Every finding on record at Homestead Health Center

Based on observation, interview, and record review the facility failed to employ a full-time certified dietary manager for the residents who resided in the facility and received meals from the facility kitchen. Findings included:- Upon request the facility was unable to provide evidence of a Certified Dietary manager (CDM). On 05/12/26 at 07:40 AM, Dietary Manager BB revealed the facility does not have a CDM and said License Nurse (LN) G does act as the CDM when needed. On 05.13/26 at 11:30 AM, Administrative Staff A revealed the Registered Dietitian monitors the kitchen and dining and Dietary Manager BB oversees the ordering for the kitchen and attends the food meetings. Administrative Staff A stated three CDM have left and the facility was currently advertising for a CDM. The facility did not provide a policy as requested on 05/14/26.

Based on observation, interview, and record review, the facility failed to prepare and serve food under sanitary conditions to prevent potential food borne bacteria. Findings included:- On 05/12/26 at 07:40 AM, an initial tour of the main kitchen revealed refrigerator temperatures were missing for the following date: 05/04/26, 05/05/26, 05/06/26, 05/07/26, 05/09/26 and 05/10/26. During the tour three male dietary staff wearing beard guards without covering mustaches, including Dietary Manager BB. Additionally, the hand-washing station lacked a foot activated trash can, and the dishwasher chemical sanitization needed repaired. the staff did not use the three-sink sanitation until asked about their procedure, The three-sink sanitation was started. On 5/12/26 at 07:40 AM Dietary Staff BB revealed the dishwasher was not working properly and a repairman would be coming out that day to fix the issue. On 05/12/26 at 11:30 AM interview with Administrative Staff A revealed she expected the staff to keep refrigerator temperatures documented daily; staff to wear the beard net properly to cover any facial hair, Administrative Staff A verified staff were to use the three-step sanitation on the dishes until the dishwasher was fixed correctly. The facility's policy Preventing Foodborne Illness-Employee Hygiene and Sanitary Practice, dated 11/2022, documented staff would wear hairnets or caps and/or beard restraints when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linen. The facility's policy Sanitization, dated 11/2022, documented the facility would maintain the service area in a clean and sanitary manner, dishwashing machines would be operated according to manufacturer's instruction. General recommendations for heat and sanitization. Manual washing and sanitizing is a three-step procedure for washing, rinsing and sanitizing, scrape food particles and wash using hot water and detergent. Sanitize with hot water at least 75 degrees Fahrenheit for 30 seconds or chemical sanitizing solution.

Based on observation, interview, and record review, the facility failed to ensure adequate infection control practices related to Enhanced Barrier Precautions, EBP (a infection control measure using gowns and gloves during high-contact care) and cleaning of the Hoyer lift (mechanical device used to transfer individuals between surfaces) and proper handwashing between clean and soiled during resident care. Findings included:- On 05/12/26 at 09:17 AM, an observation revealed Certified Nurse Aide (CNA) O and Certified Nurse Aide CNA R transferred Resident (R) 33 from the recliner to the wheelchair using the Hoyer lift. After finishing the transfer, the lift was placed in the slot in the hallway without wiping it down. On 05/12/26 at 09:25 AM, an observation revealed CNA P obtained the Hoyer lift from the slot in the hallway, took the lift in to use on R11 without cleaning the lift prior to use. On 05/13/26 at 10:30 AM, an observation revealed Licensed Nurse (LN) H was already in the room with gloves on, assisting R42 to get up for the day. CNA Q entered the room and washed hands before putting on his gloves. As the bed was being moved, CNA Q picked up an item off the floor and moved the trash can before going on the opposite side of the bed to assist R42. CNA Q did not change his gloves. LN H continued to wear the same gloves while removing the soiled brief then using body wipes to provide peri-care. Both LN H and the CNA Q changed R42's clothes and placed her shoes on. LN H went into the bathroom to wash her hands and apply new gloves. CNA Q did not remove his gloves but grabbed the trash can and put a new trash bag in it. On 05/13/26 at 10:50 AM, interviews with both LN H and CNA Q revealed they should change gloves in between the dirty and the clean care. On 05/13/26 at 01:42 PM, an observation of Certified Restorative Aide M and Certified Restorative Aide N applied a gown and gloves before entering R8 room. They transferred R8 from his wheelchair to the bed with a Hoyer lift. After placing R8 into bed, the two staff removed the peri-wipes from the container and placed them on the bedside table without a barrier along with the barrier cream. The staff then removed R8's pants and brief using the wipes on the bedside table, CNA N grabbed more peri-wipes placed them on the bedside table using the cream on the wipes. Both CNAs did not remove their gloves during the process of peri-care from dirty to clean. On 05/13/26 at 2:09 PM CNA N stated they did wipe the table down this morning, but it has been seen to be done, and now know to change your gloves during the process between clan and dirty. On 5/14/26 at 1:54 PM Administrative Staff D stated she expected the staff to clean hands before and after having contact with the resident and expected the staff to clean the Hoyer lift between residents. The facility policy Cleaning and Disinfection of Resident-Care Items and Equipment, dated 09/25, documents resident care equipment, including reusable items and durable medical equipment, will be cleaned and disinfected according to current CDC recommendation for disinfection. Only designated, reusable equipment shall be used by more than one resident. The facility policy Enhanced Barrier Precautions, dated 09/25, documented multidrug-resistant organism (MSRO) transmission is common in skilled nursing facilities contributing to substantial resident morbidity and mortality and increased health care cost. EBP will be taken when caring for individual known or suspected of having infection with multidrug resistant organism. The facility policy Handwashing/Hand Hygiene, reviewed 03/02/26, documented all personnel shall be trained and regularly in serviced on the importance of hand hygiene in preventing the transmission of health care associated infections. All personnel shall follow the handwashing/hand hygiene procedure to help prevent the spread of infection to other personnel, residents, and visitors.

Based on observation, interview, and record review, the facility failed to have a scale to obtain resident weights that was operational.Findings:- On 05/13/26 at 04:41 PM, Certified Medication Aide (CMA) R stated the Certified Nurse Aide (CNA) got the residents' weights monthly and when needed. CMA R stated she would weigh Resident (R) 5 but would have to make sure the scale was working, as it had been down. CMA R returned and stated it was still broken so she was unable to weigh R5. Review of R5's Electronic Medical Record (EMR) showed a lack of documentation of weights for 04/29/26, 05/06/26, and 05/20/26. On 05/14/26 at 03:09 PM, Administrative Nurse D stated that all residents use the scale to weigh. The scale was down since 04/28/26 and was sent to be fixed on 05/04/26. They have been unable to weigh any residents since then. On 05/14/26 at 03:09 PM, Administrate Staff A stated she called several places to rent a scale and was unable to get one. The facility policy Maintenance Service, dated 03/2025, documented the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interview, and record review, the facility failed to provide care and services to ensure acceptable parameters of nutritional status for Resident (R) 5 when the facility failed to identify weight loss, implement interventions and recommendations to prevent further loss, notify the registered dietician or the physician of the weight loss, and failed to ensure working scales in the facility. Findings included:- R5's Electronic Medical Record (EMR) revealed the following diagnoses: dementia (a progressive mental disorder characterized by failing memory and confusion), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), need for assistance with personal care, and hallucinations (sensing things while awake that appear to be real, but the mind created). R5's 04/06/26 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of six, indicating severely impaired cognition. The MDS recorded R5's weight was 156 pounds (lbs.), he had no known weight loss, and he consumed a regular texture diet with no eating or swallowing concerns. The 04/06/26 Nutritional Status Care Area Assessment (CAA) documented R5 had a potential for nutrition and weight alteration secondary to progression of Parkinson's Disease and dementia. He was currently able to feed himself after staff provided set-up and R5 was escorted to meals. R5 was able to select food choices and his weight was stable since admission in December. R5's Care Plan, dated 03/03/26, documented R5 had potential for nutrition and weight alteration. The plan directed staff to obtain a dietary consult and follow the recommendations, initially and as needed. R5's EMR from admission on [DATE] through 05/13/26 lacked documentation of any dietary consult/assessment or notes by the Registered Dietician. R5's Physician's Orders documented a regular diet, ordered on 12/15/25. R5's Physician's Orders documented an order for weekly weights on Wednesday, ordered on 02/03/26. R5's Progress Note from admission, 12/15/25 through 05/13/26 lacked any documentation of weight loss. R5's Vitals tab documented a weight on 04/15/26 of 151 lbs. with an alert of a five percent (%) decrease in 30 days. On 04/22/26 the Vitals tab had a weight of 149.7 lbs. and again had an alert of a 5% weight loss in 30 days. R5's Vitals tab and Electronic Medication Record (EMAR) showed no weight obtained on 04/29/26, 05/06/26, or 05/13/26. The record indicated staff had not weighed R5 in three weeks. On 05/13/26 at 11:56 AM, R5 sat at the dining room table beside his wife. R5 had finished one small cup of fluids and was waiting for his food to arrive. R5's wife stated she came to the facility to eat with him every lunch and dinner and he ate well. When his food arrived, R5 ate the beef stew without difficulty. During an interview on 05/13/26 at 04:43 PM, R5's wife stated she noticed he had been losing weight. She was unsure why because he ate well and loved to snack on cookies and ice cream. She said whenever he got them, R5 would always eat them. On 05/13/26 at 04:41 PM, Certified Medication Aide (CMA) R stated the CNAs got the resident's weights monthly and when needed. CMA R stated she would weigh R5 but would have to make sure the scale was working, as it had been down. CMA R returned and stated the scale was still broken so she was unable to weigh R5. On 05/14/26 at 08:32 AM, Licensed Nurse (LN) I stated the CNA or CMAs got the weight, and the nurse charted it. LN I said the dietary manager looked at the weights and if it was off, he asked for a reweight, and they sometimes did a three day reweight if needed. On 05/14/26 at 11:17 AM, Dietary Staff DD stated the CNAs got the weights, he organized them and identified the residents that had a weight loss for the Risk Meeting. He stated if a resident had a 5% wight loss in a month, they should get them on a supplement so if they miss a meal, they would have something. He discussed the weight losses with LN G and she documented it in the EMR. Dietary Staff DD was unaware that R5 had a weight loss and stated that he ate good when his wife was with him. On 05/14/26 at 11:43 AM, LN G stated the Restorative Aides got the weekly and monthly weights, and the nurse entered the weights in the EMR. LN G stated they got monthly weights on everyone, and weekly weights if the residents had a weight loss or gain, or if they were on a medication or supplement and needed extra monitoring. LN G said if a resident had significant weight loss, the staff would reweigh the resident first, then investigate the factors for the weight loss. LN G said the weight loss report went to the RD when she came in once a month. LN G stated when a new resident came in, the RD should have done an assessment at that time. LN G was not aware that R5 had weight loss but was aware that R5 was to be on weekly weights because he had gained some weight. If a resident lost weight LN G stated she would not wait for the RD to come into the facility to address. LN G would notify the provider and get an order for health shakes and whatever else was needed. On 05/14/26 at 02:30 PM, Consultant GG stated she was at the facility on 04/29/26. Consultant GG did not have access to run the report for weight loss, so the facility provided her with a list of residents with wight loss and a list of residents that needed an assessment when she came into the facility. Consultant GG was not made aware when R5 was a new resident and was not made aware of the weight loss. On 05/14/26 at 12:09 PM, Administrative Nurse D stated the RD saw all new residents on her monthly visit. Administrative Nurse D said the residents are to be weighed monthly, and some are weighed more frequently as ordered to monitor. LN G identified the residents that had a weight loss and notified the risk team at the weekly Risk Meeting. If they discussed it in the Risk Meeting, it should have been documented in the EMR. If they recognized a weight loss, they would get with the nurse and notify the RD and the provider. Administrative Nurse D said maybe they did not worry about the weight loss because he had swelling and they might have attributed the weight loss with the loss of water, but that should have been documented. Administrative Nurse D said the scale had not been working since 04/28/26 and was sent to be fixed on 05/04/26. Administrative Nurse D stated they have not been able to weigh any residents since then. The facility policy Weight Loss or Gain, dated 07/2025, documented if a resident had a significant weight change, the director of nursing would be notified, the resident would be reweighed, the resident would be referred to the RD for a nutritional assessment, and the physician and family would be notified of the weight change.

Based on observation, interview, and record review the facility failed to follow methods that conserve nutritive value, flavor, and appearance of pureed foods for Resident (R) 33. Findings included: On 05/13/26 at 11:15 AM, observation revealed Dietary Staff CC placed stew into the blender to puree the food for R33. The recipe book present showed how to cook meat and gravy, it did not show a recipe for pureed food. Dietary Staff CC reported they only put about one fourth of water into the stew and stated they did not have a recipe book to follow Dietary staff CC did not use a measuring device for an accurate amount of fluid used. On 05/13/26 at 11:20 AM, Dietary Manager BB attempted to show the recipes which indicated how to cook beef and gravy. Dietary Manager BB then revealed the kitchen did not have recipes for pureed foods. On 5.13.26 at 11:30 AM Administrative Staff A revealed she expected the kitchen staff to puree the food correctly and confirmed the facility had recipes and the staff just needs to use them. The facility did not provide a policy regarding proper food preparation for a pureed diet.

