Every finding on record at Crestview Home

Based on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. The facility census was 40. The facility did not provide the requested job description for the Dietary Manager. Review of the DM's personnel file showed: -Date of hire 10/04/2023; -No certification for food service management or dietary manager was found. During an interview on 02/24/25 at 11:32 A.M., the DM said: -He had been the DM for six months; -He has worked as a dietary aide, but does not have any managerial experience; -The facility was getting ready to start on his DM training; -He has not completed his/her DM's course. During an interview on 02/27/25 at 03:10 P.M., the Administrator said: -She would expect the DM to know all regulations related to the kitchen; -The DM had not completed the dietary training yet; -She would expect the DM to have the training completed. During an interview on 03/05/25 at 12:43 P.M., the Registered Dietitian (RD) said: -The facility is trying to work on training the DM; -He would expect the DM to have the required training to manage the kitchen.

Based on observation, interview, and record review, the facility failed to ensure staff stored food in a sanitary manner and to maintain the kitchen in a sanitary manner. The food facility census was 40. Review of the facility's policy, General Dish Room Sanitation, dated, May 2015, showed: -Dish rooms must be maintained in a clean and sanitary condition; -Items must be stored inverted (upside down) to prevent contamination. Review of the facility's policy, Cleaning Floors, dated, May 2015, showed: -Floors will be cleaned after every meal; -The dietary department must keep the floors of the kitchen free from soil and clutter. Review of the facility's policy, Refrigerators and Freezers, dated, May 2015, showed: -The floors of walk in refrigerators and freezers should be swept and mopped weekly; -Food should be stored at least 6 inches above the floor. Review of the facility's policy, Dishwashing, dated, May 2015, showed: -Check chemical dispensers for proper operation and an adequate supply of chemical. Review of the facility's policy, Wet Mopping, dated, May 2015, showed: -Dietary floors should be kept in good repair; -Cracked tiles should be repaired and replaced. Observation of the kitchen on 02/23/25 at 09:50 A.M., showed: -The hand washing sink in the kitchen was dirty with dirt and grime in the basin; -The handles on the hand washing sink were covered with dirt and debris; -A white bucket of dirty water containing debris was sitting under the hand washing sink; -The dish room floor was covered in dirt and debris; -There was a black substance on the outside of the dishwasher and under the dishwasher on the floor; -The paint was peeling off the ceiling in the dish room. Observation on 02/23/25 at 09:50 A.M., showed Dietary Aide (DA) A put a water pitcher, three glasses, and a coffee cup on to a dish rack and put the rack in the dishwasher; -The dishes ran through a wash and rinse cycle; -DA A removed the dish rack with the washed dishes from the dishwasher; -DA A did not check the sanitizer in the dishwasher before or after using the dishwasher. Review of the dishwasher sanitation and temperature log dated, February 2025, showed: -No entry indicating staff checked the sanitizer level on 02/01/25 at lunch; -No entry indicating staff checked the sanitizer level on 02/02/25 at lunch; -No entry indicating staff checked the sanitizer level on 02/05/25 at lunch; -No entry indicating staff checked the sanitizer level on 02/06/25 at lunch; -No entry indicating staff checked the sanitizer level on 02/07/25 at lunch. During an interview 02/23/25 at 10:01 A.M., DA A said: -The sanitizer should be checked before running the dishwasher at every meal; -The sanitizer level should be recorded on the sanitation and temperature log before running the dishwasher; -He/She did not know why entries were missing on the temperature and sanitation log. Observation of the serving area in the dining room on 02/23/25 at 10:12 A.M., showed: -The outside of the refrigerator was covered in dirt and debris; -The handle was covered in a brown sticky substance; -The inside and bottom of the refrigerator was covered with food debris and a brown sticky substance; -A table behind the steam table with multiple glass cups and bowls, setting face up with dirt and debris in them; -Plastic bowls setting on the table behind the steam table setting face up with dirt and debris in them; -The glass on the steam table covered in splattered food debris and smudges; -The inside left corner of the steam table with a puddle of black sticky liquid in the corner; -The steam table was on and steam was coming from under the lids on the steam table; -The lids had food debris on them; -The control knobs of the steam table were covered in sticky, brown grime with food debris stuck to them; -Dirty masking tape was hanging down from each of the control knobs on the stream table; -There were multiple tiles missing from the floor next to the steam table; -The trash can next to the hand washing sink in the serving area with no lid. Observation of the kitchen on 02/23/25 at 10:52 A.M., showed: -The walk in cooler had a wet substance the size of a basketball on the floor; -Undated zip lock bag of hamburger patties; -Undated zip lock bag of hotdogs; -A box of health shakes setting on the floor; -A package of opened and undated Brussels sprouts; -The floor of the cooler was sticky and covered with food debris; -Multiple black spots on the ceiling outside of the walk in cooler the size of nickels; -Dry storage showed a clear plastic container of thickener with the dates 09/25/24 - 10/25/24 written on the lid; -16 ounce clear plastic container of flour with the dates 08/16/24 to 10/24/24 written on the lid; -An open package of sugar with no date; -The inside of the microwave covered in dirt and debris; -Floors of the kitchen were covered in dirt and debris. Observation of the kitchen on 02/25/25 at 08:25 A.M., showed: -A rack of pots and pans stored face up; -A plastic container of whisks and spoons with dirt and debris in the bottom; -The ceiling of the kitchen with dust on it; -A black piece of plastic hanging from the sky light over the dish drying rack. During an interview on 02/25/25 at 1:25 P.M., the Dietary Manager (DM) said: -The kitchen should be clean and sanitary; -There should be no food stored on the floor in the cooler; -Food should have a date it was put into storage; -All food should be stored in a closed container; -The thickener and flour in the dry storage should have been discarded according the the dates on the containers; -The kitchen staff clean the kitchen, including the floors; -The floors in the kitchen should be swept and mopped daily; -The dietary staff tries to work on it together, but sometimes there is not enough time; -The kitchen staff is responsible for keeping the service area and the steam table clean in the dining room; -The dishwasher sanitizer should be checked three times a day and recorded on the log in the dish room; -Maintenance is in charge of repairs in the kitchen and the dining room; -The facility does not have a full time maintenance man at this time. During an interview on 02/27/25 at 03:10 P.M., the Administrator said: -She expects the kitchen to be clean and in good repair; -She expects foods to be stored appropriately; -There should not be food on the floor; -The dietary staff is in responsible for cleaning the kitchen; -Maintenance is responsible for the repairs in the kitchen; -The facility does not have a full time maintenance man right now. During an interview on 03/05/25 at 12:43 P.M., the Registered Dietitian (RD) said: -He expects the kitchen to be clean and sanitary; -He expects the kitchen to in good repair; -He expects the sanitizer in the dishwasher to be checked three times a day and recorded on the log in the dish room; -He expects dishes to be stored in a manner to prevent contamination; -He expects food to be stored in a safe manner.

Based on interview and record review, the facility failed to ensure three Certified Nursing Assistants (CNAs), of 7 sampled staff had a minimum of 12 hours of documented yearly in-service education (which should have included abuse, neglect, and dementia cares). This had the potential to affect all of the residents. The facility census was 40 residents. The facility did not provide a policy for education or and Nurse Assistant Training. Review of personnel records showed: -Certified Nurse Aide D, Date of Hire 11/22/00, Annual Education Quiz completed 6/7/24. No other education/in-service records; -CNA E, Date of Hire 10/21/22, Annual Education Quiz completed 6/6/24. No other education/in-service records; -CNA F, Date of Hire 9/17/01, Annual Education Quiz completed 6/6/24. No other education/in-service records; -Nurse Aide A, Date of Hire 10/3/24, no education/in-service records. During an interview on 02/27/25 at 12:28 PM the Quality Assurance Registered Nurse said: -Training, documentation of training, and tracking are completed by nurse leadership; -Yearly trainings for CNAs are based on a calendar year, set up by nursing Leadership; -Outside vendors, such as hospice, will also provide education for staff at times; -Ultimately the documentation, tracking and training schedule were the responsibility of the Director of Nursing (DON). During an interview on 02/27/25 at 3:10 P.M. the Administrator said: -The previous DON completed the last competency; -Education is completed by combination of the DON and the Leadership Team; -He/She expects tracking of all trainings, such as a checklist of all of the employees with their individual components; -She would expect the DON to document and track all training. -He/She did not know where the tracking and attendance records are.

Based on interview and record review, the facility failed to hire an Infection Preventionist (IP). The facility census was 40. The facility did not provide and Infection Preventionist policy. Review of the Infection Control binder showed it did not include an IP training or certification. During an interview on 2/25/25 at 3:00 P.M. the Administrator said; - The Director of Nursing (DON) said he/she completed the IP course, but had not produced certification indicating the DON had completed the task; - The facility did not have a current IP; - She knew the facility was suppose to have an IP.

Based on interview and record review, the facility failed to establish an infection prevention and control program that included an antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) that included antibiotic use protocols and a system to monitor antibiotic use. The facility census was 40. The facility did not provide an Antibiotic Stewardship policy. The facility did not provide Antibiotic Stewardship Program documentation that should include: - Protocols to optimize the treatment of infections by ensuring that residents who require an antibiotic are prescribed the appropriate antibiotic; - Procedures to reduce the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use; - Procedures to promote and implement a facility-wide system to monitor the use of antibiotics including a system of reports related to monitoring antibiotic usage and resistance data; - Designated appropriate facility staff accountable for promoting and overseeing antibiotic stewardship; - Accessing pharmacists and others with experience or training in antibiotic stewardship; - Implementation of a policy or practice to improve antibiotic use; - Regular reporting on antibiotic use and resistance to relevant staff such as prescribing clinicians and nursing staff; - Educate staff and residents about antibiotic stewardship. Review of the Infection Control binder showed the following: - January 2025 showed 10 infections, six urinary tract infection (UTI), one eye infection, one tooth infection, and two sialoadentis (infection of the salivary glands); - February 2025 showed 11 infections, eight UTIs, two respiratory infections, and one skin infection. - The infections were tracked on a color coded facility map, but no evidence was presented to show the facility staff determined the root cause analysis for the infections; - There was no evidence the facility provided the staff with infection control education. During an interview on 2/25/25 at 3:00 P.M., the Administrator said he/she did not have a current Infection Preventionist.

Based on observation, interview, and record review, the facility failed to develop and implement water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia) which had the potential to affect all residents who resided at the facility. Furthermore, the facility failed to follow infection control guidelines when one staff administered eye drops for one resident (Resident #23) without the use of gloves. The facility census was 40. The facility did not provide a Legionella policy. 1. Review of the facility's records showed they did not have an implemented water management plan. During an interview on 2/25/25 at 3:50 P.M. the Administrator said: - The facility had not had a maintenance employee for over a month; - The maintenance employee would assess the building water systems; - The maintenance employee would document water testing and monitoring; - She was not able to find the facility water management plan. 44395 2. Review of the facility provided, undated policy Gloves showed: -Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes (moist, inner linings of body cavities such as the nose, eyes, throat, etc), non-intact skin, any moist body substances (blood, sweat, tears, urine, etc) or surfaces soiled with these substances; -Use examination gloves for procedures involving contact with mucous membranes, for other resident care or diagnostic procedures that do not require sterile gloves. Review of Resident #23 Quarterly Minimum Data Set (MDS: A federally mandated assessment tool completed by facility staff) showed: -Brief Interview of Mental Status of 13, indicated very little cognitive deficit; -Partial to moderate assistance of staff for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself); -Diagnosis of Dementia (a decline in mental ability severe enough to interfere with daily life), Anxiety (excessive worry, fear and nervousness that interferes with daily life), hypertension (high blood pressure), and dry eye. Review of the resident's physician orders for February 2025 showed, Artificial tears 1 drop each eye for dry eye. Observation on 02/26/25 at 12:43 P.M. showed: -Certified Medication Technician (CMT) B did not apply gloves. -CMT B administered one drop of Artificial Tears into the resident's right eye, held pressure to the inner corner of the eye with a tissue for one minute, then applied one drop into the resident's left eye. During an interview on 02/26/25 at 12:43 P.M., CMT B said -He/She should have worn gloves to administer eye drops; -He/She just did not think and gave the eye drops after administering oral medications. During an interview on 02/27/25 at 12:28 P.M., the Quality Assurance Nurse said she would expect gloves to be worn when administering eye drops. During an interview on 02/27/25 03:10 P.M the Administrator said she would expect staff to follow infection control guidelines.

