Every finding on record at Belle Grande Nursing and Rehabilitation Center

Based on interview and record review the facility failed to ensure a resident's right to receive mail by not delivering mail to residents on Saturdays. This has the potential to affect all 96 residents residing in the facility. Findings:Review of an undated facility policy on 09/23/2025 at 4:23 p.m. titled, Resident Rights revealed the following in part .Resident Rights: The resident has a right to a dignified existences, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident including: (i) Mail: The resident has the right to privacy in written communications, including the right to 1. Send and promptly received mail.On 09/22/2025 at 1:30 p.m., the Resident Council Meeting was conducted and revealed that the residents did not receive mail on Saturdays. All residents in attendance agreed they were told they should wait until Monday to receive the mail delivered on a Saturday. The Resident Council agreed they would like their mail delivered on Saturdays and not have to wait until Monday. In an interview on 09/23/2025 at 3:31 p.m., S5 [NAME] Clerk/CNA revealed she worked for 3 months as the [NAME] Clerk and also worked on the weekends. S5 [NAME] Clerk/CNA explained the mailman does deliver mail on Saturday to the front desk. The mailman places the facility mail in a basket behind the front desk and the [NAME] Clerk will store it safely until Monday. S5 [NAME] Clerk/CNA stated that on Monday, S4 HR would pick up the mail delivered over the weekend and then distribute it to the residents. S5 [NAME] Clerk/CNA confirmed resident mail is delivered on Saturdays and she does not distribute the resident mail on Saturdays. In an interview on 09/23/2025 at 3:36 p.m., S4 HR revealed she had been in this role for 3-4 years and she and the Business Office Manager were responsible for the facility mail processes. S4 HR stated the facility mail is delivered to the front desk on Saturday and the [NAME] Clerk should store the mail safely until Monday. On Monday, she and the Business Office Manager will review and distribute the mail to the residents. S4 HR confirmed there was no process for mail distribution on Saturdays that she was aware of. In an interview on 09/23/2025 at 3:46 p.m., S1 ADM revealed she expected the resident mail received on a Saturday to be delivered to the residents. S1 ADM was unaware the [NAME] Clerk was not distributing the mail on Saturday and stated, There is no reason residents should not receive their personal mail on Saturdays.

Based on observations, interviews and record reviews the facility failed to ensure each resident's environment remained free of accident hazards. The facility failed to ensure hot water temperatures did not exceed 120 degrees for 15 (Bathroom A, Bathroom B, Bathroom C, Bathroom D, Bathroom E, Bathroom F, Bathroom G, Bathroom H, Bathroom I, Bathroom J, Bathroom K, Bathroom L, Bathroom M, Bathroom N, and Shower Room Z) resident bathroom/shower rooms. Findings: Review of the facility's undated policy titled General Policies read in part.Maintenance Services: 1. Maintaining the building in compliance with current federal, state and local laws, regulations and guidelines. Review of the facility's water temperature log by S3 Maintenance Supervisor revealed no water temperature greater than 120 degrees for the 06/2025, 07/2025, 08/2025 and 09/2025 water temperature logs. Observation on 09/22/2025 at 10:25 a.m. revealed Bathroom I's hot water temperature in the bathroom sink felt hot to touch. Observation on 09/22/2025 at 10:29 a.m., S10 Maintenance Supervisor checked Bathroom I's sink hot water and the temperature read 129.3 degrees F. Observation of hot water temperatures for residents sinks in bathroom's revealed the following:Bathroom A -125.2 degrees F. No resident concerns Bathroom B-121.2 degrees F. No resident concernsBathroom C-124.4 degrees F. No resident concerns Bathroom D-125.3 degrees F. No resident concernsBathroom E- 122.4 degrees F. No Resident concernsBathroom F-122.6 degrees F. No resident concerns Bathroom G-124.0 degrees F. No resident Concerns Bathroom H-124.4 degrees F. No resident concernsBathroom I-129.3 degrees F. No resident concernsBathroom J-123.6 degrees F. No resident concernsBathroom K-122.0 degrees F. No resident concerns Bathroom L-126.0 degrees F. no resident concerns Bathroom M -124.3 degrees F. No resident concernsBathroom N- 124.7 degrees F. no resident concernsBathroom O- 124.8 degrees F. no resident concernsBathroom P-122.5 degrees F. no resident concerns Shower Room Z-125.3 degrees F. No concerns Observations and interview on 09/22/2025 at 11:20 a.m. with S10 Maintenance Supervisor in the facility boiler room revealed 3 hot water heaters all set at 130 degrees. S10 Maintenance Supervisor stated that he had the water temperatures set at 130 to prevent legionella. S10 Maintenance Supervisor stated that he has not been notified of any resident in the facility scalded or burned by water temperatures. S10 Supervisor confirmed the above bathroom and shower room temperature were above 120 degrees F., but should not have been. Interview on 09/22/2025 at 12:48 p.m. with S1 ADM denied any scalding, burns or any complaints of hot water from residents or staff and that all water temperatures will be lowered in the facility today. S! ADM confirmed the water temperature should not have exceeded 120 degrees F.

Based on record review and interview, the facility failed to ensure that a resident who required dialysis received services consistent with professional standards of practice for 1 (#13) of 1 (#13) resident reviewed for dialysis by failing to communicate and collaborate with the dialysis facility. The facility reported 1 resident currently received dialysis.Findings: Review of Resident #13's medical record revealed an admit date of 07/01/2025 with diagnoses that included, but were not limited to, Dependent on Renal Dialysis, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal Disease. Review of Resident #13's physician's orders revealed an order for resident to attend dialysis on Monday, Wednesday, and Friday. Review of Resident #13's Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. Review of Resident #13's medical chart revealed the most recent dialysis communication sheets in chart for September were dated 09/22/2025 and 09/23/2025. On 09/23/2025 at 12:57 p.m., observation of Resident #13's dialysis daily communication binder revealed in part.one incomplete dialysis communication sheet for 09/22/2025 and one completed sheet for 09/23/2025. Further review no other dialysis communication sheets had been completed for Resident #13 during the month of September 2025. On 09/23/2025 at 1:20 p.m., an interview with S6 LPN stated, The dialysis communication binder is usually sent with the resident to dialysis, but sometimes it doesn't get sent. When Resident #13 returns from dialysis the binder is returned back to the nurse's station where it is kept. S6 LPN stated she takes Resident #13's vital signs before and after dialysis but does not document it on the dialysis communication sheet. S6 LPN acknowledged the dialysis binder should be sent with Resident #13 each time she goes to dialysis for documentation to be completed and had not been. On 09/23/2025 at 2:25 p.m., an interview with S2 DON confirmed there were only 2 communication sheets in dialysis communication binder for the month of September with the dates of 9/22/2025 and 9/23/2025. S2 DON acknowledged Resident #13 goes to dialysis three times weekly and the binder contained no dialysis communication sheets for the rest of Resident #13's September visits to dialysis.

Based on observation and interview the Facility failed to maintain a clean, sanitary environment and ensure food was served in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 96 Residents who received food prepared by the kitchen.Findings: Review of a policy titled Food storage and Labeling, with a revision date of 05/2023 read in part ,Policy: The facility will store and label all foods to ensure safety and quality.Procedures:1. All temperature controlled foods and ready-to-eat foods that are prepared in the facility shall be labeled with the food name and date.7. Food will be stored in containers that are sealable, leak proof, durable and undamaged. Observation on 09/22/2025 at 8:40 a.m. of the walk in freezer/cooler revealed:1. 1 bag of lettuce, undated.2. 1 box of garlic bread open to air. 3. 2 plastic pitchers of lemonade open and undated.4. 1 plastic pitcher of Gatorade open and undated.Interview at the time of observation with S3 Dietary Manager revealed the staff who opens a food item should label and date it, and store it properly. S3 Dietary Manager confirmed: The above listed items were not dated and they should have been; the above listed items were open to air and they should not have been.

Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care and oral care for 1 (Resident #54) of 1 residents reviewed for ADLs. Total sample size was 29.Findings: Review of the undated facility policy titled: Nail Management revealed in part: Policy: Nail management is the regular care of the toenails and fingernails to promote cleanliness and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails or pressure of shoes on toenails. It includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath. Essential points: When performed at bath time, the nail care can be done following the procedure or as a separate procedure when needed at the convenience of the resident. Review of Resident #54's clinical record revealed an admit date of 05/02/2023 with diagnoses that included in part: Dysphagia following Cerebral Infarction; Neurogenic Bowel; Muscle Wasting and Atrophy; Muscle Weakness (Generalized); Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side; and Major Depressive Disorder. Review of Resident #54's Quarterly MDS with an ARD of 10/22/2025 revealed a BIMS Score of 12, which indicated moderately impaired cognition. Resident #54 was dependent for oral hygiene and required substantial/maximal assistance with personal hygiene, and had a Peg-Tube. Review of Resident #54's Care Plan with a review date of 11/05/2025 revealed in part.problem: Self-Care ADL deficit-Resident will receive person-centered care; needs assist with bathing, hygiene, dressing, and grooming related to CVA with Right Hemiparesis. Interventions included in part.Fingernails cleaned and trimmed. Check, clean, and/or trim fingernails and toenails weekly by nurse. Bath per schedule, dependent on staff for bathing Resident #61 required limited assistance with ADLs and required assistance with oral care every day and as needed. The Care Plan further revealed that Resident #61 had left sided hemiplegia. Review of Resident #54's facility task AM/PM care with dates ranging from 08/01/2025-09/23/2025 revealed oral care was documented only on 08/18/2025, 09/03/2025, 09/09/2025, 09/22/2025, and 09/23/2025.Observation and interview on 09/22/2025 at 10:33 a.m. with Resident #54 revealed a foul odor coming from Resident #54's mouth and dirty unknown brown substance to bilateral fingernails. Resident #54 stated he doesn't refuse any care and stated he gets a shower twice a week but couldn't remember the last time he had one. Resident #54 denied anyone coming to clean his fingernails or brush his teeth today.Observation and interview on 09/22/2025 at 3:58 p.m. of Resident #54 with dirty unknown brown substance to bilateral fingernails with a foul smelling odor coming from his mouth. Resident #54 denied anyone coming in to clean his fingernails or brush his teeth.Observation and interview on 09/23/2025 at 8:33 a.m., Resident #54 stated he had a shower early early this morning. Observation of Resident #54's fingernails revealed dirty unknown substances and foul smelling odor coming his mouth. Resident #54 denied having his teeth brushed or fingernails cleaned after his shower by stating No but I would like them to and it would feel good if they did.Observation on 09/23/2025 at 10:36 a.m. revealed Resident #54 lying in bed with dirty unknown brown substance to fingernails and foul smelling odor coming from his mouth.Interview on 09/23/2025 at 10:43 a.m. with S7 Bath CNA revealed that bathing consists of bathing, shampooing hair, shaving, and cleaning nails. S7 Bath CNA stated she keeps a nail kit in the shower room to clean any resident's nails that appeared dirty. S7 Bath CNA stated she gave Resident #54 a shower early this morning. S7 Bath CNA observed Resident #54's fingernails at this time, confirmed they were still dirty, and stated Yea I should've cleaned them this morning during his shower.Interview on 09/23/2025 at 10:44 a.m., S8 CNA stated Resident #54 is dependent on staff for his ADL's. S8 CNA stated she puts mouthwash on a swab and swabs his mouth when she cares for him but can't speak if the other staff does it or not. S8 CNA confirmed Resident #54's had bad smelling breath, and stated You can smell it as soon as he opens his mouth, it's been that way for awhile.Interview on 09/23/2025 at 11:10 a.m., S9 TX LPN stated Resident #54 doesn't refuse care and will let staff clean his nails. S9 TX LPN confirmed that CNAs can perform cleaning resident's nails and that his nails should've been cleaned after his shower.Interview on 09/23/2025 at 1:39 p.m., S11 LPN stated CNAs are supposed to perform oral care along with any personal hygiene every day, especially on shower days. S11 LPN stated Resident #54 should've had his oral care and nail care done today. S11 LPN stated CNAs chart their ADL tasks on the kiosk and that's how nurses monitor to ensure ADL tasks are being completed. S11 LPN stated if the CNAs don't perform oral care then it will fall on the nurses to complete.Interview on 09/23/2025 at 1:41 p.m., S2 DON confirmed that Resident #54's fingernails should've been cleaned after his shower and oral care should've been performed and documented appropriately and had not. S2 DON stated I'm getting on it now.

Based on record review and interview, the facility failed to ensure nursing staff were competent to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of 1 (Resident #13) of 1 resident reviewed for dialysis. The facility failed to ensure nursing staff were competent in assessing Resident #13's dialysis access site, as ordered. The facility only had one resident receiving dialysis.Findings:Review of an undated facility policy titled Fistula Maintenance: Post Dialysis Care on 09/23/2025 at 11:23 a.m. revealed in part.Policy: to provide appropriate assessment, care and treatment of the vascular access post dialysis. Procedure: A. General Care for Fistulas: 1. Check for a pulse (bruit or thrill) at lease every day. Put your finger over the access site to feel the pulse. If you do not feel or hear a thrill, call the dialysis unit immediately because it may be clotted. Review of Resident #13's medical record revealed an admit date of 07/01/2025 with diagnoses that included in part.Dependent on Renal Dialysis, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal Disease.Review of Resident #13's MDS with an ARD of 07/07/2025 revealed a BIMS score of 15, which indicated intact cognition. Review of Resident #13's physician's orders revealed the following order dated 07/01/2025: Monitor dialysis access site for bruit and thrill every shift.On 09/23/2025 at 1:20 p.m., an interview with S6LPN revealed in part .When asked how do you check for thrill and bruit, S6LPN stated she feels shunt for a pulse and checks her wrist for a pulse. When asked if she ever used a stethoscope, S6LPN stated she doesn't usually use a stethoscope to check it and explained she hasn't used a stethoscope in a minute to check bruit. S6LPN stated, You can barely hear it anyways, she has a really bad shunt.In an interview on 09/23/2025 at 2:25 p.m., S2DON acknowledged S6LPN did not correctly check the thrill and bruit on the dialysis shunt for Resident #13 but should have.

Based on record review and interview the facility failed to administer the Influenza Vaccine on admit to the facility for 1 (#24) of 5 (#1 #3 # 4 # 8 #24) residents sampled for Influenza, Pneumococcal and COVID-19 immunizations.Findings: Review of the facility's undated policy titled Vaccine: Influenza read in part.Policy: All residents of the facility will be offered the influenza vaccine annually to encourage and promote the benefits associated with immunizations against influenza. Review of Resident #24's clinical record revealed an admission date of 10/30/2024 with diagnoses that included: Primary Generalized Osteoarthritis, Major Depressive Disorder, Alzheimer's Disease, Dementia, and Malignant Neoplasm of Lower Lobe Left Bronchus or Lung. Review of Resident #24's medical record revealed no evidence that she had received the Influenza vaccine in 2024 or 2025. Review of Resident #24's admission records revealed a consent form dated 10/30/2024 consenting to the Influenza vaccine. Interview on 09/24/2025 at 10:55 a.m. with S2 DON confirmed that Resident #24's responsible party had consented for the influenza vaccine while signing admission paperwork, but Resident #24 had not been administered the influenza vaccine since admission to the facility.

