Every finding on record at Life Care Center of Melbourne

Based on interview, and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Findings: Review of the policy and procedure, Quality Assurance and Performance Improvement (QAPI) dated 12/20/19, revealed the purpose of the facilities QAPI program was to promote excellence in quality care, quality of life resident choice and person-centered care. The document indicated the facility conducted Performance Improvement Plans (PIP) to examine and improve care or services in areas the facility identified as requiring attention.The facility had deficiency cited at F554 related to resident self-administration of medication during the previous recertification survey conducted 5/06/24 through 05/09/24. The same deficiency had also been cited during the recertification survey conducted the year before, on 02/05/23 through 02/08/23.During the current survey, concerns were again found with resident self-administration of medication, and the facility was found to be in noncompliance with F554. Insufficient auditing and oversight by the facility to prevent the citation was identified to be a factor in the repeated deficiency.On 9/25/25 at 3:02 PM, the Administrator stated the QAPI committee met monthly and reviewed different areas such as grievances, reportable events and deficiencies from previous surveys and complaints. She acknowledged medications were found left at the bedside by staff during this survey and said they had been working on the issue because they had been cited for this on the last survey. The Administrator produced an undated Performance Improvement Plan (PIP) for medications with actions for nursing education related to medications at the bedside and weekly random audits performed by the Unit Managers. The section titled Evaluation date and Results indicated continue PIP, minimal progress, will need to reeducate. The section was undated. The bottom of the PIP listed the action plan was completed on February 2025, to be followed up monthly at QAPI. The Administrator verbalized they were working on the issue, and she confirmed it continued to be a problem at the facility.

Based on observation, interview, and record review, the facility failed to conduct medication self-administration assessment to ensure safety for 3 of 3 residents reviewed for self-administration of medications, of a total sample of 41 residents, (#8, #86 & #113).1.Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral palsy, acute kidney failure, unspecified glaucoma, type 2 diabetes mellitus, blindness to the left eye and dysphagia. A review of the Minimum Data Set (MDS) admission Five-day assessment with assessment reference date (ARD) of 6/19/25 revealed resident # 8 had a Brief Interview for Mental Status (BIMS) Score of 14 out of 15 which indicated she was cognitively intact. The MDS assessment revealed the resident had no behaviors, nor rejection of care and her vision was highly impaired. A review of resident #8's electronic medical record revealed no physician's order to self-administer medications, no care plan for self-administration of medications, nor an assessment completed to indicate it was safe for resident #8 to self-administer her medications. A review of the Medication Administration Audit report for 9/22/25 revealed documentation that Licensed Practical Nurse (LPN) A administered the Omega 3 Oral Capsule 1000 milligrams (mg) at 10:57 AM, along with all of resident #8's other morning medications between 10:56 AM and 10:59 AM. On 9/22/25 at 12:05 PM resident #8 was in her room with a friend standing at her bedside. There was a large, clear yellowish capsule in a medication cup with some applesauce in another medication cup on the resident's bedside table. The resident stated the medication was fish oil and that because this was such a large pill, she took a long time to swallow it. Resident #8 said she had asked the nurse to leave the pills because she understood the nurses were quite busy and did not want her to be held up. She explained her friend would assist her with the medications. The resident's friend said it was okay; she would help administer the pills. The friend continued to explain that resident #8 took the small pills with no problem, but the fish oil took a while to swallow, which was why it was still there on the bedside table. On 9/22/25 at 3:48 PM, LPN A explained for resident #8 that today was the only time she did that [left the medication at the bedside] because she was called away by the Unit Manager (UM). The nurse confirmed that even though she was called away, she should not have allowed resident #8's friend to help administer the medication. The UM for the 300 and 400 halls joined the interview and LPN A explained that because the UM called her away, she left the medication with the resident's friend. The UM confirmed the resident did not have a self-administration assessment completed nor was she care planned to allow her friend to assist with self-administration of medications. The UM continued to explain that the assigned nurse, LPN A, should have not allowed the resident's friend to administer medications even if she was called away. She said LPN A should have taken the medication with her or else remained and completed the administration herself. On 9/22/2025 at 4:40 PM, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) acknowledged the situation, stated it was not their normal standard of practice to leave medications at bedside and acknowledged it should not have happened. 2. Resident #86 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, generalized weakness, insomnia and depression. A review of the MDS Quarterly assessment with ARD of 6/28/25 revealed resident # 86 had a BIMS Score of 14 out of 15 which indicated she was cognitively intact. The MDS assessment revealed the resident had no behaviors, nor rejection of care. A review of resident #86's Plan of Care revealed the resident had actual impairment to skin integrity related to seborrheic dermatitis of the face and head which was initiated on 3/07/25 and included interventions that read Treatment as ordered. On 9/22/25 at 11:48 AM, resident # 86 was in bed, alert and oriented. There was a tube of Hydrocortisone cream without a cap on her bedside table, and she stated that she used it a while ago for a rash on her face. The resident continued to explain she applied the cream to her face twice a day but stopped using it after she had lost the cap. On 9/22/25 at 3:55 PM, LPN A verified the hydrocortisone cream at resident #86's bedside. LPN A said she did not know about the Hydrocortisone cream for resident # 86 at the bedside. The UM walked into resident #86's room and verified the Hydrocortisone cream. The resident stated to the assigned nurse and the UM that the cream was given to her by the Dermatologist a while back and she used it for the rash on her face. A short time later the UM confirmed in the electronic medical record no self-administration assessment had been completed for resident #86 and said they did not even know resident #86 had an order for Hydrocortisone cream. The UM explained it was probably an old order since there were no current orders for Hydrocortisone cream. She then found an order dated March 2025 from a Dermatologist note. The UM said that resident #86 should have an order to self-administer medications and should have had an assessment completed in order to do so. On 9/22/25 at 4:40 PM, the DON and NHA said it was not the facility's standard of practice to have medications at the bedside unless the resident had an order to self-administer medications. The NHA confirmed the nurse required education on self-administration of medications. 3. Resident # 113 was admitted to the facility on [DATE], with most recent readmission 6/27/25. Her diagnoses including fibromyalgia, anxiety, depression, myocardial infarction, and low back pain. A review of the MDS quarterly assessment, with an assessment reference of 9/17/25, revealed that resident #113 had a BIMS score of 11 out of 15, indicating she was moderately cognitively impaired. On 9/22/25 at 3:26 PM, resident #133 was lying back in bed watching television. The resident's overbed table contained personal items, including a 30 milliliter (ml) bottle of Systane Lubricant eye drops. The resident stated she bought eye drops for her left eye because it gets scratchy. On 9/22/25 at 3:30 PM, Registered Nurse (RN) B, the primary care nurse, entered the room. He acknowledged the Systane lubricant eye drops, 30 milliliters on the residents table. Outside of the room a review of the resident's physician orders with RN B revealed no orders for the Systane lubricant eye drops, nor did the resident have a completed medication self-administration evaluation. On 9/23/25 at 10:12 AM, the DON stated she spoke with resident #113, and the resident did not wish to administer eye drops on her own. She explained a physician's order was obtained for the nurse to administer the eye drop to the resident. A review of the facility's policy and procedure for Self-Administration of Medication dated 9/16/24 revealed, The facility will determine through an interdisciplinary assessment if the resident is able to either safely administer medications that are requested from a central location (e.g.medication cart or medication room) or the resident is able to safely store the medication in a secure location in room, and safely administer the medication as prescribed.

Based on observation, interview, and record review, the facility failed to ensure blood glucose monitors were cleaned and disinfected appropriately between resident use to prevent the potential for transmission of blood borne pathogens on 1 of 3 Units, (Unit 200), failed to ensure appropriate Personal Protective Equipment (PPE) was donned as required prior to room entry for 1 of 1 resident on Transmission Based Precautions (TBP), (#165), failed to ensure indwelling catheter drainage bag was kept off the floor to prevent the potential of infection for 1 of 1 resident reviewed for indwelling catheter, (#165), and failed to ensure proper handling of glassware by staff during dining, of a total sample of 41 residents. Findings: 1. On 5/06/24 at 11:52 AM, during medication administration observation, Licensed Practical Nurse (LPN) A monitored blood glucose (BG) for resident #164. On 5/06/24 at 11:55 AM, LPN A proceeded to clean the glucose monitor he used with an alcohol prep pad. The LPN stated he had two glucose monitors in his medication cart, he alternated the use, then cleaned the glucose monitors with alcohol prep between resident use. On 5/06/24 at 11:56 AM, LPN A monitored BG for resident #16. He then proceeded to clean the glucose monitor again with alcohol prep. LPN A stated he used Super Sani-cloth (purple top) wipe for cleaning his medication cart but did not use the Super Sani-cloth wipes for cleaning/disinfecting the glucose monitors, he confirmed he used alcohol prep for the glucometers. Review of the manufacturers' guide for the glucose monitors used by the facility revealed only wipes with Environmental Protection Agency (EPA) registration numbers listed in the guide were to be used to clean and disinfect the blood glucose monitor. The list included the bleach germicidal wipes (yellow top), and the Super Sani-cloth wipes. Alcohol prep was not listed as a recommended cleaning/disinfecting agent for the glucose monitors. On 5/06/24 at 12:10 PM, and at 1:03 PM, the Registered Nurse/Infection Preventionist (RN/IP), stated staff could use alcohol prep, yellow top bleach germicidal wipes, or the Super Sani-cloth purple top wipes to clean the reusable blood glucose monitor. The manufacture's guide was reviewed with the RN/IP and revealed only wipes with EPA registration numbers listed in the guide were recommended for use to clean and sanitize the glucose monitors. The information was acknowledged by the RN/IP, and she stated staff were supposed to follow the manufacturer's guide. She said she thought alcohol was ok for use on the glucose monitors. On 5/06/24 at 1:11 PM, the LPN/Unit Manager (UM) stated glucose monitors must be cleaned and disinfected as recommended. On 5/07/24 at 9:35 AM, LPN A stated during his shift he had four residents who needed blood glucose monitoring. Record review revealed six residents on LPN A's assignment actually required blood glucose monitoring, and none of the residents had a diagnosis of a blood borne pathogen. On 5/08/24 at 9:06 AM, the Staff Development Coordinator (SDC) stated cleaning/disinfecting of the glucose monitor was taught using the facility's Infection Prevention and Control Program (IPCP) and Plan, in combination with the manufacturer's guide. She stated education was conducted on hire, during orientation, and annually, and competency for glucose monitor cleaning had to be completed for all nurses. The Staff Development Coordinator explained there were two glucose monitors on each medication cart which the nurses used alternately. She stated the glucose monitor must be cleaned and disinfected. She said alcohol prep could be used to clean the monitors, but the Super Sani-wipe cloth (purple top) wipes must be used to disinfect the glucose monitors. Review of the Competency checklist for Glucometer Cleaning Procedures revealed nurses were checked off for the cleaning and disinfecting procedures. The document read, Open cap of the disinfecting container and pull out 1 towelette. The use of alcohol prep was not documented/indicated. 2. Resident #165 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus type II, cognitive communication deficit, dementia, and dysphagia. Observation on 5/07/24 at 10:15 AM, showed signage for contact precautions posted on resident #165's door, and an overdoor container with the required, and adequate supply of PPE noted. Review of the medical record revealed a physician's order dated 5/01/24 for contact precautions for ten days due to Extended-Spectrum Beta-Lactamase (ESBL) in the urine, with end date of 5/11/24. ESBLs are enzymes or chemicals produced by germs like certain bacteria. These enzymes make bacterial infections harder to treat with antibiotics, (retrieved on 5/15/24 from webmd.com). On 5/07/24 at 12:12 PM, Certified Nursing Assistant (CNA) E was observed in the resident's room leaning over her bed, not wearing any gown or gloves. On exit from the room, the CNA stated she went in to remove the resident's meal tray. She stated the resident was on contact isolation, and acknowledged she leaned over the resident's bed and could have come in physical contact with the resident's bed linen. When asked why she had not worn the appropriate PPE as directed by the posted signage, she said it was a, Bad habit, and confirmed she should have donned gown and gloves prior to entry into the resident's room. On 5/07/24 at 12:31 PM, RN D stated resident #165 was on contact isolation for ESBL in her urine. The RN said directives from the Infection Preventionist was for staff to wear gown, and gloves while coming in contact with linen, emptying the Foley catheter, providing activities of daily living care, or if there was the possibility of them coming in physical contact with the resident's environment. On 5/07/24 at 12:36 PM, the LPN/ UM for the 100/200 Units, stated the protocol for contact isolation was for staff to wear a gown, and gloves if coming in contact with the resident. On 5/09/24 at 12:27 PM, the Infection Preventionist stated the appropriate PPE must be worn if staff was coming in contact with the resident's linen or environment. The Center for Disease Control and Prevention signage for Contact Isolation used by the facility directs that Providers and Staff must also: Put on gloves before room entry .Put on gown before room entry. 3. Resident #165 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus type II, cognitive communication deficit, dementia, and dysphagia. A physician's order dated 4/26/24 for indwelling catheter to straight drainage, with instructions to change for infection, obstruction or when the closed system was compromised. Observations on 5/07/24 at 10:15 AM, and 11:09 AM, noted the drainage bag of the indwelling catheter was on the floor. On 5/07/24 at 12:12 PM, CNA E acknowledged resident #165 was included in her assignment, and verbalized the resident had an indwelling catheter. The CNA stated she checked the resident's indwelling catheter every two hours. Observation of the indwelling catheter was conducted with CNA E. She acknowledged the indwelling catheter drainage bag was on the floor. When asked why the drainage bag should not be on the floor, CNA E said she was not sure. On 5/07/24 at 12:25 PM, LPN A acknowledged the indwelling catheter drainage bag was on the floor, and stated the drainage bag should not be on the floor for several reasons including the potential for infection. On 5/07/24 at 12:31 PM, RN D, the resident's primary nurse stated the indwelling catheter drainage bag should not be on floor due to the potential of infection. On 5/07/24 at 12:36 PM, the LPN/ UM for the 100/200 Unit confirmed the indwelling catheter drainage bag was not supposed to be on floor. The policy Indwelling Urinary Catheter (Foley) Management issued 4/01/2022, and reviewed 8/24/2023, instructed the indwelling catheter collecting bag was not to rest on the floor. 45646 4. During lunch observation in the main dining room on 5/06/24 at 12:02 PM, a resident requested a drink refill. The Minimum Data Set (MDS) Licensed Practical Nurse (LPN) took the glass from the resident's table. She was observed holding the glass in her left hand with her thumb and fourth finger directly touching the rim of the glass. She held the straw in the glass between her first and second fingers which overlapped the top of the glass and and also touched the rim. The MDS LPN asked another staff member where the pitcher of juice was located. She then proceeded to the area, put the glass down and filled it with juice. The MDS LPN then picked up the glass and headed toward the resident's table. When asked if she was going to serve the glass she had touched the rim of to the resident, she stated, Yes, why? The MDS LPN was reminded she had touched the rim of the glass with four of her fingers. She stated she did not realize she had done that and acknowledged she would not want to drink from a glass which had been handled by the rim. During an interview with the Infection Preventionist on 5/09/24 at 12:23 PM, she stated staff were to handle cups and glasses by holding the sides of the glass. She demonstrated the proper way to handle a glass when served to a resident. The Infection Preventionist confirmed staff handling glassware by the rim was a problem and acknowledged it presented a potential to spread infection. She explained staff members should always handle cups and glasses away from the rim to avoid potential cross contamination and should never touch the rim.

