Every finding on record at Hilltop Manor Nursing Center

Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards for Resident (R) 1. On 03/20/26 at approximately 10:30 AM, Certified Nurse Aide (CNA) M retrieved a lift sling to assist R1 with a full-body mechanical lift. CNA M took the top lift sling from the pile without verifying it was the appropriate sling for R1. CNA M and CNA N then began transferring R1 with a full body mechanical lift using the incorrect sling, which was inadequate for R1's size. The sling had a maximum weight capacity of 150 pounds, and R1 weighed 255 pounds. During the transfer the lift sling ripped at the strap, and the resident fell to the floor, resulting in a left hip and pelvis fracture. This failure placed R1 in immediate jeopardy. Findings included:- Review of the Electronic Health Record (EHR) documented R1 had diagnoses which included multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord) and muscle spasms. R1's 11/06/25 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R1 was dependent on staff for all transfers and locomotion. R1's 01/12/26 Quarterly MDS documented a BIMS score of 15, which indicated intact cognition. The assessment documented R1 utilized a wheelchair for locomotion. R1 was dependent on staff for all transfers and locomotion. R1's Care Plan documented on 04/15/15 R1 had a risk for continued decline with activities of daily living (ADL - activities such as dressing, toileting, brushing/combing hair, brushing teeth, etc.) related to diagnoses that included MS and generalized weakness. The plan documented an intervention noting R1 required the total assistance of two staff and the green full body sling for all lift transfers, dated 04/15/15. Review of R1's EHR Weights revealed on 03/16/26 at 02:42 PM, R1 weighed 255.2 pounds (lbs). Review of the facility's undated Interdisciplinary Team Review/Investigation document revealed R1 fell on [DATE] at approximately 10:30 AM. The document included a brief description of the incident where two CNA staff were transferring R1 with a mechanical lift when the sling broke mid-transfer, and included the environmental factor that the sling was not the correct size. The document included R1 was sent to the ED for evaluation and x-ray examinations that determined R1 had a fractured (broken bone) left femur (thigh bone). Review of the EHR revealed a computer tomography (CT - a specialized type of x-ray examination) report dated 03/20/26 at 01:15 PM that documented R1 had a fracture of the left femur with displacement and angulation of the fracture at least half the shift width. The report documented nondisplaced fractures of the superior and inferior pubic rami (part of the pelvic bone). R1's Progress Note dated 03/20/26 at 02:03 PM, Licensed Nurse (LN) G documented Certified Nurse Aide (CNA) staff alerted him that R1 was on the floor. LN G was on the phone with an important phone call, so an administrative nurse went down to assess the resident. When LN G arrived where R1 was, R1 was on his back on the floor under the mechanical lift with a broken sling. R1 was assessed and complained of pain in his left leg and a wound on his left forearm. R1 initially declined to be transferred to the Emergency Department (ED) for further evaluation and treatment, but later consented to be transferred to the ED. R1's Progress Note dated 03/20/26 at 02:17 PM, LN H documented a Post Fall Evaluation; the fall was witnessed and occurred in the resident's room. The entry further documented that the sling broke and resulted in an injury and ED visit. CNA M's notarized Witness Statement, dated 03/25/26, documented on 03/20/26, the staff were getting R1 up for a shower with a shower sling at 09:45 AM. CNA M documented while R1 was up in the air, the sling leg part broke when R1 was almost to his wheelchair. Administrative Nurse E's notarized Witness Statement, dated 03/25/26, documented on 03/20/26 at approximately 10:00 AM, Social Services X came to her office and stated R1 was on the floor in his room. Administrative Nurse E found R1 lying on his back with the mechanical lift near him. CNA staff reported to Administrative Nurse E that they were transferring him from the bed to a shower chair when the strap on the sling broke, and R1 fell to the floor. Administrative Nurse E noticed a large puddle of blood under R1's left foot, where a laceration was observed, and bleeding from a skin tear on his left forearm. Administrative Nurse E documented vital signs were taken, wounds were cleansed, and dressings were applied, as well as neurological checks, since R1 likely hit his head. Administrative Nurse E examined the sling and observed that a strap had broken. Administrative Nurse E educated the staff present on inspecting the equipment prior to every use. LN G arrived and assumed care prior to R1 being assisted off the floor. LN G's notarized Witness Statement, dated 03/25/26, documented on 03/20/26 at an undocumented time, LN G was informed that a resident was on the floor while LN G was on the phone. LN G asked an administrative nurse to respond to the incident until LN G was able. When LN G entered R1's room, he was on the floor beneath the mechanical lift, slightly tilted to his left side with the sling hanging from the lift. LN G documented a skin tear to the left forearm and right foot, which were cleaned and dressed. R1 was assisted back into bed, R1's representative and physician were notified, and R1 was sent to the ED after R1's physician requested staff to provided education to R1 about the importance of getting scans. CNA N's undated, notarized Witness Statement documented on 03/20/26 at approximately 10:30 AM, CNA M and CNA N were getting R1 ready for his shower. CNA N documented in the process of utilizing the lift to put R1 in his wheelchair, the bottom left strap of the sling snapped and broke, and R1 fell out onto his left side. R1 was on his hip, and blood started showing from his feet and arms. CNA M immediately went to get a nurse and other staff for assistance, and CNA N stayed with R1. After additional staff and LN G arrived and rendered aid, CNA M, CNA N, and LN G got a new sling under him and got him back into the bed. Administrative Staff A's notarized Witness Statement, dated 05/12/26 at 11:29 AM, documented during the investigation into R1's fall on 03/20/26 Administrative Staff A spoke with CNA M, who reported she just grabbed the sling on the top of the pile. Administrative Staff A documented the sling was size small to medium and was the wrong size for the resident. On 03/20/26, after the incident, R1's Care Plan was updated to include the following intervention initiated on 03/20/26:New slings individualized for shower and transfer, revised 03/23/26. During an observation on 05/12/26 at 10:50 AM, R1 rested in his bed, watching television. On 05/12/26 at 09:55 AM, Administrative Staff A stated the cause of the fall on 03/20/26 was staff using the wrong size lift sling for the resident. On 05/12/26 at 10:05 AM, Administrative Nurse E said she was in her office on the morning of 03/20/26 and CNA staff notified her that a resident fell. Upon her arrival at R1's room, R1 was lying on his back on the ground with two CNA staff members in the room. Administrative Nurse E said she observed a pool of blood under the residents left foot, and a skin tear on his left forearm. Administrative Nurse E initiated the assessment while the charge nurse was unavailable, and neurological checks were initiated. Administrative Nurse E said R1 had a diagnosis of MS, so he was unable to move on his own. Administrative Nurse E said after the fall, R1 initially denied pain when his wounds were cleaned and dressings applied. After LN G arrived, he took over resident care, and the staff was able to see that the strap on the lift had broken. Administrative Nurse E reported the sling that was in use was blue mesh, but was unable to recall what color the piping along the edge was. On 05/12/26 at 10:10 AM, CNA M said she and CNA N were getting R1 up for a bath and transferred R1 into the sling. During the transfer with the lift and sling, when R1 was approximately waist high from the floor and almost to his wheelchair, the strap on the sling broke, and he fell. CNA staff called for help, and the nurses came and assessed the resident. CNA M said that after the nurses assessed R1, CNA staff used a different sling and lifted R1 from the floor, put R1 back in bed, and the broken sling was discarded. CNA M was unable to recall who discarded the broken sling, but recalled that it was a blue mesh with unknown color piping along the edge. On 05/12/26 at 10:20 AM, CNA N was unavailable for an interview. On 05/12/26 at 10:26 AM, LN G said on 03/20/26 he was the charge nurse for the shift and was in the nurse's station on the phone with a very important phone call when CNA staff notified him that R1 fell. LN G reported another nurse responded to R1's room due to the phone call in progress. When LN G arrived at R1's room, he was on the floor with some skin tears. LN G reported he did not assess R1 since Administrative Nurse E had already assessed R1. LN G said when he arrived at R1's room, the sling was still attached to the lift with three points of attachment to the mechanical lift, and the fourth point of attachment was visibly ripped. Staff got the resident back into the bed with a different sling. R1 was offered to be sent to the ED for further evaluation and initially declined. LN G notified the physician who ordered R1 to be sent to the ED for evaluation if R1 was willing. LN G spoke with R1, who consented to go to the ED for further evaluation and treatment. On 05/12/26 at 11:00 AM, Administrative Staff A said during his investigation of the incident, which included interviews with staff, CN A M stated that prior to the fall, when they were preparing to get R1 up for his shower, she reached into the pile of slings in the clean utility and grabbed the one that was on top. The sling was a blue mesh, small/medium size, and was too small for the resident. On 05/12/26 at 02:20 PM, Maintenance U provided a sizing chart for the slings the facility uses and stated that all the slings have the same overall blue color, the piping along the edge has different colors that indicate the size that corresponds with the sizing/color chart on each individual mechanical lift. Maintenance U stated he recalled the sling that was in use for R1 when he fell on [DATE] as blue mesh with red piping along the edge of the sling. Review of the sizing chart provided by Maintenance U revealed red piping indicated a size small sling with a weight range of 75lbs to 150lbs The facility's undated Safe Resident Handling/Transfers policy documented the facility would ensure the residents are handled and transferred safely to prevent or minimize risks for injury. The policy documented the facility would ensure there were appropriate amounts of varying sizes of slings to accommodate residents. On 05/12/26 at 03:05 PM, Administrative Staff A received a copy of the Immediate Jeopardy [IJ] Template and was informed of the IJ for R1. The facility's corrective measures, fully completed on 03/30/26, included the following, which were verified by the surveyor on-site during the investigation.1. On 03/20/26, R1's Care Plan was updated to include an intervention for a new sling individualized for shower and transfers. The facility discarded old, broken/worn slings.3. On 03/20/26 at 10:00 PM, the facility completed facility-wide education related to safe transfers and appropriate sling sizing for residents.4. On 03/20/26, the facility revised its Safe Resident Handling/Transfers policy to include a provision that each resident who utilizes a sling will have one available for lifts and for showers available in their room with their name and size on the sling.5. On 03/30/26, the facility ordered multiple new appropriately sized slings for the residents in the facility.6. The facility's Quality Assurance Process Improvement (QAPI) committee addressed the concerns identified by the facility's investigation of R1's fall on 03/20/26. All corrections were completed prior to the onsite survey; therefore, the deficient practice was cited as past noncompliance at a scope and severity of J (isolated, immediate jeopardy).

The facility reported a census of 36 residents. Based on observation, record review, and interview, the facility failed to ensure that meals were served at a safe and appetizing temperature.Findings included:- During an observation on 12/28/25 at 11:33 AM, Dietary CC prepared four servings of pureed fried chicken that had a cooked temperature of 195.6 degrees Fahrenheit (F). Once pureed, the chicken was scraped into a small metal container and placed in the steam table, uncovered. Continued observation at 11:57 AM revealed Dietary Staff CC rechecked the temperature of the pureed chicken in the steam table prior to serving, and the temperature was 132.7 degrees F. The chicken and other food items for this meal were served after all holding temperatures were checked. During an interview on 12/28/25 at 12:06 PM, Dietary Staff CC verified chicken should be served at 135 degrees F or higher, as it should have a holding temperature of 135 degrees F. Dietary Staff CC verified the pureed chicken was served at 132.7 degrees F. The facility did not provide a policy related to safe, appetizing food temperatures.