Based on observations, interviews, and record review the facility failed to ensure a resident remained free from falls, by failing to ensure proper practices were followed while using a lift during a transfer for 1 (#1) of 2 (#1 and #2) sampled residents reviewed for incidents and accidents. This deficient practice resulted in an Immediate Jeopardy for Resident #1 on 03/27/2025 at 1:57 p.m., when Resident #1 fell from a mechanical lift onto the floor while being transferred by S3 CNA and S4 CNA. Resident #1 sustained a complete displacement fracture of the proximal left femur, and a subarachnoid hemorrhage as a result of the fall. The facility determined that S3 CNA and S4 CNA failed to use the appropriate sling size, and failed to place the sling loops appropriately on the lift to transfer Resident #1. The facility implemented corrective actions prior to the State Agency's investigation therefore, it was determined to be a Past Noncompliance citation. Findings: Review of the facility's 12/2019 policy titled [NAME]- Lift Transfer Procedure, read in part 1. Make sure you understand which size sling and which method of connecting the sling to the hanger bars is to be used to transfer patient. 13. Double check the sling loop connection to the hanger bar hooks to make sure the sling is securely attached with the loops in the bottom of the hanger bar hooks. Review of the facility's 12/2019 policy titled [NAME]- Lift -Using the Uni-fit Sling, read in part . each resident who uses the Vander-Lift for transferring should have a sling size (and color) listed on their wall care plan. The recommended sling size is what is to be used for the specific resident's transfer. Procedure Checkoff: 1. CNA correctly identified correct lift and sling size appropriate for the residents and identified sling part. 11. The CNA connects each of the shoulder sling loops to the hanger bar hooks on the mast using the same loop position on both sides of the sling. Review of Resident #1's medical record revealed an admitted [DATE], with diagnoses that included, in part .Schizoaffective Disorder, Bipolar Disorder, Diabetes Mellitus, Muscle Wasting with Atrophy, and Parkinson's disease. Review of a Quarterly MDS with ARD of 01/01/2025, revealed Resident #1 had a BIMS score of 11 (Moderate Cognitive Impairment). Resident #1 was dependent upon staff and required 2 + person physical assist for transfers. Review of Resident #1's Care Plan with a target date of 03/10/2025, revealed, in part . Resident #2 is at high risk for falls due to decreased mobility and diagnosis of Parkinson's. Interventions in place prior to incident: Vander-Lift x 2 person assist. Incident: 03/27/2025 Fall in room from Vander-Lift with head injury. Interventions: 03/28/2025 Vander-Lift x2 person assist with all transfers Medium (RED) lift pad. Observation on 04/07/2025 at 11:15 a.m. of Resident #1's wall care sheet posted in Resident #1's room, read in part .Vander-Lift x 2 person assist for all transfers. A red sticker was noted on the wall care sheet, which indicated a red (medium) sling was needed for transfers using a lift. Review of the facility incident report completed by S1 ADM, revealed on 03/27/2025 at 1:57 p.m., S5 Clinical Coordinator and S6 ADON were called into Resident # 1's room where she was found lying flat on floor between the legs of the Vander-Lift, and with blood under her head. S3 CNA and S4 CNA stated Resident #1 had fallen out of the lift sling and onto the floor during transfer. S5 Clinical Coordinator and S6 ADON applied pressure to Resident #1's head and had staff call an ambulance, the physician, and Resident #1's daughter. External rotation of the left leg was noted after the ambulance arrived, and Resident #1 was placed on the stretcher. Resident #1 was sent to the emergency room , where she was diagnosed with a subarachnoid hemorrhage, and complete displacement fracture involving the proximal left femur. The facility's investigation revealed the wrong size sling was used and the top right strap of the sling was hooked in the middle loop, rather than the loop closest to the pad, like the other 3 straps. Resident #1 was admitted to the hospital. She returned to the facility on [DATE]. Review of the employee written statement by S5 Clinical Coordinator revealed, in part .on 3/27/2025 at 1:57 p.m. Nurse stat was called to Resident #1's room. Resident #1 was observed lying on the floor between the legs of the Vander-Lift. The lift pad on the lift was a size large pad, and was trimmed in blue. Resident #1's care sheet included a red sticker, indicating her weight required the use of a red, or size medium, lift pad. All the straps were attached to the lift. The right strap at the head of the pad was attached in a higher notch further away from the sling, and the other 3 straps were attached to the bracket at the lowest level, closest to the lift pad. S3 CNA and S7 CNA were in the room at the time of the incident. S4 CNA had assisted with the transfer, but was no longer in the room. First aid was provided for Resident #1's head injury until the ambulance arrived. Review of the employee written statement by S4 CNA read in part S3 CNA hooked the lift up and she pulled it out, and Resident #1 then slipped out of the lift. Review of the employee written statement by S3 CNA read in part .Resident #1's dressed in blue jeans and a sweater with her socks and shoes with the lift pad under her. I went out to get assistance. I hooked up the 2 ends at the top, the other aide hooked up the 2 bottom ends. When lifting Resident #1 and moving her to sit her into her chair, she comes sliding out of the lift pad falling onto the floor. The sling was in her recliner chair. Review of the employee written statement by S7 CNA, read in part . I went in the room to go wait on the lift to get another resident up. S4 CNA and S3 CNA hooked the lifter pad on the lift. S3 CNA went to pull the lift from the bed and S4 CNA backed up the wheelchair to left of her bed. As soon as S3 CNA pulled the Vander-Lift out, the resident fell on her right side. S4 CNA then ran out the room while S3 CNA and I stayed with the resident'. Review of a written interview between S3 CNA and S1 ADM on 03/28/25: S1 ADM - Did you realize that you had placed one? loop higher than the other loop? S3 CNA - Yes, I do know all the loops are to be the same on each side and when hooking up the lift pad I thought they were on the same loop on each side. S1 ADM - The lift pad was large and she uses a medium size. Were you aware of this? S3 CNA - The sling was already in the room so I used the sling that was already in the room. Review of S3 CNA's personnel file revealed a new hire in-service and checkoff dated 02/27/2025 regarding use of the Vander-Lift for transfers, correct sling sizes, and attaching the hooks properly. Review of S4 CNA's personnel file revealed an in-service and checkoff dated 07/08/2024, and 10/07/2024, regarding use of the Vander-Lift for transfers, correct sling sizes, and attaching the hooks properly. Interview on 04/08/2025 at 9:55 a.m. with S5 Clinical Coordinator, revealed on 03/27/2025 at 1:57 p.m., she heard nurse stat announced for Resident #1's room. Upon entering the room she observed Resident #1 lying on the floor between the legs of the lift, and with blood under her head. S5 Clinical Coordinator stated a blue-trimmed sling was attached to the lift. S5 Clinical Coordinator revealed Resident #1's wall care sheet indicated she required a red sling. S5 Clinical coordinator stated the top right strap of the sling was not hooked in the loop closest to the pad, like the other 3 straps. S5 Clinical Coordinator stated that she is in charge of ensuring the right sling size is care planned and revealed that the red sling size was appropriate for Resident #1 according to her weight. Interview on 04/08/2025 at 10:21 a.m. with S6 ADON, revealed on 03/27/2025 at 1:57 p.m., she heard nurse stat yelled loudly for Resident #1's room. S6 ADON observed Resident #1 on the floor between the legs of the Vander-Lift. She stated there was blood under Resident #1's head. S6 ADON stated Resident #1's left leg was rotated outwardly, and she complained of pain to her back and left hip. S6 ADON stated after Resident #1 was transferred to the hospital, she immediately began in-servicing staff on correct use of lifts. She required all CNAs and nursing staff be checked-off on the task prior to using the lift. S6 DON stated she continued to monitor S3 CNA, S4 CNA, and random CNAs daily. Interview on 04/08/2025 at 1:11 p.m. with S7 CNA, revealed on 03/27/2025 at 1:57 p.m. she was in Resident #1's room when the fall occurred because she was waiting on the lift. S7 CNA revealed Resident #1's lift pad was already underneath her, but she could not recall the color. S7 CNA stated S3 CNA connected the top sling straps to the lift, and S4 CNA connected the bottom sling straps to the lift. S7 CNA stated S3 CNA began lifting Resident #1. S4 CNA put her foot on the lift, turning the lift towards the wheelchair. As S4 CAN turned the lift, Resident #1 fell out of the right side of the sling, and onto the floor. S7 CNA revealed staff were to use the sling size indicated on the residents' care sheets, and ensure all straps were connected properly prior to using the lift. Interview on 04/08/2025 at 1:32 p.m. with S4 CNA, revealed on 03/27/2025, she went into Resident #1's room to assist S3 CNA with transfer of the resident. S4 CNA stated the lift pad was already under Resident #1, but she could not recall the color of the lift pad. S4 CNA connected the lower straps to the lift, and S3 CNA connected the upper straps to the lift. S4 CNA stated that as S3 CNA moved the lift, Resident #1 fell out the right side of the sling and onto the floor. S4 CNA stated she had been trained on proper use of the lift, and had been checked off on the skill. S4 CNA stated two staff members were required to use and operate the lift. She was to refer to the residents' care sheets to determine the correct size lift pad for each resident. Interview on 04/08/2025 at 1:45 p.m. with S3 CNA, revealed prior to the incident, she had gotten Resident #1dressed and had put the lift pad, that was already in the room, underneath her for the transfer. S3 CNA stated she retrieved the lift and requested assistance from S4 CNA. S3 CNA stated that S7 CNA came into the room to wait for the lift. S3 CNA stated she connected the top straps of the lift pad to the lift, and S4 CNA connected the bottom straps of the lift pad to the lift. S3 CNA stated she lifted Resident #1, and was guiding the sling to the chair when Resident #1 slid out of the sling and onto the floor. S3 CNA stated she thought the straps were hooked to the lift correctly at the time of transfer. S3 CNA stated she was to look at the resident's wall care sheet to identify what color/size sling they were to use for transfer. S3 CNA stated she did not look at the wall care sheet to determine the correct sling size, but instead used the sling that was already in Resident #1's room. She did not remember what size sling was used for the transfer. Interview on 04/08/2025 at 3:05 p.m. with S2 DON, revealed she was on vacation at the time of the incident, but had been notified by S1 ADM. S2 DON ensured all staff were trained on use of lifts since the incident. S2 DON stated all existing staff had been in-serviced, and new staff were trained upon hire. Nurses were to monitor CNAs to ensure correct lift pads and lift technique were utilized. Interview on 04/09/2025 at 9:45 a.m. with S1 ADM, revealed on 03/27/2025 she was notified that Resident #1 had been sent to the hospital after falling while being transferred with a lift. Investigation by S1 ADM and S5 Clinical Coordinator revealed the correct sling size had not been used for the transfer and one of the sling straps was not correctly connected to the lift. The facility had implemented the following actions to correct the deficient practice: 1. On 03/27/2025, the administrative team began in-servicing all CNAs and nurses on proper lift technique and correct sling use. The in-services were completed on 04/05/2025. 2. On 03/27/2025, the administrative nursing team began checking-off all CNAs and nurses on the lift and slings, using return demonstration technique. The check-offs were completed on 4/5/25. 3. On 03/27/2025, all lifts were inspected by the assistant administrators to ensure they were in safe working order. 4. On 03/28/2025, S3 CNA and S4 CNA received individual counseling and in-service. Skills check-off was completed, with follow-up questions, to ensure complete understanding. 5. Beginning 03/28/2025 and continuing x 7 days, S3 CNA and S4 CNA were to ensure a nurse was present during any transfer of a resident with a lift. The nurse completed a check-off sheet, documenting use of the correct sling size and correct connection of the sling to the lift. 6. On 03/28/2025, S2 ADON ensured all residents requiring use of the Vander-Lift had the correct sling size indicated on the care sheet in their room. To provide additional clarification, the size/color of sling to be used was added to each order for the Vander-Lift which was completed on 03/28/2025 7. On 03/31/2025, the housekeeping supervisor checked all the slings in the building, ensuring they were not frayed or torn, and were in good working condition. Completed on 03/21/2025. 8. On 03/31/2025 the medical equipment company inspected all lifts in the facility to ensure they were in safe use. 9. On 03/31/2025 S1 ADM provided an in-service to all Laundry staff regarding proper laundering of lift slings. 10. On 04/07/2025 the Assistant Administrator ensured all resident rooms provided enough space for safe transfer with a lift. 11. On 03/28/2025 the DON or designee will begin to monitor a random sample of residents being transferred with a lift to ensure the correct procedure was followed. This monitor will be completed 3x a week for 6 weeks, and then monthly until compliance is reached. Any noncompliance will be addressed. 12. On 03/28/2025 The DON or designee will begin to monitor, ensuring any lift sling in a resident's room was the correct size for the resident. This monitor will be completed on a random sample of residents with lift orders 3x a week for 6 weeks, and then monthly until compliance is reached. Any noncompliance will be addressed. 13. Administration was responsible for oversight of all the implemented actions, which would be reviewed during the weekly Quality Meeting for 6 weeks. As of 03/27/2025 and once the above interventions were all implemented, the past noncompliance was considered to be corrected.

Based on interviews and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene by failing to provide incontinence care for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents. Findings: Record review revealed Resident #2 was admitted on [DATE] with diagnoses including Traumatic Subdural Hemorrhage with Loss of Consciousness, Muscle Wasting and Atrophy, Overactive Bladder, and Lack of Coordination. Review of Resident #2's Significant Change Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 02/21/2025 revealed, in part, a Brief Interview for Mental Status (BIMS) score was not conducted as resident was rarely or never understood. The resident was dependent for toileting hygiene. Toilet transfer was not attempted due to the resident's medical condition or safety concerns. Resident #2 was always incontinent of urine. Review of Resident #2's current physician orders revealed, in part, an order dated 10/25/2024 for incontinence care, indicating Resident #2 was to be checked for incontinence at least every 2 hours. Review of Resident #2's current care plan revealed, in part, bladder incontinence with a diagnosis of Overactive Bladder. Interventions included, in part, 2-person assist with incontinence care, incontinence care every 2 hours and as needed, and to keep skin clean and dry. Review of the facility's Record of Complaint dated 01/14/2025 at 1:00 p.m. revealed, in part, on 01/13/2025 Resident #2 did not receive incontinence care from 10:40 a.m. until 6:44 p.m. Review of the facility's Personnel Action form dated 01/14/2025 revealed, in part, S9 CNA was counselled because she failed to provide incontinence care for Resident #2 from 11:00 a.m. until 3:00 p.m. Review of the facility's Personnel Action form dated 01/14/2025 revealed, in part, S8 CNA was counselled because she failed to provide incontinence care for Resident #2 from 3:00 p.m. until 6:44 p.m. An interview was conducted on 04/08/2025 at 2:50 p.m. with S2 DON who confirmed Resident #2 did not receive incontinence care on 01/13/2025 from 10:40 a.m. until 6:44 p.m. S2 DON confirmed Resident #2 should have received incontinence care at least every 2 hours, but did not.

Based on observation and interview the Facility failed to maintain a clean, sanitary environment and ensure food was served in accordance with professional standards for food service safety. Findings: Review of the facility policy titled: Storage: Freezer with no review date revealed in part .Keep all frozen foods tightly wrapped or packaged to prevent freezer burn. Observation on 07/29/2024 at 8:30 a.m. of the walk in freezer/cooler revealed: 1. 1 box of corn dogs open to air and undated. 2. 1 bag of biscuits open to air. 3. 1 bag of squash open to air and undated. 4. 1 bag of breadsticks open to air. Interview at the time of observation with S4 DM revealed the staff who opens a food item should label and date it and store it properly. S4 DM confirmed: The above listed items were not dated and were opened to air.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development of communicable diseases and infections by failing to: 1. Ensure the use of Enhanced Barrier Precautions (EBP) was communicated to staff for 4 (#6, #28, #80, and #283) of 4 (#6, #28, #80, and #283) Residents reviewed for Enhanced Barrier Precautions; and 2. Perform proper hand hygiene during wound care for 1 (#283) of 2 (#6 and #283) residents reviewed Findings: 1. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP) Information And Plan with no date, revealed the following, in part: 1. Residents who will be affected by Enhanced Barrier Precautions (EBP) guidelines include residents who have the following: .chronic wound requiring a dressing regardless of the MDRO status .7. CMS has published an Enhanced barrier Precautions (EBP) sign for providers and staff to be aware of who should be on these precautions. Please place this sign on the resident's door and write the residents' room and bed assignment on the sign .8. PPE should be kept in individual towers located right outside the resident's room . Resident #6 Review of Resident #6's Physician orders dated 07/29/2024 read in part: Cleanse pressure ulcer to sacrum with wound cleaner, pat dry, apply Silvasorb and collagen and cover with border gauze every day until resolved. Observations on 07/31/2024 around 2:00 p.m. of Residents #6's room revealed no EBP signage on the door or PPE outside of the room indicating the required use of EBP when providing high-contact resident care activity. Resident #28 Review of Resident #28's Physician orders dated 07/26/2024 read in part: Cleanse pressure ulcer to right heel lateral with wound cleaner, pat dry, paint with betadine then cover with border gauze every day until resolved. Observations on 07/31/2024 around 2:00 p.m. of Residents #28's room revealed no EBP signage on the door or PPE outside of the room indicating the required use of EBP when providing high-contact resident care activity. Resident #80 Review of Resident #80's Physician orders dated 07/23/2024 read in part: Cleanse diabetic ulcer to 2nd toe on right foot with wound cleaner, pat dry, apply Santyl to slough, apply calcium alginate to granulation, cover with foam, last secure with tape every day until resolved. Observations on 07/31/2024 around 2:00 p.m. of Residents #80's room revealed no EBP signage on the door or PPE outside of the room indicating the required use of EBP when providing high-contact resident care activity. Resident #283 Review of Resident #283's Physician orders dated 07/30/2024 read in part: Cleanse pressure ulcer to left buttock with wound cleaner, pat dry, first apply collagen to wound bed and cover with bordered gauze, second apply Clotrimazole 1% to peri-wound rash, apply zinc to peri-wound rash and leave open to air every other day until resolved. Observations on 07/31/2024 around 2:00 p.m. of Residents #283's room revealed no EBP signage on the door or PPE outside of the room indicating the required use of EBP when providing high-contact resident care activity. An interview on 07/31/24 at 12:55 p.m. with S7 RN/Infection Preventionist, revealed Enhanced Barrier Precautions were not used on Resident #6, #28, #80 and #283. She stated that she was not aware that Enhanced Barrier Precautions were required for residents with pressure ulcers, venous stasis ulcers or diabetic foot ulcers. 2. 46773 Resident #283 Review of the Facility's undated policy on 07/31/2024 titled Dressing Changes (Sterile/Clean) read in part Procedure: 7: wash hands and apply clean, non-sterile gloves 13: Clean wound with prescribed solution and sterile gauze, swabs, or irrigation system as ordered 14: remove soiled gloves and wash hands or use alcohol gel. 15: Put on new pair of gloves and apply any gels or ointments. Apply primary dressing, cover with secondary dressing and secure with tape if needed or dressing, cover with secondary dressing and secure with tape if needed or dress as ordered by MD. 16: Remove gloves and discard in red bag. Wash hands Review of Resident #283 medical records revealed a admitted [DATE] with diagnoses that included: Pressure ulcer to left buttocks, Hemiplegia and hemiparesis following Cerebral Infarction, Type 2 Diabetes Mellitus, Anxiety Disorder, and Congestive Heart Failure. Review of Resident #283's 07/2024 Physician Orders revealed: 07/30/2024- Cleanse pressure ulcer to left buttocks with wound cleanser, pat dry, first apply collagen to wound bed and cover with a bordered gauze, second apply clotrimazole 1% to periwound rash, third apply zinc to periwound rash and leave open to air every other day until resolved. 07/23/2024 Cleanse puncture wound to right calf with wound cleanser, pat dry, apply hydrogel with silver, apply collagen and wrap loosely with kerlix Q day until resolved. 07/30/2024 Cleanse Hematoma to left lower calf with wound cleanser, pat dry, apply medihoney, cover with ABD pad, wrap loosely with kerlix every other day until resolved. Observation of wound care for Resident #283 on 07/31/2024 at 9:30 a.m. revealed. S5 LPN/Treatment Nurse removed old dressing to lower leg open hematoma wound, discarded dressing then reached over the clean field without changing soiled gloves or sanitizing hands, removed a 4x4 gauze, and cleansed the lower left leg hematoma wound. S5 LPN/Treatment nurse then reached over the clean field without changing gloves and removed a 4x4 gauze and cleansed the puncture wound to Resident #283's left leg. S5 LPN/Treatment Nurse was observed removing Resident #283's left buttocks wound dressing, reaching over the clean filed with soiled gloves, grabbed 4x4 gauze and cleaned the left buttocks without changing gloves and sanitizing hands. Interview on 07/31/2024 at 10:00 a.m. S5 LPN/Treatment Nurse confirmed she did not remove gloves and sanitize hands after removing the soiled dressing for each wound. S5 LPN/Treatment Nurse confirmed she should not have used the same gloves while providing wound care to 2 different wounds.

Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (#56) of 1 sampled Resident with MDS record over 120 days old. Findings: Review of the clinical record for Resident #56 revealed the Resident was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Essential Hypertension, and Hemiplegia and Hemiparesis following cerebral infarction affecting right dominant side. Review of Resident #56's Quarterly MDS Assessment with ARD of 06/26/2024 revealed the assessment had been completed. Review of the facility's MDS transmission reports revealed Resident #56's Quarterly Assessment with ARD of 06/26/2024 had been transmitted on 07/31/2024. Interview on 07/31/2024 at 8:51 a.m. with S6 LPN/MDS Nurse revealed she forgot to notify the ADON to close and transmit the 06/26/2024 Quarterly MDS. S6 LPN/MDS Nurse confirmed the Quarterly MDS assessment had not been transmitted timely and should have been.

Based on observation, interview, and record review, the facility failed to ensure Residents who are unable to carry out ADL's (Activities of Daily Living) received the necessary services to maintain good grooming for 1(Resident #62) of 2 (Resident #38 and Resident #62) Residents reviewed for ADL's. The facility failed to ensure Resident #62 received a shave. The total Sample Size was 38. Findings: Review of the facility policy titled: Hygiene and Grooming with no review date read in part . Policy: Staff will provide resident with whatever assistance is necessary to keep their facial hair properly groomed. Review of Resident #62's Electronic Health Record revealed Resident #62 was admitted to the facility on [DATE]. Resident #62 had diagnoses that included in part .Acquired Absence of Left Leg, Cognitive Communication Deficit, Phantom Limb Pain and Dementia. Review of Resident #62's Quarterly MDS with ARD of 05/21/2024 revealed Resident #62 had a BIMS score of 8 (moderately impaired cognition). Resident #62 required Substantial/Maximal Assistance from staff for Toileting, Showering/Bathing, and Personal Hygiene. Review of Resident #62's Care Plan with a review date of 08/08/2024 revealed in part .Self-care ADL deficit: Resident will receive person-centered care; needs assist with bathing, hygiene, dressing and grooming related to Left Above The Knee Amputation, Dementia. Interventions included: Assist with hygiene, dressing, and grooming as needed. Observation and interview on 07/29/2024 at 9:15 a.m. with Resident #62 revealed facial hair approximately half an inch long. Resident #62 revealed he had asked staff to shave him last week, but staff never did. Observation on 07/30/2024 at 8:43 a.m. revealed Resident #62 with facial hair approximately half an inch long. Observation and interview on 07/30/2024 at 11:45 a.m. revealed Resident #62 with facial hair approximately half an inch long. Resident #62 stated he was supposed to be shaved on his shower days. Interview on 07/30/2024 at 2:30 p.m. with S2 CNA revealed she provided care for Resident #62 on the 7:00 a.m. to 3:00 p.m. shift. S2 CNA revealed Resident #62 had received a complete bed bath on the shift before her. S2 CNA revealed she had not provided any grooming for Resident #62 on her shift. Interview on 07/30/2024 at 2:40 p.m. with S3 LPN revealed the CNA's are responsible for providing and documenting ADL care for Residents, and the nurse is responsible for monitoring the tasks. Observation and interview on 07/31/2024 at 8:30 a.m. revealed Resident #62 with facial hair approximately half an inch long. Resident #62 stated I cleaned myself up, but I still need a shave. Observation and interview on 07/31/2024 at 8:40 a.m. with S1 DON in attendance revealed Resident #62 with facial hair approximately half an inch long. Resident #62 stated he would have liked to be shaved. S1 DON confirmed Resident #62 had not been shaved and had long facial hair.

