Every finding on record at Kearny County Hospital Ltcu

The facility reported a census of 25 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to identify, implement, and reevaluate fall prevention interventions to prevent falls for six residents. Resident (R) 21 experienced a fall which resulted in multiple sinus fractures (broken bone) and R18's fall resulted in a hip fracture, which required hospitalization and surgery. Additionally, the facility failed to implement new interventions to prevent falls for R12, R17, R20 and R23, placing the residents at risk for falls with injury. Findings included: - The Electronic Health Records (EHR) documented R21 had the following diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), degenerative arthritis (a chronic condition that causes cartilage in the joints to break down over time) of bilateral (both sides) knees and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The 06/22/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R21 had a total mood severity score of four, indicating minimal depression and she had no behaviors. R21 required maximal assistance with activities of daily living (ADL) such as toileting hygiene, showering, personal hygiene, and dressing. R21 was independent with bed mobility, transfers, and ambulation. R21 had two non-injury falls and received antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) and antidepressants (class of medications used to treat mood disorders) medications during the lookback period. The 08/21/24 Falls Care Area Assessment (CAA) documented R21 was at risk for falls due to a history of falling and she was unsteady on her feet, mixed with her confusion at times. The Psychotropic Drug Use CAA documented R21 requires several medications to control her mental health diagnosis. The 09/22/24 Quarterly MDS documented a BIMS score of three, indicating severely impaired cognition. R21 required maximal assistance with bathing, toileting hygiene and personal hygiene. R21 was independent with transfers and ambulation, and she had two non-injury falls. The 10/21/24 Care Plan documented the following fall prevention interventions, initiated 06/13/23: The staff were to encourage R21 to use call light for assistance, provide a safe environment with adequate low glare light, bed in the lowest position and wheels locked. R21 was able to use walker without assistance times at times R21 had an unsteady gait and staff instructed to provide stand by assist and gait belt as needed. The 10/21/24 Physician Orders lacked any documentation regarding falls. The Fall Risk Evaluation for R21, documented the following: On 06/09/23 at 06:51PM, at risk for falls, score of 11.0. On 07/09/23 at 08:41 AM, at risk for falls, score of 11.0. On 08/09/23 at 09:19 AM, at risk for falls, score of 15.0. On 11/09/23 at 01:55 PM, no risk for falls, score of five. On 02/09/24 at 01:09 PM, at risk for falls, score of 12.0. On 02/10/24 at 02:36 PM, no risk for falls, score of nine. On 04/27/24 at 02:39 AM, at risk for falls, score of 21.0. On 08/09/24 at 12:53 PM, at risk for falls, score of 16.0. Per the facility's LTC Fall Prevention Protocol policy dated October 2020 a score of nine or greater represented the resident is at high risk for falls. The 02/10/24 at 10:21 AM Progress Note revealed staff found R21 on the floor, seated upright in front of her recliner. The note documented R21 reported she lost her balance and fell , and had no injuries noted. The 04/26/24 at 02:18 PM Progress Note revealed R21 continued to have bilateral knee pain and had more difficulty with ambulation. The 04/27/24 at 02:31 AM Progress Note revealed staff found R21 on the floor in her bathroom. The note documented R21 had severe swelling noted on the right side of her face with lesions noted on her lower lip with severe bleeding. The note included R21 had bruising noted on the back of her right and left hands and both arms, and she transferred to the hospital. The 04/27/24 at 04:39 AM Progress Note revealed R21 returned from the hospital, and R21 had fractures of the sinus bones and a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to her right cheek. The computed tomography (CT scan- test that used x-ray technology to make multiple cross-sectional views of organs, bone, soft tissue and blood vessels) scan, dated 04/27/24, revealed R21 had fractures of the anterior (front) and posterolateral (something is located on the side and toward the back of the body) walls of the right maxillary (a hollow, pyramid-shaped space in the cheekbones that's part of the paranasal sinus system [one of many small hollow spaces in the bones around the nose]) and nondisplaced (a broken bone in which the pieces of bone remain aligned and do not move out of place) fracture of the right orbital floor (forms the roof of the maxillary sinus). The Risk Management Report dated 02/10/24, included an immediate intervention to re-educated R21 to use the call light and to use the call light for assistance. The Risk Management Report dated 04/27/24, lacked intervention to prevent another fall. The Care Plan included a fall prevention intervention dated 05/09/24 (12 days after R21's fall) instructing staff to provide stand by assistance for ambulation with her walker and gait belt, noting she may refuse at times for gait belt use. During an observation on 10/21/24 at 03:54 PM, R21 sat in her recliner with a seated rolling unlocked walker in front of her. She was very hard of hearing and had bilateral hearing aids in her ears. R21 had a hard time expressing her thoughts, as she stuttered and repeated her words. During an observation on 10/22/24 at 08:04 AM, R21 sat in her recliner with a seated rolling unlocked walker in front of her. On 10/23/24 at 08:20 AM, R21 ambulated independently to her room with a seated rolling walker from the dining room. The staff provided no assistance to R21 as she ambulated. During an interview on 10/23/24 at 08:49 AM, Certified Nurse Aide (CNA) O reported when a resident fell , the staff stay with the resident and call for assistance. The Nurse would assess the resident and complete paperwork. The staff would discuss what intervention to implement to prevent another fall. The Nurse would communicate with the CNAs and it should be on the care plan or kardex in the EHR. During an interview on 10/23/24 at 08:50 AM, CNA M reported R21 would ambulate independently with her walker in and out of her room all the time. During an interview on 10/23/24 at 09:14 AM, Licensed Nurse (LN) G reported an incident report was created (after a fall) in risk manager in the EHR after the assessment of a resident, notification of responsible party, physician, Administrative Staff A and Administrative Nurse D, witness statements from staff, and immediate intervention was completed. LN G stated they verbally communicated to let staff know and placed new interventions on the EHR white board. LN G stated Administrative Nurse D and Administrative Nurse E updated the care plans in the EHR. During an interview on 10/23/24 at 11:03 AM, Administrative Nurse D reported the immediate (fall prevention) intervention was completed by verbal communication, and Administrative Nurse E would update the care plan with the new intervention. Administrative Nurse D expected care plans to be updated within 24 hours. Administrative Nurse D reported R21's care plan lacked fall interventions. During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E expected a fall intervention to be completed within 24 hours and confirmed that did not always occur. The facility policy LTC Fall Prevention Protocol dated 10/2020, documented each resident residing in this facility would be provided services and care that ensured all residents environments remain free from accident hazards as possible. The facility failed to implement effective fall prevention interventions to prevent falls for cognitively impaired 21, who had a history of falls. R21 fell at the facility and fractured her facial bones and the facility did not update the care plan with further fall prevention interventions until 12 days after her fall with major injury, placing her at risk for further falls with injury. - Resident (R) 20's Electronic Health Record (EHR) revealed diagnoses, which included dementia (progressive mental disorder characterized by failing memory, confusion) and parkinsonism (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The 12/23/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R20 had a total mood severity score of six, which indicated mild depression. R20 required set up assistance for eating and required moderate assistance with activities of daily living (ADLs) to include dressing, toileting hygiene, footwear, personal hygiene and standing. R20 required supervision for ambulation, oral care and transfers. R20 had two or more non-injury falls. The 06/22/24 Falls Care Area Assessment (CAA) documented R20 had a fall history and had falls while in facility. The 06/22/24 Cognitive Loss/Dementia CAA documented R20 required staff cues and assistance with ADL's and decisions for safety based on cognitive decline. The 06/26/24 Quarterly MDS documented a BIMS score of two, indicating severely impaired cognition. R20's total mood severity score of five, indicated mild depression. R20 required set up assistance for eating and required supervision assistance for oral care, transfers, and ambulation. R20 required maximal assistance with toileting hygiene, dressing, and standing. The resident had two or more non-injury falls and had a chair alarm. The 10/21/24 Care Plan documented the following fall prevention interventions, initiated 05/15/23: Staff were instructed to provide a safe environment with adequate low glare light, ensure the resident's bed was in the lowest position and ensure the wheels were locked on bed. The 10/21/24 Care Plan documented the following fall prevention interventions, initiated 03/15/24: Staff were instructed to determine and address causative factors of falls and follow facility post-fall policy regarding monitoring signs and symptoms of injury post fall. The 10/21/24 Care Plan lacked any documentation for the resident's chair alarm and any new fall interventions for the falls that occurred on 03/12/24 (two falls), 04/08/24, 06/05/24, 06/19/24, 06/22/24, 08/01/24, 08/06/24, and 08/28/24. The 10/21/24 Physician Orders lacked any documentation regarding falls or a chair alarm. The Fall Risk Evaluation for R21, documented the following: On 11/10/23 at 03:44 AM identified R21 as at risk for falls with a score of 16. On 02/09/24 at 07:59 PM identified R21 as at risk for falls with a score of 9. On 05/09/24 at 06:46 PM identified R21 as at risk for falls with a score of 14. On 08/09/24 at 08:01 PM identified R21 as at risk for falls with a score of 18. Per the facility's LTC Fall Prevention Protocol policy dated October 2020 a score of nine or greater represented the resident is at high risk for falls. The 03/12/24 at 02:24 AM Progress Note revealed staff found R20 on the floor leaning towards his left side, in front of his recliner. The lift chair was all the way up and his walker was approximately three feet away. R20 had socks on his feet and reported he slipped when he tried to get up to go to the bathroom. The fall that occurred on 03/12/24 at 02:24 AM, lacked an intervention and lacked a Risk Management Report. The 03/12/24 at 01:18 PM Progress Note revealed the resident had a witnessed fall, R20 ambulated independently in the dining room without his walker, bent over to pick up a cane on the floor, fell forward, and struck his head, which caused an abrasion to the top of his head. The Risk Management Report dated 03/12/24 for a fall that occurred at 01:18 PM, included an immediate intervention for staff to remind R20 to use his walker and they would assist him if they saw a safety concern. The 04/08/24 at 02:15 AM Progress Note revealed staff found R20 lying on his right side, on the floor, in front of his bathroom. R20 reported he fell and was not using his walker. The Risk Management Report dated 04/08/24 for fall that occurred at 02:15 AM, included an intervention stating R20 would be reminded to use his walker at all times and to let staff know if he needed anything. R20 had not fallen since this incident. The 06/05/24 at 11:40 PM Progress Note revealed staff found R20 seated in on the floor in a seated position against his bed. R20 reported he transferred himself out of bed and slid to the floor. The fall that occurred on 06/05/24 at 11:40 PM, lacked an intervention, an incident report, and lacked a Risk Management Report. The 06/19/24 at 12:30 AM Progress Note revealed staff entered R20s' room to answer his call light and found R20 seated on the floor with his back against the recliner. R20 reported he slid out of his chair and staff applied dycem (non-slip mat used for stabilization and gripping to prevent slipping) to the recliner. The Risk Management Report dated 06/19/24 for a fall that occurred at 12:30 AM, included an immediate intervention of dycem placed on the resident's recliner seat. The risk management report intervention included staff would continue to check on R20 every one to two hours to see if he needed to get up from his recliner. The 06/22/24 at 03:00 AM Progress Note revealed staff found R20 lying on his floor in front of his recliner. R20 reported he was walking, and he fell . The Risk Management Report dated 06/22/24 for fall that occurred at 03:00 AM, included an intervention that staff would remind R20 to call staff for assistance and staff will continue to make frequent checks on R20. The 08/01/24 at 03:55 AM Progress Note revealed staff found R20 seated on the floor in his room and in front of his bed, R20 slid off of the bed. The fall that occurred on 08/01/24 at 03:55 AM, lacked an intervention, an incident report, and lacked a Risk Management Report. The 08/06/24 at 04:00 AM Progress Note revealed staff found R20 lying on his left side on the floor beside his bed. R20 reported he rolled out of bed. The Risk Management Report dated 08/06/24 for fall that occurred at 04:00 AM, included an intervention for staff to continue to keep an eye on R20 during evening hours and when he is sleeping. Bed checks are to be completed every hour. If this continues to happen a discussion will occur with R20 about alternative ways to keep him safe while sleeping. The 08/28/24 at 03:00 AM Progress Note revealed staff found R20 on his floor tangled in blankets. R20 reported he did not know what happened. The fall that occurred on 08/28/24 at 03:00 AM, lacked an intervention and lacked a Risk Management Report. During an observation on 10/21/24 at 04:00 PM and 05:12 PM, R20 was seated in his lift chair in his room, the lift chair was approximately a quarter to halfway lifted and R20 was leaning towards the floor. No chair alarm was noted on recliner or in the resident's room. During an observation on 10/22/24 at 08:04 AM and 12:02 PM, R20 was seated in dining room in wheelchair, no alarm noted. No dycem or alarm observed on R20's recliner in his room. During an observation on 10/22/24 at 1 1:00 AM, R20 was seated in recliner watching his tv, no alarm noted. At 02:25 PM and 04:30 PM, R20 was seated in recliner in room with his feet elevated and his eyes closed. No alarm noted. During an observation on 10/23/24 at 07:43 AM, Certified Nurse Aide (CNA) M propelled R20 in his wheelchair with no foot pedals noted on wheelchair. R20 held his feet up and placed his feet on the floor one time. CNA M stopped pushing R20's wheelchair when she noticed the observation and asked R20 to take himself in his wheelchair and R20 refused. CNA M then pushed R20's wheelchair with his feet up into the dining room . During an interview on 10/23/24 at 07:45 AM, CNA M reported R20 normally would ambulate to the dining room with staff assistance, she reported R20 refused to ambulate this morning and that she would not normally push a wheelchair without foot pedals. During an interview on 10/23/24 at 07:50 AM, Licensed Nurse (LN) G reported that R20 should have foot pedals on his wheelchair when staff are pushing the wheelchair to prevent an incident. During an observation on 10/23/24 at 08:20 AM, R20 ambulated with CNA M to the TV lounge from the dining room, he used a front wheeled rolling walker and a gait belt was utilized. CNA M assisted R20 into a lift recliner in the TV lounge. During and interview on 10/23/24 at 08:26 AM, CNA M reported that R20 never had a personal alarm on his chair or any dycem noted on the seat of his recliner. CNA M reported R20 could use his left chair remote independently. During an interview on 10/23/24 at 09:14 AM, Licensed Nurse (LN) G reported an incident report was created (after a fall) in risk manager in the EHR after the assessment of a resident, notification of responsible party, physician, Administrative Staff A, and Administrative Nurse D, witness statements from staff, and immediate interventions were completed. LN G stated they verbally communicated to let staff know and placed new interventions on the EHR white board. LN G stated Administrative Nurse D and Administrative Nurse E updated the care plans in the EHR. During an interview on 10/23/24 at 11:03 AM, Administrative Nurse D reported the immediate (fall prevention) intervention was completed by verbal communication, and Administrative Nurse E would update the care plan with the new intervention. Administrative Nurse D expected care plans to be updated within 24 hours. During an interview on 10/23/24 at 01:35 PM, Administrative Nurse D confirmed that R20's care plan lacked new interventions for all of the fall dates reviewed and confirmed she did not have an incident report or investigation for the two falls. Administrative Nurse D confirmed the facility did not have a lift chair assessment and confirmed the TV lounge had lift chairs available for any resident to sit in. Administrative Nurse D had no comment when questioned about an intervention to remind a resident with severely impaired cognition to use a walker and if calling staff was an appropriate intervention to be used several times. During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E expected a fall intervention to be completed within 24 hours and confirmed that did not always occur. The facility policy LTC Fall Prevention Protocol dated 10/2020, documented each resident residing in this facility would be provided services and care that ensured all residents environments remain free from accident hazards as possible. The care plan will be reviewed and amended based on the re-assessments. The facility failed to implement effective fall prevention interventions to prevent falls for cognitively impaired R20, who had a history of falls and several falls at facility. This deficient practice placed him at risk for further falls with injury. 46960 - Review of the Electronic Health Record (EHR) for Resident (R) 18 included diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion), epilepsy (a brain disorder characterized by repeated seizures), and frontotemporal neurocognitive disorder (a brain disease that affects behavior, language and movement abilities). The 04/22/24 Annual Minimum Data Set (MDS) completed 08/16/24, documented that the Brief Interview for Mental Status (BIMS) assessment could not be completed, and the staff assessed R18 to have severely impaired cognition. The assessment documented R18 displayed no behaviors and utilized a wheelchair for locomotion and was dependent on staff for all cares except oral hygiene which required substantial/maximum assistance and eating which required partial/moderate assistance. The assessment documented R18 had two or more falls since admission or the previous assessment which included one fall with major injury. The Delirium Care Area Assessment (CAA) dated 04/22/24, documented R18 had behaviors related to the diagnosis of dementia. The Cognitive Loss/Dementia CAA dated 04/22/24, documented R18 had decreased in cognition related to disease progression. The Communication CAA dated 04/22/24, documented R18 was unable to make her needs known. The Falls CAA dated 04/22/24, documented R18 was a high risk for falls related to seizure activity and behaviors. The 07/23/24 Quarterly MDS completed 08/16/24, documented the Brief Interview for Mental Status (BIMS) assessment could not be completed and the staff assessed R18 to have severely impaired cognition. The assessment documented R18 experienced hallucinations (sensing things while awake that appear to be real, but the mind created), displayed physical and verbal behavioral symptoms directed towards others one to three days during the seven-day look-back period. R18 utilized a walker and/or wheelchair for locomotion and was dependent on staff for all cares except eating which required partial/moderate assistance from staff. The assessment documented no falls since admission or the previous assessment. The 08/16/24 Care Plan documented on 04/23/23 that R18 could ambulate with stand-by assistance and gait (manner or style of walking) belt and staff should utilize a wheelchair for longer distances, initiated on 04/23/23 and revised on 04/12/24. The 08/16/24 Care Plan documented on 07/28/23 that R18 had an actual fall related to poor balance and poor communication/comprehension ability and included the following interventions: 07/28/23, staff should assist R18 to the bathroom every two hours and as needed, initiated on 07/28/23. 07/28/23, staff would place personal items within reach and gave examples of call light, water, and purse. Additionally, staff would answer call lights promptly. 07/28/23, staff would monitor for signs/symptoms of a medication reaction. 07/28/23, staff would provide activities that promote exercise and strength building where possible and provide one-on-one activities if R18 was bedbound. 07/28/23, revised 02/21/24, staff were instructed that R18 was able to ambulate with two-person assistance and gait belt use. Review of the EHR Fall Risk assessments revealed on 01/15/24, the facility documented a fall risk score of 13 which indicated R18 was at risk for falls. Review of the EHR Fall Risk assessments revealed on 04/15/24, the facility documented a fall risk score of 11 which indicated R18 was at risk for falls. Review of the EHR Fall Risk assessments revealed on 04/30/24, the facility documented a fall risk score of 14 which indicated R18 was at risk for falls. Review of the EHR Fall Risk assessments revealed on 07/15/24, the facility documented a fall risk score of 16 which indicated R18 was at risk for falls. Review of the EHR Fall Risk assessments revealed on 10/15/24, the facility documented a fall risk score of 14 which indicated R18 was at risk for falls. The Progress Notes dated 04/22/24 at 06:40 PM documented R18 experienced witnessed fall when she tripped and fell on her left side and was assessed to be free from observable injury. The Progress Notes dated 04/23/24 at 04:00 PM documented R18 was transferred to the Emergency Department (ED) per the recommendation of Administrative Nurse D and ED staff reported an x-ray report of a left femoral (thigh bone) neck fracture (broken bone) and R18 was transferred to another hospital for continued care. The Progress Notes dated 04/24/24 at 02:45 PM documented the facility staff called the hospital who stated that R18 was in surgery for a partial hip replacement. Review of the facility Fall Investigation revealed on 03/22/24 at 06:40 PM, R18 fell without injury. The facility's root cause analysis determined staff had failed to provide stand-by assistance and gait belt use,as indicated in the care plan which caused R18's fall. The fall investigation report lacked an immediate intervention to mitigate the fall risk for the remainder of the shift. The resident's Care Plan lacked an intervention related to the fall on 04/22/24. Review of the EHR Fall Risk assessments revealed on 04/22/24, the facility documented a fall risk score of 15 which indicated R18 was at risk for falls. The Progress Notes dated 06/15/24 documented R18 had a witnessed fall without injury when R18 was ambulating (walking) with staff and she had a seizure, and staff assisted R18 to the floor. The fall investigation report lacked an immediate intervention to mitigate the fall risk for the remainder of the shift. The resident's Care Plan lacked an intervention related to the fall on 06/15/24. Review of the EHR Fall Risk assessments revealed on 06/15/24, the facility documented a fall risk score of 14 which indicated R18 was at risk for falls. The fall investigation report, dated 07/25/24 at 06:15 PM lacked a root cause analysis or immediate intervention to mitigate the risk of falls for the remainder of the shift. The Progress Notes dated 07/27/24 at 03:09 PM documented R18 lacked injuries from a fall. The note lacked further documentation related to a fall. The Progress Notes dated 07/27/24 at 06:55 PM revealed a skin evaluation documented that R18 continued to have abrasions to her upper back after a fall. The resident's Care Plan lacked an intervention related to the fall on 07/25/24. During an observation on 10/21/24 at 03:40 PM and 10/22/24 at 12:48 PM, R18 rested in the recliner in her room, watching television. During an observation on 10/23/24 at 12:00 PM, R18 sat in her wheelchair in the dining area with staff providing eating assistance. During an interview on 10/23/24 at 08:49 AM, Certified Nurse Aide (CNA) O revealed that if she saw a fall or someone on the ground, she would ask them if they were okay then use the call light for assistance and/or yell for help and notify the nurse. After the resident was assessed and assisted off the ground, the nurse did paperwork and discussed what staff could do to prevent additional falls. The nurse would communicate an intervention to the staff and that intervention would be included in the end of shift report to the oncoming shift. CNA O stated she was not aware of a book at the nurses' station that had interventions in it. Further, CNA O stated there was a book, but it was not updated anymore, and staff could look in the Kardex for the interventions. During an interview on 10/23/24 at 08:23 AM, CNA P revealed if she saw a fall or someone on the ground, she would get the nurse or pull the call light for assistance to get the nurse. She stated she could not touch the resident until the nurse came. After the nurse arrived and assessed the resident, she would do what the nurse instructed, and she would assist the nurse to get the resident up. During an interview on 10/23/24 at 09:14 AM, Licensed Nurse (LN) G revealed that when she was notified of a fall, she would perform a full assessment on the resident and render aid if needed. After the fall, initiate an investigation which included collection of witness statements and notification of the Director of Nursing (DON), the resident's representative and the resident's physician. Then would hold a discussion with staff to come up with an immediate intervention for the rest of the shift, which would go on the care plan and was reported on to the next shift through end of shift report. During an interview on 10/23/24 at 11:03 AM, Administrative Nurse D revealed when there was a fall, she expected the CNA to notify the nurse and give details as to if it was witnessed or not witnessed. The nurse would perform a full assessment and render aid or send the resident to the ER if needed. The nurse would then document the fall in the EHR and come up with an immediate intervention that was communicated verbally to the staff. The nurse would then notify Administrative Nurse E so the permanent care plan could be updated. Administrative Nurse D expected the care plan to be updated within 24 hours and expected staff to review it individually the following day and again in the weekly risk meeting. The facility policy LTC Fall Prevention Protocol dated 10/2020, documented each resident residing in the facility would be provided services and care that ensured all resident environments remain free from accident hazards as possible. The facility failed to implement fall prevention interventions after multiple falls for cognitively impaired and dependent R18, with a known history of repeated falls. R18 had an injury fall on 04/22/24, a non-injury fall on 06/15/24, and an injury fall on 07/25/24 with no fall prevention interventions identified and implemented to prevent further falls. This deficient practice resulted in actual injuries to R18 to the physical and psychosocial well-being of R18.

