Every finding on record at Gundersen St Elizabeth's Care Center

Based on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were followed for 1 of 1 resident (R54) reviewed for transmission-based precautions.Findings Include: R54's comprehensive Minimum Data Set (MDS) dated [DATE] indicated R54 had moderate cognitive impairment, used a walker for mobility, required substantial/maximal assistance for toileting, partial/moderate assistance for transferring from bed to chair. R54's diagnosis included kidney disease requiring a urinary catheter (flexible, hollow tube inserted into the bladder to drain urine when a person cannot urinate naturally). During an observation on 6/9/26 at 10:59 a.m., director of nursing (DON) entered R54's room to assist with transferring him to a chair so he can eat lunch. R54 required enhanced barrier precaution (EBP) due to an indwelling medical device (urinary catheter). DON failed to apply the appropriate personal protective equipment (PPE) prior to providing care. During an interview on 6/9/26 at 11:03 a.m., DON stated she should have been wearing the appropriate personal protective equipment (PPE) when providing care to R54. She stated R54 required enhanced barrier precautions (EBP) and additional PPE (gown and gloves) were needed due to his urinary catheter. She stated the appropriate PPE is important to prevent the spread of infection from residents to residents. A facility policy titled Enhanced Barrier Precautions dated 5/20/26, EBP is applied when a resident has an indwelling medical device (urinary catheter). EBP should be used when providing high-contact resident care activities (dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, device care, wound care) requiring gown and glove use for EBP.

Based on observation, interview, and document review, the facility failed to develop and implement a system to ensure ongoing, adequate monitoring for side effects with consumed psychotropic medications to promote continuity of care for 3 of 5 residents (R39, R56, R9); and failed to ensure the use of as-needed (i.e., PRN) psychotropic medication was limited to 14-days or extended to a certain date with supporting rationale provided by the medical provider for 1 of 5 residents (R31) reviewed for unnecessary medication use. Findings include: SIDE EFFECT MONITORING: R39 R39's annual Minimum Data Set (MDS) assessment dated [DATE], identified R39 had intact cognition and demonstrated no delusional thinking during the review period. Further, the MDS outlined R39 consumed both antianxiety and antidepressant medications. R39's Medical Plan of Care, dated 4/29/25, identified R39's medications and nursing orders with their corresponding start date(s). This identified R39 as being over [AGE] years old and having active orders for multiple psychotropic medications including: Wellbutrin (antidepressant) 300 milligrams (mg) daily with a start dated recorded 4/13/23; Trazodone (antidepressant) 50 mg twice daily (plus another 25 mg dose in the morning) with a start date recorded 6/21/24; Mirtazapine (antidepressant) 15 mg every bedtime with a start date recorded 9/26/24; and Lexapro (antidepressant) 15 mg daily with a start date recorded 3/25/25. On 5/21/25 at 7:57 a.m., R39 was observed seated in a recliner chair while in her room. R39 was interviewed and recalled consuming several medications for depression including Ativan and trazodone stating she felt, overall, the medications were fine but added aloud, They're going pretty good but I'm awfully tired. R39 stated she had felt really tired for the past several months and denied any other potential side effects of the medications. R39 stated staff were aware of her feeling tired and reiterated aloud, The Ativan and trazodone are the two that really make me sleepy. R39's most recent Behavioral Health Consultant - Follow Up note, dated 1/2025, identified R39 was seen by an outside consultant for her mental and/or behavioral health needs at the care center. The note outlined R39 had sustained a fall that morning without injury and recalled the recent Holiday season. R39's family member stopped by during the visit and the note outlined, We discussed today patient's current status of anxiety as we have been monitoring this for the last several months. Patient expresses concern over sleepiness but has agreed it is in her best interest to maintain her current level of medication as it has been more comfortable than the feeling of anxiety. The note outlined some methods to help reduce anxiety for R39, such as more out-of-room activities, and concluded with dictation, Orders Placed, and, None. The completed note lacked any review of what, if any, potential side effects of the multiple consumed psychotropics were discussed, reviewed or evaluated with R39. When interviewed on 5/21/25 at 8:01 a.m., nursing assistant (NA)-F stated R39 was usually very anxious in the morning hours and would calm down as the day progressed adding R39 would often report she doesn't feel good and of being tired. NA-F stated R39 took medication to help her anxiety but the NA(s) don't record anything in the record about that such as symptoms or interventions, rather, they just pass it on to the nurses. NA-F stated they had never heard R39 complain about medication side effects before, but acknowledged R39 often reported being tired adding she enjoys lights off in her own room. R39's record included a series of notes labeled, BEHAVIOR MONITORING/PSYCHOTROPIC MEDICATION USE ASSESSMENT, and were dated 10/2024, 3/2025, and 4/2025. These notes outlined R39's psychotropic medications were adjusted in 10/2024 and 3/2025, and listed R39's current psychotropic medication regimen and interventions to address potential behaviors. The note dated 4/2025, identified a comprehensive registered nurse (RN) evaluation was completed, and recorded R39 as alert and oriented adding, . is her own person with decision making. R39's medications were listed and included Wellbutrin XL, Trazodone, Ativan and mirtazapine. The note outlined, Resident will state on a near daily basis that she doesn't feel good or that she is tired, generally she does well participating in activities and walking to the dining room to eat. However, all of these completed notes lacked evidence what, if any, potential side effects of the consumed psychotropic medications were being monitored or evaluated. R39's ADL Care Plan, dated 4/17/25, identified R39 was independent with ambulation and used a walker. A section labeled, Behaviors, identified R39 was anxious and would, at times, complain about a crawling stomach. R39's corresponding Care Plan, printed 5/19/25, identified R39's outlined problem statements, goals, and interventions along with date of onset and/or revision. This care plan identified, BEHAVIORS . may become very anxious and tearful, please reassure/redirect me as needed; provide 1:1 when able and PRN medication (if still available) when other interventions ineffective. The care plan continued, Nurses ------ I receive scheduled Wellbutrin XL, Lexapro and Trazodone and Ativan to help manage depressive symptoms and anxiety . administer as ordered and observe for effectiveness . Observe for potential s/s [signs] increased depressive symptoms . update NM/MD as needed. However, both of these provided care plans lacked what, if any, potential medication side effects were identified for R39 or being monitored despite R39 consuming multiple psychotropic medications. R39's Med Pass AM flowsheet, dated 5/2025, identified R39's current physician-ordered medications and staff initials to demonstrate their administration and/or refusal. This identified current orders for Wellbutrin, trazodone, Ativan, and Lexapro with no refusals recorded. In addition, R39's corresponding Treatments/All flowsheet, dated 5/2025, identified R39's current nursing orders and treatments being completed along with staff initials to demonstrate their administration and/or refusal. This included a weekly skin assessment and a single flush to the ears for wax build-up; however, both the medication and treatment flowsheet(s) lacked evidence of what, if any, potential side effects with psychotropic medication were being monitored despite R39 having ongoing complaints of feeling tired. Further, R39's medical record was reviewed and lacked evidence of ongoing psychotropic medication side effect monitoring being completed to determine what, if any, effects had been identified or warranted ongoing monitoring despite R39 having potential effects (i.e., sleepiness). When interviewed on 5/21/25 at 8:39 a.m., RN-A verified they worked with R39, and explained when a psychotropic medication was adjusted then a short-lived order was placed on the MAR or TAR to monitor them for a response to the medication adjustment. However, this was more for behaviors and if they increased or decreased, and not for side effects of the medication. RN-A stated they were unsure when this was last completed for R39 and expressed it was just done if it showed on the MAR or TAR to be done and not on an ongoing basis. RN-A added, I couldn't tell you when I last charted it. RN-A stated they were unsure who or where ongoing side effect monitoring would be documented in the medical record. RN-A stated R39 complained everyday about being tired but R39 wanted the medications to continue as she'd rather be more tired without anxiety. On 5/21/25 at 10:52 a.m., the director of nursing (DON) was interviewed. DON verified they had reviewed R39's medical record and explained when a medication was adjusted then a short-lived order was placed to monitor the resident for their mood and behaviors. DON stated side effect monitoring was done by exception if noticed only. DON verified they were unable to provide documentation to show ongoing side effect monitoring but acknowledged the importance of monitoring for side effects to help ensure they don't worsen adding, We want to prevent those things. PRN MEDICATION: R31's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R31 had significant cognitive impairment. Diagnoses included progressive neurological condition, dementia, anxiety and depression. Medications received included an antipsychotic, antianxiety, antidepressant and opioid. R31's Care Area Assessment (CAA) dated 12/2/24 included psychotropic drug use. The CAA triggered related to resident having received scheduled antipsychotic medication, antianxiety and antidepressant medications. R31 received Seroquel (antipsychotic medication) twice a day and had previously received three times a day. R31 also received Buspar (used to treat anxiety) three times a day and sertraline (used to treat depression, panic disorders, and anxiety) every day. R31 also had an as needed lorazepam (used to treat anxiety and insomnia) and Seroquel available which were not used during the look back period. Administer as needed lorazepam when other interventions have been ineffective in controlling symptoms of anxiety. R31's Medical Plan of Care, last signed 5/7/25 included lorazepam 0.5 mg tablet by mouth every 4 hours as needed for anxiety. *No scheduled end date due to hospice*. R31's Medical Plan of Care was also signed on 3/26/25, 1/15/25, 10/30/24, and 7/11/24. The orders did not include a rationale to extend the medication. R31'S Medication Administration Report (MAR) for 11/21/24 through 5/21/25 were reviewed. R31 received the lorazepam medication on 11/22/24, 12/7/24, 12/11/24, 12/19/24, 12/22/24, 12/27/24, 12/29/24, 12/30/24, 1/7/25, 1/9/25, 1/13/25, 1/17/25, 1/25/25, 2/13/25, 2/15/25, 2/16/25, 2/17/25, 2/21 through 3/7/25, 3/10 through 3/12/25, 3/22/25, 4/15/25, and 5/15/25. R31's plan of care dated, 4/25/25 included self care deficit related to dementia and weakness. Behaviors included a long history of anxiety and depression and receives medications for these. Will yell out help me which disrupts the living environment. R31 is calmer when wife is with him, or 1:1 staff. As needed medications have been helpful when other interventions were not effective. Reorient and reassure R31 as needed, approach in a calm manner, introduce self each time, explain what assistance is being provided, encourage participation in diversional activities, provide 1:1 as able and use as needed medications when available. Notify hospice, nurse manager or physician if frequency of as needed medication is increased and or anxiety increases. An interview and observation on 5/19/25 at 2:58 p.m., R31's family member (FM)-A indicated R31 gets sleepy after use of the as needed medication or change in his scheduled medication and has addressed this with the facility. FM-A stated things have gotten better over the past few months. R31 stated it is going okay here at the facility and is thankful FM-A is here frequently. R31 was sitting in his recliner and was alert and answering questions, but frequently looked to FM-A to answer questions. An interview 5/21/25 at 8:06 a.m., pharmacist (Pharm-A) stated all psychotropic medications required to have an end date and need to be reviewed by the provider prior to that end date even if they are a hospice resident. Pharm-A stated for as needed use for hospice they can go out six months as long as a rationale is included. Pharm-A stated she must have missed that on R31. An interview 5/21/25 at 8:30 a.m., registered nurse, hospice case manager (RN)-H, stated she is not aware of a requirement of end date of 14 days or need for rationale if extended longer for as needed psychotropic medications. An interview 5/21/25 at 9:23 a.m., registered nurse (RN)-B, stated generally as needed psychotropic medications require a renewal and face to face every 14 days. However, hospice has told the facility that isn't the case for hospice residents. RN-B stated the facility added the statement *No scheduled end date due to hospice* behind the order so staff are aware it isn't required. An interview 5/21/25 at 10:07 a.m., the director of nursing (DON) confirmed lorazepam is required to be renewed with face to face every 14 days even if residents are on hospice. Facility policy was requested for Psychotropic Medications use. A Consultant Pharmacist policy dated 12/17/24 was received and included the purpose is to provide pharmaceutical services in an accurate and safe manner with the collaboration between the pharmacy consultant facility leadership, facility staff, practitioners and the medical director to meet the individualized needs of the residents in this facility. The pharmacy consultant will complete at least a monthly medication regimen review for each resident in the facility and will meet all other responsibilities required of a qualified consultant pharmacist as set forth in any federal or state law, statues or regulations as enacted or as may be enacted or amended. R56 R56's annual Minimum Data Set (MDS) assessment, dated 4/25/25, indicated R56 had intact cognition with no hallucinations or delusions and no behavioral symptoms including physical or verbal behavioral symptoms directed at others, or behavioral symptoms not directed toward others. Further, it indicated R56 received an antipsychotic and antidepressant medication. R56's May 2025 Medication and Treatment Administration Record (MAR/TAR), included the following orders: -aripiprazole (antipsychotic medication used to treat mental/mood disorder) 2 milligram (mg) by mouth daily AM indicate for Use: other: severe episode of recurrent major depressive disorder, with psychotic features with a start date of 2/17/25. Medication was noted as administered 5/1/25 through 5/21/25. -Celexa (antidepressant medication used to treat depression) 20 mg by mouth daily Am indication for use: depression with a start date of 5/21/24. Medication was noted as administered 5/1/25 through 5/21/25. The document lacked evidence of side effect monitoring. R56's ADL Care plan, indicated the care plan was last updated on 4/14/25 and included the following information: - Please complete pivot transfer recliner to w/c (wheelchair) and w/c to recliner only. He will require A1 (assist 1) w/2ww (with 2 wheeled walker). Use EZ stand (mechanical lift) for all other transfers). ADL Care Plan lacks evidence of side effect monitoring. R56's Care Plan, included the following information: -transferring: 2 assist with use of EZ stand. 2/11/25 foal: sand pivot w/c to recliner. Please use 2 ww for pivot only for power w/c to and from recliner. EZ stand for all other transfers. -please administer my scheduled Celexa ordered, observe my for potential s/s of increased depression including social withdrawal, changes in my usual eating/sleep pattern. R56's care plan lacked indication R56 was prescribed an antipsychotic medication, possible side effects of antipsychotic medications, and monitoring of side effects of antipsychotic medication (i.e., tardive dyskinesia or orthostatic hypotension). Further, R56's care plan lacked identification of side effects of antidepressant medication and monitoring for side effects of antidepressant medication. R56's vital sign logs, for 2/25/25 through 5/20/25 were reviewed. The document lacked evidence of orthostatic blood pressures being completed. R56's progress notes, for 2/25/25 through 5/202/25 were reviewed. Progress notes lacked evidence of side effect monitoring. R56's Behavior Monitoring/Psychotropic Medication Use assessment, dated 10/24/24, reviewed. The document identified R56 transfers with 2 assist and an EZ stand, and assessment being completed secondary to new medication order of Abilify (aripiprazole). The document lacked evidence of side effects to monitor for either antipsychotic or antidepressant medications. R56's Behavior Monitoring/Psychotropic Medication Use assessment, dated 4/24/25, reviewed. The document identified R56 had orders for aripiprazole and Celexa which was administered to R56. The document lacked evidence of side effects to monitor for either medication. During an interview on 5/19/25 at 3:21p.m., R56 was observed sitting in his room in his recliner. R56 was soft spoken but engaged in conversation. On 5/20/25 at 3:41 p.m., R56 was observed in his recliner in his room. R56 stated he was getting ready to take a nap. During an interview on 5/21/25 at 10:52 a.m., registered nurse (RN)-A stated when a resident starts on a psychotropic medication, side effects are monitored and charted as a progress note. RN-A was uncertain about ongoing side effect monitoring. RN-A stated when orthostatic blood pressures are to be checked there would be an order and it would be found on the MAR/TAR. RN-A reviewed R56's orders and MAR/TAR and verified there was no current order for obtaining orthostatic blood pressures. RN-A verified R56 had not had an orthostatic completed and documented since at least February 2025. RN-A stated R56 transfers with an EZ stand or a pivot transfer with staff assistance when going from his wheelchair to recliner. RN-A stated checking orthostatic blood pressures are important to ensure there isn't a drop in blood pressure putting residents at greater risk for falls and injuries. During an interview on 5/21/25 at 11:07 a.m., director of nursing (DON) stated documentation was completed more by exception meaning if something was wrong then it would be documented on. When asked specifically about side effect monitoring for psychotropic medications, DON stated don't technically monitor for side effects as we chart by exception. During a follow up interview on 5/21/25 at 11:46 a.m., DON stated he was unsure if it was recommended that orthostatic blood pressures be completed on residents who are on antipsychotic medications. DON stated the facility does orthostatic blood pressures after a resident falls or if there is a specific doctor order to complete them. DON stated orthostatic blood pressures are not being completed on residents who are taking antipsychotic medications. On 5/21/25 at 12:06 p.m., surveyor left consulting pharmacist (pharm)-A a voicemail message requesting a call back. During a phone interview on 5/22/25 at 9:56 a.m., pharm-A verified she was the consulting pharmacist for the facility. Pharm-A stated she was not sure if orthostatic blood pressures should be monitored when a resident was taking an antipsychotic medication. Pharm-A stated that the facility does a DISCUS (a dyskinesia identification system condensed user scale - monitors for tardive dyskinesia) every 6 months, when the medication is started to get a baseline and when the medication is discontinued. Pharm-A stated she has seen very few cases of TD (tardive dyskinesia), typically when someone who previously had TD, and with the new antipsychotics we see it less than with the older antipsychotics. R9's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R9 had intact cognition and demonstrated no delusional thinking during the review period. Further, the MDS outlined R9 consumed antidepressant medications. R9's Medical Plan of Care dated 12/18/24, identified R9's medications and nursing orders with their corresponding start date(s). This identified R9 as being over [AGE] years old and having active orders for multiple psychotropic medications including: -Trazodone (antidepressant, commonly used sleep aid) 150 mg daily at bedtime -Prozac (antidepressant) 30 mg daily in the morning R9's Care Plan, dated 12/18/24, identified R9 was unable to walk at this time due to onset of severe back pain. A section labeled Sleep identified R9 had trouble sleeping and would require Trazodone every night; notifying provider if R9 had trouble sleeping or irregular sleep pattern. A section labeled Medication identified R9 received Prozac for depression; monitor for effectiveness and side effects of these medications, report any significant changes in mood/behavior. A section labeled Behaviors identified R9 was sometimes noncompliant with medications and treatments; remind R9 the provider has ordered the medications and treatments and the benefits these provide. However, none of these care plans specified, if any, potential medication side effects were identified for R9 or being monitored despite R9 consuming multiple psychotropic medications. During interview on 5/20/25 at 10:39 a.m., nursing assistant (NA)-E stated, she isn't sure what side effects they would monitor for someone on a sleep aid, like Trazodone, because if it worked then the resident would be asleep. If the resident was still awake after taking the sleep aid then she would let the nurse know. NA-E stated, if a resident has a specific side effect to watch for, there would be an order and an area to chart in the treatment administration record (TAR). NA-E stated, she doesn't think any residents on the unit has side effects to monitor or chart on. During interview on 5/20/25 at 10:46 a.m., licensed practical nurse (LPN)-A stated, staff monitor side effects right after the resident starts a new psychotropic medication; usually 1-2 weeks are monitored. LPN-A stated, the side effects while a resident is taking a psychotropic medication include increase sleepiness, dizziness, agitation, problems with gait (walking), suicidal, or uncontrolled movements. LPN-A stated, most of the residents have been on these types of medications for a long time so they aren't being monitored for side effects. During interview on 5/21/25 at 10:52 a.m., director of nursing (DON) stated documentation was completed more by exception, meaning if something was wrong then it would be documented on. DON stated, don't technically monitor for side effects as we chart by exception. A facility-provided Psychotropic Medication policy, dated 2/2024, identified residents would receive psychotropic medications when needed to treat specific conditions or symptoms. The policy continued, Nursing employees shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the provider [listed], however, the policy lacked how the campus would monitor for side effects with non-antipsychotic psychotropics (i.e., antidepressants, hypnotics); nor direction on where this monitoring would be documented within the medical record.

