Every finding on record at New Albany Health & Rehab Center

Based on observations, interview, and facility policy review, the facility failed to label and store food properly for one (1) of three (3) kitchen tours. Findings Include: Review of facility policy titled Food Storage with a revision date of 11/28/2017 revealed, Ready-to-eat foods shall be marked with a discard date at the time of opening or preparation. During the initial tour of the kitchen with the District Dietary Manager (DM) on 6/8/2026 at 10:10 AM, the walk-in freezer was observed to have open boxes of corndogs, chicken patties, and mixed vegetables exposed to the air. In the walk-in refrigerator, a gallon milk jug that was about one-fourth (1/4) full had no date indicating when it was opened. In the dry storage room, one-third (1/3) of a bag of spaghetti noodles and one-half (1/2) of a five-pound bag of egg noodles were open and exposed to the air. A bottle of soy sauce that contained less than one-fourth (1/4) of its contents had no date indicating when it was opened. During an interview with the District Dietary Manager (DM) on 6/8/2026 at 10:30 AM, she confirmed that all opened food items should be labeled with the date they were opened and acknowledged that failure to do so could increase the risk of foodborne illness. She also confirmed that food stored in the freezer and dry storage areas should be kept sealed.

Based on record review, facility policy review, staff interviews, and resident representative interviews, the facility failed to ensure binding arbitration agreements were presented and explained in a form and manner understood by resident representatives and failed to ensure resident representatives (RR) were informed that signing the arbitration agreement was voluntary and not a condition of admission for two (2) of three (3) residents reviewed for arbitration agreements. Residents #27 and #92Findings Include:Review of the facility policy titled Binding Arbitration Agreement revealed under, Policy: This facility asks all residents to enter an agreement for binding arbitration. Additionally revealed under, Policy Explanation and Compliance Guidelines: 1. When the arbitration agreement is presented: a. The resident of his or her representative of his or her right not to sign the agreement as a condition of admission to, or as a requirement to continue to receive care at, this facility. b. The agreement must be presented to the resident and his or her representative in a form and manner that he or she understands, including in a language the resident and his or her representative understands.Review of the admission Packet revealed the Arbitration Agreement was incorporated into the electronic admission packet and presented with other admission documents.Resident #27A telephone interview on 6/10/26 at 2:41 PM, with Resident #27's RR revealed she signed paperwork for the resident's admission to the facility; however, nothing related to the arbitration agreement was explained to her. She stated, No I don't recall anyone explaining anything about resolving disputes. She revealed she was never told the agreement was voluntary and that she did not have to sign it as a condition of admission. The RR stated that if she signed the agreement, she did not recall doing so.Record review of the admission Record revealed the facility admitted Resident #27 on 5/29/26 with medical diagnoses that included Disorder of Thyroid and Manic Episode.Record review of Resident #27's Arbitration Agreement revealed an electronically signed RR signature dated 5/29/26 accepting the arbitration agreement.Resident #92A telephone interview with Resident #92's RR on 6/10/26 at 2:56 PM, revealed he signed the admission paperwork electronically after it was emailed to him. He stated nobody contacted him to determine whether he understood the documents. He stated nobody explained to him that he was signing an arbitration agreement and he asked, What exactly is it? He revealed he was not told anything about arbitration and was not informed the agreement was voluntary. He stated, No, I do not remember signing it.Record review of the admission Record revealed the facility admitted Resident #92 on 4/20/26 with a medical diagnoses that included Traumatic Subdural Hemorrhage.Record review of Resident #92's Arbitration Agreement revealed an electronically signed RR signature dated 4/17/26 accepting the arbitration agreement.An interview with the Director of Care Transition on 6/10/26 at 3:16 PM revealed she was responsible for the arbitration agreement as part of the admission process. She stated approximately 90% of admission packet paperwork was completed electronically through email and that they did not sit down with the majority of RRs and go over the Arbitration Agreement paperwork. She stated she did not contact families before or after sending the paperwork to explain arbitration and simply just informed families that If they have any questions they can reach out to me. She stated families were expected to read the document and contact her if they had questions. She stated she had not had any families refuse to sign the arbitration agreement, stating, They always sign it.An interview with the Corporate Nursing Consultant on 6/10/26 at 3:26 PM, revealed the facility's arbitration agreement was straight forward, and families were expected to read it because the agreement read that it was not required to be signed. After surveyor inquiry regarding the lengthy admission paperwork requiring signatures and whether some individuals may not read every document word for word, she stated, I would never sign anything that I did not read. She stated families had the ability to accept or decline the agreement, which indicated the agreement was voluntary.An interview with the Administrator on 6/10/26 at 3:35 PM, revealed the families were offered the option to complete the paperwork electronically or come to the facility to complete it in person. She stated families were expected to read the document and, if they did not want to sign it, they were not required to do so. She acknowledged the arbitration agreement was not presented separately from the admission paperwork and acknowledged this could be misconstrued by some families as a required admission document if not read fully. She confirmed no one contacted RRs to ensure they had read and understood the agreement, that it was voluntary, or that signing the agreement involved waiving the right to pursue future litigation.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide grooming assistance related to shaving unwanted facial hair for two (2) of (103) residents reviewed for activities of daily living (ADLS) during the initial tour. Residents #11 and #65 Findings Include: Review of the facility policy titled Activities of Daily Living revised 9/15/22 revealed under, Policy: . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care; Additionally revealed under, Policy Explanation and Compliance Guidelines: . 3. Residents who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #11 During an observation on 6/8/2026 at 11:04 AM and again on 6/9/2026 at 2:50 PM, Resident #11 was observed lying in bed with several hairs, approximately one-fourth (1/4) inch in length, were observed on her chin. She stated she does not like hair on her chin, and she sometimes must shave it herself. She stated she had just received her shower and the staff failed to shave her chin hairs. During an interview on 6/9/2026 at 3:02 PM, Certified Nursing Assistant (CNA) #1 revealed Resident #11 is scheduled for a bath on Monday, Wednesday, and Friday. She stated the shower aide should have shaved the resident's chin during her shower. She stated that shaving is an important part of grooming and personal care for residents. During an interview on 6/9/2026 at 3:13 PM, Licensed Practical Nurse (LPN) #1 revealed that the CNAs are responsible for shaving residents during their showers. She stated that making sure residents are shaved helps them feel better about themselves and makes them look clean and neat. She revealed that Resident #11 likes to apply full makeup and have her eyebrows waxed and confirmed that appearance is very important to Resident #11. During an interview on 6/9/2026 at 3:26 PM, the Director of Nursing (DON) confirmed the resident should have been shaved during her bath. Review of the admission Record indicated Resident #11 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease (COPD). Review of the Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/19/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #11 was cognitively intact. Resident #65 An observation and interview on 6/8/26 at 11:09 AM, and again on 6/9/26 at 11:02 AM, revealed Resident #65 lying in bed with long gray facial hair measuring approximately one-half (1/2) inch in length. The resident stated he preferred to be clean shaven and stated he would feel better if he were shaved. He explained he was no longer able to go to the shower room due to his health decline but received bed baths and was not always shaved on those days. The resident stated it was important to him to be well groomed. An observation and interview with CNA #2 on 6/9/26 at 11:08 AM revealed she was assigned to Resident #65. She stated that when the resident received a bed bath, he was shaved by the aide providing care on Tuesday, Thursday, and Saturday. She stated the resident should have been shaved on Saturday and confirmed the length of his facial hair did not appear consistent with having been shaved on that date. An interview with the DON on 6/9/26 at 11:20 AM revealed her expectation was that residents who preferred to be shaved would receive shaving care on their scheduled bath day. She stated the aides were responsible for providing the care and Resident #65 should be shaved according to his preference. Record review of the admission Record revealed the facility admitted Resident #65 on 2/17/26 with a medical diagnosis that included Chronic Obstructive Pulmonary Disease. Record review of the Progress Notes dated 5/20/26 revealed a BIMS summary score of 10, indicating Resident #65 was moderately cognitively impaired.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to follow the resident's comprehensive care plan for grooming preferences for two (2) of (21) care plans reviewed. Resident #11 and Resident #65. Findings include: Record review of the facility policy titled Comprehensive Plan of Care, revised 2/17/25, revealed under, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. Resident #11 Record review of Care Plan Report revealed Shave as indicated/requested. During an observation on 6/8/2026 at 11:04 AM and again on 6/9/2026 at 2:50 PM, Resident #11 was observed lying in bed. Several hairs, approximately one-fourth (1/4) inch in length, were observed on her chin. She stated she does not like hair on her chin, and she sometimes must shave it herself. She stated she had just received her shower. During an interview on 6/9/2026 at 3:02 PM, Certified Nursing Assistant (CNA) #1 revealed Resident #11 is scheduled for a bath on Monday, Wednesday, and Friday. She stated the shower aide should have shaved the resident's chin during her shower. She stated that shaving is an important part of grooming and personal care for residents. During an interview on 6/9/2026 at 3:13 PM, Licensed Practical Nurse (LPN) #1 revealed that the CNAs are responsible for shaving residents during their showers. She stated that making sure residents are shaved helps them feel better about themselves and makes them look clean and neat. She revealed that Resident #11 likes to apply full makeup and have her eyebrows waxed and acknowledged that appearance is important to Resident #11. During an interview on 6/9/2026 at 3:26 PM, the Director of Nursing (DON) confirmed the resident should have been shaved during her bath. An interview with the Minimum Data Set (MDS) Nurse on 6/10/26 at 3:35 PM, revealed the purpose of the resident's care plan was to let staff know the care the resident needed or desired. She acknowledged Resident #11 had a care plan for shaving and the care plan was not followed according to her preferences. Review of the admission Record indicated Resident #11 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease (COPD). Review of the MDS, with an Assessment Reference Date (ARD) of 3/19/2026, revealed under Section C a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #11 was cognitively intact. Resident #65 Record review of Resident #65's Care Plan Report revealed under, Focus: ADLs (activities of daily living): Resident requires assist with ADLs. The care plan further revealed under, Interventions: Shave as indicated/requested. During an observation and interview with Resident #65 on 6/8/26 at 11:09 AM, and again on 6/9/26 at 11:02 AM, Resident #65 was lying in bed with long gray facial hair measuring approximately one-half (1/2) inch in length. Resident #65 stated he preferred to be clean shaven and stated he would feel better if he were shaved. He explained he was no longer able to go to the shower room due to his health decline, but he received bed baths and was not always shaved on those days. Resident #65 stated it was important to him to be well groomed. During an observation and interview on 6/9/26 at 11:08 AM, CNA #2 confirmed Resident #65 had long, unshaven facial hair, which was inconsistent with his preference to be clean shaven. An interview with the MDS Nurse on 6/10/26 at 3:30 PM revealed the purpose of the resident's care plan was to let staff know the care the resident needed or desired. She acknowledged Resident #65 had a care plan for shaving and the care plan was not followed according to his preferences. Record review of the admission Record revealed the facility admitted Resident #65 on 2/17/26 with medical diagnoses that included Chronic Obstructive Pulmonary Disease. Record review of the Progress Notes, dated 5/20/26, revealed a BIMS summary score of 10, indicating Resident #65 was moderately cognitively impaired.

Based on staff interview, record review, and facility policy review, the facility failed to obtain a physician-ordered laboratory test for one (1) of five (5) residents reviewed for medication management and laboratory services. Resident #63.Findings Include:Review of the facility policy titled Diagnostic Services: Lab Tests and X-Ray with a revision date of 11/28/2017, revealed, It is the policy of this facility to provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.Review of Resident #63's Order Details with a Physician's order date of 12/24/2025, revealed under Description: A1C every 3 months (Dec Mar June Sept.)During an interview on 6/10/2026 at 10:00 AM, the Director of Nursing (DON) confirmed Resident #63 had physician orders for a Hemoglobin A1C to be obtained quarterly in December, March, June, and September. The DON acknowledged that the facility had failed to obtain the ordered laboratory test for March. The DON revealed that monitoring the resident's Hemoglobin A1C is important for assessing blood glucose control and ensuring appropriate diabetes management. Record review of the admission Record revealed Resident #63 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/26 revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated Resident #63 was severely cognitively impaired.

Based on observations, staff interview, record review, and facility policy review, the facility failed to ensure reasonable accommodation of resident needs by maintaining access to the call system for one (1) of (21) residents reviewed. Resident #62.Findings include:Review of facility policy titled Call Lights: Accessibility and Timely Response revealed The purpose of this policy is to ensure the facility is adequately equipped with a call light at each resident's bedside, toilet, and bathing facility to allow residents to call for assistance.5. Staff will ensure the call light is within reach of the resident and secured, as needed.During observations on 6/8/2026 at 11:28 AM and again at 2:05 PM, Resident #62 was observed lying in bed with the call light on the floor next to the wall at the head of the bed and out of the resident's reach.During an interview on 6/9/2026 at 3:36 PM, the Director of Nursing (DON) confirmed Resident #62 would not have been able to reach the call light to request assistance while it was lying on the floor. Review of the admission Record indicated Resident #62 was admitted to the facility on [DATE] with medical diagnoses that included Chronic Obstructive Pulmonary Disease (COPD).Review of the Progress Notes *NEW*, with an effective date of 2/24/2026, revealed a Brief Interview for Mental Status (BIMS) summary score of 13, indicating Resident #62 was cognitively intact.

Based on observation, staff and resident interview, record review and facility policy review the facility failed to implement a comprehensive care plan for Activities of Daily Living (ADL) for two (2) of 18 sampled residents. Resident # 57, and #62 Findings Include: Review of the facility's policy titled, COMPREHENSIVE PLAN OF CARE with a revision date of 2/17/2025, revealed under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . Resident #57 Record review of Resident #57's Care Plan Report revealed that he had an ADL self-care performance deficit related to generalized muscle weakness and had interventions that included to assist with all ADL's as needed. An observation on 06/23/25 at 11:15 AM revealed Resident #57 sitting up on the side of his bed with facial hair on his chin, above his upper lip and scattered facial hair was on his bilateral cheeks. Resident #57's hair was greasy and there was a mild body odor observed with facial hair that was approximately one-eighth to one-fourth inch long. An observation and interview on 06/24/25 at 8:05 AM with Resident #57 revealed he had facial hair to his chin, above his top lip and scattered on his bilateral cheeks. His hair was greasy and there was a mild body odor. He revealed that his bath days were Tuesdays, Thursdays, and Saturdays and they forgot about him some days. Resident #57 revealed that he did not get a bath this past Saturday and that no one came in and offered to give him a bath. He revealed that he had not had a bath since Thursday, four days ago, and he felt dirty. Resident #57 revealed that getting a good bath always made him feel better and stated, I don't feel clean when I miss my bath. He also revealed that he didn't like to have facial hair and wanted it shaved. An observation and interview on 06/24/25 at 8:25 AM with Licensed Practical Nurse (LPN) #1, revealed that the hospice aid came in the facility on Tuesdays and Thursdays to give Resident #57 his bath. During this observation, Resident #57 told LPN #1 that he had not gotten his bath on Saturday. LPN #1 confirmed that Resident #57 had greasy hair, a mild body odor, and facial hair and revealed that this was a concern. She stated, I definitely wouldn't want to go without a bath since Thursday and revealed that she would make sure he got his bath today. Record review of Resident #57's admission Record revealed an admission date of 06/19/23 and that he had diagnoses that included Chronic Obstructive Pulmonary Disease, Unspecified Heart Failure, and Need for Assistance with Personal Care. Record review of Resident #57's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/30/25 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated that he was cognitively intact. Resident #62 An observation and interview with Resident #62, on 6/24/25 at 9:15 AM, revealed she had not received a bath this week and stated, The aide on night shift told me that they no longer give baths on night shift. She then stated, I always take my baths on Monday, Wednesday, and Friday nights. Record review of the Care Plan Report for Resident #62 revealed: Requires assists with ADL'S due to diagnosis of severe protein calorie malnutrition, polyneuropathy, chronic pain, and depression. She has Limited Range of Motion (LROM) to upper and lower extremities and requires staff assists with ADL's. Interventions included, Assist with ADL'S as needed . During an interview on 6/24/25 at 2:07 PM with the Minimum Data Set (MDS) Coordinator, she confirmed that care plans were established to guide staff in providing necessary care. She stated, The care plan is in place provide appropriate care for each resident. Record review of Resident #62 admission Record revealed the resident was admitted [DATE] with diagnosis of Polyneuropathy. Record review of the MDS, Section C, with an ARD of 6/15/25, revealed a BIMS score of 15, indicating Resident #62 is cognitively intact. .

