Every finding on record at Blue River Healthcare, Inc

Based on observation and interview, the facility failed to ensure air vents were clean and in good repair for three (#1, 2, and #3) of three sampled residents reviewed for a clean and homelike environment. The administrator identified 45 residents resided in the facility. Findings: A Cleaning and Disinfecting Residents' Rooms policy, dated August 2013, read in part, .Environmental surfaces will be disinfected (or cleaned) on a regular basis .and when surfaces are visibly soiled .Clean curtains, window blinds, and walls when they are visibly soiled or dusty . 1. On 09/25/24 at 12:53 p.m., Resident #1 was observed in their room (room [ROOM NUMBER]). The air vent closest to the resident was observed to be slightly open and covered with dust. On 09/26/24 at 11:50 a.m., the air vents in Resident #1's room were observed to be covered with dust and rust spots. The resident stated maintenance could not adjust the flow of air because the vent was stuck. 2. On 09/25/24 at 1:03 p.m., Resident #2 was interviewed in their room (room [ROOM NUMBER]). The resident stated they had recently been moved from another room. The resident's current room was observed to have an air vent above the bed which was covered with dust. The resident reported they had previously been in room [ROOM NUMBER]. room [ROOM NUMBER] was observed and found to have air vents covered with dust. On 09/26/24 at 11:45 a.m., Resident #2 was observed to be out of their room. The air vent above the resident's bed was observed to be covered with dust. A second vent in the resident's room was observed to have rust spots and gaps around the edges between the vent and ceiling. 3. On 09/25/24 at 1:07 p.m., the air vent in Resident #3's room (room [ROOM NUMBER]) was observed to be covered with dust. Resident #3 stated they were not aware of the vent ever being cleaned. On 09/26/24 at 11:40 a.m., Resident #3 was observed lying in bed. The vent above the bed was observed to be covered with dust. A second vent in the resident's room was observed to be rusted with gaps between the vent and ceiling. On 09/26/24 at 12:17 p.m., maintenance staff stated they were aware the air vents needed to be replaced. They stated they had a specific budget and it might take some time, but they felt all of the vents in the facility should be replaced. They stated housekeeping staff would be responsible for cleaning the dust and dirt on the vents in resident rooms. On 09/26/24 at 12:27 p.m., the housekeeping supervisor stated vents in the resident rooms were normally cleaned every Tuesday. They stated the administrator had recently purchased new extendable dusters to be used on the vents and stated they had noticed some vents needed to be cleaned twice a week.

Based on observation, record review, and interview, the facility failed to prevent an inappropriate relationship between a staff member and resident, and ensure a resident was free from abuse for one (#1) of one sampled resident reviewed for abuse. The administrator identified 45 residents resided in the facility. They stated there was one allegation of abuse in the past 30 days. Findings: An Abuse Investigation and Reporting policy, dated July 2017, read in part, .The Administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident .Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator . Resident #1 was admitted to the facility with diagnoses which included schizoaffective disorder, depression, anxiety, and chronic pain. An MDS assessment, dated 08/13/24, documented the resident was cognitively intact and exhibited no behaviors. The assessment documented the resident was independent with activities of daily living. An incident report form, dated 09/20/24, documented Resident #1 had gone to the administrator's office and stated a staff member had sent nude pictures to their cell phone. The staff member was not in the facility at the time and was immediately suspended. On 09/25/24 at 12:53 p.m., Resident #1 was interviewed and stated they felt safe and did not report an incident of abuse. On 09/25/24 at 3:15 p.m., the administrator stated there was not a police report related to the allegation of abuse involving Resident #1. The administrator stated when the two police officers came to the facility the resident did not want to give a report and did not want to press charges. On 09/25/24 at 3:40 p.m., the corporate nurse stated the investigation was ongoing. They stated more information had been obtained from Resident #1 related to social media interactions over the past year between the resident and CMA #1. On 09/26/24 at 11:50 a.m., Resident #1 was interviewed in their room. The resident's roommate was out of the room and they asked for their door to be shut. They stated they had more than a friendship with CMA #1. They stated they had shown the administrator months of texts back and forth between them and CMA #1. They stated when CMA #1 sent nude pictures to them they became increasingly anxious and was very uncomfortable when the CMA worked. They stated when they became uncomfortable they reported the pictures to the administrator. They stated then a couple of days later they shared the numerous text messages. The resident was asked if the relationship was consensual. They stated it was okay for a long time. They stated they had a mutual understanding, but the nude pictures made them very uncomfortable. They stated that is when they reported the situation to the administrator. On 09/26/24 at 1:55 p.m., the administrator stated Resident #1 initially came to them on 09/20/24 to report CMA #1 had sent nude pictures to the resident's cell phone. The administrator stated they immediately started the abuse investigation which included required notification to authorities, appropriate reporting, interviews with staff and residents, and staff in-services. The administrator stated Resident #1 came to them again on 09/24/24 and shared months of social media messages between the resident and CMA #1. The administrator stated the abuse investigation had been completed and the allegation of abuse was substantiated.

Based on observation, record review, and interview, the facility failed to provide showers as scheduled for one (#29) of three residents reviewed for assistance with activities of daily living. The administrator reported a facility census of 48 residents. Findings: An Activities of Daily Living policy, dated March 2018, documented in part, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for .hygiene (bathing, dressing, grooming) . Resident #29 was admitted with diagnoses which included diabetes mellitus, chronic kidney disease, and chronic pain. An MDS assessment, dated 07/15/24, documented resident #29 required assistance with activities of daily living. The assessment documented the resident was cognitively intact. Resident #29's care plan, dated 07/16/24, documented the resident had a self-care deficit and required assistance with activities of daily living. Shower sheets for resident #29 were reviewed for July and August 2024. The shower sheet for 07/06/24 documented self. The sheet for 07/25/24 documented, she didn't want one she was mad. The sheet for 07/30/24 documented, COVID quarantine. The sheet for 08/17/24 documented the resident received a shower. Shower sheets for previous months were reviewed and contained very inconsistent documentation related to which residents received showers as scheduled. Resident council minutes were reviewed. The minutes for 08/09/24 documented residents complained they were not getting showers in a timely manner. The minutes documented staff in-service training was conducted on 08/16/24 related to providing showers as scheduled. On 08/28/24 at 9:34 a.m., resident #29 was observed with oily/greasy hair and reported she thought her regular shower days were Tuesday, Thursday, and Saturday. The resident reported she wasn't feeling well the previous day so didn't get a shower as scheduled. The resident stated she couldn't remember exactly when she last had a shower. On 08/29/24 at 8:57 a.m., CNA #1 reported the aides try to document showers both in the computer and on the shower sheets. The CNA reported the aides have talked to corporate staff regarding the charting of showers in the EMR. The CNA stated the system doesn't provide an option to show when it's not the resident's shower day, and therefore it looks like the aides are charting done every day. The CNA stated some of the new staff aren't sure what to do so they just click on it every day whether it's the resident's shower day or not. The CNA reported they try to keep the paper shower sheets up to date so they're more accurate, but some of the new staff are still being trained. On 08/29/24 at 10:58 a.m., RN #1 reported staff had been in-serviced related to documentation of resident showers. The RN stated administrative staff would continue to make rounds and interview residents to ensure they were getting their showers as scheduled.

