Every finding on record at Good Samaritan - Lemars

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report from Fiscal Quarter 1, 2025 (October 1 - December 31) review, facility staffing review, and staff interviews, the facility failed to meet staffing requirements in three metrics. The facility reported a census of 57 residents. Findings include: The PBJ Staffing Data Report with a run date of 4/9/25 triggered submitted weekend staffing data excessively low within the quarter. Review of staffing for nurses and Certified Nursing Assistants (CNAs) scheduled similarly for weekdays and weekends. In an interview on 4/16/25 at 11:34 AM, the DON reported she reviewed the PBJ with the Administrator yesterday and determined the incorrect information was reported due to a glitch at the main campus. In an interview on 4/16/25 at 12:04 PM, the Administrator reported he reviewed staffing and doesn't know why excessively low staffing triggered other than having more office staff working on weekdays. The Administrator reported he planned to look into things. The Administrator reported the facility failed to have a policy regarding PBJ.

Based on record review and staff interview, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for 1 of 14 resident's reviewed (Resident #38). The facility reported a census of 54 residents. Findings include: According to the MDS assessment dated [DATE], Resident #38 demonstrated long and short term memory problems and severely impaired skills for daily decision making. The resident had diagnoses including non-Alzheimer's dementia. The MDS documented the resident exhibited no behaviors in the 7 day look back period. The Care Plan revised 4/9/25 included the resident was on antipsychotic medication therapy related to a diagnosis of end-stage Alzheimer's and Dementia evidenced by episodes of hitting, yelling, and uncooperative with cares, with the need for scheduled Haldol (antipsychotic). Continued slow dose reduction. The Progress Notes dated 1/6/25 at 8:57 p.m. documented the resident received Ativan (antianxiety) 1 mg for the resident yelling out and unable to rest. The Progress Notes dated 1/7/25 at 3:48 p.m. documented the resident was very vocal most of the shift yelling, calling out, and yelling at people at meals. At 7:16 p.m. when doing eye drops the resident [NAME] chanting no at the charge nurse. At 10:36 p.m. the resident yelling out once awake from nap for supper. A one time dose of Ativan and Haldol administered. The resident continued to yell out for the rest of night. She fell asleep at 10 p.m. The Progress Notes dated 1/8/25 at 7:30 a.m. documented the resident was very vocal during breakfast, yelling and making loud noise, upsetting other residents. At 8:41 a.m. the nurse checked on the resident at the beginning of the shift. The resident attempted to hit the nurse while the nurse adjusted her blanket. On 4/17/25 at 9:13 a.m. the MDS Coordinator stated the 1/10/25 MDS should have included the residents behaviors. The Centers for Medicare and Medicaid Services (CMS)'s Resident Assessment Instrument (RAI) Version 3.0 Manual, Section E for behavior, documented the intent for the items in the section to identify behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care environment. These behaviors may place the resident at risk for injury, isolation, and inactivity and may also indicate unrecognized needs, preferences or illness. Behaviors included those that were potentially harmful to the resident themselves. The emphasis was identifying behaviors, which did not necessarily imply a medical diagnosis. Identification of the frequency and the impact of behavioral symptoms on the resident and on others was critical to distinguish behaviors that constituted problems from those that were not problematic. Once the frequency and impact of behavioral symptoms were accurately determined, follow-up evaluation and care plan interventions could be developed to improve the symptoms or reduce their impact. Steps for assessment included: a. Review of the medical record for the 7-day look-back period. b. Interview of staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7-day look-back period, including family or friends who visited frequently or had frequent contact with the resident. c. Observation of the resident in a variety of situations during the 7-day look-back period. Coding Instructions included: Code 0, behavior not exhibited: if the behavioral symptoms were not present in the last 7 days. Used this code if the symptom had never been exhibited or if it previously had been exhibited but had been absent in the last 7 days. Code 1, behavior of this type occurred 1-3 days: if the behavior was exhibited 1-3 days of the last 7 days, regardless of the number or severity of episodes that occurred on any one of those days. Code 2, behavior of this type occurred 4-6 days, but less than daily: if the behavior was exhibited 4-6 of the last 7 days, regardless of the number or severity of episodes that occurred on any of those days. Code 3, behavior of this type occurred daily: if the behavior was exhibited daily, regardless of the number or severity of episodes that occurred on any of those days.

Based on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for 1 out of 14 residents included in the comprehensive care plans (Resident #53). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #53 documented diagnoses of depression and anxiety disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Review of Resident #53's April Medication Administration Record (MAR) revealed the following orders: a. Furosemide tablet (diuretic medication) daily with a start date of 12/12/24 b. Halperidol tablet (antipsychotic medication) 3 times daily with a start date of 3/4/25 c. Lispro Injection (insulin, diabetic medication) before meals with a start date of 2/11/25 d. Lantus Solostar Injection (insulin, diabetic medication) daily with a start date of 3/26/25 e. Spirolactone tablet (diuretic medication) daily with a start date of 12/12/24 Review of Resident #53's Order Summary Report signed and dated 4/8/25 revealed the following orders: a. Furosemide tablet daily with an order date of 12/11/24 b. Halperidol tablet 3 times daily with an order date of 3/4/25 c. Lispro injection before meals with an order date of 2/11/25 d. Lantus Solostar daily with an order date of 3/25/25 e. Spirolactone tablet daily with an order date of 12/11/25 Review of the Care Plan with a revised date of 2/17/25 lacked the following things: a. Specific side effects to watch for with the usage of diabetic medication. b. Specific side effects to watch for with the usage of antipsychotic medication. c. Specific side effects to watch for with the usage of diuretic medications. Review of the facility provided policy titled Care Plan dated 12/2/24 revealed each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident ' s optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Interview on 4/16/25 at 11:32 a.m., with the Director of Nursing revealed she expects the care plan to include side effects for high risk medications.

Based on clinical record review and staff interview the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 1 of 5 residents reviewed (Resident #53). The facility reported a census of 57 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #53 documented diagnoses of depression and anxiety disorder. The MDS showed the Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Review of Resident #53's April Medication Administration Record revealed the following orders: a. Cymbalta capsule (antidepressant medication) daily with a start date of 1/21/25 b. Haleridol tablet (antipsychotic medication) 3 times daily with a start date of 3/4/25 Review of signed Order Summary Report signed 4/8/25 revealed the following orders: a. Cymbalta capsule daily with an order date of 1/21/25 b. Halperidol tablet 3 times daily with an order date of 3/4/25 Review of the Care Plan with a revision date of 2/17/25 lacked information on non-pharmacological interventions, targeted behaviors and side effects to watch for in antipsychotic medication usage and targeted behaviors with the use of anti-depressant medication usage. The facility does not have a policy on unnecessary medication usage. Interview on 4/16/25 at 11:32 a.m., with the Director of Nursing revealed she expects the care plan to include non-pharmacological interventions and targeted behaviors with usage of psychotropic medications.

Based on clinical record review and staff interview the facility failed to revise and update Care Plans to include and address high risk medications and side effects to watch for in 2 out of 15 sampled residents reviewed for Comprehensive Care Plans (Resident #17 & #30). The facility reported a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 documented diagnoses of diabetes mellitus and hypertension. The MDS showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. Review of the April 2024 Medication Administration Record (MAR) revealed the following orders: a. Insulin Glargine-Lixisenatide (diabetic medication) with a start date of 7/12/23. Review of the MDS dated [DATE] revealed diabetic medication and insulin injection taken 7 out of 7 days in the look back period. Review of the Medication Review Report signed 3/13/24 revealed the following orders: a. Insulin Glargine-Lixisenatide with a start date of 7/12/23. Review of the Care Plan undated lacked information regarding the usage and side effects of insulin injections. 2. The MDS assessment dated [DATE] for Resident #30 documented diagnoses of diabetes mellitus, edema and hypertension. The MDS showed a Brief Interview for Mental Status (BIMS) score of 13 indicating no cognitive impairment. Review of the April 2024 MAR revealed the following orders: a. Lasix with a start date of 1/25/24. b. Lantus Insulin (diabetic medication) with a start date of 2/15/24 with a discontinuation date of 4/8/24. c. Tresiba (diabetic medication) with a start date of 4/9/24. Review of the MDS dated [DATE] revealed diabetic medication and insulin injection taken 7 out of 7 days in the look back period. Review of the Medication Review Report signed 3/13/24 revealed the following orders: a. Lasix with a start date of 1/25/24. b. Lantus Insulin with a start date of 2/15/24. c. Tresiba on hold. Review of facility provided policy titled Comprehensive Care Plan and Care Conference with a reviewed date of 12/4/23 revealed the purpose of the policy is to provide an ongoing method of assessing, implementing, evaluating and updating the resident's Care Plan to help maintain the resident's highest practicable level of function, including culturally competent and trauma informed care. Interview on 04/10/24 at 01:11 p.m., with the Director of Nursing (DON) revealed insulin and diuretic medication should be on the Care Plan.

Based on observation, document review, resident interview, and staff interview the facility failed to provide nursing staff to assure residents safety by not adequately responding to call lights in a timely manner. The facility reported a census of 61 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #8 documented a Brief Interview for Mental Status (BIMS) of 13 indicating no cognitive impairment. Review of document titled, Resident Listing Report revealed Resident #8 resided in 213. On 4/10/24 at 7:55 AM a continuous observation of room [ROOM NUMBER]'s call light revealed at 7:55 AM call light was on and at 8:30 AM call light was shut off. On 4/10/24 at 8:11 AM Resident #8 stated his call light was turned on because he wanted his butt scooted over in bed. Resident #8 stated he wanted help transferring into bed. Resident #8 stated he had grown tired of waiting and transferred himself into bed. Resident #8 stated in the morning sometimes it would take longer than 15 minutes for staff to answer the call lights. Resident #8 stated he could read the clock in the room and knew how long it took the staff to answer his call light. Resident #8 stated it was 8:13 AM at that time. Review of document titled, Device Activity Report dated 4/10/24 reported on 4/10/24 the call light for room [ROOM NUMBER] was shut off after 21 minutes and 51 seconds at 12:16 AM, 4/10/24 at 5:10 AM the call light was shut after 24 minutes, 4/10/24 at 7:12 AM the call light was shut off after 16 minutes and 37 seconds, and 4/10/24 8:30 AM the call light was shut off after 36 minutes and 35 seconds. 2. The MDS dated [DATE] for Resident #59 documented a BIMS of 15 indicating no cognitive impairment. Review of document titled, Resident Listing Report revealed Resident #59 resided in room [ROOM NUMBER]. On 4/10/24 at 7:55 AM a continuous observation of room [ROOM NUMBER]'s call light revealed at 8:02 AM call light was on and at 8:31 AM call light was shut off. On 4/10/24 at 8:24 AM Resident #59 stated he wanted to go to the bathroom. Resident #59 stated the call light had been on for a bit but they are usually good about answering the call light. Review of document titled, Device Activity Report dated 4/10/24 reported on 4/10/24 the call light for room [ROOM NUMBER] was shut off after 28 minutes and 35 seconds at 8:31 AM. On 4/10/24 at 1:39 PM Staff A, Certified Nursing Assistant (CNA) stated call lights would be answered in no more than 3-5 minutes. Staff A stated sometimes it could take longer than 3-5 minutes depending on if someone had fallen or what was going on at the time. Staff A stated no one had fallen the morning of 4/10/24 from her hall. Staff A stated the facility's expectation was that call lights would be answered in less than 15 minutes. On 4/10/24 at 1:52 PM the DON stated the residents did not really complain about how long the call lights are on prior to answering. The DON stated it was hard to answer them all at times under 15 minutes, but she was aware this was the regulation. The DON stated Resident #8 never needed anything urgent. The DON stated the standard was 15 minutes and the staff is educated on that all the time. The DON stated mornings at the facility were busy. Review of policy titled, Call light reviewed 8/1/23 documented when a resident's call light is observed/heard, go to the residents room promptly and respond to resident's request as soon as possible.

