Every finding on record at Claridge Court

The facility identified a census of 38 residents. The sample included 13, with two reviewed for accidents. Based on observation, record review, and interview, the facility failed to secure potentially hazardous kitchen equipment in a safe, locked area and out of reach of six cognitively impaired, independently mobile residents.Findings Included: - On 01/12/26 at 07:00 AM, a walkthrough of the facility revealed the hallway door to the kitchen was left fully open. An inspection of the interior kitchen revealed that both interior kitchen doors were left open. No staff were observed in the kitchen or the surrounding dining area. No residents were in or around the kitchen area at the time of observation, but had access to that area.An inspection of the sink area in the kitchen revealed an unsecured lock on a cabinet below the sink. The cabinet contained four spray bottles of all-purpose cleaner. The containers contained the warning, Keep out of reach of children, hazardous to humans, can cause eye irritation, harmful if swallowed.An inspection of the interior kitchen area revealed an unlocked electrical panel labeled LP3. The panel contained the label warning Hazardous voltage, will cause death or injury.An inspection of the interior kitchen revealed a heated plate warmer containing a plate. An inspection of the warmer revealed a temperature inside of the warmer of 167 degrees Fahrenheit.An inspection of the kitchen's steam table area revealed that three of the five steam wells were on and set to high settings (level 10). The wells were empty and hot to the touch. An inspection of the three active steam wells revealed temperatures of 238 degrees, 323 degrees, and 374 degrees Fahrenheit.On 01/12/26 at 07:13 AM, Dietary Staff CC entered the kitchen. Dietary Staff CC stated she had to go down to prepare the breakfast meals and just returned to the floor. She stated the steam wells were usually turned on before the food was brought up to ensure the food remained heated.On 01/12/26 at 07:13 AM, Dietary Staff DD entered the kitchen area to prep breakfast. She stated staff usually turn the steam table on before breakfast arrived to ensure the food remained hot when served. She stated she was not sure if it was okay to leave the area unsupervised during meal delivery upstairs.On 01/12/26 at 07:15 AM, Dietary Staff DD stated the kitchen doors were to be locked when not directly supervised, but the residents know not to walk around to the serving side where the steam table was located. She stated the steam table needed to be monitored while heated.On 01/14/26 at 01:30 PM, Dietary Staff BB stated that staff came in early to warm up the steam table and prepare for breakfast. He stated staff were expected to monitor the kitchen area while it was open.The facility's Hazardous Areas, Devices and Equipment policy, revised (undated), indicated the facility was to assess and identify potential hazards within the resident's environment to minimize the risks and prevent potential accidents and injuries.

The facility identified a census of 38 residents. The sample included 13 residents, with one resident reviewed for hospitalization. Based on record review and interviews, the facility failed to provide a written notice of transfer/discharge as soon as practicable, and the facility also failed to provide a bed hold notice with the required information for Resident (R) 20. Findings included:- R20's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord), major depressive disorder (major mood disorder that causes persistent feelings of sadness), and convulsions (involuntary series of contractions of a group of muscles).R20's EMR under the Progress Notes tab revealed the following facility-initiated transfer documentation:On 06/04/25 at 01:16 AM, an Alert Note documented R20 was transferred to the hospital. The facility lacked a Bed Hold Notice that included the facility's per diem rate to hold a bed and the required written notification of transfer, as soon as practicable, upon his transfer to the hospital on [DATE].On 06/26/25 at 07:27 PM, a Health Status Note documented R20 was transferred to the hospital.The facility lacked a Bed Hold Notice that included the facility's per diem rate to hold a bed and the required written notification of transfer, as soon as practicable, upon his transfer to the hospital on [DATE].On 07/21/25 at 05:02 PM, a Health Status Note documented R20 was transferred to the hospital.The facility lacked a Bed Hold Notice that included the facility's per diem rate to hold a bed and the required written notification of transfer, as soon as practicable, upon his transfer to the hospital on [DATE].On 10/21/25 at 06:41 PM, a Health Status Note documented R20 was transferred to the hospital.The facility lacked the required written notification of transfer for R20, as soon as practicable, upon his transfer to the hospital on [DATE].On 01/13/26 at 02:09 PM, Administrative Staff B provided R20's bed hold dated 10/21/25. She stated she was unable to locate any other bed holds or any written notifications for R20's facility-initiated transfers to the hospital. Administrative Staff B stated the nurse would notify the legal representative by phone; the facility did not provide the legal representative with written notification.On 01/14/26 at 12:09 PM, Administrative Nurse E stated the resident or legal representative would be notified at the time of the transfer to the hospital. Administrative Nurse E stated the legal representative would be notified if the resident was cognitively impaired. He stated the nurse would be responsible for notifying the legal representative and providing the bed hold. Administrative Nurse E stated social services of financial should follow up to ensure the notices had been provided. The facility's undated Transfer and Discharge Notice/ Involuntary Discharge Policy documented the facility would permit each resident to remain in the facility and would not transfer or discharge a resident unless one of the allowable reasons outlined in this policy was met. All transfers and discharges would be person-centered, medically appropriate, properly documented, and communicated to the resident, resident representative, and applicable external agencies.

The facility identified a census of 38 residents. The sample included 13 residents, with two reviewed for pressure ulcers (localized injuries to the skin and/or underlying tissue, usually over a bony prominence, caused by pressure, or pressure in combination with shear and/or friction). Based on interviews, observations, and record reviews, the facility failed to ensure Resident (R) 18's pressure-reducing interventions were implemented correctly when R18's low air-loss mattress (a specialized adjustable air mattress that reduces pressure applied to the body) was not set within her current weight range.Findings Included:- The Medical Diagnosis section within R18's Electronic Medical Records (EMR) included dementia (a progressive mental disorder characterized by failing memory and confusion), type two diabetes mellitus (DM- when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), muscle weakness, and chronic kidney disease.R18's Quarterly Minimum Data Set (MDS) completed 12/08/25 indicated a Brief Interview for Mental Status (BIMS) score of seven, indicating moderate cognitive impairment. The MDS noted she required substantial to maximal assistance with bathing, dressing, toileting, transfers, personal hygiene, and bed mobility. The MDS noted she was at risk for developing pressure ulcers but had no unhealed wounds. The MDS noted that she had pressure-reducing devices for her bed and chair.R18's Pressure Ulcer Care Area Assessment (CAA) (completed 06/16/25) revealed she was at risk for pressure ulcers related to her decline in mobility, incontinence, and decreased cognition. R18's Care Plan (initiated 03/31/25) documented the following interventions:03/31/25- The plan indicated she was admitted to the facility with open areas to her coccyx and was at risk for further breakdown.03/31/25- The plan instructed staff to inspect her skin during each bathing occurrence.03/31/25- The plan indicated she had a low-air-loss mattress to relieve pressure.04/10/25- The plan instructed staff to provide side-to-side turning while in bed.05/27/25- The plan indicated she was placed on hospice service. The plan noted that hospice provided her a low-air-loss mattress and instructed staff to ensure it was set to 170 pounds (lbs.).R18's EMR under Physician's Orders revealed an order dated 06/14/25. The order indicated she had a low-air-loss mattress and instructed staff to ensure the pump was set to normal pressure at 170 lbs.On 01/12/26 at 07:45 AM, R18 lay in her bed and waited for her breakfast to arrive. Her bed was in the lowest position, and the call light was next to her. Her low-air-loss mattress pump was set to maximum weight setting (350 lbs.). The mattress pump had fixed weight settings of 80lbs, 120lbs, 150lbs, 180lbs, 210lbs, 250lbs, 280lbs, 320lbs, and 350lbs.On 01/13/26 at 08:30 AM, R18's low-air-loss mattress pump remained set to 350lbs.On 01/14/26 at 10:20 AM, R18's low-air-loss mattress pump remained set to 350lbs.On 01/14/26 at 10:23 AM, Licensed Nurse (LN) G verified R18's bed was set to 350 lbs. LN G stated her bed was to be set to her weight range, closest to 170 lbs. He stated the mattress pump was recently replaced, and the direct care staff may have bumped into the control panel while making the bed. He stated staff were expected to check the setting at least three times daily.On 01/14/26 at 12:00 PM, Administrative Nurse D stated staff were expected to check the mattress settings each shift and ensure they were set to the care-planned settings.A review of the low-air-loss mattress manufacturers' operation (Drive Model) manual indicated that the mattress system was intended to reduce the incidence of pressure ulcers while optimizing comfort. The manual indicated the mattress pump's pressure levels and firmness were preset based on the weight range and comfort settings. The manual indicated that an optimal bed system assessment should be conducted on each patient by a qualified clinician or medical provider to ensure maximum safety.The facility's Wound Care Prevention and Management policy (undated) indicated the facility was committed to the prevention of avoidable pressure injuries and to provide treatment services to heal existing wounds. The policy indicated the facility was to assess and implement interventions to include pressure-reducing devices, skin assessments, repositioning, nutritional monitoring, and preventative skin treatment.

The facility had a census of 37 residents. The sample included 12 residents and five Certified Nurse Aides (CNAs) reviewed for performance evaluations and required in-service training. Based on record review and interview, the facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care. Findings included: - A review of the facility's performance evaluation records revealed the following: CNA P, hired on 03/11/19, no yearly performance evaluations were provided upon request. CNA Q, hired on 05/24/22, no yearly performance evaluations were provided upon request. CNA MM, hired on 04/13/21, no yearly performance evaluations were provided upon request. CNA NN, hired on 08/21/18, no yearly performance evaluations were provided upon request. CNA OO, hired on 09/11/01, no yearly performance evaluations were provided upon request. Review of the email communications regarding yearly merit increases, provided by the facility, to the five CNA staff reviewed for yearly evaluations lacked evidence of any performance evaluations and/or goals or discussion regarding areas of improvement. On 02/27/24 at 10:17 AM Administrative Staff A stated the facility did not do a formal yearly performance evaluation on paper. Administrative Staff A stated they would meet with staff yearly to discuss a merit increase and performance would be discussed at that time; however, there was nothing put into writing and staff would not sign any document to show what had been discussed during the meeting. Administrative Staff A further stated the meetings were more of a conversation than a formal performance evaluation and if there were any issues then staff would have been placed on a performance improvement plan. The undated facility provided Performance Management policy documented it is the policy to conduct periodic performance reviews for all team members. The performance review is a formal process in which leaders can assess team member's strengths, areas for improvement, and potential growth. Performance reviews will be objective, and performance based. Leaders must support reviews by using specific examples and facts. Any performance review that indicates improvement is needed, a performance improvement plan must be developed and implemented. This plan will set forth performance goals, time frames, and dates for retraining and reevaluation. The facility failed to ensure five of the five CNA staff reviewed had the required yearly performance evaluations completed. This placed the residents at risk for inadequate care.

The facility identified a census of 37 residents. The facility had one kitchen and one kitchenette. Based on observation, record review, and interviews, the facility failed to ensure that food items were properly stored in a safe and sanitary manner after the original sealed package had been opened. The facility failed to ensure foods were labeled and dated after opening. This placed all residents who ate food from the facility at risk for food-borne illness. Findings included: - During the initial tour on 02/22/24 at 07:33 AM, observation revealed the following: Half of a brown cake in the small refrigerator was uncovered and not dated. Two bags of sausage lay on top of the cooking stove. A canister of sugar under the work prep table was not labeled or dated. A cooler with a see-through glass door revealed small bowls of lettuce, tomatoes, ham, cheese, onions, and a container of fish were not covered, and these items were not dated. Half of a bag of ravioli was open to the air in a small freezer and was not dated. Avocadoes and pea salad were not dated in the small side refrigerator. The walk-in freezer had one box labeled pies stored on the freezer floor. The walk-in refrigerator had a steam table pan with red sauce which contained olives sitting on the shelf, there was no date or label. On 02/27/24 at 10:44 AM a follow-up inspection of the kitchen was completed. The inspection revealed all containers were labeled and dated appropriately, and there were no food boxes on the freezer floor. On 02/27/24 at 11:00 AM Dietary staff BB stated all foods out of their original containers should be dated and labeled, and no foods should be stored on the freezer floors. The Production, Purchasing, and Storage Policy revised on 01/24 stated all stored foods not in their original packages, must be stored in approved containers that have tight-fitting lids. All containers must be labeled, and both the bin and the lid must be labeled and dated. The policy states to use of food-grade plastic bags for food storage. The facility failed to store food in a safe, sanitary manner. This deficient practice placed residents at risk for contamination and food-borne illness.

The facility identified a census of 37. The sample included 12 residents with 12 reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to revise Resident (R)7's Care Plan to reflect her implemented restorative services and goals. This deficient practice placed R7 at risk for impaired care due to uncommunicated care needs. Findings Included: - The Medical Diagnosis section within R7's Electronic Medical Records (EMR) included diagnoses of left-sided hemiparesis (weakness and paralysis on one side of the body), left-sided hemiplegia (paralysis of one side of the body), and left-hand contracture (abnormal permanent fixation of a joint or muscle). R7's Quarterly Minimum Data Set (MDS) completed 11/22/23 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she required substantial to maximal assistance with bed mobility, transfer bathing, toileting, personal hygiene, and dressing. The MDS noted she had an upper extremity impairment to one side and used a wheelchair for mobility. The MDS indicated she received restorative services for active range of motion (ROM). R7's Activities of Daily Living (ADLs) Care Area Assessment (CAA) completed 08/28/23 indicated she required assistance with her ADLs and mobility related to poor strength, endurance, and balance. The CAA indicated she had left-sided hemiparesis and was at risk for a decline in her ADLs. R7's Care Plan initiated 08/18/23 indicated she was at risk for ADLs self-performance deficit related to her left-sided hemiparesis. The plan indicated he had a left-hand contracture and instructed staff to provide skin care and monitor her hand for skin breakdown (08/31/23). The plan indicated she may need assistance with meal set-up and staff were to offer support. The plan lacked documentation related to her implemented range of motion exercises to maintain or improve her left-sided hemiparesis and hand contracture. On 02/26/24 at 08:10 AM R7 sat in her room. R7 stated staff wrapped her arm up at night to prevent swelling and she received upper body services for her left side. She stated she used to wear a brace on her left hand but refused to wear it. She stated the restorative aid comes 3-4 times weekly to work with her. On 02/27/24 at Certified Nurses Aid (CNA) O stated she completed weekly upper body range of motion exercises with R7. She stated R7 had left-side weakness and paralysis due to her medical conditions. She stated the restorative programs were not included in the care plans but included in the task section of the EMR. On 02/27/24 at 02:23 PM Licensed Nurse (LN) H stated she would have to ask the restorative aid or therapy what services R7 received. She stated that restorative services should be included in the care plan to allow all staff to know what services were provided due to her contractures. On 02/27/24 at 02:32 PM Administrative Nurse E stated the restorative services for R7 were not in the care plan but would be found under the tasks. A review of R7 Tasks in her EMR with Administrative Nurse E revealed no documented information related to her upper body range of motion exercises. Administrative Nurse E stated the services should be listed somewhere for all staff to review. The facility's provided Comprehensive Care Plan policy revised 09/2019 indicated the facility will update and revise each resident's plan of care to include current care treatment goals, and measurable objectives, and provide person-centered care. The facility failed to revise R7's Care Plan to reflect her implemented restorative services and goals. This deficient practice placed R7 at risk for impaired care due to uncommunicated care needs.

