Every finding on record at Ness County Hospital Ltcu Dba Cedar Village

Based on record review, observation, and interview, the facility failed to provide Resident (R) 1 with choices in daily routines, activities, schedules, and participation in care decisions when staff did not honor Resident (R) 1's wishes not to be showered and scrubbed. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), psychotic disturbance (any major mental disorder characterized by a gross impairment in reality perception), mood disturbance (category of mental health problems, feelings of sadness, helplessness, guilt, and wanting to die were more intense and persistent than what may normally be felt from time to time), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and chronic pain. The Quarterly Minimum Data Set (MDS), dated 04/01/2026, documented R1 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. The MDS documented R1 had mild depression. R1 had no behaviors during the look-back period. The MDS documented R1 had functional impairment on both sides of her upper extremities and required moderate staff assistance with toileting, showering, dressing, bed mobility, and transfers. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 12/11/2026, documented R1 had some confusion, mood and behavior issues, and at times denied staff assistance with activities of daily living (ADLs). The Functional Abilities CAA, dated 12/11/26, documented R1 required one staff assist with all ADLs. The CAA documented R1 had limited range of motion in both of her shoulders. The Behavioral Symptoms CAA, dated 12/11/26, documented R1 had episodes of yelling at staff and refusing care. The CAA documented R1 had mood swings, and staff could not tell how R1's day was going to go. R1's Care Plan, initiated 01/02/2024, documented R1 had an ADL self-care performance deficit. The care plan documented an intervention dated 12/02/2025 that stated R1 had a fear of water and became disturbed when she got water in her face. The plan documented R1 could have behavioral symptoms like screaming, cursing, and refusal of care, and directed staff to allow R1 time to express her feelings about situations and to anticipate R1's needs: food, thirst, toileting needs, comfort level, body positioning, and pain when R1 had behavioral symptoms. The Health Status Note, dated 05/25/2026, documented that during bathing, R1 yelled and hit at staff. Staff members switched, and R1 continued to yell out. The Health Status Note, dated 06/13/2026, documented during showering, R1 was noted to have greasy, yellow-colored flakes on her scalp. Certified Nurse Aide (CNA) M used a scalp scrubber. The scalp scrubber caused bruising to the left side of R1's head near the temple and scattered bruising on her scalp. LN G was in the shower room during the bath as R1 yelled and attempted to hit staff. R1's provider was notified of the bruising that had occurred and requested a specialized shampoo to use on R1's hair on shower days. The Health Status Note, dated 06/13/2026, documented R1 visited with another resident after her shower. The resident asked R1 how the bruising to her head happened. R1 stated, They hit me in the shower. LN G called Administrative Nurse D and reported the situation. The Provider Progress Note, dated 06/15/2026, documented R1 was an [AGE] year-old female with a complaint of scalp irritation and bruising. R1 had a history of chronic dry skin/scalp with very fine, fragile hair. R1 was noted to have new bruises after a recent bath. During a recent bath, a firm, bristled brush had been used to try to remove dry, flaky areas, which was uncomfortable and painful for R1. Afterward, petechial bruising (tiny, pinpoint red, purple, or brown spots that appear under the skin or mucous membranes) developed on the sides of the scalp. R1's scalp had bilateral petechial bruising, more prominent on the left temporal region than on the right. The provider wrote that it appeared the use of the firm bristle brush, combined with R1's fragile skin and chronic aspirin use, resulted in the bruising on both sides of her head. The provider's recommendation for the petechiae of the scalp was to avoid using a firm-bristle brush for hair/scalp care, use a soft-bristle brush or wide-toothed comb, and discuss being gentler with staff during bathing and scalp care. CNA M's unnotarized Witness Statement, dated 06/15/2026, documented CNA N and CNA M got R1 into the south bathhouse, and it was an immediate fight. CNA N had to coax R1 into the bathhouse. CNA M stated it had been well over a week since R1 had taken a bath. CNA M stated R1's hair was matted worse than normal, so they had LN G come into the bathhouse and help start on R1's hair while CNA N washed R1's body. CNA M stated she was on one side of R1, and LN G was on the other side of R1. CNA N switched places with LN G a couple of times so LN G could trim R1's fingernails. The entire time, R1 screamed, splashed water, hit, and threw herself to the side of the tub. CNA N and CNA M had to hold R1's hands while LN G cut her fingernails. CNA M stated after they got most of the knots out of R1' s hair, she went in with a scalp scrubber because the amount of dead skin and grime was beyond just washing with their hands. CNA M stated R1's head was extremely sensitive, and the scrubbing made it worse. CNA M stated when they got R1 out of the bath, she threatened to spit on CNA M and kicked CNA M several times. R1 commented, You're punishing me for what happened last time, meaning she thought CNA M had scrubbed her hair as torture or payback for when she spat all over her face and kicked her to the floor a couple of months ago. CNA N's unnotarized Witness Statement, dated 06/15/2026, documented that it was R1's bath day, so CNA M and CNA N took R1 to the bathhouse for a shower. R1 screamed and hollered at CNA M because she did not want CNA M to help. R1 threw water and kicked at CNA M and threatened to spit on CNA M. CNA M tried to redirect R1, but she did not want to be redirected. R1 swung her arms to try to hit CNA M. CNA M scrubbed R1's hair with a scalp scrubber for the flakes on her scalp. R1 swung her head back and forth, which caused redness on the left side of R1's head. CMA R's Notarized Witness Statement, dated 06/15/26, documented on 06/13/2026, R1 had gotten a whirlpool during the day shift, and it did not go well. LN G stated they had used a scrub brush to scrub R1's head. LN G stated R1 did not like that and fought LN G and CNA M. CMA R stated around 08:30 PM, she went to R1's room. R1 stated, Those girls who gave me a bath today were mean to me. There was one girl on one side and one girl on the other, and they started pulling my hair both ways. Then they started to scrub my head really hard, and it hurt me. CMA R looked at R1's head and noted R1's whole head was very red, and the left side of her head was almost bruised, and the left side of R1's head, where her sideburn was, had a very big bruise and scratches. CMA R stated R1 was very upset and said if she could walk out of the facility, she would, as she felt disrespected. CMA R stated that throughout the night shift, R1 continued to repeat the same story over and over. On 06/22/2026 at 11:00 AM, CNA M stated she did not mean to cause R1 any harm; she was just trying to get the yellow flakes out of R1's hair. CNA M stated R1 fought the whole time throughout the bath. On 06/22/2026 at 11:30 AM, Administrative Nurse D stated she did not think the staff tried to hurt R1 during the bath. Administrative Nurse D stated R1was scared of bathing and water. Administrative Nurse D stated she did not know where the scalp scrubber had come from because she had never bought anything like that for the facility, and she had made sure none of the bathhouses had any scalp scrubbers. Administrative Nurse D stated all staff had been educated regarding the new policy regarding the use of scalp scrubbers/brushes and on being gentle with residents during the bathing process. The facility's undated Person-Centered Dementia Care Policy documented residents who exhibit symptoms of dementia will receive appropriate care to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Programming for person-centered dementia care is designed to focus on each individual's remaining abilities. The programming will assist residents in engaging in meaningful day-to-day living. The person-centered dementia care provided by the facility will enhance the quality of life of individuals by focusing on the positive and creating a home filled with variety, spontaneity, and the opportunity to give care. The facility will provide dementia treatment and services, which include but are not limited to: ensuring that the necessary care and services are person-centered and reflect the resident's goals, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety.

The facility identified a census of 23 residents, with three residents reviewed for falls. Based on record review, observation, and interview, the facility failed to ensure the foot pedals were on Resident (R) 1's wheelchair when staff assisted pushing her in her wheelchair, to prevent avoidable accidents. On 09/12/25, Licensed Nurse (LN) G propelled R1 in her wheelchair, without foot pedals, and R1 put her feet on the ground, which caused R1 to fall headfirst to the floor. R1 sustained a laceration (cut) on her forehead, which measured 7.5 centimeters (cm), a small hematoma, and required emergency transfer to evaluation and eight sutures to close the laceration. Findings included:- R1's Electronic Medical Record (EMR) documented R1 had diagnoses of Lewy body dementia (a type of progressive brain disorder that leads to a decline in thinking, reasoning, and independent function), congestive heart failure (CHF- a condition with low heart output and the body becomes congested with fluid), chronic pain syndrome, and repeated falls.The admission Minimum Data Set (MDS), dated [DATE], documented R1 had short and long-term memory problems, severely impaired cognition, inattention, disorganized thinking, and physical and verbal behaviors directed towards others.The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 04/25/25, documented R1 had dementia (progressive mental disorder characterized by failing memory, confusion) with behaviors. R1's dementia affected her ability to communicate well, and she exhibited disorganized thinking.The Falls CAA, dated 04/25/25, documented R1 had previous falls. The CAA documented R1 would be monitored closely, and staff would provide activities of interest to distract R1. The CAA documented R1 required one staff assistance with ambulation in the halls and propelled herself out in the halls.R1's Care Plan, initiated 04/01/25, documented R1 had an activities of daily living (ADL) deficit due to dementia with behaviors. The care plan documented R1 was a high fall risk related to confusion and poor safety awareness, and noted she had ten falls since her admission. The care plan directed staff to encourage R1 to sit in a recliner at the nurse's station, staff to be more aware when supervising R1, staff would assist R1 to ambulate when restless, provide R1 activities that minimized the potential for falls, keep R1 in line of sight as much as possible, assist R1 out of bed when R1 awoke, and utilize an anti-roll back bar on R1's wheelchair. The care plan lacked any interventions regarding foot pedals on R1's wheelchair.LN G's Notarized Witness Statement, dated 09/15/25, documented LN G propelled R1 in her wheelchair as R1 was trying to crawl out of the chair at the nurse's station. When going down the hall, LN G stated R1 leaned forward, fell, and hit her head on the floor. R1 was assisted into her wheelchair and taken to the emergency room.Administrative Nurse E's Notarized Witness Statement, dated 09/15/25, documented Administrative Nurse E walked into the hallway and saw R1 on the floor in front of her wheelchair. Administrative Nurse E stated R1 was on one-to-one with LN G. LN G was pushing R1 down the hall when the fall occurred.The Facility Fall Investigation, dated 09/17/25, documented on 09/12/25 at approximately 03:00 PM, LN G pushed R1 down the hallway (in her wheelchair). R1 abruptly put her feet onto the floor, which caused her to fall forward out of her wheelchair onto the floor. Administrative Nurse E looked down the hall, saw R1 on the floor in front of her wheelchair, and went to assist. R1 sustained a laceration to her forehead, staff applied pressure, and the bleeding stopped. The staff assisted R1 off the floor and back into her wheelchair after foot pedals were placed, and then transferred R1 to the emergency room for evaluation. The primary care provider evaluated R1 in the emergency room. The laceration was cleansed and sutured, requiring eight sutures. A computed tomography (CT scan- a test that used X-ray technology to make multiple cross-sectional views of organs, bone, soft tissue, and blood vessels) scan of the head was completed, and the findings showed a small frontal scalp hematoma. R1 returned to the facility and was monitored per protocol. Sutures were expected to be removed in seven days. R1 had dementia and behaviors, liked to propel herself down the hall, and did not like the pedals on the chair. The investigation documented every resident in a wheelchair would have pedals on their wheelchair or in their room so they could be placed on the wheelchair when necessary. All staff would be educated on this change. Administrative Nurse D and Administrative Nurse E would monitor to ensure this was occurring. The Facility Risk Management Summary, dated 10/01/25, documented on 09/12/25 at 03:00 PM, R1 propelled herself down the hallway, followed by LN G when R1 abruptly put her feet onto the floor, which caused R1 to fall forward out of her wheelchair onto the floor. Administrative Nurse E looked down the hall and saw R1 on the floor in front of her wheelchair. R1 sustained a laceration to her forehead. Pressure was applied, and bleeding stopped. R1 was assisted off the floor and into her wheelchair by three staff members and taken to the emergency room to be evaluated. Facility recommendation for foot pedals to be placed on all wheelchairs and flipped up when residents want to propel themselves down the hall.On 10/20/25 at 10:30 AM, observation revealed R1 lay in bed and tossed and turned, appearing restless. A wheelchair was not seen in R1's room. The injury to R1's head had healed.On 10/20/25 at 11:30 AM, observation revealed several residents sitting in a music activity in the activity room. None of the wheelchairs had foot pedals present.On 10/20/25 at 11:45 AM, LN G stated she did not normally work on the floor, and the day R1 fell, she went out to help staff provide one-on-one with R1. LN G stated R1 was all over the place and tried to crawl out of the recliner by the nurse's station. LN G stated R1 was placed in her wheelchair, and R1's wheelchair did not have foot pedals on. LN G stated R1was moving down the hall by pulling herself on the handrail. LN G stated she would nudge her along occasionally and keep her from going into others' rooms. LN G stated the fall happened so fast there was nothing she could do to prevent it.On 10/20/25 at 11:50 AM, Administrative Nurse E stated the only education given to staff was on a Weekly Case Management sheet, the facility used to provide staff with education/information. Staff were told the intervention for R1's fall was to ensure the foot pedals were on her wheelchair when pushing R1 in her wheelchair.On 10/20/25 at 12:15 PM, Administrative Nurse D stated the facility had not provided any education to staff regarding ensuring foot pedals were on wheelchairs. Administrative Nurse D stated foot pedals should be on residents' wheelchairs to ensure they were readily available to use. Administrative Nurse D stated an audit was performed after R1's fall for all of the residents who used wheelchairs to ensure they all had foot pedals.The facility's Fall Risk Assessment Policy, revised 05/12/20, documented residents would be evaluated for the potential risk of falling, and appropriate measures would be taken to reduce or eliminate those risks. Staff will seek to identify environmental hazards that may contribute to falls. Interventions to prevent/minimize falls would be added to the residents' care plan. Staff would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors.

The facility had a census of 22 residents. The sample included 12 residents, with one reviewed for dignity. Based on observation, record review, and interview, the facility failed to promote dignity for one resident, Resident (R) 22, whose pajamas were soiled with urine from her waist down to the back of her knees. The facility further failed to promote dignity for R22 by taking her out into the common area and into an activity in her pajamas. This placed the resident at risk for impaired dignity. - The Electronic Medical Record (EMR) for R22 documented diagnoses of pressure ulcers, dementia (a progressive mental disorder characterized by failing memory and confusion), acute kidney failure (the kidney suddenly can't filter waste from the blood), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), vitamin deficiency (a deficiency of one or more essential vitamins), and pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R22 had severely impaired cognition. R22 was dependent upon staff for transfers and toileting hygiene. R22 required substantial assistance with dressing and lower functional impairment on both sides. The MDS documented R22 was frequently incontinent of bladder and occasionally incontinent of bowel. The Quarterly MDS, dated [DATE], documented R22 had severely impaired cognition. R22 required substantial assistance from staff for toileting hygiene, lower body dressing, and toileting, and had lower functional impairment on both sides. The MDS documented R22 was frequently incontinent of bladder and bowel. R22's Care Plan, dated 02/25/25, initiated on 11/05/24, directed staff to assist R22 with all activities of daily living (ADL). The care plan directed staff to allow her to do as much for herself as possible and assist her with personal hygiene. The care plan update, dated 12/31/24, directed staff to toilet her approximately every two hours. On 03/04/25 at 09:55 AM, R22 was in bed and had bilateral heel protectors on. CNA N removed the heel protectors and swung her legs over the side of the bed. R22 did not have any socks on, and her bare feet were placed on the footplate of the sit-to-stand mechanical lift. CNA B placed the sit-to-stand sling around the resident, attached it to the lift, and R22 was lifted to a standing position. R22's bed had a chuck (a disposable bed pad used to protect bedding or furniture from urinary incontinence) that was heavily soiled with urine. R22's back of her pajama pants was soiled with urine clear down to the back of her knees. When asked, Certified Nurse Aide (CNA) P stated R22 had been last toileted at 07:00 AM. R22 stated, I'm cold. CNA N stated, Don't worry, you're going to get a bath today. CNA N put a clean brief on R22 and clean pajama pants on, left her pajama top on, and socks. CNA N did not put R22's pressure-relieving boots back on. CNA N stated she was not sure how R22 obtained the pressure ulcer but thought it was from pushing on the footboard on her bed, and it just did not heal. R22 was pushed into the area by the nurse's station and CNA N stated, You didn't have breakfast, I will get you a Danish. At 10:34 AM, R22 was still out in the commons area, in pajamas, and no pressure-relieving boots. Activity staff asked R22 if she wanted to participate in the music activity and told her to lift her feet up so she could push her into the activity room. R22 lifted her toes up but her heels were dragging on the floor, and she lacked any protection on her feet. At 11:45 AM, when asked, R22 stated she had got to sleep in but was not dressed. At 12:00 PM, the Nursing Staff came into the activity room and stated, It's time for lunch and R22 stated, But I am not dressed. As R22 was taken to her room. CNA N stated, It's time for lunch, where is she going? CNA N was told that R22 was not dressed, and she did not want to go to lunch without being dressed. When CNA N was asked why she was not given a bath like R22 was told or had her pajamas covered, CNA N stated, She was supposed to get a bath, but my coworker is lazy. I told her she had to give her a bath right after lunch. R22 returned to the commons area dressed and had her pressure-relieving boots on. On 03/05/25 at 01:00 PM, Administrative Nurse D stated that R22 should not have been taken out into the commons area in her pajamas, but did not speak of why R22 was soaked with urine. The facility's Right to Dignity policy, dated 01/30/20, documented the facility will promote care for residents of the facility in a manner and in an environment that maintains and enhances each resident's dignity and respect in full recognition of the resident's individuality. The facility failed to promote care for R22 in a manner to maintain and enhance dignity and respect. This placed R22 at risk for impaired dignity.