The facility reported a census of 43 residents with 12 included in the sample, and eight residents reviewed for accidents. Based on observations, interviews, and record reviews, the facility failed to ensure that four residents remained free of accident hazards related to falls, Resident (R) 21, R35 and R12, and included one resident, R37, who continued to fall and obtained additional injuries. Additionally, the facility failed to ensure that R20 remained free of accident hazards when staff pushed R20's wheelchair without foot pedals and his feet were suspended above the ground. These deficient practices had the potential to negatively affect the physical and psychosocial well-being of the residents. Findings included: - Review of the Electronic Health Record (EHR) for Resident (R) 21 included the diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), diabetes mellitus type 2 (DM 2-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and generalized muscle weakness. The Significant Change Minimum Data Set (MDS), dated [DATE] documented a Brief Interview of Mental Status score of 15, which indicated intact cognition. The assessment documented that the resident utilized a wheelchair and/or a walker for locomotion. R21 was occasionally incontinent of bowel/bladder and required supervision and setup with all cares except bathing, which required substantial/maximum assistance. The assessment documented that R21 received a diuretic (medication to promote the formation and excretion of urine), and opioid (a narcotic pain medication) and a hypoglycemic (a medication to lower the concentration of sugar in the blood). The Activities of Daily Living (ADL) Functional / Rehabilitation Potential Care Area Assessment (CAA), dated 04/01/24 documented that R21 was a fall risk. The Falls CAA, dated 04/01/24 documented R21 as at risk for further falls and injury due to history of multiple falls due to decreased safety awareness and noncompliance with safety recommendations from staff. The Quarterly MDS, dated [DATE] documented a BIMS score of 15, which indicated intact cognition. The assessment documented that R21 utilized a wheelchair for locomotion. R21 was occasionally incontinent of bowel/bladder and required substantial/maximal assistance with bathing, partial/moderate assistance with dressing, supervision/setup for eating, and toileting/personal hygiene. The assessment documented that R21 received a diuretic, an opioid, and hypoglycemic medications. The 08/27/24 Care Plan documented on 03/03/21 that R21 was at risk for falls and listed the following interventions: 1. On 03/03/21, staff would instruct R21 on proper transfer techniques and to alert the staff for assistance. 2. On 04/13/21, staff would provide correct footwear to utilize at night and remind resident to alert the staff for assistance when needed. 3. On 02/08/22, staff referred R21 to physical therapy for strengthening and altered gait (manner or style of walking). 4. On 03/21/22, R21 was to use a walker for stability during all transfers. 5. On 08/27/22, staff added adhesive non-skid strips to the floor in front of R21's recliner to aid in transfers. 6. On 10/18/22, staff would educate R21 in the importance of minimizing clutter in her room. 7. On 10/27/22, staff would offer to hem up R21's pants to reduce the risk of falls and encourage R21 to ask for assistance. 8. On 06/28/23, staff would educate R21 to ensure feet were firmly on the floor before attempting to stand or transfer. 9. On 12/18/23, staff would remind the resident to utilize her walker with all ambulation (walking). 10. On 02/12/24, staff referred R21 to occupational therapy for strengthening and safety training. The Care Plan lacked documentation or intervention related to the fall on 07/01/24. The Physician's Orders lacked documentation or intervention related to fall prevention/mitigation. Review of the EHR Fall Risk assessments revealed the following: 1. On 01/26/23, the facility documented a fall risk of 13, which indicated a high risk for falls. 2. On 03/31/23, the facility documented a fall risk of 12, which indicated a high risk for falls. 3. On 06/27/23, the facility documented a fall risk of 11, which indicated a high risk for falls. 4. On 09/17/23, the facility documented a fall risk of 13, which indicated a high risk for falls. 5. On 12/08/23, the facility documented a fall risk of 13, which indicated a high risk for falls. 6. On 01/24/24, the facility documented a fall risk of 12, which indicated a high risk for falls. 7. On 06/28/24, the facility documented a fall risk of 13, which indicated a high risk for falls. 8. On 06/22/24, the facility documented a fall risk of 12, which indicated a high risk for falls. Review of the facility's fall investigations revealed the following: 1. On 03/26/24, R21 fell due to weakness, which resulted in a fracture (broken bone) of one of her vertebrae (bones of the spine) and required hospitalization . The Progress Notes documented that resident felt weak and fell in a seated position to the floor from a standing height. The immediate intervention was to send the resident to the hospital by ambulance. The care plan intervention dated 04/01/24, staff referred R21 to physical therapy for safety training and ADL retraining since R21 was wearing a thoracic lumbar sacral orthosis (TLSO - a brace or splint that limits the movement of the spine from mid back area to the sacrum [triangular bone at the base of the spine], often used after surgery or injury to the spine). 2. On 04/22/24, R21 fell but was not injured. The Progress Notes documented the resident was not wearing appropriate footwear. The fall report documented the immediate intervention was for R21 to wear appropriate footwear with ambulation with the care plan intervention dated 04/22/24 for staff to remind R21 to wear appropriate footwear. 3. On 05/27/24, R21 fell , but was not injured. The Progress Notes documented that the resident ambulated unassisted and fell to her knees from a standing height due to weakness. The fall report documented the immediate intervention was that staff would ensure the call light was within R21's reach and remind R21 to call for assistance with the care plan intervention dated 05/27/24, staff would always place a call light within R21's reach and encourage its use and encourage R21 to keep personal use items within reach. 4. On 06/05/24, R21 fell , which resulted in a fracture of her right clavicle (collar bone) but did not require hospitalization . The Progress Notes documented that the resident was ambulating with her walker without the use of shoes or non-skid socks. R21 stated on 08/26/24 at 10:40 AM that she slipped on water and that she was unaware she had spilled on the floor in the bathroom. The fall report documented the immediate intervention of staff to staff to perform visual checks on R21 every two hours with the care plan intervention dated 06/05/24, staff would perform visual checks and offer assistance every two hours for a 24-hour period. 5. On 07/01/24, R21 fell but was not injured. The facility's investigation determined that the root cause of the fall was that R21 attempted to self-transfer into a wheelchair unsuccessfully. The facility's investigation report lacked an immediate intervention put in place by the staff on duty at the time of the fall, additionally the EHR Care Plan lacked an intervention related to this incident. On 08/28/24 at 10:46 AM, Certified Nurse Aide (CNA) G stated that if a resident fell , that CNA staff would stay with the resident and alert other staff for assistance and upon the arrival of the nurse, follow the instructions given by the nurse. On 08/28/24 at 10:57 AM, Certified Medication Aide (CMA) H stated that it was discovered that a resident fell , CNA/CMA staff would ensure that the resident was safe and alert other staff for additional assistance including notifying the nurse then would follow the instructions from the nurse. On 08/28/24 at 11:18 AM, Administrative Nurse B stated that immediately following a fall, the nurse should fill out a note with any assessment findings and do a fall huddle with the staff on duty to investigate the cause of the fall. The nurse should then initiate an immediate intervention to mitigate the risk for falls for the remainder of the shift. The nurse would then notify the physician, resident representative and Administrative Nurse B. Additionally stated that if the fall happened during normal business hours, the interdisciplinary team (IDT - a team of facility staff consisting of members of various departments including but not limited to; dietary, nursing, maintenance, therapy, etc.) would hold an immediate meeting to develop a permanent care plan intervention. If the fall happened outside of normal business hours, then the IDT would meet and develop a permanent care plan intervention the following morning (or on Monday, if the fall happened on a weekend). Administrative Nurse B stated that the above information was the expectation of staff and confirmed the lack of a care plan intervention related to the fall on 07/01/24 and was unable to provide an explanation as to why the care plan lacked an intervention for the fall on 07/01/24. The facility's Falls and Fall Risk, managing policy, dated 12/2007 documented that the staff would identify interventions related to a resident's specific risks and causes to prevent falls. Additionally documented that if a resident has repeated falls that staff would implement additional or different interventions, until falls were reduced or stopped or the reason for the falls is identified as unavoidable. Further documented that the staff would include the physician and Consultant Pharmacist to re-evaluate, identify and implement interventions to minimize serious consequences of falling. The facility failed to ensure that R21 remained free of accident hazards related to falls when the facility failed to review and revise the care plan for R21 after R21 fell on [DATE]. This deficient practice had the potential to lead to ongoing increased risk for falls and the possibility of additional injuries from falls. - Review of the Electronic Health Record (EHR) for Resident (R)20 included the diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion), osteoporosis (an abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), restlessness and agitation, and repeated falls. The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of nine, which indicated moderately impaired cognition. The assessment documented R20 utilized a wheelchair for locomotion and was dependent on staff for all cares except eating and oral hygiene, which required supervision/setup. The Falls Care Area Assessment (CAA) dated 12/30/23 documented that R20 was at risk for falls secondary to decreased safety awareness, a history of multiple falls and impulsive behaviors. The Quarterly MDS dated [DATE] documented a BIMS score of six, which indicated severely impaired cognition. The assessment documented R20 was dependent on staff for all cares except eating and oral hygiene which required supervision/setup. The 08/27/24 Care Plan lacked documentation related to use or omission of foot pedals on R20's wheelchair. The Physician Orders lacked documentation related to foot pedal use on R20's wheelchair. The Assessments in the EHR lacked documentation of a safety assessment related to locomotion without foot pedals installed on R20's wheelchair. The Progress Notes reviewed 06/01/24 to 08/27/24 lacked documentation related to the use or omission of foot pedals on R20's wheelchair. Observation on 08/26/24 at 12:58 PM, revealed staff propelled R20 in his wheelchair. The wheelchair lacked foot pedals and R20 held his feet above the ground by approximately 1 to 2 inches. Observation on 08/27/24 at 07:30 AM, revealed R20 sat at a table in the dining area with peers present. The wheelchair lacked foot pedals for R20. Observation on 08/28/24 at 11:00 AM, revealed R20 sat at a table in the activity area with peers present and participated in the activity. The wheelchair lacked foot pedals. Observation on 08/28/24 at 10:25 AM, revealed R20 slowly self-propelled his wheelchair from the activity area in the direction of the dining area and used a combination of foot movement and right arm actuation of the wheel. The wheelchair continued to lack foot pedals. Observation on 08/28/24 at 10:44 AM, revealed Certified Nurse Aide (CNA) F assisted R20 in his wheelchair approximately 30 feet of the remaining distance to the dining area table. CNA F asked R20 to hold his feet up and pushed his wheelchair the remaining distance. The wheelchair lacked foot pedals. During an interview on 08/28/24 at 10:46 AM, CNA F confirmed she assisted R20 without the foot pedals on his wheelchair. Further stated that R20 does not like the foot pedals to be installed on his wheelchair and that R20 was capable of holding his feet up safely. During an interview on 08/28/24 at 10:50 AM, CNA G stated that residents do not always need to have the foot pedals on the wheelchair. Stated that the information related to foot pedals should be on the care plan, but that she did not know how to locate the care plans in the EHR. During an interview on 08/28/24 at 10:57 AM, Certified Medication Aide (CMA) H stated all residents should have pedals on their wheelchair all the time. She further stated that if a resident was self-propelling in a wheelchair that lacked foot pedals and required assistance, the staff member should go to the resident's room and retrieve the foot pedals and install them on the wheelchair before the resident was propelled to their destination. During an interview on 08/28/24 at 11:18 AM, Administrative Nurse B stated that the expectation was for staff to go to the resident's rooms and retrieve the foot pedals on their wheelchair before propelling the residents in their wheelchair. Additionally stated that if a resident doesn't want foot pedals on their wheelchair that it should be on the care plan. Further stated that a safety assessment should be performed for residents who don't need or want to have foot pedals on their wheelchairs. Administrative Nurse B confirmed the above information was lacking in R20's EHR and that R20 was not safe to be propelled in his wheelchair without foot pedals as it was a safety concern due to his medical conditions. The facility's Falls and Fall Risk, Managing policy, dated 12/2007 lacked documentation related to the use or omission of foot pedals on resident's wheelchairs. The facility failed to provide an environment free of accident hazards when staff assisted R20 with wheelchair locomotion without the foot pedals installed on his wheelchair. This deficient practice had the potential to negatively affect the resident's physical and psychosocial well-being. 50659 - Resident (R) 35's Electronic Health Record (EHR) revealed diagnoses of unspecified dementia (progressive mental disorder characterized by failing memory, confusion) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The 06/20/24 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R35 had a total mood severity score of 03, indicating minimal depression and there were no behaviors. She was independent with activities of daily living (ADLs), with toileting hygiene, dressing, personal hygiene, ambulation, and transfers. R35 required set up for meals and moderate assistance with bathing. The MDS indicated R35 experienced no falls since admission. The 06/20/24 Falls Care Area Assessment (CAA) documented R35 had potential for falls and injury related to unstable blood glucose control, decreased safety awareness, and a history of falls prior to admission. The 08/26/24 Care Plan documented fall interventions which included: On 06/25/24, staff were instructed to provide a call light within the resident's reach and encourage R35 to use it. On 06/25/24, staff were instructed to encourage R35 to wear nonskid socks or shoes. The 08/26/24 Physicians Orders lacked any documentation for safety or falls. Review of the Progress Note dated 08/20/24 at 11:57 PM, revealed R35 had an unwitnessed fall in her room she stated she slipped on water that she had spilled on her floor. The 08/26/24 Care Plan lacked a fall intervention related to R35's 08/20/24 fall. During an interview with R35 on 08/26/24 at 01:37 PM, R35 stated she had a fall last week after she spilled water on her floor. During an observation on 08/27/24 at 07:30 AM, R35 made her bed independently she wore appropriate shoes. During an interview on 08/28/24 at 10:07 AM, Administrative Nurse B confirmed that the care plans should be updated with interventions after an event/fall, in a timely manner. Administrative Nurse B reported the interdisciplinary team (IDT) met weekly and reviewed the events/falls that occurred over the past week. Administrative Nurse B revealed she was not aware that if a care plan was reviewed and no care plan intervention was completed after a fall, that it did not meet regulatory requirements. Administrative Nurse B reported that the facility was responsible for all the resident's safety. The facility's Falls and Fall Risk, Managing policy, dated 12/2007 documented that the staff would identify interventions related to a resident's specific risks and causes to prevent falls. Additionally documented that if a resident has repeated falls that staff would implement additional or different interventions, until falls were reduced or stopped or the reason for the falls is identified as unavoidable. Further documented that the staff would include the physician and Consultant Pharmacist to re-evaluate, identify and implement interventions to minimize serious consequences of falling. The facility failed to keep R35 safe, related to fall hazards. This practice had the potential to lead to negative psychosocial effects related to safety and uncommunicated needs. - Resident (R) 37's Electronic Health Record (EHR) revealed diagnoses included dementia (progressive mental disorder characterized by failing memory, confusion), weakness, and falls. The 08/14/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R37's total severity score of zero, indicating no depression. R37 required set up assistance for oral care and eating. R37 required moderate assistance with activities of daily living (ADLs), with personal hygiene and transfer. R37 required total assistance with bathing, toileting, dressing and footwear. The resident was independent with ambulation. R37 had one minor injury and two non-injury falls. The 08/16/24 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R37 had actual self-care performance related to left hand contracture and weakness. The CAA noted R37 required supervision with ambulation related to fast-paced ambulation. The 08/16/24 Falls CAA documented R37 had a history of falls and injury related to fluctuation of cognition, and self-care performance. Additionally, the resident had poor memory and decreased safety awareness. The 05/22/24 Quarterly MDS documented a BIMS score of 14, indicating intact cognition. R37 required set up assistance for oral care and eating. R37 required maximal assistance with ADLs, with personal hygiene and toileting. R37 required total assistance with bathing, dressing, and footwear. The resident independent with ambulation and transfers. R37 had one minor injury and two non-injury falls. The 08/26/24 Care Plan documented fall interventions, which included: On 03/25/23, staff were instructed to monitor and assist R37 with toileting, as needed. On 01/16/24, staff instructed to monitor R37 whenever they walked by R37's room, offer assistance, and additionally, provide reminders to use her call light for assistance. On 04/17/24, staff educated R37 on the importance to have staff pick items up off the floor for her. On 07/25/24, R37 worked with therapy and the care plan was appropriate at that time. R37 was encouraged to allow staff to ambulate with her for her safety. The 08/26/24 Physician Orders included activity level, stand by assistance with transfer and walking with walker every shift, dated 12/17/22; Physical Therapy consult as needed for falls, dated 04/18/24. Review of the Progress Note dated 01/16/24 at 04:46 PM, revealed R37 had an unwitnessed fall when she stated she tried to sit down in the recliner and fell . Review of the Progress Note dated 02/11/24 at 04:47 PM, revealed a witnessed injury fall, R37 tripped over her walker after she tried to ambulate around the walker. R37 sustained a skin-tear and bruise on left wrist, and left thumb nail had broken. The note documented the care plan was reviewed, appropriate at that time. The 08/26/24 Care Plan lacked a fall prevention intervention related to the causal factor of R37's fall with minor injury on 02/11/24, where R37 sustained a skin-tear and bruise of left wrist. Review of the Progress Note dated 03/31/24 at 11:28 AM, revealed R37 had a witnessed fall while out with friends at her church; Noted a contusion to back of her head. Review of the Progress Note dated 04/17/24 at 07:45 PM, revealed R37 had an unwitnessed fall when she stated she bent over to pick up her slippers and fell . Review of the Progress Note dated 05/21/24 at 07:10 PM, revealed R37 had a witnessed fall in the hallway. R37 turned around to go back to her room and fell to the floor. Review of the Progress Note dated 05/22/24 at 02:21 PM, revealed R37 had a witnessed fall in the activity room. R37 sat down on walker that was not locked and she fell to the floor. The 08/26/24 Care Plan lacked a fall prevention intervention related to the causal factor of R37's falls on 05/21/24 and 05/22/24. The Care Plan was revised on 05/28/24, which included: to educate the resident to not sit on the walker. Review of the Progress Note dated 07/09/24 at 09:45 PM, revealed R37 had a witnessed fall, Licensed Nurse (LN) R observed R37 ambulating fast with her four-wheel walker in the hallway. R37 then noted to lean to her right side and fell to the floor. R37 sustained a laceration and bruised area on her forehead, bruised right hand, and right arm. R37 complained of back and left wrist pain and transferred to the hospital. Review of the Progress Note dated 07/09/24 witnessed injury fall, R37 sustained a laceration (wound to the skin) and bruised area on forehead, bruised right hand, and right arm. R37 was transferred to hospital. Review of the Progress Note dated 07/10/24 at 01:30 AM, revealed R37 transported back to facility by a family member. Review of the Progress Note dated 08/12/24 at 10:45 AM, revealed R37 had an unwitnessed fall. R37 stated she was walking to fast with her walker, turned the corner at nurse's station lost her balance and fell . Review of the Progress Note dated 08/12/24 at 05:56 PM, revealed R37 had an unwitnessed fall. The resident was found on the floor, with her backed leaned against her dresser. R37 stated she felt dizzy and hit her head on the padded walker. The Care Plan lacked an intervention related to the fall on 08/12/24, and only noted R37 had two non-injury falls. During an interview with R37 on 08/26/24 at 10:04 AM, R37 stated she walked into the door frame when she exited the bathroom. Observation during the interview revealed R37 had a swollen, purple bruised area noted on her forehead. During an observation on 08/26/24 at 01:00 PM, R37 sat in the dining room eating lunch with her family member. R37 had a white bandage on her forehead. During an observation on 08/27/24 at 07:35 AM, R37 sat in the dining room eating her breakfast, noted approximately three centimeters (cm) by one centimeter, purple colored bruise on her forehead. During an observation on 08/27/24 at 09:00 AM, Certified Nurse Aide (CNA) L assisted R37 with toileting hygiene. R37 stood up independently from the toilet, then ambulated to the bathroom sink and washed her hands. During an interview on 08/26/24 at 01:10 PM, R37 stated she bumped her head on her door frame when she exited out of the bathroom earlier today. R37 and her family member laughed about her incident when R37 explained what had happened. During an interview on 08/27/24 at 09:05 AM, CNA L reported R37 did not like staff to walk with her. CNA L stated she would get mad if they tried to. During an interview on 08/28/24 at 09:46 AM, Certified Medication Aide (CMA) K reported R37 worked with a restorative aide three times a week for balance. During an interview on 08/28/24 at 10:07 AM, Administrative Nurse B confirmed that the care plans should be updated with interventions after an event in a timely manner. Administrative Nurse B reported the interdisciplinary team (IDT) would meet weekly and review the events that had occurred over the past week. Administrative Nurse B revealed she was not aware that if a care plan was reviewed and no care plan intervention was completed it did not meet regulatory requirements. Administrative Nurse B reported that the facility is responsible for all the resident's safety. The facility's Falls and Fall Risk, Managing policy, dated 12/2007 documented that the staff would identify interventions related to a resident's specific risks and causes to prevent falls. Additionally documented that if a resident has repeated falls that staff would implement additional or different interventions, until falls were reduced or stopped or the reason for the falls is identified as unavoidable. Further documented that the staff would include the physician and Consultant Pharmacist to re-evaluate, identify and implement interventions to minimize serious consequences of falling. The facility failed to keep R37 safe, related to fall hazards. This practice had the potential to lead to negative psychosocial effects related to safety and uncommunicated needs. - Resident (R)12's Electronic Health Record (EHR) revealed diagnoses included dementia (progressive mental disorder characterized by failing memory, confusion), weakness and repeated falls. The 03/27/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R12's total mood severity score of zero, indicated no depression. R12 required set up assistance for eating and required moderate assistance with activities of daily living (ADLs), with upper body dressing. R12 required maximal assistance with transfers, bathing, toileting, lower body dressing, and footwear. R12 refused to ambulate and was independent with wheelchair mobility. R35 had two or more non-injury falls since the prior assessment. The 03/30/24 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R12 required assistance with ADLs related to unsteady gait, dizziness, weakness, and unwilling to participate in restorative program. The 03/30/24 Falls CAA documented R12 had a potential for falls and injury related to decrease safety awareness, weakness, dizziness and impulsive behavior. The 06/19/24 Quarterly MDS documented a BIMS score of 14, indicating intact cognition. R12 required set up assistance for oral care and eating. R12 required total dependence with assistance with toileting, footwear and personal hygiene. R12 required maximal assistance with transfers, bathing, and dressing. R12 had one minor injury fall since the prior assessment. The 08/26/24 Care Plan documented fall interventions for R12, which included: On 01/08/24, the staff were to encourage R12 to participate in the restorative program for strengthening, continue to emphasize to R12 to use call light or call pendant to alert staff with all transfers needed. On 04/15/24, the staff were to encouraged R12 to work with physical therapy to gain strength and proper transfer technique, and R12 will ask for assistance with transfers. The 08/26/24 Physician Orders included a Physical Therapy consult as needed for falls, dated 01/10/23. The restorative program included exercise using step, safety walking, and safety transfer practices for one, six times a week, for five-fifteen minutes a day. R12's exercise regime and walking were not consistent, and he often declined to participate, dated 02/12/24. Review of the Progress Note dated 01/01/24 at 11:17 AM, revealed R12 experienced an unwitnessed fall when he stated he fell while he transferred from his wheelchair to the recliner and lost his grip on the bar, and slid to the floor. The Care Plan lacked an intervention related to R12's fall on 01/01/24, until 01/08/24 (seven days later). Review of the Progress Note dated 01/22/24 at 07:45 PM, revealed R12 had an unwitnessed fall when he stated he fell while he transferred from his recliner to his wheelchair and landed on the wheelchair in the wrong spot and caused the wheelchair to tip over onto its side. The 08/26/24 Care Plan lacked a fall prevention intervention related to the causal factor of R12's falls on 01/22/24. Review of the Progress Note dated 04/02/24 at 01:09 PM, revealed two near falls in the morning in his room. R12 was unable to move his legs and feet during a transfer with staff and started to fall to the ground, staff assisted R12 back into his wheelchair. R12 transferred self from his wheelchair to his recliner and he fell on his left knee, and staff assisted him back into the recliner. The 08/26/24 Care Plan lacked a fall prevention intervention related to the causal factor of R12's fall on 04/02/24. Review of the Progress Note dated 04/15/24 at 04:07 PM, revealed R12 had an unwitnessed fall when he stated he fell while he transferred from his recliner to the wheelchair. R12's right leg had redness and bruised area noted. Review of the Progress Note dated 04/19/24 at 09:33 AM, revealed R12 continued to work with therapy for strengthening with transfers related to several near falls. Review of the Progress Note dated 08/16/24 at 05:23 PM, revealed R12 had declined to do a safety walking with exercise bar. R35's exercise regime is not consistent, he often refused to participate. Review of the Progress Note dated 08/22/24 at 08:24 AM, revealed R12 had an unwitnessed fall in his bathroom. He stated he was in his wheelchair, reached up to put an item away on shelf over the toilet, and missed the wheelchair when he sat back down and fell to the floor. The 08/26/24 Care Plan lacked a fall prevention intervention related to the causal factor of R12's fall on 08/22/24. During an observation on 08/26/24 at 10:53 AM, R12 was seated in his recliner, in his room. There was a stop sign taped to the wall on white paper, above a safety transfer bar, to remind R12 to call staff for assistance. Observation revealed nonskid strips on the floor in front of his recliner and a red tape outline on the floor in front of his recliner. R12 stated the red tape outline marked where he needed to have his wheelchair parked when he transferred. He stated he did not always call the staff (for assistance). R12 also stated he would like to ambulate more than he does. During an observation on 08/26/24 at 10:58 AM, R12's call light was wrapped on the posit [TRUNCATED]

The facility reported a census of 43 residents with 12 residents sampled. Based on observation, interview, and record review, the facility failed to ensure one of two medication carts observed were locked while unattended. This deficiency had the potential to affect 21 residents located on the North Unit. Findings included: - During an observation on 08/27/24 at 12:05 PM, an unlocked medication cart was observed on the North Unit. Licensed Nurse (LN) Q was seated behind the nurse's station desk with her back towards the unlocked medication cart that was positioned on the outside of the nurse's station. LN Q had been communicating with a hospice nurse. The medication cart drawer was opened without LN Q noticing. During an interview on 08/27/24 at 12:06 PM, LN Q confirmed that the medication cart was the nurses' treatment cart and should not have been left unlocked as the cart contained medications and treatment supplies. LN Q then locked the cart. During an interview on 08/28/24 at 10:07 AM, Administrative Nurse B confirmed the nurses' medication/treatment cart should be locked at all times when not in use. The facility's policy Security of Medication Cart dated 04/2007, documented the medication cart shall be secured during medication passes. The medication carts must be securely locked at all times when out of the Certified Medication Aide or Nurse's view. When the medication cart is not being used, it must be locked and parked at the nurses' station or inside the medication room. The facility failed to provide proper storage of medications in a safe locked medication cart. This deficient practice had the potential to have a negative effect of the residents in the facility.

