Every finding on record at Gibson Community HSP Annex

Base on observation, interview and record review, the facility failed to complete a fall risk assessment quarterly and failed to ensure safety equipment was in use during a transfer for one of one residents (R5) reviewed for falls on the sample list of 12. This failure resulted in R5 falling and sustaining a four centimeter laceration requiring seven sutures to the forehead and a fractured humerus. Findings Include: R5's Fall Risk Assessments dated 8/16/23 and 1/29/24 document R5 is a high risk for falls. On 3/12/24 at 10:40 AM, V3 MDS (Minimum Data Set)/CP (Care Plan) Coordinator stated fall risk assessments are to be completed upon admission, with significant changes and quarterly. V3 confirmed R5 only has an August and January assessment completed. V3 is unsure why one was not completed in November stating, that was before my time, but one should have been completed in November 2023. R5's MDS dated [DATE] documents R5 is alert and oriented, and requires substantial/maximal assistance when transferring from a sit to stand position and for chair/bed to chair transfers. On 3/11/24 at 9:41 AM, R5 was sitting up in a recliner with R5's right arm in sling. R5 stated R5 fell when transferring from the chair and sustained a fractured shoulder. R5's CP dated 1/29/24 documents R5 needs extensive assistance of one for transfers using a gait belt and walker and up to extensive assist of two using a gait belt (changed from assistance of 1 which was on the original care plan dated 8/17/23) and walker to ambulate and transfer. R5 is to be encouraged to walk during the day, and staff are to bring a wheelchair behind R5 for long distances so that R5 can take a break if needed. R5 has a history of knees buckling so please be cautious of this during ambulation and transfers. R5's Progress Notes dated 2/16/24 by V9 LPN (Licensed Practical Nurse) documents at 1750 on 2/16/24, the CNA (Certified Nursing Assistant) notified the nurse that R5 had fallen in R5's room. The CNA stated she was assisting R5 and turned to unlocked R5's wheel chair to move it out of R5's way when resident fell forward. Upon entering room, R5 was noted to be lying with the right side with R5's face down on the floor with blood coming from a laceration to the right side of the head and R5's right arm was tucked up under R5's body. 911 called and transferred to the ER (emergency room ). R5 returned to the facility with a diagnosis of a Fractured right humerus and has an immobilizer in place. Per the ER nurse, R5 has 7 sutures to the right forehead. R5 has a pressure dressing to the forehead. Bruising is noted to the right forehead under the dressing pooling down to R5's right eye and back behind the right ear. R5 also has a skin tear with bruising to the right wrist. R5 is alert and able to answer questions appropriately. An undated and untitled summary into R5's fall by V2 DON (Director of Nursing) documents on 2/15/24 R5 was ambulating with the walker in R5's room and experienced a fall. R5 had painful ROM (Range of Motion) to the right upper extremity as well as a laceration to the right forehead. An x-ray of the right arm revealed a fracture of the proximal right humerus and the laceration was repaired with sutures. This summary also contained a witness statement from V10 CNA that documents V10 went into R5's room to let R5 know that the facility needed to collect a urine sample. V10 then set up the equipment in the bathroom. R5 had stood up out of the wheelchair and was beginning to ambulate to the bathroom. V10 unlocked the wheelchair to move it out of the way and as V10 turned back from moving the wheelchair, R5 was falling. The Hospital ED (Emergency Department) Summary Report dated 2/15/24 documents R5 had a fall at the nursing home due to R5's legs giving out and sustained a 4 cm (centimeter) jagged laceration above the right eyebrow and pain to the right upper extremity. R5's X-ray report dated 2/15/24 documents an impacted fracture of the proximal right humerus extending through the humeral neck and greater tuberosity. On 3/12/24 at 10:35 AM, V7 CNA stated prior to R5's fall, R5 was a one or two assist with gait belt, depending on the day, for transfers and a one assist with walker and gait belt for ambulation. V7 explained R5 would hold onto the walker and staff were to hold onto the gait belt. On 3/12/24 at 10:45 AM, V2 DON stated V10 did not have a gait belt on R5 at the time of the fall. V2 confirmed R5 has a history of falls but wants to be independent. On 3/13/24 at 1:45 pm R5 stated, staff normally use a gait belt with R5 during transfers but at the time of R5's fall, R5 did not have a gait belt in place. R5 stated at the time of the fall, R5 didn't realize staff had not placed a gait belt onto R5 and also did not realize that staff was not next to and holding onto R5 when R5 began to walk to the bathroom. The facility's Gait Belt Use Policy dated March 2023 documents gait belts are provided to secure a grasping surface to aid with resident transfer and ambulation and to prevent injury during transfer and ambulation and to prevent injury during transfer and ambulation of the resident. A gait belt must be used, if there are no contraindications, every time a resident is transferred or ambulated with assistance. When a gait belt is used, staff must have at least one hand on the gait belt supporting the resident at all times.

Based on interview and record review the facility failed to maintain complete and current resident and staff infection control logs, analyze infection data to identify trends, restrict staff from working while ill, and test symptomatic staff for COVID-19 (Human Coronavirus Infection). These failures affect eight (R1, R2, R4, R5, R6, R7, R11, R65) of eight residents reviewed for infection control and has the potential to affect all 12 residents in the facility Findings include: 1.) The Employee Illness Reports document the following: On 1/14/24 V20 Certified Nursing Assistant (CNA) called in sick due to sore throat, cough, and muscle aches. On 1/29/24 V12 CNA called in sick due to headache, runny/stuffy nose, body aches, and vomiting. On 2/5/24 and 2/7/24 V18 CNA called in due to headache and vomiting. On 2/6/24 V7 CNA called in sick due to diarrhea and vomiting. On 2/9/24 V9 Licensed Practical Nurse was sent home due to diarrhea and nausea. On 2/16/24 and 2/17/24 V9 called in due to asthma and V9 is taking an antibiotic and steroid. On 2/20/24 V17 CNA called in sick due to vomiting. On 2/21/24 V18 CNA called in sick due to vomiting. On 2/22/24 V10 CNA called in sick due to vomiting. On 3/1/24 V12 CNA called in sick due to vomiting. On 3/7/24 V17 CNA called in sick due to fever of 100.1 degrees Fahrenheit (F), headache, and muscle aches. The employee infection logs with a date range of 6/13/23-1/23/24 do not document illnesses after 1/23/24. V20's call in on 1/14/24 is not listed on this log. 03/12/24 at 12:06 PM V15 Infection Preventionist stated V15 relies on a collaborative process with V2 Director of Nursing (DON) for infection control. V15 stated V15 receives reports on employee illnesses which are tracked/logged by the human resources department and V2. On 3/12/24 at 3:15 PM V2 DON confirmed the employee illness log is not up to date. V2 stated V2 reviews the employee illness reports daily when they come in, and then V2 tries to keep an eye out for other similar illnesses in residents and staff. V2 stated residents with GI (gastrointestinal) symptoms (nausea/vomiting) are not logged on the resident infection logs, we just keep an eye out as it happens. On 3/13/24 at 10:32 AM V2 confirmed the CNAs work on both halls of the facility. 2.) The January 2024-March 2024 Monthly Infection Logs document resident infections, and there is no documentation that these infections were tracked to identify any trends or patterns. These infection logs do not document organisms identified from cultures for resident infections. R1, R2, and R6 had Urinary Tract Infections (UTIs) in January. In February R4, R5, R6, and R7 had UTIs; and R4 had a lower respiratory tract infection. R65 had a UTI in March. On 3/12/24 at 11:35 AM V3 Minimum Data Set/Care Plan Coordinator was completing the March infection control log which was incomplete and not up to date. V3 stated V3 has notes of infections, but has not yet transcribed them onto the log. V3 confirmed V3 is responsible for logging the resident infections on the monthly logs. V3 stated V3 took over for logging infections as of January 2024, and both V2 DON and V15 Infection Preventionist are notified verbally of infections as they occur. V3 stated V3 has not provided the infection logs to V15. V3 confirmed the infection logs do not identify patterns/trends of infections or organisms. V3 stated V3 does not do that and was unsure if V15 is documenting infection trends. On 3/12/24 at 12:06 PM V15 stated infections are reported to V15 by V3 and V15 is also informed of infections verbally and through a daily written report. V15 stated the infection trends/patterns are identified and documented on the quarterly infection reports, and this is not done on a monthly basis. 3.) The facility's undated COVID-19 outbreak log documents the outbreak began on 1/14/24 when V12 CNA tested positive. This log documents R5 and R11 tested positive on 1/15/24, and R6 tested positive on 1/16/24. The employee illness logs with date range 6/12/23-1/23/24 document V13 CNA URI (Upper Respiratory Infection) on 1/12/24 and 1/15/24; and V12 CNA URI on 1/13/24 and returned to work on 1/14/24. There is no documentation that these CNAs were tested for COVID-19 after symptoms began and prior to returning to work. V12's Rapid COVID-19 test dated as collected on 1/14/24 at 4:06 PM and resulted at 4:30 PM documents V12 tested positive. V12's Time Card dated 1/7/24-1/20/24 documents V12 worked on 1/14/24 from 6:09 AM until 4:30 PM. V13's Time Card dated 1/7/24-1/20/24 documents V13 worked on 1/10/24 from 6:08 AM until 6:09 PM. On 3/12/24 at 12:00 PM V12 CNA stated V12 had symptoms of headache, cough, and runny nose that began on 1/13/24. V12 stated V12 reported V12's symptoms to the nurse that day when V12 called off. V12 stated V12 did not test for COVID-19 on 1/13/24, but tested the following day while V12 was at work. V12 stated V12 waited for V12's test results and then was sent home once V12 test resulted positive. V12 stated V12 thought V12 was ok to work on 1/14/24 since V12 was feeling better, but V12 decided to test later that day when V12 had symptoms while at work. On 3/12/24 at 2:45 PM V13 CNA stated V13 recalled calling off from work in January 2024 with URI symptoms of green mucus, fever of 101.8 F., headache, coughing, and sneezing. V13 stated V13 had symptoms of body aches, shortness of breath, and feeling tired when V13 was working on 1/10/24, but V13 thought it was just a cold. V13 stated V13 took cold medication that day, worked from 6:00 AM until 6:00 PM, and did not report V13's symptoms. On 3/12/24 at 3:15 PM V1 Administrator stated we were not requiring surgical masks to be worn in the facility prior to the COVID-19 outbreak that began on 1/14/24. V2 DON stated V2 can't prove that V13 was not COVID-19 positive since V13 was not tested . V2 confirmed there is no documentation that V13 was tested in January 2024 prior to 1/17/24. V2 stated the staff should tell V2 or the nurses when they are having symptoms so that they can be tested . V2 confirmed V12 should have tested for COVID-19 prior to working on 1/14/24. V2 stated V12 was sent home from work on 1/14/24 after testing positive and that was when the facility identified the outbreak. V2 stated staff who are COVID-19 positive are restricted from work for five days, and if they are negative and symptomatic they can return to work once fever free without medication use for 24 hours. On 3/13/24 at 10:32 AM V2 confirmed the CNAs work on both halls of the facility. The facility's Long-Term Care Facility Application For Medicare and Medicaid dated 3/11/24 documents 12 residents reside in the facility. The Centers for Disease Control and Prevention Symptoms of COVID-19 dated October 26, 2022 documents COVID-19 symptoms include fever/chills, cough, shortness of breath, difficulty breathing, fatigue, body/muscle aches, headache, new loss of taste/smell, sore throat, congestion, runny nose, nausea, vomiting and diarrhea; and recommends testing if you are symptomatic. The facility's Infection Prevention policy revised June 2021 documents the infection prevention program incorporates surveillance and prevention of infections, which includes monitoring and investigating exposures and infectious disease outbreaks. This policy documents that actions taken and recommendations to address opportunities for improvement will be documented, and performance improvement and infection prevention activities is determined through information gathering and clinical analysis. This policy documents that positive cultures are investigated to identify clusters of pathogens, location, and staff involved. The facility's COVID-19 Testing Policy and Response Strategy revised September 2023 documents healthcare workers are educated on reporting positive COVID-19 tests, symptoms of COVID-19, and/or exposure to COVID-19 to their direct supervisor. This policy documents testing is required for symptomatic healthcare workers.

