Every finding on record at Meridian Rehabilitation and Health Care Center

Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions, to the residents of the facility appropriately to prevent the potential for food borne bacteria.Findings included: - During an initial tour of the kitchen on 04/27/26 at 08:57 AM, the following areas of concern were noted:The three-door reach-in freezer contained food debris on the bottom shelf.The three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf.The drain to the ice machine lacked a two-inch air gap.Two black two-tiered plastic carts, used to store clean dishes, had food debris on the bottom tier.The bottom shelf of the steamtable, used to store plate covers, had a build-up of food debris.On 04/28/26 at 01:57 PM, Dietary Staff BB confirmed the noted areas were in need of cleaning. The facility did not have a cleaning schedule or a policy regarding kitchen cleanliness.

Based on record review and staff interview, the facility failed to ensure comprehensive assessments were fully completed when staff failed to complete Care Area Assessments (CAA) that addressed the individual underlying causes, contributing factors and risk factors for Resident (R) 1, R2, R3, R4, R5, R7, R9, R10, R12, R15, R22, R28, R61, R71 R91, R98.Findings included:- R1's Electronic Health Record (EHR) recorded an Annual Minimum Data Set (MDS), dated [DATE], which trigged the Mood/Behavior, Functional Abilities/ Dementia/Cognition Loss the CAA. The CAA's lacked analysis of the findings.R2's EHR recorded a Significant Change MDS, dated 10/14/25, which triggered the Cognitive Loss/Dementia and Urinary Incontinence/Indwelling Catheter. The CAA lacked an analysis of the findings.R3's EHR recorded a Significant Change MDS, dated 09/17/25, which triggered the Cognitive Loss/Dementia, Communication, Functional Abilities, Urinary Incontinence/Indwelling Catheter, Nutritional Status, Dental Care, Pressure Ulcer, and Pain. The CAA lacked an analysis of the findings.R4's EHR recorded a Significant Change MDS, dated 12/2/25, which triggered the Cognitive Dental Care and Psychotropic Drug Use. The CAA lacked an analysis of the findings.R5's EHR recorded an Annual MDS, dated 11/24/25, which triggered the Cognitive Loss/Dementia, Urinary incontinence, Falls, Nutritional Status, Psychotropic Drug Use, and Pressure Ulcers. The CAA lacked an analysis of the findings.R7's EHR recorded an Annual MDS, dated 3/16/26, which triggered Functional Ability, Psychotropic Drug Use, Nutrition Status. The CAA lacked an analysis of the findings.R9's EHR recorded a Significant Change MDS, dated 6/20/25, which triggered Falls, and Psychotropic Drug Use. The CAA lacked an analysis of the findings.R10's EHR recorded a Significant Change MDS, dated 3/30/26, which triggered Visual Function. The CAA lacked an analysis of the findings.R12's EHR recorded an Annual MDS, dated 09/08/25, which triggered the Functional Ability. The CAA lacked an analysis of the findings.R15's EHR recorded an Annual MDS, dated 2/24/26, which triggered the Cognitive Loss/Dementia, Functional Abilities, Urinary Incontinence/ Indwelling Catheter, Falls and Nutritional Status. The CAA lacked an analysis of the findings.R22's EHR recorded a Significant Change MDS, dated 08/30/25, which triggered the Pressure Ulcer. The CAA lacked an analysis of the findings.R28's EHR recorded a Significant Change MDS, dated 12/16/25, which triggered the Psychotropic Drug Use. The CAA lacked an analysis of the findings.R61's EHR recorded an admission MDS, dated 3/10/26, which triggered the Cognitive Loss/Dementia. The CAA lacked an analysis of the findings.R71's EHR recorded an admission MDS, dated 10/27/25, which triggered the Cognitive Loss/Dementia, Psychotropic Drug Use, Psychosocial Well Being, Falls, Pain, Nutrition Status, Mood/Behavior, Pressure Ulcer. The CAAs lacked analysis of the findings.R91's EHR recorded an admission MDS, dated 3/21/26, which triggered the Urinary Incontinence/Indwelling Catheter, Psychosocial Well Being, Functional abilities, Falls, Nutritional Status, Pressure Ulcer, and Pain. The CAAs lacked analysis of the findings.F98's EHR recorded an admission MDS, dated 11/14/25, which triggered the Functional Abilities, Urinary Incontinence/Indwelling Catheter, Psychotropic Drug Use, Falls and Nutritional Status. The CAAs lacked analysis of the findings.On 04/28/26 at 07:48 AM interview with Licensed Nurse LN F reported she had stopped writing the CAA notes last year after being told by someone but could not remember who it was. That is why she did not write anything on the CAA that triggered. LN F revealed at times she would document risk concerns, but with everything was just on the main check-off on the worksheet and it was already on the MDS CAA section and why they triggered.The facility did not provide a policy regarding the CAA.

Based on observation, record review and interviews, the facility failed to provide Resident (R)2 with a dignified existence by allowing his leg urinary catheter bag to remain on his lower leg, without a dignity bag or cover. Findings included:- R2's Electronic Medical Record (EMR) documented diagnoses which included: calculus in bladder (a hardened mass of minerals that forms within the urinary bladder when urine becomes highly concentrated or remains in the bladder for too long) and dementia (a progressive mental disorder characterized by failing memory and confusion). R2's inaccurate Significant Change Minimum Data Set (MDS), dated [DATE], documented he had a Brief Interview for Mental Status (BIMS) score of one, indicating severe cognitive impairment. He was dependent on staff for toileting hygiene, had an indwelling urinary catheter (a tube inserted into the bladder to drain the urine into a collection bag), and was always incontinent of urine. R2's Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA), triggered but lacked analysis of findings. R2's Quarterly MDS, dated [DATE], documented he had a BIMS score of one. He was dependent on staff for toileting hygiene, had an indwelling urinary catheter and was always incontinent of urine. R2's Care Plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. On 04/27/26 at 09:59 AM, R2 sat in his wheelchair at the door of his room. His catheter drainage bag rested on his lower left leg supported by his shoe. The drainage bag, visible to visitors and other residents in the hallway, contained dark amber urine and lacked a privacy cover. On 04/27/26 at 11:45 AM, R2 sat in his wheelchair in the dining room. His catheter drainage bag continued to rest on his lower left leg supported by his shoe. The drainage bag, visible to visitors and other residents in the hallway, contained dark amber urine and lacked a privacy cover. On 04/27/26 at 11:49 AM, Certified Nurse Aide (CNA) M stated R2's catheter drainage bag will slide down to his lower left leg often. CNA M stated he had never placed a dignity bag on R2's drainage bag. On 04/28/26 at 07:17 AM, CNA N stated R2's urinary drainage bag would slide down from his left thigh to his lower left leg. Staff should move the drainage bag back up to R2's thigh when it slides down. CNA N stated the staff do not utilize catheter dignity bags on their hall. On 04/29/26 at 08:40 AM, Administrative Nurse E stated she had not given thought to staff utilizing dignity bags for urinary catheters on the memory care unit. The facility policy for Resident Rights, approved 12/2024, included: Each resident of the community has the right to a dignified existence including privacy and confidentiality.

Based on interviews and record review, the facility failed to ensure residents received the opportunity to participate in the care planning process when staff failed to invite Residents (R) 10 and R11 or their responsible party to care plan meetings. Findings included:1. R10's Electronic Medical Record (EMR) recorded a admission Minimum Data Set (MDS) dated 01/14/26 and a Significant Change MDS dated 03/20/26, which documented a Brief Interview of Mental Status BIMS score of 12, indicating moderately impaired cognition. R10's EMR lacked documentation of a care plan meeting conducted in the past four months.On 04/27/26 at 09:28 AM, R10 reported she was not invited to any care plan meeting.2. R11's EMR recorded an admission MDS dated 02/20/26 and a Quarterly MDS dated 03/18/26, which documented a BIMS score of 14 indicating intact cognition. R11's EMR lacked documentation of a care plan meeting conducted in the past two months.On 04/27/26 at 12:10 PM, R11 reported she was not invited to any care plan meeting.On 04/29/26 at 10:36 AM, Administrative Nurse F reported residents and or the family members were mailed or given hand given invitations to attend care planning meetings. Administrative Nurse F reported that a copy of the invitation should be uploaded in the EMR. Administrative Nurse E said the Interdisciplinary Care Conference assessment should also be completed in the EMR and confirmed she could not locate any documentation for R10 or R11 for a care plan meeting being completed. The facility's policy Care Planning, undated, documented in addition to creating parts of the resident's comprehensive care plan, Social Service representative also needs to attend the care plan meetings. In these meetings, the team presents information to the resident and/or resident information about their progress towards their care plan goals. Federal law provides that, to the extent possible, the resident, the resident's family, or the resident's legal representative should participate in the care plan meeting. An Interdisciplinary Care Conference Notes Assessment (UDA) should be completed during the care plan meeting.

Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 100's call light was within her reach. Findings included: - R100's Electronic Medical Record (EMR) documented a diagnosis of clostridium difficile (C-diff: contagious bacteria characterized by foul-smelling frequent loose bowel movements) and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid).R100's Entry Minimum Data Set was completed on 04/22/26 on her admission date. R100's admission Minimum Data Set (MDS), dated [DATE], documented that it was in progress. No information was available.R100's Base Line Care Plan, dated 04/23/26, documented staff to evaluate for change in level of consciousness. The base line care plan lacked documentation for a call light. On 04/28/26 at 08:06 AM, R100's door was closed to her room, and she could be heard yelling loudly for help several times. Licensed Nurse (LN) H asked if that was R100 yelling and donned his gown, mask, and gloves. LN H entered R100's room; she was lying on her left side in bed, and she reported she wanted to get up and she could not find her call light. R100's call light was observed on the floor under her bed.On 4/28/26 at 08:51 AM, Certified Nurse Aide (CNA) Q clipped the call light to R100's shirt with a black and silver binder clip. On 04/29/26 at 12:15 PM, R100 was in her room seated in the recliner and her call light was lying on the floor not in reach. R100 reported she wanted to go to bed and reported she could not get herself back in bed. On 04/28/26 at 09:46 AM, CNA Q reported that the binder clip was used to keep the call light attached to the resident and that the call light cord did not have a clip that was attached.On 04/29/26 at 12:18 PM, LN H reported the staff should make sure they clip the call light to the resident's clothes and reported that R100 would throw her call light on the floor. On 04/29/26 at 12:20 PM, Administrative Nurse D reported that she expected the staff to make sure all residents always have their call lights in reach. She was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy about call lights.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment in Resident (R) 87's bathroom.Findings Included:- On 04/27/2026 at 11:41 AM, an environmental tour with Maintenance Staff UU revealed the following concerns in R87's bathroom and handwashing area:Approximate four-foot section of loose baseboard to the left of and behind the toilet. Black substance on the wall and floor behind the loose baseboard to the left of and behind the toilet.Approximate three-inch crack in the toilet seat.Empty Hand Soap dispenser hanging from the wall above the handwashing sink with exposed lag bolt fasteners.On 04/27/2026 at 11:41 AM, Maintenance Staff UU confirmed the above findings and stated the soap dispenser did not work. Maintenance staff UU confirmed the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Additionally, he stated the hand soap dispenser was mounted with lag bolts over a stud and not in the sheet rock as it should be to secure it to the wall to properly secure the dispenser.On 04/29/2026 10:26 AM, Maintenance Staff UU reported the facility implemented a QR code for staff and visitors to report maintenance items for repair. He confirmed the findings above had not been reported. He confirmed the area behind the handwashing sink had leaked and flowed into the bathroom area, so the sink had been replaced but he had no report of the findings above. Additionally, Maintenance Staff UU reported the facility did not have policies for maintenance repair in resident's room.The facility did not provide a policy for safe, homelike environment.

Based on observation, interview, and record review, the facility failed to accurately complete assessments to reflect the resident's status for four residents: Resident (R) 2 related to incontinence of urine and dependence on the staff for activities of daily living (ADL), R3 related to restraints, R9 related to falls, and R10 related to Hospice services.Findings included:- R2's undated Physician Orders, documented pertinent diagnoses which included dementia.R2's 10/14/25 Significant Change in Status Minimum Data Set (MDS) documented Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive impairment. He had no impairment in functional limitation in range of motion. He was independent with eating and upper body dressing and used a walker and wheelchair (w/c) as mobility devices. R2 had an Indwelling catheter and coded as always incontinent of bladder.R2's 04/07/26 Quarterly MDS documented no changes in the assessment from above.Review of the EMR from 03/30/26 through 04/27/26 revealed no staff documentation regarding w/c mobility or dressing requirements.Review of the EMR from 03/30/26 through 04/27/26 revealed catheter care was provided each shift.On 04/27/26 at 09:59 AM, R2 sat slumped in the w/c in his room with his eyes closed, wearing a hospital gown. His indwelling urinary catheter collection bag attached to his left leg clearly visible, lacking a cover. On 04/27/26 at 11:45 AM, R2 sat in the dining room wearing a hospital gown. His urinary catheter collection bag remained on lower left leg, with spout on, lacking a cover.On 04/28/26 at 09:55 AM, Consultant MM was working with R2 in his room. R2 was wearing a green striped shirt and black pants with food crumbs on it. On 04/28/26 at 11:52 AM, CNA M put the resident's left foot on the foot pedal repeatedly when his foot fell from the foot pedal multiple times. CNA M continued to propel the resident into the dining room with his left foot skimming the floor. His black pants remain dirty.On 04/28/26 at 01:33 PM, CNA N and CNA M propelled the resident into the shower room in his w/c to provide peri-care. Both his feet skimmed the floor and both foot pedals were on the w/c. His black pants were still dirty. Staff assisted him to stand up to the handrail with extensive assistance. He was able to bear weight on both his legs but did not straighten his legs, remaining in a squatted position while standing. On 04/27/26 at 11:49 AM, CNA M stated the residents wear hospital gowns over their clothes while they eat, as they're used as clothes protectors, and the gowns are removed before they leave the dining room. CNA M also stated R2's catheter bag slides down to his lower leg all the time and they were unsure about dignity bags and never put his drainage bag in anything.On 04/28/26 at 07:17 AM, CNA N, stated the resident's urinary bag is attached to his left thigh and it shouldn't be down on his calf, but it slides down all of the time if his pants are loose. CNA N further stated if it was down his calf then staff would need to help him move it back up to his thigh area, and not to use dignity bags on the back on the unit. On 04/28/26 at 09:55 AM, Consultant M stated therapy has been working with him on w/c positioning and lateral supports in place and help the resident sit up straight.On 04/28/2 at 11:52 AM, CNA M stated the resident's left foot never stays on the foot pedal and he required total care and was dependent on staff to dress him.On 04/28/26 at 11:52 AM, CNA N stated the w/c foot pedals are pretty much useless as his feet always skim the floor while staff propel him in the wheelchair. CNA N stated the resident has had the catheter for a long time, more than a year. CNA N further stated he hasn't walked for several years, and he is dependent on staff for all his activities of daily living (ADLs). On 04/29/26 at 08:57 AM, Consultant NN reported she worked with R2 for standing strength, trying to have him use his hands more, standing strength, etc. but he doesn't stand up big and tall and kind of bent over. Consultant NN then stated he gets around well in his w/c and she worked with him last week.On 04/29/26 at 09:58 AM, LN G stated the resident does not walk, he can propel himself in his wheelchair and staff will propel him at times. LN G continued to state his feet do not always stay on the foot pedals and the foot pedals should be adjusted so that his feet stay on them and reported R2 has an indwelling catheter.On 04/29/26 at 09:02 AM, Administrative Nurse F stated she goes around with the GG form and talks with CNAs on first and second shift or will watch the residents as cares are being done to assess the residents to code the MDS. She reported R2's performance varies by day of what he can or cannot do. Administrative Nurse F stated she utilized the RAI Manual for guidance to complete the MDS accurately.On 04/29/26 at 08:40 AM, Administrative Nurse E stated the resident hasn't walked for several months and expects the staff to provide assistance with dressing when clothing is dirty and assist with positioning of his feet on the foot pedals while propelling him about the facility. She confirmed the resident had an indwelling catheter.- R3 undated physician orders documented diagnoses which included cerebral infarction (stroke - sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) with hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body).The 08/29/25 Significant Change in Status Minimum Data Set (MDS) documented a brief interview for mental status (BIMS) of 15, indicating intact cognition. She had functional limitation in range of motion on one side of her upper and lower extremities and required partial to moderate assistance with eating and substantial to maximum assistance with toileting, hygiene, dressing bed mobility; other restraint use indicated. On 04/28/2026 at 09:59 AM, R3 lay in bed with her right arm laying on pillow for positioning and bilateral grab bars at the head of the bed. R3 reported she uses the grab bars to help move and position in bed. No indication of any device which limits the resident's access to her body or voluntary movement.On 04/28/2026 at 09:34 AM, CNA Q, confirmed the facility did not use restraints, the grab bars at the head of the bed were there to help residents to reposition in the bed and to increase their independence.On 04/29/2026 at 12:43 PM, Administrative Nurse J confirmed the facility did not use any restraints and the grab bars were used as enablers to help residents to reposition in bed and to increase their independence; the MDS was inaccurate.On 04/29/2026 at 01:23 PM, Administrative Staff A confirmed facility did not use any restraints. The grab bars were used as enablers to help residents to reposition in bed and to increase their independence.- Resident (R) 9 pertinent diagnoses from physician's order EMR documented diagnoses which included diabetes, atrial fibrillation (irregular heartbeat), unsteadiness of feet, nondisplaced fracture of proximal phalanx of right lesser toes (broken toes).R9's Significant Change Minimum Data Set (MDS), dated [DATE], documented a brief interview for mental status (BIMS) of 13, indicating intact cognition. The resident required partial moderate assistance with transfer, no ambulation, and functional limitations in range of motion on one side of the lower extremities.The Quarterly MDS, dated [DATE], documented a BIMS of 13, indicating cognition; no changes in ADLs status. The MDS indicated he did not have falls. R9's EMR documented the resident experienced falls on 02/04/26 and 02/19/26.The Progress Notes (PN) documented falls as follows:02/04/2026 at 03:30AM, an aide notified a nurse that the resident was found on the floor. Upon entering the room, the resident was observed sitting on the floor on her buttocks next to the bed, leaning her head against the bed. A skin tear was noted on the right side of the forehead, measuring approximately 1 cm x 0.5 cm.When asked what happened, the resident stated, I was deep asleep and I just found myself on the floor with a lot of pain on my head Resident was alert and able to answer questions appropriately, she was able to move all four extremities without difficulty.02/19/2026 at 05:28 AM, Staff alerted the nurse that the resident was on the floor, staff walked in the room, found resident sitting on the fall mat on the floor. She landed on her buttock with legs straight, bed by her left side, and her walker across her. Staff assessed the resident head-to-toe related to unwitnessed fall, checked her skin, and noted a scratch on the right ankle.On 04/28/2026 at 08:12 AM, CNA delivered her tray while the lights are off, she sat up on the edge of her bed independently and reported she was asleep.- Resident (R) 10's pertinent diagnoses from physician's order electronic medical record (EMR) documented: diabetic mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), coronary artery disease (CAD- abnormal condition that may affect the flow of oxygen to the heart), and chronic kidney disease.R10's Significant Change Minimum Data Set (MDS), dated [DATE], documented a brief interview for mental status (BIMS) of 12, indicating moderately impaired cognition, and no hospice.The Electronic Health Records (EHR) Hospice Certification and Physician Orders documented an order for hospice services to initiate 03/17/26.The Social Service Progress Notes (PN), dated 03/16/2026 at 01:56 PM, documented that the DPOA did not want to sign her mother on to services until tomorrow, and the referral packet was sent and the Director of Nursing (DON)/Administrator informed.On 04/28/26 at 02:30 PM, R10, while lying in bed, reported that she just got a bed bath from the hospice aide.On 04/27/26 at 04:25 PM, Consultant HH reported that she could not answer the question about the MDS, and would refer to regional consultant GG.On 04/28/26 at 12:40 PM, Certified Nurse Aide (CNA) Q reported R10 received hospice services which included bathing.On 04/28/26 at 03:16 PM, Licensed Nurse (LN) I confirmed R10 received hospice services.On 04/28/26 at 02:45 PM, Administrative staff A reported that the Resident Assessment Instrument (RAI) manual is used as the policy to guide staff in the accurate completion of the MDS complete for the MDS.04/29/2026 at 01:41 PM, Consultant MDS Nurse GG confirmed the above findings reflected an inaccurate assessment and reported that he expected the MDS to be accurate. He confirmed the above assessments were into completed in accordance with the Resident Assessment Instrument (RAI) User's Manual, the above assessments were not accurate due to the following:R2 should have been coded as not rated due to the placement of an indwelling catheter instead of incontinence of urine, and his ADL status was not accurately reflected when coded as independent. R3's grab bars were used as enablers and not restraints.R9 MDS failed to reflect the resident's fall, which occurred during the look back period.R10 related to Hospice services were received during the look back period and not coded in the MDS.The Center for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, dated 10/2017, documented a significant error is an error in an assessment where the resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and/or results in an inappropriate plan of care; and/or the error has not been corrected via submission of a more recent assessment. A significant error incorrect coding of the MDS and NOT an actual significant change in the resident's health status.

Based on observation, interview, and record review, the facility failed to provide a summary of the baseline care plan to Resident (R) 100. Findings included:- R100's Electronic Medical Record (EMR) documented a diagnosis of clostridium difficile (C-diff: contagious bacteria characterized by foul-smelling frequent loose bowel movements) and congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid).R100's Entry Minimum Data Set was completed on 04/22/26 on her admission date.R100's admission Minimum Data Set (MDS), dated [DATE], documented it was in progress. No information was available.R100's Base Line Care Plan, dated 04/23/26, documented contact precautions. Staff were educated to wear gowns and masks when changing contaminated linens, place soiled linens in bags marked biohazard, and bag the linens and close the bag tightly before taking it to laundry.On 04/27/26 at 10:10 AM, R100 reported she did not know what a base line care plan was.On 04/28/26 at 08:06 AM, R100's door was closed to her room, and she could be heard yelling loudly for help several times. Licensed Nurse (LN) H asked if that was R100 yelling and donned his gown, mask, and gloves. LN H entered R100's room she was lying on her left side in bed. R100 said she wanted to get up, but she could not find her call light. R100's call light was observed on the floor under her bed.On 04/28/26 at 03:16 PM, LN I reported that the baseline care plan was started on the day the resident was admitted . She reported that the nurse would review the baseline care plan with the resident, but the charge nurse would not give the resident or family member a written copy of the base line care plan.On 04/29/26 10:36 AM, Administrative Nurse F reported that she would review the baseline care plan with the resident and/family and reported she had completed an Interdisciplinary Care Conference 48 Hours on 04/27/26. Administrative Nurse F reported that the computer must not have kept the care conference note, as it was not opened or completed in R100's EMR. Administrative Nurse F reported she thought the Social Service Designee (SSD) would have completed the care conference last week then reported that the facility had not had a SSD for three weeks now, then she changed what she had said and reported the family could not come in until 04/27/26 and could not state why there was not a opened or completed Interdisciplinary Care Conference 48 Hours completed as of 04/29/26.The facility did not provide a policy for base line care plans.

Based on observation, interview, and record review, the facility failed to provide appropriate activity of daily living (ADL) assistance to Resident (R)2 regarding changing clothing.Findings included:- R2's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion).R2's Significant Change Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of one, indicating severe cognitive impairment. The MDS inaccurately documented that he required setup assistance with lower body dressing.R2's Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 10/14/25, did not trigger.R2's Quarterly MDS, dated [DATE], documented the resident had a BIMS score of one, indicating severe cognitive impairment. The MDS inaccurately documented that he required setup assistance with lower body dressing.R2's Care Plan, revised 03/23/26, inaccurately instructed staff that the resident was independent with dressing.R2's EMR lacked staff documentation of the resident's ADL needs.On 04/28/26 at 09:55 AM, R2 sat in his wheelchair in his room. He wore black pants with food crumbs on them.On 04/28/26 at 11:52 AM, Certified Nurse Aide (CNA) M propelled the resident in his wheelchair from his room to the dining room. R2 continued to wear dirty black pants.On 04/28/26 at 01:33 PM, CNA M and CNA N changed the R2's dirty pants using total assistance. R2 was unable to participate in dressing or undressing.On 04/28/26 at 11:52 AM, CNA M stated residents should be dressed in clean clothing when they go into the dining room for a meal. CNA M stated the resident required total assistance with dressing.On 04/28/26 at 09:58 AM, Licensed Nurse (LN) G stated staff should make sure the residents are always dressed in clean clothing. LN G stated the resident required total staff assistance with dressing.On 04/29/26 at 10:08 AM, Administrative Nurse E stated it was the expectation for staff to ensure residents are always dressed in clean clothing. Administrative Nurse E confirmed the resident required total staff assistance with dressing.The facility policy for Activities of Daily Living, revised 09/24/25, included: The facility shall provide each resident with care, treatment, and services according to the resident's individualized care plan.

Based on observation, interview, and record review, the facility failed to prevent the development of and promote the healing of pressure ulcers when staff failed to ensure R101 received necessary interventions including a low air loss mattress, heels were offloaded, and a consistent repositioning plan. Findings included: - R101's Electronic Medical Record (EMR) revealed diagnoses of incomplete quadriplegia (spinal cord injury occurring at the neck where the cord is not fully severed, leaving some sensory or motor function below the injury level), limited mobility, and muscle weakness.R101's 03/11/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. R101's MDS documented no behaviors or refusals of care, and he required maximal assistance with activities of daily living (ADL) including bed mobility to roll left and right. The MDS recorded he had a Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer that was not present on admission. R101's MDS documented a pressure-reducing device was in his wheelchair and bed, and R101 was on a turn and reposition program.R101's 03/26/25 Pressure Ulcer/Injury Care Area Assessment (CAA) lacked an analysis of the findings.R101's admission Data Collection, dated 03/06/25 at 12:56 PM, documented R101 had an actual skin impairment on the sacrum but lacked documentation of what the actual skin impairment was, or what preventative skin care was needed.R101's Braden Scale (scale used to predict pressure ulcer risk), dated 03/06/25 at 04:09 PM, documented a score of 16, which indicated the resident was at risk.R101's Care Plan, dated 03/07/25, directed staff to float R101's heels while in bed and provide a pressure reduction cushion to protect his skin while up in the chair.R101's 03/06/25 Physician's Orders documented Triad paste (zinc-oxide-based, hydrophilic paste used to manage, protect, and heal moderate to heavily weeping wounds, especially in difficult-to-dress areas. It adheres to both wet and dry skin, making it effective for wounds in areas with excessive moisture) daily to the coccyx (area of skin over the tailbone) for prevention at bedtime for skin integrity. The order was discontinued on 03/07/25.R101's Interdisciplinary Care Conference 48 Hours, dated 03/07/25 at 11:33 AM, documented R101's only skin issue was a surgical site on his cervical spine.R101's Care Plan, dated 03/10/25, instructed staff to position R101 every two hours and as needed or requested for pain relief, pressure reduction and comfort. Staff were instructed R101 required two staff participation to reposition and turn in bed.R101's Weekly Skin Check, dated 03/11/25 at 05:38 AM, documented a superficial open area approximately 7.0 centimeters (cm) by 5.0 cm on the left buttock; the care plan was not reviewed, and the area was new per the documentation.R101's Daily Skilled Progress Note on 03/11/25 at 12:37 PM documented no new skin distress noted.R101's Skin and Wound Evaluation, dated 03/11/25 at 05:22 PM, documented a Stage 2 partial-thickness skin loss with exposed dermis noted on the left gluteal fold (pertaining to the buttocks or buttocks muscles), facility (in-house) acquired on 03/11/25, and measured 7.1 cm by 4.2 cm with preventative moisture barrier and control. The skin and wound evaluation was not checked off for a turning and repositioning program as an additional care.R101's 03/12/25 Physician's Orders documented apply Triad paste to the left buttock wound, nickel thick, every day and night shift, and as needed, for wound care.R101's Care Plan, dated 03/12/25, instructed staff to apply moisture barrier with each incontinent episode.R101's Daily Skilled Progress Note on 03/12/25 at 12:23 PM documented no new skin distress noted.R101's Daily Skilled Progress Note on 03/12/25 at 11:43 PM documented new skin area, with a treatment in place.R101's 03/19/25 Physician's Orders documented a right heel, deep tissue injury (DTI- purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear), and to apply skin-prep (liquid skin protectant) and a foam dressing every day shift on every Monday, Wednesday, Friday and as needed for wound care.R101's Skin and Wound Evaluation, dated 03/19/25 at 10:22 AM, documented DTI of the right heel, facility acquired on 03/19/25 measured 4.0 cm by 3.2 cm with preventive measures of air mattress and heel protection device.R101's 03/19/25 Physician's Orders documented C-boots (special boots designed to offload pressure) to be worn while in bed every day and night shift for skin integrity.R101's Skin and Wound Evaluation, dated 03/19/25 at 10:26 AM, documented Stage 3 (full-thickness pressure injury extending through the skin into the tissue below) in-house acquired pressure area of the left gluteal measured 9.0 cm by 6.9 cm, with preventative moisture barrier and air mattress. The skin and wound evaluation was not checked off for turning and repositioning program as an additional care.R101's Care Plan, dated 03/19/25, instructed staff to avoid shearing (the separation of skin layers caused by friction or trauma) while repositioning R101 in bed related to his wound and to monitor pressure areas for changes in color, sensation, temperature, and report any change to nurse. Staff were instructed to offload pressure from his heels while up in chair.R101's 03/21/25 Physician's Orders documented a left buttock coccyx wound; cleanse with normal saline or wound cleanser, apply Hydrofera Blue (a type of moist wound dressing that provides wound protection and addresses bacteria and yeast) and foam dressing every day shift, every Monday, Wednesday, Friday and as needed for wound care.R101's Weekly Skin Check, dated 03/24/25 at 10:39 AM, documented no new changes. The care plan updated question was answered as non-applicable because the care plan was current, an update was not needed.R101's Skin and Wound Evaluation, dated 03/26/25 at 04:41 PM, documented a DTI of the right heel in-house acquired on 03/19/26 measured 3.5 cm by 3.1 cm with preventive measures of a heel protection device.R101's Skin and Wound Evaluation, dated 03/26/25 at 04:45 PM, documented an unstageable (depth of the wound is unknown due to the wound bed being covered by a thick layer of other tissue and pus) in-house acquired pressure ulcer of the left gluteus on 03/12/25, which measured 9.6 cm by 5.4 cm with preventative measures of an air mattress. The skin and wound evaluation was not checked off for a turning and repositioning program as an additional care.R101's Skin and Wound Evaluation, dated 03/31/25 at 11:46 AM, documented a DTI of right heel, in house acquired on 03/19/26, which measured 3.3 cm by 2.3 cm, with preventive measures of heel protection device.R101's Skin and Wound Evaluation, dated 03/31/25 at 12:29 PM, documented an unstageable in-house acquired pressure ulcer of the left gluteus which measured 11.2 cm by 3.3 cm with preventative measure of an air mattress. The skin and wound evaluation was not checked off for turning and repositioning program as an additional care.R101's EMR lacked evidence of nutritional notes related to the wounds.R101's EMR lacked evidence that a low air loss mattress was offered and declined or provided.R101's EMR under Tasks lacked evidence of a turning and repositioning program. The EMR further lacked documentation that R101 refused repositioning.R101's EMR documented that he discharged from the facility on 04/04/25.On 04/28/26 at 09:46 AM, Certified Nurse Aide (CNA) S reported when a resident was on a turn and position program, the staff would know as it would be scheduled in the tasks in EMR for the staff sign out after they completed a task. CNA S reported she did not have access to the care plan or Kardex. She reported she relied on the other staff to let her know if a resident required preventative measures.On 04/28/26 at 12:40 PM, CNA Q reported that the staff are required to document in point of care (POC) in EMR for residents that have a turn, and position scheduled every two hours. CNA Q reported staff are to document as soon as the task is completed. CNA Q reported if a resident required to have their heels elevated and or wear booties that would also be under the tasks for the staff to document if they completed the task or if the resident refused. CNA Q reported she did not know about the Kardex in the residents EMR.On 04/28/26 at 03:16 PM, Licensed Nurse (LN) I reported that if a resident was noted with a new wound or skin area the nurse would notify Administrative Nurse E (Wound Nurse) and the provider. LN I stated the nurse should assess and obtain orders for treatments, and implement preventative interventions like booties. LN I reported that Administrative Nurse E or Administrative Nurse F (MDS Nurse) were responsible for scheduling any task on POC and said that the nurses could not add a task. LN I reported the scheduled Tasks was how the staff would know how to complete tasks that were required.On 04/29/26 at 09:30 AM, Administrative Nurse E reported that R101 was admitted on [DATE] and a foam dressing was ordered as preventative treatment. She reported that R101 did not have any open areas until 03/11/25. She said R101 would refuse to turn in bed but confirmed that it was not documented in R101's EMR. Administrative Nurse E reported that the staff should primarily know if a resident required to be turned and positioned every two hours if a resident were bedridden. Administrative Nurse E reported that she thought the Tasks in the EMR generated a turn and reposition program for the staff to sign off when completed or refused and verified that R101 did not have a turn and reposition program scheduled when he was a resident there. Administrative Nurse E reported R101 did not have an air mattress when he was a resident there and said she thought he was offered an air mattress and declined but could not locate any documentation in R101's EMR regarding that. Administrative Nurse E reported that she expected the nurse to obtain an order and document on the same day a wound is assessed that the treatment was completed.On 04/29/26 at 11:03 AM, Administrative Nurse F reported the turn and repositioning program would be scheduled in POC for the residents that required turn and positioning assistance. She stated she thought that when she clicked on the care plan for turn and reposition required, it was system generated so the CNAs could document that task.On 04/29/26 at 02:05 PM, Regional Consultant HH reported that R101 had a turn and reposition on his Kardex when he admitted . Consultant HH reported that is how the CNAs knew when a resident required assistance. Administrative Staff A reported that it was just a given, or known fact, that the residents require to be turned and positioned every two hours and reported the turn and reposition program was not available on POC when R101 was a resident here. Administrative Staff A and Consultant Staff HH reported they expected residents would not receive facility acquired pressure ulcers.The facility's policy Skin Identification, Evaluation, and Monitoring, dated 02/2026, documented the purpose of this policy is to outline a method of identification, evaluation, and monitoring for alterations in skin integrity. Communities will implement preventative measures, and an individualized care plan will be formulated upon completion of findings. Complete Braden Skin at Risk on admission, then weekly for the next three weeks following admission. Initiate preventative and/or treatment intervention as indicated. Notify community wound care nurse, and Director of Nursing of pressure injury identification. Update baseline care plan with initial interventions. Schedule regular and frequent repositioning for bed and chair bound residents.

Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards when staff failed to utilize appropriate foot pedals when propelling Resident (R) 2 in his wheelchair causing his feet to not remain safely on the foot pedals during transportation.Findings included:- R2's Electronic Medical Record (EMR) documented a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion).R2's inaccurate Significant Change Minimum Data Set (MDS), dated [DATE], documented he had a Brief Interview for Mental Status (BIMS) score of one, indicating severe cognitive impairment. The MDS noted R2 was independent with walking with the use of a walker and/or wheelchair.The Activities of Daily Living (ADL) Care Area Assessment (CAA), dated 10/14/25, did not trigger.R2's inaccurate Quarterly MDS, dated [DATE], documented he had a BIMS score of one. The MDS noted R2 was independent with walking with the use of a walker and/or wheelchair.R2's Care Plan, revised 03/23/26, instructed staff R2 had cognitive impairment due to a diagnosis of dementia (a progressive mental disorder characterized by failing memory and confusion). R2's care plan lacked staff instruction on the use of foot pedals while propelling him in his wheelchair.On 04/28/26 at 11:52 AM, Certified Nurse Aide (CNA) M propelled the resident in his wheelchair from his room to the dining room for lunch. R2's wheelchair had foot pedals in place, however R2's shoed left foot fell from the foot pedal and skimmed the floor in between the foot pedals during transport.On 04/28/26 at 01:33 PM, CNA N propelled R2 from the dining room into the shower room to provide care. R2's wheelchair had foot pedals in place, however, both of R2's shoed feet skimmed the floor in between the foot pedals during transport.On 04/28/26 at 11:52 AM, CNA M stated R2's left foot never stayed on the foot pedal of his wheelchair.On 04/29/26 at 11:52 AM, CNA N stated the foot pedals of R2's wheelchair were useless as he was not able to keep his feet on the foot pedals.On 04/29/26 at 09:58 AM, Licensed Nurse (LN) G confirmed R2's feet did not always remain on the foot pedals of his wheelchair when he was propelled by staff. LN G stated the foot pedals should be adjusted to better fit R2's needs.On 04/29/26 at 08:40 AM, Administrative Nurse E stated it was the expectation for staff to ensure R2's feet remained on the foot pedals of his wheelchair during transport; if R2's feet did not remain on foot pedals, staff would need to lower them to better fit the resident.The facility did not provide a policy regarding wheelchair safety.

Based on interview and record review, the facility failed to ensure Residents (R)28 remained free from unnecessary medications when staff failed to administer as needed (PRN) bowel medication for constipation.Findings included:- R28's Electronic Medical Record (EMR) documented a diagnosis of constipation (difficulty passing stools).R28's Significant Change Minimum Data Set (MDS), dated [DATE], documented he had a Brief Interview for Mental Status (BIMS) score of 11, indicating moderately impaired cognition. The MDS noted he was always incontinent of bowel and had no constipation.R28's Urinary Incontinence/Indwelling Catheter Care Area Assessment (CAA), dated 12/16/25, triggered but lacked an analysis of findings.R28's Quarterly MDS, dated [DATE], documented he had a BIMS score of 11, indicating moderately impaired cognition. The MDS noted he was always incontinent with his bowel.R28's Care Plan, revised 02/23/26, documented R28 had episodes of bowel incontinence and instructed staff to use disposable briefs.R28's EMR under the Orders tab, included the following physician's orders:Docusate sodium (a stool softener used to assist in the passing of stool), 100 milligrams, by mouth, every 12 hours, PRN, for a diagnosis of constipation, ordered, 10/22/25.Glycolax (a laxative used to assist in the passing of stool), 17 grams, by mouth, every 8 hours, PRN, for a diagnosis of constipation, ordered 10/22/25.R28's EMR under the Task tab revealed he did not have a bowel movement (BM) on the following dates:No BM from 04/05/26 through 04/09/26, for a total of five days.No BM from 04/21/26 through 04/25/26, for a total of five days.R28's Medication Administration Record (MAR) for April 2026 lacked documentation that staff administered either of the PRN medications.On 04/28/26 at 01:45 PM, Certified Nurse Aide (CNA) N stated R28 did have periods of constipation. CNA N stated all BMs were documented in the EMR.On 04/29/26 at 09:58 AM, Licensed Nurse G confirmed the resident did not have a BM on the dates noted and staff had not administered PRN medication for bowels.On 04/29/26 at 10:08 AM, Administrative Nurse E stated it was the expectation for nurses to administer PRN medications when a resident did not have a BM for three or more days.The facility did not provide a policy regarding bowel management.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by failing to ensure the lid of the dumpster was kept closed.Findings included:- During the initial tour of the kitchen on 04/27/26 at 08:57 AM, observation revealed the two doors to the outside dumpster were open. The ground around the dumpster was littered with used disposable gloves, used hairnets, empty restaurant take-out containers, and other unidentifiable objects. On 04/28/26 at 01:57 PM, Dietary Staff BB stated the doors to the dumpster were often not closed by staff after disposing of trash, as required.The facility did not have a policy regarding keeping the doors of the dumpster closed.

Based on observation and interview, the facility failed to ensure a safe and sanitary environment in the facility laundry.Findings included:- On 04/28/2026 at 11:55 AM, inspection of the laundry with Housekeeping/Maintenance Staff WW revealed the following concerns:Unsealed concrete floor surfaces throughout the laundry room floor.A folding tabletop had missing laminate and exposed wood.Shelving in the clean laundry area had exposed bare wood.Missing paint on the ceiling area approximately one foot by two feet. Eighteen broken tiles on the laundry floor folding area. A three-foot section of clean linen shelving and upright post had bare wooden shelves with exposed wood. The second shelf from the bottom corner pf the wooden shelving unit was missing paint. The dryer room ceiling had cardboard taped to the ceiling approximately four inches by eight inches.On 04/28/2026 at 12:04 PM, Housekeeping/Maintenance Staff UU agreed the above findings needed fixing and the shelves should be replaced. He reported the hole in the ceiling was due to a vent cover being removed and said the opening was covered with cardboard and tape.On 04/29/2026 at 10:26 AM, Housekeeping/Maintenance Staff UU reported the facility did not have policies to address laundry maintenance and repairs.

The facility reported a census of 96 residents with seven residents reviewed for abuse, neglect, exploitation and/or misappropriation of resident property. Based on observation, interview and record review, the facility failed to send completed investigation reports to the State Agency (SA) within five working days of the alleged incident(s) as required. Findings included: - Review of the facility's notifications to the SA revealed the following:On 04/08/25 incident number 1542136 was reported to the SA. The completed investigation was not submitted within the required five working days nor provided to the surveyor during an on-site visit on 02/02/26.On 07/28/25, incident number 2573926 was reported to the SA. The completed investigation was not submitted within the five working days but was provided to the surveyor during an on-site visit on 02/02/26.On 08/26/25, incident number 2600412 was reported to the SA. The completed investigation was not submitted within the five working days but was provided to the surveyor during an on-site visit on 02/02/26.On 09/02/25, incident number 2604856 was reported to the SA. The completed investigation was not submitted within the five working days but was provided to the surveyor during an on-site visit on 02/02/26.On 09/02/25, incident number 2604837 was reported to the SA. The completed investigation was not submitted within the five working but was provided to the surveyor via e-mail on 02/04/26 after an on-site visit on 02/02/26.On 09/02/25, incident number 2604872 was reported to the SA. The completed investigation was not submitted within five working days but was provided to the surveyor during an on-site visit on 02/02/26.On 12/30/25, incident number 2703687 was reported to the SA. The completed investigation was not submitted within five working days nor was it provided to the surveyor during an on-site visit on 02/02/26. On 02/02/26 at 04:00 PM, Administrative Staff A said the delay in reporting and/or providing the surveyor with the completed investigation reports were that some of them were incomplete. Administrative Staff A stated he was aware of the required time frame for submitting completed investigations to the SA. Administrative Staff A stated the facility's expectation was for the administrator to have the investigations completed and submitted to the appropriate agencies within the required timeframe. The facility's Abuse, Prevention and Prohibition Policy policy, dated 11/2025, documented the administrator would ensure a thorough investigation of allegations and document appropriate action. The administrator would also complete the final report and submit the report to the required agencies as well as maintain the report in a locked file in the administrator's office. The facility's administrator, agent or employee will not screen or otherwise withhold any reports from the appropriate agencies.

The facility reported a census of 96 residents. Based on observation, interview, and record review, the facility failed to prevent the neglect of cognitively impaired Resident (R)53, who had mental health disorder diagnoses, anger related to living in the facility, and a history of exit seeking, and the facility staff did not respond to his suicidal ideation statements after his elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). On [DATE], R53 eloped from the facility. When staff returned R53 to the facility, they placed a Wander Guard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on R53, and he reported he would never eat again. On [DATE] at 04:00 PM, R53 made statements such as give me a gun so I can shoot myself. At 10:00 PM, the resident reported he was being held against his wishes. On [DATE] at 11:30 AM, R53 reported he would not eat until someone came back to talk about him being dismissed. Staff told R53 it may be a while before someone could get to him as there are others in need of services. On [DATE] at 10:02 AM, staff assessed R53 for exit seeking behaviors and continued 15-minute checks for 24 hours until reassessed. On [DATE], new orders were received to increase Seroquel 50 mg to three times a day. On [DATE] at 03:30 PM, staff found R53 had hung himself in his room with the TV cable on the closet door frame. This deficient practice placed R53 in immediate jeopardy. Findings included: - Review of the Electronic Health Record (EHR), documented R53 had diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion) and bipolar (major mental illness that caused people to have episodes of severe high and low moods) and conduct disorder (a group of behavioral and emotional problems characterized by a disregard for others). The [DATE] Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R53's total severity score of 00, indicating no depression. The MDS documented the resident did not have behaviors during the look back period. R53 was independent with all his activities of daily living (ADL). The [DATE] Behavioral Symptoms Care Area Assessment (CAA) documented R53 had episodes of agitation and anxiety and staff would proceed to care plan with continued monitoring and assistance as needed to avoid complications and minimize risks related to behaviors, with referral to physician and/or psychiatric services as needed. The [DATE] Quarterly MDS documented R53 had a BIMS score of nine, which indicated moderately impaired cognition. The MDS indicated no depression for the resident. R53 had become very anxious and agitated about why he was at the facility and when/why he could not go home for four to six days in the seven-day look-back period. R53 was independent with all his ADL. The [DATE] Care Plan documented an intervention, dated [DATE], indicating R53 was not allowed outside of the community, independently. Staff were instructed to provide redirection, diversion, and reorientation if R53 became restless, agitated, or exit seeking. The staff were to consult the physician if R53 was not easily redirected or had continued behaviors. The resident was an elopement risk/wanderer. R53 had an actual elopement from the facility. R53 had depression and anxiety and was on a daily psychotropic medication for management, dated [DATE]. The staff would monitor, record, and report to physician as needed for harm to self, suicidal ideation's, or refusal to eat or take medications. The [DATE], Elopement Assessment documented R53 was not at risk for elopement, however the assessment documented R53 was cognitively impaired, an exit seeker, diagnosed with dementia, and required a secured unit. Review of the Progress Note revealed on [DATE] at 06:03 PM, R53 was upset about having to wait to get help to get out of the facility. R53 stated he was going to go, one way or another. The [DATE] Nurse Practitioner Note documented R53 required long term care placement in a memory care unit due to high elopement risk. Furthermore, R53 was upset to still be living in a nursing facility and had daily aggression. Review of the Progress Note revealed on [DATE] at 01:42 PM, R53 stated if he did not get dismissed, he would sneak out the back door at night. The Progress Note on [DATE] revealed the following: At approximately 07:15 AM, staff could not locate R53. At approximately 08:30 AM, the staff located R53 approximately two miles away from the facility. At 09:00 AM, Emergency Medical Services (EMS) transported R53 to the hospital for psychological evaluation and medical clearance after his elopement. At 03:00 PM, R53 returned to facility from the hospital. The staff placed a Wander Guard bracelet (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) to R53's right wrist and placed R53 on one-hour checks for the following 72 hours. The Progress Note on [DATE] revealed: At 01:28 PM, staff found R53 at his window and when asked what he was doing. R53 questioned when am I getting out of here? The Wander Guard bracelet was not on R53's wrist, it was located behind the TV in R53's room. The staff notified Physician Extender TT, who instructed staff to give R53 space to calm down and reapproach the resident in a few hours. At 02:30 PM, R53 continued to be adamant about leaving the facility and the staff contacted Administrative Nurse D. At 03:30 PM, Administrative Nurse D instructed staff to send R53 to the hospital for evaluation, per provider order. At 04:00 PM, staff informed R53 that EMS was on route to transport him to a hospital. R53 continued to make comments such as give me a gun so I can shoot myself. Staff were instructed to keep watch on the agitated resident. At 04:30 PM, R53 left the facility with EMS. At 10:00 PM, R53 returned to the facility, aggravated that he was back, and with one-on-one in place at that time. The Progress Note on [DATE] at 06:39 PM, revealed the staff continued with one-on-one monitoring for R53 and the resident was verbally aggressive toward staff. The [DATE] Physician Orders included an order for the Electronic WanderGuard bracelet to be applied to R53, staff to validate the functioning every night shift. The Progress Note on [DATE] revealed: At 08:05 AM, Physician Extender TT updated on R53's continued aggressive behavior and refusal to take medications. Physician Extender TT recommended an inpatient psychiatric stay. At 08:25 AM, the facility nurse spoke to the hospital nurse, who suggested to send R53 to the hospital for evaluation. The Progress Note on [DATE] at 01:36 PM revealed the facility nurse spoke with the nurse at 11:00 AM and was informed R53 would be diverted to another hospital for admission to a Behavioral Health Unit (BHU). At 11:30 AM, EMS transported R53, who left willingly, however he stated, I will murder you if I have a reason too. The Progress Note on [DATE] at 05:20 PM, revealed R53 returned to facility, accompanied by EMS, with no new orders. The [DATE] Physician Order required staff to check for the placement of the WanderGuard bracelet on every shift. The Progress Note on [DATE] at 11:30 AM, revealed R53 refused his lunch meal and stated he would not eat again until someone came back to talk to him about his dismissal. The staff advised R53 that it may be a while before someone could talk to him as there were others in need of services. R53 continued to stand at an exit door to watch staff enter the code to the door. The Progress Note on [DATE] at 02:37 PM, revealed staff noted a referral sent to a BHU at 11:15 AM due to increased behaviors. The BHU contacted the facility at 12:30 PM and informed them there were no beds available. The staff contacted a second behavioral unit and was informed there were no beds available. Staff sent a referral out to a third BHU at 02:41 PM, however, that unit staff stated the referral was not received and the referral was re-faxed. The Progress Note on [DATE] at 03:06 AM, revealed R53 continued one-on-one supervision. R53 remained in his room. The Progress Note on [DATE] at 10:02 AM, revealed the Administrative Nurse F assessed R53 for exit seeking behaviors. R53 was at baseline and staff would complete fifteen-minute checks for 24 hours. The Progress Note on [DATE] at 10:06 AM, revealed Administrative Nurse F assessed the resident and noted R53 continued at baseline and staff discontinued the fifteen-minute checks. Physician Extender TT's signed [DATE] Psychiatric Progress Note regarding the visit on [DATE] at 02:30 PM to 02:45 PM, documented R53 appeared disheveled, displayed irritable behavior, and had poor insight and impulse control. R53 remained focused on being released and became demanding and easily agitated. R53's conversation was tangential (different from or not directly connected with the one you are talking about) in nature, which further complicated the conversation and understanding R53's concerns. The staff reported R53's recent elopement and ongoing agitation and aggression. New order to increase on [DATE] at 12:45 PM, for R53's Quetiapine fumarate, 50 mg tablet to three times a day, for continued issues with mood and behavior. The Progress Note on [DATE] at 12:59 PM, noted R53 continued to ask for dismissal orders. The EHR lacked Progress Notes between the [DATE] at 12:59 PM and the [DATE] at 03:30 PM Progress Note. The Progress Note on [DATE] documented: At 03:30 PM, R53 was in his bed at 06:00 AM, with his eyes closed and breathing. At 08:00 AM, staff administered R53's medications and R53 asked staff when he was leaving. At approximately 11:30 AM, staff delivered lunch to R53 in his room. He asked how long he had been at the facility. At approximately 01:00 PM, R53 brought his lunch dish to the nurse's station. At approximately 03:30 PM, the staff found R53 hanging from his closet. The staff contacted the facility's management team. At 03:38 PM, Administrative Nurse D and Administrative Nurse F entered R53's room and found R53 hanging from the television cable on the closet door frame. The staff assisted R53 to the floor and began cardiopulmonary resuscitation (CPR- emergency lifesaving procedure performed when the heart stops beating). The staff called 911 and continued CPR. At 04:00 PM, EMS arrived and took over CPR. Social Service Designee contacted the guardian. At 04:05 PM, time of death was announced as EMS/Medical Coroner stopped all compressions per the guardian's request. Review of the Facility Investigation dated [DATE] revealed through record review and interview of staff, family, and physician services, determined that R53 had a previous history of possible suicide ideation's. It was determined at the time of the event, R53 was not known to be a danger to himself or others and had remained stable per his baseline. Observation on [DATE] at 11:30 AM, revealed the memory care unit courtyard exit required a code to exit and enter. There was a six-foot wooden fence that surrounded the courtyard and attached to the building. There was a small alcove area that was near the exit door, not completely visible for staff to observe when they looked out the windows to the courtyard. During an interview on [DATE] at 11:38 AM, CNA Q reported R53 eloped in 2022, and she did not know when R53 had his Wander Guard removed after the elopement in 2022. CNA Q stated she had been educated previously to never let a resident outside by themselves in the courtyard. R53 had exit seeking behaviors as he would state he wanted to leave. CNA Q said the green patio chairs in the courtyard were removed after R53 eloped on [DATE]. She also confirmed she received education after R53 eloped in [DATE] and she received education about abuse, trauma, and suicide in July after the incident. During an interview on [DATE] at 02:26 PM, CNA MM stated R53 always asked him about being able to leave the facility. CNA MM stated that he received education about elopement, abuse, and trauma after R53 eloped on [DATE]. He also stated that R53 never made verbal comments of hurting himself and he had received training on suicide. During an interview on [DATE] at 02:26 PM, CNA NN stated R53 always asked about leaving the facility and wanted to live somewhere else. CNA NN stated he received education after R53 eloped, that included elopement, abuse, and trauma. He also stated that R53 never made verbal comments of hurting himself and he had received training on suicide. On [DATE] at 03:40 PM, Licensed Nurse (LN) I stated she could not locate R53 on [DATE] at approximately 07:15 AM and said CNA P last observed R53 in the courtyard. LN I stated she checked the sign-out book and confirmed R53 had not signed out of the facility. Staff could not locate R53 on the unit and contacted all staff on pager system and announced a Dr. [NAME] at approximately 07:30 AM. Administrative staff B located the resident at approximately 08:30 AM and brought him back to the facility. LN I confirmed R53 was very agitated about residing at the facility and his behaviors were almost daily. LN I was not sure if R53 had a previous elopement from the facility. LN I stated R53 was antsy and agitated and wanted to get out. She stated that R53 was placed on one-on-one observations 24 hours a day for about two weeks. LN I stated several staff members took turns with R53's one-on-one observation. LN I reviewed Physician Extender TT psychiatric progress note that was received on [DATE], however Physician Extender TT assessed R53 on [DATE]. LN I stated that Physician Extender would write new orders in the facility if needed and that waiting six days for new orders after a visit is not usual. LN I stated R53 was very agitated about being in the facility and never voiced any suicidal ideation's to her. LN I verified R53 had no progress notes charted in the EHR between the [DATE] at 12:59 PM progress note and the [DATE] at 03:30 PM progress note, when R53 was found hung in his room. LN I stated he was still wanting to leave but not as aggressive during that time period or a note would have been written, and stated the nurses' chart by exception. LN I also stated they do not chart notes on psych (antipsychotic- class of medications used to treat major mental conditions which cause a break from reality) medications when changed, unless there was a concern. She stated the nurses would have to chart a lot on the residents, as psych medication changes occur often. LN I stated she had education for elopement, abuse, trauma, and suicidal ideation's signs and symptoms and to report concerns immediately to management. On [DATE] at 12:02 PM, LN G stated she was not at work the day R53 eloped from facility on [DATE]. She stated that she would not let a resident outside by themselves. LN G revealed that R53 was an exit seeker since the first day he admitted in December of 2022, and was not given a Wander Guard bracelet until after he eloped in December of 2022 shortly after he admitted to the facility. LN G could not recall when staff removed R53's wander guard bracelet. LN G stated that is not normal to receive new orders several days after a resident was seen by a provider. LN G stated that no progress notes were required after a medication change unless there was a concern. LN G stated she last saw R53 on [DATE] and he was his normal self. She confirmed that she received education after both incidents occurred, that included abuse, elopement, trauma, and suicidal ideation's and the facility had an elopement drill. On [DATE] at 03:00 PM, Administrative Nurse D stated that Physician Extender TT generally did not write orders in the facility when she assessed residents. Administrative Nurse D said Physician Extender TT would email to her all the signed progress notes with orders written on them if she wrote new orders. She stated it would take several days to receive the progress notes and orders back from Physician Extender TT and stated that was not acceptable. Administrative Nurse D confirmed that nurses generally charted when there was a concern. On [DATE] at 11:49 AM, Administrative Nurse F stated residents from the memory care units were not allowed to go outside in the courtyard or off the units independently. She stated R53 had always been an elopement risk and staff received education on abuse, elopement, suicidal ideation's, and trauma. She stated that the facility tried to assist R53 to get admitted to a behavioral unit a few times and he would just be sent back from the hospital. On [DATE] at 03:50 PM, phone interview with Physician Extender TT, revealed the progress notes and orders received for R53 on [DATE] from her visit on [DATE] was later than normal. She stated it typically took ,d+[DATE] hours to write, sign, and email the progress notes and orders to the Administrative Nurse D. Physician Extender TT verified she would not write orders at the facility during a visit, due to the number of residents she saw there. She stated she was not updated on R53's comment from [DATE] that he would shoot himself if he had a gun. Physician Extender TT stated she received her information from the Administrative Nurse F and the Administrative Nurse D and said the staff on the unit were not the best resource for information needed. She confirmed R53 should have received the order for his medication increase sooner than he did. The facility Suicide Threats policy dated ,d+[DATE] documented if a resident made a suicidal threat, stay with the resident, and immediately notify the nurse. The nurse would assess the resident and notify the Director of Nursing or designee and medical provider to establish a plan of care. The resident's environment would be evaluated, and potentially dangerous items removed. The interdisciplinary team would review documentations and behaviors and revise the plan of care. The facility failed to prevent the neglect of cognitively impaired, R53, with known mental illness and anger related to placement in the facility, when staff failed to respond to his suicidal ideation comments after he eloped from the facility on [DATE]. This deficient practice placed R53 in immediate jeopardy, and R53 hung himself with a cable cord from his closet door. On [DATE] at 09:10 AM, Administrative Staff A and Consultant Staff SS were provided the Immediate Jeopardy (IJ) template and notified the facility failed to prevent the neglect of cognitively impaired, R53, with known mental illness and anger related to placement in the facility, when staff failed to respond to his suicidal ideation comments after he eloped from the facility on [DATE]. This deficient practice placed R53 in immediate jeopardy, and R53 hung himself with a cable cord from his closet door on [DATE]. The facility identified and implemented the following corrective actions, completed on [DATE] after R53's suicide: 1. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting held by interdisciplinary team on [DATE]. 2. The Administrator notified the Medical Director on [DATE] at 09:00 AM. 3. The [NAME] President of Clinical Operations re-educated the Administrator and Director of Nursing on community process for recognizing signs and symptoms of suicidal on [DATE]. 4. The Corporate Director of Clinical Reimbursement educated the Administrator, Social Service staff, and Director of Nursing regarding the community process of the social service comprehensive assessment and trauma informed care assessment. Education included intended scheduled, psychosocial care planning of 5. Current associates will be re-educated by the community by the Administrator or designee on or before [DATE] or prior to working next scheduled shift on community. Trauma Informed Care process with specific focus on identification of suicidal symptoms and suicidal ideation, required notifications and immediate actions. 6. Social Service comprehensive assessments will be completed upon admission, annually and with significant change. Assessment will be documented in resident medical record. 7. Residents identified with need for trauma preventative services will have a trauma informed assessment completed upon admission, annually and with identified significant change in condition. Assessments will be documented in resident medical record. Care plan will be updated as indicated. 8. Routine angle rounds will be completed by assigned interdisciplinary team members routinely and will include staff members interviews to validate understanding of resident suicide awareness and notification requirements. Results of the angel rounds will be reported during routine morning stand up meetings. If discrepancies are identified immediate one on one educations will be completed with associate involved. 9. During weekly risk review meetings, the interdisciplinary team will review the clinical record of newly admitted residents or residents identified change in condition to validate completion of required social service assessments and or trauma informed care evaluations when indicated. The review will be documented in the resident medical record. 10. The Administrator or designee will routinely review sample selected residents for the next 60 days to validate compliance of the following: completion of the social service comprehensive assessment as appropriate, completion of trauma informed care assessment as appropriate, psychosocial care plan present when indicated that include resident specific interventions based upon assessment findings; any noted suicidal ideation as indicated. 11. Monthly review of completed weekly risk review and angle rounds results and trends will be completed by the Administrator or designee and reported to the QAPI committee for the next three months and then re-evaluate to determine if further monitoring is indicated. Due to the corrective actions the facility completed prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 96 residents and the facility identified five residents at risk for elopement. Based on observation, interview, and record review the facility failed to provide adequate supervision to cognitively impaired, independently mobile Resident (R)53, identified as a high risk for elopement. On 06/29/24 at approximately 07:15 AM, staff were unable to locate R53 in the facility. On 06/29/24 at approximately 08:30 AM, staff located R53 approximately two miles away from the facility. R53 walked down busy residential areas with a 35 mile per hour speed limit and would have crossed 20 cross walks and crossed over two river bridges. This deficient practice placed R53 in immediate jeopardy. Furthermore, the facility failed to keep R54 safe, related to fall hazards in R54's room. Findings included: - Review of the Electronic Health Record (EHR) documented R53 had diagnoses, which included dementia (a progressive mental disorder characterized by failing memory and confusion), bipolar (major mental illness that caused people to have episodes of severe high and low moods) and conduct disorder (a group of behavioral and emotional problems characterized by a disregard for others). R53 admitted to facility on 12/07/2022. The 11/20/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R53 had a total mood severity score of 00, indicating no depression and there were no behaviors documented on the assessment. R53 was independent with all his activities of daily living (ADLs). The 11/20/23 Behavioral Symptoms Care Area Assessment (CAA) documented R53 had episodes of agitation and anxiety. Staff would care plan continued monitoring of the resident and provide assistance as needed to avoid complications and minimize risks related to behaviors, with referral to physician and/or psychiatric services as needed. The 05/16/24 Quarterly MDS documented a BIMS score of nine, which indicated moderately impaired cognition. No depression noted. R53 was very anxious and agitated about why he was at the facility and when/why he could not go home for four to six days of the seven-day look-back period. R53 was independent with all his ADLs. The 07/22/24 Care Plan documented an intervention, dated 12/09/22 instructing staff R53 was not allowed outside of the community independently. Staff were instructed to provide redirection, diversion, and reorientation if R53 became restless, agitated, or began exit seeking. Staff would consult the physician if R53 was not easily redirected or had continued behaviors. The resident was an elopement risk/wanderer and on 12/09/22, R53 had an actual elopement from the facility. The Elopement Assessments revealed the following for R53: On 12/27/22, 12/09/22, 12/15/22, 03/10/23, 07/10/23, 08/21/23, 11/14/23 and 02/15/24, R53 was identified at risk for elopement. On 05/13/24 Elopement Assessment, documented R53 was not at risk for elopement, however the assessment documented R53 was cognitively impaired, an exit seeker, diagnosed with dementia, and required a secured unit. Review of the Progress Notes from 01/01/24 to 06/29/24 revealed the following: On 04/09/24 at 06:03 PM, R53 was upset about having to wait to get help to get out of the facility. R53 stated he was going to go one way or another. On 06/22/24 at 01:42 PM, R53 stated if he did not get dismissed, he would sneak out the back door at night. On 06/29/24 at approximately 07:15 am, staff were unable to locate R53. The facility notified Law Enforcement at approximately 08:00 AM. Staff were able to locate R53 at around 08:30 AM approximately two miles away from the facility. Review of the Nurse Practitioner Note dated 06/11/24, documented R53 required long term care placement in a memory care unit due to high elopement risk. Furthermore, R53 was upset to be still living in a nursing facility and had daily aggression. Review of the Facility Investigation, revealed on 06/29/24 at approximately 06:00 AM, Licensed Nurse (LN) J and Certified Nurse Aide (CNA) N provided R53 access to the courtyard to consume a cup of coffee independently. CNA N passed in report to the oncoming CNA O where R53 was. At approximately 06:45 AM, CNA P verified R53 was in the courtyard patio on the bench, with his hands folded, dressed in shirt, pants, and tennis shoes. At approximately 07:15 AM, LN I could not locate R53 and instructed CNA O and CNA P to search the entire Memory Care Unit as R53 was an elopement risk. LN I checked the sign-out book and verified R53 was not signed out. At approximately 07:30 AM, LN I, CNA O, and CNA P confirmed R53 was not in the unit or the courtyard. CNA O located a patio chair placed in the corner of the six-foot-tall fence. LN I initiated the elopement procedure and called a Dr. [NAME] code for (missing resident) over the pager system to alert all staff. All staff assisted with the search of R53 inside and outside of the facility. Staff members drove around the area of the facility, without locating R53. At approximately 07:50 AM, the Police Department was notified of R53 missing from the facility. At approximately 08:25 AM, Administrative Staff B located R53 located approximately two miles from the facility. Administrative Staff B brought R53 back to the facility at approximately 08:45 AM. The physician ordered R53 to a hospital emergency room for a psychological evaluation. Emergency medical staff transported R53 to the hospital at 09:00 AM. Observation of the area R53 would have presumably walked down was a busy residential area with a 35 miles per hour speed limit and R53 would have crossed 20 cross walks and crossed over two river bridges. Review of the weather data for the facility area from Weather Underground (www.wunderground.com) on 06/29/24 at approximately 06:45 AM, was daylight and the temperature was 77 degrees Fahrenheit. On 07/30/24 at 03:40 PM, LN I stated she could not locate R53 on 06/29/24 at approximately 07:15 AM and stated that CNA P last observed R53 in the courtyard. She instructed CNA P and CNA O to complete a thorough check of the unit to locate R53. LN I stated she checked the sign-out book and confirmed R53 had not signed out of the facility. Staff could not locate R53 on the unit and contacted all staff on pager system and announced a Dr. [NAME] at approximately 07:30 AM. LN I stated she contacted Administrative Nurse F and contacted the Police Department at approximately 08:00 AM as staff had not yet located R53. Some of the staff drove their own vehicles to locate R53. The Police Department arrived at the facility around 08:08 AM and were given a description and picture of R53. Administrative staff B located the resident at approximately 08:30 AM and he was brought back to the facility. LN I confirmed R53 was very agitated about having to reside at the facility and his behaviors were almost daily. LN I was not sure if R53 had a previous elopement from the facility. On 07/31/24 at 11:38 AM, CNA Q reported R53 had an elopement in 2022, she was unsure when R53 had his Wander Guard (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) removed after the elopement in 2022. CNA Q stated she had been educated previously to never let a resident outside by themselves in the courtyard. R53 had exit seeking behaviors as he would state he wanted to leave. The green patio chairs in the courtyard were removed after R53 eloped on 06/29/24. She also confirmed that she received education after R53 eloped in June 2024. On 07/31/24 at 02:26 PM, CNA MM stated R53 always asked him about being able to leave the facility. CNA MM stated he received education about elopement, abuse, and trauma after R53 eloped on 06/29/24. On 07/31/24 at 02:26 PM, CNA NN stated R53 always asked about leaving the facility and wanted to live somewhere else. Stated that he received education after R53 eloped on elopement, abuse, and trauma. On 07/31/24 at 11:49 AM, Administrative Nurse F stated no residents from the memory care units were allowed to go outside in the courtyard or off of the units independently. She stated R53 had always been an elopement risk and staff received education on abuse, elopement, and trauma. Observation on 07/31/24 at 11:30 AM, the memory care unit courtyard exit required a code to exit and enter. There was a six-foot wooden fence that surrounded the courtyard and attached to the building. In the courtyard there was a small alcove area that was near the exit door, not completely visible for staff to observe when they looked out the windows to the courtyard. The facility Elopements policy dated 05/2023 documented it is the policy of the facility that all residents were afforded adequate supervision to provide a safe environment possible. Residents who are at risk for elopement are provide with at least one of the following safety precautions. 1. Door alarms on facility exit 2. A personal safety device that will alert facility when resident has left the building without supervision. (Wander guard bracelet). 3. Staff supervision. The facility failed to provide adequate supervision to cognitively impaired, independently mobile R53, identified as a high risk for elopement. On 06/29/24 at approximately 07:15 AM, staff were unable to locate R53 in the facility. R53 was found approximately 45 minutes later, at 08:30 AM, approximately two miles away from the facility. This deficient practice placed R53 in immediate jeopardy. On 07/31/24 at 09:10 AM, Administrative Staff A and Consultant Staff SS were provided the Immediate Jeopardy (IJ) template for failure to provide R 53, a cognitively impaired resident who had a history of making comments about leaving, was identified as an elopement risk, and had anger issues regarding placement in the facility a safe environment from leaving the facility without staff knowledge. The immediate jeopardy was determined to first exist on 06/29/24 at 06:00 AM, when staff left R53 unsupervised, outside on a memory care unit and he climbed a fence, left the facility, and was located approximately two miles away. The facility identified and implemented the following corrective actions, completed on 07/02/24: 1. The Community Interdisciplinary Team completed a review of the community on 07/02/24 with four additional residents identified as being at risk for elopement and placed in wander guard alarms. 2. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting held by interdisciplinary team on 06/29/24. 3. The Administrator notified the Medical Director on 06/29/24. 4. Current clinical associates were re-educated by the Director of Nursing or designee before 07/02/24, or prior to working next scheduled shift on the Community Elopement policy and Community Elopement Evaluation process. Education included identification of at -risk residents, and courtyard oversight requirements. 5. Residents with a new risk for elopement or change in elopement risk will be reviewed by clinical interdisciplinary team during routine clinical huddle to verify elopement risk assessment accuracy, physician notification and preventative interventions in place as indicated. If discrepancies identified, immediate corrective action will be completed, and one on one education completed as indicated. 6. Residents identified with a change in elopement risk or who have had an actual elopement attempt will be reviewed during routine risk meeting by clinical interdisciplinary team. Review will be documented in the resident electronic medical record. 7. Routine elopement drills scheduled per community policy on varying shifts to confirm staff competency. 8. Findings of elopement drills are to be reported to the community Administrator and reviewed at the following morning meeting. If discrepancies are identified immediate correction will be completed and one on one education provided as indicated. Due to the corrective actions the facility completed prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 96 residents. The sample included 20 residents. Based on observation, interview, and record review, the facility failed to ensure the appropriate treatment and services to attain the highest practicable mental and psychosocial well-being of cognitively impaired Resident (R)53, who had a mental health disorder diagnoses, portrayed anger related to living in the facility, a history of exit seeking, and the facility staff did not respond to his suicidal ideation statements after his elopement (when a cognitively impaired resident leaves the facility without the knowledge or supervision of staff). On [DATE], R53 eloped from the facility. When staff returned R53 to the facility they placed a WanderGuard (a bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) on R53, and he reported he would never eat again. On [DATE] at 04:00 PM, R53 made statements such as give me a gun so I can shoot myself. At 10:00 PM, the resident reported he was being held against his wishes. On [DATE] at 11:30 AM, R53 reported he would not eat until someone came back to talk about him being discharged from the facility. An unidentified Staff told R53 it may be a while before someone could get to him as there are others in need of services. On [DATE] at 03:30 PM, staff found R53 had hung himself in his room with the TV cable on the closet door frame. This deficient practice placed R53 in immediate jeopardy. Findings included: - Review of the Electronic Health Record (EHR), documented R53 had diagnoses which included dementia (a progressive mental disorder characterized by failing memory and confusion) and bipolar (major mental illness that caused people to have episodes of severe high and low moods) and conduct disorder (a group of behavioral and emotional problems characterized by a disregard for others). The [DATE] Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderately impaired cognition. R53's total mood severity score of 00, indicated no depression. The MDS documented the resident did not have behaviors during the look back period. R53 was independent with all his activities of daily living (ADL). The [DATE] Behavioral Symptoms Care Area Assessment (CAA) documented R53 had episodes of agitation and anxiety and staff would proceed to care plan with continued monitoring and assistance as needed to avoid complications and minimize risks related to behaviors, with referral to physician and/or psychiatric services as needed. The [DATE] Quarterly MDS documented R53 had a BIMS score of nine, which indicated moderately impaired cognition. The MDS indicated no depression for the resident. R53 had become very anxious and agitated about why he was at the facility and when/why he could not go home for four to six days in the seven-day look-back period. R53 was independent with all his ADL. The [DATE] Care Plan documented an intervention, dated [DATE], indicating R53 was not allowed outside of the community, independently. Staff were instructed to provide redirection, diversion, and reorientation if R53 became restless, agitated, or exit seeking. The staff were to consult the physician if R53 was not easily redirected or had continued behaviors. The resident was an elopement risk/wanderer. R53 had an actual elopement from the facility. R53 had depression and anxiety and was on a daily psychotropic (alters mood or thought) medication for management, dated [DATE]. The staff would monitor, record, and report to physician as needed for harm to self, suicidal ideation's, or refusal to eat or take medications. Review of the Progress Note revealed on [DATE] at 06:03 PM, R53 was upset about having to wait to get help to get out of the facility. R53 stated he was going to go, one way or another. The [DATE] Nurse Practitioner Note documented R53 required long term care placement in a memory care unit due to high elopement risk. Furthermore, R53 was upset to still be living in a nursing facility and had daily aggression. Review of the Progress Note revealed on [DATE] at 01:42 PM, R53 stated if he did not get dismissed, he would sneak out the back door at night. The Progress Note on [DATE] revealed: At approximately 07:15 AM, staff could not locate R53. At approximately 08:30 AM, the staff located R53 approximately two miles away from the facility. At 09:00 AM, Emergency Medical Services (EMS) transported R53 to the hospital for psychological evaluation and medical clearance after his elopement. At 03:00 PM, R53 returned to facility from the hospital. The staff placed a WanderGuard bracelet to R53's right wrist and placed R53 on one-hour checks for the next 72 hours. The Progress Note on [DATE] revealed: At 01:28 PM, staff found R53 at his window and when asked what he was doing R53 questioned when am I getting out of here? The WanderGuard bracelet was not on R53's wrist, it was located behind the TV in R53's room. The staff notified Physician Extender TT, who instructed staff to give R53 space to calm down and reapproach the resident in a few hours. At 02:30 PM, R53 continued to be adamant about leaving the facility and the staff contacted Administrative Nurse D. At 03:30 PM, Administrative Nurse D instructed staff to send R53 to the hospital for evaluation, per provider order. At 04:00 PM, staff informed R53 that EMS was on route to transport him to a hospital. R53 continued to make comments such as give me a gun so I can shoot myself. Staff were instructed to keep watch on the agitated resident. At 04:30 PM, R53 left the facility with EMS. At 10:00 PM, R53 returned to facility, aggravated that he was back, and with one-on-one in place at that time. The Progress Note on [DATE] at 06:39 PM, revealed the staff continued with one-on-one monitoring for R53 and the resident was verbally aggressive toward staff. The [DATE] Physician Orders included an order for the Electronic WanderGuard bracelet (bracelet that sets off an alarm when residents wearing one attempt to exit the building without an escort) to be applied to R53, staff to validate the functioning every night shift. The Progress Note on [DATE] revealed: At 08:05 AM, Physician Extender TT updated on R53's continued aggressive behavior and refusal to take medications. Physician Extender TT recommended an inpatient psychiatric stay. At 08:25 AM, the facility nurse spoke to the hospital nurse, who suggested to send R53 to the hospital for evaluation. The Progress Note on [DATE] at 01:36 PM revealed the facility nurse spoke with the nurse at 11:00 AM and was informed R53 would be diverted to another hospital for admission to a Behavioral Health Unit (BHU). At 11:30 AM, EMS transported R53, who left willingly, however he stated, I will murder you if I have a reason too. The Progress Note on [DATE] at 05:20 PM, revealed R53 returned to facility, accompanied by EMS, with no new orders. The Progress Note on [DATE] at 11:30 AM, revealed R53 refused his lunch meal and stated he would not eat again until someone came back to talk to him about his dismissal. The staff advised R53 that it may be a while before someone could talk to him as there were others in need of services. R53 continued to stand at an exit door to watch staff enter the code to the door. The Progress Note on [DATE] at 02:37 PM, revealed staff noted a referral sent to a BHU at 11:15 AM due to increased behaviors. The BHU contacted the facility at 12:30 PM and informed them there were no beds available. The staff contacted a second behavioral unit and was informed there were no beds available. Staff sent a referral out to a third BHU at 02:41 PM, however, that unit staff stated the referral was not received and the referral was re-faxed. The Progress Note on [DATE] at 03:06 AM, revealed R53 continued one-on-one supervision. R53 remained in his room. The Progress Note on [DATE] at 10:02 AM, revealed the Administrative Nurse F assessed R53 for exit seeking behaviors. R53 was at baseline and staff would complete fifteen-minute checks for 24 hours. The Progress Note on [DATE] at 10:06 AM, revealed Administrative Nurse F assessed the resident and noted R53 continued at baseline and staff discontinued the fifteen-minute checks. Physician Extender TT's signed [DATE] Psychiatric Progress Note regarding the visit on [DATE] at 02:30 PM to 02:45 PM, documented R53 appeared disheveled, displayed irritable behavior, and had poor insight and impulse control. R53 remained focused on being released and became demanding and easily agitated. R53's conversation was tangential (different from or not directly connected with the one you are talking about) in nature, which further complicated the conversation and understanding R53's concerns. The staff reported R53's recent elopement and ongoing agitation and aggression. New order to increase on [DATE] at 12:45 PM, for R53's Quetiapine fumarate, 50 mg tablet to three times a day, for continued issues with mood and behavior. The Progress Note on [DATE] at 12:59 PM, noted R53 continued to ask for dismissal orders. The EHR lacked Progress Notes between the [DATE] at 12:59 PM and the [DATE] at 03:30 PM Progress Note. The Progress Note on [DATE] documented: At 03:30 PM, R53 was in his bed at 06:00 AM, with his eyes closed and breathing. At 08:00 AM, staff administered R53's medications and R53 asked staff when he was leaving. At approximately 11:30 AM, staff delivered lunch to R53 in his room. He asked how long he had been at the facility. At approximately 01:00 PM, R53 brought his lunch dish to the nurse's station. At approximately 03:30 PM, the staff found R53 hanging from his closet. The staff contacted the facility's management team. At 03:38 PM, Administrative Nurse D and Administrative Nurse F entered R53's room and found R53 hanging from the television cable on the closet door frame. The staff assisted R53 to the floor and began cardiopulmonary resuscitation (CPR- emergency lifesaving procedure performed when the heart stops beating). The staff called 911 and continued CPR. At 04:00 PM, EMS arrived and took over CPR. Social Service Designee contacted the guardian. At 04:05 PM, time of death was announced as EMS/Medical Coroner stopped all compressions per the guardian's request. Observation of the area, R53 would have presumably walked down was a residential area with a 35 miles per hour speed limit and R53 would have crossed 20 cross walks and crossed over two river bridges. Observation on [DATE] at 11:30 AM, revealed the memory care unit courtyard exit required a code to exit and enter. There was a six-foot wooden fence that surrounded the courtyard and attached to the building. There was a small alcove area that was near the exit door, not completely visible for staff to observe when they looked out the windows to the courtyard. During an interview on [DATE] at 11:38 AM, CNA Q reported R53 eloped in 2022, and she did not know when R53 had his WanderGuard removed after the elopement in 2022. CNA Q stated she had been educated previously to never let a resident outside by themselves in the courtyard. R53 had exit seeking behaviors as he would state he wanted to leave. CNA Q said the green patio chairs in the courtyard were removed after R53 eloped on [DATE]. She also confirmed she received education after R53 eloped in [DATE] and she received education about abuse, trauma, and suicide in July after the incident. During an interview on [DATE] at 02:26 PM, CNA MM stated R53 always asked him about being able to leave the facility. CNA MM stated that he received education about elopement, abuse, and trauma after R53 eloped on [DATE]. He also stated that R53 never made verbal comments of hurting himself and he had received training on suicide. During an interview on [DATE] at 02:26 PM, CNA NN stated R53 always asked about leaving the facility and wanted to live somewhere else. CNA NN stated he received education after R53 eloped, that included elopement, abuse, and trauma. He also stated that R53 never made verbal comments of hurting himself and he had received training on suicide. On [DATE] at 03:40 PM, Licensed Nurse (LN) I stated she could not locate R53 on [DATE] at approximately 07:15 AM and said CNA P last observed R53 in the courtyard. LN I stated she checked the sign-out book and confirmed R53 had not signed out of the facility. Staff could not locate R53 on the unit and contacted all staff on pager system and announced a Dr. [NAME] at approximately 07:30 AM. Administrative staff B located the resident at approximately 08:30 AM and brought him back to the facility. LN I confirmed R53 was very agitated about residing at the facility and his behaviors were almost daily. LN I was not sure if R53 had a previous elopement from the facility. LN I stated R53 was antsy and agitated and wanted to get out. She stated that R53 was placed on one-on-one observations 24 hours a day for about two weeks. LN I stated several staff members took turns with R53's one-on-one observation. LN I reviewed Physician Extender TT psychiatric progress note that was received on [DATE], however Physician Extender TT assessed R53 on [DATE]. LN I stated that Physician Extender would write new orders in the facility if needed and that waiting six days for new orders after a visit is not usual. LN I stated R53 was very agitated about being in the facility and never voiced any suicidal ideation's to her. LN I verified R53 had no progress notes charted in the EHR between the [DATE] at 12:59 PM progress note and the [DATE] at 03:30 PM progress note, when R53 was found hung in his room. LN I stated he was still wanting to leave but not as aggressive during that time period or a note would have been written, and stated the nurses' chart by exception. LN I also stated they do not chart notes on psych medications when changed, unless there was a concern. She stated the nurses would have to chart a lot on the residents, as psych medication changes occur often. LN I stated she had education for elopement, abuse, trauma, and suicidal ideation's signs and symptoms and to report concerns immediately to management. On [DATE] at 12:02 PM, LN G stated she was not at work the day R53 eloped from facility on [DATE]. She stated that she would not let a resident outside by themselves. LN G revealed that R53 was an exit seeker since the first day he admitted in December of 2022, and was not given a WanderGuard bracelet until after he eloped in December of 2022 shortly after he admitted to the facility. LN G could not recall when staff removed R53's WanderGuard bracelet. LN G stated that is not normal to receive new orders several days after a resident was seen by a provider. LN G stated that no progress notes were required after a medication change unless there was a concern. LN G stated she last saw R53 on [DATE] and he was his normal self. She confirmed that she received education after both incidents occurred, that included abuse, elopement, trauma, and suicidal ideation's and the facility had an elopement drill. On [DATE] at 03:00 PM, Administrative Nurse D stated that Physician Extender TT generally did not write orders in the facility when she assessed residents. Administrative Nurse D said Physician Extender TT would email to her all the signed progress notes with orders written on them if she wrote new orders. She stated it would take several days to receive the progress notes and orders back from Physician Extender TT and stated that was not acceptable. Administrative Nurse D confirmed that nurses generally charted when there was a concern. On [DATE] at 11:49 AM, Administrative Nurse F stated residents from the memory care units were not allowed to go outside in the courtyard or off the units independently. She stated R53 had always been an elopement risk and staff received education on abuse, elopement, suicidal ideation's and trauma. She stated that the facility tried to assist R53 to get admitted to a behavioral unit a few times and he would just be sent back from the hospital. The facility Suicide Threats policy dated ,d+[DATE] documented if a resident made a suicidal threat, stay with the resident and immediately notify the nurse. The nurse would assess the resident and notify the Director of Nursing or designee and medical provider to establish a plan of care. The resident's environment would be evaluated, and potentially dangerous items removed. The interdisciplinary team would review documentations and behaviors and revise the plan of care. The facility failed ensure the appropriate treatment and services to attain the highest practicable mental and psychosocial well-being to cognitively impaired, R53, with known mental illness and anger related to placement in the facility, when staff failed to respond to his suicidal ideation comments after he eloped from the facility on [DATE]. This deficient practice placed R53 in immediate jeopardy, and R53 hung himself with a cable cord from his closet door. On [DATE] at 09:10 AM, Administrative Staff A and Consultant Staff SS were provided the Immediate Jeopardy (IJ) template and notified the facility failed to prevent the neglect of cognitively impaired, R53, with known mental illness and anger related to placement in the facility, when staff failed to respond to his suicidal ideation comments after he eloped from the facility on [DATE]. This deficient practice placed R53 in immediate jeopardy, and R53 hung himself with a cable cord from his closet door on [DATE]. The immediate jeopardy was determined to first exist on [DATE] at 06:00 AM, when staff left R53 unsupervised, outside on a memory care unit and he climbed a fence, left the facility, and was located approximately two miles away. The facility identified and implemented the following corrective actions, completed on [DATE] after R53's suicide: 1. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting held by interdisciplinary team on [DATE]. 2. The Administrator notified the Medical Director on [DATE] at 09:00 AM. 3. The [NAME] President of Clinical Operations re-educated the Administrator and Director of Nursing on community process for recognizing signs and symptoms of suicidal on [DATE]. 4. The Corporate Director of Clinical Reimbursement educated the Administrator, Social Service staff, and Director of Nursing regarding the community process of the social service comprehensive assessment and trauma informed care assessment. Education included intended scheduled, psychosocial care planning of 5. Current associates will be re-educated by the community by the Administrator or designee on or before [DATE] or prior to working next scheduled shift on community. Trauma Informed Care process with specific focus on identification of suicidal symptoms and suicidal ideation, required notifications and immediate actions. 6. Social Service comprehensive assessments will be completed upon admission, annually and with significant change. Assessment will be documented in resident medical record. 7. Residents identified with need for trauma preventative services will have a trauma informed assessment completed upon admission, annually and with identified significant change in condition. Assessments will be documented in resident medical record. Care plan will be updated as indicated. 8. Routine angle rounds will be completed by assigned interdisciplinary team members routinely and will include staff members interviews to validate understanding of resident suicide awareness and notification requirements. Results of the angel rounds will be reported during routine morning stand up meetings. If discrepancies are identified immediate one on one educations will be completed with associate involved. 9. During weekly risk review meetings, the interdisciplinary team will review the clinical record of newly admitted residents or residents identified change in condition to validate completion of required social service assessments and or trauma informed care evaluations when indicated. The review will be documented in the resident medical record. 10. The Administrator or designee will routinely review sample selected residents for the next 60 days to validate compliance of the following: completion of the social service comprehensive assessment as appropriate, completion of trauma informed care assessment as appropriate, psychosocial care plan present when indicated that include resident specific interventions based upon assessment findings; any noted suicidal ideation as indicated. 11. Monthly review of completed weekly risk review and angle rounds results and trends will be completed by the Administrator or designee and reported to the QAPI committee for the next three months and then re-evaluate to determine if further monitoring is indicated. 12. Residents identified with a change in elopement risk or who have had an actual elopement attempt will be reviewed during routine risk meeting by clinical interdisciplinary team. Review will be documented in the resident electronic medical record. 13. Routine elopement drills scheduled per community policy on varying shifts to confirm staff competency. 14. Findings of elopement drills are to be reported to the community Administrator and reviewed at the following morning meeting. If discrepancies are identified immediate correction will be completed and one on one education provided as indicated. Due to the corrective actions the facility completed prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a J scope and severity.

