Every finding on record at Good Samaritan - Parsons

The facility reported a census of 33 residents. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility. This placed the residents at risk for food-borne bacteria. Findings included: - During an initial tour of the resident kitchenette on 04/09/24 at 08:30 AM, the following areas of concern were noted in the kitchen: 1. The kick plate on one of the ovens had broken off and was resting on the floor. 2. Two preparation tables had food debris on the bottom shelf. 3. Three storage racks in the dry storage room had multiple areas of missing protective coating and multiple areas of rust. 4. The stationary can opener had food debris dried onto the sharp area that would enter the can. 5. The trash can by the hand-washing sink lacked an accessible trashcan. 6. The trash can by the ice machine lacked a lid. 7. A three-tiered, wheeled cart used to transport clean dishes from the dishwashing area to their storage areas contained a build-up of food debris on all three tiers. On 04/09/25 at 08:30 AM, Dietary Staff BB confirmed the areas of concern were in need of cleaning, repair, or replacement. The facility policy for Cleaning Schedule--Food and Nutrition Services revised 11/21/24, included the facility shall provide guidelines to employees for proper cleaning of the kitchen and immobile equipment. Staff shall check each equipment item in the kitchen for cleanliness and ensure that it is in good condition. The kitchen ceiling will be checked daily for cobwebs, dust, or dirt that could fall into food. The staff shall clean and sanitize carts at the beginning of the morning and at least every four hours throughout the day.

The facility reported a census of 33 residents with 13 residents sampled, including one resident reviewed for activities of daily living (ADLS). Based on observation, interview, and record review, the facility failed to provide personal hygiene cares for the one sampled resident, Resident (R)11, when staff failed to provide facial shaving. This placed the resident at risk impaired dignity and poor hygiene. Findings included: - R11's Electronic Medical Record (EMR) revealed a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) status of 13, indicating intact cognition. She used a walker and a wheelchair for mobility and was independent with personal hygiene. The Functional Abilities Care Area Assessment (CAA), dated 07/02/24, documented the resident required staff assistance with activities of daily living (ADL) at times. The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. She used a walker for mobility and was independent with personal hygiene. R11's Care Plan' revised 04/10/25 instructed staff the resident was independent with ADL except for showers and shaving. On 04/07/25 at 12:03 PM, R11 sat in her recliner in her room watching TV. She had long facial hair visible. On 04/08/25 at 07:27 AM, R11 sat in her recliner in her room watching TV. R11 continued to have long facial hair present. On 04/07/25 at 12:03 PM, R11 stated she would like to have her facial hair shaved, but the staff do not shave her. On 04/08/25 at 12:03 PM, Certified Nurse Aide (CNA) M stated R11 required assistance with showering and shaving. CNA M stated the resident did not refuse cares. On 04/08/25 at 12:09 PM, Licensed Nurse (LN) G stated the resident received two showers per week and that staff would shave residents on their shower days. On 04/09/25 at 10:07 AM, Administrative Nurse D stated the facility expected staff to shave residents on their shower days. The facility policy for Shaving, revised 10/15/24, included that the purpose of the policy was to promote positive self-image and well-being.

The facility identified a census of 33 residents, with 13 residents sampled, including two residents reviewed for quality of care. Based on record review, interview, and observation, the facility failed to ensure adequate disease management and monitoring for Resident (R) 21 when staff failed to monitor weight and notify the provider of weight fluctuations related to R21's heart failure. The facility additionally failed to do daily weights and administer Lasix (a diuretic medication used to promote the excretion of urine to decrease swelling and fluid accumulation) as needed (PRN) for R9. These deficient practices placed the affected residents at risk for decreased quality of care and related health complications. Findings included: - R21's Electronic Medical Record (EMR) documented R21 had a pertinent diagnosis of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid). R21's Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He took diuretics and required oxygen. R21's Care Plan dated 03/04/25 documented that R21 had edema (swelling resulting from an excessive accumulation of fluid in the body tissues) to the lower legs related to heart failure and instructed staff to elevate his legs when resting and apply support hose. R21's EMR recorded a Physician Order, dated 03/04/25, for daily weights starting on 03/04/25. R21's EMR, reviewed for the timeframe from 03/04/25 through 04/08/25, revealed on 03/06/25 R21 gained 4.1 pounds from the previous day. R21's EMR lacked documentation of physician notification. A Progress Note on 03/06/25 documented R21's oxygen level was down to 86 % on five liters of supplemental oxygen. The note recorded R21 reported feeling short of air but did not want to go to the hospital. The recorded staff elevated the head of R21's bed to 90 degrees per his request and his oxygen level eventually rose to 92%. R21's EMR lacked evidence staff weighed R21 on 03/07/25. On 03/24/25, R21's EMR recorded a weight gain of 7.4 pounds from the previous day. R21's EMR lacked evidence of physician notification. A Progress Note dated 03/28/25 at 01:59 AM documented R21 had increased edema to both legs with the right being worse than the left. The note documented the nurse explained to R21 that the edema was related to the resident's CHF and encouraged R21 to wear his compression hose, and to sit in the recliner so that he could elevate his legs. A Progress Note dated 03/28/25 at 09:19 AM documented staff sent a fax notifying the provider of R21's significant edema without significant weight gain and sent weights as well. A Progress Note dated 03/28/25 at 01:52 PM documented the provider increased R21's Lasix from one time a day to two times a day. On 04/04/25 R21's EMR recorded a weight gain of 5.4 pounds from the previous day. R21's EMR lacked documentation of physician notification. On 04/06/25, R21's EMR recorded a weight gain of 5.6 pounds from the previous day. R21's EMR lacked documentation of physician notification. A Progress Note dated 04/06/25 at 09:01 PM documented R21 reported chest pain and pressure. His oxygen level was 88% on room air; staff called 911 for emergency transport to the hospital. On 04/07/25, R21's EMR recorded R21 gained pounds from the previous day. A Progress Note dated 04/07/25 at 09:20 AM documented staff sent a fax to the physician notifying him that R21 had increased, weeping edema in the legs, weight gain, and an emergency room visit. The note recorded R21 had a 3.4-pound weight increase in 24 hours. The note documented R21 received Lasix twice daily and spironolactone (a diuretic) once daily; staff requested wraps since R21's swelling prevented the compression hose application, During an observation on 04/07/25 at 12:33 PM, R21 sat in his wheelchair. His feet were on the floor, and he had edema on his legs and feet. During an interview on 04/09/25 at 09:27 AM, Licensed Nurse (LN) H stated that the physician should be notified if the resident has a weight increase of 3 pounds or more in 24 hours. LN H said she tried to obtain the weights herself since she did not trust the accuracy of other staff members. She stated when she returns from her days off, she looks at the weights and strikes out the weights that don't appear to be correct. LN H verified she struck out the weight taken on 03/06/25 on 03/10/25; the weights taken on 03/16/25, 03/20/25, 03/21/25, 03/22/25,03/23/25 were crossed out on 03/25/25 and the weights taken on 03/26/25 and 03/27/25 were crossed out on 03/27/25. LN H said she faxed the provider on Monday but has not heard back yet. During an interview on 04/09/25 at 10:18 AM, Administrative Nurse D stated that a person with daily weights for CHF should have an order with parameters to notify the provider of weight gain and said staff would notify according to the doctor's order. She said she would investigate why R21 did not have parameters on when to notify the provider. She said that a nurse should never strike out a weight that was put in by another nurse and said education would be provided to the nursing staff. During an interview on 04/09/25 at 02:40 PM, Administrative Nurse D stated that without an order they would follow the expectation to notify the physician if there was a weight gain of three pounds in a day or five pounds within a week. The facility's Standing Orders for weights for a resident with CHF documented they were to weight the resident daily for 14 days then two times a week after that. Notify the provider if there was a weight gain of 2.5 pounds within 48 hours or five pounds above the admission weight. 34056 - R9's Electronic Medical Record (EMR) revealed diagnoses, which included: congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), atrial fibrillation (A-fib-rapid- irregular heartbeat), and chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. He had no rejection of care and experienced shortness of breath (SOB) with exertion. He did not receive a diuretic medication (drugs that increase urine production, helping the body get rid of excess fluid and salt, which can be used to treat conditions like high blood pressure and edema). The resident utilized oxygen during the assessment period. The Functional Abilities Care Area Assessment (CAA), dated 10/15/24, documented the resident required varying staff assistance with activities of daily living (ADL). The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of 15, indicating intact cognition. He did not receive diuretic medication, and the resident utilized oxygen during the assessment period. R9's Care Plan revised 01/22/25, lacked staff instruction regarding the use of as needed (PRN) Lasix (a diuretic medication) use. Review of R9's EMR, revealed the following physician's order: Lasix, 40 milligrams (mg), by mouth every 24 hours, PRN, for fluid gain. Administer every day (QD) for a weight gain more than two pounds (lbs.) in one day or a five lb. gain in one week, ordered 10/04/24. R9's Medication Administration Record (MAR) for October, November and December 2024 and January, February, March, and April 1st through the 6th, 2025, revealed the resident did not receive the PRN Lasix medication. R9's EMR revealed the resident's weights were taken daily in October 2024, then changed to monthly in November 2024. R9's weights remained stable from 172.5 lbs. to 174.6 lbs. through February 2025. Staff documented his weight on 03/04/25 to be 190.8 lbs. and on 04/02/25 his weight was documented at 195.6 pounds. Staff did not administer the PRN Lasix medication. R9's EMR, on 03/05/25, staff notified the physician of the resident's weight gain of 18 lbs. and informed the physician the resident had no edema (swelling resulting from an excessive accumulation of fluid in the body tissues) or SOB. Staff were instructed to continue monitoring the resident. On 04/08/25 at 07:07 AM, R9 rested in bed with his feet and legs uncovered. R9 lacked edema in his lower extremities and had no SOB. On 04/08/25 at 12:09 PM, Licensed Nurse (LN) G stated staff weighed the resident monthly. LN G was unaware the resident had a PRN order for Lasix related to weight gain and confirmed staff should weigh the resident daily. On 04/09/25 at 10:07 AM, Administrative Nurse D stated the resident's weight gain was due to him eating better. Administrative Nurse D confirmed staff should have weighed the resident daily due to the physician's order and had not. The facility policy for Physician Orders, revised 04/06/25, included: Physician's orders are obtained to provide quality, individualized care for each resident.

The facility reported a census of 33 residents with 13 residents sampled, including one resident reviewed for activities. Based on observation, interviews, and record review the facility failed to implement an ongoing, resident-centered activity program that met his interests and preferences for Resident (R) 33. This placed the resident at risk for decreased quality of life. Findings included: - A review of R33's Electronic Medical Record (EMR) revealed a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS recorded R33 found if very important to keep up with the news, participate in his favorite activities and to go outside during nice weather; he was dependent on staff for chair to bed to chair transfers and utilized a wheelchair for mobility. The Activity Care Area Assessment (CAA), dated 09/12/24, did not trigger. The Quarterly MDS, dated [DATE], documented R33 had a BIMS score of 15, indicating intact cognition. He was dependent on staff for chair to bed to chair transfers and utilized a wheelchair for mobility. R33's Care Plan revised 03/20/25 instructed staff the resident had a diagnosis of depression. The plan directed activity staff would have one-on-one interactions with the resident to discuss his feelings relative to his unhappiness, losses, and anger. The plan instructed staff the resident had some independent interests and enjoyed conversations with family, friends, and staff. R33's EMR revealed an Activity Interest data Collection Tool, dated 09/11/24, which documented the resident's activity participation preferences included both individual and group activities. He enjoyed attending church and belonged to a local political party and had been a state representative in past years. R33's EMR, from 03/10/25 through 04/06/25, revealed the resident received the activity of Spiritual on multiple occasions. On 04/07/25 at 11:50 AM, R33 sat in his wheelchair in his room watching videos on his personal computer. On 04/08/25 at 08:17 AM, R33 sat in his wheelchair in the dining room eating breakfast. Activity Staff Z read from the facility's Daily Chronicle to the residents present. On 04/07/25 at 10:47 AM R33's representative stated the activities offered by the facility did not meet the resident's interests. The representative stated it was very important for the resident to attend his own church on Sundays and he would like to participate in outside activities offered in the community. The resident's family member stated she had been told by staff that the facility was unable to transport him to activities away from the facility. On 04/07/25 at 11:50 AM, R33 stated he enjoyed getting out and would like to attend community political events as well as attend church with his wife on Sundays. On 04/08/25 at 06:05 AM, Certified Nurse Aide (CNA) P stated the resident really enjoyed talking about politics. On 04/08/25 at 08:25 AM, Activity Staff Z stated each one-on-one activity should last about 15-20 minutes. Activity Staff Z stated the activity of Spiritual documented in the resident's EMR was one sentence that she read from the Daily Chronicle each morning in the dining room. Activity Staff Z confirmed there were no one-on-ones documented in the resident's EMR and she was unaware the resident wanted to attend community activities outside of the facility. On 04/08/25 at 12:03 PM, CNA M stated that R33 did not normally participate in the facility activities because he was not interested in the offered activities. CNA M stated the resident enjoyed talking about politics. On 04/08/25 at 12:09 PM, Licensed Nurse (LN) G stated R33 was very social and enjoyed visiting with others about politics. On 04/09/25 at 09:01 AM, Administrative Nurse D stated the facility could transport residents to any activity they wanted to attend outside of the facility. On 04/09/25 at 09:05 AM, Administrative Staff A stated the facility could transport residents to activities outside of the facility. The facility did not provide a policy for activities.