Based on observation, record review, and interview, the facility failed to administer medications per physician orders for two (#11 and #41) of five residents reviewed for following physician orders. The facility reported two medication errors in the last 90 days. Findings: An Administering Medications policy, dated April 2019, documented in part, .Medications are administered in accordance with prescriber orders, including any required time frame .The individual administering the medication checks the label three (3) times to verify the .right time .before giving the medication . 1. Resident #11 was admitted with diagnoses which included diabetes mellitus, polyarthritis, hypertension, hypothyroidism, acute kidney failure, anxiety, and chronic pain. An MDS assessment for resident #11, dated 06/03/24, documented the resident was moderately impaired with cognition. The assessment documented the resident required some assistance with activities of daily living. A Physician Order Report for resident #11, dated July and August 2024, documented to give Pepcid (famotidine) 20 mg, 1 by mouth daily, between 6:00 a.m. and 7:00 a.m., for gastro-esophageal reflux disease without esophagitis. On 08/26/24 at 8:23 a.m., ACMA #1 was observed to administer resident #11's morning medications. The medication Pepcid (famotidine) 20 mg was included with the other medications. 2. Resident #41 was admitted to the facility with diagnoses which included Alzheimer's disease, hypotension, hypokalemia, Bipolar disorder, depression, anxiety, and pain. A physician's order for resident #41, dated 11/13/23, documented the resident was to receive Pantoprazole 40 mg, one by mouth, prior to breakfast between 6:00 a.m. and 7:00 a.m. Resident #41's care plan, dated 08/05/24, documented the resident was at risk for GI distress related to GERD. An MDS assessment for resident #41, dated 08/05/24, documented the resident was severely impaired with cognition and required assistance with activities of daily living. On 08/26/24 at 8:09 a.m., CMA #1 was observed to administer resident #41's morning medications. The medication Pantoprazole was given at the same time with other medications. On 08/29/24 at 8:54 a.m., CMA #1 reported resident #41 often stayed up late so if the resident was still asleep, they held the early medication until the resident was up and gave it with the other morning medications. The CMA stated she understood Pantoprazole was supposed to be administered prior to breakfast and stated most of the time it was given as ordered. On 08/29/24 at 11:30 a.m., RN #1 reported she had just got the order changed for resident #11 to be given the Pepcid between 6:00 a.m. and 11:00 a.m. The RN stated both residents should have received their medications between 6:00 a.m. and 7:00 a.m. as ordered.

Based on record review and interview, the facility failed to assess and intervene timely for one (#1) of four sampled residents reviewed for hospitalization s. The Resident Census and Conditions of Residents report, dated 08/14/23, documented 45 residents resided in the facility. Findings: The facility's Change in a Resident's Condition or Status policy, revision date 05/2017, read in part .The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . Resident #1 was admitted with a diagnosis of dementia. Resident #1's MAR, with a date range of 08/01/23 through 08/06/23, documented on 08/06/23 the resident's medications had not been administered that morning due to condition. The MAR documented Hydrocodone-acetaminophen tab 7.5-325 mg was last given at 7:19 a.m. on 08/05/23. A nurse note, dated 08/06/23, with a time of 11:36 a.m. documented the resident had not urinated in 14 hours, with a temperature of 100.1 degrees, lethargic, BP 80/60, pulse 90, oxygen at 94% on room air and the resident was sent to the ER. Resident #1's hospital records, dated 08/06/23, documented the resident was admitted at 12:17 p.m. The reason for the admission was AMS, hypotension, and fever. The final diagnosis was sepsis, acute kidney failure, AMS, dementia, and pressure ulcer of right ankle. Resident #1's annual resident assessment, dated 08/08/23, documented the residents cognition was moderately impaired with decision making and required encouragement or cueing with eating. On 08/11/23 at 8:34 a.m., CNA #1 stated the resident normally sleeps a lot. She stated on Saturday the resident was talkative, able to be aroused, and accepting fluids. She stated on Sunday morning the resident did not seem right. She stated she realized the resident was not acting right while trying to check and change them and get them up for breakfast. She stated she was not able to get the resident to take fluids. She stated she notified the RN right when she realized the resident was not acting right. She stated she was not sure if the RN went and evaluated the resident at the time she was notified, but she knew when the RN returned from running an errand she checked on the resident and sent her to the ER. There was no documentation the resident had been assessed until 11:36 a.m. On 08/11/23 at 8:43 a.m., CNA #2 stated the resident sleeps a lot. She stated Saturday the resident was up and ate their meals. She stated the resident acted like their normal self. She stated Sunday CNA #1 and CNA #3, while rounds were being completed at around 7 a.m., had trouble arousing the resident. She stated CNA #1 notified the charge nurse. She stated at times the resident would want to sleep in and their pain medications makes them sleepy. She stated around lunch time the RN took the residents vital signs and sent the resident to the hospital. According to the MAR resident #1 had not had pain medications since 08/05/23. On 08/11/23 at 9:24 a.m., CNA #3 stated on Saturday the resident had a pain pill right before their shower and the resident was hard to keep awake while their hair was blow dried. She stated it was normal for the resident to be drowsy after taking their pain medication. She stated the resident was not feeling well the next morning when she came in for her shift at 6 a.m. On 08/11/23 at 9:48 a.m., LPN #1 stated the residents vitals signs were taken on Saturday and the residents vital signs were within normal limits. She stated she had not documented the vital signs and had not documented the resident would not wake up. She stated staff got the resident up for breakfast, but she would not eat or wake up. She stated Sunday the resident started showing serious signs, running fever, and the RN sent her out to the ER. On 08/11/23 at 10:01 a.m., RN #2 stated on Saturday the resident was a little more tired and had not eaten well. She stated the resident would respond but seemed lethargic. She stated that was the residents normal baseline at times. She stated the resident was up in their chair and did not have any issues with urination until that night. She stated there was nothing concerning with the residents status which would have made her think the resident was not at their normal baseline. Sunday morning the resident was not responding very well and their vital signs were not good. She stated she sent the resident out at that time. She stated the first time she had been notified of the resident condition was when she sent the resident out to the hospital. On 08/11/23 at 11:31 a.m., RN #1 stated she worked Saturday night into Sunday morning. She stated she checked the residents temperature that night and the resident was resting in bed with no temperature. She stated the resident had wet briefs throughout the night. The vital signs log documented the time of temperature taken was 1:05 a.m. She stated during the nurses shift change report the off going nurse told her the resident had been a little more drowsier than normal at dinner. On 08/11/23 at 3:27 p.m., the DON stated a resident found lethargic should be assessed by the nurse. The physician should be contacted and if the resident needed more evaluations send them out to the ER. She stated she would check for any documentation which would indicate the resident was assessed earlier in the morning on 08/06/23. On 08/11/23 at 3:40 p.m., the Administrator stated if a resident was found unresponsive or lethargic the staff should notify the charge nurse and get the resident transported out to the hospital. On 08/11/23 at 4:16 p.m., CMA #1 stated the resident had opened their eyes a couple of times when she took the medications into the room to administer. She stated the resident would not wake up enough to take her medications. She stated she notified the charge nurse the resident would not wake up. She stated that was normal for the resident not to wake up to take their medications early in the morning. She stated she comes back and offers the medications at a later time.

