Every finding on record at Madrid Home for the Aged

Based on direct observation, clinical record review, staff interview, and facility policy review, the facility failed to follow proper enhanced barrier precautions (EBP) procedure and protect residents and staff members from possible contamination when they did not implement EBP during high-contact cares with a resident (Resident #6). The facility reported a census of 57. Findings include: The Minimum Data set (MDS) for Resident #6, dated 06/04/2026, documented the following relevant diagnoses: benign prostatic hyperplasia (BPH), neurogenic bladder, and Parkinson's Disease. It documented the resident used a urinary catheter and was dependent on staff for the care of the device. The Care Plan for Resident #6, last revised 07/09/2026, documented the resident used an indwelling suprapubic catheter. During a direct observation on 08/05/2026 at 09:14 AM with Staff E, Certified Medication Aide (CMA), it was noted there were EBP signs instructing the staff member to wear enhanced barrier precautions during cares. Staff E assisted Resident #6 out of his shirt before changing medicated patches and then assisted him with putting his shirt back on. During this care Staff E was not observed to be wearing EBP. In an interview on 08/06/2026 at 01:20 PM with Staff A, Certified Nurse Aide (CNA), she stated Enhanced Barrier precautions are required to be worn when a resident has a device like a catherer during high care activities. She identified helping a resident dress or undress as a high care activity. In an interview on 08/06/2026 at 01:37 PM with Staff B, CNA, she stated EBP should be worn for all cares if a resident has it posted on their door. In an interview on 08/06/2026 at 02:11 PM with Staff C, Licensed Practical Nurse (LPN), stated EBP should be worn during high contact care activities and identified dressing and undressing as a high contact activity. In an interview on 08/06/2026 at 02:34 PM with Staff D, Registered Nurse (RN), she also identified dressing and undressing as a high contact care activity and stated residents with indwelling devices such as catheters should have EBP utilized during cares. In an interview on 08/06/2026 at 03:15 PM with the Regional Director of Clinical Services acting in the role of the director of nursing (DON), she acknowledged EBP should have been worn during the medication management for Resident #6 and stated it was her expectation all high contact care activities utilize EBP where appropriate. Review of a facility provided document titled Enhanced Barrier Precautions, dated 04/02/2026, instructed staff members to follow the Centers for Disease Control and Prevention (CDC) guidelines for EBP during high-contact activities. Review of the CDC website found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html identified dressing as a high-contact care activity.

Based on clinical record review staff interview, and policy review the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 4 out of 5 sampled residents reviewed (Resident #2, #29, #1, and #4). The facility reported a census of 54 residents.Findings include:1. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognitive functioning. The MDS indicated that Resident #2 was taking antidepressant medications during the look back period. The MDS further indicated that Resident #2 had diagnoses of depression, metabolic encephalopathy (an acute or subacute brain dysfunction caused by systemic illness, toxins, or organ failure rather than structural damage), and cognitive communication deficit. Review of Resident #2's Electronic Health Record (EHR) page titled, Clinical Physician's Orders revealed an order with a start date of 12/2/25 for Duloxetine HCl (antidepressant) oral capsule delayed release sprinkle 60mg to give 120mg by mouth daily. This order was discontinued on 3/21/26 and a new order was obtained for Duloxetine HCl (antidepressant) oral capsule delayed release particles 30mg to give 3 capsules by mouth one time a day. Review of the Care Plan with a revised date of 3/6/26 lacked non-pharmacological interventions and targeted behaviors with an antidepressant medication. 2. Review of Resident #29's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive functioning. The MDS indicated that Resident #29 was taking antipsychotic, and antidepressant medications during the look back period. The MDS further indicated that Resident #29 had diagnoses of Alzheimer's disease, depression, and bipolar disorder. Review of Resident #29's EHR page titled, Clinical Physician's Orders revealed an order with a start date of 5/14/25 for Quetiapine Fumarate (Antipsychotic) oral tablet 50mg to give 50mg by mouth one time a day. Further review revealed an order for Quetiapine Fumarate (Antipsychotic) oral tablet 25mg to give 25mg by mouth one time a day with a start day of 5/14/25. Further review of the Clinical Physician Order's revealed an order with a start date of 11/16/25 for Trazodone HCl (Antidepressant) oral tablet to give 25mg by mouth one time a day. Review of the Care Plan with a revised date of 12/29/25 lacked non-pharmacological interventions and targeted behaviors with an antidepressant, and antipsychotic medication. Interview on 3/25/26 at 1:15 PM with the Director of Nursing (DON) revealed that there should be non-pharmalogical interventions listed on the care plan for antipsychotic medications as well as the antidepressants. 3. Review of Resident #1's MDS dated [DATE] revealed a BIMS score of 14 indicating intact cognitive functioning. The MDS indicated that Resident #1 was taking antianxiety and antidepressant medications during the look back period. The MDS further indicated that Resident #2 had diagnoses of depression, cerebrovascular accident (CVA, or stroke, caused when blood flow to the brain is interrupted, causing brain cells to die from lack of oxygen), and dysphagia (difficulty swallowing, often caused by neurological conditions, i.e., stroke, resulting in pain, coughing, or choking while eating). Review of Resident #1's EHR page titled, Clinical Physician's Orders revealed an order with a start date of 12/22/25 for Bupropion HCl (antidepressant) oral tablet extended release 300mg to give 300mg by mouth daily. Further review revealed an order for Duloxetine HCl (antidepressant) oral capsule delayed release particles 30mg to give 3 capsules by mouth one time a day (used to treat depression, anxiety, diabetic nerve pain, fibromyalgia, and chronic musculoskeletal pain). Review of Resident #1's Care Plan with a revised date of 2/16/26 revealed it lacked non-pharmacological interventions and targeted behaviors with an antidepressant and antianxiety medication. 4. Review of Resident #4's MDS dated [DATE] revealed a BIMS score of 11 that indicated moderately impaired cognitive functioning. The MDS indicated that Resident #4 was taking antipsychotic and antidepressant medications during the look back period. The MDS further indicated that Resident #29 had diagnoses of Non-Alzheimer's dementia, anxiety disorder, depression, and psychotic disorder. Review of Resident #4's EHR page titled, Clinical Physician's Orders revealed an order with a start date of 12/27/24 for Risperidone (Antipsychotic) oral tablet 0.5mg to give 0.5mg by mouth one time a day. Further review revealed an order for Sertraline HCI (Antidepressant) oral tablet 75mg to give 75mg by mouth one time a day with a start day of 3/18/26. Further review of the Clinical Physician Order's revealed an order with a start date of 3/18/26 for Lorazepam (Antianxiety) oral tablet to give 0.5mg by mouth every 12 hours as needed for anxiety for 14 days, with an end date of 4/3/26. Review of Resident #4's Care Plan with a revised date of 2/16/26 revealed it lacked non-pharmacological interventions and targeted behaviors with an antidepressant, antianxiety, and antipsychotic medication. Review of a facility provided policy titled, Comprehensive Person-Centered Care Planning with a revision date of December 2025 indicated The comprehensive care plan will be developed and implemented consistent with the resident's rights and include measurable objectives and timeframes to meet the resident's medical, nursing, and mental/psychosocial needs that are identified in the comprehensive assessment.

Based on observations, interviews, and facility policy review, the facility failed to prepare, serve and distribute food in accordance with food service safety. The facility also failed to ensure sanitary and safe conditions in the two kitchenette areas in the facility maintained for food services. These failures posed the risk of food borne illness to the residents. The facility reported a census of 54 residents. Findings include:Observation on 3/25/26 in the facility's kitchen of the noon meal service with Staff B, Dietary Aide/Cook revealed at:11:36 a.m., he put on a pair of disposable gloves and took a plate with those gloves on he touched a pair of tongs to plate one piece of beef steak with mushroom and onion gravy from the steam table, a scoop to plate the mashed potatoes, a ladle to plate mixed vegetables, and set the plate on the steam table's counter. He then handled an insulated cart with those same gloved on, touched the sides of the cart to position it next to the steam table and opened a door of that cart. He then opened a bag of sliced bread, removed one slice of bread with those same gloved hands, placed the slice of bread on the plate, covered the plate with an insulated cover, placed the covered plate on a tray along with the paper meal slip, and handled the tray to place it in the insulated cart.11:38 a.m., he handled another plate and began plating a second meal with those same gloves on. With that pair of gloves on, he touched a pair of tongs to serve the beef steak with gray, a scoop to plate the mashed potatoes, the ladle to plate the mixed vegetables, removed one slice of bread with those same gloved hands, placed the slice of bread on the plate, placed an insulated cover over the plate, and placed it on a tray, with the resident's meal slip in the insulated meal cart.11:39 a.m., he handled another plate and began plating the third meal. With that same pair of gloves on, he touched a pair of tongs, a scoop, a ladle, removed one slice of bread with those same gloved hands, placed the slice of bread on the plate, placed an insulated cover over the plate, and placed it on a tray, along with the resident's meal slip in the insulated meal cart and closed the door of the insulated meal cart.11:40 a.m., he took off those gloves. He had not sanitized his hands after removing the gloves.During an interview on 3/25/26 at 11:46 a.m. with Staff B, Dietary Aide/Cook, the observations of his glove use were reviewed that included his touching multiple surfaces that contaminated the gloves before handling the ready-to-eat sliced bread, and not limiting glove use to only one task. Staff B, Dietary Aide/Cook, agreed that he had touched multiple surfaces prior to handling the ready-to-eat sliced bread. During an interview on 3/25/26 at 12:07 p.m. with the Dietary Manager, the observations of Staff B were discussed including his glove use, touching multiple items, and handling the ready-to-eat sliced bread with those contaminated gloves. She stated she encouraged dietary staff not to wear gloves when preparing and serving resident meals and that she expected the dietary staff to use tongs with the ready-to-eat sliced bread to place it on the plate. Review of the facility policy Use of Gloves, revised December 2024 revealed Single-use gloves may be worn by all employees when handling. single use food items to protect residents from food borne illness or spread of diseases. The procedure included: Gloved hands are an extension of the employees hands and are considered a food contact surface that can be contaminated or soiled and therefore will be used for only one task. Gloves may be worn during the following processes. Handling ready-to-eat foods. Gloves must be changed whenever hands would normally be washed or after any of the following:As soon as they become damaged or soiled.When interruptions occur in the operation.Before beginning a new task.After touching any equipment.Any time touching a surface that may be contaminated. During an interview later that same day at 12:25 p.m. with the Dietary Manager, the refrigerators in the kitchenettes on the second and third floor of the facility were discussed. She stated the snacks, nourishments, condiments, and other food items for the residents were placed in those refrigerators and that the dietary department stocked those refrigerators daily. She stated it was the responsibility of the nursing department to ensure the cleanliness and proper temperature of those refrigerators to prevent the potential for foodborne illness. Observation on 3/25/26 at 12:55 p.m. of the second-floor kitchenette revealed there was no thermometer in the fridge. On the door of the fridge there was posted a Refrigerator Temperature Check form with boxes for the 31 days of the month. The form stated the Refrigerator temperature should be 36-40 F [Fahrenheit] The form's spaces to record the Location, Month, and Year were blank. Seven of the boxes were completed with staff initials that indicated temperature readings of 38 F and 39 F. The inside of the fridge was dirty with debris noted on the shelves and dried juice on the bottom of the fridge. Observation on 3/25/26 at 1:30 p.m. of the third-floor kitchenette revealed the fridge had no Refrigerator Temperature Check form posted. The inside of the fridge had a dried brown substance on the bottom shelf of the fridge and in one of the bottom drawer's of the fridge was a Garlic Herb cream cheese container that was 1/3 full of cream cheese, dated 10/28/25. During an interview on 3/25/26 at 1:45 p.m. with the Scheduling Coordinator in the third-floor kitchenette, she stated that the dietary department was responsible for the kitchenette's refrigerators and there was supposed to be a Refrigerator Temperature Check form posted to record the fridge's daily temperature. She agreed there had been some discussion between the nursing and dietary department regarding which department was responsible for the kitchenettes. She agreed that the fridge was not clean. During an interview on 3/25/26 at 3:05 p.m. with the Director of Nursing stated it was the responsibility of the dietary department to monitor the second and third floor kitchenettes and the refrigerators in those kitchenettes. During a follow-up interview on 3/25/26 at 3:37 p.m. with the Dietary Manager, she confirmed it was the nursing department's responsibility to monitor kitchenettes and the cleanliness and proper temperature of the second and third floor kitchenette refrigerators. During an interview on 3/25/26 at 4:03 p.m. with the Administrator, he revealed he had started his role as the facility's administrator last week and stated he did not know who was responsible for the kitchenette areas on the second and third floor. Review of the facility policy Food Temperatures/Food Safety, reviewed December 2023 revealed Documentation of equipment temperatures for food storage are recorded at least daily and recorded electronically. or recorded manually in the. designated location.

Based on facility investigation review, staff interview, and facility policy review, the facility failed to report allegations of abuse to the state survey agency (SSA) within the required time period in 1 of 1 incidents reviewed. The facility reported a census of 54. The facility corrected the deficiency per past noncompliance on 3/10/26 through the following actions:The facility self identified on 3/9/26 a resident to resident event happened that met the threshold for reporting requirements under state and federal guidelines. Former administration failed to notify the SSA within 2 hours of the event happening. All staff were re-educated on the abuse policy specifically all resident to resident altercations, regardless of injury, must be reported to the supervisor immediately, who then reports it to the Director of Nursing/Administrator immediately. Audits initiated on 3/10/26 and will be conducted by reviewing nursing notes, risk management, grievances and conversations with residents/staff. Findings include: The Facility Investigation titled Resident to Resident Altercation documented an incident occurred on 02/07/2026 at approximately 5:00 PM between two residents. The document revealed the residents were immediately separated. Under additional information it is documented the incident as reported as of 03/09/2026. In a conversation on 03/24/2026 at 03:09 PM with the Systems Process and Policy Specialist, she took over for the previous administrator in early March and on 03/10/2026 noticed a resident-to-resident interaction had not been reported to the SSA as required. She reported the allegation of abuse to the SSA on 03/10/2026. She confirmed it should have been reported within 24hrs. In a conversation on 03/24/2026 at 03:19 PM with the Administrator he agreed that if the allegations met the criteria of abuse they should be reported within 24hrs without injury and within 2hrs with injury. Review of a facility provided document titled Abuse Prevention, Identification, Investigation and Reporting Policy, with a last revised day of 12/2025, stated the following: All allegations of Resident Neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation shall be reported to the Iowa Department of Inspections and Appeals, not later than two (2) hours after the allegation is made, if the events that caused the allegation resulted in serious bodily injury, or not later than twenty-four (24) hours if the events that caused the allegation involved neglect, exploitation, mistreatment, injuries of unknown origin and misappropriation, but do not result in serious bodily injury.

Based on clinical record review, staff interview, and policy review the facility failed to develop a comprehensive care plan that included problems, goals, or interventions for 3 of 8 residents (Resident #2, #29, and #27) reviewed with a diagnosis of Alzheimer's, anticoagulant medication usage, antidepressant medication usage, and catheter usage. The facility reported a census of 54. Findings include:1. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed an admission to the facility 12/2/25 from a short-term general hospital stay. The MDS further indicated that Resident #2 was taking antidepressant medications during the look back period. Review of Resident #2's Electronic Health Record (EHR) page titled, Clinical Physician's Orders revealed an order with a start date of 12/2/25 for Duloxetine HCl (antidepressant) oral capsule delayed release sprinkle 60mg to give 120mg by mouth daily. This order was discontinued on 3/21/26 and a new order was obtained for Duloxetine HCl (antidepressant) oral capsule delayed release particles 30mg to give 3 capsules by mouth one time a day. Review of Resident #2's Care Plan with a revision date of 3/6/26 revealed no problems, goals, or interventions for antidepressant medication usage. 2. Review of Resident #29's MDS dated [DATE] indicated that Resident #29 was taking anticoagulant, and antidepressant medications during the look back period. The MDS further indicated that Resident #29 had diagnoses of Alzheimer's disease, depression, and bipolar disorder. Review of Resident #29's EHR page titled, Clinical Physician's Orders revealed an order with a start date of 11/16/25 for Trazodone HCl (Antidepressant) oral tablet to give 25mg by mouth one time a day. Further review of the Clinical Physician's Order's revealed an order for Apixaban (anticoagulant) oral tablet 5mg to give one tablet by mouth two times a day with a start date of 1/20/26. Review of Resident #2's Care Plan with a revision date of 12/29/25 revealed no problems, goals, or interventions for antidepressant medication usage. Interview 3/25/26 at 1:19 PM with the Director of Nursing (DON) revealed that Resident #2 should have had antidepressants on the care plan. The DON further revealed that Dementia should have been on Resident #29's care plan with goals and interventions as well as anticoagulant medication usage, and Alzheimer's disease. 3. Review of Resident #27's quarterly review MDS, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognitive functioning. The MDS indicated that Resident #27 had an indwelling catheter. The MDS further indicated that Resident #27 had a primary diagnosis of Parkinson's Disease with dyskinesia (involuntary, erratic, and uncontrollable muscle movements), with fluctuations. The MDS indicated other diagnoses of benign prostatic hyperplasia with lower urinary tract symptoms (frequent, urgent, or weak-stream urination, waking at night, and incomplete bladder emptying), depression, and cognitive communication deficit. Review of Resident #27's EHR revealed a Health Status progress note dated 2/26/26 at 3:19 p.m. that stated .New indwelling Foley catheter placed today for urinary retention secondary to neurogenic bladder. This is resident's first catheter placement. Foley inserted to relieve retention and to assess whether urinary retention was contributing to reported discomfort. Further review of his EHR's page titled, Clinical Physician's Orders revealed the following orders: On 2/27/26, for Foley output to be completed every shift. On 3/8/26, to Ensure resident has leg drainage bag on when out of bed. On 3/15/26, Routine Catheter Change. to be completed every 4 weeks. Review of Resident #27's Care Plan, that was printed on 3/24/26 at 1:30 p.m., with a revision date of 12/29/25 revealed the care plan had not been revised by the interdisciplinary team after his 3/11/26 quarterly review assessment with a focus or problem, goals, and interventions for the resident's catheter use. During an interview and observation on 3/25/26 at 10:18 a.m. with Resident #27, he stated that his Parkinson's disease was affecting his body and slowing him down. The resident was observed not to have a leg drainage bag on, but had a bed bag attached under his wheelchair seat covered in a cloth bag. He stated the staff had not changed his catheter to a leg bag as they had no leg bags available in his room. During an interview on 3/25/26 at 3:05 p.m. with the DON revealed that she stated resident care plans were revised with each new diagnosis, change in condition, physician order, and MDS assessment. She further stated the individualized care plan would be updated with new concerns, devices (including a catheter placement), or when a new intervention was implemented. She agreed that Resident #27's physician orders and cares had changed within the last month with the placement of his indwelling catheter and should have been addressed on his care plan. She confirmed that the resident's care plan had not addressed his catheter and they had not developed goals or person-centered, measurable objectives and interventions related to his catheter use. During an interview on 3/25/26 at 4:03 p.m. with the Administrator regarding Resident #27, he agreed that his catheter use had not been addressed on his care plan with measurable goals or individualized interventions. He stated there were two instructions noted on his Kardex (an electronic document that contained daily tasks and essential resident data) on how to clean the resident's catheter bed bag and leg bag. Review of the facility policy Comprehensive Person-Centered Care Planning, reviewed December 2025 revealed: a. The comprehensive care plan will be developed and implemented consistent with the resident's rights and include measurable objectives and timeframes to meet the resident's medical, nursing, and mental/psychosocial needs that are identified in the comprehensive assessment. b. The comprehensive care plan will be. Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Based on clinical record review, observations, resident interviews, staff interviews, and policy review the facility failed to provide food at an appetizing temperature to 3 of 5 residents ( Residents #2, #29, and #41) reviewed. The facility reported a census of 54 residents.Findings include:1. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 14 indicating intact cognitive function. Interview on 3/23/26 at 10:53 AM with Resident #2 revealed that the food served is cold when delivered to the room on room trays. 2. Review of Resident #29's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive function. Interview on 3/23/26 at 11:37 AM with Resident #29 revealed that the food is often cold when it is delivered to the unit for the room trays. Resident #29 revealed that this happens frequently. 3. Review of Resident #41's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognitive function. Interview on 3/23/26 at 11:25 AM with Resident #41 revealed that the food is often served cold when delivered on the room trays. Observation on 3/25/26 at 7:33 AM revealed the food cart was delivered to the 3rd floor at this time. The food cart was then left in the hallway by the nurses office at this time.During continuous observation on 3/25/26 from 7:33 AM until 7:43 AM it was observed that the first room tray on the 3rd floor was delivered at 7:43 AM with the cart doors left open while delivering the food to the residents room. The last tray was delivered at 7:49 AM. Interview on 3/25/26 at 11:27 AM with Staff A Certified Medication Aide (CMA) revealed that on the 3rd floor the CMA is responsible for delivering trays to the rooms as dietary staff prepare the food in the kitchen. Staff A further revealed that the food is then delivered to the 3rd floor. Staff A then indicated that sometimes she will be working with residents, and not know that the food has arrived at the hallway. Staff A then revealed that the CMA is responsible for getting the drinks as well, and this takes a little bit and then food will be delivered. Observation on 3/25/26 at 11:37 AM food trays were delivered to the unit on the 3rd floor and placed in the hallway. During continuous observation on 3/25/26 from 11:37 AM until 11:54 AM revealed drinks were started to be prepared at 11:54 AM while the food delivered sat in the food cart. The first tray was delivered at 11:59 AM. A sample tray was obtained 3/25/26 at 12:04 PM with food temperatures obtained at this time from the 3rd floor food cart that was delivered. The steak with mushrooms and onion gravy temperature was 109.8 degrees, whipped potatoes were 121.3 degrees, and the mixed vegetables were 104.5 degrees. Interview on 3/25/26 at 12:24 PM with the Certified Dietary Manager (CDM) revealed that she would have liked to see the food temps higher when delivered to the floor for room trays. Interview on 3/25/26 at 12:32 PM with the Administrator revealed he would expect food temps to be at the appropriate temperatures.Review of a facility provided policy titled, Food Temperatures/Food Safety with a revision date of 12/23 indicated food temperatures should be taken periodically to assure hot foods stay about 135 degrees. Further review of the policy indicated foods should be transported quickly to maintain temperatures for delivery and service.