Based on interview and record review the facility failed to follow their antimicrobial stewardship policy by failing to accurately document the status of obtaining residents urine cultures and identify/document organisms results. This failure affects five (R1, R2, R4, R5, R6) of eight residents reviewed for infection control in the sample list of 12. Findings include: The facility's Antimicrobial Stewardship policy with reviewed date May 2023 documents the purpose of this program is to ensure appropriate use of antimicrobials which includes selecting the appropriate antibiotic, dose, duration and route to decrease toxicity and antimicrobial resistance. This policy documents to collect, track, and analyze antibiotic use and resistance patterns. This policy documents laboratory personnel will guide the proper use of tests/results and assist in ensuring that laboratory reports will be used to support optimal antibiotic use; and infection control personnel will develop/implement and document facility wide infection surveillance, prevention, and control activities. The January 2024-March 2024 Monthly Infection Logs do not document organisms from culture results as instructed on the form. R1, R2, and R6 had Urinary Tract Infections (UTIs) in January, and no cultures were obtained for R2 and R6. These logs do not document if R1 had urine cultures or the organism identified for UTIs on 1/10/24 and 12/31/23. R4, R5, and R6 had UTIs in February. These logs do not document cultures were obtained for R4 and does not document the organism from R5's urine culture. R1's urine Culture resulted on 1/10/24 documents Escherichia coli greater than 100,000 colony forming units (CFU), indicating an infection. R1's Urine Culture resulted on 12/30/23 documents Klebsiella pneumoniae greater than 100,000 CFU, indicating an infection. On 3/12/24 at 11:35 AM V3 Minimum Data Set/Care Plan Coordinator was completing the March infection control log, which was incomplete and not up to date. V3 stated V3 has notes of infections, but has not yet transcribed them onto the log. V3 confirmed V3 is responsible for logging the resident infections on the monthly logs. V3 stated V3 has not provided infection logs to V15 since V3 started in January. V3 confirmed the infection logs do not identify organisms from culture results. On 3/12/24 at 12:06 PM V15 confirmed the infection logs are incomplete and do not document if cultures were completed or the organisms from completed cultures. V15 stated culture results are reviewed and followed up on with the physician as part of the antibiotic stewardship.

Based on observation, interview and record review, the facility failed to accurately code a Minimum Data Set for one of 12 residents (R11) reviewed for restraints on the sample list of 12. Findings Include: R11's MDS (Minimum Data Set) dated 1/2/24 documents R11 is alert and oriented, uses bed rails as a restraint daily and is independent with rolling side to side. On 3/11/24 at 9:35 AM, R11 was sitting up in the recliner in R11's room. R11 stated R11 does not use any restraints explaining, I'm able to walk independent down the hall and that R11 uses upper side rails so I (R11) can turn myself in bed. I (R11) want/need them so I (R11) don't have to ask for help. R11's Side Rail assessment dated [DATE] documents R11 uses 1/4 upper rails bilaterally per request to enable in repositioning. R11's Care Plan dated 1/15/24 documents R11 can change positions in bed with assist of one and prefers to use side rails on a daily basis to help with positioning. This care plan also documents R11 has signed the bed rail agreement and understands the risks of having them in place. On 3/11/24 at 3:04 PM, V3 MDS/Care Plan Coordinator stated R11 does not use any restraints, only side rails to aid in repositioning. V3 explained V3 coded them as a restraint on the MDS because V3 thought they had to be coded that way due to R11's use of side rails.

Based on interview and record review the facility failed to develop a comprehensive care plan for Urinary Tract Infections (UTI) for one (R1) of twelve residents reviewed for care plans in the sample list of 12. Findings include: On 3/11/24 at 1:08 PM R1 stated R1 gets frequent bladder infections and is not sure what the facility does to prevent them. R1 stated R1 has burning with urination all the time which is a long term problem for R1, and staff assist R1 with toileting. R1's Nursing Notes dated 9/28/23-10/2/23 document R1 was on an antibiotic for a UTI. R1's urine Culture resulted on 1/10/24 documents Escherichia coli (bacteria found in colon) greater than 100,000 colony forming units (CFU), indicating an infection. R1's Urine Culture resulted on 12/30/23 documents Klebsiella pneumoniae greater than 100,000 CFU, indicating an infection. R1's Care Plan revised 2/28/24 does not have a problem, goal, and interventions to address R1's UTIs. On 3/12/24 at 12:00 PM V3 Minimum Data Set Coordinator stated V3 does not care plan for a history of or frequent UTIs, and information such as antibiotic use, encouraging fluids, and monitoring would be documented in the nursing notes. V3 confirmed R1 does not have a care plan for UTIs or prevention.

Based on interview and record review, the facility failed to complete psychotropic medication assessments prior to starting a psychotropic medication and failed to ensure as needed psychotropic medications were limited to 14 days or less for residents. This failure affects three of four residents (R7, R11 and R65) reviewed for unnecessary medications on the sample list of 12. Findings Include: The facility's Psychotropic Medication Policy dated 11/28/17 documents psychotropic medication is any drug that affects brain activity associated with mental processes and behavior. These medications include but are not limited to: antianxiety, antidepressant, antipsychotic and hypnotic. These medications are to be given to treat a specific condition/medical symptom that is diagnoses and documented in the clinical record. Specific condition/medical symptoms alone are not enough to justify pharmacological use. An evaluation must be done to determine other possible physical, mental, behavioral, psychosocial needs. Residents that are admitted with a psychotropic medication need an evaluation by the physician and consultant pharmacist for the use of the medication and whether a reduction or discontinuation can occur. Quarterly evaluation or more frequent if needed to determine if a reduction is warranted. Initial PRN (as needed) psychotropic medications should not exceed 14 days, unless the attending physician or prescribing practitioner believes that to extend beyond 14 days and has documented the rational and indicated the duration. 1. R11's Physician Order List dated 3/11/24 documents the following orders: Duloxetine {Antidepressant} 60 mg (milligrams) - one tablet daily ordered on 12/27/23 Hydroxyzine {Antihistamine} 50 mg - one tablet every 6 hours as needed for anxiety or itching ordered on 12/27/23 and discontinued on 1/30/24 (34 days later). R11's Psychotropic Medication Assessments for the above listed medications were completed on 1/9/24 (13 days after initiated). On 3/11/24 at 3:28 PM, V3 MDS (Minimum Data Set)/CP (Care Plan) Coordinator stated V3 is the one that completes psych med assessments and completes them quarterly when all of the assessments and MDS's are completed. V3 also stated V3 does not do assessments between times, even if a new medication is started. On 3/11/24 at 3:38 PM, V2 DON (Director of Nursing) confirmed R11 did not have any other psychotropic medication assessments completed other than the one in R11's medical record. On 3/12/24 at 9:21 AM, V2 DON stated typically PRN (as needed) psychotropic medications are ordered for 14 days however since R11's Hydroxyzine isn't your typical psychotropic medicine, that is why it did not have a 14 day time frame. It went unnoticed until pharmacy told us that because it was being used to treat R11's anxiety, that we needed to limit it to 14 days. That is why it was discontinued. 2. R65's ongoing diagnoses listing documents diagnoses of Anxiety and Major Depressive Disorder. R65's March 2024 Physician Order Sheet dated 3/7/24 documents the following orders: Clonazepam {Benzodiazepine} 0.5 mg (milligrams) - 1 tablet BID (twice a day) for anxiety Escitalopram {Antidepressant} 20 mg - one tablet daily for depression Trazodone {Antidepressant} 100 mg - one tablet at night for insomnia R65's medical record does not contain any psychotropic medication assessment. On 3/12/24 at 9:15 AM, V2 DON (Director of Nursing) confirmed R65 has not had a psychotropic medication assessment completed and stated R65 is a new admission. V2 explained, the facility typically does not do medication assessments when residents are admitted on psychotropic medications, only when they are started on them after admission to the facility. 40385 3.) R7's New Prescription Request dated 2/12/24 documents R7's order for Lorazepam (antianxiety) 2 milligrams/milliliter (mg/ml) give 0.25 ml by mouth/sublingual every four hours as needed (PRN) for agitation/anxiety/restlessness and includes a stop date of 5/10/24. This stop date is not transcribed to R7's Lorazepam order in R7's electronic medical record prior to 3/12/24. R7's February and March 2024 Medication Administration Records document R7 received Lorazepam as needed 16 times between 2/10/24 and 3/8/24. On 3/12/24 at 9:16 AM V2 Director of Nursing stated antianxiety PRN orders are ordered for 14 days and then re-evaluated for continued use with a new stop date, unless otherwise ordered. V2 stated V2 has hospice provide documentation to extend the order past the 14 days, and has been struggling with hospice to provide this documentation for R7's PRN Lorazepam. V2 stated R7's PRN Lorazepam order is good through R7's next hospice certification date. V2 reviewed R7's PRN Lorazepam order and confirmed the order does not document a stop date. V2 stated V2 puts the stop date on V2's calendar when the order is due to be re-evaluated. At 9:29 AM V2 provided pharmacy documentation that R7's PRN Lorazepam order stop date is 5/10/24. V2 stated hospice has been faxing the prescription with the stop dates to the pharmacy and not to the facility. At 9:40 AM V2 stated V2 will add the May stop date to R7's PRN Lorazepam order.

