Every finding on record at Lakepoint Wichita, LLC

The facility had a census of 79 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to use appropriate barriers while sorting soiled laundry, failed to maintain an ongoing waterborne pathogen prevention program to address and mitigate the risk for Legionella (Legionella is a bacterium which can cause pneumonia in vulnerable populations), and failed to implement Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) for Resident (R)7, R385 and R391. This placed the residents at risk of infectious diseases. Findings included: - On 12/02/24 at 12:35 PM observation revealed License Nurse (LN) H entered the room of R385 and donned gloves but no gown. LN H unclamped the end of the gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) and attached a 60-milliliter (ml) syringe to the end of the G-tube and administered 60 ml of water, followed by one carton of Jevity (a liquid nutritional supplement that is high in calories, protein, and fiber) 1.5 calorie, followed by 60 ml water then administered 100 ml of free water. LN H removed the 60-ml syringe and clamped the end of the tube. LN H lowered the resident's bed to a low position. On 12/02/24 at 01:42 PM, observation revealed Certified Nurse Aide (CNA) Q washed hands, and applied gloves but did not don gown. CNA Q emptied R7's urinary drainage bag into a urinal. CNA Q allowed the drainage port tip to touch the urine in the container. The urine output measured 2000 millimeters (ml). CNA Q removed the glove and washed hands, gloved again, then unattached the drainage port and wiped it with a moist wipe. CNA Q stated they did not have alcohol wipes. On 12/03/24 at 07:52 AM, while on tour of the laundry department, Maintenance Staff U stated the soiled laundry was sorted by laundry staff using only gloves for personal protective equipment (PPE). Maintenance Staff U stated the laundry personnel did not wear a barrier gown or apron while sorting soiled laundry. Maintenance Staff U stated there could be the possibility of cross-contamination of soiled material to the clean laundry which was folded by the same laundry staff. On 12/03/24 at 08:55 AM, LN I entered the room of R391 and donned gloves but no gown. LN I elevated the head of the resident's bed approximately 30 degrees and loosened the resident's abdominal binder. LN I unclamped the end of the G-tube and injected 10 ml of air to listen for placement with a stethoscope (a medical instrument for listening to the action of someone's heart or breathing). LN I then attached a 60-ml syringe to the end of the G-tube and administered 30 ml of water, then the resident's medication, followed by 30 ml of water. LN I removed the 60 ml syringe, clamped the end of the G-tube, and placed it under the binder. On 12/03/24 at 12:30 PM, CNA Q stated the facility had not instructed her to use personal protective equipment (PPE) for EBP when providing catheter care. On 12/03/24 at 02:22 PM, Administrative Nurse E, Consultant GG, and Administrative Nurse D verified the facility had not initiated EBP due to a lack of understanding regarding the requirements. On 12/03/24 at 03:00 PM interview with Administrative Nurse D and Nurse Consultant GG verified the residents' rooms lacked EBP signs and PPE in the rooms to inform staff they should use EBP when providing care for R385 and R391 due to the G-tubes. Administrative Nurse D said the facility would do some education with the staff regarding EBP and wearing PPE for resident care and get the residents' rooms set up with the appropriate PPE equipment and signs. On 12/04/24 at 09:48 AM, Maintenance Staff U reported that the prevention waterborne pathogen procedure was to flush toilets and run facets and showers weekly in areas where there were not many residents. Maintenance Staff U stated he had not logged or documented the weekly flushing of the toilets, faucets, and showers. The facility was unable to provide any evidence of an ongoing water management plan upon request. The facility's Laundry policy, dated 12/04/24, documented it was the policy of the facility to prevent the spread of infection by appropriate separation, collection, laundry, and storage of laundry. Facility staff will handle, store, process, and transport linens in a method to prevent the spread of infection. The facility's undated Water Management Policy documented it was the policy of this facility to ensure the appropriate precautions for the control of Legionella (Legionella is a bacterium which can cause pneumonia in vulnerable populations) bacteria are identified through a Legionella risk assessment process and appropriate control measures implemented to ensure, so far as is reasonably practicable, the health, safety, and welfare of residents, visitors, staff members, and volunteers. The minimum standards to be met include but are not limited to a description of building water systems, identification of areas where Legionella could grow and spread, the implementation, management, monitoring, and recording of precautions to include regular inspection, microbiological monitoring, temperature checks, and flushing where appropriate, and documentation of all monitoring. The facility's Enhanced Barrier Precautions (EBP) policy, dated 04/01/2024, stated the facility would follow recommendations from The Centers for Disease Control to keep residents safe from healthcare-acquired infections. The policy stated EBP would be used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high contact resident care activities in the resident's room that provide opportunities for transfer of organisms to staff hands and clothing. Residents with the following conditions require EBP for all high-contact care including chronic wounds, urinary catheters, hemodialysis access sites, and feeding tubes. the policy directed staff to post clear signage stating EBP precautions and make PPE available near or inside the resident's room. The facility failed to handle soiled laundry in a manner to prevent the spread of possible infectious material without using the appropriate barriers. The facility failed to implement a water management program for waterborne pathogens placing the residents who reside in the facility at risk of contracting Legionella pneumonia. This placed the residents at increased risk for infections. The facility failed to implement EBP for three residents. These failures placed the residents at risk for increased infections.

The facility had a census of 79 residents. Based on record review and interviews, the facility failed to submit complete and accurate staffing information through the Payroll-Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year (YR) 2023 Quarter (Q) 4 indicated excessively low weekend staffing and FY 2024 Q1 indicated excessively low weekend staffing and no Registered Nurse (RN) hours for 10 days in January 2024, seven days in February 2024 and one day in March 2024. A review of the facility's weekend staffing and RN hours of the dates listed PBJ revealed appropriate weekend staff and RN coverage. On 12/04/24 at 09:22 AM, Administrative Nurse D reported that the discrepancy may be related to the previous company owners' incorrect submission of information. The facility's undated Mandatory Submission of Uniform Format Staffing Information (PBJ) policy documented the facility will submit to CMS complete and accurate direct care staffing data, including the category of work for each person on direct care staff, including but not limited to if the individual is a registered nurse (RN), licensed practical nurse (LPN), licensed vocational nurse (LVN), certified nursing assistant, therapist, or other type of medical personnel as specified by CMS. The facility will distinguish employees from agency and contract workers. The facility will submit as directed by CMS to CMS during the established staffing reporting periods but no less frequently than quarterly. The facility failed to submit accurate PBJ data, placing the residents at risk for unidentified and ongoing inadequate staffing.

The facility had a census of 79 residents. The sample included 20 residents. Based on observation, record review, and interview, the facility failed to store and label biologicals as required when staff failed to identify and discard six expired vials of Prevnar (a vaccine that protects against 20 different strains of the Streptococcus pneumoniae bacteria) in one of three medication rooms. The facility further failed to place an open date on insulin (a hormone that lowers the level of glucose in the blood) pens in one of three treatment carts. This placed the affected residents at risk of receiving an expired and ineffective dose of Prevnar and insulin. Findings included: - On 12/02/24 at 08:20 AM, observation in the 100-hall medication room revealed six vials of Prevnar 0.5 milliliter syringes with an expiration date of August 2024. On 12/02/24 at 08:20 AM, Licensed Nurse (LN) K verified the expired Prevnar and stated expired medications were to be placed into a bin on 900 Hall and were to be destroyed with the pharmacy. On 12/02/24 at 09:23 AM, Administrative Nurse D verified expired medications should be disposed of appropriately. The facility's Medication Storage and Labeling policy, dated 05/03/24, stated medication containers having soiled, damaged, incomplete, or illegible labels would be returned to the issuing pharmacy for relabeling or destroyed by facility policy. The facility failed to dispose of six expired Prevnar syringes. This placed the residents at risk of receiving an ineffective dose of the medication. 32358 - On 12/02/24 at 08:15 AM, observation revealed in the 300-400 treatment cart Resident (R)17's Basaglar (long-acting) insulin pen, R26 and R36s' Lantus Solostar (long-acting insulin), and R46's insulin glargine (long-acting) insulin pens lacked an open date and a discard date. On 12/02/24 at 08:15 AM, Licensed Nurse (LN) J verified the above findings and stated staff should place an open date on insulin pens when they open a new one. On 12/04/24 at 10:20 AM, Administrative Nurse D stated she expected staff to place an open date on an insulin pen when they open a new one. The facility's Medication Storage and Labeling policy, dated 05/03/24, stated medication containers having soiled, damaged, incomplete, or illegible labels would be returned to the issuing pharmacy for relabeling or destroyed in accordance with facility policy. The facility failed to place an open date on R17, R26, R36, and R46s' insulin pens. This placed the residents at risk of receiving ineffective doses of insulin.

The facility had a census of 79 residents. The sample included 20 residents, with eight reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of the required stop date for Resident (R) 31, R37, R52 and R68s' as-needed (PRN) antianxiety (a class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication. The facility failed to acknowledge and follow up on the CP's request for a diagnosis for R17's Effexor (an antidepressant medication) and Haldol (an antipsychotic medication). This placed the residents at risk for inappropriate or unnecessary use of medications and related side effects. Findings included: - The Electronic Medical Record (EMR) for R31 documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteomyelitis (local or generalized infection of the bone and bone marrow), pain, atrial fibrillation (rapid, irregular heartbeat), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Medicare 5-Day Minimum Data Set (MDS), documented R31 had intact cognition and was dependent upon staff for transfers. R31 required substantial assistance with toileting, showers, dressing, and mobility, and was independent with transfers. The MDS further documented R31 received antidepressant (a class of medications used to treat mood disorders), opioid (a class of controlled drugs used to treat pain), and hypoglycemic (less than normal amount of sugar in the blood) medications. R31 was depressed for seven to 11 days and did not have any behaviors. The Quarterly MDS, dated [DATE], documented R31 had intact cognition. R31 was dependent upon staff for transfers. R31 required substantial assistance with toileting, bathing, dressing, and mobility. The MDS further documented R31 received antidepressant and diuretic (a medication to promote the formation and excretion of urine) medications and had no behaviors. R31's Care Plan dated 07/08/24, documented R31 was at risk for medication adverse reactions related to Black Box Warning (BBW-highest safety-related warning that medications can be assigned by the Food and Drug Administration) medications and directed staff to administer medication as ordered, and document and monitor for side effects and effectiveness. The care plan directed staff to encourage R31 to express her feelings as needed, determine if problems seem to be related to external causes, and monitor for targeted behaviors. The care plan further directed staff to educate the resident and family of the risks of side effects and potential adverse effects of the medication. The Physician's Order, dated 06/28/24, directed staff to administer Ativan (an antianxiety medication), 0.5 milligrams (mg), 1 tablet, every four hours, PRN, for anxiety. The order lacked a stop date. The CP's Medication Regimen Review, dated August, September, October, and November 2024, documented the CP had no recommendations related to R31's PRN Ativan. On 12/03/24 at 08:30 AM, observation revealed R31 propelled her wheelchair down the hall to her room. On 12/03/24 at 03:00 PM, Administrative Nurse D stated the Consultant Pharmacist had not reported that the Ativan did not have a stop date. The facility's Medication Administration policy, dated 03/13/24, documented the Consultant Pharmacist would review each resident's medication regimen monthly. The Consultant Pharmacist would document in each resident's clinical record the findings, conclusions, and recommendations that result from monitoring the medication regimen. The Consultant Pharmacist would communicate to the physician prescriber, if different from the primary physician, and those involved in the resident's care any findings, conclusions, and recommendations that result from monitoring the medication regimen. The facility failed to ensure the CP identified and reported that R31's PRN Ativan lacked a stop date. This placed the resident at risk for inappropriate or unnecessary use of medications and related side effects. - The Electronic Medical Record (EMR) for R37 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and atrial fibrillation (rapid, irregular heartbeat). The Medicare 5-Day Minimum Data Set (MDS), documented R37 had severely impaired cognition and was dependent upon staff for showers and transfers. R37 required substantial assistance from staff for eating, toileting, dressing, and mobility. R31 had no behaviors and did not receive any medications. The Quarterly MDS, dated [DATE], documented R37 had severely impaired cognition, and was dependent upon staff for toileting, personal hygiene, dressing, and transfers. R37 required substantial assistance from staff with oral hygiene and partial assistance with mobility. The MDS documented R37 had verbal behaviors for one to three days, rejection of care for one to three days, other behaviors for one to three days, and did not receive any medications. R37's Care Plan, dated 06/24/24, documented R37 was at risk for medication adverse reactions related to Black Box Warning (BBW-highest safety-related warning that medications can have assigned by the Food and Drug Administration) medications and directed staff to administer medication as ordered, and document and monitor for side effects and effectiveness. The care plan further directed staff to educate the resident and family of the risks of side effects and potential adverse effects of the medication, encourage her to express her feelings, and monitor for sedation. The Physician's Order, dated 06/18/24, directed staff to administer Ativan (an antianxiety medication), 0.5 milligrams (mg), 1 tablet, every four hours, PRN, for restlessness. The order lacked a stop date. The Medication Regimen Review, dated July, August, September, October, and November 2024, documented the CP had no recommendations related to the PRN Ativan. On 12/03/24 at 08:45 AM, observation revealed R37 was in bed. She hollered for help> She had removed her oxygen tubing and held it in her hands. On 12/03/24 at 02:25 PM, Licensed Nurse (LN) G stated R37 was cognitively impaired and would often call her roommate names and holler out. LN G said R37 received antianxiety medication as needed. On 12/03/24 at 03:00 PM, Administrative Nurse D stated the Consultant Pharmacist had not reported that R37's Ativan did not have a stop date. The facility's Medication Administration policy, dated 03/13/24, documented the Consultant Pharmacist would review each resident's medication regimen monthly. The Consultant Pharmacist would document in each resident's clinical record the findings, conclusions, and recommendations that result from monitoring the medication regimen. The Consultant Pharmacist would communicate to the physician prescriber, if different from the primary physician, and those involved in the resident's care any findings, conclusions, and recommendations that result from monitoring the medication regimen. The facility failed to ensure the CP identified and reported that R37's PRN Ativan lacked a stop date. This placed the resident at risk for inappropriate or unnecessary use of medications and related side effects. - The Electronic Medical Record (EMR) for R52 documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), hypertension (high blood pressure), and obsessive-compulsive disorder (OCD- an anxiety disorder characterized by recurrent and persistent thoughts, ideas, and feelings of obsessions severe enough to cause marked distress, consume considerable time, or significantly interfere with the resident's occupational, social, or interpersonal functioning). The Admission Minimum Data Set (MDS), dated [DATE], documented R52 had intact cognition and was dependent upon staff for toileting. R52 required set-up assistance for ambulation, eating, and bathing. R52 was independent with mobility, dressing, personal hygiene, and transfers. R52 had no behaviors and received antidepressant medication. R52's Care Plan, dated 11/12/24, documented R52 was at risk for medication adverse reactions related to Black Box Warning (BBW-highest safety-related warning that medications can be assigned by the Food and Drug Administration) medications and directed staff to administer medication as ordered, and document and monitor for side effects and effectiveness. The care plan directed staff to monitor and document targeted behaviors, actions taken, and effectiveness and document in the progress notes. The Physician's Order, dated 11/08/24, directed staff to administer hydroxyzine (an antihistamine), 25 milligrams (mg), by mouth every 12 hours, as needed, for anxiety. The order lacked a stop date. The CP's Medication Regimen Review, dated November 2024 documented the CP had no recommendations related to R52's PRN hydroxyzine use. On 12/03/24 at 12:47 PM, observation revealed R52 propelled her wheelchair from the dining room and stopped to hug a staff member before she continued down the hall to her room. On 12/03/24 at 02:25 PM, Licensed Nurse (LN) G stated that R52 did not have any behaviors that she was aware of. LN G said R52 took the hydroxyzine if she had anxiety. On 12/04/24 at 10:00 AM Consultant GG stated he was unable to find a physician rationale for the as-needed hydroxyzine and stated they would have the physician provide the additional information. On 12/03/24 at 03:00 PM, Administrative Nurse D stated the Consultant Pharmacist had not reported the as-needed hydroxyzine and did not have a rationale or stop date. The facility's Medication Administration policy, dated 03/13/24, documented the Consultant Pharmacist would review each resident's medication regimen monthly. The Consultant Pharmacist would document in each resident's clinical record the findings, conclusions, and recommendations that result from monitoring the medication regimen. The Consultant Pharmacist would communicate to the physician prescriber, if different from the primary physician, and those involved in the resident's care any findings, conclusions, and recommendations that result from monitoring the medication regimen. The facility failed to ensure the CP identified and reported that R52 lacked a physician rationale for the use of PRN hydroxyzine for R52's anxiety with no stop date. This placed the resident at risk for inappropriate or unnecessary use of medications and related side effects. 32358 - R68's Electronic Medical Record (EMR) documented R68 had a diagnosis of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R68's Admission Minimum Data Set(MDS) dated [DATE] documented that R68 had a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R68 received an antianxiety (a class of medications that calm and relax people) medication during the observation period. R68's Care Plan, revised 10/24/24, instructed staff to administer medication as ordered. Staff were to monitor and document the side effects and effectiveness of the medications and monitor for symptoms of anxiety including excessive worry, angry outbursts, concerns that become overly distressful, the inability to rest or relax, perseveration of ideas, or repetitive statements. R68's Physician Order, dated 10/23/24 at 09:30 PM instructed staff to administer Ativan (antianxiety medication), 1 milligram (mg) every six hours as needed (PRN) for anxiety with an indefinite end date. The Consultant Pharmacist (CP) Regimen Review on 11/20/24 lacked evidence the pharmacist identified R68's PRN Ativan order did not have the required stop date. On 12/02/24 at 12:02 PM, observation revealed R68 sat quietly in a wheelchair in front of the activity room. On 12/03/24 at 03:50 PM, Administrative Nurse D verified the CP had not alerted the facility of the lack of a stop date for R68's PRN Ativan. The facility's Medication Administration Policy, revised 03/12/24, documented the CP would review each resident's medication regimen monthly and documented in each resident's clinical record the findings, conclusions, and recommendations that resulted from monitoring the medication regimen. The CP would communicate to the physician and those involved in the resident's care the findings, conclusions, and recommendations from monitoring the medication regimen. The facility failed to ensure the CP identified and reported to the facility that R68's PRN Ativan lacked the required stop date. This placed the resident at risk for unnecessary medication side effects. 26768 - R17's Electronic Medical Record (EMR) documented diagnoses of general muscle weakness, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), major depressive disorder (major mood disorder that causes persistent feelings of sadness), hypertension (HTN-elevated blood pressure), insomnia (inability to sleep), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and acute kidney failure. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had moderately impaired cognition, disorganized thinking, and inattention which occurred continually. The MDS documented that R17 required supervision to partial/moderate assistance with self-care and mobility. The MDS further documented R17 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), and antidepressant (a class of medications used to treat mood disorders). R17's Care Plan dated 05/22/24, documented R17 had a mood disorder related to anxiety, depression, and hallucinations (sensing things while awake that appear to be real, but the mind created). The plan directed staff to administer medications as ordered and monitor and document side effects and effectiveness. The plan further documented R17 used the antipsychotic medication, Haldol, for hallucinations. R17's Care Plan dated 06/10/24, directed staff to monitor for any depressive, anxiety, or psychosis symptoms. The Physician Orders dated 04/19/24 directed staff to administer haloperidol 1 milligram (mg) at bedtime for antipsychotics and venlafaxine extended release (Effexor) 150 mg every day for an antidepressant. The Consultant Pharmacist Review dated 04/24/24, 05/21/24, and 10/20/24 requested an update of diagnosis for the use of haloperidol and venlafaxine. R17's medical record lacked the physician's response to the Consultant Pharmacist's recommendation to address the lack of diagnoses for the use of haloperidol and venlafaxine. On 12/02/24 at 04:15 PM, observation revealed R17 in the dining room participating in a board game with another resident and staff member. On 12/04/24 at 07:50 AM, Administrative Nurse D and Consultant GG verified the physician had not written a proper diagnosis for haloperidol and venlafaxine or rationale for continued use of the psychotropic drug use. The facility's Medication Administration policy, dated 03/13/2024, stated the consultant pharmacist would review each resident's medication regimen monthly and communicate recommendations to the physician or prescriber. The facility failed to acknowledge and respond to the CP's recommendation to add an indication of use for R17's haloperidol and venlafaxine. This placed R17 at risk of inappropriate use of psychotropic medication and related side effects.