Based on observation, interview, and record review, the facility failed to ensure appropriate care and services were provided to residents to prevent the development and/or deterioration of pressure ulcers (PU) for four of 12 sampled residents (Resident #28, #92, #11, and #15). Facility staff failed to ensure the physician was notified of the PU and treatment obtained timely for one resident (Resident #92). The facility failed to ensure PU precautions were adhered to for one resident, resulting in the resident developing a PU (Resident #15), and failed to thoroughly assess and document assessments and measurements, and update the physician to obtain treatment orders for a new pressure ulcer for (Resident #92) and when a PU deteriorated for (Resident #11). Furthermore, the facility failed to follow their protocol assessment and documentation of skin issues when nurses did not consistently document and/or sign shower sheets at the time of a shower for two residents (Resident #28 and #92). The facility census was 40. Review of the facility's undated policy Pressure Ulcer Care and Prevention showed: -Purpose is to prevent and treat further breakdown of pressure sores. -The nurse is responsible for implementing measures to prevent pressure ulcers; -Change bed linen promptly whenever wet or soiled; -Keep sheets dry, free of wrinkles and free of debris; -Turn the resident every 2 hours and position with pads or pillows for protection; -Assist the resident at mealtimes to assure adequate nutrition; -Offer fluids frequently for adequate hydration. Review of the facility's undated Wound Protocol document showed: -Develop a turning and repositioning schedule, at least every two hours while in bed and at least hourly in a chair; -Encourage Fluids; -Thoroughly document all wound information such as type, location, stage, length, width, depth and drainage; -Notify appropriate personnel of all new pressure ulcers. Review of the facility's Skin Monitoring: Comprehensive CNA Shower Review showed: -Perform a visual assessment of a resident's skin, report any abnormal looking skin to the charge nurse immediately. Forward any problems to the Director of Nursing for review. Use this form to show exact location and description of the abnormality. -Signature areas for the Certified Nurse Aide completing the shower, the Charge Nurse, and the Director of Nursing; -Areas for documentation of Charge Nurse Assessment, and Intervention. 1. Review of Resident #28 Quarterly MDS, dated [DATE], showed: -Brief Interview of Mental Status (BIMS) of 0 indicated severe cognitive impairment; -Moderate assistance for Activities of Daily Living (ADL's: tasks completed in a day to care for oneself); -Incontinent of urine and bowel; -At risk for PU; -No PU; -Diagnoses of: Memory Deficit after cerebral infarction (loss of memory after stroke: when blood flow to a part of the pain is blocked, causing loss of cells), Need for assistance with personal care, history of falling, and delirium (a sudden change in mental state). Review of the resident's Comprehensive Care Plan, dated 2/25/25, showed: -He/She needs assistance with ADL's; -No care plan for risk of PU or actual PU. Review of the resident's bath sheets, dated January 2025, showed: -1/1/25: no skin issues; -1/7/25: Decubitus (damage to the skin and underlying tissues caused by prolonged pressure; a bedsore or pressure ulcer) to right and left buttocks. Signed by Charge Nurse: Licensed Practical Nurse (LPN) A on 1/8/25; -1/10/25: Decubitus to right and left buttocks. No charge nurse assessment.; Signed by Charge Nurse: LPN A on 1/13/25; No DON signature; -1/17/25: Decubitus to right and left buttocks. No charge nurse assessment; Signed by Charge Nurse: LPN A on 1/17/25; No DON signature; -1/21/25: Decubitus to right and left buttocks. No charge nurse assessment; Signed by Charge Nurse: LPN A on 1/22/25; No DON signature; -1/24/25: Decubitus to right and left buttocks. No charge nurse assessment; No charge nurse signature; No DON signature; -1/27/25: Decubitus to right and left buttocks. No charge nurse assessment; Signed by Charge Nurse: LPN A on 1/27/25; No DON signature; -1/31/25: Decubitus to right and left buttocks. No charge nurse assessment; Signed by Charge Nurse: LPN A on 1/31/25; No DON signature. Review of the Resident's progress notes showed: -On 01/09/2025 at 10:11 A.M., Reported from Hospice Nurse the resident had two PU on his/her top right buttock and left inner buttock. Hospice gave order for areas to be cleansed with soap and water, pat dry, and apply zinc cream twice a day and as needed; -On 01/09/2025 at 3:40 P.M., Nurse was informed that the resident had an open area to his/her bottom. He/She found an area at the top of the resident's inner left buttock that was covered with slough (a non-living, yellow or white material in wounds, made of dead cells and other debris), unstageable (the stage of a pressure ulcer is unknown because the wound bed is covered by dead tissue), measuring 0.8 centimeters (cm) in length x 0.9 cm width x 0.1 cm depth. Wound edges and surrounding skin appeared as dry skin. Physician was in the facility and gave an order to discontinue (DC) zinc and start cleansing the area with soap and water, pat dry, apply Santyl (prescription medicine that removes dead tissue from wounds so they can start to heal) applied nickel thick to wound bed, apply border gauze dressing, and change daily. An air cushion was added to his/her recliner. Staff will assist him/her turning side-to-side during the night to keep pressure off of the open area. He/She had a pressure reduction cushion to his/her wheelchair. An air mattress was requested from hospice. -On 01/12/2025 at 2:33 P.M., The area on the resident's buttocks was cleansed and zinc was applied. Open area was barely visible and without drainage. The area appeared to be a stage 2 (a shallow open sore that has partially broken the skin's second layer); -On 01/14/2025 at 10:37 A.M., Hospice nurse DC' d the Santyl order to stage 2 ulcer. New order received to cleanse the pressure ulcer with soap and water, apply thera honey (a medical product used in wound care to promote healing) gel nickel thick, apply breathable dressing, and change daily; -No other progress notes in regards to wounds. Review of the resident's bath sheets, dated February 2025, showed: -2/3/25: Decubitus to right and left buttocks. No charge nurse assessment; No charge nurse signature; No DON signature; -2/7/25: Decubitus to left buttock and discoloration to right buttock. No charge nurse assessment. Signed by LPN B on 2/9/25; No DON signature; -2/7/25: Decubitus to left buttock and discoloration to right buttock. No charge nurse assessment. Signed by LPN B on 2/14/25; No DON signature; -2/10/25: Decubitus to left buttock and discoloration to right buttock. No charge nurse assessment. Signed by LPN A on 2/10/25; No DON signature; -2/19/25: Decubitus to left buttock and discoloration to right buttock. No charge nurse assessment. No charge nurse signature; No DON signature; -2/24/25: Decubitus to left buttock and discoloration to right buttock. No charge nurse assessment. Signed by LPN A on 2/24/25; No DON signature. Review of the resident's physician order sheets, dated February 2025, showed an order for Pressure Ulcer Care: Cleanse PU to left inner buttock with soap and water, apply thera honey gel nickel thick to wound bed, apply breathable border gauze dressing, change daily, ordered on 1/14/25. Review of the resident's monthly summary, dated 2/15/25, showed no skin issues. Review of the resident's medical record from January 2025-February 2025, showed no wound assessments documented. Observations on 02/24/25 at 10:31 A.M.,to showed the resident in the hall sitting up in his/her wheelchair with a cushion in the wheelchair. Observations on 02/24/25 at 12:00 P.M., showed -Facility staff transported the resident in the wheelchair to the dining room. Staff did not assist the resident with incontinence care or reposition the resident. -He/She was placed at the dining room table with his/her meal in front of him/her Observations on 02/25/25 at 9:10 A.M. to 11:58 A.M., showed -The resident sat up in his/her wheelchair in the hall. -At 11:58 A.M. the resident was transported to the dining room and placed at the dining room table. Facility staff did not change or reposition the resident before transporting them to the dining room. Observation on 02/25/25 at 12:17 P.M., showed: -The resident sat in the dining room in his/her wheelchair; -He/She was asleep at the table and had slid down toward the front of the wheelchair with his/her shoulders below the handle level of the wheelchair. Observation and interview on 2/26/25 at 4:47 P.M., showed: -The resident assisted to stand by staff and staff removed his/her slacks and incontinent brief; -The resident had open wound to left upper buttock fold that was a half dollar in size with white/yellow slough, the skin at the edge of the wound was peeling and dry; -The resident said the area hurts when he/she was cleansed and hurts at times when he/she was sitting. During an interview on 2/26/25 at 4:47 P.M. CNA F said: -The resident complains of pain to his/her bottom; -The resident has had the open area for awhile, not sure exact date; -He/She puts cream on the resident when he/she provided incontinent care. During an interview on 2/27/25 11:32 AM LPN B said: -The resident would take himself/herself to the bathroom and did not get himself/herself cleansed well; -His/Her wound was difficult to heal because of his/her incontinence; -His/Her wound was closed last month and is now open again. 2. Review of Resident #92 Admission MDS, dated [DATE], showed: -admitted [DATE]; -Brief Interview of Mental Status (BIMS) of 15 indicated no cognitive loss; -Occasionally incontinent; -No wounds; -No risk for skin issues; -Diagnoses of: fall with injury, osteoarthritis (a condition where the cushion at the ends of the bones (cartilage) breaks down, leading to pain, stiffness and loss of movement), urinary incontinence (involuntary loss of urine), heart failure (the heart cannot pump enough blood to meet the needs of the body), and pain. Review of the resident's baseline care plan, dated 2/5/25, showed: -Psychosocial needs will be addressed in a manner consistent with the resident's overall health and life goals; -No care plan for skin issues. Review of the resident's medical record for February 2025 showed no order for wound care. Review of the resident's Comprehensive CNA Shower Review sheets showed: -2/11/25 scattered bruising; signed by LPN A 2/11/25, no DON signature; -2/14/25 open areas to right and left buttocks; signed by LPN B 2/14/25; no DON signature; During an interview on 02/19/25 at 11:15 A.M., the resident said: -He/She had sores on his/her bottom; -The sores were not there when he/she admitted to the facility; -The sores burn and hurt badly; -He/She had the sores because he/she wets his/her pants, because he/she is unable to get to the bathroom without staff assistance and has had to wait 30 minutes or more for his/her call light to be answered. Observation on 2/19/25 at 11:40 A.M., showed: -He/She was sitting in his/her recliner, no pressure relieving cushion in place; -CNA D cleansed the resident's buttocks with cleansing wipes; -He/She had a dime sized open area to left upper buttock; -He/She had a pencil eraser size open area to right upper buttock; -Surrounding skin red, inflamed and peeling; -The resident complained of pain and burning with cleansing. During an interview on 2/19/25 at 11:40 A.M., CNA G said: -The resident had the open area for several days; -He/She had told the nurse about the area the previous week. During an interview on 02/19/25 at 11:59 A.M. LPN C said: -He/She was not aware the resident had open areas; -He/She was not told in report that the resident had open areas. During an interview on 02/26/25 at 10:05 A.M. the resident primary care physician said: -He/She had received a fax on 2/7/25 to approve admission medications; -He/She had received a fax on 2/13/25 in regards to pain and request for pain gel; -He/She saw the resident on 2/23/25 at the hospital and noted the resident had open wounds; -He/She was not notified by the facility of open wounds on the resident. 44993 3. Review of Resident #11's quarterly MDS, dated [DATE], showed: - The resident had a BIMS score of 14, indicating very little cognitive deficit; - Diagnoses included: Diabetes Mellitus (DM) type II, multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves) and wound. - He/She was completely dependant on staff for toileting needs, showers, and to get dressed; - He/She was incontinent of bowel and bladder; - He/She was a risk for the development of PU, but had none; - He/She had skin break down on his/her buttocks. Review of the resident's skin care plan, dated 8/26/22, showed the resident had a chronic wound to his/her buttock that sometimes appeared to be open and sometimes appeared to be closed. Review of the Braden Scale (a tool completed by facility staff to determine the resident's risk for PU development), dated 12/13/24, with a score of 12, indicating the resident was a high risk for the devolvement of a PU. Review of the resident's skin assessment, dated 1/5/25, showed LPN A documented on a skin assessment the resident had an open area to his/her bottom. Review of the resident's monthly summary, dated 1/9/25, LPN B documented the resident had fragile, warm, and dry skin. LPN B did not document any further details about the resident's skin breakdown. Review of the residents skin assessment, dated 1/12/25, showed LPN B completed a skin assessment, the resident continued to receive a treatment for redness on the buttocks and a small open area, will fax the resident's physician for new orders, no new orders were obtained. Review of the residents record showed the facility staff did not complete a skin assessment during the weeks of 1/19/25 and 1/26/25. Review of the resident's skin assessment dated [DATE] showed LPN A documented on a skin assessment the resident had an existing non-foot skin issue. Review of the resident's record showed the facility staff did not complete a skin assessment during the week of 2/9/25. Review of the resident's skin assessment and monthly summary, dated 2/16/25, showed: - LPN A documented on a skin assessment the resident's bottom was red and had an open area; - LPN A documented on the monthly summary the residents skin condition was good, warm and dry; - LPN A did not document any further details about the resident's skin breakdown. Review of the resident's POS, dated February 2025, showed the following orders: - 2/19/25: Barrier cream with collagen powder apply to buttocks' two times per day and as needed; - 2/15/25: Wound care team consult for the wound on the resident's bottom. Review of the medical record from January 2025 through February 2025, showed the facility staff did not document wound assessments and did not document the physician was notified of the resident's wound. Observation on 2/25/25 at 8:14 A.M., showed: - The resident lay in his/her bed; - LPN A entered the resident's room to complete wound care; - LPN A measured the resident's open wound to his/her bottom that was 6 CM long by 0.3 CM wide; - The center of the wound had a dark brown area that measured 2 CM long by 1.75 CM wide, LPN A described as eschar (a dry crusted layer of dead tissue that forms over a wound); - The wound had an area of dark pink moist skin that surrounded the wound from the gluteal cleft and both buttocks. During an interview on 2/25/25 at 8:14 A.M., LPN A said: - The wound appeared to be in worse condition than last week, because the wound looked larger than last week; - The wound was a Stage II PU; - There was an order for a wound care team to evaluate the resident's wound, but they have not been in yet; - The facility nurses complete the resident's skin assessments weekly and provides the resident's wound care as the physician has ordered it. During an interview on 2/26/25 at 10:50 A.M., LPN B said: - The resident's eschar was a new development; - The resident's wound improved for a time and then has gotten worse; - The facility staff have tried a lot of things for the resident's wound; - The facility had experienced more wounds within the last couple of months. 4. Review of Resident # 15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a BIMS score of 15, indicating no cognitive deficit; - Diagnoses included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture). - He/She required assistance from staff to transfer, toileting needs and get dressed; - He/She was incontinent of bowel and bladder; - He/She was at risk for the development of a PU but did not have a current PU. Review of the resident's face sheet showed the following diagnoses: dysphagia, oral phase (difficulty swallowing) and weakness. Review of the resident's Activities of Daily Living (ADL) care plan, dated 11/26/19, showed: - The resident was dependent on a mechanical lift and two staff for transfers; - The resident's required assistance with all his/her ADL's. Review of the residents skin care plan, dated 11/26/19, showed: - The resident was incontinent of urine; - The staff were supposed to assist the resident's with perineal care; - The resident's had compromised skin integrity between his/her thighs. Review of the resident's Braden Scale, dated 12/23/24, showed the facility staff assessed the resident had a score of 17, indicating the resident was at mild risk of the development of a PU. Review of the resident's POS, dated February 2025, showed the following orders: -11/26/24: Vitamin A&D ointment mixed with zinc, apply to the perineal area as needed to treat red skin; -8/22/24: Cleanse the resident's right inner thigh area, pat dry, apply barrier cream and then abdominal (ABD) pad for comfort daily. Review of the resident EMR showed the following: - 2/2/25 Facility staff documented on a monthly summary, the resident's skin was in good condition, warm and dry; - 2/4/25 Facility staff documented a skin assessment the resident's skin was intact. During an interview on 2/23/25 at 10:32 A.M. the Resident said: - He/She had a sore on his/her inner right thigh; - It took a while for staff to change him/her; - He/She had been up since 7:00 A.M. this morning and had not been repositioned or changed since; - He/She was wet. Observation on 2/23/25 at 1:52 P.M. showed: - The resident's was in his/her room in his/her wheel chair; - CNA C and CNA I entered the resident's room with the mechanical lift; - The CNA's assisted the resident in bed using the mechanical lift; - The resident's had a strong urine smell; - CNA C provided perineal care; - The resident's has saturated trough an incontinence brief, his/her pants and the mechanical lift sling; - The resident's bottom was red and appeared irritated; - The resident had an open area to his/her back of upper right thigh; - CNA C applied a large amount of a zinc based ointment to the open area. During an interview on 2/23/25 at 1:52 P.M., CNA C said: - He/She was trained to complete rounds every two hours; - Rounds included repositioning residents and cleaning resident's if they are wet or soiled; - Resident #15 was supposed to be repositioned every two hours; - He/She came on duty at 7:00 A.M. and did not reposition or change the resident's before now; - He/She should have ensured the resident's was dry and repositioned every two hours and as needed. During an interview on 2/23/25 at 2:03 P.M., CNA I said: - Cares were last provided for the resident at 7:30 A.M. for Resident #15; - Cares included repositioning and ensuring the resident was clean and dry; - The resident should have been changed earlier. During an interview on 2/26/25 at 10:50 A.M., LPN B said: - The resident's wound to his/her upper right thigh was chronic; - The resident was incontinent of bowel and bladder; - He/She expected staff to reposition and clean the resident every two hours and as needed; - He/She did not think the staff change and reposition the resident like they were supposed to; - Staff should not have left the resident for more than six hours with out cleaning and repositioning him/her. During an interview on 2/27/25 at 12:28 P.M., the Quality Assurance (QA) nurse said he/she expected the staff to provide repositioning and perineal care every two hours and as needed for resident's that need help. The staff should not have left Resident #15 sitting in his/her wheel chair from 7:30 A.M. to 1:52 P.M. with out repositioning and providing perineal care. During an interview on 2/27/25 at 3:10 P.M., the Administrator said staff should have repositioned Resident #15 and provided perineal care every two hours. It was not acceptable to let the resident's sit in his/her wheel chair for more that six hours without repositioning and cleaning the resident's. 5. During an interview on 2/19/25 at 2:08 P.M., Certified Nurse Aide (CNA) F said: -There are multiple residents with open areas. Resident#28, #92, #11, and #15 was among them; -He/She told the nurse and Administration about the residents open areas. During an interview on 2/19/25 at 2:39 P.M., CNA C said: -Staff have to choose between baths and residents who need help being turned and repositioned every 2 hours; -He/She cannot get everything done with the staff available. During an interview on 2/19/25 at 3:10 P.M. CNA B said staff cannot get everything done and resident's have open areas, because there was not enough help. During an interview on 2/26/25 at 10:50 A.M., LPN B said: - There seem to be a lot more wounds in the past couple of months; - He/She did not think the aids were cleaning and repositioning resident like they were supposed to; - Several residents have open areas and redness on their bottoms; - He/She expected staff to clean and reposition residents that were not able to complete the task themselves every two hours and as needed; - Some of the aides left resident up in their wheel chairs from before breakfast until after lunch without cleaning the resident or repositioning the resident. During an interview on 2/27/25 at 3:10 P.M., the Administrator said she expected staff to reposition resident's every two hours and as needed.

Based on observation and interview, the facility failed to maintain the walls, hallways, ceilings and floors in a clean and homelike environment. Furthermore the facility failed to ensure furnishings were in good repair and temperatures in the dining room remained at a comfortable level. This had the potential to effect all residents. The facility census was 40. The facility did not provide a policy for cleaning, maintenance of the facility and care of furnishings, or temperatures. 1. Observations on 2/19/25 at 10:30 A.M., showed: -Main dining room thermostat read 61 degrees Fahrenheit; -All doors to the main dining room were closed; -Window blinds in the dining room and attached hallways were drawn; -White blankets were rolled up and placed at the threshold of the doors leading to the courtyard. Observation on 2/19/25 at 11:22 A.M., showed: -Main dining room thermostat read 60 degrees Fahrenheit During an interview on 2/19/25 at 10:05 A.M., Resident #9 said: -He/She did not mind eating in the lobby because it was a comfortable temperature; -The main dining room was too cold to eat there, for a few weeks. During an interview on 2/19/25 at 11:15 A.M., Resident #92 said: -The dining room had been too cold to eat meals in for weeks; -He/She missed eating and visiting with her friends in the dining room. During an interview on 2/19/25 at 12:32 P.M., Resident #18's family member said: -The heat in the dining room had not worked for over a week. During an interview on 2/19/25 at 3:00 P.M., the Administrator said: -The facility has not employed a maintenance supervisor for a month or more;The transportation driver assists with maintenance where he/she can; -The heat in the dining room had been checked by the Maintenance Director for the facility management company; -The dining room heater cannot keep up with the cold weather; -Residents eat in their rooms and assist diners eat in the lobby area; -She does not know when the heat will be fixed. 2. Observations beginning on 2/25/25 at 12:37 P.M., showed: -The dining room floor tile cracked, with missing pieces, tiles loose with jagged edge; -Dead bugs, dust and debris in light fixtures; -Packaged Terminal Air Conditioner (PTAC: which is a self-contained heating and cooling system designed to be mounted through a wall), in courtyard hall had dust and debris inside the vent, pieces of the plastic vent cover were missing and broken; -Fire doors to 100 hall had chipped covering, with exposed wood underneath and white water damage like staining to lower half of the door; -Fire doors to service hall had large chips in Formica, with exposed wood underneath; -Corner sheetrock at service hall had large slash and gouge in sheetrock with peeling paint. Observation on 02/27/25 at 8:58 A.M., showed: -Television room at the end of the 400 hall had multiple gouges and scratches in the lower 1/3 of the sheetrock. -Glass table lamp had visible layer of dust and debris; -400 hallway had multiple gouges and scratches in the pain and sheetrock along the entire hall; -Hand rail end cap off at room [ROOM NUMBER] caused sharp edge; -Hand rail end cap loose at room [ROOM NUMBER] and opposite end cap was missing causing sharp edge; -Hand rail end cap missing at room [ROOM NUMBER]; -Hand rail end cap missing at room [ROOM NUMBER]; -Hand rail end cap loose at room [ROOM NUMBER]; -The small handrail at the corner of the dining hall and 400 hall was loose; -The handrail between room [ROOM NUMBER]-410 was loose; -Hand rail end cap was missing at room [ROOM NUMBER], caused a sharp edge; -Hand rail end cap at room [ROOM NUMBER] was missing, and caused a sharp edge; -Hand rail end cap at room [ROOM NUMBER] was off and laying on top of the handrail; -Hand rail at end of 500 hall with red, U shaped, sharp pronged metal piece with exposed two inch screw in the middle, was lying on top of the handrail. Observation on 02/27/25 at 9:06 A.M., showed: -Nurse station TV area had multiple gouges and scratches in the dry wall and paint; -Lobby area light fixtures had dead bugs, dust, and debris in lights; -PTAC unit had dust and debris in the vent and on the unit; -Multiple ceiling can lights had cobwebs; -Second PTAC unit had a broken grate and dust and debris in the vent; -The glass billboard had dried, white drips on the glass; -Long fluorescent lights had exposed bulbs; -The nurses station had scuffed and chipped paint, -The flooring carpet had multiple stained and discolored areas, -The seams of the carpet are approximately 1/4 inch apart with dust and debris in them. -The shower room on the 500 hall had dark, black mold like substance that covered 1/4 of the lower shower wall and grout of the shower and floor, exposed wires with ends capped in outlet cutout by tub, the ceiling had multiple brown water stains, and the lights had dead bugs, dust, and debris in them; -The 500 hall had multiple gouges, scratches, and chips in the paint and drywall along the entirety of the hall; -Treatment cart had rhinestone gems in partial star and curve shapes on the back of the cart, some gems were missing and a sticky/gummy substance was left behind, and had glitter letters half peeled off on the back of the cart and left a sticky/gummy uncleanable surface; -Hallway from lobby to dining room had black scuff marks along lower third of the wall; -Windows in halls to dining room had cobwebs, dust and debris; -Hallway from lobby to dining room PTAC unit had dirt and debris in the vent, cracked plastic vent cover; the wall above the unit had broken wooden trim, leaving a sharp edge, peeling sheetrock and chipped/flaking paint; -Dining room windows had dirt, dust, debris and cobwebs; lower third of the walls had nicks and scratched paint; the rolling stools (used to sit on to assist resident with meals) had cracked vinyl covering and exposed padding underneath; cabinet doors were sprung and hanging crookedly; the tile grout was black in multiple areas with a thick crusty substance; the small serving bowls/dishes, on the prep cart, had dust and debris in them and on the storage tray, the steam table had white crusty/dusty substance on the bottom shelf; the storage chart had white crusty/dusty substance on the bottom shelf and legs; the white prep table had cobwebs, dirt and debris on it and hanging from the legs and corners. During an interview on 2/19/25 at 12:32 P.M. Resident #18 family member said: -Nothing gets fixed around the facility; -There is no maintenance personnel. During an interview on 02/26/25 02:52 P.M., Housekeeping/Laundry Aide A said: -High dusting (such as lights, and corners) should be completed by any housekeeping staff who have time to get it done. -High dusting was not assigned to anyone specifically. -The staff assigned to the hall were responsible for all cleaning. -There was no deep cleaning list for common areas of the building. -The Dining room was deep cleaned weekly; spot cleaning was done after each meal; -Carpets are vacuumed daily if there was time to do it. -He/She did not know when carpets were shampooed or who was responsible for that. During an interview on 02/19/25 at 3:00 P.M., the Administrator said: -The facility had been without a Maintenance supervisor or staff for over a month; -The transportation driver helps fix things as he/she has time to do it. During an interview on 02/27/25 at 12:28 P.M., the Quality Assurance Nurse said: -The facility was having maintenance struggles and there was no current maintenance staff. -The Administrator looks at things as she can. -The part time van driver can work on work orders as time allows; -She would expect communication between the administrator and maintenance to complete work orders. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -The Maintenance Director is responsible for upkeep and repairs. -There was not a Maintenance Director for over a month; -The van driver completes things as times allows and that he can do; -Staff fill out work order; the van driver picks them up and does what he can to complete them; -High dusting in the dining room would be maintenance; the rooms and halls would be housekeeping; -Carpets would cleaned when there was a stain; the housekeeping supervisor runs a carpet cleaner on different halls on different days. MO#249706 46706

Based on observation, interview, and record review, the facility failed to provide meaningful activities to meet the needs for three of 12 sampled residents (Resident #6, #28, and #92). The facility did not have an employee responsible for the activity program and did not have a system to inform all residents in advance of available activities, including location and time, which had the potential to impact all residents in the facility. The facility census was 40. The facility did not provide a policy regarding Activities. Review of the facility provided Resident Right policy, dated April 2006, showed: -The resident has the right to a dignified existence and self determination. A Facility must protect and promote the rights of each resident. --Right to participate in activities. --Resident Rights are to be fully respected and adhered to. The facility did not provide an activity calendar. 1. Review of Resident #6 Admission Activity Assessment, dated 3/14/20, showed: - He/She liked 1:1 (1 staff to 1 resident) activities, independent leisure activities, and small group activities; -Preferred activities included: cards/games, sports/exercise, music, spiritual/religious, walking/wheeling outdoors, and watching TV. Review of the resident's Annual Activity Assessment, dated 5/3/24, showed: -He/She liked 1:1 and large group activities; -Preferred activities included: exercise/sports, music, and watching TV. Review of the resident's Annual Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 8/6/24, showed Activity preferences: -Very important for music -Somewhat important to keep up with the news, do things with groups of people, do favorite activities, go outside and get fresh air and to participate in religious practices. Review of Resident #6 Quarterly MDS, dated [DATE], showed: -Brief Interview of Mental Status (BIMS) of 4, indicated significant cognitive deficit -Dependence on staff for Activities of Daily Living (ADLs: tasks performed in a day to care for oneself) -Diagnoses of Alzheimer's Disease (a progressive brain disorder that effects memory and thinking, leading to the inability to complete daily tasks), Hypertension, Cognitive Communication Deficit (difficulty communicating because of impaired brain function), Anxiety (constant feeling of nervousness, worry or fear), Depression (constant feeling of sadness, loss of interest and low energy) and Need for assistance with personal care. Review of the resident's Comprehensive Care Plan, dated 2/18/25, showed: -Problem: Resident involved in activities one third or less of the time related to he/she can not communicate very well due to his/her speech; -Adjust the intensity, frequency, and/or duration of activities to accommodate his/her energy level and tolerance. -Encourage him/her to become involved with activities that he/she enjoys; listening to the radio -Involve him/her with those who have shared interests; -Offer him/her opportunities to get to know others through activities such as shared dining, afternoon refreshments, monthly birthday parties, reminiscence groups, etc. Review of the resident's Activity Attendance calendar showed: -No activity attendance in January. -No February Calendar provided. Observations on 02/24/25 at 9:38 A.M., showed: -Music played in his/her room, the resident was not in his/her room. -The resident sat in his/her wheelchair, in the hallway, 2. Review of Resident #28 Quarterly MDS, dated [DATE], showed: -Brief Interview of Mental Status (BIMS) of 0 indicated severe cognitive impairment; -No behaviors; -Moderate assistance for ADLs -Diagnoses of: Memory Deficit after cerebral infarction (loss of memory after stroke: when blood flow to a part of the pain is blocked, causing loss of cells), Sick Sinus Syndrome (a condition where the heart's natural pacemaker does not function properly), need for assistance with personal care, history of falling, and delirium (a sudden change in mental state). Review of the resident's Annual Activity Assessment, dated 10/1/24, showed his/her interests were crafts/arts, watching television, exercise/sports, music, talking/conversing, reading/writing and spiritual/religious activities. Review of the resident's Comprehensive Care Plan, dated 2/25/25, showed he/she needed one on one visits for socialization, and emotional support. Review of the resident's Activity Attendance calendar showed: -No activity attendance in January. -No February calendar provided. Observation on 02/24/25 at 10:31 A.M., showed: - the television on in the resident's room, -The resident sat in a wheelchair, in the hallway, with his/her head down and eyes closed. Observation on 02/25/25 at 11:10 A.M., showed: - The resident sat up in a wheelchair in the hallway. The resident looked around. No activities were being provided. 3. Review of Resident #92 Admission Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff), dated 2/17/25, showed: -Brief Interview of Mental Status (BIMS) of 15 indicated no cognitive loss -Activity preference: Somewhat important to have books, newspapers, and magazines to read, listen to music,be around animals such as pets, keep up with the news, do things with groups of people,do favorite activities, go outside to get fresh air when the weather is good, and participate in religious services or practices. -Diagnoses of: fall with injury, Osteoarthritis (a condition where the cushion at the ends of the bones (cartilage) breaks down, leading to pain, stiffness and loss of movement), Hypertension (high blood pressure), Atrial Fibrillation (a irregular and rapid heart beat), Urinary Incontinence (involuntary loss of urine), Heart Failure (the heart cannot pump enough blood to meet the needs of the body), and pain. Review of the resident's baseline care plan, dated 2/5/25, showed psychosocial needs will be addressed in a manner consistent with the resident's overall health and life goals. Review of the Resident's Activity Assessment, 2/5/25, showed: -Preferred program of 1:1; -Preferred music, reading/writing, watching TV, and talking/conversing. During an interview on 2/19/25 at 11:15 A.M., the resident said: -There is nothing to do at the facility. -He/She just stays in his/her room and watches television. -He/She gets lonely and bored. -He/She has told staff he/she gets lonely and bored. Observation on 2/19/25 at 11:15 A.M. showed the resident sat in his/her room, in the recliner, no music on, TV was not on, and one puzzle book lying on the table next to the resident. 4. Observation on 2/19/25 at 10:30 A.M., showed small group of three residents doing exercises in the lobby area, lead by a resident. No staff were involved. Resident #6, Resident #28 and #92 were not in attendance. Observations on 2/19/25 from 12:00 P.M. to 2:50 P.M., showed no activity offered or provided for all residents. Observations on 2/23/24 from 9:44 A.M. to 1:39 P.M., showed no activity offered or provided for all residents Observation on 02/23/25 at 10:32 A.M., showed no activity calendar in any of the resident's rooms. Observation on 02/23/25 at 10:41 AM showed no activity calendar posted in the hallways or lobby area. During an interview on 2/19/25 at 11:40 A.M., Certified Nurse Aide (CNA) D said: -Resident volunteers provide Bingo or exercise group occasionally. -There is no Activity personnel, as he/she was moved to the floor as an aide. During an interview on 2/19/25 at 3:00 P.M., the Administrator said: -There was no Activity Director. -The plan was to move a CNA staff member to Activity Director the first of March. -Volunteers provide bible study and BINGO. During an interview on 02/27/25 at 12:28 P.M., the Quality Assurance Nurse said: -She would expect someone to visit with resident's if he/she said he/she was lonely; -She would expect activities to be done daily. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -All staff have stepped in to help with the activities, but no one was assigned. -The previous Activity Director was moved to the floor as an aide; -A resident volunteer leads exercise. -One on one visits are completed with the Social Service visits. -She would expect visits to increase for someone who was lonely. -For residents who cannot leave their room she would expect daily visits. -There are books and magazines and a variety of things to be offered. -No one made me aware that a resident was sad because he/she could not see his/her friend during meals. -She expected staff to assist and activities to be done.

