Every finding on record at Legacy Nursing and Rehabilitation of Pollock

Based on observation, interview, and record review the facility failed to provide pharmaceutical services that assured accurate acquiring, receiving, dispensing and/or administration of medications to meet the needs of each resident. The facility had a total census of 86 residents. The facility failed to: 1. Ensure the on-coming nurse (S4 LPN) documented and signed the Narcotic count sheet at the beginning of shift; and 2. Ensure an accurate account for controlled substance medications were completed at the time of administration by S4 LPN on 1 (Cart A) of 2 (Cart A and Cart B) medication carts for Residents #1, #27, #40, #42, #51, #57, #62, #65, #72, #78, and #91.Findings: Review of an undated facility policy on 10/01/2025 at 11:36 a.m. titled, Narcotics Policy and Procedure revised on 10/2019 revealed the following in part .Policy: All controlled substances shall be counted at the change of each shift. The amount of each controlled substance on hand shall be listed on the Narcotic Count Sheet. Procedure: 1. One (1) licensed nurse from the off-going shift and one (1) licensed nurse from the oncoming shift must count and sign the Narcotic Count Sheet in front of the narcotic box. 6. The oncoming nurse shall sign his/her name on the count sheet. 1. On 10/01/2025 at 10:11 a.m , a controlled medications reconciliation was conducted with S4 LPN of Cart A. At the time of the medication reconciliation, review of the Narcotic Count Record revealed S4 LPN did not sign or document her signature as the oncoming nurse on 10/01/2025. S4 LPN confirmed that she did not sign the record when she came on shift stating I like to wait until the end of shift to sign it. S4 LPN confirmed she should have signed the Narcotic Count Record at the beginning of shift, but did not. 2. On 10/01/2025 at 10:11 a.m., a controlled medications reconciliation was conducted with S4 LPN of Cart A. S4 LPN confirmed she administered the following controlled substances for Residents #1, #27, #40, #42, #51, #57, #62, #65, #72, #78, and #91. Observation of the Individual Controlled Substances Record for the following revealed: -Resident #1-Oxycodone-APAP 7.5-325mg revealed 56 tablets/pills logged, 55 tablets/pills observed in blister pack; Alprazolam 0.25mg 14 tablets/pills logged, 13 tablets/pills observed in blister pack; Belbuca Buccal Film 750mcg 10 patches logged, 9 patches observed in zip-loc bag; -Resident #27-Clonazepam 0.5 mg revealed 28 tablets/pills logged, 27 tablets/pills observed in blister pack; -Resident #40-Lacosamide 200mg revealed 41 tablets/pills logged, 40 tablets/pills observed in blister pack; Tramadol 50mg 25 tablets/pills logged, 24 tablets/pills observed in blister pack; -Resident #42-Hydrocodone/APAP 10-325 mg revealed 2 tablets/pills logged, 1 tablet/pill observed in blister pack; -Resident #51-Hydrocodone/APAP 5-325mg revealed 17 tablets/pills logged, 16 tablets/pills observed in blister pack; -Resident #57-Hydrocodone/APAP 7.5-325 mg revealed 59 tablets/pills logged, 58 tablets/pills observed in blister pack; -Resident #62-Alprazolam 0.25 mg revealed 37 tablets/pills logged, 36 tablets/pills observed in blister pack; -Resident #65-Lorazepam 0.5 mg revealed 10 tablets/pills logged, 9 tablets/pills observed in blister pack; -Resident #72-Hydrocodone 10-325 mg revealed 46 tablets/pills logged, 45 tablets/pills observed in blister pack; -Resident #78-Alprazolam 0.5 mg revealed 10 tablets/pills logged, 9 tablets/pills observed in blister pack; and -Resident #91-Diazepam 5mg revealed 8 tablets/pills logged, observed 7 tablets/pills in blister pack S4 LPN confirmed the above findings and stated she did not sign or document the accurate count of the controlled substances immediately after administering the medications. S4 LPN stated I usually wait to do all of that in one big time. S4 LPN confirmed she should have documented the controlled substance count immediately after administering the medications for Residents #1, #27, #40, #42, #51, #57, #62, #65, #72, #78, and #91, but did not. In an interview on 10/01/2025 at 11:08 a.m., S1 DON stated that controlled substances are to be logged and documented immediately after the nurse administers the medication to residents. S1 DON confirmed that S4 LPN should have documented the Narcotic Count Record at the beginning of shift and should have documented the accurate count of controlled substances on the Individual Controlled Substances Record after administering the controlled substances, but did not.

Based on interview and record review, the facility failed to ensure Residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 3 (#10, #56, #67) of 4( #10, #56, #67, and #90) Residents reviewed for ADLS. The facility failed to ensure Resident #67 received a bath on his scheduled bath day, and failed to ensure Residents #10 and #56 received appropriate nail care. The total sample size was 37. Findings: Review of the facility's undated policy titled: Nail Care Policy and Procedure read in part.Procedure: (1) care of fingernails and toenails is part of the bath. (2) be certain nails are clean. (4) nails are to be clipped and filed smoothly. (NOTE): the podiatrist or licensed nurse clip nails for diabetic residents and residents with peripheral vascular disease. Resident #10 Review of Resident #10's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part .Dementia in other diseases classified elsewhere, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and Anxiety; Schizoaffective disorder, Depressive type. Review of Resident #10's Quarterly MDS with an ARD of 07/09/2025 revealed in part . Resident #10 had BIMS (Brief Interview Mental Status) of 14, which indicated intact cognition. Resident #10 required supervision/touching assistance for personal hygiene. Observation on 09/29/2025 at 4:14 p.m. revealed Resident #10 had a black substance on her fingers and beneath her nail beds. Observation on 09/30/2025 at 8:00 a.m. revealed Resident #10's fingernails had a black substance beneath her nail beds. Observation on 09/30/2025 at 12:54 p.m. revealed Resident #10's fingernails had a black substance beneath her nail beds. Interview on 09/30/2025 at 2:00 p.m. with S7LPN confirmed Resident #10's fingernails were in need of cleaning and should have been cleaned by staff. Resident #56 Review of Resident #56's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] with diagnoses that included in part .Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side; Morbid (severe) obesity due to excess calories; Polyosteoarthritis. Review of Resident #56's Quarterly MDS with an ARD of 09/17/2025 revealed in part . Resident #56 had BIMS of 13, which indicated intact cognition. Resident #56 required partial/moderate assistance with personal hygiene. Review of Resident #56's Care Plan initiated on 09/27/2024 with a review date of 10/05/2025 revealed in part Resident needed staff assistance for all ADL's. Interventions included: Assist me with hygiene and grooming tasks. Review of Resident #56's physician orders on 09/29/2025 at 3:54 p.m. revealed in part.-09/14/2025-podiatry to evaluate and treat thick nails and perform general foot care evaluation to prevent pain, ulcers, infections and circulatory problems. -07/20/2025-nurse to trim fingernails and toenails weekly as needed. -07/19/2025-inspect feet daily. Notify MD of any signs of injury, infections or other abnormalities. Interview on 09/30/2025 at 4:08 p.m. with Resident #56 stated her toenails had not been trimmed and she wanted them trimmed. Observation at time of interview revealed resident #56's toenails were long in length. Interview on 09/30/2025 at 4:10 p.m. S7LPN confirmed Resident #56's toenails needed to be trimmed. Resident #67 Review of Resident #67's Electronic Health Record revealed the Resident was admitted to the facility on [DATE] and had a re-entry date of 03/01/2024 with diagnoses that included in part . Cerebral Infarction, unspecified; Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side; and Altered mental status, unspecified. Review of Resident #67's Quarterly MDS with an ARD of 09/03/2025 revealed in part . Resident #67 had a BIMS of 5 indicating Severe Cognitive Impairment. Resident #67 was totally dependent on staff for transfers, toileting, bathing/showers, and bed mobility. Resident #67 had impairment on one side of upper extremity and both sides for lower extremities. Review of Resident #67's Care Plan with an initiate date of 11/17/2024 with review date of 12/13/2025 revealed in part Resident needed staff assistance with activities of daily living. Interventions included in part.Assist me with bathing, and assist me with hygiene and grooming. Interview on 09/29/2025 at 4:18 p.m. with Resident #67 stated he didn't have bath today and he would like shave. Observation at the time of the interview revealed Resident #67 had stubble facial hair. Interview on 09/30/2025 at 8:05 a.m. with Resident #67 stated he didn't have a bath today. Observation at the time of interview revealed Resident #67 had stubble facial hair. Interview with S3 CNA Supervisor on 09/30/2025 at 2:16 p.m. revealed she had bought S11CNA in Resident #67's room yesterday to give Resident #67 a bath, so Resident #67 should have had a bath. Interview with S11CNA on 09/30/2025 at 2:20 p.m. revealed he did not give Resident #67 a bath yesterday. Interview with S5CNA on 09/30/2025 at 2:24 p.m. revealed Resident #67 did not get a bath yesterday. Interview on 10/01/2025 at 9:40 a.m. with S3CNA supervisor revealed Resident #67 had not had a bath on 09/29/2025, but should have.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by failing to:1. Disinfect reusable medical equipment as required, 2. Maintain soiled linen/soiled items in a sanitary manner;2. Store clean linen in a sanitary manner; and3. Ensure staff were consistent with infection control practices for cleaning/disinfecting the environment. Findings: Review of an undated facility policy titled Infection Prevention and Control- Environmental Services read in part. Environmental Services staff shall follow infection prevention and control procedures applicable to the area he/she is assigned to. Soiled Linen: Soiled linen shall be place in an impervious bag of sufficient strength to contain wet/soiled linen without contaminating the resident environment. Soiled linen shall be bagged, in or near the resident's room, and securely closed prior to transport. Review of an undated facility policy titled Reusable Medical Devices Cleaning Policy and Procedure read in part. Reusable medical devices will be cleaned after each resident use to prevent spread of infection. All surface areas of the machine will be cleaned with disinfectant wipe according to manufacture recommendations. Review required contact time and make sure glucometer is cleansed according to contact time of product. All disinfectant to air dry. Observation on 09/29/2025 at 12:05 p.m. revealed S10 LPN removed a glucometer machine from a container on her medication cart that contained the glucometer meter and lancets. S10 LPN proceeded to a resident's room with the glucometer, performed a finger stick and then walked back to her medication cart, and placed the used glucometer back into the container without sanitizing the equipment. Interview with S10 LPN at time of observation confirmed she should have sanitized the glucometer prior to placing it back into the container on her medication cart, but did not. Observation on 09/30/2025 at 8:20 a.m. revealed S7 LPN removed a glucometer machine from a container on her medication cart that contained the glucometer meter and lancets. S7 LPN proceeded to a resident's room with the glucometer, performed a finger stick and then walked back to her medication cart, and placed the used glucometer back into the container without sanitizing the equipment. Interview with S7 LPN at time of observation confirmed she should have sanitized the glucometer prior to placing it back into the container on her medication cart, but did not.Observation on 09/30/2025 at 8:49 a.m. revealed S5 CNA assisted Resident #84 with ADL care. Observation revealed S5 CNA placed a soiled adult brief and the soiled linen removed from bed directly onto the resident's floor. S5 CNA then walked out of the room and obtained soiled linen barrels on the hall and placed them in front of the door of Resident #84's room. S5 CNA donned gloves and then placed the soiled items within the bins.Observation on 09/30/2025 at 9:10 a.m. of the facility laundry room with S12 Laundry revealed the facility stored clean mechanical lift pads on a shelf on the soiled side of the laundry room. S12 Laundry confirmed there should not be any clean laundered items stored on the dirty side of laundry room. Interview on 09/30/2025 at 9:17 a.m. with S13 HK revealed he used X-Effect disinfectant for cleaning resident's room, non-resident areas, and equipment. S13 HK stated his process for cleaning was that he sprayed the disinfectant on the area, and let it sit for 1 min before wiping. S13 HK stated sometimes he had to wipe the area right away, when he was in a hurry. Observation on 09/30/2025 at 9:22 a.m. of Hall X shower room with S14 CNA revealed she used X- Effect disinfectant for cleaning the shower after each resident use. S14 CNA stated she did not know what the dwell time was for the X-Effect disinfectant, but the Classic disinfectant she had used in the past had a 10 minute dwell time. S14 CNA stated she would have to get with housekeeping to determine the dwell time for X-Effect disinfectant. Observation of the shower curtain with the shower room revealed it had a heavy build up upon the curtain. S14 CNA stated the shower curtain had been there for as long as she could remember and stated it should be replaced. Interview on 09/30/2025 at 9:33 a.m. with S9 HK/Laundry Supervisor confirmed the clean lift pads stored within laundry should not be stored on the soiled side. S9 HK/Laundry Supervisor stated staff used X-Effect disinfectant for cleaning and stated the dwell time was 5 minutes. Review of the X- Effect product label revealed a 5 min dwell time. S9 HK/Laundry Supervisor confirmed staff should use a 5 minute dwell time when cleaning. S9 HK/Laundry Supervisor confirmed when handling soiled linen, staff was required to bring in a plastic bag to place the soiled linen in. S9 HK/Laundry Supervisor confirmed staff should never place soiled linen on the floor, and it should be contained in soiled linen bag and then placed in the appropriate container.Interview on 09/30/2025 at 2:05 p.m. with S5 CNA regarding observation on 09/30/2025 at 8:49 a.m. revealed she had forgot to bring in a bag to place the soiled adult brief and soiled linen within. S5 CNA stated she should not have placed the soiled items on the floor, and should have had a bag to contain the soiled items, but had not.Interview on 09/30/2025 at 2:18 p.m. with S3 CNA Supervisor confirmed the process for handling soiled linen/dirty items was that the CNA was to bring in a bag, and place soiled linen and trash into separate bags for transport to soiled room. S3 CNA Supervisor confirmed soiled items should never be placed directly onto the floor.

Based on interview and record review, the facility failed to ensure a Resident with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 1 (#10) of 5 (#3,#8,#33,#90) Residents reviewed for Dementia. The total sample size was 37. Findings:Review of the facility's undated policy titled: Care Planning Policy and Procedure read in part.Purpose: to provide a comprehensive plan of care addressing resident's needs, strengths, goals, and approaches. Policy: Each resident's care plan will remain current and inform staff of resident's needs, strengths, goals, and approaches. Review of Resident #10's Electronic Health Record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses that included in part. Dementia in other diseases classified elsewhere, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and Anxiety; Schizoaffective disorder, Depressive type. Review of Resident #10's Quarterly MDS with ARD of 07/09/2025 revealed in part.Resident #10 had BIMS (Brief Interview Mental Status) of 14 which indicated intact cognition. Resident #10 required setup or clean-up assistance for eating, toileting, and bed mobility and required supervision or touching assistance with transfers. Review of Resident #10's Care Plan initiated on 09/08/2025 with a review date of 11/23/2025 revealed no evidence of dementia care focus with appropriate interventions. Interview on 10/01/2025 at 9:33 a.m. with S6LPN/MDS acknowledged Resident#10's care plan did not include and support dementia with interventions.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 1(#14) of 4 (#14, #33, #49, and #75) residents reviewed for respiratory care. The facility failed to ensure respiratory equipment was properly stored. Findings: Review of the facility's undated policy titled, Nebulizer CPAP Machine Cleaning Policy and Procedure read in part . Purpose: To keep nebulizer or CPAP machine and equipment clean. Procedure: 2. Store tubing, mouthpiece, and mask in a plastic bag when not in use. Review of Resident #14's medical record revealed an admit date of 10/24/2023 with diagnoses that included: Quadriplegia, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Major Depressive Disorder. Review of Resident #14's 09/2025 Physician Orders read in part 10/24/2023 -Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 1 dose inhale orally via nebulizer every 6 hours as needed for shortness of breath. 09/24/2025-pratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 6 hours as needed for shortness of breath/wheezing. An observation on 09/29/2025 at 10:08 a.m. revealed Resident #14's nebulizer mask dated 09/24/2025, lying on the nightstand near nebulizers open to air, not secured in a bag. An observation on 09/30/2025 at 8:18 a.m. of Resident #14's room revealed the nebulizer mask continued to lay on the night stand, not secured in a bag. An interview on 9/30/2025 at 8:30 a.m., S8ADON confirmed that Resident #14's nebulizer mask was lying, open to air, on the nightstand. S8ADON stated that the nebulizer mask should have been bagged after use, but had not been.

Based on record review and interviews, the facility failed to ensure a resident's PRN order for psychotropic medication was limited to 14 days for 1 (Resident #90) of 5 residents (#3, #8, #10, #33, and #90) reviewed for unnecessary medications. Findings:Review of an undated facility policy titled, Psychotropic Medication Use Policy and Procedure, revealed the following in part.16. PRN orders for psychotropic drugs, excluding antipsychotics, are limited to 14 days. A. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days based on evaluation of the resident for the appropriateness of that medication. B. the physician shall document the rationale in the resident's medical record and indicate the duration for the PRN order.Review of Resident #90's medical record revealed an admit date of 05/09/2024 with diagnoses that included in part.Epilepsy, Vascular Dementia, Schizophrenia, Generalized Anxiety Disorder, and Major Depression Disorder. Review of Resident #90's 09/2025 physician's orders revealed an order for Lorazepam oral tablet 0.5 mg, give 1 tablet by mouth every 8 hours as needed for anxiety with an order date of 12/13/2024. Review of Resident #90's Quarterly MDS with an ARD of 11/20/2025 revealed Resident #90 received an antianxiety medication.Review of Resident #90's July, August, and September 2025 eMAR (Electronic Medication Administration Record) revealed documentation that the Lorazepam oral tablet 0.5 mg PRN order was still active and Resident #90 did not receive any dosage during these months. Review of Resident #90's Pharmaceutical Consultant Report dated 07/29/2025 revealed in part. Lorazepam oral tablet 0.5mg (Lorazepam) give 1 tablet by mouth every 8 hours as needed (PRN Psychotropic is limited to an initial 14 days and requires prescriber to evaluate resident prior to extending the order; if extending the order, document the rationale for the extended time period in the medical record). S18 MD wrote: still uses.Further record review revealed no current rationale or evaluation of Resident #90 by a physician or practitioner for the continued use of the Lorazepam PRN psychotropic medication after 07/29/2025.Interview on 09/30/2025 at 4:11 p.m., S1 DON stated Resident #90 doesn't have any behaviors or outbursts. S1 DON reviewed Resident #90's 09/2025 eMAR and confirmed the Lorazepam 0.5mg PRN order should have been discontinued and stated it was overlooked.