The facility reported a census of 36 residents. The sample included 12 residents. Based on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 3 with a feeding tube (tube for introducing high-calorie fluids into the stomach). The facility further failed to ensure adequate hand hygiene before and after personal care for R3, and R23. The facility failed to store nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask and oxygen nasal cannula in a sanitary manner for R30 and R1. Additionally, the facility failed to sanitize mechanical lift in-between residents' use. Furthermore, R23's catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) tubing dragged on the ground.Findings included:- During an observation on 12/28/25 at 08:48 AM, R30's nebulizer mask laid directly on the nightstand table, which was attached to the medication chamber that had clear liquid identified. R30's oxygen nasal cannula was wrapped around R30's wheelchair handle. R30 reported she had a bag to place the nasal cannula in at one time. During an observation on 12/28/25 at 09:18 AM, R1's nebulizer mask laid unbagged on her bedside table. There was no date on R1's oxygen nasal cannula or nebulizer equipment. During an observation on 12/28/25 at 10:30 AM, no EBP signs were visible for residents who required EBP. Follow-up observation on 12/28/25 at 03:30 PM revealed EBP signs were placed on the door frames of residents who required EBP. During an observation on 12/29/25 at 08:08 AM, Certified Nurse Aide (CNA) P and CNA transferred R3, who had a feeding tube, with a mechanical lift from his bed to his recliner. CNA P and CNA Q lacked the required EBP personal protective equipment. CNA Q removed the mechanical lift from R3's room and pushed it into R12's room without sanitizing the lift. During an observation on 12/29/25 at 08:31 AM, CNA P and CNA Q placed R23's catheter drainage bag on the mechanical lift sling at R23's shoulder level. CNA Q removed the gown and gloves and, without performing hand hygiene, wheeled R23 to the dining area. CNA P cleaned up the room, removed the gown and gloves, and, without performing hand hygiene, exited R23's room with trash. CNA P returned the mechanical lift to the storage area without cleaning it. During an observation of 12/29/25 at 10:10 AM, R23 was in the therapy room with unidentified therapy personnel. R23's catheter tubing laid directly on the floor in front of the right front wheelchair wheel. The therapy staff positioned R23's wheelchair, which caused the wheelchair to roll over the catheter tubing. During an observation on 12/29/25 at 10:36 AM, Licensed Nurse (LN) G and Certified Medication Aide (CMA) R applied gowns and gloves prior to direct care for R3's tube feeding. LN G and CMA R did not wash their hands before applying the personal protective equipment (PPE). During an interview on 12/29/25 at 08:45 AM with CNA P and CNA Q, CNA P reported that R3's precautions changed for his skin tears. She said she did not see the EBP sign on R3's door frame that morning. CNA P confirmed that she had not applied a gown for R3's direct cares any morning until she was educated by Administrative Nurse E that morning, after she provided care to R3. CNA P reported that the only resident she knew who had EBP last week was R23. CNA Q reported that she did not wash off the mechanical lift between residents, and the sanitation wipes are at the nurse's station. During an interview on 12/29/25 at 08:51 AM, CNA P and CNA Q reported the EBP signs were hung up last week, and staff were notified of the change sometime that morning. CNA Q stated she had not been wearing gowns for direct cares for residents on EBP except for R23 prior to that day. CNA P and CNA Q reported they performed hand hygiene prior to applying and after they removed their PPE. During an interview on 12/29/25 at 10:55 AM, LN G reported the EBP sign was posted outside R3's door a couple of weeks ago. LN G reported that she expected the CNAs to wear all the PPE required for EBP and said they had been trained on EBP. LN G said she washed her hands prior to applying PPE. During an interview on 12/29/25 at 12:40 PM, Administrative Nurse E (Infection Preventionist Nurse) reported that the signs for EBP had all fallen down, and she had a hard time keeping them posted outside the residents' rooms. Administrative Nurse E indicated she needed some recommendations on how to keep the signs from falling. During an interview on 12/30/25 at 09:55 AM, Administrative Nurse E revealed she expected staff to wear appropriate PPE when providing direct care for residents on EBP and reported she has trained the staff numerous times. Administrative Nurse E reported she expected the catheter tubing not to touch the floor and drag across the floor, and she expected staff to place a catheter drainage bag below a resident's waist during a transfer. Administrative Nurse E reported she expected staff to sanitize the mechanical lift and shared medical equipment with the sanitation wipes between resident use. Additionally, she reported she expected the staff to perform hand hygiene prior to applying and removing PPE. The facility's Infection Control Policy dated 09/09/25 documented this facility would facilitate safe care of all residents and staff with known or suspected communicable diseases by establishing and maintaining an infection prevention and control program. Hand hygiene procedures are to be followed by staff involved in direct resident contact. If the use of common equipment or items is unavoidable, adequately clean and disinfect them before use for any other resident with a chemical agent. The facility did not provide a policy for EBP or catheter care.

The facility reported a census of 36 residents; the sample included 12 residents sampled. Based on interviews and record review, the facility failed to ensure residents received the opportunity to participate in the care planning process when staff failed to invite Residents (R) 1 and R30 or their responsible party to care plan meetings.Findings included:1. R30's Electronic Medical Record (EMR) recorded a Quarterly Minimum Data Set (MDS) dated 08/25/25 and 11/25/25. R30's EMR lacked documentation of a care plan meeting conducted in the past six months. During an interview on 12/28/25 at 08:48 AM, R30 reported she was not invited to any care plan meeting. 2. R1's EMR recorded an admission MDS dated 11/03/25. R1's EMR lacked documentation of a care plan meeting conducted in the past two months. During an interview on 12/28/25 at 09:18 AM, R1said she did not know what a care plan meeting was and had not been invited to one since she was admitted two months ago. During an interview on 12/29/25 at 03:30 PM, Administrative Nurse F reported she invited the residents and the responsible party to the care plan meetings with a letter mailed to the responsible party, and a letter was also given to the resident at the facility. Administrative Nurse F reported she did not keep a copy of the letter and did not document in the EMR about invites to care plan meetings or when a care plan meeting was held. Administrative Nurse F reported a resident with a Brief Interview of Mental Status (BIMS) score of 12 or higher (indicating no cognitive impairment) could sign the care plan sheet at the end of the care plan in the book. Administrative Nurse F reported R30 had a BIMS of 13 and reported that she did not have a care plan sheet signed by R30 or the responsible party. Administrative Nurse F reported she did not have a signed care plan sheet for R1 and the responsible party, as R1's daughter had not been at the facility. During an interview on 12/30/25 at 01:04 PM, Administrative Nurse D revealed that residents at the facility do not go to care plan meetings. Administrative Nurse D said she was unsure whether families or residents had been invited to the care plan meetings and confirmed that no documentation existed to demonstrate families were invited to the care plan meetings. Administrative Nurse D reported she expected the care plan meetings to be held per facility policy. The facility's policy Resident Centered Care Plan Process dated 03/28/18, documented every reasonable effort will be made to accommodate the attendance of the resident and/or resident representative. If they are unable/unwilling to attend, documentation must be provided in the medical record of efforts made to accommodate attendance.

The facility reported a census of 36 residents. The sample included 12 residents with one resident reviewed for self-administration of medications Based on observation, interview, and document review the facility failed to assess Resident (R) 30 for the ability to safely self-administer Mucinex (medication used to treat congestion) and Flonase ( nasal spray to treat nasal congestion and allergies) and keep at the bedside. The facility additionally failed to ensure an order to keep those medications at the bedside and self-administer. Findings included:- R30 's Electronic Medical Record (EMR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R30's 03/01/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R30's MDS documented no behaviors and no depression. R30's MDS documented she required maximal assist with all activities of daily living (ADLs) except she required moderate assist for oral care, and she was independent with eating. R30's 03/03/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R30 triggered because she required assistance with ADLs. R30 was alert and oriented and was there for skilled services. R30's 12/28/25 Care Plan lacked documentation regarding self-administering medications. R30's Physician Orders documented budesonide inhalation suspension (a class of medication that works by decreasing swelling and irritation in the airways to make breathing easier). 0.5 milligram (mg)/2 milliliter (ml) 1 vial inhaled orally at bedtime for chronic obstructive pulmonary disease (COPD- a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing) may have it in the room for self-administration date ordered 03/24/25. R30's Physician Orders lacked an order for Mucinex and Flonase and lacked an order to keep at bedside for self-administration. R30's Self-Administration of Medication dated 02/25/25 at 03:15 PM documented R30 required assistance with storing medications in a secure location, opening and closing medication containers, and accurately telling time to know when medications would need to be taken. R30's Self-Administration of Medication dated 09/23/25 at 12:32 PM documented R30 was fully capable of storing medications in a secure location, opening and closing medication containers, and accurately telling time to know when medications would need to be taken. Physician approved R30 to have budesonide inhalation suspension in her room for self-administration. During an observation on 12/28/25 at 08:48 AM, R30 had a bottle of Mucinex 30 mg-600 mg tablets, extended release 12-hour, and Flonase on her bedside table. R30 reported she self-administered those medications on her own as she presently had a cold. During an interview on 12/29/25 at 01:30 PM, R30 reported that she was upset that Administrative Nurse D entered her room on 12/28/25 and took her bottle of cough syrup out of her room. R30 reported she put her bottle of Mucinex and Flonase away so staff would not take it. During an interview on 12/30/25 at 06:33 AM, Certified Medication Aide (CMA) U reported that residents were not allowed to have their own medications in their rooms. CMA U reported that if she did observe residents with medication in their room, she would remove the medications from the room and let the nurse know. During an interview on 12/30/25 at 11:49 AM, Licensed Nurse (LN) H reported that if any resident had any medications in their room, the resident would be assessed for self-administration, and it would be care planned. LN H confirmed that R30 had one self-administration assessment for budesonide, and nothing was noted for Mucinex and Flonase. During an interview on 12/30/25 at 01:04 PM, Administrative Nurse D reported R30 had a medicine cup of cough syrup on her table on 12/28/25 in the late afternoon, and the CMA had let her know. Administrative Nurse D reported she went to R30's room and asked her if she wanted to take her cough syrup, as it was not allowed to be left in her room, and she did not want to take it at that time, so R30 was educated that when she did want to take the medication, she could ask for it. Administrative Nurse D reported she removed the cough syrup from R30's room. Administrative Nurse D reported she did not see the Flonase or Mucinex in R30's room. The facility's policy Resident Self-Administration of Medication, dated 2025, documented it is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. All nurses and aides are required to report to the charge nurse on duty any medication found at the bedside that is not authorized for bedside storage. Unauthorized medications are given to the charge nurse for return to the family or the responsible party.

The facility had a census of 36 residents; the sample included 12 residents, including one resident reviewed for accommodation of needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R)23's foot platform remain attached to her electric wheelchair. Findings included:- R23's Electronic Health Record (EHR) included diagnoses of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), chronic kidney disease (CKD - a long-term condition where the kidneys are damaged and cannot filter blood effectively), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities) and quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord). R23's 12/23/25 5-Day Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented R23 was dependent on staff for all cares except eating, which required supervision/setup assistance. R23's Baseline Care Plan documented R23 utilized a manual wheelchair. During an observation on 12/28/25 at 01:19 PM, R23 sat in her electric wheelchair with her legs dangling unsupported from the seat of her electric wheelchair. During an interview on 12/28/25 at 01:19 PM, R23 revealed therapy staff had removed the foot platform from her wheelchair the day before, and nobody had reinstalled it. During an interview on 12/30/25 at 12:40 PM, Licensed Nurse (LN) H revealed residents who utilized electric wheelchairs should have the foot platform or pedals attached at all times to prevent the residents' legs from dangling, which would inhibit proper circulation. During an interview on 01/30/25 at 01:28 PM, Administrative Nurse D revealed residents with electric wheelchairs should have the foot platform or pedals attached all the time for safety concerns. The undated policy documented the facility would evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents is endangered. Further, the facility would make reasonable accommodations to individualize the resident's physical environment.

The facility reported a census of 36 residents; the sample included 12 residents. Based on observation, interview, and record review, the facility failed to obtain valid advanced directives (a legal document in which a person specified what actions should be taken for their health,) or assess the wishes of Resident (R) 23 related to end-of-life care.Findings included:- R23's Electronic Health Record (EHR) included diagnoses of neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), chronic kidney disease (CKD - a long-term condition where the kidneys are damaged and cannot filter blood effectively), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities) and quadriplegia (inability to move the arms, legs, and trunk of the body below the level of an associated injury to the spinal cord). R23's [DATE] 5-Day Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. The assessment documented R23 was dependent on staff for all cares except eating which required supervision/setup assistance. R23's Baseline Care Plan documented R23 was a full code (a term used to indicate the desire to receive resuscitative measures in the event of cardiac arrest). R23's EHR physician orders revealed an order for Full Code, effective [DATE]. During an interview on [DATE] at 01:57 PM R23 stated she had signed a do not resuscitate (DNR- or no code, a legal document or order that means the person does not desire CPR in the event of cardiac arrest) document in the past and was able to describe potential injuries sustained during resuscitative efforts. She said she did not want to endure that pain or discomfort. R23 revealed facility staff had not asked her if she was a full code or had a DNR. During an interview on [DATE] at 12:40 PM Licensed Nurse (LN) H revealed when a new resident arrived at the facility, one of the nurses would complete several initial assessments that included asking the resident, or their representative, if the resident was a full code or had a DNR order. During an interview on [DATE] at 01:28 PM, Administrative Nurse D revealed the admitting nurse was responsible to confirm code status with the resident and/or their representative and request copies of the advanced directives if they existed. Administrative Nurse D stated that if a resident's code status was unknown, then an assessment was performed to obtain the information from the resident or their representative. The facility's undated Advance Directives policy documented it was the policy of the facility to recognize the right of residents and/or representatives to make informed decisions about medical care including the right to accept or refuse medical treatment and the right to formulate advance directives. Further, the facility would comply with applicable laws to promote and honor treatment preferences expressed by the resident or their representative. Every resident would be asked on admission if they have advance directives and would document discussions with the resident/representative. If the resident has an advance directive, the resident/representative would be asked to provide a copy which would become part of the resident's record.