Based on observation, interview and record review, the facility failed to ensure resident care equipment was kept clean for 1 (#61) of 3 residents (#17, #61 and #77) reviewed for tube feeding. There was a total of 12 residents in the facility who received tube feedings. The total sample was 25 residents. Findings: Review of Resident #61's Physician Orders dated 06/2023 revealed an order for Glucerna 1.5 at 50 ml/hour continuous feeding via pump. Observation on 06/12/2023 at 9:15 a.m. revealed Resident #61's feeding pump was in use and noted to be dirty with sticky tan colored substance. Observation on 06/12/2023 at 11:57 a.m. revealed Resident #61's feeding pump was in use and noted to remain soiled with sticky tan substance. Observation on 06/13/2023 at 8:37 a.m. revealed Resident #61's feeding pump was in use and remained soiled with yellow/tan sticky substances. Observation on 06/13/2023 at 11:45 a.m. revealed Resident #61's feeding pump was in use and remained soiled with yellow/tan sticky substance. Interview with S2 RN on 06/13/2023 at 3:48 p.m. revealed that nurses and housekeeping staff were responsible for keeping residents' feeding pumps clean. She reported that if a nurse soiled the pump, it should be cleaned by that nurse. She confirmed that the feeding pump in Resident #61's room was dirty and should have been cleaned.

Based on observation, record review, and interview the facility failed to implement the plan of care to meet the needs of 1 (#33) out of a total of 25 sampled residents by failing to assist resident with meals and provide Ensure with meals as ordered by the physician. Findings: Review of Resident #33's Electronic Health Record revealed an admitted [DATE] with diagnoses that included in part .Moderate Protein-Calorie Malnutrition, Abnormal Weight Loss, Personal History of Traumatic Brain Injury and Flaccid Hemiplegia affecting Left Non-dominant Side. Review of Resident #33's Quarterly MDS with ARD of 01/27/2023 revealed Resident had a BIMS score of 3 (severely impaired cognition). Resident required extensive assistance, by two person physical assist with bed mobility, transfers, toileting, and 1 person physical assist with dressing, eating, and personal hygiene. Resident had upper and lower extremity range of motion impairment on left side. Resident required a mechanically altered, therapeutic diet. Review of Resident #33's Care Plan Review revealed in part . Potential for Altered Nutrition and Dehydration. Interventions: Must be fed at all times. Pureed NSOT Diet, with thin liquids, and double portions of meat and eggs. Up to dining room for all meals. One bottle Ensure on tray, three times daily, with all meals. Review of Resident #33's June 2023 Physician Orders revealed in part . One bottle Ensure on tray, three times daily, with all meals. Feeder at all meals. Pureed NSOT diet, with thin liquids. Double portions of meat and eggs. Up in dining room for all meals. Interview and observation on 06/13/2023 at 8:49 a.m. with Resident #33 revealed she was sitting up in bed, with breakfast tray on bedside table over bed. Resident #33 stated she fed herself this morning. Breakfast tray observed with approximately 25% of meal consumed. Resident stated the CNA did not assist her with meal this morning, and she did not receive a bottle of Ensure with breakfast. Interview on 06/13/2023 at 9:13 a.m. with S3 LPN and S4 CNA in Resident #33's room, revealed Resident had orders to receive Ensure with meals, and was to be fed at all meals. S4 CNA stated Resident liked to feed herself, and Resident did not always allow her (S4 CNA) to feed her. S4 CNA stated she did not assist Resident this morning with breakfast, and the Resident did not receive a bottle of Ensure with meal. S3 LPN confirmed the Resident should be up to the dining room, fed at all meals, and have a bottle of Ensure with all meals according to the plan of care, but had not. Interview on 06/14/2023 at 12:20 p.m. with S5 LPN revealed she was responsible for Resident #33's Care Planning. S5 LPN stated Resident was care planned to be assisted with all meals. S5 LPN stated Resident #33 had orders to be fed and up to the dining room for all meals, and was to have Ensure with all meals. Interview on 06/14/2023 at 12:26 p.m. with S1 ADON revealed Resident #33 had orders for: feeder at all meals, up to the dining room for all meals, and a bottle of Ensure with all meals. S1 ADON confirmed the Physician Orders had not been followed, but should have been.

Based on observation and interview the Facility failed to ensure Residents had a safe, clean, comfortable and homelike environment for 3 (Resident #2, Resident #4 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled Residents. Findings: 1. Observation on 04/12/2023 at 8:01 a.m. revealed Resident #2 sitting on her bedside commode. Resident #2's room was cluttered with equipment. The chair in her room was filled with clothing and there were wheelchair foot rests laying on top of the clothing. There was another bed in Resident #2's room. This bed was unmade and had a walker propped against it and position wedges lying on top. Resident #2 stated she did not use any of the equipment on top or on the side of the bed. Review of Resident #2's EHR revealed an admitted [DATE]. Resident #2 had the following diagnoses which included: Displaced Fracture of Olecranon Process without Intra-articular Extension of Right Ulna, subsequent encounter for Closed Fracture with routine healing; Other Lack of Coordination; Severe Morbid Obesity; and Muscle Wasting and Atrophy. Review of Resident #2's Quarterly MDS with an ARD of 03/10/2023 revealed Resident #2 had a BIMS Score of 10 (moderately impaired cognition). Interview on 04/12/2023 at 9:23 a.m. with S4 RN confirmed Resident #2 had an extra unmade bed in her room. She stated Resident #2 was a private pay and the other bed would not be used. S4 RN confirmed the bed should be made or moved out of Resident #2's room. 2. Observation on 04/11/2023 at 8:41 a.m. revealed Resident #4 sitting up in bed with oxygen in progress. There was another bed in Resident #4's room which was unmade and had boxes and clutter on top. Resident #4 stated she did not have a roommate. Observation on 04/11/2023 at 12:00 p.m. revealed Resident #4 sitting in bed eating. Resident #4's room had another bed that was not made, with boxes noted on top. Observation on 04/11/2023 at 1:15 p.m. revealed Resident #4 asleep in bed. The spilt liquid noted earlier had been cleaned, but the other bed in room remained as previously noted. Observation on 04/11/2023 at 3:04 p.m. revealed Resident #4 asleep in bed. The other bed in the room remained unmade with clutter noted on top of the mattress Observation on 04/12/2023 at 8:00 a.m. revealed Resident #4 asleep in bed. The extra bed in Resident #4's room remained unmade with boxes and clutter on top of the mattress. Review of Resident #4's EHR revealed an admitted [DATE]. Resident #4 had the following diagnoses including: Other Polyosteoarthritis; Morbid Obesity; History of Falling, Other lack of coordination; and Muscle Wasting & Atrophy. Review of Resident #4's Quarterly MDS with an ARD of 02/20/2023 revealed Resident #4 had a BIMS score of 8 (moderately impaired cognition). Interview on 04/12/2023 at 9:23 a.m. S4 RN confirmed Resident #4 had an extra unmade bed in her room. She stated Resident #4 was private pay and the other bed will not be used. She confirmed the bed should be made or moved out of the Resident #4's room. 3. Observation on 04/11/2023 at 9:00 a.m. revealed Resident #5 sitting on the side of her bed in her gown. There were clothes scattered all over the floor and a trash bag half filled with soda cans. Observation of the bottom of the window in Resident #5's room revealed ragged edged exposed brick. Resident #5's bed was against the exposed window sill. Resident #5 stated it had been out for about 2 weeks. Resident #5 stated Staff told her the window sill would be fixed, but it had not. She stated there were holes exposed and the edges were rough. Review of Resident #5's EHR revealed an admitted [DATE]. Resident #5 had the following diagnoses including: Weakness; and Encounter for other specified aftercare. Review of Resident #5's 5 day MDS with an ARD of 02/16/2023 revealed Resident #5 had a BIMS score of 15 (cognitively intact). Review of the Facility Maintenance Log revealed the broken window sill had been reported on 03/30/2023. Interview on 04/11/2023 at 3:46 p.m. with S1 Administrator revealed Resident #5 had told her about the broken window sill today and S2 Assistant Administrator had fixed it today. S1 Administrator stated she was unaware of the problem prior to today. S1 Administrator stated she did not have a maintenance man at this time and S2 Assistant Administrator was filling in until one could be hired. Interview on 04/12/2023 at 7:54 a.m. S1 Administrator revealed she had not had a maintenance man in the Facility for 3 weeks. S1 Administrator confirmed the broken window sill had been reported in the Facility Maintenance Log book on 03/30/2023. Interview on 04/12/2023 at 9:26 a.m. with S1 Administrator revealed she had not contacted Corporate office for assistance with building maintenance. S1 Administrator stated that she thought she had someone coming to work in maintenance and felt S2 Assistant Administrator would be able to handle it. S1 Administrator stated S2 Assistant Administrator missed it (referring to the window sill repair). Interview on 04/12/2023 at 9:45 a.m. with S2 Assistant Administrator revealed he did not know about the window sill in Resident #5's room until yesterday when S1 Administrator told him. S2 Assistant Administrator stated he completely missed it. S2 Assistant Administrator stated that S6 LPN had reported Resident #5's broken window sill in the maintenance log book on 03/30/2023. S2 Assistant Administrator stated S1 Administrator was on vacation last week and he had not checked the maintenance log book. S2 Assistant Administrator stated he had been trying to assist with building maintenance since the Facility did not have a maintenance person on staff. S2 Assistant Administrator confirmed his job title as Assistant Administrator.

Based on observation and interview the Facility failed to resolve Residents/Responsible Parties complaints/grievances for 1 (Resident #1) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled Residents. Findings: Review of the Facility's Grievance Procedure revealed the following: Purpose: The primary purpose of this grievance procedure is to support each resident's right to voice grievance or complaint about treatment, care, management of funds, lost clothing, or violation of rights and to assure that after receiving a complaint/grievance, the facility actively seeks a resolution and keeps the resident/family appropriately apprised of its progress toward resolution. Policy Interpretation and Implementation: Prompt effort should be made by facility staff to resolve the complaint/grievance. The resident/family should be appropriately appraised of the resolution or progress toward resolution either verbally or in writing. Review of Resident #1's EHR revealed an admitted [DATE]. Resident #1 had the following diagnoses in part Other Specified Depressive Episodes; Generalized Anxiety Disorder; Other Alzheimer's Disease; Dementia in other Disease Classified elsewhere without behavioral disturbance; and Altered Mental Status. Review of Resident #1's Care Plan with target date of 06/29/2023, revealed a problem of Self Care Deficit, potential: resident will receive person-centered care - bathing, hygiene, dressing & grooming r/t dementia/pain. Review of Resident #1's Significant Change MDS with ARD of 03/15/2023 revealed the following including: Section C - Cognitive Pattern - Resident #1 had a BIMS score of 6. Section G - Functional Status - Resident #1 required 1 person physical assist with dressing, toilet use, personal hygiene, and bathing. Section H - Bladder & Bowel - Resident #1 was frequently incontinent of urine and bowel. Review of Resident #1 04/2023 MD Orders revealed the following in part . 01/19/2023 - Incontinence care: Check for incontinence at least q 2 hours. Review of Facility's 01/2023 - 04/2023 Grievance Forms revealed there were no grievances noted concerning Resident #1. Observation on 04/11/2023 at 11:52 a.m. revealed Resident #1's daughter who was in the room with Resident #1, pulled Resident #1's shoe from under a bedside table. Stool stains were noted on Resident #1's shoe. Resident #1's daughter stated she had gone to a doctor's appointment with Resident #1 in 02/2023 and had been so embarrassed because there was stool on Resident #1's shoes and clothes. Resident #1's daughter stated she had reported this information to the nurse upon return to the Facility after the MD visit, but she was unable to remember who she talked to about Resident #1's clothing and shoes. Interview on 04/12/2023 at 9:31 a.m. with S1 Administrator in Resident #1's room confirmed there was stool on Resident #1's shoes. S1 Administrator stated she was not aware of any issues or grievances r/t Resident #1. S1 Administrator stated she would have Resident #1's shoes cleaned as soon as possible. S1 Administrator stated she would find out who the nurse was on duty when Resident #1 returned from her MD appointment. Interview on 04/12/2023 at 10:08 a.m. with S5 LPN revealed she did not remember Resident #1's daughter talking to her about the stool on Resident #1's shoes or clothing. S5 LPN stated Resident #1's daughter had talked to her about a lot of things including her mother being in the same clothes, bed being dirty and her pad being wet, but these things were fixed immediately and she did not feel a grievance needed to be written. Interview on 04/13/2023 at 8:07 a.m. with S1 Administrator revealed Staff should complete a grievance/complaint form if a family member/Resident was upset about something. Interview on 04/13/2023 at 8:34 a.m. with S3 DON revealed if there was an urgency or a Resident/Family was upset, Staff should complete a grievance/complaint form. S3 DON stated if a Resident or RP complained about a bed being dirty or a Resident wearing the same shirt 2 days in a row, Staff should complete a grievance/complaint form so that the issue could be monitored and steps could be put in place to prevent further problems.

