Every finding on record at Bear Creek Healthcare LLC

Number of residents sampled: Number of residents cited: Based on record review, interviews, and facility policy review, the facility failed to ensure the residents' orders and other electronic health records accurately and consistently reflected the resident's advanced directive decision that documented the resident did not want Cardiopulmonary Resuscitation (CPR) for one (Resident #17) of eight residents whose clinical records were reviewed for advanced directive information. The findings include: Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Resident #17 had diagnoses which included non-Alzheimer's dementia, anxiety, and depression. The MDS also revealed a Staff Assessment for Mental Status (SAMS) score of 2 which indicated Resident #17 had moderate impairment for decision making and received hospice services. Review of a Durable Power of Attorney (POA) with Health Care [NAME] signed by Resident #17 on [DATE], revealed Resident #17 chose to have CPR withheld. Review of a form titled Living Will Declaration, signed [DATE] by Resident #17's Durable Power of Attorney (DPOA) revealed, if I should have an incurable or irreversible condition that will cause my death within a relatively short time, and I am no longer able to make decisions regarding my medical treatment I direct my physician to withhold Cardiac Resuscitation to include CPR. Review of a Resuscitate/Do Not Resuscitate Order dated [DATE] signed by Residents #17's DPOA and Physician, revealed the resident had a Do Not Resuscitate (DNR) Order. Review of a Physician's Order revealed the facility admitted Resident #17 on [DATE]. An order dated [DATE] indicated the resident was a full code. Review of a Medical Doctor (MD) Progress Note dated [DATE], revealed Resident #17 was a DNR patient. Review of a Care Plan with a review date of [DATE], revealed Resident #17 had the following Advanced Directives on record; a Living Will, a Durable Power of Attorney for Health Care and a DNR order with the goal of Resident #17's Advanced Directives are in effect, and the residents wishes and directives will be carried out. Review of a MD Progress Note dated [DATE], revealed Resident #17 was a full code. Review of a Physician's Orders revealed Resident #17 had an order dated [DATE] to be admitted to hospice services with diagnosis of senile degeneration of the brain and an order dated [DATE] revealed the resident was a full code. Review of a Medication Administration Record (MAR) dated [DATE] to [DATE], revealed Resident #17 was a full code. Review of the Face Sheet for Resident #17 indicated the resident had an advanced directive for no CPR. During an interview on [DATE] at 9:33 AM, Registered Nurse (RN) #1 indicated Resident #17 was receiving hospice services for dementia. RN #1 indicated that Resident #17's Advanced Directives consisted of a POA, DNR order and a Living Will. RN #1 indicated Resident #17's Living Will indicated the resident did not want CPR. RN #1 indicated a resident's code status was documented on the Face Sheet, MAR, and Advanced Directive. RN #1 was asked if the residents' code status was included in Physician Orders and RN #1 stated that the code status was verified by looking in the medical record that Resident #17's current Physician Orders indicated the resident was a full code. RN #1 stated that Physicians' Orders should reflect the residents Advanced Directives regarding code status and after further review of Resident #17's medical record, RN #1 stated the Physicians' Orders from [DATE] to [DATE] when the facility admitted Resident #17 also showed that the resident was a full code. RN #1 stated that Resident #17's Medical Record and orders needed to be updated to reflect the resident's wishes as outlined in the residents Advanced Directive since someone could look at the record and do CPR when that is not what the resident wants. RN #1 stated, We would not want anyone to make that mistake. During an interview on [DATE] at 9:50 AM, Licensed Practical Nurse (LPN) #3 indicated Advanced Directives were kept in the resident's Medical Record and the code status was written on the MAR and on the Face Sheet. LPN #3 was asked where she would look for a resident's code status if the residents' heart stopped and she stated that if she was at the nurse's station she would look in the Medical Record and if she was on the hall she would look at the MAR. LPN #3 was asked what Resident #17's MAR indicated as the code status and LPN #3 stated that it indicated a full code. LPN #3 was asked to review Resident #17's medical record and verify what the resident's code status was in the medical record. LPN #3 reviewed Resident #17's medical record and stated the residents code status was DNR. LPN #3 stated the resident had a DNR order and a Living Will stating no chest compressions. LPN #3 was asked what the residents' current orders indicated regarding code status and LPN #3 stated the residents' current orders stated full code. LPN #3 was asked why it was important that the resident record accurately reflected the resident's Advanced Directives and code status, and LPN #3 stated, it was important so that staff know the resident's wishes and that Resident #17 did not want CPR. During an interview on [DATE] at 10:15 AM, the Assistant Director of Nursing (ADON) was asked who ensured the order for code status was correct when a resident was first admitted to the facility. The ADON stated the code status form was in the admission packet, and at the time of admission, the admissions staff member asked the resident and/or family if they have any Advanced Directives such as a living will. The ADON stated Resident #17's family chose a DNR order and the order was signed by the resident's family member. The ADON stated that the admissions staff member would put the initial information in the computer and print out the Face Sheet. The resuscitate/do not resuscitate order was brought to the nursing department and taken to the MD for signature. When the signed resuscitate/do not resuscitate order came back from the MD, the ADON would go into the computer and put the DNR code status into the orders. The ADON was asked what Resident #17's orders should say regarding the code status and the ADON stated it should say Resident #17 was a DNR. The DON was asked where she would look for code status if a resident's heart was to stop and she stated she would look at the resuscitate/do not resuscitate order because she would want to know if it had been signed by the physician or not. The ADON was asked to look at Residents #17's Physician Orders regarding the resident's code status and the ADON stated the residents face sheets stated no CPR, but Physician Orders stated full code and that was not correct. The ADON was asked why it was important that a resident's Advanced Directives and orders were correct in the Medical Record and the ADON stated it was important, so we know the resident's and resident family's wishes and know whether to start CPR. The ADON stated, If I start CPR, I cannot stop until a physician tells me to stop. This needs to be clarified immediately. During an interview on [DATE] at 10:30 AM, the Director of Nursing (DON) verified Resident #17 was on hospice services for dementia. The DON was asked if Resident #17 had an Advanced Directive and the DON stated that she believed the resident had an Advanced Directive stating DNR and no Intravenous (IV) therapy. The DON was asked where the code status was documented and she stated it was documented in the Advanced Directives, on the Face Sheet and on the MAR. The DON acknowledged that the MAR was not correct and stated, she was getting that corrected now. The DON was asked why it was important that the resident's Advanced Directives were known and the DON stated it was important so that staff know what to do. Staff should check the actual advanced directives to see what the resident's wishes are. That is what I would do. The surveyor showed the DON the MD Progress Note dated [DATE] that indicated the resident was a full code and the DON stated, I will call the doctor and clarify this with him. During an interview on [DATE] at 10:55 AM, The Administrator stated Resident #17 was on hospice services. The Administrator was asked if Resident #17 had an Advanced Directive and the Administrator stated Resident #17 was a DNR. The Administrator was asked if she was aware that Resident #17's Physicians Orders indicated the resident was a full code and the Administrator stated, she had just been made aware of that. The Administrator was asked why it was important that the resident's Medical Record accurately reflected their Advanced Directives and the Administrator stated, so that staff can carry out the wishes of the resident in case of an emergency. The Administrator stated, we are correcting it right now by reviewing all the residents' Advanced Directives and orders. Review of a facility policy titled Advanced Directives with a reviewed date 01/2024, revealed advanced directives will be respected in accordance with state law and facility policy. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advanced directive and the Director of Nursing or designee will notify the attending physician of advanced directives so that appropriate orders can be documented in the resident's medical record and plan of care.

Based on interviews, record review, and facility document review, it was determined that the facility failed to ensure care plans were updated to include interventions for incidents for (Resident #16, Resident # 18, Resident # 27) 3 residents reviewed for incidents with care plan revisions and updates. Findings include: 1. On 10/24/2024 at 11:00 AM, the Director of Nursing (DON) stated, the facility did not have a policy for care plans or care plan revisions. 2. A review of Resident #16's Face Sheet indicated, the facility admitted Resident #16 with diagnoses that included congestive heart failure, Type 2 Diabetes Mellitus, chronic obstructive pulmonary disease, vascular dementia with behavioral disturbance, cerebral infarction and polyneuropathy. a. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/12/2024, revealed, Resident #16 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. b. A review of the Incident/Accident report revealed, Resident #16, on 07/09/2024 at 5:00 PM, was observed to have a bruise to their right great toe. The resident stated the toe was smashed between the wheelchair and the doorframe. According to the report, the additional step taken to prevent recurrence was to encourage Resident #16 to be mindful of feet when wheeling the wheelchair through doorways. c. A review of the Incident/Accident report revealed, Resident #16, on 08/22/2024 at 8:00 AM, was leaning on the right side of the bed attempting to eat and fell from the side of the bed onto the floor. According to the report, the additional step taken to prevent recurrence was to encourage Resident #16 to be out of bed for all meals. d. A review of the Nurse Aide's Information Sheet for Resident #16 had no interventions for the incident that occurred on 07/09/2024 and no interventions for the incident that occurred on 08/22/2024. e. A review of Resident #16's Care Plan, dated 04/23/2024 and updated 07/23/2024, revealed Resident #16 had a risk for abnormal bleeding or hemorrhage because of antiplatelet usage and a risk for injury related to falls; due to unsteady balance and history of fall. The bruise and intervention that occurred on 07/09/2024, and the fall that occurred on 08/22/2024, were not included in the care plan. 3. A review of Resident #18's Face Sheet indicated, the facility admitted Resident #18 with diagnoses of Dementia with Lewy Bodies, Parkinson's disease and soft tissue infection. a. The quarterly MDS with an ARD of 09/16/2024 revealed Resident #18 had a BIMS score of 3, which indicated the resident had severe cognitive impairment. A review of the Incident/Accident report revealed Resident #18, on 10/11/2024, complained of pain to the right forefinger with swelling and redness noted, with no open lesion. Additional comments noted on the reports stated, the physician prescribed an antibiotic and wound care to be provided. Resident #18 was assessed and there was no indication that the area to the forefinger was caused by an injury. A review of Physician's Orders for Resident #18 revealed the resident had an order, initiated on 10/11/24, to clean lesion to right index finger with wound cleanser; apply antibiotic ointment and cover with bandage every day until healed and as needed and to start antibiotic, 1 pill every day for 7 days. A review of Resident #18's Care Plan, updated 09/24/2024, revealed Resident #18 had a risk for abnormal bleeding or hemorrhage due to daily antiplatelet use; a risk for unrelieved pain related to Parkinson's disease and cognitive deficit with limited memory; and a risk for skin breakdown related to decreased mobility and frequent episodes of incontinence of bowel and bladder. The care plan had not been updated to include the incident/infection or the antibiotic and treatment order that occurred on 10/11/2024. A review of Resident #27's Face Sheet indicated the facility admitted Resident #27 with diagnoses of anxiety disorder, muscle spasm, and bipolar disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/22/2024, revealed Resident #27 had a Staff Interview for Mental Status (SAMS) which indicated the resident was severely impaired for daily decision making. A review of the Incident/Accident report revealed that Resident #27, on 09/29/2024, received a skin tear to their left hand while pulling hand out of the side of the wheelchair when the hand caught on the bottom of the arm rest. Additional comment/steps taken to prevent recurrence indicated, treatment order for the skin tear and a larger, more comfortable and safer chair was requested from hospice. A review of the Nurse Aide's Information Sheet for Resident #27 had no interventions for the incident that occurred on 09/29/2024. A review of Physician Orders for Resident #27 revealed, resident had an order, initiated on 09/29/2024, to cleanse skin tear to left hand with wound cleanser. Pat dry. Apply strip closures and cover with dry dressing. Monitor strip closures every day and as needed. Keep covered with dry dressing until healed. A review of Resident #27's Care Plan, dated 06/18/2024, revealed Resident #27 had a terminal illness and the family had opted for hospice care for the diagnosis of senile degeneration of the brain and resident was at risk for further decline in overall condition as disease progresses. The request for a larger, more comfortable, and safer chair from hospice had not been added to the care plan. There was no care plan added to include the skin tear Resident #27 received on 09/29/2024. During an interview on 10/16/2024 at 2:20 PM, the MDS Coordinator confirmed there were no updates or interventions added to Resident #16's care plan for the incident that occurred on 07/09/2024 and no updates or interventions were added for the incident that occurred on 08/22/2024. MDS coordinator confirmed that the care plan for Resident #18 had not been updated to include the incident/accident, the treatment or the infection for the right index finger. MDS coordinator confirmed, the care plan for Resident #27's skin tear and the intervention for a larger, more comfortable and safer chair request had not been added to the resident's care plan. MDS coordinator indicated, the care plan should be updated as soon as the incident/accident happens or as soon as possible and the reason for that would be to prevent it from happening again. When asked how the staff would know what interventions were put into place, the MDS Coordinator stated the staff have ADL books but, they were being worked on and for now the staff would be told. During an interview on 10/16/2024 at 2:30 PM, the DON stated each morning Incidents/Accidents and infections were reviewed in the morning stand up meetings and the registered nurse (RN) was supposed to be updating the care plan with the information and interventions. The DON confirmed that care plans should be updated within 24 hours after an incident occurred. DON explained the importance of making sure care plans are updated was to prevent it from happening again. The DON indicated the ADL books that the staff use are supposed to be updated by the MDS Coordinator. During an interview on 10/17/2024 at 9:10 AM, RN stated there had been a misunderstanding, but now the incidents/accidents would be care planned. RN stated the incident/accident reports had been given to the MDS Coordinator thinking that the interventions would be care planned, not realizing that they were to be care planned by the RN.

Based on observation, record review, and interview, it was determined that the facility failed to follow the recipe for pureed foods to maintain nutritional value for 4 ( Resident # 8, #9, #25, and #38) residents receiving pureed foods from the facility kitchen. The findings are: On 10/15/2024 at 10:16 AM, during an observation the [NAME] prepared and pureed food items for lunch. The [NAME] pureed chicken fried steak and thinned food mixture using a total of 3 cups of hot water. On 10/15/2024 at 10:33 AM, the [NAME] pureed rolls and thinned the bread mixture with a total of 2 cups of hot water. On 10/16/2024, a list of residents with puree diets was provided by the Dietary Supervisor (DS), along with guidelines for pureeing foods, and recipes for pureed chicken fried steak and pureed rolls. The recipes for pureed foods were reviewed and the recipe for pureed chicken fried steak indicated at Step #2, add liquid if needed [ex. reserved liquid, broth, milk, gravy, or sauce] to assist with pureeing and a note that indicated, water should not be used as a liquid to puree foods. The recipe for pureed rolls indicated at Step #2, add liquid if needed [ex. reserved liquid, broth, milk, gravy, or sauce] to assist with pureeing, and a note that indicated water should not be used as a liquid to puree foods. On 10/16/2024 at 10:27 AM, the [NAME] was asked during an interview to read over the recipe. The [NAME] read the recipe and confirmed water should not have been used to thin the food mixtures. The [NAME] stated adding water takes away from the nutritional value and flavor of the foods. On 10/16/2024 at 10:33AM, the DS was asked to read over the recipe and confirmed water should not have been used to thin pureed foods. Broth, gravy, or milk would have been a better option. The DS said when water is used, it reduces the nutritional value and flavor of foods. If broth, milk, or gravy would have been used, it would have added nutrition and more flavor.

Based on interviews, record review, facility document review it was determined that the facility failed to ensure that physician orders were followed as written on telephone order for 1 (Resident #27) reviewed for physician order accuracy. Findings include: On 10/24/2024 at 11:00 AM, the Director of Nursing (DON) stated the facility did not have a policy for physician's orders or the processing of physician's orders. A review of a Face Sheet indicated the facility admitted Resident #27 with diagnoses of anxiety disorder, muscle spasm, and bipolar disorder. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/22/2024, revealed Resident #27 was severely impaired for daily decision making. The MDS indicated Resident #27 had an indication for use of a high-risk drug, an anti-anxiety medication. A review of a Physician's Telephone Order dated 09/12/2024, for Resident #27 indicated a new order for (name brand) anti-anxiety medication 0.5 mg (milligram) give 1 tablet by mouth twice a day and was signed by the physician on 10/03/2024. A review of October 2024 Physician's Orders, signed by the physician on 10/03/2024, for Resident #27 revealed an order for (name brand) Anti-anxiety medication 0.5 mg 1 tablet by mouth three times a day for anxiety disorder that had been updated on 09/12/2024. A review of Resident #27's Care Plan, dated on 06/18/2024, revealed the resident was at risk for adverse effects of psychotropic medications. Interventions included: observe for adverse effects of - (name brand) Anti-anxiety medication and report to physician if occurs, sedation, discoordination, unsteady balance, increased agitation, headache, nausea, and hallucination. A review of the Medication Administration Record (MAR) for September 2024 revealed, on 09/12/2024, an order had been added. (Name brand) Anti-anxiety medication 0.5 mg 1 tablet by mouth three times a day (TID). The original twice a day (BID) was marked out with one line through the BID with error written above the word. A review of the MAR for October 2024 revealed, an order for -(name brand) Anti-anxiety medication 0.5 mg 1 tablet by mouth TID. On 10/16/2024 at 9:49 AM, the DON confirmed the Physician's Telephone Order and the printed October Physician's Orders did not match. During an interview on 10/17/2024 at 9:20 AM, the LPN stated, that the order should have been clarified when the BID had been crossed out on the MAR. Confirmation was given by LPN that the telephone order had not been reviewed and the order had not been clarified for the (name brand) Anti-anxiety medication. During an interview on 10/17/24 at 9:00 AM, the DON indicated, the process of processing physician's orders was for the nurse to write the order, tear the top copy of the telephone order off, and fax to the pharmacy then to call the family. Once completed, the telephone order would go in a basket and would be picked up each morning. The order would then be entered into the electronic physician's orders. The DON revealed, it was important to ensure orders are transferred correctly and with any order that was unclear, that the order should be clarified.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for those residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 4 residents who received pureed diets. The findings are: 1. On 6/03/24 at 12:05 PM, the residents on pureed diets were served pureed chicken. The consistency of the pureed chicken was gritty and not smooth. At 12:30 PM, the Surveyor asked the Dietary Supervisor to look at pureed chicken and to describe it. The Dietary Supervisor confirmed the pureed chicken looks gritty and would be a choking hazard for residents who are on a pureed diet. 2. On 06/05/24 at 7:40 AM, pureed sausage served to the residents on pureed diets for breakfast was gritty and had water in it. 06/05/24 7:44 AM, the surveyor asked the Dietary Supervisor to describe the consistency of the pureed sausage. She stated, It wasn't right it needs to be pureed better to have more consistency.

Based on observation, record review, and interview, the facility failed to ensure (1) that manufacture specifications for seasonings storage were followed, (2) that dietary staff washed their hands and changed their gloves before handling food items, (3) that expired food products were promptly removed from the dining room, (4) that cold food items were maintained at 41 or below degrees Fahrenheit on ice while awaiting, and (5) that the facility kitchen was free of pests. These failed practices had the potential to affect 52 residents who received meals from the Kitchen. The findings are: 1. [DATE] 1:05 PM, the following observations were made in the kitchen area. a. An opened bottle of soy sauce was on the shelf behind the steam table. The manufacture specification on the bottle documented refrigerate after opening. b. An opened bottle of lime juice on a shelf behind the steam table. The manufacture specification on the bottle documented refrigerate after opening. The surveyor asked the Dietary Supervisor what do you use this for? She stated, We use it when we make pie. 2. On [DATE] at 3:42 PM, two of 2 Italian salad dressings in a basket on a table holding straws and spices had an expiration date of [DATE]. One of 1 Italian salad dressing in a basket on the second table holding straws and spices had expiration date of [DATE]. The surveyor showed the dressings to the Dietary Manager who stated, It was not from the kitchen. 3. On [DATE] at 4:45 PM, Dietary Cook (DC) #1 took out a pan of chicken noodle soup from the oven and placed it on the counter, picked up a pan from a rack and placed it on the counter with her fingers inside the pan. She removed a serving spoon from a drawer and used it to place 5 servings of chicken noodle soup into a pan. Without washing her hands, she picked up a clean blade and attached it to the base of the blender, then poured chicken noodle soup in the pan into a blender with contaminated blade and pureed to be served to the residents who received pureed diets. 4. On [DATE] at 4:51 PM, Dietary Cook (DC) #1 picked up the water hose with her bare hand, used it to spray leftover food from inside of the dishes, contaminating her hands. She placed the dirty dishes in the dirty racks and pushed the racks into the dish washing machine to wash. After the dishes stopped washing, she moved to the clean side of the dishwasher area and picked up clean dishes and placed them on the clean rack to be used in serving noon meal to the residents. As she was about to use it to puree other food items. The surveyor immediately stopped and asked DC #1 what should you have done after touching dirty objects and before handling clean equipment or food items? DC #1 stated, I should have washed my hands. 5. On [DATE] at 4:59 PM, the temperatures of the cold food items when checked and read on a pan of ice by the Dietary Aide (DA) #1 were. a. [NAME] tuna salad 60 degrees Fahrenheit. b. Mechanical soft tuna salad 60-degree Fahrenheit. c. Pureed tuna salad 60-degree Fahrenheit. 6. On [DATE] at 5:14 PM, DC #1 picked up a pan of cabbage and placed it on the steam table. Without washing her hands, she picked up plates to be used in portioning food items to be served to the residents for supper meal with her fingers inside of them. 7. On [DATE] at 5:19 PM, DA #2 who was on the tray line assisting with supper meal, wore gloves on her hands. DA #2 picked up cartons of beverages, supplements, tray cards, crackers and placed them on the trays. She then opened the refrigerator, removed cartons of supplements, and placed them on the trays. Without washing her hands, she picked up glasses by their rims and placed them on the trays to be served to the residents. The surveyor asked DA #2 what you should have done after touching dirty objects and before handling clean equipment? DA #2 stated, I should have changed, and removed the gloves and washed my hands. 8. Review of commercial and noncommercial pest control Records dated [DATE] documented, Target Pest 'E German Roaches. 9. ,d+[DATE] 7:45 AM, Dietary Supervisor aide opened a recipe book and 2 live roaches fell to the floor. The Dietary Manager stated, They came and sprayed last month. 10. A facility policy titled . When and how to wash your hands documented, Before you begin a task and after you touch anything that may contaminate your hands.

Based on observation, record review, and interview the facility failed to ensure the minimum data set (MDS) accurately reflected, on section A1500 the preadmission screening and assessment resident record (PASRR) a serious mental illness and/or intellectual disability affecting 1 (Resident 24) of 3 sampled Residents (Resident #3, #24, and #29) with a level II PASRR. This failed practice had the potential to affect 6 residents with a level II PASRR. The findings are: 1. Resident #24 with a diagnosis of Vascular Dementia, Parkinson's, and altered mental status. The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/11/2023 suggests a Brief Mental Status Score (BIMS) of 11 (8-12 indicated moderate cognitive impairment). a. A Care Plan documenting .Resident #24 is at risk for alteration in mood related to dx of bipolar disorder (10/24/2023) .Observe for mood changes is, crying, self-isolation, sleeping too much or too little .Observe effectiveness /side effects of medications as Observe effectiveness as ordered: Oxcarbazepine . b. On 06/04/2024 at 8:33 AM, the Surveyor observed Resident #24's Level II PASRR evaluation dated 12/08/2022. While reviewing Resident #24's chart the annual MDS dated [DATE] section A 1500 showed no mental health diagnoses. c. On 06/05/2024 at 10:02 AM, the MDS nurse reviewed Resident #24's chart and read the level II evaluation stating no services were recommended for Resident #24's mental illness and told the Surveyor Resident #24 did not have a level II PASRR. The MDS nurse then checked the Annual MDS section A1500 to make sure the MDS nurse did not incorrectly record Resident #24 as having a level II PASRR. d. On 06/05/2024 at 11:18 AM during interview, the MDS nurse confirmed Resident #24 did in fact have a level II PASSAR. The Surveyor asked why it was important to code correctly to the MDS, and if the MDS nurse used anything to guide documenting to the MDS. The MDS nurse confirmed it is important to code the MDS correctly because it paints a picture of the resident and helps to make sure they get the care they need, and the Resident Assessment Instrument (RAI) manual is used as a guide when coding to the MDS. The Surveyor requested a copy of the portion of the RAI manual instructing section A1500. e. On 06/05/2024 2:12 AM, the Assistant Administrator was asked for section from the RAI manual on section A1500. f. On 06/05/2024 at 3:15 PM, the Assistant Administrator provided a copy of section A1500 from the MDS, and there is not a MDS policy. g. On 06/05/2024 at 4:00 PM, the MDS nurse was asked to provide a copy from the RAI manual concerning section A1500. h. On 06/06/2024 at 9:00 AM, the MDS nurse provided documentation from the RAI manual titled A1500: Preadmission Screening and Resident Review (PASRR) documenting, .Code 1, Yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition .

Based on observation, record review, and interview the facility failed to ensure 1 (Resident #156) oxygen was administered at the physician ordered rate to prevent respiratory complications. This failed practice had the potential to affect 2 sampled (Residents #3, and #156) of 6 residents with oxygen orders. The findings are: Resident #156 with a diagnosis of chronic obstructive pulmonary disease. The significant Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/25/2024 suggested a Brief Mental Status Score (BIMS) of 10 (8-12 indicates moderate cognitive impairment). a. A Physician Orders (dated, 04/24/2024) .Oxygen as needed every 24 at 2 liters per minute as needed nasal cannula shortness of breath . b. A Care Plan for Resident #156 (dated, 05/07/2024) documented, .has potential for difficulty breathing related to chronic condition: COPD .Administer/observe effectiveness of treatments (see current physicians orders) Oxygen inhaler .oxygen at 2 liters per minute as per orders .Change oxygen tubing, humidifier and clean filter every Saturday and as needed . c. On 06/03/2024 at 9:36 AM, while observing, Resident #156 was observed resting quietly on 3.5 liters of oxygen nasal cannula. d. On 06/04/2024 at 8:53 AM, Resident #156 was observed receiving 3.5 liters nasal cannula. Resident appears pleasantly confused, and said he was on oxygen for shortness of breath. e. On 06/04/2024 at 2:18 PM, Licensed Practical Nurse (LPN) #3 arrived at the bedside and confirmed Resident #156 is supposed to be on 2 Liters nasal cannula. f. On 06/04/2024 at 2:16 PM, LPN #3 was asked what procedure is used to check that concentrators are working and set at the right rate. LPN #3 confirmed nursing eyeballs the oxygen when staff rounds on each shift, oxygen tubing is checked on the weekend and the rate should be checked at that time too, and the oxygen was not set on 2 liters. The Surveyor said the oxygen was observed on 3.5 liters since yesterday, and most of the day today. LPN #3 said he is supposed to be on 2 liters, and that is how it is ordered. The Surveyor asked is there any reason why nursing would want to make sure residents are going at the correct rate. LPN #4 said, Yes, it could blow him out. g. On 06/05/2024 at 1:20 PM, while interviewing the Director of Nursing (DON) the Surveyor asked what procedure staff is expected to monitor oxygen concentrator settings, and who is responsible for checking the rate. The DON confirmed that the doctor orders the rate and nursing is responsible for checking the rate with every medication pass. The rule of thumb is to look and check anytime nursing is walking down the hall. h. On 06/05/2024 at 2:12 PM, the Assistant Administrator was asked for the oxygen policy, and in-services. i. On 06/06/2024 at 8:00AM, the Assistant Administrator provided a policy titled Oxygen Administration documenting, . Procedure 1. Check physician's order for liter flow and method of administration .5. e. Set the flow meter to the rate ordered by the physician . 11. At regular intervals, check liter flow contents of oxygen cylinder .