Based on observations, interviews and record review the facility failed to maintain safegaurds and systems to control and account for scheduled medications for 4 of 6 residents reviewed. Resident #254 and Resident #306 had orders for Ativan to be used as needed for seizure disorders. The medication cassettes were tampered with and replaced with different medications. Staff removed 2 Hydrocodone tabs from the emergency kit (ekit) for Resident #307 and the Medication Administration Record (MAR) lacked documentation that these had been given. On 1/12/23, a medication cart contained a cassette with an as needed (PRN) Tramadol for Resident #43, the medication had been discontinued the end of December. The facility reported a census of 52 residents. Findings include: 1) The Minimum Data Set (MDS) dated [DATE] showed Resident #254 had a Brief Interview for Mental Status (BIMS) score of 3 (severe cognitive deficits). The resident required extensive assistance with the help of two staff for bed mobility, toileting and hygiene needs. According to the Admission Record, Resident #254 was admitted on [DATE] and had diagnosis that included malignant neoplasm, spinal stenosis, and essential tremor. According to the Care Plan updated on 10/28/21, Resident #254 had impaired cognitive function and impaired thought processes related to metastatic lung cancer. The resident used psychopharmacological medications related to dysthymic disorder. An email message was sent to the facility from the pharmacy, on June 7th at 9:18 AM and stated a cassette containing 3 pills for Resident #254 had been sent back to the pharmacy in error. The pharmacist examined the cassette that was noted to contain a PRN order of Ativan 2 milligrams (mg) tabs. The pharmacy chief noticed 2 of the lids of the cassette showed evidence of having been removed and replaced. He found that one tablet was not Ativan and identified it as melatonin. This was reported to the nursing home on 6/6/22 around 10:00 AM. A review of the record showed Resident #254 had an order for a PRN Ativan dated 3/9/22 at 2:46 PM to be taken every 15 minutes as needed for seizure activity. The Medication Record (MAR) showed the medication had not been used. A facility initiated investigation revealed that no staff members were aware of or had any knowledge of misappropriation of medications. As of 6/13/22 the facility did not have any suspects in the matter. They concluded that because the cassette tabs were easily popped out and replaced, it was difficult to recognize tampering at a glance. The pharmacy planned to send out bubble packs instead of cassettes after the incident. 2) According to an MDS dated [DATE], Resident #306 did not have a BIMS score. The resident required extensive assistance with the help of two staff for dressing, toileting and bed mobility. The admission record showed the resident was admitted on [DATE] with diagnosis that included neoplasm, Parkinson's' disease, dysphagia, and carcinoma of the skin. The Care Plan updated on 6/20/22 showed the resident had impaired cognitive functioning related to dementia. Resident #306 had a seizure disorder related to neoplasm of the brain and was on seizure precautions. The resident had a terminal prognosis and Hospice services were initiated on 7/22/21. According to a facility investigation dated 6/11/22 the nursing staff had concerns of another cassette of Ativan that possibly had medication in the cassette that was not Ativan. On 6/13/22 the cassette was found to have been disturbed. The facility completed an audit of all Ativan doses and found no other concerns. According to a written statement from LPN Staff F examined the pills and found them to be metoprolol and busperone. According to the MAR, Resident #306 did not receive any PRN Ativan doses. 3) An MDS dated [DATE] showed Resident #43 had a BIMS score of 15 (intact cognitive ability). He was independent with transfers and walking, and required extensive assistance with the help of one for toileting. The resident had diagnosis that included cellulitis of the buttock, pressure induced deep tissue damage to sacral area, and Type II diabetes. The Care Plan showed the resident was admitted to the facility on [DATE] with a fistula colostomy to the lower abdomen. He had acute pain related to deep tissue pressure sores. The Orders tab showed Resident #43 had an order dated 12/15/22 at 11:57 PM for Tramadol 50 mg PRN for pain. The order was discontinued on 12/30/22. On 1/12/23 at 8:10 AM with Registered Nurse (RN) Staff G looked at the medications in the cart for Resident #43 and discovered a cassette with the PRN Ativan was still in the medication cart. Staff G admitted it should have been destroyed at the time that it was discontinued. According to facility policy titled: Medications: Controlled last reviewed on 12/7/21, controlled medication that have been discontinued should be placed in a locked box in the medication room as soon as they have been discontinued. 4) The MDS for Resident #307 dated 6/7/22 did not include a BIMS score. The Census tab showed that he was admitted to the facility on Hospice services. The Care Plan dated 6/7/22 showed the resident had an ADL self-care performance deficit related to a diagnosis of malignant neoplasm of the left bronchus or lung, malignant neoplasm of bone, and malignant neoplasm of the liver. The resident had chronic pain needed scheduled and PRN pain management. According to the Orders tab the resident had an order dated 6/7/22 at 12:45 PM for Hydrocodone 5/325 milligrams (mg) 1-2 tabs every 6 hours. An Emergency Kit Log showed on 6/7/22 (untimed and unsigned) 2 tabs of Hydrocodone had been removed from the emergency kit. The document lacked information regarding who dispensed the medications and according to the MAR the resident did not receive the medication. A review of the facilities process for the dispensing of controlled substances from the emergency kit revealed the use of one form titled: Emergency Kit Log for three ekits stored in a closet; one with intravenous medications, one with controlled substances and one for all other medications. Another form titled: Control E-Kit sign off, included columns for the date, tag number on the kit, night/day shift change, tag number, and shift. Upon investigation, it was discovered that the tag numbers on this form many times did not match the tag numbers on the Emergency Kit Log. On 1/10/23 at 11:36 AM the DON acknowledged the ekit document did not have a column for staff signature and that this was problematic. She was not sure why the Control Kit sign off numbers did not match the emergency kit log. Upon further investigation, it was discovered the tag numbers changed when the kit went back to the pharmacy for updating. According to facility policy titled: Medications: Controlled last reviewed on 12/7/21, The facility will along with their consultant pharmacist establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation that determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled and meets all state and federal requirements for controlled medications.

Based on observation, clinical record review, and staff interviews the facility failed to ensure staff followed infection control policy and procedures for 1 out of 16 residents, (Resident #50). The facility also failed to follow infection control policy and procedures by not covering clean linen carts. The facility reported a census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #50 identified a Brief Interview for Mental Status (BIMS) of 13 which indicated cognitively intact. The MDS documented diagnoses of cognitive loss/dementia and cancer. Observation on 1/9/23 at 2:53 PM showed Staff A delivering snacks in 100 hall. As Staff A walked past Resident #50 ' s room, she noticed they were attempting to ambulate unassisted from the recliner to the bed. Staff A went into Resident #50 ' s room, took a hold of their arm, touched their bare back and assisted them into bed. Staff A then exited the room without washing their hands and entered two other rooms passing out snacks. In an interview with the Administrator on 1/10/23 at 2:45 PM, he stated the expectation would be that hand hygiene be performed prior to continuing to deliver snacks. 2. Observation on 1/9/23 at 9:46 AM showed clean linen carts tucked back into alcoves on 100 and 300 hallways with the front covers laying on top of carts exposing clean laundry. In an interview with Staff B, she stated that the expectation was for the carts to be covered.

Based on observation, interviews and record review the facility failed to follow professional standards for 1 of 3 residents reviewed. Resident #25 was at risk for decline in status and required assistance with transfers and locomotion. Staff failed to assist the Resident to walk on a daily basis and failed to move him out of his wheel chair every 3 hours. The facility reported a census of 52 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE] Resident #25 did not have a Brief Interview for Mental Score (BIMS). Resident #25 required the help of one staff for toileting, hygiene, transfers and walking. The Care Plan dated 4/24/22 showed that Resident #25 had impaired cognitive functioning related to history of cerebral infarction with aphasia. The resident was able to ambulate and staff were directed to assist him to walk 3-5 times a week. He had diagnosis that included hemiplegia, hemiparesis following cerebral infarction. The electronic record included an order dated 10/25/21 at 11:53 AM that directed staff to assist with ambulation daily and to limit that resident's time in wheel chair to 3 hours at any time. The resident was to be transferred to the recliner after lunch and dinner. The following was found on documents titled: Point of Care (POC) Response History, generated on 1/11/23 at 3:10 PM: a. Walking in room from 12/13/22 - 1/11/23 was checked off that it did not occur 47 times and was completed 8 times. b. Walking in the corridor from 12/13/22 - 1/11/23 did not occur 48 times and was completed 7 times. On 1/10/23 at 7:05 AM Licensed Practicing Nurse (LPN) Staff D said that the Certified Nursing Assistants (CNA) would walk the resident throughout the day. She said that the family had hired a lady to come and do exercises with him (Staff E). On 1/11/23 at 3:10 PM Staff E said she worked for an agency that typically would go into homes and help elderly with their needs. She said that she had been working with Resident #25 for quite a while and assisted him to walk and with exercises twice a week. She said that on several occasions, she came into the facility and found the resident on the toilet and very upset. He was able to communicate with her that he had been waiting for 45 minutes. Staff E said that the resident's bottom had a purple ring around his buttocks from the pressure of sitting there so long. She said that the staff would tell her that they didn't have enough help to walk him twice a day as they should. The following is documentation of an on-going observation of Resident #25 on 1/12/23: a. At 7:23 AM the resident was at the table in the dining room eating breakfast in his wheel chair, (WC). b. At 7:55 AM in the hallway in WC. c. At 8:21 AM in room sitting in the WC in front of television (TV) d. At 8:44 AM in room in WC in front of TV e. At 9:05 AM in room in WC in front of TV f. At 9:29 AM in room in WC in front of TV g. At 9:49 AM on the toilet h. At 10:10 AM in room in WC in front of TV i. At 10:22 AM in room in WC in front of TV j. At 10:42 AM in room in WC in front of TV k. At 11:00 AM in room in WC in front of TV l. At 11:16 AM wheeling self out to dining room m. At 11:45 AM still at table eating n. At 12:04 PM in room in WC in front of TV o. At 12:24 PM in room in WC in front of TV p. At 12:43 PM in room in WC in front of TV q. At 12:47 PM hired aide was walking him down the hallway On 1/12/23 at 1:45 PM the Director of Nursing (DON) said she understood that Resident #25 had a doctor's order to be up out of his wheel chair on a regular basis. She said he had gone to see a vascular specialist that recommended this intervention. She said that the hired helper did not substitute for what staff were to provide in way of positioning, exercise and walking.

Based on observation, interviews and record review the facility failed to prevent accidents and hazards for 1 of 3 residents reviewed. Resident #17 sustained an injury from a mechanical lift Sit to Stand sling that was too small for her. The facility reported a census of 52 residents. Findings include: According to the Minimum Data Set (MDS) dated [DATE], Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident required extensive assistance with the help of two staff for bed mobility and toileting and required extensive assistance with the help of one staff for transfers and dressing. The Care Plan updated on 2/3/22 showed that Resident #17 had an Activities of Daily Living (ADL) self-care performance deficit related to a history of Cerebrovascular Attack (CVA) and right sided weakness. The resident was a non-ambulatory and required the Sit to Stand mechanical lift for transfers. Staff were directed to use the extra-large size harness for all transfers. Resident #17 had diagnosis that included congestive heart failure, chronic kidney disease, stage 3, obesity and peripheral vascular disease. On 1/09/23 at 1:15 PM Certified Nursing Assistant (CNA) Staff C prepared the Sit to Stand mechanical lift to transfer Resident #17 from the wheel chair to the bedside commode. Before the sling was attached, the resident lifted her blouse and revealed a large, dark purple bruise on her right breast. The resident said that on the previous day, a CNA put a sling on her that was too small and I felt like I was in a strait jacket. The resident said that she told the CNA that it was the wrong size before she attached it, but the CNA responded that they couldn't find the larger sling that they would usually use to transfer her. A review of the record revealed a Nursing Note dated 1/9/2023 at 10:33 PM that showed the resident had a bruise, light to dark purple noted to the right breast measuring 17.0 centimeters (cm) x 25.0 cm. in size. According to the Sit to Stand Harness Sizing Guide, for a resident weighing 190-320 pounds, staff were to use a large sling. The Vitals tab in the electronic chart showed on 1/8/23 at 1:03 PM Resident #17 weighed 247.9 pounds. On 1/12/23 at 1:45 PM the Director of Nursing (DON) said that she had asked the physical therapy department to evaluate the resident for transfer status. The DON said she was not sure that the bruising on the right breast had been caused by the sling, but she did understand that the resident is not bearing weight very well on the Sit to Stand and may need to be changed to a Hoyer transfer.

Based on observation, interviews and record review the facility failed to provide sufficient staffing to respond to residents needs in a timely fashion for 2 of 16 residents reviewed. Resident #17 and Resident #30 reported that many times it took over 30 minutes for staff to respond to the call lights. The facility reported a census of 52 residents. Findings include: 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #17 had a Brief Interview for Mental Status (BIMS) score of 15 (intact cognitive ability). The resident required extensive assistance with the help of two staff for bed mobility and toileting and required extensive assistance with the help of one staff for transfers and dressing. The Care Plan updated on 2/3/22 showed that Resident #17 had an Activities of Daily Living (ADL) self-care performance deficit related to a history of Cerebrovascular Attack (CVA) and right sided weakness. The resident was non-ambulatory. Resident #17 required the Sit to Stand mechanical lift for transfers and staff were directed to use the extra-large size harness for all transfers. Resident #17 had diagnosis that included congestive heart failure, chronic kidney disease, stage 3, obesity and peripheral vascular disease. On 1/5/23 at 1:16 PM Resident #17 said that at times, she had waited an hour for staff to respond to her call light. She pointed to a clock on her dresser and said she watched the clock to see how long it would take and many times she had been incontinent because it took too long for them to get to her. The Census Report tab showed that Resident #17 was in room [ROOM NUMBER] A document titled: Device Activity Report generated on 1/9/23 at 1:10 PM included the following for room [ROOM NUMBER]: a. On 12/11/22 at 12:37PM the call light was on for 18 minutes and 39 seconds. b. On 12/17/22 at 9:38 AM the call light was on for 28 minutes and 45 seconds. c. On 12/25/22 at 9:07 AM the call light was on for 25 minutes 46 seconds. d. On 12/25/22 at 3:30 PM the call light was on for 28 minutes and 46 seconds. e. On 12/24/22 at 11:12 AM the call light was on for 25 minutes and 20 seconds. F. On 12/24/22 at 5:15 PM the call light was on for 30 minutes and 47 seconds. 2) According to the MDS dated [DATE], Resident #30 had a BIMS score of 14 (intact cognitive ability). The resident required extensive assistance with the help of two staff for bed mobility, locomotion and toileting. The Care Plan for Resident #30 updated on 11/23/22 showed that she was incontinent of bowel related to malignant neuroleptic syndrome and dementia. Staff were directed to provide a bed pan or bedside commode and to check the resident for toileting needs before and after meals and throughout the night. On 1/5/23 at 1:30 PM Resident #30 said at times, it would take staff close to an hour to respond to her call light. She pointed to her clock and said that she could see it from her bed and said she would watch how long it took. The Census Report tab showed that Resident #30 was in room [ROOM NUMBER] A document titled: Device Activity Report generated on 1/9/23 at 1:10 PM included the following for room [ROOM NUMBER]: a. On 1/7/23 at 7:16 AM the call light was on for 16 minutes and 45 seconds. b. On 1/7/23 at 7:44 AM the call light was on for 15 minutes and 33 seconds. A facility policy last updated on 10/21/22 titled; Call Light showed that when a resident's call light was observed/heard, staff were to go into the resident's room promptly. On 1/12/23 at 1:45 PM the Director of Nursing said she understood that the call light response was slow over Christmas because they had a fire alarm going off. Staff were expected to respond as soon as possible.

Based on clinical record review and staff interviews, the facility failed to resubmit a level 1 PASRR (Preadmission Screening and Resident Review) when additional mental health diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility reported a census of 51 residents. Findings Include: The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/28/21 for Resident #13 showed a Brief Interview for Mental Status (BIMS) of 05 indicating severe cognitive impairment. Resident #13's admitted was 6/22/21. The resident required extensive assistance with two staff for transfers, locomotion and dressing. The MDS showed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Electronic Health Record (EHR) showed Resident #13 had a PASRR level I Screening completed on 10/15/20 stating the resident did not have any major mental illness and was not on any mental health medications. PASRR I stated no level II is required. If changes occur or new information refutes these findings, a new screen must be submitted. Review of the current Care Plan showed Resident #13 used psychoactive medication with an initiation date of 6/22/21. Review of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the EHR showed the Resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . During interview on 9/16/21 at 10:15 AM the Director of Nursing stated it was her expectation that the social worker resubmit the PASRR with a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 9/16/21 at 10:18 AM with the Social worker revealed she should have resubmitted the PASRR with the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the PASRR dated 9/16/21 showed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resubmission stated a level I negative status.

Based on record review and staff interviews the facility failed to develop a baseline care plan that included the instruction on ambulation that was needed to provide safe and appropriate care for 1 out of 3 residents reviewed, (Resident # 33). The facility reports a census of 51 Residents. Findings Include: A Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. The resident had an admitted to the facility of 7/29/21. The MDS shows the resident had a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan showed a focus of activities of daily living (ADL's) self-care performance deficit due to [CONDITION(S)] and multiple embolic strokes which requires assistance. The Care Plan lacked information about ambulation until 8/19/21. Review of the Care Plan changes since last review showed ambulation with gait belt and walker was added on 8/19/21 and changed to stand by assist with walker, distance as desires or tolerates. Review of the Nurses Aid Communication book showed on 7/29/21 the resident required transfers with assistance of 1 with gaitbelt and walker and had an unsteady gait. During interview on 9/15/21 at 4:14PM the Director of Nursing stated ambulation should be on the baseline care plan so staff know how to ambulate with the resident and doesn't know why it was not on the care plan until 20 days after the resident was admitted .