The facility had a census of 79 residents. The sample included 20 residents, with eight reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure a 14-day stop date or specified duration for Resident (R) 31, R37, R52, R68 and R391's ongoing as-needed (PRN) antianxiety (a class of medications that calm and relax people with excessive anxiety, nervousness, or tension) medication and failed to get an appropriate diagnosis for R17's Effexor (an antidepressant medication) and Haldol (an antipsychotic medication). This placed the residents at risk for unnecessary medications and related complications. Findings included: - The Electronic Medical Record (EMR), for R31 documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteomyelitis (local or generalized infection of the bone and bone marrow), pain, atrial fibrillation (rapid, irregular heartbeat), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R31 had intact cognition and was dependent upon staff for transfers. R31 required substantial assistance with toileting, showers, dressing, and mobility, and was independent with transfers. The MDS further documented R31 received antidepressant (a class of medications used to treat mood disorders), opioid (a class of controlled drugs used to treat pain), and hypoglycemic (less than normal amount of sugar in the blood) medications. R31 was depressed for seven to 11 days and did not have any behaviors. The Quarterly MDS, dated [DATE], documented R31 had intact cognition. R31 was dependent upon staff for transfers. R31 required substantial assistance with toileting, bathing, dressing, and mobility. The MDS further documented R31 received antidepressant and diuretic (a medication to promote the formation and excretion of urine) medications and had no behaviors. R31's Care Plan dated 07/08/24, documented R31 was at risk for medication adverse reactions related to Black Box Warning (BBW-highest safety-related warning that medications can be assigned by the Food and Drug Administration) medications and directed staff to administer medication as ordered, and document and monitor for side effects and effectiveness. The care plan directed staff to encourage R31 to express her feelings as needed, determine if problems seem to be related to external causes, and monitor for targeted behaviors. The care plan further directed staff to educate the resident and family of the risks of side effects and potential adverse effects of the medication. The Physician's Order, dated 06/28/24, directed staff to administer Ativan (an antianxiety medication), 0.5 milligrams (mg), 1 tablet, every four hours, PRN, for anxiety. The order lacked a stop date. On 12/03/24 at 08:30 AM, observation revealed R31 propelled her wheelchair down the hall to her room. On 12/03/24 at 02:25 PM, Licensed Nurse (LN) G stated R31 did not have any behaviors, was on hospice, and may need Ativan for her anxiety. On 12/03/24 at 02:45 PM, Certified Nurse Aide (CNA) M stated R31 had no behaviors and was very nice. On 12/03/24 at 03:00 PM, Administrative Nurse D stated she was unaware R31's Ativan did not have a 14-day stop date and said she would make sure that she contacted the physician to obtain an order for a stop date or rationale for continued use. The facility's Psychotropic Medication policy, dated 07/3124, documented the attending physician must certify that a psychotropic medication was necessary to treat a specific condition or behavior. Any resident admitted with a PRN psychoactive medication would have a 14-day stop date. The facility failed to ensure R31's Ativan had a 14-day stop date or specified duration with physician rationale for extended use. This placed the resident at risk for adverse medication side effects. - The Electronic Medical Record (EMR) for R37 documented diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and atrial fibrillation (rapid, irregular heartbeat). The Medicare 5-Day Minimum Data Set (MDS), documented R37 had severely impaired cognition and was dependent upon staff for showers and transfers. R37 required substantial assistance from staff for eating, toileting, dressing, and mobility. R31 had no behaviors and did not receive any medications. The Quarterly MDS, dated [DATE], documented R37 had severely impaired cognition, and was dependent upon staff for toileting, personal hygiene, dressing, and transfers. R37 required substantial assistance from staff with oral hygiene and partial assistance with mobility. The MDS documented R37 had verbal behaviors for one to three days, rejection of care for one to three days, other behaviors for one to three days, and did not receive any medications. R37's Care Plan, dated 06/24/24, documented R37 was at risk for medication adverse reactions related to Black Box Warning (BBW-highest safety-related warning that medications can have assigned by the Food and Drug Administration) medications and directed staff to administer medication as ordered, and document and monitor for side effects and effectiveness. The care plan further directed staff to educate the resident and family of the risks of side effects and potential adverse effects of the medication, encourage her to express her feelings, and monitor for sedation. The Physician's Order, dated 06/18/24, directed staff to administer Ativan (an antianxiety medication), 0.5 milligrams (mg), 1 tablet, every four hours, PRN, for restlessness. The order lacked a stop date. On 12/03/24 at 08:45 AM, observation revealed R37 was in bed. She hollered for help. She had removed her oxygen tubing and held it in her hands. On 12/03/24 at 08:5 AM, Certified Medication Aide (CMA) R stated R37 had a lot of behaviors, was combative with staff, and often yelled at her roommate for no reason. CMA R further stated that when R37 had behaviors she would notify the nurse. On 12/03/24 at 02:25 PM, Licensed Nurse (LN) G stated R37 was cognitively impaired and would often call her roommate names and holler out. LN G said R37 received antianxiety medication as needed. On 12/03/24 at 03:00 PM, Administrative Nurse D stated she was unaware R37's Ativan did not have a 14-day stop date and said she would make sure that she contacted the physician to obtain an order for a stop date or rationale for continued use. Administrative Nurse D further stated that R37's roommate's family had requested a room move due to R37's behavior. The facility's Psychotropic Medication policy, dated 07/3124, documented the attending physician must certify that a psychotropic medication was necessary to treat a specific condition or behavior. Any resident admitted with a PRN psychoactive medication would have a 14-day stop date. The facility failed to ensure R37's Ativan had a 14-day stop date or specified duration with a physician rationale for extended use. This placed the resident at risk for adverse medication side effects. - The Electronic Medical Record (EMR) for R52 documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), posttraumatic stress disorder (PTSD- a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress), hypertension (high blood pressure), and obsessive-compulsive disorder (OCD- an anxiety disorder characterized by recurrent and persistent thoughts, ideas, and feelings of obsessions severe enough to cause marked distress, consume considerable time, or significantly interfere with the resident's occupational, social, or interpersonal functioning). The Admission Minimum Data Set (MDS), dated [DATE], documented R52 had intact cognition and was dependent upon staff for toileting. R52 required set-up assistance for ambulation, eating, and bathing. R52 was independent with mobility, dressing, personal hygiene, and transfers. R52 had no behaviors and received antidepressant medication. R52's Care Plan, dated 11/12/24, documented R52 was at risk for medication adverse reactions related to Black Box Warning (BBW-highest safety-related warning that medications can be assigned by the Food and Drug Administration) medications and directed staff to administer medication as ordered, and document and monitor for side effects and effectiveness. The care plan directed staff to monitor and document targeted behaviors, actions taken, and effectiveness and document in the progress notes. The Physician's Order, dated 11/08/24, directed staff to administer hydroxyzine (an antihistamine), 25 milligrams (mg), by mouth every 12 hours, as needed, for anxiety. The order lacked a stop date. On 12/03/24 at 12:47 PM, observation revealed R52 propelled her wheelchair from the dining room and stopped to hug a staff member before she continued down the hall to her room. On 12/03/24 at 02:25 PM, Licensed Nurse (LN) G stated that R52 did not have any behaviors that she was aware of. LN g said R52 took the hydroxyzine if she had anxiety. On 12/03/24 at 02:45 PM, Certified Nurse Aide (CNA) M stated R52 had no behaviors. On 12/04/24 at 10:00 AM Consultant GG stated he was unable to find a physician rationale for the as-needed hydroxyzine and stated they would have the physician provide the additional information. On 12/03/24 at 03:00 PM, Administrative Nurse D stated she would ensure the required information for the hydroxyzine would be obtained from the physician along with a rationale for the use of the antihistamine for R52's anxiety. The facility's Psychotropic Medication Use policy, dated 02/22/24, documented that Psycho-pharmacologic medications are drugs that affect brain activities associated with mental processes and behaviors, Psychotropic medications are divided into four broad categories: anti-psychotic, anti-depressant, anti-anxiety, antihistamine, anti-convulsant, mood-altering drugs, and hypnotic drugs. Licensed nurses would be aware of the potential side effects of psychotropic medications and report any side effects to the resident's attending physician. The physician would have a documented clinical rationale for the medication. The facility failed to ensure a stop date for the PRN hydroxyzine used for its psychotropic qualities. This placed the resident at risk for unnecessary medications and related complications. 32358 - R68's Electronic Medical Record (EMR) documented R68 had a diagnosis of anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R68's Admission Minimum Data Set(MDS) dated [DATE] documented that R68 had a Brief Interview of Mental Status (BIMS) score of seven which indicated severely impaired cognition. The MDS documented that R68 received an antianxiety (a class of medications that calm and relax people) medication during the observation period. R68's Care Plan, revised 10/24/24, instructed staff to administer medication as ordered. Staff were to monitor and document the side effects and effectiveness of the medications and monitor for symptoms of anxiety including excessive worry, angry outbursts, concerns that become overly distressful, the inability to rest or relax, perseveration of ideas, or repetitive statements. R68's Physician Order, dated 10/23/24 at 09:30 PM instructed staff to administer Ativan (antianxiety medication), 1 milligram (mg) every six hours as needed (PRN) for anxiety with an indefinite end date. On 12/02/24 at 12:02 PM, observation revealed R68 sat quietly in a wheelchair in front of the activity room. On 12/03/24 at 03:50 PM, Administrative Nurse D verified that R68's PRN Ativan had a stop date of indefinite and she was unaware it required a specified stop date. The facility's Psychotropic Medication Use policy, dated 07/31/2024, stated the use of non-pharmacological interventions for psychiatric disorders and problem behaviors related to dementia would be attempted prior to and during the administration of antipsychotic medications. The physician's order for a psychotropic drug would include both a qualifying diagnosis for the drug and a list of specific target behaviors that the staff would monitor during the drug administration. The attending physician must certify that a psychotropic medication was necessary to treat a specific condition or behavior. The drug dosage must be periodically reduced with the goal of discontinuing it or replacing it with another less potent prescription. The facility failed to ensure R68's PRN Ativan had the required stop date. This placed the resident at risk for unnecessary medication side effects. 27168 - R391's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory, confusion), Down's syndrome (chromosomal abnormality characterized by varying degrees of mental retardation and multiple defects), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R391's Admission Minimum Data Set (MDS), dated [DATE], recorded R391 had severely impaired cognition. The MDS recorded she required extensive assistance from two staff with bed mobility and transfers. The MDS lacked documentation that R391 received an antianxiety medication during the observation period. R391's Care Plan, dated 12/02/24, recorded that R391 required extensive assistance with most activities of daily living (ADL) care. R391's Care Plan documented the resident received lorazepam (antianxiety medication) for anxiety. R391's Physician's Order, dated 11/16/24, directed the staff to administer lorazepam 0.5 milligrams (mg) via gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) every four hours as needed (PRN) for anxiety. The order lacked a stop date. R391's EMR lacked evidence of a specified duration which included a physician's rationale for the extended use of the PRN lorazepam. On 12/03/24 at 08:55 AM, observation revealed R391 lying in bed with the head of the bed elevated 30 degrees. Licensed Nurse (LN) I loosened the resident's abdominal binder and administered the resident's medication via the G-tube. On 12/03/24 at 03:00 PM, Administrative Nurse D verified R391 received lorazepam PRN, with a physician order date of 11/16/24. Administrative Nurse D verified the facility did not obtain the 14-day stop date or a reason for the continued use with a rationale and a specified duration. The Psychotropic Medication Use policy dated 5/31/2024, recorded the resident's need for the psychotropic medication would be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose can be lowered or discontinued. Both the physician and the nursing staff would evaluate the effectiveness of PRN or as-needed orders for psychotropic drugs to manage behaviors. Any resident admitted to the facility with an order for psychotropic medication would be accompanied by a taper order for a specific date within the first four months of admission. Any resident with a PRN psychotropic medication would have a 14-day stop date. Prior to the end of the 14-day period, the ordering practitioner would assess the resident's response to the PRN medication and would document a thoughtful risk-benefit rationale statement for continued use of the medication. If the assessment indicates continued use of the medication, a specific duration would be included in the re-order of the medication. The physician's order for the medication would include both a qualifying diagnosis for the drug and a list of targeted behaviors that the staff would monitor during the drug administration. The facility failed to obtain a stop date for R391's use of PRN lorazepam. This placed R391 at risk for adverse side effects from the continued use of psychotropic medications. 26768 - R17's Electronic Medical Record (EMR) documented diagnoses of general muscle weakness, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, asthma (a disorder of narrowed airways that causes wheezing and shortness of breath), major depressive disorder (major mood disorder that causes persistent feelings of sadness), hypertension (HTN-elevated blood pressure), insomnia (inability to sleep), schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), and acute kidney failure. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R17 had moderately impaired cognition, disorganized thinking, and inattention which occurred continually. The MDS documented that R17 required supervision to partial/moderate assistance with self-care and mobility. The MDS further documented R17 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), and antidepressant (a class of medications used to treat mood disorders). R17's Care Plan dated 05/22/24, documented R17 had a mood disorder related to anxiety, depression, and hallucinations (sensing things while awake that appear to be real, but the mind created). The plan directed staff to administer medications as ordered and monitor and document side effects and effectiveness. The plan further documented R17 used the antipsychotic medication, Haldol, for hallucinations. R17's Care Plan dated 06/10/24, directed staff to monitor for any depressive, anxiety, or psychosis symptoms. The Physician Orders dated 04/19/24 directed staff to administer haloperidol 1 milligram (mg) at bedtime for antipsychotics and venlafaxine (Effexor) extended-release 150 mg every day for antidepressant. R17's medical record lacked physician documentation of diagnoses for the use of haloperidol and venlafaxine. On 12/02/24 at 04:15 PM, observation revealed R17 in the dining room participating in a board game with another resident and staff member. On 12/04/24 at 07:50 AM, Administrative Nurse D and Consultant GG verified the physician had not written an actual diagnosis for haloperidol and venlafaxine or a rationale for continued use of the psychotropic drugs. The facility's Psychotropic Medication Use policy, dated 07/31/2024, stated the use of non-pharmacological interventions for psychiatric disorders and problem behaviors related to dementia would be attempted before and during the administration of antipsychotic medications. The physician's order for a psychotropic drug would include both a qualifying diagnosis for the drug and a list of specific target behaviors that the staff would monitor during the drug administration. The attending physician must certify that a psychotropic medication was necessary to treat a specific condition or behavior. The drug dosage must be periodically reduced with the goal of discontinuing it or replacing it with another less potent prescription. The facility failed to ensure an appropriate indication and the required physician documentation for the continued use of R7's haloperidol and venlafaxine, placing the resident at risk for unnecessary adverse side effects.

The facility had a census of 79 residents. The sample included 20 residents, with two reviewed for dignity. Based on observation, record review, and interview, the facility failed to promote dignity for Resident (R)29, when staff referred to the resident as a feeder and stood to assist the resident with her meal. This placed R29 at risk for impaired dignity. Finding included: - The Electronic Medical Record (EMR) for R29 documented diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), major depressive disorder (major mood disorder that causes persistent feelings of sadness), delusional disorder (untrue persistent belief or perception held by a person although evidence shows it was untrue), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R29 had severely impaired cognition. R29 was dependent on staff for toileting, dressing, mobility, and transfers. R29 required assistance with eating. R29 had unclear speech and rarely made herself understood. She had highly impaired vision and adequate hearing. R29's Care Plan, dated 10/28/24, documented R29 had impaired cognition and thought process due to diagnoses of Alzheimer's dementia, and chronic disease. The care plan directed the staff to offer assistance with her needs. On 12/04/24 at 11:45 AM, observation revealed R29 sat in her Broda chair (specialized wheelchair with the ability to tilt and recline). Certified Nurse Aide (CNA) O pushed the resident from her room to the dining room. CNA O stated to the surveyor seated at the resident's table in the small dining room This is the feeder table and told the surveyor she could sit at the feeder table. CNA O stated the facility had a few feeders that sit there to eat their meals and staff assisted them to eat. On 12/02/24 at 12:22 PM, observation revealed CNA N stood beside R29 and assisted her in eating her pureed meal for approximately eight minutes. Administrative Nurse F came into the dining room and told CNA N she needed to sit down when she assisted the resident in eating. Approximately five minutes later Administrative Nurse D came to the dining room table and counseled CNA N, in front of the residents, staff, and survey team, that she needed to sit when she assisted the residents to eat because it was a dignity issue to stand beside the resident. On 12/02/24 at 03:10 PM, Administrative Nurse D stated the staff should not have called R29 a feeder as that was not dignified. Administrative Nurse D said she would educate the staff about not calling the residents feeders. The facility's Resident Rights policy, dated 12/08/23, documented each resident had the right and would be afforded the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility without interference, coercion, discrimination, or reprisal. No staff member or contracted provider of care would hamper, compel, treat differently, or retaliate against a resident for exercising Resident Rights. Each resident would be treated with dignity, would be allowed, and encouraged to make choices and to be free from neglect and misappropriation of personal property. The facility failed to promote care for R29 in a manner to maintain and enhance dignity and respect. This placed R29 at risk for impaired dignity.