The facility identified a census of 37 residents. The sample included 12 residents with two reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to maintain Resident (R) 2's low air-loss mattress pump settings at the correct weight range. This placed R2 at increased risk for pressure ulcer development. Findings included: - R2's Electronic Medical Record (EMR) documented diagnoses of peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel), difficulty in walking, generalized muscle weakness, congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), and cerebrovascular disease affecting right dominant side (group of conditions that affect the circulation of blood to the brain, causing limited or no blood flow to affected areas of the brain). The Significant Change Minimum Data Set (MDS) dated [DATE], documented R2 had a Brief Interview for Mental Status (BIMS) score of 13 which suggested intact cognition. The MDS documented R2 used a wheelchair and required partial/moderate assistance moving from a seated to a lying position, substantial/maximal assistance from moving from a seated to a standing position and was dependent on staff for transfers. The MDS further documented R2 had a skin tear, was at risk for developing pressure ulcers, and had pressure-reducing devices in place for her chair and bed. The MDS documented R2 was frequently incontinent of urine having had seven or more incontinent episodes with at least one episode of continent voiding. The Pressure Ulcer/Injury Care Area Assessment (CAA) dated 12/21/23, documented R2 was at risk for skin breakdown due to incontinence and limited mobility. The Functional Abilities CAA dated 12/21/23, documented R2 had an activities of daily living (ADL) self-care performance deficit and directed staff to assist R2 with daily tasks. R2's Care Plan with an initiated date of 01/09/24, documented R2 was at risk for impaired skin integrity due to CHF and incontinence. A goal with an initiated date of 01/09/24 documented R2 would remain free from skin breakdown due to incontinence and brief use. A Care Plan intervention with an initiated date of 01/09/24, directed staff to encourage R2 to frequently shift her weight and for staff to monitor R2's skin for moisture, and apply barrier products as needed. R2's Care Plan with an initiated date of 10/17/23 documented R2 was on diuretic therapy (medication to promote the formation and excretion of urine). R2's Care Plan lacked evidence that a low air loss mattress was in place for R2. R2's EMR, under the Orders tab, documented an order dated 12/09/23, for an air loss mattress (a mattress designed to prevent and treat pressure wounds) for skin breakdown prevention. The order lacked evidence of a mattress setting. A review of R2's EMR documented R2 weighed 109.2 lbs. on 01/15/24 and 109.6 on 02/25/24. A review of the low air-loss mattress manufacturer's operation (Protekt Aire 6000) manual indicated the mattress system was intended to reduce the incidence of pressure ulcers while optimizing comfort. The manual indicated the mattress pump's pressure levels and firmness were preset based on the weight range selected. The manual recommended the pump be set based on the resident's weight. The manual indicated the firmness of the mattress could be set within 50 lbs. weight intervals. On 02/26/24 at 01:30 PM, R2 sat in a wheelchair in her room. R2's air loss mattress was set for a body weight of 180 lbs. On 02/27/24 at 01:31 PM, R2 sat in a wheelchair in her room and watched TV. R2's air loss mattress was set for a body weight of 180 lbs. On 02/27/24 at 02:15 PM, Licensed Nurse (LN) H stated some of the low air loss mattresses provided by hospice were set based on a resident's weight. LN H further stated if the weight settings on a low air loss mattress were set too high, it made the mattress firmer, which could then contribute to skin breakdown. LN H stated a weight setting of 180 lbs. on a low air loss mattress for a resident who weighed 109.6 lbs. would be too high. On 02/27/24 at 02:31 PM Administrative Nurse E stated R2's low air loss mattress was provided by hospice and hospice would set the pressure for the mattress and that facility staff would monitor it. Administrative Nurse E stated the facility expected the nurses and Certified Nurse Aides (CNA) to check the mattress every shift to ensure it was on and working correctly. Administrative Nurse E stated she was unsure if R2's mattress was a weight-based mattress, or one based on comfort level. Administrative Nurse E observed R2's low air loss mattress in R2's room and noted the setting of 180 lbs. Administrative Nurse E stated a setting of 180 lbs. for R2, who weighed 109.6 lbs., was too high for her weight. On 02/27/24 at 03:01 PM Administrative Nurse E stated she spoke with a facility nurse and was informed that hospice had set the mattress to 180lbs due to the head of R2's bed not inflating properly. Administrative Nurse E further stated the facility would contact the company and order a new bed for R2. The facility provided a Wound Care Policy with a revision date of 04/01/22, documented It is the policy to utilize evidence-based clinical practices to provide pressure injury and wound treatments in our skilled nursing and rehabilitation health centers. The facility will comply with current nursing standards, as well as state and federal guidelines related to the identification, treatment, and documentation of alterations in the skin integrity of our residents. The facility failed to maintain R2's low air-loss mattress pump settings at the correct weight range. This placed R2 at increased risk for pressure ulcer development.

The facility had a census of 104 residents. The sample included 23 residents with four residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure an environment free from accident hazards when the facility failed to utilize wheelchair foot pedals while transporting Resident (R)18 and R22 around the facility. This deficient practice placed both residents at risk for preventable injuries and falls. Finding Included: - R18's Care Plan initiated 12/13/24 indicated he was at risk for falls related to his weakness, unsteadiness, poor safety awareness, and severe cognitive impairment. R22's Care Plan initiated 10/18/20 indicated she was at risk for falls related to poor gait/balance, muscle weakness, and severe cognitive impairment. On 02/26/24 at 07:20 AM R22 sat in her wheelchair in the hallway in front of the elevator. Certified Nurses Aid (CNA) M pushed R22 back to her room. R22's wheelchair had no foot pedals and her shoes drug on the floor as staff pushed her. On 02/26/24 at 11:32 AM CNA N pushed R18 (severely cognitively impaired resident) down the main hallway to the dining area. R18's wheelchair lacked foot pedals and his feet contacted the ground several times while being pushed. On 02/26/24 at 11:38 AM R22 was wheeled to the dining room area for lunch services by CNA M. R22's feet slid on the ground several times during transport. On 02/27/24 at 02:08 PM, CNA M stated each resident had foot pedals, but some prefer to use their feet to propel themselves. She stated the resident's feet should never drag while being pushed. On 02/27/24 at 02:32 PM Administrative Nurse E stated staff were expected to ensure the resident's feet never touch the ground while in transport. She stated staff were to ask the residents if they were okay to lift their legs. She stated all the residents had foot pedals and should use them when needed. The facility's provided Accommodation of Needs policy (undated) the facility will ensure each resident's needs for adaptive equipment will be met based on the individual needs/preferences, physical environment, and treatment goals. The facility failed to utilize a wheelchair foot pedal while transporting R18 and R22 around the facility. This deficient practice placed both residents at risk for preventable injuries and falls.

The facility identified a census of 37 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure a pulse was assessed and documented consistently for Resident (R) 4's carvedilol (medication used to treat high blood pressure) for hypertension (HTN-elevated blood pressure) to monitor for efficacy and adverse effects. This placed R4 at increased risk for unnecessary medication administration and possible adverse side effects. Findings included: - The electronic medical record (EMR) for R4 documented diagnoses of chronic respiratory failure with hypoxia (occurs when the respiratory system cannot adequately provide oxygen to the body). HTN, ischemic cardiomyopathy (the heart's decreased ability to pump blood properly, due to myocardial damage), chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Quarterly Minimum Data Set (MDS) dated [DATE] documented that a Brief Interview of Mental Status (BIMS) assessment could not be conducted due to severe cognitive impairment. The MDS indicated R4 required supervision with set-up assistance for bed mobility, transfers, walking, personal hygiene, toileting, and dressing. R4 was dependent on one staff for help with activities of daily living (ADLs), and R4 required supplemental oxygen. The Functional Care Area Assessment (CAA) dated 09/27/23 documented R4 continued to require assistance with ADLs and mobility. Nursing provided ADL, mobility, and transfer assistance. The Fall CAA dated 09/27/23 documented nursing provided safety cues and monitoring. R4 used a gait belt for transfers and had a call light at the bedside. R4's Care Plan dated 06/08/22 directed staff to administer anti-hypertensive medications as ordered. Staff should monitor for side effects, such as orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down), increased heart rate, and effectiveness. R4's Order Summary dated 06/02/23 documented an order for carvedilol one tablet of 3.125 milligrams (mg), give one tablet by mouth two times a day related to chronic heart failure. R4's clinical record lacked evidence the staff monitored R4's pulse consistently before the administration of the carvedilol. On 02/26/24 at 07:26 AM R4 sat in her recliner with her feet extended and elevated. On 02/26/24 at 11:34 R4 sat at the dining room table. She chatted with visitors and table mates. On 02/27/24 at 01:21 PM Licensed Nurse (LN) H stated that for carvedilol, a beta-blocker, the pulse should be monitored and documented before the medication was given. LN H stated the facility did have parameters for beta-blockers that the physician put in place. On 02/27/24 at 02:50 PM Administrative Nurse E stated normally nurses only assess vitals once a week. Administrative Nurse E stated the pharmacist did not want the facility to monitor pulse before giving carvedilol. Administrative nurse E stated that once-a-week vital signs assessments were sufficient. The Medication Administration Policy documented that if a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facility's Medical Director to discuss the concerns. The facility failed to ensure that staff consistently monitored R4's pulse before the administration of carvedilol. This placed R4 at risk for unnecessary medication administration and possible adverse side effects.

The facility had a census of 37 residents. The sample included 12 residents of which five were reviewed for unnecessary medications. Based on observation, record review, and interview the facility failed to ensure a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management before starting Resident (R)14's Seroquel (antipsychotic- class of medications used to treat mental disorder characterized by a gross impairment in reality testing). This placed the resident at risk for unnecessary psychotropic (alters perception, mood, consciousness, cognition, or behavior) medications and related complications. Findings Included: - The Medical Diagnosis section within R14's Electronic Medical Records (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), major depressive disorder (major mood disorder), muscle weakness, and difficulty walking. R14's Quarterly Minimum Data Set (MDS) completed 01/18/23 noted a Brief Interview for Mental Status (BIMS) assessment could not be completed due to severe cognitive impairment. The MDS indicated she had delusions (untrue persistent beliefs or perceptions held by a person although evidence shows it was untrue) but no behavioral symptoms. The MDS indicated she received antipsychotic medication on a routine basis. R14's Dementia Care Area Assessment (CAA) completed 10/24/23 indicated she had short and long-term memory impairment. The CAA noted she required cueing and assistance from staff to participate and stimulate her mind. R14's Psychotropic Drug Use CAA completed 10/24/23 indicated she was at risk for side effects related to her psychoactive medications. The CAA instructed staff to monitor medication with black box warnings (BBW- highest safety-related warning that medications can be assigned by the Food and Drug Administration). R14's Care Plan initiated on 02/08/22 indicated she had a history of behavior concerns related to dementia. The plan instructed staff to approach her in a non-threatening manner, orient her to reality, divert her attention, and talk to her to calm her down (02/18/22). The plan indicated she started Seroquel and instructed staff to monitor for side effects of the medication (10/24/23). The care plan lacked unsuccessful behavioral interventions that were attempted to manage her symptoms. A review of R14's EMR under Physician's Orders indicated an order dated 09/12/23 for her to receive 12.5 milligrams (mg) of Seroquel by mouth at bedtime for anxiety, delusions, and paranoia related to major depressive disorder. On 12/08/23 the Seroquel order was increased to give 12.5mg twice daily. On 01/26/24 the Seroquel order was increased to give 12.5mg every eight hours. R14's EMR lacked documented physician rationale that included multiple unsuccessful attempts for non-pharmacological behavioral symptom management for her Seroquel medication started on 09/12/23. The facility was unable to provide this documentation on request. On 02/27/24 at 07:34 AM Licensed Nurse (LN) H prepared R14 morning medication. LN H administered R14's medications without issues or concerns. R14 was calm and took her medication including Seroquel without behavior. On 02/27/24 at 02:15 PM, LN H stated residents with dementia were at risk for taking antipsychotic medication due to a higher mortality rate. She stated that R14's behaviors had improved in the past few months from her medication. She stated staff should also provide redirection and re-orient R14 when she is confused. On 02/27/24 at 02:32 PM Administrative Nurse E stated the facility would provide redirection, re-orientation, activities, and call family for support during R14's behaviors. She stated the medical provider usually would not document rationale or notes. A review of the facility's Psychotropic Medication Use policy 10/2022 noted the facility will provide clinical indication and comprehensive assessment to ensure the use of antipsychotic medication is necessary. The policy indicates the physician will provide a clinical rationale and complete gradual dose reductions to ensure the lowest effective dose unless contraindicated. The facility failed to ensure physician documented rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management was completed before the use of R14's Seroquel. This placed the R14 at risk for unnecessary psychotropic medications and related complications.