Based on interview and record review the facility failed to administer a COVID-19 (Human Coronavirus) booster vaccine for one (R2) of five residents reviewed for immunizations in the sample list of 12. Findings include: The facility's COVID-19 Immunization Policy & Procedure - Residents with reviewed date June 2023 documents residents will be offered the vaccine unless it is medically contraindicated or the resident has already been vaccinated. The Centers for Disease Control and Prevention Updated (2023-2024 Formula) COVID-19 Vaccine Interim 2023-2024 COVID-19 Immunization Schedule for Persons 6 Months of Age and Older dated 9/22/23 documents for persons age 12 and older administer one does of the 2023-2024 vaccine at least eight weeks after the prior COVID-19 vaccine. R2's undated profile documents R2 is over the age of 65. R2's COVID-19 2023 Vaccine Consent Form dated 1/29/24 documents R2's last COVID-19 booster vaccine was given on 10/20/21, R2 has not had COVID-19 in the last 90 days, and R2 consented to receive the 2023 booster vaccine. There is no documentation in R2's medical record that R2 was given this booster vaccine. On 3/12/24 at 4:05 PM V2 Director of Nursing confirmed R2 consented to receive the 2023 COVID-19 booster and it was not administered. On 3/12/24 at 4:40 PM V2 stated the facility didn't order the vaccine since the pharmacy required a minimum purchase of three vials, which is 30 doses. V2 stated they didn't have enough residents to support purchasing that amount since the facility had been in COVID-19 outbreak status in November and January, and the pharmacy recommended waiting 90 days after being COVID-19 positive before administering the booster vaccine.

Based on observation, interview, and record review the facility failed to prevent elopement by failing to identify behaviors of wandering/exit seeking and elopement, re-evaluate for risk of elopement, notify the physician and family of exit seeking behaviors, and develop/implement targeted behavior tracking and person-centered interventions to address exit seeking behavior for one resident (R11) reviewed for elopement in the sample list of 14. This failure resulted in R11, a resident with a known history of exit seeking and diagnosis of Dementia, leaving the facility alone and unnoticed by climbing through a window. R11 was found by a member of the community, approximately two tenths of a mile on a residential street/roadway without sidewalks, a state highway and railroad tracks approximately a quarter mile away, wearing dark clothing, while using a walker, by himself(R11) on the side of the road. R11 had the potential for serious injury and/or death of being struck by a motor vehicle or falling. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/11/23 when R11 eloped from the facility unnoticed after repeatedly exhibiting exit seeking behavior within the previous three months. V1 Administrator was notified of the Immediate Jeopardy on 5/31/23 at 3:34 PM. The surveyor confirmed by observation, interview, and record review that the immediacy was removed on 5/31/23, but noncompliance remains at Level Two because additional time is needed for the facility to continue staff education and evaluate the implementation and effectiveness of the in-service training. Findings include: The facility's incident summary of R11's elopement documents on 5/11/23 at approximately 8:10 PM another resident (R12) notified staff that R12 observed R11 exit the facility. The Elopement Policy was activated, a search was initiated, and R11 was found at approximately 8:20 PM and returned to the facility. The incident investigation dated 5/11/23 and 5/12/23 document V10 Labor & Delivery Nurse brought R11 back to the facility, and R11 had been found on [NAME] Street (approximately two tenths of a mile away from the facility). R11 told V10 that R11 was going to R11's hometown. R12 was interviewed and recalls seeing R11 climb out of the window. R12 did not notify staff because R12 did not want R11 upset with R12. A local web based weather application documents sunset was at 8:00 PM on 5/11/23. R11's Minimum Data Set (MDS) dated [DATE] documents R11 has a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, and R11 did not have any wandering behaviors noted during the 7 day review period. R11's MDS dated [DATE] documents R11 has a BIMs score of 3, indicating severe cognitive impairment, and wandering occurred 4-6 days during the 7 day review period. R11's Nursing Notes document the following: On 3/7/23 at 2:06 PM R11 attempted to walk out the front door of the facility twice. On 3/12/23 at 5:09 AM R11 set off the door alarm and was found by the door. R11 stated R11 wanted to go out to R11's car to get something. On 3/15/23 at 2:46 AM R11's departure alert system activated the door alarm near the facility's entrance and R11 was redirected to the living room area. R11 stated R11 wanted to leave. On 3/16/23 at 3:18 AM R11 wandered down the east hall and attempted to open the door to the garden. On 3/18/23 at 4:34 AM R11 went outside to look for R11's car and was brought back into the facility. R11's departure alert system had not activated the door alarm. A second departure alert device was added to R11's wheeled walker. On 4/7/23 at 6:56 PM staff observed R11 exiting the building and intercepted R11 in the parking lot. On 4/14/23 at 11:30 PM R11 insisted on leaving the facility to go to R11's hometown. R11's Care Plan dated 5/23/23 does not document any new interventions were developed/implemented to address R11's wandering and exit seeking behaviors after 3/20/23 until 5/11/23. The intervention dated 3/20/23 documents R11 has a departure alert device on R11 and on R11's walker, staff are to redirect R11 to R11's room after supper, and turn on western television shows. There is no documentation that R11's wandering/exit seeking behaviors were routinely tracked and monitored including the development and implementation of nonpharmacological interventions to respond to R11's behaviors. There are no documented elopement risk assessments completed in R11's medical record after 3/8/23 until 5/23/23. There is no documentation that R11's physician and family were notified of R11's exit seeking and wandering behaviors until 5/11/23 after R11 eloped from the facility. On 5/30/23 at 1:23 PM the perimeter of the facility near the sunroom was observed. There is a concrete slab adjacent to the windows, landscape rock and bushes, and a grassy 45 degree berm that leads to an uneven, grass yard. The concrete slab does not connect to a sidewalk. There is a sidewalk to the east of the sunroom, across the grass yard, that does not connect to the street. On 5/30/23 at 4:15 PM 19th Street (East/West street where facility is located) does not contain sidewalks. There is no shoulder or curb and approximately 1 foot of gravel on each side of the road with grassy ditches. 19th Street intersects with [NAME] Street approximately 1/4 mile away from the facility. There is no stop sign when heading North on [NAME] Street at this intersection. [NAME] Street does not contain a sidewalk, shoulder, or curb. There is approximately 1 foot of gravel on each side of the road with grassy ditches. Railroad tracks and Highway 54 are South of where R11 was found, approximately 1/4 mile away. On 5/30/23 at 1:03 PM R11 stated R11 recalls getting out of the facility a few weeks ago. R11 stated R11 climbed out the facility window when no one was looking, and R11 was trying to get to R11's hometown. R11 stated R11 walked down the road that evening and someone picked R11 up and brought R11 back to the facility. R11 stated there were no sidewalks, so R11 had to walk on the edge of the road. On 5/30/23 at 11:20 AM V9 (R12's Family) stated V9 received a call from R12 around 8:15 PM on 5/11/23 reporting that R11 got out of the facility through the sunroom window, and no staff had witnessed R11 leave the facility. R12 told V9 that R11 knew not to go through the doors due to R11's departure alert device, and R11 was wanting to go to R11's hometown. V9 stated R12 reported the incident to the nurses prior to calling V9. On 5/30/23 at 11:30 AM V8 (R11's Power of Attorney) stated the facility notified V8 that R11 escaped out of the sunroom window and was found down the road from the hospital. V8 stated R11 has a history of going near the exit doors, but had never tried to leave the facility prior to this incident. On 5/30/23 at 11:47 AM V10 Labor & Delivery Nurse stated V10 was on V10's way home from work on 5/11/23 at approximately 8:20 PM-8:30 PM. V10 was driving on [NAME] Street and saw R11 in dark clothing, walking South, with R11's walker on the side of the road in the gravel. V10 stated V10 thought it was abnormal, was concerned that R11 was going to get hit by a vehicle, and V10 offered R11 a ride. R11 told V10 that R11 lived around the bend. V10 stated R11 got into R11's van, and V10 drove R11 around asking if any of the houses were R11's. V10 then asked R11 for R11's address and R11 gave R11's hometown as R11's address. R11 was unaware of what town R11 was currently in. V10 asked about R11's family, discovered R11 was a resident of the facility, and brought R11 back to the facility. On 5/30/23 at 11:58 AM V11 Registered Nurse stated V11 was conducting door alarm checks in March, R11 was out in the parking lot and was trying to get back into the facility through the main entrance. V11 stated no staff had witnessed R11 leave the facility and R11's departure alert device did not alarm. The device was functional, but V11 believed it did not activate due to R11 wearing multiple shirts. V11 stated the 4/7/23 incident was witnessed by staff, and R11 was looking for R11's car. V11 could not recall if V11 notified R11's family of R11's exit seeking behaviors or elopement on 3/18/23, and V11 stated V11 did not notify V7 (R11's Physician). V11 stated R11 is alert and oriented to person, not place and time, and does not have good safety awareness and decision making ability. R11's exit seeking behaviors seem to be close to the first hour of change of shift from days to evenings, and V11 believes R11's behaviors are triggered by watching staff leave. On 5/30/23 at 5:39 PM V15 Certified Nursing Assistant (CNA) stated on 5/11/23 V15 last saw R11 at approximately 7:00 PM in the living room area with R12. V15 was first made aware that R11 was out of the facility when R12 stopped V15 in the hallway at about 8:10 PM. V15 stated R12 told V15 that R12 was upset because R12 and R11 got into an argument and R12 saw R11 leave the facility through the sunroom window. R11 had exited the facility sometime between 7 and 8:00 PM. V15 stated V15 immediately went to the sunroom and the middle window was open with the screen removed. V15 immediately went outside to see if V15 could see R11, V15 did not see R11 and reported the incident to V14 Registered Nurse (RN). V15 stated an elopement check was initiated and V14 and V15 continued to search for R11 outside of the facility. V15 stated it was just starting to get dark around 8:10 PM, and V10 located and returned R11 at approximately 8:30 PM. On 5/31/23 at 7:19 AM V14 RN stated during the evening medication pass V15 told me that R12 witnessed R11 leave the facility through the sunroom window. We went outside near the window, and were unable to locate R11. V14 stated V14 instructed the other nurse and CNA to conduct a head count of all other residents while V14 and V15 continued to search for R11 outside. V14 had last seen R11 between 6:30 PM and 7:00 PM. On 5/30/23 at 2:28 PM V3 MDS Coordinator confirmed R11's care plan does not identify new interventions to address R11's exit seeking behaviors after 3/20/23 until 5/11/23. On 5/30/23 at 11:01 AM V2 Director of Nursing stated R11 left the facility through the sunroom window on 5/11/23, and R12 witnessed the incident but did not report to staff right away. V2 stated R12 called and reported the incident to V9 (R12's Family) who is also an employee of the facility. R11 was found down the road near the stop sign, East of the hospital. On 5/30/23 at 12:43 PM V2 stated elopement risk assessments are documented in the resident's paper chart and completed quarterly and as needed. V2 stated if the resident has a change in cognition or a change then an elopement risk assessment is done. V2 stated R11 has always been at risk for elopement since R11 admitted and wears a departure alert device. On 5/30/23 at 2:06 PM V2 stated V2 reviewed the surveillance camera footage and R11 went down the grassy berm, and walked to the sidewalk by the building. V2 stated physician and family notification would be documented in a progress note and confirmed R11 had no targeted behavior tracking for R11's wandering/exit seeking behaviors. On 5/31/23 at 9:57 AM V2 stated the video surveillance inside the facility showed R11 heading to the dining room at 7:45 PM, and there were two CNAs at the desk. V2 stated at 7:46 PM R11 headed towards the sunroom and R12 was in the living room area, and at 7:56 PM R11 showed up on the camera outside of the facility near the sunroom. V2 confirmed there is no documentation of interventions implemented between 3/20/23 and prior to 5/11/23 or that the physician and family were notified to address R11's exit seeking and wandering behaviors. The facility's Wandering Resident/Elopement policy revised 10/3/18 documents: Wandering behaviors will be documented in the medical record. Observations of wandering behaviors will determine the level of supervision needed. Residents will be assessed for elopement risk quarterly and with significant changes in condition, and the care plan updated as needed. Residents at risk for elopement will have interventions that include the use of a departure alert device, and their care plan updated to include behaviors with specific goals and interventions. Residents who have eloped from the facility will have interventions including visual checks every 30 minutes for 24 hours initiated when the resident attempts to leave the facility more than once in a 24 hour period. Notify the family and physician of the behavior. The Immediate Jeopardy that began on 5/11/23 was removed on 5/31/23 when the facility took the following actions to remove the immediacy: 1. R11's Elopement Risk Assessment was completed and R11's Care Plan was updated on 5/31/23 by V3 MDS Coordinator. 2. On 6/1/23 at 1:28 PM V24 Director of Facilities stated on the morning of 5/12/23, V25 installed brackets on the windows to limit opening width. V24 stated an audit of all windows and doors was conducted on 5/12/23. On 5/30/23 at 1:23 PM the sunroom windows were secured with brackets to restrict opening width of approximately 4 inches. 3. The facility's purchase order dated 4/11/23 documents the facility purchased a new departure alert device tester. 4. The Treatment Record documents the nurses checked all door alarms for functioning twice daily between 3/1/23 and 5/31/23. 5. V3 MDS Coordinator completed Elopement Risk Assessments on 5/31/23 for all residents identified to be at risk for elopement, and care plans were updated. 6. On 6/1/23 at 1:44 PM V2 stated on 5/31/23 V2 placed the list of residents with departure alert devices was placed in the binder at the nurses station, and V2 will be responsible for updating the list. at 1:52 PM V2 stated V2 placed behavior tracking sheets in the binder at the nurses station on 5/31/23. On 6/01/23 at 1:52 PM the binder at the nurses station contained a list of residents with departure alert devices and behavior tracking sheets for the identified residents. 7. The Staff Sign In Sheets for In-Service dated 5/11/23 documents staff were trained on wandering residents/elopement by V1 Administrator. The Staff Sign In Sheets for In-Service dated 5/31/23 documents the facility initiated staff training on residents with departure alert devices conducted by V1 on 5/31/23. The staff training log dated 6/5/23 documents staff received training on wandering/elopement policy, behavior tracking forms, and residents with departure alert devices. 8. The facility's Wandering Resident/Elopement policy with a revised date 5/31/23 documents the policy was reviewed and updated. On 6/1/23 at 2:08 PM V1 confirmed the facility reviewed and updated the Wandering Resident/Elopement policy on 5/31/23. 9. The facility's audit tool documents V2 or designee will audit the completion of behavior tracking and effectiveness of interventions for three residents per week for a total of four weeks. On 06/01/23 at 1:36 PM V2 stated the behavior tracking forms will be completed for any residents with exit seeking behaviors and the nurses will communicate the behaviors to V2. V2 stated V2 will conduct audits to ensure behavioral interventions are in place and effective. At 1:44 PM V2 stated the audits will be conducted weekly for four weeks, or longer if needed, and reviewed at the facility's Quality Assurance meetings. 10. The facility's audit tool documents V1 or designee will audit staff response to door alarms three times per week for four weeks, and audits were conducted on 6/1/23, 6/2/23, and 6/3/23. On 6/1/23 at 1:44 PM V1 stated the door alarm audits will be continued for four weeks or longer if needed, and reviewed at the facility's Quality Assurance meetings. On 6/5/23 at 8:53 AM V1 confirmed V1 conducted elopement drills on 6/1/23, 6/2/23, and 6/3/23.