Based on observation, interview and record review the facility failed to promote and facilitate resident self-determination through support of resident choice about aspects of his or her life in the facility that were significant to the resident for 1 (#8) of 37 sampled residents. The facility failed to accommodate Resident #8's choice to have a shower during the mornings instead of during afternoons and evenings.Findings: Review of Resident #8's clinical record revealed an admit date of 01/30/2025 with diagnoses that included: Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Parkinsonism, Generalized Anxiety Disorder, and Dementia.Review of Resident #8's Quarterly MDS with an ARD of 11/05/2025 revealed a BIMS of 15, which indicated intact cognition. Resident #8 required substantial/maximal assistance with showers and bathing.Review of Resident #8's care plan with a review date of 11/08/2025 revealed Resident #8 required staff assistance with all ADLs. Interventions included in part: I prefer bathing in the tub/whirlpool in the morning. I prefer morning showers. Review of Resident #8's CNA Task flow chart for bathing/showering with a 30-day lookback revealed on the following dates:, 09/07/2025 at 12:14 p.m., 09/11/2025 at 4:18 p.m., 09/20/2025 at 1:25 p.m., 09/25/2025 at 4:10 p.m., and 09/30/2025 at 3:15 p.m. Resident #8 received a shower. Interview on 09/29/2025 at 10:09 a.m., Resident #8 stated she had issues with her bath days. Resident #8 stated she gets a shower or bath on Tuesdays, but that's not up to me. Resident #8 denied getting a shower or bath this morning. Observation of Resident #8 revealed her dressed in an orange shirt, burgundy jogging pants, and black socks.Interview on 09/30/2025 at 8:50 a.m., Resident #8 stated she'll get a bath tonight but prefers to have it in the morning. Resident #8 stated she doesn't get to choose when she gets her baths or showers and denied getting one this morning. Resident #8 had told staff before about wanting to shower or bath in the morning but couldn't remember who she spoke to and stated, They know I prefer mornings. Observation of Resident #8 revealed her still dressed in same dirty orange shirt, burgundy jogging pants, and black socks.Interview on 09/30/2025 at 8:59 a.m., S19 CNA stated Resident #8 gets her baths at night with the nightshift aides. S19 CNA stated Resident #8 doesn't resist care and is very compliant with staff. S19 CNA stated dayshift and nightshift split up the showers and she doesn't know why Resident #8 doesn't get her shower or bath in the mornings.Interview on 09/30/2025 at 3:10 p.m., Resident #8 stated, They said I have to take my baths/showers in the afternoon or at night, I never get a choice to choose when I want it. Resident #8 denied having a shower or bath this morning. Resident #8 observed dressed in same clothing from previous observations (dirty orange shirt, burgundy jogging pants, and black socks).Interview on 09/30/2025 at 3:15 p.m., S14 CNA stated Resident #8 gets a shower on Tuesdays, Thursdays, and Saturday mornings. S14 CNA confirmed Resident #8 did not get a shower until after lunch around 1:00 p.m. This surveyor questioned S14 CNA about not documenting a shower on 09/30/2025 and S14 CNA stated, Oh I forgot, let me chart that now. S14 CNA also stated that she put the same dirty clothing back on Resident #8 after giving her a shower this afternoon. Interview on 09/30/2025 at 3:39 p.m., Resident #8 revealed S14 CNA did not give her a bath today and stated, No I didn't get a bath or shower at all today. Observation of Resident #8 revealed her dressed in same clothing (dirty orange shirt, burgundy jogging pants, and black socks).Interview on 09/30/2025 at 4:11 p.m., S1 DON stated she wasn't aware of why Resident #8's preferences to have a shower in the morning were not honored, but should had been. S1 DON confirmed that after residents are bathe/showered, staff should not dress the resident in the same dirty clothing, unless it's been washed by laundry.

Based on observation, interview, and record review, the facility failed to ensure a resident with a diagnosis of dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. The facility failed to provide 1:1 observation as ordered for 1 (Resident #2) of 3 (Resident #1, Resident #2, and Resident #3) residents reviewed for abuse. This deficient practice had the potential to affect all 17 residents residing in the facility's secured unit.Review of Resident #2's medical record revealed an admission date of 07/24/2025 with diagnoses which included Dementia, Anxiety, and Psychosis.Resident #2's admission MDS with an ARD of 08/06/2025 revealed a BIMS score of 3, indicating severe cognitive impairment. Resident #2 had behavioral symptoms which interfered with activities or social interactions with others, significantly intruded upon the privacy or activity of others, and significantly disrupted care or the living environment. Resident #2's wandering behavior significantly intruded on the privacy or activities of others. Review of Resident #2's Physician's Orders revealed resident was placed on 1:1 observation every shift, on 08/09/2025. One-to-one observation every shift was discontinued on 08/13/2025 at 8:15 a.m., and re-ordered on 08/14/2025 at 6:00 a.m.Review of Resident #2's Care Plan revealed, in part.Resident #2 was hypersexual with staff and other residents. Interventions included, in part.Place on 1:1 observation every shift. Interview with S3CNA on 08/20/2025 at 3:05 p.m. revealed Resident #2 was ordered to have 1:1 observation, which required staff to stay within arm's reach. S3CNA revealed Resident #2 received 1:1 observation from 6:00 a.m. to 6:00 p.m. each day. Interview with S5LPN on 08/20/2025 at 3:30 p.m. revealed Resident #2 was ordered to have 1:1 observation every shift.Interview with S1DON on 08/21/2025 at 3:45 p.m. revealed Resident #2 was ordered to have 1:1 observation.Interview with S9CNA on 08/25/2025 at 11:22 a.m. revealed Resident #2 did not have 1:1 observation from 6:00 p.m. to 6:00 a.m. on 08/23/2025 or 08/24/2025.Interview with S6LPN on 08/25/2025 at 1:25 p.m. revealed the facility did not provide Resident #2 with 1:1 observation each day from 6:00 p.m. to 6:00 a.m.Interview with S12NP on 08/25/2025 at 2:37 p.m. revealed residents with dementia were more likely to wander and have behaviors at night. S12NP confirmed Resident #2 was to have 1:1 observation at all times.Interview with S11ADM on 08/25/2025 at 2:44 p.m. confirmed Resident #2 was ordered to have 1:1 observation every shift, but had not.

Based on record review and interview, the facility failed to ensure a resident's care plan was revised by failing to update fall interventions after each fall for 1 (#2) of 2 (#1 and #2) residents reviewed for falls. Findings: Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses that included in part .Parkinsonism, Major Depressive Disorder, Atherosclerotic Heart Disease, Unspecified Psychosis not due to a substance or known psychological condition, Unspecified fall, Unspecified Dementia, and Generalized Anxiety. Review of Resident #2's MDS with an ARD of 02/05/2025 revealed a BIMS score of 7, which indicated severe cognitive impairment. Review of the MDS revealed Resident #2 required extensive assistance with bed mobility, eating, toileting and transferring. Review of Resident #2's current care plan revealed a focus area of at risk for falls. The care plan documented the resident had falls on 02/13/2025, 02/28/2025, 03/18/2025, and 03/24/2025 (fall occurred on 03/25/2025). Interventions included Educate me on use of my call light, I need a night light on to help me see at night, I use a wheelchair for mobility, Monitor for changes in my condition that may warrant increased supervision/assistance and notify the physician, Place my frequently used items within my reach, and Refer me for therapy screen/evaluation as appropriate. Review of the MDS revealed these interventions were initiated 02/06/2025 with no new interventions put in place after falls on 02/13/2025, 02/28/2025, 03/18/2025, and 03/25/2025. In an interview on 04/02/2025 at 10:55 a.m., S6 MDS confirmed that new, individualized fall interventions are put in place after each fall occurs. S6 MDS confirmed new interventions from falls on 02/13/2025, 02/28/2025, 03/18/2025, 03/25/2025, and 03/28/2025 were not care planned but should have been. S6 MDS stated she had not added the new interventions because she had to wait until the DON closed out the incident report. In an interview on 04/02/2025 at 2:23 p.m., S2 DON reported new interventions should be added to the care plan by MDS nurse after each fall. S2 DON stated the new interventions should be added to care plan even if the incident and accident reports are not closed out. S2 DON confirmed new interventions had not been care planned after Resident #2 had falls on 02/13/2025, 02/28/2025, 03/18/2025, and 03/25/2025.

Based on record review and interview, the facility failed to provide services that meet professional standard of practice for 2 (#1 and #2) of 2 sampled residents with falls. The facility failed to ensure neurological checks were completed for 72 hours after an unwitnessed fall or fall with head injury. Findings: Review of facility's undated policy/procedure titled Incident Report Checklist revealed in part .Neuro checks implemented if head injury . Resident #1 Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses that included in part .Depression, Acute Embolism and Thrombosis of deep veins of right upper extremity, Mild Protein-Calorie malnutrition, Type 2 DM, and Unspecified Dementia. Review of Resident #1's Admission MDS with an ARD of 02/09/2025 revealed a BIMS score of 3, which indicated severe cognitive impairment. Review of the MDS revealed Resident #1 required substantial/maximal assistance with eating and rolling left and right and was dependent on staff with toileting hygiene, sitting to lying, sitting to standing, and chair/bed to chair transferring. Review of Incident Reports revealed Resident #1 had falls on 02/13/2025, 02/28/2025, and that were unwitnessed or the resident hit his head. Review of neurological observations forms for 02/13/2025, 02/28/2025, and 03/08/2025 revealed the neurological checks were not completed for 72 hours after the resident's falls. Neurological observations were completed for 21 hours on 02/13/2025, 32 hours on 02/28/2025, and 33 hours on 03/08/2025. In an interview on 04/02/2025 at 2:30 p.m., S2 DON stated neurological checks/observations should be completed for 72 hours after any unwitnessed fall or fall with head injury. S2 DON confirmed neurological checks were not completed for 72 hours for Resident #1 on 02/13/2025, 02/28/2025, and 03/08/2025 but should have been. Resident #2 Review of Resident #2's medical record revealed an admitted [DATE] with diagnoses that included in part .Parkinsonism, Major Depressive Disorder, Atherosclerotic Heart Disease, Unspecified Psychosis not due to a substance or known psychological condition, Unspecified fall, Unspecified Dementia, and Generalized Anxiety. Review of Resident #2's MDS with an ARD of 02/05/2025 revealed a BIMS score of 7, which indicated severe cognitive impairment. Review of the MDS revealed Resident #2 required extensive assistance with bed mobility, eating, toileting and transferring. Review of facility Incident Reports revealed Resident #2 had falls on 02/28/2025 and 03/25/2025 resulting in head injury. Review of neurological observations forms for 02/28/2025 and 03/25/2025 revealed the neurological checks were not completed for 72 hours after the resident's falls. Neurological observations were completed for 9 hours on 02/28/2025, and 21 hours on 03/25/2025. In an interview on 04/02/2025 at 2:30 p.m., S2 DON stated neurological checks/observations should be completed for 72 hours after any unwitnessed fall or fall with head injury. S2 DON confirmed neurological checks were not completed for 72 hours for Resident #2 on 02/28/2025 and 03/25/2025 but should have been.

Based on record review and interview, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent the development of new pressure ulcers for 2 (#1 and #3) of 2 residents investigated for skin issues by failing to: 1. Perform weekly wound assessments for Resident #3's DTI and 2. Perform wound care as ordered for Residents #1 and #3. Findings: Review of the facility's undated policy titled, Skin/Wound Documentation Policy and Procedure revealed in part .Skin and wounds will be documented upon admission, readmission, weekly, and as needed. With each dressing change, or at least weekly, the pressure ulcer (injury) wound shall be assessed and documented: date, location of ulcer and staging, size, depth of the wound, presence, location and extent of any undermining or tunneling, presence of exudate, pain, wound bed, description of wound edges and surrounding tissue, and the description of the healing of the pressure ulcer (injury). Resident #1 Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses that included in part .Depression, Acute Embolism and Thrombosis of Deep Veins of Right Upper Extremity, Mild Protein-Calorie Malnutrition, Type 2 Diabetes Mellitus, and Dementia. Review of Resident #1's Admission MDS with an ARD of 02/09/2025 revealed a BIMS score of 3, which indicated severe cognitive impairment. Resident #1 required substantial/maximal assistance with rolling left and right and was dependent on staff with toileting hygiene, sitting to lying, sitting to standing, and chair/bed to chair transferring. Review of Resident #1's physician's orders revealed the following: 03/26/2025: Cleanse abrasion to the left shin with wound cleanser, apply collagen and cover with dry dressing one time a day. 03/13/2025: Cleanse diabetic ulcer to the left 2nd toe with wound cleanser, apply betadine and cover with dry dressing one time a day. 03/13/2025: Cleanse diabetic ulcer to the left 3rd toe with wound cleanser, apply betadine and cover with dry dressing, one time a day. 03/13/2025: Cleanse diabetic ulcer to the left 4th toe with wound cleanser, apply betadine and cover with dry dressing one time a day. 03/05/2025: Cleanse diabetic ulcer to the right first toe MTP (metatarsophalangeal joint) medial with wound cleanser, apply collagen with ag (silver) and cover with dry dressing one time a day. 03/20/2025: Cleanse shearing wound to the left side of the sacrum with wound cleanser, apply skin prep and cover with dry dressing one time a day. 03/05/2025: Cleanse skin tear to the right inner elbow with wound cleanser, apply collagen and cover with dry dressing one time a day. Review of Resident #1's TAR (Treatment Administration Record) for 03/2025 revealed wound care was not completed on 03/29/2025 and 03/30/2025 for the abrasion to left shin; Wound care was not completed on 03/22/2025, 03/23/2025, 03/29/2025, and 03/30/25 for the diabetic ulcers to left second toe, left third toe, left fourth toe, and right first toe MTP; Wound care was not completed on 03/22/2025, 03/23/2025, 03/29/2025, and 03/30/2025 for the shearing wound to left side of the sacrum; Wound care was not completed on 03/22/2025 and 03/23/2025 for the skin tear to right inner elbow. In an interview on 04/02/2025 at 2:30 p.m., S2 DON confirmed Resident #1's wound care was not completed on the weekends on 03/22/2025, 03/23/2025, 03/29/2025, and 03/30/2025, but should have been. Resident #3 Review of Resident #3's medical record revealed an admitted [DATE] with diagnoses that included in part .Non-Ischemic Myocardial Injury, Fracture of Right Acetabulum, Fracture of the Right Pubis, Chronic Systolic (Congestive) Heart Failure, Hypothyroidism, Anemia, and Presence of Right Artificial Hip Joint. Review of Resident #3's State Optional MDS with an ARD of 02/08/2025 revealed a BIMS score of 13, which indicated intact cognition. Resident #3 required extensive assistance by one person with bed mobility, toileting, and transferring. Review of Resident #3's physician's orders revealed the following: 04/01/2025: Cleanse stage 3 pressure injury to the right lateral malleolus with wound cleanser, pat dry, apply Medi honey, and cover with dry dressing, one time a day. 03/17/2025: Cleanse DTI to the right lateral malleolus with wound cleanser, pat dry, paint with betadine, and cover with dry dressing one time a day. Discontinued on 03/31/2025. 04/01/2025: Cleanse unstageable pressure injury to the right lateral middle foot with wound cleanser, apply Medi honey and cover with dry dressing one time a day. Review of Resident #3's 03/2025 TAR revealed wound care was not performed for the sacral wound or DTI to the right ankle on 03/23/2025, 03/29/2025, and 03/30/2025. Review of Resident #3's progress notes dated 03/17/2025 revealed no notes regarding new wound/DTI to the right lateral malleolus. Review of NP wound care notes dated 03/17/2025 and 03/25/2025 during nursing home rounds revealed wound to the right lateral malleolus was not addressed. Review of NP wound care notes do not address the right lateral malleolus wound until 03/31/2025. In an interview on 04/02/2025 at 10:10 a.m., S4 WCN confirmed Resident #3's DTI was discovered on 03/17/2025 and a new physician's wound care order was initiated at that time. S4 WCN confirmed an assessment with measurements was not completed on 03/17/2025. S4 WCN confirmed the DTI was not assessed and measured until 03/31/2025. S4 WCN stated, It's my fault, I must have missed that. In an interview on 04/02/2025 at 2:30 p.m., S2 DON acknowledged Resident #3's DTI discovered on 03/17/2025 was not assessed until 03/31/2025. S2 DON confirmed Resident #3's wound care was not completed for the sacral wound or the DTI to the right ankle/lateral malleolus on 03/23/2025, 03/29/2025, and 03/30/2025, but should have been.