The facility reported a census of 42 residents with 14 sampled, including six residents reviewed for accidents. Based on observation, interview and record review the facility failed to ensure care planned fall prevention interventions were in place for Resident (R)32, with a history of falls, when staff failed to ensure the floor alarm was turned on, and R32 fell in her room and fractured (broken bone) her left hip. Findings included: - Review of R32's Electronic Medical Record (EMR) revealed diagnoses which included: osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) weakness (lacking strength) and dementia (progressive mental disorder characterized by failing memory, and confusion). The 01/12/23 Admission Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. She required limited assistance of one staff for walking in her room, transfers, and dressing. She required extensive assistance of one staff for toileting. Her balance was unstable, and she was only able to stabilize with staff assistance. She had impairment in functional range of motion (ROM) on one side of her upper extremity and she used a walker and wheelchair for mobility. The 01/12/23 Activity for Daily Living (ADL) Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R32 had a self-care deficit related to a history of falls before admission. The 01/12/23 Falls CAA documented R32 had a fall in the facility since admission. The resident did not always wait for staff assistance and would attempt to get up on her own. Her balance was not always stable. The 04/11/23 Quarterly MDS documented R32 had a BIMS score of 10, indicating moderate cognitive impairment. She required extensive assistance of one staff for toileting and supervision with walking in her room and corridor. She had limited ROM on one side of her upper extremity. She had two or more non-injury falls, one fall with injury (except major), and one fall with major injury since the prior assessment. The resident's balance was unsteady, and could only stabilize with staff assistance. The Fall Care Plan, revised 03/25/23, instructed staff to encourage the resident to wear appropriate footwear while ambulating or mobilizing in her wheelchair. Staff were to ensure the resident had her floor alarm next to her bed or in front of her chair to alert staff of the resident's movement and to assist the staff in monitoring the resident's movements. Review of the resident's EMR revealed fall assessments dated: 04/11/23, 03/23/23, 02/28/23 and 01/06/23, each placed the resident at a high risk for falls. Review of the resident's progress notes in the EMR revealed on 04/11/23 staff discovered the resident on the floor laying on her left side. The resident's chair was next to her bed with the floor alarm next to the chair, not sounding. The resident's walker was next to the dresser, out of reach, which was the normal for this resident. She wore appropriate footwear, had her glasses on, and the call light was on, at the time of the fall. The resident reported severe pain to her left hip. Staff assisted the resident up off the floor and onto her bed, with the use of a full-body lift and assistance of three staff. Staff called the Emergency Medical Technicians (EMT) to transport the resident to the hospital emergency room (ER) for evaluation and treatment. Review of the resident's progress notes in the EMR, revealed the resident was admitted to the hospital on 04/11/23 for a left intertrochanteric (between the bony protrusions of the thigh bone) reverse obliquity (the fracture line runs from the lesser trochanter to the small bony prominence that projects from the back and inner part of the thigh bone) proximally (center to the body) to the greater trochanter (projection at the top and outside of the thighbone) distally (away from the center of the body), exiting the lateral femoral cortex (one of the two projections on the lower extremity of the thighbone) below the vastus ridge (muscle in the front part of the thigh that helps straighten the leg) hip fracture which was repaired using open reduction internal fixation (ORIF). Review of the call light system revealed the resident initiated her call light at 09:36 PM (on 04/11/23) and turned off 09:39 PM (when staff entered her room and found her on the floor). On 06/27/23 at 07:21 AM, Certified Nurse Aide (CNA) N assisted the resident to ambulate from her bathroom to her wheelchair in her room with extensive assistance and the use of the gait (manner or style of walking) belt. The resident's gait was slow and steady. She required prompting and cueing to ambulate and to sit down into her wheelchair. On 06/27/23 at 07:21 AM, CNA N stated the resident required assistance with ambulation since she fractured her hip. CNA N said the floor alarm was no longer in use for the resident. On 06/27/23 at 02:13 PM, CNA M stated she was working the evening the resident fell . CNA M stated she had not ensured the resident's floor alarm was functioning that shift. CNA M stated she entered the resident's room on 04/11/23 in response to the resident's call light and discovered her on the floor with her head against the dresser and her back against the wall with her legs somewhat bent. Staff got the resident up from the floor with the full-body lift and put her on top of her bed. The EMTs came and transported the resident to the hospital. The resident had a fractured hip. On 06/28/23 at 05:51 AM, Licensed Nurse (LN) I stated the evening the resident fell and fractured her hip, the staff had not checked to ensure the floor alarm was turned on. If the alarm had been turned on, the staff would have heard the alarm sound and maybe gotten to the resident's room before she fell . The call light had been on for three minutes before the CNA got into the room and turned the light off and found the resident on the floor. EMTs transferred the resident to the hospital, and she returned to the facility a few days later. On 06/28/23 at 09:00 AM, Administrative Nurse D stated staff did not know the resident's floor alarm was not turned on before the resident's fall. The staff working that shift confirmed they had not checked the alarm before the resident fell . If the alarm had been turned on and sounded, the staff may have been able to get to the resident before she fell . The facility policy for Fall Prevention and Management, revised 03/29/23, included: It was the obligation of the facility to provide the safest environment possible for residents entrusted to their care. The facility failed to follow this resident's care planned fall interventions, by the failure to ensure the fall alarm was turned on, and R32 fell and fractured her hip.

The facility reported a census of 42 residents. Based on observation, interview and record review, the facility failed to maintain a safe, sanitary, and comfortable environment to prevent the development and transmission of communicable infections, regarding not properly cleaning three communal combs and brushes in the beauty shop. Findings included: - An environmental tour of the facility on 06/26/23 at 11:30 AM, with Housekeeping/Maintenance staff U revealed the following items/areas of concern with infection control, in the facility beauty shop: 1. The facility beauty shop contained three unlabeled combs with various colored hairs, lying on the counter. 2. The sink of the beauty shop had scaling and debris on the insides. 3. The counter surfaces had a build-up layer of dust over it. On 06/26/23 at 11:30 AM, Housekeeping/Maintenance staff U stated the area did not look good. The facility had a checklist for the cleaning of the beauty shop, but staff had not cleaned the area for a while. On 06/28/23 at 02:45 PM, Administrative Nurse D stated the facility had several hairdressers coming into work on different residents in the facility beauty shop. Administrative Nurse D stated the visiting hairdressers were not cleaning the beauty shop appropriately. The facility policy for, Barber/Beauty Shops, revised 12/19/22, included: All equipment used in the beauty shop will be sanitized between each resident use. The beauty shop area will be cleaned on a regular schedule. The facility failed to maintain a sanitary beauty shop area to ensure prevention of the development and transmission of communicable infections for the residents of the facility who utilized the beauty shop.

The facility reported a census of 42 residents. Based on observation and interview the facility failed to provide a clean, comfortable, and homelike environment for the residents and visitors on one resident hallway. Findings included: - Observation, on 06/26/23 at 08:00 AM, revealed a strong urine odor from the open doorway of a resident room on Hallway 2. The urine odor permeated into the hallway and to the end of the hall, which contained two other resident rooms. Both residents in these two rooms had severe cognitive deficits and could not voice displeasure in the strong foul odor. Observation, on 06/27/23 at 09:19 AM, revealed housekeeping staff V, about to clean the resident room where the foul odor came from. The room contained a strong urine odor which permeated into the hallway and the family room across the hall when the door was opened. Housekeeping Staff V stated the resident was frequently incontinent of urine and urinated on the floor in her bed, about in the room, and bathroom. Observation at that time revealed two dry pads upon the resident's bed and the bottom sheet contained a large yellow ring extending up under the pillows on the head of the bed. Housekeeping staff V removed the linen from the bed and sprayed the overlay mattress and pillows with a bleach solution and stated she did not wipe the areas off but let the bleach solution dry on the surfaces. Interview, on 06/28/23 at 08:29 AM, with Administrative Staff D, revealed staff cleaned the resident's room on 06/27/23, and confirmed that the room continued to smell of the foul urine. The resident's clothing also contained a urine odor. The urine odor permeated into the hallway when the door opened. Administrative Staff D stated staff tried multiple interventions to minimize the urinary incontinence and used bleach mixture to combat the strong urine odor. Administrative Staff D stated she recommended possibly an air purifier. The facility policy Managing Odors, reviewed 04/14/23, instructed staff the primary method of controlling odors was to ensure a thorough and systematical cleaning program that addressed the material that causes malodors. Staff instructed to mitigate the introduction of offensive odors and work to remove the intrusion of offensive odors in the building. The facility failed to ensure the environment remained free of strong offensive foul odors as much as possible when the odors became extensive beyond the scope of normal cleaning methods to ensure the health, cleanliness and homelike environment for the residents and visitors on that hallway of the facility.

The facility reported a census of 42 residents with 14 selected for review which included six residents reviewed for unnecessary medications. Based on observation, interview and record review, the facility failed to ensure one Resident (R)30 of the six residents received medications (to treat/prevent seizures) through her percutaneous (passing through the skin) endoscopic gastrostomy (a method used to view the inside of the stomach to place a tube used for administering medications and liquid nutrition) PEG as ordered by the physician. Findings included: - Review of Resident (R) 30's Physician Order Sheet, dated 03/23/23 revealed diagnoses included subarachnoid hemorrhage (bleeding in the brain), hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), seizure disorder (violent involuntary series of contractions of a group of muscles), and critical illness myopathy (a muscle disorder of the limbs and respiratory muscles). The Significant Change Minimum Data Set (MDS), dated [DATE], assessed the resident with severe cognitive impairment. The resident was dependent on staff for activities of daily living (ADL) and received greater than 51% of total calories through her PEG tube. The resident received seven days of antidepressant medication. The Nutritional Status Care Area Assessment (CAA), dated 05/09/23, assessed the resident had a feeding tube with the potential for nutritional problems due to not responding to oral intake. The Care Plan, reviewed 05/19/23, instructed staff the resident had a seizure disorder. The resident required tube feedings due to the inability to swallow and received nothing by mouth. The resident was administered platelet and antidepressant medications. Review of the Physician's Orders, dated 05/02/23 revealed the following orders: 1. Instructed the staff to flush the resident's PEG tube with 30 cubic centimeters (cc) of water before medications, 5 cc between medications and 30 cc after all medications and to document the total number of cc administered. Staff were also instructed to check for tube placement before initiation of formula and medication. 2. instructed staff to administer levetiracetam 1000 milligrams (mg), enterally (through the feeding tube directly into the stomach,) twice a day, for seizures. 3. Instructed to administer lactulose 10 grams (gm,) per 15 milliliters(ml,) 30 ml, enterally, twice a day, for constipation. 4. Instructed staff to administer Pepcid 40 mg, enterally, twice a day, for gastric reflux. 5. Instructed staff to administer fludrocortisone (a steroid medication used to treat deficiency of steroids due to multiple causes) 0.1 mg, enterally, twice a day for deficiency. 6. Instructed staff to administer artificial tears 1 percent (%), each eye, four times a day. Further physician orders, dated 05/03/23 included the following: 1. Instructed staff to administer fluoxetine hydrochloride (HCL) 40 mg, enterally one time a day, for depression. 2. Instructed staff to administer Plavix 75 mg, enterally, daily, for hemiplegia from stroke. 3. Instructed staff to administer amantadine hydrochloride (HCL) 100 mg enterally in the morning for critical illness myopathy. Review of the Medication Administration Record, (MAR) and Treatment Administration Record (TAR) dated June 2023 revealed a failure of staff to administer the resident the following physician ordered medications by the nursing staff: On 06/13/23 the morning doses of amantadine HCL 100 mg, fluoxetine HCL 40 mg, and Plavix 75 mg. In addition, the lack of administration of the morning doses, on 06/13/23 and 06/14/23, of fludrocortisone 0.1 mg, lactulose 30 ml, levetiracetam 1000 mg (medication treat/prevent seizures), Pepcid 40 mg, and two doses (06:30 am and 12:00 pm) each day of artificial tears 1% one drops each eye. Interview, on 06/28/23 at 09:48 AM, with Licensed Nurse (LN) G, confirmed the lack of administration of medications on 06/13/23 an 06/14/23 to the resident as she did not know the resident received the medications through her PEG tube. LN G stated she did administer the resident's tube feeding formula, but she was new to the facility and not familiar with the electronic medical record triggers for the administration of medications through the PEG tube. Interview, on 06/28/23 at 10:30 AM, with Administrative Nurse D, revealed at the time of the medication error, the facility had one resident with a PEG tube. Administrative Nurse D stated LN G was a new nurse to the facility, and she did not realize her responsibility to administer medications as well as the tube feeding to the resident. The facility policy Medication: Tube Administration, reviewed 03/02/23, instructed staff to verify physician orders to administer medications through a gastric tube in a safe and appropriate manner. The facility failed to ensure licensed nursing staff administered this resident with seizure disorder and critical illness myopathy's medications through her gastric tube as ordered by the physician to ensure optimal level of wellness.