Based on interview, record review, and review of the facility's policy, the facility failed to assure 100% compliance with the COVID-19 vaccination requirement by ensuring all staff were either fully vaccinated against COVID-19 or had an approved exemption from the vaccination granted based on established standards. The facility allowed one of 83 staff members (Housekeeper (HK) 1, who was approved for a medical exemption; however, the medical exemption did not meet the requirements and who was not fully vaccinated, to work in the facility, resulting in a compliance rate of 98.8%. Findings include: Review of the facility's policy titled COVID-19 Vaccination for Workforce Members and Residents, dated 06/13/22, provided by the facility, revealed .7. Exemptions. In the event any [facility] team member or resident is unable to receive the vaccinations and seeks an exemption, such individuals must provide documentation to support an exemption as follows: .b. An exemption shall be granted for an individual who has any medical condition or disabilitythat prevents the person from receiving the vaccination. [The facility] will not deny or terminate an individual's employment or residency based on a medical condition or disability. An application for an exemption for a medical condition or disability must be supported by documentation signed by a Licensed healthcare provider who is providing ongoing medical care for the individual. The documentation must indicate the individual has a medical condition or disability which a vaccination is contraindicated include: i. Severe allergic reaction (e.g., anaphylaxis). ii. History of Guillain-Barre Syndrome within six weeks after a previous influenza vaccination; or iii. A medical condition for which a licensed healthcare provider has clearly recommended deferral of COVID-19 vaccination. Review of the undated COVID-19 Staff Vaccination Status for Providers form, provided by the facility on 09/06/22, revealed that the facility had 83 staff. Further review of this form revealed it documented that one staff member (HK1) was granted a medical exemption. Review of the Exemption Form for COVID-19 Vaccination, completed by HK1, dated 09/10/21, provided by the facility, revealed the form documented Please describe the medical condition/disability or religious belief for which this exemption is requested (offer specifics to illustrate). Compromised immune system, 2 heart attacks and asthma. If seeking an exemption for a medical condition/disability, please describe how receiving the COVID-19 vaccination would be harmful to your health and wellbeing because of your medical condition or disability. Attach a statement from a health care provider currently providing care to you in connection with your medical condition or disability supporting your request for exemption. See attached doctor note from [Medical Doctor]. Review of the Physician's Note, dated 09/15/22, provided by the facility, revealed it documented Please excuse [HK1] from COVID vaccine due to medical issues. Review of HK1's Timecard Report, dated 08/07/22 to 09/07/22, provided by the facility, revealed he was hired on 10/08/19 and worked on the following dates in the last four weeks: 08/13/22, 08/19/22, 08/20/22, 08/26/22, 08/27/22, 09/02/22, and 09/03/22. During an interview on 09/06/22 at 11:59 AM, HK1 stated he submitted the medical exemption form and doctor's note due to having asthma and heart problems. HK1 also stated he had not received any of the COVID-19 vaccinations. HK1 also stated that his medical exemption was approved by the corporate office within a couple of weeks after submitting it to the human resources department. During an interview on 09/06/22 at 1:35 PM, the Chief Clinical and Public Health Officer stated that the corporation's committee comprised of legal, human resources and clinical services staff developed the COVID-19 vaccine policy and medical/religious form based on the Centers for Disease Control and Prevention (CDC) guidance and information from the Centers for Medicare and Medicaid Services (CMS) memorandums. The Chief Clinical and Public Health Officer also stated that HK1 submitted the form to Human Resources, Human Resources sent HK1's request to the committee, then the request and physician's note was reviewed by the committee, and the request was approved and sent back to the facility. The Chief Clinical and Public Health Officer indicated that the physician's note didn't list the medical reasons for not receiving the COVID-19 vaccination; however, she did not have a legal right to override the medical decision from the primary doctor because they know the medical history of the patient. During an interview on 09/06/22 at 2:12 PM, the Director of Nursing/Infection Preventionist (DON/IP) indicated the COVID-19 staff vaccination policy was developed by the corporation and the corporation's committee reviewed and approved or denied all exemption requests. The DON/IP confirmed HK1's medical exemption request was approved on 09/25/21 by the corporation's review committee.

The facility identified a census of 44 residents. The sample included 15 residents with two residents reviewed for dementia care. Based on record review and interviews, the facility failed to ensure staff provided person-centered care and services as related to dementia for Resident (R) 192. As a result, staff's inappropriate response to dementia-related behaviors resulted in a broken wrist for R192. Findings included: - R192 admitted to the facility on [DATE] and discharged on [DATE]. The Electronic Medical Record (EMR) for R192 documented the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented R192 had a Brief Interview for Mental Status (BIMS) score of six, which indicated severely impaired cognition. R192 required extensive assistance of one staff for his activities of daily living (ADLs). The MDS recorded R192 had no behaviors during the look back period. The ADL Care Area assessment dated [DATE] documented R192 needed help with ADLs and mobility. R192 had poor safety awareness, poor decision-making skills, poor strength/endurance, muscle weakness, impaired balance, and impaired mobility. Contributing factors include deconditioning, [CONDITION(S)] disease with Lewy body dementia and [CONDITION(S)]. Factors that placed him at risk included poor safety awareness, impaired balance, impaired mobility, and gait difficulty. The Mood CAA dated 04/20/22 documented R192 was significantly more depressed than his last stay in the health center. R192 reported feeling sad, having trouble concentrating, speaking slower, and having thoughts he would be better off dead all of these on most days. R192 reported feeling tired and feeling bad about himself about half the time. R192 was not as functional or helpful as he once was. R192 felt he had no purpose and thought of no longer being alive would lessen him being a burden to his spouse. R192 would never do anything to harm himself because he did not believe in that. R192's Care Plan initiated on 04/15/22 recorded R192 required extensive assistance of one person for personal hygiene. The care plan problem dated 04/15/22 listed R192 was at risk for impaired communication. An intervention dated 04/15/22 directed staff to allow adequate time for the resident's response, incorporate alternate of communication such as music, song, or visual demonstration and directed staff to incorporate visual prompting, cues, or gestures. It further directed staff to minimize environmental stimuli, and provide clear, simple instructions. R192's Care Plan recorded an intervention dated 05/02/22 which directed staff to converse with the resident while providing cares. R192's Care Plan lacked direction to staff, prior to incident on 05/15/22, with regards to dementia related behaviors or resident centered interventions on redirection. A Behavior Note dated 04/18/22 documented R192 had aggressive behaviors and was noncompliant with everything. He was delusional and combative with staff and required one to one supervision. A Physician Note dated 04/19/22 recorded R192 had debility (physical weakness, especially as a result of illness) and dementia and staff were directed to continue supportive care. The note lacked mention of behaviors, delusions, or aggression. A Behavior Note dated 04/19/22 at 01:23 AM recorded R192 was combative when staff attempted to redirect. At 11:30 PM, R192 tried to crawl out of bed, staff assisted him back to bed, and R192 was unhappy. He accepted several sips of thickened water. A Behavior Note dated 04/19/22 at 01:29 AM recorded R192 was almost out of bed. When staff tried to reposition him, he hit the aide's hand during the process. R192 was asking about his relative and not making sense when he spoke. He stated he was ok. The note recorded R192 was on frequent checks due to a risk for falls and had visual hallucinations (perception of having seen something that was not actually there). The record lacked evidence of physician notification. A Behavior Note dated 04/22/22 at 09:40 PM recorded R192 was verbally and physically abusive to staff and noted hitting and kicking behaviors while staff tried to provide cares. He insisted he could take care of himself. R192 cursed and refused to be moved by placing his feet hard on the floor so staff were unable to move the wheelchair. A Behavior Note dated 04/22/22 at 09:54 PM documented R192 exhibited psychotic (mental disorder characterized by a disconnection from reality) behaviors such as seeing people in his room and imagining things that were not true. The record lacked evidence of physician notification. A Physician Note dated 04/26/22 recorded R192 had debility dementia and directed to continue supportive care. The note lacked mention of behaviors, hallucinations, or psychotic episodes. An Incident Note dated 05/15/22 recorded R192 was complaining of pressure on his right wrist after an incident with the [unidentified] aid. At about 06:00 AM the aide tried to clean the resident's face when the resident grabbed her hand. He told the aide to go away but held on to her hand. The aide asked the resident to let go, but he did not. The aide then got ahold of the resident's right arm and, as she tried to free her hand, the aid heard a pop at the resident's wrist. The resident stated that he had no pain unless he tried to twist his hand. There was mild redness at the wrist. Staff notified the physician and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An Incident Note dated 05/15/22 recorded R192 denied pain, but reported pressure and stated it hurt to rotate his wrist out, and his pinkie finger was bothering him. Staff advised R192 not to move the hand. Staff asked R192 if he was afraid of his caregivers and he stated that he was not. The note further documented when staff asked R192 if he felt that it [no further explanation noted] was under malicious intent, R192 stated that it was lack of education and experience. The X-ray was completed and R192 went to breakfast. Upon receipt of the report, the physician was notified as well as Administrative Nurse D. Staff received a new order to send R192 to the emergency room (ER). The General Diagnostic radiology (x-ray) report dated 05/15/22 for R192 documented an acute spiral type of fracture with 1-millimeter displacement and minimal angulation. nondisplaced fracture of the right distal ulna (wrist bone). The Facility Investigation dated 05/19/22 documented R192 admitted to the facility for short term rehabilitation. He had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The investigation recorded R192 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The investigation recorded at approximately 06:00 AM on 05/15/22 Certified Nurse Aid (CNA) M went into R192's room to assist him to the restroom; R192 said he did not need to use the bathroom and did not need any help. CNA M noted saliva dripping from R192's mouth so she grabbed a tissue to assist him. R192 grabbed CNA M's arm and commanded her to get out. CNA M told R192 she would be glad to leave if R192 would let go of her arm. The investigation recorded CNA M asked R192 to let go three times, and each time R192 grabbed her harder and yelled louder for to leave. CNA M reached for R192's hand to try to pry it off hers and she heard a popping noise. The CNA then went to notify Licensed Nurse (LN) I. The investigation further documented LN I asked R192 what happened and R192 told LN I she broke it. The Witness Statement from CNA M recorded she went to the resident's room to offer him the toilet because earlier that morning he had refused. R192 said no he did not need to go, and he did not need CNA M's help. CNA M recorded she noted saliva falling from R192's mouth. She grabbed a tissue to clean it and R192 grabbed her hand and told her to get out. CNA M documented she told R192 she just wanted to clean his face and help him to the bathroom because he did not go earlier, but also told him he did not have to. CNA M recorded she told R192 to let go of her hand and she would leave and R192 tightened his grip. CNA M then told R192 he was hurting her arm and to let her go. R192 continued to squeeze harder so CNA M grabbed R192's hand and fingers to pry R192's hand away while CNA M pulled her arm back. During this action, CNA recorded she heard R192's s wrist pop. In an interview with CNA M on 08/04/22 at 01:50 PM, she stated on 05/15/22 she went in to R192's room to ask if R192 needed to go to the bathroom. R192 was in his wheelchair with his back towards her. As CNA M approached R192, she noticed he had saliva drooling from his mouth. CNA M then went into the bathroom to grab a washcloth to wipe the saliva from R192's mouth. CNA M said while attempting to wipe R192's mouth, she must have startled R192, and R192 grabbed her arm and told her to get out of his room. CNA M stated she repeatedly asked R192 to let go of her arm. R192 continued to grip her arm tighter, so she took her other hand and tried to pry R192's fingers loose from her arm. As she tried to pry R192's fingers off of her arm, both R192 and CNA M heard a pop. CNA M stated R192 had never acted this way before this incident. CNA M stated after the incident she immediately went and told the nurse about the incident. CNA M said she was suspended immediately and upon return to work, was educated on dementia training and how to handle a combative resident. CNA M stated she had dementia training/education when she was hired in 2020 and the facility did dementia training annually. CNA M stated the incident on 05/15/22 all happened so fast. CNA M said she felt she should have tried to calm him down before she attempted to pry him hand off her arm. On 08/04/22 at 02:18 PM CNA N stated she had completed dementia training/education. She said the Administrative Nurse D provided educational sheets on dementia care recently. CNA N stated she had never taken care of R192. On 08/04/22 at 03:50 PM Licensed Nurse (LN) G stated R192 had some behaviors while he was at the facility and usually, they were mild in nature. She completed dementia training annually as required and Administrative Nurse D occasionally passed out dementia education pamphlets to staff to review. On 08/04/22 at 04:23 PM Administrative Nurse D stated she became aware of the incident that happened with R192 and CNA M on 05/15/22, but was not in the facility at the time it happened. Administrative Nurse D stated CNA M was educated on dementia training, and how to care for a combative resident. The facility also held a mandatory staff meeting after the incident for the dementia education. R192 had been known to have some behaviors while he was a resident. The facility did not provide a policy for dementia care. The facility failed to ensure person centered care and services related to dementia and dementia related behaviors for R192, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/16/22 the facility implemented the following corrective actions: Staff education on the following topics: How to respond too Combative Behavior in Dementia How to respond to Anger and Aggression in Dementia Understanding challenging Behaviors in Dementia The Difference Between Alzheimer's and Dementia Stages and Progression Lewy Body Dementia R192's plan of care was updated with resident-specific interventions that addressed his behaviors. The deficient practice, corrected prior to the survey, was cited as past noncompliance.