Based on observation, interview, and record review, the facility failed to ensure an evaluation for self-administration of medication was completed, failed to obtain a physician's order for self-administration of medications, and failed to ensure medications were stored securely at the resident's bedside for 1 of 5 residents reviewed for choices, of a total sample of 41 residents, (#51). Findings: Resident # 51, an [AGE] year-old female was admitted to the facility on [DATE], with diagnoses that included, toxic encephalopathy, wedge compression fracture of Thoracic (T) 7-T8 vertebra, diabetes with diabetic neuropathy, chronic obstructive pulmonary disease, lack of coordination, and anxiety disorder. Review of the resident's admission Minimum Data Set assessment dated [DATE], revealed the resident's cognition was moderately impaired, with a Brief Interview For Mental Status score of 10 out of 15. On 5/07/24 at 10:30 AM, resident # 51 sat in her wheelchair in her room, with her tray table positioned in front of her. A vial of Brimonidine Tartrate Ophthalmic Solution 0.2%, and a vial of Timolol Ophthalmic Solution 0.5 % was noted on the resident's tray table. Resident #51 said she always kept the eye drops with her, and when asked how many drops she placed in her eyes, the resident stated, However many drops can get in there. Brimonidine eye drops is used alone or together with other medicines to lower pressure inside the eye that is caused by open-angle glaucoma or ocular (eye) hypertension, (retrieved on 5/10/24 from mayoclinic.org). Timolol is used to treat glaucoma . it works by decreasing the pressure in the eye, (retrieved on 5/10/24 from medlineplus.gov). On 5/07/24 at 10:38 AM, Licensed Practical Nurse (LPN) A stated resident #51 was ordered two different eye drops which she self-administered. Review of the resident's physician orders conducted with LPN A showed orders dated 4/23/24 for Brimonidine Tartrate Ophthalmic Solution 0.2%, and Timolol Ophthalmic Solution 0.5%, with instructions to instill one drop in both eyes two times a day for glaucoma. An order for self-administration of the medications could not be identified. This was acknowledged by the LPN. The resident's Electronic Medical Record (EMR) indicated the medications were to be administered by the clinician, and the options unsupervised/supervised administration was not checked. An assessment/ evaluation for self-administration of medication could not be identified for the resident. This was acknowledged by the LPN, and he explained a resident must be evaluated for self administration, and have a physician's order to self-administer any medication. On 5/07/24 at 10:47 AM, the 100/200 Unit LPN/Unit Manager (UM) stated for a resident to self-administer medication, an assessment for self-administration had to be completed, and if medications were to be stored at the resident's bedside, they would be kept in a locked drawer. The resident's clinical records were reviewed with the LPN/UM and revealed no documentation or physician's orders to indicate the resident was evaluated and approved for self-administration of medications. The LPN/UM stated if the medications were to be administered by the resident, it would be indicated on the physician's orders, and self-administration would be selected. On 5/08/24 at approximately 10:00 AM, the Director of Nursing (DON) stated she was made aware of the medications at resident #51's bedside. She stated residents had to have an evaluation, and physician's order in place, to self-administer medications. Review of the Medication Self-Administration Review completed on 5/07/24 after resident #51 was observed by the surveyor with eye drops in her room that were self-administered by the resident , indicated the resident required assistance to correctly read label and/or identify each medication, and to administer eye drops or eye ointment correctly. The document instructed staff to, Complete this assessment prior to resident self-administration of medication. The evaluation read, Resident may NOT self-administer medications. The policy Self-Administration of Medication issued 9/06/2017, revised 10/13/21, and reviewed 08/29/23 read, The facility will ensure that each resident who requests to self-administer medications is assessed by the interdisciplinary team (IDT) to determine if the resident is safe to self-administer medications . Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the room of, or room with, residents who self-administer.

Based on interview and record review, the facility failed to refer a resident with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 4 of 4 residents reviewed for PASARR, of a total sample of 41 residents, (#24, #47, #59 and #93). Findings: 1. Resident #24 was admitted to the facility from an acute care hospital on 8/01/22 with diagnoses that included paranoid schizophrenia, type II diabetes mellitus (DM), depression, bilateral below the knee complete traumatic amputation, and patient noncompliance with medication regimen. Review of resident #24's PASSAR Level I Screen dated 6/08/22, revealed a diagnosis of depressive disorder. Although he was identified as having received services for mental illness (MI) in the past, the MI did not affect his daily life, and there was no diagnosis of dementia. The document indicated a PASSAR Level II Screen was not required. The Minimum Data Set (MDS) Quarterly assessment dated [DATE], revealed resident #24 had a Brief Interview for Mental Status (BIMS) score of 15/15 indicating intact cognition. He had frequent depressed moods, low energy, and social isolation. He did not display any behaviors and was independent for personal care, mobility, and incontinence care. Active diagnoses included depression and schizophrenia with use of antipsychotic medications. Review of active orders dated 5/09/24 on the summary report revealed resident #24 was taking several medications to include Depakote prescribed for bipolar disorder, Paroxetine for depression, and Vraylar, an antipsychotic used to treat paranoid schizophrenia. He also had orders for monitoring of side effects from antipsychotic medications. Review of progress notes for resident #24 revealed a behavior note dated 3/31/24 that stated, CNA (Certified Nursing Assistant) attempted to provide patient care, resident became extremely upset, began yelling/cussing and using derogatory terms towards aide. Redirection attempted but ineffective resident just became increasingly upset. Review of the medical record for resident #24 revealed several care plans with review date of 3/26/24 for ADL (activities of daily living), psychotropic medications, and behaviors. The ADL care plan stated the resident had a performance deficit related to activity intolerance with shower refusals. There was a care plan for monitoring of psychotropic medications related to depression, anxiety, schizophrenia, and bipolar disorder. Interventions included medication administration, changes in behavior/mood/cognition, decline in ADL ability, hostility, aggressive or impulsive behavior, and social isolation. Resident #24 had a behavior care plan, revised on 4/12/24, which stated he had a problem with poor boundaries with staff and making inappropriate comments including sexual comments towards female staff and racial remarks. Interventions included medication administration and reporting behaviors to psychiatrist. On 05/06/24 at 12:14 PM, Resident #24 was observed in his room sat up in bed. His face was unshaven but clean and he was wearing clean clothing. He appeared sweaty and agitated. Resident #24's side of the room was disorganized and there was a smell of feces. There were several areas where dried feces were observed including the bedside commode, bedside table, hand sanitizer bottle on nightstand, and bed sheet. On 05/09/24 at 01:21 PM, the Director of Nursing (DON), stated resident #24 had behavior issues and would get upset very easily. She stated there were only certain staff members who could redirect his behavior when he was upset. His mother was very involved in his care because she would help calm him down. The DON explained they had tried to clean his room, but he would not allow it. She stated he had refused care in the past including personal care and showers. She acknowledged she was unaware a new PASSAR Level I Screen was needed for the newly identified MI diagnoses. 2. Resident #93 was initially admitted to the facility on [DATE] and readmitted on [DATE] from an acute care hospital. His diagnoses included a history of cerebral infarction, type II DM, delusional disorder, and depression. Review of resident #93's PASSAR Level I Screen dated 11/15/22, revealed no MI or dementia diagnosis. The document indicated a PASSAR Level II Screen was not required. The MDS Quarterly assessment dated [DATE], revealed resident #93 had a BIMS score of 9/15 indicating moderate cognitive impairment. He had no moods or behaviors and required substantial assistance for personal care. Active diagnoses included depression and psychotic disorder. Review of the Admission MDS dated [DATE] revealed there were no active MI disorders and a later Quarterly MDS assessment dated [DATE] had a diagnosis of psychotic disorder. Review of the active orders summary report dated 5/09/24 revealed resident #93 had orders for Lexapro to be given in the morning for mood. Lexapro is an antidepressant medication used to treat certain types of anxiety and depression, (retrieved on 5/20/24 from www.drugs.com). Review of resident #93's progress notes revealed a nursing note dated 3/22/23 asking for medication consent for antipsychotic medication due to increased agitation, and increased behaviors signed by the physician and the psychiatrist. On 4/12/24 a psychotherapy note indicated staff described the resident as being agitated, generally unhappy, and noncompliant. The resident was referred to psychiatric services for depression, anxiety, and to assess adjustment due to staff concerns about resistance to care. The psychiatrist's diagnosis was adjustment disorder with mixed anxiety and depressed mood. Review of the medical record for resident #93 revealed a care plan revised on 1/14/24 for antidepressant medication use related to depression. Interventions included observe for side effects of change in behavior, mood, and cognition. A care plan revised on 1/24/24 revealed resident #93 was resistant to care related to adjustment to nursing home placement with episodes of medication refusal, refusal of care, and refusal of assistance with personal care. On 5/06/24 at 03:13 PM, observed resident #93 wandering the hallway in his wheelchair with a sad demeanor. He stated he was doing ok and that he had not eaten lunch because it was not good. On 05/09/24 at 10:29 AM, Licensed Practical Nurse (LPN) H stated she had worked with resident #93 for a while and was very familiar with him. Resident #93 refused care sometimes when he was not in the mood. LPN H described resident #93 as sometimes non-compliant with wearing his splint, but did not have behaviors often. On 05/09/24 at 01:28 PM, the DON confirmed resident #93 had a PASSAR Level I completed on initial admission. She acknowledged the resident had a diagnosis of depression and delusional disorder on initial admission to the facility and therefore the initial PASSAR Level I was incorrect. She confirmed no new PASSAR Level I's was completed for the MI diagnoses. 45646 3. Resident #59 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus, chronic kidney disease, heart failure, dementia and chronic obstructive pulmonary disease. Review of the MDS quarterly assessment with assessment reference date (ARD) of 3/26/24 revealed resident #59 had a BIMS score of 06/15 which indicated he had severe cognitive impairment. The document indicated her active diagnoses included anxiety disorder, depression, bipolar disorder and schizophrenia. A care plan initiated 6/13/23 and revised 9/25/23 read, The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs [related to] muscle weakness, heart failure, dementia, and schizoaffective disorder. Review of resident #59's electronic medical record (EMR) revealed diagnoses of schizoaffective disorder with an onset date of 2/24/21, bipolar disorder with an onset date of 2/24/21, anxiety disorder with an onset date of 12/27/22 and depression with an onset date of 12/27/22. The record contained a Level I PASARR screening form dated 2/24/21 which did not indicate the resident had a MI or suspected MI. The record did not contain a Level II PASARR screening form. 48878 4. Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Her diagnosis included cognitive communication deficit, transient ischemic attack, and depression. She had new diagnoses after her admission that included psychotic disorder on 5/18/22, delusional disorder on 8/30/22, anxiety disorder on 10/25/22, and unspecified dementia, unspecified severity, with psychotic disturbance on 10/25/22. Resident #47's Annual MDS assessment with an ARD of 3/10/24 revealed the resident scored 3 out of 15 on the BIMS which indicated she had severely impaired cognitive skills for daily decision making. The assessment noted the resident received antipsychotic, antianxiety, and antidepressant medications. The MDS also noted the resident did not exhibit behavioral symptoms or rejection of care necessary to achieve the resident's goals for health and well-being. Review of resident #47's medical record revealed a care plan initiated on 2/04/22 and revised on 3/12/24 indicated the resident used psychotropic medications related to diagnoses to include delusions, psychotic disorder, and behavior management. The interventions included following up with the psychiatric medical doctor as needed. On 5/08/24 at 8:45 AM, the Nursing Home Administrator (NHA) and the DON conveyed it was the Social Service Director and the DON's responsibility to ensure the resident's PASARRs were completed and submitted timely. The NHA stated the expectation was the Social Service Director audit all residents on admission and collaborated with the DON if there was a change in diagnosis for a new PASARR screen to be completed. The DON verified resident #47's PASARR level I dated 1/28/22 prior to admission from the hospital was incorrect and she could not find an updated PASARR level I. The DON also stated the resident had a new diagnosis of dementia, delusional disorder, and psychotic disorder for which a new PASARR level I was not performed. The DON acknowledged the resident should have had another PASARR level I performed upon admission and again when the resident was diagnosed with a new mental disorder. The facility's PASARR policy read, The facility will ensure that potential admissions are screened for possible serious mental disorders or intellectual disabilities and related conditions. This initial pre-screening is referred to as PASARR Level I and is completed prior to admission to a nursing facility. A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later .Any resident with newly evident or possible serious mental disorder, ID (intellectual disability) or a related condition must be referred, by the facility to the appropriate state-designated mental health or intellectual disability authority for review .Individuals who may not have previously been identified by PASARR to have MD(mental disorder), ID or a related condition include, but is not limited to a resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR.

Based on interview and record review the facility failed to develop a baseline care plan for nutrition in the required timeframe for 1 of 4 residents reviewed for nutrition, of a total sample of 41 residents, (#165). Findings: Resident #165 was admitted to the facility on [DATE], with diagnoses including diabetes type II, cognitive communication deficit, dementia, and dysphagia. On 5/07/24 at 12:28 PM, resident #165's meal ticket showed the resident was on a mechanically altered diet. Certified Nursing Assistant (CNA) E removed the resident's meal tray, and stated the resident consumed approximately 20 to 25% of her meal. On 5/08/24 at 12:03 PM, resident #165 sat in her wheelchair in her room, with her lunch tray set up on the over bed table positioned in front of her. The resident's eyes were closed, and she was not eating. Review of the resident's physician's orders revealed the resident was on a mechanically altered texture, consistent carbohydrate diet. A Mini Nutritional assessment dated [DATE] indicated the resident was at risk of malnutrition. A review of the resident's clinical records revealed no baseline care plan, nor a comprehensive care plan for nutrition could be identified. On 5/09/24 at 8:49 AM, the 100/200 Licensed Practical Nurse/ Unit Manager (LPN/ UM) stated nursing staff completed the Mini Nutritional Assessment for resident #165, and a baseline care plan for nutrition should have been initiated for the resident based on results of the assessment. Review of the resident's clinical records was conducted with the LPN/UM, and she acknowledged neither a baseline nor a comprehensive care plan to address the resident's nutrition risk was identified. On 5/09/24 at 8:52 AM, the Director of Nursing (DON) stated baseline care plans were developed by the admitting nurse and were completed within 48 hours of admission. The resident's clinical records were reviewed with the DON, and neither a baseline care plan nor a comprehensive care plan for nutrition was identified. She stated the resident was admitted to the facility on a mechanical soft diet and acknowledged the Mini Nutritional Assessment conducted for resident #165 dated 4/26/24 indicated the resident was at risk for malnutrition. She said a baseline care plan should have been developed. The policy Baseline Care Plan issued 8/28/2017, and reviewed 8/11/2023 read, The baseline care plan must-be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including .Dietary orders .The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan is developed within 48 hours of the resident's admission.