The facility reported a census of 25 residents. The sample included 12 residents reviewed for person-centered care plan development. Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan for three residents, Resident (R) 74 related to psychotropic (any class of medications that alter mood or thought) medication use, opioid (a class of medications used to treat moderate to severe pain) medication use, diuretic (a class of medication to promote the formation and excretion of urine) medication use and nebulized (a device which changes liquid medication into a mist easily inhaled into the lungs) medication use. R124's Care plan lacked interventions related to the performance (or lack thereof) for activities of daily living (ADLs - activities such as walking, grooming, toileting, dressing and eating, etc.), psychotropic medication use, visual function, abnormal behaviors, nutritional status, and pain. R20's care plan lacked interventions to mitigate the risk for falls with a known history of falls. These deficient practices had the potential to lead to uncommunicated needs which would negatively impact the physical and psychosocial well-being of the residents. Findings Included: - R74's Electronic Health Record (EHR) revealed diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) and Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure) The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The assessment documented R74 utilized a walker and/or a wheelchair for locomotion. The resident received antianxiety (a class of medications that calm and relax people) medications, antidepressant (a class of medications used to treat mood disorders) medications, diuretic medications and opioid medications. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/15/24 documented R74 had periods of confusion. The Psychotropic Drug Use CAA dated 10/15/24 documented R74 had no prescribed antidepressant medication. The Pain CAA was not triggered on the assessment. The Physician Orders revealed the following orders: Ativan (lorazepam, a benzodiazepine class of medication which works on the neurotransmitters in the brain and is used to treat anxiety) 0.5 milligram (mg), give 0.5 mg every eight hours PRN for anxiety, dated 10/01/24. The order lacked a stop date or rationale for the continued use of the medication. Norco (hydrocodone-acetaminophen - an opioid pain medication) 5-325 milligrams (mg), one tablet by mouth (PO) every 12 hours PRN pain, dated 10/01/24. Ipratropium Bromide (a nebulized medication) inhalation solution 0.02 percent (%), one vial to be inhaled orally every six hours related to diagnosis of COPD. Furosemide (a diuretic medication) 20mg, PO every day related to diagnosis of CHF. Duloxetine HCl (an antidepressant medication) 30mg, PO daily related to diagnosis of anxiety/depression. Review of the Census tab on the EHR revealed that R74 admitted to the facility on [DATE]. Review of the electronic Medication Administration Record (eMAR) from 10/01/24 to 10/23/24 revealed R74 had not received any doses of PRN Ativan (lorazepam) and lacked evidence of an ordered stop date. The eMAR documented appropriate doses of the antidepressant, nebulized, and diuretic medications. During an observation on 10/21/24 at 04:41 PM, R74 sat in his recliner, watching television and appeared relaxed and calm. During an observation on 10/22/24 at 12:14 PM, R74 sat in his wheelchair at a table in the dining area with peers present and appeared relaxed and calm. During an interview on 10/23/24 at 08:49 AM, Certified Nurse Aide (CNA) O revealed resident specific cares were reported from one shift to the next during the end-of-shift report and further stated there was a book with interventions at the nurse's station, but it was not updated anymore. During an interview on 10/23/24 at 01:33 PM, Administrative Nurse D stated residents who use nebulized medications should include interventions specific to care of the equipment, additionally any medications that required additional monitoring (such as black-box warnings related to psychotropics, opioids, diuretics) were documented in the EHR next to the actual order. Administrative Nurse D confirmed that R74's care plan lacked information related to psychotropic, diuretic, opioid, or nebulized medication use. The facility failed to provide a policy related to person-centered care plan development/implementation as requested on 10/24/24. The facility failed to develop and implement a person-centered comprehensive care plan for R74 related to psychotropic medication, diuretic medication, or nebulized medication use. This deficient practice had the potential to lead to uncommunicated needs which had the potential to negatively affect the physical and psychosocial well-being of R74. 50659 The facility reported a census of 25 residents. The sample included 12 residents. Based on medical record review and staff interviews, the facility failed to complete Care Area Assessments that addressed the individual underlying causes, contributing factors and risk factors for six residents. Resident (R)8, R12, R17, R18, R74 and R124 had incomplete, or no CAA notes completed. Findings included: - During the onsite annual survey, a concern regarding the facility gathered and analyzed supplemental information based on the triggered CAAs prior to developing the comprehensive care plan was identified for six of the 12 sampled residents. Review of the Electronic Health Record (EHR) on 10/21/24 revealed the following CAA noted concerns for the following six residents: The 02/29/24 Annual Minimum Data Set (MDS) for R8 completed on 08/13/24, with incomplete analysis of Functional Abilities CAA documented R8 depends on staff for all cares. The 09/04/23 Annual MDS for R12 completed on 09/18/23, with no CAA notes completed in all of the areas triggered which included: Cognitive Loss/Dementia, Urinary Incontinence and Indwelling Catheter, Activities, Psychosocial Well Being, Falls, Visual Function, Mood State, Pressure Ulcer/Injury, Psychotropic Drug Use and ADL Functional/ Rehab Potential. The 04/20/24 Annual MDS for R17 completed on 05/24/24, with incomplete analysis of Psychotropic Drug Use CAA documented related to decline in condition, physician has increased her dose. The Falls CAA documented R17 had actual falls with no injury. The 04/22/24 Annual MDS for R18 completed on 08/16/24, with incomplete analysis of Falls CAA documented R18 is a high risk for falls related to seizure activity and behaviors. The 10/14/24 Admission MDS for R74 completed on 10/15/24, with incomplete analysis of Functional Abilities CAA documented R74 was able to go care by self with minimal staff assistance. The Psychotropic Drug Use documented R74 had no prescribed antidepressants. The 09/29/24 Admission MDS for R124 had no date for completion of the MDS, the CAA or submission record as of 10/21/24. Administrative Nurse E (MDS Nurse) confirmed during an interview on 10/23/24 at 04:00 PM an issue with EHR submission and reported that R124's CAAs were completed. Review of the following CAA's were documented with incomplete analysis. The Cognitive Loss/Delirium CAA documented R124 had a history of cognitive loss and dementia with impaired decision making for her safety. The Psychotropic Drug Use CAA documented R124 received medication as prescribed. The Dental CAA documented R124's bridges are broken related to her las injury fall. The Falls CAA documented R124 has a history of falls with the last having significant injuries. The Nutritional CAA documented not an issue with R124 at this time. During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E (MDS Nurse) confirmed the CAA Notes that were not completed or lacked analysis and risk findings. Administrative Nurse E revealed she was unsure on what to write for CAA notes. The facility's policy RAI and CAA Completion dated 10/2020, documented the purpose of the Resident Assessment Instrument is to assist the facility in providing appropriate care to residents. The assessment must accurately reflect the resident's current status. The facility failed to accurately complete the CAAs for R8, R12, R17, R18, R74 and R124 related to several CAAs triggered. This placed the residents at risk for uncommunicated care needs.

The facility reported a census of 25 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the [NAME] Data Set for seven residents: Resident (R) 12, R17, R18, R21, and R20 related to falls; R21 related to antipsychotic medication; R20 related to chair alarm; R74 related to antidepressant medication; and R8 related to antiplatelet medications. This placed the residents at risk for uncommunicated care needs. Findings included: - The Electronic Health Records (EHR) documented R21 had the following diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), degenerative arthritis (a chronic condition that causes cartilage in the joints to break down over time) of bilateral (both sides) knees and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The 06/22/24 Annual Minimum Data Set (MDS) documented R21 had two non-injury falls from 03/24/24 thru 06/22/24 and received antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) and antidepressants (class of medications used to treat mood disorders) medications during the lookback period for seven days 06/16/24 thru 06/22/24. The 08/21/24 Falls Care Area Assessment (CAA) documented R21 was at risk for falls due to a history of falling and she was unsteady on her feet, mixed with her confusion at times. The 08/21/24 Psychotropic Drug Use CAA documented R21 required several medications to control her mental health diagnosis. The 04/27/24 at 02:31 AM Progress Note revealed staff found R21 on the floor in her bathroom. The note documented R21 had severe swelling noted on the right side of her face with lesions noted on her lower lip with severe bleeding. The note included R21 had bruising noted on the back of her right and left hands and both arms, and she transferred to the hospital. The 04/27/24 at 04:39 AM Progress Note revealed R21 returned from the hospital, and R21 had fractures of the sinus bones and a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to her right cheek. The 06/01/24 through 06/22/24 Medication Administration Record lacked evidence of any antipsychotic medications administered to R21. During an observation on 10/21/24 at 03:54 PM, R21 sat in her recliner with a seated rolling unlocked walker in front of her. She was very hard of hearing and had bilateral hearing aids in her ears. R21 had a hard time expressing her thoughts, as she stuttered and repeated her words. During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E MDS Nurse confirmed R21's Annual MDS was incorrect. Administrative Nurse E stated R21 had not received an antipsychotic medication and had a major injury fall during the lookback period of the Annual MDS completed in June 2024. The facility's policy RAI and CAA Completion dated 10/2020, documented the purpose of the Resident Assessment Instrument is to assist the facility in providing appropriate care to residents. The assessment must accurately reflect the resident's current status. The facility failed to accurately complete the MDS for (R)21 related to falls and antipsychotic medications. This placed the resident at risk for uncommunicated care needs. - Resident (R) 20's Electronic Health Record (EHR) revealed diagnoses, which included dementia (progressive mental disorder characterized by failing memory, confusion) and parkinsonism (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The 12/23/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R20 had a total mood severity score of six, which indicated mild depression. R20 required set up assistance for eating and required moderate assistance with activities of daily living (ADLs) to include dressing, toileting hygiene, footwear, personal hygiene, and standing. R20 required supervision for ambulation, oral care, and transfers. R20 had two or more non-injury falls. The 06/22/24 Falls Care Area Assessment (CAA) documented R20 had a fall history and had falls while in facility. The 06/26/24 Quarterly MDS documented R20 had two or more non-injury falls from 03/26/24 through 06/26/24 and R20 had a chair alarm in the look back period of seven days from 06/20/24 through 06/26/24. The 10/21/24 Care Plan lacked any documentation for the resident's chair alarm. The 04/08/24 at 02:15 AM Progress Note revealed staff found R20 lying on his right side, on the floor, in front of his bathroom. R20 reported he fell and was not using his walker. The 04/09/24 at 09:32 PM Progress Note revealed bruising noted on right wrist and hand from previous fall. During an observation on 10/21/24 at 04:00 PM and 05:12 PM, R20 was seated in his lift chair in his room, the lift chair was approximately a quarter to halfway lifted and R20 was leaning towards the floor. No chair alarm was noted on recliner or in the resident's room. During an interview on 10/23/24 at 08:26 AM, CNA M reported that R20 never had a personal alarm on his chair or any dycem noted on the seat of his recliner. CNA M reported R20 could use his left chair remote independently. During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E MDS Nurse confirmed R20's Quarterly MDS was incorrect. Administrative Nurse E stated R20 had a minor injury fall during the lookback period of the Quarterly MDS completed in June 2024 and did not have a chair alarm. The facility's policy RAI and CAA Completion dated 10/2020, documented the purpose of the Resident Assessment Instrument is to assist the facility in providing appropriate care to residents. The assessment must accurately reflect the resident's current status. The facility failed to accurately complete the MDS for (R)20 related to falls and chair alarm. This placed the resident at risk for uncommunicated care needs. 46960 - R74's Electronic Health Record (EHR) revealed diagnoses of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) and Alzheimer's disease (a progressive mental deterioration characterized by confusion and memory failure) The Admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The assessment documented R74 utilized a walker and/or a wheelchair for locomotion. The assessment documented the resident received antianxiety (a class of medications that calm and relax people) medications, antidepressant (a class of medications used to treat mood disorders) medications, diuretic medications, and opioid medications even though the resident's record lacked evidence the resident received all of these medications during the lookback period. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 10/15/24 documented R74 had periods of confusion. The Psychotropic Drug Use CAA dated 10/15/24 documented R74 had no prescribed antidepressant medication. The Pain CAA was not triggered on the assessment. The Physician Orders revealed the following orders: Ativan (lorazepam, a benzodiazepine class of medication which works on the neurotransmitters in the brain and is used to treat anxiety) 0.5 milligram (mg), give 0.5 mg every eight hours PRN for anxiety, dated 10/01/24. The order lacked a stop date or rationale for the continued use of the medication. Norco (hydrocodone-acetaminophen - an opioid pain medication) 5-325 milligrams (mg), one tablet by mouth (PO) every 12 hours PRN pain, dated 10/01/24. Ipratropium Bromide (a nebulized medication) inhalation solution 0.02 percent (%), one vial to be inhaled orally every six hours related to diagnosis of COPD. Furosemide (a diuretic medication) 20mg, PO every day related to diagnosis of CHF. Duloxetine HCl (an antidepressant medication) 30mg, PO daily related to diagnosis of anxiety/depression. Review of the Census tab on the EHR revealed that R74 admitted to the facility on [DATE]. Review of the electronic Medication Administration Record (eMAR) from 10/01/24 to 10/23/24 revealed R74 had not received any doses of PRN Ativan (lorazepam) and lacked evidence of an ordered stop date. The eMAR documented R74 had not received any doses of the opioid pain medication. The eMAR documented appropriate doses of the antidepressant, nebulized, and diuretic medications. During an observation on 10/21/24 at 04:41 PM, R74 sat in his recliner, watching television and appeared relaxed and calm. During an observation on 10/22/24 at 12:14 PM, R74 sat in his wheelchair at a table in the dining area with peers present and appeared relaxed and calm. The facility's policy RAI and CAA Completion dated 10/2020, documented the purpose of the Resident Assessment Instrument is to assist the facility in providing appropriate care to residents. The assessment must accurately reflect the resident's current status. The facility failed to accurately complete the MDS for R74 related to documentation of psychotropic and opioid medication use, when the resident did not utilize those medications during the lookback period. This placed the resident at risk for uncommunicated care needs. - Review of the Electronic Health Record (EHR) for Resident (R) 18 included diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion), epilepsy (a brain disorder characterized by repeated seizures), and frontotemporal neurocognitive disorder (a brain disease that affects behavior, language, and movement abilities). The 04/22/24 Annual Minimum Data Set (MDS) completed 08/16/24, documented the Brief Interview for Mental Status (BIMS) assessment could not be completed, and the staff assessed R18 to have severely impaired cognition. The assessment documented R18 displayed no behaviors, utilized a wheelchair for locomotion and was dependent on staff for all cares except oral hygiene, which required substantial/maximum assistance and eating which required partial/moderate assistance. The assessment documented R18 had two or more falls since admission or the previous assessment, which included one fall with major injury. The 07/23/24 Quarterly MDS completed 08/16/24, documented the Brief Interview for Mental Status (BIMS) assessment could not be completed and the staff assessed R18 to have severely impaired cognition. The assessment documented R18 experienced hallucinations (sensing things while awake that appear to be real, but the mind created), displayed physical and verbal behavioral symptoms directed towards others one to three days during the seven-day look-back period. R18 utilized a walker and/or wheelchair for locomotion and was dependent on staff for all cares except eating, which required partial/moderate assistance from staff. The assessment documented no falls since admission or the previous assessment. The Progress Notes and fall investigation reports identified two falls which were not identified on the 07/23/24 Quarterly MDS that was completed on 08/16/24. During an interview on 10/23/24 at 04:00 PM with Administrative Staff A and Administrative Nurse E (MDS Nurse), confirmed R18's Quarterly MDS was inaccurate related to falls and confirmed that R18 had a fall that should have been captured during the 90-day look-back period between the Annual MDS dated [DATE] and the Quarterly MDS dated [DATE]. The facility's policy RAI and CAA Completion dated 10/2020, documented the purpose of the Resident Assessment Instrument is to assist the facility in providing appropriate care to residents. The assessment must accurately reflect the resident's current status. The facility failed to accurately complete the MDS for R18 related to falls and antipsychotic medications. This placed the resident at risk for uncommunicated care needs. - Review of the Electronic Health Record (EHR) for Resident (R) 8 included the diagnosis of atrial fibrillation (a rapid irregular heartbeat). The 02/29/24 Annual Minimum Data Set (MDS) completed 08/13/24 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The assessment documented that R8 was dependent on staff for all cares except hygiene, which required partial/moderate assistance and eating which required supervision and setup and R8 received oxygen. The assessment documented that R8 did not receive an antiplatelet (a class of medication that prevents blood clot formation) medication. The EHR Physician Orders documented an order for clopidogrel bisulfate (an antiplatelet medication), 75 milligrams (mg), give one tablet by mouth (PO) once daily related to diagnosis of atrial fibrillation, dated 10/02/23. Review of the electronic medication administration record (eMAR) from 02/01/24 to 02/29/24 documented appropriate documentation of administration of medication, which included clopidogrel bisulfate as ordered by the physician. During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E (MDS Nurse) confirmed R8's Annual MDS was incorrect. Administrative Nurse E stated R8 had received an antiplatelet medication during the seven-day look-back period of the Annual MDS completed on 08/13/24. The facility's policy RAI and CAA Completion dated 10/2020, documented the purpose of the Resident Assessment Instrument is to assist the facility in providing appropriate care to residents. The assessment must accurately reflect the resident's current status. The facility failed to accurately complete the MDS for R8 related to antiplatelet medications. This placed the resident at risk for uncommunicated care needs. 51334 - Review of the 04/20/24 Annual Minimum Data Set (MDS) documented R17 had two or more noninjury falls from 01/21/24 thru 04/20/24. Review of the Progress Notes from 01/21/24 thru 04/20/24 revealed no falls during this time. Review of the 07/23/24 Quarterly Minimum Data Set revealed R17 had two or more noninjury falls from 04/22/24 thru 07/23/24 and was not taking and antibiotic medication. However, the Incident Note on 06/17/24 at 12:00 AM documented R17 had a fall with no injury. The Health Status Note on 06/13/24 at 12:22 PM documented R17 was sent to the emergency room and returned and started on an antibiotic and a steroid treatment. Review of the Physician Orders in the EHR documented an order for amoxicillin 500 milligrams (mg) to be taken three times a day for 10 days. Started on 07/10/24 and finished on 07/20/24. During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E MDS Nurse confirmed R17's Annual MDS was incorrect. Administrative Nurse E stated R17 had no falls during the lookback period of the Annual MDS for April 2024 and confirmed the Quarterly MDS was incorrect because R17 had received an antibiotic medication and had one fall with minor injury during the lookback period of the Quarterly MDS for July 2024. The facility's policy RAI and CAA Completion dated 10/2020, documented the purpose of the Resident Assessment Instrument is to assist the facility in providing appropriate care to residents. The assessment must accurately reflect the resident's current status. The facility failed to accurately complete the MDS for (R)17 related to falls and antibiotic medications. This placed the resident at risk for uncommunicated care needs. - Review of the 09/04/23 Annual Minimum Data Set (MDS) documented R12 had no falls from 06/09/23 thru 09/04/23. However, Incident Note revealed R12 fell on the following dates: 06/26/23, 07/19/23, and 09/19/23. During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E MDS Nurse confirmed R12's Annual MDS was incorrect. Administrative Nurse E stated R12 had two falls with no injury and one fall will minor injury on the 09/04/23 Annual MDS. Administrative Nurse E confirmed R12's Quarterly MDS was incorrect. R12 had one fall will minor injury on the 06/06/24 Quarterly MDS. The facility's policy RAI and CAA Completion dated 10/2020, documented the purpose of the Resident Assessment Instrument is to assist the facility in providing appropriate care to residents. The assessment must accurately reflect the resident's status. The facility failed to accurately complete the MDS for (R)12 related to falls. This placed the resident at risk for uncommunicated care needs.

The facility had a census of 25 residents. Based on observation, record review, and interview, the facility failed to provide Registered Nurse (RN) coverage eight hours a day, seven days a week, placing all residents who reside at the facility at risk of lack of assessments and inappropriate care. Findings included: - Upon review of Payroll Based Journal (PBJ- a required detail information submitted by nursing homes of staffing information that is required by the Centers of Medicare and Medicaid Services [CMS]) the facility reported a lack of consecutive eight-hour RN coverage for 39 days from July 1, 2023, through June 30, 2024. Review of the Fiscal Year FY Quarter 4 2023 (July 1 - September 30, 2023), the following days lacked an RN for consecutive eight-hour coverage: 08/16/23, 08/17/23, 08/22/23, 09/04/23, 09/09/23, 09/10/23, 09/23/23 and 09/24/23. Review of the FY Quarter 1 2024 (October 1 - December 31, 2023), the following days lacked an RN for consecutive eight-hour coverage: 10/07/23, 10/21/23,11/04/23, 11/18/23, 11/19/23, 11/23/23, 12/02/23, 12/03/23, 12/16/23, 12/26/23 and 12/30/23. Review of the FY Quarter 2 2024 (January 1 - March 31, 2024), the following days lacked an RN for consecutive eight-hour coverage: 01/01/24, 01/13/24, 01/14/24, 01/27/24, 02/04/24, 03/10/24, 03/23/24, 03/24/24 and 03/31/24. Review of the FY Quarter 3 2024 (April 1 - June 30, 2024), the following days lacked an RN for consecutive eight-hour coverage: 04/07/24, 04/11/24, 04/16/24, 04/30/24, 05/04/24, 5/05/24, 05/19/24, 06/01/24, 06/02/24, 06/29/24 and 06/30/24. Upon review of the facility's schedule for Licensed Nurses of the months of July 2023, August 2023, September 2023, October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, May 2024, and June 2024 39 dates lacked consecutive eight-hour RN coverage. On 10/23/24 at 04:30 PM, Administrative Staff A stated she was aware there was no consecutive eight-hour RN coverage on the days listed above. Some of the days had partial RN coverage due to the 12-hour shifts running from 05:00 AM to 05:00 PM and 05:00 PM to 05:00 AM. The facility failed to provide a policy related to staffing coverage as requested on 10/23/24. Administrative Nurse D stated that the facility lacked a policy related to staffing coverage. The facility failed to provide Registered Nurse coverage eight consecutive hours a day, seven days per week, placing the residents who resided in the facility at risk of lack of assessment and inappropriate care.