Based on observation, interview, and document review, the facility failed to ensure alternatives (i.e., small grab bar, positioning devices) were offered, attempted and recorded in the medical record prior to the use of bilateral one-half (1/2) side rails for 4 of 4 residents (R122, R45, R56, R222) observed to have side rails attached to their bed. Findings include: R122 R122's admission Minimum Data Set (MDS) assessment dated [DATE], identified R122 had intact cognition and demonstrated no delusional thinking during the review period. Further, the MDS included a section labeled, Section P - Restraints, which identified R122 used no bed rails. R122's Restraint Use Assessment, dated 5/9/25 and located with her registered nurse (RN) charting, identified R122 as admitting from the emergency department (ED) and having a history of heart failure, obesity, and diabetes. The evaluation outlined, Upon assessment of the resident, there is no current need for any restraints at this time as she is content with her admittance to the facility. The note concluded, . continue to monitor resident for any changes . However, on 5/19/25 at 2:51 p.m., R122 was observed lying in bed while in her room. R122's bed had bilateral, chrome-colored metallic 1/2 side rails on both sides of the bed which attached to the bed frame using a single bracket on the bottom. The rail attached to the open side of the bed (side to rise/enter) was mildly loose when touched and the rail moved several inches side-to-side despite being attached to the bed. R122 stated she admitted to the care center the week prior from the hospital campus due to needing a ceiling lift for transfers. R122 stated staff had come into her room after she admitted and made me sign something about using the side rails, however, had never asked her about wanting them or not; nor any alternative devices (i.e., smaller grab bar) prior to installing them. R122 stated, rather, staff just showed up with them in the room and said 'can we install these?' to which R122 responded, Sure. R122 stated she used the rails to help with bed mobility, and she denied concerns or injury from these, thus far. R122's Consent for Use of Bed Rails/Assist Devices, dated 5/9/25, identified a written marking next to an option which read, Half (1/2) Rail, along with sections to outline potential benefits and risks with the use of the device. The form identified the rails were recommended due to two options listed as, Resident Choice/Security, and, Bed Safety. R122 signed the consent on 5/9/25, however, the spacing to have a staff member sign it was left blank. However, again, the form lacked evidence of what, if any, alternatives to a 1/2 side rail were considered, offered or discussed as a potential alternative to R122 prior to their installation. R122's corresponding Resident Assessment, dated 5/9/25, identified a section labeled, Side Rails/Assistive Devices Assessment Required, with a checkmark placed to demonstrate an affirmative (i.e., yes) response. The section included four questions to be answered by staff with a checkmark placed next to either a, Yes, or, No, response. These questions were all marked to affirm R122 was able to demonstrate safe use of the rails, able to understanding the potential risks of them, able to use her call light appropriately, and the use of the rails would enhance the resident' mobility in bed or with transfers. However, the completed evaluation lacked evidence of what, if any, alternatives to a 1/2 side rail were considered, offered or attempted prior to their installation. Further, R122's ADL care plan, dated 5/14/25, identified R122 needed assistance of two with a mechanical lift for transfers. The care plan continued and identified R122 was independent with side to side bed mobility with only assist of one as needed (i.e., PRN). Further, the plan outlined a section labeled, Siderails, which indicated, 1/2 bilateral. When interviewed on 5/20/25 at 10:38 a.m., nursing assistant (NA)-A stated they had worked with R122 multiple times prior, and described her as pretty independent with most cares. NA-A explained R122 used a mechanical lift for transfers and, with bed mobility, expressed the staff helping her generally [had] to move her while in bed as R122 seemed to struggle in boosting herself up. NA-A verified R122 used bilateral side rails, and stated she had used them since admission adding, As far as I know. NA-A stated multiple residents used them and expressed the rails were more kept with the bed, not with the person from their understanding of them. NA-A stated they had never seen other devices, such as a trapeze or smaller grab bar, used on R122's bed since she admitted and, again, reiterated it was almost always just the bilateral side rails used on resident' beds. R122's medical record was reviewed and lacked evidence of what, if any, alternatives to a 1/2 side rail had ever been presented, evaluated, or offered to R122 prior to the installation of bilateral 1/2 side rails. On 5/20/25 at 2:28 p.m., the director of nursing (DON) was interviewed. DON verified R122 had 1/2 bilateral side rails attached to her bed and expressed they were used for positioning and not as a restraint. DON explained the nurses, upon admission, evaluate the need for them through their assessment process and obtain a physician order for them before their installed. DON stated he was unable to speak to the options which may have been presented to R122 instead of a side rail as he didn't complete the assessment, however, felt there were no other options (i.e., smaller grab bar, trapeze) even to use. When questioned on what, if any, alternatives to the side rails were ever offered to R122 either upon admission or since, DON responded, That I cannot speak to. DON stated they would discuss the matter with other nurses and obtain more information. During follow-up interview, at 3:32 p.m., DON verified they were unable to locate evidence in the medical record on what, if any, alternatives had been offered or considered prior to the side rails being installed. DON stated they reviewed the facility' policy on side rails and it did direct to check for alternatives prior, such as a trapeze, before the rails are installed. DON stated they were unsure what other alternatives the center had available to install, but acknowledged smaller bars or options may well work for residents. When interviewed on 5/20/25 at 3:45 p.m., the facilities manager (FMR) stated the center used two different types of bed, and maintenance was repeatedly taking rails on and off of them as residents would admit or discharge from the campus. FMR stated an assessment of the rail safety or any alternative would be completed by nursing adding their department (maintenance) just assumed that was done prior to them requesting the rails installed. FMR stated nobody from the care center had ever asked them about what, if any, alternatives were available adding, We were never asked to look into that. R45 R45's significant Minimum Data Set (MDS) assessment dated [DATE], indicated R45 admitted to the facility on [DATE], had intact cognition and independent with transfers. The MDS indicated in section, P0100. Physical Restraints, that R45 had bed rails that were not used as restraints. R45's Consent for Use of Bed Rails/Assist Devices dated and signed by R45 on 9/11/24. The document listed benefits and potential negative outcomes of side rails. The document lacked any documentation or evidence of alternative methods/products attempted prior to the use of bed rails. Furthermore, the document had a section titled RECOMMENDATIONS: Based on physical and cognitive assessment, indications for the use of side rails or assistive devise are: resident choice/security, mobility bed safety, other which have boxes next to them to indicate. This area of the document was left blank. Furthermore, the document had a section TYPE OF RAIL/ASSIST DEVICE with small box next to the option to be marked to indicate what type of device to be used. The options included: quarter (1/4) rail, half (1/2) rail, Full rail, assistive device, and other. This area was left blank with no options marked. The consent for use of bed rails/assist device was not completed in full. R45's Resident assessment dated [DATE], indicated R45 was able to demonstrate safe use of the side rails/assistive device, verbalized understanding of potential risks, demonstrated the ability to use the call light appropriately for assistance and would use the side rails to enhance bed mobility or with transfers. A physician order dated 9/11/24 included an order for ½ (half) bilateral siderails. During an interview and observation on 5/19/25 at 3:35 p.m., R45 stated he has had bed rails since he moved into the facility last September which were observed to be on his bed. R45's bed had bilateral, chrome-colored metallic 1/2 side rails on both sides of the bed which attached to the bed frame using a single bracket on the bottom. The rail attached to the open side of the bed (side to rise/enter) was mildly loose when touched and the rail moved several inches side-to-side despite being attached to the bed. During a follow up interview on 5/20/25 at 10:30 a.m., R45 stated he used the bed rails to prop himself up at night to use the urinal. R45 stated the bed rails had always been on the bed and did not know about any alternatives to bed rails. R45 stated the bed rails had always been a little loose and denied any concerns with this. R45 denied any injuries related to using bed rails at this time. During an interview on 5/20/25 at 2:33 p.m., director of nursing (DON) stated he cannot speak to how often assessments are completed for the use of bed rails but believed it would be upon admission and with a significant change or change of condition. DON verified R45's Consent for Use of Bed Rails/Assist Devices was not completed as the section for indication for use and type of rail was left blank and stated it should have been filled out completely. During a follow up interview on 5/20/25 at 3:33 p.m., DON verified he was able to review R45's medical chart. DON stated R45 did not have any alternatives attempted prior to installation of bed rails. R56 R56's annual MDS dated [DATE], indicated R56 had intact cognition and required maximal staff assistance with bed mobility with an admission date of 5/21/24. The MDS indicated in section, P0100. Physical Restraints, that R56 had bed rails that were not used as restraints. R56's Consent for Use of Bed Rails/Assist Devices dated 5/21/24. The document listed benefits and potential negative outcomes of side rails. The document lacked any documentation or evidence of alternative methods/products attempted prior to the use of bed rails. A physician order dated 5/21/24 included an order for ½ (half) side rails to bed for mobility. During an interview and observation on 5/20/25 at 3:41p.m., R56 stated he has had bed rails since moving to the facility. R56 stated he uses them to get out of bed. R56 stated they have always been a little wiggly. R56 stated they have never been tightened since being attached to the bed nor had they become unattached when using them. R56 stated he has never tried or been offered any other devices to help with mobility beside the bedrails. R56's bed had bilateral, chrome-colored metallic 1/2 side rails on both sides of the bed which attached to the bed frame using a single bracket on the bottom. The rail attached to the open side of the bed (side to rise/enter) was mildly loose when touched and the rail moved several inches side-to-side despite being attached to the bed. During an interview on 5/20/25 at 3:33 p.m., DON verified he reviewed R56 medical chart and stated R56 did not have any alternative attempted prior to the installation of the bed rails.R222 R222's admission Minimum Data Set (MDS) assessment, dated 5/15/25, indicated R222 had moderate cognitive impairment with no behaviors. R222 had no impairment to upper or lower body extremities, was set up assist for eating and oral cares, moderate assist for upper body and showering, and dependent on staff for lower body cares. R222 was independent with repositioning side to side, moderate assist with changing to and from lying to sitting, and dependent on staff for standing and transfers. The MDS also indicated R222 had no bedrails or alarms. R222 was enrolled in hospice care. R222's provider orders included morphine as needed for pain, lorazepam as needed for pain, anxiety, sleeplessness, shortness of breath, oxygen 3 liters per minute, and venlafaxine daily for depression. R222's admission careplan indicated R222 require 1 assist for activities of daily living, had no behaviors. During observation on 5/19/25 at 4:10 p.m., R222's bed had bilateral chrome half upper side rails attached to the frame of the bed at one attachment point. The grab bar was loose. During interview on 5/19/25 at 10:50 a.m., R222 stated she uses the side rails to reposition in bed and help her sit up. R222's side rail assessment dated [DATE] was marked N/A. R222's restraint use assessment progress noted dated 5/9/25 indicated No restraints recommended. Resident declines wanting to use side rails at this time. Will re-evaluate as needed. During interview on 5/20/25 at 12:58 p.m., nursing assistant (NA)-A stated R222 can reposition self and does not use side rail often. NA-A stated the beds come with the side rails. They can be detached upon request however are kept for safety's sake. During interview on 45/20/25 at 1:20 p.m., registered nurse (RN)-E stated R222 is able to make some position changes independently however does need assistance to sit up. R222 does use the side rails to help with positioning. RN-E stated resident's require a provider order for side rails which should be indicated in the medical plan of care. RN-E confirmed R222 does not have an order for side rails. RN-E then stated, you know what, it is careplanned. RN-E confirmed R222's careplan indicated no side rails. RN-E stated physical therapy usually assesses for the need for side rails upon admission. During interview on 5/20/25 at 1:29 RN-F stated R222's family stated they wanted R222 to have the side rails, however, they could not find a consent for the side rails in the hospice book or R222's hard chart. Facility policy, Proper Use of Side Rails/Assistive Devices, dated 12/2023, identified a purpose of ensuring the safe use of side rails and assistance devices. The policy outlined these would only be used to treat a medical symptom or to assist with mobility and transfers. The policy outlined, Less restrictive interventions that will be incorporated in care planning include . Providing a trapeze to increase bed mobility . Further, the policy outlined, Documentation will indicate if less restrictive approaches are not successful, prior to considering the use of side rails/assist devices.