The facility had a census of 79 residents. The sample included 20 residents with three residents reviewed for Center for Medicare and Medicaid Services (CMS) Beneficiary Liability notices. Based on record review and interview, the facility failed to provide the CMS Form 10055, Advanced Beneficiary Notice (ABN), to the resident or their representative for Resident (R) 429. This placed the residents at risk for uninformed decisions regarding skilled services. Findings included: - The Medicare ABN form informed the beneficiaries Medicare may not pay for future skilled therapy and did not provide an estimated cost to continue their services. The form included options for the beneficiary to (1) receive specified services listed, and bill Medicare for an official decision on payment. I understand if Medicare does not pay, I will be responsible for payment, but can appeal to Medicare. (2) receive therapy listed, but do not bill Medicare, I am responsible for payment for payment of services. (3) I do not want the listed services. R429's clinical record lacked evidence the facility provided CMS form 10055 when the resident's skilled services ended on 09/15/24. On 12/02/24 at 02:35 PM, Administrative Staff B stated R429 was admitted to the facility on skilled care; when it was time for him to be discharged from skilled care, Administrative Staff B contacted the resident's representative by phone. Administrative Staff B stated that R429's representative wanted R429 to stay in the facility for a few more days due to a death in the family. Administrative Staff B said she told R429's representative the room price would increase but verified the room prices and provision of information was not provided on the CMA ABN 10055. On 12/04/24 at 09:40 AM, Administrative Staff A verified that R429 was not provided the ABN 10055. Upon request, the facility did not provide an ABN Policy. The facility failed to provide R429 with the ABN form CMS 10055 as required. This placed the residents at risk for uninformed decisions regarding skilled services.

The facility had a census of 79 residents. The sample included 20 residents with two reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 39 and R31. This placed the residents at risk for inadequate end-of-life care. Findings included: - R39's Electronic Health Record (EHR) revealed diagnoses of severe protein-calorie malnutrition (does not eat enough protein and calories to meet nutritional needs), acute kidney failure (the kidneys lose the ability to remove waste and balance fluids,) and dysphagia (swallowing difficulty). R39's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R39 had a Brief Interview for Mental Status score of three which indicated severe cognitive impairment. The MDS recorded he required extensive assistance from two staff with bed mobility, transfers, and activities of daily living (ADLs). The MDS documented the resident received hospice services. R39's Care Plan, dated 11/20/24, recorded R39 required extensive assistance with most ADL care. R39's Care Plan documented the resident was admitted to [hospice services] on 08/09/24. The care plan directed the staff to administer the medications ordered and notify the physician if there is breakthrough pain. The care plan lacked instruction on the services provided by hospice including the frequency and type of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and the hospice contact information. A review of R39's clinical record revealed the resident was admitted to hospice care on 08/09/24. The facility had a plan of care provided by the hospice in a communication book. On 12/03/24 at 10:30 AM, R39 was dressed and sat in a Broda (specialized wheelchair with the ability to tilt and recline) chair in his room. On 12/03/24 at 01:50 PM, Administrative Nurse D and Nurse Consultant GG verified the facility lacked specific information on the facility care plan that coordinated with the hospice care plan. The End of Life Palliative Care and Hospice Care policy, dated 12/07/2023, documented bereavement counseling provided by hospice providers would be supervised by the hospice social worker or Chaplin for provision of pre-death assessment and counseling for residents and family members with bereavement staff providing support following death in collaboration with facility social service, chaplain, and nursing staff. A comprehensive and timely interdisciplinary assessment of the resident and family forms the basis of end-of-life care (palliative). The interdisciplinary team completes an initial comprehensive assessment and subsequent re-evaluation through the resident and family interviews, review of medical and other available records, discussion with other providers, physical examinations and assessment, along with relevant laboratory and/or diagnostic tests or procedures. The comprehensive assessment reoccurs on a regular basis and at least quarterly and with any significant change in the resident's status or change in the resident and/or family's goals. The care plan is based on the identified and expressed preferences, values, goals, and needs of the resident and family and is developed with professional guidance and support for resident-family decision-making. The care plan is based on an ongoing assessment and reflects goals set by the resident, family, or resident's physician. The Interdisciplinary Team (IDT) provides services to the resident and the family consistent with the care plan. In addition to Chaplin's, nurses, physicians, and social workers, other therapeutic disciplines who provide palliative care services to residents and family members may include but are not limited to nursing assistants, Nutrition and Registered Dieticians, Occupational therapists, Respiratory Therapist, Pharmacists, Physical therapist, Psychologist, Speech and language pathologist. The IDT team communicates (at least weekly or more often as required by the clinical situation) to plan, review, evaluate, and update the care plan, with input from both the resident and family. The facility failed to coordinate care between the facility and the hospice provider for R39, who received hospice services. This deficient practice placed him at risk for inadequate end-of-life care. 32360 - The Electronic Medical Record (EMR) for R31 documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteomyelitis (local or generalized infection of the bone and bone marrow), pain, atrial fibrillation (rapid, irregular heartbeat), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R31 had intact cognition and was dependent upon staff for transfers. R31 required substantial assistance with toileting, showers, dressing, and mobility, and was independent with transfers. The MDS further documented R31 received antidepressant (a class of medications used to treat mood disorders), opioid (a class of controlled drugs used to treat pain), and hypoglycemic (less than normal amount of sugar in the blood) medications. R31 was depressed for seven to 11 days and was not on hospice. The Quarterly MDS, dated [DATE], documented R31 had intact cognition. R31 was dependent upon staff for transfers. R31 required substantial assistance with toileting, bathing, dressing, and mobility. The MDS further documented R31 received antidepressant and diuretic (a medication to promote the formation and excretion of urine) medications and was on Hospice services. R31's Care Plan, dated 07/01/24, documented R31 was admitted to hospice and directed staff to anticipate and meet her needs and communicate with the hospice and the physician. The care plan directed the staff to work together as a team and ensure the resident was comfortable and free of pain. The care plan documented the hospice nurse and charge nurse would work together to ensure R31 was comfortable and pain-free; the hospice staff would bathe R31. The hospice would assist in setting palliative goals and directed staff to notify the hospice and the physician of changes in condition. The care plan lacked instruction on the services provided by hospice including the frequency and type of support visits, supplies and medical equipment provided by hospice, medications covered by hospice, and the hospice contact information. A review of R31's clinical record revealed the resident was admitted to hospice care on 06/28/24. The facility had a plan of care provided by the hospice in a communication book. On 12/03/24 at 08:30 AM, observation revealed R31 propelled her wheelchair down the hall to her room. On 12/03/24 at 02:00 PM, Administrative Nurse D and Nurse Consultant GG verified the facility lacked specific information on the facility care plan that coordinated with the hospice care plan. The End of Life Palliative Care and Hospice Care policy, dated 12/07/2023, documented bereavement counseling provided by hospice providers would be supervised by the hospice social worker or Chaplin for provision of pre-death assessment and counseling for residents and family members with bereavement staff providing support following death in collaboration with facility social service, chaplain, and nursing staff. A comprehensive and timely interdisciplinary assessment of the resident and family forms the basis of end-of-life care (palliative). The interdisciplinary team completes an initial comprehensive assessment and subsequent re-evaluation through the resident and family interviews, review of medical and other available records, discussion with other providers, physical examinations, and assessment, along with relevant laboratory and/or diagnostic tests or procedures. The comprehensive assessment reoccurs on a regular basis and at least quarterly and with any significant change in the resident's status or change in the resident and/or family's goals. The care plan is based on the identified and expressed preferences, values, goals, and needs of the resident and family and is developed with professional guidance and support for resident-family decision-making. The care plan is based on an ongoing assessment and reflects goals set by the resident, family, or resident's physician. The Interdisciplinary Team (IDT) provides services to the resident and the family consistent with the care plan. In addition to Chaplin's, nurses, physicians, and social workers, other therapeutic disciplines who provide palliative care services to residents and family members may include but are not limited to nursing assistants, Nutrition and Registered Dieticians, Occupational therapists, Respiratory therapist, Pharmacist, Physical therapist, Psychologist, Speech and language pathologist. The IDT team communicates (at least weekly or more often as required by the clinical situation) to plan, review, evaluate, and update the care plan, with input from both the resident and family. The facility failed to coordinate care between the facility and the hospice provider for R31, who received hospice services. This deficient practice placed him at risk for inadequate end-of-life care.

The facility had a census of 79 residents. The sample included 20 residents, with five reviewed for behaviors. Based on observation, record review, and interview, the facility failed to complete a trauma-informed care assessment and develop a trauma-informed plan of care for Resident (R) 52 and R71, who had a diagnosis of post-traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress). This placed the residents at risk for unmet behavioral and mental health needs. Findings included: - The Electronic Medical Record (EMR) for R52 documented diagnoses of PTSD, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and obsessive-compulsive disorder (OCD- an anxiety disorder characterized by recurrent and persistent thoughts, ideas, and feelings of obsessions severe enough to cause marked distress, consume considerable time, or significantly interfere with the resident's occupational, social, or interpersonal functioning). The Admission Minimum Data Set (MDS), dated [DATE], documented R52 had intact cognition and was dependent upon staff for toileting. R52 required set-up assistance for ambulation, eating, and bathing. R52 was independent with mobility, dressing, personal hygiene, and transfers. R52 had no behaviors and received antidepressant medication. The MDS documented the resident had depression, anxiety, and PTSD. R52's EMR lacked evidence a trauma-informed care assessment was completed for R52. R52's Care Plan, dated 11/12/24, documented R52 was at risk for medication adverse reactions related to Black Box Warning (BBW-highest safety-related warning that medications can be assigned by the Food and Drug Administration) medications and directed staff to administer medication as ordered, and document and monitor for side effects and effectiveness. The care plan directed staff to monitor and document targeted behaviors, actions taken, and effectiveness and document in the progress notes. The care plan lacked interventions related to R52's PTSD to identify triggers and prevent re-traumatization. The Physician's Order, dated 11/08/24, directed staff to administer hydroxyzine (an antihistamine), 25 milligrams (mg), by mouth every 12 hours, as needed, for anxiety. The Physician's Order, dated 11/09/24, directs staff to administer sertraline (an antidepressant medication), 50 mg, by mouth, daily for depression. On 12/03/24 at 12:47 PM, observation revealed R52 propelled her wheelchair from the dining room and stopped to hug a staff member before she continued down the hall to her room. On 12/03/24 at 02:03 PM, Administrative Nurse D stated she was unaware that R52 had PTSD and did not know what assessments were required. Administrative Nurse D further stated she would make sure an assessment was completed and the triggers placed on the resident's care plan. On 12/03/24 at 02:10 PM, Administrative Nurse E stated she did not know a trauma-informed care assessment needed to be completed for R52 and stated she would make sure R52's triggers were placed on her care plan. On 12/03/24 at 02:25 PM, Licensed Nurse (LN) G stated she was unaware if there were any residents in the facility that had PTSD and stated she would like to know if there were any so she could find out what the triggers were for that resident or residents. On 12/03/24 at 02:45 PM, Certified Nurse Aide (CNA) M stated she thought R52 had PTSD but did not know what the triggers were or if there were any other residents in the facility with PTSD. The facility's Trauma Informed Care policy, dated 07/12/16, documented that, as an organization, the facility was committed to implementing trauma-informed approaches to the care provided and the organizational culture created for the residents of this facility. The policy documented incorporating a trauma-informed approach in the of the residents offers all residents a high quality of life, health, and well-being. Assessments would be completed by staff members or residents themselves to determine the history of past traumatic life events. The facility failed to complete a trauma-informed care assessment and develop a trauma-informed plan of care for R52, who had a diagnosis of PTSD. This placed R52 at risk for unmet behavioral and mental health needs. - The Electronic Medical Record (EMR) for R71 documented diagnoses of PTSD, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear, auditory hallucinations (sensing things while awake that appear to be real, but the mind created), and schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought). The Admission Minimum Data Set (MDS), dated [DATE], documented that R71 had intact cognition and required partial assistance from staff for personal hygiene, mobility, and dressing. R71 required supervision with toileting, transfers, and ambulation. R71 had no behaviors, had hallucinations and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), and sometimes isolated herself. The assessment documented R71 received antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) and antidepressant medications daily. The MDS documented the resident had depression, anxiety, schizophrenia, and PTSD. R71's EMR lacked evidence a trauma-informed care assessment was completed for R71 after admission. R71's Care Plan, dated 10/29/24, documented R71 was at risk for medication adverse reactions related to a Black Box Warning (BBW-highest safety-related warning that medications can have assigned by the Food and Drug Administration) medications and directed staff to administer medication as ordered, and document and monitor for side effects and effectiveness. The care plan directed staff to monitor and document any changes in behaviors, mood, and cognition. The care plan directed staff to consult with the pharmacy and physician to consider dosage reduction when clinically appropriate at least quarterly. The care plan lacked interventions related to R52's PTSD to identify triggers and prevent re-traumatization. The Physician's Order, dated 10/17/24, directed staff to administer Trintellix (an antidepressant), 20 milligrams mg), by mouth, daily, for depression. The Physician's Order, dated 11/18/24, directed staff to administer clozapine (an antipsychotic), 100 mg, by mouth, daily, and 150 mg, at bedtime, for schizophrenia. On 12/03/24 at 08:30 AM, observation revealed R71 ambulated with the use of her walker in the hallway after breakfast. On 12/03/24 at 02:03 PM, Administrative Nurse D stated she was unaware that R71 had PTSD and did not know what assessments were required. Administrative Nurse D further stated she would make sure an assessment was completed and the triggers placed on the resident's care plan. On 12/03/24 at 02:10 PM, Administrative Nurse E stated she did not know a trauma-informed care assessment needed to be completed for R71 and stated she would make sure R71's triggers were placed on her care plan. On 12/03/24 at 02:25 PM, Licensed Nurse (LN) G stated she was unaware if there were any residents in the facility that had PTSD and stated she would like to know if there were any so she could find out what the triggers were for that resident or residents. On 12/03/24 at 02:45 PM, Certified Nurse Aide (CNA) M stated she did not know if R71 had PTSD. The facility's Trauma Informed Care policy, dated 07/12/16, documented that, as an organization, the facility was committed to implementing trauma-informed approaches to the care provided and the organizational culture created for the residents of this facility. The policy documented incorporating a trauma-informed approach in the of the residents offers all residents a high quality of life, health, and well-being. Assessments would be completed by staff members or residents themselves to determine the history of past traumatic life events. The facility failed to complete a trauma-informed care assessment and develop a trauma-informed plan of care for R71, who had a diagnosis of PTSD. This placed R71 at risk for unmet behavioral and mental health needs.

The facility had a census of 79 residents. The sample included 20 residents in which two residents were reviewed for urinary tract infections (UTI-an infection in any part of the urinary system). Based on observation, record review, and interview, the facility failed to provide services consistent with the standards of care for Resident (R) 7's urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag). This placed R7 at risk for catheter-related complications and UTI. Findings included: - R7's Electronic Medical Record (EMR) documented diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), neuromuscular dysfunction of the bladder (the muscles that control the flow of urine out of the body do not relax and prevent the bladder from fully emptying), and a history of UTIs. The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS documented R7 was dependent on staff for toilet hygiene and transfers and had a urinary catheter. R7's Care Plan, dated 05/21/24, stated R7 had a suprapubic catheter (urinary bladder catheter inserted through the abdomen into the bladder) related to a neurogenic bladder. The care plan directed staff to provide acetic acid (vinegar) flushes per physician orders initiated on 10/10/24. The plan directed staff to change the catheter as ordered and monitor and document for pain or discomfort due to the catheter, initiated 05/21/24. Staff were to monitor, record, and report signs and symptoms of UTI to the physician, initiated 05/21/24. The plan directed staff to perform catheter care per facility policy every shift and provide a privacy bag for gravity bag when appropriate, initiated 05/21/24. The care plan lacked guidance to use Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). The Physician Order dated 05/02/24, directed staff to change the suprapubic catheter every month. The Physician Order dated 07/03/24, directed staff to provide catheter care every shift and as needed. The Physician Order dated 10/29/24 directed staff to continue precautions per facility protocol and await the final lab culture report. Due to symptoms, start Rocephin (an antibiotic) 1 gram (gm), intermuscular (IM) for three days; change catheter after R7 had been on antibiotics for a day, and provide catheter care per facility protocol. The Advanced Registered Nurse Practitioner Progress Note, dated 11/05/24, documented a history of multiple sclerosis, overactive bladder, and frequent UTIs. The note recorded that a catheter was in place with dark urine for a neurogenic bladder. The note directed to provide catheter care per facility protocol and continue precautions per facility protocol. On 12/02/24 at 01:42 PM, observation revealed Certified Nurse Aide (CNA) Q washed her hands and applied gloves but did not don a gown. CNA Q emptied R7's urinary drainage bag into a urinal. CNA Q allowed the drainage port tip to touch the urine in the container. The urine output measured 2000 millimeters (ml). CNA Q removed the gloves and washed her hands, gloved them again, then unattached the drainage port and wiped it with a moist wipe. CNA Q stated they did not have alcohol wipes. On 12/02/24 at 04:18 PM, observation revealed R7 sat in a wheelchair in the dining room with the catheter drainage bag in a privacy bag. R7's catheter tubing rested on the floor. On 12/03/24 at 07:40 AM, observation revealed R7 sat in a wheelchair at a dining table with the catheter drainage bag under her chair in a privacy bag. Approximately five inches of the catheter tubing was touching the bare floor. At 08:13 AM, R7 self-propelled her wheelchair from the dining room to her room with approximately five to six inches of catheter tubing dragging on the floor. On 12/03/24 at 01:10 PM, observation revealed R7 sat in a wheelchair in her room with approximately five inches of catheter tubing on the floor. On 12/03/24 at 12:30 PM, CNA Q stated the facility had not instructed her to use personal protective equipment (PPE) for EBP when providing catheter care. On 12/03/24 at 02:22 PM, Administrative Nurse E, Consultant GG, and Administrative Nurse D verified the facility had not initiated EBP due to a lack of understanding regarding the requirements. The facility's Foley Catheter Care policy, dated 12/07/23, stated the purpose of catheter care was to prevent possible urinary tract infections from bacteria. The policy stated the catheter and drainage bag should be kept as a closed system with the drainage bag kept at a lower level than the bladder and the drainage bag should be emptied at the end of each shift and as needed. The facility failed to provide services consistent with the standards of care for R7's urinary catheter. This placed R7 at risk for catheter-related complications and UTI.