The facility had a census of 22 residents. The sample included 12. Based on observation, record review, and interview, the facility failed to implement effective care plan interventions for Resident (R) 6 from falling and sustaining major injuries. This deficient practice placed R6 at risk for continued falls and injuries. Findings included: - The Electronic Medical Record (EMR) for R6 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), hypertension (HTN - elevated blood pressure), chronic atrial fibrillation (rapid, irregular heartbeat), fracture (broken bone) of body of sternum (t-shaped bone of front chest) and other parts of the pelvis (bones between the lower abdomen and upper thighs that connect the spine to the legs). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition, and exhibited no behaviors. R6 had functional range of motion impairment to both sides of the lower extremities, was dependent with toileting hygiene, and lower body dressing. R6 required partial/moderate assistance with personal hygiene and substantial/maximal assistance with rolling left and right, and transfers and walking were not attempted. The MDS further documented R6 had one fall with major injury since prior assessment. R6 also had two pressure injuries presenting as deep tissue injuries (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) which were present on readmission to the facility. The Fall Care Area Assessment (CAA), dated 05/08/24, documented R6 fell on [DATE] in her room at 05:12 PM, was taken to the emergency room , and had a fractured pelvis. R6 returned on 04/19/24 to her room in long-term care, ordered to be on bed rest until further notice. The CAA further documented R6 had been independent in her room prior to the fall. The facility conducted another Significant Change MDS with a Fall CAA dated 08/01/24, which documented R6 had falls on 04/09/24, 06/28/24, and 07/10/24. The CAA further documented R6 fell on [DATE], and a new pelvic fracture was present. R6, now declining the restorative program, was noncompliant with staff assistance, had poor safety awareness, several interventions implemented for fall prevention, had moderately impaired cognition but R6 did not follow directions, and had fractures at the base of the third and fourth digit (fingers). R6's Fall Care Plan dated 02/14/25, documented that R6 was at high risk for falling and had an actual fall with major injury. The Care Plan documented R6 no longer wanted to be asked about restorative therapy. The interventions dated 09/30/24 were for physical therapy and were independent in her room, she used a front-wheeled walker in the hallway. On 04/18/24, a grabber was provided. On 11/23/24, floor grip strips were placed on the floor in front of her recliner and R6 wanted to be more independent. Upon review of R6 falls revealed: The Progress Note dated 04/09/24 at 05:12 PM R6 was found in her room, lying on her right side on the floor, with a walker parked against the bathroom door. R6 complained of right hip pain and had a skin tear to the right elbow. R6 was sent to the emergency room . The Incident Summary dated 04/09/24 concluded R6 reached for an item from the floor when she fell . R6 had been admitted to the hospital for treatment. The recommendation made was to provide a reacher (a device used to help grab items from out of reach). The Computerized Tomography Scan (CT-x-ray technique of imaging to create detailed images) of the pelvis report, dated 04/09/24, revealed moderately displaced fractures of the right superior and inferior pubic ramus (a break or crack in the pelvis bones). The Progress Note dated 06/28/24 at 04:06 AM documented R6 found lying on the right side with bleeding noted to the right ring and little fingers. R6 was barefooted and reported she was going to the bathroom. R6 was sent to the emergency room . The Incident Summary dated 06/28/24 documented R6 was sent to the emergency room and received one stitch in both fingers. The recommendation was to remind R6 to call for assistance when getting up and ambulating. On 07/02/24, an X-ray report revealed that the left hand had a nondisplaced fracture at the base of the fourth digit and a questionable non-displaced fracture at the base of the third digit. The Progress Notes dated 07/10/24 at 09:56 AM documented that R6 was heard yelling and found lying on the floor. The note reported R6 had got up on her own. The physician ordered an X-ray of the right hip and pelvis. The Incident Summary dated 07/10/24 documented that R6 was unattended and had gotten up out of her chair, and R6 was given a reacher (a previous intervention) and shown how to use it so she could grab items out of her reach. And that the nursing staff would take the resident to the bathroom one hour after each meal. The CT Scan (X-ray technique of imaging creates detailed images) of the pelvis, dated 07/13/24, reported an acute comminated (bone break into three or more pieces) fracture of the right ischium (part of the hip bone or over the hip bone area), and the base of the inferior pubic ramus. The Progress Note dated 08/28/24 at 04:44 PM documented R6 signed a contract stating the staff/facility was not responsible for any falls. R6 had been educated on using the call light when she needed assistance, using her walker, and wearing appropriate footwear, including gripper socks. R6 had voiced understanding and was agreeable to this. (R6 had moderately impaired cognition). The chair alarm had been discontinued. The Progress Note dated 11/15/24 at 05:37 AM documented R6 was found on the floor in her room. R6 stated she tried going to the bathroom. R6 right forearm was bleeding and bruised, along with points on her hand. The Incident Summary dated 11/15/24 documented steri-stips (adhesive wound closures) placed on R6's forearm. The recommendation/action documented staff instructed that R6 was taken to the bathroom within one hour after meals. R6 was provided a reacher due to wanting to be self-sufficient. On 03/05/25 at 09:25 AM, R6 was in her room, standing at the dresser/TV stand, looking through the top drawer. The walker was parked next to the dresser. The call light was fastened to the left armrest of her recliner. On 03/05/25 at 09:30 AM, Certified Nurse Aide (CNA) M stated R6 does what she wants, and staff tried to catch her when she was up to be near her. CNA M reported thst R6 ate most of her meals in her room, but on occasion, she would come out to see the birds in the activity room or walk up and down the halls. On 03/05/25 at 11:00 AM, Licensed Nurse (LN) G reported that R6 was very stubborn and had poor safety awareness. LN G reviewed a document risk assessment that R6 had signed a release of responsibility form for injuries related to falls. On 03/05/25 at 01:20 PM, Administrative Nurse E verified that R6 had signed a safety education and release of responsibility form when R6 had moderately impaired cognition. Administrative Nurse E reported that the charge nurses were responsible for new interventions to prevent further falls of residents with each fall. The facility's Comprehensive Person-Centered Care Plan policy, dated 03/2022, documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs and is developed and implemented for each resident. Assessments of residents are ongoing, and care plans are revised as information about the resident and the resident's conditions change. The facility failed to implement effective care plan interventions for R6 from falling. This deficient practice placed the resident at risk for continued falls and injuries.

The facility had a census of 22 residents. The sample included 12 residents, with one reviewed for Activities of Daily Living (ADL). Based on observation, record review, and interview, the facility failed to provide meal assistance for one resident, Resident (R) 19, who required assistance. This placed R22 at risk for further weight loss. Findings included: - The Electronic Medical Record (EMR) for R19 documented diagnoses of hypertensive heart disease (heart issues that develop due to long-term high blood pressure), atrial fibrillation (rapid, irregular heartbeat), retention of urine (lack of ability to urinate and empty the bladder), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Annual Minimum Data Set Assessment (MDS), dated [DATE], documented R19 had moderately impaired cognition. R19 required partial assistance from staff for dressing, mobility, transfers, and toileting. R19 was independent with eating. The MDS documented R19 had no chewing or swallowing issues, weighed 138 pounds (lbs.), and had no weight loss or gain. The Nutrition Care Area Assessment (CAA), dated 05/09/24, did not trigger. The Quarterly MDS, dated [DATE], documented R19 had moderately impaired cognition. R19 required partial assistance with dressing, ambulation, and personal hygiene. R19 was independent with eating. R19 had no chewing or swallowing issues weighed 143 lbs. and had no weight loss or gains. R19's Care Plan, dated 02/28/25, initiated on 11/17/23, documented R19 may need assistance and one staff assistance with eating depending upon how he felt that day. The update, dated 02/26/25, directed staff to follow a regular diet as ordered, monitor intake daily, and offer alternate food or a house supplement for intake less than 50%. The care plan directed staff to offer assistance if R19 had trouble unwrapping food and drinks and monitor weight closely for gain or loss. The EMR lacked documentation of how often to weigh R19. R19's Vital Sign Log-Weights recorded the following weights: 01/13/25 146.6 lbs. 01/20/25 148.6 lbs. 01/27/25 148.6 lbs. 02/03/25 146.6 lbs. 02/10/25 142 lbs. 02/25/25 134 lbs. 03/03/25 128.9 lbs. (12.07 percent [%] weight loss in 30 days) The Nutrition/Dietary Note dated 02/26/25 documented R19's intake had declined. R19's family member requested staff assist R19 with meals. The note directed staff to offer supplements at meals when he didn't eat or wanted to order alternative food. The CDM would continue to make adjustments as needed and consult the Registered Dietician (RD). The EMR lacked documentation the RD was notified of the continued weight loss. The Medication Administration Record (MAR) dated 02/28/25 directed staff to provide a house supplement as needed. The record lacked documentation that the supplement was provided to R19. The EMR recorded R19 was admitted to Hospice (specialized care that mainly aims to provide comfort and dignity to patients, by providing physical comfort and emotional, social, and spiritual support for people nearing the end of life) on 02/27/25 due to hypertensive heart failure. On 03/03/35 at 12:05 PM, R19 was taken by wheelchair to the dining room table for the noon meal. R19 leaned against a small pillow on his right side which caused him to be lower than the table. Dietary staff sat a bowl of jello, a glass of water, and his meal of onion rings, green beans, and chicken on the table. R19 tried to adjust himself to get closer to the table. CDM BB went to the table and asked R19 if she could cut his chicken up for him and he stated, Yes. R19 continued to lean slightly to the right, he was able to eat an onion ring but as he reached for his jello, it was out of his reach. R19's fingertips touched the bowl of jello but he could not get close enough to be able to eat it. R19's tablemate R21 pushed the jello closer to R19, and he attempted to take a bite but was unable to do so. At 12:16 PM, a staff member walked up to the table and stated. Do you need some help? R19 stated, If I am going to eat something, I do. The staff member sat down next to him and assisted him with two bites of food. At 12:25 PM, the staff member got up and left the dining room, and never came back. In the dining room, there were three staff members assisting other residents, two at one table and another at a different table. R19 reached for his water and slid it to the edge of the table, but was unable to pick it up to drink. R19's tablemate R21 picked up R19's water glass and held it up to his mouth so R19 could drink. After he had drank some of his water, he tried to move away from the table, dropped his napkin, and attempted to pick it up, and a staff member saw him reaching for the floor, got up, and picked it up for him. R19 attempted to move away from the table again as his tablemate R21 looked around the dining room for someone to assist R19 and as a staff member walked by he asked her to help R19. On 3/4/25 at 09:00 AM, R19 sat in his recliner in his room. His bedside table had a bowl of cream of wheat and toast. This Surveyor asked him how his breakfast was, and he stated, I haven't tried it yet because I need help, and I cannot reach it. Certified Medication Aide (CMA) R was located at the nursing station and asked if there was staff available to assist R19 with his breakfast meal. CMA R used her communication device to ask for staff to go to his room and assist him. CNA N went into his room and stated, What do you need help with? R19 stated, Everything. CNA N stated, Do I need to sit in here with you? During that interaction, CNA O walked into the room and she and CNA R discussed who was going to sit in the room and assist R19. CNA O sat down next to R19 as he tried to eat, and she looked at her cell phone. R19 was able to receive some assistance with his meal. On 03/04/25 at 09:26 AM, Administrative Staff D stated, R19 had been ill and in the hospital from 02/03/25 to 02/08/25. Administrative Nurse D verified that he had declined since then and staff should be aware and assist him. On 03/04/25 at 10:00 AM, CNA O stated that R19 had declined recently and stated his daughter usually assisted him with his meals. CNA O further stated that R19 did require more assistance with his care and meals. On 03/04/25 at 02:33 PM, Dietary Staff BB stated she had not notified the RD of R19's weight loss. She had provided nursing staff standing orders that the RD had provided to the facility for residents when there was a weight loss. Dietary Staff BB stated if R19 ate less than 50%, staff were to offer alternative food or a supplement. Dietary Staff document meal intakes and nursing staff are to document the supplement. Dietary Staff BB stated she had planned to notify him the next day of R19's weight loss. Dietary Staff BB stated, if a resident had a 5% weight loss in a month, staff were to provide 6 ounces (oz) of orange juice twice a day, provide med pass (nutritional supplement) 2 oz four times per day, meal fortification, multivitamins with minerals, weekly weights, and document the amount he consumed. Dietary Staff BB stated she was unaware that the nursing staff had not followed the recommendations. On 03/04/25 at 02:50 PM, Administrative Nurse E stated she would look at R19's weight loss recommendations. Administrative Nurse E stated that the dietary staff was responsible for meal intake but was not aware that R19 did not receive the supplement. On 03/05/25 at 09:20 AM, Licensed Nurse (LN) G stated that there was a fax communication to the physician on 02/18/25, that R19 had a decreased appetite but was unable to locate any documentation that he was aware of how much weight R19 had lost. She stated R19 was supposed to get a bottle of Ensure (nutritional supplement) with his meals if he ate less than 50%. LN G stated she was unsure when he had received the supplement or not. LN G stated that R19 was on Hospice services and thought that they were aware of his weight loss. On 03/05/25 at 01:00 PM, Administrative Nurse D stated staff should assist R19 with his meals. The facility's Assisting the Impaired Resident with In-Room Meals policy, dated 09/13, directed staff to ensure that the necessary non-food items are in place on the tray i.e., silverware, special devices, napkins, and straws. Position the resident so his or her head and upper body are as upright as possible, position your chair where it would be convenient for you and the resident. Feed the resident slowly and allow plenty of time between mouthfuls. Encourage the resident to eat all of his meal, but do not force him or her to eat. Document how much of the meal the resident consumes and if the resident participated. Document any changes in the resident's ability to participate with the meal and if the resident had any difficulty feeding himself, chewing, or swallowing. Notify the supervisor if the resident refused the meal or to eat. The facility failed to provide meal assistance for R19, who required assistance. This placed R22 at risk for further weight loss.