Based on the Center for Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report for Quarter 1, 2026 (October 1-December 31) review and staff interviews, the facility failed to submit accurate staff reports for the PBJ Staffing Data Report. The facility reported a census of 54 residents. The facility corrected the deficiency per past noncompliance on 3/9/26 through the following actions:The facility self identified on 3/9/26 the PBJ report was not accurate due to agency hours were not submitted. The clinical specialist identified the issue and education was completed immediately with the administration. Audits initiated on 3/9/26 and will be ongoing. Findings include: The PBJ Staffing Data Report run date 3/18/26 triggered for Excessively Low Weekend Staffing October 1- December 31.Review of the facility policy titled, Payroll Based Journal Report, effective 3/17/25 and reviewed 2/2026, it is the policy of this facility to submit PBJ staffing information as required by CMS. At a minimum of quarterly, the facility will electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS.During an interview 3/26/26 at 8:25 AM the Administrator revealed the PBJ information had been submitted incorrectly by the previous Administrator who had failed to submit hours for agency staff 10/1/25-12/31/25. The Administrator stated on 3/9/26 the Clinical Specialist audited invoices for agency hours on the PBJ and they were incorrect. The Administrator revealed he was not able to obtain a report of the incorrect information. The Administrator revealed on 3/9/26 the Clinical Specialist resubmitted the agency hours that had been missing to correct the PJB report. Review of the current PBJ Analysis Summary for the 1st quarter of 2026, 10/1/25-12/31/25 revealed the hours had been corrected as no issue were found for staffing being excessively low on the weekends.

Based on observations, record review, staff interview, and policy review, the facility failed to ensure and verify food was stored, prepared, and delivered in a manner to prevent foodborne illness. The facility reported a census of 52. Findings include: During a continuous observation of the kitchen on 3/17/25 at 9:00 AM, the following was identified: a. Undated dish machine test strips stuck to the first aid kit hanging on a wall; Out of the 31 test strips, 14 strips indicated the high-temperature dish machine did not reach the required rinse temperature of >/= 180 b. Plastic jug of a chemical marked erosive was stored with food in the dry storage area c. No temperature logs maintained for the walk-in cooler, walk-in freezer, or the reach-in coolers d. No temperature logs maintained for items prepared for resident meals During a continuous observation of lunch service on 3/19/25, the following was identified: a. Staff A, Dietary Aide, seen on multiple occasions holding drinkware by the rim of the cup/glass. Staff A also seen touching their beard guard, hands in pant pockets, touch/wiping hand on pants with no hand hygiene performed before continuing with kitchen duties (prepping drink, handling plates for service) b. Staff B, Dietary Aide, seen on several occasions holding drinkware by the rim of the cup/glass. Staff B also seen lightly wiping their nose with bare hand with no hand hygiene performed before continuing with resident tray delivery c. Staff C, Cook, seen touching the lid of a trash can and the trash bag without performing hand hygiene before continuing with delivering During an interview on 3/17/25 at 9:15 AM, Staff D, Dietary D, explained dishwasher temperature test strips are done and then stuck to the first aid kit. They acknowledged .temperature test strips were not dated but stated the first couple strips were from a month ago. The current month of test strips started with the third strip down. During an interview on 3/17/25 at 10:00 AM, the Certified Dietary Manger (CDM), acknowledged the lack of temperature logs for food and coolers/freezer. They also voiced the dish machine temperature test strips stuck to the first aid kit is not the most efficient way to monitor or record. The CDM explained that historically tasks and equipment temperatures, such as cooler temperatures, were entered into an App called Freshcheq. However staff had not been consistently entering information into the App. The CDM themselves had experienced issues with logging into the app itself. Food temperature logs had been recorded on paper. The CDM could not locate food temperature logs for the months of March and February. January's food temperature log was mostly filled out while no log was maintained for December. During an interview on 3/19/25 at 2:30 PM, the CDM verbalized staff should not be holding cups/glassed by the rim when preparing drinks. The CDM also noted that hand hygiene should have been completed after staff touched their nose and the trash can. The policy Food Temperature/Food Safety, reviewed 12/2023, stated food temperatures will be documented prior to every meal, recorded electronically on the Freshcheq App or recorded manually. The policy Machine Ware Washing-High/Low Temperature, reviewed 12/2023, stated dates, temperature, and initials are recorded on the check-off sheet or within the Freshcheq App. Temperature test trips should be taped to the check-off sheet along with the temperature or a picture taken within the Freshcheq App. The policy Storage, reviewed 12/2023, stated temperatures of refrigerators and freezers will be monitored. Temperatures will be documented when the first person arrives in the AM and before the last person leaves in the PM. The policy also stated cleaning compounds, detergents, soaps, pesticides, and other toxic substances shall not be stored in food storage areas but in a locked area away from food.

Based on record review, staff interview, and policy review the facility failed to provide notice to the resident of discontinued Medicare Part A services and the right to an appeal for two of three residents (Resident #18 and #61) reviewed. The facility reported a census of 52 residents. Findings include: 1. Review of a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review completed for Resident #18, documented the resident's Medicare Part A skilled services episode start date of 11/7/24 and last covered day of Part A service of 11/29/24. The facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. The (SNF) Beneficiary Protection Notification Review revealed a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form CMS-10055 and Notice of Medicare Non-coverage (NOMNC) form CMS-10123 was not provided to Resident #18. 2. Review of a Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review completed for Resident #61, documented the resident's Medicare Part A skilled services episode start date of 11/7/24 and last covered day of Part A service of 11/29/24. The facility/provider initiated the discharge from Medicare Part A services when benefit days were not exhausted. The (SNF) Beneficiary Protection Notification Review revealed a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form CMS-10055 was not provided to Resident #61. Facility policy, Skilled Nursing Facility-ABN and NOMNC reviewed 10/2024, revealed it is the policy of the facility to provide advanced notice when Medicare plan services are ending and appropriate notification will be given to the resident or resident's responsible party as follows: Medicare Part A resident with remaining Part A days available, being discontinued from Part A services and staying in the building with notices required ABN form CMS-10055 and NOMNC form CMS-10123 two days prior to services ending. Interview on 3/20/25 at 3:12 PM, the Director of Nursing confirmed forms CMS-10055 and CMS-10123 were not completed and her expectation to follow the policy and provide the forms when required.

Based on observation, clinical record review, staff interviews and policy review, the facility failed to obtain a physician order and pharmacy order for the correct route of medication administration for 1 of 7 residents reviewed for medication administration (Resident # 7). The facility reported a census of 52 residents. Findings include: The Minimum Data Set (MDS) for Resident #7, dated 2/16/25, documented a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS included diagnoses of progressive neurological conditions, Cerebral Palsy and Epilepsy. The MDS further documented the resident had a feeding tube. The Current Discharge Medication List from the hospital dated 3/13/25 included an order for Levetiracetam Tablet 500 MG (milligrams) tablet, take 2 tablets by mouth two times a day. The Electronic Health Record (EHR) for Resident #7 included an order dated 3/13/25 for the medication Levetiracetam Tablet 500 MG (milligrams), give 2 tablets via G-Tube (gastrostomy tube, a medical device inserted through the abdomen into the stomach, used for feeding and medication delivery) two times a day for seizure, related to Epilepsy. The March Medication Administration Record (MAR) for Resident #7 included the order Levetiracetam Tablet 500 MG (milligrams), give 2 tablets via G-Tube two times a day for seizure, related to Epilepsy, beginning on 3/13/25 and signed by staff as administered. During an observation 03/19/25 at 8:05 AM, Staff E, Certified Medical Assistant (CMA), administered the medication Levetiracetam Tablet 500 MG, two tablets, to Resident #7 by mouth. Observation of the prescription label for the medication ordered the medication to be administered via G-Tube and an indicator the medication not be crushed. During an interview 3/19/25 at 8:55 AM, Staff E acknowledged the medication was administered by mouth and stated the medication had been given by mouth since Resident #7's return from the hospital on 3/13/25. During an interview 3/20/25 at 9:00 AM, Staff F, charge nurse and Licensed Practical Nurse (LPN), stated Resident #7 returned to the facility from the hospital on 3/13/25 with an order for the medication to be given by mouth. Staff F acknowledged the new order had not been changed yet in the MAR or uploaded into the orders in the EHR. Staff F further acknowledged the hospital discharge paperwork included the order for the medication to be administered by mouth, however the facility has not received a signed order from the resident's primary care physician (PCP) for this order. During an interview 3/20/25 at 9:35 AM, the Director of Nursing (DON) stated orders should be followed and the MAR should reflect the current orders. The DON stated an expectation orders are entered correctly into the MAR and double checked to ensure accuracy. If a medication route has been changed, this should be reflected in the MAR and an order should be obtained and a correct pharmacy prescription order obtained. Review of the facility policy Order Procedure, revised 10/2024, documented review the order for completeness, including route, check the electronic medical record in Point Click Care (PCC) to ensure the order was entered as prescribed. If the order was entered incorrect, discontinue the incorrect order, and re-enter the correct order.

Based on clinical record review, resident interview, staff interviews and policy review, the facility failed to provide adequate assessment and intervention for 1 of 1 residents reviewed for insulin and blood sugars (Resident #19). The facility reported a census of 52 residents. Findings include: The Minimum Data Set (MDS) for Resident #19, dated 1/23/25, documented a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS included diagnoses of progressive neurological conditions, heart failure and Diabetes Mellitus. The MDS documented he resident received insulin in the look back period. The Care Plan for Resident #19, with a revision date of 7/29/24, included a focus area Diabetes Mellitus, with a goal no complications related to diabetes through the review date, and interventions: *Diabetes medication as ordered by doctor. *Monitor/document for side effects and effectiveness. * Fasting Serum Blood Sugar as ordered by doctor. Review of the Electronic Health Record (EHR) for Resident #19 included an order for blood sugar checks BID (twice daily) and PRN (as needed) for diabetes. During an interview 3/17/25 at 11:50 AM, Resident #19 stated that morning at around 4 am, she called the CNA (Certified Nursing Assistant) into her room because she was shaky and felt her blood sugars were low. Resident #19 stated the CNA went to get her some orange juice and asked the floor nurse to check on the resident. Resident #19 stated the nurse came in and took her blood sugar and it was 51. The resident said the floor nurse just walked out after taking her blood sugar and did not come back to check on her. The resident said she was still shaky, she stated she felt sweaty and shaky and her legs were tingly. Resident #19 stated the floor nurse never returned to her room, nor did the CNA. Resident #19 stated she drank the orange juice and when her blood sugars were taken as scheduled before breakfast by another nurse that morning, around 7:30 or 8 AM, it was around 191. According to the Centers for Disease Control and Prevention (CDC), If your blood sugar drops below 55 mg/dL (milligrams per deciliter), it's considered severely low. Review of the Electronic Health Record for Resident #19 lacked documentation for the PRN (as needed) blood sugar test at 51 mg/dl on the early morning of 3/17/25. During an interview 3/19/25 at 10:18 AM, Staff G, Registered Nurse (RN), stated she did work Sunday night (3/16/25) into Monday morning (3/17/25), the 6:00 PM to 6:00 AM shift. Staff G stated Resident #19 did have a low blood sugar early Monday morning, around 4:00 AM, she recalled it was around 51 mg/dl. Staff G stated they got the resident a snack to help bring up the blood sugar. Staff G stated she does not normally check the resident's blood sugar in the night on this shift, the resident has scheduled blood sugar checks during the day. Staff G stated the resident told a CNA she was not feeling right and thought her blood sugar was low. The CNA went to tell Staff G this and Staff G went into the resident's room and took her blood sugar. Staff G stated the resident was alert and able to answer questions. Staff G stated she does not remember if she went back into the resident's room to recheck the blood sugar and to see how she was doing. Staff G stated she does not remember if she documented this blood sugar. Staff G stated she should have documented this and she should have gone back into the resident's room to recheck her blood sugar. Staff G stated she would normally give a resident a snack with this low of blood sugar and then go back and recheck their blood sugar in a half hour and check it again in an hour. Staff G acknowledged she did not do this with Resident #19, she did not go back in to check on the resident after taking her blood sugar and noting it was at 51 mg/dl. Staff G acknowledged she did not document in the MAR or in the EHR the low blood sugar. Staff G stated she believed she passed this information on to the day shift nurse. During an interview 3/19/25 at 3:48 PM, Staff H, Licensed Practical Nurse (LPN) stated she did work Monday the 17th, the 6:00 AM to 6:00 PM shift. She stated when she went into Resident #19's room that morning to do the scheduled blood sugar check, the resident told her that she did not feel right earlier that morning and asked to have her blood sugar taken. The resident told Staff H that when Staff G took her blood sugar earlier that morning, around 4:00 AM, it was around 50 mg/dl. The resident stated Staff G just walked out of her room and never came back to check on her. The resident thought it was around 4 am when Staff G took her blood sugar and it was at around 50 mg/dl. When Staff H took the resident's blood sugar that morning as scheduled, it was at 199, she does not remember exactly when she took her blood sugar however it is scheduled before breakfast. Staff H stated Staff G did not report to her that Resident #19's blood sugar was low earlier that morning and it was not documented in the MAR. Review of facility policy on blood glucose, revised 10/24, documented if no specific orders are given on when to call PCP (primary care physician) regarding blood glucose levels, call doctor if blood glucose is less than 60 mg/dl or greater than 300 mg/dl. If no specific orders are given on interventions for blood glucose levels below 60mg/dl, give resident an 8 oz glass of milk or juice and check blood glucose level again in 15 minutes. During an interview 3/19/25 at 4:01 PM, the Director of Nursing (DON) stated an expectation the nurse follow professional standards of practice for blood sugar and hypoglycemia and to provide the necessary interventions and monitoring. If the PCP has not given an order as to when to be contacted, follow facility policy. The DON also stated an expectation the blood sugar testing is documented.

Based on record review, staff interview, and policy review the facility failed to attempt a gradual dosage reduction (GDR) for a psychotropic medication (a medication that affects brain activities associated with mental processes and behavior) for 1 (Resident #16) of 5 residents and failed to limit an as needed (PRN) psychotropic medication to 14 days without a physician's review for 1 (Resident #9) of 5 residents reviewed for un-necessary medications. The facility reported a census of 52 residents. Findings included: 1. The Minimum Data Set assessment dated [DATE] for Resident #16, included diagnoses of Non-Alzheimer's dementia, anxiety disorder, psychotic disorder, and depression and the resident received antipsychotic and antidepressant medication daily. The MDS documented a score of 12, indicating mild cognitive impairment. Resident #16's Medication Administration Record (MAR) dated 3/1/25 - 3/31/25, documented an order for sertraline (antidepressant medication) 100 milligrams (mg) one time a day related to major depressive disorder with a start date of 6/23/21. Interview on 3/20/25 at 2:43 PM, the Director of Nursing confirmed no documentation of a GDR attempt for Resident #16 for the sertraline order and her expectation for an attempted GDR per policy. Facility policy Psychotropic Medication revised 7/2021, revealed residents that receive antipsychotic drugs will receive GDRs and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 2. The MDS for Resident #9, dated 1/18/25, documented a BIMS score of 15, indicating intact cognition. The MDS included diagnoses of medically complex conditions and heart failure. Review of the EHR for Resident #9 included an order for Lorazepam (a Psychotropic medication) tablet 0.5 MG (milligrams) 1 tablet by mouth every 24 hours as needed for anxiety, with a start date of 1/21/25 and a discontinued date of 2/17/25. An order for Lorazepam tablet 0.5 MG, 1 tablet by mouth every 4 hours as needed for anxiety/restlessness was started on 2/17/25 with no end date. Review of the January 2025 Medication Administration Record (MAR) for Resident #9 documented the resident was given the PRN medication of Lorazepam three days. Review of the February MAR for Resident #9 documented the resident was given the PRN medication of Lorazepam 22 days. Review of the March MAR for Resident #9 documented the resident was given the PRN medication of Lorazepam 15 of the 19 days. Review of the EHR for Resident #9 documented a Note to Attending Physician/Prescriber from the pharmacy monthly medication review dated 2/10/25, this resident has an order for a PRN anxiolytic without a stop date: Lorazepam 0.5 mg PRN for anxiety, please clarify. The physician/prescriber response was dated 3/20/25 to discontinue current order. Review of the facility policy Psychotropic Medication, effective date April 2019, documented PRN orders for psychotropic medications are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he/she should document their rationale in the resident ' s medical record and indicate the duration for the PRN order.