Based on record review and interview the facility failed to ensure that Advance Directives for three Residents (Resident #3, #19, and #32) were lawful when a Designated Power of Attorney signed an out of hospital Do Not Resuscitate (OHDNR) form prior to two residents (Residents #3 and #19) being declared incapacitated to sign. Additionally, the facility failed to ensure that one resident (Resident #32) had 2 physician letters of incapacitation prior to the Power of Attorney designee making decisions for him/her. There were 12 total sampled residents. The facility census was 40. The facility did not provide the requested policy on Advance Directives. 1. Review of Resident #3's Quarterly minimum data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/07/25, showed: -Severe cognitive impairment; -Dependent on staff for transfers, bathing, locomotion, toileting and eating; -Incontinent of bowel and bladder; -Diagnoses included dementia, high blood pressure, and urinary tract infection. Review of the resident's care plan, dated 02/20/25, showed: -Assistance for activities of daily living (ADLs); -Visual impairment; -The resident is a DNR (Do not resuscitate) code status. Review of the resident's medical record showed: -Durable power of attorney (DPOA) document signed by the DPOA 02/02/19; -The DPOA did not indicate if one or two physicians were needed to determine incapacity; -Capacity verification form dated 11/16/22 signed by only one physician, the DPOA and the Social Service Director (SSD); -The capacity form showed the resident had no capacity on 11/16/22; -Incapacitation letter, dated 05/08/24, that was signed by two physicians; -OHDNR signed by DPOA on 01/15/22 before the resident was deemed incapacitated. 2. Review of Resident #19's Quarterly MDS, dated [DATE], showed: -Severe cognitive impairment; -Partial assistance for transfers, bathing, locomotion, toileting and eating; -Incontinent of bowel and bladder; -Diagnoses included dementia, depression, and anxiety. Review of the resident's care plan, dated 02/20/25, showed: -Assistance for ADLs; -The resident had dementia; -The resident was a DNR code status. Review of the resident's medical record showed: -DPOA document signed by DPOA on 11/27/18; -The DPOA document did not indicate if one or two physicians were needed to determine incapacity; -Incapacitation letter dated 01/24/19 that was signed by two physicians; -OHDNR signed by DPOA on 01/07/19 before the resident was deemed incapacitated. 44395 3. Review of Resident #32 Quarterly MDS, dated [DATE], showed: -Brief Interview of Mental Status (BIMS) of 99 indicated significant cognitive loss. -Dependent on staff for Activities of Daily Living (ADL's: tasks completed in a day to care for oneself, such as bathing, eating, and personal hygiene). -Diagnoses of Cerebral Infarction (a condition where blood flow to part of the brain is interrupted,causing cells to die), chronic pain, Anxiety Disorder (excessive feelings of fear, worry and nervousness), Chronic Obstructive Pulmonary Disease (COPD: a lung disease that causes air flow obstruction and breathing difficulty), Dementia (a decline in mental ability that effects memory , thinking and behavior), Malignant Neoplasm of the Liver (cancerous tumor that originated in the liver). Review of the Resident Comprehensive Care Plan, dated 10/10/24, showed: -He/She had lost his/her decisional capacity and is invoked as of 4/6/2023. -He/She depended on the Durable Power of Attorney(DPOA) for health and finance to carry out wishes. Review of the resident electronic and paper medical record showed: -The DPOA document did not indicate if one or two physicians were needed to determine incapacity. -Letter of incapacity dated 1/31/23 signed by one physician. -No second letter of incapacity signed by another physician. 4. During an interview on 02/27/25 at 12:28 P.M., the Quality Assessment Nurse said: - 2 physicians should sign the letter of incapacitation unless the Power of Attorney form says otherwise. -A Do Not Resuscitate (DNR) form should not be signed by the Power of Attorney designee unless the resident has been declared incapacitated. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -Incapacity letters require two physician signatures unless otherwise stated; -She would not expect a DNR signed by the DPOA prior to the signature of the incapacitation letter.

Based on observation, record review, and interview, the facility failed to ensure staff prepared foods in a way to meet the needs of individual residents, when they did not ensure the puree (a texture-modified diet in which all foods have a soft, pudding-like consistency) food had a smooth and appropriate consistency and failed to ensure the mechanical soft diet contained meat that was ground and easy to chew. This affected two residents who had orders for a pureed diet (Residents #6, and #15) and one resident (Resident #3) who had an order for a mechanical soft diet. The facility census was 40. Review of the facility's policy titled, Types of Diets, dated, May 2015, showed: -Mechanical soft diet is a regular diet modified using chopped or ground meat; -Puree diet foods are blended to mashed potato consistency or altered to meet the needs of the residents. 1. Review of Resident #6's Quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 02/08/25, showed: -Severe cognitive impairment; -Severe visual impairment; -Dependent on staff for transfers, bathing, locomotion, toileting and eating; -Diagnoses included dementia, heart failure, and high blood pressure. A review of the resident's care plan, dated 02/20/25, showed: -The resident was on a pureed diet. A review of the resident's Physician Order Sheet (POS), dated February 2025, showed the resident had an order for a pureed diet. 2. A review of Resident #15's Quarterly MDS, dated [DATE], showed: -No cognitive impairment; -Substantial assistance of staff for transfers, bathing, locomotion, toileting and eating; -Diagnoses included depression, stroke, and high blood pressure. A review of the resident's care plan, dated 01/02/25, showed: -The resident was on a pureed diet. A review of the resident's POS, dated February 2025, showed the resident had an order for a pureed diet. 3. Review of Resident #3's Quarterly MDS, dated [DATE], showed: - Severe cognitive impairment; - Dependent on staff for activities of daily living; - Supervision with eating; - Mechanical altered diet; - Diagnoses included dementia, high blood pressure, and urinary tract infection. Review of the resident's care plan dated, 02/20/25, showed: -The resident has impaired decision making related to dementia; -Mechanical soft diet. Review of the resident's POS, dated, February 2025, showed: -11/07/22, mechanical soft diet. Observation of meal preparation for lunch on 02/25/25, at 11:31, A.M., showed: - [NAME] A began preparing the pureed lunch meal; - [NAME] A did not use a recipe to prepare the pureed lunch meal; - He/She placed two cups of yellow rice into the food processor; - He/She turned on the food processor and began adding butter and blended until it was the desired consistency; - The mixture was thick with visible pea sized chunks in it; - [NAME] A placed two cups of spinach into the food processor; - He/She turned on the food processor and blended until it was the desired consistency; - The mixture was watery and ran off the spoon; - [NAME] A began preparing the mechanical soft lunch meal; - [NAME] A placed a cooked tuna patty into the food processor; - He/She turned on the food processor and blended until it was the desired consistency; - He/she added butter to the mixture; - The mixture was dry, tough, and hard to chew. Observation on 02/25/25, at 12:18 P.M. showed: -Resident #6 and #15 were served pureed meals that were thick and had chunks in it; -Resident #3 had difficulty chewing the mechanical soft meat. Observation of the puree lunch meal test tray on 02/25/25, at 12:56 P.M., showed: -The tuna patty melt was dry and hard to chew; -The yellow rice was dry, hard and had no flavor; -The pureed yellow rice was dry and had no flavor; -The spinach was watery and ran off the spoon. During an interview on 02/25/25 at 02:17 P.M., [NAME] A said: - Pureed foods should have a pudding like consistency and not be hard to chew; - Pureed foods should not be watery; -Mechanical soft foods should not be dry and hard to chew. - Food should have a good flavor and should not be dry. During an interview on 02/25/25 at 02:30 P.M., the Dietary Manager (DM) said: - Pureed foods should have a pudding like consistency and not be hard to chew; - Pureed foods should not be watery; -Mechanical soft foods should not be dry and hard to chew; - Food should have a good flavor and should not be dry. During an interview on 03/05/25, at 10:17 A.M., the Registered Dietitian (RD) said: - He/She expects pureed foods to have a pudding like consistency and not be hard to chew; -Mechanical soft foods should not be dry and hard to chew. - Food should have a good flavor and should not be dry; - He expects the dietary staff to ensure the food is palatable. During an interview on 03/05/25 at 01:38 P.M., the Administrator said: -She expects the food to be palatable and balanced; -She expects diet orders to be followed.

Based on interview and record review, the facility failed to ensure nurse aides had a yearly performance review, with resulting individually based education plans, for three nurse aides employed longer than 12 months. The facility census was 40. The facility did not provide a policy for education, and Nurse Assistant Training. Review of personnel records showed: -Certified Nurse Aide (CNA) D, Date of Hire 11/22/00, Annual Education Quiz completed 6/7/24. No competency assessment and training plan. -CNA E, Date of Hire 10/21/22, Annual Education Quiz completed 6/6/24. No competency assessment and training plan. -CNA F, Date of Hire DOH 9/17/01, Annual Education Quiz completed 6/6/24. No competency assessment and training plan. During an interview on 02/27/25 at 12:28 PM, the Quality Assurance Registered Nurse said trainings and tracking were completed by nurse leadership. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -The previous Director of Nursing (DON) completed the last competency. -He/She did not know the date of the last competency. -He/She expects the DON to complete yearly competency education. -He/She did not know where the tracking was kept

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day seven days a week. The census was 70. The facility did not provide a policy on staffing. Observation and interview on 02/23/25 at 9:44 A.M., showed: -Licensed Practical Nurse (LPN) B was the Charge Nurse; -He/She was the only nurse at the facility; -He/She was the only nurse the previous day; -There was no RN in the facility. Review of the daily staffing sheets showed no RN on: July 2024: 6th, 7th, 20th, and 21st; August 2024: 3rd, 4th, 17th, and 18th; September 2024: 1st, 14th, 15th, and 24th; No staffing sheets provided for October; November 2024: 16th, 17th, 23rd, 28th, 29th, and 30th; December 2024: 1st, 6th, 7th, 8th, 14th, 15th, 21st, 22nd, 24th, 26th, 27th, 28th, 29th, 30th, and 31st; January 2025: 4th, 5th, 11th, 12th, 15th, 18th, 19th, 25th, and 26th; February 2025: 1st, 2nd, 22nd, 23rd, and 26th. Observation of on-line staffing services showed an advertisement for a full time RN. During an interview on 02/27/25 at 12:28 P.M., the Quality Assurance Nurse said: -He/She was the Interim Director of Nursing (DON) from December 20, 2024 until February 3, 2025. -Another RN was hired for the DON position. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -She was aware there were multiple days without a RN; -She had advertisements out for a DON for 3 years; She had advertisements out for charge nurses; -She added referral and sign on bonuses, and increased wages, but no applications were received; -She had not applied for a waiver. During an interview on 3/17/25 at 10:57 A.M., the Medical Director said: -He was not aware there were days without an RN in the facility; -Not having an RN in the facility could be detrimental to resident care in certain situations.

Based on observation, interview and record review, the facility failed to provide adequate staffing to reposition and provide incontinence care for three residents who were at risk for pressure ulcers (Residents #28, #92, and #15), failed to answer the call light in a timely manner resulting in incontinence for one resident (Resident #92), and failed to provide two showers per week to one resident (Resident #28) as a standard of care. Additionally, the facility failed to ensure enough staff were in the dining room to assist residents who required assistance during meals, resulting in one staff member going between two tables to assist eight residents who needed nutritional assistance. The facility census was 40. The facility did not supply a policy on staffing. Review of staff schedules showed: -January 14th: day shift staff included 1 Licensed Practical Nurse (LPN), 1 Certified Medication Technician (CMT), and 4 Certified Nurse Aides (CNA); Night shift included: 1 Registered Nurse (RN), 2 CNAs and 1 Nurse Aide (NA); -February 18th: day shift staff included 1 LPN, 1 CMT, and 3 CNAs; Night shift included: 2 CNAs and 1 NA; -February 19th showed: day shift staff included the Director of Nursing (DON), 2 CMTs, and 3 CNAs; Night shift included: 2 CNAs and 1 NA -February 23rd: Day shift staff included 1 Licensed Practical Nurse (LPN), 1 CMT and 4 CNAs; Night shift included: 1 RN and 2 CNAs; -February 24th: Day shift staff included: 1 LPN, 1 CMT, and 4 CNAs, Night shift included: 1 RN, 2 CNAs and 1 NA; -February 25th: Day shift staff included: 1 LPN, 1 CMT, and 5 CNAs, Night shift included:1 LPN and 2 CNAs; -February 26th: Day shift staff included 1 LPN, 1 CMT, and 4 CNAs, Night shift included: 1 LPN and 2 CNAs. 1. Review of Resident #28 Quarterly minimum data set (MDS), a federally mandated assessment completed by the facility staff, dated 1/3/25, showed: -Brief Interview of Mental Status (BIMS) of 0 indicating severe cognitive impairment; -Moderate assistance for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself); -Incontinent of urine and bowel; -At risk for pressure ulcers; -No pressure ulcers; -Diagnoses of Memory Deficit after cerebral infarction (loss of memory after stroke: when blood flow to a part of the pain is blocked, causing loss of cells), Sick Sinus Syndrome (a condition where the heart's natural pacemaker does not function properly), need for assistance with personal care, history of falling, and Delirium (a sudden change in mental state). Review of the resident's Comprehensive Care Plan, dated 2/25/25, showed: -He/She needs assistance with ADLs. Review of the resident's bath sheet showed: -He/She was scheduled for Tuesday/Friday baths; -No bath on 1/3, 1/14, and 2/18. Review of the resident's progress notes showed: -On 01/09/2025 at 10:11 A.M., reported from Hospice Nurse the resident had two pressure ulcers on his/her top right buttock and left inner buttock. Hospice gave order for areas to be cleansed with soap and water, pat dry, and apply zinc cream twice a day and as needed. -On 01/09/2025 at 3:40 P.M., nurse was informed the resident had an open area to his/her bottom. He/She found an area at the top of the resident's inner left buttock that was covered with slough (a non-living, yellow or white material in wounds, made of dead cells and other debris), unstageable (the stage of a pressure ulcer is unknown because the wound bed is covered by dead tissue), measuring 0.8 centimeters (cm) in length x 0.9 cm width x 0.1 cm depth. Wound edges and surrounding skin appeared as dry skin. Physician was in the facility and gave orders to discontinue (DC) zinc and start cleansing the area with soap and water, pat dry, apply Santyl (prescription medicine that removes dead tissue from wounds so they can start to heal) applied nickel thick to wound bed, apply border gauze dressing and change daily. An air cushion was added to his/her recliner. Staff will assist him/her turning side-to-side during the night to keep pressure off of the open area. He/She had a pressure reduction cushion to his/her wheelchair. An air mattress was requested from hospice. Review of the resident's January monthly summary showed no skin issues. Review of the resident's physician order sheets, dated February 2025, showed: -Pressure Ulcer Care: Cleanse pressure ulcer to left inner buttock with soap and water, apply therahoney gel, nickel thick to wound bed, apply breathable border gauze dressing, change daily. Ordered on 1/14/25. Observations on 02/24/25 at 10:31 A.M., showed: -The resident was in the hall sitting up in his/her wheelchair; -The resident had a cushion in his/her wheelchair. Observation on 02/25/25 from 9:10 A.M. to 11:58 A.M., showed -The resident was sitting up in his/her wheelchair in the hall; -The resident had a cushion in his/her wheelchair. -He/She was not repositioned, freshened up, or moved. Observation on 02/25/25 from 12:17 P.M. to 1:30 P.M., showed -The resident was sitting in the dining room in his/her wheelchair; -He/She was asleep at the table; -He/She was slid down toward the front of the wheelchair with his/her shoulders below the handle level of the wheelchair. -The resident had a cushion in his/her wheelchair. Observation and interview on 2/26/25 at 4:47 P.M., showed: -The resident was assisted to stand by staff; His/her slacks and saturated incontinent brief were removed; -The resident had an open wound to the left upper buttock fold, half dollar in size with white/yellow slough, the skin at the edge of the wound was peeling and dry. -The resident complained of pain to the area. During an interview on 2/27/25 11:32 AM, LPN B said: -The resident would take himself/herself to the bathroom and did not get himself/herself cleansed well; -CNA staff do not have enough time to get everything done; -Staff do the best they can to get all the residents cleaned up and taken care of; -His/Her wound was difficult to heal, because of his/her incontinence; -His/Her wound was closed last month and is now open again 2. Review of Resident #92 Admission MDS, dated [DATE], showed: -admitted [DATE]; -BIMS of 15 indicating cognitively intact; -Occasionally incontinent; -No wounds; -No risk for skin issues; -Diagnoses of fall with injury, osteoarthritis (a condition where the cushion at the ends of the bones (cartilage) breaks down, leading to pain, stiffness and loss of movement), hypertension (high blood pressure), atrial fibrillation (a irregular and rapid heart beat), urinary incontinence (involuntary loss of urine), heart failure (the heart cannot pump enough blood to meet the needs of the body), and pain. Review of the resident's baseline care plan dated 2/5/25 showed: -Psychosocial needs will be addressed in a manner consistent with the resident's overall health and life goals. During an interview on 02/19/25 at 11:15 A.M., the resident said: -He/She had sores on his/her bottom; -The sores were not there when he/she admitted to the facility; -The sores burn and hurt badly; -He/She had the sores because he/she wets his/her pants, because he/she was unable to get to the bathroom without staff assistance and has to wait 30 minutes or more, every evening, for his/her call light to be answered; -He/She knows how long he/she waits, because he/she can see the clock. Observation on 2/19/25 at 11:40 A.M., showed: -The resident was sitting in his/her recliner, -He/She had a dime sized open area to left upper buttock; -He/She had a pencil eraser sized open area to right upper buttock; -Surrounding skin red, inflamed, and peeling. -The resident complained of pain and burning to the areas. 3. During an interview on 2/19/25 at 2:08 P.M., Certified Nurse Aide (CNA) F said: -There are multiple residents with open areas; -Most residents don't get two showers a week, because there was not enough staff to do everything that needed to be done, such as turning and repositioning residents, and the residents were getting wounds. During an interview on 02/27/25 09:59 AM, CNA F said he/she was trying to get all the baths done during the shift, because later they would not have enough staff and the residents would not get a bath for a while, up to a week. During an interview on 2/19/25 at 2:39 P.M., CNA C said: -If he/she and his/her partner were able to get residents turned and repositioned every 2 hours on a shift, then the residents do not get baths; -He/She had to choose between completing baths and residents who need help being turned and repositioned every 2 hours; -He/She cannot get everything done with the staff available. During an interview on 2/19/25 at 3:10 P.M., CNA B said: -Staff cannot get everything done and multiple residents have open areas because there was not enough help. 4. Review of Resident #15's quarterly MDS dated [DATE], showed: - He/She had a BIMS score of 15, indicating no cognitive deficit; - Diagnosis included Cerebral Palsy (is a disorder that affects movement, muscle tone and posture); - He/She required assistance from staff to transfer, toileting needs, and to dress; - He/She was incontinent of bowel and bladder. Review of the resident's face sheet showed the following diagnoses: Dysphagia, oral phase (difficulty swallowing), and weakness. Review of the resident's Activities of Daily Living (ADL) care plan, dated 11/26/19, showed: - The resident was dependent on a mechanical lift and two staff for transfers; - The resident's required assistance with all his/her ADLs. During an interview on 2/23/25 at 10:32 A.M., the resident said: - He/She had a sore on his/her inner right thigh; - The facility could use more staff because it took a while for staff to change him/her; - He/She he had been up since 7:00 A.M. this morning and has not been repositioned or changed since; - He/She was wet. Observation on 2/23/25 at 1:52 P.M., showed: - The resident was in his/her room in his/her wheelchair; - Certified Nurse Aide (CNA) C and CNA I entered the resident's room with the mechanical lift; - The CNAs assisted the resident in bed using the mechanical lift; - The resident had a strong urine smell; - CNA C provided perineal care; - The resident had saturated through an incontinence brief, his/her pants, and the mechanical lift sling; - The resident's bottom was red and appeared irritated. During an interview on 2/23/25 at 1:52 P.M., CNA C said: - He/She was trained to complete rounds every two hours; - Rounds included repositioning residents, and cleaning residents if they were wet or soiled; - Resident #15 was supposed to be repositioned every two hours; - He/She came on duty at 7:00 A.M. and did not reposition or change the resident's before now; - He/She should have ensured the resident was dry and repositioned every two hours and as needed. During an interview on 2/23/25 at 2:03 P.M., CNA I said: - Cares were last provided for the resident at 7:30 A.M. for Resident #15; - Cares included repositioning and ensuring the resident was clean and dry; - There was not enough staff to keep up with the residents cares; - The resident should have been changed earlier. 5. Observation on 2/23/25 at 12:02 P.M., showed: - Two CNAs in the dining room passing trays to residents; - There were eight residents at two assist dining tables; - One CNA sat in a rolling chair at each table and rolled between the residents to assist them; - No more staff came to the dining room to help. Observation on 2/24/25 at 12:08 P.M., showed: - There were eight residents at two assist dining tables; - One CNA sat in a rolling chair at each table and rolled between the residents to assist them; - No more staff came to the dining room to help. 6. During an interview on 2/25/25 at 8:38 A.M., CNA C said: - The facility does not have enough staff working to complete his/her job; - The facility has had a lot of wounds lately because there is not enough staff to lay residents in bed, reposition them and clean them up every two hours; - The facility does not usually have a shower aide; - The CNAs on the floor are responsible for complete residents showers in addition to all their other tasks; - The facility does not have enough staff to serve the residents at meal time; - The facility does not have enough staff to assist the residents that need assistance during meals and typically have one CNA at each of the assist dining tables to go from resident to resident. During an interview on 02/27/25 at 3:10 P.M., the Administrator said: -She believed there was plenty of staff to get all cares done with the residents; -New staff had been hired on in the past month; -She was not aware of multiple wounds in the building; -She was not aware residents were not receiving two baths weekly.