Based on interview and record review the facility failed to attempt Gradual Dose Reductions of psychotropic medications, document clinical rational why dose reductions were not attempted, and care plan nonpharmacological behavioral interventions for four (R4, R8, R9, R11) of five residents reviewed for unnecessary medications in the sample list of 14. Findings include: 1.) R4's Diagnoses List dated 6/1/23 documents R4 has Dementia and Major Depressive Disorder. R4's Physician Order dated 4/25/23 documents administer Lorazepam (antianxiety) 0.5 milligrams (mg) by mouth daily. R4's Physician Order dated 10/27/22 documents to administer Paxil 40 mg by mouth daily. R4's Care Plan dated 4/25/23 documents R4 receives Paxil for depression and symptoms include feeling down and increased fatigue. R4 has anxiety and symptoms include yelling, mocking staff/residents, and throwing items. R4's behaviors also include yelling, hooting, and cussing. This care plan does not include specific nonpharmacological interventions to respond to R4's behaviors. R4's Psychotropic Medication Assessments dated 2/28/23 and 4/25/23 document R4 receives Ativan 0.5 mg daily for yelling out and mocking staff/residents, and interventions include one to one, snacks, and resting in the recliner. R4's Psychotropic Medication Assessments dated 8/18/22, 11/9/22, 2/2/23, and 4/25/23 document R4 receives Paxil 40 milligrams due to feeling down, increased fatigue, and yelling out, and interventions include activities, one to one, and family visits. These assessments document R4's behaviors have shown improvement and appear controlled. The Note to Attending Physician/Prescriber dated 2/24/23 documents the pharmacy recommended reducing R4's Paxil to 30 mg daily, and includes to document clinical rationale and symptoms exhibited if the reduction is declined. This form is signed by the physician as declined, but does not document the clinical rationale and evidence of behavioral symptoms. 2.) R8's Physician Order dated 6/1/23 documents to administer Clonazepam (antianxiety) 1 mg daily at bedtime. R8's Physician Order dated 4/7/22 documents to administer Duloxetine Hydrochloride (antidepressant) 30 mg twice daily for Restless Leg Syndrome. R8's Care Plan dated 3/30/23 documents R8 has a diagnosis of anxiety and symptoms include complaints of pain, asking to go home, and getting upset about no one visiting R8. R8 currently receives Clonazepam and takes Duloxetine for Restless Leg Syndrome. This care plan does not identify specific nonpharmacological interventions to respond to R8's behaviors. R8's Psychotropic Medication Assessments dated 4/20/22, 7/25/22, 10/5/22, 1/5/23, and 3/30/23 document R8 receives Clonazepam 1 mg daily for anxiety, symptoms of increased complaints of pain, wanting to go home, and upset about no one visiting R8. Interventions include one to one, reassurance, and pain medication. These assessments document R8's behaviors have shown improvement and appear controlled. R8's Psychotropic Assessments dated 1/5/23 and 3/30/23 document R8 receives Duloxetine 30 mg twice daily for Restless Leg Syndrome and symptoms include insomnia and feeling like bugs are on R8's legs. Interventions include one to one, repositioning, redirection, and watching television. These assessments document R8's behaviors appear controlled. The Notes to Attending Physician/Prescriber dated 12/22/22 and 4/24/23 document the pharmacy recommendation to reduce R8's Duloxetine to 20 mg twice daily, and includes to document clinical rationale and symptoms exhibited if the reduction is declined. These forms are signed by the physician as declined, but do not document the clinical rationale and evidence of behavioral symptoms. There are no documented behaviors in R8's medical record in December 2022 and April-May 2023. On 6/01/23 at 9:59 AM V2 Director of Nursing stated R8's behaviors are documented on R8's Medication Administration Record, and V2 confirmed R8's May MAR does not prompt the nurse to document R8's behaviors for the use of Clonazepam. 3.) R9's Physician Order dated 5/19/23 documents to administer Fluoxetine (antidepressant) 20 mg by mouth daily and the order dated 5/24/23 documents to administer Fluoxetine 40 mg by mouth daily. R9's Physician Order with a start date of 12/15/22 documents to administer Alprazolam (antianxiety) 0.5 mg daily. R9's Care Plan dated 5/30/23 documents R9 has diagnoses of depression and anxiety, and symptoms that include general complaints, restlessness, insomnia, verbalized depression, and health complaints. R9 takes Prozac and Alprazolam to manage R9's symptoms. This care plan does not include specific nonpharmacological interventions to respond to R9's behaviors. R9's Psychotropic Medication Assessments dated 6/30/22, 9/22/22, 12/19/22, and 3/9/23 document R9 receives Alprazolam 0.5 mg daily for anxiety and behavioral symptoms of increased complaints, restlessness, and insomnia. These assessments document R9's behaviors appear controlled. There are no documented behaviors in R9's nursing notes with nonpharmacological interventions attempted in August-October 2022 or in April-May 2023, prior to initiating Prozac on 5/20/23. R9's MARs do not document R9's behaviors in October 2022, April 2023, or May 2023. The Note to Attending Physician/Prescriber dated 10/24/22 documents a pharmacy recommendation to decrease Alprazolam to 0.25 mg daily, and includes to document clinical rationale and symptoms exhibited if the reduction is declined. This form is signed by the physician as declined, but does not document the clinical rationale and evidence of behavioral symptoms. 4.) R11's Physician Order dated 6/22/22 documents to administer Paxil (antidepressant) 20 mg daily. R11's Care Plan dated 5/23/23 documents R11 has anxiety, and symptoms include agitation, restlessness, and arguing. R11 takes Paxil for anxiety and effective interventions include one to one, activities and watching television. The Note to Attending Physician/Prescriber dated 11/18/22 documents a recommendation to consider reducing Paxil to 10 mg daily, and includes to document clinical rationale and symptoms exhibited if the reduction is declined. This form is signed by the physician as declined, but does not document the clinical rationale and evidence of behavioral symptoms. There are no documented behaviors in R11's nursing notes in October and November 2022, or on R11's November 2022 MAR. R11's Psychotropic Medication Assessments dated 6/28/22, 9/15/22, 12/2/22, 3/8/23, and 5/23/22 documents R11 receives Paxil 20 mg daily for behaviors including agitation, restlessness, wandering, and R11's behaviors appear controlled. On 5/30/23 at 12:31 PM V2 Director of Nursing stated behaviors are documented by the nurses in the nursing notes or on the MAR (Medication Administration Record). On 6/1/23 at 9:59 AM V2 stated nonpharmacological behavioral interventions should be documented on the care plan. At 11:15 AM V2 confirmed the pharmacy recommendations that documents dose reductions declined for R4, R8, R9, and R11 do not document the clinical rational and behavioral symptoms as to why the reduction is contraindicated. The facility's Medication Management policy dated 3/17/23 documents gradual dose reductions of psychotropic drugs will be periodically conducted unless clinically contraindicated. The facility's Psychotropic Medication policy dated 11/28/17 documents the following: Indications for the use of psychotropic medications may include expressions/indicators of distress, symptoms that cause functional decline, and non-pharmacological interventions were implemented and ineffective. Gradual Dose Reductions (GDRs) should be attempted, unless clinically contraindicated, within the first in two separate quarters, and annually after the first year. GDRs may be contraindicated if targeted symptoms returned/worsened after last GDR attempt and the physician has documented the rational for why a reduction is contraindicated.