The facility reported a census of 43 residents with 13 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately revise four resident's care plans after falls experienced by Residents (R)37, R35, R21, and R12. Additionally, R9's hearing bilateral hearing aides were not addressed on the resident's care plan. This placed the residents at risk for uncommunicated care needs. Findings included: - Resident (R)37's Electronic Health Record (EHR) revealed diagnoses, which included dementia (progressive mental disorder characterized by failing memory, confusion), weakness, and falls. The 08/14/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R37 had a total (mood) severity score of zero, which indicated no depression. R37 required set up assistance for oral care and eating. R37 required moderate assistance with activities of daily living (ADLs), with personal hygiene, and transfers. R37 required total assistance with bathing, toileting, dressing and footwear and was independent with ambulation. R37 had one minor injury fall and two non-injury falls. The 08/16/24 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R37 had actual self-care performance deficits related to a left hand contracture and weakness. The CAA noted R37 required supervision with ambulation related to fast-paced ambulation. The 08/16/24 Falls CAA documented R37 had a history of falls and injury related to fluctuation of cognition, and self-care performance. Additionally, R37 had poor memory and decreased safety awareness. The 05/22/24 Quarterly MDS documented a BIMS score of 14, indicating intact cognition. R37 required set up assistance for oral care and eating. R37 required maximal assistance with ADLs, personal hygiene, and toileting. R37 required total assistance with bathing, dressing, and footwear and was independent with ambulation and transfers. R37 had one minor injury and two non-injury falls. The 08/26/24 Care Plan documented fall interventions which included: 03/25/23, staff were instructed to monitor and assist R37 with toileting, as needed. 01/16/24, staff instructed to monitor R37 whenever they walked by R37's room and offer assistance; and additionally, provide reminders to use her call light for assistance. 04/17/24, staff educated R37 on the importance to have staff pick items up off the floor for her. 07/25/24, R37 worked with therapy. R37 would be encouraged to allow staff to ambulate with her for her safety. The 08/26/24 Physician Orders included the following: An order dated 12/17/22 for the resident to have an activity level, stand by assistance with transfers, and walking with walker every shift. An order dated 04/18/24 for Physical Therapy to consult as needed for falls. Review of the Progress Note dated 01/16/24 at 04:46 PM, revealed R37 had an unwitnessed fall when she stated she tried to sit down in the recliner and fell . Review of the Progress Note dated 02/11/24 at 04:47 PM, revealed the resident had a witnessed injury fall. R37 tripped over her walker after she tried to ambulate around the walker and sustained a skin-tear and bruise on the left wrist, and a broken left thumb nail. The facility reviewed the resident's care plan and found it to be appropriate at that time. The 08/26/24 Care Plan lacked a fall prevention intervention related to the causal factors of R37's fall with minor injury on 02/11/24, where R37 sustained a skin-tear and bruise of left wrist. Review of the Progress Note dated 03/31/24 at 11:28 AM, revealed R37 had a witnessed fall while out with friends at her church and had a contusion to the back of her head. Review of the Progress Note dated 04/17/24 at 07:45 PM, revealed R37 had an unwitnessed fall when she stated she bent over to pick up her slippers and fell . Review of the Progress Note dated 05/21/24 at 07:10 PM, revealed R37 had a witnessed fall in the hallway. R37 turned around to go back to her room and fell to the floor. Review of the Progress Note dated 05/22/24 at 02:21 PM, revealed R37 had a witnessed fall in the activity room. R37 sat down on a walker that was not locked and she fell to the floor. The 08/26/24 Care Plan lacked a fall prevention intervention related to the causal factor of R37's fall on 05/21/24 and 05/22/24. The Care Plan was revised on 05/28/24, which included staff educated the resident to not sit on the walker. Review of the Progress Note dated 07/09/24 at 09:45 PM, revealed R37 had a witnessed fall after Licensed Nurse (LN) R observed R37 ambulating fast with her four-wheel walker in the hallway. Staff then noted R37 to lean to her right side and fall to the floor. R37 sustained a laceration and bruised area on her forehead, bruised right hand, and bruised right arm. R37 complained of back and left wrist pain and she was transferred to the hospital. Review of the Progress Note dated 07/09/24 revealed R37 had a witnessed injury fall and sustained a laceration (wound to the skin), bruised area on forehead, bruised right hand, and bruised right arm. R37 was transferred to hospital. Review of the Progress Note dated 07/10/24 at 01:30 AM, revealed R37 transported back to facility by a family member. The Care Plan lacked an intervention related to the fall on 07/09/24, until 07/25/24 (16 days later), which noted the witnessed injury fall on 07/09/24 for R37, where she sustained a laceration (wound to the skin) and bruised area on forehead, bruised right hand, and bruised right arm. R37 was transferred to the hospital. R37 was encouraged to allow staff to ambulate with her for her safety. Review of the Progress Note dated 08/12/24 at 10:45 AM, revealed R37 had an unwitnessed fall. R37 stated she was walking to fast with her walker, turned the corner at nurse's station, lost her balance, and fell . Review of the Progress Note dated 08/12/24 at 05:56 PM, revealed R37 had an unwitnessed fall. The resident was found on the floor, with her backed leaned against her dresser. R37 stated she felt dizzy and hit her head on the padded walker. The Care Plan lacked an intervention related to the fall on 08/12/24, and only noted R37 had two non-injury falls. During an interview with R37 on 08/26/24 at 10:04 AM, R37 stated she walked into the door frame when she exited the bathroom. Observation during the interview revealed R37 had a swollen, purple, bruised area ,noted on her forehead. During an observation on 08/26/24 at 01:00 PM, R37 sat in the dining room eating lunch with her family member. R37 had a white bandage on her forehead. During an observation on 08/27/24 at 07:35 AM, R37 sat in the dining room eating her breakfast, noted approximately three centimeters (cm) by one centimeter, purple colored bruise on her forehead. During an observation on 08/27/24 at 09:00 AM, Certified Nurse Aide (CNA) L assisted R37 with toileting hygiene. R37 stood up independently from the toilet, ambulated to the bathroom sink and washed her hands. During an interview on 08/26/24 at 01:10 PM, R37 stated she bumped her head on her door frame when she exited out of the bathroom earlier today. R37 and her family member laughed about her incident when R37 explained what had happened. During an interview on 08/27/24 at 09:05 AM, CNA L reported R37 did not like staff to walk with her. CNA L stated she will get mad if we try to. During an interview on 08/28/24 at 09:46 AM, Certified Medication Aide (CMA) K reported R37 worked with restorative aide three times a week for balance. During an interview on 08/28/24 at 10:07 AM, Administrative Nurse B confirmed that the care plans should be updated with interventions after an event in a timely manner. Administrative Nurse B reported the interdisciplinary team (IDT) would meet weekly and review the events that had occurred over the past week. Administrative Nurse B revealed she was not aware that if a care plan was reviewed and no care plan intervention was completed was inappropriate. Administrative Nurse B reported that the facility is responsible for all the resident's safety. The facility's Goals and Objectives, Care Plans policy, dated 04/2009, documented that the care plans would include goals and objectives that lead to the resident's highest obtainable level of independence. Additionally, documented that when goals and objectives were not met, and the desired outcome not achieved, the care plans would be modified accordingly. The facility's Care Plans, Comprehensive Person-Centered policy, dated 04/2022, documented the facility would develop and implement a person-centered care plan for each resident with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Additionally, documented the facility's IDT would review and update the care plans when the desired outcome was not met. The facility failed to revise R37's care plan after several falls. This placed the resident at risk for uncommunicated care needs. This deficient practice had the potential to have a negative effect on the overall physical and psychosocial well-being of the resident in the facility. - Resident (R) 35's Electronic Health Record (EHR) revealed diagnoses of unspecified dementia (progressive mental disorder characterized by failing memory, confusion) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The 06/20/24 Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R35 had a total mood severity score of 03, indicating minimal depression and there were no behaviors. She was independent with activities of daily living (ADLs), toileting hygiene, dressing, personal hygiene, ambulation, and transfers. R35 required set up for meals and moderate assistance with bathing. The MDS indicated R35 experienced no falls since admission. The 06/20/24 Falls Care Area Assessment (CAA) documented R35 had potential for falls and injury related to unstable blood glucose control, decreased safety awareness, and a history of falls prior to admission. The 08/26/24 Care Plan documented fall interventions which included: 06/25/24, staff were instructed to provide call light within the resident's reach and encourage R35 to use it. 06/25/24, staff were instructed to encourage R35 to wear nonskid socks or shoes. The 08/26/24 Physicians Orders lacked any documentation related to safety or falls. Review of the Progress Note dated 08/20/24 at 11:57 PM, revealed R35 had an unwitnessed fall in her room. She stated she slipped on water that she spilled on her floor. The 08/26/24 Care Plan lacked a fall intervention related to R35's 08/20/24 fall. During an interview with R35 on 08/26/24 at 01:37 PM, R35 stated she had a fall last week after she spilled water on her floor. During an observation on 08/27/24 at 07:30 AM, R35 made her bed independently and she wore appropriate shoes. During an interview on 08/28/24 at 10:07 AM, Administrative Nurse B confirmed care plans should be updated with interventions in a timely manner after an event/fall. Administrative Nurse B reported the interdisciplinary team (IDT) met weekly and reviewed the events/falls that occurred over the past week. Administrative Nurse B revealed she was not aware if a care plan was reviewed and no care plan intervention was completed after a fall, that it did not meet regulatory requirements. Administrative Nurse B reported that the facility was responsible for all the resident's safety. The facility's Goals and Objectives, Care Plans policy, dated 04/2009, documented that the care plans would include goals and objectives that lead to the resident's highest obtainable level of independence. Additionally, documented that when goals and objectives were not met, and the desired outcome not achieved, the care plans would be modified accordingly. The facility's Care Plans, Comprehensive Person-Centered policy, dated 04/2022, documented the facility would develop and implement a person-centered care plan for each resident with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Additionally, documented the facility's IDT would review and update the care plans when the desired outcome was not met. The facility failed to revise R35's care plan after a fall. This placed the resident at risk for uncommunicated care needs. This deficient practice had the potential to have a negative effect on the overall physical and psychosocial well-being of the resident in the facility. - Resident (R)9's Electronic Health Record (EHR) revealed diagnoses included hearing loss and encephalopathy (broad term for any brain disease that alters brain function or structure). The 01/02/24 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition, and R9 had no behaviors noted. R9's total severity score of nine, indicating mild depression. R9 required set up assistance for oral care and eating. R9 required moderate assistance with activities of daily living (ADLs), with toileting and dressing. R9 required total assistance with bathing, personal hygiene, wheelchair mobility, and footwear. R9 had minimal difficulty with hearing, no devices. The 01/02/24 Communication Care Area Assessment (CAA) documented R9 had potential for communication issues related to being hard of hearing. The 06/19/24 Quarterly MDS documented a BIMS score of 12, indicating moderately impaired cognition. R9 required set up assistance for oral care and independent with eating. Total dependence for bathing, footwear and wheelchair mobility. Supervision for toileting and transfers R9 had adequate hearing with bilateral hearing aides. The 08/26/24 Care Plan documented communication interventions which included: 06/28/23, staff instructed to approach on R9's left side when communicating and repeat questions as needed. The Care Plan lacked any documentation/interventions related to R9's bilateral hearing aides. The 08/26/24 Physician Orders included an order dated 04/23/24 for staff to assist the resident with hearing aides; apply in the morning and remove at sleep. Store hearing aides in the medication cart. Review of the Progress Note dated on 04/26/24 at 06:36 AM, revealed hearing aide company fitted R9 for hearing aides and education provided. During an observation on 08/26/24 at 12:29 PM, R9 had no hearing aides noted in her ears when communicating with her. R9 stated staff did not always place them in her ears. During an observation on 08/27/24 at 07:30 AM, R9 had no hearing aides noted in her ears, while she was in bed with her eyes closed. During an interview on 08/27/24 at 09:35 AM, Certified Nurse Aide (CNA) I revealed R9 would wear her hearing aides when she allowed or requested them from the staff. During an interview on 08/27/24 at 09:40 AM, Certified Medication Aide (CMA) J reported R9 would refuse to wear her hearing aides quite often as R9 did not like the oxygen tubing and the hearing aides on together. CMA J stated that R9 would request the hearing aides when she wanted them. During an interview on 08/28/24 at 10:07 AM, Administrative Nurse B confirmed that the care plans should be updated with interventions after an event in a timely manner. Administrative Nurse B reported the interdisciplinary team (IDT) would meet weekly and review the events that had occurred over the past week. Administrative Nurse B revealed R9 should have had the hearing aides added to her care plan. The facility's Goals and Objectives, Care Plans policy, dated 04/2009, documented that the care plans would include goals and objectives that lead to the resident's highest obtainable level of independence. Additionally, documented that when goals and objectives were not met, and the desired outcome not achieved, the care plans would be modified accordingly. The facility's Care Plans, Comprehensive Person-Centered policy, dated 04/2022, documented the facility would develop and implement a person-centered care plan for each resident with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Additionally, documented the facility's IDT would review and update the care plans when the desired outcome was not met. The facility failed to revise R9's care plan after she received her new hearing aides. This placed the resident at risk for uncommunicated care needs. This deficient practice had the potential to have a negative effect on the overall physical and psychosocial well-being of the resident in the facility. - Resident (R)12's Electronic Health Record (EHR) revealed diagnoses included dementia (progressive mental disorder characterized by failing memory, confusion), weakness and repeated falls. The 03/27/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R12's total severity score of zero, indicating no depression. R12 required set up assistance for eating. R12 required moderate assistance with activities of daily living (ADLs), with upper body dressing. R12 required maximal assistance with transfers, bathing, toileting, lower body dressing and footwear. R12 refused to ambulate and was independent with wheelchair mobility. R35 had two or more non-injury falls. The 03/30/24 ADL Functional/Rehabilitation Potential Care Area Assessment (CAA) documented R12 required assistance with ADLs related to unsteady gait, dizziness, weakness and unwilling to participate in restorative program. The 03/30/24 Falls CAA documented R12 had a potential for falls and injury related to decrease safety awareness, weakness, dizziness and impulsive behavior. The 06/19/24 Quarterly MDS documented a BIMS score of 14, indicating intact cognition. R12 required set up assistance for oral care and eating. R12 required total dependence with assistance with toileting, footwear and personal hygiene. R12 required maximal assistance with transfers, bathing and dressing. R12 had one minor injury fall. The 08/26/24 Care Plan documented fall interventions which included: 01/08/24 staff were instructed to encourage R12 to participate in restorative program for strengthening. Continue to emphasize to R12 to use call light or call pendant to alert staff with all transfers needed. 04/15/24 R12 encouraged to work with physical therapy to gain strength and proper transfer technique, and R12 will ask for assistance with transfers. The 08/26/24 Physician Orders included Physical Therapy consult as needed for falls, dated 01/10/23. Restorative program exercise using step, safety walking, and safety transfer practices for one-six times a week for five-fifteen minutes a day. His exercise regime and walking are not consistent, often declined to participate, dated 02/12/24. Review of the Progress Note dated 01/01/24 at 11:17 AM, revealed an unwitnessed fall when he stated he fell while he transferred from his wheelchair to recliner and lost his grip on bar and slid to the floor. The Care Plan lacked an intervention related to the fall on 01/01/24, until 01/08/24 (seven days later). Review of the Progress Note dated 01/22/24 at 07:45 PM, revealed an unwitnessed fall when he stated he fell while he transferred from his recliner to his wheelchair and landed on the wheelchair in the wrong spot and caused the wheelchair to tip over onto its side. Review of the Progress Note dated 04/02/24 at 01:09 PM, revealed two near falls in the morning in his room. R12 was unable to move his legs and feet during a transfer with staff and started to fall to the ground, staff assisted R12 back into his wheelchair. R12 transferred self from wheelchair to recliner and he fell on his left knee, staff assisted him back into recliner. The 08/26/24 Care Plan lacked a fall prevention intervention related to the causal factor of R12's falls on 01/22/24 and 04/02/24. Review of the Progress Note dated 04/15/24 at 04:07 PM, revealed an unwitnessed fall when he stated he fell while he transferred from his recliner to wheelchair. R12's right leg had redness and bruised area noted. Review of the Progress Note dated 04/19/24 at 09:33 AM, revealed R12 continued to work with therapy for strengthening with transfers related to several near falls. Review of the Progress Note dated 08/16/24 at 05:23 PM, revealed R12 has declined to do safety walking with exercise bar. R35's exercise regime is not consistent, he often refused to participate. Review of the Progress Note dated 08/22/24 at 08:24 AM, revealed an unwitnessed fall in his bathroom. He stated he was in his wheelchair, reached up to put an item away on shelf over the toilet and missed the wheelchair when he sat back down and fell to the floor. The 08/26/24 Care Plan lacked a fall prevention intervention related to the causal factor of R12's fall on 04/19/24 and 08/22/24. During an observation on 08/26/24 at 10:53 AM, R12 was seated in his recliner, noted a stop sign taped to the wall on white paper, above a safety transfer bar to remind R12 to call staff for assistance. Nonskid strips on floor in front of his recliner. Red tape outline on the floor in front of his recliner. R12 stated the red tape outline is where he needed to have his wheelchair parked when he transferred. He stated he does not always call the staff. R12 stated he would like to ambulate more than he does. During an observation on 08/26/24 at 10:58 AM, R12's call light was wrapped on the position device on his bed located approximately five feet away, as R12 sat in his recliner. R12 stated he would like the call light placed on his tray table next to him. During an interview on 08/26/24 at 11:01 AM, Licensed Nurse (LN) Q revealed R12 had a call light pendant placed on a necklace for R12. R12, who was present for the interview, then interjected and stated he forgot he had the call light pendant. LN Q reported R12 would not always call staff for assistance, and he was a fall risk. During an observation on 08/27/24 at 07:20 AM, R12 sat in his wheelchair in his room. He stated he was just leaving to go to breakfast in the dining room. During an interview on 08/28/24 at 09:43 AM, Certified Medication Aide (CMA) K reported that R12 like to ride the stationary bike and refused to ambulate when offered. CMA K stated that if R12 completed group exercises he would refuse to participate with the restorative program. During an interview on 08/28/24 at 09:45 AM, Certified Nurse Aide (CNA) P reported that R12 would get inpatient and transfer himself when he called for staff assistance. During an interview on 08/28/24 at 10:07 AM, Administrative Nurse B confirmed that the care plans should be updated with interventions after an event in a timely manner. Administrative Nurse B reported the interdisciplinary team (IDT) would meet weekly and review the events that had occurred over the past week. Administrative Nurse B revealed she was not aware that if a care plan was reviewed and no care plan intervention was completed was inappropriate. Administrative Nurse B reported that the facility is responsible for all the resident's safety. The facility's Goals and Objectives, Care Plans policy, dated 04/2009, documented that the care plans would include goals and objectives that lead to the resident's highest obtainable level of independence. Additionally, documented that when goals and objectives were not met, and the desired outcome not achieved, the care plans would be modified accordingly. The facility's Care Plans, Comprehensive Person-Centered policy, dated 04/2022, documented the facility would develop and implement a person-centered care plan for each resident with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Additionally, documented the facility's IDT would review and update the care plans when the desired outcome was not met. The facility failed to revise R12's care plan after several falls. This placed the resident at risk for uncommunicated care needs. This deficient practice had the potential to have a negative effect on the overall physical and psychosocial well-being of the resident in the facility. 46960 - Review of the Electronic Health Record (EHR) for Resident (R) 21 included the diagnoses of cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), diabetes mellitus type 2 (DM 2-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), and generalized muscle weakness. The 04/01/24 Significant Change Minimum Data Set (MDS) for R21 documented a Brief Interview of Mental Status score of 15, which indicated intact cognition. The assessment documented that the resident utilized a wheelchair and/or a walker for locomotion. R21 was occasionally incontinent of bowel/bladder and required supervision and setup with all cares except bathing which required substantial/maximum assistance. The assessment documented that R21 received a diuretic (medication to promote the formation and excretion of urine), and opioid (a narcotic pain medication) and a hypoglycemic (a medication to lower the concentration of sugar in the blood). The Activities of Daily Living (ADL) Functional / Rehabilitation Potential Care Area Assessment (CAA), dated 04/01/24 documented that R21 was a fall risk. The Falls CAA, dated 04/01/24 documented that R21 was at risk for further falls and injury due to history of multiple falls due to decreased safety awareness and noncompliance with safety recommendations from staff. The Quarterly MDS, dated [DATE] documented a BIMS score of 15. The assessment documented that R21 utilized a wheelchair for locomotion. R21 was occasionally incontinent of bowel/bladder and required substantial/maximal assistance with bathing, partial/moderate assistance with dressing, supervision/setup for eating and toileting/personal hygiene. The assessment documented that R21 received a diuretic, an opioid and hypoglycemic medications. The 08/27/24 Care Plan documented on 03/03/21 that R21 was at risk for falls. The listed staff interventions to prevent further falls included fall prevention interventions through 06/07/24. Review of the facility's fall investigations revealed on 07/01/24, R21 fell but was not injured. The facility's investigation determined the root cause of the fall was R21 had attempted to self-transfer into a wheelchair unsuccessfully. The facility's investigation report lacked evidence of an immediate fall prevention intervention put in place by the staff on duty at the time of the fall. The 08/27/24 Care Plan lacked evidence of a fall prevention intervention related to the fall R21 experienced on 07/01/24. On 08/28/24 at 10:46 AM, Certified Nurse Aide (CNA) G stated if a resident fell , the CNA staff stayed with the resident, alerted other staff for assistance, and upon the arrival of the nurse, the CNA followed the instructions given by the nurse. On 08/28/24 at 10:57 AM, Certified Medication Aide (CMA) H stated if it was discovered that a resident fell , CNA/CMA staff ensured the resident was safe and alerted other staff for additional assistance, including notifying the nurse, and then the CNA/CMA staff followed the nurse instructions. On 08/28/24 at 11:18 AM, Administrative Nurse B confirmed the lack of a care plan intervention related to R21's fall on 07/01/24. and was unable to provide an explanation as to why the care plan lacked an intervention for the fall on 07/01/24. The facility's Goals and Objectives, Care Plans policy, dated 04/2009, documented that the care plans would include goals and objectives that lead to the resident's highest obtainable level of independence. Additionally, documented that when goals and objectives were not met, and the desired outcome not achieved, the care plans would be modified accordingly. The facility's Care Plans, Comprehensive Person-Centered policy, dated 04/2022, documented the facility would develop and implement a person-centered care plan for each resident with measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. Additionally, documented the facility's IDT would review and update the care plans when the desired outcome was not met. The facility failed to review and revise the care plan for R21 after R21 fell on [DATE]. This deficient practice had the potential to lead to ongoing increased risk for falls and the possibility of additional injuries from falls.