The facility reported a census of 96 residents. Based on interview and record review, the facility failed to provide direct care staff annual evaluations/performance reviews for five of the five certified nursing assistants sampled, to determine strengths and weaknesses in providing resident care. Findings included: - Review of five Certified Nursing Assistant (CNA) personnel files revealed the following: Review of CNA UU, with hire date of 05/29/19, revealed the lack of an annual review. Review of CNA VV, with hire date of 11/09/21, revealed the lack of an annual review. Review of CNA S, with hire date of 01/12/22, revealed the lack of an annual review. Review of CNA PP, with hire date of 11/16/21, revealed the lack of an annual review. Review of CNA T, with hire date of 12/09/19, revealed the lack of an annual review. On 08/01/24 at 02:25 PM, Administrative staff B reported employee annual reviews should be completed by the Director of nursing. On 08/05/24 at 10:36 AM, Administrative Nurse D reported she thought the Administrator was to complete staff annual reviews. She was not aware that staff annual evaluation/reviews were not getting completed. The facility lacked a policy related to employee annual performance evaluations. The facility failed to provide direct care staff an annual evaluation to determine strengths and weaknesses.

The facility reported a census of 96 residents. Based on interview and record review, the facility failed to develop, implement, and maintain an in-service training program to ensure staff completed the required 12-hour in-service education for five of the five Certified Nurse Assistants (CNA) sampled, who were employed by the facility for at least one year. This deficient practice placed the residents at risk of decreased quality of care. Findings included: - Review of five Certified Nursing Assistant (CNA) personnel files and in-service training revealed the following: Review of CNA UU, with hire date of 05/29/19, lacked 12 hours of in-service education. Review of CNA VV, with hire date of 11/09/21, lacked 12 hours of in-service education. Review of CNA S, with hire date of 01/12/22, lacked 12 hours of in-service education. Review of CNA PP, with hire date of 11/16/21, lacked 12 hours of in-service education. Review of CNA T, with hire date of 12/09/19, lacked 12 hours of in-service education, as CNA T received 0.5 hour. On 08/05/24 at 10:36 AM, Administrative Nurse D reported she was aware staff did not have the required 12-hour in-services and it was a work in progress. The director of nurses was starting to monitor the training. On 08/05/24 at 11:24 AM, Licensed Nurse (LN) staff L reported there was a computer training for some, however LN L reported not all staff have a log in for the computer training. There is an occasional employee meeting to talk about concerns, or the in-service was a piece of paper that would have to be read and signed off. On 08/05/24 at 11:57 AM, Administrative staff A reported he was aware the computer training was not utilized as it was intended. The facility lacked a policy related to requirements of 12 in-service hours. The facility failed to develop, implement, and maintain an in-service training program to ensure staff completed the required 12-hour in-service education for five of the five Certified Nurse Assistants (CNA) sampled, who were employed by the facility for at least one year. This deficient practice placed the residents at risk of decreased quality of care.

The facility reported a census of 88 residents, with 11 residents included in the sample and one resident identified as at risk for elopement. Based on interview, observation, and record review the facility failed to provide adequate supervision to prevent an elopement for cognitively impaired, independently mobile Resident (R)1, who was at risk for elopement and had a prior history of elopement. R1 left the facility, without staff knowledge or supervision at approximately 03:45 PM on 07/27/23. R1 walked 0.8 miles, in 100 degrees Fahrenheit (F) temperature, on uneven roads with no sidewalks available, and speed limits in the residential area were 30 miles per hour. R1 was outside of the facility for approximately one hour and returned to the facility around 04:50 PM, after a residential neighbor alerted the facility of a potential resident outside. This deficient practice placed the resident in immediate jeopardy. Findings included: - The Physicians Order dated 06/27/23 revealed the resident had diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion) and anxiety (mental or emotional reaction characterized by apprehension uncertainty and irrational fear). The Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate impaired cognition. The resident had no behaviors of wandering during the look back period. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a (BIMS) score of 00, indicating severely impaired cognition, and the resident had no behaviors of wandering during the look back period. An Elopement assessment dated [DATE] indicated a desire to leave the facility, had wandering activity, and anger related to placement in the facility. An Elopement assessment dated [DATE] indicated resident as cognitively impaired and independently mobile and has a history of elopement and desire to leave the facility. The Care Plan, revision date of 07/28/23, revealed the resident was an elopement risk/wanderer with exit seeking behaviors, impaired memory function, poor decision-making skills poor safety awareness, and an noted the resident eloped on 07/28/21. The facility did not have a Wander Guard system (alerts the staff when the residents with dementia wander) but was in the process of installing one. The facility placed R1 on one-on-one supervision at all times until the Wander Guard system was installed. R1 had a behavior problem of being resistant to staff redirection when R1 made unsafe decisions and R1 could become agitated and aggressive with staff. The care plan noted R1 displayed exit seeking behavior and would attempt to open any exit door, at times. The Elopement Investigation dated 07/27/23 indicated the last time staff saw R1 in the facility was at 03:45 PM. At 04:20 PM, the facility received a call from a local community resident who noticed R1 walking past her house and R1 seemed confused. The local community resident had R1 come into her house for a drink of ice water and to use the bathroom. R1 had on slacks, blouse with sleeves, light jacket, and canvas shoes. The staff placed R1 on one-on-one supervision when R1 returned to the facility. The staff assessment revealed no injuries. Facility staff changed the door codes and implemented an in-service on elopement, completed on 07/27/23. Observation on 08/03/23 at 08:00 AM revealed the facility outside front entrance door was locked and required a code to enter, or for a visitor to press the doorbell button for staff to assist entering the building. Residents are able to follow visitors out the door. 08/03/23 at 04:45 PM an observation of the route R1 walked revealed no sidewalks available with uneven road. On 08/03/23 at 02:00 PM, an unidentified direct care staff aided R1 with ambulation in the hallways R1 walked slow no shuffle. On 08/07/23 at 10:30 AM, Certified Medication Aide (CMA) S direct care staff aided R1 with ambulation in the hallways R1 walked slow no shuffle. Interview on 08/03/23 at 03:00 PM with Certified Nurse Aide (CNA) M, revealed on the evening of 07/27/23 at approximately 03:45 PM, R1 ambulated towards the exit door. CNA M took R1's hand and walked with the resident towards the front of the facility, so CNA M could deliver menus for the evening meal. The front door was locked unless the code was entered, and CNA M was unaware the resident left the facility after that time. Interview on 08/03/23 at 04:00 PM, Maintenance Staff U reported when the resident returned to the facility on [DATE], the door codes were changed within 30 minutes after R1's return. Interview on 08/03/23 at 04:30 PM with CMA R reported since the resident had an elopement, the resident required one-on-one staff supervision. Interview on 08/03/23 at 02:55 PM, Administrative Nurse D stated the staff did a facility head count as soon as the phone call came in noting that R1 could be missing. The facility had an elopement book with pictures of each resident that were at elopement risk. The facility conducted an elopement in-service/staff education, which started on 07/27/23 at approximately 05:00 PM, and staff would not be able to work until they completed the elopement in-service. The facility's Resident Elopement policy, dated 02/2010, revealed all residents would be assessed for behaviors or conditions that put them at risk for elopement. All residents identified would have these issues addressed in their individual care plan, and all staff are responsible as part of the facility's preventative maintenance program, all door alarms would be checked for proper functioning on a weekly basis. The facility failed to provide adequate supervision to prevent an elopement for cognitively impaired, independent R1 who left the facility without staff knowledge at approximately 03:45 PM on 07/27/23. R1 walked 0.8 miles, in 100 degrees F temperature, on uneven roads with no sidewalks available, and was outside of the facility for approximately one hour (returned to the facility around 04:50 PM, after a residential neighbor alerted the facility of a potential resident outside, which placed R1 in immediate jeopardy. On 08/03/23 at 05:10 PM, the surveyor provided Administrative Staff A and Administrative Nurse D with the Immediate Jeopardy (IJ) Template and were informed the facility failed to provide adequate supervision to prevent the elopement and placed R1 in IJ. The facility identified and corrected the deficient practice on 07/27/23 after 5:00 PM incident when the facility implemented the following: 1. Staff re-education for elopement and all resident at risk completed on 07/27/23 at 5:00 PM. 2. All door codes changed on 07/27/23 at 5:30 PM. 3. R1 placed on one-on-one 07/27/23 at 6:00 PM until the facility installed a wander guard system. The surveyor verified the above implemented corrective actions while onsite on 08/03/23. The deficient practice was deemed past non-compliance due to the implemented corrective actions in completed prior to the surveyor entrance. The deficient practice existed at a J scope and severity.

The facility reported a census of 86 residents, the sample included two residents for medication administration. Based on observation, interview, and record review the facility failed to administer medication to one of two sampled residents per physician orders and failed to notify the physician of multiple refusals of the order sodium chloride and failure of the facility to have the ordered sodium chloride, three times per day. This omission caused a significant medication error for R1 after multiple doses of sodium chloride (electrolyte mineral essential to body function) was not administered three times a day and caused seizures (an emergent sign of low sodium) for R1, and hospitalization for hyponatremia (abnormally low concentration of sodium in the blood). This practice placed the resident in immediate jeopardy. Findings included: - R1's 03/28/23 signed Physician's Orders revealed a diagnosis of hyponatremia (a condition where your blood sodium is too low and can affect the fluid balance, blood pressure, nerves, and muscles). The 03/29/23 admitted Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The Care Plan lacked documentation regarding refusal of medication or monitoring for signs and symptoms related to hyponatremia. The Medication Order dated 03/23/23 instructed staff to administer sodium chloride 1 gram (GM), three times a day, to the resident. The Progress Notes dated 04/19/23 revealed R1 was found unresponsive, skin clammy with snoring, and without response to a deep chest rub. The staff sent the resident to the emergency room at 05:00 AM R1 had been admitted for alter mental status hyponatremia (low sodium level) The Progress Notes, dated 06/09/23, documented staff found R1 having seizure activity with agonal breathing (an abnormal pattern of breathing) and staff called emergency medical services who transported R1 to the hospital. The lab results indicated R1's sodium level was 116 milliequivalents per liter (mEq/L), with the normal range for sodium to be at 136-145 mEq/L. The Medication Administration Record (MAR) dated 04/01/23 to 04/30/23, revealed R1 refused the ordered sodium chloride 1 gram (GM), two times a day, for twelve days. The Progress Notes lacked documentation of notification to the physician regarding R1's refusals of the ordered sodium chloride from 04/01/23 to 04/30/23. The MAR dated 05/01/23 to 05/31/23, revealed R1 refused the sodium chloride 1 GM, two times a day, for 16 days and four days missed due to lack of the medication available from the pharmacy. The MAR dated 06/01/23 to 06/14/23, revealed R1 did not receive three doses of the sodium chloride, due to the medication not available from the pharmacy. Observation on 06/14/23 08:10 AM revealed R1 walking in the hallways, smiling at other residents and staff members. Interview on 06/15/23 at 08:15 AM, revealed Certified Medication Aide (CMA) M stated if a resident refused to take medication, CMA M notified the nurse. CMA M reported R1 said the sodium chloride tablet was too big to take, but it did not have a score on the tablet to cut it in half. CMA M said she attempted to get the residents to take their medication twice, then she contacted the nurse. Interview on 06/15/23 at 09:15 AM, revealed Administrative Nurse D expected the nurse to call the pharmacy for missing medication or if a resident refuses to take ordered medication they are to notify the physician . Interview with Physician GG on 06/14/23 at 03:26 PM, revealed Physician GG did not know R1 refused the medication until recently, and Physician GG would have changed the medication to a packet that is placed in liquids at meal times, if Physician GG knew sooner. The facility's policy dated 11/2019 Significant Condition Change & Notification purpose to ensure that the resident's family and or representative and medical practitioner are notified of resident's changes such as these listed below medication error, repeated refusals to take medication. The facility failed to notify the physician of R1's multiple refusals of sodium chloride and multiple times the facility did not have the sodium chloride to administer, which resulted in a significant medication error through omission, and R1 had seizures and hospitalization . This deficient practice placed the resident in immediate jeopardy. The facility provided an acceptable plan of removal on 06/16/23 at 04:43 PM. The plan included education to all Licensed Nurses and Certified Medication Aides on 06/15/23 and on 06/16/23, for medication refusal and physician notification. 1. All orders are to be followed. 2. Report any missed doses or refusal to the charge nurse. 3. Residents assessed, and physician notified of any ordered medication dose missed or refused. 4. Documentation of notification in point click care. 5. The 10 rights of medication administration should be followed when administering resident medication. On 06/19/23, the surveyor verified the implementation of the removal plan and the deficient practice remained at a G scope and severity after removal of the immediacy.