Based on observation, record review, and interview the facility failed to ensure proper hand hygiene was performed during peri care for 1 (Resident #11) to prevent cross contamination and infection. This failed practice had the potential to affect 4 sampled (Resident #18, #31, #56, and #156) of 12 residents requiring peri care. The findings are: Resident #11 with diagnoses of Diabetes Mellitus, Heart Failure, and Anxiety. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) suggests a Brief Mental Status Score of 7 (0-7 suggests severe cognitive impairment). a. A Care Plan for Resident #11 (dated, 05/11/2023) requires total assistance with all ADL (Activities of Daily Living) activities .TOILET USE resident needs staff assistance x 1 for toileting/incontinence care . b. 06/03/2024 at 10:28 AM, the Surveyor observed Certified Nursing Assistant (CNA) #4 wiping Resident #11's buttocks and peri area using clean wipes pulled out with right hand and wiping Resident #11 with the right hand. CNA #4 removed soiled gloves and pulled on glove from the right pocket and put it on the right hand leaving the left hand bare. I only have one glove. CNA #4 completed peri care then without removing the one glove or performing hand hygiene Resident #11 was rolled onto the left side and both hands were used to pull the draw sheet and pull the clean brief over, and adjusted residents brief in the peri area. CNA #4 then rubbed lotion on the left and right shoulder, arms, and legs, then dressed resident without performing hand hygiene. CNA #4 washed hands at the sink. c. On 06/03/2024 at 10:42 AM, CNA #4 was asked the procedure for providing peri care and was asked if CNA #4 always uses her right hand to get clean wipes and wipes residents buttocks and peri area with the same hand. CNA #4 said, Yes, that is just how I do it. CNA #4 confirmed that CNA #4 should have washed the hands or put on another pair of gloves for infection control. d. On 06/05/2024 at 9:04 AM, the Dietary Manager provided a policy titled, When and How to Wash Your Hands documenting, . You should wash your hands: After you touch anything that may contaminate your hands . e. On 06/05/2024 at 1:15 PM, the Director of Nursing (DON) was asked if it was standard care to pull out clean wipes with the right hand, then use the same hand to provide peri care. The DON confirmed that it is not standard practice to go back and forth from clean to dirty with the same hand without doing hand hygiene. f. On 06/05/2024 at 2:12 PM, the Assistant Administrator was asked for the peri care policy. g. On 06/06/2024 at 8:00 AM, the Assistant Administrator confirmed the facility does not have a peri care policy.

Based on observations, interview and record review, the facility failed to ensure foods in the stand-up freezer and chest freezer were properly dated, sealed, and stored in 1 of 1 facility kitchen. This failed practice had the potential to affect 53 residents who received their meals from the kitchen as identified by the Resident List Report provided by Infection Preventionist on 12/17/2023 at 10:54 AM. The findings are: 1. a. On 12/17/2023 at 9:37 AM, an initial kitchen tour was conducted. In the back room was a three-door refrigerator, a stand-alone two-door freezer and two chest freezers. On 12/17/23 at 9:47 AM, in the left door on the bottom shelf of the stand-alone two-door freezer, was 1 resealable bag with 7 fried pork steaks in it with no date on the bag. b. On 12/17/23 at 9:49 AM, in the right door on the bottom shelf of the stand-alone two-door freezer, a was 1 resealable bag with what appeared to be 100 tater tots with no date on the bag. 2.a. On 12/17/23 at 9:55 AM, the Dessert Freezer (Chest style freezer), contained 1 Key Lime Pie with no date of when received and the cellophane was torn on the bottom 3.a. On 12/20/2023 at 12:03 PM, while observing lunch in the Closed Unit, the Surveyor observed Certified Nursing Assistant (CNA) #6 standing at the food cart with the thumb and pointer finger of the left hand resting on the rim of a brown bowl. CNA #6 placed a lid on top of the bowl using the right hand. b. On 12/20/2023 at 12:04 PM, the Surveyor asked CNA #6 if there was any reason staff might not want to hold a bowl or cup with their fingers resting on the rim. CNA #5 said They [residents] might put their mouth on there and get germs, or cross contamination. CNA #6 was asked the procedure to transfer bowls and cups to the residents. CNA #6 said, We are supposed to hold them from the bottom. c. On 12/20/2023 at 03:10 PM, the Surveyor asked the Director of Nursing (DON) why it is important to not place fingers on the rims of a resident's cup or bowl. The DON said, Infection control. The Administrator said, Alcohol gel gets on the top of the glasses also. The DON said she does not have a serving of food policy. 4. a. On 12/17/23 at 9:59 AM, the Dietary Cook was asked why it was important to have dates on the food in the freezer? Dietary Cook stated, To know when they were opened and to know when they will go bad. b. On 12/19/23 at 10:28 AM, the Dietary Manager (DM) was asked the importance of making sure the dates were on everything in the refrigerator and freezer. The DM stated, To know when they were opened or when they were received. The DM also stated, I'm trying to make sure everything is dated. I am dating everything on the package and not using the labels anymore, because they fall off in the freezer. c. On 12/20/23 at 11:31 AM, the Surveyor asked the DON why it is important to have dates on food in the refrigerator and freezer? The DON stated, So you'll know when it was opened or put in the freezer. d. On 12/21/23 at 9:33 AM, the DON stated, All of the Residents get a tray from the kitchen. e. The DM stated, We do not have a policy and procedure on food storage, we follow Federal Guidelines.

Based on observations, interviews, and record reviews, the facility failed to ensure staff did not stand over Residents while assisting them with eating for 1 (Resident #39), meal trays were removed from the serving tray and placed on the table for 2 (Residents #38 and #39) and residents who required assistance with eating were provided their meal at the same time as the other residents for 1 (Resident #44) of 3 (Residents #38, #39 and #44) sampled residents to promote dignity and respect. The findings are: 1. On 12/17/23 at 12:04 PM, observed Certified Nursing Assistant (CNA) #5 standing to feed Resident #39 at the table for Residents require assistance with eating. a. On 12/17/23 at 12:15 PM, the Surveyor asked CNA #5, How should you position yourself when feeding a resident? CNA #5 stated, At eye level. b. On 12/19/23 at 10:14 AM, the Surveyor asked the Director of Nursing (DON), how should staff position themselves when feeding a Resident? The DON stated, They should be sitting on stools at eye level with the resident. 2. On 12/17/23 at 12:07 PM, observed Residents 38 and #39) with their plates still on the serving tray. a. On 12/17/23 at 12:12 PM, the Surveyor asked CNA #5, why do some of the residents have their plates on serving trays? CNA #5 stated I'm sorry, I'm trying to control the mess. b. On 12/17/23 at 12:20 PM, the Surveyor asked Dietary Employee #1, why are some of the resident's plates on the table and others on the tray? Dietary Employee #1 stated, They are not supposed to be. The Surveyor asked, why should the plates not be on the serving trays? Dietary Employee #1 stated, It's a dignity issue. c. On 12/19/23 at 10:14 AM, the Surveyor asked the DON with the plates being left on the serving traying what issue could that cause? DON stated, That can be a dignity issue, we need to educate and care plan it if the resident prefers it that way. 3. Resident #44 had diagnoses of Dementia, Anxiety Disorder and Urinary Tract Infection. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/28/2023 indicated the resident was severely cognitively impaired on a Staff Assessment for Mental Status (BIMS) and was totally dependent on staff for eating. a. A Care Plan dated 06/08/2023 documented, .Resident #44 has impaired cognitive skills as evidenced by: Decision making problem Short term memory problem Long term memory problem understanding others Related to: Alzheimer's Disease BIMs score 3 . Provide a homelike therapeutic environment . b. On 12/17/2023 at 11:25 AM, the Infection Preventionist provided the [Facility] Admission Packet, which documented, .Resident [NAME] of Rights .Each person admitted to a nursing home has the following rights among others: .To be treated with consideration, respect, and full recognition or his/her dignity and individuality, including privacy in treatment and care for his/her personal needs . c. On 12/17/23 at 12:10 PM, observed Resident #44 sitting at the dining table with Resident #35 waiting on lunch. There were 7 residents sitting in the small dining area. CNA #2 told CNA #1 that Resident #44 was in the wrong place and was normally fed over there, pointing to the common area across the hallway. CNA #1 wheeled Resident #44 across the hall to the common area where the resident was sitting alone beside an open trashcan. Resident #44 watched the other residents being served and put her right hand down in the trash can. d. On 12/17/23 at 12:22 PM, observed CNA #2 walking over and dumping a lunch plate in the trash beside Resident #44. Resident #44 continued to wait to be fed. e. On 12/17/23 at 12:24 PM, CNA #1 placed an overbed table in front of Resident #44 and then placed an apron on Resident #44 and told her she would be back to help feed her. Resident #44 said, I can help. f. On 12/17/23 at 10:08 AM, the DON was asked if residents should be removed from the dining area and taken to another area to be served alone while other residents were eating were in the resident's field of vision. The DON said, No, that is not acceptable. Some of the residents in the unit cannot understand. 4. On 12/17/2023 at 10:54 AM, the DON provided an in-service dated 01/23/2023 titled, Resident Rights and Dignity, which documented, .Specific Resident Rights .The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . The Right to . Be treated with the fullest measure of consideration respect and dignity . oRight to dignity, respect, and freedom .Promote Resident Rights Never .neglect a resident .Provide access .Resident Rights are the Law oOur residents deserve to be treated and cared for with the utmost dignity and respect oOur residents deserve quality care . 48977

Based on observation, record review and interview the facility failed to ensure residents from the Locked Unit washed their hands after placing hands in the trash can while eating to prevent cross contamination for 1 (Resident #44) of 5 (Residents #20, #27, #35, #41, and #44) sampled residents eating in the locked unit; to implement a plan for Legionella and other water borne pathogens, and to plan a flow diagram of the facilities water. The failed practices had the potential to affect all 54 residents who resided in the facility. The findings are: 1. On 12/17/23 at 12:00 PM, the Surveyor observed Resident #44 being removed from a dining table and placed in the common area beside a small, open trashcan without a lid. Certified Nursing Assistant (CNA) #1 told Resident #44 that CNA #1 would be back to feed her. a. On 12/17/23 at 12:15 PM, Resident #44 was observed placing her right hand into the trashcan and running her fingers through the contents and touching and pulling up clear plastic and papers. b. On 12/17/23 at 12:22 PM, CNA #2 was observed walking over and dumping food from another resident's plate into the trash beside Resident #44. Resident #44 placed her right hand into the open trash can as CNA #2 walked away. c. On 12/17/23 at 12:26 PM, Resident #44 was observed with her right hand against her lips between bites. CNA #2 was observed dumping more leftovers from other resident plates into the trash can by Resident #44. d. On 12/17/23 at 12:28 PM, CNA #2 was observed scooting the trashcan away about 12 inches with her foot. e. On 12/17/23 at 12:29 PM, CNA #2 was observed using her foot to scoot the trash can over another 10 inches away from Resident #44. Resident #44 was holding a roll with the right hand and feeding herself. No hand hygiene was offered to the resident. f. On 12/20/23 at 11:51 AM, CNA #2 was asked if it was appropriate to feed residents in the common area alone. CNA #2 told the Surveyor that occasionally Resident #44 is fed in the common area by her husband and they never know when he is coming. The Surveyor asked should residents in the closed unit be seated beside the open trash can. CNA #2 said no because of germs, and they play in the trash cans. g. On 12/19/23 10:08 AM, the Surveyor asked the Director of Nursing (DON) if residents in the Locked Unit should be seated near open trash cans. The DON said, It would not be in good practice to put residents from the Unit by an open trash can. 2a. On 12/19/23 at 09:38 AM, the Surveyor asked the Maintenance Supervisor (MS) for their Legionella policy, procedures, and planning for the facility. b. On 12/19/23 at 09:41 AM, the Maintenance Supervisor provided the Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings from the CDC. The Maintenance Supervisor told the Surveyor he is not familiar with Legionella and is not familiar with the mentioned document. c. On 12/19/23 09:41 AM, the Maintenance Supervisor said he does not have a flow diagram of the building showing where Legionella and other opportunistic infections may grow in the water supply. That if they thought they had Legionella he would have to get a test kit. The Surveyor asked what would make him suspect they had Legionella. The Maintenance Supervisor said if he was told someone had it. d. On 12/19/23 09:42 AM, the Surveyor asked if there were any tests or procedures, they follow regarding water circulation. The Maintenance Supervisor said, No, but I do check on the water to make sure it is circulating and sometimes I add a little oil. e. On 12/19/23 10:08 AM, the DON was asked why it is important to have a flow diagram of the facility showing where Legionella and other opportunistic infections might grow. The DON said it is very important because residents use water so much, to drink, eat, and for personal hygiene.

Based on observation, record review and interview, the facility failed to ensure before a resident was allowed to self-administer physician ordered liquid mouthwash for dry mouth, the interdisciplinary team (IDT) conducted an assessment to determine if this practice was safe, care planned, and a system was in place to assure the medication was safely and correctly utilized by the resident for 1 (Resident #43) of 1 sampled resident who self-administered a liquid mouthwash for dry mouth medication. The findings are: a. A Physicians Order dated 10/27/23 documented Resident #43 was to receive Biotene Oral Balance 2 sprays in the mouth before meals and at bedtime. b. The December 2023 Medication Administration Record (MAR) noted Resident #43 was to receive Biotene Oral Balance 2 sprays in the mouth before meals and at bedtime at 6:00 AM, 11:00 AM, 4:00 PM and 8:00 PM. c. On 12/19/23 at 07:15 AM, the Surveyor observed the 8:00 AM medication pass with Licensed Practical Nurse (LPN) #2. After administering Resident #43's medications, the Surveyor observed LPN #2 sign off on the MAR for the 11:00 AM Biotene Oral Balance. The Surveyor did not observe the administration of the Biotene mouth spray. d. On 12/19/23 at 01:30 PM, the Surveyor asked Resident #43 did you take any mouth spray this morning? Resident #43 said, Yes, I spray it in my mouth between meals. e. On 12/19/23 at 01:35 PM, the Surveyor asked LPN #2, does Resident #43 self-administer any medications? LPN #2 stated, Yes, his Biotene, he knows when to give it. The Surveyor stated he just told me he gives it between meals, but the order states before meals and at bedtime. LPN #2 did not respond. f. On 12/19/23 at 01:36 PM, the Surveyor asked the Minimum Data Set (MDS) Coordinator if Resident #43 was care planned to self-administer medications. The MDS Coordinator stated, No. g. On 12/19/23 at 02:00 PM, the Surveyor asked the Director of Nursing (DON) do you have any residents in the facility that self-administer their medications? The DON stated, I don't believe we do. h. On 12/20/23 at 2:15 PM, a facility policy titled, Medication Administration - General, provided by the DON documented, .Self-Administration of Medication by Resident Policy Each Resident who desires to self-administer medication is permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility .If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility prior to allowing self administration . 3. The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis . 4. The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment Form, which is placed in the resident's medical record. 5. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted .

Based on observation, record review and interview, the facility failed to ensure privacy was provided to maintain dignity when flushing a percutaneous endoscopic gastrostomy (PEG) tube for 1 (Resident #52) of 1 sampled resident. The findings are: a. A Physicians Order dated 12/2/2023 documented, Flush PEG tube w/ [with] 60 ml [milliliters] of H2O [water] Q [every] shift to keep patent . b. The Care Plan dated 12/15/23 documented, . Promote dignity. Converse with resident and ensure privacy while providing care . c. On 12/19/23 at 09:00 AM, the Surveyor accompanied Licensed Practical Nurse (LPN) #1 into Resident #52's room. Observed LPN #1 flush Resident #52's feeding tube. LPN #1 removed 60cc of tap water from the sink and assisted in raising Resident #52's shirt exposing her stomach. Resident #52 held her shirt under her breast. Both the privacy curtain and door remained open during the process. When completed, the Surveyor asked LPN #1 if she always leaves the curtain and/or door open. LPN #1 responded, No, I'm sorry I was so nervous I forgot. I always close the door. The Surveyor asked why is it important for the curtain and/or door to be closed. LPN #1 answered, To provide privacy for dignity. d. On 12/20/2023 at 03:21 PM, The Director of Nursing [DON] was asked what procedures are staff expected to use to protect a resident's privacy? The DON said to shut the door, use a privacy curtain if it's a room for two residents, and to close the blinds when one's bed is to the outside. The Surveyor asked why do staff provide resident privacy? The Administrator said, Dignity. The DON said, Dignity, and it can be embarrassing for the resident. e. On 12/17/2023 at 11:25 AM, the [Facility] Admission Packet provided by the Infection Preventionist documented, .Resident [NAME] of Rights .Each person admitted to a nursing home has the following rights among others: .To be treated with consideration, respect, and full recognition or his/her dignity and individuality, including privacy in treatment and care for his/her personal needs . f. On 12/17/2023 at 10:54 AM, the DON provided an in-service dated 01/23/2023 titled, Resident Rights and Dignity, which documented, .Specific Resident Rights .The Right to . Be treated with the fullest measure of consideration respect and dignity . Specific Resident Rights . Right to privacy and confidentiality . Resident Rights are the Law oOur residents deserve to be treated and cared for with the utmost dignity and respect oOur residents deserve quality care .

Based on record review and interview, the facility failed to ensure discharge planning was conducted to promote continuity of care after discharge for 1 (Resident #56) of 1 sampled resident who was discharged in the last 90 days. The findings are: 1. On 12/19/23 at 10:04 AM, during record review, a Progress Note dated 12/9/23 at 11:30 AM documented Resident #56 was discharged from the facility and the daughter was given Resident 56's medications. a. On 12/19/23 at 10:30 AM, the Surveyor asked the Social Worker if she had a discharge summary on Resident #56. The Social Worker stated, No. I didn't do it. b. On 12/19/23 at 10:47 AM, the Surveyor asked the Director of Nursing (DON) should there have been a discharge plan in place that reflected Resident #56's needs, goals, and treatments. The DON stated yes there should have been a plan in place and if there were no needs, then it should have been documented. c. A facility policy titled, Discharge/Transfer Of A Resident, provided by the DON on 12/20/23 at 11:15 AM stated, Purpose: To provide safe departure from the facility and or to provide sufficient information for continuing or after care of the resident . PROCEDURE: Discharge: .6. Complete a Discharge Summary and the Post Discharge Plan of Care form. a. Include list of medication with instructions in simple terms. Do not use medical terms or abbreviations. b. Include instructions for post discharge care and explain to the resident and/or responsible party. c. Have the resident and/or responsible party or the person responsible for care to sign the Discharge Summary and the Post Discharge Plan of Care forms. This includes release of medications. d. Give a copy of the forms to the resident and/or responsible party or the person(s) responsible for care. e. Place the signed original copies of the forms in the clinical record .

Based on record reviews, and interviews, the facility failed to formulate a discharge summary and provide the Resident and/or responsible party with a copy per the facility policy for 1 (Resident #56) of 1 sampled resident who was discharged from the facility in the last 90 days. The finding are: 1. On 12/19/23 at 10:04 AM, during record review, a Progress Note dated 12/9/23 at 11:30 AM documented Resident #56 was discharged from the facility and the daughter was given Resident 56's medications. a. On 12/19/23 at 10:30 AM, the Surveyor asked the Social Worker if she had a discharge summary on Resident #56. The Social Worker stated, No I didn't do it. b. On 12/19/23 at 10:47 AM, the Surveyor asked the Director of Nursing (DON) should there have been a discharge summary for Resident #56. The DON stated, That was a problem. We are going to in-service on that to make sure all of our residents who discharge have that documentation. c. On 12/20/23 at 11:15 AM, the DON provided a policy titled, Discharge/Transfer Of A Resident documented, .Equipment .7. Discharge Summary and Post Discharge Plan of Care (for discharge home, lower level of care, or other long term care facility) .Discharge .6. Complete a Discharge Summary and the Post Discharge Plan of Care form. a. Include a list of medications with instruction in simple terms. Do not use medical terms or abbreviations. b. Include instructions for post discharge care and explain to the resident and/or responsible party. c. Have the resident and/or responsible party or the person responsible for care to sign the Discharge Summary and the Post Discharge Plan of Care forms. This includes release of medications. d. Give a copy of the form to the resident and/or responsible party or the person(s) responsible for care. e. Place the signed original copies of the forms in the clinical record .

Based on observations, interviews, and record reviews, the facility failed to ensure 1 (Resident (#46) of 1 sampled resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. The findings are: 1. Resident #46 had diagnoses of Dementia and Depression according to his face sheet. The Annual Minimum Data Set with an Assessment Reference Date of 10/09/23 documented Resident #46 was totally dependent for personal hygiene. The Activities of Daily Living (ADL) flow record documented that Resident #46 was totally dependent with 1 person assistance with personal hygiene. a. On 12/17/23 at 01:50 PM, observed Resident #46 sitting in a wheelchair. He had a shaggy beard and dirty jagged fingernails on both hands. Pictures taken of the fingernails. b. On 12/19/23 at 08:54 AM, observed Resident #46 lying in bed resting. His fingernails were dirty and jagged. c. On 12/19/23 at 08:54 AM, observed Resident #46 lying in bed resting. His fingernails were dirty and jagged. d. On 12/19/23 at 08:55 AM, the Surveyor accompanied Certified Nursing Assistant (CNA) #5 to observe Resident #46's nails. The Surveyor asked CNA #5, can you tell me what you see when you look at Resident #46's nails. CNA #5 stated, Dirty needs to be cleaned. I will get him. e. On 12/19/23 at 09:05 AM, the Surveyor accompanied the Infection Preventionist to observe Resident #46's nails. The Surveyor asked the Infection Preventionist, can you tell me what you see when you look at Resident #46's nails. The Infection Preventionist stated, They need to be clipped and they look dirty. f. On 12/19/23 10:04 AM, the Director of Nursing (DON) stated, I just want to let you know that [Resident #46's] nails have been cleaned. g. On 12/20/23 at 11:15 AM, the DON provided a facility policy titled, ADL [Activities of Daily Living]/Care Plan Flow Sheet that documented, .Procedure: 1. Each Certified Nursing Assistant will review and initial on each assigned resident's ADL/Care Plan flow sheet . h. On 12/20/23 at 11:45 AM, Surveyor was provided the ADL book for the D Hall, a review of the December 2023 record for Resident #46 showed no signature for personal hygiene on the 7:00 am - 7:00 pm shift for December 1, 2, 3, 4, 5, 8, 9, 18, 19; and for the 7:00 pm - 7:00 am shift for 1, 2, 3, 4, 5, 11, 12, 14, 15, 16, 19. i. On 12/20/23 at 11:50 AM Surveyor asked DON does an initial indicate that the care was done? The DON stated, Yes.

Based on observation, interviews and record review, the facility failed to ensure physician orders were followed to maintain a medication error rate of less than 5%, to prevent potential complications for 1 (Resident #43) of 1 sampled resident observed during the medication pass. The medication error rate was 5.13%, based on observations of 38 medications administered, plus 1 medication ordered and signed off on the Medication Administration Record (MAR) before time to administer the medication for a total of 2 errors detected. The findings are: a. The MAR documented Resident #43 was to receive Biotene Oral Balance 2 sprays in the mouth before meals and at bedtime. b. The MAR documented Resident #43 was to receive Metoprolol Tartrate (high blood pressure medication) 25 milligrams 1 tablet twice a day and to hold if blood pressure was less than 110/50. c. On 12/19/23 at 07:15 AM, the Surveyor observed the 8:00 AM medication pass with Licensed Practical Nurse (LPN) #2, LPN #2 checked Resident #43's blood pressure prior to administration of any medication. The Surveyor asked LPN #2 what Resident #43's blood pressure was. LPN #2 stated, 103/62, heart rate 86. LPN #2 prepared and then administered a Metoprolol 25 milligram tablet to Resident #43. After administering the medication, the Surveyor observed LPN #2 sign off on the MAR for the 8:00 AM Metoprolol and the 11:00 AM Biotene Oral Balance. The Surveyor did not observe the administration of the Biotene mouth spray. d. On 12/19/23 at 01:30 PM, the Surveyor asked Resident #43 did you take any mouth spray this morning? Resident #43 said, Yes, I spray it in my mouth between meals. e. On 12/19/23 at 01:35 PM, the Surveyor asked LPN #2, does Resident #43 self-administer any medication? LPN #2 stated, Yes, his Biotene, he knows when to give it. The Surveyor stated he just told me he gives it between meals, but the order states before meals and at bedtime. LPN #2 did not respond. The Surveyor asked what does signing the MAR mean? LPN #2 stated that you gave medication. The Surveyor asked, did you give the Biotene? LPN #2 stated, No. The Surveyor asked why did you sign the MAR for the Biotene? LPN #2 stated, Because he tells me when he gives it but not the time. The Surveyor asked did you see him give it? LPN #2 stated, No. The Surveyor asked so, how do you know it was actually given and when? LPN #2 did not respond. f. On 12/19/23 at 01:40 PM, the Surveyor asked LPN #2 when you administer the medication metoprolol what are looking at in reference to blood pressure the systolic or diastolic? LPN #2 stated both. The Surveyor asked so if either the systolic or the diastolic was too low what would you do? LPN #2 said hold the medication. The Surveyor asked LPN #2 what was Resident #43's blood pressure this morning? LPN #2 said, 103/62. The Surveyor asked, What does the order say? LPN #2 stated hold if blood pressure less than 110/50. The Surveyor asked was either the systolic or diastolic outside of parameters? LPN #2 Yes. The Surveyor asked which one? LPN #2 stated systolic. The Surveyor asked what should you have done? LPN #2 said held the medication. g. On 12/19/23 at 02:00 PM, the Surveyor asked the Director of Nursing (DON) do you have any residents in the facility that self-administer their medications? The DON stated, I don't believe we do. The Surveyor asked when a nurse puts her signature on a MAR what does that mean? The DON stated, That she gave the med [medication]. The Surveyor asked if you have a medication with blood pressure parameters what are you looking at systolic and/or diastolic? The DON stated, Both of them. The Surveyor what do you do if it is too low? The DON stated, Hold the medication. The Surveyor showed the DON the order on the MAR and Resident #46's blood pressure and asked what should have happened? The DON stated it should have been held. h. On 12/20/23 at 02:15 PM, the DON provided a policy titled, Medication Administration - General. The policy stated, .MEDICATION ADMINISTRATION - GENERAL GUIDELINES Policy Medication are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have familiarized themselves with the medication . 3. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self- administration of medications. 8.only the licensed or legally authorized personnel who prepare a medication may administer it. This individual records the administration on the resident's MAR at the time the medication is given. 9. Medications are administered within a range of 60 minutes prior to or after the scheduled time, except before or after meal orders, which are administered precisely as ordered. 10. The resident's MAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration . ORAL MEDICATION ADMINISTRATION PROCEDURE .13. Read label three times before administering medication. First when getting medication, second when putting medication in cup, and third when returning medication to the cart .

