Every finding on record at Bethel Health Care Center

The facility had a census of 57 residents. Based on observation, interview, and record review the facility failed to store food in a safe, sanitary manner to prevent contamination or spoilage in the main food preparation kitchen and the storage building with the walk-in refrigeration units. This placed the 57 residents of the facility at risk for food-borne illness. Findings included: - On 12/16/24 at 08:52 AM, observation of the facility's walk-in refrigerator revealed a crate of grapes on the floor and the walk-in freezer had an opened box with two pies, two boxes of chicken breasts, and a large flat box of strawberries, all on the floor. On 12/16/24 (Monday) at 9:02 AM, Dietary Staff (DS) CC verified the boxes of food delivered by Sysco on the previous Friday were still stored on the floor of the walk-in refrigerator and freezer. On 12/16/24 at 09:10 AM, observation revealed the freezer in the kitchen, labeled for healthcare use, contained the following opened, undated foods: Two bags of frozen peach slices One bag of mango cubes One bag of French fries One bag of frozen potato slices One bag of ham cubes Four buckets of ice cream On 12/16/24 at 09:15 AM, DS DD verified the undated bags of food in the kitchen refrigerator. On 12/17/24 at 11:30 AM, DS EE verified boxes of food should not be on the bare floor. He stated staff tried to put away the deliveries after meals or whenever they could. On 12/17/24 at 01:00 PM, DS FF verified the delivery people sometimes left boxes of food on the floor and staff would put the items in the appropriate place after the meal was served. On 12/17/24 at 16:40 PM, Consultant GG verified staff were not to store boxes of food items on the floor and were to date food packages when opened. She verified Sysco delivered food on Tuesdays and Fridays. The facility's Food Storage policy, dated 04/23/24, stated sufficient storage facilities would be provided to keep foods safe. Food would be stored in an area that was clean, dry, and free from contaminants. Food would be stored at appropriate temperatures and by methods to prevent contamination. Dry storage rooms must be well-ventilated and illuminated with adequate temperature and humidity controls to prevent condensation of moisture and the growth of mold. Food items would be stored on shelves. Food should be stored a minimum of six inches above the floor and 18 inches from the ceiling. All foods should be covered, labeled, and dated routinely to assure that foods would be consumed by their use dates, frozen, or discarded. Frozen foods should be covered, labeled, and dated. The facility failed to store food in a safe, sanitary manner to prevent contamination or spoilage. This placed the 57 residents of the facility at risk for food-borne illness.

The facility identified a census of 57 residents. The sample included 15 residents. Based on interviews and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and non-routine situations that impact staffing and resident care. This failure placed all 57 residents residing in the facility at risk for impaired care. Findings Included: - An inspection of the Facility Assessment 2024 dated July 2024 provided by the facility on 12/16/24 revealed the following: The assessment identified the faciliy had 65 dually certified beds, with an average census of 57. The assessment included a staff compentnenceis tab which listed the skill sets for all depratments. The assessment had a personnel tab which stated staff assignment were based on the acuity og the neighborhoods and staffw ere assigned to specific neighborhoofd for icnreased continuity of care. A review of the entire Facility Assessment 2024 under all tabs revealed the assessment did not identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, on each shift including weekends. The assessment lacked an informed contingency plan for events that do not require activation of the facility's emergency plan but have the potential to impact staffing and resident care. The assessment lacked a plan to maximize recruitment and retention of direct care staff. The facility provided an additional document for review, the Bethel Health Care Facility Wide Resource assessment dated [DATE]. This document also lacked the above information (specific staffing level and staffing contingency plan for events that do not meet emergency criteria but still have the ability to impact staffing and resident care). On 12/17/24 at 03:45 PM Administrative Staff A stated the facility assessment was currently what they had gathered and implemented into utilizing the current facility assessment. The facility Facility Wide Resource Assessment(FWRA) policy dated 07/31/24 documented that the Bethel Health Care Center FWRA is required by the nursing home Requirements of Participation to identify and analyze Bethels Health Care Center's resident population and identify the personnel, physical plant, environmental and emergencies response resources needed to completely care for the residents during day-to-day operations and emergencies. The FWRA serves as a resource to support decision-making regarding the day-to-day operations and resources to support the operations. The FWRA collects information about the resident population to identify the number of residents; facility capacity; the care required; staff competencies; the ethnic, cultural, and religious aspects of the unique resident population; physical; and personnel resources needed; contractual agreements; health information technology resources; environment; equipment, supplies and other services utilized. Resources are identified and evaluated to ensure that care can be provided to meet resident's needs during day-to-day and emergency operations. The FWRA would be reviewed annually and updated as needed based on changes in the resident population, new types of care and services provided, or new technology, equipment, or other resources introduced. The facility failed to conduct a thorough, updated facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and events that had the potential to impact staffing and resident care. This failure placed all 57 residents residing in the facility at risk for impaired care.

The facility had a census of 58 residents. The sample included 16 residents with, one reviewed for dignity. Based on observation, record review, and interviews, the facility failed to promote care in a manner to maintain and enhance dignity and respect for one sampled resident, Resident (R) 38, who required assistance with meals. This placed the resident at risk for impaired dignity and decreased psychosocial well-being. Findings included: - The Electronic Medical Record (EMR) for R38 recorded diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and weakness (the state or condition of lacking strength). R38's Quarterly Minimum Data Set (MDS), dated [DATE], documented R38 had moderately impaired cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment further documented R38 required supervision with one staff for meals; she held food in her mouth/cheeks or had residual food in her mouth after meals, and received a mechanically altered diet. The Activities of Daily Living [ADL] Care Plan, dated, 01/17/23 documented R38 would benefit from assistance with ADL cares due to her anxiety, cognitive impairment, and weakness. The care plan directed staff to assist with ADL cares as she allowed, as R38 had become more accepting of assistance and offer, instead of asking, if she needed help. The care plan further documented R38's left arm was weak, and some things were difficult for her to do. The EMR documented R38 was placed into hospice care on 10/05/22. On 01/18/23 at 12:12 PM, observation revealed R38's meal tray was on a small black table that was positioned off to her right side. Further observation revealed a Styrofoam bowl of melted chocolate ice cream, in an empty fruit bowl, positioned on its side, and the ice cream had spilled over onto the food tray. R38 had a grilled cheese sandwich, untouched that was still partially in the aluminum foil it came in. Continued observation revealed R38 had chocolate running down her chin from her mouth and had a chunk of peaches on her face. R38 did not receive staff assistance per the observation. On 01/19/23 at 12:19 PM, R38 stated she required a lot of assistance and she would love it if staff would sit with her at meals to visit with her and to help her when she needed it. On 01/19/23 at 12:25 PM, Administrative Nurse E stated R38 had been declining and required assistance at meals, even if just sitting and visiting with R38. Administrative Nurse E further stated it was not dignified for R38 to have food running down her face and understood the need for staff to assist R38. On 01/23/23 at 10:40 AM, Administrative Nurse D stated anyone can get messy in a short period of time and that R38's abilities for self-care fluctuated. On 01/23/23 at 11:00 AM, Certified Nurse Aide (CNA) M stated R38 received hospice care and was totally dependent upon staff for all of her care. CNA M further stated R38 ate her meals in her room but had trouble staying awake during the meal. CNA M acknowledged R38's need for assistance with meals. The facility Dignity policy, undated, documented residents at the village would have certain rights and protections under Federal Law that would help and ensure they get care and services needed, the policy further documented, residents have the right to be treated with respect and dignity, and have the right to a safe, comfortable, and homelike environment that allowed residents to be as independent as possible. The facility failed to promote care for R38 in a manner to maintain and enhance dignity and respect. This placed the resident at risk for impaired dignity and decreased psychosocial well-being.

The facility had a census of 58 residents. The sample included 16 residents, with five reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide one sampled resident, Resident (R) 38 with the necessary level of assistance for eating. This placed the resident at risk for weight loss. Findings included: - The Electronic Medical Record (EMR) for R38 recorded diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and weakness (the state or condition of lacking strength). R38's Quarterly Minimum Data Set (MDS), dated [DATE], documented R38 had moderately impaired cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment further documented R38 required supervision with one staff for meals; she held food in her mouth/cheeks or had residual food in her mouth after meals, and received a mechanically altered diet. The ADL Care Plan, dated, 01/17/23 documented R38 would benefit from assistance with ADL cares due to her anxiety, cognitive impairment, and weakness. The care plan directed staff to assist with ADL cares as she allowed, as R38 had become more accepting of assistance and offer, instead of asking, if she needed help. The care plan further documented R38's left arm was weak, and some things were difficult for her to do. The EMR documented R38 was placed into hospice care on 10/05/22. On 01/18/23 at 12:12 PM, observation revealed R38's meal tray was on a small black table that was positioned off to her right side. Further observation revealed a Styrofoam bowl of melted chocolate ice cream, in an empty fruit bowl, positioned on its side, and the ice cream had spilled over onto the food tray. R38 had a grilled cheese sandwich, untouched that was still partially in the aluminum foil it came in. Continued observation revealed R38 had chocolate running down her chin from her mouth and had a chunk of peaches on her face. R38 did not receive staff assistance per the observation. On 01/19/23 at 12:19 PM, R38 stated she required a lot of assistance and she would love it if staff would sit with her at meals to visit with her and to help her when she needed it. On 01/19/23 at 12:25 PM, Administrative Nurse E stated R38 had been declining and required assistance at meals, even if just sitting and visiting with R38. Administrative Nurse E further stated it was not dignified for R38 to have food running down her face and understood the need for staff to assist R38. On 01/23/23 at 10:40AM, Administrative Staff A stated the care plan team would look at R38's care plan and would update it to reflect R38's need for assistance at meal times. On 01/23/23 at 11:00 AM, Certified Nurse Aide (CNA) M stated R38 received hospice care and was totally dependent upon staff for all of her care. CNA M further stated R38 ate her meals in her room but had trouble staying awake during the meal. CNA M acknowledged R38's need for assistance with meals. Upon request a policy for ADL assistance was not provided by the facility. The facility failed to provide an adequate level of meal assistance for cognitively impaired R38, placing the resident at risk for weight loss.