Based on interview, observation, and record review the facility failed to identify and document the trauma-related history, post-traumatic stress disorder (PTSD), known triggers and lacked a system or process for completing trauma assessments for 1 of 1 residents (R59) with a known history of PTSD. Findings include: R59's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition with no behaviors. Diagnosis included post traumatic stress disorder and anxiety. R59 required partial to moderate assist for transfers, ambulation, toileting and personal hygiene. R59 was taking an antidepressant medication. R59's care plan dated 9/12/24, included a problem of self-care deficit related to activity intolerance, due to medical diagnoses. Resident history included he served in Vietnam. Behaviors included R59 may refuse cares at times and also forget to ask for assistance when needed. R59 may have crying episodes at times and doesn't like confined small spaces. A Behavioral Health Note dated 5/31/24 included a past psychiatric history of PTSD and readily engaged in testimony as to prior traumatic experiences. R59 has a substantial history of prior military traumas and personal losses which have been suppressed and managed through years of avoidance and distraction. R59's document review failed to include a trauma assessment or evaluation of R59's PTSD. R59's behavioral care plan failed to identify triggers or interventions related to managing R59's PTSD. On 5/19/25 at 6:05 p.m., R59 stated he served in the military and in Vietnam. R59 stated the Veterans Administration (VA) has treated him well for the most part. R59 stated he likes to be outside where he gets fresh air and when confined inside he feels sometimes like he can't get his breath. R59 would like staff to take him on walks outside more or at least just walk him outside of his room but it doesn't always happen and he feels like staff don't always listen to him. R59 was seated in his wheelchair in his room with oxygen on per nasal cannula. A walker was present. On observation 5/20/25 at 1:10 p.m., R59 was observed seated in a wheelchair in the sun room playing checkers with another resident. R59 did not have his oxygen on. On observation and interview 5/20/25 at 3:30 p.m., R59 was accompanied by nursing assistant, ambulating in the hallway with his walker with his oxygen on per nasal cannula. R59 smiled and said it feels good to be walking and be out of my room. On interview 5/20/25 at 1:37 p.m., social services (SS)-A stated she was aware R59 had a PTSD diagnosis but the facility only does mood assessments and a PTSD assessment would be done by a doctor or psychiatrist. SS-A stated they do not have a screening process in place for admissions for PTSD at this time. SS-A stated if someone has issues with PTSD we would do a behavioral care plan and do 1:1's with the resident. On 5/20/25 at 1:48 p.m., registered nurse (RN)-B stated nurses do not do a PTSD screen or assessment on admission. RN-B confirmed the care plan did not have any triggers listed, but she is aware he likes to be outdoors and doesn't like being stuck in his room with 4 walls. RN-B added R59 enjoys talking to other veterans, but only will talk about his PTSD when he wants to but not about actual events that happened. RN-B added R59 can walk on his own without staff present and frequently leaves his room on his own. On interview 5/20/25 at 2:43 p.m., RN-D stated he was not aware of R59's PTSD diagnosis and is not aware of triggers or interventions related to PTSD for R59. RN-D indicated generally he would look in the mood or behavioral care plan for triggers and interventions. On interview 5/20/25 at 3:38 p.m., nursing assistant (NA)-C and NA-D stated they were not aware of R59's PTSD. NA-C and NA-D stated they rely on other staff to let them know if they are having behaviors or not or look at the updated care plan in the book on the unit but that only covers activities of daily living like how many people to transfer, bath, etc On interview 5/21/25 at 9:38 a.m., RN-B stated the facility does not have a policy and procedure related to trauma informed care and provided Behavioral Assessments, Intervention and Monitoring policy and Abuse, Neglect, Mistreatment and Misappropriate of Resident Property policy and procedure. On 5/21/25 at 10:01 a.m., the director of nursing confirmed R59 did not have a PTSD assessment or plan of care and stated he was not aware of the trauma informed care regulations. A Behavioral Assessments, Intervention and Monitoring policy dated 12/12/24 included: - Upon admission, residents who display or are diagnosed with a mental disorder or psychosocial adjustment difficulty, or who have a history of trauma and or post-traumatic stress disorder will have referrals made for on-site or off-site psychiatric/psychological services. - Specific, individualized interventions will be put into place to aide in the behavior management that included non-pharmacological modalities. - The inter-disciplinary team will meet to review and discuss specific resident behaviors, appropriateness and effectiveness of interventions, current medications, psychiatric service recommendations. Resident behavior health needs will be addressed on the resident's person centered plan of care.

Based on observation, interview, and document review, the facility failed to ensure direct-care staff were trained and competent in the daily use of resident' medical equipment to ensure safety and reduce the risk of complication (i.e., device failure) for 1 of 1 resident (R53) who used a bed-side continuous positive airway pressure (i.e., CPAP) machine. Findings include: R53's admission Minimum Data Set (MDS), dated [DATE], identified R53 had moderate cognitive impairment but demonstrated no delusional thinking during the review period. The MDS outlined R53 had several medical diagnoses including atrial fibrillation, chronic kidney disease (CKD); and used a non-invasive mechanical ventilator while a resident at the care center. R53's Insomnia Assessment, dated 3/21/25, was recorded in her progress notes. This identified R53 denied any concerns with sleeping and used a CPAP device. On 5/19/25 at 3:05 p.m., R53 was observed seated in a recliner chair while in her room. R53's bed was positioned along the window and adjacent was a small bedside dresser which had a black-colored Resmed Airsense 10 CPAP sitting on top with an attached mask hooked onto the wall. R53 stated their significant other who visited the campus several times a week managed the device for her mostly and did the cleaning and maintenance of it for her. R53 stated the settings for the machine were pre-programmed by the significant other and staff usually just helped her turn it on to use. R53 stated the machine did, at times, have an issue or stop working with an alarm adding when that happens, she would ask staff for help with it. R53 stated she was unsure how knowledgeable staff were about the device though as some staff seemed to not know how to use it. R53 stated she started questioning staff now if they know how to use it before they touch it adding aloud, I ask them. When interviewed on 5/20/25 at 12:44 p.m., nursing assistant (NA)-B stated R53 was often not accepting of help with cares and likes to do her own thing. NA-B stated R53 used a CPAP at night adding she had done for since admission to the care center. NA-B stated the NA staff do nothing with it, however, rather the device was maintained by the nurses adding aloud, The nurses are supposed to manage that. R53's Treatments flowsheet, dated 5/13/25 to 5/20/25, identified a nursing order which read, . Cleanse CPAP daily in the AM and let air dry [am shift], with a listed start date, 03/21/2025. The order was signed off as completed each day during the period with staff initials. The provided flowsheet lacked any further information about the CPAP including settings the device should be at or any troubleshooting information about potential malfunctions or alarms which could activate. On 5/20/25 at 1:08 p.m., registered nurse (RN)-A was interviewed, and verified they were assigned care for R53. RN-A explained they had worked with R53 multiple times prior and described her as needing more help than she'd often allow for cares. RN-A verified R53 used a CPAP and nurses cleaned it, however, R53 would often re-assemble it before it was dry on her own. RN-A stated the settings were programmed into the device and the second shift was more responsible for the device, however, at times, they had to deal with the device adding a situation had happened just last week where they couldn't get the device to turn off. RN-A stated they had to call R53's significant other at home to triage and resolve the issue over the telephone adding they were concerned about screwing something up on the device. RN-A stated each CPAP machine was a little different and staff, at times, would almost have to YouTube it to learn how to use it. RN-A stated the facility had not provided them or any nurses with training on the CPAP device; nor was their a manual kept around about it adding aloud, I don't recall any. When interviewed on 5/20/25 at 1:40 p.m., the director of nursing (DON) stated there were several models of CPAP but all seemed to work on the same basic understanding and operation with function. When questioned on how these devices were taught to the direct care staff, then DON explained they used a model of a staff member learning the device, then teaching everyone else; however, DON stated they were unsure who was responsible to facilitate this model of teaching adding, That I can't speak to. The DON stated, I would hope they have some critical thinking skills and look it up online. DON stated it would potentially be difficult to teach every model of CPAP but acknowledged the devices were very important. DON stated most of their completed in-time training was done for equipment which had only one model type and voiced an example of their IV pump(s). DON reviewed the NEO (new employee orientation) checklist and verified it lacked training on CPAP device(s) or their use. DON stated they were unsure if a copy of the device' user manual was around the campus or not, however, added printing one off and having it available was likely helpful adding aloud, I like that idea. DON stated none of the direct care staff had expressed concerns about being unfamiliar with R53's CPAP prior and, if concerns were present, the staff could call a next level leader about it, too. DON acknowledged having staff trained and competent in the device was important just for safety and to reduce the risk of infection or complication. A provided CPAP (Continuous Positive Airway Pressure), Use of policy, dated 10/2024, identified general guidelines for the device which included, Only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP mask. However, the policy lacked information on what training would be completed by the care center to ensure competency with the device.