Based on observations, interviews and record review, the facility failed to ensure the Medication Administration Record (MAR) was followed to prevent a significant medication error which could result in complications for 1 (Resident #43) of 1 sampled resident who received Metoprolol (a medication for high blood pressure, chest pain, and heart failure). The finding are: a. Resident #43's MAR had an order for Metoprolol Tartrate 25 milligrams 1 tablet twice a day at 8:00 AM and 5:00 PM and to hold if blood pressure less than 110/50. b. On 12/19/23 at 07:15 AM, the Surveyor observed the 8:00 AM medication pass for Resident #43 with Licensed Practical Nurse (LPN) #2. Prior to the administration of any medication LPN #2 checked Resident #43's blood pressure. The Surveyor asked LPN #2 what the blood pressure was. LPN #2 stated 103/62, heart rate 86. The Surveyor observed LPN #2 administer a Metoprolol 25 milligram tablet to Resident #43. c. On 12/19/23 at 01:40 PM, the Surveyor asked LPN #2, when you administer the medication Metoprolol what are looking at in reference to the blood pressure, the systolic or diastolic? LPN #2 stated both. The Surveyor asked LPN #2 so if either the systolic or the diastolic was too low what would you do? LPN #2 said hold the medication. The Surveyor asked LPN #2 what was Resident #43's blood pressure this morning? LPN #2 said 103/62. The Surveyor asked what does the order say? LPN #2 stated hold if blood pressure less 110/50. The Surveyor asked LPN #2 was either the systolic or diastolic outside of the parameters? LPN #2 Yes. The Surveyor asked which one? LPN #2 stated systolic. The Surveyor asked what should you have done? LPN #2 said held the medication. d. On 12/19/23 at 02:00 PM, the Surveyor asked the DON if you have a medication with blood pressure parameters what are you looking at, systolic and/or diastolic? The DON stated, Both of them. The Surveyor asked what do you do if one is outside of the parameters? The DON stated, Hold the medication. The Surveyor showed the DON the order on the MAR and Resident #43's blood pressure and asked what should have been done? The DON stated, It should have been held. e. On 12/19/23 at 03:00 PM, the Surveyor went over the MAR with the DON about the low blood pressure recorded on 7p-7a (7:00 pm - 7:00 am) shift. The DON stated that those were not the blood pressure taken before the medication was administered and pointed out that medication was given at 5:00 pm and the blood pressure was taken after 7:00 pm. The Surveyor asked the DON where is the documentation for the blood pressures taken prior to the 5:00 pm dose? The DON could not produce any documentation that the blood pressure had been taken prior to the 5:00 pm dose administration. The DON stated, We will get that fixed. F. On 12/20/23 at 08:40 AM, the Surveyor asked LPN #3 when you administer Resident #43's metoprolol do you check his blood pressure? LPN stated, Yes. The Surveyor asked what about his 5:00 pm dose do you check his blood pressure? LPN #3 stated, Yes. The Surveyor asked where do you document the blood pressure for the 5:00 pm dose? LPN #3 stated It's not documented. We do check it, just don't document it. G. On 12/20/23 at 2:15 PM Director of Nursing provided a policy titled, Medication Administration - General. The policy documented, . MEDICATION ADMINISTRATION - GENERAL GUIDELINES Policy Medication are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medication do so only after they have familiarized themselves with the medication . ORAL MEDICATION ADMINISTRATION PROCEDURE .13. Read the label three times before administering medication. First when getting the medication, second when putting medication in cup, and third when returning medication to the cart 18. Obtain and record any vital signs necessary prior to medication administration .

Based on interviews and record review, the facility failed to ensure a medication (Biotene, a liquid mouthwash for dry mouth) was not left at the bedside for self-administration for 1 (Resident #43) of 1 sampled resident to prevent a potential for ingestion by other residents. The findings are: 1. A Physicians Order dated 10/27/23 noted Resident #43 was to receive Biotene Oral Balance 2 sprays in the mouth before meals and at bedtime. a. On 12/19/23 at 07:15 AM, the Surveyor observed medication pass for Resident #43 with Licensed Practical Nurse (LPN) #2. After administering Resident #43's 8:00 AM medications, the Surveyor observed LPN #2 sign off on the MAR for the 11:00 AM Biotene Oral Balance The Surveyor did not observe the administration of Biotene mouth spray. a. On 12/19/23 at 01:30 PM, the Surveyor asked Resident #43 did you take any mouth spray this morning? Resident #43 said yes, I spray it in my mouth between meals. c. On 12/19/23 at 01:35 PM, the Surveyor asked Licensed Practical Nurse (LPN) #2, does Resident #43 self-administer medication? LPN #2 stated, Yes, his Biotene. He knows when to give it. The Surveyor stated he just told me he gives it between meals and the order states before meals and at bedtime. LPN #2 did not respond. c. On 12/19/23 at 01:36 PM, the Surveyor asked the Minimum Data Set (MDS) Coordinator if Resident #43 was care planned to self-administer medications. The MDS Coordinator stated, No. e. On 12/19/23 at 02:00 PM, the Surveyor asked the Director of Nursing (DON) do you have any residents in the facility that self-administer their medication? The DON stated, I don't believe we do. f. On 12/20/23 at 08:45 AM, the DON stated that Biotene is just a mouth wash and that it could be purchased over the counter. The Surveyor stated Aspirin and Tylenol can be purchased over the counter, and they are kept on the med cart. The DON stated well you have a point there. g. On 12/20/23 at 2:15 PM, a facility policy titled, Medication Administration, provided by the DON documented, MEDICATION ADMINISTRATION-GENERAL GUIDELINES . Procedures 3. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self- ~ administration of medications . 8.only the licensed or legally authorized personnel who prepare a medication may administer it . SELF-ADMINISTRATION OF MEDICATION BY RESIDENT Policy .5. If the resident demonstrates the ability to safely self-administer medications, a further assessment of the safety of bedside medication storage is conducted . 6. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. The following conditions are met for bedside storage to occur: o The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy and must be locked up at all times . 7. All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage . 9. When the interdisciplinary team determines that bedside or in-room storage of medications would be a safety risk to other residents, the medications of residents permitted to self-administer are stored in the central medication cart or medication room .

Based on record review and interview, the facility failed to ensure the facility abuse policies and procedures were implemented, as evidenced by failure to ensure an injury of unknown origin and an unwitnessed fall resulting in a fracture for 1 (Resident #16) was immediately reported to the Administrator, thoroughly investigated, evidence gathered, and findings reported to the state agency to rule out the possibility of abuse and or neglect. The failed practice resulted in Immediate Jeopardy (IJ). On 10/19/22 at 1:50 pm, the facility Owner and the DON were notified of the IJ. The findings are: An Abuse/Neglect Policy provided by the Director of Nursing (DON) on 10/17/22 at 10:30 am, page 7 Identification, Unexplained bruising, skin tears .Shall be reported to the appropriate staff and investigated to determine any possible abuse, neglect . Page 8-9 An Incident and Accident form will be completed along with the state form DMS-7734. The Medical Director, Director of Nursing, Administrator, Local Police Department, and the resident's Family will be notified immediately .The Administrator, Director of Nursing, or designee will complete a thorough investigation . Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. During a record review on 10/19/22 at 9:20 am, a Nurses Note dated 4/11/22 stated, Hematoma noted to L (left) outer shin, approx (approximately) 4cm (centimeters) X 4 1/2 cm. No known injuries/accidents were reported. No c/o (complaints of) pain . A Nurses Note dated 6/18/22 at 10:30 pm stated, Res (resident) was found lying on the floor by Certified Nursing Assistant (CNA). Resident was trying to go to the bathroom floor was wet @ (at) this time. Resident had a knot on R (right) side of head with bruising present, redness noted to R side of face and Resident c/o (complained of) pain in her L (left) wrist . b. During a record review on 10/19/22 at 10:28 AM, a Nursing Note dated 4/11/22 stated, Hematoma noted to L (left) outer shin, aprox (approximately) 4cm (centimeters) X 4 1/2 cm. No known injuries/accidents were reported. No c/o (complaints of) pain . LPN c. During a record review on 10/19/22 at 10:28 AM, a Nursing Note dated 6/18/22 stated, the resident had an unwitnessed fall with a fracture of the left wrist and a hematoma to the right side of head. The Resident was sent to emergency room for evaluation. d. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident sent to emergency room for evaluation. Emergency Report states, .you have been evaluated .for the following condition (s): Acute post traumatic headache. No Poorly controlled headache. Closed nondisplaced segmental fracture of the distal left radius. Left wrist pain. Fall . e. On 10/19/22 at 9:40 am, The Surveyor asked the Director of Nursing (DON) If there was a facility incident report for the injury of unknown origin for the hematoma to the shin for Resident #16 and for the unwitnessed fall that resulted in a fracture for Resident #16? The DON stated, I will look. The Surveyor asked, Did the facility report these two incidents to the state agency? The DON stated, I will see because that was before I started. f. On 10/19/22 at 10:18 am, the DON stated, There is not an I and A (Incident and Accident Report) for this injury. Referring to the injury of unknown origin but did provide the surveyor a copy of the facility incident report for the unwitnessed fall that occurred on 6/18/22. The DON stated, There is no reportable. She (R#16) went to the ER (emergency room ). The Surveyor asked, Can R #16 tell you what happened? The DON stated, Well her Brief Interview Mental Status (BIMS) is low, but she can converse. I started in August after this happened and all I could find is this I and A. The Surveyor asked, , Should it have been reported? The DON stated, Depends on if it's witnessed or unwitnessed, if it resulted in a fracture. I can tell you that if I think it might be a reportable, I consult with the Administrator and Nurse Consultant. g. On 10/19/22 at 10:45 am, The Surveyor asked Resident #16, Have you had a fall during your time here? R #16 stated, I don't remember ever falling. R #16 stated, Oh yes, it hurt really bad but I'm not sure what was wrong. The Surveyor asked R #16, Can you tell me how you hurt it? R #16 stated, I'm not sure., When do we eat? The Surveyor asked, You aren't sure how you hurt your wrist? R #16 stated, I'm sure hungry. h. On 10/19/22 at 12:30 PM, the Surveyor asked to speak to the Administrator and was informed that the Administrator was out for the day. The Surveyor requested to speak with the staff member that was sitting in for the Administrator. The facility owner came to speak with the Surveyor stating she was filling in for the Administrator. The Surveyor asked the owner, Are you aware the R #16 had an injury of unknown origin on 4/11/22? The Owner stated, No. The Surveyor asked, Are you aware that R #16 had an unwitnessed fall resulting in a fracture on 6/18/22? The Owner stated, Let me see if the Administrator is available to talk to you by phone. She will be able to answer those questions better than I can. i. On 10/19/22 at 12:45 PM, the Surveyor spoke to the Administrator via cellular phone. The Surveyor asked the Administrator, Are you aware the R #16 had an injury of unknown origin on 4/11/22? The Administrator stated, No. The Surveyor asked, Are you aware that R #16 had an unwitnessed fall resulting in a fracture on 6/18/22? The Administrator stated, No. The Surveyor asked, , Should an incident report and an investigation be completed for an injury of unknown origin? The Administrator stated, Yes, because if it isn't known what happened and the resident can't tell you what happened then it would be considered a state reportable. The Surveyor asked, Should an incident report and an investigation be completed for an unwitnessed fall resulting in a fracture? The Administrator stated, Yes, if the resident is not able to tell what happened. The Surveyor asked, Should both of these incidents have been reported to the state agency? The Administrator stated, Yes and if I would have been aware of these, I would have reported them. Bear Creek Plan of Removal on 10/19/2022 states: 1. On 10/19/2022 the DON immediately on notification initiated a report to the OLTC for each finding related to the resident affected: the injury of unknown origin on 4/11/2022 and the unwitnessed fall with fracture on 6/18/2022. a. On 10/19/2022 the DON supervised the head to-toe assessment of the identified resident for further signs of injury of unknown origin. b. On 10/19/2022 the DON reviewed the identified resident's incident and accident reports for the past 6 months to identify any further incidents or accidents that need investigated and reported to OLTC. 2. On 10/19/2022 the DON initiated the review of residents with the potential to be affected incident and accident reports in the past 6 months including the identified resident, making corrections as necessary. 3. On 10/19/2022the DON began in-service with current nursing staff on abuse and neglect, reporting of unwitnessed falls with fracture and injury of unknown origin to the Administrator or DON so that prompt reporting of injuries of unknown origin can be properly investigated and reported to OLTC and will in-service nurses before taking assigned duties on the floor. 4. On 10/19/2022 the acting administrator in-serviced the Director of Nursing on reporting unwitnessed falls with fracture to the OLTC and promptly starting an investigation. 5. DON/designee using a monitoring tool will review nursing documentation and incident & accident reports to ensure injury of unknown origin and unwitnessed falls with fracture are properly investigated and reported to OLTC 5x weeks weeks, making corrections as necessary and reporting negative findings to the administrator. 6. DON/designee will report negative findings to the QAPI committee monthly for review and recommendations

Based on record review and interview, the facility failed to ensure that an injury of unknown origin was investigated and reported to the Office of Long Term Care (OLTC) and other agencies in accordance with state law, to enable those agencies to provide any necessary oversight of the facility's investigations and protective measures for 1 Resident #16 of 5 residents sampled (Residents #16, #30, #33, #36 and #255) of residents who were reviewed for abuse/neglect. This failed practice resulted in Immediate Jeopardy for Resident #16 and had the potential to affect all 50 residents who resided in the facility according to the Resident Census and Condition of Residents Form dated 10/17/22. On 10/19/22 at 1:50 pm, the facility Owner and the DON notified of IJ (Immediate Jeopardy). The findings are: An Abuse/Neglect Policy provided by the DON on10/17/22 at 10:30 am, page 7 Identification, Unexplained bruising, skin tears .Shall be reported to the appropriate staff and investigated to determine any possible abuse, neglect . Page 8-9 An Incident and Accident form will be completed along with the state form DMS-7734 .The Administrator, Director of Nursing, or designee will complete a thorough investigation . Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a record review on 10/19/22 at 9:20 am, a nurses note dated 4/11/22 stated, Hematoma noted to L (left) outer shin, aprox (approximately) 4cm (centimeters) X 4 1/2 cm. No known injuries/accidents were reported. No c/o (complaints of) pain . A nurses note dated 6/18/22 at 10:30 pm stated, Res (resident) was found lying on the floor by Certified Nursing Assistant (CNA). Resident was trying to go to the bathroom floor was wet @ (at) this time. Res had a knot on R (right) side of head with bruising present, redness noted to R side of face and Res c/o (complained of) pain in her L (left) wrist . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident sent to emergency room for evaluation. Emergency Report states, .you have been evaluated .for the following condition (s): Acute post traumatic headache. No Poorly controlled headache. Closed nondisplaced segmental fracture of the distal left radius. Left wrist pain. Fall . a. On 10/19/22 at 9:40, The Surveyor asked the Director of Nursing (DON) If there was a facility incident report for the injury of unknown origin for the hematoma to the shin for resident #16 and for the unwitnessed fall that resulted in a fracture for resident #16? The DON stated, I will look. The Surveyor asked, Did the facility report these two incidents to the state agency? The DON stated, I will see because that was before I started. b. On 10/19/22 at 10:18 am, the DON stated, There is not an I and A (Incident and Accident Report) for this injury. Referring to the injury of unknown origin but did provide the surveyor a copy of the facility incident report for the unwitnessed fall that occurred on 6/18/22. The DON stated, There is no reportable. She (R#16) went to the ER (emergency room ). The Surveyor asked, Can R #16 tell you what happened? The DON stated, Well her BIMS is low, but she can converse. I started in August after this happened and all I could find is this I and A. The Surveyor asked, Should it have been reported? The DON stated, Depends on if it's witnessed or unwitnessed, if it resulted in a fracture. I can tell you that if I think it might be a reportable, I consult with the Administrator and Nurse Consultant. c. On 10/19/22 at 10:45, The Surveyor asked Resident #16, Have you had a fall during your time here? R #16 stated, I don't remember ever falling. The Surveyor asked, Have you ever hurt your arm or wrist? R #16 stated, Oh yes, it hurt really bad but I'm not sure what was wrong. The Surveyor asked R #16, Can you tell me how you hurt it? R #16 stated, I'm not sure. When do we eat? The Surveyor asked, You aren't sure how you hurt your wrist? R #16 stated, I'm sure hungry. d. On 10/19/22 at 12:30 PM, the Surveyor asked to speak to the Administrator and was informed that the Administrator was out for the day. The Surveyor requested to speak with the staff member that was sitting in for the Administrator. The facility owner came to speak with the surveyor stating she was filling in for the Administrator. The Surveyor asked the owner, Are you aware the R #16 had an injury of unknown origin on 4/11/22? The Owner stated, No. The Surveyor asked, Are you aware that R #16 had an unwitnessed fall resulting in a fracture on 6/18/22? The Owner stated, Let me see if the Administrator is available to talk to you by phone. She will be able to answer those questions better than I can. e. On 10/19/22 at 12:45 PM, The Surveyor spoke to the Administrator via cellular phone. The Surveyor asked, Are you aware the R #16 had an injury of unknown origin on 4/11/22? The Administrator stated, No. The Surveyor asked, Are you aware that R #16 had an unwitnessed fall resulting in a fracture on 6/18/22? The Administrator stated, No. The Surveyor asked, Should an incident report and an investigation be completed for an injury of unknown origin? The Administrator stated, Yes, because if it isn't known what happened and the resident can't tell you what happened then it would be considered a state reportable. The Surveyor asked, Should an incident report and an investigation be completed for an unwitnessed fall resulting in a fracture? The Administrator stated, Yes, if the resident is not able to tell what happened. The Surveyor asked, Should both of these incidents have been reported to the state agency? The Administrator stated, Yes and if I would have been aware of these, I would have reported them. Based on record review and interview, the facility failed to ensure the facility abuse policies and procedures were implemented, as evidenced by failure to ensure an injury of unknown origin and an unwitnessed fall resulting in a fracture for 1 (Resident #16) was immediately reported to the Administrator, thoroughly investigated, evidence gathered, and findings reported to the state agency to rule out the possibility of abuse and or neglect. The failed practice resulted in past Immediate Jeopardy (IJ). On 10/19/22 at 1:50 pm, the facility Owner and the DON were notified of the past IJ. The findings are: An Abuse/Neglect Policy provided by the Director of Nursing (DON) on 10/17/22 at 10:30 am, page 7 Identification, Unexplained bruising, skin tears .Shall be reported to the appropriate staff and investigated to determine any possible abuse, neglect . Page 8-9 An Incident and Accident form will be completed along with the state form DMS-7734. The Medical Director, Director of Nursing, Administrator, Local Police Department, and the resident's Family will be notified immediately .The Administrator, Director of Nursing, or designee will complete a thorough investigation . Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. During a record review on 10/19/22 at 9:20 am, a Nurses Note dated 4/11/22 stated, Hematoma noted to L (left) outer shin, approx (approximately) 4cm (centimeters) X 4 1/2 cm. No known injuries/accidents were reported. No c/o (complaints of) pain . A Nurses Note dated 6/18/22 at 10:30 pm stated, Res (resident) was found lying on the floor by Certified Nursing Assistant (CNA). Resident was trying to go to the bathroom floor was wet @ (at) this time. Resident had a knot on R (right) side of head with bruising present, redness noted to R side of face and Resident c/o (complained of) pain in her L (left) wrist . b. During a record review on 10/19/22 at 10:28 AM, a Nursing Note dated 4/11/22 stated, Hematoma noted to L (left) outer shin, aprox (approximately) 4cm (centimeters) X 4 1/2 cm. No known injuries/accidents were reported. No c/o (complaints of) pain . LPN c. During a record review on 10/19/22 at 10:28 AM, a Nursing Note dated 6/18/22 stated, the resident had an unwitnessed fall with a fracture of the left wrist and a hematoma to the right side of head. The Resident was sent to emergency room for evaluation. d. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident sent to emergency room for evaluation. Emergency Report states, .you have been evaluated .for the following condition (s): Acute post traumatic headache. No Poorly controlled headache. Closed nondisplaced segmental fracture of the distal left radius. Left wrist pain. Fall . e. On 10/19/22 at 9:40 am, The Surveyor asked the Director of Nursing (DON) If there was a facility incident report for the injury of unknown origin for the hematoma to the shin for Resident #16 and for the unwitnessed fall that resulted in a fracture for Resident #16? The DON stated, I will look. The Surveyor asked, Did the facility report these two incidents to the state agency? The DON stated, I will see because that was before I started. f. On 10/19/22 at 10:18 am, the DON stated, There is not an I and A (Incident and Accident Report) for this injury. Referring to the injury of unknown origin but did provide the surveyor a copy of the facility incident report for the unwitnessed fall that occurred on 6/18/22. The DON stated, There is no reportable. She (R#16) went to the ER (emergency room ). The Surveyor asked, Can R #16 tell you what happened? The DON stated, Well her Brief Interview Mental Status (BIMS) is low, but she can converse. I started in August after this happened and all I could find is this I and A. The Surveyor asked, , Should it have been reported? The DON stated, Depends on if it's witnessed or unwitnessed, if it resulted in a fracture. I can tell you that if I think it might be a reportable, I consult with the Administrator and Nurse Consultant. g. On 10/19/22 at 10:45 am, The Surveyor asked Resident #16, Have you had a fall during your time here? R #16 stated, I don't remember ever falling. R #16 stated, Oh yes, it hurt really bad but I'm not sure what was wrong. The Surveyor asked R #16, Can you tell me how you hurt it? R #16 stated, I'm not sure., When do we eat? The Surveyor asked, You aren't sure how you hurt your wrist? R #16 stated, I'm sure hungry. h. On 10/19/22 at 12:30 PM, the Surveyor asked to speak to the Administrator and was informed that the Administrator was out for the day. The Surveyor requested to speak with the staff member that was sitting in for the Administrator. The facility owner came to speak with the Surveyor stating she was filling in for the Administrator. The Surveyor asked the owner, Are you aware the R #16 had an injury of unknown origin on 4/11/22? The Owner stated, No. The Surveyor asked, Are you aware that R #16 had an unwitnessed fall resulting in a fracture on 6/18/22? The Owner stated, Let me see if the Administrator is available to talk to you by phone. She will be able to answer those questions better than I can. i. On 10/19/22 at 12:45 PM, the Surveyor spoke to the Administrator via cellular phone. The Surveyor asked the Administrator, Are you aware the R #16 had an injury of unknown origin on 4/11/22? The Administrator stated, No. The Surveyor asked, Are you aware that R #16 had an unwitnessed fall resulting in a fracture on 6/18/22? The Administrator stated, No. The Surveyor asked, , Should an incident report and an investigation be completed for an injury of unknown origin? The Administrator stated, Yes, because if it isn't known what happened and the resident can't tell you what happened then it would be considered a state reportable. The Surveyor asked, Should an incident report and an investigation be completed for an unwitnessed fall resulting in a fracture? The Administrator stated, Yes, if the resident is not able to tell what happened. The Surveyor asked, Should both of these incidents have been reported to the state agency? The Administrator stated, Yes and if I would have been aware of these, I would have reported them. Bear Creek Plan of Removal on 10/19/2022 states: 1. On 10/19/2022 the DON immediately on notification initiated a report to the OLTC for each finding related to the resident affected: the injury of unknown origin on 4/11/2022 and the unwitnessed fall with fracture on 6/18/2022. a. On 10/19/2022 the DON supervised the head to-toe assessment of the identified resident for further signs of injury of unknown origin. b. On 10/19/2022 the DON reviewed the identified resident's incident and accident reports for the past 6 months to identify any further incidents or accidents that need investigated and reported to OLTC. 2. On 10/19/2022 the DON initiated the review of residents with the potential to be affected incident and accident reports in the past 6 months including the identified resident, making corrections as necessary. 3. On 10/19/2022the DON began in-service with current nursing staff on abuse and neglect, reporting of unwitnessed falls with fracture and injury of unknown origin to the Administrator or DON so that prompt reporting of injuries of unknown origin can be properly investigated and reported to OLTC and will in-service nurses before taking assigned duties on the floor. 4. On 10/19/2022 the acting administrator in-serviced the Director of Nursing on reporting unwitnessed falls with fracture to the OLTC and promptly starting an investigation. 5. DON/designee using a monitoring tool will review nursing documentation and incident & accident reports to ensure injury of unknown origin and unwitnessed falls with fracture are properly investigated and reported to OLTC 5x weeks weeks, making corrections as necessary and reporting negative findings to the administrator. 6. DON/designee will report negative findings to the QAPI committee monthly for review and recommendations