The facility identified a census of 36 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure a 14-day stop time for the use of an antidepressant (a class of medications used to treat mood disorders) for Resident (R) 5 on an as needed (PRN) basis, as required.Findings included:- Review of the Electronic Health Record (EHR) for R5 included diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), dysphagia (difficulty swallowing) following cerebral infarction (stroke), dementia (a progressive mental disorder characterized by failing memory and confusion) and anxiety. R5's 02/21/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. The assessment documented R5 received an antidepressant medication during the look-back period. R5's 11/17/25 Quarterly MDS documented a BIMS score of four, which indicated severely impaired cognition. The assessment documented R5 received an antidepressant medication during the look-back period. R5's 02/21/25 Psychotropic [affects mood or thoughts] Drug Use Care Area Assessment (CAA) documented R5 received Trazodone without any documented adverse reactions (unintended negative effect) or side effects. A consultant pharmacist reviewed the medications monthly for possible gradual dose reductions (GDR). R5's Care Plan reviewed 12/19/25, documented R5 utilized antidepressant medications related to anxiety, agitation, and depression. R5's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for 12/2025 documented the following:1. An order for Trazodone HCl oral tablet 50 milligrams (mg), give one-half tablet by mouth every 24 hours PRN insomnia (inability to sleep), give at bedtime (HS), dated 10/27/25. The order lacked a 14-day stop date. The order was discontinued on 12/09/25.2. An order for Trazodone HCl oral tablet 50 mg, give one tablet by mouth every 24 hours PRN insomnia; give at HS, dated 10/27/25. The order lacked a 14-day stop date. The order was discontinued on 12/09/25.3. An order for Trazodone HCl oral tablet 50 mg, give one-half tablet by mouth at bedtime for insomnia for 14 days, dated 12/09/25 and discontinued on 12/22/25. During an interview on 12/30/25 at 02:40 PM with Consultant GG and Administrative Staff A, Consultant GG outlined the medication regimen review process and stated the consultant pharmacist submitted his reports directly in the EHR. The facility would then print the recommendations and present them to the provider, then scan/fax the provider's responses back to the pharmacist as soon as possible. During an interview on 01/06/26 at 04:18 PM, Administrative Staff A revealed all psychotropic medications given on a PRN basis should have a 14-day stop time. If an order did slip through the checks that were in place, the pharmacist would address the concern on their next monthly medication regimen review. If the provider failed to add a stop time, then the pharmacist would call the provider directly and make an inquiry and request the provider provide a rationale for continued use beyond the 14-day period or to add a 14-day stop date to the order. The facility's undated Unnecessary Drugs - Without Adequate Indication for Use policy did not address the required 14-day stop time for PRN psychotropic medication use. The facility's policy Use of Psychotropic Medication(s), undated, documented the intent of the policy is to ensure that residents only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. Additionally, these medications should only be used to treat the resident's medical symptoms and not used for discipline or staff convenience, which would deem it a chemical restraint.

The facility had a census of 36 residents. The sample included 12 residents. Based on interview, observation, and record review, the facility failed to provide services to meet professional standards of care when staff failed to ensure Resident (R) 4's Electronic Medical Record (EMR) contained appropriate documentation for the paranoid schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) diagnosis. Findings included:- R4 's EMR revealed diagnoses of paranoid schizophrenia and dementia (a progressive mental disorder characterized by failing memory and confusion). R4's 04/29/25 Significant Change Data Minimum Data Set (MDS) documented a Brief Interview of Mental Status (BIMS) score of three, which indicated severely impaired cognition. R4's MDS revealed a diagnosis of schizophrenia. R4's 04/30/25/25 Cognitive Loss/Dementia Care Area Assessment (CAA) documented R4 was oriented to herself only. R4's diagnoses were dementia and paranoid schizophrenia. R4 had her own form of communication, which staff have learned to understand. R4 was able to communicate needs in her own way. She would have periods of agitation and relied on reminders to use her rosary beads and prayer. R4's 12/28/25 Care Plan lacked documentation regarding schizophrenia. R4's 07/09/15 History and Physical lacked paranoid schizophrenia as a diagnosis. R4's 08/11/16 Physician Visit Note documented no paranoia. The note lacked paranoid schizophrenia as a diagnosis. R4's 12/20/19 Physician Visit Note documented a change in the diagnosis of risperidone (an antipsychotic, a class of medications used to treat major mental conditions that cause a break from reality) to paranoid schizophrenia. R4's 04/09/24 at 03:30 PM Physician Visit Note documented a diagnosis of paranoid schizophrenia. R4's 09/07/25 Psychotropic Medication Informed Consent documented the reason for use of medications, diagnosis of paranoid schizophrenia. R4's EMR lacked physician documentation, clinical findings, and assessments supporting the addition of the schizophrenia diagnosis. During an observation on 12/28/25 at 08:35 AM, R4 sat in her chair in her room; she had visible facial hair stubble around the jawline, chin, and upper lip. R4's fingernails were long and broken. R4 was repetitive with her words, repeating numbers as she swayed back and forth in her chair. During an interview on 12/30/25 at 11:49 AM, Licensed Nurse (LN) H reported that Administrative Nurse F documented all the residents' diagnoses in the EMR. During an interview on 12/30/25 at 03:47 PM, Administrative Nurse E reported that Administrative Nurse F was unavailable at that time and could not state why R4 had a diagnosis for paranoid schizophrenia in her diagnosis tab dated 04/09/24, which occurred during her stay at the facility. During an interview on 12/30/25 at 03:50 PM, Administrative Staff A revealed a Physician Visit Note dated 04/09/24 in the EMR that had paranoid schizophrenia as a diagnosis. Administrative Staff A reported that the physician received his information from a website with current diagnoses for the residents. During an interview on 12/30/25 at 04:15 PM, Administrative Staff A revealed a Physician Visit Note dated 12/20/19, which documented a change diagnosis of risperidone to paranoid schizophrenia. Administrative Staff A could not answer if R4 had a thoroughly documented history in her EMR for that diagnosis. Administrative Staff A reported he expected to have a thorough history documented for any resident with a new paranoid schizophrenia diagnosis. The facility did not provide a policy for professional standards of care in diagnosing schizophrenia for use with antipsychotics.

The facility reported a census of 36 residents. The sample included 12 residents with three residents reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to offer and provide assistance with nail care and facial hair removal for Resident (R) 4.Findings included:- R4 's Electronic Medical Record (EMR) revealed diagnoses of paranoid schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), dementia (a progressive mental disorder characterized by failing memory and confusion) and diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). R4's 04/29/25 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R4's MDS documented she required maximal assistance with bathing and moderate assistance with personal hygiene. R4's 04/30/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) did not trigger. R4's 04/30/25 Cognitive Loss/Dementia CAA documented R4 was oriented to the person. R4's diagnoses were dementia and paranoid schizophrenia. R4 had her own form of communication, which staff have learned to understand. R4 was able to communicate needs in her own way. She would have periods of agitation and relied on reminders to use her rosary beads and prayer. R4's Care Plan revised date 06/13/24 directed staff the nurse would trim her fingernails during the weekly skin assessment and as needed. The plan directed staff to cleanse R4's fingernails on bath days and as needed, and staff were to notify the nurse if her nails needed a trim, as she was diabetic. R4's Care Plan revised date 10/23/25 directed staff to assist R4 to maintain a clean, neat, well-groomed appearance and be free of body odor daily. Staff were instructed to shave her chin if needed. During an observation on 12/28/25 at 08:35 AM, R4 sat in her chair in her room. She had visible facial hair stubble around the jawline, chin, and upper lip. R4's fingernails were long and broken. R4 was repetitive with her words, repeating numbers as she swayed back and forth in her chair. During an observation on 12/29/25 at 07:47 AM, R4 sat in a chair in the dining room, eating her breakfast. R4 had visible facial hair stubble around the jawline, chin, and upper lip. R4's fingernails were long and broken. During an observation on 12/30/25 at 07:30 AM, R4 ambulated in the hallway to the dining room with her walker. R4 was clean-shaven, but her nails were unchanged from the 12/28/25 and 12/29/25 observations. During an interview on 12/30/25 at 09:15 AM, Certified Nurse Aide (CNA) N reported that she would shave a resident if they asked and or if she noted the resident needed a shave, she would assist the resident. CNA N reported that CNA M and CNA O completed the showers and whirlpool baths. During an interview on 12/30/25 at 09:20 AM, CNA O reported that she would shave residents on their bath days, and R4 was shaved that day as she received a bath. CNA O reported that R4's facial hair grew quite fast and said she probably should be shaved more than twice a week because she would get stubble very quickly. CNA O reported she could not cut fingernails for diabetic residents and confirmed that R4 could use a nail trimmer. CNA O said R4 was a diabetic, and she was worried she might nick the resident's skin. During an interview on 12/30/25 at 10:38 AM, CNA M reported she would shave residents on their shower days, whether they were diabetic or not. CNA M reported she would write the need for nails to be trimmed by the nurse on the shower sheet that she submitted to the nurse. CNA M then changed her statement, stating she would verbally alert the nurse if a resident who was diabetic required their fingernails to be trimmed. During an interview on 12/30/25 at 11:49 AM, Licensed Nurse (LN) H stated she expected the CNAs to shave the residents who required assistance. LN H reported the CNAs would verbally notify the nurse when a diabetic resident needed their fingernails clipped. During an interview on 12/30/25 at 01:04 PM, Administrative Nurse D revealed she expected the staff to shave residents every shower day or as needed. Administrative Nurse D said she expected the nurses to cut the diabetic residents' fingernails, and the CNAs would let the nurse know when that was needed. The facility's policy Activities of Daily Living (ADLs) dated 2025 documented the facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