The facility reported a census of 44 residents with three residents sampled for accidents. The facility also identified nine residents who used wheelchairs when transported in the facility van. Based on record review and interview the facility failed to ensure Resident (R)1 remained free of accidents when she sustained a fractured patella (kneecap) on 01/20/22 after Certified Nurse Aide (CNA) M failed to apply the facility van's seatbelt over the resident's wheelchair after assisting R1 into the van, and then at a stop sign, CNA M became distracted, which caused her foot to slip off the brake and hit the gas pedal, causing the van to rear-end the car in front of the van. The impact caused unsecured R 1 to slip and fall from her chair and land on her knees, which resulted in the patella fracture. This deficient practice placed these residents in immediate jeopardy. Findings included: - R1's signed Physician Orders (PO), dated 01/05/22, documented the resident with [CONDITION(S)] (inflammation of one or more joints) and weakness. The Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition, severely impaired vision, and the resident required a wheelchair for mobility. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 10/13/21, documented the resident had self-care deficit due to [CONDITION(S)]. R1 required limited assistance of one staff member for transfers and required staff assistance for mobility due to her visual deficit. The Quarterly MDS, dated [DATE], documented the resident with a BIMS of 15, indicating intact cognition and noted she required extensive assistance of one staff member for transfers and locomotion in her wheelchair. The Care Plan, revised 01/21/22, revealed the resident had impaired visual function related to [CONDITION(S)] in both eyes. R1 required staff to guide her to all areas. An Incident Note, dated 01/20/22 at 12:30 PM, revealed Licensed Nurse G documented per CNA M's statement, at approximately 12:00 PM to 12:30 PM, R1 was in the facility van and staff M transported R1 to go eat lunch between dental appointments. CNA M stated the van collided with the vehicle in front of her and the resident slid out of her wheelchair. The vehicle the van collided with belonged to R1's family member who accompanied them to R1's dental appointments. CNA M and R1's family member assisted the resident back into her wheelchair after the motor vehicle accident. At 05:26 PM the resident was seen in the emergency room . The resident required an x-ray and computerized tomography (CT) scan. The resident returned to the facility at 10:00 PM in the facility van driven by CNA M. R1 required a knee immobilizer related to a fractured right patella, as ordered by the physician. A Communication/Visit with Physician note, dated 01/20/22 at 11:28 PM, revealed Licensed Nurse H documented R1 was seen in the emergency room for a motor vehicle accident and noted she had a fracture of the right patella, right hip pain, right knee pain, and neck pain. The physician ordered pain medications the use of a knee immobilizer as much as possible, and the resident could bear weight as tolerated with the immobilizer in place. Facility was to schedule a follow-up appointment with the physician. A Witness Statement, dated 01/20/22, CNA M revealed they left the dentist's office to get lunch before the next dental appointment. She assisted R1 into the van and secured the wheelchair to the floor, but she did not put the seatbelt around the resident or her wheelchair. She documented they were Just going down the road to get some food. Something in the van fell and startled her. She turned to look, her foot slipped off the brake, and she hit the gas pedal, which caused the van to hit the car in front of them. When they hit the car, the resident slid out of her wheelchair. The resident's family member helped staff M put R1 back in her chair. The resident denied pain and stated she was okay, so they went to lunch and back to her second dental appointment. The resident's family member notified the police of the accident during the appointment. At approximately 03:00 PM, the resident complained of a headache and increased pain in her right knee, so the family member wanted to take her to the emergency room . At 05:26 PM she was evaluated in the emergency room and x-rays completed. The resident had a fracture of the right kneecap and required a leg immobilizer. Interview on 01/24/22 at 11:05 AM with CNA M verified the above witness statement. She verified she failed to apply the seatbelt around the resident. Interview on 01/24/22 at 11:28 AM with R1 stated when the van hit her family member's car, she slid out of her wheelchair and onto the floor. She fell on her knees and fractured her knee. She stated she was unaware why CNA M did not secure her in the facility van. Interview on 01/24/22 at 11:44 AM with Administrative Staff A revealed she expected all of her transportation staff to use the seatbelt with all residents being transported in the facility van. Per the facility Vehicle Resource Packet, undated, documented .Society Driver Requirements .Policy .the operation of motor vehicles is secondary to our business. However, with the operation of these vehicles comes the responsibility for the safety of the driver, passengers .All passengers must wear a seat belt .An integral part of this responsibility is the use of seat belts by all occupants of any motor vehicle . The facility policy Abuse Definitions-Rehab/Skilled, Therapy and Rehab, revised 12/20/21, documented .Neglect: Failure of the location, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . The facility failed to ensure this resident was free of accident hazards when R1 sustained a fractured patella on 01/20/22, between 12:00 PM and 12:30 PM, when CNA M failed to apply the seatbelt over the resident's chair after assisting R1 into the van, and then at a stop sign, staff M became distracted, which caused her foot to slip off the brake and hit the gas pedal, causing the van to rear-end the car in front of the van. The impact caused R1 to slip and fall from her wheelchair and fall onto her knees, which resulted in right patella fracture. This deficient practice placed the resident in immediate jeopardy, as well as the other eight residents that required a wheelchair van transport. The facility provided an acceptable plan of removal of the immediate jeopardy on 01/25/22 at 04:32 PM. The plan included: 1. On 01/24/22 at 05:00 PM, the facility began policy education that all residents must wear seatbelts in the facility van to facility staff. 2. On 01/25/22 at 09:45 AM, a Quality Assurance (QA) meeting was held. The facility notified the medical director on 01/25/22 at 10:08 AM. 3. The transportation aide ( CNA M) received education by the environmental specialist on 01/25/21 at 11:00 AM. The aide completed check-offs for transporting residents in wheelchairs and driver road test examination. All other transportation personnel will receive this education as well. 4. The facility completed a training of Transporting Residents in a Wheelchair Checklist on 01/25/22 at 4:32 PM to the additional staff that transported residents in wheelchairs in the facility van. The survey team validated the immediate jeopardy was removed on 01/25/22 at 05:00 PM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at the scope and severity of a G level following the removal of the immediate jeopardy.

The facility reported a census of 47 residents and the facility identified 35 residents with restorative services programs which included range of motion and ambulation. Based on record review and interview, the facility failed to provide restorative nursing services to these 35 residents, which included Resident (R)13, as well as the other 34 residents, to maintain their range of motion and/or ambulation ability. Findings included: - On 12/15/21 at 02:37 PM, a confidential resident interview with Resident (R)13, revealed the facility had not provided restorative nursing programs for active range of motion or ambulation during the last month. She stated she went to group exercise in the mornings where she raised her arms, but that was a waste of time. The resident reported she asked if she could walk short distances and was told no by an unidentified facility staff. She stated later she was told the Restorative Aide could walk her around the circle. She reported the restorative aide had not offered to walk with her since that discussion a month ago. The resident stated she wanted to walk. She did not want to ride the bicycle Nu-Step or to attend the group exercises for her arms in the morning. The resident stated and demonstrated she could do those exercises herself in her room. She reported the staff helped her to the bathroom using a wheelchair. They do not have staff to provide restorative program consistently. The restorative aide got pulled to transportation and also had to work on the floor as a Certified Nurse Aide (CNA), when staff called in sick. On 12/20/21 at 03:37 PM, CNA M stated she was unaware which residents were on a restorative nursing program. She reported the Restorative Aide (RA) walked some residents to the dining room sometimes but the RA often worked the floor as a CNA and filled in for transportation. Every resident is invited to the group exercises in the morning at 10:00 AM, and it is a scheduled activity. Ten to twelve residents attend and two staff which include the Activity Director (AD) who is also a CNA. They do exercises like arm raises to music. Some residents participate while some just like to socialize. On 12/20/21 at 04:04 PM, Certified Medication Aide (CMA) reported R 13, was on a restorative program but was unaware if the resident still received those restorative services. The RA provided restorative services, however, she usually was pulled to the floor to fill in and work when short or staff call in sick. She also gets pulled to provide transportation. On 12/21/21 at 10:03 AM, Licensed Nurse (LN) stated Resident (R)13 was a very high risk for falls and had multiple falls due to impulse control issues and balance issues. She refused walk to dine program because she eats in her room. She refused to attend group exercises, she walks looking at the floor, had a stroke before admission to the facility, and the resident leans to the left. The majority of the time the facility does not have a restorative aide. The RA fills in for Transportation or she works the hall as a CNA. Restorative Nursing Services are Very hit and miss. On 12/27/21 at 10:28 AM at 03:42 PM, Administrative Nurse D verified that due to the restorative aide being pulled to work with direct cares for the residents, and providing transportation for appointments, the facility did not provide consistent Restorative Nursing Program as needed. The restorative aide was pulled then to work on the floor. Nurse D provided a list of residents and their restorative programs and identified 35 residents. She stated the restorative nursing programs recommendation were usually made through therapy at the end of therapy services. Administrative Nurse D confirmed there was not a RA today and she was scheduled to work night shift as a CNA next week. The facility lacked a policy and procedure, for Restorative & Functional Maintenance Program, which addressed how to determine the extent to which the resident received nursing restorative of functional maintenance programs ,to focus on achieving and maintaining optimal physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment (MDS) and the care plan. The facility failed to ensure needed restorative services programs for at least 35 residents identified, and any others that may currently need the services, to maintain range of motion and ambulation abilities.

The facility reported a census of 47 residents. Based on observation, interview and record review, the facility failed to provide housekeeping and/or maintenance services to maintain an orderly, sanitary, and comfortable environment in the beauty shop for the residents of the facility. Findings included: - Environmental Tour on 12/16/21 at 11:59 AM, with Administrative Staff A revealed the following concerns: 1. The filter on the hair dryer had a dusty fuzzy build-up. 2. There was loose hair around the parameter of the room throughout the Beauty Shop. 3. The sink contained loose hair remnants. 4. A rolling cart had a dust build-up. On 12/16/21 at 11:59 AM, Administrative Staff A confirmed the above findings and stated she was not aware of who was responsible for cleaning the beauty shop. The facility's policy for Barber/Beauty Shops, dated 12/02/21, revealed all equipment would be sanitized at the time of use. The purpose was to ensure the barber/beauty shop provided sanitary and safe service for residents. The facility failed to provide housekeeping and/or maintenance services to maintain an orderly, sanitary, and comfortable environment in the beauty shop for the residents of the facility.

The facility reported a census of 47 residents with 15 selected for review. The sample included one resident for skin conditions. Based on observation, interview, and record review, the facility failed to ensure Resident (R)26 received treatment and care in accordance with professional standards of practice, related to skin tears. Findings included: - Review of the resident's (R) 26's undated Physician Orders, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It affects parts of the brain that control emotions, behavior, personality, and language), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), restlessness, and agitation. The Annual Minimum Data Set (MDS) dated [DATE], documentation included the Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The resident was independent for bed mobility, transfers, walking, locomotion, toilet use, personal hygiene, and bathing. His balance during transition was not steady but he was able to stabilize without staff assistance. He had no functional limitation in range of motion. He used a walker as a mobility assistive device. The resident was not at risk for pressure ulcers. He received treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Area Assessment (CAA), for Cognitive Loss/Dementia and ADL(activities of daily living) Functional/Rehabilitation Potential, dated 11/08/21, documented he was independent with all ADL's except for supervision with his showers. The care Plan, dated 11/10/21, directed staff to monitor/document/report to health care provider as needed any signs or symptoms of causative factors or trauma. On 12/12/2021 at 05:12 PM, the Health Status Note, documentation included the resident had a skin tear to his right elbow, which the nurse dressed with [MEDICATION(S)] (nonstick dressing) and kerlix (gauze type material) after cleansing with wound with wound cleanser. The documentation lacked a wound assessment to include the measurements or description of the wound characteristics. The facility lacked evidence of follow-up to determine cause or contributing factors related to the development of the wound. On 12/13/2021 at 08:56 AM, the Health Status Note Text, included documentation that the resident had a skin tear on his right elbow, and the nurse cleaned the skin tear with wound cleanser, applied triple antibiotic ointment and applied a dressing to his wound on his right elbow. The documentation lacked a wound assessment to include measurements or a description of the wound characteristics. The facility lacked evidence of follow-up to determine cause or contributing factors related to the development of the wound. On 12/14/2021, two days after the first documentation related to the right elbow skin tear, revealed the Communication/Visit with Physician Note Text, documentation included the nurse found a dressing to the resident's right elbow and right forearm. There was drainage on the dressing. The nurse asked the resident what he had done. He stated, I can't remember but it was a couple days ago. The nurse revealed there was not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] .) by 1.5 cm, circular skin tear with dried skin to the wound bed, and was unable to approximate (close) the area as the wound was dried out. There was dark dried brown drainage on the dressing. The nurse cleaned with wound cleanser, applied [MEDICATION(S)] (non-adhering dressing) and secured with a foam pad. Documentation revealed staff would change the dressing every other day until resolved and as needed. Staff removed the dressing to the resident's right elbow and revealed a skin tear that was approximately 1.0 cm by 1.5 cm with dried skin to his elbow. Staff was unable to approximate the skin, and the wound had dark brown drainage with some yellow drainage. The old dressing was slightly moist. Staff cleansed the wound with wound cleanser, applied [MEDICATION(S)] and a foam dressing. Staff would change the dressing every other day and as needed and monitor both skin tears for signs of infection and notify physician if signs of infection occur. The was the first documented evidence of wound assessment and obtaining a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/15/21 at 03:07 PM, the resident had a bandage on his right lower arm, dated 12/15/21. Upon inquiry the resident reported he did not know how he hurt his arm. On 12/21/21 at 12:40 PM, Licensed Nurse (LN) G measured the wounds on his right elbow that measured 1.5 centimeters (CM) by 1.0 CM, and his lower right forearm radius that measured 1.0 CM by 1.9 CM. Both wounds were covered with raised scab areas. A small amount of redness was around his right elbow skin tear. On 12/20/21 at 03:37 PM, Certified Nurse Aide (CNA) M reported when a resident received a skin tear, the nurse should check the resident's skin. She stated she did not know what happened to the resident's arm. On 12/20/21 at 04:04 PM, Certified Medication Aide (CMA), stated nurses' assess the resident's skin when staff report an injury. The nurse would try to determine what caused the skin tear and put interventions in place to prevent further injury. New interventions are to be on the care plan and in a communication book. She stated she did not know what happened to the resident's arm. On 12/21/21 at 10:03 AM, LN G reported the protocol for follow-up on a skin tear included the nurse should assess the wound, try to determine the cause and initiate a new intervention to prevent further injury/trauma. The wound assessment should include measurements and wound characteristics. She stated that she noted the resident had dressings/bandages on his arm when she returned to work on 12/14/21. The resident did not know what happened, but it was there for several days. She verified there was not any previous documentation of assessment nor order for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . LN G stated she initiated a treatment and assessed the wound at that time. Additionally, she stated the facility did not monitor skin conditions other than pressure ulcers on a routine basis. LN G confirmed the staff that identified the wound on 12/12/21 did not follow protocol for assessment, order initiation, and follow-up. On 12/27/21 at 10:28 AM, Administrative Nurse D stated she did not know about the skin tears on the resident or the origin of the skin tears. She stated she expected staff to follow the facility protocol when a resident received a skin tear. Administrative Nurse D stated nurses' should assess the wound including measurements and wound characteristics and document the findings in an incident note. Administrative nursing staff should be notified when identifying a new skin tear identified and an investigation initiated into the causes to attempt to prevent further skin tears. She confirmed the facility lacked a system for monitoring effectiveness of wound care and the nurse did not follow the facility protocol when identifying the new skin tear on 12/12/21. The facility policy for Skin Tear Treatment and Prevention, dated 04/23/21, documentation included the purpose of the policy included to identify and treat skin tears as soon as possible, promote early wound healing, and to prevent further destruction of skin or infection. The procedure directed staff to note the location, size (measure) and shape of the skin tear. If unable to approximate edges, staff should apply skin barrier wipe to peri-wound and allow to dry. Apply hydrogel dressing to area and secure with a bandage roll. Change every three day and /or as needed for leakage or soiling. The facility failed to provide treatment and care in accordance with professional standards of practice, related to skin tears for the resident.