Based on record review and interviews, the facility failed to utilize gait belts for safely transferring 1 out of 1 residents reviewed (Resident #33) and leaving medication cart unlocked and unattended. The facility reported a census of 51 residents. Findings Include: 1. A Minimum Data Set (MDS) assessment dated [DATE] for Resident #33 showed a Brief Interview for Mental Status score of 9 indicating moderate cognitive impairment. The resident had an admitted to the facility of 7/29/21. The MDS showed the resident had diagnoses of dysphagia, [CONDITION(S)], unsteadiness on feet, muscle weakness, and lack of coordination. Review of the Fall Tool assessment dated [DATE] showed Resident #33 scored 20 which indicated a high fall risk. Review of the Incident Report prepared by Staff A, Registered Nurse (RN) dated 8/18/21 at 6:25 PM stated the Certified Nurse's Aide (CNA) walked the resident back from supper with gait belt and walker. Resident #33 went to sit in her recliner in the room and lost her balance and fell backwards onto her buttocks next to recliner and hit her head on the closet behind the chair. The resident does not give description as the CNA was present at the time and reported what happened. Under the Witness tab lacked any documentation of who the CNA was. Under the Action tab stated neuro checks were not completed. The Notes tab lacked any documentation. The Incident Report showed the Director of Nursing (DON) signed off and closed the incident on 8/24/21. During interview with Staff A RN on 9/15/21 at 2:22 PM she ststed she was the nurse on duty when Resident #33 had the fall. She stated when she entered the residents room there was no gait belt on the resident. Staff A RN stated to the CNA that she would need to be re-educated on the use of gait belts. Staff A RN then stated she informed the (DON) the CNA did not use a gait belt and needed to be re-educated. Staff A RN stated the DON made the comment she would re-educate the CNA on the use of gaitbelts. Staff A RN did not know why the use of the gaitbelt was put in the Incident Report and did not remember documenting it. During interview on 9/15/21 at 2:36 PM Staff B CNA stated she was not using a gait belt at the time Resident #33 fell . Staff B CNA stated the nurse told her she was going to have to have re-education on gait belt use. Staff B CNA stated no staff from the facility talked to her about the incident and the DON never questioned her or re-educated her on gait belt use. During interview on 9/15/21 at 4:14 PM the DON stated she was not aware the CNA was not using a gait belt at the time of the fall. The DON stated she did not investigate the incident and did not have a conversation with the CNA. The DON stated she does remember the nurse stated it was all handled. Review of the Gait-Transfer Belt policy dated 4/6/21 stated the purpose was to safely stabilize a transfer, to ambulate with a resident, and to aid resident in maintaining balance. The gait belts are used with assisted ambulation unless medically contraindicated. 2. In an observation 9/15/21 at 8:00 AM a medication cart was sitting in the hallway of the facility unattended and unlocked. At 8:03 AM Registered Nurse (RN) Staff C came out of the room of Resident #1 and then locked the cart. During interview on 9/16/21 at 11:46 AM the Director of Nursing said all nurses are instructed to shut down the screen and to lock the medication cart whenever they walk away from it. According to the policy titled Medications:Acquisition Receiving Dispensing and Storage dated 12/28/20 medications are to be stored and kept locked in the medication cart, drawer or cupboard.

Based on observations, record reviews and interviews the facility failed to provide proper pain management for 1 out of 1 residents reviewed (Resident #26). The facility reported a census of 51. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 identified a Brief Interview for Mental Status score of 10. A score of 10 indicated moderate cognitive impairment. The current Care Plan revealed the resident had acute pain related to a recent fistual surgery that resulted in placement of a [NAME] Drain for an anal abscess. During interview on 9/14/21 at 11:21 AM, Resident #26 stated I'm fine now, but I don't think they believed I had pain at first but they do now. Yesterday, I waited two hours before I got my pain medication. It was right before shift change. The aide told me the nurse was sitting at the nurse's station not doing anything then she went to report, so I had to wait for the next shift. After that I heard she was on the phone with a pharmaceutical company but then they should have had someone else get me a pain pill. In a follow up interview on 9/15/21 at 11:41 AM, the resident stated I called for the pain medication before shift change. Staff F was the tech I told. Staff G was the nurse but Staff H ended up giving it (pain medication) to me when she got here. A review of the 30 day report titled Device Activity Report for the period of 7/15/21 thru 9/15/21 for Resident #26's room, revealed the call light was activated before shift change on 9/13/21 at 1:43 PM then 6 more times before the administration of the pain medication at 3:12 PM. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Notes dated 9/13/21 at 3:12 PM, recorded Staff E, Registered Nurse, administered a [MEDICATION(S)]-Acetaminophen 5 mg tablet for the resident's complaints of rectal pain. In an interview on 9/15/21 at 12:13 AM, Staff F, Certified Nurses Aide, stated the resident called right before the shift change for a pain pill. I told the nurse (Staff G). The resident called again later so I talked to Staff G a second time. She was waiting for the next nurse but she was running late for her shift. When Staff I heard about it, she told Staff H to get a pain pill right away. In an interview on 9/15/21 at 12:30 AM, Staff I, Registered Nurse, stated when she heard the resident had been waiting for a pain pill she told Staff H to give it to the resident immediately. The policy titled Pain Management-Rehab/Skilled dated 11/02/2020 documented the purpose was to provide residents assistance in pain management. To promote well-being by ensuring that residents are as comfortable as possible. To consistently collect data related to pain. In an interview on 9/15/21 at 12:45 AM, the Director of Nursing stated the nurse should have given the pain pill right when it is asked for unless it's otherwise ordered, then they need to see what else can be done.

Based on resident, staff interview and record review, the facility failed to ensure staff answered resident call lights and responded to their needs in a timely manner, within fifteen minutes, for three out of three residents reviewed ( Resident #6, Resident # 26, Resident # 43). The facility reported a census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #6 identified a Brief Interview for Mental Status (BIMS) score of 15. A score of 15 indicated intact cognition. The MDS revealed the resident required extensive assistance of 2 person physical assistance for activities of bed mobility, transfers, dressing and toileting. The MDS further revealed the resident required 1 person physical assistance in locomotion per wheelchair. The MDS listed the resident as medically complex and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan initiated on 6/18/21 documented the resident as having activities of daily living (ADL) deficits. It directed staff the resident required 1 staff assistance using the E-Z Stand (a mobile mechanical device to lift a patient from a sitting to standing position ) for toilet transfers. The Care Plan further directed staff to monitor for skin breakdown and set a goal of maintaining intact skin. The Care Plan identified the resident as able to verbalize and communicate her required assistance. On 9/14/21 at 10:30 AM, an interview with Resident #6 revealed excessive waits for response to her call light requests. The resident stated they need more help. The resident stated she had a bowel movement accident recently as a result of waiting for staff assistance and felt embarrassed as a result. A review of the 30 day report entitled Device Activity Report for the period of 7/15/21 12:00 AM thru 9/15/21 11:59 PM for Resident #6's room revealed 59 call light activations that resulted in excess of 15 minutes to de-activate by staff. The resident resided in a single occupant room. In an interview on 9/16/21 at 10:55 AM, the DON stated her threshold for facility response times would be less than 10 minutes. The DON elaborated that meal times and staffing issues can impact the call light response times. The DON stated that optimally she would have an additional 3 CNAs (certified nursing assistants) on the day shift and 1-2 CNAs on the PM shift. The DON reported she is challenged to find sufficient staff to employ for optimal staffing levels. 2. The MDS dated [DATE] for Resident #26 identified a BIMS score of 10. A score of 10 indicated moderate cognitive impairment. The MDS revealed the resident required physical assistance for activities of bed mobility, transfers, dressing and toileting. On 9/14/21 at 10:53 AM, an interview with Resident #26 revealed excessive waits for response to her call light requests. The resident stated I can wait hours for someone to come at least 2-3 times a week. I watch the clock on my TV. It's more in the evenings, sometimes at night but more so in the evenings. A review of the 30 day report entitled Device Activity Report for the period of 7/15/21 12:00 AM thru 9/15/21 11:59 PM for Resident #26's room, revealed 37 call light activations that resulted in excess of 15 minutes to de-activate by staff. The resident resided in a single occupant room. 3) According to the MDS dated [DATE], Resident #43 had a BIMS score of 15 out of 15, which indicated intact cognitive function. The MDS showed the resident required extensive assistance with the help of two staff for bed mobility, transfers and toileting. In an interview on 9/15/21 at 2:45 PM Resident #42 said that especially in the evenings, the call light response is slow. The resident stated she waited so long for someone to come and help her. She stated between the hours of 2:00-4:00 in the afternoon there is only one aide in the facility and she required two for transferring so this causes a longer wait time.

Based on interviews and observation the facility failed to post a daily nursing schedule. The facility reported a census of 51 residents. Findings include: In an observation on 9/15/21 at 10:45 AM it was revealed a nursing schedule dated August 27, 2021 was posted in the window of the nurses station. On 9/15/21 at 10:47 AM the Director of Nursing (DON) in training said she was not sure where the current schedule was posted but she would check with the DON. On 9/15/21 at 11:40 AM the DON in training pointed out a schedule dated 9/15/21 where the August 27th schedule had been hanging. At 11:43 AM the DON acknowledged that the current schedule had just been changed. She stated the overnight nurse is responsible for preparing and posting the schedule for the following day.