Based on observation, record review, and interview, the facility failed to provide food preferences, snacks, and alternate food choices, to residents who requested a different meal choice, for two (#1 and #26) of two residents sampled for food choices. The Resident Census and Conditions of Residents form, dated 07/25/23, documented 42 residents received meals from the kitchen. Findings: A policy, Alternate Food Choices and Substitutions, dated 10/01/18, documented in part, .An alternate entree and vegetable will be offered at each meal .The facility supports resident choice and allowing residents to choose foods by honoring their food preferences .Other substitutions will also be available in the event a resident does not choose the main meal or the alternate . Resident council meeting minutes, dated 12/22/22, documented complaints related to the dietary department. The minutes documented the residents requested less breakfast for dinner, better snacks on the snack cart, and complained of not liking plain cheese and bread sandwiches for lunch. The dietary response, dated 12/23/23, documented they would abide by a state-approved menu which they were required to serve. The response documented alternate items were posted in the dining room and snack items were rotated and updated routinely. On 07/26/23 at 4:22 p.m., Res #1 reported the kitchen had not given her bread while the surveyors were there, but usually they received bread on their tray. The resident reported the residents were served the same food over and over, stating they received fruit cocktail and Jello all the time. The resident stated when they asked for food listed on the substitute menu, which was documented to be always available, the staff would tell them they didn't have it available due to budget cuts. The resident was asked if they could get a chef salad, and reported when they served salad, it was more like a Caesar salad and that type of lettuce choked them. The resident reported there were no snacks on the snack tray at night that diabetics could have. The resident also stated they wouldn't give them cranberry juice and was told they were not allowed to pass the cranberry juice as a snack. The resident reported they were told by staff they only had milk or fruit punch drink. On 07/27/23 at 8:30 a.m., the DM reported all items for the substitute menu were available at all times, including chef salads. The DM reported they prepared jugs of water, Kool-Aid, and milk for the snack tray. The DM reported they used to have individual milk and juice for snacks to be passed out, but due to budget cuts, she was told to prepare the bigger jugs. The DM stated they did have individual juices, which were kept at the nurses station, for residents who requested juice for a snack. On 07/27/23 at 9:15 a.m., a small refrigerator was observed at the nurse's station. Staff reported the refrigerator was used to store drinks for resident snacks. The only juice observed to be available was thickened juice. On 07/27/23 at 11:20 a.m., LPN #1 reported when a resident did not like what was being served, they would request something different from the kitchen. The LPN reported she was told by kitchen staff they needed to know beforehand or they would not have the food on the substitute menu. The LPN reported one resident did not get chef salads as often as they preferred so the activity director purchased the resident salad items to have in the resident's personal refrigerator as requested by the resident. The LPN stated she had received complaints from residents regarding the snack cart lacking choices and only one drink choice being available. On 07/27/23 at 11:30 a.m., the activities director reported they had asked one time during a meal for a resident to get a chef salad. The activities director stated kitchen staff told them it would be the next meal before the resident could get a salad so the resident was served soup and a sandwich instead. On 07/27/23 at 11:37 a.m., CNA #1 reported when a resident requested a substitute meal during the meal, the kitchen usually did not have what was requested by the resident. The CNA stated when a resident requested a chef salad, they typically would not have the ingredients to prepare one. The CNA reported the snack supply was just okay, with not a lot of variety for the residents to choose from. The CNA stated it had recently changed with only having water or Kool-Aid to serve for the evening snack. The CNA stated they no longer had juice to pass at night for residents who requested it, because they were told they were running out of the small individual containers too fast. On 07/27/23 at 12:04 p.m., the DM was interviewed regarding diabetic diets, appropriate portions related to proteins, as well as breads and starches. The DM voiced an understanding of therapeutic diets. Meal service was observed each day of the survey with proper serving scoops utilized to ensure correct serving sizes, plates filled by the meal ticket, and therapeutic diets offered as ordered. On 07/27/23 at 12:31 p.m., Res #26 reported they were admitted to the facility on [DATE]. The resident reported they were supposed to be on a carb-controlled, reduced concentrated sweets diet, but stated that wasn't always the diet they received. The resident reported they tried not to eat too many potatoes but often received potatoes on their tray. The resident reported they sent their tray back to the kitchen one time but never received a substitute or alternate meal, so now they just ate whatever the kitchen sent them and monitored their blood sugars closely. The resident reported the meals were improving and had been better while the surveyors were there, but they didn't think the kitchen staff understood alternate choices for a carb-controlled diet. On 07/27/23 at 12:36 p.m., the administrator reported they had stopped serving some of the food items they previously offered for snacks, such as cookies, Little [NAME] cakes, potato chips, and now offered crackers and fig bars. The administrator stated they no longer provided popcorn on a regular basis. The administrator reported they put out a pitcher of tea, water, or Kool-Aid, and offered different types of sandwiches. The administrator was asked if residents could get juice in the evenings, and stated she thought juices were kept in the refrigerator under the nurse's station. The administrator reported kitchen staff would be the ones to set up snacks and provide juice. The administrator stated residents should be allowed to order substitute food items as requested, and stated she knew occasionally the kitchen would run out of lettuce before the week was over and a food delivery was made.

Based on record review, observation, and interview, the facility failed to assess and monitor [CONDITION(S)] for one (#1) of one resident reviewed for [CONDITION(S)]. The administrator reported 42 residents resided in the facility. Findings: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A significant change assessment, dated 11/19/21, documented the resident was moderately impaired with cognition and required extensive assistance with activities of daily living. The assessment documented the resident was frequently incontinent of bladder and always continent of bowel. The assessment documented no skin issues. A care plan, updated 02/18/22, documented the resident was at risk for excess fluid volume related to [CONDITION(S)]. The care plan documented for the staff to monitor for lower extremity [CONDITION(S)] per facility guidelines, protocol &/ or per physician orders. On 03/07/22 at 12:01 p.m., the resident was observed to have [CONDITION(S)] to the right lower extremity. On 03/09/22 at 8:43 a.m., the resident was observed sitting up in his Geri chair. The resident was observed to have [CONDITION(S)] to bilateral lower extremities (BLE). On 03/09/22 at 1:48 p.m., registered nurse (RN) #1 reported the resident has had BLE [CONDITION(S)] for years. The RN reported there was not a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The RN reported the staff watch him. The RN reported the resident generally had good output. The RN reported there was no documentation on the resident's treatment sheet to assess or monitor the resident's [CONDITION(S)]. The RN reported they should be assessing, monitoring and documenting the resident's [CONDITION(S)]. On 03/09/22 at 2:15 p.m., the corporate nurse reported the staff should be monitoring the resident's lower extremities for [CONDITION(S)].

Based on record review and interview, the facility failed to ensure a discharge summary was completed for one (#42) of three residents reviewed. The administrator reported 42 residents resided in the facility. Findings: Resident #42 was admitted on [DATE]. A document titled Against medical advice, dated 01/01/22, documented the resident left the facility against medical advice. The clinical record contained no discharge summary. On 03/10/22 at 10:00 a.m., the interim director of nurses reported a discharge summary had not been completed.

Based on interview and record review, it was determined the facility failed to ensure a certified medication aide was certified to administer percutaneous endoscopic gastrostomy (PEG) medications and feedings. The facility reported four residents required a PEG tube. Findings: Staff records were reviewed and certified medication aide #3 had no certification to administer gastro medication or feedings. Medication administration records, dated (MONTH) and (MONTH) 2019, contained CMA #3's initials when PEG tube feedings were administered. On 09/17/19 two unidentified staff members reported they had observed certified medication aide (CMA) #3 administer PEG tube medications and feedings. One of the medication aides reported the charge nurse had told the CMA multiple times not to administer PEG medications of feedings. On 09/17/19 at 10:30 a.m., the director of nursing (DON) reported the initials on the MAR indicated [REDACTED]. On 09/17/19 at 11:20 a.m., CMA #3 reported she had initialed the MAR. The CMA reported she would prepare the PEG tube medications and feedings for the nurse to administer. On 09/17/19 at 3:19 p.m., the DON reported the CMA had initialed the MAR indicated [REDACTED]. The DON reported the issue would be addressed.