Based on observation, record review, and interview, the facility failed to ensure their abuse policies and procedures were implemented, as evidenced by failure to immediately report an injury of unknown origin and an unwitnessed fall resulting in a fracture to the Office of Long Term Care (OLTC) and other state agencies in accordance with state law and failure to ensure an investigation was immediately initiated to determine if abuse or neglect occurred for 1 of 1 (Resident #16) the sampled case mix. This failed practice resulted in Immediate Jeopardy (IJ) for 1 (Resident #16) and the potential to affect 50 residents who were living in the facility according to the list provided by the Director of Nursing (DON) on 10/17/22. On 10/19/22 at 1:50 pm, the facility Owner and the DON were notified of IJ. The findings are: An Abuse/Neglect Policy provided by the DON on 10/17/22 at 1030am, page 7 Identification, Unexplained bruising, skin tears .Shall be reported to the appropriate staff and investigated to determine any possible abuse, neglect . Page 8-9 An Incident and Accident form will be completed along with the state form DMS-7734. The Medical Director, Director of Nursing, Administrator, Local Police Department, and the resident's Family will be notified immediately .The Administrator, Director of Nursing, or designee will complete a thorough investigation . Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a record review on 10/19/22 at 9:20 am, a nurses note dated 4/11/22 stated, Hematoma noted to L (left) outer shin, aprox (approximately) 4cm (centimeters) X 4 1/2 cm. No known injuries/accidents were reported. No c/o (complaints of) pain Licensed Practical Nurse (LPN) . A nurses note dated 6/18/22 at 10:30 pm stated, Res (resident) was found lying on the floor by Certified Nursing Assistant (CNA). Res was trying to go to the bathroom floor was wet @ (at) this time. Resident had a knot on R (right) side of head with bruising present, redness noted to R side of face and Res c/o (complained of) pain in her L (left) wrist . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident sent to emergency room for evaluation. Emergency Report states, .you have been evaluated .for the following condition (s): Acute post traumatic headache. No Poorly controlled headache. Closed nondisplaced segmental fracture of the distal left radius. Left wrist pain. Fall . a. On 10/19/22 at 9:40, The Surveyor asked the Director of Nursing (DON) if there was a facility incident report for the injury of unknown origin for the hematoma to the shin for resident #16 and for the unwitnessed fall that resulted in a fracture for resident #16? The DON stated, I will look. The Surveyor asked, Did the facility report these two incidents to the state agency? The DON stated, I will see because that was before I started. b. On 10/19/22 at 10:18 am, the DON stated, There is not an I and A (Incident and Accident Report) for this injury. Referring to the injury of unknown origin but did provide the surveyor a copy of the facility incident report for the unwitnessed fall that occurred on 6/18/22. The DON stated, There is no reportable. She (R#16) went to the ER (emergency room ). The Surveyor asked, Can R#16 tell you what happened? The DON stated, Well her BIMS is low, but she can converse. I started in August after this happened and all I could find is this I and A. The Surveyor asked, Should it have been reported? The DON stated, Depends on if it's witnessed or unwitnessed, if it resulted in a fracture. I can tell you that if I think it might be a reportable, I consult with the Administrator and Nurse Consultant. c. On 10/19/22 at 10:45 am, The Surveyor asked Resident #16, Have you had a fall during your time here? R#16 stated, I don't remember ever falling. The Surveyor asked R #16, Have you ever hurt your arm or wrist? R #16 stated, Oh yes, it hurt really bad but I'm not sure what was wrong. The Surveyor asked R #16, Can you tell me how you hurt it? R #16 stated, I'm not sure. When do we eat? The Surveyor asked, You aren't sure how you hurt your wrist? R #16 stated, I'm sure hungry. d. On 10/19/22 at 12:30 pm, The Surveyor asked to speak to the Administrator and was informed that the Administrator was out for the day. The Surveyor requested to speak with the staff member that was sitting in for the Administrator. The facility owner came to speak with the surveyor stating she was filling in for the Administrator. The Surveyor asked the owner, Are you aware the R #16 had an injury of unknown origin on 4/11/22? The Owner stated, No. The Surveyor, Are you aware that R #16 had an unwitnessed fall resulting in a fracture on 6/18/22? The Owner stated, Let me see if the Administrator is available to talk to you by phone. She will be able to answer those questions better than I can. e. On 10/19/22 at 12:45 PM, The Surveyor spoke to the Administrator via cellular phone. The Surveyor asked, Are you aware the R #16 had an injury of unknown origin on 4/11/22? The Administrator stated, No. The Surveyor asked, Are you aware that R #16 had an unwitnessed fall resulting in a fracture on 6/18/22? The Administrator stated, No. The Surveyor asked, Should an incident report and an investigation be completed for an injury of unknown origin? The Administrator stated, Yes, because if it isn't known what happened and the resident can't tell you what happened then it would be considered a state reportable. The Surveyor asked, Should an incident report and an investigation be completed for an unwitnessed fall resulting in a fracture? The Administrator stated, Yes, if the resident is not able to tell what happened. The Surveyor asked, , Should both of these incidents have been reported to the state agency? The Administrator stated, Yes and if I would have been aware of these, I would have reported them. f. On 10/19/22 at 1:50 pm, the facility Owner and the DON were notified of IJ (Immediate Jeopardy). Based on record review and interview, the facility failed to ensure that an injury of unknown origin was investigated and reported to the Office of Long Term Care (OLTC) and other agencies in accordance with state law, to enable those agencies to provide any necessary oversight of the facility's investigations and protective measures for 1 Resident #16 of 5 residents sampled (Residents #16, #30, #33, #36 and #255) of residents who were reviewed for abuse/neglect. This failed practice resulted in past Immediate Jeopardy for Resident #16 and had the potential to affect all 50 residents who resided in the facility according to the Resident Census and Condition of Residents Form dated 10/17/22. On 10/19/22 at 1:50 pm, the facility Owner and the DON notified of IJ (Immediate Jeopardy). The findings are: An Abuse/Neglect Policy provided by the DON on10/17/22 at 10:30 am, page 7 Identification, Unexplained bruising, skin tears .Shall be reported to the appropriate staff and investigated to determine any possible abuse, neglect . Page 8-9 An Incident and Accident form will be completed along with the state form DMS-7734 .The Administrator, Director of Nursing, or designee will complete a thorough investigation . Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a record review on 10/19/22 at 9:20 am, a nurses note dated 4/11/22 stated, Hematoma noted to L (left) outer shin, aprox (approximately) 4cm (centimeters) X 4 1/2 cm. No known injuries/accidents were reported. No c/o (complaints of) pain . A nurses note dated 6/18/22 at 10:30 pm stated, Res (resident) was found lying on the floor by Certified Nursing Assistant (CNA). Resident was trying to go to the bathroom floor was wet @ (at) this time. Res had a knot on R (right) side of head with bruising present, redness noted to R side of face and Res c/o (complained of) pain in her L (left) wrist . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident sent to emergency room for evaluation. Emergency Report states, .you have been evaluated .for the following condition (s): Acute post traumatic headache. No Poorly controlled headache. Closed nondisplaced segmental fracture of the distal left radius. Left wrist pain. Fall . a. On 10/19/22 at 9:40, The Surveyor asked the Director of Nursing (DON) If there was a facility incident report for the injury of unknown origin for the hematoma to the shin for resident #16 and for the unwitnessed fall that resulted in a fracture for resident #16? The DON stated, I will look. The Surveyor asked, Did the facility report these two incidents to the state agency? The DON stated, I will see because that was before I started. b. On 10/19/22 at 10:18 am, the DON stated, There is not an I and A (Incident and Accident Report) for this injury. Referring to the injury of unknown origin but did provide the surveyor a copy of the facility incident report for the unwitnessed fall that occurred on 6/18/22. The DON stated, There is no reportable. She (R#16) went to the ER (emergency room ). The Surveyor asked, Can R #16 tell you what happened? The DON stated, Well her BIMS is low, but she can converse. I started in August after this happened and all I could find is this I and A. The Surveyor asked, Should it have been reported? The DON stated, Depends on if it's witnessed or unwitnessed, if it resulted in a fracture. I can tell you that if I think it might be a reportable, I consult with the Administrator and Nurse Consultant. c. On 10/19/22 at 10:45, The Surveyor asked Resident #16, Have you had a fall during your time here? R #16 stated, I don't remember ever falling. The Surveyor asked, Have you ever hurt your arm or wrist? R #16 stated, Oh yes, it hurt really bad but I'm not sure what was wrong. The Surveyor asked R #16, Can you tell me how you hurt it? R #16 stated, I'm not sure. When do we eat? The Surveyor asked, You aren't sure how you hurt your wrist? R #16 stated, I'm sure hungry. d. On 10/19/22 at 12:30 PM, the Surveyor asked to speak to the Administrator and was informed that the Administrator was out for the day. The Surveyor requested to speak with the staff member that was sitting in for the Administrator. The facility owner came to speak with the surveyor stating she was filling in for the Administrator. The Surveyor asked the owner, Are you aware the R #16 had an injury of unknown origin on 4/11/22? The Owner stated, No. The Surveyor asked, Are you aware that R #16 had an unwitnessed fall resulting in a fracture on 6/18/22? The Owner stated, Let me see if the Administrator is available to talk to you by phone. She will be able to answer those questions better than I can. e. On 10/19/22 at 12:45 PM, The Surveyor spoke to the Administrator via cellular phone. The Surveyor asked, Are you aware the R #16 had an injury of unknown origin on 4/11/22? The Administrator stated, No. The Surveyor asked, Are you aware that R #16 had an unwitnessed fall resulting in a fracture on 6/18/22? The Administrator stated, No. The Surveyor asked, Should an incident report and an investigation be completed for an injury of unknown origin? The Administrator stated, Yes, because if it isn't known what happened and the resident can't tell you what happened then it would be considered a state reportable. The Surveyor asked, Should an incident report and an investigation be completed for an unwitnessed fall resulting in a fracture? The Administrator stated, Yes, if the resident is not able to tell what happened. The Surveyor asked, Should both of these incidents have been reported to the state agency? The Administrator stated, Yes and if I would have been aware of these, I would have reported them. Based on record review and interview, the facility failed to ensure the facility abuse policies and procedures were implemented, as evidenced by failure to ensure an injury of unknown origin and an unwitnessed fall resulting in a fracture for 1 (Resident #16) was immediately reported to the Administrator, thoroughly investigated, evidence gathered, and findings reported to the state agency to rule out the possibility of abuse and or neglect. The failed practice resulted in past Immediate Jeopardy (IJ). On 10/19/22 at 1:50 pm, the facility Owner and the DON were notified of the past IJ. The findings are: An Abuse/Neglect Policy provided by the Director of Nursing (DON) on 10/17/22 at 10:30 am, page 7 Identification, Unexplained bruising, skin tears .Shall be reported to the appropriate staff and investigated to determine any possible abuse, neglect . Page 8-9 An Incident and Accident form will be completed along with the state form DMS-7734. The Medical Director, Director of Nursing, Administrator, Local Police Department, and the resident's Family will be notified immediately .The Administrator, Director of Nursing, or designee will complete a thorough investigation . Resident #16 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. During a record review on 10/19/22 at 9:20 am, a Nurses Note dated 4/11/22 stated, Hematoma noted to L (left) outer shin, approx (approximately) 4cm (centimeters) X 4 1/2 cm. No known injuries/accidents were reported. No c/o (complaints of) pain . A Nurses Note dated 6/18/22 at 10:30 pm stated, Res (resident) was found lying on the floor by Certified Nursing Assistant (CNA). Resident was trying to go to the bathroom floor was wet @ (at) this time. Resident had a knot on R (right) side of head with bruising present, redness noted to R side of face and Resident c/o (complained of) pain in her L (left) wrist . b. During a record review on 10/19/22 at 10:28 AM, a Nursing Note dated 4/11/22 stated, Hematoma noted to L (left) outer shin, aprox (approximately) 4cm (centimeters) X 4 1/2 cm. No known injuries/accidents were reported. No c/o (complaints of) pain . LPN c. During a record review on 10/19/22 at 10:28 AM, a Nursing Note dated 6/18/22 stated, the resident had an unwitnessed fall with a fracture of the left wrist and a hematoma to the right side of head. The Resident was sent to emergency room for evaluation. d. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Resident sent to emergency room for evaluation. Emergency Report states, .you have been evaluated .for the following condition (s): Acute post traumatic headache. No Poorly controlled headache. Closed nondisplaced segmental fracture of the distal left radius. Left wrist pain. Fall . e. On 10/19/22 at 9:40 am, The Surveyor asked the Director of Nursing (DON) If there was a facility incident report for the injury of unknown origin for the hematoma to the shin for Resident #16 and for the unwitnessed fall that resulted in a fracture for Resident #16? The DON stated, I will look. The Surveyor asked, Did the facility report these two incidents to the state agency? The DON stated, I will see because that was before I started. f. On 10/19/22 at 10:18 am, the DON stated, There is not an I and A (Incident and Accident Report) for this injury. Referring to the injury of unknown origin but did provide the surveyor a copy of the facility incident report for the unwitnessed fall that occurred on 6/18/22. The DON stated, There is no reportable. She (R#16) went to the ER (emergency room ). The Surveyor asked, Can R #16 tell you what happened? The DON stated, Well her Brief Interview Mental Status (BIMS) is low, but she can converse. I started in August after this happened and all I could find is this I and A. The Surveyor asked, , Should it have been reported? The DON stated, Depends on if it's witnessed or unwitnessed, if it resulted in a fracture. I can tell you that if I think it might be a reportable, I consult with the Administrator and Nurse Consultant. g. On 10/19/22 at 10:45 am, The Surveyor asked Resident #16, Have you had a fall during your time here? R #16 stated, I don't remember ever falling. R #16 stated, Oh yes, it hurt really bad but I'm not sure what was wrong. The Surveyor asked R #16, Can you tell me how you hurt it? R #16 stated, I'm not sure., When do we eat? The Surveyor asked, You aren't sure how you hurt your wrist? R #16 stated, I'm sure hungry. h. On 10/19/22 at 12:30 PM, the Surveyor asked to speak to the Administrator and was informed that the Administrator was out for the day. The Surveyor requested to speak with the staff member that was sitting in for the Administrator. The facility owner came to speak with the Surveyor stating she was filling in for the Administrator. The Surveyor asked the owner, Are you aware the R #16 had an injury of unknown origin on 4/11/22? The Owner stated, No. The Surveyor asked, Are you aware that R #16 had an unwitnessed fall resulting in a fracture on 6/18/22? The Owner stated, Let me see if the Administrator is available to talk to you by phone. She will be able to answer those questions better than I can. i. On 10/19/22 at 12:45 PM, the Surveyor spoke to the Administrator via cellular phone. The Surveyor asked the Administrator, Are you aware the R #16 had an injury of unknown origin on 4/11/22? The Administrator stated, No. The Surveyor asked, Are you aware that R #16 had an unwitnessed fall resulting in a fracture on 6/18/22? The Administrator stated, No. The Surveyor asked, Should an incident report and an investigation be completed for an injury of unknown origin? The Administrator stated, Yes, because if it isn't known what happened and the resident can't tell you what happened then it would be considered a state reportable. The Surveyor asked, Should an incident report and an investigation be completed for an unwitnessed fall resulting in a fracture? The Administrator stated, Yes, if the resident is not able to tell what happened. The Surveyor asked, Should both of these incidents have been reported to the state agency? The Administrator stated, Yes and if I would have been aware of these, I would have reported them. Bear Creek Plan of Removal on 10/19/2022 states: 1. On 10/19/2022 the DON immediately on notification initiated a report to the OLTC for each finding related to the resident affected: the injury of unknown origin on 4/11/2022 and the unwitnessed fall with fracture on 6/18/2022. a. On 10/19/2022 the DON supervised the head to-toe assessment of the identified resident for further signs of injury of unknown origin. b. On 10/19/2022 the DON reviewed the identified resident's incident and accident reports for the past 6 months to identify any further incidents or accidents that need investigated and reported to OLTC. 2. On 10/19/2022 the DON initiated the review of residents with the potential to be affected incident and accident reports in the past 6 months including the identified resident, making corrections as necessary. 3. On 10/19/2022 the DON began in-service with current nursing staff on abuse and neglect, reporting of unwitnessed falls with fracture and injury of unknown origin to the Administrator or DON so that prompt reporting of injuries of unknown origin can be properly investigated and reported to OLTC and will in-service nurses before taking assigned duties on the floor. 4. On 10/19/2022 the acting administrator in-serviced the Director of Nursing on reporting unwitnessed falls with fracture to the OLTC and promptly starting an investigation. 5. DON/designee using a monitoring tool will review nursing documentation and incident & accident reports to ensure injury of unknown origin and unwitnessed falls with fracture are properly investigated and reported to OLTC 5x weeks weeks, making corrections as necessary and reporting negative findings to the administrator. 6. DON/designee will report negative findings to the QAPI committee monthly for review and recommendations

Complaint # (AR 118) was substantiated, all or in part, with these findings. Based on observation, record review and interview, the facility failed to ensure care was provided in accordance with the resident's assessed and care planned needs, as evidenced by failure to ensure a resident who required pureed foods received a pureed snack during a food-related activity, which resulted in choking for 1 (Resident #1) of 3 (Residents #1, #4, and #6) sampled residents who required pureed diets due to swallowing problems. The failed practice resulted in past non-compliance at the level of immediate jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who was provided a regular consistency snack by unlicensed staff, resulting in a serious choking episode during which the resident lost consciousness and subsequently required transfer to the emergency room , and had the potential to cause more than minimal harm to 8 residents who had physician orders for pureed consistency diets as of 6/18/19, as documented on a list provided by the Director of Nursing (DON) on 8/7/19 at 3:28 p.m. The Administrator was informed of the past immediate jeopardy condition on 8/7/19 at 9:37 a.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an assessment reference date (ARD) of 7/10/19 documented the resident scored 10 ( 8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), was totally dependent on staff for eating, had a swallowing disorder with coughing or choking during meals, and received a mechanically altered diet. a. A physician order dated 1/28/19 on the (MONTH) 2019 Physician's Orders listing documented, .Diet 01/28/2019 .Pureed Diet with Nectar-thickened liquids . b. A physician order dated 6/11/19 documented, .Diet Order: Pureed (with) nectar thick liquids. Texture: .Pureed . c. The Resident Plan of Care dated 7/11/19 documented, Nutrition - Resident is at risk . mechanically altered diet . d. A Skilled Daily Nurses Note dated 6/18/19 at 2:00 p.m. and written by Licensed Practical Nurse (LPN) #1 documented, Currently sitting up in chair visiting (with) peers (and) staff. Proactive (with) cares (and) therapies. Denies c/o (complaints). 1420 (2:20 p.m.) Staff reported that during activities, resident was given an oatmeal cream pie. It was being discussed that resident is on a pureed diet and as we were going to resident, CNA (Certified Nursing Assistant) yelled, 'shes turning blue!' I immediately went to resident (and) she was blue and unresponsive. Firm sternal rub administered to stimulate and was uneffective (ineffective). She was leaned forward in chair while upper body was supported for delivery of back blows. Another nurse came to assist (with) back blows. She was still unresponsive. She was laid flat in the floor (and) several compressions were administered below the rib cage. Resident was set up (and) she gasped, loudly. We continued stimulation by talking to her (and) physical stim (stimulation) (rubbing back) until positive respirations were evident. She was able to state name (and) knew that she was in (city). Transport to (Hospital #1) ER (emergency room ) was called for by other staff during the episode. They arrived at 1425 (2:25 p.m.) via stretcher (with) (emergency medical services) . Speech Therapy was on SCU (special care unit) working (with) resident (other resident) at time of episode and witnessed the whole chain of events. Attempted x (times) 2 to notify (son) with (no) response. Report called in to ER (at) (Hospital #1). (Assistant Director of Nursing (ADON)), LPN notified (Medical Doctor) . 6/18/19 1420 addendum: V/S (vital signs) (after) resident was talking (and) alert were: BP (blood pressure) 187/119, P (pulse) 122, T (temperature) 97.4, R (respirations) 22, SpO2 (oxygen saturation) 93%. e. A Nurse's Note dated 6/18/19 at 7:20 p.m. documented, Res (resident) assisted back into facility via wc (wheelchair) (with) aide. Res awake. Alert (no) distress noted . Res told me she went to hospital, ask res what for, she didn't know. Informed res of her choking on cookie and let her know that was the reason she was sent out. f. A Facility Investigation Report for Resident Abuse, Neglect, Misappropriation of Property, and (&) Exploitation of Residents in Long Term Care Facilities, Division of Medical Services (DMS) form 762 dated as submitted to the Office of Long Term Care (OLTC) on 6/18/2019 at 10:00 p.m., documented the following: 1.) .Date and Time of Incident: 06/18/2019 Time: 2:30 PM Date and Time of Discovery: 06/18/2019 Time: 2:30 PM . Type of Incident: Neglect . Name of Involved Resident: (Resident #1) . Primary [DIAGNOSES REDACTED]. Complete Description of Incident: On 6/18/19 at 2:30 pm (Social Services Director) CNA / Social Director was assisting with 2 pm activities . gave (Resident #1) who is on a pureed diet a oatmeal cream pie. Resident was eating the oatmeal cream pie and became blue and unresponsive. (LPN #1) started the back blows and summoned help. (ADON) arrived and attempted back blows without success. Resident was assisted to the floor. Abdominal thrusts were started. Resident gasped for air after approx. (approximately) 5 thrusts. She opened her eyes and started talking to staff. She was able to state her name and said she wasn't hurting, but didn't remember what happened. The doctor was contacted, and the resident was sent to (Hospital #1) ER by ambulance for further evaluation. 2.) .Findings and Action Taken: (Resident #1) requires assistance with all activities of daily living . (Resident #1) can feed herself. However, she will eat very quickly without chewing her food so she is on a pureed diet with thickened liquids. According to (Activity Director), the Social Director, (name) stopped her in the hall on 6/18/19 and said, 'we're supposed to be having a popcorn social on the unit and we don't have popcorn'. (Activity Director) stated that she then went to (name), the Dietary Supervisor, and asked if she had any popcorn and she said no. (Activity Director) then stated she asked the Dietary Supervisor if she had anything else they could use for a food social on the SCU and she was told to go and ask the guys in the kitchen. (Activity Director) stated that she then went and spoke to dietary employee (Dietary Worker #1) in the kitchen and asked him for chips or something for activities on the unit. According to (Activity Director), (Dietary Worker #1) informed her that no one on SCU was on a regular diet and gave her some oatmeal cream pies and said they could eat them. (Activity Director) stated she found (name), Social Director, gave her the oatmeal cream pies, told her she could do a food social with them and then (Activity Director) went back to her office . 3.) .(Social Services Director) was interviewed and stated that (Activity Director) brought her a box of oatmeal cream pies. (Social Services Director) stated that she asked (Activity Director) who could have the oatmeal cream pies and she was told everyone could. (Social Services Director) then stated that she went to the unit and the nurse (LPN #1) was sitting in the dining area and (CNA #1) the CNA was standing next to (Resident #1). (Social Services) she put the box of pies down on the table, opened them and gave a few to (CNA #1). (Social Services Director) stated that she gave (Resident #1) a (sic) oatmeal cream pie because neither the Aide or the Nurse said anything about her not being able to have the pie . 4.) ( CNA #1) . was interviewed regarding the incident that occurred with (Resident #1) on 6/18/19 and she stated that (Social Services Director) . came to the unit for the resident activity and gave her three oatmeal pies to give out to residents. (CNA #1) stated that she went to give another resident the first pie because he was at the back door trying to go out. (CNA #1) stated that she redirected the resident and helped him with the oatmeal pie. (CNA #1) stated her back was to (Resident #1) who was sitting to the right of the back door. (Resident #1) stated that the Social Director then asked her to get (Resident #1) a drink so she went to the refrigerator and when she took the drink to (Resident #1) she noticed that her lips were turning blue. (CNA #1) then stated that she yelled for the nurse, (LPN #1), who was in the dining room and she immediately came to assist (Resident #1) and instructed (CNA #1) to get (ADON), LPN, ADON which she did . 5.) .(Speech Language Pathologist (SLP)) . was interviewed regarding the incident with (Resident #1) . she was seated on a stool working with a resident when one of the CNAs shouted 'she is choking, (Resident #1) is choking' . (SLP) stated that she jumped up and turned around and (Resident #1) was blue. (SLP) stated her first inclination was to help and she started towards (Resident #1), but the resident she was working with jumped up and so she helped her to sit back down because she was a fall risk. (SLP) said she could see that the nurse was running to care for (Resident #1), so she took care of the resident that wanted to stand up who she stated was distraught over the situation. (SLP) stated that because she was focused on a direct treatment with another resident, she was not aware that (Resident #1) was being offered a (sic) oatmeal creme pie and accepting it . 6.) .(LPN #1) was interviewed regarding the incident with (Resident #1) on 6/18/19 and she stated that she was sitting on SCU (Special Care Unit) when CNA (CNA #1) reported that (Resident #1) had been given an oatmeal cream pie. (LPN #1) said she stated, 'But (Resident #1) is on a pureed diet'. (LPN #1) stated she went to get up (immediately after being told) and the CNA yelled, 'she is turning blue!' (LPN #1) stated that she immediately went over to (Resident #1) who was in the sitting area-she was blue in the face and unresponsive. (LPN #1) stated that she attempted firm sternal rub with no response, so she leaned her forward in the chair while supporting her upper torso and started delivering back blows and called for assistance. According to (LPN #1), (ADON) came running and assisted with back blows . 7.) .(Resident #1) was transported by ambulance to (Hospital #1) ER for evaluation. (Resident #1) was evaluated in the ER . (Resident #1) was discharged on [DATE] back to the Nursing Facility from the emergency department with no new orders . 8.) .On 6/18/19 (Dietary Worker #2), Dietary Employee was interviewed regarding his knowledge what was said when the Activities Supervisor came to the kitchen for snacks. (Dietary Worker #1) stated that the Activity Director came in to the kitchen and asked for snacks and chips for F Hall. According to (Dietary Worker #1), (Dietary Worker #1) told the Activity Director they could not have chips down in the unit, that 'we have two pureed diets' and the Activity Director said she knew that and it was (Resident #1) and (Resident #4). According to (Dietary Worker #2), she took oatmeal cream pies and said she would bring the rest back . 9.) .On 6/19/19 (Dietary Worker #1) was interviewed regarding the conversation he had with the Activities Director on 6/18/19 regarding snacks on the secure unit. (Dietary Worker #1) stated that the Activity Director came to the kitchen and said, 'can I get snacks for F Hall, like chips due to the diets being mechanical soft and pureed. According to (Dietary Worker #1) the Activity Director stated she thought there were two (2) people on the unit that were on pureed diet, (Resident #4) and (Resident #1). (Dietary Worker #1) said that he agreed with her and told her the mechanical soft diets could have the oatmeal cream pies. (Dietary Worker #1) stated that 'they usually they ask for thickened drinks for the pureed people, so I assumed that they had some back there for them to have' . 10.) .Interviews were performed with other staff members, but no other staff member was involved in or aware of anything that happened related to (Resident #1) choking episode . Through this investigation I found no evidence to prove any staff member was intentionally negligent in the care they provided to (Resident #1) . Based on the interviews it would appear no one at any time suggested an alternate for the residents that were on a pureed diet . The facility provided multiple written witness statements from all of the above staff, which matched the description of the sequence of events, as above. g. An emergency room record dated 6/18/19 at 3:10 p.m. from Hospital #1 documented, .Chief Complaint: Choked (at) nursing home . History of Present Illness Chief Complaint: Pt (patient) choked on food. This started just prior to arrival and is still present. It is described as located in the central chest area and neck. At its maximum, severity described as mild. When seen in the E.D. (Emergency Department), it was almost gone . Physical Exam . Appearance: Alert. No acute distress . Respiratory: No respiratory distress. Breath sounds normal . The X-rays were interpreted by the radiologist . Disposition: discharged in good condition. Clinical Impression Atypical chest pain . Diagnostic Imaging . Single View of the Chest . Date of Study: 6/18/19 . Findings: .Impression: 1. Underinflated lungs without acute cardiopulmonary process . h. A Nurse's Note dated 6/18/19 at 7:20 p.m. documented, Res (resident) assisted back into facility via wc (wheelchair) (with) aide. Res awake, alert (no) distress noted. V/S (vital signs) obtained .Res told me she went to hospital, ask res what for, she didn't know. Informed res of her choking on cookie and let her know that was the reason she was sent out . i. A Speech-Language Pathologist Report dated 7/8/19 documented, .Modified [MEDICATION NAME] Swallow Study (MBSS) . Other Patient Observations (Resident #1) is here from (Long Term Care facility) nursing .for completion of outpatient MBSS for objective assessment of pathophysiology of oral and pharyngeal stage of swallow. Patient notably confused. CNA who accompanied patient for study reported patient to currently be on pureed consistency diet with nectar thick liquids. CNA reporting patient has experienced episodes of 'choking (times) 2 and was sent to ER in (Hospital #1)' . Reason for MBSS Referral Determine Safe PO (by mouth) Intake Suspect Aspiration .[MEDICATION NAME] products and Dole diced peaches . Reduced oral control of bolus. Patient noted to swallow soft solid (diced peach) without complete mastication (chewing) . Premature spillage of bolus from oral cavity followed by delay in swallow initiation of 2 seconds with nectar thick liquids, thin liquids, and honey thick liquids . Oral Dysphagia Present Yes . Severity of Oral Dysphagia Moderate Pharyngeal Dysphagia Present .(Resident #1) displayed moderate oral and pharyngeal dysphagia characterized by reduced bolus control, premature spillage, delay in swallow initiation, reduced tongue base retraction, reduced pharyngeal [MEDICATION NAME], and reduced closure of laryngeal vestibule. Dysphagia Moderate . Recommend Speech Therapy . Other Therapy Recommendations Pureed or Mechanical Soft with chopped meats consistency diet . Impressions / Recommendations Comment - Modified [MEDICATION NAME] Swallow 1. Pureed or Mechanical soft consistencies with chopped meats and thin liquids . j. On 8/7/19 at 1:06 p.m., the Activity Director was asked if her job duties as Activity Director permitted her to pass out food to residents and stated, No. The Activity Director was asked why not and stated, Because I'm not a certified nurse or CNA. The Activity Director was asked if she scheduled food activities on the calendar and stated, I do, and anytime we have a food social, the DON or ADON comes in and observes it. The Activity Director was asked if the DON or ADON had monitored the food socials before the incident with Resident #1 and stated, No one. The Activity Director was asked who would obtain the food for the socials and stated, I would. The Activity Director was asked who determined what food was to be served in the food socials and stated, I just went off the activities that were previously scheduled. Been director since (MONTH) 2019 and assistant since (MONTH) (YEAR). The Activity Director was asked what types of food were served for the activities and stated, Cookie social, birthday cake, coke floats, pie, and watermelon socials. The Activity Director was asked, on the day of the choking incident with Resident #1, what was the food to be served? The Activity Director stated, It was supposed to be popcorn. The Activity Director was asked if residents on a mechanically altered or pureed diet could have popcorn and stated, No. The Activity Director was asked if she had given Resident #1 or any other resident on a mechanically altered diet food on the date of the choking incident, 6/18/19 and the Activity Director stated, No I wasn't down there when that happened. The Activity Director was asked how the oatmeal cream pie cookies had gotten to the F Hall secured unit. The Activity Director stated, I gave them to the Social Director. The Activity Director was asked if she had taken the oatmeal cookies to the unit and stated, No I handed them to her in the hallway. The Activity Director was asked if she had known at the time that the cookies would be taken to the SCU and stated, I did know she was going to take them back there, but I did not know who . she could give them to. The Activity Director was asked if she had made any preparations for the residents on a mechanically altered diet to be provided with pureed oatmeal pie cookies and stated, No. k. On 8/7/19 at 1:52 p.m., the Social Services Director (SSD) was asked if she had background as nurse or CNA and stated, CNA. The Social Services Director was asked about participating with activities on 6/18/19 in the secured unit and stated, I was going to assist with the activity and the calendar said 'popcorn social', and I asked (Activity Director) that they can't have a regular diet. I don't feed these residents; we didn't even have any popcorn anyway. I asked (Activity Director) and she hem-hawed around and said she talked to (Dietary Manager) and she just laughed and said 'all of them' when I asked who could have it. I went on down and opened a box down in the unit, and (CNA #1) was standing between (Resident #4) and (Resident #1), Speech Therapist was sitting talking, doing her work with (another resident) and the nurse (LPN #1) was standing there. They seen (sic) me open the box and I got out like 5 oatmeal pies; (CNA #1) opened and handed them to her people . I opened it and gave it to (Resident #1) and, still in my gut, I know this may not be right, I just thought maybe her diet had changed because no one said anything. The Social Services Director was asked if she had handed the oatmeal cookie to the resident (Resident #1) and Social Services stated, Yes. She crammed it in and crumbs fell on her clothes. Social Services was asked where the resident was seated and Social Services stated, Right by the exit door. I walked away. Walked a few steps over to the corner of the table and (LPN #1) was a few steps over. The Social Services Director was asked if LPN #1 was available to ask questions such as about diet and Social Services stated, Yes. Social Services was asked if she had asked about the resident's diet and stated, I did not. The Social Services Director was asked if she had asked about any resident's diet and stated, No. The Social Services Director was asked what occurred after the resident began eating the oatmeal cream pie cookie and stated, I looked over and seen (sic) (Resident #1) kinda struggling and I asked (CNA #1) if she had any thickened liquids. I looked and her lips turning blue and (CNA #1) said her lips were turning blue and (LPN #1) said to go get (ADON) and she went and got her. (LPN #1) did the back blows. Social Services was asked how the resident responded and Social Services stated, She was not responding, head nodded over, (ADON) ran down there and they put her in the floor on her back, I believe compressions then. I went to (Activity Director) afterwards when the resident was awake and I seen (sic) her talking. I kept getting residents out of the way. Social Services was asked if there were any other residents who had choked on the oatmeal pie cookie and Social Services stated, No. I went to (Activity Director) office and I was so mad, and we talked about it. I ask questions now. I told her that she told me that everybody could have them. She didn't specify who everybody was. (ADON) was here . I did a witness statement, probably about 3 (p.m.) that day . (Administrator), she made us tell the story and she was trying to get an idea who to suspend and who played a part in this. And (ADON) told me to come to her office and I sat down and wrote a witness statement. Social Services was asked if there had been type of training since the incident that she had received and Social Services stated, I've done in-services with (Administrator), (DON), and (ADON). Social Services was asked what the training was about and stated, Diets like puree, mechanical soft. The DON or ADON has to be present with the serving of food at food social. We have the diet list, we get one every week and if updated. Supervision of DON and available diet. They went straight into it (in-services). l. The facility removed the immediate jeopardy and corrected the failed practices on 6/19/19, as evidenced by the following: 1.) The corrective actions on DMS form 762 dated as submitted to OLTC on 6/18/2019 at 10:00 p.m. included that the Activity Director, Social Services Director, LPN #1, and CNA #1, who were directly involved in the incident, were suspended on 6/18/19 and were not permitted to return to work until the investigation was completed. Additionally, the DMS form 762 documented the following: i). .Residents that receive a pureed diet were immediately evaluated after the choking incident to ensure they had not been given any inappropriate food and experienced swallowing difficulty. There were no negative findings. Interviews were performed with residents who received altered consistency diets and are cognitively intact and they were asked if they received their correct diet and were able to tolerate the diet given. There were no negative findings . ii). .(Activity Director) and (Social Services Director) will be allowed to return to work. They will be in-serviced by the Administrator, one on one, regarding the importance of residents receiving diet as per doctors orders, the risks of giving a resident on mechanically altered or pureed diet any other than the prescribed diet. They will be in-serviced, by the Administrator, one on one, regarding mechanically altered diets and pureed diets. They will be instructed that they must always check with the charge nurse before giving a resident any food and that when getting snacks from the kitchen they must ask the kitchen staff what the alternate is for people with altered diets such as pureed. Their performances will be monitored by administration to ensure that they follow all facility policies and procedures . iii). .(CNA #1) and (LPN #1) will return to work and they will be in-serviced on following doctor's orders regarding residents' diets by the DON (Director of Nursing), one on one. They will be informed that when a food social activity is being provided on the secure unit, they must be present and pay attention to ensure residents are receiving the correct diet. Their performance will be monitored by nurse management to ensure that they follow all facility policies and procedures . iv). .All staff were in-serviced on abuse and neglect and it was stressed that it is important residents get the correct diet ordered even during an activity as this could lead to severe adverse effects if the diet is not followed. All facility staff will be in-serviced on the importance of the resident receiving the correct diet as ordered and the risk of choking or aspiration pneumonia if they are given a diet they cannot tolerate. The in-service included information of mechanical soft diets and pureed diets . v). .A list of all residents diets has been placed in the CNA ADL (activities of daily living) book and the Nurses 24 hour Report books for ease of review. A list of diets has also been placed int he Activity Director and Social Director office, in a plastic sleeve in the activity binder, and in a plastic sleeve for ease of review in the kitchen. These lists will be updated as diet changes occur. The Dietician and Administrator will review all activity calendars prior to them being put into place each month to ensure food activities are safe and that an appropriate alternate has been identified for residents on modified diets . vi). .The Administrator/designee will monitor the diet lists in the ADL Books, 24 hour report books, Social/Activity Office, Activity Binder, and the kitchen to ensure they are current and up to date by observation and documentation on a form 2 x (times per) week for 4 weeks. Any negative findings will be corrected immediately and the Administrator notified. The Administrator/Designee will monitor 1 food social to ensure physician ordered diets are being followed by observation and documentation on a form 1 x week for 4 weeks. Any negative findings will be corrected immediately and the Administrator notified . 2.) An OLTC Witness Statement dated 6/18/19 at 6:00 p.m. by the ADON documented, On 6/18/19, I checked all the residents that have a mechanically altered diet to ensure they are receiving the ordered diet. 3.) Monitoring forms titled, Monitor Diet Lists Current and Up to Date 2 (times per) Week, received from the Administrator on 8/6/19 at 4:32 p.m., documented, Date, List diet ADL (activities of daily living) books current Y/N (Yes/No); List diet 24 hour report book current Y/N; List diets Social/Activity office current Y/N; List diets Activity Binder current Y/N; List diets kitchen current Y/N Comment. The forms documented monitoring was performed and all categories marked, Yes on 6/21/19, 6/24/19, 6/26/19, 7/2/19, 7/4/19, 7/8/19, 7/11/19, 7/15/19, 7/18/19, 7/22/19, and 7/25/19, after which the monitoring was scheduled weekly. 4.) A form titled, Monitor Diet Lists Current and Up to Date 1 (time per) Week documented, Yes for all categories on 7/30/19 and 8/6/19 and was signed by the DON. 5.) A form received from the Administrator on 8/6/19 at 4:32 p.m. documented, The Administrator/Designee will monitor 1 food social to ensure physician ordered diets are being followed by observation 1 (time)/week (times) 4 weeks. The form documented, Date Food Social Alternate choice for altered diets Y/N? . The form documented, Yes for all dates monitored, including 6/25/19 Ice cream Y (DON signature); 6/26/19 birthday cake Y (DON signature); 7/4/19 watermelon Y (DON signature; 7/17/19 coke float Y (ADON signature). Attached to this form were the activities calendars for June, (MONTH) and (MONTH) 2019. 6.) An In-Service Training Report dated 6/18/19 and provided by the Administrator on 8/6/19 at 4:32 p.m., documented, .Topic: Diet Contents or summary of training session .Everyone must check the diet before giving resident food to make sure it complies with physician-ordered diet for resident safety. Non-licensed staff must check with nurse before feeding or giving snacks to resident. Giving the incorrect diet could be a form of neglect. Resident on pureed diet can only have food that has been blended to smooth consistency with no lumps due to risk of choking or aspiration pneumonia.Conducted by: (ADON) (Administrator) . The form was signed by multiple licensed nursing staff. 7.) An In-Service Training Report dated 6/18/19, received on 8/6/19 at 4:32 p.m. from the Administrator, documented, Department Nurse Mgmt (Management) . Contents or summary of training session . Have menu in front of you in order to ensure mechanical and puree diets are appropriate (and) by the menu . Conducted by: (Administrator) . The form was signed by licensed nurses and the Dietary Manager. 8.) An In-Service Training Report dated 6/20/19 documented, .Department: All . Topic: Diet Texture Modifications Contents . See attached when a food social is provided in the secure unit nursing staff must be present and pay attention to ensure residents are given the correct diets when getting diets from the kitchen, ktichen staff must be asked what the alternate is for residents (with) altered diets such as pureed. Staff informed that lists of diets will be in 24 (hour) report ADL book Kitchen and Activity Book for ease of review .Conducted by: (ADON) (Administrator), (DON) . Inservice Texture Modifications for Puree and Mechanical Soft Diets Puree Diet: This diet is ordered for those who have difficulty chewing or swallowing regular texture food. It may also be used for those who fatigue from chewing or those who eat too fast and tend to get choked. The diet requires absolutely all food to be pureed smooth to the approximate texture of mashed potato. Small lumps in foods will not likely choke a person but the texture may inhibit eating in some. Smooth foods such as ice cream, yogurt, pudding may be served as is, but should not contain any pieces of fruit, nuts, chocolate chips, coconut, etc (et cetera). It must be of a smooth consistency. Mechanical Soft Diet: This diet is ordered for those who don't need food pureed but cannot chew everything on a regular texture diet. Dietary has a manual that explains what is allowed what is not allowed as a reference, sent with the menus We do not serve: nuts, fresh fruit (unless soft like Banana), chocolate chips, chips (may serve cheese puffs), raw vegetables (unless chopped fine-slaw or tossed salad), coconut, hard cookies, hard granola bars, hard cooked fries or breaded vegetables, or foods with large seeds. Some residents may want no raw vegetables even if chopped. Meats are chopped or ground for this diet and served with gravy, sauce, mayonnaise, etc., as appropriate to keep it moist. Dry meat will tend to be difficult to swallow. Some will have difficulty eating thick foods like peanut butter but it can be softened by mixing with applesauce. The employee signature sheet documented the signatures of all staff members, including the Social Services Director, the Activity Director, LPN #1, and CNA #1, as well as the dietary staff. This inservice indicated that the facility had initiated training to the facility staff in a timely manner regarding pureed and mechanically altered diets. 9.) On 8/6/19 at 4:35 p.m., the Administrator was asked if there had been any other residents who had choking episodes due to non-pureed or mechanically altered foods being served and stated, No. The Administrator was asked how long the monitoring would continue and stated, Forever. It will continue on. The Administrator was asked if the staff who were on leave and new hires would also be trained regarding the diets to be monitored. The Administrator stated, Yes. 10.) On 8/7/19 at 11:45 a.m., the DON was asked what monitoring had been done regarding the food socials and mechanically altered diets since Resident #1 had choked on 6/18/19. The DON stated, We are monitoring. I'm in the food activity, or the ADON is. Notes are kept. They can't serve the food unless we are there. We have diet lists posted in a binder at the desk, in the Social and Activity office, and the kitchen. The DON accompanied the surveyor to the nurses' station, where the diet list dated 8/16/19 was posted in the activities of daily living (ADL) binder. The DON then showed the surveyor the same updated diet listing posted in the Social/Activity office, and accompanied the surveyor to the d