The facility reported a census of 43 residents, with 12 residents sampled, including one resident sampled for advanced directives (a written document which indicated the medical decisions for health care professionals when the person could not make their own decisions). Based on interview and record review, the facility failed to ensure Resident (R) 35 who was cognitively intact sign a completed 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), instead they had a family member sign the directive. Findings included: - Resident (R) 35's Electronic Health Record (EHR) revealed diagnoses of unspecified dementia (progressive mental disorder characterized by failing memory, confusion) and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The [DATE] Admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. R35 had a total mood severity score of 03, indicating minimal depression and there were no behaviors. She was independent with activities of daily living (ADLs), with toileting hygiene, dressing, personal hygiene, ambulation, and transfers. R35 required set up for meals and moderate assistance with bathing. The [DATE] Cognitive Loss Care Area Assessment (CAA) documented R35 exhibited forgetfulness in regard to medications and routine. She was not happy to have to reside at the facility, is at risk for elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff) and was at risk for further decline in cognitive memory status. The [DATE] Care Plan documented DNR code dated, [DATE]. The Physician's Order dated [DATE], documented a Do Not Resuscitate order. On [DATE] review of EHR an uploaded document dated [DATE], a signed DNR by R12's family member who was not her durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) and witnessed by Licensed Bachelor Social Worker (LBSW) D. On [DATE] review of the EHR revealed an uploaded hospital note from the physician, dated [DATE], which documented discussed code status with patient, and she wanted to be a full code. The [DATE] Admission Transfer Orders from hospital were marked as a full code. On [DATE] at 07:30 AM, R35 stated that she was not asked to sign a DNR and stated that she was not sure if she wanted to continue with the DNR order. R12 stated her daughter was her health care agent. On [DATE] at 10:07 AM, Administrative Nurse B reported that R35 should have signed her own DNR and confirmed that R35's daughter is her DPOA. On [DATE] at 10:28 AM, LBSW D confirmed that R35's son signed the DNR as R35's DPOA was in the hospital. LBSW D reported that R35 was in the room when the DNR was signed and confirmed the EHR lacked a progress note of the above. She also reported she was unaware of the physician note from the hospital that R35 wanted to be a full code. The facility's Advanced Directives policy dated ,d+[DATE] documented advanced directives will be respected in accordance with state law and facility policy. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if they choose to do so. DPOA for healthcare is a document delegating authority to a legal representative to make health care decisions in case the individual delegating the authority subsequently becomes incapacitated. The facility failed (R)35 who was cognitively intact, by having a family member that was not her DPOA sign a completed DNR. This deficient practice had the potential to lead to uncommunicated needs specifically to end-of-life care.

The facility reported a census of 43 residents with 12 residents sampled. Based on interview and record review, the facility failed to provide the pneumococcal vaccine (vaccine designed to prevent pneumonia [inflammation of the lungs which can be debilitating or lethal in the elderly]) declination form to two of the five residents reviewed, Resident (R) 37 and R38. Findings included: - Review of the Electronic Health Record (EHR) and the 2023-2024 binder which contained consents and declinations in Administrative Nurse B's office on 08/28/24, lacked documentation of any pneumococcal vaccine declination form for Resident (R) 37 and R38. On 08/28/24 at 12:05 PM, Administrative Nurse B reported that R37 said she had the pneumococcal vaccine in the past and would not require one. Administrative Nurse B stated that she would look for the declinations for both residents. On 08/28/24 at 12:44 PM, Administrative Nurse B confirmed the facility could not locate any vaccination declinations for R37 and R38. Furthermore, she reported that R37's family did not provide the facility with an immunization record that R37 had received the pneumococcal vaccine in the past, and R38 had always refused any vaccination offered. The facility's Pneumococcal Vaccine policy dated 10/2022 documented all residents were offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The residents have a right to refuse the vaccine. If refused, appropriate information was documented in the resident's medical record indicating the date of the refusal. The facility failed to provide proof of declination of the pneumococcal vaccine for two residents, R37 and R38.

The facility reported a census of 43 residents. Based on observations, interviews, and record review, the facility failed to maintain effective infection control measures when Certified Medication Aide (CMA) H poked a straw through a potentially contaminated plastic film on the top of a cup containing a house supplement shake and then assisted a resident in drinking part of the shake. This deficient practice had the potential to contaminate the shake and lead to food-borne illness. Findings included: - On 08/28/24 at 11:04 AM, CMA H knocked over a cup that contained an unknown liquid and covered with a plastic film that sat on the medication cart. CMA H picked up the cup, removed a straw from the paper wrapper, and poked the straw through the plastic film. CMA H then walked into Resident (R) 1's room and assisted R1 in drinking approximately half of the liquid. On 08/28/24 at 11:11 AM, CMA H identified the liquid as a house supplement nutritional supplement shake and confirmed that she poked the straw through the potentially contaminated plastic film. CMA H stated that she should have sanitized the plastic film prior to inserting the straw or removed a small portion of the covering to insert the straw. On 08/28/24 at 11:15 AM, Administrative Nurse B stated the expectation was for staff to peel back the plastic film over a cup before inserting the straw due to infection control concerns as the plastic film could potentially be contaminated during transport from source to the medication cart. Administrative Nurse B went on to say that alternatively, the plastic film could have been sanitized with an isopropyl alcohol pad prior to a straw being poked through the plastic film. The facility's Monitoring Compliance with Infection Control policy, dated 04/2024, documented staff would adhere to infection prevention processes. The facility failed to maintain an effective infection control program when CMA H poked a straw through a potentially contaminated plastic film on the top of a cup containing a house supplement shake and then assisted a resident in drinking part of the shake. This deficient practice had the potential to contaminate the shake and lead to food-borne illness.

The facility reported a census of 42 residents with two reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) management. Based on observation, record review, and interview the facility failed to ensure appropriate indwelling urinary catheter care for Resident (R)1. On 12/24/23 at approximately 08:30 PM Licensed Nurse (LN) G flushed R1's indwelling urinary catheter, without a physician order, and used a non-sterile 60 milliliter (ml) syringe from R1's bathroom, which possibly contained some bleach and water mixture (used to clean R1's dependent drainage bag). R1 complained of burning pain immediately upon injecting the flush and LN G realized she performed the flush on the wrong patient. LN G then flushed the catheter again with the same non-sterile 60 ml syringe using tap water from the sink to take out whatever was making it burn. Approximately 15 minutes later, R1 requested Tylenol (analgesic medication) for pain and LN G flushed R1's urinary catheter again, using a new syringe and saline solution. LN G did not notify R1's physician regarding the incident. During the night LN G applied an ice pack wrapped in a towel on R1's brief to help with pain. Administrative Nurse D contacted the on-call provider the following morning at approximately 09:00 AM when R1 complained she still felt burning and pain, and staff administered additional Tylenol to R1 for pain at level 5 on the zero to 10 pain scale. This deficient practice of failing to provide appropriate indwelling urinary catheter care placed R1 in immediate jeopardy. Findings included: - The Face Sheet located in the electronic health record for R1 included diagnoses of malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of bladder, retention of urine, overactive bladder, and chronic kidney disease. The Significant Change Minimum Data Set (MDS) dated [DATE] assessed R1 with a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. R1 required extensive assistance of one person for toilet use and had an indwelling catheter. The Urinary Incontinence and Indwelling Catheter Care Area assessment dated [DATE] revealed R1 was unable to urinate due to her history of bladder cancer and urinary retention. R1 had an indwelling catheter to manage her urinary status due to an inability to manage self-catheterization. R1 required assistance to manage her indwelling catheter. The Quarterly MDS dated [DATE] assessed R1 with a BIMS score of 15 indicating intact cognition. R1 continued to have an indwelling catheter and was dependent on staff for toileting hygiene. The Care Plan dated 12/14/23 revealed R1 had an indwelling catheter due to increased confusion, inability to manage self-catheterization, inability to urinate, urine retention, and obstructive uropathy (condition in which flow of urine is blocked). Staff were to provide catheter care per protocol and switch to a leg drainage bag during the day. The Orders tab for R1 revealed a physician order dated 06/09/23, which instructed staff to rinse the vinyl urinary drainage bag with one ounce of premixed bleach solution twice a day during the times of 06:00 AM to 11:00 AM and from 07:00 PM to 11:00 PM. The order discontinued on 12/25/23. The orders lacked instructions to flush or irrigate R1's urinary catheter. The Nurse's Note dated 12/24/23 at 08:12 PM by LN G revealed R1 returned from a Christmas outing with family and had no concerns noted. The medical record lacked any further documentation until 12/25/23 at 09:27 AM. The Witness Statement by LN G for the incident on 12/24/23 at approximately 08:30 PM revealed R1 called for help in the restroom and LN G went to help her. When flushing R1's catheter, she complained of burning pain and LN G went ahead and flushed the catheter with plain water from tap and after a few minutes the pain did not subside. LN G then went and obtained a new syringe and saline and flushed the catheter twice. When LN G went back to check on R1 again, R1 said the pain was getting better and asked for Tylenol to help relax her so she could go to sleep. LN G gave R1 Tylenol and placed an ice pack covered with a towel on top of her brief to help with pain. LN G stated she also took R1 out for a walk to help relieve pain and offered lots of water to help flush the residue in case there was any. LN G stated she checked on R1 frequently during the night and when R1 awoke around 02:00 AM she asked R1 if she wanted to go out to be checked and R1 refused and said it will feel better by morning. LN G stated she reported the incident to Administrative Nurse D during shift change. The Nurse's Note dated 12/25/23 at 09:27 AM by Administrative Nurse D revealed R1 requested for her catheter to be flushed with normal saline for bladder irritation and Administrative Nurse D flushed it with 50 ml of normal saline and notified Physician Extender GG. The Nurse's Note dated 12/25/23 at 10:01 AM by Administrative Nurse D revealed R1's catheter was flushed with normal saline and a syringe previously used to flush the catheter bag with bleach. R1 complained of burning. The unidentified nurse explained to R1 what happened and R1 misunderstood and thought the flush contained bleach. Staff notified Physician Extender GG who instructed staff to monitor. R1 was given Tylenol for the pain and stated it helped. The Nurse's Note dated 12/25/23 at 01:00 PM by Administrative Nurse D revealed R1 requested to have her catheter flushed before going out with family, with blood noted, Physician Extender GG notified and stated, not to flush anymore. The Nurse's Note dated 12/25/23 at 01:47 PM by Administrative Nurse D revealed R1's urine was blood tinged and she spoke with Physician Extender GG, who instructed the facility to not flush the catheter anymore as it may be causing more irritation and further instructed staff to collect a urine sample for analysis in the morning. The Nurse's Note dated 12/26/23 at 02:02 PM revealed the results of the urinalysis noted R1's urine was blood positive 3+ (negative is normal). The Facility Investigation included a typed note dated 12/26/23 by Administrative Nurse D which revealed on the morning of 12/25/23 she came to work at 06:00 AM and LN G provided report, saying she had a med error on R1. Administrative Nurse D stated R1 had a catheter and used a leg bag during the day and at night switched to a full bag. The staff cleaned the bags with a bleach mixture using a 60 ml syringe to fill the bag. Administrative Nurse D stated LN G told her in report she irrigated R1's bladder with normal saline using the same syringe used to put the bleach mixture in the bag. Administrative Nurse D stated R1 did not have an order to irrigate the bladder and LN G irrigated R1's bladder again, concerned the syringe she used might have had some bleach residue in it. Administrative Nurse D stated R1 came to her around 09:00 AM saying she still felt burning and pain and believed she had been flushed with bleach. Administrative Nurse D stated she attempted to explain to R1 what happened, but she thought differently. Administrative Nurse D stated she contacted Physician Extender GG, advised her of the situation, and was told to continue to monitor and no need to send to the emergency room at this time. A family member arrived at the facility and discussed cleaning the bags with vinegar instead of bleach and the change was immediately implemented. Administrative Nurse D stated R1 requested for her catheter to be flushed again around 01:00 PM before going out with family and when proceeding blood-tinged urine was noted to be in the urinary collection bag. Administrative Nurse D spoke with Physician Extender GG who advised the facility to stop irrigating the bladder, obtain a urine sample for analysis in the morning, and send the sample to the laboratory. Administrative Nurse D stated on 12/26/23 R1's urine was noted to be only slightly pink and R1 stated she felt better than yesterday. The Facility Investigation dated 01/02/24 revealed on the evening of 12/24/23 LN G flushed R1's bladder using a syringe with possible chlorine (bleach) residue and R1 reported a burning sensation. LN G irrigated R1's bladder again with saline, however, R1 continued to complain of a burning sensation and was provided Tylenol for pain. Administrative Nurse D came on duty at 06:00 AM on 12/25/23 and continued to monitor the situation. R1's Durable Power of Attorney's were notified of the incident, Physician Extender GG contacted, investigation was on-going, and R1 was receiving frequent checks to ensure remedy of the situation. The corrective action in response to the incident included for chlorine (bleach) to no longer be used for irrigation of catheter bags and for white vinegar/water solution would be used from now on to disinfect. The corrective actions lacked date the actions occurred. On 01/02/24 at 11:44 AM R1 ambulated down the hallway with use of a walker to her room, and R1 sat in her recliner. Part of a urinary drainage leg bag strap extended below the bottom of R1's left pant leg. On 01/02/24 at 11:46 AM R1 stated on Christmas Eve, she did not know what time, LN G came to clean her catheter and flushed it while she was in bed. R1 stated LN G used a syringe to flush her catheter and made a mistake and used Clorox. R1 stated as soon as LN G started flushing and put it all in it burned like fire and R1 started screaming. R1 stated it was a very painful burning pain and she became tearful. R1 stated LN G flushed the catheter again with water and the pain got better but did not go away. R1 stated Administrative Nurse D was the last nurse to flush her catheter and she did not notice any blood in her urinary bag; however, her daughter noticed it the next day when at the facility. On 01/02/24 at 01:31 PM Certified Nurse Aide (CNA) M stated prior to 12/25/23 the staff would clean R1's urinary drainage bags with bleach using a syringe, which was stored in R1's bathroom. CNA M stated the facility did not provide education about cleaning the drainage bag since 12/24/23, she did not work on 12/25/23, but when she worked on 12/27/23 there was a sign in R1's bathroom on how to clean catheter bag with vinegar water. On 01/02/24 at 02:14 PM Certified Medication Aide (CMA) R stated she worked on 12/25/23 and R1 complained of pain where area of catheter was rating the pain at a 5 on the zero to 10 pain scale. On 01/02/24 at 03:04 PM Administrative Nurse D stated on 12/24/23 sometime between 07:00 PM and 09:00 PM, LN G irrigated R1's catheter without a physician's order. Administrative Nurse D stated she would have expected LN G to not flush R1's catheter without a physician order. Administrative Nurse D stated the syringe used for the flush would have been appropriate to use if it had been stored in a bag in a container and dated appropriately (changed out weekly). Administrative Nurse D stated on 12/25/23 she changed the policy to clean the urinary bags with vinegar to eliminate the use of bleach and made sure Administrative Staff A and the nurses working that day knew the policy changed. Administrative Nurse D stated when flushing/irrigating a catheter she would have used saline rather than tap water, and LN G should have notified R1's physician at the time of the occurrence when she flushed the catheter and R1 reported burning and pain. Administrative Nurse D stated she flushed R1's catheter on 12/25/23 and when she noted blood, she contacted Physician Extender GG who instructed her to stop flushing. Administrative Nurse D stated LN G did not know what to document in R1's record so she charted what she knew. Administrative Nurse D stated no facility wide, or nursing education provided after the incident, she talked with LN G however, had no written documentation of education with LN G. On 01/02/24 at 03:27 PM Physician Extender GG stated she would have expected LN G to have an order before flushing R1's urinary catheter, using a clean syringe, however, was not 100 percent sure on the facility protocol. Physician Extender GG stated it was not appropriate to flush a urinary catheter with a syringe used to clean catheter bags with and LN G should have notified her at the time of the occurrence when she flushed R1's catheter and R1 reported burning pain. Physician Extender GG stated the extra flushes might have caused the hematuria (blood in urine) and R1 and her family requested extra flushes, so she gave orders for those. Physician Extender GG stated she could not imagine there would have been not much more than drops of bleach in the syringe so could not imagine that it was super harmful and hard to know if that was the cause of the burning, R1 had a finicky bladder, and the extra flushes were probably not super helpful. Physician Extender GG stated she did not think tap water should be used to flush catheters with, and all that information should be in orders, including what to use, how much, and the steps and procedure. On 01/02/24 at 06:14 PM LN G stated on 12/24/23 around 09:00 PM she was going to R2's room to flush his catheter and had a small bottle of saline in her hand when R1 called for help. LN G stated she stopped to help R1 and after putting her to bed for some reason I went ahead and flushed R1's catheter instead of R2's. LN G stated as soon as she pushed the fluid in, she realized she had the wrong patient and R1 complained of pain. LN G stated she then got plain water and flushed to take out whatever was making it burn then left R1. LN G stated after 15 minutes R1 stated the pain was getting better but still present and asked for Tylenol, and 15 minutes after taking that R1 stated she felt better, and she went for a walk around the building with R1. LN G stated she then flushed her catheter again using a new syringe and saline, R1 went to sleep until 02:00 AM when she woke up due to being hot and at that time stated her pain was better. LN G stated she offered to send R1 out to the hospital, but she refused, and she also was trying to make R1 drink to flush it. LN G stated when she first flushed R1 by mistake, R1 did not cry or scream but stated that hurts and did not feel right. LN G stated she used a syringe from R1's bathroom and did not realize at first the syringe was for cleaning the leg bag with bleach. LN G stated she did not notify R1's physician because R1 did not act like she was in that much pain, so she was monitoring R1. LN G stated she talked to Administrative Nurse D about it in the morning telling her I made a mistake and did a treatment on the wrong patient and Administrative Nurse D stated she would do a teachable moment with her and investigate. LN G stated she had not received any education since the incident. The facility policy Catheter Irrigations and Catheter Bag Cleaning dated February 2014, revealed to sponge the catheter and tubing connections with an alcohol swab, disconnect the catheter, and allow urine to drain into a basin. Next, sponge the catheter with an alcohol swab. Insert the tip of a sterile, disposable syringe into the catheter and apply gentle pressure to the bulb. Allow the irrigating solution to drain by gravity into the emesis basin. Sponge the catheter and connecting tube with betadine. Sponge before reconnecting to the drainage tubing. For cleansing the catheter bag: after changing the urine collection bag, clean the bag with soap and warm water, rinse completely. To disinfect the collection bag: mixture of 1 tbsp of bleach to a half a cup warm water, pour solution into bag, rinse bag well with solution, and empty the bag. Do not rinse bag with water, hang bag upside down and allow to air dry. Store the clean and dry bag in a clean clear plastic bag until ready for use. The facility failed to provide appropriate urinary catheter care resulting in R1 experiencing pain and hematuria. This failure placed R1 at increased risk for infection and bladder tissue damage. On 01/03/24 at 11:36 AM Administrative Staff A was informed of the immediate jeopardy and provided the Immediate Jeopardy Template for failure to provide appropriate urinary catheter care to R1 resulting in burning, pain, and hematuria. The facility provided an acceptable plan of removal of the immediacy on 01/03/24 at 05:35 PM, which included the following corrective measures to be completed by 01/03/24 at 04:45 PM: 1. Procedure changes made to eliminate the use of chlorine for cleaning catheter bags and use of white vinegar mixture on 12/25/23. 2. Policy and Procedure change to Catheter Irrigations and Catheter Bag Cleaning implemented on 01/03/24. 3. Procedure change to stress a written order from the doctor has to be in the electronic medical record system before proceeding with procedure of irrigation on 01/03/24. 4. Procedure change to include the care of the syringe for both the irrigation and cleansing of bag to date and change out syringe every seven days on 01/03/24. 5. Training on all licensed nursing staff on 01/03/24 at 04:00 PM, completed at 04:45 PM. Competency training on procedures for irrigation of resident bladders and cleansing catheter bags. 6. Training of new licensed nursing staff on nursing procedures will occur before staff are allowed on the floor. 7. A monthly clinical competency training schedule will be presented at the January QAPI meeting. QAPI will follow-up at each meeting thereafter to ensure competency training completed for all clinical staff based upon the schedule. The surveyor verified the implementation of the above corrective actions onsite on 01/04/24 at 10:18 AM and the deficient practice remained at a G scope and severity.

