Every finding on record at Lincoln Care and Rehab

The facility reported a census of 37 residents. Five Certified Nurse Aides (CNA) were reviewed for current certified nurse aide certifications. Based on interview and record review, the facility failed to ensure one CNA had a current and valid certificate. This placed the residents at risk for decreased quality of care. Findings included: - Review of CNA LL's files revealed CNA LL was hired on 05/16/22. CNA LL's file lacked evidence of a current certified nurse aide certificate. Review of CNA LL on the Nurse Aide Registry on 05/15/25 revealed CNA LL had an inactive CNA status as of 06/07/23. During an interview on 05/15/25 at 12:00 PM, Administrative Staff A reported he expected all the CNA staff to have a current certified nurse aide certificate. The facility did not provide a policy for the renewal of certified nurse aide certificate.

The facility reported a census of 37 residents. Five Certified Nurse Aides (CNA) were reviewed for annual performance evaluations. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for CNA NN and CNA LL. This placed the residents at risk for decreased quality of care. Findings included: - Review of CNA NN's files revealed CNA NN was hired on 05/16/22. CNA NN's file lacked evidence a performance evaluation was done in the last 12 months. Review of CNA LL's files revealed CNA LL was hired on 02/29/20. CNA LL's file lacked evidence a performance evaluation was done in the last 12 months. During an interview on 05/15/25 at 12:00 PM, Administrative Staff A reported he expected all the can staff to have annual performance evaluations completed annually. The facility's Performance Management in the employee handbook dated 09/2024, documented the community believes that performance evaluations are a constructive means of improving the performance of both the employee and the community. An employee assessment is a continuous process which normally culminates the formal performance review.

The facility reported a census of 37 residents. The facility had one main kitchen where dietary staff prepare all the food. Based on observation, interview and record review the facility failed to store food items in a sanitary manner when staff failed to date food items in the refrigerator and freezer. This placed the residents at risk of food-borne illness. Findings included: - Observation on 05/12/25 at 09:40 AM revealed one bag of beef patties were placed in the freezer without closure of the plastic bag. Further observation revealed two bags of chicken in a store bag sat on the floor in the refrigerator . The freezer floor had food debris visible. There were numerous bags of vegetables and sandwich meat which lacked a date received. In the kitchen there were nine loafs of bread found with expiration date of 02/22/25 and there was mold growing on the bread. Interviewed on 05/14/25 at 12:0 PM, Dietary Manager BB stated they expected the staff to make sure that all raw meat was on the bottom shelf, and that everything was dated with the open date and expiration date and when received. Dietary Manager BB said the staff was supposed to rotate stock first in first out. Dietary Manger Bb stated they had provided education to the staff regarding the process. The policy Food Safety Requirements dated 10/24 food shall be received and stored in a manner that complies with safe food handling practices, uncooked and raw animal products and fish will be stored separately in drip- proof containers below fruits, vegetables and other ready to eat food.

The facility reported a census of 37 residents. Five Certified Nurse Aide (CNA) staff, who worked in the facility were reviewed for required in-service training. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for CNAs with the required topics and no less than 12 hours per year. This placed the residents at risk for decreased quality of care. Findings included: - On 05/15/25 at 08:30 AM, review of training records for five CNAs revealed that CNA P, who was hired on 12/30/24 lacked dementia (progressive mental disorder characterized by failing memory, confusion) training. Review of CNA NN's employee file lacked evidence the CNA received dementia training and lacked the total number of in-service hours that were completed. During an interview on 05/15/25 at 12:00 PM, Administrative Staff A reported he expected the staff to have the required education and the required 12 hours annually. The facility's policy Staff Competency dated 06/2023 documented all nurse aides shall participate in regularly scheduled in-service training classes. Each nursing assistant must attend, as a minimum, 12 hours of continuing education annually which included dementia management.

The facility reported a census of 37 residents. The sample included 12 residents. Based on observation, record review, and interviews, the facility failed to promote a sanitary, homelike environment. This deficient practice had the potential for decreased psychosocial well-being and impaired safety and comfort for the affected residents. Findings include: - During an observation on the initial tour of the facility at around 07:50 AM, several patches of white plaster spots were observed on several walls and doors of the hallway walls and entrance doors to the residents' rooms. There were several chipped floor tiles noted on the floors in the residents' hallway as well. During an observation on 05/12/25 at 08:51 AM, Resident (R) 5's bathroom floor had some holes in the flooring where the concrete floor could be seen through the holes. R5's grab bar next to the toilet had frayed worn duct tape on the handle. During an observation on 05/12/25 at 03:39 PM, R1's room had a vent cover off the ceiling that was supposed to cover the air conditioning vent; the cover sat on R1's nightstand under a book. Additionally, R1 had three beds in his room. Two of the beds were not made and had a rolled-up air mattress on them. During an interview on 05/13/25 at 09:38 AM, Housekeeping Staff QQ reported that R1's vent cover had been off for about a month now and she had reported that to Maintenance Staff U. Housekeeping Staff QQ reported that the beds were not in R1's room three days ago. During an interview on 05/13/25 at 09:38 AM, R1 reported that Maintenance Staff U had put the beds in his room to store them there a few days ago. During an interview on 05/13/25 at 03:12 PM, Certified Medication Aide (CMA) S reported that Maintenance Staff U placed the beds in R1's room on 05/12/25. CMA S did not realize the vent cover laid on the nightstand stating she was not in R1's room a lot. CMA S reported the staff used to let Maintenance Staff U know of needed repairs by notifying him via an online program on the computer when a repair was needed During an interview/observation tour on 05/15/25 at 11:28 AM, Maintenance Staff U reported that he knew about the bathroom flooring in R5's room and reported that another bathroom floor in room [ROOM NUMBER] had the same concern though no resident was currently admitted to that room. Maintenance Staff U reported that he would start a job and then be told to stop and start a different job, so it was difficult to complete tasks. During an interview observation tour on 05/15/25 at 11:28 AM, Maintenance Staff U observed the beauty shop to have tiles missing off the wall. The baseboard was coming off the wall in the hallway by the beauty shop door. room [ROOM NUMBER] had baseboard missing and door trim for the entrance. room [ROOM NUMBER] the bathroom floor was partially painted white. Maintenance Staff U reported that he needed to wait to hear what flooring was needed for the bathroom. Maintenance Staff U reported that he placed the beds in R1's room as he had no other place to store the beds when rooms [ROOM NUMBERS] were being repaired. During an interview on 05/15/24 at 11:50 AM Administrative Staff A and Consultant Staff HH reported that they were working on a master plan to complete the environmental concerns at the facility. The facility did not provide a policy for homelike environment.

The facility reported a census of 37 residents, with 12 residents sampled. Based on interviews and record review, the facility failed to ensure residents received the opportunity to participate in the care planning process when staff failed to invite Residents (R) 31, R22, R4, R6, R32, and R1 or their responsible party to care plan meetings. The deficient practice placed the residents at risk for impaired resident rights and decreased autonomy. Findings included: - During an interview on 05/12/25 at 09:00 AM, R31 reported she did not know what a care plan meeting was and had never been invited. R31's Electronic Health Record (EHR) revealed the EHR lacked any documentation of a care plan meeting conducted in the past six months. During an interview on 05/12/25 at 09:14 AM, R22 reported he had not received any care plan invites. R22's EHR lacked documentation of a care plan meeting conducted in the past six months. During an interview on 05/12/25 at 10:17 AM, R4 reported she was not invited to care plan meetings. R4's EHR lacked any documentation of a care plan meeting conducted in the past six months. During an interview on 05/12/25 at 10:42 AM, R6 reported she had never been invited to or attended a care plan meeting. R6's EHR lacked any documentation of a care plan meeting conducted in the past six months. During an interview on 05/12/25 at 11:01 AM, R32 reported he has never been to a care plan meeting. R32's EHR lacked any documentation of a care plan meeting conducted in the past six months. During an interview on 05/12/25 at 03:39 PM, R1 reported he had never been invited to a care plan meeting. R1's EHR lacked any documentation of a care plan meeting conducted in the past six months. During an interview on 05/13/25 at 02:32 PM, Social Service Designee (SSD) X reported that he would send an invitation for care plan meetings. SSD X reported unfortunately the facility had no Clinical Reimbursement Coordinator (CRC) employed at the facility since October of 2024, and the CRC would be the person responsible for scheduling care plan meetings. SSD X reported he had not sent out any care plan meeting invitation to residents and or their responsible party since October of 2024. During an interview on 05/13/25 at 02:42 PM, Administrative Nurse D reported she expected the care plan meetings to be held per facility policy. The facility's policy Resident/Family Participation - Assessment Care Plans dated 10/2024 documented that each resident and his/her family members are encouraged to participate in the development of the resident's comprehensive assessment and person-centered care plan. The resident and or his/her representative, are invited to attend and participate in the resident's assessment and care planning conference.

The facility reported a census of 37 residents, with 12 residents sampled. Based on observation, interview, and record review, the facility failed to develop and implement a system to ensure the presence of at least one staff certified in cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) for residents who desired a Full Code status (full resuscitative measures). This deficient practice placed the residents at risk for decreased quality of care and inadequate resuscitative measures. Findings included: - Review of three current staff members' CPR certificates revealed Licensed Nurse (LN) PP had a current certification from an online CPR provider, named on the card, which did not have an instructor-led hands-on skills component. Review of the transportation schedule revealed that Certified Nurse Aide (CNA) AA transported Resident (R) 32, who was a Full Code status to and from his appointments three times a week from [DATE] through [DATE]. During an observation on [DATE] at 09:45 AM, R32 returned from dialysis (a procedure where impurities or wastes are removed from the blood) with CNA AA, the transportation aide. CNA AA propelled R32 into the facility in his wheelchair from the facility van. During an interview on [DATE] at 03:23 PM, CNA AA reported she was currently CPR certified. CNA AA reported she had completed the CPR class at another facility but could not remember the exact date. During an interview on [DATE] at 10:00 AM, CNA AA reported that Administrative Staff AA would locate her CPR card. CNA AA reported that she conducted all the facility's transportation trips. During an interview on [DATE] at 12:10 PM, Administrative Staff A reported that CNA AA's CPR card had expired in [DATE]. During an interview on [DATE] at 03:53 PM, Administrative Staff A reported that he would like to provide a more complete list of staff who are CPR certified the following day. Administrative Staff A reported that most of the staff received CPR training at the facility in [DATE] and said those staff would have current CPR cards, and that information would be available on [DATE]. Administrative Staff A reported he expected at least one facility staff member on each shift would be CPR-certified and believed that the staff schedule did not have the CPR-certified staff for each shift identified on that form. During an interview on [DATE] at 10:30 AM, Administrative Staff A stated he expected staff to have a hands-on skills component when a CPR course was completed. Review of the facility's Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) dated ,d+[DATE] documented staff must maintain current CPR certifications for Healthcare Providers through a CPR provider whose training includes a hands-on session. Staff CPR certified are available 24 hours a day. This is posted in the community.

The facility reported a census of 37 residents. The sample included 12 residents. Based on observation, interview and record review, the facility failed to maintain an effective infection control program related to the enhanced barrier precaution (EBP-a set of infection control measures that use goggles, gown and gloves to reduce the spread of multidrug-resistant organisms [MDROs] in nursing homes) when providing tube feeding care (a specialized medical flexible tube made of either silicone or plastic to deliver liquid nutrition directly int the stomach) or providing a shower to the resident with the tube feeding. Additionally, staff failed to disinfect the Hoyer lift (full body mechanical lift) after use and failed to utilize adequate hand hygiene. This placed the residents at risk for infections. Findings included: - Observation on 05/12/25 at 12:05 PM revealed Licensed Nurse (LN) K in R14's room reattaching the feeding tube the resident had pulled out. LN K did not utilize a gown during the care provided. Observation on 05/13/25 at 10:43 AM revealed Certified Nurse Aide (CNA) Q and CNA JJ transferred R14 from his bed using a lift into the shower chair, Neither CNA implemented a gown for EBP before providing care. Further observation revealed the staff pushed the Hoyer out into the hall after use but did not disinfect it. Observation on 05/12/25 at 04:44 PM revealed CNA N provided peri-care to R6. CNA N assisted R6 off of the bed pan, removed the resident's wet brief, washed the residents' buttocks, and placed a new brief with the same soiled gloves. CNA N then took the bed pan to the bathroom and emptied into the toilet. CNA N removed her gloves but did not wash her hands before applying new gloves. CNA N then washed the residents front genital area. CNA N removed one glove, picked up the garbage and went to the soiled room then came out and washed her hands. On 05/14/25 at 04:11 PM CNA N reported that she should have washed her hands when she removed her gloves before cleaning the resident's peri-area. On 05/14/25 at 02:50 PM Administrated Nurse D stated she expected that all staff implement the adequate hand hygiene and EBP and said they had received education on EBP. The facility policy Multidrug-Resistant Organisms (MDRO) and Enhanced Barrier Precautions (EBP) dated 04/25 appropriate precautions will be taken when caring for individuals known or suspected to have infection or colonization with multidrug-resistant organisms (MDRO) and require Enhanced Barrier Precautions note the infection means the organism is present and causing illness. Additional guidance recommend by the CC will be reviewed and adopted as it becomes available for the prevention of spread of Muli- resistant organism. Enhanced Barrier Precautions Guidance for Cares refers to practices such as brushing teeth, combing hair and shaving are commonly bundled as part of morning and evening cares.

The facility reported a census of 37 residents, with 12 residents sampled for advanced directives (a written document, which indicates the medical decisions for health care professionals when the person cannot make their own decisions). Based on interview and record review, the facility failed to ensure one resident's advanced directives were thoroughly completed when Resident (R)7 had a do not resuscitate (DNR- or no code, a legal document or order that means the person does not desire resuscitative measures) which was only signed by a physician rendering it invalid. This placed the resident at risk for an impaired right to have advance directives honored. Findings included: - R7 's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) depression (excessive sadness), and anxiety. The 09/19/24 Quarterly Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R7 required total dependence to complete activities of daily living (ADL) including toileting, footwear, & personal hygiene. The MDS recorded R7 required maximal assistance with bathing, and moderate with assistance dressing, and transfers. The 03/10/25 Significant Change Minimum Data Set (MDS) documented the resident had a BIMS score of four, which indicated severely impaired cognition. R7 required total dependence with ADLs including toileting, footwear, & personal hygiene. The MDS recorded R7 required maximal assistance with bathing, and moderate with assistance dressing, and transfers. The MDS noted R7 received hospice services. The 04/04/25 Cognitive Loss/ Dementia Care Area Assessment (CAA) triggered due to R7 refused care at times with contributing factors of depression. The CAA recorded risk factors included self-care deficits, falls, incontinence, and decreased socialization. The CAA indicated the care plan would be reviewed to maintain ADLs, encourage activity participation, decrease falls, and maintain dietary intake and hydration. R7's Care Plan documented a DNR date revised 10/23/19. R7's Physician Orders documented a DNR order, date ordered 03/18/20. Review of R7's EHR revealed a hospice-based DNR form signed 08/15/19 by the physician. The form lacked a signature from the resident or resident's representative. During an interview on 05/13/25 at 11:16 AM, Social Service Designee (SSD) X confirmed that R7's DNR which was loaded in R7's EHR was incorrect, having only the physician's signature. During an interview on 05/13/25 at 05:01 PM, Administrative Nurse D reported that a resident should have a DNR form signed by the resident or durable power of attorney (DPOA- a legal document that names a person to make healthcare decisions when the resident is no longer able to), and it should be witnessed. Administrative Nurse D verified the DNR should not just contain a physician's signature. The facility did not provide a policy for advance directives.

The facility reported a census of 37 residents with 12 residents sampled. Five residents were reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 7's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had a 14-day stop date or a specified duration which included the physician's rationale for extended use. This deficient practice placed the R7 at risk for adverse effects associated with the use of psychotropic (alters mood or thoughts) medications. Findings included: - R7 's Electronic Health Record (EHR) revealed diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion) depression (excessive sadness), and anxiety. The 09/19/24 Quarterly Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R7 required total dependence to complete activities of daily living (ADL) including toileting, footwear, and personal hygiene. The MDS recorded R7 required maximal assistance with bathing, and moderate with assistance dressing, and transfers. The MDS recorded R7's behavior fluctuated and R7 had disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) thinking. The MDS noted R7 was easily distracted and had difficulty keeping track of what was said. The MDS recorded R7 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), an antianxiety, and an antidepressant (a class of medications used to treat mood disorders) medications on a routine basis. The 03/10/25 Significant Change Minimum Data Set (MDS) documented the resident had a BIMS score of four, which indicated severely impaired cognition. R7 required total dependence with ADLs including toileting, footwear, & personal hygiene. The MDS recorded R7 required maximal assistance with bathing, and moderate with assistance dressing, and transfers. The MDS recorded R7 rejected care one to three days during the look-back period. The MDS recorded R7 received an antipsychotic, antianxiety, and antidepressant medication on a routine basis. The 04/05/25 Psychotropic Drug Use Care Area Assessment (CAA) triggered due to R7's use of antidepressant, antianxiety, and antipsychotic medications to help manage psychiatric illness. The CAA noted risk factors included impaired balance, increased falls, and adverse effects of medication. The CAA indicated the care plan would be reviewed to monitor the effectiveness of psychotropic medications and any adverse effects of medication. The 04/04/25 Cognitive Loss/ Dementia Care Area Assessment (CAA) triggered due to R7 refused care at times with contributing factors of depression. The CAA recorded risk factors included self-care deficits, falls, incontinence, and decreased socialization. The CAA indicated the care plan would be reviewed to maintain ADLs, encourage activity participation, decrease falls, and maintain dietary intake and hydration. R7's Care Plan documented interventions on 02/22/17 which directed staff to administer medications as ordered and monitor and document side effects and effectiveness. The plan directed staff to reassure R7 that medications were safe and were not tranquilizers (a drug used to make a person calmer); staff were directed to monitor behavior episodes and attempt to determine the underlying cause. The plan noted an intervention dated 11/01/18 which directed to consult with the pharmacy and physician to consider dosage reduction when clinically appropriate. The plan directed staff to administer antianxiety medications as ordered by physician and monitor and document side effects, dated 09/21/24. R7s Physician's Orders documented an order for Ativan (antianxiety medication) 0.5 milligram (mg), give 0.5mg/0.1 milliliter (ml) topically every 4 hours PRN for anxiety, date ordered 04/07/25. The order lacked a stop date. R7's Physician's Orders documented an order for lorazepam topical cream. Give 1mg/0.1ml, apply topically to the wrist, three times a day for anxiety or restlessness, date ordered 04/07/25. R7's Medication Regimen Review (MRR) dated 04/07/25 documented no irregularities noted. R7's Medication Regimen Review (MRR) dated 05/06/25 identified there was no stop date for the PRN Ativan. R7's Medication Administration Record reviewed from 04/07/25 through 05/15/25, R7 received the PRN Ativan 21 times. R7's EHR lacked evidence of a specified duration which included a physician's rationale for the PRN Ativan . During an interview on 05/13/25 at 08:29 AM, Licensed Nurse (LN) G reported that some PRN medications required a stop date but said they could not recall which medications required a stop date. During an interview on 05/15/25 at 08:15 AM Administrative Nurse D reported that she expected the nurses to obtain a stop date for as needed psychotropic medications when the order was obtained from the physician. Administrative Nurse D reported that R7 had a MRR completed on 05/06/25 and she sent the MRR to the provider, however, she needed to send it back to the provider for clarification of a stop date, which she received 05/15/25. The facility's policy Free from Chemical Restraints, Unnecessary Psychotropic Medications dated 04/2025 documented chemical restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. The facility's policy Medication Regimen Reviews dated 02/2025 documented a review of residents with as needed psychotropic medications are limited to 14 days and if greater than 14 days the rationale for such listed in EHR.