Complaint # (AR 046) was substantiated, all or in part, with these findings. Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to prevent elopement, as evidenced by: failure to ensure windows on 1 of 1 secure unit were secured or equipped with alarms; failure to ensure the perimeter fence surrounding the wing where the secure unit was located was maintained in intact condition and free of large holes; and failure to secure the front door code in a location that was inaccessible to residents at risk for elopement, to prevent elopements for 1 (Resident #1) of 7 (Residents #1, #2, #3, #5, #6, #7, and #11) case mix residents who were at risk for elopement; and, failure to ensure residents were assessed for elopement risk upon admission, readmission and at least quarterly thereafter to ensure elopement risk was identified and addressed for 6 (Residents #2, #3, #5, #6, #7, and #11), and that current information regarding elopement risk was included in the Elopement Risk Book for staff, ensure staff were aware of which residents required close monitoring for elopement prevention for 7 (Residents #1, #2, #3, #5, #6, #7, and #11) of 7 case mix residents who were at risk for elopement. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1 who had repeated elopement attempts and eloped into the woods behind the facility, and Residents #1, #2, #3, and #5, who were at risk for elopement but were not included in the elopement risk book used to alert staff of elopement risk. The failed practices also had the potential to cause more than minimal harm to 10 residents who were at risk for elopement and resided on the unsecured A thru D Halls and 13 residents who resided on the F Hall secure unit, as documented on lists provided by the Administrator on 2/10/18. The facility was informed of the Immediate Jeopardy condition on 2/9/18 at 9:45 p.m. The findings are: 1. A facility policy titled, Elopements, received on 2/9/18 at 8:20 p.m. from the Assistant Director of Nursing (ADON), documented, Policy Statement Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Notify the Attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident/Accident; and e. Document event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall . b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials .d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area . 2. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/2/18 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); required limited assistance with transfer; was independent with locomotion on and off the unit; and had unsteady balance when moving from a seated to standing position, when walking, when turning around while walking, and during surface-to-surface transfers, but was able to stabilize without staff assistance, had no behavioral symptoms, did not reject care, and wandering behavior was not exhibited. a. An Admission Nursing assessment dated [DATE] documented, .Functional Status Transfers - Able to Transfer Independently . Ambulation - Able to Ambulate . with device type: Walker . Wheelchair / propels self . b. An Elopement Risk Assessment form dated 12/21/17 documented, Elopement Risk Assessment Factor Identification Checklist. Assess on admission, with Significant Change in Condition and at least quarterly. Finding: .Between 5-10 checks = (equals) High risk for elopement . Standard Care Plan initiated within 24 hours of assessment for score greater than 5 and for every resident who has evidenced wandering away from facility into potentially unsafe areas . Date 12/21/17 . Able to ambulate using cane, quad cane, walker or rolling walker . 5. Able to transfer independently . 6. Able to ambulate independently in wheelchair / power wheelchair . 7. History of wandering prior to nursing home placement . 13. medications: [REDACTED]. Total (elopement risk) Score 6 . Standard Care Plan Initiated or Updated? (Y or N) Y (yes) . MD (Medical Doctor), Social Services, Family and Therapy Notification? (Y or N): Y . The total score of 6 indicated the resident was at high risk for elopement; however, there was no documentation on the resident's Plan of Care to address the elopement risk until 1/5/18. c. A Nurses Note dated 12/21/17 at 6:45 p.m. documented, .Res (Resident) independent (with) transfers (and) ambulates (with) wheelchair . d. A Nurses Note dated 12/23/17 at 3:00 p.m. documented, Res noted to be using code on front door to let himself out (without) letting staff know. There was no documentation that indicated that the front door code was changed, and no reference to elopement risk on the resident's Plan of Care until 1/5/18. e. A Nurses Note dated 1/1/18 at 12:00 p.m. documented, This LPN (Licensed Practical Nurse) was sitting (at) SCU (Secure Care Unit), noticed Res (resident) was self-propelling in parking lot towards (Retail Store in adjacent parking lot) . LPN x (times) 2 to Res at this time. Res easily redirected . There was still no indication that the front door code was changed to prevent further elopement; however, monitoring the resident's whereabouts every 15 minutes was initiated at this time. f. A Nurses Note dated 1/2/18 at 9:00 a.m. documented, Currently in wc (wheelchair) propelling self around facility . Q (every) 15 m (minute) checks continue. g. A Nurses Note dated 1/3/18 at 11:00 p.m. documented, Res attempting to go up ramp to w.w. (West Wing) several times. When asked by LPN why he was attempting to go up there, res stated, 'I have a hiding place up there; I like to go and hide there'. LPN redirected at this time. The west wing connects the facility with a wheelchair ramp to the lower halls, A thru F. There was no indication that the facility closed or secured access to the West Wing ramp to prevent the resident from accessing other areas of the facility where he might be more likely to successfully elope. h. A Nurses Note dated 1/5/18 at 12:45 p.m. documented, Resident noted to be pushing wheelchair and ambulating near the end of front sidewalk. This LPN (and) CNA (Certified Nursing Assistant) to resident's side. Resident stated, 'I was just walking'. Resident became slightly agitated when attempted to re-direct. DON (Director of Nursing) spoke to resident and set limit for resident, maybe outside unassisted on sidewalk directly in front of door, in plain sight. Explained that if he wishes to go elsewhere, to seek staff assistance. He voiced understanding. A Nurses Note dated 1/5/18 at 1:00 p.m. documented, Res noted to be pushing w/c out in the parking lot. This LPN and CNA to Res side. Res stated, 'I'm not from here. I'm not going to run off. I would just like to be able to go around. I feel like I'm in jail.' Resident redirected. D/T (due to) wandering (and) elopement risk, resident moved to secure unit room . late entry 1300 (1:00 p.m.) R pushing w/c to maintenance staff in parking lot. CNA had witnessed Res wandering . i. The Resident Plan of Care dated 1/9/18, which was not signed by the interdisciplinary team, did not address elopement risk for this resident until 1/5/18, despite the elopement risk assessment findings on 12/21/17 that indicated he was at high risk for elopement and staff observations of elopement attempts between 12/23/17 and 1/4/18. An entry dated 1/5/18 on the Plan of Care documented, .R (Resident) has wandered into side yard (and) has been instructed of areas he can be. (Resident) cont (continues) to wander. R will be placed on scu (special care unit - facility's secure unit) . j. A Wander Data Collection Tool form dated 1/5/18 documented, .Evaluation Factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family / significant others voiced concerns? Yes . Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? Yes . Is the resident cognitively impaired with poor decision-making skills (i.e. (such as) poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes . Is the resident a new admission or re-admission (within past 30 days) and not accepting the new situation? Yes . Does the resident have any visual, auditory, or communication deficits? Yes . Does the resident ambulate independently, with or without the use of assistive devices (include wheelchair)? Yes.Summary of Findings . Is a wander / elopement risk . Family / Responsible party notified 1/5/18 . k. A Nurses Note dated 1/6/18 at 1:30 p.m. documented, .Res (Resident) pushing buttons on keypad to attempt to elope. Res even states 'I will open my window (and) get out.' Res also attempting to follow staff around unit .Res able to be redirected this shift . There was no documentation the windows on the secure unit were checked to ensure the resident would be unable to carry out his verbalized plan to exit through a window. l. A Nurses Note dated 1/7/18 at 8:30 a.m. documented, (Resident) (at) SU (secure unit) door. Pushing in codes on the keypad trying to open the door. Res redirected. m. A Nurses Note dated 1/8/18 at 12:00 p.m. documented, LPN on SCU at this time. Res noted to be putting in codes on key pad. Res also noted to be kicking the door. LPN to Res side at this time. Attempted verbally redirect res at this time but res cont (continues) to sit at door (and) put in codes . n. A Nurses Note dated 1/10/18 at 3:22 p.m. documented, Resident has shadowed a worker out of SCU once today and has pushed code to get out once. Both times, he has become agitated, paced (and) refused to go back to SCU. Had to have staff sit (with) res for an hour second time, before could get him back to SCU. He is also on Q (every) 15 min checks . There was no documentation that SCU staff were reminded to monitor for residents exiting the unit behind them or that the secure unit door code was changed to prevent the resident from exiting the secure unit undetected. o. A Nurses Note dated 1/15/18 at 10:00 a.m. documented, Continues to leave SCU by pushing code (at) door. Refuses to go back in by stomping feet to floor (and) holding on to guard rails on hallway to prevent wc being moved. Resident states, 'I'm tired of staring (at) those damn walls.' Non-compliant (with) awaiting staff / smoke break. Easily agitated when asked to return to unit. p. A Nurses Note dated 1/28/18 at 4:15 p.m. documented, Resident c/o (complains of) chest pain . N.O. (new order) received to send to ER (emergency room ) for eval / tx (evaluation / treatment) . 2/1/18 (at) 1:10 p.m. Rec'd (received) Res back into facility via facility van . Propels w/c by self . q. A Wander Data Collection Tool form dated 2/1/18 after the resident returned to the facility from the hospital documented, .Evaluation Factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family / significant others voiced concerns? Yes. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? Yes. Is the resident cognitively impaired with poor decision-making skills (i.e. (such as) poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes. Is the resident a new admission or re-admission (within past 30 days) and not accepting the new situation? Yes. Does the resident have any visual, auditory, or communication deficits? Yes Does the resident ambulate independently, with or without the use of assistive devices (include wheelchair)? Yes. The remainder of the form (Summary of findings and family notification) was incomplete. r. An Elopement Risk assessment dated [DATE] documented, .4. Able to ambulate using cane, quad cane, walker or rolling walker . 5. Able to transfer independently . 6. Able to ambulate independently in wheelchair / power wheelchair . 7. History of wandering prior to nursing home placement . 8. Resistant to nursing home placement . 9. Expresses desire to go home . 10. Exit seeking . 3. Medications . 2 . Total Score 9. Standard Care Plan Initiated or Updated (Y or N): Y . MD, Social Services, Family and Therapy Notification (Y or N): Y . The total score of 9 indicated the resident continued to be at high risk for elopement. s. A Nurses Note dated 2/4/18 at 3:20 p.m. documented, While smoking, res walked off porch (and) parking lot. Other nurse verbally redirected to SCU. Res cussing (at) staff stating, 'I've been held here. I'm a free man. Call the cops.' Res beating on SCU doors (and) yelling, unable to redirect . 7:15 p.m.Res at doors on SCU attempting to enter code. Stating, 'I want out of this (expletive) hole!' Unable to redirect. Beating on doors. t. A Plan of Care entry dated 2/5/18 documented, .R opened window in room (on secure unit), crawled out face first, walked to fence, crawled under fence (and) crawled into woods, put blanket down (and) laid on ground to hide. The following documentation was reviewed, related to this incident: 1.) A Nurses Note dated 2/5/18 at 12:15 p.m. by the Assistant Director of Nursing (ADON) documented, CNA went to resident's room to give resident his lunch tray, but resident was not in his room. Wheelchair was empty and sitting beside open window. Staff was alerted to missing resident. Resident was located outside in the woods next to property. He admitted to 'I climbed out that window face first, walked over to the woods, slid on my butt under the fence, then when I heard y'all yelling for me, I laid down on my blanket to take a nap.' No visible injuries noted and denied pain. Full ROM (range of motion) performed without difficulty. Resident was resistant to coming back into nursing home. Numerous staff assisted resident out of the woods and back to facility. When he got back to facility, he started complaining of back pain. Resident back in his room at 1330 (1:30 p.m.). Notified Administrator, DON, and (Medical Doctor) of situation (with) orders to send to (local hospital) ER (emergency room ) for eval of back pain, then send to (area hospital behavioral center) for psych (psychiatric) eval . 2/5/18 at 3:35 p.m. Resident has been one-on-one observation (and) will remain that way until further notice . 2/5/18 at 3:30 (local hospital) ER sent resident back to nursing home (with) no new orders. Resident was transported to (area hospital behavioral center) via nursing home van assisted by CNA (times) 2 . 2.) A Nursing Home to Hospital Transfer form dated 2/5/18 documented, .Behavioral Issues and Interventions: Elopement / wandering .Can ambulate independently . Assistive device (if applicable) w/c . 3.) An Office of Long Term Care (OLTC) Incident and Accident Report (I & A) dated 2/5/18 at 12:15 p.m. documented, .CNA noted when she took resident lunch tray to his room that his window was open and his wheelchair was parked in front of window, resident was not in room or bathroom. Code was called for elopement and all staff responded promptly. Resident was found in wooded area behind facility. Resident reported to staff that he raised window in room and climbed out of window into fenced in yard, found an area of fence which had a hole at the bottom and climbed under the fence. Resident went about 20 yards into the wooded area behind facility. When resident heard staff calling his name he laid down on a blanket in a small ravine and attempted to hide. Staff found him when he began to cough. Resident was brought back to the facility and began to complain about his lower back hurting. Resident had no apparent injuries but was sent to (local hospital) for eval and for a work up to be sent to (area hospital) for psych eval . Steps taken to prevent continued abuse or neglect during the investigation: Resident was brought back to the facility and began to complain about his lower back hurting. Resident was assessed and had no apparent injuries but was sent to (local hospital) for eval and for a work up to be sent to (area hospital) for psych eval. Resident currently resides on our special care unit due to wandering and attempted elopements. 4.) An OLTC Witness Statement Form dated 2/5/18 at 1:30 p.m. by CNA #1 documented, .Checked on (Resident #1) at 11:50 (a.m.)-12 p.m. and was in his room after we came back from smoke break around 11:30 a.m. when (staff) brought him back, went to check on him again and to bring his lunch tray at around 12:10 p.m. and 12:15 p.m. and his window was open, screen popped out, with chair in front of window. I checked bathroom and closet before going to notify the nurse. 5.) An OLTC Witness Statement Form dated 2/5/18 by LPN #1 documented, CNA came to F Hall doors and said that Res was not in his room when she took his lunch into his room. Said that his w/c was by his window and his window was open. This LPN immediately notified ADON and began looking for res - went into Res room - I went through the window that was open to the back of the facility that Res went through. Started looking for Res and anywhere in fence that he could have went thru. Yelled for other employees that there was a washed out place under the fence. I glanced over to left. Res sitting with his blanket on ground. Yelled for others to give his location. Maintenance run past me and we went under the fence and downhill to res. Res said he was sitting down resting . 3 employees assisted res to his feet . Other employees cleared path thru woods and assisted res out and to his w/c and back to facility. 6.) An Elopement Timeline dated 2/5/18 was attached to the facility's I&A Report and documented, 1130 (11:30 a.m.) - Resident brought back to F Hall from smoke break; 1150-12 (11:50 a.m. to 12:00 p.m.) - CNA checked on resident in room, resident was in his room in wheelchair; 1210 (12:10 p.m.) - CNA went to resident room to deliver lunch tray, resident wc (wheelchair) in front of window. Resident was not in wc. CNA searched bathroom and closet, unable to locate resident in room, reported to LPN at approximately 1215; 1215 (12:15 p.m.) - Elopement code called and all staff responded promptly; 1230 - Resident found lying on blanket in woods . 7.) An OLTC Witness Statement Form dated 2/5/18 documented, .Witness Full Name (Maintenance Supervisor's name) .F Hall windows all have screws securing window . u. On 2/9/18 at 10:00 a.m., the exit code card that read Code 5* was posted in plain sight inside the front of the facility, right next to the key pad to allow exit through the front door. There were no staff members posted near the door and various residents were seated in the adjacent living room area. v. On 2/9/18 at 1:40 p.m., the Assistant Director of Nursing (ADON) was asked if the resident had been on D Hall when he was initially admitted and stated, Yes. (D Hall is not a secured hall). The ADON was asked if the resident was subsequently moved to the secured unit and stated, Yes, 1/5 (1/5/18). The ADON was asked why the resident was moved to the secured unit and stated, We saw him sitting out, rolled his wheelchair outside. The ADON was asked if the code was posted at the front door that allowed exit through the door and the ADON stated, No. At 1:50 p.m., the ADON accompanied the surveyors to the front door and the code 5* remained posted on a turquoise blue card by the inside of the front door. The ADON was shown the card and asked if that was the code that opened the door and stated, Yes. The ADON pressed the code in and opened the door. The ADON was returned to the work room with the surveyors and was asked what had been done when the resident exited through the front door by entering the code, to prevent further potential elopement. The ADON stated, We redirected him and we did offer to sit outside every time he wanted to sit outside. I found one episode, 1/1/18, resident was self-propelling and was easily redirected. The ADON was asked if the resident was easily redirected and returned to the facility and stated, Yes. The ADON was referred to the Nurses Notes and asked to review for elopement. The ADON stated, On 1/2/18 at 2300 (11:00 p.m.), resident was attempting to go up ramp to west wing and, I would like to say, west wing is where residents like to sit in the atrium, because it's by the door. On 1/5/18, 12:45 p.m., resident was noted to be pushing wheelchair and to be ambulating to end of sidewalk. Resident stated, 'I was just walking'. The ADON was asked if the front of the facility joined the parking lot that was busy with traffic and stated, Yes. The ADON was asked why the resident was admitted into the secured unit and stated, That same day, 1/5/18 at 1300 (1:00 p.m.), he was again outside. The ADON was asked if the door code was posted at the front of the facility at that time and stated, Yes. The ADON was asked if the code at that time was the same code that was posted today and stated, Yes, since I've been here, 9/16 (September 16). The ADON was asked who made the decision to move the resident to the secured unit on 1/5/18 and stated, The DON (Director of Nursing) and I. The ADON was asked why there was a need to move the resident to the secured unit and stated, To help protect him from getting hurt when he wandered outside where traffic was. The ADON was asked if any diversional activities were attempted to prevent the resident from exiting and stated, We did offer, but it's not documented. I also spoke to Maintenance about getting that code changed on the front door. The ADON was asked if the code was changed and stated, No, they called the company that's over that code. I know that Maintenance was working on that. I don't know the exact date. The ADON was asked who the code was discussed with and stated, The maintenance man; I spoke with (Maintenance Supervisor name) and (Maintenance Worker #1's name). At 2:55 p.m., the ADON was asked which door she had discussed with maintenance and stated, The front; I also asked for the F hall door. The ADON was asked when she had asked maintenance about the F Hall door code and stated, I don't know, the date he was punching in the code, and I asked them to change it, and they did. The ADON was asked how the resident knew the F Hall door code and stated, He punched in the right code. At 4:05 p.m., the ADON was asked what had been done when the resident eloped on 2/5/18 and stated, I received an order to send him to the local ER (emergency room ) and if everything was clear send him to (area hospital behavior center). That was that day. The ADON was asked what had occurred that day on 2/5/18 and stated, I was outside, and I didn't think he could get out. I let (DON name), (Administrator name) know. The ADON was asked what time the resident was discovered missing and the ADON stated, 12:15 p.m. The ADON was asked when the resident was located and the ADON stated, It was 1:30 p.m. The ADON was asked if the resident was strong enough to raise the window in his room and stated, Strong enough to raise. The ADON was asked when the fence was repaired and stated, I asked maintenance that day, (Maintenance Supervisor and Maintenance Worker #1's names). The ADON was asked if both maintenance employees were told and stated, I believe I did. I know I told (Maintenance Supervisor) because he was out in the woods with us. The ADON was asked, When did maintenance repair the open area in the fence and stated, He told me that he placed some logs at the bottom of the fence and he was going to pour some Quikrete (fast-setting concrete mix) . The ADON was asked if the fence was now repaired and stated, (Maintenance Worker) has told me he placed a sheet of plywood where the ditch went under the fence. The ADON was asked when that was done and stated, Yesterday. The ADON was asked again when the repair was done to the fence and stated, Yesterday, I don't know what time. The ADON was asked if the fence had been inspected after the repair and stated, Ten o'clock. The ADON was asked if that was p.m. and stated, Yes, I asked him to make sure it was repaired. The ADON was asked if the maintenance staff were instructed on 2/6/18 to repair the fence and stated, I did not. I don't remember a specific conversation with him. The ADON was asked how the fence had been repaired and stated, A piece of plywood, it was up. I could see some logs that (Maintenance Supervisor) had placed, and I could see 2 cinder blocks. The ADON was asked if there were residents who were capable of moving cinder blocks or logs and stated, Yes, some are. The ADON was asked if there were wanderguards in use in the facility and stated, No . The ADON was asked if the resident's elopement risk assessments indicated he was at risk for elopement and stated, Yes. The ADON was asked if the resident's elopement risk information was listed in the Elopement Risk Book for staff and the ADON stated, No, he was not. The ADON was asked why the resident was not listed in the Elopement Risk Book and stated, I don't know. The ADON was asked who was responsible for updating the Elopement Risk Book and stated, It should be our MDS Coordinator. I spoke with her today. The ADON was asked if, when residents were assessed and determined to be at risk for elopement, that information should be carried over to the Elopement Risk Book and stated, Supposed to be a face sheet, wander assessment and a picture. The ADON was asked when the Elopement Risk Book should be updated and stated, With the quarterly assessment and admission. The ADON was asked who was responsible for checking the book for updated residents and stated, It should be MDS when checked. The ADON was asked what time she became aware of the resident missing on 2/5/18 and stated, I was notified at 12:15 p.m . He was mine (assigned to ADON). She (CNA #1) immediately told (LPN #1) and they searched the room, the nurse came out and told me. I went to the intercom and announced the code . Immediately went down to F Hall and did a search myself. I did not find the resident on F hall. I did see the w/c by the window in his room. The ADON was asked if the window was up in the resident's room and stated, Yes. The ADON was asked how high the window had been raised at that time and stated, As far as it can go, about 12 inches. I went outside and started searching. I had staff going down halls, checking west wing inside and out. One staff member heard him cough. I heard staff yelling 'we found him'. The ADON was asked to describe where the resident was found and stated, .approximately 50 feet, give or take, he was found in the woods on a blanket. He was taking a nap he said. The ADON was asked if the resident was on the other side of the perimeter fence and the ADON stated, Yes, 50 feet or so. He was lounging on his blanket, laid back on his bottom resting on his elbows. The ADON was asked how the resident had gotten to the other side of the fence and stated, He told us, 'I climbed out of my window head first, walked over to the woods, crawled under the fence on my bottom and took off walking through the woods. The ADON was asked how the resident was able to get to the other side of the fence and stated, Upon inspection, there is a ditch. Did not have water in it, and where the ditch is, it was washed out underneath it, under the fence . w. On 2/9/18 at 2:28 p.m., Maintenance Worker #1 was asked if there had been any door codes changed recently and stated, I have on F hall; it was recently, one of the residents had figured out the code. The Maintenance Worker was asked when the code was reprogrammed and stated, Probably a month ago, I'd say. The Maintenance Worker was asked if there had been any codes reprogrammed on any other doors and stated, No. Maintenance Worker #1 was asked if the code was reprogrammed to the front door and stated, No. The Maintenance Worker was asked how the open area in the fence was repaired and stated, The fence out there, a plywood board and drilled holes and zip tied it to the fence. The Maintenance Worker was asked why the fence had to be repaired and stated, Because we had a resident escape, attempt to escape through that part of the fence. The Maintenance Worker was asked when that occurred stated, I think Monday (2/5/18). The Maintenance Worker was asked when the fence was repaired and stated, Yesterday, it was Thursday. The Maintenance Worker was asked when he was first instructed to repair the fence and stated, That was last night, around 11:00 (p.m.) last night. The Maintenance Worker was asked who told him to repair the fence and stated, It was (ADON's name) x. On 2/9/18 from 2:40 p.m. to 2:50 p.m., the survey team was accompanied by Maintenance Worker #1 to view the fenced-in courtyard that surrounded the F Hall secured unit wing. The chain link fence had an area where there was a depressed, ditch-like area on the ground, that was approximately 3 to 4 feet wide and approximately 1 foot deep, that extended underneath the fence and continued out into a heavily wooded area. There was an approximately 8 by 4-foot plywood board that was secured to the lower portion of the fence with 5 black, plastic zip ties. The plywood board was not secured at the bottom to any area of the fence and could be easily lifted upward. At the bottom of the plywood board, there was an approximately 2-inch by 10-inch board that was propped against the bottom of the sheet of plywood to hold it in place. The 2 by 10 board was easily movable by the surveyor and was removed by the Maintenance Worker. The board was not secured to the plywood board. Underneath the fence, on the right side, there were 2 cinder blocks positioned side by side that did not cover the entire open area, and on the left side, there were 2 small landscape timbers that were not secured and were lying on the ground. There was still an opened area underneath the fence in the ditch that was approximately 2 feet wide. The ditch on the other side of the fence in the wooded area had a large rusted metal container lying in the ditch, and there were briars and logs on the ground on the other side of the ditch. No Quikrete or other filler had been used to fill in the depression in the ground under the fence. The Maintenance Worker and surveyors then walked to the outside of F Hall to the window Resident #1 crawled through on 2/5/18. The Maintenance Worker was aske (TRUNCATED)