The facility had a census of 22 residents. The sample included 12 residents, with two reviewed 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, record review, and interview, the facility failed to prevent the development of a Stage 3 (full thickness tissue loss) pressure ulcer for one resident, Resident (R) 22 who had edema (swelling resulting from an excessive accumulation of fluid in the body tissues) in her legs. The facility also failed to implement interventions to prevent further breakdown and follow the plan of care to wear pressure-relieving boots at all times. This placed the resident at risk for further breakdown. Findings included: - The Electronic Medical Record (EMR) for R22 documented diagnoses of pressure ulcers, dementia (a progressive mental disorder characterized by failing memory and confusion), acute kidney failure (the kidney suddenly can't filter waste from the blood), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), vitamin deficiency (a deficiency of one or more essential vitamins), and pain. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R22 had severely impaired cognition. R22 was dependent upon staff for transfers, toileting hygiene, and partial assistance from staff for mobility, and lower functional impairment on both sides. The MDS documented R22 was at risk for pressure ulcers, had a 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), received pressure-ulcer care, and had a pressure device for her bed and chair. The Pressure Ulcer Care Area Assessment (CAA), dated 11/15/24, documented R22's heels were floated whenever she was in bed or her recliner, and gel cushions were in her chairs. R22 has had a significant change in her condition due to acute issues with increased confusion with dementia, urinary tract infections (UTI - an infection in any part of the urinary system), and increased pain in both knees. R22's compression socks were not applied until the heel sore was healed. The Quarterly MDS, dated [DATE], documented R22 had severely impaired cognition. R22 required substantial assistance from staff for toileting hygiene, lower body dressing, and toileting, and had lower functional impairment on both sides. The MDS documented R22 was at risk for pressure ulcers, had one stage 3 pressure ulcer, received pressure ulcer care, and had a pressure device for her bed and chair. R22's Care Plan, dated 02/25/25, initiated on 11/18/25, directed staff to administer treatments as ordered and monitor for effectiveness. Float heels when in a reclining chair and bed, new wheelchair pedals on her wheelchair for a better fit, and a gel cushion for her wheelchair. The care plan further directed staff to turn/reposition R22 at least every two hours, more often as she required extensive to total assistance with repositioning R22 and required weekly treatment documentation to include measurement of each area of skin breakdown with width, length, depth, type of tissue and exudate (a mass of cells and fluid that has seeped out of blood vessels or an organ, especially in inflammation (swelling). The update, dated 12/31/24, directed staff to toilet her approximately every two hours. The update, dated 02/26/25, directed staff to have heel protectors on at all times. The Braden Scale Assessment (formal assessment for predicting pressure ulcer risk) dated 10/25/24 documented R22 was not at risk for pressure ulcers. The Braden Scale assessment dated [DATE] documented R22 was at risk for pressure ulcers. The Weekly Skin Evaluation dated 11/26/24 documented R22's right heel measured 4.5 cm x 4.2 cm and had eschar. The left heel measured 0.8 cm x 1.2 cm and was scabbed. The Weekly Skin Evaluation dated 12/24/24 documented R22's right heel measured 2.5 cm x 2 cm. The Weekly Skin Evaluation dated 01/01/25 documented R22 had a right heel pressure ulcer but lacked documentation of the measurement. The Physician's Order dated 11/04/24 directed staff to provide liquaCel (protein supplement). 30 milliliters (ml), by mouth, three times per day, for vitamin deficiency. The Physician's Order dated 11/11/24 directed staff to elevate R22's feet twice per day for edema. The Physician's Order dated 11/14/24 directed staff to administer Lasix (a diuretic [medication to promote the formation and excretion of urine]). 20 milligrams (mg), each morning, compression stockings (stockings that help blood flow back into the heart and reduce pain and swelling), knee high for a minimum of 12 hours per day and lower the footrests on the wheelchair. The Nurse's Note dated 11/14/24 at 09:17 AM documented R22 had a new onset of one plus pitting edema in both of her legs and was on an antibiotic (medication that inhibits the growth of or destroys microorganisms) for a UTI. The Nurse's Note dated 11/18/24 at 10:43 AM documented R18 had pressure sores to bilateral heels. The right heel measured five centimeters (cm) x 4.2 cm, and the left heel measures 0.8 cm x 1.2 cm. Staff were directed to apply betadine (an antiseptic used to treat wounds to prevent bacteria) to both heels twice per day until healed. The Physician's Note dated 11/19/24 at 02:05 PM documented nursing staff were concerned that R22 had a blister on her right heel and now there was an area of eschar (dead tissue) on the heel. The note further documented R22 had recently been admitted and laid in bed quite a bit and that is how the blister formed. There is currently no bogginess (spongy, soft texture) underneath the blister. The eschar was firmly attached to the heel and no cellulitis around the eschar. Nursing staff should apply the Betadine, and keep it dry to prevent infection. Should the area become loose or boggy, then the nursing staff need to notify the physician and the physician would reassess. The Nurse's Note dated 11/25/24 at 12:52 PM documented R22 had an appointment at the wound clinic. The Registered Dietician Nutrition/Dietary Note dated 11/26/24 at 09:05 AM documented R22 was new to the facility and had good food and fluid intake. R22 had skin issues on her right and left heel and received protein for extra wound healing. The note documented he recommended continuing with the plan of care. The Nurse's Note dated 11/28/24 at 08:30 AM documented R22's right heel measured 4.3 cm x 3.5 cm was black/brown in color, intact blister was noted. The left heel measured 2 cm x 1 cm open area, no drainage noted, and the edges were pink. R22's heels floated when laid down and walked to the bathroom with her walker and the assistance of two staff. The Nurse's Note dated 12/05/24 at 03:54 PM documented R22's wound on her right heel started to worsen with ambulation and her exercise program was being adjusted until the wounds healed. The Physician's Order dated 12/05/24 directed staff to apply an Iodoflex (absorbs slough, soft necrotic (dead or dying) tissue, and exudate) dressing and cover with a four-by-four silicone foam dressing, to the right heel until healed. The order was discontinued on 01/22/25. The Nurse's Note dated 12/20/24 at 09:43 AM documented R22 had eschar on her right heel. The area developed as a blister because she used her heels to push herself in bed and then underneath the blister, there was a large area of eschar that continued to improve. The Wound Care Notes dated 12/30/24 documented R22 right heel measured 1.5 cm x 1.7 cm x 0.1 cm and directed staff to wear a gel cushion to the right foot to assist with pressure reduction. The EMR lacked documentation that the order was put into place. The Physician's Order dated 01/15/25 directed staff to wear heel protectors at night and remove in the morning. The Nurse's Notes dated 01/17/25 at 11:05 AM documented R22's right heel measured 1.8 cm x 2 cm x 0.1 cm, small amount of serosanguinous (semi-thick blood-tinged drainage) exudate, and surrounding tissue edema. The Wound Care Notes dated 01/22/25 documented R22's right heel measured two cm x two cm x 0.3 cm, a moderate amount of serosanguinous exudate, and surrounding tissue edema. The Wound Care Report dated 01/29/25 documented R22's right heel had a large callous/ eschar. The wound measured 1.8 cm x 2 cm x 0.1 cm, with serosanguinous exudate, and surrounding tissue edema. The staff was directed to apply Promogran Prisma (a dressing indicated for the management of all wounds healing by secondary intent which are clear of necrotic tissue) to the wound bed, activate with normal saline, cover with a four-by-four silicone dressing, change twice a week with showers and as needed. The Wound Care Report dated 02/05/25 documented R22's right heel measured 1.1 cm x 1.2 cm x 0.3 cm, with a moderate amount of serosanguinous exudate, surrounding tissue had edema. The Wound Care Report dated 02/19/25 documented R33's right heel measured 1.6 cm x 1 cm x 0.3 cm, with a moderate amount of serosanguinous exudate, and surrounding tissue edema. The facility was directed to take a multivitamin out and follow label instructions for dosing. Take Vitamin C, 1000 mg, by mouth, daily. Limit salt and increase protein in the diet. Review of the EMR lacked documentation the above recommendation was implemented. The facility was directed to apply silvercel (a sterile non-woven pad with alginate) to the wound bed and cover it with four-by-four bordered gauze, daily and as needed. The Registered Dietician Nutrition/Dietary Note dated 02/20/25 at 04/45 PM documented R22 had increased protein at meals for wound healing and currently took Liquacel to help with the wound. The RD recommended continuing the plan of care. The Physician's Order dated 02/26/25 directed staff for the heel protectors to stay on night and day to reduce pressure on the heels. On 03/04/25 at 09:55 AM, R22 was in bed and had bilateral heel protectors on. CNA N removed the heel protectors and swung her legs over the side of the bed. R22 did not have any socks on, and her bare feet were placed on the footplate of the sit-to-stand mechanical lift. CNA B placed the sit-to-stand sling around the resident, attached it to the lift, and R22 was lifted to a standing position. R22's bed had a chuck (a disposable bed pad used to protect bedding or furniture from urinary incontinence) that was heavily soiled with urine. R22's back of her pajama pants was soiled with urine clear down to the back of her knees. When asked, Certified Nurse Aide (CNA) P stated R22 had been last toileted at 07:00 AM. R22 stated, I'm cold. CNA N stated, Don't worry, you're going to get a bath today. CNA N put a clean brief on R22 and clean pajama pants on her, left her pajama top on, and socks. CNA N did not put R22's pressure-relieving boots back on. CNA N stated she was not sure how R22 obtained the pressure ulcer but thought it was from pushing on the footboard on her bed, and it just did not heal. R22 was pushed into the area by the nurse's station and CNA N stated, You didn't have breakfast, I will get you a Danish. At 10:34 AM, R22 was still out in the commons area, in pajamas, and no pressure-relieving boots. Activity staff asked R22 if she wanted to participate in the music activity and told her to lift her feet up so she could push her into the activity room. R22 lifted her toes up but her heels were dragging on the floor, and she lacked any protection on her feet. At 11:45 AM, when asked, R22 stated she had got to sleep in but was not dressed. At 12:00 PM, the Nursing Staff came into the activity room and stated, It's time for lunch and R22 stated, But I am not dressed. As R22 was taken to her room. CNA N stated, It's time for lunch, where is she going? CNA N was told that R22 was not dressed, and she did not want to go to lunch without being dressed. When CNA N was asked why she was not given a bath like R22 was told or had her pajamas covered, CNA N stated, She was supposed to get a bath, but my coworker is lazy. I told her she had to give her a bath right after lunch. R22 returned to the commons area dressed and had her pressure-relieving boots on. On 03/04/25 at 03:15 PM, LN G washed her hands, gloved, and placed a dry chuck on the floor in front of R22's recliner. LN G removed the soiled dressing from R22's right heel, removed her gloves, and donned clean gloves. LN G cleansed the right heel wound with normal saline. LN G removed soiled gloves, donned clean gloves and placed silvercel in the wound, covered the wound with a foam dressing over it. LN G stated that R22 required more assistance after she came into the facility. She was unsure how she acquired the wound but R22 had a lot of edema and her shoes were too tight. LN G stated R22 had just recently gotten the bigger pressure relieving boot and R22 would be getting a walking boot so she could participate in physical therapy. LN G stated that R22 should have the pressure-relieving boots on at all times. On 03/05/25 at 01:00 PM, Administrative Nurse D stated she could not speak as to how R22 obtained the pressure ulcer. She stated she did not know why it took two months for R22 to have pressure-relieving boots or why interventions were not put into place. Administrative Nurse D stated, that R22 should not have been taken out into the commons area in her pajamas and should have had on her boots. The facility's Wound/Pressure Ulcer Management policy, dated 07/19, documented the facility was committed to providing a comprehensive wound management program to promote the resident's highest level of functioning and well-being. The facility was committed to minimizing the development of in-house acquired pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable. Any resident with a wound received treatment and services consistent with the resident's goal of treatment. Typically, the goal is one of promoting healing and preventing infection unless a resident's preferences and medical condition necessitate palliative care as the primary focus. The facility failed to prevent the development of a Stage 3 for R22 who had edema in her legs. The facility also failed to implement interventions to prevent further breakdown and follow the plan of care to wear pressure-relieving boots at all times. This placed the resident at risk for further breakdown.

The facility had a census of 22 residents. The sample included 12 residents of which five residents were reviewed for falls. Based on observation, record review, and interview, the facility failed to prevent Resident (R) 6 from falling and sustaining major injuries with ineffective interventions. This placed R6 risk for continued falls and injuries. Findings included: - The Electronic Medical Record (EMR) for R6 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), hypertension (HTN - elevated blood pressure), chronic atrial fibrillation (rapid, irregular heartbeat), fracture (broken bone) of body of sternum (t-shaped bone of front chest) and other parts of the pelvis (bones between the lower abdomen and upper thighs that connect the spine to the legs). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition, and exhibited no behaviors. R6 had functional range of motion impairment to both sides of the lower extremities, was dependent with toileting hygiene, lower body dressing, required partial/moderate assistance with personal hygiene and substantial/maximal assistance with rolling left and right, and transfers and walking was not attempted. The MDS further documented R6 had one fall with major injury since prior assessment. R6 also had two pressure injuries presenting as deep tissue injuries (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) which were present on readmission to the facility. The Fall Care Area Assessment (CAA), dated 05/08/24, documented R6 fell on [DATE] in her room at 05:12 PM, taken to the emergency room and had fractured pelvis. R6 returned on 04/19/24 to her room in long term care, ordered to be on bed rest until further notice. The CAA further documented R6 had been independent in her room prior to the fall. The facility conducted another Significant Change MDS with a Fall CAA dated 08/01/24, which documented R6 had falls on 04/09/24, 06/28/24, and 07/10/24. The CAA further documented R6 fell on [DATE], and a new pelvic fracture was present. R6, now declining the restorative program, was noncompliant with staff assistance, had poor safety awareness, several interventions implemented for fall prevention, had moderately impaired cognition but R6 did not follow directions, and fractures at the base of the third and fourth digit (fingers). The Fall Care Plan dated 02/14/25, documented that R6 was high risk for falling and had an actual fall with major injury. The Care Plan documented R6 no longer wanted to be asked about restorative therapy. The interventions dated 09/30/24 were for physical therapy and were independent in her room, she used a front-wheeled walker in the hallway. On 04/18/24, a grabber was provided. On 11/23/24, floor grip strips were placed on the floor in front of her recliner and R6 wanted to be more independent. Upon review of R6 falls revealed: The Progress Note dated 04/09/24 at 05:12 PM R6 was found in her room, lying on her right side on the floor, with a walker parked against the bathroom door. R6 complained of right hip pain and had a skin tear to the right elbow. R6 was sent to the emergency room . The Incident Summary dated 04/09/24 concluded R6 reached for an item from the floor when she fell . R6 had been admitted to the hospital for treatment. The recommendation made was to provide a reacher (device used to help grab items from out of reach). The computerized tomography scan (CT-x-ray technique of imaging to create detailed images) of pelvis report, dated 04/09/24, revealed moderately displaced fractures of the right superior and inferior pubic ramus (a break or crack in the pelvis bones). The Progress Note dated 06/28/24 at 04:06 AM documented R6 found lying on the right side with bleeding noted to the right ring and little fingers, R6 was barefooted and reported she was going to the bathroom. R6 was sent to the emergency room . The Incident Summary dated 06/28/24 documented R6 was sent to the emergency room and received one stitch in both fingers. The recommendation was to remind R6 to call for assistance when getting up and ambulating. On 07/02/24, an X-ray report revealed that the left hand had a nondisplaced fracture at the base of the fourth digit and a questionable non-displaced fracture at the base of the third digit. The Progress Notes dated 07/10/24 at 09:56 AM documented that R6 was heard yelling and found lying on the floor. The note reported R6 had got up on her own. The physician ordered X-ray of the right hip and pelvis. The Incident Summary dated 07/10/24 documented that R6 was unattended and had gotten up out of her chair, and R6 was given a reacher (previous intervention) and shown how to use it so she could grab items out of her reach. And that the nursing staff would take the resident to the bathroom one hour after each meal. The CT-(x-ray technique of imaging creates detailed images) of pelvis, dated 07/13/24, reported an acute comminated (bone break into three or more pieces) fracture of the right ischium (part of the hip bone or over the hip bone area), and the base of the inferior pubic ramus. The Progress Note dated 08/28/24 at 04:44 PM documented R6 signed a contract stating the staff/facility was not responsible for any falls. R6 had been educated on using the call light when she needed assistance, using her walker, and wearing appropriate footwear, including gripper socks. R6 had voiced understood and was agreeable to this. (R6 had moderately impaired cognition). The chair alarm had been discontinued. The Progress Note dated 11/15/24 at 05:37 AM documented R6 was found on the floor in her room. R6 stated she tried going to the bathroom. R6 right forearm was bleeding and bruised, along with points on her hand. The Incident Summary dated 11/15/24 documented steri-stips (adhesive wound closures) placed on R6's forearm. The recommendation/action documented staff instructed that R6 was taken to the bathroom within one hour after meals. R6 was provided a reacher due to wanting to be self-sufficient. On 03/05/25 at 09:25 AM, R6 was in her room, standing at the dresser/TV stand, looking through the top drawer. The walker was parked next to the dresser. The call light was fastened to the left armrest of her recliner. On 03/05/25 at 09:30 AM, Certified Nurse Aide (CNA) M stated R6 does what she wants, and staff tries to catch her when she is up to be near her. CNA M reported R6 ate most of her meals in her room, but on occasion she will come out to see the birds in the activity room or walk up and down the halls. On 03/05/25 at 11:00 AM, Licensed Nurse (LN) G reported R6 was very stubborn and had poor safety awareness. LN G reviewed a document risk assessment that R6 had signed a release of responsibility form for injuries related to falls. On 03/05/25 at 01:20 PM, Administrative Nurse E verified R6 had signed a safety education and release of responsibility form when R6 had moderately impaired cognition. Administrative Nurse E reported that the charge nurses were responsible for new interventions to prevent further falls of residents with each fall. The facility's Safety and Supervision of Residents policy, dated 07/2017, documented that the facility strived to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. The individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices and monitoring the effectiveness of interventions. Resident supervision is a core component of the systems approach to safety. The facility failed to prevent R6's falls, which resulted in pelvic and finger fractures with ineffective repeated intervention. This placed the resident at risk for continued falls and injuries.

The facility had a census of 22 residents. The sample included 12 residents, with five residents reviewed for falls. Based on observation, record review, and interview, the facility failed to prevent Resident (R) 6 from falling and sustaining major injuries with ineffective interventions. This deficient practice placed R6 at risk for continued falls and injuries. Findings included: - The Electronic Medical Record (EMR) for R6 documented diagnoses of chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), hypertension (HTN - elevated blood pressure), chronic atrial fibrillation (rapid, irregular heartbeat), fracture (broken bone) of body of sternum (t-shaped bone of front chest), and other parts of the pelvis (bones between the lower abdomen and upper thighs that connect the spine to the legs). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R6 had moderately impaired cognition, and exhibited no behaviors. R6 had a functional range of motion impairment to both sides of the lower extremities and was dependent with toileting hygiene, and lower body dressing. R6 required partial/moderate assistance with personal hygiene and substantial/maximal assistance with rolling left and right, and transfers and walking wwerenot attempted. The MDS further documented R6 had one fall with major injury since the prior assessment. R6 also had two pressure injuries presenting as deep tissue injuries (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) which were present on readmission to the facility. The Fall Care Area Assessment (CAA), dated 05/08/24, documented R6 fell on [DATE] in her room at 05:12 PM, was taken to the emergency room , and had a fractured pelvis. R6 returned on 04/19/24 to her room in long-term care, ordered to be on bed rest until further notice. The CAA further documented R6 had been independent in her room prior to the fall. The facility conducted another Significant Change MDS with a Fall CAA dated 08/01/24, which documented R6 had falls on 04/09/24, 06/28/24, and 07/10/24. The CAA further documented R6 fell on [DATE], and a new pelvic fracture was present. R6, now declining the restorative program, was noncompliant with staff assistance, had poor safety awareness, several interventions implemented for fall prevention, had moderately impaired cognition but R6 did not follow directions, and had fractures at the base of the third and fourth digit (fingers). R6's Fall Care Plan dated 02/14/25 documented that R6 was at high risk for falling and had an actual fall with major injury. The Care Plan documented R6 no longer wanted to be asked about restorative therapy. The interventions dated 09/30/24 were for physical therapy and R6 was independent in her room, she used a front-wheeled walker in the hallway. On 04/18/24, a grabber was provided. On 11/23/24, floor grip strips were placed on the floor in front of her recliner and R6 wanted to be more independent. Upon review of R6 falls revealed: The Progress Note dated 04/09/24 at 05:12 PM R6 was found in her room, lying on her right side on the floor, with a walker parked against the bathroom door. R6 complained of right hip pain and had a skin tear to the right elbow. R6 was sent to the emergency room . The Incident Summary dated 04/09/24 concluded R6 reached for an item from the floor when she fell . R6 had been admitted to the hospital for treatment. The recommendation made was to provide a reacher (a device used to help grab items from out of reach). The computerized Tomography Scan (CT-x-ray technique of imaging to create detailed images) of the pelvis report, dated 04/09/24, revealed moderately displaced fractures of the right superior and inferior pubic ramus (a break or crack in the pelvis bones). The Progress Note dated 06/28/24 at 04:06 AM documented R6 found lying on the right side with bleeding noted to the right ring and little fingers, R6 was barefooted and reported she was going to the bathroom. R6 was sent to the emergency room . The Incident Summary dated 06/28/24 documented R6 was sent to the emergency room and received one stitch in both fingers. The recommendation was to remind R6 to call for assistance when getting up and ambulating. On 07/02/24, an X-ray report revealed that the left hand had a nondisplaced fracture at the base of the fourth digit and a questionable non-displaced fracture at the base of the third digit. The Progress Notes dated 07/10/24 at 09:56 AM documented that R6 was heard yelling and found lying on the floor. The note reported R6 had got up on her own. The physician ordered an X-ray of the right hip and pelvis. The Incident Summary dated 07/10/24 documented that R6 was unattended and had gotten up out of her chair, and R6 was given a reacher (previous intervention) and shown how to use it so she could grab items out of her reach. And that the nursing staff would take the resident to the bathroom one hour after each meal. The CT (an X-ray technique of imaging creates detailed images) of the pelvis, dated 07/13/24, reported an acute comminated (bone break into three or more pieces) fracture of the right ischium (part of the hip bone or over the hip bone area), and the base of the inferior pubic ramus. The Progress Note dated 08/28/24 at 04:44 PM documented R6 signed a contract stating the staff/facility was not responsible for any falls. R6 had been educated on using the call light when she needed assistance, using her walker, and wearing appropriate footwear, including gripper socks. R6 had voiced understanding and was agreeable to this. (R6 had moderately impaired cognition). The chair alarm had been discontinued. The Progress Note dated 11/15/24 at 05:37 AM documented R6 was found on the floor in her room. R6 stated she tried going to the bathroom. R6 right forearm was bleeding and bruised, along with points on her hand. The Incident Summary dated 11/15/24 documented steri-stips (adhesive wound closures) placed on R6's forearm. The recommendation/action documented staff instructed that R6 was taken to the bathroom within one hour after meals. R6 was provided a reacher due to wanting to be self-sufficient. On 03/05/25 at 09:25 AM, R6 was in her room, standing at the dresser/TV stand, looking through the top drawer. The walker was parked next to the dresser. The call light was fastened to the left armrest of her recliner. On 03/05/25 at 09:30 AM, Certified Nurse Aide (CNA) M stated R6 does what she wants, staff tried to catch her when she was up to be near her. CNA M reported that R6 ate most of her meals in her room, but on occasion, she would come out to see the birds in the activity room or walk up and down the halls. On 03/05/25 at 11:00 AM, Licensed Nurse (LN) G reported that R6 was very stubborn and had poor safety awareness. LN G reviewed a document risk assessment that R6 had signed a release of responsibility form for injuries related to falls. On 03/05/25 at 01:20 PM, Administrative Nurse E verified that R6 had signed a safety education and release of responsibility form when R6 had moderately impaired cognition. Administrative Nurse E reported that the charge nurses were responsible for new interventions to prevent further falls of residents with each fall. The facility's Safety and Supervision of Residents policy, dated 07/2017, documented that the facility strived to make the environment as free from accident hazards as possible. Resident safety, supervision, and assistance to prevent accidents are facility-wide priorities. The individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices and monitoring the effectiveness of interventions. Resident supervision is a core component of the system's approach to safety. The facility failed to prevent R6's falls, which resulted in pelvic and finger fractures with ineffective repeated intervention. This deficient practice placed the resident at risk for continued falls and injuries.