The facility had a census of 37 residents. The sample included 12 residents with three residents reviewed for hospitalization . Based on observation, interview, and record review, the facility failed to provide a written bed hold policy and failed to issue written notification as soon as practicable for transfers for Resident (R) 31, R32, and R1. This placed the residents at risk for impaired rights related to returning to the facility. Findings included: - R31's Electronic Health Record (EHR) documented R31 was transferred to the hospital on 12/01/24. R31's EHR lacked evidence the facility provided a bed hold notice or written notification of the transfer to R31 and/or her representative. R32's EHR documented R32 was transferred to the hospital on 11/22/24, 01/22/25, 02/10/25, 02/25/25, and 05/05/25. R32's EHR lacked evidence the facility provided a bed hold notice or written notification of the transfer to R32 and/or his representative. R1's EHR documented R1 was transferred to the hospital on 11/01/24, 11/18/24, and 12/21/24. R1's EHR lacked evidence the facility provided written notification of the transfer to R1 and/or his representative. During an interview on 05/13/25 at 03:21 PM, Licensed Nurse (LN) G reported when a resident was transferred to the hospital, the nurse would notify Social Service Designee (SSD) X. LN G reported the nurse would have the resident sign a bed hold policy form and send it with the resident. LN G reported this is not done during an emergency staff just send a blank bed hold form and SSD X took care of the residents who did not sign. LN G reported that he would send copies of the information that the hospital would need to take care of the resident, a face sheet, current orders, labs, vital signs, code status, and call a report to the hospital. During an interview on 05/13/25 at 04:24 PM, SSD X reported that if a resident had an emergent transfer, a bed hold would be completed the next business day. He stated he would call or contact by email the resident and/or responsible party and would receive a verbal bed hold. SSD X reported he would send the bed hold to get it signed and requested the form back. SSD X reported that the bed hold form does not get uploaded in the EHR, he kept the forms in a folder. During an interview on 05/13/25 at 04:34 PM, SSD X demonstrated he had a bed hold form that R31 signed on 12/01/24. During an interview on 05/13/25 at 04:38 PM, SSD had a signed bed hold form for 11/01/24 and 11/18/24 from R1's guardian. SSD X reported he could not locate a signed bed hold for the hospital visit on 12/21/24. SSD X reported that the bed hold policy was the only form that was used when a resident was transferred out to the hospital and reported he did not have to write a cost for a bed hold on the form. During an interview on 05/15/25 at 10:47 AM Administrative Nurse D stated she expected the bed holds to be completed the same day or the next business day for all residents that were transferred to the hospital. Administrative Nurse D reviewed the facility's bed hold form and reported that it was the correct form. She said that she expected the nurses to complete the transfer e-interact in the EHR every time a resident was transferred as it contained the required information per the regulations. The facility's policy Bed Hold dated 04/2025 documented the community staff shall inform the residents upon admission and prior to transfer for hospitalization (unless for an emergency) or therapeutic leave of the bed hold policy. The bed hold information will include any charges that the resident may incur as well as the time limit established by Medicaid. Bed hold days in excess of Medicaid are considered non-covered services. A resident would be required to pay for additional days. The facility's Transfer and/ or Discharge, Including Against Medical Advice, Discharge Notification dated 04/2025 documented the community has established transfer and discharge criteria based upon federal requirements.

The facility reported a census of 37. The sample included 12 residents. Based on interviews and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for Resident (R)22, R6 and R31. This placed the residents at risk for unidentified care needs and inadequate plan of care. Findings included: - R22's Electronic Medical Record (EMR) recorded a diagnosis dated 02/09/22 of obstructive sleep apnea (a sleep disorder characterized by periods without respirations). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Section O of the MDS lacked indication of the use of a continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep). The Quarterly MDS dated [DATE] under Section O lacked indication of use of the CPAP. The Physician Orders dated 07/15/23 documented R22 was to wear the CPAP at bedtime and during naps R22's Care Plan dated 05/23/24 documented R22 had altered respiratory status related to sleep apnea. The plan noted R22 used a CPAP at bedtime. On 05/13/25 at 02:30 PM Certified Nurse Aide (CNA) T verified R22 used a CPAP machine at night. On 05/14/24 at 04:53 PM Administrative Nurse D stated she expected the MDS to accurately reflect the resident's status The facility did not provide a policy on accurate MDS assessment. 50659 - R31's Electronic Health Record (EHR) revealed diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness) and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The 11/01/24 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R31 was dependent on staff for toileting activities of daily living (ADL). The MDS recorded R31 required maximal assistance with showering, lower body dressing, and transfers. The MDS recorded R31 required set up assistance for oral care. The MDS recorded R31 had adequate vision and wore eyeglasses. The MDS recorded R31 had no issues with her teeth. The 11/22/24 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R31 required staff assistance to complete ADLs. The Dental Care CAA was not triggered. The 03/26/25 Quarterly MDS documented a BIMS of 15. The MDS recorded no changes in ADLs from the previous MDS. The MDS recorded R31 had no issues with her mouth; she had adequate vision and required no device. R31's Care Plan dated 11/30/23 documented R31 had oral and dental health problems related to poor nutrition and a history of drug use. The plan directed staff to coordinate arrangements for dental care including transportation as needed and as ordered. The plan directed staff to provide R31 mouth care assistance. An intervention dated 12/01/23 documented R31 had impaired visual function related to a CVA and a left-sided visual deficit. R31's Admission assessment dated [DATE] documented R31 did not have her own teeth and no other documentation was checked on the assessment. R31 was moderately impaired with vision could only see half of visual field no device was checked off that she had any. During an interview/observation on 05/12/25 at 09:01 AM, R31 reported that no staff had asked her about being assessed by a dentist since she admitted on [DATE]. R31 reported she had a lot of bits and pieces of teeth in her mouth. Observation revealed R31 had several broken teeth on both the top and bottom. R31 reported that she requested to have an eye exam. She reported that she could not read without reading glasses and that she had never had eyeglasses at the facility. On 05/14/24 at 04:53 PM Administrative Nurse D stated she expected the MDS to accurately reflect the resident's status. The facility did not provide a policy on accurate MDS assessment. - R6's Electronic Health Record (EHR) revealed diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) and anxiety. The 02/22/25 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS recorded R6 had received six of the seven days of insulin injections and received a hypoglycemic (a medication to control blood sugar) and used a non-invasive mechanical ventilator (breathing support delivered without inserting a tube into the windpipe). The 03/27/25 Nutritional Status Care Area Assessment (CAA) triggered due to body mass index (BMI-a calculation used to estimate body fat percentage based on height and weight) of 48. Risk factors included weight instability, impaired fluid balance, abnormal lab values, and impaired skin integrity. The CAA recorded a care plan would be maintained to address dietary and hydration status. The 11/26/24 Quarterly MDS documented a BIMS of 14, which indicated intact cognition. R6 did not receive injections, hypoglycemic medication, or use a non-invasive mechanical ventilator. R6's Care Plan dated 05/13/25 current and resolved lacked any documentation for insulin, or a non-invasive mechanical ventilator. R6's Physician Orders current and discontinued lacked any documentation for insulin, or a non-invasive mechanical ventilator. During an interview/observation on 05/12/25 10:35 AM R6 was in bed and had oxygen on via her nasal cannula. She reported that she had never used anything but oxygen through a nasal cannula to help her breath. R6 also reported that she had never received insulin and was not a diabetic. On 05/14/24 at 04:53 PM Administrative Nurse D stated she expected the MDS to accurately reflect the resident's status. Administrative Nurse D reported that R6 had no diagnosis of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) and had never required a non-invasive mechanical ventilator. The facility did not provide a policy on accurate MDS assessment.

The facility reported a census of 37. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to provide professional standards of care for Resident (R) 22 when staff failed to contact the physician for blood sugars greater than 400 milligrams (mg) per deciliter (dL) or lower than 60 mg/dL. This placed the resident at risk for impaired care and complications related to high or low blood sugar. Findings include: - R22's Electronic Medical Record (EMR) revealed a diagnosis dated 02/09/22 of type two diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin) The Annual Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS noted R22 received insulin (a medication used to treat high blood glucose)for seven days during the observation period. The Quarterly MDS dated [DATE] recorded no changes from the 12/25/24 MDS. R22's Care Plan dated 05/08/23 directed staff to monitor blood sugars as ordered, and give insulin as ordered R22's Physician Orders dated 04/20/25 ordered to notify the physician for blood sugars greater than 400 mg/dL or less than 60 mg/dl. Review of the blood sugars on 03/14/25 R22's revealed blood sugar was 418 mg/dl. The nurse's notes lacked evidence staff notified the physician. On 04/20/25 R22 had a blood glucose of 409 mg/dL. The note lacked evidence staff notified the physician. On 05/15/25 at 08:27 AM Licensed Nurse (LN) I stated the standard of practice was to document and notify the physician if the blood sugar was above 400 mg/dl. On 05/15/25 at 08:32 AM LN J said the protocol was to contact the physician for blood sugars above 400 mg/dl. On 05/15/25 at 08:20 AM Administrative Nurse D stated she expected the nurses to contact the physician for blood sugars above 400 mg/dl as per the orders. The facility policy Guidelines for Notifying Physicians of Clinical Problems guidelines are to help ensure that 1) medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record.

The facility reported a census of 37 residents. The sample included 12 residents with one dependent resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to provide ADL care including grooming of facial hair in accordance with the resident's preferences for Resident (R) 2. This placed the resident at risk for impaired dignity and poor hygiene. Findings included: - R2's Electronic Health Record (EHR) revealed diagnoses of blindness of the right and left eye, paranoid schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), and a need for assistance with personal care. The 06/20/24 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. The MDS recorded R2 had severely impaired vision and required no devices. The MDS noted R2 required moderate assistance for personal hygiene and maximal assistance for bathing. The 06/24/24 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) triggered for impaired functional and cognitive ability related to history of schizophrenia. The CAA noted R2 was blind and required assistance with ADLs, eating, set-up and clean-up assistance for meals, oral hygiene, personal cares, and bathing. The 02/26/25 Quarterly MDS documented a BIMS of 15, which indicated intact cognition. The MDS documented R2 required moderate assist with personal hygiene. R2's Care Plan revised on 01/12/23 directed staff to provide cueing and set up assistance with personal hygiene and oral care. R2's Personal Hygiene Task was not documented on the EHR. During an interview and observation on 05/12/25 at 11:30 AM R2 reported she required help getting around the facility at times as she had been blind since birth. Observation revealed R2 had prominent beard stubble on her chin with irregular borders. R2 reported that staff would need to take the facial hair off when they got a chance. Further observation revealed both R2's eyes had yellow crusty drainage; R2 reported staff clean her face when she gets a shower. During an observation on 05/13/25 at 10:11 AM, R2 had the same facial hair on her chin. During an observation on 05/14/25 at 07:59 AM R2 sat in the lounge. Further observation revealed R2's facial hair had been removed. R2 reported that her face felt better, and she smiled. During an interview on 05/14/25 at 01:24 PM, Certified Nurse Aide (CNA) KK reported that facial hair should be removed on residents' shower days or when they request it. CNA KK reported that R2 would generally not ask for her facial hair to be removed but if staff asked her if they could remove the facial hair, R2 would allow the staff. CNA KK reported some staff will shave residents and other would not. During an interview on 05/14/25 at 03:51 PM Licensed Nurse (LN) H reported that residents should be offered to have their facial hair removed on shower days and as needed or requested. He reported that R2 was blind and would not be able to see in order to remove her own facial hair. During an interview on 05/15/25 at 01:15 PM, Administrative Nurse D reported she expected staff to remove facial hair on residents during shower day, as needed, or when requested for any resident. Administrative Nurse D stated if the resident had a preference, it should be on the care plan. The facility did not provide a policy on ADL assistance for a dependent resident.

The facility reported a census of 37 residents. The sample included 12 residents with one reviewed for visual services. Based on interview and record review, the facility failed to provide visual services or facilitate access to visual services for Resident (R) 31 who had impaired visual function. This placed the resident at risk for further deterioration of vision. Findings included: - R31's Electronic Health Record (EHR) revealed diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness) and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The 11/01/24 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R31 was dependent on staff for toileting activities of daily living (ADL). The MDS recorded R31 required maximal assistance with showering, lower body dressing, and transfers. The MDS recorded R31 required set-up assistance for oral care. The MDS recorded R31 had adequate vision and wore eyeglasses. The MDS recorded R31 had no issues with her teeth. The 11/22/24 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R31 required staff assistance to complete ADLs. The Visual Function CAA was not triggered. The 03/26/25 Quarterly MDS documented a BIMS of 15. The MDS recorded no changes in ADLs from the previous MDS. The MDS recorded R31 had no issues with her mouth; she had adequate vision and required no device. R31's Care Plan dated 11/30/23 documented R31 had oral and dental health problems related to poor nutrition and a history of drug use. The plan directed staff to coordinate arrangements for dental care including transportation as needed and as ordered. The plan directed staff to provide R31 mouth care assistance. An intervention dated 12/01/23 documented R31 had impaired visual function related to a CVA and a left-sided visual deficit. R31's Admission assessment dated [DATE] documented R31 did not have her own teeth and no other documentation was checked on the assessment. R31s Physician's Orders documented an order may be seen by specialists as needed including an eye doctor of choice care as needed, date ordered 11/17/2023. R31's EHR lacked evidence the facility had offered or facilitated visual services for R31 and lacked evidence R31 had declined visual services. During an interview/observation on 05/12/25 at 09:01 AM, R31 reported that she requested to have an eye exam. She reported that she could not read without reading glasses and that she had never had eyeglasses at the facility. During an interview on 05/13/25 at 03:21 PM, Licensed Nurse (LN) G reported when a resident requested to see an eye doctor or a dentist, and it was not an emergency, the nurse wrote a progress note in the EHR or informed Social Services Designee (SSD) X verbally. During an interview on 05/13/25 at 03:23 PM, Certified Nurse Aide (CNA) KK, a transportation aid, reported she had not taken R31 to any appointments for dental or vision care. During an interview on 05/13/25 at 03:27 PM, SSD X reported when a resident requested to have a dental or eye appointment the facility would receive a consent form sent from the outside provider that comes into the facility to complete appointments. SSD X said residents had to sign a consent or declination, and all residents had standing orders. SSD X reported that R31 had declined services. SSD X verified they could not locate a declined consent or a progress note in R31's EHR. During an interview on 05/14/25 04:53 PM, Administrative Nurse D reported she expected all residents should have an eye exam once admitted as a baseline and as required or requested. The facility's policy Ancillary Services: Vision, Hearing, and Foot Care dated 10/2024 documented the residents would be provided the necessary care and services based on their comprehensive care plan. The SSD or Designee would assist with making vision appointments.

The facility reported a census of 37 residents. There were 12 residents in the sample including two residents reviewed for respiratory care. Based on observation, interviews and record review the facility failed to provide sanitary respiratory care and services when staff failed to clean the nebulizer (a device for administering inhaled medication) after each use for Resident (R) 14 and also failed to store the continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) mask in a sanitary manner for R22. This placed the residents at risk for infection and increased respiratory complications. Findings included: - R14's Electronic Medical Record (EMR) dated 08/11/22 revealed a diagnosis of pneumonia (inflammation of the lungs). The Significant Change Minimum Data Set, dated dated dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate impaired cognition. The MDS noted R14 required substantial to maximal assistance with activities of daily living (ADL). The Quarterly MDS dated [DATE] noted R14 had BIMS score of 12 which indicated moderately impaired cognition. R14's Care Plan indicated R14 is at risk for delirium related to manic episodes monitor/record and report to medical physician any new onset or signs of delirium. The care plan lacked information regarding the nebulizer is not available on the care plan. R14's Physician Orders dated 04/30/25 ordered ipratropium-albuterol solution (a medication used in a nebulizer to open airways) 0.5 -2.5 milligrams/3 milliliters three times a day. During an observation on 05/12/25 at 12:05 PM R14's nebulizer was attached to the tubing on the bedside table with clear liquid in the bottom of the chamber. During a observation on 05/13/25 at 10:17 AM R14's nebulizer was still attached to the tubing the device and had not been separated and rinsed after treatment. On 05/13/25 at 02:25 PM Certified Nurses Aide (CNA) T verified R14 had nebulizer treatments and staff were to rinse the nebulizer out after each treatment. On 05/13/25 at 02:50 PM Administrative Nurse D stated she expected the nurses to makes sure the nebulizer was cleaned and stored after each use. The facilities policy on Administering Medication through a Small Volume (Handheld) Nebulizer) dated 10/24 rinse and disinfect the nebulizer equipment according to facility protocol of wash pieces with warm soapy water, rinse with hot water, place all pieces in a bowl and cover with isopropyl alcohol soak for five minutes. Wash and dry hands when equipment is completely dry store in a plastic bag with resident's name and date on it. Change the equipment and tubing every seven days. - R22's Electronic Medical Record (EMR) recorded a diagnosis dated 02/09/22 of obstructive sleep apnea (a sleep disorder characterized by periods without respirations). The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Section O of the MDS lacked indication of the use of a CPAP. R22's Care Plan dated 05/08/23 documented R22 had altered respiratory status related to sleep apnea and used a CPAP at bedtime and during naps. During observations on 05/13/25 at 10:15 AM R22's CPAP mask was still latched to the hose and sitting on the bedside table, open to air. During observation on 05/14/25 at 09:38 AM R22's CPAP mask was attached to the tubing and hung off the bedside table open to air. On 05/13/25 at 03:30 PM Administrative Nurse D stated she expected the staff to make sure they cleaned and placed the CPAP mask in a storage bag after each use. The facility's policy CPAP/BIPAP Support dated 05/2024 did not address the procedure for cleaning and storage of the CPAP mask when not in use.