Based on observation, interview, and record review, it was determined the facility failed ensure residents with percutaneous endoscopic gastrostomy (PEG) tube received feeding as physician ordered for two (#1 and #2) of three residents reviewed. The facility reported four residents required a PEG tube. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated 08/01/19, documented the resident had a PEG tube and received medication, nutrition and hydration via the PEG tube. A dietary progress note, dated 08/14/19, documented the resident weighed 99 pounds. A physician's orders [REDACTED].until the (2 cal comes in) (every four hours). A physician's orders [REDACTED]. An annual assessment, dated 08/28/19, documented the resident was severely impaired with cognition and was totally dependent on staff for all activities of daily living. The assessment documented the resident required a feeding tube. The assessment documented the resident weighed 99 pounds. A Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A dietary progress note, dated 09/09/19, documented the resident weighed 94 pounds. A MAR, dated (MONTH) 2019, contained six missed bolus feedings of 2 cal and water as ordered by the physician. On 09/17/19 at 8:09 a.m., the resident was observed lying in bed with his eyes open. On 09/17/19 at 8:12 a.m., certified medication aide (CMA) #1 reported the resident would get his PEG tube feeding when the other CMA came into work. On 09/17/19 at 9:34 a.m., CMA #2 reported she had provided the resident with his feeding. The CMA reported he should have received his feeding before 9:00 a.m. The CMA reported there had been times when the resident did not have 2 cal available and had missed feedings. On 09/17/19 at 11:25 a.m. the resident's provider reported the facility did not have 2 cal available and she had prescribed [MEDICATION NAME] until the 2 cal arrived. On 09/17/19 at 1:05 p.m., the assistant director of nursing (ADON) reported the blanks on the MAR ultimately meant the feeding did not get completed. On 09/17/19 at 2:25 p.m., the director of nursing (DON) reported the blanks meant the feedings were not completed. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated 08/01/19, documented the resident was fed via PEG tube. The care plan documented a goal for the resident was to maintain nutritional status and a healthy weight. The care plan documented for the staff to administer tube feedings as ordered by the physician. A quarterly assessment, dated 08/10/19, documented the resident was severely impaired with cognition and was totally dependent for staff with activities of daily living. The assessment documented the resident required a feeding tube. The assessment documented the resident weighed 124 pounds. A dietary note, dated 08/14/19, documented the resident weighed 113 pounds. A MAR, dated (MONTH) 2019, documented 18 (blanks in documentation) missed feedings and 16 missed opportunities for water as ordered by the physician. A dietary note, dated 09/09/19, documented the resident weighed 105 pounds a decrease of eight pounds (7%) in one month, yet no change in tube feeding order. A MAR, dated (MONTH) 2019, documented 10 missed feedings and 12 missed opportunities for water as ordered by the physician. On 09/17/19 at 8:12 a.m., certified medication aide (CMA) #1 reported the resident would get his PEG tube feeding when the other CMA came into work. On 09/17/19 at 9:34 a.m., CMA #2 was observed to administer the resident his PEG tube feeding. The CMA did not flush the PEG tube prior to administering medication or after as ordered by the physician. The CMA reported she did not know how much water she used to flush the PEG tube after the feeding. The CMA reported the resident should have received his feeding before 9:00 a.m. On 09/17/19 at 1:05 p.m., the ADON reported the blanks on the MAR ultimately meant the feeding did not get completed. On 09/17/19 at 2:25 p.m., the DON reported the blanks meant the feedings were not completed.

Based on observation, interview, and record review, it was determined the facility failed maintain nutritional status and to ensure unplanned weight loss did not occur for two (#1 and #2) of three residents reviewed with a percutaneous endoscopic gastrostomy (PEG) tube. The facility reported four residents required a PEG tube. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated 08/01/19, documented the resident had a PEG tube and received medication, nutrition and hydration via the PEG tube. A dietary progress note, dated 08/14/19, documented the resident weighed 99 pounds. A physician's orders [REDACTED].until the (2 cal comes in) (every four hours). A physician's orders [REDACTED]. An annual assessment, dated 08/28/19, documented the resident was severely impaired with cognition and was totally dependent on staff for all activities of daily living. The assessment documented the resident required a feeding tube. The assessment documented the resident weighed 99 pounds. A Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A dietary progress note, dated 09/09/19, documented the resident weighed 94 pounds. A 5% weight loss in less than one month. The care plan had not been updated to reflect the significant weight loss. A MAR, dated (MONTH) 2019, contained six missed bolus feedings of 2 cal and water as ordered by the physician. On 09/17/19 at 8:09 a.m., the resident was observed lying in bed with his eyes open. On 09/17/19 at 8:12 a.m., certified medication aide (CMA) #1 reported the resident would get his PEG tube feeding when the other CMA came into work. On 09/17/19 at 9:34 a.m., CMA #2 reported she had provided the resident with his feeding. The CMA reported he should have received his feeding before 9:00 a.m. The CMA reported there had been times when the resident did not have 2 cal available and had missed feedings. On 09/17/19 at 11:25 a.m. the resident's provider reported the facility did not have 2 cal available and she had prescribed [MEDICATION NAME] until the 2 cal arrived. On 09/17/19 at 1:05 p.m., the assistant director of nursing (ADON) reported the blanks on the MAR ultimately meant the feeding did not get completed. On 09/17/19 at 2:25 p.m., the director of nursing (DON) reported the blanks meant the feedings were not completed. The DON reported the physician should have been notified of the resident's weight loss. The DON reported the feedings should have been administered as ordered by the physician. The DON reported the care plan should have been updated to reflect the significant weight loss. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated 08/01/19, documented the resident was fed via PEG tube. The care plan documented a goal for the resident was to maintain nutritional status and a healthy weight. The care plan documented for the staff to administer tube feedings as ordered by the physician. A quarterly assessment, dated 08/10/19, documented the resident was severely impaired with cognition and was totally dependent for staff with activities of daily living. The assessment documented the resident required a feeding tube. The assessment documented the resident weighed 124 pounds. A dietary note, dated 08/14/19, documented the resident weighed 113 pounds. A MAR, dated (MONTH) 2019, documented 18 (blanks in documentation) missed feedings and 16 missed opportunities for water as ordered by the physician. A dietary note, dated 09/09/19, documented the resident weighed 105 pounds a decrease of eight pounds (7%) in one month, yet no change in tube feeding order. The care plan had not been updated to reflect the resident's significant weight loss. A MAR, dated (MONTH) 2019, documented 10 missed feedings and 12 missed opportunities for water as ordered by the physician. On 09/17/19 at 8:12 a.m., certified medication aide (CMA) #1 reported the resident would get his PEG tube feeding when the other CMA came into work. On 09/17/19 at 9:34 a.m., CMA #2 was observed to administer the resident his PEG tube feeding. The CMA did not flush the PEG tube prior to administering medication or after as ordered by the physician. The CMA reported she did not know how much water she used to flush the PEG tube after the feeding. The CMA reported the resident should have received his feeding before 9:00 a.m. On 09/17/19 at 1:05 p.m., the ADON reported the blanks on the MAR ultimately meant the feeding did not get completed. On 09/17/19 at 2:25 p.m., the DON reported the blanks meant the feedings were not completed. The DON reported the physician should have been notified of the resident's weight loss. The DON reported the feedings should have been administered as ordered by the physician. The DON reported the care plan should have been updated to reflect the significant weight loss.

Based on observation, interview, and record review, it was determined the facility failed to revise a care plan when significant weight loss occurred for two (#1 and #2) of three residents reviewed with a percutaneous endoscopic gastrostomy (PEG) tube. The facility reported four residents required a PEG tube. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 08/01/19, documented the resident had a PEG tube and received medication, nutrition and hydration via the PEG tube. A dietary progress note, dated 08/14/19, documented the resident weighed 99 pounds. An annual assessment, dated 08/28/19, documented the resident was severely impaired with cognition and was totally dependent on staff for all activities of daily living. The assessment documented the resident required a feeding tube. The assessment documented the resident weighed 99 pounds. A dietary progress note, dated 09/09/19, documented the resident weighed 94 pounds. A 5% weight loss in less than one month. The care plan had not been updated to reflect the significant weight loss. On 09/17/19 at 8:09 a.m., the resident was observed lying in bed with his eyes open. On 09/17/19 at 2:25 p.m., the director of nursing (DON) reported the care plan should have been updated to reflect the significant weight loss. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 08/01/19, documented the resident was fed via PEG tube. The care plan documented a goal for the resident was to maintain nutritional status and a healthy weight. The care plan documented for the staff to administer tube feedings as ordered by the physician. A quarterly assessment, dated 08/10/19, documented the resident was severely impaired with cognition and was totally dependent for staff with activities of daily living. The assessment documented the resident required a feeding tube. The assessment documented the resident weighed 124 pounds. A dietary note, dated 08/14/19, documented the resident weighed 113 pounds. A dietary note, dated 09/09/19, documented the resident weighed 105 pounds a decrease of eight pounds (7%) in one month, yet no change in tube feeding order. On 09/17/19 at 2:25 p.m., the DON reported the care plan should have been updated to reflect the significant weight loss.