Based on record review and interview, the facility failed to ensure a resident's comprehensive person-centered care plan was implemented by failing to administer an antidepressant medication as ordered for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for care planning. Findings: Review of Resident #1's medical record revealed an admitted [DATE] with diagnoses that included in part .Depression, Acute Embolism and Thrombosis of deep veins of right upper extremity, Mild Protein-Calorie malnutrition, Type 2 DM, and Unspecified Dementia. Review of Resident #1's Admission MDS with an ARD of 02/09/2025 revealed a BIMS score of 3, which indicated severe cognitive impairment. Review of the MDS revealed Resident #1 required substantial/maximal assistance with eating and rolling left and right and was dependent on staff with toileting hygiene, sitting to lying, sitting to standing, and chair/bed to chair transferring. Review of Resident #1's care plan initiated on 01/28/2025 revealed the resident was care planned for Depression with interventions that included .Administer my medications as ordered by my physician and I need continuity with my care. Review of Resident #1's physician's orders revealed the following: 02/12/2025: Trazodone HCL Oral tablet 100mg, give one tablet by mouth one time a day for depression. Review of Resident #1's March 2025 Medication Administration Record revealed Resident #1 did not receive the daily dose of Trazodone 100mg on 03/24/2025, 03/25/2025, 03/29/2025, and 03/30/2025. Review of Resident #1's progress notes revealed S5 LPN made an entry on each of the above dates stating Waiting to receive from pharmacy. In an interview on 04/02/2025 at 9:00 a.m., S5 LPN confirmed Resident #1 did not receive Trazodone on the above dates. S5 LPN stated the resident did not have any Trazodone in the facility, stating she checked the medication cart and the cubby in the medication room. S5 LPN stated the medication was ordered and she didn't know why it hadn't come in. In an interview on 04/02/2025 at 2:30 p.m., S2 DON confirmed Resident #1 did not receive the daily dose of Trazodone as ordered on 03/24/2025, 03/25/2025, 03/29/2025, and 03/30/2025. S2 DON stated the nurse should have called the pharmacy to check on it when it was not available, but did not.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #3) of 3 (Resident #1, Resident #2, and Resident #3), sampled residents reviewed for respiratory care. The facility failed to ensure equipment was properly cleaned, labeled and stored. Findings: The facility's policy titled Oxygen Concentrator Cleaning Policy and Procedure with no revision date, read in part . Purpose To keep Oxygen Concentrator and equipment clean. Policy: Resident's Oxygen Concentrator will be kept clean when in resident room. Procedure: 1. All surface areas of the machine will be cleaned with disinfectant wipe or spray when needed. 2. Store Oxygen tubing, cannula, and mask in plastic bag when not in use. 3. Oxygen tubing cannula and mask to be changed out weekly and as needed. 4. Oxygen Concentrator filter to be washed out under running water weekly and as needed. Review of Resident #3's medical record revealed an admitted [DATE] with diagnosis that included in part .Chronic Obstructive Pulmonary Disease, Presence of Cardiac Pacemaker, and Cerebral Infarction Unspecified. Review of Resident #3's active Physician orders revealed the following order with a start date of 01/30/2024: Oxygen 2 liters per minute via nasal cannula as needed to keep Oxygen Saturation > 90% with Shortness of Breath every shift. Review of Resident #3's Care Plan with no review date revealed in part .I require Oxygen therapy as needed for Shortness Of Breath while lying flat; I have Asthma, Chronic Obstructive Pulmonary Disease (COPD), or Chronic Lung Disease with interventions that included in part . Administer my oxygen as ordered, I need my Oxygen when I have a respiratory crisis, I need my oxygen level tested with a pulse oximetry as ordered by my physician, and I need to have my respirations watched as appropriate. Observation and interview on 11/21/2024 at 10:30 a.m. revealed Resident #3 had an oxygen concentrator beside her bed with an uncovered and unlabeled nasal cannula lying on top of it. The oxygen concentrator had brown stains on the side of it and the filter was heavily covered with dust. Resident #3 revealed the oxygen concentrator belonged to her and she used it when she was Short of Breath. Observation and interview with S1 ADON on 11/21/2024 at 3:40 p.m. in Resident #3's room revealed the following: The oxygen concentrator with the nasal cannula lying on top of it uncovered and unlabeled, brown stains on the side of the concentrator and the filter heavily covered with dust. S1 ADON confirmed Resident #3's oxygen nasal cannula should have been covered and labeled. S1 ADON confirmed Resident #3's oxygen concentrator had brown stains on the side of it and the filter was dirty, and it should not have been.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for 9 residents that received mechanically altered diets prepared by the facility kitchen. Findings: Review of the facility's approved Menu Matrix menu revealed on 07/22/2024 the facility was on week 5. The Pureed Diet lunch to be served with serving size consisted of Beef Meatloaf 4oz., Black eye peas 4oz., Cauliflower with cheese mix 1/3 cup, and Pound cake 4 oz. Observation on 07/22/2024 at 12:10 p.m. revealed S4 Dietary [NAME] serving a pureed lunch tray using a 3 oz scoop for the pureed meatloaf. S4 Dietary [NAME] revealed she served the pureed meatloaf with a 3oz scoop but the 4oz scoop was required and should have been used. Interview on 07/22/24 at 12:15 p.m. with S6 Dietary manager confirmed that S4 Dietary cook was using the 3oz scoop instead of the 4ox scoop per serving that was supposed to be used. S6 Dietary Manager revealed that she typically checks the scoop sizes prior to serving meals but had forgotten today. She confirmed the wrong scoop size was used but should not have been.

Based on observation, interview and record review the facility failed to ensure services were provided to meet professional standards. The facility failed to: 1. Ensure controlled medications were administered at the time the medication was signed by the nurse as being administered for 9 (#4, #13, #39, #40, #43, #45, #56, #70 and #275) of 13 (#4, #13, #28, #29, #31, #39, #40, #43, #45, #56, #64, #70 and #275) Residents who received controlled medications; and 2. Ensure lab work was drawn in accordance with physician orders for 1 (#7) of 3 (#2, #7 and #21) Residents reviewed for labs. Findings: 1. Review of the facility's policy titled, Controlled Drug Management Policy And Procedure with no date, revealed the following, in part: .Administration/Recording: 1. When the medication is removed from stock, the Controlled Substance Disposition Record shall be completed to indicate a. Date, b. Time, c. Resident's name, d. Room number, e. Prescribing physician and f. Signed by the nurse administering the medication . On 07/24/2024 at 1:40 p.m., a narcotic reconciliation was done with S6 LPN and the S1 DON on Hall X medication cart. The Individual Controlled Substance Record sign out sheet was compared to the actual controlled medications on-hand, and revealed the following discrepancies which was verified by S6 LPN and S1 DON at the time of the observation: Resident #4 Review of the physician's order dated 07/20/2024 revealed Norco Oral Tablet 10-325 mg give 1 tablet by mouth two times a day. Review of the Individual Controlled Substances Record for Resident #4 revealed there were 9 tablets of Norco Oral Tablet 10-325 mg remaining. The last entry signed out by S6 LPN was on 07/24/2024, indicating that 1 tablet was given at 4:00 p.m. with 9 tablets remaining. Observations on 07/24/2024 around 1:40 p.m. of Resident #4's medication card of Norco 10-325 mg revealed there were 10 tablets remaining, instead of 9 tablets as indicated on the Individual controlled Substance Record. Resident #13 Review of the physician's order dated 04/05/2024 revealed Norco Oral Tablet 7.5-325 mg give 1 tablet by mouth every 4 hours. Review of the Individual Controlled Substances Record for Resident #13 revealed there were 63 tablets of Norco Oral Tablet 7.5-325 mg remaining. The last entry signed out by S6 LPN was on 07/24/2024, indicating that 1 tablet was given at 4:00 p.m. with 63 tablets remaining. Observations on 07/24/2024 around 1:40 p.m. of the medication card of Norco 7.5-325 mg revealed there were 64 tablets remaining, instead of 63 tablets as indicated on the Individual controlled Substance Record. Resident #39 Review of the physician's order dated 12/13/2024 revealed Norco Oral Tablet 10-325 mg give 1 tablet by mouth every 6 hours. Review of the Individual Controlled Substances Record for Resident #39 revealed there were 53 tablets of Norco Oral Tablet 10-325 mg remaining. The last entry signed out by S6 LPN was on 07/24/2024, indicating that 1 tablet was given at 2:00 p.m. with 53 tablets remaining. Observations on 07/24/2024 around 1:40 p.m. of Resident #39's medication card of Norco 10-325 mg revealed there were 55 tablets remaining, instead of 53 tablets as indicated on the Individual controlled Substance Record. Resident #40 Review of the physician's order dated 08/10/2023 revealed Xanax Oral Tablet 1 mg give 1 tablet by mouth two times a day. Review of the Individual Controlled Substances Record for Resident #40 revealed there were 23 tablets of Xanax Oral Tablet 1 mg remaining. The last entries signed out by S6 LPN was on 07/24/2024 indicating that 1 tablet was given at 8:00 a.m. and 4:00 p.m. with 23 tablets remaining. Observations on 07/24/2024 around 1:40 p.m. of Resident #40's medication card of Xanax 1 mg revealed there were 25 tablets remaining, instead of 23 tablets as indicated on the Individual controlled Substance Record. Resident #43 Review of the physician's order dated 01/24/2024 revealed Xanax Oral Tablet 0.25 mg give 1 tablet by mouth two times a day. Review of the Individual Controlled Substances Record for Resident #43 revealed there were 30 tablets of Xanax Oral Tablet 0.25 mg remaining. The last entry signed out by S6 LPN was on 07/24/2024 indicating that 1 tablet was given at 4:00 p.m. with 30 tablets remaining. Observations on 07/24/2024 around 1:40 p.m. of Resident #40's medication card of Xanax 0.25 mg revealed there were 31 tablets remaining, instead of 30 tablets as indicated on the Individual controlled Substance Record. Resident #45 Review of the physician's order dated 06/01/2024 revealed Oxycodone HCL Oral Tablets 10 mg give 1 tablet by mouth every 8 hours as needed for pain. Review of the Individual Controlled Substances Record for Resident #45 revealed there were 49 tablets of Oxycodone HCL Oral 10 mg tablets remaining. The last entry signed out by S6 LPN was on 07/24/2024 indicating that 1 tablet was given at 2:00 p.m. with 49 tablets remaining. Observations on 07/24/2024 around 1:40 p.m. of Resident #45's medication card of Oxycodone HCL10 mg revealed there were 50 tablets remaining, instead of 49 tablets as indicated on the Individual controlled Substance Record. Resident #56 Review of the physician's order dated 06/26/2024 revealed Ativan Oral Tablets 0.5 mg give 1 tablet by mouth 2 times per day. Review of the Individual Controlled Substances Record for Resident #56 revealed there were 8 tablets of Ativan Oral Tablets 0.5 mg tablets remaining. The last entry signed out by S6 LPN was on 07/24/2024 indicating that 1 tablet was given at 4:00 p.m. with 8 tablets remaining. Observations on 07/24/2024 around 1:40 p.m. of Resident #56's medication card of Ativan 0.5 mg revealed there were 9 tablets remaining, instead of 8 tablets as indicated on the Individual controlled Substance Record. Resident #70 Review of the physician's order dated 05/09/2024 revealed Lorazepam Oral Tablets 1 mg give 1 tablet by mouth 3 times per day. Review of the Individual Controlled Substances Record for Resident #70 revealed there were 9 tablets of Lorazepam 9 mg tablets remaining. The last entry signed out by S6 LPN was on 07/24/2024 indicating that 1 tablet was given at 4:00 p.m. with 9 tablets remaining. Observations on 07/24/2024 around 1:40 p.m. of Resident #70's medication card of Lorazepam 0.5 mg revealed there were 10 tablets remaining, instead of 9 tablets as indicated on the Individual controlled Substance Record. Resident #275 Review of the physician's order dated 07/06/2024 revealed Clonazepam Oral Tablets 2 mg give 1 tablet by mouth 2 times per day. Review of the Individual Controlled Substances Record for Resident #275 revealed there were 44 tablets of Clonazepam 2 mg tablets remaining. The last entry signed out by S6 LPN was on 07/24/2024 indicating that 1 tablet was given at 4:00 p.m. with 44 tablets remaining. Observations on 07/24/2024 around 1:40 p.m. of Resident #275's medication card of Clonazepam 2 mg revealed there were 45 tablets remaining, instead of 44 tablets as indicated on the Individual controlled Substance Record. An interview on 07/24/2024 with S6 LPN at approximately 1:40 p.m. at the time of the observations, revealed that she had signed the Individual Controlled Substance Record indicating the medications were administered. She reported that she should have signed out the controlled medications at the time of administration rather than ahead of time. She stated that she signed out her 4:00 p.m. narcotic medications earlier that day. An interview on 07/24/24 at 1:45 p.m. with S1 DON revealed that controlled substances should be signed out when they are administered. She stated that if a controlled substance is signed out by the nurse and not administered, the nurse should waste and/or dispose of the medicine in the presence of another nurse. S1 DON said both nurses would sign the Individual Controlled Substance Record indicating that the medication was wasted and/or destroyed. She stated that S6 LPN should not have signed out the controlled medication unless she was going to immediately administer the medication. 2. Review of Resident #7's medical record revealed an admitted [DATE], with diagnoses that included in part . Schizoaffective Disorder, Chronic Obstructive Pulmonary Disease, Epilepsy, Chronic Pulmonary Edema, and Anxiety Disorder. Review Resident #7's MDS with an ARD of 06/21/2024 revealed a BIMS of 07, which indicates severe cognitive impairment. Review of Resident #7's physicians order dated 04/19/2024 read in part . Depakote level monthly (Jan, Feb, Mar, Apr, May, Jun, Jul, Aug, Sep, Oct, Nov, Dec). Review of Resident #7's medical record revealed Depakote levels were done on 04/22/204 and 07/22/2024. An interview on 07/24/24 at 11:30 a.m. with S2 ADON revealed that she was the admitting nurse for Resident #7. She reported that the attending physician ordered Depakote levels to be done monthly. She stated that Depakote levels were done on 04/22/2024 and 07/22/2024. S2 ADON said that Depakote levels were not done in May 2024 or June 2024.

Based on observation, interview, and record review the facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for 9 Residents who were ordered and served pureed diets. Findings: Review of the facility's approved Menu Matrix menu revealed on 07/22/2024 the facility was on week 5. The Pureed Diet lunch to be served with serving size consisted of Beef Meatloaf 4oz., Black eye peas 4oz., Cauliflower with cheese mix 1/3 cup, and Pound cake 4 oz. Interview and observation on 07/22/2024 at 10:35 a.m. S5 Dietary [NAME] revealed there are 9 resident that received puree meats. S5 Dietary cook was observed using (8) 3oz meat patties, unmeasured amount of bread crumbs and 3 cups of water and added them to the blender. S5 Dietary [NAME] revealed she does not use a recipe because she had been cooking for so long. S5 dietary [NAME] stated (8) 3oz patties should be enough for the 9 pureed resident because the water and breadcrumbs have been added. Interview on 07/22/2024 at 12:15 p.m. S5 Dietary Manager confirmed the recipe for the pureed meals were not followed because she could not locate them, but should have been used. Interview on 07/23/2024 at 3:46 p.m. with S9 RD revealed the recipe for all meals should be followed to ensure residents are receiving adequate caloric intake.

Based on interview and record review the facility failed to include the Medical Director or designee in the Quality Assessment and Assurance process. Total sample size was 31. Findings: Review of the facility policy titled Quality Assurance Policy And Procedure with no review date revealed in part . Procedure: 4. The committee will consist of at minimum A. Medical Director B. Administrator C. Director of Nursing D. 3 other staff members designated by the facility Interview and record review on 07/24/2024 at 3:39 p.m. with S1 DON revealed the facility's Medical Director or designee had not been included on the Quality Assessment and Assurance Process Sign-in-sheets for March 2024 or June 2024. S1 DON confirmed the facility had no documented evidence of the Medical Director attending the Quality Assessment and Assurance Process Quarterly meetings in March 2024 and June 2024.

Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain good personal hygiene for 1 (#53 ) of 1 Residents reviewed for ADL's. The facility failed to ensure a Resident (#53) received incontinent care. Findings: Review of the facility's undated policy titled: Incontinence Care and Procedure read in part . Purpose: To keep skin clean, dry, free of irritation and odor, identify skin problems as soon as possible so treatment can be started, prevent skin breakdown, and prevent infection. Review of Resident #53's medical records revealed an admitted [DATE] with diagnoses that included: Type 2 Diabetes Mellitus, Schizoaffective Disorder, Unspecified Dementia, and Essential Hypertension. Review of Resident #53's Quarterly MDS with ARD of 04/16/2024 revealed Resident #53 had a BIMS of 01 (Severe Cognitive Impairment). Resident #53 was dependent on staff for all ADL's including toileting, shower/bathing, and personal hygiene. Review of the Facility's grievance log revealed Resident #53's family filed a grievance in 04/2024, 05/2024 and 06/2024 about Resident #53 not being provided incontinent care in a timely manner. Interview on 07/23/2024 at 12:32 p.m. with Resident #53's responsible party revealed she visits daily and Resident #53 is often saturated with urine that goes through his clothing. Resident #53's responsible party revealed she had spoken to management in the facility on several occasions and she continues to find him saturated with soil or feces when she visits. Client #53's responsible party revealed she has marked Resident #53's diapers and has come back 10-12 hours later and he was still in the saturated brief. Interview on 07/23/2024 at 9:02 a.m. with Resident #53's responsible party revealed the hospice aide came and bathed and changed him at 8:45 a.m. Resident #53's responsible party stated she marked the diaper with the time of 8:45 a.m. to see if he would be changed and will check in at 12:00 p.m. . Observation on 07/23/2024 at 12:05 p.m. with S1 DON revealed Resident #53 was wearing a soiled brief that was timed 8:45 a.m., S1 DON confirmed the resident was soiled and that the brief was timed 8:45. S1 DON stated that all residents should have Q2 incontinent care rounds made and confirmed that Resident #53 should had been provided incontinent care in a timely manner. Interview on 07/23/2024 at 12:20 p.m. S8 CNA revealed the last time he changed Resident #53 was at 10:00 a.m. This surveyor questioned S8 CNA about resident brief being timed 8:45 a.m. when we made an observation at 12:05 p.m. and S8 CNA stated he can't recall the exact time he changed Resident #53's brief and that maybe it was around 8:45 a.m S8 CNA then stated he did not change Resident #53 and that he was changed by the hospice aide after this surveyor asked if resident was changed by the hospice aide at 8:24 a.m. S8 CNA then stated he made rounds on the resident in the last 2.5 hours but could not recall time and revealed the resident was not wet. Interview on 07/23/2024 at 1:45 p.m. with S1 DON revealed the facility has had problems in the past with Resident #53 receiving incontinent care in a timely manner and that the processes that were put in place had been ineffective. S1 DON revealed the facility had recently implemented the ambassador round, where management staff make Q2 hours rounds on Resident #53 to ensure he is being provided incontinent care in a timely manner but confirmed the ambassador rounds had not been done today.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections by failing to ensure staff changed gloves and performed hand hygiene after touching contaminated areas during wound care for 1(#31) of 2 (#31 and #34) residents observed for wound care. Findings: Review of the Facility's undated policy titled Dressing Change, Clean Policy and Procedure read in part . Purpose 1. To protect the wound. 2. To prevent irritation. 3. To prevent infection and the spread of infection. 4. To promote healing. Review of Resident #31's 07/2024 Physician Orders read in part: 07/02/2024-Cleanse stage 4 pressure injury to right ischium with wound cleanser, fill wound bed with honey and collagen powder, layer with moist Dakin's gauze, cover with absorbent pad and secure with tape. 07/02/2024-Cleanse stage 4 pressure injury to left ischium with wound cleanser, fill wound bed with honey and collagen powder, layer with moist Dakin's gauze, cover with absorbent pad and secure with tape. Observation of wound care for Resident #31 on 07/23/2024 at 2:30 p.m. revealed S7 Treatment Nurse removed old dressing to right and left ischium wound, discarded dressing, then reached over the clean field without removing the soiled gloves or sanitizing hands. S7 Treatment Nurse then removed a 4x4 gauze and wound cleanser with soiled gloves and cleansed the wound. An interview on 07/23/2024 at 2:36 p.m., S7 Treatment Nurse was notified by this surveyor that she failed to remove soiled gloves and sanitize hands prior to obtaining supplies from the clean field and cleansing the wound. S7 Treatment Nurse confirmed that she should have removed the soiled gloves and sanitized her hands after removing the soiled dressing from Resident #31's ischium wound, but did not. Interview on 07/24/2024 at 11:42 a.m. with S2 ADON revealed the staff were not aware of needing to sanitize hands between gloves changing while providing wound care because the wound care policy didn't state that it should be done. S2 ADON confirmed she read the regulation and confirmed hands should have been sanitized after removing gloves while providing wound care. S2 ADON stated she will update the policy and notify staff of the changes.

Based on record review, and interview the facility failed to ensure residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene for 2 (#1 and #3) of 3 (#1, #2, and #3) sampled residents, and 4 (#R1, #R2, #R3, and #R4) of 6 (#R1, #R2, #R3, #R4, #R5, and #R6 random sampled residents. Findings: Resident #1 Review of the medical record for Resident #1 revealed an admitted [DATE], with diagnoses that included: Quadriplegia, Chronic Obstructive Pulmonary Disease, Acute Respiratory Failure with Hypoxia, Type 2 Diabetes, Hypoglycemia, Major Depressive Disorder, Chronic Pain, and Hypertension. Review of Resident #1's Quarterly MDS with an ARD of 03/25/2024, revealed a BIMS score of 15, indicating intact cognition. Review of the MDS revealed Resident #1 was dependent for shower/bath, toileting, hygiene, and toilet transfer. Review of Resident #1's care plan revealed she required staff assistance for all ADL's. Interventions included assist with bathing as needed. Review of a Grievance/Complaint Report dated 05/10/2024, revealed Resident #1 complained she was not getting her bath as scheduled. Interview with Resident #1 on 05/15/2024 at 9:43 a.m., revealed she was scheduled for a bed bath on 05/14/2024; however, the facility did not have enough CNAs to give her a bed bath on 05/14/2024. Resident #1 stated CNAs are to document when they provide ADL care, or give her a bed bath. Resident #1 revealed she required two CNAs for ADL care. Review of a Staff Rounding Tool located in Resident #1's room, and dated 05/14/2024, revealed Resident #1 did not receive a bed bath on 05/14/2024. Interview with S2 ADON on 05/15/2024 at 9:45 a.m., revealed the Staff Rounding Tool was to ensure staff provided care, and the care was documented. S2 ADON revealed on 05/14/2024, Resident #1 should have received a bed bath, and the bed bath should have been documented. S2 ADON confirmed no bed bath was documented for 05/14/2024. Resident #3 Review of the medical record for Resident #3 revealed an admitted [DATE], with diagnoses that included: Chronic Obstructive Pulmonary Disease, Cellulitis of Left Lower Limb, and Type 1 Diabetes Mellitus without Complications. Review of Resident #3's MDS with an ARD of 05/03/2024, revealed a BIMS score of 13, indicating intact cognition. Review of the MDS revealed Resident #3 required partial/moderate assistance with shower/bathe. Review of Resident #3's care plan revealed he required staff assistance for all ADL's. Interventions included to assist with bathing, hygiene and grooming. Interview with Resident #3 on 05/12/2024 at 7:04 p.m., revealed he had a Foley catheter, and he wanted a bath every day. He stated the facility did not have enough staff for him to receive a bath when he wanted a bath. Resident #3 stated his last bath was 2 days ago on 05/10/2024, and that he wanted a bath today (05/12/2024). However, there was only one CNA on hall C. Resident #3 stated she did not receive a bath on that day as requested. Interview with S3 LPN on 05/12/2024 at 7:53 p.m. confirmed Resident #3 wanted a bath today. However, she stated only one CNA worked hall C from 6:00 a.m. to 6:00 p.m. She stated she told Resident #3 she would bath him after her medication pass. S3 LPN confirmed Resident #3 did not receive a bath on this shift. #R1 Review of the medical record for R1 revealed an admitted [DATE], with diagnoses that included: Lower Back Pain, Chronic Kidney, Chronic Diastolic (Congestive) Heart Failure, and Right Heart Failure. Review of #R1's MDS dated [DATE], revealed a BIMS score of 14, indicating intact cognition. Review of the MDS revealed #R1 required partial/moderate assistance with shower/bathe. Review of #R1's care plan revealed required staff assistance for all ADL's. Interventions included to assist with bathing, hygiene and grooming. Review of #R1's Bathing Task for 05/08/2024 revealed N/A, 05/09/2024 revealed no documentation, and 05/10/2024 revealed N/A. Interview with #R1 on 05/16/2024 at 9:00 a.m. revealed he has not had a bath in one week. Interview with S4 Shower CNA on 05/14/2024 at 9:28 a.m., revealed she started as a Shower CNA on 05/07/2024. S4 Shower CNA stated she did not provide a bath to #R1 on 05/07/2024, 05/08/2024, and 05/09/2024, because she was pulled to work the floor. #R2 Review of the medical record for #R2 revealed an admitted [DATE], with a diagnosis of Disorder involving the immune mechanism. Review of #R2's MDS dated [DATE], revealed a BIMS score of 15, indicating intact cognition. Review of the MDS revealed Resident #R2 required substantial/maximal assistance with shower/bathe. Review of #R2's care plan revealed she required staff assistance for all ADL's. Interventions included to assist with bathing, hygiene and grooming. Review of #R2's Bathing Task for 05/07/2024 and 05/09/2024 revealed no documentation that he received a bath. Interview with #R2 on 05/16/2024 at 9:52 a.m., revealed the facility did not have enough CNAs. She stated she had been waiting in a BM diaper for 2 hours today. She stated her bath days are Tuesday, Thursday, and Saturday; however, she did not receive a bath on 05/07/2024 or 05/09/2024. Interview with S5 CNA 05/16/2024 at 9:54 a.m., revealed she clocked in at 7:30 a.m. at the sister facility, and then she was pulled from the sister facility to help with baths today. She revealed #R2 had been sitting in a diaper soiled with BM for 2 hours. #R3 Review of the medical record for #R3 revealed an admitted [DATE], and a readmitted [DATE]. Diagnosis included: Acute Embolism and Thrombosis, Type 2 Diabetes, Hemorrhagic Condition, Gastrointestinal Hemorrhage, Anemia, Gastro Esophageal Reflux Disease, and Depressive Disorder. Review of #R3's MDS dated [DATE], revealed a BIMS score of 15, indicating intact cognition. Review of the MDS revealed #R3 required substantial/maximal assistance with shower/bathe. Review of #R3's care plan revealed she required staff assistance for all ADL's. Interventions included to assist with bathing, hygiene and grooming. Review of #R3's Bathing Task for 05/06/2024 and 05/08/2024 revealed no documentation that she received a bath. Interview with #R3 on 05/16/2024 at 10:09 a.m., revealed the facility did not have enough CNAs. She stated she only received a whirlpool whenever the staff could get to her, and that was not often. #R3 revealed she received a whirlpool on 05/10/2024. #R4 Review of the medical record for #R4 revealed an admitted [DATE], with a readmitted [DATE]. Diagnosis included: Cerebral Infarction due to Embolism of Right middle Cerebral, Anemia, Type 2 Diabetes, Dementia, Major Depressive Disorder, Anxiety, and Pain. Review of #R4's MDS dated [DATE], revealed a BIMS score of 11, indicating moderate cognitive impairment. Review of the MDS revealed Resident #R4 was dependent on staff for shower/bathe. Review of #R4's care plan revealed she required staff assistance for all ADL's. Interventions included to assist with bathing, hygiene and grooming. Review of #R4's Bathing Task for 05/06/2024, 05/08/2024 and 05/10/2024 revealed no documentation that #R4 received a bath on those dates. Interview with #R4 on 05/16/2024 at 10:14 a.m., revealed the facility did not have enough CNAs. She stated she had not received a bath in several days. Review of Resident Council Meeting minutes revealed the following in part . March 28, 2024 at 1:44 p.m. - Nursing/CNA: More CNA staff needed for 6:00 p.m.to 6:00 a.m. April 25, 2024 at 2:40 p.m. - Nursing/CNA: More CNA staff needed for 6:00 p.m to 6:00 a.m. Interview with S8 CNA Supervsior on 05/13/2024 at 2:12 p.m., confirmed the facility was short of staff on 05/12/2024 for the 6:00 a.m. to 6:00 p.m. shifts, due to call ins, and residents did not receive baths as care planned. Interview with S10 Shower CNA/Shower on 05/14/2024 at 9:28 a.m., revealed she was the shower CNA on C hall. She stated on 05/07/2024, 05/08/2024 and 05/09/2024 she did not give whirlpools/showers because she was pulled to work the floor due to call-ins. Interview with S11 Shower CNA on 05/14/2024 at 9:38 a.m., revealed she documented N/A on the task sheets when pulled to the floor and bathes were not done She stated she did not give baths on 05/09/2024 because she was pulled to the hall to work. S11 CNA revealed the facility was short of staff. She stated she gave 1 whirlpool and 1 bedbath on 05/13/2024, because she was the only CNA on the hall. Interview on 05/15/2024 at 3:10 p.m. with S7 CNA, revealed she worked C hall alone on Sunday 05/12/2024, because the other CNA called in. Interview on 05/15/2024 at 4:00 p.m. with S11 Administrator confirmed the facility was short of CNAs.