Based on interview and record review the facility failed to ensure residents' rights to be free from physical and psychosocial abuse. The facility failed to ensure 1 (Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents was not physically abused by S4 CNA. This deficient practice resulted in an Actual Harm for Resident #5 that began on 02/01/2023, when S4 CNA struck Resident #5, a severely cognitively impaired Resident, multiple times with an electronic bed remote and a white, plastic coat hanger. Resident #5 experienced psychosocial harm in that he reported not feeling safe, a worsening fear of being hurt again, and increased anxiety resulting in an increase in Ativan (an anti-anxiety medication). Resident #5 received First Aid treatment in the facility for a left scalp laceration and abrasion to the left chest after the incident. Bruising was also noted to Resident #5's right hand. Resident #5 was sent out to a local ED for further evaluation after receiving First Aid. The facility implemented corrective actions which were completed prior to the State Agency's Investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of facility policy titled Abuse/Neglect Policy Statement revealed in part . Each resident residing in this Facility has the right to be free from verbal, sexual, mental and physical abuse, including corporal punishment and involuntary seclusion, and use of photographs or recordings in any manner that would demean or humiliate a resident (s). Residents must not be subjected to abuse by anyone, including, but not limited to, Facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. Each resident also has the right to be free from mistreatment, neglect and misappropriation of property. Review of Resident #5's clinical record revealed an admitted [DATE] with diagnoses that included: Cerebrovascular Accident, Paroxysmal Atrial Fibrillation, Seizures, Contracture of left hand, and Paralytic gait. Review of Resident #5's Quarterly MDS Assessment with an ARD of 12/05/2022 revealed Resident #5 had a BIMS score of 99 (unable to complete interview); did not exhibit physical or verbal behaviors directed toward others; required the extensive assistance of 2 or more persons for toileting, bed mobility and transfers; and had upper and lower extremity ROM (Range of Motion) limitation on one side. Review of Resident #5's Comprehensive Person Centered Plan of Care revealed a problem of: Requires hospice services for a diagnosis of CVA, Anxiety and Fear related to Actual Physical Abuse 02/01/2023. Interventions included: schedule psychiatric visits as ordered, assess for changes in mood and/or demeanor status, assess effectiveness of antianxiety medication therapy, and daily head to toe assessment x 2 weeks. Review of a facility incident report documented by S3 LPN revealed that on 02/01/2023 at 7:45 p.m., S3 LPN and S5 CNA heard someone yelling help me. S4 CNA was observed standing in the hallway near Resident #5's room and proceeded to go in. S4 CNA then asked S5 CNA to go in the room with her. S5 CNA came back shortly and reported to S3 LPN that Resident #5's head was bleeding and he had blood on his pillowcase. S5 CNA stated when S4 CNA attempted to remove the pillowcase Resident #5 swung at S4 CNA. S3 LPN went into Resident #5's room and noted the following injuries. 1. Top of left scalp; 3cm x 0.5cm small bloody drainage 2. Left clavicle area; V shaped abrasion 1cm x 2cm 3. Right hand between index finger and thumb; bruise 1cm x 0.1cm Observation on 03/13/2023 at 11:51 a.m. revealed Resident #5 sitting up in bed eating his lunch. A contracture was observed to Resident #5's left hand with a hand-roll in place. Interview on 03/13/2023 at 11:51 a.m. revealed Resident #5's speech was slow with delayed thought process, but responded appropriately with good when asked how he was feeling. Interview on 03/13/2023 at 12:07 p.m. with Resident #5 regarding the incident from 02/01/2023 revealed a worker had beat him. Resident #5 was unable to give the name of the employee or recall the date of the event. When asked what he meant by beating him, Resident #5 held up his bed remote and stated she beat me with it and pointed to the left side of his forehead. Resident #5 also stated and a coat hanger, til she broke it, but I blocked it while holding his right hand up with palm open and making blocking motions. Resident #5 also stated the Sheriff Department had come to the facility. Resident #5 shook his head no when asked if he was afraid to be in or stay at the facility. Resident #5 shook his back and forth and said no when asked if hospice workers had ever hit or been mean to him. Resident #5 shook his head back and forth and said no when asked if the employee that hit him still worked in the facility. Interview on 03/13/2023 at 2:51 p.m. with S5 CNA revealed she worked the 3:00 p.m. to 11:00 p.m. shift on 02/01/2023 on Hall E. S5 CNA stated that around 7:30 p.m. she went into Resident #5's room to assist S4 CNA. S5 CNA stated that when she entered the room Resident #5 was swinging at S4 CNA. S5 CNA stated S4 CNA was standing next to Resident #5's bed, but not touching the Resident. S5 CNA stated she left the room to get S3 LPN to come in and try to calm Resident #5 down. S5 CNA stated S3 LPN came in and asked Resident #5 what was wrong, but Resident #5 did not respond. S5 CNA stated S3 LPN then left the room and she proceeded with assisting S4 CNA reposition Resident #5. S5 CNA stated as she turned Resident #5 she noticed blood on his pillowcase and left side of his head. S5 CNA stated she immediately placed the Resident back onto his back and left the room to get S3 LPN. S5 CNA stated S3 LPN came in and checked Resident #5's head. S5 CNA stated Resident #5 had a strange look on his face and kept rubbing her hand. S5 CNA stated as S4 CNA approached Resident #5's bed he kept saying don't touch me. Telephone interview on 03/14/2023 at 8:36 a.m. with S3 LPN revealed she worked the 7:00 p.m. to 7:00 a.m. shift on 02/01/2023 on Hall E. S3 LPN stated that around 7:30 p.m. on 02/01/2023 she was outside a room on Hall E pouring nighttime medications. S3 LPN stated S5 CNA approached her at the cart and said that Resident #5 had blood on his pillowcase and Resident #5 had swung at S4 CNA, and wouldn't allow S4 CNA to change it. S3 LPN stated she told S5 CNA to leave the resident alone and she would come in and talk to him. S3 LPN stated that before she could go down to Resident #5's room S5 CNA came back to her and said that Resident #5's head was bleeding. S3 LPN stated she immediately went to the room and saw S4 CNA standing on the side of Resident #5's bed near the window. S3 LPN stated she asked Resident #5 what happened, and he turned to S4 CNA and stated she beat the s*#$ out of me. S3 LPN stated S4 CNA immediately interjected and stated who, not me. S3 LPN stated she then started checking Resident #5's head to assess his injury and noted a small cut. S3 LPN stated she told S5 CNA to stay with Resident #5, and she went up front to call the Administrator. S3 LPN stated after contacting the Administrator she returned to the room and observed S4 CNA with a trash bag going into the soiled utility room. S3 LPN stated S1 Administrator and S2 DON arrived shortly after and took over the investigation. S3 LPN stated she had never known Resident #5 to be mean or combative. Interview on 03/14/2023 at 10:50 a.m. with S2 DON revealed she received a call from S1 Administrator at 7:49 p.m. on 02/01/2023. S2 DON stated S1 Administrator told her S3 LPN had just called and told her a CNA had hit Resident #5. S2 DON stated she was told she needed to come back to the facility. S2 DON stated she returned at 8:00 p.m. and went to S1 Administrator's office. S2 DON stated she did not speak to S1 Administrator at that time because S4 CNA, S5 CNA and S3 LPN were in the Administrator's office when she arrived. S2 DON stated at that point she went to Resident #5's room to assess the Resident. S2 DON stated she noted a circular area of blood on the left side of Resident #5's forehead. S2 DON asked Resident #5 what happened and Resident #5 stated she beat my ass. S2 DON stated she asked Resident #5 where else he was hurting and Resident #5 held up his right hand and stated protecting myself. S2 DON stated she noted a purple line between Resident #5's thumb and pointer fingers on his right hand. S2 DON stated when she turned Resident #5 she noted blood on the back of his head and on his pillow. S2 DON stated she cleansed the area on Resident #5's scalp with wound cleanser to get a better look at the area, and noted a laceration. S2 DON stated while interviewing Resident #5 about how he was injured, Resident #5 stated her and kept saying remote. S2 DON stated she looked in the room for a television remote and could not find one and then Resident #5 stated bed remote. S2 DON stated Resident #5's bed remote was noted between the mattress and side rail. S2 DON stated she located the television remote and held up the bed remote and television remote, and asked Resident #5 which one. S2 DON stated Resident #5 pointed to the bed remote and made a hitting motion towards his head. S2 DON stated there was no blood present on the bed remote. S2 DON stated Resident #5 then said white hanger broken, hit me, broke it on me, press charges. S2 DON stated she then went to Resident #5's closet and noted white plastic hangers. S2 DON stated she asked Resident #5 where the hanger was and he looked over to the trash can next to his bed. S2 DON stated she then went over to the trash can and saw the can was empty and without a bag. S2 DON stated she walked out of Resident #5's room and asked S3 LPN if S4 CNA had taken trash out of the room and S3 LPN responded yes. S2 DON stated she then went to S1 Administrator's office and asked if she could bring S4 CNA to Resident #5's room to see if Resident #5 would identify her. S2 DON stated Resident #5 pointed at S4 CNA and stated yes when asked if S4 CNA was the person that had hit him. S2 DON stated she escorted S4 CNA back to the Administrator's office and proceeded to the Hall E hopper room to look for trash bags. S2 DON stated in the hopper room she observed a large white trash bag, commonly used on medication carts, with a small clear trash bag inside. S2 DON stated she opened the smaller trash bag and observed a white, plastic coat hanger that was broken in 3 pieces and a pillow case. S2 DON stated she brought the garbage bag with hanger and pillowcase to S1 Administrator's office. S2 DON stated she then escorted S4 CNA out of the building. Interview on 03/14/2023 at 11:49 a.m. with S1 Administrator revealed S3 LPN called her shortly before 8:00 p.m. on 02/01/2023, and told her that S4 CNA was in Resident #5's room and Resident #5 said she (S4 CNA) had beat him. S1 Administrator stated she asked S3 LPN if Resident #5 had any injuries and was told he had blood on his head. S1 Administrator stated she told S3 LPN not to clean any injuries, to wait until she and S2 DON got there. S1 Administrator stated she then called S2 DON and notified her of the accusation. S1 Administrator stated she returned to the facility and began obtaining statements from S4 CNA and S5 CNA. S1 Administrator stated S2 DON arrived shortly afterward and immediately went to Resident #5's room. S1 Administrator stated S2 DON returned to her office and told her what Resident #5 said S4 CNA had done to him. S1 Administrator stated S2 DON then left the office to check the trash in the soiled utility room, which is where she found the broken hanger. S1 Administrator stated S2 DON returned to the Administrative office with the garbage bag containing the broken clothes hanger and pillowcase. S1 Administrator stated S4 CNA continuously denied the allegation despite being identified by Resident #5 and the broken clothes hanger being retrieved from the trash. S1 Administrator stated S4 CNA was escorted out of the building by S2 DON on 02/01/2023, and terminated on 02/06/2023. S1 Administrator stated she then notified Resident #5's RP, PCP, hospice provider, and the local police department. S1 Administrator stated Resident #5 was sent to a local ED for evaluation that night. Review of the ED record for Resident #5 revealed in part .patient presents after report of head trauma. Assessment revealed a minimal superficial abrasion to the left temporal region. A CT Scan of Resident #5's head revealed negative for any intracranial hemorrhage, no acute findings. The ED record revealed the laceration does not need repair, stable for discharge. Resident #5 was discharged back to the Facility with no new orders. Review of Wound Assessments dated 02/02/2023 revealed the following: Laceration; forehead; scalp, left of midline. 3.00 x 0.50 x 0.10. Edges not well approximated, missing torn skin flaps. Sanguineous moderate drainage. Identified on 02/01/2023. Abrasion; left chest. 2.00 x 1.00 x 0.00. Red or darker pink, moderate irritation, No drainage. Identified 02/01/2023. Bruise; Right top of hand; in between thumb and pointer finger. 1.00 x 0.10. Dark purple/blue Identified 02/01/2023. Review of Resident #5's 02/2023 Treatment Administration Records revealed in part Cleanse laceration to left scalp with Derma Klenz, pat dry, apply TAO (Triple Antibiotic Ointment) and leave open to air q (every) day until resolved. Start 02/02/2023. Healed 02/14/2023. Cleanse abrasion to left chest wall with Derma Klenz, pat dry, apply TAO and leave open to air q day until resolved. Start 02/02/2023. Healed 02/08/2023. Monitor bruise right hand in between thumb and pointer finger for complications q day until resolved. Start 02/02/2023. Healed 02/08/2023. Review of a nurses' note dated 02/22/2023, and documented by S2 DON revealed Resident #5 expressed a fear of being hurt again, and had increased anxiety as reported by Psychiatric Nurse Practitioner. Plan to increase Ativan to 0.5mg to TID (was on BID) after RP is notified and agrees with plan. Hospice notified and reports will reach out to RP. Social worker with hospice will make visit with resident tomorrow. PCP notified. Review of Psychiatric NP note dated 02/22/2023 revealed in part Staff reports increase fearful, he isn't safe - anxious. Status worsening. Treatment Plan: increase Ativan 0.5mg per peg TID. Review of Resident #5's 02/2023 Medication Administration Record revealed Resident #5 received Ativan 0.5mg one tablet per peg tube three times per day starting on 02/28/2023, an increase from the Ativan 0.5mg 1 tablet per peg tube twice a day initially ordered on 08/11/2022. Attempts to contact S4 CNA via telephone was unsuccessful. The facility has implemented the following actions to correct the deficient practice: All staff were in serviced by the Administrator, Assistant Administrator and/or the DON on 02/01/2023- 02/06/2023 on the abuse policy which included: Review of our Abuse Policy, and the importance of reporting immediately to a charge nurse or supervisor when they observe any type of abuse. The in-servicing began immediately after becoming knowledgeable of the abuse on 02/01/2023. All interviewable Residents were interviewed regarding experiencing or witnessing abuse in the facility. All employees were interviewed regarding witnessing abuse in the facility and reporting abuse. All new hires will continue to be in-serviced upon hire to the facility. All staff will continue to have abuse training at least annually and for any non-compliance or suspected allegations of abuse. A QAPI monitor has been created to interview a random sample of Residents regarding abuse. This monitor will be completed by the Administrator or designee at least 3 times a week for 6 weeks then monthly for 2 months. A QAPI monitor has been created to interview a random sample of employees regarding abuse. This monitor will be completed by the Administrator or designee at least 3 times a week for 6 weeks then monthly for 2 months. Effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performance Improvement Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implemented if non-compliance or abuse is suspected or alleged. The Administrator will notify the Corporate Supervisor of the findings of the monitors weekly while the QAPI is in effect. The Administrator will also immediately notify the Corporate Supervisor with any suspected or actual abuse.

Based on record reviews, observations, and interviews, the facility failed to ensure cognitively impaired residents who were wanderers, and at risk for elopement were adequately supervised and not allowed to exit the building without staff knowledge, for 3 (#1, #2, and #3) of 5 sampled residents (#1, #2, #3, #4 and #5). The facility failed to: 1. Ensure Resident #1 who was severely impaired cognitively, and required supervision, was accurately assessed for a risk of elopement. Resident #1 exited the facility unsupervised on 01/07/2023 and eloped to a local pharmacy; 2. Ensure Resident #2, a severely cognitively impaired resident who wandered, was assessed as being at risk for elopement, wore a wander alert bracelet, and was on every one hour visual checks, was supervised according to her plan of care, and not allowed to exit the building and walk across a busy 3 lane street to a gas station on 01/14/2023; and 3. Ensure Resident #3, a severely cognitively impaired resident who wandered, was assessed as being at risk for elopement, wore a wander alert bracelet, and was on every one hour visual checks, was supervised according to her plan of care and not allowed to follow a resident out a door and exit the building without staff knowledge on 01/17/2023. This deficient practice resulted in an immediate jeopardy situation on 01/07/2023 at 2:21 p.m. when Resident #1 a severely cognitively impaired resident who was inaccurately assessed and required supervision exited the facility unsupervised, and walked through a busy parking lot to a local pharmacy. A staff member shopping at the pharmacy found Resident #1 arguing and cursing a pharmacy employee, and returned Resident #1 to the facility. On 01/14/2023 at 12:31 p.m. when Resident #2, a severely cognitively impaired resident assessed and care planned as an elopement risk, wore a wander alert bracelet and was on every one hour visual checks, exited the front door of the facility when a visitor entered the door code and opened the front door. The door alarm sounded, and staff reset the door alarm without investigating. Resident #2 walked across a 3 lane street to a gas station, got into the back seat of the car of 2 gas station customers and asked them to take her home. The gas station customers assumed Resident #2 was from the facility, called the facility and asked if they were missing Resident #2, and drove Resident #2 back to the facility at 12:37 p.m. On 01/17/2023 at 2:22 p.m., Resident #3, who rarely understands/rarely understood, assessed and care planned as an elopement risk, wore a wander guard bracelet, and was on every one hour visual checks, followed a resident out a door after he entered the code to the door, and exited the building without staff knowledge on 01/17/2023. At 2:28 p.m., S15 Housekeeper looked out the kitchen/dining room window and saw Resident #3 standing outside on the side of the building directly adjacent to a busy pharmacy parking lot. S15 Housekeeper escorted Resident #3 back into the building This deficient practice continued at a potential for more than minimal harm for the 13 Residents in the facility who were identified to require supervision, and/or were assessed as being at risk for elopement and wore a wander alert bracelet, (#1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, & #14). S1 Administrator was notified of the Immediate Jeopardy on 01/31/2023 at 6:25 p.m. The Immediate Jeopardy was removed on 02/01/2023 at 6:25 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews and observations that the Plan of Removal have been initiated and/or implemented: The Facility's plan to remove the immediate jeopardy situation included: In-services were initiated for all staff by the DON and Assistant Administrator on 01/31/2023 and 02/01/2023 and will be completed by 02/03/2023 at 5 pm. The in-service covered the existing policy on Wandering or Missing Resident which covers Code W, as well. Code W includes when a resident is missing, the staff will announce Code W and repeat it twice. The charge nurse will assign staff areas to begin looking for the resident. If not located in the building or grounds within 15 minutes, the charge nurse will notify the DON and Administrator to implement a plan to locate the resident. The in-service also addressed the use of the wander alert system and protocols to follow when the alarm sounds. Staff were reminded that a list of all residents with Wander Alert Bracelets is posted at each nurses' station, at the front desk and at the time clock. All staff were informed of who the 13 wanderers are and how often they should be checked. Staff were also in-serviced about the new Wander Alert Binder that was placed at each nurses' station. Staff unable to be in-serviced by 02/03/2023 at 5 pm will not be allowed to work until they are in-serviced. Any new employees will be in-serviced on the above during their orientation process. A QAPI monitor has been implemented to monitor whereabouts of all 13 residents with orders for Wander Alert Bracelets and are wearing wander alert bracelets. This monitor was started on 02/01/2023 at 8:30 am and will be completed by the ward clerk or designee every 30 minutes around the clock for 30 days, while the facility reviews all systems and procedures related to elopement precautions. The DON or designee will supervise and monitor daily during this 30 day period to ensure that ward clerk or designee are checking on whereabouts of all 13 residents. Residents will be supervised by direct care nursing staff according to their person-centered care plans. After Resident #1 left the building on 01/07/2023, she was reassessed by nursing staff and a wander alert bracelet was put in place and she was placed on one hour visual checks. After Resident #2 eloped on 01/14/2023, she was reassessed using the Wander Collection Tool on 01/16/2023. After Resident #3 eloped on 01/17/2023, she was reassessed using the Wander Collection Tool on 01/20/2023. On 02/01/2023, the Administrator placed a sign on all doors reminding visitors, family members, staff and residents to never let a resident out of the facility without checking with a nurse first. On 02/01/2023, the Administrator notified the responsible parties of each resident using our broadcast notification system. This notification addressed the importance of protecting all residents by not letting a resident out of the facility without first checking with a nurse as some of the residents have Wander Alert bracelets and are not allowed to leave the facility. On 02/01/2023, the Assistant Administrator changed the exit door codes on the Wander Alert System on each exterior door. When a resident with a Wander Alert Bracelet approaches the door, it will remain locked. If someone enters this new code and the resident is close to the door, the door will remain locked. If someone enters the new code, and the resident is farther away, the door will unlock but the alarm will sound if the resident with the Wander Alert Bracelet approaches the door or tries to go out the door. Only staff will have access to the codes to the front door as well as the smoking door which is located at the end of (Hall A). Dietary staff will have access to the code to the exterior door of the kitchen to allow access for deliveries. The Administrator, DON, and Assistant Administrator will be the only staff to have codes to all remaining doors which are located at the end of the 100 hall, on the side of the 100 hall, at the end of the 200 hall, at the end of the 300 hall, the side of the 400 hall and the dining room doors. On 02/01/2023, the Social Service Director made Wander Alert Binders to be placed at each nurses' station as well as the front desk. This binder contains the Wandering or Missing Resident policy, the list of residents with Wander Alert Bracelets along with their pictures and face sheets. On 02/01/2023, the DON placed a list of residents with Wander Alert Bracelets orders at each nurses' station, by the medication room door, at the front desk, and by the time clock. The Wander Data Collection Tool is completed by the MDS nurse upon admission, quarterly, and with a significant change in status. This tool has a scoring system indicating a resident has a Definite Risk for elopement with a score of 3 or more yes answers and is At Risk with 1-2 yes answers. Upon completion of the Yes/No answers on the front of the page, the nurse then summarizes her findings on the back of the page and determines the most appropriate intervention needed, if any. A resident may or may not need a Wander Alert Bracelet regardless of the findings from the yes/no questions, however, additional interventions are implemented based on the needs of the resident. Things considered when deciding on need for Wander Alert Bracelet include, but not limited to; their mobility, desire to leave the building and/or exit seeking behavior. The facility will choose the least restrictive measures as interventions. If deemed at risk, the IDT will discuss the most appropriate intervention. Beginning 02/01/2023, the treatment nurse during the week and the RN on the weekend or designees will check each door daily to ensure Wander Alert System is functioning properly. If there is a concern or problem, the nurse is to notify the Administrator or DON immediately and assign someone to sit by the door until appropriate repairs can be made. The treatment nurse during the week and the RN on the weekend or designees will continue to check each Wander Alert Transmitter daily with the Transmitter Testing Device to ensure proper functioning. If a transmitter fails to function properly, the nurse stays with the resident and replaces the Wander Alert Transmitter. Once replaced, the new transmitter will be checked for proper functioning. This process will continue indefinitely. Findings: Review of the facility's policy titled, Wandering or Missing Resident revealed in part . Policy: In an effort to prevent Residents from wandering away from the facility, procedures have been developed to follow when a resident leaves the facility unsupervised or without reporting to the facility staff their time of departure and time of return. Procedures: Resident Missing From Designated Area of Facility: 1. A department or resident care staff person which identified a wandering resident is missing must notify all staff of the missing resident by announcing on the public address system Code W, Resident's Name. Repeat twice. 2. The wandering resident's charge nurse shall assign direct care staff to look for the resident. 3. If the resident is not located in the buildings or the grounds within 15 minutes, the charge nurse shall notify the DON and the Administrator to implement the plan to locate the resident. 4. Any member becoming aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse, DON and the Administrator. 5. Notify the appropriate responsible party: 6. Documentation of the wandering resident: a. The care plan will be updated with diversions, approaches, and modifications that are specific to the resident's individual wandering habits. Resident #1 Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses that included in part . Unspecified Severe Dementia with Behavioral Disturbance, Major Depressive Disorder, Type 2 Diabetes Mellitus and a history of Urinary Tract Infection. Review of Resident #1's Wander Data Collection Tool dated 11/10/2022 revealed the following: Instructions: Scoring: 3 or more Yes answers = Definite Risk for elopement; 1-2 yes answers = At risk for elopement. The following 4 questions were answered yes for Resident #1: Is the resident cognitively impaired with poor decision-making skills (i.e. poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? Yes Does the resident have any visual, auditory, or communication deficits? Yes Does the resident have a diagnosis of dementia/Alzheimer's Disease, anxiety, depression, schizophrenia, OBS, delusions, or hallucinations? Yes Does the resident ambulate independently with or without the use of assistive devices (including wheelchair, scooter, walker, etc.)? Yes It was documented on the form Resident #1 had a BIMS score of 3 and based on summary of findings, Resident was not a wander/elopement risk Signed by S9 MDS and dated 11/10/2022. Review of Resident #1's Quarterly MDS with an ARD of 11/10/2022 revealed a BIMS score of 3, which indicated severely impaired cognition. The MDS revealed Resident #1 was independent with bed mobility, transferring, eating, and walking in room and corridor. Review of Resident #1's comprehensive plan of care revealed Resident #1 was not care planned for wandering or potential for prior to her elopement on 01/07/2023. In an interview on 01/30/2023 at 12:54 p.m., S6 CNA reported Resident #1 lit a cigarette in the dining room on 01/07/2023 so staff took her cigarettes away from her. S6 CNA stated Resident #1 then walked to the pharmacy next door to get some more cigarettes. S6 CNA stated one of the workers went over there for something else, saw Resident #1 and brought her back to the building. S6 CNA confirmed Resident #1 knew the door code because she was a smoker. In a telephone interview on 01/30/2023 at 2:26 p.m., S7 Laundry reported on her 30 minute break on 01/07/2023 she went to the pharmacy next door. S7 Laundry reported when she went to go check out, Resident #1 was at the register cursing loudly and arguing with the employee about getting some cigarettes. S7 Laundry reported she told Resident #1 she had her cigarettes and had to convince Resident #1 to come back to the facility with her. S7 Laundry confirmed she brought Resident #1 back into the facility and to her nurse, S8 LPN. S7 Laundry stated Resident #1 should not have been at the pharmacy unsupervised. In an interview on 01/30/2023 at 4:00 p.m., S8 LPN confirmed she did not know Resident #1 had left the building until S7 Laundry brought her back in. S8 LPN explained this happened on a Saturday and they didn't put the wander guard on until a few days later. S8 LPN confirmed Resident #1 should not have left the facility without assistance because Resident #1 was confused, and had a bad short term memory problem. S8 LPN stated Resident #1 was delusional and believed she worked in this facility for 4 years. S8 LPN reported after Resident #1 returned, staff just increased supervision. In an interview on 01/31/2023 at 1:53 p.m., S1 Administrator acknowledged Resident #1 walked to the local pharmacy without signing out or staff being aware Resident #1 had left the building. S1 Administrator stated that although Resident #1 had a BIMS of 3 and a diagnosis of Dementia, she did not consider this an elopement because Resident #1 had gone to the pharmacy in the past without supervision. S1 Administrator confirmed every one hour visual checks and a wander alert bracelet were not implemented for Resident #1 until 01/13/2023, after Resident #1's elopement on 01/07/2023. In an interview on 02/01/2023 at 9:54 a.m., S9 MDS confirmed she completed the wander data collection tool on 11/10/2022 for Resident #1. S9 MDS confirmed she marked the resident as not a wander/elopement risk although she had answered yes to 4 of the questions. S9 MDS confirmed the instructions stated 3 or more yes answers would equal definite risk for elopement, but felt like Resident #1 was not a risk for elopement. S9 MDS reported had she followed the instructions and marked Resident #1 as an elopement risk, then staff would have held a team meeting to decide if the Resident needed a wander alert bracelet. In an interview on 02/01/2023 at 10:48 a.m., the NP (Nurse Practitioner) reported she was not notified Resident #1 had left the building unsupervised until this week after the survey began. The NP reported prior to this week, she was only notified Resident #1 had lit a cigarette in the dining room so staff wanted to make Resident #1 an unsafe smoker and put a wander alert bracelet on Resident #1. The NP reported staff did not tell her that Resident #1 had left the building and went to pharmacy unsupervised, and brought it to her attention this week. The NP confirmed the Resident #1 was confused and unable to comprehend the reason the cigarettes were taken. The NP reported the facility put in a smoking schedule for Resident #1, but Resident #1 can't process that and keeps asking the NP to take her to smoke. The NP confirmed it was unsafe for Resident #1 to be out of the facility without staff's knowledge and supervision. Resident #2 Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses that included in part . Severe Dementia with Behavioral Disturbance, Schizophrenia, and Major Depressive Disorder. Review of Resident #2's Quarterly MDS with an ARD of 12/13/2022 revealed a BIMS score of 5, which indicated the resident had severely impaired cognition. The MDS revealed Resident #2 required supervision with set-up help only with bed mobility, transferring, toilet use and eating. The MDS revealed Resident #2 walked in room and corridor independently. Review of the Wander Data Collection Tool for Resident #2 revealed on 09/02/2022, Resident #2 was evaluated as having a BIMS of 3 and was evaluated as a wander/elopement risk with interventions listed as: frequent monitoring - check every 1 hour, identification bracelet, exercise, wander alert bracelet, 1 hour visual checks. Completed by S9 MDS. Resident #2 was reassessed using the tool again on 09/15/2022 and 12/16/2022 and deemed a wander/elopement risk with each assessment. Review of Resident #2's physician's orders revealed the following orders: 09/02/2022 - Wander alert bracelet on resident for elopement precautions at all times. Bracelet is located on resident's left ankle. 09/02/2022 - Check wander alert bracelet daily to ensure band is intact and transmitter is functioning properly. 09/02/2022 - Visual check for resident's location every 1 hour. 09/02/2022 - Admit under the care of Dr.________ and ____________ Hospice for diagnosis of Alzheimer's disease Review of Resident #2's comprehensive plan of care revealed Resident #2 was care planned beginning 09/02/2022 for wandering and potential for elopement. Interventions included: place resident in area where frequent observation is possible, alert staff to wandering behaviors, visual check for resident's location every hour, check wander alert bracelet daily to ensure band is intact and transmitter is functioning properly, instruct visitors to inform staff when they are leaving the designated area with the resident, and wander alert bracelet on Resident's left ankle at all times. Review of S11 Ward Clerk's written statement dated 01/14/2023 read as follows: Around 12:30 I was at my desk I was eating and talking to S14 Housekeeper. I hear the front door alarm go off. I look up I see 2 women walking towards my desk, I did not see anyone outside the door-I assumed they had held the door open too long. I asked S14 Housekeeper to please reset alarm. She went to the door, she also saw nothing outside. 5 or 10 minutes later the phone rang and I answered and a lady said I am parked across the street and a little old lady named (Resident #2) just sat in my car and asked me to take her home, I assumed since y'all are across the street she might have come from there, and I said she crossed Texas Avenue and she said yes - she said I can drive her across the street if you want and I said yes please come to the front door. I paged Nurse (S13 RN Weekend Supervisor) and a group of us met them in the parking lot. Review of S14 Housekeeper's written statement dated 01/14/2023 read as follows: I was standing by the dining room, I could hear the alarm go off and S11 Ward Clerk told me to go turn the alarm off, at this time, I never saw resident inside or out, so I had reset alarm. Shortly, S11 Ward Clerk got phone call saying (Resident #2) was at the store, and they brought her back. In an interview on 02/01/2023 at 9:19 a.m., S14 Housekeeper revealed she worked on 01/14/2023. S14 Housekeeper stated she was talking to the ward clerk around 12:00 p.m. and Resident #2 was standing there as well. S14 Housekeeper stated the next thing she knew S11 Ward Clerk received a phone call stating Resident #2 was in someone's car on the way back to the facility. S14 Housekeeper stated Resident #2 slipped away while she and S11 Ward Clerk were talking, and they never saw her leave. S14 Housekeeper stated the video camera showed that a family member opened the door to visit and Resident #2 slipped out. Review of Resident #2's nurses' notes revealed the following entry in part . 01/14/2023 at 7:19 p.m. - At approximately 12:45 p.m., S11 Ward Clerk received a phone call from a concerned customer from the store across the street questioning were we missing a female resident. That there was a confused lady at the store. Resident transported to facility via private auto. This nurse along with S13 RN, weekend supervisor went outside to get resident. Assisted resident back in building as resident approached the front entrance the door alarm started sounding. Wander guard in place and properly functioning. Head to toe assessment initiated ROM WNL. VSS Stable WNL 132/67, 73, 97.5, 18. 100%. Resident states that she was going to get a candy bar and the store didn't have what she wanted. Resident thankful for the candy and said, I should've just asked you for the candy. S2 DON, S1 Administrator notified. Son states that this is the same issue he was having at home with 24 hour sitters that once one of the workers would turn their back resident would leave out the house and they would have to chase her. Resident ambulated with rolling walker to her room. No further issues noted. By S12 LPN. In a telephone interview on 02/01/2023 at 11:37 a.m., S13 RN Weekend Supervisor revealed she worked on 01/14/2023 when the ward clerk received a phone call asking if the facility had a resident by the name of Resident #2. S13 RN Weekend Supervisor stated the person calling then drove into the facility parking lot with Resident #2 in the car. S13 RN stated the staff got Resident #2 out of the vehicle and told her she shouldn't leave the facility. S13 RN stated Resident #2 stated she had to leave, she didn't want to be at the facility. S13 RN stated she then checked Resident #2's wander guard and discovered it was working. In an interview on 01/31/2023 at 1:53 p.m., S1 Administrator acknowledged at the time the door alarm went off on 01/14/2023, S11 Ward Clerk only looked up from the front desk and failed to walk over to the front door area to investigate the alarm, because S11 Ward Clerk assumed the alarm went off because a visitor held the door open too long. Resident #3 Review of Resident #3's medical record revealed an admitted [DATE] with diagnoses that included in part . Unspecified Dementia with Behavioral Disturbance, Type 2 Diabetes Mellitus, Primary Insomnia, Restlessness and Agitation, and Generalized Anxiety Disorder. Review of Resident #3's Wander Data Collection Tool revealed Resident #3 was assessed as a wander/elopement risk on 10/21/2022 by S9 MDS. Interventions utilized included exit alarms, frequent monitoring with checks every hour, wander alert bracelet, and staff aware of resident's wander risk. Review of Resident #3's Annual MDS with an ARD of 01/20/2023 revealed the BIMS assessment was not completed as the resident is rarely or never understood. Resident #3 was coded as requiring supervision with bed mobility, transferring, and eating; extensive 1 person physical assistance with toilet use, and independent in walking in room and corridor. Resident #3 was documented as wandering behaviors occurred 1 to 3 days during the MDS assessment period. Review of Resident #3's physician orders revealed the following orders: 01/14/2022 - Wander alert bracelet on resident for elopement precautions at all times. Bracelet is located on resident's left ankle. 01/14/2022 - Check wander alert bracelet daily to ensure band is intact and transmitter is functioning properly. 01/14/2022 - Visual checks for resident's location every 1 hour. Review of Resident #3's comprehensive care plan revealed Resident #3 was care planned for Wandering: Potential for Elopement beginning 01/14/2022. Interventions included place resident in area where frequent observation is possible, if wandering away from unit, instruct staff to stay with resident, converse, and gently persuade to walk back to designated area with them, alert staff to wandering behavior, visual check for resident's location every one hour, check wander alert bracelet placement daily to ensure band is intact and transmitter is functioning properly, wander alert bracelet on resident's left ankle at all times for elopement precautions, and note which exits resident favors for elopement from facility. Alert staff working near those areas. Observation on 01/30/2023, 01/31/2023, and 02/01/2023 revealed Resident #3 was observed multiple times each day wandering the halls and around the front of the building near the front door, and the ward clerk's desk area. Observation of the facility's video camera footage on 02/01/2023 revealed at 2:22 p.m. on 01/17/2023, a Resident in a wheelchair entered the access code to unlock the door at the end of Hall A and exited the facility. Before the door closed, Resident #3 was seen exiting the facility behind the Resident in the wheelchair. In an interview at 4:00 p.m. on 01/30/2023, S8 LPN reported she worked on 01/17/2023, but was not aware Resident #3 was found outside the building until she overheard other staff members talking about it. S8 LPN stated no one ever told her about the incident, and thought she should have known as Resident #3's nurse. S8 LPN reported Resident #3 was very confused and should not be outside without supervision. In a telephone interview on 01/31/2023 at 10:58 a.m., S15 Housekeeper reported she was in the dining room getting some water, and looked up and saw Resident #3 outside on the side of the building on the walk path. S15 Housekeeper stated she went to the side kitchen/dining room door, hit the code to unlock the door, and walked Resident #3 back in by the arm. S15 Housekeeper stated she took Resident #3 straight to S1 Administrator's office and gave Resident #3 to her. In an interview on 01/31/2023 at 1:53 p.m., S1 Administrator acknowledged on 01/17/2023 Resident #3 had exited the building without staff's knowledge, but said Resident #3 didn't go anywhere except from the smoke area to the side of the building. S1 Administrator reported she did not complete an incident report or consider this incident an elopement because Resident #3 did not leave the facility grounds. S1 Administrator reported staff had already been in-serviced after Resident #2's elopement on 01/14/2023 therefore no new in-services were done as a result of Resident #3's elopement until 01/20/2023. In an interview on 02/01/2023 at 9:34 a.m., S16 RN/ADON revealed she was working at the facility on 01/17/2023 when Resident #3 walked out the door. S16 RN/ADON stated no one notified her that Resident #3 had left the facility. S16 RN/ADON stated she became aware of Resident #3's elopement later during that week. In an interview on 02/01/2023 at 10:48 a.m., the NP confirmed she was just told this week about Resident #3 being found outside the building. The NP reported Resident #3 had severe dementia and should not be outside without supervision. In an interview on 02/01/2023 at 3:00 p.m., S18 CNA reported she was pulled to work Resident #3's hall after another CNA left at 1:00 p.m. S18 CNA reported she did not know Resident #3 was to be checked every hour, and thought it was supposed to be every 2 hours. S18 CNA stated Resident #3 walks non-stop, and she did not see her go outside on her shift. S18 CNA confirmed she did not know that the resident eloped that date. S18 CNA reported Resident #3 was difficult to keep up with because she was always on the move.