Based on observation, interviews, and record review, the facility failed to identify an accurate diagnosis for anti-psychotic medication use for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 41 residents, (#71). Finding: Review of the medical record revealed resident #71, a [AGE] year-old female was admitted on [DATE], and readmitted on [DATE] from an acute care hospital with diagnoses that included dementia, anxiety disorder, bipolar disorder current episode mixed mild, and schizoaffective disorder, unspecified. The Minimum Data Set (MDS) 5-day Assessment with Assessment Reference Date 3/06/24 showed the resident scored 12 out of 15 on the Brief Interview for Mental Status that indicated she was moderately cognitively impaired. She had no indicators of psychosis (hallucinations/delusions) or behavioral symptoms. The assessment noted she required staff assistance to complete activities of daily living (ADLs), she had active diagnoses of non-Alzheimer's dementia, anxiety disorder, bi-polar disorder, and schizophrenia. She did not require the use of restraints or alarms, and she received high risk anti-psychotic, anti-anxiety, and hypnotic medications during the look-back period. The Preadmission Screening and Resident Review (PASARR) (Agency for Health Care Administration MedServ Form 004, Part A, March 2017) form completed by the hospital on 3/06/22 indicated a mental illness (MI) or suspected mental illness (SMI) of bipolar disorder. The comprehensive care plan included focuses for self-care performance deficits, dementia/impaired cognition, mood or behavior changes, adverse effects of sedative and anti-depressant medications, and read, The resident uses antipsychotic medications DX: (Diagnosis) bipolar mania, schizoaffective disorder and is followed by psychiatry. The Order Summary Report noted active physician's medication orders for Zolpidem (hypnotic)10 Milligrams (MG) for insomnia, Mirtazapine (anti-depressant) 15 MG for depression/appetite, and Olanzapine (anti-psychotic) 2.5 MG for bipolar disorder and schizoaffective disorder. On 5/07/24 at 10:13 AM, resident #71 was observed in her room sitting in a recliner. She stated she was not interested in participating in conversation with the surveyor. On 5/08/24 at 11:43 AM, Certified Nursing Assistant I stated resident #71 was often included on her assignment and knew her well. She said the resident enjoyed spending time in her room watching television and relaxing in a recliner. On 5/09/24 at 9:19 AM, The Director of Nursing (DON) explained the behavioral health monthly meetings were conducted with facility staff, the pharmacy, and psychiatric providers. She said residents' psychiatric plans of care were discussed and included any behavioral changes, gradual dose reductions of medications, and appropriate diagnoses. The DON stated resident #71's diagnosis of schizoaffective disorder was used because it had been noted on hospital records. She did not explain why the record was not revised to reflect the facility's psychiatrist diagnosis assessments. Review of the medical record revealed a revised PASARR form was completed by the DON on 2/06/24 and marked for a MI or SMI of anxiety disorder, bipolar disorder, and schizoaffective disorder. On 5/09/24 at 10:14 AM, the MDS Lead Coordinator said she completed assessments, and diagnoses were auto populated from the electronic medical record into the MDS. She explained she followed the Resident Assessment Instrument (RAI) instructions and checked the accuracy of active diagnoses with reviews of the most recent physician's progress notes and orders. She said psychiatric diagnoses that required clarification were obtained from the treating psychiatrist to ensure they were correct. She checked the medical record and acknowledged the psychiatrist's notes did not include a diagnosis of schizophrenia or schizoaffective disorder. She reviewed the 3/06/24 MDS and said it was marked for schizophrenia and was not active according to the doctor's notes. Psychotherapy notes completed by the psychologist from 5/03/23 to 9/01/23 noted diagnoses of bipolar disorder and anxiety. The weekly Psychiatric Follow Up notes completed by the psychiatrist from 2/20/23 to 3/13/24 documented the resident was assessed to have bipolar disorder and grief. In an interview with the facility's psychiatrist on 5/09/24 at 8:38 AM, he recalled resident #71, and said he treated her at the facility. He said he conducted face to face evaluations and documented his assessments on the Psychiatric Follow Up Notes which indicated the proper diagnosis. He said he rarely used a diagnosis of schizoaffective disorder and stated, Sometimes they just put that in there. Review of the facility's standards and guidelines dated 8/22/23 and titled Comprehensive Care Plans and Revisions read, The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care. a. The instructions for completing the RAI are found in the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument Instruction User's Manual 3.0 . Review of the CMS RAI version 3.0 Manual read, . Steps for Assessment 1. Medical record sources for physician diagnoses include the most recent history and physical ., progress notes, and other resources as available. Identify diagnoses: The disease conditions in this section require a physician-documented diagnosis (or by a nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) in the last 60 days.

Based on interview and record review, the facility failed to indicate the duration of as needed (PRN) anti-anxiety/anxiolytic medications for 1 of 5 residents reviewed for unnecessary medications and psychotropic medications, of a total sample of 41 residents, (#47). Findings: Review of the medical record revealed resident #47 was admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Her diagnosis included cognitive communication deficit, transient ischemic attack, and depression. She had new diagnoses after her admission that included psychotic disorder 5/18/22, delusional disorder 8/30/22, anxiety disorder 10/25/22, and unspecified dementia, unspecified severity, with psychotic disturbance 10/25/22. Resident #47's Annual Minimum Data Set (MDS) assessment with an assessment reference date of 3/10/24 revealed a score of 3/15 on the Brief Interview for Mental Status exam which indicated she had severely impaired cognitive skills for daily decision making. The Annual MDS noted the resident received antipsychotic, antianxiety, and antidepressant medications. The MDS assessment also noted the resident did not exhibit behavior symptoms or rejection of care that is necessary to achieve the resident's goals for health and well-being. Review of resident #47's medical record revealed a care plan initiated on 2/04/22 and revised on 3/12/24 indicated the resident used psychotropic medications related to diagnoses including delusions, psychotic disorder, and behavior management. The interventions included follow up with the psychiatric medical doctor as needed. Resident #47's Order Summary Report and the Medication Administration Record (MAR) showed the resident had an active order dated 11/27/24 for Lorazepam 1 milligram (mg) by mouth every 6 hours PRN for anxiety with no stop date. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include but are not limited to anti-anxiety medication. Based on a comprehensive assessment of the resident, the facility must ensure that PRN orders for psychotropic drugs are limited to 14 days. If the attending physician or prescribing practitioner believes it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order, (retrieved on 5/14/24 from www.ecfr.gov). Review of the MAR revealed the resident received 24 doses of Lorazepam PRN between 11/30/23 and 5/07/24. The 14-day duration for the PRN medication should have been 11/27/23 to 12/11/23. The MAR indicated the resident received 17 doses of Lorazepam after the 14- day duration had passed. Further review of the medical record revealed the physician did not provide a rationale for the extended time-period for Lorazepam use and did not indicate a specific duration for the anti-anxiety PRN order. On 5/08/24 at 12:42 PM, Registered Nurse (RN) B stated if a PRN medication was administered for anxiety, it should only be given for 14 days unless the doctor gave a new order with a rationale for it to be continued. RN B confirmed resident #47 had an active order for Lorazepam PRN for anxiety since 11/27/23 with no stop date which should have been limited to 14 days. He acknowledged he administered the medication to the resident yesterday, 5/07/24. RN B also confirmed there was not a provider rationale for continuing the medication past the 14 days. He stated he could not provide an answer as to why resident #47's PRN Lorazepam did not have a rationale for continuing the medication past the 14 days. On 5/8/24 at 12:51 PM, the Director of Nursing (DON) stated PRN psychotropic medications should be discontinued after 14 days unless the physician assessed the resident and documented the reason the medication needed to be continued. She acknowledged resident #47's PRN Lorazepam order should have had a 14-day stop date and the psychiatric follow-up note dated 4/04/24 by the psychiatrist showed Lorazepam with no duration or rationale for continued use. The facility's Psychotropic Medication Management Policy read, A psychotropic drug is defined in the regulations at 483.45 (c) (3), as 'any drug that affects brain activities associated with mental processes and behavior.' Psychotropic drugs include but are not limited to the following categories: anti-psychotics, anti-depressants, anti-anxiety, and hypnotics .Based on a comprehensive assessment of a resident, the facility must ensure .limiting the timeframe for PRN psychotropic medications, which are not antipsychotic medications, to 14 days, unless a longer timeframe is deemed appropriate by the attending physician or the prescribing practitioner .The resident's medical record must show documentation of adequate indications for a medication's use.

Based on interview, and record review, the facility failed to ensure documentation in the medical record was complete and accurate according to accepted professional standards and practices regarding self-administration of medications for 1 of 5 residents reviewed for choices, of a total sample of 41 residents, (#51). Findings: Resident # 51, an [AGE] year-old female was admitted to the facility on [DATE], with diagnoses including, toxic encephalopathy, wedge compression fracture of Thoracic (T) 7-T8 vertebra, diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, lack of coordination, and anxiety disorder. The resident's physician orders dated 4/23/24 was for Brimonidine Tartrate Ophthalmic Solution 0.2%, and Timolol Ophthalmic Solution 0.5%, with instructions to instill one drop in both eyes two times a day for glaucoma. Brimonidine eye drops is used alone or together with other medicines to lower pressure inside the eye that is caused by open-angle glaucoma or ocular (eye) hypertension, (retrieved on 5/15/24 from mayoclinic.org). Timolol is used to treat glaucoma . it works by decreasing the pressure in the eye, (retrieved on 5/15/24 from medlineplus.gov). On 5/07/24 at 10:30 AM, resident # 51 sat in her wheelchair in her room with her tray table positioned in front of her. A vial of Brimonidine Tartrate Ophthalmic Solution 0.2%, and a vial of Timolol Ophthalmic Solution 0.5 % was noted on the resident's tray table. Resident #51 said she always kept the eye drops with her, and when asked how many drops she placed in her eyes, the resident stated, However many drops can get in there. Review of the resident's Medication Administration Record (MAR) for the period 4/23/24 through 5/09/24 revealed nurses' signatures to indicate the medications were administered by the clinician. There was no physician order for self-administration of the medications. On 5/07/24 at 10:38 AM, Licensed Practical Nurse (LPN) A stated resident #51 was ordered two different eye drops which she self-administered. A review of the resident's physician orders conducted with LPN A revealed the medication was to be administered by the clinician. LPN A acknowledged the, Unsupervised/supervised administration box was not checked. On 5/07/24 at 10:57 AM, LPN A stated the resident's family wanted her to self-administer the eye drops and made the request approximately two weeks ago. The LPN stated there was no documentation regarding the request. He said when he gave medications to the resident's roommate, resident #51 instilled her eye drops. He acknowledged the documented administration was not done by him. On 5/08/24 at 3:29 PM, Registered Nurse (RN) C confirmed she was resident #51's primary nurse. She stated she opened the lid of the eye drops and offered to give them for resident #51, but the resident gave them on her own. The RN said she signed off on the resident's MAR indicating the eye drops were administered by staff. Review of the MAR for the period 4/23/24 through 5/09/23 revealed LPN A's signature on 4/25/24, 4/29/24, 4/30/24, and on 5/06/24. RN C's signature was noted on 4/24/24, 4/28/24, 5/01/24, 5/02/24, and on 5/05/24 indicating the resident's eye drops were administered by the clinician. However, the resident self-administered the medication for an unknown length of time during the period reviewed. On 5/09/24 at 12:32 PM, the Licensed Practical Nurse/Unit Manager (LPN/UM) for the 100/200 units stated she was not aware resident #51 self-administered her eye drops. She stated some nurses said they watched the resident administer the eye drops. The LPN/UM acknowledged the documentation/order for unsupervised/supervised self-administration of the eye drops for resident #51 could not be identified, and the medications were to be administered by the clinician. A review of the resident's MAR for the period 4/23/24 through 5/09/24 was conducted with the LPN/UM. She acknowledged signatures by nurses on the MAR indicated the eye drops were administered by the nurses. The LPN/UM stated the expectation was for nurses to ensure documentation was complete and accurate.

Based on observation, interview, and record review, the facility failed to ensure proper administration of medications for 1 resident assessed for self-administration of medications of a total sample of 33 residents (#84). Findings Resident #84's medical record reflected an admitted [DATE] and diagnoses including heart failure, cardiomyopathy, chronic obstructive pulmonary disease, rheumatoid arthritis, and anxiety. The resident's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 12/23/22 revealed the resident's cognition was intact with a Brief Interview for Mental Status (BIMS) score of 15/15. The assessment noted the resident required supervision with assistance of one person for toileting and bathing. On 2/07/23 at 9:08 AM, resident #84 sat on the side of her bed with her overbed table in front of her with medications spread out on the table. The resident stated her nurse left the medications there for her to take. The resident stated she had not taken any of the pills. There were nine pills on the table and one pill on the floor. The resident's nurse was not in the resident's room and was not seen outside the room in the hallway. On 2/07/23 at 9:09 AM, the Unit Manager observed the medications on the overbed table and verified the nurse was not in the room or hallway. She stated it is not the practice of the facility to leave medications unattended with residents unless the Interdisciplinary Team (IDT) completed an assessment to allow residents to administer their own medications. On 2/07/23 at 9:10 AM, Licensed Practical Nurse (LPN) A stated she was resident #84's nurse. Observation of the medications left on the resident's bedside table was conducted with the LPN. She confirmed that she left the medications with the resident. She said, the resident asked me check on her vitamin because it was a different color, so I went out to check and got called to another room. It is not my practice to leave the medications in the room with the residents. On 2/08/23 at 12:16 PM, the Director of Nursing stated her expectation was for the nurse to follow the five rights of medication administration. If the resident is not eligible to administer their own medications, which requires an assessment, then the nurse must remain with the resident until all the medications are taken. Review of resident #84's physician's orders and the Medication Administration Record (MAR) revealed the following medications were left at the bedside for the resident to take: Aspirin 81 milligrams (mg.) for peripheral vascular disease, Jardiance 10 mg. for diabetes, Vitamin D supplement, Florastor 250 mg. probiotic, Furosemide 20 mg. diuretic for edema, Metoprolol 25 mg. for hypertension, Potassium 10 mEq supplement, Multivitamin supplement, Robaxin 500 mg. for pain, and Norco 10-325 mg. for pain. The facility's policy Self-Administration of Medication issued 9/06/17, revised 10/03/21, and reviewed 8/26/22 read, If the resident desires to self-administer medication, the IDT will contact the resident's primary physician to make them aware of the resident request. The IDT in consultation with the primary physician for the resident will conduct an assessment of the resident's cognitive, physical, and visual ability to carry out this responsibility.