Based on observation, staff and resident interview, record review and facility policy review the facility failed to utilize Personal Protective Equipment (PPE) for a resident (Resident #188) who was under contact isolation on one (1) of three (3) survey days. Findings Include: Review of the facility policy Infection Prevention and Control with revision date of 02/17/25 revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines . An observation on 06/23/25 at 9:36 AM, revealed Certified Nursing Assistant (CNA) #1 enter Resident #188's room to answer her call light without utilizing Personal Protective Equipment (PPE). There was Contact Precaution signage on her door and a three-drawer cart outside of her room in the hall with gowns, gloves, masks and shoe covers inside. An interview on 06/23/25 at 9:40 AM with CNA #1, revealed that she went into Resident #188's room to answer her call light and did not provide care. She revealed that they did not have to wear gowns and gloves if they did not provide care. CNA #1 confirmed that Resident #188 was on contact precautions for Clostridium Difficile (C-Diff) and confirmed the contact precautions signage on the door. She revealed that the purpose of wearing gowns and gloves with a resident on contact precautions was to prevent the spread of infection and agreed that she should have worn gloves and a gown prior to entering her room. CNA #1 confirmed that she confused Enhanced Barrier Precautions (EBP) with Contact Precautions and stated, It's a little different when they are on contact precautions. She revealed that when a resident was on EBP, they could answer the call lights without having to dress out in PPE but with contact precautions, they were supposed to dress in appropriate PPE before entering the room. An interview on 06/23/25 at 9:45 AM with Registered Nurse (RN) #1, revealed that Resident #188 was on contact precautions for C-Diff. She revealed that she came from the hospital with this and had been in isolation since admission. She revealed that there was a small cart outside of her door and staff were supposed to apply gloves and gowns before entering her room to prevent the spread of infection. RN #1 revealed that the resident had completed her antibiotics and was supposed to be out of isolation, but they extended it due to her continued diarrhea. An interview on 06/23/25 at 2:05 PM with Resident #188 revealed that she spent nine days in the hospital with C-Diff prior to coming to the facility. She revealed that she still had diarrhea, but it had slowed down. Resident #188 revealed that most staff members wore gowns and gloves when they came into her room but some of them did not. An interview on 06/24/25 at 1:35 PM with Infection Preventionist (IP), revealed that Resident #188 had C-Diff and was on contact precautions. She revealed that there was a small cart placed outside of her room and staff were supposed to apply gowns and gloves before entering the room. She revealed that C-DIFF was contagious and by not wearing the proper PPE, the staff could cause the spread of infection. Record review of Resident #188's admission Record revealed an admission date of 06/10/25 and that she had diagnoses that included Enterocolitis due to Clostridium Difficile, Retention of Urine, and Unsteadiness on Feet. Record review of Resident #188's admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/17/25 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that she was cognitively intact. Record review of Resident #188's Order Summary Report revealed orders for Contact Precautions related to Enterocolitis Due To Clostridium Difficile. Record review of Resident #188's Care Plan Report initiated on 06/11/25 revealed that she had C. Difficile with interventions that included Contact Precautions.

Based on observation, staff and resident interviews, record review and facility policy review the facility failed to ensure resident's requiring assistance with Activities of Daily Living (ADL) were given care as they needed to maintain hygiene for two (2) of 18 sampled residents. Resident #57, and #62 Findings include Review of the facility's policy titled, Activities of Daily Living (ADL) with a revision date of 9/15/2022, revealed under Policy: Based on the resident's comprehensive assessment and consistent with the resident's needs and choices, the facility will ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care .Policy Explanation and Compliance Guidelines .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . Resident #57 On 06/23/25 at 11:15 AM an observation of Resident #57 revealed facial hair on his chin, above his upper lip and on his bilateral cheeks. Resident #57's hair was greasy and there was a mild body odor. His facial hair was approximately one-eighth to one-fourth inch long. On 06/24/25 at 8:05 AM an observation and interview with Resident #57 revealed he had facial hair to his chin, above his top lip and scattered on his bilateral cheeks. His hair was greasy and there was a mild body odor. He stated that his bath days were Tuesdays, Thursdays, and Saturdays and they forgot about him some days. Resident #57 revealed that he did not get a bath this past Saturday and that no one came in and offered him a bath. He revealed that he had not had a bath since Thursday, four days ago, and he felt dirty. Resident #57 revealed that getting a good bath always made him feel better and stated, I don't feel clean when I miss my bath. He also revealed that he didn't like to have facial hair and wanted it shaved. On 06/24/25 at 8:25 AM an observation and interview with Licensed Practical Nurse (LPN) #1, revealed that the hospice aid came in on Tuesdays and Thursdays to give him his baths. During this observation, Resident #57 told LPN #1 that he had not gotten his bath on Saturday. LPN #1 confirmed the facial hair, mild body odor and stated that this was a concern. She stated, I definitely wouldn't want to go without a bath since Thursday and revealed that she would make sure he got his bath today. On 06/24/25 at 10:40 AM an observation and interview with Certified Nursing Assistant (CNA) Supervisor, revealed that Resident #57's scheduled bath days were Tuesdays, Thursdays and Saturdays. She revealed that he was on hospice and that their CNAs came in on Tuesdays and Thursdays and that the facility CNAs were responsible for his baths on all other days. During this observation, Resident #57 told CNA Supervisor that he did not get his bath on Saturday and that no one had offered him a bath or shower. He also told the CNA Supervisor that he used to get his baths on Tuesdays, Thursdays, and Saturdays but he hadn't been getting them on Saturdays lately. CNA Supervisor revealed that Resident #57 was cognitively intact and if he said he hadn't been getting his showers on Saturdays lately, he hadn't. Record review of Resident #57's admission Record revealed an admission date of 06/19/23 and that he had diagnoses that included Chronic Obstructive Pulmonary Disease, Unspecified Heart Failure, and Need for Assistance with Personal Care. Record review of Resident #57's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 04/30/25 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated that he was cognitively intact. Resident #62 On 6/24/25 at 9:15 AM, an observation and interview with Resident #62, revealed Resident #62 had not received a bath this week. She stated, The aide on night shift told me that they no longer give baths on night shift. I always take my baths on Monday, Wednesday, and Friday nights. During an interview with CNA #2 on 6/24/25 at 9:17 AM, she stated Resident #62 did not have a bath on night shift, and she usually gets her baths on Monday, Wednesday, and Fridays nights, and has for as long as she can remember. Record review of the chart did not reveal any notes or documentation of Resident #62 refusing a bath. During an interview on 6/24/25 at 11:15 AM, with the Infection Preventionist, she stated, Resident #62 gets her baths at nights because she is private and doesn't want to get her bath during the day. She has been getting her baths at night for a long time. During an interview with on 6/24/25 at 2:00 PM with the Director of Nursing, she confirmed Resident #62 did not have a bath on Monday night. She stated, (Proper Name of Resident #62) gets a bath at night on Mondays, Wednesdays, and Fridays. I do not know of any reason why she has not received a bath if she wanted one. Record review of Resident #62 admission Record revealed the resident was admitted [DATE] with diagnosis of Polyneuropathy. Record review of Resident #62's MDS, Section C, with an ARD of 6/15/25, revealed a BIMS score of 15, indicating Resident #62 is cognitively intact.

Based on observation, resident and staff interview, record review and facility policy review the facility failed to ensure an environment that is free from accident hazards and the safety of a resident during care for one (1) of 18 sampled residents. Resident #31 Findings Include: Review of the facility policy titled, INCIDENT AND ACCIDENT REPORTING, with a revised date of 9/05/2023, states It is the policy of this facility that everything possible should be done to avoid accidents or incidents involving patients .Proper reporting helps correct the current incident and prevent future incidents like it . An observation and interview on 06/23/25 at 10:30 AM with Resident #31, revealed a bandage on her right arm. Resident #31 stated, The aide scratched me with her nails when she was giving me care. During an interview with Resident #31's daughter on 6/23/25 at 10:35 AM at the facility, her daughter stated that she noticed the bandage on her arm last week and stated her mother told her someone scratched her, and she saw the bandage on her right arm. Record review 6/23/25 3:21 PM, revealed no order or note regarding skin tear to right arm. Record review of the facility skin assessment dated [DATE] revealed, Right antecubital; Right forearm; Skin tear identified. New orders noted. Resident noted with skin tear to right forearm. Resident states, An aid was turning me and her nails scratched me. Treated with Xeroform gauze daily and as needed (PRN). Oriented to place. Oriented to time. During an interview on 6/24/25 at 11:38 AM, with the Wound Care Nurse, she confirmed that she was unaware of the skin tear on Resident #31's right arm until this morning, but that she had assessed the area, and new orders were given for care of the area. During an interview on 6/24/25 at 3:08 PM, with the Director of Nursing, she confirmed that the incident was not reported to her but that she had spoken with the wound nurse and that new orders were given for care of the skin tear/scratch area to the resident's forearm. She stated, We are investigating this, I am not aware of how this incident occurred and who placed a bandage on her right arm, but confirmed that there was an injury to the resident's forearm. Record review of Resident #31's admission Record revealed the resident was admitted [DATE] with diagnoses that included Parkinson's Disease. Record review of Resident #31's Minimum Data Set (MDS), Section C, with an Assessment Reference Date (ARD) of 4/24/2025, revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident is cognitively intact.

Based on staff interview, record review, and facility policy review, the facility failed to develop a baseline care plan to include the initial plan of care for delivery of services and to promote continuity of care and communication for facility staff for a newly admitted resident with a known history of eloping from home prior to admission for one (1) of three (3) care plans for residents who were at risk for elopement. Resident #1 Resident #1 left the facility unnoticed and unsupervised at an unknown time on 04/26/24 and was discovered by the local police department at a nearby business approximately 75 yards from the facility. This business notified the police at 5:38 PM and the resident was found by police at 6:01 PM and was returned to the facility. Resident #1 was last observed on 4/26/24 at 4:38 PM in his room, prior to the elopement. Resident #1 was transported back to the facility and was assessed to have no noted injuries or complaints of pain or discomfort. The State Agency (SA) identified an Immediate Jeopardy (IJ) which began on 4/26/24 when Resident #1 eloped from the facility unsupervised and undetected by facility staff. The facility's failure to provide supervision placed Resident #1 and other residents at risk for wandering and elopement, in a situation which was likely to cause serious injury, serious harm, serious impairment, or death. IJ existed at: 42 CFR 483.21(a)(1) Baseline Care Plans -F655, Scope and Severity J Findings Include: Review of the facility policy titled, Baseline Care Plan with an effective date of 9/30/23 revealed Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to prove effective and person-centered care of the resident that meets professional standards of quality care .Policy Explanation and Compliance Guidelines: .2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment hospital transfer information physician orders and discussion with the resident and resident representative, if applicable . b. Interventions shall be initiated that address the resident's current needs including: i. Any health and safety concerns to prevent decline or injury. ii. Any identified needs for supervision, behavioral interventions . Record review of Resident #1's medical record revealed there was not a baseline care plan developed to address elopement risk, monitoring or supervision needed for Resident #1. Record review of Resident #1's referral (History and Physical) to the facility dated 4/26/24 revealed the resident had an Altered mental status with recent diagnoses of Dementia and Alzheimer's with worsening Frontotemporal Dementia. Family stated that the resident left his house yesterday and was picked up by the PD (Police Department) three miles away from home and has apparently been having hallucinations. Record review of Resident #1's Elopement Evaluation was completed by Licensed Practical Nurse (LPN) #2 on 4/26/24 at 3:53 PM and revealed that the resident had a history of elopement while at home, wandering behavior with a goal directed pattern, wandering behavior that was likely to affect the safety of or well-being of self/others and had not accepted the situation of being admitted to the facility. An interview on 5/1/24 at 1:27 PM, with the Director of Nurses (DON) confirmed that Resident #1 was known to be an elopement risk when he was admitted on [DATE]. She confirmed that the resident had not had all of his assessments completed or a care plan done when he went missing. An interview on 5/1/24 at 1:34 PM, with Certified Nurse Assistant (CNA) #1 stated that she was Resident #1's CNA when he was admitted to the facility on [DATE]. She revealed that a resident's care plan tells what they need done, but she is not sure she has access to see them, and no one had told her that Resident #1 was an elopement risk. She stated if she had known she would have watched him more frequently. An interview on 5/1/24 at 1:48 PM with LPN #1 confirmed a care plan is supposed to let the staff know what care the resident needs, but she is pretty sure this resident did not have one. An interview on 5/1/24 at 2:48 PM with Registered Nurse (RN) #1 confirmed she was the Unit Manager for the unit where Resident #1 was admitted on [DATE]. She stated that she was not sure if the resident had a care plan completed before he went missing. An interview on 5/1/24 at 3:39 PM, with LPN #3 revealed she was present when Resident #1 was admitted on [DATE] and that the Minimum Data Set (MDS) nurses were not there that day. She confirmed that she did not develop a baseline care plan for the resident. An interview on 5/2/24 at 10:40 AM, with RN #2 and RN #3 revealed they were the MDS nurses and were responsible for putting in the resident's care plans. They both admitted they were not at work on Friday 4/26/24 and therefore was not aware of Resident #1's elopement risk and wandering history. RN #3 revealed that sometimes the nurses would put care plans in if they were not there or were not going to be back to work within 48-72 hours. RN #2 revealed the purpose of the care plan was to let staff know a resident's particular care needs and stated that if she had been at work on Friday 4/26/24 then she might have put the care plan in. An interview on 5/2/24 at 10:55 AM, with LPN #4 revealed she received the admitting orders from the hospital, confirmed with the doctor and then she put them in the computer. She confirmed that was all she did and did nothing about developing a baseline care plan to address his elopement risk and need for immediate and frequent supervision. She stated she did not know the resident was an elopement risk or a wanderer. Record review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] with no medical diagnoses listed. The facility provided an acceptable Removal Plan on 5/2/24. Review of the facilities Removal Plan revealed the facility took the following actions to remove the IJ: Immediate Actions: 1. Resident #1 was admitted to the facility from acute care hospital on April 26, 2024. He arrived at the facility via this facility's transportation at 3:21 pm. Resident #1 was last seen by a staff member at 4:38 pm when he received his dinner tray. The Police Department received a call of a suspicious person at 5:38 pm. Resident eloped via a window in the room. The facility was made aware of the Immediate Jeopardy on 5/2/2024 at 11:42 am. 2. Resident #1 was placed on one-on-one supervision until transferred to hospital for geriatric psychiatric services on 4/27/2024 at 7:45am. 3. Policy committee reviewed the Elopement and Missing Resident policies on 5/2/2024 at 12:50 pm, no changes were made. 4. Directive Inservice was initiated on 5/2/2024 at 2:00 pm by Licensed Nursing Home Administrator from an outside facility. Content of in-service Elopement and Missing Resident policies. Identifiers and Communication for High-Risk Elopement Residents. Identifiers include Elopement Evaluation User Defined Assessment, resident care profile on the Point Click Care dashboard, the Point of Care, and the Elopement Binders. No staff will be allowed to work until in-serviced. 5. Director of Nursing conducted 100% care plan audit on 5/2/2024 of all residents with elopement risk, 8 total. No issues found. Audit completed at 1:20 pm. 6. The Maintenance Director conducted 100% audit of all resident room windows to ensure they are secure on 5/2/2024, all windows are secure. 7. State Department of Health was notified of elopement on 4/26/2024 at 6:51 pm via complaint hotline. Attorney General notified on 5/2/2024 via web portal. Police Department had been notified at 5:38pm by neighboring business and were with resident. 8. Per facility protocol all admissions are assessed for elopement risk, all new admissions will have a baseline care plan within 48 hours of admission, residents who are at high risk for elopement are photographed and added to the elopement binders located at the reception desk and both nursing stations, an order is added for nursing to monitor for elopement, high risk elopement residents are added to the Point of Care for hourly monitoring. A review of high-risk elopement residents is completed weekly during Facility High Risk Meetings to ensure identifiers are present. New Implementations: Elopement risk has been added to the resident care profile on Point Click Care dashboard. Elopement risk has been added to the Point of Care Kardex. The facility has implemented secure conversation via electronic system to be utilized to notify staff of all admissions including those who are high risk for elopement. All new implementations were added on 5/2/2024. 9. Emergency Quality Assurance meeting held via phone conference on 4/26/2024 at 6:30 pm. Physician Assistant, Administrator, Director of Nursing, Staff Coordinator, and Quality Assurance/Infection Preventionist Nurse and Social Services. The unusual occurrence was discussed, all events before, during and after occurrence were reviewed. Committee members placed Resident #1 on one-on-one monitoring until transferred to a hospital. 10. All corrective actions to remove the IJ was completed on 5/2/2024 and the facility alleges the IJ was removed on 5/3/2024. The SA validated the facility's Removal Plan/Corrective Action on 5/6/24: The SA validated through interviews and record review that Resident #1 was admitted to the facility from an acute care hospital on April 26, 2024. He arrived at the facility via this facility's transportation at 3:21 PM. Resident #1 was last seen by a staff member at 4:38 PM when he received his dinner tray. The Police Department received a call of a suspicious person at 5:38 PM. Resident eloped via a window in the room. The facility was made aware of the Immediate Jeopardy on 5/2/2024 at 11:42 AM. The SA validated through interviews and record review that Resident #1 was placed on one-on-one supervision until transferred to hospital for geriatric psychiatric services 4/27/2024 at 7:45 AM. The SA validated through interviews and record review that the policy committee reviewed the Elopement and Missing Resident policies on 5/2/2024 at 12:50 PM, no changes were made. The SA validated through interviews and record review that Directive Inservice was initiated on 5/2/2024 at 2:00 PM by Licensed Nursing Home Administrator from outside facility. Content of in-service Elopement and Missing Resident policies. Identifiers and Communication for High-Risk Elopement Residents. Identifiers include Elopement Evaluation User Defined Assessment, resident care profile on the Point Click Care dashboard, the Point of Care, and the Elopement Binders. No staff will be allowed to work until in-serviced. The SA validated through interview and record review that the Director of Nursing conducted 100% care plan audit on 5/2/2024 of all residents with elopement risk, 8 total. No issues found. Audit completed at 1:20 PM. The SA validated through interview and record review that the Maintenance Director conducted 100% audit of all resident room windows to ensure they are secure on 5/2/2024, all windows are secure. The SA validated through interview and record review that the State Department of Health was notified of the elopement on 4/26/2024 at 6:51 PM via complaint hotline. The Attorney General was notified on 5/2/2024 via web portal. The Police Department had been notified at 5:38 PM by neighboring business and were with the resident. The SA validated through interview and record review that per facility protocol all admissions are assessed for elopement risk, all new admissions will have a baseline care plan within 48 hours of admission, residents who are at high risk for elopement are photographed and added to the elopement binders located at the reception desk and both nursing stations, an order is added for nursing to monitor for elopement, high risk elopement residents are added to the Point of Care for hourly monitoring. A review of high-risk elopement residents is completed weekly during Facility High Risk Meetings to ensure identifiers are present. New Implementations: Elopement risk has been added to the resident care profile on Point Click Care dashboard. Elopement risk has been added to the Point of Care Kardex. The facility has implemented secure conversation via electronic system to be utilized to notify staff of all admissions including those who are high risk for elopement. All new implementations were added on 5/2/2024. The SA validated through interview and record review that there was an emergency Quality Assurance meeting held via phone conference on 4/26/2024 at 6:30 PM. Physician Assistant, Administrator, Director of Nursing, Staff Coordinator, and Quality Assurance/Infection Preventionist Nurse and Social Services. The unusual occurrence was discussed, all events before, during and after occurrence were reviewed. Committee members placed Resident #1 on one-on-one monitoring until transferred to a hospital. The SA validated through observation, interviews, record reviews, and facility policy review that all corrective actions were completed on 5/2/24 and the facility alleged removal of the Immediate Jeopardy (IJ) on 5/3/24.

