Every finding on record at Creston Specialty Care

Based on observation, staff interviews, and policy review the facility failed to properly secure and store medications to minimize loss or access for 1 of 3 medication carts. The facility reported a census of 47 residents. Findings include:Continuous observation on 6/28/26 at 3:37 PM an unlocked treatment cart at the nurses' station with no staff present. Observed 6 residents in the area seated in wheelchairs or dining chairs in the living/dining area. The medication cart contained the following:The top right drawer contained stock medications including aspirin 81, Bisacodyl, magnesium, acetaminophen.The second right drawer down contained prescribed medications for 12 residents.The third right drawer down contained prescribed medications for 9 residents.The bottom right drawer contained liquid laxative, inhalers, nebulizer solution, antacids, and cough syrup.The top left drawer contained scissors and a pill cutter.The second left drawer down was locked.The third left drawer down contained lancets.At 3:43 PM the Administrator walked up to the open medication cart and asked where the nurse was. Staff F, Licensed Practical Nurse (LPN), walked up the nurses station, and over to the unlocked medication cart. Staff F confirmed the medication cart was unlocked by opening a drawer, stated that this was not her medication cart, but would lock it. Staff F proceeded to lock and secure the medication cart. On 6/28/26 at 4:01 PM Staff G, LPN, walked up to the locked medication cart and acknowledged she was the nurse who was assigned to that cart since 6:00 AM. The staff stated she should have locked the medication cart before she walked away.On 6/30/26 at 11:31 AM the Interim Director of Nursing (DON) stated the staff know the medication cart(s) need to be locked when they are not using them. The Interim DON stated she had personally provided education to all staff who provide medications and expectation that the medication carts be locked.On 6/30/26 at 12:45 PM the Regional Director of Clinical Services expected the medication carts would be locked when not in use. The facility's Security of Medication Cart Policy, undated, revealed the medication carts must be securely locked at all times when out of the nurse's view. The document included when the medication cart is not being used, must be locked and parked at the nurses' station.

Based on observation, menu review, clinical record review, staff interviews, and policy review, the facility failed to serve all of the menu items to seven (7) residents who were ordered pureed diets. The facility reported a census of 47 residents.Findings include:On 6/30/26 at 11:19 AM, a meal service observation revealed Staff I, cook, reviewed the diet sheet in the kitchen, verified the menu items to be served, and stated there were seven (7) residents who were prescribed pureed diets. She pureed eight (8) servings of broccoli and chicken but did not puree wheat rolls.During a continuous lunch service observation that began on 6/30/26 at 11:19 AM and ended at 12:22 PM, all seven (7) pureed diets were served without pureed wheat rolls.On 6/30/26 at 12:40 PM, a menu review approved 3/11/26 revealed one (1) wheat roll was included in each pureed diet.On 6/30/26 at 1:00 PM, Staff I stated she forgot to include the dinner roll in the pureed diets during preparation and service. The Certified Dietary Manager (CDM) asked Staff I if the roll had been added to the other pureed items to which Staff I replied no.On 7/01/26 at 7:41 AM, the Administrator stated the menu should be followed. Food that is on the menu should be served.A policy titled Therapeutic Diets revised [DATE] indicated therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.

Based on observations, resident interviews, staff interviews, and policy review the facility failed to provide food at an appetizing temperature to 4 of 8 residents reviewed (Resident #5, #8, #14 and #23) The facility reported a census of 47 residents.Findings include:1. The Minimum Data Set (MDS) dated [DATE] for Resident #5 documented a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment.On 6/28/26 at 3:54 PM Resident #5 stated occasionally the warm food can be served cold and he would like it warm. Resident #5 stated he does not ask for staff to warm the food up but thought they would. 2. The MDS dated [DATE] revealed Resident #8 had a BIMS of 15 indicating no cognitive impairment. On 6/28/26 at 3:19 PM Resident #8 stated the food just did not have any taste to it at all. Resident #8 stated the food is served cool once in a while as well.3. The MDS dated [DATE] revealed Resident #14 had a BIMS of 13 indicating no cognitive impairment. On 6/28/26 at 1:29 PM Resident #14 stated she mostly eats soup at dinner time and the soup was not served as warm as she would like. Resident #14 stated the lunch is not always as hot as she would like. Resident #14 stated she never asked the staff to warm the food up but she thought they would. 4. The MDS dated [DATE] revealed Resident #23 had a BIMS of 15 indicating no cognitive impairment. On 6/28/26 at 3:29 PM Resident #23 stated the food was frequently served cooler than she would like. Resident #23 stated the food was cold sometimes. Resident #23 stated she does not ask them to heat the food up but thought they would heat the food up if needed. Observation on 7:35 AM of hall 5 breakfast tray delivery revealed at 7:36 AM Resident #39's breakfast tray was taken back to the end of the hall dining room. At 7:45 AM Resident #39 was assisted in his wheelchair to the table. At 7:47 AM breakfast tray given to Resident #39. At 7:47 AM the sample tray was taken to the kitchen. At 7:47 AM the breakfast tray arrived at the kitchen for a temperature check. Cream of wheat temperature was 118 degrees and scrambled eggs were 115 degrees.On 7/01/26 at 7:57 AM Staff N, Certified Dietary Manager (CDM) stated she worked at the facility for about 9 years. Staff N stated the temperatures of the food delivered to Resident #39 should have been higher when the resident received the meal. Staff N stated she would like to see the food delivered to the resident at or above 135 degrees. On 7/1/26 at 10:10 AM the Administrator stated the policy documented the food temperature of food delivered to the resident should be 135 degrees or above.Review of policy revised 12/13 provided by the facility titled, Assisting the Resident with In-Room Meals documented to check to ensure the hot foods are hot and the cold foods are cold. Be sure the resident is ready to receive the meal. To minimize the risk of foodborne illness, the time that potentially hazardous food remains in the danger zone (41 to 135) would be kept to a minimum.

Based on observation, staff interviews, and policy review, the facility failed to date and label previously opened food packages or properly store food in the freezer and dry goods storage room. The facility reported a census of 47 residents. Findings include:On 6/28/2026 at 9:50 AM, an initial kitchen tour revealed the following items:Four (4) serving trays with multiple uncovered, unlabeled, and undated small plates containing square items and multiple small bowls of pudding-like substance were stored in the refrigerator.An unlabeled bag of small, irregularly oval shaped items was stored in a bin labeled cereal but did not identify the type.An undated, previously accessed bag of mild cheddar cheese was stored in the walk-in refrigerator.Two (2) unlabeled, resealable bags of green leafy items dated 6/23 were stored in the walk-in refrigerator.On 6/28/26 at 10:12 AM, Staff H, cook, told the Certified Dietary Manager (CDM) the 4 trays were not labeled at the beginning of the survey tour. The CDM replied that they should have been.On 7/01/26 at 7:41 AM, the Administrator stated stored food should be labeled.A policy titled Food Receiving and Storage revised [DATE] indicated opened containers must be dated and sealed or covered during storage.

Based on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to follow the physician's orders for one (1) resident (#56) by failing to apply a leg immobilizer while the resident was in bed. The facility reported a census of 47 residents. Findings include:Resident #56's Minimum Data Set (MDS) for Resident #1 dated 6/25/26 revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated completely intact cognition. It included diagnoses of traumatic brain injury (TBI), a stroke, one-sided weakness, and a right arm fracture. It indicated the resident was admitted on [DATE] and his functional abilities had not yet been assessed.A Physician's Order dated 6/22/26 indicated the resident had a right leg fracture and included an order for right leg immobilizer to remain in place when resident is in bed and overnight. Ok to remove when up ambulating and working with <physical therapy> PT.A Nurses Note Progress Note dated 6/22/26 at 2:17 PM indicated the resident had surgery on his right hip and was to wear the right lower extremity immobilizer when at rest.The Care Plan dated 6/22/26 directed staff that right leg immobilizer to remain in place when resident is in bed and overnight. Ok to remove when up ambulating and working with PT.On 6/28/26 at 3:15 PM, Resident #56 was observed asleep in his bed. His immobilizer was not applied to his right leg and was observed lying on the top of his dresser.On 6/28/26 at 3:32 PM, Staff K, Certified Medication Aide (CMA) responded to Resident #56's call light. The immobilizer was not on his right leg after she exited the room.On 6/29/26 at 2:18 PM, Resident #56 was observed asleep in his bed. His immobilizer was not on his right leg and was observed lying on his dresser.On 6/29/2026 at 2:20 PM, Staff K stated CMAs and <Certified Nurse Aides> CNAs can apply or remove assistive devices such as arm slings and leg immobilizers because they received specialized training from <physical> therapy.On 6/29/26 at 2:21 PM, Staff L, CNA stated he doesn't have it on when he's working with PT. She also stated she asked the CMA if it could be left off because he didn't have it on that morning when she went to get him up. She stated the CMA said it was ok to leave off.On 6/29/26 at 2:30 PM, Staff K stated the resident does not like the leg brace and doesn't understand its intention. She also stated he verbally said no today but did not notify the nurse of his refusal. She further stated there was no reason she didn't apply it on 6/28/26 but added there was no place to document the resident's refusal to wear it.The June 2026 Medication Administration Record (MAR), Treatment Administration Record (TAR), and Supplemental Documentation did not include the resident's leg immobilizer for staff to monitor.On 6/29/26 at 2:47 PM, Staff M, Licensed Practical Nurse (LPN) stated she was not notified that his leg brace was not applied. She also stated the order to keep his immobilizer on his RLE while asleep in bed or working with PT did not transition to the area where staff can document refusals. She added it to the MAR for staff to document if the resident refuses.On 6/29/26 at 2:58 PM, Staff M telephoned Staff K and asked if she notified the physician when she was in the building that morning. Staff K was heard stating she did not notify the provider that the resident refused the immobilizer.On 7/01/26 at 7:37 AM, the Director of Nursing (DON) stated the mobilizer needed to be on while he is at rest.The facility did not have a policy specific to following physician's orders.

Based on observation, clinical record review, staff interview, and policy review, the facility failed to lock the wheelchair during a transfer for 1 of 5 residents dependent on mechanical lift transfers (#40). The facility reported a census of 47 residents.Findings include:Resident #40's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated moderately impaired cognition. It included diagnoses of anxiety, depression, schizophrenia, muscle weakness, and unsteadiness on feet. It indicated she required setup assistance with eating, moderate assistance with oral hygiene, and was dependent with all other Activities of Daily Living (ADLs) and mobility. It also indicated she used a wheelchair for mobility.The Care Plan initiated 10/16/23 indicated the resident was dependent with transfers and directed staff to use a 2-person, mechanical lift with a sling for transfers.On 6/28/26 at 12:46 PM, Staff G, Licensed Practical Nurse (LPN) and Staff J, Certified Medication Aide (CMA) transferred Resident #40 in a mechanical lift from her wheelchair to her bed. The wheelchair was observed unlocked when she was lifted from the wheelchair.On 6/28/26 at 1:13 PM, Staff J stated wheelchairs should be locked when using a mechanical lift to transfer residents. She also stated they noticed the wheelchair was unlocked after they transferred Resident #40 to her bed.On 6/28/26 at 3:52 PM, Staff G stated they forgot to lock the resident's wheelchair but added it should have been locked during the transfer.On 7/01/26 at 7:37 AM, the Director of Nursing (DON) stated wheelchairs should be locked during resident transfers.A policy titled Lift - Mechanical revised 4/08/15 directed the user to position the wheelchair and lock the wheels when transferring a resident.

Based on observations, interviews, record reviews, and policy review the facility failed to provide services meeting profession standards for 1 of 3 residents (Resident #2). The facility failed to follow physician orders for provision of medications as per physician orders. The facility had a census of 54. Findings include:Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating normal cognition. The document provided the diagnoses of atrial fibrillation, anemia, heart failure, hypertension, and respiratory failure. The document listed Resident #2's medications included an anticoagulant. The Care Plan Dated 10/7/25 provided a focus area related to risk for urinary tract infection (UTI) related to incontinence dated 91/8/24 and revised 10/3/24. Interventions included encouraging fluids and monitoring for signs and symptoms of UTIs. An anticoagulant use related to congestive heart failure (CHF) initiated on 3/31/23 and revised 8/26/23 focus area provided an intervention for staff including monitoring for side effects (unusual bruising, bleeding gums, purpura and changes in mental status) initiated 3/29/23. Resident #2's Medication Administration Record (MAR) - Treatment Administration Record (TAR) 9/25 revealed Apixaban Oral Tablet 5 mg, give 1 tablet by moth 2 times/day (BID) related to chronic diastolic CHF with a start date of 3/29/23, hold date from 9/4/25 to 9/5/25 and hold from 9/5/25 to 9/8/25. Resident #2's MAR - TAR 10/25 revealed Cranberry Concentrate Capsule 500 mg; give 500 mg by mouth in the morning for UTI prevention with a start date of 6/28/25. The Electronic Medical Record (EMR) Progress Notes revealed the following documentation:9/4/25 12:34 PM note entered by Staff B, Licensed Practical Nurse (LPN), - Certified Nurse Assistant (CNA) alerted the nurse to blood in the resident's brief in the morning. Monitoring revealed continued blood in brief and bedpan with the provider contacted who ordered a straight catheter. Entered 9/4/25 4:50 PM note entered by the Director of Nursing (DON) - duplicate medication brought to the attention of the DON. Audit showed potential for duplication related to the facility not utilizing calendar date system for popping medications, multiple short stock medication cards present at the same time. Unable to verify if duplicate doses administered. The provider was notified and ordered to hold Eliquis in the evening. 9/4/25 entry by provider - the resident was seen for gross hematuria in her brief in the morning. Staff noted the resident received 2 extra doses of Eliquis which is suspected cause of gross hematuria. Urinalysis performed on 9/4/25 revealing red color, turbid clarity, negative bilirubin, negative ketones, large amounts of blood, negative nitrites, and trace leukocytes. Hold Eliquis if no further bleeding may restart at 5 mg BID. 9/5/25 1:47 PM note by Staff B - resident with mouth swelling, redness, pain and discomfort. Bleeding stopped overnight and presented a new issue. Contacted the provider and ordered to send to the emergency department (ED). 9/5/25 1:50 PM note by Staff B - call to the ED potential of double dosing Eliquis on 9/2 and 9/3, previous day's symptoms and complaints today of headache, pain, tingling on R side of face lip swollen on R side. 9/5/25 3:23 PM note by Staff B - the ED reported diagnosis of mouth pain, labs included hemoglobin were good. 9/5/25 7:58 PM - hold Apixaban Oral Tablet 5 mg until seen by the provider on next visit.The facility's Risk assessment dated [DATE] for Medication Error revealed on 9/2 and 9/3 there were 2 Eliquis (Apixaban) medication cards flipped facing forward with both the pills missing for those dates. There was the potential that the resident was given double the dose on 9/2 and 9/3. The document disclosed that facility nurses stated they had been told it didn't matter what date they popped for short stock mediations and had not been popping them by calendar date; therefore the DON could not be positive that extra doses had not been given. Observed on 10/9/25 at 8:30 AM Staff D, LPN, provide Resident #2 with medications. The resident received Abilify 5mg, Allopurinol 110 mg, Bumex 2 mg, Claritin 10 mg, Cranberry 450 mg, Ferrous Sulfate 65 Fe), Levothyroxine Sodium 125 mcg, Magnesium Oxide 400 mg, MiraLAX, Potassium Chloride 20 MEQ, Prednisone, Protonix 40 mg, Sertraline 150 mg, Acetaminophen Oral 500 x2, Apixaban 5 mg, Carvedilol 6.25 mg, Rivastigmine 3 mg, Zenpep 40000-126000. The facility failed to provide Resident #2 the correct medication by dispensing Cranberry 450 instead of the ordered Cranberry 500 mg.On 10/8/25 at 1:30 PM Resident #2 stated she had been given too much blood thinner and had a bleeding episode. The resident stated she had been seen by her provider. Resident #2 stated she did not have bleeding past the first day, but did go to the hospital the next day because her face was swollen. The resident did not know how much extra medication she received.On 10/8/25 at 4:31 PM Staff B stated she had been present when Resident #2 had vaginal bleeding. The staff stated everytime the resident had a brief change there had been blood present on that day. Staff B stated the resident had 2 medication cards for the same medication. The staff indicated the second card did have medications missing from it, although the documentation indicated only 1 dose had been provided on the MAR. Staff B stated when the Apixaban was held the bleeding stopped. The staff stated Resident #2 stopped bleeding overnight from 9/4 - 9/5, but then developed the swollen face and pain. The staff provided the resident was sent to the hospital per provider order and upon return only had diagnosis of mouth pain and was ordered Magic Mouthwash.On 10/9/25 at 11:11 AM Staff D confirmed the cranberry concentrate that had been given to Resident #2 was 450 mg. and the MAR dosage for cranberry concentrate was 500 mg. On 10/9/25 at 11:17 AM the DON acknowledged it was a problem if Resident #2 was receiving 450 mg and orders stated 500 mg. The staff stated the provider needed to be notified that the order was not provided as written. The DON stated that nurses need to confirm medication is what is on MAR and that was a simple error that should not be happening. The staff stated she could not say if Resident #2 got extra doses or not of Eliquis. The staff stated there were extra cards in the cart due to the medication being dispensed in short stock meaning 14 days versus normal 30 day increments. The DON stated depending on the insurance company was how Eliquis as well as some other medications would be dispensed from the pharmacy. During the course of investigation the DON stated staff had told her that with short stock medications they may not pull by the date. The DON stated could not prove or disprove whether Resident #2 got 2 double doses of Eliquis; however, with the symptoms of gross hematuria the facility went with the assumption extra medication had been dispensed with notification to the provider. The DON stated education had been provided to staff that they must dispense all medications in day order with the exception of medications that the pharmacy dispenses differently or narcotics that go backwards. The DON stated audits have been occurring since that time with no new concerns found until today with the cranberry stock medication.On 10/9/25 at 1:25 PM the Administrator stated medications should be provided as ordered. The Administrator concurred that although proof could not be provided that the resident definitely was given extra doses of Eliquis the facility did respond as if the doses had been provided with the treatment of the resident, and the training/audits completed by the DON. The Administrator stated the DON was working to manage the stock medications and get consistency with physician orders and medications received to decrease the risk of wrong medications provided. On 10/9/25 at 1:35 PM the DON provided a container of cranberry 500 that was in the medication cart and stated she was unable to confirm whether previous dates of cranberry were provided at the 450mg. or 500 mg., but did concur that cranberry 450 had been provided on this date.The facility's policy, Administering Medications, dated 4/19, revealed medications were administered in accordance with prescriber orders. The document provided that the individual administering the medication checks the label 3 times to verify the right resident, right medication, right dosage, right time and right route of administration before providing the medication.

