Every finding on record at Kansas Christian Home

Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to the residents of the facility appropriately to prevent the potential for food borne bacteria. Findings included:- During an initial tour of the kitchen on 05/12/26 at 10:07 AM, the following areas of concern were noted: 1. The reach-in freezer had food debris on the bottom shelf. 2. The two-doored reach-in refrigerator had dried-on fluids on the bottom shelf. 3. The bottom shelf of the preparation table, holding clean pots and pans, had food debris. 4. There were 13 discolored cutting boards with deep grooves throughout. 5. The trash can by the dish washing sink had dried-on food and fluids on the lid. 6. An unopened box containing 12 packages of eight hot dog buns each, rested directly on the floor of the walk-in freezer. 7. The floor in the dry supply room was completely worn down to the subflooring in several areas of the room. On 05/14/26 at 07:15 AM, Dietary Staff BB confirmed the noted areas were in need of cleaning or repair. The facility policy for Cleaning and Sanitizing, undated, included: All new hires and current employees will be educated on the importance of proper methods for cleaning and sanitizing to prevent the potential for food borne bacteria.

Based on observation, record review, and interview, the facility failed to ensure residents received assistance with activities of daily living (ADL) including facial hair removal for Resident (R) 21 and assistance with nail care for R45, R6, R16, and R18. Findings included:1. R21's Electronic Medical Record (EMR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and needed assistance with personal care. R21's 08/20/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of seven, which indicated severely impaired cognition. R21's MDS documented that she had no rejection of care during the observation period. R21's MDS documented that she required maximal assistance with personal hygiene. R21's 08/25/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R21 is a new admission after hospital stay. She has been working with therapy to improve her ability. She often overestimates her ability and will become overwhelmed with too many requests during dressing. R21's Care Plan, dated 08/26/25, documented staff were instructed to provide supervision/touching assistance of one staff to complete personal hygiene. On 05/12/26 at 03:00 PM, R21 was seated in a chair in the television lounge watching tv and reported she had not eaten since yesterday. R21 had several long white facial hairs approximately half inch on her chin. On 05/13/26 at 09:24 AM, R21 was in the therapy room seated on the bench, working with therapy. Several long white facial hairs remained on her chin. On 05/14/26 at 08:39 AM, R21 was in the dining room eating her breakfast. Several long white facial hairs remain on her chin. On 05/13/26 at 09:49 AM, Certified Nurse Aide (CNA) M reported that typically we should look at the resident's facial hair and nails every morning and complete that during morning care. On 05/13/26 at 11:13 AM, Licensed Nurse (LN) H reported the CNA should complete nail care and facial hair removal for non-diabetic residents. 2. R45's EMR recorded diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R45's 11/04/25 admission MDS documented a BIMS of 15, indicating intact cognition. R45's MDS documented that he had no rejection of care during the observation period. R45's MDS documented that he required moderate assistance with personal hygiene. R45's 11/11/25 Functional Abilities (Self-Care and Mobility) CAA documented R45 was a new admission from the hospital. He had weakness and had required additional assistance with his activities of daily living. R45's Care Plan, dated 05/07/26, documented staff were instructed to provide maximal assistance of one staff to complete personal hygiene. On 05/12/26 10:38 AM, R45 had long fingernails on all his fingers, he reported that he can't cut them himself and the staff should cut them on bath day. R45 reported he did not like his nails being so long. On 05/13/26 at 07:48 AM, R45's fingernails remained long. He reported he had a bath scheduled that day. Nail clippers were observed on the TV stand not in reach of him. On 05/14/26 at 07:55 AM, R45 was in therapy and his fingernails remained long. On 05/14/26 at 09:25 AM, CNA N reported that she did not give R45 his shower on 05/13/26 but that CNA O did. CNA N reported she did not notice R45's fingernails being long. On 05/14/26 at 10:24 AM, Administrative Nurse D revealed she expected the staff to shave residents every shower day or as needed. Administrative Nurse D said she expected the nurses to cut the diabetic residents' fingernails, and the CNAs would let the nurse know when that was needed. 3. R6's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R6's Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. She required partial to moderate staff assistance with personal cares. R6's Activity of Daily Living (ADL)/Functional Abilities Care Area Assessment (CAA), dated 12/24/25, did not trigger. R6's Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. She required substantial to maximal staff assistance with personal cares. R6's Care Plan, revised 03/24/26, instructed staff that she required substantial to maximal staff assistance with ADLs. R6's EMR from 04/01/26 through 05/11/26 (41 days), revealed she required moderate to dependent staff assistance with personal hygiene. On 05/12/26 at 01:58 PM, R6 sat at the dining table in her wheelchair. She had a dark brown, dried-on substance underneath her fingernails. On 05/13/26 at 08:57 AM, R6 sat at the dining table in her wheelchair eating breakfast. She continued to have a dark brown, dried-on substance underneath her fingernails. On 05/13/26 at 11:45 AM, Certified Nurse Aide (CNA) M stated residents' fingernails would be cut on their shower days. CNA M confirmed R6's fingernails were long and dirty. On 05/13/26 at 02:47 PM, Certified Medication Aide (CMA) R stated the staff would clean and trim residents' fingernails on their shower days. CMA R stated R6's family would often take her out of the facility to have her nails done. On 05/14/26 at 09:09 AM, Administrative Nurse D stated it was the expectation for staff to trim and smooth residents' fingernails on their shower days and as needed. 4. R16's EMR documented a diagnosis of intellectual disability (a significantly below-average score on a test of mental ability or intelligence and limitations in the ability to function in areas of daily life). R16's Annual MDS, dated 10/17/25, documented the staff assessment for cognition revealed severe cognitive impairment. He required substantial to maximal staff assistance with personal hygiene. R16's Activity of Daily Living (ADL)/Functional Abilities Care Area Assessment (CAA), dated 10/17/25, did not trigger. R16's Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. He required substantial to maximal staff assistance with personal hygiene. R16's Care Plan, revised 04/11/26, instructed staff he was dependent on staff for ADLs. R16's EMR from 04/01/26 through 05/11/26 (41 days), revealed he required partial/maximal to dependent staff assistance with personal hygiene. On 05/12/26 at 10:09 AM, R16 sat in the commons area. He had long, dirty fingernails. On 05/13/26 at 07:20 AM, R16 sat at the dining table. He continued to have long, dirty fingernails. On 05/13/26 at 11:45 AM, Certified Nurse Aide (CNA) M stated residents' fingernails would be cut on their shower days. CNA M confirmed R16's resident's fingernails were long and dirty. On 05/13/26 at 02:47 PM, Certified Medication Aide (CMA) R stated the staff would clean and trim residents' fingernails on their shower days. On 05/14/26 at 09:09 AM, Administrative Nurse D stated it was the expectation for staff to trim and smooth residents' fingernails on their shower days and as needed. 5. R18's EMR documented a diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R18's Annual Minimum Data Set (MDS), dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. He was dependent on staff for personal hygiene. R18's Activity of Daily Living (ADL)/Functional Abilities Care Area Assessment (CAA), dated 12/17/25, did not trigger. R18's Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed severe cognitive impairment. He was dependent on staff for personal hygiene. R18's Care Plan, revised 03/12/26, instructed staff that he was totally dependent on staff for personal hygiene. R18's EMR from 04/01/26 through 05/11/26 (41 days), revealed he required partial/maximal to dependent staff assistance with personal hygiene. On 05/12/2 at 08:07 AM, R18 sat at the dining table. He had long, dirty fingernails. On 05/13/26 at 07:20 AM, R18 sat at the dining table. He continued to have long, dirty fingernails. On 05/13/26 at 11:45 AM, Certified Nurse Aide (CNA) M stated residents' fingernails would be cut on their shower days. CNA M confirmed that R18's resident's fingernails were long and dirty. On 05/13/26 at 02:47 PM, Certified Medication Aide (CMA) R stated the staff would clean and trim residents' fingernails on their shower days. On 05/14/26 at 09:09 AM, Administrative Nurse D stated it was the expectation for staff to trim and smooth residents' fingernails on their shower days and as needed. The facility did not provide a policy for ADLs, as requested.

Based on interview and record review, the facility failed to ensure informed consent including purpose, risks versus benefits, and expected therapeutic benefits for the use of antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), anti-anxiety (medication used to treat symptoms of anxiety, hypnotics (a class of medications used to induce sleep) and antidepressant (a class of medications used to treat mood disorders) medications for R4. This placed the resident at risk for adverse side effects of the medications and uninformed decisions. Findings included:- R4's Electronic Medical Record (EMR) documented the following diagnoses: anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods) and obsessive-compulsive disorder (OCD- an anxiety disorder characterized by recurrent and persistent thoughts, ideas, and feelings of obsessions severe enough to cause marked distress, consume considerable time, or significantly interfere with the resident's occupational, social, or interpersonal functioning). R4's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. R4 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (medication used to treat symptoms of anxiety), antidepressant (a class of medications used to treat mood disorders), and hypnotic medications during the assessment period. R4's Psychotropic Drugs Care Area Assessment, (CAA), dated 05/30/25, documented R4 received several psychotropic medications which the pharmacy consultant and physician reviewed monthly, to maintain therapeutic uses. R4's Quarterly MDS, dated [DATE], documented she had a BIMS score of seven, indicating severe cognitive impairment. R4 received antipsychotic, antianxiety, antidepressant and hypnotic medications during the assessment period. R4's Care Plan, revised 03/02/26, instructed staff to monitor and report any adverse side effects from the psychotropic medications. R4's EMR documented the following Physician's Orders (PO): Clonazepam (a benzodiazepine used to treat the symptoms of anxiety), 2 milligrams (mg), every bedtime (QHS), by mouth (po), for a diagnosis of bipolar disorder, ordered 03/02/26. Clonazepam, 1 mg, every day (QD), po, for a diagnosis of bipolar disorder, ordered 03/02/26. Duloxetine (an antidepressant medication), 60 mg, QD, po, for a diagnosis of bipolar disorder, ordered 03/02/26. Seroquel (an antipsychotic medication), 100 mg, at 02:00 PM, po, for a diagnosis of bipolar disorder, ordered 03/02/26. Seroquel, 150 mg, every morning (QAM), po, for a diagnosis of bipolar disorder, ordered 03/02/26. Seroquel, 300 mg, QHS, po, for a diagnosis of bipolar disorder, ordered 03/02/26. Sertraline (an antidepressant medication), 75 mg, QAM, po, for a diagnosis of OCD, ordered 03/02/26. Zolpidem (a hypnotic, used to induce sleep), 12.5 mg, QHS, po, for a diagnosis of insomnia, ordered 03/02/26. Ativan (an antianxiety medication), 0.5 mg, four times per day, as needed (PRN), po, for a diagnosis of anxiety, ordered 03/07/26. Lorazepam (an antianxiety medication), 1 mg, Q 3 hours, po, PRN for a diagnosis of anxiety, not to exceed six doses per day, ordered 03/02/26. R4's Medication Administration Record (MAR) for April and May 2026, revealed staff administered medications, as ordered. R4's EMR lacked evidence of psychotropic medication consent including the risks vs benefits and the expected therapeutic benefit of the medications, as required. On 05/13/26 at 09:37 AM, Administrative Nurse D stated R4's EMR lacked signed consent forms for his psychotropic medications. The facility policy for Psychotropic Medication Use, undated, included: Psychotropic medications will only be initiated after an informed consent is completed and signed. A new consent will be completed with each dosage change.

Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 38 received the opportunity to participate in the care planning process when staff failed to invite R38, or their responsible party to the care pan meetings. Findings included:- R38's Electronic Medical Record (EMR) revealed diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). R38's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R38's MDS documented that she required maximal assistance with activities of daily living (ADLs). R38's MDS documented that she had no behaviors. R38's Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA), dated 02/13/26, documented R38 participated with restorative programs. She made some improvements over the look back period. R38's Care Plan, dated 09/17/24, documented staff would encourage R38 to make her own decisions and will provide support as needed. R38's Care Conference Note, dated 09/10/25, at an undocumented time documented the quarterly care plan meeting. Some follow up with a meeting from last week. R38 reported that her brother was coming to help her with sorting her papers. R38 had no concerns with any other department and reported she liked it at the facility and received good care. R38's EMR lacked evidence of a care plan conference after 09/10/25. On 05/12/26 at 08:13 AM, R38 reported she was unsure about the last time she attended or was invited to a care plan meeting. On 05/13/26 at 09:00 AM, R38 was in her room seated up in her bed watching television. On 05/14/26 at 09:16 AM, Social Service Designee (SSD) X reported that an email would be sent out to the resident's durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to) and the resident was given an invitation by hand to attend the care plan meeting. SSD X reported that she believed Administrative Nurse E would document a note in the EMR when a care plan meeting was held. On 05/14/26 at 09:20 AM, Administrative Nurse E reported in the past EMR, the care plan meeting would be documented in a care conference note and in the new EMR a care plan meeting would be documented in a progress note. On 05/14/26 at 9:40 AM, Administrative Nurse E reported the last care conference note that she could locate in EMR was on 09/10/25. Administrative Nurse E expected the care plan meetings to be offered and completed every three months. The facility's undated policy Care Planning -Interdisciplinary Team documented the resident, the resident's family, and/or the resident's legal representative are encouraged to participate in the development of and revisions to the resident's care plan, and every effort will be made to schedule care plan meetings at the best time of the day for the resident and family.

Based on observation, interview, and record review, the facility failed to obtain a stop date for an as needed (PRN) antianxiety medication for R4 and R3's lorazepam (an antianxiety medication). Findings included:1. R4's Electronic Medical Record (EMR) documented a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R4's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. R4 received antianxiety (medication used to treat symptoms of anxiety) during the assessment period. R4's Psychotropic Drugs Care Area Assessment (CAA), dated 05/30/25, documented R4 received several psychotropic medications which the pharmacy consultant and physician reviewed monthly, to maintain therapeutic uses. R4's Quarterly MDS, dated [DATE], documented a BIMS score of seven, indicating severe cognitive impairment. R4 received antianxiety medication during the assessment period. R4's Care Plan, revised 03/02/26, instructed staff to monitor and report any adverse side effects from the psychotropic medications. R4's EMR documented the following Physician's Order (PO): Lorazepam, 1 mg, every 3 hours, PRN for a diagnosis of anxiety, not to exceed six doses per day, ordered 03/02/26. The PRN medication lacked a stop-date, as required. On 05/13/26 at 09:37 AM, Administrative Nurse D confirmed R4's PRN lorazepam order lacked a stop date. 2. R3's Electronic Medical Record (EMR) included diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hearing loss, need for assistance with personal care, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, dementia (a progressive mental disorder characterized by failing memory and confusion), senile degeneration of the brain (progressive, age-related decline in brain function), and fracture (broken bone) of left femur (thigh bone). R3's Significant Change Minimum Data Set (MDS), dated [DATE], documented that R3 had moderately impaired cognition and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). R3 required substantial/maximal assistance with toileting hygiene, rolling left and right, sitting to lying, lying to sitting on the side of bed, sitting to standing, and chair/bed-to-chair transfers. R3 required partial/moderate assistance with upper body dressing and personal hygiene. The MDS further documented that R3 had received scheduled pain medications and as-needed (PRN) pain medication and non-medication interventions for pain. R3 had a condition/chronic disease that may result in a life expectancy of less than six months and had hospice care (specialized end-of-life care). R3 took an antidepressant (a class of medications used to treat mood disorders), an anticoagulant (a class of medications used to prevent the blood from clotting), an opioid (a class of controlled drugs used to treat pain), and a hypoglycemic (a class of medications used to treat elevated blood sugar). The Psychotropic (alters mood or thought) Drug Use Care Area Assessment (CAA), dated 03/17/26, documented R3 had an order for an antidepressant, and that the medication was reviewed by the Interdisciplinary Team (IDT), including hospice, pharmacy consultant, and Primary Care Provider (PCP), to maintain therapeutic use. The Care Plan, dated 03/17/26, documented R3 had depression related to dementia and decline in her ability. The Care Plan directed staff to administer medications as ordered, monitor for side effects and assess effectiveness. Monitor/document/report PRN and signs or symptoms of depression, including hopelessness, anxiety, sadness, insomnia (inability to sleep), anorexia (lack or loss of appetite), verbalizing negative statements, repetitive anxiousness, or health-related complaints, and tearfulness. The Physician Orders, dated 03/23/26, directed staff to administer lorazepam (an antianxiety, a class of medications that calm and relax people) 0.5 milligrams (mg) by mouth every six hours PRN for anxiety and restlessness. The order lacked a stop date. The Physician Orders, dated 03/25/26, directed staff to administer lorazepam two mgs/milliliter (ml) oral concentrate, give 0.5 ml every six hours/PRN for agitation/restlessness. The order further instructed staff to keep both types of lorazepam on a four-hour schedule and not to give both within four hours. The order lacked a stop date. The Electronic Medication Administration Record (EMAR) documented R3 utilized PRN lorazepam 15 times in the month of April, and five times in the month of May. On 05/12/26 at 01:19 PM, R3 was eating from a meal tray in her room. R3 reported being hard of hearing and asked to write questions on a piece of paper. R3 did not have complaints but would like someone to tell her family members to come and visit more often, as she was lonely. On 05/14/26 at 09:51 AM, Administrative Nurse D stated the PRN lorazepam should have a stop date, and verified the pharmacist had not caught it on the monthly reviews. The facility's undated Psychotropic Medication Use documented that any resident admitted with a PRN psychotropic will have a 14-day stop date. Prior to the end of the 14-day period, the ordering practitioner will assess the resident's response to the PRN medication and will document a thoughtful risk-benefit rationale statement for continued use of the medication.

Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the State Agency (SA) within the required time frame of the alleged incident(s) as required for Resident (R) 59. Findings included:- R59's Electronic Medical Record (EMR) documented diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion), and encephalopathy (a broad term for any brain disease that alters brain function or structure). R59's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. R59's MDS documented no behaviors. R59's Communication Assessment (CAA), dated 07/02/25, documented R59 had dementia, and hearing loss bilaterally, R59 did not wear hearing aids. R59 spoke clearly, he is generally understood and understands others, he does sometimes have more difficulty with communication when he is tired and can be confused at times. R59's Quarterly MDS, dated [DATE], documented a BIMS score of six indicating severely impaired cognition. R59's MDS documented no behaviors. R59's Care Plan, dated 11/20/23, instructed staff that R59 appreciated his wife sleeping in his room overnight as she would provide him support. R59's Progress Note, dated 10/21/25 at 02:42 PM, documented staff notified Social Service Designee (SSD) X of a possible family event. The facility established visiting hours as follows: 08:00 AM - 08:30 AM for breakfast; 10:15 AM - 01:00 PM for fitness, bingo, and lunch; 04:30 PM - 06:00 PM for trivia and dinner. The facility established visitation rules as follows: Resident's wife is not to stay the night, the door must remain open, and the resident's wife must leave when cares are being given. R59's wife acknowledged these visiting hours. R59's Skin Assessment Note, dated 10/21/25 at 05:13 PM, documented no skin issues noted during shower. R59's Progress Note, dated 10/29/25 at 10:20 AM, documented updated visitation schedule for resident's wife is as follows: 08:00 AM - 02:00 PM and 04:00 PM - 06:00 PM. The facility also updated the visitation rules for the resident's wife as follows: door to remain open, resident's wife will not stay the night unless weather is bad (no more than two consecutive nights), resident's wife is to not have clothes here, and the resident's wife is to leave room when cares are being given. On 05/13/26 at 11:43 AM, Certified Nurse Aide (CNA) O reported R59's wife slapped him sometime in October of 2025, CNA O could not recall where R59's wife slapped him she reported maybe his leg or head. CNA O stated she reported the incident to the Charge Nurse and wrote a witness statement. CNA O reported CNA P was in the room when the slap occurred and CNA P had to write a statement also. On 05/14/26 at 11:11 AM, SSD X reported that CNA O, who was SSD X's family member, reported to her that R59's wife slapped him. SSD X reported that she felt there was a conflict in interest, so she reported the alleged abuse to Administrative Nurse D. SSD X reported that R59's wife would interfere with his cares and was unable to speak for himself and that is why R59's wife was given limited visiting hours. On 05/14/26 at 11:36 AM, Administrative Nurse D reported CNA O went home and told SSD X that R59's wife hit him. Administrative Nurse D stated SSD X did not report the alleged abuse until several days later, and SSD X had placed R59's wife on restricted visits. Administrative Nurse D reported after the incident was reported, it was investigated and found out that R59's wife did not slap him. Administrative Nurse D reported the facility did not report the alleged abuse to the state agency as it was days later and did not substantiate that it occurred. On 05/14/26 at 12:05 PM, Administrative Staff A reported that he thought Administrative Nurse D had made a report to the State Agency and he expected any allegation of abuse to be reported to the State Agency. The facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 05/26/22, documented identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Investigate and report any allegations within timeframes required by federal requirements.

Based on observation, interview, and record review, the facility failed to identify and implement resident-centered fall interventions for Resident (R) 4, who was at risk for falls. Findings included:- R4's Electronic Medical Record (EMR) documented a diagnosis of bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods). R4's Annual Minimum Data Set (MDS), dated [DATE], documented R4 had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. He had one non-injury fall and one injury (except major) fall since his prior assessment. R4's Falls Care Area Assessment (CAA), dated 05/30/25, documented the resident was at a high risk for falls, with two falls since his prior assessment. R4's Quarterly MDS, dated [DATE], documented he had a BIMS score of seven, indicating severe cognitive impairment. He had two or more non-injury falls since his prior assessment. R4's Care Plan, revised 03/02/26, instructed staff to utilize a gait belt with one staff for all transfers. Staff were to place brightly colored signs in his room reminding him to use the call light to call staff when he needed to transfer. R4's EMR under Assessments documented fall assessments completed on 02/06/26, 02/16/26, 02/24/26 and 04/11/26, which placed the resident at a high risk for falls. R4's EMR under Prog Notes, on 03/02/26, documented R4 had a non-injury fall on 03/02/26 while in the shower room. The staff member attempted to transfer him from the shower chair to his wheelchair when R4 lost his balance and was lowered to the floor. The staff member had not used a gait belt during the transfer. The resident had no injuries from the fall and staff were reminded to use a gait belt while transferring the resident. R4's EMR under Prog Notes, on 04/11/26, documented R4 had a non-injury fall on 04/11/26 while in his room. R4 attempted to transfer himself from his recliner to his wheelchair unassisted when he fell to the floor. The resident had no injuries from the fall and staff were instructed to do 15-minute checks for four hours to prevent further falls. R4's EMR lacked further documentation of falls after the non-injury 04/11/26 fall. On 05/13/26 at 11:45 AM, Certified Nurse Aide (CNA) M stated he was unsure of R4's fall interventions. On 05/14/26 at 08:20 AM, Licensed Nurse (LN) G stated when a resident falls, the staff will implement a new intervention to prevent further falls. Usually, Administrative Nurse D was responsible for implementing new fall interventions following a resident's fall. On 05/14/26 at 09:09 AM, Administrative Nurse D confirmed the fall interventions were not appropriate for preventing further falls. The facility policy for Falls and Fall Risk, Managing, undated, included: Based on previous evaluations, the staff shall identify interventions related to the resident's specific risks to try to prevent further falls.

Based on observation, interview, and record review, the facility failed to monitor Resident (R) 6's physician-ordered fluid restriction. Findings included: -R6's Electronic Medical Record (EMR) included diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), major depressive disorder (major mood disorder that causes persistent feelings of sadness), chronic pain syndrome, nutritional deficiency, generalized anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, chronic kidney disease, personal history of urinary calculi (kidney stones), and urinary tract infection (UTI-an infection in any part of the urinary system). R6's Significant Change Minimum Data Set (MDS), dated [DATE], documented that R6 had staff assessment of moderately impaired cognition, continuous inattention, and disorganized thinking behavior, along with hallucinations (sensing things while awake that appear to be real, but the mind created) and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). R6 required setup or cleanup assistance with eating, was dependent on toileting hygiene, and required substantial/maximal assistance with lower-body dressing, rolling left and right in bed, sit-to-lying, lying-to-sitting, sit-to-standing, and chair/bed-to-chair transfers. R6 had an indwelling catheter (tube placed in the bladder to drain urine into a collection bag), received a scheduled pain medication regimen, and complained of coughing or choking during meals or when swallowing medication, and was provided with a therapeutic diet. The MDS further recorded that R6 received an antidepressant (a class of medications used to treat mood disorders), antibiotic (a class of medication to treat infections), a diuretic (a medication to promote the formation and excretion of urine), and an opioid (a class of controlled drugs used to treat pain). The Nutritional Status Care Area Assessment (CAA), dated 02/06/26, documented R6 was a readmit with medications that may impact fluid shifts and weight trends. The CAA further documented R6 had a no concentrated sweet (NCS) diet with 1800 milliliter (ml) fluid restriction. R6's Care Plan, dated 08/21/22, documented R6 had a nutritional status of moderate risk, with a NCS diet with a fluid restriction of 1800 ml. The plan directed the dietary department to provide 720 ml of fluids with breakfast, 240 ml of fluids with lunch, and evening meal. The plan directed nursing to provide 240 ml of fluid for the day and evening shift and 120 ml through the night shift. The Physician Order, dated 03/09/26, documented that R6 should receive a two-gram sodium diet with a 1800 ml fluid restriction and fortified foods. The physician's order also included 120 ml of 2Cal (high-calorie, protein-dense nutrition formulas) and a house supplement three times a day. The Progress Note, dated 03/19/26 and 03/26/26, documented the Interdisciplinary Team (IDT) meeting for R6 with a diagnosis of acute cystitis (inflammation of the bladder) with hematuria (blood in the urine). R6 currently receives an NCS pureed diet with 1800 ml fluid restriction, along with 2Cal 120 ml three times and house shake three times a day. The EMR lacked evidence of tracking R6's fluid intake. On 05/12/26 at 04:28 PM, R6 was sitting in a wheelchair. R6 reported having difficulty with UTIs due to the long-term use of indwelling catheters and was currently being treated with an antibiotic. On 05/13/26 at 12:15 PM, R6 was sitting in the dining room with a 240 ml of brown liquid in a glass. On 05/13/26 at 12:18 PM, Dietary Service BB reported that the dietary staff provided R6 with 720 ml of fluids with breakfast and 240 ml of fluids with lunch and the evening meal, and the nursing department provided R6 with supplements. On 05/13/26 at 12:22 PM, Licensed Nurse (LN) J reported she thought R6's fluid restriction had been discontinued. Upon review of the physician orders, LN J confirmed it had not been discontinued. LN J explained that nursing staff would record the fluid intake at the end of each shift, but the fluid intake had not been recorded. On 05/13/26 at 12:36 PM, Administrative Nurse D reported the facility had failed to transfer the fluid restriction to the new EMR when the facility changed software providers. Administrative Nurse D verified that R6's fluid intakes should have been monitored and recorded, and R6 had many changes, had declined, and been hospitalized with UTIs. The facility's undated Fluid Restriction policy documented the facility was to provide residents who have a written physician order for fluid restriction an appropriate amount of fluids each day, while allowing nursing adequate fluid to supply medications, etc. A fluid restriction plan of care is to be filled out and placed in the resident's chart under the care plan selection.

Based on observation, interview and record review, the facility's pharmacy consultant failed to report irregularities to the resident's physicians, the facility administrator and the director of nursing regarding the lack of stop dates for as needed (PRN) antianxiety medication for Resident (R)4 and R3's PRN lorazepam (an antianxiety medication). Findings included:1. R4's Electronic Medical Record (EMR) documented a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R4's Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. R4 received antianxiety (medication used to treat symptoms of anxiety) during the assessment period. R4's Psychotropic Drugs Care Area Assessment, (CAA), dated 05/30/25, documented R4 received several psychotropic medications which the pharmacy consultant and physician reviewed monthly, to maintain therapeutic uses. R4's Quarterly MDS, dated [DATE], documented he had a BIMS score of seven, indicating severe cognitive impairment. R4 received antianxiety medication during the assessment period. R4's Care Plan, revised 03/02/26, instructed staff to monitor and report any adverse side effects from the psychotropic medications. R4's EMR documented the following Physician's Order (PO): Lorazepam, 1 mg, every 3 hours, PRN for a diagnosis of anxiety, not to exceed six doses per day, ordered 03/02/26. The PRN medication lacked a stop-date, as required. R4's EMR, under the Prog Notes documented the following consultant pharmacist reviewed R4's medications on 04/26/26, 03/25/26, 02/22/26, and 01/25/26. On 05/13/26 at 09:37 AM, Administrative Nurse D confirmed R4's PRN lorazepam order lacked a stop date and verified the CP failed to identify it. 2. R3's Electronic Medical Record (EMR) included diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hearing loss, need for assistance with personal care, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, dementia (a progressive mental disorder characterized by failing memory and confusion), senile degeneration of the brain (progressive, age-related decline in brain function), and fracture (broken bone) of left femur (thigh bone). R3's Significant Change Minimum Data Set (MDS), dated [DATE], documented that R3 had moderately impaired cognition and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). R3 required substantial/maximal assistance with toileting hygiene, rolling left and right, sitting to lying, lying to sitting on the side of bed, sitting to standing, and chair/bed-to-chair transfers. R3 required partial/moderate assistance with upper body dressing and personal hygiene. The MDS further documented that R3 had received scheduled pain medications and as-needed (PRN) pain medication and non-medication interventions for pain. R3 had a condition/chronic disease that may result in a life expectancy of less than six months and had hospice care (specialized end-of-life care). R3 took an antidepressant (a class of medications used to treat mood disorders), an anticoagulant (a class of medications used to prevent the blood from clotting), an opioid (a class of controlled drugs used to treat pain), and a hypoglycemic (a class of medications used to treat elevated blood sugar). The Psychotropic (alters mood or thought) Drug Use Care Area Assessment (CAA), dated 03/17/26, documented R3 had an order for an antidepressant, and that the medication was reviewed by the Interdisciplinary Team (IDT), including hospice, pharmacy consultant, and Primary Care Provider (PCP), to maintain therapeutic use. R3's Care Plan, dated 03/17/26, documented R3 had depression related to dementia and decline in her ability. The plan directed staff to administer medications as ordered, monitor for side effects and assess effectiveness. Monitor/document/report PRN and signs or symptoms of depression, including hopelessness, anxiety, sadness, insomnia (inability to sleep), anorexia (lack or loss of appetite), verbalizing negative statements, repetitive anxiousness, or health-related complaints, and tearfulness. The Physician Orders, dated 03/23/26, directed staff to administer lorazepam (an antianxiety, a class of medications that calm and relax people) 0.5 milligrams (mg) by mouth every six hours PRN for anxiety and restlessness. The order lacked a stop date. The Physician Orders, dated 03/25/26, directed staff to administer lorazepam two mgs/milliliter (ml) oral concentrate, give 0.5 ml every six hours/PRN for agitation/restlessness. The order further instructed staff to keep both types of lorazepam on a four-hour schedule and not to give both within four hours. The order lacked a stop date. The Consultant Pharmacist(CP) Medical Record Review (MRR), dated 03/24/26, documented that R3 was receiving hospice services and recommended the physician consider evaluating the need to continue atorvastatin, calcium, vitamin D, multivitamin with minerals, and vitamin B12. The CP did not include a request for a stop date for the lorazepam PRN. The CP's MMR, dated 04/25/26, referred to the payment source and did not include a stop date for the lorazepam PRN. On 05/12/26 at 01:19 PM, R3 was eating from a meal tray in her room. R3 reported being hard of hearing and asked to write questions on a piece of paper. R3 did not have complaints but would like someone to tell her family members to come and visit more often, as she was lonely. On 05/14/26 at 09:51 AM, Administrative Nurse D stated the PRN lorazepam should have a stop date and verified the pharmacist had not caught it on the monthly reviews. The undated Pharmacy Services-Role of the Consultant Pharmacist policy documented that the CP would provide specific activities related to medication regimen review, including: a documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines. Appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities, and pertinent resident-specific documentation in the medical record, as indicated.