Based on observation, staff and family interview, record review and facility policy review the facility failed to supervise and prevent the elopement of a resident who was identified at risk for elopement as evidenced by the resident leaving the facility unnoticed and unsupervised and walking 75 yards to a local business for one (1) of three (3) at risk residents reviewed for elopement. Resident #1 Resident #1 was admitted to the facility on [DATE] at 3:21 PM. Resident #1 left the facility unnoticed and unsupervised at an unknown time on 4/26/24 and was discovered by the local police department at a nearby business. This business notified the police at 5:38 PM and the resident was found by police at 6:01 PM and was returned to the facility. Resident #1 was last observed on 4/26/24 at 4:38 PM in his room, prior to the elopement. Resident #1 was transported back to the facility and was assessed to have no noted injuries or complaints of pain or discomfort. The facility's failure to provide supervision placed Resident #1 and other residents at risk for wandering and elopement, in a situation which was likely to cause serious injury, serious harm, serious impairment, or death. The State Agency (SA) identified an Immediate Jeopardy (IJ), and Substandard Quality of Care (SQC) which began on 4/26/24 when Resident #1 eloped from the facility unsupervised and undetected by facility staff. IJ and SQC existed at: 42 CFR 483.25(d)(1)(2) Accidents -F689, Scope and Severity J Findings Include: Review of the facility policy titled, Elopement with a revision date of 5/1/15 revealed Policy: Residents will be assessed for elopement risk for admission and throughout their stay by the interdisciplinary care planning team .Definition: Elopement occurs when a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Prevention .Residents determined to be at risk for elopement will be monitored by staff for elopement signs and/or attempts, and interventions will be included in their comprehensive plan of care to address the potential for elopement Elopement Prevention Strategies .Room placement for easy observation. React to statements such as, I want to go home .Never assume everyone knows the resident is a wanderer, make it clear to all staff involved in the resident's care, even for a short period of time. Record review of Resident #1's referral (History and Physical) to the facility dated 4/26/24 revealed the resident had an Altered mental status with recent diagnoses of Dementia and Alzheimer's with worsening Frontotemporal Dementia. Family gave most of the history due to the resident was unable to answer questions. Family stated that the resident left his house yesterday and was found by PD (Police Department) three miles away from home and has apparently been having hallucinations. Record review of the facility investigation dated 4/26/2024 and titled Unusual Occurrence revealed, Resident is a .male with diagnosis of Frontotemporal Dementia .Resident was living at home prior to hospitalization , resident had a history of wandering off from home and his daughter stated she could no longer provide the care he needed. He had left home and walked 3 miles per hospital history and physical .Resident raised the window of the room and knocked out the screen .Staff on the hall going room to room looking for resident . Record review of the Police Department INCIDENT REPORT dated 4/26/24 at 17;38 (5:38 PM) revealed On Friday, April 26, 2024, I (Proper name of officer) responded to a call of a suspicious person outside (Name of local business) .Upon arrival at the business I noticed an elderly man .The male subject gave only a last name but couldn't give me his first name .seemed to be very disoriented . Record review of Resident #1's Elopement Evaluation was completed by Licensed Practical Nurse (LPN) #2 on 4/26/24 at 3:53 PM that indicated the resident had a history of elopement while at home, express the desire to go home, wandering behavior with a goal directed pattern, wandering behavior that was likely to affect the safety of or well-being of self/others and had not accepted the situation of being admitted to the facility. Record review of Resident #1's Order Summary Report with active orders as of 5/1/2024 revealed an order dated 4/26/2024, Monitor for Elopement every shift. Medical diagnoses included Heart Failure and Alzheimer's disease with late onset. An interview on 5/1/24 at 1:05 PM, with the Administrator revealed that Resident #1 was admitted in the afternoon of 4/26/24 and that she was aware that the resident was an elopement risk based on the referral received from the hospital. She revealed that the resident was upset about being in the facility and was mad at his daughter when he got here. She stated that they took his picture and put it in the elopement binder that is kept at each nurse's station and the front desk. The doors to the outside are code locked and the Unit Manager is supposed to show the residents picture to the staff and educate the staff on the resident who is an elopement risk. She stated that this is their protocol for residents that are an elopement risk. She revealed that the resident did not have a roommate when he was admitted around 3:30 PM and his dinner tray was taken to him in his room around 4:38 PM. She confirmed that this was the last time the staff saw him. She revealed that staff were up and down the hall during that time passing trays and when the aide went back in to get his dinner tray, the resident was not in there, but about 50% of the meal had been eaten. Certified Nurse Assistant (CNA) #1 assumed the resident was in the bathroom, so she went to get some supplies to help clean him up and when she got back, she knocked on the bathroom door. That is when she realized he was not in there. This was around 5:49 PM. CNA #1 immediately notified the medication nurse LPN #1 and they searched other resident rooms then called a code for an elopement resident. When they did this, staff members went through different exit doors and noticed during their walk around the building that the resident's room had the window screen laying on the ground, but his window blinds were down. They had not noticed that the window was open. There was a neighbor standing outside his home next door that pointed in the direction the resident had gone so staff members followed that direction that led to a business down a hill, below the facility that faced a main road. When the staff got to the business, they saw Resident #1 sitting on top of a garbage can and he was talking with a police officer. When the police were interviewed by staff, they revealed that they had received a call about a suspicious person being at the business around 5:38 PM. She revealed she was able to get the timeline for this incident by watching the film from the hall where Resident #1's room was, but the video erases after 5 days. She stated that they determined that the resident got out of his room by raising his window and kicking out the screen and going down the hill to the business.She revealed when they have residents admitted that are an elopement risk, they put the resident's information in the elopement binders with photos and notify everyone. She stated, He was not walking in the hall or exit seeking. She stated that after they got the resident back to the facility, she referred the resident to Geri-psych and staff remained with the resident one on one until he was transferred to Geri-psych the following morning on 4/27/24. She stated that when the resident was admitted that they did not watch him anymore than they do anyone else that is an elopement risk, which is hourly. An interview on 5/1/24 at 1:27 PM, with the Director of Nurses (DON) confirmed that any resident that is an elopement risk gets their information and picture put in the elopement binder, staff are supposed to be made aware, and they do not do any increased assessments on new admits with an elopement risk. She confirmed that the resident was admitted around 3:30 PM on 4/26/24 and was last seen around 4:30 PM on 4/26/24. She stated that the facility does not have an alarm system such as wander guard. An interview on 5/1/24 at 1:34 PM, with CNA #1 revealed she works the 7 AM-7 PM shift and was the only aide working on the unit where Resident #1 was admitted on the afternoon of 4/26/24. She revealed that no one told her that the resident was an elopement risk, but that they usually do. She knew the resident must have dementia because he had told her that he knocked out a famous boxer. She confirmed that she took the resident his dinner tray about 4:30 PM and the resident stated that he didn't want to be there and was not going to be there long. She confirmed that when she went back to pick up the dinner tray around 5:50 PM, she saw that he had eaten about half of his meal and thought he was in the bathroom. She left to go get a brief and when she came back, he still was not in the room, so she knocked on the bathroom door and that is when she realized he was not in there. She notified LPN #1, who was her manager that day, and they started looking up and down the hall and in other resident rooms for him. When they did not find him, they called a Code and that is when the staff started looking outside and someone saw the screen to his window lying on the ground. She stated that she did not notice that his window was up because his window blinds were still down. She said that a neighbor next door to the facility yelled and pointed out that the resident had gone in the direction of the business down below the hill from the facility and that is when I saw cop cars there. She stated she went down the hill and found the resident there talking with the police and she informed them that he was a resident at the facility, so they drove them back to the facility. She said when they got back to the facility they put the resident on 1:1 observation. She stated she is aware of the elopement binder and residents are normally put on our smart charting to chart about every shift if they are an elopement risk, but they never told me he was. An interview on 5/1/24 at 1:48 PM, with LPN #1 confirmed that she was the medication nurse on the unit that Resident #1 was admitted to on the afternoon of 4/26/24 around 3:30 PM. She stated that Registered Nurse (RN) #1 was the Unit manager and had told her that the resident was very confused and had been found wandering in another state. She revealed that when the resident got to the facility he was confused and thought they had been in the military together. She stated his blood pressure (BP) was a little high so as soon as his BP meds were due, I gave them to him and that was around the time he got his dinner tray. She stated that when she gave him his medicine the resident stated, Those are the last pills I'm taking from you and started talking about us being in the military again. She confirmed that the resident had not been walking the halls or trying to exit seek. She admitted to going into the therapy department after administering medications to talk to the therapist, which is across the hall from the nurse's station. At some point, CNA #1 came and told me that she could not find the resident. She confirmed that they checked all rooms and then called a Code. Staff went out the back and the front and that is when we saw his screen from his room window lying on the ground. She confirmed that the staff could not tell that the residents window was up because the blinds were still down. She stated that as far as she knows the windows do not lock in the rooms, so a resident could just raise the window and get out. She confirmed that the resident was found at a car detailing business below the facility. She confirmed that the business was on the main road that runs through the town, so it is a busy road. She revealed the resident was in a room at the back of the building, not visible from the nurse's station, did not have a roommate, was wearing a shirt and pants with tennis shoes and the weather was good, it had not rained for a few days' prior. She confirmed that when they got him back into the facility, he did not have any injuries, did not say much, and was put on 1:1 observation until he went to Geri-psych the next day. She confirmed that the CNA's are supposed to check hourly in their smart charting on the computer and the LPN's check every shift for those residents that are an elopement risk but was not sure if she had documented on the resident before he went missing. She stated, I want to say they had made his picture and put it in the elopement binder, but I am not sure. She revealed that the CNA's would find out a resident is an elopement risk by either getting a report from me or the Unit Manager. She stated that she thought she told CNA #1 that he was a wanderer but was not sure and confirmed that CNA #1 was the only aide working on the unit where the resident was admitted . She admitted that she did not tell anyone that the resident had stated that those would be the last pills he would be taking from her. Record review of Resident #1's April 2024 Electronic Medication Administration Record (EMAR) indicated that the LPN had not documented on the resident during the 12 hour day shift on 4/26/24. An observation and interview on 5/1/24 at 2:05 PM, with the Administrator confirmed Resident #1's had been in a room at the back of the building, approximately 100 feet from the nurses station. The window in the room was approximately 4 feet wide by 4 feet tall and would raise approximately 2-3 feet, with one lock and no window stopper. There was a fenced area that had an opening at one end that led to both the parking lot on the east side of the building and the back grassed area behind the facility. The parking lot had approximately 5 cars parked at this time and the grassed area behind the facility was a sloped hill leading to a wooded area along the property line that is approximately 6-10 feet drop with randomly cleared areas. Those cleared areas led to the business where the resident was found sitting on the main road that runs through the town. The approximate length from the facility to the business where the resident was found is 75 yards. The Administrator revealed that one of the residents told her on 4/29/24 that she hoped the maintenance man was ok from when he rolled down the hill on Friday. She stated that she can't swear that was Resident #1 that she was referring to, but she knows it was not the maintenance man. She confirmed that the resident did not have any scratches or injuries when they got him back to the facility. An interview on 5/1/24 at 2:39 PM, with LPN #2 revealed she is the assistant Unit Manager for the unit where Resident #1 was admitted on [DATE] at 3:21 PM. She admitted that she called the hospital and got a report on the resident before he was admitted and was told that the resident had walked across six (6) counties prior to coming to the facility. She stated that after she got the report from the hospital, she told the Unit Manager/Registered Nurse (RN) #1 that the resident was a wanderer but does not recall if she gave all of the details about him walking across 6 counties. She revealed that when the resident was admitted to the facility, that his daughter confirmed that he had walked across 6 counties to another state that was approximately 93 miles from his home and that is what put him in the hospital. She confirmed that the resident was extremely confused and agitated when he was admitted and kept stating that we did not tell him where he was going and that he wanted to go to his home. She admitted that LPN #1 was notified that the resident was a wanderer but that she did not tell the CNA's and did not tell them the report of the resident walking across 6 counties, because she thought they knew. An interview on 5/1/24 at 2:48 PM, with RN #1 confirmed she was the Unit Manager for the unit that Resident #1 was admitted to. She revealed she was present when Resident #1 was admitted to the facility, and she knew that report from the hospital was that he was a wanderer. RN #1 revealed that the resident got an elopement assessment, and they followed protocol by monitoring every 2 hours with rounds, LPN's document, the facility doors stay locked. She revealed that she was not sure she had ever seen the elopement binder and stated she had been at the facility for about 6 months, and she is sure they have probably shown it to her before. She stated that she normally gives reports to the LPNs with the CNA's present, and she thinks she told them that the resident was an elopement risk and that his daughter said he liked to walk. She revealed that she did not know that the resident had told other staff members that he did not want to be there. An interview on 5/1/24 at 2:55 PM, with Resident #1's Resident Representative confirmed that the resident had wandered away from his home several times and that she just could not keep him at home. She stated that the resident had worsened in the last few weeks and had walked away from home so far that he had to be picked up by police and was seeing children in the trees. She stated he ended up in the hospital and we just did not know what we were going to do with him, so we were so thankful when this facility agreed to take him. She stated that she told staff at the facility about his wandering away from home so much and so far, including the nurses and the Social Worker. She revealed that the Social Worker had called her Friday 4/26/24 and told her that he had got out of the facility, but they had got him back and he did not have any injuries. She stated that the Social Worker called her back later and told her that staff were going to sit with the resident 1:1 and had been referred to Geri-psych for the next day and I agreed. She said that the Social Worker had called her Monday 4/29/24 and told her she was not sure if he could come back to the facility and stated she did not know what they were going to do. An interview on 5/1/24 at 3:17 PM, with Social Services confirmed that she got a referral for Resident #1 from the hospital, and she gave it to the DON and the Administrator and was made aware by the DON that the resident had gotten out of his house and wandered off, but they approved his admission. She stated that when the resident was admitted he was very upset about being at the facility and was mad at his daughter. She admitted that she found out more information from his daughter about him getting out of the house and wandering off when he was admitted to the facility on [DATE] at 3:21 PM. She revealed that she immediately went and told the Administrator and the DON, and they started getting his information in the elopement binder. She revealed that she had just left the facility when she got a call that the resident was out of the building. She stated that when they found the resident and got him back to the facility that she called the resident's daughter and told her what had happened. She also informed her that the resident had been referred to Geri-Psych for the next day, that staff would be 1:1 with him until he was transferred, and she agreed. She stated that she had told the family that the resident needs a lock down unit. She revealed she still did not know if they were going to take him back, because she has not been told by the Administrator. She stated, He wouldn't be safe here. An observation on 5/2/24 at 10:10 AM, of the room windows for the nine residents listed in the elopement binder revealed that all windows were approximately 4 feet wide by 4 feet tall and some had window stoppers which were L brackets screwed into the window frame that would prevent the window from being raised up all the way. This observation revealed that four (4) of the resident's windows had no window locks or window stoppers. Record review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE] with no medical diagnoses listed. Review of the past weather report for the town where the facility is located revealed that on 4/26/24 the high temperature was 82 with a low of 73 and no rain. This report revealed there had been no rain for 5 days prior to 4/26/24. The facility provided an acceptable Removal Plan on 5/2/24. Review of the facilities Removal Plan revealed the facility took the following actions to remove the IJ: Immediate Actions: 1. Resident #1 was admitted to the facility from acute care hospital on April 26, 2024. He arrived at the facility via this facility's transportation at 3:21 PM. Resident #1 was last seen by a staff member at 4:38 PM when he received his dinner tray. The Police Department received a call of a suspicious person at 5:38 pm. Resident eloped via a window in the room. The facility was made aware of the Immediate Jeopardy on 5/2/2024 at 11:42 AM. 2. Resident #1 was placed on one-on-one supervision until transferred to hospital for geriatric psychiatric services 4/27/2024 at 7:45 AM. 3. Policy committee reviewed the Elopement and Missing Resident policies on 5/2/2024 at 12:50 PM, no changes were made. 4. Directive Inservice was initiated on 5/2/2024 at 2:00 PM by Licensed Nursing Home Administrator from an outside facility. Content of in-service Elopement and Missing Resident policies. Identifiers and Communication for High-Risk Elopement Residents. Identifiers include Elopement Evaluation User Defined Assessment, resident care profile on the Point Click Care dashboard, the Point of Care, and the Elopement Binders. No staff will be allowed to work until in-serviced. 5. Director of Nursing conducted 100% care plan audit on 5/2/2024 of all residents with elopement risk, 8 total. No issues found. Audit completed at 1:20 PM. 6. The Maintenance Director conducted 100% audit of all resident room windows to ensure they are secure on 5/2/2024, all windows are secure. 7. State Department of Health notified of elopement on 4/26/2024 at 6:51 pm via complaint hotline. Attorney General notified on 5/2/2024 via web portal. Police Department had been notified at 5:38 PM by neighboring business and were with resident. 8. Per facility protocol all admissions are assessed for elopement risk, all new admissions will have a baseline care plan within 48 hours of admission, residents who are at high risk for elopement are photographed and added to the elopement binders located at the reception desk and both nursing stations, an order is added for nursing to monitor for elopement, high risk elopement residents are added to the Point of Care for hourly monitoring. A review of high-risk elopement residents is completed weekly during Facility High Risk Meetings to ensure identifiers are present. New Implementations: Elopement risk has been added to the resident care profile on Point Click Care dashboard. Elopement risk has been added to the Point of Care Kardex. The facility has implemented secure conversation via electronic system to be utilized to notify staff of all admissions including those who are high risk for elopement. All new implementations were added on 5/2/2024. 9. Emergency Quality Assurance meeting held via phone conference on 4/26/2024 at 6:30 PM. Physician Assistant, Administrator, Director of Nursing, Staff Coordinator, and Quality Assurance/Infection Preventionist Nurse and Social Services. The unusual occurrence was discussed, all events before, during and after occurrence were reviewed. Committee members placed Resident #1 on one-on-one monitoring until transferred to a hospital. 10. All corrective actions to remove the IJ was completed on 5/2/2024 and the facility alleges the IJ was removed on 5/3/2024. The State Agency (SA) validated the facility's Removal Plan/Corrective Actions on 5/6/24: The SA validated through interviews and record review that Resident #1 was admitted to the facility from an acute care hospital on April 26, 2024. He arrived at the facility via this facility's transportation at 3:21 PM. Resident #1 was last seen by a staff member at 4:38 PM when he received his dinner tray. The Police Department received a call of a suspicious person at 5:38 PM. Resident eloped via a window in the room. The facility was made aware of the Immediate Jeopardy on 5/2/2024 at 11:42 AM. The SA validated through interviews and record review that Resident #1 was placed on one-on-one supervision until transferred to hospital for geriatric psychiatric services 4/27/2024 at 7:45 AM. The SA validated through interviews and record review that the policy committee reviewed the Elopement and Missing Resident policies on 5/2/2024 at 12:50 PM, no changes were made. The SA validated through interviews and record review that Directive Inservice was initiated on 5/2/2024 at 2:00 PM by Licensed Nursing Home Administrator from outside facility. Content of in-service Elopement and Missing Resident policies. Identifiers and Communication for High-Risk Elopement Residents. Identifiers include Elopement Evaluation User Defined Assessment, resident care profile on the Point Click Care dashboard, the Point of Care, and the Elopement Binders. No staff will be allowed to work until in-serviced. The SA validated through interview and record review that the Director of Nursing conducted 100% care plan audit on 5/2/2024 of all residents with elopement risk, 8 total. No issues found. Audit completed at 1:20 PM. The SA validated through interview and record review that the Maintenance Director conducted 100% audit of all resident room windows to ensure they are secure on 5/2/2024, all windows are secure. The SA validated through interview and record review that the State Department of Health was notified of the elopement on 4/26/2024 at 6:51 PM via complaint hotline. The Attorney General was notified on 5/2/2024 via web portal. The Police Department had been notified at 5:38 PM by neighboring business and were with the resident. The SA validated through interview and record review that per facility protocol all admissions are assessed for elopement risk, all new admissions will have a baseline care plan within 48 hours of admission, residents who are at high risk for elopement are photographed and added to the elopement binders located at the reception desk and both nursing stations, an order is added for nursing to monitor for elopement, high risk elopement residents are added to the Point of Care for hourly monitoring. A review of high-risk elopement residents is completed weekly during Facility High Risk Meetings to ensure identifiers are present. New Implementations: Elopement risk has been added to the resident care profile on Point Click Care dashboard. Elopement risk has been added to the Point of Care Kardex. The facility has implemented secure conversation via electronic system to be utilized to notify staff of all admissions including those who are high risk for elopement. All new implementations were added on 5/2/2024. The SA validated through interview and record review that there was an emergency Quality Assurance meeting held via phone conference on 4/26/2024 at 6:30 PM. Physician Assistant, Administrator, Director of Nursing, Staff Coordinator, and Quality Assurance/Infection Preventionist Nurse and Social Services. The unusual occurrence was discussed, all events before, during and after occurrence were reviewed. Committee members placed Resident #1 on one-on-one monitoring until transferred to a hospital. The SA validated through observation, interviews, record reviews, and facility policy review that all corrective actions were completed on 5/2/24 and the facility alleged removal of the Immediate Jeopardy (IJ) on 5/3/24.