The facility had a census of 22 residents. The sample included 12 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 4's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for use and that R13's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had an end-of-use date. This placed the residents at risk of receiving unnecessary psychotropic (alters mood or thought) medication. Findings included: - R4's Electronic Medical Record (EMR) included diagnoses of insomnia (inability to sleep), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN - elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, hypothyroidism (a condition characterized by decreased activity of the thyroid gland), and personal history of urinary tract infections. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R4 had moderately impaired cognition, had verbal and physical behaviors directed at others and other behavioral symptoms that occurred one to three days of a seven day look back period and rejection of care behaviors that occurred four to six days of the seven day look back period. R4 required partial/moderate assistance with toileting hygiene, upper and lower body dressing, transfers, and ambulation. The MDS further documented R4 received scheduled pain medication, an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), and an opioid (medication used to treat severe pain). The antipsychotic had no gradual dose reduction (GDR) attempt or physician documentation as clinically contraindicated. R4's Care Plan, dated 12/11/24, documented R4 took a medication regime with potential and adverse side effects. The Care Plan directed staff to monitor for possible signs and symptoms of adverse drug reactions of each medication and review pharmacy recommendations. The Physician Order dated 04/18/24 directed staff to administer Aripiprazole (an antipsychotic) two milligrams (mg) mouth at bedtime for insomnia. The Physician Order dated 04/15/24 directed staff to administer Sertraline (an antidepressant) 25 mg by mouth in the morning related to depression. The Physician Order dated 09/09/24 directed staff to administer Alprazolam (and antianxiety) 0.5 mg by mouth at bedtime related to anxiety disorder. The Physician Order dated 11/26/24 directed staff to administer Norco 5-235 mg (an opioid) by mouth as needed every three hours for pain for three times a day related to pain. Review of the EMR and Consultant Pharmacist monthly review from 04/2024 to 02/2025 lacked documentation regarding the unapproved indication or risk versus benefit for the continued use of Aripiprazole for insomnia. On 03/04/25 at 11:45 AM, R4 was making her way into the dining room, sitting in a wheelchair. She was alert and pleasant with the staff. On 03/05/25 at 11:55 AM, Administrative Nurse E stated that R4's use of Aripiprazole for insomnia was not an approved indication of use. The consultant pharmacist had not notified the facility or the physician of the medication's continued use. The facility's Psychotropic Medication Use policy, dated 12/02/19, documented that the physician's order for psychotropic drugs will include both a qualifying diagnosis for drugs and a list of specific target behaviors that the staff will monitor during the drug administration. All physicians' orders for antipsychotic medications would be clear and accurate and should include a diagnosis, condition, or indication for use: and the consultant pharmacist will review the appropriateness of all medication orders for medications to be administered by clinical staff. The facility failed to ensure that R4 antipsychotic medication had an approved indication for use. This placed the resident at risk of receiving unnecessary psychotropic medication. - Resident (R) 13's Electronic Medical Record (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), altered mental status, Parkinson's (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness) disease, hypertension (HTN - elevated blood pressure), insomnia (inability to sleep), and heart failure. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R13 had severe cognitive impairment, inattention, disorganized thinking continuously, verbal behaviors directed toward others, and wandering which occurred one to three days of the look-back period. R13 required partial/moderate assistance with functional abilities and supervision or touch assistance with mobility. The MDS further documented R13 received scheduled pain medication, an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), a diuretic (a medication to promote the formation and excretion of urine), and an antiplatelet (medication to prevent blood cells from forming clots). R13's Care Plan, dated 01/28/25, documented that R13 was at risk for adverse reactions related to polypharmacy (regular use of multiple medications). The care plan directed staff to monitor for possible signs and symptoms of adverse drug reactions, request the physician to review and evaluate medications per their schedule, review pharmacy consultant recommendations, and follow up as indicated. The Physician Order dated 09/06/24 directed staff to administer Alprazolam 0.5 mg every eight hours as needed for anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The order lacked an end or stop date. Review of the EMR and Consultant Pharmacist monthly review from 03/2024 to 02/2025 lacked of documentation for the use of as needed Alprazolam. On 03/04/25 at 09:15 AM, R13 walked independently without her walker with a rolled blanket in her hand, repeating, Sleeping in the chair. The staff retrieved her walker and offered her toileting assistance in her room. On 03/05/25 at 11:05 AM, Administrative Nurse E stated that it was the responsibility of the charge nurse to obtain and place a stop day for PRN psychotropic medications. Administrative Nurse E reported that the consultant pharmacist should have recommended a stop date as well. The facility's Psychotropic Medication Use policy, dated 12/02/19, documented that the resident's need for psychotropic medication will be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose could be lowered or discontinued. Both the physician and the nursing staff would evaluate the effectiveness of PRN orders for psychotropic drugs to manage behaviors. The facility failed to obtain a required stop date for R13 's PRN Alprazolam, which placed the resident at risk of receiving unnecessary psychotropic medication.

The facility had a census of 22 residents. The sample included 12 residents, of which five were reviewed for medication use. Based on observation, record review, and interview, the facility failed to ensure that Resident (R) 4's antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality) medication had an approved indication for use and that R13's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had an end-of-use date. This placed the residents at risk of receiving unnecessary psychotropic (alters mood or thought) medication. Findings included: - R4's Electronic Medical Record (EMR) included diagnoses of insomnia (inability to sleep), vascular dementia (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (HTN - elevated blood pressure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, hypothyroidism (a condition characterized by decreased activity of the thyroid gland), and personal history of urinary tract infections. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R4 had moderately impaired cognition, had verbal and physical behaviors directed at others and other behavioral symptoms that occurred one to three days of a seven day look back period and rejection of care behaviors that occurred four to six days of the seven day look back period. R4 required partial/moderate assistance with toileting hygiene, upper and lower body dressing, transfers, and ambulation. The MDS further documented R4 received scheduled pain medication, an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), antianxiety (a class of medications that calm and relax people), an antidepressant (a class of medications used to treat mood disorders), and an opioid (medication used to treat severe pain). The antipsychotic had no gradual dose reduction (GDR) attempt or physician documentation as clinically contraindicated. R4's Care Plan, dated 12/11/24, documented R4 took a medication regime with potential and adverse side effects. The Care Plan directed staff to monitor for possible signs and symptoms of adverse drug reactions of each medication and review pharmacy recommendations. The Physician Order dated 04/18/24 directed staff to administer Aripiprazole (an antipsychotic) two milligrams (mg) mouth at bedtime for insomnia. The Physician Order dated 04/15/24 directed staff to administer Sertraline (an antidepressant) 25 mg by mouth in the morning related to depression. The Physician Order dated 09/09/24 directed staff to administer Alprazolam (an antianxiety) 0.5 mg by mouth at bedtime related to anxiety disorder. The Physician Order dated 11/26/24 directed staff to administer Norco 5-235 mg (an opioid) by mouth as needed every three hours for pain for three times a day related to pain. Review of the EMR and Consultant Pharmacist monthly review from 04/2024 to 02/2025 lacked documentation regarding the unapproved indication or risk versus benefit for the continued use of Aripiprazole for insomnia. On 03/04/25 at 11:45 AM, R4 was making her way into the dining room, sitting in a wheelchair. She was alert and pleasant with the staff. On 03/05/25 at 11:55 AM, Administrative Nurse E stated that R4's use of Aripiprazole for insomnia was not an approved indication of use. The consultant pharmacist had not notified the facility or the physician of the medication's continued use. The facility's Psychotropic Medication Use policy, dated 12/02/19, documented that the physician's order for psychotropic drugs will include both a qualifying diagnosis for drugs and a list of specific target behaviors that the staff would monitor during the drug administration. All physicians' orders for antipsychotic medications should be clear and accurate and should include a diagnosis, condition, or indication for use: and the consultant pharmacist will review the appropriateness of all medication orders for medications to be administered by clinical staff. The facility failed to ensure that R4 antipsychotic medication had an approved indication for use. This placed the resident at risk of receiving unnecessary psychotropic medication. - Resident (R) 13's Electronic Medical Record (EMR) included diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion), altered mental status, Parkinson's (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness) disease, hypertension (HTN - elevated blood pressure), insomnia (inability to sleep), and heart failure. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R13 had severe cognitive impairment, inattention, disorganized thinking continuously, verbal behaviors directed toward others, and wandering which occurred one to three days of the look-back period. R13 required partial/moderate assistance with functional abilities and supervision or touch assistance with mobility. The MDS further documented R13 received scheduled pain medication, an antipsychotic (a class of medications used to treat major mental conditions that cause a break from reality), a diuretic (a medication to promote the formation and excretion of urine), and an antiplatelet (medication to prevent blood cells from forming clots). R13's Care Plan, dated 01/28/25, documented that R13 was at risk for adverse reactions related to polypharmacy (regular use of multiple medications). The care plan directed staff to monitor for possible signs and symptoms of adverse drug reactions, request the physician to review and evaluate medications per their schedule, review pharmacy consultant recommendations, and follow up as indicated. The Physician Order dated 09/06/24 directed staff to administer Alprazolam 0.5 mg every eight hours as needed for anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The order lacked an end or stop date. Review of the EMR and Consultant Pharmacist monthly review from 03/2024 to 02/2025 lacked documentation for the use of as needed Alprazolam. On 03/04/25 at 09:15 AM, R13 walked independently without her walker with a rolled blanket in her hand, repeating, Sleeping in the chair. The staff retrieved her walker and offered her toileting assistance in her room. On 03/05/25 at 11:05 AM, Administrative Nurse E stated the charge nurse was responsible for obtaining and placeing a stop day for PRN psychotropic medications. Administrative Nurse E reported that the consultant pharmacist should have recommended a stop date as well. The facility's Psychotropic Medication Use policy, dated 12/02/19, documented that the resident's need for psychotropic medication will be monitored, as well as when the resident has received optional benefits from the medication and when the medication dose could be lowered or discontinued. Both the physician and the nursing staff would evaluate the effectiveness of PRN orders for psychotropic drugs to manage behaviors. The facility failed to obtain a required stop date for R13 's PRN Alprazolam, which placed the resident at risk of receiving unnecessary psychotropic medication.

The facility had a census of 26 residents. Based on record review and interview, the facility failed to provide competent staff with the appropriate training, skills, and knowledge when two Certified Nurse Aides (CNA) administered medication to eight residents, Resident (R) 1, R2, R3,R4, R5, R6, R7, and R8, at the direction of Administrative Nurse D, because the licensed nurse on duty did not feel comfortable passing the medications. This placed the resident's at risk for medication errors and complications related to incompetent staff. Findings included: - The State Agency (SA) intake KS00184350 and KS00184390 reported on 11/25/23, the facility's Certified Medication Aide (CMA) called in due to the weather which left an agency Licensed Nurse (LN) to pass medication. The intakes alleged the Director of Nursing gave permission for two CNA on duty to assist the LN to pass medications to the residents and the administrations were documented under the LN name. On 12/05/23 at 09:11 AM, Administrative Nurse D stated there was a bad snow storm and a few of her staff called in, which included the Certified Medication Aide (CMA) that was to pass medication that evening. Administrative Nurse D further stated Licensed Nurse (LN) H, the nurse on duty, was not familiar with the residents in the facility and therefore did not feel comfortable passing the medications. Administrative Nurse D gave permission for LN H to pop the medication for the alert and oriented residents who did not need assistance, and permitted CNA M and CNA N to hand the medications to the resident. On 12/05/23 at 09:25 AM, CNA M stated LN H popped the medication for the alert and oriented residents into a cup that had the resident's name and room number. CNA M said she handed the cup of the pills to the resident to take. CNA M further stated the facility had never asked her to do that before. The facility's Administering Medications policy, dated 11/30/20, documented only persons licensed or permitted in this State to prepare, administer, and document the administration of medications may do so. New personnel authorized to administer medication would not be permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. The Director of Nursing Services would supervise and direct all nursing personnel who administer mediations and/or have related functions. The facility failed to provide competent staff who possessed the appropriate training, skills, and knowledge to administer medications. This placed the resident's at risk for medication errors.

The facility had a census of 25 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to review and revise Resident (R) 3's plan of care to include collaboration of care with the hospice (specialized care related to end of life) service and failed to include R16's use of antipsychotic (medication used to treat psychosis-any major mental disorder characterized by a gross impairment in reality testing) medication. The deficient practice placed R3 and R16 at risk for unmet care needs. Findings included: - R3's Electronic Medical Record (EMR) recorded diagnoses of collapsed vertebra lumbar (lower back) and thoracic (mid back) region, chronic kidney disease, chronic pain, adult failure to thrive, fracture of right pubis (pelvic area). The Significant Change Minimum Data Set (MDS), dated [DATE], documented R3 had moderately impaired cognition, had no signs or symptoms of psychosis, delirium (sudden severe confusion, disorientation and restlessness), or exhibited behaviors. R3 was independent with activities of daily living (ADL) except for bathing which required extensive assistance of one staff. R3 was not steady but able to stabilize without staff assistance. The MDS further documented use of scheduled pain medication regimen. R3 had pain frequently which limited day to day activities, and significant weight loss. The ADL Care Area Assessment (CAA), dated 03/23/23, documented R3 had been independent with ADLs. R3 was recently placed on hospice for pain management. The Care Plan date 04/14/23, documented R3 was now on hospice cares. The care plan directed staff to educate resident on the importance of frequent position changes, use of non-skid socks per hospice nurse, administer medications as directed by the physician and hospice team. The care plan recorded the hospice nurse and care aide would be there per hospice policy, and diretced staff to involve the resident in care and decision making to maximum potential. The care plan lacked hospice provider information, disciplines making visits/providing specific cares and supplies provided by hospice. The Progress Note dated 03/17/23 at 02:33 PM documented a meeting with hospice services, durable power of attorney (DPOA) and facility staff in which the DPOA wished to utilize hospice services. The DPOA expressed explicit wishes not to utilize the term hospice to preserve resident's mental health as R3 would feel as though she was being given up on. On 05/10/23 at 02:02 PM, observation revealed hospice staff in R3's room. R3 was independently mobile in her wheelchair looking for the next activity planned to attend. Staff informed R3 bingo was scheduled at 02:30 PM. On 05/11/23 at 01:09 PM, Administrative E stated R3 had a hospice care plan, but said it lacked collaboration of services in which the facility and hospice would be responsible for cares of R3. The facility's Care Plan Revision policy, dated 10/05/18, documented the care planning process included goal setting, interventions, referrals to other health care professionals, evaluations, referrals to other health care professionals, evaluation or resident response to treatment and revision of care and treatment in order to meet the resident's needs. Changes in a resident's condition always require changes to be made in the plan of care either by change in individual approaches or by the addition of new problems to the care revisions to the care plan will be the responsibility of a Licensed Nurse in collaboration with the resident, the representative/family, direct care staff and the entire interdisciplinary team and changes will be communicated to all staff. The facility failed to care plan collaboration of hospice care and facility responsibilities on the care plan for R3 which placed the resident at risk for unmet care needs. - R16's Electronic Medical Record (EMR) recorded diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory, confusion )without behavioral, psychotic (any major mental disorder characterized by a gross impairment in reality testing), and mood disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), personal history of traumatic brain injury, and legal blindness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had intact cognition, had no indicators of psychosis and delirium, and no behaviors exhibited. The MDS further documented R16 was independent with activity of daily living (ADL), and had non-Alzheimer's dementia. The Cognitive Loss/Dementia Care Area Assessment (CAA), date 10/28/22, documented R16 was alert and oriented to person, place and usually time, made her own decisions and was usually consistent. The CAA further documented R16 had a diagnosis of dementia, depression, and had short term memory loss. The Care Plan dated 04/12/23, documented R16 had diagnosis of psychosis, had behavioral symptoms toward others with paranoia concerning her belongings and a history of traumatic brain injury with potential for anxious mood. The care plan directed staff to medications as physician ordered, reinforce and focus on reality, allow resident to discuss anger towards the staff with caregiving issues of her belongings, and to convey an attitude of acceptance to the resident. The care plan further directed staff to maintain a calm understandable environment and approach and wanted to visit with the social service designee when upset. The care plan lacked direction related to the use of antipsychotic medications with monitoring the side effects and targeted behaviors. The Physician Order, dated 04/11/23, directed staff to administer Seroquel (an antipsychotic medication) 25 milligrams (mg) every day for unspecified psychosis not due to a substance or known physiological condition. The order lacked side effect and target behavior monitoring. The Physician Order dated 05/12/23 directed staff to administer an additional Seroquel 50 mg at bedtime. The orders then included monitoring for side effects and targeted behaviors. The Progress Note by the prescribing health care provider, dated 04/11/23 at 02:23 PM, documented R16 packed her things and reported the she was ready to leave due to voices telling her to do so. Further investigation revealed that for some time R16 had also heard family members argue out in the hallway when no family members present and verified, she had heard voices for years. The note included initiation of Seroquel to curb the voices and allow R16 to get a better nights sleep. The Progress Note date05/09/23 at 02:35 PM documented R16 came to the activity room and handed staff all her activity bucks and stated she did not need them anymore because she was moving out and going home. Later, staff went to R16's room and noticed she had all of her things in a bag. On 05/09/23 at 03:26 PM observation revealed R16 in the activity room playing cards with staff and other residents. Upon finishing the activity R16 independently left the activity room and returned to her room. Further observation revealed R16 had belongings packed into large blue plastic bags. On 05/11/23 at 01:11 PM, Administrative Nurse E stated the side effects and target behaviors for psychotropic medications should be added to the physician orders so they would be transferred to the electronic medication and treatment record. Administrative Nurse E verified this was not done, nor was the care plan updated to include the antipsychotic use to the care plan from the 04/11/23 physician ordered Seroquel. The facility's Care Plan Revision policy, dated 10/05/18, documented the care planning process included goal setting, interventions, referrals to other health care professionals, evaluations, referrals to other health care professionals, evaluation or resident response to treatment and revision of care and treatment in order to meet the resident's needs. Changes in a resident's condition always require changes to be made in the plan of care either by change in individual approaches or by the addition of new problems to the care revisions to the care plan will be the responsibility of a Licensed Nurse in collaboration with the resident, the representative/family, direct care staff and the entire interdisciplinary team and changes will be communicated to all staff. The facility failed to update R16's care plan when an antipsychotic medication was implemented which placed the resident at risk for unmet care needs.

