Every finding on record at Medicalodges Frontenac

The facility reported a census of 38 residents with three residents reviewed for elopement. Based on interview, interview and record review, the facility failed to prevent one Resident (R)1 from exiting the facility, unattended. Findings included: - Review of Resident (R)1's electronic medical record (EMR) revealed a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) review of 13, indicating intact cognition. He had limitation in range of motion (ROM) on one side of his upper extremity and used a motorized wheelchair. He was independent in wheeling 150 feet in his wheelchair. The Functional Abilities Care Area Assessment (CAA), dated 02/02/25, documented the resident required substantial to maximal assistance of staff for transfers. The care plan, revised 02/25/25, lacked staff information regarding the resident being at risk for elopement. The care plan, revised 03/16/25, instructed staff the resident had a history of an attempt to exit the facility unattended. The staff were instructed the resident had an impairment in his safety awareness. Review of the resident's EMR revealed an Elopement Assessment, dated 01/29/25, which revealed the resident was not at risk for elopement. Review of the resident's EMR revealed an Elopement Assessment, dated 03/16/25, which put the resident at risk of elopement. Review of the resident's EMR from 01/29/25 through 03/15/25, revealed no documentation of the resident having a behavior of wandering. Review of the resident's EMR, on 03/16/25, revealed staff visualized the resident at the dining room table in his motorized wheelchair awaiting dinner, at approximately 05:00 PM. The facility investigation into the elopement revealed on 03/16/25 at approximately 05:03 PM, video surveillance showed the resident exiting the facility by the front doors in his motorized wheelchair. The door alarm sounded, and a family member of another resident was visualized turning the alarm off. Staff were unaware a resident had exited the facility. The facility was notified the resident was out of the facility and staff retrieved the resident and returned him to the facility 20 minutes after exiting the facility. Assessment revealed no injury to the resident. On 03/20/25 at 11:45 AM, Certified Nurse Aide (CNA) M stated there was an elopement book at the nurses' station which contained photos and resident information of each resident who was at risk for elopement. On 03/20/25 at 03:29 PM, CNA N stated the elopement book had all the staff information for the residents who are at risk of elopement. On 03/20/25 at 04:01 PM, CNA O stated the elopement book was kept in the nurses' station with the names and pictures of the residents who were at risk of elopement. CNA O stated she would report any exit seeking behavior to the nurse. On 03/20/25 at 02:07 PM, Licensed Nurse (LN) G stated she had seen the resident at the dinner table at approximately 05:00 PM on the day of the elopement. The facility was notified of the resident being out of the facility and staff went to pick up the resident approximately one block from the facility. LN G stated she assessed the resident, and he had no injuries upon return to the facility. On 03/20/25 at 01:04 PM, Administrative Staff A stated he had been notified of the resident being outside of the facility via phone call on 03/16/25. Administrative Staff A stated he notified the facility immediately and went into the facility to begin an investigation into how the resident was able to exit the facility without staff knowledge. Administrative Staff A stated he obtained staff interviews and reviewed the video footage which showed the resident exit the facility in his motorized wheelchair, unassisted. The video revealed another resident's family member turn the door alarm off using the code. The family member did not notify staff that she had turned the alarm off. Administrative Staff A stated staff returned the facility to the facility where he was assessed and found to be uninjured. Administrative Staff A completed staff education on elopement. The facility policy for Resident Elopement Policy and Procedure, revised 12/2017, included: The facility strives to promote a safe and secure environment to help minimize risk of residents leaving the premises without the necessary supervision or authorization to do so. The facility failed to prevent this dependent resident from exiting the facility unattended.

The facility reported a census of 38 residents. Based on observation, record review and interview, the facility failed to display accurate, publicly accessible, and identifiable staffing information, daily, for the 38 residents who reside in the facility. Findings included: - Review of the facility's Daily Staffing Sheets, from 01/01/25 through 03/19/25, revealed the actual hours worked had not been completed on the daily staffing sheets. On 03/20/25 at 03:07 PM, Administrative Nurse D, stated she noticed on 03/20/25 that the forms did not include actual hours worked, as required The facility policy for Benefits Improvement Protection Act (BIPA) Nurse Staff Posting, revised 12/19, included: The actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care by shift will be recorded on the Daily Staff Posting form.

The facility reported a census of 36 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for three of the five Certified Nurse Aides (CNA) reviewed, CNA R, CNA MM, and CNA NN. Findings included: - Review of five employee personnel files, employed by the facility for greater than one year, revealed the following concerns: Certified Nurse Aide (CNA) R, hired 10/18/19, lacked an annual performance review in her personnel file. CNA MM, hired 12/15/22, lacked an annual performance review in her personnel file. CNA NN, hired 05/17/22, lacked an annual performance review in her personnel file. The facility's Employee Handbook, undated, included: In order to assist employees, improve their performance, and to identify the areas in which they excel and the areas in which they need to improve, the facility would complete annual performance evaluations. On 11/18/24 at 01:30 PM, Administrative Nurse D stated the staff's annual evaluations were not up to date. The facility failed to complete an annual performance review for this resident, employed by the facility for greater than one year.

The facility reported a census of 36 residents. Based on interview, and record review the facility failed to electronically submit to the Centers for Medicare and Medicaid Services (CMS), accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. Payroll Base Journal (PBJ), related to licensed nursing staffing information, when the facility failed to accurately report weekend staffing for Quarters 1 2024 (October 1-December 31), Quarter 2 2024 (January 1-March 31) and Quarter 3 2024 (April 1- June 30). Findings Included: - Review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year (FY), Quarter 1 2024 (October 1-December 31), Quarter 2 2024 (January 1-March 31) and Quarter 3 2024 (April 1-June 30), revealed excessively low weekend staffing. Review of the staffing schedules for the weekends revealed the staffing was the same as during the weekdays. On 11/18/24 at 03:30 PM, Administrative Staff A stated the PBJ reporting was inaccurate. The facility lacked a policy for reporting PBJ hours. The facility failed to electronically submit to CMS accurate direct staffing information, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (i.e. PBJ), related to licensed nursing staffing information when the facility failed to accurately report weekend staffing from 01/01/24 through 12/31/24.

The facility reported a census of 36 residents. Based on observation, interview, and record review, the facility failed to provide a sanitary dressing change for Resident (R)5, failed to track and trend infections and causative organisms, and failed to store personal protective equipment (PPE) in a sanitary manner to prevent the spread of infection. Findings included: - Observation, on 11/14/24 at 08:13 AM, revealed Licensed Nurse (LN) G, provided a dressing change to Resident (R)5's stage three pressure ulcer (a deep wound that involves full-thickness tissue loss, but does not expose the bone, tendon, or muscle) on the residents left buttock. LN G placed the dressing supplies directly onto the resident's overbed table without prior sanitizing the table. LN G opened the large final dressing and placed the pieces of calcium alginate (a substance used to absorb drainage from wounds) and Santyl (a substance used to remove dead tissue and promote wound healing) on the opened package interior. LN G placed four by four-inch gauze directly on the overbed table and proceeded to use the four by fours to cleanse the wound bed. Interview, on 11/14/24 at 08:15 AM, with LN G, confirmed she did not sanitize the overbed table prior to laying the supplies on it but did protect the Santyl and calcium alginate by placing it on the opened package of the final dressing interior. Interview, on 11/18/24 at 11:45 AM, with Administrative Nurse D, revealed she expected staff to sanitize the overbed table prior to placing dressing supplies on it. Administrative Nurse D stated the facility utilized the standards for practice as a guide for wound dressings. The facility policy Skills Check-Clean Dressing Change undated, instructed staff to clean a surface and provide a clean field to place supplies. The facility failed to ensure staff provided sanitary dressing changes by sanitizing the work surface prior to placing dressing supplies. - Review of the facility's Infection Surveillance Monthly Report revealed the following areas of concern: The May 2024 report documented six residents with urinary tract infections (UTI) without culture results if done. Three of the resident's signs and symptoms listed as dysuria (pain/discomfort with urination) one resident with altered mental status and one lacked signs and symptoms. All the urinary tract infections lacked culture reports, if done, and all were treated with antibiotics. One of the residents with a UTI had a treatment start date of 04/24/24 with a closed date of 05/01/24. The June 2024 report documented six residents with urinary tract infections without culture results if done. The signs and symptoms for one resident include altered mental status, fatigue/malaise (generalize ill feeling) and weakness. Three residents with dysuria and two lacked signs and symptoms, and all were treated with antibiotics. One resident began antibiotics on 06/03/24. The other six residents were carried over from May 2024 and all had a close date of 07/01/24. The July 2024 report documented the same six residents from the June report and all had a close date of 07/01/24. The September 2024 report documented one resident with a UTI with signs and symptoms of new onset of confusion and dysuria. The report lacked culture report if done, and a closed date of 11/04/24. The October 2024 report documented two residents with UTI's with signs and symptoms of new onset of confusion. One resident's sign and symptoms included dysuria, general complaints, and pain and all were treated with antibiotics. One resident had documentation of a completed culture but was not listed on the report. All had a closed date of 11/04/24. The Infection by Unit Report from May 1, 2024 through November 18, 2024, revealed 11 residents with UTIs and with four culture reports. Interview on 11/18/24 at 01:00 PM with Administrative Nurse D, revealed the facility had three infection preventionist within the past year, and the current infection preventionist was new to the role. Administrative Nurse D stated facility utilized McGeers criteria (a guideline to determine need for antibiotic initiation based on symptoms) but did not know where/if the completed documents were located. Interview, on 11/18/24 at 01:30 PM with Licensed Nurse G, revealed staff notify the medical provider of resident symptoms and usually receive orders for a urinalysis with culture if indicated. The medical provider usually awaited the culture reports, depending on symptoms. Staff receive culture results per the fax machine, and then forwards it to the medical provider. The facility policy Infection Control Surveillance revised 11/2023, instructed staff to prevent, identify, monitor, analyze, and report infections in the facility. Staff instructed to analyze data routinely to determine trends clusters and/or outbreaks in the facility. Antibiotic initiation is to be based on the specific organism identified on lab results a per the physician orders. The infection preventionist is to review antibiotic orders for dosage, route, duration, location of infection rational for antibiotic usage and met McGeers criteria for use. Staff to utilize the electronic medical record module Infection Screening Evaluation with identified changes in resident condition. The facility failed to complete the Infection Surveillance Monthly Reports to include culture results for causative organisms and failed to determine compliance with McGeers criteria, to determine the ongoing infections in the facility as required. 34056 - During an environmental tour on 11/13/24 at 08:48 AM, the following areas of concern were noted in the Utility Room on South Hall: 1. An open box of COVID-19 (an acute disease in humans caused by a coronavirus, which is characterized mainly by fever and cough and was capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) tests, which contained 25 unused tests, rested directly on the floor. 2. An open box of COVID-19 tests, which contained 32 unused tests, rested directly on the floor. 3. An open box of COVID-19 tests, which contained 96 unused tests, rested directly on the floor. 4. An open box of 160 individually wrapped plastic gowns used as personal protective equipment (PPE-clothing and equipment that is worn or used to provide protection against hazardous substances or environments), half full, rested directly on the floor. 5. An open box of 100 yellow gowns, used as PPE, three-quarters full, rested directly on the floor. 6. An unopened box of 100 yellow gowns, used as PPE, rested directly on the floor. 7. An unopened box of 100 eye shields, used as PPE, rested directly on the floor. 8. The cabinet underneath the sink was partially open and spilled out a bag of blue gowns, used as PPE, directly onto the floor. On 11/13/24 at 09:30 AM, Administrative Staff A stated the boxes should not rest directly on the floor. The boxes contained staff PPE and COVID testing supplies. The facility failed to provide a policy regarding storage of supply boxes. The facility failed to store PPE and COVID-19 testing supplies in a clean and sanitary manner.

The facility reported a census of 36 residents with 14 residents sampled, including six residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to safely transfer two Residents (R) 15 and R 32 and failed to ensure chemicals were kept locked on one resident hall, which housed eight confused residents. Findings included: - Review of Resident (R) 15's Electronic Medical Record (EMR) revealed the following diagnoses: depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and pain (physical suffering or discomfort caused by illness or injury). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. She was dependent on staff for sit to stand and chair to bed to chair transfers. The Functional Abilities Care Area Assessment (CAA), dated 05/27/24, documented the resident required total staff assistance of two staff for completion of Activities of Daily Living (ADL). The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of seven, indicating severe cognitive impairment. She required maximum assistance for sit-to-stand and chair-to-bed-to-chair transfers. The Care Plan for ADLs, revised 08/30/24, instructed staff the resident required two staff for transfers. The resident was to wear non-skid footwear at all times. Review of the resident's EMR, from 10/16/24 through 11/17/24, revealed the resident required maximum assistance to total dependence on staff for transfers. On 11/14/24 at 11:01 PM, Certified Nurse Aides (CNA) N and CNA M transferred the resident from the recliner in the commons area to her wheelchair with total assistance of two staff and the use of the gait belt (device that helps to prevent falls). The resident was unable to bear weight during the transfer with her socked feet skimming the floor in between the recliner and the wheelchair. The resident's socks were not non-skid. On 11/14/24 at 01:14 PM, CNA M and CNA N transferred the resident from her wheelchair to the recliner in the commons area with total assistance of two staff and the use of the gait belt. The resident was unable to bear her full weight during the transfer. The resident wore non-skid socks at the time of the transfer. On 11/14/24 at 11:01 AM, CNA N confirmed the resident was not always able to bear full weight during transfers. CNA N stated the resident was to wear non-skid footwear at all times. On 11/14/24 at 11:01 AM, CNA M confirmed the resident was not able to bear weight during transfers. CNA M stated the resident could bear weight at times, but not always. On 11/14/24 at 02:00 PM, CNA O stated staff were to transfer the resident with two staff and the gait belt. The resident was not always able to bear her full weight. On 11/18/24 at 01:42 PM, Administrative Nurse D stated it was the expectation that residents could bear weight in order to be transferred with a gait belt. The facility failed to provide a policy regarding safe transfers. The facility failed to safely transfer this dependent resident who was unable to fully bear her weight. - Review of Resident (R)32's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Admission Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. She had no impairment in functional range of motion (ROM) and used a wheelchair for mobility. She required moderate assistance of staff for sit-to-stand and chair-to-bed-to-chair transfers. The Functional Abilities Care Area Assessment (CAA), dated 05/21/24, documented the resident required maximum assistance of two staff or transfers with occasional use of the hoyer lift (a full body lift). The Quarterly MDS, dated [DATE], documented the resident had a BIMS score of five, indicating severe cognitive impairment. She had no impairment in functional range of motion (ROM) and used a wheelchair for mobility. She was dependent on staff for sit-to-stand and chair-to-bed-to-chair transfers. The Care Plan for Activities of Daily Living (ADL), revised 08/30/24, instructed staff the resident required maximum assistance of two staff for transfers. Staff were to utilize the sit to stand lift (a mechanical device designed to assist individuals in moving from a sitting to a standing position and vice versa) for transfers. Review of the resident's EMR, from 10/16/24 through 11/17/24, revealed the resident was dependent on staff assistance for transfers. On 11/14/24 at 08:10 AM, Certified Nurse Aide (CNA) M and CNA N transferred the resident from her wheelchair to her bed with the use of the sit to stand lift. The resident was unable to hold onto the handles of the lift for the entire duration of the transfer, as she slipped down her arms raised up, causing the belt of the lift to move upward and lodge in the resident's arm pits, which placed the resident in a suspended position with arms splayed in a manner that resembled a chicken wing. On 11/14/24 at 09:30 AM, CNA M and CNA N transferred the resident from her wheelchair to the recliner in the commons area with the use of the sit to stand lift. The resident was unable to hold onto the handles of the lift for the entire duration of the transfer, as she slipped down her arms raised up, causing the belt of the lift to move upward and lodge in the resident's arm pits, which placed the resident in a suspended position with arms splayed in a manner that resembled a chicken wing. On 11/14/24 at 09:30 AM, CNA N stated the resident would often have the lift belt raise up into her arm pits while transferring because the resident was not always able to hold onto the handles of the lift properly during transfers. On 11/14/24 at 02:00 PM, CNA Q stated the resident was not always able to bear her full weight on the sit to stand during transfers. She also was not able to always hold onto the handles which would causes the belt to slide up into her arm pits. On 11/18/24 at 01:42 PM, Administrative Nurse D stated it was the expectation that residents be able to bear weight and hold onto the handles of the lift while being transferred with the sit to stand lift. The facility failed to provide a policy regarding safe transfers. The facility failed to safely transfer this dependent resident who was unable to fully bear her weight and unable to hold onto the handles of the sit to stand lift appropriately. - During an environmental tour on 11/13/24 at 03:33 PM, the following items of concern were noted: An unlocked janitor's closet on the East Hall contained two bottles of cleaning supplies (Clorox Germicidal Bleach Spray) and (Virex II 256), which were labeled harmful if swallowed. On 11/13/24 at 03:35 PM, Consultant Staff GG stated the closet should be locked as it contained cleaning chemicals. The East Hall had 16 residents, including eight residents who were noted with confusion. The facility failed to provide a policy for unlocked chemicals. The facility failed to keep eight confused residents safe by having unlocked chemicals in the janitor's closet.

The facility reported a census of 36 residents. Based on observation and interview, the facility failed to ensure a safe, sanitary, and homelike environment in two resident rooms and one hallway. Findings included: - Observation on 11/13/24 at 10:30AM, revealed a strong urine odor in the west hallway near a resident room and inside the resident room. Observation on 11/13/24 at 10:35 AM, revealed multiple arched black streaks on the wall beside a resident's bed on the west hall. Observation on 11/13/24 at 10:40 AM, revealed a resident room on the west hall with two yellow brown irregular circle like stains on the ceiling which measured approximately 10 inches. During the environmental tour on 11/18/24 at 12:24 PM, Administrative Staff A and Housekeeping Staff V confirmed the above. Administrative Staff A stated the resident's mattress may need replaced and the black streaks were due to the positioning bar scraping against the wall repetitively and may need to reposition the bed. Housekeeping Staff V stated she would notify maintenance of the ceiling stains. The facility policy Housekeeping, Laundry, and Maintenance reviewed 02/2024, instructed staff to provide basic housekeeping services to resident living areas and utility and public areas. The facility failed to maintain a safe, sanitary, and homelike environment in two resident rooms and one hallway.

The facility reported a census of 36 residents with 14 residents sampled, including one resident reviewed for hospitalization . Based on observation, interview, and record review, the facility failed to provide Resident (R)14 a Bed Hold upon admission to an acute care hospital. Findings included: - Review of the R14's EMR, on 10/19/24, revealed the resident admitted to an acute care hospital with a diagnosis of a urinary tract infection (UTI-an infection in any part of the urinary system) and sepsis (life threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body). The resident returned to the facility on [DATE]. Review of the resident's EMR lacked a signed bed hold related to the 10/19/24 hospitalization for R14. On 11/18/24 at 12:10 PM, Administrative Nurse D stated the facility did not obtain a signed bed hold for this resident when she admitted to the hospital, and stated they expected staff to have a bed hold signed each time a resident admitted to the hospital. The facility policy for Notice of Bed Hold Policy and Returns, revised 12/14/17, included: The policy shall provide a written notice to residents, family members or legal representatives of the facility's bed hold policies at the time of transfer of a resident to a hospital. The facility failed to obtain a signed bed hold for R14 who admitted to an acute care hospital.