Based on observation, record review, facility policy and staff interviews the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 7 residents reviewed as identified by the facility at increased risk for elopement, (Resident #1) who exited the facility unsupervised. Which resulted in an immediate jeopardy to resident's health and safety. The facility reported a census of 63 residents. The Minimum Data Set (MDS) assessment dated [DATE], for Resident #1 documented [DIAGNOSES REDACTED]. The resident had scored 7 of 15 on a BI[CONDITION] (Brief Interview for Mental Status) test, which indicated severely impaired cognition. The MDS documented no wandering and supervision with locomotion off the unit. The Nursing Admit Data Collection tool dated [DATE] at 10:00 a.m., documented behavior/cognitive (*) items indicate risk for elopement: 1. Does the resident have a history of any of the following? (check all that apply) *long term memory loss-checked. *short term memory loss-checked. A Social History with an effective date of [DATE] at 10:00 a.m., documented psychosocial factors: behaviors with wanders being checked. A Care Plan, dated as initiated [DATE], identified a focus area of resident is at risk for falls related to Alzheimer Dementia with behaviors evidenced by history of falls, resident will not sustain serious injury through the review date. Interventions include: to encourage participation and plan diversional activities that are of resident interest, social activities, coffee group and cards, review as indicated for significant changes in cognition, safety awareness and decision-making capabilities. An initiated date of 2/24/20, established a goal, the resident will not leave facility unattended. Interventions included: check resident every 15 minutes, wandergard used to alert staff to residents movement and to assist staff in monitoring movement. A Progress Note dated 2/24/20 at 7:45 a.m., documented observed Resident #1 leaving breakfast table without walker, appears slightly upset. Facility charge nurse present. This staff member intervened and walker given to resident and asked if could accompany her to room. Resident replied yes please. Resident ambulated with gait steady with wheeled walker to room with this staff member. Resident mildly upset and crying, encourage resident to take deep breaths and reassured all is okay and husband would be visiting this a.m. Offered drink of water and refused. Resident seemed to accept reassurance from this staff member, and left room. CNA in hallway alerted to resident in room, sitting in recliner and behavior observed. A Progress Note dated 2/24/20 at 2:42 p.m., noted resident returns to facility from hospital accompanied by husband. Resident is tired at this time, goes to room and rests in bed. Complete head to toe assessment is completed upon return from the hospital. Wandergard bracelet is placed on right side ankle immediately upon return. Care Plan updated to include focus on elopement and15 minute checks are put into place. An Incident Summary, dated 2/24/20 at 9:00 a.m., and revision dated 2/26/20 at 8:10 a.m., documented at 6:00 a.m., this morning 2/24/20 Resident #1 was in bed sleeping. At approximately 6:45 a.m., Certified Nursing Assistant (CNA) wakes resident up to see if she was ready to get up for the day. Resident said sure and proceeded to get out of bed. Resident was already dressed, so staff assisted with set up for brushing teeth and helped comb her hair. Resident in a cheerful mood at this time and was ready for breakfast. Resident then came out to breakfast. At breakfast, resident became upset and was crying. At 7:55 a.m., staff assisted resident back to her room and resident was sitting in recliner. At 8:03 a.m. the door alarm on 100 link south door sounds. At 8:04 a.m. staff responds to door alarm and physically checks outside, but does not see anyone. Staff then turned door alarm off. At 9:00 a.m. a phone call received form Resident #1's husband that resident is in the hospital. Upon investigation with County Sheriffs office, a call was received at 8:24 a.m. of elderly woman on the side of the road. A community member was stopped and attempting to assist the resident, and witnessed the resident fall and bump her head. Sheriff arrived on scene right after community member called for an ambulance. Sheriff stated resident appears to be ok, but is disoriented. Resident is transferred to hospital per ambulance for evaluation. Report received from hospital that everything has checked out ok and resident will be retuning to us later today. While resident was out of the building, resident was wearing long pants, shoes, a jacket, and had her red purse. According to the weather report, it was 39 degrees outside at the time. After speaking with the community member who was helping the resident, she had stopped her car to ask the resident if she could help her and offered her a ride. Witness stated resident slowly fell to ground onto her knees and then to her side and bumped her head on the ground. Driver then got out of the car to help. Driver reported the resident was wearing a red jacket and had her purse. When the sheriff stopped on the road to assist them, he asked the resident her name and she was able to state her name. When asked what today's date was, resident was not able to answer correctly. At 2:20 p.m., resident returned to the facility accompanied by her husband. Nurses completed a head to toe assessment and the only thing found was bruising on bilateral knees. During assessment, wandergard bracelet was placed on residents ankle and 15 minute checks have been implemented. Nurse stated resident had laughed a couple of times while she was joking with her. Resident #1 rested in bed after completion of assessment. An emergency room Report, dated 2/24/20 at 9:00 a.m., documented patient arrived via ambulance. Patient had fallen in front of the Sheriffs department and had eloped from the Nursing Home. Patient is currently a resident there for dementia. Impression, knee contusion, fall, and contusion of head. It is reassuring that there is no immediate life-threatening condition found during patients examination. A Nursing Admit-Readmit Data Collection tool dated 2/24/20 at 2:20 p.m., documented 1. behavior/cognitive (*) items indicate risk for elopement: *long term memory loss-checked. *short term memory loss-checked. *resident may be at risk for elopement-checked. Focus-the resident has potential for elopement related to [DIAGNOSES REDACTED]. Goal- Resident will not leave the facility unattended 2. All skin observations: right front knee bruising 3.5 centimeters by 2.0 centimeter. A Communication to the Physician by facsimile, dated and signed by the physician on 2/24/20, documented concern: Resident had an elopement episode this a.m. Okay to apply wandergard alarm to decrease risk of further episodes. Physician responded: Good idea, not sure how she got out. Review of the Policy and Procedure for Alarms: Bed, Chair and Door dated 12/19, documented the policy is the center will ensure that a system is in place for all bed, chair and door alarms and these alarms are in proper working order. Alarms will be installed and placed according to the manufacturers instructions: All staff will be responsible for physically checking on the resident when an alarm goes off. Review of the Resident Elopement with no date, documented: In the event of a Resident Elopement: Elopement is defined as a resident who has impaired decision-making ability, leaves the facility with-out the knowledge or authorization of staff, regardless of injury. 1. Notify the Administrator, Director of Nursing, and Charge Nurse immediately 2. Mobilize staff to begin a search. Begin an organized, assigned street search and dependent upon staffing, send at least one person from each hall to search. THE CHARGE NURSE MUST STAY IN THE BUILDING. 3. If the resident cannot be located within a reasonable amount of time, the Charge Nurse will notify the police to assist with the search. 4. In all cases, family will be notified of the incident. 5. Notify the physician. 6. Complete the incident report in point click care as well as paper investigation sheet. When completing the sheet, be sure to include the following: *Any injuries the resident sustained [REDACTED].> *Weather conditions at the time of the elopement, raining, snowing, evening, daylight, temperature, etc. *Corrective action that was taken. 7. Notify DIA with in 24 hours. Review of the Policy and Procedure for Elopement dated 4/16, stated purpose is to: *Asses and identify residents at risk for elopement. *To clearly define the mechanisms and procedures for monitoring and managing residents at risk for elopement. *To provide a system of documentation for the prevention of, and in an event of, elopement. *To minimize risk for elopement through individualized interventions. *To provide staff members with education on elopement at orientation and at least annually. *To identify a plan in the event of resident elopement. *To provide protection for residents at risk for elopement. Policy included: *The location will be responsible for maintain a system that clearly defines the mechanisms and procedures for monitoring and managing residents at risk for elopement. These include identifying environmental hazards and residents risks: evaluating/analyzing hazards and risk: implementing interventions; and monitoring/modifying interventions as needed. *All residents will be assessed for risk of elopement through the pre-admission and/or admission process and as needed. Each location will put measures in place to minimize the risk of elopement that are individualized to resident needs and identified on the care plan. When an elopement occurs, immediate efforts to locate the resident will be taken. All occurrences will be documented and all follow-up required by state and federal regulations will occur. *Careplan team members should consider the following when assessing risk for elopement: *wandering behavior- the movement may be goal-directed (the person appears to be searching for something such as an exit) or may be non-goal directed or aimless. Non-goal directed wandering requires a response a manner that addresses both safety issues and a evaluation to identify root causes to the degree possible. Moving about the location aimlessly may indicate that the resident is frustrated, anxious, bored, hungry or depressed. Unsafe wandering and elopement can be associated with falls and related injuries. *History of elopement *Cognitive impairment *Attempts to leave location *Residents who are new admits to location *Recent alteration in residents mental status without a history of previous cognitive impairment to include memory loss, decrease awareness and disturbances in judgement, reasoning and perception. During interview on 3/2/20 at 11:30 a.m., Staff A, Certified Nursing Assistant, (CNA) stated on 2/24/20 she was scheduled to work the 300 hallway for which is not her normal hall, usually she works the 200 hallway so she was frazzled that they had switched her assignment. Staff A said that about 8:00 a.m., Staff A was in room [ROOM NUMBER] doing cares when the door alarm sound that was right next to room [ROOM NUMBER], Staff A couldn't stop what she was doing to get the door alarm. Staff A said about 8:03 a.m., went out of the room and went down the 300 hallway and then 100 hallway to see if any staff or visitors came in through the southeast door. Staff A stated she didn't see anyone that she didn't recognize so she went to the southeast door and proceeded to look out the windows, didn't see anyone, and then proceeded to punch in the code to silence the alarm. Staff A failed to announce anything over the walkie because Staff A didn't think it was a resident. Staff A proceeded to work on the 300 hallway when about 9:00 a.m., the facility director came over the walkie asked if anyone had seen Resident #1, that the husband had called the Director of Nursing and said the resident was in the emergency room at the hospital and the resident had walked out of the building and was found along the side of the road. Staff A commented she was in room [ROOM NUMBER] when the page came over the walkie. Staff A responded to the facility Director of Nursing and stated the door alarm was sounding on the south east side of the facility but when I looked out the windows I didn't see anyone so I went and silenced the door alarm. Staff A admitted they heard the southeast door alarm but when looked outside didn't see anything or anyone so Staff A punched in the code to silence the door alarm off. Staff A admitted they didn't go out the door and look around the facility, Staff A went back to taking care of residents. During interview on 2/27/20 at 9:50 a.m., the facility Director of Nursing stated on 2/24/20 at 8:03 a.m., the southeast door on the 200 hallway had alarmed, staff at 8:04 a.m., went and responded to the door alarm, peeked their head out of the door and didn't see anyone so silenced the door alarm and continued with their daily duties. The Director of Nursing was told a community member had driven by Resident #1 on 4th Avenue and saw that the resident looked lost, so the community member stopped to assist Resident #1 to see if she needed help, in the process of visiting with the resident, the community member saw the resident go down on her knees and bump her head on the curb, by that time the sheriff came by (the sheriff office is south of the facility) and asked the resident who she was, 911 was called and the resident was taken to the local hospital for an evaluation, the residents husband called the facility at 9:00 a.m., stating that the hospital had called to notify him the resident was at the emergency room , they are running test and when/if the tests come back ok, they will be discharging her back to the facility. At 2:00 p.m., the Director of Nursing received a phone call from the husband that the test results came back and no injuries were found and labs were ok so Resident #1 will be coming back to the facility. A wandergaurd was placed around the residents left ankle and 15 minute checks have been initiated. All staff got re-educated on responding to the door alarms and not to silence them until they know for sure that all the residents are accounted for, re-educated on missing/elopement residents and signed off that they understand what they need to do. During interview on 2/27/20 at 11:02 a.m., the town sheriff said he was coming to work, around 8:20 a.m., on 2/24/20, he was heading north, (the speed limit going north said 35 miles per hour) he came up over the hill and noticed a lady was on the ground about 4 feet off the highway lying on her back on the west side of the highway. He assisted the community member by staying with the lady on the ground while the lady from the community got a blanket out from her car. The community member called 911 to dispatch the ambulance to the scene. The sheriff stated he was really glad that she didn't get hit, due to this can be a very busy highway. He said there was no walker with her and that she did have long pants on, coat and a purse, the day was sunny and not breezy. He went on to say she was pretty lucky that she didn't fall and get hurt worse, like a head injury, or sustain a fracture. During interview on 3/3/20 at 9:05 a.m., the community member said she was driving south on 14th Avenue when she noticed a lady in a jacket carrying her purse on the right side of the road, past the sheriff department. She pulled up along side of the lady and asked her if she needed a ride, the lady looked at her puzzled so she pulled up in front of the lady on the right side of the road, got out and walked to the back of her car and as she was approaching her she went down on both knees and then leaned to the left and fell on to the ground and bumped the side of her head on the pavement. She went ahead and called 911 not sure who the lady was or where she came from. This happened around 8:15 a.m., on 2/24/20, about that time the sheriff came over the hill heading north and stopped on the east side of the road, and came over to assist with the lady. The sheriff asked the lady questions on who she was and where she lived and she was not able to answer any of those questions that were asked. I explained to the sheriff that I had called 911. He stayed with the lady on the shoulder while I went to my car to get a blanket out to cover her, it was sunny but the wind was cool. The ambulance came, not sure what time, loaded her up on a cot and took off, so I got back into my car and proceeded to go south and do my errands. Observation on 3/2/20 at 4:15 p.m., revealed the speed limit sign on 14th Ave SE, coming north stated 25 miles per hour, as you approach the hill and proceed to go over the hill the speed limit sign stated 35 miles per hour, as you go north off of Highway 3 onto 14th Ave SE, the speed limit stated 35 miles per hour, as you come up and go over the hill, still heading south the speed limit drops to 25 miles per hour. The distance from where the resident left the facility through the southeast door to the area where the resident was found was approximately 500 surveyor steps, for which the resident crossed a field with rough and rugged grass, a curb outside of the facility and a driveway with pot holes. The National Weather Service Forecast Office for 2/24/20, documented the temperature at 39 degrees Fahrenheit, with the wind out of the east northeast at 10.5 miles per hour During an environmental tour on 2/27/20 at 9:30 a.m., facility Director of Nursing and Business Office Manger went around to all the door alarms and they all sounded and staff responded quickly to the alarms. The facility abated the immediate jeopardy on February 24, 2020 by educating all staff that each and every time a door alarm goes off all staff, irregardless of position or department is expected to respond to the alarm and determine why the alarm went off. The immediate area outside the door which is sounding must be checked to ensure no resident is out there. If no immediate known reason why the alarm sounded, a head count must be done to ensure all residents are present and accounted for.

Based on observation, record review and staff interview the facility failed to assure food was served in accordance with professional standards for food service safety during 1 meal. The facility reported a census of 62 residents. Findings include: During an observation on 9/3/19 at 12:08 p.m. dietary staff served residents in the 200 dining room. Staff E, Dietary aide dropped a butter pat and picked it up off the floor. Staff [NAME] continued serving the residents and handling their plates with no hand hygiene. When finished serving in the 200 dining room, the dietary staff wheeled carts to the 100 dining room. At 12:22 p.m. Staff [NAME] washed her hands. She turned on the water with her bare hand, washed her hands and then turned the water off with her bare hand, before getting a paper towel and drying her hands. Staff F, Dietary Aide washed her hands. Staff F turned the water on with her bare hand, washed her hands, pulled out a paper towel and turned the faucet off and then dried her hands with that towel. During an interview on 9/4/19 at 11:47 a.m. The Dietary Manager stated if staff dropped something on the floor it should not be used and after picking it up they should wash their hands. She said after washing hands staff should use a paper towel to turn the water off and should not use that towel to dry their hands. A Hand Hygiene and Handwashing Clinical Skill Checklist during the service of meals included to wash hands before meal service, when visibly soiled, and whenever hands were contaminated by touching a resident, self or any surface. The handwashing technique included to wet hands with water, apply soap, rub hands together for at least 20 seconds, rinse hands and dry thoroughly, then use a paper towel to turn off the water faucet.

Based on interviews, observations and record review the facility failed to provide appropriate infection control procedure passing laundry and failed to complete appropriate hand hygiene with use of gloves to two of two resident's reviewed (Resident #11 and #32 ). The facility reported a census of 62. Findings include: 1. During an observation, on 9/3/19 at 10:56 AM, observed the Laundry Aide pushing an empty laundry cart without a cover. During an observation, on 9/3/19 at 11:03 AM, observed the Laundry Aide passing personal clothes with no cover noted over clothes. The Laundry Aide dropped a white pair of socks on the floor, picked them up and took them into resident's room. During an interview on 9/4/19 at 3:27 PM, the Quality Director, Registered Nurse, stated she did not believe the Laundry Aide covered the clothes when she passed the clean laundry. During an interview on 9/4/19 at 3:30 PM, the Laundry Supervisor stated she did not believe the Laundry Aide covered the personal clothes when she passed it. She stated she would visit with the Laundry Aide to see if she knew where the cover was. The Policy and Procedure form labeled Laundering and Drying Clothes and Linens revised on 01/18 indicated to package, transport, and store clean clothes and linens to ensure their cleanliness and to reasonably protect them from dust and soil. 2. The Minimum Data Set (MDS) completed for Resident #11 with an Assessment Reference Date (ARD) of 6/7/19 showed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The resident had [DIAGNOSES REDACTED]. The resident had received an application of nonsurgical dressings, with or without topical medications, other than to feet. During an interview on 9/3/19 at 2:05 PM, Resident #11 reported he had some sores on his legs. During an observation on 9/4/19 at 8:43 AM, observed Staff A, Licensed Practical Nurse washed her hands and applied gloves. She then removed the resident's blanket and pulled down a tubular net bandage on the resident's right lower leg. She continued to remove the resident's shoe, sock and the rest of the tubular net bandage. Staff A then removed the top layer of dressing and changed her gloves with no hand hygiene. Staff A cut off the wrapped bandage with scissors and laid the scissors on clean gauze on the nightstand. Staff A got normal saline vials and then removed the dressing exposing an area approximately the size of fifty-cent piece. Noted active red drainage dripping from the wound. Staff A applied a clean gauze to the wound to absorb the drainage. Staff A changed gloves without hand hygiene and squirted the normal saline onto the wound to cleanse. She then dabbed the wound with gauze as the top right corner of the wound pools with red drainage. Staff A continued to attempt to hold pressure to stop the red drainage. Without hand hygiene, Staff A touched the bags with her gloves to get new gauze. Staff A got the new dressing without changing gloves or hand hygiene and places the new bandage on the wound. Staff A then entered the bathroom and changed her gloves without hand hygiene. Staff A prepared the cream by placing the end of the q-tip onto the tip of the medication tube. Staff A applied the cream to wound and applied gauze. Staff A wrapped gauze around the wound and taped to secure in place. The nurse completed the dressing by applying a tubular net bandage over the dressing and reapplied socks and shoes. Staff A entered the bathroom to wash hands and she changed into new gloves, closed supplies and took the biohazard bag out of the garbage can. Staff A then put away the tote with dressing supplies. The Wound Culture completed on 8/28/19 indicated the resident had the infection Pseudomonas Aeruginosa to the right lower leg wound. The form labeled Skin Observation - V 2 dated 8/29/19 indicated the resident had an area to the right front lower leg. The description stated the right lower leg remained open with a measurement of 3.5 by 2.0 centimeters (cm). The description continued to report an X-Ray was completed with normal findings and the wound culture preliminary findings showed gram-negative rods. The Laboratory Specimen Report, noted on 8/30/19, indicated for the resident to [MEDICATION NAME] milligrams twice daily for 14 days. The Medication Administration Record [REDACTED]. The Treatment Administration Record for (MONTH) 2019 indicated a treatment started on 8/23/19 to the right lower leg. Cleanse with sodium chloride, pat dry, place triad cream using sterile Q-Tip then cover with four by four gauze, wrap with stretch conforming bandage, secure with tape and with tubular net bandage daily and as needed (PRN) if dressing is loose or soiled. During an interview on 9/4/19 at 9:29 AM, the Quality Director, Registered Nurse stated it was an expectation to wash hands between glove usage. The Director of Nursing agreed the staff should wash their hands between glove usage. They reported they would change out all the supplies the nurse had used and replaced with all new product. The Procedure form labeled Wound Dressing Change, with a revision date of 10/17, indicated to remove gloves and discard in the same plastic bag then perform hand hygiene. 3. According to the MDS assessment, dated 7/18/19, Resident #32 scored 9 on the BIMS, indicating cognitive impairment. The resident had an indwelling urinary catheter and utilized oxygen. The resident had open [MEDICAL CONDITION] other than ulcers, rashes, cuts. The resident had surgical wounds and the resident received application of non-surgical dressings. a. During an observation on 9/4/19 at 7 a.m. Staff B, Certified Nursing Assistant (CNA) did pericare, changed gloves, and applied barrier ointment to open wounds. She changed gloves and cleaned the resident's torso and removed gloves. Staff B gloved with no hand hygiene and emptied the catheter bag. She left the room to get the the lift with no hand hygiene, just removed gloves. She returned with the lift and Staff M, CNA assisted with the transfer to the wheelchair with the total mechanical lift. Staff B combed the resident's hair, took the oxygen tubing apart from cannula and wheeled the resident to the dining room. Staff B performed no hand hygiene during the provision of the cares. During an interview on 9/4/19 at 7:25 a.m. Staff B stated they no longer had hand sanitizer in the resident's room so she did not do hand hygiene, she just changed gloves. She said after she wheeled the resident to the dining room she returned to the room, washed her hands and took the oxygen concentrator to the dining room. During an interview on 9/4/19 at 11:25 a.m. the DON stated hand hygiene should be done when pericare completed and definitely before applying ointment to an open wound, emptying the catheter and handling the oxygen tubing. b. During an observation on 9/4/19 at 11:05 a.m. Staff D Registered Nurse washed her hands and applied gloves. Staff D removed the dressing to Resident #32's left inner lower leg to reveal a large open area with mostly red tissue with obvious depth. The dressing was approximately 3/4 covered with red drainage. Staff D removed saline tubes from a baggie which also contained gauze and cleansed the would by letting the solution run over the wound and patted with gauze. She then removed gloves, washed hands, and applied new gloves. The facility Wound Dressing Change procedure revised 10/17 directed to remove the soiled dressing and discard in a plastic bag, avoiding contact and thus contamination of other surfaces, remove gloves and discard in same plastic bag and perform hand hygiene.