The facility reported a census of 42 residents with two reviewed, Resident (R)1 and R2, for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) management. Based on observation, record review, and interview the facility failed to ensure nursing staff competency when LN G flushed R1's indwelling urinary catheter, without a physician order, and used a non-sterile 60 milliliter (ml) syringe from R1's bathroom, which possibly contained some bleach and water mixture (used to clean R1's dependent drainage bag) on 12/24/23 at approximately 08:30 PM. R1 complained of burning pain immediately upon injecting the flush and LN G realized she performed the flush on the wrong patient. LN G then flushed the catheter again with the same non-sterile 60 ml syringe using tap water from the sink to take out whatever was making it burn. Approximately 15 minutes later, R1 requested Tylenol (analgesic medication) for pain and LN G flushed R1's urinary catheter again, using a new syringe and saline solution. LN G did not notify R1's physician regarding the incident. During the night LN G applied an ice pack wrapped in a towel on R1's brief to help with pain. Administrative Nurse D contacted the on-call provider the following morning at approximately 09:00 AM when R1 complained she still felt burning and pain, and staff administered additional Tylenol to R1 for pain at level 5 on the zero to 10 pain scale. Failure to ensure competent nursing staff for appropriate urinary catheter care placed R1 in immediate jeopardy. Findings included: - The Face Sheet located in the electronic health record for R1 included diagnoses of malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of bladder, retention of urine, overactive bladder, and chronic kidney disease. The Significant Change Minimum Data Set (MDS) dated [DATE] assessed R1 with a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition. R1 required extensive assistance of one person for toilet use and had an indwelling catheter. The Urinary Incontinence and Indwelling Catheter Care Area assessment dated [DATE] revealed R1 was unable to urinate due to her history of bladder cancer and urinary retention. R1 had an indwelling catheter to manage her urinary status due to an inability to manage self-catheterization. R1 required assistance to manage her indwelling catheter. The Quarterly MDS dated [DATE] assessed R1 with a BIMS score of 15 indicating intact cognition. R1 continued to have an indwelling catheter and was dependent on staff for toileting hygiene. The Care Plan dated 12/14/23 revealed R1 had an indwelling catheter due to increased confusion, inability to manage self-catheterization, inability to urinate, urine retention, and obstructive uropathy (condition in which flow of urine is blocked). Staff were to provide catheter care per protocol and switch to a leg drainage bag during the day. The Orders tab for R1 revealed a physician order dated 06/09/23, which instructed staff to rinse the vinyl urinary drainage bag with one ounce of premixed bleach solution twice a day during the times of 06:00 AM to 11:00 AM and from 07:00 PM to 11:00 PM. The order discontinued on 12/25/23. The orders lacked instructions to flush or irrigate R1's urinary catheter. The Nurse's Note dated 12/24/23 at 08:12 PM by LN G revealed R1 returned from a Christmas outing with family and had no concerns noted. The medical record lacked any further documentation until 12/25/23 at 09:27 AM. The Witness Statement by LN G for the incident on 12/24/23 at approximately 08:30 PM revealed R1 called for help in the restroom and LN G went to help her. When flushing R1's catheter, she complained of burning pain and LN G went ahead and flushed the catheter with plain water from tap and after a few minutes the pain did not subside. LN G then went and obtained a new syringe and saline and flushed the catheter twice. When LN G went back to check on R1 again, R1 said the pain was getting better and asked for Tylenol to help relax her so she could go to sleep. LN G gave R1 Tylenol and placed an ice pack covered with a towel on top of her brief to help with pain. LN G stated she also took R1 out for a walk to help relieve pain and offered lots of water to help flush the residue in case there was any. LN G stated she checked on R1 frequently during the night and when R1 awoke around 02:00 AM she asked R1 if she wanted to go out to be checked and R1 refused and said it will feel better by morning. LN G stated she reported the incident to Administrative Nurse D during shift change. The Nurse's Note dated 12/25/23 at 09:27 AM by Administrative Nurse D revealed R1 requested for her catheter to be flushed with normal saline for bladder irritation and Administrative Nurse D flushed it with 50 ml of normal saline and notified Physician Extender GG. The Nurse's Note dated 12/25/23 at 10:01 AM by Administrative Nurse D revealed R1's catheter was flushed with normal saline and a syringe previously used to flush the catheter bag with bleach. R1 complained of burning. The unidentified nurse explained to R1 what happened and R1 misunderstood and thought the flush contained bleach. Staff notified Physician Extender GG who instructed staff to monitor. R1 was given Tylenol for the pain and stated it helped. The Nurse's Note dated 12/25/23 at 01:00 PM by Administrative Nurse D revealed R1 requested to have her catheter flushed before going out with family, with blood noted, Physician Extender GG notified and stated, not to flush anymore. The Nurse's Note dated 12/25/23 at 01:47 PM by Administrative Nurse D revealed R1's urine was blood tinged and she spoke with Physician Extender GG, who instructed the facility to not flush the catheter anymore as it may be causing more irritation and further instructed staff to collect a urine sample for analysis in the morning. The Nurse's Note dated 12/26/23 at 02:02 PM revealed the results of the urinalysis noted R1's urine was blood positive 3+ (negative is normal). The Facility Investigation included a typed note dated 12/26/23 by Administrative Nurse D which revealed on the morning of 12/25/23 she came to work at 06:00 AM and LN G provided report, saying she had a med error on R1. Administrative Nurse D stated R1 had a catheter and used a leg bag during the day and at night switched to a full bag. The staff cleaned the bags with a bleach mixture using a 60 ml syringe to fill the bag. Administrative Nurse D stated LN G told her in report she irrigated R1's bladder with normal saline using the same syringe used to put the bleach mixture in the bag. Administrative Nurse D stated R1 did not have an order to irrigate the bladder and LN G irrigated R1's bladder again, concerned the syringe she used might have had some bleach residue in it. Administrative Nurse D stated R1 came to her around 09:00 AM saying she still felt burning and pain and believed she had been flushed with bleach. Administrative Nurse D stated she attempted to explain to R1 what happened, but she thought differently. Administrative Nurse D stated she contacted Physician Extender GG, advised her of the situation, and was told to continue to monitor and no need to send to the emergency room at this time. A family member arrived at the facility and discussed cleaning the bags with vinegar instead of bleach and the change was immediately implemented. Administrative Nurse D stated R1 requested for her catheter to be flushed again around 01:00 PM before going out with family and when proceeding blood-tinged urine was noted to be in the urinary collection bag. Administrative Nurse D spoke with Physician Extender GG who advised the facility to stop irrigating the bladder, obtain a urine sample for analysis in the morning, and send the sample to the laboratory. Administrative Nurse D stated on 12/26/23 R1's urine was noted to be only slightly pink and R1 stated she felt better than yesterday. The Facility Investigation dated 01/02/24 revealed on the evening of 12/24/23 LN G flushed R1's bladder using a syringe with possible chlorine (bleach) residue and R1 reported a burning sensation. LN G irrigated R1's bladder again with saline, however, R1 continued to complain of a burning sensation and was provided Tylenol for pain. Administrative Nurse D came on duty at 06:00 AM on 12/25/23 and continued to monitor the situation. R1's Durable Power of Attorney's were notified of the incident, Physician Extender GG contacted, investigation was on-going, and R1 was receiving frequent checks to ensure remedy of the situation. The corrective action in response to the incident included for chlorine (bleach) to no longer be used for irrigation of catheter bags and for white vinegar/water solution would be used from now on to disinfect. The corrective actions lacked date the actions occurred. On 01/02/24 at 11:44 AM R1 ambulated down the hallway with use of a walker to her room, and R1 sat in her recliner. Part of a urinary drainage leg bag strap extended below the bottom of R1's left pant leg. On 01/02/24 at 11:46 AM R1 stated on Christmas Eve, she did not know what time, LN G came to clean her catheter and flushed it while she was in bed. R1 stated LN G used a syringe to flush her catheter and made a mistake and used Clorox. R1 stated as soon as LN G started flushing and put it all in it burned like fire and R1 started screaming. R1 stated it was a very painful burning pain and she became tearful. R1 stated LN G flushed the catheter again with water and the pain got better but did not go away. R1 stated Administrative Nurse D was the last nurse to flush her catheter and she did not notice any blood in her urinary bag; however, her daughter noticed it the next day when at the facility. On 01/02/24 at 01:31 PM Certified Nurse Aide (CNA) M stated prior to 12/25/23 the staff would clean R1's urinary drainage bags with bleach using a syringe, which was stored in R1's bathroom. CNA M stated the facility did not provide education about cleaning the drainage bag since 12/24/23, she did not work on 12/25/23, but when she worked on 12/27/23 there was a sign in R1's bathroom on how to clean catheter bag with vinegar water. On 01/02/24 at 02:14 PM Certified Medication Aide (CMA) R stated she worked on 12/25/23 and R1 complained of pain where area of catheter was rating the pain at a 5 on the zero to 10 pain scale. On 01/02/24 at 03:04 PM Administrative Nurse D stated on 12/24/23 sometime between 07:00 PM and 09:00 PM, LN G irrigated R1's catheter without a physician's order. Administrative Nurse D stated she would have expected LN G to not flush R1's catheter without a physician order. Administrative Nurse D stated the syringe used for the flush would have been appropriate to use if it had been stored in a bag in a container and dated appropriately (changed out weekly). Administrative Nurse D stated on 12/25/23 she changed the policy to clean the urinary bags with vinegar to eliminate the use of bleach and made sure Administrative Staff A and the nurses working that day knew the policy changed. Administrative Nurse D stated when flushing/irrigating a catheter she would have used saline rather than tap water, and LN G should have notified R1's physician at the time of the occurrence when she flushed the catheter and R1 reported burning and pain. Administrative Nurse D stated she flushed R1's catheter on 12/25/23 and when she noted blood, she contacted Physician Extender GG who instructed her to stop flushing. Administrative Nurse D stated LN G did not know what to document in R1's record so she charted what she knew. Administrative Nurse D stated no facility wide, or nursing education provided after the incident, she talked with LN G however, had no written documentation of education with LN G. On 01/02/24 at 03:27 PM Physician Extender GG stated she would have expected LN G to have an order before flushing R1's urinary catheter, using a clean syringe, however, was not 100 percent sure on the facility protocol. Physician Extender GG stated it was not appropriate to flush a urinary catheter with a syringe used to clean catheter bags with and LN G should have notified her at the time of the occurrence when she flushed R1's catheter and R1 reported burning pain. Physician Extender GG stated the extra flushes might have caused the hematuria (blood in urine) and R1 and her family requested extra flushes, so she gave orders for those. Physician Extender GG stated she could not imagine there would have been not much more than drops of bleach in the syringe so could not imagine that it was super harmful and hard to know if that was the cause of the burning, R1 had a finicky bladder, and the extra flushes were probably not super helpful. Physician Extender GG stated she did not think tap water should be used to flush catheters with, and all that information should be in orders, including what to use, how much, and the steps and procedure. On 01/02/24 at 06:14 PM LN G stated on 12/24/23 around 09:00 PM she was going to R2's room to flush his catheter and had a small bottle of saline in her hand when R1 called for help. LN G stated she stopped to help R1 and after putting her to bed for some reason I went ahead and flushed R1's catheter instead of R2's. LN G stated as soon as she pushed the fluid in, she realized she had the wrong patient and R1 complained of pain. LN G stated she then got plain water and flushed to take out whatever was making it burn then left R1. LN G stated after 15 minutes R1 stated the pain was getting better but still present and asked for Tylenol, and 15 minutes after taking that R1 stated she felt better, and she went for a walk around the building with R1. LN G stated she then flushed her catheter again using a new syringe and saline, R1 went to sleep until 02:00 AM when she woke up due to being hot and at that time stated her pain was better. LN G stated she offered to send R1 out to the hospital, but she refused, and she also was trying to make R1 drink to flush it. LN G stated when she first flushed R1 by mistake, R1 did not cry or scream but stated that hurts and did not feel right. LN G stated she used a syringe from R1's bathroom and did not realize at first the syringe was for cleaning the leg bag with bleach. LN G stated she did not notify R1's physician because R1 did not act like she was in that much pain, so she was monitoring R1. LN G stated she talked to Administrative Nurse D about it in the morning telling her I made a mistake and did a treatment on the wrong patient and Administrative Nurse D stated she would do a teachable moment with her and investigate. LN G stated she had not received any education since the incident. The facility policy Catheter Irrigations and Catheter Bag Cleaning dated February 2014, revealed to sponge the catheter and tubing connections with an alcohol swab, disconnect the catheter, and allow urine to drain into a basin. Next, sponge the catheter with an alcohol swab. Insert the tip of a sterile, disposable syringe into the catheter and apply gentle pressure to the bulb. Allow the irrigating solution to drain by gravity into the emesis basin. Sponge the catheter and connecting tube with betadine. Sponge before reconnecting to the drainage tubing. For cleansing the catheter bag: after changing the urine collection bag, clean the bag with soap and warm water, rinse completely. To disinfect the collection bag: mixture of 1 tbsp of bleach to a half a cup warm water, pour solution into bag, rinse bag well with solution, and empty the bag. Do not rinse bag with water, hang bag upside down and allow to air dry. Store the clean and dry bag in a clean clear plastic bag until ready for use. The facility failed to ensure competent nursing staff for appropriate urinary catheter care resulting in R1 experiencing pain and hematuria. This failure placed R1 at increased risk for infection and bladder tissue damage. On 01/03/24 at 11:36 AM Administrative Staff A was informed of the immediate jeopardy and provided the Immediate Jeopardy Template for failure to ensure competent nursing staff for inappropriate urinary catheter care to R1 resulting in burning, pain, and hematuria. The facility provided an acceptable plan of removal of the immediacy on 01/03/24 at 05:35 PM, which included the following corrective measures to be completed by 01/03/24 at 04:45 PM: 1. Procedure changes made to eliminate the use of chlorine for cleaning catheter bags and use of white vinegar mixture on 12/25/23. 2. Policy and Procedure change to Catheter Irrigations and Catheter Bag Cleaning implemented on 01/03/24. 3. Procedure change to stress a written order from the doctor has to be in the electronic medical record system before proceeding with procedure of irrigation on 01/03/24. 4. Procedure change to include the care of the syringe for both the irrigation and cleansing of bag to date and change out syringe every seven days on 01/03/24. 5. Training on all licensed nursing staff on 01/03/24 at 04:00 PM, completed at 04:45 PM. Competency training on procedures for irrigation of resident bladders and cleansing catheter bags. 6. Training of new licensed nursing staff on nursing procedures will occur before staff are allowed on the floor. 7. A monthly clinical competency training schedule will be presented at the January QAPI meeting. QAPI will follow-up at each meeting thereafter to ensure competency training completed for all clinical staff based upon the schedule. The surveyor verified the implementation of the above corrective actions onsite on 01/04/24 at 10:18 AM and the deficient practice remained at a G scope and severity.