Based on observation, interview, and document review, the facility failed to develop and implement a preventative, regular maintenance program of resident' beds and side rails to ensure safety and reduce the risk of complication (i.e., bed malfunction, entrapment) for 3 of 3 residents (R122, R45, R222) reviewed who used side rails on their bed. However, the lack of a program had potential to affect all 75 residents residing at either campus. Findings include: R122's admission Minimum Data Set (MDS), dated [DATE], identified R122 had intact cognition and demonstrated no delusional thinking during the review period. Further, the MDS included a section labeled, Section P - Restraints, which marked R122 as not using a bed rail with dictation, 0 = Not Used. On 5/19/25 at 2:51 p.m., R122 was observed lying in bed while in her room. R122's bed had bilateral, chrome-colored metallic 1/2 side rails on both sides of the bed which attached to the bed frame using a single bracket on the bottom. The rail attached to the open side of the bed (side to rise/enter) was mildly loose when touched and the rail moved several inches side-to-side despite being attached to the bed. R122 stated she admitted to the care center the week prior from the hospital campus due to needing a ceiling lift for transfers. R122 stated staff had come into her room after she admitted and made me sign something about using the side rails, however, had never asked her about wanting them or not; nor any alternative devices (i.e., smaller grab bar) prior to installing them. R122 stated, rather, staff just showed up with them in the room and said 'can we install these?' to which R122 responded, Sure. R122 stated she used the rails to help with bed mobility, and she denied concerns or injury from these, thus far. R45's significant change in status MDS, dated [DATE], identified R45 had intact cognition and was independent with transfers and bed mobility. The MDS section labeled, Section P - Restraints, marked R45 as not using a bed rail with dictation, 0 = not used. On 5/19/25 at 3:35 p.m., R45 was observed in his room. R45 stated he had bed rails attached to his bed since he moved into the facility last September (2024) and, upon observation, his bed had bilateral, chrome-colored metallic 1/2 side rails which attached to the bed frame using a single bracket on the bottom. The rail attached to the open side of the bed (side to rise/enter) was mildly loose when touched and the rail moved several inches side-to-side despite being attached to the bed. R222's admission Minimum Data Set (MDS) dated [DATE] indicated resident had moderate cognitive impairment with no behaviors, and being independent with repositioning side to side, needing moderate assist with changing to and from lying to sitting, and dependent on staff for standing and transfers. The MDS also indicated R222 had no bedrails or alarms. On 5/19/25 at 4:10 p.m., R222's bed was observed which had bilateral, chrome one-half upper side rails attached to the frame of the bed at one attachment point below. The grab bar was loose when touched. On 5/20/25 at 10:38 a.m., nursing assistant (NA)-A was interviewed, and verified R122 along with many other residents used bilateral side rails. NA-A stated the rails were more kept with the bed, not with the person from their understanding of them. NA-A stated they had never seen other devices, such as a trapeze or smaller grab bar, used on resident' beds and, again, reiterated it was almost always just the bilateral side rails used on resident' beds. SEE F700 FOR ADDITIONAL INFORMATION ON SIDE RAIL USE When interviewed on 5/20/25 at 3:32 p.m., the director of nursing (DON) stated the campus had multiple types of resident beds and they were unsure what, if any, routine review or maintenance program was being done for them. DON stated if a side rail was found to be loose, then staff could complete a work-order for maintenance to address it. On 5/20/25 at 3:45 p.m., the facilities manager (FMR) was interviewed, and he explained the campus used two types of resident' beds adding there had been discussion on getting some of the more dated beds to be phased out in the coming years. FMR explained when a resident discharges the campus, they receive a work-order to remove the side rails from the bed and then, often, get another work-order when a new resident comes in to re-attach the side rails. FMR stated they just assume the nursing department has completed their review of the bed or siderail to ensure safety. FMR stated there was no ongoing, routine maintenance program completed for the beds to ensure safety, either with or without the side rail(s) attached, adding aloud, No, no. FMR stated they had talked about implementing a preventative maintenance program for the beds in the past, however, had never pursued it. FMR stated the floor staff should be checking the beds to ensure safety adding such was a responsibility of them [floor staff]. Further, FMR stated they were unsure if the side rails were made by the bed manufacturer and would look into that adding aloud, That's a great question. On 5/21/25 at 10:33 a.m., a follow-up interview was held with FMR, who explained checking the bed frame and mattress for fitment (i.e., including to reduce the risk of mattress shift and entrapment with the side rail) was all on the [direct] staff. FMR stated they would occasionally have work-order come through to adjust a mattress but not often. FMR stated they had located the user's manual for the bed type(s) which directed annual maintenance should be completed, however, this was not being done. FMR stated they would start a routine maintenance program for the beds to ensure safety adding aloud, That's something we're going to have to go forward with. FMR stated there was no specific user's manual able to be located for the side rails and reiterated issues with safety or maintenance would just be addressed as discovered. A facility' provided Excel document, undated, was provided which was labeled, Work Orders Excel Spreadsheet. This identified all recently completed maintenance items done at either campus. This recorded one issue with a bed control not working, multiple examples of a bed-extender being needed/attached, and one entry which recorded, Other - has old bed, needs brown siderails attached. The provided document lacked any evidence of ongoing preventative screening or maintenance review to ensure resident' bed safety. On 5/21/25 at 10:46 a.m., a follow-up interview with the DON was held. DON stated there was no set schedule or routine for nursing staff to inspect the resident beds to his knowledge. DON stated beds should likely be inspected on a routine basis though to promote safety and reduce the risk of falls and entrapment. On 5/21/25 at 1:14 p.m. the environmental services director (ESD) was interviewed. ESD explained their staff help with a monthly bed wash on every room and complete the terminal cleaning when a resident discharges. ESD explained they inspect the mattress at that time to ensure it's intact and clean, however, this was not tracked or documented. ESD verified they were not checking for preventative maintenance on the beds or areas where potential entrapment could occur adding if a rail was loose, then a work-order would be completed and the maintenance department would address such. ESD provided a document labeled, Bed Wash, which had each unit listed on a separate page along with initials of staff who completed it. However, the document lacked instructions or directions on what specific items were performed during these monthly washes. A facility' policy on bed maintenance was requested, however, none was received.

Based on record review, and interview the facility failed to ensure a written notification of transfer and/or discharge was sent to the office of the Ombudsman for 1 of 1 (R45) residents reviewed for hospitalization . Findings include: R45's quarterly minimum data set (MDS) assessment dated [DATE], indicated R45's diagnoses included congestive heart failure (CHF), peripheral vascular disease (PVD-poor circulation), diabetes mellitus (DM), hyperlipidemia (HLD-high levels of lipids in blood), and asthma. Progress notes indicated R45 was hospitalized from 11/6/23 until 11/10/23. R45's medical record lacked evidence a written notification of transfer was sent to the Ombudsman for long term care. On 4/3/24 at 12:16 p.m., an email was received from the administrator stating they had not notified the ombudsman of the transfer for R45. During an interview on 4/3/24 at 5:37 p.m., registered nurse (RN)-A stated the facility would only notify for emergency transfers and hospitalization , however stated they were unsure of exact process, and it was normally completed by the administrator. On 4/4/24 at 2:15 p.m., the administrator confirmed the office of the ombudsman had not been notified of the hospital transfer. The facility policy Transfer or Discharge Notice last reviewed 12/21/23, indicated a copy of the notice was to be sent to the office of the state long-term care Ombudsman.

Based on record review, and interview the facility failed to provide a written notification/copy of a bed hold for 1 of 1 (R45) residents reviewed for hospitalization . Findings include: R45's quarterly minimum data set (MDS) assessment dated [DATE], indicated R45's diagnoses included congestive heart failure (CHF), peripheral vascular disease (PVD-poor circulation), diabetes mellitus (DM), hyperlipidemia (HLD-high levels of lipids in blood), and asthma. Progress notes indicated R45 was hospitalized from 11/6/23 until 11/10/23. R45's medical record lacked evidence a written notification of the bed hold policy was provided to the R45 or their representative prior to or during the hospitalization . On 4/4/24 at 12:19 p.m., an email was received from the administrator confirming that the bed hold had not been provided to the resident or their representatives. During an interview on 4/4/24 at 12:42 p.m., licensed practical nurse (LPN)-A, stated the facility had not been completing bed holds since prior to the covid-19 pandemic. On 4/4/24 at 1:13 p.m., the registered nurse manager (RN)-A stated the facility goes through bed hold information upon admission, and inform the family of transfers, however confirmed the bed hold had not been completed. On 4/4/24 at 2:15 p.m., the administrator confirmed the bed holds had not been completed. The facility policy Bed Hold Days last reviewed 12/29/23, indicated in the case of emergency transfer, the resident/responsible party was to be provided with written notice within 24 hours of transfer, and once completed to be placed in the residents chart.

Based on observation, interview and document review, the facility failed to complete an assessment on an active, daily smoker, for independence and safety with smoking, handling and storing smoking paraphernalia for 1 of 1 residents (R31) reviewed for accidents . Findings include: According to R31's annual Minimum Data Set assessment dated [DATE], R31 was assessed as being cognitively intact, used a walker for ambulation and required assistance and cueing for hygiene purposes at the facility. R31's care plan dated 3/8/22 indicated related to smoking: resident wishes will be respected whilst periodically providing education alternatives to current tobacco use. No other interventions were listed. On 1/9/23, at 1:30 p.m. R31 was observed standing outside of the facility, across the street, smoking a cigarette. R31 was appropriately dressed for the weather, wore a bright orange vest and was using a special walker with hand brakes and lights. When interviewed on 1/9/23, at 3:36 p.m. R31 was observed in his room where he had his cigarettes, and stated he kept his lighter on him. His lighter was not observed. R31 stated he kept his door closed at all times and other residents did not enter his room. R31 stated his intent to continue smoking, but understood he was not able to smoke on the facility property. R31 stated he had never had a problem with his smoking, had not suffered any burns, or burned his clothing. R31 stated staff were aware he smoked, but did not know if an assessment had been done for safety. When interviewed on 1/10/23, at 1:46 p.m. a licensed practical nurse (LPN)-A stated R31 was a known smoker and had been determined to be safe to go off campus to smoke. LPN-A stated a smoking assessment was not done by the nurses, but LPN-A thought the director of nursing (DON) would have done such an assessment, but did not know where the assessment could be found. LPN-A stated R31's smoking plan should be listed in his care plan, but also stated she was not able to locate the information in the chart. When interviewed on 1/10/23, at 2:45 p.m. the DON stated assessments should be done annually and stored in the resident's hard chart. Findings from assessments should then go into the resident's care plan to provide communication appropriate interventions to staff. DON stated they were a non-smoking facility so R31 was not to smoke on the facility property and staff did not assist him with smoking. When interviewed on 1/11/23, at 9:29 a.m. DON was not able to locate a smoking safety assessment. The facility administrator stated R31 had been observed smoking by staff, but no formal assessment had been done since he was not allowed to smoke on the facility grounds. When interviewed on 1/11/23, at 12:34 p.m. the director of physical therapy (PT)-A stated R31 had been receiving services from both physical and occupational therapy. PT-A stated assessments were done to ensure R31 was safely independent ambulating outdoors on his own, but smoking safety was not addressed. PT-A stated occupational therapy worked on general safety awareness but nothing specific to smoking. PT-A stated she had addressed smoking cessation with R31, but he was not interested. A facility policy titled Resident Smoking, dated 12/29/22, indicated the facility was a smoke-free facility and staff may not offer to assist residents off campus to smoke or to go with staff on smoke breaks, and resident care plan will reflect interventions to help with smoking cessation and adjustment to not smoking.

Based on observation, interview, and document review, the facility failed to follow the care plan which resulted in a fall for 1 of 3 residents (R1) reviewed for falls. This caused actual harm to R1 when she fell out of her recliner, fractured her pelvis in three places and eventually died . Findings include: R1's diagnosis list dated [DATE], indicated R1 had diagnoses of [CONDITION(S)], chronic obstructive pulmonary disease (difficulty breathing) and depression. R1's annual Minimum Data Set (MDS) dated [DATE], indicated R1 had moderate impairment of vision, moderately impaired cognition and required limited one person assistance with bed mobility, transfers, locomotion on/off unit, dressing and toileting. R1's MDS indicated R1 had not had any falls since the last assessment R1's Care Area Assessment (CAA) for falls dated [DATE], indicated R1 was at risk for falls related to her visual deficit fluctuating cognition and unsteady gait. R1's CAA further indicated R1 was alert and oriented with confusion and was able to use her call light appropriately. R1's CAA also indicated R1 had not had any falls in the last quarter, and R1 slept in her mechanical lift chair. R1's care plan dated [DATE], indicated R1 was at risk for falls related to age, impaired safety awareness, medication use and decreased mobility. Staff were directed to make sure R1's call light was within reach, ensure the room was free of clutter, adequate lighting, walker was within reach, and remind R1 to use her call light for staff assistance. R1's care plan also directed staff to assist R1 to the bathroom and back to her recliner. R1's ADL (Activities of Daily Living) care plan (resident care summary sheet) revised [DATE], listed a miscellaneous note that R1 verbalized understanding of risks with utilizing her electric recliner. Those risks included potential for injury including death when falling asleep in the recliner in an upright position. The ADL care plan also had the following handwritten notations: - Recliner to be kept unplugged when in use dated ,d+[DATE] (initialed by registered nurse [RN]-C). The note was highlighted in yellow dated [DATE], initialed by RN-B. R1's Consent for Power Lift Chair Form was last reviewed and signed by R1 and her responsible party dated [DATE]. On [DATE], at 10:28 a.m. a progress note entered by RN-C described R1's behavior as R1 attempting to self-transfer, and RN-C found R1's recliner in the upright position. R1 told RN-C she was getting ready to go to the bathroom. The progress note indicated to remind R1 to wait for staff, as R1 was about to slide out of her chair. The progress note also indicated RN-C would keep R1's chair unplugged, the care plan was updated, and a sign was placed in R1's room. The note indicated RN-C would pass along this information to the oncoming shift. On [DATE], at 9:34 p.m. a progress note indicated R1 had been ringing her call light frequently that evening, and was not happy that her chair was unplugged. On [DATE], at 1:45 p.m. a progress note entered by RN-B indicated R1's care plan was updated to reflect her recliner was okay to be plugged in per R1's request. R1 continued to verbalize known risks including death, if she were to improperly use the remote resulting in the recliner being put too far in the upright position. On [DATE], at 5:15 p.m. a progress note indicated at 4:15 p.m. trained medication aide (TMA)-A and nursing assistant (NA)-A notified RN-A that R1 had a fall. The progress note indicated R1 was lying on the floor, with the foot rest elevated in the upright position. The progress note indicated R1 had been hallucinating, and her hallucinations had started the previous day. The progress note indicated R1 reported severe pain, and was yelling out when staff attempted to bend her left leg. Staff noted R1's left leg was shorter than the right. The note indicated R1 reported to staff she had needed to go to the bathroom, and had fallen while getting out of her recliner. The note indicated R1 had not put the footrest of the recliner down upon attempting to get up, and her call light was not on to ask for staff assistance. The progress note lacked indication if R1's recliner was plugged in or not. R1's Hospital Discharge Summary dated [DATE], indicated R1 sustained three fractures to her pelvis. On [DATE], at 9:27 a.m. family member (FM)-A was interviewed and stated when she was informed of R1's fall, she was not made aware R1's chair was found to be unplugged. FM-A stated this concern had been raised to her several weeks ago by the facility. FM-A stated the facility called to inform her that R1's chair was unplugged due to the risk of falling. FM-A stated she told the facility both she and R1 wanted R1's reclining chair to remain plugged in, and they accepted the risk for injuries. On [DATE], at 11:41 a.m. RN-B was interviewed. RN-B stated R1's ADL care plan was updated on [DATE], and at that time, the chair was to be unplugged. RN-B stated after speaking with R1 on [DATE], she changed the ADL care plan to reflect the chair was to be kept plugged in. RN-B stated she reviewed the risks vs benefits of having the chair plugged in with R1. RN-B stated after R1's fall, staff informed her R1's chair was unplugged. RN-B confirmed R1's chair was supposed to be plugged in per her edited note on the ADL care plan sheet. On [DATE], at 12:03 p.m. TMA-A stated he found R1 laying on the floor on [DATE], at 4:15 p.m. TMA-A stated he had taken R1 to the bathroom around 3:10 p.m. that day roughly an hour prior to the fall. TMA-A stated prior to starting his shift he had been informed R1 was having some confusion during the morning shift and I could hear her yelling out, which was not normal for [R1] and delusions and to keep an eye on her. I would check on [R1] every five to 10 minutes. [R1] was not oriented the day before. TMA-A stated R1 was a one person assist with a gait belt and walker for transfers and toileting. TMA-A stated on the day of R1's fall, R1's recliner was unplugged. TMA-A noted per his knowledge of R1's care plan that R1's recliner should have been plugged in that day. TMA-A stated, It would have been the shift prior who had unplugged the chair. TMA-A reiterated R1's care plan was to have her recliner plugged in when in use, and R1's family as well as R1 knew enough to know that she wanted to it be plugged in. TMA-A also stated he had worked with R1 in the past and R1 was very compliant with using her call light for assistance to go to the bathroom. On [DATE], at 12:36 p.m. TMA-B stated she worked the morning shift the day of R1's fall. TMA-B stated R1 was not at her baseline, was not herself, she was hollering out and confused and more towards the end of the shift. [R1] was wanting to use the TV remote as the chair remote. And I let the nurse know that I had unplugged it. [recliner]. TMA-B stated she knew R1's ADL care plan directed to keep R1's recliner plugged in. TMA-B further stated, I had unplugged [the recliner] for her to not fall out, because she was trying to move. So I unplugged the chair so she would not fall out. On [DATE], at 1:20 p.m. RN-A stated [DATE], she had been made aware that R1's recliner was unplugged by staff prior to her fall. RN-A stated she agreed with staff's decision to unplug the chair due because R1 had a complete change in cognition, that had progressed very rapidly. On [DATE], at 2:00 p.m. nurse practitioner (NP)-A was interviewed. NP-A stated she had just visited with R1 at 3:50 p.m. the day of R1's fall. NP-A stated she noted a change in R1's baseline, and further added R1 exhibited major confusion. NP-A stated did not feel the fall directly resulted in R1's death, and stated the issues relating to R1's decline likely began two months prior to the fall. On [DATE], at 4:31 p.m. the director of nursing (DON) stated she had investigated R1's fall, and had interviewed TMA-A and TMA-B regarding R1's reclining chair being unplugged. The DON confirmed per R1's care plan R1's recliner was to remain plugged in. The facility policy Fall Risk assessment dated [DATE], directed the facility would evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or [CONDITION(S)]) or sensory impairments (such as decreased vision and peripheral [CONDITION(S)]) that may predispose the resident to falls. The policy further directed the facility would use assessment data to identify underlying medical conditions that may increase the risk of injury from falls and would seek to identify environmental factors that may contribute to falling. The facility policy Resident Care Plans, Development, Implementation and Revision dated [DATE], directed all team members have the responsibility of knowing and following the care plan, and alerting the team members to goals completed and/or changes needed.