The facility had a census of 92 residents. The sample included 22 residents, with six reviewed for accidents. Based on observation, record review, and interview, the facility failed to prevent a fall for Resident (R) 35, who fell from her wheelchair due to non-functioning brakes, and obtained a femur fracture (broken thigh bone). The facility further failed to assess R33, who was a fall risk, for the use of side rails. This placed the residents at risk for injury. Findings included: - The Electronic Medical Record (EMR) documented R35 had diagnoses of hypertension (high blood pressure), dementia with behavioral disturbance (progressive mental disorder characterized by failing memory, confusion), glaucoma (abnormal condition of elevated pressure within an eye caused by obstruction to the outflow), unsteadiness on feet, and peripheral neuropathy (weakness and numbness in the hands and feet). The Quarterly Minimum Data Set (MDS), dated [DATE], documented R35 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of nine, and required supervision and set-up assistance of one staff for bed mobility, transfers, dressing, and did not ambulate. The MDS further documented R35 had unsteady balance, no functional impairment, and had no falls. R35's Significant Change MDS, dated [DATE], documented R35 had moderately impaired cognition with a BIMS of 10, and required extensive assistance of two staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS further documented R35 had unsteady balance, lower functional impairment on one side, and a recent fracture repair. The Fall Care Area Assessment (CAA), dated 10/28/22, documented R35 was alert with impaired memory function, poor decision-making skills and safety awareness, required assistance with daily care needs, transfers, mobility, and had a history of a fall with injury. The Fall Assessments, dated 05/28/22 and 10/28/22 documented a high risk for falls. The Fall Assessments, dated 08/27/22, documented a low risk for falls. The Fall Care Plan, dated 03/26/22, documented R35 needed gripper strips on the floor beside the bed and directed staff to ensure R35 had appropriate footwear on when ambulating and mobilizing in her wheelchair. The update, dated 10/17/22, directed staff to put gripper strips on the floor beside the bed. The update, dated 11/05/22 directed staff to install anti-rollbacks to R35's wheelchair, encourage participation in skilled rehabilitation services for mobility and safety, and place a sign in R35's room reminding her to ask for assistance when needing items close to the floor. The care plan further directed to monitor the wheelchair brakes routinely for effective use, and consult maintenance as indicated for the need of assessment or repair. The Fall Investigation, dated 10/16/22 at 10:30 AM, documented R35 was found on the floor in her room by housekeeping staff. The resident stated she transferred herself to the wheelchair, and it rolled backwards as the locks on the wheelchair were broken. The investigation further documented R35 stated she did not hit her head but fell on her knee. The investigation documented R35 could move all extremities, did not complain of pain, and was transferred back into bed. The Nurse's Notes, dated 10/16/22 at 06:26 PM, documented R35 had right knee pain and an order for an X-ray (image of internal structures) was obtained. The X-Ray Report, dated 10/16/22, documented R35 had a minimally displaced oblique (slanting) fracture through the distal femoral diaphysis (a femur fracture), and she was admitted to the hospital. The Nurse's Note, dated 10/19/22 at 04:30 PM, noted R35 readmitted back to the facility. The facility was unable to provide any documentation that staff checked the wheelchair brakes for functionality. On 12/08/22 at 10:35 AM, observation revealed R35 laid in her bed, Certified Nurse Aide (CNA) M and CNA N sat R35 up in her bed and R35 stated They don't do a good job at transferring me. CNA N took R35's legs and moved them off of the bed as R35 stated watch my right hip. Further observation revealed CNA M placed a gait belt around R35's waist and the resident stated, you've never put that on me before. Continued observation revealed CNA M placed her right arm under R35's right arm and CNA N placed her left arm under R35's left arm and started to transfer R35. R35 started to scream and reported that the staff were hurting her chest and it felt as though staff were ripping her chest off. CNA M and CNA N quickly placed the resident back on the bed and then the two staff grabbed the gait belt and the back of the resident's pants and quickly transferred her into the wheelchair. CNA M stated, I think she is putting on a show for you, she is being dramatic. On 12/08/22 at 10:35 AM, R35 stated she transferred herself into her wheelchair on 10/16/22. She thought the brakes were locked but they were broken. R35 said when she went to sit down, the wheelchair flipped and she fell out of it, and broke her leg. On 12/08/22 at 10:45 AM, CNA M stated R35 fell out of her wheelchair because the brakes were not working. On 12/08/22 at 03:30 PM, Administrative Nurse D stated wheelchair brakes were checked weekl y when the wheelchairs were cleaned on the night shift. Administrative Nurse D further stated there was no documentation from the night shift that the brakes were not functioning properly until after R35 fell . On 12/08/22 at 03:30 PM, Maintenance Staff Q stated the wheelchair brakes were repaired when R35 came back from the hospital. On 12/13/22 at 09:45 AM, Licensed Nurse (LN) J stated night shift staff cleaned wheelchairs at night and checked to make sure the wheelchair brakes and foot pedal on the wheelchair were working properly; if there were concerns that the brakes may be broken, a report was made for maintenance to work on the wheelchair. On 12/13/22 at 01:16 PM, Administrative Nurse D stated she expected staff to check the wheelchairs for proper functioning when they were being cleaned and if there were problems, staff should have made a report sheet out, gave it to her, and she would report it to maintenance. On 12/13/22 at 03:24 PM, Consultant KK stated he expected the facility to check wheelchair brakes for proper functioning and further stated he assumed there was a schedule for the wheelchairs to be checked and any maintenance completed for wheelchairs in the facility. Consultant KK further stated if staff were supposed to be checking wheelchairs during cleaning, that should have been done. The facility's Fall policy, dated 09/17/22, documented the fall management program was to develop, implement, monitor and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life. The fall management program promoted safety, prevention, and education of both staff and residents. The facility shall ensure that a fall management program would be maintained to reduce the incidence of falls and risks and injury to the resident and promote independence and safety. The facility did not provide a policy for wheelchair maintenance. The facility failed to ensure R35's wheelchair brakes were properly functioning which caused a fall. As a result of the fall, R35 sustained a femur fracture. 25671 - The Physician Order Sheet, dated 12/02/22, recorded R33 had diagnoses of alcohol induced dementia (persistent mental disorder marked by memory loss and impair reasoning), major depressive disorder (mental illness characterized by depressed mood and significant loss of interest in life activities), insomnia (problems falling and/or staying asleep), and muscle weakness The Quarterly Minimum Data Set (MDS), dated [DATE], recorded R33 had a Brief Interview for Mental Status (BIMS) score of three (severely impaired cognition) with inattention and disorganized thinking. The MDS recorded R33 was independent with bed mobility and transfers, had impaired balance, and received antipsychotic (medication used to treat severe mental illness), antidepression (medication used to treat mood changes), antianxiety (medication used to treat agitation and restlessness) and opioid (narcotic medication used to treat moderate to severe pain) medications seven days a week. The Accident and Fall Care Plan, dated 10/20/22, recorded R33 was assessed a high risk for falls due to impaired cognition, poor safety awareness, incontinence, and a history of falls. The Accident and Fall Care Plan recorded R33 had trouble sleeping, had poor impulse control, and required staff supervision and assistance with decision making. R33's Accident and Fall Care Plan lacked documentation for the use of side rails. The Fall Risk Assessment, dated 10/17/22, recorded R33 was a high risk for falls due to cognitive impairment, limited mobility, use of assistive devices and history of falls. Review of R33's medical record lacked documentation the facility completed evaluation for the appropriate and safe use of side rails. On 12/07/22 at 03:34 PM, observation revealed R33 sat on the bed watching TV, and the upper side rails were raised on both sides of the bed. Continued observation revealed R33 could pass her extremities through the gaps in the side rails. On 12/08/22 at 01:12 PM, Certified Nurse Aide (CNA) Q stated R33 had trouble sleeping, frequently transferred out of bed without staff assistance and was a fall risk. On 12/12/22 at 11:06 AM, Licensed Nurse (LN) G stated R33 was a fall risk due to cognitive impairment, poor balance and impulsive behaviors, and the resident should not have the side rails raised on her bed. LN G stated R33 spent most of her time in bed, had trouble sleeping and frequently transferred herself out of bed. LN G stated she was not aware of a side rail assessment to evaluate R33's safe use of side rails. On 12/13/22 at 09:47 AM, Administrative Nurse D stated staff should complete an assessment to evaluate R33's safe use of side rails related to the resident's history of falls and the side rails had gaps that could entrap the resident. The facility's Side Rail policy, dated October 2022, directed staff to complete routine side rail assessments to ensure the resident's need, appropriateness, and safety for the use of side rails. The facility implemented side rails for R33 without a safety assessment or accident hazard care plan, placing the resident at risk for entrapment and falls.

The facility reported a census of 94 residents. The sample included six with three residents reviewed for neglect. Based on observation, interview, and record review the facility failed to ensure the safety of Resident (R1), who admitted to the facility with a self-care deficit, signed himself out of the facility on 09/11/22 at 01:30 PM, and failed to document an anticipated return time. R1 did not return to the facility on [DATE] and the facility staff did not begin to search for R1 until around 09:45 PM, eight hours and 15 minutes later. Administrative Nurse D did not notify law enforcement until 09/12/22 at 11:34 AM (22 hours and four minutes after R1 signed out), to file a missing person report. R1 was to be supervised while outside of the facility, if leaving the facility, and was known to sign himself out prior, with staff knowledge of R1 obtaining/consuming alcohol, against physician's orders. On 09/12/22 at approximately 03:00 PM (25 and a half hours after signing out), Licensed Nurse (LN) G observed R1 seated in his nonfunctioning motorized wheelchair, due to a depleted battery, on the sidewalk with wheels wedged between the edge of the sidewalk and the grass. The resident was located near a four lane, heavily trafficked area of Meridian and Kellogg, approximately 2.5 miles from the facility, with speed limits of 40-60 miles per hour, respectively. Staff observed R1 with noted odor, as he had defecated/urinated in his pants, which were lowered down on his body. The staff member notified the facility she located R1 and she called 911 to have R1 transported to the Emergency Department (ED) for evaluation and treatment by Emergency Medical Services (EMS). These cumulative failures placed R1 in immediate jeopardy. Findings included: - R1's 08/02/22 signed Physician Order Sheet (POS), documented the facility admitted the resident on 02/18/22, with the following diagnoses: spinal stenosis ([CONDITION(S)] condition of the spine that could cause weakness and loss of use of extremities), cervical region (pertaining to the neck), chronic pain (persistent or intermittent pain), muscle weakness (lack of muscle strength), difficulty in walking (difficulty with balance and unsteady), [CONDITION(S)] (inability to sleep), major depressive disorder (major mood disorder), history of tobacco (smoking), and alcohol abuse. The 02/25/22 Admission Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. He required two-person extensive assistance with transfers and one-person supervision with locomotion on and off of the unit. The resident was not steady and was only able to stabilize with staff assistance. The resident used a motorized wheelchair for mobility. The 02/28/22 Cognitive Loss/Dementia Care Area Assessment (CAA) documented the resident had short/long-term memory loss. The resident had pain related to spinal stenosis and was at risk for isolation, depression, and further cognitive decline. The resident required assistance from staff to make safe, rational decisions. The 02/28/22 Urinary Incontinence and Indwelling Catheter CAA documented the resident required total assistance with toileting needs and was frequently incontinent. The 02/28/22 Falls CAA revealed R1required one to two-person assistance with transfers, was only able to stabilize with staff assistance, and had weakness and pain in the back and lower extremities. The 07/04/22 Quarterly MDS documented the resident had a BIMS score of 13, which indicated intact cognition. The resident required supervision with transfers and toilet use, ambulation, and locomotion. The resident was not steady, but able to stabilize without staff assistance. R1 utilized a motorized wheelchair and was continent of bowel and bladder. The resident's Wish to Return to Community or Rescue Mission Care Plan, dated 07/01/22, included interventions that the resident was his own person and could make his own decisions. R1 could sign himself out of the facility and was required to have supervision and someone to assist with making safe decisions. Revision on 09/21/22, instructed staff that the resident could sign himself out of the facility in his motorized wheelchair with someone who was cognitively able to keep him away from hazardous conditions in the community. The resident's Fall Care Plan, dated 02/28/22, instructed staff to assess the resident's clothing for proper fit, to not leave the resident in the bathroom unattended, ensure the resident's personal items were within reach, and that R1 wore gripper socks. Revision on 03/09/22, reminded staff to ensure R1's call light was in reach and encourage him to use the call light for assistant as needed. The care plan further instructed staff to not leave the resident alone in his room in the wheelchair, offer to bring him to the nurse's station or transfer to his bed, and ensure the resident wore appropriate footwear such as non-skid socks or shoes when ambulating or mobilizing in wheelchair. The resident's Activities of Daily Living Care Performance Deficit Care Plan dated 05/02/22, included the resident could reposition himself in his bed and wheelchair. The resident required one-staff assistance with toileting. The Physician Order dated 08/02/22, instructed staff that the resident may not have alcohol, may not go out on Leave of Absence (LOA). The Health Status Note dated 09/11/22 at 01:30 PM revealed R1 signed out of the facility. The Behavior Note dated 09/11/22 at 10:30 PM, LN H documented that R1 left the facility before the 02:00 PM to 10:00 PM shift started, and R1 had not returned to the facility at this time. At approximately 09:45 PM, Certified Nurse Aide (CNA) N and CNA O drove to the near-by places R1 may have gone, to search for him. The staff members were unable to locate the resident. At 10:10 PM another group of staff went looking for R1. Review of the Health Status Note on 09/12/22 at 11:34 AM, revealed Administrative Nurse D documented the resident signed himself out of the building on 09/11/22 in the afternoon. The resident did not return at 10:00 PM. The staff were at break and looked for the resident at his usual places and he was not seen. The jail and hospitals were called, and the nurse was advised the resident was not at either of the facilities. The Medical Director and APRN were notified and they would watch for the resident at hospitals. The nurse writer called Law Enforcement and filed a missing person report. Review of a Social Services Note dated 09/12/22 at 03:49 PM, documented off-duty Licensed Nurse (LN) G called the facility to advise staff she was pulling up to her house when she saw the resident outside her window. The nurse then called the facility and informed them the resident was seen and needed assistance. EMS subsequently called the facility to report the resident was in their care. The Director of Nursing (DON) advised and recommended sending the patient to the Emergency Department (ED) for evaluation as he had been signed out of the facility for over 24 hours. Review of Health Status Note on 09/13/22 at 08:55 AM LN I documented the resident returned from acute hospital. The resident was educated that he would not be able to check himself out. The resident agreed and stated he would not try and leave. Review of the Health Status Note on 09/14/22 at 12:51 PM Administrative Nurse D and Social Services (SS) X presented to the resident's room to inquire about his wishes as a resident here. The resident was asked if he would like to stay here as a resident or find a safe place to discharge to. Resident replied, it's cold outside and my body will shut down. When asked if he wanted to stay here, he replied with I guess, for now. Administrative Nurse D advised resident that he would not be able to sign out on his own recognizance and if he wished to do this without a safe discharge plan, he would be discharged AMA. The resident voiced understanding and agreed to the terms. Administrative Nurse D and SS X left room without incident. Observation on 09/21/22 at 09:11 AM revealed the resident appropriately and safely utilized his motorized wheelchair in the hallways, stopping to visit with staff members. On 09/21/22 at 10:48 AM Administrative Nurse D reported she did not know what date R1 was able to sign himself out without supervision. She stated R1 signed himself out on 09/11/22 at 01:30 PM and the records did not reflect when he would return. Administrative Nurse D revealed on 09/12/22, she saw a text from Administrative Nurse E, which read R1 signed himself out around 02:00 PM and was still not back at the facility. Administrative Nurse D expressed concern that on 09/11/22 during 02:00 to 10:00 PM shift, the staff failed to contact her and Administrative Staff A by phone due to the incident. She reported upon arrival to work at 06:30 AM she emailed (the company office) of the situation, called the jail and ED's of area Hospitals, and was unable to find R1. On 09/13/22 at 11:34 AM, she reported the local Law Enforcement Agency was notified to complete a missing person report. Administrative Nurse D stated she received a phone call from off duty LN G on 09/12/22 at 02:49 PM who revealed R1 was near Meridian St. and Kellogg (54 and 400 highways) in his wheelchair between the sidewalk and the grass. Administrative Nurse D advised LN G called 911 to have Emergency Medical Service (EMS) transport R1 to the Hospital for an evaluation. She further stated R1 did have a cell phone, however she was unsure if staff attempted to call his cell phone. Administrative Nurse D reported she received a return call from the Corporate Office due to R1 being his own person and with a BIMS of 13 and was told the facility could not force the resident to stay in the facility. If he became agitated and wanted the motorized wheelchair outside, per therapy, R1 was to have supervision while in the motorized wheelchair. On 09/21/22 at 11:24 AM LN G reported she was near Meridian St. and Kellogg driving in her personal vehicle. She reported she observed R1 in his motorized wheelchair on the sidewalk with the wheels stuck between the sidewalk and the grass. LN G stated she notified Administrative Nurse D and was instructed to call 911 for EMS to transport the resident to the hospital. LN G revealed R1 had his pants down to his mid-thigh and had soiled himself. She revealed R1 stated he had fallen out of his wheelchair, but did not indicate how he was able to get back in. LN G stated the wheelchair and the resident's personal cell phone was covered in feces. LN G reported she stayed with R1 until EMS arrived and R1 was transported to the hospital. LN G reported R1 was the approximately 2.5 miles from the facility. On 09/21/22 at 11:47 AM R1 reported that he signed himself out around 1:30-2:00 PM and drove his motorized wheelchair to the convenient store that was four blocks from the facility. He further reported it was a nice day, so he continued to drive around. R1 reported as it began to become dark, he hit a crevasse and he was ejected from his motorized wheelchair. R1 reported two people were jogging and helped him back in his motorized wheelchair. R1 revealed he had a bowel movement in his pants, was embarrassed, and did not want to be around anyone. On 09/21/22 at 01:35 PM Hospital Emergency Department Licensed Nurse (EDLN) LL reported the resident was granted permission to leave the facility. R1 was with friends, it became dark, and he could not find his way back to the facility. EDLN LL called the Administrative Nurse D, who notified the ED and asked the ED to hold R1 until SS X could talk to him regarding the Sign Out Policy. and stated the facility refused to take him back, because he left Against Medical Advice (AMA). EDLN LL expressed her concerns with Administrative Nurse D and noted that R1 did not leave AMA, he wanted to return to the facility. EDLN LL expressed concerns with dumping the resident at the hospital, and said Administrative Nurse D hung up on her. R1 stayed in the ED until the facility decided to allow R1 to return to the facility on [DATE]. On 09/21/22 at 02:25 PM Certified Nurse Aide (CNA) M reported R1 did not know the code to exit the building and said R1 could not leave the facility without staff supervision. He required one-person assistance with most of his Activities of Daily Living (ADLs) and utilized a motorized wheelchair. On 09/21/22 at 05:11 PM the surveyor traveled distances from the facility to the location in which staff found the resident and it measured 3.0 miles. 0n 09/21/22 at 07:15 PM Consultant MM explained that R1 arrived at the ED by EMS on 09/12/22 at 02:00 PM and he was covered in feces, with minor skin breakdown on the right hip due to the feces. The facility refused to readmit R1 until SS X talked with the resident, and he agreed to not leave the facility again. When Consultant MM came to work on 09/13/22, R1 was still in the ED at 07:30 AM. On 09/22/22 at 08:58 AM Administrative Staff B reported they followed the facility's Sign Out and Sign In Policy, however it was not clear what needed to be done if the resident did not return. She revealed if R1 wanted to sign out and leave the facility grounds to go to the store, she would direct him to Administrative Staff A. She revealed on 09/11/22 R1 signed out of the facility at 01:30 PM and did not enter a time he planned to return to the facility. Administrative Staff B reported on 09/11/22 two staff members attempted to locate R1 but did not notify her to report if they had found him or not. The facility Sign In Sign Out Policy, Revised 01/2017, documented it was the policy that all residents and visitors would use the Sign Out Sign In Log when leaving the facility. The log included: resident's name, person name accompanying the resident if the resident was not taking self out, date and time leaving, and the date and time of anticipated return. The policy documented if the resident left unaccompanied, and did not return at the anticipated return time, the facility would follow process until the resident returned. The policy noted the staff would notify the Administrator, DON, resident representative, health care provider, local ER, and local law enforcement. The policy did not address staff processes in instances when a resident did not leave an anticipated return time. The facility failed to ensure the safety of Resident (R1), who admitted to the facility with a self-care deficit, signed himself out of the facility on 09/11/22 at 01:30 PM, and failed to document an anticipated return time. R1 did not return to the facility on [DATE] and the facility staff did not begin to search for R1 until around 09:45 PM, eight -hours and 15 minutes later. Administrative Nurse D did not notify law enforcement until 09/12/22 at 11:34 AM (22 hours and four minutes after R1 signed out), to file a missing person report. R1 was to be supervised while outside of the facility, if leaving the facility, and was known to sign himself out prior, with staff knowledge of R1 obtaining/consuming alcohol, against physician's orders. On 09/12/22 at approximately 03:00 PM (25 and a half hours after signing out), Licensed Nurse (LN) G observed R1 seated in his nonfunctioning motorized wheelchair, due to a depleted battery, on the sidewalk with wheels wedged between the edge of the sidewalk and the grass. The resident was located near a four lane, heavily trafficked area of Meridian and Kellogg, approximately 2.5 miles from the facility, with speed limits of 40-60 miles per hour, respectively. Staff observed R1 with noted odor, as he had defecated/urinated in his pants, which were lowered down on his body. The staff member notified the facility she located R1 and she called 911 to have R1 transported to the Emergency Department (ED) for evaluation and treatment by Emergency Medical Services (EMS). These cumulative failures placed R1 in immediate jeopardy. The facility provided an acceptable plan of removal of the immediately jeopardy on 09/26/22 at 02:00 PM. The plan included the following: 1. On 09/26/22 at 11:25 AM the facility began educating staff on the revised Sign In Sign Out policy, and education continued with staff through 02:00 PM. All staff would be educated on the updated policy prior to working. 2. The revised facility Sign In Sign Out policy, included if there was inclement weather (rain, snow, and extreme weather), the facility staff would educate the resident on the risk of exposure and encourage the resident to wait until the weather was favorable. If no anticipated returned date and time is documented on the log, after four hours, the facility would initiate notifying the Administrator and Director of Nursing, contact the location the resident was going, contact resident's representative, notify the health care provider, contact local emergency departments, and notify local law enforcement within one hour. The survey team verified onsite the facility implemented the IJ removal plan on 09/28/22 at 12:48 PM, therefore at that time, the IJ was lowered to a scope/severity level of G.

The facility census totaled 83 residents, with three sampled for elopement risk and six residents at risk for elopement. Based on observation, interview, and record review the facility failed to provide sufficient supervision to Resident (R) 1 to prevent an elopement. On 09/16/21 between 08:30 PM and 10:00PM R1 exited the facility via an unalarmed exit door and walked approximately a mile to a convenience store. He was outside the facility for approximately one and a half hours when the staff noticed the resident was not in the building. He was outside of the facility for a total of approximately five and a half hours. The resident walked past several residential blocks and down a busy, highly traveled 4 lane road with speeds of 30 to 40 miles per hour (mph), and across major intersections, within 0.2 miles of a railroad track and construction zone, and within a mile a major waterway. These failures placed R1 in immediate jeopardy. Findings included: - Resident (R) 1's pertinent diagnosis from the Physician's Orders in the electronic medical record (EMR) dated 09/09/21 revealed [CONDITION(S)] (a [CONDITION(S)] characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The 09/16/21 Admission Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) of 14, indicating intact cognition. He exhibited delusions (an untrue persistent belief or perception held by a person although evidence shows it was untrue), wandering noted one to three days of review period which placed him at significant risk of getting into a potentially dangerous place. He was independent with transfers/walking and his gait (manner or style of walking) was steady at all times. The 09/16/21 Cognitive Care Area Assessment (CAA) revealed R1 exhibited a short attention span and focused on one thing such as smoking. R1 was a new admit and wandered one time in the last seven days. He was easily redirected and needed a lot of cueing and reminders. The 09/16/21 Activities of Daily Living (ADL) CAA revealed the resident ambulated independently and required assistance in making safe rational decisions in Long-Term Care. The 09/16/21 Behavioral CAA revealed R1 wandered one day in the review period and had behaviors of getting fixated on one thing, repeating the same question or questions, such as with smoking. The 09/16/21 Falls CAA revealed he ambulated independently on smooth and uneven surfaces, able to step up and off curbs, and climb stairs. The 09/11/21 Comprehensive Care Plan revealed the resident was independent with his ADLs. He exhibited poor impulse control and moods problems due to his [CONDITION(S)] diagnosis. A revision dated 09/17/21 revealed R1 was an elopement risk/wanderer as evidenced by the fact he left the building unsupervised. Staff were to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. He exhibited poor impulse control and poor decision making. The 09/10/21 Physician Orders revealed R1 may go on leave of absence (LOA) from the facility with an escort. The 09/09/21 Nursing Admission/Readmission Data Collection revealed the resident came from the Mental Health Association for LTC care due to [CONDITION(S)]. The resident was independent with ADLs, had no skin issues, and was alert with clear speech. Elopement Assessments completed on 09/09/21 determined the resident was not at risk. An assessment on 09/17/21 described wandering activity, mental illness, anger related to placement, appearance of a t visitor which placed the resident at risk for elopement. Intervention of frequent visual monitoring placed. The 09/13/21 at 08:14 PM Orders/Administration Note revealed R1 appeared more agitated, antsy, spoke loudly at times, and was disruptive of others. The 09/15/21 at 02:06 PM Orders/Administration Note revealed R1 repeatedly exited the isolation area, repeatedly asked staff about cigarettes several times within a 15-minute period. The 09/17/21 at 01:38 AM Alert Note revealed the resident left the facility and during shift change Certified Nurse Aide (CNA) N noticed the resident was missing from the unit. Staff searched the entire building, building perimeter, and surrounding streets immediately, but was unable to locate the resident. Staff notified administration, the physician, and completed a head count of the facility residents. Staff called 911 at 11:45 PM and the police arrived at 12:40 AM to complete a report to attempt to locate the resident. The 09/17/21 at 03:03 AM Alert Note revealed at 02:09 AM, the police brought R1 back to the facility. The police found R1 at a convenience store. Licensed Nurse (LN) F completed a skin and injury assessment with no injuries found, completed vital signs, noted a blood pressure of 109/78 millimeters of mercury (mmHg), a pulse of 112 beats per minute, a respiratory rate of 16 breaths per minute (bpm), a temperature 97.1 degrees Fahrenheit, and an oxygen saturation of 94% on room air. Staff completed an elopement investigation report. An undated Elopement Investigation Worksheet revealed R1 had no history of elopement attempts since admission on 09/09/21 and was not a risk for elopement. He had a diagnosis of [CONDITION(S)] and ambulated independently. He eloped on 09/16/21 from his room and was missing during rounds at 10:00 PM. He was last seen at 08:30 PM by CNA D. R1 exited out of the 200-hall through an alarmed exit door that had been unalarmed/unlocked intentionally. Staff completed a resident count and search. LN F notified the police. The 09/17/21 Notarized Statement from CNA H and CNA O revealed they last saw R1 at 03:55 PM on 09/16/21 when he asked to smoke and at 04:30 PM on 09/16/21 when he went to smoke. The 09/17/21 Notarized Statement from CNA D revealed that at approximately 10:00 PM, CNA N indicated R1 was missing to CNA D, who last saw the resident at 08:30 PM smoking by the exit door at the end of the 200-hall. CNA N reported this to LN F, and staff searched for the resident. The 09/16/21 Notarized Statement from CNA N revealed she clocked in for work at 09:49 PM and went on rounds, but she did not see R1 in his room. She reported this to LN F. She then searched the 100-hall and 300-hall while the nurse notified administration and police. R1 returned to the facility with the police at 02:11 AM. Observation of R1 on 09/21/21 at 11:12 AM revealed the resident seated in his room located within the COVID/isolation area hall, dressed appropriately with shoes on, and packed travel bags were on the floor beside him. He fidgeted with the bags and repositioned himself in the chair frequently. There were no staff in the isolation area and the isolation entrance doors obscured a visual of the resident from nurses' station. Interview with R1 on 09/21/21 at 11:15 AM revealed his bags were packed because he was moving to another room today but did not know when he would move. He left the faciity on either Wednesday or Thursday of last week at 04:30PM/05:00PM. His room on the 200-hall was for isolation since he was a newer resident. He was let out the 200-hall exit door by a staff member at approximately 04:30 PM/05:00PM. He did not know her name. He was outside for a while and then noticed the staff member leave for the day. He then stated, he could not get back in the facility without knocking on the door, and since he ran out of cigarettes, he decided to go to a convenience store to get a drink and to buy some cigarettes. He had problems walking, and his feet hurt, so he sat down to rest for a few hours at the table and chairs in front of the convenience store because he did not know what to do or who to call. He wore long pants, tennis shoes, and a short sleeve shirt. After a few hours, police walked up to him and asked if he was R1 and told him the facility was looking for him. No staff at the facility told him he could not leave, and he did not know that he had to sign out of the facility when leaving or let someone know where he was going. After the incident, staff told him he had to sign out, but have not allowed him to sign out since the incident. His diagnosis included [CONDITION(S)] and he took his medications when they were given to him, but he had not received his [CONDITION(S)] medications for a few days after his admission to the facility on [DATE]. He also stated, he was from this city, not this area, and he knew there would be a convenience store around the facility somewhere. He did not have any falls or injuries and used the sidewalks and crossings. Interview with CNA D on 09/21/21 at 12:30 PM revealed the incident happened last Thursday. He worked from 06:00 AM to 10:00 PM that day on R1's hall. He last saw R1 at 08:30 PM out by the COVID/isolation hall exit door, a staff member was with him, but he was unsure who, and the exit door was left open. He went to lunch after that and 30 minutes later he came back to the floor and checked the residents in the 100-hall and helped CNA H on the 300-hall with resident cares and gathering trash. Then at approximately 10:00 PM, CNA N arrived for work in the isolation unit and asked LN F and CNA D where R1 was located. CNA D told her R1 was in his room and what hall, to which she responded that he could not be found there. CNA D and N went to R1's room, then searched all the resident rooms, and notified LN F that R1 could not be found. Staff then went outside the facility, walked the perimeter and drove nearby streets, but could not find him, and reported to LN F. LN F made notifications. We check on him often to make sure this does not occur again. Interview with CMA E on 09/21/21 at 02:06 PM revealed he worked his first shift at the facility on 09/16/21 from 02:00 PM to 10:00 PM on R1's hall. When he arrived at 02:00 PM for his shift, he saw a resident outside by the isolation unit exit door standing outside with the door wide open, but he did not see a staff member with the resident. He saw R1 outside of the open isolation unit exit door again without a staff member at an unknown time. The nurses sit at the nurse's station but could not see R1 in the hallway due to the isolation doors were shut to the hallway. R1 walked out of the COVID/isolation hall doors into the common area and walked toward the dining hall common area. CMA E did not see R1 after that, and around 10:00 PM staff were saying he was missing. Interview with LN F on 09/21/21 at 01:10 PM revealed he worked a shift at the facility from 04:00 PM on 09/16/21 until 09/17/21 at 07:00 AM. When he arrived, he checked on the residents in the isolation unit at approximately 04:20 PM and R1 was in his room. At approximately 07:00 PM, LN F allowed R1 to smoke in the smoking area, and he returned to his room at approximately 07:05 PM. That was the last time he saw R1 that night. Then, at approximately 10:30 PM, CNA N notified him that R1 was missing. Staff immediately searched all the hallways, the perimeter of the facility, and one staff member drove the nearby streets looking for R1. He then notified administration, the on-call staff, physician and the police at approximately 11:00 PM. Staff continued the search until the police brought R1 back to the facility at approximately 02:00 AM. LN F assessed R1, he had no injuries, his vital signs were within normal limits, and documented the incident. He stated, R1 wore pants, a shirt, a jacket, and running/tennis shoes. The incident happened in the evening, so the temperature outside was 70 degrees or so. Interview with Administrative Staff C on 09/21/12 at 11:34 PM revealed R1 was not safe to sign himself out of the facility to go to a convenience store. Interview with Social Services Director G on 09/21/21 at 12:16 PM revealed she completed R1's admission to the facility on [DATE] and did not educate R1 on the process to sign himself out and leave the facility because with COVID regulations the facility had not allowed any resident to sign out unless necessary for an appointment. She stated, the facility had a sign out book, but it was not in use currently. Interview with Administrative Nurse B on 09/21/21 at 11:36 AM revealed R1 arrived at the facility on 09/09/21, and staff completed the elopement assessment and determined he was not at risk for elopement. R1 was responsible for himself and could sign himself out of the facility. He was not told about the sign out process at the time of admission. Staff made notifications and contacted the police around 11:45 PM. R1 was out of the building for approximately 4 to 5 hours until the police found him at the convenience store approximately a mile from the facility. LN F assessed the resident and found no injuries, vital signs within normal limits, his demeanor was appropriate. Interview with Administrative Staff A on 09/21/21 at 11:36 AM revealed the facility assessed the resident's cognition when deciding if the resident was able to sign themselves out of the facility. Any self-responsible, cognitively intact resident could sign themselves out and into the facility. The COVID/isolation hall doors were closed and the exit door to the outside was intentionally unalarmed/unlocked so staff could get in to work the unit. On 09/16/21 in the late evening, CNA D reported he last saw the resident around 08:30 PM. R1 told Administrative Staff A that between approximately 08:30 PM and 10:00 PM he went outside to get fresh air because he had seen staff members leave through this door at the north end of the hallway, and then decided to go to the convenience store. Shift change at 10:00 PM was when staff were alerted to R1's absence and noticed R1 was not in his room. Staff searched the facility, the facility perimeter, drove around the surrounding area, but were unable to locate him. The temperature outside at the approximate time he left the facility was approximately 76 degrees Fahrenheit and upon return at approximately 02:00 AM was 73 degrees Fahrenheit. Administrative Staff A stated, the root causes of the incident as of right now were that the COVID/isolation hall alarmed exit door was left intentionally unalarmed/unlocked for staff entrance, R1 was not educated on the sign-out processes, and staff monitoring for residents in this hallway. Review of 01/2017 Elopement Policy revealed all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for elopement. For the purpose of this policy, missing resident shall be defined to mean a resident who has left the facility grounds without signing him/herself out of the facility. At no time shall a door alarm be turned off without the continual supervision of the exit. The facility failed to provide sufficient supervision for R1 to prevent an elopement on 09/16/21 when R1 exited the facility via an un-alarmed exit door and walked approximately a mile to a convenience store. He was outside the facility for approximately one and a half hours, when the staff noticed the resident was not in the building. He was outside of the facility for a total of approximately five and a half hours. The resident walked past several residential blocks and down a busy, highly traveled 4 lane road with speeds of 30 to 40 mph, and across major intersections, within 0.2 miles of a railroad track and construction zone, and within a mile a major waterway. These failures placed R1 in immediate jeopardy. The facility identified and corrected the deficient practice on 09/17/20 when the facility implemented the following: 1. Maintenance re-alarmed the exit door on 09/17/21 and completed a check for functionality on 09/17/21 and 09/20/21. 2. The facility educated staff on elopement and completed training on 09/17/21. Due to the facility's actions to identify and correct the deficient practice on 09/17/21, it was deemed past non-compliance at a scope and severity of J.