The facility reported a census of 36 residents; the sample included 12 residents with three residents reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards when staff failed to support the feet of two residents, Resident (R) 5 and R31, off the ground during staff-assisted wheelchair locomotion.Findings included: - During an observation on 12/28/25 at 12:56 PM, R5 was in the common area and sat in her wheelchair without foot pedals attached. She was slumped forward and appeared to be asleep. Certified Nurse Aide (CNA) T pushed R5's wheelchair from the common area, down the hall, and into R5's room. R5's feet were touching the floor while CNA T pushed R5's wheelchair. During an observation on 12/28/25 at 04:35 PM, R31 sat in her wheelchair in the common area and sat in her wheelchair without foot pedals attached. Licensed Nurse (LN) H assisted R31 from the common area and partway down the hallway. R31 held her feet up while LN H assisted with wheelchair locomotion. During an observation on 12/29/25 at 01:40 PM, R31 sat in the activity area in her wheelchair without foot pedals attached. Activity Z assisted R31 out of the activity area and partway down the hallway, with R31 holding her feet off the floor during the assisted locomotion. During an interview on 12/30/25 at 11:55 AM, CNA S revealed residents in wheelchairs should have the pedals attached to the chair and feet secured on the pedals if staff is assisting with wheelchair locomotion. During an interview on 12/30/25 at 12:18 PM, Certified Medication Aide (CMA) R revealed if a resident was self-propelling in their wheelchair without pedals, staff should go get some pedals before providing assistance. CMA R said residents should always have wheelchair pedals attached and their feet properly secured on the pedals prior to staff-assisted wheelchair locomotion. During an interview on 12/30/25 at 12:40 PM, LN H revealed residents in wheelchairs should not be assisted by staff unless the wheelchair had pedals and the resident's feet were securely placed on the pedals. LN H revealed that the facility maintained a stock of spare wheelchair pedals for use with residents whose wheelchairs do not have pedals or if staff cannot find the resident's pedals. During an interview on 12/30/25 at 01:28 PM, Administrative Nurse D revealed the facility's expectation was that staff should not assist residents in wheelchairs unless foot pedals were present. Staff should obtain and install appropriately fitting pedals to the wheelchair and appropriately secure the resident's feet on the pedals prior to providing wheelchair assistance. The facility's undated Incidents and Accidents policy did not address applying pedals to a wheelchair prior to staff-assisted wheelchair locomotion.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to identify causal factors for falls, provide adequate supervision, and implement effective interventions to prevent avoidable accidents for Resident R (32) when he had multiple falls over various dates, which resulted in fractures, contusions, increased pain, and multiple trips to the hospital. The facility also failed to identify causal factors and implement interventions to prevent falls for R22. These failures caused actual harm to R32 and placed R22 and other residents at risk for continued accidents and injuries. Findings included: - R32's Electronic Medical Record (EMR) included diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), major depressive disorder (major mood disorder which causes persistent feelings of sadness) with severe psychotic (any major mental disorder characterized by a gross impairment in reality perception) symptoms, generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, and nondisplaced intertrochanteric (upper portion of thigh bone) fracture of left femur (thigh bone). R32's Quarterly Minimum Data Set (MDS), dated [DATE], documented staff assessed the resident with moderately impaired cognition; R32 had no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by gross impairment in reality perception), or behaviors exhibited. R32 had a functional range of motion impairment on the lower extremity on one side and used a wheelchair. The MDS further documented R32 as dependent on staff for toileting, bathing, personal hygiene, dressing lower body dressing, putting on and taking off footwear, and mobility. R32 was incontinent of urine and bowel. The MDS recorded R32 had nonverbal indicators of pain and received scheduled pain medication. R32 had one fall with a major injury, and a recent surgery requiring active Skilled Nursing Facility (SNF) services for a repaired fracture of the pelvis, hip, leg, knee, or ankle. The Fall Care Area assessment dated [DATE] documented R32 at increased risk for falls due to advancing Parkinson's disease and noted the resident tended to walk the halls and forgot to use a walker at times. The overall objective in care planning for falls was avoidance through minimization of risks such as ensuring proper footwear, ensuring clothes were clean, dry, and not wet with urine, and reminding R32 to use a walker. R32's Care Plan, dated 09/20/22, documented R32 admitted from the home setting to Long Term Care (LTC) due to an increased need for assistance with personal care and increasingly unsteady gait resulting in multiple falls, all related to a diagnosis of Parkinson's disease. The care plan directed staff to frequently monitor R32's whereabouts, monitor R32 when ambulating, and remind him to use his walker; if R32's gait appeared unsteady, ask him to sit down for a few minutes until he calmed down and could proceed safely. R32's Care Plan, dated 02/16/24, documented R32 had an increased risk for falls related to impetuous behavior. The care plan directed staff to place the resident's bed in a low position with assist rails, place a fall mat, use a soft touch call light, provide frequent monitoring of whereabouts, and R32 would attend physical and occupational therapy. The care plan further directed staff to transfer R32 with the assistance of two staff and utilize a wheelchair for mobility; R32 was toe-touch weight-bearing status. The care plan documented R32 was at risk for bleeding related to anticoagulation (a medication which prevents blood from clotting) medication and increased pain related to post-surgical hip repair. Review of R32's falls as documented from the EMR and Fall Investigation Summary revealed the following: On 07/08/23 at 05:05 PM, R32 hollered from his room and reported he slowly rolled out of bed, trying to use the toilet. R32 stated he had pain on the right side down where the ribs ended. The Fall Investigation Summary recorded a corrective action of staff education to assist the resident to the toilet after meals. On 07/12/23 at 04:10 AM staff heard R32 hollering and found him in his room next to the bed. The fall was not witnessed and R32 reported he was going from his chair to his bed. R32 reported pain in his back and right hip. R32 went to the emergency room and the x-ray showed there was no fracture. The Fall Investigation Summary documented R32 had a recent antipsychotic (class of medications used to treat major mental conditions that cause a break from reality) decrease and orders to receive therapy services. The summary documented R32 had three falls in the past two weeks, and he reported the floor was slick. Staff mopped the floor and notified housekeeping to further clean the room. R32 had not been evaluated by therapy. The investigation documented nursing spoke to the therapists and asked them to evaluate R32 as soon as possible. On 07/17/23 at 04:45 PM, staff found R32 on the floor of his room. R32 reported he tripped on the slippery floor. The occurrence was not witnessed. R32 had a decreased range of motion to his left arm and guarding towards his left shoulder. At 11:00 PM, R32 returned from the emergency room with a diagnosis of a fractured clavicle (collarbone) to the left side; R32 wore a sling. No corrective action noted. On 07/28/23 at 10:00 PM, R32 was in the dining room and tried to ambulate without his walker. R32 leaned to his left side and lost balance. The Fall Investigation Summary documented R32 had been restless and was toileted and redirected several times. The summary further documented R32's family member was concerned about his recent falls. A corrective action documented that staff were educated to direct R32 to a chair that would be more appropriate, easier to get out of, and better for staff to monitor the resident to assist him in getting up due to his not asking for help. The care plan lacked the corrective action noted. On 08/17/23 at 01:10 AM R32 had an unwitnessed fall with complaints of neck and head pain and went to the emergency room . The Fall Investigation Summary documented R32 was found outside of the bathroom. His pants were wet on the floor, and he stated he was going to the bathroom. A corrective action documented that staff were educated to check, change, and toilet R32 on all rounds through the night. The summary documented rounds occurred at 11:00 PM, 01:00 AM, 03:00 AM, and 05:00 PM. The care plan lacked the corrective action noted. On 09/24/23 at 11:41 AM R32 was found sitting on the floor with his back against the door of the dining room bathroom. The fall was not witnessed and R32 reported he was hurt all over though no injury was found. The Fall Investigation Summary documented R32 had an unwitnessed fall in the dining room bathroom area and was unable to say what happened. R32 often walked around on his own, looking for the bathroom, and became unsteady while walking. A corrective action documented staff were educated to be more aware when R32 was up and walking around and to assist and direct the resident to his bathroom. The care plan lacked the corrective action noted. On 10/26/23 at 08:15 PM, R32 had an unwitnessed fall after he attempted to self-toilet and reported right elbow pain. R32 reported he was going to the bathroom due to being incontinent in his brief. The Fall Investigation Summary documented the fall was not witnessed. R32 was weak and had an unsteady gait possibly related to his COVID-19 (highly contagious respiratory virus) diagnosis. A corrective action documented the resident was weak and would need therapy services when he was out of quarantine. On 01/05/24 at 03:00 AM R32 had an unwitnessed fall in his room while he was reaching for personal items. He was incontinent at the time of the fall. R32 had recent medication changes related to antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medications. R32 had vocal complaints of right and left knee pain. The Fall Investigative Summary documented R32 was found lying on his back in his room and stated he was looking for a phone book. R32 had socks on. A corrective action documented that staff were directed to ensure R32 had non-skid socks on when in bed. The care plan lacked the corrective action noted. On 02/12/24 at 01:01 PM, R32 had a fall that was witnessed by another resident. R32 was getting up and transferring from the table. R32 complained of left hip and elbow pain and went to the emergency room . The Fall Investigation Summary documented R32 sat at a table drinking juice and another resident witnessed R32 stand and fall to the left side onto the floor. R32 complained of left hip and elbow pain, and staff sent him to the emergency room . R32 had a left hip fracture and left elbow contusion. A corrective action documented R32 was to work with therapy when he returned from the hospital. On 03/12/24 at 07:54 PM, staff found him lying on his left side with a large bulge to his left thigh area, and he complained of left elbow, thigh, and hip pain. R32 transferred himself from the wheelchair without the brakes on , and with the wheelchair footrest in the way at the time of the fall. R32 took an anticoagulant and needed to be transferred to the hospital. The Interdisciplinary Team Review Investigation documented R32 had severe cognitive impairment and was found on the floor after an unwitnessed event. The suspected root cause was while staff got R32 ready for bed, staff stepped out of his room to get help to transfer him, and R32 attempted to transfer himself. The investigation recommended an intervention to educate staff that the resident was not to be left alone in his room when he was in a wheelchair. The care plan lacked recommendations for intervention. The Progress Note dated 03/13/24, recorded R32 had a second surgical repair to his left hip. R32's Baseline Care Plan, dated 03/19/24 after readmission to the facility documented on return to the facility R32 had additional diagnoses of left basilar (lower lung area) infiltration and acute toxic metabolic encephalopathy (a broad term for any brain disease that alters brain function or structure). On 04/03/24 at 02:40 PM observation revealed R32 in his room in bed and covered with blankets. R32 yelled out for assistance and tried to get out of bed. Staff responded and took R32 to the commons area and assisted him to a recliner between the nurses' station and dining room. On 04/03/24 at 01:12 PM Certified Medication Aide (CMA) R along with Certified Nurse Aide (CNA) M assisted R32 from his wheelchair to his bed without bearing weight on the resident's left leg. R32's brief was changed due to urine incontinence. CMA R stated R32 was ambulatory and confused when he was admitted to the facility, and he had Parkinson's disease. CMA R said to prevent falls, staff assisted R32 to activities. CMA R said R32 was generally cooperative. CMA R said R32 would occasionally inform staff if he needed to have a bowel movement or be toileted, but otherwise, R32 was on a two-hour toileting schedule; he used a fall mat, had his bed in the lowest position, and should be checked frequently. On 04/04/24 at 09:30 AM, CNA N stated staff made sure R32 had his call light in reach, used a gait belt for transfers, and checked him frequently. CNA N said staff put R32's bed in the lowest position with a fall mat next to the bed, changed from wheelchair sitting to using a recliner, and staff toileted him before and after meals and during rounds. CNA N reported staff used verbal communication that to inform staff when residents fell , and staff checked the care plan in the nurses' station for any fall interventions. On 04/04/24 at 09:32 AM, Licensed Nurse (LN) G reported when a fall occurred, the nurse assessed the resident for injuries and signs of change; they notified the physician, family, and administration. LN G completed fall charting and the report was given to the Director of Nursing. LN G said staff were informed during the shift report about falls and looked at the working care plan for interventions. On 04/04/24 at 11:29 AM Administrative Nurse D verified the resident had repeated falls, which resulted in fractures and confirmed the resident's care plan was not updated with interventions by the Interdisciplinary Team (IDT) to prevent further falls. The facility's Accident/Incident Committee policy, dated 11/20/20, is documented to review post-incident documentation to ensure that adequate interventions have been put in place to reduce the risk of future occurrences. The facility failed to provide adequate supervision, identify causal factors, and implement effective interventions to prevent R32 from multiple falls, which resulted in contusions, fractures, increased pain, and hospitalization s. These failures resulted in actual harm to R32 and placed the resident at risk for further falls with injuries. 41713 - The electronic medical record for R22 documented diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), and benign paroxysmal positional vertigo (BPPV- brief episodes of mild to intense dizziness after a change in head position). R22's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R22 required partial to moderate assistance with activities of daily living (ADLS). R22 had no history of falls before admission. R22's Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. R22 required supervision with transfers from a chair and walking. R22 used a walker to assist with mobility. R22 had one fall without injury and one fall with injury since the prior assessment. R22's ADL Care Area Assessment (CAA) dated 09/11/23 documented she was working with therapy to regain strength and improve balance and gait while avoiding complications such as falls. R22's Fall CAA dated 09/11/23 documented R22 had an unsteady gait and poor balance. The plan was to minimize the risks and avoidance of complications such as injuries related to falls. R22's Care Plan last updated 04/01/24 directed staff that R22 required stand-by assist staff with transfers and walking. R22 was independent with walking in her room. R22's care plan lacked interventions directing staff regarding falls. A fall investigation dated 10/11/23 documented R22 had an unwitnessed fall without injury in her room. R22 was found on the floor next to her bed by a staff member. Staff discussed the importance of a night light with the resident and advised R22 that her bathroom light could be left on, and the door cracked to allow light in. The investigation lacked a root cause analysis. A fall investigation dated 11/12/23 documented R22 had an unwitnessed fall that resulted in a hematoma to the back of her head. R22 was found on the floor in her room in front of her recliner; she had no bottom garments or shoes on. R22 stated she got up to go to the bathroom and was leaving the bathroom to find some pull-ups and slipped and fell . R22 was assessed by the nurse, and staff notified the physician and daughter of the incident. The fall investigation lacked a root cause analysis and new fall intervention. A fall investigation dated 11/27/23 documented R22 had an unwitnessed fall without injuries in her room. R22 was calling out for help and was found on the floor next to her bed. R22 stated there were kidnappers in her room. R22 was confused. R22 complained of pain in her left knee. The nurse completed a thorough assessment and obtained vital signs. R22 was returned to bed with assistance from three staff. Staff notified R22's physician and family. The physician ordered a urinalysis (lab analysis of urine). The fall investigation lacked a root cause analysis or new fall intervention. A fall investigation dated 12/04/23 at 03:15 AM documented R22 was found in her room on the floor next to her bed by staff. R22 complained of pain in her back after she hit it on her bed when she fell . The nurse came to assist and assess the resident. R22 stated she wanted to get up to her chair, so she stood, took a few steps, and fell . Staff notified R22's representative of the fall. The investigation noted the resident has had increased confusion and a decline in mobility. Staff notified the physician and received orders for a urinalysis and lab draw. The investigation lacked a root cause analysis and an update to the care plan. A fall investigation dated 12/04/23 at 01:30 PM documented R22 had an unwitnessed fall in her room that resulted in a skin tear to her right elbow. R22 was found on the floor by the medication aide on her right side near her bathroom. R22's walker was tipped over. R22 was assessed by the nurse and the physician was notified. Staff received an order to send R22 to be evaluated at the emergency room (ER). R22 stated she got up to get ready for her appointment. R22's representative was notified and voiced concern about R22's recent decline. R22's room was moved closer to the nurse station. R22's ER visit showed R22 had a urinary tract infection (UTI-an infection in any part of the urinary system). The investigation lacked a root cause analysis and an update to the care plan. On 04/02/24 R22 walked with her walker to the dining room with a slow unsteady gait. On 04/03/24 at 08:00 AM Licensed Nurse (LN) H stated when a resident had a fall typically the resident was assessed, an investigation was conducted, and witness statements were obtained by any witnesses. LN G stated then the interdisciplinary team (IDT) would meet and come up with a new intervention for the fall. On 04/04/24 at 09:04 AM Administrative Nurse D stated R22 has had a few falls recently. Administrative Nurse D stated after a fall the nurse would assess the resident, the physician and family would be notified, and then witness statements would be obtained so the IDT team could further investigate the incident. Administrative Nurse D stated the investigation includes finding the cause and coming up with new interventions to avoid further falls. The Accident/Incident Committee policy documented a meeting would be held within a reasonable timeframe with the Administrator, Director of Nursing (DON), Assistant DON, and any other pertinent department managers. The committee should meet where the incident occurred to visualize any environmental issues that may have led to the incident. The committee would review the incident report to ensure all areas were completed. The post-fall assessment would be reviewed. The care plan would be reviewed to ensure immediate interventions were put into place after the incident. The committee would complete and update the fall risk assessment. Any additional interventions that have been made to the resident's plan of care would be communicated to the direct care staff by the DON or designee. The log of the accidents and incidents would be taken to Quality Assurance and Performance Improvement (QAPI) for review. The facility failed to ensure staff completed a thorough fall investigation for R22 which included a root cause analysis for the fall and failed to identify and implement interventions to prevent further falls. This deficient practice places R22 at risk of further fall and possible injury.

