Every finding on record at Commons at Orlando Lutheran Towers

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by not identifying an escalation in exit seeking behaviors; not implementing additional actions/interventions to prevent elopement; and not responding appropriately to an emergency exit door alarm to prevent elopement for 1 of 8 residents reviewed for elopement, of a total sample of 8 residents, (#1). These failures contributed to the elopement of resident #1 and placed her at risk of serious injury, impairment, or death. While outside the facility unsupervised, resident #1 fell and sustained a head injury and facial abrasion, leading to hospitalization. There was reasonable likelihood she could have become lost, harmed by strangers or hit by a motor vehicle. On 5/19/26 at approximately 7:30 PM, the facility failed to provide the necessary care and services to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. The facility was unaware of resident #1's whereabouts for approximately two hours, until 9:36 PM, when staff learned resident #1 had been transported to the hospital emergency department. Review of facility information identified seven residents at risk for elopement on the first day of survey. The facility's failure to provide needed care and services contributed to resident #1's elopement and threatened all residents at risk of elopement. These failures resulted in Immediate Jeopardy which started on 5/19/26 and was removed on 5/22/26 after verification of the facility's immediate actions. The scope and severity was decreased to a D, (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy). Substandard Quality of Care was identified at F600 and F689. A partial extended survey was conducted on 6/03/26.Findings: Cross reference F689. Review of the medical record revealed resident #1, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included vascular dementia, hemiplegia and hemiparesis, aphasia (difficulty communicating), cardiac arrest, congestive heart failure and atypical atrial flutter. Review of a Progress Note written by the Director of Nursing (DON) on 5/19/26 revealed she received a call at 8:26 PM that evening, informing her resident #1 was missing and an active search had begun throughout all areas of the facility including outside the facility grounds. The noted indicated the search continued both inside and outside the facility and local law enforcement were notified of the missing resident at 8:41 PM. The DON documented the search was expanded to nearby streets in the downtown area where the facility was located. The documentation by the DON noted staff were directed to inquire at local hospitals in hopes to find resident #1. The Progress Note detailed at 9:36 PM the DON was notified by the Admissions Director that the resident was being treated at the Emergency Department of the local downtown hospital. On 6/03/26 at approximately 10:05 AM and continuing through 10:48 AM, video footage from the evening of 5/19/26 was reviewed. In the beginning of the video resident #1 was viewed as she descended the staircase from the second floor. She was seen as she reached the bottom of the staircase, attempted to open the locked door into the first floor unit several times, then she turned towards the exit door, and as she walked out of view of the camera an exterior light was seen as the door opened, and the resident exited the facility. Approximately five minutes after resident #1 was seen leaving the facility on camera, the video footage showed facility security personnel turning off the alarm on the exit door. There was nothing on the video to indicate the security personnel looked outside or around to see if there was any residents who may have opened the door and left the facility. Review of the Minimum Data Set (MDS) 5-Day Medicare assessment with assessment reference date of 5/18/26 revealed resident #1 had short-term and long-term memory problems and severely impaired cognitive skills for daily decision-making. The assessment indicated resident #1 was not evaluated for her ability to go up and down one step, which was not attempted due to her medical conditions and/or safety concerns. On 6/02/26 at 10:29 AM, the Registered Occupational Therapist G clarified that resident #1 was able to walk approximately 125 feet but required hand-held assistance due to poor safety awareness. The electronic medical record (EMR) contained an elopement risk evaluation dated 5/12/26 which indicated resident #1 was at risk for elopement. Review of resident #1's care plan revealed a care plan initiated 5/12/26 which indicated resident #1 was identified as at risk for wandering/elopement and an electronic wander-alert bracelet had been applied on 5/18/26. The care plan contained an intervention to engage in purposeful activities but did not contain any interventions for redirection, increased supervision, or what to do if these behaviors occurred. Review of resident #1's physician orders revealed an order dated 5/12/26 for a psychiatry consultation due to anxiety/restlessness and an order dated 5/18/26 for an electronic wander-alert bracelet to be applied as a safety precaution, as resident had displayed and/or voiced exit-seeking behavior. The EMR contained a progress note entered by the Assistant Director of Nursing (ADON) dated 5/18/26 which indicated resident #1 became very restless after dinner, paced the unit, stated she needed to go home and pushed on exit doors. The note indicated an electronic wander-alert bracelet was in place. A progress note written by the ADON on 5/19/26 revealed resident #1 was agitated, pacing the unit, pushing doors and telling staff to leave her alone. On 6/02/26 at 3:44 PM, Certified Nursing Assistant (CNA) E verified she was working on the unit the evening of 5/19/26. She stated she saw resident #1 in the dining room between 5:30 PM - 6:00 PM. CNA E explained the resident did wander throughout the unit and would go to the emergency exit doors. On 6/02/26 at 3:19 PM, CNA D stated she was on duty the night of the incident but could not recall what assignment she had. She stated she was certain she was not assigned to resident #1. CNA D recalled she heard the emergency exit alarm around 5:30 PM and saw resident #1 approach the emergency exit door again around 6:45 PM. She explained she redirected resident #1 to the dayroom and then returned to work. In a phone interview on 6/01/26 at 2:21 PM, CNA A stated she was assigned to resident #1 on 5/19/26. She recalled the resident was very agitated that evening and was walking constantly throughout the unit. CNA A explained she passed resident #1 several times in the hallway that night with the last occurrence being around 7:25 PM as she was going to provide care to another resident. She stated that resident #1 walked very fast. CNA A clarified she did not know resident #1 was missing until she was notified by Licensed Practical Nurse (LPN) B around 8:00 PM. In a phone interview on 6/02/26 at 12:14 PM, LPN B verified she was assigned to resident #1 at the time of the elopement. She explained her regular shift was 11:00 PM -7:00 AM but she came in early to cover half a shift. LPN B stated she arrived on the unit around 7:00 PM. She recalled observing resident #1 walking down the hallway toward the back of the unit. LPN B explained resident #1 exhibited exit-seeking behavior and would go to the exit doors, push on the release bar and walk away when the alarm sounded. She recalled redirecting resident #1 back to the dayroom at least twice prior to taking over the medication cart at approximately 7:15 PM and then she made her rounds. She stated she was not aware resident #1 was missing until 7:55 PM when she went to take resident #1 her medication. On 6/02/26 at 3:31 PM, Registered Nurse (RN) C confirmed she worked the evening of 5/19/26. She stated she was familiar with resident #1. She explained resident #1 walked constantly and was very active that day. RN C stated resident #1 went to the emergency exit door several times during the shift and set off the alarm multiple times. She recalled last seeing the resident around 7:30 PM in the dayroom. She reported she was not aware resident #1 was missing until LPN B alerted her around 8:00 PM. RN C was unable to explain why resident #1 was not placed on closer supervision or other intervention despite repeatedly going to the exit doors during the shift and setting off alarms after staff redirection. On 6/01/26 at 2:56 PM, the ADON reported she was covering as a floor nurse for half of the 3:00 PM - 11:00 PM shift on 5/19/26 until a relief nurse arrived. She stated resident #1 was active during the shift and was observed walking around the unit in the common areas, dining room and hallways. The ADON reported she turned the medication cart over to LPN B at approximately 7:15 PM and went to her office to complete other tasks. She recalled she left the building around 7:50 PM. The ADON reported she was not aware resident #1 was missing until RN C called her. She recalled she was driving home and turned around to go back to the facility. The ADON explained she called the DON immediately to inform her at 8:26 PM of the elopement. In a follow-up interview on 6/04/26 at 11:26 AM, the ADON stated resident #1 was supposed to be on 30-minute checks. She explained that meant a CNA would be assigned every 30 minutes to kind of follow the resident around. The ADON was unable to provide documentation or to state where documentation was located to show which CNAs were assigned or that the 30-minute checks were completed. On 6/01/26 at 11:25 AM, resident #1's daughter stated the facility did call her on the night her mother eloped. She explained her mother was admitted to the facility after a stroke to get therapy to get stronger. Resident #1's daughter stated she still was not sure how her mother got out of the facility. She recalled her mother had never exhibited this behavior previous to admission at the facility. Resident #1's daughter clarified the facility only told her that her mother was missing, but not where she was or other details of what happened. She stated the hospital chaplain was the person who called to inform her that her mother was in the emergency room. She recalled when she visited her mother that evening, her mother had a bump on her head and a mark on her face. She reported her mother was still hospitalized with medical issues involving her heart. In a joint meeting with the Administrator and DON on 6/02/26 at 3:57 PM, the Administrator stated the facility initiated an investigation and corrective measures immediately following the elopement on 5/19/26. The Administrator explained that the facility held an Ad-HOC Quality Assurance and Performance Improvement (QAPI) meeting on 5/20/26 to review the incident and the outcome of the facility's investigation. The Administrator reported that their investigation showed that resident #1 began exhibiting increased exit seeking behaviors by pacing the unit, pushing on doors and stating she wanted to leave on 5/18/26. She stated an order was obtained for a wander-alert bracelet which was applied to resident #1 on 5/18/26. The Administrator stated staff interviews and statements indicated resident #1 went to the emergency exit doors multiple times on the evening of 5/19/26 and set off the alarms several times, after which staff had to reset them. The Administrator stated the facility believed a staff member must have reset the alarm without checking the staircase or exit doors to see if a resident had gone through those doors; however, they were unable to determine which staff had reset the alarm without checking the staircase. The Administrator stated the facility identified that resident #1 should have been on 15- or 30-minute checks and that staff failed to respond appropriately to the emergency exit-door alarms. The Administrator acknowledged that staff failure to respond to an increase in exit seeking behaviors and alarms enabled resident #1 to exit through the emergency exit door, descend a flight of stairs and ultimately exit the facility unsupervised and without staff knowledge. Review of the policy and procedure for Abuse and Neglect dated March 2018 revealed neglect was defined as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The document listed examples of situations that might constitute or could be construed as neglect, including inappropriate management of problematic behavior. The facility's policy and procedure for Elopement dated October 2014 indicated each resident would receive adequate supervision and assistance to prevent elopement from the facility. Review of corrective measures implemented by the facility revealed the following, which were verified by the survey team at the time of the survey: *On 5/19/26 at approximately 7:30 PM, resident #1 left the facility through an exit door unsupervised and was admitted to the hospital at 8:06 PM via Emergency Medical Services. *On 5/19/26 at approximately 8:45 PM, the unit emergency exit door, alarm and keypad were checked by the Supervisor. *On 5/19/26 at approximately 9:00 PM, the DON conducted a full census headcount to ensure all other residents were accounted for. *On 5/19/26 at 9:02 PM, resident representative was notified of the elopement. *On 5/19/26 at approximately 10:00 PM, the Medical Director was notified of resident elopement and transfer to hospital. *On 5/20/26 at approximately 7:30 AM, the Maintenance Supervisor checked the unit emergency exit door alarm and keypad for function with no errors noted. Weekly audits for the function of emergency exit doors, alarms and keypads continued. *On 5/20/2026, the DON, ADON and MDS coordinator reviewed the elopement risk assessment for all residents to ensure accuracy. *On 5/20/2026, the MDS coordinator reevaluated residents with wander guards for elopement risk assessment and care plan for accuracy. *On 5/20/2026, the facility's policy and procedures for elopement and wandering residents were reviewed and with no changes. *On 5/20/26, the DON initiated a review of all new admissions for documentation related to exit seeking behaviors and elopement-risk evaluations. *On 5/20/26, the DON initiated audits for exit-seeking behaviors. *On 5/20/26, additional wander-alert bracelets were put on each unit for ease of access and radios were placed throughout the facility for communication between staff. *On 5/20/26, elopement drills were initiated for all staff on all three shifts. *On 5/20/2026, the Administrator and DON began monitoring for neglect on units relate to exit seeking behaviors during community rounds. *On 5/20/2026, the Interdisciplinary Team (IDT) began to verify accuracy of care plans for residents identified as at risk for wandering/elopement. *On 5/20/2026, an ad hoc Quality Assurance and Performance Improvement (QAPI) meeting was held which included the Administrator, DON, Medical Director and members of the IDT to discuss the event including wander/elopement alert system, the elopement procedure and emergency exit-door alarms. The committee reviewed the investigation up to that point and implemented immediate actions, including information provided to staff regarding the use of one-on-one supervision if resident behavior was escalating; enhanced supervision for residents with wander/elopement alert bracelets (every 15/30 minutes as needed); and decorative door decals added to emergency exit doors. *From 5/19/26 through 5/21/26, nursing leadership provided education to all staff regarding abuse and neglect, identification of exit seeking behaviors, safety of residents, protecting a resident from exiting the building through the emergency exit doors, and one-on-one supervision for residents with increased exit-seeking behavior.- 37/47 (78.2%) of licensed nurses received education by 5/21/26.- 59/79 (74.6%) of CNAs received education by 5/21/26. - 11/13 (85%) of the therapy department received education by 5/21/26.- 4/4 (100%) of social workers received education by 5/21/26.- 7/7 (100%) of activities staff received education by 5/21/26.- 10/14 (71%) of dietary staff received education by 5/21/26.- 2/2 (100%) of maintenance staff received education by 5/21/26. *By 5/26/26, education was provided to 90% of staff. Any staff who had not received education were not allowed to work until they received the training prior to their work shift.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to ensure vulnerable residents did not exit the facility without supervision for 1 of 8 residents reviewed for elopement, of a total sample of 8 residents, (#1). This failure contributed to the elopement of resident #1 and placed her at risk of serious injury, impairment, or death. While outside the facility unsupervised, resident #1 fell and sustained a head injury and facial abrasion. There was reasonable likelihood she could have become lost, been accosted/harmed by strangers or been hit by a motor vehicle while outside the facility unsupervised. On 5/19/26 at approximately 7:30 PM, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. The facility was unaware of resident #1's whereabouts until 9:36 PM, when staff learned that resident #1 had been transported to the hospital emergency room. The facility failed to ensure resident #1 was adequately supervised to ensure vulnerable residents did not exit the facility without staff knowledge. Information provided by the facility identified seven residents at risk for elopement on the first day of survey. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy (IJ) beginning on 5/19/26 and removed on 5/22/26 after verification of immediate actions. The scope and severity of the deficiency decreased to a D, (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy). Substandard Quality of Care was identified at F600 and F689. A partial extended survey was conducted on 6/03/26.Findings: Cross reference F600. Review of the medical record revealed resident #1, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included vascular dementia, hemiplegia and hemiparesis, aphasia (trouble communicating), cardiac arrest, congestive heart failure and atypical atrial flutter. Review of the Minimum Data Set (MDS) 5-Day Medicare assessment with assessment reference date of 5/18/26 revealed resident #1 had short-term and long-term memory problems and severely impaired cognitive skills for daily decision-making skills. The assessment indicated resident #1 was not evaluated for her ability to go up and down one step, which was not attempted due to her medical conditions and/or safety concerns. On 6/02/26 at 10:29 AM, Registered Occupational Therapist G clarified that resident #1 was able to walk approximately 125 feet but required hand-held assistance due to her poor safety awareness. The electronic medical record (EMR) contained an elopement risk evaluation assessment dated [DATE] which indicated resident #1 was at risk for elopement. Review of resident #1's care plan revealed a care plan initiated 5/12/26 which indicated resident #1 was identified as at risk for wandering/elopement. The care plan focus indicated an electronic wander-alert bracelet was applied on 5/18/26. Resident #1 also had a care plan initiated 5/12/26 which indicated she was at risk for falls related to her recent hospitalization with declines in strength, balance and activity tolerance. Review of resident #1's physician orders revealed an order dated 5/18/26 for an electronic wander-alert bracelet to be applied as a safety precaution as resident had displayed and/or voiced exit-seeking behavior. The record also contained an order for Apixaban 5 milligrams given twice a day to prevent blood clots. Apixaban is an anticoagulant. It works by decreasing the clotting ability of the blood and helps prevent harmful clots from forming in the blood vessels. A person may bleed and bruise more easily while using this medicine. People who take Apixaban are cautioned to be extra careful to avoid injuries and to stay away from situations where a person could be bruised, cut, or injured, (retrieved from www.mayclinic.org on 6/10/26). The EMR contained a progress note entered by the Assistant Director of Nursing (ADON) dated 5/18/26 which indicated resident #1 became very restless after dinner, paced the unit, stated she needed to go home and pushed on exit doors. The note indicated an electronic wander-alert bracelet was in place. On 6/02/26 at 3:26 PM, Certified Nursing Assistant (CNA) F confirmed she was on duty at the time resident #1 eloped from the facility but was not on her assignment. She recalled she may have seen resident #1 around dinner time between 5:30 PM - 6:00 PM but was in another resident's room providing care when she was told resident #1 was missing. On 6/02/26 at 3:44 PM, CNA E verified she worked on the unit the evening of 5/19/26. She stated she saw resident #1 in the dining room between 5:30 PM - 6:00 PM. CNA E explained the resident wandered throughout the unit and would go to the emergency exit doors. She stated she was providing care to another resident when she was informed resident #1 could not be located. On 6/02/26 at 3:19 PM, CNA D stated she was on duty the night of the incident but could not recall what assignment she had. She stated she was certain she was not assigned to resident #1. CNA D recalled she heard the emergency exit alarm around 5:30 PM. She stated she observed resident #1 approach the emergency exit door again around 6:45 PM. She explained she redirected resident #1 to the dayroom and then returned to work. CNA D reported she was in the bathroom with another resident when she was notified resident #1 could not be located. In a phone interview on 6/01/26 at 2:21 PM, CNA A stated she was assigned to resident #1 on 5/19/26. She explained the resident was very agitated that evening and was walking constantly throughout the unit. CNA A recalled she passed the resident several times in the hallway with the last occurrence being around 7:25 PM. She stated she went to provide care to another resident at approximately 7:45 PM. CNA A explained that later when she exited the room, Licensed Practical Nurse (LPN) B asked her about resident #1 and informed her the resident could not be located. In a phone interview on 6/02/26 at 12:14 PM, LPN B verified she was assigned to resident #1 at the time of the elopement. She explained that her regular shift was 11:00 PM -7:00 AM but she came in early to cover half a shift. LPN B stated she arrived on the unit around 7:00 PM. She recalled she observed resident #1 walking down the hallway toward the back of the unit. LPN B explained resident #1 exhibited exit-seeking behavior and would go to the exit doors, push on the release bar and walk away when the alarm sounded. She recalled she redirected resident #1 back to the dayroom at least twice prior to taking over the medication cart at approximately 7:15 PM. LPN B stated she then made her rounds and was informed by the Assistant Director of Nursing (ADON) of a new medication for resident #1. She stated the medication was not in the cart, so she pulled it from the automated medication dispenser at 7:55 PM. LPN B recalled she looked around the unit and could not locate resident #1 to administer the medication. She stated she alerted other staff and a search was initiated but they were unable to locate resident #1. On 6/02/26 at 3:31 PM, Registered Nurse (RN) C confirmed she worked the evening of 5/19/26. She stated she was familiar with resident #1. She explained resident #1 walked constantly and was very active that day. RN C stated resident #1 went to the emergency exit door several times during the shift and set off the alarm multiple times. She recalled last seeing the resident around 7:30 PM in the dayroom. She reported she was later informed that resident #1 was missing. RN C stated she called the ADON, who had already left the building, to report the incident and then paged the code for a missing resident on the overhead system. She was unable to state why resident #1 was not placed on increased supervision or other intervention due to her increased exit seeking activity on that shift. On 6/01/26 at 2:56 PM, the ADON reported she was covering as a floor nurse for half of the 3:00 PM - 11:00 PM shift on 5/19/26 until a relief nurse arrived. She stated resident #1 was active during the shift and was observed walking around the unit in the common areas, dining room and hallways. The ADON reported she turned the medication cart over to LPN B at approximately 7:15 PM and went to her office to complete other tasks. She recalled she left the building around 8:00 PM. The ADON reported RN C called her while she was driving and informed her the facility was unable to locate resident #1. She stated she instructed the nurse to page the overhead code for a missing resident and immediately called the Director of Nursing (DON) to inform her of the incident. The ADON reported she turned around and headed back to the facility to help with the search. In a follow-up interview on 6/04/26 at 11:26 AM, the ADON stated resident #1 had been placed on 30-minute checks. She explained that meant a CNA was assigned to kind of follow the resident around, every 30 minutes. The ADON was unable to provide any documentation of the 30-minute checks, including which CNAs were assigned or that the 30-minute checks were completed. On 6/01/26 at 11:25 AM, resident #1's daughter stated the facility did call her on the night her mom eloped. She explained her mother was admitted to the facility after a stroke to get therapy to get stronger. Resident #1's daughter stated she still was not sure how her mother got out of the facility. She recalled her mother had never exhibited this behavior previously. Resident #1's daughter clarified the facility only told her that her mother was missing, and the hospital chaplain was actually who called to inform her that her mother was in the emergency room. She recalled when she visited her mother that evening, her mother had a bump on her head and a mark on her face. She reported that her mother was still in the hospital with medical issues involving her heart. In a meeting with the Administrator and DON on 6/02/26 at 3:57 PM, the Administrator stated the facility initiated an investigation and corrective measures immediately following the elopement on 5/19/26. The Administrator explained the facility held an ad-hoc Quality Assurance and Performance Improvement (QAPI) meeting on 5/20/26 to review the incident and the outcome of the facility's investigation. The Administrator reported their investigation showed that resident #1 exited the facility through the second-floor stairwell from the emergency exit door on the nursing unit and continued down the staircase to the first floor where she exited the facility. The Administrator explained she viewed the video from the stairwell and resident #1 could be seen descending the stairs and exiting the facility. She stated a security officer from the independent living building next door could be seen on video, approximately five minutes later, checking and resetting the door; however, no facility staff could be seen on camera checking the staircase after the alarm. The Administrator stated they were able to determine from staff interviews and statements that alarms had gone off several times that night and staff had to reset them. She clarified the emergency exit-door alarm would continue to sound unless the door was closed and a code was entered to reset the alarm. The Administrator stated the facility believed a staff member reset the alarm without checking the staircase or exit doors to see if a resident had exited through those doors. She explained the facility was unable to determine which staff had reset the alarm without checking the staircase. The Administrator acknowledged staff failure to respond to an alarm appropriately allowed resident #1 to exit through the emergency exit door, descend a flight of stairs and ultimately exit the facility unsupervised and without staff knowledge. On 6/04/26 at 1:07 PM, the Director of Resident Services stated there was an issue with the security cameras back in December 2025. He explained when the new system was initially set up in February 2026, the timestamp was incorrectly entered and was off by three hours which would account for the time difference between the time stamp on the video and actual time resident #1 exited the facility. With this revised information, the survey team reviewed the videos from the evening of 5/19/26 provided by the facility again and were able to see resident #1 as she descended the staircase from the second floor at 7:28 PM and continued to the landing on the first floor. She reached the bottom of the staircase at 7:29 PM and began pulling on the secured emergency exit door that led into the first-floor unit. Resident #1 was noted to pull on the door several times until she noticed a keypad next to the door. At 7:29 PM, she began randomly pushing buttons in an attempt to open the door and continued to pull on the door handle. At 7:30 PM, resident #1 gave up her attempt to enter the secured door, turned back toward the staircase and then turned toward the exit door to the outside of the building. Resident #1 went out of sight on the video as she reached the exit door. Exterior light could be seen on the video as the door opened at 7:30 PM and resident #1 exited facility. Review of the policy and procedure for Elopement dated October 2014 revealed an elopement referred to any incident involving a resident who left the facility suddenly, without telling anyone and/or without the knowledge or consent of the facility and without following the facility policies and procedures for signing out. The document indicated that each resident would be screened to identify residents at risk for elopement and interventions would be implemented that were consistent with the resident's needs, goals, plan of care and current standards of practice to reduce the risk of an elopement. The document clarified the facility would monitor the effectiveness of the interventions and modify them as necessary. On 6/02/26, resident #1's likely elopement route was retraced between her room and the seven level public parking garage where she was picked up by Emergency Medical Services (EMS) personnel, outside the facility. As she left her room, resident #1 would have turned left outside her door and walked approximately 20 feet until she came to another hallway and turned right. She then walked approximately 34 feet and turned left onto an adjacent hallway. She proceeded down that hallway approximately 131 feet to the emergency exit door at the end of the hallway. Resident #1 pushed on the door exit push bar which released and opened the door after 15 seconds. Resident #1 exited the unit through the emergency exit door without knowledge of the facility staff. Once outside the door, the resident would have been on a concrete landing with a staircase going up to the two upper floors and another staircase going down to the first floor and garage. Resident #1 descended 11 steps to another concrete landing, turned right and descended another staircase containing 11 steps until she reached the bottom landing. There were two doors at the bottom. One led to the first floor of the facility and the other door led to the outside which resident #1 was able to open and exit the facility. Once outside, the actual route the resident took is unknown. To arrive at the area where resident #1 was found she would have continued down the sidewalk, turned left and walked 29.5 feet to the intersection of 2 two-lane brick streets. As the sidewalk to the left was blocked for construction, resident #1 likely crossed the street and walked 45 feet to the other side and turned left on the sidewalk. She walked approximately 299 feet until she reached a sidewalk that led to the parking garage. She likely turned right and continued to walk 18.5 feet to the gate and into the garage. She walked approximately 106 feet into the garage headed toward the opposite exit. Per hospital paperwork, a bystander found resident on the ground, and she was was minimally responsive. The bystander called EMS via 911, who transported resident #1 to the hospital. Upon arrival, she was noted to have a cervical collar in place, a hematoma (a closed wound with blood inside) to her right forehead and an abrasion to the right cheek. Along the likely path, the resident would have encountered environmental dangers which included motor vehicles travelling in a busy downtown location, multiple concrete stairs and landings, uneven surfaces on the sidewalk, gravel and cobblestone roads. Historical weather data revealed on 5/19/26, the day of resident #1's elopement, the temperature at 7:53 PM was 81 degrees Fahrenheit with mostly cloudy skies, (retrieved on 5/29/26 from www.wunderground.com). Review of immediate corrective measures implemented by the facility revealed the following, which were verified by the survey team at the time of the survey: *On 5/19/26 at approximately 7:30 PM, resident #1 left the facility through an exit door unsupervised and was admitted to the hospital at 8:06 PM via EMS. *On 5/19/26 at approximately 8:45 PM, the unit emergency exit door, alarm and keypad were checked by the Supervisor. *On 5/19/26 at approximately 9:00 PM, the DON conducted a full census headcount to ensure all other residents were accounted for. *On 5/19/26 at 9:02 PM, the resident representative was notified of the elopement. *On 5/19/26 at approximately 10:00 PM, the Medical Director was notified of the resident's elopement and transfer to hospital. *On 5/20/26 at approximately 7:30 AM, the Maintenance Supervisor checked the unit emergency exit-door alarm and keypad for function with no errors noted. Weekly audits for function of emergency exit-doors, alarms and keypads continued. *On 5/20/2026, the DON, ADON and MDS coordinator reviewed the elopement-risk assessment for all residents to ensure accuracy. *On 5/20/2026, the MDS coordinator reevaluated residents with wander-alert bracelets for elopement-risk assessment and care plan for accuracy. *On 5/20/2026, the facility's policy and procedures for elopement and wandering residents were reviewed and with no changes. *On 5/20/26, the DON initiated a review of all new admissions for elopement-risk evaluations for accuracy to identify residents at risk for elopement and ensure the care plan reflects appropriate actions/interventions. *On 5/20/26, elopement drills were initiated for all staff on all three shifts. *On 5/20/2026, the Administrator and DON began monitoring for exit-seeking behaviors and elopement risk during community rounds and will continue to monitor. *On 5/20/2026, the Interdisciplinary Team (IDT) began to monitor 24-hour reports during morning stand-up for potential risk of exit-seeking behavior. *On 5/20/2026, an ad hoc QAPI meeting was held which included the Administrator, DON, Medical Director and members of the IDT to discuss the event including wander/elopement alert system, elopement procedure and emergency exit-door alarms. The committee reviewed the investigation to that point and implemented immediate actions to include information provided to staff regarding the use of one-on-one supervision if resident behavior was escalating; enhanced supervision for residents with wander/elopement alert bracelets (every 15/30 minutes as needed); and decorative door decals added to emergency exit doors. *From 5/19/26 through 5/21/26, nursing leadership provided education to all staff regarding supervision of residents, elopement policy, wandering/exit-seeking behavior, response to new or increased wandering/exit-seeking behavior to include 30- and 15-minute checks, providing one-on-one supervision if resident is going in and out of resident rooms and exit-seeking, response to door alarms, overhead paging for Code Alpha (missing resident) and security radios/radio checks.- 5/5 (100%) of nursing management staff received education by 5/20/26.- 37/47 (78.2%) of licensed nurses received education by 5/21/26.- 59/79 (74.6%) of CNAs received education by 5/21/26. - 11/13 (85%) of the therapy department received education by 5/21/26. - 4/4 (100%) of social workers received education by 5/21/26.- 7/7 (100%) of activities staff received education by 5/21/26.- 10/14 (71%) of dietary staff received education by 5/21/26.- 2/2 (100%) of maintenance staff received education by 5/21/26. *By 5/26/26, education was provided to 90% of staff. Any staff who had not received education were not allowed to work until they received the training prior to their work shift. Interviews were conducted on 6/03/26 and 6/04/26 with 21 staff members representing all shifts (6 Registered Nurses, 1 LPN, 6 CNAs, 1 maintenance staff, 2 housekeepers, 4 dietary staff, 1 therapist). Staff interviews revealed they were knowledgeable of the elopement policy and procedures, appropriate response to alarms and supervision of all residents to include those at risk for elopement. The resident sample was expanded during the survey to include five additional residents who were at risk of elopement. Observations, interviews, and record reviews conducted revealed no concerns related to elopement-risk evaluations, care plans and physician orders for residents #4 through #8. During survey, the survey team validated the education and elopement-drill participation through interviews and sign-in sheets and reviewed the wandering and elopement-risk binders for accuracy.