Based on clinical record review and staff interview, the facility failed to refer a resident to the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination who was identified with a newly evident mental disorder for one of one resident reviewed (Resident #17). The facility reported a census of 52 residents. Findings include: The Minimum Data Set assessment for Resident #17, dated 4/6/24, included diagnoses of schizophrenia and depression and revealed the resident received antipsychotic and antidepressant medications daily. The resident's PASARR Level I Screen form dated 2/24/21, documented no mental health diagnoses. The resident's medical diagnosis sheet revealed diagnosis of schizoaffective disorder, bipolar type dated 3/1/23 with diagnosis during stay at facility. During the interview on 6/4/24 at 2:45 PM, the Director of Nursing confirmed resident's new diagnosis of schizoaffective disorder and expectation for status change to be submitted with new diagnosis and new medication started.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 16 residents reviewed (Residents #4, #17, #31 and #39) for care plans. The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #31, dated 3/1/24, documented the resident had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. The MDS further documented the resident had diagnoses to include non-traumatic brain dysfunction, atrial fibrillation and non-Alzheimer's dementia. The Electronic Health Record (EHR) review for Resident #31 revealed a progress note dated 4/17/24, titled Behavior Note. The note text documented after dinner, Resident #31 wheeling self back from dining room to his hallway and attempted to leave the facility from the locked front door, triggering the elopement alarm. Resident became combative with staff when they assisted him with getting back into the building safely. Resident stating that he was just going to leave. The EHR review revealed a progress note dated 4/20/24, titled Behavior Note. The note text documented Resident #31 sitting in front of the receptionist desk refusing breakfast and refusing to move or go back to his room. Resident stating, I'm getting out of here now. Resident not actually attempting to leave the facility. Several staff attempted to redirect him with no success. The EHR review revealed a progress note dated 4/30/24, titled Behavior Note. The note text documented Resident #31 attempted to go out one of the doors by the playground, staff able to get to him before he went out. He was confused when asked where he was going. He was upset about not being able to go out the doors but then was redirected. The Care Plan for Resident #31, with an initiation date of 2/28/24, lacked a focus area, goal and interventions/tasks to address elopement concerns and behaviors. During an interview on 6/5/24 at 8:13 AM, the Director of Nursing (DON) stated the Care Plan should have been updated in April after the elopement attempts for Resident #31. The DON acknowledged the Care Plan was not updated and stated an expectation of this to take place. The DON acknowledged the resident had 3 attempts to leave the building in April of 2024 and made statements about wanting to leave. 2. The MDS assessment for Resident #4, dated 5/9/24, documented a BIMS score of 10, indicating moderate cognitive impairment. The MDS further documented diagnoses to include non-traumatic brain dysfunction, anemia, Alzheimer's disease, non-Alzheimer's dementia, anxiety, depression and bi-polar disorder. Review of the EHR for Resident #4 revealed a progress note dated 5/7/24 titled Behavior. The progress note documented the resident attempted to exit through the Tiger Tots door (side door going outside) unattended. The resident stated she wanted to get some fresh air. Review of of the EHR for Resident #4 revealed an elopement evaluation completed on 5/1/24 with an elopement risk score of 2, indicating at risk for elopement. The Care Plan for Resident #4, with an initiation date of 1/31/24, lacked a focus area, goal and interventions/tasks to address elopement concerns and behaviors. During an interview on 6/06/24 at 8:08 AM, the DON stated she would expect the Care Plan to address elopement concern for Resident #4. The DON acknowledged elopement is not addressed in the Care Plan and Resident #4 has a risk identified for elopement. 3. The MDS assessment for Resident #17, dated 4/6/24, documented a BIMS score of 14, indicating intact cognition. The MDS further documented diagnoses to include medically complex conditions, cancer, heart failure, diabetes mellitus, depression and schizophrenia. Review of the EHR for Resident #17 revealed a diagnoses of schizoaffective disorder, bipolar type, initiated on 3/1/23. Review of a Psych Progress Note, dated 4/11/23, for Resident #17 documented under the assessment section the diagnosis of schizoaffective disorder, bipolar type (modified 1/31/23), formed hallucinations of insects, irritability and anger and other specified depressive episodes. The Plan section documents resident had displayed multiple behaviors which have included cursing, screaming, threatening, accusing staff, making disruptive sounds, expressing episodes of anger/frustration, appearing to be agitated and seeming anxious or restless. The Care Plan for Resident #17, with a revision date of 10/18/23, lacked a focus area, goal and interventions/tasks area related to the diagnosis of schizoaffective disorder and related behaviors. During an interview on 6/06/24 at 10:55 AM, the DON stated an expectation the Care Plan would address Schizoaffective disorder and behaviors and interventions specifically for Resident #17. Resident #17 received the diagnosis in March of 2023 and started Risperdal (antipsychotic medication) in March of 2023. The DON acknowledged the Care Plan lacked documentation and interventions related to the Schizoaffective disorder and behaviors. Review of the facility policy titled comprehensive person-centered care planning, with a revision date of 10/23, documents the facility will update the resident ' s comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities and the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Review of facility policy titled elopement prevention, with a revision date of 11/22, under the procedure section, documents elopement interventions are addressed in resident's plan of care. 40905 4. An MDS assessment for Resident #39 dated 4/9/24, included diagnoses of hemiplegia (paralysis), affecting right dominant side and personal history of traumatic brain injury (TBI). The MDS identified the resident had a functional impairment of range of motion to an upper and lower extremity. On 6/03/24 at 11:21 AM, observed Resident #39 in a wheelchair with right hand contracted, with wrist turned inward and fingers curled into palm of hand (no brace/splint) and with brace on right ankle. Observation on 6/4/24 at 12:24 PM, Resident #39 in the dining room with staff assisting to dine and no brace on right wrist. The Rehab Communication Form, dated 8/10/23, for Resident #39 documented recommendation/instruction to place wrist brace on right wrist during the day, remove overnight. Interview on 6/5/24 at 1:24 PM, Staff A Certified Nurse Aide (CNA) stated she was unaware of a right wrist brace for Resident #39. Interview on 6/5/24 at 1:35 PM, Staff B, CNA and Staff C, CNA stated Resident #39 wears a right ankle brace but no wrist brace. Resident #39's Care Plan with focus initiated 4/5/24 documented an activities of daily living self-care performance deficit related to TBI and having right side paresis with intervention to place wrist brace on right wrist during the day, remove overnight with date initiated 8/10/23. During an interview on 6/6/24 at 9:23 AM, the Assistant Director of Nursing stated expectation to follow therapy recommendations.

Based on clinical record review, observations, staff interviews and medical procedure guides, the facility failed to provide professional standards by not obtaining an order to have an indwelling catheter by a physician for 2 of 2 residents reviewed (Resident #10 and #26). The facility reported a census of 52 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #26 documented diagnoses of traumatic spinal cord dysfunction, neurogenic bladder, quadriplegia and seizure disorder. The MDS showed the Brief Interview for Mental Status (BIMS) was not completed as Resident #26 is coded as a persistent vegetative state. The MDS has Resident #26 coded as having an indwelling catheter. The Treatment Administration Record (TAR) dated June 2024 lacked an order for the indwelling catheter and when it should have been changed next. The TAR dated May 2024 lacked an order for the indwelling catheter and when it should have been changed next. The TAR dated April 2024 lacked an order for the indwelling catheter and when it should have been changed next. The TAR dated March 2024 lacked an order for the indwelling catheter and when it should have been changed next. The TAR dated February 2024 lacked an order for the indwelling catheter and when it should have been changed next. Review of Progress Notes dated 9/16/23 revealed Resident #26 had been readmitted to the facility with the indwelling catheter. Progress Notes stated Foley catheter in place patent and draining (placed on 9/9/23). The facility catheter insertion procedure guide dated 6/13/2006 revealed that part of the procedure is to check the physician order for type and size of catheter and related diagnosis. Interview on 06/05/24 at 10:04 AM with the DON revealed Resident #26 went to the hospital in April 2023 and all the orders regarding the catheter were discontinued, the order had always been to change the catheter as needed (prn). We received the order to change it today to 18 F, so we are going to change it today. I would have expected it to be transcribed correctly upon readmission. 40905 2. An MDS assessment for Resident #10 dated 5/16/24, included diagnoses of spastic quadriplegic cerebral palsy (brain damage condition that causes paralysis of both arms and both legs, with muscle stiffness). The MDS identified the resident had an indwelling urinary catheter. Observation on 6/4/24 at 10:03 AM, of Resident #10 in bed with a catheter in place and the catheter bag in a dignity bag attached to the bed. Resident #10's electronic record of Physician Order Summary Report dated 6/4/24 at 2:38 PM, lacked an order for an indwelling catheter.

Based on observations, staff interviews, and facility policy review the facility failed to prevent significant medication errors to 4 of 4 residents reviewed (Resident #5, Resident #18, Resident #32 and Resident #37). The facility reported a census of 41 residents. Findings include 1. Resident #32's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS included diagnoses of anemia (low blood iron), deep vein thrombosis (DVT, blood clot), and hypertension (high blood pressure). The MDS listed an admitted [DATE]. The MDS indicated that Resident #32 received an anticoagulant (blood thinner) for seven out of seven days in the lookback period. Resident #32's March 2023's Medication Administration Record (MAR) listed the following orders: a. apixaban (Eliquis, a blood thinner) 2.5 milligrams (MG), started 4/29/22 and discontinued 3/13/23 to give one tablet by mouth two times a day for DVT prophylaxis (prevention). b. Eliquis Oral Tablet 2.5 MG, started 3/13/23, to give 2.5 MG by mouth two times a day related to an acute (short-term) embolism (blood clot) and thrombosis of unspecified deep veins of the right lower extremity. i. The order was held from 3/17/23 - 3/20/23, then discontinued on 3/20/23. ii. On 3/15/23 - 3/16/23 documentation indicated Resident #32 did not receive due to a hospitalization . The Photocopy of Resident #36's Eliquis 2.5 MG tablet medication cards dated 2/21/23 labeled early AM for 14 days listed two rows labeled Sunday through Saturday revealed two tablets missing from the left side of the card for Wednesday and Thursday. The Photocopy of Resident #36's Eliquis 2.5 MG tablet medication card dated 2/21/23 labeled PM for 14 days listed two rows labeled Sunday through Saturday revealed five tablets missing. The Photocopy of Resident #36's Eliquis 2.5 MG tablet medication card dated 3/7/23 labeled early AM for 14 days listed two rows labeled Sunday through Saturday. Next to Friday included a handwritten 3-10. The card had three tablets missing from the left side of the card for Wednesday, Thursday, and Friday. A letter dated 3/16/23 written by the Physician identified his medical opinion that the medication error at the nursing home did not cause Resident #32 to be hospitalized . The letter continued to add that it did exacerbate a pre-existing condition. The undated document labeled Type of Event: Missing Medication listed that Resident #32 had three 14 day medication cards of Eliquis with missing medication. The Summary indicated that Resident #32 had an order for Eliquis to give one 2.5MG tablet by mouth two times a day. The document indicated that Resident #32 potentially received an extra dose of Eliquis on 3/8/23 and 3/9/23. On 3/21/23 at 8:23 AM, Staff B, Certified Medication Aide (CMA), reported that the facility discovered that Resident #32 had a possible medication variance for Eliquis. Staff B explained that some of the residents had two 14 day cards. Staff B stated medication cards are not on the same 14 day cycle for all residents. Staff B stated the14 day cycle is not changed out on the same day. Staff B said that on 3/10/23 that Resident #32 had two AM cards with two medications missing in each. Staff B stated they did not look at the evening dose or even the card. Staff B denied recalling the bedtime dose being turned around. Staff B stated that the nurse got immediately notified. Staff B explained that the nurse took copies and told the CMA to administer that day's dose. On 3/21/23 at 8:35 AM, Staff C, CMA, stated that he administered medications on 3/9/23. Staff C reported that he gave Eliquis from only one card on 3/9/23. Staff C explained that sometimes more than one card for each dose of 14 day medications are in the cart. Staff C reported that he could not remember if the medication cart had one or two am medication cards facing forward. Staff C added that he did not date the medication card and does not when he passes medications. On 3/23/23 at 3:24 PM, Staff H, CMA, reported that she remembered a second card in Resident #32's drawer. Staff H explained that she only gave Eliquis from one card. Staff H stated that she did not remember if the second card had any medications missing from the card. On 3/20/23 at 3:30 PM, the Administrator stated certain residents have 14 day cards for certain medications. The Administrator stated typical residents have a 30 day supply but the pharmacy stated that the facility can not get a 30 day supply on certain medications due to insurance. The Administrator stated on the morning shift of 3/10/23 Staff B noticed duplicates of Eliquis for Resident #32. The Administrator said Staff B notified Staff I, Licensed Practical Nurse (LPN), at the time, who then notified Staff D, LPN/Medical Records, and the Director of Nursing (DON). The Administrator stated Staff D removed the extra 14 day cards. The Administrator added that Staff I completed an assessment on Resident #32 and did not find anything abnormal. Afterwards, Staff I sent a Situation Background Assessment Recommendation (SBAR) form to Resident #32's physician. The Physician gave no new orders and requested to be notified with any changes in assessments. The Administrator said on 3/15/23 the staff noticed Resident #32 refused to eat. The Administrator explained the staff notified the doctor via phone with no answer. The Administrator reported the staff called the office then sent Resident #32 to the emergency room (ER). The Administrator explained that Resident #32 had a history of gastrointestinal (G.I.) bleeds (bleeding in the stomach area). The Administrator reported they stopped the Eliquis and Resident #32 did not have any more bleeding. The Administrator reported that Resident #32 had a G.I. bleed. The Administrator explained that during the investigation the CMA's said they did not give any extra doses. The Administrator denied reviewing the cameras in the investigation. The Administrator stated the previous process would put cards out prior to the last dose of medication being given. The Administrator stated now the last dose is given prior to the new card being put out. The Administrator reported that they had no conclusion to the investigation. On 3/20/23 at 3:15 PM, the DON expressed the Administrator had the investigation report. The DON reported that the investigation found that some medication packs have 14 day cards instead of 30 day cards. The DON stated that Resident #32 had two cards for Eliquis 2.5 mg twice a day. The first and second cards both had doses punched out. The DON said the drawer had a third card present, the PM dose. The DON explained that the physician wrote an order to not do a basic metabolic panel (BMP, blood test) in October 2022. The DON stated the physician did not order a Hemoglobin per the family's request in October. 2. Resident #5's MDS dated [DATE] identified a BIMS score of 14, indicating no cognitive impairment. The MDS included diagnoses of anemia, heart failure, and hypertension. The MDS listed an admitted [DATE]. The MDS indicated that Resident #5 Resident #5's March 2023 MAR listed an order dated 9/27/19 for Eliquis oral tablet to give 2.5 mg by mouth two times a day. The Photocopy of Resident #5's Eliquis 2.5 MG tablet medication cards dated 3/7/23 labeled one of two for 14 days listed two rows labeled Sunday through Saturday revealed two tablets remained. The Photocopy of Resident #5's Eliquis 2.5 MG tablet medication cards dated 3/7/23 labeled two of two for 14 days listed two rows labeled Sunday through Saturday revealed the card only had five remaining tablets. 3. Resident #18's MDS dated [DATE] identified a BIMS score of 13, indicating no cognitive impairment. The MDS included diagnoses of hypothyroidism, anemia, coronary artery disease, and hypertension. The MDS listed an admitted [DATE]. The MAR included an order dated 9/28/19 for levothyroxine 75 micrograms (mcg) to give one tablet by mouth once a day. On 3/23/23 at 2:25 PM the Photocopy of Resident #18's levothyroxine 75 mcg tablet medication cards dated 3/21/23 labeled one of one for 14 days listed two rows labeled Sunday through Saturday revealed two tablets remained. The medication card contained all 14 medications, including the tablets for the days of 3/22/23 and 3/23/23. On 3/23/23 at 3:24 PM Staff H reported that Resident #18 refused her morning medications. Staff H said that Resident #18 medications got disposed of in the medication destroyer. Staff H explained that she disposed of medications on her own per the facilities policy. Staff H said she gave Resident #18 Levothyroxine from the card that had the morning's date on it. Staff H reported that the card only had one pill. Staff H stated she ripped the top off the card and threw it in the shred bin. Staff H stated she did not have to ask a nurse for a new card. Staff H stated the new card was already on the cart. Staff H stated did not look at the date on the new card. On 3/27/23 at 1:47 PM DON stated the facility's expectation is that Resident #18 Levothyroxine would not have two of the same dose cards in the medication cart at one time. On 3/27/23 at 2:33 PM, Staff D reported the pharmacy picked up the medication cards with any previous medications from the 14 day medications on 3/21/23 from a CMA working on the medication carts. The staff put in the new cards in the medication cart. Staff D stated they must have missed Resident #18' levothyroxine and added a new card into the medication cart. Staff D explained the facility's expectation that the medication cart did not have two of the same dose of levothyroxine cards in the cart at once. On 3/23/23 at 2:30 PM, Staff F, Regional Director of Quality and Clinical Services, reported the facility's expectation is that Resident #18 received levothyroxine from the medication card that was present with start date of 3/22 and 3/23 date and not from any other card. 4. Resident #37's MDS dated [DATE] identified a BIMS score of 10, indicating moderate cognitive impairment. The MDS lincluded a diagnosis of hypothyroidism. The MDS listed an admitted [DATE]. Resident #37's March 2023 MAR included an order dated 6/9/22 for levothyroxine 75 mcg to give one tablet by mouth once a day. The Photocopy of Resident #37's levothyroxine 50 mcg tablet medication cards dated 3/21/23 labeled one of one for 14 days listed two rows labeled Sunday through Saturday revealed two tablets remained. The medication card contained all 7 medications. The Medication Administration procedure revised March 2023 directed that medications must be administered in accordance with the orders, including any required time frame. If a dosage could be inappropriate, excessive, or could have potential adverse consequences for the resident, the person preparing or administering the medication should contact the resident's attending physician or the facility's Medical Director to discuss the concerns. The procedure continued to instruct that the individual(s) administering the medication must check the label three times to verify the right medication, right dosage, right time, and right method of administration before giving the medication. Documentation on the electronic Medication Administration Record (EMAR)/Treatment Administration Record (TAR) may be done one of two ways: a. Punch medication from card, administer medication, initial EMAR/TAR, or b. Punch medication from card, initial EMAR/TAR, administer medication.

Based on observation, staff interview, and policy review the facility failed to store and prepare food in accordance with professional standards for 41 of 41 residents. The facility reported a census of 41 residents. Findings include On 3/20/23 from 10:30 AM through 11:30 AM during a continuous observation of the initial kitchen tour revealed: a. The reach-in refrigerator contained four pounds (lbs) of whipped margarine and fruit jello without an open date. b. The walk-in freezer lacked an open date on a plastic container of parmesan cheese, a bag of chicken patties, a bag of breaded chicken, a 48 ounce (oz) container of strawberry ice cream, and on a bag of chicken strips. c. The walk-in freezer had large deposits of ice pooled on top of a 10 lbs box of beef square ravioli, a 31 lbs box of bean and cheese burritos, a 20 lbs box of frozen pasta, and a 3 gallon container of sherbet. The Storage Policy reviewed December 2022 revealed the following: a. Food storage areas shall be maintained in clean and orderly condition. b. Food will be purchased in quantities that can be stored properly c. Food held in the refrigerator or other storage areas shall be appropriately covered, labeled, and dated. d. Food that is prepared and not served will be stored appropriately, clearly labeled, identifiable, and dated. On 3/20/23 at 11:00 AM, Staff A, Dietary Manager, stated the facility's expectation is that all open packages should be dated. Staff A stated the facility's expectation is for no ice to be present on any of the packages in the freezer. Staff A added that the issue has been reported and addressed. Staff A explained the freezer repair directed to close the door, as the ice build up is from condensation due to the door being open. Staff A stated the food items with ice build up should and will be thrown away.

Based on clinical record review, staff interview and policy review, the facility failed to provide the resident/resident representative notice of the bed hold policy at the time of transfer for hospitalization for one of one resident reviewed (Resident #36). The facility reported a census of 41 residents. Findings include: Resident #36's Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of coronary artery disease (heart disease caused by reduced blood flow) and depression. The MDS identified a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition for decision-making. The MDS indicated that Resident #36 reentered the facility from an acute (short-term) hospital stay. The Physician Order note dated 1/2/23 at 2:13 PM indicated that Resident #36's physician gave an order to transfer him to the emergency room (ER). The Admission/Readmission UDA note dated 1/13/23 at 10:51 AM indicated that Resident #36 returned to the facility. The eMAR - Medication Administration note dated 1/13/23 at 5:30 PM identified that Resident #36 got hospitalized . The Admission Summary note dated 1/17/23 at 2:17 PM documented that Resident #36 returned to the facility. The clinical record lacked documentation of notification to Resident #36 or Resident #36's Representative regarding the bed-hold policy at the time or after he transferred to the hospital. The facility policy titled, Bed Hold Policy, revised November 2022, directed that before a nursing facility transfers a resident to a hospital, the nursing facility must provide written information to the resident or the resident's representative that specifies the duration of the state bed-hold policy, the reserve bed payment policy, and the nursing facility's policies regarding bed-hold periods. On 3/22/23 at 2:42 PM the Administrator verified that Resident #36's clinical record did not have documentation of a bed hold completed with resident's transfer to the hospital. The Administrator explained that they expected a bed hold to be provided with any hospital transfer.