The facility had a census of 41 residents. The sample included 12 residents. Based on record observation, record review, and interview, the facility failed to identify Resident (R) 32's multiple unwitnessed falls with fractures as possible neglect and report to the State Agency (SA) as required. This placed the resident at risk for unidentified and/or ongoing abuse. Finding included: - R32's Electronic Medical Record (EMR) included diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), major depressive disorder (major mood disorder which causes persistent feelings of sadness) with severe psychotic (any major mental disorder characterized by a gross impairment in reality perception) symptoms, generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, and nondisplaced intertrochanteric (upper portion of thigh bone) fracture of left femur (thigh bone). R32's Quarterly Minimum Data Set (MDS), dated [DATE], documented that staff assessed the resident with moderately impaired cognition; R32 had no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by gross impairment in reality perception), or behaviors exhibited. R32 had a functional range of motion impairment on the lower extremity on one side and used a wheelchair. The MDS further documented R32 as dependent on staff for toileting, bathing, personal hygiene, dressing lower body dressing, putting on and taking off footwear, and mobility. R32 was incontinent of urine and bowel. The MDS recorded R32 had nonverbal indicators of pain and received scheduled pain medication. R32 had one fall with a major injury, and a recent surgery requiring active Skilled Nursing Facility (SNF) services for a repaired fracture of the pelvis, hip, leg, knee, or ankle. The Fall Care Area assessment dated [DATE] documented R32 at increased risk for falls due to advancing Parkinson's disease and noted the resident tended to walk the halls and forgot to use a walker at times. The overall objective in care planning for falls was avoidance through minimization of risks such as ensuring proper footwear, ensuring clothes were clean, dry, and not wet with urine, and reminding R32 to use a walker. R32's Care Plan, dated 09/20/22, documented R32 admitted from the home setting to Long Term Care (LTC) due to an increased need for assistance with personal care and increasingly unsteady gait resulting in multiple falls, all related to a diagnosis of Parkinson's disease. The care plan directed staff to frequently monitor R32's whereabouts, monitor R32 when ambulating, and remind him to use his walker; if R32's gait appeared unsteady, ask him to sit down for a few minutes until he calmed down and could proceed safely. R32's Care Plan, dated 02/16/24, documented R32 had an increased risk for falls related to impetuous behavior. The care plan directed staff to place the resident's bed in a low position with assist rails, place a fall mat, use a soft touch call light, provide frequent monitoring of whereabouts, and R32 would attend physical and occupational therapy. The care plan further directed staff to transfer R32 with the assistance of two staff and utilize a wheelchair for mobility; R32 was toe-touch weight-bearing status. The care plan documented R32 was at risk for bleeding related to anticoagulation (a medication which prevents blood from clotting) medication and increased pain related to post-surgical hip repair. A review of R32's falls as documented in the EMR, and Fall Investigation Summary revealed the following: On 07/17/23 at 04:45 PM, staff found R32 on the floor of his room. R32 reported he tripped on the slippery floor. The occurrence was not witnessed. R32 had a decreased range of motion to his left arm and guarding towards his left shoulder. At 11:00 PM, R32 returned from the emergency room with a diagnosis of a fractured clavicle (collarbone) to the left side; R32 wore a sling. No corrective action was noted. The EMR and/or report lacked evidence the issue was identified as possible neglect and reported to the SA. On 09/24/23 at 11:41 AM R32 was found sitting on the floor with his back against the door of the dining room bathroom. The fall was not witnessed and R32 reported he was hurt all over though no injury was found. The Fall Investigation Summary documented R32 had an unwitnessed fall in the dining room bathroom area and was unable to say what happened. R32 often walked around on his own, looking for the bathroom, and became unsteady while walking. A corrective action documented staff were educated to be more aware when R32 was up and walking around and to assist and direct the resident to his bathroom. The care plan lacked the corrective action noted. The EMR and/or report lacked evidence the issue was identified as possible neglect and reported to the SA. On 03/12/24 at 07:54 PM, staff found him lying on his left side with a large bulge to his left thigh area, and he complained of left elbow, thigh, and hip pain. R32 transferred himself from the wheelchair without the brakes on and with the wheelchair footrest in the way at the time of the fall. R32 took an anticoagulant and needed to be transferred to the hospital. The Interdisciplinary Team Review Investigation documented R32 had severe cognitive impairment and was found on the floor after an unwitnessed event. The suspected root cause was while staff got R32 ready for bed, staff stepped out of his room to get help to transfer him, and R32 attempted to transfer himself. The investigation recommended an intervention to educate staff that the resident was not to be left alone in his room when he was in a wheelchair. The care plan lacked recommendations for intervention. The EMR and/or report lacked evidence the issue was identified as possible neglect and reported to the SA. The Progress Note dated 03/13/24, recorded R32 had a second surgical repair to his left hip. On 04/03/24 at 02:40 PM observation revealed R32 in his room in bed and covered with blankets. R32 yelled out for assistance and tried to get out of bed. Staff responded and took R32 to the commons area and assisted him to a recliner between the nurses' station and dining room. On 04/04/24 at 12:53 PM Administrative Staff A stated he had not reported R32's unwitnessed falls with major injury injuries because he felt there was no neglect or abuse. The facility's Abuse, Neglect and Exploitation policy, dated 11/15/23, documented the facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. Possible indicators of abuse include but are not limited to physical injury of a resident of unknown source. The administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within five working days of the incident, as required by state agencies. Reporting of all alleged violations to the Administrator, SA, adult protective services, and all other required agencies within a specific timeframe: Immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation don not involve abuse and do not result in serious bodily injury. The facility failed to identify R32's multiple unwitnessed falls which resulted in fractures as potential neglect and report to the SA as required. This placed R32 at risk for unidentified and/or ongoing abuse or neglect.

The facility identified a census of 41 residents. The sample included 12 residents with two residents sampled for hospitalization and one resident sampled for discharge. Based on observation, record review, and interview, the facility failed to provide written notice of transfer as soon as practicable to Resident (R) 13 or their representative for their facility-initiated transfers and/or discharge. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R13. Findings included: - The electronic medical record for R13 documented diagnosis of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), hypertension (HTN- elevated blood pressure), and sepsis (a life-threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body). R13's Annual Minimum Data Set (MDS) dated [DATE] documented R13 had a Brief Interview for Mental Status (BIMS) score of three which indicated severely impaired cognition. R13 required substantial/maximal assistance and was dependent on staff for all her activities of daily living (ADLs). R13's Discharge MDS dated [DATE] had been initiated but was incomplete. R13's Falls Care Area Assessment (CAA) dated 01/15/24 documented R13 had a moderated cognitive impairment and had poor safety awareness. R13 had a history of falls and was dependent on staff for transfers and most daily care. R13 usually understood conversations and could usually make needs known. R13's Care Plan last revised 03/11/24 lacked staff direction regarding discharge. A Nurses Note dated 03/16/24 at 11:28 PM documented under the Progress Notes tab of the EMR recorded that frank blood was noted when R13 was changed at 10:42 PM. R13 was assessed by the nurse and a golf ball sized amount of blood was noted in R13's brief. The nurse obtained R13's vital signs. At 10:48 PM the hospital was called, and an order was received from the on-call physician to send R13 to the emergency department. A Clinical Admission note in the Progress Notes tab of the EMR dated 03/20/24 at 02:14 PM documented R13 arrived back at the facility by way of the facility van. The facility provided a signed Private Pay Bed Hold Authorization form dated and signed by R13's representative on 03/17/24 for R13's discharge to the hospital on 03/17/24. The facility was unable to provide as requested the required written notification of transfer/discharge for R13's discharge to the hospital on 03/17/24. On 04/02/24 at 12:35 PM, R13 sat at the dining table along with other residents eating her lunch. On 04/03/24 at 03:05 PM Social Services X stated she did complete the bed holds and notified the ombudsman when a resident was transferred out of the facility or was discharged . Social Services X stated she did not deal with the transfer or discharge paperwork, but the family was notified by phone call when a resident was sent out of the facility to the hospital. On 04/03/24 at 03:08 PM Administrative Nurse D stated a bed hold policy was given to the resident and their representative when the form was signed. Administrative Nurse D stated a phone call was made to the resident's representative when a resident was transferred out of the facility for any reason, but no written form of transfer or discharge was provided to the resident or their representative that she was aware of. The undated facility policy Transfer and Discharge documented the facility's transfer/discharge notice would be provided to the resident and the resident's representative in a language and manner which they could understand. The notice would include the following at the time it was provided: The specific reason and basis for transfer and discharge. The effective date of transfer or discharge. The specific location to which the resident was to be transferred -or discharged . An explanation of the right to appeal the transfer or discharge to the State. The notice must be provided to the resident, the resident's representative if appropriate, and the LTC ombudsman as soon as practicable. The facility failed to provide written notice of transfer as soon as practicable to R13 or their representative for their facility-initiated transfers. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R13.