Based on observation, interview and document review, the facility failed to establish an on-going infection control program, which included comprehensive surveillance of resident infections that did not require an antibiotic and analysis of infections. In addition, the facility failed to ensure linens were stored appropriately to maintain clean condition. This had the potential to affect all residents in the facility. Findings include: ANALYSIS OF INFECTIONS The facility infection control logs provided by RN-E, were reviewed from 9/2018 through 8/2019. The logs included the following: 9/18 - 7 urinary tract infections [MEDICAL CONDITION], 2 upper respiratory infections (URI) 10/18 - 6 UTI, 6 pneumonia 11/18 - 8 UTI, 4 pneumonia 12/18 - 6 UTI, 3 URI, 3 pneumonia 1/19 - 8 UTI, 6 URI, 4 pneumonia 2/19 - 6 UTI, 10 URI, 5 pneumonia 3/19 - 12 UTI 4/19 - 4 UTI 5/19 - 7 UTI, 2 URI, 1 pneumonia 6/19 - 6 UTI, 1 URI 7/19 - 8 UTI, 1 URI 8/19 - 4 UTI, 1 URI, 1 pneumonia The facility was unable to provide any further information, logs or tracking tools for infections that did not require the use of an antibiotic or medication in the facility and any information of analysis of infections from 9/2018 through 8/2019. During interview on 9/12/19, at 1:55 p.m., RN-E stated no, she did not have a written analysis of the facility's infections. RN-E stated to be truthful, she has to do formal analysis to identify what needs to be done to reduce infection recurrence. RN-E stated the process was not currently in place. RN-E stated she was not tracking [MEDICAL CONDITION], but should be tracking all. She indicated currently only tracking if a resident was on an antibiotic, antifungal or on a medication for [MEDICAL CONDITION]. STORAGE OF CLEAN LINENS During tour of the facility laundry areas, on 9/12/19, at 9:35 a.m., with secretary (S)-C observation revealed the facility 100 wing, 200 wing and 300 wing clean linen closets each had a stack of clean cloth incontinent pads placed on top of a foot stool. At the time nursing assistant (NA)-A stated the foot stools do get stepped on by staff. During interview on 9/12/19, at 1:55 p.m., registered nurse (RN)-E stated stated foot stools were not designated to be used for storage of clean linens. The facility policy Infection Prevention and Control Program Committee, dated 7/16/19, indicated the infection prevention and control committee will review, evaluate, make recommendations and implement actions and/or solutions relating to all infection prevention and control action and processes involving education, prevention, surveillance, and the prevention and control of infections across all departments and services within the organization.

Based on interview and document review, the facility failed to ensure the pharmacist addressed the use of an as needed (PRN) [MEDICAL CONDITION] medication beyond 14 days for 1 of 5 residents (R5) reviewed for unnecessary medications. Findings include: R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R5 had severe cognitive impairment and [DIAGNOSES REDACTED]. R5's physician order [REDACTED]. However, R5's [MEDICATION NAME] PRN order lacked an end date, or a documented rationale for an extended time period with a specific duration. R5's pharmacy review dated 8/29/19, identified chart reviewed for September, 2019. [MEDICATION NAME] 0.5 mg added every 4 hours PRN on 8/14/19. Chart is reviewed without any concerns. During interview on 9/11/19, at 9:00 a.m., registered nurse (RN)-D confirmed the order for the PRN [MEDICATION NAME] had no end date and was being used beyond the 14 days. RN-D confirmed the pharmacy review dated 8/29/19, did not address the use of the PRN [MEDICATION NAME]. During interview on 9/12/19, at 12:10 p.m., nurse practitioner (NP)-B stated she was not aware R5 had an order for [REDACTED]. During interview on 9/12/19, at 2:15 p.m., the director of nursing (DON) stated her expectation would be to follow CMS (Centers for Medicare and Medicaid Services) guidelines for regulations for ensuring compliance for PRN [MEDICAL CONDITION] medication use and the pharmacist to ensure the facility was in compliance with the regulation requirement. The facility policy Psychoactive Medication Use, dated last reviewed 1/30/19, indicated resident's receiving psychoactive drug therapy will not receive these medications without having an acceptable [DIAGNOSES REDACTED]. The facility policy Consultant Pharmacist in LTC (long term care), dated last reviewed 10/1/18, indicated the purpose of this policy was to provide pharmaceutical services in an accurate and safe manner with collaboration between the pharmacy consultant, facility leadership, facility staff, practitioners and the medical director to meet the individualized needs of the residents in the facility. The pharmacy consultant will provide expertise and oversight in all aspects pf pharmaceutical services in the facility.

Based on interview and record review, the facility failed to ensure PRN (as needed) [MEDICAL CONDITION] medication orders were not renewed beyond 14 days without the prescribing practitioner evaluating the appropriateness of the medication for 1 of 5 residents (R5) reviewed for unnecessary medications. Findings include: R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R5 had severe cognitive impairment and a [DIAGNOSES REDACTED]. R5's care plan updated 2/21/19, included cognitive/[MEDICAL CONDITION]: R5 has severe cognitive impairment. R5 refuses cares and gets angry at times due to not understanding needs. R5 feels depressed at times. R5 is on [MEDICATION NAME] (antidepressant) and [MEDICATION NAME] (antipsychotic) to treat depression, hallucinations, and paranoid thoughts. Staff to monitor for effectiveness. Mood: R5 at risk for depression due to cognitive impairment and R5 does not understand situation and why living in facility. R5 need staff to monitor effectiveness of [MEDICATION NAME] and [MEDICATION NAME] to treat mood and depression, paranoia, resistance to cares, weeping. Alteration in thought related to dementia. Give PRN medications as ordered for specific medical symptom/behavior. Monitor effectiveness. Monitor side effects and dosage reduction when appropriate. R5's physician order [REDACTED]. However, R5's [MEDICATION NAME] PRN order lacked an end date, or a documented rationale for an extended time period with a specific duration. R5's record lacked documentation by the physician for the continued need of the PRN [MEDICATION NAME] beyond 14 days. During interview on 9/11/19, at 9:00 a.m., registered nurse (RN)-D confirmed the order for the PRN [MEDICATION NAME] had no end date and was being used beyond the 14 days. RN-D confirmed the use of the PRN [MEDICATION NAME] beyond 14 days had not been addressed by R5's physician. During interview on 9/12/19, at 12:10 p.m., nurse practitioner (NP)-B stated she was not aware R5 had an order for [REDACTED]. During interview on 9/12/19, at 2:15 p.m., the director of nursing (DON) stated her expectation would be to follow CMS (Centers for Medicare and Medicaid Services) guidelines for regulations for ensuring compliance for PRN [MEDICAL CONDITION] medication use. The facility policy Psychoactive Medication Use, dated last reviewed 1/30/19, indicated resident's receiving psychoactive drug therapy will not receive these medications without having an acceptable [DIAGNOSES REDACTED].

Based on observation, interview, and document review the facility failed to ensure an emergency kit (E-kit) that contained narcotic medication was appropriately secured for 1 of 2 emergency kits reviewed. In addition, facility failed to ensure eye drops were appropriately dated when opened to ensure outdated medications were not available for use for 2 of 3 residents (R26 and R60) reviewed for labeling of eye drops. Additionally, the facility failed to remove one stock medication from 1 of 2 rooms reviewed for appropriate medication storage. Findings include On [DATE], at 6:18 p.m. a medication storage review observation was conducted with licensed practical nurse (LPN)-[NAME] LPN-A indicated the E-kit for the nursing home was located in the employee break room in a locked cupboard. The employee lunchroom was observed to be unlocked. LPN-A unlocked the cupboard; the E-kit was a red plastic box that resembled a medium sized fishing tackle box that had numbered breakaway tabs. Contents of the E-kit included: -2 vials injectable [MEDICATION NAME] 8 milligrams/milliliter (mg/ml) -2 30 ml vials [MEDICATION NAME] concentrate solution 20 mg/1 ml -6 tabs [MEDICATION NAME] 5 mg -6 tabs [MEDICATION NAME] 50 mg -1 15 ml vial [MEDICATION NAME] 1mg/ml -1 vial injectable [MEDICATION NAME] 5mg/ml -2 15 ml vials [MEDICATION NAME] solution 2 mg/ml -6 tabs [MEDICATION NAME] 0.5 mg LPN-A confirmed the E-kit with opioid narcotics was not secured with a double locking system and the break room was accessible to all staff and visitors. LPN-A stated the E-kit was opened when a medication was needed, the numbered breakaway tabs were removed, the medication was removed and logged, then new breakaway tabs were put back on, and pharmacy was notified when a medication was removed. LPN-A indicated the pharmacy would then come pick up the box and replace it. LPN-A stated the pharmacy would count the narcotics and that was the only time the narcotics were counted. During an interview on [DATE], at 10:44 a.m. registered nurse (RN)-B confirmed the E-kit was not secured with a double locking system and the narcotics in the kit were not routinely counted. During an interview on [DATE], at 9:03 a.m. RN-D stated that she was aware the E-kit was not secured with a double locking system and probably should be. During an interview on [DATE], at 10:30 a.m. hospital pharmacist confirmed that the nursing home did not have a secured double locking system for E-kit. Pharmacist confirmed that the only time the narcotics were counted was when the E-kit was returned to the pharmacy after a medication was removed. Pharmacist indicated that the numbered break away tabs were used as a method to track when and by whom the kit was accessed; if narcotics had gone missing it would not be known until the kit was returned to pharmacy. During an interview on [DATE], at 1:06 p.m. director of nursing (DON) indicated an awareness that the nursing home E-kit was not secured with a double locking system, needed to be resolved, and would take care of the issue. During an observation on [DATE], at 7:41 a.m. licensed practical nurse (LPN)-B was preparing R60's morning medication. R60 was to receive three different eye drops and LPN-B removed them from the locked medication storage unit in R60's room. A bottle of Refresh Tears eye drops (over the counter moisturizing drops), one drop to be administered to each eye. The manufacturer's label stated they expired in (MONTH) of 2020. The bottle had not been labeled when opened and there was no indication when it had been received. LPN-B stated she was unsure of how long it would be good for after it was opened. LPN-B removed a bottle of [MEDICATION NAME] (a medication for [MEDICAL CONDITION]) eye drop solution from the medication storage unit and prepared to administer one drop to both eyes. The bottle had not been labeled when it was opened, and the box it had been shipped in from the pharmacy with the pharmacy label was not found in the storage unit. LPN-B was unable to determine when the bottle had been received from the pharmacy or when it had been opened. LPN-B also removed a bottle of Latanoprost (also for [MEDICAL CONDITION]) eye drops, one drop each eye, from the storage unit, had not been dated when they were opened. A box with the pharmacy label for the Latanoprost was located and it indicated the medication had been delivered to the facility on [DATE]. LPN-B stated this was a problem because the medication was only good for six weeks after opening. She stated, since there is no open date on the bottle we have to go by the delivery date. During an observation on [DATE], at 9:06 a.m. LPN-D found R26 had an open bottle of [MEDICATION NAME] solution 0.5% stored in the medication cart for the 300 unit. The bottle had a manufacturer expiration date of (MONTH) 2021 but a delivery date of [DATE]. The bottle had not been dated when opened. LPN-D stated she did not know how long the solution was good for. LPN-D called another nurse and then reported eye drops were only good for thirty days after opening. LPN-D also located an expired stock saline enema in the medication storage room for the 300 unit. The label on the bottle indicated it had expired (MONTH) of 2019. No residents were known to be currently using saline enemas and LPN-D removed the medication for destruction. According to an interview on [DATE], at 10:00 a.m. director of nursing (DON) stated they had been aware of concerns related to eye drops expiring sooner after opening than the manufacturer's expiration date. She stated they had problems with insurance companies stating they would not cover the cost of the medications if they were all disposed of within a ,[DATE] day time frame. Because of this, DON said she worked with their consulting pharmacist and her supervisor to come up with a list of eye drops and how long they are good for according to the medication manufacturers. DON stated they understood it was hard for nurses to remember how long the various eye drops were good for so they built reminders directly into the medication administration orders stating how long each eye drop was good for after opening the bottle, and also instructing nurses to label the bottle when opening. DON demonstrated in the electronic health record that every eye drop order instructed nurses to label the bottle upon opening. DON confirmed she did expect nurses to write the date on all eye drops when they were opened. According to the list, Refresh drops were good for 90 days after opening. DON confirmed that without a date of delivery or without having been labeled, one could not know how long R60's Refresh drops had been open. According to the list provided, Latanoprost can be stored at room temperature for only six weeks. According to the two listed manufacturers of [MEDICATION NAME] (Rising and Pacific) and DON, those drops would be good up until the date printed as expiration by the manufacturer. A product insert document for [MEDICATION NAME] did not include any information about how long the medication was good for after opening. According to a document review, Product Monograph dated (MONTH) 26, (YEAR) by drug manufacturer Sandoz for its products: T-Lo and [MEDICATION NAME]-EX (both [MEDICATION NAME]), the monograph included the following instruction for users: Write the date on the bottle when you open the eye drops and throw out any remaining solution one month after opening the bottle A product insert document for Latanoprost dated as being revised ,[DATE] included the following, Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees C (77 degrees F) for 6 weeks. A package label for Refresh Tears included the following, Discard 90 days after opening. A policy related to eye drops was requested. Facility provided a policy titled Administering Medications and dated as having last been reviewed [DATE]. The policy included the following, The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. Facility policy provided the Narcotic Management at SEMC (St. Elizabeth's Medical Center) dated [DATE], did not address storage of narcotics in the nursing home. The policy addressed narcotic medication as it pertained to the hospital nursing areas and hospital pharmacy.