The facility reported a census of 41 residents. Based on record review and interview, the facility failed to conduct Quality Assessment and Assurance (QAA) committee meetings with the required members present that included the Director of Nursing Services (DON), the Medical Director, the Nursing home administrator, owner, board member, or other individual in a leadership role, the Infection Preventionist and two other staff members, when the facility failed to have a DON present at the meetings. This had the potential to affect all residents. Findings included: - On 12/12/22 at 03:30 PM, Administrative Staff A produced sign- in sheets for quarterly QAA meetings from October 2021 through November 2022. The facility lacked documentation for the required members at the meetings, with a DON present at only in August,2022 and September 2022. On 12/15/22 at 03:44 PM, Administrative Staff A confirmed the facility had not had a DON at the quarterly meetings She stated she was unaware the DON needed to be specifically signed in. The facility's Quality Assessment and Assurance Program policy dated April 2021, documented that all department managers, the administrator, the director of nursing, infection control and prevention officer, medical director, consulting pharmacist, and other additional staff as warranted, would provide QUAPI leadership, by being part of the QUAPI/QAA committee. The facility failed to conduct quarterly Quality Assessment and Assurance (QAA) committee meetings with the required members present.

The facility reported a census of 41 residents. All residents received meals prepared in the main kitchen. Based on observation, interview and record review, the facility failed to store foods safely and sanitary by the staff's failure to date and reseal opened food items, failure to discard expired food items, and the failure to handle plates appropriately in the kitchen, to prevent the spread of food borne illnesses to the residents of the facility. Findings included: - Initial tour of the kitchen dry storage area on [DATE] at 01:50 PM, with (dietary manager) DM BB, revealed the following concerns: 1. A package of commercially available cookies, open date of [DATE], and expiration date of [DATE]. 2. Cereals included a bag of Raisin Bran, opened, with no open date or use by date and a bag of opened Rice Crispies, with no opened date or use by date. A box of carrot cake mix opened and undated. DM BB stated dry foods like cereal and mixes were shelf stable for three months. She acknowledged there was no open date to time the three months. Inspection of the stand-alone refrigerator contained a jar of olives, opened on [DATE] and had no use by date. DM BB stated refrigerated goods were stable for 6 months (no expiration date). The walk-in refrigerator revealed the following concerns: 1. A bag of sweet potatoes, visibly rotted. 2. A pan that contained opened, unsealed containers of luncheon meats (turkey, roast beef open), (bologna and ham sealed and expired) and foods that sat in a slimy liquid of an unknown composition. 3. An opened and undated bag of carrot shavings. 4. An opened and undated bag of shredded lettuce. 5. An opened and undated bag of celery stalks. Inspection of the walk- in freezer revealed opened, undated, and unsealed boxes of the following: 1. Ranch style wheat dough. 2. A package of dinner rolls. 3. A package of southern style biscuits. 4. A package of hamburger patties. 5. A package of pork cutlets. 6. A package of pastry dough. 7. A package of breakfast sausage patties. 8. Two boxes of cookie dough, 9. A Bag of blueberries. 10. A package of shrimp. 11. A package of assorted fruit chunks. A hanging utensil rack had four pitchers hanging right side up to dry, and one pitcher contained unknown debris. Under the hanging utensil rack there were two stacks of plate covers sitting upside down, and the top two plate covers contained unknown debris. DM BB reported the pitchers should be hung upside down and confirmed the dirty pitchers and plate covers. Above the food prep area, paint and calking hung from the ceiling where an air vent separated from the suspended ceiling. On [DATE] at 06:25 AM, observation tour with dietary staff CC, revealed the following areas of concerns: 1. The freezer revealed opened/undated/unsealed boxes of ranch style wheat dough and pork cutlets. These items identified during initial walk through on [DATE]. In addition, there was an opened bag of French fries opened and undated. On the cold prep table, open/unsealed packages of dehydrated mashed potatoes and pancake mix. On [DATE] at 07:04 AM, observation revealed dietary staff DD picked up a plate of food off the serving tray with her thumb over the rim of the plate and her thumb intruded into the eating surface of the plate. On [DATE] at 10:35 AM, follow up inspection with dietary staff CC revealed the dry storage had open/undated/unsealed box of carrot cake that remained on the shelf after being identified by DM BB during the initial walk through. On [DATE] at 07:05 AM, dietary staff DD reported there was no training or technique on how to serve food trays that included where to grab the rim of the plate. On [DATE] at 07:11 AM, dietary staff CC stated the facility had training that covered proper technique for serving meals. The facility's policy for Frozen Storage dated 2013, revealed all frozen food will be properly wrapped, dated, and labeled. The undated facility's policy for Dry Storage revealed Foods were to be labeled as to content and dated. Bulk foods such as rice, cookies, pasta flour, and sugar will be stored in re-closable plastic storage bags or a container and closed tight. The facility failed to store foods safely and sanitary by the staff's failure to date and reseal opened food items, failure to discard expired food items, and the failure to handle plates appropriately, to prevent the spread of food borne illnesses to the residents of the facility.

The facility reported a census of 41 residents, with 12 residents sampled, including one resident sampled for advanced directives (a written document which indicated the medical decisions for health care professionals when the person could not make their own decisions).Based on interview and record review, the facility failed to clarify Resident (R)32's advanced directives to ensure the resident had the right to formulate the wishes in the event the resident's heart stopped beating or the resident stopped breathing. Findings included: - The Electronic Health Records (EHR) documented R32 had the following diagnoses: congestive heart failure (CHF - a condition with low heart output and the body becomes congested with fluid), cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), atrial fibrillation (A-Fib - rapid, irregular heartbeat) and chronic kidney disease (a slow progression of damage to the kidneys over a long period of time which causes the kidneys to not function properly.) The [DATE] Annual Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 15, indicating intact cognition. The [DATE] Care Area Assessment (CAA) lacked documentation related to the resident's advanced directives. The [DATE] care plan documented Code Status: Full Code and instructed staff to Flag Chart: Full code. Review of the Physician Orders in R32's EHR revealed an electronic physician order dated [DATE] of Full Code (a technique of basic life support for the purpose of oxygenating the brain and heart until appropriate medical treatment can restore normal heart and ventilation action.) Further review of the resident's EHR banner listed R32 as having DNR (do not resuscitate [a medical order written by a physician that instruct health care provides not to do cardiopulmonary resuscitation (CPR]) status. Review of the scanned documents in the EHR revealed a DNR document signed by R32, a witness and physician on [DATE]. On [DATE] at 09:00 AM, Certified Nursing Aide (CNA) M reported if a resident expressed full code or DNR status, that information could be found on the banner as well as in the orders. CNA M explained that if the banner and orders weren't the same, then staff would initiate CPR until a nurse could clarify the resident's wishes and physician order. On [DATE] at 09:11 AM, Licensed Nurse (LN) G reported a resident's DNR choice should be documented on the banner, on the physician orders, and in the scanned documents. LN G explained that the nurse at the nurse's station had a list of residents with DNR orders for an easy reference. LN G reported if there was a discrepancy between the physician orders and the documents, staff would initiate CPR until the resident's wishes and the physician order could be clarified. On [DATE] at 01:27 PM, LN H reported the banner, the physician's order and the scanned documents should all match. If there was a question regarding whether to initiate CPR or not, CPR would be performed until the resident's wishes and physician order could be clarified. On [DATE] at 03:23 PM Administrative Nurse D revealed that when a resident would change their advanced directives (with or without a DNR), the form should be given to the medical records and/or social services staff, who is responsible for updating the EHR to reflect the resident's wishes and the physician order. On [DATE] at 04:23 PM, Social Services X revealed when a new advanced directive (with or without a DNR) is given to her, she would scan the document into the EHR and should change the banner to reflect the resident's decision. Social Services X reported the charge nurse on duty was responsible for changing the physician's order to reflect the resident's wishes. Review of the facility's Advanced Directives policy dated ,d+[DATE], documented the Director of Nursing Services or designee would notify the physician so appropriate orders could be documented in the EHR and the plan of care. The facility failed to ensure R32's DNR status was clearly defined and reflected in the charting system to honor R32's DNR status in the event of the resident's heart stopped or the resident quit breathing.

The facility reported a census of 41 residents, with 12 sampled, including one resident sampled for dialysis care. Based on observation, interview, and record review, the facility failed to provide Resident (R) 19 treatment consistent with professional standards of practice by not monitoring dialysis treatments appropriately by not sending or collecting the dialysis communication forms. Findings include: - The 12/13/22 Electronic Health Record (EHR) documented R19 had a diagnosis of end stage (a terminal disease because of irreversible damage to vital tissues or organs) renal (kidney) disease (ESRD). The 11/23/22 Annual Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) score of 99, and staff interview indicated moderately impaired cognition. R19 required dialysis. The 11/23/22 ADL (activities of daily living) Functional/Rehabilitation Potential Care Area Assessment (CAA), documented R19 had ESRD and received hemodialysis (procedure where impurities or wastes were removed from the blood) three times a week. The 12/01/22 Care Plan documented R19 went to hemodialysis three times a week and staff were to assess for signs and symptoms related to bleeding and infection at the dialysis shunt (tube or device implanted in the body to redirect a body fluid from one cavity to another) site. The Electronic Health Record (EHR) documented on 05/13/21, R19 had an order for hemodialysis on Monday, Wednesday, and Friday. The EHR lacked dialysis communication forms or evidence of consistent communication on dialysis days for R19. On 12/14/22 at 10:30 AM R19 sat in his room in his wheelchair following dialysis. Staff assessed the shunt site dressing on his left arm. On 12/14/22 at 10:30 AM, Licensed Nurse (LN) I stated staff should assess the resident's dressing and watch for bleeding. LN I confirmed there was no communication sheet sent or received, she stated that the dialysis center would call if anything out of the ordinary happened. LN I stated that the center would also obtain labs sometimes and send them back with R19. On 12/15/22 at 02:28 PM, Administrative Nurse D confirmed no communication other than labs would be shared with the dialysis center. Administrative Nurse D stated the dialysis center almost always drew lab and would send a copy back with R19, and the dialysis center would obtain vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) before they began dialysis. The facility's Dialysis Communication policy revised in February 2014 documented a dialysis communication form would be used to send information to and from the facility and the dialysis center. The charge nurse caring for the resident on the days of scheduled dialysis should initiate the dialysis communication form and would ensure the form was sent with the resident. Upon return the charge nurse would review the communication from and obtain necessary post dialysis assessment information. The facility failed to provide treatment consistent with professional standards of practice by the failure to prepare and collect the dialysis communication forms for R19.

The facility reported a census of 41 residents with 12 residents sampled, including two residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to obtain a physician order to appropriately administer oxygen to Resident (R)24, who used oxygen. In addition, the facility failed to properly store the resident's oxygen tubing, to prevent possible contamination of the tubing, to prevent possible respiratory complications. Findings included: - The 03/07/22 Electronic Health Records (EHR) documented that R24 had the following diagnoses: post Covid-19 condition, cough, other pneumonia (inflammation of the lungs) and pleural effusion (abnormal accumulation of fluid in the lungs). The 05/25/22 Significant Change Minimum Data Set (MDS) documented brief interview for mental status (BIMS) of seven, indicating severely impaired cognition. The resident required extensive one person assist with all activities of daily living (ADLs) except eating, which required setup. The resident received oxygen. The 11/16/22 quarterly MDS documented a BIMS of nine, indicating moderately impaired cognition. The resident received oxygen. The 05/31/22 Care Area Assessment (CAA) lacked documentation related to oxygen use. Review of the Physician Orders in R24's EHR lacked documentation of orders for oxygen use. The (9/2022 to 12/2022) Medication Administration Record (MAR) lacked documentation for the administration of oxygen or changing of the oxygen tubing or humidifier. On 12/13/22 at 08:49 AM, R24 observed resident sitting on edge of the bed wearing oxygen via nasal cannula. The oxygen tubing was undated. On 12/13/22 at 08:49 AM, the resident's wheelchair had an oxygen tank affixed to the back of the mobility chair. The oxygen tubing lacked a date. The oxygen tubing wrapped around the tank handle with the nasal cannula draped over the back of the wheelchair and no bag noted to keep it in. On 12/14/22 at 11:20 AM, R24 observed to self-propel the wheelchair in the hallway, with the oxygen tank affixed to the back, and undated oxygen tubing on the resident with no bag to place it in. On 12/15/22 at 11:35 AM, , revealed the resident's oxygen concentrator powered on, and the cannula connected and draped over the top of the machine, with no bag noted to place it in to keep it clean. On 12/15/22 at 01:27 PM, LN H revealed Activity staff Z changed all the oxygen tubing and humidifiers in the building once per week. LN H explained if a resident required oxygen, the physician should order it. On 12/15/22 at 03:35 PM, Administrative Nurse D reported if a resident was showing symptoms of hypoxia (low blood oxygen levels), they would obtain a SPO2 (a measurement of blood oxygen levels), and if the reading was less than 90% (normal is 94-99%), staff would initiate an oxygen therapy standing protocol. Administrative Nurse D reported the expectation for staff to notify the physician within 24 hours to obtain treatment orders. On 12/15/22 at 03:58 PM, Administrative Staff A stated that no policy existed to instruct staff on the procedure for oxygen delivery from tank/concentrator to the resident. Review of the 05/27/20 facility's policy for Standing Protocols documented instructions to staff to call the physician for an SPO2 (measurement of blood oxygen level) less than 90%. The policy lacked guidance to initiate or maintain oxygen use. The facility failed to obtain a physician order to appropriately administer oxygen to Resident (R)24, who used oxygen. In addition, the facility failed to properly store oxygen tubing while not in use.

The facility reported a census of 29 residents with 12 sampled, including one resident for bladder and bowel incontinence. Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent possible urinary tract infections for Resident (R) 41. Findings included: - The 12/13/22 Electronic Health Record (EHR) documented R41 had the following diagnoses: functional urinary incontinence (something keeps you from making it to the bathroom in time) and Pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of the sacrum (large triangular bone between the two hip bones). The 08/10/22 Significant Change Minimum Data Set (MDS), documented a Brief Interview for Mental Status (BIMS) score of six, indicating severely impaired cognition. R41 was always incontinent of bladder and bowel. The 11/02/22 Quarterly MDS, documented R41 had moderately impaired cognition per staff interview. R41 was always incontinent of bladder and bowel. The 08/10/22 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R41 was totally dependent on two staff for bladder and bowel incontinence. R41 was unaware of being incontinent. The 11/02/22 Care Plan documented staff assisted R41 with incontinence care every two hours and more often as needed. On 12/14/22 at 09:59 AM, Certified Nurse Aide (CNA) N and CNA O entered R41's room to assist her with repositioning and continence care. Both performed hand hygiene, donned gloves. Staff spoke with R41 to inform her of their intentions, they connected the lift to the sling behind her, and talked with her as they transferred her to her bed. They disrobed R41 and opened her brief, turned her on her right side, and CNA N cleaned bowel movement off R41, removed the dirty brief, placed a clean brief under her and assisted her to her back. CNA O cleaned the resident's front peri area and closed the brief. Wearing the same dirty gloves, CNA O and CNA N pulled up R41's pants, pulled down her shirt, and positioned her off her coccyx. CNA N positioned a blanket up on R41's front and sides. CNA O assisted with positioning the blanket, maneuvered the bed with the remote, moved the mechanical lift, touched her own hair, and then removed the dirty gloves, and used the remote to maneuver the bed to the lowest position. On 12/14/22 at 09:59 AM, CNA N confirmed she did not change her gloves or use an alcohol-based hand rub (ABHR) or wash her hands between dirty and clean tasks. She confirmed she had been educated on infection prevention but was unaware of the need to change gloves unless visibly soiled. On 12/14/22 at 09:59 AM, CNA O confirmed she did not change her gloves or use an alcohol-based hand rub (ABHR) or wash her hands between dirty and clean tasks. She confirmed staff should change gloves when moving from dirty to clean and use appropriate hand hygiene between the soiled gloves and the new gloves. On 12/15/22 at 08:45 AM, CNA O and CNA P entered R41's room to assist her with cares. Both CNA's performed hand hygiene and donned gloves. CNA P cleansed R41's front and back peri areas. She removed her soiled gloves and applied new gloves without performing hand hygiene. On 12/15/22 at 08:45 AM, CNA P confirmed she should have used ABHR or washed her hands between dirty and clean tasks, and she confirmed she had not. On 12/15/22 at 08:44 AM, Administrative Nurse D confirmed all staff had been educated on appropriate hand hygiene and she would expect them to follow the education. The August 2019, facility's Handwashing/Hand hygiene policy documented all personnel should be trained and in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. Staff should use alcohol-based hand rub (ABHR) or soap and water before moving from a contaminated body site to a clean body site during resident care. The facility failed to provide treatment and services to prevent possible urinary tract infections for R41.