The facility reported a census of 36 residents with 14 residents selected for review. Based on observation, interview, and record review, the facility failed to ensure the development of a personalize comprehensive care plan for an optimal toileting program for Resident (R)22. Findings included: - Review of Resident (R)22's medical record revealed diagnoses that included cardiomyopathy (heart disease), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and history of urinary tract infections. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The resident was always incontinent of bowel and bladder. The resident received diuretics (medication to promote the formation and excretion of urine). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/17/24, revealed the resident required total to substantial maximum assistance of two staff for cares and often refused incontinence care. The resident was able to make her needs known. The Care Plan reviewed 09/04/24, instructed staff the resident required total to substantial maximum assistance with cares, and often refused incontinence care. The resident had a history of urinary tract infections and staff instructed to encourage the resident to allow incontinence care and notify the nurse if the resident declined. Staff instructed to check and change the resident. The care plan lacked instructions on the frequency for the check and change program, interventions for refusal of incontinence care, and enhancement of incontinence products to prevent the frequent urine saturation of the bed to meet the needs of this incontinent resident. A Physician's order, dated 08/23/24, instructed staff to administer furosemide (a medication used to remove excess fluid from the body through the excretion of urine) 80 milligrams, daily for pulmonary hypertension (elevated pressure in the blood vessels of the lungs) due to heart disease. The [NAME] Bowel and Bladder assessment dated [DATE], assessed the resident had functional incontinence and required scheduled toileting. The resident refused to transfer to a bedside commode. This assessment revealed the resident had incontinence without the sensation of urine loss, had pain with movement, enuresis (incontinence at night) and received an antidepressant. Observation on 11/13/24 at 10:34 AM, revealed the resident in bed, in a slumped position toward the right. The resident was alert and answered questions. The room had a strong urine odor. The resident stated she could not find her call light which was out of her reach on the headboard of the bed. The call light was disconnected from the wall. Certified Nurse Aide (CNA) MM reconnected the call light and positioned it within reach of the resident. CNA PP checked the resident for incontinence and provided incontinence care which included change of bed linen due to urine saturation. Observation on 11/14/24 at 01:00 PM, revealed a strong urine odor in R22's room with the resident slumped to the right. Interview at that time with CNA MM, revealed the resident was changed before lunch at approximately 12:00 PM, and the resident had soaked the entire bed with urine. CNA MM stated the resident does not get out of bed and does not always notify staff the need for incontinence care. Observation on 11/14/24 at 03:01 PM, revealed the resident in bed, slumped to her right. The room had a strong urine odor. CNA P and CNA Q provided incontinence care. The resident saturated her brief and urine soaked through onto the mattress. CNA Q stated the resident was cooperative with staff with cares but often reports to staff that she did not need to be changed, when incontinent of urine. CNA Q stated staff check and change the resident every two hours. Observation on 11/18/24 at 08:50 AM, revealed the room with a strong urine odor and the resident positioned in bed, slumped to the right. The resident stated staff did not change her this morning and she felt wet. CNA QQ stated the resident refused to be changed during the 04:00 AM rounds, and she had not been changed yet this morning. The resident declined the surveyor observation of incontinence care at that time. Observation on 11/18/24 at 12:24 PM, during the environmental tour with Administrative Staff A and Housekeeping Staff V, confirmed a strong urine odor in the room. Administrative Staff A stated the mattress may need replaced. Interview on 11/14/24 at 02:56 PM, with Licensed Nurse (LN) G, revealed the resident d nodt often use her call light, preferred to lay slumped in bed and turned to her right. LN G stated the resident refused showers and to get out of bed so staff provide bed baths. Interview on 11/18/24 at 01:30 PM with Administrative Nurse D, revealed the resident refused showers so staff provided bed baths, but did not know the resident refused incontinence care or the care plan indicated the resident often refused incontinent care. Administrative Nurse D stated the resident saturated the briefs and soaked through to the mattress due to large urine capacity of her bladder and staff provided check and change every two hours. Administrative Nurse D stated the resident brief was appropriate for the resident but did not know if/when staff assessed the urinary incontinence to determine a pattern or if the check and change every two hours was adequate. The facility did not provide a policy for development of the comprehensive care plan. The facility failed to provide this dependent resident a personalized comprehensive care plan to include strategies for refusal of incomitance care, a personalized check and change program, and assessment of incontinence products to prevent leakage of urine to enhance this resident's well-being.

The facility reported a census of 36 residents with 14 residents included in the sample, including three residents reviewed for Activities of Daily Living (ADL). Based on record review, interview and observation, the facility failed to shave Resident (R) 29 on a regular basis. Findings included: - Review of Resident (R)29's electronic medical record (EMR) revealed a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). The Significant Change Minimum Data Set (MDS), dated [DATE], documented a staff assessment for cognition, which revealed moderate cognitive impairment. He had no impairment in functional range of motion (ROM) and had no rejection of cares. He was dependent on staff for personal hygiene. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 08/10/24, documented the resident was unable to make his wants and needs known to staff. The Functional Abilities CAA, dated 08/10/24, documented the resident required moderate assistance with his ADL cares. Staff were to anticipate his needs. The Quarterly MDS, dated [DATE], documented the staff assessment for cognition revealed moderate cognitive impairment. He had no impairment in functional ROM and had no rejection of cares. He was dependent on staff for personal hygiene. The Care Plan for ADLs, revised 08/20/24, instructed staff the resident required substantial to maximum assistance with ADLs related to a diagnosis of dementia. The resident was unable to make his needs known and required one staff for completion of personal cares. Review of the resident's EMR, from 10/16/24 through 11/17/24, revealed the resident required maximal assistance to being dependent on staff for assistance with personal hygiene, including facial shaving. The review also revealed the resident had no rejections of care. On 11/13/24 at 02:30 PM, the resident sat in his chair in his room. The resident had long, unshaven facial hair. On 11/14/24 at 08:07 AM, Certified Nurse Aides (CNA) N and CNA M ambulated with the resident from the dining room to his room. The resident had long, unshaven facial hair. On 11/18/24 at 08:19 AM, the resident sat at the dining room table with his peers for breakfast. The resident remained with long, unshaven facial hair. On 11/14/24 at 08:07 AM, CNA N stated staff were to shave residents on their shower days and more often if they ask. CNA N confirmed the resident was unable to voice his needs to staff. On 11/14/24 at 02:00 PM, CNA O stated staff were to shave residents on their shower days. On 11/14/24 at 02:00 PM, CNA P stated staff should shave residents on their shower days. CNA P stated the resident did not refuse cares. On 11/18/24 at 01:30 PM, Administrative Nurse D stated residents should be shaven on shower days and in the mornings when they are getting up and ready for the day. The facility lacked a policy for ADLs. The facility failed to ensure this dependent resident was shaven on a regular basis.

The facility reported a census of 36 residents with 14 residents selected for review, which included two residents reviewed for urinary incontinence. Based on observation, interview, and record review, the facility failed to ensure adequate toileting opportunities for Resident (R)22. Findings included: - Review of Resident (R)22's medical record revealed diagnoses that included cardiomyopathy (heart disease), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and history of urinary tract infections. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The resident was always incontinent of bowel and bladder. The resident received diuretics (medication to promote the formation and excretion of urine). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/17/24, revealed the resident required total to substantial maximum assistance of two staff for cares and often refused incontinence care. The resident was able to make her needs known. The Care Plan reviewed 09/04/24, instructed staff the resident required total to substantial maximum assistance with cares, and often refused incontinence care. The resident had a history of urinary tract infections and staff instructed to encourage the resident to allow incontinence care and notify the nurse if the resident declined. Staff instructed to check and change the resident. A Physician's order, dated 08/23/24, instructed staff to administer furosemide (a medication used to remove excess fluid from the body through the excretion of urine) 80 milligrams, daily for pulmonary hypertension (elevated pressure in the blood vessels of the lungs) due to heart disease. The [NAME] Bowel and Bladder assessment dated [DATE], assessed the resident had functional incontinence and required scheduled toileting. The resident refused to transfer to a bedside commode. This assessment revelaed the resident had incontinence without the sensation of urine loss, had pain with movement, enuresis (incontinence at night) and received an antidepressant. Observation, on 11/13/24 at 10:34 AM, revealed the resident in bed, in a slumped position toward the right. The resident was alert and answered questions. The room had a strong urine odor. The resident stated she could not find her call light which was out of her reach on the headboard of the bed. The call light was disconnected from the wall. Certified Nurse Aide (CNA) MM reconnected the call light and positioned it within reach of the resident. CNA PP checked the resident for incontinence and provided incontinence care which included change of bed linen due to urine saturation. Observation, on 11/14/24 at 01:00 PM, revealed a strong urine odor in R22's room with the resident slumped to the right. Interview at that time with CNA MM, revealed the resident was changed before lunch at approximately 12:00 PM, and the resident had soaked the entire bed with urine. CNA MM stated the resident does not get out of bed and does not always confirm with staff the need for incontinence care. Observation, on 11/14/24 at 03:01 PM, revealed the resident in bed, slumped to her right. The room had a strong urine odor. CNA P and CNA Q provided incontinence care. The resident saturated her brief and urine soaked through onto the mattress. CNA Q stated the resident was cooperative with staff with cares but often reports to staff that she did not need to be changed, when incontinent of urine. CNA Q stated staff check and change the resident every two hours. Observation, on 11/18/24 at 08:50 AM, revealed the room with a strong urine odor and the resident positioned in bed, slumped to the right. The resident stated staff did not change her this morning and she felt wet. CNA QQ stated the resident refused to be changed during the 04:00 AM rounds, and she had not been changed yet this morning. The resident declined the surveyor observation of incontinence care at that time. Observation, on 11/18/24 at 12:24 PM, during the environmental tour with Administrative Staff A and Housekeeping Staff V, confirmed a strong urine odor in the room. Administrative Staff A stated the mattress may need replaced. Interview, on 11/14/24 at 02:56 PM, with Licensed Nurse (LN) G, revealed the resident does not often use her call light, and prefers to lay slumped in bed, turned to her right. LN G stated the resident refused showers, so staff provide bed baths and the resident refused to get up out of bed. Interview, on 11/18/24 at 01:30 PM with Administrative Nurse D, revealed the resident refused showers so staff provided bed baths, but did not know the resident refused incontinence care. Administrative Nurse D stated the resident saturated the briefs and soaked through to the mattress due to large urine capacity of her bladder and staff provided check and change every two hours. Administrative Nurse D stated the resident brief was appropriate for the resident but did not know if/when staff assessed the urinary incontinence to determine a pattern. The resident did have a history of urinary tract infections, and was treated with antibiotics in March, April, and May 2024. The facility policy Incontinence Management Policy reviewed 02/2024, instructed staff to assess the resident's history and pattern of bladder function and compete a three day toileting diary upon admission annually and with significant change in health status. The plan of care will address individualized focus, goals and interventions directed towards managing the resident's bladder incontinence. The facility failed to provide this dependent resident a thorough assessment of her urinary incontinence to ensure staff provided an optimal toileting plan to decrease the risk of urinary tract infections.

The facility reported a census of 36 residents. Based on observation, interview, and record review, the facility failed to ensure staff followed the principles of antibiotic stewardship to ensure the residents received appropriate antibiotics for causative organisms. Findings included: - Review of Resident (R)22's medical record revealed diagnoses that included cardiomyopathy (heart disease), depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness), and history of urinary tract infections. The Annual Minimum Data Set (MDS), dated [DATE], assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. The resident was always incontinent of bowel and bladder. The resident received diuretics (medication to promote the formation and excretion of urine). The Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), dated 08/17/24, revealed the resident required total to substantial maximum assistance of two staff for cares and often refused incontinence care. The resident was able to make her needs known. The Care Plan reviewed 09/04/24, instructed staff the resident required total to substantial maximum assistance with cares, and often refused incontinence care. The resident had a history of urinary tract infections and staff instructed to encourage the resident to allow incontinence care and notify the nurse if the resident declined. Staff instructed to check and change the resident. A Physician's Order dated 03/22/24, instructed staff to administer cefdinir (an antibiotic) 300 milligrams (mg) twice a day for seven days for urinary tract infection (UTI). The causative organisms (proteus mirabilis and Escherichia coli) per culture report were susceptible to the antibiotic. A urine sample obtained by a catheter (a flexible tube) inserted into the blader for a sterile urine sample on 03/26/24 revealed no UTI for R22. A Physician's Order dated 04/03/24 instructed staff to administer Macrodantin (an antibiotic) 100 mg twice a day for seven days for UTI for R22. The medical record lacked a culture report for the use of this antibiotic. A Physician's Order dated 05/20/24, instructed staff to administer cefuroxime axetil (an antibiotic) 250mg twice a day for UTI for R22. The culture report revealed the causative organism as proteus mirabilis which was susceptible to the antibiotic. Interview, on 11/18/24 at 01:00 PM with Administrative Nurse D, revealed the resident received the antibiotic order from the emergency room physician and the facility did not receive the culture report. The facility policy Infection Control Surveillance revised 11/2023, instructed staff to review the clinical record for diagnostic or lab results which support the use of current antibiotics prescribed. The facility failed to obtain the culture results to ensure the appropriate use of Macrodantin ordered on 04/03/34, was effective to ensure antibiotic stewardship to prevent multidrug resistant bacterial infections for this incontinent resident with UTIs.

The facility reported a census of 33 residents. The sample included three residents reviewed for transfers with mechanical lifts. Based on observation, interview, and record review, the facility failed to ensure adequate staff to safely transfer residents, in accordance with professional standards, Occupational Safety and Health Administration (OSHA) guidelines, Food and Drug Administration (FDA) guidelines, and manufacturers recommendations, with use of a mechanical lift. The facility identified eight residents who required a full body mechanical lift and four residents who required a sit-to-stand mechanical lift for transfers. Nursing staff reported they utilized the mechanical lifts for resident transfers, without a second staff member present, due to lack of staff availability to perform the transfers correctly. Interviews with six residents confirmed staff regularly did not utilize two staff members with mechanical lift transfers. This deficient practice placed these 12 residents in immediate jeopardy. (R1, R2, R3, R4, R5, and R6) Findings included: - During an onsite survey from (04/17/24 and 04/18/24) a concern was identified that facility staff did not utilize two staff for mechanical lift transfers, per best practice and safety guidelines. The facility identified eight residents who required a full body mechanical lift and four residents who required a sit-to-stand mechanical lift, for transfers. Interviews with alert and oriented residents, who required use of mechanical lift transfers, revealed the following concerns: R1 required a wheelchair for mobility device and mechanical sit-to-stand lift for transfers due to functional limited immobility in bilateral (both) lower extremities, per the 04/26/24 Admission Minimum Data Set (MDS). R1's Activities of Daily Living (ADL) Care Plan, revised 02/07/23, guided staff that R1 had increased difficulty with transfer and required two staff with the mechanical sit-to-stand lift for transfers. During an interview on 04/17/24 at 02:30 PM, R1 reported that on many occasions the nursing staff transferred him with one staff member utilizing a full body mechanical lift. R1 reported he was unsure how long the nursing staff had been transferring him utilizing the mechanical lift with one staff member but said it had been for a few months. R2 required a wheelchair for mobility device and total assistance by two staff for transfer with use of full body mechanical lift due to functional limited immobility in bilateral lower extremities, per the 02/10/24 Annual MDS. R2's ADL Care Plan, revised, 03/18/23, guided staff that R2 required total assistance of two staff for transfer with use of full body mechanical lift. On 04/17/24 at 02:48 PM, R2 reported that one staff transfers him with the full body mechanical lift. R3 required a wheelchair for mobility device a mechanical sit-to-stand mechanical lift due to functional limited immobility in left upper and lower extremities, per the 03/20/24 Quarterly MDS. R3's ADL Care Plan, revised, 02/07/23, guided staff that R2 required total assistance by two staff for transfer with use of sit-to-stand mechanical lift. During an interview on 04/17/24 at 03:01 PM, R3 reported she required the sit-to-stand mechanical lift for transfer and stated that one staff member transfers her. R4 required use of a wheelchair mobility device and total assistance by two staff for transfer with use of full body mechanical lift due to morbid obesity and decreased strength, per the 02/24/24 Quarterly MDS. R4's ADL Care Plan, revised 04/08/24, guided staff that R4 required total assistance of two staff for transfer with use of full body mechanical lift. During an interview on 04/17/24 at 04:14 PM, R4 reported she required a full body mechanical lift for transfers and that one staff member transferred her most of the time. R5 required a wheelchair mobility device and total assistance of two staff for transfer because she was non-ambulatory and used a full body mechanical lift, per the 02/03/24 Quarterly MDS. R5's ADL Care Plan, revised 02/01/23, guided staff that R5 required total assistance of two staff for transfer with use of full body mechanical lift. During an interview on 04/17/24 at 04:48 PM, R5 reported that one staff member transferred her with the full body mechanical lift. R6 required a wheelchair mobility device and total assistance of two staff for transfer with use of a full body mechanical lift due to functional limited immobility in right upper and lower extremities, per the 04/29/23 Annual MDS. R6's ADL Care Plan, revised 11/09/22, guided staff that R5 required total assistance of two staff for transfer with use of the full body mechanical lift. During an interview on 04/17/24 at 05:33 PM, R6 (identified by the facility as alert and oriented) reported one staff transfers her with the full body mechanical lift most of the time. Per the OSHA website (osha.gov), Lift, Transfer & Reposition Policy noted the staff procedure that all resident care will be provided in a safe, appropriate, and timely manner in accordance with the individual resident's Care Plan. Per the FDA website document titled: Patient Lifts Safety Guide, page two revealed Patient falls from lifts may cause injuries, including head trauma, fractures and death. Page six noted that most lifts required two or more caregivers to safely operate lift and handle patient. Per page four of the mechanical lift manufacturers recommendations, available online, noted the Statement of Intended Use which guided staff that the mechanical lifts must be operated by a minimum of two people. On 04/17/24 at 02:19 PM, Certified Nurse Aide (CNA) M reported she knew the full body mechanical lift and the sit-to-stand lift mechanical lift required at least two staff members for use, however it was quicker to transfer a resident by themselves instead of waiting for the Float CNA to come over to the hall and assist with a transfer. CNA M reported there was a Hospitality Aide but the hospitality aides were not allowed to assist with transfers. During an interview on 04/17/24 at 02:55 PM, Nurse Aide in Training (NAT) O reported she witnessed nursing staff transfer the residents with the mechanical full body lift and the mechanical sit-to-stand lift with one staff member. During an interview on 04/18/24 at 06:19 AM, CNA P reported they regularly utilized the full body mechanical lift and the sit-to-stand lifts by themselves and for approximately three months had been transferring residents without two staff assistance. During an interview on 04/18/24 at 06:33 AM, LN H reported that the CNAs did not let the Licensed Nurses (LN) know when they required help with mechanical lift transfers. During an interview on 04/18/24 at 07:30 AM, LN G reported the CNAs should ask for assistance if they need to transfer a resident. LN G reported she was aware that staff transferred with one staff member and had advised administration in the past. During an interview on 04/18/24 at 01:38 PM, Physical Therapist HH reported for the safety of the residents, during the transfer utilizing the full body mechanical lift and the sit-to-stand mechanical lift, per therapy recommendations and the recommendations of the manufacturer's, there must be two staff members operating the mechanical lift and the sit-to-stand at all times. During an interview on 04/18/24 at 03:14 PM, Administrative Nurse D reported she was not aware the staff utilized the mechanical full body lifts or the mechanical sit-to-stand lifts alone. Administrative Nurse D reported she was not aware that the License Nurse (LN) were aware the CNAs were transferring residents with one staff member. The facility did not have a policy for the use of utilizing the mechanical lifts, but staff education was provided in their orientation checkoffs. Administrative Nurse D expected the nursing staff to advise licensed nurses or the Director of Nursing if someone needed assistance with the mechanical lifts. During an interview on 04/18/24 at 03:14 PM, Consultant GG reported she was not aware that nursing staff were transferring residents with the mechanical full body lift and the sit-to-stand against the facility or manufacturer's recommendations. She reported nursing staff have been educated that there should be two staff members with any mechanical lift transfers. The facility lacked a policy on mechanical lift transfers. The facility failed to ensure the safe transfers of 12 residents the facility identified as requiring a mechanical lift for transfers, when staff utilized only one staff member during mechanical lift transfers. This deficient practice placed these 12 residents in immediate jeopardy (IJ). On 04/18/24 at 02:05 PM, Administrative staff A was provided an IJ template for failure to ensure adequate staff to ensure the safe transfer of 12 residents, in accordance with professional standards, Occupational Safety and Health Administration (OSHA) guidelines, Food and Drug Administration (FDA) guidelines, and manufacturers recommendations, with use of a mechanical lift. The immediate jeopardy was determined to first exist on 02/20/24 at 01:53 PM when an anonymous complaint was reported to the State Agency regarding staff utilizing one person mechanical lift transfers. The facility provided an acceptable plan of removal on 04/18/24 at 03:26 PM with the following corrective actions: A Quality Assurance and Performance Improvement (QAPI) meeting held with the Medical Director on 04/18/24. All nursing staff will receive education from the Director of Nursing or designee on the requirement to have two staff present for mechanical lift transfers and the resident transfer requirements to have two staff present for mechanical lift transfers and the resident transfer requirements located in the plan of care/Kardex. All nursing staff will complete a skills demonstration on mechanical lift transfers by end of day on 04/18/24 or before their start of their next shift. The survey team validated the removal of the immediate jeopardy on 04/18/24 at 04:45 PM, following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at an E scope and severity level.