Based on staff and resident interviews, record review and facility policy review, the facility failed to resolve a grievance of missing clothing for six (6) of 11 residents reviewed for grievances. Resident #9, Resident #28, Resident #39, Resident #47, Resident #54, and Resident #66. Findings Include: Record review of the facility policy titled Conflict Resolution and Resident Complaint and Grievance Process with a revision date of 09/06/2022 revealed under, Complaints and Grievances: . If a grievance is not resolved, the investigation is not complete, or if the corrective action is still being evaluated within the seven (7) day timeframe, the facility shall send a response to the resident stating that the facility continues to work to resolve the complaint and the facility shall follow-up with another response within 24 hours. During the Resident Council meeting on 12/05/23 at 1:10 PM, Resident #54 revealed that items of missing clothing have been a big concern at the previous resident council meetings. She revealed that she frequently gets clothes delivered to her room that are not hers. Residents #9, Resident #28, Resident #39, Resident #47, and Resident #66 agreed that they frequently get other residents' clothing and see other residents wearing their clothes in the hallway. The residents revealed that their clothes are clearly labeled and wonder what could be happening in the laundry for so many items to disappear. Resident #39 revealed that she lost a top that was sentimental to her that her grandson had made. She revealed that the top could never be replaced due to the significance, but the staff did try to find it. Resident #9 revealed she was missing a sweater and two (2) pairs of pants that have not been replaced. She voiced that no one had returned to her to follow up on the issue. Resident #66 revealed she was missing a black pantsuit for about two (2) months. She stated that no one had followed up with her regarding the issue. Resident # 47 revealed she was missing three (3) tops and a couple of pairs of jogging pants. She revealed she was not concerned with the jogging pants because she slept in them, but she would like to find the tops. Resident # 28 revealed she was missing four (4) T-shirts. She stated the facility looked but was unable to locate them. Residents #28 and Resident #47 mutually agreed that staff did not follow up with them regarding the missing items. The residents revealed they notified Activity Director #1 and laundry regarding the missing clothing and the facility did attempt to locate the missing items but were unsuccessful. The residents agreed that the missing items/receiving the wrong clothing had been an issue for a while. An interview with Activity Director #1 on 12/06/23 at 8:30 AM, revealed that when a resident complained about missing items in the Resident Council meeting, she made a note and went to look for the item herself, by first looking in the resident's room. She revealed that most of the time she found the clothing, but if she did not, she notified the Housekeeping Supervisor, and they looked through the laundry. She revealed if they were unable to locate the item, she would turn it over to the Social Worker. She revealed that she did get with the Assistant Director of Nursing (ADON) to handle some things. She confirmed that she did not do any documentation on the process; therefore, she had no proof to provide that the residents' concerns, that were voiced in the past Resident Council meetings, were addressed, and resolved. An interview with Housekeeping #1 on 12/06/23 at 8:45 AM, revealed missing clothing items have been a concern for the residents. She stated the Certified Nurse Aides (CNA's) usually came to notify the laundry department or the resident complained about missing clothing when the laundry staff delivered the clothing to the resident's room. She revealed that she was made aware of some residents having the wrong clothes this past weekend, and she got those corrected. She revealed they have a label machine in the laundry where they label all clothing for the residents. She revealed they have a lot of trouble with newly admitted residents because their clothes do not always get labeled, and they struggle to find who they belong to. An interview with the Assistant Director of Nursing (ADON) on 12/06/23 at 8:58 AM, revealed the facility did not have a written follow-up process regarding the resident concerns that were mentioned in the Resident Council Meeting. She revealed nursing concerns were brought to her and an in-service was conducted. All other things were taken to the Department Supervisor to address the concern. She confirmed that they handled the issues that were discussed in the Resident Council meetings by verbally telling the Department Head, and therefore they have no documentation to prove the issues discussed were acted upon or resolved. An interview on 12/6/23 at 3:58 PM with the Housekeeping Supervisor revealed that she was aware that residents complained about missing clothes or mislabeled clothes, but she was usually able to find them or fix them. She stated that she did not receive a copy of the Resident Council meeting minutes, but that the Activities Director came and talked to her about the complaints that came up during the meeting. She revealed that if she was unable to find a resident's missing clothes, then she would go and tell the Social Worker. She stated that she had never documented anything about what she did to resolve the missing or mislabeled clothing and understands that if the residents complain about laundry issues during every resident council meeting, then maybe something different should be done to fix it. An interview on 12/6/23 at 5:00PM, with Social Services #1 confirmed that she was aware of the resident complaints about missing clothes. She stated that she had attended Resident Council meetings before but had not heard of a complaint regarding the laundry for a while. She revealed that no one had come and told her that the residents were complaining at almost every resident council meeting regarding laundry issues. She stated that she had never completed a grievance form for a complaint at a resident council meeting. She agrees that an ongoing complaint by residents with no documentation of what was done to resolve the complaint could be considered an unresolved grievance. An interview on 12/06/23 at 5:40 PM, with the Administrator revealed that she received an email copy of the Resident Council meeting and was aware that missing clothing had been a pattern of concern for the residents over the past six (6) months. She confirmed laundry issues were discussed every month. She acknowledged that the facility should have a better system in place to track and follow up on the resident's voiced concerns that were mentioned in Resident Council. She confirmed that without documentation, the facility cannot prove the issues were addressed and resolved. Record review of the Resident Council meeting minutes dated July 19, 2023, revealed Residents #9, Resident #28, Resident #39, and Resident #66 were in attendance. Also revealed under, Laundry: Residents are still having multiple clothes hung on hangers, this also results in residents either thinking they have missing clothes, or they have other resident's clothes. I suggested to have some families, if able to remove items or out of season clothing, to insure more room in their closets. Us as staff will do checks when allowed by residents for correct labeling. Record review of the Resident Council meeting minutes dated August 21, 2023, revealed Residents # 9, Resident #28, Resident #47, and Resident #66 were in attendance. Also revealed under, Laundry: . We are still finding other people's clothes in the rooms; I have corrected some that were brought to me. Just be on the lookout please. It seems to be the east hall most of the time. Record review of the Resident Council Meeting minutes dated September 26, 2023, revealed Residents #9, Resident #28, Resident #39, Resident #47, and Resident #66 were in attendance. Also revealed under, Laundry: Please start double checking names on clothes in what room they go to. We have residents that have room changes at times. I have given a small list of items to look for that residents state they are missing. Record review of the Resident Council meeting minutes dated October 24, 2023, revealed Residents #28, Resident #39, and Resident #66 were in attendance. Also revealed under, Laundry: . Please double check names to the resident's room when putting up laundry. There still are a lot of missed placements in the wrong rooms. Record review of the Resident Council meeting minutes dated November 28, 2023, revealed Residents #9, Resident #28, Resident #39, Resident #47, and Resident #66 were in attendance. Also revealed under, Laundry: Residents #66 and #9 has clothes that were mixed in closets that belonged to other residents. I have started on helping fix this Record review of the Resident Council meeting minutes dated 7/19/23, 8/21/23, 9/26/23, 10/24/23 and 11/28/23 revealed no written follow up/or tracking record to prove that the residents' voiced concerns were acted upon or that a follow-up was conducted regarding missing clothing items. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/02/23 revealed under section C, a Brief Interview for Mental Status (BIMS) score of 14, which indicates Resident # 9 is cognitively intact. Record review of the MDS with an ARD of 9/08/23 revealed under section C, a BIMS score of 09, which indicates Resident # 28 is moderately cognitively impaired. Record review of the MDS with an ARD of 11/23/23 revealed under section C, a BIMS score of 14, which indicates Resident # 39 is cognitively intact. Record review of the MDS with an ARD of 10/19/23 revealed under section C, a BIMS score of 12, which indicates Resident # 47 is moderately cognitively impaired. Record review of the MDS with an ARD of 10/06/23 revealed under section C, a BIMS score of 15, which indicates Resident # 54 is cognitively intact. Record review of the MDS with an ARD of 10/20/23 revealed under section C, a BIMS score of 15, which indicates Resident # 66 is cognitively intact.