Based on observations, resident and staff interviews, and policy review the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 3 of 4 residents reviewed (Residents #1, 2 and 4). The facility reported a census of 54. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The document listed Resident #1 as occasionally incontinent of bladder. The resident required partial/moderate assistance for transfers and toileting. Resident #1's Care Plan dated 9/29/25 revealed an Activities of Daily Living (ADLs) focus area, dated 7/24/25, with interventions indicating the resident required partial assistance x1, stand pivot transfer, dated 7/24/25 and revised 9/30/25, and parietal assistance x1 for toileting, dated 7/24/25 and revised 9/30/25. The document included a urinary incontinence focus area dated 7/24/25 and revised 7/25/25. Interventions include assistance to the bathroom/commode and perineal cleansing as needed dated 7/24/25.On 10/9/25 at 10:17 AM Resident #1 stated the facility since her admission has had low staffing especially in the afternoons and overnight shifts. The resident stated she has had to wait longer than 15 minutes for assistance with toileting and had episodes of incontinence. The resident stated the incontinence episodes made her very upset. 2. Resident #2's MDS dated [DATE] revealed a BIMS score of 13/15 indicating normal cognition. The document listed the resident as always incontinent of bladder and occasionally incontinent of bowel movements. The resident required total assistance of staff for transfers and toilet hygiene. The Care Plan Dated 10/7/25 provided a focus area related to risk for urinary tract infection (UTI) related to incontinence dated 91/8/24 and revised 10/3/24. Interventions included encouraging fluids and monitoring for signs and symptoms of UTIs. The ADL focus area dated 10/11/23 included interventions of use of a padded Hoyer (dependent mechanical lift) x2 staff for transfers dated 7/31/25, dependent on 2 staff for toileting with use of a bedpan, and partial assistance of 1-2 staff for bed mobility.On 10/8/25 at 1:30 PM Resident #2 stated staffing was worse on the 2-10 shift and has had to wait over 1 1/2 hours to be changed. The resident stated on one occurrence that she had asked staff for assistance to be toileted after lunch and before bingo. The resident stated she watched several staff at the nurses station talking, but no one would assist her with the toileting request. Resident #2 stated she went to bingo in wet pants as she would have been late if they had ever had come to help her and bingo was an activity that was really important to her. Resident #2 stated her personal hygiene was also really important to her and it made her feel terrible that she had to sit in wet pants for 1.5 hours. The resident stated staff have taken an extended period of time for answering her call light leading to bowel incontinence which upsets her.On 10/9/25 at 10:17 AM Resident #1 stated she was present when Resident #2 asked for assistance to complete toileting at the end of lunch and before bingo. Resident #1 stated she also asked staff for assistance on behalf of Resident #2 and no assistance was provided. The resident stated she was aware of Resident #1 having an incontinence episode and having to sit in wet pants during bingo. 3. Resident #4's MDS was in progress due to admission on [DATE]. The electronic health record (EHR) provided Resident #4 had a diagnosis of nondisplaced fracture of the greater trochanter of the right femur with routine healing. The EHR Nursing Admission/readmission Evaluation provided the resident required 1 person assist for transfers and 1 person partial assistance for toileting. The document revealed the resident was alert and oriented to person, place, time and situation. A continuous observation on 10/9/24 began at 7:04 AM with Resident #4's call light turned on. Observed several Certified Nurse Assistants (CNAs), nurse and the Administrator walk past the resident's room with the call light on. At 7:22 AM observed Resident #3 sitting on the edge of the bed and saying someone please help. At 7:26 AM Staff C, CNA, went into the resident's room and the call light was shut off. The call light was on for 22 minutes. A continuous observation on 10/9/25 began at 10:46 AM noting Resident #4's call light was on with auditory beeping heard. Observed several staff standing at the nurses station. The resident's call light went off at 10:50 AM with no staff going in the room. Resident #4 stated the call light had been on for longer than 15 minutes. The resident acknowledged earlier in the day she had called out for help as she needed to use the bathroom and no one had answered her call light. The resident stated the call light had just been on and turned off herself and had a family member assist her as had incontinence episode waiting for staff. The family member confirmed light had been on and staff did not come to assist prior to the incontinence episode. On 10/8/25 at 4:12 PM Staff A, CNA, stated she worked both AM (6-2) and PM (2-10) shifts. The staff stated there had been times where the facility was shorter on staff on the PM shift with there being 2-3 staff present. The staff acknowledged when there were fewer staff it was more difficult to answer call lights in less than 15 minutes. On 10/8/25 at 4:31 PM Staff B, Licensed Practical Nurse (LPN), stated call lights can be on for a long period of time. The staff stated a call light on longer than 15 minutes was long. Staff B stated call lights were on longer than 15 minutes on the 2-10 shift. The staff stated there were several residents who required more assistance and there were not always enough staff present to assist them. On 10/9/25 at 11:08 AM Staff C stated it was difficult at times answering call lights in less than 15 minutes. On 10/9/25 at 11:17 AM the Director of Nursing (DON) she expected call lights to be answered as soon as possible. The DON acknowledged the standard answer is usually 15 minutes but sometimes at meals or just after lights may be longer due to multiple residents needing things at the same time. When asked about a 22 minute call light, the DON and Assistant Director of Nursing (ADON) agreed that would be a little longer than they would want. When provided with the knowledge of the resident calling out for help, they concurred that would not be something they would want to happen. The DON and ADON further agreed that they did not like that a resident turned a call light off when they were tired of waiting for staff and asked for a family member to assist them. The DON and ADON acknowledged that residents reporting incontinence episodes due to waiting for assistance was not the best scenario.On 10/9/25 at 1:25 PM the Administrator stated she would like call lights answered as soon as possible preferably within 15 minutes but knows that may not be happening. The Administrator acknowledged staffing had been a concern as the facility had hired several CNAs that were younger and still in high school. The Administrator stated with the younger staff it has been difficult getting them to work for their 2-10 shifts and their inability to use lifts without additional assistance from other staff. The Administrator stated her administrative staff (DON, ADON and herself) have been trying to help with answering call lights and attending to resident needs.The facility's Answering the Call Light Policy, dated 3/2, revealed the purpose was to ensure a timely response to the resident's needs and requests. The facility's Dignity Policy, dated 2/21, disclosed demeaning practices and standards of care that compromise dignity were prohibited with the example of promptly responding to a resident's request for toileting assistance.

Based on clinical record review, staff interview, and guidance from the 2024 Resident Assessment Instrument (RAI) Manual, the facility failed to complete and transmit Comprehensive Minimum Data Set (MDS) Assessments following a significant change within federal guidelines for 5 of 5 residents (#2, #17, #31, #34 and #45) reviewed for MDS Assessments. The facility reported a census of 47 residents. Findings include: 1. The Census Line portion of the Electronic Health Record (EHR) of Resident #2 documented the resident enrolled in hospice care on 11/1/24. The Medicare Hospice Election form additionally dated 11/1/24 as the date of hospice services to begin for Resident #2. The Significant Change MDS of Resident #2 was dated 11/12/24. Page 58 of the MDS recorded a completion date of 11/26/24, which was 25 days after hospice election. 2. The Census Line portion of the Electronic Health Record of Resident #17 documented the resident enrolled in hospice care on 3/12/25. The Medicare Hospice Election form additionally dated 3/12/25 as the date of hospice services to begin for Resident #17. The Significant Change MDS of Resident #17 was dated 3/21/25. Page 58 of the MDS recorded a completion date of 4/4/25, which was 23 days after hospice election. 3. The Census Line portion of the Electronic Health Record of Resident #31 documented the resident enrolled in hospice care on 3/31/25. The Medicare Hospice Election form additionally dated 3/31/25 as the date of hospice services to begin for Resident #31. The Significant Change MDS of Resident #31 was dated 4/8/25. Page 58 of the MDS recorded a completion date of 4/21/25, which was 21 days after hospice election. 4. The Census Line portion of the Electronic Health Record of Resident #34 documented the resident enrolled in hospice care on 7/18/24. The Medicare Hospice Election form additionally dated 7/18/24 as the date of hospice services to begin for Resident #34. The Significant Change MDS of Resident #31 was dated 7/24/24. Page 58 of the MDS recorded a completion date of 8/5/24, which was 18 days after hospice election. 5. The Census Line portion of the Electronic Health Record of Resident #45 documented the resident enrolled in hospice care on 2/8/25. The Medicare Hospice Election form additionally dated 2/8/25 as the date of hospice services to begin for Resident #45. The Significant Change MDS of Resident #45 was dated 2/18/25. Page 58 of the MDS recorded a completion date of 3/4/25, which was 24 days after hospice election. According to the 2024 RAI Manual, a Significant Change (comprehensive) assessment is required to be performed when a terminally ill resident enrolls in a hospice program. The RAI states the MDS completion date must be no later than 14 days after the determination that the criteria for a Significant Change are met. On 5/7/24 at 11:24 am, the Director of Nursing stated education will be provided to the MDS Coordinator regarding the timing of MDS completions. On 5/7/25 at 1:47 pm, via email, Regional Clinical Reimbursement Specialist stated the facility had no policy regarding MDS Assessments. She stated the facility follows the RAI manual.

Based on observations, clinical record review, family and staff interviews, and policy review, the facility failed to support the residents right to her choice by not assisting the resident in leaving her room despite multiple requests for 1 of 3 residents screened (Resident #33). The facility reported a census of 47. Findings Include: The quarterly Minimum Data Set (MDS) for Resident #33, completed 04/15/2025, documented her brief interview for mental status score as 05, indicating severely impaired cognition. It documented the following relevant diagnoses: cerebrovascular event (stroke), Non-Alzheimer's dementia, anxiety disorder, depression, and vascular dementia with behavioral disturbance. It documented the resident required a wheelchair for mobility and that she was fully dependent on staff for wheelchair mobility. The Care Plan for Resident #33, last revised on 05/03/2025, documented the resident has periods of increased anxiety behaviors. It instructs staff to assist the resident to a quieter, less populated place if she becomes agitated and to provide emotional supports and reassurance. It also directs staff to implement supports as ordered by physician. The Medication Administration Record for Resident #33 for the month of May, printed on 05/07/2025, documented the number of targeted behaviors the resident had, as well as the interventions attempted to calm the resident. It detailed the possible interventions as: encourage to voice concerns, one on one with staff, call family or friend, weighted blanket, calming music, take a walk, diversional activity, and other. A direct observation on 05/05/2025 at 10:08 AM revealed Resident #33 calling repeatedly for help. She called this surveyor over and asked for help. She began to cry, stating she could not move her wheelchair because it was locked, and that she would like to leave her room. After leaving the room she continued to call for help, and a certified nurse aide (CNA) responded for a moment to speak to the resident, closed her door, and walked away (Staff A). The resident continued to call for help until she was removed from her room for lunch service at 11:22 AM. A direct observation on 05/07/2025 at 07:43 AM revealed Resident #33 again calling for help and asking to leave her room. Numerous staff members were observed walking by while the resident continued to ask to leave her room and call for help. At 08:17 AM Resident #33 left her room using her wheelchair on her own, before being stopped by Staff A, and returned to her room at 08:20 AM. Her wheelchair wheels were locked at this time. In an interview on 05/05/2025 at 11:24 AM with Resident #33's family member, he stated he has previously addressed issues with the facility when they would lock his wife's wheelchair wheels and place her in her room without trying other interventions. He stated he feels they lock her in her room like it's a prison and don't let her come out. He stated she calms down quickly when provided with one on one support and that is one of the interventions they are supposed to try instead of letting her just yell in her room. An interview on 05/05/2025 at 10:29 AM with Staff A, CNA, she stated she had locked the resident's wheelchair brakes so the resident could not leave her room, as she was currently being disruptive. She stated she was not going to try other interventions until Resident #33's husband arrived. She stated he was supposed to arrive by noon. An interview on 05/08/2025 at 12:28 PM with Staff B, CNA, she stated staff are directed to assist dependent residents out of their rooms when they request assistance with that. She state she was familiar with Resident #33 and that if one intervention fails, they should try other interventions. She stated one-on-one care is something they are supposed to offer. An interview on 05/08/2025 at 12:31 PM with Staff A, CNA, she acknowledged she should have helped Resident #33 out of her room when she asked, and she had attempted other interventions beyond quiet time as Resident #33 had continued to loudly vocalize in her room, indicating the intervention had failed. She stated she is supposed to help dependent residents leave their room when they request it outside of extraordinary circumstances. An interview on 05/08/2025 at 12:35 PM with Staff C, Licensed Practical Nurse (LPN), she stated if a resident requested to leave their room and was dependent on staff to leave, she would help them get where they were going. She stated she was familiar with Resident #33, and that they are supposed to try a variety of interventions until something works. She further stated they have been instructed not to lock Resident #33's wheelchair brakes as she is capable of independent wheelchair mobility on an inconsistent basis. An interview on 05/08/2025 at 11:49 AM with the Director of Nursing, she stated her expectation is for staff to assist residents who are dependent on staff to leave their room when they ask unless they're on isolation protocols for illness. She stated her expectation was for staff to provide a variety of interventions, not just try one intervention. Review of a facility provided document titled Resident Rights, with a last revised date of December 2012, it stated in section 1, subsection D, that residents are to be free from corporal punishment or involuntary seclusion. In subsection H it stated the resident will be supported by the facility in exercising his or her rights.

Based on clinical record review, resident and staff interview, and guidance from the Centers for Disease Control and Prevention (CDC), and policy review, the facility failed to offer and provide the recommended COVID-19 vaccine to eligible residents for 1 of 5 resident reviewed for vaccines (#40). The facility reported a census of 47 residents. Findings include: The vaccine record of Resident #40 indicated the resident refused the appropriate COVID 19 vaccine. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated completely intact cognition. It included diagnoses of heart failure, chronic kidney disease, diabetes mellitus, seizure disorder, anxiety, depression, and asthma. It also indicated the resident was not up to date with her COVID-19 vaccination. The Electronic Health Record (EHR) Progress Notes included documentation dated 11/26/24 which indicated the resident declined the COVID-19 vaccine. On 5/07/25 at 1:08 PM, a document titled COVID-19 2024-2025 Vaccine Consent Form included the written statement Refused 11/26/24 with no resident or staff signatures. On 5/07/25 at 3:46 PM, Resident #40 stated she was not offered the COVID-19 vaccine. She confirmed she declined the influenza and pneumococcal vaccines, but stated she would take the COVID-19 vaccine if offered. On 5/07/25 at 3:50 PM, the Director of Nursing (DON) stated she didn't know why the COVID-19 declination form lacked the resident's or staff member's signature. The CDC document titled 2024-2025 COVID-19 Vaccination Guidance for People 6 months of Age and Older dated 3/14/25 included the following guidance for adults age [AGE] years of age and older: a) Unvaccinated (0 doses); Give 1 dose now, followed by 1 dose 6 months later. b) Any number of previous doses of any COVID-19 vaccine, NOT including 1 dose of any 2024-25 COVID-19 vaccine; Give 1 dose at least 8 weeks after the last dose, followed by 1 dose 6 months later. c) Any number of previous doses of any COVID-19 vaccine, INCLUDING 1 dose of any 2024-25 COVID-19 vaccine; Give 1 dose 6 months after the last dose of the 2024-25 COVID-19 vaccine. d) Any number of previous doses of any COVID-19 vaccine, INCLUDING 2 doses of any 2024-25 COVID-19 vaccine; No further doses are indicated. On 5/08/25 at 11:49 AM, the DON stated the resident should have given and staff should have obtained a signature on the declination when she was originally asked if she wanted a vaccine. Staff use consents and declinations to determine if a resident was asked if they wanted a vaccine. A policy titled Vaccination of Residents dated 10/2019 indicated all residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. It also indicated: 1. Prior to receiving vaccinations, the resident or legal representative will be provided information and education regarding the benefits and potential side effects of the vaccinations. (See current vaccine information statements at https://www.cdc.gov/vaccines/hcp/vis/index.html for educational materials.) 2. Provision of such education shall be documented in the resident's medical record.