The facility census totaled 86 residents with 12 residents included in the sample, and four reviewed for falls. Based on observation, interview, and record review the facility failed to ensure an environment free of accident hazards when facility staff utilized a full mechanical lift, with known signs of instability to transfer residents. On 06/07/21, Resident (R) 12 fell out of the top of a shower sling (incorrect sling type) from the full mechanical lift used to transfer her from her bed to her wheelchair and required an emergency room transfer for evaluation of a large bump to the back of her head from hitting it on the lift. The facility further failed to identify the causal factor of the fall on 06/07/21 when the investigation did not identify the staff utilized the unstable lift, used the incorrect sling, and both direct care staff did not provide the supervision necessary to facilitate a safe transfer. These failures placed R12, and seven other residents who used full mechanical lift for transfers, in immediate jeopardy. The facility also failed to complete a fall investigation, determine the cause of the fall, and revise the care plan with fall prevention strategies for a non-injury fall that R11 experienced on 08/03/21. Findings included: - R12's pertinent diagnoses from 07/06/21 Physician's Order Summary revealed [CONDITION(S)] disease (a group of conditions that affect the circulation of blood to the brain, causing limited or no blood flow to affected areas of the brain), [CONDITION(S)] (paralysis of one side of the body) affecting right dominant side, and [CONDITION(S)] (MS, progressive disease of the nerve fibers of the brain and spinal cord). The 11/06/20 Annual Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) of 11, indicating moderate cognitive impairment. The resident required extensive assistance of two staff for transfers, noted impairment to the upper and lower extremities (limbs) on one side of her body, and used a wheelchair for mobility. R12 experienced no falls since the last assessment. The 11/06/20 Activities of Daily Living (ADL) Care Area Assessment (CAA) revealed staff provided physical assistance and cues for ADLs. The 11/06/20 Fall CAA revealed R12 would be free from falls and staff anticipated her needs. The 08/03/21 Quarterly MDS revealed the resident had a BIMS of 11, indicating moderate cognitive impairment. The resident was totally dependent on two staff for transfers, noted impairment to her upper and lower extremities on one side of her body, and used a wheelchair for mobility. The MDS noted R12 had no falls since the last assessment and noted she received daily anticoagulant (blood thinner) medication in the seven-day review period. R12's 03/01/16 Care Plan revealed a revision on 04/26/17 that noted she had a history of stroke/[CONDITION(S)] accident (CVA, sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) The 03/01/16 Activities of Daily Living (ADL) Care Plan revealed a revision dated 08/09/19 noting the resident required two staff assistance with a full mechanical lift for transfers. The care plan lacked direction for the required sling type. The 03/01/16 Fall Care Plan revealed a revision dated of 06/08/21 that stated R12 was at risk for falls due to the resident needing a full mechanical lift with two staff assistance. The 06/07/21 at 02:14 PM Situation, Background, Assessment and Recommendation (SBAR) Note revealed Certified Nurse Aide (CNA) D and CNA M laid the resident down after her shower and then her family came to visit. CNA D raised the resident off of the bed with the mechanical lift while CNA M walked around the bed, and then the resident fell from the top of the sling, hitting her left shoulder and her head on lift. Imaging at the hospital revealed no head injuries. The SBAR Note documented the resident's actions of grabbing the sling instead of folding her arms across her body as the root cause of the fall. The SBAR Note documented the immediate intervention was to re-educate and remind the resident to fold her arms across her body during lift transfers. The 06/07/21 at 02:00 PM Occurrence Report fall investigation revealed the resident fell at 01:52 PM and stated her head hurt. The nurse noted a large raised area to the occipital lobe [back of the head]. Staff notified the physician and the resident was sent to the emergency room (ER). Witness statement for CNA M noted R12 had been laid down [in bed], her family arrived, and the staff had to switch slings because we gave the resident a shower. CNA D lifted the resident off the bed, while CNA M walked around the bed, and R12 somersaulted out of the shower sling and hit her left shoulder and head on lift. Review of 06/07/21 at 02:24 PM SBAR Communication Form and Progress Note revealed R12 fell from the full mechanical lift sling during transfer. She had a large raised area to her occipital (back of the head) lobe from hitting her head on the base of the mechanical lift. The resident stated, my head hurts. The staff notified the physician and sent R12 to the ER for evaluation. The 06/08/21 at 09:18 AM Follow-up Report for Occurrence fall investigation revealed staff transferred the resident from her bed to the wheelchair when R12 fell out of the sling to the floor hitting her shoulder and head on the base of the lift. The physician gave orders to send the resident to the ER due to the height of the fall and hitting her head. The fall investigation identified the resident's actions of grabbing the sling instead of folding her arms across her body as the root cause of the fall with the immediate intervention noted to re-educate and remind the resident to fold arms across her body during lift transfers. The 06/07/21 Hospital Documentation Summary revealed the resident experienced a bump to the back of her head and a headache and imaging of her head and spine showed no abnormalities. The 08/01/20 to 08/16/21 Work History Report for mechanical lifts revealed maintenance staff inspected all lifts on 08/31/20, 10/16/20, 12/03/20, 02/10/21, 04/08/21, 06/08/21, and 08/16/21 with no abnormalities noted. Observation of R12 on 08/17/21 at 03:50 PM revealed the resident seated in her wheelchair in the common area near the front of the building. Observation revealed a blue net shower sling placed under the resident between the resident and the wheelchair. Observation on 08/18/21 at 07:50 AM revealed CNA N and CNA E used a regular grey sling to transfer R12. CNA E held the sling secure and ensured the slings correct placement while on the right side of the resident. CNA N worked the lift control with one hand and held the sling secure with the other hand on the left side of the resident while lifting/transferring in the mechanical lift. Observation revealed the lift arm noted to be wobbling from side to side, while transferring the resident. Interview with R12 on 08/17/21 at 03:52 PM revealed the day she fell out of the mechanical full lift, she had just taken a shower, the CNAs helped her to dress, and then put her to bed. Her family came for a visit, so the CNAs started to lift her up in the sling, she fell and got a big bump on her head. She then stated, she fell about two to four feet to the floor. Interview with CNA C on 08/17/21 at 09:42 AM revealed she worked at the facility since the middle of 2021 and that the wobbly full mechanical lift has been that way since her first day. She reported the wobbly lift to Maintenance Staff G and H multiple times, and she did not tell the nurse because she just went straight to the maintenance staff with her concern. Interview with CNA D on 08/17/21 at 04:55 PM revealed she and CNA M were getting R12 up to her wheelchair. The resident did not cross her arms and held onto the sides of the net shower sling for the transfer from her bed to wheelchair because we needed to hurry because her family was here, that is the only sling we had, and we wanted to be quick She then stated, everything was tied right, all the hooks, and the resident slipped out of the top of the sling. It happened so fast, she did not know how it happened. The CNAs received regular evaluations every year on sling/lift use. She thought the shower slings were too slippery and did not know if the sling was the right size, but did state, we have used this sling for [R12] before for showers, but the CNAs do not like to use the shower slings unless the resident was being placed in the shower chair, not for normal transfers. Interview with CNA E on 08/18/21 at 07:53 AM revealed staff were not to use the blue net shower slings for R12 for regular transfers because of her fall from the lift. She stated if a sling was not placed high enough above the shoulders with the shower sling, a resident could slide out the bottom or top, and that was why staff do not use them for regular transfers. R12 did tend to hang onto the sling for support, but that would not have caused her to slide out. The shower slings could be slippery and were just not as safe as the crisscross regular ones. When CNAs would get a resident up with the full mechanical lift and sling, one staff should use the lift controls and one staff should hold the sling in the correct position to stabilize the sling. Interview with Licensed Nurse (LN) F on 08/18/21 at 10:32 AM revealed the blue net shower slings were not to be used for regular transfers, and the facility had about six to seven full mechanical lifts that needed regular slings. When staff transferred residents with the full mechanical lift, two staff assist, with one using the controls, and the other guiding the sling and ensuring correct placement of the sling. The CNAs knew to go to the maintenance staff to let them know of any equipment issues. She had not heard anything about a wobbly lift. Interview with LN I on 08/18/21 at 11:50 AM revealed no CNAs mentioned anything about a wobbly or unsafe lift to him. Interview with Maintenance staff G on 08/18/21 at 08:51 AM revealed he checked the mechanical lifts every other month for functionality, took off the wheels, cleaned them, and greased everything. When shown the lift that was wobbly he then stated, I was not told about this lift's condition and he removed the lift from the floor for maintenance. Interview with Maintenance Director H on 08/18/21 at 11:53 AM revealed today was the first he heard about a wobbly lift and no staff mentioned the lift before today. Maintenance checked the lifts on a weekly basis, but does not document the weekly checks, only every other month checks. Interview with Administrative Nurse B on 08/18/21 at 08:20 AM revealed he expected staff to use the blue net shower slings for resident showers, and the regular slings should be used to transfer the resident any other time. Interview with Administrative staff A on 08/18/21 at 05:00 PM revealed he could not find CNA M's mechanical lift competency as requested on 08/17/21. Review of 01/2017 Safe Lifting and Movement of Residents policy revealed staff responsible for direct resident care will be trained in the use of mechanical lifting devices. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order. Review of revised 09/17/19 Fall Policy revealed the facility shall ensure, following any falls, details of the fall will be recorded, and potential causal factors identified, investigated, and interventions will be implemented. The facility failed to ensure an environment free of accident hazards, when facility staff utilized a full mechanical lift, with known signs of instability, for R12's transfer from her bed to her wheelchair on 06/07/21 causing her to fall from the top of the shower sling from the full mechanical lift. She required an emergency room transfer for evaluation of a large bump to the back of her head from striking the lift. The facility further failed to identify the causal factor of the fall on 06/07/21 when the investigation did not identify the staff utilized the unstable lift, used the incorrect sling, and both direct care staff did not provide the supervision necessary to facilitate a safe transfer. These failures placed R12, and seven other residents who used full mechanical lift for transfers, in immediate jeopardy. On 08/18/21 at 04:15 PM, the Administrative staff A and the Administrative Nurse B were provided with the IJ template and notified of the failure to ensure staff utilized the correct sling, utilized a lift noted as wobbly, and the lack of identifying causal factors related to the fall from the top of the lift experienced by R12, placed R12 and the seven other residents who required full mechanical lift transfers in immediate jeopardy. The immediate jeopardy was determined to first exist on 06/07/21 at approximately 02:00 PM, when the facility staff did not provide the appropriate sling type or the appropriate assistance to R12 which caused a fall from the full mechanical lift, in which she hit her head and required emergency room evaluation. The facility presented an acceptable plan for removal of the immediate jeopardy on 08/18/21 at 08:33 PM when the facility maintenance pulled the unsafe lift from the floor for maintenance which revealed a loose shoulder bolt on the mast of the lift that goes through the mast and holds the arm in place securely per Administrative Staff A interview. Maintenance completes every other month checks on lifts, and when needed. Re-education to staff was initiated on fall processes, competency on full mechanical lifts and slings, and they were educated on defective equipment, where to put it and who to notify for repairs. All staff will complete the training before they are allowed to work another shift. All topics would be reviewed at the daily clinic review, and the corporate nurse educator will review fall occurrence reports weekly. The fall and lift policies were reviewed, and QAPI will audit monthly. The survey team validated the immediate jeopardy was removed on 08/19/21 at 07:30 AM following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a E (pattern, with no actual harm) scope and severity following the removal of the immediate jeopardy. - R11's pertinent diagnoses from the Physician's Orders in the electronic medical record (EMR) dated 06/14/21 revealed: [CONDITION(S)] (a rapid, irregular heart beat) and muscle weakness. The 05/11/21 Admission Minimum Data Set (MDS) revealed a brief interview for mental status (BIMS) of 11, indicating moderately impaired cognition. The resident required supervision and assistance of one staff for transfers, total dependence on one staff with toileting, and used a wheelchair for mobility. R1 was at risk for falls with none noted in the review period. The 05/11/21 Cognitive Loss Care Area Assessment (CAA) revealed R11 exhibited inattention, disorganized thinking, and difficulty focusing attention. The 05/11/21 Activities of Daily Living (ADL) CAA revealed R11 required supervision to total staff assistance for ADLs. He ambulated in his room and used a wheelchair for his main mode of locomotion. The 05/11/21 Fall CAA revealed R11 exhibited balance problems, was only able to stabilize with staff assistance, and had falls prior to entry into facility. The 07/22/21 Quarterly MDS revealed a BIMS score of 10 which indicated moderately impaired cognition. The resident required supervision and assistance of one staff with transfers, extensive assistance of one staff with toileting, and used a wheelchair and walker for mobility. He had one non-injury fall noted since the last assessment. Review of the 05/04/21 Fall Care Plan revealed R11 was a fall risk. A revision dated 07/06/21 revealed staff were to place assistive devices and personal items in reach when the resident was in his recliner with the call light in reach. He must not be left in the bathroom unattended and must have appropriate footwear or non-skid socks in place for ambulation. The care plan lacked a revision after the 08/03/21 fall. The 05/04/21 and 05/26/21 Fall Risk Data Collection assessments revealed R11 was at high risk for falls. Another Fall Risk Data Collection assessment completed on 06/14/21 noted the resident was at low risk for falls. An 08/03/21 at 04:22 PM Activity Note revealed R11 reported he fell in the bathroom a while ago and got himself up, stated he had a bruise on his knee, but was gone. Staff completed a skin assessment with no bruising noted. Staff notified Administrative Nurse B. Review of 08/03/21 at 06:53 PM Health Status Note revealed staff reported the fall to Administrative Nurse B who also assessed the resident with no abnormalities. The resident was able to perform full range of motion. Observation on 08/19/21 at 10:14 AM to 12:04 PM revealed R11 lying on bed with his head up, watching television with no visible bruising or distress with shoes in place. CNA P walked up and down the resident hallway and checked on the resident. He did not activate the call light during this observation. Interview with R11 on 08/17/21 at 04:00 PM revealed he fell out of his wheelchair and scratched his knee up the last time he fell . Interview with Certified Nurse Aide (CNA) O on 08/17/21 at 02:35 PM revealed she does not know of any falls for R11 other than the one when he first arrived at the facility. Interview with Licensed Nurse (LN) J on 08/19/21 at 02:59 PM revealed he was the nurse working on 08/03/21 when the resident said he fell . LN J stated, [R11] said he fell a couple times, but he checked [R11] over and did not see anything, so that is why he did not fill out a fall occurrence/investigation or Situation, Background, Assessment and Recommendation (SBAR) form/note. He also mentioned that he notified Administrative Nurse B. Interview with Administrative Nurse B on 08/19/21 at 01:34 PM revealed he was unaware of a fall on 08/03/21. R11 mentioned he bumped his knee on the cabinets in his room that day, but no one told him R11 fell . His expectation for resident falls were that the nurse should document the fall and any injuries, like the size/location of the injury/wound and document wound care as well. The facility's revised 09/17/19 Fall Policy revealed the facility shall ensure, following any falls, the facility staff completes an occurrence report. Details of the fall will be recorded, and potential causal factors identified, investigated and interventions will be implemented. The facility failed to complete a fall investigation, determine the cause of the fall, and revise the care plan with fall prevention strategies for a fall that R11 experienced on 08/03/21.

The facility had a census of 84 residents with 8 residents selected for sample. The sample included 3 residents with current pressure ulcers or recently healed pressure ulcers. Based on observation, interview and record review, the facility failed to provide 2 of 3 residents with care (timely repositioning, incontinence care, nutritional supplements) to prevent pressure ulcer development and/or promote healing of existing pressure ulcers. (Residents #1 and #5) Resident #1 developed facility acquired pressure ulcers to both heels after admission to the facility. Those wounds healed and then in (MONTH) 2019 another pressure ulcer developed on the left heel and deteriorated to its current unstageable status. On 6/25/19 staff discovered 2 new open areas to the inner gluteal folds as well as a new Stage 1 pressure ulcer (skin changes due to pressure which affect only the top layer of skin) to the right heel. Staff also failed to provide resident #1 with care to promote healing of the existing pressure ulcer, including timely repositioning, maintaining the resident in a position to improve circulation to the affected left foot/heel, and avoiding application of pressure to the wound on the left heel during transfers. Findings included: - Resident #1's clinical record included a comprehensive [DIAGNOSES REDACTED]. The 12/11/18 Annual MDS (Minimum Data Set) identified the resident with no current pressure ulcers. The 3/7/19 Quarterly MDS identified the resident with a current Stage 2 pressure ulcer which is an open, shallow wound with a partial loss of dermis (the lower/inner layer of the two layers of skin). The 6/7/19 Significant Change MDS identified the resident with the need for extensive assistance of two staff for bed mobility and transfers, an inability to walk, total bowel incontinence, use of an indwelling bladder catheter (tube placed in the bladder to drain urine into a collection bag), and the presence of one current unstageable pressure ulcer. The 6/7/19 care plan noted the presence of a pressure ulcer on the left outer heel related to impaired bed mobility and poor self-care motivation. The care plan directed to provide the nutritional supplement Prostat 30 cc's (cubic centimeters) twice daily for wound healing. The care plan also directed staff to administer wound treatments and medications as ordered and monitor for effectiveness. According to the care plan, staff should apply bilateral pressure reduction boots at all times except during showers. The care plan lacked specific guidance related to the resident's need for repositioning. The care plan also noted the resident's bowel incontinence and dependence on staff for changing of soiled incontinence briefs. The resident required extensive assistance of two staff for all transfers and experienced difficulty with bearing weight and pivoting during transfers. A Braden assessment (a standardized type of skin assessment used to measure specific risk for skin breakdown) completed on 3/7/19 identified the resident as low risk for skin breakdown. A Braden assessment completed on 6/3/19 identified the resident as high risk for skin breakdown. A weekly skin assessment completed on 3/19/19 identified the resident with no skin breakdown. A Pressure Ulcer Weekly Wound Eval completed on 3/21/19 noted the presence of a wound to the left heel, classified as a Stage 2 ulcer, which measured 0.5 cm (centimeters) by 1.8 cm. The document also noted the presence of a deep tissue injury (localized area of persistent non-blanchable deep red, maroon, purple discoloration as a result of intense and/or prolonged pressure and shear forces) which measured 2 cm by 2 cm and presented as a closed blister on the right heel. The Pressure Ulcer Weekly wound evaluations and Weekly Skin assessment forms completed from 3/21/19 - 4/24/19 described the pressure wounds to the left and right heels as healing blisters. Beginning on 5/20/19, wound information recorded on the Pressure Ulcer weekly forms noted the presence of a Stage 2 pressure ulcer to the left heel which, on that date, measured 5.2 cm by 4.2 cm with a depth of 0.1 cm. A 5/28/19 Pressure ulcer weekly document noted worsening of the left heel wound which the writer described as a deep tissue injury with measurements of 5.2 cm by 7 cm. The 6/10/19 Pressure ulcer weekly document included left heel wound measurements of 6 cm by 4.5 cm. with eschar (dead tissue) present. The 6/17/19 Pressure ulcer weekly document included left heel wound measurements of 6 cm by 6 cm with eschar present and described the wound as worsening. The facility provided a Weekly Pressure Ulcer Report for the week of (MONTH) 20-26, 2019 which identified resident #1 with a facility acquired pressure ulcer to the left heel which staff first identified on 5/15/19. At the time of the assessment for the report, the wound appeared larger and measured 8.3 cm by 7.2 cm and consisted of 10% granulation tissue (tissue formed during wound healing) and 90% eschar. During observations on 6/25/19 at 10:00 a.m., 10:30 a.m., 11:15 a.m. and 12:53 p.m., resident #1 sat in a wheelchair in the dining room with both legs hanging down resting on the foot pedals. The resident wore thick padded booties to both feet. The resident appeared weak and frail, with his/her head lowered and shoulders slumped. The resident spoke in a very soft voice and repeatedly said, I'm so tired. There were no observations of staff repositioning the resident during the 3.5 hour time period, no observations of staff elevating the resident's lower legs and/or feet to increase circulation to the feet, and no observations of staff offering the resident the opportunity to toilet or providing incontinence care. On 6/25/19 at 1:00 p.m., in response to surveyor request for resident repositioning and care, Direct Care Staff [NAME] and Direct Care Staff J took resident #1 to his/her room and transferred the resident from the wheelchair to a standing position via a sit to stand mechanical lift. The resident verbalized pain upon standing and it was noted the resident beared weight on the left heel with the large, worsening, unstageable pressure ulcer. During this observation, staff realized the resident experienced bowel incontinence and had a large amount of liquid stool oozing out of the top of his/her slacks in the front and back as well as down the groin/inner thigh area. The stool was extremely malodorous and acidic smelling. When staff removed stool from the resident's buttocks, two open areas were noted on the left and right inner gluteal folds and the resident complained of pain when staff wiped across those areas. According to Direct Care Staff J, the open areas on the right and left inner gluteal folds were new. During an observation on 6/25/19 at 2:45 p.m., Wound Nurse C and Licensed Nurse D completed a dressing change on the pressure ulcer on resident #1's left heel. The wound was covered with eschar that rolled back at the upper edges and appeared moist. The area of breakdown involved the entire heel and extended up the back of the heel. At surveyor request, staff removed the padded boot from the right foot. The resident's right foot was red, unblanchable, and felt boggy/spongy to the touch. According to Wound Nurse C, that area of abnormality on the right heel was new. Wound Nurse C later reported he/she considered the new area to the right heel as a Stage 1 pressure ulcer which measured 7 cm by 4 cm. During an interview on 6/25/19 at 1:00 p.m., Direct Care Staff [NAME] confirmed resident #1 was not repositioned, changed, or toileted in the 3.5 hour time period from 9:30 a.m. - 1:00 p.m. During an interview on 6/25/19 at 2:00 p.m., Administrative Nurse B reported the resident came back from therapy at approximately 9:30 a.m. that morning. According to Nurse B, staff should have repositioned the resident or placed him/her in bed or the recliner at some point during the morning and also should have checked for incontinence and changed the resident before lunch. During an interview on 6/25/19 at 2:45 p.m., Wound Nurse C reported the resident originally had wounds on both heels, but those areas healed for a few weeks and then the left heel broke down again. Although Wound Nurse C could not recall the exact date when staff discovered the new area of breakdown to the left heel, he/she knew it occurred sometime after the end of (MONTH) 2019. Wound Nurse C reported the left heel wound is facility acquired and most likely caused by the resident rubbing his/her heel on the bottom of the foot rest on the recliner. During an interview on 6/26/19 at 11:00 a.m., Administrative Nurse B reported the open areas on the inner gluteal folds were assessed and believed to be a result of skin contact with the stool rather than pressure wounds. During an interview on 6/26/19 at 1:30 p.m., Mid-level Practitioner H verbalized knowledge of resident #1's facility acquired left heel pressure ulcer but was unaware of the unblanchable area to the right heel. According to Practitioner H, the resident should not be left sitting in the wheelchair with his/her feet hanging down for prolonged periods of time due to the impact that position had on blood circulation. The facility's (MONTH) (YEAR) Pressure Ulcer/Pressure Ulcer Prevention policy directed staff to implement, monitor and modify interventions to attempt to stabilize, reduce of remove underlying risk factors for pressure ulcer and, if a pressure ulcer or pressure injury is present, provide treatment to heal it and prevent the development of additional pressure ulcers/pressure injuries. The policy listed specific expected interventions for residents based on their Braden skin assessment scores. For residents identified as high risk, such as Resident #1, interventions included a turning and repositioning program, toileting and incontinence care and management of friction and shear by utilizing proper positioning and repositioning. The facility failed to provide resident #1 with care (timely repositioning, incontinence care) to prevent pressure ulcer development and/or promote healing of existing pressure ulcers. Resident #1 developed facility acquired pressure ulcers to both heels after admission to the facility. Those wounds healed and then in (MONTH) 2019 another pressure ulcer developed on the left heel and deteriorated to its current unstageable status. On 6/25/19 staff discovered 2 new open areas to the inner gluteal folds as well as a new Stage 1 pressure ulcer (skin changes due to pressure which affect only the top layer of skin) to the right heel. Staff failed to provide resident #1 with care to promote healing of the existing pressure ulcer, including timely repositioning, maintaining the resident in a position to improve circulation to the affected left foot/heel, and avoiding application of pressure to the wound on the left heel during transfers. - Review of a progress note dated 6/3/19 for resident #5 revealed the resident had [DIAGNOSES REDACTED]. in walking. Review of the resident's admission minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status score (BIMS) of 00 indicating the resident could not complete the interview. Review of the pressure ulcer CAA dated 4/19/19 revealed there was no skin issues present but the resident was at risk due to his/her cognitive impairment, thin frail skin, and needing assistance from staff to complete his/her activities of daily living (ADL's). Review of the care plan revised 6/20/19 revealed the resident had a pressure ulcer to his/her right heel due to impaired mobility and friction from rubbing his/her foot against the mattress and the facility would educate caregivers on the causes of skin breakdown; including: transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. If the resident refused treatment staff would confer with the resident, interdisciplinary team (IDT) and family to determine why and try alternative methods to gain compliance with treatments. Staff would document the interaction. Review of the resident's admission Braden's scale (a tool used to assess a patient's risk of developing a pressure injury) completed on 4/8/19 revealed a score of 14 indicating the resident was at moderate risk for developing a pressure injury. Review of the 6/24/19 skin assessment revealed the resident had a pressure ulcer which measured 2.3 centimeters (cm), by 1.4 cm. An observation on 6/25/29 at 7:20 AM revealed the resident sat in his/her reclining back wheelchair. Further observation of the resident on 6/25/19 at 10:15 AM (approximately 3 hours later) revealed the resident sat in the exact spot in the dining room in his/her reclining back wheelchair. During an interview on 6/25/19 at 7:20 AM, direct care staff [NAME] stated the resident was totally dependent on staff for all repositioning. Staff [NAME] stated the resident had a sore on his/her right heel and always wore a boot to protect the area . During an interview on 6/25/19 at 10:25 AM, staff [NAME] acknowledged the resident had not received any care since 7:20 AM. During an interview on 6/25/19 at 4:45 PM, licensed nursing staff G stated the resident was to be turned and repositioned every two hours and as needed (PRN), the resident was required to have his/her boot to the right heel to protect the pressure area During an interview on 6/25/19 at 4:30 p.m., administrative nursing staff B stated he/she expected staff to turn and reposition the resident every two hours and PRN. Review of the Pressure Ulcer/Pressure Injury Prevention policy dated 04/2018 revealed interventions that could be used to minimize pressure included: Turning and repositioning every two to three hours when in bed, or more frequent depending on the need of the resident. Every hour when in a chair. The facility failed to reposition resident #5 in a timely manner to prevent the development/worsening of pressure ulcers.

The facility had a census of 84 residents, with 8 residents selected for sample. Based on observation, interview and record review, the facility failed to provide 3 of 8 residents with adequate supervision and/or assistive devices to prevent accidents when staff failed to properly transfer resident #1 with a sit to stand mechanical lift and when staff failed to complete assessment of causal factors after each fall for residents #3 and #7 and then develop/implement new fall prevention strategies based on those causal factors. Resident #3 fell on [DATE] and staff failed to immediately assess for causal factors and then implement appropriate interventions to prevent additional falls. The resident fell again on 11/5/18 and sustained a laceration to his/her head which required placement of staples for wound closure. Findings included: - Resident #3's clinical record included a comprehensive [DIAGNOSES REDACTED]. The 4/11/19 Annual MDS (Minimum Data Set) identified the resident with severe cognitive impairment (Brief Interview for Mental Status) score of 4, the need for supervision of one staff for transfers, steady balance at all times, and no functional limitations in range of motion of the upper or lower extremities. According to the assessment, the resident experienced 2 non-injury and one injury fall since the prior assessment. The 4/25/18 care plan identified the resident as at risk for falls due to gait and balance issues. The care plan included multiple fall prevention interventions, including: Ensure the call light was within reach at all times and encourage the resident to use the call light. Respond promptly to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Ensure resident is out of the room when the floor is wet. Ensure resident is within arms reach during therapy sessions. Ensure resident's walker is within eyesight when seated at table to serve as a reminder for (him/her) to use when getting up from the table to ambulate. Ensure resident wears appropriate footwear, no skid socks and/or shoes when ambulating or mobilizing in wheelchair (WC). Medication review with possible adjustments. Staff to monitor and remind resident to use (his/her) walker at all times. Fall risk assessments completed periodically since 8/28/18 all identified resident #3 as high risk for falls. Progress notes and Follow up reports for falls included the following: 8/29/18 at 2:59 p.m.: Described a fall experienced by the resident during an attempt to stand up from the toilet. According to the follow up report, the facility identified a problem with a riser used on the toilet seat and fixed that issue. 9/28/19: Described a fall experienced by the resident in the dining room during an attempt to ambulate without his/her walker. According to the follow up report, staff implemented a plan to ensure the resident's walker remained next to him/her in the dining room, so it was available when the resident decided to leave the table. 11/2/18 at 9:02 a.m.: Described the resident's report that he/she experienced a fall the day prior, but could not remember where or why the fall occurred. Upon examination, the resident had a bite mark to the left upper lip and a bruise under the left eye. 11/5/18 at 12:48 p.m.: Described the resident's ambulation into the dining room with a bleeding, open wound approximately 4 cm (centimeters) in length to the back of his/her head from a fall. According to the note, staff sent the resident to an emergency room and the resident received staples to close the wound. The facility provided Follow Up Reports for both the 11/2/18 and 11/5/18 falls. Review of those two documents showed staff completed both reports on 11/7/18 within 30 minutes of each other, 5 days after the 11/2/18 fall and 2 days after the 11/5/18 fall with injury. The clinical record lacked evidence staff completed a timely assessment of the 11/2/18 fall and then developed/implemented appropriate fall prevention strategies based on the causal factors of that fall prior to the 11/5/18 fall in which the resident sustained [REDACTED]. During frequent observations on 6/25/19 from 8:00 a.m. - 1:00 p.m., resident #3 lay sleeping in bed. According to Direct Care Staff E, the resident required medication during the previous night and that medication caused him/her to remain sleeping throughout the morning. During an interview on 7/1/19 at 1:50 p.m., Administrative Nurse B confirmed resident #3 experienced multiple falls since admission to the facility. Nurse B also confirmed the resident experienced a fall with a laceration to the head on 11/5/18. According to Nurse B, the charge nurse should notify the on call manager when a resident experienced a fall, and then they would work together to come up with an appropriate intervention for that fall. Nurse B further reported some nurses chose to place the new intervention on the care plans at the time, but others opted to pass along the new intervention information in end of shift report. Administrative Nurse B further reported he/she then reviewed each fall and completed the fall investigations/follow up reports as soon as possible, determined the causal factors/root cause analysis of each fall, and then updated the care plan with an intervention to address the root cause if necessary. Upon review of resident #3's clinical record, Nurse B reported the immediate intervention after resident #3's 11/2/18 fall was to obtain a UA (urinalysis - examination of urine) since the resident seemed to have more confusion than normal. Staff also decided the resident needed to be seen by the physician after the 11/2/18 fall, but that did not occur until 11/6/18, the day after the resident fell , sustained a laceration to the head and was transported to an emergency room for placement of staples. During an interview on 7/1/9 at 3:05 p.m., Physician N reported he/she believed the root cause of all resident #3's falls to be dementia and weakness. According to Physician N, completion of a root cause analysis/assessment of causal factors would not have changed the resident's [DIAGNOSES REDACTED]. The facility's revised (MONTH) 2014 Fall Prevention policy included, .Following any falls, the facility staff completes an Occurrence Report. Details of the fall with be reported and potential causal factors identified and investigated. Interventions will be immediately implemented following each fall and added to the resident's plan of care . The facility failed to complete assessment of causal factors after resident #3's 11/2/18 fall and then develop/implement appropriate fall prevention strategies based on causal factors. The resident experienced another fall on 11/5/18 and sustained a head wound which required placement of staples for closure of the wound. - Resident #1's clinical record included a comprehensive [DIAGNOSES REDACTED]. The 6/7/19 Significant Change MDS (Minimum Data Set) identified the resident with no cognitive impairment (Brief Interview for Mental Status) score of 13 and the need for extensive assistance of 2 staff for transfers. The resident had a current unstageable (a wound in which the base is not visible due to being covered with slough or eschar which are different types of dead tissue) deep tissue injury. The 6/7/19 Care Plan noted the resident's need for extensive assistance of two staff for all transfers and difficulty with bearing weight as well as a pressure ulcer on the left heel. The care plan did not direct staff to use a sit to stand lift for transfers. The clinical record lacked evidence of completion of an assessment to determine how staff should transfer the resident safely. During an observation on 6/25/19 at 1:00 p.m., Direct Care Staff [NAME] and J prepared to transfer resident #1 from the wheelchair to the bed via the sit to stand mechanical lift. The resident appeared very frail and weak, and sat in the wheelchair with his/her head down and shoulders slumped forward. The resident wore thick padded boots on both feet and had a gauze dressing partially visible on the left foot/heel. Staff placed the upper body strap/sling around the resident's back and assisted the resident to place his/her hands on the handlebar of the lift while staff raised him/her to a standing position. The resident began to moan repeatedly as staff raised the resident upright. As staff raised the resident, they realized he/she had experienced bowel incontinence which soiled the abdomen above the slacks as well as the lower back and inner thighs. Direct Care Staff [NAME] and J opted to leave the resident suspended in the sit to stand lift while they provided incontinence care and changed the resident's clothing. The resident repeatedly complained of pain and said Oh, oh, it hurts. It hurts. and Please. It hurts several times as staff cleaned the resident. As the cleaning process continued, the resident put his/her head down and slumped forward, with his/her hands resting on the handlebar of the lift. In this position, the sling/strap that was previously lower on the back and abdomen raised until it rested directly under the resident's arm, with all of his/her weight placed on that area. The resident winced, moaned, and verbalized complaints of pain during the 18 minute time period the staff required the resident to remain suspended in the sling while they provided incontinence care and staff continued to provide care without appropriately addressing the resident's pain. Licensed Nurse K entered the room toward the end of the observation and, in response to surveyor concerns about the resident's pain and prolonged time spent in the lift, asked Direct Care Staff [NAME] and Direct Care Staff J to lay the resident in the bed. During an interview on 6/25/19 at 2:00 p.m., Administrative Nurse B reported staff should have placed resident #1 in the bed in order to complete incontinence care rather than leaving him/her suspended with the lift for a prolonged period of time. Administrative Nurse B also reported direct care staff used the transfer method they determined was the most safe method, so if staff felt the sit to stand lift was the most safe, they were allowed to use the lift without consulting a nurse or therapist. According to Nurse B, there was no system in place to ensure a licensed professional evaluated the method chosen by direct care staff to transfer residents to ensure those methods were safe and met the needs of the resident. During a telephone interview on 6/26/19 at 1:30 p.m., Mid-Level Practitioner H reported resident #1 is too weak to use a sit to stand lift because (he/she) isn't strong enough to bear weight. Practitioner H also reported the wound on the resident's left foot would cause pain if he/she was asked to bear weight on it. The facility's (MONTH) 2014 Safe Lifting and Movement of Residents policy included, Nursing staff, in conjunction with the rehabilitation staff, shall assess individual resident's needs for transfer assistance on an ongoing basis. Staff will document resident's transferring and lifting needs in the care plan. Such assessment shall include resident's mobility and degree of dependency, weight bearing ability The facility failed to provide adequate supervision during a mechanical lift transfer when staff left resident #1 suspended in a sit to stand lift for 18 minutes while staff provided incontinence care. During that time period, the resident cried out in pain, slumped forward, and failed to adequately bear weight on his/her feet, including the left foot on which the resident had an unstageable pressure ulcer. - Review of resident #7's physician's orders [REDACTED]. Review of the minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 2 (severe cognitive impairment), required extensive assistance of one staff for bed mobility, transfers, and toileting and limited assistance of one staff for walking and locomotion. The resident did not use an assistive device for ambulation and had not fallen since admission. Review of the cognitive care area assessment (CAA) dated 5/7/19 revealed the resident was unable to make safe and rational decisions related his/her dementia and required staff assistance to complete his/her activities of daily living (ADLs). Review of the behavioral CAA dated 5/7/19 revealed the resident was a new admit to the facility and wandered up and down the hall on the secured dementia unit. Review of the urinary incontinence CAA dated 5/7/19 revealed the resident was incontinent and required staff assistance for toileting and incontinence care. The resident's toileting plan directed the staff to toilet the resident before, after meals, at bedtime and every 2 hours. Review of the falls CAA dated 5/7/19 revealed the resident was at risk for falls related to incontinence, poor safety awareness related to cognitive impairment, and the resident received medication known to increase his/her risk for falls. Review of the fall risk assessment dated [DATE] revealed the resident scored a 39 (high risk for falls). Review of the care plan dated 5/11/19 revealed the resident was at risk for falls related to his/her [DIAGNOSES REDACTED]. The care plan directed the staff to anticipate and meet the resident's wants and needs, ensure the resident wore shoes or non-slip socks while he/she ambulated, encourage the resident to use the wheelchair, and the facility applied a perimeter mattress (a mattress with raised edges to define the edge of the bed) to the resident bed. Review of resident #7's progress notes dated 5/9/19 revealed the resident was observed on the floor by the dementia unit doors. The resident ambulated without his/her walker and he/she was unable to voice how the fall occurred. Review of the fall investigation dated 5/9/19 revealed the resident required hands on assistance of the staff to move from place to place, the resident's gait pattern changed when he/she walked through doorways and he/she exhibited jerking and instability when the resident turned while he/she used the assistive device. The facility recommended physical therapy (PT) and occupational therapy (OT) services to screen the resident to evaluate his/her ability to ambulate and evaluate his/ her safe use of the wheelchair. Review of the care plan on 6/26/19 revealed the facility failed to update the resident's care plan. Review the progress note dated 5/21/19 at 11:39 p.m. revealed the resident was found on his/her knees with a wound to the right side of his/her head. The facility notified the resident's physician and transferred the resident to the hospital for evaluation and treatment. Review of the progress note dated 5/22/19 at 8:57 p.m. revealed the resident returned to the facility at 4:55 p.m. with sutures to his/her right occipital area. Review of the fall investigation dated 5/22/19 revealed the facility failed to determine the casual factors of the fall. The facility again requested a PT/OT evaluation and educated the family and staff on resident safety when they exited the secured dementia unit. The facility determined the fall was a no fault fall and documented the care plan was updated. Review of the care plan on 6/26/19 revealed the facility failed to place the new intervention on the resident's care plan. Review of the fall investigation dated 6/9/19 at 6:00 a.m. revealed a staff member reported the resident ambulated through the door of his/her room, lost his/her balance and fell . The resident landed on his/her buttocks and struck his/her head and neck on the handrail outside of his/her room. The resident received two skin tears to the left side of his/her neck one measured 4 centimeters (cm) and one measured 3 cm. The resident also had a 3 cm raised area to his/her posterior left ear. The facility placed a perimeter mattress on the resident's bed to deter the resident from getting out of the bed unassisted and recommended PT/OT screen again as requested with the falls on 5/9/19 and 5/21/19. The facility documented the care plan was updated on the fall investigation however, review of the care plan on 6/26/19 revealed the care plan had not been updated with the new interventions for the 6/9/19 fall with injuries. Review of the physician's orders [REDACTED]. which can increase his/her risk for falls. 1. [MEDICATION NAME]- a diuretic for heart failure 2. [MEDICATION NAME]- an antipsychotic for [MEDICAL CONDITION] 3. [MEDICATION NAME]-an antipsychotic for [MEDICAL CONDITION] 4. Carvedilol-an antihypertensive for high blood pressure Review of the resident's record revealed he/she was discharged from the facility on 6/22/19 at 2:16 p.m. and admitted to another nursing facility. Interview on 6/26/19 at 2:33 p.m. with administrative nurse B revealed he/she expected the care plans to be updated after every fall and believed the fall investigations were thorough, determined the causal factors of the fall and new interventions were implemented. Administrative nurse B revealed he/she was responsible for updating the new care plan interventions after falls to reduce the resident's risk for further falls or injury. The facility's revised (MONTH) 2014 Fall Prevention policy included, .Following any falls, the facility staff completes an Occurrence Report. Details of the fall with be reported and potential causal factors identified and investigated. Interventions will be immediately implemented following each fall and added to the resident's plan of care . The facility failed to complete a timely and thorough investigation of resident #7's falls on 5/9/19, 5/21/19 and 6/9/19 to determine the casual factor of the falls and implement an appropriate intervention to reduce the resident's risk for further falls.