The facility reported a census of 55 residents. The facility failed to provide adequate supervision to Resident (R1) identified by the facility as cognitively impaired and independently mobile, who displayed active potential elopement (an incident in which a cognitively impaired resident with poor or impaired decision making ability/safety awareness leaves the facility without the knowledge of staff) behaviors just hours before R1 left the facility overnight in a heavily populated area without staff knowledge of his/her location. The facility staff returned R1 to the facility about 18 hours later when staff located the resident over 3 miles away from the facility at a bus station (past two major rivers, railroad tracks, and several heavily motorized roadways with the highest speed limit posted 60 miles per hour). This deficient practice placed R1 in immediate jeopardy. Findings included: - Review of R1's 05/03/19 physician progress notes [REDACTED]. side uncontrolled. Review of the 05/10/19 admission Minimum Data Set (MDS) revealed the resident had a brief interview for mental status (BIMS) score of 6, indicating severe cognitive impairment. The resident had no wandering behaviors identified on the assessment. The resident received daily insulin injections and daily antidepressant medications. Review of the 05/16/19 cognitive loss/dementia Care Area Assessment (CAA) revealed the resident had cognitive and memory problems as evidenced by a brief interview for mental status (BIMS) score of less than 13. The resident had a [DIAGNOSES REDACTED]. The resident could make simple decisions, could be impulsive, and repetitive. The resident was at risk for further changes in cognition and memory. Review of the 05/16/19 activities of daily living (ADL) CAA revealed the resident had an ADL functional decline secondary to an acute on chronic illness, increased confusion, depression from spouse passing months ago, uncontrolled diabetes mellitus type 2, and a urinary tract infection [MEDICAL CONDITION]. The resident needed supervision and cueing with ADL tasks. Therapy treated the resident for ADL training and strengthening. Review of the facility Elopement Risk observation tool dated 07/28/19 revealed the resident admitted [DATE] to long term care. The resident had modified independence with cognitive skills for daily decision-making. The resident had some difficulty in new situations only and was independent with walking/mobility. The resident had no behaviors or wandering but had depression. There were no elopement/wandering interventions in place at the time of the assessment and based on the assessment the resident was not identified as an elopement risk. Review of the 05/21/19 care plan revealed the resident liked to keep herself busy walking, was alert to person, place, and situation and could make daily simple decisions. The resident could be impulsive and repetitive and had a BIMS score of less than 13. The care plan further revealed the resident was forgetful at times and staff provided cues/reminders of daily tasks. The resident had a potential risk for falls and injury due to a history of falls prior to hospitalization , weakness, impulsiveness, and cognitive/memory problems with decrease in safety judgement. The 05/21/19 care plan lacked any intervention related to elopement as of 08/01/19 at 10:30 AM. Review of the progress note dated 05/04/19 at 02:36 AM revealed Licensed Nurse (LN) D found the resident ambulating herself to the bathroom using her walker, but not wearing non-skid socks or shoes. The staff explained to her the importance and the resident verbalized understanding. The resident did not use her call light. The resident stated, I miss my (family member) so much. The resident stated she liked to go outside for a walk and to look at flowers and plants. Review of the 05/12/19 at 11:11 PM progress note revealed the resident requested to talk to someone, so she did not have to cry due to missing her spouse. Review of the 05/13/2019 at 07:41 AM progress note revealed the resident said, I'm ready to go home! Review of the 05/14/2019 at 03:40 PM progress note revealed the resident's durable power of attorney (DPOA) stated the resident wanted to go home, but he did not believe the resident could live on her own again or else the same situation that led to resident's recent hospitalization would occur again. The DPOA stated R1 would not purchase medication, leave on electricity, and would only use cold water, because it all cost too much. The DPOA stated it was not an option for R1 and her family member to live together. Review of the 05/20/2019 at 03:00 PM progress note revealed completion of a client assessment, referral and evaluation (CARE) assessment on 05/20/2019 which determined R1 functionally qualified for long-term care (LTC) services. R1 did not understand why she could not return to her home and was visibly upset. The DPOA and R1's family member explained to her that she did not take care of herself when she was at home and the family member could not take care of her. For example, R1 did not take her shots for diabetes for 2 years prior to her hospitalization . The assessor who completed the CARE assessment stated R1 masked well, but cognitively did not score well. Review of the 05/20/19 at 07:06 PM progress note revealed the resident was notified today that she would not be discharged from the facility as soon as she would like. The progress note revealed R1 was upset and did not understand the concept of everything. Review of the 05/25/19 at 11:07AM progress note revealed R1 expressed wishes to go home. Review of the 05/25/2019 at 05:29 PM progress noted revealed the resident ambulated independently throughout the facility, was tearful, and wanted to go home. Review of the 05/31/19 at 06:44 PM progress note revealed the resident stated to the nurse, I am not diabetic and neither of my family member is, I do not know why they give me insulin. The resident was very emotional and tearful. Review of the 07/25/2019 at 05:42 AM progress note revealed Licensed Nurse (LN) G discovered R1 called her family member and said she needed $60 to pay for Chinese take-out from the kitchen staff, then called him back and said it was $300. R1's stories changed multiple times and the family member came in and gave R1 $60. Review of the 07/26/2019 at 01:23 AM progress note revealed LN G noted the resident had behaviors and lied to staff and family about owing staff money, what she could and could not eat/drink, and went into shower rooms unsupervised for showers. Review of the physician progress notes [REDACTED]. The resident had dementia and an explanation about her medical condition was not retained. Review of the 07/30/2019 at 05:14 PM progress note written by Administrative Nurse B revealed the resident had only three shirts and three pants in her closet. Unidentified facility staff helped R1 find her clothes and found them packed away in luggage as well as approximately 8 snack bars. Review of the 07/30/2019 at 05:55 PM progress note written by Administrative Nurse B revealed the resident talked to family members of other residents to ask them to help her with her bags to go out to get on the bus to California. Administrative Nurse B took down the codes to the doors and alerted staff to be on the watch. Administrative Nurse B also spoke to the resident's DPOA about these concerns and whether this living environment suited her needs. Administrative Nurse B noted R1 as high functioning dementia with impulsive hoarding and packing tendencies with elopement potential. The DPOA was going to contact the family member in California to speak to R1 to let her know that was not possible. Administrative Nurse B noted R1 had $60 given to R1 by her DPOA wanted the facility to get the money back if possible to reduce risk of R1 leaving. Review of the 07/30/2019 at 06:05 PM progress noted revealed Administrative Nurse B and LN G unpacked R1's things and removed the luggage to reduce triggers. Review of the 07/30/2019 at 11:09 PM progress note revealed around 07:00 PM LN G walked by R1's room, heard R1 talking on the phone, and R1 sounded upset. At around 7:30 PM LN G started to ask staff if they saw R1 and no one saw the resident. LN G directed staff to go room to room, perimeter of the building, and drive the neighborhoods. LN G contacted Administrative Nurse B, who then contacted Administrative Staff A who came to the facility. LN G called the family member of R1 and reported to him the situation and asked if he heard from her. The family member said no. Review of the 07/31/2019 at 10:40 AM progress note written by Administrative Nurse B revealed staff notified Physician C of the elopement of R1 and R1 had not returned to the facility at that time. Per family member report, the family contacted R1 by phone at 10:10 PM on 7/30/19 and R1 said she was with a friend eating dinner, with no intention of returning to the facility. Review of the 07/31/2019 at 5:17 PM progress note revealed the resident returned to the facility at approximately 01:45 PM accompanied by Physician C, Administrative Nurse B, and Administrative Staff A. Staff placed the resident on 15-minute checks for safety/suicide watch and R1 continued to wander about the facility. The staff observed R1 talking to other residents and staff, and R1 stated I will be here less than 24 hours then my (family member) will come to get me. Review of the physician progress notes [REDACTED]. The resident left the facility, slept at a friend's house and was found on the way to a bus station. The physician discussed risks of leaving and noted R1 was not concerned. The resident missed her spouse, mentioned interest in hurting herself if made to go back to facility, but agreed to go back with knowing her family member would pick her up the next day. The resident had a BIMS of 7 and the physician noted in his/her opinion the resident was more intact than the BIMs indicated. The physician noted the resident walked well and gave great detailed information about her escapade and her reasoning. The resident had diabetes type 2, major depressive order, and noted the resident's dementia [DIAGNOSES REDACTED]. The note stated the resident eloped and returned safe to the facility. The physician note stated the resident's dementia could be quite milder than realized. Review of the 08/01/19 at 03:45 AM progress note revealed the resident ambulated independently and continued 15-minute checks due to elopement and suicidal remarks. The resident stated she will be going home at 10:00 AM to see her children, she missed them a lot, and stated she will be back soon. Observation on 8/1/19 at 08:19 AM revealed the resident walked out of his/her room (across from administrator's office) with shower items in his/her arms and walked with a staff member to the shower room just down the hallway. The resident was pleasant and walked with a waddling/shuffle-type gait (manner/style of walking) toward the shower room. When asked how she was doing the resident stated fine and continued her walk toward the shower room with the unidentified staff member. Observation on 8/1/19 at 11:46 PM revealed the resident stood at the nurse's station with her family member and talked in a pleasant manner with positive affect toward facility staff. The resident walked toward the reception desk and bowed a few forward bows and then walked out the front door of the facility with her family member. Interview with Administrative Staff A on 07/31/19 at 03:02 PM revealed the facility had an elopement on 07/30/19. Administrative Staff A said upon review of the facility camera footage the resident left the faciity on [DATE] at 7:20 PM and facility staff began looking for R1 about 20 minutes later. Administrative Staff A said R1 had her cell phone when she left and did not answer the phone when facility staff attempted to call. Administrative Staff A stated the facility staff were able to locate R1 at the bus stop on 07/31/19 attempting to buy a bus ticket, but R1 did not have enough money, so R1 called her family member who alerted the facility. Administrative Staff A said R1 threatened to kill herself with a butter knife if she had to return to the facility. Administrative Staff A stated R1's family member would come tomorrow (7/31/19) to pick R1 up and before R1 would return to the facility the staff got R1's family member on the phone to confirm what Administrative Staff A said was true. Administrative Staff A said she would stay all night (07/31/19) to watch R1 and the facility moved R1 to the room directly across from Administrative Staff A's office. Administrative Staff A said the resident never talked about leaving prior (to the elopement) or was exit seeking. Administrative Staff A said R1 did not want to go outside usually, and yesterday (07/30/19) the resident packed a suitcase, after having received her Kansas Identification card. Administrative Staff A said on 07/30/19 R1 packed all her things and asked the family member of another resident if they would carry out her suitcase. The family member of the other resident relayed that information to the facility staff and the staff unloaded the suitcase and locked the suitcase away. Administrative Staff A said at 05:45 PM the resident sat in the living room of the facility and stated to an unidentified therapist staff, she had a bus ticket to California, however the unidentified therapist staff did not do anything further with that information. Administrative Staff A stated Administrative Nurse B told staff to keep an eye on R1 due to her packed bag and talking about going to see her family member. Administrative Nurse B removed the posted door code. Administrative Staff A said she did not know the resident knew the code, but stated the resident sat in the living room area (in view of the posted door code area) regularly and R1 was a lot smarter than she came across. Administrative Staff A said the resident walked right up to the front door at 07:20 PM on 07/30/19, punched in the code and walked right out the front doors, without staff knowledge. Interview with Physician C on 07/30/19 at 03:19 PM revealed in her opinion, R1 is cognitively intact and stated the resident left the facility, went to a friend's house to sleep, went to Mass this morning, and ate at a restaurant before R1 walked herself to the bus station downtown. Physician C said R1 knew where she was because she said she knew her way around downtown and knew things about downtown area. Physician staff C said R1 planned it out and stated from her prior encounters with R1 she did not expect the resident to be cognitively intact. Physician C stated R1's BIMS score of 6 was due to a speech thing because physician C thought R1 was pretty demented, but stated no she is not. Physician C stated she wanted R1 to continue taking her medication and insulin and R1 said oh don't worry about it, I can take care of myself and I know my way around. Interview with Administrative Nurse B on 07/31/19 at 03:25 PM revealed (per review of video footage) R1 waited until no staff were in the lobby (living room area) so that the staff did not see R1 leave. Administrative Nurse B said the resident packed very well and packed her phone charger, clothes, and even snacks. Administrative Nurse B stated in nursing school she was instructed to unpack the bag and lock it up to remove possible elopement triggers. Administrative Nurse B further stated that action may have upset R1. Administrative Nurse B said she took down the door code, notified staff, unpacked R1's bag, and then received a call an hour later that R1 was missing. Review of the facility policy titled Elopement and Missing Residents, Procedures revised (MONTH) 2014 defined an elopement as an incident in which a resident with impaired decision-making ability, oblivious to their own safety needs leaves the facility without the knowledge of staff. The facility failed to provide adequate supervision to R1 who eloped from the facility on 07/30/19 and did not return until almost 18 hours later on 07/31/19. The facility removed the immediate jeopardy on 08/02/19 at 03:00 PM by implementing the following measures: 1. The facility trained all staff regarding the procedures for elopement prevention, which included how to handle an elopement that occurred. 2. The facility revised the facility policy regarding elopement to include: Sometimes screening tools fail to identify a resident at risk for elopement. Any newly identified risk for elopement (packing, talking about leaving without knowledge of scheduled outing, exit seeking) should be immediately reported to charge nurse. The Charge nurse will assess the situation and notify DON and Administrator of changes in behaviors. Resident to remain under 1:1 supervision from the time risk is identified until appropriate prevention/intervention measures have been put into place and care plan updated. 3. The facility identified one other resident at risk for elopement and had appropriate elopement interventions in place as of 08/01/19 at 11:45 AM. 4. The facility placed resident R1 on 1:1 staff supervision upon return to the facility through discharge on 08/01/19. After removal, the deficient practice remained at a scope and severity of a D.

The facility census totaled 57 residents. The sample included 3 residents reviewed for abuse. Based on observation, interview and record review, the facility failed to investigate an allegation of sexual misconduct by resident #1, who reported direct care staff member E said I have your breakfast right here and pointed to his/her genital area. Finding included: - Review of resident #1's physician's progress note dated 6/10/17 revealed the following Diagnoses: [REDACTED]. Review of the annual minimum data set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident required set up assistance for bed mobility, and eating. Review of the activities of daily living (ADL) care area assessment (CAA) dated 3/8/17 revealed the resident had the potential for functional mobility changes secondary to chronic pain, [DIAGNOSES REDACTED]. The resident completed his/her locomotion and personal care needs independently. The resident preferred to reside in long-term care (LTC) related to a history of falls at home, low back pain, and he/she fatigued easily. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 15. The resident required set up help and supervision with bed mobility, dressing, and eating. He/she required limited assistance of one staff member for transfers. Review of the care plan last reviewed on 6/20/17 revealed the resident fractured his/her right hip. The care plan directed the staff to assist the resident with transfers and ambulation, and assess and manage his/her pain as directed by the physician. Review of the undated certified nursing assistant (CNA) care plan revealed the resident requested a same sex staff member for all personal care and bathing. Review of an email provided by the facility sent by licensed nurse F to administrative nurse B revealed on May 15th, 2017 at 2:28 a.m. staff B's email read resident #1 stated direct care staff E made him/her uncomfortable when he/she brought a room tray to his/her room. The resident stated staff E had no manners, does not know how to treat people, does not know how to talk to people, moved to fast and was not careful, and he/she does not want staff E in his/her room at any time. Staff B responded to the email on May 15th, 12:33 p.m. Staff B wrote this calls for a teachable moment, there are forms at the nurse's station for this purpose, please meet with staff E regarding this issue and how he/she should approach and communicate with the residents, staff E signs and you sign it then staff E gets a copy and I get a copy. Please let him/her understand that this is not a write up, but for him/her to learn. Further review of the email revealed a response from staff F on May 17th, 2017 at 7:28 p.m. Staff F wrote. I can try, however anytime I have tried to direct staff E, he/she interrupts and says, I know, I know or Duh! He/she was very sarcastic and he/she found him/her difficult to work with. Observation on 6/21/17 at 8:29 a.m. revealed the resident sat in bed, ate breakfast and watched TV. The resident expressed his/her wants and needs without difficulty. The resident was pleasant and conversed with a guest in his/her room. Interview on 6/21/17 at 8:29 a.m. with resident #1 revealed he/she did not want to cause any trouble or upset anyone and denied the allegation of abuse. Interview with direct care staff D on 6/21/17 at 5:54 a.m. revealed resident #1 reported direct care staff E was creepy and requested staff E not provide care to him/her ever again. Staff D revealed the nurse on shift assigned resident #1 to a same sex staff member each time staff E worked. Interview with direct care staff E on 6/21/17 at 10:53 a.m. revealed I had no knowledge of the allegation of sexual misconduct or being talked to about the incident. Staff E revealed licensed nurse F informed him/her the resident was weirded out by him/her and the resident does not want him/her back in the room. Staff E revealed licensed nurse F directed him/her not to provide care for resident #1 and administrative nurse B had not spoken to him/her in regards to the resident's allegation of abuse. Staff E confirmed he/she worked until June 1st when he/she was suspended through June 6th, 2017 pending the outcome of an investigation regarding an allegation of abuse filed by resident #2. Review of the notarized witness statement dated 6/21/17 in regards to resident #1's allegation of sexual misconduct on 5/15/17 from direct care staff E revealed I entered resident #1's room to make sure the lunch tray order had been taken. The resident informed me that it had been. I then exited the room. Later that day my licensed nurse F reported to me that the resident was uncomfortable or weirded out by me so I was not to return to care for that resident. No further contact between me and the resident has occurred. Interview with social service staff C on 6/21/17 at 9:16 a.m. revealed the resident requested to speak with him/her in regards to a complaint about the direct care staff E. The resident revealed staff E pointed to his/her genital area and stated, I've got your meal right here. Staff C revealed he/she reported resident #1's concern to administrative nurse B immediately. Staff C revealed he/she only investigated missing items or money and all clinical investigations or complaints were handled by administrative nurse B. Interview with administrative staff A on 6/21/17 at 7:53 a.m. revealed he/she knew resident #1 reported direct care staff E made inappropriate gestures toward his/her genital area and stated, I have your breakfast right here. Staff A revealed the resident reported the complaint to social service staff C a couple of weeks ago. Staff A revealed the facility did not have an investigation report regarding the allegation of abuse. Interview with administrative nurse B on 6/21/17 at 9:49 a.m. revealed he/she received an email on May 15th, 2017 regarding the incident and received a verbal complaint from social service staff C on May 16th, 2017. Staff B revealed the resident reported direct care staff E made him/her feel uncomfortable when he/she brought in the room tray. The resident reported staff E had no manners, does not know how to treat or talk to people, moved too fast, was not careful, and the resident does not want staff E in his/her room at any time. Interview with administrative nurse staff B on 6/21/17 at 9:49 a.m. revealed he/she spoke with the resident regarding his/her allegation of abuse. Staff B revealed the resident told him/her that he/she just did not like the person. Staff B confirmed he/she chose not to investigate the allegations of abuse and failed to report the allegation to the State mandated reporting agency because he/she does not think direct care staff E's behavior constituted abuse. Staff B revealed he/she spoke with staff E regarding the incident with resident #1 and gave him/her a verbal warning with administrative staff G as a witness. Staff B confirmed he/she had no record of the meeting or disciplinary action discussed with staff E. Staff B confirmed the facility failed to notify the resident #1's family or physician of the allegation of abuse. Review of the witness statement written and notarized on 6/21/17 by administrative nurse B revealed On May 15th at 2:28 a.m. licensed nurse F communicated with me via email regarding a complaint from resident #1 the issues were as followed: direct care staff E has no manners, he/she does not know how to treat people, moves to fast, and is not careful and does not want him/her in the room until further notice. I responded to licensed nurse F to sit him/her down and do a teachable moment and document addressing the following: complaints this was on May 15th at 12:33 p.m. on May 17th from licensed nurse F's response I concluded that the Human Resource (HR) staff G and myself needed to talk to this employee. I had to mention on May 16th approximately. after lunch I spoke to the resident #1 and questioned him/her regarding direct care staff E's behavior, resident #1 basically repeated the same issues of being rushed all the time and rude when talking to people. I asked if direct care staff E has been back to take care of you, resident #1 stated, He/she wouldn't because the nurse told him/her to. The same day at around 4 p.m. We, HR staff G and I, called direct care staff E in for his/her side of the events and revealed the above complaints for the resident. Staff E was unaware of what resident #1 was talking about so we had to mention the resident's name. Staff E denied remembering ever being rude, understood and took responsibility that resident's perception was reality. He/she will be more aware of his/her demeanor and [MEDICAL CONDITION] of his/her actions. The 30 minute discussion with direct care staff E was considered a verbal warning and was not documented. Review of the time sheets for staff E revealed his/she worked the following days after resident #1 reported the alleged abuse: 5/15-5/16/17, 5/18-5/22/17 and 5/25-5/30/17. Review of the Abuse policy dated 12/10 revealed the alleged perpetrator would be clocked out and not to return to the building pending the results of the investigation. The staff were directed to call the administrator and/or Director of Nursing (DON) immediately. Review of the abuse investigation policy last revised 4/14 revealed all reports of resident abuse, neglect, and injuries of unknown source were promptly and thoroughly investigated by facility management. The individual conducting the investigation would interview the person reporting the incident, interview any witness to the incident, interview the resident, interview other residents to whom the accused employee provided care or services and review all events leading up to the alleged incident. The results of the investigation were recorded on approved documentation forms and reported to the state mandated reporting agency. The facility failed to investigate an allegation of staff-to-resident abuse reported by resident #1 and failed to provide protection for residents, from the alleged perpetrator until the facility investigated the allegation.