Based on interview and document review, the facility failed to transmit a Death in Facility Minimum Data Set (MDS) assessment for 1 of 1 residents (R1) within 14 days after death. Findings include: Review of R1's nursing progress notes indicated R1 passed away on 6/20/19. Review of R1's MDS log identified no MDS was completed after R1 passed away on 6/20/19. During an interview on 9/12/19, at 10:15 a.m. registered nurse (RN)-A indicated she was responsible for completing the MDS. RN-A reviewed R1's MDS tracking logs, confirmed the death in the facility MDS was not completed for R1 and should have been. During an interview on 9/12/19, at 10:18 a.m. director of nursing (DON) verified, the death in facility MDS tracking record for R1 was not transmitted within the 14 days of death. The Resident Assessment Instrument Manual (RAI), last updated in (MONTH) (YEAR), directed a Death in Facility: must be completed when the resident dies in the facility, must be submitted within 14 days after the MDS completion date. A facility policy, MDS Assessment, reviewed on 9/4/19, indicated, State submissions will be completed as necessary to meet encoding and transmitting guidelines per CMS (Centers for Medicare and Medicaid Services) and RAI manual. Facilities will maintain resident assessments as indicated in the RAI manual.

Based on observation, interview and document review, the facility failed to ensure liquid [MEDICATION NAME] (a schedule IV controlled substance used to reduce anxiety) was destroyed in a manner to reduce the risk of potential diversion which had potential to affect 3 of 3 residents (R15, R38, R93) observed to have medication awaiting destruction. In addition, the facility failed to ensure liquid [MEDICATION NAME] was labeled and reconciled in a manner to allow routine counting and tracking of the medication to reduce the risk of diversion. This had potential to affect 2 of 2 residents (R85, R96) who had current orders for the medication. Findings include: Destruction On 8/20/18 at 4:33 pm, during a tour of the medication room on the 100 wing with licensed practical nurse (LPN)-A, LPN-A explained unused controlled medication were counted at each shift change until the director of nursing (DON), the clinic manager, or pharmacist removed them from the regular controlled lock box and placed in another lock box. LPN-A was unsure of the exact process for destroying discontinued controlled but believed the pharmacist took care of it. When interviewed on 8/22/18 at 8:15 am, DON confirmed the pharmacist comes once a month to complete medication destruction. DON verified her and the registered nurse (RN)-C do occasionally remove unused controlled and place them in a locked box labeled controlled medication awaiting RPh destruction, but they do not destroy them. DON believes that the destruction of medications took place at the facility with two pharmacists. During a phone interview on 8/22/18 at 3:00 pm, with Pharmacist (RPh)-B, RPh-B verified that approximately two to three years ago they changed the destruction of medication process. RPh-B explained she takes the medications out of the facility and to another facility for destruction, and stated even though regulations recommend medications be destroyed on site. RPh-B confirmed the DON and RN-C will sometimes remove unused controlled from access and put them inside a red tackle box. RPh-B further explained she picks up the unused controlled on a monthly basis and brings them to an offsite location for destruction; at which time medications are destroyed with two pharmacist. RPh-B confirmed no one in the facility verifies the count or signs off with her when she removes the medication from the facility. On 8/22/18 at 3:55 pm, an observation of the waiting for destruction by pharmacy red tackle box was done with the DON. Verification of the contents was compared against the individual controlled record sheets. Three opened liquid [MEDICATION NAME] bottles are amongst other medication in the container. [MEDICATION NAME] bottles are dark in color without visible measurement identification on them. DON explained according to the RPh-B staff are to use a perpetual way to measure these [MEDICATION NAME] amounts. Reconcile During an observation of the medication storage room on wing 100 on 8/20/18 at 4:33 pm, two dark colored vials of liquid [MEDICATION NAME] with a label covering the entire bottle, preventing visibility of the measurement markings, were observed. Review of R85's Medical Plan of Care, unsigned, indicated an order dated 8/21/18 for [MEDICATION NAME] 2 mg/ml give 1 mg (0.5 ml) by mouth sublingual as needed every four hours. Review of R96's Medical Plan of Care, unsigned, indicated an order dated 8/2/18 for [MEDICATION NAME] 2 mg/ml give 0.25 ml (0.5 mg) by mouth or sublingual two times a day. During an interview with registered nurse (RN)-B on 8/23/18 at 7:15 am, RN-B explained it is difficult to obtain an accurate measurement of [MEDICATION NAME] because the label covers the measurement guide on the bottle and because of the dark colored bottle. RN-B expressed this perpetual measurement makes her uncomfortable. Review of Narcotic Procurement/Accountability/Inventory/Destruction in Long-term Care Facilities policy with last revised date of 7/18/17, indicated an outdated or discontinued medication must remain in the long-term care facility to be destroyed by the pharmacist from St. Elizabeth's hospital and a licensed nurse or a second pharmacist. On 8/23/18 at 11:15 am, DON forwarded an email regarding past discussion between DON and pharmacist. Email dated 4/12/18, confirmed DON had noted liquid [MEDICATION NAME] is not in a measurable container for controlled count and requested pharmacy to look in to ordering it in a container that has visual measurement. Return email dated 4/13/18 from RPh-B verified [MEDICATION NAME] cannot be repackaged and that perpetual inventory of the product is allowed by State of MN Board of Pharmacy. A follow-up email dated 8/23/28 from RPh-C confirmed the wholesaler is able to get supply of previous brand and will order one to ensure the bottles have markings on side. No further documentation was provided to confirm destruction of medications were completed by two pharmacists.

Based on observation, interview, and document review the facility failed to adhere to the Assessment for Self Administration of Medications for 1 of 3 residents (R24) who self-administered a nebulizer medications. Findings include: Review of the medical record for R24 indicated he was admitted to the facility on [DATE] with advanced dementia. R24's quarterly Minimum Data Set ((MDS) dated [DATE], identified severely impaired cognition. An assessment for self-administration of medications dated 6/27/18, identified R24 would not be safe to self-administer medications related to cognitive impairment, visual deficit, impaired motor coordination, and a history of non-compliance with medications. R24's Medical Plan of Care signed on 7/5/18 and August, (YEAR) MAR indicated resident is NOT ok to self-administer nebulizers after set-up. On 8/22/18 at 11:23 am, R24 was observed sitting in his wheelchair in his room with the nebulizer mask down around his neck, pulling on it while yelling how do you run this contraption. When interviewed on 8/22/18 at 11:34, the registered nurse (RN)-D confirmed she had placed the nebulizer mask on R24 and left the room. RN-D had only been gone a couple of minutes before being alerted R24 had the mask around his neck and needed help, at which time she returned to his room and placed the mask back on and left the room again. RN-D confirmed that she checks back in with R24 a couple times during the duration of the nebulizer, but does leave him alone. RN-D explained not long ago all the residents had assessments for self-administration completed by a registered nurse and if they couldn't be alone, it would be stated on the medication administration record (MAR) following the medication order. RN-D reviewed the MAR and verified there was nothing confirming self-administration behind the order, at which time RN-D stated I'm unsure of his order. When asking where else she could find the information, RN-D stated I don't look for it elsewhere, if it's not stated then they are ok to be left alone and I check on them frequently. During an interview with the DON on 8/22/18 at 2:05 pm, DON confirmed assessments for self-medications administration were completed recently on all residents. DON verified there are to be no vials of medication at any resident's bedside table. She confirmed if appropriate, documentation would state ok to leave alone with neb on the medical plan care. DON verified R24's MAR stated not ok to be alone after set-up. Review of Self-Administration of Medication, Assessment of policy last reviewed on 8/24/17 indicated each resident will be assessed mentally and physically to determine whether self-administering medication is clinically appropriate for the resident.

Based on interview and document review, the facility failed to complete, encode and transmit Death in Facility Record for 2 of 3 residents (R)1 and R2 reviewed for resident assessment. Findings include: Review of R1's electronic medical record (EMR) indicated R1 was admitted to the facility on [DATE]. R1's progress note dated [DATE], indicated facility was notified R1's passed away at 4:45 a.m. Review of R1's Minimum Data Set (MDS) were reviewed and identified an entry assessment was completed on [DATE], and an admission assessment was completed on [DATE], R1 did not have a Death in Facility Tracking Record in the EMR. R2's EMR indicated R2 was admitted to the facility on [DATE]. R2's progress notes indicated R2 passed away on [DATE]. R2's MDS assessments were reviewed from [DATE] to [DATE]. R2 did not have a Death in Facility Tracking Record in the EMR. An interview on [DATE] at 7:29 a.m., identified registered nurse (RN)-A was unaware of R1's and R2's MDS assessments. RN-A explained R1 and R2's MDS assessments were completed by the prior MDS coordinator who was no longer employed at the facility. RN-A started as MDS coordinator in (MONTH) (YEAR), following completion of an MDS training and certification program. RN-A was unsure why R1 and R2 had MDS assessments identified over 120 days. RN-A reviewed R1's progress notes and verified R1 was transferred to the emergency room and died in the hospital on [DATE]. Additionally, RN-A verified R1 and R2 required completion and submission of Death Tracking Records within 14 days of their passing. During an interview on [DATE] at 8:45 a.m., the DON's expectation was to have MDS assessments be completed accurately and in a timely manner according to the RAI manual. Review of the facilities MDS Assessment policy indicated residents of the facility must have MDS assessments completed in accordance with the center for medicare services (CMS) guidelines as outlined in the Resident Assessment Instrument (RAI) Manual. Review of the RAI manual Version 3.0 Manual, version 1.15 R dated (MONTH) (YEAR), indicated a Death in Facility Tracking Record was to be completed with in seven days after the resident's death and transmitted within 14 days after the resident's death.

Based on observation, interview, and document review, the facility failed to revise the care plan for 1 of 1 residents (R90) for appropriate use of a heating pad. Findings include: Review of the medical record for R90 indicated he was admitted to the facility on [DATE] with chronic low back pain, debility, and mild cognition impairment. R90's quarterly Minimum Data Set ((MDS) dated [DATE], indicated R90 had intact cognition. A pressure sores & skin assessment dated [DATE] indicated R90 is at risk for skin breakdown due to age, decline in mobility, and diagnostic history. A pressure ulcer note dated 5/14/18 indicated review of R90's skin and stated remains accurate and appropriate, when referencing the 4/30/18 assessment above. Review of R90's care plan updated 6/19/18, does not include the use of a heating pad. On 8/20/18 at 3:02 pm, a heating pad was observed at the head of R90's bed. Further review of documentation, including medical doctor (MD) progress note dated 7/18/18 and nurses notes dated 8/1/18 to 8/20/18, did not identify the use of a heating pad, or an order for [REDACTED].>On 8/21/18 at 3:08 pm, during an interview with R90 in his room, R90 stated he has pain lower back pain all the time from an injury many years ago. When asked to rate his pain, he says it all depends on what he is doing and won't give a number. R90 denies pain keeping him awake at night or limiting his daily activities. R90 will take Tylenol on occasion (maybe once every four to five days) which does help. When asked about the heating pad, he stated he got it about two or three weeks ago and the staff are aware he has it. R90 denies ever getting burned from the heating pad and states he always wears his sweatshirt to bed to protect his skin. R90 expressed that this heating pad automatically shuts off after two hours and there are three temperatures on it, he always uses it on low temperature. On 8/22/18 at 8:15 am, the DON verified her awareness of R90's heating pad which was purchased from the facility pharmacy. DON was under the understanding that R90 had decided not to use the heating pad. DON called registered nurse (RN)-C to answer further questions. RN-C stated R90 had been complaining of left or right hip pain and wanted to bring in his own heating pad, at which time the facility ordered one. RN-C verified the heating pad has a UL cord, it is in good condition, and there was no direct skin contact. RN-C stated R90 decided he did not want to use the heating pad after he read the instructions. RN-C verified no assessment was completed and it was not added to the care plan because she was under the impression that he wasn't using it. RN-C confirmed that she has not followed up with R90. DON and RN-C verified 8/8/18 was the purchase date of the heating pad. DON confirmed the she will have the nurse complete an assessment for use and safety, along with an evaluation of R90's skin. Review of policy titled Applying Cold/Warm Therapy, with last reviewed date of 8/21/18, was reviewed and indicated cold or warm compress must have a physician's orders [REDACTED].