The facility reported a census of 37 residents. The sample included 12 residents sampled with one resident reviewed for dementia (progressive mental disorder characterized by failing memory, and confusion) care services. Based on observation, record review, and interviews, the facility failed to provide nonpharmacological dementia care and services to promote Resident (R) 7's highest practicable level of function and well-being. This placed the resident at risk for decreased quality of life. Findings included: - R7 's Electronic Health Record (EHR) revealed diagnoses of dementia (progressive mental disorder characterized by failing memory, and confusion) depression (excessive sadness), and anxiety. The 09/19/24 Quarterly Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of five, which indicated severely impaired cognition. R7 required total dependence to complete activities of daily living (ADL) including toileting, footwear, & personal hygiene. The MDS recorded R7 required maximal assistance with bathing, and moderate with assistance dressing, and transfers. The MDS recorded R7's behavior fluctuated and R7 had disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject) thinking. The MDS noted R7 was easily distracted and had difficulty keeping track of what was said. The MDS recorded R7 received an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), an antianxiety, and antidepressant (class of medications used to treat mood disorders) medications on a routine basis. The 03/10/25 Significant Change Minimum Data Set (MDS) documented the resident had a BIMS score of four, which indicated severely impaired cognition. R7 required total dependence with ADLs including toileting, footwear, & personal hygiene. The MDS recorded R7 required maximal assistance with bathing, and moderate with assistance dressing, and transfers. The MDS recorded R7 rejected care one to three days of during the look-back period. The MDS recorded R7 received antipsychotic, antianxiety, and antidepressants on a routine basis. The 04/05/25 Psychotropic Drug Use Care Area Assessment (CAA) triggered due to R7's use of antidepressant, antianxiety, and antipsychotic medications to help manage psychiatric illness. The CAA noted risk factors included impaired balance, increased falls, and adverse effects of medication. The CAA indicated the care plan would be reviewed to monitor the effectiveness of psychotropic medications and any adverse effects of medication. The 04/04/25 Cognitive Loss/ Dementia Care Area Assessment (CAA) triggered due to R7 refused care at times with contributing factors of depression. The CAA recorded risk factors included self-care deficits, falls, incontinence, and decreased socialization. The CAA indicated the care plan would be reviewed to maintain ADLs, encourage activity participation, decrease falls, and maintain dietary intake and hydration. R7's Care Plan lacked interventions to address dementia care needs. R7's Physician's Orders documented an order for Seroquel (an antipsychotic) oral tablet 25 milligram (mg), give 25 mg by mouth, three times a day for schizoaffective disorder (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), date ordered 02/27/25. R7's Physician's Orders documented an order for Sertraline (an antidepressant) 50 mg tablet, give 50 mg by mouth, two times a day for anxiety, date ordered 02/27/25. R7's Physician's Orders documented an order for rivastigmine transdermal patch (a medication used to manage and treat dementia) apply one patch 4.6 mg/24 hour one time a day for R7 refusing oral medications, remove patch and apply a new patch and remove per schedule, date ordered 02/27/25. R7's Physician's Orders documented an order for Haldol (antipsychotic) 50 mg/ milliliter (ml), inject 0.5 ml intramuscularly monthly every 28 days related to schizoaffective disorder, date ordered 03/20/25. R7s Physician's Orders documented an order for Ativan (antianxiety medication) 0.5 milligram (mg), give 0.5mg/0.1 milliliter (ml) topically every 4 hours as needed for anxiety, date ordered 04/07/25. R7's Physician's Orders documented an order for lorazepam topical cream. Give 1mg/0.1ml, apply topically to the wrist, three times a day for anxiety or restlessness, date ordered 04/07/25. R7's April 2025 and May 2025 Medication Administration Record (MAR) revealed staff monitored and recorded occurrences of target behavior symptoms as follows: Ativan: behavior codes: 0. None 1. Verbal aggression: cursing, threatening, yelling 2. Physical aggression: hitting 3. Delusions 4. Paranoia-obsession of negative event/health concerns 5. Sexual aggression 6. Refusal of meds and cares. Record non-pharmacological behavioral interventions. Intervention codes: 0. None 1. Called daughter 2. Talk to in calm voice 3. Provided reassurance 4. Offer drink-likes Mountain Dew as needed for behavior monitoring. R7's April and May 2025 MAR lacked documentation of behavioral occurrences. R7's May 2025 Monitoring Behavior Symptoms in the Tasks in R7's EHR, documented on 05/08/25 at 05:35 AM, R7 had the following behaviors frequent crying, repetitive movement, yelling, screaming, kicking or hitting, pushing, grabbing, pinching, scratching, and spitting. R7's 'Progress Note on 12/31/24 at 06:42 AM documented R7 sometimes had difficulty starting and staying involved in recreational activities as evidenced by a short attention span. The note recorded R7 enjoyed nail spa and activities with food/drink, and she also enjoyed one-on-one visits which let her be more relaxed and vent or just chat about her day/nights. The note documented R7 would get very confused sometimes and was not easily redirected and noted that staff can offer a snack, sit with R7, and hold her hand. R7's 'Progress Note on 01/12/25 at 12:36 PM documented R7 refused to allow Certified Nurse Aides (CNAs) to give personal cares including peri-care. The note recorded the nurse, and two CNAs were able to assist R7 into the shower to clean up bowel movement from R7's buttocks, vaginal area and legs and in the process, R7 pinched staff, scratched staff, and struck out to anyone within reach. Staff notified the on-call provider and received a one time order for lorazepam 0.5mg. Staff pulled the lorazepam from R7's routine card of lorazepam. Staff gave R7 a shower, cleaned her up, and kept her away from peers until her mood was less aggressive. R7's Physician Visit Note on 01/12/25 documented that clinical staff were concerned with increased aggressive behaviors; R7 was combative with staff, kicking and hitting them while they were providing care for her. The note documented the nurse reported this was a common behavior for the resident but more so that day. The note documented R7 also received an Invega (an antipsychotic medicine) injection the previous day for the first time. The noted documented staff were advised to give R7 an additional dose of lorazepam 0.5mg by mouth to help calm her. But the resident refused to take her medication including the additional dose of lorazepam. The note documented R7's family got involved and tried to encourage the resident; staff were advised to try to reapproach the resident at a later time to see if she could be redirected. The note recorded an acute care follow up would be coordinated since staff felt adjusting R7's medications would be helpful in caring for patient. R7's Progress Note on 02/12/25 at 04:31 PM documented R7 threw a cup of water at another resident. R7 was taken away from the resident she threw the water at. The note documented R7 was unable to be understood with things she said and was frequently yelling out and grabbing the staff that walk by; R7 was resistant to care, grabbing staff's arms and clothing. R7's 04/09/25 Physician Progress Note documented general: [AGE] year old female with fall and some increased behaviors this weekend, R7 remained on hospice, and they reached out for med changes discussion with staff and hospice today about underlying schizophrenia and need for continued psych follow up. During an observation on 05/12/25 at 09:20 AM, R7 tried to slap the surveyor during initial interview. During an observation on 05/13/25 at 10:53 AM CNA JJ assisted R7 out of her recliner and into her wheelchair. Administrative Nurse D followed R7 around in her wheelchair for a few moments and R7 wanted to go back into her recliner and called out loudly. Social Service Designee (SSD) X transferred R7 to her recliner. During an observation on 05/14/25 at 01:38 PM, R7 parked her wheelchair in front of the loveseat where R15 was seated. R7 grabbed at R15's walker after she hit it a few times, R7 then stood up in a semi-crouched position and sat on the loveseat next to R15. R15 had a frown on her face and sat on the loveseat for approximately a minute and R15 stood up and moved to a chair away from R7. Activity Director Z walked past R7 and R15 while R7 had a hold of R15's walker. During an observation on 05/14/25 at 01:51 PM Administrative Nurse D assisted R7 from the love seat to her wheelchair and asked Licensed Nurse (LN) H if R7 had received any pain medications lately. During an interview on 05/12/25 at 11:27 AM, R7's representative reported that there was one resident that R7 did not like so staff keep them separated. R7's representative stated they did not know the other resident and said that no recent altercations had been reported to them. During an interview on 05/14/25 at 01:21 PM, CNA KK reported that R7 would self-transfer at times and staff would intervene. CNA KK reported that residents' care plans would have directions to the staff on interventions and approaches to address the resident's needs. During an interview on 05/14/25 at 02:03 PM, CNA O reported that R7 attempted to transfer herself and staff would need to intervene. CNA O reported she noticed earlier that R7 had lifted her hand towards R15 but R15 did not notice it and staff intervened. CNA O stated R7 kept staff busy at times because she liked to move around in her wheelchair and sometimes she liked her baby doll and other times she did not. CNA O reported the staff just needed to redirect R7 a lot. During an interview on 05/14/25 at 02:21 PM, Activity Director Z reported she did not notice R7 holding onto a walker in front of R15. Activity Director Z reported the lounge was a common area and said she did not believe that R15 would have a problem with R7. During an interview on 05/14/25 at 04:53 PM, Administrative Nurse D reported that she and Administrative Nurse E were responsible to update and review the care plans. Administrative Nurse D reported she was shocked that R7 did not have dementia addressed on her care plan. The facility did not provide a policy for dementia care.

The facility reported a census of 37 residents, with 12 residents sampled, with five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to act upon the pharmacist's monthly medication review (MRR) for Resident (R) 32. The deficient practice had the potential to lead to the residents receiving unnecessary medications. Findings included: - Review of the Electronic Health Record (EHR) for R32 included diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), end-stage renal disease (ESRD-a terminal disease of the kidneys) and anxiety. The 07/24/24 Significant Change Minimum Data Set (MDS) documented R32 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R32 required maximal assist from staff for bathing, standing, and wheelchair mobility activities of daily living (ADL). The MDS recorded R32 required moderate assistance with toileting, transfer, and lower body dressing. The MDS recorded no behaviors and R32 required dialysis (a procedure where impurities or wastes are removed from the blood). R32 received no psychotropic medications. The 08/02/24 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R32 triggered for functional abilities due to increased self-care deficit, and cognitive skills for daily decision-making abilities. The 08/02/24 Psychosocial Well-Being CAA documented R32 triggered for psychosocial well-being due to little interest in activities. R32 indicated that occasional loss of interest in activities due to decreased energy, therefore placing him at risk of decreased social involvement and self-isolation. The 03/25/25 Quarterly MDS documented a BIMS score of 15, and he had no depression or behaviors. The MDS recorded R32 received an antidepressant (a class of medications used to treat mood disorders) and an antianxiety (a class of medications that calm and relax people). R32'S Care Plan dated 04/15/25 documented R32 used anti-anxiety medications related to anxiety disorder, staff instructed to provide education to R32 about risks, benefits, and the side effects and/or toxic symptoms of medication. Staff instructed to administer anti-anxiety medications ordered by physician. Monitor and document side effects and effectiveness. Staff instructed to monitor/record occurrence of target behavior symptoms (Specify: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. R32's Care Plan dated 05/13/25 lacked any non-pharmacological interventions. R32's Physician Orders documented an order for hemoglobin A1c (HbA1c-blood test used to evaluate the level of glucose control over the past 90 days) laboratory draw one time every six months for diabetes, date ordered 07/14/24. R32's Physician Orders documented an order for citalopram hydrobromide tablet (antidepressant) 20 milligrams (mg), give one tablet by mouth, one time a day for depression date ordered 03/07/25. R32's Physician Orders documented an order for buspirone (antianxiety) HCl Oral tablet 5mg, give two tablets by mouth, two times a day for anxiety, date ordered 04/03/25. R32's Medication Regimen Review (MRR) dated 07/26/24 documented there were irregularities noted, see report. Review of EHR lacked the actual report and response from physician or nurse. R32's Medication Regimen Review dated 09/26/24 documented there were irregularities noted, see report. Review of EHR lacked the actual report and response from physician or nurse. R32's Medication Regimen Review dated 01/08/25, documented the pharmacist requested a HbA1c lab draw next lab day and every six months. R32's Laboratory Results in EHR documented a HbA1c 7.5 dated on 07/26/24 that was obtained at dialysis facility. No other HbA1c was noted in EHR. During an interview on 05/15/25 at 07:43 AM, Administrative Nurse D reported that R32 refused his lab to be drawn at the facility as R32 reported his labs would be drawn at dialysis. Administrative Nurse D reported that unfortunately, dialysis did not draw the HbA1c and the last one obtained was 07/26/24. During an interview on 05/15/25 at 09:05 AM Administrative Nurse D reported that she could not locate the missing MRR for R32. She reported she was not employed at that time and she epcted the MRR to be followed up in a timely manner. The facility's Medication Regimen Reviews dated 02/2025 documented the consultant pharmacist shall review medication regimen per state and federal guidelines. The irregularity reports on a separate written form would include the resident's name, relevant drug, and the irregularity that had been identified. Provide the physician with access to report to review irregularity and document reviewed, if any action had been required, and or rationale for no change based on the reported irregularity.

The facility reported a census of 37 residents. The sample included 12 residents with one reviewed for dental services. Based on interview and record review, the facility failed to provide dental services or facilitate access to dental services for Resident (R) 31 who had widespread dental decay. This placed the resident at risk for further deterioration of dentition (of or having to do with teeth) and related complications. Findings included: - R31's Electronic Health Record (EHR) revealed diagnoses of major depressive disorder (major mood disorder that causes persistent feelings of sadness) and cerebrovascular accident (CVA-stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The 11/01/24 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. R31 was dependent on staff for toileting activities of daily living (ADL). The MDS recorded R31 required maximal assistance with showering, lower body dressing, and transfers. The MDS recorded R31 required set up assistance for oral care. The MDS recorded R31 had adequate vision and wore eyeglasses. The MDS recorded R31 had no issues with her teeth. The 11/22/24 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) documented R31 required staff assistance to complete ADLs. The Dental Care CAA was not triggered. The 03/26/25 Quarterly MDS documented a BIMS of 15. The MDS recorded no changes in ADLs from the previous MDS. The MDS recorded R31 had no issues with her mouth; she had adequate vision and required no device. R31's Care Plan dated 11/30/23 documented R31 had oral and dental health problems related to poor nutrition and a history of drug use. The plan directed staff to coordinate arrangements for dental care including transportation as needed and as ordered. The plan directed staff to provide R31 mouth care assistance. R31's Physician's Orders documented an order may be seen by specialists as needed including a dentist of choice care as needed, dated ordered 11/17/2023. R31's Admission assessment dated [DATE] documented R31 did not have her own teeth and no other documentation was checked on the assessment. R31's EHR lacked evidence the facility had offered or facilitated dental services for R31 and lacked evidence R31 had declined dental services. During an interview/observation on 05/12/25 at 09:01 AM, R31 reported that no staff had asked her about being assessed by a dentist since she admitted on [DATE]. R31 reported she had a lot of bits and pieces of teeth in her mouth. Observation revealed R31 had several broken teeth on both upper and lower. R31 reported she was able to eat well. During an interview on 05/13/25 at 03:21 PM, Licensed Nurse (LN) G reported when a resident requested to see an eye doctor or a dentist, and it is not an emergency, the nurse wrote a progress note in the EHR or informed Social Services Designee (SSD) X verbally. During an interview on 05/13/25 at 03:23 PM, Certified Nurse Aide (CNA) KK, a transportation aid, reported she had not taken R31 to any appointments for dental or vision cares. During an interview on 05/13/25 at 03:27 PM, SSD X reported when a resident requested to have a dental or eye appointment the facility would receive a consent form sent from the outside provider that comes into the facility to complete appointments. SSD X said residents had to sign a consent or declination, and all residents had standing orders. SSD X reported that R31 had declined services. Though SSD X verified they could not locate a declined consent, or a progress note in R31's EHR. During an interview on 05/14/25 04:53 PM, Administrative Nurse D reported she expected all residents should have a dental exam once admitted as a baseline. The facility's policy 'Routine Dental Care dated 10/2024 documented each resident would receive routine dental care, an initial evaluation of the resident's dental needs and preventative care and treatment.