The facility census totaled 57 residents. Three residents were reviewed for falls. Based on observation, interview and record review, the facility failed to investigate causal factors of falls and implement appropriate interventions to prevent further falls which resulted in significant injuries for 2 of the 3 residents reviewed for falls. (#5-laceration with sutures and #6- femur fracture and brain bleed) Findings included: - Review of resident #6's history and physical dated 6/18/17 revealed the following Diagnoses: [REDACTED]. Review of the significant change minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 3 (severely impaired cognition). The resident required extensive assistance of one staff member for bed mobility, transfers, and toileting. The resident required limited assist of one staff member for walking in the corridor, locomotion on the unit and the resident had frequent bowel and bladder incontinence. Review of resident #6's quarterly MDS dated [DATE] revealed a BIMS score of 3. The resident required extensive assist of one staff member for bed mobility, transfers, and toileting. The resident required limited assistance of one staff member for walking in the corridor, locomotion on the unit and the resident had frequent bowel and bladder incontinence. Review of the cognitive loss care area assessment (CAA) dated 10/11/16 revealed the resident had cognitive and memory deficit as evidenced by a BIMS score which indicated the resident had severe intellectual impairment. The resident exhibited a slow thought process, slow speech, and slowed response time. Review of the activities of daily living (ADL) CAA dated 10/11/16 revealed resident #6 had self-care deficit secondary to muscle weakness, impaired functional mobility, problems with sequencing with ADL tasks, and progression of his/her dementia. Review of the Urinary CAA dated 10/11/16 for resident #6 revealed the resident had urinary incontinence and required staff assist with toileting needs and hygiene. Review of the falls CAA dated 10/11/16 revealed the resident had a history of [REDACTED]. Resident #6 required assist of one staff member for transfers and locomotion and frequently did not alert staff for assistance which increased his/her risk for falls. Review of resident #6's ADL care plan directed the staff to provide the resident with minimal to limited assist of one staff member with dressing, transfers, and locomotion in the wheelchair. Review of resident #6's urinary incontinence care plan dated 10/12/16 directed the staff to remind the resident to call for assistance with toileting, assist the resident with toileting every 1-2 hours while awake, toilet the resident prior to going to bed, and toilet the resident when awake or every 1 to 3 hours during the night to reduce incontinence episodes. Review of the fall care plan dated 10/12/16 revealed the resident had a history of [REDACTED]. to alert staff for the resident's need for assistance. Further review of the care plan revealed the facility updated the care plan on 4/7/17. The care plan directed the staff to ensure the resident had non-skid strips on the floor by the bed. The facility updated the care plan on 6/14/17 to read non-skid strips to the floor, currently waiting for the resident to return from the hospital to see if his/her bed needed to be rearranged for transfer status, then apply strips as needed. The facility updated the care plan on 6/15/17 to read sensor alarm on while in bed to alert staff for the resident's need for assistance. Review of resident #6's fall risk assessment dated [DATE] revealed the resident had a score of 15 (indicated high risk for falls). Review of resident #6's progress notes dated 4/14/17 at 7:15 p.m. revealed a visitor informed the staff resident #6 was on floor in his/her room. Staff found the resident on the floor lying on his/her back next to the bed. The resident was fully dressed with shoes on and the wheelchair within reach. The resident's neurologic check revealed no abnormal findings and the resident showed no changes in his/her range of motion (ROM) and denied pain or discomfort. The resident was could not verbalize how he/she ended up on the floor. Review of the accident investigation dated 4/14/17 at 7:15 p.m. revealed the failed to identify the causal factors of the fall and implement a new intervention to reduce the resident's risk for further falls. Review of the progress note dated 5/20/17 at 8:45 p.m. for resident #1 revealed a certified medication aide (CMA) passed the medications and heard a crashing noise coming from the resident's room. The staff entered the resident's room to investigate and observed the resident lying on his/her back in front of the closet. The resident told the staff he/she got up to cook some breakfast. Resident #6 had a small bluish colored bruise on the outer right arm by his/her shoulder blade, a hematoma to the left inner elbow, and a 0.5 centimeter (cm) x 0.4 cm abrasion to the right knee. The resident's neurologic checks and ROM were within normal limits. The facility failed to complete an accident investigation for the resident's fall on 5/20/17 at 8:45 p.m., failed to determine causal factors of the fall, and failed to implement a new intervention to reduce the resident's risk for further falls. Review of the accident investigation dated 6/10/17 at 11:50 p.m. for the fall documented on 6/12/17 at 11:35 a.m.) revealed the facility failed to determine the casual factors of the fall and the facility determined they would wait for the resident to return from the hospital and determine a new intervention to be implemented. The resident returned to the facility on [DATE] and the facility implemented a sensor alarm to the resident's bed to alert staff to the resident's attempts at unassisted transfers. Review of resident #6's progress note dated 6/12/17 at 12:25 a.m. revealed the charge nurse found the resident on floor in hallway next to his/her room. Resident #6 laid on his/her right side with his/her legs out straight. The resident had obvious bleeding to right side of his/her head. The charge nurse applied pressure to the resident's head. The charge nurse observed a large hematoma (a solid swelling of clotted blood within the tissues) to the right temple and the resident had a laceration to right side of his/her scalp. The charge nurse contacted the resident's Durable Power of Attorney (DPOA) and the DPOA requested the facility send the resident be sent to hospital for evaluation. The charge nursed contacted the primary care physician (PCP) and received an order to send the resident to the hospital for evaluation and treatment as indicated. Review of resident #6's progress note dated 6/12/17 at 6:41 a.m. revealed the hospital informed the facility the resident fractured his/her right femur (the bone of the thigh) and sustained a subdural hematoma (a collection of blood on the surface of the brain). Review of the resident's progress note dated 6/15/17 at 4:20 p.m. revealed the resident readmitted to the facility with orders for skilled therapy to regain his/her prior level of function. Review of resident #6's progress note dated 06/18/2017 at 12:48 p.m. the resident passed away. The facility notified the PCP and received the order to release the resident's remains to the mortuary. The DPOA and Hospice team informed. Interview with licensed nurse H on 6/26/17 at 10:25 a.m. revealed the charge nurses were responsible for the completion of the incident report and updating the care plan immediately after a fall. Staff H did not know who completed the fall investigation report. He/she revealed the facility had a fall meeting once a week and the administrative nurse team discussed the falls, determined the root cause for the falls and determined if the intervention put in place at the time of the fall was appropriate or needed to be changed. Interview with administrative staff A on 6/26/17 at 10:08 a.m. revealed the fall occurred on 6/11/17 at 11:50 p.m. but recorded in the resident's record on 6/12/17 at 12:35 a.m. He/she revealed the facility watched the video footage of the fall and determined the resident ambulated into the hall way independently. The resident stepped on part of his/her hospital gown and lifted his/her foot to pull the gown out and fell . Staff A revealed the resident was last toileted at 9:45 p.m. and the resident did not put on his/her call light for assistance. Interview with administrative nurse B on 6/21/17 at 1:48 p.m. revealed the facility determined the casual factor of the fall on 6/11/17 was the resident self-transferred him/herself without the assistance of staff and ambulated into the hallway. Staff B revealed the risk management team met once weekly to discuss the falls and determined the root cause of each fall and updated the care plan. Staff B revealed he/she believed the staff followed the care plan and had all the planned interventions in place at the time of resident #6's fall. Interview with administrative nurse B on 6/26/17 at 12:56 p.m. revealed the resident had the non-slip strips to the floor in front of his/her bed prior to the fall on 4/14/17. He/she revealed the facility believed the intervention was appropriate and decided to continue the intervention and failed to implement a new intervention for the resident. He/she confirmed the facility failed to complete an incident report and accident investigation, failed to determine the root cause of the fall and failed to implement a new intervention to reduce the resident's risk for falls. Staff B confirmed the policy for falls directed the staff to investigate all falls and implement new interventions after each fall to reduce the resident's risk for falls. Staff B revealed all the falls were tracked and trended and reviewed with the Quality Assurance team which included the medical director at the monthly meeting. Interview on 6/26/17 at 2:42 p.m. with physician I revealed the facility's policy was to investigate each fall and attempt to determine the cause and implement new interventions to help reduce the resident risk for further falls and injury related to falls. Physician I revealed the facility tracked and trended all falls and he/she reviewed them monthly in the facility's Quality Assurance meeting. Review of the facility's Falls and Fall Risk Managing policy last revised 12/2007 revealed: the staff will identify interventions related to the resident's specific risk and causes to try and prevent the resident from falling and try to minimize complications from falling. If falls re-occurred despite initial interventions, staff would implement additional or different interventions or indicate why the current approach remained relevant. The facility failed to thoroughly investigate falls to determine the root cause and implement new intervention after each fall to reduce the resident's risk for further falls which resulted in a fall with fractured femur and a subdural hematoma for resident #6. - Review of resident #5's physician progress notes [REDACTED]. Its primary feature is cognitive decline, which can lead to hallucinations, as well as varied attention and alertness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness). Review of resident #5's quarterly minimum data set ((MDS) dated [DATE] revealed the resident had short and long-term memory loss with moderately impaired decision making ability. The resident required extensive assist of one staff member for transfers, dressing, and toileting. The resident required limited set up help and supervision of one staff member for locomotion on and off the unit and had frequent bowel and bladder incontinence. The MDS revealed the resident had falls with injuries since the last assessment. Review of resident #5's significant change MDS dated [DATE] revealed the resident had short and long-term memory loss with severely impaired decision making ability. The resident required total assist of two staff members for transfers. The resident required extensive assist of two staff members for bed mobility, dressing, and locomotion on and off the unit. The MDS indicated the resident had falls with injury since the last assessment. Review of the cognitive loss care area assessment (CAA) dated 3/22/17 revealed the resident demonstrated difficulty following verbal and non-verbal direction secondary to progression of dementia and the risk for further cognitive and functional mobility changes as the dementia progressed. Review of urinary incontinence CAA dated 3/22/17 revealed the resident had incontinence of bowel and bladder secondary to the need for staff assistance with all transfers, and clothing management. The Staff checked and changed the resident routinely. Review of the fall CAA dated 3/22/17 revealed the resident had increased risk for falls related to a history of multiple falls despite interventions, cognitive impairment and poor safety awareness. Review of the activities of daily living (ADL) CAA care plan dated 4/18/16 directed the staff to check and change the resident every two hours during the day and every 1-3 hours during the night, transfer the resident using two staff members and mechanical lift, and place the resident in an electric recliner for naps and rest time. Review of resident #5's falls care plan last reviewed on 3/27/17 directed the staff to transfer the resident the mechanical lift and two staff, keep the bed in the lowest position, and place a concave mattress on resident #5's bed, increase the resident's supervision when he/she was agitated or restless, and ensure the resident was in an attended area at times to prevent falls. Further review of the falls care plan revealed the facility failed to implement a new intervention to the resident's care plan after the resident rolled out of bed on 6/4/17 and 6/10/17. The staff failed to update the care plan on 5/12/17 with the intervention for the bed alarm and staff used the same intervention for the fall on 5/28/17. The staff failed to put the bed alarm on the care plan after the 5/28/17 fall. Review of resident #5's fall risk assessment dated [DATE] revealed score of 19 (high risk for falls). Review of the undated certified nursing assistant (CNA) care plan directed the staff to transfer the resident with assist of two staff members and a mechanical lift, propel him/her in the wheelchair, the resident had a high risk for falls, and to keep the resident in the common areas for visual monitoring. Review of the progress note dated 5/12/17 at 7:45 a.m. revealed staff found the resident on the floor in his/her room. The staff documented the resident had a small skin tear to the left middle finger. The facility staff documented a bed alarm to be obtained and placed on the bed. Review of the resident's accident investigation for the fall dated 5/12/17 at 6:30 a.m. revealed the facility determined the resident self-transferred his/herself and implemented a bed alarm and as the new intervention to prevent further falls. Review of resident #5's progress note dated 5/28/17 at 4:08 p.m. the staff observed the resident on the floor next to his/her bed. The resident sustained [REDACTED]. The resident stated I fell out of the bed. The staff documented the plan to initiate a body alarm. Review of resident #5's accident investigation for the fall dated 5/28/17 at 3:15 p.m. revealed the facility determined the resident's confusion and restlessness as the root cause of the fall and implemented a bed alarm as the new intervention to prevent further falls. Review of resident #5's progress note dated 6/04/17 at 5:37 p.m. revealed the staff observed the resident on the on the fall mat at 2:30 p.m. with no injuries. The staff documented the resident had a bed alarm in place and it failed to sound and determined the alarm was deactivated. Review of the accident investigation report dated 6/4/17 at 2:30 p.m. revealed the facility determined the bed alarm not being turned on as the root cause of the fall. The facility failed to initiate a new intervention and document the facility had initiated the bed alarm in the past 7-10 days. Review of the resident's progress note dated 6/10/17 at 2:40 p.m. revealed the resident fell at 2:20 p.m. The staff observed the resident with his/her head in a pool of blood lying on the his/her right side on the fall mat in front of his/her bed. The resident stated I fell out of my bed and hurt my head! The physician gave orders to send the resident to the emergency department (ED) to have the laceration assessed and stitched if needed. Review of resident #5's progress note dated 6/10/17 at 8:35 p.m. revealed the resident returned from the ED via emergency medical services (EMS). The resident received two sutures to his/her right eyebrow. The resident had a skin tear to his/her right elbow covered with a bandage. The resident received x-rays to rule out possible fracture to the anterior and posterior ribs. Review of the cervical computed tomography (CT-a diagnostic procedure) ordered by the physician on 6/10/17 revealed a suspected left anterior (front) first rib fracture with a possible fracture of a right posterior (back) rib fracture. The resulted identified a suspected incomplete imaged sternal (chest bone) fracture and request a CT imaging of the chest with possible contrast (a substance used to enhance structures or fluids in the body). Further review of resident #6's record revealed the facility failed to follow the request for the chest CT. Review of the accident investigation report dated 6/10/17 at 2:20 p.m. revealed the facility determined the resident's lack of a bed rail as the casual factor of the fall. The facility implemented a plan to add bed rails to the resident's bed and a fall mat as the new intervention to prevent the risk of further falls. Observation on 6/26/17 at 3:45 p.m. revealed resident #5 positioned in the center of a concaved mattress (hollowed or curved inward) with a fall mat to floor next to the bed. Direct care staff J and direct care staff K entered the room and transferred the resident to the Broda chair (specialized wheelchair) with a mechanical lift and placed his/her feet on the foot pedal for safety and positioning. Interview on 6/26/17 at 3:22 p.m. with direct care staff J revealed the resident no longer required a bed alarm and used a concave mattress to reduce his/her risk for falls. He/she believed the facility removed the bed alarm a month or so ago but did not know the exact date or why. Staff J revealed the direct care staff did not have access to the resident's official care plan but the facility produced a CNA care plan for the direct care staff. Staff J revealed the direct care staff would look at the CNA care plan for guidance of the resident's fall interventions. Interview on 6/26/17 at 2:42 p.m. with administrative nurse B revealed the resident fell multiple times and the staff had exhausted all interventions to keep him/her from falling. Staff B revealed the staff failed to update the care plans correctly on 6/26/17 and the required further education to determine the root cause and implement new interventions to prevent further falls. Interview on 6/26/17 at 2:42 p.m. with physician I revealed the facility's policy was to investigate each fall and attempt to determine the cause and implement new interventions to help prevent the resident's risk for further falls and injury related to falls. Physician I revealed the facility tracked and trended all falls and he/she reviewed them monthly in the facility's Quality Assurance (QA) meeting. Interview on 6/27/17 at 9:57 a.m. with administrative staff A revealed the QA team met monthly and reviewed all the falls in the building for tracking and trends. Staff A revealed the facility had not identified the failure to determine the root cause and implement a new intervention after each fall as a problem. Review of the facility's Falls and Fall Risk Managing policy last revised 12/2007 revealed: staff would identify interventions related to the resident's specific risk and causes to try and prevent the resident from falling and try to minimize complications from falling. If falls re-occurred despite initial interventions, staff would implement additional or different interventions or indicate why the current approach remained relevant. The facility failed to thoroughly investigate falls to determine the root cause and implement new interventions after each fall to reduce the resident's risk for further falls which resulted in a fall which resulted in laceration that required sutures for resident #5.