Every finding on record at Good Samaritan - Wamego

The facility identified a census of 39 residents with three residents reviewed for elopement. Based on record review, observation, and interview, the facility failed to ensure staff provided adequate supervision to cognitively impaired Resident (R) 1, who had a history of wandering and elopement, to prevent R1 from exiting the facility unsupervised through an unlocked kitchen area and door. On 05/04/24 at approximately 05:58 PM R1 sat in the dining room finishing his supper. The only Certified Nurse Aide (CNA) in the dining room assisted another resident out of the dining room. R1 then got up from his table and, with his walker, walked to the dishwasher room. R1 attempted to open the door but it was locked. R1 left his walker at that doorway and walked back towards the front of the dining room. R1 walked to the next doorway, which was open and permitted R1 to enter the kitchen. R1 walked through the facility kitchen and went out the back door of the kitchen at 06:02 PM. The regular alarm sounded and Licensed Nurse (LN) G checked the alarm system that was going off. The alarm system indicated the interior kitchen door and another outside door by the dietary manager's office were triggered. LN G looked towards the dining room and Dietary Staff BB, who was coming down the hall, stated the cook went out for a break and must have set off the alarm. LN G shut off the alarm. Dietary Staff BB walked outside four minutes later and discovered R1 outside by the dumpsters. Dietary Staff BB asked R1 he was doing and R1 said, Enjoying the weather. R1 was eating ice cream at the time. CNA M came outside with the trash and both aides redirected R1 back into the facility without incident. R1 was outside on the property unattended for 4 minutes. The facility failed to ensure R1 received adequate supervision to prevent him from entering the kitchen unattended and exiting the facility unsupervised and unbeknownst to staff. This failure placed R1 in immediate jeopardy. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of cognitive communication deficit, weakness, disorientation, a history of falls, and difficulty walking. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had a Brief Interview for Mental Status (BIMS) score of five, which indicated severe cognitive impairment. The MDS documented R1 required moderate assistance from staff for toileting hygiene, bathing, and lower body dressing. The MDS documented R1 required supervision for ambulation. The MDS documented R1 had a history of delusions and wandering. The MDS documented R1 had two or more non-injury falls and one fall with a minor injury during the observation period. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 11/17/23, documented R1 had increased confusion and disorientation. The Functional Abilities CAA, dated 11/17/23, documented R1 was independent with most of his activities of daily living (ADL) with general oversight and limited assistance with bathing. The CAA documented R1 was able to move about the facility independently with a front-wheeled walker. The Behavioral Symptoms CAA, dated 11/17/23, documented R1 had a history of wandering and had attempted to exit the building without assistance. The CAA documented R1 utilized a WanderGuard (a bracelet that helps monitor residents who are at risk of wandering) that alerted staff with a separate alarm when opening an exit door. R1's Care Plan documented R1 would not leave the facility unattended (01/05/24). Staff were directed to offer to take R1 for walks outdoors if weather permitted (12/06/23). Staff were directed to ensure R1's WanderGuard was in place and functioning properly (01/26/24). R1's family would be educated to use the sign-in/sign-out sheet at the nurse's station (01/23/23). Staff were directed to ensure exit door alarms were in working order (01/23/23). R1's Elopement Risk Assessment, dated 04/10/24, documented R1 as at risk for elopement. The assessment documented R1 had a history of leaving the building, a history of wandering, increased confusion, and forgetfulness, had wandered in the last 60 days, had elopement attempts in the past, had packed his belongings in the past, had repeatedly opened doors/set off secure door alarms, verbalized statements about leaving, and wandered with no rational purpose and attempted to open doors. The Mood/Behavior Note, dated 03/27/24 documented R1 continually wandered around his room and into the hallway without his walker. The staff had to continually remind R1 to use his walker, however R1 was unable to remember sixty seconds after being reminded. R1 did not feel like he lived here and wanted to go home. The Mood/Behavior Note, dated 04/10/24, documented R1 had increased agitation due to his belief that another female resident was his wife. R1 attempted to go into the female resident's room at which time the female resident told R1 to get out. Staff stepped in, closed the door, and tried to redirect R1. R1 became angry and stated he was going to hit someone if they did not let him be. The Mood/Behavior Note, dated 04/24/24, documented R1 was showing an increased risk for elopement. R1 had been going to exits and stated he wanted to find his car. R1 was opening and closing doors in the facility looking for an exit. R1 stood at one exit, and he read, door will open in 15 seconds then asked the nurse if they should go for it. The staff redirected R1 to his room to watch a movie. R1 sat in his recliner with his eyes closed. The Communication with Physician Note, dated 05/04/24 documented staff informed LN I and LN G that R1 was found outside by the dumpster. Upon arriving on scene, R1 was with CNA M and Dietary Staff BB. The staff assisted R1 back into the facility by wheelchair and obtained R1's vital signs. The staff completed R1's skin assessment with no skin abnormalities noted. The staff notified R1's primary care physician and responsible person of the situation. The staff notified maintenance staff of the WanderGuard system not activating and had staff watch the door until fixed. The undated Facility Incident Report revealed on 05/04/24 at approximately 05:58 PM R1 sat in the dining room finishing his supper. There was one aide in the dining room at the assisted table. The aide got up and assisted another resident out of the dining room. R1 then got up from his table with his walker and walked to the dishwasher room. The door was closed. R1 attempted to open the door but it was keypad locked. R1 left his walker at the doorway turned around and walked back towards the front of the dining room. R1 walked to the next doorway and found entry into the kitchen. The kitchen door was open (if closed would have required a keypad lock). R1 walked through the kitchen and went out the back door of the kitchen at 06:02 PM. The regular alarm sounded (that door did not have a WanderGuard alarm). LN G was seen checking the alarm system that was going off. The alarm system indicated the interior kitchen door and another outside door by the dietary manager's office. LN G looked towards the dining room and Dietary Staff BB came up the hall and stated the cook was in her car and must have set off the alarm when going out for a break. LN G shut off the alarm. Dietary Staff BB walked outside four minutes later and discovered R1 outside by the dumpsters. Dietary Staff BB asked what R1 was doing and R1 said, Enjoying the weather. CNA M went outside with the trash and both aides redirected R1 back into the facility without incident. R1 was outside on the property unattended for four minutes. LN G escorted R1 to his room, vitals were taken and were within normal limits, and a skin assessment was completed (no abnormalities found). CNA M's Witness Statement, dated 05/04/24, documented CNA M was taking out the trash and saw R1, called R1's name, and went to R1. CNA M called LN G to inform her of what happened. Dietary Staff BB's Witness Statement, dated 05/04/24, documented Dietary Staff BB saw LN H turn off the alarm as he was walking by. Dietary Staff BB went out back to let the cook know about another resident and saw R1 outside without his walker. Dietary Staff BB asked R1 what he was doing out there and R1 said, Just enjoying the weather. CNA M came out with the trash and the staff called both nurses, who came out and redirected R1 back into the facility. LN G's Witness Statement, dated 05/04/24, documented CNA M called her personal cell phone and informed LN G R1 was outside of the building by the dumpster trash can. R1 was fully clothed and had on a jacket and a ball cap. R1 had on his shoes. The sky was clear, still daylight, and the air was warm on the skin. CNA M and Dietary Staff BB were with R1, each had a hold of one of R1's arms and stood by R1. R1 walked back into the facility with CNA M and LN I. LN I assisted LN G with R1. R1 did not have his walker with him. R1 had no obvious injury, had a strong gait, and no shortness of air was noted. On 05/16/24 at 09:45 AM R1 sat in the day room drinking coffee and watching people. R1 had a WanderGuard to his right wrist. His walker was at his side. On 05/16/24 at 10:15 AM, observation revealed the path R1 took through the kitchen had pots and pans, drawers with knives and utensils, cleaning products, and a hot grill. Observation of the outside area revealed a concrete parking lot with cracks in the concrete, an air conditioning unit, two large dumpsters, and a street with a posted speed limit of thirty miles an hour. On 05/16/24 at 10:00 AM, Administrative Nurse D stated if the kitchen staff had closed the door to the kitchen, then R1 would not have been able to run the keypad lock to the door and would not have gotten out of the building. Administrative Nurse D stated she immediately put an intervention in place the kitchen door must always remain closed. On 05/16/24 at 10:30 AM, Administrative Staff A stated that a CNA did come to the kitchen door to check the alarm but did not see anything. Administrative Staff A stated the cook was on break out in the parking lot and if she had been parked different direction, she would have seen R1 come out of the building. The Elopement Policy, dated 07/11/23, documented the SNF location will be responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring residents/clients at risk for elopement. These include identifying, evaluating, and analyzing environmental hazards and risks and implementing monitoring and modifying interventions as needed. On 05/16/24 at 03:10 PM Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template which noted the facility's failure to ensure R1 received adequate supervision to prevent him from entering the kitchen unattended and exiting the facility unsupervised and unbeknownst to staff, placed R1 in immediate jeopardy. All corrective actions were completed on 05/14/24 and included: R1's WanderGuard was checked and was working properly. Immediate education for all staff and kitchen staff to keep the kitchen door closed when the kitchen is not occupied. The facility immediately checked all residents who had WanderGuards to make sure the WanderGuards were functioning properly. The facility also checked all of the WanderGuards on the doors to make sure they were functioning as well. All residents with WanderGuard were assessed and their elopement assessment was updated if needed to make sure it was up to date. The facility would also use walkie-talkies to communicate when exit-seeking behaviors were seen with any resident. R1's Care Plan was updated by adding a nursing order for the nurse to sign off and write progress notes if he was exit seeking and added it to the care plan for the aides to document. Since all corrections were completed before the onsite survey, the citation was deemed past noncompliance.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to store, prepare, and service food in a sanitary manner for the residents who reside in the facility and receive meals from the facility kitchen which placed the residents at risk for foodborne illness. Findings included: -On 01/30/24 at 08:32 AM, during the initial tour of the facility's kitchen, observation revealed the walk-in refrigerator stored a five-pound open, unsealed, undated roll of meat on the eye level shelf. On the shelf directly under the open unsealed meat roll were four small bowls of chopped lettuce and four cream-type pie slices which were not covered or labeled. Further into the walk-in refrigerator was an open, undated, unsealed bag of chopped lettuce, celery stocks, and hash brown type of potato patties. The walk-in freezer contained three plastic-wrapped waffles and an open unsealed box of chicken strips that lacked open dates. Upon further observation, Dietary Staff (DS) BB prepared over-easy cooked eggs for resident consumption. On 01/30/24 at 08:32 AM, DS CC verified food storage should be labeled to content, date open, covered, or sealed in the refrigerator and freezers. DS CC said meat should be stored on lower shelves and stated the eggs used for the over-easy eggs were not pasteurized. The facility's Food-Supply Storage policy, dated 05/11/23, documented that foods that have been opened or prepared are placed in an enclosed container, dated, labeled, and stored properly. Raw foods will be stored on shelves below cooked foods. The facility failed to store, prepare, and service food in a sanitary manner for the residents who reside in the facility and receive meals from the facility kitchen which placed the residents at risk for foodborne illness.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with trauma triggers and coping strategies for Resident (R)19 and failed to address sexual behaviors for R3. The placed R19 and R3 at risk for impaired care due to uncommunicated care needs. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of pain, malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of left female breast, degenerative disease of nervous system, repeated falls, generalized anxiety(mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (major mood disorder which causes persistent feelings pf sadness), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), need for assistance personal care, dementia (progressive mental disorder characterized by failing memory, confusion), severe with psychotic (any major mental disorder characterized by a gross impairment in reality perception) disturbance, Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) disease with early onset, and visual hallucinations (sensing things while awake that appear to be real, but the mind created) and auditory hallucinations. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R19 had moderate cognitive impairment, and exhibited no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness)or psychosis (any major mental disorder characterized by gross impairment in reality perception) and exhibited no behaviors. R19 required partial/moderate assistance with most activities of daily living. The MDS further documented R19 received scheduled and as-needed pain medication, an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antianxiety (class of medications that calm and relax people), an antidepressant (class of medications used to treat mood disorders). Antipsychotics were received on a routine basis only, with a gradual dose reduction (GDR) on 09/12/23 and the physician had not documented a GDR as contraindicated. R19's Care Plan, dated 01/16/24, documented R19 had a psychosocial well-being deficit, reliving trauma related to a history of sexual abuse and family discord and diagnoses of anxiety and depression. The care plan lacked triggers and coping strategies. The Trauma Assessment, dated 10/09/21, documented R19 experienced sexual trauma perpetrated by family during R19's youth. The trauma symptoms and triggers that caused reliving a traumatic experience of startling easily to sudden noises, and coping strategies for relieving a traumatic experience R19 preferred that staff knock on her door prior to entering so that they did not startle her and leave the bathroom light on at night. On 02/05/24 at 11:00 AM, Certified Nurse Aide (CNA) M stated she was not aware of R19's trauma history but that information would be helpful with care due to the resident's confusion. On 02/05/24 at 10:34 AM, Licensed Nurse (LN) G reported she was not aware of R19's of trauma triggers or coping strategies but tried to document on behaviors R19 exhibited. On 02/05/24 at 01:00 PM, Administrative Nurse D verified R19's care plan should have trauma triggers and coping strategies. The facility's Care Plan policy, dated 11/01/23, documented to develop a comprehensive care plan using an interdisciplinary team approach to provide guidance to the interdisciplinary team in developing the initial care plan. Residents will receive and be provided the necessary care and services to attain or maintain the highest practicable well-being in accordance with the comprehensive assessment. Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician's orders. The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. It will address the relationship of items or services required and facility responsibility for providing these services. The facility failed to revise/include R19's care plan to include trauma triggers and coping strategies which placed the resident at risk for impaired care due to uncommunicated care needs. 32360 - The Electronic Medical Record (EMR) documented R3 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), edema (swelling caused due to excess fluid accumulation in the body tissues), pain, and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition and was independent with all activities of daily living (ADL), had no behaviors, and received antianxiety (class of medications that calm and relax people) and antidepressant (class of medications used to treat mood disorders) medications. The Quarterly MDS, dated [DATE], documented R3 had intact cognition and was independent with ADL, had no behaviors, and received antianxiety and antidepressant medication. R3's Care Plan, initiated on 03/18/20, documented R3 had the potential to relive trauma related to his wife's passing and his own near-death experience. The plan directed staff to remove R3 to a calm, safe environment, allow him to vent and share feelings when conflict arises, and provide opportunities for him to participate in care and decisions about his care. The update, dated 10/22/20, directed staff to assist R3 with activities that were meaningful and of interest, encourage, support, and maintain as much independence and control as possible; and engage R3 in one-on-one conversations about his interests during times of increased activities. The update, dated 03/31/22, directed staff to consult with psychiatric services as needed. The plan lacked direction to staff related to R3's sexual advances, behaviors, and comments. The Physician's Order, dated 07/22/21, directed staff to administer clonazepam (antianxiety medication), 0.5 milligrams (mg), by mouth, in the morning for anxiety, The Physician's Order, dated 06/26/23, directed staff to document any sexual advances, behaviors, and comments to staff and/or other residents every day and evening shift. R3's Medication Administration Record (MAR) for November 2023, lacked behavior monitoring documentation on the following days: 11/01/23 11/02/23 11/04/23 11/05/23 11/06/23 11/08/23 11/09/23 11/11/23 11/12/23 11/16/23 11/20/23 11/21/23 11.23/23 11/24/23 11/26/23 R3's MAR for December 2023, lacked behavior monitoring documentation on the following days: 12/02/23 12/07/23 12/08/23 12/12/23 12/15/23 12/17/23 12/18/23 12/23/23 12/24/23 12/29/23 12/30/23 R3's MAR for January 2024 lacked behavior monitoring documentation on the following days: 01/04/24 01/09/24 01/11/24 01/12/24 01/15/24 01/18/24 01/19/24 01/22/24 01/23/24 01/25/24 01/26/24 01/30/24 The Nurse's Notes, dated 02/04/23 at 08:52 AM, documented during insulin (controls the amount of sugar in the blood by moving into the cells) administration, R3 spanked the nurse's butt and he was advised to not do that again as that was the second time it happened. The Nurse's Note, dated 06/20/23 at 09:50 AM documented R3 was found in the activity room, seated in a chair, with his pants down. The note further documented that staff asked R3 why he had his pants down, and he just laughed. The Nurse's Note, dated 06/26/23 at 08:30 AM, documented R3 attempted to kiss the nurse during a medication pass. The Nurse's Note, dated 08/24/24 at 12:12 PM, documented R3 grabbed the nurse around the hip with his arm and pulled her towards him, The staff told R3 no and informed him he could not touch staff like that. On 01/30/23 at 02:50 PM, observation revealed R3 ambulated down the hall with his walker into the activity room. On 02/05/24 at 10:00 AM, Licensed Nurse (LN) G stated the nurse documented in the MAR whether or not R3 had any behaviors. LN G stated if R3 had behaviors, the behaviors were documented in the progress note. On 02/05/24 at 10:45 AM, Certified Nurse Aide (CNA) M stated R3 did not have any behaviors. On 02/05/24 at 12:35 PM, Administrative Nurse D stated staff should make sure they were signing the MAR whether R3 had any sexual behaviors toward staff. Administrative Nurse D said the care plan should reflect the resident and his behaviors. The facility's Care Plan policy, dated 11/01/23, documented the interdisciplinary team would review care plans at least quarterly and would be reviewed, evaluated and updated when there is a significant change in the resident's condition. The facility failed to revise R3's Care Plan to direct staff with interventions when R3 had inappropriate behaviors. This placed R3 at risk for imapired care due to uncommunicated care needs.

The facility had a census of 41 residents. The sample included 12 residents, with one reviewed for discharge. Based on interview and record review, the facility failed to develop a discharge plan for one sampled resident, Resident (R) 40, who discharged to home with family. This placed the resident at risk for unidentified discharge goals and impaired discharge planning. Findings included: - The Electronic Medical Record (EMR) for R40 documented diagnoses of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), encephalopathy (a broad term for any brain disease that alters brain function or structure), hypertension (high blood pressure), dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory, confusion), and weakness. The EMR lacked evidence a discharge care plan had been developed upon admission to the facility. The Nurse's Note, dated 11/03/23 at 11:40 AM, documented R40 was admitted to the facility after hospitalization for sepsis and planned to return home after therapy. On 01/31/24 at 08:45 AM, Administrative Nurse E verified there was not a care plan or a recapitulation of R40's stay in the facility. Administrative Nurse E stated she thought R40 was going to remain in the facility. The facility's Discharge and Transfer policy, dated 01/03/24, documented that the social worker or designated individual will, prior to discharge, coordinate a discharge plan with the interdisciplinary team and resident and/or responsible party, and arrange community resources and referrals. The facility failed to develop a discharge plan for R40, who planned to go back to the community after therapy. This placed the resident at risk for unidentified discharge goals and impaired discharge planning.

