care. According to the plan of care the resident was supposed to have an alarming seat belt in place at the time of the fall. The only documentation in the medical record of the 1/2 tray was a physician's orders [REDACTED]." The plan of care did not include interventions to ensure the resident's safety with the change from an alarming seat belt to the use of a 1/2 tray. There was no documentation of when the 1/2 tray was actually initiated. Interview with the Administrator on 08/08/12 at 1:15 P.M. revealed he called the company that provided the 1/2 tray earlier in the day and was told tray was delivered on 08/15/12. During interview on 08/08/12 at 3:30 P.M., the DON and Administrator verified Resident #32 fell when she was left alone in her room unsupervised. This certification deficiency substantiates Complaint Control Number OH 882.