Based on record review and physician and staff interviews, the facility failed to assess and provide timely CPR (Cardiac [MEDICAL CONDITION] Resuscitation) for a resident that stopped breathing and had no pulse and the resident had no code status orders (Resident #1). Resident #1 had no heartbeat or respirations at 4:20 p.m. and the staff did not implement CPR. The ambulance crew arrived to the facility at 4:36 p.m., started CPR and transported the resident to the hospital where the resident was deemed expired. Six other residents did not have code status orders and the facility reported a census of 62 residents. Findings include: 1. Resident #1 had a MDS (Minimum Data Set) assessment with a reference date of [DATE]. The MDS identified the resident had a Brief Interview of Mental Status (BIMS) score of 13. A score of 13 indicated the resident had no cognitive impairments. The MDS identified the resident's admitted as [DATE]. The resident required extensive assistance of one staff with bed mobility, transfers, dressing, and toileting. The resident had [DIAGNOSES REDACTED]. The Care Plan, initiated [DATE], reflected the resident required [MEDICAL TREATMENT] (filtering of toxins from the blood process) related to end stage [MEDICAL CONDITION] and directed staff monitor/document/report signs and symptoms of [MEDICAL CONDITION] such as changes in level of consciousness, and changes in heart and lung sound. The Nursing Progress Notes indicated the following: On [DATE] at 12:58 p.m. Resident #1 was alert and cooperative with cares. The resident transferred with gait belt, assistance of one staff person and walker. Resident #1 required assistance to dress his/her lower body and personal hygiene. A late entry dated [DATE] at 3:15 p.m. indicated Resident #1 called staff to his/her room and reported feeling like he/she was dying. An assessment revealed the resident's oxygen saturation level was 80% on 2 liters of oxygen per nasal cannula. Oxygen was increased to 4 liters and the saturation level increased to 88%. Upon notification, the physician directed staff to increase the oxygen and utilize a mask or nasal cannula to deliver oxygen. Resident #1's spouse was notified. On [DATE] at 6:00 a.m. Resident #1 left the facility per wheelchair van for [MEDICAL TREATMENT], and returned to the facility at 11:40 a.m. Resident #1 transferred per gait belt, assistance of one staff and walker. A late entry dated [DATE] at 2:55 p.m. indicated Resident #1 required 5 liters of oxygen for low oxygen saturation levels. The resident required 3 liters of oxygen to maintain oxygen saturation level greater than 90%. The nursing note indicated Resident #1 was too tired to help with cares. On [DATE] at 3:10 a.m. Resident #1 required 3 liters of oxygen per mask for low saturation levels (no level was indicated in the progress note). The resident required assistance of one staff, gait belt and wheeled walker for transfer to the bathroom. On [DATE] at 3:02 p.m. the nursing staff noted Resident #1's oxygen saturation levels dropped when oxygen is not fully on or when the resident mouth breaths then increased when oxygen was delivered per mask. A late entry dated [DATE] at 3:50 p.m. indicated Resident #1 required oxygen delivered per mask after Staff M assessed the resident's oxygen saturation level in the lower 80 %. The progress note indicated Resident #1 transferred with assistance of one staff, gait belt and a walker and required a wheelchair for transfer to the dining room for the evening meal. The progress note revealed nursing staff observed Resident #1 remove his/her oxygen mask. A late entry dated [DATE] at 1:55 p.m. indicated Staff H, physical therapy assistant (PTA), reported Resident #1 was not acting right and had low oxygen saturation levels. Staff D, RN, increased oxygen to 4 liters per mask. The resident's oxygen saturation levels increased to 90%. Resident #1 reported he/she was fine and did not require a physician's assessment. A late entry dated [DATE] at 7:39 p.m. for a 2:00 p.m. assessment revealed at Staff B, licensed practical nurse (LPN), completed a nursing assessment. Staff B indicated Resident #1 was responsive with oxygen saturation levels in the low 90's%. The progress note indicated Staff H reported concerns that Resident #1's oxygen saturation levels were low. Staff H expressed concern regarding how Resident #1 looked and felt. Staff B noted the resident had a temperature of 100.1 degrees and administered Tylenol. Resident #1's Medication Administration Record [REDACTED]. Staff B completed this progress note approximately 3 hours after Resident #1 was transferred to the hospital after the resident sustained [REDACTED]. On [DATE] at 6:44 p.m. revealed at 4:24 p.m. Resident #1's was discovered lying on the floor on his/her stomach. The resident's face was in a pool of blood with a large amount of blood around his/her head. The nurse indicated initially Resident #1 was breathing however became cyanotic and the resident's pulse and respirations ceased. Upon arrival of the emergency response staff, Staff B provided notification Resident #1 was breathing when she entered the room. Emergency response staff began cardiopulmonary resuscitation (CPR). Staff B completed this progress note approximately 2 hours after Resident #1 was transferred to the hospital with no pulse or respirations. Staff interviews as follows: On [DATE] at 1:45 p.m. Staff I, certified nursing assistant (CNA), stated she worked with Resident #1 on [DATE] prior to his/her fall. Staff I indicated she had not routinely provided cares to the resident, but aware Resident #1 was extra tired. Staff I stated he/she seemed very tired/distraught that day and was different and kept removing the oxygen mask. Staff I reported her observation to Staff E, registered nurse (RN). Staff I observed Staff E in Resident #1's room at approximately 2:30 p.m. while she passed snacks. The resident refused a snack. Staff I observed Staff E had a stethoscope while with the resident. At approximately 3:30 p.m. Staff I responded to Resident #1's call light and request to transfer from his/her bed to the chair. The resident refused to use the bathroom at this time. Staff I indicated Resident #1 refused to use the toilet around noon when he/she returned from [MEDICAL TREATMENT]. Staff I used a gait belt to transfer Resident #1 to his/her chair then placed the oxygen concentrator to the left of his/her chair. She assured the oxygen mask was on, and noted there was shorter tubing to the concentrator to eliminate a fall hazard. She elevated the resident's lower extremities in the chair, covered him/her with a blanket and placed the call light in reach. Resident #1 indicated he/she would nap. Staff I was unable to recall where she placed the remote to the electric lift chair, and indicated other staff had observed Resident #1 attempt to self- transfer. Staff I stated after she provided transfer assistance to Resident #1, physical therapy staff asked how he/she was doing because she provided physical therapy services to the resident after he/she returned from [MEDICAL TREATMENT]. Staff I stated she did not observe the Director of Nursing (DON) that day, and was not sure if she was in the facility when she began her shift. Staff I indicated she sometimes stops in to visit with the DON. Staff I stated she did not observe the DON with Staff E. Staff I provided transfer assistance to other residents, then clocked out and left the facility for her break at approximately 4:15 p.m. She did not observe the ambulance or police vehicles in the facility parking lot when she left the facility. While at a stop sign to return to the facility, Staff I observed the ambulance and police cars at the facility, and parked across the street so she was out of the way. Staff I returned to the facility after the emergency response vehicles left the facility and clocked in. Staff I was notified Resident #1 had fallen and had 2 gashes to his/her head. Staff F informed her emergency response staff were performing chest compressions as the resident left the facility. On [DATE] at 11:14 a.m. Staff F, CNA, indicated on [DATE] at approximately 4:15 p.m. she observed Resident #1 on the floor in his/her room. Staff F stated the resident was lying face down on his/her stomach. The resident had a blank stare, was pale and kind of gasped for air. Blood was observed on the floor under the resident's head. Staff F notified the nurse per walkie talkie. Staff E, RN, entered the room and asked the resident if he/she could talk. Resident #1 did not respond. Staff E called for assistance of another nurse then left the room. Staff B, licensed practical nurse (LPN), entered the room. Staff F observed Staff B check for a pulse and indicated she felt a very light pulse. Staff F and Staff B placed towels under the resident's head. Staff B nudged Resident #1 and directed he/she stay with us. Staff B stated 4:29 but Staff F was uncertain if that indicated the time Resident #1 quit breathing. Staff F stated the ambulance arrived within approximately 5 minutes. Staff B did not initiate CPR. After emergency response staff asked Staff B the resident's code status, Staff B left the room to check code status while they initiated CPR (cardiopulmonary resuscitation). Staff F stated she did not observe Staff E do any assessment except ask the resident if he/she could say anything prior to exiting the resident's room. Staff F stated after Staff E exited the resident's room, Staff B entered. Staff B did not have a stethoscope, however was not able to find one. Staff B spoke to the resident but did not have a stethoscope to assess his/her heart or lungs. On [DATE] at 12:57 p.m. Staff E, RN, stated on [DATE] he began his shift at 2:00 p.m. He stated a CNA reported Resident #1 was weak while at [MEDICAL TREATMENT]. He was not aware of any additional concerns such as low oxygen saturation levels or elevated temperature reading. Staff E indicated he was not aware Staff B administered Tylenol for an elevated temperature reading. Staff E stated he assessed Resident #1's vital signs at approximately 3:00 - 3:30 p.m. Staff E recalled no concerns at that time and thought the resident had oxygen on per nasal cannula because he/she did not want to keep the mask on. Staff E stated he provided enteral feeding to a resident across the hall from Resident #1's room. Staff E requested assistance from the DON. At approximately 4:20 p.m. Staff F requested Staff E come to Resident #1's room. The DON provided assistance with the enteral feeding then Staff E left the room. Staff E stated he observed Resident #1 on the floor with his/her face in blood. He lifted the resident's head and placed a towel under him/her. Staff E stated he assessed the resident's respirations and noted they were blowing and approximately ,[DATE] respirations per minute. Staff E stated he did not have a stethoscope or blood pressure cuff to complete the assessment however he looked at a clock on the wall in Resident #1's room to assess his/her respirations. Staff E confirmed he did not document his assessment of the resident's respirations, and then stated he really just made sure Resident #1 was breathing and had a pulse. Staff E stated the resident's pulse was weak, however did not count the resident's heartbeat. Staff E stated he planned to complete a fall assessment when he returned to the resident's room. Staff E then stated he was only in Resident #1's room for approximately 15 seconds and just checked to see if the resident was breathing and had a pulse. Staff E stated he requested nurse assistance, and then left the resident's room to get a stethoscope, blood pressure cuff and begin transfer paperwork. Staff E stated while walking down the hall he observed Staff B responding with a tote used for vital signs assessment. He stated he directed Staff B complete the assessment to include vital signs. Staff E stated he returned to the nurse ' s station and began the transfer (paper work). Staff E stated he notified 911 at approximately 4:20 p.m. and asked for the resident's code status. Staff E noted it as not listed in the computer or in the code status book at the 100 hall nurse ' s station. Staff E confirmed if no code status is listed, staff are to perform basic CPR (cardiopulmonary resuscitation). At approximately 4:30 p.m. emergency response staff arrived at the facility. Staff E stated an officer in a black uniform had a defibrillator with him. An officer in a tan uniform directed facility staff meet the ambulance crew at the door. Staff E continued with paperwork. At approximately 4:40 p.m. emergency response staff exited the facility. Staff B approached Staff E and directed he wait on paperwork and fax later if needed. Staff B reported at 4:29 p.m. Resident #1 had no respirations or pulse. On [DATE] at 6:00 a.m. Staff B stated she was responsible for Resident #1's nursing cares on [DATE] day shift. While at [MEDICAL TREATMENT], [MEDICAL TREATMENT] staff reported difficulty maintaining Resident #1's oxygen saturation levels. After [MEDICAL TREATMENT], Staff H reported Resident #1's oxygen saturation levels ranged from 70 to 80 percent and noted the resident appeared tired. Staff B increased the resident's oxygen to 4 liters and stated she would return. Staff B recalled Staff H continued to monitor the resident's oxygen saturation levels while she was away. The resident did not respond or open his/her eyes, and Staff B was unsure if the resident was more confused when the oxygen saturation levels were low. Staff B indicated she then took a break and left the facility. Staff B admitted she did not auscultate the resident's lung sounds when she responded to concerns of low saturation levels, instead waited to assess the resident's lung sounds after her break. She stated the resident's lung sounds were clear. Staff B stated after oxygen was increased Resident #1 was fine and therapy was completed without difficulty. Staff B indicated she returned to the facility, and at approximately 2:30 - 2:45 p.m. was assigned to a different hall. During a follow up interview on [DATE] at 8:28 a.m. Staff B stated she heard Resident #1 fell on her walkie-talkie, however, she was not the resident's nurse at the time of the fall. Staff requested a nurse to the resident's room right away. When she entered Resident #1's room, she observed Resident #1 on the floor lying on his/her stomach. The resident's face was in blood on the floor. The resident was unable to respond to her request to talk, however noted he/she was breathing very slowly, and then began to gasp. Resident #1 became cyanotic. The resident blinked, and then his/her eyelids were half closed. Staff B attempted to elicit response by rubbing the resident's back and chest. Staff B stated she couldn't really find a pulse. She attempted a sternal rub but was unable to turn the resident. Staff B stated the police arrived. She reported the resident was breathing upon entry, however, she no longer felt a pulse. The police requested the resident's code status. Staff B requested Resident #1's code status over the walkie-talkie and Staff E was unable to locate code status. The policemen initiated CPR (cardiopulmonary resuscitation) while Staff B remained in the room to answer questions. Staff B identified the facility code status book location as in the 100 hall nurse ' s station. The code status book contained a list of residents' names with code status. Staff B stated she would prefer to have known the resident's code status rather than have to ask and probably would have initiated CPR before. Staff B did not ask for Resident #1's code status prior to arrival of the police department. On [DATE] at 5:23 p.m. Staff B stated at 4:29 p.m. Resident #1's pulse and respirations ceased. Prior to this time, his/her pulse was very weak/thready. On [DATE] at 11:44 a.m. Staff S, emergency staff, stated he and Staff T arrived at the facility and staff were not aware of what was going on or why we were there. They found a male nurse on the phone and he directed where they were to go. Upon entry to Resident #1's room, he observed the resident face down and very pale. The emergency response crew noted no facility staff performed CPR, and initially thought the resident had been laying there a long time. The nurse reported the resident was breathing 15 minutes prior, but did not know the resident's code status. Staff S hooked up a portable defibrillator which advised no shock. He clarified if the heart is not beating, the defibrillator will not shock, so they are to begin chest compressions. The nurse left the room to check the resident's code status. The resident was transferred by ambulance staff to the local hospital. Staff S stated initially upon their arrival, no one seemed to know what was happening and no facility staff were performing CPR so they thought the resident had been lying on the floor a long time. On [DATE] at 12:50 p.m. Staff T, emergency staff, stated he arrived at the facility with Staff S. Staff T stated initially he was disturbed at best. The facility reported a (resident) was down and no staff knew the ambulance was called. Staff T called the dispatcher to clarify the call, and the dispatcher then called the facility for direction. Staff T stated upon entry to Resident #1's room, he observed the resident lying face down on the floor in a pool of blood and no facility staff were doing anything. He observed 2 female staff in the resident's room, but was not aware of their names. Staff T stated initially they had no idea when the resident was last observed, then one of the staff reported Resident #1 took his/her last breath at 4:29 p.m. Staff T stated that was 4:34 p.m. Staff T and Staff S rolled the resident over and applied the defibrillator which advised no shock. Staff T and Staff S began CPR/chest compressions. Staff T stated I have no idea why they (facility staff) did not begin chest compressions after they reported he/she took the last breath at 4:29 p.m. and indicated disappointment as to how the situation was handled. Staff T again stressed no one knew what was going on. Staff T recalled the scene and stated it appeared Resident #1 fell near the closet and hit his/her head hard. According to the ambulance report, on [DATE] at 4:36 p.m. the ambulance staff responded to report of an unresponsive (resident) face down. The description section noted bleeding to the right side of the head and skin tears to the right elbow and wrist area. The ECG revealed asystole (no heart beat) and CPR started by law enforcement officers. The ambulance report assessment noted the resident as unresponsive, cold/mottled/pale with fixed and dilated pupils. Lung sounds were absent. The ambulance crew transferred the resident to the hospital. According to the emergency room Visit Notes, dated [DATE], Resident #1 was found face down on the floor in a pool of blood and unresponsive at the facility. The resident was found to be in asystole and dead on arrival. Per request of the resident's spouse, aggressive treatment was not performed and he/she was declared deceased . Resident #1's spouse was interviewed on [DATE] at 11:44 a.m. The resident's spouse stated on the night prior to the fall, Resident #1 was tired, however that was not unusual. On [DATE] during [MEDICAL TREATMENT], [MEDICAL TREATMENT] staff phoned to report the resident's oxygen saturation levels were low. At approximately 4:30 p.m. the facility called to report Resident #1 was being transferred to the hospital for admission and requested the spouse meet Resident #1 at the hospital. Upon arrival to the hospital, Resident #1's spouse was notified that Resident #1 had fallen and it was bad. The resident's spouse was informed Resident #1 passed away. On [DATE] at 9:24 a.m. Resident #1's physician stated he would expect to be notified of a change in condition such as lower oxygen saturation levels and elevated temperature readings. Additional staff interviews as follows: On [DATE] at 1:38 p.m. Staff P, [MEDICAL TREATMENT] RN, stated on [DATE] Resident #1 arrived to [MEDICAL TREATMENT] and appeared more weak than usual. She noted Resident #1's oxygen tank was not turned on and his/her oxygen saturation level was 55%. Oxygen was applied and increased which caused the saturation level to increase to ,[DATE]%. Staff P stated she notified the facility that oxygen saturation levels were low and the resident appeared weaker. [MEDICAL TREATMENT] chairside notes dated [DATE] at 6:57 a.m. revealed Staff P assessed Resident #1's lung sounds with rales/crackling and wheezing to bilateral upper and lower lungs. Staff P's narrative notation indicated Resident #1 was short of breath and required oxygen at 5 liters to attain saturation levels of 88%. [MEDICAL TREATMENT] chairside notes dated [DATE] at 11:15 a.m. indicated Staff P assessed Resident #1's lung sounds as decreased and or no breath sounds to bilateral lower lobes. A Nursing Note dated [DATE] as a late entry for [DATE] indicated upon arrival to the [MEDICAL TREATMENT] clinic Resident #1 had a nasal cannula applied however was unable to stand. Staff noted the resident's oxygen tank was not on or flowing. His/her oxygen saturation level was 55%. The oxygen tubing was connected to an oxygen concentrator at 10 liters. Resident #1's oxygen saturation level increased to ,[DATE]%, and the oxygen was titrated down to 2.5 liters. On [DATE] at 9:35 a.m. Staff R, [MEDICAL TREATMENT] patient care technologist, recalled Resident #1 more weak than usual on the morning of [MEDICAL TREATMENT] and required assistance of 2 staff to transfer. Staff R recalled Resident #1 as short of breath when Staff P noticed the oxygen tank not turned on. On [DATE] at 9:25 a.m. Staff Q, [MEDICAL TREATMENT] office manager, stated the morning of [DATE], staff reported Resident #1's oxygen tank not on upon arrival and he/she experienced shortness of breath, and his/her oxygen saturation levels were low. Staff Q stated Staff P reported the concerns to the facility. Staff Q provided a copy of Resident #1's advance directives, dated [DATE] and signed by the physician on [DATE], which indicated Resident #1 did not desire resuscitation (DNR) in the event his/her heart stopped beating. A [MEDICAL TREATMENT] physician's note dated [DATE] (late entry) and was signed by the physician ' s Assistant (PA) The note indicated Staff Q reported upon arrival to [MEDICAL TREATMENT], Resident #1's oxygen saturation level was assessed at 55% when staff noticed the oxygen tank was not turned on. Oxygen 10 liters was administered until the resident's oxygen saturation level reached 87% then reduced to 2.5 liters. On [DATE] at 12:01 p.m. Staff H, physical therapy staff (PTA), stated when she entered Resident #1's room, the resident kept saying, ok thank you. She noted oxygen was on per nasal cannula. Her assessment revealed the resident's oxygen saturation levels as ,[DATE]%. Staff H stated she applied the oxygen mask and reported her findings to Staff B, LPN. Staff B increased the oxygen from 2 liters to 4 or 5 liters. Staff H stated she remained with Resident #1 and monitored his/her status. Staff H stated after several minutes, the oxygen saturation level was in the 90's. Staff H stated she continued to note concerns with Resident #1's status, and notified Staff D. Staff D entered and the resident's saturations levels increased. As the saturation levels increased, the resident began to act like self again. Staff H stated Resident #1 had a fever of 101 or so which was unusual. Staff B administered Tylenol. Staff H did not observe Staff B auscultate Resident #1's lung sounds. Staff H stated she provided therapy services to Resident #1 after [MEDICAL TREATMENT] before, but on [DATE] was just abnormal for him/her. Staff H stated that Staff B informed her something about low saturation levels. On [DATE] at 8:08 a.m. Staff D (Registered Nurse) reported the resident ' s oxygen saturation levels ranged from ,[DATE]%. The resident did not respond when asked if he/she was alright. The resident refused to go to the hospital or physician's office for an evaluation, and refused to have the nurse notify his/her spouse and then reported he/she was fine. Staff H reported a change in the resident's normal activity. Resident #1 reported no further complaints. On [DATE] at 11:53 a.m. the Director of Nursing (DON) stated approximately 20 minutes after she left the faciity on [DATE], she was notified the ambulance was there. She phoned the facility and was notified of Resident #1's injury and death. The DON stated Staff F found Resident #1 on the floor, face down and requested nursing come to Resident #1's room. The DON stated Staff E responded to the resident's room then returned to the nurse ' s station to call 911. Staff B responded and indicated Resident #1 was breathing. Staff B attempted to stimulate the resident, and then noted there were no respirations, however, was not physically able to roll the resident. The DON stated at the approximate time respirations ceased, police entered the room and inquired about his/her code status. Staff B was not aware and informed the officers the resident was breathing when she entered the room. The police officers then began CPR. The DON stated Resident #1's clinical record did not include a code status. If there is no code status listed, staff are trained to initiate CPR. The DON observed Resident #1's room and indicated there was blood approximately 2' up the door fame. The DON stated through investigation and staff interviews she determined at approximately 3:30 p.m. Staff I transferred Resident #1 to his/her chair. Resident #1 refused to use the toilet. Staff I reported Resident #1 transferred as normal for him/her and indicated his/her oxygen was on per concentrator. Staff I placed the oxygen concentrator to the left of the resident's chair. Staff F discovered the resident on the floor and indicated the oxygen concentrator was moved and positioned in front near the door. Resident #1 had fallen onto his/her right side between the closet and recliner chair. The DON stated at approximately 4:10 p.m. Staff E provided enteral feeding to a resident across the hall and requested assistance from her. The DON stated she walked by Resident #1's room and noted the door was partially open however was unable to observe the recliner or resident. She had the resident been on the floor at that time, she would have observed his/her legs. The DON confirmed knowledge that nursing staff did not provide CPR and indicated it all happened at the same time and there was no opportunity to initiate CPR until the police arrived and rolled the resident. She confirmed Staff B notified the police that Resident #1 was breathing and she witnessed his/her last breath. At that point the police hooked up the defibrillator and began CPR. The DON then confirmed knowledge that six (6) residents (Residents #4, #8, #9, #10, #11, and #12) currently residing in the facility did not have a code status. On [DATE] at 9:40 a.m. the Social Services staff confirmed there was no code status indicated for Resident #1 at the time of his/her fall/death. Typically, at the time of admission she discusses Advanced Directives with the resident and/or family members to attempt to determine the resident's code status; however, most don't want to talk about it. The Social Service staff then completes a progress note to indicate code status, or lack of. If no code status is identified, a medical record then adds the resident to the physician's list to discuss code status and write an order. The Social Services staff confirmed 6 residents that currently resided in the facility did not have a code status indicated. On [DATE] at approximately 4:30 p.m. a copy of Resident #1's advance directives, received by the surveyor from [MEDICAL TREATMENT], was provided to the Administrator, Director of Nursing, and health information licensed practical nurse (LPN). All indicated they were not aware Resident #1 had advanced directives signed and requested do not resuscitate (DNR). The Social Services staff reviewed provided code status information as follows: 2. Resident #4 had an admission date of [DATE]. The clinical record lacked evidence to indicate his/her code status. On [DATE] at 1:20 p.m. Resident #4 stated the social worker spoke with him/her one time. The resident stated he/she wanted staff to begin CPR if his/her heart stopped beating. At the time of the interview Resident #4 correctly stated the year, location and indicated accurate information regarding the current President of the United States stating his name slips my memory right now. 3. Resident #8 had an admission date of [DATE]. The clinical record lacked evidence to indicate his/her code status. On [DATE] at 1:43 p.m. Resident #8's spouse stated he/she wanted staff to initiate CPR in the event Resident #8's heart stopped beating. The spouse was able to recall staff asked the same question at [MEDICAL TREATMENT] however was not able to recall Resident #8's wishes. 4. Resident #9 had an admission date of [DATE]. The clinical record lacked evidence to indicate his/her code status, however verbally stated did not want resuscitate (DNR). The Social Services Designee stated Resident #9 was alert and oriented and should be identified as interviewable. On [DATE] at approximately 11:00 a.m. Resident #9 stated he/she did not wish to be resuscitated in the event his/her heart stopped beating and was unable to recall staff discussing this at the time of admission. At the time of the interview, Resident #9 correctly stated the date and indicated ,[DATE] was his/her sibling's birthday. Resident #9 then correctly stated the current year and President of the United States. 5. Resident #10 had an admission date of [DATE]. The clinical record lacked evidence to indicate his/her code status. 6. Resident #11 had an admission date of [DATE]. The clinical record lacked evidence to indicate his/her code status. 7. Resident #12 had an admission date of [DATE]. The clinical record lacked evidence to indicate his/her code status. The facility policy Advance Care Planning and Advance Directives, dated ,[DATE], directed at the time of admission, the social worker asks the resident/healthcare decision-maker whether he or she has prepared an advance directive such as a living will, durable power of attorney for healthcare decisions, etc. Social services will inform the resident/healthcare decision-maker of the right to consent or refuse medical treatment and provide a copy of the advance directives policy and state-specific information regarding advance directives. Social services will inform resident/healthcare decision-maker that a meeting will be set up within the week to begin discussions about their wishes in regards to advance care planning. Staff members will meet with resident/healthcare decision-maker to answer questions and determine if he or she wishes to develop or amend advance directives. If advance directive has been formulated, a copy will be scanned in. As necessary, physicians will be contacted for orders that reflect the resident's wishes. *At the time of the complaint investigation, the complaint was coded as a K, immediate and serious jeopardy. By [DATE], the facilty had implement measures that adequately addressed the jeopardy by providing inservices to all licensed nursing staff and the grid placement was lowered to the E level . Resident #9 requested not to receive CPR and was one of the 6 residents with an unclear preference. The facility had not completed measures to ensure the resident did not receive the CPR and verify the other remaining 5 residents. The Nurse's Meeting held on [DATE] consisted of an inservice regarding the CPR policy and Procedure handouts. A