Complaint # (AR 046) was substantiated, all or in part, with these findings. Based on observation, record review, and interview, the facility's Administration and Nursing Administration failed to identify and promptly address an ongoing lack of adequate supervision to prevent resident elopement, as evidenced by: failure to ensure windows on 1 of 1 secure unit were secured or equipped with alarms; failure to ensure the perimeter fence surrounding the wing where the secure unit was located was maintained in intact condition and free of large holes; and failure to secure the front door code in a location that was inaccessible to residents at risk for elopement, to prevent elopements for 1 (Resident #1) of 7 (Residents #1, #2, #3, #5, #6, #7, and #11) case mix residents who were at risk for elopement; and, failure to ensure residents were assessed for elopement risk upon admission, readmission and at least quarterly thereafter to ensure elopement risk was identified and addressed for 6 (Residents #2, #3, #5, #6, #7, and #11), and that current information regarding residents' elopement risk was included in the Elopement Risk Book for staff, to ensure staff were aware of which residents required close monitoring for elopement prevention for 7 (Residents #1, #2, #3, #5, #6, #7, and #11) of 7 case mix residents who were at risk for elopement. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1 who had repeated elopement attempts and eloped into the woods behind the facility, and Residents #1, #2, #3, and #5, who were at risk for elopement but were not included in the elopement risk book used to alert staff of elopement risk. The failed practices also had the potential to cause more than minimal harm to 10 residents who were at risk for elopement and resided on the unsecured A thru D Halls and 13 residents who resided on the F Hall secure unit, as documented on lists provided by the Administrator on 2/10/18. The facility was informed of the Immediate Jeopardy condition on 2/9/18 at 9:45 p.m. The findings are: 1. The Job Description and Performance Standards for the Administrator position, received from the Business Office Manager (BOM) on 2/10/18 at 12:05 p.m., documented, .The purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' needs in compliance with federal, state and local requirements . Authority is delegated to the individual in this position to: Develop, maintain and implement operational policies and procedures to meet residents . Develop a monitoring system to assure compliance with federal, state and local requirements . 1. Operate the facility in accordance with the established policies and procedures of the governing body in compliance with federal, state, and local regulations . 3. Establish systems to enforce the facility policies and procedures . 8. Supervise all department supervisors and administrative staff . 2. The Job Description and Performance Standard for the Director of Nursing Services position, received from the BOM on 2/10/18 at 12:05 p.m., documented, .Purpose of this position . to provide nursing management, set resident care standards for all direct care providers, and provide complete supervision and management for the nursing department . Assess residents . Set resident care standards in accordance with accepted current standards of care to provide high quality care to residents; Develop and implement policies and procedures for nursing care of residents; Supervise and manage all aspects of the nursing department; Assess, direct and supervise residents' care needs . 3. Direct, evaluate and supervise all resident care and initiate corrective action as necessary. 4. Assess resident care needs and assist in development of individualized plans of resident care . 8.identify concerns and implement corrective action to improve resident care. 9. Assume responsibility for analysis of incident and accident investigation reports to determine cause(s) and implement corrective action(s), when appropriate . 15. Identify safety hazards and initiate corrective action . 3. The Job Description for the Nursing Supervisor (Assistant Director of Nursing Services), received from the BOM at 12:05 p.m. on 2/16/18, documented, .The purpose of this position is to assist the Director of Nursing Services in assessing resident care needs and implementing appropriate action. Implement nursing policies and procedures. Supervise staffing for the nursing department and supervise the quality of care provided to residents .Authority is delegated to the individual in this position to: Implement nursing policies and procedures. Supervise nursing care provided to residents. Assure adequate staffing to provide nursing care .The primary functions and responsibilities of this position are as follows: 1. Direct, evaluate and supervise all resident care and initiate corrective action. 2. Make daily resident rounds and report status of nursing care to the Director of Nursing Service and Administrator . 7. Assist with analysis of incident and accident investigation reports to determine cause(s) and implement corrective action(s) when appropriate . 18. Identify safety hazards and initiate corrective action as necessary . 24. Be responsible for the safety of residents under his/her care or supervision . 4. A facility policy titled, Elopements, received on 2/9/18 at 8:20 p.m. from the Assistant Director of Nursing (ADON), documented, Policy Statement Staff shall investigate and report all cases of missing residents. Policy Interpretation and Implementation 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. 2. If an employee observes a resident leaving the premises, he/she should: a. Attempt to prevent the departure in a courteous manner. b. Get help from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. 3. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall: a. Examine the resident for injuries; b. Notify the Attending Physician; c. Notify the resident's legal representative (sponsor) of the incident; d. Complete and file Report of Incident / Accident; and e. Document event in the resident's medical record. 4. If an employee discovers that a resident is missing from the facility, he/she shall . b. If the resident was not authorized to leave, initiate a search of the building(s) and premises; c. If the resident is not located, notify the Administrator and Director of Nursing Services, the resident's legal representative (sponsor), the Attending Physician, law enforcement officials .d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area . 5. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 1/2/18 documented the resident scored 13 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); required limited assistance with transfer; was independent with locomotion on and off the unit; and had unsteady balance when moving from a seated to standing position, when walking, when turning around while walking, and during surface-to-surface transfers, but was able to stabilize without staff assistance, had no behavioral symptoms, did not reject care, and wandering behavior was not exhibited. a. A Nurses Note dated 12/23/17 at 3:00 p.m. documented, .Res (Resident) noted to be using code on front door to let himself out (without) letting staff know . There was no documentation that indicated that the front door code was changed, and no reference to elopement risk on the resident's Plan of Care until 1/5/18. b. A Nurses Note dated 1/1/18 at 12:00 p.m. documented, .This LPN (Licensed Practical Nurse) was sitting (at) SCU (Secure Care Unit), noticed Res (resident) was self-propelling in parking lot towards (Retail Store in adjacent parking lot) . LPN x (times) 2 to Res at this time. Res easily redirected . There was still no indication that the front door code was changed to prevent further elopement; however, monitoring the resident's whereabouts every 15 minutes was initiated at this time. c. A Nurses Note dated 1/2/18 at 9:00 a.m. documented, .Currently in wc (wheelchair) propelling self around facility . Q (every) 15 m (minute) checks continue . d. A Nurses Note dated 1/3/18 at 11:00 p.m. documented, .Res (Resident) attempting to go up ramp to w.w. (West Wing) several times. When asked by LPN why he was attempting to go up there, res stated, 'I have a hiding place up there; I like to go and hide there'. LPN redirected at this time . The west wing connects the facility with a wheelchair ramp to the lower halls, A thru F. There was no indication that the facility closed or secured access to the West Wing ramp to prevent the resident from accessing other areas of the facility where he might be more likely to successfully elope. e. A Nurses Note dated 1/5/18 at 12:45 p.m. documented, .Resident noted to be pushing wheelchair and ambulating near the end of front sidewalk. This LPN (and) CNA (Certified Nursing Assistant) to resident's side. Resident stated, 'I was just walking'. Resident became slightly agitated when attempted to re-direct. DON (Director of Nursing) spoke to resident and set limit for resident, maybe outside unassisted on sidewalk directly in front of door, in plain sight. Explained that if he wishes to go elsewhere, to seek staff assistance. He voiced understanding . f. A Nurses Note dated 1/5/18 at 1:00 p.m. documented, .Res (Resident) noted to be pushing w/c out in the parking lot. This LPN and CNA to Res side. Res stated, 'I'm not from here. I'm not going to run off. I would just like to be able to go around. I feel like I'm in jail.' Resident redirected. D/T (due to) wandering (and) elopement risk, resident moved to secure unit room . late entry 1300 (1:00 p.m.) R pushing w/c to maintenance staff in parking lot. CNA had witnessed Res wandering . g. The Resident Plan of Care dated 1/9/18, which was not signed by the interdisciplinary team, did not address elopement risk for this resident until 1/5/18, despite the elopement risk assessment findings on 12/21/17 that indicated he was at high risk for elopement and staff observations of elopement attempts between 12/23/17 and 1/4/18. An entry dated 1/5/18 on the Plan of Care documented, .R (Resident) has wandered into side yard (and) has been instructed of areas he can be. (Resident) cont (continues) to wander. R will be placed on scu (special care unit - facility's secure unit) . h. A Wander Data Collection Tool form dated 1/5/18 documented, .Evaluation Factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family / significant others voiced concerns? Yes . Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? Yes . Is the resident cognitively impaired with poor decision-making skills (i.e. (such as) poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes . Is the resident a new admission or re-admission (within past 30 days) and not accepting the new situation? Yes . Does the resident have any visual, auditory, or communication deficits? Yes . Does the resident ambulate independently, with or without the use of assistive devices (include wheelchair)? Yes.Summary of Findings . Is a wander / elopement risk . Family / Responsible party notified 1/5/18 . i. A Nurses Note dated 1/6/18 at 1:30 p.m. documented, .Res (Resident) pushing buttons on keypad to attempt to elope. Res even states 'I will open my window (and) get out.' Res also attempting to follow staff around unit .Res able to be redirected this shift . There was no documentation the windows on the secure unit were checked to ensure the resident would be unable to carry out his verbalized plan to exit through a window. j. A Nurses Note dated 1/7/18 at 8:30 a.m. documented, .Resident (at) SU (secure unit) door. Pushing in codes on the keypad trying to open the door. Res redirected. k. A Nurses Note dated 1/8/18 at 12:00 p.m. documented, .LPN on SCU at this time. Res noted to be putting in codes on key pad. Res also noted to be kicking the door. LPN to Res side at this time. Attempted verbally redirect res at this time but res cont (continues) to sit at door (and) put in codes . l. A Nurses Note dated 1/10/18 at 3:22 p.m. documented, .Resident has shadowed a worker out of SCU once today and has pushed code to get out once. Both times, he has become agitated, paced (and) refused to go back to SCU. Had to have staff sit (with) res for an hour second time, before could get him back to SCU. He is also on Q (every) 15 min checks . There was no documentation that SCU staff were reminded to monitor for residents exiting the unit behind them or that the secure unit door code was changed to prevent the resident from exiting the secure unit undetected. m. A Nurses Note dated 1/15/18 at 10:00 a.m. documented, .Continues to leave SCU by pushing code (at) door. Refuses to go back in by stomping feet to floor (and) holding on to guard rails on hallway to prevent wc (wheelchair) being moved. Resident states, 'I'm tired of staring (at) those damn walls.' Non-compliant (with) awaiting staff / smoke break. Easily agitated when asked to return to unit . n. A Nurses Note dated 1/28/18 at 4:15 p.m. documented, .Resident c/o (complains of) chest pain . N.O. (new order) received to send to ER (emergency room ) for eval / tx (evaluation / treatment) . 2/1/18 (at) 1:10 p.m. Rec'd (received) Res back into facility via facility van . Propels w/c by self . o. A Wander Data Collection Tool form dated 2/1/18 after the resident returned to the facility from the hospital documented, .Evaluation Factors: Has the resident wandered? Did the resident wander at home, in previous living settings, family / significant others voiced concerns? Yes . Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? Yes . Is the resident cognitively impaired with poor decision-making skills (i.e. (such as) poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes . Is the resident a new admission or re-admission (within past 30 days) and not accepting the new situation? Yes . Does the resident have any visual, auditory, or communication deficits? Yes . Does the resident ambulate independently, with or without the use of assistive devices (include wheelchair)? Yes. The remainder of the form (Summary of findings and family notification) was incomplete. p. An Elopement Risk assessment dated [DATE] documented, .4. Able to ambulate using cane, quad cane, walker or rolling walker . 5. Able to transfer independently . 6. Able to ambulate independently in wheelchair / power wheelchair . 7. History of wandering prior to nursing home placement . 8. Resistant to nursing home placement . 9. Expresses desire to go home . 10. Exit seeking . 13. Medications . 2 . Total Score 9. Standard Care Plan Initiated or Updated (Y or N): Y . MD, Social Services, Family and Therapy Notification (Y or N): Y . The total score of 9 indicated the resident continued to be at high risk for elopement. q. A Nurses Note dated 2/4/18 at 3:20 p.m. documented, .While smoking, res (Resident) walked off porch (and) parking lot. Other nurse verbally redirected to SCU. Res cussing (at) staff stating, 'I've been held here. I'm a free man. Call the cops.' Res beating on SCU doors (and) yelling, unable to redirect . 7:15 p.m.Res at doors on SCU attempting to enter code. Stating, 'I want out of this (expletive) hole!' Unable to redirect. Beating on doors . r. A Plan of Care entry dated 2/5/18 documented, .R (Resident) opened window in room (on secure unit), crawled out face first, walked to fence, crawled under fence (and) crawled into woods, put blanket down (and) laid on ground to hide . The following documentation was reviewed, related to this incident: 1.) A Nurses Note dated 2/5/18 at 12:15 p.m. by the Assistant Director of Nursing (ADON) documented, .CNA went to resident's room to give resident his lunch tray, but resident was not in his room. Wheelchair was empty and sitting beside open window. Staff was alerted to missing resident. Resident was located outside in the woods next to property. He admitted to 'I climbed out that window face first, walked over to the woods, slid on my butt under the fence, then when I heard y'all yelling for me, I laid down on my blanket to take a nap.' No visible injuries noted and denied pain. Full ROM (range of motion) performed without difficulty. Resident was resistant to coming back into nursing home. Numerous staff assisted resident out of the woods and back to facility. When he got back to facility, he started complaining of back pain. Resident back in his room at 1330 (1:30 p.m.). Notified Administrator, DON, and (Medical Doctor) of situation (with) orders to send to (local hospital) ER (emergency room ) for eval (evaluation) of back pain, then send to (area hospital behavioral center) for psych (psychiatric) eval . 2/5/18 at 3:35 p.m. Resident has been one-on-one observation (and) will remain that way until further notice . 2/5/18 at 3:30 (local hospital) ER sent resident back to nursing home (with) no new orders. Resident was transported to (area hospital behavioral center) via nursing home van assisted by CNA (times) 2 . 2.) A Nursing Home to Hospital Transfer form dated 2/5/18 documented, .Behavioral Issues and Interventions: Elopement / wandering .Can ambulate independently . Assistive device (if applicable) w/c . 3.) An Office of Long Term Care (OLTC) Incident and Accident Report (I & A) dated 2/5/18 at 12:15 p.m. documented, .CNA noted when she took resident lunch tray to his room that his window was open and his wheelchair was parked in front of window, resident was not in room or bathroom. Code was called for elopement and all staff responded promptly. Resident was found in wooded area behind facility. Resident reported to staff that he raised window in room and climbed out of window into fenced in yard, found an area of fence which had a hole at the bottom and climbed under the fence. Resident went about 20 yards into the wooded area behind facility. When resident heard staff calling his name he laid down on a blanket in a small ravine and attempted to hide. Staff found him when he began to cough. Resident was brought back to the facility and began to complain about his lower back hurting. Resident had no apparent injuries but was sent to (local hospital) for eval and for a work up to be sent to (area hospital) for psych eval . Steps taken to prevent continued abuse or neglect during the investigation: Resident was brought back to the facility and began to complain about his lower back hurting. Resident was assessed and had no apparent injuries but was sent to (local hospital) for eval and for a work up to be sent to (area hospital) for psych eval. Resident currently resides on our special care unit due to wandering and attempted elopements. 4.) An OLTC Witness Statement Form dated 2/5/18 at 1:30 p.m. by CNA #1 documented, .Checked on (Resident #1) at 11:50 (a.m.)-12 p.m. and was in his room after we came back from smoke break around 11:30 a.m. when (staff) brought him back, went to check on him again and to bring his lunch tray at around 12:10 p.m. and 12:15 p.m. and his window was open, screen popped out, with chair in front of window. I checked bathroom and closet before going to notify the nurse. 5.) An OLTC Witness Statement Form dated 2/5/18 by LPN #1 documented, CNA came to F Hall doors and said that Res was not in his room when she took his lunch into his room. Said that his w/c was by his window and his window was open. This LPN immediately notified ADON and began looking for res - went into Res room - I went through the window that was open to the back of the facility that Res went through. Started looking for Res and anywhere in fence that he could have went thru. Yelled for other employees that there was a washed out place under the fence. I glanced over to left. Res sitting with his blanket on ground. Yelled for others to give his location. Maintenance run past me and we went under the fence and downhill to res. Res said he was sitting down resting . 3 employees assisted res to his feet . Other employees cleared path thru woods and assisted res out and to his w/c and back to facility. 6.) An Elopement Timeline dated 2/5/18 was attached to the facility's I&A Report and documented, 1130 (11:30 a.m.) - Resident brought back to F Hall from smoke break; 1150-12 (11:50 a.m. to 12:00 p.m.) - CNA checked on resident in room, resident was in his room in wheelchair; 1210 (12:10 p.m.) - CNA went to resident room to deliver lunch tray, resident wc in front of window. Resident was not in wc. CNA searched bathroom and closet, unable to locate resident in room, reported to LPN at approximately 1215; 1215 (12:15 p.m.) - Elopement code called and all staff responded promptly; 1230 - Resident found lying on blanket in woods . 7.) An OLTC Witness Statement Form dated 2/5/18 documented, .Witness Full Name (Maintenance Supervisor's name) .F Hall windows all have screws securing window . s. On 2/9/18 at 10:00 a.m., the exit code card that read Code 5* was posted in plain sight inside the front of the facility, right next to the key pad to allow exit through the front door. There were no staff members posted near the door and various residents were seated in the adjacent living room area. t. On 2/9/18 at 1:40 p.m., the Assistant Director of Nursing (ADON) was asked if the resident had been on D Hall when he was initially admitted and stated, Yes. (D Hall is not a secured hall). The ADON was asked if the resident was subsequently moved to the secured unit and stated, Yes, 1/5 (1/5/18). The ADON was asked why the resident was moved to the secured unit and stated, We saw him sitting out, rolled his wheelchair outside. The ADON was asked if the code was posted at the front door that allowed exit through the door and the ADON stated, No. At 1:50 p.m., the ADON accompanied the surveyors to the front door and the code 5* remained posted on a turquoise blue card by the inside of the front door. The ADON was shown the card and asked if that was the code that opened the door and stated, Yes. The ADON pressed the code in and opened the door. The ADON was returned to the work room with the surveyors and was asked what had been done when the resident exited through the front door by entering the code, to prevent further potential elopement. The ADON stated, We redirected him and we did offer to sit outside every time he wanted to sit outside. I found one episode, 1/1/18, resident was self-propelling and was easily redirected. The ADON was asked if the resident was easily redirected and returned to the facility and stated, Yes. The ADON was referred to the Nurses Notes and asked to review for elopement. The ADON stated, On 1/2/18 at 2300 (11:00 p.m.), resident was attempting to go up ramp to west wing and, I would like to say, west wing is where residents like to sit in the atrium, because it's by the door. On 1/5/18, 12:45 p.m., resident was noted to be pushing wheelchair and to be ambulating to end of sidewalk. Resident stated, 'I was just walking'. The ADON was asked if the front of the facility joined the parking lot that was busy with traffic and stated, Yes. The ADON was asked why the resident was admitted into the secured unit and stated, That same day, 1/5/18 at 1300 (1:00 p.m.), he was again outside. The ADON was asked if the door code was posted at the front of the facility at that time and stated, Yes. The ADON was asked if the code at that time was the same code that was posted today and stated, Yes, since I've been here, 9/16 (September 16). The ADON was asked who made the decision to move the resident to the secured unit on 1/5/18 and stated, The DON (Director of Nursing) and I. The ADON was asked why there was a need to move the resident to the secured unit and stated, To help protect him from getting hurt when he wandered outside where traffic was. The ADON was asked if any diversional activities were attempted to prevent the resident from exiting and stated, We did offer, but it's not documented. I also spoke to Maintenance about getting that code changed on the front door. The ADON was asked if the code was changed and stated, No, they called the company that's over that code. I know that Maintenance was working on that. I don't know the exact date. The ADON was asked who the code was discussed with and stated, The maintenance man; I spoke with (Maintenance Supervisor name) and (Maintenance Worker #1's name). At 2:55 p.m., the ADON was asked which door she had discussed with maintenance and stated, The front; I also asked for the F hall door. The ADON was asked when she had asked maintenance about the F Hall door code and stated, I don't know, the date he was punching in the code, and I asked them to change it, and they did. The ADON was asked how the resident knew the F Hall door code and stated, He punched in the right code. At 4:05 p.m., the ADON was asked what had been done when the resident eloped on 2/5/18 and stated, I received an order to send him to the local ER and if everything was clear send him to (area hospital behavior center). That was that day. The ADON was asked what had occurred that day on 2/5/18 and stated, I was outside, and I didn't think he could get out. I let (DON name), (Administrator name) know. The ADON was asked what time the resident was discovered missing and the ADON stated, 12:15 p.m. The ADON was asked when the resident was located and the ADON stated, It was 1:30 p.m. The ADON was asked if the resident was strong enough to raise the window in his room and stated, Strong enough to raise. The ADON was asked when the fence was repaired and stated, I asked maintenance that day, (Maintenance Supervisor and Maintenance Worker #1's names). The ADON was asked if both maintenance employees were told and stated, I believe I did. I know I told (Maintenance Supervisor) because he was out in the woods with us. The ADON was asked, When did maintenance repair the open area in the fence and stated, He told me that he placed some logs at the bottom of the fence and he was going to pour some Quikrete (fast-setting concrete mix) . The ADON was asked if the fence was now repaired and stated, (Maintenance Worker) has told me he placed a sheet of plywood where the ditch went under the fence. The ADON was asked when that was done and stated, Yesterday. The ADON was asked again when the repair was done to the fence and stated, Yesterday, I don't know what time. The ADON was asked if the fence had been inspected after the repair and stated, Ten o'clock. The ADON was asked if that was p.m. and stated, Yes, I asked him to make sure it was repaired. The ADON was asked if the maintenance staff were instructed on 2/6/18 to repair the fence and stated, I did not. I don't remember a specific conversation with him. The ADON was asked how the fence had been repaired and stated, A piece of plywood, it was up. I could see some logs that (Maintenance Supervisor) had placed, and I could see 2 cinder blocks. The ADON was asked if there were residents who were capable of moving cinder blocks or logs and stated, Yes, some are. The ADON was asked if there were wanderguards in use in the facility and stated, No . The ADON was asked if the resident's elopement risk assessments indicated he was at risk for elopement and stated, Yes. The ADON was asked if the resident's elopement risk information was listed in the Elopement Risk Book for staff and the ADON stated, No, he was not. The ADON was asked why the resident was not listed in the Elopement Risk Book and stated, I don't know. The ADON was asked who was responsible for updating the Elopement Risk Book and stated, It should be our MDS Coordinator. I spoke with her today. The ADON was asked if, when residents were assessed and determined to be at risk for elopement, that information should be carried over to the Elopement Risk Book and stated, Supposed to be a face sheet, wander assessment and a picture. The ADON was asked when the Elopement Risk Book should be updated and stated, With the quarterly assessment and admission. The ADON was asked who was responsible for checking the book for updated residents and stated, It should be MDS when checked. The ADON was asked what time she became aware of the resident missing on 2/5/18 and stated, I was notified at 12:15 p.m . He was mine (assigned to ADON). She (CNA #1) immediately told (LPN #1) and they searched the room, the nurse came out and told me. I went to the intercom and announced the code . Immediately went down to F Hall and did a search myself. I did not find the resident on F hall. I did see the w/c by the window in his room. The ADON was asked if the window was up in the resident's room and stated, Yes. The ADON was asked how high the window had been raised at that time and stated, As far as it can go, about 12 inches. I went outside and started searching. I had staff going down halls, checking west wing inside and out. One staff member heard him cough. I heard staff yelling 'we found him'. The ADON was asked to describe where the resident was found and stated, .approximately 50 feet, give or take, he was found in the woods on a blanket. He was taking a nap he said. The ADON was asked if the resident was on the other side of the perimeter fence and the ADON stated, Yes, 50 feet or so. He was lounging on his blanket, laid back on his bottom resting on his elbows. The ADON was asked how the resident had gotten to the other side of the fence and stated, He told us, 'I climbed out of my window head first, walked over to the woods, crawled under the fence on my bottom and took off walking through the woods. The ADON was asked how the resident was able to get to the other side of the fence and stated, Upon inspection, there is a ditch. Did not have water in it, and where the ditch is, it was washed out underneath it, under the fence . Refer to F689 for further details regarding the facility's failures for Resident #1. 6. On 2/8/18 at 8:23 p.m., the exit door on the A Hall was wide open. On the other side of the door, there was a hallway with an exit door on each side, approximately 1 foot from the A Hall exit door. A wheelchair ramp led upward to an upper level where there was a physical therapy department, dining area, multiple empty resident rooms with unlocked windows, and multiple exit doors. There were no codes posted on these exit doors and the doors were all locked. There were no residents or staff members housed on the upper west wing facility level. 7. On 2/9/18 at 8:20 p.m., a list titled, Residents At Risk for Elopement was provided by the ADON. The list documented there were 4 residents who resided on the A thru D halls who were at risk for elopement and 4 residents who resided on the F Hall secure unit who were at risk for elopement, including Resident #1. On 2/10/18 at 11:30 a.m. after the facility updated their elopement risk assessments, an updated list provided by the Administrator documented there were actual (TRUNCATED)