Cross Refernce F759 Based on observation, staff interview, record review and facility policy review the facility failed to administer resident medications based on professional standards of practice for 10 of 36 medication administration opportunities. Resident #9 and Resident #59 Findings include. Review of the facility policy titled, Medication Administration with a revised date of 06/08/2023 revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. Review of the facility policy titled, Medication Errors with a revised date of 09/05/2023 revealed, The facility shall ensure medications will be administered as follows: According to physician's orders . In accordance with accepted standards and principles which apply to professionals providing services. Resident #59 On 12/6/23 at 7:50 AM, a medication administration observation with Licensed Practical Nurse (LPN) #1 revealed medication administration to Resident #59. The total number of medications administered to Resident #59 was 11. During medication reconciliation, a record review of the Order Summary and Medication Administration Record (MAR) revealed that Resident #59 did not receive six (6) medications that were prescribed by the Physician to be given during that medication administration time, and one medication that was administered was given in the wrong form. Medications omitted were Allopurinol tablet 100 mg (milligrams), Aspirin 81 mg chew, Pravastatin tablet 40 mg, Thiamine HCL tablet 100 mg, Vitamin D2 capsule 50,000-unit, Vitamin D3 tablet 50 mcg (micrograms), and Ferrous Sulfate Elixir 220/5ml (milliliters) 7.5 ml was not given but a pill form was substituted. On 12/6/23 at 9:45 AM, during an interview with LPN #1, she confirmed that she had missed giving Resident #59 six medications that were due to be given when she gave his morning medications and confirmed she did not give Ferrous Sulfate Elixir but had substituted the medication for Iron 325 mg in pill form. She stated, Well it equals out to the same dose as the elixir and confirmed she did not have a physician's order to substitute the medication form. LPN #1 confirmed she did not give Thiamin, Vitamin D2 or Vitamin D3 and stated, I'll just give it to him when he gets his next medications because it's just a vitamin. She revealed I guess I missed the medications because I was nervous. LPN #1 revealed she does all her medication passes for all the residents that she is assigned to and then goes to the nurses' station and documents for all of them at one time. Inquired how she could keep it straight and not miss medications, or important things to document for each resident at that specific time and LPN #1 revealed I usually don't miss any medications. A review of the facility Admission Record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses that included Localization related symptomatic epilepsy and epileptic syndromes with complex partial seizures, Vitamin D deficiency, Major depressive disorder, Hypertensive heart disease with heart failure. A review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 10/12/2023 revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident #59 had moderate cognitive impairment. Resident # 9 On 12/6/23 at 8:10 AM, a medication administration observation with LPN #1 revealed 11 medications were administered to Resident #9. During medication reconciliation, a record review of the Order Summary and Medication Administration Record revealed that Resident #9 did not receive three (3) medications that were prescribed by the Physician to be given during that medication administration time. Medications omitted were Amitiza Oral Capsule 8mcg, Aspirin 81 mg chew, and Azo-standard oral tablet. An interview on 12/6/23 at 9:55 AM, LPN #1 confirmed that she didn't give Resident #9 the Amitiza medication because it wasn't in the cart. An observation was made that the medication was checked off as given yesterday with a date of 12/5/23 and LPN #1 confirmed the initials were hers and it was checked off as given. LPN #1 revealed, I'm going, to be honest, I'm not sure if it was given. I had a trainee with me, and she was marking off the medications. LPN #1 confirmed she had missed Resident #9's three medications. LPN #1 confirmed with a review of the narcotic log that the Norco 10 mg was given to the resident she did click yes on the MAR that it was given but it was not logged out in the narcotic logbook. She revealed I wrote it on my paperwork and then when I document at the end of the med pass, I will write it in the narcotic log. She confirmed that when a narcotic is given, she should have documented it at that time in the narcotic log. A review of the facility Admission Record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that included Sick sinus syndrome, Hyperlipidemia, Vitamin D deficiency, and constipation. A review of the MDS Section C with an ARD of 11/02/2023 revealed a BIMS score of 14 which indicated Resident #9 is cognitively intact. On 12/6/23 at 4:40 PM, in an interview with the Assistant Director of Nurses (ADON) revealed when medications are given, we encourage a triple check, checking the card, dose, and the Medication Administration Record (MAR) checking back and forth. She revealed it is our policy that as a medication is given the nurse documents on the electronic Medication Administration Record (EMAR) whether it was given or not, she revealed nurses are not supposed to wait until all the medications are given for all their residents, and then document. She revealed that leaves a lot of room for errors and is against our policy. She confirmed that with these medications being missed it could have caused a negative outcome if it was continual practice. The ADON confirmed this is just not acceptable nursing practice and confirmed that when a narcotic is pulled it is our policy that it is written down immediately in the narcotic logbook. On 12/6/23 at 5:05 PM, during an interview with the Director of Nurses (DON) confirmed when a nurse is administering medications, they are supposed to do real-time charting. When they pull the MAR up, they look at the medications to be given and pull those medications. Our policy is for the medication to be documented as given before that nurse moves on to the next resident. She confirmed that with this deficient practice, some important medications could have been missed. She confirmed that the medication that was given to Resident #59 was given in the wrong form and the nurse should have given the medication as the Physician ordered and not substituted it into a pill form. She confirmed that still equates to a medication error. She confirmed the medications were not given according to their policy and that the medication processes are set up like they are for the safety of the residents and to protect the license of the nurse. She revealed documentation is how a nurse protects themselves and how they make sure they don't make an error to cause harm to a resident. She revealed this was unacceptable and the nurse was not following the facility's medication administration policy.

Based on staff interviews, record review and facility policy review the facility failed to monitor for the side effects of an anticoagulant (blood thinner) for one (1) of five (5) resident medication reviews. Resident #15 Findings Include: Record review of the facility policy titled High-Risk Medication - Anticoagulants with a revision date of 12/22/2022 revealed under, Policy: This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. Also revealed under, Policy Explanation and Compliance Guidelines: . 4. The resident's plan of care shall alert staff to monitor for adverse consequences . Record review of the December 2023 Medication Administration Record (MAR) for Resident # 15 revealed an order with a start date of 9/05/23, Eliquis tab (tablet) give 1 (one) tablet by mouth every 12 hours related to Personal History of other Venous Thrombosis and Embolism. Record Review of the December 2023 Medication Administration Record (MAR) revealed no documentation to monitor for the side effects of the anticoagulant medication Eliquis. An interview with Registered Nurse (RN) #1 on 12/06/23 at 3:30 PM revealed that Resident #15 was receiving an anticoagulant (Eliquis) and did not have a monitoring tool to monitor for signs of bleeding. She revealed the monitoring tool should be tied to the anticoagulant order for the nurses to chart, but it was not. She confirmed there should be a place on the Medication Administration Record (MAR) to document the observations. She revealed inadequate monitoring of the anticoagulant medication places the resident at risk for bleeding. An interview with the Director of Nursing (DON) on 12/06/23 at 3:50 PM, confirmed that there should be a monitoring tool to document the signs of bleeding for all residents that take an anticoagulant. She revealed that if it's not documented, then it was not done, and this placed Resident #15 at risk of bleeding. Record review of the Admission Record for Resident # 15 revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Personal History of other Venous Thrombosis and Embolism. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/19/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) score of 10, which indicates Resident #15 is moderately cognitively impaired.

Cross Reference F658 Based on observation, staff interview, record review, and facility policy review the facility failed to maintain a medication error rate of less than 5% by ensuring that residents received all physician-ordered medications for 10 of 36 medication administration opportunities observed during medication pass. The medication error rate was 27.78%. Findings include: Review of the facility policy titled, Medication Administration with a revised date of 06/08/2023 revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .11. Review MAR (Medication Administration Record) to identify the medication to be administered . 19. Sign MAR after administration. 20. If medication is a controlled substance, sign the narcotic book. Review of the facility policy titled, Medication Errors with a revised date of 09/05/2023 revealed, .POLICY: It is the policy of this facility to provide protection for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of . medication errors. 1. The facility shall ensure medications will be administered as follows: a. According to physician's orders . c. In accordance with accepted standards and principles which apply to professionals providing services . Resident #59 On 12/6/23 at 7:50 AM, a medication administration observation with Licensed Practical Nurse (LPN) #1 revealed, a medication administration to Resident #59. The medications administered were Colchicine Oral Capsule 0.6 mg (milligrams), Depakote Sprinkles oral capsule 125 mg (2 capsules), Iron 325 mg tablet, folic acid tablet 1 mg, Potassium Chloride capsule 1000E (milliequivalent) ER (extended release), Atenolol tablet 100 mg, Baclofen tablet 10 mg, Levetiraceta solution 100mg/ml (milliliter), Sodium bicarbonate tablet 650 mg, Vimpat oral solution 10mg/ml 20ml, and Diltiazem tablet 60 mg. The total number of medications administered to Resident #59 was eleven. During medication reconciliation, a record review of the Order Summary and Medication Administration Record (MAR) revealed that Resident #59 did not receive six (6) medications that were prescribed by the Physician to be given during that medication administration time, and one medication that was administered was given in the wrong form. Medications omitted were Allopurinol tablet 100 mg, Aspirin 81mg chew, Pravastatin tablet 40 mg, Thiamine HCL tablet 100 mg, Vitamin D2 capsule 50,000-unit, Vitamin D3 tablet 50 mcg, and Ferrous Sulfate Elixir 220/5ml 7.5 ml was not given but a pill form was substituted. An interview on 12/6/23 at 9:45 AM, LPN #1 confirmed that she had missed giving Resident #59 six medications that were due to be given when she gave his morning meds and confirmed she did not give Ferrous Sulfate Elixir but had substituted the medication for Iron 325 mg in pill form. She stated, Well it equals out to the same dose as the elixir. LPN #1 She confirmed she did not have a physician's order to substitute the medication form. LPN #1 confirmed she did not give Thiamin, Vitamin D2 or Vitamin D3 and stated, I'll just give it to him when he gets his next medications because it's just a vitamin. She revealed I guess I missed the medications because I was nervous. LPN #1 revealed she does all her medication passes for all the residents that she is assigned to and then goes to the nurses' station and documents for all of them at one time. Inquired how she could keep it straight and not miss medications, or important things to document for each resident at that specific time. LPN #1 revealed I usually don't miss any medications. A review of the facility Admission Record revealed Resident #59 was admitted to the facility on [DATE] with diagnoses that included Localization related symptomatic epilepsy and epileptic syndromes with complex partial seizures, Vitamin D deficiency, Major depressive disorder, Hypertensive heart disease with heart failure. A review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 10/12/2023 revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated Resident #59 had moderate cognitive impairment. Resident #9 On 12/6/23 at 8:10 AM, a medication administration observation with LPN #1 revealed medication administration to Resident #9. The medications administered were Ciprofloxacin HCL tablet 500mg, Carvedilol tablet 3.125 mg, Cranberry tablet 450 mg, Docusate sodium capsule 100 mg (2 capsules), Torsemide Oral tablet 20 mg, Symbicort Inhalation Aerosol 2 (two) puffs inhalation, Hydrocodone/APAP tablet 10-325 mg tablet, Vitamin D tablet 2000-unit, Gabapentin tablet 600 mg, Clopidogrel tablet 75 mg, and Gentamicin Sulfate Ophthalmic solution. The total number of medications administered to Resident #9 was eleven. During medication reconciliation, a record review of the Order Summary and Medication Administration Record revealed that Resident #9 did not receive three (3) medications that were prescribed by the Physician to be given during that medication administration time. Medications omitted were Amitiza Oral Capsule 8 mcg, Aspirin 81 mg chew, and Azo-standard oral tablet. An interview on 12/6/23 at 9:55 AM, LPN #1 confirmed that she didn't give Resident #9 the Amitiza medication because it wasn't in the cart. State Agency observed medication was checked off as given yesterday with a date of 12/5/23, LPN #1 confirmed the initials were hers and it was checked off as given. LPN #1 revealed, I'm going, to be honest, I'm not sure if it was given. I had a trainee with me, and she was marking off the medications. LPN #1 confirmed she had missed Resident #9's three medications. A review of the facility Admission Record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that included Sick sinus syndrome, Hyperlipidemia, Vitamin D deficiency, and constipation. A review of the MDS Section C with an ARD of 11/02/2023 revealed a BIMS score of 14 which indicated Resident #9 is cognitively intact. An interview on 12/6/23 at 4:40 PM, the Assistant Director of Nurses (ADON) revealed when medications are given, we encourage a triple check, checking the card, dose, and the MAR checking back and forth. She revealed it is our policy that as a medication is given the nurse documents on the electronic MAR whether it was given or not, she revealed nurses are not supposed to wait until all the medications are given for all their residents, and then document. She revealed that leaves a lot of room for errors and is against our policy. An interview on 12/6/23 at 5:05 PM, the Director of Nurses (DON) revealed when a nurse is administering medications, they are supposed to do real-time charting when they pull the MAR up, they look at the medications to be given and pull those medications, our policy is for the medication to be documented as given before that nurse moves on to the next resident. She confirmed that with this deficient practice, some important medications could have been missed. She confirmed that the medication that was given to Resident #59 was given in the wrong form and the nurse should have given the medication as the Physician ordered and not substituted it into a pill form. She confirmed that still equates to a medication error. She confirmed the medications were not given according to their policy and that the medication processes are set up like they are for the safety of the residents and to protect the license of the nurse. An interview on 12/6/23 at 5:35 PM, the Administrator (ADM) confirmed that their policy on medication administration was not being followed and it should have been.

Based on observation, staff and resident interview, record review and facility policy review the facility failed to honor a resident's food choice for one (1) of three (3) residents reviewed. Resident #17 Findings Include: Review of the facility policy titled, Resident Rights and Responsibilities with a revision date of 10/10/22 revealed .5. Self Determination .b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident . An observation and interview on 12/04/23 at 11:39 AM, with Resident #17 stated she does not like rice, and they keep serving her rice. An observation of the resident's lunch tray revealed the resident had rice served on her tray and her meal ticket revealed that rice was a dislike. An interview on 12/5/23 at 10:15 AM, with District Dietary Support revealed that the Certified Nurse Assistants (CNA) goes around to a list of residents and tells those residents what the menu is for the day and what the alternate is. She stated she is not sure who developed that list of residents. She revealed that the dietary staff look at the resident's meal ticket to determine their diet order, likes and dislikes. Record review with her confirmed that rice was served for lunch on 12/4/23 and 12/5/23. An observation and interview on 12/5/23 at 12:15 PM, revealed that Resident #17 received rice on her lunch tray today and the resident stated that she received rice on her tray a lot, but she just doesn't eat it. She stated she has told them about this many times and they have it listed on her meal ticket as a dislike, but they just keep sending it. An interview and record review on 12/5/23 at 2:00 PM, with District Dietary Support confirmed that Resident #17 had a dislike noted on her meal ticket that indicated the resident disliked rice. She stated that with that dislike noted then the resident should never receive rice because she does not like it. She stated she could get an alternate for that, like mashed potatoes. She admitted that she served the food onto the resident's trays today for lunch and she missed that the resident disliked rice. She confirmed that the CNA did go and ask the residents on the list that she provided a copy of if they wanted the alternate meal. An review of the list of residents requesting an alternate revealed a list of 15 resident names, which did not include Resident #17. She stated she is not sure if the CNA asked all the residents or just the ones on this list. An interview on 12/5/23 at 2:15 PM, with CNA #2 confirmed that she was given a list of residents to ask daily if they want an alternate meal. She stated she was given this list about two months ago from the previous Director of Nurses (DON). A review of the list revealed Resident #17 was not included on the list. She verified if the residents name was not on the list, then she did not go ask them about an alternate meal. An interview on 12/5/23 at 3:45 PM, with the Administrator confirmed that if a resident indicated rice was a dislike and it was noted on their meal ticket then they should not receive rice. Record review of the facility menu for the week of survey revealed that rice was served for lunch on 12/4/23 and 12/5/23. Record review of Resident #17's meal ticket dated 12/5/23 revealed rice was noted as a dislike. Record review of Resident #17's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Ankylosing Spondylitis Lumbar Region. Record review of Resident #17's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/13/23 revealed under Section C a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact.