Based on record review and staff interview the facility failed to update the Care Plan to accurately reflect the Resident's plan of care after a new diagnosis with the addition of a significant medication for two of 5 residents reviewed (Resident #16 and Resident #37). The facility reported a census of 41 residents. Findings include: 1. Resident #16's Minimum Data Set (MDS) assessment dated [DATE] included a diagnosis of Dementia. The MDS identified a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment for decision-making. The MDS listed that Resident #16 took an antidepressant (medication used to treat depression) for six out of seven days in the lookback period. Resident #16's Medical Diagnosis Sheet documented a new diagnosis of anxiety disorder on 2/24/23. Resident #16's March 2023 Medication Administration Record (MAR) included the following orders: a. Buspirone (medication used to treat anxiety), started 2/27/23, 5 milligrams (mg) give 1 tablet every day and evening shift related to anxiety disorder. b. Celexa (medication used to treat depression), started 9/20/22, tablet 10 mg give 1 tablet by mouth one time a day related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Resident #16's Care Plan, with a target date of 5/23/23 lacked documentation of a diagnosis of anxiety disorder, the use of an antianxiety medication, or the use of an antidepressant medication. 2. Resident #37's MDS assessment dated [DATE], included diagnoses of depression, adjustment disorder with mixed anxiety, depressed mood, and lymphedema (swelling due to a build-up of fluid in the body). The MDS listed that Resident #37 received an antidepressant, antipsychotic, and diuretic medications for seven out seven days in the lookback period. The MDS identified a BIMS score of 10, indicating moderate cognitive impairment for decision-making. Resident #37's March 2023 MAR included the following orders: a. Desvenlafaxine (antidepressant), started 8/9/22, 100 mg daily for Depressive Disorder b. Abilify (antipsychotic), started 12/7/22, 5 mg daily for Major Depressive Disorder c. furosemide (diuretic to decrease fluid build-up), started 9/2/22, 20 mg daily for Lymphedema. d. Insulin detemir solution (used to treat elevated blood sugars), started 8/8/22, 100 unit/milliliters (ml) Inject 20 units subcutaneously two times a day related to type 2 diabetes mellitus with unspecified complications. The Care Plan with a target date of 5/16/23 lacked documentation of that Resident #36 used, what side effects, or symptoms to observe with the use of diuretic, antianxiety, insulin, and antidepressant medications. On 3/23/23 at 1:32 PM, Staff F, Regional Director of Quality and Clinical Services, confirmed the medications (antidepressant, antianxiety, and diuretic) were not included in Resident #16 and Resident #37's Care Plans. Staff F reported they expected the Care Plans to be updated with new medications, side effects, and monitoring.

Based on record review and staff interview, the facility failed to meet professional standards of quality by not following a physician's order for one of twelve residents reviewed (Resident #37). The facility reported a census of 41 residents. Findings include: Resident #37's Minimum Data Set (MDS) assessment dated [DATE], included a diagnosis of diabetes mellitus. The MDS listed that Resident #37 received insulin for seven out seven days in the lookback period. The MDS identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment for decision-making. Resident #37's Clinical Physician Order Sheet listed a physician's order for 9/23/22 for a HgA1C (lab work that measures the average amount of sugar in the blood for diabetes over three months) every 6 months starting on the 9/23/22. Resident #37's clinical record lacked documentation of a completed HgA1C. On 3/23/23 at 3:30PM, the Administrator confirmed that did not have the HgA1C completed. The Administrator explained that she expected the staff to follow the physician's orders.

Based on record review, observation, and staff interviews, the facility failed to ensure the facility provided adequate supervision and appropriate interventions to ensure against hazards from self (Resident #9) and failed to ensure the maintenance of safe hot water temperatures to prevent potential injury to residents. The sample consisted of 7 residents reviewed with falls. The facility identified a census of 85 residents. Findings include: 1. Resident #9 had a MDS (Minimum Data Set) assessment with a reference date of 1/19/2017. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS documented the resident had impaired short-term and long-term memory, moderately impaired decision making skills, and required cues and staff supervision. The MDS documented the resident required extensive assistance of one staff person for transfers, and limited assistance of one staff for bed mobility and ambulation. The MDS indicated the resident had unsteadiness when transferred from one surface to another surface, stood up from a seated position, and when ambulated. The MDS revealed the resident had 2 or more falls since admission, and took antipsychotic, antianxiety, and antidepressant medications. The MDS dated [DATE], revealed Resident #9 had short-term and long-term memory impairment, and decision making skills severely impaired. The MDS revealed the resident independent with bed mobility, transfers, and ambulation. The MDS indicated the resident had unsteadiness when transferred from one surface to another surface, stood up from a seated position, and when ambulated. The MDS revealed the resident had 2 or more falls with injury since the prior MDS assessment, and took antianxiety and antidepressant medications. The care plan dated 7/10/17, identified the resident had a risk for falls. The Care Plan interventions included the following: a. Staff to use gait belt, and attempt one staff assistance and front-wheeled walker whenever the resident was up. If the resident refused all interventions, staff to ensure resident safe and keep the resident in view whenever the resident up. b. Ensure resident wearing appropriate footwear, and gripper socks worn in bed c. Hip protectors on over pull-up/brief as the resident allows d. Keep door to resident's room open at night, and whenever resident in room to better hear resident activities e. Motion sensor on when resident in bed f. Non-skid strips by the bed, recliner, and at the foot of the bed g. Dress in appropriate length pants or fold pant cuff up to prevent resident from walking on pants. The care plan indicated the resident had a history of [REDACTED]. The care plan revealed the resident sent to the ER (emergency room ) after a fall on 7/6/17. The care plan included a fall risk protocol with the following interventions: a. A heightened awareness of resident with a fall risk and to watch the resident more closely b. Monitor appropriate bed, rails, and safety devices c. Skid strips in all places needed d. Gripper socks or shoes on at all times A fall risk assessment completed on 6/26/17 identified the resident had a high risk for falls. Incident reports for Resident #9 included the following: 1/4/17 at 6:15 p.m.- resident found on floor in the hallway. Staff reported they last saw the resident walking in the hallway. Staff instructed someone should be present when residents' in the hallway. 1/8/17 at 4:10 p.m.- resident found lying on back in hallway, and had no walker. 1/14/17 at 9:10 p.m.- resident found lying on right side on floor by bed without apparent injury. 1/21/17 at 12:40 p.m.- resident found lying on right side on bathroom floor in another resident's room. The resident had pants and underwear around lower legs, and had a skin tear to the right temple. 1/21/17 at 7:40 p.m.- staff heard a thud, searched rooms, and found resident on floor mat by bed. 1/24/17 at 2:25 a.m. - resident found lying on floor between bed and small table. Motion alarm placed. 1/26/17 at 9:40 a.m.-resident fell on to buttocks in the dining room. Staff reported the resident paced around the dining room and lost balance, and sustained a skin tear to the right elbow. Steri-strips applied to the elbow. 1/26/17 at 9:20 p.m.- resident walked unstable all shift, picked up items in reach, and bent toward floor to retrieve items. Staff heard resident yelling, and found resident sitting on floor in another resident's room. The resident incurred a skin tear to the left elbow. The interventions put in place included a motion sensor in room when the resident in bed and geri-sleeves as the resident allowed. 3/16/17 at 12:10 p.m.- resident bent over chair in dining room and slid onto the floor. 3/23/17 at 9:45 a.m. - resident found lying on right side, naked, on floor next to a closed bathroom door. 4/18/17 at 11:50 a.m.- resident paced dining room floor, stepped backward several steps and lost balance, hit head on floor and upper back on table. The intervention included fold pant cuffs up. 4/27/17 at 3:10 p.m.-staff heard a thud and found resident lying on right side with blood on right forehead and right forearm. The resident had a 1 cm x 2.4 cm laceration to the right forehead, 2.1 cm x 1.5 cm skin tear on the right forearm, and a hematoma to the forehead. Resident sent to ER for evaluation. 5/24/17 at 6:30 p.m. - Aide requested the resident wait and hold onto the handrail while aide retrieved and brought walker to resident. The resident lunged toward staff. Staff documented the resident had a very quick mood change. 6/11/17 at 12:15 p.m. - resident had fall and hit head when he/she walked down the hallway. Blood noted to the back left side of head. The intervention included to ensure hallway clear. The report indicated the resident required one staff assistance for mobility. 7/5/17 at 7:15 p.m.- staff heard a noise and found the resident lying on right side on floor at the foot of the bed. The resident had a 3.1 x 1.2 x 0.2 cm laceration to the right forehead. A motion alarm in place and working. The report indicated the resident independent with standby staff assistance as needed. 7/6/17 at 12:30 p.m.- resident found lying on floor with blood on head and floor. The resident had a large laceration to right forehead where previous injury had occurred on 7/5/17. Resident sent to the ER. The major injury determination form dated 1/9/17 for injury that occurred on 1/8/17 at 4:10 p.m., revealed the resident ambulated with one staff assistance and a 4-wheeled walker as allowed. The resident commonly refused assistance or forgot the walker. The major injury determination form dated 1/21/17 for injury that occurred on 1/21/17 at 12:40 p.m., revealed the resident had received a suppository and a short time later, the resident self transferred to the bathroom and fell . The resident required assistance of one staff and a 4-wheeled walker. A nurse practitioner note dated 5/1/17, revealed resident seen in theER on [DATE] after the resident had an unwitnessed fall. The resident had a skin tear to the right eyebrow and hematoma. The ED (emergency department) Physician Note dated 5/24/17, revealed resident brought to ED following a fall. The resident had a 4 centimeter (cm) laceration to the right forehead and a skin tear to the right elbow measuring 3.5 cm and 1.5 cm. A fax communication to the physician on 7/5/17, documented the med aide heard a loud noise at 5:15 p.m., and found the resident lying on floor on right side at the foot of the bed, and walker away from reach. The resident had an open area to the right forehead. The resident denied dizziness but reported he/she had felt dizzy at times. Resident transferred to the hospital. A hospital discharge summary revealed the resident admitted to hospital on [DATE], and discharged on [DATE], indicated the resident had [DIAGNOSES REDACTED]. The radiology CT head scan report dated 7/6/17, revealed a small right front temporal subdural hematoma (brain hemorrhage behind the forehead and temples). The nurse's notes revealed the following: 4/18/17 at 3:23 p.m.- At 11:50 a.m., resident stepped backward and lost balance, and struck head on floor. 4/27/17 at 11:42 p.m.- At 3:10 p.m., resident observed on floor in peer's room, lying on right side, with blood to forehead and right forearm. The resident had a laceration on right forehead, skin tear to right forearm, and a hematoma to forehead. Resident sent to the ER for evaluation. 5/24/17 at 10:17 a.m.- At 6:30 p.m., resident fell on right side and hit right forehead on tile floor. Resident sent to the ER. 6/12/17 at 6:21 a.m.- At approximately 12:15 p.m., resident had fall in hallway. Resident possibly tripped over another resident and hit back of head. 7/5/17 at 8:11 p.m.- At 5:15 p.m., med aide heard a loud noise. Resident found on right side lying at foot of bed and walker out of reach. An open area noted to right forehead that measured 3.1 cm by 1.2 cm by 0.2 cm, bruises to right elbow that measured 2.4 cm by 1.8 cm, and 4.1 cm by 2.2 cm dark blue, and resident reported he/she felt dizzy sometimes. Resident transferred to the hospital. 7/6/17 at 1:23 p.m. - At 12:30 p.m., found resident lying on floor, thrashing back and forth, and hollered out. Resident sent to the ER for evaluation. 7/6/17 at 6:10 p.m. - Call received from ER nurse. Resident admitted to hospital for observation due to right forehead laceration and a subdural bleed. The ER nurse report 3 internal sutures and 6 external sutures applied. 7/7/17 at 1:21 p.m. - Resident returned to care facility. The physician's orders [REDACTED]. patch, lorazepam (for anxiety) 0.25 mg twice a day (BID), tramadol (anti-inflammatory pain medication) 50 mg BID, Toprol XL (for high blood pressure) 25 mg daily, meloxicam (anti-inflammatory pain med) 7.5 mg daily, trintellix (antidepressant) 10 mg daily, mirtazapine (antidepressant) 15 mg at bedtime, Norco (narcotic) 5/235 mg 1 tab every 6 hours as needed for pain. During observation on 7/10/17 at 1:35 p.m., Resident #9 laid in bed on his/her right side. Bed in low position. At 1:44 p.m., another resident wandered into Resident #9's room and triggered a motion sensor alarm. Staff E, Certified Medication Assistant (CMA) guided the wandering resident from the room and reset the motion sensor alarm. Staff E placed the sensor alarm on the resident's dresser located on the opposite wall from the bed. The resident's eyes remained closed when the alarm sounded. At 2:40 p.m., the resident sat on the edge of the bed. No alarm sounded. At 2:43 p.m., the resident stood in the middle of the room between bed and recliner chair, next to walker. As the resident started to move, he/she stepped backward, and alarm sounded. A Certified Nursing Assistant (CNA) entered the room. The resident rubbed the right side of head. Dried dark blood noted to the resident's right forehead, a hematoma observed to the back right side of the resident's head. In an interview 7/11/17 at 1:50 p.m., Staff E, CMA, reported staff needed to keep Resident #9 in sight when the resident moved around or when resident in his/her room. The resident sometimes used walker. Staff E reported on 7/6/17, she had just opened the double doors to the activity room and heard a bang. Staff D stated she walked down the hall and found Resident #9's legs sticking out from a chair in the Alcove. Staff E reported Staff F, CNA, in another resident's room and couldn't leave that resident, and Staff H, Unit Aide, had walked another resident out of the dining room. Staff E reported the resident had an unsteady and shuffled gait. A motion sensor placed in the resident's room but the sensor had to be placed in a location which picks up the resident movement, to detect arms or legs moving. Staff E stated she placed the resident's walker next to the bed, so the resident had to move walker when tried to get up. In an interview 7/11/17 at 1:40 p.m., Staff F, CNA, reported Resident #9 often refused walker. On 7/6/17, the resident fell and hit right forehead on the floor. Staff F reported the resident very unbalanced and unsteady on feet, and even more unsteady when walked, but the resident refused to use walker. Staff F reported she assisted another resident to the bathroom when she heard a noise. Resident #9 lay on the floor in the Alcove, just outside of the room where Staff F was in. In an interview 7/11/17 at 3:55 p.m., Staff G, CMA, reported the resident often refused cares and failed to use walker at times. Staff G reported the resident had fallen frequently, and always fell to the right side. The resident had episodes when unsteady, but staff needed to pay attention to the resident's location and what the resident was doing. Staff G stated she had worked on 7/5/17 evening, and had just helped the resident to bed. Staff G stated she left the resident's room on way to obtain medications, when another CNA requested her assistance for another resident. Staff G then obtained medications and walked down the hall toward Resident #9's room when she heard a resident fall. Staff G looked over to the resident's room and saw the resident's door closed. When Staff G entered the resident's room, she found the resident lying on the floor hollering for help. Staff G reported all residents with alarms placed had room door left open in order for staff to hear alarm and monitor those residents. Staff G reported she thought a wandering resident had closed the resident's door. In an interview 7/12/17 at 9:05 a.m., Staff H, Unit Aide, stated she had worked on 7/6/17 when Resident #9 fell . Staff H reported she gave Resident #9 the walker, then went and assisted another resident out of the dining room. Staff H reported she turned around and Resident #9 lying on the floor and screaming. Staff E, CMA, came to assist the resident. In an interview 7/12/17 at 9:55 a.m., Staff I, Restorative Aide (RA) and CNA, reported staff tried to place walker within reach but the resident forgetful and not able to comprehend how to use the walker. Staff I stated she re-approached and gave the resident the walker if she saw the resident without walker. In an interview 7/12/17 at 10:45 a.m., Staff J, Physical Therapist, reported the nurse or RA would let therapist know if a resident needed a therapy evaluation. Staff J reported they sometimes received a referral for a resident after a fall. Staff J advised Resident #9 last seen on 10/28/2015 for therapy. Staff J reported at that time, the resident required maximum assistance for transfers and mobility. In an interview 7/12/17 at 3:50 p.m., Staff C, CMA, reported on 7/5/17, she assisted Staff G with another resident and heard a noise. Staff C walked to Resident #9's room and found the resident lying on the floor with the sensor alarm going off; she was trying to figure out where the noise was coming from. The resident had the walker close by he/she had been walking with the walker. In an interview 7/12/17 at 3:58 p.m., Staff L, Unit Aide, reported on 7/5/17, she had passed snacks to the residents on the unit. Staff L stated she heard a scream, and walked toward Resident #9's room, and found the resident's room door closed. When she opened the door, she saw the resident lying on the floor by the bathroom door, at the foot of the bed. Staff L reported the resident lying in bed the last time she saw the resident. Staff L stated she thought another resident who wandered had closed the resident's door. Staff L stated they had 3 staff working on 7/5/17, but sometimes needed additional staff working due to several residents required continued monitoring. Staff L reported residents' had fallen because staff couldn't be near a resident to prevent fall, when staff provided cares for other residents. In an interview 7/12/17 at 5:25 p.m., Staff M, Registered Nurse, (agency staff) reported he had worked on 7/6/17 and administered treatments on another unit when he received a call on the warlike device for a nurse Stat (immediately) to come to the second floor unit, for a resident on the floor. Staff M reported when he arrived, he found Resident #9 lying on right side with head toward the foot of the bed and his/her head bleeding. Staff reported to Staff M, that they had just put the resident to bed, and 2 staff went to help another resident, then they heard a noise. The sensor alarm had gone off. Staff M, reported the resident required assistance of 1 staff as allowed by the resident prior to the fall, but sometimes refused assistance. And that sensor alarms have to be checked every shift, and need to be positioned in a location in order to detect the resident's movement. In an interview with the Director of Nursing (DON) on 7/12/17 at 11:00 a.m., the DON stated anytime a resident had a fall, they determined if a therapy referral needed and looked at the reason for a fall. The DON reported he reviewed all falls and put interventions on the care plan. The DON reported a number of interventions used but it depended on the resident. After every fall, he evaluated the interventions tried and if interventions effective. The DON reported staff needed to keep Resident #9 in view and tried to get the resident to use the walker. The DON had been unsure if there had been a therapy referral in the past few months after the resident had a number of falls. At 3:20 p.m., the DON reported no policy for falls but they used a Fall Scene Incident Report and reviewed the information for quality assurance, and to help identify the root cause of a fall. 2. During the initial tour of the facility on 7/10/17, between 8:22 to 9:22 a.m., a random check of hot water temperatures, with surveyor thermometer, revealed the following: Room 151 - temperature of 126 degrees Fahrenheit (F.) Room 156 - temperature of 122 degrees F. During the environment tour on 7/12/17, from 9:00 a.m. to 11:00 a.m., the Plant Manager verified there are 2 water heaters, used to provide hot water to areas of resident use, which are set at 130 degrees. He reported the water temperatures at the point of use varied greatly within a floor, from floor to floor and time of day, due to the age of the plumbing system and mixing valve. He acknowledged routine water temperature testing identified temperatures exceeded 120 degrees at times, which measured as high as 125 to 126 degrees, but reported on the same day, in another area, the temperature could be in the low upper 90's to low 100's. The Plant manager reported this made it difficult to find an adjustment for the mixing valve that would result in consistent temperatures throughout the building. On 7/12/17, at 11:00 a.m., the Plant Manager measured bathroom sink temperatures, with a facility thermometer, in room 151 at 124 degrees F. and a temperature in room 156 at 119.3 degrees F. On 7/12/17, at 11:15 a.m., bathroom sink temperatures measured at 125.6 degrees F. in room 151 and 119.7 degrees F. in room 156. Review of documents titled Weekly Random Water Temps, from 1/2/17 to 7/6/17, revealed 141 documented temperatures ranging 121-127 degrees. Review of a policy titled Hot Water Heaters/Hot Water Temperature, dated June 2016, revealed in part . Water temperatures will be checked weekly and recorded temperatures adjusted as needed to maintain between 95 to 120 degrees Fahrenheit. During an interview on 7/12/17, at 11:45 a.m., the Administrator and Director of Nursing (DON) reported they had not been aware of any issues with hot water temperatures exceeding 120 degrees F. They confirmed there had been no resident burns related to hot water temperatures or staff/resident complaints about the water being too hot. During a follow-up interview on 7/12/17, at 1:40 p.m., the Administrator reported the Plant Manger turned the water heaters down 10 degrees, refilled them and would check temperatures later to ensure they fell in the desired range. The Administrator identified 10 residents, with a Brief Interview of Mental Status (BIMS) score below 13 (which indicated impaired cognition), who were independent in their use of the bathroom.