Based on observation, interview, and record review, the facility failed to ensure collaboration between the facility and hospice which included a hospice (a program that gives special care to people who are near the end of life) service visit frequency, medications, medical equipment, and the resident representative's preference for Resident (R) 3. Findings included: -R3's Electronic Medical Record (EMR) included diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), hearing loss, need for assistance with personal care, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, dementia (a progressive mental disorder characterized by failing memory and confusion), senile degeneration of the brain (progressive, age-related decline in brain function), and fracture (broken bone) of left femur (thigh bone). R3's Significant Change Minimum Data Set (MDS), dated [DATE], documented that R3 had moderately impaired cognition and delusions (untrue, persistent belief or perception held by a person although evidence shows it was untrue). R3 required substantial/maximal assistance with toileting hygiene, rolling left and right, sitting to lying, lying to sitting on the side of bed, sitting to standing, and chair/bed-to-chair transfers. R3 required partial/moderate assistance with upper body dressing and personal hygiene. The MDS further documented that R3 had received scheduled pain medications and as-needed (PRN) pain medication and non-medication interventions for pain. R6 had a condition/chronic disease that may result in a life expectancy of less than six months and had hospice care (specialized end-of-life care). R6 took an antidepressant (a class of medications used to treat mood disorders), an anticoagulant (a class of medications used to prevent the blood from clotting), an opioid (a class of controlled drugs used to treat pain), and a hypoglycemic (a class of medications used to treat elevated blood sugar). R3's Care Plan, dated 03/17/26, documented that R3 had a terminal prognosis related to senile degeneration of the brain. The plan included the hospice service of choice name, address, and phone number. The plan directed staff to consult with the physician and social services to have hospice care for the resident in the facility. The plan did not include the frequency of licensed nurses, clergy, nurse aides, social services, medication, supplies, and medical equipment provided by the hospice provider. The Physician Order, dated 02/26/26, directed staff to admit R3 to the hospice provider for a terminal diagnosis of senile degeneration of the brain. On 05/12/26 at 01:19 PM, R3 was eating from a meal tray in her room. R3 reported being hard of hearing and asked to write questions on a piece of paper. R3 did not have complaints but would like someone to tell her family members to come and visit more often, as she was lonely. On 05/13/26 at 10:20 AM, Certified Nurse Aide (CNA) O reported R3's hospice provider had staff come to the facility three times a week. The hospice nurse came once a week, and the hospice aide came twice a week for bathing and other care the resident needed. CNA O reported the hospice provider was responsible for personal care items of briefs, wipes, incontinence under pads, and creams. CNA O reported that if staff needed supplies, they would tell the charge nurse. On 05/14/26 at 08:32 AM, Licensed Nurse (LN) K reported R3's physician orders contained the hospice agency and phone number. LN K reported that the physician orders would be where she would look to find a contact number, and was not clear on the use of the care plan for references to the hospice agency services and supplies. On 05/14/26 at 09:51 AM, Administrative Nurse D reported R3's care plan had contained information related to the hospice services, medication, and supplies, but the facility had changed software providers, and the information had not been transferred to the current care plan. The facility's undated Hospice Services policy documented that each resident would receive, and the facility would provide, the necessary care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The facility would coordinate care planning with the hospice provider, including all services and supplies provided by the hospice provider, including: nursing services, nurse aide services, social services, chaplaincy services, durable medical equipment, medications, and grief support to family members.

Based on interviews, observation, and record review, the facility failed to ensure adequate hand hygiene eye medication administration for Resident (R) 47 and during a dressing change for R45. Findings included:1. On 05/12/26 at 04:03 PM, Certified Medication Aide (CMA) T applied one glove to her left hand without performing hand hygiene. CMA T administered one drop of R47's timolol ophthalmic (lower elevated eye pressure) eye drops into each eye. CMA T held onto the bottle of eye drops with her ungloved right hand and then used her left hand to hold R47's eyelid open. CMA T used the same tissue to wipe each eye after the eye drop was administered with her ungloved right hand. On 05/12/26 at 04:10 PM, CMA T reported that she did not realize that she had only worn one glove and she should have used a glove on each hand after she washed in her hands. CMA T reported that she thought she used a different tissue. 2. On 05/13/26 at 07:32 AM, Licensed Nurse (LN) H removed the R45's dressing from his left heel with her right hand and cleansed the open area. LN H then removed R45's right sock and washed his right heel; she removed her gloves and applied new gloves without performing hand hygiene. LN H applied Skin-prep (liquid skin protectant) to the intact skin surrounding the open area of his left heel then she applied Skin-prep to the right heel. LN H removed her gloves and without performing hand hygiene she opened a Hydrogel (water-based gel that donates moisture and aids autolytic debridement) dressing, applied new gloves, and applied the dressing to the left heel and covered that dressing with a foam adhesive dressing. She removed her gloves and performed hand hygiene. LN H took her pen out of her pocket and dated the dressing on the left heel. On 05/13/26 7:45 AM, LN H reported she should have performed hand hygiene when she removed her gloves and before she applied new gloves during the dressing change. On 05/14/26 at 11:30 AM, Administrative Nurse F reported that she expected the staff to wash their hands after they removed gloves before applying new gloves. On 05/14/26 at 12:32 PM, Administrative Nurse D expected staff to wear gloves on both hands when they administered eye drops and to use a separate tissue for each eye. The facility did not provide a policy on hand washing.

Based on interview and record review the facility failed to offer and provide or obtain an informed declination for the pneumococcal vaccine (vaccine designed to prevent pneumonia [inflammation of the lungs which can be debilitating or lethal in the elderly]) for Resident (R) 4. Additionally, the facility failed to offer and provide or obtain informed declination for the influenza vaccine (vaccine designed to prevent highly contagious viral infection) form to R6. Findings included:1. R4's Electronic Medical Record (EMR) lacked documentation of a pneumococcal vaccine being administered after responsible party wrote wants all near the column of vaccines that were recommend on the Vaccine(s) Declination form COVID-19 vaccine (a vaccine designed to prevent highly contagious respiratory virus), Influenza Vaccine, Pneumococcal Vaccine, and Shingles Vaccine (a vaccines to prevent a viral infection that causes a painful, blistering rash). None of the vaccines had a check mark to decline in box under the declination column. 2. R6's EMR lacked documentation of an influenza vaccine being offered 2025 through 2026 flu season. On 05/14/26 at 10:45 AM Administrative Nurse F produced the requested influenza/pneumococcal vaccine forms and reported that she could not locate an influenza form for R6 for 2025-2026 influenza season. Administrative Nurse F reported that the form R4 responsible party signed 04/10/2024 was a declination form for all the vaccines offered to him in 2024. Administrative Nurse F then reviewed the form again and confirmed that it stated wants all and none of the vaccines were checked off as declined. On 05/14/26 at 10:50 AM Administrative Nurse D reported she expected all the residents to have the Influenza/Pneumococcal Vaccines offered. Administrative Nurse D reported she expected the residents EMR to have the information if the vaccines were offered/administered or declined. The facility's policy Influenza and Pneumonia Immunization Policy, undated, documented recognizing the major impact and mortality of influenza and/or pneumonia disease on residents of nursing homes; and the effectiveness of vaccines in reducing healthcare costs and preventing illness, hospitalization and death, this facility has adopted the following policy statements: All residents, staff and volunteers of this facility will be offered the influenza vaccine annually, unless there is a documented contraindication or if the resident or representative refuses the vaccine(s) after appropriate education related to the risk of the conditions and the risk of failure to receive the vaccine(s) status. All admissions throughout the year will be offered the pneumovax injection as desired by the resident and approved by the primary care physician after investigation/inquiry related to current immunization status. Every year, a log documenting how many people (residents, staff, and volunteers) receive the influenza and pneumovax vaccine, as well as the number who refused and did not receive the vaccination, will be available to the State Health Department and the State Survey Agency.

Based on interview and record review the facility failed to offer and provide or obtain an informed declination for the COVID-19 vaccine (a vaccine designed to prevent highly contagious respiratory virus) for Resident (R) 6 and R21. Findings included:1. R6's Electronic Medical Record (EMR) lacked documentation of a COVID-19 vaccine being offered since 2022. 2. R21's EMR lacked documentation of a COVID-19 vaccine being offered since 2021. On 05/14/26 at 10:45 AM, Administrative Nurse F produced the requested COVID-19 vaccine forms and reported that she could not locate a recent COVID-19 offered and provided or obtained an informed declination for R6 and R21. On 05/14/26 at 10:50 AM, Administrative Nurse D reported she expected all the residents to have the COVID-19 Vaccine offered. Administrative Nurse D reported she expected the residents EMR to have the information if the vaccines were offered/administered or declined. The facility did not provide a policy on COVID-19 Vaccine.

The facility reported a census of 46 residents. The sample included three residents reviewed for neglect. Based on observation, interview, and record review, the facility failed to protect dependent Resident (R)1 from harm, when staff did not follow the resident's care plan, which instructed nursing staff to utilize a slide board (assist users and caregivers in the safe transfer from wheelchair to bed) to transfer the resident. On 10/18/24 at approximately 12:00 PM, Licensed Nurse (LN) G requested assistance from Certified Medication Aide (CMA) M when the resident requested to use the restroom. Certified Medication Aide (CMA) M entered the resident's room and observed the resident sitting in her wheelchair. CMA M offered to transfer R1 from her wheelchair to the bed to use the bed pan per her care plan, but the resident requested to use the toilet in the bathroom. CMA M propelled the resident to the bathroom, placed a gait belt around the resident's body, wrapped her arms around the resident, and completed a stand and pivot transfer from the resident's wheelchair to the toilet while LN G removed the resident's pants and brief. This failure resulted in broken bones in her right lower leg. Findings include: - R1's Physician Order Sheet (POS) dated 11/17/24, documented the resident was admitted on [DATE] with the following diagnoses: diabetes mellitus (the body cannot use glucose, there was not enough insulin made or the body cannot respond to the insulin), osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk) with pathologic fracture (a break in a bone that is caused by an underlying disease), acute (condition characterized by a relatively sudden onset of symptoms that are usually severe), osteomyelitis (local or generalized infection of the bone and bone marrow) of the right ankle and foot, nondisplaced (a type of bone break where the bone cracks in one spot and stays aligned) trimalleolar (fracture of the ankle that involves the lateral malleolus, the medial malleolus, and the distal posterior aspect of the tibia) fracture (broken bone) of the right lower extremity, and above the knee amputation (AKA, surgical removal of a body part) of left extremity. The 09/04/24 Admission Minimum Data Set (MDS), revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required a manual wheelchair, propelled by staff, for mobility device due to above the knee amputation of the left extremity and non-bearing weight on right extremity. The resident was dependent on staff for transfers and toileting. The resident required a slide board for transfers. The resident was incontinent of bowel and bladder. The ADL [Activities of Daily Living] Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 09/10/24, documented the resident had an above the knee amputation of the left extremity. The resident had a recent surgery on her right ankle due to a fracture prior to admission to the facility. She had a non-weight bearing status on admission and was working with therapy for transfers. She required assistance for all activities of daily living (ADLs). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 09/10/24, documented the resident required assistance from staff with toileting due to the resident's inability to transfer to the toilet and difficulty maintaining a sitting balance. The Fall Care Area assessment (CAA), dated 09/10/24, documented the resident had a fall score of ten that indicated the resident was at risk for falls. The resident had an above the knee amputation of left extremity and fracture of right ankle. The resident had non-weight bearing status and required the use of a mechanical lift for transfers on admission. R1's Care Plan, dated 09/16/24, instructed staff that the resident did not ambulate. The resident had an above the knee amputation of left extremity; she was non-weight bearing on right extremity due to surgical repair of right ankle related to a fracture. The resident was independent with meals and oral hygiene. The resident required moderate assistance by nursing staff with dressing her upper body. The resident required total assistance by nursing staff with dressing her lower body, bathing, transfers, and toileting. She required a mechanical lift for all transfers. On 10/16/24, the revised care plan instructed staff that the resident's transfer status was revised to include use of the slide board. R1's Morse Fall Scale, dated 08/28/24, documented a score of ten, which indicated the resident was a low risk for falls. R1's Morse Fall Scale, dated 10/03/24, documented a score of 35, which indicated the resident was a low risk for falls. R1's Xray report, dated 10/18/24, documented the resident had an oblique (slope) acute (condition characterized by a relatively sudden onset of symptoms that are usually severe), nondisplaced (a type of bone break where the bone cracks in one spot and stays aligned) fracture of midshaft (middle) tibial (shinbone is the larger, stronger, and anterior (frontal). The resident also obtained an acute (condition characterized by a relatively sudden onset of symptoms that are usually severe) fracture (broken bone) of the distal (end) fibular shaft (The fibular shaft lies distal to the neck and has three surfaces, lateral, medial, and posterior). Review of the Facility Investigation, dated 10/25/24 documented on 10/18/24 at approximately 12:00 PM, R1 turned on her call light. LN G answered the resident's call light. Upon LN G answering the resident's call light, the resident requested to use the restroom. LN G stepped out of the resident's room and asked CMA M for assistance toileting the resident. The resident advised the nursing staff that she did not want to use the bed pan, instead she wanted to use the bathroom. Staff offered the resident to use the bed pan and the resident declined. CMA M placed a gait belt on the resident and completed a stand and pivot transfer from the resident's wheelchair to the toilet. LN G assisted with pulling down the resident's pants and underpants before sitting on the toilet. The nursing staff heard a pop sound during the transfer. LN G completed an assessment while the resident was on the toilet and could not visualize any issue. The nursing staff transferred the resident from the toilet to her wheelchair with the stand and pivot maneuver. On 10/18/24 at approximately 01:30 PM, the resident was assisted back to bed. LN G assessed the residents' right leg and ankle. LN G observed a bump with bruising to right lower extremity. LN G obtained an order for a mobile Xray. On 10/18/24 at 06:00 PM during nursing shift change, mobile xray had not arrived to the facility. The facility received an order to transfer the resident to the Emergency Department (ED) for an evaluation. The resident returned to the facility on [DATE] at approximately 12:00 AM. The findings of the investigation included: the resident had a closed, comminuted (bone broken in at least two places), non-displaced tibial fracture and a distal fibular fracture of the right lower extremity. The residents returned with a posterior splint on right extremity. On 10/18/24 Emergency Department (ED) summary documented the resident with a closed, comminuted (bone broken in at least two places), non-displaced tibial fracture and a distal fibular fracture of the right lower extremity. On 10/18/24 while in the ED, they placed a posterior splint on the resident's right leg. The resident would need to follow-up closely with her orthopedist. Review of Witness Statement, dated 10/18/24, revealed Certified Medication Aide (CMA) M was asked to assist Licensed Nurse (LN) G to transfer R1 from the wheelchair to the toilet. CMA M documented R1 transferred the resident to her bed, however the resident wanted to use the bathroom. CMA M used a gait belt, completed the stand and pivot transfer to transfer the resident from her wheelchair to the toilet. During transfer, LN G, CMA M, and R1 heard a popping sound. The resident complained of pain. CMA M asked the LN G if pain medication should be given to the resident and LN G declined at that time. On 10/18/24 at approximately 01:30 PM, CMA M documented she assisted the resident to bed. At that time CMA M observed discoloration and a lump to her leg. CMA M reported her observation to LN G. Review of Witness Statement, dated 10/18/24, Licensed Nurse G documented she asked CMA M how R1 transferred and R1 placed her arms around CMA M's neck. CMA M then placed R1's foot on top of her foot to ensure resident did not bear any of her own weight during transfer. CMA M then picked up R1 from her wheelchair and transferred her to the toilet. While the CMA M had the resident in standing position, LN G removed the resident's pants and brief. When CMA M placed the resident onto the toilet seat, the heard a pop sound that sounded like a joint popped. After the resident finished using the restroom CMA M transferred the resident from the toilet to her wheelchair using a stand and pivot transfer. Several hours later, after the transfer, the resident complained of pain to her right anterior ankle. The right anterior ankle was warm to touch with mild swelling noted to right shin. The health care provider was notified to request a Xray of right lower extremity. During interview on 12/02/24 at 09:01 AM Administrative Nurse A verified the facility incident report reflected LN G and CMA M did not follow the resident's care plan regarding transfers. Administrative Nurse A stated she expected LN G to review all of the resident's care plan prior to transfers and before all cares. The facility's policy for Safe Lifting and Movement of Residents, dated 09/05/17, documented the facility shall protect the safety and well-being of the residents, promote quality of care, and use appropriate transfer devices. The facility failed to protect the resident from harm, when nursing staff did not utilize the appropriate transfer equipment to safely meet the needs of R1 that caused an oblique acute, nondisplaced fracture of mid tibial shaft. The resident also obtained an acute fracture of the distal fibular shaft.