The facility had a census of 58 residents. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication for Resident (R) 47's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment in reality testing) medication, Seroquel. This placed the resident at risk for adverse side effects related to antipsychotic use. Findings included: - The Electronic Medical Record (EMR) for R47 recorded diagnoses of dementia with behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). R47's 5 Day Medicare Minimum Data Set, dated dated [DATE], documented R47 had long and short term memory problems with moderately impaired decision making skills and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and ambulation in the corridors. The MDS further documented R47 had disorganized thinking, verbal behaviors, rejection of care, wandering, had delusions (something that is believed to be true or real but that is actually false or unreal), and received an antipsychotic medication seven days during the lookback period. R47's Care Plan, dated 10/31/22, documented R47 had a history of aggressive behaviors, used antipsychotic medication for dementia with behaviors, and received psychiatric services. The care plan directed staff to administer medication as ordered by the physician, observe for and report any side effects, review the use of psychotropic medication use with the resident and/or family as needed. R47's Abnormal Involuntary Movement Scale (AIMS), (assessment for detection of involuntary movements related to use of antipsychotic medication) dated 11/09/22, recorded a score of 0 (a score of two or higher indicated the resident has involuntary movements). The Physician Orders, dated 04/20/22, directed staff to administer the resident Seroquel (antipsychotic), 25 milligrams (mg) by mouth in the morning for dementia without behavioral disturbance. The Physician Orders, dated 09/29/22, directed staff to administer the resident Seroquel, 75 mg twice a day for dementia with behavioral disturbance. The order further directed staff to administer 25 mg and 50 mg tablets to equal 75 mg. The Psychiatry Progress Note dated 11/30/22 documented R47 had diagnoses of dementia with behavioral disturbance, delusional disorder, insomnia (difficulty sleeping) and anxiety. The note, under the Symptom Description and Subjective Report recorded R47 was oriented to person but disoriented to place and time. R47 had exit seeking at times and was redirectable. Staff reported R47 had some falls, but no dizziness. R47 continued to have some wandering and exit-seeking at night time but was mostly redirectable. The section Response to Medication recorded only not specified. The note recorded R47 continued Seroquel 25 mg in the morning, 75 mg in the afternoon and 75 mg at bedtime in the Existing Prescribed Medication and Medication Moving Forward sections, though both sections were blank under the Symptoms Being Treated fields. On 01/17/23 at 02:31 PM, observation revealed R47 independently ambulated down the west hall without an assistive device. Further observation revealed R47 was turning right to go down a small hallway which led to another resident household. Administrative Nurse E saw the resident and went to assist him back to his room for toileting assistance. On 01/19/23 at 09:00 AM, Administrative Nurse E stated R47 had behaviors and at times required 1:1 assistance. On 01/23/23 at 10:40 AM, Administrative Nurse D stated staff spend a lot of time with R47 and he required Seroquel medication. Administrative Nurse D stated he would investigate the diagnosis and asked if he just needed to get the diagnosis changed. The facility Policy and Procedure Antipsychotic Medications policy, undated, documented the interdisciplinary team would ensure any resident who used antipsychotic drugs received gradual dose reduction and behavioral interventions unless clinically contraindicated in an effort to discontinue these drugs to ensure the resident did not receive unnecessary medications and the lowest possible dose was administered for the shortest amount of time. The policy further documented, residents who have not used antipsychotic drugs was not given the drug unless antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the resident's clinical record. The facility failed to ensure an appropriate indication for the use of R47's Seroquel, placing the resident at risk for adverse side effects.

The facility reported a census of 59 residents, with four residents sampled. Based on observation, interview and record review, the facility failed to prevent cross contamination for one of four residents, Resident (R) 1 when staff failed to prevent a urinary catheter (insertion of a catheter into the bladder to drain urine into a collection bag) collection bag from lying on the floor without a barrier. Findings included: - The Physician order [REDACTED]. The significant change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating she had moderate cognitive impairment. She had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) and required extensive assistance of two staff for toileting. The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 12/03/2019, documented the resident had an indwelling catheter in place due to [MEDICAL CONDITION]. The quarterly MDS, dated [DATE], documented the resident had a BIMS score of 6, indicating she had severe cognitive impairment. She had an indwelling urinary catheter and required total assistance of two staff for toileting. The Activities of Daily Living (ADL) care plan, dated 04/30/2020, documented the resident required assistance of two staff for ADLs. On 06/24/2020 at 09:28 AM, the resident sat in her wheelchair in her room. The urinary catheter collection bag lay directly on the floor without a barrier. On 06/24/2020 at 10:31 AM, Certified Nurse Aide (CNA) M, stated she had gotten the resident up that morning. CNA M stated the collection bag should not lie directly on the floor. On 06/24/2020 at 02:05 PM, Administrative Nurse D stated the resident's catheter collection bag should not have rested directly on the floor. The facility's policy for Daily Urinary Catheter Change, undated, documented staff were to make sure the catheter tubing and drainage bag were kept off of the floor. The facility failed to prevent cross contamination when staff failed to keep the urinary catheter collection bag from coming into direct contact with the floor.

The facility reported a census of 59 residents with 17 selected for review. Based on observation, interview and record review, the facility failed to ensure one resident, Resident (R) 42's, health information regarding her [DIAGNOSES REDACTED]. Findings included: - Review of R42's Physician order [REDACTED]. Observation, on 09/04/19 at 12:31 PM, revealed the resident seated in the common dining room finishing her noon meal. Another unidentified resident and Certified staff P remained in the dining room with various staff and residents walking by the dining area. Consulting staff GG began conversing with the resident, in a normal voice, to encourage the resident to go outside. Staff GG stated, to the resident, Research shows that people with [MEDICAL CONDITION] Disorder benefit from being outside. Interview, on 09/05/19 at 4:30 PM, with administrative nursing staff D, indicated the expectation that all staff ensure confidentiality of resident diagnoses. Interview, on 09/09/19 at 1:30 PM, with Consulting staff GG, revealed he realized he violated the resident's right to privacy when he spoke about [MEDICAL CONDITION] Disorder to the resident. The facility policy titled, Notice of Privacy Information Practices, dated 9-23-13, indicated confidential information about residents to unauthorized persons is strictly prohibited. The facility failed to ensure staff kept this resident's health information including her [DIAGNOSES REDACTED].

The facility reported a census of 59 residents, with 17 selected for review. Based on observation, interview, and record review the facility failed to review and revise the care plans to acurately provide the care for two Residents (R) 20, related to fall prevention, and R6 related to the use of geri sleeves. Findings Included: - The Physician order [REDACTED]. and pain). The Significant change Minimum Data Set (MDS), dated [DATE], recorded the resident admitted on [DATE]. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition and she had a short and long-term memory problem. She had range of motion impairment on one side of her upper extremity and impairment to both sides of her lower extremities. She required extensive assistance of two staff members with bed mobility, transfers, dressing, and toileting, required the extensive assistance of one staff member for locomotion on and off the unit, and with her personal hygiene. She had 2 or more falls since the prior assessment with one injury, not major, and one major injury. The Quarterly MDS, dated [DATE], indicated the resident had a BIMS score of 99, which indicated severely impaired cognition. She had disorganized thinking, inattention present and that did not fluctuate through the day and wandered daily. Her balance while walking was not steady and was only able to stabilize with extensive assistance of one staff member. She required extensive assist of 1 staff for transfer and ambulation. She had one fall with injury since prior assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/11/18, indicated the staff were unable to complete the BIMS as the resident simply smiled at the nurse when she attempted to ask her questions. The Falls CAA, dated 10/11/18, indicated staff used a motion sensor remote alarm as the resident's dementia was profound and that she did not use the call light. She had no safety awareness and simply got up to move to do what she needed (such as toileting). The CAA indicated that the alarm in no way limited her movements and that it did not keep her from doing what she was trying to do. The alarm simply alerted the staff of her movements to allow the staff to go and help with her needs. The Fall Risk Assessment, identified a score of 10 to 99 indicated the resident was at a high risk for falls. Fall Risk Assessment's completed and scored as follows: 12/13/18 score of 21; 01/01/19 score of 21; 01/29/19 score of 26; 03/28/19 score of 25; 05/21/19 score of 28; 08/01/19 score of 28; 08/11/19 score of 32; and 09/08/19 score of 32. A fall risk assessment for the fall on 03/10/19 was not completed. The fall care plan, dated 05/21/19, indicated the resident had falls on 01/01/19; 01/29/19; 03/10/19; 03/28/19; and 05/21/19. The care plan had written in notes for falls on 08/01/19; and 08/11/19. The care plan lacked an update after the fall on 12/13/18 in which the resident was wearing slip on shoes and included the following interventions: 10/14/18 - staff were to encourage her to wear tennis shoes and not to wear slip on shoes 10/17/18 - was to wear non-skid footwear 01/29/19 -place a pressure sensitive alarm to her bed, wheelchair and recliner, (no date documented) - place an auto locking brake system on her wheelchair. 03/28/19 - Encourage resting in visible areas to promote safety. 08/01/19 - Staff to keep floor free of small items. (Already put into place on fall investigation dated 12/13/18). 08/11/19 - Keep resident close as she is very unsteady (Same as 03/28/19). The facilities Fall Investigation, dated 12/13/18, recorded a fall on 12/13/18. R20 had been sleeping in a chair in her room, and staff found the resident lying on her right side on the floor, next to the chair, in front of the closet door. The investigation further documented there was a small piece of food next to her on the floor, she had on slip on shoes (care planned 10/14/18 not to wear slip on shoes), and had been toileted at approximately 09:30 PM. The indicated intervention directed staff to ensure there was no debris left on the floor by the resident. The care plan lacked evidence of an updated intervention for this fall. The Nursing Note, dated 03/28/19 at 07:32 PM, documented the resident attempted to stand from the recliner, landing on her knees with no injury noted. Intervention was to rest in populated areas. The Nursing Note, dated 05/21/19 at 02:49 AM, indicated the resident had a fall resulting in a laceration to her forehead requiring sutures. The note indicated that the resident was observed by facility staff to stand up from her wheelchair and fall forward, with the alarm sounding. The intervention directed when staff noticed the resident becoming restless to offer her a change. For example, help her to a different chair or take her to the bathroom . The Nursing Note, dated 08/01/19 at 10:02 PM, indicated the resident had a fall when she attempted to pick up small debris from the floor around the trash can. The intervention noted on the care plan was to continue to keep small trash off the floor around the resident. This was a repeat of the resident's action for the fall on 12/13/18 . The Nursing Note, dated 08/11/19 at 09:13 PM, indicated that R20 had a fall after she stood up from the recliner and lost her balance. The resident's personal alarm alerted staff. The intervention was to keep her close as she is unsteady. This was a repeat intervention from the fall on 03/28/19 (Encourage resting in visible areas to promote safety). Observation, on 09/04/19 at 11:13 AM, R20 observed with aid of Certified Nurse Aide (CNA) O and Licensed Nurse (LN) G stand up from the recliner in West POD area and ambulated her. R20 had a steady gait, a gait belt in place, one staff assisted and one pushed wheelchair behind, to her bathroom. On 09/05/19 at 01:30 PM, (CNA) O, reported R20 was to have an alarm in place, and to keep her busy. She stated R20 had multiple falls and she knows to look at the care plan for new interventions. On 09/05/19 at 03:03 PM, Licensed Nurse (LN) G, stated the intervention and update of the care plan was the responsibility of the nurse present at the time of the fall. She stated she did check as she was performing her tasks by asking the CNA's if they had followed the planned interventions. She stated the new interventions are shared to all staff through emails, clip board (tool used to report resident status at the end of the shift), and report. She confirmed that the interventions on both the 08/01/19 and the 08/11/19 falls were duplicates of previous falls. Observation, on 09/09/19 at 07:40 AM, revealed R20 sitting in the recliner in West POD area, alarm in place, call light within reach, shoes on. R20 had a dressing in place above her right eye, with bruising noted over her right eye and down her right cheek. On 09/09/19 at 02:00 PM, Administrative Nurse D, indicated the interventions, even though duplicated, were appropriate for the falls. Staff D stated it was unrealistic to expect new interventions if there was an intervention in place that worked for that fall. Staff D indicated R20 had a fall on 09/08/19, and the intervention was to have two staff with all planned transfers. On 09/09/19 at 02:00 PM, Administrative Nurse D, stated the interventions, even though duplicated, were appropriate for the falls. He stated that it was unrealistic to expect new interventions if there was an intervention in place that worked for that fall. He did indicate he knew R20 had a fall on 09/08/19, and that he knew the intervention was to have two staff with all planned transfers. Review of the facility's undated policy titled, Changes to Care Plan, indicated the procedure for falls would be that the care plan will be revised after every fall to include specific instructions to the staff based on the causal factors identified at the time of the occurrence and during the fall investigatory process to prevent or reduce the possibility for recurrence of a fall. Review of the facility's undated policy titled, Fall Prevention and Fall Follow-up, indicated the procedure of a prevention protocol will be initiated with documentation on the care plan. The facility failed to review and revise the fall care plan for this resident to ensure the resident remained free of repeated falls. - Review of Resident (R) 6's Physician order [REDACTED]. (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). Review of the admission Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS indicated the resident required extensive assistance of 1 staff for bed mobility, transfer and dressing. The resident had impairment in range of motion in both upper and lower extremities bilaterally. This MDS indicated the resident admitted to the facility with a stage two pressure ulcer and a skin tear. The quarterly MDS, dated [DATE], indicated the resident's BIMS score of 14, required extensive assistance of 1 staff for bed mobility, transfer and dressing. The resident had impairment in range of motion in his upper and lower extremities. The Pressure Ulcer Care Area Assessment (CAA), dated 6-7-19, assessed the resident with multiple bruises on both arms as well as scabs on skin. Nursing staff presented the resident with gerisleeves (soft protective sleeve like devises to protect skin) and the resident agreed to wear the sleeves to help prevent skin tears and bruising. The care plan, dated 05/28/19 advised staff of the resident's fragile skin and staff were to assist him with position changes. The care plan lacked evidence instructing staff to assist the resident to apply the gerisleeves to protect the resident's fragile skin. A nurses' note, dated 08/12/19, indicated the resident had a skin tear to his left forearm from a change in clothing and staff cleaned the area and applied a dressing. This note lacked measurements of the skin tear or the dressing type. Observation, on 09/03/19 at 10:51 AM, revealed the resident seated in his recliner in his room. The resident had an approximate six centimeter (cm) bruise on his left forearm with a darker blue/purple raised area in the center of the bruise. The resident did not have gerisleeves on. The resident appropriately answered questions and stated he did not know how or when the bruise occurred. The resident stated he had a skin tear several weeks ago on his left arm. The resident stated he did not think the skin tear was in the area of the bruise. Interview, on 09/05/19 at 10:00 AM with Licensed Nurse G revealed she did not know how or when the resident obtained the bruise on his left forearm. Observation, on 09/05/19 at 10:00 AM, revealed the resident seated in his recliner in his room. The resident did not have gerisleeves on. Licensed Nurse G measured the bruise area, at that time, as. Staff G noted the darker raised area in the bruise and measured it as 2.3 cm by 2.4 cm. Staff G stated she would document the bruise in the electronic record. Interview, on 09/05/19 at 11 :00 AM, with Certified Nurse Aide M, revealed she did not know the resident had a bruise on his left forearm, but that the resident usually did have areas of bruising on his arms. Interview , on 09/09/19 at 02:24 PM with Licensed Nursing Staff G, stated she did assess the resident, on 08/12/19, for a skin tear and documented this in a nurses' note dated 8-12-19. Staff G stated skin tears should be monitored daily and measured weekly on the MAR/TAR or under the Skin Assessment tab. Staff G did not enter and intervention on the care plan as the resident. Staff G stated the Certified Nurse Aides report skin irregularities to the charge nurse when they bathe the resident or at any other time such as when assisting the resident with dressing. Staff G stated the resident received a bath on evening shift on Tuesdays and Fridays. Interview, on 09/09/19 at 11:00 AM with Administrative Nurse D, confirmed the CAA for Pressure ulcers, dated 6-10-19, indicated gerisleeves should be applied to the resident's arms, but was not written on the care plan. Staff D stated staff should document skin tears and bruises on the MAR indicated [REDACTED]. Staff D confirmed nursing staff did not document the left forearm bruising until 09/05/19 or put any interventions in place on the care plan. The facility Changes to Care Plan policy, undated, instructed staff that changes due to an adverse event may require an update to the plan of care. The facility failed to review and revise this resident's plan of care to include gerisleeves after the resident experienced a skin tear (8-12-19) and left forearm bruise (6.1 centimeter (cm) by 9.4 cm.) and failed to ensure staff assisted the resident to apply the protective gerisleeves to prevent further bruising and skin tears.