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice related to knee immobilizer application, the physician order, and failed to create a comprehensive care plan for 1 of 1 resident reviewed for limited range of motion, of a total sample of 43 residents, (#180). Findings:Resident #180 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia, osteoporosis, history of falls, hip and left knee fractures, and status post left total knee arthroplasty (knee replacement surgery). Review of the quarterly Minimum Data Set assessment dated [DATE], revealed resident #180 had a Brief Interview for Mental Status score of 5 out of 15, which meant she had severely impaired memory. The assessment indicated resident #180 had limited range of motion to her arms and her left leg. The MDS documented she used a wheelchair for mobility and was dependent on staff for toileting, personal hygiene, lower body dressing, and mobility. On 1/05/26 at 10:49 AM, resident #180 was in her room, sitting in her wheelchair. She had a left knee immobilizer in place with a folded pillowcase stuffed under the immobilizer. The resident was unable to say why she had the immobilizer or why the pillowcase was there. Review of current physician orders for resident #180 showed no telephone order or other active order in the electronic medical record for the left knee immobilizer. Review of resident #180's care plan, with a most recent review date of 1/06/26, revealed no interventions related to application of a knee immobilizer or use of a pillowcase for resident comfort. On 1/07/26 at 1:30 PM, Certified Nursing Assistant (CNA) A stated this was the first time she worked with resident #180 and was not aware how often to apply or remove the immobilizer or why the pillowcase was there. CNA A said she was educated on application of immobilizers in the past and said she put the pillowcase in the immobilizer because it was previously there when she removed the immobilizer to give the resident a shower. On 1/07/26 at 1:25 PM, Licensed Practical Nurse (LPN) B said this was the first time she was assigned to resident #180 and was aware of the immobilizer but was not aware of the frequency or removal of the immobilizer. LPN B confirmed in the electronic medical record there was no physician order for the immobilizer, but there should be. The LPN stated therapists checked the orders and applied or removed the immobilizer. Upon entering resident #180's room with LPN B at approximately 1:30 PM, the nurse noted the immobilizer had not been applied correctly by CNA A who had just showered her. On 1/07/26 at 2:08 PM, LPN C said she was assigned to resident #180 over the past three days. She explained residents usually were admitted with physician orders from the hospital. LPN C reviewed resident #180's medical records and confirmed there were no orders for the immobilizer. She again said therapists checked the orders and applied or removed the immobilizer. On 1/08/25 at 11:18 AM, the Physical Therapy Assistant (PTA) said he worked with resident #180 daily and was aware she had an immobilizer. The PTA said he saw the folded pillowcase inside the immobilizer and did not remove it because the resident had complained of discomfort in the past. On 1/08/25 at 11:10 AM, the Director of Rehabilitation Services (DOR) said therapists reviewed physician orders on their electronic program. She explained their process was to review the hospital discharge records including physician orders and assistive devices or equipment used by the residents. After reviewing hospital records, the DOR stated their EMR generated an order for the therapists. The DOR said the therapists would reapply any device if they were not applied correctly. The director explained in regard to the pillowcase inside the resident's immobilizer, My expectation would be for therapists to remove anything placed inside an immobilizer and inform a nurse. On 1/08/26 at 11:52 AM, the Director of Nursing (DON) said she was aware there was no physician order for resident #180's immobilizer. The DON confirmed her expectation was for a physician order to first be obtained by a nurse for use of any device or devices such as an immobilizer. The facility's policy titled, Medication and Treatment Orders, revised July 2016 indicated medications/treatments shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications/treatments in this state. The policy, further detailed verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order.