The facility reported a census of 49 residents and identified five as elopement risks. Three of these five were included in the sample. Based on record review and interview, the facility failed to provide adequate supervision and assistive devices to prevent one of the three residents reviewed, Resident (R)1, assessed as a fall and elopement risk, from leaving the facility through an exit door without staff knowledge. Findings included: - R1's signed Physician Orders (PO), dated 05/24/21, documented the resident had a diagnosis of [CONDITION(S)] (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people) and Alzheimer's disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of seven, indicating severe cognitive impairment. The resident required extensive assistance of two staff members for transfer and locomotion in the hallway and he used a wheelchair for mobility. The Activities of Daily Living Functional/Rehabilitation Care Area Assessment (CAA), dated 06/09/21, documented the resident had a self-care deficit due to Alzheimer's disease, poor coordination, and poor balance with an unsteady gait. Due to cognitive impairment, the staff were to assist the resident with all Activities of Daily Living (ADL). The Fall CAA, dated 06/09/21, documented the resident was a high risk for falls due to the diagnosis of Alzheimer's disease and the resident thought he could do more for himself that he could. R1 was unsafe to transfer or walk alone. The Care Plan, revised on 05/27/21, documented R1 had potential for elopement due to confusion and dementia (a chronic or persistent disorder of the mental process caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). The resident was unable to get out of his chair and walk independently. The resident did not actively talk about leaving the facility. If the resident attempted to exit the building, talked about leaving the facility, or mobility status changed and he could get up on his own, a personal alarm that activates the exit door alarm would be ordered and placed on the resident. An Admission Elopement Assessment, dated 05/23/21, documented the resident as an elopement risk. An Elopement Assessment, dated 06/20/21, documented the resident attempted elopement (did not get out an exit door) and verbalized to a staff member he wanted to find his car. The staff member redirected the resident, but later in the shift another resident let him out the back door. The resident's medical record lacked any documentation that Certified Medication Aide (CMA) R did notify Licensed Nurse (LN) G, on the day of the elopement that earlier in the day the resident told her he wanted to leave the facility. Therefore, staff did not place an alarmed bracelet on the resident, to sound if he went near an exit door. Review of Accuweather.com's weather history for June 20, 2021, revealed the weather was 97 degrees when the resident eloped from the facility. Interview, on 06/23/21 at 10:14 AM, with Certified Nurse Aide (CNA) M, revealed Dietary Staff (DS) BB found the resident outside in the smoking area of the facility and he notified the staff via walkie-talkie. She immediately went outside to find the resident sitting in his wheelchair yelling at the parked facility transport van. The resident thought he needed to get back to the facility and CNA M redirected him and told him he was already at the facility. CNA M asked the resident to go back into the building and he cooperated. CNA M stated R1 had no exit seeking behaviors prior than one time earlier in the day, before he did elope out of the exit hall 3 door without staff knowledge. Interview, on 06/23/21 at 04:42 PM, with Administrative Nurse D, revealed the resident stated at 03:00 PM, the afternoon of 06/20/21, to CMA R, that he needed to go find his car. CMA R and the resident were standing in the front lobby of the facility when the resident made the statement. CMA R did not report to the charge nurse and she should have so that interventions could have been put into place to prevent the elopement later in the day. Interview, on 06/23/21 at 05:50 PM, with CMA R, revealed R1 talked to her about looking for his car and they were standing by the aviary at the time. R1 was not exit seeking. She redirected the resident and staff R stated R1 seemed to be fine after that. She did not report to the charge nurse that the resident talked to her about leaving to find his car. She should have reported so interventions could be put into place. The facility policy Elopement - Rehab/Skilled, revised 10/30/20, documented . Policy .The location will be responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring residents at risk for elopement .During the Stay .1. Residents who begin to exhibit new behaviors that put them at risk for elopement or attempt to elope during their stay in the location will be assessed and monitored . The facility failed to provide adequate supervision and assistive devices to prevent R1 from leaving the building through an exit door of the facility, without staff knowledge and placing the resident at risk for accidents outside of the facility.

The facility reported a census of 50 residents. Based on observation, record review, and interview the facility failed to maintain an effective infection control program when the facility failed to use appropriate hand hygiene during a wound treatment for [REDACTED]. Finding included: - The tour of the laundry area conducted, on 03/12/2020 at 11:06 AM, with Housekeeping/Laundry Supervisor U revealed infection control concerns which included: 1. There was a thick dust build up on the vents over the washing machines and in the dryer area. 2. The filter on the large washing machine contained a buildup of lent and dust. On 03/12/2020 at 11:30 AM, Housekeeping/Laundry Supervisor U confirmed the above findings related to the surfaces in the laundry processing area to prevent cross contamination. The facility policy for, Procedure for Laundry Room, dated 03/2016, documentation included, Due to the bio-load introduced into the soiled room/area and the necessity to maintain the clean laundry room/area to preserve the cleanliness of the laundered material, it is crucial that frequent cleaning, disinfecting, and inspections of the laundry room occur. All surfaces should be damp dusted with a disinfectant cleaner at least weekly. The facility failed to ensure the proper handling, storage, and processing of laundry to prevent the spread of infection and cross contamination for the residents of the facility. - The Physician Orders, dated 03/09/2020, for Resident (R)50, included an order for [REDACTED]. On 03/11/2020 at 11:41 AM, Licensed Nurse (LN) G, donned a gown and gloves outside of R50's room (R50 was on contact precautions). Then, with gloved hands, LN G knocked on R50's door, moved a table away that was in front of her, unplugged the intravenous medication pump from the wall, moved the pole that the pump was on closer to R50. With the same (now contaminated) gloved hands, LN G then cleaned the intravenous access site with an alcohol wipe, flushed the access site, spiked the bag of medication, primed the intravenous medication tubing, setup the intravenous pump, connected the tubing to the access site, then removed the contaminated gloves and sanitized her hands. On 03/11/2020 at 11:53 AM, LN G verified that the gloves should have been removed, hand hygiene performed, and new gloves applied before cleaning and accessing the intravenous site, after she had entered the room and touched multiple objects with the same gloved hands. On 03/11/20 at 03:49 PM, Administrative Nurse D, confirmed LN G should have removed the gloves, performed hand hygiene, and applied new gloves after touching multiple objects in the room of R50 before accessing the intravenous site. The facility policy for, Contact Precautions procedure, revised 12/19, instructed the staff to don gloves upon entry into the room, and to change gloves and wash hands after contact with material that could contain high concentrations of microorganisms. The facility failed to remove contaminated gloves, perform hand hygiene, and apply new gloves after touching multiple objects before accessing the intravenous site of R50, to reduce the transmission of infection to this resident.

The facility reported a census of 50 residents. Based on observation and interview, the facility failed to store, prepare, and serve food under sanitary conditions to the residents of the facility. Findings included: - During the initial tour of the dietary department, on 03/09/2020 at 09:27 AM, revealed the following area/items of concern: 1. The air vents, over the food prep area and over the stove, in the ceiling had rust and were dusty. 2. The ceiling tiles, over the food prep area, had a thick layer of dust. 3. The white wooden cabinets, throughout the kitchen, had peeling paint, which exposed bare wood that is an unsanitizable surface. 4. There was brown sticky substances on the back of the stove/grille. 5. There is a sticky, greasy build-up on the handle of the oven. 6. The inside of the microwave had peeling paint, revealing metal. On 03/09/2020 at 09:45 AM, dietary staff BB verified the above areas requiring cleaning. The facility policy, dated 04/2016, Kitchen Cleaning Routine, documented to properly and thoroughly clean the kitchen and dining areas. Procedure-The following cleaning must be done with the indicated frequency . The facility failed to store, prepare, distribute, and serve food under sanitary conditions for the residents of the facility.

The facility reported a census of 50 residents with 15 residents sampled which included four residents sampled for respiratory care. Based on observation, interview and record review the facility failed to ensure that residents who needed respiratory care received such care consistent with professional standards of practice for two Residents (R)27 and R 11 associated with the use of oxygen. Findings Included: - Review of Resident (R)27's Physician Orders, dated 01/20/2020, documentation included [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], documentation included the resident rarely/never understands and was not able to complete the Brief Interview for Mental Status. He had short- and long-term memory problems and with severely impaired decision-making skills. The MDS lacked documentation of oxygen usage. The quarterly MDS, dated [DATE], lacked documentation of oxygen usage. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/14/2019, did not trigger and lacked documentation related to oxygen use. The care plan (CP), dated 02/12/2020, did not address the use of oxygen for the resident. The Physician order [REDACTED]. Call the provider/practitioner with nursing report, as needed for dyspnea (difficulty breathing), [MEDICAL CONDITION] (abnormal deficiency in the concentration of oxygen), or acute [MEDICAL CONDITION], ordered 10/09/2019. The Vitals Tab of the electronic medical record (EMR), documented the most recent oxygen saturation, dated 02/07/2020, as 96 %, on room air. Additionally, the most recent oxygen saturation below 90%, documented on 12/12/2019, as 88.0 % on room air. The EMR lacked documentation of monitoring of oxygen saturation levels to determine the necessity or effectiveness of the use of the oxygen. On 03/09/20 at 10:02 AM, the resident received oxygen at three liters per minute by way of nasal cannula. The humidifier bottle and tubing were not marked to reflect the date of the most recent change of the tubing and humidifier bottle. On 03/10/2020 at 04:32 PM, the humidifier bottle was almost empty and lacked water to cover the internal tube that humidified the air to the nasal cannula. The resident pulled the nasal cannula from his nose and left it across his forehead. On 03/10/2020 at 04:47 PM, Licensed Nurse (LN) H verified the humidifier bottle was almost empty and the resident with the tubing pulled out from his nose and positioned on his forehead. He reported the humidifier bottle and tubing should be changed every week and labeled with the date. LN H verified he did not make rounds to check tubing or humidifier bottles that he depended on the aides to inform him. On inquiry he stated no one had reported that the resident's humidifier bottle was empty or tubing was not labeled appropriately. On 03/09/20 at 11:32 AM, the resident's spouse reported the resident used oxygen all the time and it dried his nasal passages. On 03/11/2020 at 09:49 AM, Certified Nurse Aide (CNA) M reported the care plan provided guidance for the resident's care. He received oxygen continuously and staff should check for placement of the tubing to keep it off the floor and that it remained covered when not in use. She stated the humidifier bottle should be checked to make sure there was water present to prevent the resident's nose from drying out. CNA M reported the night shift nurse changed out the oxygen tubing and humidifier bottles every week and should write the date when she changed the tubing and humidifier bottle. The charge nurses should monitor the oxygen equipment, fill the humidifier bottles with water, and monitor the resident's oxygen saturation to determine the need for oxygen. On 03/11/2020 at 02:09 PM, LN I stated the care plan provided guidance regarding the resident's individual needs and preferences. She reported the staff should monitor for effectiveness of the oxygen usage. She reported the resident used continuous oxygen for the last couple of months. LN I stated she personally checked the oxygen saturation periodically and documented it in the EMR. She stated if the resident took the oxygen off, his oxygen saturations would drop to 80%. She verified the most recent documentation of the resident's oxygen saturation levels were 02/07/2020, and her most recent documentation was 10/2019. LN I agreed the staff did not monitor the residents use of oxygen appropriately. She verified the EMR lacked documentation the night staff changed the oxygen tubing and humidifier bottle weekly. LN I stated she did not remember checking the oxygen equipment and/or effectiveness. On 03/11/2020 at 03:24 PM, CNA N reported the care plan should guide the staff on the care associated with the resident's oxygen use. She reported the resident used oxygen all the time since he started using it. The staff should check the liter flow, water in the humidifier bottle, and if there were any problems the staff should let the charge nurse know. CNA N stated she was not sure what the resident's status was, that one nurse would say the resident needed it all the time while the other nurse would say the resident used it prn. CNA N stated she had not seen the nurses checking the resident's oxygen saturation or fill the humidifier bottle. On 03/11/2020 at 03:47 PM, LN J reported the resident admitted with a as needed (prn) order for oxygen and he would use the oxygen when the resident's oxygen saturations dropped below 90%. The resident used oxygen for at least the last three to four weeks. Nurses should check for water levels in the humidifier bottles to prevent the resident's nasal passages from drying. LN J stated the oxygen saturations were documented in the Vitals Tab of the EMR. On 03/12/2020 at 08:22 AM, Administrative Nurse E confirmed the oxygen order as noted above. She verified the care plan lacked guidance for the staff related to the use of oxygen for the resident. Administrative Nurse E stated the staff should monitor the resident's oxygen saturations to determine the need for oxygen and the effectiveness. The staff should document the oxygen saturation in the EMR. She agreed the staff did fail to monitor the resident's oxygen use and provide care as she would expect. The facility policy for Oxygen Administration with Nasal Cannula, dated 10/2017, documentation included fill humidifier bottle, with distilled water and keep filled adequately at all times. Assess resident for at least 15 to 30 minutes after beginning of therapy and at regular intervals depending on the resident's condition. Disposable equipment should be changed weekly or according to manufacturer's instructions and marked with date and initials when changes. The facility failed to ensure the resident who needed respiratory care received such care consistent with professional standards of practice related to the monitoring for the need and effectiveness of oxygen therapy. - The Medication Review Report, dated 01/07/2020, for Resident (R)11, included [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], assessed R11 as having a Brief Interview of Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. R11 did not have any shortness of breath, fever, or use of oxygen, and his pneumonia vaccine was up to date. Did not receive any respiratory therapy or antibiotic medication. The significant change MDS, dated [DATE], assessed R11 with a BIMS score of 9, shortness of breath with exertion, and he used oxygen. He was not on an antibiotic, did not receive respiratory services, and his pneumonia vaccine was up to date. The care plan, dated 12/14/19, included a new problem, dated 02/21/2020, that R11 had a PRN (as needed) order for oxygen therapy related to [MEDICAL CONDITION]. R11 was to receive oxygen therapy at one to four liters per minute per nasal cannula for dyspnea (difficulty breathing), [MEDICAL CONDITION] (inadequate supply of oxygen), acute [MEDICAL CONDITION] (chest pain), and oxygen saturations less than 88%. Furthermore, the care plan included a new problem added on 02/28/2020, that R11 had a respiratory infection. The resident had a new physician order, on 03/07/2020 for [MEDICATION NAME] (an antibiotic) due to pneumonia, and on 03/08/2020 for [MEDICATION NAME] (medication delivered by inhalation per a nebulizer machine-a device which changes liquid medication into a mist easily inhaled into the lungs). On 03/10/2020 at 10:29 AM, the oxygen tubing lacked a date staff changed it, the nebulizer mask kit lacked a date staff changed it, and the nebulizer mask kit remained connected together and hanging from the strap that connected to the mask from the nebulizer machine. On 03/11/2020 at 08:48 AM, R11's oxygen tubing remained connected to the oxygen concentrator was laying on the floor, undated. The nebulizer kit remained connected and laying on top of the bedside stand, undated, and with a small amount of clear liquid in the bottom of the medicine cup, and the mask contained visible smears on it. On 03/11/2020 at 09:17 AM, R11 was sitting in the recliner in his room with the oxygen cannula in place to his nose, and with the tubing undated. On 03/11/2020 at 11:13 AM, Licensed Nurse (LN) G, placed [MEDICATION NAME] into the medicine cup of the undated, connected, nebulizer kit and placed the mask on R11's face. When the treatment completed, LN G removed the mask and disconnected the tubing from the medicine cup, rinsed the pieces to the nebulizer kit with hot water, then placed the pieces of the nebulizer kit on a paper towel near the nebulizer machine. On 03/11/2020 at 11:37 AM, LN G revealed that the kit remained connected when she entered the room because the previous nurse did not take it apart after the treatment was done this morning. When staff cleaned the kit it was to air dry, and then be placed in a container. The staff changed the kit weekly on Thursdays along with the oxygen tubing. Furthermore, she revealed that she would date the tubing and the kit if she changed them, but the night shift nurse says the tubing did not have to be dated anymore, and that the oxygen nasal cannula that inserted into the resident's nose should not be on the floor and the tubing should be stored in a plastic bag on the side of the concentrator when not in use. On 03/11/2020 at 03:36 PM. Administrative Nurse D, confirmed that oxygen tubing should be stored in a bag to protect it when not in use and should not be on the floor. The bag should be attached to the concentrator. The tubing was changed weekly, it was to be signed out on the TAR (treatment administration record), and she did not believe it was a policy to date the tubing. Furthermore, she revealed that the nebulizer kits should be stored open to air after cleansing with soap and water. The oxygen tubing and nebulizer kits are changed out weekly. The facility policy for, Nebulizer procedure, revised 03/18, instructed staff that following medication administration staff were to rinse the equipment with hot water and place it on a paper towel to air dry. The facility policy for, Oxygen Administration with Nasal Cannula, Face Mask, or Face Tent procedure, revised 10/17, instructed when oxygen was not in use, store the cannula in a plastic bag secured to the oxygen concentrator. Furthermore, it instructed that disposable equipment should be changed weekly or according to the manufacturer's instruction and marked with the date and the staff's initials. The facility failed to store the resident's oxygen tubing in a plastic bag when not in use, failed to date the tubing of the oxygen and nebulizer kit when changed, and failed to clean and store the nebulizer kit per facility procedure, to prevent further respiratory infections for the resident.