The facility reported a census of 59 residents with 17 selected for review which included one resident reviewed for skin conditions. Based on observation, interview and record review, the facility failed to ensure monitoring for the one resident reviewed, Resident (R) 6's skin tear and right forearm bruise. Findings included: - Review of Resident (R) 6's Physician order [REDACTED]. (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). Review of the admission Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score of 14, indicatingintact cognition. The MDS indicated the resident required extensive assistance of 1 staff for bed mobility, transfer and dressing. The resident had impairment in range of motion in both upper and lower extremities bilaterally. This MDS indicated the resident admitted to the facility with a stage two pressure ulcer and a skin tear. The quarterly MDS, dated [DATE], indicated the resident's BIMS score of 14, required extensive assistance of 1 staff for bed mobility, transfer and dressing. The resident had impairment in range of motion in his upper and lower extremities. The Pressure Ulcer Care Area Assessment (CAA), dated 6-7-19, assessed the resident with multiple bruises on both arms as well as scabsoskin. Nursing staff presented the resident with gerisleeves (soft protective sleeve like devises to protect skin) and the resident agreed to wear the sleeves to help prevent skin tears and bruising. The care plan, dated 05/28/19 advised staff of the resident's fragile skin and staff were to assist him with position changes. The care plan lacked evidence instructing staff to assist the resident to apply the gerisleeves to protect the resident's fragile skin. A nurses' note, dated 08/12/19, indicated the resident had a skin tear to his left forearm from a change in clothing and staff cleaned the area and applied a dressing. This note lacked measurements of the skin tear or the dressing type. Review of the electronic medical record under the tab Skin Assessment, lacked documentation of the skin tear. Review of the Medication Administration Record (MAR) and the Treatment Administration Record, for (MONTH) 2019 lacked documentation of the skin tear. Observation, on 09/03/19 at 10:51 AM, revealed the resident seated in his recliner in his room. The resident had an approximate six centimeter (cm) bruise on his left forearm with a darker blue/purple raised area in the center of the bruise. The resident did not have gerisleeves on. The resident appropriately answered questions and stated he did not know how or when the bruise occurred. The resident stated he had a skin tear several weeks ago on his left arm. The resident stated he did not think the skin tear was in the area of the bruise. Interview, on 09/05/19 at 10:00 AM with Licensed Nurse G revealed she did not know how or when the resident obtained the bruise on his left forearm. Observation, on 09/05/19 at 10:00 AM, revealed the resident seated in his recliner in his room. The resident did not have gerisleeves on. Licensed Nurse G measured the bruise area, at that time, as 6.1 cm by 9.4 cm. Staff G noted the darker raised area in the bruise and measured it as 2.3 cm by 2.4 cm. Staff G stated she would document the bruise in the electronic record. Interview, on 09/05/19 at 11 :00 AM, with Certified Nurse Aide M, revealed she did not know the resident had a bruise on his left forearm, but that the resident usually did have areas of bruising on his arms. Interview, on 09/09/19 at 02:24 PM with Licensed Nursing Staff G, stated she did assess the resident, on 08/12/19, for a skin tear and documented this in a nurses' note dated 8-12-19. Staff G stated skin tears should be monitored daily and measured weekly on the MAR/TAR or under the Skin Assessment tab. Staff G stated the Certified Nurse Aides report skin irregularities to the charge nurse when they bathe the resident or at any other time such as when assisting the resident with dressing. Staff G stated the resident received a bath on evening shift on Tuesdays and Fridays. Interview, on 09/09/19 at 11:00 AM with Administrative Nurse D, confirmed the , dated 6-10-19, indicated gerisleeves should be applied to the resident's arms, but was not written on the care plan. Staff D stated staff should document skin tears and bruises on the MAR or Skin Assessment Sheet for monitoring and confirmed this was not done for the skin tear the resident obtained on 08/12/19. Staff D confirmed nursing staff did not document the left forearm bruising until 09/05/19 or put any interventions in place. Interview, on 09/09/9 at 11:00 AM, with Administrative Nursing staff F, revealed she offered the gerisleeves to the resident today . The facility Skin and Wound policy, dated 9/2019, indicated a resident with a noted alteration in skin integrity will receive treatment per facility protocol to promote optimal healing. Bruises will be entered onto the MAR and monitored for at least 5 days. This policy indicated staff to monitor wounds daily. The facility failed to monitor this resident's skin tear (8-12-19), failed to identify the left forearm bruise (6.1 centimeter (cm) by 9.4 cm.) and failed to ensure staff assisted the resident to apply the protective gerisleeves to prevent further bruising and skin tears.