Based on observation, interview and record review the facility failed to increase supervision of residents at risk for elopement and respond to alarms appropriately, for 2 (Resident #1 and Resident #2) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) sampled residents for elopement. The facility failed to: 1. Ensure door exit alarms could be heard by all staff in residents' rooms when the doors are closed; 2. Ensure a system of staff response was in place when the door alarm sounded, and staff were knowledgeable of the response system; and 3. Ensure Administration was notified when staff became aware that the alarm system and doors were not functioning properly. This deficient practice resulted in an Immediate Jeopardy situation on 05/17/2023 at 6:15 p.m., when Resident #1 who had a diagnosis of Dementia, exhibited exit seeking behaviors and wore a Wanderguard bracelet, exited the facility after the door exit alarm. Resident #1 was found by local police at 6:30 p.m. near a busy four lane highway that ran parallel to the facility. The facility's continued failure to identify potential system failures and respond appropriately, resulted in the immediate jeopardy continuing on 06/04/2023 at 8:00 a.m., when Resident #2 who had a diagnosis of Dementia, exhibited exit seeking behaviors and wore a Wanderguard bracelet, exited the facility, although staff were aware of a previous door malfunction, walked alongside a busy four lane highway, crossed a two lane highway that intersected the four lane highway, and was found at a convenience store by store staff 0.2 miles away. This deficient practice continues at a potential for more than minimal harm for all 5 residents (#1, #2, #3, #4 and #5) assessed as being at risk for elopement, have exit seeking behaviors, and wore Wanderguard alert bracelets. S1Administrator was notified of the Immediate Jeopardy situation on 07/18/2023 at 3:21 p.m. The Immediate Jeopardy situation was removed on 07/19/2023 at 5:00 p.m. when an acceptable plan of removal was presented. The facility's plan to remove the immediate jeopardy situation included the following: On May 17, 2023 Resident #1619 eloped from the facility. On June 4, 2023 Resident #1586 eloped from the facility. These incidents have the potential to affect all 5 residents who are at risk for elopement, and have been identified with exit seeking behaviors and require supervision. Staff being unable to hear the Wanderguard alarm sound when in a resident's room with the door closed, and thus failed to adequately supervise these residents, has been identified as the root cause of the elopement. The facility put the following corrective actions in place for the residents affected by the alleged deficient practice: On 07/18/2023 at 4:00 p.m., an operational check was completed on all exit doors by the Medical Equipment vendor to evaluate the current operational status of the magnetic door locking system. The volume was increased on the Hall W exit door. All exit Door codes were changed on 07/18/2023 by the Medical Equipment vendor. On 07/18/2023 at 4:30 p.m., an assigned employee was placed at the nurse's station as a Door Watch across all shifts to monitor the facility's Wanderguard annunciator panel to ensure the residents' safety and well-being. Door Watch staff will be in-serviced by the Administrator/Designee on required duties prior to assuming the Door Watch assignment. Door Watch staff will have no additional duties. Door alarm monitoring will be documented every 30 minutes by assigned staff. The Administrator/Designee will supervise the door watch documents 5 times weekly for 4 weeks to ensure no further issues have occurred. The Elopement and Wandering Resident Policy was reviewed and updated on 06/05/2023. The Elopement Risk Binder was reviewed on 07/18/2023 by the Director of Nursing to ensure the binder information is current. The Elopement Risk Binder will be updated by the MDS staff when a resident is identified with changes in cognition and if there are new admissions to the facility that meet the criteria for elopement risk and require a Wanderguard bracelet. The binder will be reviewed by the Director of Nursing/Designee weekly to ensure continued accuracy. Wanderguard bracelet for Resident #1586, #1596, #1604, #1607, and #1619 were checked on 07/18/2023 to ensure proper working order, and were functioning properly. Education of all staff by the Administrator/Designee on residents at risk for elopement and proper monitoring of those residents and current residents at risk for elopement began immediately on 07/18/2023, and will be completed on 07/19/2023. Upon hire, employees will be educated on the Elopement and Wandering Residents Policy, and annually thereafter unless such actions occur again. The QA Committee will supervise staff education to ensure all staff are properly educated. Resident that have been identified as elopement risk will be supervised by Administration/Designee or nursing staff/designee every 15 minutes for 7 days, then every 30 minutes for 7 days, then every hour continuously. The Administrator/Designee will monitor elopement risk documentation 5 times a week for 4 weeks. The QA Committee will discuss during daily or weekly meetings the interventions put in place as a result of the elopements that occurred on 05/17/2023 and 06/04/2023, and evaluations of interventions and if there is a need for an altered plan of interventions. The QA Committee will designate each department head to monitor/supervise weekly for a minimum of 3 months. The magnetic locking door system will be checked every 30 minutes by Administrative/Designee or nursing staff for 2 weeks then every hour for 2 weeks. The Administrator/Designee will monitor the door locking system checks 5 times a week for 4 weeks. Elopement Risk Assessments are completed by the MDS staff for all new admissions. A QAPI Performance Improvement Project will be implemented to review all corrective actions. All findings will be discussed at the monthly QAA meeting for a minimum of 3 months and quarterly thereafter for continued compliance and further interventions if needed Estimated completion date of 07/19/2023. For the remainder of this document Resident #1 is #1619, Resident #2 is #1586, Resident #3 is #1607, Resident #4 is #1596, and Resident #5 is #1604. Findings: Resident #1 Review of the facility Elopement policy revealed the following in part . Policy Statement: Please contact 911. Review of the Elopement policy revealed no information regarding prevention of elopement, or the procedure to follow in the event a door alarm sounds. Review of Resident #1's Face Sheet revealed an admitted [DATE] with diagnoses that included: Unspecified Dementia; Schizoaffective Disorder; Major Depressive Disorder, recurrent; Anxiety Disorder; and Insomnia, unspecified. Review of Resident #1's Wanderguard consent form dated 04/12/2023 revealed Wanderguard to wheelchair secondary elopement risk. Recommended restraint: Wanderguard with census checks q 2 hours. Medical symptoms warranting use: wanders in hallways in wheelchair and verbalizes she wants to go home. Reassess in 90 days. Review of Resident #1's Quarterly MDS with an ARD of 07/07/2023 revealed Resident #1 had a BIMS of 14 (cognitively intact). Resident #1 had behavior symptoms (pacing) not directed toward others, and was dependent with chair to bed transfers and walking 10 feet. Resident #1 used a wheelchair for mobility. Review of Resident #1 Comprehensive Care Plan revealed the following in part . Elopement: Potential for elopement r/t current diagnosis dementia 06/05/2023. Plan: 1. Redirect and reorient as needed. 2. Elopement/Wandering risk assessment for potential for elopement completed on admit, quarterly, and prn. 4. Apply Wanderguard bracelet if indicated with transmitter test q day. 5. Monitor and document visual census check as indicated. 6. Utilize a discrete personal identifier so staff is aware resident is at risk for elopement (running man placed on resident's door). 9. Notify MD and RR of any actual elopements. Has Wanderguards with census checks q 30 minutes. 07/07/2023 - Continue with Wanderguard to right lower leg with census checks of 1 hour. Continue with Wanderguard on front of w/c when/if resident gets up in w/c for short periods. Review of Resident #1's 04/03/2023 Risk of Elopement/Wandering Review revealed in part . Resident #1 verbalized that she wanted to go home, but did not seek exits. 04/12/2023 - Resident #1 verbalized that she wanted to go home, did not seek exits, but told S6 LPN that she wanted to leave, Wanderguard placed on front of w/c. 05/17/2023 - Resident #1 eloped from building with Wanderguard already attached to w/c. Wanderguard with census checks q 30 minutes for 24 hours, and Wanderguard to left lower leg and continue with Wanderguard on front of w/c. 05/18/2023 - Census checks to every hour. 06/04/2023 - Resident #1 has history of elopement. Continue with Wanderguard and census checks. 06/06/2023 - Wanderguard moved to right lower leg secondary to edema/wound to left lower extremity. 07/07/2023 - Continue with Wanderguard to right lower leg and front of w/c when Resident #1 gets up for short periods. Continue with census checks every hour. Review of Resident #1's Physician's Orders revealed the following: 04/12/2023 at 9:00 a.m. - Wanderguard with census checks q 2 hours. Wanderguard placed on front of w/c. Wander Guard transmitter test q day 6/2 shift. 05/17/2023 at 6:45 p.m. - Wanderguard with census checks q 30 minutes x 24 hours. Wander Guard to left lower leg and continue with Wanderguard on front of w/c. 05/18/2023 at 3:30 p.m. - Continue Wanderguard on front of w/c and left lower leg, and change census checks to q hour. 06/04/2023 (no time noted) - Change Wanderguard with census checks to q 30 minutes. 06/06/2023 (no time noted) - Wander Guard changed to right lower leg with census checks q 15 minutes x 72 hours as of 06/05/2023, then q 30 minutes x 72 hours then q 1 hours (expiration 01/2024) secondary to edema/wound to LLE. Continue with Wander Guard on front of w/c. Review of the facility's 05/19/2023 Investigation Report revealed an incident was reported to S1 Administrator on 05/17/2023 at 6:36 p.m., that local police brought Resident #1 back to the facility after recovering her from the side of the highway. Observation on 07/17/2023 at 10:04 a.m. revealed Resident #1 lying in bed, and a Wanderguard bracelet was noted to Resident #1's right lower leg. Resident #1 was alert and oriented to person and place. Interview with Resident #1 at that time however, revealed she was unable to remember leaving the facility unsupervised on 05/17/2023. Telephone interview conducted on 07/17/2023 at 10:49 a.m. with S5 CNA revealed she worked the night Resident #1 left the building. S5 CNA stated she did not work on Resident #1's hall, but she heard the alarm go off. S5 CNA stated she went to the nurse's station to see which door was alarming, and went to the door at the end of Hall W. S5 CNA stated she opened the door, looked around, and did not see anyone. S5 CNA stated she could not remember if there were any cars in the parking lot. S5 CNA stated she did not see anyone outside so she thought the door was messed up. S5 CNA stated she went back to the nurse's station and as she arrived, the door alarm went off again. S5 CNA stated she went back to Hall W door and looked outside again and did not see anyone. S5 CNA stated she then went back to her hall to work. S5 CNA stated she told the nurse on duty, but was not instructed to do anything further. S5 CNA stated she did not perform a resident check at that time, and was not instructed to do so. S5 CNA stated the CNA assigned to Hall W, came and told her the police brought Resident #1 back to the facility. Interview on 07/17/2023 at 11:12 a.m. with S6 LPN revealed she was not working at the facility when the incident with Resident #1 occurred, but she received a telephone call from S1 Administrator and went to the facility. S6 LPN stated she received report that Resident #1 had been picked up down the highway by the local police and returned to the facility. S6 LPN stated Resident #1 was assessed when she returned and was found without any injuries. S6 LPN stated she sat with Resident #1 upon return and ask her how she left the building. S6 LPN stated Resident #1 said she put in the code and left. S6 LPN stated she asked what the code was, and Resident #1 did not give the correct code. S6 LPN stated staff were instructed to check doors when they heard an alarm. Telephone interview on 07/17/2023 at 11:52 a.m. with S4 LPN revealed she was assigned to Hall W the night of the incident with Resident #1. S4 LPN stated she came out of a resident's room on Hall W at approximately 6:30 p.m., to find a police officer and Resident #1 standing outside of the door at the end of Hall W. S4 LPN stated the police officer stated she was bringing me (S4 LPN) a patient. S4 LPN stated she had not been notified an alarm had gone off, and she had not heard an alarm. S4 LPN stated she last observed Resident #1 at 4:30 p.m. S4 LPN stated before Resident #2's elopement, a resident was able to leave the building if the door was opened for them with a Wanderguard on, but since then, the Administrator had fixed things up, the alarm now sounded if a resident was near the door with a Wanderguard. Telephone interview on 07/17/2023 at 1:42 p.m. with S8 CNA revealed she worked on Hall W the night Resident #1 left the facility. S8 CNA stated she was in another resident's room on Hall W at the time the event occurred. S8 CNA stated she did not hear an alarm go off. S8 CNA stated she heard the police officer beating on the door at the end of Hall W, and the officer had Resident #1 with her. S8 CNA stated she saw Resident #1 in the living room of the facility about 10 minutes before the police arrived with Resident #1. S8 CNA stated that when Resident #1 returned, she kept yelling out an address that she wanted to go to. Interview on 07/17/2023 at 2:17 p.m. with S10 Maintenance revealed he did no actual monitoring of the alarms on the facility doors, but was contacted if there was a problem. S10 Maintenance stated he was not aware of how the Wanderguard alarm functioned if the code was put in and the door was opened. Interview on 07/18/2023 at 8:30 a.m. with S1 Administrator revealed the alarm system had alarm tones which were different if a resident was loitering (near the door), or if the exit doors were opened. S1 Administrator stated the special tones were initiated after the incident with Resident #2 on 06/04/2023. Observation beginning on 07/18/2023 at 8:30 a.m. revealed S2 LPN placed a Wanderguard on her ankle, went to the front door of the facility, and demonstrated the alarm for a loitering resident. The alarm sounded. At this time, the surveyor went into a resident's room on Hall W which was 4 doors down from the exit door, and shut the door. The loitering alarm could not be heard. S2 LPN was then asked by the surveyor to open the exit door of the facility on Hall W, and the alarm sounded. At 8:34 a.m., the surveyor and S9 CNA went into a resident's room on Hall W and closed the door. The surveyor and S9 CNA were unable to hear the exit alarm when the door to a room on Hall W was closed. S9 CNA confirmed she was unable to hear the alarm. Interview on 07/18/2023 at 8:36 a.m. with S1 Administrator confirmed she was unable to hear the exit alarm from a resident's room on Hall W when the door was closed. S1 Administrator stated she did not investigate this issue after the incident on 05/17/2023, because a CNA reported that she heard the alarm. S1 Administrator stated she did not know how this issue could be resolved without having alarms in each room. S1 Administrator confirmed that residents are still at risk for elopement due to inability of staff to hear alarms. Interview on 07/18/2023 at 12:25 p.m. with S1 Administrator revealed there was no documented education given to employees concerning response to the facility alarm system before or after the 05/17/2023 incident. Resident #2 Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included: Unspecified Dementia, Hyperlipidemia, Major Depressive Disorder and Essential Hypertension. Review of Resident #2's Quarterly MDS with an ARD of 05/17/2023 revealed BIMS of 6, which indicated severe cognitive impairment. Resident #2 required one-person physical assist with personal hygiene, toilet use and dressing; and supervision with locomotion on and off the unit. Resident #2 was coded for behaviors of wandering. Review of Resident #2's Care plan with a review date of 08/17/2023 revealed in part . Elopement: potential for elopement r/t current diagnosis Dementia - Plan 1. Redirect and reorient as needed. 4. Monitor and document visual census. Review of Resident #2's 07/2023 Physician Orders read in part . 06/04/2023 - Wanderguard with census checks Q1 hour. 03/06/2023 - Wanderguard Transmitter test every day. Review of Resident #2's Risk of Elopement/Wandering assessment read in part . 05/17/2023 - Resident is at risk for elopement/wandering, as evidence by: wanders hallways and verbalizes I need to get out of here on occasion. Continue with Wanderguard with census checks Q2 hours. 06/04/2023- Resident is at risk for elopement /wandering, as evidence by: Resident eloped from facility x 1. Continue with Wanderguard with census checks Q1hour after Q 30 minute checks x 24 hours. Appropriate interventions have been reviewed and modified: personal safety alarm devices, exit and stairwell alarms, frequent monitoring, staff aware or residents wander risk. Plan of care updated. Review of the facility's Investigation Report revealed on 06/04/2023 at 8:10 a.m., S3 RN received a telephone call from a local convenience store that a female resident was at their store under the protection of a local deputy. Resident #2 was then picked up from the convenience store by facility staff, and brought back to the facility at 8:20 a.m. where she was immediately assessed with no injuries noted. An interview on 07/18/2023 at 9:10 a.m. with S3 RN revealed that she worked as the weekend Registered Nurse and Treatment Nurse on 06/04/2023. S3 RN stated when she arrived to work on 06/04/2023 at 5:30 a.m., she noticed Resident #2 sitting in a chair in the lobby near the front door. S3 RN stated she put the code in the front door and was able to open the door. S3 RN stated she felt the door may have been malfunctioning because of how close Resident #2 was sitting to the door without alarming when she entered the building. S3 RN stated she told S11 LPN that she felt there was an issue with the door, and S11 LPN reset the door. Afterwards, S3 RN assisted Resident #2 to the door and the door alarm lights blinked indicating proper function. S3 RN stated that around 8:00 a.m. she went back to the nurses' station after passing medications, and noticed the front door was not closed properly and the alarm was not sounding. S3 RN stated she opened the front door and looked around outside to if there was anyone outside, but she didn't see anyone. S3 RN stated she then notified staff to do a census check to make sure all residents were accounted for. S3 RN revealed at 8:10 a.m., a clerk/employee from a local convenience store called and notified them that they believed they had one of their residents there. S3 RN stated she went to the store and picked up Resident #2, and once they got her back into the building, the door alarm went off. S3 RN stated that Resident #2 was assessed after she was brought back into the facility, and family and facility MD was notified. S3 RN revealed S1 Administrator was notified of the incident and Resident #2 was then placed on 1:1 observation. S3 RN revealed that if there were any issues with the door alarm system, staff were told they were to notify S1 Administrator. S3 RN stated that S1 administrator was not notified of a door malfunction until after Resident #2 eloped from the building. An interview on 07/18/2023 at 10:00 a.m. with S1 Administrator revealed that she was notified on 06/04/2023 at 8:15 am that Resident #2 had eloped. S1 Administrator stated that S11 LPN informed her of a potential issue with the door when she called to notify her that Resident #2 had eloped. S1 Administrator stated that once she got to the facility, she investigated and noted that there were no issues with the door lock or alarm at that time. S1 Administrator stated there was no routine maintenance for the alarm system, and that the door alarm system company only came out when they were called. An interview on 07/19/2023 10:45 a.m. with S11 LPN revealed that she worked the day Resident #2 eloped. S11 LPN stated a few minutes before 8:00 a.m., she saw Resident #2 in the hallways and Resident #2 was upset because she saw a little boy in the facility that she thought he was her son, and wanted him to go with her. S11 LPN stated Resident#2 was redirected and then went to the dining room. S11 LPN stated she continued with her medication pass. S11 LPN revealed that at 8:10 a.m., she was notified by a staff member that a resident had eloped, and was at a local convenience store. S11 LPN denied hearing an alarm sound the morning prior to the elopement. S11 LPN stated on the morning of 06/04/2023, there was a resident (unsure which one) was able to get close to the front door without it alarming, so she used a key to reset the door alarm system to ensure that it functioned properly. S11 LPN stated that on 06/04/2023 at 2:00 p.m., she notified S1 Administrator that she did not feel the front door was functioning as it should, and S1 Administrator initiated a door watch at that time. S11 LPN revealed that she did not notify S1 Administrator of a door malfunction prior to the elopement that took place on 06/04/2023. Interview on 07/18/2023 at 12:25 p.m. with S1 Administrator revealed the Elopement policy was used as education for the in-service given after Resident #1 eloped from the facility. S1 Administrator confirmed there was no information concerning responding to facility alarms. An Interview on 07/19/2023 at 2:25 p.m. with S1 Administrator revealed that she should be notified immediately if there are any issues with the function of the doors. S1 Administrator stated she was unaware a key had been used to reset the door alarm on the morning of 06/04/2023. S1 Administrator confirmed that staff should have notified her prior to Resident #2's elopement on the morning of 06/04/2023, when they felt there was an issue with the front door, and they did not.