The facility identified a census of 44 residents. The sample included 15 residents. Based on observation, record review and interview, the facility failed to ensure the catheter bag of resident (R)39 was kept off the floor. The facility failed ensure that clean laundry was covered while being delivered to resident rooms and clean laundry was kept off the floor. These deficient practices placed the residents at risk for increased infection and transmission of communicable disease. Findings included: - On 08/02/22 at 09:1 AM staff propelled the clean laundry/linens cart down the hallway uncovered. On 08/02/22 at 09:44 PM R39 laid in bed. His catheter bag laid on the floor in his room. On 08/03/22 09:14 AM a bag of clean hospital gowns and bed pads sat on floor right outside of R14's room. On 08/04/22 at 02:08 PM Housekeeping Staff U stated that any clean laundry transported on or in a cart from the basement up to resident rooms should be covered. Bags of clean linen should never be put on the floor. In ann interview on 08/04/22 at 02:18 PM, Certified Nurse Aide (CNA) P stated the catheter should never be on the floor. It should be hung on the side of the bed away from the door. In an interview 08/04/22 at 02:23 PM, Licensed Nurse (LN) H stated the catheter bag should never touch the floor. If a catheter bag had been on the floor the bag should be changed. On 08/04/22 at 4:23 PM Administrative Nurse D stated the catheter bag should never be on the floor, the bag should be changed if found on the floor. The facility Housekeeping and Laundry Quality and Service policy reviewed 7/10/12 lacked any documentation regarding the transporting of clean linens. The facility failed to ensure R39's catheter bag was kept off the floor. The facility failed to ensure that clean laundry was covered while being delivered and clean laundry was kept off the floor. This placed facility residents at increased risk for infection and transmission of communicable disease.

The facility identified a census of 44 residents. The sample included 15 residents with one resident reviewed for death. Based on record review, and interviews, the facility failed to complete a baseline care plan for R42, which placed her at risk of impaired cares related to unidentified or uncommunicated care needs. Findings included: - R42's electronic medical record (EMR) from the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Entry Minimum Data Set (MDS) recorded R42 admitted on [DATE]. R42's Baseline Care Plan was not initiated after her admission. Review of the EMR lacked a baseline care plan. On [DATE] at 11:33 AM Administrative Nurse D stated a baseline care plan was not started for R42 after admission. Administrative Nurse stated R42 was admitted on a Friday and then passed away Monday morning before the 48 hours had expired. On [DATE] at 03:50 PM Licensed Nurse (LN) G stated a baseline care plan was opened in the EMR upon a new admission. LN G stated that every department had a part to fill out for the new admission's baseline care plan. LN G stated that the admission coordinator or the director of nursing notified the staff of open baseline care plan that were to be completed within the 48 hours. On [DATE] at 02:20 PM Administrative Nurse E stated a baseline care plan was completed in 48 hours. Administrative Nurse E stated the admission nurse would open the baseline care plan in the EMR for the new admission and every department would complete their portion of the baseline care. Administrative Nurse E stated she would review the baseline care plan after the 48 hours. The facility Baseline Care Plan policy last reviewed [DATE] documented any resident admitted to the facility would have a Baseline Care Plan formulated and developed within 48 of admission. The facility failed to develop a baseline care plan for R42, which placed her at risk for impaired cares related to unidentified or uncommunicated care needs.

The facility identified a census of 44 residents. The sample included 15 residents with one resident reviewed for hospice and end of life. Based on observation, record review, and interviews, the facility failed to revise the care plan with the correct hospice company for Resident (R) 20, which placed her at risk of delayed services for end of life comfort. Findings included: - R20's Electronic Medical Record (EMR) from the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 13 which indicated intact cognition. The MDS documented that R20 required extensive assistance of one staff member for activities of daily living (ADLs). The MDS documented R20 received hospice services during the look back period and prior to admission. The Quarterly MDS dated [DATE] documented a BIMS score of seven which indicated severely impaired cognition. The MDS documented that R20 required extensive assistance of one staff member for ADLs. The MDS documented R20 received hospice servicers during the look back period. R20's ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 1255/10/21 documented R20 required assistance with her ADLs and was recently admitted on to hospice services. R20's Care Plan dated 12/16/21 documented the facility and hospice staff would coordinate bath days to provide comfort and hygiene for R20. The Care Plan revised on 02/08/22 documented R20 was admitted on to hospice services before admission. Review of the hospice communication book for R20 revealed the hospice provider was different than what was listed on R20's current care plan. On 08/03/22 at 12:22 PM nursing staff pushed R20 into the dining room; she ate lunch without assistance. On 08/03/21 at 10:22 AM Licensed Nurse (LN) H stated R20 was not on the hospice listed on the Care Plan. LN H retrieved the communication book for the correct hospice provider for R20. On 08/04/22 at 02:20 PM Administrative Nurse E stated the social services staff completed the care plan related to hospice services. On 08/04/22 at 02:38 PM Social Services X stated she completed the hospice care plan for R20. Social Service X stated R20 was admitted to the facility on hospice services. Social Services X verbalized the correct hospice provider for R20's services. Social Services X reviewed R20's care plan in the EMR and stated the hospice company listed on the care plan was a mistake and she corrected the name of the hospice. The facility Comprehensive Care Plan policy dated 09/30/19 documented the comprehensive care plan would describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The facility failed to ensure the correct hospice company was listed on R20's care plan, which placed R20 at risk of delayed services for end of life services.

The facility reported a census of 44 residents. The sample included 15 residents with 15 reviewed for quality of life. Based on observation, record review, and interviews, the facility failed to ensure all staff, across all shifts, honored Resident (R)14's preferences, requests and choices to ensure R14's quality of life. This deficient practice placed R14 at risk for decreased psychosocial wellbeing. Findings Included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's Annual Minimum Data Set (MDS) noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated that she required limited assistance from one staff for bed mobility, transfers, dressing, and personal hygiene. The MDS noted that she required extensive assistance for toileting. A review of R14's Activities of Daily Living (ADL's) Care Area assessment dated [DATE] noted that she required help with her ADL's and mobility due to poor muscle strength and endurance, and impaired balance. R14 received medication that may cause side effects for risk of falls. R14's Care Plan indicated that she had an ADL self-care deficit related to her medical conditions. The care plan indicated she required extensive assistance by one staff member for locomotion, transfers, toileting, bed mobility, dressing, and bathing. The plan indicated that she utilized a wheelchair for locomotion and staff were to encourage her to activate her call light for assistance. The care plan noted that she required prompt responses to all request for assistance. The care plan noted that that she was able to make her needs known and staff should honor her choices. On 08/02/22 at 08:23 AM R14 stated that the facility took great care of her except for one staff member. She stated that he often made her feel like she had to do everything for herself and request her to do things that she felt she could not complete due to her physical limitations. A review of a Complaint Investigation Statement dated 08/03/22 completed by Social Services X noted that R14 reported a complaint that Certified Nurses Aid (CNA) N asked her to complete care tasks that she could not physically tolerate including pulling her brief off during toileting, putting her slippers on, adjusting her bed linens, and sitting herself up in bed at night. On 08/03/22 at 02:03PM R14 reported that the previous night she activated her call light for assistance to the restroom. She stated that she was extremely weak and tired and needed assistance from staff to help her get out of bed and go to the restroom. She stated she was lying in bed and could not remove her covers. She stated that CNA N made her feel as though she should already be out of bed on her own. She required CNA N to assist her to sit up on the bed, put her slippers on, and transfer her to the restroom. She stated that throughout the provision of assistance, CNA N made her feel as though she asked for too much help and that she should have been able to complete the transfer without CNA N's help. She stated that while preparing to use the restroom, CNA N asked her to pull her own brief down and take it off. R14 stated that she has never been asked to do that by anyone before because she could not physically bend down low enough to remove the brief without falling or hurting herself. She stated that CNA N could not understand why she could not complete the task. She stated that he never readjusted the bed for her upon laying back down and she had to do it herself. On 08/04/22 at 02:05PM CNA N stated that has worked with R14 for a few months and believed that she should have been able to function during the night at the same level as during the daytime. He stated that during the dayshift, R14 needed very little help with getting out of bed and transferring to the toileting. He stated that every time he answered her call light on previous nightshifts, R14 was already sitting on the side of the bed ready to transfer to her wheelchair but the night of 08/03/22 he stated that something was different with her. CNA N confirmed he did ask R14 to perform some care task independantly as he was just trying to make sure R14 was okay and not declining. A review of the facility's Resident Right's policy revised 12/2020 noted that the facility is dedicated to enhancing the quality of life for each resident by treating each resident with dignity, courtesy, and promoting the right to choose the way they live and the care they receive. The facility failed to ensure all staff, across all shifts, honored R14's preferences, requests and choices to ensure R14's quality of life. This deficient practice placed R14 at risk for decreased psychosocial wellbeing.

The facility identified a census of 44 residents. The sample included 15 residents with one resident reviewed for bowel and bladder maintenance Based on observation, record review and interview, the facility failed to ensure Resident (R) 39's indwelling catheter (a soft hollow tube inserted into the urethra or bladder) urine collection bag was stored off the floor, and was hung lower than bladder level. This deficient practice placed R39 at increased risk for infection, [CONDITION(S)], and other catheter related complications. Findings included: - The electronic medical record (EMR) for R39 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] documented R39 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R39 required extensive to total assistance of one staff for his activities of daily living. R39 required the use of an indwelling catheter. The Urinary Care Area Assessment (CAA) dated 07/19/22 documented R39 had a catheter. R39 was at risk for skin breakdown and [CONDITION(S)]'s. Nursing provided catheter care. The Urinary Catheter Care Plan revised on 07/19/22 directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance of room door; secure the catheter bag to resident's leg with stat lock (a device used to secure the catheter tubing) and be sure to keep the bag off the floor. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R39 would continue with the catheter indefinitely. R39 would start [MEDICATION(S)] (an antibiotic medication used to treat infections) per sensitivity. On 08/02/22 at 09:44 PM R39 laid in bed. His catheter bag laid on the floor in his room on the left side of his bed, with no dignity cover present. On 08/03/22 at 11:26 AM R39 sat in his recliner. The catheter bag hung on the bedside table, above bladder level, and urine was visible moving back (backflow) in the catheter tubing. No dignity bag was in use. In an interview on 08/04/22 at 02:18 PM Certified Nurse Aide (CNA) P stated the catheter should never be on the floor. It should be hung on the side of the bed away from the door. The bag should be below the level of the bladder. A cover should be placed when the resident was in the wheelchair, out in public or when using the walker. In an interview 08/04/22 at 02:23 PM Licensed Nurse (LN) H stated the catheter bag should never touch the floor. If a catheter bag had been on the floor the bag should be changed. The catheter should not be hung at a level higher than the bladder such as the bedside table as that would place a resident at risk to develop and infection. On 08/04/22 at 04:23 PM Administrative Nurse D stated the catheter bag should never be on the floor, the catheter bag should be changed if found on the floor. Administrative Nurse D said the bag should be hung at a level lower than the bladder and should never be attached/hung from the bedside table. The Catheter Care policy dated 2001 documented: Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. The urinary drainage bag must always be held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The facility failed to ensure staff kept R39's catheter bag off the floor and failed to ensure the bag was maintained at a level below the bladder to prevent backflow. This put R39 at increased risk for complications related to catheter use.

The facility reported a census of 44 residents. The sample included 15 residents with one reviewed for nutrition and hydration . Based on observation, record review, and interviews, the facility failed to promote adequate hydration and nutrition when staff failed ensure accessible drinking water within reach for Resident (R)12. This deficient practice placed R12 at risk for altered hydration. Findings Included: - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R12's Quarterly Minimum Data Set (MDS) noted to Brief Interview for Mental Status (BIMS) score of ten indicating moderate cognitive impairment. The MDS noted that she required limited assistance from one staff for transfers, toileting, and bathing. The MDS noted that she was independent for eating. The MDS noted no significant weight loss or gain within the last six months. R12's Nutritional Care Area Assessment (CAA) indicated that she was on a regular diet. The CAA noted that she had memory loss from dementia and suffered from confusion at times. A review of R12's Care Plan revised 06/14/22 indicated that she was at risk for dehydration and malnutrition related to her medical diagnoses. The care plan indicated that staff should encourage fluid intake throughout the day. The care plan noted that she often asked the dietary aids to order her meals during meal services. On 08/04/22 at 07:20 AM R12's drinking water sat on the bedside table, located at the foot of her bed and out of reach. R12 was awake and awaiting her breakfast. R12's water remained out of reach until breakfast arrived at 08:45AM On 08/04/22 at 04:02 PM in an interview, Certified Nurses Aid (CNA) O stated that staff should be ensuring that the residents are comfortable and have what they need in reach at all times. She stated that water should be within reach and refilled when needed. On 08/04/22 at 04:22 PM in an interview, Administrative Nurse D stated that staff should be frequently checking on resident's needs during each interaction and ensuring that the resident's have what they need and easily accessible. She stated that R12's water should have been within reach and not positioned at the foot of the bed. A review of the facility's Hydration Management policy revised 11/2013 noted that nurses will provide and encourage fluid intake at bedside, mealtime, and on routine basis as part of cares. The policy noted that resident with high risk of dehydration will have specific interventions related to maintaining hydration in the care plan. The facility failed to promote adequate hydration for R12 when staff placed R12's water out of her reach. This deficient practice placed R12 at increased risk for altered hydration.