Based on observation, record review and interview, the facility failed to ensure safety precautions were implemented during facility van transportation to reduce the risk of injuries in the event of sudden stops or accidents for 1 (Resident #2) of 5 (Residents #1 through #5) case mix residents who were transported in facility vans while sitting in a wheelchair. The failed practice resulted in past Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #2 whose wheelchair tipped over during transport in the facility van resulting in the resident receiving a cut lip and a bruised face. The facility was informed of the Past Immediate Jeopardy on 8/6/13 at 4:10 p.m. This failed practice had the potential to affect 48 residents who are transported while in a wheelchair in the facility van according to a list provided by the Director of Nursing on 8/7/13. The findings are: 1. The Van Protocol dated May 17, 2010 documented, " ...Purpose: to ensure that residents are transported to hospitals, medical clinics, dentist office, and other needed locations as safe as possible in the facility van. . . . Protocol: 1. For residents in wheelchairs: . . . b. The restraint is intended to keep the resident from falling from the wheelchair not as a means to secure the resident to the van - similar to the effect of seat belts. . . . f. Using the straps provided, strap the front wheels of the wheelchair to the floor brackets. g. Synch the straps as tight as possible. Wiggle the wheelchair several times until the synch is as tight as possible. h. For the back wheels of the wheelchair, synch either both back wheels together and to the floor or synch/strap each back wheel of the wheelchair to the floor bracket. i. Do not strap only one back wheel. j. Using the seatbelt provided ensure that each end of the seatbelt is secured to the floor and place the other end of the seatbelt through the arms of the wheelchair and buckle in front of the resident. . . ." 2. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of 6/19/13 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status; required extensive assistance with transfers, dependent for locomotion on and off the unit; and mobility device was a wheelchair. a. An Incident/Accident Report (I&A)' dated 7/12/13 documented, "Time of incident 1440 (2:40 p.m.), Exact location of incident/accident: other (checked) Specify: facility van. . . Res. (resident) was in wheelchair in van and res chair tipped over to (L) left when van stopped at light. Res. did not fall out of chair due to safety belt. Res. hit mouth causing a small cut to (upper) inner lip. 0.2 x 0.2 (centimeter) bruise noted to inner knee. . . ." A Nurses Note dated 7/12/13 at 1440 documented, "It was reported to this nurse while res was in facility van her wheelchair flipped over. Res didn't come out of chair due to safety belt. Res. hit her mouth on another wheelchair causing a small cut to the inside upper lip. . . . LE (late entry) Res also has a sm (small) 0.2 x 0.2 purple bruise to left inner knee & bruising to (upper) lip (outer)." b. On 8/6/13 at 10:59 a.m., the resident was interviewed. She stated, "She (Employee #1) hit the brakes real hard, my chair wasn't tied down real good, I went forward and hit the wheelchair in front of me. It broke a couple teeth in my dentures and cut my lip. I didn't have the seat belt on. I had my belt on in the chair. I don't know if the chain broke or what. They took my teeth and had them fixed." At 11:08 a.m., the non-case mix resident who was in the van with the resident was interviewed. The resident stated that Resident #2 rode behind him and that Employee #1 hit the brakes causing Resident #2's wheelchair to go under his wheelchair and flip over. He stated that he had his wheelchair seat belt on. c. On 8/6/13 at 12:51, Employee #1 was asked what happened concerning Resident #2's wheelchair turning over. The employee stated that she put 2 straps on the front frame of the wheelchair. When asked if the van seat belt was used on Resident #2, the employee stated that she did not put the van seatbelt on the resident. Employee #1 was asked, "Did you know to put the wheelchair seatbelt on the resident?" Employee #1 stated, "No, not really." She was then asked, "Prior to the incident had you been trained on how to secure resident wheelchairs in the van?" Employee #1 stated, "No". At 1:09 p.m., Employee #2 was asked how Resident #2 had been secured to the van on 7/12/13. Employee #2 stated that she did not see how the resident was secured in the van, but had asked Employee #1 if all the residents were secured in the van. The employee added that she had not been trained prior to the incident on how to properly secure the residents in the van, but that a couple of Certified Nursing Assistants (CNAs) had shown her how. d. On 8/6/13 at 12:51 p.m., Registered Nurse (RN) #1 was asked, "Prior to this incident was staff trained on how to properly secure residents in the van?" RN #1 stated, "Some were trained, I couldn't tell you exactly which ones, but some were." The RN was asked, "What about Employee #1 and #2?" RN #1 stated, "I don't know if they were or not." The RN was asked, "Prior to the incident was there a policy and procedure on how to properly secure residents in the van?" RN #1 stated, "No, we had a policy but it was very vague, so we redid it." At 1:50 p.m., the Administrator was asked who was in-serviced on properly securing of wheelchairs in the van for transportation. The Administrator stated that prior to the incident that staff was not in-serviced on how to properly secure wheelchairs in the van, "Just the ones who normally drove the van." The Administrator added that Employee #1 had not been trained. 3. The facility took the following actions to remove the Immediate Jeopardy and correct the failed practices prior to the survey entrance date: a. On 7/12/13 (Friday) after the incident the van involved was immediately taken out of commission according to the Administrator. b. The QA & A Process Identification and Solution form filled out by the Administrator on 7/15/13 documented, " ...both vans were visually inspected by maintenance and administration ...the resident was not secured properly ...To ensure all staff members were trained in positioning residents properly in vehicle, securing straps and belts appropriately, and correct van lift operation transportation via facility van was stopped on both vans. The vans were parked, locked and all keys secured by the administrator ..." On 7/15/13 (Monday) the incident was reviewed during the morning meeting and a Quality Assessment and Assurance (QA&A) Process Identification and Solution was implemented: ". . . Problem identified: Improper securing of resident in van, failure to use vehicle seat belt. Goal: All transported residents will be secured appropriately including straps and seat belts. Plan of Action/Correction: Review of I&A in daily meeting 7/15/13. Identified incident for QA&A identification and solution: Reviewed new policy with competencies developed for resident transportation and adopted policy, use of competencies, van logs and maintenance logs. Administrator prepared to perform in-service, train staff and complete competencies today (7/15/13) for CNAs designated as drivers for the van. Both vans were visually inspected by maintenance and administration. Inspection and investigation into the incident revealed the resident was not secured properly, the staff member had secured the wheelchair as she had noted it done when the resident exited the vehicle earlier (to the front x 2) in addition to the driver, braking and second staff member riding in front passenger rather than with residents in the back. Prepared competencies and "Resident Transportation Program" In-services were delayed pending arrival and installation of the new straps. Plan for 100% in-service for retraining of drivers will include; secured wheelchair, no transportation of residents in Geri chairs; appropriate placement, tie down, seat belts; residents with an order for [REDACTED]. . . Training CD (compact disk) for Sure Loc ratchet straps was purchased from Arkansas Van Conversion; On July 16th, Sure Loc ratchet straps arrived and after watching the training video were installed by maintenance with demonstration provided. . . In-service of all staff began on July 17th. . . . Staff was given a copy of the policy "Resident Transportation Program", completed a competency and those individuals designated as drivers were provided with the job description and were asked to provide a current driver license for the file. . . . No residents were transported by the facility van during the investigation and retraining. A QI (Quality Improvement) audit tool was developed for use by the facility to monitor compliance of staff with securing residents wheelchair and seatbelts properly before leaving the facility. . . . New hires will receive training during orientation and will not transport or assist as 2nd rider without completion of competency. The facility plans to ensure compliance with safety measures and training as well as adhering to the policy: by use of facility and upon return to the facility number of residents transported, number in wheelchair, seated; secured with seat/shoulder belts as well as secured properly front and back with Sure Lock system. The audit will be performed daily once transportation resumes." c. A new policy and procedure "Resident Transportation Program" was developed on 7/16/13. Addendums to the original policy include an additional QAPI (Quality Assurance and Performance Improvement) section which documented, " ...Logs will be completed by staff member transporting residents. A QI van audit tool will be used to ensure compliance with positioning of residents securing of wheel chairs, proper use of shoulder and seat belts ..." Employees began implementing the QI Van audit logs on 7/19/13 which requires staff to check and verify: number of residents, number of wheelchairs, number of residents sitting in van seats, wheelchairs strapped, seat belts applied and the name and initials of the responsible staff members for that transport. In-services to educate and ensure compliance with transportation safety included a return demonstration session for the designated van drivers with the safety strap installation company, a 'Resident Transportation Protocol' was provided and signed by the designated van drivers and an all staff in-service 'Transporting by Van' was conducted with 100% participation documented.

Complaint # was substantiated, all or in part, in these findings. Based on record review and interview, the facility failed to ensure the physician was immediately consulted regarding significant changes in condition following a fall with a possible head injury for 1 (Resident #1) of 2 (Residents #1 and #3) case-mix residents who experienced falls with possible head injuries on or after 7/3/12. The failed practice resulted in past Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 and had the potential to affect 2 residents who had experienced falls with possible head injuries on or after 7/3/12, as documented on a list provided by the Assistant Director of Nursing (ADON) on 7/20/12 at 12:00 p.m. The Administrator was notified of the Past Immediate Jeopardy on 7/20/12 at 11:35 a.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 5/14/12 documented the resident scored 3 (0-7 indicates severe impairment) on the Brief Interview for Mental Status and was required extensive to total assistance of staff for activities of daily living and transfers. a. An Incident/Accident Report dated 7/3/12 at 9:05 p.m. documented, "Res (resident) was found in floor in hallway. Some redness noted to L (left) side of face. (No) C/O (complaints of) any pain... Was person involved seen by a physician? No... Was person involved taken to a hospital? No... Reduce distractions (and) provide redirection if necessary." The Nurse's Note dated 7/3/12 at 9:05 p.m. documented, "CNA (Certified Nurse Assistant) came (and) got this nurse. Res was found lying on L side in floor in the hallway on the SCU (Secure Care Unit). Res fell while CNA x (times) 2 were in another room providing pt (patient) care. Some redness noted to L (left) side of face. (No) C/O any pain or discomfort. Dr. (doctor) #1 and (family member) notified. V/S (vital signs): ... Res now lying in bed (with) call light (and) H2O (water) in reach." This entry was signed by Licensed Practical Nurse (LPN) #1. b. The Nurse's Note dated 7/3/12 at 9:30 p.m. documented a "late entry" written on 7/6/12, "Notified (physician #1) (with) resident assessment d/t (due to) fall - All V/S WNL (within normal limits) - no obvious injury other than nose bleed on R (right) side. Response: Monitor (and) report (changes)." The late entry was signed by LPN #2. c. The Nurse's Note dated 7/3/12 at 11:00 p.m. documented, "CNA reported to this LPN, (Resident) attempting to get up (without) assistance X several attempts. This LPN observes anxiousness when redirecting (Resident). Gave [MEDICATION NAME] 1 mg (milligram) 1 PO (by mouth) @ (at) this time. This LPN notes dark purple-blue discoloration to R (right) eye. (Resident) also C/O pain to touch, no other delayed injuries noted @ this X. Will cont (continue) to monitor (resident) behavior." This entry was documented by LPN #3. The Nurse's Note dated 7/4/12 at 12:00 a.m. documented, "(Resident) cont to show S/S (signs and symptoms) anxiousness, getting up several X's, (Resident) redirects with much difficulty. This LPN notes (Resident) has two nose bleeds, sm (small) amt (amount) blood (bright red) per episode, bleeding controlled @ this X. Will cont to monitor." This entry was documented by LPN #3. The Nurse's Note dated 7/4/12 at 1:00 a.m. documented, "V/S ... This LPN gave Tyelonal 325 mg, (two) PO per C/O headache @ this X." This entry was documented by LPN #3. The Nurse's Note date 7/4/12 at 1:20 a.m. documented, "CNA reported to this LPN, (Resident) being resistant (with) incont (incontinent) care, became combative knocking CNA to floor, (Resident) was redirected (with) success, now lying in bed (with) eyes open, will cont to monitor behavior." This entry was documented by LPN #3. The Nurse's Note date 7/4/12 at 2:10 a.m. documented, "(Resident) cont to get up (and) down, this LPN notes another "drip" nosebleed. (Resident) denies headache @ this X. This LPN also notes discoloration to R (right) eye worse (with) slight swelling. Will cont to monitor." This entry was documented by LPN #3. The Nurse's Note dated 7/4/12 at 4:00 a.m. documented, "(Resident) seems much calmer @ this X. (No) S/S restlessness/anxiousness noted, lying in bed (with) eyes open. No voiced C/O noted, C/L (call light) in reach." This entry was documented by LPN #3. The Nurse's Note dated 7/4/12 at 5:30 a.m. documented, " CNA reported to this LPN (Resident) refusing assistance (with) incont care after several attempts, Aide to try again in a few mins (minutes). (Resident took a.m. (morning) meds (medications) (without) difficulty, denies any pain or headache @ this X..." This entry was documented by LPN #3. There was no documentation in the Nurse's Notes or the physician's orders [REDACTED]. d. The Neurological Assessment Flow Sheet documented, "7/3/12 2300 (11:00 p.m.): ... headache/dizzy ... 2315 (11:15 p.m.): ... headache/dizzy ... 2330 (11:30 p.m.): ... headache/dizzy, ... 2345 (11:45 p.m.): headache/dizzy, ... 2400 (12:00 p.m.): ...nosebleed, ... 0100 (1:00 a.m.): ... nosebleed, ... 0200 (2:00 a.m.): ... nosebleed, ... 0600 (6:00 a.m.): ... none, ...". There were no documented neuro checks on the Neurological Assessment Flow Sheet or in the Nurses Notes prior to 11:00 p.m. on 7/3/12. e. The Nurse's Note dated 7/4/12 at 6:50 a.m. documented, "Reported to (physician#1) that Res (resident) had C/O headaches (and) dizziness throughout the night. Also had nose bleeds off (and) on. N/O (new order) to send to ER (emergency room ) for eval (evaluation). ER (and) family notified @ this time." f. The (hospital) Emergency Physician Record dated 7/4/12 documented, "...Chief complaint: Fall injury to head ... Clinical Impression: Fracture: (Right) orbit (and) maxillary sinus..." g. On 7/19/12 at 11:10 a.m., the surveyor asked LPN #3 about Resident's #1's fall on 7/3/12. LPN #3 stated, "I cared for (Resident #1) the shift after his fall. His nose bleed would be one drip. The CNA on the previous shift had reported the headache and the CNA on my shift reported the dizziness. I did not notify the doctor. Normally the doctor would have been notified. I wanted to send him out but, I was new and was 2 days off orientation. (LPN #4) was the other nurse working that night. I had told her about him and she told me to let day shift send him out. They have more staffing for that. It was against my nursing judgment. The DON (Director of Nursing) told me to not ever worry about sending someone. If they need to go to ER, to call the ambulance and send." LPN #4 was not available for interview during the survey. h. On 7/19/12 at 4:05 p.m., the surveyor asked the Acting DON, Registered Nurse (RN) #1, about the resident's fall on 7/3/12. The RN stated she was aware of the fall and that neuro (neurological) checks were not started until 11:00 p.m. RN #1 stated, "Headaches, dizziness, and nosebleed are changes. The MD (medical doctor) should have been notified of these changes when they occurred and not waited until 6:50 (a.m.) in the morning." i. On 7/19/12 at 4:25 p.m., the surveyor asked LPN #1 about Resident #1's fall on 7/3/12. The LPN stated she remembered when the resident fell and the LPN stated, "When a resident falls and hits their head, normally they would be sent to ER. He did not go to ER because he didn't hit his head. I went down there he was lying on his side and had his hand propped under his head. We didn't get him up... We asked him if he was hurting and he said, 'no'. Checked hips and knees, and movement of arms and legs. I thought the redness was from where he propped himself up on his fist. We got him up in the wheelchair and he waved at me and another nurse. I touched around the redness and asked him if it hurt and he said, 'no'. It was so chaotic that night, it slipped my mind to start neuro checks." j. On 7/19/12 at 5:20 p.m., the surveyor asked the ADON about the resident's fall and the ADON stated, "I am familiar with (Resident #1) and the fall on 7/3/12. They should have started the neuro checks after the fall. The 7-3 (7:00 a.m. - 3:00 p.m. shift) LPN (LPN #5) caught me at the door on morning of 7/4/12 and said, 'I had to send (Resident #1) to the ER.' I asked her what was wrong. She said he fell and had a big place on his eye. It looked bad and I sent him out. I told her she did exactly what one needed to. When I reviewed the documentation of the fall, I identified that he had fallen and apparently had a head injury and notified the DON and we started the investigation." 2. On 7/19/12 at 4:30 p.m., the Administrator provided a QA Plan . The plan documented, "7/3/12 Problem Identified: On 7/3/12 at 2105 (9:05 p.m.), resident (Resident #1) fell while CNAs were in another room. LPNs on 3-11 (3:00 p.m. - 11:00 p.m. shift) and 11-7 (11:00 p.m. - 7:00 a.m. shift) did not perform neuro checks or send to ER when symptoms presented. Started neuro checks 3 hrs (hours) later ... Action Plan: ... All LPNs /RNs will be in-serviced on recognizing signs (and) symptoms of neuro deficits/injury..." 1) On 7/19/12 at 4:30 p.m., the Adminstrator provided a document titled, "Head Injury Symptoms: When To Seek Medical Care by MedicineNet.com" that documented: "Head Injury Symptoms: When to Seek Medical Care ... Often, the injury that causes brain damage may not be dramatic or very traumatic, and the person may not initially lose consciousness. But for those few, where the head is hit in just the right place with just the right amount of force, the potential for swelling in the brain is real. The New Orleans Criteria found seven symptoms that suggest when to obtain a CT (computerized tomography) scan. These same seven symptoms are reasonable as a guide to seek medical attention after a head injury: 1. Headache2. Vomiting 3. Short term memory loss 4. [MEDICAL CONDITION] 5. [MEDICAL CONDITION] 6. Physical evidence of trauma to the head or neck 7. Age over 60 ..." 2) On 7/19/12 at 5:03 p.m., the surveyor asked the Administrator about the resident's fall and the Administrator stated she was aware of the resident's fall on 7/3/12. She stated, "We did an in-depth investigation because when the ADON came in on 7/4/12 around 8:00 a.m. the LPN told her as soon as she got here, she had sent (Resident #1) out because he had fallen. The ADON discovered he had fallen and no neuro checks were done. They had called the physician but, they did not call the doctor when he had the changes of nosebleed, headache and dizziness. Investigation was started and QA'd (Quality Assurance) and staff in-serviced." 3. On 7/20/12 at 10:25 a.m., the surveyor asked the ADON what type of monitoring was implemented to ensure the in-service regarding falls with head injuries was effective. The ADON stated, "The fall investigation form is filled out by the nurses and given to me. We discuss it with the team every morning and follow through with documentation in the Nurses' Notes and check that all protocols were followed. There have been no other incidents since (Resident #1's) of neuro checks not being started immediately and not sending (the resident to the ER) if the resident needs to go to the hospital. We have a more thorough process with checking all areas and documentation of Nurses' Notes. When someone falls on the weekend they call the supervisor on call."On 7/20/12 at 12:00 p.m., the ADON provided: a. A policy and procedure titled "Condition Change". The policy documented, "CONDITION CHANGE, OF THE RESIDENT (OBSERVING, RECORDING, AND REPORTING) Basic Responsibility: Licensed Nurse ... Purpose To observe, record and report any condition change to the attending physician so proper treatment will be implemented. ... Procedure 1. After all resident falls, injuries or changes in physical or mental function, monitor the following: ... Observe for swelling and discoloration; if present, chart size, site, amount and color. ... Observe and inquire if resident has headache or pain. ... Take vital signs and include temperature. ... Observe for bleeding from ears, nose, throat. Observe for unequal pupils. ... Observe for pain. ... Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director. ..." b. A policy and procedure titled "Fall Protocol" that documented, "... GENERAL GUIDELINES FOR ASSESSMENT MAY INCLUDE, BUT ARE NOT LIMITED TO: *Change in physical and/or cognitive function *Pain *Medication *Environment *Communication deficits ... CHARGE NURSE DUTIES 1) Assess the resident for injury. Neuro check is required for all head injuries X (times) 72 hours using the Neurological Assessment form. * Q (every) 15 min (minutes) for the first hour * Q 30 min X 2 * Q Hr. (hour) X 2 * Q 4 Hrs. X 2 * Q shift for the remaining 72 hours and until stable 2) Notify the physician and responsible party. 3) Notify Director of Nursing and Administrator. 4) Complete the Incident and Accident Report. 5) Complete the Fall Investigation Form. 6) Implement interventions to prevent further falls. ..."