The facility reported a census of 39 residents with five residents sampled and one resident reviewed for served food in a form that met the resident's individual needs. Based on observation, interview, and record review, the facility failed to ensure staff provided cognitively impaired Resident (R) 2 with her prescribed mechanical soft diet (a modified diet that consists of soft, easy-to-chew foods that require minimal chewing) with ground meat texture, and instead served cut-up chicken to the resident, on her plate. R2 began to cough and choked on her food. The staff had to suction R2 when R2 could not clear her airway with coughing. The facility transferred R2 to the hospital later that evening. The hospital admitted R2 for fever, pneumonia, and dehydration. This deficient practice placed all residents at risk in immediate jeopardy. Findings Included: - Review of the Electronic Health Record (EHR) documented R2 had diagnoses of dysphagia (swallowing difficulty), and dementia (progressive mental disorder characterized by failing memory, confusion). The 12/08/24 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of 99, which indicated severely impaired cognition. R2 required supervision assistance with activities of daily living (ADL) of eating. R2 required a mechanically altered diet (modifying food textures by chopping, grinding, or pureeing foods to make them easier to chew and swallow, especially for individuals with difficulty swallowing or chewing). The 12/27/24 Nutrition Status Care Area Assessment (CAA) documented R2's weight was stable with a nutritional status identified as at risk for decline. The CAA noted it was important to ensure R2 received adequate nutrition. The resident's plan of care included to ensure adequate nutrition plan is in place. The 12/27/24 Cognitive Loss/Dementia CAA documented R2 had a diagnosis of dementia and dysphagia, R2 could verbalize her needs though was hard to understand R2 at times and required extra time for communications or alternate forms of communications. The 09/19/24 Quarterly MDS documented the resident had a BIMS score of five, which indicated severely impaired cognition. R2 required supervision for eating and a mechanically altered diet. The resident's Care Plan documented R2 was at risk for altered nutritional status. and included the following interventions: 02/22/17 - Staff were instructed to provide set-up assist for eating. 02/21/17 - Staff were instructed to monitor diet texture intolerance or chewing difficulty. 01/24/23 - Staff were instructed to serve diet as ordered and monitor intake and record. 06/04/23 - Staff were instructed to monitor R2 at meals and snack times, as R2 had experienced coughing/choking episode 12/2022. R2 and durable power of attorney (DPOA- legal document that named a person to make healthcare decisions when the resident was no longer able to) educated on risks vs benefits of mechanical soft texture diet, thin liquids. R2's diet was modified per R2's request from a puree texture diet to a mechanical soft texture diet. 06/04/23 - Staff were instructed to serve diet as ordered, mechanical soft, ground meats, and thin liquids. Review of the Physician Orders documented on 02/09/23 the resident required a regular diet, with mechanical soft, ground meat texture ordered, related to dysphagia. The 02/24/25 at 01:50 PM Progress Note revealed Administrative Nurse B was alerted that R2 had a possible choking episode in the dining room. Staff observed R2 in her wheelchair coughing, with blue coloring noted to her lips. R2 was encouraged to cough harder and was able to cough up a moderate amount of mushy substance. Administrative Nurse C suctioned R2, which resulted in a moderate amount of thick clear mucus. After suctioning, R2's lips and skin were pink. The resident's physician ordered a chest Xray. The 02/24/25 at 07:08 PM Progress Note revealed R2 had made loud grimacing sounds, was inconsolable, skin color ashen (pale gray color), and staff noted foam on the corners of her mouth. The resident's oxygen saturation (percentage of oxygen in the blood) measured 77 percent on room air and R2's use of accessory muscles (when more effort is required to breathe) were noted. The resident's pulse was 142 and temperature was 97.8 Fahrenheit. Staff assisted R2 to her wheelchair, applied oxygen at four liters via nasal cannula. Lung sounds of crackles and rhonchi (coarse, low-pitched, rattling sounds heard in the lungs during breathing) were noted to the resident's upper lobes, and staff were unable to assess the lower lobes. During this time chest Xray results were received with new pulmonary opacities (areas of increased density) in the lung bases, which was concerning for bronchopneumonia (a type of pneumonia, a condition that causes inflammation of the lungs). Staff were unable to increase the resident's oxygen saturation reading above 83 percent on oxygen tank. At 07:16 PM the resident's physician was notified and gave an order to send R2 to the hospital. The 02/25/25 at 01:01 AM Progress Note revealed R2 admitted to the hospital for pneumonia, fever, and dehydration. The 02/27/25 Hospital Discharge note revealed R2 had a diagnosis of aspiration pneumonia. During an interview on 03/10/25 at 01:59 PM Certified Nurse Aide (CNA) F reported staff had to be present in the dining room for all meals, if a resident was on an altered mechanical diet. CNA F reported those residents could not eat in their rooms unless someone was present with them. Dietary staff were not to serve diets unless nursing staff were present in the dining room. CNA F reported that R2 received chopped meat for her meals many times prior to her choking episode in February 2025. During an interview on 03/10/25 at 02:10 PM, Dietary Staff F, reported he was here the day R2 choked on her cut up chicken and reported R2 had no problems days prior to or at breakfast the day of her choking when she ate. R2 received her meat cut up and reported he was told to serve it that way, as that was how R2 wanted her food. Dietary Staff F reported after the resident choked R2's food was served at a mechanical soft consistency, and she pointed at the food processor the cook used to prepare the food. Dietary Staff F reported he received education after R2 choked. Dietary Staff showed the new laminated cards that were created for all the residents. R2's laminated card revealed mechanical soft diet and choking hazard. Dietary Staff F reported the only new item on R2's card was the choking hazard. During an interview on 03/10/25 at 02:22 PM, Dietary Staff I (Cook), reported she was here the day R2 choked on her cut up chicken. Dietary Staff I reported she prepared R2's plate of food, covered it up, placed it in the steam table, and went on lunch break. Dietary Staff I reported she was trained to just cut up R2's food and reported doing that since she was hired in May 2024. Dietary Staff I reported she was suspended until she had education on how to prepare food that was ordered for the residents. Dietary Staff I reported there was new laminated cards created after R2 had the choking episode. She reported the old, laminated card did not state R2 was a choking hazard like the new card stated. Dietary Staff I reported the facility had a total of four residents on mechanical soft diets. Dietary Staff I reported that R6 received her meats just cut up also until R2 had the choking episode. Dietary Staff I reported the other two residents received the correct mechanical soft diet. During an interview on 03/10/25 at 02:32 PM, CNA G reported before dietary staff served the resident in the dining room, nursing staff should be in the dining room to assist the residents. CNA G reported staff should let the dietary staff know if there was a concern with the food and consistency the residents received for their meal. CNA G was not sure how long R2 received cut up food instead of the ground soft food. CNA G stated R2 had not complained since she started receiving ground food after she had a choking episode but noted she would voice it, if she did not like it. During an interview on 03/10/25 at 02:43 PM R6 who had a BIMS 15 reported that her meat was not always ground up she use to receive her meat cut up until recently. During an interview on 03/10/25 at 02:45 PM Dietary Staff F reported R6's meat was cut up before R2 choked and noted now she required a mechanical soft ground meat consistency. During an interview on 03/10/25 at 03:27 PM Licensed Nurse (LN) D reported R2 had a near choking episode on 02/24/25 and reported that Administrative Nurse C and Administrative Nurse B witnessed the choking episode. She reported Administrative Nurse C suctioned R2 to get the food out of her throat. LN D reported R2 required a mechanical soft diet. LN D stated R2 and her DPOA signed a risk versus benefit agreement for no pureed foods a long time ago, but agreement was not for a mechanical soft diet. LN D reported there was not a nurse in the dining room when R2 choked. She reported someone from management, and the medication aide should be in the dining room for meals. LN D reported R2 was left in the dining room by herself and then served her meal the day she had the choking episode. LN D reported she worked the day R2 had a near choking episode and assessed R2 later that day. During an interview on 03/10/25 at 04:06 PM, Activity Director J reported she believed R2 received the correct consistency the day she had the choking episode. Activity Director J reported she did get alarmed as R2 was coughing so Activity Director J stopped Administrative Nurse B and Administrative Nurse C to assess R2 in the dining room. During an interview on 03/11/25 at 08:12 AM, Administrative Nurse C reported that she was called into the dining room by Activity Director J when she was walking by with Administrative Nurse B. Activity Director J requested assistance for R2 who was coughing. Administrative Nurse C reported R2 had a very wet cough and was not able to clear her airway enough. Administrative Nurse C reported she hit R2's back to assist her and she stopped coughing and made a gurgle sound. Administrative Nurse C reported she placed a glove on her hand and assessed R2's mouth and was able to remove a little piece of chicken and saliva. Administrative Nurse C reported Administrative Nurse B retrieved the crash cart and Administrative Nurse C noticed R2 had her dentures in her mouth and removed the dentures then suctioned R2 with a yankauer suction catheter (a medical device used to remove fluid and debris from the mouth or airway) orally for about thirty seconds. Administrative Nurse C reported she suctioned phlegm and R2 had stopped coughing and a chest Xray was ordered. Administrative Nurse C reported she had not realized what type of diet consistency R2 ordered prior to the choking episode and reported R2 received cut up chicken for her meal that day and not a mechanical soft diet. During an interview on 03/11/25 at 03:58 PM with Consultant Staff K (Registered Dietician) reported the mechanical soft diet order was more for the meat consistency, and she did have a concern R2 received cut up chicken instead of the ground chicken the day R2 choked on her food that was served by the facility staff. The facility's policy Therapeutic Diets dated 10/2024 documented mechanically altered diets mean one in which the texture of diet is altered. When the texture is modified, the type of texture modification must be specific and part of the physician's order. The facility's policy Tray Identification dated 10/2024 documented to assist in setting up and serving the correct food trays/diets to residents. The food service manager or supervisor would check trays for correct diets before the food is transported to designated area. Nursing staff should check each food tray for correct diet before serving resident. If there is an error, the nurse supervisor would notify the dietary staff immediately so the appropriate food could be served. On 03/11/25 at 05:40 PM, Administrative Staff A and Administrative Nurse C were provided the Immediate Jeopardy (IJ) template and notified the facility failed to ensure staff provided cognitively impaired Resident (R) 2 with her prescribed mechanical soft diet with ground meat texture, and instead served cut-up chicken to the resident, on her plate. R2 began to cough and choked on her food. The staff had to suction R2 when R2 could not clear her airway with coughing. The facility transferred R2 to the hospital later that evening. The hospital admitted R2 for fever, pneumonia, and dehydration. This deficient practice placed all residents at risk in immediate jeopardy. The facility identified and implemented the following corrective actions, completed on 03/02/25 after R2's choking episode. 1. Suspended the employee who prepared the food. 2. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting held by interdisciplinary team on 02/26/25. 3. Re-educated staff mitigation for choking to include reeducation on following care plans and food prep per diet classification. 4. Audit of all the residents diet classifications orders and care plans. 5. Audit of tray cards for correct diet classifications. 6. Correction of care plans and tray cards if discrepancies found. 7. Audit diets prepared correctly with two cooks, two times a week for 30 days. 8. Audit of altered diets two times a week for 30 days. 9. Administrator oversight of audits and dietary choking compliance. Due to the corrective actions the facility completed prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J (isolated, immediate jeopardy) scope and severity.

The facility reported a census of 34 residents, with 12 residents included in the sample and one resident sampled for cardiopulmonary resuscitation (CPR, emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.). The facility identified 26 residents with full code status, indicating the resident wishes for life saving measures to be utilized in emergent situations, to include CPR. Based on interview and record review, the facility staff failed to initiate CPR on a full-code Resident (R)86 on [DATE] at approximately 01:25 PM, when Licensed Nurse (LN) C and Certified Nurse Aide (CNA) D found the resident without respirations and pulseless. The staff thought the resident was a Do Not Resuscitate (DNR) due to the nursing report sheet did not list FULL beside R86's name to indicate the resident's full code status. Due to the lack of an effective code system in place to identify full code and DNR residents, staff failed to follow R86's wishes to be resuscitated. Findings included: - R86's Electronic Health Record (EHR) revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R86 admitted to the facility on [DATE] and the Admission Minimum Data Set (MDS) and the Care Area Assessment (CAA) remained in progress. The [DATE] Care Plan indicated R86 requested CPR measures be performed, including to initiate CPR when appropriate and continue until paramedics arrive to take over. A [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Nursing Note dated [DATE] at 03:26 PM by LN C documented when she received report at 06:00 AM, the night shift nurse stated R86 had been up a lot through the night and had some behaviors. The night shift nurse reported she gave R86 some as needed (PRN) [MEDICATION(S)] (pain medication) right before the end of her shift and R86 rested in her bed. LN C went in to check on R86 about 09:30 AM and found R86 still sleeping, but did move around some when she was touched and staff talked to her. The staff obtained R86's temperature, pulse, and respirations which were all within normal limits. R86 was warm to the touch and did not appear to be in any distress. LN C stated Certified Medication Aide (CMA) I reported that R86 did not wake when he tried to administer R86's medications for the noon mediation pass. LN C went into R86's room around 12:45 PM to check on R86 again because she was still sleeping and had not eaten lunch. R86's vital signs continued to be in normal range with a temperature of 98.6 Fahrenheit (F), respirations of 18 breaths per minute, oxygen level of 97 percent, and a pulse between 70 and 80 beats per minute (baseline vital signs obtained upon admission on [DATE] were a temperature of 98.4 F, respirations of 18 breaths per minute, oxygen level of 97 percent, and a pulse of 98 beats per minute). R86 was warm, but did not respond to touch and voice. LN C left R86's room to attend another resident. At around 01:25 PM CNA D told LN C she thought something was wrong with R86. LN C checked on R86 and found her to be pulseless, without respirations, clammy (skin cool and moist), and very pale in color. LN C notified hospice and the Director of Nursing (DON). An observation on [DATE] at 08:46 AM revealed each resident had a dot next to their name on a nameplate located outside of their room. The red dot indicated the resident was a full code or a blue dot which indicated the resident was a DNR. An interview on [DATE] at 10:50 AM CNA D stated sometime after 01:00 PM on [DATE] she noticed R86 was still sleeping and she tried to wake R86, but she did not respond. CNA D stated R86 was still warm, and her skin was pale in color. CNA D stated she notified the charge nurse immediately and the nurse responded, but did not attempt CPR. CNA D stated she was not CPR certified. CNA D stated she did not know how to identify if a resident was a full code or DNR except by looking at a resident's chart. CNA D stated the colored dots next to the resident's name have been there ever since she has worked at the facility, but she did not know what the colored dots indicated. An interview on [DATE] at 11:00 AM CNA E stated she received education on code status during orientation. CNA E stated the resident nameplates had colored dots either red (full code) or blue (DNR). CNA E stated the colored dots had been in use as long as she had worked at the facility. An interview on [DATE] at 09:40 AM CNA F stated her CPR recently expired and was currently working on renewing it. CNA F stated this was her sixth shift working at this facility and she did not know which staff in the facility at this time had CPR certification. An interview on [DATE] at 9:40 AM CMA I reported he was CPR certified and he knew three of the CNAs that worked the same shift were also CPR certified. An interview on [DATE] at 10:40 AM LN G stated the nursing shift report usually had the resident's code status. LN G stated the residents had either a red or blue dot next to their names by the resident door to their room. LN G stated if she found a pulseless resident who was a full code she would call for help, ask someone to call 911, start CPR, and would continue with CPR until the Emergency Medical Service (EMS) arrived. An interview on [DATE] at 09:35 AM LN H stated she was CPR certified, but did not know who else working with her was CPR certified. LN H further stated the facility failed to provide her with this information. LN H stated she knew of the colored-dot code status system. An interview on [DATE] at 12:00 PM Administrative Nurse B stated she expected staff to check the code status and start CPR if they were a full code. Administrative Nurse B stated the resident code status was on resident charts, in the care plan, and they used the dot system on the resident's nameplate next to resident's door. Administrative Nurse B stated newly hired staff were given education on code status during orientation, and CPR education was completed on a yearly basis using computer training. Administrative Nurse B stated reeducation on CPR was started on [DATE] and was still in process until all facility staff were educated. Administrative Nurse B stated agency staff would be educated when they arrived to work at the facility. The ,d+[DATE] Cardiopulmonary Resuscitation (CPR) and Basic Life Support (BLS) policy revealed, The community staff, certified in CPR, will provide basic life support, including CPR, to a resident requiring such an emergency prior to the arrival of emergency medical personnel and subject to related physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility failed to have an effective code status system to ensure nursing staff correctly identified the code status of R86 when staff failed to initiate CPR when R86 was not breathing and was pulseless. The facility failure placed R86 in immediate jeopardy. On [DATE] at 05:17 PM, the Administrator was provided with the IJ template and notified that the facility failed to implement CPR on a non-responsive, full-code resident (R86) found by direct care staff and licensed nurse staff without respirations and was pulseless on [DATE] at approximately 01:25 PM. Due to the lack of orientation for agency staff on the facility code system to identify full code and DNR residents, staff failed to perform CPR on a resident who desired resuscitation (R86). The facility identified and implemented corrective measures to remove the immediate jeopardy on [DATE], which the surveyors verified onsite on [DATE], when the facility implemented the following actions: 1. Audit all residents to ensure they have a signed code status order, and care plan. 2. Educated nurses on where to look and identify code status. 3. Educate that as nurses in facilities we cannot decide not to do CPR- this must be physician only. 4. Education on if there is no code status, residents are to be considered full code until otherwise identified. 5. Validate that all code status were put into the computer properly. The deficient practice remained at a G (isolated with actual harm) scope and severity following the removal of the immediate jeopardy.