The facility had a census of 41 residents. The sample included 12 residents. Based on record review and interview, the facility failed to develop a discharge summary that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post-discharge plan for Resident (R)40. This placed the resident at risk for impaired care and services. Findings included: - The Electronic Medical Record (EMR) for R40 documented diagnoses of sepsis (a life-threatening systemic reaction that develops due to infections that cause inflammation throughout the entire body), encephalopathy (a broad term for any brain disease that alters brain function or structure), hypertension (high blood pressure), dementia without behavioral disturbance (a progressive mental disorder characterized by failing memory, confusion), and weakness. The EMR lacked evidence a discharge care plan had been developed upon admission to the facility. The Nurse's Note, dated 11/03/23 at 11:40 AM, documented R40 was admitted to the facility after hospitalization for sepsis and planned to return home after therapy. R40's clinical record lacked evidence of a recapitulation of R40's stay. On 01/31/24 at 08:45 AM, Administrative Nurse E verified there was not a care plan or a recapitulation of R40's stay in the facility. Administrative Nurse E stated she thought R40 was going to remain in the facility. The facility's Discharge and Transfer policy, dated 01/03/24, documented that the social worker or designated individual will, prior to discharge, coordinate a discharge plan with the interdisciplinary team and resident and/or responsible party, and arrange community resources and referrals. The facility failed to develop a discharge summary that included a recapitulation of the resident's stay and post-discharge plan for Resident R40. This placed the resident at risk for impaired care and services.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide cueing or assistance with eating for Resident (R) 17 who had weight loss. This placed the resident at risk of continued weight loss and unmet care needs. Findings included: - R17's Electronic Medical Record (EMR) documented diagnoses of pain, spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), essential tremor, gastroesophageal reflux disease (GERD-backflow of stomach contents to the esophagus), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, dementia (progressive mental disorder characterized by failing memory, confusion), heart disease, and muscle weakness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had severe cognitive impairment, delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and wandering behavior that occurred one to three days of the observation period. R17 required supervision or touch assistance with eating, was 60 inches tall, weighed 112 pounds (lbs.), and had no weight loss. R17 was on a mechanically altered diet. R17's Care Plan, dated 12/18/23, documented R17 had an activity of daily living (ADL) self-care deficit related to requiring extensive assistance with most ADLs secondary to a diagnosis of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) and dementia. The care plan directed staff R17 was independent but did require supervision at times of increased fatigue and may require some assistance and cueing. R17's Care Plan, dated 12/18/23, documented R17 had an unexpected weight loss related to increased fatigue and sleeping more secondary to a diagnosis of dementia and Parkinson's disease. The care plan directed staff R17 was independent but does require supervision, at times of increased fatigue may require some assistance and cueing. On 01/30/24 at 12:47 PM, observation revealed R17 sat in the dining room for the midday meal. She was provided with beef vegetable soup, half a deli sandwich, and blueberry pear cobbler. R17 sat at the table and looked at the food with occasional tremors in her hands. No staff offered assistance to R17, and the resident did not eat her meal. On 01/31/24 at 07:58 AM observation revealed R17 sat in her wheelchair. Staff brought the resident to the dining room and assisted her with the menu selection for breakfast. Staff brought R17 a cup of coffee and a cloth napkin, and wrapped silverware. R17 unwrapped the silverware in a slow process and drank from the coffee cup. At 08:04 AM R17's breakfast was brought to the table. The meal consisted of scrambled eggs and a cut-up pancake with syrup. R17 held the silverware in her right hand but used her left hand to raise the food to her mouth. R17 had tremors in her hands and had difficulty getting food onto the silverware. At 08:22 AM, R17 continued to struggle with getting food to her mouth which was a slow process using both hands and she continued to have tremors. No staff offered any assistance or cueing. At 08:45 AM staff offered to cut up the food. R17 indicated no as the food was already in bite-size pieces. The staff did not offer assistance with eating. R17 appeared to get stuck and/or frozen at times. At 09:10 AM R17 ate most of the pancake and only a few bites of eggs. On 02/01/24 at 11:58 AM observation revealed staff brought R17 to the dining room and placed her at her table. R17 picked up a pencil and attempted to fill out the menu selection but struggled to complete it due to hand tremors. At 12:07 PM a staff member assisted R17 with filling out menu choices, and dietary staff furnished R17 with coffee and supplement. At 12:38 PM, R17 received a cheeseburger. Staff assisted with placing sauce on the hamburger. R17 struggled to place lettuce and onion on the burger and ate using both hands, but the lettuce kept falling onto her lap. R17 continued to struggle to keep the burger together. No staff offered additional assistance. On 02/05/24 at 11:00 AM Certified Nurse Aide (CNA) M verified R17 had had a weight loss and staff weighed her weekly. CNA M reported R17 was able to feed herself but took a very long time to eat. CNA M said in the past, staff offered to help her and R17 told staff I can do it. On 02/05/24 at 10:34 AM, Licensed Nurse (LN) G stated she had known R17 for a long time and said R17 may have lost 10 pounds. LN G said the resident received supplements, used weighted silverware, and cups with lids, and took a long time to eat. LN G said R17 did not like to be fed, but staff should offer assistance. On 02/05/24 at 01:00 PM Administrative Nurse D verified R17 had weight loss, and took a long time to eat, but should be offered assistance and provided with fresh hot foods if taking a long time. The facility's Restorative-Identifying Decline in Activities of Daily Living, dated 01/16/24, documented the purpose of identifying declines in ADL function and to consider interventions to avoid ADL decline. Residents with disease processes such as Parkinson's disease can result in a loss of independence. ADL decline associated with certain disease processes is unavoidable but with restorative interventions, the effects of the disease can be slowed. The facility failed to provide cueing or offer assistance to R17 at mealtimes who had weight loss. This placed the resident at risk for continued weight loss and unmet care needs.

The facility had a census of 41 residents. The sample included 12 residents, with four reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 22's personal alarm system was monitored as ordered to prevent elopement (when a cognitively impaired resident leaves the facility without staff knowledge or supervision). This placed the resident at risk for preventable accidents. Findings included: - The Electronic Medical Record (EMR) for R22 documented diagnoses of weakness, unsteadiness on feet, hypertension (high blood pressure), cognitive-communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition), and disorientation (having lost one's self of direction). The Admission Minimum Data Set (MDS), dated [DATE], documented R22 had intact cognition and required extensive assistance from one staff for dressing and toileting, and limited assistance from one staff for bed mobility, transfers, ambulation, and personal hygiene. The MDS further documented R22 had disorganized thinking that fluctuated, was unsteady, and had upper functional limitation on one side. The Significant Change MDS, dated [DATE], documented R22's cognition was not assessed and required set-up assistance for personal hygiene, and supervision for toileting, showers, dressing, transfers, and ambulation. The MDS further documented R22 had no functional limitation and had no falls. R22's Care Plan, dated 11/27/23, initiated on 01/23/23, directed staff to offer to take R22 for a walk outdoors if weather permitted, ensure Wander Guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) was in place and properly functioning, educate families to use the sign in/sign out sheet at the nurse's station, and ensure that exit door alarms are in working order. The Physician's Order, dated 01/23/23, directed staff to ensure Wander Guard was functioning properly two times per day. R22's Medication Administration Record (MAR), dated November 2023 lacked documentation the Wander Guard was assessed to be working properly on the following days: Day Shift-11/04/23, 11/05/23, 11/11/23, 11/12/23, 11/20/23, 11/23/23, 11/24/23, 11/26/23 Evening Shift-11/01/23, 11/04/23, 11/09/23, 11/11/23, 11/12/23, 11/21/23, 11/24/23, 11/25/23. 11/30/23 R22's MAR dated December 2023 lacked documentation the Wander Guard was assessed to be working properly on the following days: Day Shift-12/15/23, 12/18/23, 12/19/23, 12/23/23 Evening Shift-12/02/23, 12/03/23, 12/07/23, 12/08/23, 12/15/23, 12/16/23, 12/17/23, 12/21/23, 12/24/23, 12/29/23, 12/30/23 R22's MAR dated January 2024 lacked documentation the Wander Guard was assessed to be working properly on the following days: Day Shift-01/04/24, 01/09/24, 01/12/24, 01/16/24, 01/18/24, 01/19/24, 01/22/24, 01/23/24, 01/25/24, 01/26/24, 01/30/24 Evening Shift-01/04/24, 01/05/24, 01/11/24, 01/15/24, 01/20/24, 01/22/24, 01/25/24 On 02/05/24 at 10:00 AM, Licensed Nurse (LN) G stated R22 got confused at times and wandered around the facility but LN G did not know of any time R22 had left the facility unsupervised. LN G further stated she checked R22's Wander Guard when she worked and documented it in the MAR after she checked it. On 02/05/24 at 10:45 AM, Certified Nurse Aide (CNA) M stated R22 had a Wander Guard that would sound whenever he got close to the doors. CNA M further stated that R22 liked to go to the doors and look out but never tried to leave the facility unattended. The facility's Elopement policy, dated 07/11/23, All skilled nursing residents would be assessed for risk of elopement through the pre-admission and/or admission process and as needed. In the event of a suspected missing resident, check locations where the resident would spend time, and if unable to locate the resident, contact the administrator, director of nursing services, and charge nurse. The area would be searched and if the resident was found, the resident would be evaluated for injuries. In all cases, the family, physician, and other agencies as required by state and/or federal regulation would be notified. The facility failed to ensure the personal alarm system used to prevent elopement for R22 was monitored as ordered. This placed the resident at risk for preventable accidents.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 19 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident which placed R19 at risk for impaired quality of life. Findings included: - R19's Electronic Medical Record (EMR) documented diagnoses of pain, malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of left female breast, degenerative disease of nervous system, repeated falls, generalized anxiety(mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (major mood disorder which causes persistent feelings pf sadness), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), need for assistance personal care, dementia (progressive mental disorder characterized by failing memory, confusion), severe with psychotic (any major mental disorder characterized by a gross impairment in reality perception) disturbance, Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) disease with early onset, and visual hallucinations (sensing things while awake that appear to be real, but the mind created) and auditory hallucinations. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R19 had moderate cognitive impairment, and exhibited no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness)or psychosis (any major mental disorder characterized by gross impairment in reality perception) and exhibited no behaviors. R19 required partial/moderate assistance with most activities of daily living. The MDS further documented R19 received scheduled and as-needed pain medication, an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antianxiety (class of medications that calm and relax people), an antidepressant (class of medications used to treat mood disorders). Antipsychotics were received on a routine basis only, with a gradual dose reduction (GDR) on 09/12/23 and the physician had not documented a GDR as contraindicated. R19's Care Plan, dated 01/16/24, documented R19 had a psychosocial well-being deficit, reliving trauma related to a history of sexual abuse and family discord and diagnoses of anxiety and depression. The care plan lacked triggers and coping strategies. The Trauma Assessment, dated 10/09/21, documented R19 experienced sexual trauma perpetrated by family during R19's youth. The trauma symptoms and triggers that caused reliving a traumatic experience of startling easily to sudden noises, and coping strategies for relieving a traumatic experience R19 preferred that staff knock on her door prior to entering so that they did not startle her and leave the bathroom light on at night. On 02/05/24 at 11:00 AM, Certified Nurse Aide (CNA) M stated she was not aware of R19's trauma history but that information would be helpful with care due to the resident's confusion. On 02/05/24 at 10:34 AM, Licensed Nurse (LN) G reported she was not aware of R19's of trauma triggers or coping strategies but tried to document on behaviors R19 exhibited. On 02/05/24 at 01:00 PM, Administrative Nurse D verified that R19's Care Plan should have trauma triggers and coping strategies. The facility's Trauma Informed Care policy, dated 11/16/23, documented the purpose to provide trauma-informed care and avoid re-traumatizing residents. Trauma-informed care means being intentional by anticipating and avoiding institutional processes and practices that are likely to re-traumatize a resident who has a history of trauma. Staff will ensure that residents who experience trauma receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization. The facility failed to communicate relevant information from R19's trauma history to allow staff to provide trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization. This placed the resident at risk for impaired quality of life.

The facility has a census of 41 residents. The sample included 12 residents, with eight residents reviewed for behaviors. Based on observation, record review, and interview, the facility failed to monitor Resident (R) 3 for sexual behaviors and failed to provide supervision for R11, who had resident-to-resident altercations. This placed the residents at risk for decreased quality of life. Findings Include: - The Electronic Medical Record (EMR) documented R3 had diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), edema (swelling caused due to excess fluid accumulation in the body tissues), pain, and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition and was independent with all activities of daily living (ADL), had no behaviors, and received antianxiety (class of medications that calm and relax people) and antidepressant (class of medications used to treat mood disorders) medications. The Quarterly MDS, dated [DATE], documented R3 had intact cognition and was independent with ADL, had no behaviors, and received antianxiety and antidepressant medication. R3's Care Plan, initiated on 03/18/20, documented R3 had the potential to relive trauma related to his wife's passing and his own near-death experience. The plan directed staff to remove R3 to a calm, safe environment, allow him to vent and share feelings when conflict arises, and provide opportunities for him to participate in care and decisions about his care. The update, dated 10/22/20, directed staff to assist R3 with activities that were meaningful and of interest, encourage, support, and maintain as much independence and control as possible; and engage R3 in one-on-one conversations about his interests during times of increased activities. The update, dated 03/31/22, directed staff to consult with psychiatric services as needed. The plan lacked direction to staff related to R3's sexual advances, behaviors, and comments. The Physician's Order, dated 07/22/21, directed staff to administer clonazepam (antianxiety medication), 0.5 milligrams (mg), by mouth, in the morning for anxiety, The Physician's Order, dated 06/26/23, directed staff to document any sexual advances, behaviors, and comments to staff and/or other residents every day and evening shift. R3's Medication Administration Record (MAR) for November 2023, lacked behavior monitoring documentation on the following days: 11/01/23 11/02/23 11/04/23 11/05/23 11/06/23 11/08/23 11/09/23 11/11/23 11/12/23 11/16/23 11/20/23 11/21/23 11.23/23 11/24/23 11/26/23 R3's MAR for December 2023, lacked behavior monitoring documentation on the following days: 12/02/23 12/07/23 12/08/23 12/12/23 12/15/23 12/17/23 12/18/23 12/23/23 12/24/23 12/29/23 12/30/23 R3's MAR for January 2024 lacked behavior monitoring documentation on the following days: 01/04/24 01/09/24 01/11/24 01/12/24 01/15/24 01/18/24 01/19/24 01/22/24 01/23/24 01/25/24 01/26/24 01/30/24 The Nurse's Notes, dated 02/04/23 at 08:52 AM, documented during insulin (controls the amount of sugar in the blood by moving into the cells) administration, R3 spanked the nurse's butt and he was advised to not do that again as that was the second time it happened. The Nurse's Note, dated 06/20/23 at 09:50 AM documented R3 was found in the activity room, seated in a chair, with his pants down. The note further documented that staff asked R3 why he had his pants down, and he just laughed. The Nurse's Note, dated 06/26/23 at 08:30 AM, documented R3 attempted to kiss the nurse during a medication pass. The Nurse's Note, dated 08/24/24 at 12:12 PM, documented R3 grabbed the nurse around the hip with his arm and pulled her towards him, The staff told R3 no and informed him he could not touch staff like that. On 01/30/23 at 02:50 PM, observation revealed R3 ambulated down the hall with his walker into the activity room. On 02/05/24 at 10:00 AM, Licensed Nurse (LN) G stated the nurse documented in the MAR whether or not R3 had any behaviors. LN G stated if R3 had behaviors, the behaviors were documented in the progress note. On 02/05/24 at 10:45 AM, Certified Nurse Aide (CNA) M stated R3 did not have any behaviors. On 02/05/24 at 12:35 PM, Administrative Nurse D stated staff should make sure they were signing the MAR whether R3 had any sexual behaviors toward staff. Upon request, a policy for behavior was not provided by the facility. The facility failed to monitor R3's behaviors. This placed the resident at risk for decreased quality of life. - The Electronic Medical Record (EMR) documented R11 had diagnoses of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), weakness, and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS), dated [DATE] documented R11 had severely impaired cognition and required extensive assistance from two staff for bed mobility, transfers, toileting, and locomotion. The MDS further documented R11 had other behaviors daily and did not take any medication. The Annual MDS, dated [DATE], documented R11 had severely impaired cognition and required substantial/maximum assistance for dressing, partial/moderate assistance with mobility, showers, and toileting, and the MDS further documented R11 had verbal behaviors one to three days per week. R11's Care Plan, dated 12/19/23, initiated on 05/01/23, directed staff to intervene as necessary to protect the rights and safety of others, and approach and calmly speak to him. The plan directed staff to divert his attention, remove him from the situation, and take him to an alternate location as needed. The care plan further directed staff to have one-to-one conversations with R11 when he had disruptive behaviors. The Nurse's Note, dated 04/11/23 at 08:50 AM, documented R11 yelled at another resident in the hall and told him to move out of his way and that he was going to run right into him. The Nurse's Note, dated 05/01/23 at 03:41 PM, documented that R11 kicked at another resident while in the activity room. The Nurse's Note, dated 05/27/23 at 10:57 AM, documented R11 pushed another resident's wheelchair in the common area and stated the resident was in the way. When the staff asked him to stop, R11 began to yell at the nurse and raised his hand to her. The Nurse's Note, dated 05/28/23 at 07:22 PM, documented R11 yelled at another resident and told them to shut up or to shut their mouth. Staff attempted to redirect R11 and he cursed and continued to tell other residents to shut up. The Nurse's Note, dated 06/27/23 at 05:02 PM documented R11 cursed at kitchen staff when the resident was asked not to talk negatively to another resident. The Nurse's Note, dated 10/13/23 at 03:11 PM, documented R11 kicked at and hollered at another resident and called her names. The Nurse's Note, dated 10/15/23 at 05:15 PM, documented R11 pushed another resident's wheelchair to move her out of the way so she wouldn't enter into the dining room. The Nurse's Note, dated 10/21/23 at 02:15 PM, documented R11 pushed another resident in her wheelchair and yelled at her to move and stop removing her shoes and socks. The note further documented the nurse intervened and asked the resident to let go of the resident's wheelchair three times and the nurse had to physically move the other resident away from the resident. The Nurse's Note, dated 11/28/23 at 11:21 AM, documented R11 became upset with another resident and attempted to kick her but hit the wheel of her chair instead. The note further documented staff attempted to separate them and told him to stop and he began to call staff names. On 01/303/24 at 03:20 PM, observation revealed R11 was beside R9 and began to kick at her wheelchair. R11 tried to pull R9's wheelchair back as R9 tried to roll forward. Further observation revealed that R11 told R9 to stop going toward the fish tank as she continued to try to move away from him. On 02/05/24 at 10:00 AM, Licensed Nurse (LN) G stated R11 had behaviors and tried to boss other residents around but R11 never hit another resident. LN G stated R11 liked control and the residents frustrated him. On 02/05/24 at 10:45 AM, Certified Nurse Aide (CNA) M stated when R11 got mad at another resident she separated the residents, made sure they were safe, and told the nurse. CNA M stated R11 never hit a resident, just kicked at their wheelchair. Upon request, a policy for behaviors was not provided by the facility. The facility failed to provide adequate supervision and redirection to R11, who had behaviors. This placed the resident at risk for decreased quality of life.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist identified and reported that Resident (R) 8 lacked a 14-day stop date or specified duration with physician rationale for as-needed (PRN) psychotropic (alters mood or thought) medication and R3 lacked evidence of blood sugar checks and insulin administration as ordered. This placed the residents at risk for inappropriate use of medications. Findings included: - R8's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) without residual deficit, chronic kidney disease, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, insomnia (inability to sleep), heart failure, dementia (a progressive mental disorder characterized by failing memory, confusion), mild without behavioral disturbance, psychotic (any major mental disorder characterized by gross impairment in reality perception) disturbance, generalized weakness, need for assistance with personal cares. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R8, had moderate cognitive impairment, no delirium (sudden severe confusion, disorientation, and restlessness) or psychosis, and had not exhibited behaviors. R8 required substantial/maximum with activities of daily living. R8 received scheduled pain medications and an antianxiety (class of medications that calm and relax people), an antidepressant (class of medications used to treat mood disorders), a diuretic (medication to promote the formation and excretion of urine), and opioid medication to treat pain). The MDS further documented R8 had a condition or chronic disease that may result in a life expectancy of less than six months and received hospice (specialized care for end-of-life) care. The Psychotropic Drug Use Care Area Assessment (CAA), dated 03/20/23, documented R8 was prescribed an antidepressant secondary to a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R8's Care Plan, dated 12/18/23, documented R8 was on medication with a Black Boxed Warning (BBW- highest safety-related warning that medications can be assigned by the Food and Drug Administration) and or warnings of adverse consequences. The care plan directed staff to monitor for adverse side effects such as drowsiness, tiredness, dizziness, weakness, dry mouth, diarrhea, nausea, and change in appetite and to report as necessary. The Physician Order, dated 10/02/23, directed staff to administer lorazepam (antianxiety medication) 0.5 milligrams (mg) by mouth every 12 hours as needed (PRN) anxiety or agitation. The order lacked a stop date. The Progress Note, dated 09/30/23 at 10:56 AM, documented R8 was very anxious and continuously looked for her daughter. R8 was tearful about money and family members; the staff called hospice to get lorazepam ordered. The monthly Consultant Pharmacy Reviews for R8 lacked mention of the required 14-day stop date or need for a specified duration for the PRN lorazepam. On 02/01/24 at 12:23 PM observation revealed R8 in the dining room. The staff brought her meal to the table. R8 was very appreciative and excited about the hamburger. On 02/05/34 at 10:34 AM, Licensed Nurse (LN) G reported R8 was confused and did not remember her children had passed away. LN G stated that R8 could be very verbal. LN G stated she had not administered lorazepam to R8 on her shifts. On 02/05/23 at 01:00 PM, Administrative Nurse D verified R8's lorazepam order lacked a 14-day stop date and evaluation to continue PRN use. The facility's Medication: Drug Regimen Review, dated 02/10/23, documented to prevent medication errors that could cause harm to a resident or result in resident hospitalization , and identify the potential for adverse side effects. Drug Regimen Review is a process that includes both medication reconciliation and a review of all medications a resident is currently using to identify and prevent potential clinically significant medication issues. For any mood-altering and pain medications (particularly opioids, antipsychotics, antianxiety, antidepressants, hypnotics, etc.) ask how long they have been on the medication and why and add this information to the resident care plan. The facility failed to ensure the Consultant Pharmacist identified and reported that R8 lacked a 14-day stop date or specified duration with physician rationale for PRN lorazepam use. This placed R8 at risk for inappropriate use of medication. 32360 - The Electronic Medical Record (EMR) documented R3 had diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough made, or the body cannot respond to the insulin) type 2, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), edema (swelling caused due to excess fluid accumulation in the body tissues), pain, and hypertension (high blood pressure). The Annual Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition and was independent with all activities of daily living (ADL) except supervision with toileting. R3 was continent of bowel and bladder and received insulin daily. The Quarterly MDS, dated [DATE], documented R3 had intact cognition and was independent for ADL. R3 was continent of bowel and bladder and received insulin daily. R3's Care Plan, dated 12/27/23, initiated on 03/31/22, directed staff to monitor, document, and report to the physician any signs and symptoms of hypoglycemia (low blood sugar), refer to the medication administration record (MAR) and treatment administration record (TAR) for Accucheck (measures sugar in the blood) and insulin schedule. The Physician's Order, dated 08/31/22, directed staff to check R3's blood sugar four times per day, notify the physician if his blood sugar was less than 80 milligrams per deciliter (mg/dl) or greater than 450 mg/dl, and give juice if less than 80. R3's Medication Administration Record/Treatment Administration Record (MAR/TAR) for November 2023, lacked blood sugar check documentation on the following days and times: 5:00 PM-11/15/23, 11/28/23,11/29/23 09:00 PM-11/04/23, 11/13/23 R3's MAR/TAR for December 2023, lacked blood sugar check documentation on the following days and times: 05:00 PM-12/13/23, 12/31/23 09:00 PM-12/25/23 R3's MAR/TAR for January 2024, lacked blood sugar check documentation on the following days and times: 07:00 AM-01/30/24 05:00 PM-01/03/23, 01/19/24 09:00 PM-01/05/24, 01/29/24, 01/30/24 The Physician's Order, dated 09/14/22, directed staff to administer Novolog (rapid-acting insulin). 12 units (U), subcutaneous (beneath the skin), in the evening for diabetes mellitus type 2. R3's MAR/TAR for November 2023, lacked insulin administration documentation on the following days: 11/15/23 11/28/23 11/29/23 R3's MAR/TAR for December 2023, lacked insulin administration documentation on the following days: 12/13/23 12/31/23 R3's MAR/TAR) for January 2024, lacked insulin administration documentation on the following days: 01/03/24 01/19/24 01/28/24 The Medication Regimen Reviews, dated January 2023-January 2024, failed to identify the lack of documentation for R3's insulin and blood sugar checks. On 01/30/23 at 02:50 PM, observation revealed R3 ambulated down the hall with his walker into the activity room. On 02/05/24 at 10:00 AM, Licensed Nurse (LN) G stated the nurse documented in the MAR after she obtained R3's blood sugar and insulin administration On 02/05/24 at 12:35 PM, Administrative Nurse D verified the lack of documentation and stated staff should make sure they were signing the MAR after they obtained R3's blood sugar and administered his insulin. Administrative Nurse D stated she had not been made aware by the Consultant Pharmacist of the missing documentation. The facility's Medication: Drug Regimen Review policy, dated 2/10/23, documented the pharmacist would complete a written report noting any drug irregularities or issues of concern for each resident reviewed. The pharmacist would also complete the Medication Regimen Review Summary and a report would be given to the director of nursing services upon completion of each monthly drug regimen review. The report reviewed medication to ensure that doses and duration are appropriate to each resident's clinical condition, age, and comorbidities, monitoring education for efficacy and adverse consequences, potential medication irregularities, medication-related errors, and gradual dose reduction. The facility's Consultant Pharmacist failed to identify and report the lack of insulin administration documentation for R3. This placed the resident at risk for physical decline.