Complaint # was substantiated (all or in part), in these findings. Based on record review and interview, the facility failed to ensure that neurological checks were immediately implemented for a resident following a fall with a possible head injury and the physician was immediately consulted when changes in the resident's condition occurred to prevent a delay in treatment for 1 (Resident #1) of 2 (Residents #1 and #3) case mix residents who experienced falls with possible head injuries on or after 7/3/12. The failed practice resulted in past Immediate Jeopardy which caused or could have caused serious harm, injury or death to Resident #1 and had the potential to affect 2 residents who experienced falls with possible head injuries on or after 7/3/12, as documented on a list provided by the Assistant Director of Nursing (ADON) on 7/20/12 at 12 noon. The Administrator was notified of the Past Immediate Jeopardy on 7/20/12 at 11:35 a.m. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 5/14/12 documented the resident scored 3 (0-7 indicates severe impairment) on the Brief Interview for Mental Status and was required extensive to total assistance of staff for activities of daily living and transfers. a. An Incident/Accident Report dated 7/3/12 at 9:05 p.m. documented, "Res (resident) was found in floor in hallway. Some redness noted to L (left) side of face. (No) C/O (complaints of) any pain... Was person involved seen by a physician? No... Was person involved taken to a hospital? No... Reduce distractions (and) provide redirection if necessary." The Nurse's Note dated 7/3/12 at 9:05 p.m. documented, "CNA (Certified Nurse Assistant) came (and) got this nurse. Res was found lying on L side in floor in the hallway on the SCU (Secure Care Unit). Res fell while CNA x (times) 2 were in another room providing pt (patient) care. Some redness noted to L (left) side of face. (No) C/O any pain or discomfort. Dr. (doctor) #1 and (family member) notified. V/S (vital signs): ... Res now lying in bed (with) call light (and) H2O (water) in reach." This entry was signed by Licensed Practical Nurse (LPN) #1. b. The Nurse's Note dated 7/3/12 at 9:30 p.m. documented a "late entry" written on 7/6/12, "Notified (physician #1) (with) resident assessment d/t (due to) fall - All V/S WNL (within normal limits) - no obvious injury other than nose bleed on R (right) side. Response: Monitor (and) report (changes)." The late entry was signed by LPN #2. c. The Nurse's Note dated 7/3/12 at 11:00 p.m. documented, "CNA reported to this LPN, (Resident) attempting to get up (without) assistance X several attempts. This LPN observes anxiousness when redirecting (Resident). Gave [MEDICATION NAME] 1 mg (milligram) 1 PO (by mouth) @ (at) this time. This LPN notes dark purple-blue discoloration to R (right) eye. (Resident) also C/O pain to touch, no other delayed injuries noted @ this X. Will cont (continue) to monitor (resident) behavior." This entry was documented by LPN #3. The Nurse's Note dated 7/4/12 at 12:00 a.m. documented, "(Resident) cont to show S/S (signs and symptoms) anxiousness, getting up several X's, (Resident) redirects with much difficulty. This LPN notes (Resident) has two nose bleeds, sm (small) amt (amount) blood (bright red) per episode, bleeding controlled @ this X. Will cont to monitor." This entry was documented by LPN #3. The Nurse's Note dated 7/4/12 at 1:00 a.m. documented, "V/S ... This LPN gave Tyelonal 325 mg, (two) PO per C/O headache @ this X." This entry was documented by LPN #3. The Nurse's Note date 7/4/12 at 1:20 a.m. documented, "CNA reported to this LPN, (Resident) being resistant (with) incont (incontinent) care, became combative knocking CNA to floor, (Resident) was redirected (with) success, now lying in bed (with) eyes open, will cont to monitor behavior." This entry was documented by LPN #3. The Nurse's Note date 7/4/12 at 2:10 a.m. documented, "(Resident) cont to get up (and) down, this LPN notes another "drip" nosebleed. (Resident) denies headache @ this X. This LPN also notes discoloration to R (right) eye worse (with) slight swelling. Will cont to monitor." This entry was documented by LPN #3. The Nurse' s Note dated 7/4/12 at 4:00 a.m. documented, "(Resident) seems much calmer @ this X. (No) S/S restlessness/anxiousness noted, lying in bed (with) eyes open. No voiced C/O noted, C/L (call light) in reach." This entry was documented by LPN #3. The Nurse's Note dated 7/4/12 at 5:30 a.m. documented, "CNA reported to this LPN (Resident) refusing assistance (with) incont care after several attempts, Aide to try again in a few mins (minutes). (Resident took a.m. (morning) meds (medications) (without) difficulty, denies any pain or headache @ this X..." This entry was documented by LPN #3. There was no documentation in the Nurses Notes or physician order [REDACTED]. d. The Neurological Assessment Flow Sheet documented, "7/3/12 2300 (11:00 p.m.): ... headache/dizzy ... 2315 (11:15 p.m.): ... headache/dizzy ... 2330 (11:30 p.m.): ... headache/dizzy, ... 2345 (11:45 p.m.): headache/dizzy, ... 2400 (12:00 p.m.): ...nosebleed, ... 0100 (1:00 a.m.): ... nosebleed, ... 0200 (2:00 a.m.): ... nosebleed, ... 0600 (6:00 a.m.): ... none, ..." There were no documented neuro checks on the Neurological Assessment Flow Sheet or in the Nurses' Notes prior to 11:00 p.m. on 7/3/12. e. The Nurse's Note dated 7/4/12 at 6:50 a.m. documented, "Reported to (physician#1) that Res (resident) had C/O headaches (and) dizziness throughout the night. Also had nose bleeds off (and) on. N/O (new order) to send to ER (emergency room ) for eval (evaluation). ER (and) family notified @ this time." f. The (hospital) Emergency Physician Record dated 7/4/12 documented, "...Chief complaint: Fall injury to head ... Clinical Impression: Fracture: (Right) orbit (and) maxillary sinus..." g. On 7/19/12 at 11:10 a.m., the surveyor asked LPN #3 about Resident's #1's fall on 7/3/12. LPN #3 stated, "I cared for (Resident #1) the shift after his fall. His nose bleed would be one drip. The CNA on the previous shift had reported the headache and the CNA on my shift reported the dizziness. I did not notify the doctor. Normally the doctor would have been notified. I wanted to send him out but, I was new and was 2 days off orientation. (LPN #4) was the other nurse working that night. I had told her about him and she told me to let day shift send him out. They have more staffing for that. It was against my nursing judgment. The DON (Director of Nursing) told me to not ever worry about sending someone. If they need to go to ER, to call the ambulance and send." LPN #4 was not available for interview during the survey. h. On 7/19/12 at 4:05 p.m., the surveyor asked the Acting DON, Registered Nurse (RN) #1, about the resident's fall on 7/3/12. The RN stated she was aware of the fall and that neuro (neurological) checks were not started until 11:00 p.m. RN #1 stated, "Headaches, dizziness, and nosebleed are changes. The MD (medical doctor) should have been notified of these changes when they occurred and not waited until 6:50 (a.m.) in the morning." i. On 7/19/12 at 4:25 p.m., the surveyor asked LPN #1 about Resident #1's fall on 7/3/12. The LPN stated she remembered when the resident fell and the LPN stated, "When a resident falls and hits their head, normally they would be sent to ER. He did not go to ER because he didn't hit his head. I went down there he was lying on his side and had his hand propped under his head. We didn't get him up ... We asked him if he was hurting and he said, 'no'. Checked hips and knees, and movement of arms and legs. I thought the redness was from where he propped himself up on his fist. We got him up in the wheelchair and he waved at me and another nurse. I touched around the redness and asked him if it hurt and he said, 'no'. It was so chaotic that night, it slipped my mind to start neuro checks." j. On 7/19/12 at 5:20 p.m., the surveyor asked the ADON about the resident's fall and the ADON stated, "I am familiar with (Resident #1) and the fall on 7/3/12. They should have started the neuro checks after the fall. The 7-3 (7:00 a.m. - 3:00 p.m. shift) LPN (LPN #5) caught me at the door on morning of 7/4/12 and said, 'I had to send (Resident #1) to the ER.' I asked her what was wrong. She said he fell and had a big place on his eye. It looked bad and I sent him out. I told her she did exactly what one needed to. When I reviewed the documentation of the fall, I identified that he had fallen and apparently had a head injury and notified the DON and we started the investigation." 2. On 7/19/12 at 4:30 p.m., the Administrator provided a QA Plan. The plan documented, "7/3/12 Problem Identified: On 7/3/12 at 2105 (9:05 p.m.), resident (Resident #1) fell while CNAs were in another room. LPNs on 3-11 (3:00 p.m. - 11:00 p.m. shift) and 11-7 (11:00 p.m. - 7:00 a.m. shift) did not perform neuro checks or send to ER when symptoms presented. Started neuro checks 3 hrs (hours) later ... Action Plan: ... All LPNs /RNs will be in-serviced on recognizing signs (and) symptoms of neuro deficits/injury..." 1) On 7/19/12 at 4:30 p.m., the Adminstrator provided a document titled, "Head Injury Symptoms: When To Seek Medical Care by MedicineNet.com" that documented: "Head Injury Symptoms: When to Seek Medical Care ... Often, the injury that causes brain damage may not be dramatic or very traumatic, and the person may not initially lose consciousness. But for those few, where the head is hit in just the right place with just the right amount of force, the potential for swelling in the brain is real. The New Orleans Criteria found seven symptoms that suggest when to obtain a CT (computerized tomography) scan. These same seven symptoms are reasonable as a guide to seek medical attention after a head injury: 1. Headache2. Vomiting 3. Short term memory loss 4. [MEDICAL CONDITION] 5. [MEDICAL CONDITION] 6. Physical evidence of trauma to the head or neck 7. Age over 60 ..." 2) On 7/19/12 at 5:03 p.m., the surveyor asked the Administrator about the resident's fall and the Administrator stated she was aware of the resident's fall on 7/3/12. She stated, "We did an in-depth investigation because when the ADON came in on 7/4/12 around 8:00 a.m. the LPN told her as soon as she got here, she had sent (Resident #1) out because he had fallen. The ADON discovered he had fallen and no neuro checks were done. They had called the physician but, they did not call the doctor when he had the changes of nosebleed, headache and dizziness. Investigation was started and QA'd (Quality Assurance) and staff in-serviced." 3. On 7/20/12 at 10:25 a.m., the surveyor asked the ADON what type of monitoring was implemented to ensure the in-service regarding falls with head injuries was effective. The ADON stated, "The fall investigation form is filled out by the nurses and given to me. We discuss it with the team every morning and follow through with documentation in the Nurses' Notes and check that all protocols were followed. There have been no other incidents since (Resident #1's) of neuro checks not being started immediately and not sending (the resident to the ER) if the resident needs to go to the hospital. We have a more thorough process with checking all areas and documentation of Nurses' Notes. When someone falls on the weekend they call the supervisor on call." On 7/20/12 at 12:00 p.m., the ADON provided: a. A policy and procedure titled "Condition Chang". The policy documented, "CONDITION CHANGE, OF THE RESIDENT (OBSERVING, RECORDING, AND REPORTING) Basic Responsibility: Licensed Nurse ... Purpose To observe, record and report any condition change to the attending physician so proper treatment will be implemented. ... Procedure 1. After all resident falls, injuries or changes in physical or mental function, monitor the following: ... Observe for swelling and discoloration; if present, chart size, site, amount and color. ... Observe and inquire if resident has headache or pain. ... Take vital signs and include temperature. ... Observe for bleeding from ears, nose, throat. Observe for unequal pupils. ... Observe for pain. ... Have someone stay with the resident while the nurse is calling the attending physician, if necessary. If you are unable to reach the attending physician or the physician on call, call the facility medical director. ..." b. A policy and procedure titled "Fall Protocol" that documented, "... GENERAL GUIDELINES FOR ASSESSMENT MAY INCLUDE, BUT ARE NOT LIMITED TO: *Change in physical and/or cognitive function *Pain *Medication *Environment *Communication deficits ... CHARGE NURSE DUTIES 1) Assess the resident for injury. Neuro check is required for all head injuries X (times) 72 hours using the Neurological Assessment form. * Q (every) 15 min (minutes) for the first hour * Q 30 min X 2 * Q Hr. (hour) X 2 * Q 4 Hrs. X 2 * Q shift for the remaining 72 hours and until stable 2) Notify the physician and responsible party. 3) Notify Director of Nursing and Administrator. 4) Complete the Incident and Accident Report. 5) Complete the Fall Investigation Form. 6) Implement interventions to prevent further falls. ..."

Complaint # was substantiated (all or in part) with these findings: Based on observation, record review and interview, the facility failed to ensure alarms were working or attached, to ensure falls were thoroughly investigated to determine causative factors and to ensure planned interventions were consistently implemented and evaluated for effectiveness for 4 (Resident #1, 2, 3 and 5) of 5 (Resident #1 through 5) case mix residents, who had falls or a history of falls. This failed practice resulted in actual harm for Resident #5 who sustained a fractured humerus after falling and was likely to cause more than minimal harm for 23 residents in the facility who had bed or chair alarms according to the list provided by the Director of Nurses (DON) on 3/20/12. The findings are: 1. The facility ' s Policy and Procedure titled " Incident and Accident Investigation " received from the DON on 3/20/12 documented, "Purpose . . . 2. To identify any injuries after a resident sustains an accident or incident. Investigation Procedure. . . 3. Interview the resident to determine cause of any conditions identified. 4. Interview any witnesses to determine cause of any conditions identified. . . 14. Attempt to determine the cause of any conditions identified. 15. Implement preventive measures as appropriate. . . ." 2. The facility ' s Fall Protocol received from the DON on 3/20/12 documented "Basic Responsibility: License Nurse. Purpose: 1. To assess residents at risk for falls. 2. To follow-up and evaluate all falls. 3. To identify the reason for the fall. . . . Fall Prevention Program Components . . . Resident Care Plan will reflect the risk of falls and specific interventions to prevent falls. . . Staff will be inserviced on the Fall Prevention Program upon hire and annually. All falls will be tracked and monitored using the Fall Log to determine trends and reported to the QA&A (Quality Assessment and Assurance) Committee. . . . Intervention Resources . . . Place bed in lowest position. Provide low bed with mats. Provide bed/chair alarms. . . ." 3. The facility ' s Policy and Procedure titled Fall Risk Assessment received from the DON on 3/20/12 documented, "Policy: All Residents will be assessed for high risk for falls. . . . Procedure: 2. Any resident that has fallen will be placed on a high risk for falls program. The resident will be continually monitored for a period of no less than 3 months. . . Intervention: Residents on high risk for falls program may have interventions including but not limited to: . . . b. Frequent reorientation with repetitive instruction and encouragement of call light use. . . i. Implement chair and bed alarms as appropriate. . . . Appropriate interventions will be put into place, care planned and documented." 4. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 2/3/12 documented the resident scored 2 (0 - 7 severe impairment) on the Brief Interview for Mental Status (BIMS); required extensive assistance of 2 persons with transfers; did not walk in the room or hall in the last 7 days; required extensive assistance with toilet use, balance with sit to stand, transfer on and off the toilet; surface to surface transfers were not steady and only able to stabilize with human assistance; and had no falls since prior assessment. a. A Fall Risk assessment dated [DATE] documented the resident had intermittent confusion, had 1-2 falls in the past 3 months, was ambulatory, incontinent, had a balance problem with standing, walking jerking or unstable when making turns and required use of assistive devices. The resident ' s total score was 18. A total score of 10 or above represents HIGH RISK. b. The Plan of Care dated 2/2/12 documented, "At risk for injury related to fall risk. Requires assistance with transfers and mobility. At risk for fracture related to Osteoporosis. Goal: Staff will provide safe transfers and mobility preventing injury through next review. . . . Assist to transfer using good body mechanics and proper technique. 2/12/12 fall from amb (ambulating) out of bed - cont (continue) careplan, bed alarm - ensure in place as res. has hx (history) of self remo. (removal). 3/10/12 fall in room - cont careplan - winged mattress applied." c. A Nurses Notes dated 2/12/12 at 3:30 a.m. and signed by Licensed Practical Nurse (LPN #1) documented, "CNA (Certified Nursing Assistant) heard a noise in Rm (room) & noted Res. sitting on bathroom floor. Res. stated she got (up) to go to the BR (Bathroom) & legs gave out & she fell on her bottom. Denies pain. Sm. abrasion noted to (right) knee. Res assisted to toilet & back to bed. Bed alarm was not heard to be sounding when res. was (up) out of bed. (Checked) bed alarm & alarm went off when pressure released off of pad. Res. instructed to use C/L (call light). . ." 1) An Incident/Accident Report dated 2/12/12 at 3:30 a.m. and signed by Licensed Practical Nurse (LPN #1) documented, ". . . Res. (Resident) (up) unassisted, bed alarm did (not) sound. Res stated her legs gave out & (and) she fell down on her bottom. Sm. (small) abrasion noted to (right) knee. . . Instructed Res. to use c/l (call light) for assist." 2) On 3/19/12 at 10:30 p.m., LPN #1 was asked: " What did you do about the alarm not sounding? " The LPN stated, "It was on and it was not sounding. I replaced the alarm. The alarm was on, we checked it at shift change." The LPN was asked if they could walk without assistance. She stated, "She could ambulate with the walker with stand by assistance. She would turn the alarm off by herself. I would try to keep the alarm out of the resident's reach." 3). On 3/19/12 at 10:39 p.m., Certified Nursing Assistant (CNA) #4 was asked, " How often are the alarms checked? The CNA stated, "Every time we go into rooms on rounds and at the beginning of the shift." The CNA was asked if after the resident fell , she was able to determine why the alarm wasn't working. The CNA stated, "No, I don't really remember back that far. If she got up and the alarm sounded, I would have re-enforced the use of the call light for assistance." d. The Nurses Notes dated at 2:40 p.m. and signed by Licensed Practical Nurse #2 documented, "CNA called nurse to res. room. Res. had went to the restroom and fell on her way back to the bed. Upon inspection of the res, she has a laceration above (left) eyebrow, her (left) shoulder seemed to be out of socket, & she was c/o (left) hip pain. . 4:15 p.m. (hospital) called-res had a Fx'd (fractured) (left) humerus head. They were going to splint it & DC (discharge) her back here." 1) An Incident/Accident Report dated 3/10/12 at 2:40 p.m. documented, ". . . Res attempted to go to the restroom without assistance. Res fell in room. Laceration above (left) eyebrow, (left) shoulder appears out of socket. Res. c/o (complained) (left) hip pain. . . ." 2) On 3/18/12 at 2:36 p.m., RN #1 was asked, " Was resident's bed alarm on when the resident fell on [DATE]? " RN #1 stated, "It wasn't going off. The Aides said the resident sometimes turns it off. I didn't check it." 3) On 3/19/12 at 3:52 p.m., CNA #2 was asked, " Tell me what happened when the resident fell on [DATE]. " The CNA replied, "When I got here, I took her to the bathroom, the bed alarm was working, then put the resident back to bed. I went to get supplies and when I came back the resident had fallen. I don't know if the alarm was sounding when she fell . When I put her back in the bed, I put the call light in reach and turned the alarm back on." The CNA was asked if the resident had a decline since the fall. The CNA stated, "She could walk with assistance and could feed herself. She normally ate in her room." e. On 3/17/12 at 2:06 p.m. the resident was lying on the bed in her room. The bed pressure alarm box was not blinking to indicate it was active. CNA #1 picked up the alarm box and beat it against his hand, then the light on the box started blinking to show it was active. f. On 3/18/12 at 8:21 a.m., the resident was sitting in a wheelchair at the assist dining room table. At 9:31 a.m., the resident was assisted to the bathroom, 2 CNAs transferred the resident from the wheelchair to the toilet. At 10:57 a.m., the resident was in the bed, the alarm was blinking indicating the alarm was active. At 12:08 p.m., the resident was sitting in a wheelchair at the assist dining room table. g. On 3/19/12 at 4:00 p.m., CNA #3 was asked, " What interventions did the resident have in place to prevent falls? The CNA stated, "She had a bed alarm and she would turn it off. I would report to the nurse and move the alarm to another location where it couldn't be reached. When she would turn it off, it (alarm) was on the dresser where she could reach it." The CNA was asked if the resident had a decline since the fall. The CNA stated, "Before the fall she was a 1 person assist, the resident was walking with the walker. She did use the wheelchair some. She doesn't get up as much as she did and requires more assistance with transfers." h. On 3/20/12 at 9:45 a.m. CNA #5 was asked, " Has the resident's condition changed since she fell ? " The CNA stated, " Before the fall, sometimes she was a little wobbly and we could assist her. Most of the time she could get up by herself and go to the bathroom. She could turn off the alarm. Sometimes she would take the batteries out." The CNA was asked, "What did you do to prevent her from turning off the alarm? " She stated, "There was nothing we could do to prevent it. You couldn't stop her from turning it off." The CNA was asked, "Did you ever move the alarm where she couldn't turn it off? " She stated, "She would pull on the cord until she pulled it to her, no matter where we put it." The CNA was asked, "Was there a way to attach the alarm to the bed? " She stated, "Her alarm doesn't have anything on it to attach it." The CNA was then asked, "Since her fall, have you noticed a decline in her ADL's (Activities of Daily Living)? " She stated, " Yes, she is now a 2 person assist. She moans when we move her." The CNA was asked, "Any decline in eating? " She stated, "Yes, she was eating at a regular table in the dining room before the fall, now she is at an assist table. It takes a lot of encouragement to get her out of the bed." i. On 3/20/12 at 11:20 a.m., LPN #2 was asked, " On the day that the resident fell was the alarm sounding? " LPN #2 stated, "I was counting and getting report when the resident fell . The CNA came and got me and when I went into the room, the alarm was not sounding." The LPN was asked, " Which CNA reported to you? " The LPN stated, " I'm not sure who the CNA's were in the room. But (RN#1) and (LPN #3) were in the room." The LPN was asked, "Has there been a change in the resident's condition since the fall? The LPN stated, " Yes, they get her up in the wheelchair now. She was very independent before the fall. She fed herself in the dining room. She was not at the assist table." LPN #2 was asked, " How often do you check alarms? " LPN #2 stated, "We check them every 2 hours. (Resident #5) likes to turn hers off and get up and go by herself." The LPN was asked, "What did you do to prevent her from turning off the alarm? " LPN #2 stated, "Just re-enforced that she needed to leave the alarm on and use the call light for assist." The LPN was asked, " Did you ever move the alarm to keep the resident from turning it off? " LPN #2 stated, "No." j. On 3/21/12 at 9:40 a.m., LPN #3 was asked, " Do you remember when (Resident #5) fell and can you tell me what happened. " LPN #3 stated, "I can't remember if a CNA or dietary came and reported that the resident's head was bleeding. She was lying on the floor by the recliner and I noticed blood. I went and called the doctor and the hospital." The LPN was asked, "When you went into the room was the alarm sounding? " The LPN stated, "I don't think so, but I don't really remember." LPN #3 was asked, "Before the fall was the resident ambulatory? " LPN #3 stated, " Yes, but she has always been weak, she would do everything herself." The LPN was asked, "Were you told that the resident turns her alarm off? " The LPN stated, " Yes, we tried moving the box, but she could still move and turn it off." LPN #3 was asked, "Did you ever secure the alarm out of the resident's reach to prevent the resident from getting it? LPN #3 stated, "I have not personally." 2. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly MDS with an Assessment Reference Date of 2/13/11 documented the resident scored 1 (0-7 severe impairment) on the BIMS, was dependent of one person for bed mobility, transfers, dressing and personal hygiene and had functional limitations on one side of lower extremity. a. A fall risk assessment dated [DATE] documented a total score of 15. The form indicated a score of 10 or above represented HIGH RISK. b. The Plan of Care dated 1/3/12 documented, "At risk for fall related injury as evidenced by: Hx (history) of falls, poor safety awareness related to cognitive deficit, requires assistance with transfers due to effects of Parkinson's. Resident is unable to ambulate or stand due to weakness. Unaware of her own limitations. . . . Bed and chair alarm to alert staff of resident attempting to rise without assistance. Check to ensure proper working order. 10/12/11 Fall in room continue CP (care plan). 11/15/11 Rolled out of bed on mat cont. (continue) care plan." c. On 3/19/12 at 9:07 a.m. and 9:57 a.m., the resident was sitting in a wheelchair and the alarm was not attached to the resident. 3. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an Assessment Reference date of 12/23/11 documented the resident scored 5 (0-7 severely impaired) on a BIMS, required extensive assist of one person with transfers and ambulation and has had no falls since the last assessment. a. The Fall Risk Assessment form dated 12/22/11 documented a total score of 18. The form indicated a score of 10 or above represented HIGH RISK. b. The Plan of Care dated 1/3/12 documented, "Resident has impaired cognitive skills and long term memory deficit, poor decision making skills related to Dementia. . . . Bed and chair alarm to alert staff to ensure resident's safety. . . At risk for injury related to falls due to history of falls, poor safety awareness, requires assistance with transfer and ambulation due to unsteady gait and balance takes a daily antidepressant medication. . . . May use chair alarm while up in wheelchair & may use bed alarm while in bed to alert staff when (Resident #2) attempting to ambulate without assist. " c. On 3/1712 at 12:07 p.m., the resident was in a wheelchair. The resident ' s alarm was not attached to the resident . d. On 3/18/12 at 12:01 p.m., the resident was in a wheelchair. The alarm was not attached to the resident. 4. Resident #3 had [DIAGNOSES REDACTED]. The Significant Change MDS dated [DATE] documented the resident scored 10 (8-12 moderately impaired) on the BIMS, required extensive assistance with transfers and ambulation, was not steady with sit to stand and surface to surface transfers or walking and turning and had no falls since the last assessment. a. The Fall Risk assessment dated [DATE] documented a total score of 23. The form indicated a score of 10 or above represented HIGH RISK. b. The Plan of Care dated 1/5/12 documented, "At risk for fall related injury related to right side weakness and neglect as result of recent CVA, poor safety awareness, noncompliant with safety interventions. . . Bed/chair alarm, ensure working order of alarms. 2/28/12 fall in room, 2/29/12 fall in room - bed alarm applied 1. Monitor function of alarm. 2. Monitor placement. 2/29/12 fall in room placed on low bed. 2/29/12 fall in room - Cont. low bed & (and) alarm." c. On 3/18/12 at 7:50 a.m., the resident was lying on a low bed in the room. The alarm was not blinking to indicate that it was on and the switch was turned off. d. On 3/19/12 at 8:50 a.m. and 3:05 p.m., the resident was lying on the bed in the room. The alarm was not turned on. 5. On 3/21/12 at 8:45 a.m., Director of Nursing (DON) was asked, " How do you investigate falls? " RN#2 stated, "What we do, we read the I&A's (Incident and Accident) and see what was documented and review the I&A ' s daily in morning meeting, talk to the CNAs, Review the area where the fall occurred to see about hazards, look at meds (medications)." The RN was asked, " Do you document follow up investigation on falls? " DON stated, " I think LPN #4 does that. I will check to see. " The DON also stated that LPN #4 was responsible for reviewing all I&A reports for completeness. The RN was asked how new employees were trained regarding alarms. The RN stated, "Orientation list that they are checked off on. We pair them with another CNA. We educate them on alarms and daily routines." DON was asked, " Have you inserviced the staff in the past year about alarms, placement, checking them, etc.? " DON stated, "I did not find where we have had an inservice on alarms." On 3/21/12 at 8:50 a.m., RN#2 stated that LPN #4 does not do a post fall investigation.