The facility reported a census of 46 residents, with one resident sampled for cardiopulmonary resuscitation (CPR- emergency medical procedure for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.). Based on interview and record review the facility failed to ensure Licensed Nurse (LN) A and/or Certified Nurse Aide (CNA) B, who were CPR certified, started CPR prior to contacting and turning over care to emergency medical services for Resident (R)1 when he lacked the presence of vital signs (no pulse or respirations) and had a full code status (signed documentation which indicated the status of a resident with respect to his desire for resuscitative efforts, unless the resident specifically requested not to be resuscitated) in his medical record and the resident expired. This deficient practice placed R1 in immediate jeopardy. Findings included: - Review of R1's Physician Order Sheet (POS) dated [DATE] revealed the resident had the following Diagnoses: [REDACTED]. congested with fluid). Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severely impaired cognition. Review of the resident's Care Plan related to code status revealed the following interventions: [DATE] - The resident had a full code status. [DATE] - Facility staff would respect the resident's wishes regarding his right to have CPR. [DATE] - The facility would communicate his choice of code status to all appropriate staff members. [DATE] - The resident's wishes were for staff to initiate CPR if they found him pulseless or breathless. Staff would continue CPR on the resident until paramedics arrived at the facility to take over. Review of the Nursing Note dated [DATE] at 02:05 AM revealed at approximately 01:30 AM CNA B reported to LN A, R1 stopped breathing and did not respond to the CN[NAME] LN A was with another resident who had an emergency, but rushed to R1's room. LN A checked the resident and noticed he had stopped breathing, had no pulse, and no circulation at the time of the assessment. LN A reported the resident did not move with painful stimulus. LN A called emergency management, who arrived within minutes and confirmed the resident was no longer breathing. The resident's mouth and nose were full of frothy saliva, which ran down his cheek. The reporter notified the resident's family and the facility's director of nursing. The resident remained in his bed. The note lacked any indication the writer assessed the resident to have clinical signs of irreversible death. Review of the resident's record for [DATE] lacked any evidence facility staff initiated CPR when they found the resident not breathing, without pulse and/or circulation. Further review of the resident's record lacked any evidence the resident had a do not resuscitate (DNR) order. Review of the Emergency Management System's (EMS) Prehospital Care Report Summary dated [DATE] at approximately 01:34 AM revealed a paramedic in the facility (attending to another resident) entered R1's room and found a certified nurse aide (CNA B) present with the resident. The nurse aide reported the resident passed and he had a DNR order, so no lifesaving interventions were performed on the resident. The paramedic reported he/she triaged the resident based on the facility staff's report the resident had a DNR order in place, no pulse and/or no heart tones. The paramedic returned to the other resident's room to assist with the other emergency. When a second team of emergency management staff arrived at the facility to assist with R1, they were told the resident had a DNR and facility staff were searching for paperwork. Facility staff then reported to emergency management staff they thought the resident had a DNR, but when they copied the resident's information, they realized the resident required CPR. Just prior to the second team of emergency management staff arrival to the resident's room, the fire department moved the resident to the floor, but did not start lifesaving interventions. The report identified the resident has being down, without lifesaving interventions for at least 15 minutes. Emergency management staff placed the resident back into his bed and released the resident back to facility nursing staff. An interview with CNA B on [DATE] at 09:21 AM interview revealed R1 awake at approximately 11:00 PM, with no concerns. CNA B went into the R1's room around 01:00 AM and found the resident with some foam around his mouth, not breathing, and cold to touch. CNA B stated he called for the nurse and ran to notify LN A of the resident's condition. CNA B found LN A on the phone with EMS discussing an emergency with another resident. CNA B stated LN A ran to check on the resident and then ran back to call EMS again for more help. CNA B stated LN A told him to stay with the resident while he got more help to get R1 on to the floor to do CPR. CNA B stated the first EMS team arrived at the facility approximately two to three minutes from the time LN A left R1's room. LN A reported to EMS that he had two critical residents. The paramedics split up and one went to R1's room, assessed him, and stated he was code black (deceased ) with no further interventions placed for R1 at that time. CNA B stated he did not tell the paramedic R1 had a DNR status, because he knew the resident was a full code. CNA B stated when the second EMS team arrived to R1's room they placed him on the floor and assessed him. The second EMS team also identified the resident as code black. The EMS team assisted CNA B to place R1 back into his bed and CNA B provided the resident with cares. An interview with LN A on [DATE] at 04:21 AM revealed on [DATE] R2 had an emergency so he called [DATE] and copied documents to send with her to the hospital for treatment. LN A stated he was on the phone with the [DATE] dispatcher when CNA B reported R1 was not breathing and he thought the resident was deceased . LN A told the dispatcher he needed to go so he could assess another resident with a medical emergency. LN A took the facility oxygen/crash cart to R1's room to assess him and administer aide. LN A entered the resident's room and observed R1 in bed, on his back, cool to the touch with a frothy white sputum in his nose. LN A stated he applied oxygen to the resident and attempted to obtain a pulse, blood pressure, respirations and painful stimuli. LN A instructed CNA B to stay with the resident while he ran to the desk to place a call to EMS again. LN A stated while he was on the phone with EMS dispatch for the second time the first EMS team arrived at the door to the facility. An unidentified staff member let EMS staff into the facility. LN A stated he continued to answer dispatch's questions regarding R1's condition while he tried to advise the EMS team in the building of the situation with R1 and another resident with a medical emergency. The EMS team divided up and one went to R1's room, while the other went to the other resident with a medical emergency's room. LN A reported he finished answering dispatch's questions as the paramedic came up to the desk and reported R1 was code black (deceased ). LN A reported he went to the other resident's room to assist with her since the paramedic reported R1 as a code black. LN A reported the facility provided training regarding resident code statuses located on resident face sheets and based on the color of dot on a resident's door. LN A stated he thought R1 had been deceased for a while when he performed his assessment. LN A revealed if he thought he did anything wrong it was not telling CNA B to start CPR on R1. LNA stated he was focused on saving the other resident and did not feel R1 could be saved so he did not advise CNA B to start CPR. Interview with Administrative Nurse C on [DATE] at 10:08 AM revealed LN A contacted her at approximately 01:55 AM. Administrative Nurse C reported she had just left the facility when LN A called her to report he had two critical residents. Administrative Nurse C stated she headed back to the building. LN A reported he was on the phone with EMS when CNA B reported R1 was not breathing. LN A told Administrative Nurse C he ran to ran to assess R1 and found him not breathing and cold to the touch. The resident's family arrived at the facility at approximately 02:09 AM and were upset they were not contacted by the facility sooner. The resident's family called EMS dispatch from the facility to inquire as to why they did not start CPR while in the facility. Administrative Nurse C stated she audited the resident's code status and the facility system to identify resident code status and found no discrepancy. Review of the facility policy Cardiopulmonary Resuscitation (CPR) revised (MONTH) (YEAR) revealed if an individual (resident, visitor, or staff) was found unresponsive and not breathing normally, a licensed staff person certified in CPR would initiate CPR unless it was known that a DNR order, which specifically prohibited CPR and/or external defibrillation existed for that individual. The facility failed to ensure Licensed Nurse (LN) A and/or Certified Nurse Aide (CNA) B, who were CPR certified started CPR prior to contacting and turning over care to emergency medical services for Resident (R)1 when he lacked the presence of vital signs (no pulse or respirations) and had a full code status (signed documentation which indicated the status of a resident with respect to his desire for resuscitative efforts, unless the resident specifically requested not to be resuscitated) in his medical record and the resident died . This placed R1 in immediate jeopardy. The deficient practice was cited as past non-compliance when facility implemented corrective action on [DATE] as follows: 1. All staff were in-serviced on mock codes, reporting change in resident condition to the nurse, nurse assessment and a CPR refresher. Any staff who were not present were not allowed to return to work until the completion of in-servicing. 2. The facility in-serviced the Social Service Designee, Medical Records and Director of Nursing regarding the used of a transportable physician order for [REDACTED]. 3. All resident code statuses were audited, which included a dot (red if the resident had a DNR order and a blue if the resident required CPR) placed on the resident's door and the resident's medical record.

The facility census totaled 47 residents with 2 sampled for medication administration errors. Based on interview and record review the facility failed to ensure 1 of 2 residents (#1) remained free from a significant medication error when staff gave the resident the wrong medication and he/she required hospitalization to reverse the effects of the medications he/she received. Findings included: - The physician's orders [REDACTED].#1 revealed the following [DIAGNOSES REDACTED]. hypertension (elevated blood pressure), pain, anxiety disorder (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear) and [MEDICAL CONDITION] disorder (is a chronic mental health condition characterized primarily by symptoms of [MEDICAL CONDITION], such as hallucinations or delusions, and symptoms of a mood disorder, such [MEDICAL CONDITION] depression). Review of the POS [REDACTED] [MEDICATION NAME] delayed release (medication to treat [MEDICAL CONDITION] and mood stabilizer), 750 milligrams (mg), twice a day starting 3/2/17 for unspecified [MEDICAL CONDITION]. [MEDICATION NAME] (medication to treat tremors caused by use of other medications), 5 mg, twice a day starting 11/11/16 for [MEDICAL CONDITION] disorder. [MEDICATION NAME] (medication to lower blood pressure), 20 mg, twice a day starting 11/11/16 for hypertension. [MEDICATION NAME] (medication to treat depression), 20 mg, daily starting 12/6/16 for major [MEDICAL CONDITION]. [MEDICATION NAME] (medication to treat [MEDICAL CONDITION]), 3 mg, four times a day starting 12/6/16 for [MEDICAL CONDITION]. Review of the July 2017 Medication Administration Record [REDACTED]. Review of the nursing notes revealed the following: On 7/15/17 at 10:01 a.m.; direct care staff A (with additional training to administer medications) notified licensed nurse B that he/she gave the resident the wrong medications. Nurse B discovered the resident was given [MEDICATION NAME] (a narcotic pain medication for severe pain) 8 mg. The resident was not prescribed narcotics at this time. Nurse B assessed the resident as sweaty with a blood pressure (BP) of 93/62 (normal 120/80), pulse of 99 (normal 60-100 beats per minute), respirations of 10 (12-20 breaths per minute) and oxygen saturation of 88% (normal 95-100 with readings below 90 considered low) and the nurse applied oxygen at 2 liters per minute by nasal cannula. Nurse B notified Physician C about the medication error and physician C directed to monitor the resident for a decrease in blood pressure and respiration and if he/she continued to drop then send the resident to the emergency room , since the facility did not have access to [MEDICATION NAME] (a medication used to reverse overdose of narcotic medications). On 7/15/17 at 10:24 a.m.; the resident's blood pressure continued to drop to 82/44, pulse 66, and respirations of 6 with oxygen saturation at 95% on 2 liters of oxygen by nasal cannula. Nurse B called for emergency medical services (EMS) who arrived around 9:50a.m. Upon arrival the resident's BP dropped to 50/32, pulse of 60, respirations of 4. EMS administered [MEDICATION NAME] before transferring resident to the hospital by ambulance around 10:30 a.m. Review of the discharge documents from the hospital dated 7/17/17 revealed the resident was seen on 7/15/17 for accidental overdose on [MEDICATION NAME] 8 mg which was prescribed for another patient and given to him/her by mistake. Initially, he/she was hypotensive (low blood pressure) and hypoxic (a condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level), patient improved significantly following administration of [MEDICATION NAME] in the emergency department and was moved to the intensive care unit and started on a [MEDICATION NAME] drip. He/she was later weaned off the [MEDICATION NAME] drip after his/her BP was maintained and his/her mental orientation returned to baseline. He/she was able to maintain oxygen saturation without supplemental oxygen in less than 12 hours. Nursing notes dated 7/16/17 at 12:53 p.m. indicated the resident returned to the facility on [DATE] around 12:00 p.m. by facility transportation. He/she was alert, oriented and ambulated independently. Review of the facility's investigation revealed on 7/15/17 direct care staff A (with additional training to administer medications) administered the resident the following medications which were prescribed for another resident #2: [MEDICATION NAME] (a medication to remove excess fluids from the body) 20 mg [MEDICATION NAME] (to lower blood pressure) 40 mg [MEDICATION NAME] (to treat infection) 100 mg [MEDICATION NAME] (narcotic pain medication) 8 mg Potassium chloride (to treat low potassium) 10 milliequivalent [MEDICATION NAME] (to lower blood pressure) 6.25 mg [MEDICATION NAME] (to treat nerve pain or [MEDICAL CONDITION]) 400 mg [MEDICATION NAME] (to treat acid reflux) 20 mg The written statement by direct care staff A revealed he/she began the usual medication pass on 7/15/17 at 6:45 a.m. and later (no time given) resident #2 approached direct care staff A, upset that he/she had not received his/her medications yet. He/she discovered a medication error had occurred and resident #1 took a concerning turn for the worse, so he/she notified nurse B of the error approximately 30-45 minutes post ingestion. Direct care staff A indicated he/she lacked enough training to know the facility had 2 residents with the same first name on the same unit. He/she indicated 7/15/17 was his/her 2nd day passing medications on that unit. The written statement by licensed nurse B included notification around 9:30 a.m. by resident #2 he/she had not had his/her morning medications. The nurse explained to the resident he/she would get the medications soon and direct care staff A was new. When the nurse checked with direct care staff A he/she learned of the medication error. The statement included the events as the same as the above nursing note. The facility identified the 3 halls were divided into 2 separate units for medication administrations with a different staff member assigned to pass medications on each of the 2 units. Review of the facility schedule revealed direct care staff A marked as orientation to medication administration on 7/3/17, 7/5/17 and 7/6/17 but did not indicate which unit the orientation was assigned. The schedule had no other days for orientation recorded. The schedule listed direct care staff A assigned to pass medications on the day shift for 7/15/17 but did not specify which unit. Interview on 8/7/17 at 1:57 p.m. with licensed nurse B revealed direct care staff A passed medications on the east unit and he/she was not in orientation on 7/15/17. Nurse B said he/she had not worked with staff A prior to 7/15/17 on the east hall as nurse B had worked the other unit. He/she indicated staff A appeared comfortable with the medication pass and did not ask any questions. Nurse B reported the same information as in the written statement and nursing note. Interview on 8/7/17 at 12:40 p.m. with administrative nurse D revealed prior to the medication error on 7/15/17, the facility did not conduct a competency for staff trained to administer medications and/or licensed nursing staff. He/she said new hires received standard orientation to the facility and at least 3 days on the medication cart before staff passed medications independently. Since the medication error, the facility had all current staff licensed or certified to pass medications take a competency test and all new hires will take the test before passing medications. The facility's policy for administration procedures for all medications dated 11/2014 directed staff to review the 5 rights (3) times which included for staff to identify the resident using (2) identification methods before administering medications (photo plus verbal confirmation of last name, photo and confirmation by family member and such). The facility's policy for nursing services-building competency evaluations dated 5/2017 directed the competency process would assess the knowledge and skills of the nursing staff in the specific skill being assessed. The new employee orientation and verification of skills would be completed upon hire for all nursing services personal with follow up evaluation and competency obtained with a post-test and/or skills check list for medication management and pharmacy services. Skill competency would be evaluated at time of hire, annually and with identified need. The facility failed to ensure resident #1 remained free from a significant medication error when staff gave the resident the wrong medication and he/she required hospitalization to reverse the effects of the medications he/she received.

The facility census totaled 49 residents. Three residents were reviewed for elopement. Based on observation, interview, and record review the facility failed to monitor resident #1's Wander Guard bracelet (alarm to alert staff at attempts to leave the building unsupervised) for placement and functionality, and the facility failed to ensure the facility's wander guard system functioned properly which allowed resident #1 to elope from the facility without the staff's knowledge and placed resident #1 and 10 other residents identified as an elopement risk at risk for immediate jeopardy for harm related to elopement. Findings included: - Review of the physician's progress note dated 6/15/17 revealed the following Diagnosis: [REDACTED]. Review of resident #1's admission minimum data set (MDS)dated 3/23/17 revealed a brief interview for mental status (BIMS) score of 12 (moderately impaired cognitive function), and the resident transferred and walked independently. Review of the cognitive care area assessment (CAA) dated 3/29/17 revealed the resident refused care. medication, and required an extended admission to the State psychiatric hospital. Review of the activities of daily living (ADL) CAA dated 3/29/17 revealed the resident ambulated independently without an assistive device. Review of the 6/19/17 quarterly MDS revealed a BIMS score of 10 (moderately impaired decision making). The resident was independent with transfers and ambulation. Review of the care plan last revised on 7/7/17 revealed the resident was at risk for elopement. The care plan directed the staff to apply a wander guard (alarm to alert staff at attempts to leave the building unsupervised) to the resident's left wrist and check for proper functioning and the placement of the wander guard every shift. Place his/her picture in elopement book at the front desk, provide the resident with supervision while outside, redirect the resident when the wander guard system sounded and the resident attempted to leave the building unattended, and directed the staff to ensure the resident's safety at all times. Review of the resident's elopement risk assessment dated [DATE] revealed a score of 23 (high risk for elopement). Review of resident #1's nursing note dated 5/28/17 at 11:30 p.m. revealed the resident attempted to leave the building unaccompanied by staff. The resident's wander guard bracelet activated the wander guard alarm system and alerted the staff to his/her attempted elopement. The staff intervened and redirected the resident away from the exit doors. Review of resident #1's nursing note dated 7/6/17 at 6:16 p.m. revealed the resident opened and exited the facility via an emergency exit door on the east side of the building. The progress note revealed the resident had his/her wander guard bracelet in place and the alarm failed to activate when resident #1 exited the building unattended. However, the alarm activated as the resident re-entered the facility accompanied by staff. Interview on 7/13/17 at 4:45 p.m. with environmental service staff F revealed the resident eloped from the east emergency exit door, exited a chain link fenced area outside of the east exit door and staff found the resident approximately 150 feet from the facility. Staff F confirmed the distance between the area the resident stood on the sidewalk measured 5 feet 10 inches from a heavily traveled residential street. Staff F confirmed the speed limit on the street as 40 miles per hour and he/she confirmed the traffic at the time of the elopement was generally heavy. Staff F confirmed the wander guard system failed to alarm at the time the resident exited the building and when tested upon the resident's return to the building, the wander guard system beeped four times then reset itself. Staff F revealed he/she contacted the technical support company for the wander guard system and the technical support personnel had not scheduled a time to conduct an onsite visit to check the wander guard system at the time of the interview. Staff F revealed he/she provided daily checks of the wander guard door alarms systems to ensure the alarms functioned. Review of resident #1's July treatment administration record (TAR) through 7/7/17, lacked evidence the facility completed daily monitoring of the wander guard bracelet for placement and functioning. The resident eloped from the facility on 7/6/17. Review of an email dated 7/11/17 timed 6:22 p.m. revealed the facility contacted the wander guard door company regarding the wander guard door check inconsistencies. The technical support company revealed the way the unit is operating now is the correct way (press door button and the unit alarms), however, I've not heard of a wander guard unit beeping four times and resetting itself. Further review of the email revealed We can set up a tech to come onsite and test your system. There are seven doors in total, but your facility had only expressed concern with testing 5 of them, particularly the east hall door. Interview on 7/12/17 at 3:15 p.m. with direct care staff D revealed he/she observed a resident standing outside the fence that surrounded the east emergency exit. He/she revealed the wander guard alarm had not sounded at the time of the resident's elopement from the facility. Staff D revealed the direct care staff were responsible for checking the wander guard bracelet's placement functioning daily. Interview on 7/12/17 at 4:12 p.m. with Licensed nursing staff E revealed the facility identified resident #1 at high risk for elopement and placed a wander guard bracelet on him/her to alert staff of the resident's attempt to elope from the facility. He/she revealed the licensed nursing staff were responsible for checking each resident identified as an elopement risk for placement and functioning of the wander guard bracelet. Staff E revealed he/she worked the day resident #1 eloped from the facility. Staff E revealed he/she observed the resident standing in the parking lot unattended by staff and confirmed the wander guard alarm did not sound when the resident exited the east emergency exit door. He/she revealed the staff checked the wander guard system on the east emergency exit door for functioning after the resident returned to the facility and the wander guard alarm did not sound when tested it only beeped four times and reset itself. Interview on 7/12/17 at 4:30 p.m. with administrative staff A revealed the facility tested the wander guard system on each exit door daily and the staff checked each resident daily to ensure the wander guard bracelet was in place and functioning correctly. Staff A confirmed resident #1 eloped from the facility on 7/6/17 at 4:55 p.m. Staff A provided documentation of the daily exit door alarm checks. Interview on 7/13/17 at 8:12 a.m. with administrative nurse B confirmed resident #1 had increased risk for elopement and wore a wander guard bracelet to alert staff of his/her attempts to leave the facility unsupervised. Staff B revealed the wander guard alarms on the exit doors were checked 7 days a week. Administrative staff B revealed the direct care staff and licensed nurses were responsible for checking the placement of the wander guard bracelet and the bracelets functioning daily and findings were recorded on the TARs. He/she confirmed the facility failed to initiate the daily checks on the TARS for resident #1 prior to his/her elopement on 7/6/17. Review of the wander guard instructional manual revealed the company recommended testing the door monitors at least weekly on each shift to ensure functioning and recommended the testing of the wander guard bracelet before using it for a resident and daily thereafter. The instructional manual revealed failure to test the wander guard and the bracelets per the recommendations could result in injury or death to a person in the facility's care. Review of the Missing Resident policy last revised 2/14/14 revealed the facility intended to ensure the health, safety, and welfare of residents at all times. In the event a resident went missing; the facility would initiate interventions to minimize any harm to the resident. The facility failed to initiate and complete monitoring for resident #1's wander guard bracelet for placement and functionality and the facility failed to ensure the facility's wander guard system functioned correctly which permitted resident #1 to elope from the facility which placed resident #1 and 10 other residents identified as elopement risk at risk for immediate jeopardy for harm from elopement. The deficient practice was abated on 7/10/17 at 2:00 p.m. by educating all charge nurses and certified staff and all additional staff on the completion of elopement risk assessments, elopement guidelines, daily monitoring and testing of the wander guard bracelets and documentation in the resident's record, daily testing of the wander guard system, and monthly wander guard drills. The deficient practice remained at the scope and severity of an E.