The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with effective interventions for Resident (R) 32 and R22 who had falls with injuries. This placed R32 and R22 at risk for ongoing falls and injury due to uncommunicated care needs. Findings included: - R32's Electronic Medical Record (EMR) included diagnoses of Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), major depressive disorder (major mood disorder which causes persistent feelings of sadness) with severe psychotic (any major mental disorder characterized by a gross impairment in reality perception) symptoms, generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) disorder, and nondisplaced intertrochanteric (upper portion of thigh bone) fracture of left femur (thigh bone). R32's Quarterly Minimum Data Set (MDS), dated [DATE], documented staff assessed the resident with moderately impaired cognition; R32 had no delirium (sudden severe confusion, disorientation, and restlessness), psychosis (any major mental disorder characterized by gross impairment in reality perception), or behaviors exhibited. R32 had a functional range of motion impairment on the lower extremity on one side and used a wheelchair. The MDS further documented R32 as dependent on staff for toileting, bathing, personal hygiene, dressing lower body dressing, putting on and taking off footwear, and mobility. R32 was incontinent of urine and bowel. The MDS recorded R32 had nonverbal indicators of pain and received scheduled pain medication. R32 had one fall with a major injury, and a recent surgery requiring active Skilled Nursing Facility (SNF) services for a repaired fracture of the pelvis, hip, leg, knee, or ankle. The Fall Care Area assessment dated [DATE] documented R32 at increased risk for falls due to advancing Parkinson's disease and noted the resident tended to walk the halls and forgot to use a walker at times. The overall objective in care planning for falls was avoidance through minimization of risks such as ensuring proper footwear, ensuring clothes were clean, dry, and not wet with urine, and reminding R32 to use a walker. R32's Care Plan, dated 09/20/22, documented R32 admitted from the home setting to Long Term Care (LTC) due to an increased need for assistance with personal care and increasingly unsteady gait resulting in multiple falls, all related to a diagnosis of Parkinson's disease. The care plan directed staff to frequently monitor R32's whereabouts, monitor R32 when ambulating, and remind him to use his walker; if R32's gait appeared unsteady, ask him to sit down for a few minutes until he calmed down and could proceed safely. R32's Care Plan, dated 02/16/24, documented R32 had an increased risk for falls related to impetuous behavior. The care plan directed staff to place the resident's bed in a low position with assist rails, place a fall mat, use a soft touch call light, provide frequent monitoring of whereabouts, and R32 would attend physical and occupational therapy. The care plan further directed staff to transfer R32 with the assistance of two staff and utilize a wheelchair for mobility; R32 was toe-touch weight-bearing status. The care plan documented R32 was at risk for bleeding related to anticoagulation (a medication which prevents blood from clotting) medication and increased pain related to post-surgical hip repair. A review of R32's falls as documented from the EMR, and Fall Investigation Summary revealed the following: On 07/08/23 at 05:05 PM, R32 hollered from his room and reported he slowly rolled out of bed, trying to use the toilet. R32 stated he had pain on the right side down where the ribs ended. The Fall Investigation Summary recorded a corrective action of staff education to assist the resident to the toilet after meals. On 07/12/23 at 04:10 AM staff heard R32 hollering and found him in his room next to the bed. The fall was not witnessed and R32 reported he was going from his chair to his bed. R32 reported pain in his back and right hip. R32 went to the emergency room and the x-ray showed there was no fracture. The Fall Investigation Summary documented R32 had a recent antipsychotic (class of medications used to treat major mental conditions that cause a break from reality) decrease and orders to receive therapy services. The summary documented R32 had three falls in the past two weeks, and he reported the floor was slick. Staff mopped the floor and notified housekeeping to further clean the room. R32 had not been evaluated by therapy. The investigation documented nursing spoke to the therapists and asked them to evaluate R32 as soon as possible. On 07/17/23 at 04:45 PM, staff found R32 on the floor of his room. R32 reported he tripped on the slippery floor. The occurrence was not witnessed. R32 had a decreased range of motion to his left arm and guarding towards his left shoulder. At 11:00 PM, R32 returned from the emergency room with a diagnosis of a fractured clavicle (collarbone) to the left side; R32 wore a sling. No corrective action was noted. On 07/28/23 at 10:00 PM, R32 was in the dining room and tried to ambulate without his walker. R32 leaned to his left side and lost balance. The Fall Investigation Summary documented R32 had been restless and was toileted and redirected several times. The summary further documented R32's family member was concerned about his recent falls. A corrective action documented that staff were educated to direct R32 to a chair that would be more appropriate, easier to get out of, and better for staff to monitor the resident to assist him in getting up due to his not asking for help. The care plan lacked the corrective action noted. On 08/17/23 at 01:10 AM R32 had an unwitnessed fall with complaints of neck and head pain and went to the emergency room . The Fall Investigation Summary documented R32 was found outside of the bathroom. His pants were wet on the floor, and he stated he was going to the bathroom. A corrective action documented that staff were educated to check, change, and toilet R32 on all rounds through the night. The summary documented rounds occurred at 11:00 PM, 01:00 AM, 03:00 AM, and 05:00 PM. The care plan lacked the corrective action noted. On 09/24/23 at 11:41 AM R32 was found sitting on the floor with his back against the door of the dining room bathroom. The fall was not witnessed and R32 reported he was hurt all over though no injury was found. The Fall Investigation Summary documented R32 had an unwitnessed fall in the dining room bathroom area and was unable to say what happened. R32 often walked around on his own, looking for the bathroom, and became unsteady while walking. A corrective action documented staff were educated to be more aware when R32 was up and walking around and to assist and direct the resident to his bathroom. The care plan lacked the corrective action noted. On 10/26/23 at 08:15 PM, R32 had an unwitnessed fall after he attempted to self-toilet and reported right elbow pain. R32 reported he was going to the bathroom due to being incontinent in his brief. The Fall Investigation Summary documented the fall was not witnessed. R32 was weak and had an unsteady gait possibly related to his COVID-19 (highly contagious respiratory virus) diagnosis. A corrective action documented the resident was weak and would need therapy services when he was out of quarantine. On 01/05/24 at 03:00 AM R32 had an unwitnessed fall in his room while he was reaching for personal items. He was incontinent at the time of the fall. R32 had recent medication changes related to antianxiety (a class of medications that calm and relax people) and antidepressant (a class of medications used to treat mood disorders) medications. R32 had vocal complaints of right and left knee pain. The Fall Investigative Summary documented R32 was found lying on his back in his room and stated he was looking for a phone book. R32 had socks on. A corrective action documented that staff were directed to ensure R32 had non-skid socks on when in bed. The care plan lacked the corrective action noted. On 02/12/24 at 01:01 PM, R32 had a fall that was witnessed by another resident. R32 was getting up and transferring from the table. R32 complained of left hip and elbow pain and went to the emergency room . The Fall Investigation Summary documented R32 sat at a table drinking juice and another resident witnessed R32 stand and fall to the left side onto the floor. R32 complained of left hip and elbow pain, and staff sent him to the emergency room . R32 had a left hip fracture and left elbow contusion. A corrective action documented R32 was to work with therapy when he returned from the hospital. On 03/12/24 at 07:54 PM, staff found him lying on his left side with a large bulge to his left thigh area, and he complained of left elbow, thigh, and hip pain. R32 transferred himself from the wheelchair without the brakes on and with the wheelchair footrest in the way at the time of the fall. R32 took an anticoagulant and needed to be transferred to the hospital. The Interdisciplinary Team Review Investigation documented R32 had severe cognitive impairment and was found on the floor after an unwitnessed event. The suspected root cause was while staff got R32 ready for bed, staff stepped out of his room to get help to transfer him, and R32 attempted to transfer himself. The investigation recommended an intervention to educate staff that the resident was not to be left alone in his room when he was in a wheelchair. The care plan lacked recommendations for intervention. The Progress Note dated 03/13/24, recorded R32 had a second surgical repair to his left hip. R32's Baseline Care Plan, dated 03/19/24 after readmission to the facility documented on return to the facility R32 had additional diagnoses of left basilar (lower lung area) infiltration and acute toxic metabolic encephalopathy (a broad term for any brain disease that alters brain function or structure). On 04/03/24 at 02:40 PM observation revealed R32 in his room in bed and covered with blankets. R32 yelled out for assistance and tried to get out of bed. Staff responded and took R32 to the commons area and assisted him to a recliner between the nurses' station and dining room. On 04/03/24 at 01:12 PM Certified Medication Aide (CMA) R along with Certified Nurse Aide (CNA) M assisted R32 from his wheelchair to his bed without bearing weight on the resident's left leg. R32's brief was changed due to urine incontinence. CMA R stated R32 was ambulatory and confused when he was admitted to the facility, and he had Parkinson's disease. CMA R said to prevent falls, staff assisted R32 with activities. CMA R said R32 was generally cooperative. CMA R said R32 would occasionally inform staff if he needed to have a bowel movement or be toileted, but otherwise, R32 was on a two-hour toileting schedule; he used a fall mat, had his bed in the lowest position, and should be checked frequently. On 04/04/24 at 09:30 AM, CNA N stated staff made sure R32 had his call light in reach, used a gait belt for transfers, and checked him frequently. CNA N said staff put R32's bed in the lowest position with a fall mat next to the bed, changed from wheelchair sitting to using a recliner, and staff toileted him before and after meals and during rounds. CNA N reported staff used verbal communication that to inform staff when residents fell , and staff checked the care plan in the nurses' station for any fall interventions. On 04/04/24 at 09:32 AM, Licensed Nurse (LN) G reported staff were informed during the shift report about falls and looked at the working care plan for interventions. On 04/04/24 at 11:29 AM Administrative Nurse D verified the resident had repeated falls, which resulted in fractures, and confirmed the resident's care plan was not updated with interventions by the Interdisciplinary Team (IDT) to prevent further falls. The facility's Resident Centered Care Plan Process dated 03/28/18, documented that care, treatment, and services are planned and provided to each resident in an interdisciplinary, comprehensive, and collaborative manner to ensure that all interventions are appropriate to the needs of the resident. Care planning will be implemented through the integration of assessment of findings, consideration of prescribed treatment plan, and development of goals of the resident that are reasonable and measurable. This will be considered a working care plan and will be kept on paper at the nurse's desk to document daily changes or updates to the plan of care. It is the responsibility of every member of the Interdisciplinary Team (IDT) to read, understand, and follow the comprehensive, person-centered care plan and to report any changes, no matter how slight or significant to the IDT for immediate care plan revision. The facility failed to revise the care plan with interventions to prevent falls for R32. This placed R32 at risk for further falls related to uncommunicated care needs. 41713 - The electronic medical record for R22 documented diagnoses of congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), and benign paroxysmal positional vertigo (BPPV- brief episodes of mild to intense dizziness after a change in head position). R22's Admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R22 required partial to moderate assistance with activities of daily living (ADLS). R22 had no history of falls before admission. R22's Quarterly MDS dated [DATE] documented a BIMS score of 15 which indicated intact cognition. R22 required supervision with transfers from a chair and walking. R22 used a walker to assist with mobility. R22 had one fall without injury and one fall with injury since the prior assessment. R22's ADL Care Area Assessment (CAA) dated 09/11/23 documented she was working with therapy to regain strength and improve balance and gait while avoiding complications such as falls. R22's Fall CAA dated 09/11/23 documented that R22 had an unsteady gait and poor balance. The plan was to minimize the risks and avoidance of complications such as injuries related to falls. R22's Care Plan last updated 04/01/24 directed staff that R22 required stand-by assist staff with transfers and walking. R22 was independent with walking in her room. R22's care plan lacked interventions directing staff regarding falls. A fall investigation dated 10/11/23 documented R22 had an unwitnessed fall without injury in her room. R22 was found on the floor next to her bed by a staff member. Staff discussed the importance of a night light with the resident and advised R22 that her bathroom light could be left on, and the door cracked to allow light in. The investigation lacked a root cause analysis. A fall investigation dated 11/12/23 documented R22 had an unwitnessed fall that resulted in a hematoma to the back of her head. R22 was found on the floor in her room in front of her recliner; she had no bottom garments or shoes on. R22 stated she got up to go to the bathroom and was leaving the bathroom to find some pull-ups and slipped and fell . R22 was assessed by the nurse, and staff notified the physician and daughter of the incident. The fall investigation lacked a root cause analysis and new fall intervention. A fall investigation dated 11/27/23 documented R22 had an unwitnessed fall without injuries in her room. R22 was calling out for help and was found on the floor next to her bed. R22 stated there were kidnappers in her room. R22 was confused. R22 complained of pain in her left knee. The nurse completed a thorough assessment and obtained vital signs. R22 was returned to bed with assistance from three staff. Staff notified R22's physician and family. The physician ordered a urinalysis (lab analysis of urine). The fall investigation lacked a root cause analysis or new fall intervention. A fall investigation dated 12/04/23 at 03:15 AM documented R22 was found in her room on the floor next to her bed by staff. R22 complained of pain in her back after she hit it on her bed when she fell . The nurse came to assist and assess the resident. R22 stated she wanted to get up to her chair, so she stood, took a few steps, and fell . Staff notified R22's representative of the fall. The investigation noted the resident has had increased confusion and a decline in mobility. Staff notified the physician and received orders for a urinalysis and lab draw. The investigation lacked a root cause analysis and an update to the care plan. A fall investigation dated 12/04/23 at 01:30 PM documented R22 had an unwitnessed fall in her room that resulted in a skin tear to her right elbow. R22 was found on the floor by the medication aide on her right side near her bathroom. R22's walker was tipped over. R22 was assessed by the nurse and the physician was notified. Staff received an order to send R22 to be evaluated at the emergency room (ER). R22 stated she got up to get ready for her appointment. R22's representative was notified and voiced concern about R22's recent decline. R22's room was moved closer to the nurse station. R22's ER visit showed R22 had a urinary tract infection (UTI-an infection in any part of the urinary system). The investigation lacked a root cause analysis and an update to the care plan. On 04/02/24 R22 walked with her walker to the dining room with a slow unsteady gait. On 04/04/24 at 09:42 Administrative Nurse F stated she was responsible for updating the care plans after the MDS was completed, but all nurses were able to update the care plan as needed after a fall or anything like that. On 04/04/24 at 12:13 AM Administrative Nurse D stated she was not aware that R22's care plan had not been updated with the new interventions put in place for R22 after her falls. Administrative Nurse D stated she would speak with staff to educate them and ensure that fall interventions were added to R22's care plan. The Resident Centered Care Plan Process policy last updated 03/28/18 documented at 90-day intervals, or more frequently based on the response to the resident's condition the interdisciplinary team would evaluate the resident's progress toward meeting the goals of care, treatment, and services. Revise the plan for care, treatment, and services. Collaborate with the resident and representative and family in reviewing and revising the plan for care, treatment, and services. The resident had the right to request revisions to their plan of care. The MDS/Care Plan Coordinator would serve as the coordinator for the care planning process. The interdisciplinary team would collaborate on the review and revision of the plan for care, treatment, and services. The facility failed to revise R22's Care Plan with interventions to prevent further falls. This deficient practice placed R22 at risk of further falls due to uncommunicated care needs.

The facility reported a census of 41 residents, with all receiving meals from one main kitchen. Based on observation, interview, and record review the facility failed to store and serve food in in a sanitary manner when observation revealed undated foods in the kitchen refrigerator and when dietary staff used gloves but cross-contaminated the gloves during food service. Findings included: - On 06/13/22 at 07:58 AM, an initial tour of the kitchen accompanied by Dietary Staff (DS) F revealed a wall of half-size refrigerators with the following food found with no open or use by date: a half-cut onion wrapped in plastic wrap, a bowl of corn relish, a container of baked beans, a bag of cherries undated, a tomato partly cut up, a tub of French Onion dip with no date, a bowl of cut green peppers with no date, a bowl of sour cream not dated, and a large tub of sliced cheese. DS F removed and disposed of the undated food items from the refrigerators. On a follow-up tour of the kitchen on 06/14/22 at 12:20 PM, DS F prepared food for the noon meal. DS F lined a large pan with a paper lining using her bare hands. She then donned gloves and handled a pan of rolls. She lifted the pan and placed them on the counter by the lined pan and proceeded to tear the rolls apart, placing them in the lined pan, after handling the underneath side of the roll pan and counter, with the same gloves. DS F then served the food with the same gloves touching the plates, utensils, pans on the stove, and continued to handle the rolls with the same gloved hands, which were cross-contaminated from other surfaces touched. On 06/14/22 at 12:25 PM after asking DS F about the continued cross-contaminated gloves used in the observation, DS F then removed the gloves and continued serving the meals and using tongs to serve rolls and used good hand hygiene after she removed the gloves. DS F reported she did not realize she could not touch other things if she had gloves on. She thought she was safe to touch with gloves. On 06/14/22 at 12:40 PM Certified Dietary Manager G stated she expected DS F to know how to serve and contributed it to being nervous with a surveyor watching her but stated she should use the correct way, no matter who was in the kitchen. The 07/2014 Food Receiving and Storage policy revealed all foods stored in the refrigerator or freezer would be covered, labeled and dated (use by date). The 2016 Proper Handwashing and Proper Glove Usage policy revealed staff would be reminded that gloves become contaminated just as hands do and were to be changed often. When in doubt, staff were to remove gloves and wash hands. Gloves were to be used whenever direct food contact was required. The facility failed to ensure food was stored and served in a sanitary manner by having undated, unmarked food in the refrigerator, and the failure to change gloves when contaminated before touching other food items.