The facility had a census of 84 residents with 8 residents selected for sample. Based on observation, interview and record review, the facility failed to manage pain for 1 of 8 residents during a transfer and incontinence care. Resident #1 repeatedly cried out in pain during a transfer with a sit to stand lift in which staff expected the resident to bear weight on a heel with a large unstageable pressure ulcer (a wound in which the base is not visible). Staff left the resident suspended in the lift for a total of 18 minutes while they provided care following bowel incontinence. Staff continued to provide care to the resident despite verbal and non-verbal indicators of pain. Findings included: - Resident #1's clinical record included a comprehensive [DIAGNOSES REDACTED]. The 6/7/19 Significant Change MDS (Minimum Data Set) identified the resident with no cognitive impairment (Brief Interview for Mental Status score of 13), and the need for extensive assistance of 1 or 2 staff for bed mobility and transfers. According to the assessment, the resident received scheduled and as needed pain medication as well as non-medication interventions for pain, yet experienced occasional pain as high as a 6 on a 1-10 scale within the previous 5 days. The resident had a current unstageable (a wound in which the base is not visible due to being covered with slough or eschar which are different types of dead tissue) deep tissue injury. The 6/7/19 Care Plan noted the resident's generalized lower back pain and directed staff to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. During an observation on 6/25/19 at 1:00 p.m., Direct Care Staff [NAME] and J prepared to transfer resident #1 from the wheelchair to the bed via the sit to stand mechanical lift. The resident appeared very frail and weak, and sat in the wheelchair with his/her head down and shoulders slumped forward. The resident wore thick padded boots on both feet and had a gauze dressing partially visible on the left foot/heel. Staff placed the upper body strap/sling around the resident's back and assisted the resident to place his/her hands on the handlebar of the lift while staff raised him/her to a standing position. The resident began to moan repeatedly as staff raised the resident upright. As staff raised the resident, they realized he/she had experienced bowel incontinence which soiled the abdomen above the slacks as well as the lower back and inner thighs. Direct Care Staff [NAME] and J opted to leave the resident suspended in the sit to stand lift while they provided incontinence care and changed the resident's clothing. The resident complained of pain and said Oh, oh, it hurts. It hurts. and Please. It hurts several times as staff cleaned the resident. Staff responded each time by saying We're hurrying, Give us a minute or We're almost done. The resident's complaints of pain increased the longer he/she remained suspended in the sling, with later comments such as My feet. Oh, my feet and Oh, please, please. I need to sit down. The resident also complained about pain to his/her buttocks as staff cleaned the area. As the cleaning process continued, the resident put his/her head down and slumped forward, with his/her hands resting on the handlebar of the lift. In this position, the sling/strap that was previously lower on the back and abdomen raised until it rested directly under the resident's arm, with all of his/her weight placed on that area. The resident winced, moaned and verbalized complaints of pain during the 18 minute time period the staff required the resident to remain suspended in the sling while they provided incontinence care and staff continued to provide care without appropriately addressing the resident's pain. Licensed Nurse K entered the room toward the end of the observation and, in response to surveyor concerns about the resident's pain and prolonged time spent in the lift, asked Direct Care Staff [NAME] and Direct Care Staff J to lay the resident in the bed. As staff lowered the resident onto the bed, he/she said, Oh, Oh, that's so much better. During an interview on 6/25/19 at 2:00 p.m., Administrative Nurse B reported staff have placed resident #1 in the bed in order to complete incontinence care rather than leaving him/her suspended with the lift for a prolonged period of time. According to Nurse B, direct care staff should have also stopped what they were doing and advised the nurse of the resident's pain before they continued to provide care. During a telephone interview on 6/26/19 at 1:30 p.m., physician extender staff H reported resident #1 is too weak to use a sit to stand lift because (he/she) isn't strong enough to bear weight. Staff H also reported the wound on the resident's left foot would cause pain if he/she was asked to bear weight on it. According to staff H, he/she had received no calls or concerns from facility staff related to pain experienced by resident #1. Staff H reported he/she expected staff to utilize pain medication ordered for the resident to manage his/her pain and to let him/her know if pain management was a problem. Although requested, the facility failed to provide a policy related to pain management. The facility failed to to manage pain for resident #1 during a transfer and incontinence care. Resident #1 repeatedly cried out in pain during a transfer with a sit to stand lift in which staff expected the resident to bear weight on a heel with a large unstageable pressure ulcer. Staff left the resident suspended in the lift for a total of 18 minutes while they provided care following bowel incontinence. Staff continued to provide care to the resident despite verbal and non-verbal indicators of pain.

The facility had a census of 84 residents, with 8 residents selected for sample. Based on observation, interview and record review, the facility failed to ensure 2 of 8 sampled residents were free of significant medication errors. Staff administered 8 times the ordered dose of the blood pressure medication [MEDICATION NAME] to resident #2 after failing to clarify the order with the practitioner. The resident developed a rapid pulse rate following administration of the medication and required transfer and admission to the hospital with a [DIAGNOSES REDACTED].#5 who did not have a [DIAGNOSES REDACTED]. Findings included: - Resident #2's clinical record included a comprehensive [DIAGNOSES REDACTED]. the lungs). Progress Notes written on 1/5/19 at 11:31 p.m. noted resident #2's blood elevated blood pressure of 168/121 (normal blood pressure is a systolic/top number below 120 and a diastolic/bottom number below 80). According to the note, Licensed Nurse I phoned Mid-Level Practitioner H about the elevated blood pressure and the practitioner ordered Claudadine (sic) 8 tablet of .1 mg (milligram) one time . Licensed Nurse I entered the medication order in the computer system as [MEDICATION NAME] - give 0.8 mg by mouth one time only for hypertension. According to the MAR (medication administration record), Licensed Nurse I administered 0.8 mg of [MEDICATION NAME] to resident #2. A progress note dated 1/5/19 at 11:50 p.m. described resident #2's physical symptoms of a rapid, unsteady pulse rate which jumped from 88 bpm (beats per minute) to 110 bpm. According to the note, the resident complained of pain to the neck and left arm at that time. The licensed nurse then called EMS (emergency medical services) and arranged for transport to the hospital. The note described the resident with A-fib ([MEDICAL CONDITION], a rapid and irregular heart beat) and a pain rating of 10 on a 1-10 scale with 10 being excruciating pain. Documentation from the hospital to which the resident transported identified the resident with [MEDICAL CONDITION] (low blood pressure) and [MEDICAL CONDITION] (low pulse rate) upon arrival. The hospital contacted the Poison Control Center and followed their recommendations for an overdose of [MEDICATION NAME]. According to the note, the resident admitted to the hospital after treatment in the emergency room . A hospital Discharge Summary dated 1/17/19 listed the resident's discharge [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED]. The facility's investigation into the previously described medication error referred to a conversation with Licensed Nurse I about his/her administration of 8 [MEDICATION NAME] tablets (total of 0.8 mg) to resident #2 on 1/15/19. Nurse I reported he/she questioned the dose and discussed the dose with two other licensed nurses and they decided the dose was correct. Nurse I reported he/she did not call the practitioner back to clarify the order. A notarized statement written by Licensed Nurse I described resident #2's elevated blood pressure and pulse rate which necessitated the phone call to Mid-Level Practitioner H. According to the statement, the practitioner ordered [MEDICATION NAME] 8 X .1 mg. Nurse I reported he/she questioned the order and asked another nurse if the order seemed right. The other nurse questioned the order as well, so they took it to a third nurse who allegedly said yes, it sounds right. Nurse I then administered the medication to the resident. In the statement, Licensed Nurse I explained he/she didn't feel comfortable questioning Practitioner H because he/she called the practitioner prior to the night of 1/15/19 and the practitioner became upset when called at night. In a 1/18/19 written statement, Mid-Level Practitioner H reported he/she ordered 0.1 mg of [MEDICATION NAME] as a one time dose for resident #2 due to an elevated blood pressure. The nurse then repeated the order back to the practitioner correctly and the practitioner confirmed it. According to the practitioner's statement, It's a mystery to me where the 8 tablets came from. If that is what (Licensed Nurse I) heard, (he/she) should have asked for further clarification. During an interview on 6/25/19 at 11:50 a.m., Administrative Staff B confirmed Licensed Nurse I administered 0.8 mg of [MEDICATION NAME] to resident #2 on 1/15/19 when Mid-Level Practitioner H intended for the resident to receive 0.1 mg of [MEDICATION NAME]. According to Nurse B, Licensed Nurse I no longer worked at the facility. During a telephone interview on 6/26/19 at 1:30 p.m., Mid-Level Practitioner H acknowledged his/her written statement dated 1/18/19 and confirmed the statement included relevant concerns about the incident. Practitioner H had no further information to add to his/her statement. The facility's undated General Dose Preparation and Medication Administration, Assistance or Observation policy lacked guidance related to the 5 rights of medication administration to ensure safe administration of medications. The facility failed to ensure resident #2 was free of significant medication errors when staff administered 8 times the ordered dose of [MEDICATION NAME] to the resident after failing to clarify the order with the practitioner. The resident required transfer and admission to the hospital with a [DIAGNOSES REDACTED]. - Review of a progress note dated 6/3/19 for resident #5 revealed the resident had [DIAGNOSES REDACTED]. in walking. Review of the resident's admission minimum data set ((MDS) dated [DATE] revealed the resident had a brief interview for mental status score (BIMS) of 00 indicating the resident could not complete the interview. Review of the resident's cognitive care area assessment (CAA) dated 4/19/19 revealed the resident had severe cognitive impairment. Review of resident #5's physician orders [REDACTED]. Review of a facility reported incident investigation report revealed a medication error occurred on 5/9/19 at approximately 9:00 PM involving resident #5. Administrative nursing staff B administered medications on the secured dementia unit during this time and prepared [MEDICATION NAME] (insulin) 25 units to be given to a resident. Staff B utilized a shadow box (box located on the outside of resident rooms which contain a picture and the name of the resident residing in the room) to identify the resident before administering the [MEDICATION NAME]. The shadow box only had a picture and did not have a resident name included in the box. Staff B addressed resident #5 with a name that was not his/hers and the resident nodded his/her head. Staff B believed resident #5 acknowledged he/she was the correct resident. Staff B then administered the insulin to resident #5. Later during shift change report, staff B realized he/she had administered the insulin to the wrong resident. Resident #5's blood sugar was taken and found to be low with a reading of 59 milligrams per deciliter (mg/dL) (normal range is approximately 80 to 120 mg/dl). The facility updated resident #5's shadow box to include his/her name and staff B was provided education on the 5 right of medication administration and 2 ways of identifying a resident. During an interview on 6/26/19 at 12:11 PM, administrative nursing staff B revealed he/she failed to correctly identify the resident prior to giving insulin and gave another resident's insulin to resident #5 instead. Staff B revealed his/her expectation of the facility staff was to follow the five rights of medication administration to reduce the right for future medication errors. The facility failed to provide an insulin administration policy as requested on 7/1/19. The facility failed to ensure nursing staff correctly identified a resident prior to administering insulin resulting in the wrong resident receiving insulin.

The facility census totaled 84 residents with 7 residents in the sample and 1 sampled for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview and record review the facility failed to reassess the resident's pressure ulcer risk following a significant change in his/her condition, failed to develop interventions to prevent pressure ulcer development and failed to develop interventions to promote healing of pressure ulcers after development for cognitively impaired dependent resident #2. The resident developed a suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or sheer) to the right heel and a stage 2 (partial thickness skin loss, the ulcer is superficial and presents as an abrasion, blister or shallow crater) pressure ulcer to the right buttock. Findings included: - Review of a physician progress notes [REDACTED].#2 revealed the resident had poor overall health, he/she lacked the ability to perform his/her own activities of daily living (ADL) with the severity of dementia (progressive mental disorder characterized by failing memory, confusion) graded as severe. The note identified the resident had late onset [MEDICAL CONDITION] (progressive mental deterioration characterized by confusion and memory failure). The admission minimum data set ((MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 0 indicating severe cognition impairment. The resident had hallucinations (sensing things while awake that appear to be real, but the mind created), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), verbal and other behaviors directed towards others on 1-3 days of the 7 day observation period, which did not impact the resident's life or others and he/she did not reject cares. He/she required limited assistance of 1 person for bed mobility, transfers, locomotion and extensive assist of 1 for dressing and toilet use. He/she had frequently bowel and bladder incontinence. He/she had a risk for pressure ulcer development with interventions of a pressure reducing device in the chair and the bed. He/she did not have a turning/reposition program. The significant change MDS dated [DATE] included the same BIMS score and behaviors as the 6/23/17 MDS. The resident required limited assistance with bed mobility and extensive assistance of 1 staff for transfers, walking in the room or corridor, dressing, eating, toilet use and personal hygiene. The resident always had bowel and bladder incontinence. He/she had the same pressure ulcer risk and interventions as the 6/23/17 MDS. Review of the cognition care area assessments (CAAs) dated 8/18/17 revealed the resident had short and long-term memory problems which required staff to anticipate his/her needs. The urinary incontinence CAA dated 8/18/17 indicated the resident had a significant change in cognitive and physical ability, had urinary incontinence and did not recognize the urge to toilet. The pressure ulcer CAA dated 8/18/17 identified the resident as at risk for skin issues due to cognitive impairment, incontinence and frail/fragile skin. The resident needed staff assistance to keep him/her clean, dry, and repositioned to reduce the risk of skin issues. He/she had a pressure reducing mattress and cushion in the wheelchair. The Braden (a standardized assessment for pressure ulcer risk) scale dated 7/7/17 included a score of 19 (19-23 no risk). The assessment identified the resident with slightly limited mobility, occasionally moist skin, frequent ambulation, no limitation in mobility and probable inadequate nutrition with no apparent problems for friction/shear). The clinical record lacked evidence the facility conducted a Braden assessment to determine the residents risk for pressure ulcer development following the significant change in the resident's ADL abilities from limited to extensive assistance from frequently incontinent to always incontinent, and a decline in appetite. The self-care performance deficit care plan dated 6/27/17 revealed the resident required 1-2 staff to reposition/turn in bed, extensive assistance for dressing/undressing with cognitive impairment which made it difficult for him/her to remember how to do things and he/she resisted cares. He/she required 1-2 staff assistance with personal hygiene, toileting and transfers. Review of the care plan on 8/22/17 revealed, although the facility identified the resident at risk for development of pressure ulcers on the admission MDS 6/23/17 and the significant change MDS 8/11/17, the care plan lacked interventions to address those risks. Review of the nursing notes (NN) between 6/16/17 and 8/23/17 revealed the following: On 6/19/17 at 5:41 AM the resident had urinary incontinence bladder and required extensive assist with bed mobility and toileting. NN on 6/30/17 at 9:56 AM recorded the resident received skilled services of physical and occupational therapy for strengthening following a recent decline in ADL abilities. NN on 7/19/17 at 4:27 AM the revealed resident slept quietly in bed with the call light in reach, no change in range of motion or level of consciousness and denied pain. The notes lacked evidence staff assisted the resident with turning and repositioning. NN on 8/6/17 at 5:41 AM the resident had slept and was lethargic all evening shift (2 PM-10 PM) and very difficult to awaken. NN on 8/9/17 at 8:38 PM documented Hospice services admitted the resident for decreased appetite and orders for comfort care. The nursing notes lacked evidence staff performed a further evaluation of the resident's increased risk for pressure ulcer development and lacked any interventions implemented to prevent pressure ulcer development. The nursing notes between 8/9/17 and 8/20/17 at 3:28 AM do not identify the resident's mobility, ADL abilities, or the need for turning and repositioning. NN on 8/21/17 at 10:58 AM recorded staff found a new skin issue on the resident's right buttock and a water filled blister on his/her left heel. The nurse applied an antibiotic ointment to the buttock and placed a call to the Hospice nurse to come and evaluate. The nursing note lacked evidence of information regarding measurements of the areas or any interventions the nurse put into place to promote healing or prevent worsening. Review of the weekly skin assessments revealed the following: On 8/3/17 staff noted the resident with intact skin, no new impaired skin areas and no care plan review. On 8/10/17 admitted to Hospice or palliative care, no new changes this week, no new impaired skin areas and no care plan review. On 8/17/17 staff noted the resident received Hospice services with no new changes this week, no new impaired skin areas and no care plan review. Observation on 8/22/17 at 11:21 AM revealed direct care staff A and direct care staff C entered the room to get the resident dressed and into the wheelchair for lunch. The resident rested on his/her back with both heels directly on the mattress. The sheet under the resident's right heel and extending up to the calf area had a large discolored area of a reddish/brown dried fluid. When staff A rolled the resident onto his/her right side, observation revealed the resident had an uncovered open wound with jagged edges about the size of a 50 cent piece on the right buttock. The bed sheet directly under the wound exhibited an area of red discoloration from wound drainage. Licensed nurse D noted the wound appearance, did not take measurements and direct care staff A cleansed over the area with a disposable incontinent wipe. Licensed nurse D then applied a liberal amount of [MEDICATION NAME] (a skin protectant to promote healing of skin other than open wounds) to the open area. When the nurse was asked about the wound the nurse reported he/she did not know it was open and draining. The nurse said the resident had a blister on the heel which must have broken and drained when asked about the dried fluid discoloration on the sheet. Observation at this time revealed the entire right heel appeared dark blue/black in color and the lateral heel blister had ruptured. Licensed nurse D said he/she was informed in report this morning of a blister to the right heel. Observation of the left heel revealed redness and the nurse said the heel felt mushy (boggy or spongy heels are usually seen in people who are beginning to get a pressure ulcer from keeping the foot/heel in the same place for too long). On 8/22/17 at 11:40 AM direct care staff A and direct care staff C applied non-skid socks to the resident's feet, assisted him/her to stand and placed him/her in a wheelchair. Direct care staff A propelled the resident out to the dining room table. Observation revealed both feet/heels rested on the hard plastic foot pedal. Observation at 11:50 AM, 12:05 PM, 12:22 PM, 12:32 PM, 12:50 PM, 1:08 PM, 1:20 PM and 1:38 PM and 1:50 PM revealed the resident remained in the wheelchair at the dining room table with his/her feet/heels on the hard plastic foot pedals. At 2:35 PM observation revealed the resident still in the wheelchair at the table with staff trying to engage him/her in an activity. The resident's feet/heels remained on the hard plastic foot rest with the right foot slid forward allowing more pressure onto the heel area. Direct care staff E did not know when the resident was last repositioned and said he/she waited for the coworker to return and start rounds. He/she reported the resident would be assisted to bed at that time. The resident remained in the wheelchair with his/her heels directly on the foot pedal without cushioning or pressure prevention for 2 hours and 55 minutes. Observation on 8/22/17 at 3:08 PM revealed the resident rested in bed on his/her right side. Hospice licensed nurse H entered the room to provide care and assessed the right buttock wound as a stage 2 pressure ulcer which measured 2 centimeters (cm) by 2.5 cm and superficial depth. He/she cleansed the area with a wound cleanser and applied a butterfly shaped foam adhesive dressing. Licensed nurse H reported the first notification he/she received about the new pressure ulcers occurred earlier that morning. He/she assessed the right heel as a suspected deep tissue injury (purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of the underlying soft tissue from pressure and/or sheer) from the bottom of the heel and up over the calcaneus bone which measured 7 centimeters (cm) by 5 cm and the outside of the heel had a ruptured 2 cm by 3 cm blister. He/she cleansed the area with wound cleanser, skin prep (a liquid film-forming dressing which upon application to intact skin, forms a protective film) and applied a foam padded adhesive dressing. Observation on 8/23/17 at 7:50 AM revealed direct care staff A and direct care staff C assisted the resident to dress. Direct care staff C attempted to put shoes on the resident who moaned as if in pain, then staff C decided to just have him/her wear non-skid socks. Staff A and staff C assisted the resident to stand and pivot transfer to the wheelchair. Staff C placed the resident's feet/heels directly onto the hard, plastic footrest of the wheelchair and propelled the resident to the dining room table. Throughout the breakfast meal observation revealed the resident's feet/heels remained on the footrest. At approximately 8:45 AM licensed nurse J was interviewed about interventions or padding the heels and he/she said he/she would get some padded booties for the resident's feet. Interview on 8/22/17 at 11:30 AM with direct care staff A revealed he/she became aware of the resident's skin breakdown on the buttock and right heel in the change of shift report around 6:00 AM. He/she did not know of any interventions to prevent pressure ulcers because the resident got up and walked independently until about 2 weeks ago. He/she was unaware of any changes in the care plan after the areas were discovered other than making sure the resident was repositioned. Interview on 8/22/17 at 2:50 PM with direct care staff E revealed he/she did not know of the resident's skin issue or any pressure ulcer prevention measures. He/she said the last time he/she worked with the resident he/she walked around independently. Interview on 8/23/17 at 6:05 AM with direct care staff K revealed he/she heard in report at the start of the shift (10 PM-6 am on 8/22/17) about the intervention for staff to reposition the resident every 2 hours and to elevate the resident's heels. He/she did not know of any pressure ulcer prevention measures in place before 8/22/17. Interview on 8/23/17 at 6:26 AM with licensed nurse L revealed he/she assisted the direct care staff at night with checking the residents for incontinence and repositioning. The nurse said prior to 8/21/17 he/she would not normally check on the resident because the resident could and did get up on his/her own and walked about. On 8/21/17 in report he/she was not told about the buttock being reddened and sheared in appearance. While assisting direct care staff with cares he/she observed the area and directed the staff to turn the resident side-to-side every 2 hours. Interview on 8/23/17 at 9:40 AM with licensed nurse J revealed he/she had cared for the resident for about 3 weeks and the resident's status was about the same. Prior to Monday 8/21/17 he/she did not feel like the resident was at risk for pressure ulcers because he/she slept all night and sat up in the wheelchair during the day. He/she assessed the area on Monday which direct care staff reported as a quarter sized area of shearing, the area did not appear as a shallow crater, and the skin around it was wrinkly like a skin tear. He/she attempted to pull the skin back over the opening, cleaned the area and applied an antibiotic ointment. He/she did not apply a dressing and left the wound open to the air. He/she reported placing a call to the hospice nurse and left a message and reported the area during shift report around 2:00 PM. He/she did not implement any pressure ulcer prevention or protocols and did not know of the facility's pressure ulcer policy and procedure. Interview on 8/23/17 at 9:53 AM with administrative nurse B revealed an expectation for staff to assist the resident with repositioning every 2 hours when the resident needed assistance with bed mobility. He/she reviewed the resident's care plan and confirmed the care plan lacked any information regarding pressure ulcer prevention or interventions following development which would promote healing. He/she confirmed the facility failed to reassess for pressure ulcer risk after the significant change in the resident's condition. He/she reported the bed mattress and wheelchair cushion used were pressure reducing but not pressure relieving. He/she could not identify any interventions in place to prevent the right heel pressure ulcer development. He/she explained the resident had an overall decline in health, ADL abilities and appetite about a month ago related to dementia. Review of the manufactures guidelines for application/use of [MEDICATION NAME] ointment revealed the ointment should be applied to protect skin from incontinence, to protect the skin around wounds, for stage 1 (intact skin of non-blanchable redness) pressure ulcers and for external use only. Directions for how to apply included to apply a thin layer of [MEDICATION NAME] to skin surrounding the wound, cover the wound and wound edges with an appropriate dressing which should extend beyond the areas of [MEDICATION NAME] to ensure tape adherence. Review of the facility's Pressure Ulcer Prevention dated 1/2017 revealed the facility planned for staff to conduct a standardized pressure ulcer risk assessment (Braden Scale) to identify residents at risk for development of pressure ulcers. The assessment should be completed upon admission, every week for 4 weeks, quarterly and when a significant change in the resident's condition was noted. Staff developed an individual plan of prevention to meet the resident's needs. Interventions which could be used included: use of lift sheets to reduce friction/shearing, turning and repositioning every 2-3 hours when in bed or more frequently depending on the needs of the resident, every hour when in the chair. The policy directed staff to relieve pressure to the resident's heels by using pillows or other devices. The facility failed to reassess the resident's pressure ulcer risk following a significant change in his/her condition, failed to develop interventions to prevent pressure ulcer development and failed to develop interventions to promote healing of pressure ulcers after development for 1 sampled resident (#2). This failure allowed the resident to develop a suspected deep tissue injury to the right heel and a stage 2 pressure ulcer to the right buttock.