The facility had a census of 79 residents. The sample included 20 residents, with one reviewed for hospitalization . Based on observation, record review, and interview, the facility failed to notify the State Long Term Care Ombudsman (LTCO) for Resident (R) 31's facility-initiated discharge to the hospital. This placed R31 at risk for impaired rights. Findings included: - The Electronic Medical Record (EMR) for R31 documented diagnoses of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), osteomyelitis (local or generalized infection of the bone and bone marrow), pain, atrial fibrillation (rapid, irregular heartbeat), and peripheral vascular disease (PVD- slow and progressive circulation disorder causing narrowing, blockage, or spasms in a blood vessel). The Medicare 5-Day Minimum Data Set (MDS), dated [DATE], documented R31 had intact cognition and was dependent upon staff for transfers. R31 required substantial assistance with toileting, showers, dressing, and mobility, and was independent with transfers. The MDS further documented R31 received antidepressant (a class of medications used to treat mood disorders), opioid (a class of controlled drugs used to treat pain), and hypoglycemic (less than normal amount of sugar in the blood) medications. R31 was depressed for seven to 11 days and did not have any behaviors. The Quarterly MDS, dated [DATE], documented R31 had intact cognition. R31 was dependent upon staff for transfers. R31 required substantial assistance with toileting, bathing, dressing, and mobility. The MDS further documented R31 received antidepressant and diuretic (a medication to promote the formation and excretion of urine) medications and had no behaviors. R31's Care Plan dated 07/08/24, documented R31 was at risk for medication adverse reactions related to Black Box Warning (BBW-highest safety-related warning that medications can be assigned by the Food and Drug Administration) medications and directed staff to administer medication as ordered, and document and monitor for side effects and effectiveness. The care plan directed staff to encourage R31 to express her feelings as needed, determine if problems seem to be related to external causes, and monitor for targeted behaviors. The care plan further directed staff to educate the resident and family of the risks of side effects and potential adverse effects of the medication. The Nurse's Notes, dated 06/25/24 at 01:12 PM, documented the nurse entered R31's room and saw R31's head lying on her meal tray. The nurse attempted to wake up R31 and she had a blank stare, mumbled words, and was limp. The note further documented the nurse informed the physician and obtained R31's blood sugar, and it was 71 milligrams per deciliters (. The family requested R31 to be seen at the hospital. R31's EMR lacked documentation staff notified the LTCO of the resident's discharge from the facility. On 12/03/24 at 01:48 PM, Social Service X stated she had not been employed in June when R31 was sent to the hospital. Social Service X supplied documentation sent to the LTCO of the residents who had been discharged for the last few months and verified R31's discharge was not sent to the LTCO. On 12/03/24 at 02:00 PM, Administrative Nurse D stated that R31's hospital discharge should have been sent to the LTCO and the person responsible for sending information to the LTCO no longer worked at the facility. The facility's Notifying Resident of Facility-Initiated Discharge policy, dated 07/31/24, documented the facility would notify the State Long Term Care Ombudsman of a facility-initiated transfer/discharge at the same time the resident/representative was notified by providing the LTCO of a copy of the transfer/discharge letter. The facility failed to notify the LTCO of R31's facility-initiated discharge to the hospital. This placed the resident at risk for impaired rights.

The facility had a census of 79 residents. The sample included 20 residents. Based on observation, record review, and interview the facility failed to ensure an environment free from accident hazards when staff left a container of toilet bowl cleaner, a container of Comet, two aerosol spray deodorants, and a container of Virex in an unlocked wooden cabinet. This placed the two cognitively impaired, independently mobile residents at risk for preventable accidents or injuries. Findings included: - On 12/02/24 at 11:10 AM, observation in the 200-hall quiet area located by the visitor bathroom revealed three unlocked bottom doors of a wooden cabinet that contained the following: A one-quart container of the Works toilet bowl cleaner. Observation revealed the label read: causes skin burns and irreversible eye damage. Harmful if swallowed or absorbed through the skin. Do not get in the eyes, on skin, or on clothing. Wear goggles or safety glasses, protective clothing, and rubber (or chemical-resistant) gloves. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, using tobacco, or using the toilet. Remove contaminated clothing and wash clothing before reuse. Do not breathe vapor or fumes. Keep out of reach of children. A 1.31-pound (lb.) container of Comet (powdered disinfectant cleaner). Further observation revealed the label read: moderately irritating to eyes, skin, and mucous membranes. Avoid contact with eyes, skin, or clothing. Harmful if swallowed or inhaled. Avoid breathing vapor. Remove and wash contaminated clothing before reuse. Wash thoroughly with soap and water after handling and before eating, drinking, chewing gum, or using tobacco. Do not mix with products that contain ammonia or dangerous fumes. Two aerosol spray deodorants. Observation revealed the label read: For external use only. Keep out of reach of children. If accidentally swallowed get medical help or contact a Poison Control Center right away. Do not use it on broken skin or irritated skin. A half-full 946 milliliter (ml) container of Virex (disinfectant cleaner). Further observation revealed the label read keep out of reach of children. On 12/02/24 at 11:15 AM, Maintenance Staff (MS) V verified the above findings and stated the chemicals should be kept in a locked housekeeping cart. MS V removed the items and gave them to the housekeeper, who locked them in her cart. On 12/04/24 at 10:10 AM, Administrative Staff A stated he expected staff to store chemicals in a locked cabinet. The facility's Chemical Storage Policy, revised 03/12/24, documented that all chemicals that are deemed hazardous to residents would be stored in a locked area or used under supervision. This is defined as any chemical that would cause harm or stated to keep away from children. The facility failed to ensure an environment free from accident hazards when staff stored harmful chemicals in an unlocked cabinet. This placed the two cognitively impaired, independently mobile residents at risk for preventable accidents or injuries.

The facility census totaled 88 residents, with three residents in the sample and reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide a safe environment for one resident by the failure to implement interventions to prevent repeated falls with major injury for Resident (R) 2, who had a fall that resulted in a fractured wrist. Findings included: - R2's Physician orders revealed the following diagnoses included chronic respiratory failure, alcoholic cirrhosis of liver (chronic degenerative disease of the liver) with ascites (abnormal fluid buildup in the abdominal cavity), congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R2's Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of seven, indicating severely impaired cognition. The resident had no behaviors and used a wheelchair for mobility. The resident was independent with toileting, personal hygiene, and ambulation. The resident was able to bend over and pick items off the ground without difficulty. The resident had no toileting plan and was continent of bladder and bowel. The resident had no shortness of breath. She had a terminal diagnosis. R2 had one fall since admission with no injury. Medications included antipsychotic (class of medications used to treat major mental conditions which cause a break from reality), antianxiety (class of medications that calm and relax people), antidepressant (class of medications used to treat mood disorders), diuretics (medication to promote the formation and excretion of urine), and opioid pain medications. The resident required the use of oxygen and received hospice services. No change of condition assessment done to reflect the residents current status including multiple falls with a fracture to the arm. The Care Area Assessments (CAA) dated 06/05/25 revealed the following: The Cognitive Loss/Dementia CAA revealed R2 was alert and oriented and could make her needs known to staff without difficulty. She was non-compliant at times with staff during cares. Staff were to provide redirection as needed. R2 could participate in daily cares and activities with minimal difficulty. Staff should always encourage the use of the call light and place it within reach. The Functional Abilities CAA documented R2 required moderate assistance with transfers and mobility and was dependent on staff for bathing. The Urinary Incontinence/Indwelling Catheter CAA documented the resident required supervision assistance with toileting and was continent of urine. The Falls CAA documented the resident was at risk for falls due to weakness, decreased mobility, medication use, history of falls, and a recent admit to hospice. She required moderate assistance with cares, transfers, and mobility. She reported a history of falls at home prior to admission and had one non-injury fall since admission. Staff encouraged the resident to use the call light when she needed assistance and place the call light within reach. Staff provided non-slip footwear for the prevention of falls. The Psychotropic Drug Use CAA documented the resident had a history of depression and received duloxetine (medication used to treat depression) for management of depression. She had a history of anxiety and received alprazolam (medication used to treat antianxiety) for management of anxiety. She had a history of insomnia and received Seroquel (antipsychotic) for management. She had no signs of depression, anxiety, or insomnia. Staff would monitor for signs of depression, anxiety, and insomnia every shift. She was free from adverse effects of antidepressant, antianxiety, and antipsychotic medication use. Staff were to monitor for adverse effects of medication use every shift. Review of the Fall Risk assessment dated [DATE] revealed the resident had a high risk for falls. R2' s fall Care Plan, dated 06/06/24, revealed the resident had a risk for falls related to impaired vision and poor judgement. Staff were to assist the resident to meals as tolerated and were to assist with bed mobility and transfers as necessary. The Charge Nurse was to monitor for side effects of medication that may increase fall risks and notify the physician. The care plan lacked guidance related to her incontinence. R2 had a fall on 06/05/24 and the intervention used was staff educated the family to notify staff for assistance and not to help or move the resident. R2 had a fall on 06/12/24. Interventions was that staff sent R2 to the hospital/ER. Staff was to place a fall mat at the resident's bedside and remove slippers from the resident's room, R2 was to wear non-skid socks and or shoes with grip on the bottom (family would provide). The date initiated in the care plan was 06/13/24. R2 had a fall on 06/27/2024. Intervention for the fall was staff rearranged the furniture in the resident's room. R2 would become aggressive with staff when they attempted to redirect her when she sat and/or crawled on the floor. Intervention was staff were to step away and attempt later, and/or attempt to redirect with another staff member, dated 07/01/2024. R2 had a fall on 07/08/24. Intervention was staff replaced/shortened the oxygen tubing due to safety. Hospice/Physician were to review R2's medications, dated 07/09/24. Revision of the fall care plan on 07/29/2024 included staff removed the fall mat due to the resident tripped over it. The Nurse's notes dated 06/05/2024 at 07:30 PM, revealed a family member reported the resident fell to her buttocks in her room. Family members informed staff they picked the resident up themselves from the floor and family reported to staff she did not hit her head. The resident denied pain or discomfort. Range of motion (movement of all joints) within normal limit. Staff educated the family to not move the resident if she fell . The nurse's notes lacked root cause of her fall to implement an intervention that caused R2's fall. The Fall Investigation dated 06/05/24 at approximately 11:10 PM, revealed staff called the charge nurse to the resident's room. The resident was in the bathroom on the floor, with her feet out in front of her and an unspecified type of walker beside on her left side and unlocked. There was feces (bowel movement) on the floor and feces and toilet paper in the toilet. Two staff assisted the resident to stand with a gait belt to a wheelchair, then assisted R2 to her recliner. R2 stated she missed her walker while attempting to sit down and fell to the floor. R2 denied hitting her head. ROM was normal. R2 reported she needed to go to the bathroom. The facility lacked a root cause analysis and an intervention for the fall. The Nurse's notes dated 06/10/24 at 03:51 PM, revealed during the weekly skin assessment, R2 had blanchable bruising to her coccyx and left hip from a recent fall. The Fall Investigation dated 06/12/24 at 05:48 PM, nursing staff heard a loud noise coming from the resident's room. Staff went to check on the resident and could not open her door. The resident was able to move away from the door enough for staff to enter. Staff found the resident on the floor, crying and complaining of pain. The right arm/wrist showed an obvious deformity. The resident pain assessed the pain 10/10. Staff had R2 transferred to the emergency room for evaluation and treatment. The root cause determined was R2 was non-compliant at times. She received medication that heavily medicated her, and she removed her O2 at times. The Nurse's notes dated 06/12/24 at 11:16 PM, revealed the resident returned to the facility at 10:30 PM. R2 had a wrist fracture, and her right hand was in a cast. The Nurse's notes dated 06/17/24 at 09:19 PM, revealed the resident had a witnessed fall, by her caregiver who stood in the hall, by her room. She sat on her buttocks and did not hit her head. The facility lacked a root cause analysis or intervention to prevent further falls. The Nurse's notes dated 06/27/24 at 01:55 AM, revealed a Certified Nursing Assistant (CNA) reported the resident was on the floor at 03:20 AM. R2 was on the floor with only her T-shirt on, her shorts and brief were in the bathroom doorway. She had no shoes or socks on. There was a puddle of urine in front of the toilet. The resident was not making enough coherent words to make the nurse understand what she had been doing. No injury. The Fall Investigation dated 06/27/24 at 03:04 AM, CNA reported the resident was on the floor. Upon entering the room, the resident observed sitting on the floor in front of her bed facing her bed with her feet near the frame of the bed. The resident's side table was sitting to her right, just wearing a T-shirt, her shorts and brief were in the doorway of the bathroom and there was a puddle of urine on the bathroom floor in front of the toilet. Resident was assessed for injuries. No injury. Resident was not talking coherently enough for nurse to understand what happened. Interventions included the resident reeducated to use her call-light when needing to go to the bathroom. The Nurse's notes dated 07/08/24, a physician visit revealed the resident was on the floor of her room. She reported that she tried to make it to the bathroom and fell . She had a scrape on her head. She denied any loss of consciousness or worsening pain. Per hospice, her pain medications were going to be decreased per family request. The Fall Investigation dated 07/08/24 at 08:50 AM, the resident found on the floor after staff heard a crash. The resident on top of a fan that was on the floor. She had an abrasion on her forehead, but was not able to tell staff what she hit. She had been removing her O2 tubing and getting it caught on things. The resident said she was going to the bathroom and fell . She said the fan hit the wall when she landed on it. Review of the CNA tasks documentation for toileting from 07/01/24 thru 07/30/24 revealed the resident was limited to substantial assistance all but one day with toileting and was incontinent of urine daily. No toileting schedule documented for the resident. Observation on 07/29/24 at 12:45 PM revealed the resident appeared frail and weak. She sat on the side of the bed talking quietly to a hospice social worker. The resident had O2 per nasal cannula at 15 liters per minute. Her skin color was jaundiced (a yellow discoloration of the skin and eyes) and her lips were dark. Observation on 07/29/24 at 03:50 PM, revealed certified nurse's aide (CNA) C and CNA D assisted the resident off the toilet in the bathroom. The resident had O2 per cannula on at 15 Liters per minute, with two concentrators. The resident was very confused and talked about seeing things that were not there. Her lips were very dark and fingertips cyanotic (bluish discoloration of the skin). CNA C changed the resident's wet brief and cleaned up a puddle of urine on the bathroom floor by the door. A gait belt was placed on the resident and CNA C and D ambulated the resident back to her bed. The resident had a slow unsteady gait and had no shoes or socks on. A pair of slip-on slippers were at the side of the bed. Observation on 07/30/24 at 07:20 AM, the resident was up in her room walking around by herself barefoot. Certified Medication Aide (CMA) E was in the hall and noticed the resident being up. The resident was confused and had her O2 cannula off and wrapped around the bedside table and on the floor. CMA E entered the resident's room and was attempted to get the resident to sit down on her bed, but the resident continued walking around until CMA E was able to talk the resident into sitting on her bed and replaced her O2. The resident was restless and confused. Her house slippers were at the side of the bed. No other footwear seen in room. Interview on 07/29/24 at 03:55 PM, CNA C reported sometimes the resident would get up and walk to the bathroom by herself. Staff tried to keep an eye on her to catch her and assist her. She was usually confused and hallucinated seeing things that are not there. She had falls by trying to ambulate on her own and currently had a broken arm. Interview on 07/29/24 at 04:05 PM, CNA D reported the resident was usually confused. She needed assistance due to being weak when up by herself, but she would get up by herself anyway. She tended to remove her O2 cannula, then could not breathe. Interview on 07/30/24 at 07:30 AM, CMA E reported R2 was very restless and would not sit for long before she would stand up and ambulate again. She has had multiple falls, but staff do not know how to keep her down to keep her from the falls. She is confused and worse when she took her O2 off, which she did frequently. She had a cast on her arm from a fall about a month ago. She picked at the cast until she got it off. That is the third cast she has had. Interview on 07/30/24 at 10:00 AM, CNA G reported the resident was not on a toileting program. She just would get up and take herself. She has fallen trying to go to the bathroom. Interview on 07/30/24 at 10:05 AM, Licensed Nurse (LN) H reported the resident did not have a voiding diary and was not on a toileting plan. She thought the resident took herself to the bathroom and staff just checked on her throughout the day, probably about every two hours. On 07/30/24 at 12:45 PM, Administrative Nurse B reported there was no toileting program. She did think a toileting plan would put staff in the resident room more frequently so the resident would not be trying to toilet herself causing her to have falls with injury. The facility policy for Accident, Incident, Unusual Occurrence Documentation dated 03/13/24 revealed when a resident experiences an incident or accident, the nurses caring for the resident will record the resident's response. The effect of the incident or accident on the resident including results of a physical examination, and vital signs will be documented. Assessment of the resident may include any or all changes from baseline status reporting changes to the physician. Record new physician orders received and instructions for follow up care or requested notification of changes in condition. The resident's designated responsible party will be notified of the occurrence. The nurse will document the notification of appropriate parties. The facility failed to provide a safe environment for a cognitively impaired resident, with a history of multiple falls and low vision, to prevent repeated falls, with one fall that resulted in a fractured wrist.

The facility reported a census of 60 residents with four residents selected for review for activity of daily living (ADL's). Based on observation, interview, and record review, the facility failed to ensure bathing opportunities as per resident preference for three residents (R) 1, R2, and R3 of the four residents reviewed for activities of daily living. Findings included: - Review of Resident (R)1's Physician Order Sheet, dated 09/02/23, revealed diagnoses included cerebral vascular accident (CVA stroke sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), hemiplegia (paralysis of one side of the body muscular weakness of one half of the body), pain, and major depressive disorder (major mood disorder). The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident had modified independence in decision making with some difficulty in new situations. The resident was dependent on staff for transfer and dressing and required physical help with bathing. The resident had impairment in functional range of motion on one side of her upper extremities and no impairment of her lower extremities. The resident used a wheelchair for mobility. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 12/22/22, assessed the resident required assistance for bathing and was frequently incontinent of bowel and bladder. The Care Plan, revised 09/01/23, instructed staff the resident preferred her bathing opportunities twice a week, on Monday and Thursday, after dinner. Review of the AL ADLs log dated 09/01/23 through 09/26/23 and review of the Shower Sheets, revealed the resident received a shower on 08/31/23 and 09/11/23 (11 days between bathing opportunities). The resident received a shower on 09/13/23 and 09/18/23 (five days between bathing opportunities). On 09/25/23 at 04:30 PM, the resident sat in her wheelchair in her room. The resident stated she did not receive showers twice a week as she usually preferred in the evening. Interview, on 09/26/23 at 04:10 PM, with Certified Nurse Aide CNA M, revealed staff showered the resident after the evening meal, CNA M stated usually there is enough staff to get tasks done if all staff work together. Interview, on 09/26/23 at 04:30 PM, with Administrative Nurse C, revealed staff do not always document in the electronic medical record that showers were given, and staff should fill out a Shower Sheet with each shower. Administrative Nurse confirmed the shower on 08/31/23 and 09/11/23 (11 days). The resident received a shower on 09/13/23 and 09/18/23 (five days). The facility policy Honoring Preferences, undated, instructed staff to honor the resident's preferences and add them to the care plan. The facility failed to provide a bathing opportunity for this resident twice a week, per the resident preference and as care planned to promote optimal physical and mental wellbeing. - Review of Resident (R)2's Physician Order Sheet, dated 07/25/23, revealed diagnoses included hypertension (elevated blood pressure), chronic obstructive pulmonary disease (COPD: progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), coronary artery disease (abnormal condition that may affect the flow of oxygen to the heart), and depression. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 09, which indicated the resident had moderate cognitive impairment. The resident required supervision for bathing. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 04/03/23, assessed the resident required supervision of one staff member for bathing. The Care Plan, reviewed 09/07/23, instructed staff the resident preferred to shower three times a week on Monday, Wednesday, and Friday. Review of the AL ADLs log from 09/01/23 through 09/26/23 and Shower Sheets, revealed the resident received a shower on 09/12/23, 09/13/23, 09/15/23, 09/18/23, 09/19/23, 09/20/23 and 09/21/23 (7 showers in 26 days. The documentation lacked evidence of a bathing opportunity for the week of 09/04/23. Interview, on 09/26/23 at 09:00 AM, with Certified Nurse Aide (CNA) N stated the resident required supervision with showers. Interview, on 09/26/23 at 04:30 PM, with Administrative Nurse C, revealed staff do not always document in the electronic medical record that showers were given, and staff should fill out a Shower Sheet with each shower. The facility policy Honoring Preferences, undated, instructed staff to honor the resident's preferences and add them to the care plan. The facility failed to provide a bathing opportunity for this resident three times a week, per the resident preference and as care planned to promote optimal physical and mental wellbeing. - Review of Resident (R) 3's Physician Order Sheet, dated 09/11/23, revealed diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), chronic pain syndrome, spinal stroke (blood clot in the spine) and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14, which indicated normal cognitive status. The resident was dependent of staff for transfers and bathing. The ADL (Activity of Daily Living) Functional/Rehabilitation Potential Care Area Assessment (CAA), dated 07/12/23, assessed the resident required extensive assistance for bathing. The Care Plan, reviewed 07/12/23, instructed staff the resident admitted with pressure areas on her coccyx (last set of bones in the spinal column, tail bone), ischium (bone that forms the lower part of the pelvis) and MASD (moisture associated ski damage). Review of the Al ADLs bathing log from 07/12/23 (admission) through 09/26/23, revealed the resident received four bathing opportunities, 09/15/23, 09/18/23, 09/19/23, and 09/21/23. The bathing log lacked documentation of the resident bathing from 07/12/23 to 09/14/23, a total of 65 days. Interview, on 09/26/23 at 09:30 AM, with the resident, revealed the resident positioned in bed. The resident stated she had a concern that she did not receive shower bathing opportunities and had two showers since admission (07/12/23). The resident stated she was supposed to received bathing opportunities on Wednesdays and Saturdays and preferred showers to bed baths. Interview, on 09/26/23 at 04:30 PM, with Administrative Nurse C, revealed staff do not always document in the electronic medical record that showers were given, and staff should fill out a Shower Sheet with each shower. The facility policy Honoring Preferences, undated, instructed staff to honor the resident's preferences and add them to the care plan. The facility failed to provide a bathing opportunity for this resident twice a week, per the resident preference and as care planned to promote optimal physical and mental wellbeing.