The facility identified a census of 40. The sample included 14 residents. Based on observations, record reviews, and interviews, the facility failed to perform adequate hand hygiene before and after administering medications, failed to perform hand hygiene before and after donning (put on) and doffing (remove) gloves during foley catheter (tube inserted into the bladder to drain urine into a collection bag) care for Resident (R) 7, failed to perform adequate hand hygiene before and after delivering meal trays, failed to perform hand hygiene before and after donning and doffing gloves during wound care for R140, failed to ensure proper mask usage near resident meal trays, and failed to transport soiled linens in a sanitary manner. Findings included: - An observation on 03/22/21 at 07:58 AM revealed Certified Medication Aide (CMA) R prepared medications for a resident, did not perform hand hygiene before or after he prepared medications or before or after he administered medications to resident. An observation on 03/23/21 at 09:36 AM revealed Certified Nurse Aide (CNA) N gathered supplies for foley catheter care for R7. She did not perform hand hygiene before she donned gloves. After she completed catheter care, she doffed gloves. No hand hygiene performed before she donned new gloves. She assisted R7 with changing an incontinence brief then doffed gloves. No hand hygiene performed before she donned new gloves. CNA N assisted R7 with getting dressed. After she helped R7 put on his pants and shirt, she transferred him with the hoyer lift (total body mechanical lift used to transfer residents) and washed R7's face with a washcloth. She then doffed her gloves, and no hand hygiene was observed after doffing gloves. An observation on 03/23/21 at 10:00 AM revealed CNA M entered room [ROOM NUMBER] and asked the resident if she was done eating, resident stated yes. CNA M stated she would be back to grab her breakfast tray. CNA M did not perform hand hygiene upon entering or when exiting room. An observation on 03/23/21 at 10:07 AM revealed CNA M entered room [ROOM NUMBER] to retrieve breakfast tray, she did not perform hand hygiene upon entering or when exiting room. An observation on 03/23/21 at 10:09 AM revealed CNA M entered room [ROOM NUMBER] to retrieve breakfast tray, she did not perform hand hygiene upon entering or when exiting room. An observation on 03/24/21 at 08:15 AM revealed Licensed Nurse (LN) I washed hands then gathered dressing change supplies from treatment cart for R140 before she donned gloves. She removed R140's incontinence brief and rolled R140 to his left side, she removed the soiled dressings in place on R140's coccyx (small triangular bone at the base of the spine) area. LN I cleansed the wounds and doffed gloves. She did not perform hand hygiene before she donned new gloves. She measured the wounds then applied new dressing to wounds. She doffed gloves but did not perform hand hygiene before she donned new gloves. She applied skin prep (a solution when applied that forms a protective waterproof barrier on the skin) to both heels and doffed gloves. She did not perform hand hygiene before she donned new gloves. She removed dressing from lower left leg wound and cleansed the wound. She applied a new dressing to left leg wound, did not change gloves or perform hand hygiene during left leg wound dressing change procedure. She doffed gloves; no hand hygiene observed after doffing gloves. An observation on 03/24/21 at 09:10 AM revealed CNA M exited room [ROOM NUMBER] after getting resident's breakfast order, no hand hygiene when exiting room. An observation on 03/24/21 at 09:12 AM revealed CNA M delivered breakfast tray to room [ROOM NUMBER] and assisted resident with tray set up, no hand hygiene upon entering or when exiting room. An observation on 03/24/21 at 12:31 PM revealed CNA M pulled her surgical mask down to take a drink while leaning over the meal tray cart. She replaced her mask after drinking and proceeded to push the cart down the hallway for tray delivery. She did not perform hand hygiene after touching mask. In an observation on 03/24/21 at 12:37 PM, LN H delivered lunch tray to room [ROOM NUMBER] and assisted with tray set up, did not perform hand hygiene before she retrieved tray from cart or after she delivered tray to resident. In an observation on 03/24/21 at 12:39 PM, CNA M delivered lunch tray to room [ROOM NUMBER] and assisted with set up of tray, no hand hygiene upon entering room or when exiting room. In an observation on 03/24/21 at 12:52 AM, CNA M exited room [ROOM NUMBER] with soiled linen in bag, no hand hygiene observed. She swung bag around as she walked down the hall. She proceeded to enter room [ROOM NUMBER] with soiled linen bag in hand and talked to resident, no hand hygiene observed upon entering room or when exiting room. As she walked to soiled utility room to deposit soiled linen bag, she swung bag around in hallway. No hand hygiene performed afterward. In an observation on 03/24/21 at 12:57 PM, CNA M delivered lunch tray to room [ROOM NUMBER], she left room with room tray shortly afterward as resident did not want to eat what was on the tray. No hand hygiene performed upon entering room or when exiting room. In an interview on 03/24/21 at 01:05 PM, CNA M stated she performed hand hygiene after every resident encounter and hand hygiene should be done after anything was completed with a resident. She stated she placed soiled linens in a bag and took it straight to the soiled utility room. She stated she did not go into other resident rooms with the soiled linen bag and she performed hand hygiene after she placed it in the soiled utility room. In an interview on 03/24/21 at 01:23 PM, LN H stated she performed hand hygiene after every resident contact and before and after she passed a meal tray. She stated hand hygiene was performed after walking out of each resident room. She stated soiled linen was placed in a bag and brought to the soiled utility room, she stated the soiled linen bag was not brought into other resident rooms. In an interview on 03/24/21 at 01:27 PM, CNA N stated if hands were visibly soiled or after peri-care then she washed hands with soap and water. She stated she performed hand hygiene when she entered a resident's room. In an interview on 03/24/21 at 01:43 PM, LN G stated she sanitized her hands when she doffed gloves and before she donned new gloves. She stated she sanitized her hands before and after any procedures. In an interview on 03/24/21 at 01:48 PM, LN H stated she sanitized her hands when she delivered a meal tray and washed her hands with soap and water if she performed peri-care. In an interview on 03/24/21 at 02:33 PM, Administrative Nurse D stated she expected hand hygiene before and after hands-on resident care, but she did not expect hand hygiene after each meal tray was delivered. She stated she did not perform hand hygiene when she served trays. She expected soiled linens to be placed in a bag and taken down to soiled utility room, she stated soiled linen bags should not be taken into other resident rooms. She stated she expected hand hygiene to be performed after doffing gloves. The facility's Infection Prevention and Control Manual, dated 2019, directed that hand hygiene was the primary means of preventing the transmission of infection and the purpose of hand hygiene was to cleanse hands to provide a clean and healthy environment to residents, team members, and visitors, and to reduce the risk to the healthcare provider of infections acquired from a resident. The facility's Catheter Care, Urinary policy, last revised September 2014, directed facility maintained clean technique when handling catheter and directed that hands were washed and dried thoroughly before putting on gloves before the catheter cleaning procedure. The policy directed staff removed gloves after procedure and washed hands thoroughly. The facility's Wound Care Policy, effective 01/01/2017, directed wound care guidelines were utilized to provide guidance and recommendations regarding wound care and pressure injuries. The policy lacked direction on proper hand hygiene and donning/doffing gloves during wound care. The facility failed to ensure adequate infection control practices and hand hygiene during medication administration, before/after donning/doffing gloves during foley catheter care, before/after meal tray delivery, and before/after donning/doffing gloves during wound care. The facility also failed to ensure proper mask usage near resident meal trays and transportation of soiled linens in a sanitary manner. These deficient practices had the risk to spread infection and illness to all residents and staff.

The facility identified a census of 40 residents. The sample included 14 residents. Based on observations, interviews, and record reviews the facility failed to provide services, consistent with professional standards of practice, to prevent new pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) from development and to promote healing of existing pressure ulcers when they failed to ensure Resident (R) 28 was provided with off-loading boots while he rested in bed. Findings included: - The Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS) dated [DATE] documented R28 had long and short-term memory deficits. He required extensive to total staff assistance with his Activities of Daily Living (ADLs). He was at risk for pressure ulcer development. R28 had one stage 2 pressure ulcer (partial thickness skin loss with exposed dermis), which was present on admission. He was provided a pressure reducing device for his chair and wheelchair, a turning/repositioning program, nutrition/hydration intervention to manage skin problems, pressure ulcer care, applications of ointments/medication other than to feet, and application of dressings to the feet. The Quarterly MDS dated [DATE] documented R28 had long and short-term memory deficits. He required extensive to total staff assistance with his ADLs. He was at risk for pressure ulcer development. R28 had one stage 2 pressure ulcer, which was present on admission. He was provided with a pressure reducing device for his wheelchair and bed, and applications of ointments/medications other than to feet. The Pressure Ulcer Care Area assessment dated [DATE] documented R28 required staff assistance with bed mobility and had a stage 2 pressure ulcer on his right Achilles (heel). The pressure ulcer was a chronic non-healing ulcer and he was admitted with the ulcer. The nursing staff provided skin inspections, a low air loss mattress, pressure reducing cushion for his wheelchair, and frequent position changes while he was in bed. R28 wore heel lift boots while in his bed. The Comprehensive Care Plan revised 03/16/21 documented R28 was admitted with a stage 2 pressure ulcer to his right lower leg above his heel. The staff administered treatments to the wound as ordered by the physician. The staff avoided positioning R28 directly on his right heel. The Care Plan directed staff to ensure off-loading boots were placed on both feet when he was in bed and in his wheelchair. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cover with Xeroform (a non-adherent protective dressing to help maintain a moist wound environment, while promoting healing), cover with four inch by four inch gauze pads, wrap with Kerlix (a rolled bandage which cushions and protects wounds) and secure with tape every Tuesday, Friday, and Sunday dated 03/17/21. The Braden Assessments (an assessment tool used to assess a person's risk of developing pressure ulcers) dated 01/12/20 documented R28 was at moderate risk and on 03/18/21 was at high risk for pressure ulcer development. The Skin & Wound Evaluation dated 03/16/21 documented R28 had a stage 2 pressure ulcer present on admission to his right heel which measured 5.2 centimeters in total area, 2.3 centimeters in length, and 4.0 centimeters in width. There was no drainage and the surrounding skin was fragile and at risk for breakdown. On 03/23/21 at 08:00 AM R28 laid in his back while in his bed. His heels were placed directly on the mattress. The off-loading boots were on a chair in his room. On 03/23/21 at 09:10 AM Licensed Nurse (LN) G provided wound care to R28. The right Achilles pressure ulcer was pink with one small scab about the size of a pencil eraser. There was no odor or drainage to the wound. LN G placed a non-skid sock on R28's right foot after the new dressing was placed on the wound. The boots remained on the chair. On 03/23/21 at 02:06 PM R28 laid in bed, on his back, both heels rested flat on the mattress. The protective boots were on a chair, in the corner of the room. On 03/23/21 at 04:30 PM R28 rested in his bed in the same position. The boots were in the chair. On 03/24/21 at 01:27 PM Certified Nurse Aide N stated she looked at residents' skin daily when she assisted them with toileting and dressing. R28 had a sore on his heel and he wore protective boots on his feet when he was in bed at night. On 03/24/21 at 01:48 PM LN H stated skin assessments were done weekly by the nurses. The wound nurse measured wounds weekly. R28 had a chronic wound due to his fragile skin. R28 did not wear the protective boots when he sat in his wheelchair since he would scratch his legs as he tried to pull the boots off but, he wore them in bed for protection. On 03/24/21 at 02:33 PM Administrative Nurse D stated the nursing staff did weekly skin assessments and the wound nurse provided wound assessments weekly. R28 had a chronic wound to his heel which had closed but had recently opened. He wore his protective boots when he was in bed. The facility's Wound Care Policy dated 01/01/17 documented the facility utilized evidence based clinical practices to provide pressure injury and wound treatments. The facility complied with current nursing standards, as well as state and federal guidelines related to the identification, treatment, and documentation of alterations in the skin integrity of the residents. The facility failed to ensure R28 wore his pressure relieving boots when he was in bed. This had the potential for the worsening of his pressure ulcer and/or the development of new pressure ulcers.