Based on staff interviews, record review and facility policy review, the facility failed to complete a thorough investigation for one (1) of three (3) residents with incidents reviewed. Resident #27 Findings Include: Record review of the facility policy titled Incident and Accident Reporting with a revision date of 9/05/2023 revealed under, Policy: . It is important that the incident and accident report and investigation be completed timely and thoroughly to ensure an accurate record of the event . Record review of the Incident Note dated 11/24/23 at 2:34 PM revealed, Resident noted sitting in floor with back against w/c (wheelchair) wheels locked on w/c (wheelchair) cushion was under resident able to move upper ext (extremities) without pain. c/o (Complains of) back et hip pain et ambulance services called at this time. No other injuries noted at this time. neuro (neurological) checks initiated et wnl (within normal limits) at this time. transferred from floor to stretcher via 4 (four) ems (emergency medical services). Resident alert et verbal at this time. Leaving facility via ambulance services at this time. md (medical doctor)/don (director of nursing)/rr (resident representative) notified et aware of fall at this time. Record review of the CT (Cat Scan) Spine Lumbar w/o (without) contrast dated 11/24/23 revealed under, Impression: 1. Acute appearing obliquely oriented fracture involving the anterior superior aspect of the L1 vertebral body extending into an anterior osteophyte Record review of the Post Fall Evaluation completed by Registered Nurse #1 dated 11/24/23 revealed under, Fall Details . 18. Unwitnessed fall with c/o (complaints of) back et hip pain voiced upon movement. Record review of the fall investigation conducted by the Assistant Director of Nursing (ADON) undated, revealed Resident # 27's fall occurred in the common area by the fish tank around approximately 2:00 PM on 11/24/23. The fall investigation revealed the resident was unsure of what happened. Possible contributing factors was documented as Repositioning in the chair-cushion slipped with an intervention of Dycem under cushion. An interview with Registered Nurse (RN) # 1 on 12/06/23 at 3:10 PM, revealed that she was the unit manager the day that Resident # 27 fell . She revealed that she could not recall who observed the resident on the floor and stated after she was notified of the fall, she went to assess the resident along with a medication nurse. She stated that the resident was found on the floor in the lounge area in front of the fish tank. She stated she did a quick head to toe assessment and the resident was complaining of hip and back pain. The doctor was called, and the resident was transferred to the emergency room . She revealed that Resident # 27's wheelchair cushion slid out of the wheelchair and was located under the resident on the floor. She confirmed that she was unsure if anyone witnessed the fall and confirmed that she did not document a witness in the incident report. An interview with the Director of Nursing (DON) on 12/06/23 at 3:45 PM, confirmed that she did not do a thorough investigation into Resident #27's fall. She stated the only thing that was done pertaining to the fall was an incident report. She revealed that she was told by the nursing staff that the resident slid from the wheelchair, and it was not a high-impact fall. She stated that after the resident was transferred to the hospital, they determined he had a back fracture, but it did not occur to her to do an investigation. She revealed that she had spoken with the son who confirmed that the resident had a fall at home before his admission to the facility, and he agreed that the fracture most likely occurred at home. She confirmed that despite the residents' fall at home, a thorough investigation should have been conducted at the facility since the fall was unwitnessed and resulted in a major injury. An interview with the Assistant Director of Nursing (ADON) on 12/06/23 at 3:55 PM, confirmed that she did not conduct a thorough investigation into Resident # 27's unwitnessed fall. An interview with the Administrator on 12/06/23 at 4:05 PM, revealed that she was aware of Resident # 27's fall and the back fracture. She revealed that after the resident's fall, an investigation was conducted by the Assistant Director of Nursing (ADON), however no proof of a thorough investigation was provided to the Survey Ageny. She acknowledged that the staff could have done a better job on the investigation and the documentation. Record review of the Admission Record for Resident # 27 revealed that the resident was admitted to the facility on [DATE] with medical diagnoses that included Alzheimer's Disease, Muscle Wasting and Atrophy, Atrial Fibrillation and Acute Kidney Failure. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 revealed, under section C, a Brief Interview for Mental Status (BIMS) score of 04, which indicates Resident #27 is severely cognitively impaired.

Based on observation, staff and resident interview, record review and facility policy review the facility failed to provide privacy for a resident with a urinary catheter as evidence by no privacy bag covering the urine drainage bag for one (1) of four (4) residents with catheters reviewed. Resident # 79 Findings Include: Record review of facility policy titled Resident Rights dated 2020, revealed, The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 7. Privacy and confidentiality. a. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment .personal care . Record review of facility note on letterhead revealed Our catheter policy does not use the verbiage 'privacy bag'. It is added to include this verbiage as of 12/6/23, staff are being in serviced on the use of privacy bags. This was signed by the Administrator and dated 12/6/23. An observation and interview on 12/5/23 at 2:50 PM, of Certified Nursing Assistant (CNA) #1 during catheter care for Resident #79 revealed a catheter bag attached to the left side of the bed with yellow urine noted in the tubing and bag. The catheter bag was not covered with a privacy bag. CNA #1 revealed she was unsure why this resident had a catheter bag without the privacy flap attached since the privacy catheter bag is the type used in the facility. She revealed an uncovered bag was a dignity concern for the resident. During an interview on 12/5/23 at 2:53 PM, Resident #79 revealed she was unaware her bag was uncovered. She stated she preferred it to be covered. During an interview and observation with the Assistant Director of Nursing (ADON)/Wound Manager on 12/5/23 at 2:55 PM, the ADON observed the catheter bag without a privacy bag, and she revealed it was the facility's policy for a urinary catheter bag to have a privacy bag. She stated she was unsure why this bag without a privacy flap was being used. She confirmed the use of a privacy bag was for dignity and privacy for each resident with a urinary catheter and should be in use. During an interview on 12/5/23 at 2:59 PM, the Director of Nursing (DON) revealed a urinary catheter bag should be in a privacy bag or a bag with a privacy flap to protect the resident's privacy. She confirmed that by not using a privacy bag for this resident, the facility failed to honor the resident's right for privacy. During an interview on 12/5/23 at 3:10 PM, the Administrator confirmed the facility failed to protect the resident's right for privacy and dignity by not ensuring the urinary catheter bag was covered. Record review of Order Summary Report revealed a physician's order dated 11/20/23 for a Foley catheter to bedside drainage bag. Record review of Resident #79's Admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included Obstructive and Reflux Uropathy. Record review of Resident #79's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/16/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

Based on staff interview, record review and facility policy review the facility failed to implement a comprehensive care plan for monitoring of side effects of an anticoagulant (Resident #15) and to provide a privacy bag on a urinary catheter bag (Resident #79) for two (2) of 21 resident care plans reviewed. Resident #15 and Resident #79 Findings Include: Record review of facility policy titled, Comprehensive Care Plan dated 10/10/22, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #79 Record review of Resident #79's Comprehensive Care Plan, date initiated 9/5/23, revealed, Focus Potential to injury related to presence of an Indwelling Foley catheter to dependent drainage related to the diagnosis of Neurogenic Bladder .Intervention/Tasks #16 French catheter .draining to BSDB (bedside drainage bag) with privacy bag provided . An observation on 12/5/23 at 2:50 PM, of Certified Nursing Assistant (CNA) #1 during catheter care for Resident #79 revealed the catheter bag was not covered with a privacy bag. During an interview and observation with the Assistant Director of Nursing (ADON)/Wound Manager on 12/5/23 at 2:55 PM, the ADON observed the catheter bag without a privacy bag, and she revealed it was the facility's policy for a urinary catheter bag to have a privacy bag. An interview on 12/6/23 at 3:15 PM, with the Minimum Data Set (MDS) Coordinator revealed she was responsible for entering care plans for the residents. She revealed a care plan was developed for each resident for their specific needs and was used by the staff to provide resident care. She confirmed the care plan for this resident included an intervention to provide a privacy bag for the urinary catheter for privacy and this was not done, therefore, the plan of care was not followed. Record review of Order Summary Report revealed a physician's order dated 11/20/21 for a Foley catheter to bedside drainage bag. Record review of Resident #79's Admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included Obstructive and Reflux Uropathy. Record review of Resident #79's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/16/23, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. 47874 Resident #15 Record review of Resident # 15's Care Plan revealed, Resident is at risk for bleeding related to use of anticoagulant therapy secondary to diagnosis of HX (history) of DVT (Deep Vein Thrombosis .Intervention/Tasks . Monitor for signs of bleeding. Record Review of the December 2023 Medication Administration Record (MAR) revealed no documentation to monitor for the side effects of the anticoagulant medication Eliquis. An interview on 12/06/23 at 3:30 PM, with Registered Nurse (RN) #1 revealed that Resident #15 was receiving an anticoagulant (Eliquis) and did not have a monitoring tool to monitor for signs of bleeding. She confirmed that the residents' care plan was not followed for monitoring the signs of bleeding. An interview with the Director of Nursing (DON) on 12/06/23 at 3:50 PM, confirmed that Resident # 15's care plan was not followed to monitor for signs of bleeding. Record review of the Admission Record for Resident # 15 revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Personal History of other Venous Thrombosis and Embolism. Record review of the MDS with an ARD of 9/19/23 revealed, under section C, a BIMS score of 10, which indicates Resident #15 is moderately cognitively impaired.

Based on record review, staff interview, and facility policy review, the facility failed to follow a care plan related to monitoring of pain for Resident #4, for 1 of 21 care plans reviewed for pain. Resident #4 was observed to have facial grimacing and complaint of pain by crying and yelling out and had not been assessed/reported to the physician. Findings Include: Review of facility policy titled, Comprehensive Plan of Care, dated 10/27/14, stated, Plans of Care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals for the resident related to clinical [DIAGNOSES REDACTED]. Review of Resident #4's Care Plan, dated 6/11/15, revealed approaches to observe for worsening of pain symptoms/report to the physician and administer pain medications as ordered. Observation on 03/15/16 at 11:15 AM, with LPN #2 present, revealed that Resident #4 was grimacing and moaning with her knees drawn to her chest. LPN #2 asked the resident if she was in pain and Resident #4 stated, Yes. LPN #2 informed the resident that she would let her nurse know that she needed something for pain. Observation on 03/16/16 at 10:30 AM of Resident #4 revealed the resident moaning out in pain and facial grimaces and her knees drawn toward her chest. Interview with LPN #1 on 03/16/16 at 10:30 AM regarding observed pain of Resident #4 and that the State Agency (SA) did not see any pain medications on the current Electronic Medication Administration Record (EMAR). LPN #1 confirmed that Resident #4 did not have any medications for pain on the EMAR and stated she'd not given her any medications or assessed her yet, I've been behind, I'm about to get to her. In a later interview on 3/16/16 at 11:30 AM, LPN #1 stated, I found out what happened, Somebody went into the computer and changed her (pain medication) order and she is not receiving it every day now, she only gets it every 14 days. LPN #1 confirmed that the last time the resident received pain medication was on 03/12/16. Interview and observation of Resident #4 on 3/16/16 at 11:40 AM revealed the resident moaning and yelling out. LPN #1 was present and asked Resident #4 if she had pain and the resident yelled loudly yes. LPN #1 administered Tylenol to Resident #4. Record review of LPN #1's nurses note dated 03/16/16 at 12:00 noon stated, Resident remains in bed. Continues to whine and cry. Continues to grimace during care. Records revealed that Resident #4 was administered Tylenol 325 MG caplet, 2 caplets administered related to moaning/gasping, crying/whining. Interview with the Nurse Practitioner (NP) on 3/17/16 at 1:20 PM revealed she had not been notified of Resident #4's complaint of pain until the day before (3/16/16). Interview with Registered Nurse #1 (MDS Nurse) on 03/17/16 at 1:00PM stated, I initiated that (pain) care plan on her readmission on 06/10/15 because she had pain medication and had a potential for pain due to her [DIAGNOSES REDACTED]. Resident #4 was admitted to the facility on [DATE] with diagnoses, which included [MEDICAL CONDITION] with pain, [MEDICAL CONDITIONS] and Dementia. The most recent Brief Interview for Mental Status (BIMS) was conducted on 03/09/16 and revealed resident is rarely or never understood at that time. BIMS score was conducted on readmission to the facility on [DATE] when the care plan was developed and the resident scored a 14 BIMS, indicating full cognitive ability.

Based on observation, staff interview, record review and facility policy review, the facility failed to properly assess and treat pain for Resident #4 for one (1) of nine (9) residents reviewed for pain as evidenced by Resident #4 was observed to have moaning, crying out and complaint of pain that had not been assessed/treated. Findings Include: Review of facility policy titled, Pain: Assessment, Scale and Management, dated 01/09/15, revealed Residents shall be assessed at regular intervals for the presence of pain, at which time the resident should be asked to classify his/her pain on a scale of 0-10. Attempts to control pain shall be employed until the resident reaches an acceptable comfort level. The physician shall be notified of any adverse reactions and the pain management plan shall be revised to better suit the needs of the resident. During initial tour of the facility on 03/15/16 at 11:15 AM with Licensed Practical Nurse (LPN) #2, an observation of Resident #4 was made. The door to Resident #4's room was closed upon entering and LPN #2 stated that the resident has a history of Dementia, but can answer simple yes/no questions appropriately, that Resident #4 has declined recently with her appetite, refuses to eat and is receiving Palliative care from the facility. Resident #4 was observed lying in her bed on her right side with her knees drawn inward to her chest and her head drawn downward to her knees, and her head is leaned over into the side rail of the bed. Resident #4 was observed moaning and crying out. Resident #4 appears emaciated with her tongue and lips dry and cracked. LPN #2 asked the resident if she was hurting and the resident loudly stated, Yes. LPN #2 informed the resident that she would let her nurse know that she was in pain. Interview on 03/16/16 at 9:30 AM with Certified Nursing Assistant (CNA) #2 confirmed that Resident #4 does not get up out of the bed as much as she used to because, she don't feel good and has pain. When asked if CNA #2 informed the resident's nurse when she was experiencing pain, she stated, Oh yeah. Observation on 03/16/16 at 10:30 AM of Resident #4 revealed her door closed to her room, lying in her bed on her right side with her knees drawn inward to her chest, her head slumped down into the side rail of the bed, and moaning with facial grimaces noted. Review of Resident #4's medical record did not reveal scheduled monitoring of pain daily or during each shift. Record review revealed that the physician's orders [REDACTED]. Interview on 03/16/16 at 10:40 AM with Resident #4's nurse, LPN #1, regarding the last time that the resident had taken medication for pain or had been assessed for pain, she stated, I've not given her medication yet. I've been behind this morning. I'm about to get to her. LPN #1 reviewed resident #4's Electronic Medication Administration Record (EMAR) while the State Agency (SA) Representative was standing at the medication cart and LPN #1 confirmed that she did not see anything that was scheduled to be given to Resident #4 for pain. Interview on 03/16/16 at 11:30 AM with LPN #1 when asked by the SA if resident #4 had been assessed for pain or been given any medication for pain, LPN #1 stated, No I haven't given her anything or assessed her for pain, but I did find out what happened. Somebody went into the computer system and changed her order for Tylenol to every 14 days instead of every day. LPN#1 confirmed that the last time resident #4 was given anything for pain was on 03/12/16. LPN #1 confirmed that Resident #4 just received Tylenol once every two (2) weeks and on that 14th day every eight (8) hours. LPN #1 stated, I hadn't noticed it until you asked me about it. The SA asked LPN#1 what she will do at this point and she stated, I've went back in the computer and changed it to an everyday order instead of an every 14 day order, but it won't be due until 4:00 PM for her to receive it. The SA asked LPN #1 if she would normally obtain an order to administer pain medications from the Nurse Practitioner (NP) who is standing at the nurse's desk, visibly in sight, and LPN #1 stated, I've got to chart first and then I'll get her an order for [REDACTED]. At 11:40 AM on 3/16/16, the SA walked back to Resident #4's room, door to the room was closed, knocked on the door and entered the room and observed the resident's curtain drawn around her bed and Resident #4 was heard loudly moaning and yelling out when the SA entered the room. The SA walked around the privacy curtain, the resident was alone in the room and had noted facial grimaces. LPN #1 then entered the room behind the SA Representative. Resident #4 was lying in her bed with her knees up to her chest and lying on her side. Resident #4 attempted to raise her head when spoken to, opened her eyes and nodded her head gesturing yes and stated loudly, Yes, when asked by the nurse if she was in pain. The SA asked LPN #1 why the resident's privacy curtain was drawn and she stated, I was going to see if that would calm her down. LPN #1 then administered two (2)caplets of Tylenol 325 mg crushed in applesauce. Resident #4 swallowed the medication without difficulty and drank a full 4 ounce cup of water after taking the Tylenol. Record review of the nurse's note for 12:00 noon on 3/16/16, documented by LPN #1, indicated that two (2)caplets of Tylenol 325 mg were administered to Resident #4 due to whining/crying and resident continues to grimace. There was no documentation of the type/location/intensity of the pain. Interview with LPN #2 at 12:15 AM on 03/16/16 confirmed that she was making some changes to Resident #4's Tylenol order on 02/27/16 and stated, I guess I changed it to an every 14 day order instead of an every eight (8) hour order. LPN #2 confirmed that resident #4 was in pain the day prior (03/15/16) on our initial tour and stated she did not let the resident's nurse know she was in pain because she used to having those residents, and knew Resident #4 had Tylenol ordered and thought it would be scheduled for the resident to take. Record review revealed that prior to the Tylenol being discontinued on 02/27/16, the daily pain assessment rating appeared on the EMAR and from 02/01/16 until the Tylenol was discontinued on 02/27/16. Resident #4 rated her pain as a 0-6 daily even with the Tylenol administered. The pain scale available was a 0-10. (0=none and 10=severe). Thus, Resident #4's pain had not been assessed/documented on a routine basis. Record review of Departmental Notes revealed that on 03/16/16 at 4:15 PM Resident #4 was moaning, restless with non-verbal cues present, and the Nurse Practitioner (NP) was notified. The NP ordered [MEDICATION NAME] ([MEDICATION NAME]) HCL 50 milligrams (mg) tablet every six (6) hours. A Physician' order on 03/17/16 revealed to discontinue [MEDICATION NAME] and begin [MEDICATION NAME] 5/325 mg by mouth every eight (8) hours. Interview with the NP on 03/17/16 at 1:20 PM confirmed that she is in the facility Monday through Friday from around 8 AM until 5 PM and that she had never been made aware that Resident #4 was experiencing pain until yesterday around 4:00 or 5:00 PM. The NP confirmed that she gave an order for [REDACTED]. The NP confirmed that when she arrived at the facility this morning, on 03/17/16, she noticed that Resident #4 was still in pain so, I ordered her [MEDICATION NAME] 5/325 MG one (1) tablet every eight (8) hours. Interview with Certified Nursing Assistant (CNA) #2 on 03/17/16 at 1:20 PM confirmed that last Tuesday (03/08/16) was a good day for Resident #4, and that was the last day she remembered her eating well, she even helped feed herself that day, but since then she has cried out and hasn't wanted to eat. During an observation on 03/17/16 at 1:30 PM, Resident #4 was resting in her bed, eyes closed and upright in bed lying on her back. When spoken to, Resident #4 opened her eyes and stated, No, when asked if she was hurting. Record review of Resident #4's most recent History and Physical on 01/27/16 revealed a [DIAGNOSES REDACTED]. Review of the Nurse's Notes dated 03/08/16 stated, Remains palliative care. The facility admitted Resident #4 on 01/02/15 with [DIAGNOSES REDACTED]. The BIMS scored 14 on re-admission to the facility on [DATE], indicating full cognitive ability. The most recent Brief Interview for Mental Status (BIMS) was conducted on 03/09/16 and revealed Resident #4 was rarely or never understood at that time.