Based on interview, and record review, the facility failed to follow professional standards of practice for blood glucose monitoring as ordered by the physician, for 1 of 3 residents reviewed for blood glucose monitoring, of a total sample of 6 residents, (#1). Findings: Resident #1 was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included pneumonia, acute respiratory failure, type 2 diabetes mellitus, chronic kidney disease, and atrial fibrillation. Review of the Hospital Medical Certification for Medicaid Long-Term Care Services and Patient Transfer form dated 6/04/24 revealed resident #1 was alert, oriented, followed instructions and capable to make her own healthcare decisions. Resident #1 had a care plan for Diabetes Mellitus dated 6/05/24. The goal was to minimize the risk of complications related to low or high blood glucose through the review date. Interventions included staff to administer diabetes medication as ordered by the physician and to monitor side effects and effectiveness of the medications. Additional interventions included staff to monitor and report low or high blood glucose signs or symptoms. An Order Summary Report dated 6/13/24 revealed a physician order dated 6/05/24 for accu-checks AC (before meals), HS (at bedtime), and as needed for anti-diabetics. The order directed nurses to call the physician if results were less than 70 or greater than 300. Review of the Medication Administration Record (MAR) for June 2024 and the medical record revealed 12 omissions of documentation of accu-check performed from 6/05/24 to 6/12/24, when the resident was transferred to the hospital. On 8/29/24 at approximately 9:00 AM, the Director of Nursing (DON) confirmed resident #1's MAR was missing documentation on 12 occasions from the period of 6/05/24 to 6/12/24 to show accu-checks were performed as ordered. She stated her expectation was nurses would follow the physician orders and document the accu-check results in the chart. The DON was unable to provide any additional evidence the missing accu-checks were performed for resident #1 in accordance with physician orders.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to assure accurate receiving and dispensing of a high-risk antipsychotic medication for 1 of 8 residents observed for medication administration, (#8) and failed to ensure medications were administered per physician's order prior to hemodialysis for 1 of 1 resident reviewed for dialysis, (#82), of a total sample of 48 residents. Findings: 1. Review of the medical record revealed resident #8 was admitted to the facility on [DATE] from the hospital. His diagnosis included schizoaffective disorder, bipolar, Alzheimer's disease, dementia, type II diabetes, and stage 4 kidney disease. Resident #8's Admission Minimum Data Set (MDS) with an assessment reference date of 2/26/24 revealed the resident scored 13 out of 15 on the Brief Interview for Mental Status which indicated he did not have any cognitive impairment. The MDS assessment indicated resident #8 required moderate assistance from the staff with transfers. The Admission MDS also noted the resident did not exhibit behavioral symptoms or rejection of care that is necessary to achieve the resident's goals for health and well-being. Resident #8's Admission MDS assessment revealed the resident received high risk medications that included antipsychotic and antidepressant medications. Review of resident #8's medical record revealed that a care plan was initiated on 2/21/24 which indicated the resident used psychotic medications related to schizophrenia and bipolar disorder and the interventions included to administer psychotropic medications as ordered by a physician. On 3/26/24 at 9:41 AM, Registered Nurse (RN) A administered aripiprazole 20 milligrams (mg) tablet along with Vraylar 4.5 mg capsule to resident #8 during the medication administration observation. The pharmaceutical strip pack noted the resident's name, aripiprazole 20 mg and Vraylar 4.5 mg, to be administered on Tuesday, 3/26/24. A record review post medication administration observation of resident #8's order summary report and the medication administration record (MAR) revealed the provider ordered aripiprazole 20 milligrams (mg) by mouth once a day for antipsychotic to be discontinued on 2/26/24 and the provider then prescribed Vraylar 4.5 mg by mouth once a day for antipsychotic to start on 2/27/24. Aripiprazole and Vraylar are antipsychotic medications that are used to treat schizophrenia. There are moderate interactions with using aripiprazole and Vraylar together. Using aripiprazole with Vraylar together may increase side effects such as drowsiness, blurred vision, dry mouth, heat intolerance, flushing, decreased sweating, difficulty urinating, abdominal cramping, constipation, irregular heartbeat, confusion, and memory problems. Side effects are more likely to occur in the elderly .The recommended maximum number of medicines in the 'antipsychotics' category to be taken concurrently is usually one, (Retrieved on 4/05/24 from www.Drugs.com). On 3/26/24 at 10:28 AM, RN A checked resident #8's MAR and discovered that aripiprazole had been discontinued on 2/26/24. She acknowledged that she administered aripiprazole during the medication administration observation at 9:41 AM and she also indicated that she administered it the day before. She confirmed that she should not have administered aripiprazole to the resident since it was discontinued. RN A conveyed she should have checked the MAR to ensure that the medication matched the physician order before administering it. RN A observed that aripiprazole was also in the medication cart and was included in the resident's medication regimen for the next day. She reiterated that aripiprazole should not be included in the pharmacy strip pack for the resident since it had been discontinued on 2/26/24. On 3/26/24 at 11:00 AM, the Licensed Practical Nurse (LPN) Supervisor on the 200 unit accessed resident #8's electronic medical record and stated that aripiprazole was discontinued on 2/26/24. She indicated that the pharmacy delivered strip packs for resident #8 on Mondays, Wednesdays, and Fridays, each containing a two-day supply of medications. She stated that the most recent medication strip pack delivered by the pharmacy was on Monday 3/25/24 that contained aripiprazole and Vraylar among others. She confirmed that aripiprazole should not have been administered by RN A on 3/26/24 and that it should not have been included in the pharmacy strip pack that was scheduled to be administered on Tuesday, 3/26/24 and Wednesday, 3/27/24. She emphasized that nurses are required to verify the resident's medications in the medication cart against the physician's orders on the MAR before administering them. On 3/27/24 at 8:50 AM, the Director of Nursing (DON) confirmed that aripiprazole 20 mg was discontinued on 2/26/24 and should not have been given to the resident. The DON acknowledged that RN A should have checked the MAR before giving the medication. She conveyed that prefilled medication strip packs are delivered in trays from the pharmacy on Mondays, Wednesdays, and Fridays that contain a two-day supply of medications and were placed in the medication cart by the pharmacy and the nurse on duty. She confirmed when a medication was discontinued, it would automatically interface with the pharmacy informing them of the discontinued medication. She stated that aripiprazole should not have been delivered by the pharmacy. She also reiterated when a nurse verifies a medication, the nurse was expected to ensure the medications align with the physician orders on the MAR before administering them. She mentioned if there was not a physician order for a medication that was included in the strip pack, the nurse must not administer the medication, should remove the medication from the strip pack, and notify the supervisor and the provider. On 3/27/24 at 2:13 PM, the Pharmacy Operations Manager stated that on 2/26/24 they received an order from the facility to discontinue aripiprazole and on 2/27/24 received an order to start Vraylar. She conveyed that orders are entered into the operating system by a tech and then reviewed and verified by the pharmacist for accuracy. She also conveyed if a medication is discontinued, the pharmacy is to discontinue it from the resident's profile. She confirmed that aripiprazole continued to be delivered on Mondays, Wednesdays, and Fridays for a month after it was discontinued and that it should not have been sent out after the discontinued date of 2/26/24. She acknowledged that the discontinued aripiprazole remained on resident #8's profile until 3/27/24 and that both aripiprazole and Vraylar were delivered to the resident in the pharmacy strip packs until 3/27/24. The Pharmacy Operations Manager acknowledged the potential adverse reactions for aripiprazole would be drowsiness, leukopenia, neutropenia, hyperglycemia, and extrapyramidal systems such as Parkinsonism, dystonia, and tardive dyskinesia. The Pharmacy and Facility's Medication Orders policy read, Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe .Any dose or order that that appears inappropriate .is verified by nursing with the attending physician. The Pharmacy and Facility's Preparation and General Guidelines policy read, The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage of directions, the physician's orders are checked for the correct dosage schedule. 32131 2. Resident #82, a [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on 5/24/23. Her diagnoses included end stage renal disease (ESRD), peripheral vascular disease, cardiomyopathy, hypertensive heart, chronic kidney disease with heart failure with stage 5 chronic kidney disease, chronic systolic (congestive) heart failure, and venous thrombosis and embolism. Hemodialysis is a procedure that uses a machine to do the job of your kidneys. The machine pumps your blood through a dialyzer, or artificial kidney. The dialyzer filters fluid, salts, and waste from your blood. Once they are removed, clean blood from the dialyzer returns to your body through a vein. (retrieved on 4/08/24 from drugs. com). Review of the quarterly MDS assessment dated [DATE], revealed the resident's cognition was moderately impaired with a Brief Interview For Mental Status score of 9 out of 15, and the assessment noted the resident received dialysis. The resident's physician's orders dated 7/01/23, directed staff to give all medications at least 6 hours prior to hemodialysis (HD) or after returning, and on 8/04/23, revealed the resident's dialysis days were Monday/Wednesday/Friday, and chair time was 11:30 AM. Review of the resident's Medication Admin Audit Report for her dialysis days in March 2024, revealed the following medications were administered between 7:56 AM and 10:00 AM, approximately one to three hours prior to dialysis on March 1st, 4th, 6th, 8th, 11th, 13th, 15th, 18th, 20th, 22nd, 25th, and 27th. Liquid protein 30 milliliters, Sevelamer carbonate 800 milligram (mg) 2 tablets for chronic kidney disease, Carvedilol 12.5 mg, Losartan Potassium 25 mg for high blood pressure, and Levothyroxine 112 microgram (mcg) for hypothyroidism. The medications were not given at least 6 hours prior to dialysis as per the physician's order. On 3/27/24 at 2:40 PM, RN E stated the resident went out to dialysis three days per week, Monday, Wednesday, and Friday. RN E stated the resident received her medications between 8 AM to 9 AM, and her dialysis chair time was at 11:30 AM. The resident's physician orders were reviewed with RN E, and she acknowledged physician order dated 7/01/23 directed staff to give all medications at least 6 hours prior to Hemodialysis or after returning. RN E stated the order was a standard order, and she did not know what the facility's protocol was if the order was not carried out. On 3/27/24 at 2:58 PM, LPN B stated the physician order for medication to be given at least 6 hours prior to dialysis was a standing order for residents on dialysis, and the order populated to the resident(s) MAR. She said the order should be carried out, and if staff was unable to do so, the physician should be notified, so adjustments in the medication administration schedule could be made. On 3/28/24 at 11:04 AM, the resident's physician orders, and the Medication Admin Audit Report for the period 3/01/2024 through 3/27/2024 were reviewed with the DON. She acknowledged that the resident's medications were not administered as per physician order on the days the resident had dialysis. A care plan for ESRD with dialysis was created on 10/19/22 with revision on 8/02/23. An intervention initiated on 11/26/22 was give all medications at least 6 hours prior to HD or after returning. The policy Medication Administration -General Guidelines dated April 2018 read, Medications are administered in accordance with written orders of the prescriber.

Based on interview, and record review, the facility failed to ensure pharmacy recommendations were acted upon in a timely manner for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 48 residents, (#82). Findings: Resident #82, a [AGE] year-old female was admitted to the facility on [DATE], with her most recent readmission on 5/24/23. Her diagnoses included end stage renal disease, peripheral vascular disease, cardiomyopathy, hypertensive heart and chronic kidney disease with heart failure with stage 5 chronic kidney disease, chronic systolic (congestive) heart failure, venous thrombosis and embolism. A pharmacy recommendation dated 10/17/23 indicated the resident received levothyroxine at 9:00 AM, and the recommendation was to administer 112 micrograms (mcg) as a single dose on an empty stomach, and read, Consider dosing at 6 am. Levothyroxine is used in adults and children to treat hypothyroidism (underactive thyroid-a condition where the thyroid gland does not produce enough thyroid hormone). Directions included, Take levothyroxine tablets and capsules on an empty stomach, at least 30 to 60 minutes before breakfast with a full glass of water. Take the medicine at the same time each day. (retrieved on 4/08/24 from drugs.com). Review of the resident's physician's orders revealed an order dated 10/09/23 for levothyroxine 112 mg daily for hypothyroidism. Review of the resident's Medication Administration records for the period October 2023 through March 2024 revealed the medication levothyroxine was scheduled for administration at 9:00 AM. On 3/27/24 at 9:07 AM, the Director of Nursing (DON) stated the Consultant Pharmacist reviewed residents' medications, made recommendations, and sent a report via email to her. The DON stated that the recommendations were distributed to the Physician/Providers for review and response, and the expectation was that recommendations would be addressed within thirty (30) days of receipt. On 3/28/24 at 12:25 PM, resident #82's pharmacy recommendation dated 10/17/23, the resident's physician order and MARs were reviewed with the DON. She acknowledged the findings and said the recommendation should have been addressed within 30 days of receipt. The DON said that specific recommendation was a nursing task, and nurses could change the time of administration of the medication in the resident's electronic medical record. The policy Medication Regimen Review dated April 2018 read, Recommendations are acted upon and documented by the facility staff and/or prescriber .The Director of Nursing or designated licensed nurse address and document recommendations that do not require a physician intervention.

Based on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessment was accurate for Functional Range Of Motion (ROM) for 1 of 2 residents reviewed for Limited ROM of a total sample of 48 residents, (#84). Findings: Resident #84, a [AGE] year-old male was admitted to the facility on [DATE], with diagnoses which included nontraumatic subdural hemorrhage, hemiplegia and hemiparesis affecting the right dominant side, dementia, and chronic diastolic (congestive) heart failure. Review of the resident's quarterly MDS assessment with Assessment Reference Date of 2/04/24 revealed the resident's cognition was moderately impaired with a Brief Interview for Mental Status score of 8 out of 15. Section GG 0115 for functional limitation in range of motion was coded 0 for the resident's upper extremity, indicating the resident had no impairment in functional limitation in ROM to his upper extremity, and was coded 1 for the resident's lower extremity, indicating the resident had functional limitation in ROM to one side of his lower extremity. Review of the Occupational Therapy discharge summary with dates of services from 9/07/23 through 12/27/23 revealed the resident was referred to the facility's Restorative Nursing Program with diagnosis that included contracture of the right hand/wrist/shoulder. A care plan for self-care deficits related to stroke with right sided weakness, limited ROM to the right upper extremity, and the right lower extremity, was created on 3/21/20, with revision on 3/27/24. On 3/25/24, at 11:52 AM, and on 3/26/24 at 9:25 AM, resident #84 was sitting up in bed watching television, his right hand was contracted, and no splint was noted to the resident's right hand. On 3/27/24 at 9:59 AM, Licensed Practical Nurse (LPN) D, stated the resident's right hand was contracted. She said the resident was on therapy's caseload, and a right resting hand splint was placed and removed by therapy per therapy's schedule. On 3/27/24 at 11:57 AM, the LPN MDS Coordinator explained that MDS assessments were completed by conducting observation of the resident(s), interviews with staff, and by doing a 7 day look back review of the residents' clinical records. The LPN MDS Coordinator stated she completed resident #84's quarterly MDS assessment with ARD of 2/04/24. A review of the resident's quarterly MDS section GG0115 for Functional Limitation in Range of Motion was conducted with the LPN MDS Coordinator. She stated resident #84 had contracture of his right hand and verbalized that the assessment was inaccurate. The LPN MDS Coordinator said she coded for limitation in ROM for the resident's lower extremity but did not accurately assess/code ROM to the resident's upper extremity. The facility did not have a policy pertaining to accuracy of assessment, but stated they followed the directives of the Resident Assessment Instrument (RAI) Manual. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11 dated October 2023 GG0115 read The intent of GG0115 is to determine whether functional limitation in range of motion (ROM) interferes with the resident's activities of daily living or places them at risk of injury. The RAI defined functional limitation in range of motion as Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk of injury. Coding instructions were, Code 0, no impairment, if resident has full functional range of motion on the right and left side of upper/lower extremities. Code 1, impairment on one side: if resident has an upper-and/or lower extremity impairment on one side that interferes with daily functioning or places the resident at risk of injury.

Based on observation, interview, and record review, the facility failed to prevent a medication administration error rate of 5% or greater for 1 out of 8 residents observed for medication administration, of a total sample of 48 residents, (#8). There were 3 medication errors in 25 opportunities for a medication error rate of 12%. Findings: Review of the medical record revealed resident #8 was admitted to the facility on [DATE] from the hospital. His diagnosis included schizoaffective disorder, bipolar, Alzheimer's disease, dementia, type II diabetes, and stage 4 kidney disease, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, and anemia in chronic kidney disease. Resident #8's Admission Minimum Data Set (MDS) with an assessment reference date of 2/26/24 revealed the resident scored 13 out of 15 on the Brief Interview for Mental Status which indicated he did not have any cognitive impairment. The MDS assessment indicated resident #8 required moderate assistance from the staff with transfers. The Admission MDS also noted that the resident did not exhibit behavioral symptoms or rejection of care that is necessary to achieve the resident's goals for health and well-being. Resident #8's Admission MDS assessment revealed the resident received high risk medications that included antipsychotic and antidepressant medications. Review of resident #8's medical record revealed a care plan initiated on 2/21/24 that indicated the resident used psychotic medications related to schizophrenia and bipolar disorder. Interventions included staff to administer psychotropic medications as ordered by a physician. On 3/26/24 at 9:41 AM, Registered Nurse (RN) A prepared the scheduled medications for resident #8 and placed the pills into the medicine cup, totaling 14 pills. RN A then verified the count of pills in the cup, ensuring there were 14 pills present. She administered the medications to resident #8, who was in his room. A record review post medication administration observation of resident #8's order summary report and the medication administration record (MAR) revealed the provider ordered Aripiprazole 20 milligrams (mg) by mouth once a day for antipsychotic to be discontinued on 2/26/24. It also showed active orders for ferrous sulfate 325 milligrams (mg) by mouth one time a day for anemia and Proscar 5 mg by mouth one time a day for BPH. Ferrous sulfate and Proscar were scheduled to be administered daily at 9:00 AM. On 3/26/24 at 10:28 AM, RN A checked resident #8's medication administration record and discovered that Aripiprazole had been previously discontinued on 2/26/24. She acknowledged that she administered Aripiprazole during the medication administration observation at 9:41 AM. She stated she should not have administered Aripiprazole to the resident since it was discontinued. She also stated there were active orders on the MAR for Proscar and ferrous sulfate that she failed to administer as prescribed. RN A recalled there were 14 pills in the medication cup and confirmed that neither Proscar nor ferrous sulfate were included in the pills she administered to the resident. RN A conveyed she should have checked the MAR to ensure that resident #8's medications matched the physician orders before administering them. On 3/26/24 at 11:00 AM, The Licensed Practical Nurse (LPN) Supervisor on the 200 unit accessed resident #8's electronic medical record and stated that Aripiprazole was discontinued on 2/26/24. She confirmed that Aripiprazole should not have been administered by RN A. She emphasized that nurses were required to verify the resident's medications in the medication cart against the physician's orders on the MAR before administering them. On 3/27/24 at 8:50 AM, the Director of Nursing (DON) confirmed that Aripiprazole 20 mg was discontinued on 2/26/24 and should not have been given to the resident. The DON acknowledged that RN A should have checked the MAR before giving the medication. She also reiterated when a nurse verified medications, the nurse was expected to ensure the medications aligned with the physician orders on the MAR before administering them. The facility's medication orders policy read, Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe .Any dose or order that that appears inappropriate .is verified by nursing with the attending physician. The facility's preparation and general guidelines policy read, Medications are administered as prescribed in accordance with good nursing principles .The mediation administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage of directions, the physician's orders are checked for the correct dosage schedule.