The facility reported a census of 25 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility. Findings included: On 10/21/24 at 02:37 PM during an initial tour of the main kitchen and refrigerator storage areas with Dietary Staff BB, the following areas of concern were observed: One unsealed/uncovered tray fruit-gelatin dessert located in the refrigerator. One uncovered, extra-large, metal steam container full of sandwich baggies, which contained unidentifiable food and lacked a date or label located in the freezer. One unsealed bag of hotdogs, without a date or label and located in the freezer. One unsealed bag of pepperoni, without a date or label and located in the freezer. One unsealed bag of frozen fish patties, without a date or label and located in the freezer. One sealed container of bulk breadcrumbs without a date or label. Seven sealed plastic containers of cereal with a use by date of 05/29/24, no opened date documented and located in main kitchen. Twenty cutting boards with uncleanable surfaces showing discoloration along with deep slices that were visible. During an observation on 10/21/24 at 02:37 PM the refrigerator labeled 2R had a temperature of 42 degrees Fahrenheit (F). Further observation on 10/21/24 revealed temperature logs on unit refrigerators and freezers were not maintained and temperatures documented were out of range of the facility stated policy. Review of Food Storage Refrigerator Temperature log sheets revealed the following documentation: Refrigerators were to be maintained between 33 and 36 degrees Fahrenheit, and freezers maintained between -0 to -10 degrees Fahrenheit. There was notation documented on the sheet that R corresponded with refrigerator and F corresponded with freezer. 09/10/24 through 10/22/24 the refrigerator labeled 1R was documented 43 times as out-of-range. 09/10/24 through 10/22/24 the refrigerator labeled 2R was documented 53 times as out-of-range. 09/10/24 through 10/22/24 the refrigerator labeled 3R was documented 64 times as out-of-range. 09/10/24 through 10/22/24 the refrigerator labeled 4R was documented 38 times as out-of-range. 09/10/24 through 10/22/24 the refrigerator labeled 5R was documented 40 times as out-of-range. 09/10/24 through 10/22/24 the freezer labeled 6F was documented 32 times as out-of-range. 09/10/24 through 10/22/24 the refrigerator labeled WR1 was documented 58 times as out-of-range. 09/10/24 through 10/22/24 the freezer labeled WR1 was documented 35 times as out-of-range. The freezer lacked temperatures logged for 10/1/24 through 10/22/24 on the morning log sheet. 09/10/24 through 10/22/24 the refrigerator labeled CC was documented 60 times as out-of-range. 09/10/24 through 10/22/24 the freezer labeled CC was documented 32 times as out-of-range. The freezer lacked temperatures logged for 10/1/24 through 10/22/24 on the morning log sheet. On 10/21/24 at 02:57 PM, an interview with Dietary Manager BB revealed she expected staff to label and date opened food items. Dietary Manager BB stated that the above concerns identified with kitchen and freezer storage, which included undated and unsealed items were unacceptable. Dietary Manager BB revealed that once food was put into the freezer it was good for 6 months and that was why the expiration date was to be documented on the label. On 10/22/24 at 11:45 AM, an interview with Dietary Staff CC revealed every shift was required to document the refrigerator and freezer temperatures, which started on 09/10/24 when the written logs were made. Before the written logs each refrigerator and freezer had their own thermometer that would remotely take temperatures every 15 minutes then it would upload it to the facility software. Staff would be notified when the temperature was off by an alarm sounding from that refrigerator or freezer. On 10/24/24 at 09:48 AM, an interview with Dietary Manager BB reveled she expected all staff to complete the temperature logs and notify her if any refrigerators or freezers were out of range. Once staff notified her of out-of-range temperatures she was able to fix it promptly as she previously had in the past. On 10/24/24 at 10:18 AM, an interview with Dietary Staff BB reveled the paper refrigerator logs provided were all the records of refrigerator temps that existed. Dietary Staff BB stated that the facility recently changed how it recorded refrigerator temperatures. The facility's policy Food Storage dated 07/2019 reveled that all foods are to be covered, labeled, and dated. Facility policy stated stock was required to be rotated and used in the order of first in - first out method allowing staff ensure food consumed by ready-to-eat date. Temperatures for the refrigerators are to be between 35-39 degrees and freezer are to be 0 degrees or below Fahrenheit. Temperatures are to be monitored always by a cloud-based thermometer. When temperatures are out-of-range, an alarm is sent to the Directors phone, Productions phone and Purchasing phone. The facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.

The facility reported a census of 25 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly, and in a sanitary condition, ensuring the lids were down to cover the disposed waste and prevent the potential harboring/feeding of pests. Findings included: - Initial tour of the outside trash dumpsters on 10/21/24 at 02:37 PM with Dietary Manager BB, revealed two out of the seven dumpsters had the lids in the open position. On 10/21/24 at 02:37 PM, Dietary Manager BB, revealed she was not aware of the requirement to have trash covered. On 10/23/24 at 10:48 AM, Administrative Nurse D, stated she was unaware that dumpsters fell under dietary responsibility and believed the city was responsible for the conditions, repairs, and maintenance the dumpsters required. The facility's policy Waste Disposal dated 09/2019 revealed that all waste would be kept covered unless in production and any leaks, creaks or dents in the trash can or to the lid would be reported to the production manager. The facility failed to provide sanitary garbage and refuse containers that were maintained with lids closed or otherwise covered. This deficient practice had the potential to lead to the harborage and feeding of pests.

The facility reported a census of 25 residents. Based on observation, interview, and record review the facility failed to provide administrative services in a manner to effectively and efficiently use resources to attain/maintain each resident's highest physical, mental, and psychosocial well-being, for all 25 residents that resided in the facility. Findings included: The facility failed to provide Resident (R) 17 care in a dignified manner when it referred to the table where the resident was placed as a feeder table in the electronic charting. This deficient practice placed the resident at risk for decreased psychosocial well-being. (See F550). The facility failed to ensure R124, R20, R21, R15, and R74 had accurate advanced directives completed. This deficient practice had the potential to lead to uncommunicated needs regarding the resident's choice in end-of-life care. (See F578). The facility failed to promote a clean homelike environment for five residents R2, R8, R23, R74 and R124. These deficient practices had the potential to spread possible infections to the residents in the facility and had the potential to lead to negative psychosocial effects related to non-home-like environment. (See F584). The facility failed to provide written notification of facility-initiated discharges/transfers to the resident or resident's representative, or the LTCO. This placed the residents at risk of uninformed care choices. (See F623). The facility failed to provide written notification of the facility's bed hold policy to the resident or resident's representative with facility-initiated discharges/transfers. This placed the residents at risk of an impaired ability to return to the facility and to the previous room for R18, R12 and R23. (See F625). The facility failed to accurately complete the CAAs for R8, R12, R17, R18, R74 and R124 related to several CAAs triggered. This placed the residents at risk for uncommunicated care needs. (See F636). The facility failed to complete a Quarterly Minimum Data Set (MDS) assessment in a timely manner for eight residents, R8, R10, R12, R17, R18, R19, R20, and R21. This placed the residents at risk for unmet care needs and inaccurate assessments. (See F638). The facility failed to complete a comprehensive MDS assessment in a timely manner for ten residents. Resident (R)8, R10, R12, R15, R17, R18, R19, R20, R21 and R124. This placed the residents at risk for unmet care needs and inaccurate assessments. (See F640). The facility failed to accurately complete the MDS for R8, R20, and R12 related to falls. This placed the residents at risk for uncommunicated care needs. (See F641). The facility failed to complete a baseline care plan for R74 and R124. This deficient practice had the potential to lead to uncommunicated needs. (See F655). The facility failed to develop and implement a person-centered comprehensive care plan for R74 related to psychotropic medication, diuretic medication, or nebulized medication use. This deficient practice had the potential to lead to uncommunicated needs which had the potential to negatively affect the physical and psychosocial well-being of R74. (See F656). The facility identified a census of 25 residents, which included 12 residents sampled. Based on interviews, observations, and record review, the facility failed to review and revise the care plans with appropriate interventions for eight of the sampled residents; R23 related to treatment of an area of pressure ulcer/injury and enhanced barrier precautions (EBP - a set of infection control interventions designed to reduce transmission of resistant organisms which employs targeted gown and glove use during high contact cares) related to wound care and urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care; R19, R15, R20, R21, R17, R12 and R18 related to development and implementation of appropriate interventions to prevent multiple falls. These deficient practices resulted in uncommunicated care needs. (See F657). The facility reported a census of 25 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to identify, implement, and reevaluate fall prevention interventions to prevent falls for six residents. Resident (R) 21 experienced a fall which resulted in multiple sinus fractures (broken bone) and R18's fall resulted in a hip fracture, which required hospitalization and surgery. Additionally, the facility failed to implement new interventions to prevent falls for R12, R17, R20 and R23, placing the residents at risk for falls with injury. (See F689). The facility failed to accurately assess a resident's nutritional status on admission R124. This placed the resident at risk for uncommunicated care needs and potential nutritional deficits. (See F692). The facility failed to properly clean and store the nebulizer for R12, R8 and R74; failed to ensure R18's room remained free of used nebulizer equipment not required for R18's medical care; and failed to ensure that the nasal cannulas were stored appropriately when not in use for R12 and R8. These deficient practices had the potential to have a negative impact on the residents' physical well-being and at risk for respiratory infection. (See F695). The facility failed to ensure the Physician visits were conducted in person and documented as required for R124 for admission. This placed the resident at risk for uncommunicated care needs. (See F714). The facility failed to provide Registered Nurse coverage eight consecutive hours a day, seven days per week, placing the residents who resided in the facility at risk of lack of assessment and inappropriate care. (See F727). The facility failed to ensure the posted daily nurse staffing sheets included the daily census and nursing hours, as required. (See F732). The facility identified a census of 25 residents. The sample included 12 residents with the residents reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care services. Based on observation, record review, and interviews, the facility failed to support Residents (R)19 and R124 and implement care planned interventions to address dementia care needs. This deficient practice placed the residents at risk for impaired ability to achieve and/or maintain their highest practicable level of functioning and wellbeing. The facility failed to implement individualized interventions, as well as revise the care plan accordingly, to address individualized interventions related to the resident's symptomology and rate of progression as evidenced by observation, record review, and/or interview. (See F744). The facility reported a census of 25 residents. The sample included 12 residents with six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon the pharmacist's monthly medication review (MRR) on 06/30/24 for Resident (R)18 and R19. The deficient practice had the potential to lead to the residents receiving unnecessary mediations. (See F756). The facility failed to ensure a 14-day stop date or physician rationale for continued use beyond the 14 days, for R74's PRN psychotropic medication, Ativan. This deficient practice had the potential for R74 to receive an unnecessary psychotropic medication. (See F758). The facility failed to ensure the safe and secure storage of resident medication when observation onsite revealed an unlocked and unattended medication cart, not in the line of vision of staff, in the resident hallway. (See F761). The facility failed to assess the dietary preferences of R124 in order to provide foods to meet the resident's preferences. (See F806). The facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility. (See F812). The facility failed to provide sanitary garbage and refuse containers that were maintained with lids closed or otherwise covered. This deficient practice had the potential to lead to the harborage and feeding of pests. (See F814). The facility failed to accurately complete a PBJ report for four quarters. Which placed all residents who reside at the facility at risk of lack of assessments and inappropriate care. (See F851). The facility failed to conduct at least one performance improvement project, annually. This deficient practice has the potential to affect all 25 residents of the facility. (See F867). The facility failed transport clean linens in a method to protect clean linens from dust or soiling when staff left the clean linen cart uncovered during transport. The facility further failed to maintain an effective infection control program related to the maintaining an annually reviewed Infection Prevention and Control Program. The facility failed to provide respiratory care consistent with professional standards of care for R8, R18 and R74 regarding the use and cleaning of the nebulizer equipment and R12 oxygen supplies were not stored in a clean manner. The facility staff failed to utilize enhanced barrier precautions when providing catheter care and wound care on R23. These deficient practices had the potential to spread possible infections to the residents in the facility. (See F880). The facility failed to provide ongoing antibiotic stewardship to ensure appropriate antibiotic use for the residents of the facility to prevent antibiotic resistance and the spread of multi drug resistant organisms. (See F881). The facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. This failure has the potential to affect all 25 residents. (See F882). The facility failed to provide proof of declination or proof of immunization of the pneumococcal vaccine for these five residents and failed to receive the witness signature for the influenza vaccine for two residents. (See F883). The facility failed to ensure four of the five Certified Nurse Aides (CNA) sampled lacked the required 12 hours per year in-service training. (See F947). The facility failed to provide administrative services in a manner to effectively and efficiently use resources to attain/maintain each resident's highest physical, mental, and psychosocial well-being, for all 25 residents that resided in the facility.

The facility had a census of 25 residents. Based on observation, record review, and interview, the facility failed to accurately complete a Payroll Based Journal (PBJ- a required detail information submitted by nursing homes of staffing information that is required by the Centers of Medicare and Medicaid Services [CMS]) reports for Registered Nurse (RN) coverage eight hours a day, seven days a week and failed to accurately complete a PBJ report for Licensed Nursing Coverage 24 hours/day. Which placed all residents who reside at the facility at risk of lack of assessments and inappropriate care. Findings included: - Review of the Fiscal Year FY Quarter 4 2023 (July 1 - September 30), the following days lacked an RN for consecutive eight-hour coverage: 08/16/23 (WE), 08/17/23 (TH), 08/22/23 (TU), 09/04/23 (MO), 09/09/23 (SA), 09/10/23 (SU), 09/23/23 (SA) and 09/24/23 (SU). Review of the FY Quarter 1 2024 (October 1 - December 31), the following days lacked an RN for consecutive eight-hour coverage: 10/07/23 (SA), 10/21/23 (SA),11/04/23 (SA), 11/18/23 (SA), 11/19/23 (SU), 11/23/23 (TH), 12/02/23 (SA), 12/03/23 (SU), 12/16/23 (SA), 12/26/23 (TU) and 12/30/23 (SA). Additionally, the following days lacked Licensed Nurse 24 hour coverage: 11/04 (SA); 11/08 (WE); 11/23 (TH); 11/24 (FR). Review of the FY Quarter 2 2024 (January 1 - March 31), the following days lacked an RN for consecutive eight-hour coverage: 01/01/24 (MO), 01/13/24 (SA), 01/14/24 (SU), 01/27/24 (SA), 02/04/24 (SU), 03/10/24 (SU), 03/23/24 (SA), 03/24/24 (SU) and 03/31/24 (SU). Review of the FY Quarter 3 2024 (April 1 - June 30), the following days lacked an RN for consecutive eight-hour coverage: 04/07/24 (SU), 04/11/24 (TH), 04/16/24 (TU), 04/30/24 (TU), 05/04/24 (SA), 05/05/24 (SU), 05/19/24 (SU), 06/01/24 (SA), 06/02/24 (SU), 06/29/24 (SA) and 06/30/24 (SU). Upon review of the facility's schedule for Licensed Nurses of the months of July 2023, August 2023, September 2023, October 2023, November 2023, December 2023, January 2024, February 2024, March 2024, May 2024, and June 2024 a total of 39 dates lacked RN consecutive eight-hour coverage. During an interview on 10/23/24 at 04:30 PM, Administrative Staff A reported she was aware that there was no consecutive eight- hour RN coverage on the days listed above. Some of the days had partial RN coverage due to the 12-hour shifts running from 05:00 AM to 05:00 PM and 05:00PM to 05:00 AM. The facility failed to provide a policy on PBJ reporting. The facility failed to accurately complete a PBJ report for four quarters. Which placed all residents who reside at the facility at risk of lack of assessments and inappropriate care.

The facility reported a census of 25 residents. Based on observation, interview, and record review, the facility failed to ensure the Quality Assessment and Assurance (QAA) program (a management process for long-term care (LTC) facilities that ensures care practices are consistently applied and quality standards are met) conducted at least one performance improvement project annually, that focused on high-risk or problem prone areas, identified by the facility, through data collection and analysis. This failure has the potential to affect all 25 residents. Findings included: - On 10/24/24 at 12:03 PM, Administrative Nurse D reported the required members do meet at least quarterly for the facility's Quality Assurance Performance Improvement (QAPI) program. Administrative Nurse D reported that no annual performance improvement project had been conducted for the facility and she stated, It is a work in progress. The facility's policy Quality Assurance and Performance Improvement dated 08/2024, documented the facility strives, on continuous basis, to respond to identified needs of the communities in our service and to improve those systems and processes that support the delivery of high quality patient services. The facility failed to conduct at least one performance improvement project, annually. This deficient practice has the potential to affect all 25 residents of the facility.

The facility reported a census of 25 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed transport clean linens in a method to protect clean linens from dust or soiling when staff left the clean linen cart uncovered during transport. The facility further failed to maintain an effective infection control program related to the maintaining an annually reviewed Infection Prevention and Control Program (IPCP) (a practical, evidence-based approach preventing patients and health workers from being harmed by avoidable infections). The facility staff failed to utilize enhanced barrier precautions (a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) (EBP) when providing catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) care and wound care on Resident (R) 23. The facility failed to provide respiratory care consistent with professional standards of care for R8, R18 and R74 regarding the use and cleaning of the nebulizer (device which changes liquid medication into a mist easily inhaled into the lungs) equipment and R12 oxygen supplies were not stored in a clean manner. This deficient practice had the potential to spread possible infections to the residents in the facility. Findings included: Observation on 10/21/24 at 12:12 PM, R18 had an intact nebulizer hanging from wall-mounted flow meter. Observation on 10/21/24 at 02:50 PM, R12 had oxygen tubing draped over wheelchair and not dated. Observation on 10/21/24 at 03:30 PM, R23 no Enhanced Barrier Precautions signage, or equipment noted for R23 in room or outside of room. R23 had a foley catheter and an open pressure ulcer. Observation on 10/21/24 at 04:25 PM, R8 had an intact nebulizer on bedside table, no date noted. Additionally, clear liquid noted in chamber. Observation on 10/21/24 at 04:41 PM, R74 had an intact nebulizer on bedside table, no date noted. Additionally, clear liquid noted in chamber. Observation on 10/22/24 at 12:45 PM, R8 had an intact nebulizer on bedside table, no date noted. Additionally, clear liquid noted in chamber. Observation on 10/22/24 at 12:14 PM, R74 had an intact nebulizer on bedside table, no date noted. Additionally, clear liquid noted in chamber. Observation on 10/22/24 at 03:48 PM, R23 received wound care by Licensed Nurse (LN) G, no personal protective equipment (PPE - equipment worn to protect against physical, chemical, and biological hazards) was worn by LN G. Certified Nurse Aide (CNA) N and CNA O also assisted LN G with wound care and provided peri-care and neither CNA donned PPE. Interview on 10/22/24 at 04:00 PM, CNA O reported if a resident was on any precautions, a sign would be hung on the resident's door outside, and a cart with ppe to be worn by staff would be outside the resident's door. Interview on 10/22/24 at 04:15 PM, CNA N reported if a resident was on any precautions, a sign would be hung on the resident's door outside, and a cart with ppe to be worn by staff would be outside the resident's door. She also confirmed there was no sign in R23's bathroom and the cart in R23's bathroom that contained gowns was not for EBP it was for his personal belongings and brief's. Interview on 10/22/24 at 04:22 PM, Certified Medication Aide (CMA) S reported if a resident was on precautions a sign would be posted outside a resident's door. CMA S reported if a resident has a wound or a catheter the staff should wear PPE when providing care. Interview on 10/22/24 at 04:36 PM, LN G reported that R23 was not on any precautions, and she would not have done anything differently when performing wound care. Observation on 10/23/24 at 07:40 AM, R12's oxygen tubing draped over bedside table with nasal canula on the floor. Observation on 10/23/24 at 08:48 AM, R18 had an intact nebulizer hanging from wall-mounted flow meter. Interview on 10/23/24 at 09:55 AM, Licensed Nurse (LN) G reported that nebulizer equipment should be dated and rinsed out and air dried after each use. Interview on 10/23/24 at 10:35 AM, Administrative Nurse D expected staff to rinse out the nebulizers and place the equipment on a towel to air dry after each use. Administrative Nurse D revealed that the oxygen tubing should be stored in a bag and placed on a hook when not in use. Additionally, she reported all oxygen/respiratory equipment should be dated and replaced once a month or as needed. Administrative Nurse D reported she did not know why R18 had a nebulizer in her room. Interview on 10/23/24 at 02:08 PM, Administrative Nurse D reported staff would know that any resident was on EBP as a sign is posted in the residents' bathroom with PPE stored in bathroom for staff to use. EBP should be sed at all times when providing wound care or catheter care. Observation on 10/24/24 at 08:33 AM, four unidentified laundry staff members delivered personal linens to the residents' rooms in the 200 hallway. The cover was not replaced over the clean personal linen that remained in the cart when the laundry staff walked away from the linen cart. Observation on 10/24/24 at 08:35 AM, Laundry Staff U reported that the linen cart should have been covered after removing the linen that was to be delivered. Interview on 10/24/24 at 08:54 AM, Laundry Director V reported the uncovered linen in the hallway was an concern. Interview on 10/24/24 at 10:20 AM, Administrative Nurse D reported that the linen should be covered in the hallway when being delivered, she also reported the facility's policy Infection Prevention Plan had not been reviewed annually. The facility's policy Infection Prevention Plan dated 05/2021, documented infection prevention is an important consideration in every decision and plan. Infection prevention must be integral responsibility of all personnel. It required cooperation between all departments. It is the responsibility of administration to oversee and provide resources for the Infection Prevention Program. The facility lacked a policy on care of respiratory equipment. The facility lacked a policy on EBP. The facility's policy Storage of Laundry Supplies dated 05/2024, documented all linens will be stored, handled, transported and processed in a manner that prevents the transmission of microorganisms (an organism that can be seen only through a microscope. Microorganisms include bacteria, protozoa, algae, and fungi) to other patients and areas. Clean linens shall be transported to patient care areas by use of covered carts with solid bottoms by laundry staff. The facility failed transport clean linens in a method to protect clean linens from dust or soiling when staff left the clean linen cart uncovered during transport. The facility further failed to maintain an effective infection control program related to the maintaining an annually reviewed Infection Prevention and Control Program. The facility failed to provide respiratory care consistent with professional standards of care for R8, R18 and R74 regarding the use and cleaning of the nebulizer equipment and R12 oxygen supplies were not stored in a clean manner. The facility staff failed to utilize enhanced barrier precautions when providing catheter care and wound care on R23. These deficient practices had the potential to spread possible infections to the residents in the facility.

The facility reported a census of 25 residents. Based on interview and record review the facility failed to ensure staff adhered to the principles of antibiotic stewardship through monitoring for the appropriate use of antibiotics prescribed for residents to prevent antibiotic resistance and spread of multidrug resistant organisms within the facility. Findings included: - Interview, on 10/24/24 at 10:20 AM, with Administrative Nurse D reported that a resident who received an order for an antibiotic would have finished the medication before she had time to evaluate the antibiotic, labs, and residents' Electronic Health Record (EHR). Administrative Nurse D reported that the hospitals EHR does not communicate with the facilities' EHR and that would make it difficult to assure appropriate use of antibiotics. She reported the provider would give and order for an antibiotic prior to receiving the culture and sensitivity report back and the resident would not be on the correct antibiotic when report was received as it was not a susceptible antibiotic. Additionally, the provider is not updated on the incorrect antibiotic as the resident had finished the course of the original antibiotic order. Administrative Nurse D revealed that the charge nurse would open the Infection Prevent Report on EHR and not complete or answer the questions correctly. The facility's policy Antimicrobial Stewardship for Long Term Care dated 05/2021, documented the facility was committed to combat bacterial resistance and minimize adverse effects related to treatment with antimicrobial (a substance that kills or prevents the growth of microorganisms, such as bacteria, viruses, fungi, or mold) medications. It is a coordinated program of interventions that are designed to improve and measure appropriate use of antimicrobials. The facility failed to provide ongoing antibiotic stewardship to ensure appropriate antibiotic use for the residents of the facility to prevent antibiotic resistance and the spread of multi drug resistant organisms.