Based on record review, observation, and staff interviews, the facility failed to adequately supervise a resident as directed by the Care Plan in order to keep the resident safe (Resident #4). The sample consisted of 3 residents and the facility identified a census of 64 residents Findings included: 1. Resident #4 had a Minimum Data Set (MDS) assessment with a reference date of 5/6/16. The MDS identified Resident #4 with moderately impaired cognition, disorganized thinking that fluctuates, required extensive assistance of 1 staff for bed mobility, transfers, ambulation in the room, toileting, personal hygiene, and bathing. The MDS indicated the resident had walked in the hall 1 to 2 times during the assessment period, not steady and required staff to stabilize during transitions and walking. The MDS indicated the resident had no range of motion impairment, and used a walker or wheel chair for mobility. The MDS indicated the resident had no falls during the previous assessment period. The resident's active [DIAGNOSES REDACTED]., and idiopathic normal pressure [DIAGNOSES REDACTED] (excessive spinal fluid in the brain). A Falls Tool dated 1/19/16 revealed the resident had a score of 15. A score of 15 identified the resident had a medium risk for falling. The Care Plan identified a focus problem initiated on 9/15/15. The resident had a risk for falls due to a [DIAGNOSES REDACTED]. A Target Date of 3/10/16 documented a goal for no serious resident injury through the review period. The interventions directed the staff the resident had a bed/pad alarm in the chair or wheel chair since 9/15/15 to alert staff to the resident's movement. Additional interventions directed staff the resident required hard soled shoes or gripper socks when ambulating or mobile in the wheel chair and to monitor the resident for significant changes in gait, mobility, cognition, safety awareness, and decision making capacity. An incident description, dated 5/10/16 at 6:20 p.m. indicated Staff A, CNA (Certified Nurse's Aide), had been assigned to care for the resident. Staff A stated the resident had finished supper and the resident was self- propelling in a wheel chair back to his/her room and Staff followed a few feet behind the resident. Staff A planned to assist the resident to the bathroom and then to an alarmed recliner. The CNA was needed by another resident and thought she had time to assist the other resident and left Resident #4 unattended. Staff A stated the resident's wheel chair became stuck on his/her room threshold, the resident stood to pull the wheel chair over the threshold, and the resident fell . The form revealed the fall to be unwitnessed. The resident had a pain level of 10 out of 10, and the pain location was not documented. An Investigation form dated 5/10/16 at 6:20 p.m. revealed Staff A had heard an alarm sounding in another resident's room prior to Resident #4's fall. The DNS (Director of Nursing Services) re-educated Staff A that the resident needed an alarm per the Care Plan even when staff had the resident in sight because the CNA may be called away. The investigation indicated the resident had not waited for the CNA to return, unable to wheel self over the threshold, stood up and fell , and all other Care Plan interventions had been in place. A Progress Notes New entry dated 5/11/16 at 1:07 a.m., indicated the nurse called to Resident #4's room on 5/10/16 at 6:10 p.m. The nurse found the resident on the floor on his/her abdomen, and stated his/her right arm hurt. The resident stated the arm hurt too much to move it. The nurse had the resident transferred to the hospital. The resident had a diagnosed of a fractured right arm. A Progress Notes entry dated 5/11/16 at 9:38 a.m. revealed the resident had not been admitted to the hospital and planned to return to the facility in the afternoon. A hospital Consultation report dated 5/10/16 documented an x-ray identified the resident had a spiral fracture of the right proximal humeral shaft. The physician's treatment plan included a shoulder immobilizer for short term use and possibly a hanging arm cast later on. The resident's May 2016 Medication Record revealed the following medications given for pain (pain scale of 1-10 with 0 - no pain and 10 as severe pain: a. The resident received Hydrocodone-Acetaminophen 5/325 mg. (milligrams) for pain at the following times and received relief: 5/11/16 at 8:49 p.m. for a pain level of 7 (out of 10). 5/12/16 at 8:38 a.m. for a pain level of 2. 5/13/16 at 12:33 a.m. for a pain level of 7. 5/16/16 at 3:15 a.m. for a pain level of 3 and at 8:46 p.m. for a pain level of 8. 5/17/16 at 9:51 p.m. for a pain level of 8. 5/18/16 at 9:40 p.m. for a pain level of 7. 5/19/16 at 9:56 p.m. for a pain level of 7. 5/21/16 at 3:50 a.m. for a pain level of 5, 12:30 p.m. for a pain level of 5, and at 10:29 p.m. for a pain level of 8. b. The resident received Acetaminophen 650 mg. for pain at the following times and received pain relief: 5/12/16 at 12:42 p.m. for a pain level of 4 (out of 10). 5/13/16 at 4:48 p.m. for a pain level of 5. 5/14/16 at 7:30 a.m. for no pain and at 8:21 p.m. for a pain level of 4. 5/15/16 at 3:22 a.m. and 2:41 p.m. for a pain level of 5. 5/16/16 at 4:17 p.m. for a pain level of 8. 5/17/16 at 6:02 p.m. for a pain level of 5. 5/18/16 at 5:36 p.m. for a pain level of 8. 5/19/16 at 1:18 p.m. for a pain level of 5. 5/20/16 at 8:30 p.m. for a pain level of 4. 5/21/16 at 4:19 p.m. pain level not documented. 5/22/16 at 3:26 p.m. pain level not documented and at 9:50 p.m. for a pain level of 3. 5/23/16 at 3:32 a.m. for a pain level of 3, 12:40 p.m. for a pain level of 4, and at 10:25 p.m. and pain level not documented. 5/24/16 at 1:31 p.m. and pain level not documented and 8:57 p.m. for a pain level of 3. 5/25/16 at 4:23 a.m. for a pain level of 4. The resident's May 2016 Treatment Record revealed the resident wore an immobilizer to the right arm at all times and allowed to sit up in a chair with the weight of the arm providing a natural traction from 5/12/16 to 5/25/16. An observation 5/25/16 at 1:00 p.m. identified the resident sitting in a wheel chair in the therapy room with a pressure pad alarm attached to the wheel chair and a cloth on the resident's right hand. An OT (Occupational Therapist) worked with the resident's fingers. The resident stated his/her hand had edema (swelling) and the OT verified the edema. During an interview on 5/25/16 at 11:30 a.m., the DNS verified Resident #4 had not had a personal alarm on at the time of the fall. The DNS stated the resident had 1 alarm at the time, the alarm had been left in the resident's recliner, and now the resident had 2 alarms. During an interview on 5/25/16 at 1:45 p.m., the DNS stated the evening of Resident #4's fall/fracture, she educated all staff on the importance of keeping alarms on residents, even when the staff had the resident in sight. The resident had 30 minute checks from 5/11 to 5/18/16 after the fall, an alarm audit completed of the entire building, and the resident was encouraged to leave the room door partially open. The DNS stated the resident had a fall in January 2016. The facility wanted to move the resident closer to staff observation, and the family refused.