Based on observation, interview, and record review, the facility failed to ensure that a resident was free of a significant medication error regarding administration of a discontinued high risk antipsychotic medication for 1 out of 8 residents observed for medication administration, of a total sample of 48 residents, (#8). Findings: Review of the medical record revealed resident #8 was admitted to the facility on [DATE] from the hospital. His diagnosis included schizoaffective disorder, bipolar, Alzheimer's disease, dementia, type II diabetes, and stage 4 kidney disease. Resident #8's Admission Minimum Data Set (MDS) with an assessment reference date of 2/26/24 revealed the resident scored 13 out of 15 on the Brief Interview for Mental Status that indicated he did not have any cognitive impairment. The MDS assessment indicated resident #8 required moderate assistance from the staff with transfers. The Admission MDS also noted that the resident did not exhibit behavior symptoms or rejection of care that is necessary to achieve the resident's goals for health and well-being. Resident #8's Admission MDS assessment revealed that the resident received high risk medications that included antipsychotic and antidepressant medications. Review of resident #8's medical record revealed that a care plan was initiated on 2/21/24 that indicated the resident used psychotic medications related to schizophrenia and bipolar disorder and the interventions included to administer psychotropic medications as ordered by a physician. On 3/26/24 at 9:41 AM Registered Nurse (RN) A administered Aripiprazole 20 milligrams (mg) tablet along with Vraylar 4.5 mg capsule to resident #8 during the medication administration observation. The pharmaceutical strip pack noted the resident's name, Aripiprazole 20 mg, Vraylar 4.5 mg, and the directions for administration on Tuesday, 3/26/24. A record review post medication administration observation of resident #8's order summary report and the medication administration record (MAR) revealed the provider ordered Aripiprazole 20 milligrams (mg) by mouth once a day for antipsychotic to be discontinued on 2/26/24 and the provider also prescribed Vraylar 4.5 mg by mouth once a day for antipsychotic to start on 2/27/24. Aripiprazole and Vraylar are antipsychotic medications that are used to treat schizophrenia. There are moderate interactions with using Aripiprazole and Vraylar together. Using Aripiprazole with Vraylar together may increase side effects such as drowsiness, blurred vision, dry mouth, heat intolerance, flushing, decreased sweating, difficulty urinating, abdominal cramping, constipation, irregular heartbeat, confusion, and memory problems. Side effects are more likely to occur in the elderly .The recommended maximum number of medicines in the 'antipsychotics' category to be taken concurrently is usually one, (Retrieved on 4/5/24 from www.Drugs.com.) On 3/26/24 at 10:28 AM, RN A checked resident #8's medication administration record and discovered that Aripiprazole had been discontinued on 2/26/24. She acknowledged she administered Aripiprazole during the medication administration observation at 9:41 AM and she also indicated she administered it the day before. She confirmed she should not have administered Aripiprazole to the resident since it was discontinued. RN A conveyed she should have checked the MAR to ensure the medication matched the physician order before administering it. RN A observed that Aripiprazole was also in the medication cart and was included in the resident's medication regimen for the next day. She reiterated that Aripiprazole should not be included in the pharmacy strip pack for the resident since it had been discontinued on 2/26/24. On 3/26/24 at 11:00 AM, the Licensed Practical Nurse (LPN) Supervisor on the 200 unit accessed resident #8's electronic medical record and stated that Aripiprazole was discontinued on 2/26/24. She indicated the pharmacy delivered strip packs for resident #8 on Mondays, Wednesdays, and Fridays, each contained a two-day supply of medications. She stated that the most recent medication strip pack delivered by the pharmacy was on Monday 3/25/24 that contained Aripiprazole and Vraylar among others. She confirmed that aripiprazole should not have been administered by RN A on 3/26/24 and it should not have been included in the pharmacy strip pack that was scheduled to be administered on Tuesday, 3/26/24 and Wednesday, 3/27/24. She emphasized that nurses were required to verify the resident's medications in the medication cart against the physician's orders on the MAR before administering them. On 3/27/24 at 8:50 AM, the Director of Nursing (DON) confirmed that Aripiprazole 20 mg was discontinued on 2/26/24 and should not have been given to the resident after that date. The DON acknowledged that RN A should have checked the MAR before giving the medication. She conveyed that prefilled medication strip packs were delivered in trays from the pharmacy on Mondays, Wednesdays, and Fridays that contain a two-day supply of medications and were placed in the medication cart by the pharmacy and the nurse on duty. She confirmed when a medication is discontinued, it would automatically interface with the pharmacy informing them of the discontinued medication. She stated that Aripiprazole should not have been delivered by the pharmacy. She also reiterated when a nurse verified a medication, the nurse was expected to ensure the medications align with the physician orders on the MAR before administering them. She mentioned if there was not a physician order for a medication that was included in the strip pack, the nurse must not administer the medication, should remove the medication from the strip pack, then notify the supervisor and the provider. On 3/27/24 at 2:13 PM, the Pharmacy Operations Manager stated that on 2/26/24 they received an order from the facility to discontinue Aripiprazole and on 2/27/24 received an order to start Vraylar. She conveyed that orders were entered into the operating system by a tech, then reviewed and verified by the pharmacist for accuracy. She also conveyed if a medication was discontinued, the pharmacy was to discontinue it from the resident's profile. She confirmed that Aripiprazole continued to be delivered on Mondays, Wednesdays, and Fridays for a month after it was discontinued and that it should not have been sent out after the discontinued date of 2/26/24. She acknowledged the discontinued Aripiprazole remained on resident #8's profile until 3/27/24 and both Aripiprazole and Vraylar were delivered to the resident in the pharmacy strip packs until 3/27/24. The Pharmacy Operations Manager acknowledged the potential adverse reactions for Aripiprazole would be drowsiness, leukopenia, neutropenia, hyperglycemia, and extrapyramidal symptoms such as Parkinsonism, dystonia, tardive dyskinesia. The pharmacy and facility's Medication orders policy read, Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe .Any dose or order that that appears inappropriate .is verified by nursing with the attending physician. The pharmacy and facility's Preparation and General guidelines policy read, The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage of directions, the physician's orders are checked for the correct dosage schedule. Isolated Class III

Based on observation, interview and record review, the facility failed to provide care and services for midline Intravenous (IV) catheters according to standards of practice and plan of care for 2 of 3 residents reviewed for IV catheters of a total sample of 46 residents, (#59 and #67). Findings: 1. Resident #59 was admitted to the facility on [DATE], and most recently readmitted on [DATE] from an acute care hospital. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set Five-day assessment with assessment reference date [DATE] revealed resident #59 had a Brief Interview for Mental Status score of 14 which indicated he was cognitively intact. Additionally, the assessment revealed the resident did not reject care from staff and received [CONDITION(S)]. On [DATE] at 10:05 AM, resident #59 was seated in his wheelchair waiting for transportation to [CONDITION(S)]. A midline IV catheter was visible to his right upper arm. The clear adhesive dressing was not dated and unlabeled, with a piece of clear tape across the bottom holding the dressing down. The resident stated he had not received any medications in the IV for about a week and he didn't know why he still had the midline. His right hand was swollen, and the resident explained it had been like that for about a week. A midline catheter is put into a vein by the bend in your elbow or your upper arm . The midline tube ends in a vein below your armpit .midline catheter may allow you to receive long-term IV medicine or treatments .(retrieved [DATE] www.drugs.com). On [DATE] at 4:37 PM, resident #59 was awake and alert, sitting up in bed. He had the midline IV in his right upper arm with the clear dressing that was undated and unlabeled with clear tape on the bottom edge of the dressing. There was dark brown blood in the tubing. He explained the doctor told him the IV should be removed since it was not being used, and said, No one has done it. On [DATE] at 12:11 PM, resident #59's wife was at the bedside. He had the same midline IV catheter in his right arm with the clear dressing undated and dried blood still in the tubing. The resident reported the nurse hadn't looked at his IV at all today, and no one had changed the dressing for a while. Resident #59's wife stated she asked staff last week why he still had the IV, but they never gave her an answer. On [DATE] at 12:16 PM, the Assistant Director of Nursing (ADON) acknowledged the resident's unlabeled and undated midline IV catheter with the dark brown blood in the tubing underneath the dressing. She indicated the dressing should have been dated and initialed by the nurse and that nurses were responsible to assess the IV catheter site every shift. The ADON reviewed resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She conveyed there were no orders for flushes, dressing changes, or assessments. She noted resident #59's midline IV catheter was inserted at the beginning of April and the nurse who entered the order for the midline did not enter any orders for the care of the midline IV. The ADON explained orders to assess the midline catheter and IV site and dressing changes would normally be a part of the care nurses provided for a midline IV. She said the resident had orders for IV antibiotics and flushes but those orders expired after antibiotic therapy was completed. The ADON indicated the protocol was for the nurse to ask the physician for orders to discontinue the IV when the IV antibiotic medications were completed. She said if the IV was to be left in place, orders would be given for flushes, dressing changes and assessments. The ADON acknowledged midline IV catheters were an infection risk, especially for someone who received hemodialysis. They ADON confirmed there was no documentation in the resident's medical record to indicate the midline catheter dressing was changed or assessed since it was inserted on [DATE]. Review of resident'#59's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no other orders documented by nurses in April for midline IV catheter care including dressing changes, or for nurses to assess the midline catheter for infection or complications. Resident #59 had a care plan for intravenous lines, Receiving IV therapy and at risk for complications,the type of IV access was left blank. The goal was for resident #59's IV line to remain patent and have no complications. Interventions for resident #59's IV line were for staff to administer fluids as ordered, educate resident and family about central line associated bloodstream infection prevention, explain purpose of IV and procedure prior to start, observe for complications, dislodgment of IV catheter, swelling, redness, pain, separation of IV lines, shortness of breath, drainage or soiled IV dressing, phlebitis, infiltration, or bleeding. Further interventions included Provide IV site care as ordered. Review of the Nurse Progress Notes revealed no documentation of midline IV catheter dressing changes or assessments from the date the midline catheter was inserted on [DATE] until the line was discontinued on [DATE]. On [DATE] at 11:37 AM, Licensed Practical Nurse, (LPN) C said she had cared for resident #59 on the previous Monday and Tuesday shifts. She stated she knew to check the IV catheter based on the report she received from the previous nurse or based on the orders in the computer. She confirmed standard orders for midline IV catheters included flushes, and assessment of the IV catheter site usually every shift. LPN C explained when the IV medications were complete, she knew to call the physician and ask if midline was to be discontinued. She indicated she did not get report on the previous Monday or Tuesday about the IV catheter from the previous shift and there were no orders in the electronic record for the care of the IV. She that if the resident had an IV, that should be communicated by the nurses in the shift change report. She stated, That is something you would tell the next nurse, part of the information you would give and expect to get. On [DATE] at 12:04 PM, LPN D said she usually cared for resident #59 on her assignment. She reported he had the midline catheter inserted at the beginning of April to receive IV antibiotics for a urinary tract infection. LPN D explained she thought midline IV catheter dressings should be changed every seven days and the dressing needed to be labeled with a date and initialed. LPN D recalled the past Sunday that resident #59 still had the IV so she told the night nurse during report to call the doctor and get order to discontinue the IV but did not explain why she did not call the physician herself. LPN D noted the night nurse did not do it. LPN D stated the nurse should know to call the physician and get the IV discontinued when the IV medication order was completed. On [DATE] at 10:50 AM, the Director of Nursing (DON) stated the nurse should put in the orders for care of the midline IV catheter when it was inserted. She said for a clear dressing on a midline IV catheter such as resident #59's, the standard of care was to change the dressing every five to seven days or more often as needed. She conveyed a midline catheter was supposed to be flushed at least daily if no meds were going through it, and nurses should assess the site every shift for problems with the IV or the dressing. The DON explained if the nurse found a problem with the midline IV catheter such as patency, they would call the contracted IV team to come in and assess the line. She explained nurses should not use tape to hold down the IV dressing, instead the dressing should be changed, dated, initialed and documented in the medical record. She acknowledged that while the IV was not being used for medications, it would still need care from nurses such as flushing the line, changing the dressing, and assessing the IV for signs and symptoms of infection or other complications. She explained the IV team came on the evening of [DATE] to see resident #59's midline IV catheter once it had been brought to their attention by the surveyor. She stated the IV team was not able to salvage resident #5''s midline IV catheter because of dried blood in the line. Review of the Insertion of Peripheral IV Catheter dated ,d+[DATE] revealed general guidelines to, change dressing and perform site care if dressing becomes soiled, is no longer intact. The guidelines indicated the label on the dressing should include the date and time of dressing placement, initials, gauge size and length of catheter. The document directed that the IV catheter should be removed when there is suspected contamination, complication or when therapy is discontinued. Review of the document, Flushing Midline and Central Line IV Catheters dated ,d+[DATE] revealed the general guideline that midline IV catheters will be flushed at regular intervals to maintain patency. Review of the document Midline Dressing Changes dated ,d+[DATE] revealed general guidelines to change midline catheter dressing every five to seven days or more often it is wet, dirty, not intact or compromised in any way using sterile technique. The document also instructed staff to record the date and time the dressing was changed in the resident's medical record along with the signature and title of the person recording the data. 2. Resident #67 was admitted to the facility on [DATE] from an acute care hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a Midline IV line inserted [DATE] in the right arm for administration of IV antibiotics and the line was re-inserted in the same location on [DATE] as it was not functioning properly. She received [MEDICATION(S)] (IV antibiotic) every 6 hours for brain abscess through [DATE]. There was a prior order dated [DATE] to discontinue PICC (peripherally inserted central catheter) line but no new orders were entered post Midline IV insertion [DATE] or [DATE] regarding new IV type and care. There were prior orders in effect dated [DATE] for catheter site dressing changes every week and as needed that were not specific to the type of IV present nor the location. On [DATE] at 10:35 AM, resident #67 was observed sitting up in wheelchair at the bedside. She had a gauze dressing with transparent dressing over the right upper arm midline IV site. There was no visible date noted on the IV dressing. The resident was alert and oriented to person and place. She said, I was receiving IV antibiotics for brain infection. On [DATE] at 9:35 AM, resident #67 was observed sitting up in wheelchair and the midline IV in her right upper arm appeared same as yesterday's observation. There was no date on gauze dressing and the IV insertion site could not be visualized due to the presence of gauze. On [DATE] at 10:15 AM, Registered Nurse (RN) B was in the resident's room and observed the residents's midline dressing on right upper arm without a date. RN B validated observation of gauze dressing present without date and stated, when gauze is present dressing should be changed at minimum every 2 days. On [DATE] at 10:25 AM, the Unit Manager (UM) stated the resident had a midline inserted in her right arm on [DATE] and due to complications, she had another visit by the IV team on [DATE]. The UM added, the IV team would have applied new dressing on [DATE]. The UM indicated she could not find any evidence in the medical record to show the nurses changed IV site since [DATE]. The UM said she thought that if gauze was present then the IV site dressing needed to be changed every ,d+[DATE] days. On [DATE] at 10:45 AM the UM provided the facility policy for Midline Dressing Changes and validated the policy was to change dressing every 2 days/48 hours if gauze present. The UM added, the reason an IV site should be changed at least every 2 days as there was increased risk of infection due to moisture when gauze was present On [DATE] at 10:57 AM, the DON said the standard of practice was for nurses was to change gauze dressing every 48 hours and transparent film dressing every ,d+[DATE] days. The DON added, the nurses should have changed it 24 hours after the initial insertion and re-insertion of IV because there could be blood on the gauze which could lead to increased risk infection if not removed. According to the facility Midline Dressing Changes policy dated [DATE], Change midline catheter dressing 24 hours after insertion if placed with gauze .Use a sterile, transparent, semi-permeable membrane (TSM) or gauze dressing. If gauze dressing is used cover with a TSM dressing and change the dressing every 48 hours .