The facility reported a census of 47 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible foodborne illness for the residents in the facility. Findings included: - Observation, on 07/01/24 at 08:45 AM, revealed the following areas of concern in the dry goods pantry: One unsealed 25 pound (lbs.) bag of rice and one unsealed open 50 lbs. bag of flour in the dry goods pantry. One opened five lbs. container of teriyaki sauce with an expiration date of 04/21/24. One gallon of Worcestershire sauce, with no opened date and no expiration date, with approximately one-fourth of the gallon remaining. Observation, on 07/01/24 at 08:50 AM, revealed 12 boxes of frozen food stored directly on the floor of the walk-in freezer. Interview, on 07/01/24 at 11:30 AM, with Dietary Staff BB revealed the delivery of frozen foods came on Friday, and confirmed staff should place the items on shelves in the freezer. Observation, on 07/02/24 at 02:48 PM, during the environmental tour with Dietary Staff BB, revealed the following areas of concern: The side-by-side refrigerator contained a piece of unidentified meat wrapped in plastic, dated 06/10/24. One partially used gallon container of thousand island dressing dated 03/15/24 and a five lbs. container of salsa dated 03/15/24. Plastic wrapped sliced ham, with an open date of 06/23/24. One large, opened bag of mixed lettuce for salad, undated with noted wilting and brown discolorations on multiple pieces of lettuce. During an interview on 07/02/24 at 02:48 PM, Dietary Staff BB confirmed these items were out of date. The double-doored oven contained several areas of bubbled burned food debris on the bottom of the inside. The sides and door contained splatters and grime on the surfaces. The can opener contained grime on the surface. One large fry pan contained multiple scratches in the cooking surface. The floor cleaning machine was stored between two metal shelves holding clean serving pans and storage containers. During an interview on 07/02/24 at 03:00 PM, Dietary Staff BB confirmed the areas of concern. The facility policy Food Receiving and Storage revised 07/15/21, instructed staff to store food in a manner that complies with safe food handling practices. Pesticides and other toxic substances will not be stored in the kitchen area. The facility failed to store, prepare, and serve food in a sanitary manner to prevent potential foodborne illness for the residents.

The facility reported a census of 47 residents. Based on observation, interview, and record review, the facility failed to conduct annual performance reviews for two of five Certified Nurse Aide/Medication Aides reviewed, to ensure the residents received adequate cares. Findings included: - Review of five Certified Nurse/Medication Aide's (CNA/CMA) employment records revealed the facility did not complete two of the five CMA/CNA's annual performance reviews, as follows: 1. CMA/CNA R, hired on 09/15/1995, with the most recent Annual Performance Evaluation, dated 08/20/22 (22 months past due). 2. CMA/CNA S, hired on 08/21/18, with the most recent Annual Performance Evaluation, dated 11/14/22 (19 months past due). On 07/03/24 at 12:44 PM, Administrative Staff D stated CMA/CNAs employed more than one year should have an annual performance evaluation. She verified the above findings and reported that all nursing staff were available to assist all residents of the facility. The facility lacked a policy to address the completion of an annual performance evaluation/review for CMA/CNA staff employed for a year or more. The facility failed to conduct an annual performance review for CMA/CNA staff that provided care throughout the facility to all the residents of the facility to ensure the residents received adequate cares.

The facility reported a census of 47 residents. Based on observation, interview and record review, the facility failed to monitor and serve food at safe palatable (pleasant to taste) temperatures as required. Findings included: - During an interview on 07/01/24 at 09:19 AM, Resident (R)31 revealed the food served to him was not hot. During an interview on 07/01/24 at 10:08 AM, R10 revealed he ate his meals in his room, per his choice, and the food was usually served cold. During an interview on 07/01/24 at 10:15 AM, R43 revealed the food was cold when he received it. Observation, on 07/02/24 at 11:07 AM, revealed dietary staff as they prepared food carts for lunch service to the 300 hall. A tray containing 11 slices of cheesecake sat on top of the food cart. Observation, on 07/02/24 at 11:35 AM, revealed Dietary Staff CC took the broccoli out of the steam oven and did not take the temperature, until requested. The temperature was 132 degrees Fahrenheit (F). Dietary Staff CC stated she did not know broccoli required a temperature before serving and returned it to the steamer. Dietary Staff DD obtained the temperature of the cheesecake on top of the food cart and noted it was above 50 degrees F and stated the cheesecake should not be above 42 degrees and did not know why staff removed it from the refrigerator 30 minutes before the cart was ready for distribution to the 300 hall. Observation on 07/02/24 at 11:53 AM, revealed Dietary Staff CC obtained temperatures of the food items on the steam table and revealed the cut carrots at 100 degrees F and the ground chicken at 100 degrees F. Dietary Staff CC stated when she removed the items from the oven/steamer, the temperatures were 165-190 degrees F. Dietary Staff CC stated she did not know the temperatures should be obtained prior to serving. Interview on 07/02/24 at 12:00 PM with Dietary Staff BB, revealed the facility utilized an electronic temperature monitoring/recording system, and the system did not work satisfactory, with lack of recording of the food temperatures so staff used a paper recording system. Dietary Staff BB confirmed lack of temperatures to ensure the steam table maintained food at 135 degrees F throughout the meal service. Observation on 07/03/24 at 09:16 AM revealed Dietary Staff BB provided a test tray and obtained the temperature of the scrambled eggs at 100 degrees F and hash browns at 100 degrees F. Dietary Staff BB and surveyors tasted the food, and all confirmed the food was not hot and minimally warm. The facility policy Food Preparation and Service revised 01/26/23, instructed staff to cook fresh frozen of canned fruits and vegetables to a temperature of 135 degrees F. Potentially hazardous foods (meats, poultry, seafood cut melon eggs milk, yogurt, and cottage cheese) must be maintained below 41 degrees or above 135 degrees F per type of food. The facility failed to ensure foods were maintained at 135 degrees F on the steam table and foods served to residents were maintained at palatable temperatures as required.

The facility identified a census of 47 residents, which included 16 residents sampled and reviewed for care plan development. Based on interview, observations, and record review, the facility failed to develop a comprehensive person-centered care plan for one resident. Resident (R) 35 comprehensive person-centered care plan was not completed in a timely manner of 21 days from admission. This deficient practice had the potential to lead to uncommunicated needs, which could lead to negative impacts on the resident's physical, mental and psychosocial well-being. Findings included: - R35's Electronic Health Record (EHR) revealed diagnoses that included nontraumatic chronic subdural hemorrhage (SDH-serious condition, typically caused by head injury, where blood collects between the skull and the surface of the brain), muscle weakness, and repeated falls. The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of 15, indicating intact cognition. The resident had a total mood severity score of 01, indicating minimal depression and no behaviors noted. R35 required limited assistance with activities of daily living (ADLs), with bed mobility, bathing, toileting hygiene, and dressing, supervision with ambulation, and eating. R35 was occasionally incontinent of bladder. The Quarterly MDS dated [DATE], documented a BIMS of 11, indicating moderately impaired cognition. R35 required limited assistance of staff with ADLs. R35 was non-ambulatory, independent with transfers and dependent for staff for wheelchair mobility. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 09/21/23, documented R35 had minimal visual impairment and she used a magnifying glass instead of glasses. The Urinary Incontinence CAA dated 09/21/23, documented R35 as occasionally incontinent of bowel and bladder and required more assistance in the evening. The Care Plan dated 07/02/24, revealed R35 required staff to provide assistance with ambulation with one staff assistance and a walker, as she requested. Staff were to provide assistance with toileting if the resident requested. R35 required staff to set up personal items and clothing daily. Review of the Progress Notes from 08/10/23 to 07/03/24 lacked any documentation in regard to completion of a care plan. On 07/01/24 at 10:19 AM, R35 sat in her recliner in her room, with her feet propped up on her wheelchair in front of recliner. R35 was watching television she was fully dressed, no socks on feet, slippers on floor in front of recliner. On 07/02/24 at 08:12 AM, R35 stated that she did not remember stating what she said yesterday, states that the staff are very nice here and states that the staff help her when she needs it. On 07/02/24 at 08:30 AM, Certified Medication Aide (CMA) Staff S stated R35 would call staff for assistance when needed. CMA S stated that the care plan on the EHR is where the staff need to read what care any resident is required to have. On 07/03/24 at 12:46 PM, Administrative Nurse E stated R35 admitted to facility on 08/10/23 and agreed that R35's person-centered care plan was not developed within seven days of required MDS. Administrative Nurse E revealed that she could not find the baseline care plan in the EHR, stated it was deleted after the comprehensive care plan was completed. On 07/03/24 at 01:00 PM Administrative Staff Nurse E stated she completed the person-centered care plan for R35 in November of 2023 when she realized the care plan had not been written by previous MDS nurse who is no longer employed at facility. The facility's policy for Care Plan, Comprehensive Person Centered, dated 03/02/23 documented: A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the residents' physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person centered care plan is developed within seven days of completion of the required comprehensive assessment. The facility failed to develop a comprehensive person-centered care plan for one resident. R 35 comprehensive person-centered care plan was not completed in a timely manner of 21 days from admission. This deficient practice had the potential to lead to uncommunicated needs which could lead to negative impacts on the resident's physical, mental and psychosocial well-being.

The facility reported a census of 47 residents with 16 residents included in the sample. Based on observation, record review, and interview, the facility failed to review and revise the care plan for one Resident (R)1 regarding weekly weights and interventions to prevent further weight loss. Findings included: - Review of R1's diagnoses from the Electronic Health Record (EHR) documented, 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), diverticulitis (inflammation of the diverticulum, in the colon, which caused pain and disturbance in bowel function), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R1 required limited assistance with activities of daily living (ADLs), with bed mobility, toileting hygiene, and dressing, set-up for eating. R1 was occasionally incontinent of bladder. The resident required a regular diet consistency and no added salt. The Quarterly MDS dated [DATE], documented a BIMS of 12, indicating moderately impaired cognition. The resident had a total mood severity score of 01, indicating minimal depression and no behaviors noted. R1 required limited assistance of staff with ADLs, set-up for eating. The resident required a regular diet regular consistency and no added salt. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 12/14/23, documented R1 required assistance with her ADLs. The Nutritional CAA dated 12/14/23, documented R1's weight was stable. The facility encouraged balance meals. The Care Plan dated 07/02/24, revealed R1 required staff to provide assistance to take R1 to and from meals as requested and provided supervision and set up assistance. Staff were to assist the resident as needed. Staff were instructed to see the EHR for current physician orders and treatments. Staff were instructed to monitor weights weekly and as needed. The Physician's Order dated 07/02/24, documented house supplement twice a day and a snack of choice daily for weight loss ordered 06/10/24. Lacked documentation for how much was consumed. On 07/02/24 at 02:43 PM, Administrative Nurse E revealed the weight loss and interventions should be on the care plan, that it is an Interdisciplinary Team effort, that Dietary staff BB generally adds the nutritional concerns to the care plan on the EHR. Administrative Nurse E stated that it was noted in the middle of June 2024 that R1's weight loss was not due to the fluid shifts in her body, but a true weight loss. On 07/02/24 at 03:15 PM, Dietary Staff BB revealed R1 had a true weight loss and agreed that the weight loss and interventions were not on R1's care plan. Dietary Staff BB stated that she was generally the staff member that care plans for the nutritional section of residents' care plans. On 07/03/24 at 10:30 AM, Administrative Nurse D agreed weight loss, weekly weights, and supplements should have been on R1's care plan. The facility's policy for Care Plan, Comprehensive Person Centered, dated 03/02/23 documented: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents' physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven days of completion of the required comprehensive assessment. Assessments are on going and care plans are revised as information about the residents and the residents' condition change. The facility failed to review and revise the care plan for one Resident R1 regarding weekly weights and interventions to prevent further weight loss. This deficient practice had the potential to lead to uncommunicated needs which could lead to negative impacts on the resident's physical, mental and psychosocial well-being.