The facility reported a census of 59 residents, with 17 selected for review, including five residents reviewed for accidents. Based on observation, interview, and record review the facility failed to ensure one of the five residents reviewed received supervision and assistive devices to remain free of accidents, including Resident (R) 20 who experienced falls with repeated ineffective interventions implemented including keeping debris picked up around the resident, keeping the resident close and in populated areas during periods of rest and ensure the resident did not wear slip on shoes. Findings Included: - The Physician order [REDACTED]. and pain). The Significant change Minimum Data Set (MDS), dated [DATE], recorded the resident admitted on [DATE]. The MDS indicated the resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition and she had a short and long-term memory problem. She had range of motion impairment on one side of her upper extremity and impairment to both sides of her lower extremities. She required extensive assistance of two staff members with bed mobility, transfers, dressing, and toileting, required the extensive assistance of one staff member for locomotion on and off the unit, and with her personal hygiene. She had 2 or more falls since the prior assessment with one injury, not major, and one major injury. The Quarterly MDS, dated [DATE], indicated the resident had a BIMS score of 99, which indicated severely impaired cognition. She had disorganized thinking, inattention present and that did not fluctuate through the day and wandered daily. Her balance while walking was not steady and was only able to stabilize with extensive assistance of one staff member. She required extensive assist of 1 staff for transfer and ambulation. She had one fall with injury since prior assessment. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 10/11/18, indicated the staff were unable to complete the BIMS as the resident simply smiled at the nurse when she attempted to ask her questions. The Falls CAA, dated 10/11/18, indicated staff used a motion sensor remote alarm as the resident's dementia was profound and that she did not use the call light. She had no safety awareness and simply got up to move to do what she needed (such as toileting). The CAA indicated that the alarm in no way limited her movements and that it did not keep her from doing what she was trying to do. The alarm simply alerted the staff of her movements to allow the staff to go and help with her needs. The Fall Risk Assessment, identified a score of 10 to 99 indicated the resident was at a high risk for falls. Fall Risk Assessment's completed and scored as follows: 12/13/18 score of 21; 01/01/19 score of 21; 01/29/19 score of 26; 03/28/19 score of 25; 05/21/19 score of 28; 08/01/19 score of 28; 08/11/19 score of 32; and 09/08/19 score of 32. A fall risk assessment for the fall on 03/10/19 was not completed. The fall care plan, dated 05/21/19, indicated the resident had falls on 01/01/19; 01/29/19; 03/10/19; 03/28/19; and 05/21/19. The care plan had written in notes for falls on 08/01/19; and 08/11/19. The care plan lacked an update after the fall on 12/13/18 in which the resident was wearing slip on shoes and included the following interventions: 10/14/18 - staff were to encourage her to wear tennis shoes and not to wear slip on shoes 10/17/18 - was to wear non-skid footwear 01/29/19 -place a pressure sensitive alarm to her bed, wheelchair and recliner, (no date documented) - place an auto locking brake system on her wheelchair. 03/28/19 - Encourage resting in visible areas to promote safety. 08/01/19 - Staff to keep floor free of small items. (Already put into place on fall investigation dated 12/13/18). 08/11/19 - Keep resident close as she is very unsteady (Same as 03/28/19). The facilities Fall Investigation, dated 12/13/18, recorded a fall on 12/13/18. R20 had been sleeping in a chair in her room, and staff found the resident lying on her right side on the floor, next to the chair, in front of the closet door. The investigation further documented there was a small piece of food next to her on the floor, she had on slip on shoes (care planned 10/14/18 not to wear slip on shoes), and had been toileted at approximately 09:30 PM. The indicated intervention directed staff to ensure there was no debris left on the floor by the resident. The care plan lacked evidence of an updated intervention for this fall. The Nursing Note, dated 03/28/19 at 07:32 PM, documented the resident attempted to stand from the recliner, landing on her knees with no injury noted. Intervention was to rest in populated areas. The Nursing Note, dated 05/21/19 at 02:49 AM, indicated the resident had a fall resulting in a laceration to her forehead requiring sutures. The note indicated that the resident was observed by facility staff to stand up from her wheelchair and fall forward, with the alarm sounding. The intervention directed when staff noticed the resident becoming restless to offer her a change. For example, help her to a different chair or take her to the bathroom . The Nursing Note, dated 08/01/19 at 10:02 PM, indicated the resident had a fall when she attempted to pick up small debris from the floor around the trash can. The intervention noted on the care plan was to continue to keep small trash off the floor around the resident. This was a repeat of the resident's action for the fall on 12/13/18 . The Nursing Note, dated 08/11/19 at 09:13 PM, indicated that R20 had a fall after she stood up from the recliner and lost her balance. The resident's personal alarm alerted staff. The intervention was to keep her close as she is unsteady. This was a repeat intervention from the fall on 03/28/19 (Encourage resting in visible areas to promote safety). Observation, on 09/04/19 at 11:13 AM, R20 observed with aid of Certified Nurse Aide (CNA) O and Licensed Nurse (LN) G stand up from the recliner in West POD area and ambulated her. R20 had a steady gait, a gait belt in place, one staff assisted and one pushed wheelchair behind, to her bathroom. On 09/05/19 at 01:30 PM, (CNA) O, reported R20 was to have an alarm in place, and to keep her busy. She stated R20 had multiple falls and she knows to look at the care plan for new interventions. On 09/05/19 at 03:03 PM, Licensed Nurse (LN) G, stated the intervention and update of the care plan was the responsibility of the nurse present at the time of the fall. She stated she did check as she was performing her tasks by asking the CNA's if they had followed the planned interventions. She stated the new interventions are shared to all staff through emails, clip board (tool used to report resident status at the end of the shift), and report. She confirmed that the interventions on both the 08/01/19 and the 08/11/19 falls were duplicates of previous falls. Observation, on 09/09/19 at 07:40 AM, revealed R20 sitting in the recliner in West POD area, alarm in place, call light within reach, shoes on. R20 had a dressing in place above her right eye, with bruising noted over her right eye and down her right cheek. On 09/09/19 at 07:45 AM, CNA O stated R20 had a fall on 09/08/19 when she stood up from her wheelchair and she (CNA O) removed the pressure pad alarm. CNA O assisted the resident to sit back in the wheelchair. CNA O turned around to place and connect the alarm pad in the recliner, the resident stood up, tripped over CNA O's foot, and hit her head/ face on the tv stand in the POD (an open area in the facility for the residents to relax). The facility sent the resident to the emergency room for evaluation and treatment. Her daughter brought her back to the facility. The printed paper Care Plan recorded the new intervention directed staff to have two people present for all planned transfers with the resident. On 09/09/19 at 02:00 PM, Administrative Nurse D, indicated the interventions, even though duplicated, were appropriate for the falls. Staff D stated it was unrealistic to expect new interventions if there was an intervention in place that worked for that fall. Staff D indicated R20 had a fall on 09/08/19, and the intervention was to have two staff with all planned transfers. Review of the facility's undated policy titled, Fall Prevention and Fall Follow up, indicated the objective was to assess residents for the potential of falls and to identify causal factor, if any, after initial falls. A prevention protocol will be initiated with documentation on the care plan. Prevention protocol 1) Root cause analysis for will be completed for all falls. 4) Keep all items (i.e.: call light, bathroom lights on at night, water, etc.) within reach. 6) In limited circumstances, the use of a personal alarm, bed and/or chair alarms may be indicated. The facility failed to implement appropriate interventions to prevent further falls for R20 when they repeated interventions already in place which failed to prevent the resident from experiencing further falls.

The facility reported a census of 59 residents with 17 selected for review, including 5 residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to notify the physician for further instruction of one of the 5 resident's reviewed, Resident (R) 13's continued refusal of a respiratory medication to prevent respiratory complications. Findings included: - Review of Resident (R)13's Physician order [REDACTED]. The annual Minimum Order Set (MDS), dated [DATE], assessed the resident's Brief Interview for Mental Status (BIMS) score of 13 indicating normal cognitive function (12-15) and received 7 days of antianxiety and antidepressants in the 7 day look-back period. The quarterly MDS, dated [DATE], assessed the resident's BIMS score of 15. The care plan, updated 6-25-19, advised staff Breo Ellipta (corticoid steroid (a medication to decrease inflammation) and a [MEDICATION NAME][MEDICATION NAME] (a medication used to open airways) administered by an inhaled device) may cause issues related to pulse, muscle spasms shortness of breath and infection. Staff advised of a Black Box Warning for this medication. A physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED] June 2019; refused 11 times. July 2019; refused 13 times. August 2019; refused all 31 days. September 2019; refused 7 times as of 09/08/19. A care plan meeting notes, dated 6-25-19, documented the resident doesn't want to use her inhaler anymore ) A faxed note sent to the pulmonologist. on 6-26-19, documented the resident refused her Breo inhaler every day for the past 6 days. A pulmonologist assessment, dated 7-1-19, instructed staff to continue administration of the Breo inhaler A physician visit, dated 07/03/19, documented [MEDICAL CONDITION]. This seems to be stable with regular nebulizer treatments. A physician visit, dated 08/07/19, documented the physician reviewed the nursing home records/chart including the resident's allergies and medications/MAR. Interview, on 09/05/19 at 02:33 PM, with Licensed nurse H, revealed she thought the physician was aware of the resident's refusal of Breo Ellipta as the resident's physicians (pulomonologist and primary care physician) made multiple changesof the resident's in halers . LN H stated he /she spoke to the resident about the need for the inhaler and explained the consequences of refusal and offered techniques to combat side effects. Interview, on 09/09/19 at 03:00 PM, with Consultant HH revealed he did not notice the resident's pattern of refusal of Breo Ellipta and thought the facility may want to notify the physician of the extent of the refusal . Interview, on 09/09/19 at 10:30 AM with Administrative Nurse E, revealed staff failed to notify the physician of the resident's refusal for the 31 days of (MONTH) and staff should have The Medication Administration policy, revised 2019, instructed staff if a resident refused medication to document the refusal and the reason why.This policy did not address when to notify the physician of the resident's refusal. The facility failed to notify the physician of the resident's continuous refusal of the physician ordered Breo Ellipta inhaler for 31 days in (MONTH) 2019 for further instruction to ensure the resident's respiratory status remained stable.

The facility reported a census of 59 residents with 17 selected for review which included one resident reviewed for skin conditions. The facility failed to ensure and maintain an infection control program to reduce transmissions of infections for the one resident reviewed, Resident (R) 6 during a dressing change procedure to a pressure ulcer wound. Findings included: - Review of Resident (R) 6's Physician order [REDACTED]. (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness). Review of the admission Minimum Data Set (MDS), dated [DATE], indicated the resident's Brief Interview for Mental Status (BIMS) score of 14, indicating normal cognitive status. The MDS indicated the resident required extensive assistance of one staff for bed mobility, transfer, and dressing. The resident had impairment in range of motion in both upper and lower extremities bilaterally. The MDS indicated the resident admitted to the facility with a stage two pressure ulcer. The quarterly MDS, dated [DATE], indicated the resident's BIMS score remained 14 and he required extensive assistance of one staff for bed mobility, transfer, and dressing. The resident had impairment in range of motion in his upper and lower extremities. Observation, on 09/05/19 at 10:00 AM, revealed Licensed Nurse (LN) G assisted the resident to stand and ambulate to the bathroom. Observed on the resident's right buttocks was a dressing rolled up and no longer intact around all of the four edges. LN G then donned two pair of gloves and removed the dressing, then removed the first pair of gloves and was about to cleanse the pressure area with normal saline. After questioned if that was an approved procedure LN G removed gloves, sanitized her hands, and applied clean gloves. The facility policy Glove Use, dated 11/17, directed the staff to change gloves during resident cares if moving from a contaminated body site to a clean body site. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before caring for another patient. The facility failed to ensure and maintain an infection control program to reduce transmissions of infections for R6 during a dressing change procedure to a pressure ulcer wound.

The facility reported a census of 54 residents, with 3 sampled for review of elopement. Based on observation, interview and record review, the facility failed to ensure 1 (#01) of the 3 sampled residents, did not exit the facility without staff knowledge. The resident exited the facility main entrance door on 6/12/18 at 6:22 PM, crossed a residential street, and was found by a neighbor on a back patio area at 7:15 PM. The facility staff lacked knowledge of the resident's elopement (leaving without staff knowledge), for approximately 1 hour, until the police returned the resident to the facility. This deficient practice placed the resident in immediate jeopardy. Findings included: - Resident #01's electronic medical record revealed the resident admitted on [DATE], with [DIAGNOSES REDACTED]. The admission MDS (minimum data set), dated 5/11/18, revealed the resident experienced severe cognitive impairment and unable to score a BIMS (brief interview for mental status). The resident had a history of [REDACTED]. The resident walked without assistance or devices. The care plan, dated 5/14/18, included instructions to the staff, regarding behaviors of wandering and resisting cares. The plan provided redirection or diversional activities to correct his/her problem of boredom or searching for something familiar. The resident liked to walk and walked for miles routinely for years. The plan included the need for physical activity to reduce the need to wander. The plan also included opportunities for mental stimulation that matched his/her past likes. On 5/2/18, the facility placed a WanderGuard bracelet (device that sets off an alarm when residents wearing one attempt to exit the building without an escort) to the resident's wrist. The care plan documented, that on 5/11/18 and again on 5/30/18 documented the resident cut the WanderGuard bracelet off. The staff decorated the WanderGuard to as a bracelet and replaced it on his/her wrist. On 6/7/18, the resident became violet when unable to remove the device from the wrist. Then the facility removed the bracelet, placed a WanderGuard inside a teddy bear and in a purse carried by the resident. Per interview with licensed nursing staff B and nurse's notes, on 6/12/18 at 7:35 P.M., the police department called the facility and reported neighbors found the resident approximately ½ mile from the facility, on their shady patio. The police returned the resident to the facility. According to interview, on 6/14/18 at 11:15 A.M., with licensed nursing staff B, the facility was unaware the resident left the building, until the police called. The reviewed door video, revealed a visitor entered the facility and allowed the resident to leave out the door at 6:22 P.M. The resident returned with the police at 7:40 P.M., (1 hour and 18 minutes later). Licensed nursing staff C assessed the resident without injury and a temperature of 98.1 degrees Fahrenheit. Nurses notes on 6/12/18, noted a family member arrived at the same time as the resident returned. The family member convinced the resident to let the nursing staff put a WanderGuard device on his/her ankle and shoe, by telling him/her it was a health monitoring device ordered by his/her doctor. Observation on 6/14/18 at 11:45 A.M., revealed the resident walked in the hallway with the WanderGuard on his/her left ankle and shoe. The resident ambulated with a steady gait without need for assistance or assistive devices. The facility Policy and Procedure for Elopement and Missing Resident, dated 6/2017, included procedures for wanders and missing residents. The facility failed to provide adequate supervision and or assistive devices, to keep this known high-risk elopement wandering resident from exiting the facility without staff knowledge. The resident wandered from the building, crossed one residential street and onto a patio approximately ½ mile from the facility. This deficient practice placed the resident in immediate jeopardy. The investigation revealed the facility abated the immediate jeopardy on 6/14/18 at 10:00 A.M., when the facility completed the following: 1.) The facility immediately placed the resident on 15-minute checks, upon return to the facility on [DATE] at 7:30 P.M. 2.) Staff updated the care plan, to include more diversional activities and family involvement. 3.) The family agreed to help and convinced the resident his/her physician had ordered the WanderGuard device as a health monitoring device and guard was placed on the resident's shoe and ankle. 4.) An all staff letter was e-mailed, to remind staff the resident was considered high risk for elopement and the need to keep resident's safe. Elopement re- training was starting for all staff. 5.) An all staff review and retraining was completed on 6/14/18 at 10:00 A.M. 6.) The facility held a risk management/QA (quality assurance) meeting on 6/14/18 at 10:00 A.M. with 8 staff members present and the medical director contacted per phone. The staff reviewed the elopement and response as well as the plan of correction and staff education. The deficient practice remained at the scope and severity of a D.