The facility reported a census of 50 residents with 15 sampled for review. Based on observation, interview, and record review, the facility failed to develop and implement a plan of care for respiratory cares related to oxygen use for one sampled Resident (R) 27. Findings Included: - Review of Resident (R)27's Physician Orders, dated 01/20/2020, documentation included [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], documentation included the resident rarely/never understands and was not able to complete the Brief Interview for Mental Status. He had short- and long-term memory problems and with severely impaired decision-making skills. The MDS lacked documentation of oxygen usage. The quarterly MDS, dated [DATE], lacked documentation of oxygen usage. The ADL Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 05/14/2019, did not trigger and lacked documentation related to oxygen use. The care plan (CP), dated 02/12/2020, did not address the use of oxygen for the resident. The Physician order [REDACTED]. Call the provider/practitioner with nursing report, as needed for dyspnea (difficulty breathing), [MEDICAL CONDITION] (abnormal deficiency in the concentration of oxygen), or acute [MEDICAL CONDITION], ordered 10/09/2019. The Vitals Tab of the electronic medical record (EMR), documented the most recent oxygen saturation, dated 02/07/2020, as 96 %, on room air. Additionally, the most recent oxygen saturation below 90%, documented on 12/12/2019, as 88.0 % on room air. The EMR lacked documentation of monitoring of oxygen saturation levels to determine the necessity or effectiveness of the use of the oxygen. On 03/09/20 at 10:02 AM, the resident received oxygen at three liters per minute by way of nasal cannula. The humidifier bottle and tubing were not marked to reflect the date of the most recent change of the tubing and humidifier bottle. On 03/10/2020 at 04:32 PM, the humidifier bottle was almost empty and lacked water to cover the internal tube that humidified the air to the nasal cannula. The resident pulled the nasal cannula from his nose and left it across his forehead. On 03/10/2020 at 04:47 PM, Licensed Nurse (LN) H verified the humidifier bottle was almost empty and the resident with the tubing pulled out from his nose and positioned on his forehead. He reported the humidifier bottle and tubing should be changed every week and labeled with the date. LN H verified he did not make rounds to check tubing or humidifier bottles that he depended on the aides to inform him. On inquiry he stated no one had reported that the resident's humidifier bottle was empty or the tubing was not labeled appropriately. On 03/09/20 at 11:32 AM, the resident's spouse reported the resident used oxygen all the time and it dried his nasal passages. On 03/11/2020 at 09:49 AM, Certified Nurse Aide (CNA) M reported the care plan provided guidance for the resident's care. He received oxygen continuously and staff should check for placement of the tubing to keep it off the floor and that it remained covered when not in use. She stated the humidifier bottle should be checked to make sure there was water present to prevent the resident's nose from drying out. CNA M reported the night shift nurse changed out the oxygen tubing and humidifier bottles every week and should write the date when she changed the tubing and humidifier bottle. The charge nurses should monitor the oxygen equipment, fill the humidifier bottles with water, and monitor the resident's oxygen saturation to determine the need for oxygen. On 03/11/2020 at 02:09 PM, LN I stated the care plan provided guidance regarding the resident's individual needs and preferences. She reported the staff should monitor for effectiveness of the oxygen usage. She reported the resident used continuous oxygen for the last couple of months. LN I stated she personally checked the oxygen saturation periodically and documented it in the EMR. She stated if the resident took the oxygen off, his oxygen saturations would drop to 80%. She verified the most recent documentation of the resident's oxygen saturation levels were 02/07/2020, and her most recent documentation was 10/2019. LN I agreed the staff did not monitor the residents use of oxygen appropriately. She verified the EMR lacked documentation the night staff changed the oxygen tubing and humidifier bottle weekly. LN I stated she did not remember checking the oxygen equipment and/or effectiveness. On 03/11/2020 at 03:24 PM, CNA N reported the care plan should guide the staff on the care associated with the resident's oxygen use. She reported the resident used oxygen all the time since he started using it. The staff should check the liter flow, water in the humidifier bottle, and if there were any problems the staff should let the charge nurse know. CNA N stated she was not sure what the resident's status was, that one nurse would say the resident needed it all the time while the other nurse would say the resident used it prn. CNA N stated she had not seen the nurses checking the resident's oxygen saturation or fill the humidifier bottle. On 03/11/2020 at 03:47 PM, LN J reported the resident admitted with a as needed (prn) order for oxygen and he would use the oxygen when the resident's oxygen saturations dropped below 90%. The resident used oxygen for at least the last three to four weeks. Nurses should check for water levels in the humidifier bottles to prevent the resident's nasal passages from drying. LN J stated the oxygen saturations were documented in the Vitals Tab of the EMR. On 03/12/2020 at 08:22 AM, Administrative Nurse E confirmed the oxygen order as noted above. She verified the care plan lacked guidance for the staff related to the use of oxygen for the resident. Administrative Nurse E stated the staff should monitor the resident's oxygen saturations to determine the need for oxygen and the effectiveness. The staff should document the oxygen saturation in the EMR. She agreed the staff did fail to monitor the resident's oxygen use and provide care as she would expect. The facility policy Care Plan, dated 12/2019, documentation included the plan of care will be modified to reflect the care currently required/provided for the resident. The facility failed to develop and implement a plan of care for respiratory care related to oxygen use for the resident.

The facility identified a census of 53 residents. Based on observations, record review and interview, the facility failed to store, prepare and serve food under sanitary conditions in the kitchen, for the residents in the facility. Findings included: - The kitchen environment tour observation, on [DATE] at 8:57 am, revealed the following areas/items of concern: 1.) One cantaloupe had excessive softness and a hole into the side of the rind. 2.) Two bags of red grapes with mold mixed in with the grapes in the bottom of the bag. 3.) The north window sill and window, above the dish washing sink, contained recessing with a build-up of dirt and grime. 4.) The white cabinets, on the south wall, had excessive grime build-up and with dirt and food crumbs on the inside of the drawers below. 5.) The white cabinets, on the south wall, contained 8 various containers of opened and unopened food spices, that expired dating back to (YEAR). On [DATE] 08:57 am, during the initial tour of the kitchen, dietary staff D, revealed he/she was not aware of the cantaloupe softness with the hole into the rind, or of the mold in the 2 bags of grapes, and of the 8 expired food spices in the cabinet. Staff D agreed that the window sill was dirty with excessive grime and explained it should be clean on the regular weekly schedule. The facility policy, dated ,[DATE], for General Sanitized Policy & Procedure, instructed staff to provide guidelines that limited the chance of foodborne illness at locations that prepare and/or serve food. The facility policy, dated ,[DATE], for Cleaning Schedule, instructed the staff to promote a system that identified cleaning tasks to be completed for #12, Window and window sills. The facility failed to store, prepare and serve food under sanitary condition in the kitchen for the residents of the facility.

The facility reported a census of 53 residents. The sample included 16 residents with 1 reviewed for discharge. Based on interview and record review, the facility failed to complete a medication reconciliation for the 1 (#52) sampled resident, who discharged from the facility. Findings included: - The signed physician order [REDACTED].#52, dated 12/04/2018, documented the resident had the following [DIAGNOSES REDACTED].) kidney disease, [MEDICAL CONDITION] (CKD- any one of a large group of conditions, including infectious, [MEDICAL CONDITION], obstructive, vascular, and neoplastic disorders) , major [MEDICAL CONDITION] (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), [MEDICAL CONDITION] (condition of elevated blood lipid levels), [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues), and asthma (disorder of narrowed airways that caused wheezing and shortness of breath). The Admission/5 day MDS (minimum data set), dated 11/21/2018, documented the resident admitted to the facility on [DATE]. The MDS revealed the resident had a BIMS (brief interview for mental status) score of 13, indicating he/she had intact cognition. The resident was independent with bed mobility, transfers, walking, locomotion, dressing, eating, toilet use, and personal hygiene. The discharge MDS, dated [DATE], revealed the resident discharged from the facility with return not anticipated. Review of the nursing notes, dated 11/16/2018, documented the resident admitted to the facility for skilled services. Nurses notes, dated 12/08/2018, documented the resident discharged to home with home health services. The post discharge plan, dated 12/8/2018, documented the resident's destination was to home with a diet of diabetic controlled carbohydrate, 1800 calorie diet. The staff gave the resident a reminder of doctor appointments needed in the 1 to 2 weeks after discharge. He/she had special services set up with home health. The staff instructed the resident with activity as tolerated, use your walker with ambulation at all times, weight daily, check your blood sugar every morning and every afternoon at 3 PM and as needed and also to keep a log of the blood sugars for the doctor to review at next the appointment. The Discharge summary, dated 12/8/2018, documented the resident's admission [DIAGNOSES REDACTED]. The resident had poor short term memory, without mood or behavioral issues, but was non-compliant with his/her diet. The resident was up with a front wheeled walker independently at discharge, ate, bed mobility, and transferred independently. Needed set-up help with showers. Was continent of bowel and bladder. The resident was non-compliant with the diet which placed risk for re-hospitalization . Home health care to follow-up with insulin and medication administration. The motivated resident really wanted to stay home, not to be readmitted , and to be as independent as possible. However, the discharge lacked a reconciliation of the resident's medications at discharge. On 03/12/2019 at 3:31 PM, Administrative staff C advised, the facility worked as a team towards discharge. After receiving an order for [REDACTED]. Staff C further stated on this resident, the staff completed a discharge form as he/she was to discharge home, discharge summary and a list of medications would of been done. This resident was discharged with anticipation not to return. On 03/12/2019 at 4:48 PM, Administrative staff C, advised they did not do a reconciliation of the resident's medications. Staff C stated the facility had not been doing a medication reconciliation when a resident discharged from the facility. The facility policy entitled, Discharge and Transfer, revised on 09/2017, documented the charge nurse or designated individual would: complete the discharge home form, obtain an order from the physician for discharge him/her to home with medications, complete the discharge or therapeutic leave medication list, complete the miscellaneous information section of the admission record, complete the discharge summary and care plan. The facility failed to complete a medication reconciliation, consisting of comparing the resident's pre and post-discharge medications, for this resident discharged to home.