The facility reported a census of 33 residents. The sample included three residents reviewed for transfers with mechanical lifts. Based on observation, interview, and record review, the facility failed to ensure nursing personnel had the knowledge, competencies and skill sets to provide care to safely transfer residents, in accordance with professional standards, Occupational Safety and Health Administration (OSHA) guidelines, Food and Drug Administration (FDA) guidelines, and manufacturers recommendations, with use of a mechanical lift. The facility identified eight residents who required a full body mechanical lift and four residents who required a sit-to-stand mechanical lift for transfers. Nursing staff reported they utilized the mechanical lifts for resident transfers, without a second staff member present. Interviews with six residents confirmed staff regularly did not utilize two staff members with mechanical lift transfers. Findings included: - During an onsite survey from (04/17/24 and 04/18/24) a concern was identified that facility staff did not utilize two staff for mechanical lift transfers, per best practice and safety guidelines. The facility identified eight residents who required a full body mechanical lift and four residents who required a sit-to-stand mechanical lift, for transfers. Interviews with alert and oriented residents, who required use of mechanical lift transfers, revealed the following concerns: R1 required a wheelchair for mobility device and mechanical sit-to-stand lift for transfers due to functional limited immobility in bilateral (both) lower extremities, per the 04/26/24 Admission Minimum Data Set (MDS). R1's Activities of Daily Living (ADL) Care Plan, revised 02/07/23, guided staff that R1 had increased difficulty with transfer and required two staff with the mechanical sit-to-stand lift for transfers. During an interview on 04/17/24 at 02:30 PM, R1 reported that on many occasions the nursing staff transferred him with one staff member utilizing a full body mechanical lift. R1 reported he was unsure how long the nursing staff had been transferring him utilizing the mechanical lift with one staff member but said it had been for a few months. R2 required a wheelchair for mobility device and total assistance by two staff for transfer with use of full body mechanical lift due to functional limited immobility in bilateral lower extremities, per the 02/10/24 Annual MDS. R2's ADL Care Plan, revised, 03/18/23, guided staff that R2 required total assistance of two staff for transfer with use of full body mechanical lift. On 04/17/24 at 02:48 PM, R2 reported that one staff transfers him with the full body mechanical lift. R3 required a wheelchair for mobility device a mechanical sit-to-stand mechanical lift due to functional limited immobility in left upper and lower extremities, per the 03/20/24 Quarterly MDS. R3's ADL Care Plan, revised, 02/07/23, guided staff that R2 required total assistance by two staff for transfer with use of sit-to-stand mechanical lift. During an interview on 04/17/24 at 03:01 PM, R3 reported she required the sit-to-stand mechanical lift for transfer and stated that one staff member transfers her. R4 required use of a wheelchair mobility device and total assistance by two staff for transfer with use of full body mechanical lift due to morbid obesity and decreased strength, per the 02/24/24 Quarterly MDS. R4's ADL Care Plan, revised 04/08/24, guided staff that R4 required total assistance of two staff for transfer with use of full body mechanical lift. During an interview on 04/17/24 at 04:14 PM, R4 reported she required a full body mechanical lift for transfers and that one staff member transferred her most of the time. R5 required a wheelchair mobility device and total assistance of two staff for transfer because she was non-ambulatory and used a full body mechanical lift, per the 02/03/24 Quarterly MDS. R5's ADL Care Plan, revised 02/01/23, guided staff that R5 required total assistance of two staff for transfer with use of full body mechanical lift. During an interview on 04/17/24 at 04:48 PM, R5 reported that one staff member transferred her with the full body mechanical lift. R6 required a wheelchair mobility device and total assistance of two staff for transfer with use of a full body mechanical lift due to functional limited immobility in right upper and lower extremities, per the 04/29/23 Annual MDS. R6's ADL Care Plan, revised 11/09/22, guided staff that R5 required total assistance of two staff for transfer with use of the full body mechanical lift. During an interview on 04/17/24 at 05:33 PM, R6 (identified by the facility as alert and oriented) reported one staff transfers her with the full body mechanical lift most of the time. Per the OSHA website (osha.gov) Lift, Transfer & Reposition Policy noted the staff procedure that all resident care will be provided in a safe, appropriate and timely manner in accordance with the individual resident's Care Plan. Per the FDA website document titled: Patient Lifts Safety Guide, page two revealed Patient falls from lifts may cause injuries, including head trauma, fractures and death. Page 6 noted that most lifts required two or more caregivers to safely operate lift and handle patient. Per page four of the mechanical lift manufacturers recommendations, available online, noted the Statement of Intended Use which guided staff that the mechanical lifts must be operated by a minimum of two people. Interviews with the facility staff revealed the following concerns: On 04/17/24 at 12:33 PM, Administrative Staff A reported that he was not aware that nursing staff utilized the full body mechanical lift or the sit to stand mechanical lift alone. The the mechanical full body lift and the mechanical sit-to-stand lift do require a second staff member. We do not have a staffing policy and that staffing is based on acuity and census. Staff competencies had not been completed for approximately one year for the staff that have bee On 04/17/24 at 02:19 PM, Certified Nurse Aide (CNA) M reported she knew the full body mechanical lift and the sit-to-stand lift mechanical lift required at least two staff members for use, however it was quicker to transfer a resident by themselves instead of waiting for the Float CNA to come over to the hall and assist with a transfer. CNA M reported there was a Hospitality aide but the hospitality aides were not allowed to assist with transfers. During an interview on 04/17/24 at 02:55 PM, Nurse Aide in Training (NAT) O reported she witnessed nursing staff transfer the residents with the mechanical full body lift and the mechanical sit-to-stand lift with one staff member. During an interview on 04/18/24 at 06:19 AM, CNA P reported they regularly utilized the full body mechanical lift and the sit-to-stand lifts by themselves and for approximately three months had been transferring residents without two staff assistance. During an interview on 04/18/24 at 06:33 AM, LN H reported that the CNAs did not let the Licensed Nurses (LN) know when they required help with mechanical lift transfers. During an interview on 04/18/24 at 07:30 AM, LN G reported the CNAs should ask for assistance if they need to transfer a resident. LN G reported she was aware that staff transferred with one staff member and had advised administration in the past. During an interview on 04/18/24 at 01:38 PM, Physical Therapist HH reported for the safety of the residents, during the transfer utilizing the full body mechanical lift and the sit-to-stand mechanical lift, per therapy recommendations and the recommendations of the manufacturer's recommendations, there must be two staff members operating the mechanical lift and the sit-to-stand at all times. During an interview on 04/18/24 at 03:14 PM, Administrative Nurse D reported she was not aware the staff utilized the mechanical full body lifts or the mechanical sit-to-stand lifts alone. Administrative Nurse D reported she was not aware that the License Nurse (LN) were aware the CNAs were transferring residents with one staff member. The facility did not have a policy for the use of utilizing the mechanical lifts, but staff education was provided in their orientation checkoffs. During an interview on 04/18/24 at 03:14 PM, Consultant GG reported she was not aware that nursing staff were transferring residents with the mechanical full body lift and the sit-to-stand against the facility or manufacturer's recommendations. She reported nursing staff have been educated that there should be two staff members with any mechanical lift transfers. The facility lacked a staffing policy. The facility failed to ensure staff competency and skill sets to ensure the safe transfers of 12 residents the facility identified as requiring mechanical lift transfers.

The facility reported a census of 34 residents with three selected for review for activities of daily living (ADL's). Based on observation, interview, and record review, the facility failed to provide adequate bathing for two of the three sampled, who were dependent on staff for bathing services, Resident (R)1 and R3. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of contracture (abnormal permanent fixation of a joint or muscle) to left and right hand, aphasia (condition with disordered or absent language function), intellectual disabilities (a significantly below-average score on a test of mental ability or intelligence and by limitations in the ability to function in areas of daily life), and cognitive communication deficit. The Annual Minimum Data Set (MDS) dated [DATE] assessed R1 with a short-term and a long-term memory problem with severely impaired decision making. R1 did not reject care and was totally dependent on two or more staff for bathing. R1 had range of motion limitations to both side of upper extremities and lower extremities. The Cognitive Loss/Dementia Care Area assessment dated [DATE], revealed R1 was non-verbal and had contractures to his left and right hand. The Quarterly MDS dated [DATE] revealed R1 had no changes to his memory, decision making, range of motion, and continued to not reject care. The Care Plan dated 01/29/24 revealed R1 transferred with a Hoyer lift (total body mechanical lift) and required two to threes staff assistance for showering. The staff were to provide a shower on Monday and Thursday during the day shift. The Task tab in the electronic medical record (EMR) revealed R1 was to receive a shower on the day shift on Monday and Thursday. The Documentation Survey Report dated December 2023 revealed R1 lacked bathing on 12/07/23, 12/18/23, 12/25/23, and 12/28/23, missing four of eight opportunities for bathing. R1 was given a partial bath on 12/21/23 and lacked bathing 12/22/23 through 12/31/23 (10 days without being bathed). R1 received two bed baths and two partial baths and lacked receiving a shower for the month. The Documentation Survey Report dated January 2024 revealed R1 lacked bathing on 01/04/24, 01/18/24, and 01/29/24, missing three of nine bathing opportunities. R1 received a bed bath on 01/25/24 and lacked bathing 01/26/24 through 01/31/24. R1 received a shower on 01/01/24 and lacked receiving any other showers for the month; R1 received one bed bath and four partial baths for the month. The Documentation Survey Report dated 02/01/24 through 02/12/24 revealed R1 received a partial bath on 02/05/24, indicating R1 lacked bathing from 01/26/24 through 02/04/24 (10 days). R1 lacked bathing on 02/08/24, missing two of four bathing opportunities from 02/01/24 through 02/12/24. R1 received a bed bath on 02/12/24 and lacked a shower for the 12 days reviewed in February 2024. On 02/13/24 at 01:47 PM, observed R1 sitting up in a reclining wheelchair in the television room, his hands and elbows in contracted position, hair appeared greasy, and a white flake visible in his hair. On 02/13/24 at 02:56 PM, Licensed Nurse (LN) G stated the staff document bathing in the EMR and the electronic system flags us if no shower. LN G stated if the staff were unable to complete bathing on their shift, they should try to complete on the next shift as soon as soon as they could. On 02/14/24 at 09:41 AM, Certified Nurse Aide (CNA) R stated R1 was to be bathed on day shift and staff try to give him one shower a week and a bed bath on the second scheduled day of the week. CNA R stated there had been days in the last several months R1 did not receive a bath as scheduled and it is passed on to the evening shift. CNA R stated when providing a partial bath is when a resident's face and staff would give good peri-care and when providing a bed bath R1's hair should be washed with use of a basin and wash cloths. On 02/14/24 at 12:09 PM, Administrative Nurse D stated she expected the residents to be bathed twice a week, with a minimum of one shower a week and a bed bath for the second one. Administrative Staff D stated R1 is a safety concern in the shower sometimes. On 02/14/24 at 12:12 PM, Administrative Staff A stated the facility lacked a bathing policy and followed the standards of care. Administrative Staff A stated he expected the residents to get bathing as scheduled. The facility failed to provide R1 with bathing nine of 21 opportunities from 12/04/23 through 02/12/24 resulting in two periods during that time R1 lacked bathing for 10 days. - The Medical Diagnosis tab for R3 included diagnoses of secondary Parkinsonism (when similar symptoms of Parkinson's disease [slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness] caused due to other disease, illness, or medication) and dementia (progressive mental disorder characterized by failing memory, confusion) with behavioral disturbance. The Quarterly Minimum Data Set (MDS) dated [DATE] assessed R3 with a Brief Interview of Mental Status score (BIMS) of one, indicating severe cognitive impairment. R3 did not reject care and was totally dependent of one staff for bathing. The Annual MDS dated [DATE] assessed R3 with a BIMS score of one and she did not reject care. The Cognitive Loss/Dementia Care Area assessment dated [DATE] revealed the staff needed to anticipate R3's needs if unable to do so and she had a diagnosis of dementia. R3 was easily distracted and her conversation was irrelevant and rambling. The Care Plan dated 12/10/23 revealed R3 preferred to receive a shower on Wednesday and Saturday on the day shift and required assistance of one staff for personal care. The Task tab in the electronic medical record (EMR) revealed the staff were to bathe R3 on the day shift on Wednesday and Saturday. The Documentation Survey Report dated December 2023 revealed R3 lacked bathing on 12/09/23, 12/16/23, 12/20/23, 12/27/23, and 12/20/23, missing five of nine opportunities. R3 received a shower on 12/23/23 and lacked any type of bathing 12/24/23 through 12/31/23. The Documentation Survey Report dated January 2024 revealed R3 lacked bathing from 01/01/24 through 01/09/24, indicating she lacked receiving any type of bath from 12/24/23 through 01/09/23 (17 days). R3 lacked bathing on 01/03/24, 01/06/24, and 01/20/24, missing three of nine bathing opportunities for the month. The Documentation Survey Report dated 02/01/24 through 02/12/24 revealed R3 lacked bathing on 02/10/24, missing one of three opportunities for bathing between 02/01/24 and 02/12/24. On 02/13/24 at 01:52 PM observed R3 sitting up in a wheelchair in the television room, with her hands closed, and arms crossed. Her hair was braided, however there were loose strands of hair from the braid, the bottom of the braid lacked a band to secure if from coming loose, and the top of her hair appeared greasy. On 02/13/24 at 02:56 PM, Licensed Nurse (LN) G stated the staff document bathing in the EMR and the electronic system flags us if no shower. LN G stated if the staff were unable to complete bathing on their shift, they should try to complete on the next shift as soon as soon as they could. On 02/14/24 at 12:09 PM, Administrative Nurse D stated she expected the residents to be bathed twice a week, with a minimum of one shower a week and a bed bath for the second one. Administrative Staff D stated R1 is a safety concern in the shower sometimes. On 02/14/24 at 12:12 PM, Administrative Staff A stated the facility lacked a bathing policy and followed the standards of care. Administrative Staff A stated he expected the residents to get bathing as scheduled. The facility failed to provide R3 with bathing nine of 21 opportunities from 12/02/23 through 02/10/24 resulting in a period of 17 days in that time R3 lacked bathing.