The facility reported a census of 84 residents with 17 residing in the memory care unit. The sample included 5 residents from the memory care unit. Based on observation, interview, and record review, the facility failed to ensure 3 of 3 residents remained as accident free as possible. The facility failed to complete root cause analyses to identify causal factors and failed to provide adequate supervision to prevent falls for 1 of 3 residents sampled for falls. Resident #4 experienced 2 falls within 3.5 weeks, one which resulted in a fall that required hospitalization in the intensive care unit for an acute (rapid onset) 2-3 millimeter (mm) subdural hematoma (SDH- a rupture of blood vessels between the brain and the outermost layer that covers the brain- acute being the most dangerous type of SDH) and 5 staples to the back of the resident's head. Upon return from the hospital resident #4 required use of a wheelchair due to his/her inability to stand. The facility also failed to identify causal factors related to falls experienced by resident #1 and #2. Findings included: - Review of resident #4's undated physician order sheet revealed [DIAGNOSES REDACTED]. Review of the annual minimum data set ((MDS) dated [DATE] revealed the resident had short and long-term memory problems and severely impaired cognitive skills for daily decision making and continuously present signs of delirium (inattention). The resident required extensive assistance of 2 staff with bed mobility and transfers and required extensive assistance of one staff with walking in his/her room and corridor, and with locomotion on and off the unit. The resident was not steady and could only stabilize with staff assistance for all balance during transitions and walking. The resident did not have any functional limitation in range of motion to upper or lower extremities. The resident used a wheelchair for mobility and did not experience any falls since the prior assessment. The resident received daily antianxiety medication. The MDS revealed the facility did not use restraints with the resident. Review of the 2/8/17 quarterly MDS revealed the resident had short and long-term memory problems and moderately impaired cognitive skills for daily decision making. The resident had fluctuating inattention and disorganized thinking present. The resident required the same assistance with bed mobility, transfers, walk in room and corridor, and locomotion on unit as prior assessment. The resident required extensive assistance of 2 staff with locomotion off of the unit. The resident had no change in range of motion, and did not use a mobility device. The resident fell on ce since the 11/8/16 prior assessment, without injury. Review of the Fall care area assessment (CAA) dated 8/11/16 revealed the resident had a risk for falls, very poor safety awareness, and often bent down to the floor to pick up things that were not there. The resident was often unsteady on his/her feet. The resident maintained a sitting balance when in a chair, had impaired balance when transferring and was unsteady, and had poor balance at times. The resident had a [DIAGNOSES REDACTED]. The CAA revealed staff would assist the resident with transfers and ambulation and check and change the resident at least every two hours to keep him/her dry to reduce the risk of falls. Review of the Cognitive loss/dementia CAA dated 8/11/16 revealed the resident had a [DIAGNOSES REDACTED]. The resident required extensive to total assistance from staff for his/her activities of daily living (ADLs). The resident could be resistive to cares at times and might take two staff to assist him/her. The staff anticipated the resident's needs and wants, and provided the resident with the assistance needed to complete his/her ADLs due to the resident's severe cognitive deficit. Review of the fall risk assessment dated [DATE] at 12:35 p.m. identified the resident as a low risk of falls (score of 12), revealed the resident fell recently, had no history of falls in the past 6 months, and the resident had no memory or recall ability. The resident displayed no agitated behavior in the last 7 days, was ?confined to a chair, and oriented. The resident could not walk even when assisted by staff. Review of the fall risk assessment dated [DATE] at 7:45 p.m. identified the resident as a high risk for falls (score of 21) and revealed the resident admitted less than 3 months prior, fell in the last 6 months, did not have memory or recall ability, no agitated behavior in last 7 days, and was not confined to a chair. The resident exhibited loss of balance while standing, required hands-on assistance to move from place-to-place, exhibited instability when turning, and he/she used an assistive device. Review of the fall risk assessment dated [DATE] revealed the resident fell within the last 6 months during the day, had injuries with past falls, and the resident did not recognize danger. The questionnaire identified the main reason for past falls for the resident included: age related declines in function and shuffling or other gait issues. The resident usually wore slipper socks and often stood and tried to ambulate without assistance. The resident's gait was unsteady which led to falls and injury. Review of the Falls/safety care plan revised on 2/15/17 revealed the resident had an increased risk of injury from falls related to frequently wandering, poor safety awareness due to cognitive impairment ([DIAGNOSES REDACTED]. The resident could ambulate independently, with a slow steady gait and placed him/herself on the floor at times as a behavior. The care plan included the following interventions for the resident: 11/21/12: The resident was most content when allowed to wander. Staff were to redirect if wandering behavior became intrusive to others. 10/22/13: The resident enjoyed wandering around on the locked unit. 7/7/14: The resident needed to be in an area continuously monitored on the Unit (unit 3-memory care unit) when he/she was awake. The resident required frequent visual checks when he/she slept in his/her room. 5/29/15: Place the resident in a place where staff could monitor him/her. 1/13/16: fall 1/14/16: Staff would turn the table so the resident could to scoot his/her chair away from the table. 1/28/16: witnessed non-injury fall 1/28/16: When the resident participated in group exercise, have a staff member sit/stand next to the resident. 8/3/16: fall with skin tear 8/4/16: Keep the resident's bed in the lowest position when in bed, and a fall mat next to the resident's bed. 1/23/17: non injury fall 1/24/17: When the resident got restless and did not want to sit down, staff were to walk with the resident to ensure he/she did not fall. 2/15/17: fall with injury 2/15/17- The staff sent the resident by emergency medical services (EMS) to the emergency room (ER) for further evaluation. 2/17/17-The resident used a wheelchair upon return to the facility, due to his/her inability to stand. The staff were to monitor the resident's ability to ambulate and stand, over the weekend. The resident required assistance of 1-2 staff for safety with ambulation and transfers. 2/20/17: Physical therapy to evaluate and treat due to fall and use of wheelchair upon return to the facility. The resident fell on [DATE], 10/14/15, 1/13/16, 1/28/16, 8/3/16, 1/23/17, and 2/15/17. Review of the fall details report dated 1/23/17 revealed the resident fell (non-witnessed), refused to sit in his/her chair, got out of the chair, walked around the dining room (which was normal for the resident), lost his/her balance and fell . Skin assessment revealed no injury noted to resident #4 and 2 staff assisted the resident back to his/her chair by use of a gait belt. The conclusion of the assessment revealed the resident did not want to sit in his/her chair and walked around the dining room, lost his/her balance and fell . Staff were to walk with the resident when he/she got restless and to ensure the resident did not fall. The report did not identify causal factors which contributed to the fall. Review of the nurse's note dated 2/15/17 at 11:54 a.m. revealed the resident fell (non-witnessed) and sustained a laceration to the back of his/her head. The laceration measured 2 centimeters (cm) in length and full depth. Licensed nursing staff L heard a banging noise and observed resident #4 laying on the floor on his/her back in front of the nurse's station. Prior to the fall the staff observed the resident seated at the dining room table. Staff L stated the resident lost his/her balance while ambulating independently, and fell to the floor on the resident's back. Staff applied a pressure dressing to stop bleeding and sent the resident to the hospital by Emergency Medical Services (EMS) for evaluation and treatment. Review of the facility investigation from a fall incident on 2/15/17 regarding resident #4 revealed he/she sustained a 4 centimeter (cm) laceration (cut) to back of his/her head (right side) which required 5 staples to close, and an acute (rapid onset)) 2-3 millimeter (mm) subdural hematoma (a rupture of blood vessels between the brain and the outermost layer that covers the brain). The investigation stated the resident normally ambulated about with limited assistance, and he/she might need guidance when he/she was going to another resident's room or walking into an area where there was a group of people. The resident walked with his/her head down which prevented him/her from seeing obstacles in the distance. The investigation revealed staff from unit 3 (memory care unit) called direct care staff I (worked in unit 2) to assist the staff in unit 3, due to the resident fall. The signed witness statement from direct care staff J revealed he/she worked 6:00 a.m. until 2:00 p.m. on 2/15/17 and stated he/she did not witness the fall, but returned from lunch and hung his/her jacket up and heard a loud noise. Staff J wrote he/she stood up at the nurse's station and saw resident #4 on the floor. The investigation revealed the ER sent the resident to the intensive care unit (ICU) at the hospital on [DATE] and the resident admitted back to the facility on [DATE]. Review of the facility fall investigation revealed the facility failed to identify the causal factor that contributed to the fall. Review of the daily staffing sheet from 2/15/17 revealed one nurse and two direct care staff were scheduled to work on the memory care unit between 6:00 a.m. and 2:00 p.m. Further review revealed one direct care staff member left at 11:27 a.m. and that left one nurse and one direct care staff for the memory care unit between 11:27 a.m. and 12:36 p.m. The restorative aide that was also scheduled on 2/15/17, (and usually assisted at lunch on the memory care unit) did not work (called in) on 2/15/17. Observation of resident #4 on 3/30/17 at 11:30 a.m. revealed the resident sat in his/her wheelchair in the dining room of the memory care unit. The back of the resident's wheelchair sat against the wall behind the resident and the dining room table was pushed up over the lap of the resident. The resident stood up from his/her wheelchair and held a hand on the table in front of him/her, but could not fully stand up as the dining room table became pressed against the front of his/her thighs. The direct care staff stood by the resident as the resident stood/ paced in place. The resident looked right and left and moved his/her legs both left and right put could not gain access out and was stuck between the table and the wheelchair that was pushed up against the wall. Observation on 4/3/17 at 9:10 a.m. revealed the resident sat in his/her wheelchair with the back of the wheelchair against the wall and the table pushed over the resident's lap to over the resident's mid-thigh. Direct care staff D sat in the dining room at the next table with his/her back to resident #4. Staff D played with the blocks with three residents at a table, while resident #4 sat at his/her table with one other resident, and no activities on his/her table and the resident moved his/her feet but could not stand up at the table was placed over the lap of resident #4. At 9:24 a.m. the resident stoop up from the wheelchair and pushed on the table with his/her thighs to attain a more erect position and then rubbed the table with his/her hand and tried to maneuver away from the wheelchair to the left, but could not. The front of the resident's thighs rubbed the table when he/she stood. Interview with direct care staff E on 3/30/17 at 11:40 a.m. revealed the resident was more difficult because the resident liked to stand. Staff E stated the resident had a history of [REDACTED]. Staff E said the staff had to put the table very close in front of the resident and the back of his/her wheelchair against the wall to keep the resident from falling and to keep the resident from wandering. Staff E stated he/she went to change the resident one day and the resident walked to the middle of the dining room and was not steady and no one was in the dining room to observe him/her because the staff were busy elsewhere. Interview with licensed nursing staff K on 3/30/17 at 12:37 p.m. revealed the resident had a pad alarm, fall mat, and when the resident sat in his/her wheelchair the staff attempted to have one on one or be visually seen by staff when he/she sat by the nurse's station. Staff K said he/she had not seen the resident ambulate independently, and stated the resident used the wheelchair. Staff K stated the area where the resident currently sat (with the back of the wheelchair against the wall and table over the resident) was the resident's designated spot. Staff K stated the purpose of the table pushed up close was so the resident did not fall forward. Staff K stated there were a few times the dining room was not monitored if the staff had to run and go do something real quick down the hallway. Interview with licensed nursing staff H on 4/3/17 at 6:55 a.m. revealed the resident did not communicate and could get up on his/her own and the resident walked with a lean. Staff H stated before the fall the resident walked all around the unit and got down on his/her hands and knees and picked up things from the floor and then independently got back up. Staff H stated the resident walked back and forth and said that was all the resident wanted. Staff H stated the resident used to sit in a dining room chair (before the resident required his/her wheelchair) by the wall with his/her back to the wall. Staff H stated the resident required assistance to walk. Interview with licensed nursing staff M on 4/5/17 at 8:53 a.m. revealed on 2/15/17 a direct care staff from the memory care unit came to get staff M to assist with resident #4's fall, so the staff could get EMS called. Staff M stated there was one nurse and one aide when Staff M went back to the memory care unit to assist. Interview on 4/5/17 at 4:10 p.m. with administrative nursing staff A revealed he/she expected staff to fill out the fall information after a fall to show what staff observed and what happened, the Situation, Background, Assessment, Recommendation form (SBAR - used to help facilitate communication of an event), notify administration, family, and physician. Staff A stated the staff should position a resident in a wheelchair so the resident had enough room to push back and move away from the table. Staff A said on day shift 2/15/17 the memory care unit had 1 nurse and 2 aides on the schedule, but one aide was at lunch and the other aide had to leave at 11:27 a.m., so between 11:27 a.m. and 12:36 p.m. the facility should have had an extra staff member in the memory care unit to assist with the meals. Staff A verified the resident fell in the memory care unit around 11:50 a.m. on 2/15/17 and the memory care unit had to pull staff from other units to assist. Review of the facility policy on falls revised 2/2014 revealed the staff placed residents identified as high risk for falls on the S.A.F.E. program (Safety Assessment, Fall prevention and Education). Following any falls, the facility staff completed an occurrence report. Details of the fall were reported and potential causal factors identified and investigated. Interventions were immediately implemented following each fall and added to the resident's plan of care. All occurrence reports were reviewed at the daily quality assurance (QA) meeting to ensure staff immediately implemented and added an intervention to the plan of care and the appropriateness of the current intervention. The facility failed to identify causal factors for the falls for resident #4 and failed to ensure adequate monitoring for resident #4 who fell and sustained a laceration to the back of his/her head (required 5 staples), an acute subdural hematoma, ICU hospitalization , and returned to the facility with decreased mobility. - Review resident #2's undated physician orders revealed the resident had the following Diagnoses: [REDACTED]. Review of the resident's admission minimum data set (MDS) assessment dated [DATE] revealed facility staff assessed the resident to have short and long-term memory problems. The resident had severely impaired daily decision making skills. The resident had inattention and disorganized thinking. The resident required extensive assistance of one person for transfers, locomotion off the unit and walking in the corridor. The resident required limited assistance of one person for walking in his/her room and locomotion on the unit. The resident required total dependence of one person for toileting. The resident required a wheelchair for mobility. The resident had no falls identified prior to admission. The resident had 2 or more no injury falls and 2 or more injury (except major) falls since his/her admission to the facility. Review of the Cognitive Loss/Dementia care area assessment (CAA) dated 12/22/16 revealed resident had a [DIAGNOSES REDACTED]. The CAA stated staff needed to anticipate the resident's needs and wants. The resident could not follow commands. The resident had nonsensical speech, did not speak English as a first language and did not answer appropriately when asked questions. The resident had confusion, disorientation (related to his/her new surroundings because he/she newly admitted to the facility), forgetfulness and short attention span. Staff identified the resident as not orientated to place or time. Review of the Falls CAA dated 12/22/16 revealed the facility did not have information related to resident's falls prior to coming to the facility. The resident fell since he/she admitted to the facility. At the time of the assessment the resident had 5 falls since admission. The resident fell without injury on 2/17/16. The resident fell twice on 2/19/16, once with injury and one without. The resident fell on [DATE] with injury and fell on [DATE] with no injury. The resident maintained a sitting balance. The facility identified the resident's transfers as unsafe based on observations. The resident was impulsive, had no safety awareness and could not follow simple commands. The resident had unsteadiness, poor balance, and severe cognitive impairment. The resident had no environmental factors (presented as a fall risk). The resident's representatives were concerned about the resident's recent falls. The facility explained to the resident's representatives related to his/her severe cognitive impairment he/she had impulsiveness and staff would make sure to keep the resident safe and free from injury related to falls. The resident's electronic clinical record lacked evidence of an initial care plan that included fall interventions prior to 12/17/16, even though the resident had incontinence, poor decision making and cognitive impairment at the time of admission. Review of the resident's progress notes dated 12/15/16 revealed the resident admitted to the community, had confusion and did not know his/her physical limitations. Review of the resident's progress note dated 12/16/16 revealed the resident had confusion and he/she did not know his/her physical limitations. Review of the behavior note dated 12/17/16 revealed the resident was up and down most of the day, ate non-food items (such as napkins, papers, utensils)and attempted to self-transfer multiple times. On 12/17/16 the resident fell in his/her room. Review of the facility fall investigation revealed at 3:00 PM staff responded to a bed alarm and found the resident on the floor without injury. The resident sat on his/her bottom with his/her back against the bathroom door. Two staff assisted the resident with the use of a gait belt back to his/her wheelchair and staff toileted the resident at that time. The resident could not say how he/she fell . Review of the investigation lacked evidence the facility identified the causal factors that led to the resident's fall. Review of the resident's care plan for falls revealed the following interventions: 12/17/16 - Staff would do neurological checks. The resident would have a chair alarm in his/her wheelchair while he/she sat in his/her wheelchair. The resident required a fall mat at bedside when in bed. The resident required his/her bed be in lowest position when in bed. The resident would receive physical/occupational therapy for strength and mobility. The care plan lacked specific interventions directly related to the causal factors of the fall. Review of the resident's behavior note dated 12/18/16 revealed the resident continued to stand up from his/her wheelchair and he/she walked without staff assistance. The resident's wheelchair alarm sounded. Staff continuously redirected and reminded the resident to wait for assistance. The resident could not understand direction and did not know his/her physical limitations. Staff provided one-on-one care to prevent resident falls due to resident's lack of compliance with transfers. The resident rejected care throughout shift. On 12/19/16 at 5:30 AM revealed the resident fell resulting in a laceration of the left eyebrow and injury to the left side of his/her lip. Review of the facility fall investigation revealed the nurse entered the resident's room and found the resident lying on his/her left side with his/her left hand under his/her head. The resident had restlessness and mumbled. The nurse reported the resident became hard to hold still while he/she cleaned the blood from the resident's left eyebrow. The resident also had blood on his/her mouth and a chipped tooth (from prior to admission) in the front of his/her mouth. The witness identified the resident as barefoot, wearing a dry brief and shirt. The resident could not state how he/she fell . The resident had a bed alarm on his/her bed that did not sound, although tested and working properly when the resident got up from his/her bed. The investigation lacked evidence the facility identified the causal factor related to the resident's fall. On 12/19/16 at 5:50 AM, the resident fell a second time in his/her room. Review of the fall investigation revealed the resident got up from bed and walked in his/her room. The resident grabbed the vital signs machine located in his/her room. The witness heard the resident's bed alarm sound when he/she stood up off the bed. The witness saw the resident grab the vital signs machine, loose his/her balance and fall to the floor near his/her closet. The witness broke the resident's fall, but the resident did make it to the floor. The resident scooted on his/her bottom and hands to his/her bed. Staff helped the resident to stand, dressed the resident and took him/her to the commons area for observation. On 12/19/16 at 2:20 PM the resident fell a 3rd time. The facility identified the resident as oriented to his/her self only and the resident did not communicate effectively. The resident often tried to get out of his/her wheelchair and bed without assistance which led to falls. The witness to the fall stated as he/she talked with another resident he/she heard a chair alarm go off. The witness saw the resident get up/out of his/her chair and try to walk. As the resident got up staff ran over to the resident to catch him/her. The resident teetered badly and the witness grabbed the resident's shirt as he/she slid against the wall to the ground. The conclusion of the investigation revealed an alarm sounded and staff could not get to the resident before he/she fell . The resident had an injury to his/her eyebrow and mouth from a fall earlier in the day. The facility received a treatment order for the resident's injuries. The facility called a psychologist to see the resident. The investigation lacked evidence staff identified the causal factor related to the resident's fall. Review of the behavior note dated 12/19/16 revealed the resident attempted to get up from his/her wheelchair and refused to go to bed and lie down. The resident required one-on-one observation to prevent falls. The resident received as needed (PRN) pain medication for his/her chipped tooth and the laceration to his/her left eye. The resident's care plan had the following updates: 12/19/16- The facility contacted a psychiatrist for medication management related to anxiety and impulsiveness. The facility had a psychiatrist scheduled to evaluate the resident on 12/19/16. Staff notified and resident's physician and placed the resident on doctor's list. The resident had an order for [REDACTED]. Staff repositioned the resident's alarm. The resident had new medications ordered by the psychologist, which included Neurontin (medication used to relieve nerve pain) and Paxil (antidepressant medication). The resident's care plan lacked any evidence of interventions specifically related to the causal factor of the resident's falls on 12/19/16. The resident fell on [DATE] in his/her room. At 5:35 PM staff observed the resident laying on the floor on his/her right side with his/her head outside the doorway of his/her room. The nurse observed bleeding from the resident's lower lip with an open area 1 centimeter (cm) on left side of the lower lip. The nurse initiated treatment to the resident's lip per facility protocol. The resident could not state what happened due to language barrier and confusion. The investigation revealed the resident's bed alarm was unplugged. Staff repositioned the resident's bed alarm to the opposite side of the bed. The facility investigation lacked a causal factor of the resident's fall. Review of the progress note dated 12/20/16 revealed the resident required a chair and bed alarm. The resident did set off his/her chair/bed alarm during the shift. On one occasion the resident looked for the bathroom and he/she did not know what the resident needed on the other occasions. Review of the resident's care plan lacked evidence the facility identified he/she looked for the bathroom at least one occasion when he/she set off his/her bed/chair alarm. Review of the resident's care plan revealed: 12/20/16- Staff moved the resident's bed alarm box out of reach from resident. The resident's care plan lacked an update specific to the causal factor related to the resident's fall. 12/21/16- Staff updated the resident's care plan with the following intervention: The resident used a merry walker (walker/chair combination ambulation device) when up for ambulation assistance for the resident's protection and safety. Staff checked and released the merry walker every 2 hours and PRN for toileting/repositioning. Staff would monitor the whereabouts of the resident at all times and redirect PRN. Review of the progress note dated 12/21/16 revealed the resident moved to facility memory care unit (MCU). The resident fell on [DATE]. The resident sat in his/her merry walker at the dining table in the dining room with staff supervision. The resident stood up and walked sideways in the Merry Walker, taking a few steps left. Staff headed to assist the resident while he/she remained in with visual view. The resident tipped over the left side of the merry walker and fell with the walker onto floor. The resident landed on his/her back and hit the back of his/her head on the floor. Review of the care plan lacked evidence of intervention related to the resident's fall on 12/22/16. Further review of the resident's care plan revealed the following intervention: 12/23/16- Staff took the resident out of the merry walker. The resident continued to work with therapy. The resident fell with injury on 12/27/16 at 8:30 PM. The fall investigation revealed a nurse found the resident in a dining room chair being assisted by another nurse. The resident had a bleeding abrasion to the left eyebrow. A direct care staff found the resident lying on his/her left side on dining room floor, bleeding from the left eyebrow. The conclusion to the investigation revealed the resident had been in the dining room attempted to self-transfer. The resident re-opened a previous abrasion above left eye. Review of the fall investigation lacked a causative factor for the resident's fall. Review of the resident's care plan lacked an updated intervention to prevent falls on 12/27/16, further review of the resident's care plan revealed: 12/28/16- Staff transferred the resident's chair alarm with the resident when he/she sat in the dining room chair. The resident's care plan lacked specific interventions related to the causative factors related to the resident's fall. Review of the behavior note dated 12/29/16 revealed the resident self-transferred multiple times from his/her wheelchair. The resident had unsteady gait and did not follow directions related to his/her inattention. The resident fell without injury on 1/3/17. The investigation revealed the resident sat at the dining table in his/her wheelchair folding towels as an intervention for restlessness with the nurse present. The resident pushed on the table propelling him/herself backwards in the wheelchair. The resident then scooted forward onto the edge of the wheelchair seat turned sideways only having his/her right buttock on seat. The nurse began to make his/her way to the resident when the resident scooted back again and fell on the floor to his/her buttocks and left elbow. The resident's wheelchair alarm sounded. The conclusion to the investigation revealed the resident sat in his/her wheelchair and slid out of wheelchair while a nurse was present before the nurse could help the resident. The resident's care plan revealed the following intervention: 1/3/17- The facility added an anti-slider (device used to keep a resident from sliding out of his/her wheelchair) to the resident's wheelchair Review of the behavior note dated 1/5/17 revealed the resident had restlessness and attempted to self-transfer. The resident fell without injury on 1/24/17. Review of the fall investigation revealed a nurse had the resident in his/her office at the time of the fall. The nurse went to another unit in the facility and quickly returned to find the resident lying on floor on his/her stomach. The resident quickly got him/herself up on his/her knees and crawled on the floor. Conclusion of the fall revealed staff observed the resident was wet at the time of the fall. Staff set up a toileting sc

The facility census totaled 93 residents. The sample included the review of 3 residents with falls. Based on record review of a closed medical record and interviews, the facility failed to promptly address the newly developed hip pain for 1 of 3 sampled residents. (#1014) The resident's pain required treatment with a [MEDICATION NAME]-based pain medication ([MEDICATION NAME]) and caused the resident to remain in bed throughout the day. The resident experienced the pain for over 12 hours before the facility staff received a physician's orders [REDACTED]. Findings included: - Review of a closed record for resident #1014 revealed the resident moved into the facility on [DATE]. According to the first nurse's note that contained the staff's initial assessment of the resident, dated 3/12/12 and timed 1:50 p.m., revealed the resident came into the facility accompanied by family. The note described the resident in the following manner: used a wheelchair, a high fall risk, alert and oriented with forgetfulness, used oxygen at 2L/NC (2 liters per nasal cannula), purse lip breathing noted, denied difficulty to breathe, continent of bowel and bladder, aware of need to void and received Hospice services. The note identified that the resident appeared restless and that staff continued to remind the resident to use the call light. The note further described how staff placed a bed alarm and floor mat in the resident's room. Review of a pain assessment, completed on 3/12/12 by staff, identified the resident did not experience any pain. Directions for the assessment guided staff to complete the assessment upon admission, quarterly, annually and with any significant change in status. Review of a fall risk assessment, initially completed on 3/13/12, identified the resident at a moderate risk for falls. The staff updated the fall risk assessment on 3/16/12 and 3/26/12. The updated assessment on 3/16/12 identified the resident at high risk for falls and directed staff to update the care plan, Kardex, review medical symptoms with physician, discuss with family, weekly safety committee review and refer to therapy. The update on 3/26/12 again identified the resident at high risk for falls. Review of the interim care plan, dated 3/12/12, provided the following guidance to staff on caring for the resident: continent of bladder, used bathroom, wore small incontinent pads, staff to assist. Up ad lib (as desired), up with assist from staff. Used w/c (wheelchair) for locomotion, ambulated with 1 staff assist, transferred with 1 staff assist, high risk for falls. The staff updated the care plan on 3/15/12 and identified the staff found the resident on the floor. The new interventions implemented included a fall mat by bed, bed alarm to bed; move closer to nurses ' station. The staff again updated the care plan on 3/20/12. The new intervention included the initiation of a walk to dine program trial. On 3/25/12 staff updated the care plan and identified the following: hip X-ray, send to ER (emergency room ), position self, is a DNR (Do Not Resuscitate). Review of the daily nurse's notes from 3/12-18/12 revealed the nursing staff documented the resident as up in the wheelchair every day, out to meals in the dining room but with a poor appetite and frequently required closer monitoring by staff because the resident attempted to stand up and walk away from the wheelchair independently, which required frequent intervention and redirection from staff. Review of a nurse's note, dated 3/19/12 at 10:00 p.m. revealed staff had moved the resident from Unit I to Unit II. The note also described the resident as agitated, attempted to stand and stating "I am going home!" The note identified that staff gave the resident a dose of PRN (as needed) [MEDICATION NAME] (antianxiety medication), but the resident continued the anxious behavior. Staff then redirected the resident, who remained calm for a while, then attempted to stand up out of the wheelchair independently. The staff kept the resident within reach. Review of a nurse's note, dated 3/21/12 at 03:45 a.m. revealed the resident had no complaints of pain/discomfort noted. Review of a nurse's note, dated 3/25/12 at 07:10 a.m. revealed Licensed nurse A found the resident lying on his/her left side, on the floor, at 6:30 a.m. The note described staff A noted dried blood by the resident's right arm, and an old skin tear that had re-opened to the resident's left arm. The resident's underwear was down to the resident's knees and urine was on the floor under resident. The resident stated he/she hit his/her head. The nurse identified the resident conducted range of motion within normal limits, had no bruises noted to the resident's head or any other areas except the left elbow. The note described that 2 staff assisted the resident to bed then to the wheelchair. Staff assisted the resident to dress and then out to nursing station. The note lacked any assessment of pain, or any notification of the physician, family, or hospice staff of the fall. Review of a Neurological Assessment Flow sheet, started on 3/25/12 at 6:30 a.m. for resident #1014, revealed Licensed nurse A identified the resident complained about left leg pain. Licensed nurse A then assessed the resident's neurological status again at 6:45 a.m., 7:00 a.m., and 7:15 a.m. and the nurse identified the resident had no complaints. The continued neurological assessments completed at 7:30 a.m., 7:45 a.m., 8:00 a.m., 8:15 a.m., 8:30 a.m., 9:00 a.m., 9:30 a.m., 10:00 a.m., 10:30 a.m., 11:00 a.m., 12 noon, 1:00 p.m., and 2:00 p.m. revealed Licensed nurse A identified the resident continued to complain of left leg pain. Review of the pain assessment revealed the staff failed to complete the pain assessment with the new onset of hip pain, a significant change in status. Review of the resident's MARs (Medication Administration Record) dated 3/15/12 - 4/14/12 revealed on 3/12/12 the physician ordered staff to administer [MEDICATION NAME] 5 ([MEDICATION NAME] plus [MEDICATION NAME] pain medication, used to treat moderate to severe pain) 1 tablet every 4 hours PRN (as needed) for pain and [MEDICATION NAME] (an opioid narcotic pain medication, used to treat severe pain) 20mg(milligrams)/ml (milliliters) give 0.25mg every 2 hours SL (sublingually-under the tongue) PRN pain/air hunger. According to the MAR, the resident had not received any medications for pain until 3/25/12 at 7:00 a.m., when direct care staff B, certified to give medications, administered a dose of [MEDICATION NAME] to the resident because of "increased hip pain." Staff B identified at 8:30 a.m. that the medication had been effective. According to the MAR, on 3/25/12 at 1:00 p.m. staff B again gave another dose of [MEDICATION NAME] for signs/symptoms of pain and at 1:45 p.m. identified the medication as effective. Finally, the MAR indicated [REDACTED]. Review of a nurse's note, dated 3/25/12 at 9:35 a.m. revealed Licensed nurse A called the family to report the fall and the re-opened skin tear. The note lacked documentation if the staff mentioned the newly developed pain to the family or an assessment of the pain. Review of a nurse's note, dated 3/25/12 at 1:30 p.m. and 7 hours after the staff found the resident on the floor, revealed Licensed nurse A called Consultant G to report the fall and increased pain in the left hip. Consultant G gave an order for [REDACTED]. Review of a nurse's note, dated 3/25/12 at 3:00 p.m. revealed Licensed nurse C, charge nurse for the next shift, identified the resident complained of pain to the left hip. Staff C documented he/she administered [MEDICATION NAME] for the pain. Thirty minutes after the administration of the pain medication, the note identified the resident continued to complain of pain, and the resident was unable to move his/her left leg. License nurse C documented they called the Hospice service to have the hospice nurse paged and also called the family to report Licensed nurse C's assessment and the family member told the nurse that he/she would be there in a few minutes." The nurse's note dated 3/25/12 at 7:30 p.m. identified the family member at the resident's bedside. The nurse documented the family member stated " When they called in morning they told me no injury" and continued to ask if the Hospice nurse had arrived yet. The family member then stated if the Hospice nurse had not called back or arrived within 15 minutes he/she wanted Licensed nurse C to call an ambulance. Licensed nurse C then paged the Hospice nurse for the 2nd time, 4 1/2 hours after the original page. On 3/25/12 at 8:00 p.m., Consultant E, a nurse for Hospice, called the facility and wanted to talk to the family member. After talking with the family member, Consultant E talked with Licensed nurse C and said it was okay to send the resident to the hospital for evaluation. On 3/25/12 at 8:10 p.m., Licensed nurse C called Consultant G, who gave an order to send the resident into the emergency room for evaluation of the pain in the left hip after a fall. Licensed nurse C documented the arrival of the ambulance and transport to a local ER at 8:30 p.m., 14 hours after staff found the resident on the floor. At the ER, the physician's assessment determined the resident had a [MEDICAL CONDITION]. On 7/17/12 at 11:18 a.m., Direct care staff B identified he/she remembered working the morning of 3/25/12. When asked what the reasons were that he/she had given the resident the [MEDICATION NAME], staff B stated "because the nurse asked me to." When asked how the reasons for giving the [MEDICATION NAME], staff B identified the resident was in "excruciating" pain, crying out, and moaning. When asked who assessed the effectiveness of the [MEDICATION NAME], Staff B stated that he/she thought that Licensed nurse A had, but upon looking at the MAR, stated that it must have been him/her since he/she signed it. Staff B said that he/she remembered checking on the resident after the 1:00 p.m. dose of [MEDICATION NAME] because the the resident lay in bed with his/her eyes closed, and so Staff B thought that medication had helped the resident's pain. Staff B stated the resident had not complained of pain prior to the fall. Staff B identified he/she helped Licensed nurse A to pick the resident up off the floor. Staff B stated together the staff assisted the resident up into the wheelchair, assisted the resident to dress, and then assisted the resident to lie back down on the bed. Staff B identified the resident stayed in bed the entire shift because of the pain the resident experienced. On 7/17/12 at 12:08 p.m. Licensed nurse C stated that he/she started work about 3:00 p.m., so he/she went to go check on the resident first thing. He/she said the resident required a lot of supervision, so he/she put the resident by the nurse's station while he/she worked to closely monitor the resident. Staff C stated that when he/she entered the resident's room, saw the resident lying in bed and called the resident's name, he/she would not look at the staff, so staff C reached out to touch the resident's right hip. The resident did not respond so then staff C touched the left hip and the resident screamed "so bad." The first shift had gotten an order for [REDACTED]. Staff C stated he/she thought the resident was "suffering." Staff C said the problem was the resident received Hospice services, and some people do not want to go to hospitals when they go on Hospice. Nurse C identified they called the family, who immediately came out and when the family saw the resident, it upset the family. The family agreed the resident needed to go to the hospital, so another call was made to the hospice nurse and when the hospice nurse returned the call, talked with the daughter and all agreed that the resident needed to go into the hospital, so Staff C called Consultant G and obtained an order to send the resident into the hospital for an evaluation. On 7/17/12 at 1:43 p.m. Licensed nurse A stated that the resident did not complain about pain when Licensed nurse A checked the resident's range of motion (ROM) directly after he/she found the resident on the floor. When asked why he/she directed staff to administer [MEDICATION NAME] for left hip pain at 7:00 a.m., nurse A said the resident was always complaining about pain, pain all over. Licensed nurse A thought it would be better if the staff gave the resident something for pain so that the resident would not be so sore. Licensed nurse A also said the resident never complained specifically about pain in the leg or hip after the fall, and did not remember documenting the resident complained of left leg pain on the neurological assessment sheet. Licensed nurse A stated he/she had asked the resident if he/she experienced pain right before Licensed nurse A called and reported to the fall to the daughter. The resident had denied pain at that time, so that was why Licensed nurse A did not report the pain to the daughter. Licensed nurse A stated that he/she called the doctor in the afternoon to report the pain in the hip "to be on the safe side." Licensed nurse A thought that the resident needed an X-ray that day, but it was Consultant G who thought that since the staff could manage the resident's pain with [MEDICATION NAME] and there were no visible changes in the leg that the X-ray could wait until the next morning. Licensed nurse A thought he/she had called the family to report that order, but could not remember for sure. On 7/17/12 at 1:23 p.m. Administrative Nurse D stated that he/she believed that the resident had not exhibited any pain from the fall until the afternoon and that the nurse in charge had not gotten the order to have the resident evaluated in the ER until later in the evening because the family wanted the Hospice nurse to come out and evaluate the resident first. Administrative nurse D thought there was some problem with getting Hospice to return the call, but once the hospice nurse did call, Licensed nurse C obtained the okay to send the resident into the hospital. Nurse D agreed that Licensed nurse C should not have waited for 4 1/2 hours before re-paging the hospice nurse. On 7/18/12 at 11:08 a.m. Consultant G identified he/she did not remember this day or the phone calls with it specifically, but that it was protocol that if a resident was not having severe pain, if staff were managing the resident's pain, then he/she did not give orders for staff to send the resident into the ER until the next business day, especially if the resident is a hospice patient. Consultant G identified that usually the hospice orders [MEDICATION NAME] and if it was managing the resident's pain, then there was no need to send the resident into the ER. Consultant G agreed that the staff must have reported to him/her that the resident's pain was not too bad. When Consultant G found out later that day that the resident was in severe pain, Consultant G agreed to have the resident seen. If a resident is in severe pain, then they always give orders to be evaluated in the ER. On 7/18/12 at 10:30 a.m. Physician F, who worked with the Hospice service that resident #1014 received services from, identified that if a resident received Hospice services, it did not mean that that resident could not go to the emergency room to be evaluated for a broken hip. Physician F identified that it is the Hospice's policy to take care of the resident in the best way possible, and if that meant going to the hospital to fix a broken hip or manage the pain, then that's what needed to happen. Review of the facility's policy on Resident Assessments, dated 11/2010, guided staff to complete several assessments upon admission, annually, quarterly and with any significant change in status. The assessments listed included a pain assessment. The facility staff failed to promptly assess a resident who had newly developed pain after a fall, which resulted in the resident remaining in bed all day due to the pain that required treatment with an opioid pain medication. The resident experienced this pain for over 12 hours.