Based on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 3 Residents (#1, #2 and #3) of 5 sampled residents (#1, #2, #3, #4 and #5). The facility failed to: 1. Have an effective system in place to ensure Residents (#1, #2, and #3) who were known to require supervision, were wanderers, and were assessed as being at risk for elopement and/or wore a wander alert bracelet, were adequately supervised to prevent them from exiting the building without supervision; 2. Ensure staff were effectively trained and competent in supervising Residents (#1, #2, #3) who were identified as wanderers and were at risk for elopement; and 3. Ensure staff accurately assessed Resident #1 using the Wander Data Collection tool and implemented interventions to prevent Resident #1 from exiting the building without supervision. This deficient practice resulted in an immediate jeopardy situation on 01/07/2023 at 2:21 p.m. when Resident #1 a severely cognitively impaired resident was inaccurately assessed and required supervision exited the facility unsupervised, and walked through a busy parking lot to a local pharmacy. A staff member shopping at the pharmacy found Resident #1 arguing and cursing a pharmacy employee, and returned Resident #1 to the facility. On 01/14/2023 at 12:31 p.m. Resident #2, a severely cognitively impaired resident assessed and care planned as an elopement risk, wore a wander alert bracelet and was on every one hour visual checks, exited the front door of the facility when a visitor entered the door code and opened the front door. The door alarm sounded, and staff reset the door alarm without investigating. Resident #2 walked across a 3 lane street to a gas station, got into the back seat of the car of 2 gas station customers and asked them to take her home. The gas station customers assumed Resident #2 was from the facility, called the facility and asked if they were missing Resident #2, and drove Resident #2 back to the facility at 12:37 p.m. On 01/17/2023 at 2:22 p.m., Resident #3, who rarely understands/rarely understood, assessed and care planned as an elopement risk, wore a wander guard bracelet, and was on every one hour visual checks, followed a resident out a door after he entered the code to the door, and exited the building without staff knowledge on 01/17/2023. At 2:28 p.m., S15 Housekeeper looked out the kitchen/dining room window and saw Resident #3 standing outside on the side of the building directly adjacent to a busy pharmacy parking lot. S15 Housekeeper escorted Resident #3 back into the building. This deficient practice continued at a potential for more than minimal harm for the 13 Residents in the facility who were identified to require supervision, and/or were assessed as being at risk for elopement and wore a wander alert bracelet, (#1, #2, #3, #4, #6, #7, #8, #9, #10, #11, #12, #13, & #14). S1 Administrator was notified of the Immediate Jeopardy on 01/31/2023 at 6:25 p.m. The Immediate Jeopardy was removed on 02/01/2023 at 6:25 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews and observations that the Plan of Removal have been initiated and/or implemented: The Facility's plan to remove the immediate jeopardy situation included: S19 Corporate Nurse in-serviced the Administrator, Assistant Administrator, DON, and ADON on 02/01/2023 on the policies and procedures related to elopement as well as internal protocols. Corporate Nurse will monitor for compliance two times per month for two months and then monthly until compliance is maintained. The DON and Administrator in-serviced the ADON, Maintenance, Activity Director, Dietary Manager, Admissions Coordinator, Business Office Manager, Human Resources, Therapy Department, Charge Nurse, and MDS nurses on 02/01/2023 on policy and procedures related to elopement as well as internal protocols. In-services were initiated for all staff by the DON and Assistant Administrator on 01/31/2023 and 02/01/2023 and will be completed by 02/03/2023 at 5:00 p.m. The in-service covered the existing policy on Wandering or Missing Resident which covers Code W, as well. Code W includes when a resident is missing, the staff will announce Code W and repeat it twice. The charge nurse will assign staff areas to begin looking for the resident. If not located in the building or on the grounds within 15 minutes, the charge nurse will notify the DON and Administrator to implement a plan to locate the resident. The in-service also addressed the use of the wander alert system and protocols to follow when the alarm sounds. Staff were reminded that a list of all residents with Wander Alert Bracelets is posted at each nurses' station, at the front desk and at the time clock. All staff were informed of who the 13 wanderers are and how often they should be checked. Staff were also in-serviced about the new Wander Alert Binder that was placed at each nurses' station. Staff unable to be in-serviced by 02/03/2023 at 5:00 p.m. will not be allowed to work until they are in-serviced. Any new employee will be in-serviced on the above during their orientation process. A QAPI monitor has been implemented to monitor whereabouts of all 13 residents with orders for Wander Alert Bracelets and are wearing wander alert bracelets. This monitor was started on 02/01/2023 at 8:30 am and will be completed by the ward clerk or designee every 30 minutes around the clock for 30 days, while the facility reviews all systems and procedures related to elopement precautions. On 02/01/2023, the Administrator placed a sign on all doors reminding visitors, family members, staff and residents to never let a resident out of the facility without checking with a nurse first. On 02/01/2023, the Administrator notified the responsible parties of each resident using our broadcast notification system. This notification addressed the importance of protecting all residents by not letting a resident out of the facility without first checking with a nurse as some of the residents have Wander Alert bracelets and are not allowed to leave the facility. On 02/01/2023, the Assistant Administrator changed the exit door codes on the Wander Alert System on each exterior door. When a resident with a wander alert bracelet approaches the door, it will remain locked. If someone enters this new code, and the resident is close to the door, the door will remain locked. If someone enters the new code, and the resident is farther away, the door will unlock but the alarm will sound if the resident with the wander alert bracelet approaches the door or tries to go out the door. Only staff will have access to the codes to the front door as well as the smoking door which is located at the end of Hall A. Dietary Staff will have access to the code to the exterior door of the kitchen go allow access for deliveries. The Administrator, DON, and Assistant Administrator will be the only staff to have codes to all remaining doors which are located at the end of the 100 hall, on the side of the 100 hall, the end of the 200 hall, the end of the 300 hall, the side of the 400 hall, and the dining room doors. On 02/01/2023, the Social Services Director made Wander Alert Binders to be placed at each nurses' station as well as the front desk. This binder contains the Wandering or Missing Resident policy, the list of residents with wander alert bracelets along with their pictures and face sheets. On 02/01/2023, the DON placed a list of residents with wander alert bracelet orders at each nurses' station, by the medication room door, at the front desk and by the time clock. The Wander Data Collection Tool is completed by the MDS nurse upon admission, quarterly, and with a significant change in status. This tool has a scoring system indicating a resident has a Definite Risk for elopement with a score of 3 or more yes answers and is At Risk with 1-2 yes answers. Upon completion of the yes/no questions on the front of the page, the nurse then summarizes her findings on the back of the page and determines the most appropriate interventions needed, if any. A resident may or may not need the wander alert bracelet regardless of findings from the yes/no questions, however additional interventions are implemented based on the needs of the resident. Things considered when deciding on need of a wander alert bracelet include, but not limited to; their mobility, desire to leave the building and/or exit seeking behavior. The facility will choose the least restrictive measures as interventions. If deemed at risk, the IDT team will discuss the most appropriate intervention. Beginning 02/01/2023, the treatment nurse during the week and the RN on the weekend or designees will check each door daily to ensure the Wander Alert alarm is functioning properly. If there is a concern or problem, the nurse is to notify the Administrator or DON immediately and assign someone to sit by the door until appropriate repairs can be made. The treatment nurse during the week and the RN on the weekend or designees will continue to check each Wander Alert Transmitter daily with the Transmitter Testing Device to ensure proper functioning. If a transmitter fails to function properly, the nurse stays with the resident and replaces the Wander Alert Transmitter. Once replaced, the new transmitter will be checked for proper functioning. This process will continue indefinitely. This deficient practice continued at a potential for more than minimal harm for the 13 Residents in the facility who were assessed to be wanderers and/or an elopement risk. Findings: Cross Refer to F689 Review of the facility's policy titled, Wandering or Missing Resident revealed in part . Policy: In an effort to prevent Residents from wandering away from the facility, procedures have been developed to follow when a resident leaves the facility unsupervised or without reporting to the facility staff their time of departure and time of return. Procedures: Resident Missing From Designated Area of Facility: 1. A department or resident care staff person which identified a wandering resident is missing must notify all staff of the missing resident by announcing on the public address system Code W, Resident's Name. Repeat twice. 2. The wandering resident's charge nurse shall assign direct care staff to look for the resident. 3. If the resident is not located in the buildings or the grounds within 15 minutes, the charge nurse shall notify the DON and the Administrator to implement the plan to locate the resident. 4. Any member becoming aware of a resident not being at the designated area or activity shall proceed to notify the charge nurse, DON and the Administrator. 5. Notify the appropriate responsible party: 6. Documentation of the wandering resident: a. The care plan will be updated with diversions, approaches, and modifications that are specific to the resident's individual wandering habits. Resident #1 In an interview on 01/31/2023 at 1:53 p.m., S1 Administrator acknowledged Resident #1 walked to the local pharmacy without staff being aware Resident #1 had left the building. S1 Administrator stated that although Resident #1 had a BIMS of 3 and a diagnosis of Dementia, she did not consider this an elopement because Resident #1 had gone to the pharmacy in the past without supervision. S1 Administrator confirmed every one hour visual checks and a wander alert bracelet were not implemented for Resident #1 until 01/13/2023, after Resident #1's elopement on 01/07/2023. In an interview on 02/01/2023 at 9:54 a.m., S9 MDS confirmed she completed the wander data collection tool on 11/10/2022 for Resident #1. S9 MDS confirmed she marked the resident as not a wander/elopement risk although she had answered yes to 4 of the questions. S9 MDS confirmed the instructions stated 3 or more yes answers would equal definite risk for elopement but reported she felt like the Resident #1 was not at risk for elopement. S9 MDS further reported had she followed the instructions and marked Resident #1 as an elopement risk, then staff would have held a team meeting to decide if the Resident needed a wander guard. In an interview on 02/01/2023 at 10:48 a.m., the NP (Nurse Practitioner) reported she was not notified Resident #1 had left the building unsupervised until this week after the survey began. The NP reported prior to this week, she was only notified Resident #1 had lit a cigarette in the dining room so staff wanted to make Resident #1 an unsafe smoker and put a wander alert bracelet on Resident #1. The NP reported staff did not tell her that Resident #1 had left the building and went to pharmacy unsupervised, and brought it to her attention this week. The NP confirmed the Resident #1 was confused and unable to comprehend the reason the cigarettes were taken. The NP reported the facility put in a smoking schedule for Resident #1, but Resident #1 can't process that and keeps asking the NP to take her to smoke. The NP confirmed it was unsafe for Resident #1 to be out of the facility without staff's knowledge and supervision. Resident #2 In an interview on 01/31/2023 at 1:53 p.m., regarding Resident #2, S1 Administrator acknowledged at the time the door alarm went off on 01/14/2023, S11 Ward Clerk only looked up from the front desk, and failed to walk over to the front door area to investigate the alarm, because S11 Ward Clerk assumed the alarm went off because a visitor held the door open too long. Resident #3 In an interview on 02/01/2023 at 9:34 a.m., S16 RN/ADON revealed she was working at the facility on 01/17/2023 when Resident #3 walked out the door. S16 RN/ADON stated no one notified her that Resident #3 had left the facility. S16 RN/ADON stated she became aware of Resident #3's elopement later during that week. In an interview on 02/01/2023 at 10:48 a.m., the NP confirmed she was just told this week about Resident #3 being found outside the building. The NP reported Resident #3 had severe dementia and should not be outside without supervision. In an interview on 01/31/2023 at 1:53 p.m., S1 Administrator acknowledged Resident #3 had exited the building without anyone's knowledge, but said Resident #3 didn't go anywhere except from the smoke area to the side of the building. S1 Administrator reported she did not consider this an elopement because the resident never left the facility grounds. S1 Administrator acknowledged staff were not notified of the elopement or in-serviced on elopement precautions for 3 days following Resident #3's elopement.