Based on observation, interview and record review, the facility failed to assist a dependent resident with Activities of Daily Living (ADL) care related to the cleaning of nails for 1 resident reviewed for ADL care of a total sample of 33 residents (#176). Findings: Resident #176's medical record reflected the resident was admitted to the facility on [DATE] with diagnoses including paralysis to the left side of his body after a stroke, lack of coordination, muscle weakness, speech and language deficits after stroke and type 2 diabetes mellitus. The resident's Minimum Data Set (MDS) Admission assessment, dated 1/25/23, revealed the resident could understand others and be understood. The assessment showed a Brief Interview for Mental Status score of 5 which indicated severe cognitive impairment. The assessment showed he had no behaviors towards others or himself and had no rejection of care during the look back period. Section G of the assessment revealed resident #176 required extensive assistance from one staff for dressing, toileting, personal hygiene, and bathing. The assessment indicated he had impairment in his functional range of motion on one side of both his upper and lower body. Resident #176's care plan for activities of daily living (ADL) reflected that he required assistance and therapy services to maintain or attain his highest level of function. Interventions included staff assistance with mobility and ADLs as needed. Resident #176 had an additional care plan for ADL self-care performance deficit. Interventions included staff assistance with bathing, dressing and personal hygiene. The resident's Certified Nursing Assistant (CNA) task flowsheet for Personal Hygiene: Self Performance revealed tasks such as how the resident maintained washing and drying of face and hands were included as part of the ADL care. Personal hygiene was documented as performed by staff on all 14 days of the lookback period from 1/25/23 to 2/07/23 at least once a shift. The resident's CNA Kardex revealed Personal Hygiene/Oral Care as part of the care CNAs would provide for resident #176. The document described the resident required assistance with care for personal hygiene and oral care but did not give any specific direction on what that care consisted of or how much assistance was required by staff. On 2/05/23 at 5:54 PM, resident #176 was alert and oriented to person and place. He sat up in bed with his finished meal tray on his bedside table. He stated his left arm was flaccid from a previous stroke and was at the facility for therapy. The nails on his right, dominant hand were dirty with a blackish substance underneath them. Resident #176 stated someone had cut his nails previously, but he wanted them to be cleaned and cut again. He explained no one from the facility had offered to clean them. On 2/07/23 at 10:34 AM, resident #176 sat up in bed wearing a hospital gown. He stated he was waiting for therapy. He stated he needed a shower and again stated no one had cleaned his nails. He showed his right hand in which every fingernail had the blackish colored substance underneath. He was unable to lift his left hand except by using his right hand to grab it and lift it up. On 2/07/23 at 5:31 PM, resident #176 was in his room in bed, alert and oriented to self. He showed his right hand, and all five nails were still dirty with blackish substance under them. He again reiterated he would like someone to clean his nails for him. At approximately 5:36 PM, CNA A delivered resident #176's dinner tray and he began to eat using his right hand with the dirty nails. The resident was not assisted with cleaning his hands before his meal. On 2/07/23 at 5:39 PM, CNA A stated she was the assigned CNA for resident #176. She explained daily care of residents included mouth care, bathing, and dressing. She explained hands and faces were cleaned before dinner and nails should be cleaned daily. CNA A stated she usually checked the nails before dinner then confirmed resident #176's nails were dirty while he was eating his dinner. She acknowledged resident #176 was unable to clean his nails himself due to the paralysis of his left arm and she apologized to him. On 2/07/23 at 5:45 PM, Licensed Practical Nurse (LPN) B stated CNAs should clean resident's nails when they do their daily care. She confirmed resident #176's nails were dirty with a black colored substance underneath them. LPN B stated CNAs should ask residents if they wanted their nails cleaned or trimmed whenever they give care. At that time, resident #176 indicated to LPN B he did want his nails cleaned. On 2/07/23 at 5:49 PM, the 100/200 Unit Manager (UM) stated nails should be checked every day when CNAs gave hygiene care on every shift. She explained nails were trimmed on nail day but the cleaning of nails should be done with bathing every shift. The 100/200 UM confirmed the CNA in resident #176's room was now cleaning his dirty nails. She acknowledged resident #176 was unable to move his left arm and thus unable to clean his right hand and nails himself and depended on staff to provide the care for him. Review of the Activities of Daily Living (ADLs) policy and procedure, last reviewed 8/22/22, read, The resident will receive assistance as needed to complete activities of daily living (ADLs). The document indicated the facility must provide care and services for ADLs in accordance with professional standards, the person-centered care plan and the resident's choices for ADLs including fingernail care. The Certified Nursing Aide (CNA) Job Description revealed the CNA was responsible for providing routine daily nursing care to assigned patients to assure patient safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each patient.

Based on observation, interview, and record review, the facility failed to change wound dressing per physician orders for 1 of 3 residents reviewed for skin conditions of a total sample of 33 residents (#104). Findings: Resident #104' medical record revealed he was admitted to the facility on [DATE] with diagnoses of malignant neoplasms of nasal cavity, middle ear, and sinuses. The resident was alert and oriented and able to answer questions appropriately. On 02/05/2023 at 2:00 PM, the resident was resting in bed and his wife and daughter were in the room. A dressing was noted on top of the resident's head, dated 1/31/23, that was loose and peeling off. The resident stated it had been a week since it was last changed and thought maybe the doctor would change it at his appointment this week. On 02/06/2023 at 12:00 PM, resident #104 was in his room. At 3:26 PM, the dressing to the back of resident's head remained the same. It was dated 1/31/23, was loose and coming off. The resident stated he did not know when it was due to be changed. On 02/07/23 at 8:45 AM, the resident's dressing to the top of his head remained the same, dated 1/31, was loose and coming off. The resident stated he was going for a dermatology appointment today and maybe his dressing would be changed at the dermatologist's office. The resident's medical record revealed a physician order dated 1/09/23 at 9:00 PM for wound care that read, Apply skin prep to lesion on scalp, cover with border foam for comfort-one time a day every Tuesday, Thursday, Saturday and as needed for if loose or soiled. A review of the Treatment Administration Record (TAR) noted wound care to scalp lesion was signed as being completed on Thursday 2/02/2023 and Saturday 2/04/2023. A weekly skin inspection was noted as completed on 2/06/2023. On 2/07/23 at 9:00 AM, the Unit Manager (UM) checked the resident's orders and stated the resident had a cancerous lesion to the top of his head and his dressing should have been changed on Saturday 2/04/2023. She reviewed the TAR and noted the dressing change to the resident's head was signed as being done on 2/04/2023. On 2/07/23 at 9:05 AM, the resident sat up in his wheelchair and the dressing to his head had been removed. He stated the nurse had just removed it and would be back in a few minutes. The Wound Nurse returned to the resident's room and said she removed the resident's dressing as it was coming off and discarded the dressing. She stated she did not see the date of 1/31/23 on the dressing. At 9:30 AM, the UM acknowledged the dressing was not done on 2/04/2023 as indicated on the TAR.

Based on observation and interview, the facility failed to ensure steam table insert pans used to serve resident food was left in the sanitizing solution for sufficient time to allow for proper sanitation. Findings: On 3/29/21 at 10:10 AM, Cook D washed steam table inserts at the 3 compartment sink. She washed the pans in sink 1, rinsed the pans in sink 2 and dipped the pans in sink 3 that had quaternary ammonia sanitizer solution. She then set the inserts on clean side of the sink to air dry. She said the pans should stay in the sanitizing solution for 2 seconds. The manufacturer's directions were posted on the wall above the 3 compartment sink. The posters outlined the process to wash, rinse, and leave in sanitizer for a minimum of 10 seconds. On 4/01/21 at 3 PM , the Food Service Director presented the recent food service education on proper sanitation procedures that was done on 2/15/21. The education included manual washing and sanitizing times. Cook D signed that she had participated in the education on 2/15/21.

Based on observation, interview and record review, the facility failed to accurately assess Minimum Data Set (MDS) assessment for 1 of 45 residents, (#357). Findings: Review of resident #357's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed she had moderate cognitive impairment, and required extensive assistance of two staff for activities of daily living (ADL). Section J1800 of the MDS documented the resident did not have any falls since admission. Review of the falls/ incident report revealed resident #357 fell in her room on 3/19/2021 at 7:30 AM during shift change while trying to get up on her own. Review of the care plan for resident #357 documented she was at risk for falls related to a history of a fall with fracture prior to admission, cognitive impairment, and dementia and had an actual fall after admission. Review of resident #357's nursing progress notes dated 3/19/2021 at 8:01 AM, noted she had an unwitnessed fall and was observed lying on the floor between the left side of the bed and the wall. The resident had said she was trying to turn the air off. The progress note indicated that physician orders [REDACTED]. Observations conducted on 03/29/2021 at 3:53 PM and on 03/30/21 at at 9:45 AM and 10:31 AM revealed resident #357's bed in the lowest position and falls mats on the floor by the bedside. Interview with Licensed Practical Nurse E on 3/31/2021 at 10:21 AM revealed she was the nurse who received report the day the resident was found on the floor and recalled it was during shift change. She indicated the fall was discussed with the team. On 4/1/2021 at 2:32 PM, the Registered Nurse (RN) MDS Coordinator stated the facility had a new MDS staff member. She stated the MDS staff missed documenting resident #357's fall on the MDS assessment. She said, our procedure is that we go to the morning meeting, discuss the falls, update interventions and communicate frequently about what is happening with residents. We review risk reports every morning before we go to morning meeting. She reviewed the Medicare five-day MDS dated [DATE] section J, question 1800 and said, we missed it.

Based on observation, interview and record review, the facility failed to maintain oxygen flow rate as per physician order for [REDACTED].#361). Findings: 1. Resident #86 was admitted to the facility in May 2020 with [DIAGNOSES REDACTED]. On 3/30/21 at 11:00 AM, resident #86 sat in her wheelchair. She wore a nasal cannula and received oxygen (O2) via concentrator. The O2 flow rate was set at 2.5 liters per minute (LPM). The rear filter in the concentrator was noted to be covered with white dust like particles. A review of the March 2021 physician orders dated 3/9/21 noted O2 at 2 LPM via nasal cannula. Clean oxygen concentrator filter with soap and water weekly every Sunday starting 2/28/21. On 3/30/21 at 1:58 PM, Licensed Practical Nurse (LPN) C said she had just assisted the resident to eat dessert. She stated she did not notice the O2 concentrator was set at 2.5 LPM. LPN C and the Unit Manager (UM) checked the flow rate and acknowledged the flow rate was set at 2.5 LPM and not at the physician ordered rate of 2.0 LPM. The UM also acknowledged the concentrator was dirty with white dust around the edges. 2. Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 3/30/21 at 4:49 PM, resident #52 was in her wheel chair. She received oxygen via nasal cannula. On 3/31/21 at 11:27 AM, she was laying in bed with her head elevated and the nasal cannula in place. The filter in the concentrator was dusty around the edges. Upon lifting the edge of the filter from the concentrator, the internal side of the filter was covered in dust. The Unit Manager (UM) acknowledged the concentrator filter was completely covered with dust. Review of physician orders for resident #52 dated 5/19/20 noted to clean oxygen concentrator filter with soap and water weekly every Tuesday. 3. Review of resident #12's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the five-day Minimum Data Set (MDS) assessment dated [DATE], revealed she was cognitively intact, and received oxygen therapy. Review of the physician's orders dated 3/29/2021 noted to administer oxygen at 2 liters per minute and clean the O2 concentrator filter with soap and water weekly every Sunday. On 3/29/21 at 12:45 PM, 3/30/21 at 10:21 AM, 1:56 PM, 4:19 PM and 3/31/21 at 11:14 AM revealed both O2 concentrator filters were dusty and dirty. On 3/31/21 at 2:51 PM, Licensed Practical Nurse E acknowledged both O2 concentrator filters were dusty and dirty. 4. Review of resident #361's medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed she had severe cognitive impairment, and received O2 therapy. Review of the resident's physician's orders dated 3/29/21 noted to administer O2 at 3 liters per minute. Observations conducted on 3/30/21 at 12:43 PM and 4:26 PM revealed resident #361's oxygen concentrator filter was dusty and dirty. On 03/31/21 at 2:55 PM, the Central Supply Coordinator stated he changed oxygen tubing and filters every week whenever he could get to it, but not on any particular day. He did not explain why the concentrator filters were dirty and dusty. Review of the facility policy for Oxygen Administration/Safety/Storage/Maintenance dated 5/15/20-infection control #4. Clean exterior of the concentrators weekly with EPA registered hospital disinfectant .the external filter should be checked daily and all dust should be removed. Filters should be washed with soap and water once each week and as needed. Dry with a towel and reinsert. Discard and replace when damaged. The Facility Assessment tool dated 1/11/21 noted the facility was able to care for residents with [MEDICAL CONDITIONS], Pneumonia, Asthma , [MEDICAL CONDITION] and [MEDICAL CONDITION]. Staff training Education and Competencies including Specialized Care including oxygen administration.

Based on observation, interview and record review, the facility failed to maintain an infection control program to prevent the potential spread of infection by failing to wash hands between glove changes during and after wound care for 1 of 3 residents reviewed for pressure ulcers out of a total sample of 45 residents, (#4). Findings: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed she had short-and long-term memory deficits and required extensive assistance of 2 staff for activities of daily living. The assessment indicated she had a stage 3 pressure ulcer to her right heel. On 4/01/21 at 7:30 AM, during wound care observation, Licensed Practical Nurse (LPN) A washed her hands and donned clean gloves. LPN A lifted resident #4's right heel and observed the pressure ulcer area using both her gloved hands. She stated the dressing had fallen off during morning care. She removed her soiled gloves, and donned a clean pair of gloves without washing her hands. LPN A then cleansed the pressure ulcered area of the right heel with saline. There was small amount of serous drainage. She then patted area dry, removed and discarded her soiled gloves. She did not wash or sanitize her hands before donning another pair of clean gloves. LPN A continued and completed the wound dressing change for resident #4. She then removed her soiled gloves into a disposable bag. LPN A, then gathered the disposable bag and exited resident #4's room without washing or sanitizing her hands before exiting. LPN A then entered the soiled utility room, disposed the bag and exited the room without washing her hands. On 04/01/21 at 7:40 AM, LPN A stated that was her process. She stated, I don't know the facility policy regarding washing or sanitizing hands during a wound dressing change. On 04/01/21 at 7:43 AM, the Unit Manager of the 300-400 hallway said the process for wound care included washing hands whenever gloves were removed. On 04/01/21 at 9:19 AM, the Director of Nursing (DON) said the expectation was for nurses to wash their hands after a dressing change. She noted the expectations was that staff followed the policy and procedure as outlined in the resource manual for hand hygiene. Review of the facility's policy for Wound Care Treatment Clean Dressing Change page 2 Chapter 4: Treatment Wound Care Resource Manual revealed Procedure Note . Follow hand hygiene protocol, .Cleanse the wound as directed. Remove your gloves and discard them. Follow hand hygiene protocol. Put on new gloves and perform wound care as ordered .Secure the dressing with tape if indicated. Remove your gloves and discard them .Follow hand hygiene protocol . Review of facility policy Hand Hygiene Chapter 6 General Resident Care A Guide to Infection Prevention and Control Purpose To decrease the risk of transmission of infection by appropriate hand hygiene. Review of resource manual Procedures- Hand Hygiene revised May 15, 2020 page 1-Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact: before putting on gloves; .after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, .nonintact skin, or wound dressings (If hands aren't visibly soiled); after removing gloves; and after contact with inanimate objects in the patient's environment.