The facility reported a census of 59 residents with 14 selected for review, including 4 residents reviewed for accidents. Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive devices to prevent accidents for 3 of 4 residents reviewed, including properly transfer 1 resident with a mechanical lift that resulted in a right ankle fracture (#33). Failure to ensure proper placement of 1 resident feet on wheelchair pedal which resulted in an ankle fracture (#54) and failure to implement interventions to prevent further falls for 1 (#12) resident who sustained 2 falls. Findings included: - Review of resident #33's physician order [REDACTED]. The quarterly MDS (Minimum Data Set Assessment), dated 4-20-17, assessed the resident with a BIMS (brief interview for mental status) score of 4, which indicated severe cognitive impairment with disorganized thinking. The resident required extensive 2 person physical assist for bed mobility and transfer, extensive 1 person physical assist for locomotion on and off unit and exhibited unsteady balance, only able to stabilize with staff assist. The resident had functional impairment on one side lower extremity. The resident used a wheel chair for mobility. The resident was frequently incontinent of urine and always incontinent of bowel and on a toileting plan. The resident responded adequately to simple direct communication only. The resident was on a scheduled pain medication and received no PRN (as needed) and no non-medicated interventions. The resident experienced one non-injury fall since the prior assessment. The significant change MDS, dated [DATE], assessed the resident with a BIMS of 1 indicating severe cognitive impairment with disorganized thinking. The resident's functional status included extensive 2 person physical assist for bed mobility, total dependence two person physical assist for transfers, locomotion and did not walk. One person physical assist and toilet use total dependence two person physical assist. The resident is always incontinent of bowel and bladder and not on a toileting program. The resident has had falls since admission, one with major injury since admission or prior assessment. The CAA (care area assessment), dated 6-30-17, for cognitive loss/dementia (progressive mental disorder characterized by failing memory, confusion), documented the resident had a history of [REDACTED]. The resident continued to have episodes of increased confusion often a result of an infections. Pain currently was an issue and staff were trying to minimize use of narcotics for they seem to make him/her rather lethargic. The CAA (care area assessment), dated 6-30-17, for falls evidenced the resident fell during a failed transfer utilizing the sit to stand lift after a bath on 6-24-17, currently staff use the a maxi-lift (total body lift) for all transfers since he/she was non weight bearing. The care plan, dated 5-16-16 for falls, instructed staff to use the sit to stand lift to toilet and transfer. The resident may sit on the toilet if the lift was in place to facilitate bowel movement. The care plan lacked instruction to the staff as to the number of staff required for the transfer. The fall risk assessment, dated 4-19-17 noted the resident intermittently confused, required elimination with assistance, history of multiple falls and 1-2 falls in the last three months, confined to a chair, vision and hearing deficits. The fall risk assessment lacked assessment of the resident's balance stability. The three day voiding diary,, dated 11-18-16, indicated staff were to utilize the sit-to-stand lift for all transfers to the toilet. One problem for the resident was he/she started voiding whenever upright: staff noted the resident voids when sitting down on the toilet with the lift and then always voids some more when being raised up. The resident has had multiple CVA/TIA type events. Review of the nurses notes dated, 6-18-17 at 07:20 am,evidenced the resident exhibited increased confusion this night shift, attempted to crawl out of bed multiple times trying to look for a black book. Resident was wanted assistance to the toilet while on the toilet. Resident attempted to get off the sit-to-stand lift during transfer. Review of the nursing notes, dated, 6-24-17 at 09:13 A.M., evidenced staff member F stated that he/she had given the resident a bath. While staff transferred the resident with a sit to stand lift from the bath chair to his/her wheelchair, the resident became weak, started to lift up his/her elbows then let go of the lift and slid out. The resident hit his/her head on the seat of the wheelchair and his/her buttocks on the floor. At 7:40 A.M. direct care staff notified this nurse of the fall. The resident was laid on the floor on his/her back with his/her right leg bent. His/her head was under the wheelchair seat by the shower area, his/her pants down, attends half way up. The resident stated he/she had pain to his/her right leg. Noted his/her left ankle was at an unnatural angle. Nursing staff obtained a physician order [REDACTED]. to send resident to hospital per ambulance for treatment. At 11:50 A.M., the resident returned with [DIAGNOSES REDACTED]. Follow up in clinic on 6-26-17 at 9:00 A.M., continue current medications, and administer Norco (narcotic pain medication), 5/325 mg. (milligrams) 1-2 every six hours as needed, for pain. On 7-26-17 at 2:05 P.M., direct care staff F stated the resident would bear some weight but not his/her full weight. On the day that he/she fell staff F had finished bathing resident and had gotten him/her out of the bath and pulled the sit to stand lift up to transfer. The resident had a grip on the sit to stand lift handles and when Staff F assisted the resident to lift up, to pull up the residents brief and pants, the resident bent her arms toward her chest then raised her elbows upward and fell through the sling, to the floor. On 7-26-17 at 4:03 P.M., licensed staff D stated before the resident fell and broke his/her leg, the resident would use the sit to stand lift and used 2 people as needed to transfer him/her. On 7-26-17 at 3:38 pm administrative staff B revealed staff perform the MDS fall assessments quarterly. The resident had impaired ability to stand and was non-ambulatory for a long time. The facility policy for mechanical lift use, dated 6/2016, in place at the time of the residents fall, advised staff to assess the resident's condition, both physically and mentally to determine tolerance for the procedure. Select the proper lift as written in the care plan and as directed by the nurse. If there was a change of status for the resident and staff felt like the resident could not be safely transferred as care planned do not transfer the resident without discussing it with other nursing staff. Staff should not use the lift to transport the resident over long distances. The facility failed to safely transfer the cognitively impaired resident, in the sit to stand lift, with assistance of two staff as identified on the 4-20-17 MDS. The resident sustained [REDACTED]. - The Physician order [REDACTED].#54 had [DIAGNOSES REDACTED]. Feelings of sadness, helplessness, guilt, wanting to die was more intense and persistent than what may normally be felt from time to time), chronic pain (pain which persists for a long period, often for the remainder of a person's lifetime), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and history of nontraumatic intracerebral hemorrhage (bleeding from a ruptured blood vessel in the brain). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a BIMS (Brief Interview for Mental Status) score of 15, which revealed intact cognition. He/she used a wheelchair and required extensive assistance of 1 for locomotion on the unit. The resident had functional limitation in range of motion (ROM) of the upper and lower extremities bilaterally. He/she had not had falls since the prior assessment. The Care Area Assessment (CAA) for Activities of Daily Living (ADL), dated 8-29-16, documented the resident had left sided neglect (a person ' s failure to pay attention to a particular portion of space), was non-ambulatory, and had poor transfer ability. The quarterly MDS, dated [DATE], documented the resident continued to require extensive assistance of 1 for locomotion and used a wheelchair. He/she continued to have functional limitation in ROM of the upper and lower extremities. The resident received scheduled and PRN (as needed) pain medications. He/she received physical therapy (PT) for 4 days of the assessment period for a total of 153 minutes. The care plan for ADLs (Activities of Daily Living), dated 11-20-16, instructed staff the resident had one sided paralysis (the loss of muscle function and sensation, or both) and weakness on the left side. The resident was non-ambulatory and used a wheelchair for locomotion. On 11-15-16, PT changed the resident's high back wheelchair to a regular wheelchair to encourage the resident to self-propel. The plan of care lacked instruction to the staff regarding proper placement of the resident's dependent leg/foot and the need for both foot pedals for the resident's wheelchair when staff propelled the resident. The care plan for Cognition, dated 5-23-17, instructed staff the resident had severely impaired problem solving ability due to a major stroke. The resident's vision was poor and he/she had a left sided deficit and double vision due to the stroke. The resident's left side was flaccid (weak soft and flabby) and he/she had left side weakness. An addition to the care plan, dated 11-28-16, included, the resident had a sore left ankle and the resident liked to have his/her ankle wrapped. Staff were to keep the resident's shoes on for support. Additional interventions added to the care plan, on 12-01-16, included: 1. Stirrup splint to the left fibula X 6 weeks. 2. Non-weight bearing. 3. Re-X-ray in 3 weeks. 4. See PCP (Primary Care Physician) on 12-20-16, while on facility rounds. Review of the nurses notes, dated 11-24-16, per AOD (Answers on Demand, electronic documentation), documented, during locomotion in the wheelchair, the resident's left foot came off of the foot rest and twisted underneath the wheelchair. The resident yelled out and staff stopped propelling the wheelchair and put the resident's foot back on the foot rest. The nurse noted swelling to the left ankle. The resident refused to go to the emergency room , at that time. Staff elevated the resident's foot and administered PRN (as needed) pain medications. Review of the X-ray report, dated 11-29-16, revealed an undisplaced fracture of the distal (situated away from the center of the body) fibula (the outer and usually smaller of the two bones between the knee and the ankle) lateral (from the side or sides) cortex (outer layer of tissue). The 12-20-16 Kansas Mobile Solutions report, included: Exam indication--Follow-up fracture. Impression--Fracture is now slightly more visible, seen best on lateral view. Position and alignment remain excellent and no complications noted. Nurses notes, on 11-29-16, revealed the facility notified the PCP (Primary Care Physician) and received the following orders: 1. Stirrup splint to the left fibula X 6 weeks. 2. Non-weight bearing. 3. Re-X-ray in 3 weeks. Review of the facility's investigation of the incident, dated 11-29-16, reported the resident's left foot came off of the wheelchair foot pedal while staff propelled the resident. The resident's left ankle was slightly tender, had minimal swelling and the resident was able to rotate the area. Intervention for the incident was to add a heel cord (a strap to prevent the resident's foot from falling off of the foot pedal) on the foot pedal of the wheelchair. The report did not indicate what the root cause of the incident was. On 7-26-17 at 11:45 a.m., the resident sat at the dining room table in his/her wheelchair. The resident's left foot rested flat on the foot pedal which had a heel cord attached. The resident wore appropriate footwear. His/her right foot crossed over his/her left shoe. The wheelchair had only the left foot pedal in place. On 7-26-17 at 12:34 p.m., the resident was being taken to his/her room following lunch. Direct care staff O instructed the resident to put his/her right foot over his/her left foot while being propelled in the wheelchair. On 7-25-17 at 1:56 p.m., the resident stated a staff member had been taking him/her into the dining room when his/her foot came off of the foot pedal and went underneath the wheelchair. The resident stated the staff had been in a hurry and when they went over the threshold into the dining room his/her foot bounced off. Staff offered to take him/her to the emergency department, but he/she declined at that time. The pain was a sharp pain. An X-ray was not offered to him/her until several days later. The resident stated he/she had not propelled him/herself in the wheelchair in quite a while, prior to the incident as well as currently. On 7-26-17 at 12:34 p.m., direct care staff O stated, the resident only had 1 foot pedal on his/her wheelchair because he/she would be able to propel him/herself with the right foot if he/she wanted. Staff O stated they had not seen the resident propel his/herself. On 7-27-16 at 9:30 a.m., direct care staff M stated the resident had a lot of pain in his/her ankle following the incident and was unable to bear weight on the extremity. On 7-27-17 at 3:24 p.m., direct care staff L stated, the resident had swelling and bruising to his/her ankle following the incident and complained of a lot of pain to the area. Staff L would notify the nurses when the resident complained of pain. On 7-28-17 at 7:36 a.m., direct care staff J stated he/she had witnessed the incident with the resident. Staff J stated the resident in the wheelchair. Staff J stated another staff was pushing the other staff member had been in a hurry and moving quickly while propelling the resident and the resident's left foot came off of the foot pedal and went underneath the wheelchair. The resident hollered out in pain and the other staff member stopped immediately, put the resident's foot back onto the foot pedal and took the resident to his/her room. The resident only had one foot pedal on the wheelchair at the time of the incident. On 7-28-17 at 8:03 a.m., licensed nursing staff I stated, the resident had a history of [REDACTED]. Staff I reported that was the reason it took the facility so long to get an X-ray for the ankle. Staff I stated the area did have swelling and bruising following the incident and the resident had an increase in pain. On 7-27-17 at 2:28 p.m., administrative staff A stated, the facility had done an internal investigation of the incident, however, did not state if he/she had determined the root cause of the incident. On 7-28-17 at 9:46 a.m., physician office staff R stated, the facility notified the PCP of the resident's accident on 11-29-16, when the facility notified the office of swelling and bruising to the resident's left ankle and requested an X-ray. The PCP ordered an X-ray at that time. If the facility had notified the PCP of the incident at the time of occurrence, the PCP more than likely would have ordered an X-ray immediately rather than waiting several days. The facility lacked a policy for accidents. The facility failed to ensure proper placement of the resident's dependent limb on the foot pedal of the wheelchair when staff propelled the resident. The resident's foot came off of the foot pedal, hit the floor and became twisted under the wheelchair before staff were able to stop the resident's forward motion. The resident experienced a fractured ankle. - Review of resident #12's Physician order [REDACTED]. The quarterly MDS (minimum data set), dated 5-4-17, assessed the resident with a BIMS (brief interview for mental status) score of 05, Indicating severe cognitive impairment (0-7), required limited assistance with bed mobility, transfer, locomotion on the unit, dressing and toilet use. The resident's balance was steady at all times except for turning around and facing the opposite direction which was not steady but able to stabilize without staff assistance, no impairment of upper or lower extremities and no falls. The significant change MDS, dated [DATE], assessed the resident's BIMS score of 7, indicating severe cognitive impairment, required limited assistance for bed mobility, transfer, walk in corridor, dressing and toilet use, with a steady balance moving from seated to standing position, walking, on and off the toilet and not steady, but able to stabilize when turning around, no impairment in range of motion of upper or lower extremities and used a walker for mobility, was occasionally incontinent of bladder, had 1 fall non-injury and received an anticoagulant 7 out of 7 days on the look back period. The CAA (care area assessment), dated 7-14-17, for cognitive function assessed the resident with a BIMS of 3 upon return from acute care (7-6-17). The CAA, for falls, dated 7-14-17, assessed the resident with 2 falls in recent months with 1 fall on 6-28-17 as the resident was walking down the hall without his/her walker, tripped and fell face first onto the floor which resulted in a laceration to his/her nose from his/her glasses. The resident sustained [REDACTED]. The care plan for falls, dated 6-28-17, after a fall in the hallway (6-28-17), advised staff to assist the resident to always have his/her walker when walking. The care plan for falls, updated 7-14-17, was to rearrange the resident's room, remove the bathroom door and replace it with a shower curtain, use a motion alarm at night, and to consult physical therapy . The fall assessment scores, dated 1-31-17, assessed the resident with a score of 9 indicating at risk for falls (0-4 not at risk), and a fall assessment score on 7-6-17 score of 18 indicated the resident at risk for falls. Review of the fall scene investigation, dated 6-28-17 at 11:30 am, revealed the resident was ambulating independently in the hallway without his/her walker, and lost his/her balance, fell face forward resulting in a 2.5 by 0.1 centimeter laceration to his/her nose from his/her glasses and required acute care evaluation. Review of the fall scene investigation report, dated 7-7-17 at 5:50 pm, revealed the resident ambulated with bare feet, and no assistive device to go to the bathroom and was found in the doorway to his/her room . Initial interventions included to leave the bathroom light on at night and keep the door open. Staff also rearranged the resident room to assist him/her to find the bathroom. Conclusion: room rearranged to help him/her find bathroom easier. Staff documented the resident did not sustain an injury from this fall. Observation, on 7-26-17 at 1:10 pm, revealed the resident ambulated with a walker and direct care staff E provided stand by assistance. The resident's gait was steady and balanced. Staff E stated the resident had a decline in status after the second fall, and now received physical therapy. Staff E stated the resident declined restorative services prior to the falls. Observation , on 7-26-17 at 3:45 pm, revealed the resident sitting up on the side of his/her bed without shoes, but wore socks. The resident was alert to person and past events. Observation, on 7-27-17 at 4:44 pm, revealed the resident seated in the common living area in front of the aviary. The resident's walker was in front of the resident within reach. Interview, on 7-27-17 at 6:55 am, with licensed nursing staff C, revealed the resident did get up by his/herself to go to the bathroom and needs his/her walker for ambulation, but there was a motion sensor which staff activate at night, and sounds at the desk. Staff C revealed an intervention of rearranging the resident's room after the second fall, made the flow to the bathroom easier. Interview, on 7-27-17 at 8:25 am, with direct care staff F, revealed the resident does try to get up on his/her own but requires staff assistance for ambulation with his/her walker and does not use his/her call light. Staff F stated the resident's room has a motion detector, but staff activate it at night. Staff F stated direct care staff provide frequent visualization of the resident during the day and provide opportunities for toileting every 2 hours. Staff F stated the resident did not use the call light for assistance. Interview, on 7-27-17 at 10:40 am, with administrative nursing staff B, revealed staff believe the fall on 6-28-17 at 11:30 pm, resulted when the resident heard something in the hallway and the resident got up out of bed to investigate, forgot to use his/her walker, and fell in the hallway. Staff B stated the resident was ambulating without his/her walker which was very unusual for the resident. Staff B stated the fall resulted in a head injury with a laceration to the bridge of his/her nose. The intervention for this fall was to assist the resident to use his/her walker. Staff B stated the resident required stand by assistance with his/her walker to ambulate. After the fall, staff kept the resident's door open and provided frequent checks of the resident at night. Staff B stated the second fall occurred after return from acute care (7-5-17 through 7-6-17 for bradycardia (slow heart rate) and urinary tract infection). Staff noted a change in the resident's mental status (more confusion) upon return from acute care. The resident was found on the floor (7-7-17 at 5:50 am ) outside his/her room, and investigation determined the resident attempted to find his/her bathroom. Staff rearranged the resident's room and on 7-18-17 placed a motion detector in the resident's room. Interview, on 7-27-17 at 2:36 pm, with licensed nursing staff D, revealed staff remind the resident to use his/her walker, and staff need to take the resident to the bathroom before and after meals. Staff try to observe the resident frequently throughout the day, but do not use the motion detector during the day. Staff D stated as the day progresses, the resident becomes more unsteady and confused. Staff stated the resident sits in his/ her chair in his/her room, but does not use the call light when he/she needs to toilet or ambulate. Interview, on 7-27-17 at 4:45 pm, with direct care staff F, revealed staff frequently walk by the resident when he/she was seated in the lobby area and felt the resident was safe. Fall prevention policy undated indicated prevention protocol will be initiated with documentation on the care plan, staff to determine and complete root cause analysis for the fall, resident will be assisted with all transfers and ambulation if indicated, staff to provide reminders to the resident of the potential for falls and provide reminders to ask staff for assistance. Staff to use assisted devices as needed per physical therapy and occupational therapy, and in limited circumstances the use of a personal alarm in bed or chair may be indicated. The facility failed to ensure appropriate interventions were put into place for this cognitively impaired resident after the resident fell on [DATE] to prevent further falls and injury (found on the floor 7-7-17).