Based on interview and record review the failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 residents (#1 and #2) in a sample of 5 residents (#1, #2, #3, #4 and #5) reviewed for elopement. The facility's Administration failed to: 1. Ensure supervision was increased for residents at risk for elopement when staff became aware of improper functioning of door alarms and doors; 2. Ensure an effective system of staff response was in place when the door alarm sounded; and 3. Ensure staff were effectively trained and knowledgeable of their system of response, and adhered to training. This deficient practice resulted in an Immediate Jeopardy situation on 05/17/2023 at 6:15 p.m., when Resident #1 who had a diagnosis of Dementia, exhibited exit seeking behaviors and wore a Wanderguard bracelet, exited the facility after the door exit alarm. Resident #1 was found by local police at 6:30 p.m. near a busy four lane highway that runs parallel to the facility. The facility's continued failure to identify potential system failures and respond appropriately, resulted in the immediate jeopardy continuing on 06/04/2023 at 8:00 a.m., when Resident #2 who had a diagnosis of Dementia, exhibited exit seeking behaviors and wore a Wanderguard bracelet, exited the facility, although staff were aware of a previous door malfunction, walked alongside a busy four lane highway, crossed a two lane highway that intersected the four lane highway, and was found at a convenience store by store staff 0.2 miles away. S1Administrator was notified of the Immediate Jeopardy situation on 07/18/2023 at 3:21 p.m. The Immediate Jeopardy situation was removed on 07/19/2023 at 5:00 p.m. when an acceptable plan of removal was presented. The facility's plan to remove the immediate jeopardy situation included the following: Summary of Events: On July 1, 2023 at 3:21 p.m. the Administrator was notified of an Immediate Jeopardy situation for the facility's administration failure to implement a system to provide supervision to prevent elopement. An Immediate Jeopardy Template was provided at this time. The following actions were implemented immediately: On 07/18/2023 at 4:00 p.m., an operational check was completed on all exit doors by Medical Equipment Company staff to evaluate the current operation status of the magnetic door locking system. The volume was increased on Hall W exit door. Door codes were also changed on 07/18/2023 by Medical Equipment Company staff. On 07/18/2023 at 4:30 p.m., an assigned employee was placed at the nurse's station as a Door Watch across all shifts to monitor the facility Wanderguard annunciator panel to ensure the resident's safety and well-being. Door Watch staff will be in-serviced by the Administrator/Designee on required duties prior to assuming the Door Watch assignment. Door alarm monitoring will be documented every 30 minutes by assigned staff. The Administrator/Designee will monitor the door watch documentation 5 times weekly for 4 weeks to ensure no further issues have occurred. The Elopement Risk Binder was reviewed on 07/18/2023 by the Director of Nursing to ensure the binder information is current. The Elopement Risk Binder will be updated by the MDS staff when a resident is identified with changes in cognition. On 07/19/2023 at 4:10 p.m. Administration was in-serviced by VP of Operations on Policies and Procedures for Elopement to include prevention of elopement and interventions if an elopement occurs. On 07/19/2023 at 4:15 p.m. Administration was in-serviced by VP of Operations on Supervision of Residents at Risk for Elopement. VP of Operations will ensure Administration/Designee monitors resident elopement risks by auditing risk documentation weekly x 4 weeks. Resident Specific Actions: Wanderguard bracelet for Residents #1586, #1596. #1604, #1607 and #1619 were checked on 07/18/2023 to ensure proper working order. Residents that have been identified as elopement risk will be monitored by Administrative/Designee or nursing staff every 15 minutes for 7 days, then every 30 minutes for 7 days, then every hour continuously. The Administrator/Designee will monitor elopement risk documentation 5 times a week for 4 weeks. The Elopement Risk Binder was reviewed on 07/18/2023 by the Director of Nursing to ensure the binder information is current. The Elopement Risk Binder will be updated by the MDS staff when a resident is identified with changes in cognition and if there are new admissions to the facility that meet the criteria for elopement risk and require a Wanderguard bracelet. The binder will be reviewed by the Director of Nursing/Designee weekly to ensure continued accuracy. QAPI: On 07/19/2023 at 9:00 a.m. the QAPI Committee met to review and conduct a Root Cause Analysis and review policies and procedures for possible changes. A QAPI Performance Improvement Project will be implemented to review all corrective actions. All findings will be discussed at the monthly QAA meeting for a minimum of 3 months and quarterly thereafter for continued compliance and further interventions if needed. Education of all staff by the Administrator/Designee on residents at risk for elopement and proper monitoring of those residents and current residents at risk for elopement began immediately on 07/18/2023 and will be completed on 07/19/2023. Education will be continued monthly for 1 month. Upon hire employees will be educated on the Elopement and Wandering Residents Policy and annually thereafter unless such actions occur again. The QA Committee will supervise staff education to ensure all staff is properly educated and compliant. On 07/19/2023 the Administrator completed a reconciliation of the required Elopement and Wandering Residents education. No current employee or new will be allowed to work until staff education of Elopement and Residents Policy has been completed. Estimated completion date of 07/19/2023. For the remainder of this document Resident #1 is #1619, Resident #2 is #1586, Resident #3 is #1607, Resident #4 is #1596, and Resident #5 is #1604. This deficient practice continues at a potential for more than minimal harm for all 5 residents (#1, #2, #3, #4 and #5) assessed as being at risk for elopement, have exit seeking behaviors, and wore Wanderguard alert bracelets. Findings: Cross refer to F689. Review of the facility Elopement policy revealed the following in part . Policy Statement: Please contact 911. Review of the Elopement policy revealed no information regarding prevention of elopement, or what to do if a door alarm goes off. Interview on 07/18/2023 at 8:30 a.m. with S1 Administrator revealed the alarm system had alarm tones which were different if a resident was loitering near the door, or if the exit doors were open. S1 Administrator stated the special tones were initiated after the incident with Resident #2 on 06/04/2023. Interview on 07/18/2023 at 8:36 a.m. with S1 Administrator confirmed she was unable to hear the exit alarm from a resident's room on Hall W when the door was closed. S1 Administrator stated she did not investigate this issue after the incident on 05/17/2023, because a CNA reported that she heard the alarm. S1 Administrator stated she did not know how this issue could be resolved without having alarms in each room. S1 Administrator confirmed that residents were still at risk for elopement due to inability of staff to hear alarms. An interview on 07/18/2023 at 9:10 a.m. with S3 RN revealed that she worked as the weekend Registered Nurse and Treatment Nurse on 06/04/2023. S3 RN stated when she arrived to work on 06/04/2023 at 5:30 a.m., she noticed Resident #2 sitting in a chair in the lobby near the front door. S3 RN stated she put the code in the front door and was able to open the door. S3 RN stated she felt the door may have been malfunctioning because of how close Resident #2 was sitting to the door without alarming when she entered the building. S3 RN stated she told S11 LPN that she felt there was an issue with the door and S11 LPN reset the door. S3 RN stated that around 8:00 a.m. she went back to the nurses' station after passing medications, and noticed the front door was not closed properly and the alarm was not sounding. S3 RN stated she opened the front door and looked around outside to if there was anyone outside, but she didn't see anyone. S3 RN stated she then notified staff to do a census check to make sure all residents were accounted for. S3 RN revealed at 8:10 a.m., a clerk/employee from a local convenience store called and notified them that they believed they had one of their residents there. S3 RN stated she went to the store and picked up Resident #2, and once they got her back into the building the door alarm went off. S3 RN stated that Resident #2 was assessed after she was brought back into the facility and family and facility MD was notified. S3 RN revealed S1 Administrator was notified of the incident and Resident #2 was then placed on 1:1 observation. S3 RN revealed that if there were any issues with the door alarm system, staff were told to notify S1 Administrator. S3 RN stated that S1 administrator was not notified of a door malfunction until after Resident #2 eloped from the building. An interview on 07/18/2023 at 10:00 a.m. with S1 Administrator revealed that she was notified on 06/04/2023 at 8:15 am that Resident #2 had eloped. S1 Administrator stated that S11 LPN informed her of a potential issue with the door when she called to notify her that Resident #2 had eloped. S1 Administrator stated that once she got to the facility, she investigated and noted that there were no issues with the door lock or alarm at that time. S1 Administrator stated there was no routine maintenance for the alarm system, and that the door alarm system company only came out when they were called. Interview on 07/18/2023 at 12:25 p.m. with S1 Administrator revealed the Elopement policy was used as education for the in-service given after Resident #1 eloped from the facility. S1 Administrator confirmed there was no information concerning responding to facility alarms. S1 Administrator confirmed there was no documented education given to employees concerning response to the facility alarm system before or after the 05/17/2023 incident. An interview on 07/19/2023 at 2:25 p.m. with S1 Administrator revealed that she should be notified immediately if there are any issues with the function of the doors. S1 Administrator stated she was unaware a key had been used to reset the door alarm on the morning of 06/04/2023. S1 Administrator confirmed that staff should have notified her prior to Resident #2's elopement on the morning of 06/04/2023, when they felt there was an issue with the front door, and they did not.

Based on observation, interview and record review the facility failed to review and revise the plan of care for 2 of 5 sampled residents who had falls (#4 and 2). The facility's total census was 50 according to the Resident Census and Conditions of Residents form. The facility failed to: 1. care plan interventions to lock the bed wheels for a resident with cognitive impairment and at high risk for falls to prevent the resident from falling out of bed (#4); 2. care plan interventions to lock the bed wheels upon hospital return after the resident fell out of bed between the wall and the bed and received a closed head injury (#4); 3. care plan interventions to lock the bed wheels for a resident with falls, at high risk for falls and who transferred without assistance (#2). Resident #4 was admitted to the facility with an original admission date of [DATE] and a current admission date of [DATE]. The resident was assessed to have moderate impairment in cognition with intermittent confusion, high risk for falls and required extensive one person assistance for bed mobility. Interview with multiple staff member revealed conflicting stories concerning the resident's ability to move herself in bed. Some staff stated the resident was able to turn herself in bed at times, and others stated the resident could not turn herself in bed at all. The resident had not been assessed for the use of side rails for safety, nor had the resident been care planned for the bed to be locked. On 5/21/11 at 10:30 p.m. the resident was found face down on the floor between her bed and the wall. The resident received a large hematoma to her left eyebrow, contusion near her hairline, moderate amount of bleeding from areas of her head, bruising to several places on her left arm, abrasions and swelling, and she complained of moderate pain to her knees. The resident was transferred to the emergency room , and the physician documented a clinical impression of Concussion and Post Concussio[DIAGNOSES REDACTED]. The resident was admitted for overnight observation with [DIAGNOSES REDACTED]. The resident returned from the hospital to the facility on [DATE] at 7:45 p.m. and was transferred to another facility on 6/10/11. The facility identified the incident as a fall due to the resident being found on the floor. Interview with staff revealed the resident's bed wheels were not locked when she was found on the floor on 5/21/11. After the resident returned to the facility from the hospital on [DATE] the facility did not review and revise the care plan for a measure to lock her bed wheels. Findings: 1. Review of physician's orders [REDACTED]. Review of the MDS assessments dated 01/04/11 and 03/30/11 reflected the resident received a Summary Score of 4 out of 15 on the Brief Interview of Mental Status. The assessment reflected the resident received a score of 3 for repetition of three words, a score of zero for temporal orientation to (year, month and day), and a score of 1 for recall of the three words asked earlier. According to the MDS 3.0 Data Collection Tool a score of 4 was interpreted as severe impairment. Further review of the above MDS assessments for ADL Self Performance for bed mobility (how the resident moved to and from lying position, turns side to side and positions body while in bed) reflected the resident received Extensive Assistance (resident involved in activity, staff provide weight bearing support). For ADL Support Provided, the resident received one person physical assist. The assessments reflected bed rails were not used for the resident. Review of Case Mix Documentation (by nurses across all shifts) dated from 04/08/11 to 04/11/11 reflected the resident was moderately impaired in decision making skills and was forgetful and confused. Documentation of ADL Self Performance for bed mobility reflected the resident received Limited Assistance (resident highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight bearing assistance) on the day and evening shifts, and on the night shift she received Extensive Assistance. Documentation for ADL Support Provided reflected the resident received one person physical assist during all shifts. There was no further documented nurses' notes or case mix documentation from 04/11/11 to 5/21/11. Review of the resident's Fall Risk assessment dated [DATE] reflected a score of 15, high risk for falls. The assessment reflected the resident's mental status was intermittent confusion. Review of the current POC dated 04/10/11 reflected a problem of potential for trauma related to falls. According to the POC the following fall prevention measures were in place for the resident at the time of her fall on 5/21/11: Keep room well lighted; adjust bed in low position; star on door to identify fall risk; encourage to call for assistance; notify physician and family of falls. The POC did not reflect a measure to lock the resident's bed wheels after placing the resident in bed. The POC did not reflect measures to prevent the resident from falling out of bed. Review of the current Nurse Aide's Information Sheet (no date) reflected the resident was often confused and forgetful. The sheet reflected the resident did not use side rails. The sheet did not reflect a measure to lock the resident's bed wheels after placing the resident in bed. Review of an Incident and Accident Reporting Form dated 05/21/11 at 10:30 p.m. for resident #4 revealed the resident was [AGE] years old and was found by the nurse lying face down on the floor beside her bed. The resident was described to have a large "goose-egg" on the left eyebrow, bleeding, contusion near the hair line, bruising on her arms, moderate pain to her knees and abrasion and swelling as injuries. The report reflected no side rails were ordered and none were present. The resident's condition before the incident was described as confused and disoriented. Review of nurses' notes documented by S4LPN dated 05/21/11 at 10:30 p.m. revealed the nurse heard the resident say '"Can someone bring me a blanket?"' The nurse walked into the resident room and found the resident lying on the floor beside her bed. The nurse asked the resident, "Did you just roll out of the bed onto the floor?", and the resident stated, "I didn't know I was on the floor." The note reflected S4LPN called for the CNAs to help. The note reflected the resident was examined and found to have a large "goose-egg" hematoma to the left eyebrow, a contusion further back into the hairline, bruising showing in several places on her left arm, moderate pain to her knees, and a moderate amount of bleeding from areas of her head. The notes reflected the resident was transferred to the hospital via ambulance at 10:47 p.m. Review of the Hospital's Emergency Physician Record dated 05/21/11 reflected the resident had injuries to her left forehead and did not remember what happened to her. The emergency room physician rendered a clinical impression of Concussion, Post Concussio[DIAGNOSES REDACTED] and Dementia. Review of the Hospital Discharge Summary dated 5/22/11 reflected the resident was admitted for overnight observation with [DIAGNOSES REDACTED]. Review of the facility's Fall Prevention Program Policy and Procedure reflected beds would be maintained in low position and wheels locked for residents identified as high risk. Interview with S4LPN on 6/21/11 at 9:50 a.m. revealed she reported to work at 10:00 p.m. on 05/21/11 to work the night shift from 10:00 p.m. to 6:00 a.m. S4LPN revealed that at 10:30 p.m. she heard resident #4 call out for someone to bring her a blanket. S4LPN stated that when she entered the resident's room she found the resident lying face down on the floor between her bed and the wall. S4LPN stated that she immediately called for the CNAs to help her. S4LPN revealed that the resident's usual bed position was the right side and head pushed completely against the wall in the corner. S4LPN stated that when she found the resident, the right side and head was at an angle and positioned away from the wall, the foot of the bed was close to the wall, and the resident was lying on the floor with her head toward the head of the bed. S4LPN stated that when she moved the bed to help the resident, the wheels were not locked, and the bed moved easily. Telephone interview with S6CNA on 06/21/11 at 12:10 p.m. revealed she cared for the resident on the evening shift of 05/21/11 from 2:00 p.m. to 10:00 p.m. S6CNA revealed the resident was not able to get out of bed on her own, but she could reposition herself in the bed by using her feet and hands. S6 stated that she put the resident to bed after supper and last saw the resident around 9:30 p.m. S6 stated that the resident's bed was positioned against the wall with the head in the corner. S6 stated that they always made sure that residents' beds were locked. Telephone interview with S7 CNA on 06/21/11 at 12:20 p.m. revealed she also care for resident #4 on the evening shift of 05/21/11 from 2:00 p.m. to 10:00 p.m. S7CNA revealed that at approximately 9:30 p.m. the resident was in bed, and she gave the resident a cookie and cleaned her up. S7 stated that the resident was able to move in bed but she could not roll without physical help. S7 stated no side rails were used for the resident, and they always made sure that residents' beds were locked. Interview with S11CNA on 06/21/11 at 1:50 p.m. revealed the resident could move in bed, but could not really roll over, and the only way the resident could have fallen out of the bed was if the bed was not locked. Interview with S2DON on 06/21/11 at 9:30 a.m. confirmed it was the facility's policy to lock the bed wheels for all residents at high risk for falls. Interview with S2DON and S3LPN/MDS on 06/21/11 at 3:35 p.m. confirmed the resident's POC dated 4/10/11 did not reflect a measure to have the resident's side rails up for safety while in bed or to lock the resident's bed wheel after placing the resident in bed. Review of nurses' notes reflected the resident returned to the facility from the hospital on [DATE] at 7:45 p.m. and was transferred to another facility on 6/10/11. Review of the clinical record from 05/22/11 to 6/10/11 did not reflect an update of the resident's POC for measures to lock the resident's bed wheels. Further interview with S2DON and S3LPN/MDS on 6/22/11 at 2:45 p.m. confirmed that after the resident returned from the hospital on [DATE] her POC was not updated to include a measure to lock the bed wheels. Interview with S1Administrator on 6/21/11 at 3:00 p.m. revealed resident #4 was in a new bed at the time of her fall, and the bed's wheels were capable of being locked. 2. Observation of resident #2 on 6/20/11 at 12:50 p.m. and at 2:30 p.m. revealed the resident was lying in bed. The resident's bed was not locked. Interview with the resident revealed she transferred in and out of bed and walked without assistance. Observation on 6/21/11 at 10:40 a.m. revealed the resident was not in her room. Observation at that time revealed the head of the resident's bed moved easily when leaned against. The bed wheels did not contain a lock nor were there any type of safety gripper under the wheels to prevent the head of the bed from moving when leaned against. Observation on 6/21/11 at 2:45 p.m. with S12CNA revealed the resident was lying in her bed with her wheelchair located beside her bed. Observation at that time revealed the resident's bed moved easily when leaned against. Interview with S12CNA at that time revealed the resident transferred herself from her wheelchair to her bed without assistance. S12CNA revealed that she was not aware that the resident's bed was not locked. Observation and interview with S1Administrator and S2DON on 6/21/11 at 3:00 p.m. confirmed the resident's bed was not locked and moved easily when pushed or pulled. Review of a Fall Risk assessment dated [DATE] and 5/10/2011 reflected the resident was at high risk for falls. Review of the MDS assessment dated [DATE] for ADL Self Performance for transfer reflected the resident received Supervision with setup help only. Review of the POC dated 5/05/11 reflected a problem of Impaired Mobility with Fall Potential related to weakness, diagnosis, and drug therapy. The goal was for the resident to be free from falls and injury over the next review. There was no measure in the care plan to assure the resident's bed wheels were locked to prevent falls. Review of the Incident and Accident Reporting Form dated 5/5/11 at 5:45 a.m. reflected the resident was found with a purplish-blue discoloration to the right side of head just above her hair line with a trace of [MEDICAL CONDITION] noted. The form reflected the resident stated that she rolled out of bed and got up on her own. Interview with S2DON and S3LPN/MDS nurse on 6/22/11 at 3:30 p.m. confirmed that the resident was at high risk for falls, transferred to and from her wheelchair and bed without staff assistance, and the resident had not been care planned for the bed wheels to be locked.