Based on observation, interview and record review, the facility failed to maintain a secure environment by implementing front desk procedures to ensure vulnerable residents did not exit the facility without supervision, and failed to perform thorough elopement risk evaluations to establish appropriate and individualized safety interventions for 1 of 3 residents at risk for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was high likelihood he could have fallen off his electric mobility scooter, gotten lost or been hit by a car. On 1/02/21 at approximately 1:00 PM, the facility failed to prevent resident #1, a physically and cognitively impaired resident with [MEDICAL CONDITION] from exiting the facility unsupervised. Resident #1 exited the facility through the front lobby doors on his scooter and traveled west on the sidewalk. He drove his scooter over sections of cracked and uneven pavement including an area that had a sharp downward slope and crossed 2 driveways. The facility was unaware of resident #1's whereabouts until another resident informed staff that resident #1 left the building. A staff member caught up with him approximately 356 feet away from the facility. Resident #1 ignored initial attempts by the staff member to re-direct him and continued to drive his scooter for another 200 feet before turning around and heading back to the facility. The facility's failure to provide adequate supervision resulted in Immediate Jeopardy. The Immediate Jeopardy began on 1/02/21 and was removed on 1/04/21. F689 was determined to be past noncompliance when the facility fully corrected the noncompliance on 1/12/21. Findings: Resident #1, an [AGE] year old male, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. [MEDICAL CONDITION] is a disorder that results from damage to sections of the brain responsible for language, often after a stroke. The disorder causes impairment of speech and difficulties with comprehension of language, reading and writing (retrieved on 2/28/21 from the National Institute of Health, National Institute on [DIAGNOSES REDACTED] and Other Communication Disorders www.nidcd.nih.gov). Resident #1 was re-admitted to the facility on [DATE] after a 10-day hospital admission for coronavirus disease (COVID-19). A Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form 3008 dated 12/27/20 revealed resident #1 had [MEDICAL CONDITION]. On re-admission to the facility, an Elopement Risk Evaluation dated 12/28/20 indicated resident #1 was not at risk for elopement. However, the 6-question form had 2 inaccurate responses that showed resident #1 did not have dementia and did not ambulate independently. Resident #1 would have been deemed at risk for elopement if any of the 6 questions were answered yes but all were answered no. Review of the previous Elopement Risk Evaluation dated 8/26/20 revealed the same responses were documented indicating no risk for elopement. A Speech Therapy Discharge Summary dated 12/29/20 showed resident #1's baseline was 75% accuracy related to understanding yes/no questions and 50% accuracy in following 2-step commands. The document indicated that for Functional Communication Measures, resident #1 scored 2 of 7 in spoken language comprehension and 1 of 7 in spoken language expression. According to the American Speech-Language-Hearing Association, a score of 1 denotes least functional and 7 denotes most functional (retrieved on 3/03/21 from the American Speech-Language-Hearing Association.www.asha.org). Resident #1's discharge recommendation was he . requires gesture and visual cues to increase comprehension of yes/no questions. Review of resident #1's medical record revealed an Event Note dated 1/02/21 at 5:47 PM that read, Resident was observed at the top of the road across from the hospital in his motorized scooter/(wheelchair). Review of the Minimum Data Set (MDS) 5-day Medicare assessment with assessment reference date (ARD) of 1/04/21 revealed resident #1 had unclear speech and limited ability to express his ideas and wants but comprehended most conversation. Resident #1 had a Brief Interview for Mental Status score of 2, indicating severe cognitive impairment. The MDS assessment incorrectly indicated resident #1 had not exhibited wandering behavior in the 7-day lookback period as he eloped from the facility on 1/02/21, 2 days before the ARD. Resident #1 required extensive assistance from 2 staff members for bed mobility and transfers, including into and out of his scooter, and extensive assistance from 1 staff member for dressing and personal hygiene. The MDS assessment revealed resident #1 did not walk during the lookback period and was self-sufficient once in his electric scooter. He had unsteady balance during surface-to-surface transfers and was only able to stabilize with assistance from staff. Resident #1 had impairments of his arm and leg on one side, and limited range of motion .that interfered with daily function or placed resident at risk for injury. The MDS assessment revealed resident #1 had medically complex conditions and received insulin and an anticoagulant or blood-thinning medication daily. The Centers for Disease Control and Prevention (CDC) noted elderly patients who take blood thinners are at high risk for catastrophic brain injuries after a fall (retrieved on 2/28/21 from www.cdc.gov). Review of the medical record revealed resident #1 had a care plan for communication problems related to [MEDICAL CONDITION], initiated on 8/12/19. The approaches included speaking to him clearly and slower than normal, anticipating his needs, and using simple, consistent words and cues. A care plan for activities of daily living (ADL) self-care deficit related to dementia, paralysis on one side, impaired balance and limited mobility was initiated on 8/08/19. It indicated resident #1 required a brace to assist with lifting his paralyzed right foot, and stocking-like sleeves on both arms when out of bed to prevent skin injuries. Resident #1 transferred between the bed and his scooter with the assistance of 2 staff members and a full-body mechanical lift. A care plan for impaired cognitive ability and thought processes was initiated on 8/27/19 to ensure staff allowed extra time for resident #1 to respond to questions. The approaches included cue, reorient and supervise as needed. Resident #1 had a care plan for risk for falls related to gait and balance issues from paralysis of his right side, initiated on 10/05/19. The goal was to minimize his risk for falls and injury. Resident #1's care plan for behavior problems was initiated on 8/05/19. The goals included resident would not have behaviors that were harmful to himself. Interventions initiated on 8/14/19 directed staff to document resident #1's wandering behaviors, attempt to divert him when he displayed exit-seeking behaviors, monitor him frequently and Provide for safe wandering - resident is an elopement risk. On 2/20/21 from 12:27 PM to 12:47 PM, resident #1 was observed having lunch in the main dining room. He was seated on a blue electric mobility scooter that was parked parallel to a table. The scooter's seat was swiveled at a 90-degree angle to face the table. When resident #1 completed his lunch, he turned his body towards the front of the scooter then drove a short distance away from the table. Resident #1 placed his left hand under his right knee and attempted to lift his paralyzed right foot from the floor onto the base of the scooter. He was not wearing a foot brace as noted in the ADL care plan, and he was not able to complete the task. The staff member assigned to the dining room assisted resident #1 by lifting his right foot and positioning it safely on the base of the scooter. She assisted him to turn and secure the scooter seat in a front-facing position. Resident #1 then used his left hand to position his stiffly extended right arm and contracted right hand onto his lap before he drove out of the dining room. On 2/20/21 at 12:56 PM, resident #1 was seated on the scooter in his room. Resident #1's ability to communicate verbally was extremely limited. He was able to give yes/no answers to some questions and used hand signals to respond to others. Resident #1 was asked if he recently left the facility through the front door. He nodded and pointed to the scooter. Resident #1 was not able to either verbally or non-verbally communicate additional details regarding the incident. He quickly became frustrated as he was not able to make himself understood. Resident #1 ended the conversation by lifting his shoulders and shrugging. On 2/20/21 at 1:30 PM, Certified Nursing Assistant (CNA) A stated resident #1 had a speech problem, but since she was regularly assigned to care for him, she usually understood what he said. CNA A explained resident #1 would have difficulty communicating if lost outside the facility and might be hesitant to trust strangers. She stated resident #1 had declined physically since December 2020 and now required more assistance with ADLs, particularly for transfers into and out of his scooter. On 2/20/21 at 1:52 PM, Licensed Practical Nurse (LPN) B, stated resident #1 had been hospitalized a few times recently and his overall health had declined. She said, I feel that he has both cognition and communication problems. LPN B explained resident #1 was alert but not fully oriented. She said, I think this resident needs to be inside the facility. I don't think he can drive the scooter safely outside because of hazards like traffic and even people on bicycles. On 2/20/21 at 2:01 PM, Registered Nurse (RN) C, stated resident #1 never really spoke, but asked for things by pointing or repeating the word hey. RN C stated resident #1 was on her assignment on the day he eloped. She remembered she last saw him near the front door when she went to the lobby to receive a delivery from the pharmacy. RN C could not remember the time of the delivery but recalled about an hour later someone informed her resident #1 was found outside the facility at the end of the street by the roundabout. She stated when resident #1 returned to the unit she asked why he left the building and he shrugged his shoulders. RN C said, I don't think he's safe outside. Sometimes he bumps into walls here with the scooter. I've seen him. RN C explained resident #1 was not able to communicate easily with strangers and had trust issues with people he did not know. On 2/20/21 at 2:22 PM, the Physical Therapist (PT) stated resident #1 had COVID-19 in November 2020 and had a general decline in status after this illness. The PT explained resident #1 had [MEDICAL CONDITION] and said, With familiar objects and people he is ok, but after COVID he was hit hard. I believe he has frustration due to inability to express himself easily. Outside of the facility, it would be challenging to communicate with him. The PT confirmed resident #1 left the building unattended on 1/02/21. He said, I heard he was found by the roundabout. The PT stated resident #1 would not have been safe on the sidewalk outside the facility before his illness. He explained since his bout with COVID-19, resident #1 would be even less safe driving his scooter outside the facility. He stated resident #1 managed well inside the facility since he was familiar with the controlled environment. The PT acknowledged there were circumstances or situations outside the facility that might be dangerous and confusing to resident #1. Review of the facility's investigation documentation dated 1/15/21, revealed resident #1 eloped from the facility and was . at risk of harm or injury. The document indicated on 1/02/21 at approximately 1:20 PM, resident #1 was seated near an exterior exit door at the front of the facility. The facility's investigation showed resident #1 left the facility unnoticed by staff when the relief receptionist opened the front door for a delivery person. The document revealed a few minutes later another resident notified the relief receptionist that resident #1 exited the building, and she went outside to look for him. The report indicated resident #1 was found less than 3 minutes later, . wheeling on the sidewalk towards the therapy gym entrance which was approximately 100 feet away. The facility's investigation revealed the relief receptionist easily re-directed resident #1 back to the building. The facility had video recording from their security cameras but were unable to provide this to validate the time resident #1 exited the facility or the length of time he was outside. In addition, resident #1 did not wheel himself out of the facility. Rather, he drove an electric mobility scooter. These mobility aids can travel at speeds of 4 to 8 miles per hour or faster, and cover distances up to 15 miles or more on a single charge, depending on the scooter model and battery size (retrieved on 3/03/21 from the Senior List.www.theseniorlist.com). On 2/20/21 at 2:52 PM, the relief receptionist stated resident #1 used head movements to respond to questions and also communicated with her by pointing at items such as the remote control to indicate he wanted to watch television. She said, I only understand because I know him and his routine. She stated on the day resident #1 eloped, he was seated on his electric scooter in the vestibule near the exterior exit door at the front of the facility. She explained he often sat in this location to watch people as they entered and exited through the door. The relief receptionist did not recall the exact time of the incident. She recalled it was after lunch when another resident told her resident #1 had exited out the front door. On 2/20/21 at 2:56 PM, resident #1's elopement route was traced with the relief receptionist. She identified the location she caught up with resident #1 on the sidewalk, which was past the therapy gym and the employee parking lot, a significant distance further away from the facility's front door than noted in the Nursing Home Adverse Incident Report. The relief receptionist stated resident #1 was on his electric scooter on the sidewalk and she stood in the grass beside him. She acknowledged the pavement was uneven and there was a sharp drop in the sidewalk at the site she found resident #1. The relief receptionist said, He pointed to the hospital and made noises. I did not understand his words. I did not know where he wanted to go. I told him we had to go back because it was not safe. He ignored me and continued to drive the scooter. He didn't say any words and he just kept on going. She stated she was eventually able to convince resident #1 to turn his electric scooter around at the end of the street. The relief receptionist stated she called the facility's front desk when she located resident #1 and RN D, the weekend nursing supervisor, joined her on the sidewalk to escort resident #1 back inside. Observations along the elopement route revealed resident #1 traveled west on the sidewalk in front of the facility. He crossed a driveway that led into a small parking lot, then continued along the sidewalk and around a curve past the facility's therapy gym. He drove his scooter over sections of cracked and uneven pavement bordered by a grassy area that sloped down towards the adjacent street. Resident #1 then crossed the sloping 27-foot wide driveway that led to the large employee parking lot. Resident #1 was found on the sidewalk a few feet beyond this driveway, a total of 356 feet away from the vestibule of the facility where he was last seen. He traveled an additional 200 feet to the end of the street where it intersected with a roundabout across from a large hospital, while the relief receptionist convinced him to return to the facility. The temperature on 1/02/21 at 1:00 PM was 81 degrees Fahrenheit, with broken clouds and 72% humidity (retrieved on 2/28/21 from Time and Date.Com.www.timeanddate.com). On 2/20/21 at 3:32 PM, RN D recalled she ran outside when she was informed resident #1 exited the facility. She stated the relief receptionist and resident #1 were on the way back to the facility and she met them at the employee parking lot driveway. RN D said, It is not a good idea for him to be outside the facility. She explained resident #1 communicated with gestures and grunts and listeners had to guess what he was trying to say. RN D stated resident #1 usually sat by the front door every day. She was not aware he was considered an elopement risk before that day. On 2/21/21 at 4:19 PM, the MDS RN explained during a review of care plans in the past, she noted resident #1 had a care plan for elopement. She stated a review of his assessments showed no risk factors for elopement, so she resolved or discontinued the care plan. The MDS RN explained she reinstated a care plan for elopement after the incident on 1/02/21, and resumed the previous approaches developed in 2019 from the original care plan. The MDS RN was not aware resident #1 had active interventions for elopement risk in the care plan for behaviors. Interviews were conducted with the facility's Executive Director (ED) and Director of Nursing (DON) on 2/20/21 from 4:24 PM to 5:05 PM. The DON stated to her knowledge resident #1 could make his needs known and had no prior history of attempting to leave the facility. During a review of the facility's investigation and witness statements with the ED and DON, discrepancies were noted between written statements and information obtained from staff interviews and review of resident #1's medical record. The relief receptionist was asked to retrace the elopement route with the ED and DON to validate where resident #1 was actually found. On arrival at the site, they denied any previous knowledge that resident #1 traveled past the staff driveway and almost to the end of the street. The ED and DON maintained they conducted a thorough incident investigation, but the relief receptionist reiterated she informed them verbally of the actual location resident #1 was found and RN D's progress note on that day corroborated the information. The ED confirmed when resident #1 exited the facility he had an old driver's license in his pocket with his previous address in the community, not the facilty's address. On 2/21/21 at 11:36 AM, the DON stated she reviewed resident #1's medical record after the elopement incident. She said, I looked at his chart and medical record to see if he was an elopement risk. I went back 1 year, and he was not an elopement risk according to the assessments. The ED stated she reviewed resident #1's MDS assessments and noted no wandering behaviors that would have triggered an elopement care plan. She explained the facility identified the root cause of the elopement was that the relief receptionist opened the front door and did not follow the procedure to observe the door until it fully closed. The ED stated she felt resident #1's elopement care plan prior to the incident . must have been an oversight and rolled over from the previous system. The DON acknowledged MDS/care plan staff were responsible for reviewing and revising care plans to accurately reflect residents' current needs. The ED and DON were informed resident #1's Elopement Risk Evaluation forms dated 8/26/20 and 12/28/20 inaccurately indicated he did not have a [DIAGNOSES REDACTED]. They did not respond when asked if an accurate evaluation would have triggered appropriate and individualized care plan interventions for resident #1, a vulnerable resident at risk for elopement, whose daily routine was to sit beside the front lobby exit door. Review of the Elopement Policy revised in February 2009, revealed the facility would support residents' right to live in a safe and secure environment. Elopement was defined as occurring when a resident with impaired cognition left the facility without knowledge of staff. The procedure indicated the facility would assess residents to identify the potential for elopement and develop a specific plan and interventions. The Facility Assessment Tool reviewed in January 2021 revealed the facility was able to care for residents with dementia and behaviors that required interventions. The document indicated the facility would provide person-centered care by identifying hazards and risks, and ensuring staff were aware of care plan interventions that reflected a resident's preferences and routines. The job description for the Receptionist revised on 5/11/16, revealed a requirement for proficiency in . greeting guests, administrative duties, patient rights, and safety . The Adjusted Checklist for New Facility Associate Orientation revised on 6/09/20 revealed all new employees including the receptionist received training on elopement. Review of corrective measures implemented by the facility revealed the following, which were verified by the survey team: * Resident #1 was re-assessed after being returned to the facility and deemed to be at risk for elopement on 1/2/21. * All residents in the facility were re-assessed for elopement risk and their care plans were reviewed and updated as needed on 1/2/21. * Education on elopement, monitoring of camera and door, and resident #1 as a new elopement risk was provided to 23 staff member on shift on 1/2/21. * Elopement binders were reviewed by the DON and updated on 1/03/21. * Education was provided to the receptionists regarding the hand off process and procedure for monitoring the camera and door on 1/03/21. * Staff education was provided on evaluating and monitoring residents at risk for elopement. Review of in-service attendance sheets and elopement drill records with after action report revealed education was initiated on 1/02/21. By 1/12/21, 160 of 178 staff members from all departments, a total of 90%, had been educated. The facility will not permit staff to return to work without proof of education. MDS nurses received education on maintaining accurate care plans. Interviews conducted with 2 receptionists and 13 staff members representing nursing and therapy departments indicated they were knowledgeable of elopement procedures and supervision of residents at risk for elopement. * The Quality Assurance and Performance Improvement (QAPI) committee held an ad hoc meeting on 1/04/21 to review the elopement policy and decision tree for reporting event. A Performance Improvement Plan (PIP) was developed and audit tools were created to monitor accuracy of the elopement binder and receptionists' compliance with the front desk procedure of checking both camera and door before opening the door. The DON now reviews all elopement risk evaluations to ensure accuracy. The QAPI plan was reviewed with the interdisciplinary team on 1/05/21 and 1/07/21. On 1/28/21 at the scheduled QAPI meeting, the elopement incident, drills and policy and weekly audit forms were reviewed. The elopement was also discussed on 1/28/21 in the Medical Director's Facility Oversight Committee Meeting. Results of QAPI audits will be followed by the committee for a minimum of 3 months. Audits were verified. The sample was expanded to include all residents who were at risk for elopement. Observations and record reviews conducted revealed no concerns related to elopement risk evaluations and care plans for residents #2 & #3.