The facility reported a census of 25 residents. Based on interview and record review the facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program (IPCP). This failure has the potential to affect all 25 residents. Findings included: - During an interview on 10/22/24 at 09:15 AM, Administrative Staff A revealed the facility did not employ a qualified IP. Administrative Staff A reported the IP in the hospital would answer questions for Administrative Nurse D and Administrative Nurse E when needed. Administrative Staff A reported that neither Administrative Nurse D nor Administrative Nurse E have completed an Infection Prevention and Control Program (IPCP). During an interview on 10/24/24 at 10:20 AM, Administrative Nurse D confirmed she had not started a IPCP at this time. The facility's policy Infection Prevention Plan dated 05/2021, documented the designated IP would be responsible for the day-to-day functions of facility infection prevention program. The IP's duties include: Developing a system for identifying, investigating, reporting, and preventing the spread of infections. The facility failed to designate a qualified Infection Preventionist (IP), who had completed specialized training in infection prevention and control, to be responsible for the facility's Infection Prevention and Control Program. This failure has the potential to affect all 25 residents.

The facility reported a census of 25 residents. Based on interview and record review, the facility failed to ensure four of the five Certified Nurse Aides (CNA) sampled lacked the required 12 hours per year in-service training. This placed the residents at risk for decreased quality of life and/or inadequate care. Findings included: - On 10/24/24 at 10:00 AM, review of training records for five CNAs employed by the facility for more than one year revealed four CNAs had less than 12 hours of documented in-service training for the previous 12 months as follows: CNA N had 10 hours and 38 minutes of documented training. CNA R had nine hours and 32 minutes of documented training. CNA Y had 10 hours and six minutes of documented training. Social Services Designee (SSD)/CNA X had nine hours and 24 minutes of documented training. On 10/24/24 at 10:00 AM, Administrative Staff A confirmed that CNAs were required to have 12 hours of training annually and stated there were no records of additional training for those CNAs. The facility did not provide a policy related to CNA continuing education and in-service training as requested on 10/24/24. The facility failed to ensure four of the five Certified Nurse Aides (CNA) sampled lacked the required 12 hours per year in-service training.

The facility reported a census of 25 residents, with 12 residents sampled and reviewed for advanced directives (a written document, which indicates the medical decisions for health care professionals when the person could not make their own decisions). Based on interview and record review, the facility failed to ensure five resident's advanced directives were thoroughly completed. Resident (R)124 had a Do Not Resuscitate (DNR- or no code, a legal document that means the person does not desire cardiopulmonary resuscitation [CPR is an emergency lifesaving procedure performed when the heart stops beating] in the event of cardiac arrest) form that was only located in the Code Status binder at nurse's station. However, the electronic health record (EHR) lacked a DNR order and lacked the uploaded DNR document for R124. Additionally, R15 had no order for a DNR in the EHR. R21 and R20 had a durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) signed DNR uploaded in the EHR, however, the EHR lacked an upload of the DPOA paperwork. R74 had no code order or scanned documents related to advanced directives in the EHR. Findings included: - During the onsite annual survey, a concern regarding advanced directives was identified for five of the 12 sampled residents. Review of the Electronic Health Records (EHR) on [DATE] revealed the following advanced directive concerns for the following five residents: R20 and R21 lacked documentation of the DPOA paperwork. R124 lacked a DNR order and lacked an uploaded DNR form. R15 lacked an order for DNR. R74 had no code order or scanned advanced directive documents. On [DATE], review of the Care Plan for R124, R74, R15, and R20 on [DATE] revealed lack of advanced directive information for each resident. On [DATE], the Physician Orders in the EHR lacked any orders for advanced directives for R124, R15, and R74. On [DATE], the EHR revealed a DNR signed by a family member and witnessed by Social Service Designee (SSD) X for R20 dated on [DATE] and for R21 dated [DATE]. During an observation on [DATE] at 08:53 AM, a butterfly sticker was noted above R21, R124, R20, and R15's bed on the light. During an interview on [DATE] at 02:30 PM Licensed Nurse (LN) G reported a butterfly sticker was placed above the resident's bed, on the wall light, to alert staff the resident is a DNR. During an interview on [DATE] at 04:15 PM, Certified Nurse Aide (CNA) N reported she did not know what the butterfly sticker meant on a resident's light above their bed. During an interview on [DATE] at 08:35 AM, LN G reported that Social Service Designee (SSD) X would be responsible for completion of the advanced directive paperwork. The DNR order would be placed in EHR by a nurse. LN G reported that if a resident had a DNR form filled out, the paperwork was placed in the Code Status book located at the nurse's station. Additionally, the DNR form would be uploaded in the EHR, and a provider order would be written in the EHR. LN G confirmed R124 had a DNR form in the code status book, but no order in EHR or uploaded DNR form in EHR. During an interview on [DATE] at 08:42 AM, Administrative Nurse D reported if a resident had a DNR form, it would be uploaded in the EHR, and a provider order would be in the EHR. Administrative Nurse D reported that if the DNR was signed by the DPOA, that paperwork would need to be uploaded in the EHR also. During an interview on [DATE] at 09:03 AM, SSD X reported Administrative Nurse E would obtain a provider order for code status and place the order in EHR. SSD X revealed that she would complete the remainder of the advanced directive paperwork. SSD X confirmed R21 and R20's DPOA paperwork was not in uploaded in the EHR, and she could not locate the DPOA paperwork. SSD X reported that Administrative Staff B would have the required DPOA paperwork. SSD X reported she would sometimes not see the DPOA paperwork when the DNR was being signed by a DPOA and she would witness the DNR. SSD X confirmed that R124, R15 and R 74 lacked a provider order in EHR. During an interview on [DATE] at 09:35 AM, Administrative Staff B revealed R20 and R21 should have their DPOA paperwork uploaded in the EHR. Additionally, Administrative Staff B reported the EHR changed [DATE] and all the DPOA forms should be uploaded. She reported the EHR in the facility did not communicate with the EHR in the hospital. The facility's Advanced Directives policy dated [DATE], documented advanced directives are documents which state resident's choice about medical treatment, or name someone to make their decision about medical treatment for them if they are unable to make those decisions for themselves. If the resident states they have executed an advanced directive, ask them to supply a copy to be scanned in the EHR. If a resident does not have an advanced directive, educate them and provide resident and or surrogate with written information. The facility failed to ensure R124, R20, R21, R15, and R74 had accurate advanced directives completed. This deficient practice had the potential to lead to uncommunicated needs regarding the resident's choice in end-of-life care.

The facility reported a census of 25 residents. The sample included 12 residents. Based on observation and staff interviews, the facility failed to promote a clean homelike environment for five residents. Resident (8) had a chair seat repaired with duct tape and R124 had a bureau drawer, which had lacked part of the veneer on the drawer facing and the remaining veneer was loose and brittle. Additionally, R2, R74, R23 and R124 had fall mats, which were cracked and had worn down surfaces all that were identified as non-cleanable surfaces and a non-home-like environment. These deficient practices had the potential to spread possible infections to the residents in the facility. Findings included: During an observation on 10/23/24 at 01:21 PM. R124 had a fall mat on her floor in her room, which had several cracks, tears and worn-down surfaces. During an interview on 10/24/24 at 08:38 AM, Housekeeping Staff II reported she would clean the fall mats with disinfectant cleaner and that it was not her job to report the fall mat that were worn down. Housekeeping Staff II reported she would only replace a cracked or torn pillow. During an interview on 10/24/24 at 09:00 AM, Housekeeping Supervisor W confirmed the fall mat was a non-cleanable surface and Housekeeping Staff should report equipment that is worn down, cracked, or torn to provide a home-like environment. During an observation on 10/24/24 at 11:01 AM, an environmental tour was completed with Maintenance Director JJ and Administrative Nurse D, which revealed R8 had a chair seat that was repaired with duct tape, Maintenance Director JJ reported that chair belonged to R8. Administrative Nurse D confirmed the chair was an un-cleanable surface and not a home-like environment. R74, R23 and R2's rooms had fall mats which were cracked and had worn surfaces, identified by Administrative Nurse D and Maintenance Director JJ as non-cleanable surfaces and non-home-like environment. Additionally, R124 had a bureau drawer that lacked part of the veneer on the drawer facing and what remained of the veneer was loose and brittle, identified by Administrative Nurse D and Maintenance Director JJ as a non-cleanable, accident hazard and non-home-like environment. The facility lacked a policy on clean home-like environment. The facility failed to promote a clean homelike environment for five residents R2, R8, R23, R74 and R124. These deficient practices had the potential to spread possible infections to the residents in the facility and had the potential to lead to negative psychosocial effects related to non-home-like environment.

The facility had a census of 25 residents. The sample included 12 residents with three reviewed for discharge. Based on observation, interview, and record review the facility failed to provide written notice to the resident or resident representative for facility-initiated transfers for Residents (R)18, R12, and R23 when they transferred to the hospital. The facility also failed to send a copy of the notice to the Office of the Long-Term Care Ombudsman (LTCO - a public official who works to resolve resident issues in nursing facilities) of R18, R12, or R23's discharge. This placed the residents at risk of uninformed care choices. Findings included: - Review of the Electronic Health Record (EHR) census log for R18 revealed a discharge from the facility to a hospital on 04/23/24 and readmitted to the facility on [DATE]. The EHR lacked documentation related to written notification of the resident or resident's representative or notification of the LTCO related to this discharge/transfer. Review of the EHR census log for R12 revealed a discharge from the facility to a hospital on 01/14/24 and readmitted to the facility on [DATE]. The EHR lacked documentation related to written notification of the resident or resident's representative or notification of the LTCO related to the discharge/transfer. Review of the EHR census log for R23 revealed a discharge from the facility to a hospital on 09/23/24 and readmitted to the facility on [DATE]. The EHR lacked documentation related to written notification of the resident or resident's representative, or evidence the facility sent a copy of the notification to the LTCO related to this discharge/transfer. During an interview on 10/23/24 at 11:03 AM, Administrative Nurse D revealed that Social Services Designee (SSD) X was responsible for the discharge notifications and did not know if SSD X notified the LTCO for discharges. During an interview on 10/23/24 at 11:03 AM, SSD X revealed she did not know of the regulatory requirement to notify the resident or resident's representative or the LTCO in writing of discharges from the facility. The facility did not provide a policy related to discharge notifications as requested on 10/24/24. The facility failed to provide written notification of facility-initiated discharges/transfers to the resident or resident's representative, or the LTCO. This placed the residents at risk of uninformed care choices.

The facility had a census of 25 residents. The sample included 12 residents with three reviewed for discharge. Based on observation, record review, and interviews, the facility failed to provide a written bed hold policy notice to Residents (R)18, R12, and R23, or the resident's representatives, when they transferred to the hospital. This deficient practice had the risk of impaired ability to return to the facility and to the previous room for R18, R12 and R23. Findings included: - Review of the Electronic Health Record (EHR) census log for R18 revealed a discharge from the facility to a hospital on 04/23/24 and readmitted to the facility on [DATE]. The EHR lacked documentation related to written notification of the resident or resident's representative or notification of the LTCO related to this discharge/transfer. Review of the EHR census log for R12 revealed a discharge from the facility to a hospital on 01/14/24 and readmitted to the facility on [DATE]. The EHR lacked documentation related to written notification of the resident or resident's representative or notification of the LTCO related to the discharge/transfer. Review of the EHR census log for R23 revealed a discharge from the facility to a hospital on 09/23/24 and readmitted to the facility on [DATE]. The EHR lacked documentation related to written notification of the resident or resident's representative, or evidence the facility sent a copy of the notification to the LTCO related to this discharge/transfer. During an interview on 10/23/24 at 09:14 AM Licensed Nurse (LN) G revealed that when a resident goes to the hospital, Social Services Designee (SSD) X handled the bed hold process During an interview on 10/23/24 at 11:03 AM, SSD X revealed she did not know of the regulatory requirement to notify the resident or resident's representative in writing of a bed hold notice with discharges from the facility. SSD X stated the bed hold policy is only reviewed with residents and their representatives during the admission process. During an interview on 10/23/24 at 11:03 AM, Administrative Nurse D revealed SSD X was responsible for the discharge notifications and was unaware of the regulatory requirement that residents or resident's representatives were to be notified in writing with a bed hold notice. Administrative Nurse D stated SSD X discussed the bed hold policy with the resident or resident's representative with each new admission and she was unaware if the bed hold policy/notice was discussed with the residents or resident's representative at the time of a transfer/discharge. The facility did not provide a policy related to written bed hold notifications as requested on 10/24/24. The facility failed to provide written notification of the facility's bed hold policy to the resident or resident's representative with facility-initiated discharges/transfers. This placed the residents at risk of an impaired ability to return to the facility and to the previous room for R18, R12 and R23.

The facility reported a census of 25 residents. The sample included 12 residents. Based on interview and record review, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment in a timely manner for eight residents, Resident (R) 8, R10, R12, R17, R18, R19, R20 and R21. This placed the residents at risk for unmet care needs and inaccurate assessments. Findings included: - During the onsite annual survey, the surveyor identified a concern regarding the lack of quarterly MDS assessments completed in a timely manner for eight residents. Review of the Electronic Health Record (EHR) on 10/21/24 revealed the following quarterly MDS noted concerns for the following eight residents: R8's EHR recorded a quarterly MDS, dated [DATE]. R8's EMR recorded the quarterly MDS, dated [DATE], was completed on 09/26/24 and submitted on 09/26/24. (11 days later) R10's EHR recorded a quarterly MDS, dated [DATE]. R10's EMR recorded the quarterly MDS, dated [DATE], was completed on 09/26/24 and submitted on 09/26/24. (10 days later) R12's EHR recorded a quarterly MDS, dated [DATE]. R12's EMR recorded the quarterly MDS, dated [DATE], was completed on 07/09/24 and submitted on 07/10/24. (16 days later) R17's EHR recorded a quarterly MDS, dated [DATE]. R17's EMR recorded the quarterly MDS, dated [DATE], was completed on 09/04/24 and submitted on 09/04/24. (34 days later) R18's EHR recorded a quarterly MDS, dated [DATE]. R18's EMR recorded the quarterly MDS, dated [DATE], was completed on 08/16/24 and submitted on 08/16/24. (10 days later) R19's EHR recorded a quarterly MDS, dated [DATE]. R19's EMR recorded the quarterly MDS, dated [DATE], was completed on 09/04/24 and submitted on 09/04/24. (36 days later) R20's EHR recorded a quarterly MDS, dated [DATE]. R20's EMR recorded the quarterly MDS, dated ,d+[DATE]//24, was in progress but not completed or submitted as required. (11 days late) R21's EHR recorded a quarterly MDS, dated [DATE]. R21's EMR recorded the quarterly MDS, dated ,d+[DATE]//24, was completed on 10/22/24 and submitted on 10/23/24. (16 days later) During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E, the facility's MDS Nurse, confirmed that quarterly MDS assessments were in progress or completed late. The facility's policy RAI and CAA Completion dated 10/2020, documented the purpose of the Resident Assessment Instrument is to assist the facility in providing appropriate care to residents. The assessment must accurately reflect the resident's current status. MDS assessments will be completed and submitted according to the regulatory time periods. The facility failed to complete a Quarterly Minimum Data Set (MDS) assessment in a timely manner for eight residents, R8, R10, R12, R17, R18, R19, R20, and R21. This placed the residents at risk for unmet care needs and inaccurate assessments.

The facility reported a census of 25 residents. The sample included 12 residents. Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment in a timely manner for ten residents. Resident (R)8, R10, R12, R15, R17, R18, R19, R20, R21 and R124. This placed the residents at risk for unmet care needs and inaccurate assessments. Findings included: - During the onsite annual survey, the surveyor identified a concern regarding the lack of comprehensive MDS assessments completed in a timely manner for ten residents. Review of the Electronic Health Record (EHR) on 10/21/24 revealed the following comprehensive MDS noted concerns for the following 10 residents: R8's EHR recorded a comprehensive MDS, dated [DATE]. R8's EMR recorded an Annual MDS, dated [DATE], was completed on 08/13/24 and submitted on 08/14/24. (167 days later) R10's EHR recorded a comprehensive MDS, dated [DATE]. R10's EMR recorded an Annual MDS, dated [DATE], was completed on 05/10/24 and submitted on 05/22/24. (82 days) R12's EHR recorded a comprehensive MDS, dated [DATE]. R12's EMR recorded an Annual MDS, dated [DATE], the EHR lacked an Annual MDS for 09/04/24. (366 days) R15's EHR recorded a comprehensive MDS, dated [DATE]. R15's EMR recorded an Admission MDS, dated [DATE], was completed on 08/27/24 and submitted on 08/27/24. (181 days) R17's EHR recorded a comprehensive MDS, dated [DATE]. R17's EMR recorded an Annual MDS, dated [DATE], was completed on 05/24/24 and submitted on 05/31/24. (41 days) R18's EHR recorded a comprehensive MDS, dated [DATE]. R18's EMR recorded an Annual MDS, dated [DATE], was completed on 08/16/24 and submitted on 08/16/24. (116 days) R19's EHR recorded a comprehensive MDS, dated [DATE]. R19's EMR recorded an Annual MDS, dated [DATE], was completed on 11/01/23 and submitted on 11/01/23. (18 days) R20's EHR recorded a comprehensive MDS, dated [DATE]. R20's EMR recorded an Annual MDS, dated [DATE], was completed on 06/22/24 and submitted on 06/24/24. (184 days) R21's EHR recorded a comprehensive MDS, dated [DATE]. R21's EMR recorded an Annual MDS, dated [DATE], was completed on 08/21/24 and submitted on 08/21/24. (60 days) R124's EHR recorded a comprehensive MDS, dated [DATE]. R124's EMR recorded an Admission MDS, dated [DATE], was in progress but not completed or submitted as required. (22 days) During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E, the facility's MDS Nurse, confirmed that comprehensive MDS assessments were in progress or completed late. The facility's policy RAI and CAA Completion dated 10/2020, documented the purpose of the Resident Assessment Instrument is to assist the facility in providing appropriate care to residents. The assessment must accurately reflect the resident's current status. MDS assessments will be completed and submitted according to the regulatory time periods. The facility failed to complete a comprehensive MDS assessment in a timely manner for ten residents. Resident (R)8, R10, R12, R15, R17, R18, R19, R20, R21 and R124. This placed the residents at risk for unmet care needs and inaccurate assessments.