The facility reported a census of 37 residents with four selected for review including three reviewed for accident hazards. Based on observation, record review, and interview, the facility failed to provide assistive devices to prevent a fall one of the three sampled residents, Resident (R)2, when a Certified Nurse Aide (CNA) was propelling R2 in her wheelchair, R2 placed her feet on the floor, and then fell forward out of the wheelchair hitting her face which resulted in a traumatic hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to her forehead. Findings included: - The Medical Diagnosis tab for R2 included diagnoses of cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area), dementia (progressive mental disorder characterized by failing memory, confusion), and arthritis (inflammation of a joint characterized by pain, swelling, heat, red and limitation of movement). The Annual Minimum Data Set (MDS) dated [DATE] assessed R2 with a Brief Interview of Mental Status (BIMS) score of two, indicating severe cognitive impairment. She required extensive assist of one staff for locomotion, had no range of motion impairment to her lower extremities, and used a wheelchair for mobility. R1 had no falls since the last assessment. The Quarterly MDS dated [DATE] assessed R2 with a BIMS score of one, indicating severe cognitive impairment. She continued to require extensive assistance of one staff for locomotion, had no changes to her range of motion, continued to use a wheelchair for mobility, and had no falls since the prior assessment on 02/25/23. The Falls Care Area assessment dated [DATE] for R2 revealed R2 required the use of a wheelchair for mobility and required the staff to propel. The Care Plan dated 03/31/23 for R2 revealed she could propel her own wheelchair around the facility and sometimes needed the staff to assist her. The facility investigation Witness Statement dated 05/20/23 by Certified Nurse Aide (CNA) M revealed she was taking R2 from the dining room to the lobby when R2 put her feet down on the floor and went out her chair. As R2 was going forward CNA M grabbed her to keep her from falling forward but she still went forward and hit the floor face planting the floor. CNA M observed R2 with a big goose egg on her forehead. The facility investigation Witness Statement dated 05/20/23 by CNA N revealed she observed R2 being moved from the dining room and she started to lean forward in her wheelchair. CNA M reached around her upper chest to stop R2 from falling, however R2 continued falling forward and out of her wheelchair. R2 hit her forehead and had an instant goose egg. The Progress Note dated 05/20/23 at 06:15 PM revealed a thud was heard and R2 observed on the floor with her head turned to the left. After log rolling her, R2 was rubbing the left side of her face and a goose egg was already on her forehead. R2 was talking and saying, oh God. Ambulance called and emergency medical services arrived at 06:25 PM and transported her to the emergency room . The Progress Note dated 05/20/23 at 06:42 PM revealed the foot pedals to R2's wheelchair were not in place at the time of the fall. The Progress Note dated 05/20/23 at 08:30 PM revealed R2 returned to the facility from the emergency room with a diagnosis of traumatic hematoma of forehead. The Progress Note dated 05/22/23 at 11:53 AM revealed the interdisciplinary team met and identified the root cause of the fall was R2's foot pedals were not on her wheelchair and education was done immediately to CNA M for residents which required to be pushed in the wheelchair by staff, they needed to have foot pedals in place. On 06/08/23 at 11:17 AM Administrative Nurse D stated further investigation revealed R2 had been placed in the wrong wheelchair when she had fell on [DATE], her feet were not able to touch the floor in her wheelchair. On 06/08/23 at 12:43 PM observed R2 sitting in a wheelchair at the dining room table, feet resting on pedals of the wheelchair while the staff was feeding her lunch. On 06/08/23 at 01:00 PM Administrative Staff A stated the facility lacked a policy for when wheelchair pedals should be used, it was a standard of practice. On 06/08/23 at 03:56 PM R2 could not recall falling out of the wheelchair when interviewed. The facility failed to ensure staff were aware not to move a resident in a wheelchair without pedals in place and ensuring the staff new the correct wheelchair to put a resident in, resulting in R2 falling forward out of her wheelchair while being propelled, hitting the floor face first, and causing a traumatic hematoma to the left side of her forehead.

The facility reported a census of 36 residents. Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent. Observation of 25 physician ordered medications revealed three medications administered by staff in error, resulting in a medication error rate of 12 percent. These errors affected Resident (R)1, R3, and R5. Findings included: - 1.) The Certified Medication Aide Medication Administration Record (CMA MAR) dated May 2023, revealed an order dated 05/05/23 for sucralfate (antacid) oral tablet, by mouth, two times a day, related to gastroesophageal reflux disease (GERD - backflow of stomach contents to the esophagus). The order included instructions to not administer within 30 minutes of an antacid, or two hours of other medications. Observation on 05/16/23 at 05:25 PM, revealed Licensed Nurse (LN) H administer medications to R1 which included the Sucralfate along with multiple other medications. On 05/17/23 at 11:02 AM, Administrative Nurse D stated when asked if Sucralfate should be given the same time as other medications, no it should not be given with other medications or within two hours of taking them. 2.) The Licensed Medication Administration Record (MAR) dated May 2023, for R5, included a diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The MAR included an order dated 04/07/21 for Novolog (insulin) flex pen solution pen injector, 100 units per milliliter, subcutaneously (under skin), eight units, before meals, plus correction dose according to sliding scale orders, related to diabetes mellitus. Observation on 05/16/23 at 04:38 PM, revealed Licensed Nurse (LN) G prepare the insulin pen for administration to R5, which lacked an open date, for R5. LN G failed to perform a safety test of the pen and needle to ensure an accurate dose by removing air bubbles prior to administration (via an air shot). LN G injected the insulin into R5's skin and immediately removed the insulin pen after pressing the injection button at the end of the pen all the way. LN G failed to keep the pen in place after pressing the injection button at the end of the pen. On 05/16/23 at 04:40 PM, LN G stated that it was a new pen and then added the open date to the pen. LN G stated she had never done an air shot with the insulin pens before. On 05/16/23 at 05:43 PM, Administrative Nurse D stated she was not aware if the insulin pens required an air shot, the pen should be held in place until empty and was not sure the exact time the pen should be held into place after the injection button at the end of the pen was pressed all the way but should hold for a little bit. The facility policy Medication Administration Subcutaneous Insulin dated January 2023 revealed the licensed staff should always perform the safety test before each injection to ensure an accurate dose by removing air bubbles and ensuring the pen and needle work properly. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any tiny air bubbles raise up towards the needle. Press the injection button all the way in, check if insulin comes out of the needle tip. The test may have to be performed several times before insulin is seen. After inserting the needle into the skin at a 90-degree angle, deliver the dose by pressing the injection button in all the way. The number in the dose window will turn to zero as you inject. Keep the button pressed all the way in and slowly count to 10 before withdrawing the needle from the skin to ensure that the full dose will be delivered. 3.) The Licensed Medication Administration Record (MAR) for R3 dated May 2023 included a diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). The MAR included an order dated 11/17/22 for Novolog (insulin) flex pen solution pen injector, 100 units per milliliter, subcutaneously (under skin), before meals, per sliding scale, related to diabetes mellitus. On 05/16/23 at 04:40 PM, LN G stated she had never done an air shot with the insulin pens before after observation of another resident's insulin administration. Observation on 05/16/23 at 04:50 PM, revealed Licensed Nurse (LN) G, prepare R3's insulin pen for administration without performing a safety test of the pen and needle to ensure an accurate dose by removing air bubbles prior to administration (via an air shot). LN G injected the insulin into R3's skin and immediately removed the insulin pen after pressing the injection button at the end of the pen all the way. LN G failed to keep the pen in place after pressing the injection button at the end of the pen. On 05/16/23 at 05:43 PM, Administrative Nurse D stated she was not aware if the insulin pens required an air shot, the pen should be held in place until empty and was not sure the exact time the pen should be held into place after the injection button at the end of the pen was pressed all the way, but should hold for a little bit. The facility policy Medication Administration Subcutaneous Insulin dated January 2023 revealed the licensed staff should always perform the safety test before each injection to ensure an accurate dose by removing air bubbles and ensuring the pen and needle work properly. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. Hold the pen with the needle pointing upwards. Tap the insulin reservoir so that any tiny air bubbles rise up towards the needle. Press the injection button all the way in, check if insulin comes out of the needle tip. The test may have to be performed several times before insulin is seen. After inserting the needle into the skin at a 90-degree angle, deliver the dose by pressing the injection button in all the way. The number in the dose window will turn to zero as you inject. Keep the button pressed all the way in and slowly count to 10 before withdrawing the needle from the skin to ensure that the full dose will be delivered. The facility failed to provide a policy for medication administration of these medications. The facility failed to ensure a medication error rate less than five percent, placing the residents at risk for adverse drug effects with the three resident's medication errors of 25 observed which resulted in a 12 percent error rate.

The facility reported a census of 36 residents with five selected for review, including three residents reviewed for unnecessary medication. Based on observation, interview, and record review, the facility failed to ensure three of the residents reviewed, Resident (R)1, R3, and R4 received their physician ordered medication as ordered. Findings included: - The facility reported the medication pass times were as follows: 1. AM pass times were from 06:00 AM to 10:00 AM. 2. Noon pass times were from 10:00 AM to 02:00 PM. 3. PM pass times were form 02:00 PM to 07:00 PM. 4. HS (hour of sleep) pass times were at the resident's bedtime. The Certified Medication Aide Medication Administration Record (CMA MAR) dated May 2023, for Resident (R)4 included an order on 04/25/23, for scopolamine (medication which creates a calming effect on the muscles in the stomach and bowels, can be used to treat nausea and vomiting), transdermal patch, 72 hours, apply one patch, transdermal, one time a day, every three days, related to disturbances of salivary secretions. On 05/10/23, the staff documented a O indicating other, see progress note for the AM pass time and on 05/16/23, the MAR was blank for the AM administration time. The Progress Note dated 05/10/23, for R4, for the scopolamine patch, revealed med not available. The Licensed MAR dated May 2023 for R4 revealed orders on 05/02/23, for hydrocodone-acetaminophen (used to treat moderate to severe pain), 5/300 milligrams (mg), give one tab, by mouth, twice a day, related to pain. The AM pass time had documentation of O from 05/03/23 through 05/08/23 and on 05/09/23. The MAR lacked documentation that the medication was given (blank space). The HS (hour of sleep) pass time had documentation of O on 05/03/23, 05/06/23, and 05/07/23. The discontinuation of this order occurred on 05/09/23. The Progress Note for R4 dated 05/03/23 at 12:25 PM, for the hydrocodone-acetaminophen revealed waiting on pharmacy to deliver. The Progress Note for R4 dated 05/06/23 at 09:41 PM, for the hydrocodone-acetaminophen revealed awaiting delivery from the pharmacy. The Progress Note for R4 dated 05/07/23 at 07:25 PM for the hydrocodone-acetaminophen revealed not available. The Progress Note for R4 dated 05/08/23 at 08:12 AM, for the hydrocodone-acetaminophen revealed not available. On 05/16/23 at 11:18 AM, Licensed Nurse (LN) G stated she had just completed her morning medication pass and she was not able to locate the scopolamine patch for R4. LN G stated the medication has been signed for that it arrived she but could not find it and the other nurse was helping her try to locate it. On 05/16/23 at 03:08 PM, LN G stated the scopolamine patch for R4 could not be found and she was going to check with the oncoming nurse to see if the location of the medication was known. On 05/16/23 at 05:43 PM, Administrative Nurse D stated if a resident is out of a medication the pharmacy should be called and medications should be ordered when there are about seven pills left in a card. Administrative Nurse D stated the licensed nurses were to reorder medications, and the facility just switched from the CMA's passing medications to the nurses passing medications. If a medication is unavailable, a note would be made to indicate that, and an alert would show up on the dashboard of the EMR. Administrative Nurse D stated she checks the dashboard in the morning, will check to see why a medication was not given, such as checking the medication room to make sure the medication was not placed in the wrong spot. On 05/17/23 at 09:53 AM, Administrative Nurse D stated the facility did not have a policy for medication ordering, it was a nursing standard of practice. On 05/17/23 at 11:10 AM, Administrative Nurse D stated when the MAR has a blank spot, the staff failed to document the completion of the medication administration. The facility failed to ensure R4's medication arrived timely for administration increasing the risk of R4 having adverse effects from not receiving her physician ordered medications. - The facility reported the medication pass times were as follows: 1. AM pass times were from 06:00 AM to 10:00 AM. 2. Noon pass times were from 10:00 AM to 02:00 PM. 3. PM pass times were form 02:00 PM to 07:00 PM. 4. HS (hour of sleep) pass times were at the resident's bedtime. The Licensed Medication Administration Record (MAR) for R3 dated April 2023 revealed and order on 10/31/22 for Lantus (insulin) Solostar Solution Pen-injector, 100 units/milliliter, inject 14 units, subcutaneously (under skin), at bedtime, related to diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin). On 04/06/23 the MAR revealed documentation of O indicating other, see progress note for the HS pass. The Progress Note dated 04/06/23, for the Lantus insulin, for R3 revealed awaiting delivery from pharmacy. The Certified Medication Aide Medication Administration Record (CMA MAR) dated April 2023 for R3 revealed an order dated 11/26/22, for glimepiride (medication used to treat diabetes), one milligram (mg), give two mg, by mouth, two times a day, related to diabetes mellitus. The AM pass time revealed documentation of O on 04/02/23, 04/04/23, 04/06/23, and NA indicating not required/not applicable on 04/05/23. The Progress Note dated 04/02/23 at 09:54 AM, for the glimepiride for R3 revealed not available. The Progress Note dated 04/04/23 at 09:13 AM, for the glimepiride for R3 revealed no med. The Progress Note dated 04/06/23 at 07:29 AM, for the glimepiride for R3 revealed med on order. On 05/16/23 at 05:43 PM, Administrative Nurse D stated if a resident is out of a medication the pharmacy should be called and medications should be ordered when there are about seven pills left in a card. Administrative Nurse D stated the licensed nurses were to reorder medications, and the facility just switched from the CMA's passing medications to the nurses passing medications. If a medication is unavailable, a note would be made to indicate that, and an alert would show up on the dashboard of the EMR. Administrative Nurse D stated she checks the dashboard in the morning, will check to see why a medication was not given, such as checking the medication room to make sure the medication was not placed in the wrong spot. On 05/17/23 at 09:53 AM, Administrative Nurse D stated the facility did not have a policy for medication ordering, it was a nursing standard of practice. The facility failed to ensure R3's medication arrived timely for administration increasing the risk of R3 having adverse effects from not receiving her physician ordered medication. - The facility reported the medication pass times were as follows: 1. AM pass times were from 06:00 AM to 10:00 AM. 2. Noon pass times were from 10:00 AM to 02:00 PM. 3. PM pass times were form 02:00 PM to 07:00 PM. 4. HS (hour of sleep) pass times were at the resident's bedtime. The Order Summary Report dated 05/17/23 for R1 included diagnoses of osteomyelitis (local or generalized infection of the bone and bone marrow) of vertebra (bone of the spinal column), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, mood disturbance, gastroesophageal reflux disease (GERD - backflow of stomach contents to the esophagus), aftercare following surgery on the nervous system. The Certified Medication Aide Medication Administration Record (CMA MAR) dated May 2023 for R1 revealed an order dated 05/05/23, for pantoprazole sodium (used to treat GERD), 40 milligrams (mg), one tablet, by mouth, one time a day, related to GERD. The AM medication pass time revealed documentation of O, indicating other, see progress notes, on 05/06/23, 05/08/23, 05/09/23, 05/10/23, 05/15/23, and 05/16/23. The Progress Notes dated 05/06/23 for R1 for the pantoprazole revealed med not available. The Progress Notes dated 05/08/23 for R1 for the pantoprazole revealed medication on order. The Progress Notes dated 05/09/23 for R1 for the pantoprazole revealed waiting on medication to come in. The Progress Notes dated 05/10/23 for R1 for the pantoprazole lacked a reason why the staff did not administer the medication. The Progress Notes dated 05/15/23 for R1 for the pantoprazole revealed med on order. The Progress Notes dated 05/16/23 for R1 for the pantoprazole revealed med not available. The Progress Notes dated 05/16/23, for R1 revealed a call was placed to pharmacy about not receiving pantoprazole and would be sent out tonight. The CMA MAR dated May 2023 for R1 revealed an ordered dated 05/05/23, for sucralfate (antacid) oral tablet, one gram, by mouth, two times a day, related to GERD. On 05/16/23 for the AM pass the staff documented O. The Progress Notes dated 05/16/23 for R1 for the sucralfate revealed med not available. The CMA MAR dated May 2023 for R1 revealed an order dated 05/08/23 for Cipro (antibiotic), 500 mg, by mouth, two times a day, for eight days, related to a urinary tract infection. On 05/11/23 and 05/16/23 for the AM pass, the staff documented O. The resident received eight of eight doses for the PM pass and six of eight doses for the AM pass. The Progress Note dated 05/11/23 for R1 for the Cipro revealed none available - completed. The Progress Note dated 05/16/23 for R1 for the Cipro revealed antibiotic done. The Licensed MAR dated May 2023 for R1 revealed an order dated 05/06/23, for Lyrica (used to treat nerve pain), 75 mg, by mouth, two times a day, related to aftercare following surgery on the nervous system. The staff documented O for the AM and PM pass on 05/09/23, 05/10/23, and 05/11/23. The Progress Note dated 05/09/23 at 11:20 AM, for R1 for the Lyrica revealed med not in facility, pharmacy notified. The Progress Note dated 05/09/23 at 01:20 PM, for R1 for the Lyrica lacked documentation of reason not given. The Progress Note dated 05/10/23 at 11:21 AM, for R1 for the Lyrica revealed med not in facility and pharmacy called, awaiting on script from physician. The Progress Note dated 05/10/23 at 01:44 PM, for R1 for the Lyrica lacked documentation of the reason not given. The Progress Note dated 05/11/23 at 11:23 AM, for R1 revealed a call placed to the physician to make sure the script for the Lyrica had been sent to the pharmacy via message left for the office nurse and asking for return call to let the facility know if the script had been sent. The Progress Note dated 05/11/23 at 12:00 PM, for R1 for the Lyrica revealed med not available. The Progress Note dated 05/11/23 at 05:02 PM, for R1 for the Lyrica revealed med not available. The Licensed MAR dated May 2023 for R1 revealed an order dated 05/08/23 for Cefazolin (antibiotic) intravenous (IV) solution reconstituted, two grams, IV, every eight hours, for osteomyelitis. The MAR revealed a blank spot (lacked documentation) for the 10:00 PM dose on 05/15/23. The Licensed MAR dated May 2023 for R1 revealed an order dated 05/05/23 for alprazolam (antianxiety), one mg, by mouth, BID, related to anxiety. The order discontinued on 05/11/23 at 03:56 PM. The MAR revealed O for the AM and PM pass on 05/09/23 and 05/10/23 and the AM pass on 05/11/23. The Progress Note dated 05/09/23 at 11:19 AM, for R1 for the alprazolam revealed med not in facility, pharmacy notified. The Progress Note dated 05/09/23 at 01:20 PM, for R1 for the alprazolam lacked reason the medication not administered. The Progress Note dated 05/10/23 at 11:21 AM, for R1 for the alprazolam revealed med not in facility and pharmacy called awaiting on script from physician. The Progress Note dated 05/10/23 at 01:44 PM, for R1 for the alprazolam lacked the reason the medication not administered. The Progress Note dated 05/11/23 at 11:23 AM, for R1 revealed a call placed to the physician to make sure the script for the alprazolam had been sent to the pharmacy via message left for the office nurse and asking for return call to let the facility know if the script had been sent. The Progress Note dated 05/11/23 at 11:59 AM, lacked the reason the medication not administered. On 05/16/23 at 10:15 AM, R1 stated they ran out of my medicine and pointed to the empty IV bag of Cefazolin hanging from an IV pole in his room, last time received it was in the evening, and they usually wake me up when they poke me, and pointed to the IV access site on upper right arm (the side opposite of the side of the IV pole and R1 bed against the wall). R1 stated he usually has his arms covered up, so they have to uncover them to get to the IV access site. On 05/16/23 at 11:18 AM Licensed Nurse (LN) G stated she just completed her morning med pass and had two medications missing, which did not include any medications for R1. On 05/16/23 at 05:43 PM Administrative Nurse D stated if a resident is out of a medication the pharmacy should be called and medications should be ordered when there are about seven pills left in a card. Administrative Nurse D stated the licensed nurses were to reorder medications, and the facility just switched from the CMA's passing medications to the nurses passing medications. If a medication is unavailable, a note would be made to indicate that, and an alert would show up on the dashboard of the EMR. Administrative Nurse D stated she checks the dashboard in the morning, will check to see why a medication was not given, such as checking the medication room to make sure the medication was not placed in the wrong spot. On 05/17/23 at 09:53 AM, Administrative Nurse D stated the facility did not have a policy for medication ordering, it was a nursing standard of practice. On 05/17/23 at 11:10 AM, Administrative Nurse D stated when the MAR has a blank spot, the staff failed to document the completion of the medication administration. The facility failed to ensure R1's medication arrived timely for administration increasing the risk of R4 having adverse effects from not receiving his physician ordered medication.