The facility census totaled 49 residents. Three residents were reviewed for elopement. Based on observation, interview, and record review the facility failed to monitor resident #1's Wander Guard bracelet (alarm to alert staff at attempts to leave the building unsupervised) for placement and functionality, and the facility failed to ensure the facility's wander guard system functioned properly which allowed resident #1 to elope from the facility without the staff's knowledge and placed resident #1 and 10 other residents identified as an elopement risk at risk for immediate jeopardy for harm related to elopement. Findings included: - Review of the physician's progress note dated 6/15/17 revealed the following Diagnosis: [REDACTED]. Review of resident #1's admission minimum data set (MDS)dated 3/23/17 revealed a brief interview for mental status (BIMS) score of 12 (moderately impaired cognitive function), and the resident transferred and walked independently. Review of the cognitive care area assessment (CAA) dated 3/29/17 revealed the resident refused care. medication, and required an extended admission to the State psychiatric hospital. Review of the activities of daily living (ADL) CAA dated 3/29/17 revealed the resident ambulated independently without an assistive device. Review of the 6/19/17 quarterly MDS revealed a BIMS score of 10 (moderately impaired decision making). The resident was independent with transfers and ambulation. Review of the care plan last revised on 7/7/17 revealed the resident was at risk for elopement. The care plan directed the staff to apply a wander guard (alarm to alert staff at attempts to leave the building unsupervised) to the resident's left wrist and check for proper functioning and the placement of the wander guard every shift. Place his/her picture in elopement book at the front desk, provide the resident with supervision while outside, redirect the resident when the wander guard system sounded and the resident attempted to leave the building unattended, and directed the staff to ensure the resident's safety at all times. Review of the resident's elopement risk assessment dated [DATE] revealed a score of 23 (high risk for elopement). Review of resident #1's nursing note dated 5/28/17 at 11:30 p.m. revealed the resident attempted to leave the building unaccompanied by staff. The resident's wander guard bracelet activated the wander guard alarm system and alerted the staff to his/her attempted elopement. The staff intervened and redirected the resident away from the exit doors. Review of resident #1's nursing note dated 7/6/17 at 6:16 p.m. revealed the resident opened and exited the facility via an emergency exit door on the east side of the building. The progress note revealed the resident had his/her wander guard bracelet in place and the alarm failed to activate when resident #1 exited the building unattended. However, the alarm activated as the resident re-entered the facility accompanied by staff. Interview on 7/13/17 at 4:45 p.m. with environmental service staff F revealed the resident eloped from the east emergency exit door, exited a chain link fenced area outside of the east exit door and staff found the resident approximately 150 feet from the facility. Staff F confirmed the distance between the area the resident stood on the sidewalk measured 5 feet 10 inches from a heavily traveled residential street. Staff F confirmed the speed limit on the street as 40 miles per hour and he/she confirmed the traffic at the time of the elopement was generally heavy. Staff F confirmed the wander guard system failed to alarm at the time the resident exited the building and when tested upon the resident's return to the building, the wander guard system beeped four times then reset itself. Staff F revealed he/she contacted the technical support company for the wander guard system and the technical support personnel had not scheduled a time to conduct an onsite visit to check the wander guard system at the time of the interview. Staff F revealed he/she provided daily checks of the wander guard door alarms systems to ensure the alarms functioned. Review of resident #1's July treatment administration record (TAR) through 7/7/17, lacked evidence the facility completed daily monitoring of the wander guard bracelet for placement and functioning. The resident eloped from the facility on 7/6/17. Review of an email dated 7/11/17 timed 6:22 p.m. revealed the facility contacted the wander guard door company regarding the wander guard door check inconsistencies. The technical support company revealed the way the unit is operating now is the correct way (press door button and the unit alarms), however, I've not heard of a wander guard unit beeping four times and resetting itself. Further review of the email revealed We can set up a tech to come onsite and test your system. There are seven doors in total, but your facility had only expressed concern with testing 5 of them, particularly the east hall door. Interview on 7/12/17 at 3:15 p.m. with direct care staff D revealed he/she observed a resident standing outside the fence that surrounded the east emergency exit. He/she revealed the wander guard alarm had not sounded at the time of the resident's elopement from the facility. Staff D revealed the direct care staff were responsible for checking the wander guard bracelet's placement functioning daily. Interview on 7/12/17 at 4:12 p.m. with Licensed nursing staff E revealed the facility identified resident #1 at high risk for elopement and placed a wander guard bracelet on him/her to alert staff of the resident's attempt to elope from the facility. He/she revealed the licensed nursing staff were responsible for checking each resident identified as an elopement risk for placement and functioning of the wander guard bracelet. Staff E revealed he/she worked the day resident #1 eloped from the facility. Staff E revealed he/she observed the resident standing in the parking lot unattended by staff and confirmed the wander guard alarm did not sound when the resident exited the east emergency exit door. He/she revealed the staff checked the wander guard system on the east emergency exit door for functioning after the resident returned to the facility and the wander guard alarm did not sound when tested it only beeped four times and reset itself. Interview on 7/12/17 at 4:30 p.m. with administrative staff A revealed the facility tested the wander guard system on each exit door daily and the staff checked each resident daily to ensure the wander guard bracelet was in place and functioning correctly. Staff A confirmed resident #1 eloped from the facility on 7/6/17 at 4:55 p.m. Staff A provided documentation of the daily exit door alarm checks. Interview on 7/13/17 at 8:12 a.m. with administrative nurse B confirmed resident #1 had increased risk for elopement and wore a wander guard bracelet to alert staff of his/her attempts to leave the facility unsupervised. Staff B revealed the wander guard alarms on the exit doors were checked 7 days a week. Administrative staff B revealed the direct care staff and licensed nurses were responsible for checking the placement of the wander guard bracelet and the bracelets functioning daily and findings were recorded on the TARs. He/she confirmed the facility failed to initiate the daily checks on the TARS for resident #1 prior to his/her elopement on 7/6/17. Review of the wander guard instructional manual revealed the company recommended testing the door monitors at least weekly on each shift to ensure functioning and recommended the testing of the wander guard bracelet before using it for a resident and daily thereafter. The instructional manual revealed failure to test the wander guard and the bracelets per the recommendations could result in injury or death to a person in the facility's care. Review of the Missing Resident policy last revised 2/14/14 revealed the facility intended to ensure the health, safety, and welfare of residents at all times. In the event a resident went missing; the facility would initiate interventions to minimize any harm to the resident. The facility failed to initiate and complete monitoring for resident #1's wander guard bracelet for placement and functionality and the facility failed to ensure the facility's wander guard system functioned correctly which permitted resident #1 to elope from the facility which placed resident #1 and 10 other residents identified as elopement risk at risk for immediate jeopardy for harm from elopement. The deficient practice was abated on 7/10/17 at 2:00 p.m. by educating all charge nurses and certified staff and all additional staff on the completion of elopement risk assessments, elopement guidelines, daily monitoring and testing of the wander guard bracelets and documentation in the resident's record, daily testing of the wander guard system, and monthly wander guard drills. The deficient practice remained at the scope and severity of an E.

The facility census totaled 48 residents with 22 sampled. Based on observation, interview, and record review the facility failed to consistently assess and monitor the resident's skin to identify pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and failed to develop and implement interventions to prevent further pressure ulcers and promote healing for 1 of 1 residents reviewed for pressure ulcers. (#34) The resident developed two stage 3 (full thickness of skin loss involving damage to tissue that may extend down to the underlying tissue presenting as a deep crater) on each outer ankle and 1 unstageable (obscured full-thickness skin and tissue loss) ulcer on the resident's left heel. Findings included: - Review of resident #34's signed physician order [REDACTED]. dominant side, pain, diabetes type 2 (when the body cannot use glucose, there is not enough insulin made or the body cannot respond to the insulin). Review of the annual MDS (minimum data set) dated 12/15/15 revealed a BIMS (brief interview for mental status) score of 15, indicating the resident had no cognitive impairment. The resident required extensive assistance of 2 staff with bed mobility, transfers, and toileting. The resident required supervision and assistance with eating, with limitations in ROM (range of motion) of his/her upper and lower extremities on one side. The resident had a toileting program and had frequent urinary incontinence and bowel incontinence all of the time. The resident had a pressure ulcer and had a risk for further pressure ulcer development. The resident had one stage 2 (partial-thickness skin loss with exposed dermis, second layer of skin) pressure ulcer present on admission/reentry on 11/13/15. The description of the ulcer revealed [MEDICATION NAME] (healing) tissue in wound bed. The resident had pressure reducing devices for his/her chair and bed, and did not have a turning/repositioning program or a nutritional program to manage skin problems. The resident received restorative services, for bed mobility training, 3 days out of the 7 day observation period. Review of the pain CAA (care area assessment) dated 12/21/15 revealed the resident stated he/she had frequent pain to both feet at night. The resident described his/her pain as aching to his/her feet at night that disrupted his/her sleep. The resident had decreased mobility, but not complete immobility. The resident stated Tylenol (a pain medication) relieved the pain and he/she also received [MEDICATION NAME] (a medication) for nerve pain. Review of the nutritional CAA dated 12/21/15 revealed the resident's weight above his/her ideal body weight. The resident usually ate 100% of meals and often asked for second and third servings if available. The resident required extensive assist of two staff for completion of transfers, toileting, and bed mobility. The resident could feed him/herself after staff set up assistance. Review of the pressure ulcer CAA dated 12/21/15 revealed the resident had an existing stage 2 pressure ulcer to his/her left heel that measured 1.5 cm (centimeters) X 2.0 cm. The resident had an air mattress on his/her bed to relieve pressure. The resident also had left [MEDICAL CONDITION] and required extensive assist of one to two staff for ADL (activities of daily living) completion. Review of the quarterly MDS dated [DATE] revealed a BIMS score of 15, indicating no cognitive impairment. The resident did not have any changes in ADLs, ROM, urinary incontinence, pain, or pressure reducing devices or turning/repositioning program. The resident had no pressure ulcers but had a risk for the development of pressure ulcers. Review of the care plan initiated on 4/17/15 and last reviewed on 6/30/16 revealed the following interventions specifically related to pressure ulcers: 4/17/15 - Braden scale (assessment to determine pressure ulcer risk) to be completed by licensed nursing staff quarterly and PRN (as needed). 4/17/15 - Toilet the resident before and after meals and check and change during the night on rounds. 4/17/15 - Monitor AFO (ankle/foot brace) for proper fit. 4/17/15 - Provide a pressure relieving mattress on the bed and cushion on the wheelchair. 4/17/15 - Staff to monitor and report to the charge nurse signs and symptoms such as reddened areas, bruising, skin tears, abrasions, or other skin abnormalities. 4/17/15 - Licensed nurse to provide weekly and PRN skin assessments. The care plan lacked interventions related to repositioning and to wear heel protector boots when in bed as ordered by the physician on 6/13/16 and lacked new interventions after the development of the pressure ulcers. Review of the weekly skin assessments revealed the following: 1/27/16 to 2/27/16 - revealed the left heel wound healed. 2/27/16 - revealed right ankle with treatment in place for protection. The assessment did not identify what kind of treatment. 3/2/16 - identified no skin concerns related to resident's heels or ankles 3/5/16 - right outer ankle with no drainage or redness - left heel with no drainage or redness 3/12/16 - no mention of ankles or heels 3/16/16 - left heel ulcer healed with dressing in place for protection. Right outer ankle with no descriptions of concerns related to right ankle. 3/19/16 and 4/9/16 - left heel and right outer ankle with treatment in place but no description of the treatment or the skin. 4/23/16 -left heel with redness protective pad in place. The medical record lacked evidence licensed nursing staff completed skin assessments for the resident in the month of May. 6/18/16 - open areas to both ankles. A treatment was in place and the pressure ulcer was resolving. 6/22/16 - open areas noted to both ankles, continue with treatment as ordered. 6/28/16 - open areas observed to both ankles continue with treatment as ordered. 7/6/16 - open areas observed to both ankles continue with treatment as ordered resolving. The skin assessments lacked measurements, wound description and progression for staff to be able to monitor effectiveness of current treatment plan and healing progression. Review of the weekly electronic wound assessment dated [DATE] revealed the resident had a right outer ankle suspected deep tissue injury identified on 5/27/16 measuring 2.0 cm (centimeters) x 1.2 cm x 0.2 cm. Staff identified the wound on 5/23/16 and thought the resident received it from bumping his/her wheelchair. Staff applied duoderm (a type of dressing) and off-loaded the wound. The nurse practitioner assessed the resident and ordered a Doppler study (test to evaluate blood flow) related to pain and the ankle wound. Review of the week 2 electronic wound assessment dated [DATE] revealed the right outer ankle wound measured 1.1 cm x 1.7 cm x 0.2 cm deep with thin watery drainage. The wound bed had 100% reddish granulation tissue (new, healing tissue). The resident had prevalon boots (a type of foam protective boot) on when in bed, pillows used with positioning for increased comfort and support. Review of the Doppler report dated 6/7/16 revealed the resident had no arterial occlusion (meaning the resident had good blood flow). Review of the wound assessment and treatment flowsheet dated 6/13/16 completed by the nurse practitioner revealed the resident had two stage 3 pressure ulcers on each of his/her outer ankles: 1. left lateral malleolus (outside ankle) - Pressure ulcer stage 3 measuring 0.8 cm x 1 cm x 0.4 cm with thin fiber necrotic (pertaining to the death of tissue in response to disease or injury) tissues with a small amount of tan exudate (drainage). Skin around the wound had discoloration with [MEDICAL CONDITION]. 2. Right lateral malleolus with a stage 3 pressure ulcer measuring 1.4 cm x 2 cm x 0.3 cm. The description of the wound and surrounding tissue was the same as the left malleolus ulcer. Review of the physician's orders [REDACTED]. Review of the pressure ulcer weekly audit paper form dated 7/7/16 revealed the resident had bilateral lower extremity wounds resolving. The resident complained of pain to the areas and rated it an 8/10 (0 = no pain and 10 = worst pain ever). The resident received scheduled and PRN pain medications. The right open wound measured 0.6 cm x 1.25 cm (no depth measurement obtained) and the left ankle measured 0.5 cm x 0.5 cm (no depth measurement obtained). The resident had an open left heel ulcer that measured 1.5 cm x 1.8 cm with eschar (dead tissue) in part of the wound bed. Review of the resident's medical record from 5/15/16 to development of the pressure ulcer on 5/23/16 revealed the resident had not discharged from the facility for any length of time. The facility had no assessment to identify where the pressure ulcers developed or when the left heel ulcer and left ankle ulcer developed. The record lacked any evidence staff identified the ulcer on left outer ankle until 6/13/16 when the nurse practitioner assessed the wounds. The record also lacked consistent measuring and monitoring of the wound to ensure identification and healing of the wounds. Observation on 7/7/16 at 6:40 AM revealed the resident sat in his/her wheelchair in the main dining room in a reclining wheelchair with an AFO (ankle/foot splint) on his/her left foot and a regular shoe on his/her right foot with bilateral ace wraps. Observation on 7/7/16 at 7:02 AM revealed the resident propelled him/herself over to the coffee pot and got another cup of coffee and went back to his/her table. The resident continued to have the AFO on his/her left foot. Observation on 7/7/16 at 9:51 AM direct care staff H and direct care staff W assisted the resident to transfer from the wheelchair to the bed. The resident reached up for the transfer pole and staff used a gait belt to assist the resident to stand. The resident pivoted on his/her right leg and staff assisted the resident to get all the way into the bed. Observation revealed staff failed to apply the physician ordered foam prevalon boots. Observation on 7/7/16 at 1:23 PM revealed administrative staff I and licensed nursing staff J changed the dressings on the resident's ankles and left heel. Observation of the resident's right ankle revealed a measurement of 1.2 cm x 1 cm. Staff J failed to measure the depth of the wound. The wound bed had red granulation tissue with the surrounding skin color reddish. The nurse cleaned the wound and applied treatment as ordered then covered with folded gauze, then large dressing for protection with a hole cut to offset the ankle and then secured the dressing with kling (a type of dressing wrap) wrap. Staff J then removed the foam dressing from the resident's left heel and outer ankle. Staff J stated the left heel wound was new and unstageable. When staff J removed the foam dressing from the left heel observation revealed a small amount of bloody drainage on the foam. Staff proceeded to clean the wounds. The left outer ankle wound bed had red granulation tissue with no drainage noted. Observation of the left heel revealed an open type blister with a wet wound bed and eschar surrounding 100% of the visible wound bed area. Staff J proceeded to cover the left ankle and heel as he/she did the right ankle. Staff J completed the dressing changes, but failed to apply the physician ordered prevalon boots on the resident when he/she finished the treatment. Observation on 7/11/16 at 9:22 AM revealed the resident lay in bed on his/her back with his/her feet resting on the surface of the mattress without any type of boots on to protect his/her heels and ankles. Observation on 7/11/16 at 2:57 PM revealed the resident propelled him/herself backwards in the wheelchair and had a walking shoe on his/her left foot and as he/she went backwards his/her left foot drug on the floor, partially on outer side. The resident then turned around and propelled him/herself forward down to the end of the hall. Observation on 7/11/16 at 3:27 PM revealed a pair of blue foam prevalon heel protectors on the resident's bed, and the resident sat in his/her wheelchair outside. Observation on 7/12/16 at 5:55 PM revealed the resident in bed on his/her right side. Observation revealed the resident's prevalon boots were on the floor beside the head of the bed. Observation on 7/13/16 at 6:10 AM revealed the resident lay in bed on his/her back. The resident's legs were not elevated and his/her feet turned outward with his/her outer ankles resting on the mattress. The prevalon boots were on the floor by the bed. During an interview on 7/11/16 at 3:28 PM the resident stated he/she had been up in the wheelchair since lunch because he/she wanted to go out and smoke at 1:00 PM. The resident stated staff had not repositioned him/her in the chair since he/she got up for lunch. The resident also stated he/she had foam boots he/she wore at night. During an interview on 7/11/16 at 2:09 PM administrative nursing staff A reported he/she could not find any other evidence of staff assessing/monitoring the resident's pressure ulcers. During an interview on 7/11/16 at 2:11 PM direct care staff K reported the aides needed to report any skin changes to the charge nurses and he/she tried to keep the resident off his/her back when in bed. The resident needed to wear boots when he/she lay in bed, however, he/she did not have to wear the boots 3 months ago prior to the development of the pressure ulcers. During an interview on 7/11/16 at 2:46 PM direct care staff L reported the resident could not to be in the wheelchair for long periods of time. Staff L also reported he/she rolled the resident in bed for repositioning. Staff stated the resident wore a brace on his/her left ankle otherwise the nurse took care of the resident's pressure ulcers. During an interview on 7/11/16 at 4:39 PM licensed nursing staff M reported the nurses changed the dressings according to the schedule and as needed. Staff M stated the resident had a brace he/she wore on his/her left ankle, and staff needed to elevate his/her legs when in bed but the resident did not always comply with that. Staff M stated the resident also had heel protectors on he/she needed to wear whenever he/she lay in bed. During an interview on 7/12/16 at 10:24 AM administrative nursing staff A reported he/she expected the nurses to monitor and document the resident's wounds on a weekly wound assessment record and document completion of the treatment on the treatment record. Staff A stated the resident should be turned when in bed and should not be up in the wheelchair too long. Staff should also prop the resident's feet up and float his/her heels to keep pressure relieved. During an interview 7/12/16 at 3:25 PM physician Y reported if the resident had an order for [REDACTED]. The facility failed to ensure resident #34 wore his/her prevalon heel protectors when in bed as ordered by the physician. The resident developed two stage 3 pressure ulcers on his/her outer ankles and one unstageable pressure ulcer on his/her left heel while in the facility and the facility failed to ensure staff consistently assessed the wound measurements, wound description, and progression of the wound in order to develop and monitor effective interventions to promote healing and prevent further development of pressure ulcers.