- Resident (R) 20's Electronic Health Record (EHR) revealed diagnoses, which included dementia (progressive mental disorder characterized by failing memory, confusion), and parkinsonism (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness). The 12/23/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R20 had a total mood severity score of six, which indicated mild depression. R20 required set up assistance for eating and required moderate assistance with activities of daily living (ADLs) to include dressing, toileting hygiene, footwear, personal hygiene, and standing. R20 required supervision for ambulation, oral care, and transfers. R20 had two or more non-injury falls. The 06/22/24 Falls Care Area Assessment (CAA) documented R20 had a fall history and had falls while in facility. The 06/22/24 Cognitive Loss/Dementia CAA documented R20 required staff cues and assistance with ADL's and decisions for safety based on cognitive decline. The 06/26/24 Quarterly MDS documented a BIMS score of two, indicating severely impaired cognition. R20's total mood severity score of five, indicated mild depression. R20 required set up assistance for eating and required supervision assistance for oral care, transfers, and ambulation. R20 required maximal assistance with toileting hygiene, dressing, and standing. The resident had two or more non-injury falls and had a chair alarm. The 10/21/24 Care Plan documented fall prevention interventions, initiated 05/15/23, which included staff were instructed to provide a safe environment with adequate low glare light, ensure the resident's bed was in the lowest position and ensure the wheels were locked on bed. The 10/21/24 Care Plan documented following fall prevention interventions, initiated 03/15/24, which included staff were instructed to determine and address causative factors of falls and follow facility post-fall policy regarding monitoring signs and symptoms of injury post fall. The 10/21/24 Care Plan lacked any documentation for the resident's chair alarm and any new fall interventions for the falls that occurred on 03/12/24 (two falls), 04/08/24, 06/05/24, 06/19/24, 06/22/24, 08/01/24, 08/06/24, and 08/28/24. The 10/21/24 Physician Orders lacked any documentation regarding falls or a chair alarm. The 03/12/24 at 02:24 AM Progress Note revealed staff found R20 on the floor leaning towards his left side, in front of his recliner. The lift chair was all the way up and his walker was approximately three feet away. R20 had socks on his feet and reported he slipped when he tried to get up to go to the bathroom. The fall that occurred on 03/12/24 at 02:24 AM, lacked an intervention and lacked a Risk Management Report. The 03/12/24 at 01:18 PM Progress Note revealed the resident had a witnessed fall, R20 ambulated independently in the dining room without his walker, bent over to pick up a cane on the floor, fell forward, and struck his head, which caused an abrasion to the top of his head. The Risk Management Report dated 03/12/24 for a fall that occurred at 01:18 PM, included an immediate intervention for staff to remind R20 to use his walker and they would assist him if they saw a safety concern. The 04/08/24 at 02:15 AM Progress Note revealed staff found R20 lying on his right side, on the floor, in front of his bathroom. R20 reported he fell and was not using his walker. The Risk Management Report dated 04/08/24 for fall that occurred at 02:15 AM, included an intervention stating R20 would be reminded to use his walker at all times and to let staff know if he needed anything. R20 had not fallen since this incident. The 06/05/24 at 11:40 PM Progress Note revealed staff found R20 seated in on the floor in a seated position against his bed. R20 reported he transferred himself out of bed and slid to the floor. The fall that occurred on 06/05/24 at 11:40 PM, lacked an intervention, an incident report, and lacked a Risk Management Report. The 06/19/24 at 12:30 AM Progress Note revealed staff entered R20s' room to answer his call light and found R20 seated on the floor with his back against the recliner. R20 reported he slid out of his chair and staff applied dycem (non-slip mat used for stabilization and gripping to prevent slipping) to the recliner. The Risk Management Report dated 06/19/24 for a fall that occurred at 12:30 AM, included an immediate intervention of dycem placed on the resident's recliner seat. The risk management report intervention included staff would continue to check on R20 every one to two hours to see if he needed to get up from his recliner. The 06/22/24 at 03:00 AM Progress Note revealed staff found R20 lying on his floor in front of his recliner. R20 reported he was walking, and he fell . The Risk Management Report dated 06/22/24 for fall that occurred at 03:00 AM, included an intervention that staff would remind R20 to call staff for assistance and staff will continue to make frequent checks on R20. The 08/01/24 at 03:55 AM Progress Note revealed staff found R20 seated on the floor in his room and in front of his bed, R20 slid off of the bed. The fall that occurred on 08/01/24 at 03:55 AM, lacked an intervention, an incident report, and lacked a Risk Management Report. The 08/06/24 at 04:00 AM Progress Note revealed staff found R20 lying on his left side on the floor beside his bed. R20 reported he rolled out of bed. The Risk Management Report dated 08/06/24 for fall that occurred at 04:00 AM, included an intervention for staff to continue to keep an eye on R20 during evening hours and when he is sleeping. Bed checks are to be completed every hour. If this continues to happen a discussion will occur with R20 about alternative ways to keep him safe while sleeping. The 08/28/24 at 03:00 AM Progress Note revealed staff found R20 on his floor tangled in blankets. R20 reported he did not know what happened. The fall that occurred on 08/28/24 at 03:00 AM, lacked an intervention and lacked a Risk Management Report. During an observation on 10/21/24 at 04:00 PM and 05:12 PM, R20 was seated in his lift chair in his room, the lift chair was approximately a quarter to halfway lifted and R20 was leaning towards the floor. No chair alarm was noted on recliner or in the resident's room. During an observation on 10/22/24 at 08:04 AM and 12:02 PM, R20 was seated in dining room in wheelchair, no alarm noted. No dycem or alarm observed on R20's recliner in his room. During an observation on 10/22/24 at 11:00 AM, R20 was seated in recliner watching his tv, no alarm noted. At 02:25 PM and 04:30 PM, R20 was seated in recliner in room with his feet elevated and his eyes closed. No alarm noted. During an interview on 10/23/24 at 08:26 AM, Certified Nurse Aide (CNA) M reported that R20 never had a personal alarm on his chair or any dycem noted on the seat of his recliner. During an interview on 10/23/24 at 09:14 AM, Licensed Nurse (LN) G reported Administrative Nurse D and Administrative Nurse E updated the care plans in the EHR. During an interview on 10/23/24 at 11:03 AM, Administrative Nurse D reported that Administrative Nurse E would update the care plan with the new intervention. Administrative Nurse D expected care plans to be updated within 24 hours. During an interview on 10/23/24 at 01:35 PM, Administrative Nurse D confirmed that R20's care plan lacked new interventions for all of the fall dates reviewed. During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E expected a fall intervention to be completed on the care plan within 24 hours and confirmed that did not always occur. The facility policy LTC Fall Prevention Protocol dated 10/2020, documented each resident residing in this facility would be provided services and care that ensured all residents environments remain free from accident hazards as possible. The care plan will be reviewed and amended based on the re-assessments. The facility failed to update care plan with fall prevention interventions to prevent falls for cognitively impaired R20, who had a history of falls and several falls at facility. This deficient practice placed him at risk for further falls with injury. - The Electronic Health Records (EHR) documented R15 had the following diagnosis of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The 02/28/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of two, indicating severely impaired cognition. R15 had a total mood severity score of one, indicating minimal depression and wandering behaviors one to three days of the observation period. R15 required moderate assistance with activities of daily living (ADL) such as showering and oral care. R15 was independent with bed mobility, transfers, and ambulation. R15 had no falls in lookback period. The 08/27/24 Falls Care Area Assessment (CAA) documented R15 did not have a fall while in facility and noted there was a potential for fall related to dementia and times of confusion. The 08/30/24 Quarterly MDS documented a BIMS score of three, indicating severely impaired cognition. R15 was independent with transfers and ambulation, she had one non-injury fall, and received antidepressant medications during the lookback period. The 10/21/24 Care Plan documented staff were instructed to provide stand by assist and use a gait belt at times if R15 was unsteady, date initiated 02/21/24. Staff were instructed to provide supervision with ambulation to monitor for safety, date initiated 06/14/24. The 10/21/24 Care Plan lacked any new intervention for fall on 08/23/24. The Progress Note on 08/23/24 at 08:15 AM, R15 had an unwitnessed fall when she lost her balance and fell , R15 reported that her shoe was falling off and caused her to fall. The Risk Management Report dated 08/23/24, lacked review and lacked an immediate intervention to prevent another fall. During an interview on 10/23/24 at 08:49 AM, Certified Nurse Aide (CNA) O reported the staff would discuss what intervention to implement to prevent another fall. The Nurse would communicate the intervention with the CNAs and it should be on the care plan or kardex in the EHR. During an interview on 10/23/24 at 09:14 AM, Licensed Nurse (LN) G reported Administrative Nurse D and Administrative Nurse E updated the care plans in the EHR. During an interview on 10/23/24 at 11:03 AM, Administrative Nurse D reported that Administrative Nurse E would update the care plan with the new intervention. Administrative Nurse D expected care plans to be updated within 24 hours. During an interview on 10/23/24 at 01:35 PM, Administrative Nurse D confirmed that R15's care plan lacked new interventions for all of the fall dates reviewed. During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E expected a fall intervention to be completed on the care plan within 24 hours and confirmed that did not always occur. The facility policy LTC Fall Prevention Protocol dated 10/2020, documented each resident residing in this facility would be provided services and care that ensured all residents environments remain free from accident hazards as possible. The care plan will be reviewed and amended based on the re-assessments. The facility failed to update care plan with fall prevention interventions to prevent falls for cognitively impaired R15, who had a history of falls. This deficient practice placed her at risk for further falls with injury. - The Electronic Health Records (EHR) documented R21 had the following diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), degenerative arthritis (a chronic condition that causes cartilage in the joints to break down over time) of bilateral (both sides) knees, and bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods). The 06/22/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of three, indicating severely impaired cognition. R21 had a total mood severity score of four, indicating minimal depression and she had no behaviors. R21 required maximal assistance with activities of daily living (ADL) such as toileting hygiene, showering, personal hygiene, and dressing. R21 was independent with bed mobility, transfers, and ambulation. R21 had two non-injury falls and received antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) and antidepressants (class of medications used to treat mood disorders) medications during the lookback period. The 08/21/24 Falls Care Area Assessment (CAA) documented R21 was at risk for falls due to a history of falling and she was unsteady on her feet, mixed with her confusion at times. The 09/22/24 Quarterly MDS documented a BIMS score of three, which indicated severely impaired cognition. R21 required maximal assistance with bathing, toileting hygiene, and personal hygiene. R21 was independent with transfers and ambulation, and she had two non-injury falls and received antidepressant medications during lookback period. The 10/21/24 Care Plan documented the following fall prevention interventions, initiated 06/13/23: The staff were to encourage R21 to use call light for assistance, provide a safe environment with adequate low glare light, bed in the lowest position and wheels locked. R21 was able to use walker without assistance times at times R21 had an unsteady gait and staff instructed to provide stand by assist and gait belt as needed. The 02/10/24 at 10:21 AM Progress Note revealed staff found R21 on the floor, seated upright in front of her recliner. The note documented R21 reported she lost her balance and fell , and had no injuries noted. The 04/26/24 at 02:18 PM Progress Note revealed R21 continued to have bilateral knee pain and had more difficulty with ambulation. The 04/27/24 at 02:31 AM Progress Note revealed staff found R21 on the floor in her bathroom. The note documented R21 had severe swelling noted on the right side of her face with lesions noted on her lower lip with severe bleeding. The note included R21 had bruising noted on the back of her right and left hands and both arms, and she transferred to the hospital. The 04/27/24 at 04:39 AM Progress Note revealed R21 returned from the hospital, and R21 had fractures of the sinus bones and a hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to her right cheek. The Risk Management Report dated 02/10/24, included an immediate intervention to re-educated R21 to use the call light and to use the call light for assistance. The Risk Management Report dated 04/27/24, lacked an intervention to prevent another fall. The Care Plan included a fall prevention intervention dated 05/09/24 (12 days after R21's fall) instructed staff to provide stand by assistance for ambulation with her walker and gait belt, noting she may refuse at times for gait belt use. During an observation on 10/21/24 at 03:54 PM, R21 sat in her recliner with a seated rolling unlocked walker in front of her. She was very hard of hearing and had bilateral hearing aids in her ears. R21 had a hard time expressing her thoughts, as she stuttered and repeated her words. During an observation on 10/22/24 at 08:04 AM, R21 sat in her recliner with a seated rolling unlocked walker in front of her. On 10/23/24 at 08:20 AM, R21 ambulated independently to her room with a seated rolling walker from the dining room. The staff provided no assistance to R21 as she ambulated. During an interview on 10/23/24 at 08:49 AM, Certified Nurse Aide (CNA) O reported the staff would discuss what intervention to implement to prevent another fall. The Nurse would communicate with the CNAs and it should be on the care plan or kardex in the EHR. During an interview on 10/23/24 at 09:14 AM, Licensed Nurse (LN) G reported Administrative Nurse D and Administrative Nurse E updated the care plans in the EHR. During an interview on 10/23/24 at 11:03 AM, Administrative Nurse D reported that Administrative Nurse E would update the care plan with the new intervention. Administrative Nurse D expected care plans to be updated within 24 hours. During an interview on 10/23/24 at 01:35 PM, Administrative Nurse D confirmed that R20's care plan lacked new interventions for all of the fall dates reviewed. During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E expected a fall intervention to be completed on the care plan within 24 hours and confirmed that did not always occur. The facility policy LTC Fall Prevention Protocol dated 10/2020, documented each resident residing in this facility would be provided services and care that ensured all residents environments remain free from accident hazards as possible. The care plan will be reviewed and amended based on the re-assessments. The facility failed to update care plan with fall prevention interventions to prevent falls for cognitively impaired R21, who had a history of falls. This deficient practice placed her at risk for further falls with injury. 51332 - Review of the Electronic Health Records (EHR) for Resident (R)23 included the diagnoses of a stage 4 pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) of sacral region (large triangular bone/area between the two hip bones which included a deep pressure wound that reaches the muscles, ligaments, or even bone), primary osteoarthritis (a degenerative change to one or many joints characterized by swelling and pain), sacroiliitis (an inflammation of the sacroiliac joint [SI], usually resulting in pain), spinal stenosis (condition where the spinal canal, the passageway for the spinal cord, becomes narrowed, putting pressure on the spinal cord or nerve roots), bursitis (a common condition that causes pain in a joint), and insomnia (inability to sleep). The 06/10/24 Annual Minimum Data Set (MDS) documented R23 had a Brief Interview for Mental Status (BIM) score of 13, which indicated intact cognition. The MDS indicated R23 was dependent on staff for all care except eating and oral hygiene, which required set up/supervision. The resident utilized an indwelling catheter and was always continent of bladder and frequently incontinent of bowel. Review of the EHR on 10/22/24 lacked a Quarterly MDS that was due on 09/10/24 for R23 (28 days overdue). Review of the 09/19/24, Care Plan lacked documentation of interventions related to the inclusion of Enhanced Barrier Precautions (EBP) related to a chronic wound and urinary catheter care. The 08/26/24 at 08:09 PM Progress Note revealed R23 documentation of a stage 4 pressure ulcer to R23's sacral area noted to be healing well with a new dressing applied. Scant white colored drainage seen and wound without odor. The 08/17/24 at 08:15 PM Progress Note revealed R23 documentation of a stage 4 pressure ulcer to R23's sacral area to have the skin around the wound turned slightly red. Wound required to be cleansed, packed and dressing reapplied. The 07/26/24 at 01:52 PM Progress Note revealed R23 documentation of a stage 4 pressure ulcer to R23's coccyx area to minimal drainage as evidence on the old packing. The skin around the wound was observed to be pink and blanchable. Wound Care Center orders noted to be changed. The 07/20/24 at 11:35 PM Progress Note revealed documentation of a wound care to R23's stage 4 pressure ulcer to R23's coccyx area. Dressing was removed due to being saturated during shower. Coccyx wound was measured at a length of 3-centimeter (cm) by a width of 3cm. Packing was observed to have green drainage on it with granulation present. Wound required to be cleansed, packed and dressing reapplied. It was noted that this was an improvement from previous measurement of a length of 2.5-centimeter (cm) by a width of 1.8cm and depth of 3cm on 07/11/2024 at 06:55 PM. During an observation on 10/22/24 at 03:48 AM, R23 was having a wound dressing change performed by Licensed Nurse (LN) G, which required the assistance of Certified Nurse Aide (CNA) O and CNA N. During the dressing change, the only personal protective equipment (PPE- gowns, face shields and/or eyeglasses/goggles, and gloves) worn by staff were gloves. Staff were unaware that EBP were infection control measures implemented to prevent the transmission of multidrug-resistant organisms (MDROs) required during wound care with R23. R23's wound measured at a length of 1.5-centimeter (cm) by a width of 0.5cm. The surveyor witnessed no hand hygiene during the dressing change. On 10/22/24 at 03:58 AM, CNA N stated catheter care was performed in the mornings when getting ready to start the day. CNA N noted staff would be aware if any residents were on precautions by a sign alerting them outside the resident's room door before they walked into the room. On 10/22/24 at 03:58 AM, CNA O stated staff performed catheter care in the mornings before the resident was out of bed and when they were visibly soiled. CNA O stated staff knew which type of precautions to use on residents in the facility by a sign posted outside of the resident's door and a cart of PPE supply located directly outside of that resident's room. CNA O stated that during rounds, each shift received a verbal report. During the interview, CNA O stated that the off-going CNA would tell the oncoming CNA if a resident went on precautions. On 10/22/24 at 04:36 PM, LN G stated catheter care was to be performed in the morning when a resident first got up for the day and whenever they were visually soiled. LN G stated precautions were posted outside of the resident's room and communicated during the nurse-to-nurse report. LN G stated the facility did not have any residents she was aware of who required special precautions. On 10/23/24 at 02:08 PM, Administrative Nurse D stated R23 was on EBP, and the staff was to be aware of this by the sign in the resident's bathroom, along with a cart of PPE supplies. Administrative Nurse D stated she expected staff to use the proper PPE when providing close-contained care such as dressing, toileting, transferring, wound care, and catheter care. During an interview on 10/23/24 at 04:00 PM Administrative Staff A and Administrative Nurse E, confirmed that there were several late MDS's submitted and completed late which included R23. Administrative Nurse E reported that when she took over the MDS position there were MDS's that were over a year late. Administrative Nurse E stated that there are residents that do not have their Quarterly MDS completed and confirmed that some are as late as a month. Administrative Nurse E stated she attempts to try to up care plans with new interventions after falls or change and it should be completed the next day. The facility failed to review and revise the person-centered comprehensive care plan for R23, including interventions related to the inclusion of EBP related to a chronic wound and urinary catheter care. These deficient practices had the potential for uncommunicated needs that could negatively impact R23's physical and psychosocial well-being. 51334 - Review of the 09/04/23 Annual Minimum Data Set (MDS) revealed R12 had no memory problems per staff interview. The MDS documented no falls since the previous assessment. Review of the Falls Care Area Assessment (CAA) dated 09/18/23, identified concerns of balance problems during transfers and the use of antianxiety and antidepressant medications. The CAA documented falls would be addressed in the care plan. Review of the 06/06/24 Quarterly Minimum Data Set revealed R12 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated severe cognitive impairment. R12 had two or more noninjury falls and one minor injury fall since the previous assessment. The 10/21/24 Care Plan lacked revision regarding new fall interventions for the falls for R12 on 01/09/24, 02/29/24, 03/09/24, 06/07/24, two falls on 07/03/24, 07/13/24, 08/14/24, 08/20/24, 09/09/24 and 10/19/24. (See F689) Observation on 10/22/24 at 01:41 PM, R12 was in her recliner with her call light within reach. Fall mat beside her bed. During an interview on 10/23/24 at 08:49 AM, Certified Nurse Aide (CNA) O reported when a resident fell , the staff on duty, CNAs and charge nurse would discuss what intervention to implement to prevent another fall. The nurse would communicate the new intervention with the CNAs, and it should be on the care plan in the EHR. During an interview on 10/23/24 at 09:14 AM, Licensed Nurse (LN) G revealed that after the fall, staff initiate an investigation and then hold a discussion with staff to come up with an immediate intervention for the rest of the shift, which would go on the care plan and was reported on to the next shift through end of shift report. During an interview on 10/23/24 at 11:03 AM, Administrative Nurse D reported the immediate intervention was completed by verbal communication, and Administrative Nurse E updated the care plan with the new intervention. Administrative Nurse D expected care plans to be updated within 24 hours. Administrative Nurse D reported R12's care plan lacked revisions regarding fall interventions. During an interview on 10/23/24 at 04:00 PM, Administrative Nurse E expected a fall intervention to be completed within 24 hours and confirmed care plan interventions were not revised for the falls listed above. The facility policy LTC Fall Prevention Protocol dated 10/2020, documented each resident residing in this facility would be provided services and care that ensured all residents environments remain free from accident hazards as possible. Every resident will be evaluated for casual factors after each fall. The care plan will be updated based on the assessment. The facility failed to revise the care plan with fall prevention interventions for cognitively impaired R12, who had repeated falls. - Review of the Electronic Health Record (EHR) revealed Resident (R)17 had the following diagnoses: pulmonary fibrosis (a process that causes lung scarring, in which fibrotic tissue blocks the movement of oxygen into the bloodstream. Low oxygen levels (and the stiff scar tissue itself) can cause shortness of breath), psychosis (any major mental disorder characterized by a gross impairment in reality perception), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), chronic obstructive pulmonary disease (COPD- progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), cognitive decline, osteoporosis (chronic arthritis without inflammation), bilateral osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain) in the knees, and hearing loss. Review of the 04/20/24 Annual Minimum Data Set (MDS) revealed the resident had highly impaired hearing and moderately impaired vision. The MDS noted the Brief Interview for Mental Status (BIMS) score of 99, indicated the interview could not be completed. The staff interview for cognition revealed R17 rarely or never understood others but was understood per staff interview. The MDS documented the resident had memory problems. R17 knew the season, room location, and that she was in a nursing facility. The staff reported the resident had a total mood score of three, which indicated no depression. R17 was occasionally incontinent of bladder and was independent with transfers and toilet transfers. R17 required setup or touching assistance for transfers. The resident had an impairment to both arms. The resident received anticoagulant, diuretic and antidepressant medications and received oxygen. The MDS documented two or more noninjury falls since the previous assessment. Review of the Falls Care Area Assessment (CAA) dated 05/24/24, revealed R17 was at risk for falls due to a history of falls. Review of the 07/23/24 Quarterly Minimum Data Set revealed R17 had highly impaired hearing and moderately impaired vision. The Brief Interview for Mental Status (BIMS) of 99, the resident rarely or never understood others but was understood per staff interview. The MDS documented the resident had memory problems, knew she was in a nursing facility, but did not know the season, room location, or staff. The staff interview completed with a total mood score of 3, which indicated no depression. R17 used a walker and a wheelchair, was occasionally incontinent of bladder and bowel, required substantial to maximum assistance for toilet transfers, partial assistance for other transfers. The resident took diuretic and antidepressant medications and was on oxygen. The MDS documented R17 had two or more noninjury falls and one minor injury fall since the previous assessment. The 10/21/24 Care Plan documented the following fall interventions, initiated 05/10/23 assist with ambulation and transfers, utilizing therapy recommendations. The Care Plan provided no information on what the therapy recommendations were. This was updated on 10/11/24 to include as tolerated related to comfort care. The 10/21/24 Care Plan documented the following fall interventions: 07/07/23, bed in lowest position and keep the call light in reach. 07/21/23, use a walker. 06/22/24, use the sit-to-stand lift for transfers when resident was weak or having confusion. Review of the Care Plan documented the following fall interventions; indicated a lack of new interventions related to falls on the following: 06/17/24 fall with no injury, 09/26/24 fall with minor injury and 09/30/24 fall with minor injury. Review of the Fall Risk Evaluation assessment (a fall risk assessment that predicts the likely hood of falls) completed on 01/07/24, 04/07/24, 06/27/24, 07/07/24 and 10/07/24 documented R17 had a high fall risk. Review of progress notes from 01/01/24 to 10/21/24 revealed two falls with no root cause analysis and no new care plan intervention to prevent further falls on the following days: Incident Note on 06/17/24 at 12:00 AM documented R17 had a fall with no injury. R17 was found on the floor with spilled water. The resident was confused and stated she got on the floor because her legs were weak, so she was scooted across the floor. Staff were unable to reorient the resident. They applied oxygen and her oxygen saturation increased to 90 percent (%). R17 had been confused and removing her oxygen according to the progress notes since 06/13/24. Health Status Note on 06/13/24 at 12:22 PM documented R17 was sent to the emergency room and returned for confusion and had an oxygen saturation of 73%. Started on an antibiotic and a steroid treatment. The Risk Management Report dated 06/17/24 for a fall that occurred at 12:00 AM, included an immediate intervention for frequent checks until a bed alarm could be placed. The Care Plan has no mention of an alarm for the resident. The Incident Note on 09/26/24 at 02:19 AM documented the bed alarm alerted staff to her room where the resident was seated on the floor with a 10 centimeter (cm) skin tear over a large bruise and staff applied a dressing. The resident stated she was reaching for something on her table. The Risk Management Report dated 09/26/24 for a fall that occurred at 02:00 AM for R17, included no immediate inte [TRUNCATED]