The facility reported a census of 59 residents. Based on observation, record review and interviews, the facility failed to store, prepare, distribute and serve food under sanitary conditions to prevent the spread of food borne illnesses to the residents. Findings included: - During the main kitchen initial tour, on 7/25/17 at 8:02 AM, observations revealed the following: 1.) The trash can by the handwashing sink with a dirty foot pedal and the foot pedal did not work. 2.) Four white tubs exteriors with scraps and dirt which was not a cleanable surface. 3.) The refrigerator doors with dried food and food on the bottom of the refrigerator. 4.) The outside of the ice machine with a dried white substance. 5.) The wire rack for clean dishes with bottom shelf rusty. 6.) The rack for cans with dust, crumbs and a sticky build-up on the slats. 7.) The inside of the steam table wells, adjacent to the food pans, had a brown build-up. 8.) Fifteen (15) ice cream scoops with scuffed plastic handles which created an uncleanable surface. 9.) The back of the stove with a heavy dark build-up. 10.) The stainless steel bread rack with rusty areas. 11.) The dessert cart wheels were dirty and the handles with a build-up of food debris. 12.) The large standing mixer with chipping paint on the top as well as mixing apparatus of the machine with dust. 13.) The paper towel holder was dirty. On 7/25/17 at 8:22 AM, observation of the main dining room revealed: 1.) Rust spots on the inside of the freezer door. 2.) The inside of the oven with crumbs and food debris. On 7/25/17 at 9:15 AM, observation of the north kitchenette revealed the following: 1.) The inside of the cabinet drawers with a layer of grime. 2.) The oven contained burnt food debris. 3.) The microwave contained food debris. On 7/27/17 at 2:00 PM, dietary staff N confirmed the observations noted above and stated the facility has hard water and that is why there is the lyme build-up on the ice machine. Review of the facility dietary cleaning schedule lacked documentation of scheduled cleaning task completion. The facility lacked a policy regarding kitchen sanitation and cleaning. The facility failed to store, prepare, distribute, and serve food in a sanitary manner to the residents to prevent food borne illnesses.

The facility reported a census of 59 residents. Based on observation and interview the facility failed to provide a sanitary environment for the residents, staff and the public. Findings included: - During the initial kitchen tour, on 7-25-17 at 8:02 AM, observation revealed the parameter of the floor with debris build-up and a large, dark thickened liquid circle on the floor around the ice machine drain. On 7-27-17 2:00 PM, dietary staff N, confirmed the finding above and stated the pipes from the ice machine got bumped when the floor was swept and mopped and the water pooled on the floor, which caused the build-up and black ring on the floor. The facility lacked a policy regarding the sanitation and maintenance of the kitchen floor. The facility failed to provide maintenance and housekeeping services to maintain the environment in an orderly and sanitary manner in cleaning the kitchen floor.