The facility identified a census of 47 residents with 16 sampled. Based on observation, interview, and record review, the facility failed obtain daily weights as ordered on 03/28/24 for cognitively impaired Resident (R) 1, who had an identified weight loss. This deficient practice had the potential to negatively affect the resident's physical well-being. Findings include: - Review of R1's diagnoses from the Electronic Health Record (EHR) documented, 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), diverticulitis (inflammation of the diverticulum, in the colon, which caused pain and disturbance in bowel function), and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident had a total mood severity score of 00, indicating no depression and no behaviors. R1 required limited assistance with activities of daily living (ADLs), with bed mobility, toileting hygiene, and dressing, set-up for eating. R1 was occasionally incontinent of bladder. The resident required a regular diet consistency and no added salt. The Quarterly MDS dated [DATE], documented a BIMS of 12, indicating moderately impaired cognition. The resident had a total mood severity score of 01, indicating minimal depression and no behaviors noted. R1 required limited assistance of staff with ADLs, set-up for eating. The resident required a regular diet regular consistency and no added salt. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 12/14/23, documented R1 required assistance with her ADLs. The Nutritional CAA dated 12/14/23, documented R1's weight was stable. The facility encouraged balance meals. The Care Plan dated 07/02/24, revealed R1 required staff to provide assistance to take R1 to and from meals as requested and provided supervision and set up assistance. Staff were to assist the resident as needed. Staff were instructed to see the EHR for current physician orders and treatments. Staff were instructed to monitor weights weekly and as needed. Review of the Progress Notes from 08/10/23 to 07/03/24 documented the following: On 02/29/24 at 09:09 AM, Consultant GG documented, R1's weight review, noting the resident's weight was up 7.5% in six months and up 3.1 percent (%) in one month. The resident had weight gain noted. On 03/16/24 at 01:18 PM, R1 was sent to hospital for possible stroke. On 04/11/24 at 09:13 AM, Consultant GG documented, R1's weight was down 9% in one month but was impacted by fluid shifts and a hospital stay. On 04/25/24 at 10:28 AM, Consultant GG documented, R1's weight was down 16 pounds since 03/13/24. R1 went to the hospital and returned with a weight loss. R1's usual weight was between 160 and 170 pounds (lbs.). On 05/09/24 at 09:31 AM, Consultant GG documented R1's weight was down 6.4% in one month and R1 stated she was not trying to lose weight. On 05/16/24 at 04:32 PM, Dietary Staff BB documented R1's weight was 150.8 (lbs.) with meal intakes at 50% and questioned a dietician referral. On 05/29/24 at 10:29 AM, the resident's physician was updated on weight loss. On 06/10/24 at 12:39 PM, Consultant GG documented R1's weight was 141 lbs. and recommended adding a house supplement twice a day and snack of choice daily for decreased appetite and weight loss. On 06/12/24 at 08:06 AM the facility notified the physician extender of the resident's weight loss and loss of appetite. Review of R1's Physician's Order in the EHR revealed a 03/28/24 order for daily weights. Review of weights in the EHR from 03/28/24 until 07/01/24 documented the following weights for R1: 04/07/24 at 06:47 AM, 161.2 lbs. 04/14/24 at 07:24 AM, 162.2 lbs. 04/21/24 at 06:56 AM, 163 lbs. 04/28/24 at 08:34 AM, 153.2 lbs. 05/05/24 at 08:06 AM, 150.6 lbs. 05/12/24 at 07:01 AM, 150.8 lbs. 05/19/24 at 07:05 AM, 150.2 lbs. 05/26/24 at 09:23 AM, 150.9 lbs. 06/02/24 at 07:04 AM, 145.6 lbs. 06/07/24 at 07:55 PM, 139.6 lbs. 06/08/24 at 07:59 AM, 141.2 lbs. 06/09/24 at 07:01 AM, 141.6 lbs. 06/10/24 at 06:49 AM, 141 lbs. 06/11/24 at 07:22 AM, 142.6 lbs. 06/12/24 at 09:31 AM, 142 lbs. 06/13/24 at 09:52 AM, 142.2 lbs. 06/15/24 at 08:15 AM, 143 lbs. 06/17/24 at 01:42 PM, 141.1 lbs. 06/18/24 at 09:56 AM, 142.6 lbs. 06/19/24 at 07:10 AM, 139.8 lbs. 06/20/24 at 08:10 AM, 140 lbs. 06/21/24 at 09:39 AM, 137.8 lbs. 06/22/24 at 06:44 AM, 142.1 lbs. 06/23/24 at 06:18 AM, 142.4 lbs. 06/24/24 07:49 AM, 141.8 lbs. 06/25/24 at 11:25 AM, 142.6 lbs. 06/26/24 at 11:47 AM, 143 lbs. 06/27/24 at 01:20 PM, 141.6 lbs. 06/28/24 at 01:42 PM, 139.8 lbs. 06/29/24 at 07:46 AM, 138.8 lbs. 06/30/24 at 09:02 AM, 140 lbs. 07/01/24 at 12:35 PM, 138.0 lbs. Observation on 07/01/24 at 12:36 PM, revealed R1 sat on the side of bed and watched television. R1 stated she was waiting for her lunch to be delivered. On 07/02/24 at 01:24 PM, Licensed Nurse (LN) H stated R1 lost weight after the resident was ill in late March 2024 and the resident had just not been herself since then. LN H stated the resident also had a lot of edema (swelling resulting from an excessive acumulation of fluid in the body tissues) that she needed to be treated for. On 07/02/24 at 02:08 PM, LN H stated the amount of house shake a resident consumed should be on the medication administration record and agreed that it was not on R1's medication administration record. LN H verified with CMA T that R1 consumed 50% of her 120 milliliter house shake and added that to the EHR order for further documentation. LN H stated that R1 became a daily weight in June of 2024. On 07/02/24 at 02:43 PM, Administrative Nurse E agreed that the current orders on the EHR stated the resident required a daily weight since 03/28/24 but could not find any daily weights documented in EHR until 06/07/24. Administrative Nurse E stated the order must have changed to weekly, but they could not locate a physician order. Administrative Nurse E stated that the house shake amount consumed should be documented in the EHR by staff. On 07/03/24 at 10:30 AM, Administrative Nurse D stated the daily weight order was correct from 03/28/24 and noted she placed the order in the EHR when R1 readmitted to the facility and could not explain why a daily weight was not completed until 06/07/24. Administrative Nurse D stated there could be an issue with the EHR system being used and would need to reach out to the company. The facility did not provide a policy regarding weight loss and following a physician order. The facility failed to obtain daily weights as ordered for R1 on 03/28/24. This deficient practice had the potential to negatively affect the resident's physical well-being.

The facility reported a census of 58 residents, with 5 residents sampled for review. Based on observation, interview, and record review, the facility failed to provide supervision and assistive devices to ensure 1 (#1) cognitively impaired resident remained free from injury when staff were aware of the resident who required 2 staff for transfers, and were aware the resident was unsafe in an electric reclining chair which resulted in bilateral femur fractures. The facility further failed to provide (#5) adequate interventions to keep the resident as free from falls as possible. Findings included: - Resident # 1 admitted on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS (minimum data set), dated 4/24/17, revealed the resident had a BIMS (brief interview for mental status) score of 4, indicating severely impaired cognition for daily decision making. The resident was dependent on 2 staff assistance for transfer and toileting. The resident had functional limitation in range of motion on one side of his/her body that included the upper and the lower extremity. The annual MDS, dated [DATE], revealed the resident had a BIMS score of 3. No other changes. Review of the Fall Assessment, dated 7/17/17, with a score of 10, revealed a moderate risk for falls. Review of the lift chair assessment, dated 12/15/15, documented the resident lacked the ability to understand, remember, or use the remote control unassisted or unsupervised, and he/she was unable to raise the chair to the up position without assistance. The resident was not a candidate for using the lift chair unassisted or unsupervised. The fall CAA (care area assessment), dated 7/27/17, documented the resident with an increased risk for falls because of his/her impaired cognition and he/she was unable to bear weight. The fall risk care plan, dated 7/21/17, directed staff to use a mechanical lift with 2 staff for safe transfers. Place an orange star (a system staff used to identify the resident with a high risk for falls) on the resident's door frame of his/her room. Review of the nurse's progress notes from 7/26/17 to 8/8/17, documented the resident fell on [DATE], at 10:45 am, after direct care staff H transferred the resident from the bedside commode to the recliner. Direct care staff H turned away from the resident, and when he/she faced the resident, the resident's recliner elevated, and the resident fell to the floor. The resident complained of pain in both legs and knees, and staff transferred the resident to the hospital for evaluation and treatment. Review of the radiology report, dated 8/3/17, evidenced the resident fractured both distal femurs (fractures of the thigh bones just above the knee joint) and fractured the proximal tibia/fibula (shin bones) with soft tissue hematomas (ruptured blood vessel that leaks blood into the surrounding fatty tissue). On 8/29/17 at 12:05 pm, direct care staff C, reported residents that need to transfer with a full body mechanical lift require the assistance of 2 staff. On 8/29/17 at 1:44 pm, licensed nursing staff D, identified 2 staff need to transfer the resident with the mechanical lift. He/she reported staff were aware that the sit-to-stand and full body mechanical lifts required 2 staff for residents who required a mechanical lift for transfers. He/she reported staff completed electric reclining chair assessments for safety of all residents who had an electric recliner on admission. On 8/29/17 at 1:57 pm, direct care staff E, reported he/she worked on the day the resident fell , and direct care staff H did not seek assistance from staff to assist with the resident's full body mechanical lift transfer (and transferred the resident alone). Direct care staff E reported that transfers of all residents with mechanical lifts, all the time, without exception, required 2 staff. On 8/29/17 at 2:47 pm, direct care staff F, reported 2 staff required to transfer any resident that used a mechanical lift. On 8/29/17 at 4:12 pm, direct care staff G, reported upon hire, administrative staff informed him/her to never use a mechanical lift by themselves. On 8/29/17 at 4:24 pm, direct care staff H, verified he/she transferred the resident from the bedside commode to the electric recliner alone, turned away to empty the commode, and when the resident replied he/she was going down, staff turned around and the resident's lift chair was in a standing position, and the resident slid down to the floor. Staff reported the resident must have played with the recliner remote, and reported the resident played with the recliner remote in the past. Direct care staff H verified he/she was aware that 2 staff were required to operate the mechanical lifts, but we have (staff) all transferred lift people with 1 staff at one time or another. In addition, he/she verified that administrative staff provided an in-service to staff regarding 2 staff members present to operate the mechanical lifts. On 8/30/17 at 11:14 am, physician I, verified the resident had a fall at the facility that resulted in fractures, and staff should follow this resident's individualized care plan to keep the resident as safe as possible. On 8/30/17 at 10:30 am, administrative nursing staff B, reported electric lift chair assessments were only completed on admission and as needed, and he/she stated 2 staff were to transfer the resident with the mechanical lift. He/she was unable to determine if the resident fell from the mechanical lift or the electric recliner, and verified the resident had fractures that resulted from the resident's fall on 8/2/17. On 8/30/17 at 12:30 pm, administrative staff A, verified 2 staff were needed to transfer the resident from the commode to the recliner in the mechanical lift, and he/she verified the resident sustained [REDACTED]. The accident policy, dated 11/28/16, documented safety risks and environmental hazards identified on an ongoing basis, that included employee monitoring. In addition, the facility lacked a policy for transfers with mechanical lifts and resident recliner assessment policy. The facility failed to follow this cognitively impaired resident's care plan to provide 2 staff for transfer with the mechanical lift. One staff transferred the resident, who fell and sustained multiple fractures of both legs. In addition, the facility failed to remove the electric lift chair, for this resident who was not a candidate for using the lift chair unassisted or unsupervised. - The signed physician orders, dated 8/25/17, of resident # 5, documented the resident admitted on [DATE], with the following [DIAGNOSES REDACTED]. The significant change MDS (minimum data set), dated 7/14/17, revealed the resident had a BIMS (brief interview for mental status) score of 3, indicating severely impaired cognition. He/she required extensive assistance of 1 staff for transfers, ambulation, and locomotion. The resident's balance was unsteady, and he/she had impairment of one side of his/her upper extremity. The resident had one non-injury fall and 1 major injury fall since the previous assessment. Review of the Fall Assessment, dated 7/14/17, with a score of 13, revealed high risk for falls. The fall CAA (care area assessment), dated 7/20/17, documented the resident had a fall that resulted in a right wrist fracture as well as one non-injury fall. The resident received therapy, and encouragement to wait for staff assistance, and staff placed cue notes around the room for the resident to read. The resident has difficulty maintaining his/her balance. The fall care plan, dated 6/29/17, guided staff to encourage the resident to use the front wheeled walker in the hallway with a gait belt and assistance of 1 staff. On 8/22/16, additional instructions to staff not to rush the resident, and safely encourage his/her independence. Staff are to check on the resident frequently when walking by the resident's room. Staff to place the bed at a level when the resident sits on the bed, the resident's feet are firmly planted on the floor. Staff may need to increase assistance from 1 to 2 staff, or use a mechanical lift if needed. On 6/22/17, addition included, PT/OT (physical and occupational therapy) evaluated the resident, and provided the resident a soft touch call light. On 7/14/17, additionally, staff discussed regarding a bedside commode or a toileting plan at bedtime. On 8/23/17, additionally, the resident had an unwitnessed fall, and neurological assessments started. On 8/24/17, mobile x-ray revealed a fracture of the left inferior pubic ramus (part of the pelvis). On 8/27/17, a 3 day voiding diary to assess/establish voiding routine, however, the care plan lacked interventions for the 8/23/17 fall. Review of the progress notes, from 8/20/17 to 8/29/17, revealed the resident was on antibiotics for a urinary tract infection, and he/she had periods of confusion, packing clothing, and wanting to leave. On 8/23/17 at 5:06 pm, staff reported the resident fell in his/her bathroom. The resident's walker was in the bedroom across the room, by the resident's bed. Staff reported the resident was tearful, and upset with him/herself. On 8/24/17 at 5:19 am, the resident called for assistance to the bathroom, and he/she complained of left hip pain. A mobile X-ray at 8:51 am, confirmed a minimally displaced fracture of the left inferior Pubis Ramis. The staff felt the fall could have been caused by poor vision, and the resident went to an eye appointment for assessment, that revealed the resident's vision was not a factor in the resident's fall. On 8/25/17, the physician ordered the elder to use a wheelchair and not walk for 2 weeks. The resident could transfer by pivoting. Review of the 3 day voiding diary from 8/27/17 at 6:00 am to 8/29/17 at 11:00 am, revealed the voiding diary lacked documentation on 8/2/17 from 6:00 am until 2:00 pm, with the exception of documentation at 7:00 am. On 8/29/17, the voiding diary lacked documentation. On 8/29/17 at 10:42 am, the resident sat in a wheelchair in the commons room, with feet elevated. Staff propelled the resident into his/her room, and 2 staff transferred the resident from the wheelchair to the bed with a sit to stand lift. Staff did not offer to toilet the resident as part of the voiding assessment. Staff placed a call light on the resident's abdomen, and clipped a sensory call light at the edge of the bed towards the edge of the bed, approximately half way from the head to the foot of the bed. On 8/29/17 at 4:34 pm, 2 staff transferred the resident from the bed to the wheelchair with a gait belt. The resident pivoted from the bed to the wheelchair. On 8/29/17 at 10:33 am, licensed nursing staff J, identified the resident tries to get up on his/her own, and staff are aware the resident attempts to get up, so when staff walk by the room, they frequently check on him/her. Staff J verified the resident sustained [REDACTED]. Licensed nursing staff J stated staff did not place any new intervention in place to prevent further falls, because staff were waiting for the assessments to be completed. On 8/29/17 at 10:50 am, direct care staff K, reported the resident fell while attempting to toilet him/herself. On 8/29/17 at 11:15 am, direct care staff L, was unaware the resident was on a voiding diary to assess the resident's voiding pattern. On 8/29/17 at 11:15 am, administrative staff M, verified a voiding assessment was not an intervention, and staff lacked an appropriate intervention to keep the resident safe from falls while the assessments were being completed. On 8/29/17 at 4:54 pm, direct care staff O, reported the resident might have fallen when the resident turned around to turn the bathroom light on or off. On 8/29/17 at 4:56 pm, direct care staff N, reported to keep the resident safe, staff are to have 2 call lights for him/her. One call light is placed on his/her chest, and the other at the edge of the bed. They (staff) put a lock on the light switch today, and it was not on yesterday. Staff N reported the resident did not ambulate due to the resident being in a wheelchair now. On 8/30/17 at 10:30 am, administrative nursing staff B, reported the facility identified the resident was turning around, and the eye appointment was to assess if low vision could have been a cause of the fall. He/she verified assessments would not keep residents safe, and the resident did not have an intervention at the time of the fall to keep the resident as safe as possible. The facility's accident policy, dated 11/28/16, documented safety risks and environmental hazards identified on an ongoing basis, that included employee monitoring. In addition, the facility's urinary continence and incontinence policy, dated 11/22/16, documented staff will screen for ongoing assessments. Furthermore, the facility's policy for care plans, dated 11/21/16, documented care plans are revised as information about the resident and the resident's condition change. The facility failed to place fall interventions for this resident who had a fall, to keep the resident as safe as possible.