Based on interview and record review the facility failed to ensure for the appropriate use of antibiotics for residents. This failure affects four of four residents (R8, R9, R10, R12) reviewed for antibiotic stewardship in the sample list of 14. Findings include: The facility's Antimicrobial Stewardship Policy and Procedure with a revised date of February 2022 documents, The purpose of this policy is to ensure the proper and safe use of antimicrobials throughout the facility. The objective of the Antimicrobial Stewardship Program will be to improve patient outcomes through optimization of antimicrobial therapy by selection of appropriate antibiotic dose, route and duration of treatment. 1.) R8's Nursing Note dated 05/06/2023 08:07 PM documents R8 returned from the emergency room with a diagnosis of Urinary Tract Infection (UTI) and orders for Amoxicillin (antibiotic) 250 milligrams (mg) by mouth twice daily for 7 days. R8's May 2023 Medication Administration Record documents R8 received Amoxicillin as ordered from 5/6/23 through 5/13/23. R8's Urine Culture dated as collected on 5/6/23 documents multiple organisms were noted and the urine was likely contaminated. There is no sensitivity report listed to determine if Amoxicillin is the appropriate antibiotic to treat the infection. There is no documentation that another urine culture was obtained. On 5/31/23 at 9:23 AM V2 Director of Nursing stated stated R8's urine culture resulted as probable contaminants and no organism was identified. V2 stated the results are faxed to the physician and the physician lets us know if they want to change the ordered antibiotic. V2 stated the facility utilizes cultures to determine if antibiotics are appropriate. V2 confirmed cultures determine if bacteria is susceptible to the prescribed antibiotic. V2 stated the physician will start an antibiotic and then change it if needed based on the culture results. 2.) R9's Nursing Notes document on 4/6/23 at 3:54 PM R9 complained of hearing and seeing hallucinations including a band playing in the hallway, voices during the night, seeing things growing out of the sidewalk, and hearing a motor running when R9 opened R9's magazine. R9's family reported that R9 had called with the same complaints at 5:00 AM. On 4/7/23 R9's physician gave orders for a urinalysis with culture and sensitivity. There is no documentation that R9 had voiced concerns of UTI symptoms such as pain, burning with urination, frequent urination, or changes in urine characteristics. R9's Physician Order with a start date 4/7/23 and stop date of 4/14/23 documents to administer Ciprofloxacin (antibiotic) 250 mg by mouth twice daily for 7 days for diagnosis of Urinary Tract Infection. R9's April 2023 Medication Administration Record documents R9 received Ciprofloxacin as ordered 4/7/23-4/14/23. R9's Urine Culture dated as collection on 4/7/23 documents there was no bacterial growth, indicating no active infection. On 6/01/23 at 9:35 AM V2 stated R9's antibiotic for UTI was continued based on R9's complaints. V2 confirmed R9's urine culture indicated no bacterial growth. V2 stated the facility goes by what the physicians order. 32853 3.) R10's Face Sheet documents an admitted [DATE] with diagnoses including Unspecified Fracture Upper End of Humerus and Muscle Wasting and Atrophy. R10's Minimum Data Set (MDS) dated [DATE] documents R6 has severe cognitive impairment and documents that R10 is always incontinent of bowel and bladder. R10's medical record documents R10 had a Urinalysis completed on 4/21/23. R10's Laboratory Report documents results of the Urinalysis dated 4/22/23 and documents >100,000 CFU/ml (Colony forming unit/milliliter) Gram Negative Rods and the organism identified as Proteus Mirabilis ESBL (Extended Spectrum Beta-Lactamase). This report documents that it was faxed to the physician on 4/22/23 and 4/23/23. R10's Laboratory Report dated 4/23/23 documents the culture and sensitivity results that Proteus Mirabilis ESBL is resistant to Ciprofloxacin. R10's Nurse's Notes dated 4/21/23 through 5/5/23 document complaints of flank pain, dark urine with a foul odor and blood tinged urine with some blood spots in the adult incontinent brief. These Nurse's Notes document that V7 Physician did not treat R10's Urinary Tract infection until 5/5/23 and then treated the UTI with Ciprofloxacin which was documented as being resistant. On 6/01/23 at 9:36 AM, V2 Director of Nursing confirmed that the Physician didn't want to order an antibiotic he thought it was a fluke. He was going to retest but he ended up treating (R10) later. V2 confirmed there was not a new UA completed before starting the antibiotic and confirmed the Physician treated with Ciprofloxacin which was resistant on the culture and sensitivity report. 4.) R12's Medication Administration Record dated 4/1/23 through 4/30/23 documents R12 was admitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure and Type 2 Diabetes. R12's MDS dated [DATE] documents R12 is cognitively intact and is frequently incontinent of urine. R12's Nurse's Notes dated 4/1/23 documents R12 complained of not feeling well, pain and burning with urination, increased frequency of urination and little amounts of void at times. R12's Nurse's Notes dated 4/2/23 continue to document the same urinary complaints as 4/1/23. R12's Nurse's Notes dated 4/3/23 documents R12 reported blood tinged urine and the Physician was notified. R12's Nurse's Notes dated 4/03/2023 at 5:12 PM by V17 Licensed Practical Nurse documents that V23 R12's Physician returned the call and ordered Macrobid (antibiotic) 100 MG (milligrams) BID (twice a day) X (times) 5. Two capsules pulled from STAT (back up medication supply) safe, and started today. R12's Nurse's Notes dated 4/4/23 and 4/5/23 documents R12 complained of continued urinary urgency. R12's Nurse's Notes dated 4/6/23 documents R12 complained or burning upon urination. R12's Nurse's Notes dated 4/21/23 documents R12 complained of burning with urination and stated there was blood on the toilet paper after urination. R12's Electronic Medication Administration Record dated 4/1/23 through 4/30/23 documents R12 received Nitrofurantin Mono-MCR 100 mg (milligrams) one by mouth twice a day for five days. On 5/31/23 at 11:01 AM, V13 stated that R12's Physician is V23 and V23 sometimes only goes by the symptoms. V13 stated that it's not very easy to get V23 to do any urine cultures. On 6/01/23 at 9:37 AM, V2 Director of Nursing stated that V23 hardly ever orders UA's (Urinalysis). On 6/05/23 at 8:08 AM, V2 confirmed that there was no UA ordered for R12 for the 4/3/23 antibiotic treatment and stated V23 treated R12 according to R12's symptoms and there is no culture.

Based on record review and interview the facility failed to treat a Urinary Tract Infection with a positive Urinalysis and confirmed symptoms for one of one residents (R10) reviewed for Urinary Tract Infections in the sample list of 14. Findings include: R10's Face Sheet documents an admitted [DATE] with diagnoses including Unspecified Fracture Upper End of Humerus and Muscle Wasting and Atrophy. R10's Minimum Data Set (MDS) dated [DATE] documents R6 has severe cognitive impairment and documents that R10 is always incontinent of bowel and bladder. R10's Nurse's Notes dated 4/20/2023 at 5:28 PM by V12 Licensed Practical Nurse (LPN) documents (R10) had an unresponsive episode this afternoon. (R10) was sitting in (reclining geriatric chair) with (spouse) by side. When staff was in room checking on (R10), (R10) went unresponsive and eyes rolled back. Spoke with (Nurse at V7's/R10's Physician's office) and made aware of episode. New order received to straight cath (catheterize) resident for UA (Urinalysis) and C&S (Culture and Sensitivity). (Spouse) here and aware of new orders. Will continue to monitor (R10). R10's Nurse's Notes dated 4/21/2023 at 7:18 AM by V21 LPN documents, UA C&S collected by straight cath using sterile technique per order. R10's Nurse's Notes dated 4/21/2023 at 2:22 PM by V13 LPN documents, UA result faxed to (V7's) office. Tylenol given this morning for flank pain and is effective. Continues to be incontinent of B&B (bowel and bladder) urine is dark and foul smelling. Fluids encouraged but intake is poor and has difficulty swallowing without coughing. R10's Nurse's Notes dated 4/23/2023 at 2:17 PM by V22 LPN documents, U/A C&S results came in from lab and were faxed to both (V7's) office and (V23 Physician's) office as (V23) is on call for (V7). (V23) paged and returned call re: (regarding) results with instructions given to take results to hospital pharmacist and have him call (V23), which was done. (Spouse) asked about results and was informed of the above. R10's Laboratory report dated 4/22/23 documents results of the Urine Culture as >100,000 CFU/ml (Colony forming unit/milliliter) Gram Negative Rods and organism identified as Proteus Mirabilis ESBL (Extended Spectrum Beta-Lactamase). This report documents that it was faxed to the physician on 4/22/23 and 4/23/23. R10's Nurse's Notes dated 4/24/2023 at 11:43 AM by V13 documents, Spoke with (V7's) nurse regarding urine culture result and actions taken by (V23) over the weekend. States the culture is on (V7's) desk for (V7's) review. Urine continues dark with strong odor some drops of blood noted on (incontinent brief) at times. Does complain of lower back pain at times. Tylenol given with some relief. Contact precautions for ESBL in urine. R10's Nurse's Notes dated 4/25/2023 at 2:15 PM by V13 documents, Urine continues unchanged. R10's Nurse's Notes dated 4/26/2023 at 01:48 PM by V13 documents, (V7) here this morning to assess. No new orders at this time. Contact precautions remain in place for ESBL in urine no treatment at this time other than encouraging fluids. Urine is foul and dark on (incontinent brief) scant amounts of blood noted at times. Tylenol given this morning to promote comfort. R10's Nurse's Notes dated 5/04/2023 at 1:54 PM by V13 documents, (R10) continues weak with frequent complaints of pain in random places legs and feet to lower back. Tylenol helps for short periods. Appetite continues to decline eating only a few bites at a meal. Fluids encouraged but little taken. Night shift had report blood tinged urine in brief in the night. Message left for (V7). R10's Nurse's Notes dated 5/05/2023 at 1:53 AM by 21 documents, Call back from (V7's) office. New orders received for Cipro (Ciprofloxacin/antibiotic) PO (by mouth) BID (two times a day) x (times) 10 days. First dose given this shift. No adverse reactions noted from ABT (Antibiotic) for UTI (Urinary Tract Infection). (R10) complaining about lower back pain. PRN Tylenol given' R10's Laboratory Report dated 4/23/23 documents the Proteus Mirabilis ESBL is resistant to Ciprofloxacin. R10's medical record does not document any further urinalysis after the one collected on 4/21/23 before treatment on 5/5/23 (14 days later). On 5/31/23 at 12:45 PM, V13 stated that (R10) was not treated with an antibiotic for the UTI with ESBL on 4/23/23. V13 stated the (V7) decided not to treat. (V13) stated that (V7) went off (R10's) symptoms and (R10) is allergic to all kinds of antibiotics. V13 stated that (V7) did not want a recheck of the urine either. V13 stated that V7 believes (R10) was treated with an antibiotic after that but no UA was done if it's not in the chart and V13 confirmed there is not a UA in the chart after 4/21/23. On 6/01/23 at 9:36 AM, V2 Director of Nursing confirmed that the Physician didn't want to order an antibiotic he thought it was a fluke. He was going to retest but he ended up treating (R10) later. V2 confirmed there was not a new UA completed before starting the antibiotic.