Based on observation, interview, and record review, it was determined the facility failed notify the physician of significant weight loss for two (#1 and #2) of three residents reviewed with a percutaneous endoscopic gastrostomy (PEG) tube. The facility reported four residents required a PEG tube. Findings: 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated 08/01/19, documented the resident had a PEG tube and received medication, nutrition and hydration via the PEG tube. A dietary progress note, dated 08/14/19, documented the resident weighed 99 pounds. A physician's orders [REDACTED].until the (2 cal comes in) (every four hours). A physician's orders [REDACTED]. An annual assessment, dated 08/28/19, documented the resident was severely impaired with cognition and was totally dependent on staff for all activities of daily living. The assessment documented the resident required a feeding tube. The assessment documented the resident weighed 99 pounds. A Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A dietary progress note, dated 09/09/19, documented the resident weighed 94 pounds. A 5% weight loss in less than one month. The clinical record contained no documentation the physician had been notified of the significant weight loss. A MAR, dated (MONTH) 2019, contained six missed bolus feedings of 2 cal and water as ordered by the physician. On 09/17/19 at 8:09 a.m., the resident was observed lying in bed with his eyes open. On 09/17/19 at 8:12 a.m., certified medication aide (CMA) #1 reported the resident would get his PEG tube feeding when the other CMA came into work. On 09/17/19 at 9:34 a.m., CMA #2 reported she had provided the resident with his feeding. The CMA reported he should have received his feeding before 9:00 a.m. The CMA reported there had been times when the resident did not have 2 cal available and had missed feedings. On 09/17/19 at 11:25 a.m. the resident's provider reported the facility did not have 2 cal available and she had prescribed [MEDICATION NAME] until the 2 cal arrived. On 09/17/19 at 1:05 p.m., the assistant director of nursing (ADON) reported the blanks on the MAR ultimately meant the feeding did not get completed. On 09/17/19 at 2:25 p.m., the director of nursing (DON) reported the blanks meant the feedings were not completed. The DON reported the physician should have been notified of the resident's weight loss. The DON reported the feedings should have been administered as ordered by the physician. The DON reported the care plan should have been updated to reflect the significant weight loss. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A care plan, dated 08/01/19, documented the resident was fed via PEG tube. The care plan documented a goal for the resident was to maintain nutritional status and a healthy weight. The care plan documented for the staff to administer tube feedings as ordered by the physician. A quarterly assessment, dated 08/10/19, documented the resident was severely impaired with cognition and was totally dependent for staff with activities of daily living. The assessment documented the resident required a feeding tube. The assessment documented the resident weighed 124 pounds. A dietary note, dated 08/14/19, documented the resident weighed 113 pounds. A MAR, dated (MONTH) 2019, documented 18 (blanks in documentation) missed feedings and 16 missed opportunities for water as ordered by the physician. A dietary note, dated 09/09/19, documented the resident weighed 105 pounds a decrease of eight pounds (7%) in one month, yet no change in tube feeding order. The clinical record contained no documentation the physician had been notified of the significant weight loss. A MAR, dated (MONTH) 2019, documented 10 missed feedings and 12 missed opportunities for water as ordered by the physician. On 09/17/19 at 8:12 a.m., certified medication aide (CMA) #1 reported the resident would get his PEG tube feeding when the other CMA came into work. On 09/17/19 at 9:34 a.m., CMA #2 was observed to administer the resident his PEG tube feeding. The CMA did not flush the PEG tube prior to administering medication or after as ordered by the physician. The CMA reported she did not know how much water she used to flush the PEG tube after the feeding. The CMA reported the resident should have received his feeding before 9:00 a.m. On 09/17/19 at 1:05 p.m., the ADON reported the blanks on the MAR ultimately meant the feeding did not get completed. On 09/17/19 at 2:25 p.m., the DON reported the blanks meant the feedings were not completed. The DON reported the physician should have been notified of the resident's weight loss. The DON reported the feedings should have been administered as ordered by the physician. The DON reported the care plan should have been updated to reflect the significant weight loss.