Based on Staff Interview, Record Review and Facility Policy Review, the facility failed to follow the care plan related to the required number of staff assessed for the use of a full-body lift (Resident #11) and the use of bed/chair alarms (Residents #10 and #13), for three (3) of 20 care plans reviewed. Findings Include: The Total Care Plan Policy revealed it was to be used to identify problems that affect the resident and his/her care needs, identify the interventions related to the specific problems, and identify the discipline responsible for performing the intervention. Resident #10 Record review of Resident #10's care plan revealed a potential for fall care plan with bed alarm listed as an intervention and pt (patient) does unplug alarms @ (at) times written. This intervention was dated 10/8/14. Review of the facility's Nursing Instructions for CNAs for Resident #10 revealed, Bed and W/C pad alarm. Record review for Resident #10 revealed a physician's orders [REDACTED]. Nurse to check alarms to bed and WC Q (every) shift for placement and functional status. Review of the facility's Resident Incident Report for Resident #10 revealed, on 11/18/14, staff found resident on the floor and the alarm was on the bed but not connected. Resident was sent to the ER (emergency room ) with [MEDICAL CONDITION] Left Rib. In an interview on 04/15/15 at 10:25 AM, the DON stated she was not sure by the incident report if the alarm was sounding at the time of the incident. Record of the facility's face sheet revealed, the facility admitted the resident on 09/03/14. Resident #10's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/25/15 revealed Resident #10 had a BIMS (Brief Interview of Mental Status) score of 11, indicating the resident had moderately impaired cognition. The MDS with ARD of 02/25/15 scored the transfer at four (4) (requiring total assist), ambulation at eight (8) (did not occur). Resident #11 Record review of Resident #11's care plan, dated 1/17/12 and updated through 5/14/14, revealed Resident #11 was care planned for the use of a total body lift for Activities of Daily Living ( ADLs) and was at risk for falls due to [DIAGNOSES REDACTED]. Resident #11 required a total lift with all transfers. Review of a Resident Incident Report , dated 3/2/14 at 1:45 PM, revealed CNA #4 transferred Resident #11 from the bed to the wheel chair with a total lift and [MEDICAL CONDITION] sling alone. The report, prepared by RN #5, revealed Resident #11 slipped from the lift sling, causing pain and injury to Resident #11's left arm and coccyx. A review of the Activities of Daily Living (ADL) cardex titled Nursing Instructions for Certified Nursing Assistants, dated 4/16/13, that was current at the time of the incident, revealed Resident #11 was to be transferred using a total lift [MEDICAL CONDITION] sling with two (2) person assist. On 4/16/15 at 3:47 PM, an interview with the (Minimum Data Set) MDS nurse reported, upon admission a lift assessment was completed on each resident. An algorithm was followed and the findings were then implemented into each resident's care plan. Lift and transfer usually fall under the category of ADLs. The information was then communicated to the CNAs through the use of the ADL cards. Further communication related to lifts and fall risks were coded on the resident's room door. Any changes to this status were reported at the beginning of each shift and door tags and ADL cards were updated. On 4/16/15 at 3:25 PM, a telephone interview with the former DON verified the information for lifts were on each resident's ADL card. She stated the CNAs knew that all sling lifts were to be a two person assist. She stated CNA #4 knew this and said so, but made a bad judgment call in doing it alone. On 4/16/15 at 4:24 PM, the current Director of Nurses (DON) revealed staff know about the use of lifts or any changes to residents' care plans through a communication sheet and through updating the ADL forms. She stated she personally monitored compliance through direct observation ensuring staff were following residents' care plans. Review of the facility's face sheet revealed, the facility admitted the resident on 4/02/10. Resident #11's [DIAGNOSES REDACTED]. Review of the MDS with the Assessment Reference Dates of 2/12/14, revealed Resident #11 had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The resident's Functional Status for transfer revealed she required total dependence and two person physical assistance. Resident #13 Review of the facility's fall risk assessment scored Resident #13 at 16-17, indicating resident was at high risk for falls. Review of Resident #13's care plan revealed a care plan for potential for falls due to a history of falls. Nurses to check ordered alarms to w/c (wheelchair) Q (every) shift for proper placement and functional status was an intervention. Record review revealed current April 2015 physician's orders [REDACTED]. Nurse to check alarms to bed and WC Q (every) shift for placement and functional status. Review of the facility's Resident Incident Report for Resident #13 revealed on 03/17/14 the facility found the resident the floor in front of a recliner. No pad alarm on recliner. Observation on 4/16/15 at 9:55 AM revealed Resident #13 in bed with hospice staff in room. CNA #1 unplugged alarm on bed upon sounding. Review of the facility's face sheet revealed, the facility admitted the resident on 06/12/12. Resident #13's [DIAGNOSES REDACTED]. Review of the MDS with ARD of 02/03/14 revealed that Resident #13 had a BIMS score of 03 the resident had severely impaired cognition.

Based on observation, staff interview, record review, incident report review, manufacturer's instructions review, and facility policy review, the facility failed to use a lift per policy/protocol with resident transfers resulting in a fracture for one (1) of three (3) reported incidents, (Resident #11) and failed to prevent accident and hazards for residents as evidenced by failure to ensure physician ordered resident bed/chair alarms were connected and functioning for three (3) of 14 Residents reviewed for falls (Residents # 5, #10, and #13). Findings Include: Resident #11 The undated document entitled Mechanical Lift Program documented the Purpose was to provide individuals with the safe assistance of mechanical lifts as indicated by their condition. The Policy included, Each resident will be assessed for the need for mechanical lift assistance and for the type of mechanical lift indicated and the appropriate sling size. All nursing staff will be oriented to Program Policy and Procedures and complete a skills check-off. Operating Instructions for Total Lifts provided by the Lift Company included, .Follow any specific lift/transfer instructions for the resident. Use the number of staff required for the procedure. Always operate the lift according to the procedure and only after hands on training. The Lift/Transfer/Repositioning Evaluation Algorithm for Resident #11 dated 2/12/14 completed and signed by Registered Nurse (RN) #2, revealed the resident should be a Total Lift for all transfers with 2 staff required and a large amputee sling. A review of the Activities of Daily Living (ADL) instructions entitled Nursing Instructions for CNA's, dated 4/16/13, revealed Resident #11 was to be transferred using a total lift amputee sling with two (2) person assist. Review of the Nursing and Restorative Care Instructions form for the 7-3 shift revealed Certified Nurses Assistant (CNA) #4's initials charted. Review of a Resident Incident Report , dated 3/2/14 at 1:45 PM, revealed CNA #4 transferred Resident #11 from the bed to the wheel chair with a total lift and amputee sling alone. The report, prepared by RN #5, revealed Resident #11 slipped from the lift sling, causing pain and injury to Resident #11's left arm and coccyx. RN #5 notified the Geriatric Nurse Practitioner and in house x-rays of Resident #11's left arm and coccyx were ordered. Review of the initial Radiology Report dated 3/2/14, reported findings of no radiographic evidence of acute fracture or dislocation. On 4/16/15 at 10:30 AM, an interview with Licensed Practical Nurse (LPN) #2 recounted the event involving Resident #11's fall from the sling on 3/2/14. When she arrived in the room, Resident #11 had a sling under her. She was close to the door on her back. When LPN #2 tried to move Resident #11 a little, she cried out with pain complaining of her left arm. She recalled the charge nurse and the resident's nurse arrived and LPN #2 left. On 4/16/15 at 10:40 AM, an interview with CNA #3 regarding the fall of Resident #11 on 3/2/14 revealed, CNA #4 came out of Resident #11's room yelling, somebody help me. CNA #3 ran to help and saw Resident #11 on the floor, near the door with a sling under her. She recalled nobody else was in the room assisting CNA #4. Resident #11 kept saying, my arm, my arm. CNA #3 helped roll Resident #11 onto her back, off of the arm she was complaining hurt. She recalled the charge nurse and two other CNAs, using the total lift to assist Resident #11 back to bed. CNA #3 revealed the staff are in-serviced quite frequently on the lifts. Review of a nurse's note, dated 3/6/14 at 4:00 PM, revealed RN #5 documented Resident #11 continued to complain of pain in her left arm. The Geriatric Nurse Practitioner was again notified and ordered for Hydrocodone APAP 5/325 milligrams (mg) by mouth every four (4) hours for one dose then, return to every six (6) hours as needed for pain. The orders also included a repeat x-ray on the left arm the following day, 3/7/14. Review of an electronically signed Radiologist report of Resident #11's left arm dated 3/7/14 at 1:02 PM, subsequently revealed a stable fracture of the left proximal ulna. Record review of nurses' notes reflected the Geriatric Nurse Practitioner visited Resident #11 on 3/7/14 at 2:00 PM, reviewed the chart, and gave new orders to add osteopenia to Resident #11's diagnoses. A referral was ordered with an Orthopaedist and for Resident #11 to wear a sling to the left arm when she was out of bed and for the hand to be at the level of the heart. On 4/16/15 at 5:00 PM, an interview with the Geriatric Nurse Practitioner (GNP) revealed he recalled being phoned about Resident #11's fall. The GNP said he ordered x-rays and pain medication. The x-rays findings were negative for a fracture. The GNP reported Resident #11 continued to complain of pain and had some edema in her left arm. The GNP reported he ordered a repeat X-ray that confirmed Resident #11 did have a fracture and he ordered pain medication and an orthopaedic referral. The GNP stated, I see it happen all the time; the initial fracture not being revealed and it showing up later. On 3/3/14, the date after the incident, LPN #3 re-evaluated Resident #11 and determined to use a large, divided leg total lift. Comments for special use include: Cradle sling prior to lifting. On 4/16/15 at 1:45 PM, an interview with the Director of Nurses (DON) revealed Resident #11's sling order was changed on 3/3/14 as a precautionary measure just in case the lift/sling could have been part of the accident. On 4/16/15 at 1:48 PM, an interview with LPN # 3 stated she was part of the decision making team after Resident #11's fall. LPN #3 said the decision to change Resident #11 to a divided leg sling on 3/3/14 was for resident comfort after talking to her and evaluating her for safety. The evaluation as of 4/6/15 remained a divided leg cradle sling prior to lifting. Review of a New Fracture Investigation, completed by LPN #3 on 3/7/14 , revealed a Left ulna fracture resulting from a fall on 3/2/14. Review of a Resident Incident Report dated 3/7/14, completed by RN #5 revealed the Incident Type as a Fall with Fracture, Type of Injury as Major Injury, Location was resident room, Equipment was a motorized lift and Associate Involved was CNA #4. The narrative of the incident and description of injuries stated the resident fell from a lift sling during a transfer. Immediate actions taken were a resident body audit and notification of the Provider. The x-rays on 3/2/14 were negative for fracture, repeated 3/7/14 and found to be positive for a left ulna fracture and reportable to the State. Post-Incident Actions reported Immediate Post-Incident Action as: In-service. Included with the Resident Incident Report prepared on 3/7/14, a hand written statement signed by RN #2, revealed LPN #3 asked RN #2 to assist in evaluating Resident #11. Resident was sitting on a green sling and LPN #3 and RN #2 changed it to a large sling, as ordered to be used. The nurses then transferred Resident #11 to bed using the total lift, large sling. Resident #11 was provided incontinent care that required rolling from side to side and the resident did complain of left arm pain, which RN #2 described as unusual, due to this being the resident's CVA side. Review of the facility's fall investigation on 3/10/14, revealed CNA #4 phoned the former DON and advised the DON that she was resigning, and she was very sorry about the incident with Resident #11. This was signed by the former DON. The same day, CNA #4's written resignation was received by the former DON. Documentation reflected the Administrator reported the incident to the Attorney Generals Office on 3/10/14. On 4/16/15 at 3:25 PM, a telephone interview with the former DON verified the information for lifts were on each resident's ADL card. She revealed the CNAs knew that all sling lifts were to be a two person assist. She stated CNA #4 knew this and said so, but made a bad judgment call and thought it best that she resign and did so. A review of CNA #4's Personnel File revealed a Personnel Action, dated 3/3/14, revealed a one on one in-service and a written warning was given to CNA #4. CNA #4 was counseled and made aware of Resident #11's two (2) assist requirement for transfer and appropriate sling must be used as assessed as part of the resident's care and must be followed accordingly. Under employee comments, CNA #4 stated I knew that she was a two assist, but I made a bad decision to go ahead and do it by myself. The document was signed by the former DON, and by CNA #4 on 3/10/14. Review of the document Safe Resident Handling Program Skills Check list revealed CNA #4's signature on two occasions, 6/5/12, 4/6/13 and a sign-off signature by the trainer that read CNA #4 understood and would comply with the Safe Resident Handling Policy that clinical staff would utilize lift and transfer assistive devices as assessed. On 4/16/15 at 8:47 AM, an interview with RN #3 revealed she was the facility's Educator, but the use of the Lifts was conducted by the Restorative Care Team and RN #2 was over that team. RN #3 reported that lifts and transfers were part of the new employee educational program. She said she provided a demonstration with a return demonstration for each type of lift and the slide. The slings were color coded and a corresponding sticker was on the residents' doors. Observation on 4/16/15 at 9:18 AM revealed RN #3 explained Resident #11's door with the code system. Resident #11's door was labeled T2, indicating she was a total lift with two team members required. On 4/16/15 at 1:30 PM, an interview and observation with CNA #5 revealed a demonstration between an amputee sling and a divided leg sling and how they are labeled. CNA #5 revealed today's cardex showed Resident #11 required a divided leg cradle sling. CNA #5 demonstrated it's use. She said she would never get someone up in a sling alone, that she never wanted to put herself or a resident in danger. On 4/16/15 at 4:10 PM, an interview with the Administrator revealed the facility ensured new hires are trained in the lift program before they come in contact with the residents. The facility contracted with a lift company that comes several times per year for training sessions, and they also train the trainers who the train new hires between times. On 4/15/15 at 2:25 PM, an interview with Resident #11 revealed she was dropped from a sling by CNA #4 in March of last year during a transfer. She said CNA #4 used the wrong sling, the one for an amputee and she has one leg. They didn't send me to the hospital for a few days. My left arm hurt me really bad. I kept telling them it was broken. It all happened during the day time, I think around 2 o'clock. They put me back in my wheel chair using a different sling. Review of the facility's face sheet revealed, the facility admitted the resident on 4/02/10. Resident #11's [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 2/12/14, prior to the fall, revealed Resident #11 had a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Review of section G for Transfer revealed resident required a two person assist, full assist for transfer and amputee. Resident #5 Review of the facility's policy entitled, Audio Alarm Policy, not dated, revealed, Audio alarms will be applied as ordered by the physician, checked by the Certified Nursing Assistant (CNA) every two hours when rounds are made, checked by the nurse when medication pass is done and checked by other staff when in contact with the resident. The functioning of the alarm and battery will be monitored by the nurses each shift. Documentation will include the CNAs' ADL (Activities of Daily Living) care plan. Monitoring of the alarms will be documented on the CNAs' ADL care plan. The monitoring of the functioning of alarms and battery will be documented on the MAR (Medication Administration Record). Interview on 04/15/15 at 3:50 PM with the DON (Director of Nursing) concerning the Resident Incident Report for Resident #5, revealed, The DON read the report dated 01/18/15 bed/chair alarm plugged in but not sounding and 2/11/15 the wheel chair alarm wasn't on the wheelchair, the CNA forgot to put it back on. Review of the facility's Assessment of Risk of Falls revealed, Resident #5's fall risk total at nine (9) and 10, indicating resident was high risk. Review of the physician's orders [REDACTED]. Review of the MAR (Medication Administration Record) for Resident #5 revealed Nurse to monitor for functioning and placement Q (every) shift. Review of the facility's Resident Incident Report for Resident #5 revealed, on 01/18/15, the Resident was on the floor and the bed alarm was plugged in but not sounding. On 02/11/15, the Resident was on the floor and the alarm was not on the wheelchair. Review of the facility's face sheet revealed, the facility admitted the resident on 12/23/14. Resident #5's [DIAGNOSES REDACTED]. Review of the MDS with ARD of 03/21/15 had a BIMS score of 15 indicating the resident was cognitively intact. The MDS with ARD of 12/29/14 scored the transfer at three (3) (requiring two (2) person assist), ambulation at eight (8) (did not occur). The MDS with ARD of 03/21/15 scored transfer at three (3) (requiring two (2) person assist, ambulation at eight (8) (did not occur). Resident #10 Record review on 04/14/15 at 2:45 PM for Resident #10 revealed a physician's orders [REDACTED]. Nurse to check alarms to bed and WC Q (every) shift for placement and functional status. Review of the facility's Resident Incident Report for Resident #10 revealed, on 11/18/14, staff found resident on the floor and the alarm was on the bed but not connected. Resident was sent to the ER (emergency room ) with Fracture of the 4th Left Rib. Review of the facility's Nursing Instructions for CNAs for Resident #10 revealed, Bed and W/C pad alarm. Review of the MAR (Medication Admission Record) for Resident #10 revealed, Nurse to check alarm to bed and WC Q shift for placement and functional status. In an interview on 04/15/15 at 10:25 AM, the DON read aloud the incident report for Resident #10, dated 11/18/14, which revealed, Resident (#10) was found in the floor. Resident transported to the ER per ambulance. The resident complained of pain in right shoulder and right hip and left hip and left knee. X-ray showed a fracture of the 4th left rib. Record of the facility's face sheet revealed, the facility admitted the resident on 09/03/14. Resident #10's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/25/15 revealed Resident #10 had a BIMS (Brief Interview of Mental Status) score of 11, indicating the resident had moderately impaired cognition. The MDS with ARD of 02/25/15 scored the transfer at four (4) (requiring total assist), ambulation at eight (8) (did not occur). Resident #13 Review of the facility's Resident Incident Report for Resident #13 revealed, on 03/17/14 the Resident was found on the floor in front of a recliner. No pad alarm on recliner. On 03/24/14, a CNA found the resident lying on the floor.No documentation was noted of the alarm sounding. On 05/05/14, a CNA found the resident on the floor in front of the recliner after hearing her call for help. No documentation was noted of the alarm sounding. On 10/02/14, when called to room by Resident #10's roommate, staff found the resident on the floor. No documentation was noted of the alarm sounding. On 11/26/14, staff found resident lying on the floor. No documentation was noted of the alarm sounding. Record review revealed current April 2015 physician's orders [REDACTED]. Nurse to check alarms to bed and WC Q (every) shift for placement and functional status. Observation on 4/16/15 at 9:55AM of Resident #13 in bed with hospice staff in room. CNA #1 unplugged alarm on bed upon sounding. Review of the facility's fall risk assessment scored Resident #13 at 16-17, indicating resident was at high risk for falls. Review of the facility's face sheet revealed, the facility admitted the resident on 06/12/12. Resident #13's [DIAGNOSES REDACTED]. Review of the MDS with ARD of 02/03/14 revealed that Resident #13 had a BIMS score of 03 the resident had severely impaired cognition.