The facility census totaled 31 residents, with three sampled for wandering behaviors and a total of four residents at risk for elopement in the dementia (a progressive mental disorder characterized by failing memory, confusion) unit. Based on observation, interview, and record review the facility failed to provide sufficient supervision to cognitively impaired Resident (R) 1, identified by the facility as a low elopement risk with known wandering history, to prevent an elopement. On [DATE] at approximately 04:50 AM R1 exited the facility via an alarmed fire exit door to an unlit fenced area that had an unsecured gate. The resident exited this gate and walked approximately 593 feet through a grassy flat area and a parking lot to the connected hospital's laundry room window after staff failed to search the entire perimeter of the building. She was outside the facility for approximately ,d+[DATE] minutes, when the laundry staff noticed the resident knocking on the laundry room window within a quarter mile of a busy highway with speed limits of 40 to 60 miles per hour (mph). These failures placed R1 and four other residents at risk for elopement in the dementia unit in immediate jeopardy. Findings included: - R1's pertinent diagnoses from the Physician's Order Electronic Medical Record (EMR) and Order Summary Report dated [DATE] revealed auditory hallucinations (the sensory perceptions of hearing noises without an external stimulus) and dementia. The [DATE] Admission Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) of 11, indicating moderately impaired cognition. The resident had no wandering behavior during the review period. The resident was independent with ambulation/transfers and used a wander/elopement alarm (Wander Guard- bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) daily. The [DATE] ADL Care Area Assessment (CAA) revealed R1's diagnosis of dementia caused a decline in physical functioning, and staff allowed R1 to be as independent as possible with activities of daily living (ADLs). The [DATE] Quarterly MDS revealed a BIMS of 03, indicating severely impaired cognition. The resident had no wandering behavior during the review period. The resident was independent with ambulation/transfers, and a used a wander/elopement alarm daily. R1's [DATE] Elopement Risk Assessment revealed the resident was low risk for elopement. The [DATE] Cognitive Care Plan revealed R1's cognitive impairment left her totally dependent to needing limited assistance from staff for safe decision making. She resided in the dementia locked unit. The [DATE] ADL Care Plan revealed R1 ambulated without assistive devices, had a Wander Guard due to potential for wandering. Staff checked the Wander Guard for placement each shift, responded to alarms and were to know R1's whereabouts. If she appeared to have increased agitation and wandering, this was not normal. She also experienced hallucinations, seeing things that were not there. A revision dated [DATE] revealed R1 eloped and staff placed an alarm on the temporary Coronavirus (COVID) door (placed to separate a hallway in the case of a positive COVID resident) and R1 still had her Wander Guard. A revision dated [DATE] revealed the physician restarted the resident on her mental health medication for hallucinations. R1's Behavior Documentation in the EMR revealed: On [DATE] R1 was tearful and stated her deceased brother and his wife were talking to her. On [DATE] R1 heard voices and stated to staff that her nephew called from the facility parking lot and was having a [CONDITION(S)]. She had her bags packed and stated she needed to get out. On [DATE] the resident paced up and down the hallway, terrified, tearful, exit seeking, and hearing voices. She knocked on the exit doors, and staff attempted to re-direct her, but attempts were not effective. On [DATE] R1 was still hearing voices that told her to dial 911 with the phone on the unit, resulting in a follow-up call from the Sheriff's office asking if everything was ok. On [DATE] R1 did not sleep all night, paced the unit, and asked staff to switch off everything [causing noise]. Licensed Nurse (LN) G's [DATE] at 10:49 AM Progress Note revealed two staff completing rounds heard the exit door alarm to the back unit go off when opened. Staff went out of the exit door and other staff went out front of the facility to look for the resident. Staff from housekeeping brought the resident back after they found her knocking on laundry room window and told them a man was out there threatening everyone in the building, insisting to call police, and searching for a phone. A follow-up progress note completed by LN G at 01:29 PM revealed the resident had no injuries and vital signs were within normal limits. The [DATE] Facility Reported Incident revealed at approximately 04:50 AM Certified Nurse Aide (CNA) E notified LN D and G that the fire door exit light in the dementia unit was flashing and R1 could not be found. CNA E and F went out to the fenced area that has two gates that must be secured with locks. The other staff went out the front of the building to look for the resident in the dark but did not go past the north side of the fenced area. The fenced area was poorly lit, and staff did not see the resident or the west gate that was slightly open. Staff then went back inside the facility to search, and the wander/elopement alarm in the connected hospital corridor sounded off. Laundry staff H and I walked R1 to the nurse's station. LN G assessed R1 and returned her to the dementia unit. Laundry staff H stated the resident knocked on the laundry room window. Upon investigation in the daylight, the west gate of the fenced area was slightly open with the bottom fencing rolled away from frame, which could not be seen in the dark by staff. In the dementia unit, staff placed a temporary door at the end of the hall in the case the facility needed to utilize the COVID unit. Both CNA E and F reported that R1 had been wandering in and out of the COVID unit door the night before her elopement, and they allowed her to do this because the fire door exit behind the temporary COVID door had an alarm without knowing with this temporary door in place, the fire exit door alarm could not be heard. CNA E's [DATE] Witness Statement revealed about 04:50 AM she completed bed checks and R1 walked through the temporary COVID door. The other staff said R1 wandered all night through these doors with no issues, so she finished report and found that the fire door exit light was flashing, and the fire door was open. LN D's [DATE] Witness Statement revealed she was in the medication room counting and CNA E seemed frantic. CNA E told LN D that the fire door exit light was flashing, and the door was found open. Staff looked for R1, but laundry staff brought R1 back to unit. The undated Witness Statement from LN G revealed she was in the medication room counting, noticed staff going towards the dementia unit. Staff indicated a resident opened the back door, exited, and they could not find her. All staff went outside to look for the resident, and then when they came back in the facility, she was back in the unit. Observation on [DATE] at 09:32 AM revealed the dementia unit temporary COVID door with an alarm placed approximately 4 feet (ft.) from the exit fire door. Per Administrative Nurse A, the temporary COVID door on [DATE] was approximately 10 to 15 ft from the exit door near rooms 109 and 110. The fire door exit had a 15 second wait time to open the door, and the alarm had short bursts of sound. The fenced area had three gates, and all three gates currently had locks securing the area. The residents path took her out the West gate that had been unsecured, and through a flat grassy area around the north side of the connected building and to the northwest parking lot to the laundry room window. The approximate length of this journey was 593 ft, and the highway with speed varying from 40 miles per hour (mph) to 60 mph was approximately ¼ mile from the northwest point of the facility. Interview with CNA B on [DATE] at 10:15 AM revealed she worked the other hall that night. CNA B and CNA J were finishing report at approximately 05:00 AM, when CNA E poked her head out of the dementia unit, said the fire door exit light was going off, and R1 could not be found. CNA B, LN G and LN D went out the front doors and around the north side of the building to the East/North side of the fenced area, while CNA F and E looked inside the perimeter of the gated area for R1. CNA B stated, it was so dark, and we did not have flashlights. She did not know why staff did not search the whole perimeter of the building and did not know there was a West gate to the fenced area, so staff only looked on the East and North side of the fence. When staff reentered the building, CNA J was with R1 at the nurse's station. Staff was then told R1 exited the fenced area out of the West gate and ambulated around the building over to the laundry room window. The laundry staff brought R1 in and led her back to the unit. The nurse checked R1 for injuries and she had none. She was outside alone for approximately 10 minutes or less. She then stated, [R1] ambulated independently very well, and was not surprised that the resident had made it that far, but she does get confused. Interview with CNA C on [DATE] at 03:07 PM revealed R1 wandered and had a Wander Guard. CNA C stated, [R1] would only push/exit seek at the fire door exit, but she had not exhibited that behavior in a very long time. Last week was the first time in a very long time she had exit seeked/pushed on the fire door exit to get out. She is easily re-directable, but the temporary COVID wall threw her off. Interview with LN D on [DATE] at 11:54 AM revealed R1 eloped right at the change of shift while she was giving report/counting medications, and LN D saw staff rushing around. The staff told her the back door in the dementia unit was open. Staff then ran outside, but it was still dark at 05:00 AM. Staff searched the fenced area where the exit door was and looked at the surrounding streets. When staff went back inside, R1 was found by laundry staff. R1 ambulated independently and always wandered. R1 experienced hallucinations recently and LN D checked R1's Wander Guard on her shift to ensure functionality and placement. LN D did not hear any alarm going off and stated there was not a Wander Guard alarm on the fire exit door that R1 exited. She then stated, the night before she eloped, [R1] was pacing the unit, restless and wandering. [R1] told her that the voices were telling her to turn off anything producing sound. [R1] was out of the building approximately 5 minutes, and the staff reacted right away. Interview with Administrative Nurse A on [DATE] at 09:05 AM revealed shift change was at 05:00 AM on [DATE], and staff started bed checks. R1 had been up all night pacing the unit with prevalent hallucinations, recent possible urinary tract infection, and labs were drawn due to her increased behaviors. She wandered in and out of the temporary COVID unit doors, and up/down the hallway all night without exiting the building. Staff could not hear the fire door alarm going off behind the temporary COVID unit wall/door, but the strobe light in the dementia unit living room started flashing, and when staff saw this, they knew the fire door exit had been accessed/opened. CNA E then ran out to the nurse's desk, and CNA F ran down the hallway through the COVID doors to the fire door exit, which had a 15 second wait to open/alarm. The resident went missing at 04:50 AM per the unit cameras through the temporary COVID door, and she was found by the laundry staff outside the laundry room window on the northwest side of the building at about 04:56 AM. R1 wore a shirt, pants, shoes, and a jacket, and the weather at that time was 71 degrees. It was pitch black outside except for the street lights, but the fenced area that R1 exited had no lighting. CNA F and CNA E went to the fenced area to look for R1, and LN G, LN D and CNA B ran out the front doors of the facility to look outside the fenced area. Staff did not see R1 in the fenced area, the West gate was barely cracked open, but staff could not see this. Then, all staff came back inside the facility because they thought she had to still be inside. CNA F and E continued the search in empty rooms, and that was when the Wander Guard/elopement sensor alarmed, and laundry staff H walked R1 to the unit. LN G assessed R1, finding no injuries. R1 stated to the nurse that she was trying to find the Sheriff's department because her nephew was having a [CONDITION(S)]. R1 has always experienced hallucinations, just not this severe. Administrative Nurse A went to investigate the fenced area and found the West gate barely open. The Fire Marshal requested the facility use locks on the gates, and those were supposed to be in place, but she suspected the lawn mowing company forgot to secure the gate lock and that was how R1 exited the fenced area. There was no Wander Guard alarm on the fire door exit either. Her expectation of the staff was that they follow the facility policy for elopement and should have walked the full perimeter of the building, but it was so dark and the area was not well lit. The staff would have noted the open West gate and would have found her before she made it to the laundry room window. The staff have access to flashlights at the nurse's station as well. Review of ,d+[DATE] Resident Elopement Policy defined elopement as an incident in which a resident who has impaired decision-making ability and was oblivious to his/her own safety needs leaves the facility without the knowledge or supervision of staff. Responding to door alarms are a part of our security system for which all staff had responsibility. When a door alarm sounds, staff should check the elopement system to identify the resident, check the exit at which alarm sounded to see who went out or came in, and reset alarm after making sure that all residents are accounted for. All staff should thoroughly and systematically search the facility and grounds as soon as the health and safety of residents for whom they are responsible allows. First, look outdoors as far as you can see from all exits. Second, walk the perimeter of the building, looking as far in all directions as you can see, and looking in all vehicles. The charge nurse should note and document all times and actions taken. The facility failed to provide sufficient supervision to cognitively impaired R1 to prevent an elopement on [DATE] when R1 exited the facility via an alarmed fire exit door to an unlit fenced area that had an unsecured gate. The resident exited this gate and walked approximately 593 feet through a grassy flat area and a parking lot to the connected building's laundry room window after staff failed to search the entire perimeter of the building. She was outside the facility for approximately ,d+[DATE] minutes, when the laundry staff noticed the resident knocking on the laundry room window within a quarter mile of a busy highway with speed limits of 40 to 60 miles per hour (mph). These failures placed R1 and three other residents at risk for elopement in the dementia unit in immediate jeopardy. On [DATE] at 04:12 PM, Administrative Nurse A was provided with the IJ template and notified that the facility failed to provide appropriate supervision to cognitively impaired Resident (R)1, identified by the facility as at risk for wandering and who exhibited exit seeking behaviors, to prevent an elopement of approx. ,d+[DATE] minutes through an alarmed door to an unsecured poorly lit gated area, when staff failed to complete a full perimeter check which constituted immediate jeopardy at F689. The immediate jeopardy at F689 also constituted Substandard Quality of Care at 42 CFR 483.25. The immediate jeopardy was determined to first exist on [DATE] at approximately 04:50 AM, when R1 eloped out of the alarmed fire exit door. The facility identified and corrected the deficient practice on [DATE] when the facility implemented the following: 1. Maintenance placed a new lock on the west gate, securing the fenced area and completed fence inspections twice a day. 2. Lights/camera installed to outside fenced area to improve surveillance. 3. Alarm placed on temporary COVID unit doors. 4. The facility educated staff on elopement starting on [DATE] and completed by [DATE]. 5. Quarterly elopement drills. Due to the facility's actions to identify and correct the deficient practice on [DATE], it was deemed past non-compliance at a scope and severity of K (patterned, immediate jeopardy to resident health and safety).

The facility census totaled 28 residents. Based on observation, interview, and record review the facility failed to ensure safe water temperatures in areas accessible to residents which had the potential to cause serious [CONDITION(S)] from extremely hot water temperatures in excess of 140 degrees Fahrenheit (F) (acceptable water temperature 120 F or below with a 3 degree variance + or -). The facility failed to monitor and document water temperatures accessible to residents in their personal restroom sink or sinks accessible in public areas, which placed residents who lived on one of two halls in the facility at risk for [CONDITION(S)] and in immediate jeopardy. Findings included: - Observations during the screening process of the resurvey on 05/24/21 revealed water temperatures greater than 140 F in one sink located in one of two Whirlpool rooms with a temperature of 141.2 F as well as the following resident rooms: 10:45 AM (room 210) 142.1 F 11:00 AM (room 208) 140.3 F 11:28 AM (room 207) 141.3 F An observation on 05/24/21started at 03:36 PM and completed at 3:37 PM on the 100 Hall revealed the following room water temperatures: 101- 127.5 F 102- 124.7 F 103- 125.2 F 104- 124.1 F 105- 125.6 F During an interview on 05/24/21 at 12:20 PM, Certified Nurse Aide (CNA) D revealed she had not noticed any problems with hot water except in the mornings when the water could be a little colder. During an interview on 05/24/21 at 1:29 PM, Activities Staff E revealed no residents complained about the water being too hot or that a resident has been burned. She revealed the issue was more with the water not getting hot enough when she does a foot soak or other activities for the residents. During an Interview on 05/24/21 at 12:35 PM Maintenance Staff (MS) C revealed the facility's expectation was for the Maintenance Staff to check the water temperature once monthly or whenever the staff had the opportunity. He revealed the facility first noticed the hot water issue in February 2021 during the cold weather snap and identified a problem with the circulation pump activator, which was housed on the holding tank and caused a problem getting hot water. MS C revealed he turned the gauge up in order to get the circulation pump to activate and disperse hot water throughout the system. MS C stated the facility ordered a new part to fix the issue. He revealed the Maintenance staff failed to document the water temperature tests results because no one ever asked to see them. During a follow up interview on 05/24/21 at 4:35 PM, MS C revealed the holding tank held the water heaters. In order to get water from the holding tank out to the floor the circulating pump had to kick on and the water temperature needed to be more than 125 F. During an interview on 05/24/21 at 12:39 PM, with Administrative Nurse B revealed she had not received any complaints from residents about the water being too hot, but instead it has been too cold. She revealed no staff members or residents complained about the water temperatures being too hot and there were no reported concerns dealing with hot water injuries. During the interview, MS C approached and stated he turned down the water temperature and the water temperature should be back down into the normal range by later that day. During a follow up interview on 05/26/21 at 2:30 PM, with Administrative Nurse B revealed she expected the water temperatures to be monitored and documented, on a daily basis. Review of the Water Management Policy dated 08/2020 revealed, Maintain hot water temperature at the return at the highest temperature allowable by state regulations or codes, preferably greater than 124 F. Water temperatures would be checked by Maintenance daily. The facility failed to consistently monitor and document water temperatures in areas accessible to residents and as a result failed to identify unsafe water temperatures in excess of 140-degree F. This failure placed residents who lived on one of two halls in the facility in immediate jeopardy for potential [CONDITION(S)]. The immediate jeopardy was abated to an E and verified by the surveyor on-site on 05/25/21 at 08:51 AM by taking the following actions: 1. Once temperatures above 140 F were identified, the water temperature was immediately turned down. Upon recheck and verified by the surveyor on-site all resident room sinks measured below 140 F. 2. The facility implemented daily checks by maintenance staff of water temperatures in all resident rooms, whirlpool/shower rooms, and common areas. Maintenance Staff will document findings daily, 7 days per week. 3. All Maintenance Staff received education regarding water safety and monitoring of water on 5/25/21 and was verified through sign-in sheets and competency evaluation forms by the surveyor on-site. 4. The facility held an emergency Quality Assurance Performance Improvement (QAPI) meeting held on 05/24/20 at 06:55 PM with Infection control, Medical Director, and CEO. The abatement plan was discussed and approved by the present QAPI team. Water temperature checks will be presented at QAPI meetings quarterly.

The facility census totaled 35 residents with three residents included in the sample for restraint use. Based on observation, interview, and record review the facility failed to ensure Resident (R)1 remained free from the utilization of a restraint for the convenience of staff resulting in increased agitation requiring the use of an anti-psychotic (class of medications used to treat [MEDICAL CONDITION] and other mental emotional conditions) medication and bruising to R1's left hand. Findings included: - Review of R1's 11/11/19 signed Physician order [REDACTED]. Review of the 11/19/19 Admission Minimum Data Set (MDS) included a [DIAGNOSES REDACTED]. R1 had a brief interview for mental status (BIMS) score of two, indicating severe cognitive impairment. He displayed physical behavioral symptoms between one to three days during the seven-day review period placed him and others at significant risk for physical injury. The resident required one staff member to supervise the resident during locomotion on and off the unit. R1 was not steady, but able to stabilize without human assistance while walking and standing. He did have one non-injury fall since his admission to the facility. There was no documentation of [MEDICAL CONDITION] medication usage during the review period. Review of the 11/19/19 Cognitive Loss/Dementia Care Area Assessment (CAA) revealed R1 had a [DIAGNOSES REDACTED]. He could make simple needs known and would often have a difficult time with thought completion. Review of the 11/19/19 Behavioral CAA revealed the resident swung at staff while the staff attempted to redirect him. The residents 11/22/19 Care Plan advised staff to offer to take the resident outside when the weather was nice, provide one-on-one care if R1 did not want to participate in a group activity, and to speak to him about the past. The resident calmed when his hand was held and he required assistance to stand up from a low recliner. Review of the 01/23/20 at 11:00 PM Nurses Note revealed at 10:30 PM the resident sat in a recliner in the living room and became aggressive and combative. He hit Certified Nurse Aide (CNA) D and swung at CNA [NAME] The resident called staff names and cursed at them. At 10:35 PM the staff notified Administrative Nurse C of the resident's behavior and contacted the on-call physician, who then ordered [MEDICATION NAME] (class of medications used to treat [MEDICAL CONDITION] and other mental emotional conditions) 5 milligrams (mg) intramuscular (IM) one time. The staff administered the medication at 10:40 PM per the order. The resident remained under supervision of three staff members after they assisted him to a recliner and he appeared calmer at 11:00 PM. Nurses note dated 01/24/20 at 02:46 AM revealed at 01:15 AM the resident rested in a recliner and staff noted a hematoma (bruise) to the dorsal (back) surface of the left hand. The staff applied an ice pack, the resident tolerated it well and monitoring continued. Nurses Note dated 01/24/20 at 11:42 AM revealed at 06:45 AM Licensed Nurse (LN) I arrived and noted R1's left hand as swollen and blue/blackish in color. She administered pain medication and notified the on-call physician for request of an X-Ray of that hand. Review of the facility video footage for 01/23/20 revealed certified nursing aide (CNA) D held the gait belt to keep the resident in a recliner from 10:07 PM until 10:14 PM causing increased agitation to the resident. The resident struck at CNA D's arms multiple times while she gripped the gait belt. At 10:14 PM, CNA D assisted R1 up from the chair and assisted with ambulation around the commons area. There were no other staff noted in the video during the seven minutes that CNA D prevented the resident from rising. Review of the signed and notarized witness statement, dated 01/24/20, from CNA D revealed she sat next to R1 and he wanted up. She asked him to sit and wait until the other CNA returned. CNA D then gently motioned for him to sit back down by holding R1's gait belt. After he became agitated, he hit CNA's D arm repeatedly with the side of his fist and the back of his hand resulting in his hand getting hurt. CNA D's statement revealed her intention was to keep him safe in the chair due to his unsteadiness on his feet and she noted it was not her intention to restrain or harm him. Observation of R1 on 01/24/20 at 04:27 PM revealed he ambulated with a walker and gait belt with two staff members following close behind. Suddenly R1 stopped and attempted to kick the staff behind him by kicking backwards. He then proceeded down the hallway with his walker and the two staff continuing walking behind him. Observation of the resident on 01/24/20 at 04:49 PM revealed the resident walked with a walker, LN E, and a gait belt in the hallway. The resident walked along and suddenly pushed the walker away from him leaving him with just the gait belt and LN E. Interview with Certified Medication Aide (CMA) H on 01/29/20 at 10:25 AM revealed she noted R1 had increased behaviors, kicking and punching, after dinner and that just one person sat with him aided in reducing the amount of behaviors. She believed preventing a resident from rising was a form of a restraint, such as holding the gait belt. Interview with LN [NAME] on 01/27/20 at 4:57 PM revealed R1 frequently had behaviors, such as kicking and hitting, but allowing him to watch out the windows or taking him outside when the weather allowed, really calmed him down. During an interview with Administrative Nurse C on 01/27/20 at 02:43 PM revealed CNA D was on her second night of orientation when the incident occurred. Administrative Nurse C found out about the incident when the Life Enrichment staff reviewed the video footage to help determine what happened to R1's hand. She received notification at approximately 09:30 AM on 01/24/20 reporting CNA D utilized a gait belt as a restraint from walking which caused increased behaviors for the resident. Administrative Nurse C reported the video footage was difficult to watch and she expected CNA D to have handled the situation differently. Administrative Nurse C said the facility suspended CNA D on 01/24/20 and then terminated her employment on 01/27/20. Review of the policy entitled Abuse, Neglect & Exploitation, approved 10/2019, revealed abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Review of the policy entitled Restraints - Physical and Chemical, approved 03/2009, defined physical restraints as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. A physician's orders [REDACTED]. The facility failed to ensure R1 remained free from restraint use for convenience for seven minutes when CNA D maintained a hold of the gait belt to prevent him from rising from a recliner. This increased R1 agitation resulting in behaviors which led to bruising on his left hand and the use of an antipsychotic medication.