The facility had a census of 41 residents. The sample included 12 residents, with six reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to follow physician orders for Resident (3), who received insulin (controls the amount of sugar in the blood by moving into the cells), and failed to monitor R3's blood sugar as ordered. This placed the resident at risk for physical decline. Findings included: - The Electronic Medical Record (EMR) documented R3 had diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough made, or the body cannot respond to the insulin) type 2, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), edema (swelling caused due to excess fluid accumulation in the body tissues), pain, and hypertension (high blood pressure). The Annual Minimum Data Set (MDS), dated [DATE], documented R3 had intact cognition and was independent with all activities of daily living (ADL) except supervision with toileting. R3 was continent of bowel and bladder and received insulin daily. The Quarterly MDS, dated [DATE], documented R3 had intact cognition and was independent for ADL. R3 was continent of bowel and bladder and received insulin daily. R3's Care Plan, dated 12/27/23, initiated on 03/31/22, directed staff to monitor, document, and report to the physician any signs and symptoms of hypoglycemia (low blood sugar), refer to the medication administration record (MAR) and treatment administration record (TAR) for Accucheck (measures sugar in the blood) and insulin schedule. The Physician's Order, dated 08/31/22, directed staff to check R3's blood sugar four times per day, notify the physician if his blood sugar was less than 80 milligrams per deciliter (mg/dl) or greater than 450 mg/dl, and give juice if less than 80. R3's Medication Administration Record/Treatment Administration Record (MAR/TAR) for November 2023, lacked blood sugar check documentation on the following days and times: 5:00 PM-11/15/23, 11/28/23,11/29/23 09:00 PM-11/04/23, 11/13/23 R3's MAR/TAR for December 2023, lacked blood sugar check documentation on the following days and times: 05:00 PM-12/13/23, 12/31/23 09:00 PM-12/25/23 R3's MAR/TAR for January 2024, lacked blood sugar check documentation on the following days and times: 07:00 AM-01/30/24 05:00 PM-01/03/23, 01/19/24 09:00 PM-01/05/24, 01/29/24, 01/30/24 The Physician's Order, dated 09/14/22, directed staff to administer Novolog (rapid-acting insulin). 12 units (U), subcutaneous (beneath the skin), in the evening for diabetes mellitus type 2. R3's MAR/TAR for November 2023, lacked insulin administration documentation on the following days: 11/15/23 11/28/23 11/29/23 R3's MAR/TAR for December 2023, lacked insulin administration documentation on the following days: 12/13/23 12/31/23 R3's MAR/TAR) for January 2024, lacked insulin administration documentation on the following days: 01/03/24 01/19/24 01/28/24 The Medication Regimen Reviews, dated January 2023-January 2024, failed to identify the lack of documentation for R3's insulin and blood sugar checks. On 01/30/23 at 02:50 PM, observation revealed R3 ambulated down the hall with his walker into the activity room. On 02/05/24 at 10:00 AM, Licensed Nurse (LN) G stated the nurse documented in the MAR after she obtained R3's blood sugar and insulin administration On 02/05/24 at 12:35 PM, Administrative Nurse D verified the lack of documentation and stated staff should make sure they were signing the MAR after they obtained R3's blood sugar and administered his insulin. The facility's Blood Glucose Monitoring policy and procedure, dated 01/31/24, directed staff to verify the physician's order, perform quality control tests daily or as directed by the manufacturer, document the results in the log. The policy further directed staff to perform the blood glucose check and document once completed. The facility's Medication Administration policy, dated 03/29/23, documented that if a medication was given but not signed for, the responsible medication person has 24 hours to sign, provided there was definitive evidence that the medication was administered. If not signed for within 24 hours, it was considered a medication error and an incident report must be completed. The staff are to document that the medication was given as soon as possible after administration. The facility failed to follow physician orders for R3, who received insulin and failed to monitor R3's blood sugar as ordered. This placed the resident at risk for physical decline.

The facility had a census of 41 residents. The sample included 12 residents of which six were reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 8 had a stop date for the use of as-needed (PRN) lorazepam (antianxiety-class of medications that calm and relax people), R9 had an approved indication or the required documentation for the use of Seroquel (antipsychotic- class of medications used to treat major mental conditions which cause a break from reality), and R19 had complete behavior documentation related the use of three psychotropic (alters mood or thought) medications. This placed the residents at risk of receiving unnecessary psychotropic medications. Findings included: - R8's Electronic Medical Record (EMR) documented diagnoses of cerebral infarction (stroke - the sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) without residual deficit, chronic kidney disease, chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, insomnia (inability to sleep), heart failure, dementia (a progressive mental disorder characterized by failing memory, confusion), mild without behavioral disturbance, psychotic (any major mental disorder characterized by gross impairment in reality perception) disturbance, generalized weakness, need for assistance with personal cares. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R8, had moderate cognitive impairment, no delirium (sudden severe confusion, disorientation, and restlessness) or psychosis, and had not exhibited behaviors. R8 required substantial/maximum with activities of daily living. R8 received scheduled pain medications and an antianxiety (class of medications that calm and relax people), an antidepressant (class of medications used to treat mood disorders), a diuretic (medication to promote the formation and excretion of urine), and opioid medication to treat pain). The MDS further documented R8 had a condition or chronic disease that may result in a life expectancy of less than six months and received hospice (specialized care for end-of-life) care. The Psychotropic Drug Use Care Area Assessment (CAA), dated 03/20/23, documented R8 was prescribed an antidepressant secondary to a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R8's Care Plan, dated 12/18/23, documented R8 was on medication with a Black Boxed Warning (BBW- highest safety-related warning that medications can be assigned by the Food and Drug Administration) and or warnings of adverse consequences. The care plan directed staff to monitor for adverse side effects such as drowsiness, tiredness, dizziness, weakness, dry mouth, diarrhea, nausea, and change in appetite and to report as necessary. The Physician Order, dated 10/02/23, directed staff to administer lorazepam (antianxiety medication) 0.5 milligrams (mg) by mouth every 12 hours as needed (PRN) anxiety or agitation. The order lacked a stop date. The Progress Note, dated 09/30/23 at 10:56 AM, documented R8 was very anxious and continuously looked for her daughter. R8 was tearful about money and family members; the staff called hospice to get lorazepam ordered. R8's EMR lacked a specified duration with rationale for the PRN lorazepam. On 02/01/24 at 12:23 PM observation revealed R8 in the dining room. The staff brought her meal to the table. R8 was very appreciative and excited about the hamburger. On 02/05/34 at 10:34 AM, Licensed Nurse (LN) G reported R8 was confused and did not remember her children had passed away. LN stated that R8 could be very verbal. LN stated she had not administered lorazepam to R8 on her shifts. On 02/05/23 at 01:00 PM, Administrative Nurse D verified R8's lorazepam order lacked a 14-day stop date and evaluation to continue PRN use. The facility's Psychotropic Medications policy, dated 12/06/23, documented to evaluate behavior interventions and alternatives before using psychotropic medications and to eliminate unnecessary psychotropic medications. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug used in excessive doses including duplicate drug therapy, for excessive duration, without adequate monitoring, without adequate indications for use, and in the presence of adverse consequences that indicate the dose should be reduced or discontinued and a combination of the previous described of the reasons. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document the rationale in the resident's medical record and indicate the duration of the PRN order. The facility failed to ensure R8 had a stop date for the use of PRN lorazepam which placed the resident at risk of receiving unnecessary psychotropic medication. - R9's Electronic Medical Record (EMR) documented R9 had diagnoses of cognitive communication deficit, disturbance of salivary secretions, generalized muscle weakness, Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) disease, vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), moderate with psychotic (severe mental disorder that cause abnormal thinking and perceptions) disturbance. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R9 had severe cognitive impairment, inattention behavior which fluctuated, no psychosis (any major mental disorder characterized by gross impairment in reality perception), and wandering behavior which occurred four to six days of the look back period. The MDS further documented R9 received an antipsychotic on a routine basis only, a gradual dose reduction (GDR) attempt on 08/31/23, and no physician documentation of GDR as clinically contraindicated. The Behavioral Symptoms Care Area Assessment (CAA), dated 08/28/23, documented R9 had Alzheimer's disease, was observed to display short- and long-term memory impairment, disorientation, speech is often confused and jumbled, and was rarely or never understood. R9's Care Plan, dated 12/18/23, documented R9 used psychopharmacological medication related to the dementia process evidenced by the use of Seroquel (a class of medications used to treat major mental conditions that cause a break from reality). The care plan directed staff to provide the following sleep encouragement techniques: limit caffeine intake after morning time, decrease the noise level in the evenings, provide lighting that is conducive to sleep, regular bedtime routine, maximize daily activities, and encourage socialization. The care plan continued to direct staff to attempt non-medication approaches which were not specified. The Physician Order, dated 09/01/23, directed staff to administer Seroquel 12.5 milligrams (mg) by mouth one time a day related to vascular dementia, moderate, with psychotic disturbance. The Consultant Pharmacist Review, dated 04/03/23, documented the use of Seroquel, an antipsychotic for other than schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), Huntington's diseases (rare abnormal hereditary condition characterized by progressive mental deterioration, a disabling central nervous system movement disorder), or Tourette's (condition of the nervous syndrome causing uncontrollable repetitive movements or unwanted sounds) is discouraged and can lead to a reduced star rating and fines for the facility. Antipsychotics for the behavior of dementia show a 35 percent (%) increase in mortality and a 50% increase in hospitalization s. Periodic review is needed due to the Boxed Warning (BBW- highest safety-related warning that medications can have assigned by the Food and Drug Administration) for sudden death and the risk of elevated lipids (fatty acids in the blood), glucose (blood sugar), extrapyramidal ( EPS-movement disorders as a result of taking certain medications), seizures (violent involuntary series of contractions of a group of muscles), stroke, pneumonia (inflammation of the lungs), falls, and leg or lung blood clots. For the behavior of dementia, results may be not better than a placebo. Guidelines advise limiting antipsychotic use to residents who present a danger to themselves or others or show persistent inconsolable distress. The Consultant Pharmacist Review, dated 01/03/24, documented the same concern as on 04/03/23. The physician's response dated 01/10/24 documented no change, the medication remained effective and without significant side effects. R9's clinical record lacked evidence of documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefit for the continued use of R9's Seroquel. On 02/05/24 at 10:34 AM Licensed Nurse G stated she was aware of the approved diagnoses for the use of R9's Seroquel use. On 02/05/24 at 01:00 PM, Administrative Nurse D verified the diagnosis of R9's dementia for Seroquel use was not appropriate. The facility's Psychotropic Medications policy, dated 12/06/23, documented to evaluate behavior interventions and alternatives before using psychotropic medications and to eliminate unnecessary psychotropic medications. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug used in excessive doses including duplicate drug therapy, for excessive duration, without adequate monitoring, without adequate indications for use, and in the presence of adverse consequences that indicate the dose should be reduced or discontinued and a combination of the previous described of the reasons. Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. The facility failed to ensure an approved indication or the required physician documentation for R9's use of Seroquel, which placed the resident at risk of receiving unnecessary psychotropic medication. - R19's Electronic Medical Record (EMR) documented diagnoses of pain, malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of left female breast, degenerative disease of nervous system, repeated falls, generalized anxiety(mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, major depressive disorder (major mood disorder which causes persistent feelings pf sadness), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), need for assistance personal care, dementia (progressive mental disorder characterized by failing memory, confusion), severe with psychotic (any major mental disorder characterized by a gross impairment in reality perception) disturbance, Alzheimer's (progressive mental deterioration characterized by confusion and memory failure) disease with early onset, and visual hallucinations (sensing things while awake that appear to be real, but the mind created) and auditory hallucinations. The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R19 had moderate cognitive impairment, and exhibited no signs or symptoms of delirium (sudden severe confusion, disorientation, and restlessness)or psychosis (any major mental disorder characterized by gross impairment in reality perception) and exhibited no behaviors. R19 required partial/moderate assistance with most activities of daily living. The MDS further documented R19 received scheduled and as-needed pain medication, an antipsychotic (class of medications used to treat major mental conditions that cause a break from reality), antianxiety (class of medications that calm and relax people), an antidepressant (class of medications used to treat mood disorders). Antipsychotics were received on a routine basis only, with a gradual dose reduction (GDR) on 09/12/23 and the physician had not documented a GDR as contraindicated. The Psychotropic Drug Use Care Area Assessment (CAA), dated 10/23/23, documented R19 was prescribed an antidepressant secondary to the diagnosis of depression, an antipsychotic secondary to delusions and hallucinations, and an antianxiety medication secondary to the diagnosis of anxiety. Nursing staff were to monitor closely for adverse effects. R19's Care Plan, dated 01/16/24, documented R19 had impaired cognitive function and/or impaired thought processes related to occasional confusion, memory impairment, hallucinations, and delusions impairment secondary to a diagnosis of dementia. The plan directed staff to monitor, document, and report to the health care provider any changes in cognitive function, specifically changes in decision-making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. R19's electronic Treatment Administration Record, (TAR) with a start date of 02/20/23, instructed staff to write progress notes to explain if R19 had signs or symptoms of depression, nightmares, or insomnia (inability to sleep) two times a day related to major depressive disorder. R19's January 2024 TAR record lacked documentation of behavior monitoring on morning medication passes on January 10, 11, 14, 16, 18, 21, 22, 23, 27 and 31. The bedtime medication pass lacked documentation of monitoring on January 20. On 02/05/24 at 01:00 PM, Administrative Nurse D stated monitoring for psychotropic drug use should be completed. The facility's Psychotropic Medications policy, dated 12/06/23, documented to evaluate behavior interventions and alternatives before using psychotropic medications and to eliminate unnecessary psychotropic medications. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug used in excessive doses including duplicate drug therapy, for excessive duration, without adequate monitoring, without adequate indications for use, and in the presence of adverse consequences that indicate the dose should be reduced or discontinued and a combination of the previous described of the reasons. Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. While the use of PRN psychotropic medications is not encouraged, if a prn physician's order is received, ensure that the order has clear parameters, ie., severe agitation that does not respond to the other care plan interventions. It is important to initiate other care plan interventions before the use of PRN psychotropic medications. If the attending physician or prescribing practitioner believes that it is appropriate for the prn order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the prn order. The facility failed to complete behavior documentation related to the use of three psychotropic medications which placed R19 at risk of receiving unnecessary psychotropic medications.

The facility had a census of 43 residents. The sample included 14 residents, with three reviewed for nutrition. Based on observation, record review, and interview the facility failed to provide the correct physician ordered nutritional supplement for Resident (R)34, who had a significant unplanned weight loss. The facility failed to notify the Registered Dietician and/or physician when R34 continued to decline an ordered nutritional supplement. The facility further failed to identify and implement additional interventions to prevent weight loss, which included the resident's preferred meals and snacks and failed to attempt to fortify routinely consumed food items. These deficient practices placed R34, who had a significant loss of 15.54 percent in 30 days at continued risk for unintentional weight loss, malnutrition, and related complications. Findings included: -The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] recorded R34 had a Brief Interview for Mental status (BIMS) score of 14, which indicated intact cognition. She required extensive assistance of one to two staff with all activities of daily living (ADLs) except eating, for which she was identified as independent. The MDS recorded R34 had no swallowing issues and weighed 150 pounds (lbs.). The Quarterly MDS dated [DATE] documented the resident had moderate cognitive impairment, required extensive assistance of one staff for activities of daily living, had pain, and received routine and as needed pain medication. R34 weighed 131 lbs., was 64 inches tall, and had weight loss while on a physician prescribed weight loss regimen. The MDS further documented R34 had pressure ulcers and received antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression- abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), anticoagulant (medication that prolongs clotting time), and opioid (a substance used to treat moderate to severe pain) medications. The Nutritional Status Care Area Assessment (CAA), dated 01/17/22, documented R34 had poor oral intake and suffered from several pressure ulcers, which were present on admission. R34 was currently prescribed liquid protein, and a multivitamin due to skin issues and a heart healthy diet related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Care Plan revised on 07/18/22, documented R34 had unplanned weight loss related to decreased appetite related to pain. The care plan directed staff to weigh R34 weekly, offer snacks and meals that R34 preferred, review overall meal plan with the resident/family, and adjust goals and interventions to meet the resident's preferences and weight goals. The care plan recorded an intervention initiated on 01/04/22, revised on 07/18/22, which directed staff to know the resident was on a heart healthy diet and was able to feed herself. She benefited from Boost pudding twice daily and Boost Breeze twice daily. Staff were to encourage adequate fluid and food intake. The care plan lacked mention of R34's food preferences and/or preferred snacks. The Physician Order, dated 01/04/22, directed staff to provide a heart healthy diet. The Physician Order, dated 04/07/22, directed staff to give Boost Pudding (a nutritional supplement high in calories and protein) two times a day for supplement. The Nutritional Status Progress Note, dated 05/27/22, documented R34 weighed 154.4 lbs., which showed a loss of 5.2 percent (%) since 04/26/22, and weight loss related to fluid shifts. Resident continued treatment to right heel and buttock. She received liquid protein, a multivitamin, and vitamin C daily to promote healing. Diet was to be heart healthy with a Boost pudding twice a day to increase calories and prevent further weight loss. Staff were to monitor weight trends, intake, and skin integrity. Refer to RD as needed. R34's EMR recorded a weight of 154.4 lbs. on 06/01/22. R34's EMR recorded a weight of 131.8 lbs. on 06/20/22 which represented a 22.6 lbs. (14.64 %) loss in 20 days. The Nutritional Status Progress Note, dated 06/24/22, documented R34's weight was 131 lbs., which showed a significant weight loss of 14% in two weeks. Resident continued treatment to right heel and buttocks. She received liquid protein, a multivitamin, and vitamin C daily to promote healing. Diet remained heart healthy with Boost pudding twice a day. Intake was variable. Recommended Boost Breeze twice a day to increase calories and prevent further weight loss. Monitor weight trends, intake, and skin integrity and referred to RD as needed. On 06/28/22 a Progress Note documented staff sent a fax to the resident's physician regarding dietician recommendations. The Physician Order, dated 06/30/22, directed staff to give juice-enhanced (Boost Breeze) two times a day for supplement. This order was discontinued on 07/21/22. R34's EMR recorded a weight of 130.4 lbs. on 07/05/22, which represented a 15.54 % loss in one month. On 07/22/22 The Nutritional Status Progress Note, dated 07/22/22, documented R34 weighed 131 lbs., which was a 15.8% weight loss since 06/13/22, 18.5% loss since 04/19, and a loss of 12% since 01/21/22. She received treatment to area on buttocks. She received liquid protein, a multivitamin, and vitamin C daily to promote healing. Diet was heart healthy, Boost pudding and Boost Breeze twice a day, but Boost Breeze had been discontinued due to R34 refusal. Continue current dietary plan, monitor weight trends, intake, and skin integrity. Refer to RD as needed. Review of the intake records in R44's EMR revealed during the month of June 2022 R34 refused the morning Boost pudding five times and the evening Boost pudding five times. The supplement was recorded as not applicable (NA) six times. The July 2022 intake record for the Boost pudding revealed R34 refused the morning supplement seven times, and nine opportunities were recorded as NA. R42 refused the evening supplement 22 times and three opportunities were recorded as NA. The August 2022 (08/01/22-08/09/22) intake record revealed R34 refused the morning supplement one time, and the supplement was recorded NA on four occasions. The evening supplement was refused five times and recorded as NA on one occasion. On 08/08/22 at 12:00 PM R34 sat in the dining room in her wheelchair at a large table with other women. She had chicken noodle soup, French fries, and cooked carrots. She ate her soup slowly, but independently . On 08/10/22 at 08:36 AM, observation revealed staff taking R32's breakfast into the resident's room. The resident was awake with the head of the bed elevated and watching the TV. Meal tray consisted of one egg, one banana, one slice of toast, half a long john doughnut, a cup of coffee and Boost Breeze. On 08/09/22 at 02:00 PM Licensed nurse (LN) H reported R34 received supplements. LN H said she was unsure about R34's weight situation. On 08/10/22 at 08:47 AM Administrative Nurse E stated it was the nursing staff who were to provide the physician ordered supplement to the resident. She stated she noticed while passing the breakfast tray on 08/09/22 R34 had Boost Breeze on the breakfast tray, but the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrative Nurse E stated the dietary staff must have provided the Boost Breeze on R32's breakfast tray because the resident ate breakfast in her room. Administrative Nurse E stated when staff chart NA it meant either the resident was not available, or the boost was not available. On 08/12/22 at 08:42 AM Consultant RD stated she was not aware R34 refused the Boost pudding supplement. She reported she would have continued to try other interventions to supplement R34's intake. She stated she expected facility staff to inform her with monitoring results for R34, including intake and refusals. Consultant RD stated the dietary manager was new and Consultant RD continued to work with the facility kitchen/dietary staff to address any resident concerns. On 08/12/22 at 08:42 AM Consultant RD stated the facility would continue to implement interventions as needed. She said the facility staff informed her R34 ate mostly noodle soup, but had recently started ordering more off the menu. The facility's Identifying Residents With Impaired Nutritional Status and Nutritional Risk policy, dated 05/31/22, recorded residents with impaired nutritional status or risk may be identified by nursing, food and nutrition services and other healthcare professionals by using the EMR weights, food and fluid intake, reports, mealtime observations and other pertinent information. The policy documented those at risk may include pressure ulcers or wounds, significant weight loss/gain (5% in 30 days, 7.5% in 90 days, 10% in 180 days), unplanned weight loss/gain, decline in food/fluid intake. The facility failed to provide the correct physician ordered nutritional supplement for R34, who had a significant unplanned weight loss. The facility failed to notify the RD and physician when R34'd routinely declined the ordered supplement. The facility further failed to identify and implement additional interventions to prevent weight loss which included the resident's preferred meals and snacks and failed to attempt to fortify routinely consumed food items. These deficient practices placed R34, who had a significant loss of 15.54 % in one month (36 days) at continued risk for unintentional weight loss, malnutrition, and related complications.