The facility reported a census of 60 residents with five residents selected for review, which included three residents reviewed for unnecessary medication administration. Based on observation, interview, and record review, the facility failed to administer one resident's (R)3 Percocet (narcotic pain medication), and Metformin (a medication used to lower blood sugar), cyclobenzaprine (a muscle relaxer), doxycycline and cefdinir (antibiotics) as ordered by the physician. Findings included: - Review of Resident (R) 3's Physician Order Sheet, dated 09/11/23, revealed diagnoses of paraplegia (paralysis characterized by motor or sensory loss in the lower limbs and trunk), chronic pain syndrome, spinal stroke (blood clot in the spine) and diabetes (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). The Admission Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 14, which indicated normal cognitive status. The resident received antidepressant and diuretic (medication to remove excess fluid) medications during the seven-day look-back period. The resident received as needed pain medication and received non medication interventions for pain. The pain interview revealed the resident stated she had no pain. The Pain Care Area Assessment (CAA), dated 07/12/23, did not trigger. The Care Plan reviewed 07/12/23, instructed staff to offer the resident non medication interventions which included cool/warm packs, repositioning in bed or chair, walk around the community, prior to administering as needed pain medications. Review of the Physician Orders revealed the following: On 09/05/23, the physician instructed staff to administer Percocet, 5 milligrams (mg)-325 mg, every four hours. Review of the Medication Administration Record (MAR), for September 2023, revealed the following areas of concern: On 09/07/23, staff administered the 10:00 AM dose of Percocet at 12:40 PM, and the 02:00 PM dose administered at 02:03 PM with an interval of one hour and 20 minutes. On 09/09/23, staff administered the 06:00 AM dose of Percocet at 07:38 AM and staff administered the 10:00 AM dose at 09:03 AM, for an interval for one hour and 25 minutes. On 09/09/23, staff administered the 10:00 PM dose of Percocet on 09/10/23 at 01:16 AM and staff administered the 02:00 AM dose at 01:56 AM, for 40-minute interval. On 07/12/23, the physician instructed staff to administer Metformin (a medication the lowers the blood glucose level) Extended Release, 500 mg, twice a day. Review of the Medication Administration Record (MAR), for September 2023, revealed the following areas of concern: On 09/08/23, staff administered the 08:00 AM dose at 12:23 PM, (four hours and 23 minutes late), and the 05:00 PM dose administered at 06:30 PM (one and a half hours late). On 09/11/23, the 08:00 AM, the Percocet dose was not administered. On 09/13/23, staff administered the 08:00 AM dose at 01:30 PM (5- and one-half hours late). On 09/14/23, staff administered the 08:00 AM dose at 12:54 PM (four and 54 minutes late). and the 05:00 PM dose was administered at 4:57 PM. On 07/19/23 the physician instructed staff to administer cyclobenzaprine (a muscle relaxer), 5 mg, every eight hours, as needed. On 09/04/23 at 12:26 AM, staff administered a dose of cyclobenzaprine and another dose on 09/04/23 at 01:03 AM (37 minutes between doses). On 09/14/23 the physician instructed staff to administer doxycycline hyclate (an antibiotic) 50 mg, twice a day, for seven days. On 09/14/23, the physician instructed staff to administer cefdinir 300 mg, twice a day, for seven days. On 09/17/23 staff administered the 08:00 AM doses of both medications at 11:47 AM (three hours and 47 minutes late) and the 05:00 PM dose administered at 04:08 PM. (four hour and 21 minutes interval). On 09/19/23 staff administered the 08:00 AM doses of both medications at 01:20 PM (5 hours and 20 minutes late), and the 05:00 PM doses were administered at 04:34 PM. (three-hour ten-minute interval). Interview, on 09/26/23 at 09:30 AM, with the resident, revealed she has constant pain, and the physician had been adjusting pain medications. The resident stated she is most comfortable in bed but did like to get up in her power chair to smoke. Interview, on 09/27/23 at 10:00 AM, with Certified Nurse Aide (CMA) R, revealed she administered the medication at the time on the MAR, but if the resident was not awake and the medication needed to be given with food, or on an empty stomach, she would need to adjust the time and notify the charge nurse. Interview, on 09/27/23 at 10:30 AM, with Administrative Nurse D, revealed the electronic medical record system did not allow for staff to adjust the time of administrations and the recorded time of administration may not be truly accurate as the time that the medication was given. Review of the Narcotic Count sheet for the scheduled Percocet doses revealed staff did not indicate exact time of administration but indicated the scheduled time for administration. The facility policy Administering Medications Using Electronic Medication Administration Record undated, instructed staff to administer medications in a safe manner and complete accurate and timely real time documentation of all medication administration using the Electronic Medical Record system utilized in the facility. Administered means that the medication is given to and ingested by the resident by the prescribed route and within 60 minutes from the time it was ordered and scheduled on the electronic medication administration record. Medications that require a maintained blood level will be administered within one hour before or one hour after the scheduled time except the following types that would be administered as close to the ordered time as possible. BID (twice a day) medication would not be administered in a shorter time than eight hours apart. TID (three times a day) would not be administered in a shorter time than five hours apart. QID (four times a day) medications would not be administered in a shorter time than four hours apart. The facility failed to administer this resident's Percocet (narcotic pain medication), Metformin (a medication used to lower blood sugar), cyclobenzaprine (a muscle relaxer), doxycycline, and cefdinir (antibiotics) as ordered by the physician to enhance efficacy and prevent adverse effects.

The facility identified a census of 58 residents. The sample included 15 residents with eight residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure residents remained free from avoidable accidents and injuries. On 01/06/23 staff transferred Resident (R) 38 but failed to use appropriate gait belt technique. This failure resulted in a fall with a femur (thigh bone) fracture, which required surgical repair. The facility also failed to ensure adequate supervision during toileting for R10, who had a non-injury fall as a result. The facility further failed to ensure R14's bed was left in a safe position which placed R14 at increased risk for falls and related injury. Findings included: - R38's Electronic Medical Record (EMR), from the Diagnoses tab, documented diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), cerebral infarction (stroke-sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain), and difficulty in walking. The Significant Change in Status Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of eleven, which indicated moderately impaired cognition. R38 required extensive assistance of one staff member for transfers and toileting. The MDS indicated R38 was unsteady moving from a seated position to a standing position and was only able to stabilize with human assistance. The Significant Change in Status MDS dated [DATE] documented a BIMS score of eight, which indicated moderately impaired cognition. The MDS documented R38 required total dependence on two staff members for transfers and extensive assistance of two staff for most other activities of daily living (ADL). R38's Falls Care Area Assessments CAA dated 01/11/23 recorded R38 was at risk for falls secondary to his recent fall with fracture, his medical diagnoses, and his medication regime. R38 was on several medications that could affect his strength and balance. The CAA recorded R38 had a fall on 01/06/23 during a transfer that resulted in a fracture to the left femoral neck and required surgical repair on 01/08/23. R38's historical Care Plan dated 03/28/22 documented R38 was at risk for falls. An intervention dated 02/28/22 directed staff R38 required extensive assistance with transfers. The care plan did not indicate how many staff or type of transfer. R38's current Care Plan dated 01/06/23 documented R38 was at risk for falls due to his personal history of falls, history of stroke compression fractures, and pain. The MDS recorded an intervention dated 01/09/23 which directed R38 had a fall with injury on 01/06/23 and staff received education on transfers with the use of the gait belt. R38's EMR recorded a note, under the Notes tab, dated 01/05/23 which recorded the interdisciplinary team (IDT) discussed R38 in IDT meeting regarding his fall risk. Staff planned to contact R38's representative about Hospice (end of life care) screening. R38 was on an antidepressant (medication which treats persistent feels of sadness). R38's Buspar (medication given to treat anxiety) was decreased. The note recorded R38 had several falls in December and had Covid (highly contagious respiratory virus) that month as well. R38's EMR recorded a note dated 01/06/23 at 06:00 PM, entered on 01/07/23 at 10:59 AM by Licensed Nurse (LN) G which documented at about 04:30 PM on 01/06/23 a Certified Nurse Aid reported to LN G that R38 fell mid-transfer. The note further documented while staff transferred R38 from his bed to his wheelchair, instead of sitting backwards into the wheelchair, he fell forward onto the ground. Staff initiated neurological assessments. R38 sat in his wheelchair while staff performed range of motion (ROM) and R38 denied pain at that time. The nurse felt R38's scalp and noted no new issues and the resident denied any pain during the assessment. Staff then assisted R38 to the dining room where he ate his normal amount of dinner. Upon reassessment, about an hour after the fall, R38 sat in his wheelchair with his bilateral feet propped up. He denied complaints of pain at that time. The note documented the on-call management staff were informed of the fall at 04:38 PM; the provider received notification at 04:51 PM; and R38's representative received notification at 05:15 PM. R38's EMR recorded a note dated 01/07/23 at 02:13 AM which documented staff notified R38's physician that R38 complained of hip pain post fall which occurred at around 04:30 PM the previous day. The physician ordered an x-ray to both R38's hips. R38's EMR recorded a note dated 01/07/23 at 08:27 AM which noted the x-ray results showed an acute, nondisplaced left femoral neck (where the femur shaft connects to the femur head which articulates to the hip joint) fracture. R38's physician gave orders to send R38 to the emergency room . R38's EMR recorded a note dated 01/10/23 at 06:04 PM, which recorded R38 readmitted to the facility after a fall which fractured his hip. The facility's staff members helped with transferring R38 from the gurney to his bed. He had a left hip incision that was 7 centimeters (cm) long, with a dressing in place. R38's ROM was limited due to the fracture. The unsigned Resident Incident Reporting Form documented an incident date of 01/06/23 at 04:30 PM. The form included the note entered on 01/07/23 at 10:59 AM by LN G. The form documented R38's vital signs and a pain score of zero. The form listed a staff witness of CNA T and an incident location of R38's room. The form listed the event type as a fall, found on floor. The following form sections were all noted as not applicable (N/A): Medications/Infusions; Adverse Clinical Event; Treatment/Procedure; Administrative; Abuse. The form noted it was completed by LN G and included notification times to R38's physician and representative. The form listed the incident had a severity rating of 3 which the form defined as an adverse event that did not result in death or serious disability and did not require medical intervention to prevent death or serious disability and directed to track and trend, but no root cause analysis was required. Under the severity ranking section the form documented fracture and No was entered. The form contained a section which directed For Falls also complete these sections. The form recorded yes to the query regarding if the resident's care plan was followed, if staff were transferring with the appropriate number of staff, if the resident's sued assistive devices and if the device was in sue at the time of the fall. The forms documented No to the question regarding if the residnet had a restraint or positioning device ordered and N/A regarding if the restraint/device was in use at the time of the incident. The form further recorded N/A to the query if counseling /education of staff was necessary. An undated Witness Statement from LN G recorded the same note entered on 01/07/23 at 10:59 AM. An undated Witness Statement from CNA T recorded CNA T was getting R38 up to take him to dinner on 01/06/23. R38 went forward and not backward, onto the floor and not into the chair. CNA T asked R38 if he was hurt and where, and R38 said no. CNA T let the nurse know about the fall. Upon request, the facility provided copies of the staff education on the use of gait belts with transfers which was provided after R38's fall and referenced in his plan of care. The education was provided to CNA T. CNA T signed and acknowledged the facility policy Use of Transfer Belt/gait Belt on 01/07/23. The facility provided a competency titled Competency Checklist-One-Person Transfer, signed by CNA T and Administrative Nurse E. The facility was unable to provide documentation of further education and/or ongoing monitoring related to the concern. The facility could not provide a completed investigation related to R38's fall on 01/06/23. On 03/07/23 at 11:51 AM R38 rested in bed. His wheelchair had anti-rollbacks in place and was next to his bed and his call light was in reach. On 03/09/23 at 08:05 AM CNA T stated that she only vaguely remembered the incident on 01/06/23 as it was a while ago. CNA T stated R38 required extensive assistance with transfers. CNA T stated she did use a gait belt when she transferred R38 on the day he fell , but when he started going forward, CNA T could not stop him from falling. She stated she could not remember if she had two hands or one hand on the gait belt or if she had applied the belt correctly. She said she was uncertain, but thought she stood beside or behind R38 during the transfer. On 03/09/23 at 08:12 AM Administrative Nurse E stated prior to his fall, R38 required extensive assistance from one staff with the use of a gait belt. Administrative Nurse E stated that unless the care plan directed the use of a mechanical lift, the staff would do a stand pivot with a gait belt for extensive assisted transfer. She said if she felt the resident was unsteady or too weak, she would get a second person to assist. Administrative Nurse E said the facility were doing a lot of training on gait belt use and positioning, and after the incident, gait belts were placed in all the rooms. On 03/09/23 at 08:17 AM Therapy Consultant JJ stated prior to R38's fall, R38 required minimum to moderate assistance with transfers. Consultant JJ stated therapy always recommended the use of a gait belt, for safety, with all stand pivot transfers. Consultant JJ confirmed R38 received therapy services after the fall, and stated R38 had returned to his previous level of function. On 03/09/23 at 10:58 AM Administrative Nurse D said extensive assistance of one staff would mean a stand pivot transfer. She said if a lift was needed, it was specified on the care plan. Administrative Nurse D stated that staff should always use a gait belt when performing a stand pivot transfer with the residents. Administrative Nurse D stated when R38 fell , CNA T used a gait belt but did not use it correctly. Administrative Nurse D said CNA T held the gait belt overhand from the top; so, when R38 lost his balance, CNA T could not support R38's weight and he fell forward. Administrative Nurse D said the facility response to the incident was education specific to the involved CNA. She stated the facility further ensured all residents had gait belt available in the rooms. Administrative Nurse D stated the facility conducted several huddles and conducted in-person demonstrations and return demonstration on the use of gait belts, but the facility did not do formal education or competency checks with all relevant staff. Administrative Nurse D confirmed that no formal investigation, which included a root cause analysis and facility actions, was completed for R38's fall; she stated it would be a good idea to have all the efforts conducted by the facility documented. Review of the facility competency checklist titled Certified Nurse Aide Clinical Skill Competency Checklist effective 10/31/17 revealed a clinical competency that required demonstration of proper technique for gait belt use, and a pivot transfer using gait belt. Review of the undated facility Competency Checklist-One-Person Transfer revealed the following steps: Apply gait belt and stand facing the resident with feet shoulder width apart. Have resident place hands on staff member's shoulders and the staff would grasp the belt firmly at each side of the resident. The undated facility policy Use of Transfer Belt/Gait Belt directed staff to wrap the gait belt around the elder's waist and buckle it securely in the front. Stand in front of the elder with the staff member's knees bent, feet apart and back straight. Position one hand on either side of the gait belt with an underhand grip and assist elder to move forward. The facility failed to ensure staff used appropriate gait belt transfer technique during a staff assisted transfer for R38, who required extensive staff assistance. As a result of this failure, R38 fell and sustained a fracture which required hospitalization and surgical intervention. 45668 -The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of benign prostatic hyperplasia (BPH- non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), difficulty walking, heart failure, retention of urine, and a history of falling with fractures (broken bone). R10's Quarterly Minimum Data Set (MDS) dated [DATE] noted a Brief Interview for Mental Status (BIMS) score of 12 indicating mild cognitive impairment. The MDS indicated he required extensive two-person assistance for bed mobility and transfers. The MDS noted he required extensive assistance from one staff for personal hygiene and toileting. The MDS indicated no falls since last assessment. R10's Admission MDS dated [DATE] indicated he required supervision and physical assistance from one staff member for all transfers and toileting. The MDS indicated he had a fracture related to a fall prior to admission to the facility. A review of R10's Communication Care Area Assessment (CAA) completed 08/08/22 indicated he had difficulty understanding and being understood by others due to his cognitive loss. The CAA identified risk factors for falls, self-care deficits, weight loss, and decline in mood related to his communication concerns. R10's Activities of Daily Living (ADLs) CAA completed 08/08/22 indicated risk factors for falls, self-care deficits, weight loss, and decline in mood related to his medical diagnoses. The MDS indicated he had impaired balance and transitions during transfers, functional impairment in activity, and decreased safety awareness. R10 was not triggered for a Falls CAA. A review of R10's Baseline Care Plan initiated 07/25/22 indicated he was a fall risk. The plan indicated he required assistance from two staff for bed mobility, transfers, grooming, and toileting (07/25/22). A review of R10's current Care Plan revised 09/08/22 revealed he had a non-injury fall on 08/08/22 and instructed staff to educate him on using his call light. This entry was created on 03/08/23 and back dated to start on 08/08/22. A review of R10's EMR under Progress Notes revealed on 08/08/22 at 08:00PM R10 was found on the floor of his room after attempting to self-transfer to his wheelchair. The note indicated R9 was using his walker at the time of the fall. The note indicated that staff assisted him to the restroom and left him alone. The note revealed R10 stated I don't know why she had to leave I was not going to be long. A review of the Fall Investigation under Witness Statements indicated direct care staff last saw R10 in his restroom at 07:45PM. The investigation noted Resident should be reminded to use his call button after using the bathroom use. The investigation revealed that R10 had was confused and trying to get to his wheelchair after using the restroom. On 03/06/23 R10 slept in his bed. R10's bed was in the low position. R10's urinary catheter (tube inserted into the bladder to drain urine) collection bag was visible from the hallway without a privacy bag. The bottom of R10's collection bag was on the floor. R10's wheelchair sat in the corner of the room. His unbagged nasal cannula and oxygen tubing hung over the oxygen cannister. On 03/09/23 at 09:38AM, Certified Nurse's Aide (CNA) M stated that R10 should be monitored during personal hygiene and toileting. She stated that residents should be supervised to prevent falls and injuries from occurring. She stated that R10 was a fall risk and should no be left alone during toileting. She stated that other fall prevention intervention includes call light placement, frequent checks, and ensuring the residents needs are met. On 03/06/23 at 10:03AM, Licensed Nurse (LN) G stated that residents identified with fall risk should be closely supervised during ADL care. She stated staff should never leave a resident alone when toileting. She stated that the direct care staff have access to the resident's care plan and should know the level of assistance and supervision required for each resident. On 03/09/23 at 10:21AM, Administrative Nurse D stated staff should never leave residents at risk for falling alone during toileting. She stated that they should ensure each resident's call light is within reach. She stated that R10 had encourage resident to use call light added to his care plan after the fall occurred. The undated facility policy Accident Prevention directed all staff members of the facility would ensure the each elder's environment remained as free from accident hazards as possible and each elder would receive adequate supervision and assistive devices to prevent accidents. The facility failed to provide supervision for R10 resulting in a non-injury fall after toileting. This deficient practice placed R10 at risk for preventable falls and injuries. 41713 - The electronic medical record (EMR) for R14 documented diagnoses of hypertension (elevated blood pressure), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), and contracture of the lower leg muscle (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity). The Annual Minimum Data Set (MDS) dated [DATE] documented R14 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R14 required extensive assistance of one or more staff for activities of daily living (ADLs)supervision and assist of one staff for eating. R14 had functional limitation in range of motion (ROM) in both upper and lower extremities on both sides. R14 required the use of a wheelchair for mobility. R14 had no history of falls since the prior assessment. The Quarterly MDS dated [DATE] documented R14 had a BIMS score of 15 which indicated an intact cognition. R14 required extensive assistance of two or more staff for bed mobility R14 had functional limitation (ROM) in both upper and lower extremities on both sides. R14 required the use of a wheelchair for mobility. The MDS recorded R14 had no history of falls since the last assessment. The Care Area Assessment (CAA) for falls was not triggered. The ADL CAA dated 05/05/22 documented this care area triggered secondary to assistance required in ADLs, impaired balance and transition status and functional ability, during transfers, and functional impairment in activity. Contributing factors include generalized weakness, and decreased safety awareness. Risk factors include further ADL decline, falls, incontinence, skin breakdown, and pain. The Falls Care Plan initiated 0521/21 documented R14 was at risk for falls and used a Hoyer lift (an assistive device used to allow a person to be lifted and transferred with a minimum of physical effort) for transfers. Staff was to observe R14 for the need of physical or occupational therapy. Staff was to observe him for changes in his condition that may warrant increased supervision/assistance and notify the physician. The care plan lacked evidence R14 had a preference for the bed in a high position. R14's clinical record lacked evidence of safety education related to his bed height. On 03/06/23 at 11:47 AM R14 laid in his bed, the bed height was at a height approximately three feet from the floor, R14's head and upper torso was leaned over to the left side. On 03/07/23 at 08:44 AM R14 laid on his back in bed, with a neck pillow around neck, his bed height was at hip height (approximately 36 inches/ three feet). On 03/07/23 at 12:03 PM R14 laid in bed, his upper torso was leaning to the left, support pillow around his neck, call light in reach, bed level elevated. On 03/07/23 at 01:56 PM R14 laid in bed with his torso leaning to the left side of his bed. R14 stated he was having pain, he turned on his call light and an aide came into room and asked him if he needed anything. R14 told the aide he was having some pain and the aide exited the room before repositioning R14. On 03/07/23 03:35 PM R14 was bent over in bed holding a drink. R14'sneck pillow on but head bent completely to left and body tilting to the left. R14's pancake call light was out of reach on residents lap area, with bedside table pulled close obstructing his reach. R14's drink (Styrofoam cup with lid and straw). R14 asked this writer to take drink as he was holding the drink in his left hand and unable to reach the table to set drink down. With the health facility surveyor (HFS) intervention R14 activated call light and staff responded in less than one minute. The staff member canceled the call light and went and got another staff to come assist with repositioning. Bed in high height. On 03/08/23 at 09:26 AM R14 sat in his bed with the head of the bed elevated, neck pillow around neck. R14's bed was at a medium high position (about three feet). On 03/09/23 at 09:48 AM Certified Nurse Aide (CNA) M stated a resident who was a fall risk should have their bed in low position. CNA M stated R14 did prefer to have his bed at a higher level most of the time. On 03/09/23 at 10:31 AM Licensed Nurse (LN) G stated beds should be kept in a low position if a resident was a fall risk. R14 had been educated by staff of the increased risk of falls due to the bed being at a higher height. On 03/09/23 at 10:45 AM Administrative Nurse D stated R14 was particular about the height of his bed. Administrative Nurse D stated R14 preferred his bed at a higher height so he would be able to view his television better. Administrative Nurse D stated R14 was educated on the risk of having his bed at the higher height but acknowledged this was not reflected in R14's plan of care or medical record. The undated facility policy Accident Prevention directed all staff members of the facility would ensure the each elder's environment remained as free from accident hazards as possible and each elder would receive adequate supervision and assistive devices to prevent accidents. The facility failed to ensure that R14's bed was maintained at a safe level while R14 occupied the bed. This placed R14 at risk for increased falls and/or possible further injury.