Based on observation, interview and record review, the facility failed to ensure residents had complete, accurate and individualized care plans, to address the specific needs of the residents, for five of 12 sampled residents (Residents #28, #92, #11, #15, and #36). The facility census is 40. Review of the facility provided, undated, policy Care Planning showed the facility Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Review of the facility provided, undated policy Care Area Assessments showed Care Area Assessments (CAAs) will be used to develop individualized care plans. 1. Review of Resident #28 Quarterly Minimum Data Set (MDS, a federally mandated assessment completed by facility staff), dated 1/3/25, showed: -Brief Interview of Mental Status (BIMS) of 0 indicated severe cognitive impairment; -No behaviors; -Moderate assistance for Activities of Daily Living (ADLs: tasks completed in a day to care for oneself); -No falls; -No pressure areas; -Chair alarm used daily; -Bed alarm not used; -Diagnoses of: Memory Deficit after cerebral infarction (loss of memory after stroke: when blood flow to a part of the pain is blocked, causing loss of cells), Sick Sinus Syndrome (a condition where the heart's natural pacemaker does not function properly), Need for assistance with personal care, History of falling, Delirium (a sudden change in mental state). Review of the resident's medical record showed: -9/26/24 Elopement Assessment completed with a score of 8, indicated an increased risk for elopement; -1/09/2025 progress note showed the resident had an open area to his/her buttock. Review of the resident's Comprehensive Care Plan, dated 2/25/25, showed: -The resident had a risk for falls: keep his/her call light within reach, ensure appropriate non-skid footwear, encourage him/her to ask for assistance; -No care plan for use of an alarm; -No care plan for elopement; -No care plan for pressure ulcers. During an interview on 02/24/25 at 10:36 A.M., Certified Nurse Aide (CNA) B said: -The resident was an elopement risk; -The orange dot on his/her name plate indicated the elopement risk. Observations on 02/24/25 at 10:31 A.M., showed: -Resident was sitting up in his/her wheelchair, self propelling chair; -Alarm pad lying under incontinent padding on bed, attached to alarm box; -Name plate at door has orange quarter size dot. Observation on 02/25/25 at 11:10 A.M., showed: -Resident was sitting up in his/her wheelchair, self propelling chair; -Alarm pad lying under incontinent padding on bed, attached to alarm box. During an interview on 02/27/25 at 9:37 A.M., Licensed Practical Nurse B said: -Orange stickers on the door indicate elopement risk. -The resident's care plan should say they are an elopement risk, have wounds, and anything pertinent in order to provide care to the resident. 2. Review of Resident #92 Admission MDS, dated [DATE], showed: -BIMS of 15 indicated no cognitive loss -Diagnoses of: fall with injury, osteoarthritis (a condition where the cushion at the ends of the bones (cartilage) breaks down, leading to pain/, stiffness and loss of movement), high blood pressure, atrial fibrillation (a irregular and rapid heart beat), urinary incontinence (involuntary loss of urine), heart failure (the heart cannot pump enough blood to meet the needs of the body), and pain. Review of the resident's baseline care plan, dated 2/5/25, showed: -Psychosocial needs will be addressed in a manner consistent with the resident's overall health and life goals. -No care plan for pressure ulcers or skin concerns. Review of the resident's Physician order sheet showed an order, dated 2/19/25, to apply zinc to open area twice a day until healed, obtained by the Director of Nursing. During an interview on 2/19/25 at 11:15 A.M., Resident #92 said he/she had sores on his/her bottom. Observation of Resident #92 on 2/19/25 at 11:40 A.M., showed he/she had a dime sized open area to the left buttock and a pencil eraser sized area to the right buttock, with red peeling skin surrounding the open wounds. During an interview on 2/19/25 at 11:40 A.M. Certified Nurse Aide (CNA) G said: -The resident had an open area for at least a week. -He/She had notified the nurse. During an interview on 2/19/25 at 11:59 A.M. LPN C said he/she was not aware of resident #92 open area. During an interview on 02/27/25 at 11:32 A.M. LPN B said care plans should be updated with changes as the change occurred. 44993 3. Review of Resident #11's quarterly MDS, dated [DATE], showed: - The resident had a BIMS score of 14, indicating little cognitive deficit; - Diagnoses included: Diabetes Mellitus (DM) type II; - He/She was completely dependent on staff for toileting needs, showers, and to get dressed: - He/She was incontinent of bowel and bladder; - He/She was a risk for the development of pressure ulcers (PU), but had none; - He/She had skin break down on his/her buttocks. Review of the Braden Scale (a form completed by the facility staff to determine the resident's risk for developing a wound), dated 1213/24, showed the resident at a high risk of developing a wound. Review of the January 2025 progress notes showed the following: - 1/5/25: LPN A documented on a skin assessment that the resident had an open area to his/her bottom; - 1/9/25: LPN B documented on the monthly summary that the resident had fragile, warm, and dry skin. LPN B did not document any further details about the resident's skin breakdown; -1/12/25: LPN B completed a skin assessment, the resident continued to receive a treatment for redness on the buttocks and a small open area, will fax the resident's physician for new orders. Review of the resident's February 2025 skin assessments showed the following: - 2/2/25: LPN A documented on a skin assessment the resident had an existing non-foot skin issue. - 2/16/25: LPN A documented on a skin assessment the resident's bottom was red and had an open area. Review of the resident's skin care plan, dated 8/26/22, showed: - The resident had a chronic to his/her buttock that sometimes appeared to be open and sometimes appeared to be closed; - The care plan did not include the resident's current PU. Observation on 2/25/25 at 8:14 A.M. showed: - The resident was lying in his/her bed; - Licensed Practical Nurse (LPN) A entered the resident's room to complete wound care; - The resident had a wound to his/her bottom that was 6 centimeters (CM) long by 0.3 CM wide; - The center of the wound had a dark brown area that measured 2 CM long by 1.75 CM wide. During an interview on 2/25/25 at 8:14 A.M., LPN A said: - The wound appeared to be in worse condition than last week; - Any of the nurses can update the resident's care plan. During an interview on 2/27/25 at 11:39 A.M., The MDS Coordinator said: - He/She helps with care planning, but most care plans and updates are completed by the nurses; - The resident's care plan should have included his/her wound to his/her buttocks. During an interview on 2/27/25 at 3:10 P.M. the Administrator said she would expect the resident's wound to be care planned with current interventions. 4. Review of Resident #15's quarterly MDS, dated [DATE], showed: - He/She had a BIMS score of 15, indicating no cognitive deficit; - Diagnoses included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture). - He/She required assistance from staff to transfer, toileting needs and get dressed; - He/She received a therapeutic diet and a mechanically altered diet; - He/She had weight loss. Review of the resident face sheet showed the resident had the following diagnoses: Dysphagia, oral phase (difficulty swallowing) and weakness Review of the residents Physician Order Sheet (POS), dated February 2025, showed an order dated 9/5/24 for pureed food with honey thick liquids. Review of the residents weights showed the following: - 9/2/24- 248.4 pounds (lbs); - 10/3/24- 242.6 lbs; - 11/3/24- 234.4 lbs; - 11/30/24- 232.4 lbs; - 12/2/24- 224.2 lbs; - 1/1/25- 224 lbs; - 2/1/25 222.2 lbs; - Decreased 26.2 lbs and 10.5% of the resident's body weight over the past 6 months. Review of the resident's nutrition status care plan, dated 2/25/20, showed: -The resident was at risk for weight loss; - The resident was on a pureed diet with honey thick liquids; - The residents significant weight loss was not addressed in the resident's care plan. During an interview on 2/27/25 at 3:10 P.M. the Administrator said the resident's significant weight loss should have been included in his/her care plan. 5. Review of Resident #36's quarterly MDS, dated [DATE], showed: - The resident had a BIMS score of four, indicating severe cognitive deficit; - The resident required assistance with eating, toileting and getting dressed; - The resident was 72 inches tall and 148 pounds; - The resident had a mechanically altered diet; - The MDS did not indicated the resident had a significant weight loss. Review of the resident's POS, dated February 2025, showed an order dated 12/2/24 for nectar thick liquids. Review of the residents weight log showed the following: -10/29/24 153.6 lbs; 11/3/24 152.6 lbs; 12/3/24 157 lbs; 1/1/25 156.4 lbs; 2/1/25 147.6 lbs; - The resident decreased 9.4 pounds and 5.98% in the past 2 months. Review of the resident's undated comprehensive care plan showed the facility staff did not address the resident's weight loss. 6. During an interview on 02/27/25 at 11:39 A.M., the MDS Coordinator said: -Most of the care plan is completed by the Charge Nurses; -Resident specific care plans should include weight loss, the use of a nebulizer and oxygen, fall status and prevention interventions, psychosocial stuff, residents receiving hospice services, magic cup orders, contractures, wounds and skin issues; -Primary care plans are related to the day to day care, behavioral issues; -Communication was challenging; he/she was not always notified of changes; better communication between departments would ensure relevant information gets added to the resident care plans; -He/She checks morning notes for changes. During an interview on 02/27/25 12:28 P.M., the Quality Assurance Nurse said: -She would expect Nebulizers, urinary tract infections, wounds and weight loss to be care planned for each individual resident; -She expected every nurse to be able to access, update and utilize the care plan; -The facility had a MDS coordinator that goes between other facilities; -The charge nurses need more education to increase their comfort with care planning. During an interview on 02/27/25 03:10 P.M the Administrator said: -She would expect any one can and would update a care plan, -The MDS Coordinator ensure the information is in the care plan; -She expected the CNA staff to report any changes to the Charge Nurse and the Charge Nurse to update the care plan; -She expected the care plan to be a snapshot of the specific resident and the care they require.

Based on observation, interview, and record review, the facility staff failed to store nebulizer machine masks in a bag when not in use for two residents (Resident # 15 and #38) of 12 sampled residents. The facility census was 40. The facility did not provide a policy for nebulizer masks. 1. Review of Resident #15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnosis included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture). Review of the resident's face sheet showed the following diagnoses: Dysphagia, oral phase (difficulty swallowing), bronchitis, and weakness. Review of the residents Physicians Order Sheet (POS), dated February 2025, showed an order dated 9/16/24 for Ipratropium-Albuterol (a liquid medication inhaled to treat breathing problems) 0.5 milligram (MG)- 3 MG per 3 milliliter (ML) nebulizer four times daily. Observation on 2/23/25 at 10:32 A.M., in the resident's room showed a nebulizer machine sitting on the sink with the mask resting in the sink bowl, not covered. Observation on 2/23/25 at 1:52 P.M., showed the resident's nebulizer machine was sitting on the sink with the mask lying on the sink bowl with no cover. Observation on 2/23/25 at 2:40 P.M., showed the resident was using the nebulizer mask to receive a breathing treatment. Observation on 2/25/25 at 9:20 A.M., showed the residents nebulizer mask was sitting directly on the sink. During an interview on 2/26/25 at 10:50 A.M., Licensed Practical Nurse (LPN) B said: - Nebulizer masks are supposed to be placed in a plastic bag when not in use; - Nebulizer masks should not be placed directly on the sink or the sink bowl. During an interview on 2/27/25 at 12:28 P.M., the Quality Assurance (QA) nurse said: - He/She expected nebulizer masks to be in bags when not in use. 2. Review of Resident's #38's quarterly MDS, dated [DATE], showed: - He/She had a BIMS score of 15, indicating no cognitive deficit; - Diagnoses included: Heart failure and chronic obstructive pulmonary disease (COPD, a disease that affects how a person breaths). - He/She required some assistance with activities of daily living (ADLs). Review of the resident's POS, dated February 2025, showed the following orders: - 11/13/24: albuterol sulfate 2.5mg/ 3 ml (0.83%) per nebulizer two times daily to treat COPD; - 11/13/24: change nebulizer tubing monthly. Observation on 2/23/25 at 11:44 A.M., showed: - The resident was sitting in his/her recliner; - The resident's nebulizer machine was sitting directly on a side table with no barrier and the nebulizer mask was sitting on a towel, not in a bag. Observation on 2/24/25 at 11:20 A.M., showed the resident's nebulizer was was sitting directly on a towel and not in a bag. During an interview on 2/27/25 at 12:28 P.M. the Quality Assurance (QA) nurse said: - He/She expected nebulizer masks to be in bags when not in use.

Based on observation, interview, and record review, the facility failed to prevent a significant weight loss for one of 12 sampled resident's (Resident #15), when the facility did not provide the resident with his/her physician ordered Magic Cup (a nutritional supplement that contains additional calories and protein for persons experiencing involuntary weight loss) daily at lunch. The facility census was 40. The facility did not provide a significant weight loss policy. Review of Resident #15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnoses included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture) and dysphagia (difficulty swallowing); - He/She required assistance from staff to transfer, with toileting needs and to dress; - He/She received a therapeutic diet and a mechanically altered diet; - He/She had weight loss. Review of the resident's face sheet showed the following diagnoses: Dysphagia, oral phase and weakness. Review of the resident's nutrition status care plan, dated 2/25/20, showed: -The resident was at risk for weight loss; -The resident was on a pureed diet with honey thick liquids. Review of the resident's Physician Order Sheet (POS), dated February 2025, showed the following physician orders: - 9/5/24: Pureed food with honey thick liquids due to dysphagia; - 9/5/24: Magic Cup with lunch daily for weight loss. Review of the resident's weights showed the following: - 9/2/24: 248.4 pounds (lbs); - 10/3/24: 242.6 lbs; - 11/3/24: 234.4 lbs; - 11/30/24: 232.4 lbs; - 12/2/24: 224.2 lbs; - 1/1/25: 224 lbs; - 2/1/25: 222.2 lbs; - Decreased 26.2 lbs and 10.5% of the resident's body weight over the past 6 months. Review of progress notes in the electronic medical record (EMR) showed the following: - 11/15/24: The Registered Dietician (RD) documented: The reason for consult was for the resident's weight change. The resident's current diet order was pureed with honey thickened liquids, Magic Cup with lunch daily. The resident's intake at meals was 51-75% of meals consumed. The resident's current weight was 234.4 pounds with a 3.4% in weight loss over the past 30 days; - 12/11/24: The RD documented: The reason for the consult was for the resident's weight change. The resident's current diet order was pureed with honey thickened liquids. Magic Cup with lunch daily. The resident's meal intake was 51-75%. The resident's weight was 224.2 lbs; - 1/8/25: The RD documented: The reason for the consult was for weight change. The resident's current weight was 224.0 lbs. - 2/6/25 The RD documented the reason for the consult was for weight change. The resident's current was weight: 222.2 lbs. the resident's weight on 8/5/24 247.4 lbs indicating the resident lost 10.2% of his/her weight over the past six months. The resident's weight loss appears to have halted since last seen. The current interventions remain appropriate, and no changes warranted at this time. Observation on 2/23/25 at 12:12 P.M., showed: - The resident was at the dining table; - The staff served the resident his/her lunch meal and did not give the resident a Magic Cup; - The resident ate approximately 50% of his/her meal and left the dining room. Observation on 2/24/25 at 12:08 P.M., showed: - The resident was served his/her lunch meal; - The resident was not served a Magic Cup; - The resident consumed approximately 75% of his/her meal. Observation on 2/25/25 at 12:26 P.M., showed: - The staff served the resident his/her lunch meal; - The staff did not provide a Magic Cup to the resident; - The resident consumed approximately 75% of his/her meal. During an interview on 2/26/25 at 3:48 P.M., the Dietary Manager (DM) said he/she expected the resident to receive his/her Magic Cup as it was ordered by the physician. During an interview on 2/26/25 at 10:50 A.M., Licensed Practical Nurse (LPN) B said: - He/She expected the staff to provide the resident a Magic Cup at lunch, because it was ordered; - He/She was not aware the resident was not receiving the Magic Cup; - He/She was not aware the resident had significant weight loss; - There was lack of communication between nursing and dietary. During an interview on 2/27/25 at 12:28 P.M., Quality Assurance (QA) Nurse A said -The facility had monthly risk meetings that include the RD; -The resident's weights are discussed during the meetings; - He/She expected staff to provide Resident #15 his/her Magic Cup as ordered. During an interview on 2/27/25 at 3:10 P.M. the Administrator said she expected staff to give Resident #15 his/her Magic Cup as ordered.