The facility had a census of 43 residents. The sample included 14 residents. Based on observation, record review, and interview, the facility failed to identify causative factors and implement resident-centered interventions to prevent falls for Resident (R) 30 and R14 who had falls which resulted in fractures, and R2, R36, R40 , and R42 who had multiple falls. Findings included: - The Medical Diagnosis section within R30's Electronic Medical Record (EMR) included diagnoses of history of falling, [CONDITION(S)] (long-term, progressive disease of the lungs characterized by shortness of breath), age-related physical debility, wedge compression fracture of second lumbar vertebra, history of [CONDITION(S)] (TIA-mini stroke), muscle weakness, pain, difficulty in walking, [CONDITION(S)] (progressive deterioration of the retina) and [CONDITION(S)], nondisplaced fracture of greater trochanter of left femur (thigh bone) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R30 had intact cognition, exhibited no behaviors, requires supervision of one staff member for most activities of daily living (ADLs), was not steady and only able to stabilize with staff assistance with balance during transition and walking. The MDS documented R30 was occasionally incontinent of bladder and had a condition or chronic disease that may result in a life expectancy of less than six months. The MDS further documented one non injury fall. The Fall Care Area Assessment (CAA), dated 07/11/22, documented R30 required supervision with transfers and ambulation, but would often refuse to call staff for assistance or utilize her front wheeled walker even with staff encouragement. She was working with physical and occupational therapy and discharged from services on 06/28/22. Staff checked on R30 frequently. The Fall Care Plan initiated 03/22/21, documented R30 had an actual fall with injury .The care plan directed staff to monitor R20 for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity function and check orthostatic blood pressure changes and manage predisposing conditions. The Care Plan listed the following interventions: On 06/24/21 intervention initiated which directed staff to remind R30 about how to manage oxygen tubing to help reduce or prevent falls. On 12/10/21 intervention initiated which directed staff to educate R30/family/interdisciplinary team (IDT) as to causes of falls and encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. On 12/21/21 intervention initiated which directed staff to educate R30/family about safety reminders and what to do if a fall occurs. On 05/18/22 intervention initiated which directed staff to ensure resident was wearing appropriate footwear non-slip socks or slippers at all times. On 05/20/22 intervention initiated which directed staff to offer the resident a snack after lunch. On 06/05/22 intervention initiated which directed staff to minimize the potential for falls the staff to check R30's water jug in her room. The Progress Notes recorded the following falls: 10/24/21 at 04:30 PM R30 reported she had fell to the floor landing on her knees and crawled to the recliner to pull herself up, then walked over to her bed. No investigation provided upon request. The care plan lacked new intervention to prevent to prevent further falls. 11/08/21 at 01:39 AM R30 lost her balance and fell which was witness by a Certified Nurse Aide (CNA). Resident had skin tears to left arm and told the nurse she hit the grab bar when she had fallen an hour before in her bathroom (first fall on that date) but did not want to tell anyone. Investigation initiated and intervention to instruct and modify environment, and potentially tangled in the tubing from the oxygen. 12/07/21 R30 self-reported a fall, had dark bruises to left forearm and both hands. Investigation initiated. The care plan lacked new intervention to prevent further falls. 12/27/21 at 07:10 PM R30 reported to a CNA, she had fallen and hurt herself. Nurse documented bruising to the pad of her hands below and up to her thumbs on both hands. The right thumb looked out of place/possibly dislocated. She had two skin tears to her left forearm. R30 reported both areas were painful, and she hit her head on the door frame. Staff observed a small bump to top of R30's skull, and R30 also reported pain in the left great toe. R30 was sent to the emergency room . No investigation provided upon request. The care plan lacked new intervention to prevent further falls. 05/15/22 at 02:56 PM staff found R30 on the floor in the hallway. She had a skin tear to her left shin, abrasion to left knee and complained of pain to her left hip. Resident sent to the emergency room for evaluation. 05/15/22 at 04:49 PM R30 returned from the emergency department. The x-ray impression documented a right and left inferior ramus (pubic bone) fractures. Investigation initiated 0n 05/20/22 and care plan updated with intervention to offer snack after lunch. 07/01/22 at 10:03 PM, R30 sat on her buttocks in front of commode. She reported her legs gave out. The note further documented the bedside commode was removed from the room to encourage increased use of call light. Investigation initiated. The care plan lacked new intervention to prevent further falls 07/11/22 at 03:50 AM R30 found sitting on the floor. Reported she was going to sit on the commode, but commode had been removed. R30 complained of pain in right arm and buttocks. Note documented significant skin tear to right forearm. Investigation initiated and suggested returning commode to the room. This was not reflected on the care plan. 07/13/22 at 08:35 PM R30 on the floor in front of door. R30 reported she was on her way back from the bathroom and her legs gave out. The note documented the bathroom light was not functioning at that time. Investigation initiated. The care plan lacked intervention to prevent further falls. 07/20/22 at 07:25 PM R30 observed on the floor in her room. Investigation initiated and suggested the resident to be moved to be closer to the nurse and nurse aide station. The care plan did not reflect the suggestion nor interventions to prevent further falls. 07/26/22 at 01:23 PM R30 observed kneeling beside her bed. Investigation initiated. The care plan lacked intervention to prevent further falls. 07/26/22 at 06:41 PM R30 found transferring self to commode. R30 was half on commode and hanging onto the bed. Resident had right elbow skin tear and right lower leg skin tear. No investigation provided upon request. The care plan lacked intervention to prevent further falls. On 08/10/22 at 08:20 AM observation revealed in bed, wearing oxygen tubing via nasal cannula. The oxygen machine along the wall at the foot of her bed. A bedside commode was placed at the foot end of her bed. The lights were off, and she had her eyes closed. The walker was placed near the door of the room, not within reaching distance from the bed. On 08/09/22 at 01:43 PM Licensed Nurse (LN) H reported when a resident fell the staff were to do an investigation called a Fall Huddle to determine a root cause, then the incident is documented into the EMR and an intervention placed to prevent falls are to be placed there and it carries over to the care plan. The MDS nurse then will check the care plan to ensure updates current. On 08/10/22 at 02:13 PM Administrative Nurse E verified the nursing staff on duty initiated an investigation and are to place a new intervention in the risk management EMR to prevent further falls. Falls are discussed at the daily meeting, then she reviews the care plan to update as needed. On 08/10/22 at 04:14 PM Administrative Nurse D stated with each fall a new and appropriate intervention should be immediately be implemented and the care plan should reflect the intervention. The facility's Fall Prevention and Management, policy dated 03/30/22, documented a root cause analysis is completed from the Fall Huddle to review identifying the cause of a problem so that the best solution can be identified and put into place. Staff to continue to monitor effectiveness of the interventions. The facility failed to investigate causative factors for repeated falls and identify and implement interventions for R30 who had multiple falls including falls with major injury. This placed R30 at ongoing risk for fall related injury. - The Electronic Medical Record (EMR) for R14 recorded diagnoses of [CONDITION(S)] disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), [CONDITION(S)] (swelling resulting from an excessive accumulation of fluid in the body's tissue) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R14 had severely impaired cognition and required limited assistance of one staff for transfers, toileting, and personal hygiene. The MDS documented R14 had unsteady balance, no functional impairment, and had two or more non injury falls. The Fall Care Area Assessment (CAA), dated 08/30/21, documented R14 had falls prior to admission, self-transferred often, and did not ask for assistance. The Fall Risk Assessments, dated 05/22/22, 06/21/22, and 07/08/22, documented the resident a high risk for falls. The Fall Care Plan, dated 06/22/22, initiated on 08/24/21, directed staff to ensure bed was lowered to lowest position while in bed, ensure her walker was placed next to the bed while the resident was lying down, ensure R14 wore non-skid socks when ambulating, and place a soft mat at bedside while in bed every shift. The update, dated 09/02/21, directed staff to provide a scoop mattress and floor mat alarm per family and R14's request to help reduce fall risk. The Fall Investigation, dated 11/15/21 at 08:40 AM, documented R14 had attempted to dress herself, had non grip socks on, and her walker was not near her. The investigation further documented R14's fall mat was not in use The Nurse's Note, dated 11/15/21 at 07:26 PM, documented staff found R14 on the floor beside her bed with both hands behind her back holding herself in a sitting position. The resident wore a bra, sweater, an incontinence brief, and her socks. The resident was crying out that her shoulder hurt. The resident was assessed, and staff lifted her off the floor with the full mechanical lift and two nurses. The note documented R14 was taken to the hospital emergency room . The X-ray (creates pictures of the inside of your body) Report, date 11/15/21, documented R14 had an acute mildly inferiorly displaced fracture (broken) of the distal clavicle (collarbone) The Physician's Order, dated 11/16/21, directed staff to keep R14's arm at her side to bathe, wear a sling ( a device to limit movement of the shoulder or elbow while it heals) for comfort, and follow-up in six weeks. On 08/09/21 at 10:13 AM, observation revealed R14 sat in her wheelchair in the living room area. Further observation revealed Certified Nurse Aide (CNA) N placed a gait belt around the resident's wait, placed a walker in front of her, and assisted R14 to stand up to ambulate. R14's balance was steady, and she was able to ambulate a few steps with CNA N holding onto her gait belt. On 08/09/22 at 10:13 AM, CNA N stated R14 was usually in the living room area for staff to keep an eye on her because she tries to stand up and she would fall. CNA N further stated she has an alarmed mat that was to be kept beside her bed. On 08/10/22 at 02:53 PM, Licensed Nurse (LN) J verified she had been the nurse at the time of the fall and the fall mat was not in place beside R14's bed. On 08/10/22 at 03:44 PM, Administrative Nurse D stated she expected staff to implement fall interventions and to follow the interventions that were on the care plan. The facility's Fall Prevention and Management policy, dated 03/30/33, documented the facility used a proactive approach before a fall occurred and care planned the appropriate interventions. The policy further documented for a fall prevention and management program to be successful, must be accountability from the leadership and caregivers to assist in creating an effective fall prevention and management program with positive outcomes. The facility failed to follow cognitively impaired R14's care plan as a result of this deficient practice, R14 fell , and sustained a fractured clavicle. - The Electronic Medical Record (EMR) documented R36 had diagnoses of [CONDITION(S)] disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), [CONDITION(S)] (swelling resulting from an excessive accumulation of fluid in the body's tissue), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). The Annual Minimum Data Set (MDS), dated [DATE], documented R36 had intact cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, and toileting. The MDS further documented R14 had unsteady balance, upper functional impairment on one side, and had one non injury fall. The Quarterly MDS, dated [DATE], documented R36 had intact cognition and required extensive assistance of two staff for bed mobility, transfers, dressing, and extensive assistance of one staff for toileting. The MDS further documented R36 had unsteady balance, upper functional impairment on both sides, and had two or more falls without injury. The Fall Assessments, dated 03/22/22, 04/15/22, 05/24/22, 06/01/22, and 08/02/22 documented a high risk for falls. The Fall Care Plan, dated 07/18/22, initiated on 04/07/22, directed staff to assist R36 with getting ready for bed and ensure she approved of her clothing, monitor her for significant changes in gait, mobility, and positioning devices, provide a soft touch call light while in bed or chair to alert staff if she attempted to transfer, ambulate without assistance, and ensure R36 wore appropriate footwear when ambulating. The update, dated 06/02/22, directed staff to avoid clothing that is a fall risk. The Investigation Report, dated 03/22/22 at 06:30 AM, documented R36 had an unwitnessed, non-injury fall in her room while trying to take a walker out of her room. The investigation documented staff observed the resident seated on the floor with her back against her dresser. The clinical record lacked evidence of a resident centered intervention was put into place to prevent further falls. The Nurse's Note, dated 06/01/22 at 08:45 PM, documented the resident was found seated on the floor by her bedside table, with her pants down around her knees and no footwear in place. The Certified Nurse Aide (CNA) reported she had been in the room and assisted the resident with her top but had gotten called away before she had completed R36's bedtime cares. The note further documented R36 had a slightly reddened area approximately 1-inch x 5 inch at the spine, skin intact, and no other injury. The resident was assessed for other injuries and would continue to monitor her. The Fall Scene Huddle, dated 06/01/22 at 08:45 PM, documented staff started to assist R36 with getting ready for bed. The staff assisted her with her top and left to go to another resident room. The huddle further documented R36 removed her shoes and fell while trying to remove her pants. On 08/09/22 at 09:35 AM, observation revealed R36 sat in her recliner with her pants at her ankles, and stated, the water is coming! Further observation revealed CNA O placed a gait belt around the resident's waist and assisted the resident to stand so she could pull up the resident's pants and take her to the bathroom. Continued observation revealed R36 ambulated slowly to the bathroom and was assisted on to the toilet. On 08/09/22 at 09:35 AM, CNA O stated R36 was a one person assist with transfers, often tried to stand up on her own and would fall. CNA O further stated staff check on her a lot to make sure she is not trying to walk by herself. On 08/10/22 at 09:35 AM, Licensed Nurse (LN) I stated R36 was a high fall risk and staff check on her when they go up and down the hall as the resident would stand up unassisted and used her furniture as a device to walk around her room. On 08/10/22 at 03:55 PM, Administrative Nurse D stated the resident was a high risk for falls and staff should not have left her alone during cares. The facility's Fall Prevention and Management policy, dated 03/30/33, documented the facility used a proactive approach before a fall occurred and care planned the appropriate interventions. The policy further documented for a fall prevention and management program to be successful, must be accountability from the leadership and caregivers to assist in creating an effective fall prevention and management program with positive outcomes. The facility failed to follow R36's care plan for falls and failed to implement resident centered interventions for falls placing the resident at risk for further falls. - The Electronic Medical Record (EMR) for R40 documented diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and [CONDITION(S)] (failure of the veins to adequately circulate the blood). The Admission Minimum Data Set (MDS), dated [DATE], documented R40 had long and short term memory problems with moderately impaired decision making skills and required extensive assistance of two staff for bed mobility, transfers, toileting, and extensive assistance of one staff for dressing and personal hygiene. The MDS further documented R40 had unsteady balance, had no functional impairment, and had one fall since admission. The Fall Assessments, dated 06/06/22 and 07/02/22 documented R40 a high risk for falls. The Fall Care Plan, dated 08/07/22, initiated on 06/10/22, directed staff to encourage participation and plan diversion activities such as busy blanket, help staff fold laundry, listen to music, and 1:1 socializing with staff, a soft touch call light used to alert staff to resident's movement. The update, dated 07/12/22, directed staff to take the resident on a wheelchair stroll inside or outside if she is restless to help her feel she can move around, as she is unsafe to get up on her own. The update, dated 08/07/22 directed staff to move the resident to bed A with the bed against the wall with her concave (scooped) mattress and fall mat in place on the open side of the bed, and keep a dim light on her side of the room. The Fall Scene Huddle, dated 07/08/22, documented R40 was in the living room area as she waited to be taken to bed. The resident was told multiple times by several staff to remain seated in her chair. The huddle further documented Dietary Staff CC passed by the resident on her way to clock out to go home and reminded her to stay seated in her wheelchair. The huddle documented Dietary Staff CC passed by the resident again and reminded R40 to stay seated and as the resident tried to sit back down in the wheelchair, she did not get on the seat completely and slid onto the floor. The resident received a skin tear to her right elbow which measured 3 centimeters (cm) x 4.5 cm. The Fall Scene Huddle, dated 08/07/22, documented R40 was found on the floor in her room and had slid between the bed and wall at the window. The huddle further documented R40 obtained a small skin tear to the back of her right hand that measured 3 cm x 0.1 cm, and bandage closures were applied. On 08/09/22 at 10:17 AM, observation revealed a fall mat beside R40's bed and a soft touch call light lying on her bed. Further observation revealed R40 had bilateral arm protectors on and sat on the side of the bed. Continued observation revealed CNA O placed a gait belt around R40's waist and assisted the resident to stand, pivot turn, and sat her into her wheelchair. On 08/10/22 at 08:30 AM, observation revealed R40 sat in her roommate's recliner and stated she had walked there all by herself. On 08/09/22 at 10:17 AM, CNA O stated R40 was one of the highest risks for falls, and she liked to get up by herself and fall. On 08/10/22 at 11:50 AM, Licensed Nurse (LN) I stated R40 loved to listen to music and staff involve her in activities. R40 had a fall mat, scooped mattress and a fidget blanket (a sensory and therapy blanket for residents who have dementia) to help prevent falls. On 08/10/22 at 03:55 PM, Administrative Nurse D stated staff should have tried other interventions instead of just telling R40 to sit down. The facility's Fall Prevention and Management policy, dated 03/30/33, documented the facility used a proactive approach before a fall occurred and care planned the appropriate interventions. The policy further documented for a fall prevention and management program to be successful, must be accountability from the leadership and caregivers to assist in creating an effective fall prevention and management program with positive outcomes. The facility failed to implement interventions for fall prevention for cognitively impaired R40, placing her at risk for further falls. - The Electronic Medical Record (EMR) for R42 documented had diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and difficulty walking (a change in normal walking pattern). The Admission Minimum Data Set (MDS), dated [DATE], documented R42 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and the resident did not ambulate. The MDS further documented R42 had unsteady balance, lower functional impairment on both sides, and had a fracture prior to admission. The Quarterly MDS, dated [DATE], documented, R42 had severely impaired cognition and required extensive assistance of twos staff for bed mobility, transfers, and extensive assistance of one staff for dressing, toileting, and personal hygiene. The MDS further documented R42 had unsteady balance, had lower functional impairment on one side, and had one non injury fall. The Fall Assessments, dated 05/12/22 documented R42 a high risk for falls and 06/22/22, and 08/04/22 documented R42 a medium risk for falls. The Activities of Daily Living (ADLs) Care Plan, documented an intervention initiated on 04/21/22 which directed R42 required extensive assistance of two staff for transfers and ensure proper use of gait belt. The Fall Care Plan, dated 07/26/22, initiated on 05/13/22, directed staff to ensure R42 wore appropriate footwear (slip resistant shoes) when ambulating or mobilizing in her wheelchair and wore gripper socks when in bed. The update, dated 06/22/22, directed staff to ensure a gait belt was used during transfers. The Fall Scene Huddle, dated 06/22/22 at 06:10 PM, documented R42 was lowered to the floor during a transfer after her knees buckled and she lost her balance. The huddle further documented the resident did not have on a gait belt at the time of transfer and R42 did not receive an injury. The Fall Scene Huddle, dated 08/04/22 at 07:25 AM, documented R42 was lowered to the bathroom floor during a transfer after she was unable to pivot or lift her feet. The huddle further documented the resident did not have on a gait belt at the time of transfer and R42 did not receive an injury. On 08/09/22 at 09:00 AM, observation revealed, CNA N placed a gait belt around the resident's waist and placed a transfer disk on the floor in front of the resident. CNA N told the resident to lean forward and use her hands to push off the arms of the wheelchair. CNA N and CNA O each took one arm of the resident, placed their hands under the resident's arms and tried to assist the resident to stand. R42 had a hard time standing but the CNA's were about to stand her up and pivot into the recliner. On 08/09/22 at 09:00 AM, CNA N stated the resident came into the facility with a cam boot (a medical device worn to immobilize and for weight bearing for injuries to the foot), it was awkward and the resident would trip over it and fall. CNA N further stated R42 did not try to get up by herself anymore and staff always should use a gait belt while transferring her because she is a difficult transfer. On 08/10/22 at 12:15 PM, Licensed Nurse (LN) I stated R42 does not get up by herself anymore and that the last fall she had, staff had to lower her to the floor. LN I further stated she thought staff used a gait belt during that fall but was not sure. On 08/10/22 at 03:55 PM Administrative Nurse D stated she expected staff to follow the care plan and use a gait belt during transfers of a resident. On 08/10/22 at 05:42 PM, CNA M stated she had received training for neglect and would consider neglect as not honoring requests, not listening to the resident, not using gait belts during transfers, not answering the call light, and not providing good care. The facility's Abuse and Neglect policy, dated 03/31/22, documented the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The abuse/neglect policies and procedures cannot and do not guarantee that abuse will never occur. To prevent such occupancies, all reasonable measures within our control would be taken. The facility failed to ensure staff used a gait belt during transfers resulting in two falls. This deficient practice placed the resident at risk for injury.