The facility reported a census of 53 residents, with 16 residents sampled for review. Based on interview and record review, the facility failed to notify a representative of the office of the state long term Ombudsman when any of the facility residents, including 1 (#52) sampled resident, required hospitalization . The findings included: - The signed physician order [REDACTED].#52, dated 12/04/2018, documented the resident had the following [DIAGNOSES REDACTED].) kidney disease, [MEDICAL CONDITION] (CKD- any one of a large group of conditions, including infectious, [MEDICAL CONDITION], obstructive, vascular, and neoplastic disorders) , major [MEDICAL CONDITION] (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), [MEDICAL CONDITION] (condition of elevated blood lipid levels), [MEDICAL CONDITION] (swelling resulting from an excessive accumulation of fluid in the body tissues), and asthma (disorder of narrowed airways that caused wheezing and shortness of breath). The Admission/5 day MDS (minimum data set), dated 11/21/2018, documented the resident admitted to the facility on [DATE]. The MDS revealed the resident had a BIMS (brief interview for mental status) score of 13, indicating he/she had intact cognition. The resident was independent with bed mobility, transfers, walking, locomotion, dressing, eating, toilet use, and personal hygiene. The discharge MDS, dated [DATE], revealed the resident discharged from the facility with return not anticipated. Review of the nursing notes, dated 11/16/2018, documented the resident admitted to the facility for skilled services. Nurses notes, dated 12/08/2018, documented the resident discharged to home with home health services. The post discharge plan, dated 12/8/2018, documented the resident's destination was home with a diet of diabetic controlled carbohydrate, 1800 calorie diet. The resident was given a reminder of doctor appointments needed in 1 to 2 weeks after discharge. He/she had special services set up with home health. The staff instructed the resident with activity as tolerated, use your walker with ambulation at all times, weight daily, check your blood sugar every morning and every afternoon at 3 PM and as needed and also to keep a log of the blood sugars for the doctor to review at next the appointment. The Discharge summary, dated 12/8/2018, documented admission [DIAGNOSES REDACTED]. The resident had hearing issues. understood staff easily, communicated without difficulty, wears glasses. The resident had poor short term memory, without mood or behavioral issues, but was non-compliant with his/her diet. The resident was up with front wheeled walker independently at discharge, ate, bed mobility, and transferred independently, but needed set-up help with showers and was continent of bowel and bladder. The resident was non-compliant with the diet which placed him/her at risk for re-hospitalization . Home health care was to follow-up with insulin and medication administration. The motivated resident really wanted to stay home, and not be readmitted , and to be as independent as possible. On 03/12/2019 at 3:31 PM, Administrative nursing staff C advised, the social worker made the notification to the ombudsman after a resident's discharge. On 03/12/2019 at 4:19 PM, Administrative nursing staff C explained that the social worker reported to staff C, he/she only made notification to the ombudsman when the residents transferred to the hospital. Staff C further advised the social worker probably did not notify the ombudsman, since the resident discharged to his/her own home instead of to the hospital. On 03/12/2019 at 4:30 PM, Administrative staff A advised, the notification to the ombudsman was only done when the resident discharged to the hospital, and not when it was resident initiated. This resident discharged home, but staff did not believe he/she was ready for discharge and the resident wanted to. The facility policy, entitled Ombudsman, revised 02/2017, lacked any direction on when to make notification when a resident discharged from the facility. The facility policy, entitled Discharge and transfer, revised 09/2017, lacked any direction on when to make notification to the Ombudsman after a resident discharge. The facility failed to notify a representative of the office of the state long-term Ombudsman, for any resident, who discharged from the facility, other than to the hospital, which included this resident.

The facility reported a census of 49 residents, with 3 residents sampled for accidents. Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive devices for 2 of the 3 residents reviewed, including failure to provide the care planned intervention of non-skid socks to prevent repeated falls for resident #1, who fell and fractured the right hip and failed to provide an intervention for a fall for resident #2. Findings included: - The physician's order [REDACTED].#1, dated 10/2/15, documented the resident ' s [DIAGNOSES REDACTED]. The significant change minimum data set (MDS), dated [DATE], documented the resident ' s brief interview for mental status (BIMS) score of 6, indicating severely impaired cognition, and required extensive assistance of 1 staff for bed mobility, transfers, and ambulation. The resident had one non-injury fall since the prior assessment. The quarterly MDS, dated [DATE], documented the resident ' s BIMS score of 8, indicating moderately impaired cognition, and required extensive assistance of 2 staff for bed mobility, and extensive assistance of 1 staff for transfers, and ambulation. The assessment documented no falls since the prior assessment. The care area assessment for falls, dated 3/31/15, documented the resident with potential for falls related to a history of numerous falls with injury. The resident was very unsteady and required assist of 1 staff, but will get up alone. The resident had several alarms on to alert staff of his/her movement. The care plan, dated 9/30/15, documented the resident at risk for falls related to a history of falls, was unaware of safety needs, and directed staff with the following interventions: beginning 3/12/14 - low bed with floor mat beside bed, educate resident not to bend over to pick up dropped items, encourage the resident to use grabber or ask for assistance, encourage participation and plan diversional activities of the resident's interest; beginning 3/17/15 - night light used to maximize resident safety during the night; beginning 7/8/15 - pressure sensitive pad alarm on bed and in chair, floor monitoring system placed where the alarm alert comes over the wireless call system, placed by the bed and by the chair in the lobby; beginning 10/9/15 - ensure the resident wore appropriate footwear and non-skid socks while in bed at all times. The nurse ' s note, dated 10/27/15 at 6:20 AM, the resident was found lying on the floor on his/her back and stated he/she was heading to the bathroom. The assessment revealed external rotation of the right lower extremity and the resident complained of pain to the right hip. The resident ' s alarms were functioning properly and the bed was in the low position. The resident was sent to the hospital by ambulance. The nurse ' s note, dated 10/27/15 at 10:20 AM, documented the report from the hospital nurse confirmed the resident with a fracture of the right hip and the resident admitted to the hospital for surgery, scheduled the next day. Observation of the resident, on 12/8/15 at 9:08 AM, revealed the resident sat in a recliner in the lobby, with shoes on the feet, a tab alarm attached to the resident ' s shirt and a mat alarm on the floor in front of the resident. At 2:14 PM, staff sat 1:1 with the resident in the hall, due to the resident ' s restlessness, with the resident in the wheelchair and the tab alarm attached to the resident ' s shirt. On 12/8/15 at 10:06 AM, direct care staff C reported he/she provided care for the resident on 10/27/15, the night the resident fell . Staff C was aware of the new intervention of wearing non-skid socks at night, but over-looked putting them on the resident when he/she got the resident up and down from bed during the night of 10/27/15. Staff C stated it just slipped his/her mind that the resident needed the non-skid socks on. Staff C was told about the newest intervention through a mini in-service sheet, which Staff C signed off on, but just did not remember to put the socks on the resident. Staff C answered the resident ' s call light and did not realize the correct socks were not on the resident ' s feet. Staff C stated the resident had a shuffle gait and his/her feet slip when he/she walks, and that is why staff were to use the gripper socks on the resident. On 12/8/15 at 10:08 AM, direct care staff D reported he/she worked the night shift, from 10:00 PM to 6:00 AM on 10/27/15, when the resident fell and broke his/her hip. Staff D toileted the resident 3 times during the night shift and noted the resident was wearing wooly socks (fuzzy socks that did not have a non-skid sole) on his/her feet at the time. Staff D was aware the resident should wear only non-skid socks at night, but stated he/she did not check to see if the socks were that type or not, but assumed the socks had the grips on the bottom. On 12/8/15 at 10:25 AM, direct care staff E reported all new interventions are kept in a book in the employee break room which staff reviewed daily and signed off on each mini in-service sheet. Signing the sheets confirmed the staff members read and understand the new interventions or changes in a resident ' s care. Staff E signed the in-service sheet regarding the resident ' s non-skid socks to be worn at night, but stated that there are so many in-services to remember he/she could not always keep track of them and just forgot. Staff E worked the 2:00 PM to 10:00 PM shift and verified he/she put the resident to bed on the night the resident fell and broke his/her hip. Staff E dressed the resident in night clothes and regular socks, because staff E forgot the resident was to wear only non-skid socks at night. The resident had non-skid socks available, but staff E just did not put them on the resident that night. On 12/8/15 at 11:13 AM, licensed nursing staff F stated the nurse ' s communicate all new interventions or changes with the resident ' s care to all staff by filling out a mini in-service sheet, placed the sheet in the break room and all staff should sign the sheet when they have read and understand the changes in the resident ' s care. Staff F monitors the interventions by doing frequent rounds and checks of the residents. Staff F just came on shift and staff alerted him/her that the resident ' s alarm sounded and the resident fell . When staff F entered the room, the resident was on the floor, wearing night clothes and regular socks. Staff F noted rotation of the right leg, indicating a possible fractured hip, and sent the resident to the hospital by ambulance. On 12/8/15 at 3:09 PM, administrative nursing staff B reported the most recent intervention for the resident ' s previous fall had been non-skid socks at night and staff did not follow that on 10/27/15, when the resident fell and fractured his/her hip. The investigation of the fall revealed a facility system failure in how to communicate new interventions to direct care staff due to the volume of mini in-services posted on a daily basis. The policy for fall prevention and management, dated July 2015, documented to identify potential risks and take steps to mitigate the risk before actual harm occurs. After a fall occurs, investigate to determine the cause of the fall, identify risk factors, and take steps (interventions) to prevent the fall from happening again. Continue to monitor the condition and effectiveness of the interventions. The facility failed to provide the care planned intervention of non-skid socks at night, to prevent repeated falls for resident #1. The resident fell and suffered a fractured right hip, which required surgical intervention. - The physician's order [REDACTED].#2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS), dated [DATE], documented the resident ' s brief interview for mental status score as 6, indicating severely impaired cognition, and required limited assist of 1 staff for bed mobility, transfers, and walking in the room/corridor with a walker and wheel chair for mobility. The resident had 1 non-injury fall since the prior assessment. The significant change MDS, dated [DATE], documented the resident required extensive assist of 2 staff for bed mobility and transfers, with no other changes since the prior assessment. The care area assessment for falls, dated 11/24/15, documented the resident with potential for falls related to a history of falls. Interventions have been in place and the resident was no longer as mobile as previously. The care plan, dated 5/20/15, documented the resident at risk for falls related to confusion and imbalanced gait and directed staff with the following interventions: keep bathroom light on and the bathroom door open to find the bathroom instead of wandering into the hall, remind the resident not to bend over to pick up dropped items and encourage the use of a grabber (an extended assistive device used to pick up small items without bending over) or to ask for assistance, ensure that the resident is wearing appropriate footwear of shoes or sandals when ambulating or mobilizing in the wheelchair, and wear non-skid socks at all times, a bed sensor alarm is used to alert staff to the resident's movement. The care plan lacked an update for the fall on 10/9/15. The update, on 11/07/15, documented a floor alarm was to be by the resident ' s bed or any chair he/she was in. The nurse ' s note, dated 10/9/15 at 7:26 AM, documented staff found the resident sitting upright next to the bed with alarms sounding and unable to tell staff how he/she fell . The intervention of a floor sensor pad next to the bed was placed. (This intervention was not updated in the care plan). The nurse ' s note, dated 11/7/15 at 4:04 AM, documented the resident was found on the floor by staff sitting upright to the left side of the bed. The resident ' s vital signs were normal and there was no sign of injury. The clinical record lacked documentation the facility staff assessed the cause and developed a new intervention after the fall. Observation of the resident, on 12/8/15 at 9:01 AM, revealed 2 staff transferred the resident from a wheel chair to the couch in the lobby with rubber soled slippers on the resident ' s feet. The pressure alarm sounded as the resident stood from the wheelchair, and as staff transferred the resident onto the couch. A pressure alarm pad noted on the floor in front of the resident. At 2:12 PM, the resident observed sitting on the couch with feet elevated and rubber soled slippers on the feet, with an alarm under the resident and a pressure alarm pad on the floor in front of the resident. On 12/8/15 at 11:13 AM, licensed nursing staff F reported nursing staff are expected to put a new intervention on the care plan at the time of the fall that gets to the root cause of the fall and prevents similar falls. Staff F reviewed the resident ' s medical record and confirmed the resident had one fall in October and one in November, but there had only been one new intervention developed and written on the care plan, not 2. Staff stated the floor alarm staff placed on the care plan for the November fall intervention, but had actually been in place prior to that fall, since the fall in October. On 12/8/15 at 1:48 PM, direct care staff G the resident had the floor alarm in place since before the most recent fall in November, and staff was unable to say what the new intervention was after the November fall. On 12/8/15 at 2:19 PM, direct care staff H stated the resident required 1-2 staff to assist for transfers to the wheelchair, which staff propel for the resident. The resident was a fall risk, with tab alarm used at all times, and a pressure pad on the floor in front of the resident for when he/she tries to stand without staff assist. The floor pressure alarm had been in place for a while, but staff H was not able to remember the date staff began to use it, and staff H was unaware of the new intervention placed when the resident fell in November. On 12/08/15 at 2:37 PM, administrative nursing staff A reported he/she is responsible for writing care plans for the residents. Staff A stated he/she knew the floor alarm was in place for the resident since the fall in October because he/she worked as a charge nurse on 10/22/15 and recalled answering the resident ' s floor alarm when it triggered on that day. Staff A stated the floor alarm was in place after the fall on 10/9/15, but the care plan was not updated to reflect that. Staff A further stated the fall on 11/7/15 did not actually have a new intervention placed by the nurse because what that nurse documented as an intervention was the floor mat, which was already in place. Staff A expected the nurse caring for a resident who fell to put a new intervention in place at the time of the fall. On 12/8/15 at 3:09 PM, administrative nursing staff B reported he/she expected the nurse to place a new intervention for each resident after a fall, and was not aware there was not one done for this resident. The policy for fall prevention and management, dated July 2015, documented to identify potential risks and take steps to mitigate the risk before actual harm occurs. After a fall occurs, investigate to determine the cause of the fall, identify risk factors, and take steps (interventions) to prevent the fall from happening again. Continue to monitor the condition and effectiveness of the interventions. The facility failed to assess the cause and provide an intervention after a fall, to prevent further falls, for this resident with repeated falls.