The facility identified a census of 58 residents. The sample included 15 residents with four residents reviewed for nutrition. Based on observation, record review, and interview, the facility failed to identify and respond to weight loss for Resident (R)14 to prevent further loss. The facility failed to ensure R14 had the required built-up eating utensils and staff assistance during meals and failed to involve the registered dietician (RD) and R14's physician to evaluate and initiate interventions to prevent further loss. This deficient practice resulted in a significant weight loss of 12.59 percent (%) over six months (August 2022 to February 2023) for R14 and placed this resident at risk for other adverse effects. Findings included: - The Electronic Medical Record (EMR) for R14 documented diagnoses of hypertension (elevated blood pressure), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), Parkinson's disease (a chronic and progressive movement disorder that initially causes tremor in one hand, stiffness or slowing of movement), and contracture of the lower leg muscle (occurs when your muscles, tendons, joints, or other tissues tighten or shorten causing a deformity). The Annual Minimum Data Set (MDS) dated [DATE] documented R14 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R14 required supervision and assistance of one staff for eating. R14 had functional limitation in range of motion (ROM) in both upper and lower extremities, required the use of a wheelchair for mobility, and had no weight loss in the last month or last six months. The Quarterly MDS dated [DATE] documented R14 had a BIMS score of 15, which indicated intact cognition. R14 required limited assistance of one staff for eating. R14 had functional limitation (ROM) in both upper and lower extremities and required the use of a wheelchair for mobility. The MDS inaccurately recorded R14 had no history of weight gain or weight loss during the last six months. The Pressure Ulcer Care Area Assessment (CAA) dated 05/05/22 documented R14 was a risk for pressure ulcer development due to ADL/functional/mobility impairment. The physician was to be notified of any abnormal findings. The dietician was to monitor food and fluid intake and implement dietary interventions, as necessary. The Nutritional Status Care Plan dated 05/21/22 documented R14 was at risk for alteration in nutritional status and directed staff to weigh R14 routinely though did not direct any specific frequency . The dietician was to visit annually and as needed. The Assistive Dining Care Plan dated 12/22/22 documented R14 required built-up utensils while dining due to tremors (involuntary shaking or movement, ranging from slight to severe, and commonly affecting hands, legs, face, head, or vocal cords). R14 required restorative dining services with verbal cues for use of built-up utensils and verbal cue for meal completion. Under the Orders tab documented an order for R14 dated 05/21/21 to obtain weights monthly and as needed. Upon review of R14's recorded weights from 05/01/22 to 03/01/23: R14's weight on 05/01/22 was 184 pounds (lbs.). R14's weight on 08/01/22 at 08:16 AM was 189 lbs. R14's weight on 10/17/22 was 178.4 lbs. R14's weight on 12/01/22 was 163.2 lbs. R14's weight on 02/03/23 was 165.6 lbs., which indicated a 12.59 percent in six months. R14's weight on 03/01/23 was 161.8 lbs., representing an additional 3.8 lbs. loss. The EMR for R14 lacked evidence of notes from the registered dietician and the physician during the months of August 2022 to December 2022 to address R14's significant weight loss. A Clinical Note dated 01/12/23 at 10:35 AM documented R14 was discussed in a weekly risk meeting. The note recorded R14's weight had been trending down and R14 had a rehospitalization and COVID (a respiratory disease) since August. R14 had no recent falls. A Nursing Clinical Note for R14 dated 02/09/23 at 08:21 PM documented the resident was reviewed during the weekly interdisciplinary team (IDT) meeting. Resident declined hospice, had not falls, and had a significant weight change of -14.13 percent, 23.4 pounds in 180 days contributed to a hospital visit in the fall of 2022. No interventions needed per registered dietician. A Written Physician Order dated 02/09/23 for R14 documented the resident had a significant weight change of 14.13% in 180 days. No new interventions were initiated. A Dietary Clinical Note dated 02/10/23 at 01:42 PM for R14 documented R14's current body weight was 165.6 pounds, and he did have a significant weight loss over 180 days (-14%). Weight was currently stable for the last 30 days. Per risk meeting discussion, resident had a hospital stay in the fall of 2022 that most likely contributed to his weight loss (constipation, possible impacted stool that was relieved). R14 was on a regular diet with regular textures and thin liquids. Per available chart data oral intakes were fair with average of 50 to 100% at meals. R14 did participate in restorative dining. Nutrition related medications reviewed, and no supplements were currently ordered. Oral intakes were adequate, weight stable for last 30 days, no new nutritional recommendations, and R14 was to continue current plan of care. The registered dietician would monitor and was available, as needed. Review of R14's meal intake over the last three months documented R14's oral food intake was 50 to 100%. On 03/07/22 at 01:22 PM R14 sat up in his bed with the bedside table across his bed with a Styrofoam food container with his lunch in it and plastic eating utensils. There were no staff present supervising or cueing. On 03/08/23 at 09:29 AM R14 was eating breakfast in his room with the head of his bed elevated, and a neck pillow present around his neck. A Styrofoam container and plastic utensils were noted on his bedside table and there were no staff supervising or cueing. On 03/09/23 at 08:55 AM Consultant HH stated R14 had been evaluated by the therapy department quarterly, before the MDS was completed, to determine what type of adaptive devices or services were needed. R14 required the use of built-up utensils and restorative dining during meals. The dietary staff were responsible for ensuring R14 had the appropriate utensils and plate, per the dietary orders. The dietary staff had a card in the kitchen for each resident that documented what diet the resident was on, along with any specialty utensils or plate needed. On 03/09/23 at 09:40 AM Certified Nurse Aide (CNA) M stated the CNAs were responsible for obtaining the resident weights and then the weights were turned in to the nurse for review. On 03/09/23 at 10:31 AM Licensed Nurse (LN) G stated R14 should have the built-up utensils while eating. LN G stated the dietary staff should provide R14 with his adaptive utensils at meals. On 03/09/23 at 10:45 AM Administrative Nurse D stated the registered dietician came to the facility every couple of weeks to review the resident's weights and food intake. Administrative Nurse D stated she had been reviewing a lot of the residents EMR and had noted R14 had shown a significant weight loss several months ago. Administrative Nurse D stated she was unable to say what had been done for R14 prior to her joining the facility in December 2022. Administrative Nurse D stated R14 had been evaluated by the registered dietician and by the physician, but no new orders had been initiated by either. The undated facility policy Monitoring Weights directed all elders of the facility would be evaluated for weight stabilization for timely identification of weight loss and treatment would be provided when possible and accepted by the elder and/or surrogate decision maker to prevent weight loss unless the eider's physician has indicated a planned weight loss program. The policy defined significant weight loss as: three pounds in one week, 5% loss in 30 days, 7.5% loss in 90 days, or 10% loss in 180 days. The policy directed the physician, elder and/or surrogate decision maker would be notified immediately (within twenty-four (24) hours) of any elder meeting the definition of significant weight loss in this policy. The facility failed to identify and address R14's weight loss before a significant loss occurred. The facility failed to ensure R14 had the ordered built-up eating utensils and restorative dining during meals and failed to ensure the registered dietician and physician addressed R14's weight loss in a timely manner. This deficient practice resulted in a significant weight loss for R14 and placed this resident at risk for other adverse effects and health concerns.

The facility identified a census of 58 residents. Based on record review, and interviews, the facility failed to ensure the staff person designated as the Infection Preventionist (IP), who was responsible for the facility's Infection Prevention and Control Program, completed specialized training in infection prevention and control. This deficient practice placed all residents at risk for lack of identification, tracking/trending, and treatment of infections. Findings included: - On 03/06/23 the facility identified Administrative Nurse D as the designated IP. On 03/09/23 at 01:05 PM Administrative Nurse D stated the facility did not have a certified Infection Preventionist at this time. Administrative Nurse D stated the facility was in the process of correcting the situation. The facility was unable to provide a policy related to the Infection Preventionist. The facility failed to ensure a staff person was a staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This deficient practice placed all residents at risk for lack of identification, tracking/trending, and treatment of infections.

The facility identified a census of 48 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to ensure Residents (R)7, R9, R35, and R42 received care in a dignified manner during meal service. The facility additionally failed to ensure R30, R48, and R50 received assistive cares in a dignified manner during basic cares and interactions. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - On 03/06/23 at 12:02AM R32 (a totally dependent severely cognitively impaired resident) was in the dining room waiting for breakfast. R32 was making cooing sounds and chewing on her blanket. Staff abruptly stated, stop being silly to R32 and pulled the blanket away from her mouth. R32 did not have her doll with her. At 12:45AM R32's food arrived. An unidentified direct care staff came over to the table and loudly stated, I'll feed her and sat next to her. On 03/06/23 at 12:10PM R7 sat in the dining room and waited for her lunch. R7's supplemental oxygen tank was low. An unidentified staff member approached her from behind and changed out her oxygen tank without speaking to her or asking permission. Once R7 became aware of the staff member she asked, Am I out of air again? On 03/07/23 at 07:30 AM R35 sat at a table in the dining room. He had a drink in front of him. R35 remained at the table, without being served breakfast. At 08:01 AM, another unidentified resident who arrived at the table after 07:30 AM, was served breakfast but R35 did not receive his breakfast meal. At 08:25 AM, a staff member told R35 his omelet would be ready soon. At 08:38 AM R35 stated he had been sitting at table since 07:30 AM, waiting for breakfast. R35 stated he wished he could at least get a roll while he waited because he was concerned about his blood sugar. At 08:41 AM, after over a one hour wait, R35 finally received his breakfast meal. On 03/07/23 at 08:39AM R42 sat at the dining room table to wait for his breakfast. Dietary Staff EE then brought R42's plate and sat it down in front of him. Dietary Staff EE walked away as R42 asked wait, wait to her. Dietary Staff EE continued to walk away stating I know, the rest is coming, we are making it. R7 shrugged his shoulders and shook his head. On 03/07/23 at 07:20AM R9 (severely cognitively impaired resident) entered the dining hall and was told by staff to sit at the table for breakfast. R9 went to the table and sat. At 07:30AM R9 exited the dining hall and wandered around the 300 Hall. R9 went back and forth several times between the dining hall and 300 Hall waiting on his meal to be served. R9 was served his meal at 08:50AM. R9's representative stated that meals took a long time to be served and R9 got restless and started wandering when he was not actively engaged in an activity. On 03/08/23 at 10:51AM in an interview with Dietary Staff BB, she stated that staff were expected to treatment all residents with respect during meal services. She stated that while it does get busy during service, staff are still expected to listen to the needs and concerns of the residents we are serving. She stated that residents should not be waiting over thirty minutes to receive their meals. On 03/09/23 at 01:20PM Administrative Nurse D stated that residents will often wake up before breakfast start and come to the dining hall. She stated that staff should offer them a snack or drinks to hold them over before breakfast begins. She stated staff should engage with each resident and ensure their needs are cared for. A review of the facility's Right to Dignity policy (undated) noted staff will treat and speak to elders with respect. The policy indicated that plastic utensils and dishware will not be used routinely. The policy noted staff will provide privacy and respect each resident's dignity during all meals and activities. The facility failed to provide promote dignity during meal services. This deficient practice placed the residents at risk for decreased psychosocial well-being. - On 03/07/23 at 11:40AM R30 (severely cognitively impaired resident) was at the piano area after group activities. R30 was crying as she sat in the middle of the room. Activity Staff Z approached R30 and asked her What's wrong? R30 did not respond and continued to cry. Activity Staff Z continued to ask her what was wrong. R30 stated I don't want to say. Activity Staff Z continued to ask her what was wrong in the middle of the piano area with multiple residents passing her. On 03/07/23 at 11:23AM R50 (severely cognitively impaired resident) was at the piano greeting other residents. A nurse walked up with a four-centimeter by four-centimeter (4cm x 4cm) foam dressing and wound cleanser spray bottle. The nurse put the bottle and gauze down on the piano and asked R20 to pull up her arm sleeves to check a wound. R50 pulled both arms up and let the nurse look then dropped them. The nurse left the area and R50 returned to greeting people. On 03/07/23 at 12:24 PM R48 was transported by an unidentified staff member in a bath chair from his room in the 200 Hall to the shower room in the 100 Hall. R48 was only partially covered by two towels, his naked buttocks and belly were visible as he passed down the hall. On 03/09/23 at 09:03AM Certified Nurse's Aide (CNA) M reported that all residents should be treated with dignity and respect. She stated that staff should be addressing them by their preferred names. The stated staff should ask permission before performing cares on the residents and offering privacy. She stated that residents should feel safe and welcome when in the facility. On 03/09/23 at 09:03AM Licensed Nurse (LN) G stated that staff were expected to ensure each resident is address by their preferred name. She stated that staff were expected to ask permission from the residents before cares and ensure privacy is given to the resident. She stated that she should sit and talk with the resident and help them engage socially. A review of the facility's Right to Dignity policy (undated) noted staff will treat and speak to elders with respect. The policy noted staff will provide privacy and respect each resident's dignity during all meals, cares provided, and during activities. The facility failed to promote dignity during basic cares and interactions. This deficient practice placed the residents at risk for decreased psychosocial well-being.