The facility had a census of 43 residents. The sample included 14 residents, with eight reviewed for falls. Based on observation, record review, and interview, the facility failed to update interventions on the care plan to prevent falls for Resident (R) R2, and R30. This deficient practice placed the residents at increased risk for fall related injuries due to uncommunicated care needs. Findings included: -The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Minimum Data Set (MDS), dated [DATE], documented the R2 had intact cognition, exhibited no behaviors, required extensive assistance of one to two staff for activities of daily living, was not steady and only able to stabilize with staff assistance with surface to surface transfers. The MDS documented R2 always incontinent of bladder and bowel with no urinary toilet program and had two or more falls with no injuries and two or more falls with injury. The MDS further documented R2 had a condition or chronic disease that may result in life an expectancy of less than six months. The Fall Care Area Assessment (CAA), dated 05/12/22, documented R2 required extensive to total support with all Activities of Daily Living (ADLs) but was able to feed himself. R2 was alert to self, staff anticipated needs due to fluctuating cognitive status. R2admitted to hospice services with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The Fall Care Plan initiated 01/03/22, documented R2 had an actual fall with minor injury. The care plan directed staff to lay the resident down when he showed signs of lethargy (state of sleepiness or deep unresponsiveness and inactivity) and fatigue; keep R2 in visible/community areas in the late evening when he wanted to stay up in order for more staff to visualize his attempts to transfer self. The Progress Notes recorded the following falls. 12/29/21 at 01:15 PM resident fell on to the floor out of his wheelchair. R2 was to be lifted into his bed for a nap but toppled out the front of the wheelchair. R2 had minor carpet burn to left forehead and reported his nose hurt. Investigation initiated and on 01/03/22 Care Plan intervention to lay R2 down if lethargic. 01/05/22 at 03:04 PM resident returned to the facility via wheelchair pushed by staff when he slid out of the wheelchair onto the foot pedals, when going over the door transition piece. The note documented R2 worked with therapy for a new wheelchair with better positioning. Investigation signed completed 02/22. The care plan lacked new intervention to prevent falls 02/12/22 R 07:20 PM R2 found on the floor and he reported hitting his head but had no pain. Nursing order to place fall mat next to bed. Investigation initiated and care plan intervention to use of fall mat. 02/28/22 at 07:27 PM R2 found on floor on the fall mat, three staff assisted the resident to bed and bed placed in the lowest position. The note recorded R2's toes to be bandaged. The note did not specify what injury to toes. On 02/28/22 at 07:49 PM R2 found on floor again. Investigation initiated and care plan intervention of resident may prefer to sleep in recliner as suggested by resident's family member. 03/03/22 at 04:53 PM R2 found on floor on fall mat, this incident lacked investigation upon request. The care plan lacked new intervention to prevent further falls. 03/18/22 at 10:00 PM R2 found on sitting on mat on the floor in his room, this incident lacked investigation upon request. The Care plan lacked new intervention to prevent further falls 03/19/22 at 03:17 PM R2 observed sitting on the floor, this incident lacked investigation upon request. The care plan lacked new intervention to prevent further falls. 03/20/22 at 11:00 PM R2 observed lying on fall mat, investigation initiated. The care plan intervention to monitor resident every hour was initiated. 03/23/22 at 08:21 AM R2 observed lying on his right side on the floor. Investigation initiated. The care plan lacked new intervention to prevent further falls. 03/25/22 at 07:38 PM R2 found on floor on fall mat. Investigation initiated. The care plan lacked new intervention to prevent the further falls. 04/08/22 at 06:30 AM staff reported R2 with possible fall the evening prior, but staff no longer on duty for details. R2 reported right arm and head pain. Investigation initiated. The care plan intervention to keep resident visible community areas in the late evening when he wants to stay up to keep him from self-transferring. 05/04/22 at 06:35 PM R2 found on floor in his room, reported his hitting head on the floor and complained of neck pain. Sent to hospital and returned at 10:10 PM. Investigation initiated. The care plan lacked new intervention to prevent further falls. 05/23/22 at 04:14 PM R2 found sitting on fall mat. Investigation initiated. The care plan intervention to use soft touch call light. 05/27/22 at 02:12 PM R2 on fall mat on floor. R2 complained of discomfort to right great toe. Investigation initiated. The care plan intervention to replace fall mat with non-slip mat. On 08/09/22 at 07:58AM observation revealed R2 remained in bed. His bed was in a low position and a mat on the floor next to the bed. On 08/09/22 at 01:43 PM Licensed Nurse (LN) H reported when a resident fell , the staff were to do an investigation called a Fall Huddle to determine a root cause. The incident was documented in the EMR and an intervention to prevent falls was placed there and it carried over to the care plan. The MDS nurse checked the care plan to ensure updates were current. On 08/10/22 at 02:13 PM Administrative Nurse E verified the nursing staff on duty initiated an investigation and are to place a new intervention in the risk management EMR to prevent further falls. Falls were discussed at the daily meeting, then she reviewed the care plan to update as needed. On 08/10/22 at 04:14 PM Administrative Nurse D stated with each fall a new and appropriate intervention should be immediately be implemented and the care plan should reflect the intervention. The facility's Fall Prevention and Management, policy dated 03/30/22, documented a root cause analysis is completed from the Fall Huddle to review identifying the cause of a problem so that the best solution can be identified and put into place. Staff to continue to monitor effectiveness of the interventions. The facility failed update R2's care plan with resident-centered interventions to attempt to prevent falls which placed the resident at risk for further falls and injury. - The Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change Minimum Data Set (MDS), dated [DATE], documented R30 had intact cognition, exhibited no behaviors, requires supervision of one staff member for most activities of daily living (ADLs), was not steady and only able to stabilize with staff assistance with balance during transition and walking. The MDS documented R30 was occasionally incontinent of bladder and had a condition or chronic disease that may result in a life expectancy of less than six months. The MDS further documented one non injury fall. The Fall Care Area Assessment (CAA), dated 07/11/22, documented R30 required supervision with transfers and ambulation, but would often refuse to call staff for assistance or utilize her front wheeled walker even with staff encouragement. She was working with physical and occupational therapy and discharged from services on 06/28/22. Staff checked on R30 frequently. The Fall Care Plan initiated 03/22/21, documented R30 had an actual fall with injury .The care plan directed staff to monitor R20 for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity function and check orthostatic blood pressure changes and manage predisposing conditions. On 06/24/21 intervention initiated directed staff to remind R30 about how to manage oxygen tubing to help reduce or prevent falls. On 12/10/21 intervention initiated directed staff to educate R30/family/Interdisciplinary Team (IDT) as to causes of fall and encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility. On 12/21/21 intervention initiated directed staff to to educate R30/family about safety reminders and what to do if a fall occurs. On 05/18/22 intervention initiated directed staff to ensure resident is wearing appropriate footwear non-slip socks or slippers at all times. On 05/20/22 intervention initiated to offer a snack after lunch. On 06/05/22 intervention directed staff to minimize the potential for falls the staff to check her water jug in room. The Progress Notes recorded the following falls: 10/24/21 at 04:30 PM R30 reported she had fell to the floor landing on her knees and crawled to the recliner to pull herself up, then walked over to her bed. No investigation provided upon request. The care plan lacked new intervention to prevent to prevent further falls. 11/08/21 at 01:39 AM R30 lost her balance and fell which was witness by a Certified Nurse Aide (CNA). Resident had skin tears to left arm and told the nurse she hit the grab bar when she had fallen an hour before in her bathroom (first fall on that date) but did not want to tell anyone. Investigation initiated and intervention to instruct and modify environment, and potentially tangled in the tubing from the oxygen. 12/27/21 at 07:10 PM R30 reported to a CNA, she had fallen and hurt herself. Nurse documented bruising to the pad of her hands below and up to her thumbs on both hands. The right thumb looked out of place/possibly dislocated. She had two skin tears to her left forearm. R30 reported both areas painful and she hit her head on the door frame. A small bump to top of skull, and then also reported pain in left great toe. R30 was sent to the emergency room . No investigation provided upon request . The care plan lacked new intervention to prevent further falls. 05/15/22 at 02:56 PM R30 found on floor in the hallway, skin tear to left shin, abrasion to left knee and complained of pain to left hip. Resident sent to the emergency room for evaluation. 05/15/22 at 04:49 PM R30 returned from the emergency department. The X-Ray impression documented a right and left inferior ramus (pubic bone) fractures. Investigation initiated 0n 05/20/22 and care plan updated with intervention to offer snack after lunch. 06/05/22 at 08:33 PM facility nurse received phone call from R30's family member, reported R30 called and reported she had fell in her room, on the way to the bathroom to get water. Investigation initiated and care plan updated with instructions to check water pitcher every time when in room. 07/01/22 at 10:03 PM, R30 found sitting on her buttock in front of commode. She reported her legs gave out. The note further documented the bedside commode was removed from the room to encourage increased use of call light. Investigation initiated. The care plan lacked new intervention to prevent further falls 07/11/22 at 03:50 AM R30 found sitting on the floor. Reported she was going to sit on the commode, but commode had been removed. R30 complained of pain in right arm and buttocks. Note documented significant skin tear to right forearm. Investigation initiated and suggested returning commode to the room. This was not reflected on the care plan. 07/13/22 at 08:35 PM R30 on the floor in front of door. R30 reported she was on her way back from the bathroom and her legs gave out. The note documented the bathroom light was not functioning at that time. Investigation initiated. The care plan lacked intervention to prevent further falls. 07/20/22 at 07:25 PM R30 observed on the floor in her room. Investigation initiated and suggested the resident to be moved to be closer to the nurse and nurse aide station. The care plan did not reflect the suggestion nor interventions to prevent further falls. 07/26/22 at 01:23 PM R30 observed kneeling beside her bed. Investigation initiated. The care plan lacked intervention to prevent further falls. 07/26/22 at 06:41 PM R30 found transferring self to commode. R30 was half on commode and hanging onto the bed. Resident had right elbow skin tear and right lower leg skin tear. No investigation provided upon request. The care plan lacked intervention to prevent further falls. On 08/10/22 at 08:20 AM observation revealed in bed, wearing oxygen tubing via nasal cannula. The oxygen machine along the wall at the foot of her bed. A bedside commode was placed at the foot end of her bed. The lights were off, and she had her eyes closed. The walker was placed near the door of the room, not within reaching distance from the bed. On 08/09/22 at 01:43 PM Licensed Nurse (LN) H reported when a resident fell the staff were to do an investigation called a Fall Huddle to determine a root cause, then the incident is documented into the EMR and an intervention placed to prevent falls are to be placed there and it carries over to the care plan. The MDS nurse then will check the care plan to ensure updates current. On 08/10/22 at 02:13 PM Administrative Nurse E verified the nursing staff on duty initiated an investigation and are to place a new intervention in the risk management EMR to prevent further falls. Falls are discussed at the daily meeting, then she reviews the care plan to update as needed. On 08/10/22 at 04:14 PM Administrative Nurse D stated with each fall a new and appropriate intervention should be immediately be implemented and the care plan should reflect the intervention. The facility's Fall Prevention and Management, policy dated 03/30/22, documented a root cause analysis is completed from the Fall Huddle to review identifying the cause of a problem so that the best solution can be identified and put into place. Staff to continue to monitor effectiveness of the interventions. The facility failed to update R30's care plan with resident-centered interventions to prevent falls which placed the resident at risk for further falls and injury

The facility had a census of 43 residents. The sample included 14 residents. Based on observation, record review and interview, the facility failed to appropriately treat Resident (R) 8's pain following a fall which resulted in a fractured right hip. This placed R8 at increased risk for unresolved pain and impaired comfort. Findings included: - R8's Medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS), dated [DATE], documented R8 had severe cognitive impairment, required extensive assistance of one to two staff for activities of daily living, was not steady, and only able to stabilize with human assistance with balance and transition. He had no functional range of impairment or therapy services. The MDS documented R8 had no pain, and fell prior to being admitted . The MDS further documented R8 fell since admission two or more times with no injury. He had received an antianxiety (medication used to treat anxiety) medication for three days of the look back period. On 04/20/22 R8's Fall Care Plan, directed staff to place phone and tablet within his reach. R8 utilized a soft touch call light and directed to place a soft touch call light where R8 attempted to ambulate or transfer without assistance. Educate/instruct resident and family on safe use of assistive devices, place call light in reach and remind R8 to utilize. The care plan further documented do not keep R8's feet elevated in the recliner and offer to toilet R8 every two hours. On 04/20/22 the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The Progress Note dated 04/19/22 at 01:03 PM documented R8 had been admitted from the hospital for skilled services. The note further documented he fell twice at home and transferred to the hospital were he had been treated for [MEDICAL RECORD OR PHYSICIAN ORDER] The Progress Note dated 04/19/22 documented at approximately 04:25 PM, R8 called out and a Certified Nurse Aide (CNA) found him on the floor. R8 denied pain and no injuries found. The Progress Note dated 04/19/22 at 09:00 PM recorded R8 was again found on the floor in front of his recliner. The Progress Note dated 04/20/22 at 11:20 AM documented a care conference with R8's relative and recorded R8 was a fall risk and fell a few times since admission. The Progress Note dated 04/20/22 at 12:57 PM documented R8 was found on his hands and knees picking up his cell phone and tablet off the floor. The Progress Note dated 04/22/22 documented the physician authorized a floor mat and low bed. The note further documented an increase in the dose of antianxiety medication to one milligram (mg) of [MEDICATION(S)] ( a sedative used to treat anxiety) up to three times a day (TID) as needed for agitation. The Progress Note dated 04/23/22 at 06:06 PM documented R8 sat on the floor in his room. R8 stated he was trying to go to the bathroom. He was wearing slick socks, his pants were partially down, and his wheelchair was unlocked. The Progress Note at 02:21 AM dated 04/23/22, documented staff assisted R8 to the bathroom and noted a dark purple bruise with greenish color border to R8's coccyx (tailbone). The Progress Note dated 04/26/22 at 08:34 AM documented staff called the physician and reported that R8 complained of increased pain in his hips since the last fall. Staff used the total body lift due to the resident did not want to stand. The Progress Note dated 04/26/22 at 08:34 AM documented R8 yelled out when staff attempted to move his lower extremities and/or transfer the resident. Staff used the full body lift due to safety. The Progress Note dated 04/26/22 at 10:04 AM documented physician ordered X-Ray to pelvis. The Progress Note dated 04/26/22 at 01:00 PM documented R8's x-Ray findings revealed a fracture to his right hip; the resident was transferred to a hospital. The Progress Note dated 05/02/22 at 02:00 PM documented R8 had been hospitalized and his conditions and complications treated during most recent hospitalization for acute pain and debility secondary to an acute right hip fracture. Skilled services were provided. Review of the April 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident received [MEDICATION(S)] one mg three times a day on 04/23/22, 04/24/22, and one time a day on 04/25/22. The clinical record lacked evidence pain medication was ordered and /or administered from 04/23/22 through 04/26/22 when R8 was discharged to the hospital with a right hip fracture. On 08/10/22 at 12:26 PM observation revealed R8 ate lunch in the dining room while seated in a wheelchair . On 08/10/22 at 03:32 PM, Administrative Nurse D stated R8 should have been treated with pain medication when he complained of pain. Administrative nurse D confirmed R8 should have received other interventions, including pain management, prior to receiving increased doses of an antianxiety medication for agitation. The facility's Pain Management policy, dated 12/07/21, documented the registered nurse will assess current pain levels and develop with the physician and interdisciplinary team interventions that may be non-pharmacological, as well as pharmacological. The registered nurse will review response to medication interventions and work closely with the physician to assist in the individualized pain management plan. The nurses working directly with resident must continually monitor and observe the resident for success of the pain management plan and report to the nurse manager and prescriber as necessary to keep the resident comfortable. The facility failed to appropriately treat R8's complaints of pain following a fall which had resulted in a right hip fracture, placing the resident at risk for continued untreated pain.

The facility had a census of 43 residents. The sample included 14 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interview, the facility's Consultant Pharmacist (CP) failed to identify Resident (R) 42's PRN (as needed) alprazalom (a sedative used to treat anxiety) did not have a stop date, and failed to identify an inappropriate diagnosis for R2's [MEDICATION(S)] (antipsychotic medication), placing the resident at risk for unnecessary [CONDITION(S)] (altering mood or thought) medications. Findings included: - The Electronic Medical Record (EMR) for R42 documented had diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and difficulty walking (a change in normal walking pattern). The Admission Minimum Data Set (MDS), dated [DATE], documented R42 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and the resident did not ambulate. The MDS further documented R42 received antianxiety medication on a routine basis. The Black Box Warning Care Plan, dated 06/22/22, initiated on 04/21/22, directed staff to monitor for adverse effects, limit dosages and durations to the minimum required, and report as necessary. The care plan further directed staff to consult with the pharmacy; healthcare provider to consider dosage reduction when clinically appropriate and to monitor R42's condition based on clinical practice guidelines or clinical standards of practice. The Physician's Order, dated 06/05/22, directed staff to administer [MEDICATION(S)] 0.5 milligrams (mg) every 24 hours PRN for anxiety. The order lacked a stop date for the PRN [MEDICATION(S)]. The Medication Regimen Review, dated 07/06/22, lacked evidence the CP identified the PRN medication did not have a stop date. The Medication Regimen Review, dated 08/01/22, lacked evidence the CP identified the PRN medication did not have a stop date. On 08/10/22 at 11:50 AM, observation revealed R42 sat in her recliner, her eyes were closed. On 08/10/22 at 03:45 PM, Administrative Nurse D verified the order did not have a stop date and that the pharmacist did not bring it to her attention in July or this month. 08/11/22 at 05:30 PM, the CP was unavailable. The facility's Medication: Drug Regimen Review policy, dated 01/25/22, documented the drug regimen review was a process that included both medication reconciliation and a review of all medications for a resident was currently using to identify and prevent potentially clinically significant medication issues. The drug regimen review was performed for each resident at least once a month by a licensed pharmacist. This review included a review of the resident's medical chart. The facility's CP failed to identify and report the lack of a stop date on R42's PRN [MEDICATION(S)]. This placed the resident at risk for adverse side effects related to [CONDITION(S)] medication - R2's Medical Diagnosis section of the Electronic Medical Record (EMR) included diagnoses of hypertension (elevated blood pressure), depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness ), [CONDITION(S)] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) chronic kidney disease, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure, and dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R2 had intact cognition, required extensive assistance of one to two staff members for activities of daily living, received scheduled pain medication, insulin (injectable medication to lower blood sugars), antipsychotic (class of medications used to treat [CONDITION(S)]- any major mental disorder characterized by a gross impairment in reality testing ,and other mental emotional conditions), antianxiety (class of medications that calm and relax people with excessive anxiety- mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, nervousness, or tension), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness, and an antibiotic (medication used to treat infections). Then MDS further documented the antipsychotic was received on a routine basis only, had not had a gradual dose reduction or physician documentation the gradual dose reduction was clinically contraindicated. The [CONDITION(S)] Drug Use Care Area Assessment (CAA), dated 07/22/22, documented R2 was prescribed [MEDICATION(S)] for diagnosis of Lewy body dementia. The CAA further documented nursing and pharmacist monitor medication and adverse effects frequently and report as necessary. The Care Plan documented R2 took medication with a warning of adverse consequences. The care plan further documented consult with pharmacy, and healthcare provider to consider dose reduction when clinically appropriate. The Physician Order dated 03/23/22, direct staff to administer [MEDICATION(S)] 25 milligrams (mg) by mouth two times a day related to [CONDITION(S)]. The Pharmacy Consultation Report, dated 06/01/22, recommended a gradual dose reduction, to discontinue use, or change dosage, to the medication. The pharmacist did not comment on the approved uses of [MEDICATION(S)] for [CONDITION(S)]. On 08/09/22 at 01:20 PM R2 sat in his wheelchair in his room following lunch. He watched TV and his call light was attached to his wheelchair. In 08/10/22 at 04:30 PM, Administrative Nurse D reported the pharmacist reviewed the charts monthly. The pharmacist gave recommendation to the facility. Administrative Nurse D stated she sent the recommendations to the physicians for review and response. She was unable to find whether this was done or not. She verified she was responsible for this task. The facility's Medication: Drug Regimen Review policy, dated 01/25/22, documented the drug regimen review was a process that included both medication reconciliation and a review of all medications for a resident was currently using to identify and prevent potentially clinically significant medication issues. The drug regimen review was performed for each resident at least once a month by a licensed pharmacist. This review included a review of the resident's medical chart. The facility failed to ensure the CP identified and reported an appropriate diagnosis for the use of antipsychotic medication for R2. This placed the resident at risk for adverse side effects with the use of [MEDICATION(S)].