Based on observation, interview and document review, the facility failed to assess and evaluate causal factors for a fall and failed to ensure interventions were implemented to reduce the risk of fall for 1 of 5 residents (R42) who was reviewed for accidents. Findings include: R42's current [DIAGNOSES REDACTED]. R42's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The MDS further identified R42 required assistance of one person for transfers with inability to steady self without staff assistance. R42's care area assessment (CAA) for falls, dated 1/8/18, indicated R42 had a previous fall and was at moderate risk for falls related to impaired safety awareness. R42's fall risk assessment dated [DATE], indicated he was nonambulatory, required assist of one for transfers, and was noncompliant. The assessment further identified R42 was able to use his call light appropriately, communicate his needs, but did transfer on his own even after reminders to ring for staff assist. R42's care plan, last reviewed 8/17/18, indicated R42 was at risk for falls related to weakness. Current interventions included: one assist with mobility, toileting, keep bed in low position, remind to use call light, call light within reach, seat belt on when in scooter and anticipate needs. Review of R42's incident report dated 7/14/18 at 5:30 p.m. revealed: Resident had been found on floor in bathroom. When asked what happened resident responded, I'm sitting on the floor and get me up. The fall resulted in a skin tear to right elbow measuring 0.2 centimeters (cm) requiring a dressing to be placed. During observation and interview on 8/22/18, at 8:20 a.m. R42 was observed sitting in scooter, with right foot on floor, left foot on platform of scooter, leaning to the left asleep with seat belt latched. Nursing assistant (NA)-A indicated R42 would self transfer and needed frequent reminders to use his call light for help. She further indicated he wore a self releasing seat belt in scooter due to a previous fall but was not aware of any other interventions in place to prevent falls. During interview on 8/22/18, at 8:30 a.m. R42 indicated he transfers on his own even though staff have told him he shouldn't. During interview on 8/22/18, at 8:53 a.m. licensed practical nurse (LPN)-B indicated many times R42 independently transfers self into bathroom, and has previously fallen. We encourage him to use a call light, but he is noncompliant. During interview on 8/22/18, at 1:32 p.m. registered nurse (RN)-D stated the facility used standard of care interventions such as grippy socks, proper foot wear, nonskid floor strips and night lights in addition to fall prevention interventions identified in care plan. RN-D further indicated a post fall investigation worksheet is completed to identify causal factors and new interventions; however, RN-D confirmed they had missed it and was unable to identify interventions implemented following R42's fall on 7/14/18. RN-D indicated an intervention could have been identified to prevent reoccurance of the fall. During interview on 8/22/18, at 2:30 p.m. the director of nursing (DON) stated R42's fall on 7/14/18 had not been reviewed by the interdisciplinary team. The DON further stated she was not sure why this was missed, but confirmed without the post fall investigation worksheet no evaluation or implementation of interventions had occurred. The facility policy titled Falls - Assessment/Reporting revised 2/1/95, included: to provide a means of evaluation of cause of fall, events for trending, tracking and initiating intervention.