The facility identified a census of 39 residents. The sample included 3 residents reviewed for abuse. Based on interview and record review, the facility failed to prevent potential further abuse after resident #39 alleged direct care staff M threw a phone at him/her. The facility's failure to suspend the alleged perpetrator (staff M), to protect the other residents, placed all residents in immediate jeopardy on 2/19/19. The immediate jeopardy was removed on 2/25/19 Findings included: - Review of resident #39's electronic medical record (EMR) revealed the following Diagnoses: [REDACTED]. characterized by a combination of symptoms that interfere with a person's ability to work, sleep, study, eat, and enjoy once-pleasurable activities) and [MEDICAL CONDITION] (inability to sleep). Review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) of 14, indicating intact cognition. Resident had no behaviors. The resident required extensive assistance of 1 to 2 staff with activities of daily living (ADLs). The resident received an antidepressant, anticoagulant and antibiotic medication for 7 days. Review of the Care Area Assessment (CAA) for activities of daily living (ADL) revealed he/she elected hospice (care service aimed at providing comfort measures to people with a terminal diagnosis) care starting 2/4/19. He/she required total to extensive assistance of 1-2 staff with ADLs and bathing. He/she was alert and oriented with forgetfulness and was able to verbalize his/her needs. The resident was able to use the call light, however he/she would use the call light and then scream for help. He/she had tremors and a high level of anxiety. The CAA for mood dated 2/11/2019 revealed the resident did not enjoy doing the things he/she used to do related to his/her tremor. He/she found it embarrassing to be in public. He/she also reported that he/she felt depressed daily, had trouble sleeping, and felt tired all the time. He/she had a [DIAGNOSES REDACTED]. His/her [MEDICAL CONDITION] had been a life-long issue. Staff members were to encourage the resident to attend activities on days when his/her tremor was less noticeable. Family visit daily for extended periods of time. Team members were to assist the resident with getting his/her TV on the channel he/she preferred as he/she liked watching TV in his/her room. The CAA for behavior dated 2/11/2019 revealed the resident had a [DIAGNOSES REDACTED]. Most days his/her family visited for several hours at a time. When they were not visiting the resident could become anxious and call out for help. Staff members were to reassure the resident that he/she was alright and they will check on him/her frequently. At times sitting and visiting with the resident helped. Also speaking in a soft, calm voice helped reduce the resident's anxiety at times. The care plan for ADLs dated 11/15/2018 instructed staff to report to the nurse if the resident was anxious or agitated. If the resident was anxious or agitated staff were to approach calmly, do not argue, allow the resident time to say what he/she needed or wanted and do not make him/her do something he/she did not want to do. The care plan for major [MEDICAL CONDITION] dated 10/23/2018 instructed staff if resident yelled at them, they were to let the resident know they were leaving his/her room and going to get the charge nurse. If the resident was not safe to leave alone in his/her room, staff should complete the service then get the nurse. The care plan for anxiety dated 12/1/2018 instructed staff to offer comfort and reassurance to the resident when he/she yelled out. When the resident became agitated, staff should give him/her space, but monitor and re-approach after the resident had time to calm down. If the resident was yelling when staff approach, staff were to talk in a soft, calming voice. Facility started an investigation on 2/19/2019 and concluded the investigation around 2/25/2019. Review of the facility investigation revealed on 2/19/2019 late in the evening, documented the resident was restless and requesting to get in and out of bed. Licensed nursing staff G gave the resident his/her medications as ordered for anxiety. The resident asked to go to bed. At approximately 8:00 PM direct care staff M responded to the resident's call light. The resident was yelling out for help and swinging his/her legs over the side of the bed, trying to get out. Direct care staff M helped the resident put his/her feet back in bed. Resident #39 took the call light/pillow speaker that was on his/her lap and threw it at direct care staff M. Direct care staff M tried to catch it, but it bounced off his/her hand and fell back on the bed. At that time, direct care staff M was not aware of it hitting the resident. Per facility investigation, afterwards direct care staff M left the room and notified licensed nursing staff G of the incident. Direct care staff M and licensed nursing staff G went back into the resident's room together and helped the resident get up in his/her wheelchair and assisted him/her to call his/her family member. The resident then called his/her family member and stated direct care staff M threw a phone at him/her. Resident's family member called licensed nursing staff G around 8:30 PM and told staff G what the resident had told him/her. After the phone call, licensed nursing staff G went into resident's room to meet with him/her. There was no indication of a mark or injury noted at that time. Licensed nursing staff G asked resident #39 what happened, and the resident said he/she threw his/her phone at direct care staff M and direct care staff M threw it back at him/her. Licensed nursing staff G noted that resident's phone was across the room and not within the resident's reach. Per facility investigation at approximately 8:30 PM direct care staff M and licensed nursing staff G brought the resident out to the living room outside of his/her room, so he/she could be observed. The resident was at risk for falls due to his/her restlessness and anxiety medication. Within 5-10 minutes, the resident began screaming again that he/she wanted to get back in bed. The resident began propelling him/her self into his/her room. When direct care staff M tried to get the resident to wait until he/she could get licensed nursing staff G to help, resident #39 scratched and tried to bite direct care staff M. At that time, licensed nursing staff G reassigned direct care staff M to the other side of the health center. Licensed nursing staff G then got another direct care staff member to care for the resident. Per facility investigation, the next day administrative nursing staff D met with resident's family member to discuss the incident. The resident's family member had concerns that the team was not honoring the resident's nighttime preferences. Administrative nursing staff D met with resident #39 to discuss his/her preferences. Staff members witness statements revealed staff only put the resident to bed or got him/her out of bed at his/her request. The resident did not say anything to administrative nursing staff D about direct care staff M throwing something at him/her. Per facility investigation, the resident continued to have restlessness and anxiety throughout the week, so the resident's physician ordered [MEDICATION NAME] (antipsychotic) to be started. The family member agreed with trying the new medication. Per facility investigation, over the weekend, on 2/24/2019 the resident's family member emailed facility administrative staff A informing them resident had a bruise on his/her forehead. Family member told administrative staff A he/she thought it was due to the altercation with direct care staff M. Per facility investigation, on 2/24/2019 administrative nursing staff D received an email from administrative staff A in regard to the email he/she received from resident #39's family member and the bruise the family member observed on the forehead of resident #39. Administrative staff A then instructed administrative nursing staff D to suspend staff M pending investigation. Per facility investigation, administrative nursing staff D stated he/she arrived to work on 2/25/2019 and observed the resident sitting at dining room table eating breakfast. Administrative nursing staff D stated they were able to see the resident's forehead and he/she had a bruise measuring approximately 1 inch in length and one-quarter of inch wide, with yellow discoloration surrounding the bruise. He/she went on to state the bruising was consistent with the width of a call light/pillow speaker device. Interview on 6/19/2019 at approximately 8:45 AM with Administrative staff A acknowledged that direct care staff M was not suspended until family member notified them on 2/24/2019 of the bruise on resident #39 forehead. Administrative staff A stated they thought they knew what happened, the resident threw it at direct care staff M and it bounced off his/her hand and hit the resident. Direct care staff M never provided care to the resident again and none of the other residents complained about him/her. The facility educated on abuse, neglect and exploitation annually and as needed. Education for abuse, neglect and exploitation was provided to all staff on 2/25/2019 and one on one education on abuse, neglect and exploitation with direct care staff M. Staff A stated the facility policy recorded when an allegation of abuse was made against staff, the staff member should be suspended immediately. Interview on 6/19/2019 at approximately 9:15 AM with Administrative Nursing Staff D acknowledged direct care staff M was reassigned to a different unit after resident #39 alleged direct care staff M threw a phone at her and that direct care staff was not immediately suspended pending an investigation. Administrative nursing staff D stated the facility policy does not specifically state when a staff member would be suspended. Staff received education annually and as needed on abuse, neglect and exploitation. Facility policy on Resident Abuse, Neglect, Exploitation Requirements revised 1/21/2019 stated, if the alleged perpetrator was on the premises of the community, obtain a witness, and place the team member on an unpaid suspension pending further investigation. The facility failed to prevent further abuse and ensure appropriate corrective actions by the failure to remove the alleged perpetrator from working with all residents in the facility. This placed all residents in immediate jeopardy. The facility was provided written notification of the immediate jeopardy on 6/19/19 at 12:05 PM. The deficient practice was cited as past non-compliance as the immediate jeopardy was removed when the facility completed the following corrective actions on 2/25/19 : The alleged perpetrator was suspended on 2/24/19. The facility completed education on Abuse, Neglect, and Exploitation and Caring for Residents with Dementia with alleged perpetrator on 2/25/19 prior to returning to work. The facility completed same education with all team members on 2/25/19. The incident was taken to QAPI (Quality Assurance and Performance Improvement) committee for ongoing monitoring. The facility continually monitors for any allegations of abuse through frequent interviews conducted by social worker, lifestyle department, and nursing team members.

The facility identified a census of 38 residents and there were 3 sampled residents. Based on record review and interview the facility failed to implement a physician ordered chair alarm to prevent a head injury fall which required hospital treatment for 1 of 3 (#3) residents sampled for accidents. Findings include: - Review of resident #3 physician order [REDACTED]. Review of the admission MDS (Minimum Data Set) dated 7/28/2015 documented the resident had severe cognitive impairment, required extensive assistance of 2 or more staff with transfers, bed mobility, and dressing; and he/she was dependent on staff with toileting, personal hygiene, and locomotion on and off the unit. He/she had no falls since admission. Review of the Quarterly MDS (Minimum Data Set) dated 1/21/2016 documented the resident had severe cognitive impairment, required extensive assistance of 2 or more staff with bed mobility and transfers and was dependent on staff with locomotion on and off the unit. Review of the Fall CAA (Care Area Assessment) dated 8/3/2015 document the resident was at risk for falls, had impaired vision, confusion, and staff reported the resident does not use the call light to ask for assistance. Review of the care plan dated 2/03/2016 revealed the resident was at risk for falls due to factors which included impaired vision and dementia. The care plan directed staff to anticipate the resident's needs, assist with ADLS (activities of daily living) to include mobility in his/her Broda chair (a specialized wheelchair which tilted and reclined). Staff were directed to ensure a chair alarm was placed at all times on his/her Broda chair. Review of a physician order [REDACTED]. Review of a nursing progress note dated 3/10/2016 at 2:45 P.M. documented staff informed the nurse the resident was on the floor in the common area, laying on his/her left side, with a pool of blood under his/her head. The resident was unable to tell the nurse what happened. The nurse provided immediate first aide care and transferred the resident to the hospital trauma unit. The resident returned to the facility at 9:30 P.M. with a dressing to his/her left forehead and bruising around his/her left eye. Staff received a verbal order from the emergency room not to remove the dressing. emergency room staff informed the nurse the resident had sutures and something applied since the resident's forehead skin was gone. Review of the undated fall worksheet documented on 3/10/2016 at 2:45 P.M. the resident attempted to get up from his/her Broda Chair and tripped on the Broda chair pedal after his/her feet were tangled in the footrest. The worksheet failed to identify the use of a chair alarm. Review of a physician progress notes [REDACTED]. During an interview on 5/4/2016 at 2:08 P.M. direct care staff O said on the day of the fall he/she moved the resident from watching the birds to the fireplace room. Staff O said the resident was in a Broda chair and he/she was not aware of an alarm. During an interview on 5/4/16 at 1:06 P.M. licensed staff H stated when the resident fell he/she was at the nurse's station and heard someone say oh no. He/she found the resident on the floor in the fireplace room with a small pool of blood under his/her head. Staff H said no chair alarm was heard. During an interview on 05/05/2016 at 7:30 A.M. licensed nursing staff I stated when the fall occurred no alarms sounded. Staff I said he/she heard a thump and the housekeeper said oh no and alerted him/her to the fall. During an interview on 05/05/2016 at 8:28 A.M. administrative nursing staff D stated normally chair alarms were not placed on the Broda Chair. He/she said the purpose of the chair enabled the resident to stretch out his/her legs, lean back, and stretch his/her back. The facility failed to implement a physician ordered intervention to prevent a head injury fall which required hospital treatment for [REDACTED].