The facility reported a census of 36 residents. Based on observation, interview, and record review, the facility failed to maintain an effective infection control program with the failure to ensure the urine collection bag for Resident (R)1 did not have direct contact with the floor, was kept below bladder level during a transfer, and the failure to empty the urine collection bag in a sanitary manner. Additionally, the facility failed to ensure the staff changed the intravenous (IV) administration kit (tubing) for R1, who received a physician ordered antibiotic every eight hours. These practices failed to follow infection control standards to reduce the risk of causing or spreading infections for these two residents. Findings included: - The Licensed Medication Administration Record (MAR) dated May 2023, for Resident (R)1 included an order on 05/08/23 for Cefazolin sodium (antibiotic), intravenous (IV) solution reconstituted, two grams (gm), IV, every eight hours related to osteomyelitis (local or generalized infection of the bone and bone marrow) of vertebra (bone of the spinal column). The MAR revealed Licensed Nurse (LN) H administered the antibiotic IV dose scheduled on 05/16/23 at 06:00 AM. The Licensed MAR lacked instructions for when the staff were to change the IV administration kit. On 05/16/23 at 10:15 AM, observed in R1's room next to his bed, an empty medication bag for Cefazolin was hanging from an IV pole, with an administration kit connected to the empty bag and through a medication pump. The tubing lacked a date to indicate when the staff last changed the tubing. On 05/16/23 at 01:03 PM, LN G stated the IV tubing should be changed every 48 hours or sooner if need be and usually dated with a white paper tape with the staff initials and date. LN G stated the MAR does not instruct when to change the tubing and verified the resident's current IV tubing lacked a date. On 05/16/23 at 02:45 PM, LN H was getting ready to administer the resident's Cefazolin, stated she had replaced the IV tubing (administration kit) as she noticed the prior tubing did not have a date. She thought she had saw tape on it (to indicate the date changed) that morning when administering that dose (scheduled at 06:00 AM). LN H stated she had changed the tubing on Friday, however, but did not know if it had been changed since that time and the MAR lacked instruction on when it needed to be changed. LN H stated, Some say 96 hours, I like to change it every 72 hours and it depended on the facility. On 05/16/23 at 05:43 PM, Administrative Nurse D stated the Licensed Nurse should date the IV tubing when placing a new tubing and staff should change the tubing every 24 hours. If the tubing lacked a date, it should probably not be used. The facility policy for, Infusion Therapy Procedures Summary dated August 2021, revealed the administration set/IV tubing for intermittent use should be changed every 24 hours. The facility failed to ensure the Licensed Nurse staff changed the tubing every 24 hours to prevent the risk of causing an infection to R1, who had IV medication ordered to be administered every eight hours. - The Order Summary Report for R1 revealed he admitted to the facility on [DATE] and the report included a diagnosis of retention of urine. The Treatment Administration Record (TAR) lacked an order with instructions for the use of a urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Certified Medication Administration Record (CMA MAR) dated 05/01/23 through 05/16/23, revealed R1 had an order dated 05/08/23 for Cipro (antibiotic), 500 milligrams, twice daily, by mouth, related to urinary tract infection. The Care Plan dated 05/12/23 revealed R1 had a catheter related to retention of urine and for the staff to monitor output every shift and to change the catheter every 30 days. On 05/16/23 at 10:03 AM, observed R1 in bed with a urine collection bag hanging from the frame of his bed with tea colored urine in the collection bag. On 05/16/23 at 11:22 AM, R1 observed in the shower room, sitting in a shower chair, and his urinary collection bag sat in direct contact with the shower floor and approximately 2-3 inches of the catheter tubing. Certified Nurse Aide (CNA) M and Certified Medication Aide (CMA) R were in the shower room assisting R1 with a shower. The collection bag remained in contact with the floor the duration of the shower. When ready to move the shower chair, CNA M moved the catheter bag off the floor and hung it from the shower chair frame. Both staff then moved R1 in the shower chair to his room where they assisted R1 to transfer from the shower chair to his bed using a mechanical lift. During the transfer, the urinary collection bag was above the level of R1's bladder. Once in bed, CMA R hung the urinary collection bag on the bed frame and when loosing the fitted sheet, the urinary collection bag fell to the floor. CMA R picked up the bag and hung it back on the bed frame. When CMA R and CNA M assisted R1 to turn in the bed, the urinary collection bag came loose from the bed frame and had contact with the floor and when positioned on his right side, the bag suspended in the air from where the anchor on the left thigh held the tubing in place. After staff completed cares for R1 in bed, CMA R picked up the urinary collection bag and hung it back on the bed frame, then used a urinal, dated 05/05/23, to empty the urine collection bag. During that process, CMA R touched the drainage tube of the collection bag to the inside of the urinal when she began to empty the bag and when removing the drainage tube, to place in the holder on the collection bag without cleaning the drainage tube first. On 05/16/23 at 05:43 PM, Administrative Nurse D stated urinary collection bags should not be in contact with the floor, and if that occurs, the bag should be wiped down. The urinary collection bag should be in a cover bag and when draining the collection bag, the drainage tube should not have contact with the collection device. Administrative Nurse D stated she did not know if the drainage tube should be cleaned afterwards, however the collection bag should remain below the level of the bladder. On 05/17/23 at 09:53 AM, Administrative Nurse D stated the facility used nursing standards of practice for catheter management when asked for the facility policy. The facility failed to ensure the infection control remained appropriate with catheter management techniques which were used for R1's urinary catheter to prevent risk of development of further urinary tract infection.

The facility reported a census of 37 residents, with eight residents identified with mechanically altered diets. Based on interview and record review, the facility failed to follow the physician ordered therapeutic diet for Resident (R)1, who required a mechanically altered diet of ground meat with gravy, and all other items pureed, with honey thick liquids. On [DATE] at 11:36 PM, staff gave the resident a peanut butter and jelly sandwich in her room and left the resident unsupervised. The resident choked and staff attempted the Heimlich maneuver (a first-aid procedure for dislodging an obstruction from a person's windpipe in which a sudden strong pressure is applied on the abdomen, between the navel and the rib cage) without success. The resident became unconscious and died . The failure to provide the correct diet texture placed R1, and eight other residents identified with mechanically altered diets, in immediate jeopardy. Findings included: - Resident (R)1 had diagnoses in the clinical record that included dysphagia (swallowing difficulty), Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling the fingers, masklike faces, shuffling gait, muscle rigidity and weakness that can also affect chewing/swallowing), and gastroesophageal reflux (backflow of stomach contents to the esophagus). The Annual Minimum Data Set (MDS), dated [DATE], revealed the resident with a 'Brief Interview for Mental Status' (BIMS) score of 15, indicating intact cognition. The resident required supervision with set up assistance for eating and required a mechanically altered diet. The Nutritional Status Care Area Assessment (CAA), dated [DATE], documented the resident received a pureed diet with thin fluids, and noted the resident was to be in the dining area for all meals. The Quarterly MDS, dated [DATE], revealed the resident had a BIMS of 14, indicating intact cognition. She required supervision with set up assistance for eating and required a mechanically altered diet. The Nutrition Care Plan, revised on [DATE], guided staff to know the resident required minced/moist and honey thick liquids. Dietary would provide ground meat with gravy and all other items pureed and honey thick liquids. The Physician's Diet Order dated [DATE] included a no added salt diet, pureed texture, honey consistency, gravy- minced/moist, and honey thick liquids. Dietary would provide ground meat with gravy and all other items were to be pureed with honey thick liquids, related to dysphagia. Speech therapy was to treat the resident two to three times a week for 12 weeks, related to dysphagia. Review of the Speech Swallow Study results dated [DATE], documented R1's diet should consist of minced and moist ground meat with gravy and pureed sides, and medications were to be crushed in applesauce. The resident would use the Go Slow strategy, which included to swallow twice with each bite/sip and ensure residue cleared and bites/sips of less than one tablespoon. The resident required honey thick/moderately thick liquid consistency. Review of the [DATE] Modified Barium Swallow Study (MBS), revealed a recommendation of diet level MM5 (minced and moist), honey thick liquids, and the resident should be fully upright and alert for oral intake, with small single bites, and sips only. The resident should swallow twice as needed to reduce oral and pharyngeal (throat) residue, crush medication, and place in puree for administration. The resident should consider referral to a gastroenterologist (physician specialized in the gastrointestinal tract) for evaluation. Review of the Speech Evaluation and Plan of Treatment dated [DATE], documented the resident's family requested a diet upgrade from puree to regular texture. Speech recommended a modified barium swallow study because of the resident's past choking history. The analysis included behaviors impacting safety and uncontrolled talking while eating. The resident had exacerbation (an acute increase in the severity of a problem of signs and symptoms) as the intake continued, and the resident had an impulsive rate, unsafe intake amounts with decreased self-correction, and decreased safety awareness. The diet recommended mechanical soft/ground texture, puree consistencies, and moist puree consistency. Recent MBS completed and recommended new diet level of minced and moist consistency. The plan documented the facility did not offer this level and they would offer ground/minced meat with gravy and puree for other items. The resident required supervision for oral intake and required close supervision. The Nurse's Note dated [DATE] revealed at approximately 11:30 PM, the resident was up in her wheelchair, restless, and not wanting to sleep. She wanted something to eat, and some peanut butter and jelly sandwiches were set out by the kitchen for residents to enjoy if they became hungry. Staff gave the resident half a sandwich and a few minutes later, staff and the nurse heard noises coming from in the direction of the resident's room. Certified Nurse Aide (CNA) (M) went down the hall, located the resident in her room, brought the resident in her wheelchair to the doorway, and alerted the nurse. The CNA attempted to perform the Heimlich maneuver on the resident, and other CNA on duty arrived to assist. The CNA brought the resident up to the nurse's desk, while staff continued to dislodge an object from her airway, with the use of the Heimlich maneuver. Some pieces of the object did dislodge from the resident's airway, however, the resident was still unable to breathe, so staff placed an emergency call to 911. The licensed nurse notified emergency services that the resident choked on a peanut butter and jelly sandwich, and stated staff attempted to clear the airway per Heimlich maneuver. The ambulance technicians called the resident's death at midnight. On [DATE] at 10:18 AM, Administrative Staff A reported the facility had no formal risk/benefit contract that a resident would sign if the resident would choose not to follow the physician's ordered diet. On [DATE] at 11:27 AM, Certified Nurse Aide M reported the nurse instructed him to give the resident a peanut butter and jelly sandwich, because the nurse said when the resident screamed out, sometimes it was out of hunger. CNA M reported he sat the resident up in her bed, gave her the sandwich, then went to check on other residents. After a few minutes, he saw the resident up in her wheelchair at her bedroom doorway, and her voice stuffing up and she eventually reached for her throat, and he knew she was actively choking. He attempted the Heimlich maneuver three times, then looked down the hall and yelled for help a couple of times, then propelled the resident to the nurses' station. The nurse assessed the situation and she was unable to assist with the Heimlich maneuver due to her physical ability, so another CNA attempted to assist him. The resident lost consciousness and the nurse instructed the CNAs to place the resident on the floor and try to dislodge the best we could. The nurse then put on her gloves and attempted to dislodge and clear her throat, but by that time, the resident had lost consciousness. The local law enforcement (Sheriff) and emergency medical services technicians were unable to clear her throat and revive her. On [DATE] at 11:40 AM, Therapy Staff HH reported the resident was on a pureed diet for quite some time. The family inquired about a diet upgrade, so it was recommended to have a swallow study done because of her history of choking. The resident was to be served minced moist or mechanical ground consistency foods with gravy, and everything else was to be pureed. Peanut butter was not minced moist and the dry bread should not have been given to the resident. The bread should have also been pureed. The resident should not have received the peanut butter sandwich. From a safety perspective, staff should supervise any resident with minced moist meat/gravy with puree. On [DATE] at 11:55 AM, LN G reported in the past, the resident was restless from time to time when she was hungry. The only choice on the snack cart was a peanut butter sandwich or potato chips. LN G instructed CNA M to give the resident the peanut butter sandwich. A few minutes later, he brought her up to the desk and he did the Heimlich maneuver a couple of times, then she coughed and passed out. The resident had pieces of food behind her lips, and she reported she did a finger sweep in attempt to dislodge food particles. She reported she had CNA M continue to provide Heimlich thrusts while she called for emergency services. LN G stated, a while back they put her on pureed, my understanding she could have mechanical soft, but she was busy and had other distractions. On [DATE] at 12:26 PM, Dietary Staff BB reported after R1 died , the snack carts now had a list of resident names that received mechanically altered diets. The folder with the names went out with the snack cart. On [DATE] at 12:32 PM, Dietary Staff CC reported the resident was on a pureed diet for over a year. A few months back, the resident's diet changed to a mechanical soft meat and pureed diet. R1 enjoyed pudding and ice cream. If there was no pudding or ice cream on the snack cart, the nurse had a key to the kitchen to get her pureed foods. On [DATE] at 01:21 PM, Administrative Nurse D reported the nurse gave the resident a sandwich, because that was what she typically gave the resident as a snack and the resident choked. Her expectation for staff was to look at what the resident's diet orders were and provide the resident with the ordered diet. R1 required set up assistance with eating, and anyone with a mechanically altered diet should be supervised. Staff should not have given the resident bread as bread must be pureed. Administrative Nurse D reported after R1 choked and died , an emergency in-service was provided to staff on where to find diet orders, and not to give residents food with altered diets without supervision. The 2012 facility policy for summary of diets, documented mechanical soft consistency was for individuals with limited or difficulty in chewing regular textured goods. The diet eliminates hard, sticky, crunchy or hard to chew foods. Foods should be moist and fork tender. The pureed diet should be pureed or soaked as needed. The bread serving at the noon and evening meals is generally pureed in with the meat and the vegetable. The facility failed to provide Resident (R) 1 with the therapeutic diet as ordered by the physician. The resident required a mechanically altered diet of ground meat with gravy and all other items were to be pureed and honey thick liquids, as ordered [DATE]. On [DATE] at 11:36 PM, staff gave the resident a peanut butter and jelly sandwich in her room and left the resident unsupervised. The resident choked and staff attempted the Heimlich maneuver without success. The resident became unconscious and died . These failures placed the resident in immediate jeopardy. The facility identified and implemented corrective actions to address the deficient practice on [DATE], which included the following: 1. All staff educated on where to accurately locate the residents' diet orders on the charts. The education was completed on [DATE] at 04:45 PM. 2. All diet orders reviewed by staff for all residents and verified as consistent with their individual care plans. This audit completed on [DATE] at 04:45 PM. 3. Unscheduled QAPI meeting held on [DATE] with the interdisciplinary team. The DON contacted the Medical Director (who is also the resident's physician) on [DATE] at 05:40 PM. 4. All employees educated on not allowing residents on altered diets to eat unattended in their rooms. The education completed on [DATE] at 08:00 PM. 5. Training began immediately following the event. On [DATE] at 08:00 PM only four staff needed to complete the trainings and the DON reported they would be trained prior to working their next shift in the facility. 6. The staff added a listing of residents' diet orders to the snack carts on [DATE] at 08:00 AM. The list highlighted the residents with altered diets. The snack carts would offer choices for all diet orders. Due to the facility's corrective actions implemented on [DATE] and completed on [DATE] at 08:00 AM, prior to the surveyors entrance, this deficient practice was cited as past non-compliance and existed at a J (isolated, immediate jeopardy to resident health or safety) scope and severity.