Based on interview and record review, the facility failed to provide nursing care and services to ensure the highest practicable well-being for 1 of 3 residents reviewed for accidents. The facility's failure to appropriately evaluate, assess and treat resident #248 in a timely manner resulted in harm. Resident #248 was admitted to the facility for rehabilitation after a stroke. During less than 2 weeks in the facility, resident #248 fell and sustained a right wrist fracture, then suffered second [MEDICAL CONDITION] her thighs when a cup of hot coffee spilled onto her lap. Resident #248 suffered pain from the injuries, and was unable to fully participate in and obtain maximum benefits from therapy services due to these incidents. Findings: Resident #248 was admitted to the facility on [DATE] for rehabilitation services. Her [DIAGNOSES REDACTED]. On [DATE] at 9:54 AM, during a telephone interview, resident #248's daughter stated her mother suffered major injuries that were not treated appropriately or in a timely manner while in the facility. She explained her mother was admitted to the facility for rehabilitation services after a stroke which caused weakness to the left side of her body. She stated her mother ambulated with a walker before the stroke, and her goal was to return to normal with help from the therapists. The daughter explained that on the first night in the facility, her mother fell . She stated she received a telephone call at about 6:00 AM on [DATE] to inform her that her mother fell at about 3:00 AM that morning, but did not sustain any injuries. The daughter stated she arrived at the facility between 7:30 AM and 8:00 AM. She said, Mom was at the nurses' station. As soon as I stood beside her I saw that her arm was swollen and purplish black. I had to tell the nurse my mom was in severe pain and injured. The daughter stated an x-ray was ordered only after she brought the injury to the nurse's attention. She confirmed the x-ray was done about 2 hours later and showed a right wrist fracture, but her mother was not sent to the hospital for hours afterward. The daughter stated her mother was readmitted to the facility with a cast on her right arm, to resume therapy services. However, resident #248's daughter explained her mother had another setback on [DATE] when staff gave her a cup of hot coffee and she spilled it on herself. The daughter stated her mother needed help to eat and drink because of the cast on her right arm and weakness of her left arm. She was notified that her mother would be sent to the emergency room to have the burn treated, but when she got to the hospital her mother was not there. On arrival at the facility later that morning, the daughter stated she found her mother in bed, unclothed from the waist down, with [MEDICAL CONDITION] her thighs exposed. She was told they decided not to send her mother to the hospital, and a supervisor eventually placed dressings on the burns. The daughter stated her mother was transferred to the hospital for another medical issue a few days later where [MEDICAL CONDITION] assessed by a plastic surgeon. She stated her mother was eventually transferred to another facility to continue therapy, but her insurance coverage soon reached its limit and she was discharged home. The daughter said, She did not get the full benefits of rehab after her stroke. Because of the fracture and then the burn, it limited what she could do in therapy. Resident #248's daughter explained her mother suffered pain from both injuries, still had the right arm cast, now used a wheelchair for mobility instead of a walker, and needed more help with personal care than she did before. In a telephone interview on [DATE] at 5:39 PM, licensed practical nurse (LPN) B stated she was assigned to resident #248 on the night she fell and fractured her right wrist. LPN B confirmed resident #248 had an unwitnessed fall and was found on the floor just after 3:00 AM on [DATE]. LPN B stated she evaluated resident #248 and did not see any bruising or swelling on her body at that time. She acknowledged although resident #248 could have hit her head, she did not initiate neurochecks to rule out a head injury according to facility policy and procedure. LPN B stated she did a verbal shift change report with the on-coming registered nurse (RN) A at 6:45 AM and said, I did not do walking rounds. We don't usually do that, so we did not look at the resident together. LPN B stated she was not aware of any symptoms of pain after the fall, but acknowledged she did not thoroughly re-evaluate resident #248 prior to the end of her shift. On [DATE] at 2:25 PM, RN A stated she received a verbal report from the off-going night nurse, LPN B, regarding resident #248's fall. She explained LPN B informed her there was no bruising, pain or other injury related to the fall. RN A said, I did not do walking rounds. I did not see the resident until the family asked me to look at her wrist. It was swollen and painful, possibly discolored. RN A confirmed she administered Tylenol for pain and notified the physician. She stated an x-ray was ordered and it showed a right wrist fracture. RN A recalled the physician was notified and discussed sending resident #248 to the hospital emergency department or having an advance practice nurse practitioner (ARNP) apply a cast or brace. RN A said, It was still up in the air. I think he said he was sending an ARNP over. RN A stated while resident #248 waited for the ARNP to arrive, she became nauseated then vomited, and another nurse expressed concern that vomiting after a fall could be a symptom of a head injury. RN A confirmed she called the physician again and received an order to send resident #248 to the hospital for evaluation. RN A said, I was unaware at that time that we were to do neurochecks because of the unwitnessed fall. It never occurred to me . Neurological checks or neurochecks are usually done after an unwitnessed fall to identify signs of a head injury. The evaluation includes checking level or consciousness, vital signs, pupil size and reactivity to light and hand grip strength. Standard clinical nursing practice suggests this evaluation should be done immediately after the fall, then every 15 minutes for 2 hours, every 30 minutes for 2 hours and every 60 minutes for 4 hours. The frequency is gradually decreased over 72 hours. (www.hcpro.com) In a telephone interview on [DATE] at 6:00 PM, LPN C stated she was assigned to resident #248 on [DATE] when she spilled a cup of hot coffee onto her lap at about 7:30 AM. LPN C stated she did the initial skin evaluation, informed the physician the skin on resident #248's thighs was red but intact, and notified the daughter of the injury. She explained resident #248 was returned to the nurses' station and within 15 minutes she was observed rubbing her legs together. LPN C said, She looked uncomfortable like she was in pain. You know, when [MEDICAL CONDITION] can keep on burning. LPN C stated she re-evaluated resident #248 and noted the condition of the burned areas had worsened, so she called the physician again and received an order to send resident #248 to the hospital emergency room for treatment. LPN C stated she notified the on-call RN nursing supervisor of the order according to facility protocol and started the hospital transfer paperwork. LPN C stated she received a telephone call from a member of management staff who instructed her not to send resident #248 to the hospital. She said, I was asked to send a photo to someone, not sure who. Once management was involved, it was out of my hands. LPN C confirmed she used her personal phone to take a photograph of resident #248'[MEDICAL CONDITION] her thighs. She stated resident #248 remained in bed until the ,[DATE] LPN Unit Manager arrived to re-evaluate her burn. LPN C said, I advocated to have the resident sent out. I believed she needed to go to the hospital. But I followed the direction of my supervisors and management. During interviews conducted with the Director of Nursing (DON) on [DATE] at 4:43 PM and 6:41 PM, she stated LPN B should have re-evaluated resident #248 before the end of her shift after the fall, and the assigned CNAs should have reported any skin changes to the nurses. The DON said, I feel like some member of the nursing staff should have noticed it. She stated her expectation was all nurses and CNAs would do walking rounds to observe every resident during change of shift report. The DON validated neurochecks were never initiated and conducted by LPN B and RN A according to policy. The DON confirmed she was aware the attending physician gave LPN C an order to send resident #248 to the hospital after she [MEDICAL CONDITION] her thighs. The DON confirmed her expectation was physicians' orders would be followed in a timely manner, but could not explain why this was not done in a timely manner for resident #248. She said, I would never instruct a nurse not to follow a physician's orders [REDACTED]. In a telephone interview on [DATE] at 6:37 PM, the attending physician acknowledged he initially gave the assigned nurse an order to send resident #248 to the hospital emergency room for evaluation of the burns. The physician recalled he received a telephone call from the facility's administrator about 20 minutes later. He explained she described resident #248'[MEDICAL CONDITION] painful and blistered, indicative of a second degree burn. The physician stated he replaced the hospital transfer with an in-house treatment order after a discussion with the administrator. On [DATE] from 6:50 PM to 7:06 PM, an interview was conducted with the administrator, on-call RN supervisor and the ,[DATE] LPN UM. The administrator stated the on-call RN supervisor informed her resident #248'[MEDICAL CONDITION] superficial. She said, I called (the attending physician) and described the wound to him from the information I received from the on-call nursing supervisor's assessment. However, the on-call RN supervisor stated she remained at home and never went to the facility to assess resident #248. She explained she called the ,[DATE] UM and instructed her to go to the facility and evaluate resident #248's burns. Review of resident #248's medical record revealed a nurse's Event Note dated [DATE] at 3:34 AM regarding an unwitnessed fall. There was no documentation of neurochecks or re-evaluation on that shift. An Alert Note dated [DATE] at 8:30 AM indicated a family member informed the assigned nurse of resident #248's right wrist swelling, bruising and pain. Resident #248 had a right wrist x-ray done that morning at 9:40 AM. The report was signed by the radiologist approximately 1 hour later at 10:32 AM, and indicated resident #248 had fractures of the radius and ulna and soft tissue swelling. The Transfer to Hospital Summary revealed resident #248 was transferred to the hospital at 1:30 PM with symptoms of a possible head injury and no cast or splint applied to her wrist, 10 hours after the fall. Review of nursing progress notes revealed on [DATE] resident #248 spilled hot coffee on her lap at approximately 7:30 AM. Review of physician's orders [REDACTED].#248's second [MEDICAL CONDITION] [DATE] at 11:14 AM. An Event Note revealed resident #284 had the treatment applied at 11:36 AM, approximately 4 hours after she suffered the burn injuries. Review of resident #248's medical record revealed Modified Barthel Index forms dated [DATE] on admission, and [DATE] on re-admission after her fall. The evaluation tool was used to determine the level of assistance resident #248 required with ADLs. On admission, resident #248 was able to feed herself with set up but on re-admission after the fracture she could only bring food to her mouth, but could no longer scoop the food. Review of the facility's Admission/Readmission Collection Tool dated [DATE] at 1:05 PM, revealed resident #248 was alert and oriented to person only, had no mood or behavior issues and reported a pain level of 0 on a 0 to 10 scale. Resident #248 required extensive assistance for bed mobility, transfers, toileting and personal hygiene, and limited assistance for ambulation and eating. The evaluation indicated she had an unsteady gait, balance issues and was at risk for falls. The admission progress note read, Denied any pain or discomfort . Here to attend therapy for strengthening. Continent of bladder. The Minimum Data Set (MDS) 5-day Medicare scheduled assessment, with assessment reference date of [DATE] was conducted within 2 weeks of admission. The assessment revealed resident #248 required extensive assistance from 1 person for eating, a decline in comparison to her needs on admission. She was unsteady during transitions and was only able to stabilize with staff assistance. Resident #248 did not walk during the look back period. Instead, the MDS assessment revealed resident #248 now used a wheelchair for mobility and had functional limitation in range of motion of 1 upper extremity. She was no longer continent, instead she frequently had urinary incontinence. Resident #248 was pain-free on admission, but the MDS assessment indicated she received pain medication as needed (PRN) for indicators of pain that were observed every day in the 5-day look back period. She displayed non-verbal sounds (crying, moaning or groaning), vocal complaints (ouch or stop), facial expressions (grimaces, winces or furrowed brow) and protective body movements or postures (guarding, massaging or holding a body part). Section J Health Conditions and Section M Skin Conditions revealed resident #248 suffered a fall with fracture [MEDICAL CONDITION] her stay in the facility. Resident #248's medications included antianxiety medications on 4 days and opioid or narcotic pain medication on 5 days. The facility's policy and procedure for Neurological Assessment (,[DATE]), revealed a neurological assessment flowsheet would be initiated after a fall. The document indicated assessments would be conducted at least every 4 hours for the first 24 hours and should include pupillary, motor and limb responses. Review of the Incident Management Process Policies & Procedures (2008) revealed an objective to . react promptly and efficiently when incidents occur, responding to the resident's immediate medical needs .