The facility census totaled 90 residents with 27 included in the sample. The sample included the review of three residents with pressure ulcers. Based on observation, interview, and record review, the facility failed to ensure a resident who entered the facility without pressure ulcers did not develop them unless clinically unavoidable and failed to follow the physician's orders [REDACTED]. (#43) The resident developed two Stage III pressure ulcers on both lower buttocks, over a bony prominence (ischial tuberosity). Findings included: - Review of an admission MDS (Minimum Data Set-a required assessment) dated 9/26/11 identified resident #43 with short and long term memory problems, moderately impaired cognition, required limited assistance from one staff with bed mobility, transfers, did not have any unhealed pressure ulcers, at risk for the development of pressure ulcers, and staff provided pressure reducing devices for the resident's bed and chair. Review of the quarterly MDS dated [DATE] identified the resident with short and long term memory problems, moderately impaired cognition, required limited assistance from one staff with bed mobility, required extensive assistance from one staff with transfers, did not have any unhealed pressure ulcers, at risk for the development of pressure ulcers, and staff provided a pressure relieving device for the resident's chair and bed. Review of the Pressure Ulcer CAA, dated 10/3/11, identified the resident as occasionally incontinent of bowel and bladder, required staff assistance with repositioning, a [DIAGNOSES REDACTED]. Review of the care plan, last reviewed on 2/20/12 directed staff to encourage frequent turning, assist to turn as needed, and on 4/5/12 staff wrote the following guidance: Left lower buttock cleanse with Normal Saline, pat dry, then apply Santyl (name of ointment) to area, cover with Border Drsg (dressing), change daily and PRN (as needed). The care plan also directed staff to use proper positioning and repositioning, use pressure reduction support surface in chair, Skin checks weekly by direct care staff during scheduled bathing, daily observation during care - report any findings to the charge nurse. On 2/29/12 staff wrote in "Bilateral ischial pressure ulcer uses Santyl and optiform and ABD (abdominal dressing) daily and Roho (type of pressure reducing cushion) cushion in w/c (wheelchair), Rt (right) heel wipe with skin prep daily and TED (compression stockings that prevent [MEDICAL CONDITION]) hose and boot x1 w/c, 2/22/12 Rt heel redness, apply skin prep offload 4 layer ABD with hole in middle, wrap with Kerlix, secure change QOD (every other day) and PRN, 2/22/12 [MEDICATION NAME] BID (twice a day) until wound healed. [MEDICATION NAME] (protein) level next lab day, 2/29/12 Prostat 101 BID 30mL (milliliters), 4/4/12 - Apply [MEDICATION NAME] paste to Rt buttock BID and PRN when soiled." Review of the physician's telephone orders, revealed on 2/12/12 at 10:55 a.m., staff wrote a telephone order from the physician that directed staff to cleanse areas to Right and Left lower buttocks with normal saline and pat dry, apply [MEDICATION NAME] (type of dressing) followed by [MEDICATION NAME], (another type of dressing) and change daily and PRN. The facility contacted Physician WW to monitor and treat the wounds on the resident's buttocks. On 2/29/12 Physician WW saw the resident and documented both wounds as Stage III (involving subcutaneous tissue but not muscle or bone) ischial pressure ulcers and measured the one on the left buttock as 3.9cm (centimeters) in width by x 3.1cm in length, with the one on the right buttock measuring 2.3cm x 2.7cm. Physician WW also directed staff to place a Roho cushion (a type of cushion) on the resident's wheelchair and to turn the resident from side to side while in bed. Physician WW monitored the pressure ulcers weekly and documented the healing progression of both areas. On 4/4/12, Physician WW identified the pressure ulcer on the right buttock as healed. The physician continued to monitor and treat the pressure ulcer on the left buttock weekly. On 5/9/12, Physician WW measured the ulcer as 1.4cm x 1.6cm and directed staff to apply Santyl ointment with [MEDICATION NAME], and cover with Border gauze dressing, change daily. On 5/16/12, Physician WW documented the remaining pressure ulcer measurements as 1.8cm x 1.5cm (slightly larger than the previous measurement of 1.4cm x 1.6cm) and identified the "Left ischial buttock persists with stool soilage. Discontinue dressing orders, turn side to side every 2 hours." On 5/10/12 at 11:18 a.m., observation revealed direct staff O and X assisted the resident with a shower. Staff O removed the resident's clothes, then assisted the resident to stand at a rail and removed an incontinent brief and dressing over an open area on the left lower buttock. Observation of the dressing revealed it contained a date of 5/9/12. Observation of the open area revealed it was looked approximately 2cm in size, pale, with no bleeding. Staff O bathed the resident, then dried the resident off and started to dress the resident. Staff O left the resident in the shower room with Staff X as Staff O left the shower room to go get the nurse to apply the resident's dressing to his/her buttock. Staff O returned in a few minutes and announced the nurse was on break and they would go ahead and dress the resident and the nurse would apply the dressing to the buttock later. They placed a clean brief and slacks, and then had the resident stand. Staff O held onto the resident for support as Staff X vigorously dried the resident's buttocks. The resident called out "Hey that hurts!" and Staff X said "I'm sorry, I'll pat to see if that helps" and stopped rubbing and patted the resident's buttocks dry. Staff O and X then pulled up the lower clothing and assisted the resident to sit in a wheelchair. Staff O assisted the resident to the dining room for the noon meal. On 5/10/12 at 12:49 p.m., observation revealed the resident finished eating. Direct care staff M assisted the resident out of the dining room and into the hallway. On 5/10/12 at 12:55 p.m., Licensed nursing staff G, then propelled the resident down the hall to the nurse's desk and had the resident wait there. On 5/10/12 at 1:04 p.m. observation revealed Direct care staff N propelled the resident down the hall to the resident's room. Staff N met Direct care staff M in the resident's room, and together they used a gait belt and assisted the resident to stand and pivot onto the bed. Staff N and M then placed a body pillow under the resident's right hip and side, covered the resident, and placed a mat at the bedside, then left the resident. Direct care staff O came in as staff M and N were leaving, and thanked the staff for helping out. Staff M, N and O did not check the resident's incontinent brief. On 5/10/12 at 1:55 p.m. observation revealed Direct care staff O wheeled the resident down the hall to Station I, stating, "I am taking (the resident) to (Social Service KK's) office." On 5/10/12 at 2:07 p.m., observation revealed Social Service KK propelled the resident into the office, where an eye doctor used the office. On 5/10/12 at 2:13 p.m., observation revealed Direct care staff Q assisted the resident away from Social Service KK's office and took the resident to his/her room. Once there, Direct care staff Z joined Direct care staff Q, and together they toileted the resident. They had the resident stand in the bathroom and they removed the resident's slacks and brief. Observation revealed the brief was dry except for the open area that lacked a dressing. There was a pinkish area where the drainage from the wound had stuck to the brief and Direct care staff Q had to tug on the brief to get the brief to release from the wound. Staff Q confirmed that the brief was dry, but contained drainage from the open wound. Once done on the toilet, Staff Q and Z placed a clean brief, pulled up the slacks and brief and took the resident back to the eye doctor. On 5/10/12 at 3:38 p.m., Licensed nursing staff I entered the resident's room where the resident lay in bed on his/her back. Direct care staff Q and Z both came into the room and helped to situate the resident in bed. Staff Z removed the brief to expose the left buttock. Staff Z had to again tug on the brief to release the brief from the ulcer. Licensed nursing staff I cleansed the area, which now had bloody drainage, and applied the ordered Santyl ointment, then Xeroform gauze, and a covered gauze dressing. Once done, Staff I looked at the brief and determined there was drainage on it from the open area and so Staff I directed Direct care staff Q and Z to change the brief. Staff failed to follow the physician's orders [REDACTED]. On 5/16/12 at 3:00 p.m., Direct care staff V confirmed the resident had a pressure ulcer on a buttock. Staff V stated if he/she had to remove the dressing, he/she would let the nurse know and put the resident back to bed to wait on the nurse to apply the dressing. On 5/17/12 at 1:21 p.m., Direct care staff M stated the resident had a sore on a buttock, and that the staff were to make sure the resident did not lay on his/her back, that they turned the resident from side to side. Staff M further identified if the dressing fell off the pressure ulcer, he/she would let the nurse know. On 5/16/12 at 5:08 p.m., Licensed nursing staff I confirmed the resident had a pressure ulcer that was healing and was followed by a wound doctor. Staff I said that if the dressing comes off, the direct care staff let him/her know and he/she reapplied it, but it does not happen that often. As for the repositioning, the direct care staff make sure that they follow the doctor's orders about repositioning the resident so that it will heal. Staff I knew the direct care staff followed the orders because the resident's pressure sore was healing. On 5/17/12 at 1:11 p.m. Licensed nursing staff Y stated that the resident did have a pressure ulcer on the left buttock. Nurse Y identified the resident started out with two, but the staff got one of them healed, and now the resident just had the one. On 5/18/12 at 11:00 a.m., Administrative Nursing staff B stated that the resident did have one pressure ulcer--the resident had started out with two, but the nursing staff had healed one. Nurse B said when Physician WW saw the resident this last week; he/she discontinued all the dressings because the ulcer was healing. Nurse B agreed that the Direct care staff should have reminded the Licensed nurses that the resident's dressing was off, but that it must not have hurt the resident too much if the doctor discontinued the dressing. On 5/17/12 at 1:45 p.m. Consultant QQ confirmed he/she cared for the resident, however, the facility had a consultant wound physician, Physician WW, who did a marvelous job of monitoring and treating the resident's wounds. Consultant QQ stated any concerns for the wound the facility had he/she deferred to the wound doctor. On 5/23/12 at 12:19 p.m., Physician WW stated that when he/she started seeing the resident he/she did assess the wounds as a stage III, but they were a shallow stage III. When asked what he/she thought caused the ulcers, Physician WW stated he/she never definitively determined the wounds were caused from pressure, but since the wounds were on both buttocks and the resident sat up in a wheelchair and laid on his/her back in bed, Physician WW decided to treat the wounds like they were pressure ulcers. So now the staff offload the buttocks (turn the resident from side to side) and the ulcer on the right buttock has healed and the ulcer on the left buttock is healing. When told that staff had pulled the brief from the ulcer after the drainage had caused the brief to stick to the ulcer, Physician WW confirmed that action impeded the ulcer's healing process, but Physician WW thought that was an anomaly because the ulcer no longer had drainage. Review of the facility's 2001 policy on applications of dressings revealed that it provided guidance to staff on how to apply a clean dressing, but failed to provide guidance to staff on how promptly to reapply an ordered dressing that has been removed. The facility failed to ensure a resident who entered the facility without pressure ulcers did not develop pressure ulcers unless the resident's clinical condition demonstrated that the ulcers were unavoidable. The resident developed two avoidable, Stage III ulcers, one on each buttock. The facility failed to provide the prompt reapplication of a dressing for a pressure ulcer to promote healing.

The facility census totaled 90 residents with 27 included in the sample. The sample included the review of 4 residents at risk for the facility's provision of nutritional needs. Based on observation, interview, and record review, the facility failed to identify, develop and implement dietary interventions to address a significant weight loss for 1 of 4 sampled residents to ensure the weight loss the resident experienced was unavoidable. (#106). The resident's weight declined from 182 pounds in October 2011 to 153 pounds in April 2012. This represented a loss of 29 pounds, or 15.9% of the resident's body weight, a severe weight loss. The facility also failed to follow the physician's orders [REDACTED].#83 and #117). Findings included: - Review of an admission MDS (Minimum Data Set-a required assessment), dated 10/26/11, identified resident #106 with short and long-term memory problems, severely impaired cognition, no issues/problems with eating/drinking, and with a steady weight of 182 pounds. Review of the quarterly MDS dated [DATE] identified the resident with short and long-term memory problems. severely impaired cognition, no issues with eating/drinking, and with a steady weight of 158. The assessment failed to identify the resident's weight loss of 24 pounds, or 13% of the resident's body weight, between the two assessments. The MDS 3.0 manuel identified a significant weight loss as a loss of 5% within 30 days or 10% within 6 months. Review of the nutrition CAA (Care Area Assessment-a further assessment) dated 11/1/11 identified the resident had a [DIAGNOSES REDACTED]. The CAA identified the resident received a regular, NAS (No Added Salt) diet. Review of the care plan, dated 4/10/12 instructed staff to encourage the resident to follow the diet as ordered, provide snacks as needed, provide supplements as recommended by the dietitian, monitor for the need for texture change, assist the resident with meals as needed, consult with the dietitian as needed, and provide a fortified NAS diet, give 120cc (cubic centimeters) of 2cal (type of supplement) QID (four times a day) due to continued weight loss. Review of the dietitians recommendation revealed on 12/21/11 the dietitian from Hope (a program of all-inclusive care for the elderly) ordered staff from both Hope and the facility to add 120cc 2Cal QID due to continued weight loss. Review of the recapitulation of orders, dated 4/11/12, identified the physician wanted staff to provide the resident with a mechanical soft, NAS, fortified foods diet, plus 120cc 2cal QID. Review of the weight record, located in the record, revealed the resident moved into the facility on [DATE]. Staff documented the following weights for the resident. 10/20/11 181.7 10/23/11 181.4 11/4/11 176.2 11/11/11 175.6 11/18/11 175.2 12/2011 169.8 1/10/12 167.2 2/4/12 163.8 3/2012 155.0 4/10/12 157.5 4/13/12 155.7 4/20/12 152.9 5/7/12 151.1 Review of the current MAR (Medication Administration Record) dated 4/15-5/14/12, included directions for staff to provide 2cal 120cc po (by mouth) QID for weight loss. The start date for the order revealed it started on 12/21/11. Staff signed the order to indicate the resident received the supplement as ordered. Review of the resident's current dietary card revealed that the card identified the resident received a mechanical soft, no added salt diet, but lacked any mention of the fortified diet. Review of a dietary progress note, dated 12/27/11, identified that Consultant W made recommendations to the physician who then ordered staff to change the resident's diet to a fortified diet, NAS, and give 120cc of 2cal QID due to continued weight loss. Dietary staff EE identified the resident ate 75-100% at his/her meals, and received snacks as needed. Staff EE identified he/she planned to continue to monitor the resident's weight and intake for any changes. Review of the dietary progress note dated 1/12/12 and completed by Dietary staff EE, revealed the resident continued to lose weight. It also identified the resident had a [DIAGNOSES REDACTED]. Dietary EE identified the resident wondered a lot up and down the halls. Staff EE finished the note by identifying that he/she planned to continue to monitor the resident's weights monthly. The dietary progress note dated 2/17/12 identified the physician changed the texture of the resident's diet to mechanical soft to ease chewing ability and oral intake. The dietary progress note dated 3/14/12, and completed by Consultant W, identified the resident had a significant weight loss of 7.3% in one month, that the resident would not sit very long to eat and wandered throughout the facility. Consultant W identified the staff planned to change the monitoring of the resident's weights to weekly and to continue the current dietary interventions. Review of the dietary progress note dated 5/11/12, completed by the Dietary EE, identified the resident continued to lose weight, and that the resident had a significant weight loss at 3 and 6 months. The note identified the resident then required the assistance of one staff with eating at times. Staff EE identified they planned to ask nursing to obtain the resident's weights weekly to monitor the resident's weights. Observation on 5/10/12 at 7:47 a.m. revealed the resident sat in a chair at a table in the dining room on the Special Care Unit. Direct care staff FF served the resident an 8oz (ounce) container of milk, a 6oz glass of grape juice, a 10oz glass of ice water. The resident did not drink independently and the staff did not encourage the resident to drink. On 5/10/12 at 7:52 a.m., licensed nursing staff GG served the resident a breakfast of scrambled eggs, oatmeal, and toast. The food on the tray looked the same as all the other trays, and did not have obvious changes to fortify the food. Licensed nursing staff GG tried to encourage the resident to eat independently by placing the toast in the resident's hand, but he/she refused to grasp it, so then staff GG gave the resident two bites of oatmeal, which he/she did eat. Staff GG told direct care staff FF that they would need to assist the resident to eat. At 7:55 a.m., direct care staff FF sat next to the resident to assist him/her to eat while Licensed nursing staff GG finished passing out the remainder of the trays. On 5/10/12 at 7:58 a.m., staff FF stopped assisting the resident and went around the room, helping other residents, encouraging them to eat, or giving them a bite of food. Licensed nursing staff GG asked staff FF if resident #106 was done eating. Staff FF said "No, but (he/she) is eating (independently). See? (He/She) is holding (his/her) toast." Observation of the resident revealed he/she held the toast, dipping it in the small cup of milk, but did not eat any of it. On 5/10/12 at 8:02 a.m., observation revealed the resident stood up from the table. Staff FF saw the resident and asked the resident if he/she was done, then removed the clothing protector. At 8:06 a.m., Licensed nursing staff GG came into the dining room and assisted the resident to sit back down at the table. The resident then started to eat the scrambled eggs with his/her hands. Licensed nursing staff GG gave the resident bites of oatmeal, and then gave him/her the small plastic cup with milk in it, which the resident drank from. At 8:17 a.m. observation revealed the resident finished eating. Observation revealed the resident had eaten all of the food, all of the juice, all of the milk and half of the water. Staff had not added any butter or sugar to the oatmeal to fortify the cereal, or offered the resident additional amounts of food. On 5/14/12 at 7:56 a.m. observation revealed Licensed nursing staff GG gave the resident a breakfast of a pancake, oatmeal, an 8oz carton of milk, 10oz ice water, and a 4oz glass of cranberry juice. Staff GG cut up the pancake and the resident started to eat independently. Soon, though, the resident put the bowl of oatmeal on the pancake. The oatmeal looked the same as all the other oatmeal served to the residents, and did not have any change in consistency or color to indicate staff added calorie enhancing changes such as cream, sugar or butter. The staff failed to serve the resident a fortified diet as ordered. On 5/14/12 at 8:10 a.m., Administrative staff A entered the dining room, and asked the resident if he/she wanted sugar or milk on the oatmeal. The resident said no. Observation on 5/14/12 at 8:13 a.m. revealed the resident stood up and walked away from the table. Licensed nursing staff GG stopped and asked the resident if he/she was done eating, if he/she was full, and the resident replied yes. The resident wandered in the dining room around other residents who continued to eat and then out in the hallway. None of the staff present, including Licensed nursing staff GG, and direct care staff FF encouraged or assisted the resident back to the table to finish eating, or offered help/assistance to the resident. Observation of the resident's plate revealed the resident ate 1/2 of the pancake, a bite or two of the oatmeal, 1/2 the glass of red juice, and 2oz of the milk and none of the ice water. Observation on 5/14/12 at 10:36 a.m. revealed Dietary staff II prepared the noon meal for the residents. When asked, Dietary staff II stated that he/she used recipes to prepare meals and did not add any other calories to the foods like butter, sugars or milk/cream. Dietary staff II stated that he/she used the facility's lists to prepare the different diets. Dietary staff EE provided a copy of the list---it identified the number of residents on pureed, mechanical soft and Low Concentrated Diets. The list of different diets the facility used to guide the Dietary staff to prepare lacked directions for fortified diets. On 5/16/12 at 4:53 p.m. direct care staff PP stated that he/she knew the resident got a supplement between meals, but did not know if the resident had lost weight. Staff PP said the resident still ate well, but that the resident wandered or paced much of the day and worked off the food that he/she took in. Staff PP said that staff needed to help the resident to eat, that he/she would eat with staff help. On 5/17/12 at 1:53 p.m., direct care staff FF stated that the resident did not like to sit for long and so staff had to be careful and encourage the resident to keep eating while he/she sat to make sure he/she took in enough. Staff FF said that staff had to help the resident to finish eating. On 5/14/12 at 9:43 a.m., Dietary Staff EE described the facility's system to identify weight loss in the residents. Staff EE said that the nursing staff took all the resident's weights on a monthly basis by the 10th of each month, unless staff monitored them weekly, and those were done on Mondays. Then, the weights were documented in a weight book and given to either Administrative Nurse B or Dietary staff EE to enter into a computerized program that then identified weight losses, including significant weight losses, for the residents. The facility then had a group that met weekly to address residents with actual weight losses or those with decreased intakes. Staff EE identified the members of the committee included Administrative Nurses B, C, D, R, S and Licensed nursing staff GG. When asked at that time, Dietary staff EE provided the computerized Resident Weight Report for the year 2012. Review of the report revealed that the report lacked the resident's admission weight of 182 pounds, but had monthly weights entered. According to the May 2012 report, the resident had a significant weight loss of 9.63% over 3 months (from the weight documented in February 2012 of 167.2 pounds to the weight in May of 151.1 pounds) and 13.80% over 6 months (from the weight in November 2011 of 175.3 pounds to the weight in May of 151.1 pounds). On 5/17/12 at 12:42 p.m., Dietary Staff EE identified the plan to increase the resident's intake included the resident received snacks between meals and supplements. At that time, Dietary staff EE provided the therapeutic breakouts of the meals. The breakouts did not provide guidance on fortifying the meals. On 5/17/12 at 2:34 p.m. Licensed nursing staff E stated that the resident wandered a lot and that contributed to the resident's weight loss. Staff E identified the resident received snacks between meals. When asked if the staff needed to encourage and assist the resident to eat, staff E said yes, and identified the resident did not sit for very long. On 5/18/12 at 11:00 a.m., Administrative Nurse B stated that the resident's family wanted the resident on comfort care; they did not want any heroics done. On 5/17/12 at 12:42 p.m., Consultant W stated that the facility did identify the resident's weight loss in March 2012, and that Consultant W had asked the facility to implement weekly weights. Consultant W agreed that intervention did not prevent further weight loss, but provided extra monitoring. Consultant W identified the facility had met earlier that morning and they now planned to provide extra calories to the resident. On 5/21/12 at 4:18 p.m., Physician RR confirmed he/she was aware of the resident's weight loss. Physician RR stated that in February he/she had contacted the resident's family to report the weight loss and the family had requested the resident be given comfort care, so Physician RR stated that he/she wanted to respect the family's wishes. Physician RR did identify that the facility should still take steps to enhance the resident's foods, including providing extra calories (fortifying) the resident's food, providing extra portions at times the resident ate, as well as serving finger foods to the resident as the resident paced. Review of the facility's undated policy on Resident Weight Monitoring revealed guidance to the staff that if a resident's monthly weight showed a significant change-either loss or gain-(such as 5% in 30 days, 7.5% in 90 days or 10% in 180 days) the staff were to reweigh the resident. It also identified that the Food Service Manager and/or consultant Dietitian were to review the resident's nutritional status and make recommendations for interventions in the Nutritional Progress notes. The Food Service Manger or Consultant Dietitian notified nursing of any recommendations that have been documented. Nursing then contacted the physician to convey recommendations and obtain any new orders. Finally, the guidance to staff included the reminder that if staff obtained weekly weights on residents, they must be reviewed weekly and action must be taken for any significant change, but it lacked identification of which staff were to review the weights. . The facility failed to identify and develop new interventions for a resident with weight loss, failed to follow the planned interventions of fortifying the diet and failed to consistently encourage the resident to eat for a resident with a weight loss. The resident's weight went from 182 pounds down to 153 pounds, or 29 pounds or 15.9% of the resident's body weight-a severe weight loss-from October 2011 to May 2012. The facility's failure to follow the plan to fortify the diet, provide consistent encouragement to eat and develop new interventions made the resident's weight loss unavoidable. - Review of an admission MDS (Minimum Data Set) dated 4/25/12 identified resident #117 with a BIMS (Brief Interview for Mental Status) score of 11/15 (indicated moderately impaired cognition), required supervision from one staff for eating, received a therapeutic diet, had no difficulty with chewing/eating, and with a steady weight. Review of the nutritional CAA (Care Area Assessment) dated 4/30/12 identified the resident with a history of [MEDICAL CONDITION] prior to admission, and with a good appetite. The CAA also identified the resident had an ordered diet that included low phosphorous due to End Stage [MEDICAL CONDITIONS]. Review of the care plan, dated 4/31/12, directed staff to provide a diet as ordered - low phosphorous, to modify meal schedule to accommodate [MEDICAL TREATMENT]-send sack lunch and medications, monitor labs, including Sodium and Potassium levels, encourage the resident to follow diet as ordered by physician - Regular low phosphorous, provide snacks as needed per facility routine, assist with meals as needed, and on 5/3/12 staff identified that the resident was to receive Prostat 64 (a supplement) 30cc (cubic centimeters) TID (Three times a day), Nepro Supplement BID (twice a day) and as needed, and double eggs at breakfast and double meat at meals. Review of the resident's current dietary card revealed the following information: regular diet, double eggs for breakfast and double meat for lunch and supper. The card did not identify a low phosphorous diet. Review of the communication sheets from the [MEDICAL TREATMENT] unit revealed on 4/27/12 the [MEDICAL TREATMENT] staff documented the resident's laboratory results for [MEDICATION NAME] (protein) was low. The [MEDICAL TREATMENT] unit identified the resident needed double meat portions if the resident would eat it. Review of the dietary recommendations revealed on 5/3/12 the dietitian recommended the resident receive 2 supplements, Prostat 64 30cc TID and Nepro Supplement BID and as needed, plus double eggs at breakfast and double meat portions with meals. Review of the communication sheet from [MEDICAL TREATMENT] unit dated 5/14/12 revealed the [MEDICAL TREATMENT] staff again identified the resident's [MEDICATION NAME] level at 3.6 g/dl (grams per deciliter), which was below the [MEDICAL TREATMENT]'s goal level of 4.0 g/dl and asked staff to encourage the resident to eat more protein. Review of the information from website www.nephinc.com/food-lists.asp, revealed foods high in phosphorous content included: Meat: lamb, liver, pork, turkey, veal and fish Breads and starches: bulgur, cornbread, frosted miniwheats, lentils, raisin bran, golden grahams, shredded wheat and trail mix Dairy: chocolate milk, chocolate pudding, milk, milkshakes, ricotta cheese, Swiss cheese and yogurt. The website identified foods that were moderately high in phosphorous content included the following: Meat: bacon, beef, chicken, chicken pot pie, fish and sea food, canned tuna Breads and starches: biscuits, waffle, pancake, cheerios, Wheaties, wheat Chex, oatmeal Dairy: cheddar cheese, cottage cheese, custard, fat-free cheese, mozzarella, provolone, instant pudding. Observation on 5/10/12 at 8:23 a.m. revealed the resident sat in a wheelchair in the dining room. Staff had served the resident a breakfast of one scoop of scrambled eggs, oatmeal, 3 strips of bacon and toast. The resident ate independently. On 5/10/12 at 9:09 a.m. observation revealed the resident finished eating. Observation of the resident's tray revealed the resident had eaten all of the breakfast. On 5/10/12 at 12:14 p.m., observation revealed the resident lay in bed. Direct care staff O told Licensed nursing staff G that the resident did not want to eat anything. Staff G told Direct care staff O to offer the resident something to eat, even if he/she did not want to eat. Direct care staff O took a room tray to the resident. On 5/10/12 at 12:20 p.m. observation of the room tray that Direct care staff O served the resident as he/she lay in bed revealed it contained one scoop of shredded chicken, mashed potatoes and gravy, peas, cake, and a 4oz glass of peach juice and a 10oz glass of ice water. The tray did not have double meat on it. On 5/10/12 at 12:40 p.m., Direct care staff X helped the resident to finish the rest of the noon tray and the resident ate all of the food. Staff X left the 4oz of juice and glass of ice water for the resident to finish. On 5/10/12 at 7:55 a.m., observation revealed the resident sat in a wheelchair in the dining room. Staff served the resident a bowl of oatmeal and a plate with 2 pancakes. The resident started to eat independently. Observation revealed the resident ate 75% of the pancakes and all of the oatmeal. The tray lacked the double portion of eggs. On 5/16/12 at 3:10 p.m., Direct care staff V stated that the resident received a regular diet. When asked if the resident received extra portions, Staff V said only if the resident asked for them, and sometimes he/she did. On 5/17/12 at 1:21 p.m., Direct care staff M stated that the resident had a regular diet, that he/she did not get any special fluids. When asked about if the resident received double portions, Staff M said only when the resident asked for extra helpings, and then the staff gave it to him/her. When asked if the resident had any restrictions to his/her diet, Staff M said no. On 5/14/12 at 10:03 a.m., Dietary staff EE explained that none of the residents received eggs for breakfast on 5/14/12 because the facility had no eggs. When asked how they provided the nutritionally equivalent dietary substitutions, Staff EE said the facility knew they were not going to be nutritionally equivalent when they did not have a protein for the breakfast. On 5/17/12 at 12:42 p.m., Dietary staff EE stated that the dietary staff should follow the diet and give the resident extra protein. On 5/16/12 at 5:08 p.m., Licensed nursing staff I identified the resident received a regular consistency diet, but with a low phosphorous diet. When asked if staff I knew what constituted a low phosphorous diet, he/she said that he/she did not know for sure, he/she would have to look it up. On 5/17/12 at 1:11 p.m. Licensed nursing staff Y said that the resident received a regular diet with no restrictions and did not receive double portions, but that staff were allowed to give the resident extras if he/she asked for them. On 5/18/12 at 11:00 a.m., Administrative Nurse B, when told that the resident did not receive the ordered extra protein at meals, stated that the resident should be getting the ordered diet, and said he/she would talk with the dietary department to make sure they corrected that problem. On 5/17/12 at 12:42 p.m., Consultant W agreed that the staff should follow the physician's orders [REDACTED]. Consultant W stated he/she planned on going over a low phosphorous diet with the dietary staff, which he/she obviously needed to provide some education to the staff on that. On 5/17/12 at 1:45 p.m. Consultant QQ, stated that the resident did receive [MEDICAL TREATMENT] and although Consultant QQ followed the resident's care, when it came time to the care that dealt with the [MEDICAL TREATMENT] end of things, Staff QQ deferred to the [MEDICAL TREATMENT] health care practitioners. Consultant QQ said that when it came to the diet, and lab results, the facility was in contact with the [MEDICAL TREATMENT] unit and the [MEDICAL TREATMENT] unit kept a pretty close eye on those things and the facility was to follow the orders from [MEDICAL TREATMENT]. On 5/17/12 at 2:30 p.m., Administrative Nurse B stated the facility did not have a specific policy regarding providing the ordered diet, but that it was expected that the staff follow the physician's orders [REDACTED]. The facility failed to provide the ordered double eggs at breakfast and double meat at lunch and supper to attempt to obtain the goal range for the resident's [MEDICATION NAME] level (protein stores). - Review of an admission MDS (Minimum Data Set-a required assessment) dated 1/12/12 identified resident #83 with short and long-term memory impairment and severely impaired cognition. The assessment identified the resident had no issues with chewing/swallowing and had a steady weight of 120 pounds. Review of the quarterly MDS (Minimum Data Set-a required assessment) dated 3/31/12 identified the resident with short and long-term memory impairment and severely impaired cognition. The assessment identified the resident had no issues with chewing/swallowing and had a steady weight of 120 pounds. Review of the Nutritional CAA (Care Area Assessment) dated 1/18/12, identified the resident as edentulous, received a puree diet, with pressure wounds and received additional nutritional supplements Review of the resident's care plan, dated 4/10/12, directed staff to encourage the resident to follow the diet as ordered by physician - Puree, super cereal with breakfast, provide snacks as needed per facility routine, supplements per Consultant's recommendation and physician approval-2 cal. 60ml (milliliters) QID (four times a day), [MEDICATION NAME] BID (twice a day), assist with meals as needed, nectar thick liquids, thicken all supplements. On 1/24/12 staff added the anti-depressant [MEDICATION NAME] as an appetite stimulant. On 2/3/12, the physician ordered staff to provide Prostat 30cc (cubic centimeters) BID and 2/12/12 [MEDICATION NAME] BID, 2cal 60mL TID both for low protein stores, and on 3/29/12 the physician ordered staff to add [MEDICATION NAME] daily to enhance appetite. Review of the physician's history and physical, dated 1/11/12, revealed the resident had a history of [REDACTED]. Review of the dietary intake records for March 2012 revealed that the resident's meal and snack intake between 3/1 and 3/15 averaged between 60-100%. The documentation revealed that between 3/15 and 3/31, the resident average intake of meals and snacks ranged from 0-60%. The nurse's notes revealed a lack of notification of the family of the decline in dietary intake. Review of the dietary intake records for April 2012 revealed that between 4/1 and 4/10, the resident's meal and snack intake continued to decline, with the resident averaging between 0-50%. Review of a nurse's note, dated 4/9/12 and timed 8:45 a.m. revealed that the staff documented the resident had a poor appetite and pocketed food rather than swallowing it. Review of an additional nurse's note, dated 4/9/12 and timed 5:30 p.m. revealed that the physician ordered staff to obtain a speech therapy evaluation to address the resident's pocketing food and for the possibility of a tube feeding evaluation. On 4/10/12 at 7:00 a.m., the resident left the facility to go to the hospital. On 5/16/12 at 3:00 p.m., Direct care staff V identified that the resident had started out eating well, but then he/she stopped eating. Staff V stated that it was like the resident had lost his/her appetite. Staff V said that in the last week before the resident went to the hospital, the resident even stopped swallowing and started pocketing the food in his/her cheeks rather than swallowing. On 5/17/12 at 1:21 p.m. Direct care staff M stated that the resident got a pureed diet and thickened fluids and that the resident stopped eating about a week before he/she went to the hospital. Staff M said that before that the resident ate pretty well and drank fluids well, but that last week the resident just stopped swallowing. On 5/17/12 at 12:42 p.m. Dietary staff EE stated that the resident's weights had been steady except for the last one, obtained the first of April, and that showed a pretty significant decline. Staff EE said that the plan involved monitoring the resident's weights monthly. Staff EE agreed staff knew the resident had stopped eating well, and agreed that the staff could have taken the resident's weight prior to the scheduled time to identify if the resident had lost weight. Staff EE stated the staff had identified the resident had a weight loss in April, but did not have enough time to address it before the resident went to the hospital. On 5/16/12 at 5:08 p.m. Licensed Nursing staff I stated that the resident had stopped eating and started to pocket his/her food. Staff I stated that the resident received a pureed diet, but still, staff would feed him/her and then 2 hours later look in his/her mouth and see food still in his/her cheek. On 5/17/12 at 1:11 p.m. Licensed Nursing staff Y stated that the resident had never really eaten well while he/she lived here, but that during the last week or two weeks that he/she just stopped swallowing. Staff Y knew the doctor had been notified, because it seemed to him/her they were going to put in a [DEVICE] (tube directly into the stomach) or something the day the resident went to the hospital. On 5/18/12 at 11:00 a.m., Administrative Nurse B stated that the resident started to deteriorate and was not taking in as much food in the week or so before he/she left to go to the hospital. Staff B stated they did not think the weight loss was not because the facility did not try. On 5/17/12 at 12:42 p.m., Consultant W stated that the facility monitored the resident's weights and they had stayed pretty steady until the last weight. The facility had identified the weight loss and would have addressed it, but the resident just wasn't here in the facility long enough before he/she went to the hospital. On 5/17/12 at 1:45 p.m. Consultant QQ stated that the facility did notify him/her of the resident's overall decline. Consultant QQ stated that he/she had been in contact with the family and they were contemplating hospice when the resident went to the hospital. When asked why Consultant QQ ordered a speech evaluation for a [DEVICE] the day before the hospitalization , Consultant QQ stated they did that because the family had some reservations about hospice or end of life services, so Consultant QQ wanted the family to be aware of all the options. However, the resident left for the hospital prior to the evaluation. Consultant QQ identified the resident as medically unstable prior to the hospitalization . Review of the facility's system for monitoring important changes in residents revealed slips of colored paper that the direct care staff fill out that included the resident's name, vital signs and the direct care staff's signature, date and time they identified the important change. Some changes included on the slip of paper included when the resident ate less than usual and drank less than usual. Once completed, direct care staff were to give the paper to the Licensed nursing staff, who then assessed the resident and completed an SBAR (Situation Background Assessment Request) note (Physician/Nurse Practitioner/Physician Assistant Communication and Progress Note). The SBAR form included the resident's information and included information on decreased intake/fluids. The Licensed nursing staff were then to fax or call the information to the physician. review of the resident's medical record revealed [REDACTED]. The facility failed to promptly address a resident's declining oral intake status and develop interventions to assist the resident to maintain adequate intake.