The facility identified a census of 58 residents. The sample included 15 residents. Based on observation, record review, and interviews, the facility failed to maintain a homelike environment. This deficient practice placed the residents at risk for decreased psychosocial well-being. Findings Included: - On 03/06/23 at 07:00AM an inspection of the facility's kitchen and dining service was completed. Observation of the breakfast and lunch service on 03/06/23 and for both breakfast and lunch for the duration of the survey revealed the residents received their room trays served in Styrofoam plate (boxes) with plastic silverware and disposable cups. On 03/08/23 at 10:51AM Dietary Staff BB stated the facility currently did not have a insulated food delivery cart to keep the trays warm so the kitchen used the Styrofoam plates for residents eating in their rooms. On 03/08//23 at 11:11AM in an interview with Dietary Staff CC reported the facility was still using Styrofoam boxes due to COVID-19 (highly contagious, potentially life-threatening respiratory virus). A review of the facility's Right to Dignity policy (undated) revealed the facility will not routinely use plastic/paper silverware, cups, bowls, or plates. The facility failed to maintain a homelike environment. This deficient practice placed the residents at risk for decreased psychosocial well-being.

The facility reported a census of 54 residents, with 20 identified as a full code (a technique of basic life support for the purpose of oxygenating the brain and heart until appropriate medical treatment can restore normal heart and ventilation action) advanced directive status. Based on interview and record review the facility failed to appropriately identify and confirm newly admitted Resident (R) 6's code status during an emergency. The staff found R6 on her bedroom floor, unresponsive and in [CONDITION(S)], which initiated the need for Emergency Medical Services (EMS) and the start of Cardio-pulmonary Resuscitation (CPR). Facility staff obtained a resident face sheet, indicating the resident had a Do Not Resuscitate (DNR) code status and provided it to EMS personnel, resulting in the cancellation of CPR by EMS. R6 was wrongly identified as a different resident, who had a DNR directive, when R6 did in fact require a full code, indicating the need for CPR. The inability of the facility staff to properly identify R6's code status and name, caused R6 to go without CPR for over three minutes before EMS personnel correctly identified the resident and then they initiated CPR again, without success. The facility failure placed this resident in immediate jeopardy. Findings included: - The [DATE] signed Physician's Interagency Transfer Record and admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet with a Run Date/Time of [DATE] at 02:19 AM revealed Resident (R)6 admitted to the facility on [DATE] at 12:52 PM with a Full Code advanced directive status. R6's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Clinical Notes Report revealed an assessment by Licensed Nurses (LN) G dated [DATE] at 05:18 AM documented the direct care staff found the resident unresponsive on the floor of her room at 11:10 PM (on [DATE]). The staff last saw the resident at 10:20 PM on the bench of her walker at the side of her bed, facing her bed, with no distress observed. LN G noted the resident was unresponsive and pulseless at 11:15 PM and noted the resident was a FULL code with chest compressions initiated at 11:15 PM. According to the assessment, the resident was absent of radial pulse, morbidly obese, difficult to locate carotid pulse, with no chest rise, skin cold and clammy, with bluish discoloration to the hands, and her pupils were equal and nonreactive to light. The note revealed staff notified emergency medical services and LN G reported the resident had a Full code directive to the dispatcher. Staff completed five cycles of CPR when EMS arrived on the scene at 11:23 PM. EMS pronounced the time of death at 12:03 AM on [DATE]. Review of the Fire Department Report revealed on [DATE] the fire department dispatched to the facility for a not breathing call with CPR in progress. On arrival EMS was on scene and had taken over patient care and code blue (cardiac or respiratory arrest with ongoing resuscitation efforts) at 11:30 PM. The facility staff handed the emergency response officer patient paperwork, which noted the resident was a DNR. The emergency response officer looked at the paperwork and said they needed the DNR, not just the face sheet that said Advanced Directive was DNR. Emergency responders continued with CPR for several cycles until the nurse got back with the printed off paper that confirmed the DNR status, and code black (cardiac or respiratory arrest after discontinued resuscitation efforts or no resuscitation efforts due to specific criteria outlined in treatment protocols, such as a DNR) was given at 11:27 PM. As the emergency response fire squad were leaving the parking lot, they were called back to the scene by the emergency response officer and they were in code blue, and again doing CPR. The facility LN H identified the patient as R7, when in fact the resident they were working on was R6, a full code patient, not a DNR. Full resuscitative efforts were given, but R6 was triaged Code Black 12 cycles later at 12:03 AM. The Witness Statement by Certified Nurse Aide (CNA) M, signed and dated [DATE], revealed on the night of the incident ([DATE]) she and CNA N saw the resident on the floor of her room, unconscious, and they both left R6 to get the LN. CNA M said the LN asked for the vital machine and went to R6's room, but then came running down the hall asking for the crash cart. The LN asked CNA M and CNA N to start CPR. The Witness Statement by LN H, signed and dated [DATE], revealed on [DATE] at 10:22 PM LN (LN G) told her she had someone coding. LN H asked the aide who came out of the room who the resident was to which the aide identified the resident as R7. LN H then returned to the nurse's station and immediately called the DON and pulled up the documentation for R7 and noticed R7 was a DNR. LN H then gathered all documentation for R7 and went to the room where the LN (LN G), EMTs, and CNA were and realized the resident was not R7. LN H immediately went to the ,d+[DATE] hallway nurse's station to find out who the resident was and called the DON back. The DON informed LN H the resident was a new admission who arrived that afternoon. LN H gave the phone to the nurse on that assignment and proceeded to take the correct documentation to the EMTs for R6. The Witness Statement by Administrative Nurse D, signed and dated [DATE], revealed LN H called her at 11:23 PM on [DATE] and Administrative Nurse D attempted to walk LN H through accessing paperwork on the computer. LN H informed Administrative Nurse D, LN G was in the room and EMS was already in the facility. Administrative Nurse D informed LN H she would call her back once she could gain remote access. LN H called her back at 11:23 PM and stated it was not R7 who coded, but it was R6. Administrative Nurse D arrived to the facilty at approximately 11:59 PM and EMS continued compressions on the resident. EMS pronounced the resident deceased at 12:03 AM. Administrative Nurse D notified Administrative Staff A of the situation at 01:04 AM on [DATE]. Interview with CNA N on [DATE] at 01:33 PM revealed she saw the resident on the floor in her room face up, her face was blue and her arms were above her head. CNA N checked the resident's wrist and felt a pulse. She told the LN (LN G) the resident was on the floor, but the room number had no name. When the LN, CNA N, and CMA M went to the room, the LN said the resident was a full code and said to start CPR. We started CPR and the LN called EMS. She got a copy of the face sheet. CNA N said she talked to the 911 dispatcher and because the resident was a new resident, they did not know her that well. CNA N said another LN (LN G) told her the resident was R7 and said R7 was a DNR. CNA N then ran down to the room to tell them the resident was a DNR, but the first nurse said no it was not R7, and this resident was a full code. Interview with Administrative Staff A and Administrative Nurse D on [DATE] at 11:50 AM attest when in-house staff found the resident, they initiated CPR, called EMS, and obtained the crash cart. They stated staff continued CPR until EMS arrived. Staff obtained the face sheet for the resident and the CNA told the team the resident was a DNR. It was noted by the nurse the paperwork was for the wrong resident, and the CNA went to get the correct face sheet. Administrative Staff A and Administrative Nurse D stated EMS/Fire stopped CPR and remained hands-off for four minutes, calling a CODE BLACK. The CNA came back with the correct face sheet and noted the resident was in fact a full code, so EMS/Fire restarted CPR, but stopped once Administrative Staff D arrived on-site. The facility CPR Policy, updated [DATE], revealed the facility staff were responsible for determining the Advance Directive information on admission and it would be documented in the resident's clinical record. The facility staff would be in-serviced at the time of hire, prior to providing direct care, and at least annually, and contracted staff would be trained prior to providing any direct care to any resident. The facility developed a system of identification of CPR status for immediate identification of the resident's code status (located under advanced directives order in the electronic charting system). In the event a resident was found without vital signs or unresponsive by any staff member, that staff member will immediately notify an LN and will stay in the presence of the resident and begin CPR if appropriate per resident advanced directives. The LN was responsible for verifying the resident's wishes for CPR, based on the wishes of the resident and/or DPOA. The facility failed to appropriately identify and confirm newly admitted R6's code status during an emergency, misidentified the resident as R7 (a DNR resident) which caused EMS to stop CPR measures on R6 for over three minutes before R6's was correctly identified and her full code status acknowledged and acted upon. This failure placed R6 in immediate jeopardy. On [DATE] at 04:50 PM Administrative Staff A was provided a copy of the IJ template and notified that the facility failure to appropriately identify and confirm newly admitted R6 code during an emergency placed R6 in immediate jeopardy. On [DATE] at 07:29 PM Administrative Staff A provided a plan for removal of the IJ which included the following actions taken: 1. Before the DON left around 04:00 AM on [DATE], the DON provided on site education to the staff present at the facility regarding the CPR/Code Status policies and procedures, immediately post code. The DON rounded on entire facility and ensured all residents had appropriate name tags on their doors. 2. On [DATE] the facility implemented hospital transfer packets to be kept at nurses' stations for their respective residents: including but not limited to their code status, signed DNR if applicable, their face sheet, and their DPOAH. 3. Education would be provided at an all staff, mandatory in service, on [DATE] covering the facility CPR/Code Status Procedure. The surveyor verified the implementation of the removal plan onsite on [DATE]. The deficient practice remained at a G (isolated, with actual harm) scope and severity following removal of the immediate jeopardy.

The facility had a census of 88 residents, with five residents selected for sample. Three of the five residents required staff assistance with toileting. Based on observation, interview and record review, the facility failed to ensure that two of three residents maintained bowel and/or bladder continence unless their clinical condition became such that continence was no longer possible. The two residents had no cognitive impairment. Both residents reported feeling urges to void and/or defecate prior to voiding or having bowel movements and believed they had the physical ability to sit safely on a toilet. Staff failed to offer the two residents the opportunity to use the toilet for bowel movements and/or urination, and instead instructed them to urinate/defecate in their incontinence briefs. Both residents verbalized feelings of embarrassment and degradation as a result of having bowel movements/urinating in their briefs. (Residents (R) 53, R35) Findings included: - Resident (R) 5's clinical record included a comprehensive [DIAGNOSES REDACTED]. The 10/10/19 quarterly Minimum Data Set (MDS) identified R5 with no cognitive impairment (Brief Interview for Mental Status score of 15), total dependence on two staff for transfers and toileting, and an inability to ambulate. According to the MDS, R5 used an indwelling bladder catheter (tube placed into the bladder to drain urine into a collection bag) and experienced occasional incontinence of bowel. The undated care plan directed staff to use a full mechanical lift for transfers and to provide extensive assistance with toileting. The care plan lacked information related to R5's toileting preferences. The facility could not provide evidence of completion of a bowel and/or bladder assessment within recent months. During an observation on 10/22/19 at 09:25 AM, Certified Nurse Aide (CNA) N and CNA O transferred R5 from the bed to the motorized scooter via a Hoyer mechanical lift. The resident had a suprapubic catheter (urinary bladder catheter inserted through the skin) attached to a drainage bag. The resident was alert, oriented and able to verbalize her needs at the time of the observation. During an interview on 10/22/19 at 04:15 PM, R5 reported she has lived at the facility for a total of three years. According to R5, she is not allowed to use a toilet or commode for bowel movements because I can't stand and they told me I have to be able to stand to use the toilet. R5 reported she recognized the urge to have a bowel movement but staff have told her to just go in my brief and we will clean you up. R5 cried and had tears running down her face as she recalled the feeling of embarrassment at defecating in her brief. As she explained, I feel degraded every day of my life when I have to do that. I would be so eternally grateful if I could just have the use of a toilet again. R5 further explained her embarrassment at sitting in my own feces and waiting for staff to respond to the call light. R5 reported she just prays I don't have company while I'm sitting there like that. Additionally, R5 reported she sometimes has tod leave her room to search for staff to help clean her up and said, That's embarrassing too. Who wants to go all over the building looking for help when you're sitting in your own feces? During an interview on 10/23/19 at 08:20 AM, Certified Medication Aide (CMA) R reported staff have never offered R5 the opportunity to use the toilet because she just tells us when she needs changed and we change her. During an interview on 10/23/19 at 10:00 AM. Administrative Nurse D denied knowledge that staff failed to offer R5 the opportunity to use the toilet for bowel movements. The facility's 01/01/2019 Restorative Bowel and Bladder Management policy included, Each elder will be assessed for bladder and bowel functioning within seven days of admission, quarterly and at the time of any change in condition that affects continence. The policy directed staff to ensure that all elders, where physically possible, are toileted. The facility failed to offer the R5 the opportunity to use the toilet for bowel movements, and instead instructed her to defecate in her incontinence brief. R5 verbalized feelings of embarrassment and degradation as a result of having bowel movements in her brief. - Resident (R) 3's clinical record included a comprehensive [DIAGNOSES REDACTED]. The 7/31/19 quarterly Minimum Data Set identified R3 with no cognitive impairment (Brief Interview for Mental Status score of 13), total dependence on staff for transfers and toileting, and functional limitations in range of motion on both extremities on one side of the body. According to the assessment, R5 experienced frequent bowel and bladder incontinence and did not participate in a toileting program. The undated care plan noted R3's need for extensive assistance of two staff for toilet use and directed staff to offer the bed pan as needed. The care plan also directed staff to prompt and assist to use toilet every 2-3 hours and prn (as needed). The facility could not provide evidence of completion of a bowel and/or bladder assessment in recent months. During an observation on 10/22/19 at 07:20 AM, R3 required assistance of Certified Nurse Aide (CNA) N and Certified Medication Aide (CMA) R to transfer from the bed to the wheelchair via a full mechanical lift. R3 had a left sided [MEDICAL CONDITION] and utilized a prosthetic device for that extremity. R3 was alert, oriented, and able to verbalize her needs. At the time of the observation, R3 wore a disposable incontinence brief. During an interview on 10/22/19 at 03:30 PM, R3 reported she had the ability to recognize urges to have a bowel movement or to urinate. According to R3, she is not allowed to use the toilet or a commode for urination or bowel movements because I can't stand and they say I have to be able to stand to get on the toilet. Instead of using the toilet, R3 reported staff told her to just go in my pants and they will come clean me up. R3 reported she would love to sit on the toilet instead of just going in my pants. It would be way less embarrassing and humiliating to sit on the toilet. I would love that. R3 described use of the toilet as, That's never been an option for me according to staff. I just do what they tell me I have to do. During an interview on 10/23/19 at 08:20 AM, Certified Medication Aide (CMA) R reported staff had never offered R3 the opportunity to use the toilet because she's a lift and can't stand. CMA R reported the facility has special slings with cutouts for the rectal/genital area but stated those slings were only used for showers. During an interview on 10/23/19 at 10:00 AM. Administrative Nurse D denied knowledge that staff failed to offer R3 the opportunity to use the toilet for bowel movements/urination. The facility's 01/01/2019 Restorative Bowel and Bladder Management policy included, Each elder will be assessed for bladder and bowel functioning within seven days of admission, quarterly and at the time of any change in condition that affects continence. The policy directed staff to ensure that all elders, where physically possible, are toileted. The facility failed to offer the R3 the opportunity to use the toilet for bowel movements/urination, and instead instructed her to go in her incontinence brief. R3 verbalized feelings of embarrassment and humiliation as a result of using the incontinence brief for bowel movements and urination.