Based on observation, interview, and record review the facility failed to properly store residents respiratory equipment: nebulizer and continuous positive airway pressure masks. This failure affects two of two residents (R118, R67) reviewed for respiratory care in the sample list of 14. Findings include: 1.) On 5/30/23 at 9:18 AM R118 stated R118 uses a nebulizer 3-4 times per day. R118 was asked where R118's nebulizer mask and tubing is stored, and R118 pointed to the overbed table. R118's nebulizer mouthpiece and tubing was lying on the overbed table, uncovered. R118's May 2023 Medication Administration Record documents Budesonide 0.5 milligrams (mg) per 2 milliliters (ml) via nebulizer is scheduled twice daily at 8:00 AM and 5:00 PM, and Ipratropium bromide 0.5 mg/2.5 mg Albuterol 0.5 mg per 3 ml via nebulizer is scheduled three times daily at 5:00 AM, 1:00 PM, and 9:00 PM. On 5/31/23 at 2:38 PM V2 Director of Nursing stated nebulizer equipment, mouthpiece, and tubing should be washed after use, allow to air dry, and then stored in a plastic bag. The facility's undated Nebulizer Treatment policy documents to wash with soap and water every night and air dry. This policy does not address the storage of nebulizer masks/mouthpiece and tubing when not in use. 32853 2.) R67's Order Summary Report dated June 2023 documents diagnoses including Personal history of Malignant Neoplasm of Bronchus, Peripheral Vascular Angioplasty Status, Chronic Obstructive Pulmonary Disease and Sleep Apnea and documents an admitted [DATE]. This Order Summary documents an order dated 5/19/23 for Auto CPAP (Continuous Positive Airway Pressure) 8-13 with 4L O2 (oxygen) bled in on at bedtime. Refill with distilled or sterile water prior to use. Every Sunday at 10:00 AM, Clean CPAP Humidifier, mask/accessory, and tubing. Using milk soapy water and rinse with tap water. Then soak in a solution of one part white distilled vinegar and three parts tap water for approximately 30 minutes, rinse with tap water and air dry weekly. This Order Summary also has an order to empty humidifier and allow to air dry and rinse mask and tubing with tap water and hang to air dry daily. On 5/30/23 at 9:05 AM, R67's CPAP mask was uncovered on the overbed table. On 5/31/23 at 10:01 AM, R67's CPAP mask and tubing were sitting out on the bedside stand uncovered. 06/01/23 11:40 AM V2 Director of Nursing confirmed R67's CPAP mask and tubing were laying out in the open and not covered.

Based on interview and record review the facility failed to offer one or both Centers for Disease Control (CDC) recommended Pneumococcal Disease Vaccines to five (R3, R4, R8, R9, R10) of five residents reviewed for Pneumonia Vaccines in the sample list of 10. Findings Include: 1.) R3's Face Sheet (current) documents R3 was admitted to the facility on [DATE] and is over the age of 65. R3's Immunization Record dated 7/20/22 does not document R3 was offered the PCV 13 (Pneumococcal conjugate vaccine) as required and recommended per CDC. There is also no documentation to indicate R3 has received the PCV (Pneumococcal conjugate vaccine) 15 or the PCV (Pneumococcal conjugate vaccine) 20. 2.) R4's Face Sheet (current) documents R4 was admitted to the facility on [DATE] and is over the age of 65. R4's Immunization Record dated 7/20/22 does not document R4 was offered the PCV 13 (Pneumococcal conjugate vaccine) as required and recommended per CDC. There is also no documentation to indicate R4 has received the PCV (Pneumococcal conjugate vaccine) 15 or the PCV (Pneumococcal conjugate vaccine) 20. 3.) R8's Face Sheet (current) documents R8 was admitted to the facility on [DATE] and is over the age of 65. R8's Immunization Record dated 7/20/22 does not document R8 was offered the PPSV 23 (Pneumococcal polysaccharide vaccine) as required and recommended per CDC. There is also no documentation to indicate R8 has received the PCV (Pneumococcal conjugate vaccine) 15 or the PCV (Pneumococcal conjugate vaccine) 20. 4.) R9's Face Sheet (current) documents R9 was admitted to the facility on [DATE] and is over the age of 65. R9's Immunization Record dated 7/20/22 does not document R9 was offered the PCV 13 (Pneumococcal conjugate vaccine) as required and recommended per CDC. There is also no documentation to indicate R9 has received the PCV (Pneumococcal conjugate vaccine) 15 or the PCV (Pneumococcal conjugate vaccine) 20. 5.) R10's Face Sheet (current) documents R10 was admitted to the facility on [DATE] and is over the age of 65. R10's Immunization Record dated 7/20/22 does not document R10 was offered the PCV 13 (Pneumococcal conjugate vaccine) as required and recommended per CDC. There is also no documentation to indicate R10 has received the PCV (Pneumococcal conjugate vaccine) 15 or the PCV (Pneumococcal conjugate vaccine) 20. On 7/20/22 at 2:20 pm, V2 Director of Nursing confirmed the facility does not offer or give information on the various types of Pneumonia Vaccines other than PPSV 23. V2 stated that the facility's contracted Pharmacy attended June's Quality Assurance meeting and brought the CDC guidelines on recommended Pneumonia Vaccines and the facility has not yet updated their policy and implemented these other CDC recommended Pneumonia Vaccines. V2 stated Our Pneumonia Vaccine Policy is out of date and we just did not have these updated recommendations in place.

Based on record review, observation and interview the facility failed to prevent cross contamination during wound care by using contaminated gloves to provide wound care for one (R13) of two residents reviewed for wound care in a sample list of 13 residents. Findings include: R13's Physician order [REDACTED]. This same POS also documents [REDACTED]. R13's Care Plan documents R13 as frequently incontinent and at risk for skin breakdown due to limited mobility, incontinence and need for staff assistance with bed mobility and positioning. Minimum Data Set (MDS) for R13 dated 1-29-2020 documents a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 points (severely cognitively impaired). This same MDS documents R13 requires extensive assistance of two staff for bed mobility, transfers and toileting. On 03/11/20 at 10:40 AM V3, Licensed Practical Nurse completed wound care for R13's open inner Right Buttock Boil recently infected [MEDICAL CONDITION] and R13's open areas on inner Left Buttock. R13 was standing in front of commode that contained moderate sized bowel movement with back of R13's legs touching front of commode chair. Commode had not been emptied nor cleaned. R13 became tired after V3 cleansed R13's inner buttock wounds and sat down on soiled commode seat. R13 again stood to complete wound care. With gloved hands, V3 used V3's third finger on right hand to apply aloe/calmo cream to R13's open inner right buttock boil and then without changing gloves, washing hands or using Alcohol Based Hand Rub (ABHR), V3 used same contaminated gloved finger to apply aloe/calmo cream to open inner left buttock wounds. On 3/11/2020 at 11:00 AM V3 stated should have cleansed commode bucket before attempting treatment for [REDACTED]. V3 stated should treat each wound individually to prevent cross contamination of wounds. On 3/11/2020 at 3:30 PM V2, Director of Nurses stated nurses should treat one wound at a time in order to prevent cross contamination during wound care. The facility policy titled Wound Care Observation Checklist for Infection Control which is undated documents the following: 1. Multi-dose wound care medications (ointments, creams) should be dedicated to a single resident whenever possible or a small amount of medication should be aliquoted into a clean container for single-resident use; 2. Gloves should be changed and hand hygiene performed when moving from dirty to clean wound care activities. 4. Aseptic non-touch technique refers to a procedure that aims to prevent the transmission of microorganisms to the wound. Clean gloves should not directly come in contact with the wound bed. Sterile applicators should be used to apply medications. 5. In addition to reusable medical equipment, any surface in the patient/resident's immediate care area contaminated during a dressing change should be cleaned and disinfected.

Based on record review, observation and record review the facility failed to prevent cross contamination during wound care for a Stage II pressure wound on one (R165) resident out of two residents reviewed for wound care in a sample list of 13 residents. Findings include: Physician order [REDACTED]. R165's Care Plan documents a Stage II pressure ulcer on left buttock. Minimum Data Set ((MDS) dated [DATE] documents R165's Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15 points which indicates moderately cognitively impaired. This same MDS also documents R165 as requiring limited assistance of one staff for bed mobility, transfers, toilet use and personal hygiene. On 03/11/20 at 9:10 AM V3, Licensed Practical Nurse completed pressure wound care for R165's Stage II pressure ulcer on left buttock. V3 placed wound cleanser, gauze and physician ordered cream on back of bathroom sink in R165's bathroom. V3 did not clean sink off or place clean towel down to create clean field before placing wound supplies on back of contaminated sink. V3 touched R165's buttocks including open pressure ulcer on left buttock then wearing same contaminated gloves and without washing hands, changing gloves or using Alcohol Based Hand Rub (ABHR), picked up gauze and cleansed R165's left buttock pressure ulcer with contaminated gauze. On 3/11/20 at 9:25 AM, V3 stated staff should provide a clean field for supplies when completing wound care. V3 also stated should have changed gloves, used ABHR, or washed hands between touching R165's open wound and using wound supplies. On 3/11/20 at 3:35 PM V2, Director of Nursing stated nurses should provide clean field for wound supplies when completing wound care. V2 also stated staff should change gloves, wash hands or ABHR when moving from a contaminated area to a clean area to prevent cross contamination. The facility policy titled Pressure Injury/Skin Tear Management revised 7/19 documents the following: Procedure: Disinfect the resident's bedside table with disinfectant wipe. Place supplies on the clean table. Trying to arrange them according to order of use to avoid any cross contamination. The facility policy titled Hand Hygiene-CDC (Centers for Disease Control) Guidelines revised 4/19 documents the following: Policy: All staff shall use the hand-hygiene techniques, as set forth in the following procedure. Hand hygiene consist of either use of soap and water or ABHR. Follows are times when hand hygiene must be performed: *After coming in contact with patient's intact skin. *After coming in contact with bodily fluids, dressings, etc., and hands are not visible soiled. If hands are not visible soiled, hands may be disinfected with either an ABHR or soap and water. Notes: Always follow Standard Precautions.