The facility had a census of 25 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 16 the appropriate treatment and services to attain highest practicable mental and psychosocial (interrelation of social factors and individual thought and behavior) well-being, when staff failed to provide R16 with behavioral health services. This placed the resident at risk for unmet behavioral health care needs. Findings included: - R16's Electronic Medical Record (EMR) recorded diagnoses of major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), dementia (progressive mental disorder characterized by failing memory, confusion )without behavioral, psychotic (any major mental disorder characterized by a gross impairment in reality testing), and mood disturbance, anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), personal history of traumatic brain injury, and legal blindness. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R16 had intact cognition, had no indicators of psychosis and delirium (sudden severe confusion, disorientation and restlessness), and no behaviors exhibited. The MDS further documented R16 was independent with activity of daily living (ADL), and had non-Alzheimer's dementia. The Cognitive Loss/Dementia Care Area Assessment (CAA), date 10/28/22, documented R16 was alert and oriented to person, place and usually time, made her own decisions and was usually consistent. The CAA further documented R16 had a diagnosis of dementia, depression, and had short term memory loss. The Care Plan dated 04/12/23, documented R16 had diagnosis of psychosis, had behavioral symptoms toward others with paranoia concerning her belongings and a history of traumatic brain injury with potential for anxious mood. The care plan directed staff to medications as physician ordered, reinforce and focus on reality, allow resident to discuss anger towards the staff with caregiving issues of her belongings, and to convey an attitude of acceptance to the resident. The care plan further directed staff to maintain a calm understandable environment and approach and wanted to visit with the social service designee when upset. The Physician Order dated 04/11/23 directed staff to administer Seroquel (an antipsychotic medication) 25 milligrams (mg) every day for unspecified psychosis not due to a substance or known physiological condition. The order lacked side effect and target behavior monitoring. The Physician Order dated 05/12/23 directed staff to administer an additional Seroquel 50 mg at bedtime. The orders then included monitoring for side effects and targeted behaviors. The Progress Note by prescribing health care provider, dated 04/11/23 at 02:23 PM, documented R16 packed her things and reported the she was ready to leave due to voices telling her to do so. Further investigation revealed that for some time R16 had also heard family members argue out in the hallway when no family members present and verified, she had heard voices for years. The note included initiation of Seroquel to curb the voices and allow her to get better night's sleep. The Progress Note, date05/09/23 at 02:35 PM, documented R16 came to the activity room and handed staff all her activity bucks and stated she did not need them anymore because she was moving out and going home. Later, staff went to R16's room and noticed she had all of her things in a bag. R16's clinical record lacked evidence the resident was offered or provided psychological health services to address her diagnoses and behaviors. On 05/09/23 at 03:26 PM observation revealed R16 in the activity room playing cards with staff and other residents. Upon finishing the activity R16 independently left the activity room and returned to her room. Further observation revealed R16 had belongings packed into large blue plastic bags. On 05/15/23 at 12:19 PM Social Service Designee (SSD) X reported she tracked behaviors for residents and had done some one on one visits with R16 and documented the visits in the progress notes. SSD X reported she visited R16 when the resident was upset about something and visits where not routine. SSD X stated R16 had not been seen by psychological health care providers. On 05/15/23 at 12:42 PM Administrative Nurse D reported mental health consulting came to the facility on a monthly basis but confirmed R16 had not received mental health consultation prior to or after the initiation of an antipsychotic medication. Administrative Nurse D reported the resident had not been referred to mental health care. Administrative Nurse D said R16 may have refused, but said the facility did not have documentation of a refusal. The facility's Psychotropic Medication policy, dated 02/2019, documented per Centers for Medicare and Medicaid Services (CMS) regulations state that each resident's drug regimen must be free from unnecessary drugs and define what is considered and unnecessary drug. In addition, CMS regulations state that residents who have not previously used anti-psychotic drugs should not the given these drugs unless anti-psychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record. The resident's need for the psychotropic medication will be monitored as well as when the resident has received optional benefits from the medication and when the medication cam be lowered or discontinued. Both the physician and the nursing staff will evaluate the effectiveness of prn orders for psychotropic drug to manage behavior. Non-Pharmacologic Alternatives: use of alternative non-pharmacologic interventions for psychiatric disorders and problem behaviors related to dementia will be attempted prior to and during administration of antipsychotic medications including but not exclusive to: try interesting the resident in something else (redirecting) based on the resident's past routines and preferences, provide intensive one to one direct care, allow the resident to have time alone, understand that all behaviors is a form of communication of an unmet need of the resident, Talk to the resident about what is bothering them (emotional support), leave the resident and return at a later time (re-approaching), get the family involved in resident's day to day life at the facility, provide a consistent staff person to care for the same resident in order to establish an ongoing relationship between the two. The facility failed to provide R16 the appropriate treatment to attain the highest practicable mental, services to attain highest practicable mental and psychosocial well-being for the resident which placed R16 at risk for unmet behavioral health care needs.

The facility had a census of 25 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 1's physician-ordered medication regimen lacked indications for use. This placed the resident risk of unnecessary or ineffective medication therapy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of chronic pain, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), heart failure, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), encounter for attention to gastrostomy (surgical creation of an artificial opening into the stomach thru the abdominal wall) and colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body), and personal history of urinary tract infections. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had modified independence with decision making, inattention, and disorganized thinking which fluctuated, no indicators of psychosis or behaviors. R1 was totally dependent with one to two staff for activities of daily living (ADLs). The MDS further documented R1 received scheduled pain medication, insulin (medication used to treat blood sugar), and antidepressant (medication used to treat depression). The Medication Care Plan, dated 04/06/23, documented R1 had medication regimen with potential reactions and adverse side effects. Upon review of the EMR of physician prescribed medications the following medications lacked an indication for use: Acidophilus (probiotic) capsule by mouth twice a day. Order dated 09/12/22. Adult Multivitamin (multivitamin-) tablet; 18 milligrams (mg) iron-400 micrograms (mcg)-25mcg: one tablet a day. No order date. Aspirin (pain reliver and blood thinner) 81 mg chewable tablet once a day. Order date 02/17/23. Claritin (allergy medication) 10 mg tablet once a day. Order date 09/12/22. Calcium 600 mg with Vitamin D3 600 mg-10mcg (400 units) chewable tablet once a day. Order date 09/12/22. Miralax (laxative) powder 17 grams/dose, one capful daily. Order date 10/18/22. Potassium chloride 10 milli-equivalent (meq) extended release capsule, two capsules two times a day. Order date 02/17/23. Albuterol sulfate solution (medication used to treat cough or obstructive airway disease) for nebulizer 2.5 mg/ 3 ml (0.083%) by inhalation three times a day. Order date 12/21/22. Upon review of the monthly Consultant Pharmacy report, the pharmacist did not identify and report the medications listed above lacked an indication for use. On 05/09/23 at 03:30 PM R1 laid in bed on her left side facing the wall. On 05/11/23 at 01:11 PM, Administrative Nurse E reported she was aware of some of R1's medication were without diagnoses and said it was the charge nurses who should be entering the diagnosis with the physician orders. Administrative Nurse E stated the medical records department did not want diagnoses entered if the resident did not already have the diagnoses. The facility's Pharmaceutical Review Per Interdisciplinary Team, policy dated 01/2020, documented to provide pharmaceutical care with outcome management, quality assurance, drug utilization review, incident review, unnecessary drug review and indications for pharmaceutical orders. To maintain the residents highest mental, physical, and psychosocial well-being. Procedure include but not limited to resident chart reviews: check medication for diagnosis and indication. The facility failed to ensure the Consultant Pharmacist identified and reported the lack an indication for use on R1's medications which placed the resident at risk for ineffective medication therapy.

The facility had a census of 25 residents. The sample included 12 residents with five residents reviewed for unnecessary medications. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1's physician-ordered medications included an indication for use. This placed the resident risk of unnecessary or ineffective medication therapy. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of chronic pain, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), heart failure, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), encounter for attention to gastrostomy (surgical creation of an artificial opening into the stomach thru the abdominal wall) and colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body), and personal history of urinary tract infections. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had modified independence with decision making, inattention, and disorganized thinking which fluctuated, no indicators of psychosis or behaviors. R1 was totally dependent with one to two staff for activities of daily living (ADLs). The MDS further documented R1 received scheduled pain medication, insulin (medication used to treat blood sugar), and antidepressant (medication used to treat depression). The Medication Care Plan, dated 04/06/23, documented R1 had medication regimen with potential reactions and adverse side effects. Upon review of the EMR of physician prescribed medications the following medications lacked an indication for use: Acidophilus (probiotic) capsule by mouth twice a day. Order dated 09/12/22. Adult Multivitamin (multivitamin-) tablet; 18 milligrams (mg) iron-400 micrograms (mcg)-25mcg: one tablet a day. No order date. Aspirin (pain reliver and blood thinner) 81 mg chewable tablet once a day. Order date 02/17/23. Claritin (allergy medication) 10 mg tablet once a day. Order date 09/12/22. Calcium 600 mg with Vitamin D3 600 mg-10mcg (400 units) chewable tablet once a day. Order date 09/12/22. Miralax (laxative) powder 17 grams/dose, one capful daily. Order date 10/18/22. Potassium chloride 10 milli-equivalent (meq) extended release capsule, two capsules two times a day. Order date 02/17/23. Albuterol sulfate solution (medication used to treat cough or obstructive airway disease) for nebulizer 2.5 mg/ 3 ml (0.083%) by inhalation three times a day. Order date 12/21/22. On 05/09/23 at 03:30 PM R1 laid in bed on her left side facing the wall. On 05/11/23 at 01:11 PM, Administrative Nurse E reported she was aware of some of R1's medication were without diagnoses and said it was the charge nurses who should be entering the diagnosis with the physician orders. Administrative Nurse E stated the medical records department did not want diagnoses entered if the resident did not already have the diagnoses. The facility's Pharmaceutical Review Per Interdisciplinary Team, policy dated 01/2020, documented to provide pharmaceutical care with outcome management, quality assurance, drug utilization review, incident review, unnecessary drug review and indications for pharmaceutical orders. To maintain the residents highest mental, physical, and psychosocial well-being. Procedure include but not limited to resident chart reviews: check medication for diagnosis and indication. The facility failed to ensure R1's physician-ordered medications included an indication for use. This placed the resident risk of unnecessary or ineffective medication therapy.

The facility had a census of 25 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to label two insulin (hormone that lowers the level of glucose in the blood) vials with an open date and an expiration date. This deficient practice placed Residents (R) 1 and R20 at risk to receive expired insulin. Findings included: - On [DATE] at 09:08 AM, observation of the facility's medication room revealed two opened, undated insulin vials; a Novolin R (fast acting insulin) vial for R20, and a Humulin R (fast acting insulin) vial for R1. On [DATE] at 09:08 AM, Licensed Nurse (LN) G verified staff should have dated the insulin vial when it was opened. [DATE] at 01:10 PM, Administrative Nurse D verified staff were to date insulin vials when opened. The facility's Insulin Storage policy, dated [DATE], stated opened insulin vial or flex pens would be checked every morning shift for resident identification label, date, time and initials of when opened and expiration date labeled. The facility failed to label two insulin vials with an open date and an expiration date, placing R1 and R20 at risk to receive expired and/or ineffective insulin.

The facility identified a census of 25. The sample included 12 residents with five reviewed for medications. Based on observation, interview, and record review, the facility failed to implement antibiotic use protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk of adverse events, including antibiotic resistance, when the facility failed to monitor effectiveness and identify inappropriate extended administration of antibiotic eyedrops for Resident (R) 1. This placed the resident at risk for complications related to antibiotic use. Findings included: - R1's Electronic Medical Record (EMR) documented diagnoses of chronic pain, depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), heart failure, diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), multiple sclerosis (progressive disease of the nerve fibers of the brain and spinal cord), encounter for attention to gastrostomy (surgical creation of an artificial opening into the stomach thru the abdominal wall) and colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body), and personal history of urinary tract infections. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R1 had modified independence with decision making, inattention, and disorganized thinking which fluctuated, no indicators of psychosis or behaviors. R1 was totally dependent with one to two staff for activities of daily living (ADLs), and had function range of motion impairment of upper and lower extremities. The MDS further documented R1 received scheduled pain medication, insulin (medication used to treat blood sugar), and an antidepressant (medication used to treat depression). The Physician Order dated 05/05/23, directed staff to administer Ciprofloxacin (Cipro-antibiotic) HCL 0.3 percent (%) one drop: ophthalmic (eye) three times a day. The order did not specify the diagnosis for use, or which eye/ eyes to be treated, and lacked a stop date. The Progress Note dated 05/05/23 at 05:12 PM, documented R1's eyes were watering and puffy. R1 stated that they were not bothering her. R1 had a small amount of green drainage. Staff spoke with R1's provider and received an order for Cipro eye drops three times a day for five days and an order to obtain a culture. On 05/10/23 at 01:12 PM, observation revealed R1 in the therapy room with staff preforming range of motion on R1 lower extremities. Once finished, staff brought R1 to the activity room to watch the birds. On 05/11/23 at 12:02 PM Certified Medication Aide (CMA)R reported administering R1's eye drops to both eyes. CMA R stated the diagnosis was usually on the electronic medication administration record (EMAR) and verified the EMAR lacked a diagnosis or stop date. On 05/15/23 at 10:13 AM, Licensed Nurse (LN)H verified R1's EMAR lacked instructions related to site of administration (right, left or both eyes) for the use of Cipro and the stop date. LN H stated the nurse who initiated the order should have included the information. On 05/15/23 at 12:47 PM, Administrative Nurse D reported the facility had obtained a culture of R1's eye drainage, but confirmed the antibiotic order lacked specific directions to which or both eyes and the EMAR lacked a stop date. The facility's undated Antibiotic Stewardship Program documented the Antibiotic Stewardship will ensure that every/patient/resident got an antibiotic only when one is needed, with the right agent, at the right dose and for the right duration. The facility failed to implement antibiotic use protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk for adverse events, including antibiotic resistance, when the facility failed to monitor effectiveness and identify inappropriate extended administration of antibiotic eyedrops for R1, which placed the resident at risk for complications related to antibiotic use.

The facility had a census of 15 residents. The sample included eight residents, with three reviewed for accidents. Based on observations, record review, and interview, the facility failed to revise one of eight care plans, Resident (R) 4. Findings included: - R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required limited assistance of one staff for bed mobility, toileting and extensive assistance of one staff for dressing. The MDS documented the resident had upper functional impairment on both sides and had no skin issues. The Skin Care Plan, dated 05/12/21, directed staff to complete weekly skin assessments and to inform the nurse of any new skin breakdown. The care plan lacked documentation of interventions to prevent bruises for the resident. The Bath Sheet, dated 09/11/21, lacked documentation the resident had any skin issues. Review of R4's nurse's notes for the period of 09/01/21 to 09/13/21 lacked documentation of any bruises on the resident. On 09/13/21 at 10:25 AM, observation revealed a purple bruise on the resident's left forearm and on top of the resident's left hand. On 09/14/21 at 01:30 PM, Certified Nurse Aide (CNA) M stated she was unaware of the bruises on the resident and stated when the resident had skin issues, she told the nurse. On 09/15/21 at 10:00 AM, Licensed Nurse (LN) G stated she was not aware the resident had any bruises and would have completed an incident report and notified the physician and family. On 09/15/21 at 10:15 AM, LN G stated she interviewed the resident who stated she had probably gotten them flinging her arms around and hitting it on something. On 09/15/21 at 10:30 AM, Administrative Nurse E stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/15/21 at 10:35 AM, Administrative Nurse D verified interventions to prevent bruises should be on the care plan. The facility's Care Plan Revision policy, dated 10/05/18, documented any change in the problems, goals, specific interventions, or reasonable time frames of goals will be revised on the resident's plan of care. Revisions to the care plan would be the responsibility of a licensed nurse in collaboration with the resident, the representatives, direct care staff, and the entire interdisciplinary team and changes communicated with all staff, all shifts. The facility failed to identify and implement interventions to prevent bruising for R4, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] .

The facility had a census of 15 residents. The sample included eight residents, with three reviewed for accidents. Based on observation, record review, and interview, the facility failed to prevent accidents for one of three sampled residents, Resident (R) 4, who had bruises on her left forearm and hand. Findings included: - R4's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had moderately impaired cognition and required limited assistance of one staff for bed mobility, toileting and extensive assistance of one staff for dressing. The MDS documented the resident had upper functional impairment on both sides and had no skin issues. The Skin Care Plan, dated 05/12/21, directed staff to complete weekly skin assessments and to inform the nurse of any new skin breakdown. The care plan lacked documentation of interventions to prevent bruises for the resident. The Bath Sheet, dated 09/11/21, lacked documentation the resident had any skin issues. Review of R4's nurse's notes for the period of 09/01/21 to 09/13/21 lacked documentation of any bruises on the resident. On 09/13/21 at 10:25 AM, observation revealed a purple bruise on the resident's left forearm and on top of the resident's left hand. On 09/14/21 at 01:30 PM, Certified Nurse Aide (CNA) M stated she was unaware of the bruises on the resident and stated when the resident had skin issues, she told the nurse. On 09/15/21 at 10:00 AM, Licensed Nurse (LN) G stated she was not aware the resident had any bruises and would have completed an incident report and notified the physician and family. On 09/15/21 at 10:15 AM, LN G stated she interviewed the resident who stated she had probably gotten them flinging her arms around and hitting it on something. On 09/15/21 at 10:30 AM, Administrative Nurse E stated the resident had a history of flinging her arms around and getting bruises and verified the resident's medical record lacked documentation regarding the bruises or interventions to prevent bruises in the care plan. On 09/15/21 at 10:35 AM, Administrative Nurse D verified staff had not notified the nurse of the resident's bruises and lack of documentation in the medical record. The facility's Skin Integrity, policy, dated 07/23/19, documented the nurse would conduct a full body skin assessment for each resident weekly to ensure no areas of concern have developed and each nurse aide would examine the resident's total body skin with each bathing experience and would report any abnormalities to the nurse using the bathing sheet. The facility failed to prevent bruises for R4, who had a history of bruising easily, placing the resident at risk for further injuries.