The facility had a census of 50 residents. Thirty seven of the fifty residents formulated an advanced directive which indicated they chose resuscitation in the event of cardiac/respiratory arrest (cessation of a heartbeat and respirations). Based on observation, interview and record review, the facility failed to have systems in place to ensure availability of qualified staff to perform CPR (cardiopulmonary resuscitation) 24 hours per day/7 days per week, failed to have a system in place to correctly identify each resident's resuscitation preferences, and failed to have systems in place to ensure staff knew each resident's preferences for resuscitation vs. no resuscitation. Facility failure to have systems in place to correctly identify CPR status, failure to educate staff about how to determine each resident's CPR status, and failure to have CPR certified staff on duty 24 hours per day, 7 days per week placed all 50 facility residents in immediate jeopardy. Findings included: - Resident #1's clinical record included a [DATE] Annual MDS (Minimum Data Set) that identified the resident with no cognitive impairment, the need for supervision only for transfers and ambulation and no prognosis of life expectancy of less than 6 months. CAAs (Care Area Assessments) completed on [DATE] for ADLs (activities of daily living) noted resident #1 had no cognitive impairment. The [DATE] Care Plan noted the resident's respiratory issues and directed staff to provide inhalers as ordered by the physician and use supplemental oxygen at 4 L (liters) per nasal cannula to maintain oxygen saturation levels (the measure of how much oxygen the blood carried as a percentage of the maximum it could carry) above 90%. The care plan also described the resident's preference for a Full Code (CPR/cardiopulmonary resuscitation) and directed staff to perform CPR as needed. On [DATE], resident #1 signed an advanced directive document which included his/her preference for CPR. Nursing schedules for the night of [DATE] from 10:00 p.m. to 6:00 a.m. indicated the facility had 3 staff on duty, which included Licensed Nurse E, Direct Care Staff D and Direct Care Staff F. Progress Notes dated [DATE] at 2:45 a.m. described how a direct care staff member heard resident #1's audible, abnormal breathing and called for Licensed Nurse E. Nurse E assessed the resident, assisted him/her to the bathroom, and then left the resident on the toilet while he/she left the room to get a medicated inhaler to help improve the resident's breathing. Within a few moments after he/she left the room, Licensed Nurse E heard resident #1's roommate yelling and immediately returned to the room and found resident #1 on the bathroom floor. According to the documentation, resident #1 was non-responsive but still breathing when found. Licensed Nurse E sent Direct Care Staff F to call 911 while he/she and Direct Care Staff D started CPR and used the emergency defibrillator (a device used to stimulate a heart beat by application of an electric current to the chest wall or heart). According to the progress note, EMS (Emergency Medical Services) staff arrived at 2:50 a.m., and assumed responsibility for the resuscitation effort. EMS personnel pronounced the resident deceased at 3:25 a.m. During an interview on [DATE] at 3:45 p.m. Administrative Nurse B denied awareness of the CPR certification status for 2 of the 3 staff members who worked the night shift on [DATE] ( Direct Care Staff D and Direct Care Staff F). Nurse B reported Licensed Nurse E, the only nurse on duty the night of [DATE] and the nurse who initiated CPR on resident #1, lacked current CPR certification. According to Nurse B, Nurse E's CPR certification expired 3 years earlier. On [DATE] at 4:20 p.m., Administrative Nurse B reported Direct Care Staff D, the other staff member who provided CPR to resident #1 on [DATE], also lacked current CPR certification. Nurse B continued to lack knowledge of Direct Care Staff F's CPR certification status. According to Administrative Nurse B, the facility did not require staff, including licensed nurses, to obtain/maintain CPR certification. During an interview on [DATE] at 9:35 a.m. Licensed Nurse K reported no one asked him/her about CPR certification at the time of hire and no one mentioned a need for it since hire. According to Nurse K, he/she had current CPR certification. Nurse K lacked knowledge of which other staff members held current CPR certification. During an interview on [DATE] at 2:07 p.m., Licensed Nurse E confirmed he/she worked the night shift on [DATE], the night resident #1 expired. Nurse E confirmed he/she initiated CPR on the resident, used the defibrillator, and did chest compressions until EMS staff arrived. According to Nurse E, he/she lacked CPR certification on [DATE]. Licensed Nurse E also reported no one in management ever asked him/her about CPR certification during the more than two years he/she worked at the facility. On [DATE] at 4:30 p.m., survey staff requested a list of all current employees and their CPR certification status. According to Administrative Staff A, the facility lacked that information and reported it would take some time to get it. According to Staff A, the facility did not maintain CPR certification status in employee files. During an observation on [DATE] at 4:35 p.m., Administrative Staff B went from staff member to staff member to ask about proof of CPR certification. On [DATE] at 5:15 p.m., Administrative Staff A provided a list of the current facility nursing staff which included the names of those with documented, current CPR certification. According to that list, the facility had 46 employees, 11 of whom had current CPR certification. Of the 8 licensed nurses on the list, two held current CPR certification. All 8 licensed nurses worked at the facility for longer than 90 days. According to the facility's [DATE] CPR Policy, Licensed Nursing Staff and facility van drivers will be CPR certified. Licensed Nursing staff certification will be obtained within 90 days of hire Review of nursing schedules for the time period from [DATE] - [DATE], a total of 56 days/168 shifts, 32 of the 168 shifts lacked CPR certified staff on duty. The facility failed to have systems in place to ensure availability of qualified staff to provide CPR twenty four hours per day, 7 days per week, for the 37 facility residents who expressed a preference for CPR in the event of cardiac/respiratory arrest. This facility failure placed all 37 residents in immediate jeopardy. - On [DATE] at 4:00 p.m., a chart rack behind the nurses station held charts for all facility residents. The name labels on each chart were either red or blue. On [DATE] at 4:20 p.m., Administrative Nurse B described a system for staff to easily identify each resident's code status which consisted of looking at the spine of the resident's chart cover. If the chart had a red label, that meant the resident had a preference for no resuscitation and was a DNR (do not resuscitate). If the chart had a blue label, that meant the resident had a preference for CPR. During an interview on [DATE] at 4:47 p.m., Direct Care Staff G reported he/she had no idea how to tell a resident's code status. During an interview on [DATE] at 4:50 p.m., Direct Care Staff G reported They don't tell us anything about who is CPR and denied knowledge of a means to know a resident's code status. During an interview on [DATE] at 1:15 p.m., Direct Care Staff I reported some residents had green labels and some had red labels on their charts and that indicated the resident's code status. According to Staff I, he/she could not remember what each color meant but thought the red meant the resident was a DNR. The facility failed to have a system in place to ensure staff knew each resident's preferences as related to resuscitation status. This failure placed all facility residents in immediate jeopardy. - As requested, the facility provided a list which included the names of all 50 current residents and their code status. According to that list, non-sampled resident #7 was a full code which meant he she had a preference for CPR (cardiopulmonary resuscitation) in the event of cardiac/respiratory arrest (cessation of pulse and respirations). On [DATE] at 4:20 p.m., Administrative Nurse B described a system for staff to easily identify each resident's code status which consisted of looking at the spine of the resident's chart cover. If the chart had a red label, that meant the resident had a preference for no resuscitation and was a DNR (do not resuscitate). If the chart had a blue label, that meant the resident had a preference for CPR. During an observation on [DATE] at 9:50 a.m., non-sampled resident #7 had a red label on his/her chart which indicated the resident was a DNR even though the list provided by the facility indicated resident #7 was a full code. On [DATE] at 10:30 a.m., Medical Records Staff J provided a copy of an advanced directive signed by the resident on [DATE] which indicated resident #7 wanted CPR performed in the event of cardiac/respiratory arrest. During an interview on [DATE] at 1:20 p.m., Administrative Nurse B reported he/she lacked knowledge of why resident #7 had a red label on his/her chart when the resident clearly expressed a desire for resuscitation. The facility failed to have a system in place to correctly identify the advanced directive preferences of resident #7. The facility abated the Immediate Jeopardy on [DATE] at 10:00 p.m. by implementation of the following: *Evaluated CPR certification status for all nursing staff employees *Ensured each shift had a minimum of one CPR certified staff on duty 24 hours per day/7 days per week. *Provided CPR training for all licensed nurses who currently lacked CPR certification *Developed and implemented a system to ensure accuracy of the posting of each resident's preferences for CPR vs. no CPR. *Developed and implemented a system which allowed all staff to know a resident's code status. *Provided staff education on expected responses to residents with cardiac/respiratory arrest. *Trained all staff on new systems described previously. *Implemented a new system to ensure newly hired licensed staff and van drivers had valid CPR certification prior to starting work. *Developed direct care staff care sheets which included each resident's code status *Revised the actual nursing schedule to clearly identify which staff members had current CPR certification. *Developed and implemented a plan to conduct mock code drills to ensure staff responded appropriately to situations of cardiac/respiratory arrest. The deficient practice remained at a scope/severity of F after abatement.

The facility had a census of 51 residents with 17 residents in the sample. Based on observation, interview and record review the facility failed to ensure a resident who entered the facility continent received the appropriate treatment and services to remain continent for 1 of 1 residents reviewed. (#27) Findings included: - Review of the annual MDS (Minimum Data Set) dated 7/11/2014 revealed a BIMS (Brief Interview for Mental Status) score of 15, which indicated intact cognition. The resident was independent with toileting with set up assist from staff. The resident was always continent of urine and bowel. The resident had severe visual impairment. Review of the Vision CAA (Care Area Assessment) dated 7/25/2014 revealed the resident had severe visual impairment, which had the potential to effect his/her day to day activities. Review of the ADL (activities of daily living) CAA dated 7/25/2014 revealed the resident was able to perform most of his/her ADL's independently. A potential for increased assistance with ADL's was possible due to the resident's visual decline. Review of the quarterly MDS (Minimum Data Set) dated 12/18/2014 revealed a BIMS score of 15, which indicated intact cognition. The resident required one person supervised assist with toileting. The resident was always continent of urine and occasionally incontinent of bowel. The resident had severe visual impairment. Review of the resident's care plan dated 12/21/2014 revealed the resident required 24 hour care due to the inability to care for him/herself and was independent with toileting. The care plan directed staff to provide cues and/or assist the resident with toileting if needed Review of nursing progress notes dated 2/20/14, 3/20/14, 4/11/14, 5/22/14, 6/30/14, 7/11/14, 8/28/2014, 9/25/14, 10/30/14, 11/27/14, 12/18/14, 1/16/14 and 2/19/15 revealed the resident was continent of bowel and bladder. Review of a bladder assessment form dated 2/27/13 revealed the resident was continent of urine and was able to toilet him/herself independently. Follow up assessments dated 4/18/13, 7/17/13, 10/6/13, 4/12/14 and 6/22/14 revealed the resident remained continent of urine and was independent with toileting. Review of the resident care sheet dated 2/4/2015 revealed the resident was continent of bowel and bladder, independent with toileting and wore underwear. During an observation on 2/23/2015 at 10:09 a.m. the resident was lying in bed with eyes closed. The resident smelled of urine. During an observation on 2/25/2015 at 7:19 a.m. the resident was lying in his/her bed. The resident smelled of urine. The resident remained in his/her bed at 7:35 p.m., 7:50 a.m., 8:05 a.m., 8:20 a.m., 8:35 a.m., 8:50 a.m., and at 9:05 a.m. At 9:12 a.m. direct care staff C entered the resident's room and asked the resident if he/she wanted a shower. A small amount of dried bowel was noted in the resident's brief. During an interview on 2/24/2015 at 2:22 p.m. the resident reported he/she experienced occasional urinary incontinence, which he/she contributed to urgency (involuntary passage of urine occurring soon after a strong sense of urgency to void). The resident reported he/she notified staff when he/she experienced incontinence and staff brought him/her a clean brief. The resident stated he/she performed his/her own incontinence care. During an interview on 2/24/2015 at 4:23 p.m. direct care staff D revealed he/she determined the level of care a resident needed for toileting was based on whether or not the resident turned on his/her call light. Staff D reported the resident had some days when he/she was not capable of making it to the bathroom in time and experienced incontinence of bowel and urine. Staff D reported when the resident was incontinent he/she would then turn on the call light and request a pull up. He/she reported the resident cleaned him/herself or would ask for help if needed. Staff D stated the resident's visual impairment was not a factor related to incontinence and he/she believed the resident was capable of locating items needed for pericare. During an interview on 2/25/2015 at 9:43 a.m. direct care staff C reported staff checked on the resident twice a shift for incontinence and/or the resident would put on his/her call light for a new brief as needed. Staff C reported he/she had access to a mini care plan called the resident care sheet, which nursing staff provided to the CNA's (certified nursing assistants). Staff C reported the resident care sheet indicated whether a resident was continent or incontinent. Staff C confirmed the resident care sheet indicated the resident was continent of bowel and urine, was independent with toileting and wore his/her own underwear. During an interview on 2/25/2015 at 4:52 p.m. licensed nursing staff F reported he/she believed the resident was continent of urine, however the aides were encouraged to check on the resident frequently. Staff F reported he/she had no knowledge of whether resident wore his/her own underwear or briefs. Staff F reported the CNA's were provided a resident care sheet and revisions were made as needed by the nurse. During an interview on 2/26/2015 at 7:47 a.m. administrative nursing staff A reported the resident assessment coordinator was responsible for updating resident care sheets, however since the resident assessment coordinator resigned the responsibility was his/hers. Staff A reported he/she lacked knowledge the resident experienced incontinent episodes. Staff A reported the resident's entire care plan needed to be updated to reflect his/her current status of incontinence and the staff needed education on the resident's need for assist with his/her ADL's. During an interview on 2/26/2015 at 2:39 p.m. physician E reported he/she expected staff to notify him/her if a resident who was once continent experienced incontinence. Review of the facility's policy dated 1/19/2015 for Incontinence Management/Bladder Function Guideline revealed the purpose of the bladder management program was to restore or maintain as much normal bladder function as possible through evaluation and monitoring for compliance. General guidelines included; development of a scheduled toileting program specific to the resident with a revised toileting schedule as needed to ensure the resident's needs were met. The facility failed to assess and implement interventions to maintain or improve resident #27's continence status. Resident #27 was continent and experienced episodes of incontinence.