The facility had a census of 59 residents with a sample of 14, with 4 residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to thoroughly investigate and report an allegation of neglect to the state agency as required, for an accident involving an injury for 1 (#54) of the 4 residents reviewed. Findings included: - The Physician order [REDACTED].#54 had [DIAGNOSES REDACTED]. Feelings of sadness, helplessness, guilt, wanting to die was more intense and persistent than what may normally be felt from time to time), Chronic pain (pain which persists for a long period, often for the remainder of a person's lifetime), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and history of nontraumatic [MEDICATION NAME] hemorrhage (bleeding from a ruptured blood vessel in the brain). The annual Minimum Data Set (MDS), dated [DATE], documented the resident had a BIMS (Brief Interview for Mental Status) score of 15. Locomotion on the unit required extensive assistance of 1. The resident had functional limitation in range of motion (ROM) of the upper and lower extremities bilateral. The resident used a wheelchair. The Care Area Assessment (CAA) for Activities of Daily Living (ADL), dated 8-29-16, documented the resident had left sided weakness, was non-ambulatory, and had poor transfer ability. The quarterly MDS, dated [DATE], documented the resident continued to require extensive assistance of 1 for locomotion and used a wheelchair. He/she continued to have functional limitation in ROM of the upper and lower extremities. The resident received scheduled and PRN (as needed) pain medications. He/she received physical therapy (PT) for 4 days for a total of 153 minutes. The care plan for ADLs (Activities of Daily Living), dated 11-20-16, instructed staff the resident had one sided paralysis (the loss of muscle function and sensation, or both) on the left side weakness on the left side. The resident was non-ambulatory and used a wheelchair for locomotion. On 11-15-16, PT changed the resident's high back wheelchair to a regular wheelchair to encourage the resident to self-propel. The care plan for Cognition, dated 5-23-17, instructed staff the resident had severely impaired problem solving ability due to a major stroke. The resident's vision was poor and he/she had a left sided deficit and double vision due to the stroke. The resident's left side was flaccid and he/she had right side weakness. The care plan, dated 11-20-16, instructed staff the resident had one sided paralysis (the loss of muscle function and sensation, or both) on the left side weakness on the left side. The resident was non-ambulatory and used a wheelchair for locomotion. On 11-15-16, PT changed the resident's high back wheelchair to a regular wheelchair to encourage the resident to self-propel. An addition to the care plan, dated 11-28-16, included, the resident had a sore left ankle and the resident liked to have the ankle wrapped. Staff were to keep the resident's shoes on for support. An addition to the care plan, dated 12-01-16, included: 1. Stirrup splint to the left fibula X 6 weeks. 2. Non-weight bearing. 3. Re-X-ray in 3 weeks. 4. See PCP (Primary Care Physician) on 12-20-16, while on facility rounds. Review of the nurses notes, dated 11-24-16, per AOD (Answers on Demand, electronic documentation), documented, during locomotion in the wheelchair, the resident's left foot came off of the foot rest and twisted underneath the wheelchair. The resident yelled out and staff stopped propelling the wheelchair and put the resident's foot back on the foot rest. The nurse noted swelling to the left ankle. The resident refused to go to the emergency room at that time. The resident's foot was elevated and PRN pain medications were given. Review of the X-ray report, dated 11-29-16, revealed an undisplaced [MEDICAL CONDITION] (situated away from the center of the body) fibula (the outer and usually smaller of the two bones between the knee and the ankle) lateral (from the side or sides) cortex (outer layer of tissue). Nurses notes on 11-29-16, revealed the facility notified the PCP and received the following orders: 1) Stirrup splint to the left fibula X 6 weeks. 2. Non-weight bearing. 3. Re-X-ray in 3 weeks. Review of the facility's investigation of the incident reported the resident's left foot had come off of the foot pedal of the wheelchair while being propelled by staff. The resident's left ankle was slightly tender, had minimal swelling and the resident was able to rotate the area. Intervention for the incident was to add a heel cord on the foot pedal of the wheelchair. Staff were educated. A therapy report revealed the resident had enough control of his/her foot and leg to keep it on the pedal with proper placement. On 7-25-17 at 1:56 p.m., the resident stated a staff member had been taking him/her into the dining room when his/her foot came off of the foot pedal and went underneath the wheelchair. The resident stated the staff had been in a hurry and when they went over the threshold into the dining room, his/her foot bounced off. Staff offered to take him/her to the emergency department, but he/she declined, at that time. On 7-27-17 at 2:28 p.m., administrative staff A stated, it was the facility's understanding of the process that if an incident is observed by staff, and nothing improper took place, the facility would investigate the incident but not report the incident to the state. The facility policy for Resident Freedom From Abuse, Neglect, Exloitation, undated June 2017, included: the administrator or designee will immediately report, but no later than 2 hours after an incident, if the events result in serious boldly injury. The facility failed to thoroughly investigate and report to the state agency as required, an allegation of neglect which resulted in an injury for this dependent resident.

The facility reported a census of 59 residents with 14 selected for review. Based on observation, interview and record review, the facility failed to review and revise the plan of care with appropriate interventions for cognitively impaired resident #12 who sustained a fall. Findings included: - Review of resident #12's Physician order [REDACTED]. The quarterly MDS (minimum data set), dated 5-4-17, assessed the resident with a BIMS (brief interview for mental status) score of 05, Indicating severe cognitive impairment (0-7), required limited assistance with bed mobility, transfer, locomotion on the unit, dressing and toilet use. The resident's balance was steady at all times except for turning around and facing the opposite direction which was not steady but able to stabilize without staff assistance, no impairment of upper or lower extremities and no falls. The significant change MDS, dated [DATE], assessed the resident's BIMS score of 7, indicating severe cognitive impairment, required limited assistance for bed mobility, transfer, walk in corridor, dressing and toilet use, with a steady balance moving from seated to standing position, walking, on and off the toilet and not steady, but able to stabilize when turning around, no impairment in range of motion of upper or lower extremities and used a walker for mobility, was occasionally incontinent of bladder, had 1 fall non-injury and received an anticoagulant 7 out of 7 days on the look back period. The CAA (care area assessment), dated 7-14-17, for cognitive function assessed the resident with a BIMS of 3 upon return from acute care (7-6-17). The CAA, for falls, dated 7-14-17, assessed the resident with 2 falls in recent months with 1 fall on 6-28-17 as the resident was walking down the hall without his/her walker, tripped and fell face first onto the floor which resulted in a laceration to his/her nose from his/her glasses. The resident sustained [REDACTED]. The care plan for falls, updated 6-28-17, after a fall in the hallway (6-28-17), advised staff to assist the resident to always have his/her walker when walking. The care plan for falls, updated 7-14-17, was to rearrange the resident's room, remove the bathroom door and replace it with a shower curtain, use a motion alarm at night, and to consult physical therapy . The fall assessment scores, dated 1-31-17, assessed the resident with a score of 9 indicating at risk for falls (0-4 not at risk), and a fall assessment score on 7-6-17 score of 18 indicated the resident at risk for falls. Review of the fall scene investigation, dated 6-28-17 at 11:30 am, revealed the resident was ambulating independently in the hallway without his/her walker, and lost his/her balance, fell face forward resulting in a 2.5 by 0.1 centimeter laceration to his/her nose from his/her glasses and required acute care evaluation. Review of the fall scene investigation report, dated 7-7-17 at 5:50 pm, revealed the resident ambulated with bare feet, and no assistive device to go to the bathroom and was found in the doorway to his/her room . Initial interventions included to leave the bathroom light on at night and keep the door open. Staff also rearranged the resident room to assist him/her to find the bathroom. Conclusion: room rearranged to help him/her find bathroom easier. Staff documented the resident did not sustain an injury from this fall. Observation, on 7-26-17 at 1:10 pm, revealed the resident ambulated with a walker and direct care staff E provided stand by assistance. The resident's gait was steady and balanced. Staff E stated the resident had a decline in status after the second fall, and now received physical therapy. Staff E stated the resident declined restorative services prior to the falls. Observation, on 7-26-17 at 3:45 pm, revealed the resident sitting up on the side of his/her bed without shoes, but wore socks (not girpper socks). The resident was alert to person and past events. Observation, on 7-27-17 at 4:44 pm, revealed the resident seated in the common living area in front of the aviary. The resident's walker was in front of the resident within reach. Interview, on 7-27-17 at 6:55 am, with licensed nursing staff C, revealed the resident did get up by his/herself to go to the bathroom and needs his/her walker for ambulation, but there was a motion sensor which staff activate at night, and sounds at the desk. Staff C revealed an intervention of rearranging the resident's room after the second fall, made the flow to the bathroom easier. Interview, on 7-27-17 at 8:25 am, with direct care staff F, revealed the resident does try to get up on his/her own but requires staff assistance for ambulation with his/her walker and does not use his/her call light. Staff F stated the resident's room has a motion detector, but staff activate it at night. Staff F stated direct care staff provide frequent visualization of the resident during the day and provide opportunities for toileting every 2 hours. Staff F stated the resident did not use the call light for assistance. Interview, on 7-27-17 at 10:40 am, with administrative nursing staff B, revealed staff believe the fall on 6-28-17 at 11:30 pm, resulted when the resident heard something in the hallway and the resident got up out of bed to investigate, forgot to use his/her walker, and fell in the hallway. Staff B stated the resident was ambulating without his/her walker which was very unusual for the resident. Staff B stated the fall resulted in a head injury with a laceration to the bridge of his/her nose. The intervention for this fall was to assist the resident to use his/her walker and this was documented on the care plan. No other interventions were documented on the care plan for this fall. Staff B confirmed the resident exhibited severely impaired cognitive status. Staff B stated the resident required stand by assistance now with his/her walker to ambulate. After the fall on 6-28-17, staff kept the resident's door open and provided frequent checks of the resident at night. Staff B confirmed staff failed to add these interventions to the plan of care. Staff B stated the second fall occurred after return from acute care (7-5-17 through 7-6-17 for [MEDICAL CONDITION] (slow heart rate) and urinary tract infection). Staff noted a change in the resident's mental status (more confusion) upon return from acute care. The resident was found on the floor (7-7-17 at 5:50 am ) outside his/her room, and investigation determined the resident attempted to find his/her bathroom. Staff rearranged the resident's room and on 7-18-17 placed a motion detector in the resident's room. Fall prevention policy, undated, indicated prevention protocol will be initiated with documentation on the care plan, staff to determine and complete root cause analysis for the fall, resident will be assisted with all transfers and ambulation if indicated, staff to provide reminders to the resident of the potential for falls and provide reminders to ask staff for assistance. Staff to use assistive devices as needed per physical therapy and occupational therapy, and in limited circumstances the use of a personal alarm in bed or chair may be indicated. The facility failed to review and revise the resident's plan of care after the resident sustained [REDACTED].

The facility reported a census of 59 residents. Based on interview and record review, the facility failed to post the daily staffing schedule with the actual staffing hours, as required. Findings included: - On 7/28/17 at 8:39 AM, administrative staff P stated he/she was not aware of the need to adjust the daily posting when a staff member called in. Furthermore, staff P stated he/she had not adjusted the actual hours worked, ever, on the daily staff posting. As an example: Review of the facility daily staff hours posting sheets revealed that on 7/6/17, on the evening shift schedule, 6 CNA's (certified nurses aide), 3 CMA's (certified medication aide), and 2 nurses scheduled for 56 residents. The nurse posting sheet lacked the accurate number of CNA's, listed 4, and lacked the accurate number of hours for the CNA's, which was listed as 6 actual hours worked instead of 45.5 actual hours worked. The undated facility policy for nurse staff posting advised the nursing department clerical staff or their designee will calculate the number of full time equivalent for each shift of the previous day for the nursing employees that provided direct care to the residents on those shifts. The facility failed to post the daily staffing schedule with the actual staffing hours worked, as required.