Based on record review and staff interview, the facility failed to adequately and timely assess Resident #3 for adequate pain control and medication following a fall and failed to assess and implement the facility bowel protocol. The sample consisted of 18 residents and the facility reported a census of 92 residents. Findings include: 1. Resident #3 had a MDS (Minimum Data Set) assessment with a reference date of 4/7/16. The MDS identified the resident had had [DIAGNOSES REDACTED]. The MDS indicated the resident had a BIMS (Brief Interview for Mental Status) score of 7. A score of 7 identified the resident as moderately impaired for cognition. The MDS documented the resident required assistance for bed mobility, transfers, and walking. The MDS documented the resident required the use of a walker for mobility. The Care Plan dated 4/15/16, directed staff the resident used a front wheeled walker and ambulated independently. The resident used a wheelchair for long distances. The Care Plan identified the resident as a fall risk. The Fall Scene Incident Report dated 4/18/16 at 5:25 a.m. documented the resident needed assistance per the Care Plan. The report listed an intervention for the resident to have a pad alarm. The Departmental Notes dated 4/18/16 at 6:31 a.m. documented the resident fell at 5:25 a.m. landing on the left side and the resident complained of extreme pain especially with movement. The Departmental Notes documented the resident did not have bruising, legs had equal length, and no leg rotation noted. The Departmental Notes documented the resident had facial grimacing and could not stand still enough to obtain a blood pressure. The Departmental Notes documented Staff AK, licensed practical nurse, sent a facsimile to the ARNP (Advanced Registered Nurse Practitioner). Staff K documented he administered Tylenol. The Medication Administration Record [REDACTED]. The resident received a [MEDICATION NAME] for pain. The facsimile dated 4/18/16 at 6:00 a.m. documented the resident fell at 5:25 a.m. The resident complained of extreme pain in the left extremity with no rotation noted, and able to bear weight when standing but unstable. The Fall Scene Incident Report dated 4/18/16 at 6:50 a.m. documented the resident received assistance per the Care Plan. Staff M, licensed practical nurse, contacted the on call physician and received an order for [REDACTED].>The Departmental Notes documented at 6:50 a.m. the resident fell on the left side. The Departmental Notes documented the resident screamed out in pain when the nurse placed her hands on the right hip. The Departmental Notes documented the resident had no leg shortening or rotation. The Departmental Notes documented Staff M notified the on call physician who ordered a portable x-ray. The Departmental Notes documented Staff M called portable x-ray to set up a time and notified the resident's family. The Fall Scene Incident Report dated 4/18/16 at 8:15 a.m. documented the resident could not bear weight or straighten the right leg. The resident complained of pain. Staff H, registered nurse, called 911 after conferring with family. The Departmental Notes documented at 8:15 a.m. indicated the resident complained of pain in the right hip. The Departmental Notes documented the resident held and guarded the right hip as well as expressed pain. The notes documented the resident could not sit or stand. The Departmental Notes documented Staff H called 911 after speaking with family to send the resident to the emergency room . During an interview on 6/17/16 at 12:36 p.m. the resident's physician stated he had the on call phone when Staff M phoned him stating the resident fell . Staff M informed him the resident had no shortening or rotation of the leg. The physician could not recall if Staff M had informed him the resident had been screaming in pain when staff touched the right hip. The physician stated he still would have ordered the portable x-ray but would have given orders for pain medication to keep the resident comfortable. Even if the resident had a [MEDICATION NAME] for pain, he would have ordered more fast acting medications. The physician stated the resident had an acetabular fracture or [MEDICAL CONDITION] bone where the hip fits. The physician stated no facsimile would be received prior to 8:00 a.m. when the clinic opened. The Departmental Notes documented the resident returned to the facility on [DATE]. Resident #3 had a MDS with a reference date of 4/7/16. The MDS identified the resident required moderate assistance with toile use. The MDS documented the resident as occasionally incontinent of bowel. The bowel record for May 2016 documented the resident did not have a bowel movement from 5/25/16 to 5/31/16. The Physician's Standing Orders for Bowel Management instructed staff to administer Milk of Magnesia on day 2 without a bowel movement, a [MEDICATION NAME] suppository on day 3 without a bowel movement, and if no bowel movement after 4 days to assess and if positive, notify the physician. The Medication Administration Record [REDACTED]. The Departmental Notes dated 5/31/16 at 1:32 p.m. documented the resident had gone 6 days without a bowel movement and stool had to digitally be removed from the resident. The resident complained of pain three separate times when staff performed perineal care. On 6/15/16 at 11:55 a.m. Staff H, registered nurse, was interviewed and stated the resident should have had Milk of Magnesia on the 28th and then a suppository on the 29th. Staff needed to assess and call the physician on the 29th.

Based on record review, observation and staff interviews, the facility failed to properly attach a mechanical lift sling to the lift device resulting in a fall, hip fracture and pain for 1 of 18 residents reviewed (Resident #11). The facility reported a census of 92 residents and the sample consisted of 18 residents. Findings included: 1. Resident #11 had a MDS (Minimum Data Set) assessment with a reference date of 3/31/16. The MDS identified the resident as severely impaired cognitively and required extensive assistance of 2 staff for transfers. The resident did not ambulate. The resident's February 2016 physician's orders [REDACTED]. The Departmental Notes indicated the following: The Departmental Notes dated 4/22/16 at 2:49 p.m. indicated at 12:45 p.m. the staff called the nurse to the resident ' s room. The nurse identified the resident on the floor with head over the right leg of the Hoyer (mechanical) lift and his/her legs over the left leg of the lift. The Certified Nursing Assistant (CNA) and Director of Nursing (DON) stated the resident had fallen out of the Hoyer. The resident winced and cried out in pain when staff palpated the resident's hips. Staff called an ambulance and the resident was transported to the hospital. A CT (Computerized Tomography) of the left hip identified a nondisplaced fracture of the left hip. Staff documented in the Departmental Notes a late entry on 4/22/16 at 3:57 p.m. The note indicated the nurse administered Tylenol at 1:30 p.m. to ease the pain after the fall. At 10:22 p.m. the documentation reflected the staff received a call from hospital emergency room stating the resident had a left femoral neck fracture and the decision had been made not to repair the fracture. On 4/23/16 at 12:04 a.m. staff documented the resident had returned to the facility at 11:30 p.m. via ambulance. Staff noted the resident did not complain of pain at rest but if moved would yell out in pain. Staff received orders for pain medication, Norco (Hydrocodone and Acetaminophen) 5/325 milligrams (mg.) every six hours as needed for pain. Prior to the fall/fracture the resident had received Tylenol 325 mg. 2 tabs every morning and evening; Norco 5/325 1 tablet twice daily; Fentanyl 12 mcg./ hour patch applied to the skin and changed every 3 days; and Tylenol 325 mg. 2 tabs every 4 hours as needed. In March 2016 the resident received no prn pain medications. Prior to the fall/fracture on 4/22/16 the resident had used no prn pain medications in April 2016. On 4/23/16 at 5:26 a.m. staff noted the resident grimaced and yelled out with cares and repositioning. At 1:05 p.m. staff documented the resident made some facial grimacing when being turned. On 4/23/16 at 6:45 p.m. staff did a skin assessment and found the resident had a 3 cm. by 3 cm. light colored bruise with swelling on the left elbow; a 3.5 by 3.5 cm. bruise on the right shoulder and a 4 by 4 cm. bruise on the right buttock. On 4/23/16 staff documented on the Medication Administration Record (MAR) the prn (as needed), the nurse administered Norco at 12:03 a.m. On 4/24/16 at 2:55 a.m. staff documented the resident complained of discomfort with repositioning at 2:30 a.m. The nurse administered Norco for pain. On 4/24/16 staff documented on the MAR prn Norco given at 2:53 a.m.; 12:03 p.m.; and 11:57 p.m. On 4/25/16 the staff received a physician's orders [REDACTED]. On 4/27/16 at 12:19 a.m. staff documented the resident complained of pain after turning and repositioning and wanted a pain pill. On 4/27/16 staff documented on the MAR prn Norco given at 12:08 a.m. On 4/28/16 at 6:15 p.m. staff documented the resident had been complaining of pain in the left hand and forearms. The resident had active range of motion in the hand but limited in the shoulder and elbow which staff found normal for the resident but noted the resident did cry out in pain when straightening the arm. The elbow remained bruised and slightly swollen. On 4/28/16 staff documented on the MAR Norco given at 1:51 a.m. and 6:09 p.m. On 4/28/16 at 4:32 p.m. staff documented new orders received for an x-ray to the left elbow. A 4/28/16 x-ray report indicated osteoporosis found with bursitis and a small joint effusion. The report documented abnormal alignment at the radiocapitellar joint space suggesting at least partial age-indeterminate subluxation of the radial head/partial dislocation. The radiologist also suspected a nondisplaced fracture of the intra-articular radial surface and radial neck. On 4/29/16 at 3:25 a.m. staff documented the resident complained of discomfort when turned. On 4/29/16 staff documented on the MAR Norco given at 1:41 a.m. and 10:29 a.m. On 4/29/16 at 3:35 p.m. staff received an order to increase the Fentanyl patch to 25 mcg. and continue to change every 3 days and to increase the routine Norco 5/325 mg. to 3 times daily. On 4/30/16 staff documented on the MAR prn Norco given at 4:28 a.m. and 6:12 p.m. On 5/1/16 at 5:29 a.m. staff documented the resident complained of generalized discomfort. On 5/1/16 staff documented on the MAR prn Norco given at 1:15 a.m. and 4:21 p.m. On 5/2/16 at 2:11 a.m. the resident voiced complaints of pain to be a 2 on a scale of 1-10. At 12:57 p.m. staff documented the resident had pain in the left elbow rated at 5. On 5/2/16 staff documented on the MAR prn Norco given at 2:09 a.m. On 5/3/16 staff notified the physician via facsimile. The facsimile indicated the resident had been restless in the evenings and at times at night. The resident had wanted to get out of bed. Staff requested an order to administer Ativan as needed for restlessness. On 5/4/16, staff noted a physician's orders [REDACTED]. twice daily. On 5/3/16 at 11:28 p.m. the resident moaning and restless in bed with an arm hanging over the edge of the bed. On 5/3/16 staff documented on the MAR prn Norco given at 3:38 p.m. and 11:27 p.m. On 5/4/16 staff documented on the MAR prn Norco given at 2:44 p.m. and 11:40 p.m. On 5/4/16 the physician ordered an antianxiety medication Ativan 0.5 mg. every 4 hours for restlessness/anxiety. Staff documented on the MAR prn Ativan given at 3:51 p.m. On 5/5/16 staff documented on the MAR prn Ativan given at 4:47 p.m. On 5/6/16 staff documented on the MAR prn Norco given at 3:09 a.m. and 11:34 p.m. On 5/7/16 staff at 1:53 a.m. staff documented the resident had been yelling out and when asked if he/she had pain the resident stated yes. On 5/7/16 staff documented on the MAR prn Ativan given at 10:18 a.m. and 3:04 p.m. Staff documented prn Norco given at 10:18 a.m. and 10:57 p.m. On 5/8/16 staff documented on the MAR prn Ativan given at 3:57 p.m. and prn Norco given at 3:58 p.m. On 5/9/16 staff documented on the MAR prn Norco given at 5:36 p.m. On 5/10/16 at 1:51 a.m. staff documented the resident moaning and stated he/she had pain. On 5/10/16 staff documented on the MAR prn Ativan given at 4:38 p.m. and prn Norco given at 1:25 a.m. and 4:38 p.m. On 5/11/16 staff documented on the MAR prn Norco given at 2:24 a.m. and 3:57 p.m. On 5/12/16 staff documented on the MAR prn Ativan given at 9:54 p.m. On 5/13/16 staff documented on the MAR prn Norco at 5:17 p.m. On 5/14/16 staff documented on the MAR prn Norco given at 2:19 a.m., 3:34 p.m. and 9:59 p.m. On 5/15/16 staff documented on the MAR prn Ativan given at 12:29 a.m. On 5/16/16 at 11:30 p.m. staff documented in the Departmental Notes the resident yelled out and when asked about pain the resident said yes, and then yelled for his/her family. When told what time it was and family would be back the next day the resident continued to yell. On 5/16/16 staff documented on the MAR as prn Ativan and Norco given at 11:53 p.m. On 5/18/16 staff documented on the MAR prn Norco given at 4:02 p.m. On 5/19/16 staff documented on the MAR prn Ativan given at 2:01 p.m. and 8:53 p.m. On 5/19/16 staff sent a facsimile report to the physician which noted the resident had been more restless especially in the afternoon wanting to get out of bed. They noted the resident had been getting Ativan routinely twice daily but still required prn Ativan most days. On 5/20/16 at 11:25 p.m. staff documented in the Departmental Notes an order received to increase the Ativan to 0.5 mg. 3 times daily and to increase the Fentanyl patch to 37 mcg. On 5/20/16, staff documented on the MAR prn Ativan given at 1:42 p.m. and prn Norco at 5:07 a.m. On 5/22/16 staff documented on the MAR prn Ativan given at 12:11 p.m. On 5/23/16 staff documented on the MAR prn Ativan given at 4:10 p.m. and prn Tylenol also at 4:10 p.m. On 5/25/16 staff documented on the MAR prn Ativan given at 3:57 p.m. On 5/28/16 staff documented on the MAR prn Norco given at 10:55 a.m. On 5/31/16 staff documented on the MAR prn Tylenol and Ativan given at 5:42 p.m. On 6/3/16 staff documented on the MAR prn Norco given at 10:23 a.m. On 6/9/16 staff received a physician's orders [REDACTED]. On 6/10/16 at 10:47 a.m. staff documented in the Departmental Notes they spoke with the resident's family about the resident's x-ray reports and steady decline since the fracture. The facility received an order for [REDACTED]. On 6/11/16 at 2:28 a.m. staff documented in the Departmental Notes the resident moaned during repositioning. On 6/11/16 staff documented on the MAR prn Norco given at 1:42 a.m. On 6/12/16 staff documented on the MAR prn Norco given at 1:01 a.m. On 6/14/16 at 12:53 p.m. Staff A, Certified Nursing Assistant (CNA), was interviewed and confirmed she had been the aide present with Staff B, Registered Nurse, former Director of Nursing, when the resident fell from the lift sling. Staff A demonstrated how they had connected the 4 straps of the lift sling to the lift hooks as the resident sat upright in a recliner. The CNA had been on the right and the DON had been on the left. After connecting the straps to the lift the lift raised the resident out of the chair with the DON operating the lift and the CNA guiding the resident's body. The CNA stated as she turned the resident's legs away from the lift base and upright support, the front left strap came loose and the resident fell from the sling. She stated she had checked the straps she applied herself to assure they were fully engaged in the hooks, but had not checked the DON's. Staff A demonstrated how difficult, if not impossible, it would be for the straps to come out of the hooks with the weight of the resident suspended if they had been properly applied. Staff A stated she believed the strap must have rested on top of the hook and slid off as the resident was moved in the lift. When the strap slid off, the resident fell out of the sling to the floor. On 6/14/16 at 3:44 p.m. the former DON was interviewed and confirmed she assisted Staff A transfer the resident with the Hoyer Lift from the recliner to the bed. The former DON stated she and Staff A had compared which color straps to use and checked to ensure the strap was engaged on the hook. The former DON stated she wasn't sure what happened and confirmed she had applied the strap which had come loose causing the resident to fall.