The facility reported a census of 69 residents. Based on observation, interview and record review, the facility failed to maintain an accurate system to ensure staff were aware of the code status of residents in the facility. The facility failed to have systems in place to ensure availability qualified staff to perform CPR (cardiac-pulmonary resuscitation) 24 hours a day/7 days a week for the 22 full code residents, and identified 22 with a full code status (chose to receive resuscitation cardiac/respiratory arrest, cessation of a heartbeat and respirations). This placed all residents in the facility in immediate jeopardy. Findings included: - Resident #1's quarterly MDS (minimum data set), dated [DATE], revealed the resident's cognition intact with a BIMS (brief interview for mental status) score of ,[DATE]. The resident had no behaviors, no signs of [MEDICAL CONDITION], no change in mental status, and had poor balance with all transfers but able to stabilize without physical assistance. The resident required limited assistance of 1 staff for bed mobility, walking, transfers, dressing, toileting and hygiene needs. The care plan, dated [DATE], included; Staff to offer emotional support and contact other departments as well to provide this. Resident states he/she can feel '[MEDICAL CONDITION] activity' and migraines increase due to shakiness and blurred vision. Staff to ensure he/she is safe and comfortable. Notify primary care physician with any concerns and issues. One person assist with transfer and ambulation. Must use gait belt. Requires an assist of 1 with all other activities of daily living needs. The care plan identified the resident had advanced directives with Do Not Resuscitate. The resident will expire with dignity and in comfort with no heroic measures. Do not start CPR if his/her heart stops beating and he/she is no longer breathing. The resident has chosen a Do Not Resuscitate status. The nurses notes, dated [DATE] at 1:32 PM, documented that at approximately 8:30 AM, licensed nursing staff J came to the nurses station to ask this writer (licensed nursing staff I), for another Oximeter as staff J obtained a oxygen saturation level of 61% on the resident. Staff I went to the resident's room and was unable to obtain a oxygen saturation level as the resident's fingers were cool to touch. The resident was able to follow simple directions at this time. Staff I was unable to obtain a blood pressure reading but finally obtained a reading of ,[DATE] manually. Staff I then directed a direct care staff to go obtain a warm blanket to wrap the arm and hand in hopes to warm it up to get an oxygen saturation level. Still unable to obtain the level. (Lacked any times during these procedures) At approximately 9:00 AM, a direct care staff ran to the nurses station stating the resident was now frothing at the mouth. Staff I immediately went to the resident's room and found him/her unresponsive and noted no respirations or pulse. Staff I called for a crash cart and initiated CPR (cardiac-pulmonary resuscitation). when the code status was verified staff I stopped CPR. On [DATE] at 6:10 PM, interview with administrative staff A and licensed administrative staff B, revealed former resident #1 expired on [DATE] in the morning at approximately 8:30 to 9:00 AM. A CNA (certified nurse aide) entered the resident's room and the resident had a frothy substance around his/her mouth, and the CNA did not think the resident was breathing. The CNA then informed a licensed nurse, who assessed the resident and began chest compressions. Another licensed nurse went to check in the computer to see what the resident's advance directive instructed staff to do. The second nurse returned and informed the first nurse the resident had a DNR (Do Not Resuscitate) status, so the first nurse stopped CPR (cardiopulmonary resuscitation) before the EMTs (Emergency Medical Technicians) arrived. The resident had felt cool to touch with pale color when the nurse entered the room to assess him/her. The first nurse was in charge of a different nursing unit and was not familiar with the residents on this unit. On [DATE] at 6:40 PM, licensed administrative staff B explained the facility system to ensure the staff timely access to identify each residents advance directive/code status. Staff B reported each residents door contained a name plate with the resident's name and if the resident had a DNR, the name plate contained a small butterfly sticker. The residents with full code status would not have the butterfly. At that time, observation of former resident #1's door, revealed the name plate contained the butterfly sticker, which indicated the resident desired a DNR, or no attempts at resuscitation. On [DATE] at 7:15 PM, observation during a tour revealed resident #2 sleeping in a bed, with noted personal items in the room. However, the resident's room door lacked a name in the name plate and/or a butterfly sticker. On [DATE] at 7:20 PM, licensed nursing staff E explained if a CNA (certified nurse aide) came out of resident #2's room and reported him/her not breathing, he/she would go to check the resident, start CPR if needed, and send someone to check the resident's code status in the computer because that is where you find out if the resident was a full code or a DNR status. When the staff found out, and if the resident was a DNR, then staff E would stop the CPR. Licensed nursing staff D reviewed resident #2's medical record in the computer and reported a label sign on the admission sheet revealed resident #2 was a DNR. On [DATE] at 7:30 PM, direct care staff F, came to the nursing desk and provided licensed nursing staff D and E with a resident roster, which included the residents names, some with a butterfly beside the name and some without. Staff F informed staff D and E, this roster would inform them of the resident's code status. However, at this time, review of the resident roster, indicated resident #2 without a butterfly symbol. This indicated the resident was a full code status, which did not match the computer record for this resident. Staff E explained the paper roster was not updated and the staff could not follow it. Both licensed nurse staff D and E, stated they would not know what to do if resident #2 was found not breathing. Furthermore, both licensed nurses D and E reported he/she was certified in CPR. However, when staff D provided his/her certification card for CPR, it expired on [DATE]. When staff E provided certification card for CPR, it expired in November of 2015. On [DATE] at 7:55 PM, licensed nurse staff C, in charge of the other nursing unit, stated his/her certification card for CPR expired on [DATE]. At this time, staff C reported he/she would often compare the paper resident roster/butterfly list with each resident's computer record to make sure they were correct. However, staff C confirmed he/she failed to compare these for this nursing unit for approximately the last month or so. On [DATE] at 8:10 PM, administrative nursing staff B reported going through personnel files in the office and he/she found a current CPR certification card for licensed nursing staff C. The facility lacked a policy for facility system for identification of the current code status the resident desired. The facility policy and procedure, dated [DATE] for Cardio-Pulmonary Resuscitation (CPR), included the following: CRITICAL: Do Not stop CPR for more than 10 seconds unless: *The elder is revived. *A doctor or EMS (emergency medical service) arrives. * Or you are unable to continue due to physical exhaustion and there is no other trained person to relieve you. Furthermore, review of the facility provided nursing schedule, from [DATE] through [DATE], in comparison with the facility identified nursing staff with current CPR certification, revealed on 5 night shifts (10 PM to 6 AM), the facility lacked anyone onsite with current CPR certification. These night shifts included; [DATE], [DATE], [DATE], [DATE] and [DATE]. The facility failed to have systems in place to ensure availability of qualified staff to provide CPR 24 hours a day/7 days a week as required and failed to have a system in place to alert staff of residents code status. This deficient practice placed the resident in the facility in immediate jeopardy. On [DATE] at 8:30 PM, administrative staff A, administrative licensed nursing staff B and G, received notification, the facility system for identifying the residents of the facility desired code status, left the residents of the facility in immediate jeopardy for not receiving the code status they desired. Immediately the staff reviewed and revised the resident's desired code status to match, in the computerized medical records, the resident roster butterflies and the butterfly stickers on the resident's doors. The facility abated the immediate jeopardy on [DATE] at 4:30 PM, when the facility, in-serviced all of the nursing staff related to the system to identify the residents code status. The facility also reviewed and corrected all of the residents documented code status, in all areas of the system, to ensure staff timely knowledge of correct code status for each resident of the facility. This deficient practice remained at the scope and severity of F.