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was transmitted within the required 7 day time frame for 1 of 1 resident reviewed for assessments of a total sample of 46 residents, (#2). Findings: Review of resident #2's medical record documented she was admitted to the facility on [DATE] and was transferred to the hospital 11/04/21. Review of the Discharge Return Anticipated MDS assessment dated [DATE] revealed the assessment was completed but not transmitted to the National MDS database at Centers for Medicare and Medicaid Services (CMS). On 04/20/22 at 9:38 AM, MDS Supervisor D stated resident #2's MDS assessment had been completed but was not transmitted to CMS within the required 7 days. She said the assessment should have been transmitted to CMS on 11/11/21, it was our error. According to CMS.gov, The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps the nursing home staff identify health problems.

Based on observation, interview, and record review, the facility failed to ensure respiratory therapy was administered as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/19/22 at 1:43 PM, resident #29 was observed lying in bed without oxygen nasal canula nor any oxygen at the bedside. On 4/19/22 at 3:15, the Unit Manager (UM) acknowledged resident #29 was not receiving oxygen and the oxygen concentrator was across the room against the wall. She stated the oxygen was ordered as needed (PRN) and the concentrator was in the room in case the resident needed it. The UM reviewed the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated the resident was on hospice and continued to review the chart for a hospice order for prn oxygen . The UM was only able to find documentation in the hospice care plans and comprehensive assessment which indicated the resident was on 2 liters of oxygen prn. She stated, no, these are not orders. On 4/19/22 at 3:50 PM, the Director of Nursing (DON) reviewed resident #29's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the nurse probably forgot to add the continuous when the oxygen orders were ordered. Review of resident #29's care plans revealed a care plan for altered respiratory status/difficulty breathing related to shortness of breath. The goal noted the resident would not experience complication related to shortness of breath with an intervention to administer oxygen at 2 liters as ordered. Review of the Treatment Administration Record for April 2022, revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The start date was 2/28/22, which the nurses signed every shift as being administered.

Based on observation, interview and record review, the facility failed to prevent medication administration error rate of 5% or greater for 2 of 8 residents sampled for medication administration, (#279 and #84). There were 2 medication errors in 27 opportunities for a medication error rate of 7.41%. Findings: 1. On 4/18/22 at 9:17 AM, Licensed Practical Nurse (LPN) A prepared resident #279's scheduled medications. He removed 1 tablet Multivitamin (MTV) with Mineral from the cart stock medication bottle and placed it in a pill cup with the resident's other oral medications. He then proceeded to administer the medications to the resident who was in her room. Review of the medical record for resident #279 revealed she was admitted to the facility on [DATE]. A current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not include Mineral to be given with MTV. On 4/18/22 at 11 AM, LPN A in the presence of the 7th floor Unit Manager (UM) showed his medication cart drawer only contained MTV with Mineral and no plain MTV. The UM acknowledged LPN A made a mediation error by giving the cart stock MTV that also contained mineral as the order was for plain MTV. LPN A indicated he was not aware there was difference between plain MTV and MTV with Mineral. 2. On 4/18/22 at 11:25 AM, Registered Nurse (RN) B was observed checking resident #84's blood sugar which was 312. RN B stated, since the resident's blood sugar is over 100 he can have insulin. RN B proceeded to prepare the insulin pen [MEDICATION(S)] [MEDICATION(S)] 100 units/milliliter (ml) and dialed the dose to 10 units. RN B then administered 10 units of insulin subcutaneous (SQ) into the resident's left abdomen. [MEDICATION(S)] is a fast-acting mealtime insulin that works to control blood sugar when you eat. (https://www.[MEDICATION(S)].com) Review of the medical record for resident #84 revealed he was readmitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A current physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/18/22 at 1:04 PM, the 7th floor UM reviewed resident #84's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The UM validated the nurse gave the wrong dose of insulin at the wrong time. On 4/18/22 at 1:46 PM, RN B stated, I got confused because they just recently changed his insulin orders and we usually give insulin prior to meals not after. The UM added, the nurses should check the orders in the electronic medical record (EMR) and if not clear then double check the paper chart. On 4/21/22 at 10:50 AM, the Director of Nursing acknowledged the 2 medication errors regarding resident #279 and #84. She indicated the facility had plain MTV and MTV with Minerals on hand for medication cart stock and that nurses needed to triple check their medications to avoid errors. Review of the facility's policy and procedures for Medication Administration General Guidelines revised April 2018 read, Medications are administered as prescribed in accordance with good nursing principles and practice Five Rights- Right resident, right drug, right dose, right route and right time Medications are administered in accordance with written orders of the prescriber Medications are administered within 60 minutes of scheduled time, except before, with or after meals orders, which are administered based on mealtimes

Based on observation, interview and record review, the facility failed to ensure the high temperature dishwashers in 2 of 2 kitchens were monitored for sufficient pressure flow, (Main kitchen & Windsor Tower). Findings: On 11/02/20 at 9:39 AM, the main kitchen high temperature dishwasher was observed with the Director of Resident Services (RSD) and the Executive Chef (EC). The wash temperature was 160 °Fahrenheit (F) and the rinse temperature was 195 °F. There was no visual pressure gauge present to monitor the water pressure of the rinse water. Review of the daily monitoring log did not track the pressure during the rinse cycle. The RSD and the EC said they were not aware the pressure needed to be monitored. On 11/02/20 at 10:00 AM, the Windsor Tower's high temperature mechanical dishwasher was observed with the RSD, EC and the Windsor Towers Certified Dietary Manager (CDM). The wash temperature was 162°F, the rinse temperature was 195°F. There was no visual pressure gauge present to monitor the water pressure of the rinse water. The CDM was not aware the pressure of the rinse water needed to be monitored. Review of the monitoring logs for both dish washing machines for September 2020 to November 4, 2020 noted there was no documentation of the water pressure. Review of the manufacturer's specification sheet noted the water flow pressure should be 15-25 pounds per square inch (PSI). Review of Food and Drug Administration Food Code 2017 Chapter 4-501.113 Mechanical(NAME)Washing Equipment, Sanitization Pressure. The flow pressure of the fresh hot water SANITIZING rinse in a WAREWASHING machine, as measured in the water line immediately downstream or upstream from the fresh hot water SANITIZING rinse control value, shall be within the range specified on the machine manufacturer's data plate and may not be less than 35 kilopascals (5 PSI) or more than 200 kilopascals (30 PSI).

Based on observation, interview and record review, the facility failed to ensure that the pots, pans and cutting boards were sanitized to prevent the potential for foodborne illness in the kitchen that served the 7th floor rehabilitation unit in the Towers. Findings: On 2/18/19 at 11:15 AM, observations of the Towers kitchen that serviced the 7th floor rapid rehabilitation unit of the nursing home revealed Cook O washing pots, pans and cutting boards in the three compartment sink. She washed the items in the first sink, rinsed the items in the middle sink, then dipped them in the sanitizer sink and immediately removed the items and placed them on the drain board. She did not allow the items to remain in the sanitizer for a sufficient time to allow the sanitizer solution to effectively work for the minimum of 1 minute per manufacturer's specification. The sanitizer was at 200 parts per million of quaternary ammonium compound sanitizer. The nursing home director of resident services confirmed that she did not allow the proper time in the sanitizer. Interview with the facility executive Chef on 02/21/19 at 2:57 PM confirmed that cook O had recently completed orientation and should have known the proper technique for sanitizing. The pans, utensils and cutting boards should have been in the sanitizer for 1 minute.