The facility had a census of 57 residents, with 25 residents sampled. Based on observation, record review, and interview, the facility failed to provide necessary treatment and services to prevent urinary tract infections for 1 (#31) of the 2 sampled residents reviewed for urinary catheter. Findings included: - The admission MDS (minimum data set), dated 7-28-15, revealed the resident had a BIMS (brief interview for mental status) of 14, indicating the resident was cognitively intact. The resident required extensive assistance of 2 for bed mobility, transfers and toilet use. Furthermore, the MDS documented the resident was occasionally incontinent of bladder. The quarterly MDS, dated [DATE], revealed the resident had an indwelling Foley catheter. Review of the urinary CAA (care area assessment), dated 7-28-15, revealed the resident had a history of [REDACTED]. Review of the care plan, dated 11-10-15, documented the Foley catheter was discontinued on 11-06-15 and reinserted on 11-20-15 due to [MEDICAL CONDITION]. Staff were instructed to observe the resident's urine for color and odor and report any complaints of pain to the nurse. Observation on 12-09-15 at 12:00 p.m., revealed the resident in his/her wheelchair at the dining room table. The dignity bag (cover bag) containing the Foley catheter urine collection bag rested directly on the floor, underneath the resident's wheelchair along with a section of the catheter tubing. Observation on 12-10-15 at 1:36 p.m., revealed direct care staff C and D transferred the resident from his/her wheelchair to the bed with assist of the sit to stand mechanical lift. While moving the resident to the bed on the lift, the catheter collection bag drug directly on the floor underneath of the base on the lift. Once the resident was on the bed, staff C began removing the resident's pants. While removing the resident's pants, the catheter urine collection bag was lifted up above the level of the resident's bladder and observation revealed the urine ran back down the tubing towards the resident. On 12-15-15 at 6:45 a.m., observation revealed the resident in his/her wheelchair at the dining room table. The catheter urine collection bag, rested directly on the floor, underneath the wheelchair, with the tubing also directly resting on the floor. On 12-15-15 at 9:11 a.m., observation revealed the resident in his/her wheelchair at the table in the commons area. The resident's catheter urine collection bag and tubing rested directly on the floor. Direct care staff G began to push the resident in his/her wheelchair to their room when the front wheel of the wheelchair ran over the catheter tubing which drug along underneath of the wheelchair. On 12-14-15 at 10:02 a.m., direct care staff D stated, the staff needed to keep the catheter collection bag under the level of the resident's bladder during cares. On 12-15-15 at 9:11 a.m., licensed nursing staff B stated, the resident's catheter urine collection bag, dignity bag and tubing should not be on the floor underneath the resident's wheelchair. The tubing should be completely coiled into the dignity bag along with the Foley catheter bag. No part of the catheter or tubing should touch the floor. On 12-15-15 at 9:13 a.m., administrative nursing staff A stated, the staff receive proper catheter care education during their certified nursing staff (CNA) and nursing classes. The facility does not offer any further catheter care training at this time. Staff should ensure the catheter bags are not touching the floor or lifted above the level of the resident's bladder. The facility's undated policy, for Providing Catheter Care, instructs staff to keep the bag below the level of the resident's bladder and to keep the bag and tubing from the floor. The facility failed to provide necessary treatment and services to prevent urinary tract infections for this dependent resident with a urinary Foley catheter.

The facility reported a census of 60 residents, with 3 residents reviewed for accidents. The facility identified 42 residents that use the whirlpool bathtubs. Based on observation, interview and record review, the facility failed to provide a safe environment for resident #1, by not having a system in place to assure proper use of the safety equipment while transferring in and out of the whirlpool bathtub. The resident fell during an unsafe transfer and sustained three fractures to vertebrae in the lower back. Findings included: - The physician orders, dated July 2014, documented resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS (minimum data set), dated 3/27/14 (prior to the fall), documented the resident with a BIMS (brief interview for mental status) score of 11, indicating moderately impaired cognition. The resident required extensive assist of 1 staff for transfers and locomotion on/off unit, and physical help in part of bathing activity of 1 staff. The resident had functional limitation with impairment on both sides of lower extremities in range of motion and used a walker and wheelchair for mobility. The resident had PRN (as needed) pain medications available with no pain noted, and no falls noted. The fall CAA (care area assessment), dated 3/27/14, identified the therapy notes included that the resident ambulated (walked) 40-50 feet with assist, required verbal cues for sequencing and safety and noted quick fatigue. The resident had poor safety awareness, and staff would care plan for fall risk. The Quarterly MDS, dated [DATE] (after the fall), documented the resident's BIMS score of 13, indicating he/she was cognitively intact. The resident required extensive assist of 2 staff for transfers, 1 staff for locomotion on/off unit and was totally dependent on 1 staff for bathing. The resident had functional limitation with impairment on both sides of the lower extremities in range of motion and used a wheelchair for mobility. The resident had scheduled and PRN pain medications used with frequent pain rated at 7/10 on the pain scale; one fall noted with major injury. The Care Plan, last updated 6/20/14, documented the resident was at risk for falls and included the following fall interventions before the fall: The resident fatigues easily, allow for rest breaks; wear non-skid footwear; keep the floor clutter free and dry; keep the room well lit; keep the call light in reach; transfers as tolerated, may use maxi lift with increased pain. The care plan update after the fall documented the following: The resident had a fall on 6/12/14, was seen in ER (emergency room ), CT (computed tomography, a type of x-ray) of the lumbar spine indicated fractures of the transverse process, and has a follow up appointment today. Follow the recommendations of the physician regarding movement - encourage activity as tolerated, only limit activity with pain; able to walk to meals with one assist; may need to rest part way or only want to walk part way; not walking more than a few steps currently due to pain; anticipation is that the resident will be walking again as the fractures heal. The record lacked a care plan for bathing or using the safety belt during transfers into and out of the whirlpool tub. The Fall Risk Assessment, dated 7/15/14, documented a score of 17, at risk of falling. The nurses note, dated 6/12/14 at 11:05 PM, documented staff was assisting the resident out of the whirlpool and slid out of the shower chair at 8:45 PM. The residents back and back of the head hit the whirlpool, and his/her lower back was red. The resident left via ambulance at 9:05 PM to go to the emergency department of the hospital. On 7/28/14 at 12:45 PM, Direct Care Staff D reported there was now a manual, pointing to a book on a shelf on the wall by the tub, that staff could refer to and it explained the use of the belt and chair lift into the tub, but the manual was new, it didn't used to be there. Staff D demonstrated use of the chair and belt, stating that he/she used the belt, except for once in a while there was not a belt available in the bathroom. Staff D was unable to report when there was no belt or for how long of a period there was no belt. On 7/28/14 at 1:06 PM, the resident reported that he/she remembered the fall in the tub last month. The resident reported leaning forward in the lift chair while coming out of the tub and the staff had said to lean back, to not fall forward. The resident reported that as he/she leaned back in the chair, he/she slipped out of the chair onto the floor and hit his/her back on the door edge of the tub. The resident confirmed that he/she did not have a belt on in the bath lift chair at the time of the fall and that a belt had never been used by any of the staff when taking a bath prior to the fall on 6/12/14. The resident reported that he/she went to the emergency room after the fall and was told there were some fractures in his/her back. On 7/28/14 at 12:52 PM, Housekeeping Staff E reported that he/she attended monthly safety meetings and that it was recently brought to the committee's attention that the belts for the lift chairs in the whirlpool tubs were not always on the chairs. Staff E reported that the belts were often lying off to the side of the lift, slung over a cabinet or wrapped up and stored on a shelf somewhere in the bathroom, therefore not always being used by the staff during baths. On 7/28/14 at 1:14 PM, Maintenance Staff F reported that the belts to the whirlpool lift chairs had to be replaced recently because they were cracked and the staff felt like it was an infection control problem, making the belt a non-cleanable surface. Staff F reported maintenance staff checked the belts on a routine when the monthly lifts were all serviced. Staff F reported that in the past, the check mark on the maintenance log meant staff had just made sure that there was a belt for the chair, not whether it was in good condition. But, in a safety committee meeting in early July, it was brought to maintenance staff's attention that the condition of the belt needed checked as well as they were in disrepair. On 7/28/14 at 1:19 PM, Resident #3 confirmed that staff did not use the belt in the past, the belt was new. On 7/28/14 at 1:23 PM, Resident #2 reported that he/she used the whirlpool tub twice a week. Resident #2 reported that staff currently used a belt in the chair, but that was a recent change. On 7/28/14 at 1:56 PM, Licensed Nursing Staff C reported that the belt in the north bathroom had not worked in the past, reporting that it was frayed. Staff C was unable to give a timeframe that a belt was not used, but confirmed that one was not in use at the time of the resident's fall out of the lift chair on 6/12/14. On 7/28/14 at 5:20 PM, Direct Care Staff H reported that there was not a belt in the bathroom on the night the resident fell out of the lift chair. Staff H reported as staff lifted the resident out of the tub in the chair and began to lean forward, so staff H directed the resident to lean back. As the resident did, he/she slipped out of the chair onto the floor, hitting his/her back on the edge of the tub on the way down. Staff H reported that the nurse asked where the belt for the chair was, and staff H told the nurse that he/she didn't know there was one and had never seen a belt in the bathroom or ever used one. Staff confirmed that he/she worked in the facility for almost a year and that the training did not include use of a belt on the lift chair. Staff H reported that the belt that was put into the bathroom after the fall was tattered and old. Staff reported working 5-6 days a week on the evening and day shifts and gave baths to residents every time he/she worked. Staff confirmed that he/she did not know anything about a belt until the day the resident fell , after the fall. Staff H reported that several of the residents still asked what the belt was all about because they were not used to it; they had not seen them until recently. On 7/28/14 at 5:45 PM, Administrative Nursing Staff B reported that on 6/12/14, the CNA was bathing the resident in the whirlpool tub; the resident leaned forward, then back and slid out of the shower chair. As a result of the fall, the resident had three fractured vertebrae. Staff B confirmed that at some point, staff removed the belt from the bathroom, and prior to the resident's fall, he/she was not aware of that. Staff B reported that it was an expectation that the staff orientation on hire included proper use of the belt with the lift chair but reported that he/she was not able to confirm that it was actually being done. On 7/28/14 at 6:20 PM, Direct Care Staff I reported working at the facility for 2 years, and worked on multiple halls of the facility, and confirmed that he/she had never used a belt on the whirlpool tub chair lift, in the 2 years before this resident's fall. Staff I confirmed that he/she was not trained to use the belt and that prior to the resident's fall there was not a belt available in the North hall bathroom, but there were two of them in the west hall bathroom. Staff I was not able to recall how long there was no belt in the north bathroom, but reported that sometimes there were belts on a shelf or lying around in the bathroom, not on the lift chair. Staff I confirmed that even though the belts were in the bathroom sometimes, they were not used prior to this resident's fall. On 7/28/14 at 6:40 PM, Administrative Staff A confirmed that the belt may have not always been on the lift chair, it may have been rolled up on top of the tub. Staff A reported that he/she was not aware the belts were not being used during the baths and that it was his/her expectation that all staff had been trained to use the belt and was not aware this was not happening until after the resident fell from the chair. The facility provided manual, Cascade Patient Transfer Lift System, Safe Operations and Daily Maintenance Instructions, dated 2/10/07, directed staff to bring the seat belt around the resident, to the D-ring connector, adjust the belt to insure safety while transporting, and after completing the bath, release the seat belts from around the resident and transfer the resident using proper nursing techniques and assistance if required. The manual included a warning in bold print, which documented: Failure to secure the resident properly with the seat belt could result in injury to the resident. The facility failed to provide a safe environment for this resident by not ensuring proper use of the safety equipment while transferring in and out of the whirlpool bathtub, resulting in the resident falling and fracturing three vertebrae.