Based on observation, record review and staff interview, the facility failed to provide the necessary services to maintain a resident's well-being for 1 resident under [MEDICAL TREATMENT] services (Resident #12). The facility reported a census of 65 residents. Findings included: According to the [DIAGNOSES REDACTED].#12's [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The same physician's orders [REDACTED]. The Physician orders [REDACTED]. Resident #12's Comprehensive Care Plan dated 12/26/13 included a problem for the resident to have an alteration in health maintenance and included 1 area of concern as a 1500 cc fluid restriction. Even though staff identified the resident's 1500 cc fluid restriction as a concern, the care plan lacked any approach for nursing staff to manage the fluid restriction. Review of Resident #12's daily Dining Report forms revealed staff documented the resident's fluid intakes at every meal. Ongoing record review revealed nursing staff failed to document the resident's fluid intakes outside of meals such as with his/her medications or any other fluids the resident took in outside of his/her meals. Observation of Resident #12's bedroom on 1/29/14 at 9:35 A.M., revealed the following: a. an empty 10 ounce glass sat on the bedside table. b. a 4 ounce glass with an unknown fluid approximately 1/4 full sat on the bedside table. Review of a facsimile dated 11/4/13, a Renal Dietitian documented Resident #12 had an average fluid gain of 4.17 kilograms (9 pounds 3 ounces). The Dietitian documented the fluid gain as too high. During interview on 1/29/14 at 3:15 P.M., the Renal Dietitian stated she expected nursing staff to document all fluid intakes for a resident on a fluid restriction. The Dietitian stated a weight gain between [MEDICAL TREATMENT] treatments (such as the weight gain as documented by the Dietitian on 11/4/13), is likely due to fluid and not calories. The Dietitian identified a weight gain of more than 3 kilograms (6 pounds 6 ounces) between [MEDICAL TREATMENT] treatments too high. During interview on 1/29/14 at 11:00 A.M., 100 hallway Registered Nurse (RN) unit manager reported facility nurses awareness of Resident #12's allowance for fluids in a 24 hour period outside of meals as 420 cc. The RN unit manager confirmed nursing staff lacked documentation of the total fluid intake the resident took in with medication pass or otherwise, per shift. During interview on 1/29/14 at 2:52 P.M., Staff D Licensed Practical Nurse, reported Resident #12 only being allowed 360 cc of fluids in a 24 hour period outside of fluids taken in at meal times. Staff D reported the resident always wanted more to drink and had been noted consuming other resident's fluids. Staff D reported getting calls from the [MEDICAL TREATMENT] center with a concern the resident consumed too much fluid as the [MEDICAL TREATMENT] center staff reported not being able to pull all of the fluid off of the resident. Staff D confirmed she does not keep track of Resident #12's fluid intakes with medication pass or otherwise during her shift. During interview on 1/29/14 at 3:00 P.M., Staff E, RN, identified Resident #12's allowance for fluid intake in a 24 hour period (outside of fluids taken with meals) as 420 cc. Staff E confirmed not documenting the resident's fluid intake with medication pass or otherwise during her shift. During interview on 1/30/14 at 9:00 A.M., the 100 hallway RN Unit Manager stated, keeping track of Resident #12's fluid intake with med pass or any nursing measure not necessary as all nurses knew the resident's limitations.

Based on observation, record review and staff interviews, the facility failed to adequately assess and provide timely interventions in order to meet the resident ' s nutritional needs. Resident #1 continued to have weight loss issues since admission and there was a lack of early intervention in order to prevent significant weight loss and to promote healing of a pressure ulcer. The sample consisted of 13 residents and the facility reported a census of 65 residents. Findings included: 1. Resident #1 had a Minimum Data Set (MDS) assessment with an assessment reference date of 1/17/14. The MDS identified Resident #1's cognition as severely impaired. The same MDS revealed Resident #1 required extensive assistance from staff with eating and had no difficulty with swallowing. The resident had an admission date of [DATE]. The MDS identified the resident with [DIAGNOSES REDACTED]. The MDS reflected the resident weighed 135 pounds and had lost 5% or more in the past month or 10% in the past 6 months. The resident did not have a physician ordered weight loss regimen, received a mechanically altered diet. The resident had a stage II pressure ulcer. An Initial Temporary Care Plan dated 4/10/13 identified an alteration in nutrition. The approach directed staff to provide a diet with consistent carbohydrates. According to a facsimile (fax) to a physician dated 8/14/13, staff documented a psychiatric evaluation had been scheduled for Resident #1 due to continued paranoid delusions. Staff described the resident as agitated, aggressive and described the behaviors as affecting the resident's functionality. Review of additional faxes to the resident's Physician revealed the following: On 12/12/13 - Staff reported the resident not feeling well and had very little fluid and food intake. The Physician's office returned the fax to the facility on [DATE] with no new orders. On 12/21/13 - Staff reported the resident as declining and very combative. Staff reported the resident as flaccid and has had little to eat or drink over the past couple of days. The resident's physician ordered a urinalysis with culture if indicated but no further laboratory tests. On 12/23/13 - Staff reported the resident continued to have little fluid intake and described the resident as not eating. Staff reported the resident's weight on 12/1/13, as 153.4 pounds (lbs) and on 12/21/13 as 140.4 lbs with a weigh loss of 13 lbs. The Physician's office returned the fax on 12/23/13 with no new orders. Review of Resident #1's food intake forms revealed the following daily food intakes by percentage: November 2013 - 47.82 % December 2013 - 18.28% January 2014 - Staff documented the resident consumed no food 22 days out of 27 days reviewed. Staff documented the resident consumed only 25 % intake on 1/9 and 1/18 and 8.3 % intake on 1/13, 1/15 and 1/22/14. Resident #1's Comprehensive Care Plan dated 7/25/13, included a problem for altered nutrition. The same care plan documented the resident left 25% of most meals uneaten. The care plan documented the resident's weight on 4/13/13 as 168 lbs and a weight on 7/13/13 as 162 lbs. An updated Comprehensive Care Plan dated 9/5/13 documented the resident with insidious weight loss and documented the resident ' s weight on 8/13/13 at 161 lbs. An updated Comprehensive Care Plan dated 11/21/13 documented the resident's weights as 162 lbs on 7/13/13, 161 lbs on 8/13/13 and 155 lbs on 11/13/13. Ongoing review of the care plan revealed staff documented the resident's weight loss as ongoing due to the resident's refusal of meals. The care plan lacked any new approach to address the resident's ongoing weight loss such as a supplement etc. Review of Resident #1's Nutrition Assessments revealed the facility Dietitian documented the following: On 4/21/13 - The Dietitian documented the resident's current weight as 168 pounds (lbs). The Dietitian documented the resident's intakes varied greatly. The dietitian documented the resident's intakes could possibly increase after the resident became more familiar with the facility. 7/23/13 - The Dietitian documented the resident's weight as 162 lbs. The Dietitian documented the resident had emesis at times and started on the medication [MEDICATION NAME] (used for excessive gastric acids). The Dietitian documented the resident consumed 50 -100% of his/her meals. 9/3/13 - The Dietitian documented the resident's weight as 161 lbs and documented the resident had a urinary tract infection on 8/22/13. A Dietitian documented the resident's intakes continued to vary. The Dietician did not recommend interventions to promote a weight gain. 11/19/13 - The Dietitian documented the resident's weight as 155 pounds and the resident continued to have no specific concerns with eating, chewing or swallowing. The Dietitian documented the resident's diet changed to consistent carbohydrate diet with ground meats on 10/4/13. (Note: review of a facsimile sent to Resident #1's Physician on 10/14/13, staff requested to change the resident's diet to ground meat as the resident frequently refused to wear his/her dentures). Review of an Interdisciplinary Progress Note dated 1/6/14, the Dietitian documented the resident's weight as 135 lbs. The Dietitian documented the resident's intakes as 0-25 %. The Dietitian documented a recommendation for the resident to received Carnation Instant Breakfast powder in whole milk three times a day. According to a physician telephone order dated 1/14/14, nursing staff obtained an order for [REDACTED]. Furthermore, ongoing review of the resident's food intake form for January revealed the resident consumed no food or nutrients for 11 out of 12 days between 1/1 - 1/12/14. Nursing staff failed to provide the resident with any type of nutrient even after the Dietitian recommended Carnation Instant Breakfast on 1/6/14). According to a Nutrition assessment dated [DATE], the facility Dietitian documented the resident continued to refuse to eat and at times took the Carnation Instant Breakfast drink. The Dietitian documented the resident with a 16.15% weight loss (significant weight loss) in 180 days and a 13.46% weight loss (significant weight loss) in 90 days The Dietitian documented due to very poor intakes, she suggested the resident also receive a 2 ounce low sugar supplement 3 times a day. According to a physician telephone order dated 1/27/14, nursing staff obtained an ordered for the resident to receive a 12 ounce sugar free supplement three times a day (5 days after the Dietitian recommended the supplement). Furthermore, ongoing review of the resident's food intake form for January revealed the resident consumed no food or nutrients for 5 of the 6 days between 1/22 - 1/27/14. Nursing staff failed to provide the resident with any type of nutrient even after the dietitian recommended an additional supplement on 1/22/14). During observation on 1/27/14 at 11:56 A.M., Staff A, Certified Nurse Aid (CNA) sat next to the resident on a chair and attempted to feed the resident while the resident sat up in his/her bed. The resident refused any bite of food, but consumed 100% of his/her Carnation Instant Breakfast drink. During the same observation, Staff A reported the resident preferred only to drink. During observation on 1/28/14 at 9:20 A.M., Staff B, CNA, sat next to the resident on a chair and attempted to feed the resident while the resident sat up in bed. Observation revealed the resident refused to take any bites of food. Staff B reported even though the resident refused to drink his/her supplement at that time, Staff B reported the resident generally did drink his/her supplement. During an interview on 1/28/14 at 9:00 A.M., the facility Dietitian reported when she makes a recommendation for a resident with weight loss, she gives a nutrition form to either the facility Director of Nursing, the facility Care Plan Coordinator or a Nurse who can take an order, with the recommendation. The facility Dietitian stated if no one is available to hand the form to, she places the form with recommendations in a mailbox for the staff described above. During an interview on 1/29/14 at 8:35 A.M., the Cottage, Registered Nurse (RN) Unit Manager stated not being certain for the extended length of time between the Dietitian's recommendations for Carnation Instant Breakfast and/or the supplement and the time it took for nursing staff to obtain an order and offer the resident the nutrients. During an interview on 1/30/14 at 8:30 A.M., Staff H, RN reported not being certain if Carnation Instant Breakfast could be given to a resident without a physician's orders [REDACTED].