The facility identified a census of 47 residents with 3 residents sampled for accidents. Based on observation, interview, and record review, the facility failed to ensure the safe transfers of 2 residents, #1, who experienced a right distal femur fracture during transportation in wheelchair out of the facility, and #3 a resident that required wheelchair transportation out of the facility. Findings included: - According to the clinical face sheet, the facility admitted resident #1, on 8/9/12. Review of the physician admission orders [REDACTED]. Review of the Medicare 5-day admission Minimum Data Set 3.0 Assessment, dated 8/21/12 and documented the resident with a Brief Interview for Mental Status (BIMs) score of 15/15 (intact cognition), and required extensive assistance from staff for all activities of daily living, with the exception of eating. This same Minimum Data Set further recorded the resident with falls in the last month and a fracture related to a fall. Review of the Care Area Assessment, dated 9/13/12, documented the resident with impaired vision, impaired balance, and a fall that resulted in a right hip fracture. Review of the resident's plan of care, dated 8/29/12, documented the resident with actual injury/fall, impaired mobility, balance, vision, and hip fracture with repair. The care plan directed staff to provide a wheelchair for mobility while the resident had weight bearing restrictions, staff to push to desired location, and staff to follow hip precautions from physician orders [REDACTED]. A care plan revision, dated 9/24/12, directed limited to stand-by-assistance from staff for transfers with use of a gait belt. Review of the nursing notes, dated 10/21/12 timed 7:15 AM, documented the resident required extensive assistance from one staff member for activities of daily living, and mode of transportation in wheelchair propelled by staff. Nursing notes, dated 10/22/12 timed 3:05 PM, documented when the resident returned to the facility from a physician appointment, facility staff pushed the resident in a wheelchair into the building and caught the residents foot on the ground, and bent his/her right knee back. The resident stated, "Ouch, it hurts." Nursing notes, dated 10/22/12 timed 3:25 PM, recorded the resident's right leg immobilized with a wheelchair pedal and pillow, ice applied to the right knee, and resident transported to physician's office. Nursing notes, dated 10/22/12 timed 5:10 PM, documented the transportation staff called the facility from the physician's office, reported to staff that an x-ray revealed a fracture of the resident ' s right femur above the knee replacement prosthesis, and the physician would directly admit the resident to the hospital. Review of the facility reported investigation, dated 10/24/12, documented the resident's wheelchair lacked foot pedals or leg rests. Review of the acute hospital history and physical, dated 10/23/12, documented the resident required surgical repair of the right distal femur fracture. On 11/7/12 at 1:00 PM, the resident, at an acute care hospital, sat upright in bed and stated, "Going to have therapy this afternoon and I need a pain pill before, because it will hurt like (expletive)." During an interview, on 11/7/12 at 10:35 AM, direct care staff G reported the resident required staff to push him/her in the wheelchair for mobility in the facility, prior to the 10/22/12 incident. On 11/07/12 at 9:06 AM, consultant therapy staff I reported that staff worked with the resident in walking with the front wheeled walker, but had to push the wheelchair when the resident sat in it, prior to the 10/22/12 incident. On 11/7/12 at 10:20 A.M., licensed nursing staff H reported the resident walked with therapy in the hall, but required staff to push him/her when seated in the wheel chair, prior to the 10/22/12 incident. On 11/6/12 at 2:15 PM, licensed nursing staff C, reported the facility now provided a "one-size fits all" wheel chair with foot pedals attached so staff can transport the residents out of the facility easier and safer. 11/7/12 at 11:30 A.M., administrative staff A, reported that the facility provided one wheelchair for transportation staff that was large enough to fit most of the residents and staff always to use the leg/foot rests during transportation. Administrative staff A revealed the facility lacked a policy to direct staff. Review of the facility provided, corporation newsletter, dated 10/12/12, article, Centers Should Review Changes in Wheelchair Use, documented, "Wheelchair footrests support and protect a resident's lower legs and feet from injury and provide balance to the wheelchair. When a resident requires assistance from staff for wheelchair transportation, that resident must have the wheelchair's footrests in place at all times. Transporting a wheelchair dependent resident without footrests in place increases the risk of injury to the lower extremities. No resident should be transported in a wheelchair without footrests ...Residents have been seriously injured ...when staff transported residents in wheelchairs without the footrests in place ...Centers also should have a policy to enforce that no staff member is transporting a wheelchair-dependent resident without the footrests in place." As of 11/7/12, the facility lacked a policy to direct staff in the safe transportation of residents in wheelchairs out of the facility to appointments. The facility failed to provide appropriate assistive devices (foot pedals on the residents wheelchair), when transferring this resident with impaired lower extremity mobility, in a manner to prevent an accident. This failure resulted in the resident sustaining a fractured femur that required surgical repair. - According to the clinical [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (Minimum Data Set) 3.0 Assessment, dated 8/19/12, documented a Brief Interview for Mental Status (BIMS) of 14/15, independent with activities of daily living, not steady but able to stabilize without staff assistance when moving from seated to standing position, walking, turning around and surface to surface transfers. This same Minimum Data Set documented two or more non-injury falls since admission or the last assessment. Review of the plan of care dated 8/29/12, documented the resident with impaired mobility with potential for falls related to spinal stenosis, advanced age and history of falls and non-compliance. This same plan of care directed staff to: - The resident wears back brace for spinal stenosis (wears as desired and required no assistance with the brace), and uses wheel chair PRN (as needed). - Monitor for unsteady gait and intervene as needed Review of the pain management review, dated 11/5/12, documented on Sunday, 11/4/12, the resident started having some numbness in his/her lower extremities and achiness all over. Review of a facility fax communication to the physician, dated 11/4/12, recorded the resident with an old scratch to his/her right lower extremity that according to the resident, had been there for a while, but noticed the leg started to feel tender with redness around area. Review of a Physician orders, dated 11/5/12, ordered the antibiotic Keflex 500 milligrams, 1 orally, for 7 days for cellulitis of the right lower leg. On 11/06/2012 at 3:00 PM, the resident lay on his/her bed, wore supplemental oxygen, reported that he/she had been really sick that started with a scratch on the leg, on very expensive antibiotics and could not stand to touch the leg and could hardly move it Observation, on 11/7/12 at 11:10 A.M., revealed licensed nursing staff C pushed the resident in a wheelchair, through the facility, out the dining room exit door, onto the sidewalk and into the facility transportation van. The resident's legs and feet noted handing dependent and without support. Observation revealed the resident's wheel chair lacked any leg rests or foot pedals. On 11/6/12 at 2:15 PM, licensed nursing staff C, reported the facility now provided a "one-size fits all" wheel chair with foot pedals attached so staff can transport the residents out of the facility easier and safer. On 11/6/12 at 4:32 PM, direct care staff F, reported that the resident is really sick, not feeling well, and required assistance of two staff for transfers today. On 11/7/12 at 10:16 AM, direct care staff D, reported the resident has complained of weakness and used his/her wheel chair today. On 11/7/12 at 11:15 AM, licensed nursing staff E, reported the resident recently received antibiotics for a leg wound, experienced increased confusion today and facility staff transported the resident to the hospital emergency room . Licensed nursing staff E confirmed the resident in his/her own wheelchair today. 11/7/12 at 11:30 A.M., administrative staff A, reported that the facility provided one wheelchair for transportation staff that was large enough to fit most of the residents and staff always to use the leg/foot rests during transportation. Administrative staff A revealed the facility lacked a policy to direct staff. Review of the facility provided, corporation newsletter, dated 10/12/12, article, Centers Should Review Changes in Wheelchair Use, documented, "Wheelchair footrests support and protect a resident's lower legs and feet from injury and provide balance to the wheelchair. When a resident requires assistance from staff for wheelchair transportation, that resident must have the wheelchair's footrests in place at all times. Transporting a wheelchair dependent resident without footrests in place increases the risk of injury to the lower extremities. No resident should be transported in a wheelchair without footrests ...Residents have been seriously injured ...when staff transported residents in wheelchairs without the footrests in place ...Centers also should have a policy to enforce that no staff member is transporting a wheelchair-dependent resident without the footrests in place." The facility lacked a policy to direct staff in the safe transportation of residents in wheelchairs out of the facility to appointments. The facility failed to provide appropriate assistive devices (wheelchair footrests/pedals) for this resident that required staff assist with wheelchair transportation out of the facility, which placed this resident at risk for possible injury.