The facility reported a census of 42 residents including four residents reviewed for accidents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 4 remained free from accident hazards when staff failed to maintain a safe room arrangement after a fall on 03/29/22, when the resident fell and sustained a forehead laceration on the night stand next to his bed requiring a trip to the emergency room . Administrative Nurse D re-arranged the resident's room after the fall on 03/29/22 and moved the nightstand away from his bed. On 04/29/22, the resident sustained another fall in his room which resulted in a laceration to the back of his head, requiring a trip to the emergency room , and requiring staples after hitting his head on the nightstand placed next to his bed. Findings included: - The Physician Order Sheet (POS), dated 05/11/22, documented R4 with diagnoses of dementia with behavioral disturbance (chronic disorder of the mental processes caused by brain disease or injury marked by memory disorders, personality changes and impaired reasoning), [CONDITION(S)], and [CONDITION(S)] disease (a progressive nervous system disorder that affects movement). The Annual Minimum Data Set (MDS), dated [DATE], documented the resident with a Brief Interview for Mental Status (BIMS) score of 5, or severely impaired cognition. The resident required extensive assistance of one staff member for bed mobility, transfers, and toilet use. He used a walker and wheelchair for mobility and the facility documented the resident had no falls since the prior assessment. The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 04/25/22, instructed staff that the resident required assistance with cares and transfers, and used a wheelchair which staff or resident could propel. The resident was able to walk short distances with a walker and staff assistance. The resident required staff to remind and encourage him to use his call light and to wait for assistance with care. The Falls CAA, dated 04/25/22, instructed the staff that the resident was a fall risk due to [CONDITION(S)] disease, [CONDITION(S)], and dementia. The Care Plan, updated 05/12/21, documented the following interventions: 1. On 03/29/22, the resident was sent to the emergency room for evaluation after a fall. Due to the fall, the staff moved the bedside table (dresser) away from the bed and padded the positioning bar. 2. On 03/30/22, Staff were not to put the resident to bed when he became agitated. 3. On 04/29/22, as an intervention for this resident's fall, staff moved the bedside dresser away from the bed (again) and put the resident's recliner in the dresser's place. 4. On 05/02/22, all staff educated to not move/rearrange the resident's bedside dresser back over by the resident's bed. 5. On 05/05/21, staff made aware that the resident was a high fall risk. A Fall Note, dated 03/30/22 at 01:19 AM Licensed Nurse (LN) H documented staff found the resident sitting on the floor with blood on the floor. The resident stated he fell out of his bed. He had bleeding and swelling on the left side of his forehead. Staff sent R4 to the emergency room for evaluation and treatment. A Progress Note, dated 03/30/22 at 11:27 AM, Administrative Nurse D documented a fall review with the interdisciplinary team for a fall the resident sustained on 03/29/22 at 10:00 PM. The root cause of the fall was that the resident became agitated and delusional that evening and attempted to transfer out of bed on his own, falling out of bed. The resident's fall mat was in place by the bed. Blood was found on the bedside table. The resident was sent to the emergency room where he was found to have a urinary tract infection and placed on antibiotics. A room evaluation determined to be the cause of the injury and the intervention was to move the bedside table away from his bed. A Fall Note, dated 04/29/22 at 11:40 PM, LN G documented the resident found sitting on the floor next to the beside dresser with the top of the dresser behind and to the left of the resident on the floor. A moderate amount of blood was found on the floor near the resident. The resident sustained a 0.5 -centimeter (cm) laceration (wound to the skin) to the base of his skull. Staff sent the resident to the emergency room for evaluation and treatment. A Nurse's Note dated 04/30/22 at 03:13 AM, LN G documented the resident returned to the facility from the emergency room via facility van. R4 received two staples to the laceration at the base of his skull and the urinary analysis was negative for a urinary tract infection. A Progress Note, dated 05/03/22, Administrative Nurse D documented a fall review with the interdisciplinary team for a fall the resident sustained on 04/29/22 at 11:40 PM. The root cause of the fall was that the resident got up out of bed without the use of assistive device or staff assistance. He was sent to the emergency room for treatment due to hitting his head and he sustained a 0.5 cm laceration to the back of his head. Administrative Nurse D again moved the nightstand from the side of his bed and put R4's recliner in its place. An alert was sent out to the staff and all departments to not move the recliner or nightstand back to the prior position. Observation on 05/31/22 at 01:51 PM revealed R4 sat in his wheelchair at the West Hall nurse's station in view of staff. He was alert and calm and visited pleasantly with staff and other residents. He was able to propel himself in his wheelchair around the room. Observation on 05/31/22 at 03:56 PM revealed R4's room remained clean and uncluttered. The fall mat was next to his bed on the floor. The recliner and his nightstand positioned away from the bed as per the plan of care. Interview on 06/01/22 at 11:05 AM, Certified Medication Aide (CMA) R revealed the resident was a fall risk and when he was in bed he tried to get up. CMA R stated the resident fell in the past and she didn't know much about his fall on 04/29/22, but that he hit his head. Interventions to reduce R4's falls were a low bed, fall mat, and non-skid strips on the floor in his room. He also spent a lot of time up in his wheelchair propelling around the facility and he liked to stay by the nurse's stations. CMA R did not report any other interventions for the resident. Interview on 06/01/22 at 11:47 AM, LN I revealed the resident was a fall risk and did not use the call light. He did not wait on staff to help him to the bathroom. The resident became agitated at times, so she calmed him down by talking with him and spending some time. She knew he had a fall on 04/29/22 and had a laceration, but did not know much about the fall. The resident liked to be up in his wheelchair and out in the facility most of the day. LN I reported staff monitored him frequently, but she could not recall the fall interventions in R4's room. Interview on 06/01/22 at 01:44 PM, Administrative Nurse D stated on 04/29/22, the resident stood up from his bed and fell against a small nightstand with drawers by his bed. He hit the back of his head on the nightstand as there was blood on it. R4 had a previous fall on 03/29/22 where the same thing happened, only he sustained a laceration to his forehead. Administrative Nurse D stated she went to his room after his first fall and personally re-arranged the furniture and added the intervention to the care plan. She stated that somebody moved the furniture back to its original place before his fall on 04/29/22, and she was not aware of who did the moving of the furniture. After that fall, she moved the furniture again and alerted staff to not move the furniture in his room. The staff should have followed the care plan. The facility policy Falls Management, revised 12/17, documented .the plan of care is to address individualized resident focus, goals, and interventions directed towards reducing the resident's risk of injury and potential reoccurrence of falls . The facility failed to ensure R4's room remained free from accident hazards when staff failed to maintain a safe room arrangement after a fall on 03/29/22, when the resident fell and sustained a forehead laceration on the nightstand next to his bed. Administrative Nurse D re-arranged the resident's room after the fall and moved the nightstand away from his bed. On 04/29/22, the resident sustained another fall in his room which resulted in a laceration to the back of his head requiring staples after hitting his head on the same nightstand that staff placed next to his bed.

The facility reported a census of 55 residents and identified 10 residents that smoked. The sampled for review included three of these 10 residents. Based on observation, interview, and record review, the facility failed to ensure a safe smoking environment on their back patio where the residents went outside to smoke. One of the three sampled residents, Resident (R) 1 went out on the back patio to smoke in his wheelchair. The wheelchair wheel got caught in a crack in the cement and the resident tipped over in his wheelchair. R1 sustained right arm pain, a hematoma to his right forehead, and abrasions to his right knee and left shin. A trip to the emergency room for evaluation confirmed the resident also sustained a right shoulder [MEDICAL CONDITION] humerus (a break of the upper part of the bone of the arm) which required surgical repair. Findings included: - The electronic medical record evidenced the facility admitted Resident (R) 1 on 11/23/18. The Primary Care Physician (PCP) listed [DIAGNOSES REDACTED]. The 01/05/19 annual Minimum Data Set (MDS) assessment identified the resident with a Brief Interview for Mental Status (BIMS) score of 15/15, indicating cognition intact. The assessment verified the resident as independent with transfers and mobility in his wheelchair. The Falls Care Area Assessment (CAA), dated 01/05/19, documented the resident was up without assistance as wanted, with the use of a wheelchair for mobility. The resident was able to make his needs/concerns known. The resident voiced understanding and returned verbal instructions on how to use the call light for assistance. The resident experienced no recent falls. The Care Plan revised 04/09/19 included, I choose to smoke even though it is an identified health risk. I am at risk for falls. Anti-tip device added to my wheelchair to prevent my wheelchair from tipping backwards. Smoking Evaluations for the resident, dated 05/28/19 and 09/03/19 both revealed the resident as a safe independent smoker. His evaluation also revealed that he usually got up and smoked during the night . The facility's self- investigation report, dated 09/13/19, documented that on 09/03/19 at 12:35 AM, another resident, R2, opened the patio door to go outside and smoke, turned around and told the nursing staff that R1 was on the ground outside. Three nursing staff went outside and found the resident lying on his right side, facing the fence with his wheelchair tipped over on the right side. The nursing staff noted blood on the cement from a hematoma on the resident's right forehead, right knee, and left shin. After assisting the resident to his wheelchair, staff assisted the resident into the facility for further assessment. The nursing staff and the resident determined he was lying on the cement patio for approximately 20 minutes. Licensed Nurse (LN) C assessed the resident with a 0.1 cm (centimeter) by 0.5 cm abrasion to the left shin, a 4.5 cm by 4.5 cm abrasion to the right knee, and a 3.5 cm by 3.0 cm hematoma to the right forehead. The resident moved all extremities however he moved his right arm using his left arm to move it. The resident's right shoulder hurt more with movement. The nursing staff applied a temporary sling and a pillow under the right arm. Staff notified an on-call physician and obtained orders to send the resident to the hospital emergency room (ER) for evaluation and treatment. The progress notes, dated 09/03/19 at 07:45 AM, included that the resident returned via facility transport from the ER following the fall. The resident sustained [REDACTED]. The resident's right arm remained in a shoulder immobilizer and the resident had a follow up appointment with an orthopedic surgeon. The resident had a new prescription for [MEDICATION NAME] (pain medication) one tablet orally every four to six hours as needed for moderate pain. The progress notes on 09/05/2019 noted the facility van transported the resident to see an orthopedic surgeon. The surgeon scheduled the resident's right humerus repair surgery for [REDACTED]. On 09/28/19 (two days following the operation) nurses notes revealed the hospital discharged the resident back to the facility. On 10/17/19 at 9:10 AM, Maintenance Staff B provided a tour of the residents' smoking area outside the new wing lobby onto the cement patio. The area presented with 3 large jagged cracks across the 25 feet cement pad which varied from 1/4 inch to 1/2 inch wide. According to Staff B the resident made it across two cracks, headed to where he usually sat in his wheelchair, and tipped over when his wheelchair tire caught in the third crack. The facility staff moved the residents' smoking area to a different area until the cracks could be repaired. Maintenance staff power washed out the cracks and let them dry. Staff B became ill and was not at work for a while and on 10/17/19 Staff B filled the cracks in the cement with a caulking compound . Maintenance Staff B explained that the cracks were on the patio for a long time, but the facility staff did not find it as a problem until the resident fell in the wheelchair. At that time, consultant staff F verified the cracks were in the smoking patio for a long time and staff failed to identify the areas as hazardous in need of repair until this incident with the resident falling in the wheelchair. Observation on 10/17/19 at 10:20 AM, the resident rested in bed with his sling off and verified he hit a crack in the patio cement with his wheelchair tire and tipped over. He reported he knew another resident would be out shortly to smoke and did not worry about being on the cement for a long period of time. He verified he routinely smoked on the patio unless the weather was bad and then he always smoked out front of the facility near the entrance. On 10/17/19 at 2:05 PM, Social Service Designee [NAME] confirmed only two of the 10 smokers in the facility required supervision while smoking. Three of the 10 resident smokers were ambulatory and the other 7 residents utilized wheelchairs for mobility. The facility's undated policy for Housekeeping, Laundry and Maintenance, included Maintenance- Basic Services Performed. 1.) Debris, ice, snow and other hazards must be removed and traffic areas kept safe . 8.) The maintenance person is responsible for the routine repair and maintenance of the facility and equipment . The facility failed to ensure a safe smoking environment on their back patio where the residents went outside to smoke. The cement patio contained three large cracks across the patio area measuring from ¼ to ½ inch wide in various areas along the cracks. R1 went out on the back patio to smoke in his wheelchair. The wheelchair wheel got caught in a crack in the cement and the resident tipped over. R1 sustained right arm pain, a hematoma to his right forehead, and abrasions to his right knee and left shin. A trip to the emergency room for evaluation confirmed the resident sustained [REDACTED].

The facility reported a census of 53 residents with 3 residents selected for sample review of elopement. Based on observation, interview, and record review the facility failed to ensure one resident (#1) of 3 reviewed received care and services to ensure the resident remained free of elopement. Resident #1 exited from the facility, without staff's knowledge on 11/10/18 at approximately 3:05 AM, and without adequate clothing for the outside temperature of 19 degrees Fahrenheit, which placed the resident in immediate jeopardy. Findings included: - Resident #1, re-admitted to the facility on [DATE] after a psychiatric in-patient hospitalization . The physician order [REDACTED]. a cognitive communication deficit (a deficit causing problems with attention, memory, organization, problem solving/reasoning and executive functions). An admission MDS (minimum data set), dated 3/2/18, included a BIMS (brief interview of mental status) score of 13/15, indicating intact cognition. The resident expressed having trouble with sleep, feeling tired, and appetite concerns, but lacked any behavioral concerns. The staff identified the resident as independent to supervised for ADLs (activities of daily living), including mobility. The quarterly MDS, dated [DATE], scored the resident with a BIMS of 14/15, indicating intact cognition, without mood or behavioral concerns, and required supervision for most ADLs including mobility. The quarterly MDS, dated [DATE], scored the BIMS of 14/15, indicating intact cognition and identified the resident with appetite concerns. The staff identified the resident needed supervision for mobility off the unit. The assessment lacked identification of wandering. The staff assessed the resident for elopement risk on admission and determined the resident was not at risk. However, additional assessment identified an increased risk, as follows: On 6/25/18 the resident scored 10 indicating moderate risk (8-12) On 7/23/18 the staff assessed the resident at a score of 18 indicating high risk (13+) On 11/10/18 the staff assessed the resident at a score of 16 indicating high risk (13 +) Review of a care plan meeting and care plan review, on 10/25/18 lacked evidence of any planned interventions for elopement risk. A care plan developed for elopement risk on 11/10/18 (following the elopement on 11/10/18 at 3:05 AM) included the following problems and interventions: Provide education to resident on the need to communicate with the staff when wanting to go for a walk or exit the facility, for any reason. Provide education to the resident on the safety of leaving the facility. Provide supervision to the resident when going out of the building. When exhibiting exit seeking behavior, please evaluate by completing the elopement assessment in PCC (point click care-computer software). Encourage the resident to attend activities to keep him/her busy. Know that if the resident begins packing his/her belongings, that is a sign that the resident may be thinking about leaving. Review of nursing and interdisciplinary notes from 5/25/18 to 11/20/18 included the following: On 5/25/18 at 8:52 PM, a police officer arrived at the facility, stating the resident called 911, indicating he/she needed fresh ice water. On 8/3/18 at 8:34 AM, documentation identified the resident required supervision with ambulation and exhibited poor judgement due to mental illness. On 8/10/18 at 8:28AM the resident reported to staff he/she vomited his/her breakfast and wanted to know why staff were poisoning him/her. On 8/19/18 at 9:00 PM, the resident locked him/herself into an employee's vehicle and told the staff he/she was trying to escape. Staff documented placing the resident on 15-minute checks until staff could develop a more permanent care plan. On 10/12/18 at 3:10 PM, staff documented the resident as alert and oriented times 3 (person, place and time) with some confusion and he/she ambulated independently. On 11/10/18 at 3:45 AM, staff documented the facility received a phone call at 3:13 AM from the police department, indicating a resident walked away from the facility and knocked on a neighbor's door. The resident told the neighbors he/she was cold and that he/she lived at the facility. The staff documented reporting to the police the staff were unaware of a resident being gone and immediately alerted staff to do visual checks on the residents. The police reported the resident was safe and the police would return the resident to the facility. The police arrived at the facility with the resident, who was dressed in a pair of jeans, a light weight shirt, and without a coat. The nurse completed one on one with the resident while conducting an assessment and discussing the dangers of going outside without protective clothing, such as a coat, with the cold temperature. The resident laughed stating that he/she went out the back door. Staff documented the resident had knowledge of the code as he/she would use the code to go to the courtyard during the daytime, however always returned inside. Staff placed the resident on a one on one status for the duration of the shift. Vital signs were monitored with a temperature of 97.9 degrees Fahrenheit. Extremities were pink in color, with the resident exhibiting full range of motion. Staff assisted the resident into pajamas and into bed with covers on the resident. Additional information in the investigation included a witness statement from the direct care staff M, which documented he/she returned from break at 1:30 AM and began bed check on residents on the hall. Staff documented checking on resident #1 at approximately 2:00 AM. The staff indicated the resident was in a good mood and staff M visited with the resident until approximately 2:30 AM. The staff continued with bed checks and when completed returned to the desk to start charting. Another CNA (certified nurse aide) ran from the other hall and reported that the resident eloped, and staff M immediately went to look for him/her. Per the documentation the staff failed to complete every 15-minute checks on the resident. Observation of the resident, on 11/20/18 at 1:21 PM, identified the resident seated in a wheelchair, in his/her room, propelling about the room independently. The resident reported he/she felt safe at the facility and then began expressing delusional thoughts, such as receiving shocks through his/her bed, which was not electrical (per the resident). On 11/20/18 at 12:48 PM, direct care staff F reported knowledge of the residents at risk for elopement and reported the facility updated a book containing the residents pictures and information at each nursing desk which occurred when the resident eloped from the facility. The staff reported he/she was not on duty at the time the elopement occurred however, stated that all staff are expected to monitor the resident and the others at risk closely. This resident remained on 15-minute monitoring and ensure the resident does not actively exit seek. The staff reported being surprised the resident left the premises as he/she often sat outside unattended and never left the grounds previously. On 11/20/18 at 12:53 PM, licensed nursing staff C reported the residents at risk for elopement are posted with pictures at the nursing desks and pertinent information was available in the elopement books. The staff reported the resident eloped last weekend when the resident decided in the middle of the night to go star gazing. The staff reported being unaware of the resident ever attempting to elope previously and used to sit outside on the patio unattended. On 11/20/18 at 2:03 PM, direct care staff G reported he/she was now only aware of 3 residents being able to go outside without any assistance. They are all smokers and are mostly independent. On 11/20/18 at 2:10 PM, direct care staff H reported the residents at risk are posted at the desk for quick staff review. The staff included this resident and reported the resident displayed exit seeking at times and staff monitor the resident every 15 minutes for this reason. On 11/20/18 at 3:10 PM, direct care staff I verified the resident was an elopement risk and at the time of the elopement the resident lived on another hall, where more independent residents lived. The staff reported the resident remained on frequent checks which are documented in the computer. On 11/20/18 at 4:20 PM, direct care staff J reported that evening before the resident eloped the resident had not been any different than usual. Often sat near the front door, watching anyone who exited or entered the building. The staff further reported he/she had heard some rumors about the resident getting into an unlocked vehicle but did not know anything except through rumors. On 11/20/18 at 4:25 PM, licensed nursing staff K reported the resident had reported that day that his/her family were coming to take the resident out for a while. The staff reported he/she checked the book which indicated those planned to go off grounds and did not see plans for the resident. The staff notified the resident of that, who seemed to accept the information well. On 11/20/18 at 4:50 PM, social services/activity staff L reported he/she visited with the resident at the time of the resident locking him/herself into an employee's vehicle. The staff and resident discussed the resident's impulsive behaviors and the staff encouraged the resident to talk to staff L or another staff member whenever feeling like that. Additionally, staff L recalled that the facility placed the resident on 15-minute checks at that time. The staff indicated believing that staff implemented a care plan, however, indicated being unaware why that was not addressed at the following care plan meeting on 10/25/18. Interview with administrative nursing staff B on 11/20/18 at 5:02 PM, identified vague recollections of the incident on 8/19/18 and indicated he/she did not investigate the incident to determine any changes needed to keep the resident safe. The staff recalled the staff initiated 15-minute visual checks for the resident, at that time. A finding meeting with administrative staff members A, E, B, D, and social services staff L verified the failure to adequately monitor and provide supervision for this resident who exited the building and locked him/herself into an employee's vehicle. The staff failed to investigate and determine methods of keeping the resident safe and continued to allow the resident access to outdoors, without changing the door codes and the resident again exited the building in the early morning hours, walked approximately 2 blocks, in temperatures of 19 or 20 degree weather, without outer clothing to protect the resident from the cold temperatures. The facility policy, dated 12/17 included 1) residents are to be assessed for elopement risk within 24 hours of admission, quarterly, annually and with any significant change. 2) If identified risk is present, the interventions implemented are to be documented on the care plan. 3) Social service personnel are to maintain a facility elopement book which was accessible to direct care staff, including photos of the residents, resident's face sheets, resident information sheets and the residents care plan regarding the risk for wandering and elopement. The facility failed to adequately assess the resident's risk for elopement and failed to develop and implement a plan of care to provide supervision and assistive devices to maintain the resident's safety after the first incident on 8/19/18 when the resident exited the facility and locked him/herself into an employee's automobile; The resident then eloped on 11/10/18 at 3:05 AM, without staff knowledge, with outdoor temperatures of 19 or 20 degrees, and without a coat. The facility was notified by law enforcement personell that the resident was out of the facility and then was returned to the facility by the law enforcement personnel. This placed the resident in immediate jeopardy. The deficiency was cited as past non-compliance as of 11/11/18 at 10:15 PM when the facility completed the following: 1) Placed the resident on one to one staff supervision, immediately upon return to the facility on [DATE] at approximately 3:45 AM. 2) Nurse assessed resident every 4 hours for 72 hours after return to the facility, starting on 11/10/18 at 3:45 AM. 3) Reviewed the facility camera to establish a timeline. 4) Notified the family and the PCP (primary care physician) on 11/10/18 at 7:30 AM. 5) Completed elopement assessments on all residents, throughout the day on 11/10/18. 6) Updated the care plans of all residents at risk for elopement, throughout the day on 11/10/18. 7) Updated the elopement notebooks, throughout the day on 11/10/18. 8) Emergency elopement drill was conducted on 11/10/18 at 1:00 PM. 9) Moved the resident to another room further into the facility with closer supervision, on 11/10/18. 10) Posted signage at all exits notifying visitors to not let residents exit with them, on 11/10/18. 11) Conducted a QAPI meeting with the Administrator, DON and the Medical Director, on 11/10/18 at 3:56 PM. 12) Changed the door codes on 11/10/18 and again on 11/11/18. 13) Provided staff education to all staff including review of the elopement policy and the importance of timely 15-minute visual checks; started on 11/10/18 at 3:50 AM and completed at 11/11/18 at 10:15 PM. Per administrative staff A, 2 additional staff, out of state at the time, received training before working their next shifts. Additionally, 1 person on FMLA (family medical leave act) will receive training prior to returning to work.