Based on observation, interview, and record review, it was determined the facility failed to provide supervision to prevent falls for three (#32, #144, and #26) of three residents reviewed for falls. The facility failed to: a. Thoroughly assess fall risks for residents #32 and #144. b. Develop and/or update care plans with interventions to prevent falls for residents #32, #144, and #26. c. Implement care plans to prevent falls for residents #32, #144, and #26. Resident #32 experienced multiple falls including a fall with a laceration that required staples and a fall with a [MEDICAL CONDITION] that required surgery. Resident #144 experienced a fall with a displaced hip and was transferred to the hospital for evaluation and treatment. The facility reported 40 residents lived in the facility. Findings: 1. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment, dated 07/24/18, documented the resident was cognitively intact and exhibited mild depression. The assessment documented the resident was independent with activities of daily living. The assessment documented the resident received an antipsychotic, antidepressant, anticoagulant, and an opioid for seven days of the look back period. A care plan, dated 07/24/18, documented the resident performed activities of daily living (ADLs) independently. The care plan documented a goal for the resident was to continue ADLs without a decline. A care plan, updated 09/12/18, documented the resident was at risk for falls and utilized a walker to assist with ambulation. The care plan documented a goal was for the resident to be free of falls and injuries. The care plan documented interventions for the staff to ensure the resident utilized his walker with ambulation, complete a fall risk assessment quarterly, and to keep hallways and room free of clutter. A nurse note, dated 01/11/19 at 4:15 a.m., documented the resident slid from his wheelchair and landed on his buttocks. The note documented no injuries noted. An actual fall care plan, dated 01/11/19 at 4:15 a.m., documented the resident slid out of his wheelchair onto the floor. The care plan documented no injuries noted to the resident. The actual fall care plan contained no interventions to prevent further falls. A nurse note, dated 01/14/19 at 2:00 a.m., documented the resident was found sitting on the floor in front of his wheelchair. The note documented the resident had a 1 centimeter (cm) skin tear to his right wrist. An actual fall care plan, dated 01/14/19, documented the resident was found sitting on the floor in front of his wheelchair. The care plan documented the resident was sleeping and slid out of his wheelchair. The care plan documented the resident had a skin tear to the back of his right wrist. The actual fall care plan contained no interventions to prevent further falls. A physician's orders [REDACTED]. The order documented for the staff to monitor the resident. A nurse note, dated 03/17/19 at 11:30 a.m., documented the resident tried to stand utilizing his walker while at the dining room table. The note documented the resident fell and hit his head causing a 3 cm laceration. The note documented the resident was sent to the emergency room for treatment. The note documented the resident returned from the hospital at 2:35 p.m. with three staples to the laceration of the head. The clinical record contained no documentation the care plan had been updated to include interventions to prevent further falls. A nurse note, dated 03/21/19 at 3:00 a.m., documented, Resident slid from bed onto buttocks causing red area to right hip and 3 cm skin tear back of right hand. S/T approximated and steri-strips applied after cleaning with nss. Residents clothes were changed and assisted back to bed. Did state, Some hip pain. Gave Tylenol and resident went to sleep almost immediately. A nurse note, dated 03/21/19 at 6:00 a.m., documented, Night shift reports resident fell out of bed at 0300 during the night. Resident calling out for assist to void-voided x 1 per urinal states he broke his hip. C/O pain right hip . Physician notified and received orders for mobile x-ray. A nurse note, dated 03/21/19 at 11:00 a.m., documented mobile x-ray arrived. The note documented a possible fracture, the physician was notified, and an order received to send the resident to the emergency room . A nurse note, dated 03/22/19 at 11:30 a.m., documented the resident had surgery related to a right [MEDICAL CONDITION]. The clinical record contained no documentation the care plan had been updated to include interventions to prevent further falls. A quarterly assessment, dated 03/27/19, documented the resident was severely impaired with cognition, exhibited mild depression and exhibited verbal behaviors toward others. The assessment documented the resident required limited assistance of one staff member for most activities of daily living. The assessment documented the resident had one fall with no injuries, one fall with injury, and one fall with a major injury. The assessment documented the resident received an antipsychotic, antidepressant, anticoagulant, a diuretic, and an opioid for seven days of the look back period. The assessment documented the resident required hospice care. A nurse note, dated 06/24/19 at 6:00 a.m., documented, the resident was found on the fall mat beside his bed. The note documented no injuries noted to the resident. The clinical record contained no documentation the care plan had been updated to include interventions to prevent further falls. A physician's orders [REDACTED]. [MEDICATION NAME] 20 mg QD for depression-07/10/18; [MEDICATION NAME] 2 mg daily with 5 mg to = 7 mg; [MEDICATION NAME] 0.5mg TID for anxiety-04/30/19; [MEDICATION NAME] 10-325 mg BID for pain-04/30/19; Risperidal 0.5 mg QHS for behavior disturbance-06/27/19; ABH gel 1 mg/Ml apply one syringe topically to inner wrist BID, Hold if sedated for 06/27/19; [MEDICATION NAME] 10-325 mg Q6 hours PRN for pain-04/30/19; Fall precaution-Initial you are aware and monitoring; [MEDICATION NAME] 40 mg BID at 8 and noon-07/12/19; [MEDICATION NAME] 0.125 mg daily for [MEDICAL CONDITION]-07/13/19; Admit to hospice of choice-Aspire. On 07/30/19 at 10:18 a.m., the resident was observed sitting up in a Geri chair in the front lobby with his eyes closed. On 07/30/19 at 2:18 p.m., the resident was observed lying in bed with his eyes closed and a fall mat at the bedside. On 07/31/19 at 10:23 a.m., the resident was observed lying in bed with his eyes closed and a fall mat at the bedside. On 07/31/19 at 9:53 a.m., the assistant director of nursing (ADON) reported an incident report had not been completed nor a state reportable for the fall which resulted in staples to the resident's head on 03/17/19. The ADON reported the incident report should have been completed. The ADON reported she could not locate documentation to include interventions to prevent future falls. The ADON reported there had not been a fall risk assessment completed. The ADON reported interventions should have been implemented and the care plan updated after the resident experienced falls in (MONTH) 2019. 2. Resident #144 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse note, dated 06/18/19 at 10:30 p.m., documented the resident had numerous bruises and sore areas related to recent falls prior to admission. A nurse note, dated 06/27/19 at 4:00 a.m., documented the resident was found on the floor in her room. The note documented family was notified and the family reported the resident had a history of [REDACTED]. A physician order, dated 6/27/19, documented to obtain an x-ray of bilateral hip/pelvis related to pain following the fall. A follow-up nurse note documented the resident had voiced pain and an order was received for a mobile x-ray. The note documented x-ray results revealed the resident to have a displaced right hip. The note documented the resident was sent to the hospital for evaluation and treatment. The closed medical record was reviewed. A baseline care plan with check boxes was observed with no resident name, date, or signature. There was no documentation related to the resident's history of falls. A social services note, dated 07/02/19, documented the resident had been sent to the emergency roiagnom on [DATE]. The note documented the resident was discharged from the facility on 07/01/19. On 07/31/19 at 11:58 a.m., the assistant director of nursing (ADON) reported there was no care plan initiated for this resident and a baseline care plan, to include fall interventions, should have been initiated upon admission. On 07/31/19 at 1:22 p.m., the director of nursing (DON) reported a fall risk assessment, to include interventions to prevent falls, should have been completed when the resident was admitted to the facility. 3. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan, updated 10/12/18, documented the resident was at risk for falls. The care plan contained no interventions to prevent falls. A quarterly assessment, dated 05/23/19, documented the resident was severely impaired with cognition. The assessment documented the resident was totally dependent on staff for all ADLs. A physician's orders [REDACTED].fall precautions-daily and to monitor and document . An incident report, dated 07/18/19 at 09:30 a.m., documented the resident was found on the floor beside the bed on a floor mat without apparent injury. The report documented the resident was assessed. The report documented the physician and family were notified. The report documented no new orders were received. The report documented preventative measures for the staff to check the resident every two hours and as needed, and to position the resident properly in bed to ensure safety. A nurse progress note, dated 07/18/19 at 9:30 a.m., documented the resident was found on the padded mat at the bedside on the floor. The note documented the resident was assessed. The note documented no bruising, abrasions, or discoloration noted. The note documented the resident was assisted back to bed. The nurse notes documented monitoring occurred through 07/20/19 at 11:15 p.m. The care plan had not been updated to reflect the fall on 07/18/19. On 07/31/19 at 11:58 a.m., the ADON reported the care plan should have been updated to reflect the fall, with interventions implemented to prevent further falls.

Based on interview and record review, it was determined the facility failed to complete a facility assessment. The facility reported 40 residents lived in the facility. Findings: On 07/31/19 at 3:46 p.m., the administrator (ADM) was asked for the facility assessment. The ADM reported he did not know what a facility assessment was. The ADM reported he would search for the facility assessment. On 07/31/19 at 4:00 p.m., the ADM reported he was unable to locate the facility assessment.

Based on interview and record review, it was determined the facility failed to perform a comprehensive assessment in a timely manner for five (#19, 15, 40, 18, and #37) of 26 residents reviewed for resident assessments. Findings: On [DATE] at 1:55 p.m., the minimum data set (MDS) coordinator reported she had a list of residents for which comprehensive assessments should have been completed and submitted but were not performed in a timely manner. The MDS coordinator provided the following information for residents who had not had a comprehensive assessment completed as indicated: 1. Resident #19 had an annual assessment due on [DATE] and had not been completed in a timely manner. 2. Resident #15 should have had a significant change assessment completed on [DATE]. The MDS coordinator reported the resident was discharged on [DATE] and the discharge assessment was completed but had not been transmitted. 3. Resident #40 was discharged by death on [DATE]. The MDS coordinator reported a discharge assessment had not been completed to remove the resident from the system. 4. Resident #18 should have had an annual assessment completed on [DATE] but this had not been completed. 5. Resident #37 should have had an annual assessment completed on [DATE] but this had not been completed.

Based on interview and record review, it was determined the facility failed to assess residents once every three months for eight (#19, 7, 31, 33, 32, 18, 43, and #35) of 26 residents reviewed for quarterly assessments. The facility reported 40 residents lived in the facility. Findings: On 07/31/19 at 1:55 p.m., the minimum data set (MDS) coordinator reported she had a list of residents for which quarterly assessments should have been completed and submitted but were not performed in a timely manner. The MDS coordinator provided the following information for residents who had not had a quarterly assessment completed as indicated: 1. Resident #19 should have had a quarterly assessment completed by 06/17/19 but this had not been completed. 2. Resident #7 should have had a quarterly assessment completed by 06/06/19 but this had not been completed. 3. Resident #31 should have had a quarterly assessment completed by 05/19/19 but this had not been completed. 4. Resident #33 should have had a quarterly assessment completed by 06/18/19 but this had not been completed. 5. Resident #32 should have had a quarterly assessment completed by 06/27/19 but this had not been completed. 6. Resident #18 should have had a quarterly assessment completed by 06/08/19 but this had been transmitted late. 7. Resident #43 should have had a quarterly assessment completed by 06/23/19 but this had not been completed. 8. Resident #35 should have had a quarterly assessment completed by 06/15/19 but this had not been completed.