The facility census totaled 92 residents with 3 sampled for accident hazards related to risk of elopement (absent from the facility without staff's knowledge). Based on observation, interview and record review the facility to ensure staff accurately assessed residents and used the results of those assessments to develop individualized interventions to prevent elopement for 3 of 3 residents (#1, #2 and #3). The facility's failure to accurately assess resident #1 for elopement risk placed the resident in immediate jeopardy when resident #1 exited the building without staff's knowledge on 4/14/17 at 10:38 PM. He/she propelled his/her wheelchair through the facility parking lot towards a busy city street (less than 0.1 of a mile away). He/she encountered a raised area in the asphalt parking lot and fell from the wheelchair where he/she was found by a visitor to the facility who alerted staff. Findings included: - Review of the Inter-Agency Transfer (IAT) record dated 3/22/17 (date of admission to the facility) for resident #1 revealed a [DIAGNOSES REDACTED]. The admission minimum data set ((MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment. He/she displayed no behaviors and required extensive assistance of 1 staff for activities of daily living (ADLs) and used a wheelchair for mobility. Review of the cognition care area assessment (CAA) dated 4/3/17 revealed the resident had a history of [REDACTED]. He/she was pleasant and cooperative and had poor decision making skills. He/she did not make his/her needs known and staff needed to anticipate his/her needs. The fall CAA dated 4/3/17 indicated he/she needed extensive assistance with transfers and wheelchair mobility. He/she experienced several non-injury falls since admission. The ADL CAA did not trigger for a further assessment. Review of the Wander Data Collection Tool dated 3/22/17 revealed directions for staff to mark Yes or No for each evaluation factor. If there were any yes answers, it directed staff to summarize on side two of the assessment and complete the Summary of Findings corresponding to each evaluation number using the intervention codes at the top of the page. The scoring directions included 3 or more Yes answers indicated a definite risk for elopement; 1-2 Yes answers indicated at risk for elopement. Staff answered no to all questions for this resident on 3/22/17. The questions were as follows: 1. Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? 2. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? 3. Does the wandering intrude on the privacy or activities of others? 4. Was the resident cognitively impaired with poor decision-making skills (poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? 5. Was the resident a new admission or re-admission (within past 30 days) and not accepting the new living arrangement? 6. Does the resident have any visual, auditory or communication deficits? 7. Does the resident have a [DIAGNOSES REDACTED]. persistent belief or perception held by a person although evidence shows it was untrue) or hallucinations (sensing things while awake that appear to be real, but the mind created)? 8. Does the resident ambulate independently, with or without the use of assistive devices (include wheelchair)? 9. Does the resident verbally express the desire to go home or pack belongings to leave? Has the resident talked about going on a trip? 10. Does the resident receive any medication that increases the restlessness or agitation? 11. Was there a new behavior or had there been any changes in functional status/routine (new medication, pain, acute illness/infection, personal tragedy, new active diagnosis, upsetting information)? 12. Was the resident seeking to find spouse/family? 13. Does the resident's former lifestyle/profession reflect the current behaviors/wandering (night watchman, mailman, worked third shift)? Staff marked all answers no which inaccurately assessed the resident on question #7 and #8. Those questions answered as yes indicated the resident had risk factors and needed further evaluation. Review of the Summary of Findings on page two revealed staff did not complete it. Staff failed to determine the resident's risk for elopement and what triggered factors needed further evaluation and/or interventions for prevention of elopement. Review of the admission care plan dated 3/22/17 revealed the resident displayed moderately impaired cognition with short and long term memory problems, usually understood others and made him/herself understood. He/she had disorganized thinking but no behaviors and required assistance of 2 staff with transfers and 1 assist with wheelchair mobility. The care plan lacked any identification of elopement risk until 4/15/17 when staff added elopement risk, a wander guard (a device worn by an at risk resident which alerted staff when he/she approached an exit door) bracelet on left leg per protocol and monitor resident's whereabouts throughout the shift. The care plan included a non-injury fall on 3/26/17 with the addition of non-skid socks at all times, a non-injury fall on 3/27/17 with intervention of family member to spend the night with the resident and a non-injury fall on 4/2/17 and intervention of pressure alarm for chair and bed at all times. Review of the interdisciplinary notes between 3/22/17 and 4/28/17 (discharge) revealed no admission nursing note. A physician note dated 3/23/17 at 12:42 PM revealed the resident lived at home with family. He/she had a history of [REDACTED]. He/she had a recent hospitalization for [DIAGNOSES REDACTED] (a broad term for any brain disease which alters brain function or structure) with unclear reason. He/she did well initially then started having worsening confusion with rehospitalization on [DATE] and received treatment for [REDACTED]. A neuropsych (neuropsychology is a branch of psychology which is concerned with how the brain and the rest of the nervous system influenced a person's cognition and behaviors) evaluation revealed he/she had a major neurocognitive disorder and needed 24/7 care. The family felt he/she could meet the resident's needs at home and he/she discharged on [DATE] to home. Since that time he/she had increased weakness, increased confusion, falls and inability to care for self. He/she saw his/her primary care physician who referred the resident to the emergency department for testing which revealed no acute illness or changes and the resident was not hospitalized . The physician made a recommendation for skilled nursing and the resident transferred to the facility on [DATE]. The admitting social service note dated 3/23/17 at 1:49 PM revealed the resident admitted on [DATE] from acute care hospital for skilled services and referred to the IAT for diagnoses. The note indicated the resident wore glasses but did not indicate the extent of the resident's vision deficit. A nursing note dated 3/23/17 at 10:16 PM revealed the resident had confusion present, required 1 person assist with cares and used a wheelchair for ambulation. On 3/26/17 at 4:43 PM the note indicated at around 3:00 PM the resident's family member reported to the nurse the resident was on the floor. Upon arrival the nurse noted the resident sitting on his/her buttocks leaning on his/her chair. When asked what happened, he/she reported sliding off the chair. He/she attempted to go to the bathroom. The resident did not use the call light for help. Staff assessed for injury with none noted, assisted the resident off the floor, reminded the resident of the need to call for help when he/she needed to get up and recommended to wear non-skid socks at all times. On 3/27/17 at 9:20 PM a nurse wrote around 8:00 PM staff found the resident sitting on the floor in the TV area. Staff did not find a wheelchair or walker present. Staff indicated the resident walked from his/her room to the TV area without assistance. Staff assessed the resident for injury and found none. Staff implemented an intervention for a family member to stay with the resident in the evening and overnight to prevent falls. On 4/2/17 at 9:58 PM a nurse wrote at 9:15 PM staff found the resident crawling in the hallway. He/she had a small abrasion to the right knee. Staff implemented an intervention of a pressure alarm to the chair and bed at all times to alert staff of self-transfers. On 4/14/17 at 10:02 PM the note indicated the resident was alert, oriented with confusion. He/she could voice needs and used a wheelchair for ambulation with pressure alarm in place. The facility reported to the State agency on 4/17/17 the resident exited from the facility without staff's knowledge on 4/14/17 and staff found the resident outside at about 10:50 PM. Review of the facility's investigation revealed on 4/14/17 at 10:42 PM per video tape of the front entrance, staff saw the resident approach the door, pushed on the door, then moved over in his/her wheelchair and pushed the keypad and opened the door letting him/herself outside. At about 10:45 PM a visitor to the facility alerted the Assisted Living nurse of the resident sitting on the ground in the parking lot with a wheelchair by him/her. The nurse performed an assessment and found no injury and assisted him/her back into the wheelchair then back into the facility and to his/her nurse for further assessment. The nurse implemented one-on-one attention from staff and placed a wander guard. The next note dated 4/15/17 at 3:21 AM indicated staff visualized the resident seated in the wheelchair by the nursing station at 10:30 PM during shift changes. When the nurse returned he/she found the resident was not in the area. The nurse looked in the resident's room and bathroom but did not locate him/her. Staff began searching the 900 hall for the resident when a nurse from the Assisted Living portion of the facility notified the nurse of the resident being found on the ground outside with the wheelchair tipped over. Staff assisted the resident to his/her room, performed a body check of the resident and found no scratches or bruises. He/she could not tell staff what he/she tried to do. The nurse implemented a wander guard bracelet at that time to alert staff when the resident came to close to the door. A notarized statement from direct care staff A revealed on 4/14/17 he/she saw the resident in the 900 hall nursing station around 10:30 PM in the wheelchair. A notarized statement from direct care staff B revealed on 4/14/17 the resident sat in the nursing station with another nurse. Staff B needed to answer another resident's call light and left the resident in the nursing station. A notarized statement from licensed nurse E revealed he/she saw the resident at the beginning of his/her shift (10 pm-6 am) in the 900 hall nursing station in his/her wheelchair. He/she then went to the 300 hall to help a co-worker and upon return the resident was gone. Nurse E said he/she went to the resident's room and finished rounds on the 900 hall when he/she saw a direct care staff and an assisted living employee approaching with the resident and notified him/her of the resident falling outside. A notarized statement from licensed nurse C revealed at approximately 10:45 PM on 4/14/17 a visitor came to the nurse and reported a man in the parking lot needed help. Upon arrival outside to the parking lot the nurse noted the resident in a supine (flat on one's back, face upward, stretched out) position with legs extended in front of him/her, a wheelchair to the left of him/her and in a upright position. The resident could not remember what happened when asked. The nurse assessed the resident with no apparent injuries, assisted him/her to stand and he/she walked to the wheelchair with assistance from the nurse. The nurse returned the resident to the facility. Interview on 5/1/17 at 3:49 PM with direct care staff G revealed the resident usually had a family member here. He/she could propel independently in the wheelchair but usually the family member pushed him/her. Staff G reported the resident was confused. However, if a person did not know the resident he/she might not be able to tell. He/she said the resident would move about looking for his /her family members at times so the staff tried to keep him/her close because of his/her fall risk. Interview on 5/2/17 at 8:19 AM with direct care staff H revealed the resident could get up and move about in his/her wheelchair independently. He/she was confused at times. If a person were to ask him/her about previous work then he/she could talk about it but if you asked about current events he/she could not. Staff H reported the resident did not wander about but he/she would look for a family member when he/she saw another resident with a family member. Interview on 5/1/17 at 3:40 PM with licensed nurse F revealed he/she completed a wander assessment when a resident admitted or readmitted and every 90 days. He/she marked the questions based on his/her knowledge of caring for the resident and from report and documentation from the hospital. He/she reported he/she did not use the scoring of the wander data collection tool when identifying a resident's elopement risk. He/she looked more at the behavior of trying to leave for determining elopement risk. He/she reported not knowing about completing page two of the assessment and he/she usually only signed and dated it. If he/she determined the resident was at risk for elopement then he/she would immediately place a wander guard on the resident. Interview on 5/2/17 at 10:45 PM with licensed nurse J revealed he/she would complete the wander data collection tool on newly admitted residents. He/she reported only answering the questions on the front page and he/she did not use the score to determine if the resident needed a wander guard. He/she would consider the resident at risk if the resident had exit seeking behavior or said he/she wanted to leave. Interview on 5/1/17 at 4:19 PM with administrative nurse D revealed he/she did not usually have the nurses complete the summary on page two of the wander data collection tool. If the nurse felt the resident was at risk then he/she put a wander guard on the resident. He/she said the staff did not think the resident would attempt to leave as he/she displayed no exit-seeking behavior. He/she confirmed the questions #7 and #8, answered as no, were incorrect for the resident's status at the time of admission. The facility policy titled Quality Control Check for Wander Guard System dated 4/16/16 revealed the purpose of the wander guard was to ensure the safety for residents who were at risk for wandering. The policy directed staff to complete the wander guard assessment upon admission, every quarter and as needed. The policy did not instruct staff on how to complete the assessment, determine the risk factors or develop individualized interventions for elopement prevention. The policy directed staff in the event a resident was at risk the charge nurse had access to a wander guard. The facility failed to ensure staff accurately assessed and used the results of the assessment to develop individualized interventions to prevent elopement for resident #1 who newly admitted on [DATE] with [DIAGNOSES REDACTED].#1 exited the building without staff's knowledge on 4/14/17 at 10:38 PM. The resident propelled his/her wheelchair through the facility parking lot towards a busy city street (less than 0.1 of a mile away). He/she encountered a raised area in the asphalt parking lot, fell from the wheelchair and a visitor to the facility found him/her and notified staff. The facility abated the immediate jeopardy on 5/2/17 at 12:35 PM by implementation of the following measures: 1. Placement of a wander guard on the resident and initiated one-on-one supervision. 2. Maintenance staff changed the door code on 4/15/17 at 8:00 AM. 3. The DON/Nurse Administration educated all licensed nurses on the wander guard assessment and how to complete it. Each nurse would be educated prior to working the next scheduled shift. 4. Wander guard assessments would be completed on each resident to ensure accuracy with appropriate interventions by 5/2/17 at 2:00 PM. The assessments were completed by DON and nurse administration team. 5. DON/ADON would complete training on new hire and every 6 months licensed nurses in regards to the elopement policy and wander guard assessment tool. 6. Administrator and DON reviewed the policy on 5/1/17 at 6:00 PM with no changes made. 7. DON and/or designee would check admissions within 24 hours to ensure the nurse completed the assessment accurately and appropriate interventions were initiated. 8. DON or designee would complete chart audits to include the timely and accurate completion of the wander assessment tool for a minimum of 10 residents weekly for 4 weeks then monthly thereafter. The results of the audits would be brought to Quality Assurance committee for review and actions plans developed as indicated. The deficient practiced remained at a scope and severity of a D. - Review of the April 2017 signed physician's orders [REDACTED].#2 revealed [DIAGNOSES REDACTED]. The annual minimum data set ((MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 5, indicating severe cognitive impairment. He/she displayed behaviors in the 7 day observation period as follows: rejection of care on 1-3 days and no wandering behavior. He/she required extensive assistance of 1 staff for activities of daily living (ADLs) and used a wheelchair for mobility. The quarterly MDS dated [DATE] revealed the same cognition, behaviors, ADL assistance and wheelchair use as the 8/26/16 MDS. Review of the care area assessments (CAA) dated 9/7/16 revealed: The cognition CAA identified the resident with multiple co-morbidities and severe cognitive impairment. He/she had difficulty making him/herself understood at times due to inability to finish his/her thoughts and misunderstanding parts of conversations. He/she attempted to cover up his/her confusion by changing the subject at times. The ADL CAA indicated the resident required limited to extensive assist with ADLs, used a wheelchair for all mobility and independently propelled the wheelchair for short distances. The behavior CAA indicated the resident may resist care and may scream out which staff could re-approach at a later time or with different staff to elevate the behavior. Review of the Wander Data Collection Tool assessments revealed directions for staff to mark Yes or No for each evaluation factor. If there were any yes answers, it directed staff to summarize on side two of the assessment and complete the Summary of Findings corresponding to each evaluation number using the intervention codes at the top of the page. The scoring directions included 3 or more Yes answers indicated a definite risk for elopement; 1-2 Yes answers indicated at risk for elopement. The questions were as follows: 1. Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? 2. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? 3. Does the wandering intrude on the privacy or activities of others? 4. Was the resident cognitively impaired with poor decision-making skills (poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? 5. Was the resident a new admission or re-admission (within past 30 days) and not accepting the new living arrangement? 6. Does the resident have any visual, auditory or communication deficits? 7. Does the resident have a [DIAGNOSES REDACTED]. persistent belief or perception held by a person although evidence shows it was untrue) or hallucinations (sensing things while awake that appear to be real, but the mind created)? 8. Does the resident ambulate independently, with or without the use of assistive devices (include wheelchair)? 9. Does the resident verbally express the desire to go home or pack belongings to leave? Has the resident talked about going on a trip? 10. Does the resident receive any medication that increases the restlessness or agitation? 11. Was there a new behavior or had there been any changes in functional status/routine (new medication, pain, acute illness/infection, personal tragedy, new active diagnosis, upsetting information)? 12. Was the resident seeking to find spouse/family? 13. Does the resident's former lifestyle/profession reflect the current behaviors/wandering (night watchman, mailman, worked third shift)? On 5/31/16 staff marked question #4 as yes (cognitive impaired), #5 as yes (visual/auditory/communication deficits), #6 as yes ([DIAGNOSES REDACTED].#10 (medications). The nurse identified 5 areas as possible risk factors for elopement but failed to complete the summary of findings. The nurse marked not at risk on page two of the assessment without any explanation. On 8/22/16 staff marked the same questions yes as the 5/31/16 assessment and staff failed to complete the section #2 for summary of findings and risk on page two of the assessment. The nurse recorded in section #4 (the form included 4 sections for quarterly reviews) not at risk and signed 8/22/16. On 11/22/16 staff marked the same questions yes as the 5/31/16 assessment. The nurse identified 5 areas as possible risk factors for elopement but failed to complete the summary of findings. He/she marked not at risk on page two of the assessment without any explanation. On 2/20/17 staff marked the same questions yes as the 5/31/16 assessment with no summary of findings or whether he/she was at risk for elopement. The care plan with a revision date of 2/23/17 included a hand written entry dated 1/11/17 wander guard initiated. The care plan did not include the reason for the placement and the timing did not coordinate with any of the above assessments. There was not a specific problem of elopement risk or any signs to watch for just that he/she wore a wander guard. The cognition care plan directed staff to provide redirection and cues as needed. Offer simple direct instruction and offer cueing as needed to maximize communication and participation. Observe for changes in cognitive status. The self-care deficit care plan directed staff to place needed supplies on the bedside table within reach, break tasks up into smaller steps and allow rest breaks between tasks. He/she required extensive assistance with personal hygiene, dressing, transfers and wheelchair mobility but he/she was able to self-propel for short distances. Review of the March and April 2017 treatment administration record reviewed the resident wore a wander guard and staff checked the placement daily. Observation on 5/1/17 at 1:09 PM revealed the resident independently propelled in the hallway towards his/her room. He/she wheeled past his/her room and looked around as if trying to locate his/her room. Direct care staff K assisted the resident to his/her room and to the bathroom. The resident stood with staff assist, took a few steps and sat independently on the toilet. The resident wore a wander guard on his/her left ankle. Interview on 5/1/17 at 1:15 PM with direct care staff K revealed the resident propelled him/herself from his/her room to the dining room and/or lobby area every day. He/she did not wander to other areas the staff K had observed. Staff K reported the resident was at risk for elopement and wore a wander guard bracelet. He/she said if the resident got to close to the exit door, an alarm would sound and staff should respond immediately to redirect the resident. Interview on 5/1/17 at 2:51 PM direct care staff L said the resident was a 1 person assist with ADLs but he/she could be resistive at times. He/she could propel him/herself in the wheelchair but did not walk. He/she could take a few steps to get on/off the toilet or in/out of bed. Staff L said the resident had an elopement risk and wore a wander guard and the nurses managed the system. If the door alarm sounded the door and resident number would come across the pager and he/she would respond to keep the resident safe. He/she reported the resident had not tried to leave in a long time. He/she mostly just went from his/her room to the dining room. Interview on 5/1/17 at 1:27 PM licensed nurse M revealed the resident was at risk for elopement, wore a bracelet on his/her ankle to alert staff if he/she went too close to the exit doors. He/she would take the resident over by the door every morning to make sure the device functioned properly. He/she recorded the test on the resident's treatment administration record. He/she reported the resident had not tried to exit for a long time. Interview on 5/1/17 at 3:40 PM with licensed nurse F revealed he/she had not completed a wander assessment for this resident but when he/she completed an assessment on newly admitted or readmitted resident he/she marked the yes-no questions on the front page of the assessment based on his/her knowledge of caring for the resident and from report and documentation from the hospital. He/she would sign and date the back side (page two) but did not write a summary or use the scoring part of the wander data collection tool when identifying a resident's risk for elopement. He/she looked more at the behavior of trying to leave for determining elopement risk. If he/she determined the resident was at risk for elopement then he/she would immediately place a wander guard on the resident. Interview on 5/2/17 at 10:45 PM with licensed nurse J revealed he/she had not completed a wander data collection tool for this resident. He/she explained the procedure as completing the front page questions of the wander data collection tool on newly admitted residents. He/she did not use the scoring portion of the tool to determine if the resident needed a wander guard. He/she would consider the resident at risk if the resident had exit-seeking behavior or said he/she wanted to leave. Interview on 5/1/17 at 4:19 PM with administrative nurse D revealed he/she did not usually have the nurses complete the summary on page two of the wander data collection tool. If the nurse felt the resident was at risk for elopement then he/she put a wander guard on the resident. He/she confirmed the 4 assessments identified the resident as at risk based on the yes answers and that staff failed to accurately and properly complete page two of the assessment. The facility policy titled Quality Control Check for Wander Guard System dated 4/16/16 revealed the purpose of the wander guard was to ensure the safety for residents who were at risk for wandering. The policy directed staff to complete the wander guard assessment upon admission, every quarter and as needed. The policy did not instruct staff on how to complete the assessment, determine the risk factors or develop individualized interventions for elopement prevention. The policy directed staff in the event a resident was at risk the charge nurse had access to a wander guard. The facility failed to ensure staff thoroughly assessed and used the results of the assessment to develop individualized interventions to prevent or reduce the risk of an elopement for this cognitively impaired and independently mobile resident. - Review of the April 2017 signed physician's orders [REDACTED].#3 revealed a [DIAGNOSES REDACTED]. The admission minimum date set ((MDS) dated [DATE] revealed staff assessed the resident with moderately impaired cognition. He/she had no behaviors and required extensive assistance of 1 staff for activities of daily living (ADLs) and ambulated with a cane. The care area assessments (CAA) dated 2/2/17 included a cognition CAA which indicated the resident had moderate impairment in cognition and poor safety awareness with periods of inattention. He/she had expressive aphasia (condition with disordered or absent language function). He/she resisted cares and seemed to prefer being left alone. His/her mental status was difficult to assess due to non-compliance and impaired communication. The ADL CAA indicated he/she used a communication board at times to communicate his/her needs. He/she required extensive assistance with ADLs and walked with a cane and staff assistance. Review of the facility's Wander Data Collection Tool revealed directions for staff to mark Yes or No for each evaluation factor. If there were any yes answers, it directed staff to summarize on side two of the assessment and complete the Summary of Findings corresponding to each evaluation number using the intervention codes at the top of the page. The scoring directions included 3 or more Yes answers indicated a definite risk for elopement; 1-2 Yes answers indicated at risk for elopement. The questions were as follows: 1. Has the resident wandered? Did the resident wander at home, in previous living settings, family/significant others voiced concerns? 2. Does the wandering place the resident at significant risk of getting to a potentially dangerous place (stairs, outside the facility)? 3. Does the wandering intrude on the privacy or activities of others? 4. Was the resident cognitively impaired with poor decision-making skills (poor decisions, cues, intermittent confusion, inattention, disorganized thinking)? 5. Was the resident a new admission or re-admission (within past 30 days) and not accepting the new living arrangement? 6. Does the resident have any visual, auditory or communication deficits? 7. Does the resident have a [DIAGNOSES REDACTED].