Based on record review and interview, the facility failed to provide adequate supervision to prevent injuries for 1 of 3 residents reviewed for accidents. The facility's failure to provide adequate supervision to prevent an avoidable fall and an avoidable burn resulted in actual harm. Resident #248 fell and sustained a right wrist fracture. She was hospitalized for [REDACTED]. Four days after re-admission, resident #248 was provided with a cup of hot coffee and suffered second [MEDICAL CONDITION] her thighs when the hot liquid spilled on her lap. Findings: Resident #248 was admitted to the facility on [DATE] for rehabilitation services. Her [DIAGNOSES REDACTED]. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 7/17/19, revealed resident #248's primary [DIAGNOSES REDACTED]. Review of the facility's Admission/Readmission Collection Tool dated 7/17/19 at 1:05 PM, revealed resident #248 had highly impaired vision, was able to make herself understood and was alert, but oriented to person only. Resident #248 required extensive assistance for bed mobility, transfers, toileting and personal hygiene, and limited assistance for ambulation and eating. The evaluation indicated she had Gait disturbance/unsteady gait/balance issue. The data collection tool, completed by licensed practical nurse (LPN D), revealed resident #248's gait was unsteady during transfer to the bedside commode. The document revealed resident #248 had a risk alert for falls. The admission data collection forms included a Resident/Family Education Assessment & Interdisciplinary Flow Record. LPN D's documentation indicated she provided resident #248 with education on the call light and television remote. The document indicated resident #248 understood basic information, was accepting of education and had only visual limitations to learning. LPN D selected a verbal rather than demonstration teaching method, despite resident #248's cognitive limitations. In a telephone interview on 9/06/19 at 6:09 PM, LPN D confirmed she completed resident #248's initial evaluation on 7/17/19. LPN D described resident #248 as alert and oriented to person, confused and agitated. She recalled the daughter was present and assisted her mother to the bathroom often. LPN D said, I did not know her baseline, but the daughter mentioned that (resident) was confused and anxious. I had to call the doctor for an order for [REDACTED].#248's anxiety began escalating towards the end of the day shift. The Skilled Nursing Documentation form, completed on 7/17/19 during the 7:00 PM to 7:00 AM shift by LPN B, revealed resident #248 required extensive assistance with activities of daily living (ADLs) as a result of a stroke, and Remains forgetful and confused . Left sided weakness persists. LPN B did a Fall Risk Evaluation dated 7/18/19, that indicated resident #248 Ambulates with problems and with devices and required partial physical support during a balance test or stood but did not follow directions. The evaluation revealed resident #248 did not have significant drops in blood pressure with position changes. Her fall risk evaluation score was 10, but there was no legend on the form to correlate the score with the severity of the fall risk. During the evaluation process that shift, LPN B initiated baseline care plans including risk for falls. The goal read, The resident will not sustain serious injury requiring hospitalization . The interventions included assist with ADLs as needed, call light within reach and orient resident to the room. A care plan for ADL assistance directed staff to assist with mobility and ADLs as needed. A care plan for impaired cognition and impaired thought process indicated resident #248 had Changes in ability to recall events since hospitalization , difficulty making decisions, impaired decision making, long term memory loss. The goal was resident #248 would follow 1 to 2 step instructions. Review of a nursing Event Note dated 7/18/19 at 3:34 AM, revealed resident #248 was found lying on her left side on the floor, at the foot of her bed. LPN B evaluated resident #248 and documented she denied pain, had no bruising and had positive range of motion to all extremities. LPN B wrote, Pt did not have non skid socks on. Call light was not in reach. Medicated 20 minutes earlier . for increased anxiety. In a telephone interview conducted with LPN B on 9/06/19 at 5:39 PM, she recalled resident #248 was anxious and repeatedly attempted to get out of bed without assistance on the night she fell . She explained the assigned certified nursing assistant (CNA) attempted standard interventions such as toileting and offering food and fluids. LPN B stated the interventions were ineffective and resident #248 remained anxious, restless and confused. She said, We kept putting her back to bed. Pretty much for the entire shift she was trying to get out of bed. Earlier that night I had her sitting next to me while charting at the nurses' station. LPN B stated after a while, resident #248 asked if she could go to bed, so she instructed a CNA to sit with resident #248 in the room. LPN B explained the CNA left the room to answer a call light and when she returned, she found resident #248 on the floor. She said, I don't know why the CNA left her without telling anybody. LPN B stated after the fall, they placed resident #248 in her wheelchair and brought her to the nurses' station so everyone could watch her. LPN B said, I kept her next to me, next to the med cart, while passing meds. When asked if she took resident #248 into other residents' rooms during medication administration, she acknowledged she left resident #248 in the hallway beside the medication cart. Review of nursing notes dated 7/18/19 revealed Registered Nurse (RN) A was assigned to resident #284 on the next shift. She wrote, Family notified myself early this morning of (right) wrist bruising and swelling. RN A noted resident #248 complained of right wrist pain. She informed the attending physician and received orders for an x-ray. The x-ray indicated resident #248 had a right wrist fracture and the physician informed RN A that an advanced practice nurse practitioner (ARNP) would be sent to the facility to apply a splint. Resident #248 had a change in condition and vomited before the ARNP arrived. The attending physician was notified and gave an order to send her to the hospital emergency room for possible symptoms of a head injury from her unwitnessed fall. On 9/06/19 at 2:25 PM, RN A stated she spoke to the resident's daughter about her mother being at risk for falls. She explained at the time she fell , resident #248's room was at the furthest end of the hall, away from the nurses' station. In addition, RN A stated resident #248 was in the window bed, away from the door. RN A said, It was my idea to move her closer to the nurses' station. I wanted her where she could be seen easily from the hallway. On 9/06/19 at 2:50 PM, the 100/200 Unit Manager (UM) stated a fall risk evaluation was done on admission, and appropriate interventions would be selected based on [DIAGNOSES REDACTED]. The 100/200 UM explained if a newly admitted resident was at high risk for falls, the facility could put interventions in place including having a staff member sit with the resident or providing 1:1 supervision as long as the high fall risk existed. She stated immediate interventions included lowering the bed and keeping the resident at the nurses' station. The 100/200 UM was asked how often staff were expected to check on newly admitted resident. She explained it took about 24 hours to do an admission, so nursing staff saw new residents regularly during that period. However, she validated there was no specific rounding schedule to monitor new residents who were at risk for falls. On 9/06/19 at 3:59 PM, the Occupational Therapist (OT) stated she assessed resident #248 on the morning of 7/18/19 and confirmed it was definitely not advisable for her to attempt walking on her own as she was not steady on her feet. The OT said, There was so much neglect from the stroke, with decreased awareness of the left side and difficulty sequencing. She could follow simple directions (but) her safety awareness was poor. The OT explained resident #248 would probably not be able to remember to use a call light or retain other room orientation information provided by the nurse. On 9/06/19 at 4:43 PM, the Director of Nursing (DON) stated residents at risk for falls should have basic fall prevention interventions in place such as a low bed, non-skid footwear and the call light within reach. She stated staff made rounds every 2 hours, and there was no requirement for more frequent rounds for newly admitted residents. The DON confirmed nurses were expected to pass on pertinent information during shift change report, including necessary precautions for identified risks. She stated nurses were expected to implement immediate, appropriate interventions to ensure resident's safety. On 9/06/19 at 5:05 PM, the Community Liaison (CL) explained her responsibilities included meeting with potential new residents and their families at the hospital, and educating them on the transition from hospital to rehab setting. She stated she reviewed the medical record and spoke with nurses in the hospital, but could not make clinical decisions because she was a CN[NAME] The CL explained she would refer any red flags such as a patients who required [MEDICATION NAME] (an antipsychotic drug), sitters or used restraints to the DON for further review to verify that the facility could meet the patients' needs. The CL stated she met resident #248 and her daughter in the hospital on the day before she was admitted to the facility. She described resident #248 as alert and oriented x 3, that is to person, place and time. Review of the Patient Assessment Form completed by the CL on 7/16/19, revealed resident #248 could not complete the admissions paperwork although she was deemed to be alert and oriented x 3. The assessment form indicated resident #248 required minimal assistance with bed mobility, transfers and ambulation, and could walk a distance of 25 feet. However, this information was inconsistent with the admission evaluation completed by LPN D the following day that showed resident #248 was alert and oriented x 1, and required extensive assistance for bed mobility and transfers. Review of the hospital medical record revealed resident #248 was on fall precautions and required bed and chair alarms. However, this information was not noted on the assessment form by the CL. The CL explained she saw resident #248 again in the hospital on [DATE], after she fractured her wrist, to discuss re-admission to the facility. The CL stated resident #248 remained alert and oriented x 3, and during that visit her 2 daughters were present. The CL stated she informed the daughters the facility had concerns about their mother's safety. She stated the daughters agreed to her suggestion that their mother be placed in a room closer to the nurses' station. The CL said, I explained we also needed to discuss supervision. I gave them names of sitter service companies and they decided to take turns instead. I told them I would put them in a room with an extra bed. When asked why resident #248 would require sitters, either privately paid or family members, she explained it was the consensus of the facility's interdisciplinary team (IDT) members. The CL stated she attended daily IDT meetings and the group decided resident #248 required heightened supervision due to her fall with injury. The CL stated the family was aware the expectation was someone would remain with resident #248 24 hours daily. The CL said, I don't recall who I told about the family providing 24 hour supervision, but it is usually handled by admissions after that. I don't handle it from that point on. On 9/06/19 at 5:23 PM, the Admissions Director (AD) recalled resident #248's re-admission after her fall with fracture. She said, . the only thing I can remember was everybody discussing her in morning meeting a few days before she came back. It was a regular morning meeting, attended by all department heads including the DON, administrator and Unit Managers. The discussion was that she would need 1:1 supervision. I remember that phrase. The AD stated to her knowledge, the CL informed resident #248's family of the requirement for supervision 24 hours daily. The AD was asked if the need for 1:1 supervision would be included in the admission information provided to facility staff. She stated she would usually inform the admitting nurse verbally. The AD stated she was not sure what nursing staff would do if no one showed up to provide 1:1 supervision for resident #248. She said, I would think they would have a CNA sit with the resident until they could sort it out. That's common sense, right? On 9/06/19 at 6:00 PM, LPN C confirmed she was the assigned nurse when resident #284 was readmitted from the hospital after fracturing her wrist. She stated she was never informed by anyone that resident #284 required 1:1 supervision. LPN C explained if she had been told this was necessary, she would have notified a manager and organized 30-minute rotations for each CNA until management assigned a staff member to be a sitter. LPN C said, I would not leave the resident alone. Review of the Admission/Readmission Collection Tool completed by LPN C on 7/23/19 revealed resident #284 had a new admitting [DIAGNOSES REDACTED]. The document indicated she had vision impairment and was able to make herself understood. LPN C evaluated resident #284's level of consciousness as confused and oriented to person only. This conflicted with the assessment form completed in the hospital by the CL that again indicated resident #248 was alert and oriented x 3. The data collection tool revealed resident #284 required supervision with eating, limited assistance with bed mobility, and extensive assistance with transfers, toileting and ambulation. LPN C noted resident #284 could not . grasp, hold objects, feel with hands due to a cast on her right hand and forearm. The attached admission/readmission progress note revealed resident #284 was confused and blind in her left eye. Review of the medical record revealed a Modified Barthel Index form dated 7/24/19. The evaluation tool was used to determine the level of assistance resident #248 required with ADLs. The evaluation indicated resident #248 could not scoop her food, and Can bring food to mouth only. Resident #248 was referred to the Restorative Nursing Program (RNP) for assistance with meals related to [DIAGNOSES REDACTED]. Review of CNA flowsheets revealed resident #248 required either extensive assistance or was totally dependent for eating during the 8:00 AM and 12:00 PM meals on 7/26/19, 7/28/19 and 7/29/19. However, the flowsheet indicated she was independent with set-up help only on 7/27/19. Review of a Change in Condition Evaluation form dated 7/27/19 revealed resident #284 suffered a burn when she spilled a cup of hot coffee onto her lap. The nursing progress note, written by the assigned nurse LPN C, indicated the incident occurred at 7:30 AM. The initial skin evaluation showed redness to resident #248's inner groin. However, LPN C re-evaluated the area 15 minutes later and observed a . decline in skin integrity. A physician's orders [REDACTED].#248 was diagnosed with [REDACTED]. On 9/06/19 at 2:50 PM, the 100/200 UM stated on 7/27/19, resident #248 asked for coffee, hit it over and spilled it on herself. She explained a CNA obtained the cup of the coffee from the kitchen. The 100/200 UM confirmed resident #248 required assistance with her meals so either a family member or a CNA usually fed her. On 9/06/19 at 3:30 PM, therapy progress notes were reviewed with the Director of Rehabilitation (DOR). She stated resident #248 was re-evaluated by therapists on re-admission, on 7/24/19, after she returned with a right arm cast. She stated OT referred resident #248 to restorative dining as she required instruction and cues to self-feed, and needed staff to open containers and cut food. The DOR said, She required supervision for attention to task and for safety. On 9/06/19 at 3:59 PM, the OT stated although resident #248 could use her left side, functional use was decreased because of the stroke. The OT explained the left side neglect caused resident #248 to forget her left arm existed. She stated after a discussion between the Speech Therapist and herself, resident #248 was referred to restorative dining because she needed supervision and cuing with eating. The OT acknowledged giving resident a hot liquid was not advisable as she had limited use of her right hand due to the cast, and would not remember to use the left hand. She said, I think she would have needed careful supervision to handle hot liquids. On 9/06/19 at 4:09 PM, the administrator explained the CL reviewed charts in the hospital before the facility admitted new residents. She stated if the CL identified concerns related to medications and behaviors, she would contact the DON for clinical guidance. The administrator stated most newly admitted residents were at risk for falls. She explained facility staff got to know each resident during the first 24 to 72 hours in the facility. However, when asked if the facility conducted more frequent checks or implemented additional interventions for newly admitted residents during the 24 to 72 hour period, she said, Every 2 hours is standard for checks for every resident, and is appropriate. She denied any concern with placement of a resident at risk for falls at the end of a hallway away from the nurses' station as . that might be everyone on a hall. The administrator explained the CL met with resident #248's family at the hospital prior to re-admission, after she suffered the right wrist fracture. She said, We recommended 1:1 care until we could figure out the resident. We asked for the family to provide 3 to 5 days of 1:1 care. When they could not provide it we started 1:1, after she got burned. The administrator acknowledged resident #248 was not on 1:1 supervision when she was set up with hot coffee. She said, Her assessment did not say that she could not eat and drink by herself. However, she validated resident #248 was deemed to need 1:1 supervision at that time. The administrator explained she was not made aware the family was not providing 1:1 supervision. She said, It was not communicated by nursing staff. We did not know. On 9/06/19 at 4:43 PM, the DON acknowledged she initiated 1:1 supervision by CNAs as a nursing intervention only after resident #248 suffered second [MEDICAL CONDITION] hot coffee. She stated she was told the family agreed they would provide supervision 24 hours daily. She said, I don't know if nursing was aware. I'm sure (the CL) would have told nursing when they brought her back in from the hospital. The DON confirmed she never informed nurses resident #248 required 1:1 supervision when she was readmitted . She stated she was not sure if or how long the family stayed with resident #248. The DON acknowledged if nursing staff were not aware resident #248 required 1:1 supervision or of an arrangement with the family to provide that service, they would not know to alert a supervisor if her family did not fulfill the arrangement. In a telephone interview conducted on 9/06/19 at 6:00 PM, LPN C recalled resident was seated near the nurses' station on the morning she suffered the burn injury, but did not have 1:1 supervision. LPN C explained resident #248 had a hard cast that went around her thumb and across her hand. She stated resident #248's fingers were exposed, but she could not completely close her hand into a firm grasp. LPN C said, It wasn't the best decision to give her hot coffee. I would not have given it to her. LPN C explained the CNA who gave resident #248 the hot coffee was not assigned to her. She stated the staff member was just walking by and when resident #248 asked for a cup of coffee. LPN C said, She was just being nice. On 9/06/19 at 6:41 PM, when informed of LPN B's description of resident #248's restless, anxious behavior during her first night in the facility, the DON said, I was not aware she was that agitated. I would expect nurses to let the on-call know if there were behaviors they couldn't handle it. When asked about resident #248's re-admission, the DON said, I don't even remember if 1:1 supervision was discussed in morning meetings. I did not think it was necessary. I believe rounds every 2 hours would have been good enough on admission and re-admission. A telephone interview was conducted with resident #248 and her daughter on 9/05/19 at 9:54 AM. The daughter explained prior to admission to the facility, her mother was confused as a result of a stroke. She confirmed her mother required both bed and chair alarms in the hospital for safety. When the daughter asked resident #248 if she used the call light on the night she fell , resident #248 said, I don't remember. I didn't know if there was a light. The daughter stated she was not aware the facility expected the family to provide 24-hour coverage to ensure her mother's safety. She confirmed her mother never had sitters until after she was burned. The Minimum Data Set (MDS) 5-day Medicare scheduled assessment with assessment reference date of 7/29/19 revealed resident #248 had moderate difficulty hearing, moderately impaired vision and short-term and long-term memory loss. She had modified independence with cognitive skills for daily decision-making and some difficulty in new situations only. The assessment indicated resident #248 required extensive assistance with transfers and eating. She was unsteady during transitions and was only able to stabilize with staff assistance. The MDS assessment revealed resident #248 had functional limitation in range of motion of 1 upper extremity. Section J Health Conditions and Section M Skin Conditions revealed resident #248 suffered a fall with fracture and burns. Review of the policy and procedure for Fall Management reviewed 4/15/19, revealed a purpose, To promote patient safety and reduce patient falls by proactively identifying, care planning and monitoring of patients' fall indicators. The document defined avoidable accidents as those that occur due to failure to Implement interventions, including adequate supervision . consistent with a resident's needs . to eliminate or reduce the risk of an accident.