The facility census totaled 41 residents with 12 residents included in the sample. Based on observation, interview and record review the facility failed to revise the comprehensive care plan to include Resident (R) 19's wandering and risk of elopement. Findings included: - R19's 06/01/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 01/25/22 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental status (BIMS) indicating severe cognitive impairment. The resident wandered from one to three days of the seven-day observation period. The resident required extensive assistance with most daily care, and was independent with ambulation. The resident received antianxiety and antidepressant medications daily in the seven-day observation period. The 01/25/22 Cognitive Loss/Dementia Care Area Assessment (CAA) revealed the resident had a few fluctuating behavioral symptoms. Wandering was her biggest behavior and was usually limited to going from chair to chair in the commons area. R19 required assistance with all activities of daily living (ADL) and had a slight decline in continence. The 01/25/22 Behavioral Symptoms CAA triggered due to the resident wandering, but noted her wandering consisted of short distances in the common area. The CAA noted the behavioral symptoms (wandering) would be care planned. The 10/14/21 Elopement Risk Assessment revealed the resident was at risk and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] The 02/13/19 Care Plan revealed the resident had impaired cognition related to dementia. Staff were to escort her to the areas she likes in the facility, as she got lost easily. R19 tended to gravitate to quiet areas, where small groups of people were. She liked to sit in the glider by the front door, in the therapy room, on the couch in the television area, her room, and in the administrator's office. The 02/13/19 Care Plan did not include the residents wandering or risk for elopement. Observation on 06/13/22 at 02:30 PM revealed the resident was in an office with no other person present. The resident was touching flowers that were in the room and there were no staff present in the office with her. No staff were present in the area to see her enter or exit the office. Observation on 06/13/22 at 03:00 PM revealed the resident ambulated in the hall, with no destination, and had a steady gait. The resident did not answer questions when spoken to. Observation on 06/13/22 at 03:30 PM revealed the resident was walking behind two visitors going toward the door to exit. The resident stood by the door as they exited but made no attempt to exit. Observation on 06/14/22 at 05:05 PM revealed the resident walked in the front lobby. She entered into the unattended nurse's station area and wandered around alone. The resident touched and handled numerous things on the counters of the nurse's station (enclosed room open on both ends), including a box of covid tests. The resident picked up the public bathroom keys and left the room. She walked with the keys for approximately one minute before a housekeeper saw the keys and took them from her. After that, the resident continued to wander around the building. During an interview on 08/14/22 at 09:30 AM, Certified Nurse Aide (CNA) D reported it was the job of all the staff to keep an eye on the resident and where she goes. The resident got anxious with a lot of people or if in confined spaces. She walked the perimeter of the living room but sat off to the side or back, away from people. CNA D noted R19 wandered a lot, but CNA D had never seen her try to leave or go out the door. During an interview on 08/15/22 at 03:00 PM, CNA E reported the CNA's decided who would watch R19 each day but stated they all kept an eye on R19. She wandered around but she did not try to go out the door, so staff let her go and just supervise where she was. On 06/13/22 at 03:35 PM when the surveyor asked Licensed Nurse (LN) B the name of the resident wandering around, LN B stated oh that is just little [R19]. She just wanders around during the day. On 06/15/21 at 08:00 AM LN B produced a form called 'Elopement Risk that showed the resident was at risk for elopement. On 06/15/21 at 03:20 PM Administrative Staff A reported she would get the resident elopement risk added to the care plan. The undated facility policy for Care Plan Revision revealed changes in an elder's condition often required changes to be made in the plan of care either by change in individual approaches or by the addition of new problems to the plan of care. The facility failed to revise the comprehensive care plan to include Resident (R)19's wandering and risk of elopement.

The facility reported a census of 41 residents with 12 included in the sample. Based on observation, interview and record review the facility failed to provide adequate supervision for a wandering Resident (R) 19, identified as at risk of elopement, which placed her at risk for wandering into unsafe areas/situation. Findings included: - R19's 06/01/22 Physician Orders revealed the following diagnoses: other abnormalities of gait (manner or style of walking) and mobility, dementia (progressive mental disorder characterized by failing memory, confusion), need for assistance with personal care, and anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 01/25/22 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental status (BIMS) indicating severe cognitive impairment. The resident wandered from one to three days of the seven-day observation period. The resident required extensive assistance with most daily care and was independent with ambulation. The resident received antianxiety and antidepressant medications daily in the seven-day observation period. The 01/25/22 Cognitive Loss/Dementia Care Area Assessment (CAA) revealed the resident had a few fluctuating behavioral symptoms. Wandering was her biggest behavior and was usually limited to going from chair to chair in the commons area. R19 required assistance with all activities of daily living (ADL) and had a slight decline in continence. The 01/25/22 Behavioral Symptoms CAA triggered due to the resident wandering, but noted her wandering consisted of short distances in the common area. The CAA noted the behavioral symptoms (wandering) would be care planned. The 10/14/21 Elopement Risk Assessment revealed the resident was at risk and had a history of attempted elopement. The 02/13/19 Care Plan revealed the resident had impaired cognition related to dementia. The staff was to escort her to the areas she likes in the facility, as she got lost easily. R19 tended to gravitate to quiet areas, where small groups of people were. She liked to sit in the glider by the front door, in the therapy room, on the couch in the television area, her room, and in the administrator's office. The 02/13/19 Care Plan did not include the residents wandering or risk for elopement. Observation on 06/13/22 at 02:30 PM revealed the resident was in an office with no other person present. The resident was touching flowers that were in the room and there were no staff present in the office with her. No staff were present in the area to see her enter or exit the office. Observation on 06/13/22 at 03:00 PM revealed the resident ambulated in the hall, with no destination, and had a steady gait. The resident did not answer questions when spoken to. Observation on 06/13/22 at 03:30 PM revealed the resident walking behind two visitors going toward the door to exit. The resident stood by the door as they exited but made no attempt to exit. Observation on 06/14/22 at 05:05 PM revealed the resident walked in the front lobby. She entered into the unattended nurse's station area and wandered around alone. The resident touched and handled numerous things on the counters of the nurse's station (enclosed room open on both ends), including a box of covid tests. The resident picked up the public bathroom keys and left the room. She walked with the keys for approximately one minute before a housekeeper saw the keys and took them from her. After that, the resident continued to wander around the building. During an interview on 08/14/22 at 09:30 AM, Certified Nurse Aide (CNA) D reported it was the job of all the staff to keep an eye on the resident and where she goes. The resident got anxious with a lot of people or if in confined spaces. She walked the perimeter of the living room but sat off to the side or back, away from people. CNA D noted R19 wandered a lot, but CNA D had never seen her try to leave or go out the door. During an interview on 08/15/22 at 03:00 PM, CNA E reported the CNAs decided who would watch R19 each day but stated they all kept an eye on R19. She wandered around but she did not try to go out the door, so staff let her go and just supervise where she was. On 06/13/22 at 03:35 PM when the surveyor asked Licensed Nurse (LN) B the name of the resident wandering around, LN B stated the residents name and said she just wandered around during the day. On 06/15/21 at 08:00 AM LN B produced an Elopement Risk form which showed R19 was at risk for elopement. On 06/15/21 at 03:20 PM Administrative Staff A reported she would get the resident elopement risk added to the care plan. The facility failed to ensure staff provided adequate supervision for R19, a wandering resident identified as at risk of elopement, which placed the resident at risk of wandering into unsafe areas/situations.

The facility census totaled 41 residents with 12 sampled including five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the consultant pharmacist identified the lack of monitoring for potential side effects in the use of antipsychotic medications received, when facility staff did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment for Resident (R) 26. Findings Included: - The 06/14/22 Physician's Orders in the Electronic Health Record (EHR) documented R26 with diagnosss of dementia (progressive mental disorder characterized by failing memory, confusion) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The 02/02/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. The assessment failed to identify the use of an antipsychotic medication daily for R26. The 05/02/22 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The assessment failed to identify the use of an antipsychotic medication daily for R26. The 01/13/22 Physicians Orders documented an order for [MEDICATION(S)] (antipsychotic medication) 25 milligrams (mg) half a tablet twice a day. The monthly Pharmacy Medication Record Review (MRR) for January 2022 through May 2022 lacked documentation regarding the lack of an AIMS assessment for R26, who received [MEDICATION(S)] twice daily during this time frame. The Resident Assessments in the EHR from 01/01/22 to 06/15/22 lacked documentation of an AIMS assessment completed for R26 concerning the use of an antipsychotic medication. On 06/15/22 at 08:30 AM, R26 sat at a table in the dining room, visiting with three other residents, and exhibited no abnormal involuntary movements during the observation. On 06/16/22 at 08:40 AM Administrative Staff B stated the facility completed AIMS assessments at least quarterly and confirmed the facility did not complete this for R26. On 06/16/22 at 01:55 PM Consultant Staff H confirmed he looked at items like the AIMS assessment periodically and stated he needed to follow those more often. The 11/2020 Drug Regimen Review policy documented a contracted or employed licensed pharmacist would review all medications for appropriate monitoring by facility staff for efficacy and adverse side effects. The facility failed to ensure the consultant pharmacist identified the lack of monitoring for potential side effects in the use of antipsychotic medications received, when facility staff did not complete an AIMS assessment for R26.

The facility census totaled 41 residents with 12 sampled including five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure adequate monitoring of potential side effects for antipsychotic medications received, when facility staff did not obtain an Abnormal Involuntary Movement Scale (AIMS) assessment for Resident (R) 26. Findings Included: - R26's 06/14/22 Physician's Orders in the Electronic Health Record (EHR) documented diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The 02/02/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. The assessment failed to identify the use of an antipsychotic medication daily for R26. The 05/02/22 Quarterly Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The assessment failed to identify the use of an antipsychotic medication daily for R26. The 01/13/22 Physicians Orders documented an order for [MEDICATION(S)] (antipsychotic medication) 25 milligrams (mg) half a tablet twice a day. The Medication Administration Record for 01/13/22 through 06/15/22 documented R26 received [MEDICATION(S)] twice daily. The Resident Assessments in the EHR from 01/01/22 to 06/15/22 lacked documentation of an AIMS assessment completed for R26 concerning the use of an antipsychotic medication. On 06/15/22 at 08:30 AM, R26 sat at a table in the dining room, visiting with three other residents, and exhibited no abnormal involuntary movements during the observation. On 06/16/22 at 08:40 AM Administrative Staff B stated the facility completed AIMS assessments at least quarterly and confirmed the facility did not complete this for R26. On 06/16/22 at 01:55 PM Consultant Staff H confirmed he looked at items like the AIMS assessment, periodically and stated he needed to follow those more often. The 11/2017 Psychoactive Medication Policy documented that nursing staff would perform an AIMS assessment on any resident on an antipsychotic medication on a quarterly basis and changes would be reported to the physician. The facility failed to monitor for potential side effects in the use of antipsychotic medications received when facility staff did not complete an AIMS assessment for R26.