The facility identified a census of 39 residents. The sample included 21 residents. Based on observation, record review, and interview the facility failed to ensure the resident's environment remained free of accident hazards and each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents reviewed for falls, (#31) who fell and sustained hip and back fractures. Findings included: - The signed physician's orders [REDACTED].#31 dated 5/1/15 revealed [DIAGNOSES REDACTED]. The quarterly minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 8 (moderate cognitive impairment). He/she had no rejection of care behaviors. He/she required supervision, and setup help from staff for bed mobility, transfers, toileting and personal hygiene; limited assistance of 1 for dressing; and extensive assistance of 1 for bathing. His/her balance during transitions and walking was not steady, but able to stabilize without human assistance. He/she had no functional limitations of range of motion and had 1 fall since the previous assessment. The annual minimum data set ((MDS) dated [DATE] revealed a BIMS was not done related to the resident was unable to answer the questions. A staff assessment of mental status revealed he/she had short and long term memory impairment. He/she had no rejection of care behaviors. He/she required extensive assistance of one person for bed mobility, transfers, dressing, toileting and personal hygiene. He/she was totally dependent on one person for bathing. He/she was not steady, only able to stabilize with human assistance when moving from seated to standing position, moving on and off the toilet and surface-to-surface transfer. He/she had no functional limitations of range of motion. He/she was frequently incontinent of bowel and bladder, had 1 fall since the previous assessment, received 7 days of antianxiety and antidepressant medication and 4 days received a diuretic. He/she received no therapies. The quarterly minimum data set ((MDS) dated [DATE] revealed a BIMS score was 7 (severe cognitive impairment). He/she had no rejection of care behaviors. He/she required extensive assistance of one person for bed mobility, dressing, toileting, personal hygiene and bathing. His/her balance during transitions and walking was not steady, only able to stabilize with human assistance. He/she had no functional limitations of range of motion. He/she was frequently incontinent of bowel and bladder, had 2 falls since the previous assessment. The Care Area Assessment (CAA) for falls dated 11/5/14 revealed the resident fell recently in his/her room. He/she was weak and had poor safety awareness. He/she did not use his/her call light, staff anticipated his/her needs. His/her medications increased his/her risk of falls. The care plan dated 10/3/13 and last reviewed on 12/31/13 for fall risk secondary to poor safety awareness, memory deficits, and impaired balance revealed staff reviewed resident falls per the facility policy. Call light and frequently used items made available for his/her use. Staff were to cue and remind him/her to use his/her walker and to lock the brakes on his/her walker. Staff to check his/her pathway in room was free of clutter. On 2/21/14 physical therapy screen. On 3/18/14 the care plan was reviewed. On 6/9/14 keep pathways uncluttered. On 6/27/14 add a bed alarm. On 9/1/14 bed in low position. On 11/16/14 keep his/her bed at regular height, place the wheelchair and the walker next to his/her bed and ensure that both were locked, and that pathway in room was free of clutter. On 12/31/14 place his/her wheelchair next to his/her bed. Make sure his/her wheelchair was locked. On 2/8/15 bed bolsters as ordered. On 2/15/15 hospice to evaluate the current mattress. On 3/4/15 discontinue the bed alarm. On 3/6/15 offer him/her toileting assistance. On 3/30/15 bed against the wall at regular height and place his/her wheelchair and/or walker next to his/her bed ensuring they were locked. On 4/1/15 his/her room was re-arranged to ensure clutter free pathways. On 4/2/15 he/she preferred walker. On 4/8/15 add a perimeter mattress on his/her bed. On 4/17/15 remove perimeter mattress from the resident's bed and placed motion device in his/her room. On 4/21/15 the resident was moved from bed W (window) to bed D (door) to be closer to the bathroom. On 4/25/15 placed a scoop mattress on his/her bed. Review of the resident's fall risk assessments (a score over 9 was considered at risk for falls) from March, 2014, through April, 2015, revealed at risk for falls and ranged from 14 to 25. The fall investigation for the 2/21/14 unwitnessed fall provided by the facility revealed the resident was doing self care (hygiene in the bathroom) when he/she lost his/her balance and fell hitting the right side of his/her face. The right side of his/her face and right lower thigh had small amount of swelling. Interventions were to have physical therapy screen the resident. The fall investigation for the 6/8/14 unwitnessed fall provided by the facility revealed the resident's roommate reported the resident fell , picked his/herself up and sat in his/her recliner. A bruise was found on his/her left elbow. Licensed nursing staff M encouraged the cognitively impaired resident to use his/her call light. On 6/9/14 keep pathways uncluttered. The fall investigation for the 8/6/14 unwitnessed fall provided by the facility revealed the resident was found lying on his/her back in the bathroom with his/her legs positioned towards the door, his/her head faced the wall, and had a skin tear to his/her right inner forearm. He/she reported severe pain to his/her left hip. He/she was transported to a local hospital and was admitted for a fractured left femur (broken thigh bone). Record review revealed staff did not assess for causal factors to develop effective interventions to prevent further falls. The fall investigation for the 8/30/14 unwitnessed fall provided by the facility revealed the resident fell from the toilet in his/her bathroom resulting in an abrasion (scraping or rubbing away of a surface, such as skin, by friction). Record review revealed staff did not assess for causal factors to develop effective interventions to prevent further falls. The fall investigation for the 10/7/14 unwitnessed fall provided by the facility revealed staff found the resident sitting on the floor in between his/her roommate's bed and dresser, with his/her back and head leaning against the dresser. He/she sustained a laceration to his/her right inner elbow and a bruise on his/her left outer elbow. Record review revealed staff did not assess for causal factors to develop effective interventions to prevent further falls. The fall investigation for the 11/16/14 unwitnessed fall provided by the facility revealed staff found the resident on the floor with his/her back resting against the wall facing the mirror. Both of his/her legs were folded with the bottom of his/her feet flat on the floor with no injuries. Interventions were keep his/her bed at regular height, place the wheelchair and the walker next to his/her bed and ensure that both were locked, and that his/her pathway in room was free of clutter. The fall investigation for the 12/31/14 unwitnessed fall provided by the facility revealed the resident was found sitting on the bathroom floor with his/her legs straight forward and back resting against the wall facing the mirror with no injury. Licensed nursing staff H reminded the cognitively impaired resident to use his/her call light for assistance with transfers and walking. On 12/31/14 the care plan was revised to bed at regular height. Place his/her wheelchair next to his/her bed. Make sure his/her wheelchair was locked. The fall investigation for the 1/27/15 unwitnessed fall provided by the facility revealed the resident was found by a direct care staff sitting on the floor in his/her room by the bathroom entrance. His/her walker was in the bathroom and the bathroom floor was wet and appeared the resident tried to clean him/herself with wet paper towels that were in the trash can. He/she had no apparent injury. Record review revealed staff did not assess for causal factors to develop effective interventions to prevent further falls. The fall investigation for the 2/6/15 unwitnessed fall provided by the facility revealed the resident was found laying on the floor of the left side of his/her bed sleeping with no injury. On 2/8/15 bed bolsters added as ordered. The fall investigation for the 2/15/15 unwitnessed fall provided by the facility revealed staff found the resident sitting on the floor with linens behind his/her back and buttocks, legs and knees were folded with the bottom of his/her feet planted on the floor with no injury. Record review revealed staff did not assess for causal factors to develop effective interventions to prevent further falls. The fall investigation for the 2/28/15 unwitnessed fall provided by the facility revealed the resident sat on the floor with his/her back resting against the bed, legs extended outward, and facing the door with no injuries. Encourage the cognitively impaired resident to use his/her call light for assistance. Record review revealed staff did not assess for causal factors to develop effective interventions to prevent further falls. The fall investigation for the 3/6/15 unwitnessed fall provided by the facility revealed the resident sat on the floor with no injury. Interventions were to offer him/her toileting assistance. The fall investigation for the 3/30/15 unwitnessed fall provided by the facility revealed the resident was sitting on the floor next to the bed with his/her back against bed and facing the door. He/she had a skin tear on his/her right shin, and a hematoma on his/her right forehead above the eye and on the back of his/her right hand. Interventions were to place his/her bed against the wall at regular height and his/her wheelchair and/or walker next to his/her bed ensuring they were locked. The fall investigation for the 3/31/15 unwitnessed fall provided by the facility revealed the resident sat on floor in his/her bathroom and incontinent of bowel and bladder. He/she did not use his/her assistive device. The 3/31/15 progress notes revealed a skin tear on his/her left knee with a small amount of bloody drainage and a purple area on his/her left forearm. On 4/1/15 his/her room was re-arranged to ensure clutter free pathways. The fall investigation for the 4/3/15 unwitnessed fall provided by the facility revealed the resident was found sitting on the floor in his/her room with no injury. Record review revealed staff did not assess for causal factors to develop effective interventions to prevent further falls. The fall investigation for the 4/7/15 unwitnessed fall provided by the facility revealed the resident sat on the floor next to his/her bed without his/her pants or brief on. A small skin tear was on his/her left shin. His/her left knee was xrayed with no results documented. On 4/8/15 interventions were to add a perimeter mattress on his/her bed. The fall investigation for the 4/9/15 at 3:30 PM unwitnessed fall provided by the facility revealed the resident was on the floor next to his/her bed. He/she had a small skin tear on his/her left ankle. Record review revealed staff did not assess for causal factors to develop effective interventions to prevent further falls. The fall investigation for the 4/9/15 at 8:30 PM unwitnessed fall provided by the facility revealed the resident was on the floor next to his/her bed with no injuries. Record review revealed staff did not assess for causal factors to develop effective interventions to prevent further falls. The fall investigation for the 4/17/15 unwitnessed fall provided by the facility revealed the resident was on the floor next to his/her bed. Two small skin tears were on his/her left upper extremity and the care plan intervention was to remove the perimeter mattress from the resident's bed and a motion device was placed in his/her room. The fall investigation for the 4/20/15 unwitnessed fall provided by the facility revealed the resident was on the floor next to his/her bed with no injury. On 4/21/15 the resident was moved from bed W (window) to bed D (door) to be closer to the bathroom. On 4/25/15 the care plan was updated revealing a scoop mattress placed on his/her bed. On 5/07/2015 at 2:43 P.M. the resident sat on the side of his/her bed, lunch tray on bedside table in front of him/her. He/she was drowsy. At 3:03 P.M. the administrative nursing staff D and direct care staff S entered his/her room and recommended he/she lie down in the bed, a motion alarm was sounding. The resident had removed his/her pants and non-slip socks, and wore only a shirt. Direct care staff S offered to put his/her pants back on. The room was clear of clutter and the call light was at the resident's bedside. The bed was at his/her wheelchair level with a scoop mattress on the bed. The bed was against the north wall and a positioning bar was on the head of the bed. A motion alarm was on the east wall positioned to detect his/her movement if he/she stood up. Observation on 5/11/2015 at 8:47 A.M. he/she was alert and sitting on his/her bed side eating breakfast with bedside table in front of him/her. The room was not cluttered and his/her call light was next to the resident. The motion alarm was in place. Observation on 5/11/2015 at 9:45 A.M. licensed nursing staff J asked the resident if he/she was okay when responding to the motion alarm sounding. The resident was sitting on his/her bed with a breakfast tray on the bedside table in front of him/her. His/her shoes and socks laid on the floor. Observation on 5/11/2015 at 11:11 A.M. he/she was sitting up on the bed re-positioning him/herself without triggering the motion alarm, and wore non-slid socks on both feet. At 11:28 A.M. the resident had his/her head down sleeping while sitting up on the side of the bed. Observation on 5/11/2015 at 3:08 P.M. the resident came out of his/her bathroom sitting on the chair of his/her walker with direct care staff P pushing it to his/her bed side. Direct care staff P transferred him/her with a gait belt and encouragement for the resident's cooperation to his/her bed with little assist from him/her or weight bearing. The resident was breathing heavily. He/she had both non-slip socks on and the motion alarm was turned on. Observation on 5/12/2015 at 2:10 P.M. he/she sat on the side of his/her bed with his/her head down, sleeping. The motion alarm was in place. The bed was level with the wheelchair, call light at his/her side, no room clutter, and non-slip socks on both feet. On 5/11/2015 at 9:51 A.M. an interview with direct care staff T revealed the resident ate by him/herself and did not like help, but sometimes required staff assistance. He/she required stand by assist when ambulating to the bathroom. On 5/11/2015 at 5:26 P.M. an interview with direct care staff P revealed that he/she stayed close to his/her room to monitor the resident as much as possible due to his/her falls. Fall interventions for the resident and when he/she became restless were for staff to ask him/her if he/she was in pain, offer to toilet him/her, ask him/her what made them move around, and/or take him/her on a walk. Direct care staff P revealed he/she tried to stay in the resident's area, but helped other residents during the day. The resident had no memory anymore and was hard of hearing requiring staff to talk louder to him/her. Direct care staff P reported the resident had a standing/motion alarm. He/she would not tell staff when he/she needed to void, went him/herself, and refused cares at times. On 5/12/15 at 1:53 P.M. an interview with direct care staff revealed when the resident's bed alarm sounded, he/she responded as quickly as he/she could. Fall interventions for the resident were to walk him/her, toilet him/her, check the battery of the resident's alarm if it did not sound when he/she put the resident to bed. On 5/12/2015 at 2:42 P.M. an interview with licensed nursing staff H revealed the resident slept on one day and on another day he/she was alert. He/she would not always use his/her call light and ambulated by him/herself. He/she was difficult at times, refusing cares or help. The fall care plan interventions were for the bed to be at wheel chair height, a sensor alarm related to his/her removing a chair alarm, and frequently checking him/her at least every hour and as necessary. On 5/12/2015 at 1:39 P.M. interview with administrative staff D revealed he/she did not have fall investigations for the resident. He/she reported that the interdisciplinary team (IDT) and he/she met weekly and reviewed the resident's recent falls and discussed interventions to put in place to prevent his/her further falls. He/she stated he/she did not have documentation of the weekly IDT analysis and interventions of the resident's falls. On 5/13/15 at 12:40 P.M. interview with consultant staff KK revealed he/she was at the facility every Friday and he/she saw the resident with problems. He/she discussed fall interventions with nursing staff and the administrative team concerning the resident. He/she would not ask for help. He/she did not know what to do about the resident's falls without applying restraints. The facility tried everything from a mat on the floor, a personal alarm, changing his/her bed placement, to the facility's last attempt of a motion sensor, and he/she said a one-on-one sitter was not affordable. The resident was always independent and that created the problem along with his/her dementia. The facility's resident fall and injury prevention and monitoring plan revised on June 2006 documented staff updated the care plans for accidents or incidents if necessary and communicated them to staff, implementing measures to prevent accidents and falls. The facility failed to assess for causal factors to develop effective interventions to prevent further falls for this cognitively impaired resident who had a history of [REDACTED].