Based on clinical record review, staff interview and policy review, the facility failed to administer pain medication according to physician orders for 1 of 3 residents reviewed for pain assessment (Resident #1). The facility reported a census of 57. Findings include: The Minimum Data Set (MDS) of Resident #1, dated 10/14/24 documented a Brief Interview of Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Further BIMS interviews conducted on 10/21/24 and 10/29/24 revealed a score of 15, indicating cognition intact. The MDS documented diagnoses that included: arthritis, fracture, anxiety, depression and bipolar disorder. The MDS recorded the resident experienced pain during the 5-day look back period and received medications for pain both scheduled and as needed. The MDS recorded the resident as having frequent pain over the 5 day lookback period, and the pain interfering with participation in therapy frequently. The Care Plan dated 10/11/24 documented a Focus of Pain related to current diagnosis. The Care Plan directed staff to anticipate the need for pain relief and respond immediately to any complaints of pain. The Medication Administration Record (MAR) of Resident #1 for October of 2024 documented the resident had orders for acetaminophen and ibuprofen (two types of over the counter pain medications) for scheduled pain medications. The MAR additionally documented two as needed pain medication orders. The MAR reflected an order for Oxycodone (a narcotic pain medication), 5 mg, give one tablet every four hours as needed for pain, if pain is rated between 1-5 (on a 00 to 10 pain scale with 10 being the worst pain imaginable). The MAR reflected a second order for Oxycodone, 5 mg, give two tablets every four hours as needed for pain if pain is rated between 6-10. The MAR documented the resident received 12 doses of Oxycodone, 5 mg, one tablet, between 10/11/24 and 10/30/24. Of the 12 doses documented, the resident had rated her pain as a 6 or higher on eight of those times. 10/11/24 - Rated pain as an 8, received one tablet of Oxycodone 10/12/24 - Rated pain as a 6, received one tablet of Oxycodone 10/17/24 - Rated pain as a 7, received one tablet of Oxycodone 10/26/24 - Rated pain as a 9, received one tablet of Oxycodone 10/27/24 - Rated pain as a 6, received one tablet of Oxycodone 10/28/24 - Rated pain as an 8, received one tablet of Oxycodone 10/29/24 - Rated pain as a 10, received one tablet of Oxycodone 10/30/24 - Rated pain as an 8, received one tablet of Oxycodone On 12/31/24 at 10:53 am, the Director of Nursing stated if a resident has orders based on pain scale, it is the expectation that the order that correlates to that pain scale should have been given. Any pain rated higher than five should have been two pills, not one. The facility policy Administering Medications, Revision Date April 2019, documented the following: Point 4 - Medications are administered in accordance with prescriber orders, including any required time frame. Point 8 - If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. Point 10 - The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on clinical record review, observations, family interview, staff interviews and facility policy review, the facility failed to maintain a safe environment due to staff members not following safety precautions during resident transfers, resulting in Resident #21 to have three falls in a three month period. This resulted in harm to Resident #21 due to increasing pain, causing the need for increased pain management, and needing a higher level of assistance for transfers. The facility reported a census of 55 residents. Findings include: The Minimum Data Set (MDS) Assessment of Resident #21, dated 4/23/24 identified a Brief Interview of Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. The MDS documented the resident required partial assistance of 1 staff member for sitting to standing position, transfers and toileting. The MDS documented a diagnosis of repeated falls. The MDS documented the resident took no scheduled or as needed pain medications during the look back period and had received no non-medication interventions for pain. The MDS documented the resident denied having pain during the lookback period. The MDS coded the resident had experienced one fall in the last quarter. The Care Plan of Resident #21, reviewed 5/3/24 revealed the resident to have a history of falls. The Care Plan directed staff to hold a gait belt (a mobility device worn around the resident's waist to assist caregivers to safely move residents with mobility issues) during transfers. The Care Plan also identified a Focus Area of Activities of Daily Living, which instructed the resident required a partial assist for transfers, dated 11/15/23. On 6/17/24 at 3:55 pm a family member of Resident #21 stated the resident had two recent falls and is now a two person assist. He also stated x-ray results were being waited on as the resident has been complaining of pain since the last fall. The Incident Report dated 3/30/24 documented the resident had a fall at 7:00 am when returning from using the restroom. The Incident Report reflected the staff was not using a gait belt when the fall occurred. Review of the Medication Administration Report (MAR) revealed the resident rated her pain at 0 53 times out of 60 documentation's in the month of April, 2024. She received no as needed acetaminophen for pain during the month of April 2024. The Incident Report dated 5/28/24 documented the resident had a fall at 11:27 pm when being transferred to the bed. The Incident Report reflected the staff had a gait belt on the resident but turned away from the resident momentarily to fix the bed and the resident lost balance and fell to the ground. On 6/19/24 at 12:58 pm, the Director of Nursing (DON) confirmed the Certified Nurse Aide (CNA) had let go of the gait belt during the instance on 5/28/24 when the employee was turning the bed down prior to transferring the resident into the bed. The Clinical Physician Orders revealed an order dated 5/29/24 for 2 view x-rays of the left knee. The X-ray Report signed by the provider on 5/30/24 documented no acute fracture, malalignment or aggressive osseous lesion. Review of the (MAR) revealed the resident rated her pain at 0 every day during the month of May of 2024 except 1 time prior to her May 28th fall and 2 times following the fall. She received no as needed acetaminophen for pain during the month of May 2024 until 5/29/24, the day after the fall. She received 5 doses in the last three days of the month. Facility documentation of the resident walking to meals, scheduled three times a day, reflected the resident walked to a meal only 5 times after her fall on 5/28/24, with dates reviewed through 6/19/24. The Progress Notes documented the following: On 5/29/24 at 12:14 am post-fall, resident complaining of increased left knee and hip pain. On 5/29/24 at 1:48 pm the resident continues to complain of left knee discomfort. Left knee without redness. Able to move knee with assist. Was able to stand on it in therapy, refused to take a step. Refused to get up for lunch, stated I am comfortable and don't want to move to hurt again. On 5/30/24 at 1:56 pm resident up for a bath this am. Transferred with assist of 2 and the gait belt. Resident was favoring left leg upon transfer complaining of left knee hurting. As needed acetaminophen given and effective. X-rays completed as ordered. On 6/1/24 at 1:43 pm resident refused to get up for breakfast and ate in her bed. She did get up for lunch and transferred with assist of 2 and was bent over a lot. Left knee slightly swollen, complaining of pain, more if she straightens knee. On 6/1/24 at 10:21 pm the resident still cannot lay on the left leg. Complains of pain. Treatment done as per order. On 6/4/24 at 2:59 pm the resident continues with pain discomfort. Rated knee pain at 4/10, as needed acetaminophen given. On 6/5/24 at 12:59 am resident complained of left knee pain with movement, area slightly swollen. Leg elevated with pillow, diclofenac applied (topical pain reliever) and as needed acetaminophen given. On 6/5/24 at 1:02 pm resident complaint of left knee pain. Has taken as needed acetaminophen twice and eased pain. She will have leg straight in bed in AM and when this nurse goes in her leg is straight and the she will bend up and complain of pain. Transfer with assist of 2. On 6/5/24 at 2:24 pm resident refused two times to do restorative exercises complaining her knees are hurting her too much. On 6/6/24 at 1:17 am resident continues to complain of knee pain, Diclofenac applied. Resident states cream effective, area slightly swollen, and no redness noted. On 6/6/24 at 12:26 pm blood pressure was elevated this am, has subsided and stabilized. Resident having pain in left leg, 7/10. Resident came out for breakfast, but refused for lunch. Sitting on side of bed to eat due to pain. As needed pain medication administered. On 6/7/23 at 12:33 pm received order for resident to have Physical Therapy evaluation due to knee pain. On 6/7/24 at 2:07 pm resident has not asked for acetaminophen at all today, although when biofreeze was applied, resident grabbed and guarded her leg. On 6/8/24 at 6:51 pm resident complained of left hip pain, acetaminophen administered which was ineffective. Aspercream and diclofenac applied with better results. Physician notified and ordered a 2 view x-ray on the left hip for pain and limited range of motion. On 6/9/24 at 2:21 pm resident alert and oriented. Refusing 2 view left hip x-ray that was ordered for pain and limited range of motion. She said she is feeling better now. Review of the Treatment Administration Record revealed a new order was received on 6/1/24 for topical pain medication to the left knee three times a day. The Incident Report dated 6/9/24 documented the resident had a fall at 7:15 pm when transferring the resident to bed. The Incident Report reflected the staff was not using a gait belt when the fall occurred. The Progress Notes documented the following: On 6/10/24 at 4:05 pm resident continues with pain on her left leg, thigh and knee area. Diclofenac applied to area. No new injuries from witnessed fall. On 6/11/24 at 2:02 am as needed acetaminophen during this shift, resident complaining of knee pain, diclofenac cream applied. On 6/11/24 at 2:02 pm resident is alert and oriented with times of confusion. Has pain in both legs although the left leg is worse. Taking acetaminophen as needed although asking for it about every 4 hours. On 6/11/24 at 11:15 pm resident is alert and oriented. Pain to bilateral knees, the left more severe. Treatment completed per orders. Vital signs within normal limits. As needed acetaminophen available for pain. On 6/12/24 at 2:30 pm resident complaining of pain in both knees. She requested to have as needed acetaminophen before getting out bed and was effective. Treatment to knees done and effective. On 6/13/24 at 1:16 am resident reports moderate pain on left knee, does not want to take acetaminophen at this time, diclofenac used. On 6/14/24 at 11:15 am received verbal order for anterior (front) posterior (back) view of left pelvis/hip (order for an x-ray). On 6/14/24 at 12:16 pm resident is alert with times of confusion. Needs pain medication before breakfast as she has physical therapy afterwards and her pain hinders any progress. 3/10 in left knee. On 6/14/24 at 5:14 pm X-ray report received. No acute fracture or dislocation. On 6/15/24 at 3:37 pm resident continues to receive as needed acetaminophen for complaints of knee pain and states is helping. Resident currently being assisted for all transfers with 2 staff and gait belt, mobility via wheelchair. On 6/16/24 at 3:25 pm resident continues to take as needed acetaminophen 325 milligrams (mg) before breakfast for complaints of knee pain and has been effective, also using topical pain medication to knees. On 6/17/24 at 12:01 pm resident is alert with times of confusion. Having pain in her left knee that she rates 3/10 today. Medication assists with pain although resident has not asked for any today. On 6/18/24 at 2:43 pm resident transfers with assist of 2 and gait belt. States the cream helps her knees. On 6/18/24 at 10:10 pm resident is alert and oriented. Is an assist of two with gait belt. Treatment completed to knees per order. Resident complained of knee pain when transferring. Has not yet asked for as needed pain medications this shift. Review of the (MAR) revealed the resident rated her pain at 0 11 times out of the first 37 entries during the month of June, 2024. She received as needed acetaminophen 18 times during the first 19 days of the month. On 6/19/24 at 11:25 am, the Administrator stated the facility has a quality assurance meeting daily Monday-Fridays. She stated for any falls or incidents, the charge nurse places an immediate intervention onto the care plan and then it is reviewed during the next quality assurance meeting. The intervention is kept if appropriate or updated if needed. Root cause analysis is done, asked the 5 whys of a fall. On 6/19/24 at 12:07 pm, Staff I, LPN stated the normal procedure for a fall is for one employee to stay with the resident and another to get the nurse, if two people are in the room. If only one person is in the room, that person stays with the residents and calls or flags someone down for help. She stated if an injury is suspected, they make the resident as comfortable as possible but leave him/her on the floor until the physician is notified and it is deemed if the resident needs to be sent to the hospital or not. On 6/19/24 at 3:57 pm, observed Staff F, CNA and Staff G, CNA performing a two person transfer from the bed to the wheelchair for Resident #21. Staff F assisted the resident into a seated position and Staff G obtained footwear for the resident. Staff F obtained a gait belt and a front wheeled walker and set the wheelchair near the bed while Staff G changed the resident's socks and placed her shoes on her feet. Staff F applied the gait belt around the resident. Both staff stood to one side of the resident, holding the gait belt. Staff provided cues for the resident to stand. Once the resident stood, verbal cues were given for taking steps. Staff F moved the wheelchair closer to the resident and verbal cues continued to guide the resident safely into a seated position in the wheelchair. On 6/20/24 at 9:06 am, Resident #21 had her call light on. Staff K, CNA answered the call light and the resident requested to use the restroom. Staff K replied she would go find a second staff member and be right back. On 6/20/24 at 9:07 am, Staff K, CNA and the Assistant Director of Nursing (ADON) were observed transferring the resident from the wheelchair to the toilet. Both employees washed hands and donned gloves. Staff K placed a gait belt on the resident. The ADON guided the wheelchair into the restroom. Staff K assisted the resident to stand at the grab bars and while holding the gait belt, assisted the resident to slowly move to her right towards the toilet. The resident was able to slowly side step to the toilet. The ADON assisted in lowering the residents clothing and Staff K assisted the resident to sit on the toilet. Once safely sitting on the toilet, the call light was given to the resident and staff provided privacy. On 6/20/24 at 9:09 am, Staff K stated the resident had been a two person assist because of pain since her fall, but prior to the fall had been a 1 person assist. The facility policy Falls and Fall Risk, Managing, revision date March, 2018 documented a Policy Statement of Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The portion of the policy titled Resident-Centered Approaches to Managing Falls and Fall Risk Point 1: The staff, with the input of the attending physician, if appropriate, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. The portion of the policy titled Monitoring Subsequent Falls and Fall Risk Point 1: The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.

Based on observation, interview, guidance from the 2022 US Food & Drug Administration (FDA) Food Code, and facility policy, the facility failed to serve food in a sanitary manner during breakfast meal service. The facility identified a census of 55 residents. Findings include: Continuous observation of the breakfast meal service began on 6/18/24 at 7:37 am. Staff A, Cook, began preparing breakfast trays and placing them in the serving window to nursing staff to serve to residents. The items served included biscuits, sausage gravy, scrambled eggs, fried eggs, oatmeal, cream of wheat, and fortified hot cereal as well as a variety of cold cereals. Upon the beginning of the observation, Staff A, [NAME] noted to be wearing disposable, single use gloves. She was using tongs to put the biscuits on plates, adding the remainder of the food to the plates, placing the plate on a tray, reaching for a plate cover, and then placing the tray on the serving window. After making several plates, at 7:42 am, Staff A observed to place the tongs to the side of the steam table. For the next 10 plates she prepared, she read the menu card to the tray on her left, picked up a biscuit with her gloved hands, sliced it open with a knife, placed it on a plate, picked the plate up to spoon the gravy over the biscuits, then touched multiple serving utensils, steam tray covers and bowls to add the additional food items per the menu. Using both hands, she set the plate down on the tray, reached down to pick up a food cover, covered the plate, and picked up the tray with both hands to place in the serving window. Her gloved hands were touching the ready to eat food, the plates, the trays, the plate covers and the serving utensils on steam table and for the cold cereals for multiple trays prepared. At 8:00 am, the Certified Dietary Manager (CDM) noted Staff A touching the food instead of using tongs. When asked if she needed tongs Staff A responded she had tongs there but didn't need them. Staff A stated she had been wearing gloves when she set up the steam table so felt everything she was touching was considered clean so it was ok to touch the food. The CDM provided education to Staff A and the meal service completed with Staff A using tongs for the ready to eat food. The CDM stated Staff A is new to her role and will continue to receive education on food service. Chapter 3 - 14 of the FDA Food Code 2022 directs: If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. The facility policy Preventing Foodborne Illness - Food Handling, revision date July, 2014 reflected a Policy Statement of: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized.

Based on observation, staff interviews, and policy review, the facility failed to protect resident information from unauthorized access for 5 of 5 residents (#33, #54, #59, #219, #268). The facility reported a census of 55 residents. Findings include: On 6/17/24 at 6:48 AM, observed a document titled Hall 2 Hot Chart dated 6/17/24 on a medication cart that included visible personal health information for 5 residents. On 6/17/24 at 8:24 AM, Staff H, Licensed Practical Nurse (LPN) stated the sheet on the medication cart was a communication sheet that contained resident information. A policy titled Confidentiality of Information and Personal Privacy revised October 2017 indicated the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. It also indicated access to resident personal and medical records will be limited to authorized staff and business associates. On 6/19/24 at 2:48 PM, the Director of Nursing (DON) stated communication sheets should not be facing up with resident information.