The facility reported a census of 72 residents, with 3 residents sampled for elopement. Based on observation, interview and record review the facility failed to provide adequate supervision to prevent the elopement of one of the three sampled residents (#1) from the facility. The confused resident, who was unstable while walking, exited the front door of the facility without staff knowledge, and was found approximately 30 minutes later, approximately 0.3 miles from the facility, on a busy roadway, walking directly toward the freeway access intersection which was less than one half of a block ahead of the resident, placing the resident in immediate jeopardy. In addition, the facility failed to maintain an environment free of accident hazards for the 10 independently mobile and confused resident of the facility with unsecured doors without alarms and unsecured rooms that contained numerous accident hazards. Furthermore, the facility failed to educate staff and visitors about the risk of confused residents exiting the facility when the exit doors were opened. Findings included: - The Physician's Admission Order, dated 4/20/15, documented resident #1 admitted to the facility on [DATE] from the facilities independent living area with [DIAGNOSES REDACTED]. The admission Minimum Data Set, dated dated [DATE], documented the resident with brief interview for mental status score of 7, indicating severely impaired cognition and required supervision of staff for ambulation with a walker. The resident was unsteady, but able to stabilize without staff assistance and did not wander. The care area assessment for cognition, dated 4/27/15, identified the resident with severe impairment and had admitted to the facility from campus (independent and assisted living homes on the facility grounds) due to a decline in cognition related to dementia. The assessment for ADLs (activities of daily living) documented the resident required supervised assist, used a walker for ambulation, and had memory issues which required routine reminders. The resident was also identified as a fall risk with a documented fall since admission that resulted in an abrasion to the forehead and left toe. The resident had complained of pain prior to the fall and had medications and [DIAGNOSES REDACTED]. The interim care plan for new admission, dated 4/20/15, documented the resident as confused and directed staff to reorient the resident and the resident was self-mobile with a walker and lacked identification of elopement risk. The updated comprehensive care plan, dated 5/12/15, documented the resident required supervision for all ADLs (activities of daily living) and used a walker for ambulation. The resident was identified at risk for falls and directed staff to assist with ambulation, supervise with the walker, and provide frequent visual checks while passing the residents room. The resident was identified with impaired cognition and directed staff that independence was very important to the resident, allow him/her to be as independent as safely possible. The care plan lacked identification of elopement risk. The admission elopement risk assessment, dated 4/20/15, documented risk factors including dementia, depression, difficulty in new situations regarding daily decision making, required supervision for walking on and off the unit, and a recent move to the facility. The assessment then identified the resident as not an elopement risk, however the residents clothing was labeled with identification as a preventative action and staff were directed to initiate a care plan. The interim CP lacked any identification of elopement. The admission fall risk assessment, dated 4/20/15, documented the resident with intermittent confusion, poor balance, and a score of 14, indicating high fall risk. The nurse's notes, dated from 4/20/15 to 5/21/15, documented the resident to be weak and with increased confused, anxiety, observed by staff stumbling and leaning against the wall while walking, with multiple falls, and started on an antibiotic for pneumonia. The nurse's note, dated 5/24/2015 at 3:08 PM, documented the resident came by the nurse's station, as always after lunch. When greeted, the resident replied, I am going home, as he/she does quite often. The nurse then went to do other cares with other residents and after about 15 minutes received a phone call asking if the resident was allowed to be outside, and that the resident was about a block and a half away from facility. The nurse called the nurse manager on duty to go get the resident who reported the resident stated he/she was going to the store. On 6/17/15 9:30 AM, observation revealed the resident ambulate to the door and back to the bed without the walker, with a moderate pace and steady gait. At 11:24 AM and 3:04 PM, the resident ambulated down the hall independently with the walker. On 6/17/15 at 9:32 AM, the resident reported he/she remembered leaving the facility alone, stating he/she used to live about 3 blocks away and wanted to go see how they were doing with the buildings. The resident stated it is a few miles now, but then, it was not that many miles. Leaving upset them (the staff), but the resident felt he/she did not do anything wrong. The resident stated he/she just walked up to the door, opened it, and walked out. The resident stated it took probably 15 to 20, maybe 30 minutes before staff found the resident. On 6/17/15 at 11:49 AM, direct care staff D reported the resident frequently walked up and down the halls independently and would go to the front of the facility and look out the door. On 6/17/15 at 5:09 PM, direct care staff J reported the resident usually sits up front by the door. The resident would repeatedly tell staff that family is coming to get him/her, but staff did not always know if that was true or not. Staff J stated the resident used a walker and was independent, staff J did not supervise or offer assistance when the resident was walking around the facility. On 6/17/15 at 6:24 PM administrative nursing staff B confirmed the resident eloped from the facility through the front door using the code to open the door without staff knowledge on 5/24/15. On 6/18/15 at 8:42 AM, licensed nursing staff L reported the resident was independent in ambulation, stating staff did not supervise or do frequent checks on the resident. On 6/18/15 at 9:08 AM, direct care staff M reported the resident was totally independent in ambulation and staff did not help the resident. Staff M stated the resident was rarely in the room, walked all over the facility, really liked to sit up front by the door, and knew the code to get out because he/she had lived on the facility campus since 2009 and used the code daily to come and go from the facility for meals. On 6/18/15 at 9:35 AM, direct care staff N reported seeing the resident while off work driving in his/her car, on 5/24/15 at about 1:10 PM. Staff N saw the resident walking along the street and pulled over to ask what the resident was doing. The resident replied he/she was going for a walk, but did not know exactly where he/she was going. Staff N then drove on past the resident, stating he/she was familiar with the resident from working with him/her in independent living in the past, and thought the resident had moved into the skilled nursing part of the facility since then, but was not certain. Staff N thought maybe the resident should not be out and away from the facility without supervision, called the nurse, and was told the resident should not be there and staff had not been aware he/she was gone. Staff N then called the van driver from the assisted living and gave the location of the restaurant by where staff N had seen the resident walking. Staff N had gone on to the gas station and came back to where the resident had first been seen walking by the restaurant parking lot, stating the facility van was there at that time to meet staff N, but the resident was not there anymore. The staff began looking for the resident, and saw that he/she had continued to walk another block near another restaurant located on the main street and was walking toward the interstate overpass and round-a-bout (another half block ahead). Staff N stated the resident seemed fine the first time staff N saw the resident walking. But, after staff N went to the gas station, turned around and came back, and found the resident, it was close to 1:30 PM. At that time, staff N reported the resident was clearly exhausted, sweaty and clammy. Staff N described the environment where the resident was found with a lot of traffic on the road, stating he/she was walking on the main road at that time, which comes in right off the interstate. Staff N also explained it was Memorial weekend, and there is a large cemetery across the street from where the resident was found, and staff N had never seen the road as busy as it was that day with the traffic in and out of the cemetery. Staff N stated that the facility staff had to block off traffic with their vehicles to be able to get to and pick up the resident safely. A tour of the neighborhood around the facility, on 6/18/15 at 12:30 PM, revealed the shortest route to the location where the resident was found from the front door of the facility was through a residential neighborhood that lacked any sidewalks, leaving only the traffic area of the road for the resident to walk. The vehicle odometer read 0.2 miles through the residential area to the first restaurant where the resident was seen. This intersection is on a residential road, with a posted 20 mph (mile per hour) speed limit and a higher traffic road in a commercial area, with a posted 35 mph speed limit. The final destination where the resident was picked up by facility staff was 0.3 miles from the facility. The wunderground.com website documented the weather on 5/24/15 at 1:30 PM was 66.2 degrees fahrenheit, cloudy, humid and with no precipitation. The facility failed to provide adequate supervision for this resident who eloped from the facility, without staff knowledge, and was found approximately 30 minutes later, approximately 0.3 miles from the facility, on a busy roadway, walking directly toward the freeway access intersection, which was less than one half of a block ahead of the resident placing the resident in immediate jeopardy. The facility abated the immediate jeopardy, on June 19, 2015, at 11:40 AM by initiating the following: The facility developed and implemented a facility wide system to assure correction and continued compliance with the regulations. All resident's at risk for elopement were re-assessed by nursing staff. All door codes were posted in a more discrete manner. Signs were placed at exit doors educating all who enter or exit to be aware of residents in the vicinity of the door and to seek assistance from staff as needed. All staff attended an in-service, held on 6/18/15 at 1:00 PM and 5:00 PM, regarding abuse, neglect and exploitation and elopement, including identifying factors for a resident at risk for elopement. This immediate jeopardy was abated, on June 19, 2015 at 11:40 AM; however, the deficiency remained at a scope and severity of a D. - The facility tour, on 6/17/15 from 12:06 PM to 12:53 PM, revealed 3 unsecured stairwell doors to access the basement that lacked alarms. The basement contained numerous accident hazards, should a confused mobile resident go through these doors or through the elevators which lacked a wanderguard alarm system. The accident hazards included a boiler room and a laundry room that were not secured and unattended by facility staff during this time. The basement also contained 4 exterior exit doors. Each of these doors opened multiple times during the tour, with no audible alarm sounding and no staff responded to the open doors. The boiler room contained one pallet of 16 each 5 gallon buckets of paint, 1 gallon of joint compound, one pallet full of used one gallon paint buckets stacked approximately 5 feet tall, a work bench with a rusty saw and a grease gun, a joint compound bucket with paint thinner written in marker across the label, 2 air compressors, 4 boilers, 2 furnaces, and an approximate 2 foot round hole in the floor approximately 4 feet deep with a sump pump in the bottom of the hole. The laundry room contained multiple shelving units, fully stocked with chemicals and supplies including 12 each 32 oz (ounce) germicidal, 7 each 32 oz liquid crème cleanser, 24 each 32 oz tile and grout rejuvenator, 18 each 32 oz. Magic bio enzymatic foul odor stain eliminator, 4 each 1 gallon tubs hydrogen peroxide, 10 each containers germicidal wipes, and 6 each 1 gallon buckets germicidal bleach. Each of these containers had labels that read, Danger poison, keep out of reach of children. Also, on the shelves was a box knife with the blade open. A table in the room contained a hot plate press, approximately 3 inch by 5 inch, with a digital read out on the machine that said 389. The heat from the press could be felt from several inches away. At 1:51 PM, the laundry room remained open and unattended by staff. The hot plate press temperature measured 338 degrees Fahrenheit. An open area in the basement contained exercise equipment for the resident's use and an open work area for the maintenance staff that contained numerous wheelchair parts (foot pedals, wheels and unidentified parts) piled on a table approximately 2 foot high as well as under the table and extending out into the walk path by approximately one foot, a rusty saw hung on the wall, the cabinet under the sink contained one gallon of bleach and on the counter next to the sink was an open container of powdered scrubbing cleanser with bleach labeled Danger poison, keep out of reach of children. On 6/17/15 at 12:53 PM, direct care staff D stated the doors in the facility that have alarms use the code 36*, including the elevators, which lead to the basement. Staff D stated the residents use the elevators independently and know the code to the doors. Staff stated there are doors that go to the outside from the basement and the stair well doors that access the basement do not have alarms. Staff confirmed it was possible for the confused residents to gain access to the basement independently without sounding an alarm. On 6/17/15 at 1:02 PM, direct care staff G reported that the alarm for door 13 sounded, which was the door in the basement near the laundry room. But, when staff G was called by the nurse to go check the door, staff G told the nurse it was just housekeeping staff that were coming and going. Staff G had gone downstairs and looked at the door, did not see anyone in the hall, so staff G thought it was not a problem. Staff stated the door in the hall between the laundry room and boiler room was the only basement door with an alarm. On 6/17/15 at 1:55 PM, Licensed Nursing Staff E reported any cognizant resident would know the 36* door code. Staff E confirmed that the residents who are cognitively intact do not know which residents are not, and they could allow a confused resident to go into the elevator with them without staff knowledge, as this is not monitored by staff and residents come and go independently on the elevators to the basement. On 6/17/15 at 2:53 PM, an alert and oriented resident (#5) reported he/she used the code to go out of the facility all the time and did not know which residents are not allowed out of the facility. On 6/17/15 at 3:02 PM, an alert and oriented resident (#6) reported he/she exited the building frequently and 6600 is the new code for the front door. The resident stated he/she went out whenever he/she wanted to go and did not know who should go out and who should not. The other doors to go out are 3600, or maybe it is 36. The resident stated it is posted on the door, so the resident does not have to remember the code. On 6/17/15 at 3:12 PM, an alert and oriented resident (#7) reported he/she went out the front door all the time, used the code 36*, and used the elevator all the time with the same code. The resident stated he/she was sure there were residents that maybe should not go out the door, but had no idea who they were. The resident stated it was common that several of the residents used the elevator to go downstairs together after one of the residents punches in the code and the resident had no idea if the other residents who get on the elevator are supposed to go out or not. On 6/17/15 at 4:34 PM, Licensed Nursing Staff I reported the door codes do not get changed. There was one door downstairs out of the conference room that had an alarm and the one by the laundry room. No other doors in the basement had alarms. On 6/17/15 at 6:24 PM, Administrative Nursing Staff B stated the facility door codes had always been posted directly on the door, not disguised or discretely posted. Staff B confirmed the doors to the stairwell had the key in them and to open the doors, you turn the key and pull the door open, making those doors unsecure. Staff B confirmed the facility lacked any signage or education to visitors that talked about alerting visitors or independent residents to confused residents near the door. Staff B confirmed the facility had 10 independently mobile and confused residents. On 6/18/15 at 7:24 AM, maintenance staff K reported the facility door codes had not been changed in [AGE] years, until 6/6/15, when only the front door alarm code was changed. Staff K reported that the boiler room door had not been locked for at least a year. Staff K further reported that there are a total of 4 exit doors in the basement that access to the outside, unsecured areas. Only the door in the hall between the boiler room and the laundry room had an alarm on it, and staff usually did not respond when that alarm sounds because it is too far down in the basement to go check it. Staff K stated that the staff just turn the alarm off at the nurse's station and say something like, It is ok, it is just laundry or maintenance going out. Staff K reported that the exit door in the conference room had an alarm that was only turned on at night, but not all of the time. Otherwise anyone can come and go from the basement without staff knowledge. Staff K reported the maintenance staff are never educated about letting residents in or out of the facility, and had no idea which residents were allowed to go out or not. Staff K reported that several of the residents know the door codes and use the codes to exit the facility and the stairwell doors to the basement do not lock, are accessible by anyone who can turn the key, and do not have alarms. On 6/18/15 at 11:50 AM, Administrative Staff A confirmed the stairwell doors to the basement were not secured or alarmed, allowing any resident access. Staff A also confirmed that there were numerous accident hazards in unsecured and unattended rooms in the basement in the form of chemicals, paints, tools and equipment with the potential to hurt a confused resident if they entered the basement unattended. Furthermore, there were 4 exit doors in the basement that allowed access to the outside unsecured areas and only one of these doors was alarmed. The facility lacked a policy for storage of chemicals or accident hazards and lacked a policy for security of exit doors. The facility failed to maintain an environment free of accident hazards for the 10 independently mobile and confused residents of the facility. The facility contained 3 unsecure doors without alarms that accessed stairwells to the basement level, 3 exterior exit doors in the basement level that were unsecure and without alarms, an unsecure boiler room and an unsecure laundry room that were unattended and contained numerous accident hazards. - On 6/17/15 at 1:04 PM, an unidentified resident was observed sitting by a locked coded exit door of the facility. A maintenance staff member was standing at the door with a 5 gallon bucket of paint and tools in hand and his/her back to the seated resident. The staff member could not initially get the code to open the door, and then saw that it was posted on the door in bold print that the code had been changed with the new code identified. The staff member opened the door and exited the facility. The unidentified resident stated, Oh, he/she got that open, now is my chance, I have to go! The resident got up and ambulated independently behind the maintenance staff, who never looked back to see the resident exit behind him/her through the open door. On 6/17/15 at 1:09 PM, an unidentified resident stood at the same door pushing 36* (the old code to the door). Maintenance staff H approached the resident from behind and asked the resident if he/she needed help, then entered the new code that was posted on the door and let the resident exit the facility while telling the resident the code had been changed and pointing out the new sign on the door with the code. Then, Staff H stated he/she had been told the facility had changed the code today because a resident at some point had tried to get out the door. Staff H knew some residents should not go out the doors, but was unable to identify those residents. When asked about the resident who staff H had just let exit through the door, Staff H stated the resident lived somewhere at the facility, but was unable to confirm where and staff H was also unable to confirm if the resident was allowed to exit the facility alone. On 6/17/15 at 6:24 PM, Administrative Nursing Staff B stated the facility had failed in communicating the residents at risk for elopement to all of the staff, including housekeeping and maintenance. Staff B stated the staff in general knew if an alarm went off that is a problem, but otherwise did not know the elopement risk residents. Staff B confirmed the facility lacked any signage or education to visitors that talked about alerting visitors to confused residents near the door. On 6/18/15 at 7:24 AM, maintenance staff K reported the maintenance staff are never educated about letting residents in or out of the facility and have no idea which residents should go out or not. The facility failed to educate staff and visitors about the risk of confused residents exiting the facility when the exit doors were opened.