The facility reported a census of 52 residents with 5 residents selected for sample review of accidents secondary to inappropriate wheelchair transportation. Based on observation, interview, and record review the facility failed to ensure 5 of 5 (#1, 2, 3, 4, and 5) resident's reviewed wheelchairs were properly and safely used when staff propelled the residents without appropriate foot pedals in place. Furthermore, resident #3 fell from the wheelchair, while being propelled by a staff member in the wheelchair without foot pedals and sustained a neck fracture. Findings included: - Resident #3's [DIAGNOSES REDACTED]. The annual MDS (minimum data set), dated 1/20/18, identified a BIMS (brief interview of mental status) score of 7/15, indicating the resident with severe impairment of cognition, required total dependence of staff for locomotion and used a wheelchair for locomotion. The quarterly MDS, dated [DATE], included a BIMS score of 4/15, indicating severely impaired cognition, and identified the resident was totally dependent of staff for locomotion, with the use of a wheelchair. A CAA (care area assessment), dated 1/30/18, for ADLs included: the resident required extensive assistance with transfers, with a sit to stand lift and assistance of 2 staff. The assessment noted the resident could usually self-propel him/herself from one location to another, and would occasionally ask for assistance with transport, when tired. The care plan, dated 6/23/18, instructed staff the resident needed to have foot pedals on his/her wheelchair if staff pushed him/her. When self-propelling, the resident did not require foot pedals. Added 2/17/15. Review of the resident's progress notes, in the EHR (electronic health record) included: On 7/20/18 at 12:30 PM, staff documented a fall note describing a fall. The LPN (licensed practical nurse) received notification of a fall near the dining area. Upon arrival at the dining room, the resident was on the floor, laying on his/her back with legs bent at the knees. The resident was moving about, and another staff nurse continued assessment of the resident. Lacerations assessed and treated to the forehead and right hand, with vital signs and neurological checks started. The resident kept trying to sit upright and staff explained to the resident the importance of lying still during the assessment. The DON (director of nursing) arrived and indicated the family requested the resident be sent to the ER (emergency room ) for evaluation and staff then notified EMS (emergency medical services). Staff assisted the resident into the wheelchair, to return to his/her room to complete cares prior to EMS arriving. During cares a second laceration was found on the back of the resident's head, however, before the nurse could assess this wound the EMS arrived. EMS personnel performed a preliminary assessment and tilted the resident's head forward (towards his/her chest) to look at the wound on the back of the resident's head. Staff reported to the EMS that the staff propelled the resident in the wheelchair, when the resident dropped his/her feet, causing the resident to fall forward out of the chair and onto the floor. The resident complained of pain in his/her head. The resident remained alert and oriented to person, place and situation throughout the incident and moved all extremities without complaints of pain. Staff noted on neurological checks the resident's eyes bilaterally as sluggish. The resident identified the pain level of 7 to the forehead and knees, without any pain medication administered due to sending to ER. Staff listed a new intervention of adding foot pedals to the resident's wheelchair. Messages left for physician without response at this time. On 7/20/18 at 4:40 PM, the residents spouse notified the facility of the resident being transferred to a larger hospital. A (hospital) Consultation report, dated 7/20/18, identified the resident's chief complaint included a cervical spine fracture, with a prior history of a posterior cervical fusion in 2011, wheelchair bound since that time. A history and physical, dated 7/20/18, included the Impression of a CT (computed tomography scan) outside films, C-spine and MR (magnetic resonance imaging scan) cervical spine testing which identified a C2 (cervical spine at the 2nd vertebrae) fracture, head contusion and contusion of both hands. The resident complained of head and neck pain. Interviews, on 7/25/18 at 11:55 AM, with administrative nursing staff C reported the resident propelled him/herself in the wheelchair, but often preferred staff to push him/her in the wheelchair. On 7/25/18 at 12:23 PM, administrative staff A reported on 7/20/18 at 12:30 PM, the staff member heard a noise outside the office door, in the dining room and saw the resident on the floor. Staff A noted a staff member present with the resident and staff A went to get a nurse. The resident was fully awake, moving and being verbally inappropriate. The resident was lying partially face down but also on his/her belly, with his/her face turned sideways. The nurses assessed the resident and then took him/her to his/her room to provide cares, while staff notified EMS. EMS arrived and took the resident out of the building on a gurney. On 7/25/18 at 12:44 PM, direct care staff D reported that any staff pushing a resident in a wheelchair are expected to have foot pedals on the chair. The staff verified that was not a well enforced procedure prior to the resident's fall. On 7/25/18 at 12:50 PM, direct care staff E reported the resident stopped the staff member on the opposite end of the building and asked the staff member to push him/her to the dining room. After telling the resident to raise his/her feet, staff E pushed the resident approximately 75 to 100 feet, when suddenly he/she dropped his/her feet causing the chair to suddenly stop and the resident to fall forward, landing on the floor. The chair did not have foot pedals in place, at the time of the fall. The staff reported the resident usually self-propelled, only occasionally asking someone for assistance, therefore he/she did not use foot pedals on the wheelchair. When the nurse arrived staff E explained what occurred with the resident. The only complaints of pain staff E heard the resident say was regarding his/her head and he/she kept asking about how much he/she was bleeding. The staff reported he/she completed a witness statement which was reviewed with the staff. On 7/25/18 at 1:21 PM, direct care staff F reported he/she was not present during the incident, however, verified the resident self-propelled in the wheelchair and did sometimes ask for staff to push him/her in the wheelchair. Staff F recalled the resident never had foot pedals for the chair, to his/her knowledge. On 7/25/18 at 1:33 PM, direct care staff G reported that occasionally the resident asked the staff member to push him/her and did not recall ever using foot pedals on the resident's chair. On 7/25/18 at 1:43 PM, direct care staff H reported the resident was on the floor when staff H arrived at the dining room. The staff member reported getting the resident up that morning and assisted the resident with transferring, dressing and his/her personal hygiene. The staff verified the resident did not use foot pedals on his/her wheelchair and never had, to his/her knowledge. On 7/25/18 at 2:00 PM, administrative staff B reported that when staff reviewed the incident the management determined the direct care staff failed to follow the resident's care plan. The staff immediately began evaluating all residents using wheelchairs and assessed to determine their needs for foot pedals. Staff are currently providing education to all direct care staff and the nurses to ensure that staff assess any resident that required a staff member to propel their wheelchair for the need to utilize foot pedals. The facility policy for falls management, dated 12/17, instructed the residents are assessed in the first 4 hours of admission using a standardized fall risk assessment to identify individualized risk factors. Residents are then to be re-evaluated quarterly and with changes. The facility failed to ensure this resident, at times dependent on staff for locomotion, while in a wheelchair, received assistive devices (foot pedals) and supervision to ensure the resident remained free of injury. Staff propelled the resident in the wheelchair, without foot pedals on the wheelchair, as planned. The resident was unable to hold his/her feet up off the floor, and when his/her feet dropped, he/she came to an abrupt stop, causing the resident to fall forward onto the floor, which resulted in lacerations and a cervical spine fracture. - This deficient practice also affected residents # 1, 2, 4, and 5 when observations identified the residents lacked foot rests on the resident's chairs while staff propelled the resident's wheelchairs, with the resident's attempting to hold his/her feet up without much clearance between the resident's feet and the floor.

The facility reported a census of 61 residents. Based on observation, interviews and record review, the facility failed to provide 1 (#01) of 3 sampled resident's medications, as ordered by the physician, consistent with professional standards of practice, to maintain the highest practicable mental and psychosocial well-being, upon readmission to the facility. The resident failed to receive 4 medications as ordered. The resident displayed verbal and physical behaviors toward staff during cares and had to return to the behavioral unit for re-evaluation and further treatment. Findings included: - The medical record evidenced the facility readmitted resident #01 from a behavior unit on 3/28/17. [DIAGNOSES REDACTED]. The 2/4/17, significant change MDS (minimum data set) assessment identified the resident with a BIMS (brief interview for mental status) of 3 (severe cognition impairment), with display of physical and verbal behaviors, in need of extensive assist with all activities of daily living and received daily antipsychotic medications. The 2/4/17 CAA (care area assessment) for behaviors included, the resident has been having increasing episodes of irritation and agitation in the late afternoon, evening and night hours. Can be redirected with diversional activities. The care plan, dated 3/28/17 included, resident at risk for aggression towards self/others related to maladaptive mood and behavior. Administer medications as ordered to manage behaviors. Observe mood and behaviors. Medication review with psychiatrist/facility MD/Pharmacist at each visit. Please offer the resident non medication interventions first for agitated behavior, but if needed, please offer any PRN (as needed) medications that are ordered. Staff were to redirect aggressive behaviors with alternative activities and report changes in behavior to the nurse. Staff were to inform the physician as indicated. The behavior unit documented discharge orders, sent to the facility with the resident, identified 4 new prescription orders on 3/28/17 which included: 1.) Cyanocobalamin (Vitamin B 12), 1000 mg.(milligrams), daily. 2.) Marinol ( for increased appetite), 2.5 mg., TID (3 times a day). 3.) Celexa (antidepressant), 15 mg., daily. 4.) Trazodone (antidepressant), 50 mg., daily at bedtime. The new medications added to the regimen were ordered for 30 days. On 4/12/17 the facility sent a fax to the primary care physician which included, the resident was trying to kick staff as they walk by, hit and scratch them. The resident was calling staff names and stated that he/she loved them then said he/she hated them and tried to hit and scratch them. Interventions included for staff to get the resident up into the wheelchair when he/she showed combativeness. The physician added an order for [REDACTED]. The facility investigation and root cause analysis findings, dated 4/17/17, revealed, the facility readmitted the resident to the facility on [DATE], from a hospital behavior unit. Licensed nurse B input the resident's information and orders into the electronic health record, indicating the only order change was to add Haldol (antipsychotic agent) daily. Over the next 2 weeks the resident continued with physical and verbal behavior outbursts toward staff. The progress records verified the facility, on 4/13/17, contacted the behavior unit for possible readmission to the inpatient unit. The family agreed and the behavior unit readmitted the resident on 4/13/17. Following the admission and review of the long term care facility medication records, the behavior unit discovered a lack of administration for 4 medications and 1 dosage change, per physician orders, not administered in the facility, since the discharge on 3/28/17 (17 days). The missed medications included, Celexa (antidepressant), 15 mg., daily, Trazodone (antidepressant), 50 mg., daily at bedtime, Marinol (for increased appetite), 2.5 mg., TID (3 times a day), and Cyanocobalamin (Vitamin B 12), 1000 mg, daily. Upon readmission to the behavioral unit on 4/14/17, documentation on the admission assessment included, the resident's readmission referral was due to increased verbal and a physical aggression toward staff. He/she also seemed to be leaning to the left more often and became combative when staff offered cares. Per signed and witnessed, written statement on 4/19/17, licensed nurse B explained he/she failed to identify, review and input the new medication orders into the electronic system on 3/28/17, due to surrounding circumstances with other residents and a physician extender making rounds at that time. Per interview with licensed nurse A, on 4/27/17 at 12:15 P.M., the medical records nurse did not complete an admission audit and the admission failed to be reviewed at the daily clinical meeting the next day, on 3/29/17. On 4/27/17 at 10:00 A.M., observation revealed the resident sat in a broda chair beside a family member who attended a group activity with him/her. At noon the resident failed to demonstrate any verbal or physical unwanted behaviors, during the observations. On 4/27/17 at 1:10 P.M., direct care staff C reported the resident may have demonstrated increased verbal and physical outbursts mainly toward staff for a few days prior to his/her readmission to the behavior unit on 4/14/17. On 4/27/17 at 2:40 P.M., certified staff D reported the resident acted about the same all days. On 5/1/17 at 4:30 P.M., the behavioral unit psychiatrist stated he/she didn't know if the lack of medications, as were ordered, caused the increased verbal and physical behaviors and the need for the resident's readmission to the unit, but it certainly was best if mediations were given as prescribed on discharge. The facility's undated admission policy and procedure, included: The charge nurse should obtain the orders and transcribe them into the computer. Complete resident admission assessments. Order medications and supplies. Medical records should review the admissions checklist daily for the first 72 hours to ensure completion. The facility nursing staff failed to review and identify new prescribed medication orders and input them into the electronic system for this resident upon return from hospitalization . The resident failed to receive 4 medications as ordered (for 17 days). The resident displayed verbal and physical behaviors toward staff during cares and had to return to the behavioral unit for re-evaluation and further treatment. The investigation revealed the facility was in past-noncompliance as of 4/18/17, as the facility: 1.) New admission packets were initiated for all new admissions and readmissions. 2.) All licensed nursing staff were educated on the facility's; Required Clinical Documentation Schedule; Clinical Admission Checklist; New Admission Wellness Check; and on the Admission Audits. Friday and weekend admissions, checklist will be scanned and emailed to the DON within 24 hours of admission. After 5 PM and weekend admissions, discharge orders will be scanned and emailed to the DON immediately upon arrival of admission. All orders for new admissions and readmissions will be checked and verified by 2 nurses, with both nurses signing the discharge orders. For Friday and weekend admissions, the on-call clinical nurse will come into the facility within 24 hours of admission to review the admission wellness check form. The admission will then be reviewed again at the Monday Daily Clinical Excellence meeting. This in-servicing began at 2:00 PM on 4/14/17, and was completed by 5:40 PM on 4/18/17, with the last nurse signature. 3.) New admissions will be reviewed at the Daily Clinical Excellence meeting per the new admission wellness check form. 4.) The DON/ADON and/or Medical Records nurse will Audit all New Admissions per the Admission Audit form. 5.) The facility completed an emergency QAPI targeted review in-house, then committee reviewed the incident and targeted a review, at the next QAPI meeting on 4/25/17.