Based on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for 1 (#73) of 3 sampled residents (#18, #41, and #73) who required the use of a self-releasing seat belt while up in a wheelchair. This deficient practice resulted in an actual harm for resident #73, a cognitively impaired resident with a language barrier, on 03/24/2021 at approximately 3:00 p.m., when S3 PT returned the resident to her room from therapy without a self-releasing seat belt in place, and instructed the resident not to get out of her wheelchair. S3 PT left the resident alone in her wheelchair, and resident #73 fell to the floor while attempting to get out of her wheelchair. The resident was sent to the emergency room and diagnosed with an Acute Subcapital Right Proximal Femur Fracture, and an Acute Fracture of the Greater Tuberosity of the Right Humerus. Findings: Observation on 04/19/2021 at 10:30 a.m. revealed the resident was lying in bed with a pillow under the left knee and bilateral heel protectors in place. S6 Treatment nurse revealed she was in the room checking the right arm sling. S6 Treatment nurse communicated with the resident by pointing to areas of her body and trying to relate it in Spanish. S6 Treatment nurse revealed the resident spoke Spanish only, but could make most of her needs and concerns known at times by using facial expressions and hand gestures. S6 Treatment nurse also revealed that staff used a communication board, or would have a nurse who spoke Spanish translate when it was too difficult for the resident to understand. Observation revealed S6 Treatment nurse would ask the resident questions, and the resident would just smile and shake her head yes to any question asked. Review of the resident's clinical record revealed an admitted [DATE], with diagnoses that included: [CONDITION(S)], Dysphagia, Major Depressive Disorder, Muscle wasting and Atrophy, [CONDITION(S)] and [CONDITION(S)] following [CONDITION(S)], right dominate side. Review of a Quarterly MDS Assessment with an ARD of 02/03/2021 revealed the BIMS Summary Score was left blank, and there was documentation that the resident was rarely/never understood. Further review revealed the resident required extensive physical assist of 1+ person for bed mobility, dressing, toileting and personal hygiene, and extensive assistance of 2+ person for transfers. The MDS revealed the resident had ROM impairment to one side for upper and lower extremities, and utilized a wheelchair for mobility. Review of the resident's Comprehensive Care Plan with an onset date of 05/07/2020 revealed a problem of: At high risk for falls related to CVA with right [CONDITION(S)], and falls from wheelchair on 07/07/2020 and 08/14/2020 with no injuries. The care plan revealed on 03/24/2021 the resident sustained a fall from wheelchair with an Acute Subcapital Right Proximal Femur Fracture, and Acute Fracture of the Greater Tuberosity of the Right Humerus. Care plan approaches included: resident may be in room unattended in wheelchair due to new order of self-releasing seat belt to wheelchair (effective 08/17/2020) and give resident verbal reminders not to ambulate without assistance. Review of the Post-Incident Actions notes dated 03/24/2021 at 3:00 p.m. revealed S7 CNA found the resident lying on the floor on her right side in front of the wheelchair next to the bed. The resident had just returned from therapy. The resident was assisted up to bed by 3 person assist, and the resident appeared to be in pain, holding her right arm and guarding her right hip area. The resident was also pushing on her diaper. The resident's right outer hip area and right elbow/arm were red. The resident moaned with extension of right arm; however, no obvious deformities were noted to extremities. Review of the Radiology Interpretation dated 03/24/2021 revealed 1. Acute Subcapital Right Proximal Femur Fracture 2. Acute Fracture to the Greater Tuberosity of the Right Humerus. Review of the nurses' notes revealed the resident was transferred to the hospital on 3/24/2021 and returned to the facility on [DATE] with non-weight bearing for 6 weeks with Orthopedics to follow-up for recommendations in 2 weeks. Therapy would continue to work with resident on PROM during 6 weeks of bed rest pending order at orthopedics follow-up appointment. Review of a statement dated 03/24/2021 and written by S5 PTA revealed in part Prior to the fall she had entered the resident's room to get the resident up for therapy. The resident was in need of personal grooming and changing before therapy session. S5 PTA assisted S4 CNA in cleaning, dressing and minimal to light moderate assistance in transferring the resident from the bed to the wheelchair. The resident was transported to the therapy room for therapy by S3 PT. Review of an addendum dated 4/02/2021 to S5 PTA 03/24/2021 statement revealed that under normal circumstances per protocol, S4 CNA would have secured the seat belt upon transferring the patient to the wheelchair. Review of a statement dated 03/24/2021 and written by S7 CNA revealed in part . While walking down the hall she heard the resident moaning. She went into the room and found the resident lying on her right side with her head on the bar of her bedside table, and yelled for a nurse STAT. Review of a statement dated 03/24/2021 and written by S3 PT revealed in part At the conclusion of Physical Therapy, he brought the resident back to her room and noticed the resident's bed sheets were still soiled. He spoke with S4 CNA and she stated leave her in the wheelchair, I have to change the sheets. S3 PT positioned the resident in her room in the wheelchair and told her to stay in chair until the CNA was able to come change the linen and put her back to bed. Resident shook her head in agreement. Review of a statement dated 04/01/2021 the incident that occurred on 03/24/2021 and written by S8 LPN revealed in part She was at the nurses' station when she heard Nurse Stat being hollered on Hall 3 and was first nurse to arrive. Upon entering room resident was found lying on the floor on the right side of body between closet and bed, her head was on the bedside table behind her. The resident was assessed and no deformities or bleeding from the head. Resident was questioned if she was okay and she verbalized in her own language of Spanish that she was hurting, which S8 LPN understood. After an assessment was completed the resident was transferred to the bed with a 3+ person assist. Once in bed another assessment was done and upon exam when the resident's right arm was touched she moaned and had facial grimacing. S8 LPN call the Primary Care Physician and informed her of the fall with obvious pain upon touch to the right side of the body extremities. Order obtained for x-rays of right shoulder, elbow, wrist, pelvic/hip, and knee. Neuro checks were initiated. Review of a statement dated 03/24/2021 and written by S4 CNA revealed in part She had helped S5 PTA get the resident up. S3 PT brought the resident back to the room about 10 minutes later. She then heard Nurse Stat and that was when the resident was found on the floor. Review of an addendum dated 4/02/2021 to S4 CNA's 03/24/2021 revealed her normal duties were to obtain weights of residents, assist with feeding, monitor flow of the dining room, and float to any hall where other CNAs needed assistance, or if a call - in occurred, she would be assigned to the hall to fill in. She had worked with the resident on Hall 3, but she wasn't always out of the bed and she had not transferred her before this date. After changing the resident with assistance of S5 PTA and placing her in her wheelchair, it was assumed that therapy was taking care of the resident's needs. S5 PTA left out of the room with the resident and she tended to other task, and to her knowledge the resident was in safe hands going to therapy. Interview with S5 PTA on 4/19/2021 at 11:00 a.m. revealed she had worked at the nursing home for approximately 5 years. She revealed on the day of the incident with Resident #73, she had gone to the resident's room after lunch to get the resident up and bring her to therapy. She stated the resident was soiled when she got to the resident's room, so she assisted the S4 CNA with cleaning her up and transferring her to the wheelchair. S4 PTA revealed that she expected the CNA to know what care the resident needed and to have provided it, including the safety devices (self-releasing seat belt). She confirmed the resident did not have on a seat belt after she was placed in the wheelchair. She stated she brought the resident to therapy and passed her off to S3 PT. Interview with S3 PT on 4/19/2021 at 11:15 a.m. revealed the resident had been coming to therapy since February, 2021, but at times therapy was done in her room. He stated that he had not noticed if the resident had come to therapy on 03/24/2021 with a seatbelt in place. He stated the PTAs went and got the resident from her room most of the time, and he was not aware she wore a seat belt. He stated he would normally bring the resident back to the room after therapy and would put her back to bed. He stated on 03/24/2021, he took the resident back to her room after completing therapy session and noticed that her bed was dirty. He revealed he left the resident in the room and went out the door and told S4 CNA that the bed linens were dirty and that the resident was in her room. He further stated that he could not remember if the resident had a self-releasing seat belt in place when he returned her to her room. Interview with S4 CNA on 4/19/21 at 11:30 a.m. revealed she worked with the resident on 03/24/2021 when she had a fall and sustained fractures. She stated her normal duties were weights, dining and occasional filing, but if someone called in and the need was required, she would work as the floor CNA. She stated she had worked in the facility for [AGE] years. She stated on 03/24/2021 sometime after lunch, therapy had come to get the resident for her therapy session and found her soiled. She stated she and S5 PTA cleaned the resident up and got her up into the wheelchair. She stated S5 PTA took the resident on to therapy. S4 CNA revealed she had only worked with the resident while she was in bed, and had not had transferred her to her wheelchair prior to that day. She revealed she was not aware that the resident required a seat belt. She stated she did not even see the seat belt on the wheelchair, or look for the wall care plan, because she was handing her off to therapy. Interview with S1 Administrator on 4/21/21 at 10:45 a.m. revealed after she was notified of the incident on 03/24/2021, an investigation was immediately initiated. She revealed they had determined that when Resident #73 had a room change on 03/17/2021, the resident's Wall Care Plan was not moved to her new room. As a result, the resident had a significant fall and sustained fractures.

Based on observation, interview and record review the facility failed to ensure a resident with a history of pressure ulcer received an initial assessment by the RN after a denuded area (open area) was discovered on her sacrum for 1 (#5) of 4 (#1, #2, #3, #5) sampled residents with pressure sores out of a total sample of 5. The Resident Census and Conditions of Residents form reflected the facility had a total census of 112 residents. According to the Resident Census and Conditions of Residents form there were 23 current residents with pressure sores and only 4 residents had pressures on admission. Resident #5 had been in the nursing home since 6/19/08. On 2/19/13, the client developed a Stage 2 pressure ulcer to her sacrum. The area healed on 2/27/13. On 4/9/13, the resident was assessed by S3 LPN/Treatment Nurse and discovered the resident had an open area to her sacrum. S3 LPN/Treatment Nurse stated she left a message for the physician, but did not wait for an order, instead she wrote her own order and began treating the wound without a physician's orders [REDACTED]. On 5/29/13, S3 LPN/Treatment notified the RN of the wound. S3 LPN/Treatment Nurse stated she notified the RN due to the wound increased in size and began to look worse. S7 RN assessed the wound and reclassified the wound as a Stage 2 pressure sore. An actual harm occurred to resident #5 when the facility failed to ensure the resident's wound was assessed and staged by the RN for 50 days resulting in the resident not receiving the correct treatment to the wound. The resident's wound increased in size, began to have drainage, and the edges became macerated. The resident was not assessed by the RN until 5/29/13 and was not placed referred to the wound clinic until 6/27/13. On 7/2/13 the resident was placed on Bactrim DS one every 12 hours for 14 days due to wound infection. Review of the wound care clinic note dated 7/23/13 revealed [DIAGNOSES REDACTED]. Findings: Review of the facility's Policy and Procedure for Ulcer Management reflected under the Treatment/Evaluation section, referred to Assessment as: Important that each existing pressure ulcer be identified, whether present on admission or developed after admission, and that factors that influenced its development, the potential for development of additional ulcers or for the deterioration of the pressure ulcer be recognized, assessed, and addressed regarding overall assessment and interventions. Further review reflected under the Staging section that pressure ulcers would be staged by an RN on a weekly basis. Review of the resident's record reflected she had Diagnosis: [REDACTED]. The resident had been on Hospice until 6/27/13 when the resident began going to wound care clinic. Further review of the resident ' s record reflected she she had a weight loss of 12 lbs. in February, 2013. The record reflected the resident ' s was bedbound, incontinent of the bowels, required assistance of two staff to turn and reposition self and all ADLs. Observation of the residnet on 7/24/13 at 11:15 a.m. revealed the resident was lying in a low bed with the HOB elevated, with a fall mat on the right side on the floor. The resident did not respond when spoken too, however, her eyes and mouth were open. The resident was turned according to turn schedule posted. Review of the Norton scale dated 1/31/13 reflected resident #5 was at high risk for pressure ulcers. Review of the Braden Scale dated 4/30/13 reflected the resident was at high risk for pressure sores Review of the Treatment Totes date 2/19/13 reflected the resident had a Stage 2 pressure ulcer to her sacrum that healed on 2/27/13. Review of the Treatment Notes dated 4/3/13 reflected S3 LPN/Treatment nurse had assessed the resident and documented the resident had fragile scar tissue to sacrum. Review of the Treatment Notes dated 4/9/13 reflected the resident had a denuded area to the sacrum that measured 1.5 cm X 1 cm X <0.2, wound bed was red/pink with no drainage. The physician and the resident's responsible party were notified. Treatment was ordered. Review of a physician's orders [REDACTED]. Review of the Treatment Notes dated 4/13/13 at 12:58 p.m. reflected the resident had a denuded area to sacrum which measured 1.5 cm X 1 cm X <0.2 cm with the wound bed red/pink, no drainage or odor noted. Treatment changed to [MEDICATION NAME] from Silversorb and Collagen dressing at family's request. The Physician and RP were notified per S3 LPN/Treatment Nurse. Review of the 4/13/13 Treatment Notes timed 2:52 p.m. reflected S3 LPN/ Treatment Nurse wrote new orders to change the treatment to denuded scar tissue on the sacrum to [MEDICATION NAME] everyday as requested per family. Review of the 4/17/13 and 4/24/13 the Treatment Notes reflected no change per S3 LPN/Treatment Nurse. Review of the 5/6/13 Treatment Notes documented by S9 LPN reflected an area that measured 1 cm X 0.2 cm X 0.1 cm was noted to the sacrum of a denuded area. There was no drainage and the area was pink in color. Further review reflected an order was obtained to cleanse the sacrum with wound cleanser, apply Silversorb, collagen and a dressing. The Physician and RP were notified. Review of the 5/8/13 Treatment Notes documented by S3 LPN/ Treatment Nurse reflected the denuded area to sacrum measured 1.3 cm X 0.6 cm X <0.2 cm. Further review reflected the residen 's treatment orders were changed back to just [MEDICATION NAME] with the Physician and RP being notified. Review of the 5/15/13 Treatment Notes documented by S3 LPN/Treatment Nurse reflected a denuded area to sacrum measured 1.3 cm X 1 cm X <0.2 cm. Review of the 5/21/13 Treatment Notes documented by S3 LPN/Treatment Nurse reflected the resident's denuded area to the sacrum measured 1.3 cm X 1 cm X 0.2 cm with the wound bed red/pink, no drainage or odor noted. The treatment to the area changed to Silversorb and Collagen followed by non-bordered foam. The Physician and RP were notified. Review of the 5/29/13 Treatment Notes reflected the resident had a denuded area to sacrum was reclassified as Stage 2 pressure ulcer, measurements 2 cm X 1.2 cm X .3 cm. The wound bed was pale pink, had a scant amount of pink drainage, no odor noted, edges slightly macerated and attached. The periwound was fragile and scar tissue was prone to denudment and maceration. There were new treatment orders, and wound care was rendered. The staging of the wound was done by S7 RN/Former DON. Review of the Skin Condition Record for Non-Pressure Ulcer Skin Conditions form reflected the date the wound was first observed was 4/9/13 site/location reflected a denuded area to sacrum 1.5 cm X 1 cm X <.2 cm, with silversorb and collagen as the treatment. Documentation of the wound remained on the Skin Condition Record for Non-Pressure Ulcer Skin Conditions form until 5/29/13 when S7 RN/Former DON initially assessed the wound. Review of the Pressure Ulcer Assessment and Causal Factors form dated 5/29/13 reflected S7 RN/Former RN documented the ulcer was 2 cm X 1.2 cm X 0.3 cm. Further documentation reflected the wound was a Stage 2 pressure sore that had no odor, was pink and had scant amount of drainage. The wound bed had 50% [MEDICATION NAME] tissue and 50% granulation tissue, the wound edges were macerated, edges were attached, and the periwound skin had pink tissue. The physician and the RP were notified. Review of the Treatment Notes dated 6/5/13 reflected the resident's Stage 2 Pressure Ulcer was reclassified as a Stage 3 Pressure Ulcer that measured 2.8 cm X 1.4 cm X 0.3 cm. The wound bed was 50% pale pink with 50% scattered yellow slough. There was scant pink exudate with no odor, edges were slightly macerated and attached and the periwound was prone to denudment and maceration. The treatment was changed to Santly and collagen and cover with border gauze daily. Review of the Treatment Notes dated 6/26/13 reflected a Stage 3 Pressure Ulcer that measured 3.2 cm X 1.5 cm with 40 % moist red and pink granulated tissue and 60 % yellow and tan adhered slough. The wound had a small amount of pink and bloody drainage, no odor, the edges were macerated and the periwound had fragile scar tissue. The wound was viewed by S7 RN/Former DON and the FNP. The resident was set up with an appointment for wound care clinic on 6/27/13. Review of the Treatment Notes date 6/27/13 reflected the resident went to Wound Care Clinic for an assessment of her Stage 3 Pressure Ulcer to the sacrum. New orders were obtained from the wound care clinic. Review of the physician's orders [REDACTED]. Review of the Nurses' Notes and Physicians' orders dated 7/2/13 reflected the resident was placed on Bactrim DS one every 12 hours for 14 days due to wound infection. The RP was notified. Review of Treatment Notes dated 7/9/13 reflected the pressure ulcer to sacrum measured 3.8 cm X 2 cm and unable to determine the depth. The wound bed had 10% red granulated tissue, 80 % yellow and tan adhered slough and 10% soft black eschar, edges were rolled with maceration, hardness and slight indurating with slight positive [DIAGNOSES REDACTED] noted 2 cm circumference. The wound had no odor, small amount yellow and bloody exudate. The wound was viewed and staged by S2 RN/DON. Further review of the Treatment Notes dated 7/9/13 reflected the wound care clinic was called and a fax was received revealing the resident's wound had been debrided at the wound care clinic. No significant change noted to wound with only very top layer of slough removed from wound bed leaving tan, dark yellow and gray tissue remaining in wound bed, slight foul odor and a small amount of bloody and yellow exudate. The treatment orders were to continue as previously ordered. Review of the last documented Treatment Note dated 7/23/13 reflected the resident had gone out to the wound care clinic that morning. The wound measured 4 cm X 2.5 cm with moderate foul odor and large amount of yellow exudate, with 10% granulated tissue, 45 % yellow slough and 45% eschar, edges attached, balanceable [DIAGNOSES REDACTED] with hardness circumference. The wound was assessed and staged by S2 RN/DON. Review of the wound care clinic notes dated 7/23/13 reflected at [DIAGNOSES REDACTED]. Review of the Weekly Pressure Ulcer Report dated 7/23/13 reflected the resident had an unstageable pressure ulcer with an original date of 5/29/13 and acquired in the facility. The pressure sore measurements reflected the length was 4 cm, the width was 2.5 cm and the depth was unable to determine. The wound to the sacrum had drainage and the wound treatment was Santyl/Mesalt. The last time the physician was notified was on 7/23/13. Interview with S3 LPN/Treatment Nurse on 7/24/13 at 11:45 a.m. revealed she had not normally been taking care of resident #5. S3 stated the other Treatment Nurse, S8, was currently on vacation. S3 stated she had been taking care of the resident until about 1 month ago when the family requested S8 LPN/Treatment Nurse take over her care. S3 stated she had been doing wound care on weekends, off and on since [DATE]. Further interview with S3 LPN/ Treatment Nurse stated when the regular wound care nurse resigned; she took her position in April, 2013. S3 stated her training consisted of shadowing S8 for a couple of weeks, approximately 2 -3 times per week until she started treatments on her own. S3 stated she has not received any other wound care training from the facility. Review of the Comprehensive Care Plan with a goal date of 7/30/13 reflected the resident was care planned for skin integrity impaired related to incontinent of bowels, decreased mobility and [DIAGNOSES REDACTED]. There were no other interventions documented when there was an open area noted to the resident's sacrum. Review of the facility's Policy and Procedure for Ulcer Management reflected under the Treatment/Evaluation section, referred to Assessment as: Important that each existing pressure ulcer be identified, whether present on admission or developed after admission, and that factors that influenced its development, the potential for development of additional ulcers or for the deterioration of the pressure ulcer be recognized, assessed, and addressed regarding overall assessment and interventions. Further review reflected under the Staging section that pressure ulcers would be staged by an RN on a weekly basis. Interview with S3 LPN/Treatment Nurse on 7/24/13 at 2:15 p.m. revealed her definition of a denuded area meant there was a small open area in the skin. S3 LPN/ Treatment Nurse stated that she had not considered the area on resident #5 to be on a pressure area. S3 LPN/ Treatment Nurse stated she didn't know the coccyx was a pressure area at that time, but looking back now, she would have considered it a pressure area and would have considered the denuded area an open pressure sore. S3 LPN/ Treatment Nurse confirmed the open area was on a pressure area when she first observed it. S3 LPN/ Treatment Nurse stated she had only been working as a wound care nurse for approximately 10 days. S3 LPN/ Treatment Nurse revealed she did not know if she had notified S7 RN/Former DON to look at the area when she first observed it. S3 LPN/ Treatment Nurse stated if she had, S7 RN/Former DON would have written a note or done an assessment note. S3 LPN/ Treatment Nurse stated when she found something she normally reported it to S8 LPN/Treatment Nurse, not the RN. Further interview with S3 LPN/Treatment Nurse on 7/24/13 at 2:15 p.m. revealed that when she first observed wound she called and left the physician a message and wrote an order for [REDACTED]. Further interview with S3 LPN/Treatment Nurse on 7/24/13 at 2:15 p.m. also confirmed on 4/13/13 she changed the treatment that day when she was working as the floor nurse (not as wound care nurse) when another nurse S17 LPN on the evening shift changed the wound care treatment. S3 LPN stated she changed the wound care treatment orders back to just [MEDICATION NAME] because the family requested. S3 LPN/ Treatment Nurse stated S7 RN/Former, herself and the hospice nurse discussed the dressing change. S3 LPN/ Treatment Nurse stated the hospice nurse told her the area opened and closed frequently and the treatment had always been [MEDICATION NAME] ointment with no dressing. Continued interview with S3 LPN/Treatment nurse on 7/24/13 at 2:15 p.m. confirmed on 4/9/13 and 4/13/13 she started the treatments without getting an order from the physician. S3 LPN/ Treatment Nurse stated she changed the order to just [MEDICATION NAME] per family request, not a physician's orders [REDACTED]. Observation on 7/25/13 at 10:30 a.m. of wound care for resident #5 with S3 LPN/Treatment Nurse reflected she set up her area on an over bed table. S3 LPN/ Treatment Nurse cleaned the wound and applied Santyl Ointment and Mesalt packing and then covered the area with a dressing. S3 LPN/ Treatment Nurse changed her gloves during the procedure as needed and there were no infection control problems observed. The wound measurements were as documented on the Weekly Pressure Ulcer Report. Interview with S2 RN/DON on 7/25/13 at 3:30 p.m. revealed the facility did not have standing wound care orders. S2 RN/DON also confirmed a denuded area on the coccyx would be considered an open pressure sore. S2 RN/DON confirmed 5/29/13 was the first documented assessment by an RN of the wound found on 4/9/13. Interview with S2 RN/DON and S1 ADM on 7/25/13 at 4:00 p.m. confirmed the resident had a history of [REDACTED]. S1 and S2 confirmed there was no RN assessment until 5/29/13. Both S1 and S2 confirmed S3 LPN/Treatment Nurse should not have left a message for the Physician or wrote the order until she had received it from the Physician, both stated that was not the facility's normal practice. Both S1 and S2 confirmed S3 LPN/Treatment Nurse should not have changed resident #5's wound care treatment per family request. Interview with S2 RN/DON on 7/24/13 at 3:30 p.m. revealed the facility did not have standing wound care orders. S2 also confirmed a denuded area on the coccyx would be considered an open pressure sore. S2 RN/DON confirmed 5/29/13 was the first documented assessment by an RN. Interview with S2 RN/DON and S1 ADM on 7/24/13 at 4:00 p.m. confirmed the resident had a history of [REDACTED]. S1 and S2 confirmed there was no RN assessment until 5/29/13.