The facility census totaled 80 residents, with 20 residents included in the sample. Two residents were reviewed for accidents. Based on interview, record review, and observation, the facility failed to thoroughly investigate all falls and implement appropriate fall interventions to prevent accidents for 2 of 2 residents (#49 and #97), resulting in injury for resident #49. The facility also failed to ensure the resident environment remained free of accident hazards by the failure to properly secure chemicals. This had the potential to affect 22 cognitively impaired and independently mobile residents. Findings included: - Review of resident #49's quarterly MDS (Minimum Data Set) dated 3/25/13 revealed a BIMS (Brief Interview for Mental Status) score of 8, indicating moderate cognitive impairment. The resident had not had any falls since admission/entry or reentry. The resident required supervision and set-up for transfers, walk in room/corridor, locomotion on/off unit, and toilet use. The resident had no falls since admission/entry or reentry. The resident admitted to the facility on [DATE]. Review of the significant change MDS dated [DATE] revealed a BIMS score of 10, indicating moderate cognitive impairment. The resident required limited assistance or one staff assist with transfers, and toilet use. The resident needed extensive assistance with walking in the room/corridor. The resident was not steady and only able to stabilize with staff assistance for the following: moving from seated to standing, walking, turning around, moving on/off toilet and surface-to-surface transfers. The resident had impairment on both sides of upper and lower extremities. The resident had a fall in the month prior to admission/entry or reentry. The resident had a fracture related to a fall in the 6 months prior to admission/entry or reentry. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 7, indicating severe cognitive impairment. The resident required extensive assistance of one with transfers, locomotion on unit, and toilet use. The resident had two or more falls since admission/reentry and two or more with injury none major. Review of the Cognitive Loss/Dementia CAA (Care Area Assessment) dated 6/26/13 revealed the resident had confusion, disorientation, and forgetfulness. The resident had recently fallen and sustained a hip fracture. The resident had no change in cognitive status from the previous admission or assessment. Review of ADL's (Activities of Daily Living) Functional Status/Rehabilitation Potential CAA dated 6/26/13 revealed the resident required assistance with ADL's due to his/her recent hip fracture. The resident forgot his/her limitations at times and would attempt to do ADL's without assistance. The Falls CAA dated 6/26/13 revealed a fall assessment of 16, which indicated the resident had an increased risk for falls. He/she received medications that increased the risk for falls. He/she had a hip fracture from last fall prior to hospitalization . Review of resident's Fall care plan initiated 3/28/13, revealed interventions that directed staff to be alert regarding the resident's condition and initiate facility fall guidelines. The care plan alerted staff that the resident ambulated with a walker and to keep the resident's bed at a level when he/she sat on the side of the bed his/her feet were firmly planted on floor. A revision to the care plan on 5/26/13 directed staff to remind the resident to stand slowly and pause before attempting to ambulate. Review of the resident's care plan for Falls, initiated, three weeks after the resident returned to the facility after a hospitalization , on 7/8/13 last revised 2/26/14, revealed interventions directed staff to be alert regarding the resident's condition and initiate facility fall guidelines. The care plan alerted staff that the resident ambulated with a walker, to keep the resident's bed at a level when he/she sat on the side of the bed his/her feet were firmly planted on the floor, remind the resident to stand slowly and pause before attempting to ambulate, frequent visual checks, and offer to "stand by" while the resident performed tasks as tolerated. A revision to the care plan on 12/5/13 alerted staff to increase visual checks on resident at night. A revision to the care plan on 2/26/14 revealed elastic waist band for trousers were suggested by staff to the resident, but resident declined to wear the trousers. Review of a Non-Immediate Communication to physician dated 5/9/13, revealed staff found the resident on the floor at 9:43 a.m. The resident reported he/she attempted to get out of bed due to back and right hip pain, attempted to grab the walker, and the resident lost his/her balance and fell to the floor. Review of a Nurse's Progress Note dated 5/26/13, revealed staff found the resident on the floor at 2:05 p.m. The resident reported he/she changed his/her brief then tried to pull up his/her pants and lost balance and fell to floor in his/her room. The resident complained of pain to the right hip with slight movement. The resident left at 3:15 p.m. via ambulance for the hospital and admitted with a right hip fracture. The resident was readmitted [DATE] to facility. Fall investigation dated 5/26/13 revealed the resident had just changed his/her brief and stood to pull up his/her pants. Review of a Fall Investigation dated 8/21/13, revealed the resident was ambulating with his/her walker lost his/her balance at 4:07 a.m. The facility failed to determine the root cause of the fall. The staff failed to revise the care plan. Review of a second Fall Investigation dated 8/21/13 at 5:15 a.m., revealed the resident stated he/she did not know he/she was up till he/she hit the floor then he/she woke up. The facility failed to identify the root cause of the fall. Review of a Fall Investigation dated 8/29/13 at 9:35 p.m. revealed the resident lost his/her balance while ambulating. The facility failed to investigate to determine the root cause of the fall. The staff reviewed the care plan, but but did not put new interventions in place. Review of a Fall Investigation dated 8/30/13 revealed the resident turned on the bathroom call light, upon entering resident's room staff found the resident on the floor between the wall and toilet at 4:36 a.m. The resident reported he/she was cleaning his/her bottom when he/her lost his/her balance and fell to floor. The staff reviewed the care plan, but did not put any new interventions in place. Review of a Fall Fax Report to physician dated 11/19/13 revealed the resident was going to get up to bathroom on side of bed and slid off to his/her knees. Fall Investigation from 11/19/13 revealed resident turned on call light and when the aide answered the resident was on his/her knees by side of bed, the staff assisted the resident up and to bathroom. The staff reviewed the care plan, but did not put new interventions in place. Review of a Fall Fax Report to physician dated 11/25/13 revealed staff found the resident on the floor at 5:50 a.m. The resident reported he/she got up with the walker and went to the chair. The resident stated he/she just went down. The facility failed to identify root cause of the fall on 11/25/13. The staff did not identify any new interventions on the care plan. Review of a Fall Fax Report to physician dated 12/5/13 revealed staff answered the call light and found the resident on floor in front of the recliner on his/her right side at 1:43 a.m. The resident stated he/she reached for crackers on the floor and fell out of the chair. The Fall Investigation for 12/5/13 revealed staff found the resident on the floor in his/her room in front of the recliner. The resident was able to turn on the call light for assistance. The resident stated he/she reached for crackers and fell to the floor. Review of a Fall Fax Report to physician dated 12/26/13 revealed staff found the resident on the floor in the bathroom between the commode and the wall at 2:21 a.m. The resident did not remember if he/she hit his/her head and did not want to go to the bathroom. Fall Investigation for 12/26/13 revealed the resident was putting lotion on his/her arms in the bathroom. Review of a Fall Fax Report to physician dated 1/9/14 revealed staff found the resident on the floor in front of the recliner at 5:54 a.m. The resident stated he/she came from the bathroom and missed the chair when he/she sat down and slid down to the floor. The Fall Investigation for 1/9/14 revealed resident walked to sit in the recliner from the bathroom. Review of a Fall Fax Report to physician dated 1/25/14 revealed staff found the resident sitting upright in front of a recliner on the floor at 9:00 p.m. The resident stated, "I slid out when I tried to stand." The Fall Investigation for 1/25/14 revealed the resident sat in the recliner and started to get up. The facility did not identify the root cause of the resident's fall. Review of a Fall Fax Report to physician dated 1/28/14 revealed staff found the resident laying on his/her right side in the bathroom. The resident reported he/she tried to pull his/her pants up and fell . The facility failed to identify the root cause of the fall. The staff reviewed the care plan, but put did not identify any new interventions. Review of a Fall Fax Report to physician dated 2/5/14 revealed the staff heard a sound and found the resident on his/her right side on the bathroom floor with his/her walker in reach and a wet brief on the floor beside him/her at 2:41 a.m. The resident had a 3 cm x 3 cm (centimeter) bruise to right wrist and a small laceration 0.2 cm x 0.2 cm. Review of a Fall Investigation from 2/5/14 revealed resident in bathroom trying to change his/her wet pull up brief. The staff failed to revise the care plan. Review of Non-Immediate Communication Fax to physician dated 2/14/14 revealed resident had fallen twice once at 12:35 a.m. when the resident fell out of the recliner and once at 6:40 a.m. when the resident fell asleep and fell to the floor. The resident refused to sleep in his/her bed, refused to ask for help, gait/balance unsteady. The facility failed to investigate to identify the root cause of the fall. Review of a Fall Fax Report to physician dated 2/14/14 revealed the resident slid out of the recliner onto floor, without injury. The facility failed to identify the root cause of the fall. Review of the Fall Investigation for 2/14/14 revealed the resident fell asleep on the toilet and fell between the toilet and the wall at 1:08 p.m. The facility failed to identify the root cause of the fall. The staff failed to revise the care plan. Review of Fall Fax Report to physician dated 2/27/14 revealed staff found the resident on the floor at 5:42 a.m. The resident reported he/she was making the bed and lost his/her balance. The resident sustained [REDACTED]. The staff failed to revise the care plan. Review of a Fall Investigation from 3/5/14 revealed the resident got out of bed and lost his/her balance and fell to the floor at 5:49 a.m. The facility failed to identify the root cause for fall. Review of a Fall Fax Report to physician dated 3/12/14 revealed the resident fell to his/her knees and had a small open area 0.1 cm x 0.1 cm on the left side of his/her nose. The facility failed to investigate to identify the root cause of the fall. Observation on 3/13/14 at 4:00 p.m. revealed the resident backed out of his/her room in the wheelchair and applied foot rests to the wheelchair independently. The resident used the hand rails in the hallway to self-propel. On 3/17/14 at 8:05 a.m., observation revealed the resident in a wheelchair in the coffee room, he/she locked the wheelchair and stood at the counter sat down, then wheeled him/herself to the refrigerator, locked the wheelchair, and stood to look in the freezer. No staff were present in the area. On 3/18/14 at 9:49 a.m. observation revealed the resident sat in the bathroom on the toilet with his/her walker in reach, socks on, no shoes in place, pants off. The resident stated he/she needed help. Surveyor stopped direct care staff S and asked him/her to check on the resident. Staff S assisted the resident to perform peri-care then put on the resident's pants. Staff S put shoes on the resident and then assisted him/her to wash his/her hands and transfer to wheelchair. Staff S was unaware resident transferred him/herself into the bathroom. On 3/19/14 at 10:15 a.m. observation revealed the resident was in his/her room, sat in a wheelchair and attempted to stand. The resident was wobbly and unsteady. The resident's walker and call light were not in reach. Surveyor stopped staff S in the hall at that time to assist the resident to transfer to his/her recliner for the resident's safety. On 3/17/14 at 1:25 p.m. interview with resident revealed he/she did not use the call light because he/she felt if he/she used the call light before he/she got up, that would be "pestering" the staff. The resident revealed he/she did not know if he/she needed help "until it was too late." On 3/17/14 at 1:47 p.m. interview with direct care staff D revealed he/she did not know if the resident was fall risk, but did not think the resident had fallen in awhile. Staff D reported he/she asked the nurse and checked the care plan to find out if the resident was a fall risk. Staff D reported he/she tried to encourage the resident to let staff help, but he/she stated the resident liked to be very independent. Staff D reported the resident refused care and at that point staff D tried to further assist or gave the resident a few minutes and returned to check on him/her. Staff D stated the resident did not get angry and the resident allowed stand-by assistance. On 3/17/14 at 1:53 p.m. interview with licensed nursing staff E revealed the resident was fall risk and he/she fell quite often. Staff E reported the resident would not ask for help. Staff E stated he/she tired to monitor and remind the resident to call for help. Staff E reported the resident got angry if staff tried to help him/her. Staff E also stated the resident had an unsteady gait and poor balance. On 3/17/14 at 3:14 p.m. interview with licensed nursing staff M revealed after every fall the staff put a new intervention on the care plan. Staff M reported he/she did not chart frequent checks on the resident's record. On 3/18/14 at 10:18 a.m. interview with administrative nursing staff N revealed he/she expected staff to evaluate and see what was the causation of fall and to care plan a new intervention after every fall to prevent falls from happening again. On 3/19/14 at 11:40 a.m. interview with administrative nursing staff B revealed he/she expected after every fall staff to complete a fall assessment and review the care plan interventions and updated them. Staff B did not expect a new intervention to be in place after every fall because staff could not always come up with a new intervention. Staff B expected staff to initial and date care plans after falls. Staff B reported for fall investigations, the Director of Nursing, medical records and Care Plan Coordinator all had a meeting after a fall occurred. Staff B expected the investigation to include an evaluation of the resident's environment, therapies, medications, and health conditions. He/she stated investigations should determine the root cause of the fall. Regarding the resident's injury fall on 5/26/13 Staff B revealed the fall may have been prevented, but the resident would still have tried to get up. Staff B confirmed the fall on 5/9/13 was not revised in the care plan with a new intervention. Staff B reported he/she believed the resident did have adequate supervision and reported frequent checks were not charted, but he/she expected the staff to be checking on resident every 30 minutes to 1 hour. Review of the facility's Fall Management Program Policy revealed residents found at risk for falls would be have specific interventions developed to meet individual needs. For any falls the facility was to complete an incident reports and determine causative factors. The facility failed to investigate the root cause of the resident's falls, implement appropriate fall interventions to prevent further falls including supervision, and implement planned interventions resulting in a fractured hip for resident #49. - Review of resident # 97's physician orders [REDACTED]. Review of the significant change MDS (minimum data set) dated 4/30/13 revealed a BIMS (brief interview for mental status) score of 11, indicating moderate cognitive impairment. The resident required supervision with setup help for bed mobility, extensive assistance of one staff for transfers, walking in the room, dressing, toileting, and personal hygiene, and total dependence on one staff for locomotion on and off the unit. The resident was not steady and only able to stabilize with staff assistance for moving from a seated to standing position, walking, turning around when walking, moving on and off the toilet, and surface-to-surface transfers. The resident had not fallen since admission on 4/9/13. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 13, indicating no cognitive impairment. The resident required supervision with setup assistance for bed mobility, extensive assistance for transfers, walking in the room and corridor, dressing, toileting and personal hygiene, and total dependence on one staff for locomotion on and off the unit. The resident was not steady and only able to stabilize with staff assistance for moving from a seated to standing position, walking, turning around when walking, moving on and off the toilet, and surface-to-surface transfers. The resident had fallen once with no injury since the prior assessment. Review of the Falls CAA (care area assessment) dated 5/2/13 revealed the resident had a fall assessment score of 42, which indicated the resident had a high risk for falls. The resident reported he/she blacked out at times. The resident worked with therapy to increase his/her abilities and independence. Staff reported the resident did not walk in the hall and only in his/her room. The resident used a wheelchair for locomotion and staff walked him/her with a gait belt. The resident did not have a walker. Review of the care plan dated 1/15/14 revealed the resident was at risk for falls related to Parkinson's, experiencing black outs, a history of falls, and received diuretic and opioids (narcotic pain medication). The care plan directed staff to assess for orthostatic hypotension, use gait belt to assist the resident with ambulation and transfers, and do not leave the resident unattended in wheelchair in the bedroom. It also directed staff keep the bed in the lowest position with a mat on the exit side while he/she rested. Staff placed gripper strips in front of chair and exit side of bed, and placed double bars on the side of the toilet to assist the resident with balance when transferring. Resident may ambulate in room but uses wheelchair for longer mobility. It also had an update dated 12/10/13 that directed staff to remind the resident he/she needed assistance with transfers. Review of a fall event dated 12/10/13 revealed the resident had an unwitnessed fall in his/her room and reported he/she had spilt water and tried to clean it up. The resident had fallen in the past 31-180 days and had confusion. The investigation lacked information regarding when staff last provided care for the resident and if interventions were or were not in place as planned. Review of a fall event dated 2/15/14 revealed staff witnessed the resident fall at the sink in his/her room, had confusion, and had previous fall in the past 31-180 days. Staff took immediate actions for adaptive equipment and determined the cause of the fall to be the resident reported him/her though he/she was still by the bed and sat down. The room was dark. Staff did not investigate to determine the cause of the fall or revise the care plan with new interventions. Review of a fall event dated 2/23/14 revealed the resident had an unwitnessed fall in his/her room, and the resident could not tell staff what happened. It revealed the CNA (Certified Nurse Aide) answered the call light and found the resident on the floor partially on the mat. The investigation lacked information as to when staff last provided cares for the resident and if interventions to prevent falls were followed as planned. Interview with the resident on 3/13/14 at 4:15 p.m. revealed the resident reported he/she had not fallen in a long time but could feel when it was coming on and it would happen all of a sudden. The resident reported he/she "kind of just blacked out." During an interview on 3/18/14 at 1:40 p.m. direct care staff D stated the resident had a mat beside the bed, the bed lowered to the floor, and staff kept the call light by him/her. During an interview on 3/18/13 at 3:13 p.m., licensed nursing staff F stated the resident had fallen on 2/15/14 and 2/23/14. Staff needed to remind the resident frequently to ask for help and walk the resident with a gait belt and walker to the dining room. The nurse aides walked the resident to give him/her opportunities to ambulate, staff check on the resident frequently when they went up and down the hall to care for others. Staff F stated he/she would expect the aides to check on the resident every 30-45 minutes. Staff F also stated the laundry and housekeeping staff was good about letting nursing know of any concerns. Staff F stated the resident's care plan should be updated with every fall to try new interventions each time a resident fell based on the determination of the cause of the fall. Staff F stated the nurse also did a new fall risk assessment and a pain assessment with each fall. An interview with administrative nursing staff B on 3/18/14 at 3:30 p.m. revealed when a resident fell , he/she expected staff to review the care plan, put the date of the fall, and update it if needed. Staff F also stated the investigations were not thorough to determine the root cause and determine the effectiveness of current interventions. Review of the Fall management program dated 5/8/06 revealed following any falls the facility staff were to complete an incident report and a post fall assessment to determine causative factors. The facility failed to thoroughly investigate falls to determine the cause and evaluate the effectiveness of current fall prevention measures. - Observation on 3/12/14 at 10:16 a.m. revealed 2 Yankee candle metered deodorizing refill cans with a label warning to keep out of reach of children in the unlocked room with scales that was accessible to residents. On 3/12/14 at 10:28 a.m. administrative nursing staff K stated staff should not have the cans accessible to residents. On 3/12/14 at 4:40 p.m. observation revealed a can of Lysol Neutra-air with warning to keep out of reach of children in the unlocked public women's bathroom. An interview with licensed nursing staff Y at the time, reported it should be locked and not in an area accessible to residents. During an interview on 3/19/14 at 8:44 a.m. maintenance staff Z stated hazardous chemicals should be stored under lock and key. Interview with administrative nursing staff B on 3/19/14 at 3:10 p.m. revealed he/she expected staff to keep all chemicals locked in cabinets. Review of the undated facility policy for Chemical Storage revealed staff were to store items per the manufacturer's recommendations. The facility failed to secure chemicals to prevent accidents for 22 cognitively impaired and independently mobile residents.

The facility census totaled 81 residents with 12 residents sampled. Of those 3 were reviewed for accidents. Based on observation, interview, and record review the facility failed to follow the care plan for 1 of 3 residents who subsequently had a fall. (#11) Findings included: - Review of resident # 11's signed POS (Physicians order sheet) dated 1-21-14 included the following Diagnoses: [REDACTED]. Review of the quarterly MDS (Minimum Data Set 3.0, a required assessment) dated 3-10-14 revealed the resident had short and long term memory deficit , severely impaired decision making ability and dependent on staff for all cares. The resident had no falls since the prior assessment. Review of the care plan last reviewed on 3-19-14 revealed risk for falls related to spastic actions and sitting balance deficit. The interventions included initiate facility fall guidelines, make sure wheelchair seat belt is fastened properly, frequent visual checks when passing the door of the residents room, required a specialty wheelchair for transport with head and foot supports , transfer with sling lift and assist of 2. The care plan included the following update on 5-20-14 Visual check to ensure seat belt is fastened day and eves when up in wheelchair. Review of the "event" report dated 4-28-14 at 6:11 p.m. revealed a description of the fall that the "resident leaning in wheelchair " and fell on to the floor on the front of his/her body, hitting right forehead causing a quarter sized bump and also bumped his/her lip causing a small amount of bleeding. Staff applied ice to the resident's forehead. It included the physician and family were notified and the care plan was updated on 4-28-14 with "make sure seat belt is fastened". The event also included the nursing progress note indicating the resident was up in his wheelchair in the chapel/livingroom leaning on side of wheelchair and fell out face first onto floor lying on front of body. The Event report failed to identify when resident was last seen, when he/she was taken to the chapel area, or if any staff were in the area to supervise the resident. It did identify the resident was leaning on the side of wheelchair prior to fall but did not identify if anyone reported it or tried to reposition the resident properly in the chair. It also included that the resident did not have the seat belt fastened and the direct care stated he/she forgot to fasten it. Review of the most recent fall risk assessment dated [DATE] revealed the resident scored a 22 indicating high risk for falls (10 or greater = high risk for falls). Observation on 6-2-14 at 8:11 a.m. the resident sat in the front foyer looking out the windows in specialty wheelchair with seat belt connected. The resident sat in an area that was in view of the receptionist and the nurses ' station. During an interview on 5-28-14 at 11:36 a.m. direct care staff L stated the resident had a seat belt on the chair and staff needed to check before leaving the room to make sure it was on and fastened because the resident wiggles a lot and may fall. During an interview on 6-2-14 at 12:05 p.m. licensed nursing staff M stated the fall event indicated checking the seat belt was added to the MAR when the is up in wheelchair. During an interview on 5-28-14 at 3:12 p.m. administrative nursing staff F stated that particular aide knew the seat belt should have been fastened and just didn't realize she had forgotten to fasten it. Review of the fall management program dated 5-18-2006 revealed following any falls the facility staff are to complete an incident report and a Post fall assessment to determine causative factors. The facility failed ensure direct care staff followed the planned care for a resident who subsequently fell .