The facility reported a census of 82 residents, with 3 residents sampled for medication administration. Based on interview and record review, the facility failed to administer [MEDICATION NAME] (a blood thinner used to treat and prevent blood clots) injections as ordered, for 3 consecutive doses, for 1 (#1) of the 3 residents sampled. The resident experienced a stroke and admitted to the hospital intensive care unit following the missed administration of the [MEDICATION NAME]. This practice resulted in a significant medication error for this resident. Findings included: - The physician's order [REDACTED].#1 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The 5 day Minimum Data Set, dated dated [DATE], documented the resident ' s brief interview for mental status score of 11, indicating moderately impaired cognition, and required extensive assist of 2 staff for all activities of daily living. The resident received injections and anticoagulant (medications used to thin the blood) medications on 7 out of 7 days. The care plan, dated 10/26/15, documented the resident received anticoagulants, including [MEDICATION NAME] and [MEDICATION NAME] injections. The plan of care directed staff to monitor the resident ' s lab work, and to remind the resident not to bump into things when moving around due to increased potential of bruising and/or bleeding. The physician's order [REDACTED]. The PT/INR ([MEDICATION NAME] time and international normalized ratio) lab, drawn on 10/28/15 at 6:45 AM, documented the resident ' s PT 15.1 and INR at that time was 1.2. The nurse ' s note, dated 10/31/2015 at 11:03 PM, documented the [MEDICATION NAME] medication as unavailable. The nurse ' s note, dated 11/1/2015 at 8:54 AM, documented the [MEDICATION NAME] as on order from the pharmacy. Review of the October and November 2015 Medication Administration Record [REDACTED]. The PT/INR ([MEDICATION NAME] time and international normalized ratio) lab, drawn on 11/2/15 at 6:40 AM, documented the resident ' s PT 15.8 and INR 1.3. The nurse ' s note, dated 11/2/15 at 7:19 PM, documented the resident ' s family member reported a concern of the resident being disoriented. Staff reported the resident became disoriented in the shower. The physician ordered staff to send the resident to the hospital for evaluation. The nurse ' s note, dated 11/3/15 at 12:07 AM, documented the resident admitted to the hospital intensive care unit (ICU). The hospital emergency room report, dated 11/2/15 at 8:00 PM, documented on arrival to the hospital, the resident exhibited left-sided facial drooping and was very confused. The resident had a stroke scale score of 4 (score of 1-4 indicating a minor stoke). The resident admitted to the ICU for frequent neurological checks and observation. The hospital admission labs, dated 11/2/15, documented the PT of 16.6 and INR of 1.4, still below the therapeutic level/target value the physician order [REDACTED]. The physician history and physical, dated 11/4/15, documented the resident with [MEDICAL CONDITION]([MEDICAL CONDITION] or stroke) with minimal left [MEDICAL CONDITION] (muscle weakness or [DIAGNOSES REDACTED]), gait imbalance (difficulty walking), cognitive impairment (confusion) and left sided facial droop. On 11/18/15 at 8:09 AM, the resident ' s family member C stated, on Monday, 11/2/15 at about 1:30 PM, a nurse told the family that the resident had not had the [MEDICATION NAME] injections over the weekend because the facility ran out and did not get the medication filled. So, the nurse went and got a shot out of what he/she called the emergency stash and gave it to the resident. Family C brought to the attention of the nurse that the resident was really confused and not him/herself. When asked what the facility was doing about it or what the nurse thought about it, he/she said the resident seemed fine. Family member C insisted the nurse call the doctor, who said to send the resident to the hospital. When family C arrived at the hospital with the resident, the physician told family member C the resident had a stroke and would be admitted to the ICU for monitoring. On 11/18/15 at 11:42 AM, administrative nursing staff B reported he/she was not aware the resident had not received all of the doses of [MEDICATION NAME] as ordered. Staff B expected the nurse who administered the last dose of any medication to reorder the medication from the pharmacy. The nurse also should call the physician each time a dose of [MEDICATION NAME] was not given, for further orders from the physician. On 11/18/15 at 2:05 PM, licensed nursing staff D reported he/she was the nurse that administered the [MEDICATION NAME] dose on Saturday morning, 10/31/15, and was also the nurse the morning of 11/1/15. The 10/31/15 morning dose staff D administered to the resident was the last dose administered, but staff D was not aware of that, at the time. Staff D thought other facility staff had already ordered the [MEDICATION NAME] from the pharmacy, and made a nurse ' s note that the medication was on order. Staff D stated, on 11/1/15, he/she did not notice on the Medication Administration Record [REDACTED]. Staff D recalled licensed nursing staff E saying the medication was not at the facility and that staff E had ordered the medication from the pharmacy. Staff D stated the nurse is supposed to call the pharmacy if there is no dose of a medication available, but staff did not call because staff E had already done it. Staff D never thought about getting the medication out of the E-kit (emergency kit, a supply of medications available for administration). Staff D did not notify the physician the [MEDICATION NAME] lacked administration, or notify the DON (director of nursing). Staff D stated he/she should have called the pharmacy again and made a nurse ' s note about what was going on. On 11/18/15 at 2:38 PM, licensed nursing staff E stated he/she thought staff D ordered the [MEDICATION NAME], but it was not available to administer the night of 10/31/15 or 11/1/15. Staff E stated he/she should have called the pharmacy again. Staff E did not look in the E-kit for the medication. Staff E did not notify the physician or the DON that he/she had not given the medication on 10/31/15 or 11/1/15. Staff D stated they should have notified the physician, and the DON. On 11/18/15 at 2:54 PM, pharmacy consultant staff F stated the pharmacy received a request from the facility for [MEDICATION NAME] by fax (facsimile) on 10/31/15 at 5:59 AM. This was after hours, so the after-hours service received the fax, and returned a call to the facility to talk with a nurse and find out what they needed. Consultant F stated the pharmacy should have sent the order to the facility that day, on 10/31/15. However, pharmacy records show the next [MEDICATION NAME] went to the facility on [DATE]. Consultant F was unable to determine why the [MEDICATION NAME] did not ship to the facility when it was ordered. On 11/18/15 at 4:02 PM, pharmacy consultant staff G reported the pharmacy used a local 24 hour pharmacy (called backup) to deliver orders to the facility that are needed quickly or after hours. Consultant G stated the pharmacy received a faxed request for [MEDICATION NAME] syringes from the facility on 10/31/15, but the pharmacy was out of stock. The weekend pharmacy staff failed to contact the facility and let them know the pharmacy was out of stock and failed to place an order with the backup pharmacy. Also, the facility staff never placed a follow-up call to the pharmacy saying the order never arrived, as they should have. On 11/23/15 at 8:59 AM, Physician H reported that he/she had not been notified about the resident ' s missed doses of [MEDICATION NAME] until after the fact. Physician H was told about the omitted doses on the day the resident admitted to the hospital, on 11/2/15. The nurse that day called and told physician H the resident had not received the [MEDICATION NAME] over the weekend and that he/she was acting abnormal and very confused. The resident ' s anticoagulant levels were not therapeutic on admission to the hospital. Physician H stated the missed doses of [MEDICATION NAME] absolutely contributed to the fact that the resident had a stroke on 11/2/15, because had the [MEDICATION NAME] been administered as ordered, the resident may have had a therapeutic level at that time. Physician H expected the nurse to call if they were not giving a dose of [MEDICATION NAME], so physician H could have done something else for the resident ' s anticoagulant therapy on those days until the [MEDICATION NAME] was available again. The facility ' s risk management policy, dated 8/13, evidenced staff should document any event experienced by a resident which is a deviation from normal, to assess risk and take action to reduce the identified risk to an acceptable level. The events to be entered into the risk management module upon occurrence included medication errors. The facility ' s medication ordering and receiving policy, dated 9/10, documented a medication ordered for a resident in the facility may be unavailable for dispensing from the pharmacy. The facility nurse must make every effort to ensure that a medication ordered for the resident is available to meet the resident ' s needs. Nursing staff shall, if the shortage will impact the resident ' s immediate need of the ordered product, notify the attending physician of the situation, obtain a new order and discontinue the current order for the non-available medication. The facility failed to administer 3 doses of [MEDICATION NAME] injections, as ordered by the physician, for this resident on 10/31/15 and 11/1/15. The resident admitted to the hospital on [DATE] after suffering a stroke. This practice resulted in a significant medication error for this resident.

The facility identified a census of 102 residents with 26 residents sampled. Based on observation, interview and record review, the facility failed to provide adequate supervision or assistive devices for 2 of 3 residents reviewed for accidents, (#72) a cognitively impaired resident who experienced an unwitnessed fall that resulted in a fractured hip which required surgical intervention and resident (#117) who staff sat in an unsafe recliner and whom staff failed to provide planned interventions (a mat beside the bed). Furthermore, the facility failed to eliminate accident hazards to ensure the safety of 8 residents on 3 of 5 halls in resident bathrooms, and 8 common-use showers/toilet rooms on 5 halls. Findings included: - According to the face sheet, the facility admitted resident #72 on 6/10/09. Review of the Care Area Assessment (CAA) for the November 2011 for a significant change Minimum Data Set (MDS) 3.0 Assessment, documented the resident at risk for falls due to dementia, potential impulsive behaviors and the resident's inability to transfer or ambulate independently. Review of the quarterly MDS, dated [DATE], documented the resident with short and long-term memory loss, severely impaired decision making skills, required extensive assistance from staff for mobility, transfers, eating, total assistance from staff for toileting, personal hygiene, and experienced falls since the prior assessment. Review of the quarterly MDS, dated [DATE], documented the resident with short- and long-term memory loss, severely impaired decision-making skills, required extensive assistance from staff for transfers, bed mobility and eating and total dependence of staff for locomotion on and off the unit, dressing, toileting and personal hygiene. This same MDS documented the resident experienced falls since the prior assessment. Review of the Fall Risk assessment dated [DATE], scored (9) and revealed a score of 7-18 at high risk for falls. Review of the resident's plan of care review, dated 12/1/11, with additional updates on 5/22/12, identified the resident as a fall risk, impaired safety awareness related to cognitive impairment and potential for urinary tract infection due to a history of incontinence of bowel and bladder. The plan of care included interventions: - Cue/prompt/assist to toilet before/after meals, and bedtime as needed. The resident able to adjust clothing. Do hygiene. - Assist resident to toilet before/after meals/bedtime and as needed. - Bed alarm when in bed, body alarm when in wheelchair or recliner. - Ambulate with HHA (hand-held assist) or FWW (front wheeled walker) 6 days a week. The resident's plan of care further documented the resident with falls on 1/4/12 at 9:30 AM, 2/6/12 4:00 AM, 2/20/12 12:00 AM, 5/27/12 3:55 AM, 6/11/12 4:45 PM, and 9/13/12 9:30 AM. Review of the post-incident action addendum to the plan of care, dated 9/13/12 at 9:30 AM, recorded the resident with an unobserved fall. The addendum documented, "Resident was in wheelchair in room with body alarm attached. Resident assisted self with walker to bathroom and fell . Body alarm was sounding." Immediate post-incident action documented, "Resident will be toileted immediately after meals (already a prior care plan intervention which did not occur prior to this fall) and will not be left unattended in wheelchair in his/her room." Review of the acute hospital history and physical, dated 9/13/12, recorded the resident admitted with a comminuted completely displaced right proximal femur fracture and past medical history that included a stroke with right-sided weakness. Review of a physician's orders [REDACTED]. Observation, on 11/1/12 at 7:30 AM, direct care staff X and HH transferred the resident from the bed to his/her wheelchair. Staff stood the resident on his/her left leg, as the resident kept his/her right leg in a flexed protected position without bearing any weight on the extremity, personal body alarm noted intact and functioning. On 10/29/12 at 10:30 AM, administrative nursing staff D reported the resident fell in the facility and sustained a fractured hip on 9/13/12. On 10/31/12 at 10:26 AM, direct care staff HH reported the resident required 2-person lift with a previous fracture to the right hip, and wore a body alarm in bed and in his/her chair. On 10/31/12 at 4:35 PM, direct care staff W reported the resident with a personal alarm, and pivots a little bit on the left side with a a 2-person transfer. Direct care staff W continued that before the resident broke his/her hip, staff use to toilet the resident who experienced some periods of incontinence. On 11/1/12 at 7:30 AM, direct care staff X reported, "The resident does not bear weight on the right leg, keeps it protected, they said it shattered and did as good as they could to repair it." On 11/1/12 at 1:15 PM, licensed nursing staff V reported that before the hip fracture, "The resident previously ambulated to the bathroom with a walker and two staff, would not use his/her call light and wore body alarms because at times he/she would, at intervals, get up and walk." On 11/1/12 at 3:30 PM, administrative nursing staff D reported the resident able to walk to the bathroom with assistance prior to the fall. On 11/1/12 3:45 PM, administrative nursing staff C confirmed the resident fell due to a toileting issue. On 11/1/12 3:45 PM., administrative nursing staff A reported, at the time of the fall, on 9/13/12, the resident was in his/her wheelchair and toileted prior to breakfast. Administrative nursing staff A continued that a staff member wheeled the resident back to his/her room, after breakfast and failed to toilet or lay down the resident. The resident got a hold of his/her walker and tried to get up, to walk to the bathroom and fell . Staff A verified the facility failed to identify which staff had assisted the resident at that time. The facility provided policy, Fall Prevention Policy and Procedure, dated 6/16/10, documented that,..."Every resident will be evaluated for falls upon admission and subsequently thereafter when the resident's condition changes or at least quarterly. The care plan will state the goals, interventions and approaches for every resident who is identified as being at risk for falls. Staff will be trained to be alert to risk and hazards for falls in the environment. The falls prevention approaches will be evaluated by the Quality Improvement Committee to determine the effectiveness of the approaches." The facility failed to follow the resident's individual plan of care to toilet this cognitively impaired resident after meals to prevent falls. The resident attempted to self toilet and experienced a fall that resulted in a fractured hip which required surgical intervention. - During stage 1 of the survey, on 10/29/12 from 7 AM to 10/30/12 at 10:30 AM, observation revealed rusty toilet bolts extended from the base of the toilet/floor upwards 1 1/2 to 2 inches, without a protective covering, that revealed a sharp edge, creating an accident hazard, in 3 resident bathrooms on the E hall, 3 resident bathrooms on the north hall, and 2 resident bathrooms on the South hall. Observation during environmental tour on 11/1/12 from 2 PM to 4 PM, revealed the following rooms with rusty toilet bolts that extended up from the base of the toilet/floor upwards 1 1/2 to 2 inches without a protective covering that revealed a sharp edge, creating an accident hazard: The center hall whirlpool room, Center hall resident restroom, West hall men's shower, West hall all resident shower, East hall shower room, South hall shower room, North hall weight room, North hall shower room Interview with Housekeeping/Maintenance/Laundry staff U, during environmental tour on 11/1/12 from 2 PM to 4 PM, reported he/she unaware the uncovered toilet bolts which created a safety hazard and that housekeeping staff took off the covers to clean the toilets. Housekeeping/Maintenance/Laundry Staff U reported he/she would have to glue the covers back on the bolts. The facility failed to ensure the environment remained as free as accident hazards as possible in multiple resident bathrooms and common resident areas. - Record review of the chart face sheet, revealed resident #117 admitted to the facility 10-19-12. The admission assessment, dated 10-19-12, assessed the resident as continent of urine, using the urinal, alert, friendly, cooperative, lethargic, and answers questions readily, total assistance with transfers, on bed rest, ambulates short distance, with poor hearing,and adequate vision. The admission care plan, dated 10-19-12, failed to identify the resident as a fall risk. - Review of investigation reports for the resident revealed unobserved falls on: 10-20-12 fell out of bed 10-21-12 fall twice during the night 10-25-12 fell out of recliner The post incident action, dated 10-25-12, advised staff...."the resident was sitting in recliner, recliner tipped over and resident was found on floor, with the action to place a fall pad beside the recliner when the resident sitting in the recliner. The East Hall Action Rounds, dated 10-30-12, advised staff of the use of safety fall pad, pressure alarm and personal alarm. Observation, on 10-29-12 at 10:30 am, revealed the resident sitting in a recliner with the foot lift elevated in their room. Observation revealed the personal alarm attached to the residents right shoulder. The resident leaned forward in the chair several times during the observation, without setting off the personal alarm. Interview, on 10-29-12 at 10:30 am, with the resident's family, revealed the resident becomes confused, and climbs out of bed and the recliner. Observation, on 10-30-12 at 3:30 PM, revealed the resident sitting in their room in their recliner with feet elevated. The resident's family member present in the room. No fall mattress under/near the recliner. Observation, on 10-31-12 at 7:42 am, revealed the resident sitting their room in their recliner with the feet elevated, no fall mat on the floor near the recliner, and no family, staff in the room. The personal alarm attached to the resident's right shoulder. Interview, on 10-31-12 at 2:33 PM, with direct care staff J, revealed the resident tipped over the recliner, and was found on the floor in the evening of 10-25-12. Staff J reported to prevent falls, staff place a personal alarm on the resident when in the recliner and bed, along with the pressure alarm when the resident positioned in bed and a mattress on the floor by the resident's bed. Interview, on 10-31-12 at 4:53 PM, with direct care staff M, revealed the resident climbs over the side rails on the bed, and also the recliner. Staff M reported to prevent falls, staff advised to place the personal alarm on the resident when in bed and recliner, along with the pressure alarm when the resident in bed and position a mattress by the resident's bedside. Observation, on 11-1-12 at 11:30 am, revealed a mattress on the floor beside the resident's recliner. Interview with the resident's family member revealed lack of positioning of the mattress beside the recliner until today. The family member stated the resident tipped the recliner when the resident attempted to get up and sat on the edge of the elevated foot rest. Observation, on 11-1-12 at 11:30 am, revealed housekeeping, maintenance, laundry staff U, brining another recliner into the room. Staff U states the current recliner has a tendency to tip over, and the replacement recliner is heavier. The facility failed to utilized the planned fall prevention strategies of a fall pad by the recliner, and failed to replace a known easily tipping recliner with a more stable one in a timely manner to prevent further falls and possible injury for this resident at risk for falls.

The facility reported a census of 106 residents and identified 29 residents as self-mobile with confusion. Sixteen residents were selected for review. Based on observation, record review and interviews, the facility failed to provide adequate supervision and/or assistive devices to prevent one (#9) resident's head from becoming entrapped between the air mattress and a siderail. Furthermore, the facility failed to ensure the medication room remained secured to prevent accident hazards, and failed to keep chemicals inaccessible to the 29 self-mobile/confused residents, in the west hall shower room, and in the east hall men's bathroom. Findings included: - The facility readmitted resident # 9 on 10/31/07. The 8/3/10 quarterly minimum data set assessment identified the resident with cognitive impairment, the need for assistance with bed mobility and transfers and on hospice care. The resident's previous history included a hip fracture from a fall in the facility. The current plan of care, updated 7/13/10, included a potential for falls, assistance with all activities of daily living, 1/2 side rails to assist with positioning, bed alarms and fall pad beside the bed. The facility completed a fall assessment, on 8/9/10, and identified the resident as low risk for falls with a score of 8 (with above 10 at high risk). A side rail assessment, on 8/9/10, evidenced, "Res. (resident) non-weight bearing, continue with 1/2 rail." Nurses notes documented, "On 9/19/10 at 2400 (midnight), heard alarm (pressure pad) sounding, ran to resident's room and found resident with feet on the fall pad, and trunk on the bed. Res. (resident) head was caught between the bedrail and the mattress. Blood noted on the floor and on the left arm. ... Skin tear measured 11 by 9 cm (centimeter) superior to left elbow laterally... Tylenol, 325 mg. II (650 mg)., given to resident due to complaint of pain by crying and guarding the arm." Per nurses notes the facility nursing staff applied multiple steri-strips per facility skin tear protocol. At 4:00 A.M., a 3 cm bruise appeared on the right lower jaw with scattered ecchymosis to the right cheek from the fall. Also a 4 by 4 cm bruise to the upper mid-chest. Observation, on 9/20/10 at 9:00 A.M., revealed the resident lay in bed with a 1/2 siderail on the left side of the bed. The siderail fit up against the mattress and the wheels of the bed noticeably absent. The facility investigation, dated 9/21/10, revealed the resident's left front wheel came off the bed, allowing the bed to lean. The air mattress rolled the resident and the resident's head became entrapped between the mattress and the side-rail. Nurses notes dated 9/20/10 (no time), documented licensed nurse C completed an environmental check of the resident's room. The nurse laid on the bed to test the bed's stability and noted it difficult to stop self from rolling off the bed. On 9/21/10 at 3:23 P.M., certified staff I reported the siderail previously separated from the bed at times. Staff held their hands approximately 4-5 inches apart to demonstrate the distance. 9/21/10 at 2:30 P.M., Licensed nursing staff J changed the resident's left arm dressing, soaked with seeping blood. Staff J added additional 2 steri strips to the previous multiple strips that covered the long skin tear, approximately 11 centimeters in length. On 9/22/10 at 3:20 P.M., maintenance personal E reported the bed wheel previously reattached to the bed, " A couple of months ago," without knowledge of any problem since that time. Maintenance personnel felt the wheel came off when staff, "Yanked the siderail up." The facility failed to ensure the resident's bed remained free of entrapment hazards between the bed air mattress and the siderail. The resident rolled in bed, into the side rail when the wheel from the bed came off and the bed tipped. The resident became entrapped, with their head between the bedrail and the air mattress, after staff failed to notice the wheel off the bed. The resident's head remained dangerously entrapped between the bed and the siderail, which caused redness to the resident's left cheek and neck, and a 11 by 9 cm skin tear to the resident's left forearm. Therefore placing this resident in danger of strangulation. - Observation during the initial tour of the facility, on 9/20/10 identified the following unlocked chemicals: 1. A gallon of Seabreeze (astringent), on a tablet, in the unlocked shower room, on the west hall, at 8:54 a.m. The label on the Seabreeze stated, "Keep out of reach of children for external use only." 2. Two spray bottles of Stay Dry (perineal wash), on the counter, in the unlocked men's bathroom, on the East hall, The label on these bottles stated, "Keep out of reach of children for external use only." Licensed nursing staff member C stated, on 9/20/10 at 9:02 a.m., "Staff should not leave these doors unlocked, they know better." The facility failed to ensure the 29 confused mobile resident remained free of accidents hazards. - Observation during the initial tour of the facility, on 9/20/10 at 9:00 a.m. identified the medication room door, on the new wing, propped open. This door remained unlocked for at least 15 minutes, unattended with no staff present. This room contained multiple bubble packs of resident medications, ready for return to the pharmacy, and the locked emergency drug box. Numerous stock medications stored on the shelves such as aspirin, milk of magnesia, and Tylenol. The refrigerator contained resident's insulin and other injectables. The facility failed to ensure the medication room remained secured to prevent accident hazards for the 29 confused mobile residents.