Based on interview and record review, it was determined the facility failed to complete and transmit resident assessments within the required time period for 11 (#19, 15, 40, 18, 37, 7, 31, 33, 32, 43, and #35) of 26 residents reviewed for timely transmission of assessments. The facility reported 40 residents lived in the facility. Findings: On [DATE] at 1:55 p.m., the minimum data set (MDS) coordinator reported she had a list of residents for which comprehensive or quarterly assessments should have been completed and transmitted but were not performed in a timely manner. The MDS coordinator provided the following information for residents who did not have assessments completed and transmitted as required: 1. Resident #19 had an annual assessment due on [DATE] and this was not completed in a timely manner. The resident should have had a quarterly assessment completed [DATE] and this was not completed. 2. Resident #15 should have had a significant change assessment completed [DATE]. The MDS coordinator reported the resident was discharged [DATE] and the discharge assessment had not been transmitted. 3. Resident #40 was discharged by death on [DATE]. The MDS coordinator reported a discharge assessment had not been completed and transmitted to remove the resident from the system. 4. Resident #18 should have had an annual assessment completed on [DATE] and this had not been completed. The resident should have had a quarterly assessment completed [DATE] and had been transmitted late. 5. Resident #37 should have had an annual assessment completed by [DATE] and this had not been completed. 6. Resident #7 should have had a quarterly assessment completed by [DATE] and this had not been completed. 7. Resident #31 should have had a quarterly assessment completed by [DATE] and this had not been completed. 8. Resident #33 should have had a quarterly assessment completed by [DATE] and this had not been completed. 9. Resident #32 should have had a quarterly assessment completed by [DATE] and this had not been completed. 10. Resident #43 should have had a quarterly assessment completed by [DATE] and this had not been completed. 11. Resident #35 should have had a quarterly assessment completed by [DATE] and this had not been completed.

Based on observation, interview, and record review, it was determined the facility failed to develop and implement a baseline care plan for two (#27 and #144) of four residents reviewed for baseline care plans. Findings: 1. Resident #27 was admitted on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment, dated 04/21/19, documented the resident was cognitively intact. The assessment documented the resident required limited assistance with most activities of daily living. The assessment documented the resident received antipsychotics, antidepressants, and opioids seven of seven days previous. On 07/30/19 at 11:10 a.m., the resident was observed making a private phone call in a back office with glass walls. On 07/30/19 at 4:29 p.m., the assistant director of nursing (ADON) reported the resident did not have a care plan. The ADON reviewed the resident's chart and reported a baseline care plan should have been initiated on admission. 2. Resident #144 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse note, dated 06/18/19 at 10:30 p.m., documented the resident had numerous bruises and sore areas related to recent falls prior to admission. A nurse note, dated 06/27/19 at 4:00 a.m., documented the resident was found on the floor in her room. The note documented family was notified and reported the resident had a history of [REDACTED]. The closed medical record was reviewed. A baseline care plan with check boxes was observed with the no resident name, date, or signature. There was no documentation related to the resident's history of falls. On 07/31/19 at 11:58 a.m., the assistant director of nursing (ADON) reported there was no care plan initiated for this resident and a baseline care plan should have been initiated upon admission.

Based on observation, interview, and record review, it was determined the facility failed to develop and implement a comprehensive care plan for four (#39, 27, 37, and #144) of 26 residents reviewed. The facility reported 40 residents lived in the facility. Findings: 1. Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive care plan, dated 06/05/18, contained no documentation regarding [MEDICAL CONDITION] drug use. An admission assessment, dated 06/18/18, documented the resident was severely impaired with cognition, exhibited mild depression, and exhibited no behaviors. The assessment documented the resident required limited assistance with activities of daily living. The assessment documented the resident received an antipsychotic, an antidepressant, a hypnotic, and an anticoagulant for seven days of the look back period. A quarterly assessment, dated 03/27/19, documented the resident was severely impaired with cognition and exhibited no depression. The assessment documented the resident received an antipsychotic and an antidepressant for seven days of the look back period. A physician's orders [REDACTED].[MEDICATION NAME] 100 mg QHS depression-10/30/18 . On 07/30/19 at 10:21 a.m., the resident was observed sitting up in a Geri chair in the back lobby watching television. On 07/31/19 at 2:45 p.m., the assistant director of nursing (ADON) reported the antidepressant should have been included in the comprehensive care plan. 2. Resident #27 was admitted on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment, dated 04/21/19, documented the resident was cognitively intact. The assessment documented the resident required limited assistance with most activities of daily living. The assessment documented the resident received antipsychotics, antidepressants, and opioids seven of seven days previous. On 07/30/19 at 11:10 a.m., the resident was observed making a private phone call in a back office with glass walls. The resident had previously reported feelings of being overheard while making phone calls. The area provided for residents was observed to maintain privacy. On 07/30/19 at 4:29 p.m., the ADON reported a care plan had not been developed and implemented for this resident. 3. Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. A care plan, dated 02/05/18, documented the resident had short-term memory problems. The care plan did not address the use of an antipsychotic. The care plan did not address the use of an anticoagulant with monitoring of lab values on a weekly basis (PT/INR). A physician order, dated 09/17/18, documented to obtain a PT/INR weekly. A physician order, dated 02/07/19, documented to give [MEDICATION NAME] ([MEDICATION NAME]) 3 milligrams (mg) daily. A [DIAGNOSES REDACTED]. A medication regimen review (MRR), dated 02/07/19, addressed the need to obtain a [MEDICATION NAME] time with international normalized ratio (PT/INR) weekly as ordered by the physician. The MRR documented the resident was currently receiving [MEDICATION NAME] 3 mg by mouth daily. A physician order, dated 02/07/19, documented to give [MEDICATION NAME] (an antipsychotic) 1 mg at night. A [DIAGNOSES REDACTED]. A quarterly assessment, dated 02/17/19, documented the resident was severely impaired with cognition. The assessment documented the resident required moderate assistance with most activities of daily living. The assessment documented the resident received an antipsychotic six of seven days, an antidepressant six of seven days, an anticoagulant six of seven days, and opioids six of seven days previous. On 07/30/19 at 3:01 p.m., the director of nursing (DON) reviewed the resident's care plan. The DON reported the use of an antipsychotic, as well as the anticoagulant with lab monitoring, should be included in the resident's care plan. On 07/30/19 at 3:17 p.m., the resident was observed in the dining area, sitting at a table drinking tea. The resident was observed throughout the survey to propel himself per his wheelchair. 4. Resident #144 was admitted on [DATE] with [DIAGNOSES REDACTED]. A nurse note, dated 06/18/19 at 10:30 p.m., documented the resident had numerous bruises and sore areas related to recent falls prior to admission. A nurse note, dated 06/27/19 at 4:00 a.m., documented the resident was found on the floor in her room. The note documented family was notified and reported the resident had a history of [REDACTED]. On 07/31/19 at 11:58 a.m., the ADON reported the resident was discharged from the facility on 07/01/19. The ADON reported a comprehensive care plan was never developed for this resident.