Based on observation, record review, and staff interviews, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 2 of 6 residents reviewed. Resident #4 was transferred to a telephone in a hallway per wheelchair and left alone by staff to complete the call. The resident self-propelled the wheelchair back to his/her room and suffered a head injury while attempting to transfer out of the wheelchair without staff assistance. Resident #1 had a motion sensor alarm and pad alarm to alert staff when the resident would become restless, uncomfortable, or needing assistance to get out of bed. Resident #1 fell and suffered a dislocated hip when the nurse failed to turn the motion sensor on to work in conjunction with the pad alarm and the resident attempted to get out of bed without help. The facility reported a census of 96 residents. Findings include: 1. Resident #4 had an admission MDS (Minimum Data Set) assessment, with a reference date of 11/19/15. The MDS identified the resident had [DIAGNOSES REDACTED]. The resident had recently had major abdominal surgery to remove a tumor and entered the facility for skilled rehabilitation care. The MDS documented the resident had a severely impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 4. The BIMS scale identified cognitive impairment for scores of 0-7. The resident required extensive assistance of one staff member for bed mobility and transfer. The MDS noted the resident did not have any falls during the six months prior to admission to the facility. The functional status section for the resident revealed the resident did not have any impairment of function of extremities. The MDS noted since admission on 11/12/15 and through the MDS assessment date of (11/19/15), the resident had one fall at the facility with injury (not major). A Fall Scene Incident Report dated 11/14/15 identified the staff found the resident sitting on the floor in his/her room leaning against the bed at 3:30 a.m. An assessment revealed the resident did not have any injuries. Interventions after the fall included the placement of a bed pad alarm and re-education of the resident to use the call light pendant. The report noted the resident was alert to self only and confused at the time of the fall. The next day mild bruising was noted under the resident ' s right eye and documented by nursing staff. Review of a Fall Scene Incident Report dated 11/16/15 identified the staff found the resident on the floor in front of the recliner at 5:45 PM when the resident ' s pad alarm sounded. The report noted the resident attempted to self- transfer. The report revealed the resident did not experience any injuries. The report noted the resident was alert to self and forgetful. The nurse then placed signs in the resident ' s room in several locations reminding the resident to call for assistance when he/she wanted to. During an interview on 12/16/15 at 2:00 PM with Staff B, RN, (Registered Nurse), stated she was working when the resident fell a second time on 11/16/15. She stated the resident did not have injuries and after a full assessment the RN completed the Fall Scene Incident Report and notified a family member and the physician. Staff B stated she placed signs in the resident ' s room as a reminder to call for assistance. Review of a Fall Scene Incident Report dated 11/26/15 identified the resident experienced a third fall at 3:30 p.m. The document noted the staff found the resident on the floor of the bedroom and the pad alarm on the resident ' s wheelchair sounded. The report noted the staff found the resident lying on the right side with his/her face toward the floor in front of a large armoire and a three drawer side table. The resident had injuries including swelling over the left eye and a laceration at hairline mid-forehead with a large amount of blood on the floor by the resident ' s face. A drawing by Staff B represented the layout of the resident ' s room and identified when found on the floor that the resident ' s head was near the bedside table and his/her feet were tangled in the wheelchair legs. The report reflected the staff sent the resident to the ER (emergency room ) and subsequently admitted to acute care. During an interview on 12/16/15 at 2:00 PM with Staff B, RN, she stated on 11/26/15 at approximately 3:30 PM two Certified Nurse ' s Aides (CNAs) responded to an alarm sounding in the resident ' s room and found the resident on the floor. Staff B was notified and started her assessment of the resident ' s injuries and vital signs. She instructed a CNA to call 911 immediately. The RN referenced the documentation she made in the Departmental Notes (Nurse ' s Notes) and stated the resident did not respond verbally to stimuli but would move his/her eyes when spoken to. The RN stated she kept pressure on the resident ' s laceration and continued to assess the resident. The resident had small tremors but no noticeable seizure activity. She stated the resident appeared to have fallen and hit his/her head on a bedside table or a large armoire in the room. She stated it appeared that the resident was attempting to self-transfer out of the wheelchair when he/she fell . Staff B stated and described the resident as only orientated to self but had no active response after the fall except for moving eyes. The hospital Admission Document Report dated 11/26/15 indicated the resident was admitted to the hospital with [REDACTED]. The report noted the resident arrived to the ER with a Glasgow Coma Scale (GCS) of 12 (the Glasgow Coma Scale is the most common scoring system used to describe the level of consciousness in a person following a traumatic brain injury- Severe: 3-8, moderate: 9-12, mild: 13-15). Record review of a Discharge summary report revealed the resident was discharged to another long term care facility on 12/2/15. The report noted a head CT (computerized tomography scan) of the brain revealed the resident did not experience an acute intracranial hemorrhage but a large scalp hematoma and laceration was noted. The pocket care plan (PCP) revised and dated 11/25/15 revealed Resident #4 was to be independent without a FWW (walker) in the room after up and dressed in the morning and directed staff to assist the resident with ambulation using the FWW when outside of the room, to and from meals and at night,. Staff was directed to take the resident ' s pad alarm along and place it under the resident at destination when ambulating the resident out of the room. During an interview on 12/16/15 at 6:00 PM with Staff D, CNA and Certified Medicine Aide, CMA, stated she was working as a CMA on 11/26/15. Staff D stated during the shift change report around 2:00 PM, she was told Resident #4 had a change in status and was now independent in his/her room and needed a pad alarm in the wheelchair if the resident was brought out of the room. Staff D stated during narcotic count she and Staff E, CMA/CNA , were asked to transport Resident ' s #4 to a telephone in the hall to take a personal phone call. She stated they transferred the resident into the wheelchair in her room with the pad alarm underneath the resident and took him/her across the hallway to a phone mounted on the wall. She stated they left the resident seated in the hallway visiting on the phone in the hallway. Staff D stated she was not aware the resident ' s PCP directed the staff to ambulate the resident with the forward wheeled walker when outside of the room. She stated since there was no chair by the phone in the hallway, she thought the resident would be safer in the wheelchair with the pad alarm under the resident. The CNA stated she carries the pocket care plan (PCP) to reference resident status while caring for residents. She stated she did not look at the PCP to double check the resident ' s ambulation status because she was told in report the resident ' s status was independent in room and in his/her wheelchair with pad alarm when out of room. She stated she thought the resident was allowed to transfer from the wheel chair to another surface independently. She stated she had not witnessed the resident doing this. On 12/17/15 at 8:30 a.m. Staff E, CNA/CMA, was interviewed and stated she was counting narcotics at shift change with Staff D when they were asked to transfer Resident #4 to the phone in the hallway. She stated she knew the resident was independent in the room because she saw it on the PCP but did not see the ambulation instructions. Before this date she had seen the resident self-propelling in the wheelchair around the facility so she thought it would be OK to bring the resident to the phone in the wheelchair. She stated she was not told that the resident was to be ambulated only when out of the room. On 12/16/15 at 11:30 AM Staff F, Physical Therapist and Director of Rehabilitation Services was interviewed and stated she recommended Resident #4 be independent in his/her room without the use of the wheeled walker on 11/25/15. Staff F stated when out of the room the resident was to be contact guard assist of staff (CGA) for ambulation with the wheeled walker. She stated when the physical therapy department makes a recommendation for a change in status for mobility for a resident staff are informed at the weekly Medicare meeting and the PCP is revised to reflect the change. Staff F stated Resident #4 had demonstrated he/she could safely transfer alone from one stationary surface to another and could safely be independent in the room because the surfaces the resident would transfer from were all stationary. She stated the resident was to be ambulated outside of the room and was to have the pad alarm under him/her when seated in the dining room for meals. She stated when a resident is deemed to be safe for independent transfer and ambulation in room only the physical therapy staff discourages the use of the wheelchair so the resident will not be tempted to self-transfer into or out of a wheelchair that could conceivably roll and to avoid wheelchair dependence. She stated her notes from the meeting did not specifically state to remove the wheelchair from the resident ' s room, however removing the wheelchair from the room is a standard safety instruction and staff should was been cognizant of the fact that Resident #4 should have not been left alone while in his/her wheelchair without staff supervision. Review of notes dated 11/25/15 revealed documentation hand written by Staff F which stated Resident #4 was to be staff one assist with forward wheeled walker to and from meals - take alarm. Resident was to be independent in room during day and evening with one assist out of room. During an interview on 12/16/15 at 9:30 a.m. with Staff C, RN, she stated she stated when Resident #4 was admitted to the facility the resident was very confused and initially non-complaint with staff directions to call for help when wanting to get up. The resident was evaluated to be assist of one staff with gait belt and FWW for ambulation and transfers. She stated the resident would self-propel his/her wheelchair around the facility. She stated over the course of the resident ' s stay she progressed with physical therapy, became less confused, became more compliant with staff instruction, and physical therapy recommended she become independent in her room only. Staff C stated the wheelchair and the FWW were to be kept out of the resident ' s room for safety. On 12/17/15 at 11:30 AM , the Director of Nursing was interviewed and stated she has heard the Physical Therapist relay instructions to staff in regards to removing a wheelchair from a resident ' s room in the past but denied the therapist recommended this for Resident #4. The DON stated her notes from the 11/25/15 Medicaid meeting did not note the recommendations regarding the wheelchair. 2. Resident #1 had a quarterly MDS with a reference date of 9/3/15. The MDS identified the resident had [DIAGNOSES REDACTED]. The MDS documented the resident had a severely impaired cognition as evidenced by a BIMS score of 1. The MDS identified the resident required extensive assistance of one staff member for bed mobility, transfers and activities of daily living. The MDS noted the resident had signs and symptoms of inattention and disorganized thinking which would fluctuate. The resident displayed physical and verbal behaviors, not directed towards others (including hitting, scratching self, pacing,) were noted on a daily basis during observation throughout the MDS assessment period of six days. The MDS noted the resident had not experienced any falls since the prior MDS assessment period. The Pocket Care Plan (PCP) dated 12/15/15 indicated Resident #1 was to be assisted by two staff members for transfers with a FWW and gait belt and an EZ stand (mechanical stand aide) could be used on a PRN (as needed) basis. Staff was directed the resident requested the gait belt on when up. Safety interventions noted on the PCP included use of a pad alarm at all times and a motion sensor to be used when the resident was in in bed or recliner in his/her room. Review of a Fall Scene Incident Report dated 12/9/15 revealed Staff G, RN, documented the staff found the resident on the floor of his/her room when responded to the sound of the resident ' s pad alarm. The RN documented the motion sensor was not in the room when the resident was found on the floor. Record review of Departmental Notes (Nurse ' s Notes) reflected the following documentation: 12/9/15 at 10:41 PM- Staff G assessed the resident after the fall and found the resident could not bear weight on the left leg and had extreme pain. The family and physician were notified and the resident was taken to the emergency room for evaluation. 12/10/15 at 2:49 AM- Staff H, Licensed Practical Nurse (LPN) noted the resident was found to have a dislocated left hip (prior hip replacement) and the physician was going to attempt to put the hip back into place (closed reduction) after sedating Resident #1. 12/10/15 at 5:48 AM- Staff H documented the resident returned to the facility with physician orders [REDACTED]. Observation on 12/15/15 at 12:30 PM identified Resident #1 seated in a wheelchair in the resident TV room. Staff I and Staff J, CNAs) used an EZ stand mechanical lift to transfer the resident into a recliner. The resident had a knee immobilizer on the left extremity and tolerated the transfer without pain. On 12/16/15 at 3:30 PM, Staff G, RN, was interviewed and stated she was the nurse assigned to Resident #1 on 12/9/15. She stated she completed the resident ' s wound treatment and left the room but was unsure of the exact time. The next time she saw the resident was when the CNA notified her that the resident had fallen at approximately 7:30 PM. She completed a full assessment and notified the physician of the resident ' s pain and inability to bear weight. The resident was sent to the emergency room . She stated initially she thought the motion sensor was not in the room and she documented this on the Fall Scene Incident Report. Later she realized the motion sensor was in the room but she forgot to turn it on after completing the wound treatment and exiting the room. Staff G stated the resident has two alarms- the bed pad alarm and the motion sensor. She stated when in the recliner or in bed the pad was to be under the resident to alert staff if the resident stands up off the pad. She stated the motion sensor was a device which would sound if the resident was restless and worked with in conjunction with the pad alarm. She stated the staff would check on the resident if the motion sensor sounded to ward off ' a possible fall as the resident usually tried to get up when he/she was restless. On 12/16/15 at 12:10 PM, the Director of Nursing (DON) was interviewed and stated Resident #1 was care planned to have a pad beneath him/her at all times and a motion sensor when in the bed or recliner in the room. The DON stated the resident has two alarms so staff could attempt to anticipate when the resident is restless, uncomfortable or needing something. The DON stated the motion alarm will sound if the resident has increased movement while in bed. On 12/17/15 at 10:50 AM, the DON was interviewed and stated the motion sensor alarm was a back-up alarm for the bed pad alarm. She stated staff were outside the door when the pad alarm sounded and immediately entered the room. The DON stated she doubted the motion sensor would have sounded and alerted staff before the resident fell .