Based on observation, interview and record review the facility failed to ensure a resident with the history of pressure ulcers received the necessary treatment and services to promote healing and prevent infection, and prevent pressure sores from redeveloping for 1 (#5) of 4 (#1, #2, #3 and #5) sampled residents with pressure sore out of a total sample of 5 residents. The facility's total census according to the Resident Census and Conditions of Residents was 112. According to the Resident Census and Conditions of Residents there were 23 residents with current pressure sores and only 4 had pressure sores on admission. The facility failed to: 1. ensure S3 LPN/Treatment Nurse notified the RN of a denuded area (open area) identified on resident #5 ' s sacrum area, so the RN could assess and stage the wound on 4/9/13; 2. ensure the S3 LPN/Treatment Nurse obtained a physician's orders [REDACTED]. 3. ensure S3 LPN/Treatment Nurse did not change the physician's order [REDACTED]. 4. ensure S3 LPN/Treatment Nurse had knowledge of a pressure wound and causative factors. Resident #5 has been in the nursing home since 6/19/08. On 2/19/13 the client developed a Stage 2 pressure ulcer to her sacrum, that healed on 2/27/13. On 4/9/13 the resident was assessed by S3 LPN/Treatment Nurse and discovered the resident had an open area to her sacrum. S3 LPN/Treatment Nurse stated she left a message for the physician, but did not wait for an order, instead she wrote her own order and began treating the wound without physician's orders [REDACTED]. On 5/29/13, S3 LPN/Treatment notified the RN of the wound. S3 LPN/Treatment Nurse stated she notified the RN due to the wound increased in size and began to look worse. S7 RN assessed the wound and reclassified the wound as a Stage 2 pressure sore. The failure of an assessment by the RN placed the resident in actual harm when the resident's wound was not assessed and staged by the RN for approximately 50 days. The resident's wound increased in size, began to have drainage, and the edges became macerated. The resident was not assessed by the RN until5/29/13 and was not referred to the wound clinic until 6/27/13. On 7/2/13 the resident was placed on Bactrim DS on every 12 hours for 14 days due to a wound infection. Review of the wound care clinic note dated 7/23/13 revealed a [DIAGNOSES REDACTED]. Findings: Review of the facility's Policy and Procedure for Ulcer Management reflected under the Treatment/Evaluation section, referred to Assessment as: Important that each existing pressure ulcer be identified, whether present on admission or developed after admission, and that factors that influenced its development, the potential for development of additional ulcers or for the deterioration of the pressure ulcer be recognized, assessed, and addressed regarding overall assessment and interventions. Further review reflected under the Staging section that pressure ulcers would be staged by an RN on a weekly basis Review of the resident's record reflected she had Diagnosis: [REDACTED]. The resident had been on Hospice until 6/27/13 when the resident began going to wound care clinic. Further review of the resident's record reflected she she had a weight loss of 12 lbs. in February, 2013. The record reflected the resident was bedbound, incontinent of the bowels, required assistance of two staff to turn and reposition self and all ADLs. Observation of the resident on 7/24/13 at 11:15 a.m. revealed the resident was lying in a low bed with the HOB elevated, with a fall mat on the right side on the floor. The resident did not respond when spoken too, however, her eyes and mouth were open. The resident was turned according to turn schedule posted. The resident was also on an alternating air matress. Review of the Norton scale dated 1/31/13 reflected resident #5 was at high risk for pressure ulcers. Review of the Braden Scale dated 4/30/13 reflected the resident was at high risk for pressure sores Review of the Treatment Totes date 2/19/13 reflected the resident had a Stage 2 pressure ulcer to her sacrum that healed on 2/27/13. Review of the Treatment Notes dated 4/3/13 reflected S3 LPN/Treatment nurse had assessed the resident and documented the resident had fragile scar tissue to sacrum. Review of the Treatment Notes dated 4/9/13 reflected the resident had a denuded area to the sacrum that measured 1.5 cm X 1 cm X <0.2, wound bed was red/pink with no drainage. The physician and the resident's responsible party were notified. Treatment was ordered. Review of a physician's orders [REDACTED]. Review of the Treatment Notes dated 4/13/13 at 12:58 p.m. reflected the resident had a denuded area to sacrum which measured 1.5 cm X 1 cm X <0.2 cm with the wound bed red/pink, no drainage or odor noted. Treatment changed to [MEDICATION NAME] from Silversorb and Collagen dressing at family's request. The Physician and RP were notified per S3 LPN/Treatment Nurse. Review of the 4/13/13 Treatment Notes timed 2:52 p.m. reflected S3 wrote new orders to change the treatment to denuded scar tissue on the sacrum to [MEDICATION NAME] everyday as requested per family. Review of the 4/17/13 and 4/24/13 the Treatment Notes reflected no change per S3 LPN/Treatment Nurse. Review of the 5/6/13 Treatment Notes documented by S9 LPN reflected an area that measured 1 cm X 0.2 cm X 0.1 cm was noted to the sacrum of a denuded area. There was no drainage and the area was pink in color. Further review reflected an order was obtained to cleanse the sacrum with wound cleanser, apply Silversorb, collagen and a dressing written per phone order by S9 LPN. The Physician and RP were notified. Review of the 5/8/13 Treatment Notes documented by S3 LPN reflected the denuded area to sacrum measured 1.3 cm X 0.6 cm X <0.2 cm. Further review reflected the resident's treatment orders were changed back to just [MEDICATION NAME] with the Physician and RP being notified. Review of the 5/15/13 Treatment Notes documented by S3 LPN/Treatment Nurse reflected a denuded area to sacrum measured 1.3 cm X 1 cm X <0.2 cm. Review of the 5/21/13 Treatment Notes documented by S3 LPN/Treatment Nurse reflected the resident's denuded area to the sacrum measured 1.3 cm X 1 cm X 0.2 cm with the wound bed red/pink, no drainage or odor noted. The treatment to the area changed to Silversorb and Collagen followed by non-bordered foam. The physician's order [REDACTED]. There was no documentation of a physician visit or assessment of the wound. The Physician and RP were notified. Review of the 5/29/13 Treatment Notes reflected the resident had a denuded area to sacrum was reclassified as Stage 2 pressure ulcer, measurements 2 cm X 1.2 cm X .3 cm. The wound bed was pale pink, had a scant amount of pink drainage, no odor noted, edges slightly macerated and attached. The periwound was fragile and scar tissue was prone to denudment and maceration. There were new treatment orders, and wound care was rendered. The staging of the wound was done by S7 RN/Former DON. Review of the Skin Condition Record for Non-Pressure Ulcer Skin Conditions form reflected the date the wound was first observed was 4/9/13 site/location reflected a denuded area to sacrum 1.5 cm X 1 cm X <.2 cm, with silversorb and collagen as the treatment. Documentation of the wound remained on the Skin Condition Record for Non-Pressure Ulcer Skin Conditions form until 5/29/13 when S7 RN/Former DON initially assessed the wound. Review of the Pressure Ulcer Assessment and Causal Factors form dated 5/29/13 reflected S7 RN/Former RN documented the ulcer was 2 cm X 1.2 cm X 0.3 cm. Further documentation reflected the wound was a Stage 2 pressure sore that had no odor, was pink and had scant amount of drainage. The wound bed had 50% [MEDICATION NAME] tissue and 50% granulation tissue, the wound edges were macerated, edges were attached, and the periwound skin had pink tissue. The physician and the RP were notified. Review of the Treatment Notes dated 6/5/13 reflected the resident's Stage 2 Pressure Ulcer was reclassified as a Stage 3 Pressure Ulcer that measured 2.8 cm X 1.4 cm X 0.3 cm. The wound bed was 50% pale pink with 50% scattered yellow slough. There was scant pink exudate with no odor, edges were slightly macerated and attached and the periwound was prone to denudment and maceration. The treatment was changed to Santyl and collagen and cover with border gauze daily. Review of the Treatment Notes dated 6/26/13 reflected a Stage 3 Pressure Ulcer that measured 3.2 cm X 1.5 cm with 40 % moist red and pink granulated tissue and 60 % yellow and tan adhered slough. The wound had a small amount of pink and bloody drainage, no odor, the edges were macerated and the periwound had fragile scar tissue. The wound was viewed by S7 RN/Former DON and the FNP. The resident was set up with an appointment for wound care clinic on 6/27/13. Review of the Treatment Notes date 6/27/13 reflected the resident went to Wound Care Clinic for an assessment of her Stage 3 Pressure Ulcer to the sacrum. New orders were obtained from the wound care clinic. Review of the physician's orders [REDACTED]. Review of the Nurses' Notes and Physicians' orders dated 7/2/13 reflected the resident was placed on Bactrim DS one every 12 hours for 14 days due to wound infection. The RP was notified. Review of Treatment Notes dated 7/9/13 reflected the pressure ulcer to sacrum measured 3.8 cm X 2 cm and unable to determine the depth. The wound bed had 10% red granulated tissue, 80 % yellow and tan adhered slough and 10% soft black eschar, edges were rolled with maceration, hardness and slight indurating with slight positive [DIAGNOSES REDACTED] noted 2 cm circumference. The wound had no odor, small amount yellow and bloody exudate. The wound was viewed and staged by S2 RN/DON. Further review of the Treatment Notes dated 7/9/13 reflected the wound care clinic was called and a fax was received revealing the resident's wound had been debrided at the wound care clinic. No significant change noted to wound with only very top layer of slough removed from wound bed leaving tan, dark yellow and gray tissue remaining in wound bed, slight foul odor and a small amount of bloody and yellow exudate. The treatment orders were to continue as previously ordered. Review of the last documented Treatment Note dated 7/23/13 reflected the resident had gone out to the wound care clinic that morning. The wound measured 4 cm X 2.5 cm with moderate foul odor and large amount of yellow exudate, with 10% granulated tissue, 45 % yellow slough and 45% eschar, edges attached, balanceable [DIAGNOSES REDACTED] with hardness circumference. The wound was assessed and staged by S2 RN/DON. Review of the wound care clinic notes dated 7/23/13 reflected at [DIAGNOSES REDACTED]. Review of the Weekly Pressure Ulcer Report dated 7/23/13 reflected the resident had an unstageable pressure ulcer with an original date of 5/29/13 and acquired in the facility. The pressure sore measurements reflected the length was 4 cm, the width was 2.5 cm and the depth was unable to determine. The wound to the sacrum had drainage and the wound treatment was Santyl/Mesalt. The last time the physician was notified was on 7/23/13. Review of the History and Physical Form the hospital where the resident was admitted on [DATE], revealed the resident was admitted with [DIAGNOSES REDACTED]. Interview with S3 LPN/Treatment Nurse on 7/24/13 at 11:45 a.m. revealed she had not normally been taking care of resident #5. S3 LPN/Treatment Nurse stated the other Treatment Nurse, S8, was currently on vacation. S3 stated she had been taking care of the resident until about 1 month ago when the family requested S8 LPN/Treatment Nurse take over her care. S3 LPN/Treatment Nurse stated she had been doing wound care on weekends, off and on since [DATE]. Further interview with S3 LPN/ Treatment Nurse stated when the regular wound care nurse resigned; she took her position in April, 2013. S3 LPN/Treatment Nurse stated her training consisted of shadowing S8 for a couple of weeks, approximately 2 -3 times per week until she started treatments on her own. S3 LPN/Treatment Nurse stated she has not received any other wound care training from the facility. Review of the Comprehensive Care Plan with a goal date of 7/30/13 reflected the resident was care planned for skin integrity impaired related to incontinent of bowels, decreased mobility and [DIAGNOSES REDACTED]. There were no other interventions documented when there was an open area noted to the resident's sacrum. Interview with S3 LPN/Treatment Nurse on 7/24/13 at 2:15 p.m. revealed her definition of a denuded area meant there was a small open area in the skin. S3 LPN/Treatment Nurse stated that she had not considered the area on resident #5 to be on a pressure area. S3 LPN/Treatment Nurse stated she didn't know the coccyx was a pressure area at that time, but looking back now, she would have considered it a pressure area and would have considered the denuded area an open pressure sore. S3 LPN/Treatment Nurse confirmed the open area was on a pressure area when she first observed it. S3 LPN/Treatment Nurse stated she had only been working as a wound care nurse for approximately 10 days. S3 LPN/Treatment Nurse revealed she did not know if she had notified S7 RN/Former DON to look at the area when she first observed it. S3 LPN/Treatment Nurse stated if she had, S7 RN/Former DON would have written a note or done an assessment note. S3 LPN/Treatment Nurse stated when she found something she normally reported it to S8 LPN/Treatment Nurse, not the RN. Further interview with S3 LPN/Treatment Nurse on 7/24/13 at 2:15 p.m. revealed that when she first observed wound she called and left the physician a message and wrote an order for [REDACTED]. S3 LPN/Treatment Nurse confirmed she had changed the treatment without verbal order from the physician. S3 LPN/Treatment Nurse confirmed she would just write the order and send it to the physician and he would sign it. Further interview with S3 LPN/Treatment Nurse on 7/24/13 at 2:15 p.m. also confirmed on 4/13/13 she changed the treatment to the resident ' s wound while she was working as the floor nurse (not as wound care nurse) after S17 LPN, on the evening shift had changed the wound care treatment. S3 LPN stated she changed the wound care treatment orders back to [MEDICATION NAME] because that was the family's request. S3 LPN/Treatment Nurse stated S7 RN/Former, herself and the hospice nurse discussed the dressing change the resident ' s dressing change on 4/13/13. S3 LPN/Treatment Nurse stated the hospice nurse told her the area opened and closed frequently and the treatment had always been [MEDICATION NAME] ointment with no dressing Continued interview with S3 LPN/Treatment nurse on 7/24/13 at 2:15 p.m. confirmed on 4/9/13 and 4/13/13 she started the treatments without getting an order from the physician. S3 stated she changed the order to just [MEDICATION NAME] per family request, not a physician's orders [REDACTED]. Interview with S2 RN/DON on 7/25/13 at 3:30 p.m. revealed the facility did not have standing wound care orders. S2 also confirmed a denuded area on the coccyx would be considered an open pressure sore. S2 RN/DON confirmed 5/29/13 was the first documented assessment by an RN of the wound found on 4/9/13. Since 5/29/13, the resident ' s wound has been assessed by an RN weekly. Interview with S2 RN/DON and S1 Adm on 7/25/13 at 4:00 p.m. confirmed the resident had a history of [REDACTED]. S1 and S2 confirmed there was no RN assessment until 5/29/13. Both S1 and S2 confirmed S3 LPN/ Treatment Nurse should not have left a message for the Physician or wrote the order until she had received it from the Physician, both stated that was not the facility's normal practice. Both S1 and S2 confirmed S3 LPN/Treatment Nurse should not have changed resident #5's wound care treatment per family request.