The facility had a census of 43 residents. The sample included 14 residents with five reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to obtain from the physician, blood sugar parameters for Resident (R) 10, who received insulin (injectable hormone used to control blood sugar levels). This placed R10 at risk for hyperglycemic (high blood sugar) or hyperglycemic (low blood sugar) episodes. Findings included: - The Electronic Medical Record (EMR) documented R10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS), dated [DATE], documented R10 had intact cognition and was independent with all activities of daily living (ADL). The MDS further documented R10 received insulin, an antidepressant (a class of medication that is used to treat mood disorders and relieve symptoms of depression), a diuretic (medication to promote the formation and excretion of urine), and an opioid (medication to treat moderate to severe pain) during the look back period. The Diabetic Care Plan, dated 03/08/22 directed staff to monitor, document, and report signs and symptoms of [CONDITION(S)] or [CONDITION(S)] to the doctor and to refer to the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order lacked blood sugar parameters for the resident. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 200 - 299 administer 1 unit 300 - 399 administer 2 units 400 - 499 administer 4 units The TAR, dated May 2022, documented the following days R10's accu-check was over 500. 05/09/22 - 513 05/31/22 - 500 The EMR lacked documentation the physician was notified of the accu-check reading. The TAR, dated June 2022, documented the following day R10's accu-check was over 500. 06/11/22 - 512 The EMR lacked documentation the physician was notified of the accu-check reading. The Communication with the Physician Note, dated 07/13/22 at 06:38 PM, documented R10's accu-check was 598 and the physician directed staff to administer 5 units of [MEDICATION(S)] and retake the resident's accu-check after one hour after the initial evening accu-check and administer [MEDICATION(S)] per the sliding scale. On 08/09/22 at 07:40 AM, observation revealed R10 ate breakfast in her room while watching television. On 08/09/22 at 08:00 AM, Licensed Nurse (LN) K stated R10 had a sliding scale for insulin but did not have parameters for her accu-checks. LN K stated the sliding scale goes to 499 and she assumed that when the accu-checks were over 499, the nurse should call the physician for further orders. On 08/10/22 at 03:45 PM, Administrative Nurse D stated there should be parameters for the resident's blood sugar and that staff should contact the physician if the accu-checks were over 500. A policy for blood sugar parameters was not provided by the facility, The facility failed to obtain, from the physician, blood sugar parameters for R 10. This placed R10 at risk for hyperglycemic or hyperglycemic episodes.

The facility had a census of 43 residents. The sample included 14 residents, with five reviewed for unnecessary medication. Based on observation, record review, and interview, the facility failed to obtain a stop date for Resident (R) 42's as needed (PRN) [MEDICATION(S)] (a sedative used to treat anxiety) and failed to ensure an appropriate diagnosis for R2's [MEDICATION(S)] (antipsychotic medication). This placed the residents at risk for adverse side effects. Findings included: - The Electronic Medical Record (EMR) for R42 documented had diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and difficulty walking. The Admission Minimum Data Set (MDS), dated [DATE], documented R42 had severely impaired cognition and required extensive assistance of two staff for bed mobility, transfers, toileting, and the resident did not ambulate. The MDS further documented R42 received antianxiety medication on a routine basis. The Black Box Warning Care Plan, dated 06/22/22, initiated on 04/21/22, directed staff to monitor for adverse effects, limit dosages and durations to the minimum required, and report as necessary. The care plan further directed staff to consult with the pharmacy, healthcare provider to consider dosage reduction when clinically appropriate and to monitor R42's condition based on clinical practice guidelines or clinical standards of practice. The Physician's Order, dated 06/05/22, directed staff to administer [MEDICATION(S)] 0.5 milligrams (mg) every 24 hours PRN for anxiety. The order lacked a stop date for the PRN [MEDICATION(S)]. On 08/10/22 at 11:50 AM, observation revealed R42 sat in her recliner, her eyes were closed. On 08/10/22 at 03:45 PM, Administrative Nurse D verified the order did not have a stop date. The facility's [CONDITION(S)] Medications policy, dated 12/01/21, documented PRN [CONDITION(S)] (alters mood or thought) medications are limited to 14 days and if the attending physician believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. The facility failed to identify the lack of a stop date for R42's PRN [MEDICATION(S)], placing the resident at risk for receiving unnecessary [CONDITION(S)] medication. - R2's Medical Diagnosis section of the Electronic Medical Record (EMR) included diagnoses of hypertension (elevated blood pressure), depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness ), [CONDITION(S)] (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) chronic kidney disease, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), heart failure, and dementia (progressive mental disorder characterized by failing memory, confusion) without behavioral disturbance. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R2 had intact cognition, required extensive assistance of one to two staff members for activities of daily living, received scheduled pain medication, insulin (injectable medication to lower blood sugars), antipsychotic (class of medications used to treat [CONDITION(S)]- any major mental disorder characterized by a gross impairment in reality testing ,and other mental emotional conditions), antianxiety (class of medications that calm and relax people with excessive anxiety- mental or emotional reaction characterized by apprehension, uncertainty and irrational fear, nervousness, or tension), antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness, and hopelessness, and an antibiotic (medication used to treat infections). The MDS further documented the antipsychotic was received on a routine basis only, had not had a gradual dose reduction or physician documentation the gradual dose reduction was clinically contraindicated. The [CONDITION(S)] [altering mood or thought] Drug Use Care Area Assessment (CAA), dated 07/22/22, documented R2 was prescribed [MEDICATION(S)] for diagnosis of Lewy body dementia. The CAA further documented nursing and pharmacist monitor medication and adverse effects frequently and report as necessary. The Care Plan documented R2 took medication with a warning of adverse consequences. The care plan further documented consult with pharmacy, and healthcare provider to consider dose reduction when clinically appropriate. The Physician Order dated 03/23/22, direct staff to administer [MEDICATION(S)] 25 milligrams (mg) by mouth two times a day related to [CONDITION(S)]. The Pharmacy Consultation Report, dated 06/01/22, recommended a gradual dose reduction, to discontinue use, or change dosage, to the medication. The pharmacist did not comment on the approved uses of [MEDICATION(S)] for [CONDITION(S)]. On 08/09/22 at 01:20 PM R2 sat in his wheelchair in his room following lunch. He was watching TV and his call light was attached to his wheelchair. In 08/10/22 at 04:30 PM, Administrative Nurse D reported the pharmacist reviews the charts monthly. The pharmacist gives recommendation to the facility. Administrative Nurse D stated she then sends the recommendations to the physicians for review and response. She was unable to find whether this was done or not. She verified she was responsible for this task. The facility's [CONDITION(S)] Medication policy, dated 12/01/21, documented each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in the presence of adverse consequences that indicate the dose should be reduced or discontinued. The facility failed to ensure an appropriate diagnosis for the use of antipsychotic medication for R2. This placed the resident at risk for adverse side effects.

The facility identified a census of 39. The sample included six residents reviewed for accidents/hazards. Based on observation, record review, and interviews the facility failed to ensure the environment was free of trip hazards, failed to investigate causative factors for falls and failed to develop interventions in response to Resident (R)2's change of condition and need for increased assistance. This deficient practice resulted in a fall with a fracture for R2 who was cognitively impaired, at risk for falls, and had a history of falls with injury. On 09/24/21 R2 fell and sustained a right shoulder fracture (broken bone) which required evaluation and treatment at the emergency room (ER) at the acute care hospital. Findings included: - The Diagnoses tab in the Electronic Medical Record (EMR) for R2 listed diagnoses of pain, history of falling, heart failure, and muscle weakness. The Admission Minimum Data Set (MDS) dated [DATE] documented R2 had a Brief Interview for Mental Status score of 11, which indicated she had moderately impaired cognition. She required assistance of one staff for supervision with activities of daily living (ADLs) and walked with set up assistance only. The MDS documented R2 had a fall in the month prior to admission and had a fracture related to a fall in the six months prior to admission. The Falls Care Area assessment dated [DATE] recorded FR2's family reported R2 fell at home prior to admission to the facility. R2 fell around Thanksgiving when she lived independently which caused a compression fracture. R2 did not recall falling. R2's family reported they were unsure how many other falls R2 had when she lived independently. R2 had no falls since admission to the facility and was monitored for significant or acute changes in fall risk. The Quarterly MDS dated [DATE] documented R2 had a BIMS of eight which indicated moderately impaired cognition. She required supervision and set up assistance only for walking. The MDS documented R2 had no falls since the prior MDS assessment on 06/10/21. The Care Plan focus dated 03/11/21 documented R2 had impaired cognitive function/dementia (progressive mental disorder characterized by failing memory, confusion or impaired thought processes) as evidenced by confusion, forgetfulness, and disorientation. Interventions, dated 03/12/21 documented R2 needed supervision with all decision making and directed staff to cue, reorient, and supervise as needed. The Care Plan focus dated 03/08/21 documented R2 needed restorative intervention due to ADL self-care performance deficit, limited physical mobility, and communication problems. An intervention dated 03/08/21 directed staff R2 required staff assistance of one staff member with walking, a walker, and the use of a gait belt (belt used to help transfer a person from one place to another). The Care Plan focus dated 03/08/21 recorded R2 was at risk for falls related to a history of a fall with a compression fracture. Interventions dated 03/08/21 directed staff to ensure R2 wore appropriate footwear when ambulating and to monitor R2 for significant changes in gait, mobility, positioning devices, standing/sitting balance, and lower extremity joint function. The Care Plan focus dated 06/10/21 recorded R2 had an actual fall with no injury related to weakness as evidenced by her need for assistance. Interventions dated 06/10/21 directed staff to ensure R2 wore appropriate footwear (non-slip shoes or gripper socks) when she ambulated and to ensure that her walker was nearby. Another intervention dated 06/10/21 recorded R2 liked to get ready for bed early, just after dinner, and directed staff to monitor and remind her that staff would assist her in getting ready for bed after she finished her evening meal. A Communication Note, dated 09/18/21 under the Progress Notes tab recorded R2 had acted off for the last two days. R2 stated to the nurse I just don't feel well, and I don't know why. R2 had a fall that morning (09/18/21) at 05:00 AM and was found on the floor with no injuries. R2 did not want to get out of bed for the past couple of days. R2's vital signs were within normal limits and her pain level was consistent with her normal response. The nurse requested an order for a urinalysis (lab test to determine presence of a urinary tract infection). A Communication/Visit with Physician Note dated 09/18/21 recorded R2 had shown a change of condition over the past couple of days. R2 sustained a fall at 05:00 AM. Urinalysis results came back positive for bacteria and a new order was sent over for an antibiotic (medication used to treat bacterial infection). The clinical record lacked further details of the fall at 05:00 AM and lacked evidence interventions were implemented for the documented change in condition and/or fall. The facility was unable to provide an investigation of causative factors related to the 09/18/21 fall. The handwritten Fall Scene Huddle Worksheet dated 09/18/21 at 05:00 AM, provided by the facility on 10/05/21 at 03:40 PM, documented R2 was found on floor(unwitnessed) in R2's room. She was incontinent at the time of the fall. The worksheet documented staff last saw R2 at 04:45 AM (15 minutes prior to fall). The worksheet lacked documentation in box 7. Comments which directed staff to add a care plan intervention. A Communication - Other Note, dated 09/20/21 recorded at 04:00 AM staff found R2 on floor in the hallway on her right side between the legs of the Hoyer lift (mechanical lift). Her head was up off the floor and she denied hitting her head. Her walker was standing upright next to the Hoyer lift. R2 wore regular socks and no shoes. When asked what happened, she stated she was trying to go home. Staff assessed R2 and assisted her off the floor. R2 ambulated with use of her walker with stand by assistance back to her room. R2 had no visible signs of injury . A Communication - Other Note, dated 09/20/21, recorded R2 had a fall on 09/18/21 at 04:00 AM. Staff observed her sitting on her floor in her room. Staff spoke with R2 about the incident and noted the resident showed signs of increased confusion. R2 started an antibiotic after completion of a urinalysis. R2 showed continued signs of confusion, weakness and not wanting to get out of bed. She did not leave her bed on Sunday, and only ate approximately 35-40 percent of meals. R2 kept stating I just don't feel well. On Monday (09/20/21) R2 had another fall at 05:00 AM. Staff found R2 sitting in the hallway with her walker upright, and the resident was sitting next to the Hoyer lift. Staff assessed R2 again on 09/20/21 and noted the process of transferring from the bed to the chair made R2 extremely exhausted, and she complained of weakness and generally not feeling well. Staff noted R2 showed an overall increase in weakness and tiredness. The note recorded staff spoke with therapy services about an evaluation for physical therapy (PT) and occupational therapy (OT). The note further recorded staff kept R2's door open, reminded her to use the call light before transferring. Staff were educated to provide two-hour checks. A Communication/Visit with Physician Note, dated 09/20/21 recorded R2 had a new order for a PT/OT evaluation. The clinical record lacked evidence the facility investigated, identified, and addressed the potential trip hazard of the Hoyer lift in the hallway. It further lacked evidence the facility identified and addressed the increased need for staff assistance due to R2's increased weakness and malaise (vague uneasy feeling of body weakness, distress or discomfort). The facility was unable to provide an investigation related to the 09/20/21 fall. The handwritten Fall Scene Huddle Worksheet dated 09/20/21 at 04:00 AM, provided by the facility on 10/05/21 at 03:40 PM, documented R2 was found on floor(unwitnessed) in the hallway. She was incontinent at the time of the fall. The worksheet documented staff last saw R2 at 01:09 AM, nearly three hours prior to fall. In box 7. Comments which directed staff to add a care plan intervention, the worksheet documented R2 was on antibiotics for a urinary tract infection. A Communication/Visit with Physician Note, dated 09/24/21 at 06:30 PM recorded R2 had a witnessed fall in the hallway and had an injury to the right side of her head above her temple. She grabbed the dish cart in the hall and the dish cart wheeled (moved) and the resident fell on her right side. Two nurses observed the occurrence and ran to try to catch her, but the fall happened too fast. R2's glasses fell off her face and she hit her head and had a goose egg (swelling) to her head, and she complained of right arm pain. Staff called emergency medical services to transport R2 to the hospital. A Communication - Other Note, dated 09/24/21 at 11:04 PM documented R2 returned to facility via an ambulance gurney. R2 was awake, alert, and responsive to verbal and physical stimuli. R2 had a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to right side of her head above her eye. R2 also has a right shoulder fracture and her arm was in a sling with a swath in place. R2 reported a pain level of nine out of ten (pain scale with ten being the worst pain) and staff administered acetaminophen ( pain medication). The undated, unsigned Facility Investigation documented the corrective action regarding the 09/24/21 fall as staff were to remind R2 to use her call light and her walker at all times. Staff were to monitor the location of R2's walker to ensure she had easy access to it. Staff removed the dish cart from the hallway and placed the cart out of the residents' line of sight. To ensure ongoing effectiveness of the corrective actions, the report documented staff would continue to educate the resident on the use of her walker and call light when ambulating. An observation on 10/04/21 at 11:50 AM revealed a Hoyer lift parked in the hallway, parallel with the wall though not in an egress . On 10/04/21 R2 was unavailable for observation due to admission to acute care hospital. In an interview on 10/04/21 at 01:57 PM Certified Nurse Aid (CNA) N stated the residents who were at risk for falls were those who were more independent. She stated the CNAs had Cheat Sheets which indicated how the residents transferred. The Cheat Sheet indicated if the resident used a lift and the sling size. CNA N stated when staff transferred a resident after using the lift, staff should place the lift out of the way. She said the CNAs received a verbal report from the nurses and did walking rounds with the off going CNA. CNA N stated both the CNA and nurses were responsible for passing in report any fall interventions implemented for the residents. CNA N said she always checked the residents' surroundings to make sure things were in reach and safe. She also tried to keep track of the last time the residents were toileted. CNA stated R2 never had any falls until she got sick. She said R2 was more confused after her illness and R2 was unable to tell staff what she was doing and why. CNA N stated R2 was not often incontinent and would try to take herself to the bathroom frequently. In an interview on 10/04/21 at 02:21 PM Licensed Nurse (LN) H stated when a resident fell , nursing staff investigated the fall, and filled out an incident report. She stated the incident should be charted in the computer and the nurse supervisors were also alerted. LN H said residents with cognitive deficits who were able to stand up and walk were at the highest risk for falls. LN H stated she could access risk management in the EMR and look up the past 30 days to see if the resident had any falls. She further stated nursing staff had a report and meetings to get in touch with which residents were at risk. LN H stated she cared for R2 at the end of September. LN H stated she was asked to insert an intravenous (IV) cannula for R2 and the next day, R2 fell . In an interview on 10/04/21 at 02:33 PM Administrative Nurse D stated she recently started in the position and she was not in the facility the week R2 had her falls, during 09/18/21-09/24/21. Administrative Nurse D stated the facility had a daily huddle where staff discussed how to prevent residents from falling. In an interview with Administrative Nurse E on 10/04/21 at 03:00 PM, Administrative Nurse E stated for every fall, whether witnessed or unwitnessed staff were to follow up on the fall, investigate why the fall occurred, and check on the resident to prevent further falls. She further stated falls were discussed by the administrative team every morning for the previous day. On 10/04/21 at 03:15 PM Administrative Staff A stated staff talked about falls every morning and discussed which residents had falls. She said Administrative Nurse F did the fall investigations and developed interventions to help prevent future falls. Administrative Staff A stated she felt the facility should have done a better job at reviewing R2's falls. She said when the administrative team found out about falls through report in morning or afternoon, it was shared with Administrative Nurse F and discussed in the morning meeting. On 10/04/21 Administrative Nurse F was unavailable for interview. The facility policy dated 09/17/2021 Fall Prevention and Management-Rehab/Skilled, Therapy & Rehab documented the risk of falling for residents in long-term care locations substantially increases due to decreased mobility, frailty, muscle weakness, gait disturbance, and disease progression. The facility failed to ensure the environment was free of trip hazards, failed to investigate causative factors for falls and failed to develop interventions in response to R2's change of condition and need for increased assistance after two falls, on 09/18/21 and 09/20/21. R2 fell again on 09/24/21 which resulted in a fracture of the right shoulder which required evaluation and treatment at the local hospital .

The facility had a census of 41 residents. The sample included three residents reviewed for elopement. Based on observation, record review, and interview, the facility failed to provide adequate supervision to prevent an elopement for one of three sampled residents, Resident (R) 1, assessed as risk for elopement, exited the building through a window on 01/24/21 without staff knowledge, and ambulated one block from the facility before facility staff assisted him back to the facility. This deficient practice placed the resident in immediate jeopardy. Findings included: - R1's Physician order [REDACTED].), and open-angle [MEDICAL CONDITION] (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow). The Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented R1 did not wander during the 5-day look back period, was independent with activities of daily living (ADLs), and ambulated independently with a walker. The Cognitive Patterns/Dementia Care Area Assessment (CAA), dated 09/23/20, documented R1 had moderately intact cognition with observed confusion and memory impairment. The Visual Function CAA, dated 09/23/20, documented R1 had difficulty seeing, extremely hard of hearing, and staff had to speak to him very loudly. The ADL CAA, dated 09/23/20, documented R1 required supervision to limited assistance with ADLs and staff monitored R1 to ensure he did not need increased assistance. The Falls Care Plan, initiated 09/17/20, directed staff to monitor R1 for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint function. The Elopement Care Plan, initiated 09/17/20, documented wander guard used to alert staff to resident's movement and to assist staff in monitoring movement. The 01/24/21 update directed staff to check on R1 every 15 minutes. The 01/27/21 update documented window alarm placed. The 03/05/21 update directed staff to minimize potential of resident behavior problems by modifying environmental factor and daily routine such as not giving resident a knife in the dining room to eliminate possibility of resident taking the knife to use as a tool to elope. The 03/22/21 updated directed staff to check on R1 every 30 minutes. The revised ADL Care Plan, dated 10/27/20, documented R1 was able to walk independently with the use of a walker and required staff supervision to ensure he did not abandon his walker. The care plan directed staff to monitor the resident for significant changes in his ability to walk and notify nursing staff. The Physician Order, dated 09/23/20, directed staff to place a wander guard device on R1 for wandering, change the device every three months and as needed, and check placement two times a day. The Progress Note, dated 01/07/21 at 08:51 AM, documented R1 was very agitated due to being locked up. The Progress Note, dated 01/22/21 at 01:36 PM, documented R1 wandered to the front door and leaned on the door sounding the alarm. The Progress Note, dated 01/24/21 at 05:15 PM, documented at 04:20 PM staff received a telephone call from a neighbor who reported a male tried to escape out of a window. Staff started checking every room, when they came to R1's room his door was closed, the bathroom door was closed, his walker leaned up against the side wall, and the bed was against the wall next to the slightly cracked open window. The nurse opened the window and the screen fell outwards, so the nurses went outside looking for R1. While the nurses were outside looking for R1, a vehicle pulled into the parking lot next to the facility. The driver reported a man was sitting outside a house down the street. The nurses went approximately one block where R1 sat on a stool outside provided by a man who reported he saw R1 walking unsteadily down the street, so he had R1 sit down. R1 told the man he escaped after being abducted from his home. The man realized R1 lived at the facility. When the nurse approached R1 he stated, well, I guess you found me. The local police arrived along with Administrative Staff A and talked R1 into going back to the facility. At 04:50 PM R1 ambulated back into the facility to his room. The nurse assessed R1 with a head-to-toe assessment with no injury found, initiated 15-minute checks in the care plan, and educated staff. The Progress Note, dated 02/01/21 at 04:55 AM, documented staff found R1 put his walker in front of his door to alert him when staff came to check on him. Staff educated R1 this act could cause a fall, R1 understood and moved the walker. On 03/22/21 at 01:11 PM, observation revealed the two windows in R1's room were unlocked and had white alarms affixed to the window. This surveyor opened the window and the alarm sounded. At 01:13 PM Certified Nurse Aide (CNA) M came in the room and turned off the alarm. On 03/22/21 at 11:58 AM, R1 stated he wanted to go home, but when he tried to open an exit door the alarm would sound, so he crawled out the window without telling anyone. R1 stated he would do it again if he got the chance and if he could get a pipe, he would hit it on a window and bust out of the facility. On 3/23/21 at 10:06 AM, CNA N stated if a resident was an elopement risk, she would check on them every 30 minutes or sooner, then document the observation in the CNA charting right away. CNA N stated she used a Cheat Sheet that gave her direction on how to care for the residents. Review of the Cheat Sheet from her pocket, gave direction to check on R1. The Cheat Sheet lacked information R1 was an elopement risk or how often staff were to check on him. On 3/22/21 at 03:00 PM, Licensed Nurse (LN) G stated R1 vocalized he didn't want to be in the facility and would go up to the doors, so they kept the wander guard on him. When R1 was in his room he usually yelled at his friend to get him out of the facility. On 01/24/21, LN G did not know the exact time, an unidentified staff member had been in R1's room and told R1 it was getting close to supper time. At 04:20 PM she received a telephone call from a neighbor about a resident escaping out of a window. LN G was one of the nurses who found R1 a block away from the facility sitting on a stool with a man who reported he saw R1 walking unsteadily down the street, so he had him sit down. Facility staff were able to bring the resident back into the facility, assessed him with no injury noted, and staff checked on him every 15 minutes. On 3/23/21 at 12:13 PM, Administrative Nurse D stated the facility was not a locked unit, was the resident's homes, and the windows could open. Administrative Nurse D stated R1 took the screen off his window, replaced the screen, and could voice he did not want to be in a locked unit. The facility's revised Elopement-Rehab/Skilled policy, dated 10/30/20, documented elopement as a resident who needs supervision leaves the premises or a safe area without authorization and/or any necessary supervision to do so. The facility was responsible for maintaining a system that clearly defines the mechanisms and procedures for monitoring residents at risk for elopement. These included identifying environmental hazards and resident risks; evaluating/analyzing hazards and risks; implementing interventions; and monitoring/modifying interventions as needed. The facility failed to provide R1 adequate supervision to prevent an elopement, assessed as risk for elopement, exited the building through a window on 01/24/21, and ambulated one block from the facility before facility staff assisted him back to the facility, placing R1 in immediate jeopardy. The facility removed the immediate jeopardy on 03/24/21, when they installed window stops so the windows could only be raised to eight inches, educated all staff on residents at risk for elopement, interventions to prevent elopements, and review of the elopement policy. This deficient practice remained at a scope and severity of a D.