The facility had a census of 43 residents. The facility identified 5 residents as cognitively impaired and independently mobile, with wandering behaviors. The sample included 3 of those residents. Based on observation, interview and record review, the facility failed to develop and implement interventions to prevent elopement for 1 of 3 residents (#1) according to the elopement risk assessment. Resident #1 eloped (left the facility without staff knowledge) from the facility after being assessed as a high risk for elopement, with no elopement prevention interventions in place on the resident's plan of care. A visitor let resident #1 out of the facility and the facility failed to realize the resident left the building until the visitor reported to facility staff he/she let the resident out of the building and the resident was no longer in view. A staff member from the facility found the resident on the side of a busy residential road with ½ of his/her walker on the road and ½ of his/her walker on a sloped rocky shoulder that dropped to a ditch; approximately 10 minutes later and approximately 100 feet away from the facility. In addition to the busy residential street in front of the facility, the road led to a major highway with an on/off ramp approximately ½ mile away from the facility. The facility failure placed resident #1 in immediate jeopardy. Findings included: - Review of the physician progress notes [REDACTED].#1 had dementia (progressive mental disorder characterized by failing memory, confusion). Review of the resident's annual minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) of 7, indicating moderate cognitive impairment. The resident had disorganized thinking continuously present, that did not fluctuate. The resident had hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality.) The MDS identified no wandering behaviors were exhibited by the resident. Review of the cognitive loss/dementia care area assessment (CAA) dated 1/3/17 revealed the resident had a [DIAGNOSES REDACTED]. The assessment identified the resident as alert, pleasant and aware of his/her needs. The resident had occasional confusion and sometimes exhibited nervousness. The assessment identified the resident as easily redirected and he/she did well with verbal cues and reminders. The facility developed a care plan to monitor for additional changes in cognition that indicated acute processes (having severe symptoms and a short course) and any need for additional evaluation. Review of the activity of daily living (ADL)/functional rehabilitation CAA dated 1/3/17 revealed the resident ambulated independently with a walker. Review of the falls CAA dated 1/3/17 revealed the resident had a risk for falls due to occasional unsteadiness and poor safety awareness at times, the resident ambulated with a roller walker and occasionally needed to be reminded to use his/her walker. Review of the resident's care plan revealed: 1/2/17 - Staff completed an elopement risk assessment and identified the resident as low to moderate risk for elopement. The facility Inter-disciplinary team (IDT) reviewed and determined the resident as not at risk for elopement. The resident did not exhibit exit seeking behavior and had never attempted to leave the building unsupervised. 1/12/17 - The resident had difficulty remembering and easily became confused related to dementia. 1/12/17 - The resident ambulated independently using a roller walker. Occasionally, the resident required some supervision or limited assist for cuing or guiding. 1/25/17 - The resident was noted with increased agitation, packing, moving items, difficulty redirecting and exit seeking. Facility staff notified the resident's physician. The intervention lacked any further direction to staff when the resident exhibited the behaviors. 2/16/17 - The resident received Seroquel (antipsychotic medication) used for the targeted behavior exit seeking, packing belongings and/or if staff could not re-direct him/her. The resident's care plan lacked any specific direction/intervention related to the resident's high elopement risk, exit-seeking or what to do if staff were unable to redirect him/her. Review of the elopement risk assessment dated [DATE] revealed the resident had a score of 12.5, indicating a high risk of elopement. The resident exhibited exit-seeking behavior or requested to go home. The resident was easily distracted, experienced periods of altered perception, experienced periods of restlessness, and had mental function which varied over the course of the day. The resident requested for staff to let him/her out at times. The assessment identified the resident as pleasant and easily redirected and he/she had continued confusion which varied day to day. Review of the elopement risk assessment dated [DATE] revealed the resident had an elopement score of 9, which indicated he/she had a high risk for elopement. The facility identified the resident as easily distracted, experienced periods of altered perception, periods of restlessness and his/her mental function varied over the course of the day. The resident had risk factors for elopement, but per staff report the resident had not made attempts to leave the building unattended. The resident reported when the weather was nice he/she would like to be able to go outdoors to the courtyard. The interdisciplinary team decided no interventions were indicated for the resident at that time. Review of the nurse's note dated 1/24/17 at 10:50 PM revealed the resident had increased confusion, moved stuff out of his/her room and became agitated/aggressive towards staff. The facility provided one on one supervision of the resident with no improvement. The note revealed staff let the resident move things around in his/her room and let him/her calm down. Review of the nurse's note dated 1/25/17 at 10:09 PM revealed the resident had confusion during the shift. The resident attempted to get out of the facility doors. Review of the electronic medication administration record note dated 2/9/17 at 9:10 PM revealed the resident had Seroquel for the targeted behaviors of rummaging, inability to redirect the resident, going into other residents rooms, elopement attempts and being agitated throughout the evening. Review of the nurse's note dated 2/11/17 at 5:02 AM revealed the resident had been awake several times and had been hard to redirect to go back to bed. Staff reported the resident was up in his/her room walking around and going through his/her belongings. Review of the nurse's note dated 2/22/17 at 1:00 AM revealed the resident wandered across the hall from his/her own room. Staff approached the resident and he/she stated he/she was gathering his/her things to leave with his/her family. Further review of the resident's nurse's notes lacked any evidence of the resident's elopement from the facility on 2/22/17. Review of the investigation report, provided by the facility on 3/7/17 revealed on 2/22/17 at 3:10 PM another resident's visiting family member assisted resident #1 out the front door to sit on the front porch of the facility. When the other resident's family member returned he/she did not observe resident #1 on the porch. Another visitor to the facility notified the charge nurse that he/she observed resident #1 ambulating with a walker on the side of the road in front of the facility. Two staff members immediately responded to find the resident approximately 10 paces (a unit of length consisting either of one normal walking step or of a double step, returning to the same foot) from the facility property line. When administrative staff A and therapy staff B reached the resident dietary staff C had already arrived to the resident and called the facility to notify them the resident was out of the building. Facility staff assisted the resident back in the building at approximately 3:15 PM. Review of the Weather Underground historical data revealed the temperature on 2/22/17 at approximately 3:00 PM measured 75 degrees Fahrenheit (a measurement of the scale of temperature). The facility reported the resident had on a short sleeved button down shirt with a long -sleeved sweater cardigan over it, long pants and black lace-up rubber soled shoes. During an observation on 3/9/17 at 10:52 AM administrative staff A entered a code into the pad and with the surveyor went out the coded front door of the facility into a glassed entry way and through another, which led to the front area of the facility. Observation of the front of the facility revealed a sitting area with cushioned, iron, outdoor chairs. A sidewalk off of the sitting area led to a large facility parking area that stretched along the front of the building. Directly in front of the facility parking lot sat a residential road with small rocky shoulders, which measured approximately 3 foot, on approximately a 45 degree incline down into a ditch. The paved shoulder of the road lacked space for someone to ambulate with a walker. The parking lot had some rocky areas/divots where the concrete had broken. Through the parking lot to the driveway that had been repaired were areas of different colors of pavement and varied levels of height. Staff A walked out onto the road, turned right and continued about ½ distances between the facility driveway and the next city street. Further measurements of distance on 3/9/17 at 12:08 PM revealed the distance from the door of the facility to the road where staff located the resident measured approximately 350 feet. Observation of the road where staff found the resident revealed a moderately busy road; 5-7 cars, trucks and semis passed while the surveyor walked from the facility to the location where the resident was found by staff when he/she left the facility without staff knowledge and returned to the facility(approximately 5-10 minutes), multiple times. An observation on 3/9/17 at 4:20 PM revealed the resident ambulated down a hallway adjacent to the one that contained his/her room, using a wheeled walker. The resident looked at the doorways and read the names of residents who lived in the rooms as he/she passed. The resident stated he/she was looking for his/her room. During an interview on 3/9/17 at 10:52 AM administrative staff A revealed on 2/22/17 he/she sat in his/her office with the door open to the commons area/nurse's station and happened to be listening to what went on in that area. Staff A reported hearing another resident's family member ask if resident #1 had come back into the facility. He/she stated he/she previously worked as a direct care staff and automatically got up from his/her chair to see what was going on. By the time staff A got to the commons area/nurse's station a community member came in and reported a resident sitting outside of the building. Staff A reported therapy staff B arrived outside to the resident at the same as him/her. When staff A arrived dietary staff C was already with the resident. He/she reported the resident sat on his/her wheeled walker and therapy staff B pushed the resident up to the building. He/she did not know how long the resident remained outside of the building. He/she reported the temperature outside as warm and the resident had appropriate clothing on at the time he/she located him/her. An interview on 3/9/17 at 11:22 AM with direct care staff D revealed the resident had an elopement risk. Staff D stated the resident always tried to go to the exits. He/she stated facility staff saw him/her and tried to stop him/her. Staff D further reported there were times the resident set off the facility door alarms while trying to get out the door. An interview with direct care staff E on 3/9/17 at 12:46 PM revealed the resident had a risk of elopement. Staff E stated if facility staff did not watch the resident, he/she had an ability to get places fast. The resident got up and walked around the facility and did not always know why or where he/she intended to go. The resident reported he/she needed to see or do something with people who were not at the facility, if asked where he/she planned to go. The resident did go to the doors and had gone to the doors at least a couple of times in the weeks before he/she had another resident's family member let him/her out on 2/22/17. He/she reported most family members were at the facility a lot and knew what residents were and were not supposed to leave the facility, so he/she did not know if the door had a sign or how family members would know not to let a resident outside. An interview with therapy staff B at 2:33 PM on 3/9/17 revealed he/she responded when he/she heard the resident was outside of the building. He/she stated the resident had recently, in the last few weeks started looking for doors. During an interview on 3/9/17 at 11:14 AM with licensed nursing staff F revealed before the resident left the faciity on [DATE], the interdisciplinary team determined the resident did not have a risk of elopement because he/she would be up and about in the facility and never made any attempts to leave the building. Staff F stated when the resident had anxiety it had to do with him/her looking for his/her room or the bathroom. Staff F also reported the resident looked for his/her kids, but staff could easily re-direct him/her. He/she reported staff had updated the resident's care plan to include Seroquel with a targeted behavior because the resident had started packing his/her stuff and wanted to leave, but would not go to the doors. Staff F reported he/she completed the resident's elopement risk assessments since he/she started working at the facility. Staff F reported he/she would have done another elopement assessment if there would have been a significant change MDS and/or with any significant change in condition reported by facility staff. He/she would not consider packing and unpacking a change in the resident's condition because it was not uncommon for the resident to do that. He/she would have looked at doing another elopement assessment if the resident began challenging a facility door or if he/she had a urinary tract infection (UTI) that would have increased behaviors/confusion. An interview with dietary staff C at 1:05 PM on 3/9/17 revealed on 2/22/17 he/she pulled out of the facility's parking lot, once he/she got down to where the 1st row of trees (distance from the door of the facility to the road staff located the resident measured approximately 350 feet) he/she witnessed the resident on the side of the road. Staff C reported the resident stood on the side of the road ½ on the pavement and ½ on the rocky shoulder. Staff C stopped his/her car and got out to be with the resident. He/she reported he/she called the facility and the person who answered the phone stated staff was already on their way outside. An interview at 3:05 PM on 3/9/17 with licensed nursing staff G revealed the resident had a high risk for elopement. Staff G stated the resident went to the front door and pushed on it at times. He/she stated the resident had been checking doors around the facility for the last couple of months. Staff G stated the resident was easily redirected when approached by facility staff. An interview with administrative nursing staff H at 2:18 PM on 3/9/17 revealed if the resident had exit-seeking or wandering behaviors he/she expected facility staff to engage the resident in activities. Staff H reported the resident seemed to have had more sundowners (a type of mood or sleep disorder often associated with the early stages of dementia and/or Alzheimer's) lately. He/she expected staff to notice if the resident went near the door and spend some time with him/her. When staff completed the 1/2017 elopement assessment the resident did not have exit-seeking behaviors. Staff H stated over the last 6 months the resident exhibited confusion with difficulty finding his/her room. He/she stated facility staff probably should have done another elopement assessment when the resident started to have behaviors. The elopement assessments popped up quarterly, so facility staff should have done another elopement assessment as needed (PRN). Staff H stated when the resident's behaviors started to happen they should have added interventions to the resident's care plan. He/she expected the care plan to identify something like a target behavior or what to watch out for and how staff monitored the resident's behavior. Staff H stated the resident had an order for [REDACTED]. He/she only expected an incident (elopement of resident #1) like this documented in the facility risk management documentation. He/she did not expect any documentation in nurse's progress notes when a resident got out of the building. He/she expected a follow up from the incident, such as behavior monitoring in the facility progress notes after an incident. Review of the undated facility policy preventative action plan for elopement of residents revealed, if an elopement risk assessment determined a resident to be at risk the facility would begin immediate action to prevent an elopement from occurring. Such actions included notification of the resident/responsible party of the results of the assessment and action plan, notification of the resident's physician and the resident's care plan would be updated to reflect the risk for elopement and approaches taken to prevent such. If the resident's elopement risk assessment reflected a score that indicated a risk for elopement, but the interdisciplinary team agreed after review that the resident was not at risk, the interdisciplinary team would indicate that on the assessment. The resident's care plan would reflect the decision of the interdisciplinary team also. The elopement risk assessment would be reviewed thereafter on a quarterly basis or with any significant change. The facility identified resident #1 as cognitively impaired, independently mobile and therefore at increased risk of elopement. The facility failed to re-assess resident #1's cognitive abilities periodically when he/she started packing and exit-seeking, failed to place interventions to prevent an elopement when the resident's elopement risk assessment identified the resident as a high risk, failed to ensure the resident did not leave the facility without staff knowledge, and failed to supervise the resident when he/she walked to a moderately busy residential road with rocky shoulders, an incline into a ditch, with cars/trucks/semis passing by and the on/off ramp to a highway within approximately half a mile from the facility. The facility abated the immediate jeopardy on 3/10/17 by implementation of the following corrective actions: The facility checked door alarms for functionality and reported all alarms tested to be fully operational. A family member opened the facility door for the resident without alerting staff, setting off the door alarm or permission to take the resident out of the community by their responsible party/staff. The facility reeducated the family member who let the resident out. The facility sent letters to current residents/family members on 2/27/17 and re-educated them on the needs of the community residents for a safe/secure living space. Family members were reminded they were not able to escort or allow any resident out of the building without prior knowledge/authorization of the charge nurse. The administrator posted a sign at the front exit door that cautioned family members not to let residents out of the facility as stated above. The facility re-educated staff about the family education provided by the facility and about the preventative action plan for elopement of residents and missing residents. The facility would review and update all resident care plans to reflect specific diversional activity for those identified with exit seeking behaviors. A facility designee would monitor care plans to assure updates occurred with changes in resident condition. Care plans would continue to be reviewed and updated daily by the facility designee. Full review of care plans would continue to occur at quarterly care plan meetings to assure interventions were maintained and continued to be appropriate. The quality assurance and performance improvement (QAPI) team would re-assess and provide direction for additional interventions/monitoring as indicated and update residents care plans as needed. The deficient practice remained at a scope/severity of D.