The facility had a census of 24 residents. The sample included 12 residents, with 2 reviewed for skin issues. Based on observation, record review, and interview the facility failed to develop and implement interventions to prevent bruising (blood or bleeding under the skin due to trauma of any kind: typically black and blue at first, with color changes as healing progresses) for 2 of 2 sampled residents. (#20, #15) Findings included: - Resident #20's quarterly (MDS) Minimum Data Set assessment, dated 5/30/19, documented the resident had severe cognitive impairment, fluctuating altered level of consciousness, and delusions. The MDS documented the resident required total assistance of 1 to 2 staff for all activities of daily living, frequently incontinent of bladder, always incontinent of bowel, and at risk for pressure ulcers. The pressure ulcer (CAA) Care Area Assessment, dated 1/17/19, documented the resident had no skin issues, was assisted by staff with all activities of daily living, and nursing performed weekly skin assessments. The 6/5/19 care plan documented the resident had potential for skin breakdown due to limited mobility and significant weight loss. The care plan recorded the resident was on comfort care, staff performed weekly skin assessments, repositioned the resident every 2 hours and as needed, assisted with all cares, and transferred the resident using a maxi lift (a mechanical lift designed for lifting and positioning residents) The 5/6/19 skin assessment documented a 2 cm (centimeter) by 2 cm bruise on the resident's right forearm, discoloration on both forearms, left foot 5th toe with redness, and an open area on the tip going under the toe, without drainage or odor. The medical record lacked a skin assessment for 5/13/19. The 5/20/19 skin assessment documented the resident had a 1-inch red area on his/her left forehead, 1-inch old purple bruising on his/her left hand, 5 inch by 3.5 inch bruise on his/her upper left arm, and a 0.5 cm old purple bruise on his/her right hand. The 5/27/19 nurse's note recorded no new skin issues. The medical record lacked a skin assessment for 6/3/19. The 6/6/19 nurse's note recorded the resident had a 2.5 cm by 2.5. cm red swollen area to his/her right hand, 5th finger knuckle. The 6/10/19 skin assessment recorded the resident's skin was warm, dry, pink, intact, with no redness, open areas, or bruising. The 6/17/19 nurse's note recorded the resident had a 1 cm by 1.25 cm scabbed area to his/her right forearm with a 4.5 cm by 4 cm bruise around the scab measuring 8 cm by 14 cm. The resident reported he/she had been pinched by the lift. The 6/24/19 skin assessment recorded the resident had an old red bruise on his/her right shoulder, fading bruise to his/her left wrist, fading bruise to his/her left upper arm, and healing skin tear to his/her right forearm. The 6/27/19 nurse's note recorded the resident had a 4 cm by 5 cm healing skin tear to his/her right forearm. The 7/1/19 skin assessment recorded the resident had a 4 cm by 2 cm healing skin tear to his/her right forearm, 2 cm by 1 cm red purple bruise just below skin tear, 8 cm by 6 cm red purple bruise to left forearm, and a 4 cm x 2 cm red purple bruise below his/her left forearm. On 7/9/19 at 10:50 AM, observation revealed staff repositioned the resident and changed the resident's night clothing. The resident verbalized he/she did not want to get out of bed. On 7/9/19 at 11:00 AM, Direct Care Staff N stated the resident had been up all through the night and did not go to bed until after 4 AM. Direct Care Staff N reported the resident could be resistant to cares, had very fragile skin, obtained bruises, and his/her skin tore easily. On 7/9/19 at 11:00 AM, Direct Care Staff O stated he/she reported any new skin conditions to the charge nurse as soon as he/she found new areas. On 7/9/19 at 3:00 PM, Administrative Nurse D stated the only investigation regarding skin issues reported to the state agency was on 6/17/19. Administrative Nurse D verified there had been no investigations regarding the bruises of unknown origin. The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy, dated (MONTH) 2019, documented an investigation of injuries of unknown origin or suspicious injuries, must be immediately investigated to rule out abuse, injuries included, but are not limited to, bruising of the inner thigh, chest, face and breast, bruises of an unusual size, multiple unexplained bruises, and or bruising in an area not typically vulnerable to trauma (i.e., lateral aspects of forearms). The facility failed to investigate bruises of unknown origin for Resident #20, placing the resident at risk of injury. - Resident #15's annual (MDS) Minimum Data Set assessment, dated 5/9/19, documented the resident had severely impaired cognition, inattention, disorganized thinking, altered level of consciousness, hallucinations, verbal symptoms not directed towards others, and wandering. The MDS further documented the resident required extensive to total assistance of 1 to 2 staff with activities of daily living, at risk for pressure ulcers, and received scheduled pain medication. The pressure ulcer (CAA) Care Area Assessment, dated 5/9/19, documented the resident was wheelchair bound, required extensive assistance with all transfers, nursing performed skin assessments, and had no skin issues. The care plan, dated 7/8/19, documented the resident had potential for skin breakdown and pressure ulcers related to impaired mobility, incontinence, and impaired cognition. The care plan directed staff to notify the nurse immediately for any new areas of skin breakdown, redness, blisters (an area of skin covered by a raised, fluid filled bubble), bruises (blood or bleeding under the skin due to trauma of any kind: typically black and blue at first, with color changes as healing progresses), or discoloration observed during baths or daily cares. The 5/19/19 skin assessment recorded the resident had a 3 cm (centimeter) by 2 cm greenish purple bruise to his/her left elbow, 1.5 cm by 1.5 cm red purple bruise on his/her right elbow, and a 1 cm by 2 cm green purple bruise to his/her right upper leg. The 5/26/19 skin assessment recorded the resident's skin was warm, dry and intact, with no open areas. The medical record lacked a skin assessment on 6/2/19. The 6/9/19 skin assessment recorded a 1.5 cm x 2 cm new bruise on the resident's left wrist, and a 2.5 cm by 4.5 cm new bruise on his/her right wrist. The 6/16/19 skin assessment recorded the resident had a dark purple bruise to his/her right anterior forearm, and a red bruise to his/her right posterior forearm. The record lacked measurements. The 6/17/19 nurse's note recorded staff reported a skin tear to the resident's right forearm, and the nurse treated the skin tear with 3 steri-strips (wound closure strips for small wounds). The 6/23/19 skin assessment recorded the resident had a 4 cm by 5 cm by 3 cm combination of green bruises on his/her left posterior arm, 1 cm by 1.5 cm green bruise to his/her right elbow, 3 cm old skin tear with 2 steri strips present with a 5 cm x 8 cm green bruise around the skin tear, a 1 cm by 1 cm green purple bruise to his/her right wrist, and a 1 cm x 1 cm green purple bruise to the resident's right hand. The 7/7/19 skin assessment recorded the resident had a 2 cm by 2 cm old green bruise on his/her left upper thigh, 3 cm x 2 cm purple bruise to the left forearm, and a 4 cm x 8 cm old yellow with light purple edges bruise on the resident's right forearm. On 7/8/19 at 3:07 PM, staff assisted the resident into the bathroom using a gait belt, and pivot transferred the resident onto the toilet. On 7/8/19 at 3:15 PM, Direct Care Staff Q stated when he/she found any skin issues they were reported to the charge nurse. On 7/9/19 at 3:00 PM, Administrative Nurse verified there were no investigations regarding the bruises of unknown origin. The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy, dated (MONTH) 2019, documented an investigation of injuries of unknown origin or suspicious injuries must be immediately investigated to rule out abuse, injuries included, but are not limited to, bruising of the inner thigh, chest, face and breast, bruises of an unusual size, multiple unexplained bruises, and or bruising in an area not typically vulnerable to trauma (i.e., lateral aspects of forearms). The facility failed to investigate bruises of unknown origin for Resident #15, placing the resident at risk for injury.