Based on observation, record review and interviews with staff and family members, the facility failed to ensure that the resident environment remains as free of accident hazards; and each resident receives adequate supervision and assistance devices to prevent accidents. (Resident #4, #8, #9, #10, #11, and #13). The sample consisted of 16 residents and the facility reported a census of 112 residents. Findings include: Resident #9 was found in the stairwell off of the 4th floor which led to concrete stairs and found in the 4th floor elevator attempting to go home. Resident #11 lived on the 3rd floor and attempted several times to leave the facility and finally exited out the main entrance of the building. Resident #11 had entered 4th floor via the first floor elevator. Once moved to a secured CCDI (Chronic Confusion or Dementing Illness) unit on 2nd floor, the resident continued to leave the unit via the elevator. On 7/10/14 at 4:45 p.m. the resident was seen exiting the elevator on first floor by the social worker. The resident was returned to the second floor. On 7/10/14 at 10:27 p.m. the resident was found on the first floor after riding the elevator off of the second floor. The resident was found using the bathroom and once finished was redirected to the second floor. Resident #13 was found on the floor on 7/13/14 and the alarm had not sounded. On 7/23/14 the staff received telephone calls twice that the resident was located in the independent apartment area of the facility. Resident #8 was to be in a low bed and staff found the resident in bed at high level on 8/16/14 at 8:00 a.m. with his/her neck caught in the side rail and feet on the floor. On 8/17/14 at 8:15 a.m., the resident was found on the floor in front of a wheelchair with a gash to the forehead. Resident #10 was in a wheelchair and found caught in the main entrance door. The resident was then moved to a secured unit. The resident lived on the first floor. A visitor found Resident #4 on the floor at 7:40 p.m. on 7/5/14. The resident's alarm had not sounded to alert staff the resident was getting up unattended. On 7/19/14 at 7:50 p.m., the resident was found in another resident's room sitting on the floor. The alarm did not sound. Staff had applied a weighted device (across lap) to remind the resident not to self- transfer. The device was not on the resident at the time of the fall. On 7/26/14 at 6:50 p.m. the resident was found in another resident's room on the floor. The resident had needed to toilet. The resident deactivated the alarm several times. The resident continued to self-transfer and on 7/29/14 at 4:10 a.m. the resident fell and received a temporal laceration and fractured hip. Findings include: 1. Resident #9 had a Minimum Data Set (MDS) assessment with a reference date 5/9/14 which identified the resident had a BIMS (Brief Interview for Mental Status) score of 7. A score of 7 reflected a severe cognitive impairment. The MDS identified the resident's admitted as 5/5/14. The resident had the following signs and symptoms of delirium: inattention and disorganized thinking. The resident had no behavior symptoms identified, including wandering. The resident required extensive assistance from staff for bed mobility, transfers, ambulation, toileting, and personal hygiene. A "balance during transitions and walking" test identified the resident as not steady but able to stabilize without staff assistance when moving from seated to walking, turn around while walking and moving on and off toilet and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The resident had no falls with injury since the previous assessment. The resident also had impaired vision but did not wear corrective lenses. Resident #9 resided on the 4th floor of the facility. A fall risk assessment dated [DATE] identified the resident had a score of 24. Risk factors identified included a drop in blood pressure readings with change of position that was greater than 20 points (orthostatic blood pressure), intermittent confusion, 3 or more falls in the prior 3 months, assistance required with elimination, and gait/balance deficits. Review of the Physical Therapy notes, dated 5/23/14, reflected the resident as assessed as independent in his/her room and stand by assistance with verbal cues in the hallway. An elopement risk assessment, dated 5/5/14, identified Resident #9 at risk for elopement. The Care Plan, updated daily and dated 6/8/14, identified the resident at risk for fall and required the staff to assist him/her out of the room with verbal cues to walk closely to his/her walker when ambulating. The same Care Plan identified a safety concern and directed staff to utilize a motion detector in the resident's room at night. (A motion detector is a device positioned in a manner to allow an alarm to sound when motion is detected in the area the device is positioned and used to alert staff that a resident is up independently.) The Care Plan identified the resident had behaviors and directed staff to redirect and talk about children, work and life as a child. An incident report, dated 6/8/14 at 9:30 PM, revealed staff heard an alarm sounding and found Resident #9 at the 4th floor stairwell landing with his/her walker. The resident had removed a Velcro "Stop" sign and voiced a desire to return home. (A strip of mesh with a Stop Sign in the middle was secured to the stairwell door frame by Velcro in attempt to redirect residents from the stairwell door). Resident #9 was redirected. An incident report, dated 6/8/14 at 9:45 PM, revealed staff heard the elevator and discovered Resident #9 had removed the Velcro "Stop" sign, and entered the elevator to go home. The resident was redirected and a motion detector was placed on the room door. On 8/27/14 at 4:41 PM Staff ZZ, certified nursing assistant (CNA) confirmed Resident #9 ambulated with his/her walker to the stairwell door and opened the door to the stairwell in attempt to go home, then noted all the stairs. Staff ZZ stated she was able to redirect the resident back to his/her room and the resident was later diagnosed with [REDACTED]. Staff ZZ stated she was the only staff on 4th floor that night, and typically there are 14 residents there. Staff ZZ stated some residents require 2 staff to transfer and/or a mechanical lift. Staff ZZ stated there were instances she was with a resident and an alarm sounds for another resident. 2. Resident #11 had a Minimum Data Set (MDS) assessment with a reference date 6/5/14 of which reflected the resident had a BIMS score of 6 and unable to complete the cognition interview due to impaired memory. The MDS identified the resident's admitted as 3/4/14. The resident had the following signs and symptoms of delirium: inattention and disorganized thinking. The resident had no behavior symptoms identified, including wandering. The resident required supervision of staff with bed mobility, transfers, ambulation, and limited assistance toileting and personal hygiene. A "balance during transitions and walking" test identified the resident as steady at all times. The resident had [DIAGNOSES REDACTED]. The resident had experienced no falls with an injury since the previous assessment. Resident #11 resided on the 3rd floor of the facility. A fall risk assessment, dated 3/16/14 identified the resident had a score of 16. Risk factors identified included intermittent confusion, 1-2 falls in the prior 3 months, and decrease in muscular coordination and required assistive device to ambulate. An elopement risk assessment, dated 3/4/14, identified the resident at risk for elopement and precautions must be initiated. The Care Plan, updated daily and dated 6/2/14, identified the resident at risk for fall, but independent with his/her walker when ambulating. The Care Plan identified the resident had verbal and physical behaviors and directed staff to redirect, offer choices or offer to call the resident's brother. The same Care Plan directed staff to assist the resident to bed with one (1) staff if the resident is sleeping in the lobby. The Incident Reports revealed the following: a. An incident report, dated 3/5/13 at 8:55 PM, revealed the 3rd floor staff received a telephone call from the 1st floor staff to notify that Resident #11 attempted to exit the main entrance. The incident report reflected Resident #11 had been in the lobby for "some time" waiting for his/her sibling to bring medications which was a frequent delusion for the resident. The report revealed the staff returned the resident to the 3rd floor as the implemented intervention. b. An incident report, dated 4/29/13 at 7:30 AM, revealed the resident attempted to leave the facility thru the main entrance. Resident #11 informed staff his/her sibling would take him/her to his/her apartment. The staff redirected the resident to his/her room on 3rd floor. The incident report identified the risk factors included confusion/disorientation. c. An incident report, dated 9/11/13 at 2:00 PM, revealed the resident opened the south lobby doors (1st floor). The incident report lacked evidence of an intervention implemented to prevent future recurrences. d. An incident report, dated 2/10/14 at 11:00 AM, revealed the resident was going to the 1st floor lobby via the elevator and entered the 4th floor. The incident report reflected the resident, "appeared lost" and was returned to the 3rd floor. The incident report lacked evidence of an intervention implemented to prevent future recurrences. The incident report identified risk factors of a fall history. The Care Plan, updated on 6/5/14, identified the following new safety intervention: "Staff to retrieve resident from Peterson Lobby (main entrance lobby) at bedtime and accompany him/her back to 3rd floor." The clinical record lacked evidence of an occurrence which required the implementation of an intervention. e. A Fall Scene Incident Report dated 6/7/14 at 4:45 AM; revealed Resident #11 sustained a fall due to a loss of balance and lost strength/appeared to get weak. The incident report identified this as an "isolated incident'. The report identified no interventions. Departmental Notes, dated 6/12/14 at 5:37 AM, revealed Resident #11 went up and down the elevator through the night shift. Staff were not able to redirect the resident and at 5:15 AM exited the facility doors. Staff responded to the alarmed doors and redirected the resident to return to the facility. The Director of Nursing was notified and directed (the staff) to place the resident in the CCDI (Chronic Confusion or a Dementing Illness) unit. (The CCDI unit is a secure unit with alarmed doors and elevator which require a numeric passcode to enter or leave.) The clinical record lacked evidence of a completed incident report. Departmental Notes, dated 6/13/14, included a quarterly assessment completed by social services staff. The social services staff documented Resident #11 has been spending more time in the 1st floor lobby, spent more time packing up his/her personal items with the belief that a sibling is coming to pick him/her up, which is a delusion. Departmental Notes, dated 6/13/14 at 3:17 PM revealed Resident #11 exited the main lobby doors at 8:30 AM to wait for his/her sibling. The resident was redirected back into the facility. f. An incident report, dated 6/21/14 at 10:30 PM, revealed the resident was observed standing outside of the main entrance lobby unattended by staff with a door alarm sounding. The resident was taken to the CCDI (Chronic Confusion and Dementing Illness) Unit. The incident report noted related factors including a history of leaving the facility, fall history and confusion/disorientation. Departmental Notes, dated 6/22/14 at 10:00 AM, revealed Resident #11 "ran" approximately 15 feet up the hallway after the nurse opened the locked doorway and before the door closed. The resident agreed to return to the CCDI unit if the nurse would make a phone call for the resident (to brother). The clinical record lacked evidence of an incident report. On 8/28/14 at 11:04 AM, Staff L, registered nurse (RN) stated Resident #11 attempted to exit the locked doors used to separate the halls on the CCDI unit and not the stairwell door. Departmental Notes, dated 6/23/14, revealed Resident #11 moved to the CCDI unit for safety concerns such as elopement risk and wander risk. g. An incident report, dated 6/24/14 at 10:45 AM, revealed the resident wanted in the elevator and yelled at/grabbed dietary staff in attempt to enter the elevator to leave the CCDI unit. The incident report noted related factors included a fall history and confusion/disorientation. The staff redirected the resident as an intervention. h. An incident report, dated 6/26/14 at 7:15 PM, revealed the resident entered the elevator then pushed his/her walker at staff when staff attempted to redirect off the elevator. The elevator doors closed with the resident in the elevator. The incident report noted related factors included a fall history and confusion/disorientation. A Departmental Note dated 7/10/14 at 4:45 PM, revealed Resident #11 was observed exiting the elevator on 1st floor of the facility by the social worker. The resident returned to the second floor without incident. The note reflected on 7/10/14 at 10:27 p.m., the resident was found down on the first floor after riding the elevator from the second floor. The resident was found to be using the bathroom and once finished was redirected back to the second floor. The incident report noted related factors included a fall history, arthritis/osteoporosis and confusion/disorientation. The intervention implemented revealed staff escorted Resident #11 back to the CCDI unit. (The CCDI unit is a secure unit with alarmed doors an alarmed elevator which require a numeric passcode to enter or leave. The passcode and directions for use are posted on the elevator directly above the keypad. An interview on 8/2/14 at 12:30 with Staff SS, certified medical assistant, revealed Resident #11 could read the passcode. Observation revealed the passcode located above the keypad. Observations revealed the following: On 8/21/14 at 12:20 PM and 8/25/14 at 12:45 p.m., Resident #11 sat next to the elevator in a straight back chair with a wheeled walker beside the resident. 3. Resident #13 had a Minimum Data Set (MDS) assessment with a reference date of 7/28/14 which reflected the resident had a BIMS score of 14. A score of 14 identified the resident as having no cognitive deficits. The MDS identified the resident's admitted as 6/30/14 and had signs and symptoms of disorganized thinking. The resident had no behavior symptoms identified, including wandering. The resident required extensive assistance of staff with bed mobility, transfers, ambulation, toileting, and personal hygiene. A "balance during transitions and walking" test identified the resident as not steady but able to stabilize without staff assistance to turn around while walking. The resident had [DIAGNOSES REDACTED]. The resident had experienced no falls with an injury since the previous assessment. The resident also had impaired vision and required corrective lenses. Resident #13 resided on the facility's 1st floor. Fall risk assessments, dated 6/30/14, 7/7/14 and 7/28/14 showed the resident at high risk for a fall. Risk factors identified included disoriented, 3 or more falls in the prior 3 months and gait/balance deficits. Elopement risk assessments, dated 7/7/14 and 7/28/14, identified Resident #13 at risk for elopement. The Care Plan, updated daily and not dated, identified the resident at risk for falls and required the staff to assist him/her with transfers and to the bathroom. The same Care Plan identified a safety concern and directed staff to utilize a high/low bed with a floor mat for 72 hours. Departmental Notes, dated 7/7/14 at 1:39 PM, revealed Resident #13 expressed a desire to return to his/her own apartment. The nursing staff reminded (the resident) of the need for therapies in order to increase strength due to safety concerns, i.e. fall history, prior to returning to apartments. The nursing staff documented the resident's dementia is definitely more advanced and affects his/her short term memory and that the resident is not safe to return to his/her home (apartment.) Departmental Notes, dated 7/8/14 at 5:19 PM revealed the resident continued to question reasoning of why he/she could not return home (apartment). Departmental Notes, dated 7/9/14 at 9:23 AM, identified Resident #13 as very anxious and perseverant about desire to go to his/her apartment. The social worker accompanied the resident to his/her apartment to help pacify this anxiousness. The daily Care Plan, dated 7/10/14, identified a safety risk and directed a pad alarm at all times when out of bed. Departmental Notes, dated 7/10/14 at 7:56 PM, revealed staff observed the resident traveling down the hall in the apartment area looking for his/her room at 3:15 PM. The resident was returned to the 1st floor without difficulty. Departmental Notes, dated 7/13/14 at 6:16 AM revealed the resident was found on the floor. The alarm did not sound. The resident's Care Plan was updated on 7/14/14 to apply a layer of Dicem in the wheelchair and recliner, and transfer the resident to and from meals. Departmental Notes, dated 7/16/14 at 4:11 PM, revealed staff shared concerns with the resident's family member and determined that the resident would likely not be able to return to his/her apartment due to cognitive and safety concerns. Departmental Notes, dated 7/23/14 at 9:29 AM, revealed nursing staff received a phone call from a resident in the apartments informing them that Resident #13 was in the apartment area in his/her wheelchair looking for a chiropractor's office for complaints of neck pain. The resident was returned to the facility. Departmental Notes, dated 7/23/14 at 3:18 PM, revealed the nursing facility was notified that Resident #13 was in the apartment area. Nursing staff returned the resident to the facility. On 8/26/14 at 2:50 PM, the facility Director of Nursing (DON) was interviewed and stated because the building is secure; residents are free about the facility floors unattended if their Care Plan does not state that they require staff to escort them. The DON stated the residents can come and go as they please as long as they do not require staff to escort them about the facility. On 8/25/14 at 3:25 PM a tour of the facility basement was completed with the facility Administrator. The maintenance door was labeled "locked and closed at all times." The door was not locked at this time. Upon entry, observation of several chemicals/aerosols labeled "Keep Out of Reach of Children" were noted, electrical tools, hand tools, and per facility Administrator, "all things that should be locked." The laundry room door opened to the "soiled" side (where dirty linen is received) and noted chemicals and aerosols labeled "Keep Out of Reach of Children." The Administrator confirmed the door was to be locked and usually there are staff in view. The basement door was opened at 3:34 PM and an alarm sounded. The basement door opens to the outdoors. The facility Administrator stated we are on camera and pointed to a camera which was able to be observed by 1st floor nursing staff. No staff from the 1st floor responded to the door alarm. At 3:37 PM, the facility Assistant Administrator responded to the door alarm and stated she was in the basement activity room. The facility Administrator stated, "this is a big facility" in response to the lack of response from 1st floor nursing staff. He then confirmed there was ample time for a resident to exit the building and get to the hazardous items identified during the observation of the basement area. The facility Administrator confirmed knowledge of the resident located in the basement area unattended by facility staff but argued he/she used to live in the apartments down here. The Administrator then stated the resident should not be in the apartment area unattended. On 8/25/14 at 3:43 PM, 1st floor nursing staff state no alarm sounded. The camera was viewed on the 1st floor nurse's station which did not show the basement doorway. The facility Administrator confirmed the camera did not show the basement stairwell, and then stated then it's recorded. On 8/25/14 at 3:53 PM the facility Administrator stated he phoned the alarm company and the switch was "bad." The alarm company was enroute to repair the switch. The Administrator then stated they (staff) check the alarm monthly and it was last checked 7/31/14. However, the Administrator stated they only test the alarm for sound and not to observe if staff respond to the alarm. On 8/27/14 at 3:44 PM, the DON provided a list of residents that are independently mobile with or without assistive device (such as walker or wheelchair) that do not require staff to escort them about the facility. A list was provided and included residents identified with cognitive deficits as well as residents completely dependent upon staff for activities of daily living. The Director of Nursing confirmed Resident #13 and Resident #9 were listed. The Director of Nursing stated this building is secured by alarms and the alarms work. The Director of Nursing then confirmed staff did not respond to the alarmed stairwell door on the 4th floor when checked with the facility Assistant Administrator. Note: At the time of the complaint investigation, the complaint was coded at a "K", immediate and serious jeopardy. By 8/25/14, the facility had implemented measures that adequately addressed the jeopardy and the grid placement was lowered to the "E" level. An additional staff person was added to the 4th floor at all times until the stairwell doors are fitted with a Mag Locking device. Each floor exit doors will have Mag Locking devices. A motion detector was added to the north end of the 4th floor hallway to alert staff when the resident might be approaching the north stairwell. The motion detector will be removed when the Mag Lock devices are on the doors. The 4th floor residents were assessed for being an elopement risk and may enter the stairwell. As of 9/16/14, the facility continued to need to: ? Ensure the exit doors are monitored with a motion detector and additional staff so residents are not entering the stairwells until the locking device doors on installed on each floor. ? Continue to assess residents for being an assessment risk. ? Continue to monitor exit doors for activation of alarms and staff response. 4. Resident #10 had a MDS assessment with a reference date 6/29/14 of which reflected the resident had a BIMS score of 9. A score of 9 identified the resident as moderately cognitively impaired. The resident had the following signs and symptoms of delirium: inattention and disorganized thinking. The resident had the following behavior symptoms identified: wandering and the risk of wandering to a dangerous place. The resident required limited assistance of staff with bed mobility, transfers, ambulation and extensive assistance with toileting. A "balance during transitions and walking" test identified the resident as not steady, only able to stabilize with staff assistance when moving from seated to walking, turn around while walking and moving on and off toilet and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The resident had no falls with injury since the previous assessment. The resident also had impaired vision and hearing. A fall risk assessment, dated 6/25/14, identified the resident had a score of 14. Risk factors for falls identified included: intermittent confusion, 1-2 falls in the prior 3 months, ambulatory and incontinent and normal gait/balance. An elopement risk assessment, dated 6/25/14, identified the resident was not at risk for elopement because the resident was not able to independently ambulate with or without assistive devices. The elopement assessment, fall risk assessment and MDS assessment did not correlate with the resident's ability to independently transfer. The Care Plan, updated daily and dated 6/25/14, identified the resident at risk for fall and required one (1) staff to assist ambulate, and a wheelchair for long distances. The Care Plan was updated on 6/26/14 to one staff assist with a front wheeled walker in the resident's room and a wheelchair when out of the room and a pad alarm in the recliner and bed at all times due to self- transfers. An incident report, dated 6/29/14 at 6:00 PM, reflected the resident attempted to exit the facility and was found in the main entrance door with the rear wheel of the wheelchair caught on the door frame. Staff attempted to redirect without success for 30 minutes while the resident held the door. The intervention implemented revealed the resident was taken to 2nd floor, the CCDI unit and elopement risk was added to the Care Plan. The resident was later moved to the 2nd floor CCDI unit. Observation on 8/21/14 at 10:13 AM, the facility Assistant Administrator assisted the surveyor with checking the door alarms. Identified was the following: a. On 8/21/14 at 10:14 AM the surveyor opened the stairwell door to the 4th floor which caused the alarm to sound. The sounding alarm was silenced at 10:15 AM by 4th floor staff. No staff opened the door to check the stairwell. At 10:17 AM the MDS RN (nurse that completes MDS assessments)exited the 4th floor via the stairwell door and stated nursing staff were at the nurse's station. The 4th floor stairwell door was opened again at 10:20 AM. The facility Assistant Administrator confirmed a resident would be down the stairwell from the alarm that sounded 6 minutes prior and was silenced by staff. The alarm was again silenced by staff. The surveyor and Assistant Administrator were able to hear staff using a Walkie Talkie to request maintenance staff check door alarms that sounded. The Assistant Administrator opened the door and canceled the maintenance request. The facility beautician and housekeeper confirmed they heard the alarm. The beautician stated she turned the alarm off the first time because she didn't see anyone leave. Staff II, certified medication assistant (CMA), confirmed she heard the alarm but did not check the stairwell because the beautician said no one was there. All staff stated when a door alarm sounds they are to open the door and look down the stairwell to ensure no resident left the floor. b. On 8/21/14 at 10:30 AM the surveyor opened the stairwell door to the 3rd floor which caused the alarm to sound. The door alarm was silenced at 10:34 AM. No staff opened the door to check the stairwell. At 10:35 a resident's family member opened the door to allow the surveyor and Assistant Administrator enter the 3rd floor. Staff HRH, unit aide, confirmed she silenced the door alarm without looking down the stairwell. She then stated that she was cleaning tables when the alarm sounded and saw a staff member leave the 3rd floor. The Assistant Administrator confirmed no staff entered or exited the 3rd floor stairwell door while the surveyor and Assistant Administrator were standing in front of the door with the alarm sounding. 5. Resident #8 had a MDS assessment with a reference date 6/19/14 of which reflected the resident had a BIMS score of 2, and was unable to complete the cognition interview due to impaired memory. The MDS identified the resident's admitted as 4/30/12. The resident had the following signs and symptoms of delirium: inattention and disorganized thinking. The resident had the following behavior symptoms identified: physical behavior towards others and staff and rejection of care. The resident required total assistance of staff with bed mobility, transfers, personal hygiene, and toileting. The resident was nonambulatory. A "balance during transitions and walking" test identified the resident as not steady, only able to stabilize with staff assistance when moving from seated to walking, turn around while walking and moving on and off toilet and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The resident had no falls with injury since the previous assessment. The MDS reflected the resident had severely impaired vision and wore no corrective lenses. A fall risk assessment, dated 1/3/13 identified the resident had a score of 12. Risk factors identified included disoriented chair bound, and poor vision. The same fall risk assessment identified the resident was unable to ambulate/balance independently. The daily Care Plan, dated 8/15/14, identified (the resident) as a safety risk and the resident required a low bed with a body pillow to the outer side (of bed). The Care Plan reflected Resident #8 could not use a call light, required a mechanical lift (Hoyer) for all transfers and wheelchair for distances. The Care Plan identified the resident as blind. An Incident Report, dated 8/16/14 at 8:00 AM, revealed the resident was found with his/her neck in the side rail of the bed with his/her feet on the floor. The corresponding Departmental Notes, dated 8/16/14 at 8:36 AM, reflected the resident was found with his/her neck caught in a bedside rail with his/her feet on the floor. The bed was elevated at full height. A red mark was noted on the anterior and left side of the resident's neck. The intervention implemented directed staff to have the bed at low level at all times except during cares and a body pillow to be placed beside the resident and railing. The side rail was also padded and a mat was placed on the floor beside the bed. An Incident Report dated 8/17/14 at 8:15 PM, indicated the resident was observed on the floor in front of his/her wheelchair and sustained a 2/5 centimeter (cm) "gash" to his/her forehead. The intervention implemented was identified as a layer of Dicem between the Hoyer pad and wheelchair. (The Hoyer pad is a lift sheet used with the mechanical lift and used to transfer the resident as this resident was unable to transfer without assistance of staff or a mechanical lift.) Resident #8 was transferred to the emergency room for treatment of [REDACTED]. On 8/25/14 at 10:35 AM Staff C, LPN, confirmed she was the nurse on duty when Resident #8 fell out of the wheelchair. Staff C stated she walked by the resident's room at approximately 7:45 PM to complete cares on another resident and observed Resident #8 in his/her wheelchair. Staff C stated she didn't see any other aides in the area so she completed another treatment when she was notified that the resident was on the floor. Staff C indicated she thought the resident attempted to self-transfer and landed face first on the floor and sustained a split on his/her forehead/hairline which required sutures. Staff C stated she was in charge of the 2nd 3rd and 4th floor that night. On 8/25/14 at 1:45 PM Staff GG stated she was the med aide (CMA, certified medication assistant) the morning Resident #8 was discovered in the bed side rail. Staff GG stated she was on the other hall passing med's and the housekeeper said the resident was falling out of bed. I called Staff K, the nurse, and she did the assessment. Staff FF stated the last person that turned the resident didn't have a pillow behind the resident's back. Staff FF stated Resident #8 was not able to transfer independently and required 2 staff and a Hoyer lift (mechanical lift). Staff FF stated when the resident fell out of bed; he/she had a hospice bed with side rails rather than the high low bed. On 8/26/14 at 2:25 PM Staff FF CMA, stated she was in the nurse's station charting with the nurse on duty when she was told Resident #8 was on the floor. Staff FF stated she took Resident #8 into his/her room at approximately 7-7:30 PM then went to the west hall to answer call lights. Staff FF stated Staff DD observed the resident leaning in his/her wheelchair so she propped the resident with a pillow, which was not the "norm." Staff FF stated the resident probably was leaning because he/she was tired fell asleep and fell out of the wheelchair. Staff FF stated the resident was not leaning when she took him/her to their room. 6. According

Based on clinical record review and staff interviews, the facility failed to routinely assess Resident #4 for pain following hip surgery and provide an [MEDICATION NAME] as needed. The facility failed to assess Resident #6 for breathing difficulties and provide oxygen therapy as needed. The sample consisted of 16 residents and the facility reported a census of 112 residents. Findings include: 1. According to the MDS assessment with a reference date 7/15/14, Resident #4 had a BIMS (Brief Interview for Mental Status) score of 3. A score of 3 identified the resident as severely cognitively impaired. The MDS identified the resident's admitted as 7/3/14. The resident had the following signs and symptoms of [MEDICAL CONDITION]: inattention and disorganized thinking. The resident had the following behavior symptoms identified: wandering to include the risk of wandering into a dangerous place, rejection of care and behaviors that disrupt the environment and/or intrude on the privacy of others. The resident required limited assistance of staff with bed mobility, transfers, ambulation, toileting, and personal hygiene. A "balance during transitions and walking" test identified the resident as not steady but able to stabilize without staff assistance when moving from seated to walking, turn around while walking and moving on and off toilet and surface to surface transfers. The resident had [DIAGNOSES REDACTED]. The resident had experienced one fall with no major injury since the previous assessment. The initial Care Plan, dated 7/3/14, identified the resident required the assistance of 1 staff person to transfer and 2 staff to get out of his/her low bed. The resident required a wheelchair for distance. The Care Plan reflected the resident had a low bed with a mat and automatic brakes on his/her wheelchair. The Care Plan reflected the resident had a fall and wore a cast do to a wrist fracture. A Fall Risk assessment, dated 7/3/14, identified the following fall risk factors: a fall history, chair bound and required staff assistance for elimination, balance problem while standing and while ambulating with a decrease in muscular coordination and intermittent confusion. The clinical record revealed the following: a. An Incident Report, dated 7/5/14 at 7:40 PM, revealed a visitor discovered Resident #4 on the floor. The resident's alarm did not sound. The report reflected the maintenance person was notified and applied automatic brakes to the wheelchair. Departmental Notes, dated 7/4/14, 7/5/15, 7/7/14, 7/9/14, 7/10/14, 7/16/14, 7/17/14, 7/19/14, 7/21/14, and 7/24/14 revealed the resident attempted to self-transfer/ambulate and could silence the pad alarm by placing a weighted device on the alarm. An Incident Report, dated 7/26/14 at 6:50 PM, revealed Resident #4 was found on the floor in another resident's room. The resident informed staff he/she needed to use the toilet. The immediate intervention as a result of the fall, was for staff to toilet the resident before and after meals and to be the first resident after the evening meal. An Incident Report, dated 7/29/14 at 4:00 AM, revealed the resident was found on the floor. The Incident Report indicated the resident ambulated to the bathroom and tripped over a pair of shoes. Resident #4 sustained a laceration to the right temple and complained of right hip and sacrum pain. The immediate intervention implemented was for staff to ensure items were picked up off the floor. An x-ray report, dated 7/29/14, revealed a nondisplaced [MEDICAL CONDITION] neck (hip) and a CT (computerized tomography) scan recommended for further evaluation. A written note at the bottom of the x-ray report directed staff to review the findings with the resident's family to determine how "aggressive" the family would like to be "with age and quality of life" and to determine their desire for surgical intervention or "comfort measures." The resident's family requested comfort measures only rather than surgical intervention. Departmental Notes revealed the following: a. On 7/29/14 at 10:24 AM the resident continued to complain of pain. The facility requested a physician's orders [REDACTED]. b. On 7/29/14 at 4:25 PM nursing documentation revealed a physician order [REDACTED]. c. On 7/30/14 at 2:37 PM and 6:34 PM extra strength Tylenol was administered for complaints of hip pain. A physician's orders [REDACTED]. (a day after the fall with [MEDICAL CONDITION].) The resident received a [MEDICATION NAME] ([MEDICATION NAME]) 5/325 mg tablet on 7/30/14 at 9:31 PM, nearly 18 hours after the fall with fracture. d. Departmental Notes dated 8/3/14 at 1:54 PM 1 tablet of [MEDICATION NAME] 5-325 mg tablet administered for hip pain. e. Departmental Notes, dated 8/4/14 at 8:40 AM, revealed 1 [MEDICATION NAME] 5-325 mg administered as the resident was "crying in pain." f. Departmental Notes, dated 8/4/14 at 6:05 PM, revealed 1 [MEDICATION NAME] 5-325 mg tablet administered as the resident was "crying in pain." g. Departmental Notes, dated 8/5/14 at 5:28 PM, revealed 1 [MEDICATION NAME] tablet 5-325 mg administered as the resident was "crying in pain." h. Departmental Notes, dated 8/7/15 at 7:15 PM, revealed 1 [MEDICATION NAME] 5-325 mg tablet administered as the resident was "crying in pain". i. Departmental Notes, dated 8/6/14 at 5:37 PM, 8/9/14 at 3:03 PM, 8/10/14 at 3:21 PM, 8/11/14 at 6:44 PM, 8/12/14 at 6:29 PM, and 8/14/14 at 10:54 A.M. and 7:26 P.M. revealed 1 [MEDICATION NAME] 5-325 milligram tablet administered for complaints of pain. (The record identified the staff did not routinely assess the resident for pain. Multiple times the resident cried out in pain and if an assessment had been routinely performed, the pain would not have been to the point of the resident being uncomfortable and crying out for an [MEDICATION NAME].) On 8/14/14, Physical Therapy was initiated for gait training. On 8/25/14 at 12:35 PM, Staff KK, CMA, stated she would "definitely" want routine pain meds if she had a [MEDICAL CONDITION]. 2. According to the facility Face Sheet, Resident #6 had an admission date of [DATE]. On 9/3/14 at 10:07 AM, the facility Director of Nursing (DON) stated a Minimum Data Set (MDS) assessment was not completed as the resident's stay was less than 14 days. The undated Care Plan identified Resident #6 as a hospice patient to receive supportive cares and oxygen as needed. Departmental Notes dated 6/21/14 at 8:35 AM, revealed the oncoming nurse, Staff H registered nurse (RN), entered the building and discovered Resident #6 sitting in the skilled lobby recliner "struggling to breath." Staff H documented Resident #6 was "unresponsive" with an oxygen level of 66%. Staff immediately provided oxygen at 4 liters per nasal cannula. After 5 minutes the resident's oxygen level reached 79% but remained "unresponsive. The resident was then transferred to his/her room. The TAR (Treatment Administration Record) for June 2014 directed staff on 6/18/14 to provide oxygen 2-4 liters per nasal cannula as needed. On 8/25/14 at 11:27 AM Staff H (registered nurse) stated in June she came to work and discovered Resident #6 sitting in a recliner in the lobby without oxygen. Staff assessed the resident's oxygen level and noted it was "very, very low" because there wasn't any oxygen in the lobby with him/her. Staff H stated she asked the night nurse (Staff B, registered nurse) about the oxygen levels overnight and Staff B responded oh yeah that's what else I was supposed to do. Staff H stated Resident #6 was often in the lobby recliner as he/she was not comfortable in bed but again noted there was no oxygen in the lobby when she entered the building. On 8/25/14 at 8:50 AM Staff B, licensed practical nurse (LPN), stated there were, "too many people and not enough nurses." Staff B confirmed a resident was having respiratory difficulty one night so the LPN gave the resident a nebulizer treatment per resident request. Staff B stated the nurse came on duty and yelled at me for not checking the oxygen status and the resident's vital signs. My next shift I was sent home and told to come to work the next day. When I arrived they had me correct some documentation, and then was fired. Staff B shared concerns with working in the facility as the only nurse for 120 residents and the difficulty she experienced trying to complete all assessments and treatments for all residents and expressed concerns with the falls residents experienced due to "short staffing." Staff B stated she had another resident that had fallen when the day shift nurses arrived that morning. On 8/25/14 at 3:50 PM Staff JJ, CMA (Certified Medical Assistant), informed the surveyor that Resident #6 passed away in June or July.