Based on record review, observation and interview the facility failed to provide complete incontinence care for one (R1) resident reviewed for incontinence care in a sample list of 13 residents. Findings Include: R1's Face Sheet documents [DIAGNOSES REDACTED]. R1's Care Plan documents R1 is frequently incontinent and needs assistance with hygiene and perineal care. Minimum Data Set ((MDS) dated [DATE] documents R1 as requiring extensive assistance of two staff for toileting. This same MDS documents R1 as being frequently incontinent of urine. R1's Physician order [REDACTED]. On 03/11/20 at 12:40 PM V4 Certified Nurse Aide (CNA) performed incontinence care for R1. V4 placed no rinse foam cleanser on disposable wipe and wiped R1's perineal area one time while R1 was standing with V4 standing behind R1. V4 cleansed R1's perineal area by approaching from R1's backside. V4 did not approach R1 from the front. V4 without changing gloves, using Alcohol Based Hand Rub (ABHR) or washing hands then used a second disposable wipe to rinse R1's perineal area. Approximately quarter sized saturated area of brown substance observed on both wipes after V4 wiped R1's perineal area. V4 used each of the two disposable wipes to wipe one time with each wipe. V4 did not cleanse inner perineal area. V4 did not dry perineal area. On 3/11/2020 at 12:50 PM V4 stated should have provided complete incontinence care but could not due to V4 could not see area to be cleansed. V4 stated should use skin cleanser on outer perineal area and folds of inner perineal area and should dry area thoroughly when performing complete incontinence care. On 3/11/2020 at 3:40 PM V2, Director of Nursing stated staff should provide complete incontinence care including thorough cleansing of outer and inner perineal area followed by thorough drying of perineal area. The facility policy titled Foley Catheter/Perineal Care revised 10/15 documents the following: Female patient: Clean sides of labia first in downward motion, washing from front to back with soap and water or no rinse soap. Separate labia with one hand and wash with other, using gentle downward [MEDICAL CONDITION] from the front to the back, using a clean section of the washcloth with each stroke. Avoid cleaning the rectum at the same time as the vagina to avoid contamination of the urethra or vagina. Using a clean washcloth, gently rinse the vaginal area and pat dry with a clean, dry towel. Turn patient on side, cleanse rectum with clean wash cloth using soap and water or no rinse soap. Use front to back motion, using clean area of cloth with each stroke. Use clean wash cloth to rinse and a clean towel to gently pat dry area.

Based on observation, record review and interview the facility failed to ensure that a hard surface chemical sanitizer used for food contact surface cleaning was maintained at an effective concentration and failed to maintain resident personal water pitchers free of mineral deposits. This had the potential to affect all 14 residents. The findings include: On 02/25/19 9:32 AM a spray bottle of a clear liquid was on the food preparation counter in the dietary department. The label on the bottle was illegible. V3 Dietary Manager (DM) stated at that time this was the sanitizer for surface sanitizing. The facility's test kit for quaternary ammonium was used at that time to test the chemical concentration. The test strip turned yellow which indicated no measurable sanitizer. Another spray bottle of sanitizer was hanging on the ledge of the three compartment sink. This sanitizer bottle had a label that identified it as a quaternary ammonium sanitizer. The chemical test strip also registered no measurable sanitizer. Dietary V7 stated at 9:40 am the sanitizer bottle was last refilled from the sink dispenser at 4:00 am that morning. DM V3 stated the concentration of the sanitizer should be at 200 parts per million (ppm) quaternary ammonium. 02/25/19 9:58 AM V3 checked the chemical right out of chemical dispenser and it registered no measurable ppm sanitizer. There was air in the draw tube between the chemical reservoir and the dispenser. After running the sanitizer longer it registered at 200 ppm. The manufacturer's label for the sanitizer listed the concentration range for sanitizing at 200-400 ppm. 2. On 02/27/19 08:30 AM a cart with 39 inverted plastic water pitchers was in the clean utility room. There were white lime (mineral) deposits on the inside bottom of most of the water pitchers. V4 Certified Nurse Aide (CNA) stated at that time water pitchers are changed each day and are sent to the dietary department for washing. V4 stated the inverted pitchers are clean pitchers. On 2/27/19 at 9:00 AM V1 Administrator was shown the water pitchers with the mineral deposits. V1 confirmed the water pitchers needed to be delimed. On 2/27/19 at 11:40 AM V3 Dietary Manager stated the water pitchers come up from the Annex every afternoon. The water pitchers are inverted on a cart and then go into the dishmachine and are placed wet inverted back on the cart. V3 stated the dietary staff had not noticed the lime build up inside the resident water pitchers. V3 stated the lime can be removed with a vinegar soak. The facility Resident Census and Conditions of Residents form dated 2/25/19 documented a census of 14 residents.

Based on interview and record review, the facility failed to safely transfer R8 by failing to follow the manufacturer's instructions for a mechanical lift, resulting in a fall for one of three residents (R8) reviewed for falls in the sample of eight. Findings include: R8's Face Sheet dated 2/27/19 documents R8 has [DIAGNOSES REDACTED]. R8's Minimum Data Set ((MDS) dated [DATE] documents R8 has short and long term memory impairment, and R8 is severely impaired with daily decision making. This MDS documents R8 has total dependence of two or more staff for transfers. R8's Fall Assessments dated 7/17/18 and 10/10/18 document a score of 11 indicating R8 is at moderate risk for falls. R8's Care Plan dated 1/10/19 documents R8 is dependent upon two staff and the use of a mechanical lift for transfers. This Care Plan documents R8 is at risk for falls due to [MEDICAL CONDITION] and documents an intervention dated 11/8/18 to re-educate staff on mechanical lift transfers and techniques. R8's Nurses Note dated 11/8/18 at 2:01 PM documents two unidentified Certified Nursing Assistants (CNAs) transferred R8 from the bed to the wheelchair with a mechanical lift. This note documents when R8's legs were moved from the bed, the strap on the mechanical lift sling came unhooked from the mechanical lift causing R8 to fall to the floor. The Note documents R8's left cheek and shoulder hit the floor, and pinkness was noted to R8's left cheek. R8's Nurses Note dated 11/13/18 at 5:56 AM documents R8 had bruising to the left cheek and left shoulder from previous fall. R8's Incident Report dated 11/8/18 documents a summary by V2 Director of Nursing (DON) of R8's fall investigation. This summary documents attempts were made to re-enact the cause of R8's fall, but was unsuccessful. This summary documents staff were interviewed, but does not document the names of the staff interviewed or their statements. This summary documents R8's fall intervention as providing re-education to staff on proper transfer techniques using the full mechanical lift, and observations are to be completed of each CNA (unidentified) performing a mechanical lift transfer in accordance with the facility's (Mechanical lift) Use Competency. On 2/26/19 at 12:57 PM V2 DON stated V8 and V11 were the CNA's involved in R8's fall on 11/8/18. V2 stated the strap of the sling slipped off of the mechanical lift causing R8's fall. On 2/26/19 at 1:24 PM V8 CNA stated on 11/8/18 V8 and V11 CNA, were transferring R8 from R8's bed to the wheelchair. V8 stated V8 had hold of R8's feet and when V8 lifted R8's legs, one of the straps of the sling holding R8's legs slipped off of the mechanical lift causing R8 to slip out of the sling and onto the floor. V8 stated the mechanical lift does not have safety hooks to keep the strap of the sling from slipping off of the mechanical lift. V8 stated R8 was not fully lifted in the air off of the bed prior to V8 moving and lifting R8's legs, causing the sling strap to slip off of the mechanical lift. V8 was asked if R8 had been fully suspended in the air, would R8's weight have prevented the strap from slipping off of the mechanical lift and prevented R8's fall. V8 replied yes. On 2/27/19 at 8:58 AM V2 DON stated V2 does not have written statements or interviews from V8 or V11 regarding R8's fall on 11/8/18. The facility's undated (Mechanical Lift) Use Competency documents to demonstrate a mechanical lift transfer, including placing the sling beneath the resident, and lifting the resident into a sitting position until the resident's buttocks clear the bed by 1 to 2 inches. The User-Service Manual for the mechanical lift dated 2008, documents a warning to follow lifting instructions from the manual titled How to Use a Patient Lifter. The undated manual titled How to Use a Patient Lifter documents when performing a mechanical lift transfer from the bed, raise the mechanical lift until the resident's buttocks are above the bed surface, and then grasp the resident's legs to position the resident's legs over the side of the bed. This manual documents not to push or pull the resident off of the bed, and suggests lowering the bed if the resident can not be lifted above the surface of the bed.

Based on observation, interview and record review the facility failed to assess resident bed rails for entrapment risk for eight of eight residents ( R1, R8, R7, R12, R5, R9, R10 and R14) reviewed for bed rails in the sample of eight residents and four residents (R2, R4, R3 and R13) off the sample. Findings include: During the building tour of the 200 Wing Certified Unit on 2/26/19 at 12:20 PM R1, R2, R3, R4, R5, R7, R8, R9, R10, R13, R14 and R12 had upper bed rails on their beds. The beds for R1, R4, and R14 had bedrails that had large openings between the rails of the bedrails that could pose an entrapment hazard. Examples include: 1. The Physician order [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents R4 is moderately cognitively impaired and that R4 requires extensive assistance with bed mobility and transfers. The Care Plan dated 2/7/19 documents R4 is legally blind and hearing impaired. The Care Plan dated 2/7/19 documents R4 uses bilateral half bed rails to assist with bed mobility and repositioning. On 2/25/19 at 10:00 am R4 was in bed with a bed rail in the up position. On 2/26/19 at 10:15 am V2 Director of Nurses stated V2 does not have a paper assessment for resident beds for entrapment risk. V2 stated V2 does not measure the gaps inside resident's bed rails but V2 completes a visual assessment for entrapment risk. At that time V2 provided an undated guideline for assessing bed rail entrapment risk entitled Assessment/evaluation for Conformance to FDA's (Food and Drug Administration) Bed System Entrapment Zones. The guideline states the open area within a bed rail (Zone 1) should be less than 4 and 3/4 (four and three quarter) inches, representing head breadth. On 2/26/19 at 2:05 PM the three spaces within R4's bed rails were measured with V2 present. The three openings in R4's bed rails measured seven by seven and a half inches. At that time V2 confirmed the open areas within R4's bed rails are larger than the recommended maximum space of less than four and three quarters inches. 2. The Physician order [REDACTED]. The Care Plan updated 12/10/18 documents R14 has a history of falls, transfers with staff assistance, a gait belt and a walker and that R14 uses half side rails to assist with bed mobility and repositioning. On 02/26/19 at 1:47 PM R14 stated staff always put R14's bed rails up when R14 is in the bed. On 2/26/19 at 10:15 am V2 Director of Nurses stated V2 does not have a paper assessment for resident beds for entrapment risk. V2 stated V2 does not measure the gaps inside resident's bed rails but V2 completes a visual assessment for entrapment risk. At that time V2 provided an undated guideline for assessing bed rail entrapment risk entitled Assessment/evaluation for Conformance to FDA's (Food and Drug Administration) Bed System Entrapment Zones. The guideline states the open area within a bed rail should be less than 4 and 3/4 (four and three quarter) inches, representing head breadth. On 2/26/19 at 2:00 PM the three spaces within R14's bed rails were measured with V2 present. Two of the three spaces within the bed rail measured six and a half inches by seven inches and one of the spaces within the bed rail measured seven by seven inches. At that time V2 confirmed the open areas within R14's bed rails are larger than the recommended maximum space of less than four and three quarters inches. 3. The Physician order [REDACTED]. The Minimum (MDS) data set [DATE] documents R1 is severely cognitively impaired and requires extensive assistance from staff for bed mobility. The Care Plan dated 1/11/19 documents R1 uses half upper side rails to assist with bed mobility and repositioning. On 2/26/19 at 9:00 AM R1 was in bed positioned on R1's side with bilateral half side rails in the up position. On 2/26/19 at 10:15 AM V2 stated V2 does not have documentation of an assessment of R1's bed and bed rails for entrapment risk. On 2/26/19 at 10:30 AM V9 Maintenance Director stated the maintenance staff complete annual bed inspections for defects in the facility's beds but they do not assess the beds or bed rails for risk of entrapment or measure the gaps within the bed rails or between the bed rails and the mattress. On 2/26/19 at 2:20 PM V1 Administrator stated the guideline Assessment/evaluation for Conformance to FDA's (Food and Drug Administration) Bed System Entrapment Zones is the facility's standard operating procedure. V1 stated staff should be evaluating resident bed rails for entrapment risk. At that time V1 could not provide documentation of bed rail entrapment risk assessments for any resident bed with bed rails in the facility (including those also occupied by R2, R3, R5, R7, R8, R9, R10, and R13). V1 stated V1 thought the maintenance staff were assessing resident beds and bed rails to ensure they met the guideline. 4. On 2/25/19 at 9:31am, V5 CNA, (Certified Nursing Assistant) and V6, CNA, assisted R12 to bed, then pulled up the top bilateral upper side rails. During care R12 did not attempt to use the side rails for positioning with the encouragement of V5 and V6. R12's Side rail Assessment and Consent, dated 1/10/19, documents that R12 is to utilize the side rails to sit up in bed, and encourage R12 to participate in bed mobility by using hand over hand assistance. 02/26/19 11:00 AM, V2, Director of Nursing, stated that maintenance does not do any entrapment risk assessment, for any of the beds with side rails.