The facility had a census of 39 residents. The sample included 5 residents, with 4 reviewed for elopement risks. Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent an elopement for 2 of 5 sampled residents. Cognitively impaired Resident #1 eloped from the facility, and ambulated approximately 2-3 blocks before staff found the resident and returned him/her to the facility, placing the resident in immediate jeopardy. Cognitively impaired Resident #5 eloped from the facility without staff knowledge, was observed by a visitor in the facility parking lot, and staff returned him/her to the facility, placing the resident in immediate jeopardy. Findings included: - Resident #1's (POS) Physician order [REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 2/20/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 4, indicating severe cognitive impairment, with inattention, disorganized thinking behaviors, and delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue). The MDS recorded the resident had other behavioral symptoms not directed toward others, rejection of care occurred 1 to 3 days in the 7 day lookback period, and wandering behavior that occurred daily. The MDS recorded the resident required extensive assistance with setup help only for bathing, limited assistance of 1 staff for dressing, supervision with setup help only for personal hygiene, independent with staff supervision for eating and toilet use, independent with bed mobility, transfers, walking in room and corridor, and locomotion on and off the unit. The MDS recorded the resident's balance was not steady, but he/she was able to stabilize without staff assistance. He/She had no functional limitation in (ROM) Range of Motion, and used no assistive devices for mobility. The MDS recorded the resident was occasionally incontinent of bladder, always continent of bowel, frequently had severe pain, and had no falls. The 6/21/17 Behavioral Symptoms (CAA) Care Area Assessment recorded the resident wandered daily throughout the day, and verbalized that he/she thought that an opposite gender resident in the facility was his/her spouse. The CAA recorded the resident had a sleep disorder and dementia with behavioral disturbances. The 2/22/18 care plan recorded the resident was a high risk for elopement related to impaired cognition with independent mobility and frequent wandering. The care plan recorded, on 10/17/17, the resident attempted to elope out the front door, but was easily redirected. The care plan directed the resident to consult with staff before going outside. The care plan recorded on 3/21/18 the resident eloped out the front door, staff changed the resident's wanderguard (a wrist or ankle band that automatically locks doors or alarms if the person moves outside a defined area without being accompanied by an authorized person), and staff were to redirect the resident when he/she was near an exit. The care plan further directed staff to assess, record, and report changes to the physician, risk factors for potential elopement such as: wandering, repeated requests to leave the facility, statements such as I'm leaving, I'm going home, attempts to leave the facility, and elopement attempts from previous facility or hospital. The care plan further directed staff to check the resident's wanderguard device for proper functioning and placement per facility protocol or manufacturer's recommendations, discuss with the resident's family risks of elopement and wandering, and develop an activities program to divert attention and meet the resident's needs for social cognitive stimulation. The care plan further directed staff if the resident wandered in a potentially unsafe area or situation, redirect to a safer area, leave the resident safe and reassess regularly. The care plan directed staff to take a photograph of the resident to maintain on file for identification purposes, with family or resident consent. If the resident was missing from the facility, follow the elopement protocol, notify his/her physician and family immediately, and document. The 1/20/18 Social Services Designee (SSD) note recorded on 1/17/18 the resident tried to walk out of the front door, he/she was agitated, but staff easily redirected him/her. The 2/27/18 Risk for Elopement assessment recorded the resident wandered daily, was independently ambulatory, and had impaired cognition. The assessment recorded the resident had a BIMS score of 4, continued an elopement risk, and had a wanderguard in place. The 3/21/18 at 3:40 PM, nurse's note documented the resident walked out of the front door, staff found him/her walking down the street, and the kitchen staff returned the resident safely to the facility. The 3/21/18 untimed SSD note recorded the resident walked through the door and went outside, he/she walked to the school but was picked up by staff. Staff changed the resident's wander alarm, even though it was working, and called the alarm company. Review of the facility's emergency (P[NAME]) Plan of Correction, revealed immediate corrective actions put into place on 3/21/18, after the elopement included the following: re-educated the staff on door alarm checks, educated the staff to watch the door the entire time they are resetting the alarm, placed a sign by the alarm keypad to watch the door, staff were to be aware of the surroundings and monitor elopement risk residents in the vicinity of the exits and redirect them. On 3/21/18 at 5:00 PM, staff changed another resident's wanderguard bracelet because the alarm did not sound when the resident went past the doors. On 3/21/18, the facility called the door alarm company to install keypad locks on the front main entrance door to (LTC) Long Term Care and the hospital door to the LTC. The company gave the facility an (ETA) Estimated Time of Arrival of Tuesday, 3/27/18 to start the process for the lock placement. The Plan for monitoring: Daily door alarm and wander guard alarm checks, weekly elopement exercises to monitor staff response to door alarming, checking outside the door and re-educate as needed. The resident ambulated approximately 2-3 blocks on a paved, uneven street, in 62 degrees Fahrenheit weather, without staff knowledge, before he/she was found and returned to the facility at 3:40 PM (31 minutes later). Per facility door alarm records documented, the door alarms and wanderguard alarms were checked daily, including on 3/21/18, with both alarms functioning properly. The 3/26/18 untimed (SSD) Social Serviced Designee note recorded the resident opened front door to let in a guest. The resident stated no need to run, I'm not going out. On 3/28/18 at 2:50 PM, observation revealed staff checked the front door entrance alarm and wanderguard alarm by having the resident stand next to the front door with the door open. The wander guard alarm and door alarm sounded, and the resident made no attempt to leave the facility. On 3/29/18 at 11:02 AM, observation revealed the resident walked up the South hallway by his/her room, gait steady, and wearing boots, hat and a coat. Further observation revealed the resident wandered the halls, but made no attempt to exit the facility. On 3/29/18 at 3:00 PM, surveyor observation of the area where staff found the resident on 3/21/18 revealed a paved street, speed limit 20 mph, no sidewalks, with cars parked along the sides of the street. Observation revealed the street had small hills with grassy uneven ground along the sides of the street. On 3/28/18 at 2:00 PM, Administrative Nurse D stated the facility ordered locks for the (LTC) Long Term Care main entrance and the hospital doors to the LTC, and verified currently none of the facility doors lock, they had alarm key pads but not locks. On 3/28/18 at 2:28 PM, Administrative Nursing Staff E stated there were wanderguard alarms on the door from the kitchen to the acute side of the building. The North exit door had a coded keypad alarm but no wanderguard alarm, and the wooden fence that goes around the North and South exit doors does not have a wanderguard alarm on it. Administrative Nurse E stated the front door had a wanderguard alarm and a coded key pad alarm that went off if anyone went in or out of the facility. The court yard door and the therapy door each had a box alarm (the box alarm will sound if the alarmed door is opened without pushing the button to clear the alarm. A wanderguard alarm sounds if a resident wearing a wanderguard goes close to the alarmed exit door. Neither alarm locked the door). On 3/29/18 at 10:28 AM SSD X stated on Wednesday, 3/21/18, he/she was in care plan meetings, and left temporarily to see if a resident wanted to come to the care plan meeting. SSD X stated he/she was on the South hall headed toward the nurse's station. When he/she heard the door alarm sounding, he/she hollered on his/her radio, door check. Medication Aide M hollered back, door clear so SSD X shut off the alarm. SSD X stated he/she did not look toward the door because Medication Aide M was standing by the door. SSD X stated he/she shut off the alarm and went back to the care plan meeting. SSD X entered the correct code 3 times to get a green checkmark to show the door was clear. SSD X stated around 20-30 minutes later staff told him/her staff found the resident outside by a house across the street from the tennis courts, about a block and a half away from the facility. SSD X stated the resident was wearing a gray winter coat, hat, and cowboy boots. When he/she came back to the facility, he/she acted normal, and did not say anything about why he/she left or where he/she was going. SSD X stated he/she did not ask the resident where he/she was going. SSD X stated he/she commented to the resident, I heard you went for a walk, the resident responded, yep, and laughed. No visible injuries were observed. SSD X stated Administrative Nurse D immediately put a sign up to direct staff to look at the door alarming before putting in the code to reset the alarm. SSD X stated all staff were on a higher alert and were watching the 2 main elopement risk residents closer. SSD X stated the resident did not make an attempt to leave the facility again after he/she returned back inside. SSD X stated the weather that day was sunny and around 60 degrees outside. He/she stated administration directed staff to be more alert and aware when the resident was by the door, and to watch for changes in his/her mood, and agitation. On 3/29/18 at 11:06 AM, SSD X stated staff checked the wanderguards daily. He/she checked the resident's wanderguard the morning of 3/21/18 and it functioned correctly at that time and also when the resident came back into the facility. SSD X stated he/she called the company and changed the resident's wanderguard after the resident's elopement. On 3/29/18 at 11:14 AM, Dietary Staff AA stated he/she left work around 3:20 PM on 3/21/18, and drove east on a residential street. He/she saw the resident, almost 3 blocks down the street from the facility. Dietary Staff AA stated he/she saw the resident from the back, and pulled up beside the resident. Dietary Staff AA stated he/she asked the resident, What are you doing?, the resident responded, I can't seem to find my way home. Dietary Staff AA stated he/she told the resident he/she would take him/her home and the resident said he/she felt like he/she had been walking for hours, but just didn't know which way to turn. Dietary Staff AA stated the resident got in the car, without being asked, and returned to the facility. Dietary Staff AA stated he/she brought the resident in the back door by the kitchen around 3:30 PM. Dietary Staff AA stated he/she knocked on the conference room door, where care plan meetings were taking place, and told Administrative Nurse D that he/she found the resident 2 ½ to 3 blocks away, and brought him/her back to the facility. Dietary Staff AA stated the resident acted normal for him/her. On 3/29/18 at 11:38 AM, Medication Aide M stated on 3/21/18 the door alarm was going off around 3:00 PM, so he/she started walking down the North hallway toward the nurse's station, because SSD X called for a door check. Medication Aide M stated there were people who were trying to come in so he/she was helping them in. Nurse Aide M stated the door alarm was sounding, but the wanderguard alarm was not. Nurse Aide M stated he/she did not see the resident around the door anywhere, so he/she let the visitors in, called door clear, and SSD X typed in the code. Nurse Aide M stated after he/she and SSD X cleared the alarm, they looked around to make sure there wasn't anyone trying to exit the facility, and Nurse Aide M went back down the north hall. Medication Aide M stated prior to that, between 2:30 PM and 3:00 PM, Medication Aide M gave the resident coffee and a snack, when the resident was in the lobby area resting on the couch. Medication Aide M stated the resident stayed on the couch while Medication Aide M moved the snack cart by the nurse's station. Medication Aide M stated later, Administrative Nurse D walked up the hall with the resident, and stated that a dietary aide had found him/her by the little white church. Medication Aide M stated Administrative Nurse D checked the camera, found out it was him/her and SSD X that cleared the door, and Administrative Nurse D called him/her and SSD X into his/her office and stated that SSD X had his/her back to the door, while Medication Aide M was talking to the people who were coming in, and the resident went out the door behind him/her. Medication Aide M stated the resident's wanderguard did not go off, and he/she was unsure if the front door was still open at that time. Medication Aide M stated staff obtained the resident's vital signs, checked the resident and found nothing wrong with him/her. Medication Aide M stated since this elopement, the facility had a new elopement policy in place and the cameras at the desk were on all the time, so when staff were typing in the code, the front door and walkway were visible. The cameras were now showing at the desk and not just in Administrative Staff D's office. Medication Aide M stated he/she had not received any education yet, but staff were instructed by Administrative Nurse D to be more alert when calling the door clear. On 3/29/18 at 2:20 PM, Dietary Staff AA stated the street the resident walked down had a speed limit of 15 or 20 (mph) miles per hour, the street had no sidewalk on it except a small patch where the resident was found. Dietary Staff AA stated the resident would have had to walk around the cars that were parked on the street, and the street had a lot of hills on it, to get to where the resident was found. The facility's Resident Elopement Identification and Reduction policy, dated (MONTH) (YEAR), documented the purpose of the policy was to identify residents at risk for elopement to help reduce the risk of elopement, to locate a missing resident as quickly and safely as possible, to identify problems that may prevent elopement from happening again, to determine if any harm occurred or if there is an immediate threat to a resident or resident's health and safety. An elopement of a resident is defined as a resident with impaired decision making ability, oblivious to safety needs and residents at risk for injury leaving the confines of the facility, without staff knowledge. The facility's Elopement Risk Visual Check policy, dated 2/15/18, documented when the door alarmed the charge nurse was to notify staff aides, per the radio, of a door check. Aides will respond stating each door location and if that door was clear. Following completion of the door checks the charge nurse will then identify each Elopement Risk Resident by initial for a visual check. Aides will respond stating each specified resident location. In the event an elopement occurs, the charge nurse will then follow the elopement policy. When a charge nurse was not present, the designated Certified Medication Aide will assume the role stated above for the door check and Elopement Risk Resident check. The facility failed to provide adequate supervision to prevent elopement for Resident #1, who eloped from the facility on 3/21/18 at approximately 3:09 PM, placing the resident in immediate jeopardy. The facility abated the immediate jeopardy on 3/29/18, after completion of the following: Nurse Aide M was placed on 90 day probation, Resident #1's wanderguard was changed and checked to assure it was working correctly, daily door alarm checks with staff response, daily resident wanderguard checks, SSD and/or Director of Nursing will exit the building for alarm checks weekly, staff now have access to the front entrance camera. Staff were educated and retrained on elopement policies and procedures, documentation and notification of resident's provider revised elopement risk visual checks, and signs placed on the main entrance door alerting visitors to watch for residents. There are locks to be placed on the facility front entrance and hospital entrance as soon as available, and policy and procedure for elopement risk visual checks were updated and reviewed. The deficient practice remained at a scope and severity of a D. - Resident #5's admission (MDS) Minimum Data Set assessment, dated 3/10/18, recorded the resident had a (BIMS) Brief Interview for Mental Status score of 3, indicating severe cognitive impairment, with fluctuating inattention, altered level of consciousness, and a mood severity score of 21, indicating severe depression. The MDS recorded the resident had delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), physical and verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, and rejection of care that occurred 1 to 3 days in the 7 day lookback period. The MDS recorded the resident was totally dependent on 1 staff for bathing, required extensive assistance of 2 staff for transfers, extensive assistance of 1 staff for locomotion on and off the unit, limited assistance of 2 staff for bed mobility, walking in room, toilet use, and limited assistance of 1 staff for dressing, eating, and personal hygiene. The MDS recorded the resident's balance was not steady, only able to stabilize with staff assistance, had no functional limitation in (ROM) Range of Motion, used a walker and wheelchair for mobility, and was frequently incontinent of bowel and bladder. The MDS recorded the resident received (PRN) as needed pain medications, had almost constant severe pain, shortness of breath with exertion, a history of falls, and one non-injury fall since admission. The 3/10/18 Cognitive Loss/Dementia (CAA) Care Area Assessment recorded the resident had dementia (progressive mental disorder characterized by failing memory, confusion) with slowly declining cognition, and a BIMS score of 3. The CAA recorded the resident could not remember his/her own last name when signing, had impaired vision requiring large print for reading, and had constipation and [MEDICAL CONDITION] (abnormal condition that may affect the flow of oxygen to the heart). The 3/10/18 Behavioral Symptoms CAA recorded the resident had dementia, constipation, history of kyphoplasty (a procedure designed to stop the pain caused by a spinal fracture), and impaired vision. The CAA recorded the resident had no glasses at the (LTC) Long Term Care facility. The 3/28/18 care plan recorded the resident was a high risk for falls related to his/her history of falls with fracture, impaired cognition, poor safety awareness with impulsivity (behavior without adequate thought), impaired mobility, incontinence, and his/her disease processes. The care plan directed staff to ensure the resident's call light was within reach, encourage the resident and his/her family to use it for assistance as needed, and staff to respond promptly to all requests for assistance by the resident and his/her family. The care plan recorded the resident's cognition impaired his/her ability to remember how to use the call light, and directed staff to ensure a safe environment with: floors even and free from spills or clutter, adequate, glare-free light, handrails on the walls, and the resident's personal items were within reach. The care plan recorded the resident walked with a (FWW) Four Wheeled Walker, (CGA) Contact Guard Assistance (staff assisting needs to merely have one or two hands on patients body, but provides no other assistance to perform the functional task), and a gait belt, with staff bringing his/her wheelchair PRN. The care plan recorded the resident performed most locomotion using his/her wheelchair, and had a Tab alarm (a pull cord alarm that clips on the back of the patients clothing and if they move too far, the pull cord will release the magnet or tab and the alarm will sound) for his/her bed, chair, and wheelchair. The care plan recorded the resident required glasses for reading, refused to wear them, and was able to see at a distance without difficulty. The care plan directed staff to observe, document, and notify the resident's physician PRN for signs and symptoms of acute eye problems. The 3/28/18 care plan recorded the resident had behavior problems related to his/her disease processes, evidenced by combativeness with cares, wandering, rejection of care, false verbalizations regarding reality, hollering out, agitated physical behavior not directed toward others. The 4/8/18 care plan update recorded the resident wandered and was at risk for elopement. The care plan directed staff to walk with the resident daily or more frequently as needed, mark the resident's room door with his/her name or familiar photo, to aide in remembering and finding his/her room location, complete an Elopement risk assessment per facility protocol, apply a wanderguard (a wrist or ankle band that automatically locks doors or alarms if the person moves outside a defined area without being accompanied by an authorized person) to reduce risk of elopement, and check the device (wanderguard) for proper functioning and placement per facility protocol or manufacturer's recommendations. The care plan recorded if the resident wandered into a potentially unsafe area or situation, redirect to a safer area, and reassess regularly. The care plan directed staff to take a photograph of the resident to maintain on file for identification purposes, with family consent, add the resident's information to the elopement book, observe, document, and report changes in neurological status to his/her physician, and use communication techniques to facilitate optimal interaction. The care plan recorded the resident required staff assistance with dressing, undressing and all other (ADLs) Activities of Daily Living. The 4/8/18 care plan update recorded staff placed a wanderguard on the resident, and directed staff to monitor per facility policy, and the (SSD) Social Services Designee was notified. The 4/9/18 care plan update recorded the resident's photo and information were added to the Elopement Risk book. The medical record recorded the facility admitted the resident on 3/2/18. His/her family member brought the resident to the facility because the family member was waking in the mornings and finding the resident gone. The family member stated on one day he/she looked all over the house, called another family member and found the resident in the basement messing around in one of the rooms. The 3/2/18 Risk for Elopement assessment recorded the resident was not at risk for elopement. The 3/16/18 Risk for Elopement assessment recorded the resident was not at risk for elopement, had a BIMS score of 3, used a wheelchair for long distances, and required staff assistance with transfers and ambulation. The 4/8/18 at 2:00 PM, nurse's note documented another resident asked Resident #5 to take him/her outside, as Resident #5 had the front lobby door open. The note documented a staff member redirected both residents away from the door, and explained to Resident #5, that he/she needed to ask for help when other residents asked him/her for assistance. The note documented the resident expressed understanding, stated the other resident told him/her it was okay, then he/she laughed, and sat down on the couch by the snack nook. The 4/8/18 at 4:00 PM, nurse's note recorded the nurse was alerted by staff that the resident was outside, and no one saw how he/she got outside. The nurse's note recorded the on-call administrative staff, and SSD X were notified regarding placing a wanderguard on the resident. The 4/8/18 at 6:10 PM, nurse's note recorded the resident's family member and physician were notified that the resident had eloped to the parking lot and staff placed a wanderguard on the resident. The facility's investigation recorded on 4/8/18 at approximately 3:49 PM, the resident left the facility without staff supervision or awareness. The investigation recorded a visitor in another resident's room, through the window, observed the resident standing in the parking lot, and alerted staff. The investigation recorded staff were alerted on the radio that a resident was in the parking lot, and immediately went outside to assist and redirect the resident back into the facility. The investigation recorded another resident's family member drove to the facility, and stated he/she saw the resident standing in the parking lot, parked his/her vehicle, then got out and spoke to the resident. The investigation recorded the visitor stated the resident was confused, looking for his/her family member, and a short time later (approximately 1 minute) staff assisted the resident back into the facility without incident. The investigation recorded staff notified the resident's family, physician, (DON) Director of Nursing, and administration, and placed a wanderguard on the resident as he/she did not have one on prior to the elopement. Per the facility's camera, on 4/8/18, the resident walked out the front door at 3:49 PM, without an assistive device, gait steady. The camera recorded 2 staff members at the desk, a PRN nurse and an agency medication aide, and the nurse reset the alarm without checking outside the front door. The camera recorded the resident stood in the entry way just over 2 minutes prior to exiting the door. The camera recorded at 3:49 PM, the resident was in view outside the facility, walked out the front exterior to the outside, walked to the front of the hospital, stood in front of the hospital, then walked across the parking lot, looked into parked cars in the parking lot, then returned to the sidewalk. The camera recorded at 3:56 PM another resident's family member pulled up in his/her vehicle, saw the resident, got out of his/her vehicle, and spoke to the resident. The resident stated he/she was looking for his/her family member. The camera recorded at 3:57 PM 2 staff members returned the resident to the facility, without incident. The 4/9/18 Risk for Elopement assessment recorded the resident was at risk for elopement. The resident had eloped on 4/8/18 through the facility front door, and staff redirected the resident back into the facility without difficulty. The assessment recorded staff applied a wanderguard on the resident, the policy was followed, and the resident made no further attempts to leave the facility that evening. The assessment recorded most of the resident's locomotion was with a wheelchair, the resident was ambulatory, and his/her status was changed to an elopement risk. On 4/10/18 at 10:02 AM, observation revealed the resident rested in bed, lying on his/her left side, with eyes closed. Observation revealed the side rails were raised, and no alarms present. Observation revealed the resident displayed no signs or symptoms of pain or discomfort, made no attempt to get up out of bed, and the resident's walker and wheelchair were close to the resident's bed, but not within the resident's reach. Per the facility's inaccurately dated witness statement, Medication Aide O documented another resident's family member thought the resident was outside, so Medication Aide O looked outside, observed the resident leaning against the back of a car, and alerted staff over radio. Medication Aide O documented the incident was reported to the nurse and staff went outside to get the resident. On 4/10/18 at 1:16 PM, Medication Aide Q stated the resident mostly required cueing with ADLs, required 1 staff assistance for ambulating, but tended to walk by himself/herself, was supposed to use a walker but often forgot it. Medication Aide Q stated he/she was not sure if the resident was CGA or (SBA) Stand-By Assist (staff assisting does not touch the patient or provide any assistance, but he/she may need to be close by for safety in case the patient loses his/her balance or needs help to maintain safety during the performed task), and staff hang on to the gait belt, but do not follow the resident with a wheelchair. Medication Aide Q stated he/she had not looked at the care plan, the nurses normally tell us when they change something on the care plan. Medication Aide Q stated staff were told the resident eloped and was in the parking lot talking to someone, the resident was not normally very active, and had not tried to elope before. Medication Aide Q stated after the resident eloped staff had to re-read the elopement policy. Medication Aide Q stated he/she was unaware of what changes were made to the policy, because he/she did not actually read the policy, but signed the paper saying he/she had. Medication Aide Q stated the resident did not have any alarms, previously had a tab alarm, but it was discontinued about 2 weeks ago, because the resident would unhook it himself/herself. Now the resident had no alarms, but has a wanderguard which staff placed after he/she eloped. On 4/10/18 at 2:34 PM, Nurse I stated a staff member called on the radio that there was a resident outside. The resident was standing outside talking to another resident's family member, the resident did not have his/her walker and was not wearing a wanderguard. Nurse I stated he/she reset the alarm, but did not check the door first. Nurse Aides M and P went outside and assisted the resident. Nurse I stated after the resident was brought back into the facility, he/she did not assess the resident, because he/she was not aware he/she was supposed to. Nurse I stated he/she called the on call nurse, and he/she told Nurse I to call SSD X because Nurse I wanted to place a wanderguard on the resident. He/she then notified the resident's family and physician. Nurse I stated the resident was acting normal for him/her, did not have any alarms, and around 5:30 PM, a wanderguard was placed on the resident. Nurse I stated he/she had not received any education on elopements prior to starting work, but he/she read the policy and procedure after the elopement. Nurse I stated Administrative Nurse F informed him/her to read the policy and that was completed around 6:30 PM that night. Administrative Nurse F informed Nurse I, before he/she read the policy, that Administrative Nurse F had implemented someone to sit at the front door around the clock. Nurse I stated prior to the elopement, the policy stated staff were supposed to look and see if there was someone in the breezeway before calling an all clear. Nurse I stated he/she was not aware of this prior to the elopement. Nurse I stated when he/she started working at the facility, he/she did not review all the p(TRUNCATED)