The facility had a census of 41 residents. The sample included 11 residents. Based on observation, record review, and interview the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of the 11 sampled residents, when staff failed to assess the resident after a choking incident. (#22) Findings included: - Resident #22's [DIAGNOSES REDACTED]. in the heart's major blood vessels), muscle weakness, lobar pneumonia (that affects a large and continuous area of the lobe of a lung), hypoxemia (abnormal deficiency in the concentration of oxygen in arterial blood), fluid over load, [MEDICAL CONDITION] (long-term, progressive disease of the lungs characterized by shortness of breath), and difficulty in walking. The admission (MDS) Minimum Data Set assessment, dated 5/16/18, documented the resident had a (BIMS) Brief Interview of Mental Status score of 4, which indicated severe cognitive impairment. The MDS documented the resident required extensive staff assistance with dressing, limited staff assistance with mobility, transfers, toilet use, personal hygiene, walking in room and corridor, and locomotion off and on the unit. The MDS documented the resident required staff supervision and set up help with eating, and had no problems chewing or swallowing. The (CAA) Care Area Assessment for nutrition, dated 5/22/18, documented the resident/resident representative reported no problems. The CAA for activities of daily living did not trigger. The quarterly MDS assessment, dated 8/14/18, documented the resident had severe cognitive impairment, needed extensive assistance with bed mobility, walking in room and corridor, dressing, toilet use, personal hygiene, bathing, and transfers. The MDS further documented the resident was not steady on his/her feet, was occasionally incontinent of urine, and required limited assistance of 1 staff for eating and no swallowing or chewing problem. The 5/10/18 comprehensive care plan, reviewed on 8/23/18, potential for infections, instructed staff to communicate if the resident showed signs of decline, disorientation, periods of lethargy (sleepiness or deep unresponsiveness and inactivity), restlessness and agitation. The [MEDICAL CONDITION] care plan documented a new [DIAGNOSES REDACTED]. The care plan instructed staff to administer oxygen at 2 liters per nasal cannula, to the resident, as needed, to maintain oxygen saturation (measure of how much oxygen the blood carried as a percentage of the maximum it could carry) greater than 90%. The 10/9/18 at 12:50 PM, nurse's note documented the resident went to see the physician and labs were drawn in the physician office. The note documented the residents (WBC) White Blood Count of 14.7 mm3 (cubic millimeters), (Mosby's manual of Diagnostic and Laboratory Tests documents normal WBC 5-10), and the doctor instructed staff to notify him/her of any new or worsening symptoms. Review of the medical record from 10/10/18 through 10/12/18 lacked documentation staff assessed the resident's condition. The 10/13/18 at 8:43 AM, nurse's note recorded the resident started choking at breakfast and did not drink his/her Ensure (nutritional supplement drink), after poor intake. On 10/14/18 at 8:11 AM, the vitals record documented the resident's blood pressure of 178/102, and pulse 80 bpm. The 10/14/18 at 10:54 AM, nurse's note documented the resident's pallor (unhealthy pale appearance) continued to be poor, he/she moaned periodically, and stated he/she did not feel well. The note documented the resident received medications and other nursing interventions to keep the resident as comfortable as possible. The medical record lacked assessment of the resident's and/or vital signs. On 10/15/18 at 9:04 AM, observation revealed the resident sat at the dining room table, skin color pale gray, and the resident verbalized a soft moan type sound. On 10/15/18 at 9:20 AM, Nurse J stated the resident was more alert today, had been sleepier, and no longer was able to communicate his/her needs with staff. The 10/15/18 at 11:59 AM, nurse's note documented the resident had a choking episode that weekend (10/13-10/14) when eating a meal, which required staff to use the [MEDICATION NAME] maneuver (an emergency response technique used to dislodge food or another object from a person's airway when they are choking, as it provides an increase in pressure in the abdomen and chest, enabling the object to be expelled). On 10/15/18 at 2:10 PM, Administrative Nurse D verified staff had not notified the physician regarding the choking incident. He/she reported the nurses on duty that day did not perform the [MEDICATION NAME] maneuver on the resident as the resident was able to cough and the nurses did not feel the resident choked but kept an eye on him/her for further needs. Administrative Nurse D verified staff did not follow up with an assessment of the resident after the incident. Review of the medical record revealed the next documentation on 10/15/18 at 11:13 PM (12 hours later) when staff assessed the resident's temperature at 101.7 (F) Fahrenheit (normal range 97.8 to 99.1), respirations 28 (normal range 12 to 18), and oxygen saturation 77% on room air (normal value ranges 95 to 100%). The record lacked evidence staff provided supplemental oxygen to the resident and notified the physician. The 10/16/18 at 2:26 AM, nurse's note documented the resident yelled out more than normal that evening and into the night, the nurse checked the resident, he/she felt warm to touch, his/her skin color was pale, and the nurse checked the resident's vital signs. The note documented the resident's vital signs were, respirations 28 with labored breathing, oxygen saturation was 77% on room air and his/her pulse was 128-140 (bpm) (normal value 60 to 100 bpm) beats per minute. The note documented the nurse placed oxygen on the resident and his/her oxygen saturation remained 83-85%. The nurse gave the resident Tylenol for his/her temperature, then notified the physician. The note documented the physician instructed staff to take the resident to the emergency room for evaluation. The 10/16/18 at 3:37 AM, nurse's note documented a call from the hospital emergency room reporting the resident was admitted to the hospital with [REDACTED]. The urinary system includes the bladder, kidneys, ureters (the tube that carries urine from the kidney to the bladder) and the urethra (the tube that carries urine out of the body). The 10/16/18, hospital admission history and physical report documented the resident was brought to the hospital by wheelchair. The nursing home staff reported the patient choked on food 2 to 3 days ago and declined since then. Prior to arrival, the nursing home staff reported oxygen saturation of 77% on room air and heart rate 120-140 beats per minute. A Chest X-Ray revealed the patient had bilateral infiltrates (substances more dense than air in the lungs) that was more extensive on the right versus the left. Urine looked dark and concentrated with sediment a with Foley catheter (a tube inserted in the bladder to drain urine) placed in ER. A urine culture was obtained and the patient had an elevated WBC of 16.7 mm3. The antibiotic [MEDICATION NAME] 750 mg IV (intravenously) was initiated in the ER to cover the patient's aspiration pneumonia and urinary tract infection and an anti-fungal medication [MEDICATION NAME] 500 mg IV given daily to cover completely for aspiration pneumonia. Patient required supplemental oxygen at 10 L (liters) NRB (non-rebreather mask) to keep oxygen saturation above 92%. Patient will require more than 2 midnight stays to adequately treat multiple diagnosis. On 10/22/18 at 3:10 PM, Staff Nurse K verified he/she was the charge nurse for Resident #22, on (MONTH) 13, (YEAR). He/she stated the nurse aides came to him/her and requested he/she check the resident, because of choking. Staff Nurse K reported when he/she got to the resident, the resident was coughing and talking, then the resident began to have a type of choking cough and she performed the [MEDICATION NAME] maneuver, and the resident did not expel anything from his/her mouth but seemed to swallow what had caused the coughing. Staff Nurse K verified the event took place on 10/13/18, between 8:30 AM to 9:30 AM, and he/she did not take the resident's vital signs or notify the physician of the occurrence. On 10/22/18, upon request, the physician declined an interview. The facility's 5/2017 Nursing Documentation Guidelines/Timelines policy documented day to day type documentation of specific occurrences will be completed by a licensed nurse in the appropriate progress note determined by the content of the note. Upon request, the facility did not provide a policy and procedure directing staff assessment of resident with change in condition. The facility failed to provide timely treatment and nursing care in accordance with professional standards of practice for Resident #22, when staff failed to provide appropriate assessments after a choking incident. The facility transferred the resident to the emergency room for treatment of [REDACTED]. The resident passed away on 10/16/18, at the hospital.

The facility reported a census of 47 residents. The sample included 3 residents reviewed for accidents. Based on record review, observation and interviews the facility failed to provide supervision and assistive devices to prevent a fall with injury during a transfer using the mechanical lift for 1 sampled resident (#1). Resident #1 fell (during transfer) from a full body sling (a cradling soft harness attached to a mechanical lift) when staff improperly positioned the attachment straps and the resident's arms. The resident sustained [REDACTED]. Findings included: - The February 2017 physician's orders [REDACTED].#1 included [DIAGNOSES REDACTED]. The annual MDS (Minimum Data assessment) dated 11/22/16 documented the resident had a Brief interview for Mental Status (BIMS) score of 15 which indicated intact cognition. He/she was not resistive to cares, and required total assistance of 1 to 2 staff with activities of daily living (ADLs) such as bed mobility, dressing, toilet use, transfers and personal hygiene. The MDS recorded the resident had range of motion difficulties, was unstable with surface to surface transfers and used a wheel chair for mobility. The Care Area Assessment (CAA) dated 11/22/16 for ADLs documented the resident had a lengthy history of both shoulders dislocated which prevented him/her from pushing up from a seated position or pulling self to stand. He/she required the use of a total body lift to transfer safely due to not being able to stand and transfer. The fall CAA dated 11/22/16 also recorded the resident used a total lift for transfers and he/she was at risk due to his/her immobility and dependence on staff for transfers. The CAA recorded a care plan would be developed for the resident transfers. The 5 day readmission MDS dated [DATE] lacked documentation of any cognitive or functional changes with the resident. The electronic record lacked documentation of a recent fall risk assessment and/or mechanical lift use assessment. The resident's care plan revised on 11/22/15 documented the resident required 2 staff to turn side to side for repositioning and his/her sling (size large) for total lift to get to a sitting position. The residents care plan revised on 1/11/17 (after the fall) recorded the resident required 3 staff to assist with his/her total body sling, lift, and transfer. Review of the facility investigation documented on 1/4/17 at approximately 4:30 to 5:00 P.M. staff members Q and R assisted the resident to his/her wheelchair using a total body lift with a size large sling per the resident's care plan instruction. Direct care staff verified the color coded strap attachments, lifted the resident with the mechanical lift and positioned the resident over his/her wheelchair. The investigation recorded resident #1 pulled his/herself up using the middle straps (to reposition his/her self) while direct care staff R pulled up on the back of the sling to bring the resident to a seated position. Direct care staff stated the left shoulder strap released and the resident fell head first to the floor (from an approximate 3.5 foot height) and landed on his/her left side. The nurse's note dated 1/4/17 at 5:24 P.M. documented direct care staff Q ran into the hall to summon a nurse after the resident fell to the floor. Nurse H observed the resident on the floor with his/her wheelchair behind his/her head. The lift was at the resident's feet and direct care staff R was on the resident's left side. The left side of the full body sling was dangling from the lift, the resident's legs were twisted under him/her and the resident yelled out. Resident #1 stated that he/she fell when staff transferred him/her. Staff notified Emergency Medical Services (EMS). The emergency room note dated 1/4/17 at 4:36 P.M. documented the resident bumped his/her head but did not lose consciousness, had mild swelling and moderate discomfort to lifting of the right knee off the table, and x-rays revealed a fracture just above the knee. The resident was subsequently transferred to a different hospital for surgical pinning of the fracture and returned to the facility on [DATE] at approximately 9:00 P.M. On 2/22/16 at 3:30 P.M. the resident observed in bed sleeping. His/her right leg had some swelling and he/she wore anti-embolitic hose (compression hosiery designed to aid in preventing blood clots). On 2/22/17 at 4:49 P.M. the resident stated he/she slipped from the lift but could not remember details. He/she stated he/she had been back to see the orthopedic physician and received range of motion exercises and felt stronger. On 2/22/17 at 2:42 P.M. licensed staff nurse H stated on 2/22/17 at around 4 in the evening he/she was called to the resident's room (after the fall) and direct care staff members Q and R stated they were transferring the resident from the bed to the chair and something happened to the lift, they were not able to articulate anything else. Staff H stated the moment the sling was out of the resident's room, staff inspected it and staff did not find anything wrong with the sling. Staff H further stated staff discovered some of the little (locking) clips on the lift would pop up in different directions if too much pressure was applied to them. The resident was found with his/her knees under him/her, where they bend at the knee and staff moved the wheelchair to allow him/her to straighten his/her legs and lay more freely. On 2/22/17 at 5:58 P.M. administrative staff A stated a Root Cause Analysis was done because the facility considered the resident's fall a critical incident. Administrative staff A stated the resident's fall was not due to just one thing but a couple of things. I don't know if it would have changed the outcome. On 2/23/17 at 11:16 A.M. direct care staff Q stated direct care staff always tell the residents to hug themselves (hands/arms across chest) when staff go to lift them. The resident had a habit of pulling up on the middle straps of the lift at times. When staff Q and R went to lift him/her the strap on the upper left shoulder came loose, and he/she fell head first out of the lift. Staff Q stated staff identified the little spring clip that holds the strap in place was loose and he/she might have pushed the strap above the clip (the strap belongs under the clip for appropriate placement) after the resident was put on the ambulance. On 2/23/17 at 6:04 P.M. direct care staff R stated (of the resident's fall) the strap came undone. Staff R was at the back of the lift, behind the resident. The resident always grabbed the middle straps to pull his/herself up in the sling during a transfer. Direct care staff R stated as the resident pulled up on the middle straps, staff R pulled back on the sling. Staff R did not think the lift had been lowered yet when the resident fell out of the sling. Direct care staff R stated he/she heard two distinctive noises when the resident fell ; the first sounded like the ping of metal that the spring clip makes when it is released and the second sounded like a breaking tree limb branch (fracture). The facility's policy titled Fall Prevention and Management revised July 2015 lacked documentation related to the use of mechanical lifts and/or body's slings. The facility's policy titled Safe Resident handling Program revised January, 2016 documented: the Safe Resident Handling Program (SRHP) enabled caregivers to safety support residents who required partial or total support to ambulate, transfer and reposition. The policy lacked documentation specifically to address the use of mechanical lifts and/or positioning of the resident while cradled in a full body sling. The facility failed to ensure the body sling lift straps on the mechanical lift were locked in a secure position, and failed to advise the resident to keep his/her hands/arms free of the straps during a transfer which resulted in a fall and fracture for this mobility impaired, dependent resident.