The facility had a census of 47 residents, with 3 residents reviewed for falls. Based on observation, interviews, and record reviews, the facility failed to ensure 1 of the 3 sampled residents (#1) reviewed, received adequate supervision and assistive devices to prevent accidents. The resident fell from a power lift chair and sustained 3 fractures of the lower extremities. Findings included: - Resident #1,admitted to the facility on [DATE], with [DIAGNOSES REDACTED].(elevated blood pressure). Staff recorded in the resident's 5/6/12 MDS (Minimum Data Set) a BIMS (Brief Interview for Mental Status) score of 14 (a score of 13-15 indicated cognition intact), required total assistance of 2 staff with bed mobility and transfers, walking in the room and corridor did not occur, locomotion off the unit required total assistance of 1 staff, used a wheelchair, and without a history of falls. Staff recorded on the resident's 5/7/12 Falls Data Collection Tool the resident scored an 18 (a score of 12 or more equaled high risk. Proceed to care plan approaches, review and revise as appropriate). Under the cognitive status section on the form, a staff member underlined "confused". Staff recorded on the resident's 5/15/12 CAAS (Care Area Assessment Summary) the following: Activities of daily living trigger - The resident had multiple diagnosis. The resident required assistance of 1 to 2 staff for activities of daily living. The resident can do some things like feed self, use the remote control, read books, etc. The resident can communicate their needs verbally. The resident can not move their legs much at all, but can use their arms. The resident did experience pain and stayed in bed. Falls trigger - The resident at risk for falls. The resident had problems with balance at times. The resident used a sit-to-stand lift to get up and down and two staff members. The family understood the risk the resident had for falling and agreed with the plan of care. Staff recorded in the resident's 5/16/12 care plan, for the concern of impaired mobility with the potential for a fall, the following interventions: A large lift sling and assistance of 2 staff, as needed. The resident used a motorized scooter independently. Total assistance of 2 staff for turning or repositioning. May use a regular wheelchair instead of the power scooter, as needed, for confusion. The resident is not to have the bed controls in reach. (The resident puts it (the bed) too high.) On 6/10/12, staff added an intervention on the care plan which read, "TABS alarm prn (as needed) confusion." On the 6/10/12 (Sunday) nursing notes, at 12:15 PM, staff recorded, "The resident with confusion, trying to get up and walk. Able to say where (the resident) is, what year it is, and who (the nurse) was, but answered 'December' when asked what month...Smiling and joking but is more confused than usual..." At 1:10 PM, this licensed staff member documented faxing the resident's physician requesting an order for [REDACTED]. At 1:30 PM, staff documented in the nursing notes, "Put TABS alarm on resident - to let us know if (the resident) tries to get out of bed unassisted." Review of the facility's 24 hours shift report sheet revealed staff documented the following: On 6/10/12, on the 6 AM to 2 PM shift and on the 2 PM to 10 PM shift, staff recorded increased confusion. The 10 PM to 6 AM shift documented no confusion reported. Documentation on the bottom of this 24 hour report sheet read, "(The resident) - faxed for UA (urine analysis)...Put TABS on (the resident) until (the resident) is less confused." On 6/11/12 at 9:45 AM, staff recorded in the nursing notes, "...No confusion from myself or the 2 CNAs (Certified Nurse Aides) that work with (the resident) daily." On 6/11/12 at 11:35 AM, staff recorded in the nursing notes, "(The resident) sitting in recliner. (The resident) had put the foot down and chair was leaning forward some. It is power lift chair. I asked (the resident) what (the resident) was doing and (the resident) replied, 'Oh, my (child) just left so I was going after them.' I said (the resident) your (child) was not here and you need help getting up. (The resident) replied, 'Well, I walked here to my house.' I put the recliner back up and put the control out of (the resident's) reach..Left message at (the resident's physician's) office to see if fax sent yesterday could be addressed." At 12 noon, the physician responded and ordered staff to obtain an urine analysis and culture and sensitivity if indicated. Staff failed to attach the TABS alarm to the resident, as care planned, when the resident exhibited signs of confusion. Review of the facility's 24 hours shift report sheet revealed staff documented the following: On 6/11/12, on the 6 AM to 2 PM shift, staff recorded the resident as confused and need to get urine analysis. The remaining 2 shifts did not document any confusion. On 6/12/12 at 7:30 AM, staff recorded in the nursing notes staff obtained the urine analysis. At 10 AM, staff recorded a copy of the urine analysis faxed to the resident's physician. The 6/12/12 urine analysis report revealed results of TNTC (too numerous to count) white blood cells, rare red blood cells, and 3+ bacteria, (indicating an infection). On 6/12/12 at 10:51 AM, staff recorded in the nursing notes, "Called to (the resident's) room STAT (immediately) after hearing (the resident) call out 'Help'. Found (the resident) lying on back with R (right) lower extrem (extremity) in hurdler stretch position. Deformity noted to R (right) hip region pedal pulse to R (right) top of foot very faint. RN (Registered Nurse)...calling EMS (Emergency Medical Services)...After questioning what happened, res (the resident) stated, 'I fell out of my chair.' CNA...stated, "(Nurse), I had this recliner with feet positioned up." Remote to lift recliner noted on floor. (The resident) states 'I put it down. Yes, I used that.' as CNA was showing res (the resident) remote. Did not move (the resident) at all. Did position pillow behind head and covered (the resident). At 10:45 AM, EMS started...IV (intravenous) in R (right) anticubital...Fentanyl push given...Assisted (the resident) to stretcher by 5 staff..." On 6/12/12 at 3:41 PM, staff recorded in the nursing notes, "Rec'd (Received) call...notifying admission to (local hospital) with surgery tomorrow for R (right) hip fx (fracture), L (left) tibia fx, and add dx (diagnosis) of UTI (urinary tract infection), electrolyte disturbance and WBC (white blood count) elevation..." At 4:23 PM, staff recorded in the nursing notes received a call from the emergency room informing the facility the resident sent to intensive care due to decline and a drop in the resident's blood pressure, and a reported outlook of poor. Review of the 6/12/12 emergency room 's discharge summary revealed the following: Arrived at 11:46 AM and admitted to the ICU (Intensive Care Unit) at 4:08 PM in critical condition, with [DIAGNOSES REDACTED]. The 6/12/12 x-rays results revealed the following: Left Knee - Transverse nondisplaced fracture of the proximal left tibial shaft. Pelvis - Offset and foreshortened subtrochanteric fracture of the right femur Right foot - There is a fracture of the distal right fibular shaft. On 6/13/12 at 1:55 PM, staff recorded in the nursing notes the local hospital called to inform the facility of the resident's transfer back to the facility, as the family placed the resident on Hospice services and comfort care. At 4:30 PM, the resident returned to the facility by ambulance. On 6/13/12, the resident was readmitted back to the facility, with [DIAGNOSES REDACTED]. The resident was admitted with hospice services. The physician had recorded the resident's prognosis was unstable and to splint the resident ' s left leg for comfort. On 7/2/12 at 8:18 AM, administrative licensed staff A stated, "(The resident) had some confusion on Sunday (6/10/12). (Licensed staff C) faxed the doctor to check (the resident's) urine, and (licensed staff C) put a TABS on (the resident's) bed. (Licensed staff C) wrote in the care plan the TABS as needed. On Monday, (the resident) was clearer, no confusion. I was in a resident's room across the hall from (the resident's) room and looked across the hall and noticed the foot of (the resident's) recliner was down. I asked (the resident) why (the resident's) feet were down. (The resident) said (the resident's child) was here. I put (the resident's) feet back up...I took the chair controls out of (the resident's) reach. (The resident) was showing signs of confusion. (The resident's child) was not here. I told the CNAs to keep an eye on (the resident). We got the UA on 6/12/12 and sent it out at 7:30 AM. Got the results back at 10 AM and a urine culture was set up...I think (the resident's) shower was done at 7:30 AM. After the shower, (licensed staff E) changed the dressings. Around 9 AM, the dressings were changed. (The resident) was alert and oriented then. At 10 AM, (licensed staff E) went down to (the resident's) room to tell (the resident) the results of the urine test, and (the resident) was alert and oriented then. A little after 10 AM, the aides changed (the resident's) brief and got (the resident) up in the recliner, as (the resident) was confused. At 10:40 AM, (the resident's child) talked to (the resident) on the phone. Then (licensed staff E) talked to (the resident's child) on the phone about (the resident's) urine test. (Direct care staff F) came in and told the nurse (direct care staff F) thought (the resident) was confused...(Direct care staff F) didn't think (the resident) needed the alarm. They (The direct care staff) knew the TABS was in the bed." On 7/2/12 at 11:42 AM, licensed staff A stated, "The staff's signature on the care tracker care plan indicates they (direct care staff) read the care plan, not necessarily used the device." On 7/2/12 at 12:14 PM, when asked to see about the mini-inservice book, licensed staff A the mini-inservice book lacked documentation for the CNAs (Certified Nurse Aides) to review regarding the addition of a prn (as needed) TABS alarm for this resident. At that time, this licensed staff member stated, "Staff should have included the new intervention of a TABS alarm in the mini-inservice book. We have told the CNAs that it is their responsibility to read the mini-inservice book to know what changes have been made regarding residents' cares. They have to sign that they have read the mini-inservice book." On 7/2/12 at 5:04 PM, when asked why the Sunday day shift nurse only faxed the physician requesting an order for [REDACTED]. I did not put the TABS alarm on Monday at 11 AM as I didn't think (the resident) was that confused. When I found the feet of the recliner down, I called the doctor and asked for the UA order now." On 7/2/12 at 9:45 AM and 5:30 PM, administrative staff B stated, "After (the resident)fell and I came to (the resident's) room, (the resident) said (the resident) had slipped out of (the resident's) chair. (The resident) was alert at that time. (The resident's) foot rest was down and the seat of the recliner was level like a regular chair, not tilted up. (The resident's) left leg was out in front of (the resident) and (the resident's) right leg was bent back behind (the resident). It looked like (the resident) had leaned down to pick up something of the floor and just slid out of the chair..." On 7/2/12 at 9:51 AM, direct care staff F stated, "I usually worked on the day shift on... (the hall where the resident resided). I did not work the weekend before (the resident) fell . I came in on Monday, me and (direct care staff D) worked together...I remember (the resident) was alert and oriented. (The resident) started getting confused in the afternoon. Like (the resident) thinks (the resident) can walk, that is how I knew (the resident) was confused. I remember putting (the resident) in the recliner on Monday, and (licensed staff A) told us to check on (the resident). We did 15 minute checks. I don't recall (the resident) trying to get up on Monday. We put the chair controls in the side pocket of (the resident's) lift chair, and all (the resident) has to do is reach down and get it. I don't think (the resident) messed with the chair on Monday. On Tuesday morning, I was assigned to this hall (100 hall). Almost around 7 AM, the nurse, (licensed staff E), was walking into (the resident's) room to do the dressing on (the resident') bottom, and I told (licensed staff E) that that day was (the resident's) shower day. (The resident) was not confused in their room or during the shower. I got the UA on Tuesday morning after the shower...Snacks came out about 10 AM. I brought (the resident's) snack down to (the resident's) room after 10 AM, and (the resident's) bed covers were on the floor. I asked (the resident) what (the resident) was doing. (The resident) said I need to get up to walk, need to get off the bed. I told (the resident) couldn't walk. I called for some help to get (the resident) up...(Direct care staff G) got the lift, and we put (the resident) in (the resident's) recliner around 10:30 AM. I put some pillows behind (the resident's) back and under (the resident's) legs, put (the resident's) table by the resident, and gave (the resident) the call light. (The resident) still wasn't comfortable, so we repositioned (the resident) in the chair, reclined (the resident) back. I told her she could eat lunch in the recliner. Then (licensed staff E) called me on the walkie to tell me that (another resident) needed to go to the bathroom. When I went to go talk to (licensed staff E) about (the resident), (licensed staff E) was on the phone to (the resident's child). (The resident's child) had called (licensed staff E) to talk to about (the resident') confusion. Then we heard someone yell help or some type of yell. (The resident's) call light came on my pager. I entered (the resident's) room, and (the resident) was on the floor. (The resident's) recliner had the foot rest down. I paged the nurse and told the nurse I needed the nurse in room 114...(The resident) was in an ackward position. (The resident) still had their covers on. We called EMS...The chair controls were not in the pocket and were dangling off the side of the chair. (The resident) said when I asked if (the resident) had messed with the controller, (the resident) said, "Yes". I put it (the chair) down. Over the weekend, (direct care staff D) told me they put a TABS alarm on as (the resident) was really confused over the weekend. I was told (the resident) was confused over the weekend. We were using the alarm in bed only. My understanding was to use the alarm only in bed. We didn't transfer the TABS alarm to the recliner when we transferred (the resident). At that time, (the resident) wanted to walk and in (the resident's) her right mind, (the resident) knew (the resident) couldn't walk." On 7/2/12 at 10:55 AM, direct care staff D stated, "...(The resident) had moments of confusion off and on. (The resident's) confusion came on when (the resident) had an UTI (urinary tract infection). I worked the weekend before (the resident) fell . To me, (the resident) had a few episodes where (the resident) was confused. (The resident) wasn't talking about normal things, like getting up. I notified the nurse about it. (The resident) didn't think (the resident) was in (this town). (The resident) couldn't tell me where (the resident) was. (The resident) was telling me (the resident's) family was supposed to be here and didn't show up. Then (the resident's child) called and reminded (the resident) they weren't coming down. (The resident) said (the resident) was having to get up and check on them in the car outside, as they had fallen asleep in the car. I told (licensed staff C) that day that (the resident) said (the resident) was going to Lawrence. (Licensed staff C) decided (this licensed staff) was going to put a TABS alarm on to be on the safe side so we would hear the alarm go off. The nurses and aides check the alarms when we go in there. I told the evening shift aide what had taken place during the day so they knew what to do. The nurse writes down anything new. (Direct care staff F) and I took care of (the resident) on Monday. (The resident) had (the resident's) alarm on Monday morning. I saw her at 6 AM that morning. She seemed fine, no signs of confusion. (The resident) knew us all and where (the resident) was. We turned her around 7:30 AM and got her ready for breakfast. She was OK then too, talking normal. (The resident) was laughing about how (the resident) acted over the weekend...We tried to get the UA on Monday, but were not able to get enough urine for the test. I was off on Tuesday. The alarm was prn (as needed) for confusion only..." On 7/2/12 at 10:45 AM, licensed staff E stated, "...I saw (the resident) a few times that morning (6/12/12). I did (the resident's) blood sugar at 7 AM and helped reposition (the resident). I noted no confusion in the morning...repositioned (the resident) before 7:30 AM in (the resident's). I told (the resident) about the bladder infection and that (the resident) would be starting on an antibiotic. I had a phone call, around 10 something, from (the resident's child). (The resident's child) had called (the resident) on the phone and thought (the resident) was confused. The only thing (the resident) didn't get right was the day. I told (the resident's child) (the resident) had an UTI (urinary tract infection). Then when I was talking to (the resident's child), (direct care staff F) came in and told me (the resident) was confused. (Direct care staff F) said (the resident) was going to get up to walk and see (the resident's) sister. I hung up the phone and (direct care staff F) and I were talking. We heard some one yell one time, then room 114's call light came on. (The resident) had turned on the call light. (Direct care staff F) was already walking down there. I started walking to room 114. (Direct care staff F) said over the walkie that they needed a nurse STAT in room 114. (The resident) was on (the resident's) back, next to (the resident's) recliner. We called it the hurtler position. (The resident's) right leg, the knee was next to (the resident's) femur. We put a pillow under (the resident's) head. I called the nurse to call 911. (The resident) at that time, was alert and called us all by name. (The resident) said (the resident) slid out of the chair. (The resident) said (the resident) had used the lift chair control. The foot rest was tucked under the recliner. The seat of the recliner was like a regular chair. The chair was up against (the resident). We did not even know about the TABS alarm that we were supposed to use. The TABS alarm was in (the resident's) bed. After the phone call with (the resident's child). (direct care staff F) I were discussing (the resident's) confusion. Putting the alarm on kind of fell through the cracks. It was not passed on. There was no mini-inservice about the TABS alarm. The mini-inservice is a notebook used for new changes, We all have to read and initial it when we read it...Neither (direct care staff F) nor I knew about the TABS alarm. It might be on the care tracker if she had a TABS alarm on during the night. The nurses change the care plan and put it on the mini-inservice...It was not reported during shift change about (the resident) needing the TABS alarm." On 7/2/12 at 11 AM, direct care staff G stated, "...On Tuesday (6/12/12), (direct care staff F) and me did (the resident's) shower around 7:15 AM. I went down hall 3 to help...When we got her up for the shower, (the resident) said, 'I haven't seen you for a while. Where have you been?' I saw (the resident) when (the resident) asked to be repositioned around 9:30 AM or 10 AM. (The resident) was confused and wanting to get out of bed and walk. I don't know if (the resident's) alarm was on (the resident) when in bed. I don't believe (the resident) was supposed to have an alarm in bed. After we repositioned (the resident), (direct care staff F) went and told the nurse about (the resident's) confusion. We read everyone's care plan daily. It is in the Kiosk (electronic record) on the wall. I don't remember if I read (the resident's) care plan that day. I went to help (the aide) after (the aide) hollered for the nurse...(The resident's) right foot was up by (the resident's) shoulder. (The resident) was still a little confused. (The resident) didn't have a TABS alarm in the lift chair..." On 7/2/12 at 11:45 AM, licensed staff C reported working on the day shift from 6 AM to 2 PM on the weekend of 6/9 and 10/12. This licensed staff stated, "On Saturday (6/9/12), (the resident) had no changes. On Sunday (6/10/12), (the resident) started getting confused. For (the resident) that was not that unusual. Like saying I have to move. (The resident) knew where (the resident) was, knew the year, but not the month. (Direct care staff D) reported that to me. I went down and talked to (the resident). (The resident's) (grandchild) came in to see (the resident) and wanted us to call the doctor to get an UA (urine analysis). I went ahead and put a TABS alarm on (the resident) in bed. When I wrote it (TABS alarm) in the care plan, I didn't specify. I wrote it prn (as needed) for confusion. I did not specify in the chair or bed. I put the TABS on in the afternoon and it was on when I left at 2:30 PM. I told (direct care staff D) and the aides usually pass it along during shift rounds any new information. I was not working the day (the resident) fell ...(The resident) was usually in the bed or up in the wheelchair." On 7/2/12 at 3:10 PM, licensed staff H stated, "...(The resident) had some confusion...We have mini-inservices about any changes with the residents. I set them on each hall. The aides and nurses have to sign that they have read it..." The facility's prevention and management of falls practice guidelines policy, revised on 4/2011, recorded, "...RISK EVALUATION...Implementation of interventions, including adequate supervision, consistent with resident needs, goals, plan of care...in order to reduce the risk of an accident. Monitor the effectiveness of the interventions and modify the interventions as necessary,...EDUCATION Education should be provided in an ongoing manner to staff...in order to expand awareness of factors influencing falls and interventions available...The interdisciplinary team should attend a stand up/change in condition meeting daily (M-F) in order to be made aware of any occurrences of falls and to increase care related communication..." The facility failed to ensure this sampled resident reviewed received adequate supervision and assistive devices to prevent accidents. Direct care staff, through interviews, lacked the knowledge the resident had an intervention for the use of an alarm when confused. The resident fell from a power lift chair and sustained 3 fractures of the lower extremities.