Based on observation, interview, and record review, the facility staff failed to ensure a resident (Resident #15) with limited range of motion (ROM) to his/her left hand received treatment to prevent further ROM loss. The facility census was 40. Review of the facility's undated policy titled, Range of Motion, showed: - ROM was suppose to be provided to prevent contractures from becoming worse; To maintain normal ROM; - The facility staff can provide passive range of motion (PROM) for residents that cannot complete it themselves; To simulate circulation. Review of Resident #15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnosis included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture); - He/She required assistance from staff to transfer, with toileting needs, and to dress; - He/She was incontinent of bowel and bladder. Review of the resident's face sheet showed the following diagnoses: Dysphagia, oral phase (difficulty swallowing) and weakness. Review of the resident's Activities of Daily Living (ADL) care plan, dated 11/26/19, showed: - The resident was dependent on a mechanical lift and two staff for transfers; - The resident's required assistance with all his/her ADLs; - The resident's care plan did not address decreased ROM for the resident's left hand. Review of the resident's Physician Order Sheet (POS) dated 2/25 showed the resident did not have an order for ROM services or a device to prevent decreased ROM. Observation on 2/23/25 at 10:32 A.M., showed: - The resident had a contracture to his/her left hand; - The resident's fingers curled in and the resident was not able to straighten them; - The resident did not have a device to prevent his/her fingers from curling in. During an interview on 2/23/25 at 10:32 A.M., the resident said: - He/She did not have any thing to help his/her fingers from curing in; - The staff did not help him/her with ROM and did not provide PROM; - He/She would like to receive ROM so he/she does not lose more function of his/her hand. During an interview on 2/26/25 at 10:00 A.M., Certified Nurse Aide (CNA) C said: - The facility did not have staff to provide ROM for Resident #15; - He/She was not told to provide PROM for the resident with cares. During an interview on 2/26/25 at 10:50 A.M. Licensed Practical Nurse (LPN) B said: - There was no ROM program at the facility; - The CNAs were supposed to complete ROM with cares. During an interview on 2/27/25 at 3:10 P.M., the Administrator said: - The facility did not have a current ROM program; - The CNAs can complete PROM with cares; - The CNAs should be doing PROM and stretching with Resident #15 when they provide care.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, or psychosocial well-being for one of three sampled residents (Resident #7) when staff failed to obtain a physician ordered blood transfusion in January 2025 for an anemic resident in a timely manner. The blood transfusion was not carried out until fourteen days after it was ordered. The facility census was 43. Review of facility policy titled Physician Orders, undated, showed physician's orders must be signed by the physician and dated when such order was signed. Review of facility policy titled Lab Reporting Guidelines, undated, showed: -Guidelines will be followed to ensure that lab recommendations are completed timely; -Nurse will received the lab for a lab draw; write a telephone order and document the order on the physician order sheet (POS) or note the order on the POS when written by the physician. -The nurse will document on the lab report that the physician had been notified to include how they were notified, when (time and date) and the nurse's signature; -The lab report will be placed in the medical record under the lab section; -When any new orders were received, this will again be documented on the 24 hour report. 1. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 11/22/24, showed: -They had moderate cognitive impairment; -They were dependent on a wheelchair; -They took an antiplatelet medication (a medication that prevents blood platelets from sticking together and forming blood clots); -Diagnoses included: Arthritis hypercalcemia (condition where there is high level of calcium in the blood), anemia, and high blood pressure. Review of care plan, dated 12/7/24, showed the resident: -had cognitive loss and their DPOA (Durable Power of Attorney) had been invoked by two physicians; -their designated family member directed health care needs. Review of physician's orders showed: -Faxed order, dated 1/16/25, Type and cross 2 units PRBC (packed red blood cells) and transfuse, pre-treat with Tylenol 650 mg (milligram) by mouth and Benadryl 12.5 mg 30 minutes prior to start. Give Lasix (a water pill) 40 mg intravenous (IV) x 1 between units, for diagnosis anemia . Review of the resident's medical record showed no documentation the physician orders were carried out. Review of progress notes, dated 12/1/25-2/11/25, showed: -On 1/17/25, physician ordered a blood transfusion due to low hemoglobin levels; -On 1/27/25, resident returned to the facility from hospital appointment to have blood transfusion. Hospital did not have right blood type in stock so the resident did not receive transfusion. -On 1/30/25, Resident received 1 unit of packed red blood cells (PRBC). During an interview on 2/11/25 at 1:40 P.M., Family Representative A said: -Resident had experienced some fatigue that physician had been concerned about; -Resident did not receive a blood transfusion right away in January when it was ordered; -They were unsure why a delay occurred in the resident receiving the blood transfusion. During an interview on 2/11/25 at 11:48 A.M., Licensed Practical Nurse (LPN) A said: -Laboratory results went directly to the resident's physician; -The facility staff did not receive the resident's lab results unless they specifically requested them; -There should have been some documentation in the progress notes on the care resident received. During an interview on 2/11/25 at 2:15 P.M., Physician's Registered Nurse (RN) A said: - The resident had Complete Blood Count (CBC) (a medical test that measures the number and types of various cells in the blood) drawn on 1/16/25 and their hemoglobin was 7.5 g/dl; -The physician sent an order for blood transfusion to occur and for facility to pre-treat resident with Tylenol and Benadryl; -He/she called the facility to notify them of the orders and faxed the orders on 1/16/25 by 5:00 P.M.; -The hospital outpatient said the facility dropped the resident off on 1/27/25 without an appointment and they did not have the resident's blood type on hand; -The resident did not get the transfusion until 1/30/25; -When the physician's office sends orders to the facility- the facility staff are able to call the hospital to schedule the transfusion; -Without the blood transfusion the resident had a risk of having their hemoglobin levels drop further and experience additional fatigue. During an interview on 2/11/25 at 2:20 P.M., LPN A said: -He/she was unsure why resident's blood transfusion was delayed in January. -BOM (Business office manager) was the person who scheduled appointments and arranged transportation to appointments for residents; -When the BOM is out of facility the Human Resources (HR) staff person is supposed to cover for the BOM. During an interview on 2/11/25 at 3:10 P.M., BOM said: -Faxes were received on the fax machine located in the main business office of facility; -She takes faxes to the west nurses station; -The nurses were responsible for writing any orders and appointments that need made on the faxed orders received; -Faxes were then brought back to him/her in the front office for scheduling of appointments; -He/she was responsible for scheduling appointments for the residents; -Paperwork and orders did sometimes get missed; -Resident #1's paperwork said family was going to schedule resident's appointment; -He/She contacted Resident #1's family member and they advised they were not taking care of appointment for transfusion; -The facility driver took the resident to his/her transfusion appointment on 1/27/25 and all the pretransfusion mapping was completed at that time but transfusion did not occur because the hospital did not have the resident's blood type on hand; -He/She took resident back to outpatient clinic on 1/30/25 for the transfusion; -When he/she was not working in facility the HR staff was their back up regarding checking faxes and taking phone calls and writing down appointments. During an interview on 2/11/25 at 3:30 P.M., Family Representative B said: -They did not agree or tell facility they would take resident to their second blood transfusion due to the extensive time commitment of 3-6 hours that the transfusions took to complete; -There was a communication break between administration and nurses at the facility. During an interview on 2/11/25 at 3:23 P.M., Physician said he/she expected their order for blood transfusion to be carried out within 5-7 days. During an interview on 2/11/25 at 3:50 P.M., Director of Nursing said he/she expected physicians orders to be carried out as soon as possible. During an interview on 2/11/24 at 4:11 P.M., Administrator said: -He/she expected facility staff to follow physicians orders; -Physician's orders were received in main office at fax machine and were taken to the west nurses station charger nurse; -The charge nurse took orders off fax and entered them into electronic medical record; -Physician then electronically signed the orders in electronic medical record; -Business Office Manager makes resident appointments; -When BOM was out of facility the Administrator or HR staff made appointments. MO248336

Based on observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (Resident #15) received necessary assistance with activities of daily living (ADL). Resident #15 was dependent on a mechanical lift and two staff for transfers and required assistance with all his/her ADL's. Facility staff failed to reposition the resident every two hours and to provide timely perineal care. The facility census was 40. The facility did not provide a policy for timing and repositioning and perineal care for a resident's. 1. Review of Resident # 15's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff), dated 12/27/24, showed: - He/She had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit; - Diagnoses included: Cerebral Palsy (is a disorder that affects movement, muscle tone and posture); - He/She required assistance from staff to transfer, toileting needs, and get to dressed; - He/She was incontinent of bowel and bladder. Review of the resident's face sheet showed the following diagnoses: Dysphagia, oral phase (difficulty swallowing) and weakness. Review of the resident's Activities of Daily Living (ADL) care plan, dated 11/26/19, showed: - The resident was dependent on a mechanical lift and two staff for transfers; - The resident's required assistance with all his/her ADL's. Review of the residents skin care plan, dated 11/26/19, showed: - The resident was incontinent of urine; - The staff were supposed to assist the resident's with perineal care; - The resident's had compromised skin integrity between his/her thighs. During an interview on 2/23/25 at 10:32 A.M., the Resident said: - He/She had a sore on his/her inner right thigh; - It took a while for staff to change him/her; - He/She he had been up since 7:00 A.M. this morning and has not been repositioned or changed since; - He/She was wet. Observation on 2/23/25 at 1:52 P.M., showed: - The resident's was in his/her room in his/her wheel chair; - Certified Nurse Aide (CNA) C and CNA I entered the resident's room with the mechanical lift; - The CNA's assisted the resident in bed using the mechanical lift; - The resident had a strong urine smell; - CNA C provided perineal care; - The resident had saturated through an incontinence brief, his/her pants, and the mechanical lift sling; - The resident's bottom was red and appeared irritated. During an interview on 2/23/25 at 1:52 P.M., CNA C said: - He/She was trained to complete rounds every two hours; - Rounds included repositioning residents, and cleaning residents if they are wet or soiled; - Resident #15 was supposed to be repositioned every two hours; - He/She came on duty at 7:00 A.M. and did not reposition or change the resident's before now; - He/She should have ensured the resident's was dry and repositioned every two hours and as needed. During an interview on 2/23/25 at 2:03 P.M., CNA I said: - Cares were last provided for the resident at 7:30 A.M. for Resident #15; - Cares included repositioning and ensuring the resident was clean and dry; - The resident should have been changed earlier. During an interview on 2/26/25 at 10:50 A.M., Licensed Practical Nurse (LPN) B said: - Resident #15 was incontinent of bowel and bladder; - The staff do not change the resident's like they are supposed to; - He/She expected the resident to be repositioned and perineal care provided every two hours and as needed; - The resident's really needed to be laid down every two hours because of his/her skin breakdown and incontinence. During an interview on 2/27/25 at 12:28 P.M., the Quality Assurance (QA) nurse said he/she expected the staff to provide repositioning and perineal care every two hours and as needed for resident's that need help. The staff should not have left Resident #15 sitting in his/her wheel chair from 7:30 A.M. to 1:52 P.M. with out repositioning and providing perineal care. During an interview on 2/27/25 at 3:10 P.M., the Administrator said staff should have repositioned Resident #15 and provided perineal care every two hours. It was not acceptable to let the resident's sit in his/her wheel chair for more that six hours without repositioning and cleaning the resident's.