Based on observation, interview and record review the facility failed to reduce the risk of accident hazards by failure to ensure interventions were implemented in accordance to the plan of care for resident transfer (#1) for 1 of 6 residents (#2, 3, 4, 5, 6) sampled for prevention of incidents and accidents. The facility failed to ensure the intervention for a 2 person assist for transfer was implemented at all times as ordered (#1). Resident #1 was admitted to the nursing home on 10/13/11 with the [DIAGNOSES REDACTED]. Documentation reflected the resident was assessed at high risk for falls and required a 2 person assist for transfer. The intervention for a 2 person assist was included in the Comprehensive Plan of Care and the Resident Care Sheet. Documentation and interview confirmed the resident experienced a fall when she was assisted to stand up to a scale for weight on 12/20/12 with the assistance of 1 CNA. As a result of the fall the resident experienced pain in her left upper extremity and required transfer to the emergency room . The resident was diagnosed with [REDACTED]. The resident returned to the nursing home on 12/20/12 and continued to experienced episodes of pain in her left upper extremity. Findings: 1. Observation of resident #1 on 3/21/13 at 7:30 a.m. revealed S4 CNA, S5 CNA and S6 CNA assisted the resident to weigh. Observation revealed S4 CNA physically assisted the resident as she sat up on the side of the bed. Further observation revealed S6 CNA placed a gait belt around the resident's waist, and S6 CNA and S5 CNA physically assisted the resident to stand and transfer to the weight chair. Observation revealed S4 CNA stood behind the weight chair and assisted with resident positioning and calibration of the scale. Review of the December, 2012 physician's orders [REDACTED]. Further review revealed an order dated 10/13/11 for the use of a 2 person transfer at all times. Review of the resident's Quarterly MDS assessment dated [DATE] (ARD) reflected the resident was totally dependent and required a two person physical assist for bed mobility and transfer. Further review of the assessment reflected the resident had a functional limitation in the range of motion of the left upper and lower extremity on one side. Review of the assessment reflected the active [DIAGNOSES REDACTED]. Review of the resident's Fall Risk assessment dated [DATE] reflected a score of 12 and on 2/21/13 - 18. Review of the assessment reflected the resident was assessed at high risk for fall with a score of 10 or greater. Review of the resident's Comprehensive Care Plan reflected the problem of at High Risk for Falls related to dependent for transfer and related [MEDICAL CONDITION] Left [MEDICAL CONDITION]. Documentation reflected the goal for the problem was- the resident will remain free of falls and injury with the use of nursing interventions. The problem had the goal dates of 12/13/12, 3/15/13 and 5/25/13. Review of the approaches for the problem reflected the use of a 2 person assist for all transfers. Review of the Resident Care Sheet that was at the resident's bedside reflected the resident was on the Falling Star Program and required a 2 person assist for transfer. Review of resident #1's Nurses' Note dated 12/20/12 reflected the resident had a fall on 12/20/12 at 2:40 p.m. when S4 CNA attempted to stand the resident for weight. Further review of the documentation reflected the resident lost her balance and fell on top of the CNA. Documentation by S9 LPN reflected the resident's shoulder hit the floor and the resident complained of pain in her left upper extremity. Documentation in the nurses' notes reflected the resident was sent to the ER and returned to the facility at 10:50 p.m. with the [DIAGNOSES REDACTED]. Documentation reflected the resident returned with a shoulder immobilizer in place to the left upper extremity. Documentation in the nurses' note dated 12/20/12 at 11:43 p.m. and 12/22/12 at 12:24 a.m. reflected the resident complained of pain and discomfort in the left arm. Interview on 3/20/13 at 2:30 p.m. with S4 CNA confirmed she had attempted to assist the resident to stand for a weight on 12/20/12 and had provided a 1 person assist. Further interview of S4 reflected the resident lost her balance and fell . The S4 CNA stated the instructions for a 2 person assist were posted at the resident's bedside and confirmed the 2 person transfer assist intervention was in place before the 12/20/12 fall occurred. Interview on 3/21/13 at approximately 10:30 a.m. with S9 LPN confirmed she was the resident's nurse on 12/20/12 when the resident fell and was transferred to the ER. Further interview confirmed the above findings in her nurse' note documentation for 12/20/12. Interview on 3/21/13 at 7:55 a.m. with the resident's Clinical Care Coordinator S3 LPN reflected she had been in her current position for the facility approximately 2.5 years. Interview of S3 reflected she was responsible for the resident's MDS Assessment and Care Plan. Interview of S3 confirmed the MDS assessment dated [DATE] reflected the resident had paralysis and weakness in the left upper and left lower extremity, was not steady and required the assistance of two people for transfer. Interview of S3 confirmed the resident was assessed to be at high risk for falls and was care planned for a 2 person assist for transfer related to her risk for fall. Interview of S3 confirmed the resident had required a two person transfer since she was admitted to the facility in 2011. Interview on 3/20/13 at 3:12 p.m. with S2 DON confirmed the Nurse' Note documentation reflected the resident had experienced a fall and injury on 12/20/12 when one CNA had attempted to weigh the resident. Further interview confirmed the resident had been care planned for a 2 person transfer assist at the time of the fall on 12/20/12.

Based on observation, interview and record review the facility failed to reduce the risk of accident hazards by failure to ensure interventions were implemented in accordance to the plan of care for resident transfer (#1, #6), and failure to modify the plan of care for resident transfer to be consistent with the resident's assessed needs (#3) for 3 of 6 residents (#2, #4, #5) sampled for prevention of incidents and accidents. The facility failed to ensure the intervention for a 2 person assist for transfer was implemented at all times as ordered (#1). Resident #1 was admitted to the nursing home on 10/13/11 with the [DIAGNOSES REDACTED]. Documentation reflected the resident was assessed at high risk for falls and required a 2 person assist for transfer. The intervention for a 2 person assist was included in the Comprehensive Plan of Care and the Resident Care Sheet. Documentation and interview confirmed the resident experienced a fall when she was assisted to stand up to a scale for weight on 12/20/12 with the assistance of 1 CNA. As a result of the fall the resident experienced pain in her left upper extremity and required transfer to the emergency room . The resident was diagnosed with [REDACTED]. The resident returned to the nursing home on 12/20/12 and continued to experienced episodes of pain in her left upper extremity. Findings: 1. Observation of resident #1 on 3/21/13 at 7:30 a.m. revealed S4 CNA, S5 CNA and S6 CNA assisted the resident to weigh. Observation revealed S4 CNA physically assisted the resident as she sat up on the side of the bed. Further observation revealed S6 CNA placed a gait belt around the resident's waist, and S6 CNA and S5 CNA physically assisted the resident to stand and transfer to the weight chair. Observation revealed S4 CNA stood behind the weight chair and assisted with resident positioning and calibration of the scale. Review of the December, 2012 physician's orders [REDACTED]. Further review revealed an order dated 10/13/11 for the use of a 2 person transfer at all times. Review of the resident's Quarterly MDS assessment dated [DATE] (ARD) reflected the resident was totally dependent and required a two person physical assist for bed mobility and transfer. Further review of the assessment reflected the resident had a functional limitation in the range of motion of the left upper and lower extremity on one side. Review of the assessment reflected the active [DIAGNOSES REDACTED]. Review of the resident's Fall Risk assessment dated [DATE] reflected a score of 12 and on 2/21/13 - 18. Review of the assessment reflected the resident was assessed at high risk for fall with a score of 10 or greater. Review of the resident's Comprehensive Care Plan reflected the problem of at High Risk for Falls related to dependent for transfer and related to CVA with Left Hemiparesis. Documentation reflected the goal for the problem was- the resident will remain free of falls and injury with the use of nursing interventions. The problem had the goal dates of 12/13/12, 3/15/13 and 5/25/13. Review of the approaches for the problem reflected the use of a 2 person assist for all transfers. Review of the Resident Care Sheet that was at the resident's bedside reflected the resident was on the Falling Star Program and required a 2 person assist for transfer. Review of resident #1's Nurses' Note dated 12/20/12 reflected the resident had a fall on 12/20/12 at 2:40 p.m. when S4 CNA attempted to stand the resident for weight. Further review of the documentation reflected the resident lost her balance and fell on top of the CNA. Documentation by S9 LPN reflected the resident's shoulder hit the floor and the resident complained of pain in her left upper extremity. Documentation in the nurses' notes reflected the resident was sent to the ER and returned to the facility at 10:50 p.m. with the [DIAGNOSES REDACTED]. Documentation reflected the resident returned with a shoulder immobilizer in place to the left upper extremity. Documentation in the nurses' note dated 12/20/12 at 11:43 p.m. and 12/22/12 at 12:24 a.m. reflected the resident complained of pain and discomfort in the left arm. Interview on 3/20/13 at 2:30 p.m. with S4 CNA confirmed she had attempted to assist the resident to stand for a weight on 12/20/12 and had provided a 1 person assist. Further interview of S4 reflected the resident lost her balance and fell . The S4 CNA stated the instructions for a 2 person assist were posted at the resident's bedside and confirmed the 2 person transfer assist intervention was in place before the 12/20/12 fall occurred. Interview on 3/21/13 at approximately 10:30 a.m. with S9 LPN confirmed she was the resident's nurse on 12/20/12 when the resident fell and was transferred to the ER. Further interview confirmed the above findings in her nurse' note documentation for 12/20/12. Interview on 3/21/13 at 7:55 a.m. with the resident's Clinical Care Coordinator S3 LPN reflected she had been in her current position for the facility approximately 2.5 years. Interview of S3 reflected she was responsible for the resident's MDS Assessment and Care Plan. Interview of S3 confirmed the MDS assessment dated [DATE] reflected the resident had paralysis and weakness in the left upper and left lower extremity, was not steady and required the assistance of two people for transfer. Interview of S3 confirmed the resident was assessed to be at high risk for falls and was care planned for a 2 person assist for transfer related to her risk for fall. Interview of S3 confirmed the resident had required a two person transfer since she was admitted to the facility in 2011. Interview on 3/20/13 at 3:12 p.m. with S2 DON confirmed the Nurse' Note documentation reflected the resident had experienced a fall and injury on 12/20/12 when one CNA had attempted to weigh the resident. Further interview confirmed the resident had been care planned for a 2 person transfer assist at the time of the fall on 12/20/12. Review of the policy for the Fall Prevention Program reflected the goal of the program was to prevent falls by enabling staff to recognize the residents who have been identified as high risk for potential falls so appropriate interventions could be implemented. 2. Observation on 3/20/13 at 11:15 a.m. of resident # 6 revealed he was lying in bed with the bed in a low position. Bilateral, full side rails were up and his call bell was within reach. There was a Resident Care Sheet at the head of the bed that indicated Vander lift x 1 person assistance with all transfers, and wheelchair for ambulation. Interview on 3/20/13 at 11:15 a.m. with resident # 6 revealed he had slurred speech related to [DIAGNOSES REDACTED]. He stated he could not walk. Interview on 3/20/13 at 11:30 a.m. with S11 CNA revealed resident #6 was a high fall risk. She stated interventions to prevent him from falling included, his bed was kept in a low position, the Vander lift was used with the assistance of at least 1 person and a seat belt was used in his wheelchair as a reminder for him not to get up without assistance. S11 CNA stated the Resident Care Sheet and the Kiosk had information regarding the level of care the resident required. Review of the Face Sheet reflected an admission date of [DATE]. Review of the March, 2013 Physician order [REDACTED]. Review of the Fall Risk Assessment form reflected resident # 6 had a score of 9 on 1/24/13. The form reflected a total score of 10 or above indicated a high risk for falls. Review of the hospital re-entry MDS dated [DATE] reflected under Section G (Functional Status) that extensive assistance with 2+ persons physical assistance provided. Interview on 3/21/13 with S12 LPN/MDS confirmed resident # 6 was coded for 2+ persons assistance on the 2/12/13 MDS. She stated the resident was coded with 2+ persons assistance because he had received assistance from 2 persons during the assessment period. She stated he only required 1 person assistance with the use of the Vander lift. Review of the Care Plan for resident #6 reflected a problem indicating high risk for falls related to weakness/impaired mobility, impaired cognition, and poor vision. There was an update on 3/16/13 with a fall/CNA sat resident on the floor. The approaches included the use of a wheelchair for long distance mobility, transfer mechanically with the lift (Vander), encourage resident to assist with transfer, and to keep the bed in its lowest position with wheels locked. On 6/22/12 the approaches were updated to reflect the use of a self-releasing seat belt while in the wheelchair. On 3/16/13 an approach was added that the CNA was written up for not using the Vander lift. Interview on 3/21/13 at 9:20 a.m. with S13 LPN revealed S14 CNA attempted to transfer resident #6 without using the lift on 3/16/13. S13 LPN stated she was on duty that day and S14 CNA reported to her that the she attempted to transfer resident #6 without using the lift. S14 CNA reported to her that the resident became too heavy for her to handle and she had to lower him to the floor. She stated the S14 CNA immediately reported the occurrence to her and the resident was assessed and found to have no obvious injuries. Interview on 3/21/13 at 9:30 a.m. with S14 CNA revealed on 3/16/13 she attempted to transfer resident #6 without using the Vander lift. She stated she asked the treatment nurse to help her but the treatment nurse told her she could not help. S14 CNA stated the treatment nurse told her she may need to use the lift. S14 CNA stated she had transferred the resident the day before without the lift and she thought she could do it again. She stated the resident wasn't helping that day and he became too heavy for her so she had to lower him to the floor. S14 CNA stated the resident did not get hurt and she immediately notified the nurse. S14 CNA stated she had been taught during orientation to use the Resident Care Sheet to find out the assistance required for transferring residents. She stated resident # 6 had a Resident Care Sheet above the head of his bed that indicated he required the use of 1 person with the Vander lift for transfers. Review of the Nurses' Notes for resident # 6 dated 3/16/13 at 12:23 p.m. reflected the lift was not used to transfer and the resident became too heavy so S14 CNA placed him on to the floor. There were no apparent injuries or bruises at that time. The Nurse Practitioner and the responsible party were notified. Interview on 3/21/13 at 9:40 a.m. with S1 Administrator revealed S14 CNA had provided care for resident # 6 on 3/16/13. She stated S14 CNA told her that she asked the treatment nurse to assist her with the transfer of resident # 6 but the treatment nurse told her she could not help and she told her she needed to use the Vander lift. S1 Administrator stated S14 CNA told her she knew she should have used the lift after the treatment nurse told her to look at the Resident Care Sheet. She stated she read the sheet but thought she could transfer the resident by herself. S1 Administrator stated she counseled S14 CNA on Monday, March 18th and told her if this occurred again she would be terminated. Further interview with S1 Administrator revealed when any CNA was hired, instructions were given on how to obtain information regarding the assistance needed to care for residents. She stated a copy of this training was given to each new CNA. S1 Administrator stated S14 CNA should have used the Vander lift to transfer resident # 6 on 3/16/13 but she did not. Review of the Personnel Action form dated 3/18/13 for S14 CNA reflected she was counseled by S1 Administrator regarding failure to use the lift on residents and her next offense would result in her termination. Review of the In-Service Documentation form dated 3/19/13 by S1 Administrator reflected training was done on the use of lifts as instructed on the Resident Care Sheets. 3. Observation of resident #3 on 3/20/13 at 11:35 a.m. reflected the resident was seated in a wheelchair in the DR. Review of the March, 2013 physician's orders [REDACTED]. Review of the Physical Therapist documentation reflected the resident was started on PT on 1/16/13 due to a recent hospitalization and a decline in strength, activity tolerance and functional mobility/transfers with the [DIAGNOSES REDACTED]. The assessment reflected the resident was at High Risk for Falls. Review of S10 PT's Progress Note dated 2/5/13 reflected documentation the resident required maximum assistance (76-99% assist) with verbal instructions and cues for transfer from sit to stand. Interview on 3/21/13 at 11:20 a.m. with S10 PT confirmed documentation in the PT assessment dated [DATE] and the Progress Note dated 2/5/13 reflected the resident required the maximum assistance of 2 people (76-99% assist) for transfers from bed to chair, sit to stand and stand to sit. Review of the Fall Risk assessment dated [DATE] reflected the resident was at high risk for fall with the score of 13 (high risk if score is 10 or >). Review of the Admit MDS assessment dated [DATE] (ARD date) reflected the resident was assessed to require the extensive assistance of a 2 person physical assist for transfer and bed mobility. Further review of documentation reflected the resident was not steady when moved from a seated to standing position and when transferrred from the bed to chair. Documentation reflected the resident had a functional limitation in the range of motion in the upper and lower extremity on one side. Review of the Comprehensive Care Plan reflected the problem of at high risk for falls related to weakness secondary to the [DIAGNOSES REDACTED]. The goal date for the problem was 5/5/13. Further review of the documentation reflected the intervention to assist with transfers as needed, and Falling Star Program. Review of the Resident Care Sheet reflected the resident had Right Sided Paralysis and one person assistance for resident transfer. Review of documentation in the Nurses' Notes by S8 LPN CCC dated 2/6/13 at 11:46 a.m. reflected the resident was transferred from the bed to the wheelchair X 1 CNA and the resident was able to assist by holding onto the SR for transfers and her ability to stand while transferring. Review of the nurses' notes dated 2/6/13 at 11:23 p.m. reflected the resident was lowered to the floor by the CNAs due to the resident's leg weakened and she was not able to stand. Interview on 3/21/13 at 11:41 a.m. with S8 LPN CCC confirmed her documentation in the Nurses' Notes dated 2/6/13 at 11:46 a.m. Interview on 3/21/13 at 11:41 a.m. with S3 LPN CCC reflected the resident's transfer depended on the particular CNA and her capability and experience with the resident and that sometimes one person was able to transfer the resident dependent on how the resident was doing that day. Interview on 3/21/13 at 11:41 a.m. with S2 DON and S3 LPN CCC confirmed the MDS assessment dated [DATE] (ARD) reflected the resident had [DIAGNOSES REDACTED] or hemiparesis and required extensive assistance of 2 person physical assist for transfers and bed mobility. Further interview confirmed the resident's assessment reflected she was not steady when moved from a seated position to standing and when transferred from the bed to the chair and had a functional limitation in ROM with impairment on one side of the upper and lower extremity. Interview with S2 DON and S3 LPN confirmed the resident's assessments reflected the resident required a 2 person assist for transfer, the resident was at high risk for fall and had experienced a fall. Interview of S2 DON confirmed the Comprehensive Care Plan and the Resident Care Sheet had not been modified to reflect the level of assistance that was required for transfer and that was consistent with the resident's documented assessments.