Based on observations, staff interviews, record reviews, and policy review, the facility failed to identify areas or devices in the building to reduce the risk and prevent the growth of Legionella or other waterborne pathogens. The facility also failed to appropriately perform hand hygiene and failed to protect stock treatment supplies from cross-contamination. The facility reported a census of 55 residents. Findings include: 1. On 6/19/24 at 12:58 PM, Staff B, Maintenance Supervisor, stated the facility had three showers used to bathe residents. He stated one shower was routinely used and the other two were used secondary if the primary shower was out of service. At 12:58 PM, Staff B, Maintenance Supervisor, stated the secondary showers' water supply lines had been routinely flushed but hadn't been documented. An undated document titled Weekly Flushing of Plumbing Fixtures for un-used rooms directed staff to run water in all sinks, faucets, showers, and tubs for at least three minutes and to flush all toilets three times to completely empty tanks and traps. Staff B revealed the form had not been completed. A policy titled Legionella Water Management Policy revised 2017 indicated the purposes of the Water Management Program were to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's disease. On 6/19/24 at 2:52 PM, the Administrator stated there were four (4) resident showers and one (1) was not routinely used. She also stated staff should follow the aforementioned facility policy. 50471 2. The Minimum Data Sheet (MDS) assessment dated [DATE] for Resident # 27 identified Moisture Associated Skin Damage (MASD). The MDS documented diagnoses that included: septicemia, diabetes mellitus (DM), and infection and inflammation reaction due to internal right knee prosthesis. The MDS revealed the resident received pressure reducing device for the bed and pressure reducing device for the chair. The Care Plan of Resident #27, revision date 5/27/24 reflected a focus area of skin impairment. The Care Plan documented the resident to have excoriation of the coccyx. (the tailbone). The Order Entry documented Resident #27 to have an order for a 1:1 ration of [NAME] (Calmoseptine, a moisture barrier ointment) and antifungal to be applied to the buttocks twice a day until healed. On 6/19/24 at 9:46 AM, observed Staff J, Licensed Practical Nurse (LPN) performing a treatment to Resident #27's buttocks. Staff J obtained two tubes of the prescribed ointments from the medication cart and brought them into the resident's room. Staff J verified the ointments were stock supply and were not dedicated for single patient use. Upon entering the room, Staff J was not observed to have performed hand-washing or hand hygiene prior to donning gloves. After donning gloves, Staff J provided incontinent care on Resident #27. Without changing gloves or performing hand hygiene, Staff J then squeezed a proper amount of ointment from the first treatment tube into her hand. She then picked up the second tube of treatment cream and placed that ointment into her hand as well to combine the two ointments. She then applied ointments to Resident #27's buttocks, failing to change gloves or perform hand hygiene. Staff J then removed the soiled gloves, but did not perform hand-washing or hand hygiene. Staff J performed hand-washing prior to exiting the room. Staff J took the ointment containers out of the room and placed them back in the medication cart. Staff J failed to prevent cross contamination, exposed the ointment containers during treatment. In an interview on 6/19/24 at 2:17 PM, the Director of Nursing (DON) reported staff should be placing the ointment in a medication cup, hand-washing or hand hygiene should be completed prior to the treatment, when visibly soiled, and after disposing soiled gloves. The facility policy title Handwashing/Hand Hygiene revised 8/2019 included the following documentation: Policy Statement-This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly soiled 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents c. Before preparing or handling medications d. After contact with a resident's intact skin e. After removing gloves f. After personal use of the toilet or conducting your personal hygiene. 8. Hand Hygiene is the final step after removing and disposing of personal protective equipment. 49628 3. The Progress Note in the Electronic Medical Record (EHR) dated 5/31/24 completed by the Director of Nursing (DON) revealed Resident #54 scored 14/15 on the Brief Interview for Mental Status (BIMS) score indicating the resident is cognitively intact. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 presented upon admission to the facility with an indwelling catheter. Resident #54 presented with medical a diagnosis of obstructive and reflux uropathy, unspecified. Orders dated 5/27/24 revealed use of enhanced barrier precautions due to indwelling Foley catheter. The Care Plan printed 6/19/24 included the following interventions: catheter care every shift, monitor and document any pain or discomfort related to the catheter, monitor, document and report as needed any signs or symptoms of urinary tract infection, and enhanced barrier precautions when performing high-contact care activities. Observation on 6/19/24 at 2:10 PM Staff C, Certified Nursing Assistant, donned gown and gloves prior to entering Resident #54's room for management of catheter bag. Staff C obtained supplies including a clean trash bag, gradient cylinder, and alcohol wipe from the resident's bathroom. Staff C provided education to the resident regarding the need to empty the catheter. The staff placed the trash bag on the floor, and the cylinder on top of the trash bag. The staff wiped the drainage tube with the alcohol wipe and proceeded to drain the bag. Staff C emptied the cylinder into the toilet with the trash bag remaining under the cylinder during emptying and rinsing. Staff removed a single glove while in the resident's room, and removed the gown and remaining glove while exiting the room. Staff C discarded the gloves and gown in a labeled trash receptacle in the hallway. The staff opened 3 drawers of a storage container outside the resident's room before locating the hand sanitizer. On 6/19/24 at 2:24 Staff C stated it would have been helpful if hand sanitizer would have been out to use prior to putting gloves on. In an interview on 6/19/24 at 2:17 PM the DON stated staff should complete hand hygiene at the start of treatment, when gloves are visibly soiled, when removing dirty gloves and when leaving a resident's room. The facility policy titled Handwashing/Hand Hygiene revised August 2019 instructed staff to perform hand hygiene prior to applying non-sterile gloves.

Based on observations, resident interview, staff interviews, clinical record review, and facility policy the facility failed to provide dignity by leaving a trash bag with bandage wrappers on a resident's bed (Resident #54). The facility further failed to provide dignity to Resident #54 by not putting his socks back on and covering his legs. The facility reported a census of 55 residents. Findings Include: Review of the Progress Note in the Electronic Medical Record (EHR) dated 5/31/24 completed by Director of Nursing (DON) revealed Resident #54 scored 14/15 on the Brief Interview for Mental Status (BIMS) indicating the resident is cognitively intact. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 presented upon admission to the facility with 2 stage II pressure ulcers. Observation on 6/18/24 at 11:07 AM revealed Staff D, Licensed Practical Nurse (LPN), place a clean trash bag on Resident #54's bed for completion of dressing change to bilateral feet. Staff D placed the used packaging and adhesive covers of the new bandages in the trash bag. The staff picked up the remaining unused bandages, scissors and left the resident's room at 11:25 AM. The trash bag remained on the bed and the resident's lower legs were uncovered. Observation on 6/18/24 at 11:27 AM Resident #54 turned the call light on. Staff E, Certified Medication Aide (CMA), entered the resident's room at 11:28 AM. The resident requested Staff E bring Staff D back to his room and remove the trash that was left behind. Staff E spoke with Staff D, and returned to the resident's room alone. Staff E entered Resident 54's room, donned the resident's socks, replaced the bedding, and removed the trash. On 6/18/24 at 11:29 AM Staff E stated Resident #54 requested the trash be removed from the bed, his socks to be put back on, and be covered back up. Staff E observed the trash bag on the bed and the resident's feet uncovered. On 6/18/24 at 11:49 AM Resident #54 stated was pissed off that Staff D left his room without replacing his socks, blankets and left the trash on the bed. The resident stated staff have often not covered his lower body following completion of personal cares. Resident #54 revealed he does not feel as though he is being cared for. On 6/18/24 at 1:21 PM the Director of Nursing (DON) stated when changing dressings/applying new dressing the trash bag would be next to the nurse for use. When completed the treatment, the trash bag should be tied up and taken out with the nurse. The facility policy Wound Care revised October 2010 revealed staff should discard disposable items into the designated container. Staff should further reposition the bed covers and ensure the resident is comfortable upon completion.

Based on observations, clinical record review, staff interviews, and policy review the facility failed to ensure a medication error rate of less than 5%. During observations of medication administration, the facility had 2 errors out of 25 opportunities for errors resulting in an error rate of 8% (Residents #23). The facility identified a census of 55 residents. Findings include: On 6/18/24 beginning at 8:13 AM, the administration of 8 pills observed for Resident #23. Two (2) medication errors observed during this time. During the medication pass for Resident #23, observed Staff I, Licensed Practical Nurse (LPN), remove the following medications from the medication cart: (1) Hydrocodone/APAP 7.5/325 mg tablet (1) Aspirin 81 mg tablet (1) Fexofenadine Hydrochloride 180 mg tablet (1) Gabapentin 100 mg tablet (1) Levothyroxine 88 mcg tablet (1) Pantoprazole 20 mg tablet (2) Senna-Plus 50/8.6 mg tablets Staff I, LPN counted the medications, verified there were 8 pills and gave them to the resident. The Clinical Physician Orders revealed an order dated 8/20/22 for the resident to have Fiber 500 mg one (1) tablet for the daily dose. The Clinical Physician Orders did not include an order for Fexofenadine Hydrochloride. On 6/18/24 at 11:51 AM, Staff I verified she gave the resident Fexofenadine Hydrochloride (antihistamine) instead of a Fiber medication because she didn't look at the medication bottle. She also stated the Fiber 500 mg medication was not stocked in the medication cart and was not administered during morning medication administration. A policy titled Administering Medications revised April 2019 indicated medications shall be administered in a safe and timely manner and as prescribed. It also indicated the individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. On 6/19/24 at 2:48 PM, the Director of Nursing (DON) stated three (3) checks should be done when medications are administered.

Based on clinical record review, staff interviews, Nurse Practitioner (NP) interview and facility policy review the facility failed to assess weights per orders, lung assessments and edema assessments per care plan for 1 of 3 residents reviewed with Congestive Heart Failure (Resident #3). The facility identified a census of 55 residents. Findings include: A Minimum Data Set (MDS) assessment form dated 11.15.23 indicated Resident #3 had diagnosis that included anemia, atrial fibrillation (AF), renal insufficiency/failure, diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hypovolemic shock and a history of urinary tract infections. The assessment indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 (cognitively intact) and required staff assistance with activities of daily living (ADL's). A Care Plan identified a Focus area of an altered cardiovascular status related to cardiomyopathy, CHF and AF initiated 11.14.23. The Interventions/Tasks included the following as dated: a. Monitor, document and report as needed (PRN) any changes in lung sounds on auscultation (example (i.e.) crackles, rubs and etc ), edema and changes in weight. Review of the facilities Treatment Administration Record (TAR) dated 10.1.23 thru 10.31.23 directed the facility staff to assess the resident's weight three (3) days on the day shift with a start date of 10.6.23. The facility failed to assess the resident's weight on 10.8.23. The Progress Notes for Resident #3 documented the following: On 11.11.23 at 12:56 p.m. Admit note with weight 336.7 lbs (pounds), history of CHF, lungs clear ad edema right and left inner ankle. The note lacked documentation of pitting edema. On 11.12.23 at 3:52 a.m. no SOB (shortness of breath) with lying flat. On 11.14.23 at 12:42 p.m. no SOB or cough and lungs clear. On 11.15.23 at 2:14 p.m. SOB lying flat and resident complaining of being SOB and nausea. The note lacked documentation of any edema. On 11.16.23 a Provider encounter documented 3-4 plus pitting edema bilateral lower extremities (BLE). Weight 339 lbs. Orders for PRN Bumex 1.5 tabs daily for 5 days and a daily weight. Notify the provider if greater than 3lbs. The Progress Notes lack daily assessments of edema. A TAR form dated 11.1.23 thru 11.30.23 directed the facility staff to assess the resident's weight daily on the day shift for 5 days and to have reported a weight gain of greater than 3 pounds in 24 hours dated 11.17.23. The facility staff failed to weigh the resident 11.17, 11.18 and 11.21.2023. The Progress Note entries failed to include the following as dated: On 12.4.23 - The staff failed to assess the resident's lung and/or breathing status the entire 24 hours. On 11.29.23 at 4:36 p.m. - Lung and/or breathing status not documented following the resident's complaint of shortness of breath (SOB) with the therapist. On 11.26.23 - The staff failed to assess the resident's lung sounds the entire 24 hours. A Certificate of Death form (not dated) indicated the resident passed away on 12.18.23 at 1 a.m. with an immediate cause of cardiac arrest, as a consequence of anion gap metabolic acidosis secondary to lactic acidosis as a consequence of decompensated liver cirrhosis an underlying cause of septic shock and other significant conditions of acute renal failure that required renal replacement therapy, acute hypoxemic respiratory failure that required mechanical ventilation, morbid obesity, type II dm and a complicated urinary tract infection. During an interview on 1.3.24 at 10:40 p.m. a NP indicated the routine Bumex and PRN Bumex order originated from the resident's Cardiologist when she was admitted to the facility. On 11.11.23 the NP discontinued the PRN order and changed the order to routine only and to continue daily weights d/t her continual weight gain. The NP confirmed the staff failed to check daily weights. On 11.16.23 (no time) the NP discontinued the daily weights due to her refusal. Review of the resident's medical record at the same time revealed no consistent refusal of the resident's daily weight per physician order. During an interview 1.3.24 at 11:29 a.m. the NP indicated the resident's weights and the lack of the facility staff to monitor could have played a role in her death however there had been other factors as well such as, diet, water intake, salt, activity level and urine output. The NP would have expected the staff to check the resident's weights and to have followed physician orders. During an interview 1.3.24 at 12:02 p.m. an Occupational Therapy Assistant (OTA) confirmed therapy had not weighed the resident during her care and treatment. During an interview 1.3.24 at 11:15 a.m. the Director of Nursing (DON) indicated the facilities standing orders following a resident's admit had been a daily check of weights every day (QD) for 3 days. The DON confirmed staff failed to follow those expectations with this resident. The DON also indicated she crossed off the weights for 11.18, 11.19, 11.20 and 11.28 for the resident because she felt they had not been accurate. During an interview 1.3.24 at 11:42 a.m. the DON confirmed staff should have taken daily weights for any resident on a PRN diuretic. A record review 1.3.24 at 2:00 p.m. revealed a MD note on 11.21.24 addressed the resident's weight at 328.5. (which had been not accurate according the resident's medical record, seen entry above) A Change in a Resident's Condition or Status policy revised 2.2021 included the following directives: a. The nurse recorded in the resident's medical record information relative to changes in the resident's medical/mental condition and/or status.