Based on interview and record review, the facility failed to arrange and conduct care plan meetings that were attended by the required members of the interdisciplinary team for 4 of 24 residents reviewed for comprehensive care plans, of a total sample of 49 residents, (#66, #39 #75 & #15). Findings: Resident #66 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of 8/09/19 revealed that resident #66 had adequate hearing and vision, clear speech and no issues with comprehension. Her Brief Interview for Mental Status (BIMS) score of 15 on a 0 to 15 scale indicated she was cognitively intact. Section Q of the MDS assessment Participation in Assessment and Goal Setting revealed resident #66 and her family participated in the assessment. Review of the medical record revealed resident #66 had a care plan for returning home independently, initiated on 8/08/19. The goals were resident #66 would verbalize/communicate an understanding of the discharge plan and describe the desired outcome (and) communicate required assistance post-discharge and services required to meet needs before discharge. The interventions included encourage resident to discuss concerns related to upcoming discharge, establish a discharge plan with resident and her family, evaluate her motivation to return home and make arrangements with community resources to promote post-discharge independence. Resident #66 also had care plans for activities, nutrition, post-operative pain and therapy services. All care plans were revised on 8/21/19 by MDS Coordinator, licensed practical nurse (LPN) D. On 8/26/19 at 12:51 PM, resident #66 stated she received a written invitation to a care plan meeting scheduled for 8/21/19 at 1:30 PM. She explained her daughter took time off work and arrived at the facility at 12:30 PM that day to ensure she was on time for the care plan meeting. Resident #66 stated the only person who came to the meeting was MDS LPN D. Resident #66 said, Why plan a meeting if they're not going to be here? I wanted to discuss issues with getting my [MEDICAL CONDITION] medications late. Resident #66 stated both she and her daughter wanted to know when she was going home and find out about home care services. Resident #66 said, There was a little written paragraph on a paper from therapy, but it didn't really explain much. She explained MDS LPN D was angry and so was she. Two days later, on 8/28/19 at 9:26 AM, resident #66 stated no staff member had yet contacted her regarding rescheduling the care plan meeting. The invitation letter for resident #66's care plan meeting read, (Resident #66) is due for his/her plan of care to be reviewed by our interdisciplinary team on 8/21/19 at 1:30 PM. We invite you to be part of the care planning process. On 8/28/19 at 4:55 PM, resident #66's Care Plan Conference Record form dated 8/21/19, was reviewed with the Lead MDS Coordinator and MDS Coordinator Registered Nurse (RN) E. They confirmed the attendees listed on the form were MDS LPN D, MDS RN E, the Director of Rehabilitation (DOR), resident #66 and her daughter. MDS RN [NAME] stated although she signed the form she had not attended the meeting. She explained she signed care conference forms because an RN's signature was required and LPN D was the person assigned to attend the meetings. The Lead MDS Coordinator validated resident #66 was alert and oriented and stated she had no reason to doubt the care plan meeting was not conducted as it should have been. She confirmed the care plan meeting form indicated the required members of the interdisciplinary team (IDT) were not present. She acknowledged no RNs or certified nursing assistants (CNAs) with responsibility for resident #66's care, nor any representative of food and nutrition services attended the meeting. The Lead MDS Coordinator could not explain why the DOR signed the care plan meeting form if she did not attend. MDS RN [NAME] reviewed resident #66's progress notes and confirmed there was no documentation regarding a care plan meeting or the need to re-schedule a meeting. Resident #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS admission assessment with ARD of 6/26/19 revealed resident #39 had adequate hearing and vision, clear speech and no issues with comprehension. He had a BIMS score of 13 on a 0 to 15 scale, which indicated he was cognitively intact. Section Q of the MDS assessment Participation in Assessment and Goal Setting revealed resident #39 participated in the assessment. Review of resident #39's medical record revealed his care plans had an onset date of 6/19/19 and a target date of 9/19/19. On 8/27/19 at 2:57 PM, resident #39 stated he received notice of a care plan meeting via a letter he found on his bed. He explained the care plan meeting was arranged for a Monday, which was his scheduled [MEDICAL TREATMENT] day. Resident #39 stated when he returned to the facility from [MEDICAL TREATMENT], he told someone in the front office that he missed the care plan meeting. Resident #39 stated the person said, Don't worry about it. He confirmed the care plan meeting was never re-scheduled. Resident #39 explained his health status had improved and he felt the care plan meeting was important because he needed to make plans regarding his discharge home. On 8/28/19 at 4:38 PM, the Lead MDS Coordinator stated care plan meetings were held on admission and then quarterly. A review of the Care Plan Conference Record dated 7/08/19, revealed resident #39 did not attend the care plan meeting. The form was signed by MDS LPN D, the DOR, ADOR, certified dietary manager (CDM) and MDS RN E. The Lead MDS Coordinator confirmed the care plan meeting was not attended by the required IDT members or resident #39. She acknowledged it was possible to re-schedule care plan meetings to promote residents' involvement in their care decisions. The Lead MDS Coordinator confirmed the form was incomplete, and MDS RN [NAME] stated although she signed the attendance section, she was not at the meeting. Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was discharged to the hospital on [DATE], and re-admitted on [DATE] with a new [DIAGNOSES REDACTED]. The MDS admission assessment with ARD of 8/02/19 revealed resident #75 had adequate hearing and vision, clear speech and no issues with comprehension. Her BIMS score of 14 on a 0 to 15 scale indicated resident #75 was cognitively intact. Section Q of the MDS assessment Participation in Assessment and Goal Setting revealed resident #75 and her family participated in the assessment. Review of resident #75's medical record revealed a care plan related to her return home was initiated on 7/29/19, and revised on 8/29/19 by the Lead MDS Coordinator. The goals were resident would . verbalize/communicate an understanding of discharge plan and describe the desired outcome . and discuss the services she would need at home, prior to discharge. Review of the resident #75's medical record revealed a copy of a letter dated 7/30/19, inviting her to a care plan meeting with the IDT on 8/09/19 at 1:15 PM. The invitation read, We invite you to be part of the care planning process . The intention of this meeting is to address the overall therapy progress of our rehab patient plan. However, review of the Care Plan Conference Record dated 8/09/19 revealed a brief written summary of resident #75's progress in therapy and the the ADOR's signature as the only meeting attendee. The form was otherwise blank, and did not indicate a care plan meeting was held. On 8/28/19 at 5:35 PM, MDS RN [NAME] confirmed the form suggested resident #75's care plan meeting was never conducted. She said, It was a Friday and I was off that day, the 9th. When asked if the department had a process to ensure care plan meetings occurred on her days off, MDS RN [NAME] explained either the Lead MDS Coordinator or MDS LPN D should have attended the meeting. On 8/29/19 at 8:29 AM, resident #75 stated she did not recall receiving a written or verbal invitation to a care plan meeting, and stated she was certain she never attended one. Resident #15 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The MDS admission assessment with ARD of 6/20/19 revealed resident #15 had long-term and short-term memory problems. She had a prognosis of less than 6 month's life expectancy and received hospice services. Section Q of the MDS assessment Participation in Assessment and Goal Setting revealed resident #15 and her family participated in the assessment. Review of resident #15's medical record revealed there were no IDT progress notes related to care plan meetings, no invitation letter and no Care Plan Conference Record. On 8/28/19 at 5:30 PM, MDS RN [NAME] stated she was responsible for arranging care plan meetings and sending out invitation letters to residents. She acknowledged IDT discussion that involved residents and their family members was very important in the process of care plan development. MDS RN [NAME] reviewed her notebook with care conference schedules from (MONTH) to (MONTH) 2019 and was not able to find resident #15's name. She said, It appears that I missed setting up the meeting. On 8/29/19 at 1:07 PM, the Social Services Director (SSD) acknowledged it was important to have residents and their families involved in the planning of care. She said, It's crucial to have the collaboration between hospice and the facility in achieving goals for residents' care. I have not been involved with the resident. The social worker (SW) explained she had spoken to resident #15's husband a few times, but neither the SSD or the SW could recall attending a care plan meeting for resident #15. On 8/29/19 at 2:39 PM, the hospice RN case manager (CM) stated she was not aware of any care plan meetings held for resident #15 since her admission to hospice services in (MONTH) 2019, prior to that afternoon. The RN CM validated it was important for facility and hospice staff to meet and discuss resident #15's care. She said, The care plan meeting lets me know what the facility needs and what I can do to help the patient. In an interview conducted with the DOR on 8/29/19 at 1:15 PM, she explained it was important to conduct care plan meetings on admission to obtain information on prior living situations and safe discharge options. She acknowledged the IDT approach was essential. The DOR stated her assistant usually got the care conference forms, filled out a summary and then returned the forms to MDS staff. She explained her assistant attended the meetings and said, I attend if she is not there. A few minutes later at 1:24 PM, the Assistant Director of Rehab (ADOR) stated MDS staff usually provided her with a weekly schedule for the care plan meetings. She explained she often filled out the forms and returned them to MDS staff prior to the meetings. The ADOR stated she was off work on 8/21/19 and did not attend resident #66's care plan meeting. When asked why her signature was on the list of meeting attendees, she said, I probably filled out the form the day before. The ADOR explained her signature on care plan conference forms did not necessarily indicate she attended every meeting, rather it indicated she was the person who completed the therapy summary. Review of the job description for RN MDS Coordinator revised on 6/28/16, revealed he/she was responsible for coordination and completion of care plans in accordance with regulations. The facility's policy and procedure for Resident Assessment Instrument & Care Plan reviewed 4/29/19, revealed the development of individualized person-centered care plans should include IDT review and input from the patient and any other requested participants. The document read, A written explanation must be included in the patient's medical record if participation of the patient and their representative is determined not to be practicable for the development of the resident's care plan.