The facility identified a census of 38 residents. The sample included 3 residents reviewed for elopement risk and falls. Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent elopement, for 1 of 3 residents. Resident #1 had prior exit seeking behavior, and exited the facility without staff knowledge on 2 different occasions. This deficient practice placed Resident #1 in immediate jeopardy. The facility failed to thoroughly assess, investigate, and develop intervention changes to prevent falls for 1 of 3 residents reviewed. Resident #2 had multiple falls, 1 fall with a major injury. Findings included: - The physician's orders [REDACTED].#1 had [DIAGNOSES REDACTED]. The quarterly (MDS) Minimum Data Set assessment, dated 4/5/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 6, indicating severely impaired cognition, inattention, and he/she rejected care. The MDS documented the resident required limited assistance of 1 staff for transfers, walking in his/her room and corridor, dressing, toilet use and hygiene. The MDS further documented the resident required supervision for bed mobility and total staff assistance for locomotion, had unsteady balance, but could rebalance on his/her own. The MDS documented the resident had bilateral range of motion impairment to his/her upper extremities, used a walker and wheelchair, received 2 days of active range of motion, and did not wander. The quarterly (MDS) Minimum Data Set assessment, dated 6/15/17, documented the resident had a (BIMS) Brief Interview for Mental Status score of 3, indicating severely impaired cognition, inattention, and he/she rejected care. The MDS documented the resident required limited assistance of 1 staff for dressing, bed mobility, and was independent with walking in his/her room/hallway. The MDS further documented the resident had unsteady balance, but could rebalance on his/her own. The MDS documented the resident had bilateral range of motion impairment to his/her upper extremities, used a walker and wheelchair, and did not wander. The 1/10/17, (ADL) Activities of Daily Living (CAA) Care Area Assessment documented the resident had returned to independently walking with use of a wheeled walker. The behavior CAA documented the resident had a history of [REDACTED]. The CAA further documented the resident had [MEDICAL CONDITION] (progressive mental deterioration characterized by confusion and memory failure) and moderate hearing loss. The 1/16/18 care plan included interventions initiated on 5/20/2014, which directed staff to ensure the resident wore a wanderguard bracelet (prevents at risk residents from leaving the facility unless they are accompanied), and to check the bracelet for proper functioning per the facility's protocol or to follow the manufacturer's recommendations. The care plan directed staff beginning 5/20/14 to ensure the resident wore appropriate footwear when walking, or up in the wheelchair, and to place the call light in reach. Review of the facility's Elopement Risk Assessments, dated 6/21/17, 9/1/17, and 11/10/17 documented questions on page 1 were answered as yes, which indicated the resident was at risk for elopement. The questions answered yes referred to the resident's poor decision making skills, a [DIAGNOSES REDACTED]. Review of page 2 of the form revealed the summary portion of the form was not completed, and did not document if the resident was or was not an elopement risk. The form made no recommendations for interventions or further actions. The 7/11/17 physician narrative note documented the resident's memory was poor, but he/she could carry on a conversation on that date. The note documented the resident could move his/her extremities on command and walked with a walker. The 7/22/17 at 4:30 PM, investigation report documented a review of the camera revealed the resident was outside of the facility for a total of 7 minutes in 100-degree (F) Fahrenheit temperature. The investigation documented the resident walked to the end of the awning and across the grass to a shaded area of the north part of the hospital, by the gazebo gate, when Nurse Aide M found the resident. The report documented as a conclusion, several residents congregated at the front door. The staff were down the south hall and did not hear the alarm. A nurse charted in the activity room and did not hear the alarm. Dietary Aide BB walked around the corner after the resident exited and the alarms sounded, with no other staff around the nurse's station. The investigation recommended: 1) a review of the door check on a 1 to 1 basis with staff and a review of the door check and policy and procedure at a staff meeting, 2) A radio would be kept in the gated area of the dining room, with the intent to use the radio for emergency use or when nursing staff are needed immediately, and 3) Increase the alarm activation to monitor staff response times and clearing of the doors. The 7/22/17 at 4:40 PM, progress note documented the resident walked out of the facility, the kitchen staff witnessed this and notified a nurse aide. Nurse Aide M found the resident and redirected the resident back to the facility safely. The progress note documented the resident's representative and physician were notified. The Kansas State University Weather Data Library reported the temperature on 7/22/17 at 4:00 PM was 105 degrees F and at 5:00 PM was 104 degrees F. The 8/1/17 at 3:05 PM, progress note documented the resident attempted to exit the building through the front doors. The nurse educated the resident it was unsafe to exit through this door and redirected the resident to the patio door. The note documented the resident exited through the patio door into the gazebo area and entered the back door of the hospital's main dining room, where the hospital staff nurse redirected the resident to the facility hallway, and notified the facility staff the resident was redirected. The progress note lacked documentation administrative staff, the physician, and resident representative were notified, and did not include a care plan change. The Kansas State University Weather Data Library reported the temperature on 8/1/17 at 3:00 PM was 85 degrees F. The 8/17/17 at 4:35 PM, progress note documented the resident exited through the front doors when a guest opened the door and walked down the sidewalk with his/her walker. The note documented Nurse N caught up with the resident and the resident stated he/she was going to the red car. Nurse N redirected the resident into the building. The progress note lacked documentation nursing staff completed a physical assessment, notified the administrative staff, the physician, and the resident's representative, or a care plan change. The Kansas State University Weather Data Library reported the temperature on 8/17/17 at 4:35 PM was 91 degrees F. On 2/14/18 at 1:25 PM, observation of the front entrance of the facility revealed the grassy area from the awning to the gazebo gate and the exterior wall of the hospital dining room, had uneven ground, a flag pole, and a square raised metal surface, approximately 3 feet by 3 feet with a manhole cover in the center. Observation further revealed the ground dipped around both areas. The resident would have had to step up, onto the raised sidewalk, then down and back onto the grass to reach the area by the evergreen tree. Observation revealed a driveway that leads to the hospital and nursing home entrance, with a sidewalk parallel to the edge of the parking lot. On 2/14/18 at 3:30 PM, observation of the secured gazebo/patio area revealed the concrete patio was surrounded by a tall wooden fence, with a gate on the parking lot side, a grassy area, an entrance into the nursing home on one side, and an entrance into the hospital on the opposite side from the facility. On 2/13/18 at 8:55 AM, observation revealed Nurse Aide N, Nurse Aide O, and Nurse Aide P assisted the resident to transfer from the bed to a commode. Staff applied a gait belt, used 2 staff to assist the resident to stand, and the 3rd aide to hold the resident's affected right leg, to ensure the resident did not bear weight on the leg. Staff assisted the resident to pivot from the commode to the wheelchair. Staff placed a footboard, foam pressure relieving cushions on both feet, with gripper socks on, and the pressure alarm pad in place. On 2/13/18 at 2:03 PM, Nurse G stated the 15-minute checks of the lobby, activity room, and halls, started after the resident fell on [DATE], were completed from 12:00 PM to 1:00 PM and from 4:00 PM to 10:00 PM. Nurse G stated at time frames that are not listed, staff are frequently in and out of the areas, and were not documented. On 2/13/18 at 4:30 PM, Nurse G stated at the monthly staff meeting, on 8/17/17, following the 7/22/17 elopement, the former Administrative Nurse directed the staff to check the door when it alarmed, but did not review the steps of the door alarm policy and procedure. Nurse G stated the front entrance door does not lock down, if a wanderguard bracelet sets off the alarm or if a person fails to enter the code, the door alarm and or wanderguard alarm sounds, but the door will still open. Nurse G stated the admission nurse completed an Elopement Assessment form, then the MDS Nurse completed an updated Elopement Assessment form with each quarterly MDS. Nurse G verified the summary section on the resident's Elopement Assessment forms were not completed. Nurse G stated the facility cared for 17 cognitively impaired and independently mobile residents. The 2/13/18 witness statement, Nurse G documented on 7/22/1,7 he/she sat in the activity room working on monthly laboratory information, heard the door alarm, and radioed the aides to check the doors. Nurse G stated the alarms continued to sound for another 3 minutes, he/she then stood and asked if the alarm was checked. Nurse G documented Nurse Aide M had exited the front of the building and observed the resident outside with his/her walker and assisted the resident back into the building. The 2/13/18 witness statement, Nurse Aide M documented on 7/22/17 he/she was down the north hall and heard both door alarms go off. Nurse Aide M documented he/she reached the door, and a kitchen staff member informed him/her the resident had gone outside. The witness statement further documented Nurse Aide M found the resident on the long side the building wearing tennis shoes, slacks, a shirt, and a knit sweater, with his/her walker. Nurse Aide M documented the resident was looking at the trees alongside the building. Nurse Aide M documented the resident was asked what he/she was doing outside and the resident stated he/she was looking for help. The resident accepted Nurse Aide M's assistance and walked along side of the building back to the front door and re-entered the building. Once inside, Nurse Aide M asked the resident what he/she needed help with, and the resident stated help to use the bathroom. Nurse Aide M documented the 30-minute checks for individual residents had been stopped, but the 15-minute time checks at the desk were completed. The 15-minute checks involved looking up both hallways, the lobby, dining room, and activity room. Nurse Aide M documented the person completing the check, made sure the residents were ok, their walkers within reach, and alarms were on. The 2/14/18 witness statement revealed Nurse H documented on 8/1/17, the resident had tried to go out the front doors of the facility, but was reminded by staff to use the patio door if he/she wanted to go outside, because going out the front door was not safe. The resident then went out to the patio, but came back in the facility through the hospital dining room doors. Nurse H documented the hospital nursing staff then notified him/her that the resident had entered through the hospital dining room, because the alarm sounded. The resident was then escorted back to the long-term care facility by hospital staff. Nurse H documented on 8/17/17 the resident was let out the front doors by a guest. When the alarm was checked, another staff member observed the resident had gone out the door. Nurse H documented he/she walked with the resident and talked. The resident informed Nurse H the red car in the parking lot was his/hers. Nurse H further documented the resident was educated that the car belonged to someone else. The resident then agreed to come back inside the building with Nurse H. Nurse H verified a skin assessment was not completed, due to the fact the resident had just walked outside and returned into the building. The 2/20/18 witness statement, Dietary Staff BB documented, on 7/22/17, he/she came out of the kitchen to go to the dining room, and heard the front door alarm. He/she arrived at the lobby of facility and observed 3 residents at the front door, 1 resident was pushing on the front door, and the alarm sounded. Dietary Staff BB noticed no staff in the lobby or nurse's station, as he/she continued to the facility dining room to perform tasks. Dietary Staff BB observed from the south window in the dining room, the resident walked down to the end of the sidewalk in front of facility, but he/she was unsure if the resident was completely unattended. Dietary Staff BB continued to perform tasks in the dining room, but looked periodically to the south windows and still had the resident in view, while the alarms continued to sound. The resident had walked down the sidewalk, going east at that time. Dietary staff BB documented he/she became concerned and left the dining room to find a staff member, when Nurse Aide M entered the lobby. Dietary Staff BB asked Nurse Aide M if someone was with the resident in front of the facility. Nurse Aide M immediately went outside the front door of the facility, intercepted the resident, and walked him/her back into the facility. On 2/14/18 at 11:00 AM, Administrative Nurse D verified the 8/1/17 attempted elopement and the 8/17/17 elopement were not reported to administrative staff for investigation. On 2/14/18 at 11:15 AM, Nurse H verified there was no documentation the physician and the resident representative were notified the resident exited the building on 8/1/17 and 8/17/17. Nurse H stated on 8/17/17, the resident was dressed in a shirt and slacks, his/her normal attire. Nurse H stated the resident walked on the side walk, out from under the awning, turned left, and headed down the sidewalk, bordering the parking lot, toward the hospital. On 2/14/18 at 2:20 PM, Social Service Staff X reported the wanderguard devices and doors were checked one time each week. Social Service Staff X stated the wanderguard devices life expectancy was 3 years and he/she tracked the expiration dates. On 2/14/18 at 3:15 PM, Administrative Nurse D verified an investigation was not completed for the 8/1/17 or the 8/17/17 incidents. Administrative Nurse D verified a physical assessment and a care plan change were not completed for the 7/22/17 and 8/17/17 elopement incidents. The facility's 4/16/12 Resident Elopement Identification and Reductions policy documented the purpose was to identify problems that may prevent elopement from happening again,to determine if any harm occurred or if there was an immediate threat to a resident or the resident's health and safety. The procedure defined an elopement as any resident, with impaired decision-making ability and is oblivious to his/her own safety needs, who left the facility without the knowledge of staff. The procedure documented a resident at risk for possible elopement shall be placed on a 15-minute position schedule check and all staff are to be aware of the resident's risk and scheduled placement checks. If a resident is at high risk for elopement, an alarm device will be attached to the resident to activate the outside door alarm if the resident elopes. Residents that are at elopement risk will be on the resident's care plan and on the pocket care plans. The procedure directed administrative staff or a designee to investigate and report to the state agency hotline as required. The facility procedure directed the staff to complete a thorough investigation of the incident and listed a page full of questions to be answered. Is the resident's cognition impaired with poor decision-making skills? Is the resident a wanderer? Does the resident have a history of elopement? Does the resident ambulate independently or with an assistive device? Is an individual resident safety alarm system used? Was the safety alarm functioning? Was the safety alarm tested ? What exit door did the resident use to elope from the building? If the door of the exit is unknown, what exit door or doors is it likely that the resident eloped from? Was the door alarm activated? If not, was the exit door under staff visual control? Was the door alarm functioning? Is there a plan of care for the resident for wandering? Is the plan of care current? What time was the resident elopement noticed? How long was the resident outside? When was the resident last seen? Who found the resident (facility staff, housekeeping, nursing, family, visitor, etcetera)? Where was the resident found? Did the resident sustain any injuries? What was the weather condition at the time of elopement? Was the elopement policy followed? The facility failed to provide adequate supervision for Resident #1, who wandered out of the facility onto an unsafe grassy area, in high temperatures, without staff knowledge, on 7/22/17 and 8/17/17, which placed the resident in immediate jeopardy. The facility abated the immediate jeopardy on 2/16/18 at 1:27 PM, when the facility completed all staff in-services which included review of the revised elopement policy, including staff responsibility to investigate and report all cases of missing residents, and notify the primary care physician and responsible party, the revised elopement risk visual check policy, new forms to change door alarm checks from weekly to daily, and wanderguard checks from weekly to daily. Access to the front entrance camera on the computer next to the door alarm to ensure no resident is outside along with checking the door. SSD (Social Services Director) or DON (Director of Nursing) will exit the building for alarm check weekly and document, and signs placed on the door to alert visitors to watch for residents at the door and notify staff. The MDS (Minimum Data Set) assessment coordinator educated on proper documentation and completion of elopement assessments. The deficient practice remains at a scope and severity of a D. - The physician's orders [REDACTED].#2 had [DIAGNOSES REDACTED]. with an increased fracture risk), [MEDICAL CONDITION] stage 3 (moderate kidney damage which affects the kidneys ability to excrete wastes, concentrate urine and conserve electrolytes), and a [MEDICAL CONDITION] humeral neck (a break in the long bone of the upper arm near the shoulder). The quarterly (MDS) Minimum Data Set assessment, dated 6/29/17, documented Resident #2 had a (BIMS) Brief Interview for Mental Status score of 5, indicating severely impaired cognition, with delusions. The MDS documented the resident was independent with (ADLs) Activities of Daily Living, except for dressing and hygiene. The MDS further documented the resident's balance was unsteady, could rebalance himself/herself, had no range of motion impairment, used a walker, was continent of bowel and bladder, and not on a toileting program. The MDS documented the resident had no falls and received a diuretic (medication that increases the execution of urine from the body) for 7 days of the look-back period. The significant change MDS, dated [DATE], documented Resident #2 had a BIMS score of 5, indicating severely impaired cognition. The resident had physical and verbal behaviors, which placed the resident at risk for injury, and interfered with his/her care. The MDS documented the resident required extensive assistance of 1 staff for bed mobility and toilet use, total assistance of 1 staff for locomotion off the unit, and limited assistance of 1 staff for hygiene, transfers, walking in his/her room, and dressing. The MDS further recorded the resident had impaired balance, required staff assistance to rebalance, and had range of motion impairment to 1 side of his/her upper extremities. The MDS documented the resident used a wheelchair, was on a toileting program, had 1 fall with a major injury, received a diuretic medication for 7 days, and 1 day of active range of motion during the look-back period. The ADLs (CAA) Care Area Assessment, dated 9/20/17, documented the resident rejected care, had behaviors toward staff, and no longer walked. The CAA documented 2 staff pivot transferred the resident with a gait belt, used a wheelchair for locomotion, and he/she was hospitalized between 9/13/17 to 9/18/17. The falls CAA documented staff found the resident on 8/25/17 at 11:10 PM, after a fall down the south hall. The CAA documented the resident did not have his/her walker, staff now transfer the resident with 2 staff and perform a pivot transfer to a wheelchair, due to use of a shoulder immobilizer (device used to suspend a person's arm with or without a cast, keeps the shoulder from moving the arm). The 1/16/18 care plan included interventions and the date initiated: 12/15/11 - wanderguard to the resident's ankle, pivot transfer with assistance of 1 to 2 staff, with use of a gait belt 8/29/13 - place the call light within the resident's reach and encourage the resident to use it 9/19/17 - locomotion by wheelchair 9/19/17 - ensure appropriate footwear, when up in the chair, the wheelchair, and with transfers 9/22/17 - (AROM) active range of motion to the left upper extremity, right lower extremity, and cervical spine with or without resistance, AROM to the right elbow, wrist, finger, and use of the bike. 10/24/17 - staff to put gripper socks on the resident 10/27/17 - chair and tag alarm on the resident 12/15/17 - wear glasses, staff to ensure cleanliness 12/18/17 - gripper socks on at bedtime and while in bed 1/9/18 - fall mat on the floor by the bed 1/29/18 - begin right shoulder AROM The Fall Risk Evaluation form documented a score greater than 19 was a high risk for falls and recorded the following: 7/3/17 - score 17 9/12/17 - score 26 12/4/17 score 26 The facility's 8/25/17 at 6:35 PM, fall investigation form documented the resident walked without his/her walker and lost his/her balance. The form documented the resident walked independently in his/her room, had dementia and a right shoulder fracture. The form lacked documentation of root, cause, and analysis, the type of footwear worn, the location, and what the resident was doing at the time of the fall. The form recommended the (cognitively impaired) resident always use his/her walker, with no care plan change to prevent future falls. The 8/25/17 at 9:29 PM, hospital history and physical documented the resident fell in the evening, was unable to state what happened, complained of right shoulder pain, and appeared alert when he/she spoke. The history and physical documented the resident was excessively sleepy, had a stable fracture to the right greater tubercle (a small rounded projection, on the bone surface of the upper arm), and had a dry splint using a shoulder immobilizer, with an arm sling. The facility's 9/26/17 untimed, fall investigation form documented staff found the resident on the floor in the day room, lying on his left hip, with the wheelchair on the resident's right side, and no socks or shoes on. The form documented staff assessed the resident and found no injury. The resident reported he/she was cleaning the floor. A nurse aide reported the alarm sounded and the floor was dry. The form further documented staff notified the resident's representative and physician were notified, but there was not a care plan change to prevent future falls. The 10/24/17 at 5:45 AM, Fall Investigation form documented staff found the resident laying on his/her right side on the floor next to the bed. The resident reported he/she needed to use the bathroom. The form documented the bed and floor were wet with urine, and the resident slid off the bed, and had regular socks on. The form documented staff notified the resident's representative and physician were notified. The 10/26/17 at 1:20 PM, nurse's progress note documented the nurse reviewed the resident's 10/24/17 fall, and reported the resident slid from the bed onto the floor, denied pain, had a bruised area noted, and the resident was not to walk for a month until re-evaluated. The 10/27/17 at 4:50 PM, nurse's progress note documented the physician ordered a tag and chair alarm. The 11/16/17 at 5:40 PM, nurse's progress note documented staff contacted the resident's representative about obtaining a new pair of shoes for the resident. The facility's 12/18/17 at 6:45 AM, fall investigation form documented staff found urine and bowel movement on the floor, after the resident attempted to get up to the toilet on his/her own. The form documented staff last observed the resident in bed at 6:15 AM. The nurse documented staff were to apply gripper socks on the resident while in bed (which was an intervention already in place). The 12/18/17 at 8:45 AM, nurse's progress note documented staff notified the resident representative and physician that staff found the resident on the floor, alarms sounded, and the resident was incontinent of bladder and bowel, slipped, fell , and had no injuries. The note lacked documentation if the resident wore gripper socks as care planned. The 12/20/17 at 9:45 PM, nurse's progress note documented, 2 days after the last fall, the resident had a protruding area to the right hip, which was hard and unmovable, irregular shaped, with the right leg slightly shortened and rotated outward. The note further documented the resident was confused, staff notified the physician, applied oxygen, and continued to monitor the resident's status. The 12/20/17 at 11:40 PM, nurse's progress note documented the resident had no bruise to the right hip, the right leg was shorter than the left, but there was no outward or inward turn of the hip. The note further documented the resident grimaced with hip movement, and the physician ordered the resident to be non-weight bearing, with bed rest. The 12/20/17, physician note documented the resident fell a few days ago, complained of pain on the right side of his/her ribs, had no bruising or swelling, and stated it hurt to take a breath. The note documented the resident had a history of [REDACTED]. The 12/21/17 at 1:00 PM, x-ray report of the ribs and hips revealed no fractures. The note documented the resident's arm remained in a sling for post [MEDICAL CONDITION] shoulder. The 12/22/17 at 4:00 PM, nurse's progress note documented the resident was started on [MEDICATION NAME] (antibiotic medication) and [MEDICATION NAME] (medication that relaxes muscles in the airways and increases air flow to the lungs). The 1/29/18 physical therapy program evaluation directed staff to provide active range of motion to both upper and lower extremities, with or without resistance, perform pulleys, no resistance to the right shoulder, ride the nu-step (seated device with a stepping motion) dexterity exercised as needed, and all staff to assist the resident to walk to meals. The 2/9/18 at 2:45 AM, nurse's progress note documented staff found the resident laying on the floor halfway under the bed. The note documented 2 nurse aides entered the resident's room, found the resident almost parallel to the bed and scooted him/herself around and ended up partially under the bed. The note documented the resident was shaken, nervous, and complained his/her head and back hurt. The note documented staff notified the physician and he/she ordered staff send the resident to the emergency room . The note lacked documentation of the resident's footwear, whether gripper socks were worn at the time of the fall. The physician did not change or provide any new orders. On 2/12/18 at 1:45 PM, observation revealed Nurse Aide Q and Nurse Aide R assisted the resident to lay down on his/her bed. The aides applied the gait belt, as the resident stated he/she wanted to go to bed. The resident was confused, staff repeated what they were doing a few times, and with assistance of 2 staff, pivot transferred the resident to sit on the edge of the bed, then transferred the resident to a lying position. Observation further revealed an assist bar on the bed, pad and pull tag alarm, towel tucked behind the resident's back, bed lowered to lowest position, fall mat on the floor, and call light placed in the resident's reach. On 2/14/18 at 11:15 AM, Nurse H stated the resident used the wheelchair for mobility most of the time and could move around on his/her own. Nurse H stated the resident had declined over the last 9 months, was very confused, and had falls. Nurse H stated any of the nurses could make a care plan change and add an intervention to prevent falls, but stated this was usually left for the person completing the MDS. Nurse H stated the nurses complete the fall investigation and forwarded the form to administrative staff. Nurse H verified the resident was care planned to wear gripper socks when in and out of bed, and he/she continued to attempt to stand from the wheelchair. Nurse H stated the nurses continued to re-educate staff, since the incidents involved the resident not wearing gripper socks at the time of the fall. On 2/14/18 at 11:45 AM, Nurse Aide S stated the resident was independent with ADLs, although he/she required occasional assistance with some ADLs. Nurse Aide S stated staff assisted the resident to get up, toilet, and dress. Nurse Aide S stated the resident could walk independently, while staff provided stand by assistance, and another staff followed with the wheelchair. Nurse Aide S stated fall interventions included a tag and pad alarm, gripper socks at night, and at times during the day. Nurse Aide S stated the resident could report if he/she needed to use the bathroom, then stated staff assist him/her to the bathroom every 2 hours. Nurse Aide S reported the resident was confused and continued to try and stand up from the wheelchair, by swinging his/her feet outside of the wheelchair pedals. On 2/14/18 at 3:15 PM, Administrative Nurse D verified staff should follow the care plan and the pocket care plan as documented, which included use of gripper socks, and other fall interventions. The facility's undated Assessing Falls (TRUNCATED)