Based on clinical record review, facility investigative file review, resident and staff interviews, and facility policy review the facility failed to administer 6 of 6 resident's (Resident #7, #57, #58, #59, #60 and #61) medications as ordered by the physician. The facility also failed to waste narcotics with two nurses. The facility reported a census of 53 residents. Findings include: 1. According to the admission Minimum Data Set (MDS) with a reference date of 4/27/23 documented he had a Brief Interview of Mental Status (BIMS) score 13 out of 15. A BIMS score of 13 suggested a he had no cognitive impairment. The MDS documented he required limited assistance of one staff for bed mobility, dressing, personal hygiene and extensive assistance of two staff for transfers, toilet use. The MDS documented he did not receive an opioid during the 7-day review period. The MDS listed the following diagnoses for Resident #57: atrial fibrillation, renal failure, benign prostatic hyperplasia, septicemia, urinary tract infection, diabetes mellitus, paraplegia, quadriplegia, traumatic brain injury, anxiety, depression, and renal dialysis. The Care Plan focus area with an initiation date of 4/1/21 documented #57 used opioid medications for cervical pain and pressure wounds. An additional Care Plan focus area with an initiation date of 5/12/23 indicated he experienced frequent pain in his back related to Ankylosing Spondylitis (arthritis affecting the spine and large joints. He had an order for Oxycodone (narcotic pain reliever) every six hours as needed (PRN) for pain. This medication has a black box warning: addiction, abuse, and misuse. The Progress Notes documented Staff C, Licensed Practical Nurse (LPN), administered Resident #57's order of oxycodone 5 milligrams (mg) by mouth every 6 hours as needed (PRN) for pain on the followig datesL On 5/19/23 at 6:18 AM, 9:44 AM, 5:16 PM and 5:29 PM. On 5/22/23 at 6:15 AM. On 5/25/23 at 8:00 PM On 5/26/23 at 6:33 AM On 6/14/23 at 8:37 AM resident was discharged from the facility. Review of Resident #57's June 2023 Medication Administration Record revealed the following PRN order with a start date of 5/8/23: oxycodone 5 mg by mouth every 6 hours PRN for pain. The order was not signed out as being given in June of 2023. Review of Resident #57's Individual Narcotic Record for his oxycodone 5mg 1 tablet every six hours order revealed Staff C had documented she administered this medication on the following dates and times: a. 6/1/23 at 6:10 AM b. 6/2/23 at 6:10 AM c. 6/2/23 at 8:20 AM (2 hours after the last dose was administered) d. 6/2/23 at 12:10 PM (4 hours after the last dose was administered) e. 6/2/23 at 5:50 PM (6 hours after the last dose was administered) f. 6/2/23 at 6:00 PM (1 hour after the last dose was administered) On 7/20/23 at 2:00 PM an attempt to call the resident on the phone number documented in his chart was made. The call went to voicemail, a message was left with a call back number. At the conclusion of the investigation the resident had not returned the call. 2. According to the admission MDS with a reference date of 4/24/23 documented Resident #58 had a BIMS score of 14 out of 15. A BIMS score of 14 suggested she had no cognitive impairment. The MDS indicated she required limited assistance of one staff for bed mobility, transfers, dressing, and toilet use. The MDS documented she did not receive an opioid during the 7-day review period. The MDS listed the following diagnoses: burns of 40-49% of body surface with 20-29% third degree burns, anxiety, depression, and restless leg syndrome. The Care Plan focus area with an initiation date of 4/19/23 documented she used opioid medications (oxycodone) due surgery and burns. The care plan instructed staff to administer the opioid medication as physician ordered and monitor for side effects. The care plan documented oxycodone has a black box warning: addiction, abuse and misuse. Review of Resident #58's June 2023 MAR revealed the following orders: a. Oxycodone 5mg 1 tablet by mouth one time a day at 5:00 AM, with a start date of 5/26/23. Staff C did not sign out the order as being given b. Oxycodone 5mg 1 tablet by mouth PRN for pain. May give 30 minutes prior to shower/cares if pain is greater than a 5 on the scale 0-10, with a start date 4/26/23. Staff C did sign out the order as being administered on 6/2/23 at 9:17 AM c. Oxycodone 5mg 1 tablet by mouth every 4 hours PRN for pain with a start date of 4/26/23. The order was not signed out as being given by Staff C. Review of Resident #58's Individual Narcotic Record for her oxycodone 5mg 1 tablet everyday order revealed Staff C had documented she administered this medication on the following dates and times: a. 6/2/23 at 5:00 AM b. 6/2/23 at 7:10 AM c. 6/2/23 at 10:40 AM d. 6/2/23 at 3:20 PM Review of Resident #58's Individual Narcotic Record for her oxycodone mg 1 tablet every 4 hours as needed revealed Staff C has documented she administered this medication on the following dates and times: a. 6/2/23 at 2:15 PM b. 6/2/23 at 5:00 PM The Progress Notes documented Staff C administered Resident #58's oxycodone 5mg every 4-hour PRN medication on the following dates: On 5/13/23 at 9:39 AM, 12:10 PM, and 2:15 PM On 5/19/23 at 6:10 AM and 10:10 AM On 5/22/23 at 6:06 AM and 7:59 AM On 5/22/23 at 8:45 AM, 12:45 PM, 2:45 PM and 4:45 PM On 6/30/23 at 1:00 PM Resident #58 was discharged from the facility. On 7/20/23 at 2:58 PM Resident #58 stated her 5:00 AM dose of oxycodone was given by the overnight nurse between 5:00 AM -5:30 AM. She occasionally utilized her PRN order to be taken before showers or cares. If she needed her every 4 hour PRN she would maybe ask for it every 6 hours not every 4 hours and would ask of it if she needed it; which was off and on. 3. According to the Admission MDS reference tool with an assessment date of 6/13/23 documented a BIMS score of 13 out of 15. A BIMS score of 13 suggested Resident #59 had no cognitive impairment. The MDS documented she required extensive assistance of two staff for bed mobility, transfer, toilet use and limited assistance of one staff for dressing and personal hygiene. The MDS documented she received an opioid for 6 days during the 7-day review period. The MDS documented the following diagnoses for Resident #59: traumatic ischemia of muscle, renal failure, malnutrition, depression, respiratory failure, chronic pain, and pain in right knee. The Care Plan Focus Area with an initiation date of 6/9/23 documented she used opioid medications (oxycodone) related to traumatic ischemic muscle. The care plan instructed staff to administer opioid medication as physician ordered and monitor for side effects. Resident #59 had chronic pain, osteoarthritis. Staff were advised to anticipate her need for pain relief and respond immediately to any complaint to pain. The care plan documented she took oxycodone, Celebrex and Lyrica for pain. Review of the Progress Notes for Resident #59 documented by Staff C revealed she administered Tylenol one time: 5/15/23 at 3:50 PM. Review of Resident #59's May 2023 MAR revealed the following order: Oxycodone 10 mg by mouth four times a day (QID) for pain with a start date of 4/19/23 and discontinued date of 5/18/23. The MAR revealed Staff C signed out the order as given on: a. 5/15/23 at 11:00 AM b. 5/15/23 at 5:00 PM Review of Resident #59's Individual Narcotic Record for her oxycodone 5mg 1 tablet four times a day (QID) order revealed Staff C had documented she administered this medication on the following dates and times: a. 5/15/23 at 6:00 AM b. 5/15/23 at 11:00 AM (wasted) c. 5/15/23 at 3:00 PM d. 5/15/23 at 3:00 PM e. 5/15/23 at 5:11 PM f. 5/17/23 at 10:55 PM (wasted) g. 5/17/23 at 10:55 PM 4. According to the Quarterly MDS assessment tool with a reference date of 5/9/2023 documented Resident #60 had a BIMS score of 4 out of 15. A BIMS score suggested she had severe cognitive impairment. The MDS documented she required extensive assistance of two staff for bed mobility, dressing and was total dependent of two staff for transfers, toilet use. Resident #60 received an opioid 7 days of the 7-day review period. The MDS listed the following diagnoses of Resident #60: pressure ulcer of sacral region, anemia, coronary artery disease, heart failure, renal failure, dementia, anxiety, and atrial fibrillation. The Care Plan Focus Area with an initiation date of 4/6/23 indicated she had pain because of her pressure ulcers. Staff were to anticipate her need for pain relief and respond immediately to any complaint of pain. Resident #60 used opioid medications and staff were advised to administer the medication as physician ordered. She experienced frequent pain in pressure areas. Staff were advised to administer pain medications as ordered. She had an order for oxycodone three times a day and one time prior to dressing changes as needed for pain. This medication has a black box warning such as addiction, abuse, and misuse. Review of Resident #60's progress note revealed Staff C had no documentation referencing the administration of any PRN medications. Review of Resident #60's May 2023 MAR revealed the following orders: a. Oxycodone 5mg give one tablet by mouth three times a day (TID) for pain at 6:00 AM, 2:00 PM, and 9:00 PM, with a start date of 4/5/23. The order was signed out as being given by Staff C on: -5/15/23 at 2:00 PM -5/17/23 at 9:00 PM -5/24/23 at 2:00 PM -5/25/23 at 2:00 PM -5/26/23 at 2:00 PM -5/27/23 at 2:00 PM -5/28/23 at 2:00 PM Review of Resident #60's June 2023 MAR revealed the following order: a. Oxycodone 5mg give one tablet by mouth three times a day (TID) for pain at 6:00 AM, 2:00 PM, and 9:00 PM, with a start date of 4/5/23. The order was signed out as being given by Staff C on: -6/1/23 at 2:00 PM -6/1/23 at 9:00 PM -6/4/23 at 2:00 PM -6/5/23 at 2:00 PM Review of Resident #60's Individual Narcotic Record for her oxycodone 5mg 1 tablet TID order revealed Staff C had documented she administered this medication on the following dates and times: a. 5/15/23 at 5:00 AM by another staff member b. 5/15/23 at 6:00 AM c. 5/15/23 at 11:00 AM Review of Resident #60's Individual Narcotic Record for her oxycodone 5mg 1 tablet TID order revealed Staff C had documented she administered this medication on the following dates and times: a. 6/4/23 at 11:00 AM b. 6/4/23 at 5:30 AM c. 6/5/23 at 12:00 PM 5. According to the admission MDS assessment tool with a reference date of 4/5/23 Resident #7 had a BIMS score of 15 out of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented she required extensive assistance of two staff for bed mobility, transfers, dressing, and toilet use. The MDS indicated she received an opioid 6 days during the 7-day review period. The MDS listed the following diagnoses: viral hepatitis, diabetes mellitus, thyroid disorder, anxiety, bipolar disorder, spinal stenosis, and stimulant abuse. The Care Plan focus area with an initiation date of 3/31/23 indicated she had chronic pain related to spondylosis (degenerative arthritis of the spine). The care plan documented she received oxycodone/acetaminophen (Percocet) for her pain management. This has a black box warning: risk of medication errors, addiction, abuse and misuse. The Progress Noted documented Staff C administered Resident #7's PRN Percocet 5-325 mg PRN on the following dates: On 5/15/23 at 7:24 AM, 10:15 AM, and 12:15 AM. On 5/17/23 at 6:10 PM On 5/24/23 at 8:05 AM and 12:20 PM. On 5/28/23 at 12:10 PM On 6/1/23 at 3:31 AM, 6:00 AM, and 11:20 AM On 6/4/23 at 6:40 AM and 3:36 PM On 6/5/23 at 6:30 AM Review of Resident #7's May 2023 MAR revealed the following orders: a. Percocet 5/325 mg give 1 tablet by mouth every 4 hours as needed for pain with a start date of 4/10/23. This order was signed out as being given by Staff C on: -5/15/23 at 7:24 AM, 10:15 AM, 12:15 PM, and 3:58 PM -5/17/23 at 6:10 PM -5/24/23 at 8:05 AM and 12:20 PM -5/28/23 at 12:10 PM b. Percocet 5/325 mg give 1 tablet by mouth two times a day (BID), with a start date of 5/23/23. The medication was scheduled to be administered on the AM and PM medication pass. This order was signed out as being given by Staff C on: -5/15/23 on the AM medication pass -5/24/23 on the AM medication pass -5/26/23 on the AM medication pass -5/27/23 on the AM medication pass -5/28/23 on the AM medication pass -5/29/23 on the AM medication pass Review of Resident #7's June 2023 MAR revealed the following orders: a. Percocet 5/325 mg give 1 tablet by mouth two times a day (BID) with a start date of 5/23/23. The medication is scheduled to be administered on the AM and PM medication pass. This order was signed out as being given by Staff C on: -6/1/23 on the AM and PM medication pass -6/4/23 on the AM and PM medication pass -6/5/23 on the AM medication pass b. Percocet 5/325 mg give 1 tablet by mouth every 4 hours as needed for pain with a start date of 4/10/23. This order was signed out as being given by Staff C on: -6/1/23 at 3:31 AM, 6:00 AM and 11:20 AM -6/4/23 at 6:40 AM and 3:36 AM -6/5/23 at 6:30 AM Review of Resident #7's Individual Narcotic Record for her Percocet 5/325 mg 1 tablet every four hours PRN revealed Staff C had documented she administered this medication on the following dates and times: a. 5/15.23 at 6:15 AM b. 5/15/23 at 10:15 AM c. 5/15/23 at 12:15 PM (2 hours after the last dose was administered) d. 5/15/23 at 4:15 PM e. 5/15/23 at 5:30 PM (1.25 hours after the last dose was administered) f. 5/17/23 at 6:10 PM g. 5/17/23 at 9:50 PM (3.5 hours after the last dose was administered) h. 5/23/23 at 6:05 AM i. 5/23/23 at 8:00 AM (2 hours after the last dose was administered) j. 5/23/23 at 12:20 PM k. 5/23/23 at 4:00 PM l. 5/23/23 at 5:30 PM (1.5 hours after the last dose was administered) m. 5/25/23 at 3:30 PM n. 5/25/23 at 5:30 PM (2 hours after the last dose was administered) o. 5/26/23 at 8:40 PM p. 5/26/23 at 11:10 PM (2.5 hours after the last dose was administered) q. 5/26/23 at 5:25 PM r. 5/27/23 at 6:30 AM s. 5/27/23 at 11:45 PM t. 5/27/23 at 5:00 PM (documentation is back tracking) u. 5/28/23 at 6:00 AM v. 5/28/23 at 11:10 AM w. 5/28/23 at 2:06 PM (3 hours after the last dose was administered) x. 5/28/23 at 5:00 PM (3 hours after the last dose was administered) Review of Resident #7's Individual Narcotic Record for her Percocet 5/325 mg 1 tablet twice a day (BID) revealed Staff C had documented she administered this medication on the following dates and times: a. 5/24/23 at 10:00 AM b. 5/24/23 at 2:00 PM c. 5/24/23 at 5:50 PM d. 5/26/23 at 9:00 AM e. 5/26/23 at 2:00 PM f. 5/26/23 at 6:30 PM g. 5/27/23 at 9:15 AM h. 5/27/23 at 12:00 PM i. 5/27/23 at 5:00 PM j. 5/28/23 at 6:10 AM k. 5/28/23 at 12:10 PM l. 5/28/23 at 5:28 PM m. 5/28/23 at 10:15 AM n. 5/28/23 at 3:40 PM o. 5/29/23 at 6:10 AM p. 5/29/23 at 10:25 PM q. 5/29/23 at 12:44 PM r. 5/29/23 at 2:56 PM s. 5/29/23 at 5:30 PM t. 6/1/23 at 6:00 AM u. 6/1/23 at 8:40 AM v. 6/1/23 at 11:20 AM w. 6/1/23 at 3:30 PM x. 6/1/23 at 5:00 PM y. 6/1/23 at 7:30 PM z. 6/1/23 at 9:50 PM aa. 6/2/23 at 11:35 AM bb. 6/4/23 at 6:40 AM cc. 6/4/23 at 10:00 AM dd. 6/4/23 at 12:00 PM ee. 6/4/23 at 3:30 PM ff. 6/4/23 at 5:45 PM gg. 6/5/23 at 6:30 AM hh. 6/5/23 at 7:55 AM 6. According to Resident #61's significant change MDS assessment tool with a reference date of 5/8/23, she had a BIMS score of 15 out of 15. A BIMS score of 15 suggested no cognitive impairment. The MDS documented she required extensive assistance of two staff for bed mobility, dressing and total dependent of two staff for transfers, toilet use and bathing. The MDS indicated she received an opioid 2 days during the 7-day review period. The following diagnoses were listed for Resident #61: spinal stenosis, atrial fibrillation, renal failure, respiratory failure, right and left hip pain, obstructive sleep apnea and morbid obesity. The Care Plan focus area with an initiation date of 12/22/20 documented she had pain related to her diagnosis of spinal stenosis, pain in both hips and radiculopathy. Staff are to respond immediately to any complaints of pain. The care plan indicated she had an order for Oxycodone every 6 hours as needed for pain. This medication has a black box warning: addiction, abuse and misuse. The Progress Notes documented Staff C administered Resident #61's oxycodone 5mg every 6 hour PRN on the following dates: On 5/15/23 at 7:46 AM, 10:51 AM, 4:08 PM, 5:14 PM, 6:46 PM, and 9:22 PM On 5/17/23 at 6:46 PM On 5/24/23 at 8:58 AM Review of Resident #61's June 2023 MARS revealed the following order: a. Oxycodone 5mg, give 1 tablet by mouth four times a day (QID) for pain, with a start date of 5/24/23 and discontinued date of 6/5/23. The order was scheduled to be given at 12:00 AM, 6:00 AM, 12:00 PM and 6:00 PM. The order was signed out as being given by Staff C on: -6/1/23 at 12:00 PM and 6:00 PM -6/4/23 at 12:00 PM and 6:00 PM b. Oxycodone 5mg, 1 tablet by mouth every 4 hours for pain, with a start date of 6/5/23. The order was not signed out as being given by Staff C. Review of Resident #61's Individual Narcotic Record for her Oxycodone 5mg, 1 tablet every 6 hours order revealed Staff C signed out the medication as being given on: a. 5/15/23 at 7:00 AM b. 5/15/23 at 11:00 AM (4 hours after the last dose was administered) c. 5/15/23 at 3:00 PM (4 hours after the last dose was administered) d. 5/15/23 at 5:30 PM (2.5 hours after the last dose was administered) e. 5/17/23 at 6:00 PM (1.5 hours after the last dose was administered) f. 5/17/23 at 9:00 PM (3 hours after the last dose was administered) The facility investigation included the following information: a. On 6/6/23 the Director of Nursing (DON) interviewed Resident #58: I know my pain medicine is PRN every 4 hours and knows not to ask for it sooner, so she does not ask. She has not really been in any more pain than normal. She usually did not take more than one PRN pain mediation a day. Resident #58 remembered on Saturday 6/3/23 she asked for a PRN medication and went about 6 hours between administration times, which was normal for her. When asked if Staff C gave her a stockinette that caused her pain, she denied this. She also denied asking for pain medication more than she normally would on Friday 6/2/23. b. On 6/6/23 the DON interviewed Resident #57 and he indicated would ask for a PRN for pain maybe once a day, never more than that. He remembered on Friday (6/2/23) he never asked for anything for pain medication. He added he rarely ever asked for anything for pain. He did mention that dialysis days are harder for him but does not usually ask for a pain pill. c. On Monday 6/5/23 the day nurse brought attention to the DON regarding narcotics not being signed out in the Electronic Health Record (EHR) but signed out in the narcotic book. When reviewing the narcotic book and EHR the same nurse was signing out oxycodone 5mg more often than ordered for two residents on hall 5. On Friday 6/2/23 Resident #57 was noted in the narcotic book as receiving oxycodone 5mg at 6:10 AM, 8:20 AM, 12:10 PM, 5:50 PM and 6:00 PM by Staff C but nothing was signed out in his EHR. When asked about this Staff C stated that she wrote the 12:10 PM one in late, but it was given after the resident returned from dialysis around 3-3:30 PM because he complained of pain when transferring. The other time Staff C stated she did not realize it was too soon to give the medication. The resident did not remember if he got a pain pill on 6/2/23. His wife knows that he was in pain, but could not recall if he received the pain pill or not. On 6/2/23 Resident #58 was noted in the narcotic book to have received oxycodone 5mg at 5:00 AM, 7:10 AM, 8:40 AM, 10:40 AM, 2:15 PM, 3:20 PM, and 5:00 PM by Staff C. Nothing was signed out in Resident #58's EHR. This resident has two cards of oxycodone, one that was scheduled one time a day and the other was PRN every 4 hours. The bolded times are taken from the one tab every day card. When Staff C was questioned, she stated the resident was up to the nurse's station several times that day asking for pain medication. The nurse had gotten a new stockinette for the resident and that was uncomfortable so this was the reason she wanted pain medication. Staff C was educated on the importance of charting in the narcotic book and charting in the EHR. If documenting in the EHR the nurse would have been made aware that is was too soon to give the medication. Also educated the importance of following doctor's orders and charting. The narcotic count is all correct. d. Nurse Interview Regarding Narcotics: Staff C interviewed by the DON on 6/7/23: DON: Resident #57's order is every 6 hours, you gave him oxycodone several times before the 6 hour intervals, did you follow the order? Do you follow the MAR? Staff C: I try to follow the order, and the MAR. I don't know what I did. DON: They were given 2, 3, 4, hours and one given after 10 minutes. Staff C: The 10 minute one, I think he choked on it. There was no swallowing it because it was dissolved. DON: Resident #58 had two cards of oxycodone. You gave them at 7am and 10 am on one card and at 8:40 AM on the other card. Staff C: I don't even think I realized there was 2 cards. DON: 5:00 AM, 7:10 AM, the other card 8:40 AM, then back to the first card at 10:40 AM, and back to the second cards at 10:00 AM. Staff C: Is that the one we talked about? DON: Yes. Staff C: She was like is it time yet, and I was looking at the times. I don't think I realized there was two cards. DON: One card is 1 tab a day and you pulled 3 out on one day. Staff C: (She did not say anything to this.) DON: Was she taking them? You don't have 4 hours between. Did she take that many? Staff C: I would assume she took them; she was coming up to the nurse's station and asking for them then going back to her room to take them. DON: Did you realize there's a time limit between them? Staff C: Right, did I go between cards and did not realize it hadn't been 4 hours? DON: one care you went a couple hours. It's scheduled once a day. The PRN card you went 2, 3, 6 hours. Staff C: I guess I don't know. I don't know what I was thinking. I really did not realize there was two cards. DON: There are a couple that you wrote wasted and then turned around and gave it at the same time. Staff C: Because something happened, like something happened to it so I'd have to start over. DON: You have to waste narcotics with another nurse. A couple you signed out one, turned around and signed another one out at the same time on a second line. Staff C: Because something happened. DON: You did not write waste. Staff C: Yeah. I usually work in facilities where I am the only nurse, like there is nobody to sign. DON: There is several of us here during the day. Staff C: I know, I am not used to having a team of nurses. DON: Did you realize that you're giving some after 20 minutes of giving it? Staff C: (mumbled) Then said, I haven't given anything after 20 minutes. DON: One was 10 minutes, some were like one time a day then gave it in the morning at 5am, gave another at 6:00 AM. Were you just not paying attention? Not able to read the MAR? Not reading the MAR? Staff C: They are not signing it out so it's open on when she does her medication pass. It's telling me to give it if they don't sign it out then it shows that it's late in the morning. DON: It does not show up late for the next shift if the night shift does not give it. Staff C: Labs show up. DON: They are scheduled different. Staff C: There's a couple times I have helped the night shift finish their medication pass because it was agency that wasn't super knowledgeable who the people are, so I would help them. I don't know what days it was but a couple of times I have helped them finish their medication pass. DON: Another resident had their medication given at 5:00 AM and you gave another dose at 6:20 AM. You did not sign any of these out in the EHR. Staff C: Hmmm hmmm, I don't know. DON: The are all oxycodone. Staff C: I'm not sure. I'm not sure what I did. DON: Are you giving them to the residents? Staff C: Yeah, I don't know what to say. I wish I did but I don't know what to say. e. Summary of Investigation: On 6/5/23 the charge nurse from hall 5, Staff D Registered Nurse (RN) advised the DON that oxycodone was documented in the narcotic record book as given to two residents on 6/2/23 but not documented in the EHR. The DON began an investigation and it was found that one nurse, Staff C was signing out oxycodone for both residents before the order allowed in the medical record. This prompted another investigation into the halls 1 and 4 narcotic records and orders. Upon interview with Staff C, she stated she was giving the medication to the residents as she was signing them out of the narcotic record book. Interviews with alert residents stated they did not have additional pain on the dates questioned and did not receive additional PRN medications. One resident specifically stated that she was given a different color pill than what the other nurses give her when Staff C works. In total over the three week period Staff C worked, the DON found 63 pills documented in the narcotic record as given to the residents but not documented in the EHR. The nurses were counting each day but the count was correct in the cart as it was signed out in the narcotic book. Education and medication pass observations are continuing with the licensed nursing team including medication aides regarding proper documentation of narcotic medications. On 7/19/23 at 11:53 AM Staff D stated one day she went to sign out a narcotic medication for a resident, she looked back and saw inconsistent pattern. Medications were being signed out too frequently, oxycodone if she remembers correctly. She alerted her supervisor right away. When asked what documentation is required when administering a narcotic medication, she indicated you document on the MAR and narcotic book. Each medication card of narcotics has a number written on it that signifies the page to turn for the count sheet that correlates with that medication. Once on the page for that medication, you sign out that you are administering the medication. For example, in the narcotic book a resident's narcotic medication card would have the number 20 written on it. You would then get the narcotic book that contains the count sheets and turn to page 20. On that page you would document the date, time and how many tablets you are administrating and how many tablets remain. When you sign out a PRN medication in the EHR it will prompt you to document a progress note in reference to administrating the medication. Some staff will not document too much but she likes to put the resident's rating of the pain and the location of the pain. When asked if it was acceptable to give a PRN medication before the ordered time, Staff D stated it was not ok do that. If you called the doctor and got an order to give it more frequently. But if they don't get a doctor's order the nurse should follow the doctor's orders. On 7/19/23 at 2:16 PM the DON indicated she was notified by the staff nurse of issues with narcotic documentation. They noted the narcotic was signed out but no notes were found in the EHR, other times she was not charting in the narcotic book. The investigation started on hall 5 which was their skilled hall. She decided she should look at other resident's records. When she did that, she found more issues. The issues found pertained to residents that had orders for oxycodone. She then decided to look at all residents that had an order for oxycodone that resided in the facility. She tried to match what was given, charted on and timeframe the medications were given. She noted different administration times on different cards. She educated staff on counting, to let her know if anything was off but everything was fine so there were no triggers with the counts not being done. She looks at the narcotic counts and books weekly. She just learned that on her EHR dashboard there is an option to see when PRN's were given in the previous 72 hours. When she learned this, she noticed a lot had been given. She reported to her Administrator, did the report and called the cops. She completed interviews with residents and did call Staff C. When she spoke to one resident, her roommate (Resident #61) was in the room at the same time. The roommate stated she wondered about that nurse. When asked what nurse she stated Staff C. When asked why she indicated she was in more pain when she would work and her pills did not look right. When Resident #61 questioned her about it, Staff C did not have any answers for her. When the DON asked Staff C if she was giving medications like she was supposed to she indicated she thought so. She even asked Staff C if she knew how to ready orders that were every 4 hours and she said she did. The DON stated Staff #57 had dialysis from 10:00 AM-3:00 PM. So when she signed out he had received a PRN at noon, she questioned Staff C. Staff C stated he came back and said his back hurt. The DON asked Resident #57 if he received a pain pill after dialysis, he yelled at her and indicated he did not need pain pills. Staff C told the DON he choked on the pill and that was why she pulled another pill so she could give it to him. Staff C told the DON she wasted the medication herself when he choked. Resident #58 told the DON that Staff C never gave her a stockinette and that she did not ask for PRN medications that often. The DON told Staff C it looked like she went back and forth with medications or give the medications sooner than they should be with no documentation that she received an order from the doctor to do so. Staff C kept saying I don't know. She never had issues with Staff C. She always came to work, wanted to be here, never would have guessed this kind of behavior her. Only thing she thought was off was her husband would come to the facility when Staff C had her lunch break every single day. She would go on and on about him being on disability. Review of the facility's Controlled Substances Policy with a revision date of 4/2019 revealed the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medication. The policy documented: 10. Upon Administration: a. The nurse administering the medication is responsible for recording: (1) Name of resident receiving the medication; (2) Name, strength and dose of the medication; (3) Time of administration; (4) Method of administration; (5) Quantity of the medication remaining; and (6) Signature of nurse administering medication 11. Upon Disposition: b. Medications that are opened and subsequently not given are destroyed. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet. Review of the facility's Controlled Substance Record Book (Protocol) with an effective date of 2/14/22 revealed this document sets for the facility's procedure for completing the Controlled Substance Record Book. 3. Refusal of already punched out medication or contaminated medication: if a resident refused a medication that has already been punched out of the medication card or if a medication is dropped on the floor or became contaminated, two nurses need to cosign the sheet that the medication was wasted. 5. Signing out a Controlled Substance: When administrating a controlled substance, the following areas needs to be signed in the Controlled Sub