Based on observation, record review, and staff interview, the facility failed to provide adequate supervision and implement interventions to prevent injuries for one (1) of four (4) residents reviewed who sustained a fall with fractures (Resident #1). The facility reported a census of 63 residents. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 14 on the Brief Interview for Mental Status (BIMS) cognitive test indicating no cognitive impairments. Resident #1 required one staff to physical assist with activities of daily living (ADL's) including transfers, toilet use and with personal hygiene. Resident #1 required limited assistance with ambulation. The assessment identified Resident #1's balance as not steady and only able to stabilized with staff assistance when walking, when moving from seated to standing position, when turning around, when moving on and off the toilet, and during surface to surface transfer. Resident #1's [DIAGNOSES REDACTED]. A Falls Data Collection Tool dated 10/18/13 scored Resident #1 at 23, with a score above 12 representing a high risk of falls. The tool recorded assessments completed after falls on 01/24/13, 02/24/13, 04/15/13, 04/29/13, 05/30/13, 06/11/13, 07/31/13, 08/05/13, 10/18/13, and 10/24/13. The Care Plan dated 03/27/13 identified Resident #1 with the potential for accidental injury manifested by a history of falls, weakness, weight bearing as tolerated on the left leg, and complaints of dizziness and fatigue. The approaches included: a. 05/30/13 fall alarms on at all times. 07/09/13 discontinued chair alarm. b. 06/18/13 assist of 1, gaitbelt, and walker with transfers. c. 08/05/13 chair alarm at all times, place clip out of reach of resident. The Incident Details reports documented: a). On 08/05/13 at 4:30 p.m. Resident #1 had been found lying on the floor on his/her back in front of the toilet. The report identified a new intervention for staff to use a chair/clip alarm at all times. The report noted Resident #1 voiced an understanding of the alarm and not transferring him/her(self). The form identified the clip alarm should be out of Resident #1's reach. b). On 10/18/13 at 7:00 p.m. Resident #1 on the dining room floor lying on his/her left side with his/her face on the floor. The wheelchair pedals caught under Resident #1's legs. c.) On 10/24/12 at 7:55 p.m. staff found Resident #1 on his/her buttocks with his/her left leg out straight and the right leg bent at the knee out to the right side. Resident #1 stated he/she got up to wash his/her hands and put the wheelchair in the shower and fell . The Interdisciplinary Progress Notes dated 10/24/13 at 7:55 p.m. documented a CNA called for the charge nurse to Resident #1's room. Staff found Resident #1 on his/her buttocks in the bathroom with the left leg extended out in front and right leg bent at the knee out to the right side. The CNA reported that prior to the fall the CNA walked in Resident #1's room to ask about a shower and Resident #1 had transferred him/her(self) from the wheelchair to the toilet. Resident #1 stated he/she shut the alarm off. The CNA transferred Resident #1 back into the wheelchair and stepped out of the room for towels to wash Resident #1 up and found Resident #1 on the floor. Resident #1 stated he/she got up out of the wheelchair to wash his/her hands and put wheelchair in the shower and fell . The wheelchair was in front of Resident #1 when found. Resident #1 stated he/she had shut his/her alarm off. Resident #1 was admitted to the hospital. The Interdisciplinary Progress Notes dated 10/25/13 documented the fall investigation revealed Resident #1 knew how to turn off the personal alarm. Resident #1 stated when the alarm sounded, he/she knew how to turn it off. They discovered this behavior through the investigation. A hospital Discharge Summary documented Resident #1 admitted [DATE] and discharged [DATE] with [DIAGNOSES REDACTED]. Resident #1 presented to the emergency room after he/she had a fall at the nursing care facility on 10/24/13. After having a discussion with the resident and the resident's power of attorney/family member, and taking his/her comorbid conditions into consideration, the family did not want any aggressive management of the fracture. They wanted to pursue conservative management with stabilization of the hip and pain control. During hospitalization , Resident #1 had adequate pain control with narcotic medications, stabilization of the hip, and regular PT and OT for exercise and strength training. The care plan dated 3/27/13 identified an intervention on 10/29/13 to place the alarm box out of reach of Resident #1. Replace clip with key, and use only the pad. A Physical Therapy Plan of Care dated 10/30/13 documented Resident #1 fell on [DATE], due to a loss of balance. The fall resulted in a left hip fracture and the resident presented to therapy with the chief complaint of left hip pain, weakness and impaired ability to perform bed mobility, transfers and ambulation. An Occupational Therapy Plan of Care dated 10/30/13 documented Resident #1 fell [DATE] while walking to the bathroom. The fall resulted in a left hip fracture and pelvic fracture, and Resident #1 presented with complaints of pain and weakness and impaired ability to perform self cares and functional transfers/ambulation. Interviews: During an interview on 12/10/13 at 12:05 p.m. Staff A CNA stated Resident #1 could unhook the alarm. Wherever they clipped it, Resident #1 unhooked it. Resident #1 had the alarm that clipped and the sensor pad. Resident #1 had never turned the sensor pad off for her. Resident #1 would try to get up on his/her own. Resident #1 was noncompliant with what they told him/her. During an interview on 12/10/13 at 12:22 p.m. Staff B Licensed Practical Nurse (LPN) stated she thought Resident #1 had a pressure pad alarm and a clip alarm connected to the same (alarm) box. Resident #1 could unclip the alarm, but had the pressure alarm (pad) under him/her. Staff B was not aware of Resident #1 turning the alarm off. Resident #1 would try to get up quite a bit. After Resident #1 fell , they discovered he/she turned the alarm off. They replaced the magnetic device to something not as easy to remove and replace. During an interview on 12/10/13 at 12:34 p.m. Staff C LPN stated she couldn't recall if Resident #1 had 2 alarms, he/she had the pressure pad alarm for sure. She was not aware Resident #1 could shut it off. She said to silence the alarm they had to remove the clip from the alarm box and put it back in. Staff C demonstrated how removing the clip (from the alarm box) set the alarm off, and putting it back in shut it off. During an interview on 12/10/13 at 12:47 p.m. Staff D CNA stated Resident #1 could unclip (the alarm) from his/her clothing, but not aware he/she ever turned the pressure pad alarm back off. She said Resident #1 would try to get up even after many reminders. During an interview on 12/10/13 at 1:40 p.m. Resident #1's family member stated Resident #1 could remove the clip and replace it to shut the alarm off prior to the day he/she fell and fractured his/her hip. The family member stated he/she knew this because staff told him/her about it. During an interview on 12/10/13 at 1:50 p.m. Staff E CNA stated she worked the evening Resident #1 fell and fractured his/her hip. She worked the hall Resident #1 resided on. Resident #1 had the pressure pad alarm and the clip alarm. Resident #1 could remove the clip him/herself. Staff E stated Resident #1 had turned the alarm off and taken him/herself to the bathroom. Staff E assisted Resident #1 back to the wheelchair with the alarm on. Staff E told Resident #1 not to self transfer. Resident #1 agreed to a shower and Staff E left the room for towels. Staff E stated she told the other CNA Resident #1 had shut the alarm off and would need to keep an eye on him/her the rest of the evening. When Staff E returned to the room Resident #1 was on the floor and had turned the alarm off again. Staff E stead Resident #1 did this (turned the alarm off) on another shift and she reported to the charge nurse, who had a talk with Resident #1 about it. Staff E thought they moved the alarm box further away so Resident #1 couldn't reach it. During an interview on 12/10/13 at 2:19 p.m. Staff F CNA stated Resident #1 had a pressure pad alarm and a clip to his/her clothing. Resident #1 removed the clip frequently. Resident #1 turned the alarm off a couple of times prior to the evening he/she fell and fractured his/her hip. Staff F told the nurse if Resident #1 did it on her shift. During an interview on 12/10/13 at 2:42 p.m. Staff G Registered Nurse (RN) stated she worked the evening Resident #1 fell . Resident #1 told Staff G he/she tried to park his/her wheelchair in the shower, and his/her walker sat in the room. Resident #1 stated getting up to wash his/her hands, and that he/she shut his/her alarm off. Staff G denied knowledge Resident #1 could shut the alarm off. During an interview on 12/10/13 at 4:04 p.m. Staff H CNA stated she did not work the night Resident #1 fell , and had not worked for a while before the fall. She heard Resident #1 would shut the alarm off for other staff, but did not do it when she worked. She didn't know what staff did when this occurred. She said she would alert the Director of Nursing (DON) right away if Resident #1 did it on her shift. She said if Resident #1 could do that it kind of defeated the purpose of the alarm. During an interview on 12/10/13 at 4:13 p.m. Staff I CNA stated she worked the evening of Resident #1 fell and fractured his/her hip, but did not work Resident #1's hall. She said she saw Resident #1 that shift and he/she seemed antsy. Staff I stated she did see Resident #1 put the clip in the (alarm) box to shut the alarm off. She did not report it because she thought the charge nurses were aware. During an interview on 12/11/13 at 11:12 a.m. Staff J CNA stated she worked the evening Resident #1 fell and fractured his/her hip. Staff J stated Resident #1 was very impatient, and if not helped right away would get up. Staff J knew Resident #1 turned the alarm off by unplugging the clip and plugging it back in. Staff J caught Resident #1 in the bathroom after doing it. Staff J stated they kept telling the nurses Resident #1 did it, but they didn't do anything. During a Concerns and Findings meeting with facility staff on 12/11/13 at 11:00 a.m. the DON stated she talked to the CNA's and they could not pinpoint what nurse they reported to regarding Resident #1 shutting the alarm off. They said they reported, but the nurse's said they didn't know. The DON thought there was confusion because Resident #1 could take the clip off. She said supervisory staff and nurses did not know she could actually turn the alarm off. She told the nurses if they knew, they needed to report it on so they could look at interventions. She said the CNA's didn't report it on. She said having the string that clipped to Resident #1's clothing actually made it easier for him/her to shut it off, and if they knew he/she was doing that, they could have changed it prior to the fall. An Interdisciplinary Rehab Rounds record dated 11//08/13 documented Resident #1 had severe pain when moving the left hip. Resident #1 required maximum assistance for bed mobility. Resident #1 progressed to use the EZ Stand (mechanical) lift for pivot transfers and toilet transfers. On 11/11/13 the record documented Resident #1 progressed slowly, very sleepy, and tolerated standing for 1 minute 30 seconds before sitting secondary to pain and fatigue. Resident #1 max to total assist for self cares, and EZ Stand for transfers. An Incident Details report dated 11/13/13 at 7:10 p.m. documented Resident #1 slipped or fell , sitting on the foot pedals of the wheelchair. Resident #1 stated he/she slid down. The alarm sounded and alerted staff to check on Resident #1. The comments documented Resident #1 had the Hoyer sling under him/her and slid on the cushion in the wheelchair. Resident #1 slid down onto the foot pedals of the wheelchair. Resident #1 also had foam boots that slid on the floor. The new intervention included to remove the sling from under Resident #1 immediately when he/she returned from dialysis, and remove Resident #1's foam boots. The care plan dated 11/14/13 identified a potential for accidental injury with the approaches: a. Transfer with EZ Stand with 1 assist and large sized harness. b. Pad alarm at all times, do not use clip, keep alarm box out of resident's reach. c. Remove EZ sling and heel boots when resident returns from dialysis. During an observation on 12/11/13 at 8:23 a.m. Resident #1 sat at the dining room table. The alarm box hung low on the back of the wheelchair to the left. Resident #1 sat on a lift pad in the chair. During a Concerns and Findings meeting with facility staff on 12/11/13 at 11:00 a.m. the DON stated typically they did not put the sling in until right before Resident #1 left for dialysis. The facility Policy and Procedure for Alarms: Bed, Chair and Door identified the charge nurse would ensure that staff were knowledgeable regarding the alarm system. The facility procedure for a Fallen or Injured Resident included monitoring the effectiveness of interventions put in place to prevent further falls.