See event ID 5ME012 Based on record review and interview, the facility failed to provide adequate supervision for one resident (Resident #1), when the facility staff failed to implement interventions on 10/5/21 and 10/7/21 after the facility staff noted the resident displayed exit seeking behaviors and attempting to exit the facility unsupervised. On 10/8/21, at approximately 3:00 A.M., the facility was notified by the local hospital that the resident was at the hospital. The resident returned to the facility at 5:10 A.M. by the local police department. The resident was placed on one-on-one (1:1) supervision at that time. The facility failed to ensure staff carried out 1:1 interventions after the first elopement when the day shift staff did not continue the 1:1 supervision after 6:00 A.M. which resulted in the resident eloping the facility again later that same day. The resident was last seen by staff at 7:00 A.M. on 10/8/21 and the facility was notified by a private citizen the resident was seen walking along a busy State highway at approximately 7:35 A.M. to 7:45 A.M. and was found between the facility and the hospital on the opposite side of the road of the facility. The facility census was 63. The Administrator was notified on 10/15/21 at 3:45 P.M. of an Immediate Jeopardy (IJ) which began on 10/8/21. The IJ was removed on 10/19/21, as confirmed by surveyor onsite verification. Review of the undated facility policy titled Elopement, Response to Suspected Code Silver showed the following: - The following individual may have responsibility for preventing resident elopement specific to state professional licensing requirement, registered nurse (RN), licensed practical nurse (LPN), certified medication technician (CMT), certified nurse aide (CNA); - Elopement for the purpose of this policy and procedure, is defined as a situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety needs and therefore at risk for injury outside the confines of the facility, has left the facility without knowledge of the staff; - This definition of elopement does not include a resident who is at risk for elopement but whose exit from the facility is known to staff, who are responding to the exit; - Furthermore, the definition of elopement does not include residents: o Who is not a risk for elopement due to their cognitive abilities; o Who leave the facility with the intent to return within a short period of time (for example, within approximately two hours); o Who have ability to leave and return safely; o Residents who fit this description are requested to sign in and out or in some similar manner, to let staff know of their departure and anticipation time of return; - The purpose of this elopement policy is to: o Identify residents at risk for elopement; o Protect residents that are not capable of protecting themselves; o Provide the techniques and equipment to minimize safety risks; - A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents; - Door alarms are tested each shift at least once a month. The results of the test are then recorded; - When found, assess for injuries and document. Make sure a plan has been developed to ensure protective oversight; - Notify all in search that the resident has returned, call family/responsible party and Medical Director; - The care plan is to be revised by the Minimum Data Set (MDS) Coordinator or designee to include further preventative interventions to prevent reoccurrence; - DON or designee to in-service staff on plan of care implemented within 48 hours of incident and addressed to all personnel involved in direct care of the resident and alerting non-nursing staff to precautions and elopement policy and procedure; - The Department of Health and Senior Services (DHSS) may be notified if there is reason to believe the resident is likely to be in harm or danger. Review of the undated facility policy titled Resident Elopement showed the following: - The facility provides 24-hour protective oversight and maintains the quality of life for each resident; - The pre-admission screening process should thoroughly evaluate the potential resident's wandering or hiding risk. This information is gathered from the family, physician, social worker, friends, hospital staff, facility staff, general observation and information on pre-screening tools; - If during the preadmission screening, a resident is classified as an elopement risk, place in the locked unit. If your facility does not have a locked unit, give the family a list of area facilities that have locked units and assist them with placement at the facility of their choice; - If a resident is admitted with no previous elopement potential, but verbalizes or attempted to leave the facility, the following criteria should be followed: o Evaluate the resident to see if they meet the criteria for a locked unit (if your facility has one); o Director of Nursing (DON) must notify the resident's physician as soon as possible; o Have the Social Services Director (SSD) notify the resident's family for assistance and information; o Address the potential in a care plan and implement the interventions list on the care plan; o Place resident in a room that is in the line of sight of the nurses' station; o Instruct one certified nurse aide (CNA) per shift in the care of the resident. The CNA must observe the resident at all times, but especially during meal times, medication administration times, scheduled activities of daily living (ADLs), every time the door alarm sound, and as indicated by the care plan. The charge nurse must indicate on the assignment sheet which CNA is responsible; o When a resident is observed attempting to leave the premises, facility should implement the following actions immediately: - Attempt to prevent departure; - Should the attempt to intercept fail, obtain assistance from other staff members in the immediate area; - Instruct another staff member to inform the charge nurse, DON, or Administration that the resident is attempting to leave the facility; - Be courteous in preventing the departure and in returning the resident to the facility; - Document in the resident's records the wandering behavior, including immediate prevention measures. Also document interventions initiated to prevent this from happening again; - Notify the attending physician and legal representative or family member. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/30/21, showed: - admitted [DATE]; - Diagnoses included non-traumatic brain dysfunction, manic depression; schizophrenia. - Brief Interview for Mental Status (BIMS, structured evaluation aimed at evaluating aspects of cognition in elderly patients), score of 15 out of 15, which indicated no cognitive impairment; - Independent with mobility; - Wandering behavior not exhibited. Review of Resident #1's medical record showed the facility did not have a PASRR screening on file for the resident, although the resident had diagnoses of a mental disorder. Review of Resident #1's Level II PASARR screening, conducted on 9/29/20, signed by the assessor on 10/5/20, and obtained from Central Office Medical Review Unit (COMRU) on 10/14/21, showed: - He/she required nursing facility placement due to severely impaired judgement/insight. He/She was unable to make reasonable judgements about the importance of medication compliance and follow up with psychiatry. - He/she required around the clock supervision and oversight to assure he/she and others are safe. - He/she required a secured environment to prevent elopement due to impulsivity and severe lack of judgement. Review of the resident's admission elopement assessment, dated 3/23/21, showed staff indicated the resident was not at risk of wandering or elopement. There were no other elopement assessments in the resident's medical records. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/28/21, showed: - Diagnoses included non-traumatic brain dysfunction, manic depression; schizophrenia. - Brief Interview for Mental Status (BIMS, structured evaluation aimed at evaluating aspects of cognition in elderly patients), score of 15 out of 15, which indicated no cognitive impairment; - Independent with mobility - Wandering behavior not exhibited Review of the resident's nurses notes showed the following: - Notes regarding the resident's behavior changes began on 9/20/21 - Behavioral issues with the resident were documented on the following days: 9/20/21, 9/21/21, 9/22/21, 9/23/21, 9/24/21, 9/25/21, 9/26/21, 9/27/21, 9/29/21, 9/30/21, 9/30/21, 10/1/21, 10/2/21, 10/3/21, 10/4/21, 10/5/21, 10/6/21, 10/7/21, 10/8/21; - The behaviors documented during the dates listed above included attempting to elope from the facility, actually eloping from the facility, making sexual comments to staff, physically grabbing staff, hitting exit doors, swallowing a lit cigarette (10/5/21), demanding staff to call the sheriff, cussing at staff, threatening staff, not sleeping and wandering the facility at night, rearranging furniture in the hallway, walking in to resident rooms uninvited, including the opposite sex (10/3/21), refusing medications (10/2/21), talking to other residents inappropriately (9/30/21), ideation of self-harm (9/30/21) hearing voices (9/29/21), walking throughout the facility and courtyard barefooted, becoming quickly agitated, calling the police, delusions of being in the special forces (9/26/21), mind racing; - Nurse note dated 9/24/21 stated the resident was sent to the hospital on 9/24/21 for a psychiatric evaluation, but returned to the facility on the same day with additional medication orders and a note for the resident to have a psychiatric evaluation as soon as possible or the next week; - Nurse note, dated 9/30/21, stated the resident was sent to the hospital for evaluation and treatment with regard to hearing voices and plans to harm him/herself, the resident returned to the facility later on 9/30/21 with new medication orders; - Nurse note, dated 10/3/21, stated the resident was sent to the hospital to be treated for psychiatric behaviors per the resident's request and returned to the facility on [DATE]. The note indicated it was recommended the resident have different placement and to see a counselor. Review of the resident's significant change in condition Minimum Data Set (MDS), a federally mandated assessment tool completed by the facility staff, dated 9/28/21, showed the following: - Cognitively intact; - There was evidence of an acute change in mental status from the resident's baseline with inattention (difficulty focusing attention), and disorganized thinking indicated; - The resident had delusions, verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds); - The behavioral symptoms put the resident at significant risk for physical illness or injury, significantly interfered with the resident's care, significantly interfered with the resident's participation in activities or social interactions, put others at significant risk for physical injury, significantly intruded on the privacy or activities of others, and significantly disrupted care or living environment; - Wandering was indicated, occurring daily. The impact of wandering indicated the wandering placed the resident at significant risk of getting to a potentially dangerous place and it significantly intruded on the privacy or activities of others. The behavior was indicated that it had gotten worse compared to prior MDS assessments. Review of the resident's care plan, dated 10/4/21, showed staff did not include any information regarding the resident wandering or being an elopement risk or any attempts the resident had made to elope from the facility as indicated in the nurses notes and MDS assessment. During an interview on 10/13/21 at 4:10 P.M., the DON said: - She did not see any quarterly elopement assessments for Resident #1; - The charge nurse on duty completes the clinical admission, including required assessments at the time of admission. The MDS Coordinator was responsible to complete quarterly assessments and significant change assessments. During an interview on 10/13/21 at 4:41 P.M., the MDS Coordinator said she: - Had been the MDS Coordinator since September. - Completed an elopement assessment at admission and quarterly; - Thought the nurses do the admission and quarterly assessments, but she had done some; - Did not know if there were any quarterly elopement assessments completed for the resident. Review of the resident's nurses' notes showed the following: - 10/5/21 at 2:09 A.M., note by MDS Coordinator, said he/she was notified from a CNA that the resident was talking about breaking glass and leaving through the doors. The note did not indicate any further interventions were put in place at the time or that the DON, Administrator, physician, or guardian being notified of the incident. - 10/5/21 at 3:55 A.M., the police came to talk to the resident on 10/5/21 per the guardian's request when the guardian called the facility after the resident called him/her around 3:30 A.M. yelling and cussing at him/her to have him/her removed from the facility that night. The resident was not taken to the hospital at that time. - 10/5/21 at 3:55 A.M., note by LPN C, aides and another resident reported to him/her that the resident was trying to get out the doors. The note did not indicate staff put any further interventions in place at that time or that the DON, Administrator, physician, or guardian being notified of the incident. Review of the 15 Minute Resident Check document for the resident, dated 10/5/21, showed the following: - At 2:00 A.M. staff noted the resident was threatening to elope (initialed by Agency CNA E). - At 2:30 A.M. staff documented the resident was trying to leave the facility (initialed by Agency CNA E). -At 2:45 A.M. staff documented the resident was trying to leave the facility (initialed by Agency CNA F). - At 3:00 A.M. staff documented the resident was trying to leave the facility (initialed by Agency CNA E). - There were no other 15 minute checks in the medical record between 10/5/21 and 10/8/21 when the resident returned from the first elopement. During a phone interview on 10/28/21 at 3:43 P.M., Agency CNA E said he/she: - Had worked at the facility since December 2020; - The resident had a definite behavior change three weeks before the resident eloped. The resident became more paranoid about his/her room, had erratic behavior, was not sleeping, was talking and not making a lot of sense and going in to others' rooms uninvited; - Thought the resident had been on 15 minute checks for a couple days after being sent to the hospital; he/she kept up with the 15 minute checks until he/she was told by the charge nurse that he/she could stop; he/she found out later than he/she could have stopped after 24 hours; - Thought the resident was on 15 minute checks, because he/she wanted to leave; - On 10/5/21, the resident said he/she wanted to leave and was going to leave one way or the other. He/she thought the resident was taken to the hospital that night, with a police escort due to his/her behaviors; - The resident was trying to leave the facility on the 10/5/21; he/she pushed on two different doors and set off the alarms. He/she reported it to the charge nurse, but could not remember who the charge nurse was; - Report was received from the day shift by a written report from the hall, but it depended on how busy the day shift was if there was anything written, but they also receive verbal report. During a phone interview on 10/29/21 at 2:53 P.M., Agency CNA F said: - The resident was on 15 minute checks on 10/5/21, because he/she was going to hurt him/herself either that day or the day prior. The resident had been sent to the hospital and when he/she returned, he/she was put on 15 minute checks; - On 10/5/21 the resident was actively pushing on an exit door to leave the facility, but could not because the door was locked and needed a code. He/she reported this to the nurse (he/she believed it was LPN C). He/she was not aware of an incident prior to that when the resident attempted to elope. Review of the resident's nurse notes showed the following: - 10/7/21 at 2:10 A.M., LPN C indicated the resident went through one door towards South Hall and when the aides went to the South Hall the resident attempted to leave the facility through the South entrance. The note did not indicate any further interventions put in place at that time or that the DON, Administrator, physician, or guardian have been notified of the incident; - 10/8/21 at 3:30 A.M., LPN C noted the resident was upset and walking down 500 hall, the resident hit the door on the transition door to outside, then turned and walked towards South Hall; - 10/8/21 at 4:10 A.M., LPN C wrote the South Charge Nurse (LPN A) notified him/her the police called and stated the resident was at the hospital in the town; DON and Administrator were notified; - 10/8/21 at 5:10 A.M., LPN C noted the resident returned to the facility via police escort. Resident was placed on 15 minute physical sight checks and 1:1 person at this time. All staff educated to help ensure the resident was safe and in the building. The resident said he/she was (mad) so he/she went to the hospital and called the police. The resident was pacing around the facility with CNA walking with him/her. Review of the 15 Minute Resident Check document for the resident, dated 10/8/21, showed the following: - Staff began 15 minute checks at 5:10 A.M. (when the resident returned from the first elopement); - LPN C signed off at each 15 minute increment beginning with 5:15 A.M., after the resident returned, through 8:30 A.M., when the resident returned the second time. - At 5:15 A.M., 5:30 A.M., and 5:45 A.M. the document indicated the resident was on 1:1. - At 6:00 A.M. and 6:15 A.M., staff indicated the resident was in the 500 hallway, but did not indicate 1:1. - At 6:30 A.M., staff indicated the resident was on South Hall and on 1:1. - From 6:45 A.M. to 7:00 A.M., staff indicated the resident was in the courtyard, smoking. - From 7:15 A.M. to 8:15 A.M., staff indicated the resident was out of the facility (OOF). - At 8:30 A.M. staff indicated the resident returned to the facility. Review of the resident's nurse notes showed the following: -10/8/21 at 8:30 A.M., LPN D noted around 7:00 A.M. the resident was reported to be leaving out of the door. LPN D and the night nurse (LPN C) followed, the resident left the grounds and was on the road by the facility. The resident went to the emergency room and asked to make a physician's appointment. Resident was placed on 1:1 at the time of returning. During a phone interview on 10/15/21 at 1:54 P.M., Resident #1 said: - He/she had watched staff coming in and out the doors; - Staff made him/her mad because they would not light a cigarette and then he/she found out he/she did not have any cigarettes. He/she left through the doors by his/her room the first time he/she left the facility. He/she went to Hy-[NAME] and got in the dumpster, then walked to the hospital. No one knew he/she was gone for two hours; - The second time he/she left the facility through the front doors. LPN A and LPN B were counting medications at the front (South) nurse station. The resident asked LPN A for cigarettes and LPN A told the resident he/she would have to wait until they were done counting medications. The resident thought that by the time he/she got his/her cigarettes, smoke time would be over. LPN A told the resident why don't you just leave like last night, the resident said Really? and LPN B said I do not have to put up with your shit. The resident left out the front doors, went to a service station across the street from the facility and told the man working that he/she just left the facility. The man looked busy so the resident left the service station, found a stick, then went to Hy-[NAME] and told them what he/she did earlier that morning. Staff caught up with him/her half way to the hospital. He/she would have made it to the hospital if he/she would not have stopped at the service station and Hy-[NAME]; - He/she did not tell anyone he/she was leaving; - Both times he/she left the facility, he/she put pressure on the doors, they beeped and unlocked. The resident indicated the doors did alarm. Review of Resident #2's quarterly MDS dated [DATE] showed the following: - Cognitively intact. During an interview on 10/14/21 at 1:07 P.M., Resident #2 said he/she: - He/She was friends with Resident #1. They spoke frequently and smoked together; - He/She witnessed Resident #1 attempting to leave the facility on two occasions. He/she did not remember the exact dates, but they were within the last two weeks. One time the resident tried to go out the front doors (South Hall) and the second time he/she tried to go out the doors close to the resident's room at 3:00 A.M.; - Did not report the resident's attempts to elope, because it was not his/her business and he/she thought staff knew; - On 10/8/21, Resident #1 and he/she did come back in the building to get cigarettes during the 7:00 A.M. smoke break, but when he/she turned around, Resident #1 was gone. During an interview on 10/9/21 at 9:15 A.M., the Administrator said: - She received a call around 4:13 A.M. on 10/8/21, from LPN C who reported the resident walked to the hospital; - The resident had gotten mad, because LPN A had refused to light a cigarette for him/her. - The police brought the resident back to the facility and staff put him/her on 15 minute checks; - The resident went outside around 7:00 A.M. in the courtyard for the scheduled smoke time that was supervised by staff; - At some point between shift change, a fall occurring, report being given, and getting residents in to the dining room for breakfast, the resident left again. No staff witnessed the resident leaving; the facility then received a call that the resident was walking toward the hospital. LPN C and LPN D went to meet him/her. The resident had a one inch metal pipe he/she was doing [NAME] arts with that he/she said he/she found in a ditch. The resident was adamant about going to the hospital. The resident walked to the hospital with staff and returned via police escort and was put on 1:1; - She was not aware of any alarms for either incident of elopement; - She was not aware of any other attempts to elope. During an interview on 10/9/21 at 11:50 A.M., the Administrator said: - LPN C put the resident on 1:1 then stepped down to 15 minute checks on 10/8/21. 15 minute checks were typical practice after an elopement, so LPN C went above what was typical practice; - The facility did not have other residents in the facility at risk for elopement. - Some residents wander around the facility, but no one who would actually leave. During a phone interview on 10/14/21 at 3:50 P.M., Agency CNA A said: - He/she worked the night Resident #1 eloped from the facility; - He/she was in a room changing a resident when he/she heard an alarm, he/she ran out of the room to the West Hall double doors where the alarm was going off. He/she did not see anything or anyone around so he/she tried to reset the alarm, but could not do it so Agency CNA D reset the alarm (shut it off). He/she then asked Agency CNA C if he/she knew where Resident #1 was because the resident wandered around the facility and caused trouble. Agency CNA C said the resident was in his/her room. No one checked the resident at that time. He/she was not sure what time this was, but it was during the early hours of the morning; - He/she finished doing rounds and got a call that the resident was at the hospital; - The resident came back to the facility between 5:00 A.M. and 6:00 A.M. and he/she was assigned to the resident for 1:1; - The resident bragged about leaving the facility saying I got you guys in trouble and I am going to get you in trouble again; the resident was completely unstable; it was a game to the resident. - He/she left the resident with the charge nurse and aide (he/she did not know names) on the South hall around five to ten minutes after 6:00 A.M. and left; - No one told him/her that the resident was an elopement risk and he/she was not aware of any previous attempts to elope. During a phone interview on 10/20/21 at 3:26 P.M., Agency CNA D said: - He/she worked at the facility the on the night shift the night Resident #1 eloped from the facility; - He/she had seen the resident come up the center hall and heard the resident hit a door and assumed it was the door leading out to the courtyard; - Went in to another resident's room on the same hall to provide care. When he/she left the room, he/she heard a door alarm going off, it was the exit door (not to the enclosed courtyard) closest to Resident #1's room. He/she saw Agency CNA A trying to put in the code to shut off the alarm, but was not putting in the correct code, so he/she (CNA D) put the correct code in to shut off the alarm; - Asked Agency CNA A and Agency CNA C where Resident #1 was. Agency CNA C said the resident was in his/her bedroom so he/she went back to work; - Resident #1's demeanor was aggressive and he/she had been making comments about leaving throughout that shift. During a phone interview on 10/14/21 at 4:38 P.M., Agency CNA C said: - He/she worked the night shift when Resident #1 eloped the first time; - The resident was always walking around, agitated, and banging stuff; - Sometimes the doors did not act right, they would only beep one time. He/she did not hear a beep that morning, he/she heard a boom; Agency CNA D and Agency CNA A heard the boom too; - No one checked the resident's room, because the resident was constantly going in and out of his/her room; - The resident was supposed to be on 15 minute checks that morning, but the DON said the night before just to keep an eye on the resident; - Staff receive report from the off going staff, but it was not always correct; - He/she was not aware of any other elopement attempts; - The resident was constantly wandering in to other resident rooms. During an interview on 10/9/21 at 8:35 A.M., LPN C said: - He/she was the night charge nurse when the resident eloped the first time on 10/8/21; - He/she saw the resident walking down the hallway towards the South Nurses' Station. The resident was mad; he/she hit a door hard enough the alarm sounded, but the resident did not go out. That was the last time he/she saw the resident; - He/she received a call a little after 4:00 A.M. from the police that the resident was at the hospital; - The police brought the resident back and he/she placed the resident on 15 minute, physical sight, checks. At that time, he/she had an extra staff member so he/she put the resident on 1:1 at that time; - When the day shift came in, the extra staff member Agency CNA A left around 6:30 A.M. to 6:45 A.M., he/she stepped down the 1:1 to 15 minute checks, because he/she did not have the staff to continue the 1:1; - The staff working on the West hall were responsible for completing the 15 minute checks. - Shift change was at 6:30 A.M., staff start getting residents up for breakfast at this time; - Right after the residents' smoke break, around 7:00 A.M. to 7:15 A.M., he/she was notified by an aide (did not remember who) and the Business Office Staff notified him/her that the resident had left the building again. He/she thought the aide actually saw the resident leave the facility; - He/she and LPN D (the oncoming charge nurse) were doing report when he/she was notified the resident had left the facility. He/she and LPN D left the facility to try to find the resident; - They found the resident by Hy-[NAME]; - He/she was not aware of any prior incident where the resident attempted to elope. During a phone interview on 10/13/21 at 4:10 P.M., LPN C said: - He/she signed the 15 minute check forms; - He/she was the charge nurse on duty so he/she and the aides on duty were completing the 15 minute checks and he/she signed the 15 minute check form; - The incident on 10/5/21 noted in the nurses' notes Resident #2 and a staff member (did not remember who) told him/her that the resident was trying to leave the facility. He/she went to talk to the resident who said he/she was just frustrated; - He/she did not specifically remember calling the DON or Administrator regarding the incident on 10/5/21 or 10/7/21. Typically with an incident like this, he/she would either call the DON or Administrator or print off the nurse note regarding the incident and give it to the DON or Administrator. He/she told all the aides and nurses in the facility at that time to just keep an eye on the resident; - On 10/7/21, he/she printed off the nurse note and gave it to the Administrator. He/she told all the aides and nurses in the facility to just keep an eye on the resident. There was several times he/she called the DON at night regarding the resident's behaviors, but did not remember if this was one of them; - He/she was not aware of any other incidents of the resident trying to elope. During an interview on 10/9/21 at 10:26 A.M. LPN C said: - He/she and the DON decided to put the resident on 1:1 when he/she returned to the facility following the first elopement. He/she made the decision to step it down to 15 minute checks, because he/she lost the additional staff; - The resident was walking around and calm and did not appear agitated when he/she stepped down 1:1 to 15 minute checks; - She did not discuss with the DON stepping down 1:1 to 15 minute checks. During a phone interview on 10/9/21 at 10:32 A.M., LPN D said: - He/she came into the facility for shift change and was doing report with LPN C on the morning of 10/8/21(after the first elopement); - He/she thought a housekeeper had seen the resident leave the facility (the second elopement), he/she thought Housekeeper A or another housekeeper (could not remember the staff's name), but said more than one staff were running down the hall saying that the resident had left; - He/she and LPN C left the facility and found the resident on the same side of the road and walked with the resident to the hospital; - The resident had been saying for awhile that he/she wanted out of the facility, but he/she had not tried to elope that he/she was aware of; - LPN C told staff at shift change that the resident was supposed to be on 1:1. During an interview on 10/13/21 at 11:45 A.M., CNA A said: - He/she came to the facility on [DATE] at around 6:00 A.M. and got report that the resident had eloped around 3:00 A.M.; - At that time, the resident was on 1:1 with Agency CNA A; - Agency CNA A came off duty at around 6:00 A.M.; - He/she was told the resident was supposed to be on 1:1 by the night nurse (LPN C) and the aides on the night shift, but no one said who was assigned to the resident once Agency CNA A left; - He/she began getting residents up for breakfast. Once he/she got the residents up, he/she told Agency CNA B that he/she was going to go check on the resident. He/she could not find the resident after checking the resident's room and hallways; - Business Office Staff came running down the hall and said the resident had left the building. He