Based on observations, clinical and facility record review, and staff interviews, the facility failed to implement interventions and provide adequate supervision and proper use of assistive devices to mitigate a resident's risk for elopement and an accident for 2 of 5 residents reviewed (Resident #1 and 2). Elopement is when a cognitively impaired resident leaves the facility without staff knowledge or permission. On 8/16/22 sometime between 3:45 AM and 4:15 AM Resident #1 exited the building. The staff stated the doors were alarming but were ignored. The staff were not aware the resident had left the building until the hospital called informing them she was in their emergency room . The resident did not have a wanderguard bracelet on, had been exit seeking earlier in the shift and staff failed to implement interventions to ensure the residents safety. The resident was found by hospital staff outside the hospital neighboring the facility. She was found approximately 200 feet down a steep hill from the facility door where she eloped. On 8/16/22, the temperature outside was 63 degrees, with humidity at 100 percent and probable light rain in the area. The staff brought the resident back from the hospital and assessed the resident and found no injuries. This situation presented an Immediate Jeopardy to resident health and safety. Also, on 4/18/22 sometime after supper, Staff H transferred Resident #2 by herself using a mechanical lift. While the resident remained upright in the lift, Staff H stepped away from the resident to obtain a supply item. The lift then tipped over and the resident fell to the floor. An X-ray completed on 4/20/22 showed the resident sustained a fractured humerus. The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) assessment tool dated 8/7/22, documented Resident #1 admitted to the nursing home on 8/1/22 from the hospital. The MDS documented she had diagnoses that included a displaced fracture of the left tibia, atrial fibrillation, hypertension, urinary tract infection (UTI) in the last 30 days, Alzheimer's disease, arthritis, dementia, spasmodic torticollis, cutaneous abscess of the right lower limb, and staphylococcal arthritis of the right knee. The MDS documented the resident scored 3 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant she demonstrated severely impaired cognitive function. The MDS also documented she had hallucinations and delusions, but did not exhibit any behaviors. The MDS revealed Resident #2 required assist of 2 staff for bed mobility, transfers, and toilet use and the activity only occurred once or twice. The MDS coded she required one person physical assist for locomotion, dressing, personal hygiene, and bathing and the activity only occurred once or twice. The MDS showed she did not walk in her room or the hall and no restraints or alarms were used. The MDS identified Resident #2 took an anticoagulant daily for the last 7 days. The Care Plan dated 8/1/22 documented Resident #1 demonstrated impaired cognitive function related to dementia and had periods when she became restless and fearful. The care plan directed staff to anticipate and meet her needs, approach her in a calm manner, divert her attention, and remove her from situations to an alternate location as needed. The care plan dated 8/18/22 documented her husband realized it is not safe to take her home because she could become restless when her husband is not with her. The care plan dated 8/16/22 documented the resident is independent with ambulation (walking) using an assistive device and is at risk for elopement related to disorientation to place, history of attempts to leave the facility unattended, impaired safety awareness and wandering aimlessly. The care plan directed staff to alert other staff to her wandering behavior; approach her in a positive and calm manner; distract her from wandering by offering pleasant diversion (structured activities, food, conversation, TV shows, books and her iPad), and to place a monitoring device on her that sounds alarms when she leaves the building. The facility's Elopement Prevention Protocol dated January 2021 documented staff should place a resident that displays active exit seeking behavior on 1:1 observation and to place the intervention on the care plan and on the Medication Administration Record. The Education for All Staff documented if you hear an alarm sounding, check immediately and do not turn off the alarm until you know why it went off and everything is ok. The Wandering Evaluation dated 8/1/22 documented Resident #2 scored a 4 (at low risk for elopement). The Admission Evaluation dated 8/1/22 documented she required total assist for transfers and was receiving PT and OT. The Physician Progress Note dated 8/8/22 documented the resident has been walking with a walker since the weekend. She voiced no concerns to the physician except she was worried about her mother. The In-Home Therapy Intervention and Recommendation Worksheet dated 8/15/22 documented a home safety evaluation was completed in the home with the spouse present. The worksheet documented recommendations were reviewed with the spouse and daughter. The Progress Notes documentation included the following: - On 8/4/22 at 4:33 PM, therapy recommendation to try and complete sit to stand transfers using a front wheeled walker (FWW) as well as pivots between chair and surfaces. Walk as able to and from the bathroom for toilet use. Assist of one with FWW. - On 8/8/22 at 3:19 AM, Resident #2 confused, looking for her spouse, and attempted to transfer herself independently several times during the shift. - On 8/15/22 at 10:30 AM, Resident #2 ambulates with a FWW and assist of one staff. Resident #2 does get up unassisted and needed reminders to wait for assistance. She is excited about going for a home visit today. - On 8/15/22 at 4:09 AM communication from therapy to nursing contained a recommendation for the resident to walk with modified independence and FWW in her room and building. The communication directed staff to redirect the resident for safety, location, and task due to cognitive status and also continue to provide assistance for toilet use and personal hygiene as needed. - On 8/16/22 at 4:42 AM resident attempted to escape from Hall 5 more than once during the night and was redirected by the nurse on more than one occasion to sit near the nurse station or to her room where she could try to sleep. At 4:15 AM, she managed to sneak out of hall five through the north door. The door alarm could not be easily noticed when going off. Nurse managed to bring her back into the building. - On 8/16/22 at 9:00 AM attempted to call husband and daughter regarding elopement, left message. - On 8/16/22 at 1:01 PM spouse notified of resident's elopement with no concerns. - On 8/16/22 at 2:02 PM nurse practitioner notified of the elopement. - On 8/17/22 at 4:05 AM independent in her room. Door seeking behavior noted. Wander guard on. - On 8/17/22 at 8:38 AM resident is at risk for wandering. Wanderguard applied on 8/16/22. On 8/22/22 at 2:20 PM the Director of Nursing (DON) stated the resident had a home safety evaluation on 8/15/22. She stated the family voiced concern the evaluation would upset the resident because she would think she was staying home. She stated the resident did not want to lay down that evening or on night shift. The night nurse stated the resident kept going to the door to look out and set off the alarms. The night nurse reported he provided 1:1 supervision for Resident #2 at the nurse's station until he had to provide cares for another resident; the aides were in another room providing cares as well. She stated the resident got out of the facility while the staff were in resident rooms. The nurse reported when he came out of a resident's room, the alarms were sounding. He was just getting ready to start a head count when the facility received a call from emergency room staff to inform them the resident was there. The DON stated hospital staff found Resident #2 down the hill by the dumpsters. She reported they reviewed cameras and she was outside of the building approximately thirty minutes and dressed in slacks, a sweater, and shoes. She stated she was assessed with no injuries and they applied a wander guard immediately. The DON reported staff should have responded to the door alarms right away and they re-educated staff right away. She commented that she did not receive any calls prior to the elopement and the night nurse should have asked for help with supervising the resident. She added that Resident #2 will be moving to a secure memory care unit possibly this week. On 8/23/22 at 10:35 AM Staff A stated she was working the night of 8/15/22 to 8/16/22. She stated Staff B was the charge nurse up front and Staff C was the charge nurse on Hall 5. She reported the alarm sounded that night and she remembers asking Staff B about the alarm, and Staff B told her it was fine. She stated she was concerned because Staff B kept pushing the button to silence the alarm and after the third time, she asked Staff B again if everything was okay; Staff B told her it was fine, that it was just the door on Hall 5. Staff A stated Staff C was the nurse in charge on Hall 5. She reported she can hear the door alarms throughout the entire building and had been taught to physically go to the door that is alarming and would have done so that night, but the nurse stopped her. She added she thought Staff B had talked to Staff C and that was why she was silencing the alarms, but she did not know for sure. She reported that after the elopement there was a note at the desk that we all had to read re-educating us on door alarms and elopements. On 8/23/22 at 11:30 AM Staff D stated she has been an aide at the facility for almost two years, works nights on occasion, and has worked with Staff C. She stated she is able to hear the alarms throughout the entire building and has been taught if there is a door alarm sounding, she is to go to that door immediately. She added she has noticed Staff C nod off or fall asleep on night shift and due to this, she has had to ask him questions more than once. On 8/23/22 at 12:35 PM Staff C stated he was working Hall 5 the night of 8/15/22 to the morning of 8/16/22. He stated Resident #1 was awake most of the night. He stated he tried to take her to her room to sleep and she would lay down, but after a few minutes she would be up wandering the halls again. Staff C reported she was up looking for her husband and he tried to redirect her and asked her to sit at the nurse's station so she was more visible. He stated she kept going to the doors and one time she got the door open that opens to the main parking lot. He reported he was able to bring her back in and she went to her room and he had to go provide care in room [ROOM NUMBER]. Staff C said when he came out of room [ROOM NUMBER] he heard the door alarm sounding, but could not hear the alarms while in the room. He made an attempt to locate her and at that point, the other nurse (Staff B) came and told him the hospital called and told them Resident #1 was in their emergency room (ER). Staff C stated he went to the hospital, retrieved the resident, and escorted her back to the facility. When asked, he stated reported the facility did not communicate to him about the door alarms and he had not received any teaching or education about how to respond to door alarms prior to this incident. Staff C added he never thought she would leave the facility and thought she would go back to sleep and commented she is very confused and needs more supervision than what the facility can give her. He reported from now on, he will respond to all door alarms with a quicker response and if there is a resident trying to get out he will call for help. He stated he has nodded off at work before but denied doing so the night of the incident. On 8/23/22 at 1:05 PM Staff E stated she only worked the night of 8/15/22 from 6:00 PM to 10:00 PM. She stated she has worked with Staff C before and has never witnessed him sleeping at work. She stated if a door alarm goes off she has been taught to respond to it immediately. She stated she would go out the door to see if she could see a resident and if she didn't then she would alert all staff and start a head count. Observation on 8/23/22 at 1:00 PM revealed when in room [ROOM NUMBER] with the door closed and Hall 5 door alarm sounding, the alarm is audible but not loud. The DON stated door alarms do not sound over the radio walkie. Observation also revealed facility staff responded to the door al; arm within seconds. Observations on 8/23/22 outside the facility revealed a lake 3/4 of a mile south of the facility and a busy highway 1/4 of a mile north of the facility. The speed on the street in front of the building is 35mph. The highway 1/4 mile away is on the edge of town and advances from 45mph to 55mph and the door from which the resident exited is right behind the back side of the hospital. Observation also revealed a hill with a very steep decline which the resident would have descended to arrive at the area by the dumpsters where hospital staff found her approximately 200 feet from the facility door she where she exited. On 8/23/22 at 2:05 PM Staff B stated she is a nurse and has worked at the facility for three years. The night of the incident around 4:00 AM she received a call from the hospital ER informing her they had Resident #1. She said she went to the skilled unit where the back door alarm was sounding with staff C unaware the resident had exited. He told her he would go to the hospital and bring the resident back to the facility. Staff B said earlier that night around 3-3:30 AM, the other door on the skilled unit was alarming up front. She stated the alarm went off twice that night and at the time she said she went to Hall 5 and saw Staff C bringing Resident #1 back inside. She stated she could hear the door alarms throughout the entire building but said she could not hear the back door at the front nurse's station the night Resident #1 got out. When asked, she reported she had never observed Staff C sleep while he is working at night. In a subsequent interview on 8/24/22 at 10:10 AM, Staff B stated after the hospital ER called she went back to the skilled unit and said she saw Staff C sitting at the nurse's station and heard the door alarm sounding. On 8/23/22 at 2:38 PM Staff F stated around 3:00 AM or after the doors kept alarming. She stated she was at the front desk so she got up and looked down toward Hall five, picked up her radio, and asked if Hall 5 was okay. She stated Resident #1 had been wandering up and down the hall earlier so that is why she automatically looked there first, but Staff B responded and said everything was okay. Staff F reported the alarm also sounded twice when she was sitting at the nurse's desk completing a training, but Staff B was beside her and told her everything was ok. She stated Staff B never picked up the phone or got up to go back to Hall 5 when the doors were alarming, she just silenced the alarm and told her it was ok. Staff F commented that staff had informed management about Staff C falling asleep before, although nobody saw him sleeping the night the resident eloped. On 8/24/22 at 9:40 AM the climatologist stated the weather for Creston Iowa was 63 degrees, humidity 100 percent, wind from the east at 6 mph, overcast, probable fog, and the possibility of light rain in the area. The facility was notified of the Immediate Jeopardy on 8/23/22. It was determined the IJ had been removed on 8/17/22 when the facility took the following actions: 1. Provided re-education to staff regarding missing residents and elopement protocol on 8/16/22. 2. Provided re-education to staff regarding residents making statements of leaving, asking where is my husband or wife, increased wandering or attempts to leave - use new intervention such as: keep the resident in your line of sight or 1:1 supervision 3. Completed Risk Management 4. Assessed Resident #2 from head-to-toe; no new areas of injury identified 5. Applied a wanderguard bracelet on Resident #2's person and documented this action on the resident's care plan. 6. Doors and alarms checked to ensure proper functioning 7. Re-evaluated ambulation status and cognition of other residents 8. Regional Clinical Nurse Consultant entered facility and verified and ensured compliance and correction of immediate jeopardy situation on 8/17/22. 2. The Minimum Data Set (MDS) assessment tool for Resident #2 dated 3/1/22 documented the resident had diagnoses that included late onset Alzheimer's disease, hypertension, diabetes, dementia, muscle wasting and atrophy. The MDS also documented Resident #2 demonstrated severe cognitive impairment and required extensive assist of two staff for bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. The MDS revealed she had not had any falls since the last assessment. The Care Plan dated 1/28/20 documented Resident #2 required extensive assistance from staff for activities of daily living (ADL's) and mobility. The care plan intervention dated 3/11/21 directed staff to transfer the resident with a mechanical lift and assist of 2 people for all transfers. The facility policy Lifting Machine, Using a Mechanical dated July 2017 documented the following: - Purpose: To establish the general principles of safe lifting using a mechanical lifting device. - General Guidelines: At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. The Progress Notes documentation included the following: On 4/20/22 at 7:15 AM per the medication aide the resident is complaining of right arm pain and right wrist pain. Upon assessment resident noted to have swelling to upper arm but none noted at the wrist. No discoloration noted. Resident given routine oxycodone and will have her provider assess it on her rounds. On 4/20/22 at 9:41 AM communication from therapy to nursing with recommendation for physical therapy screen after a fall. Nursing to get orders for transfer assistance at this time. On 4/20/22 at 3:00 PM provider rounds and assessed right arm with new orders for x-ray of right arm, forearm and right humerus. Biotech notified per staff nurse and family notified. On 4/20/22 at 5:04 PM X-ray company at the facility and x-rays done. On 4/20/22 at 5:58 PM Administrator and Director of Nursing informed of resident complaint, orders and x-rays done. On 4/20/22 at 10:24 PM resident returned from the emergency room (ER) with right arm splinted and in a sling. Peripheral pulses palpable. Resident non-compliant with portions of assessment including hand grasps and finger movements and resident states she does not want to when encouraged to participate. Resident resting comfortably in bed without complaints and call bell in reach. On 4/20/22 at 11:40 PM splint to be on at all times due to the fracture. Resident states she is having pain so pain medication administered. On 4/21/22 at 10:30 PM spoke to daughter and explained investigation started into cause of resident's fracture. Explained one nurse aide stated resident had an incident on Monday that could have caused the injury. Family wanting updates as info available. On 4/21/22 at 10:30 AM resident scheduled for a follow up appointment with ortho on 4/28/22 at 10:45 AM On 4/22/22 at 1:12 PM call to family with consent received to have physical therapy evaluate and treat. On 4/23/22 at 1:05 PM resident complaining of discomfort. Right upper extremity in the sling with ace wrap and brace intact. Routine oxycodone and Tylenol given with some effect. Resident in bed at this time with Hoyer used for transfers. On 4/25/22 at 12:06 PM order received to increase oxycodone due to increased pain with transfers. On 4/25/22 at 4:27 PM follow up call to daughter notifying her of investigation. On 4/26/22 at 9:31 AM restorative did active assistive range of motion (AAROM) to bilateral lower extremities and AAROM to left upper extremity. Right upper extremity remains in a sling. No yelling out or complaints of pain and no facial grimacing. On 4/28/22 at 12:44 PM resident returned from ortho appointment with orders to continue the current splint. Follow up scheduled for 3 weeks with an x-ray. The Incident Report dated 4/25/22 documented Resident #2 had a fall while in the sit to stand lift on 4/18/22 at 5:30 PM. Staff G stated Staff H came out to the dining room and asked if she heard her page. She stated she told her she did not hear it. Staff H told her she needed help because the sit to stand lift flipped over sideways with the Resident #2 in it. Staff G quickly went to her room and saw the stand in an upright position and the resident not attached to it but laying on the floor very close to the bed. Staff G stated she paged for a nurse to come into room [ROOM NUMBER] stat. She stated there was no answer and no one came. She stated her and Staff H got the resident up by using a full body lift. Staff G stated she left the room, answered call lights and went to the nurses station but no one was there and she could not find anyone. The Radiology Report dated 4/20/22 documented a right humerus comminuted fracture of the proximal right humeral shaft is noted with medial apex angulation and approximately 2 cm of medial subluxation of the distal fracture component. Recommend orthopedic evaluation. On 8/23/22 at 10:35 AM Staff A stated she has been taught proper transfers with Hoyer lifts and sit to stand lifts. She stated she was taught on hire and yearly all the staff have to come in and be checked off in person and demonstrate proper transfers with lifts. On 8/23/22 at 11:30 AM Staff D stated she has been taught proper transfers with Hoyer lifts and sit to stand lifts. She stated they have been taught they are to use 2 to 3 staff for Hoyer lifts and 2 staff for EZ stand lifts at all times. On 8/24/22 at 1:56 PM the Administrator stated during the investigation of Resident #2's fracture they identified a nurse aide transferred the resident by herself and the sit to stand tipped over. Another aide called on the walkie to get help and two aides got her up on their own without a nurse assessing her. The facility terminated the aides involved and re-educated the rest of the staff to always use 2 staff with mechanical lift transfers and not to move a resident after a fall until a nurse can complete a post-fall assessment. On 8/25/22 at 12:55 PM Staff G stated she was working the evening of 4/18/22 during Resident #2's fall. She stated she was in the dining room assisting at supper. She stated she heard her radio sound but did not hear who it was or what they wanted. She stated Staff H came into the dining room and asked if she heard her page. She stated that Staff H told her Resident #2 had fallen out of the sit to stand lift. She stated when she walked into the resident's room the sit to stand was upright but the resident was on the floor laying on her arm. She stated Staff H told her she was using the stand herself, had the resident in a standing position in the stand when she stepped away to get a brief, the entire sit to stand lift tipped over. She stated she immediately paged for a nurse twice but no one came. She stated she wasn't thinking and helped Staff H get the resident up. She stated they used a full body lift to put the resident into bed for the night. She stated when she left the room she searched for a nurse but could not find one. She stated she was going to tell them later but assumed Staff H would tell a nurse. She stated the aides have been taught to not use any lift by ourselves. She added that at least two staff are to use any mechanical lift at all times. She stated they have been taught to page a nurse when a resident falls and leave the resident on the floor until the nurse comes to assess the resident. Multiple attempts to reach Staff H for an interview were unsuccessful. On 8/25/22 at 1:35 PM the Director of Nursing (DON) stated it wasn't until 4/20/22 that they could tell something was wrong with Resident #2. She stated during interviews with staff, Staff G informed them that Resident #2 fell while Staff H was transferring her the other night. Staff G stated Staff H came and got her to help get the resident up off the floor. The DON stated she feels like Staff H was trying to hide it. During the interview with Staff H she denied everything and denied even being in her room and taking care of her. She stated the nurses on that night were Staff B and Staff E both of them deny hearing any pages for help. She stated she expects the aides to stay with the resident and send another aide to go get the nurse. The aides are not to move the resident until the nurse assesses them for any injury. Review of the Point of Care Audit Report dated 4/18/22 for Resident #2 revealed Staff H signed on 4/18/22 at 8:31 PM that she provided two person transfer assistance with a lift when she transferred Resident #2 that evening.