The facility reported a census of 36 residents with 6 in the sample. Based on observation, interview, and record review the facility failed to investigate causal factors of falls for 3 of 3 residents sampled for accidents (#1, #2, and #3). The facility also failed to provide adequate supervision and develop and implement effective and appropriate fall prevention interventions to prevent a fall in which resident #1 sustained an ear laceration and required sutures and resident #2 sustained a lip laceration and required sutures. The facility also failed to store chemicals securely to prevent accidents. Findings included: - Review of resident #1's annual MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 11, indicating moderate cognitive impairment. The resident required limited assistance of 1 staff for transfers and toileting. He/she was independent with walking in the room and corridor, and locomotion on the unit. The resident had frequent urinary incontinence, occasional bowel incontinence and currently participated in a toileting program. The resident had one non-injury fall since the previous quarterly assessment. Review of the Fall CAA (Care Area Assessment) dated 10/13/14 revealed resident #1 had a [DIAGNOSES REDACTED]. Resident #1 fell on [DATE] when he/she slid to the floor from the recliner. Resident #1 ambulated by him/herself without supervision within the unit and with supervision outside the unit. He/she had a slightly shuffled gait and could fully bear weight. The resident was oriented to his/her surroundings and aware of important areas within the unit. He/she needed cues and reminders as well as limited assistance with ADL (activities of daily living) cares. As his/her dementia progressed, his/her physical functioning continued to decline. Review of the ADL Functional/Rehabilitation CAA dated 10/13/14 revealed resident #1 had frequent bowel and bladder incontinence. Resident #1 knew where the bathrooms were, but staff needed to remind him/her to use the bathroom and provide incontinent hygiene as needed. The resident wore adult incontinence products and if he/she took it off, he/she did not always put a clean one on. Review of a 4/3/15 quarterly MDS assessment revealed a BIMS score of 3, indicating severe cognitive impairment. Resident #1 required limited assistance of 1 staff for bed mobility, transfers, walking in the room and corridor, locomotion on the unit, and he/she required extensive assistance with toileting and personal grooming. The resident had one non-injury fall and one minor injury fall since the previous assessment. Review of resident #1's Fall Risk assessments revealed: *1/14/15-a score of 15, with over 9 indicating risk for falls *4/8/15-a score of 19 *5/7/15-a score of 17 Review of resident #1's care plan, initiated 10/12/12, revealed the resident had a history of [REDACTED]. *Monitor for orthostatic hypotension (a form of low blood pressure that occurred from standing up from sitting or lying down) *Take the resident's blood pressure prior to administering blood pressure medications daily. *Provide the resident a night light in his/her room *Sit with the resident and help him/her get back to sleep when he/she woke up unexpectedly *Keep the call light within reach *Provide activities throughout the day *Report all falls with injury to the physician immediately *Encourage the resident to wear shoes for ambulation *Monitor and decrease the resident's psychotropic medications per facility policy *Remove obstacles from the resident's path *Complete a fall risk assessment every 3 months. If the fall risk increased, staff were to implement new interventions to prevent falls. Staff revised the care plan on: *10/6/14 -assist the resident to an upright position in his/her recliner in the event he/she began to slide down. *11/20/14- the resident experienced a fall, staff were to assist resident #1 with ambulation to and from meals. *12/4/14- the staff found the resident on the floor in another resident's room. Staff were to re-direct the resident out of other resident's rooms and provide appropriate supervision. * 5/8/15- staff were to ensure: 1. Resident #1's bed alarm and chair alarm worked at all times. 2. A clear visual path from the dining room to the resident's recliner. 3. Use of a chair alarm in the recliner and dining chair. 4. Use of a halo bed buddy system for positioning in bed. 5. The resident had continuous oxygen via nasal cannula to maintain oxygen saturations above 90%. 6. To provide assistance to the resident with a gait belt for ambulation. 7. To toilet the resident every 1.5-2 hours. 8. To provide activities for the resident when he/she got up at night. The resident's care plan did not address the injury to the resident's ear or the care/monitoring it required after a fall on 4/28/15. Review of a Fall Investigation dated 1/16/15 at 1:10 AM revealed staff found resident #1 after he/she fell in his/her room while attempting to get out of bed unassisted. The investigation revealed the resident had a recent severe upper respiratory infection, was alert, confused, wandered at the time of the fall, and had a decrease in orientation in the previous 7 days. Per the investigation the resident called for help, but the call light was not in reach. The resident toileted last at 12:00 AM and ate last at 7:00 PM. The investigation indicated no problems with the resident's environmental factors. Per the investigation staff implemented a new intervention to show the resident where his/her room was and ask the resident to ring for assistance. The Fall Investigation revealed administrative nurse J reviewed the investigation on 2/9/15 (3 ½ weeks later) and he/she recommended a bed alarm to the resident's bed, continue other fall precautions, and consistent reminders to ring and wait for assistance. Staff failed to review and revise and add an intervention to the resident's care plan to prevent further falls. The investigation did not identify the root cause of the fall. Review of a Fall Investigation dated 1/16/15 at 9:30 PM (a second fall on that day) revealed staff found resident #1 on the floor in the hallway by the fire doors. The resident stated he/she just slipped hit his/her head. The investigation did not include information relating to the root cause of the fall. The Fall Investigation revealed administrative nurse J reviewed the investigation on 2/9/15 (3 ½ weeks later) with a recommendation to routinely check on the resident when he/she was in his/her room to prevent falls. Staff failed to add the intervention to the care plan. Review of a Fall Investigation dated 3/14/15 at 9:00 PM revealed staff lowered resident #1 to the floor during ambulation because the resident felt weak and dizzy. Staff determined the cause of the fall was due to his/her cancer treatments and weekly chemotherapy. The investigation revealed the resident had become weaker and less steady and the resident required staff assistance for ambulation for safety at that time. The Fall Investigation revealed administrative nurse J reviewed the investigation on 4/30/15 (about a month and ½ later) and made recommendations to ambulate with the resident using 2 staff if the resident felt weak or dizzy or put the resident in the wheelchair if he/she appeared too weak to ambulate distances. Staff failed to update the care plan to include the entire recommendation, and only added staff were to ambulate with the resident with a gait belt when he/she felt dizzy. Review of a Fall Investigation dated 4/3/15 at 5:20 PM revealed staff lowered resident #1 to the floor during an assisted transfer/ambulation. Per the investigation the resident stated he/she was dizzy at the time of the fall. The investigation indicated the resident received chemotherapy treatments every 2 weeks during that time, had become weaker, and required staff assistance at times for safety. The investigation revealed the resident did not have a gait belt in place. The Fall Investigation revealed administrative nurse J reviewed the investigation on 4/13/15 (10 days later) and recommended for staff to use a gait belt with the resident while up ambulating, especially if the resident felt weak or just finished chemotherapy. The investigation did not identify possible causal factors of the resident's fall. Review of a Fall Investigation dated 4/20/15 at 6:00 AM revealed staff found resident #1 on the floor by his/her bed on his/her buttocks. Per the investigation the resident stated he/she was trying to get up, but did not indicate why the resident tried to get up. The investigation indicated the resident did not ring his/her call light. He/she had a [DIAGNOSES REDACTED]. The investigation reported the resident tried to be independent and not ask for assistance from staff. The investigation did not include information relating to the root cause of the fall. The Fall Investigation revealed administrative nurse J reviewed the investigation on 5/1/15 (11 days later) and recommended the bed in low position and bed alarm in place at all times when the resident rested in bed. Staff failed to include an intervention related to the position of the bed when the resident lay in bed as recommended in the investigation. Instead staff added on 4/23/15 (3 days later), for staff to use a bed alarm to alert staff when the resident tried to get up. Review of a Fall Investigation dated 4/28/15 at 3:30 PM revealed staff found resident #1 on the floor in another resident's bathroom with a laceration and minor bleeding to his/her left ear. Per the investigation the resident had bowel and bladder incontinence at the time of the fall. The resident reported he/she fell and hit his/her ear on the toilet. Staff sent the resident to the ER (emergency room ) for sutures and examination. The Fall Investigation revealed administrative nurse J reviewed the investigation on 5/7/15 (9 days later) and entered the following findings and recommendations: The resident had a decline in condition due to chemotherapy and cancer. A few months prior, the resident ambulated independently without devices, but at the time of the fall the resident required assistance of 1 or 2 staff and a gait belt for ambulation depending on his/her steadiness. The resident had not attempted to get up unassisted for months. The resident left the SCU (special care unit) living room area independently without assistance from staff. The resident fell in another resident's bathroom while attempting to toilet him/herself. The resident reported to staff he/she needed to use the bathroom when staff found him/her on the floor. The resident could not tell staff how he/she fell or what he/she hit his/her ear on in the fall. The CNAs (Certified Nursing Assistant) assigned to the SCU were in rooms with other residents when the fall occurred. The programmers were performing activities with other residents when the resident left the common area. The nurse had his/her medication cart parked on the southwest side of the living room area beside the resident's recliner, which made the recliners in the living room difficult to visualize from the dining room area. The SCU director was in his/her office when the fall occurred. Interventions to prevent the resident from falling: Chair alarm in the chair at all times, bed alarm in place when in bed, the medication cart would not be parked in a way to block the view from the dining room to the living room, staff were to toilet resident #1 every 1.5-2 hours with prompting to get up and go to the restroom by staff, and staff were to monitor the resident while up in the recliner at all times. Staff updated the care plan with the chair alarm only on 4/29/15. Review of a progress note dated 4/28/15 at 4:48 PM revealed staff found resident #1 in another resident's room. Per the note the resident had an incontinent bowel and bladder episode and fell . The resident stated he/she hit his/her left ear on the toilet. Staff indicated in the note that resident #1 had bleeding and a laceration to the top part of his/her ear, staff cleaned the resident up, and sent the resident to the ER (emergency room ). Review of the ER report dated 4/28/15 revealed the resident presented with a laceration to his/her left ear. The resident could not tell staff how it happened. The report indicated the resident had a 4.5 cm (centimeter) laceration to the left ear that involved underlying cartilage. The physician noted he/she sutured approximately a 7 cm total area. Observation on 4/30/15 at 4:44 PM revealed resident #1 lay in a recliner in the dining room with the foot rest partially up. The resident had tennis shoes on and his/her eyes were closed. His/her walker sat folded up and rested on the wall behind the recliner. A personal alarm box sat next to the resident in the chair. The resident's left ear had a laceration across the ear. No further observations were made due to the resident discharged from the facility. Interview with direct care staff H on 4/30/15 at 4:40 PM revealed normally 2 programmers, who sat with the residents and provided activities, and 2 CNAs (certified nurse aides) were staffed during the week and the weekends. Staff H reported a nurse was not scheduled on the SCU. He/she revealed resident #1 fell and his/her ear. Staff H reported he/she did not really know much about the resident's fall. He/she stated he/she cared for 9 residents on the SCU. Interview with direct care staff G on 6/18/15 at 11:34 AM revealed he/she visualized resident #1 ' s ear after the fall and it had been detached with cartilage exposed. Staff G confirmed the resident needed stiches to his/her ear. Staff G reported resident #1 normally walked alone but had an unsteady gait at times. Interview with licensed nursing staff I on 6/18/15 at 1:36 PM revealed resident #1 needed some assistance getting up on occasion. Staff I reported resident #1 walked on his/her own, staff assisted the resident to the bathroom, but the resident spent most of his/her time in the day room. Staff I reported the resident had a steady gait, shuffled his/her feet a little, and walked slowly. Staff I reported resident #1 had an occasional fall. He/she reported the resident began to have more frequent falls when the resident began to have more exhaustion and weakness. Staff I confirmed the last fall the resident had, the resident sustained [REDACTED]. Interview with administrative nursing staff J on 7/14/15 at 2:12 PM revealed staff completed fall investigations through the facility's risk management process to determine the best possible course of action to prevent another fall. He/she reported fall interventions were required to be in place immediately following any fall to prevent another fall. Staff J stated he/she worked with the charge nurses and the MDS Coordinator to determine appropriate fall interventions following any resident fall. Staff J reported the fall investigation process could take time, so the nursing staff had to intervene as soon as a fall happened to prevent another fall. He/she reported he/she normally completed fall investigations, then the facility risk management team reviewed them and sometimes had further suggestions for fall interventions. Staff J reported resident #1 began requiring stand-by assistance with ambulation due to dizziness and weakness. Staff J reported resident #1 had 5 falls between October 2014 and January 2015. He/she stated 1 of those falls happened when the resident repositioned him/herself in the recliner and slid off the end, 2 of the falls occurred when the resident attempted to get out of his/her recliner unassisted, a fourth fall happened while the resident moved from his/her chair in the dining room and got his/her foot tangled in the leg of it, and the fifth fall happened while the resident ambulated independently in the corridor outside the SCU common room where the resident stated he/she slipped and fell . Staff J reported interventions following falls included: increased toileting assistance (reminders, cuing, and personal hygiene assist), redirection when confused and lost in SCU, assistance for seating in the dining room, and increased times assisted to the toilet (every 1.5 hours while awake). Staff J reported all of the falls before March 2015 were during independent ambulation or transfer. He/she stated in March and April 2015, following chemotherapy, the resident had 2 falls where staff lowered the resident to the floor during transfer or ambulation. Staff J stated the resident had dizziness and weakness causing the resident to be unable to stand without support. Staff J revealed interventions following those falls included: 2 person assisted transfer and ambulation. He/she reported on 4/20/15, staff found resident #1 on the floor beside his/her bed after attempting to get up without assistance. Staff J reported staff applied a bed alarm to the resident's bed so staff knew when the resident attempted to get up without assistance. Staff J reported on 4/28/15 resident #1 sat in the SCU living room/common area in the resident's recliner. He/she reported resident #1 got up out of the recliner independently and started down the main SCU corridor looking for his/her room and a bathroom. Staff J reported a CNA found the resident on the floor in the bathroom of another resident's room. He/she reported staff were unable to determine how the fall happened due to resident #1's long and short term memory loss related to the resident's [DIAGNOSES REDACTED].#1's fall. Staff J reported interventions implemented following the fall included: a chair alarm in place at all times while the resident sat in the recliner in the SCU living room area, a bed alarm in place at all times while in bed, the CMA (Certified Medication Aide) and nurses were to place the medication cart on the north side of the living room area so the programming staff had a direct visual of the residents in their recliners in the SCU living room area, toilet resident #1 per his/her toileting plan every 1.5-2 hours with prompting to get up and go to the restroom by staff, and monitor the resident by nursing staff at all times while up in recliner. He/she reported staff were not to leave the SCU unattended without staff observing the activities of residents. Review of the facility's policy for Fall Prevention, dated 11/2001, revealed the nurse needed to individualize the resident ' s care plan based on the fall assessment and interventions chosen to prevent a fall from occurring. If a resident fell the staff were to: assess the resident for injury; complete a progress note regarding the fall, any injuries sustained, and new interventions placed to prevent another fall; update the care plan to reflect new interventions based on the fall; notify the resident's physician and family; complete a Fall Assessment and Investigation Report; and complete the appropriate documentation following the Fall Work Flow Plan. The facility failed to identify the root cause of falls, complete fall investigations in a timely manner, and provide adequate supervision and appropriate and effective interventions to prevent falls for resident #1 who fell and sustained a left ear laceration that required sutures. - Review of resident #2's significant change MDS (Minimum Data Set) dated 2/9/15 revealed a BIMS (Brief Interview for Mental Status) score of 0, indicating severe cognitive impairment. The resident required extensive assistance of 2 or more staff for bed mobility, transfers, and toileting. The resident had frequent bowel and bladder incontinence and had a toileting program. The resident did not experience falls after admission. Review of the Fall CAA (Care Area Assessment) dated 2/17/15 revealed the resident had short and long-term memory loss with confusion. The resident fell on [DATE] when staff assisted him/her from the chair. The resident depended on staff for his/her ADL (activities of daily living) care. The resident recently hospitalized with pneumonia and his/her physical functioning declined since his/her return. The resident needed assistance with transfers and ambulation, cues and reminders, and needed more help at meal times. Review of a quarterly MDS dated [DATE] revealed the resident had a short and long-term memory problem and severely impaired cognitive skills for daily decision making. The resident required extensive assistance of 2 or more staff for: bed mobility, transfers, walking in the room and corridor, toileting, and personal hygiene. The resident had one minor injury fall and one fall without injury. Review of the resident's Fall Risk assessments revealed scores of: *11/1/14-10, with 9 or above indicating the resident had increased risk of falls *2/24/15-18 *4/28/15 and 5/2/15- 24 Review of the resident's care plan, last reviewed by staff on 5/13/15, revealed interventions directed staff to: *2/10/14: walk with the resident if he/she had anxiety and wanted to walk, monitor the resident's whereabouts at all times, respond to safety alarms immediately, keep the resident's call light in reach, and toilet the resident every 2 hours during the day, before and after meals, and 3-4 times at night. *2/14/14: be aware the resident refused to call for assistance with transfers and ambulation, keep areas free of clutter, and complete a fall assessment every 3 months. *Interventions dated 12/20/14 revealed the resident fell and to assess for dizziness or blood loss with cares and assist with 1 staff for ambulation, sitting, or lying down PRN (as needed). *2/18/15: provide assistance of 2 staff with transfers and at times use the stand-up lift (mechanical lifting/transfer device), keep furniture in the same place in his/her room, escort the resident to meals and other activities, and leave the resident in a safe position and return at a later time if the resident became upset with transfers. *3/26/15: use a bed alarm to alert staff if the resident got out of bed unassisted. *4/26/15: the resident fell . The care plan did not alert staff to the resident's injury that occurred with the fall or the care of the injury. Staff failed to review/revise the care plan with an intervention to prevent further falls until 4/29/15. *4/29/15: monitor and redirect the resident if he/she left the locked unit living room area without staff. *4/30/15: use a chair alarm for the resident. *5/8/15: the resident fell and staff were to check the resident hourly and re-orient the resident to his/her environment. Review of a fall investigation dated 12/20/14 at 1:20 PM revealed the resident fell while attempting to sit in a recliner in the SCU (special care unit) living room area. The resident normally ambulated independently without assistive devices without a gait belt. Staff reported the resident just lost his/her balance while sitting and fell to the side. Normally the resident could transfer him/herself safely. Staff obtained a urinalysis and found the resident had a urinary tract infection and treated the resident for it. The fall investigation did not include investigation into other causes or contributing factors of the resident's fall. Staff marked the investigation complete on 12/30/14, 10 days after the fall. Review of a fall investigation dated 4/26/15 at 5:35 PM revealed staff found the resident on the floor at the north end of the hall after a fall when he/she attempted to get up without assistance. The resident required staff assistance with all transfers and ambulation for safety. The wheelchair sat beside the resident at the time staff found him/her. The investigation revealed staff did not see the resident leave the common area prior to the fall, the resident needed close monitoring, and should not be wandering in the halls outside the locked unit living/dining room without supervision as he/she had no safety awareness. Administrative nurse J reviewed the incident on 5/1/15 (5 days later) and recommended the resident be supervised at all times when not in the living/dining room area of the locked unit, except when in bed. Staff placed a chair alarm on the resident's wheelchair. The investigation also revealed the resident sustained [REDACTED]. The investigation did not include causal factors or identify the root cause of the fall. Review of a fall investigation dated 5/8/15 at 10:11 AM revealed staff heard the resident's bed alarm and found the resident on the floor sitting next to his/her bed. Administrative nurse J reviewed the incident on 5/26/15 (2 ½ weeks later) and recommended routine observation checks of the resident while in bed, keep the bed in the low position, and keep a fall mat on the floor beside the bed. The investigation did not include causal factors or identify the root cause of the fall. Observation on 4/30/15 at 4:49 PM revealed the resident lay in a recliner in the living area. The resident's foot rest was in the up position and the resident wore house slippers. The resident's left hand and wrist had purplish/green bruising on the top of the hand and the palm. The resident had 1/2 a tennis ball sized bump to his/her left forehead. The resident also had a personal pressure alarm in place. No sutures were visible. Observation on 6/17/15 at 11:53 AM revealed the resident sat in a chair in the living room area with his/her feet raised. The resident wore a gait belt and house slippers. He/she did not have any visable bruises. The resident had a 1/2 tennis ball sized lump to his/her left forehead. The resident had his/her eyes closed and snored. He/she had a personal pressure alarm in place. Interview with direct care staff G on 6/18/15 at 11:35 AM revealed the resident stood up and walked with 1-2 staff. He/she reported at times the staff used a sit-to-stand lift. Staff G reported the resident used a bed alarm and he/she did not know of any falls for the resident. Interview with direct care staff H on 6/18/15 at 2:26 PM revealed the resident's gait varied depending on the day. He/she reported the resident had a chair alarm in place and staff constantly checked on the resident. He/she reported the resident never left the living room unattended. He/she also reported he/she was present on 4/26/15 when the resident fell . Staff H reported he/she had been setting up tables when he/she saw the resident down the hall on the floor. Staff H reported he/she did not see the resident's wheelchair that day. Interview with licensed nursing staff I on 6/18/15 at 1:57 PM revealed the resident required quite a bit of assistance. Staff I reported normally the resident could not get up and walk on his/her own. He/she reported the resident's gait varied depending on the day, but the resident usually needed assistance of 1 staff for ambulation. Staff I reported the resident was a fall risk because the resident had times of confusion and agitation and the resident could not express him/herself. Staff I reported the resident tried to get up by him/herself often at times. He/she reported the resident fell around the end of April 2015 and had a laceration to his/her lip that required stitches or sutures. Interview with administrative nursing staff J on 7/14/15 at 2:12 PM revealed resident #2 had 2 falls between 12/20/14 and 4/26/15. Staff J reported the physician decreased the resident's psychotropic medications by stopping his/her Geodon and Exelon patch in January and February because his/her behaviors and activity level had changed. Staff J reported the resident started to become more active and attempted to ambulate on his/her own. Staff J reported the resident was very unsteady on his/her feet, so staff were assisting him/her with ambulation whenever he/she attempted it. Staff J reported the resident could use his/her wheelchair for mobility within the SCU. Staff J reported the resident fell on [DATE] during a staff assisted transfer and ambulation when resident #2 lost his/her balance while attempting to sit down in a recliner in the common area. Staff were unable to hold him/her up, per staff J report, even using the gait belt due to the resident's large size. Staff J reported when the resident fell on [DATE], he/she propelled him/herself around the SCU common area and corridor in his/her wheelchair when he/she attempted to stand up from the wheelchair in the corridor and fell . Staff J confirmed staff did not witness the fall but the resident told staff he/she fell standing up out of his/her wheelchair. Staff J reported the resident had not attempted to get out of his/her recliner or wheelchair without assistance prior to that fall and normally asked for assistance and waited for staff to help him/her. Staff J reported the resident did not have a chronic history of falling. Review of the facility's policy for Fall Prevention, dated 11/2001, revealed the nurse needed to individualize the resident's care plan based on the fall assessment and interventions chosen to prevent a fall from occurring. If a resident fell the staff were to: assess the resident for injury; complete a progress note regarding the fall, any injuries sustained, and new interventions placed to prevent another fall; update the care plan to reflect new interventions based on the fall; notify the resident's physician and family; complete a Fall Assessment and Investigation Report; and complete the appropriate documentation following the Fall Work Flow Plan. The facility failed to investigate causal factors of falls and provide adequate supervision to prevent further falls from occurring for resident #2, who fell and sustained a laceration requiring stitches to his/her upper lip. - Review of resident #3 ' s signed physician orders [REDACTED]. to the brain). Review of an admission MDS (Minimum Data Set 3.0, a required assessment) dated 1/8/15 revealed BIMS (Brief Interview for Mental Status) of 7, indicating severe cognitive impairment. The resident required extensive assistance of two or more staff for bed mobility, transfers, toileting, and personal hygiene. The resident was frequently incontinent of bladder and on a toileting program. The resident had a fall in the 2-6 months prior to admission with a fracture related to a fall during that time. The resident had one minor injury fall since admission. Review of the Fall CAA (Care Area Assessment) dated 1/9/15 revealed the resident had [DIAGNOSES REDACTED]. The resident was alert and oriented to self and family. The resident was dependent on staff for his/her ADL (activities of daily living) cares, with cues and reminders. The resident used a stand up lift (mechanical lifting/transferring device) with 2 staff due to weakness and pain in both lower extremities. The resident could use his/her call light for assistance and to make his/her want/needs known. The resident did not generally attempt to get up from bed or the chair without assistance. When asked if he/she could stand up and walk without assistance he/she replied no.