Based on observation, interview and document review, the facility failed to ensure safety measures were implemented for 12 of 74 residents (R42, R62, R46, R89, R82, R98, R56, R90, R97, R61, R10, & R4) allowed to use the facility whirlpool without staff in attendance, and without application of the seat belt from the tub chair. This posed a potential for serious harm or death for the 12 residents identified and resulted in an immediate jeopardy (IJ) situation. The IJ began on 9/28/17, at 10:25 a.m. when facility leadership first became aware residents had been left alone in the whirlpool. On 9/28/17, at 11:10 a.m. the director of nursing (DON) and Registered Nurse (RN)-F were informed of the IJ situation. The immediate jeopardy was removed on 9/28/17, at 3:30 p.m. but noncompliance remained at the lower scope and severity level of E, a pattern, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. In addition to the IJ related to whirlpool bath safety, the facility also failed to complete a community safety assessment for 1 of 1 resident (R45) who independently utilized a motorized scooter in the community. Findings include: During an observation on 9/27/17 at 7:38 a.m., the surveyor walked by the bathing room located on the 100 wing and observed the bathing room door was open. Although a privacy curtain was in place, there was an approximate 12 inch unclosed area allowing view of R42 in the whirlpool tub. The surveyor knocked on the open bathing room door and announced herself with no response from the resident. Upon entering the room, R42 was observed to be seated in the whirlpool tub with no staff present in the bathing room. The whirlpool jets were on and the tub was filled with water approximately 3 inches from the top which came to R42's chest area. R42 had a call light within reach, and the right arm of the chair R42 was sitting in was in the down position, however the padded safety belt from the tub chair was not in place. At 7:46 a.m. nursing assistant (NA)-A entered the room and questioned R42 as to whether he was ready to get out of the tub. At that time, NA-A told the surveyor she and other nursing assistants use their discretion to determine whether residents can be left alone in the bathtub. When asked if an assessment for safety was completed for residents to determine whether they were safe to be left alone in the whirlpool, NA-A stated she was unaware of any such assessment having been completed. R42's [DIAGNOSES REDACTED]. R42's care plan dated 9/26/17, identified R42 needed one person assist in the whirlpool. The care plan identified R42 has dementia that affected his memory and ability to understand at times, had chronic bilateral knee pain, glaucoma, macular degeneration, and vision loss to his right eye. The care plan identified R42 is at risk for falls due to knee pain and weakness and has a history of falling out of his wheel chair reaching for items. R42's MDS dated [DATE], identified R42 needed physical assistance in part of bathing activity and required one person assist. The record lacked identification if R42 could be left unattended in the whirlpool and what safety devices were appropriate. During an observation on 9/27/17 at 8:41 a.m., R62 was observed in the whirlpool tub with NA-A present. The NA stated she was waiting for assistance from a colleague to transfer R62 out of the tub. At 8:47 a.m., NA-B arrived to help NA-A assist R62 out of the tub. During an interview at that time, NA-B stated most residents in the facility receive whirlpool baths and some like to sit and soak. NA-B stated she knew which residents could be left unattended because she was familiar with the residents and used her discretion. When questioned, NA-B stated she was unaware of whether there was any type of safety assessment completed to determine whether residents could be left alone in the tub. NA-B stated the only safety device used with the whirlpool was to keep the call light within reach and proceeded to state that residents usually soak for approximately 10 to 15 minutes. R62 was assisted out of the whirlpool tub at 8:52 a.m. on 9/27/17. Immediately following R62 getting out of the tub, NA-A was interviewed and asked about the use of safety devices while residents were in the tub. NA-A stated the safety devices for the whirlpool tub included the use of the arm on the right side of the whirlpool chair which residents are asked whether they want up or down, and the black padded chair belt that goes around the resident's abdomen, or under the resident's arms, and clips in the back of the tub chair. NA-A stated she would utilize the safety belts for residents that were unable to maintain stability in the tub chair. However denied any knowledge of an assessment being completed regarding who can or cannot maintain stability while in the tub chair. NA-A further stated she'd given R42 a bath earlier, and confirmed that although the chair arm was in the down position, she had not applied the safety belt. NA-A stated R62 had been left unsupervised while soaking in the whirlpool for approximately 10 minutes. On 9/27/17, at 9:11 a.m. Registered Nurse (RN)-A was interviewed about resident safety while in the whirlpool bath. RN-A stated there are two black safety straps for use when residents have a whirlpool bath but would need to verify whether the straps needed to be utilized at all times. RN-A also stated there was a call light available in the tub room which would need to be in reach for the resident. RN-A was unsure how far staff should be filling the tub with water. When asked, RN-A verified there was no assessment completed to determine whether a resident could be left in the tub unattended, or to determine which safety devices should be utilized. RN-A stated if a resident had been assessed for safety while utilizing the whirlpool tub, it would be documented on the resident's care plan along with any other safety devices the resident required. When asked about R62 having been left unsupervised for ten minutes, RN-A stated R62 was not cognitively intact, had been declining in strength and should definitely not be left unsupervised while in the whirlpool tub. R62's [DIAGNOSES REDACTED]. A nursing progress note dated 7/13/17, identified R62 to have dementia, generalized depression, and anxiety, and indicated R62 was unable to complete a brief interview of mental status (BIMS) assessment secondary to dementia. The note stated R62 required 24 hour supervision, was unable to make decisions, and had impaired safety awareness. R62's care plan dated 9/24/17, identified R62 needed assist of one in the shower or whirlpool. The care plan further identified R62 does not use a call light, had cognitive impairment, and had a history and was at risk for falls due to safety awareness. R62's Minimum Data Set (MDS) assessment dated [DATE], identified R62 needed total dependence with bathing and one person assist. The record lacked identification if R62 could be left unattended in the whirlpool and what safety devices were appropriate. During an observation on 9/27/17 at 10:25 a.m., NA-C was entering the tub room located on the 200 wing. NA-C stated she was giving R46 a bath. Upon entering the tub room, R46 was observed in the tub without any staff present in the room. It was observed the right chair arm was in the down position however, the padded safety belt was not in place, nor was the call light within reach. The tub water was approximately 4 inches from the top of the tub and came to the resident's upper abdomen. There was a stationary call light located to the left of the entry door which did not reach adequately to the tub and was therefore unavailable for the resident's use. NA-C confirmed R46 was unable to reach the call light. NA-C stated a determination about a resident's ability to be left alone in the tub would be indicated on the care plan. Following the bath, NA-C confirmed that R46's care plan did not identify whether or not f he could be left alone in the tub, or any safety measures needed while in the whirlpool tub. R46's [DIAGNOSES REDACTED]. A cognitive loss progress note dated 7/31/17, identified R46 to have cognitive impairment with a BIMs score of 10 out of 15 and R46 had impaired decision making. R46's care plan dated 8/10/17, directed that one person assist in the shower or whirlpool. The care plan identified R46 to be at risk for falls due to impaired safety awareness, balance issues, chronic pain, and psychoactive medications. R46's MDS assessment dated [DATE], identified that R46 needed physical help and one person assist with bathing. The record lacked identification if R46 could be left unattended in the whirlpool and what safety devices were appropriate. On 9/27/17, at 11:11 a.m. NA-D was interviewed regarding safety measures to be utilized when residents are in the whirlpool tub. NA-D stated that she placed the safety belt on some residents, using her discretion for when to place it on dependent residents. NA-D also said she thought if the care plan indicated a resident required assist of one staff for bathing, staff should not leave the resident unattended in the bathtub. NA-D added that the whirlpool chair arm should be down and the call light should be in reach at all times. Following review of the care plan, NA-D verified R62's care plan did not indicate whether the resident could be left unattended in the bathtub. 9/27/17, at 2:58 p.m. RN-B was asked about when residents could be left alone while in the whirlpool. RN-B stated that it would need to be care planned and the resident would need to be able to utilize the call light appropriately. RN-B also stated she would need to review operating manuals for the tub, and the facility's expectations of bathing since the baths are usually completed on the day shift. RN-B stated specific resident safety assessment information regarding the safe use of the tub should be indicated on the resident's care plan. Following review of the record, RN-B confirmed R62 did not have a safety assessment specific to use of safety devices required while in the tub, nor assessment of whether the resident could be left alone for periods of time. RN-B stated she would not leave R62 alone since R62 was not cognitively intact and can't independently use the call light. RN-B was unaware of the manufacturer or facility expectations regarding use of the whirlpool chair seatbelts. On 9/27/17, at 3:13 p.m. the director of nursing (DON) stated that all bathing rooms have operating instructions in them and she expected her staff to have read the instructions about how to operate the whirlpool tubs. The DON also said she was unaware whether the posted tub information was based on the recommendations of the manufacturer's operating manual, and acknowledged education regarding whether residents could be left alone in the whirlpool, or safety devices required had not been completed by the facility. On 9/27/17, at 3:25 p.m. a telephone interview with a representative of Master Care Integrity (the whirlpool tub manufacturer) was conducted. The representative stated the safety belts are not mentioned on the on-site operations reference however, are referenced in the operation manual guide. The representative clarified the two padded safety belts that should be utilized at all times, one for the upper body and one for the lower body, and stated if residents are left unattended without the proper safety devices there was a possibility the resident could slide down into the water. On 9/27/17, at 4:47 p.m. the DON stated there was no safety assessment completed to determine whether a resident could safely be left unattended for periods of time while in the whirlpool tub. The DON said she expected all staff to use the padded safety belts around a resident's torso area and additionally one on the upper torso if the resident was unable to maintain an upright position. The DON stated she expected documentation of risk/benefits to be completed if a resident refused to use the safety straps. In addition, the DON confirmed the current resident care plans do not identify whether a resident could be left unattended in the whirlpool. The DON could not verify what staff were being taught during orientation regarding operation of the whirlpool tub. At 5:05 p.m. the DON verified that the 200 and 300 wing bathing room call lights do not reach the tub fully and would not be within a resident's reach. In addition, the DON verified that the 300 wing does not have tub operating instructions posted for staff reference when giving a whirlpool bath. On 9/28/17, at 12:34 p.m. NA-J who stated she regularly gave residents baths on the 100 wing was asked which residents she had left unattended while they soaked for periods of time in past several months. NA-J identified R89, R82, R42, R98, R56, R62, and R10 by name. On 9/28/17, at 12:51 p.m. R42 was interviewed and stated when he takes a whirlpool staff leave him unattended as he soaks. R42 stated the girls take off and leave and you never know what minute they will come back. R42 stated he was not offered any type of safety belt while in the tub. R89's [DIAGNOSES REDACTED]. A cognitive loss progress note dated 2/13/17, identified R89 had a BIMS score of 12 of 15 as cognitively impaired. R89's care plan dated 9/25/17, identified R89 needed extensive assist of one in the whirlpool. The care plan also identified R89 to have a history of agitation, an elopement attempt, was at risk for falls due to impaired safety awareness. R89's MDS dated [DATE], identified R89 needed physical help in part of bathing with one assist. The record lacked identification if R89 could be left unattended in the whirlpool and what safety devices were appropriate. R82's [DIAGNOSES REDACTED]. R82's care plan dated 9/26/17, identified R82 needed assist of one in the whirlpool. The care plan identified R82 had some memory loss and relied on staff for cues. R82 was at risk for falls due to weakness, cardiac issues, and cognitive impairment. R82's MDS dated [DATE], identified R82 needed physical help in part of bathing with one person assist and scored a 10 of 15 as cognitively impaired on the BIMS assessment. The record lacked identification if R82 could be left unattended in the whirlpool and what safety devices were appropriate. R98's [DIAGNOSES REDACTED]. R98's care plan dated 9/24/17, identified R98 needed assist of one in the whirl pool and had sciatic nerve pain. R98's MDS dated [DATE], identified R98 needed physical help in bathing with one person assist. The record lacked identification if R98 could be left unattended in the whirlpool and what safety devices were appropriate. R56's [DIAGNOSES REDACTED]. R56 was a full code. A cognitive loss progress note dated 10/18/16, identified R56 to have major depression with psychotic features, dementia with delusional thinking, and a BIMS score of 3 of 15. The note identified R56 needed 24 hour supervision and does not use the call light even with daily education. R56's care plan dated 9/24/17, identified R56 needed assist of one in the shower or whirlpool. The care plan identified R56 does not understand the call light, has impaired safety awareness, and was at risk of elopement. R56's MDS dated [DATE], identified R56 was total dependence with bathing with one assist and scored 8 of 15 as cognitively impaired on the BIMS assessment. The record lacked identification if R56 could be left unattended in the whirlpool and what safety devices were appropriate. R10's [DIAGNOSES REDACTED]. A cognitive progress note dated 6/13/17, identified R10 to have a BIMS score of 10 of 15 as cognitively impaired and short term memory impairment. R10's care plan dated 9/25/17, identified R10 needed one person assist in the shower or whirlpool. R10 had a left foot amputation, memory loss, and was at risk for falls due to impaired safety awareness and weakness. R10's MDS dated [DATE], identified R10 needed physical help in part of bathing with one person assist and a BIMS score 7 of 15 as cognitively impaired. The record lacked identification if R10 could be left unattended in the whirlpool and what safety devices were appropriate. On 9/28/17, at 1:00 p.m. NA-C, who indicated she regularly gave resident baths on the 200 wing, was asked which residents were left unattended while they soaked for periods of time in the past few months. NA-C identified R46, R90, R97, and R61 by name. R90's [DIAGNOSES REDACTED]. R90's care plan dated 9/8/17, identified R90 needed assist of one in the whirlpool. Further, R90 was at high risk for falls due to leg weakness and chronic pain in legs, feet, arms, and hands. R90's MDS assessment dated [DATE], identified R90 needed physical help in part of bathing with one person assist. The record lacked identification if R90 could be left unattended in the whirlpool and what safety devices were appropriate. R97's [DIAGNOSES REDACTED]. R97's care plan dated 9/28/17, identified R97 needed assist of one in the shower or whirlpool. R97 had a history of [REDACTED]. R97's MDS assessment dated [DATE], identified R97 was total dependence with one person assist for bathing. The record lacked identification if R97 could be left unattended in the whirlpool and what safety devices were appropriate. R61's [DIAGNOSES REDACTED]. R61's care plan dated 9/8/17, identified R61 needed assist of one in the whirlpool. R61 had dementia with behaviors, impaired insight and judgement, and had a history and at risk for falls due to pain. The care plan identified R61 had depression and indications of feeling bad about self. R61's MDS assessment dated [DATE], identified R61 needed physical help with one assist with bathing and a BIMS score of 9 out of 15 as cognitively impaired. The record lacked identification if R61 could be left unattended in the whirlpool and what safety devices were appropriate. On 9/28/17, at 1:42 p.m. NA-K who said she regularly gave resident baths on the 300 wing, was asked if she left any residents unattended to soak while in the whirlpool tub. NA-K said she had left R4 unattended while in the whirlpool. R4 was observed at that time seated in the wheel chair being pushed to her room. The resident's bottom was observed to be scooted forward in the chair. NA-K stated R4 always scoots forward in her chair and staff frequently need to reposition her. R4's [DIAGNOSES REDACTED]. A cognitive loss progress note dated 4/3/17, identified R4 to have significant cognitive impairment with a BIMS score of 3 out of 15. R4's care plan dated 9/27/17, identified R4 needed assist of one in the whirl pool. R4's MDS assessment dated [DATE], identified R4 needed physical help with one person assist for bathing and R4 was unable to complete the BIMS assessment due to cognition. The record lacked identification if R4 could be left unattended in the whirlpool and what safety devices were appropriate. The facility's posted instructions Operating Instructions for MasterCare Integrity bath model MB-80 lack direction on using safety devices. The document stated only trained operators are allowed to operate the bath system. Further, the document indicated it was only intended as a reference guide. The posted instructions were located in the 100 and 200 wing bathing rooms. The facility's nursing assistant orientation records indicated staff were to be aware of the whirlpool/how to adjust water temp/clean/use lift properly. The orientation record lacked identification of whether residents could be left alone and the safety devices of the whirlpool. The Master Care Model MB-80 Operating Instructions stated to read and follow all instructions in manual. The manual identified individuals should be secured with the two safety belts that are provided by placing one on the upper body and on the lap portion of the residents. The manual also directed staff to turn the tub fill valve open when filling the tub and to fill just below the overflow and turn the valve off. This is several inches below the top of the tub. The Cascade Elite Transfer tub manual used in the 300 wing bathing room stated this tub is used for nursing homes under direct supervision of trained staff. The manual directed for residents to be secured with safety belts on the upper and lower portions of a resident's torso. The facility's policy titled Shower/Tub Bath last revised on 8/1/17, directed staff to stay with resident throughout the bath unless otherwise care planned. The policy identified if a resident requested to spend extended periods of time in the whirlpool or shower the resident needed to be identified as safe to be left alone, have the call light within reach, and safety checks be completed. The facility's policy titled Use of Whirlpool Tub last reviewed on 9/2/11, directed staff to follow tub manufacturer's operation and procedure manual for operating the tub and/or transport chair. The immediate jeopardy that began on September 28, 2017, was removed on September 28, 2017, when the facility had educated all staff responsible for bathing residents not to leave residents alone for any amount of time unless the resident has been assessed to be safe in the tub without supervision. In addition staff were educated to use recommended manufacturer safety measures during use of the whirlpool tub. In addition the facility initiated resident assessments for bathing safety if the would choose to be left alone in the tub to soak. Although the IJ was removed, noncompliance remained at the lower scope and severity level of an E, which is a pattern, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility has not had time to complete all assessments, or for the interdisciplinary team (IDT) to fully develop interventions to address the concerns and how to audit to ensure compliance. R45 LACKED A SAFETY ASSESSMENT WHEN OUT IN THE COMMUNITY USING A SCOOTER: A fall report for R45 dated 6/2/17, indicated the resident tipped an electric scooter over while he was off the hospital/nursing home property. The report indicated R45 had tipped over after hitting a waterhole cover on the side of the road on a local street. Falling this incident, the facility implemented no new interventions. On 9/14/17, a fall report indicated R45 had failed to return back to the facility following an independent time out of the facility with the scooter. The report indicated facility staff had called the resident's daughter to locate the resident by a GPS located on the resident's scooter. The report indicated the police had been called and had subsequently reported R45 had fallen off his scooter on a walking path between the facility and a local eating establishment, Slippery's. The report further revealed an ambulance had been called to the scene of the fall, however R45 had denied injury, refused care and returned to facility with his sister versus the ambulance or police. Review of R45's progress notes dated 6/2/17 to 9/14/17, indicated 18 documented incidents when R45 had left the facility alone with his scooter without signing out, or times R45 would refuse to allow staff to assist him with personal cares prior to independently leaving facility on his scooter. R45's medical record indicated [DIAGNOSES REDACTED]. The physician's notes also indicated; I have been told by the facility, that on several occasions (R45) was found by police out side the facility, covered in feces and urine. He also used his motorized scooter to physically intimidate other staff members. Review of R45's quarterly Minimum Data Set ((MDS) dated [DATE] indicated an admission date of [DATE]. The MDS also indicated a Brief Interview for Mental Status (BIMS) score of 9/15, which indicated moderate cognitive impairment. Review of R45's current care plan, identified a self-care deficit related to diabetes, depression, COPD (chronic obstructive pulmonary disease), mild left hemiparesis (weakness) manifested by incomplete activities of daily living (ADL's), decreased ADL participation, some ability to make decisions, and non-compliance with treatment recommendations. The care plan also included a problem area of potential for injury related to: impaired safety awareness and leaving unsupervised on a motorized scooter. On 9/27/17 at 7:56 a.m., LPN (licensed practical nurse)-F stated, if we catch him before leaving facility we ask him to sign out. We check the dining room, the floor, and check outside if we cannot find him. If unable to locate him and it's getting late we call his daughter and she will track him on a GPS tracking device located on his scooter. We have tried to keep the scooter out of his room, as he will self-transfer and has fallen in the process, but family requested it be returned. He is very non-compliant and his family is ok with him going outside alone and independently using his scooter, since the last fall on 9/14/17, we obtained a new physician's orders [REDACTED]. On 9/27/17 at 8:13 a.m., NA-Q stated, sometimes (R45) will ask for help onto the electric scooter if we are in the room. He often refuses to use his call light for help. If we are walking by, and see him attempting to self-transfer we will go in assist with transfer and will ask where he is going. Otherwise he will just self-transfer, even though he is a two assist for safety. 9/27/17, at 8:46 a.m. NA-P said, R45 usually does not leave on the day shift, it is usually in the late afternoon or evening. On 9/27/17, at 9:55 a.m. the facility's Medical Director/primary physician was interviewed and stated that she had spoken with R45's daughter and explained the need for further cognitive testing by occupational therapy (OT) to determine the resident's safety when in the community with his scooter. The medical director also stated the cognitive testing needed to be as soon as possible for the safety of R45, and stated after having spoken with R45's daughter, the daughter had been okay with the OT cognitive testing which was completed on 9/28/17. The medical director further stated R45 was not safe to leave the facility alone at this time due to the most recent events of 9/14/17 when he'd fallen while outside the facility. However, the medical director also stated that R45's family member (FM)-A was very active with R45's care and wishes. The medical director stated, (FM-A) is trying hard to keep R45 as independent at possible as his independence with the scooter is crucial to maintain his quality of life.' On 9/27/2017, at 10:18 a.m. RN (registered nurse)-F was interviewed concerning R45's safety when in the community with his scooter. RN-F said, (R45) will go to Slippery's, a local restaurant/bar on pretty much a nightly basis to socialize with friends. (R45) is on 30-minute checks while in the facility. Once we know he has left or is gone, we chart that R45 left facility. We attempt to change or toilet (R45) prior to his leaving the facility. We constantly encourage (R45) to sign out and have a cell phone with him so he can for help if needed. (R45) is able to use cell phone correctly to call for help. On 9/27/17, at 5:00 p.m. licensed practical nurse (LPN)-F said that R45 refuses to wear the seatbelt that is on his scooter. We encourage him to use the arm rest for stability and we have encouraged (R45) not to go out tonight. RN-E clarified she'd spoken with the resident regarding going out and stated, it would be best if he does not go out of the facility tonight. From what I know, no community safety assessment was completed prior to 9/27/17. 9/27/17, at 5:01 p.m. NA-O said that if R45 wants to go out into the community there is no way to really stop stop him. He gets pretty upset with you if you try to stop him. (R45) wants to do (R45's) thing. He has swung at me in the past when we don't let him go outside. He usually leaves between 2:00 p.m. in the afternoon to 7:00 p.m. in the evening. On 9/27/17, at 5:21 p.m. NA-N was asked about R45 and said, When he is leaving we make sure his pants are up, and make sure the chair arms are down as he does not like to use them. He usually leaves after supper or around 6:00 p.m. to 6:30 p.m. He usually comes back around 10:00 p.m. On 9/27/17, at 5:42 p.m. RN-D said that R45's family is very involved with his cares. They have a GPS tracker on the scooter. RN-D said, We encourage him to sign out but he refuses to sign in and out often. If it is already dark out when he leaves we try to encourage him not to go. But (R45) is (R45). We do our best to keep him safe but R45 makes own choices and decisions. On 9/27/17, at 6:29 p.m. during an interview with the DON (Director of Nursing) regarding R45's community safety. The DON said, We are going to have an OT assessment for safety completed soon. The DON further verified there had not been a community safety assessment completed for R45 even though there had been incidents in the community with falls. The facility's policy regarding falls was provided The policy, Assessment /Reporting last reviewed 2/17/16, indicated the purpose was to provide clinical assessment and/or intervention post fall, and to provide a means of evaluation of cause of fall, events for trending, tracking and initiating interventions. The facility policy for Resident Sign Out last reviewed 5/3/11, indicated the purpose was to allow residents to be independent and enjoy life outside the facility while providing accountability to staff of the resident's whereabouts. The facility's policy for Motorized Mobility Aids (Electric Wheelchairs/Scooters) last reviewed 5/1/2013, indicated the purpose was to: provide residents with the opportunity to safely utilize motorized vehicles and to maintain their independence /qualify of life. To establish guidelines for motorized mobility aid usage within St. Elizabeth's. To provide a safe environment for everyone and to prevent damage to the physical structure of the facility. Resident requesting to utilize a motorized mobility aid during stay at St. Elizabeth's medical center must have an evaluation completed by the therapy department to ensure resident is appropriate to safely operate this type of equipment. Residents will be evaluated based on situation, performance, and physical/mental capabilities.