The facility had a census of 51 residents with 17 sampled residents. Based on observation, record review and interview, the facility failed to ensure 1 resident received appropriate treatment and services to prevent a decline in range of motion (#26) and failed to provide range of motion services for resident #59. This failure affected 2 of 2 residents sampled for range of motion services. Findings included: - Review of the signed physician's orders [REDACTED].#26 dated 2/20/15 revealed a [DIAGNOSES REDACTED]. Review of #26's Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview for mental status) score of 12 indicating moderate cognitive impairment. The resident required extensive assistance of 2 staff for ADLs (activities of daily living). The resident received occupational therapy 5 days weekly and started on 9/15/14. He/she had no splint or brace device. Review of resident #26's Annual MDS dated [DATE] revealed a BIMS score of 15 indicating no cognitive impairment. The resident required extensive assistance of 2 staff for ADLs. The resident received range of motion restorative services 6 days per week. He/she had no splint or brace device. Review of the ADL CAA (care area assessment) dated 12/19/14 revealed the resident had a [DIAGNOSES REDACTED]. The CAA revealed the resident was alert and oriented and able to inform staff of his/her needs. Review of resident #26's care plan revised on 1/30/14 revealed he/she required 2 staff assistance with ADLs due to his/her physical function deficit. Staff provided range of motion to both arms to maintain strength and range of motion. Staff monitored and reported any changes in physical functioning and/or range of motion ability. The care plan did not address how often or the number of repetitions regarding the range of motion services provided by staff. Review of the OT (occupational therapist) progress and discharge summary dated 10/20/14 revealed the resident's goals were met and he/she discharged from therapy services. The resident had the ability to feed him/herself finger foods and demonstrated increased muscle strength to the left arm. Staff required no further supervision while appropriately placing a palm protector and wrist/hand orthotic (a rigid splint device worn at night). The summary note revealed the resident made progress due to OT services with increased tolerance to wearing a hand orthotic at night and palm protector (a soft splint device that fits over the fingers to protect the skin on the palm of the hand from the finger nails by creating a space between the fingers and the palm) during the day. The resident required staff assistance to apply both the orthotic device and the palm protector. The therapy department educated staff on the use of the orthotic and a restorative program was developed. The current orders revealed restorative staff provided ROM (range of motion) services to the upper and lower extremities for 3 to 5 minutes twice daily. The therapy schedule from 2/1/15 to 2/25/15 lacked documentation that staff provided therapy services for 1 day shift and 10 evening shifts. The medical records lacked any documentation of services provided for December of 2014 or January of 2015. During an observation on 2/25/15 at 2:21 PM, restorative staff H stated the resident had two different splint devices currently in use to prevent contractures, a palm protector used during the day between meals and a rigid splint device during the night time hours. Staff H reported the direct care staff applied the palm protector and the nurse staff applied the splint at bedtime and removed it in the mornings. During observation, staff H verified staff failed to apply the palm protector after the noon meal. Staff H pulled the resident's fingers open to apply the palm protector and revealed several reddened fingernail impressions on the resident's palm. Staff H agreed if the palm protector had been in place the marks would not have been there. Staff H then attempted to pull the resident's fingers open and apply the rigid splint device. Resident #26 yelled out with pain at this time. Staff H continued to slowly pull the resident's fingers open and applied the rigid splint device. Staff H was unable to apply the splint device appropriately due to the residents fingers would not straighten out enough to rest on the splint area but remained curved and the finger tips pressed into the wool lining on the splint. Staff H reported the resident's finger contractures had declined as they used to open and straighten out. Staff H reported due to staffing changes he/she was recently put in charge of the restorative program. Staff H was unaware of the residents change in condition. During an interview on 2/24/15 at 2:36 PM direct care staff L did not know about restorative therapy for this resident. During an interview on 2/25/14 at 2:21 PM resident #26 reported staff do not apply the brace during the overnight hours and sometimes applied the palm protector during the day when he/she reminded them. The resident reported staff do not provide range of motion exercises on his/her upper and lower extremities daily and have not for a long time. During an interview on 2/25/15 at 10:34 AM licensed nurse J reported resident #26 did not receive restorative therapy any longer. During an interview on 2/25/15 at 2:21 restorative staff H reported the orthotic device was for prevention of contractures. Staff H reported the resident's fingers had become contracted from lack of consistent use of the orthotic device. During an interview on 2/25/15 at 4:34 PM administrative nurse staff A reported restorative therapy was provided to the residents by restorative staff. He/she reported the therapist provided specific orders for each resident when therapy ended for the restorative program to follow. Staff A was unaware the restorative staff did not use the splint at night and did not always use the palm protector during the day hours. Staff observed and interviewed the resident and verified the resident had a decline with an increase in contractures of the fingers on his/her left hand. During an interview and observation on 2/26/15 at 10:01 AM therapy staff K reported the resident had OT services and discharged on [DATE] due to meeting his/her goals. Staff K reported after therapy ended a quarterly assessment should have been done in January. Staff K was unable to provide documentation of an assessment for January and reported the assessment was scheduled for February. Staff K reported the resident was able to grasp finger foods and feed him/her self independently for snacks. Staff K placed a bag of crackers on the resident's bedside table and asked him/her to get a snack and eat it. The resident reached toward the snack crackers and then moved his/her first finger a slight amount but was unable to move the other three fingers. The resident made several attempts to move his/her fingers and grasp the crackers but was unable to do so and stated "I can't". Staff K reported this was an obvious decline. Staff K reported the decline would occur if the staff failed to use the overnight orthotic for this resident. Staff K was unaware of the decline in contracture status prior to the survey. During an interview on 2/26/15 at 2:47 PM according to the physician, he/she did not review restorative notes. Physician E reported he/she expected the therapy department to monitor the progress or decline of the resident's who received therapy. Physician E reported he/she did not expect notification if a resident declined but expected staff to request an order for [REDACTED]. The facility failed to provide treatment and services as ordered and failed to monitor and report decreased ROM ability for a resident on a restorative therapy program. This failure to provide therapeutic services resulted in a decline in the resident's ability to maintain the functional use of his/her left hand. - Review of resident #59's signed physician orders [REDACTED]. Review of the admission MDS (minimum data set) dated 11/7/14 revealed a BIMS (brief interview for mental status) score of 15 which indicated no cognitive impairment. The MDS revealed he/she required extensive assistance of two persons for bed mobility transfers, toileting, and dressing. The resident had range of motion (ROM) impairment on both sides of his/her lower extremities and used a wheelchair for mobility. Review of the ADL (activities of daily living) CAA (care area assessment) dated 11/7/14 revealed the resident needed extensive assistance with most ADLs related to being paraplegic. He/she was able to wheel him/herself around the facility and did things with his/her hands well. He/she used a slide board for transfers and worked with therapies to manage with his/her [MEDICAL CONDITION]. Review of the care plan, initiated 12/4/14, revealed an exercise program three times a day. Make sure nurse aides perform range of motion, document how long and document refusal. The resident's care plan directed staff to monitor and report changes in ROM (range of motion) ability. The physician's orders [REDACTED]. Make sure nurse aides complete range of motion, document how long and document refusal. Review of the restorative flow sheet for the month of February revealed it was blank. Interview with the resident on 02/25/2015 at 8:11 AM revealed he/she did not refuse ROM. The resident stated that he/she was not getting ROM but staff was charting that it was done. He/she felt that it was important to prevent his/her legs from developing contractures. Prior to this week, the resident had not been getting ROM on a daily basis. The resident said when he/she did not get the ROM it was harder for him/her to transfer him/herself from the bed to the wheelchair. Interview with direct care staff L on 02/24/2015 at 3:18 PM revealed the restorative aide or an aide on first shift were to do ROM. Also the aides on 2nd shift were to do ROM. The resident had refused ROM once or twice. Interview with licensed nursing staff J on 02/25/2015 at 11:06 AM revealed the resident did not refuse range of motion and liked to have the ROM done. During an interview on 2/25/15 at 4:34 PM administrative nurse staff A reported the therapist provided specific orders for the aides to follow, after each resident completed physical therapy. The facility failed to provide restorative ROM services for resident #59 as ordered.

The facility had a census of 51 residents, with 17 sampled. The sample included review of weight loss for 4 residents. Based on observation, interview and record review, the facility failed to ensure that 1 of 4 residents did not experience avoidable weight loss. One resident (#59) experienced severe weight loss of 8.6% in 90 days and the facility failed to identify weight loss as a problem, evaluate for the cause of the weight loss and develop/implement appropriate strategies to address weight loss. Findings included: - Review of resident # 59's admission MDS (minimum data set) dated 11/7/14 revealed a BIMS (brief interview for mental status) score of 15 which indicated no cognitive impairment. The assessment revealed he/she had a mood score of 6 which indicated mild depression. Review of the nutritional status CAA (care area assessment) dated 11/4/14 revealed the resident was on a regular diet with no chewing or swallowing problems. Diet is appropriate and tolerated well. He/she receives a room tray at breakfast and the 2 other meals in the small dining room and his average meal intake is 83%. He/she is able to voice his/her preferences and needs, to staff. There was no history of weight loss. Staff was to encourage and assist the resident when needed. The Certified Dietary Manager was to monitor meals, weights and labs as available. Review of the resident's care plan, initiated 12/5/2014 revealed an intervention to educate the resident's family on food safety and potential risks to the resident's health and monitor meal consumption. Review of the nutritional assessment completed by the dietitian dated 2/5/14 showed the resident remained on a regular diet with no chewing or swallowing concerns. Diet is appropriate and tolerated fair. He/she had a history of [REDACTED]. He/she received a room tray for breakfast, he/she received lunch and dinner in the small dining room and his/her average meal intake was 51%. He/she was able to voice his/her preferences and needs to staff. The resident has food items available that he/she buys from outside sources. His/her weight is down 9# over the past 90 days. Staff was to encourage and assist the resident as needed. The Certified Dietary Manager was to monitor meals, weights and labs as available. Record review showed the resident weighed 197 pounds on admission 11-10-14. On 1/6/2015 the resident weighed 189 pounds, which was an 8 pound weight loss and the clinical record lacked evidence the facility notified the physician or implemented interventions to prevent further weight loss. On 2/10/2015 the resident weighed 180 pounds, which was a additional 9 pound weight loss. Again the clinical record lacked evidence the facility notified the physician or implemented interventions to prevent further weight loss. The review of the resident's weights revealed a severe weight loss of 8.63% over 90 days. Observation on 02/24/2015 at 12:13 PM revealed the resident was in the small dining room and had a pork chop, carrots, potatoes and a blonde brownie. The resident said the food tasted good. The resident ate 75% of his/her lunch. Observation on 2/25/15 at 8:11 AM revealed the resident had a bowl of cereal in his/her room. The resident ate 100% of the breakfast. Interview with resident #59 revealed he/she only liked to have a bowl of cereal for breakfast and tried to stay away from a lot of breads because it caused him/her to have constipation. Interview with direct care staff I on 02/25/2015 at 1:40 PM revealed the resident had a good appetite he/she did skip meals but, family did bring in food for the resident to eat. Interview with dietary staff F on 02/26/2015 at 8:46 AM revealed he/she monitored for weight loss and if there was weight loss the RD (registered dietitian) would be notified. The resident would be weighed weekly instead of monthly. The staff had stated if weight loss occurred an intervention would be put in place. The staff was unable to identify any intervention the staff had put in place related to the weight loss for resident #59. Interview with administrative nursing staff A on 02/26/2015 at 9:03 AM revealed the weights are tracked through a program and he/she also had the ability to look up if any resident had weight loss. The RD came monthly and reviewed residents with weight loss then made recommendations. Nursing Staff A said the staff should review and revise the care plans as necessary. Nursing Staff A's expectations were to have any intervention in place for the weight loss or weight gains. Nursing staff A said the residents with weight loss were moved from monthly weights to weekly weights. The weights were them given to the CDM, who entered the weights in the computer. Any weight losses were brought up for discussion at the stand-up meeting. Interview with Registered Dietitian staff N on 2/26/15 at 11:43 am revealed he/she came to the facility every two weeks. Staff F was to notify him/her of any residents with a significant weight loss. He/she was unaware this resident had a significant weight loss and had not reviewed this resident. Interview with physician E staff on 2/26/2015 at 2:40 PM revealed he/she was not aware of the resident weight loss and it had been not brought up in the QA (quality assurance) meetings. Physician E said the facility should have notified him/her regarding the weight loss. Review of the facility policy for weight monitoring, revealed when weight change is severe, the licensed nurse will notify the resident's physician, obtain and carry out treatment orders given. A nutritional screen will be completed and referred to the dietitian for any patient needing additional interventions. The facility failed to ensure resident #59 did not experience an avoidable weight loss. Resident #59 experienced a severe weight loss of 8.63% in 90 days, and the facility failed to identify weight loss as a problem, evaluate for the cause of the weight loss, and develop/implement appropriate strategies to address weight loss.

The facility census totaled 53 residents, with 3 reviewed for accidents. Based on observation, interview and record review, the facility failed to keep the environment as free of accident hazards as possible and provide sufficient supervision and assistive devices to prevent accidents through a failure to follow a physical therapist's assessment for safe transfers and follow the planned interventions for 1 of 3 sampled residents. (#44) Resident #44 fell when walking independently and received a laceration to the forehead that required sutures, as well as a hospital stay to monitor a small bleed on the brain. Findings included: - Review of an annual MDS (Minimum Data Set--a required assessment) with an ARD (Assessment Reference Date) of 11/16/10 identified resident #44 without cognitive deficits or memory problems, required supervision assistance from nursing staff with walking, transfers, with a steady gait while walking and turning around, used a walker, and without falls since the prior assessment. The Fall CAA (Care Area Assessment) with a date of 12/1/10 identified the resident at risk for falls related to psychotropic drug use. The Psychotropic Drug Use CAA dated 12/1/10 identified the resident at risk for falls due to the use of psychotropic drugs and identified the resident's previous fall on 8/12/10 when the resident slid off the bed and onto the floor. Review of the nurse's notes, dated 1/19/11, revealed the resident ambulated from the dining room back to their room after the evening meal. The note identified the resident stated that their walker "slipped out" from under them and the resident fell to the floor, then the resident called out for help and staff responded. After that fall, the staff identified they planned to obtain a physical therapy evaluation for the resident's "gait instability." Review of the Physical Therapy notes, dated 1/21/11, revealed the "resident fell down the other day." The note also identified the resident exhibited a "tendency to pick up (their) walker and carry it" thereby losing their balance to the right side. The therapist also identified the resident as "unable to handle moderate displacement" with balance. The plan included physical therapy working with the resident 3-4 times a week to improve gait, balance, and transfers. Review of the most recent quarterly MDS with an ARD of 2/15/11 identified the resident now exhibited moderate cognitive deficits, required supervision assistance from staff with transfers, walking and with an unsteady gait, but able to stabilize without human assistance, used a walker, and experienced one non-injury fall since the previous assessment (fell on [DATE]). The care plan, dated 3/10/11, identified the resident at risk for falls due to a history of falls, and instructed staff to ensure the call light remained within the resident's reach, ensure the resident wore footwear to prevent slipping, to keep the environment well lit and free of clutter, to cue the resident to sit for a while before standing up and to walk slowly, instruct the resident to use a walker when ambulating, for staff to utilize reminders for safety regarding ambulation and transfers, and remind the resident to stay focused on walking. On 3/18/11, the Physical Therapy (PT) department ended the resident's therapy that started on 1/21/11 due to the resident met their maximum potential. The PT discharge summary described the resident's level of function with ambulation as "Pt (patient) ambulates over changes in surface, around obstacles, with 4-wheeled walker and MIN (minimal) assist." It also assessed the resident's gait as "The patient currently is able to ambulate 30 feet with moderate (assist) requiring the use of a 4-Wheeled Walker." The discharge summary continued to identify the resident at "high risk of falls due to the resident's tendency to pick up the walker on air and getting off balance." The facility failed to update the care plan to reflect the increased level of assistance the resident required for transfers and ambulation as assessed by the physical therapist. Review of a Post Fall Investigation Summary (an initial investigation conducted by the charge nurse at the time of the fall, kept in the chart, that identified what staff thought caused the fall and what interventions needed to be implemented to prevent a reoccurrence), dated 3/28/11 identified the resident experienced a fall. The fall occurred 10 days after discharge from physical therapy. Charge Nurse G completed the summary and identified the resident fell as a result of a loss of balance, "it was early in the a.m. and the resident wasn't quite awake. Resident should be qued (sic) to sit on (their) bed for a while before standing up." In different handwriting, an unidentified writer wrote in the following: "Additionally, resident's slippers twisted on (their) foot, causing (the resident) to trip." Review of the facility's complete fall investigation, dated 3/28/11, identified the fall as a witnessed fall, due to a loss of balance or unsteadiness. In the investigation, staff identified the time of occurrence as 6:40 a.m., and the nurse aide had told the resident to use the bathroom. The investigation revealed the resident did not have an alarm within reach, and the resident used a walker at the time they fell . The resident stated "(they) weren't awake yet and tripped." The investigation included the hand-written statements from both nurse aides in the room at the time of the resident's fall. Nurse Aide L identified the resident had been on the bed and stood up. The resident wore red checkered slippers and walked toward the bathroom. The resident had taken 2-3 steps when the slipper turned sideways and the resident started to fall. "I couldn't catch (the resident) in time." The resident fell over their own feet, falling face first to the floor striking the right side of their head on the floor. The nurse was called immediately. The second witness, Nurse Aide Q, identified the floor as not wet and nothing on it, the resident tripped over their own feet. The investigation contained the following statement from Nurse Aide Q: "The resident ambulates on (their) own so we were here but not assisting. (Nurse Aide L) was by the TV and I was by the closet. It happened so fast, neither one of us could catch (the resident)." Administrative Nursing Staff A called the incident into the State Agency as possible abuse/neglect and then conducted a more thorough investigation. Review of the facility's thorough investigation revealed more of the same information, including the resident "stood up and began ambulating independently." The investigation led to the fact that the resident's footwear caused the fall. This investigation identified the resident required a trip to the emergency room to suture a laceration to the resident's forehead, as well as an admission into a surgical/trauma unit to monitor a small brain bleed. The conclusion of the investigation revealed no indication of any type of abuse and "review of the care plan indicates that this resident ambulates independently with a front wheeled walker, thus the care plan was being followed." If staff provided the minimal assistance with ambulation as assessed by the PT 10 days earlier (by walking with the resident and with the use of a gait belt), staff would have had the opportunity to intervene in the resident's footwear problems and potentially lessen the impact of the fall. On 4/28/11 at 4:45 p.m., Administrative Staff A stated that Nurse Aide L was, in fact, standing next the resident when the resident fell in their room on 3/28/11. When asked why Nurse Aide Q stated the aides were not assisting the resident at the time of the fall and Staff A's own investigation identified the resident ambulated "independently", Staff A said "that's not what I meant." Staff A lacked knowledge of why staff failed to update the care plan to include the increased assistance the resident required after the physical therapy treatment. Observation of the resident on 4/26/11 at 4:15 p.m. revealed the resident sat in a wheelchair in their room, wearing a personal body alarm. Observation on 4/27/11 at 9:45 a.m. revealed the resident lay in bed in their room. Observation of a wheelchair revealed it was positioned next to the bed. The resident did not have a personal body alarm on at that time, and observation revealed a lack of one available for the resident on the wheelchair. On 4/28/11 at 10:00 a.m., the resident sat in a wheelchair in a semi-circle of other residents as they listened while staff read the paper. The resident wore a personal body alarm during this time. Review of the 3/10/11 care plan revealed no new interventions for staff to apply a body alarm to the resident. The care plan lacked any new interventions for staff to follow after the fall on 3/28/11. Interview on 4/27/11 at 4:20 p.m. with Nurse Aide R revealed the resident did have a recent fall. Aide R stated the resident now wore a personal body alarm whenever staff were not around. When the resident was around staff, like during mealtimes, the staff removed the body alarm. On 4/28/11 at 9:50 a.m., Nurse Aide L stated the resident did not wear a body alarm. When asked how they knew this, Aide L pointed to "Resident Care Sheets." Aide L stated that Administrative Nurse B and Administrative Staff S update the care sheets "frequently" to reflect the changes in the care plans. Review of the most recent updated care sheets found that they lacked guidance to the staff about placing a personal body alarm. The Resident Care Sheets lacked any directions to staff about assistance with ambulation, just that the resident used a walker, had short-term confusion, and staff were to "re-orient and cue PRN (as needed)." Staff failed to update the care plan to effectively communicate the residents increasing needs for supervision and assistance with walking, as well as to include the addition of a personal care alarm. The facility failed to ensure staff provided assistance with walking and transfers to a resident who required increasing assistance from staff. The resident fell while walking independently and sustained a laceration that required sutures and a small brain bleed. Staff also failed to consistently implement the intervention of a personal body alarm.