The facility reported a census of 36 residents with 6 residents in the sample. Based on observation, interview, and record review the facility failed to develop and implement effective interventions to prevent weight loss for 2 of 3 residents reviewed for weight loss. (#4 and #5) Resident #5 sustained significant weight loss of 9.3% in a little over a month. The facility also failed to collaborate with resident #4's physician to develop a safe weight loss plan for him/her. Findings included: - Review of #5's physician signed patient summary from the hospital dated 1/16/15 revealed a [DIAGNOSES REDACTED]. Review of an admission MDS (minimum data set) dated 12/22/14 revealed the resident had short and long-term memory problems and severely impaired cognitive skills for daily decision making. The resident did not exhibit rejection of care. The resident required limited assistance of one staff for walking in the room and corridor, extensive assistance of one staff for transfers, and supervision with setup help for eating. The resident did not have any oral, dental or swallowing problems and had not experienced weight loss. Review of the Pressure Ulcer CAA (care area assessment) dated 12/23/15 revealed the resident had a [DIAGNOSES REDACTED]. The resident had short and long-term memory loss with confusion. The resident depended on staff for limited to extensive assistance with his/her ADL (activities of daily living) cares, along with cues and reminders. The resident had a good appetite and needed setup assistance with meals and fluids. Review of a quarterly MDS dated [DATE] revealed a BIMS (brief interview for mental status) score of 0, indicating severe cognitive impairment. The resident did not exhibit rejection of care. The resident required extensive assistance of two staff for transfers, and extensive assistance of one staff for eating. The resident did not walk. The resident did not have any oral, dental or swallowing problems and had not experienced weight loss. Review of resident #5's care plan, last reviewed 6/17/15, revealed interventions directed staff to: 12/16/14: · Weigh weekly and monitor for weight loss · Provide encouragement for eating. · Provide a regular diet. · Monitor food intake at meals and snacks. · Encourage to eat at least 75% of each meal 2/24/15: · Provide a supplement of choice 4 oz. (ounces) TID (three times a day) and encourage him/her to drink it. (3/24/15- revised from 4 oz. to 8 oz.) 6/17/15: · Get the resident up last for meals and lay him/her down first after meals. The facility failed to implement additional interventions to prevent weight loss from 3/24/15-6/17/15, even though the resident's weight continued to decline. Review of the resident's lab reports revealed: 12/12/14- [MEDICATION NAME] (blood test used to measure the amount of protein in the blood, used in part to determine a person's nutritional status) 3.2 grams per deciliter (g/dL) with the normal range of 3.5-4.8 g/dL. 2/6/15- [MEDICATION NAME] 3 g/dL (low) 3/20/15- Pre-[MEDICATION NAME] (blood test used to determine nutritional status) 17mg/dL (milligrams per deciliter) with the normal range of 18 mg/dL -38 mg/dL. Review of the resident's weights revealed: 12/12/14- 120.2 lbs. (pounds) 12/30/14- 123.4 lbs. In the hospital from 1/9/15 for a fever of 104 degrees Fahrenheit until1/16/15 when he/she returned on antibiotics for a urinary tract infection per the notes listed below. 1/16/15- 126.4 lbs. 1/21/15- 122.2 lbs. 1/29/15- 120.6 lbs. 2/11/15- 114.4 lbs. 2/20/15- 114.6 lbs. (a loss of 11.8 lbs. from 1/16/15-2/20/15 or 9.3% of the resident's body weight) In the hospital from 3/9/15-3/13/15 with a non-productive cough and diminished lung sounds per a note listed below. 3/20/15- 114.3 lbs. 3/30/15- 110 lbs. 4/8/15- 109.8 lbs. 4/14/15 and 4/27/15- 107.8 lbs. 5/13/15- 108.2 lbs. 5/22/15- 111.2 lbs. 6/3/15- 107.8 lbs. 6/11/15- 105.4 lbs. (a loss of 4.6 lbs. from 3/30/15- 6/11/15 or 4.2% of the resident's body weight) Review of the resident's progress notes revealed: 12/12/14- Physician note- The resident received a regular diet. A review of the resident's symptoms revealed a change in appetite, anorexia (lack or loss of appetite), and not eating well. The resident weighed 120.2 lbs. and the physician planned for him/her not to have any significant weight loss. 1/9/15- Staff sent the resident to the hospital, where he/she admitted , with a fever of 104 degrees Fahrenheit. Staff did not note any [MEDICAL CONDITION] (fluid retention in the tissues) 1/16/15- The resident readmitted to the facility with antibiotics for a urinary tract infection. Staff did not note any [MEDICAL CONDITION]. 1/20/15- The resident ate and drank well. 1/22/15- Dietary note by the dietician- The resident weighed 122 lbs. and received a regular diet. The resident usually ate well for the first couple of bites of meals but lately had refused dinner. The dietician recommended offering supplements when the resident refused to eat. 2/20/15- Staff received an order for [REDACTED]. 2/21/15- physician progress notes [REDACTED]. Assessment revealed malnutrition with weight loss. Supplements with meals were to be added and staff were to encourage oral intake at meals. 3/9/15- The resident admitted to the hospital for observation with a non-productive cough and diminished lung sounds. 3/14/15-readmitted the resident to the facility on [DATE]. The resident ate and drank well. 3/14/15- Dietary note by the dietician- The resident weighed 114.6 lbs. with a 9.19% weight loss over the previous month. The resident received a regular diet with a 4 oz. supplement of choice at meals, which was recently added. The resident had an intake of 25-50% since readmission from the hospital and received calcium with vitamin D. The dietician recommended to monitor oral intake and weight status. 3/15/15- The resident ate well that morning. 3/24/15-The resident was not eating well. Staff faxed the physician to possibly increase his/her supplements. 4/4/15- The resident drank some at supper and then refused anymore liquids. Continue to offer fluids. 4/10/15- Physician note- The resident's recent (3/20/15) pre-[MEDICATION NAME] was down at 17 mg/dL and the resident started supplements TID. The physician's assessment included malnutrition with weight loss. The physician planned to have staff encourage the resident to eat. 5/27/15- Order received to start vitamin C and zinc to promote wound healing daily. 6/9/15- Dietary note by the dietician- The resident weighted 107.8 lbs. and had experienced a 10.32% weight loss in the past 6 months which was considered severe. The resident received a regular diet with intake of 25-75% at most meals. The resident was previously on a supplement, but the dietician did not know if the resident took it. The resident received calcium with vitamin D, vitamin C, and zinc. The dietician recommended to add supplements if the resident accepted. 6/16/15- The resident's weight dropped 12.31 % in 6 months and he/she weighed 105 lbs. The resident's family member reported to staff that was a normal weight for the resident. Staff sent the physician a fax requesting Ensure 4 oz. with meals. 6/17/15- Staff received an order to recheck the resident's [MEDICATION NAME] and weight loss. Administer [MEDICATION NAME] (a protein drink) 4 oz. TID with snacks and 4 oz. of Ensure with meals. 6/19/15- Dietary note by the CDM- The resident continued to lose some weight, but the family was not concerned. The resident's family stated the resident was always a very thin person. The resident ate 25-50% of meals and snacks and had an order for [REDACTED]. Review of a fax from the physician on 2/20/15 revealed an order to start a supplement of choice 4 oz. TID with meals for weight loss, however staff did not update the care plan with the new order until 2/24/15. Review of a fax from the physician on 3/24/15 revealed an order to increase the resident's supplement to 8 oz. TID with meals for continued weight loss. Observation on 6/17/15 at 12:27 PM, the resident sat in the dining room and received, pears, lasagna, green beans, french bread, peach cobbler, water, cranberry juice, milk, and chocolate boost. Staff cut up the resident's food for him/her. At 12:45 PM direct care staff G assisted the resident to eat. At 1 PM, the resident remained at the dining table and staff G encouraged the resident to eat and drink. The resident ate all of his/her lasagna, a few bites of beans, a few bites of cobber, and a few bites of bread. The resident drank 90% of his/her boost, and all of his/her milk. Interview with licensed nurse C on 6/18/15 at 1:20 PM revealed resident #5 did not have a very big appetite, but could voice hunger and thirst. Staff I reported staff encouraged him/her to eat and he/she received a supplement TID. Staff I reported the resident could feed him/herself but liked to have staff feed him/her. Staff I reported he/she did not know of an exact amount, but it seemed like the resident had lost a little bit of weight. Staff C reported the weekend direct care staff obtained the weights for the residents, then the CDM and administrative nurse J reviewed the weights. Interview with dietary staff D on 6/18/15 at 1:41 PM revealed they had discussed resident #5 during care plan meetings and his/her family thought he/she was doing great. Staff D reported he/she thought maybe they needed to change the timing of the resident's supplement, but reported the resident did not have a physician's order yet to change it. Interview with administrative nurse J on 7/14/15 at 2:12 PM revealed dietary supplements were documented by the person recording dietary intake and the direct care staff that set up for meals and snacks were the main staff members that documented the dietary intake and supplement intake. Staff J also reported he/she expected the nurses to document supplement administration in the treatment section of the MAR. Staff J reported he/she worked with dietary staff D to follow up on any dietician recommendations and discussed the recommendations and weights weekly at care plan meetings. Staff J reported staff weighed each resident weekly. Staff J reported resident #5 had a weight loss following his/her admission from a geropsychiatric unit (12/12/14) and upon admission, staff began decreasing his/her [MEDICAL CONDITION] medications immediately because the resident was overmedicated. At that time he/she required feeding assistance for all meals and still required set up assistance and strong encouragement with meals. After reducing his/her medications, he/she became better able to feed him/herself and interacted with others and continued to slowly gain back the weight he/she lost while staff tapered his/her medications. At times, staff J reported, the resident could be very forceful in his/her refusal to eat. Interview with dietary consultant staff N on 7/22/15 at 4:12 PM revealed the facility notified him/her if a resident's weights trended downward if it was over 3-5% in a month and that was what he/she expected. Consultant N also reported he/she charted on all the residents every 3 months. Consultant N reported resident #5 moved to the long-term care facility from skilled care at the hospital a while prior to the weight loss. He/she reported the resident just was not eating or doing a lot at that time and he/she did not recall any [MEDICAL CONDITION] or diuresis (use of medications to rid the body of excess fluids) at that time. Consultant N reported discussing the resident's weight loss with his/her family member who did not seem concerned at all. Consultant N reported after he/she saw the resident, the CDM followed up on his/her recommendations and nursing could also read his/her note with recommendations to follow up as well. Per consultant N, staff normally followed up on his/her recommendations by the next day, which was his/her expectation. Consultant N did not know staff did not follow up on his/her recommendation to start supplements on 1/22/15 until 2/20/15. A phone interview was attempted with the physician on 7/20/15 at 1:25 PM and a message left. The physician did not return the phone call. Review of the facility policy for Weights, revised 12/2008, revealed staff were to call the dietary manager if a resident had 5% weight loss or more within 30 days or 10% or more in 180 days and request a dietary consult. The dietary manager and the director of nursing would consult on weight losses and discuss interventions to prevent further weight loss problems. Review of the facility policy for Nutritional Services, revised 08/2010, revealed high risk patients would be identified and reassessed weekly. The nursing staff or physician could order a reassessment of nutritional needs as necessary for significant weight loss, a significant change in eating habits or lab work indicative of nutritional concern. The following were high risk patients: unplanned weight loss of 5% over one month, 7.5% over 3 months, 10% over 6 months, serum [MEDICATION NAME] less than 3.5 mg/dL, or stage II or greater pressure ulcer. The facility failed to implement interventions to prevent further weight loss after resident #5 started to steadily lose a significant amount of weight (9.3%) from 1/16/15- 2/20/15 and then again from 3/30/15-6/17/15, when the resident experienced more continued weight loss (4.2%). - Review of resident #4's signed physician history and physical dated 2/25/15 revealed the following Diagnoses: [REDACTED]. Review of the quarterly MDS (minimum data set) dated 2/5/15 revealed a BIMS (brief interview for mental status) score of 9, indicating moderate cognitive impairment. Resident #4 required total assistance of 2 or more staff for bed mobility and transfers and supervision and set-up for eating. Staff provided the resident a therapeutic diet and resident #4 had not experienced any weight loss. Review of an annual MDS dated [DATE] revealed resident #4 had a BIMS score of 11, indicating moderate cognitive impairment. The resident required extensive assistance of 2 or more staff for bed mobility. He/she required total assistance of 2 or more staff for transfers. The resident received nutritional/hydration interventions. Review of the Nutritional Status CAA (Care Area Assessment) dated 5/7/15 revealed resident #4 received a NCS (no concentrated sweets) diet with a protein supplement TID (three times a day). Resident #4 preferred Special K (brand of supplement) and watched his/her weight limiting and often refusing desserts and breads. The resident asked for small portions and ate 50-100% of his/her meals. Resident #4 could make his/her own menu choices and feed him/herself after set-up from staff. He/she needed to have meals and drinks placed where he/she could easily reach items as he/she had a limited reach. The resident had a plate guard on his/her plate at meal times. He/she also preferred to sleep in the mornings and usually did not eat breakfast. Review of the ADL (activities of daily living) CAA dated 5/7/15 revealed resident #4 had a [DIAGNOSES REDACTED]. The resident was hospitalized in 2/2015 for flap repair to his/her buttocks wound that resolved well. The resident had a sitting limit of 90 minutes at a time TID and needed reminders of this limit due to the resident wanted to sit up longer. Resident #4 complied with the sitting limit after explanation provided. The resident depended on staff for ADL care, transferred via lift sling, needed staff to reposition him/her, made his/her needs known, made menu choices, and fed him/herself after set-up assist. Review of resident #4 ' s care plan, last reviewed by staff on 5/6/15, revealed the resident had total dependence on staff for his/her ADLs and his/her teeth were in good repair. Interventions included: 10/30/12- Provide setup assistance at mealtime. Educate the resident on the importance of protein as he/she tended to cut back on meats to decrease calorie consumption as he/she wanted to lose weight. Weigh the resident weekly. Ensure the dietician assessed him/her every 3 months. Administer vitamin supplements daily as ordered. Monitor food intake at meals and snacks. Assist with a supplement each day and encourage him/her to drink it. Encourage him/her to eat at least 75% of the meal, if not, offer a substitute. 2/11/13- Remind him/her the importance of eating as he/she got so focused on weight loss that he/she forgot he/she needed nutrition and calories for wound healing. 6/19/13 -Please ensure the resident received increased protein with his/her meals for proper skin/wound prevention. 2/4/14- The resident requested small portions and if he/she was still hungry, he/she asked for more. 12/17/14- Provide a plate guard on the resident ' s plate so the food did not fall off. 2/12/15- Provide a special K drink with each meal. 3/24/15- Multivitamin and zinc added to promote wound healing Review of the resident ' s lab reports revealed: 10/13/14- [MEDICATION NAME] (blood test used to measure the amount of protein in the blood, used in part to determine a person ' s nutritional status) 4.3 grams per deciliter (g/dL) with the normal range of 3.5-4.8 g/dL. 2/25/15- [MEDICATION NAME] 3.3 g/dL (low) 3/2/15- [MEDICATION NAME] 2.7g/dL (low) 3/9/15- [MEDICATION NAME] 3.1 g/dL (low) 3/16/15- [MEDICATION NAME] 3.4g/dL (low) 3/23/15- [MEDICATION NAME] 3.5 g/dL (normal) Review of the resident ' s weights revealed: 12/30/14- 168.5 lbs. (pounds) 1/7/15- 170 lbs. 1/14/15- 170.5 lbs. 1/29/15- 168.4 lbs. 2/20/15- 163.5 lbs., a weight loss of 7 lbs., (4% of his/her body weight), since 1/14/15 (approximately one month prior). The resident was hospitalized from [DATE]-3/24/15 for surgery on a wound. 3/30/15- 152 lbs. 4/8/15- 152.5 lbs., a weight loss of 18 lbs. (10.6% of his/her body weight) since 1/14/15 (approximately 3 months prior). 4/27/15- 153.4 lbs. 5/13/15- 154 lbs. 6/3/15- 153.5 lbs. 6/11/15- 155 lbs. Review of the resident's progress notes revealed: 12/16/14- The resident blurted out dietary restrictions for other residents in the dining room to staff while not following his/her own diet. 1/12/15- Received orders for zinc and a multivitamin to promote wound healing. 2/2/15- Staff sent a fax to the physician asking for special K protein drink to be given with meals due to condition of the resident's wound. 2/3/15- Received order for special K protein drink with meals. 2/7/15- Dietary note by the dietician- The resident experienced a 14.86% weight loss over the past 6 months. The resident received a NCS (no concentrated sweets) diet with variable intake, and generally refused breakfast and some other meals. The resident's weight loss had been beneficial, but further weight loss should be avoided. The resident weighed 168.4 lbs. 2/18/15 Dietary note by the CDM (certified dietary manager)- Limited concentrated sweets diet and to aide in him/her losing weight, he/she also refused breakfast because he/she wanted to sleep in. The resident received a supplement of choice for added protein. Ate 100% of lunch and 25-100% of supper. 3/31/15 Dietary note by the dietician-The resident weighed 152 lbs. and received a regular NCS diet. The resident previously received a protein supplement of choice with meals but the physician did not re-order it since his/her return from the hospital. The resident refused breakfast daily and ate 50-100% of lunch and dinner. The resident received vitamin C. The dietician recommended re-instating the protein supplement of choice with lunch and dinner to help reduce weight loss and aid in wound healing. 4/27/15 Dietary note by the CDM- The resident requested a snack of special K high protein drink BID (twice a day) and weighed 152.4 lbs. 4/29/15- Staff received an order for [REDACTED].>5/6/15- Staff received an order to change the resident ' s diet to NCS diet as the resident wished to continue to lose weight. 5/8/15 Dietary note by the dietician- The resident weighed 153 lbs. and received protein supplements TID with meals per his/her request. The resident also received vitamin C, calcium [MEDICATION NAME], and zinc. Review of a physician order sheet dated 10/1/14 revealed the following orders: *Regular NCS 3 times per day at 8:00 a.m., 12:00 p.m., and 5:00 p.m. *Supplement of choice daily at 8:00 a.m. for nutrition/wound preventions. Review of the resident's oral intake from 10/1/14-6/18/15 revealed staff did not document nutritional supplements until 2/9/15, even though the care plan listed he/she should have a supplement daily since 10/30/12. From 2/9/15- 6/17/15, the resident received a supplement 79 times out of 381 opportunities. Review of the TAR (treatment administration record) for October 2014 revealed: *Supplement not administered 9 times out of 31 days with follow-up that the resident remained in bed at breakfast and declined supplement all 9 times Review of the TAR for November 2014 revealed: *Supplement not administered 11 times out of 30 days with follow-up that the resident remained in bed at breakfast and declined supplement all 11 times Review of the TAR for December 2014 revealed: *Supplement not administered 7 times out of 31 days with follow-up that the resident remained in bed at breakfast and declined supplement 6 times; on 12/8/14 follow-up of protein supplement added to lunch Cappuccino. Review of the TAR for January 2015 revealed: *Supplement not administered 12 times out of 31 days with follow-up that the resident remained in bed at breakfast and declined supplement Review of the TAR for February 2015 revealed: *Supplement not administered 8 times out of 28 days with follow-up that the resident remained in bed at breakfast and declined supplement Review of the TARs for April 2015 revealed: *treatment of [REDACTED]. Staff did not administer the supplement twice on 4/30/15 due to refusal. Review of the Tar for May 2015 revealed: *Supplement not administered 12 times out of 31 days with follow-up that the resident remained in bed at breakfast and declined supplement, and he/she refused the supplement twice. Review of the TAR for June 1-29, 2015 revealed: *Supplement not administered 12 times out of 31 days with follow-up that the resident remained in bed at breakfast and declined supplement, and refused the supplement 5 times. Review of a hospital physician progress notes [REDACTED]. Review of a hospital physician progress notes [REDACTED]. Observation on 6/17/15 at 11:45 AM revealed the resident's room door closed with several voices coming from inside. At 11:59 AM, the door to the resident's room sat open and the resident was not inside the room. A Hoyer lift (mechanical lifting/transfer device) sat inside the room. At 12 PM, the resident sat in the dining room and reported the food was good. The resident received lasagna, green beans, chocolate shake, water, iced coffee, and lettuce salad. The resident fed him/herself and ate everything except 1/2 of the green beans. Observation on 6/17/15 at 5:07 PM revealed the resident chose an alternate meal of popcorn shrimp, French fries, and apple salad. The resident had a chocolate shake and water to drink and fed him/herself everything. Interview with direct care staff B on 6/18/15 at 11:08 AM revealed the resident required setup assistance for meals and fed him/herself. Interview with licensed nurse C on 6/18/15 at 1:20 PM revealed the resident fed him/herself. The resident received zinc, a multivitamin, and drank protein supplements twice a day unless he/she refused. Staff C reported nursing documented supplements intake in the MAR (medication administration record) /TAR. Staff C reported the resident ' s weight was stable at the time and the resident usually skipped breakfast, and then ate lunch and supper well. Staff C reported the resident lost some weight in the past so the physician added protein supplements. Staff C reported the weekend direct care staff obtained weights each weekend, then dietary staff and administrative nurse J reviewed the weights. Interview with dietary staff D on 6/18/15 at 1:41 PM revealed the resident received Special K supplements per his/her request. Staff D reported the nursing staff documented whether or not the resident received or consumed the supplements. Staff D reported the resident preferred not to eat breakfast and slept in and wanted to lose weight. Staff D reported he/she thought the resident was young enough that he/she still wanted to be thin. Staff D reported the resident ' s would not eat everything and was kind of picky because he/she did not want to gain any weight. Staff D reported the staff tried to encourage protein intake, especially for the wound healing. Staff D reported he/she reviewed the weights of the resident ' s he/she care planned weekly and then in care plan meetings he/she discussed the resident ' s appetite and weights. Staff D reported the dietician looked at weights and made recommendations after weight changes and during care plan reviews. Staff D reported the dietician came to the facility monthly. Interview with administrative nurse J on 7/14/15 at 2:12 PM revealed dietary supplements were documented by the person recording dietary intake and the direct care staff that set up for meals and snacks were the main staff members that documented the dietary intake and supplement intake. Staff J also reported he/she expected the nurses to document supplement administration in the treatment section of the MAR. Staff J reported he/she worked with dietary staff D to follow up on any dietician recommendations and discussed the recommendations and weights weekly at care plan meetings. Staff J reported staff weighed each resident weekly. Staff J reported resident #4 had been on his/her own weight loss plan for at least 2 years. The resident wanted to lose weight and worked very hard to do it. Staff J reported resident #4 restricted what he/she ate and drank and refused to eat things he/she thought were too high in calories which could cause weight gain. Staff J reported the resident had good understanding about the things he/she should and should not eat to lose weight. Staff J reported the resident lost 20 lbs. in the past 180 days and was ecstatic about it. Staff J reported resident #4 agreed to drink a protein drink to add calories and protein to his/her diet a couple times per day. A phone interview was attempted with the physician on 7/20/15 at 1:25 PM and a message left. The physician did not return the phone call. Review of the facility policy for Weights, revised 12/2008, revealed staff were to call the dietary manager if a resident had 5% weight loss or more within 30 days or 10% or more in 180 days and request a dietary consult. The dietary manager and the director of nursing would consult on weight losses and discuss interventions to prevent further weight loss problems. Review of the facility policy for Nutritional Services, revised 08/2010, revealed high risk patients would be identified and reassessed weekly. The nursing staff or physician could order a reassessment of nutritional needs as necessary for significant weight loss, a significant change in eating habits or lab work indicative of nutritional concern. The following were high risk patients: unplanned weight loss of 5% over one month, 7.5% over 3 months, 10% over 6 months, serum [MEDICATION NAME] less than 3.5 mg/dL, or stage II or greater pressure ulcer. The facility failed to ensure resident #4 developed and implemented appropriate interventions to maintain the resident ' s nutritional status within acceptable parameters, resulting in a weight loss of 10.5% in 3 months. The facility also failed to collaborate with the resident ' s physician to develop a weight loss plan for resident #4, as he/she desired to lose weight.