Based on observation, record review and interview the facility failed to provide each resident an environment that was as free as possible from accidental hazards over which the facility had control for 4 of 5 sampled residents who had falls (#2, 3, 4 and 5). Out of a total census of 50, 15 residents had experienced falls from 04/02/11 to 06/14/11, 5 of whom were included in the sample. The facility failed to: 1. follow facility policy and procedure to lock the bed wheels for a resident identified at high risk for falls by failing to lock the bed wheels after placing the resident in bed (#4); 2. care plan interventions to lock the bed wheels for a resident at high risk for falls, and after the resident fell out of bed between the wall and the bed and received a closed head injury (#4) and for a resident identified at high risk for falls and who transferred without assistance (#2); 3. ensure proper and safe bed wheel locking mechanisms for residents with falls and at high risk for falls (#2 and 3); 4. follow the care plan to lock the bed wheels for a resident with falls and at high risk for falls (#3); 5. re-assess a resident's fall risk factors and assess for the use of a self-releasing safety belt for a resident who had multiple falls with injuries and at high risk for falls (#5); 6. re-assess and develop interventions for a resident who had multiple falls and at high risk for falls (#5); and 8. have a system in place to ensure bed wheels were locked for residents identified as being high risk for falls and a system in place to monitor and correct bed locking hazards for bed wheels that either did not lock or that still moved easily while in the locked position for multiple beds through the facility. Resident #4 was admitted to the facility with an original admission date of [DATE] and a current admission date of [DATE]. The resident was assessed to have moderate impairment in cognition with intermittent confusion, high risk for falls and required extensive one person assistance for bed mobility. Interview with multiple staff member revealed conflicting stories concerning the resident's ability to move herself in bed. Some staff stated the resident was able to turn herself in bed at times, and others stated the resident could not turn herself in bed at all. The resident had not been assessed for the use of side rails, nor had the resident been care planned for the bed to be locked. On 5/21/11 at 10:30 p.m. the resident was found face down on the floor between her bed and the wall. The bed was positioned against the wall when the resident fell , and the bed wheels were not locked. The resident received a large hematoma to her left eyebrow, contusion near her hairline, moderate amount of bleeding from areas of her head, bruising to several places on her left arm, abrasions and swelling, and she complained of moderate pain to her knees. The resident was transferred to the emergency room , and the physician documented a clinical impression of Concussion and Post Concussio[DIAGNOSES REDACTED]. The resident was admitted for overnight observation with [DIAGNOSES REDACTED]. The resident returned from the hospital to the facility on [DATE] at 7:45 p.m. and was transferred to another facility on 6/10/11. The facility identified the incident as a fall due to the resident being found on the floor. Interview with staff revealed the resident's bed wheels were not locked, and there were no side rails in use when she was found on the floor on 5/21/11. The facility did not follow their fall prevention policy to lock the bed wheels for a resident identified at high risk for falls. Findings: Review of the facility's Fall Prevention Program Policy and Procedure reflected beds would be maintained in low position and wheels locked for residents identified as high risk for falls. 1. Review of physician's orders [REDACTED]. Review of the MDS assessments dated 01/04/11 and 03/30/11 reflected the resident received a Summary Score of 4 out of 15 on the Brief Interview of Mental Status. The assessment reflected the resident received a score of 3 for repetition of three words, a score of zero for temporal orientation to (year, month and day), and a score of 1 for recall of the three words asked earlier. According to the MDS 3.0 Data Collection Tool a score of 4 was interpreted as severe impairment Further review of the above MDS assessments for ADL Self Performance for bed mobility (how the resident moved to and from lying position, turns side to side and positions body while in bed) reflected the resident received Extensive Assistance (resident involved in activity, staff provide weight bearing support). For ADL Support Provided, the resident received one person physical assist. The assessments reflected bed rails were not used for the resident. Review of Case Mix Documentation (by nurses across all shifts) dated from 04/08/11 to 04/11/11 reflected the resident was moderately impaired in decision making skills and was forgetful and confused. Documentation of ADL Self Performance for bed mobility reflected the resident received Limited Assistance (resident highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight bearing assistance) on the day and evening shifts, and on the night shift she received Extensive Assistance. Documentation for ADL Support Provided reflected the resident received one person physical assist during all shifts. There was no further documented nurses' notes or case mix documentation from 04/11/11 to 5/21/11. Review of the resident's Fall Risk assessment dated [DATE] reflected a score of 15, high risk for falls. The assessment reflected the resident's mental status was intermittent confusion. Review of the clinical record did not reflect an assessment for measures to prevent the resident from falling from the bed after the resident had been assessed as high risk for falls, intermittent confusion and the ability to maneuver self in bed with only Limited Assistance at times. Review of the current POC dated 04/10/11 (prior to the resident being found on the floor) reflected a problem of potential for trauma related to falls. According to the POC the following fall prevention measures were in place for the resident at the time of her fall on 5/21/11: Keep room well lighted; adjust bed in low position; star on door to identify fall risk; encourage to call for assistance; notify physician and family of falls. The POC did not reflect a measure to lock the resident's bed wheels after placing the resident in bed. The POC did not reflect measures to prevent the resident from falling out of bed. Review of the current Nurse Aide's Information Sheet (no date) reflected the resident was often confused and forgetful. The sheet reflected the resident did not use side rails. For turn and position the sheet reflected a check mark by (self, every 2 hours, with 1 assist). The sheet did not reflect a measure to lock the resident's bed wheels after placing the resident in bed. The sheet did not reflect a section concerning locked bed wheels. Review of an Incident and Accident Reporting Form dated 05/21/11 at 10:30 p.m. for resident #4 revealed the resident was [AGE] years old and was found by the nurse lying face down on the floor beside her bed. The resident was described to have a large "goose-egg" on the left eyebrow, bleeding, contusion near the hair line, bruising on her arms, moderate pain to her knees and abrasion and swelling as injuries. The report reflected no side rails were ordered and none were present. The report reflected the resident's bed height was adjusted "down". The resident's condition before the incident was described as confused and disoriented. The report did not reflect information concerning locked bed wheels for the resident. Review of nurses' notes documented by S4LPN dated 05/21/11 at 10:30 p.m. revealed the nurse heard the resident say '"Can someone bring me a blanket?"' The nurse walked into the resident room and found the resident lying on the floor beside her bed. The nurse asked the resident, "Did you just roll out of the bed onto the floor?", and the resident stated, "I didn't know I was on the floor." The note reflected S4LPN called for the CNAs to help. The note reflected the resident was examined and found to have a large "goose-egg" hematoma to the left eyebrow, a contusion further back into the hairline, bruising showing in several places on her left arm, moderate pain to her knees, and a moderate amount of bleeding from areas of her head. The notes reflected the resident was transferred to the hospital via ambulance at 10:47 p.m. Review of the Hospital's Emergency Physician Record dated 05/21/11 reflected the resident had injuries to her left forehead and did not remember what happened to her. The emergency room physician rendered a clinical impression of Concussion, Post Concussio[DIAGNOSES REDACTED] and Dementia. Review of the Hospital Discharge Summary dated 5/22/11 reflected the resident was admitted for overnight observation with [DIAGNOSES REDACTED]. Interview with S4LPN on 6/21/11 at 9:50 a.m. revealed she reported to work at 10:00 p.m. on 05/21/11 to work the night shift from 10:00 p.m. to 6:00 a.m. S4LPN revealed that at 10:30 p.m. she heard resident #4 call out for someone to bring her a blanket. S4LPN stated that when she entered the resident's room she found the resident lying face down on the floor between her bed and the wall. S4LPN stated that she immediately called for the CNAs to help her. S4LPN revealed that the resident's usual bed position was the right side and head pushed completely against the wall in the corner. S4LPN stated that when she found the resident, the right side and head was at an angle and positioned away from the wall, the foot of the bed was close to the wall, and the resident was lying on the floor with her head toward the head of the bed. S4LPN stated that when she moved the bed to help the resident, the wheels were not locked, and the bed moved easily. S4LPN stated that side rails were not used for the resident, and there were no side rails in place when she found the resident on the floor. Further interview with S4LPN at that time revealed that information obtained from the resident was not reliable due to her intermittent confusion. S4LPN stated that she did not expect resident #4 to be able to tell her what happened to her when she asked her if she had just rolled out of bed onto the floor. Telephone interview with S5CNA on 6/20/11 at 3:15 p.m. revealed she worked on 05/21/11 from 10:00 p.m. to 6:00 a.m., and at approximately 10:30 p.m. she and another CNA assisted S4LPN to get resident #4 off the floor and back into her bed. S5 stated the resident was not able to get up out of bed on her own, but she could roll herself in bed and would roll when told to do so. S5 stated that side rails were not used for the resident. S5 stated the resident was confused and forgetful at times, but she would usually press the call bell for assistance. Telephone interview with S6CNA on 06/21/11 at 12:10 p.m. revealed she cared for the resident on the evening shift of 05/21/11 from 2:00 p.m. to 10:00 p.m. S6CNA revealed the resident was not able to get out of bed on her own, but she could reposition herself in the bed by using her feet and hands. S6 stated that she put the resident to bed after supper and last saw the resident around 9:30 p.m. S6 stated that the resident's bed was positioned against the wall with the head in the corner. S6 stated that side rails were not used for the resident, and that they always made sure that residents' beds were locked. Telephone interview with S7CNA on 06/21/11 at 12:20 p.m. revealed she also cared for resident #4 on the evening shift of 05/21/11 from 2:00 p.m. to 10:00 p.m. S7CNA revealed that at approximately 9:30 p.m. the resident was in bed, and she gave the resident a cookie and cleaned her up. S7 stated that the resident was able to move in bed but she could not roll without physical help. S7 stated no side rails were used for the resident, and they always made sure that residents' beds were locked. Interview with S8CNA on 06/20/11 at 3:35 p.m. revealed worked with the resident during the day shift, and the resident required assistance to get up because she could not get out of bed on her own. S8 stated that the resident could roll over in the bed on her own, but she was on a turn schedule. S8 stated that side rails were not used for the resident, and the resident was confused at times. S8 stated that she did not know of the resident having falls or trying to get out of bed on her own. Interview with S9CNA and S10CNA on 06/21/11 at 1:40 p.m. and 1:45 p.m., respectively, revealed the resident could roll herself in bed, but was not able to get out of bed on her own. S9 and S10 stated that side rails were not used for the resident. Interview with S11CNA on 06/21/11 at 1:50 p.m. revealed side rails were not used for the resident. S11 stated that the resident could move in bed, but could not really roll over, and the only way the resident could have fallen out of the bed was if the bed was not locked. Interview with S2DON on 06/21/11 at 9:30 a.m. revealed that an evaluation for the use of side rails for a resident was based on the resident's ability to move in bed, if the resident needed the side rails to turn or pull up in bed, if the resident asked for side rails, or for resident safety. S2DON revealed that she and the RN owner were responsible for conducting all risk assessments and evaluations for side rails. S2DON stated that to her knowledge the resident was not able to get out of bed on her own or turn her self in bed on her own. S2DON confirmed that the resident did not have side rails in use and had not been evaluated for side rail use for safety while in bed. S2DON confirmed it was the facility's policy to lock the bed wheels for all residents at high risk for falls. Interview with S2DON and S3LPN/MDS nurse on 06/21/11 at 3:35 p.m. confirmed the resident's POC dated 4/10/11 (prior to the resident being found on the floor) did not reflect a measure to have the resident's side rails up for safety while in bed or to lock the resident's bed wheel after placing the resident in bed. Review of nurses' notes reflected the resident returned to the facility from the hospital on [DATE] at 7:45 p.m. and was transferred to another facility on 6/10/11. Review of the clinical record from 05/22/11 to 6/10/11 did not reflect an updated assessment of the resident's fall risk or update of the resident's POC to reflect measures to lock the resident's bed wheels. Review of the clinical record did not reflect that the facility identified the cause of the resident's fall in order to put measures in place to prevent another fall. Further interview with S2DON and S3LPN/MDS nurse on 6/22/11 at 2:45 p.m. confirmed that after the resident returned from the hospital on [DATE] she was not reassessed for fall risks, she was not evaluated for the use of side rails for safety, nor had her POC been updated to include a measure to lock the bed wheels. Interview with S1Administrator on 6/21/11 at 3:00 p.m. revealed resident #4 was in a new bed at the time of her fall, and the bed wheels were capable of being locked. 2. Observation of resident #5 on 6/20/2011 at 1:48 p.m. revealed the resident was sitting in her wheelchair in her room visiting with her son. There was no safety belt or chair alarm in place. Observation at 2:19 p.m. revealed two CNAs transferred the resident to her bed. Observation on 6/22/2011 at 12:45 p.m. revealed the resident was in her wheelchair propelling herself in the hallway with another resident. There was no safety belt or chair alarm in place. The resident was observed to lean forward from a sitting position in her wheelchair, to reach her hand toward the floor and pick up an item off the floor. Interview with the resident's son 6/22/2011 at 1:48 p.m. revealed revealed the resident had a long history of falls at home prior to living in the facility. The resident's son stated that the resident was forgetful and would try to get up and walk. The resident's son revealed that he had spoken with the facility about getting his mother a seat belt while sitting in the wheelchair. Review of the resident's Admission Record Face Sheet reflected the resident an original admission date of [DATE] and a current admission date of [DATE]. The admitting and primary [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] reflected the resident received a Summary Score of 10 out of 15 on the Brief Interview of Mental Status. The assessment reflected the resident was successful with repetition of three words, missed the correct year by greater than 5 years, accurate for the correct month within 5 days, able to report the correct day of the week, and was able to recall the three words asked earlier. Further review of the above MDS assessments for ADL Self Performance for transfer (how the resident moved between surfaces to and from bed, chair, wheelchair, standing position) reflected the resident received Extensive Assistance (resident involved in activity, staff provide weight bearing support). For ADL Support Provided, the resident received two persons physical assist. Review of the Fall Risk assessment dated [DATE] reflected the resident was given a score of 14, high risk for falls. The assessment reflected the resident's mental status was alert and oriented times 3. Review of POC dated 4/12/11 reflected the following fall prevention measures were in place for the resident: Star on door to identify fall risk; notify physician and family of falls; nurse to monitor and assist as needed; refer to therapy as indicated; keep call light within reach; answer call light quickly to prevent falls; keep room free of clutter; apply side rails in bed; educate resident on transfer and ambulation safety; give medications as ordered. Review of the Incident Report Logs reflected the resident had 7 falls during the months of April, May and June, 2011. The Logs reflected the resident fell on [DATE], 4/25/11, 5/25/11, 6/1/11, 6/9/11 and twice on 6/14/11. During 4 of the 7 falls the resident received injuries. Review of Incident and Accident Reporting Form dated 4/22/11 at 2:20 p.m. reflected the resident stated that she got up from the wheelchair, attempted to sit on the bed but the bed moved, and the resident sat on the floor. The resident received an abrasion to her back. The facility included a measure in the care plan for wheel locks applied to the resident's bed and to lock the bed wheels at all times. Review of Incident and Accident Reporting Form dated 4/25/11 at 4:30 p.m. reflected the resident got up from the bed and when she attempted to get back in bed, she sat down on the floor. The resident received an abrasion to the right shin and the left calf. Review of Incident and Accident Reporting Form dated 5/25/11 at 11:10 p.m. reflected the resident was found sitting on the floor beside her bed. The resident stated she was trying to get to the bathroom but she got weak. Review of Incident and Accident Reporting Form dated 6/1/11 at 8:30 p.m. reflected the resident was found sitting on the floor at the foot of her bed. Review of Incident and Accident Reporting Form dated 6/9/11 at 7:10 p.m. reflected the resident was standing trying to hang up her clothes and fell . The resident received skin tear wounds to her right hand/fingers and elbow area. Review of Incident and Accident Reporting Form dated 6/14/11 at 1:30 p.m. reflected the resident was found sitting on the floor in front of her wheelchair. The resident stated that she bumped her head. Review of Incident and Accident Reporting Form dated 6/14/11 at 7:00 p.m. reflected the resident was in her wheelchair in her room and fell between her wheelchair and bed when she tried to pick up something from the floor. Review of PT and OT notes reflected the resident started therapy for gait, transfer and balance training on 4/18/11; however, the resident continued to fall. Further review of clinical record did not reflect re-evaluation of the the resident's fall risk factors after the resident had experienced 7 falls in the facility. There was no further documented fall risk assessment after admission on 3/30/11. There was no documentation to reflect the resident had been evaluated for other measures to reduce the number of falls. Review of an update to the POC dated 6/14/2011 reflected the facility had ordered a chair alarm for the resident; however, there was no documented assessment. Interview with S2DON on 6/21/11 at 11:53 a.m. revealed the resident's chair alarm was ordered on [DATE], but there was no documented assessment. S2DON stated the chair alarm had not been received, and that it took about two weeks before it would arrive. S2DON stated the resident had no falls since 6/14/2011, and staff were trying to met her needs right away. Interview with S2DON and S3LPN/MDS nurse on 6/22/11 at 2:45 p.m. revealed fall risk assessments were conducted by the RN during the MDS assessment for admission, quarterly and significant change. S2DON revealed the fall risk assessments were not updated after residents experienced multiple falls. Further interview with S2DON at that time revealed resident # 5's chair alarm still had not arrived. S2DON revealed that at approximately 1:30 p.m. today she had dug in the back of a drawer and found a chair alarm and had placed it on the resident's wheelchair. S2DON stated that she did not know she had one, and that the facility does not normally keep extras on hand. S2DON confirmed at that time resident #5 had not been re-evaluated for fall risk factors after 3/30/11 and the resident experiencing 7 falls, and the resident had not been evaluated for the use of other measures to reduce the number of falls the resident was experiencing. 3. Observation of resident #2 on 6/20/11 at 12:50 p.m. and at 2:30 p.m. revealed the resident was lying in bed. The resident's bed was not locked. Interview with the resident revealed she transferred in and out of bed and walked without assistance. Observation on 6/21/11 at 10:40 a.m. revealed the resident was not in her room. Observation at that time revealed the head of the resident's bed moved easily when leaned against. The bed wheels did not contain a lock nor were there any type of safety gripper under the wheels to prevent the head of the bed from moving when leaned against. Observation on 6/21/11 at 2:45 p.m. with S12CNA revealed the resident was lying in her bed with her wheelchair located beside her bed. Observation at that time revealed the resident's bed moved easily when pushed or pulled. Interview with S12CNA at that time revealed the resident transferred herself from her wheelchair to her bed without assistance. S12CNA revealed that she was not aware that the resident's bed did not lock. Observation and interview with S1Administrator and S2DON on 6/21/11 at 3:00 p.m. confirmed the resident's bed was not locked and moved easily when pushed or pulled. S1Administrator revealed that the facility had identified a problem with beds not locking, but she was not aware that resident #5's bed did not lock because she had not assessed all the beds in the facility. Review of the Incident and Accident Reporting Form dated 5/5/11 at 5:45 a.m. reflected the resident was found with a purplish-blue discoloration to the right side of head just above her hair line with a trace of edema noted. The form reflected the resident stated that she rolled out of bed and got up on her own. Review of a Fall Risk assessment dated [DATE] and 5/10/2011 reflected the resident was at high risk for falls. Review of the facility's Fall Prevention Program Policy and Procedure reflected beds would be maintained in low position and wheels locked for residents identified as high risk. Review of the MDS assessment dated [DATE] for ADL Self Performance for transfer (how the resident moved between surfaces to and from bed, chair, wheelchair, standing position) reflected the resident received Supervision (oversight, encouragement or cueing). For ADL Support Provided, the resident received setup help only. Review of the POC dated 5/05/11 reflected a problem of Impaired Mobility with Fall Potential related to weakness, diagnosis, and drugs. The goal was for the resident to be free from falls and injury over the next review. There was no measure in the care plan to assure the resident's bed wheels were locked to prevent falls. Interview with S2DON and S3LPN/MDS nurse on 6/22/11 at 3:30 p.m. confirmed that the resident was at high risk for falls, transferred to and from her wheelchair and bed without staff assistance, and the resident had not been care planned for the bed wheels to be locked. 4. Observation on 6/20/11 at 1:45 p.m. and 2:30 p.m. revealed resident #3 was not in his room. The resident's bed was not locked and moved easily when pulled from the wall. Observation on 6/20/11 at 2:01 p.m. revealed the resident was sitting in his wheelchair in the smoke room. Observation on 6/21/11 at 10:30 a.m. revealed the resident was not in his room, and his bed was not locked and moved easily when pulled from the wall. Observation at 2:30 p.m. revealed the resident was lying in his bed, and the bed was not locked. The resident's wheelchair was at the bedside. The resident stated at that time that he transferred from the wheelchair to the bed without help. Review of Incident and Accident Reporting Form dated 5/9/11 at 9:30 a.m. reflected the resident was found lying on the floor next to his bed drowsy and confused. The form reflected the resident stated that he fell when he turned on his side in the bed. Review of Incident and Accident Reporting Form dated 6/9/11 at 1:30 a.m. reflected the resident was found lying on the floor in his room. The resident stated that he fell . The resident received bruising to his lower back. Review of a Fall Risk assessment dated [DATE] reflected the resident was at high risk for falls. Review of the MDS assessment dated [DATE] for ADL Self Performance for transfer reflected the resident received Supervision with setup help only. Interview on 6/20/11 at 2:30 p.m. with S13LPN revealed the resident transferred without assistance. Review of the POC dated 6/09/11 reflected a problem of Impaired Mobility with Fall Potential related to weakness, diagnoses, and drug therapy. The goal was for the resident to be free from falls and injury over the next review. There was a measure in the care plan to lock the resident's bed wheels to prevent falls. Observation of the resident's bed and interview with S1Administrator and S2DON on 6/21/11 at 3:10 p.m. confirmed the resident's bed was not locked. S1Administrator revealed that the facility had identified a problem with beds not locking, but she was not aware that resident #3's bed did not lock because she had not assessed all the beds in the facility Interview with S2DON and S3LPN/MDS nurse on 6/22/11 at 3:30 p.m. confirmed that the resident was at high risk for falls, transferred to and from her wheelchair and bed without staff assistance, and the resident had been care planned for the bed wheels to be locked. 5. Observation of room a on 6/20/11 at 1:45 p.m. and 2:30 p.m. and on 6/21/11 at 10:30 a.m. of the bed occupied by the roommate of resident #3 (discussed in finding #4) revealed the roommate's bed was not locked and moved easily when pulled or pulled. Observation of room b on 6/21/11 at 10:30 a.m. revealed the first bed was not locked and moved easily when pulled from the wall. Observation of room c revealed the bed next to the window was not locked and moved easily when pulled from the wall. These rooms were observed to be occupied by residents. Observation and/or interview with S1Administrator and S2DON on 6/21/11 at 3:00 p.m. and on 6/22/11 at 1:40 p.m. concerning the above rooms and/or beds confirmed the beds were not locked and moved easily when pushed or pulled. S1Administrator confirmed that the facility had identified a problem with beds not locking approximately a year ago, and she ordered a type of non-skid stopper that prevented the beds from moving. S1 stated that the non-skid stoppers had been placed under the wheels of some beds. However, she was not aware the above beds did not lock because she had not conducted a facility wide check of all beds to see whether they were capable of locking or if they needed to have the non-skid stoppers applied. S1Administrator stated that she left it up to the CNAs and Housekeeper to report beds that did not lock. Interview with S2DON on 6/22/11 at 2:05 p.m. revealed (after surveyor intervention) she had assessed every bed in the facility and had identified several beds that did not lock or that moved easily when pushed or pulled. S2DON stated that she had started applying the non-skid stoppers to some of the beds.