Based on observations, clinical record and facility policy review, and staff interviews, the facility failed to provide adequate nursing supervision and assistance devices to prevent accidents for 3 of 3 residents reviewed (Residents # 47, # 62, and # 66). On 12/30/20, Staff G, Certified Nursing Assistant (CNA) assisted Resident # 66 to the bathroom without a using a gait belt in accordance with facility policy and then proceeded to leave the resident unattended before reaching the inside of the bathroom or assisting her to the toilet in accordance with her plan of care. As a result, the resident fell and hit her head, sustained a hematoma to the back of her head, and exhibited a change in mental status which required the facility to transfer her to the hospital for evaluation. A Computed Tomography (CT) scan completed at the hospital identified the resident had an anoxal injury to her brain which included a small punctate hemorrhage. In addition, staff failed to safely transport residents via wheelchair without foot pedals which put them at risk for injury (Resident # 47 and 62) and also failed to secure 2 of 4 medication carts properly according to facility policy with residents in the vicinity. The facility reported a census of 62 residents. Findings include: 1. According to the admission Minimum Data Set (MDS) dated [DATE], Resident # 66 had diagnoses that included hypertension and arthritis. The MDS documented the resident scored 14 of 15 possible points on the Brief Interview for Mental Status (BIMS) test, which meant the resident demonstrated intact cognitive abilities. The MDS showed she required limited assist of 1 staff for surface-to-surface transfers and walking in and out of the room, used a walker and wheel chair, and was not steady. The MDS revealed Resident #66 could only able to stabilize with staff assist when moving from a seated position, walking, turning around, and moving on and off the toilet. Resident #66's Care Plan dated 12/11/20 documented the resident could not transfer independently and required staff assistance with mobility related to weakness. The Care Plan directed staff to provide assist of one person with all transfers and a wheeled walker for all ambulation (walking). Resident # 66's Kardex Report dated 12/11/20 included the following: Mobility - Front wheeled walker or wheelchair Transfers - Transfer assistance with 1 staff and front wheeled walker Toilet Use - Assist the resident to the toilet with 1 staff and front wheeled walker. An Incident Report dated 12/30/20 at 9:31 AM, documented staff heard a loud noise from the resident's room and found them on the floor in the bathroom doorway lying flat with legs outward. The nursing assessment described the resident as alert and responsive, range of motion (ROM) at the time within normal limits (WNL), and all extremities equal in length with no rotation noted. The report showed the resident denied any pain but did hit her head. The report revealed staff saw a large hematoma on the back of the left side of the resident's head that measured 20 x 5 cm. Staff observed the resident wore no grippers, but did have her [CONDITION(S)] wraps on at the time. Resident #66 reported she used the front wheeled walker (FWW) but was unattended; she reported she was going to the bathroom - he left me and I could not do it. Neurological Evaluation #1 dated 12/30/20 at 6:45 AM, documented the resident as alert and oriented to person, place, time, and situation with pupils equal, reactive to light, and 2 millimeters (mm) in size. The report revealed she could follow the nurse's finger with her eyes, respond to simple commands, and verbalize appropriately. The report showed Resident # 66 had sensation in all extremities, demonstrated equal strength in both hands, and described her pain as a 3 on a 1 to 10 scale (0=nothing, 10=worst pain ever experienced). Neurological Evaluation #2 at 7:00 AM, documented the resident as alert and oriented to person, place, time, and situation with pupils equal, reactive to light, and 2 mm in size. The report revealed she could follow the nurse's finger with her eyes, respond to simple commands, and verbalize appropriately. The report showed Resident # 66 had sensation in all extremities, demonstrated equal strength in both hands, and described her pain as 2/10. Neurological Evaluation #3 at 7:15 AM documented the resident as alert and oriented to person, place, time, and situation with pupils equal, reactive to light, and 2 mm in size. The report revealed she could follow the nurse's finger with her eyes, respond to simple commands and verbalize appropriately. Resident # 66 had sensation in all extremities, demonstrated equal strength in both hands, and described her pain as a 3/10. Neurological Evaluation #4 at 7:31 AM documented the resident as alert but drowsy and oriented to person, place, time, and situation with pupils equal, reactive to light, and 2 mm in size. The report revealed she could follow the nurse's finger with her eyes, respond to simple commands and verbalize appropriately. Resident # 66 had sensation in all extremities, demonstrated equal strength in both hands, and described her pain as a 2/10. Neurological Evaluation #5 at 7:54 AM documented staff could not determine the resident's orientation to person, place, or time, level of alertness, pupil characteristics or response, or pain level. A Phone Order dated 12/30/20 at 7:49 AM directed staff to transfer Resident # 66 to the emergency room for evaluation and treatment. The Emergency Department to Hospital Admission record contained a Computed Tomography (CT) scan of Resident # 66's head or brain without contrast completed on 12/30/20 at 9:40 AM due to a traumatic injury from fall identified the resident sustained a concussion/head injury. The CT documented finding a small punctuate hemorrhage within the right [MEDICATION(S)] semiovale (the central area of white matter tissue in the brain composed of nerve fibers) found underneath the cerebral cortex (a sheet of neural tissue that is outermost to the cerebrum, the largest and uppermost portion of the brain) felt to represent evidence of axonal injury of the brain. An axonal injury of the brain is the shearing (tearing) of the brain's long connecting nerve fibers (axons) that happens when the brain is injured as it shifts and rotates inside the bony skull, according to https://www.hopkinsmedicine.org/health/conditions-and-diseases/traumatic-brain-injury Another CT scan of Resident # 66's head or brain without contrast completed on 12/31/20 at 12:35 AM due to altered mental status/memory loss, confusion or disorientation identified moderate-to-severe head trauma. The CT report documented an acute, but stable 3 mm punctated acute parenchymal hemorrhage (a bleed that occurs within the brain, disrupts normal blood flow and subsequently deprives the brain of oxygen). During an interview on 11/16/21 at 12:59 PM, Staff K, Dietary explained had she worked as a CNA at the time and verified she had gone into the room across the hall to assist the nurse and told Staff G CNA to go help Resident #66. Staff K reported she told Staff G Resident #66 required assist of 1 staff (for transfers and walking) and added she would be right back over to help. During an interview on 11/17/21 at 9:40 Staff G reported the incident happened too long ago for him to remember but he had written a statement at the time of the fall and provided it to the DON. According the statement dated 12/3/121 and written by Staff G, on 12/30/21 he had been training with hall 5 CNA (Staff K) when she went to assist another resident and sent him across the hall to help the resident wake up. The resident stated she needed to use the bathroom so Staff G assisted her to the bathroom door, where Resident #66 said she would be okay. Staff G went to obtain linens and heard the fall while at the linen shelf. Staff G entered the resident's room and saw Staff K, CNA and Staff L, Licensed Practical Nurse (LPN) helping Resident #66 in the door of the bathroom. During an interview on 11/17/21 at 12:06 PM Staff L LPN reported Staff K and Staff G were getting people up on hall 5 while she passed medications. Staff L said she went into a resident's room to provide a treatment with Staff K's assistance and Staff K sent Staff G across the hall. Staff L reported she finished the treatment and as she walked to the room next door, she passed Staff G carrying linens in the hallway. The next thing she knew, she heard a loud noise and she and Staff K ran into Resident #66's room and found her on the floor in the doorway between the bathroom and the room. Staff L stated Resident #66 lay flat on her back wearing her [CONDITION(S)] wraps but not her gripper socks. She was alert but tearful and had her walker but no gait belt. Staff L reported the post-fall assessment revealed the resident had full range of motion in her extremities with no shortening; they placed a gait belt around the resident's waist to assist her up and took her to the bathroom at her request. Staff L said she noted Resident # 66 had a hematoma on the back of her head and the resident confirmed she hit her head. Staff L applied ice and secured it with Kling gauze. Staff L remembered the resident started to get drowsy by the third set of neuros and had called her daughter, but handed to the phone to Staff L, who told her daughter that her mother had been left unattended when walking and fell . Staff L reported Staff G claimed he did not know what it meant when Staff K said the resident required assistance of one staff, but then commented that Staff G had been to the facility before during clinicals for nursing school and had also worked as a CNA at another facility. The facility document tilted Gait Belts (for use in ambulation and transfer) from Nursing Guidelines; and Procedure Manual dated January 2015 directed all staff should use gait belts to allow for easier handling of residents which should help to avoid injuries both to resident and staff. Guidelines: a. Each staff member will have a gait belt readily available for use when on duty. b. Provide instruction to resident. c. Apply the belt around the resident's waist snug enough to eliminate the possibility of sliding up on the ribs. d. Assist the resident to the edge of the chair/bed/surface, with both feet on the floor. e. Use proper body mechanics: Bend, lift with your knees, not your back. Keep your back straight at all times. f. Bring resident to a standing position by grasping the belt with both hands, while remaining upright yourself. g. Use the belt during walking to stabilize the resident by grasping the belt firmly in the middle of the resident's back. h. Walk alongside and slightly behind the resident, while holding onto the belt. i. If resident begins to lose their balance, draw the resident close to you, ease them down with your hold of the gait belt. This protects you and the resident from head or body injury. Call for assistance and do not move the resident until the nurse assesses them. 2. According to the MDS dated [DATE], Resident # 62 had diagnoses that included [CONDITION(S)], fracture, and anxiety disorder and had major surgery within 100 days of admission to the facility. The MDS documented the resident scored 6 on the BIMS test which indicated the resident displayed severely impaired cognitive abilities. The MDS also documented he required extensive assist of 1 staff for transfers and locomotion on and off the unit, had experienced a fall within the last month and sustained a fracture related to a fall in the last 6 months. A Care Plan dated 10/16/21 documented Resident # 62's could not transfer independently and was at risk for falls. The Care Plan directed staff to provide a safe environment without clutter, ensure he wore appropriate footwear, and provide assist of one staff for surface-to-surface transfers. A Wheelchair (use of) policy from the Nursing Guidelines and Procedure Manual dated January 2015 contained the following information: Purpose; To provide mobility for the non-ambulatory resident with safety and comfort. Guidelines; Assist resident into wheelchair using proper transfer techniques, lower the foot rest and place the resident's feet on it keeping the resident's feet and legs in good body alignment. Elevate legs as ordered. During an observation on 11/08/21 at 12:48 PM, Staff D CNA pushed Resident # 62 down the hallway in his wheel chair without foot pedals for approximately 24 feet while the resident held his feet just a bit above the surface of the floor 3. According to the MDS dated [DATE], Resident #47 had diagnoses that included [CONDITION(S)] and hip fracture. The MDS documented the resident scored 3 on the BIMS test which indicated the resident displayed severely impaired cognitive abilities. The MDS also documented Resident #47 reported he required extensive assist of 2 staff for transfers and locomotion on the unit, was not steady, could only stabilize himself with staff assistance when he moved from a seated to a standing position, and demonstrated a lower extremity impairment one side. Resident # 47's Care Plan dated 9/28/21 documented the resident could not transfer independently and was at risk for falls. The Care plan directed staff to provide a safe environment without clutter, ensure the resident wore appropriate footwear, provide assist of one staff with all transfers, and use a wheelchair for distance and a walker for short distances. During an observation on 11/09/21 at 7:53 AM Staff E CNA pushed Resident # 47 from the Occupational Therapy Kitchen down the hallway to his room for approximately 84 feet; the resident held his feet just above the surface of the floor. During an interview on 11/16/21 at 2:39 PM with the Director of Nursing (DON), she reported she expected staff to apply wheelchair pedals to the wheelchair prior to pushing a resident and place a gait belt on resident prior to assisting them with ambulation. 4. Observation on 11/09/21 at 08:48 AM revealed an unlocked medication cart in hallway 5 approximately 20 feet from the dining area where 2 residents in wheelchairs ate breakfast. In an observation on 11/09/21 at 08:49 AM, Staff C, LPN exited room #40 (approximately 50 feet from the unlocked medication cart). Staff C stated he had been away from the cart for a couple of minutes to assist a resident in their room. 5. Observation on 11/18/21 at 06:35AM revealed an unlocked medication cart without staff present in front of the nurse's station off the main dining room with 3 residents present in the dining area. Staff A, LPN walked away from the medication cart and through a set of double doors approximately 70 feet from the medication cart to screen surveyor prior to entry into facility. Following the screening, Staff A, LPN returned to the medication cart and acknowledged it they left it unlocked and without supervision. A facility policy titled Medications, Administration Guidelines from Nursing Guidelines and Procedure Manual, January 2015 Edition directed staff to keep the medication carts locked. When asked in an interview on 11/17/21 at 2:38 PM, the Director of Nursing verified the facility expected staff to keep medications carts locked when not in use.