Based on record review and interview, the facility failed to provide adequate supervision for one resident (Resident #1), when the facility staff failed to implement interventions on 10/5/21 and 10/7/21 after the facility staff noted the resident displayed exit seeking behaviors and attempting to exit the facility unsupervised. On 10/8/21, at approximately 3:00 A.M., the facility was notified by the local hospital that the resident was at the hospital. The resident returned to the facility at 5:10 A.M. by the local police department. The resident was placed on one-on-one (1:1) supervision at that time. The facility failed to ensure staff carried out 1:1 interventions after the first elopement when the day shift staff did not continue the 1:1 supervision after 6:00 A.M. which resulted in the resident eloping the facility again later that same day. The resident was last seen by staff at 7:00 A.M. on 10/8/21 and the facility was notified by a private citizen the resident was seen walking along a busy State highway at approximately 7:35 A.M. to 7:45 A.M. and was found between the facility and the hospital on the opposite side of the road of the facility. The facility census was 63. The Administrator was notified on 10/15/21 at 3:45 P.M. of an Immediate Jeopardy (IJ) which began on 10/8/21. The IJ was removed on 10/19/21, as confirmed by surveyor onsite verification. Review of the undated facility policy titled Elopement, Response to Suspected Code Silver showed the following: - The following individual may have responsibility for preventing resident elopement specific to state professional licensing requirement, registered nurse (RN), licensed practical nurse (LPN), certified medication technician (CMT), certified nurse aide (CNA); - Elopement for the purpose of this policy and procedure, is defined as a situation where a resident with impaired decision-making ability, who is oblivious to his/her own safety needs and therefore at risk for injury outside the confines of the facility, has left the facility without knowledge of the staff; - This definition of elopement does not include a resident who is at risk for elopement but whose exit from the facility is known to staff, who are responding to the exit; - Furthermore, the definition of elopement does not include residents: o Who is not a risk for elopement due to their cognitive abilities; o Who leave the facility with the intent to return within a short period of time (for example, within approximately two hours); o Who have ability to leave and return safely; o Residents who fit this description are requested to sign in and out or in some similar manner, to let staff know of their departure and anticipation time of return; - The purpose of this elopement policy is to: o Identify residents at risk for elopement; o Protect residents that are not capable of protecting themselves; o Provide the techniques and equipment to minimize safety risks; - A specific system has been developed to notify staff that an external door has been opened in an area accessible to residents; - Door alarms are tested each shift at least once a month. The results of the test are then recorded; - When found, assess for injuries and document. Make sure a plan has been developed to ensure protective oversight; - Notify all in search that the resident has returned, call family/responsible party and Medical Director; - The care plan is to be revised by the Minimum Data Set (MDS) Coordinator or designee to include further preventative interventions to prevent reoccurrence; - DON or designee to in-service staff on plan of care implemented within 48 hours of incident and addressed to all personnel involved in direct care of the resident and alerting non-nursing staff to precautions and elopement policy and procedure; - The Department of Health and Senior Services (DHSS) may be notified if there is reason to believe the resident is likely to be in harm or danger. Review of the undated facility policy titled Resident Elopement showed the following: - The facility provides 24-hour protective oversight and maintains the quality of life for each resident; - The pre-admission screening process should thoroughly evaluate the potential resident's wandering or hiding risk. This information is gathered from the family, physician, social worker, friends, hospital staff, facility staff, general observation and information on pre-screening tools; - If during the preadmission screening, a resident is classified as an elopement risk, place in the locked unit. If your facility does not have a locked unit, give the family a list of area facilities that have locked units and assist them with placement at the facility of their choice; - If a resident is admitted with no previous elopement potential, but verbalizes or attempted to leave the facility, the following criteria should be followed: o Evaluate the resident to see if they meet the criteria for a locked unit (if your facility has one); o Director of Nursing (DON) must notify the resident's physician as soon as possible; o Have the Social Services Director (SSD) notify the resident's family for assistance and information; o Address the potential in a care plan and implement the interventions list on the care plan; o Place resident in a room that is in the line of sight of the nurses' station; o Instruct one certified nurse aide (CNA) per shift in the care of the resident. The CNA must observe the resident at all times, but especially during meal times, medication administration times, scheduled activities of daily living (ADLs), every time the door alarm sound, and as indicated by the care plan. The charge nurse must indicate on the assignment sheet which CNA is responsible; o When a resident is observed attempting to leave the premises, facility should implement the following actions immediately: - Attempt to prevent departure; - Should the attempt to intercept fail, obtain assistance from other staff members in the immediate area; - Instruct another staff member to inform the charge nurse, DON, or Administration that the resident is attempting to leave the facility; - Be courteous in preventing the departure and in returning the resident to the facility; - Document in the resident's records the wandering behavior, including immediate prevention measures. Also document interventions initiated to prevent this from happening again; - Notify the attending physician and legal representative or family member. 1. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 3/30/21, showed: - admitted [DATE]; - Diagnoses included non-traumatic [CONDITION(S)], manic depression; [CONDITION(S)]. - Brief Interview for Mental Status (BIMS, structured evaluation aimed at evaluating aspects of cognition in elderly patients), score of 15 out of 15, which indicated no cognitive impairment; - Independent with mobility; - Wandering behavior not exhibited. Review of Resident #1's medical record showed the facility did not have a PASRR screening on file for the resident, although the resident had diagnoses of a mental disorder. Review of Resident #1's Level II PASARR screening, conducted on 9/29/20, signed by the assessor on 10/5/20, and obtained from Central Office Medical Review Unit (COMRU) on 10/14/21, showed: - He/she required nursing facility placement due to severely impaired judgement/insight. He/She was unable to make reasonable judgements about the importance of medication compliance and follow up with psychiatry. - He/she required around the clock supervision and oversight to assure he/she and others are safe. - He/she required a secured environment to prevent elopement due to impulsivity and severe lack of judgement. Review of the resident's admission elopement assessment, dated 3/23/21, showed staff indicated the resident was not at risk of wandering or elopement. There were no other elopement assessments in the resident's medical records. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 6/28/21, showed: - Diagnoses included non-traumatic [CONDITION(S)], manic depression; [CONDITION(S)]. - Brief Interview for Mental Status (BIMS, structured evaluation aimed at evaluating aspects of cognition in elderly patients), score of 15 out of 15, which indicated no cognitive impairment; - Independent with mobility - Wandering behavior not exhibited Review of the resident's nurses notes showed the following: - Notes regarding the resident's behavior changes began on 9/20/21 - Behavioral issues with the resident were documented on the following days: 9/20/21, 9/21/21, 9/22/21, 9/23/21, 9/24/21, 9/25/21, 9/26/21, 9/27/21, 9/29/21, 9/30/21, 9/30/21, 10/1/21, 10/2/21, 10/3/21, 10/4/21, 10/5/21, 10/6/21, 10/7/21, 10/8/21; - The behaviors documented during the dates listed above included attempting to elope from the facility, actually eloping from the facility, making sexual comments to staff, physically grabbing staff, hitting exit doors, swallowing a lit cigarette (10/5/21), demanding staff to call the sheriff, cussing at staff, threatening staff, not sleeping and wandering the facility at night, rearranging furniture in the hallway, walking in to resident rooms uninvited, including the opposite sex (10/3/21), refusing medications (10/2/21), talking to other residents inappropriately (9/30/21), ideation of self-harm (9/30/21) hearing voices (9/29/21), walking throughout the facility and courtyard barefooted, becoming quickly agitated, calling the police, delusions of being in the special forces (9/26/21), mind racing; - Nurse note dated 9/24/21 stated the resident was sent to the hospital on 9/24/21 for a psychiatric evaluation, but returned to the facility on the same day with additional medication orders and a note for the resident to have a psychiatric evaluation as soon as possible or the next week; - Nurse note, dated 9/30/21, stated the resident was sent to the hospital for evaluation and treatment with regard to hearing voices and plans to harm him/herself, the resident returned to the facility later on 9/30/21 with new medication orders; - Nurse note, dated 10/3/21, stated the resident was sent to the hospital to be treated for psychiatric behaviors per the resident's request and returned to the facility on [DATE]. The note indicated it was recommended the resident have different placement and to see a counselor. Review of the resident's significant change in condition Minimum Data Set (MDS), a federally mandated assessment tool completed by the facility staff, dated 9/28/21, showed the following: - Cognitively intact; - There was evidence of an acute change in mental status from the resident's baseline with inattention (difficulty focusing attention), and disorganized thinking indicated; - The resident had delusions, verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed toward others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds); - The behavioral symptoms put the resident at significant risk for physical illness or injury, significantly interfered with the resident's care, significantly interfered with the resident's participation in activities or social interactions, put others at significant risk for physical injury, significantly intruded on the privacy or activities of others, and significantly disrupted care or living environment; - Wandering was indicated, occurring daily. The impact of wandering indicated the wandering placed the resident at significant risk of getting to a potentially dangerous place and it significantly intruded on the privacy or activities of others. The behavior was indicated that it had gotten worse compared to prior MDS assessments. Review of the resident's care plan, dated 10/4/21, showed staff did not include any information regarding the resident wandering or being an elopement risk or any attempts the resident had made to elope from the facility as indicated in the nurses notes and MDS assessment. During an interview on 10/13/21 at 4:10 P.M., the DON said: - She did not see any quarterly elopement assessments for Resident #1; - The charge nurse on duty completes the clinical admission, including required assessments at the time of admission. The MDS Coordinator was responsible to complete quarterly assessments and significant change assessments. During an interview on 10/13/21 at 4:41 P.M., the MDS Coordinator said she: - Had been the MDS Coordinator since September. - Completed an elopement assessment at admission and quarterly; - Thought the nurses do the admission and quarterly assessments, but she had done some; - Did not know if there were any quarterly elopement assessments completed for the resident. Review of the resident's nurses' notes showed the following: - 10/5/21 at 2:09 A.M., note by MDS Coordinator, said he/she was notified from a CNA that the resident was talking about breaking glass and leaving through the doors. The note did not indicate any further interventions were put in place at the time or that the DON, Administrator, physician, or guardian being notified of the incident. - 10/5/21 at 3:55 A.M., the police came to talk to the resident on 10/5/21 per the guardian's request when the guardian called the facility after the resident called him/her around 3:30 A.M. yelling and cussing at him/her to have him/her removed from the facility that night. The resident was not taken to the hospital at that time. - 10/5/21 at 3:55 A.M., note by LPN C, aides and another resident reported to him/her that the resident was trying to get out the doors. The note did not indicate staff put any further interventions in place at that time or that the DON, Administrator, physician, or guardian being notified of the incident. Review of the 15 Minute Resident Check document for the resident, dated 10/5/21, showed the following: - At 2:00 A.M. staff noted the resident was threatening to elope (initialed by Agency CNA E). - At 2:30 A.M. staff documented the resident was trying to leave the facility (initialed by Agency CNA E). -At 2:45 A.M. staff documented the resident was trying to leave the facility (initialed by Agency CNA F). - At 3:00 A.M. staff documented the resident was trying to leave the facility (initialed by Agency CNA E). - There were no other 15 minute checks in the medical record between 10/5/21 and 10/8/21 when the resident returned from the first elopement. During a phone interview on 10/28/21 at 3:43 P.M., Agency CNA E said he/she: - Had worked at the facility since December 2020; - The resident had a definite behavior change three weeks before the resident eloped. The resident became more paranoid about his/her room, had erratic behavior, was not sleeping, was talking and not making a lot of sense and going in to others' rooms uninvited; - Thought the resident had been on 15 minute checks for a couple days after being sent to the hospital; he/she kept up with the 15 minute checks until he/she was told by the charge nurse that he/she could stop; he/she found out later than he/she could have stopped after 24 hours; - Thought the resident was on 15 minute checks, because he/she wanted to leave; - On 10/5/21, the resident said he/she wanted to leave and was going to leave one way or the other. He/she thought the resident was taken to the hospital that night, with a police escort due to his/her behaviors; - The resident was trying to leave the facility on the 10/5/21; he/she pushed on two different doors and set off the alarms. He/she reported it to the charge nurse, but could not remember who the charge nurse was; - Report was received from the day shift by a written report from the hall, but it depended on how busy the day shift was if there was anything written, but they also receive verbal report. During a phone interview on 10/29/21 at 2:53 P.M., Agency CNA F said: - The resident was on 15 minute checks on 10/5/21, because he/she was going to hurt him/herself either that day or the day prior. The resident had been sent to the hospital and when he/she returned, he/she was put on 15 minute checks; - On 10/5/21 the resident was actively pushing on an exit door to leave the facility, but could not because the door was locked and needed a code. He/she reported this to the nurse (he/she believed it was LPN C). He/she was not aware of an incident prior to that when the resident attempted to elope. Review of the resident's nurse notes showed the following: - 10/7/21 at 2:10 A.M., LPN C indicated the resident went through one door towards South Hall and when the aides went to the South Hall the resident attempted to leave the facility through the South entrance. The note did not indicate any further interventions put in place at that time or that the DON, Administrator, physician, or guardian have been notified of the incident; - 10/8/21 at 3:30 A.M., LPN C noted the resident was upset and walking down 500 hall, the resident hit the door on the transition door to outside, then turned and walked towards South Hall; - 10/8/21 at 4:10 A.M., LPN C wrote the South Charge Nurse (LPN A) notified him/her the police called and stated the resident was at the hospital in the town; DON and Administrator were notified; - 10/8/21 at 5:10 A.M., LPN C noted the resident returned to the facility via police escort. Resident was placed on 15 minute physical sight checks and 1:1 person at this time. All staff educated to help ensure the resident was safe and in the building. The resident said he/she was (mad) so he/she went to the hospital and called the police. The resident was pacing around the facility with CNA walking with him/her. Review of the 15 Minute Resident Check document for the resident, dated 10/8/21, showed the following: - Staff began 15 minute checks at 5:10 A.M. (when the resident returned from the first elopement); - LPN C signed off at each 15 minute increment beginning with 5:15 A.M., after the resident returned, through 8:30 A.M., when the resident returned the second time. - At 5:15 A.M., 5:30 A.M., and 5:45 A.M. the document indicated the resident was on 1:1. - At 6:00 A.M. and 6:15 A.M., staff indicated the resident was in the 500 hallway, but did not indicate 1:1. - At 6:30 A.M., staff indicated the resident was on South Hall and on 1:1. - From 6:45 A.M. to 7:00 A.M., staff indicated the resident was in the courtyard, smoking. - From 7:15 A.M. to 8:15 A.M., staff indicated the resident was out of the facility (OOF). - At 8:30 A.M. staff indicated the resident returned to the facility. Review of the resident's nurse notes showed the following: -10/8/21 at 8:30 A.M., LPN D noted around 7:00 A.M. the resident was reported to be leaving out of the door. LPN D and the night nurse (LPN C) followed, the resident left the grounds and was on the road by the facility. The resident went to the emergency room and asked to make a physician's appointment. Resident was placed on 1:1 at the time of returning. During a phone interview on 10/15/21 at 1:54 P.M., Resident #1 said: - He/she had watched staff coming in and out the doors; - Staff made him/her mad because they would not light a cigarette and then he/she found out he/she did not have any cigarettes. He/she left through the doors by his/her room the first time he/she left the facility. He/she went to Hy-[NAME] and got in the dumpster, then walked to the hospital. No one knew he/she was gone for two hours; - The second time he/she left the facility through the front doors. LPN A and LPN B were counting medications at the front (South) nurse station. The resident asked LPN A for cigarettes and LPN A told the resident he/she would have to wait until they were done counting medications. The resident thought that by the time he/she got his/her cigarettes, smoke time would be over. LPN A told the resident why don't you just leave like last night, the resident said Really? and LPN B said I do not have to put up with your[OBSCENITY] The resident left out the front doors, went to a service station across the street from the facility and told the man working that he/she just left the facility. The man looked busy so the resident left the service station, found a stick, then went to Hy-[NAME] and told them what he/she did earlier that morning. Staff caught up with him/her half way to the hospital. He/she would have made it to the hospital if he/she would not have stopped at the service station and Hy-[NAME]; - He/she did not tell anyone he/she was leaving; - Both times he/she left the facility, he/she put pressure on the doors, they beeped and unlocked. The resident indicated the doors did alarm. Review of Resident #2's quarterly MDS dated [DATE] showed the following: - Cognitively intact. During an interview on 10/14/21 at 1:07 P.M., Resident #2 said he/she: - He/She was friends with Resident #1. They spoke frequently and smoked together; - He/She witnessed Resident #1 attempting to leave the facility on two occasions. He/she did not remember the exact dates, but they were within the last two weeks. One time the resident tried to go out the front doors (South Hall) and the second time he/she tried to go out the doors close to the resident's room at 3:00 A.M.; - Did not report the resident's attempts to elope, because it was not his/her business and he/she thought staff knew; - On 10/8/21, Resident #1 and he/she did come back in the building to get cigarettes during the 7:00 A.M. smoke break, but when he/she turned around, Resident #1 was gone. During an interview on 10/9/21 at 9:15 A.M., the Administrator said: - She received a call around 4:13 A.M. on 10/8/21, from LPN C who reported the resident walked to the hospital; - The resident had gotten mad, because LPN A had refused to light a cigarette for him/her. - The police brought the resident back to the facility and staff put him/her on 15 minute checks; - The resident went outside around 7:00 A.M. in the courtyard for the scheduled smoke time that was supervised by staff; - At some point between shift change, a fall occurring, report being given, and getting residents in to the dining room for breakfast, the resident left again. No staff witnessed the resident leaving; the facility then received a call that the resident was walking toward the hospital. LPN C and LPN D went to meet him/her. The resident had a one inch metal pipe he/she was doing [NAME] arts with that he/she said he/she found in a ditch. The resident was adamant about going to the hospital. The resident walked to the hospital with staff and returned via police escort and was put on 1:1; - She was not aware of any alarms for either incident of elopement; - She was not aware of any other attempts to elope. During an interview on 10/9/21 at 11:50 A.M., the Administrator said: - LPN C put the resident on 1:1 then stepped down to 15 minute checks on 10/8/21. 15 minute checks were typical practice after an elopement, so LPN C went above what was typical practice; - The facility did not have other residents in the facility at risk for elopement. - Some residents wander around the facility, but no one who would actually leave. During a phone interview on 10/14/21 at 3:50 P.M., Agency CNA A said: - He/she worked the night Resident #1 eloped from the facility; - He/she was in a room changing a resident when he/she heard an alarm, he/she ran out of the room to the West Hall double doors where the alarm was going off. He/she did not see anything or anyone around so he/she tried to reset the alarm, but could not do it so Agency CNA D reset the alarm (shut it off). He/she then asked Agency CNA C if he/she knew where Resident #1 was because the resident wandered around the facility and caused trouble. Agency CNA C said the resident was in his/her room. No one checked the resident at that time. He/she was not sure what time this was, but it was during the early hours of the morning; - He/she finished doing rounds and got a call that the resident was at the hospital; - The resident came back to the facility between 5:00 A.M. and 6:00 A.M. and he/she was assigned to the resident for 1:1; - The resident bragged about leaving the facility saying I got you guys in trouble and I am going to get you in trouble again; the resident was completely unstable; it was a game to the resident. - He/she left the resident with the charge nurse and aide (he/she did not know names) on the South hall around five to ten minutes after 6:00 A.M. and left; - No one told him/her that the resident was an elopement risk and he/she was not aware of any previous attempts to elope. During a phone interview on 10/20/21 at 3:26 P.M., Agency CNA D said: - He/she worked at the facility the on the night shift the night Resident #1 eloped from the facility; - He/she had seen the resident come up the center hall and heard the resident hit a door and assumed it was the door leading out to the courtyard; - Went in to another resident's room on the same hall to provide care. When he/she left the room, he/she heard a door alarm going off, it was the exit door (not to the enclosed courtyard) closest to Resident #1's room. He/she saw Agency CNA A trying to put in the code to shut off the alarm, but was not putting in the correct code, so he/she (CNA D) put the correct code in to shut off the alarm; - Asked Agency CNA A and Agency CNA C where Resident #1 was. Agency CNA C said the resident was in his/her bedroom so he/she went back to work; - Resident #1's demeanor was aggressive and he/she had been making comments about leaving throughout that shift. During a phone interview on 10/14/21 at 4:38 P.M., Agency CNA C said: - He/she worked the night shift when Resident #1 eloped the first time; - The resident was always walking around, agitated, and banging stuff; - Sometimes the doors did not act right, they would only beep one time. He/she did not hear a beep that morning, he/she heard a boom; Agency CNA D and Agency CNA A heard the boom too; - No one checked the resident's room, because the resident was constantly going in and out of his/her room; - The resident was supposed to be on 15 minute checks that morning, but the DON said the night before just to keep an eye on the resident; - Staff receive report from the off going staff, but it was not always correct; - He/she was not aware of any other elopement attempts; - The resident was constantly wandering in to other resident rooms. During an interview on 10/9/21 at 8:35 A.M., LPN C said: - He/she was the night charge nurse when the resident eloped the first time on 10/8/21; - He/she saw the resident walking down the hallway towards the South Nurses' Station. The resident was mad; he/she hit a door hard enough the alarm sounded, but the resident did not go out. That was the last time he/she saw the resident; - He/she received a call a little after 4:00 A.M. from the police that the resident was at the hospital; - The police brought the resident back and he/she placed the resident on 15 minute, physical sight, checks. At that time, he/she had an extra staff member so he/she put the resident on 1:1 at that time; - When the day shift came in, the extra staff member Agency CNA A left around 6:30 A.M. to 6:45 A.M., he/she stepped down the 1:1 to 15 minute checks, because he/she did not have the staff to continue the 1:1; - The staff working on the West hall were responsible for completing the 15 minute checks. - Shift change was at 6:30 A.M., staff start getting residents up for breakfast at this time; - Right after the residents' smoke break, around 7:00 A.M. to 7:15 A.M., he/she was notified by an aide (did not remember who) and the Business Office Staff notified him/her that the resident had left the building again. He/she thought the aide actually saw the resident leave the facility; - He/she and LPN D (the oncoming charge nurse) were doing report when he/she was notified the resident had left the facility. He/she and LPN D left the facility to try to find the resident; - They found the resident by Hy-[NAME]; - He/she was not aware of any prior incident where the resident attempted to elope. During a phone interview on 10/13/21 at 4:10 P.M., LPN C said: - He/she signed the 15 minute check forms; - He/she was the charge nurse on duty so he/she and the aides on duty were completing the 15 minute checks and he/she signed the 15 minute check form; - The incident on 10/5/21 noted in the nurses' notes Resident #2 and a staff member (did not remember who) told him/her that the resident was trying to leave the facility. He/she went to talk to the resident who said he/she was just frustrated; - He/she did not specifically remember calling the DON or Administrator regarding the incident on 10/5/21 or 10/7/21. Typically with an incident like this, he/she would either call the DON or Administrator or print off the nurse note regarding the incident and give it to the DON or Administrator. He/she told all the aides and nurses in the facility at that time to just keep an eye on the resident; - On 10/7/21, he/she printed off the nurse note and gave it to the Administrator. He/she told all the aides and nurses in the facility to just keep an eye on the resident. There was several times he/she called the DON at night regarding the resident's behaviors, but did not remember if this was one of them; - He/she was not aware of any other incidents of the resident trying to elope. During an interview on 10/9/21 at 10:26 A.M. LPN C said: - He/she and the DON decided to put the resident on 1:1 when he/she returned to the facility following the first elopement. He/she made the decision to step it down to 15 minute checks, because he/she lost the additional staff; - The resident was walking around and calm and did not appear agitated when he/she stepped down 1:1 to 15 minute checks; - She did not discuss with the DON stepping down 1:1 to 15 minute checks. During a phone interview on 10/9/21 at 10:32 A.M., LPN D said: - He/she came into the facility for shift change and was doing report with LPN C on the morning of 10/8/21(after the first elopement); - He/she thought a housekeeper had seen the resident leave the facility (the second elopement), he/she thought Housekeeper A or another housekeeper (could not remember the staff's name), but said more than one staff were running down the hall saying that the resident had left; - He/she and LPN C left the facility and found the resident on the same side of the road and walked with the resident to the hospital; - The resident had been saying for awhile that he/she wanted out of the facility, but he/she had not tried to elope that he/she was aware of; - LPN C told staff at shift change that the resident was supposed to be on 1:1. During an interview on 10/13/21 at 11:45 A.M., CNA A said: - He/she came to the facility on [DATE] at around 6:00 A.M. and got report that the resident had eloped around 3:00 A.M.; - At that time, the resident was on 1:1 with Agency CNA A; - Agency CNA A came off duty at around 6:00 A.M.; - He/she was told the resident was supposed to be on 1:1 by the night nurse (LPN C) and the aides on the night shift, but no one said who was assigned to the resident once Agency CNA A left; - He/she began getting residents up for breakfast. Once he/she got the residents up, he/she told Agency CNA B that he/she was going to go check on the resident. He/she could not find the resident after checking the resident's room and hallways; - Business Office Staff came running down the hall and said the resident had left the building. He/she told Business Office S