Based on observation, interview and record review, the facility failed to provide enteral feeding per physician's orders and per facility policy for 1 of 3 residents, (#26). Findings: Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #26 did not have swallowing disorder and had a feeding tube. On 02/19/19 at 10:12 AM, LPN F administered 1 can of 2 Cal HN bolus feeding via peg tube to resident #26 diluted in approximately 8 ounces of tap water. She was observed to push the plunger of the syringe slowly when she gave the bolus feeding and stated, we usually do it because the resident does not want to stay longer in bed. When she completed the feeding, she was asked how many cans of 2 Cal HN was supposed to be given to the resident and she replied, one. A review of physician orders dated 10/25/18 read, 2 Calorie High Nutrition (Cal HN) 2 cans in the morning and 1 can two times a day bolus feeding at 2 PM and 8 PM via peg tube. A review of the Medication Administration Record [REDACTED]. On 02/20/19 at 2:31 PM, LPN F was asked about the order for the morning tube feedings. She stated that the current order was to give 1 can of 2 Cal HN 3 times a day. She also stated that starting tomorrow on, 02/21/19, the order will be changed to give 2 cans of 2 Cal HN in the morning. She could not provide the physician order for [REDACTED]. On 02/21/19 at 9:46 AM, the 3rd floor charge nurse verified the bolus order for resident #26 was to give 2 cans 2 Cal HN at 10:00 AM, 1 can at 2:00 PM and 8:00 PM. She confirmed that LPN F should have given 2 cans of 2 Cal HN during the morning feed. At 2:52 PM, the ADON stated that nurses were not supposed to push the plunger when administering bolus feeding. The Policy and Procedure on enteral feedings - safety precautions revised (MONTH) 2014 revealed promoting feeding tolerance 1. administer only full strength feeding tube formulas. Do not add water or dilute liquid or reconstituted enteral nutrition formulas Based on the Enteral Nutrition Practice Recommendations as written in the Journal of [MEDICATION NAME] and Enteral Nutrition, Volume 33, Number 2, March/April 2009, of the American Society for [MEDICATION NAME] and Enteral Nutrition (A.S.P.E.N), bolus feedings are defined as formula delivered by gravity via a syringe over approximately 15 minutes.

Based on observation, interview, and record review, the facility failed to ensure that pain management was provided consistent with professional standards of practice for 1 of 2 sampled residents, (#69). Findings: Resident #69 was admitted on [DATE] and re-admitted to the facility on [DATE] from acute care hospital post surgical repair of fractured left femur (2/13/19). Her [DIAGNOSES REDACTED]. The most recent minimum data set (MDS) assessment dated [DATE] showed resident #69's brief interview for mental status (BIMS) was 14 indicating she was cognitively intact. The resident required extensive to total assistance of 1-2 persons for her activities of daily living (ADL). Within the last 5 days prior to the MDS assessment, the resident was receiving scheduled pain medication and nonpharmacological interventions for pain. A care plan dated 7/23/18 and revised on 2/19/18 for pain, post-surgical repair of left introchanteric (spiral line of the femur) fracture included interventions to, observe for signs of pain, intervene as needed, encourage to report to caregiver if experiencing pain especially to left leg, non-pharmacological approaches- reposition left leg comfortable, use pillow to support/position .observe effectiveness of pain management program, observe for signs of pain, intervene as needed, and provide [MEDICATION NAME] as ordered. The nursing readmission screening dated 2/16/18 indicated that the resident came back to the facility due to fractured left femur, she was oriented to person, place time and situation, required assistance from staff with her ADLs, used wheelchair and had no pain at time when screening was done. On 2/18/19 at 11:49 AM, resident #69 was observed lying in bed alert and oriented to person and place. She was able to state where she was from and the type of work that she used to do. She was asked why she was at the facility and said that she had fallen in the bathroom and then she began to cry and indicated that she wanted her left leg repositioned. Surveyor went to get the nursing staff and the 4th floor Unit Manager (UM) immediately came into the room and repositioned the resident's leg with pillow. The UM said that the resident had received [MEDICATION NAME] (prescription drug used to treat pain) for pain at 10 AM. The UM explained to the resident that she would call the physician to obtain an order for [REDACTED]. On 2/18/19 at approximately 12:45 PM, the UM said she obtained new physician order for [REDACTED].>Review of resident #69's medical record revealed physician order dated 2/16/19 for [MEDICATION NAME] 50 milligrams (mg) by mouth every 8 hours prn (as needed) for pain and order dated 2/18/19 for [MEDICATION NAME] 5-325 mg by mouth every 8 hours prn for pain left femur fracture. On 2/19/19 at 10:25 AM, resident #69 was observed in the therapy room at the facility and was able to stand up with 2 staff holding her on each side for less than 5 seconds and then they assisted her back in the wheelchair. She did not complain of increased pain while standing and was not crying during the observation. On 2/19/19 at 4:20 PM, resident #69 was observed in bed asleep and then on 2/20/19 at 8:45 AM she was observed in bed eating breakfast and said that her hip was not giving her much pain today. On 2/20/19 at 1:45 PM, resident #69 was observed sitting up in wheelchair in her room and her daughter was present at the bedside. The assigned Licensed Practical Nurse (LPN) E came into the room and indicated that she was giving the resident a [MEDICATION NAME] pill for pain. The nurse did not ask the resident what her pain level was prior to giving the medication. On 2/21/19 at 10:00 AM a review of resident #69's medication admiration records (MAR) revealed since her return from the hospital on [DATE] to the present date there was only 1 dose of [MEDICATION NAME] 50 mg given on 2/18 at 4:13 PM. This did not match the controlled record medications that were signed out by the 2 nurses. The following medication were signed out on the controlled medication record with no evidence in the MAR indicated [REDACTED] [MEDICATION NAME] 50 mg - 2/17/19 at 9 AM, 2/17/19 at 5 PM, and 2/18/19 at 10 AM. [MEDICATION NAME] 5-325 mg- 2/19/19 at 7:45 AM, 2/20/19 at 1:45 PM and 2/21/19 at 8:45 AM (this dose was put on the MAR by LPN at 10:31 AM after nurse was interviewed by surveyor 1 hour and 46 minutes after the actual time of administration of the medication). A review of the MAR indicated [REDACTED]. On 2/21/19 at 10:15 AM LPN E verified that she had given resident #69 [MEDICATION NAME] 3 times this week. She stated that she had forgotten to document on the MAR indicated [REDACTED]. LPN E confirmed that she singed out [MEDICATION NAME] 5-325 mg 1 tablet at 8:45 AM this morning and then after interview with surveyor she entered it in the MAR indicated [REDACTED]. On 2/21/19 at 10:30 AM, the 4th floor UM verified that as per the controlled drug sign out sheet, [MEDICATION NAME] was signed out as given 4 times, and [MEDICATION NAME] 3 times. There was only 1 entry in resident #69's MAR for [MEDICATION NAME] given at 4:13 AM on 2/18/19. The UM verified that the medication orders were entered correctly in the EMR system however did not have an explanation as to why the nurses were not documenting the resident's pain level pre medication, the time doses were given or effectiveness of medication post administration. On 2/21/19 at 12:09 PM, the Director of Nurses verified that as per standards of nursing practice, the nurses should be doing timely documentation of administration of pain medications and follow up documentation as to the effectiveness of pain medications. The DON also confirmed that if the nurses had documented that they administered the pain medication on the MAR indicated [REDACTED]. The DON agreed that there was potential for errors regarding controlled pain medications as the resident could receive the medication too early since the nurses were not documenting the actual time the controlled medications were given. On 2/21/19 at 4:09 PM a telephone interview was conducted with LPN I with the 4th floor UM present. LPN I verified that she worked on 2/17/18 and signed out [MEDICATION NAME] at 9 AM and 5 PM per the controlled sign out record. She was asked as to why she had not documented the time the medication was given or the resident's pain level and the effectiveness of the medication. The LPN I stated that she was certain that she had signed off on both medications that she gave just prior to leaving at 7 PM. The UM confirmed with her that there was no evidence in the medical record to support that she had. Review of the facility policy and procedure for, Administering Pain Medication, revised (MONTH) 2010 read, Pain management is defined as the process of alleviating the resident pain to a level that is acceptable to the resident .Be familiar with the .signs of pain. For example: Verbal expressions such as groaning, crying .Acute pain should be assessed every 30-60 minutes after the onset and reassessed as indicated after [MEDICATION NAME] relief is obtained .

Based on observation, interview and record review the facility failed to provide justification for the continued use of muscle relaxant medication for 1 of 6 residents reviewed for unnecessary medications, (#88). Findings: Resident #88 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/20/19 at 9:26 AM the resident was sitting in a reclining chair in the activity room. She was confused and not able to answer any screening questions. A review of the physician orders [REDACTED]. A pharmacy monthly medication regimen review dated (MONTH) 20, (YEAR) documented a recommendation by the consultant pharmacist to, Please reduce the [MEDICATION NAME] HCL by tapering over 2-4 weeks as follows, with the end goal of discontinuation while initiating [MEDICATION NAME] 1000 mg every 8 hours as needed (not to exceed 4000 mg from all sources of [MEDICATION NAME] in 24 hours). The rationale for the recommendation was that muscle relaxants have strong sedating [MEDICATION NAME] properties, are associated with increased risk for fractures and have questionable efficacy at doses tolerated by older adults. [MEDICATION NAME] is among the recommended alternatives. A review of the resident's medical record did not reveal any changes to the [MEDICATION NAME] order or any rationale for the continued use of the medication. Resident #88's October, November, (MONTH) (YEAR), (MONTH) 2019 and (MONTH) 1-21 2019 Medication Administration records (MAR) revealed that she continued to receive [MEDICATION NAME] HCL 10 mg three times daily. On 02/21/19 at 11:56 AM, interview with registered nurse (RN) K resident #88's case manager for hospice revealed that the pharmacy recommendations were addressed by the primary physician. It was not ordered by hospice. On 02/21/19 at 1:41 PM, interview with the 3rd floor License Practical Nurse (LPN) F validated that he signed the verbal order from the resident's Advanced Registered Nurse Practitioner (ARNP) to continue the medication on 11/23/18. He did not explain why a rationale was not provided for the continued use of [MEDICATION NAME] as per the pharmacy recommendation. There was also no documentation that the Director of Nursing reviewed and signed the consultation report as required.