The facility had a census of 40 residents. The sample included 16 residents. Based upon observation, record review and interviews the facility failed to provide timely effective interventions to prevent falls for 1 (#58) resident and failed to monitor the wanderguard system for 2 residents (#42, #40) at risk for elopement. Findings included: - Resident #58 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) 3.0 dated 9/17/13 identified the resident had moderately impaired cognition, had short term memory problems, required extensive assistance of two plus persons for assistance with bed mobility, transfers, and toilet use, did not walk in the room/corridor, required extensive assistance with one person physical assistance with locomotion on unit, was totally dependent upon staff for locomotion off the unit, used a walker, and wheelchair, was not steady and only able to stabilize with human assistance with moving on/off the toilet, surface to surface transfers, and the activity of walking or turning around did not occur, and had no falls prior to admission or since admission. The resident's Fall Risk assessment dated [DATE] identified the resident scored 26. According to the legend a score over 9 indicated the resident was at risk for falls. A nurse's note dated 9/11/13 and timed 8:45 A.M. documented the resident fell last evening (day of admission). Interventions included bed bolsters, a personal alarm, and call light in place. The care plan included the interventions to ensure the call light and frequently used items were within reach. A physician's orders [REDACTED]. A nurse's note dated 9/14/13 (time unknown) documented the resident had poor safety judgment, and attempted to climb out of bed. Staff placed a curved mattress on the resident's bed and the resident had a low bed and roll mats. A nurses' note dated 9/15/13 and timed 4:47 P.M. documented a staff member heard the resident calling for help and upon arrival to the room found the resident on his/her right side on the floor on the side of bed closest to his/her closet. Staff assisted the resident off the floor and into his/her wheelchair, the resident stated he/she wanted to go to the restroom, and staff assisted him/her to the toilet. Staff explained to the (cognitively impaired) resident to use the call light, the resident appeared to understand but attempted to get up to go to the toilet on his/her own this afternoon without calling for staff assistance. The resident's personal alarm was in place. According to the resident's care plan the facility continued the same interventions. A nurse's note dated 9/19/13 and timed 4:56 P.M. documented the resident's family was interested in getting a private duty caregiver. Staff discussed private duty agencies with the family and provided information about a few agencies. The resident's Incident Details report for the 9/19/13 fall at 11:15 P.M. documented the staff heard the resident yelling and as staff entered the room they found the resident on the floor by the window. The resident's personal alarm was removed from his/her shirt and hung intact on the resident's bed. The resident stated he/she fell but did not know why or remember how. Staff observed 2 linear abrasions on his/her right chin with a very small amount of blood, and staff cleaned the area and left it open to air. Corrective measures included the facility would apply bed bolsters. A nurse's note dated 9/20/13 and timed 8:50 A.M. documented the resident attempted to climb out of his/her bed. A nurse's note dated 9/29/13 and timed 4:32 P.M. documented staff heard the resident calling for help, staff found the resident on the floor by his/her bedside lying on his/her right hand, and the resident stated he/she attempted to get up. According to the resident's care plan the resident did not use his/her call light, staff anticipated the resident's needs and the facility continued the interventions. An Incident Detail dated 10/9/13 revealed the resident received 2 skin tears to his/her right upper extremity. The personal caregiver (not employed by the facility) noted the skin tears after toileting the resident and placing him/her back to bed. Staff would monitor the resident's arms with each transfer. A nurse's note dated 10/23/13 and timed 4:24 P.M. documented the resident's personal caregiver called for assistance and reported the resident attempted to go from a sitting to standing position, the resident started sliding down, and he/she lowered the resident to the floor next to the resident's low bed. The resident's left leg was straight forward, and the resident's right leg was slightly bent. The resident's Incident Detail report dated 10/23/13 and care plan revealed documented staff instructed the resident's personal caregiver to call for assistance by turning on the resident's call light prior to moving the resident into a sitting position on the edge of his/her bed and the resident had poor sitting balance. A nurse's note dated 11/15/13 and timed 9:13 A.M. documented the resident fell in his/her bathroom, hit his/her right forehead, the bleeding would not stop and the facility transferred the resident to the hospital. Interventions included not to leave the resident unattended when in the bathroom. A physician's progress note dated 11/15/13 (time unknown) documented the physician saw the resident for a fall with a head injury. The resident was apparently in the bathroom, tried to wipe himself/herself, lost his/her balance, fell forward and suffered a laceration (deep cut or tear in the skin) on his/her right temporal-occipital area (area of the head). The laceration on the resident's right temporal area was not very deep but unfortunately he/she thought there was an arterial damage that caused the pulsation of the blood. Steri-Strips (adhesive strips used to close small wounds) were placed on the area to try to stop the bleeding but without any success, and the resident was transferred to the hospital for possible stitches or staples. A nurse's note dated 11/16/13 and timed 9:48 P.M. documented staff changed the dressing on the resident's forehead and the stitches on the resident's forehead remained intact. On 1/15/14 at 8:35 A.M. personal caregiver MM and OO assisted the resident with oral care. At that time personal caregiver MM stated the personal caregivers provided direct care which included dressing and transfers. Personal caregiver MM stated the resident required assistance of 2 with transfers. On 1/15/14 at 1:20 P.M. personal caregiver MM and direct care staff Q transferred the resident from the wheelchair to his/her bed using a gait belt. Observation revealed the personal caregiver nor direct care staff Q placed the personal alarm on the resident after the resident was in bed. On 1/15/14 at 2:50 P.M. the resident laid in bed without a personal alarm. Observation revealed a winged mattress and side rails in place. On 1/15/14 at 9:50 P.M. private caregiver MM stated on the day the resident fell in the bathroom, he/she was coming on duty, he/she and the off going personal caregiver transferred the resident to the toilet. He/she exited the resident's room, the other personal caregiver left the resident unattended in the bathroom and the resident fell . He/she stated the facility had a care plan book to identify the resident ' s needs but the facility never showed him/her where the book was. On 1/15/14 at approximately 3:59 P.M. direct care staff R stated the resident was at risk for falls. Direct care staff R stated after the resident was admitted to the facility the resident attempted to get out of bed without staff assistance, the facility spoke with the resident's family and the family hired personal caregivers. Direct care staff R stated the facility's staff assisted the personal caregivers with transfers. Direct care staff R stated staff should not leave the resident unattended on the toilet. Direct care staff R stated personal caregivers left the resident unattended in the bathroom and the resident fell . Direct care staff R stated 2 staff employed by the facility and 1 personal caregiver transferred the resident via a stand up lift. Direct care staff R stated the facility communicated resident's care via the care plan. On 1/15/14 at approximately 4:10 P.M. licensed nurse J stated the resident could not transfer independently. Licensed nurse J stated the resident had personal caregivers 24 hours per day to ensure the resident did not fall. The personal caregivers and facility staff assisted the resident with transfers. The resident had a wing mattress on his/her bed, and wore the personal alarm when in the wheelchair. The care guide was the communication tool that informed staff of the resident's care. On 1/16/14 at 12:27 P.M. administrative nursing staff D stated the resident's first interventions included a personal alarm and bolsters. Administrative nursing staff D stated the bolsters were later replaced with the wing mattress. Administrative nursing staff D stated the resident's personal caregiver sat the resident on the edge of the bed, the resident slid off of the bed, and staff instructed the personal caregivers to call for staff assistance prior to sitting the resident on the side of the bed. Administrative nursing staff D stated when the fall occurred on 11/15/13, 2 personal caregivers had transferred the resident to the toilet. One of the personal caregivers left the room to clock in and the other personal caregiver left the resident unattended on the toilet while he/she retrieved the resident's clothing and the resident fell . Administrative nursing staff D stated there should always be 1 facility staff present when the resident was transferred. The facility failed to provide effective interventions for this cognitively impaired resident with a history of falls who fell and required sutures. The facility failed to ensure the resident wore the personal alarm when in bed as physician ordered and planned. - The significant change Minimum Data Set 3.0 ((MDS) dated [DATE] for resident #40 revealed a Brief Interview for Mental Status score of 7, indicating moderate cognitive impairment. The resident required extensive assistance from 1 staff member for bed mobility, dressing, and bathing. He/she had 1 non-injury fall since the prior assessment. The 10/25/13 Care Area Assessment (CAA) for falls revealed the resident received medications that had potential to effect his/her stability. The resident was considered a fall risk with a [DIAGNOSES REDACTED]. Staff reminded and cued the resident for his/her daily routine. The 10/25/13 CAA for Activities of Daily Living (ADLs) revealed the resident had experienced a significant change and he/she required increased staff assistance with dressing, toileting, and personal hygiene. The 8/5/13 care plan regarding elopement with a revision date of 10/24/13 revealed the resident wore a wanderguard secondary to his/her dementia, attempted to leave the unit, and was unable to recall he/she was in a room on the healthcare unit. Staff assisted him/her to his/her room for toileting. The resident's wanderguard was checked per the facility protocol. The elopement risk assessment dated [DATE] revealed the resident had the potential to learn the door code but was not at risk to wander or elope from the facility. The elopement risk assessment dated [DATE] revealed the resident was not at risk to wander or elope from the facility. The elopement risk assessment dated [DATE] revealed the resident was not at risk to wander or elope from the facility. The nurse's note dated 7/29/13 at 10:08 P.M. revealed the resident had been in his/her family member's room for most of the evening and at approximately 9:30 P.M. staff noted him/her was missing from the unit. The resident was found on another floor of the building wandering in his/her wheelchair. The resident told staff he/she had been looking for his/her room. No injuries were noted. A wanderguard was placed on the resident's wrist. The nurse's note dated 8/8/13 at 3:17 P.M. revealed the resident wandered at times and wore a wanderguard at all times. Observation on 1/16/14 at 9:10 A.M. all wanderguard monitored exits were checked with maintenance staff X and found to be operational. Interview on 1/15/13 at 1:33 P.M. with direct care staff O revealed wanderguards were checked by the nurses everyday. Interview on 1/15/14 at 1:14 P.M. with licensed nursing staff H revealed the resident had a wanderguard. It was every staff's responsibility to make sure the alarms or wanderguards were working. If they were found to not be functioning he/she would replace the battery or the whole appliance with one that functioned. Interview on 1/15/14 at 2:20 P.M. with administrative nursing staff D revealed night nurses checked the wandergard bands nightly and maintenance checked the devices at the exits weekly. Interview on 1/16/14 at 11:00 A.M. with administrative nursing staff D revealed the old wandergard system was checked with a piece of equipment staff carried from person to person and lit up indicating the wristband was functioning or not functioning. The checks were done nightly. Sometime before Christmas the system was replaced. At the present time the nurses checked the wristbands were in place every shift but did not check their function. The equipment to check the function was not received from the manufacturer to date. The placement checks were charted on the treatment administration record (TAR). The facility failed to provide a policy regarding wanderguard checks. The facility failed to monitor the functioning of the wanderguard for this moderately cognitively impaired resident with a personal history of elopement from the healthcare floor. - The signed physician's orders [REDACTED]. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/4/13 revealed a Brief Interview For Mental Status (BIMS) score of 3, indicating severe impairment. The resident required supervision of 1 for bed mobility, transfers, toilet use, personal hygiene, and walking, limited assistance of 1 person for dressing, and supervision and set up for eating, and required 1 person physical assistance for bathing, was steady at all times when walking, was not steady but able to stabilize without human assistance when moving from a seated to a standing position, turning around and facing the opposite direction while walking, moving on and off the toilet, and during surface to surface transfers, the resident had no upper or lower extremity impairment, and used a walker. An Activities of Daily Living (ADL) Maintenance Care Plan dated 9/10/13 and last updated on 12/16/13, revealed the resident required assistance with ADL's due to dementia and recent hip fracture and ambulated independently with a walker. A care plan on elopement dated 10/28/13 revealed the resident was an elopement risk due to dementia. He/she frequently asked to leave the unit to go south and look for his/her car. He/she could easily be redirected, enjoyed sports programs on television, and participated in activities. Staff would walk with the resident on a daily basis, took him/her outside if weather permitted, and followed policies and procedures for the wanderguard. Nurses notes dated 5/1/13 at 6:09 P.M. the resident had not returned to the unit by 5:45 P.M. from a daycare program he/she attended. The nurse called the operator to ask if the resident had returned to the facility, and the operator stated he/she had arrived. The nurse sent security and an aide to check around the facility for the resident. The resident was found wandering by the elevator. Staff assisted the resident back upstairs. A wandergard (a bracelet that locks down a door when a resident that was at risk for elopement approaches) was placed on the resident and staff took the resident to the dining room to eat dinner. Social Service note on 5/14/13 at 3:47 P.M. revealed the resident was admitted from a facility apartment to the health care center. The resident had 24 hour caregivers as he/she was found walking in the early morning hours outside. He/she had a poor memory and wandered around the community. Nurses Notes dated 6/13/13 at 8:57 A.M. revealed the resident was up several times during the night. He/she would dressed and wandered the hallways. He/she was easily redirected back to room. Nurses Notes dated 6/24/13 at 5:48 P.M. revealed the resident returned from daycare and a wandergard was placed on the resident, a few minutes later staff observed the resident pulled it off. A new wandergard was placed and staff explained to the resident to keep it on for safety purposes. Nurses Notes dated 7/19/13 at 10:05 A.M. revealed the resident did not wear a wandergard on. Staff assisted the resident downstairs to go to daycare. Staff later found the bracelet in the trash in the resident's room. Nurses Notes dated 8/4/13 at 12:41 P.M. revealed the resident followed a visitor to the gold elevator down to the first floor to the courtyard sidewalk. The receptionist assisted the resident back in the building after alerted by the visitor. The resident had a wanderguard on but it did not activate when the resident got in the elevator. The battery was active when staff checked it with the battery tester. The resident was carrying his/her electric razor and told the receptionist he/she was going to a store to have it fixed. The event occurred at 11:00 A.M. The wanderguard was replaced and checked. Nurses Note dated 8/5/13 at 8:13 P.M. after resident returned from daycare he/she was restless and attempted to leave the unit several times. Staff placed the wandergard upon his/her return and it sounded a few times. An elopement risk assessment completed on 12/1/13 showed the resident attempted to leave by non-traditional exits, had a combative behavior, was resistant to redirection away from exits, wandered aimlessly, had a history of [REDACTED]. Record review on 1/16/13 at 12:59 P.M. revealed wanderguard checks on the Treatment Administration Record for August, November, and December, 2013, and January, 2014, but lacked documentation for September 2013 and October 1-27, 2013. Observation on 1/16/14 at 8:50 A.M. the resident sat at the breakfast table and wore a wandergard bracelet. Interview on 1/15/13 at 1:33 P.M. with direct care staff O stated everyone checked functioning of alarms. There was no specific schedule, we check them all the time. Wandergards were checked by the nurses everyday. Interview on 1/15/14 at 1:50 P.M. with licensed staff H revealed all staff made sure the alarms were working every time they were hooked up. If one was not functioning I would replace the battery or the whole appliance with one that did function properly. Interview on 1/15/14 at 2:20 P.M. with administrative nursing staff D revealed night nurses checked wandergard bands nightly and maintenance checks the devices at the exits weekly. Interview on 1/16/14 at 11:00 A.M. with administrative nursing staff D revealed the old wandergard system was checked with a piece of equipment staff carried from person to person and lit up indicating the wristband was functioning or not functioning. The checks were done nightly. Sometime before Christmas the system was replaced. At the present time the nurses checked the wristbands were in place every shift but did not check their function. The equipment to check the function was not received from the manufacturer to date. The placement checks were charted on the treatment administration record (TAR). A policy for wandergard checks was requested from the facility but was not received. The facility failed to monitor the functioning of the wandergard for this cognitively impaired, independently mobile resident with a history of elopement.

The facility reported a census of 35 residents. The sample included 5 residents. Based on observation, record review, and interview, the facility failed to provide supervision (regarding transfers) to prevent accident with injury for one sampled resident (#1). Findings included: - Resident # 1's Physician order [REDACTED]. The quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE], documented the resident's Basic Interview for Mental Status of 12, indicating intact memory and good cognitive ability. The MDS recorded the resident required extensive to total assistance of two staff members with bed mobility transfers, and most activities of daily living (ADls). This same assessment documented the resident's bowel and bladder incontinence, impairment on one side upper extremities, and use of a wheelchair. The MDS further recorded the resident is not steady with transfer's from surface to surface and cannot stabilize without human assistance. Review of a facility investigation that included a radiology report dated 11/29/10 revealed; resident #1 incurred a fall from bed resulting in a fracture of the distal femur that required surgical repair. Review of the resident ' s care plan dated 4/15/11 revealed an intervention dated 4/6/11 directing staff to use two persons for all transfers. On 5/2/11 at 3:30 P.M. licensed nursing staff A presented an ADL quide sheet (used by the nursing assistants) which also documented resident #1 required 2 person assist with transfers. Also, at this time, direct care staff C stated care staff receive report during shift change regarding resident mobility and transfer status. Continued review of another facility reported investigation dated 4/13/11, documented the resident ' s returned from a scheduled orthopedic appointment on 4/14/11 with a hard cast covering the foot and ankle extending to just below the knee. The investigation further documented contact with the physician who confirmed a new fracture in close proximity to the old one. On 5/2/11 at 10:00 observation, during resident transfer, revealed the resident ' s left leg immobilized with a brace, elevated on a pillow and wheelchair leg lift and a hard cast from just below the left knee including the foot/ankle with only the toes visible. Two staff members assisted with the transfer. Direct care staff A stated "{resident} is always a two person transfer, " as long as I ' ve been working here." On 5/3/11 at 4:00 P.M., (regarding the recently fitted left leg cast), the resident explained: "When {staffer/name} got me up from bed; my left foot was turned backward. It hurt at the time, but then when I sat down it was ok-and then it didn't hurt again until I laid down that night and they put it on the pillow." The resident stated this incident happened approximately 2 weeks ago. Resident #1 continued that, "men (male staff) usually get me up by themselves- it's the women who need help." Continued review of the facility reported investigation dated 4/14/11 confirmed, a male direct care staffer transferred the resident without aide of a second staff member. The resident ' s statement confirmed his/her left foot/toe "caught" and caused pain." The facility lacked a specific policy regarding resident transfers. However, on 5/2/11 at 3:00 P.M. administrative staff B acknowledged that two person transfers applies to both male and female nursing assistants, and that in this instance at least one staff member was not following facility policy. On 5/3/11 at 11:40 A.M. administrative staff A, outlined corrective action(s) taken by the facility to decrease possible recurrence including staff education, review of policies and staff communication. The facility failed to follow the resident ' s care plan regarding transfers, resulting in a fractured leg for this dependent resident.