Based on record review and physician and staff interviews, the facility failed to assess a resident with an excessive weight gain and implement further interventions for 1 of 13 residents reviewed (Resident #2). The facility reported a census of 60 residents. Findings include: 1. Resident #2 had an MDS (Minimum Data Set) assessment with a reference date of 8/31/12 which reflected [DIAGNOSES REDACTED]. The MDS identified the resident with a Brief Interview Mental Status score of 14 which indicated intact cognitive functioning. According to the MDS, the resident weighed 289 pounds during this assessment period. The MDS identified an admission date of [DATE]. The care plan with an update of 9/21/12 identified a problem with potential for weight loss related to inadequate nutrient intake, diabetes and [MEDICAL CONDITION]. The care plan identified a goal to maintain the resident's nutritional status with a weight of 289 pounds or below. The care plan did not direct staff how often to check the resident ' s weights. The physician admission orders [REDACTED]. The following weights were obtained in pounds: Date/Weight 6/1/12--269 (admission) 6/5/12--263.40 6/14/12--267.40 6/18/12--266.20 6/25/12--264 7/3/12--265.20 7/8/12--268.40 7/17/12--264.60 7/23/12--276.00 7/27/12--268.40 7/30/12--272.80 8/6/12--271.40 8/13/12--271.80 8/21/12--279 8/28/12--281 9/4/12--289 9/10/12--292.60 9/26/12--297.80 10/3/12--316.20 reweighed 319.20 10/10/12-349.9 10/23/12-348.4 10/30/12--329.50 11/1/12-333.30 A physician notification form dated 10/10/12 informed the physician the resident had been uncooperative and complained of pain in the legs, back, abdomen, generalized weakness with the resident stating he/she believed they had a stroke. The notification did not inform the physician of the excessive weight gain. The physician ordered laboratory tests in the morning. A physician notification form dated 10/11/12 informed the physician the resident had had a 54.2 pound weight gain in the last 30 days alone and 77.8 pound weight gain since admission. The staff documented a calculation of 22% increase in weight in 90 days for a total of 78.4 pound gain. The form documented the resident complained of overall discomfort, weakness and left arm pain. The physician ordered the resident to be taken to the emergency room . A hospital progress note dated 10/12/12 documented the resident admitted into the hospital with massive fluid [MEDICAL CONDITION], markedly distended abdomen, increased facial swelling, abdominal panniculus [MEDICAL CONDITION] and marked weight gain of 50 pounds over the past few months. The note also documented the resident had 2 liters of urine in his/her bladder. The note indicated the resident had a urinary catheter and the fluid quickly came off. The resident received [MEDICATION NAME] (diuretic) and diuresis about 2000 cubic centimeter (cc) s overnight. Review of the record revealed the resident returned to the facility from the hospital on [DATE]. The physician admission orders [REDACTED]. Review of the record also did not identify an admission weight. The record revealed a weight on 10/25/12 of 348.4 pounds. On 10/31/2012 at 2:49 P.M., the Nurse Consultant was interviewed and stated the facility had no weighing policy and no weight notification policy. The Consultant stated each situation is treated individually. On 11/1/2012 at 8:25 A.M., the Physician was interviewed and reviewed and resident ' s [DIAGNOSES REDACTED]. The physician stated that although the resident was difficult to weigh, he expected the facility to weigh him/her weekly but more importantly, the facility should monitor the urinary output and blood pressure. The physician confirmed the resident had 2 liters of urine in the bladder upon admission to the hospital. The physician also stated he would expect to be notified by the facility of a 5 to 7 pound weight increase in a week. Review of a discharge summary dated 10/22/12 revealed the resident admitted with [MEDICAL CONDITION], diabetes, obesity, fluid retention, [MEDICAL CONDITIONS] of chronic disease. The summary documented the resident was stable enough to transfer back to the nursing home from her/his [MEDICAL CONDITION]. The clinical record did not have documentation for the monitoring of the amount of urine output other than a physician notification that the resident voiced complaints of dysuria on 9/20/2012.

Based on observation, record review and staff interviews, the facility failed to have adequate personnel to ensure the health needs of the residents are met and failed to ensure each resident received adequate supervision to ensure against hazards from self and elements in the environment (Resident #1). The sample consisted of 5 residents and the facility reported a census of 63 residents Resident #1 had severely impaired cognitive deficits due to dementia and required extensive assistance of 2 people for activities of daily living. Resident #1 had a history of [REDACTED]. On 6/16/2012, during the night shift, Staff A attended to Resident #1 and performed incontinency care, positioned the resident and attached an alarm to the resident ' s gown. Staff A performed this alone and left to respond to another alarm sounding. Staff A left the bed in an elevated height. The resident fell out of bed and staff found the resident in a prone position on the floor. The fall resulted in a fractured humerus (upper arm) and multiple fractured facial bones. The resident remained in the hospital until 6/19/2012 and required oxygen therapy due to facial fractures and analgesic medications. On the night of the incident, the facility had 2 Certified Nursing Assistants caring for 63 residents and 1 nurse. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with a reference date of 3/23/12. The assessment identified Resident #1 with a BIMS (Brief Interview for Mental Status) score of 3. A score of 0-7 indicated a severely impaired cognitive status. Resident #1 required extensive assistance of 2 staff with bed mobility, transfers, dressing, toilet use, personal hygiene and bathing. Resident #1 experienced episodes of bowel and bladder incontinence functioning. Resident #1's [DIAGNOSES REDACTED]. The Care Plan dated 10/8/09 indicated Resident #1 had a problem with a potential for injury related to history of falls and impaired mobility. The Care Plan goal was for the resident to have no significant injury related to a fall. The approaches directed staff to transfer the resident with a mechanical lift and the assistance of 2 people and to use a personal alarm when the resident lay in bed. (Resident had experienced a fall on 8/3/2011 when getting up from an exercise bicycle/fractured femur). The Nurse ' s Notes and Incident/Accident Occurrences form dated 6/16/2012 at 2:00 a.m. revealed the nurse heard the resident yelling and entered the resident ' s room. The staff person found the resident lying face down beside the bed. The resident had a ? centimeter gash on the forehead and the nose bled profusely. The resident lay on left arm and when moved by staff, the resident experienced pain. The body alarm hanging on gown. The resident had a 3 inch skin tear on the left upper arm and a 1/4th inch gash on the 2nd knuckle of the right hand. The nurse performed neurological checks and identified sluggish pupils. The nurse could not complete the neurological exam because the ambulance arrived to transport the resident to the hospital. An Internal Quality Assurance Investigation form was presented and indicated the body alarm had not been attached to the bed properly and the bed height not in a low position. On 6/16/2012 at 8:30 a.m., the facility contacted the hospital emergency room . The hospital staff reported the physician admitted the resident into the hospital due to facial and arm fractures. The radiology report dated 6/16/12 identified multiple bilateral facial fractures and an impacted humeral neck (upper arm/shoulder) fracture. The physician Discharge Summary report indicated a date of discharge as 6/19/2012. The resident had been hospitalized for [REDACTED]. The summary identified a secondary [DIAGNOSES REDACTED]. The Discharge Summary indicated the resident would continue with the required skilled nursing care and oxygen support until more of the facial swelling decreased. The resident had an indwelling bladder catheter in place. The resident received Vicodin (narcotic analgesic) every 4 hours as needed for pain and a Fentanyl (narcotic analgesic) patch, 12 micrograms, placed every 3 days. On 6/26/12 at 12:00 p.m. Staff A (Certified Nursing Assistant) was interviewed and stated she worked the overnight shift on 6/15/12 and assigned to Resident #1. At 12:00 a.m. Staff A entered the room of Resident #1 and found Resident #1 incontinent of urine. Staff A raised the bed to a level comfortable for her and proceeded to change the resident ' s brief and provided perineal care before positioning the resident onto his/her right side with a pillow placed behind his/her back for support. Staff A clipped the personal alarm onto Resident #1's gown, provided the call light and offered fluids. Staff A stated at this time, she heard an alarm and responded to another resident's room. Once resolved, Staff A stated she believed she finished with Resident #1 and moved onto the next room. At 2:00 a.m. Staff A stated she heard a yell for help and found Resident #1 lying on his/her stomach (prone) on the floor. Staff A called for the nurse. Staff A stated the personal alarm had not sounded but remained attached to the resident. The alarm box sat next to Resident #1 on the floor. Staff A stated she did not check the alarm box to ensure it as properly secured to the bed before leaving earlier that shift. Staff A also noted the bed as in a raised position and she realized she had failed to lower the bed following the cares provided earlier. Staff A stated it as facility rules to put the bed in the lowest position following cares and when distracted by the alarm, had failed to return to the room to ensure the bed lowered and all safety interventions in place. Staff A accompanied the surveyor to the bed Resident #1 used at the time of the incident. Staff A elevated the bed to the position/height she believed the bed raised to at the time of the incident. When measured, the elevation from the floor to the top of the mattress measured 28 inches. In an interview on 6/26/12 at 3:35 p.m. Staff B (Licensed Practical Nurse) stated she worked the overnight shift on 6/15/12 as a charge nurse. At 1:30 a.m. Staff B went down Hall 2 glancing in each room. Resident #1 was observed in bed. Staff B stated had not been aware what height the bed raised to. At 2:00 a.m. Staff A called Staff B to Resident #1's room. Resident #1 found lying next to the bed, on the floor, face down, head turned to the side, left arm underneath him/her and both legs out straight, parallel to the bed. Resident #1 bled from his/her face. Staff B proceeded with an assessment of the resident ' s injuries. Staff B noted the bed elevated about 27 inches from the mattress to the floor. The personal body alarm had not sounded and remained attached to Resident #1. The box had been observed on the floor next to the resident. Staff B stated Resident #1 had the capabilities of following simple instructions and depending on his/her abilities at that moment, might be capable of participating in cares and only needed one person assistance with cares. Staff B stated before care givers are to leave a resident ' s room, they are to make sure all alarms are in place and functioning, the bed is in the lowest position and residents are centered in the bed. On 6/27/12 at 2:00 a.m. Staff C (Certified Nursing Assistant) was interviewed and stated he worked the overnight shift on 6/15/12 and assigned to Halls 1 and 4. Staff C stated staff called him to help with Resident #1 following the fall, but had no contact with Resident #1 up to that point. Staff C stated on the overnight shift he is assigned 2 halls and works with the other aide with residents which require two person assistance. When providing cares, the bed is usually elevated to a height comfortable to work at. Staff take turns with peri cares so one staff isn't always doing the cares. Upon completing cares, the bed is put in the lowest position, alarms attached and floor mats placed at side of the bed. On 6/27/12 at 10:35 a.m. Staff D (Director of Nursing) was interviewed and stated she expected staff to reposition residents (who are unable to reposition themselves minimally) every two hours, residents who have an incontinent episode are to be provided peri care, after cares are provided alarms are to checked, bed is to be in the lowest position, call light to be available, fluids offered and a visual sweep of the room to look for cleanliness, safety, resident comfort and positioning. The overnight shift nursing staff are expected to do rounds every two hours and provide cares as needed. Call lights are answered as they occur. Residents requiring total dependence for bed mobility are to be assisted by two staff for positioning, peri cares and to assure safety. On 6/26/12 at 7:50 p.m., Staff E (Certified Nursing Assistant) was interviewed and stated she works the overnight shift. Her normal routine would be to make rounds with off going shift, gather supplies, pass towels, answer call lights and continue rounds beginning at 12:00 a.m. assuring all residents are checked, changed and repositioned as needed. Staff E stated if she needs help with peri cares she can call the nurse or other aide. Staff E noted she is usually assigned two halls (30 residents) and finds the workload heavy with just two aides. Staff E stated she usually provides peri cares by herself and added with only two aides it is difficult to meet the needs of the residents in a timely manner. On 6/26/12 at 1:46 p.m. Staff F (Certified Nursing Assistant) was interviewed and stated she works the day shift. Staff F stated one aide is assigned to each hall and two halls team up to work together. During peri cares there are usually two aides in the room. Once finished, the resident is placed in the center of the bed, alarms and safety precautions are put in place, the bed lowered to the lowest setting, floor mats put in place and call light provided to the resident. On 6/26/12 at 1:36 p.m. Staff G (Certified Nursing Assistant) was interviewed and stated she works the day shift. Staff G stated when doing peri care you are to have two people at all times to help position the resident. The bed can be raised to a comfortable height. Once peri care is completed, staff are to position the resident in the center of the bed, lower the bed to the lowest level, make sure alarms are functioning properly and attached to the resident correctly. Staff G stated these standards are taught by the facility upon hire. On 6/26/12 at 2:07 p.m. Staff H (Certified Nursing Assistant) was interviewed and stated she works the day shift. Staff H stated one aide is assigned to each hall and two halls team up to work together. During peri cares there are usually two aides, but at times peri cares are provided by only one aide. When providing peri cares, beds are raised and when finished, alarms and safety precautions are put in place, the bed lowered to the lowest setting and the call light provided to the resident. On 6/26/12 at 2:36 p.m. Staff I (Certified Nursing Assistant) was interviewed and stated she works the evening shift. Staff I stated one aide is assigned to each hall and two halls partner to work together. Residents capable of actively participating in their cares can be provided peri cares by a single staff and those unable require the second staff. When finished with cares, the alarms are checked, positioning of the resident is proper, fluids offered and bed is in its lowest setting. Staff I stated these standards were addressed during her orientation and is also reinforced through their accu nurse system. On 6/26/12 at 3:02 p.m. Staff J (Certified Nursing Assistant) was interviewed and stated she works the evening shift. Staff J stated after providing cares, residents is to be centered in the bed, offered water, have their bed lowered and assure all alarms and safety interventions are in place. Staff J indicates she knows these standards through her schooling and as facility rules. On 6/26/12 at 2:17 p.m. Staff K (Certified Nursing Assistant) was interviewed and stated she works the evening shift. Staff K stated one aide is assigned to each hall and two halls partner to work together. On some occasions there are only three aides at certain times during the evening shift. Staff K noted she has sometimes had to provide peri cares by herself. Staff K stated following cares, all safety interventions are in place, call light is provided and the bed put into its lowest position. On 6/26/12 at 8:20 a.m. Staff L (Registered Nurse) stated she works overnight shifts. Staff L stated she is available to help staff during the overnight shift and noted ideally at least 3 aides are needed. Staff L stated Resident #1 required two person assistance with repositioning and peri cares. Resident #1 does not typically move around in bed too much.