Based on interview and record review the facility failed to ensure staff followed facility policies and plan of care for safe transfer for R1 and R2. R1 was transferred without the use of a gait belt resulting in R1 falling receiving craniocerebral injuries. R2 was improperly transferred with a mechanical lift resulting in R2 falling from the mechanical lift receiving orbital and frontal sinus fractures. R1 and R2 are two of three residents reviewed for falls in a sample of three. Findings include: 1. R1's physician's orders [REDACTED]. The same POS documents R1 receives anti-coagulation therapy with the following medications: [REDACTED]. R1's fall assessment dated [DATE] documents R1 was moderate risk for falls. R1's MDS (Minimum Data Set) dated 12/4/18 documents R1 is cognitively intact, requires extensive assist with one staff for transfers and R1's balance is not steady requiring one staff assist to be stabilized. R1's care plan dated 12/13/18 documents R1 ambulates with a walker with extensive assist of one staff. Facility Incident Report dated 12/18/18 documents R1 fell at 10 PM. R1 was being assisted out of the restroom with staff and lost R1's balance. R1 fell backwards and hit R1's head on the door. R1 has a hematoma to the back right side of R1's head that was bleeding. R1 was alert per R1's norm and answers all questions appropriately. ROM (Range of Motion) assessed to upper and lower extremities, within normal limits. R1 denied any hip or leg pain. No internal or external rotation noted to lower extremities. Upper extremities ROM assessed R1 denies any pain or discomfort. Hematoma with abrasion to back right side of head. R1's Nurses Notes dated 12/19/18 at 12:07AM state (R1) fell at 10 PM. (R1) was being assisted out of the restroom with staff and lost R1's balance. (R1) fell backwards and hit (R1's) head on the door. (R1) has a hematoma to the back right side of (R1's) head that was bleeding. (R1) alert per norm and answers all questions appropriately. ROM assessed to upper and lower extremities, WNL (within normal limits). (R1) denied any hip or leg pain. No internal or external rotation noted to lower extremities. Upper extremities ROM assessed. (R1) denies any pain or discomfort. (R1) stated tailbone and the back of head hurt. (R1) was assisted up with staff assistance to wheelchair. (R1) again denies any pain or discomfort to upper or lower extremities with transfer. Vital Signs 97.8(Temperature), 67(Pulse), 20(Respiration), 203/82(Blood Pressure), 97% oxygen room air. Area to back of the head cleansed and assessed. (R1) assisted to recliner in room with staff assistance. Neuros(Neurological checks) initiated. (R1) complained of increasing pain to tailbone and head. (R1) states (R1) feels tired and off. Physician notified of the fall and (R1's) condition. Order received to send (R1) to emergency room . R1's Nurses Note on 12/19/18 at 1:31 AM states emergency room called to give report on (R1) and (R1) is being transferred to another hospital. R1's Hospital Emergency Department Discharge Summary dated 12/20/18 documents under Discharge Diagnosis: [REDACTED]. Section titled Impression documents There is interval progression of [MEDICAL CONDITION] (bleeding in near the brain), left-sided subdural hemorrhage, hemorrhagic parenchymal contusion and traumatic subarachnoid hemorrhage is demonstrated. V4, CNA (Certified Nursing Assistant) stated on 1/2/19 at 2:40 PM, (R1) and I went to the restroom (R1) pulled her own pants up after she was done. I was standing right next to her. (R1) stood up from the toilet and pulled up (R1's) pants. (R1) and I walked out of the bathroom shut the bathroom's door we were facing her room we were walking toward the sink for (R1) to wash her hands in the sink which is in the resident's room not the bathroom. I was standing right next to (R1) and (R1) just fell straight back. No, I did not have a gait belt on (R1) or I was not touching her. I was just standing right next to her. I don't work the annex part, I work in OB. I was floated to that area because they needed help. I asked the staff how (R1) transferred and the staff stated (R1) uses her walker. (R1) was not unsteady with gait, (R1) was sitting in her recliner chair and (R1) stood straight up and I handed (R1) her walker. (R1) was not unsteady at all with walking. We went into the bathroom. (R1) was finished and we walked out to the sink and I saw (R1) fall back, I tried to grab (R1) but it happened so fast. V2, Director of Nurses (DON) stated on 1/2/19 at 2:50 PM (V4) was standing by (R1's) left side from our interview with (V4). There was no gait belt on (R1). (R1) was considered extensive assist. One person assist. Facility policy requires a gait belt to be use on all transfers requiring assistance. (R1) should have had a gait belt on during the transfer. The facility's undated policy titled Gait Belt Use states A gait belt must be used, if there are no contraindications, every time a resident is transferred or ambulated with assistance. If a gait belt is used, you must have at least one hand on the gait belt supporting the resident at all times. 2. R2's Face Sheet dated 1/3/19 lists the following Diagnosis: [REDACTED]. R2's fall assessments dated 2/16/18 documents R2 to be at high risk for falls. R2's MDS assessment dated [DATE] documents R2 to be severely cognitively impaired, and totally dependent on two staff persons for all transfers. R2's care plan dated 11/7/18 documents R2 requires two staff assist with transfers and R2 to be transferred with a mechanical lift. The Facility's form dated 5/8/18 titled Resident Incident Report documents R2 had a fall on 5/8/18 at 7:15 PM. Section titled Narrative of Incident and Description of Injuries documents (R2) jerked during transfer per mechanical lift and fell to the floor approximately 4 feet landing on left side, hitting left side of (R2's) head on lower bar of mechanical lift. Noted laceration to the left side of head and blood coming from (R2's) mouth. Applied pressure to open area on head and called ambulance for transfer. R2's Nurses notes dated 5/8/18 at 8:06 PM documents Nurse was called to room at 7:15 PM per CNA(V5) and upon entering the room I saw (R2) on the floor between the bottom bars of mechanical lift on (R2) left side with blood on left side of head and coming from the mouth. CNA (V5) states she was transferring (R2) to bed per mechanical lift and (R2) jerked causing (R2) to fall to the floor approximately 4 feet landing on left side with left side of head hitting the bar at the base of the mechanical lift. R2's Hospital Emergency Department Summary Report documents under History of Present Illness: (R1) fell at nursing home from mechanical lift, approximately 4 feet, complains of facial trauma, epistaxis, left eyebrow laceration and neck pain. Section titled Diagnosis: [REDACTED]. Facility undated Mechanical Lift Policy documents All Mechanical Lift transfers should be with two assist. V2, DON stated on 1/2/19 at 2:50 PM (R2's) injury was due to improper transfer with the mechanical lift. The CNA (V5) was removed from the floor immediately and was terminated the next day. The facility's mechanical lift policy states there must be 2 people to use the mechanical lift. V2 confirmed only V5 was present during R2's mechanical lift.

Based on interview and record review the facility failed to safely transfer one of three residents (R1) reviewed for falls in a sample of three which resulted in the resident (R1) falling causing a humerus and femur fracture. Findings include: The Incident Report dated 1/6/17 documents on 1/2/17 R1 was being assisted by E3 Certified Nursing Assistant CNA from the commode to her bed. R1 was standing with her walker when she lost her balance and fell . R1 complained of pain to her right arm and right leg. X-rays revealed a fractured right humerus and fractured right femur. R1 was admitted to the hospital and underwent surgery to repair the right femur fracture. The Minimum Data Set MDS dated [DATE] documents R1 required extensive assistance of at least one staff member for transfers and toileting. The MDS documents R1 is not steady and is only able to stabilize self with staff assistance when moving from a seated to standing position or moving on and off the toilet. The Care Plan dated 11/28/16 documents R1 required one assist with transfers and is at high risk for falls. On 1/18/17 at 4:05 PM E7 Care Plan and MDS Coordinator stated the documentation in the Care Plan of R1 requiring one assist with transfers, means that R1 requires one staff member to assist her (R1) using a gait belt and keeping their hands on her at all times. E7 stated the MDS documentation of extensive assistance of one staff member means R1 required the staff member to do 50% or more of the work and should be using a gait belt while actively supporting the resident. E7 stated that the CNA (E3) who was helping R1 transfer on 1/2/17 should have been using a gait belt and should have been hands on at all times while the transfer was in process. On 1/18/17 at 10:19 AM E3 CNA confirmed she was the CNA that was assisting R1 with transferring back to bed from the commode when she fell on [DATE]. E3 stated she did not use a gait belt during the transfer and that she was not aware that she needed to use a agit belt with R1 during transfers. E3 stated that she turned to move the commode away from R1's bed and she did not have hands or eyes on R1 at the time of her fall. On 1/18/17 at 11:15 AM Z1 Physician confirmed R1 sustained a right femur fracture and right humerus fracture from the fall that occurred on 1/2/17. The X-ray test dated 1/3/17 documents the indication for the test to be, pain and deformity after falling. The x-ray results document an, acute oblique fracture involving the mid shaft of the right femur and a fracture through the surgical neck of the right humerus with mild impaction. On 1/19/17 at 9:00 AM E1 Administrator acknowledged that E3 CNA should have put a gait belt on R1 while transferring her and stated E3 was disciplined for not using the gait belt when assisting residents with transfers and mobility.