Based on observation, staff interviews, and clinical record review the facility failed to ensure all residents received adequate supervision against hazard from self and others and the health service supervisor failed to plan for and direct the nursing services in order that the resident ' s needs are met. The facility did not implement appropriate and timely interventions for Resident #4 who exhibited aggressive behaviors towards two residents (Residents #8 and #3). The resident sample consisted of eight residents and the facility reported a census of 112 residents. Findings include: 1. Resident #4 had an admission Minimum Data Set (MDS) assessment with a reference date of 6/28/13. The MDS identified Resident #4 had severely impaired cognition related to [DIAGNOSES REDACTED]. The MDS revealed the resident required limited assistance of one staff member to complete activities of daily living, and ambulated with assist of one staff and a wheeled walker. The resident was identified by the MDS as having fluctuating signs of delirium including inattentive behavior and disorganized thinking. The MDS mood assessment revealed the resident was short tempered and easily annoyed nearly every day during the assessment period. Resident #4 had behavioral symptoms including: verbal behaviors directed towards others (threatening others, screaming at others, and cursing at others) and pacing, rummaging, and throwing and smearing food or body fluids). Impact of the behaviors on the resident reflected the resident at significant risk for physical illness or injury and interfered with the resident ' s participation with social interactions. The MDS noted Resident #4 weighed 234 pounds and 72 inches tall (6 feet). The resident's Care Plan initiated on admission and updated when changes were made, instructed staff to assist the resident with ambulation, toileting, and activities of daily living. Safety precautions noted staff was to monitor whereabouts frequently due to elopement risk. The care plan did not identify the resident as having a history of aggressive behaviors and did not provide interventions for the resident when aggressive behaviors were exhibited. Prior to the facility admission, Resident #4 had an in-patent stay at a psychiatric hospital starting on 5/24/13. Review of the Ascend Management Innovations report generated on 5/30/13 at the psychiatric hospital, the resident was assessed as having difficulty interacting with others and the past six months a history of violent behavior. A psychiatrist ' s history dated 6/10/13 revealed the resident was admitted for evaluation due to aggressive behavior (the resident hit another resident on the head) at the previous long term care facility where the resident was living. The psychiatrist stated the resident usually is quiet, keeps to him/herself, does not say anything and does better in a low stimuli environment. The facility Admission Assessment by nursing staff dated 6/17/13, documented assessments of Resident #4's cognitive status, nutrition, elimination, sleep patterns, skin integrity, respiratory status, vital signs and pain level. The section for mood and behavior status was left blank with no documentation noted. The resident was admitted to the facility CCDI (Chronic Confusion or a Dementing Illness) Unit, Review of Resident #4's Departmental Notes (narrative notes by various departments including nursing, social services, dietician, activities, and restorative) revealed the following documentation by staff: 6/19/13 at 11:30 a. m. (nursing): The resident was sitting in the CCDI dining room eating when a peer (Resident #3) attempted to take the resident ' s food. The resident hit peer in the stomach. No injuries. Resident redirected. 6/21/13 at 3:19 p.m. (nursing): Resident moved from CCDI unit to room 315 (third floor regular long term care unit). 6/24/13 at 7:04 p.m. (Social Services): Another resident ' s family member reported to the Social Worker that Resident #4 was standing in the resident ' s doorway shaking his/her fists at both the resident and family member and then pushed the exit door and set off the alarm. Resident #4 was escorted back to his/her room by the Social Worker. 6/26/13 at 3:40 p.m. (nursing): Fax sent to the physician for anti-anxiety medication as requested by the resident ' s spouse due to his/her concerns regarding the resident ' s anxiety and behaviors. The physician ordered Ativan 12.5 milligrams every four hours as needed for anxiety and instructed staff to inform physician if continuing concerns or ineffective as dose/frequency can be changed. The June and August 2013 Medication Administration Record (MAR) for Resident #4 revealed the resident was not administered any Ativan (anti-anxiety medication) during that time period. Review of the Department Notes revealed the following: 7/9/13 at 11:52 a.m. (nursing): Resident inappropriately grabbed a female staff member on the breast, perineal area, and bottom while the staff member was providing cares to the resident. Intervention was for a male staff member to take over the resident ' s cares for the rest of the day. 7/10/13 at 2:21 p.m. (nursing): Resident #4 was being escorted to the dining room by staff when another resident waved to Resident #4. Resident #4 tried to hit the other resident and staff intervened and there was no resident contact. Resident #4 was seated in a recliner and given food. 7/14/13 at 7:35 p.m. (nursing): The resident ' s daughter reported when she awakened the resident napping, the resident was disoriented and shook a fist at her. 7/27/13 at 4:02 p.m. (nursing): Resident was in the dining room in recliner. Staff then observed by staff standing in front of Resident #8 with fists drawn, Staff intervened. The entry did not reflect any contact between Resident #4 and Resident #8 or any injuries to Resident #8. 5:12 p.m. fax to physician (nursing): The resident (#4) struck another resident (#8) on the right forearm and held his/her fists up to the resident (#8). 9:26 p.m. (nursing): Spouse very worried about resident hitting peer and requests the resident ' s psychiatrist be notified about the day ' s incident. Staff questioned the resident who told staff he/she did not mean to hit peer, was not mad at peer, was frustrated because the room was too loud and the resident wanted to go home. 7/29/13 at 1:08 p.m. (nursing): Fax from primary care physician acknowledging the resident hit a peer. No new orders noted. 8/3/13 at 10:20 a.m. (nursing): At 5 a.m. this nurse was notified Resident #4 was missing from third floor. Resident was subsequently discovered on the elevator. Assessment revealed no injuries and the resident was placed on hourly observations for three days. 8/17/13 at 6:09 a.m. (nursing): Resident found on floor by staff in room. No injuries noted. Physician and family notified. 11:34 a.m. (nursing): Resident found on floor in room kneeling by bed. No injuries noted. Physician and family notified. 8/22/13 at 10:45 a.m. (nursing): Resident found on floor next to bed. Injuries included abrasion to knee 2.3 centimeters (cm) by 3/6 cm, skin tear to left forearm 0.5 cm by 0.5 cm, skin tear to bridge of nose 0.5 cm by 0.1cm, and skin tear above right eye 0.6 cm X 0.1 cm. Physician and family notified 9/4/13 at 8:14 p.m. (behavior record entry) an unidentified CNA checked the category that stated "hitting others". There is no documentation revealing who the resident hit. 9/5/13 8:18 p.m. (nursing): order received by physician to decrease resident ' s Seroquel (anti-depressant) to 25 milligrams each bedtime. 9/13/13 at 12:29 a.m. (nursing): Resident became aggressive in the main dining room after supper this shift. This nurse observed Resident #4 had taken a walker and pinned Resident #2 against the wall. Another staff member escorted Resident #4 to his/her room. The resident ' s physician was called and ordered the resident to be transferred to the emergency room for psychiatric evaluation. 5:36 p.m. (nursing): Spoke with wife who stated Resident #4 was readmitted to the psychiatric hospital and the Seroquel medication was increased back to 50 milligrams at bedtime. On 10/1/13 at 11:00 a.m. with Staff E, Licensed Practical Nurse (LPN) was interviewed and stated she worked day shift on third floor 9/12/13 and left the facility at 6:16 p.m. When she left, she stated Resident #4 was asleep in a recliner in the left far corner of the dining room watching TV. Staff E stated Resident #2 was seated at a table diagonally across the room from Resident #4 in the near right corner of the room. Staff E stated she did not recall seeing Resident #1 in the dining room at that time. She stated when Resident #4 had aggressive behaviors he/she was redirected by talking with his/her or having the resident read or watch TV. She stated she was aware of previous incidents with the resident. On 10/2/13 at 8:40 a.m. Staff L, Certified Nursing Assistant (CNA), stated she was working on third floor on 9/12/13 when she was called by a nurse to come to the dining room to assist with residents. Staff L stated when she arrived in the dining room Staff N, CNA, was leading Resident #4 from the dining room towards the resident ' s room. She stated she saw Resident #1 on the floor next to the resident ' s wheelchair which was tipped over onto its side. She stated Resident #1 was lying in the center of the room between the far left corner of the room and the table in the near right corner of the room where Resident #2 was standing. Staff L stayed with Resident #1 while the nurse assessed the resident and made phone calls. She stated the resident was unresponsive to verbal commands. She stated after Resident #1 left for the emergency room , she questioned Resident #4 about the incident, Staff L stated she asked Resident #4 if he/she had been sitting in the recliner and he/she replied " yes " . She asked the resident if anyone had been bothering his/her and he/she replied " no". She asked the resident if anyone had been bothering him/her and he/she replied " no " . She asked the resident if the lady/man in the wheelchair was in the way and the resident replied " yes " . When the CNA asked the resident about pinning Resident #2 against the wall with the wheeled walker, the resident looked confused and would not answer. The CNA stated the resident was only able to answer "yes " or " no " to questions and she thought his/her answers usually were appropriate to the question asked. On 9/30/13 at 3:15 p.m. Staff K, Registered Nurse (RN), was interviewed and stated she usually worked on first floor but on 9/12/13, she was the only nurse supervising the second, third, and fourth floors. She stated she was on the third floor when she looked down the hall into the dining room and saw Resident #4 had pinned Resident #2 against the wall in the near right corner of the dining room with a wheeled walker. She called for assistance from Staff L, CNA, and Staff N, CNA, and told Staff N to take Resident #4 to his/her room. She then saw Resident #1 on the floor next to an overturned wheelchair. She assessed Resident #1, who was unresponsive, called the physician and ambulance, and notified the family of the resident ' s incident and transferred Resident #1 to the emergency room . She stated she had recently been off work for vacation and was unaware that Resident #4 had aggressive behaviors. 2. The annual Minimum Data Set (MDS) assessment, with a reference date of 7/25/13, identified Resident #1 with a brief interview for mental status (BIMS) score of 3. A score of 3 identified the resident with severely impaired cognition. The MDS revealed the resident required extensive to total assistance of two staff members with transfers, ambulation, and all activities of daily living. The resident did not have any functional limitations in range of motion but and used a wheelchair for mobility. The MDS noted the resident's primary [DIAGNOSES REDACTED]. The resident was noted to have wandering behaviors for 1-3 days of the MDS assessment period. The resident's plan of care dated 9/30/13 and updated when changes were made, instructed staff to assist the resident with activities of daily living. The care plan did not address behavior issues for Resident #1. The care plan noted the resident had a DNR (do not resuscitate) order. Review of the resident's Departmental Notes (narrative notes by various departments including nursing, social services, dietician, activities, and restorative) revealed the following documentation by nursing staff: 9/13/13 at 12:37 a.m. (nursing): Resident was observed lying on right side on floor in dining room after supper (with wheelchair tipped over about four feet away). Resident was found to be unresponsive during assessment and vital signs were within normal limits. Pupil assessment revealed bilateral pupils were reactive to light but eyes were slowly vacillating back and forth. The physician and family were notified and the resident was transferred to the emergency department. Review of the emergency room notes, dated 9/12/13, revealed the resident suffered a non-displaced skull fracture, a small brain bleed, and a right clavicle fracture from the fall. The emergency room nurse documented when the resident ' s daughter arrived at the emergency room , the daughter stated she was told another resident at the facility became aggressive and pushed resident #1 out of the wheelchair. The notes revealed the physician discussed the resident ' s condition with the family and since the resident was not to be resuscitated or have any aggressive treatment, the resident would return to the facility. Further review of Resident #1 ' s Departmental Notes revealed the following entries: 9/13/13 at 2:46 a.m. (nursing): Returned to facility. Has red-purple bruise with moderate edema to right side of head and a large blue bruise extending from right shoulder to upper chest. Opening left eye occasionally. Not speaking at this time. 9/13/13 at 9:15 p.m. (nursing): Primary physician saw resident at 5:00 p.m. and ordered comfort cares, discontinued current medications and lab orders, and ordered anti-anxiety and pain medication. Continued review of Departmental Notes revealed the resident became slightly more alert and responded to verbal stimuli by opening eyes (9/21/13) and was able to sit up in a wheelchair (9/22/13). However the resident declined quickly and became unresponsive to all stimuli (9/27/13). On 10/2/13 the resident passed away. During an interview on 9/30/13 at 12:00 p.m. with the Assistant Director of Nurses (ADON) and Staff C, MDS/care plan nurse, the ADON stated a thorough investigation was completed after the incident on 9/12/13 when Resident #4 pinned Resident #2 against the wall and Resident #1 was found nearby on the floor next to his/her tipped over wheelchair. The ADON stated the episode was not witnessed by staff. The administrative staff determined through interviews, re-enactment of the incident, and evidence at the scene of the incident that most likely Resident #4 tipped Resident #1 ' s wheelchair over as the resident headed towards Resident #2. The ADON stated it was unlikely Resident #1 tipped the wheelchair over by him/herself as the resident weighs 121 pounds. The ADON stated staff sat in the wheelchair and attempted to tip it over onto the side and were unable to do so. The ADON stated there was no eye witness however the staff felt evidence indicated the incident occurred this way. The ADON stated Resident #1 was admitted from a psychiatric hospital and did not have major disruptive behaviors prior to coming to the facility. She stated the resident was lethargic and seemed overly fatigued and this is why the physician decreased the resident ' s Seroquel on 9/5/13. She stated the resident was initially placed on the CCDI unit until the resident pushed Resident #3 on 6/19/13. The resident was transferred to third floor (regular long term care unit) because staff felt there would be less disturbances for the resident on third floor and peers would not attempt to take his/her food. The Director of Nursing was interviewed on 10/2/13 at 11:00 a.m. and stated the interventions implemented for Resident #4 included separation from the environment aggravating the resident and consults with the primary physician on medication changes (addition of Ativan and decrease of Seroquel). A change in staffing was also implemented on 8/29/13 and the nurse ' s shifts were staggered so there was more nursing coverage for the night shift. She stated aggressive behavior is not identified on a resident ' s care plan until the staff has proof of aggressive behavior from the resident. When asked if she felt the incidents involving Resident #4 between 6/19/13 and 9/12/13 were aggressive in nature she stated yes and stated the care plan could have identified the aggressive behaviors associated with the resident but did not. The Director of Nursing stated the staff were informed of behaviors of residents during oral change of shift reports and entries documented in the staff communication book which staff is to read at the beginning of each shift. Review of the staff communication book from 8/15/13 through 9/12/13 did not reveal any communications documenting behaviors of Resident #4. Communication book records for 6/17/13 through 8/14/13 were requested by the surveyor but were not provided by the facility. The family of Resident #1 (spouse and son) was interviewed on 10/1/13 at 2:45 p.m. The son stated Resident #1 had been at the facility for two years. He stated the resident was not very verbal prior to the incident however the resident would sit up in a wheelchair and recognized the family when they visited. They acknowledged the resident had declined in condition quickly since the incident. The son stated the spouse was also a temporary resident of the facility in the skilled unit and would return home when stronger. 3. The quarterly Minimum Data Set (MDS) assessment with reference date of 8/1/13 identified Resident #8 with a severely impaired cognition related to [DIAGNOSES REDACTED]. The MDS revealed the resident required extensive to total assistance of two staff members with transfers, ambulation, and all activities of daily living. The resident did not have any functional limitations in range of motion but and used a wheelchair for mobility. The resident ' s plan of care dated 10/2/13 and updated when changes were made, instructed staff to use the Sit to Stand lift when transferring the resident into the wheelchair. Safety concerns noted the resident was not to be left alone in his/her room when in the wheelchair. The Departmental Notes revealed the following documentation by staff: 7/27/13 at 4:04 p.m. (nursing); This resident was sitting in wheelchair in dining room when staff observed another resident (#4) standing in front of this resident with fists drawn. This resident told staff that he/she was struck on his/her right forearm. This nurse observed a 3 centimeter (cm) red area on the resident ' s right forearm. No other injuries noted. 8/9/13 at 1:58 p.m. (activities): Though resident usually does not initiate conversation, he/she is able to hold a conversation with either staff or family. Sometimes it is unclear what he/she is trying to say because she has a hard time finding his/her words. 8/9/13 at 2:15 p.m. (social services): He/she is able to converse with others but she has a hard time finding words. 8/23/13 (Late entry for 8/16/13) at 11:50 a.m. (nursing): Weekly skin check done. Resident has 2 bruises on right arm. A 7 cm by 6 cm on bicep area and a 9 (cm) by 2 (cm) elbow area. Continued review of Resident #8's Departmental Notes revealed the resident did not experience any falls or injuries between 7/17/13 and 8/16/13. On 10/2/13 at 10:30 a.m. Staff L, CNA stated she was working on third floor on 7/27/13 and heard someone yelling in the dining room. She stated Resident #1 was standing with clenched fists in front of Resident #8. Resident #8 stated " He/she hit my arm " . The CNA noted Resident #8 had a red mark on his/her arm approximately 3 inches in diameter. Resident #4 was removed from the dining room immediately. She stated she questioned Resident #4 later in his/her room by asking " yes " or " no " questions as this was how the resident communicated. Staff L asked the resident if he/she hit Resident #8 and Resident #4 replied " yes " . The CNA asked the resident if Resident #8 was in his/her way and the resident replied " yes " During an interview on 10/2/13 at 10:30 a.m. Staff G, (CNA), stated she was working on third floor on 7/27/13 when she heard some commotion in the dining room. She stated as she walked to the dining room she heard a slapping sound. When she entered the dining room she saw Resident #8 seated in a wheelchair with his/her arms held up as if defending him/her. Resident #4 was standing in front of Resident #8 with clenched fists. She stated she escorted Resident #4 to his/her room and asked the resident if he/she and Resident #8 were arguing. The resident replied " no " . The CNA asked if he/she needed to use the bathroom and the resident replied " no " . She then asked if he/she had been headed towards his/her room and the resident replied " yes " . The CNA asked if Resident #8 was in his/her way and the resident replied "yes " . During an interview with the Director of Nurse's (DON) on 10/2/13 at 11:00 a.m. she stated the facility does not have policies for dealing with aggressive residents or resident to resident altercations. She provided an undated list of facility protocols which instruct staff with cares. Some of the protocols listed include skin, catheter, fall, weight loss, feeding tube, wandering risk, and restraints. The list does not include protocols for dealing with aggressive residents or resident to resident altercations. The DON stated policy is to remove a resident from the facility if the resident harms another resident. When a resident demonstrates aggressive behaviors the facility tries to limit the resident ' s behaviors with redirection and consulting with physicians about possible medication changes. When asked if Resident #4's psychiatrist was notified of behaviors as requested by the resident ' s spouse on 7/27/13, the DON stated she was unsure and would check the resident ' s record. Record review revealed the resident's primary physician was notified of the incident on 7/27/13 and did not issue a new order at that time.