Based on observation, interview and record review the facility failed to implement, monitor and ensure compliance with isolation precautions to prevent cross-contamination and spread of contagious pathogens for 2 of 4 residents reviewed for infections, (#304, #305). Findings: On 02/19/19 at 9:20 AM an observation revealed resident #305 assigned to room [ROOM NUMBER] and resident #304 assigned to room [ROOM NUMBER]. Both residents shared a common bathroom. Resident #305 was in the shared bathroom with his Certified Nursing Assistant (CNA) who was providing activities of daily living (ADL) care. On 02/19/19 at 9:53 AM an interview with resident #305 revealed that he had been having diarrhea for the past 3 days. I let them know but they have not done anything. I had blood work drawn yesterday but no stool specimen was done. Review of resident #305's medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Documentation of his temperatures revealed he was afebrile until 02/17/19 when his temperature increased to 99.4 degrees. Physician orders dated 02/18/19 included [MEDICATION NAME] (antibiotic)100 milligrams (mg) orally (po) twice a day (bid) for 7 days for increased white blood cells (WBC) and reddened incision site. The CNA bowel documentation log revealed that on 02/17/19 he had 2 episodes of large loose diarrhea, on 02/18/19 he had 1 episode of loose diarrhea and on 02/19/19 he had 3 episodes of loose diarrhea. On 02/19/19 at 4:50 PM, resident #305 was now observed to be on isolation precautions with personal protective equipment (PPE) set up in the hallway outside of his room. On 02/19/19 at 4:51 PM Registered Nurse (RN) C stated that resident #305 had been having diarrhea for 3 days and he was now on isolation precautions for possible [MEDICAL CONDITIONS] until a stool specimen was obtained. According to the Centers for Disease Control (CDC) [MEDICAL CONDITION] is a bacteria that causes life-threatening diarrhea. It is usually a side-effect of taking antibiotics. Symptoms include diarrhea: loose watery stools, fever, stomach tenderness, loss of appetite and nausea. In its spore form D-Diff also resists most routine environmental cleaning agents and may last for months on surfaces. It has been noted that those receiving short-term rehabilitation after hospitalization may be at particularly high risk for [MEDICAL CONDITION] infection. Because patients with [MEDICAL CONDITION] infection are considered the major source for transmission measures include contact precautions, in a private room if available until diarrhea resolves, use of personal protective equipment, limited transport and movement outside of the room, use of disposable or dedicated patient-care equipment and prioritize cleaning and disinfecting of rooms. On 02/20/19 at 9:23 AM, Certified Nursing Assistant (CNA) D stated that resident #305 required minimum assistance with transfer and ambulated with a walker to the bathroom. She said that he was incontinent of bowel and bladder, wore briefs, and was on isolation. He did complain of a stomach ache. They obtained a stool sample this morning and he was being moved to a private room. There were visitors in the room at this time and only one of the visitors was wearing a gown. The wife is not wearing a gown. On 02/20/19 at 9:38 AM an observation of resident #305 was conducted with the Windsor Unit Manager (WUM). Resident #305's wife was observed in the room, sitting in a chair by the window without the use of personal protective equipment (PPE). The WUM explained to the wife that it was highly recommended that she wear the gown while in the room. The wife stated, I don't really care to wear gown in the room. The WUM then stated, We prefer that you wear the gown but you do need to wash your hands. At this time, the WUM stated that both residents used the shared bathroom and resident #305 was offered a commode and he refused so we are moving him to the first floor rapid rehabilitation unit. The Infection Control Practitioner (ICP) was notified of the isolation for suspected [MEDICAL CONDITION] yesterday. When the WUM was asked why resident #305 was not moved yesterday when they suspected that he may have [MEDICAL CONDITION], she stated, We should have. The WUM was then asked what the facility policy and procedure was for isolation? The WUM stated that all staff and anyone entering the room was required to wear PPE. The reason for the PPE is to make sure that we do not spread the [MEDICAL CONDITION] to any other residents or staff. When she was asked why she did not explain to resident #305's wife that she must wear PPE, the WUM could not explain. Infection Control note dated 02/20/19 documented loose stools times 3 per day on 02/19/19, culture pending, started on antibiotic [MEDICATION NAME] at this time, culture date 02/19/19 and contact isolation. Room Change Notification Form dated 02/20/19 documented present room [ROOM NUMBER], future room [ROOM NUMBER], change requested by staff, reason for request to move to a private room and resident was notified and approved. On 02/20/19 at 10:17 AM the Infection Control Practitioner arrived on the unit. She stated that was the facility policy that when a resident had [MEDICAL CONDITION] they are in a non-shared bathroom. The resident (non-infected) who shared the bathroom is given a commode to use. Resident #304 will be moved to another room. All staff and visitors are required to use the PPE/CDC guidelines. On 02/20/19 at 10:31 AM the Director of Nursing, (DON) stated that resident #305 was placed on isolation last evening and the other resident (#304) was given a commode. The reason we give the other resident the commode is so that he is not in the same bathroom with the [MEDICAL CONDITION] stool. I understand that he was using the bathroom at the end of the hallway. We also move the resident that is not contagious. When asked why resident #305 was moving to the rapid rehabilitation unit room [ROOM NUMBER], the DON stated that resident #305 was staying in his room (715) here on the unit and the adjoining resident (#304) was moving to another room. Resident #305 is not changing his room. Review of resident #304 medical record revealed he was admitted to the facility on [DATE] to room [ROOM NUMBER] with [DIAGNOSES REDACTED]. Review of his care plan dated 02/05/19 noted that the resident was incontinent of bladder related to mobility deficits. Goal: for resident to be receptive to staff cueing and assistance with toileting. Interventions included to assist with toileting and cue resident to use the bathroom as needed. On 02/20/19 at 5:30 PM interview with resident #304 (now in room [ROOM NUMBER]) and his wife revealed that the resident had been at the facility for 3 weeks. The resident's wife stated that she became aware of the issue with the resident in room [ROOM NUMBER] last night (02/19/19) when she saw the staff putting on yellow gowns to go into his room and the sign on his door to see nurse before entering. I know he has something contagious and we were all using the same bathroom so we have already been exposed. I stay here all the time and sleep here on a cot. I use the bathroom all the time. When resident #304 was asked if he was using the bathroom at the end of the hall he stated that he never used the bathroom at the end of the hall, I was using my bathroom. This contradicted the DON's statement that resident #304 was using the bathroom at the end of the hall. On 02/21/19 at 11:49 AM the ICP stated that resident #305's stool culture was positive for [MEDICAL CONDITION]. The Nurses, CNAs and Unit Managers were responsible for making sure that isolation and use of the PPE was maintained. The goal was to prevent infection, contain and prevent spread of infection to other residents, staff, family and all other individuals in the facility. On 02/21/19 on 2:13 PM resident #305 was in his room sitting at the side of the bed. Occupational Therapist (OT) N and Activity Assistant M both wearing PPE were providing therapy. Upon completing an interview with resident #305 it was noted that the container to discard used PPE was approximately 3 feet from the resident. Both OT N and Activity Assistant N stated, It is not common sense that we have to put on the PPE before entering the room but we take the PPE off right next to the resident. On 02/21/19 at 2:10 PM the WUM stated that the PPE is set up outside of the room so that staff can put on the PPE before entering the room to protect their clothing. He is positive for [MEDICAL CONDITION]. The WUM could not explain why the container to dispose of the PPE was right next to the resident. She stated that the container should not be next to the resident. Review of the facility Policies and Practices - Infection Control, dated (MONTH) 2014, read, Policy Statement, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infection. Policy Interpretation and Implementation 1. This facility's infection control policies and practices apply equally to all personnel . residents, visitors . and general public 2. The objectives of our infection control policies and practices are to: a. Prevent, detect, investigate, and control infections in the facility, b. Maintain a safe, sanitary, and comfortable environment for all personnel, residents, visitors, and general public, d. Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions Review of the facility policy [MEDICAL CONDITION], dated (MONTH) (YEAR), read, Policy Statement, Measures will be taken to prevent the occurrence of [MEDICAL CONDITION] among residents and precautions will be taken while caring for residents with [DIAGNOSES REDACTED]icile to prevent transmission to other residents Review of the facility Contact Precaution, dated 03/01/07, read, In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect with environmental surfaces or resident-care items in the resident's environment b. Resident Placement . (2) Isolate the individual in a private room if it is not feasible to contain drainage, excretions . f. Resident-Care Equipment (1) When possible, dedicate the use of non-critical care equipment items such as a stethoscope, sphygmomanometer, bedside commode, or rectal thermometer to a single resident (or cohort of residents) to avoid sharing between residents

Based on record review and interview, the facility failed to ensure the the Minimum Data Set(MDS) discharge assessment was transmitted within the appropriate time frame for one of one resident reviewed (#1). Findings: Resident #1 was admitted on [DATE] for a short term admission related to a urinary tract infection. He was discharged on [DATE]. The MDS 14 day assessment with reference dated on 9/05/18 was completed on 9/16/18 but not transmitted. The discharge assessment dated [DATE] was completed on 9/16/18. It was not transmitted. On 2/19/19 at 4:47 PM interview with the MDS supervisor B revealed that resident #1 had a primary insurance plan Medicare replacement policy. The facility was to only submit the entry, admission 5 day assessment and the discharge assessment. The part time MDS assistant who no longer works at the facility completed the discharge assessment. He confirmed that the assessment was not transmitted timely. Review of the per the Resident Assessment Instrument 3.0 users manual confirmed that the missing submission was the discharge assessment. The discharge assessment should have been transmitted within 14 days of completion. It was greater than 140 days late.

Based on observation, record review and interview, the facility failed to provide supervision to prevent accidents/injuries for 1 of 3 sampled residents (#3). Findings: Record review revealed that resident #3 had a history of [REDACTED]. Shortly after admission, the resident began falling and having behaviors placing her at risk for falls at the facility. Review of the Interdisciplinary Notes (IDN) revealed the following: 1. 5/29/10 7:29 a.m. resident alert with confusion transferred self from bed to chair. 2. 6/5/10 CNA (Certified Nursing Assistant) alerted nurse to resident's room, reporting resident on floor. No signs/symptoms of injury. 3. 7/13/10 12:51 p.m. skin tear. Resident attempting to transfer self from wheelchair to lounge chair 4. 7/23/10 8:07 resident found on floor in hallway. Skin tear noted to left upper arm. 5. 9/2/10 found on floor, skin tear to right elbow and nose. 6. 9/4/10 8:59 p.m. found on floor in dining room. Further review of the resident's medical record between 6/01/10 to 9/10/10 revealed that the physician had ordered safety devices such as bed & chair alarms, alarm belt, and low bed with floor mats. The resident continued to have falls. Interdisciplinary Note (IDN) dated 9/23/10 indicated that at 3:33 a.m. the resident fell and staff observed the resident on the floor on her back. The resident sustained [REDACTED]. The resident's physician and daughter were notified and the resident was taken to the hospital. emergency room records revealed that the resident also sustained a fractured left elbow. Hospital records indicate the resident is diagnosed with [REDACTED]. The resident returned to the facility on [DATE]. The 3008 Form indicated that the resident requires assistance with ambulation and transfer. As of 10/15/10, the falls care plan indicated the resident was using a self-releasing alarm belt in the wheelchair. On 11/29/10, the physician upgraded the resident's restraint/safety device to a non-releasing seat belt while in chair and discontinued the self-releasing belt. The Physical Restraint Reduction Assessment, also dated 11/29/10, indicated the resident continues to get up from the chair unassisted with falls. Review of the falls care plan with a goal date of 3/16/11 revealed the resident was at risk for fall or injury related to mobility deficits, generalized weakness, fatigues easily, cognitive deficits, memory deficits, poor insight into physical limitations, poor safety awareness, orthostatic hypotension, history of falls, potential side effects of medications, requires assistance with transfers, right knee weakness, poor trunk control, elevated anxiety levels in the evening. On 12/01/10, the physician increased the resident's antidepressant medication, Celexa, to 10 milligrams to be given twice a day. Antidepressant medication increases the risk for falls due to the possible risk of increased somnolence. On 12/08/10, the physician discontinued the resident's chair alarm, but continued the bed alarm. IDN dated 1/10/11 at 5:50 a.m. indicated that the resident was using a bedside commode and stood up and fell . An approach was added to the resident's fall care plan on 1/10/11. This new approach read, "Resident will be attended by staff when using BSC (bed side commode)." Occupational therapy (OT) screening was done on 1/14/11, four days after the resident fell . It revealed "no significant functional decline at this time." The OT note did not address safety or positioning when seated in the dining room chair without the non-releasing seat belt. Twelve days later, on 1/22/11, the resident fell again and was injured. The IDN dated 1/22/11 at 10:40 p.m. read, "resident was transferred from w/c (wheelchair) to dining room chair during supper time. CNA failed to put alarm on dining room chair. Resident apparently got up to leave dining area and fell . AROM (active range of motion) to exts (extremities). Complains of pain to (R) knee. MD notified, stat x-rays were done, results called in stat to MD, orders given to send to hospital. Picked up by Rural Metro at 10:30 pm. Resident's daughter notified of transfer." Review of physician orders did not reveal orders for a chair alarm at that time. Review of the resident's hospital records from the 1/22/11 hospital admission revealed that the resident sustained [REDACTED]. The causes of a hemothorax is usually traumatic, from a blunt or penetrating injury to the thorax, resulting in rupture of the serous membrane either lining the thorax or covering the lungs. On 2/23/11 at 6:30 p.m., the 3-11 nurse was interviewed. The nurse recalled the event and indicated that she was resident #3's 3-11 nurse on the date of the fall, 1/22/11. She stated resident is on a walk to dine program and that a CNA assisted the resident to the dining room and placed the resident in a dining room chair. The nurse stated the staff did not put an alarm on the dining room chair. The interview continued with observation in the dining room with the nurse who explained/diagramed where the resident sat and the locations of other staff in the dining room. The resident was seated at a 6 person table and this nurse had her back to the resident because she was assisting another resident at the head of the table. The nurse was unaware the resident had gotten up from the table until she heard the fall. The nurse said the resident got up and was walking towards the exit door when she fell . The nurse recalled that there were 4 CNAs in the dining room at the time, but they were assisting other residents. It was determined, based on the interview with this nurse, that at the time of the fall, staff was not sitting with the resident and did not have visual contact with the resident despite the resident's need for assistance with transfer and history of getting up from the chair without assistance. On 2/23/11 at 7:15 p.m.. the Assistant Director of Nursing (ADON) was asked if the facility had conducted a fall investigation. She did not provide any evidence of an investigation of the fall at the time of this request. On 2/23/10 at 7:40 p.m., the 3rd Floor Unit Manager (UM) was interviewed. She indicated that that she received a phone call on the evening of 1/22/11 when resident #3 fell . She confirmed that the physician discontinued the chair alarm when the non-releasing belt was ordered. Several minutes later at 8:10 p.m., the UM was interviewed again. The resident's fall on 1/10/11 was discussed. She stated that a nurse placed resident #3 on the bedside commode and left the room in order to answer call lights/alarms. The UM stated that it was her understanding that no one was in the room with the resident when she fell . This information was conveyed to resident #3's daughter. The IDN dated 1/10/11 was reviewed with the UM. The note indicated that a CNA was with the resident when she fell off the bedside commode. The UM was not aware that staff had documented that a CNA was present when the resident fell on [DATE]. On 2/24/11 at 11:45 a.m. resident #3's daughter was interviewed, via phone. The daughter stated that she was informed by staff that her mother was alone in the room when she fell off the bedside commode on 1/10/11. The daughter confirmed the fall on 1/22/10 that caused her mother to go to the hospital. She stated her mother always ate her meals in the wheelchair. She stated that prior to the fall on 1/22/11, she was at the facility during meal time. She observed staff attempting to take her mother out of the wheelchair and place her in a dining room chair. She stated that staff informed her that a new protocol was being implemented of transferring residents to regular dining room chairs. The daughter requested that her mother remain in the wheelchair during meals. Based on the interviews by staff and record review it was determined that the facility had not assessed resident #'3's fall risk while sitting in a regular dining room chair. The resident required close supervision by staff when the physician ordered non-release belt was removed. Resident #3 did not receive the appropriate supervision this resident required from staff per the care plan based on the fact that the nurse had her back to the resident and the CNA staff were engaged with other residents.