Based on observations, interviews, and record review, the facility failed to follow their policy for change in condition and physician notification for one resident (Resident #1) when the resident fell and sustained a fracture. The facility failed to notify the physician until the next morning and did not send the resident for x-rays and evaluation until 24 hours after the fall. This had the potential to affect all residents who are at risk for falls. The facility census was 57. Review of the facility's policy for resident change of condition dated 3/15 showed: -Purpose to observe, record and report any condition change to the attending physician so that proper treatment can be implemented; -After all resident falls, injuries or changes in physical or mental function, monitor for swelling, discoloration, and pain; -Notify the attending physician, the physician on call or the medical director; -Monitor the resident's condition. 1. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by staff dated 1/5/17 showed: -Unable to make decisions; -Transfers with extensive assistance of two staff members; -Uses a wheelchair with the assistance of one staff member; -No history of falls. Review of the facility's event report for a fall dated 1/30/17 at 6:27 P.M. showed: -Location of the fall was in the main dining room; -Resident exhibited pain to both knees; -Right knee red, bump below the right knee; -Range of motion (ROM) limited in lower extremity; -Resident alert and perceives the environment clearly and responds appropriately to stimuli; -Resident responds to name, pain and environment; -Immediate measures taken were [MEDICATION NAME], cold and elevate the affected extremity. Review of the nurse's note dated 1/30/17 at 6:27 P.M. showed: -Resident observed in the main dining room coming out of the wheelchair onto the floor. Resident assisted from the floor by mechanical lift back into the wheelchair then into bed. Right knee red, bump noted under right knee. Knee elevated and ice applied. PRN (as needed) pain pill given as ordered. During an interview on 2/9/17 at 1:55 P.M. Nurse Aide (NA) A said: -The resident was sitting in a high back wheelchair and he/she could not see the resident; -He/she was pushing the resident out of the dining room when he/she heard the resident scream; -He/she walked around the chair and saw the resident on the floor with his/her knees bent; -He/she did not see the resident fall out of the wheelchair; -The foot pedals were on the wheelchair, but the wedge for the wheelchair pedals were not on the chair or the foam support for the back of the knees were not on the wheelchair; -The resident yelled to get him/her off the floor; -Three staff members got the resident off the floor using a mechanical lift; -The resident did not complain of pain as the staff were getting him/her off the floor; -Once the resident was in bed, the resident complained of severe pain to his/her knee and lower leg; -The resident had a bump the size of a quarter below the knee cap; -The resident continued to complain of pain the rest of his/her shift; -The area to the right knee was red and warm to touch. During an interview on 2/10/17 at 11:20 A.M. Certified Nurse Aide (CNA) A said: -He/she worked the evening shift on 1/30/17 and assisted NA A to put the resident to bed after the fall; -The resident complained of pain when he/she was being transferred to the bed. Review of the fax communication from the facility to the physician dated 1/30/17 showed: -Resident was observed in the wheelchair falling down out of the chair to the floor in the main dining room. Right knee red, bump below the knee. Ice applied and elevated. PRN pain pill given as ordered. Will monitor. -No physician's orders; -No confirmation of the fax communication to the physician. Review of the Medication Administration Record [REDACTED].M. for complaints of knee pain. Review of the nurses' notes dated 1/30/17 at 10:55 A.M. recorded as a late entry on 2/2/17 at 11:12 A.M. signed by Licensed Practical Nurse (LPN) B showed: -In regards to the resident fall on this date, this writer was the night charge nurse from 6:30 P.M. until 6:30 A.M. on 1/31/17. The resident was monitored related to swelling to the right leg just below the knee. The resident complained of pain only when the leg was moved. Scheduled [MEDICATION NAME] (a narcotic pain medication) was administered at 10:00 P.M., then PRN [MEDICATION NAME] (a narcotic pain medication)was administered at 1:20 A.M. and 6:15 A.M. on 1/31/17. Resident swelling increased through the night with ice initially. Resident was moved side to side at bed checks and did complain of pain with movement. It was this writers opinion that the resident should be seen by the physician and this was passed along to the day shift nurse on 1/31/17. During a telephone interview on 2/9/17 at 2:40 P.M. LPN B said: -He/she came on duty at 6:30 P.M. on 1/30/17 and was told that the resident had slid out of the wheelchair and had a bump to the lower right knee; -He/she assessed the right leg at 8:00 P.M. and the leg was swollen and the resident complained of pain. He/she gave the resident the scheduled pain medication; -The resident was given pain medication at 1:00 A.M. on 1/31/17 and again at 6:00 A.M. for complaints of pain in the right leg; -The swelling in the right leg got worse throughout the night; -The resident would yell out in pain when the right leg was touched; -He/she passed this information to the day shift nurse; -He/she did not notify the physician of the increase in swelling or pain. Review of the MAR indicated [REDACTED].M. for complaint of right leg pain. Review of the nurses notes dated 2/2/17 at 6:20 P.M. as a late entry signed by LPN A showed: -This writer arrived on shift what date and report ended at 7:30 A.M. This writer assessed the residents leg related to a fall on 1/30/17, compared to assessment on the 30th, the residents leg looked better. Resident denied pain or discomfort at this time. Leg was slightly swollen and bruised on the right lower part. Writer felt swelling around the leg. This writer immediately called the residents primary physician office at 8:00 A.M. and spoke with the physician's nurse. Physician ordered an x-ray of the right hip, knee and ankle related to the fall on 1/30/17. Order for the x-ray given to the Business Office Manager for scheduling. During a telephone interview on 2/9/17 at 2:15 P.M. LPN A said: -He/she worked the day shift on 1/31/17; -The night shift nurse reported that the resident fell on [DATE] and had been in a lot of pain; -The resident's primary physician was called at 8:00 A.M. and informed of the fall with pain, redness and swelling; -Orders were received to send the resident to the hospital for x-rays; -The resident complained of pain when the leg was touched; -The right leg was swollen with bruising; -The orders for the x-ray was communicated to the Administrator and Director of Nursing (DON); -The facility van was unavailable until late in the afternoon. During an interview on 2/10/17 at 11:40 A.M. CNA B said: -He/she took care of the resident on the day shift on 1/31/17; -The resident yelled out in pain when the leg was touched or when he/she was rolled side to side; -The resident's right leg was swollen and warm to touch. Move this up to be in chronological order During an interview on 2/10/17 at 12:30 P.M. CNA C said: -He/she took care of the resident on the day shift on 1/31/17; -The right knee was swollen and the leg was warm to touch; -The resident complained of severe pain in the right leg. During an interview on 2/10/17 at 12:40 P.M. NA A said: -The right leg was swollen with a large bump below the knee cap. -He/she got the resident out of the bed for the facility van driver to take her to the hospital for x-rays; -The resident would cry out in pain when the right leg was touched; During a telephone interview on 2/10/17 at 11:20 A.M. the facility van driver said: -He/she took the resident to the hospital by the facility van on 1/31/17 around 6:00 P.M.; -The resident was in a wheelchair with his/her legs in a down position; -The resident cried out in pain the entire time he/she was in the van. Review of the telephone order dated 1/31/17 showed x-ray of the right hip, knee and ankle related to recent fall with bruising and swelling to the right lower leg. Review of the nurses notes dated 1/31/17 at 6:09 P.M. showed x-ray of the right hip, knee and ankle related to fall, bruising and swelling noted to right leg. Review of the outpatient orders dated 1/31/17 showed: -X-ray to the right hip, knee and ankle due to fall and right leg pain with bruising and swelling. Exam needs to be performed today ASAP (as soon as possible). Review of the radiology report from a local hospital dated 1/31/17 at 6:35 P.M. showed: -Fracture to the right tibia and fibula (bones located in the lower leg); -[MEDICAL CONDITION] femoral neck (the joint located at the hip). Review of the emergency room report from a local hospital dated 1/31/17 at 7:40 P.M. showed: -fell at the nursing home on 1/30/17 around 5:30 P.M. Right leg pain, swollen and bruising; -Elder person with dementia, comes to the emergency room from the outpatient department after he/she underwent an x-ray of the right hip, knee and ankle showed a [MEDICAL CONDITION] femoral neck, right tibia and fibula. The cause of the fracture is under concern in that it was reported that the resident fell out of a wheelchair.; -The resident will be transferred to another hospital for orthopedic consultation. During an interview on 2/9/17 at 1:30 P.M. the Administrator said: -The facility investigated the fall that occurred on 1/30/17; -The resident was being pushed out of the dining room by a NA; -The resident lunged forward and fell out of the wheelchair; -The resident had a bump on his/her knee, but the nurse didn't think it was broken; -Towards the morning of 1/31/17, the night nurse felt the leg was getting worse and passed this information to the day shift nurse; -The day shift nurse called the doctor and received orders to send for x-rays, but did not order these x-rays to be done immediately; -The facility van had two other transports already scheduled for 1/31/17 that could not be canceled; -The resident was taken to the outpatient department for x-rays as soon as the van became available. During a telephone interview on 2/10/17 at 8:15 A.M. Physician A said: -He/she was not made aware the resident fell until 8:00 A.M. on 1/31/17; -He/she did not receive any fax communications from the facility on 1/30/17; -He/she was told the resident did not have any pain and there was no signs of injury; -He/she would have expected the facility to notify him/her on 1/30/17 of the fall with injuries; -The facility has a has a list of physicians who are on call after hours to be notified; -He/she was the physician on call on 1/30/17; -Standards of practice dictate that when a resident falls, the physician should be notified; -He/she would have expected a phone call on 1/30/17. During an interview on 2/10/17 at 10:15 A.M. the DON said: -He/she was the charge nurse from 6:00 A.M. to 6:30 P.M. on 1/30/17; -He/she was in the dining room when the resident fell ; -He/she did not see the resident fall; -He/she assessed the resident once the resident was lifted by a mechanical lift in the wheelchair and noted a bump to the right lower knee; -The resident was put in bed; -The right knee was a little red and the resident complained of pain in the knee; -He/she gave the resident a pain pill; -He/she wrote the fax communication to the physician but did not fax it; -He/she worked as a medication aide on 1/31/17 on the day shift; -LPN B said the resident's leg looked worse and the resident should be seen by the physician; -The physician should have been notified of the fall on 1/30/17; -The resident should have been sent to the hospital for x-rays by ambulance and not wait for the facility van to be available. During an interview on 2/10/17 at 1:00 P.M. the Administrator said: -The physician should have been notified on 1/30/17 of the fall; -The resident should have been sent to the hospital sooner. MO 3

Based on interviews and record review, the facility failed to ensure staff transferred one of nine sampled residents (Resident #1) in a safe manner as directed by his/her care plan, which resulted in a mildly displaced fracture of the proximal left humerus (fractured left arm). The facility census was 86. 1. Review of the facility's transfer activities policy, dated March 2015, showed: - Obtain assistance of another individual if necessary for safe transfer. - Depending upon the amount of assistance required, the nurse may either support the resident on his/her affected side or stand in front of the resident. Support may be provided by use of a waist belt (also known as a gait belt). Note: do not support the resident under the arms as this prevents the resident from using his/her unaffected extremity. Do not allow resident to put arms around your neck. - With your knees flexed and your legs slightly apart, face the resident, grasp resident around the waist supporting his/her back and head. Rise to a standing position, at a pre-arranged signal, by straightening your knees and supporting the resident's knees. Allow the resident to gain his/her balance before proceeding. Support the weak leg with your knee if necessary. - Encourage resident to stand erect with trunk straight and both knees extended if possible. - Have resident pivot on his/her unaffected leg,feel location of bed or chair with back of leg and lower him/herself onto bed or chair. Do not allow resident to fall into the bed or chair. 2. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally-mandated assessment instrument completed by facility staff, dated 6/9/15, showed facility staff assessed the resident as follows: - Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated resident was cogitatively intact for daily decision making. - Resident needed two staff for assistance with transfers to and from bed to chair and from chair to toilet. - Resident had upper and lower extremity impairment on one side. - Resident was not steady when moving to sit or to stand and could only be stabilized with human assistance. - The facility recorded they provided no therapy hours services to the resident during the assessment period. Review of the resident's undated closet care plan (the resident's individual plan of care which hung inside each resident's closet for direct care staff to reference) showed: - Assist of two staff with transfers; - On 6/9/15, staff added a line which instructed staff to not use resident's left arm during a transfer; - Resident needed some staff assistance with turning as left side was paralyzed. - The plan did not address the use of a gait belt or that staff should notify the charge nurse and social services if the resident refused to allow staff to use one. Review of a physical therapy plan of care, dated 5/25/15, signed by Physical Therapist (PT) B showed: - Staff referred resident for a physical therapy evaluation because resident had declined in transfers due to increased weakness and contracture of left lower extremities. - Staff noticed a decline approximately two weeks ago which resulted in increased skin tears with transfers and increased in safety concerns with transfers. - Current value showed resident 60 to 79% impaired when changing and maintaining body position functional limitation. - Resident requires moderate assistance for transfers and full assistance to maintain left upper extremities safety with transfers. Left ankle contracture limits safety with transfers. - Goal: Resident will improve stand pivot transfers to one assist with safety awareness of two cues from staff. - Staff to send therapy plan of care to physician for a therapy order. Review of the resident's care plan, initiated on 12/29/13 and last updated on 6/10/15, showed: - Resident needed two staff assistance to transfer to bed and out of bed. - Resident did not like a gait belt; staff should encourage him/her to allow staff to use the gait belt for everyone's safety. - Resident was unable to bear weight on his/her left arm and leg due to a stroke. - If resident declined for staff to use a gait belt, staff should notify the charge nurse and social services. - Staff had not added any new interventions or updated the plan to show how staff were to transfer him/her if the resident refused to allow them to use a gait belt since they initiated the care plan in 2013. During an interview on 6/16/15, at 2:30 P.M., PT A said they had not worked with the resident on transfers, so he/she did not know if the resident required one staff or two staff to assist the resident with transfers. Their therapy company picked up the facility a few weeks ago as a client to provide therapy and had just started the process to evaluate all the residents for safer transfers. Review of the resident's physician order [REDACTED].>- CVA with hemiparesis (stroke with paralysis); - [PROCEDURE] (breast removal); - Back pain; - Chronic abdominal (stomach) pain. During an interview on 6/16/15, at 1:40 P.M., Certified Nurse Aide (CNA) E said he/she worked the floor on 6/10/15. He/she last noticed the resident when he/she assisted residents with their evening meal in the Fire Side (assist) dining room. The resident seemed fine at that time. The resident needed one assist to the bathroom. He/she did not know if the resident's care plan showed the resident to be a one or two staff assist in and out of bed. He/she always waited for help and used two staff to transfer the resident in and out of bed. He/she did not feel comfortable transferring the resident by his/herself. The resident would not allow staff to use a gait belt, therefore two people were needed. During an interview on 6/16/15, at 2:00 P.M., Certified Medication Technician (CMT) A said he/she worked the evening of 6/10/15. He/she gave the resident his/her medication in the Fire Side dining room some time before 6:00 P.M. The resident seemed okay at that time. Some staff transferred the resident by themselves and other staff needed help when they transferred the resident to and from bed and wheelchair. During an interview on 6/16/15, at 8:20 A.M., the resident said an accident caused his/her injured arm and shoulder. He/she told CNA A not to bear hug him/her like he/she did before. CNA A said he did not bear hug him/her, then lifted him/her by placing his/her arms under his/her arms. CNA A lifted him/her out of the wheelchair and placed him/her on the bed. There was a big pop and he/she knew his/her shoulder was broke. It hurt like a son a gun. He/she asked for a pain pill, but staff told him/her the nurse was at the residential care facility (RCF) and he/she would have to wait. He/she asked for a pain pill again about midnight, but it was 3:00 A.M. before he/she received the requested pain pill. CNA A did not usually assist him/her in and out of bed, but had done so three times in the last week. Each time, CNA A lifted him/her by his/her arms. Most of the time, two staff helped him/her out of bed. Sometimes only one person put him/her to bed. CNA A said he/she was strong enough to do it by him/herself. Staff gave him/her a sleeping tablet before he/she went to bed that evening and he/she dozed off and on during the night, but woke multiple times in severe pain. He/she told the nurse CNA A hurt his/her arm and shoulder when he/she put him/her to bed. During an interview on 6/16/15, at 3:40 P.M., CNA A said: - He/she put the resident to bed by him/herself about 7:30 P.M. on 6/10/15. - His/her partner was busy getting another resident ready to go to the hospital. - He/she did not use a gait belt to transfer the resident because the resident was care planned not to use a gait belt. - He/she faced the resident, with his/her hands under the resident's arms, picked up the resident from his/her wheelchair and placed the resident on his/her bed. - He/she did not hear any noises or popping sounds. - The resident did not call out in pain or say anything was wrong. - The resident asked him/her for a pain pill about 9:30 P.M., and he/she told the nurse. - He/she did not know why the resident needed the pain pill. - He/she seldom worked on the resident's hall. - He/she normally worked on the west hall and more than half of the residents on the west hall required two people for transfers. - Staff knew how to transfer residents by the information provided on the resident's care plan found in the resident's room. During an interview on 6/17/15, at 10:25 A.M., CNA B said: - He/she worked the center hall on the evening on 6/10/15. - He/she normally put the resident to bed, but he/she was busy with a hospital transfer and CNA A put the resident to bed. - He/she believed he/she answered the resident's call light during the night and the resident asked for a pain pill. - He/she told the nurse, but it was not time for him/her to have another pain pill. - The resident usually complained a lot and he/she did not ask where the resident's pain was located. - The resident did not indicate anything unusual was wrong. - He/she did not remember the resident saying anything about his/her arm or shoulder hurting. - He/she did not remember what time he/she was in the resident's room when the resident complained of pain. - He/she always transferred the resident by his/herself. - The resident's care plan called for a one person transfer and a copy of the care plan hung in the resident's closet. - He/she taught other CNAs how to transfer the resident. - He/she had worked at the facility for years. - He/she always transferred the resident by having the resident raise his/her arms up, then he/she held onto the resident around the waist and helped the resident stand up, from his/her wheelchair on his/her good foot. - He/she then would place the resident's wheelchair next to the bed. - He/she would ask the resident place his/her good arm around him/her and pivot the resident to the bed. - Once the resident sat on the bed, he/she would take the resident's good foot, move it back, have the resident stand up, then he/she scooted the resident back into bed. - He/she did not know how two people could transfer the resident since they did not use a gait belt. - Someone told him/her years ago the resident signed a paper that he/she did not want a gait belt used to transfer him/her. - He/she had never used a gait belt when he/she transferred the resident. Review of the resident's nurses' notes showed a late entry, dated 6/11/15, at 4:30 A.M., showed Graduate Nurse (GN) A wrote: - The resident said when CNA A put him/her to bed last night he/she hurt his/her arm. - When CNA A picked him/her up, the arm popped. - He/she assessed the resident and found no skin tear or bruising. - He/she gave the resident a pain pill and the resident rested the rest of the night. During an interview on 6/17/15, at 4:55 P.M., Licensed Practical Nurse (LPN) A said: - He/she worked as the charge nurse on the evening of 6/10/15. - Staff had already put the resident to bed when he/she started his/her shift about 7:00 P.M. - The resident asked for a pain pill around midnight, but they had an incident on the RCF and he/she had to go over and help. When he/she returned the resident was asleep. - About 3:00 A.M., the resident put on his/her call light and he/she sent GN A to see if the resident needed the requested pain pill. GN A reported to him/her the resident said CNA A hurt his/her arm. - They went to talk to the resident who seemed more upset about not getting his/her pain pill than something being wrong with his/her arm. The resident received the requested pain pill and slept the rest of the night. The resident did not mention his/her arm hurting at any other time during his/her shift. - He/she had been very busy sending two residents to the hospital and had given most of the evening floor responsibilities to GN A. The resident often requested medication for pain during the night and often complained of pain therefore, he/she had not been overly concerned about the resident's arm/shoulder since the resident said nothing further about his/her arm or shoulder hurting during his/her shift. - Staff told him/her when he/she started a year ago, the resident was a one person transfer. He/she had never put the resident to bed, but had taken the resident to the bathroom by his/herself. - He/she had never seen this resident's or any resident's care plan. He/she did not know the resident's care plan said two staff should assist the resident in and out of bed. - He/she did not know the facility had updated the resident's care plan on 6/10/15, to show two staff should assist the resident to the bathroom. - He/she had never been in the MDS office and no one had informed him/her residents' care plans were located there. He/she only had the knowledge found in the resident's chart or the information given to him/her by other staff on how to care for the residents. During an interview on 6/17/15, at 11:00 A.M., GN A said: - LPN A provided him/her orientation of the evening of 6/10/15. - Either CNA A or LPN A told him/her the resident requested a pain pill. When he/she went into the resident's room around 3:00 P.M., the resident told him/her the big guy CNA A hurt his/her arm when he/she put him/her to bed that evening. - He/she assessed the resident's arm and found no pain, no bruise and no skin tear. He/she thought the resident wanted the pain pill for pain in his/her foot. - When he/she told CNA A and LPN A, what the resident said about CNA A hurting his/her arm last evening. CNA A made some sort of comment he/she couldn't make out and chuckled to his/herself. - Staff told him/her the resident required only one person to transfer him/her without a gait belt. Staff told him/her the resident signed a waiver not to use the gait belt. Review of the resident's nurses' notes, dated 6/11/15, at 11:45 A.M., showed LPN B documented the resident complained of left arm/shoulder pain. The resident stated The big guy on night shift, (CNA A) jerked on it last night, it popped really loud and hurt terrible. At that time the nurse touched the resident's shoulder and the resident yelled ouch. Nurse contacted Physician A, who ordered the resident be sent to the emergency room for an evaluation. Review of the resident's medication administration records for 6/10/15 and 6/11/15, showed: - Staff administered as needed Lortab (medication for severe pain) 7.5 milligram (mg) twice on the 10th and twice on the 11th and as needed Xanax (anxiety medication) 0.25 mg during the night shift on 6/10/15. The records provided by the facility did not show why staff gave the resident the pain medication. - Staff were to assess resident for pain on a scale of zero to 10 on each shift. Staff did not document they assessed the resident's pain on the 2:00 P.M. to 10:00 P.M. or 10:00 P.M. to 6:00 A.M. shift on 6/10/15, and assessed the resident's pain as zero on the 6:00 A.M. to 2:00 A.M. shift on 6/11/15. Staff assessed the resident during the 6:00 A.M. to 2:00 P.M. shift and sent the resident to the ER because of arm/shoulder pain. Review of the resident's radiology report from Hospital A, dated 6/12/15, showed a mildly displaced fracture of the proximal left humerus (upper arm) just below the surgical neck (below shoulder adjacent to armpit). During an interview on 6/16/15, at 2:36 P.M., Registered Nurse (RN) A said the CNAs knew how to transfer a resident by the closet care plans. The MDS coordinator was responsible to update the closet care plans. During an interview on 6/16/15, at 2:50 P.M., Certified Nurse Aide (CNA) C said each resident's closet contained the care plan. The care plan instructed staff on how to care for the residents including the number of staff needed to safely transfer the resident to and from bed and wheelchair. During an interview on 6/11/15, at 4:00 P.M., with the director of nursing (DON) and assistant director of nursing (ADON) they said: - The resident's care plan called for staff to not use a gait belt. After seeing what the resident's actual care plan said, they said it had to be a typing error and called the MDS Coordinator to come to the office. - The ADON said when she worked the floor she used two people to put the resident to bed. The resident could go to the bathroom with only one person to assist. - The ADON said You just do it, (he/she was) not sure how to explain. when asked how to transfer the resident without a gait belt. - They expected staff to follow the resident's care plan and use two people to transfer a resident if the care plan said to use two people. - They knew they had a problem with transfers and had physical therapy (PT) evaluating the residents on how they should be transferred. The resident was one of their concerns because he/she had received skin tears during transfers. During an interview on 6/16/15, at 4:15 PM., the MDS Coordinator said she was new to the position and had just started updating the residents' care plans during their annual and quarterly assessments. She was responsible to update the closet care plans at that time and as needed. Staff had always told her the resident would not allow the use of a gait belt. She had not noticed the resident's care plan directed otherwise. Review of a written statement provided by Physician A, dated 6/17/15, showed Physician A wrote: - The resident's arm likely fractured when staff lifted him/her by his/her arms out of his/her wheelchair and onto the bed. The resident told Physician A he/she heard/felt a pop and had pain when staff transferred him/her to bed. - The resident had a history of [REDACTED]. MO 7 Randy Wade FAN II found the facility in substantial compliance during a revisit on 7/30/15.