The facility identified a census of 46 residents. The sampled included 3 residents. Based on observation, interview, and record review, the facility failed to perform accurate elopement risk assessments and failed to provide adequate supervision to one resident (#1) to prevent the resident from leaving the facility unsupervised. The facility staff did not know the resident was missing from the facility until a (therapy staff) notified the facility the cognitively impaired resident was walking away from the facility and down the street. The resident was outside for approximately 36 minutes without staff knowledge. This deficient practice placed the resident in immediate jeopardy. Findings included: - Review of the facility preadmission screening tool dated 4/28/14 for resident #1 documented the resident ambulated with an unsteady gait and stand-by-assistance with a walker. The resident experienced a fall on 4/19/14 that resulted in a left wrist fracture, bruising bilaterally to legs, left shoulder, right toe, wore a splint on his/her left arm for a fractured left wrist, and had cataracts. The preadmission screening tool recorded the resident was not at risk for elopements. Review of the physician signed admission orders [REDACTED]. The resident used a wheelchair or chair alarm at all times, required assistance of one staff for activities of daily living (ADLs), and would likely remain in the nursing home indefinitely. The computerized clinical diagnosis list documented Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure) on 5/1/14. Review of the admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] recorded the resident with a BIMS (brief interview for mental status) score of 10, which indicated moderate cognitive impairment. The resident required extensive assistance with ADLs except for supervision with eating and limited staff assistance with walking in the corridor and on the unit. This same MDS documented the resident with impaired balance, unable to stabilize balance without staff physical assistance, impairment of one upper extremity, and a history of falls prior to admission. Review of the Care Area Assessment (CAA) for activities of daily living (ADLs) dated 5/14/14 recorded the resident with Alzheimer's disease, a degenerative progressive disease that had limited his/her cognition level, and required the resident to need assistance with ADLs. The resident was scheduled to have cataract interventions and surgeries later in the month. The resident seemed to come across as coherent, but was not, required simple step by step instruction, and needed frequent reminders as he/she was unable to retain information. Review of the CAA for falls dated 5/14/14 documented the resident with falls, a left wrist fracture on admission, unsteady balance, required assistance from one staff with a gait belt and cueing and contact guard for ambulation, and an alarm ordered on admission as a safety precaution. Review of the admission nursing note dated 5/1/14 timed 5:21 P.M., documented at 5:10 P.M., the resident admitted to the facility from home, suffered a fracture to the left wrist weeks ago, and his/her family was not able to provide increased care. The resident ambulated into the facility holding onto a family member's arm with a slow steady gait, cooperative with assessment, and able to answer most questions. The resident ' s answers were questionable though, with his/her [DIAGNOSES REDACTED]. Review of the social service admission assessment dated [DATE] recorded the resident was alert to person and place, had intact long-term memory, and impaired short term memory. The facility expected the resident to remain in the facility. Review of the resident ' s comprehensive plan of care dated 5/21/14 documented the resident with impaired cognitive function, dementia, or impaired thought processes, a [DIAGNOSES REDACTED]. The plan of care directed staff to: -Monitor/document/report to health care provider any changes in cognitive function, specifically changes in: decision making ability, memory, recall, and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. -Discuss concerns about confusion, disease process, nursing home placement with resident/family. -Provide weight bearing support for ambulation with a gait belt, contact guard assist of one staff member using single point cane (revised on 5/26/14) for a platform walker to support the resident ' s left wrist. The plan of care documented the resident had an actual fall prior to admission, experienced a fractured wrist and directed staff to place a personal alarm to alert staff to the resident's movement and assist staff in monitoring movement when in his/her room. Nursing notes dated 5/6/14 timed 4:54 P.M. documented the resident ' s family member reported the resident was angry and certain that he/she was perfectly able to be at home and care for him/herself. Review of the " Standards of care " meeting note dated 5/13/14 documented the resident with a BIMS score of 10, no [DIAGNOSES REDACTED]. This document recorded the resident was not an elopement risk. Review of the initial MDS and care plan note dated 5/21/14 timed 8:48 A.M. recorded the resident required limited to extensive assistance of one staff with most ADLs due to impaired cognition, [DIAGNOSES REDACTED]. The resident ambulated with assistance of one staff member and a single point cane, and was occasionally unsteady. The resident received physical, occupational, and speech therapy and used a body alarm while in his/her room. Review of the care plan review note dated 5/21/14 timed 11:39 A.M. recorded the resident required cueing often, directed staff to keep instructions brief and simple, and to continue contact guard assistance of one staff member with transfers. Review of a care plan change note dated 5/26/14 timed 6:46 P.M. directed staff to encourage the resident to push up with his/her right hand with transfers, ambulate with a platform roller walker, and contact guard assistance of one staff member. Review of the nursing notes dated 6/13/14 timed 3:50 A.M., documented the resident had a body alarm for safety, and staff checked on the resident throughout the night. Review of the nursing notes dated 6/14/14 timed 10:36 P.M., recorded at 8:24 P.M. the nurse received a call from direct care staff N that he/she and direct care staff O were at the corner with the resident. Nursing staff directed social service staff X to go get the resident. Direct care staff N and O returned to the building and reported the resident was in the car with social service staff X, the resident refused to come back to the building, and they were going to his/her house to settle him/her down. The direct care staff reported they found out the resident was out of the building because a staff, who worked in the therapy department came in the facility and told them he/she was driving by and saw the resident at the end of the block. Nursing notes documented at 9:25 P.M., noted the resident returned to the facility with family, social services staff X, and required convincing to come into the building. The staff placed a Wanderguard bracelet on the resident and began 15 minute checks at midnight to help prevent another elopement. The resident had no alarms on at the time of elopement to alert staff that he/she left. The resident mentioned at supper that his/her family was coming to get him/her and take him/her home, but he/she did not state or imply a desire to leave on his/her own. Review of the facility provided investigation documented the facility admitted the resident on 5/1/14 from his/her family member's house. On 6/14/14 the resident ambulated with a walker out the front door of the facility. The resident was alert and oriented to person and place. On 5/13/14, the care team discussed the resident ' s elopement risk and found him/her not at risk due to no exit seeking behaviors. The facility determined at 7:44 P.M. the resident was at the keypad and let him/herself out of the building and at 8:00 P.M. A therapy staff member notified nursing staff the resident was on the street ambulating. After security cameras were reviewed, staff was interviewed and revealed the facility's alarms did not sound. Security camera footage revealed the resident let him/herself out of the building without setting off the alarm. (The staff witness statements and interviews revealed facility staff found the resident at 8:20 P.M., approximately 36 minutes after the security camera footage revealed the resident left the building unattended.) According to Wunderground.com on 6/14/14 at 7:52 P.M., the temperature was 82.9 degrees Fahrenheit with a heat index of 86.5, visibility of 10 miles, a south wind at 19.6 miles per hour (MPH) gusting to 28.8 MPH, mostly cloudy, and the civil twilight occurred at 9:26 P.M. Observation on 7/1814 at 8:30 A.M. direct care staff R walked slowly holding on to the gait belt and the resident ' s elbow as the resident used a standard rolling walker. Observation revealed a Wanderguard bracelet on the resident ' s left ankle. On 7/18/14 at 12:27 P.M. the resident asked direct care staff R to take him/her to his/her room. Direct care staff R placed a gait belt on the resident and then walked with the resident and his/her walker from the dining room to the hall. The resident asked the staff member, " Where are you taking me? " Direct care staff R replied, " To your room and the bathroom. " The resident asked, " Where is that? " Direct care staff said, " I ' ll show you. " As they continued to walk, the resident reported, " I don ' t want to go in there. " Direct care staff assisted the resident into a recliner in the lobby and placed a personal tab alarm on the resident ' s clothing and back of the recliner. On 7/18/14 at 12:45 P.M. during an interview, the resident when asked if he/she went for a walk outside the building by him/herself, replied " I don ' t know. " When asked, do you go out to see your doctor? The resident replied, " My (family member) takes me to see doctor (name). " Is he/she your cataract doctor? " I don ' t know. " I understand you had cataract surgery, can you see better? " I don ' t know. " " When can I get out of here? " Observation on 7/18/14 at 2:30 P.M. revealed the facility building was on the south side of the street across from the local hospital emergency entrance. The stop sign at the end of the street was approximately one tenth of a mile from the entrance to the facility. The street north of the facility was an unmarked speed limit and the street within the hospital drive emergency entrance recorded 20 miles per hour limit. Observation of the workings of the front automatic door on 7/18/14 at 2:45 P.M., revealed the signage taped on the front door glass approximately six inches above the door handle that directed " to unlock door press 9-4-8-2*. " Signage directly below this instruction directed, " When the alarm is sounding and the red light is flashing on the magnetic lock, press 9482* to open the door first, then press 67* to silence the alarm. " Observation of the workings of the front entrance door on 7/18/14 at 3:20 P.M. revealed the door had a coded alarm pad. At this time surveyor HH pushed on the door handle without entering the security code which set off the system alarm. The door opened within 15 seconds, and continued to alarm until direct staff S reset the alarm by entering the code, posted on the front door into the lock pad. The next observation after putting in the alarm code in the lock pad, the front door opened automatically and stayed open approximately 20 seconds before it attempted to close. At this time surveyor HH held the door open and prevented the automatic door from closing. After another approximately 25 to 30 seconds the door alarm sounded (for a total of approximately 45-50 seconds of the door opening before the alarm sounded). During this observation, administrative nursing staff D reported that was a long time for the door to remain open without alarming. On 7/18/14 at 10:00 A.M. administrative nursing staff D reported staff did a preadmission screening prior to the resident coming to the facility and the resident just sat there during the screening, did not have a [DIAGNOSES REDACTED]. Administrative nursing staff D reported the security video revealed the resident put the code in the lock pad and left the facility. Administrative nursing staff reported the same code was still posted on the door. On 7/18/14 at 10:27 A.M. Social Services staff X reported on 6/14/14 sometime between 8:00 P.M. and 8:30 P.M. a licensed nursing staff asked him/her to drive down the street and bring the resident back to the facility. Social Services staff X revealed the resident walked with a platform walker and insisted he/she was going home and not to bring him/her back to the facility. On 7/18/14 at 10:45 A.M. licensed nursing staff I reported the facility staff called on 6/14/14 and reported the resident left the facility without supervision. Licensed nursing staff I reported the resident ambulated with a platform walker to support his/her left arm with the fracture. Licensed nursing staff I revealed the resident stated he/she did not want to come back to the facility and when the resident lived with their family, asked to go home. On 7/18/14 at 11:15 A.M. direct care staff N revealed on the evening of 6/14/14 a staff member told him/her the resident was out of the building and down the street. Direct care staff N reported he/she and direct care staff O ran and caught up with the resident at the stop sign at the end of the street at approximately 8:20 P.M. Direct care staff N reported the resident ambulated with a platform walker, stood on the side of the street, and stated he/she was going home. On 7/18/14 at 12:40 P.M. licensed nursing staff J reported the resident made one comment when he/she first admitted about " When I go home " . Licensed nursing staff J reported staff did not assess the resident as an elopement risk prior to his/her leaving the facility unattended on 6/14/14, and the resident now had a Wanderguard bracelet. Licensed nursing staff J reported the staff had to make up their own elopement assessment and with a resident admission assessment each staff did the elopement assessment a little differently. On 7/18/14 at 1:15 P.M. administrative nursing staff D revealed the staff did elopement assessments with standards of care meetings and the diagnoses of dementia was not in computer on 5/13/14 for the resident. Review of the resident ' s scanned documents in the computer at this time revealed the physician ' s admission orders [REDACTED]. Administrative nursing staff D reported the facility changed out the entire video security system on 6/19/14 and 6/20/14 and the video of the resident entering the code into the door pad was not available. On 7/18/14 at 2:00 P.M. direct care staff R reported the resident required stand by assistance of one staff for ADLs and later in the day asked staff, " Who are you? Why are you here? " On 7/18/14 at 2:15 P.M. administrative nursing staff D reported the leadership team and hall coordinator or MDS coordinator reviewed the behaviors that the direct care staff documented in the computer, then the team decided if the resident was an elopement risk. Staff performed preadmission and admission screenings for elopement, and discussed each resident with the standards of care meeting monthly that included alarms and Wanderguard/elopement risks. The resident had no behaviors documented in the computer and staff did not assess the resident as an elopement risk. After the event, staff asked the resident if he/she used the code to get out. The resident asked, " What code? " He/she did not know what staff was talking about. The code was still posted on the door going outside and staff did not change the code. On 7/18/14 at 2:50 P.M. direct care staff P reported on 6/14/14 he/she toileted the resident approximately 4:45 P.M. and last saw the resident at approximately 7:30 P.M. seated in the lobby. Direct care staff P reported he/she heard an alarm while he/she assisted another resident, and reported another staff member cancelled the door alarm between approximately 8:00 P.M. and 8:30 P.M. and said family members exited the building. Direct care staff P reported the resident asked staff, " Why am I here? What is this place? " The resident required a personal alarm in his/her room for the bed and recliner when out of site from staff. The resident did not need the alarm in the dining room or when seated in the lobby. On 7/18/14 at 2:54 P.M. direct care staff Q reported he/she administered the resident ' s medications on 6/14/14 at approximately 7:15 P.M. and revealed another direct care staff turned the door alarm off, and later was informed the resident was down the road. Direct care staff Q reported the resident was now on 15 minute checks and had a Wanderguard. On 7/18/14 at 3:00 P.M. direct care staff O reported on 6/14/14 approximately 30 minutes prior to knowledge of the resident leaving the facility without supervision, the door alarm sounded. Direct care staff O revealed therapy staff GG entered the facility and reported to the staff the resident was walking down the street. Direct care staff O reported he/she and direct care staff N ran down the street and found the resident at approximately 8:20 P.M., standing with his/her platform walker about 6 inches from the curb on the street at the stop sign (approximately one tenth of a mile from the facility). Direct care staff O stated social services staff X drove down and met the resident and staff, convinced the resident to get into the car, and took over care of the resident. On 7/18/14 at 3:15 P.M. licensed nursing staff H revealed during the evening meal, the resident mentioned that his/her family was coming to get him/her. Licensed nursing staff H reported he/she last saw the resident on 6/14/14 at approximately 8:00 P.M. in the lobby prior to his/her exit from the facility and a therapy staff member came in and told direct care staff the resident was down the street and out of the building. Licensed nursing staff H revealed the staff had no actual documentation forms or format for elopement assessments. On 7/18/14 at 4:08 P.M. therapy staff GG reported he/she left the facility between 7:00 and 8:00 P.M. on 6/14/14 and saw the resident walking in the street away from the building with a platform walker at a decent pace. Therapy staff GG revealed he/she had a small child with him/her and drove back to the facility to inform the staff the resident was unaccompanied. Therapy staff GG reported the resident received speech therapy but involvement in therapy depended on the day, had cataract surgery, and had poor safety awareness and poor insight into his/her impairment. Review of the facility policy Elopement dated September 2013 recorded an elopement occurred when a resident left the premises or safe area without authorization and/or any necessary supervision to do so. The policy purpose was to 1) assess and identify residents at risk for elopement and 2) clearly define the mechanisms and procedures for monitoring and managing residents at risk for elopement. These included identification of environmental hazards and individual resident risks including the need for supervision; evaluating/analyzing hazards and risks/implementing interventions, including adequate supervision, consistent with a resident ' s needs, goals, plan of care and current standards of practice and monitoring/modifying interventions as needed. All prospective residents were assessed to determine if they were at risk for elopement. At the time of admission, identify all residents who were at risk for elopement on the care plan with interventions specific to the resident to minimize individual risk. Care plan team members should consider the following when assessing risk of elopement 1) cognitive impairment 2) residents who were new admissions to the center 3) recent alteration in resident ' s mental status without a history of previous cognitive impairment to include memory loss, decreased awareness, and disturbances in judgment, reasoning, and perception. The facility failed to have a system in place to direct staff to perform accurate elopement risk assessments and failed to provide supervision to prevent this cognitively impaired resident from leaving the facility unattended (for approximately 36 minutes). This placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 7/25/14 at 6:00 A.M. when they: On July 21, 2014 at 8:00 A.M. the facility removed the door code from its current location and added it to the top of the doorframe. A posted sign and door code was now separate. On June 14, 2014 resident #1 was care planned for a Wanderguard and 15 minute checks after elopement. On July 21, 2014 at 12:00 P.M. the contracted Door and Fire Company changed the length of time the door stayed open to 15 seconds and then the alarm would sound. On June 16, 17, 18, 19 and 20, 2014 administrative nursing staff E along with administrative nursing staff D, and administrative staff A, held in-services regarding wandering residents, residents with exit seeking behaviors, and what to do in case of an elopement. Staff read and signed the in-service stating they understood how residents were cared for. In-services were held on July 21st at 10 A.M., 22nd at 1:00 P.M., 23rd at 8:00 P.M., 24th at 3:00 P.M., and 25th at 6:00 A.M., 2014 with administrative nursing staff E, administrative nursing staff D, and administrative staff A, to review facility elopement policy, residents with exit seeking behaviors and wandering residents. The facility would review the new door code location, new door opening time and frequency of alarm going off now that door was only opening for ten seconds. Staff would sign they attended the inservice and understand the policy and procedure. Effective July 18, 2014 at 5:30 P.M. when (the facility) got a new admission, staff initiated 15 minute checks for 72 hours as a possible elopement on all residents and included on their care plan. Effective July 21, 2014 staff completed an elopement risk evaluation upon admission and then quarterly thereafter. Social services completed the evaluation and would direct any questions to the nursing staff. Upon admission, residents with these behaviors were screened to ensure the facility could adequately care for them. If the facility was unable to meet their needs, the facility would work to find better placement. The facility would continue to review each resident monthly during the " standards of care " meeting and would include possible elopements, wandering behavior, attempts to leave the center or alteration in the resident ' s mental status without a previous history of cognitive impairment. The QAPI (Quality Assurance Performance Improvement) team would meet on July 21, 2014 to review the abatement statement and have input from the team on any further action they should take. The facility would use the model for improvement and the quality improvement worksheet to ensure systems were put in place to be in compliance with meeting needs of residents with exit seeking behavior. If the medical director was not able to attend the Quality Assurance meeting, the Administrator and the DNS (director of nursing services) would speak with him/her to review the same information and receive his/her input. This deficiency remains at a scope and severity of a D.

The facility had a census of 44 residents. The sample included 5 residents. Based on observation, interview and record review the facility failed to provide adequate supervision and a safe environment free from accident hazards and elopement for 1 of 5 residents reviewed for accidents including elopements. Resident #1 who was cognitively impaired and assessed by the facility as an elopement risk, opened the unlocked door to the boiler room which independently mobile had access to and which also had another door that led to the outside of the facility, fell down the stairs and broke his/her ankle. This failure placed the resident in immediate jeopardy for serious harm or death to occur. Findings included: - The admission (MDS) Minimum Data Set 3.0 assessment, dated 4/30/13, indicated resident # 1 had a (BIMS) Brief Interview for Mental Status score of 6 which indicated moderate cognitive impairment. The MDS indicated the resident was independent with most (ADLs) Activities of Daily Living. The 4/30/2013 (CAAs) Care Area Assessment indicated the resident had a history of [REDACTED]. The quarterly MDS, dated [DATE], indicated the resident had a BIMS score of 3 which indicated a severe cognitive impairment. The MDS indicated the resident was independent with most ADLs and wandered daily. The MDS further indicated the resident used no assistive devices and had 2 or more non-injury falls since the prior assessment. The 10/31/2013 care plan instructed staff to provide activities that promoted diversion and to review and modify environmental hazards that could cause or contribute to a fall. The care plan instructed the staff to visually check on the resident every 15 minutes while he/she was awake and every 30 minutes while he/she was in bed provide a wander guard (departure alert system) and a laser alarm while in bed. The 1/9/14 care plan revision instructed the staff to have a personal alarm on at all times. On 11/26/2013 at 5:13PM, a nurse's note indicated a wander guard door alarm sounded, as the resident opened a door to the outside of the facility and began to fall. The note indicated the resident sat on the floor and told staff to help him/her get up. The note indicated the staff assisted the resident into a wheelchair and took him/her to his/her room for assessment. The resident complained of pain to his/her right shoulder, he/she did hit his/her head and had a small area to right brow where his/her glasses hit his/her face. The note indicated the resident had a skin tear to his/her left ring finger. The note further indicated the resident had no deformity to the shoulder area and he/she was able to move his/her arms. Staff notified the physician and he/she ordered Lortab (a narcotic pain medication) for pain, ice for the pain and swelling and directed staff to make an appointment tomorrow with the physician if resident continued to complain of pain. The 11/27/13 at 10:05 AM, nurse's note indicated the resident had slept in that day and had required assistance from 1 staff with ADLs and getting ready for the day and had required extensive assistance with dressing. The note further indicated the resident's right shoulder is swollen and slightly red with bruising starting and warm to the touch. The note indicated the resident was favoring the right arm and not moving it or using it to eat. The 11/27/2013 at 10:42AM, nurse's note indicated the staff received an order from the physician to send the resident to the emergency room for right shoulder pain. The 11/27/13 Radiology report indicated the resident had a non-displaced (occurs when the pieces of the fractured bone are still aligned) distal (away from the center of the body) right clavicle (a long bone that serves as a strut between the scapula and the sternum) fracture (is the separation of an object or material into two, or more, pieces under the action of stress). Fall risk assessments on 1/2, 1/5, 1/7, and 1/8/14 indicated the resident was a high risk for falls. The 1/5/2014 at 1:47 PM, nurse's note indicated the staff found the resident on the floor in a visitor's bathroom, in the dining room hallway, with no apparent injuries noted, and he/she was taken to his/her room to rest. The nurse's note indicated the resident wandered around the facility today and mentioned wanting to leave the building. The 1/6/2014 at 3:02 PM, nurse's notes indicated the resident wandered throughout the facility and often asked to leave the facility. The 1/7/2014 at 2:45 PM, nurse's note indicated the maintenance staff called the nurse to the dining room hallway. The note indicated the maintenance staff had found the resident on the floor of the boiler room, sitting upright below the lowest step,"shivering", as the outside door was open as well. The note indicated the staff checked the resident's vital signs, and the resident stated "I was following you to grandmas." Review of the medical record revealed the facility immediately contacted emergency services to transfer the resident to the emergency room . The 1/7/2014 radiology report revealed the resident had a moderately displaced oblique fracture(a fracture in which the break has a curved or sloped pattern) of the distal fibula (the outer and thinner of the two long bones of the lower leg) arising from the level of the tibial plafond (the end of the shin bone, just above the ankle joint) and a small lucency (an area absorbing less radioactive energy than the surrounding tissue) at the tip of the medial malleolus which may represent a small avulsion fracture (an injury to the bone in the area where a tendon or ligament attaches to the skeleton). The 1/7/2014 at 9:08 PM, nurse's note indicated the nurse had received a call from the hospital indicating the resident had received a bi-malleolar fracture (a fracture of the ankle that involves the lateral malleolus and the medial malleolus) of his/her left ankle from the fall earlier today and would return to the facility the next day. A 1/8/2014 physician's orders [REDACTED]. The 1/9/14 at 2:53PM, nurse's note indicated the resident was non weight bearing on the left lower leg, with a cast in place, and his/her legs were to be elevated most of the time except during meals, toileting, or therapies. The note indicated the resident was to be in a high back wheel chair with extender. The note further indicated the resident required 2-3 staff assistance with ADLs. On 1/14/2014 at 10:00 AM, observation revealed a locked door to the boiler room located across from the visitor's bathroom in the hallway toward the dining room. Further observation revealed upon opening the door there were 3 cement steps to go down into the boiler room with no handrails present. The light switch was to the left of the door and did not turn on automatically. The room was cold and the floor at the bottom of the steps was cement. Inside the room were wheelchairs, walkers, bedside commodes and tables and 2 water heaters. There was a door at the back of the room that went to the outside and the room lacked any windows. Continued observation revealed the room locked from the inside of the room. Further observation revealed a hook latch at the top of the door and keypad on the door for entry, which was being used. On 1/14/2014 at 11:39 AM, observation revealed the resident seated in a high back wheel chair in the living area with a pink cast to his/her left ankle, passively participating in an activity. On 1/14/2014 at 11:47 AM, Maintenance Staff B reported the facility had a key lock on the boiler room door with the key located on the top of the door frame, which had to manually be removed to unlock the door. Maintenance Staff B confirmed the door had been left unlocked and reported he/she did not know who had left the door unlocked. Maintenance Staff B continued to confirm the facility had changed the lock to a key pad which automatically locked the door, after the resident had fallen. On 1/14/2014 at 12:18 PM, Nurse Aide A reported the resident wandered throughout the building and asked to go home. Nurse Aide A reported he/she does go to boiler room at times to get supplies and the door was to remain locked at all times. On 1/14/2014 at 1:30 PM, Administrative Staff C reported he/she did not know who left the door to the boiler room unlocked at the time of the fall. Administrative staff C reported nursing staff and therapy go into the boiler room because medical equipment is stored there. On 1/14/2014 at 1:53 PM, Maintenance Staff B reported no one regularly checks to see if the boiler entrance door is unlocked and all staff are responsible for making sure the door is locked when the hook is not latched. Maintenance Staff B reported the boiler room had steps 24 inches from the top of the stairs to the bottom, had no natural lighting, and when he/she found the resident the light was not on and the room was dark. On 1/14/2014 at 2:29 PM, Nurse D reported the boiler room door was not checked on a daily basis and the resident had gone to the boiler room door and attempted to open it in the past. The facility failed to provide supervision and assistive devices to ensure an environment free of accident hazards for Resident #1. This failure placed the resident in immediate jeopardy for serious harm or death to occur when the staff left the door to the boiler room unlocked and Resident # 1 fell down the cement steps into the dark room and sustained a fractured ankle. It was 40 degrees outside the day of the resident's fall, and the door to the outside of the boiler room locked from the inside giving the resident access to elope from the facility, past the outside door is a gradual slopping yard in the back of the facility in a residential neighborhood. The immediate jeopardy was abated on January 20, 2014, when the facility developed an in-service and educated the staff regarding wandering residents, residents with exit seeking behaviors and the new keypad locks were installed on the boiler room doors. The facility implemented a daily audit to ensure the interior boiler room door is locked at all times. The facility will conduct the audit daily for 6 months. The facility's Quality Assessment team will meet on 1/20/14 to ensure systems are put in place to be in compliance with meeting the needs of residents with exit seeking behaviors. The deficient practice remains at a scope of a G.