On 02/06/18 at 2:50 p.m., the Oklahoma State Department of Health (OSDH) was notified of an immediate jeopardy (IJ) situation related to the facility's failure to ensure residents with known wandering behaviors did not elope from the facility and the staff being unaware the residents had eloped from the facility for an unknown amount of time. On 02/06/18 at 3:18 p.m., the OSDH verified an immediate jeopardy situation existed related to the facility's failure to ensure two residents with wandering behaviors had not eloped from the facility for an unknown amount of time. On 02/06/18 at 3:20 p.m., the ADM, DON, and ADON were informed of the IJ situation which consisted of substandard quality of care. On 02/06/18 at 5:25 p.m., the ADM, DON, and ADON provided the plan of removal for the immediate jeopardy. The plan of removal was accepted and documented the following: Elopement Plan of Action Education: In-services to be held quarterly. All staff members shall be required initial in-service before clocking in for the shift. Initial in-service shall be completed by 12:00 p.m. on 07Feb2018 (sic). Employees: Educated on signs and symptoms of decreased cognitive status and proper reporting techniques; ensuring resident safety. Residents: All residents listed on Elopement Risk List (located at Nurses (sic) station shall be screened upon admission and quarterly thereafter if they meet risk criteria. Current residents on list shall be screened quarterly. Elopement risks shall be completed no later than 12:00 p.m. on 07Feb2018 (sic). MDS: Careplan (sic) shall be updated (no later than 12:00 p.m. on 07Feb2018) (sic); reflecting risk outcomes and updated quarterly. Each of their charts shall be marked with a HI-VIS colored tags no later than 12:00 p.m. on 07Feb2018 (sic). Charge Nurse: Charge Nurse shall indicate every 2 (two) hours the resident is physically located in the building. Nurse shall be responsible for circling each 2 hour check as well as printing, signing their name and date of shift. Charge Nurse shall utilize elopement checklist no later than 12:00 p.m. 07Feb2018 (sic). Facility Lock Down (tbd) (to be determined) Administrator shall check with Life Safety regarding lock down procedures vs. fire safety rules and regulations. If approved, point of entry and exit to building shall be routed to East Lobby doors from 6pm-6am. On 02/07/18 at 11:00 a.m., on duty staff members were asked when they received education for residents who were at risk for elopement. All staff members were able to verbalize the plan of removal instituted on 02/07/18. On 02/07/18 at 12:45 p.m., a tour of the facility was conducted. Interviews were conducted with staff members from the nursing department, housekeeping, dietary, and maintenance. Staff members were able to explain the in-service education provided for residents with [DIAGNOSES REDACTED]. The staff members were able to discuss what their role was in reporting to the charge nurse when a resident attempted to leave the facility or a change of condition was observed with the residents. Licensed staff members were able to verbalize their responsibility in assessing, monitoring, intervention, and reporting when residents attempted to elope or was successful in elopement from the facility. Licensed staff members stated it was the responsibility of the charge nurse to ensure residents were physically within the facility and for circling two hour checks as well as printing, dating, and signing the 24 hour form. The charge nurse was able to discuss the utilization of the elopement checklist. On 02/07/18 at 10:45 a.m., the facility was informed the IJ was removed effective 02/07/18 at 10:45 a.m. On 02/07/18 at 1:10 p.m., the ADON reported the staff were in the process of assessing and monitoring residents who were at risk for elopement. The deficient practice remained at a potential for more than minimal harm at a pattern level. Based on observation, record review, and interview, it was determined the facility failed to ensure two (#3 and #4) of two residents reviewed for elopement were identified as a potential risk for elopement from the facility. Residents #3 and #4 exited the facility on the same date, at different times, for an unknown amount of time and staff members were unaware of the residents being outdoors, and unsupervised during the evening hours. The ADM reported 50 residents lived at the facility. Findings: An undated facility policy titled, Missing Resident(s) documented, The facility shall report missing residents to the Department after a search of the facility and facility grounds and a determination by the facility the resident is missing. In addition, the facility shall make a report to local law enforcement agencies within two (2) hours if the resident is still missing .The facility shall also report to the attending physician, responsible party, and the OSDH (Oklahoma State Department of Health) and update with applicable information. 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An admission assessment had not been initiated or completed when the resident was admitted to the facility. A Care Area Assessment (CAA) was not completed for a comprehensive care plan to be developed to meet the resident's needs. A care plan, dated 12/19/17, documented the resident experienced both short and long term memory loss. The care plan documented, .is high function enough for other residents and guest to not understand her confusion, (name deleted) attempts to leave periodically and is an elopement risk. The care plan documented a goal was for the resident not to try and elope and to be safely inside the facility. The care plan documented, approaches were for the staff to instruct other residents not to give (name deleted) the door codes, for the resident's safety. The care plan documented to remind visitors not to assist residents out of the door or give residents the code to the door. The care plan documented for the staff to monitor the resident's location frequently and to ensure (name deleted) was safe and accounted for. A nurse's note, dated 12/23/17 at 6:50 p.m., documented, This nurse received phone call from (name deleted) Sheriff office asking if we were missing a resident. Officer stated that Resident had been found outside of facility et.(and) brought to Sheriff department et. that they would bring her back to facility. A nurse's note, dated 12/23/17 at 7:00 p.m., documented the ADON had been notified of incident. The note documented the staff were instructed to conduct thirty minute checks for the resident. The nurse's note documented the resident had an abrasion to her right knee measuring 2.5 cm x 3 cm. The note documented the abrasion was cleansed and triple antibiotic ointment was applied to the abrasion. A nurse's note, dated 12/23/17 at 7:35 p.m., documented, Residents daughter called facility et. spoke c (with) this nurse. I explained that resident had gotten out of facility s (without) staff knowing et (and) that I would have ADON call her. On 02/06/18 at 11:10 a.m., the ADON was asked for the state reportable incident form for when the resident was out of the building. The ADON reported a state reportable incident report had not been submitted to the Oklahoma State Department of Health (OSDH). The ADON was asked when a resident leaves the facility and the facility is unaware the resident is not in the facility if a state reportable incident report should be submitted. The ADON reported she was not aware when residents eloped from the facility a state reportable incident report should be submitted. The ADON reported education would be conducted with the staff. On 02/06/18 at 1:15 p.m., the ADON was interviewed. The ADON was asked how the resident had exited the facility without the staff members being aware the resident was outdoors after dark and was not dressed appropriately for the season. The ADON reported one of the residents possibly opened the door for the resident. At that time, the ADON was asked if the security camera recordings had been reviewed to determine when, where, and how the resident actually exited the facility without the staff being aware the resident was outdoors. The ADON reported the ADM had reviewed the security camera recordings. The ADON was asked without an admission assessment being completed, how a care plan was developed for the resident to identify wandering behaviors and the potential for elopement from the facility. The ADON reported she was unsure how the care plan had actually been developed for the resident. The ADON was asked should staff be aware of where residents were at all times. The ADON reported the staff should be monitoring residents who were identified with wandering behaviors and exhibited the potential for elopement. On 02/06/18 at 2:30 p.m., the ADM was interviewed. The ADM was asked after reviewing the security tapes how the resident was able to elope from the facility and what time the resident actually exited the facility. The ADM reported the security cameras had not functioned for an extended period of time. The ADM was asked if technical repair had been conducted. The ADM reported different technicians had assessed the security camera system and were unable to determine what the technical issues consisted of. At that time, the ADM was asked how the resident possibly eloped from the facility. The ADM reported a current resident was interviewed and reported he/she had unlocked the door for the resident to elope. The ADM reported the resident had been educated not to assist residents to elope. The ADM was asked for the documentation to support the resident's education. The ADM reported there was no documentation available. On 02/06/18 at 2:40 p.m., the ADM was interviewed. The ADM was asked if a state reportable incident report was submitted to the OSDH when the resident had eloped from the facility. The ADM reported since the resident was out of the facility less than two hours he did not feel a state reportable incident report was indicated at that time. 2. Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A quarterly assessment, dated 11/22/17, documented the resident was severely impaired in cognition and was independent for transfers and ambulation. The assessment documented the resident required supervision of one staff member to dress. The assessment documented the resident was independent and required setup assistance to eat. The assessment documented the resident was always continent of bowel and was occasionally incontinent of urine. A nurse's note, dated 11/23/17 at 2:00 a.m., documented the resident had exhibited increased wandering behaviors. A nurse's note, dated 12/23/17 at 12:00 a.m., documented, CNA had 1 resident in the shower & heard knocking on back door. discovered (sic) this Resident known to wander freq. outside the door. No apparent injury. Dr. (name deleted) & family notified-v/s (vital signs) 97.2 F., 68-18-129/70-O2 sat. 97% on room air. On 02/06/18 at 10:04 a.m., the resident was observed lying in bed. The resident was well groomed and no odors were noted. The resident was unaware of the date and time. On 02/06/18 at 11:10 a.m., the ADON was asked for the state reportable incident form for when the resident was out of the building unattended. The ADON reported a state reportable incident report had not been submitted to the OSDH. On 02/06/18 at 2:10 p.m., the ADM was interviewed. The ADM was asked if a state reportable incident report was submitted to the OSDH when the resident had eloped from the facility. The ADM reported since the resident was out of the facility less than two hours he did not feel a state reportable incident report was indicated at that time.