Based on observation, interview and record review the facility failed to conduct a comprehensive and complete reassessment of residents' for fall risk factors for 2 residents (#4 and 5) out of a total sample of 5 residents with falls. The facility's total census was 50, according to the Resident Census and Conditions of Residents form. The facility failed to: 1. assess a resident for the use of side rails, for a resident who was known not to be able to get out of bed on her own, and who could roll herself in bed at times (#4); 2. assess a resident for interventions to prevent another fall from bed upon return from the hospital after falling out of bed and receiving a closed head injury (#4); 3. re-assess a resident's fall risk factors and identify interventions to prevent falls from wheelchair for a resident identified as being at high risk for falls (#5) who experienced 7 falls from 4/22/11 to 6/14/11. 4 of the 7 falls resulted injury to the resident. Resident #4 was admitted to the facility with an original admission date of [DATE] and a current admission date of [DATE]. The resident was assessed to have moderate impairment in cognition with intermittent confusion, high risk for falls and required extensive one person assistance for bed mobility. Interview with multiple staff members revealed conflicting stories concerning the resident's ability to move herself in bed. Some staff stated the resident was able to turn herself in bed at times, and others stated the resident could not turn herself in bed at all. The resident had not been assessed for the use of side rails, nor had the resident been care planned for the bed to be locked. The resident had a history of [REDACTED]. On 5/21/11 at 10:30 p.m. the resident was found face down on the floor between her bed and the wall. The resident received a large hematoma to her left eyebrow, contusion near her hairline, moderate amount of bleeding from areas of her head, bruising to several places on her left arm, abrasions and swelling, and she complained of moderate pain to her knees. The resident was transferred to the emergency room , and the physician documented a clinical impression of Concussion and Post Concussio[DIAGNOSES REDACTED]. The resident was admitted for overnight observation with [DIAGNOSES REDACTED]. The resident returned from the hospital to the facility on [DATE] at 7:45 p.m. and was transferred to another facility on 6/10/11. Interview with staff revealed the resident's bed wheels were not locked when she was found on the floor on 5/21/11, and side rails were not in use. The facility failed to assess the resident for side rail use and failed to lock the bed wheels for the resident. The facility identified the incident as a fall due to the resident being found on the floor on 5/21/11. After the resident returned to the facility from the hospital on [DATE] the facility did not evaluate the resident for the use of side rails. Findings: 1. Review of physician's orders [REDACTED]. Review of the MDS assessments dated 01/04/11 and 03/30/11 reflected the resident received a Summary Score of 4 out of 15 on the Brief Interview of Mental Status. The assessment reflected the resident received a score of 3 for repetition of three words, a score of zero for temporal orientation to (year, month and day), and a score of 1 for recall of the three words asked earlier. According to the MDS 3.0 Data Collection Tool a score of 4 was interpreted as severe impairment. Further review of the above MDS assessments for ADL Self Performance for bed mobility (how the resident moved to and from lying position, turns side to side and positions body while in bed) reflected the resident received Extensive Assistance (resident involved in activity, staff provide weight bearing support). For ADL Support Provided, the resident received one person physical assist. The assessments reflected bed rails were not used for the resident. Review of the resident's Fall Risk assessment dated [DATE] reflected a score of 15, high risk for falls. The assessment reflected the resident's mental status was intermittent confusion. Review of Case Mix Documentation (by nurses across all shifts) dated from 04/08/11 to 04/11/11 reflected the resident was moderately impaired in decision making skills and was forgetful and confused. Documentation of ADL Self Performance for bed mobility reflected the resident received Limited Assistance (resident highly involved in activity, received physical help in guided maneuvering of limbs or other non-weight bearing assistance) on the day and evening shifts, and on the night shift she received Extensive Assistance. Documentation for ADL Support Provided reflected the resident received one person physical assist during all shifts. There was no further documented nurses' notes or case mix documentation from 04/11/11 to 5/21/11. Review of the clinical record did not reflect an assessment for measures to prevent the resident from falling from the bed after the resident had been assessed as high risk for falls, intermittent confusion and the ability to maneuver self in bed with only Limited Assistance at times. Review of the POC dated 04/10/11 (prior to the resident being found on the floor) reflected a problem of potential for trauma related to falls. The POC did not reflect a measure for the use of side rails while in bed. Review of the current Nurse Aide's Information Sheet (no date) reflected the resident was often confused and forgetful. The sheet reflected the resident did not use side rails. For turn and position the sheet reflected a check mark by (self, every 2 hours, with 1 assist). Review of an Incident and Accident Reporting Form dated 05/21/11 at 10:30 p.m. for resident #4 revealed the resident was [AGE] years old and was found by the nurse lying face down on the floor beside her bed. The resident was described to have a large "goose-egg" on the left eyebrow, bleeding, contusion near the hair line, bruising on her arms, moderate pain to her knees and abrasion and swelling as injuries. The report reflected no side rails were ordered and none were present. The resident's condition before the incident was described as confused and disoriented. Review of nurses' notes documented by S4LPN dated 05/21/11 at 10:30 p.m. revealed the nurse heard the resident say '"Can someone bring me a blanket?"' The nurse walked into the resident room and found the resident lying on the floor beside her bed. The nurse asked the resident, "Did you just roll out of the bed onto the floor?", and the resident stated, "I didn't know I was on the floor." The note reflected S4LPN called for the CNAs to help. The note reflected the resident was examined and found to have a large "goose-egg" hematoma to the left eyebrow, a contusion further back into the hairline, bruising showing in several places on her left arm, moderate pain to her knees, and a moderate amount of bleeding from areas of her head. The notes reflected the resident was transferred to the hospital via ambulance at 10:47 p.m. Review of the Hospital's Emergency Physician Record dated 05/21/11 reflected the resident had injuries to her left forehead and did not remember what happened to her. The emergency room physician rendered a clinical impression of Concussion, Post Concussio[DIAGNOSES REDACTED] and Dementia. Review of the Hospital Discharge Summary dated 5/22/11 reflected the resident was admitted for overnight observation with [DIAGNOSES REDACTED]. Interview with S4LPN on 6/21/11 at 9:50 a.m. revealed she reported to work at 10:00 p.m. on 05/21/11 to work the night shift from 10:00 p.m. to 6:00 a.m. S4LPN revealed that at 10:30 p.m. she heard resident #4 call out for someone to bring her a blanket. S4LPN stated that when she entered the resident's room she found the resident lying face down on the floor between her bed and the wall. S4LPN stated that she immediately called for the CNAs to help her. S4LPN revealed that the resident's usual bed position was the right side and head pushed completely against the wall in the corner. S4LPN stated that when she found the resident, the right side and head was at an angle and positioned away from the wall, the foot of the bed was close to the wall, and the resident was lying on the floor with her head toward the head of the bed. S4LPN stated that when she moved the bed to help the resident, the wheels were not locked, and the bed moved easily. S4LPN stated that side rails were not used for the resident, and there were no side rails in place when she found the resident on the floor. Telephone interview with S5CNA on 6/20/11 at 3:15 p.m. revealed she worked on 05/21/11 from 10:00 p.m. to 6:00 a.m., and at approximately 10:30 p.m. she and another CNA assisted S4LPN to get resident #4 off the floor and back into her bed. S5 stated the resident was not able to get up out of bed on her own, but she could roll herself in bed and would roll when told to do so. S5 stated that side rails were not used for the resident. Telephone interview with S6CNA on 06/21/11 at 12:10 p.m. revealed she cared for the resident on the evening shift of 05/21/11 from 2:00 p.m. to 10:00 p.m. S6CNA revealed the resident was not able to get out of bed on her own, but she could reposition herself in the bed by using her feet and hands. S6 stated that side rails were not used for the resident. Telephone interview with S7 CNA on 06/21/11 at 12:20 p.m. revealed she also cared for resident #4 on the evening shift of 05/21/11 from 2:00 p.m. to 10:00 p.m. S7 stated that the resident was able to move in bed but she could not roll without physical help. S7 stated no side rails were used for the resident. Interview with S8CNA on 06/20/11 at 3:35 p.m. revealed worked with the resident during the day shift, and the resident required assistance to get up because she could not get out of bed on her own. S8 stated that the resident could roll over in the bed on her own, but she was on a turn schedule. S8 stated that side rails were not used for the resident, and the resident was confused at times. Interview with S9CNA and S10CNA on 06/21/11 at 1:40 p.m. and 1:45 p.m., respectively, revealed the resident could roll herself in bed, but was not able to get out of bed on her own. S9 and S10 stated that side rails were not used for the resident. Interview with S11CNA on 06/21/11 at 1:50 p.m. revealed side rails were not used for the resident. Interview with S2DON on 06/21/11 at 9:30 a.m. revealed that an evaluation for the use of side rails for a resident was based on the resident's ability to move in bed, if the resident needed the side rails to turn or pull up in bed, if the resident asked for side rails, or for resident safety. S2DON revealed that she and the RN owner were responsible for conducting all risk assessments and evaluations for side rails. S2DON stated that to her knowledge the resident was not able to get out of bed on her own or turn her self in bed on her own. S2DON confirmed that the resident did not have side rails in use and had not been evaluated for side rail use for safety while in bed. Review of nurses' notes reflected the resident returned to the facility from the hospital on [DATE] at 7:45 p.m. Review of the clinical record from 05/22/11 to 6/10/11 did not reflect an updated assessment of the resident's fall risk. Further interview with S2DON and S3LPN/MDS nurse on 6/22/11 at 2:45 p.m. confirmed that after the resident returned from the hospital on [DATE] she was not reassessed for fall risks or evaluated for the use of side rails for safety. S1DON revealed that she did not evaluate the resident for side rail use because to her knowledge the resident could not roll over in bed without assistance. 2. Review of resident #5's Admission Record Face Sheet reflected an original admission date of [DATE] and a current admission date of [DATE]. The admitting and primary [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] reflected the resident received a Summary Score of 10 out of 15 on the Brief Interview of Mental Status. The assessment reflected the resident was successful with repetition of three words, missed the correct year by greater than 5 years, accurate for the correct month within 5 days, able to report the correct day of the week, and was able to recall the three words asked earlier. According to the MDS 3.0 Data Collection Tool a score of 10 was interpreted as moderate impairment Further review of the above MDS assessments for ADL Self Performance for transfer (how the resident moved between surfaces to and from bed, chair, wheelchair, standing position) reflected the resident received Extensive Assistance (resident involved in activity, staff provide weight bearing support). For ADL Support Provided, the resident received two persons physical assist. Review of the Fall Risk assessment dated [DATE] reflected the resident was given a score of 14, high risk for falls. The assessment reflected the resident's mental status was alert and oriented times 3. Review of the Incident Report Logs reflected the resident had 7 falls during the months of April, May and June, 2011. The Logs reflected the resident fell on [DATE], 4/25/11, 5/25/11, 6/1/11, 6/9/11 and twice on 6/14/11. During 4 of the 7 falls the resident received injuries. Observation of the resident #5 on 6/20/2011 at 1:48 p.m. revealed the resident was sitting in her wheelchair in her room visiting with her son. There was no safety belt in place. Observation at 2:19 p.m. revealed two CNAs transferred the resident to her bed. Observation on 6/22/2011 at 12:45 p.m. revealed the resident was in her wheelchair propelling herself in the hallway with another resident. There was no safety belt in place. The resident was observed to lean forward from a sitting position in her wheelchair, reaching her hand toward the floor to pick up an item off the floor. Interview with the resident's son 6/22/2011 at 1:48 p.m. revealed the resident had a long history of falls at home prior to living in the facility. The resident's son stated that the resident was forgetful and would try to get up and walk. The resident's son revealed that he had spoken with the facility about getting his mother a seat belt while sitting in the wheelchair. Review of Incident and Accident Reporting Form dated 4/22/11 at 2:20 p.m. reflected the resident stated that she got up from the wheelchair, attempted to sit on the bed but the bed moved, and the resident sat on the floor. The resident received an abrasion to her back. Review of Incident and Accident Reporting Form dated 4/25/11 at 4:30 p.m. reflected the resident attempted to get back in bed, and she sat on the floor. The resident received an abrasion to the right shin and the left calf. Review of Incident and Accident Reporting Form dated 5/25/11 at 11:10 p.m. reflected the resident was found sitting on the floor beside her bed. The resident stated she was trying to get to the bathroom but she got weak. Review of Incident and Accident Reporting Form dated 6/1/11 at 8:30 p.m. reflected the resident was found sitting on the floor at the foot of her bed. Review of Incident and Accident Reporting Form dated 6/9/11 at 7:10 p.m. reflected the resident was standing trying to hang up her clothes and fell . The resident received skin tear wounds to her right hand/fingers and elbow area. Review of Incident and Accident Reporting Form dated 6/14/11 at 1:30 p.m. reflected the resident was found sitting on the floor in front of her wheelchair. The resident stated that she bumped her head. Review of Incident and Accident Reporting Form dated 6/14/11 at 7:00 p.m. reflected the resident was in her wheelchair in her room and fell between her wheelchair and bed when she tried to pick up something from the floor. Review of PT and OT notes reflected the resident started therapy for gait, transfer and balance training on 4/18/11; however, the resident continued to fall. Further review of clinical record did not reflect re-evaluation of the the resident's fall risk factors after the resident had experienced 7 falls in the facility. There was no further documented fall risk assessment after admission on 3/30/11. There was no documentation to reflect the resident had been evaluated for other measures to reduce the number of falls. Review of an update to the POC dated 6/14/2011 reflected the facility had ordered a chair alarm for the resident; however, there was no documented assessment. Interview with S2DON on 6/21/11 at 11:53 a.m. revealed the resident's chair alarm was ordered on [DATE], but there was no documented assessment. S2DON stated the chair alarm had not been received, and that it took about two weeks before it would arrive. S2DON stated the resident had no falls since 6/14/2011, and staff were trying to met her needs right away. Interview with S2DON and S3LPN/MDS on 6/22/11 at 2:45 p.m. revealed fall risk assessments were conducted by the RN during the MDS assessment for admission, quarterly and significant change. S2DON revealed the fall risk assessments were not updated after residents experienced multiple falls. S2DON confirmed at that time resident #5 had not been re-evaluated for fall risk factors after 3/30/11 and after the resident experienced 7 falls, and the resident had not been evaluated for other measures to reduce the number of falls the resident was experiencing.