Based on observation, interview, record review and policy review the facility failed to ensure that residents were not neglected during transfer for one (1) of four (4) residents reviewed (Resident #1). Resident #1 had been assessed for the use of a gait belt with the assistance of two (2) persons for transfers and was transferred without the use of a second person on 5/21/12. Resident #1 was diagnosed with [REDACTED]. Findings include: Observation and interview on 6/5/12 at 9:45 a.m. revealed that Resident #1 was in a Geri-chair close to the nurse's station and was alert with confusion. Resident #1 had a sling intact to her left arm. There was no bruising or swelling noted to Resident #1's exposed left arm/shoulder area. Resident #1 had no facial grimacing or signs of discomfort. Observation of Resident #1's room door revealed a label next to the resident's name with "GB x 2." Interview with Certified Nurse Aide (CNA) #2, who was standing at the door, revealed that the label meant that the resident was to be transferred with a gait belt with two (2) person assist. Record review revealed that Resident #1 moved into the home on 8/10/11 with [DIAGNOSES REDACTED]. Review of the Minimum Data Sets (MDS), dated [DATE] and 5/50/12, revealed a Brief Interview for Mental Status score of 0, which indicated that Resident #1 was cognitively impaired. Review of the MDS, dated [DATE], revealed that Resident #1 required two (2) persons assistance with bed mobility and had not been transferred within the past seven (7) days. Review of the MDS, dated [DATE], revealed that Resident #1 required extensive assistance of two (2) persons for transfer assistance and bed mobility. Review of the home's "Lift/Transfer/Repositioning Evaluation Algorithm", dated 2/6/12, for Resident #1, noted that a total lift with one (1) person assistance was to be used for transfers, and two (2) person assistance was required for bed mobility/repositioning. Review of the evaluation, dated 2/26/12, noted that Resident #1 was to be transferred using a gait belt with assistance of two (2) persons with an update on 5/10/12 with no changes. Review of Resident #1's "Nursing Instructions for CNAs (Certified Nurse Aides)/ADL (Activities of Daily Living)" sheet, dated 2/26/12, noted that Resident #1 was to be transferred with a gait belt with two (2) persons. Review of an "Inservice (In-service) and Notification of Change to Care Plan" form, dated 2/26/12, for Resident #1, noted: "Resident now requires GB x 2 with the assistance of 2 staff." This form was signed by Certified Nurse Aide #1 as an acknowledgement of being notified of the change for Resident #1. Review of the May 2012 physician's orders [REDACTED]. Review of the x-ray report, dated 5/21/12, revealed an acute [MEDICAL CONDITION] humerus. Review of a nurse's note, dated 5/21/12 at 12:00 p.m., revealed that staff had reported [MEDICAL CONDITION] and pain to Resident #1's left shoulder and arm. Orders were received for an x-ray. Resident #1's RP (responsible party) was notified and reported that the resident had no complaint of pain or concerns the evening prior. At 7:00 p.m. on 5/21/12 x-ray results were reported to the physician of a fractured humerus with orders and placement of a sling on the left arm. Resident #1's left arm was noted to be purple in color, warm to touch with moderate [MEDICAL CONDITION]. The radial pulse was strong and Resident #1 was able to move her fingers but refused to move her arm. There was no facial grimacing except with movement of the left arm. A pain injection was administered. Review of an Incident Report, dated 5/21/12 at 11:00 a.m., revealed that Resident #1 yelled "That hurts me" when her left upper arm was touched. Resident #1's arm was noticed with a great deal of [MEDICAL CONDITION], was tight and hot. Review of the home's investigation, dated 5/21/12, revealed that the medication nurse had attempted to give Resident #1 an insulin injection in the left arm and noted the arm to be [MEDICAL CONDITION] and hot to touch. An assessment was done by the charge nurse and an x-ray was ordered with a result of fracture to the left humerus. After interview with staff and investigation it was not clear how the incident had occurred; however, the facility protocol had not been followed with transferring the resident from the bed to the Geri-chair and the staff member responsible (Certified Nurse Aide #1) was suspended and in-service was to be provided addressing the use of ADL (activities of daily living) and facility protocol. The facility conclusion was to terminate Certified Nurse Aide #1 for not following the care plan that was outlined for Resident #1, though they could not determine the actual cause of the injury. The facility's investigation revealed signed statements by staff who had provided care for Resident #1 on all three (3) shifts for 5/19/12 and 5/20/12 with no indication that Resident #3 had pain or injury during that time or any known incidents. Interview with Certified Nurse Aide (CNA) #1 on 6/5/12 at 12:00 p.m., revealed that she had transferred Resident #1 by herself with the use of a gait belt on the morning of 5/21/12. CNA #1 stated that she was aware that Resident #1 required a two (2) person assist with the gait belt for transfers but no one else was around at the time and breakfast trays were coming out so she went ahead and transferred Resident #1 alone. CNA #1 denied any fall, near fall, bump or incident while transferring Resident #1 and stated that Resident #1 didn't act any different than usual when she transferred her from the bed to the Geri-chair. CNA #1 stated that she pushed Resident #1 to breakfast and then checked her around 9:45 a.m. and the resident was dry and had no complaints at that time. CNA #1 stated that she and another CNA had put Resident #1 back to bed when Licensed Practical Nurse #1 had said that her arm was hurting. Interview with Licensed Practical Nurse (LPN) #1 on 6/5/12 at 10:08 a.m. revealed that Resident #1 was fine the morning of 5/21/12, then when Resident #1 went to give her insulin injection around 11:00 a.m. Resident #1 screamed out something like "That hurts me." LPN #1 stated that she noticed a slight swelling to the left upper arm but no bruising at that time. LPN #1 stated that she asked CNA (Certified Nurse Aide) #1 if Resident #1 complained when she had gotten her up that morning and was told that she didn't holler out but may had said "Oh" but nothing more than usual. LPN #1 stated that she later learned that CNA #1 had transferred Resident #1 by herself and that Resident #1 required two (2) persons for assistance with the gait belt for transfers. Interview with Registered Nurse (RN) #1 on 6/5/12 at 10:45 a.m. revealed that Licensed Practical Nurse (LPN) #1 had reported (5/21/12) that Resident #1 had a complaint of pain and swelling to her left shoulder when she attempted to give her insulin injection. RN #1 stated that she assessed Resident #1 and found swelling around the upper left arm/shoulder area and the area was warm to touch. RN #1 stated that there was no bruising at that time but later that afternoon the upper arm had started turning blue and Resident #1 complained of pain with movement of the arm. RN #1 stated that she talked with CNA #1, who had been assigned to Resident #1, and CNA #1 had denied any knowledge of an incident. RN #1 stated when she called CNA #1 back to see who had helped her transfer Resident #1 that CNA #1 had admitted to transferring the resident without assistance. RN #1 stated that CNA #1 still denied that any incident had occurred and was aware that Resident #1's care plan (activities of daily living card) documented the requirement of two (2) people for transfer. RN #1 stated that CNA #1 gave no reason for not using a second person to assist with Resident #1's transfer. RN #1 stated that she advised CNA #1 that she was suspended until the investigation was completed. Interview with the Director of Nurses (DON), with the Administrator present on 6/6/12 at 10:30 a.m., revealed that CNA (Certified Nurse Aide) #1 had not used two (2) person assistance as required when she transferred Resident #1 (5/21/12). The DON stated that she could not prove that the fracture for Resident #1 was a direct result of CNA #1's transfer of the resident, but that it could have been possible. The DON stated that CNA #1 had denied any incident, trauma or fall of Resident #1 during the transfer. The DON stated that CNA #1 admitted to knowing that Resident #1 required a two (2) person assist with transfer using the gait belt and also admitted to knowing that she was supposed to follow the care plan and had not done so. The DON stated that CNA #1 had been counseled prior on following the CNA care plan. The Administrator stated that CNA #1 was suspended then terminated for not following the care plan for Resident #1. Review of the home's "Residents' Free from Abuse and/or Neglect Policy", noted: "It is the policy of this facility that all residents will be free from physical, mental and/or verbal abuse and/or neglect."

Based on observation, interview, record review and policy review, the facility failed to ensure that physician orders [REDACTED].#1). Resident #1 had orders for a chair pad alarm beginning on 8/10/10. Resident #1 fell on [DATE] sustaining a hematoma to her head. Resident #1 was transferred to the emergency room (ER). Resident #1 did not have a chair pad alarm in use at the time of the fall. Staff interview revealed that Resident #1 had not consistently had the chair pad alarm in use since it was ordered on [DATE]. Findings Include: Cross refer to F-323 for the facilities failure to ensure that physician's orders [REDACTED].#1. Resident #1 stood from her chair while in the bathroom, fell and sustained a hematoma to the head.

Based on observation, interview, record review and policy review, the facility failed to ensure that one (1) of three (3) residents reviewed had chair alarms in place as ordered by the physician to alert staff of attempts to ambulate without supervision (Resident #1). Resident #1 had an order for [REDACTED]. Resident #1 fell on [DATE] and sustained a hematoma to her head and was transferred to the emergency room . Resident #1 did not have a chair pad alarm at the time of the fall. Findings Include: Observation of Resident #1 on 10/12/10 at 9:45 a.m. revealed that she was in a wheelchair with a lap buddy in place. Resident #1 was alert and oriented to person only but did answer some questions appropriately. Resident #1 was able to remove the lap buddy on command. An alarm sounded when the lap buddy was removed two (2) staff members responded to the alarm within 30 seconds. Resident #1 had no recall of any previous falls. Review of Resident #1's physician's orders [REDACTED]. Review of a "Resident Incident Log" revealed that Resident #1 fell on [DATE] at 9:30 a.m. and was transferred to the emergency room for an evaluation. Review of a "Resident Transfer Form" dated 9/22/10 revealed that Resident #1 fell while attempting to go to the bathroom and sustained an injury to her posterior head with a golf ball sized knot. Review of a nurse's note dated 9/22/10 at 9:30 a.m. revealed that Resident #1 fell in the bathroom. Resident #1 was taking her diaper off and slipped on the diaper. She sustained a posterior injury to the head-(golf ball sized). Orders were received to send Resident #1 to the ER. Review of the ER report dated 9/22/10 at 10:00 a.m. revealed that Resident #1' chief complaint was an injury to the head. The initial assessment revealed a hematoma with clinical impression of a contusion to the scalp and head injury. The physical exam revealed swelling to the back of the head. Resident #1 was sent back to the facility on [DATE] at 11:55 a.m. Review of a Cat Scan (CT) dated 9/22/10 revealed no hemorrhage, infarction, or mass lesions were identified. Review of Resident #1's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/7/10 revealed that she had long and short term memory problems and had moderate cognitive impairment. Resident #1 had documented falls in the past 30 days per the MDS. Resident #1 had a documented fall risk assessment 9/7/10 that had a score of "11". A score of " 07-18" indicated that Resident #1 was a high risk for falls. Review of Resident #1's care plan dated 1/28/10 revealed that she had a potential for falls related to a history of falls. She had fallen three (3) times while in the facility prior to the fall on 9/22/10. The care plan had an intervention date of 8/16/10 for a wheel chair pad alarm. On 9/24/10 the care plan was updated for a bed pad alarm and the nurse to check ordered alarms every shift for proper placement and functional status. Review of the "Nursing Instructions for CNA's", also known as the Kardex or ADL sheet, documented beginning 5/1/10 -8/31/10 revealed an intervention "alarm pad to w/c (wheelchair)". There was no date stating when the intervention was added. The Kardex dated 9/1/10-9/28/10 had a line drawn through the "alarm pad to w/c" (with no date), and the Kardex from 9/28/10-10/11/10 revealed that a "self release alarm, lap buddy, bed pad alarm, and floor pad alarm" was dated 9/29/10. There were CNA signatures documented every shift indicating that care was performed per documentation on the Kardex. Review of the Medication Administration Record (MAR) for September 2010 revealed "Nurse to check ordered alarm to bed and w/c every shift for placement and functional status". This was documented from 9/1/10-9/30/10 every shift as being performed. There was no documentation on the August 2010 MAR to check for alarms on Resident #1. Interview with CNA #1 on 10/12/10 at 9:45 a.m. revealed that she was not aware that Resident #1 had alarms prior to the fall that caused Resident #1 to and hit her head. CNA #1 stated that she was across the hall the day that Resident #1 fell and when she came into the room there was no alarm in the wheelchair. CNA #2 was yelling for the nurse to help. Interview with CNA #2 on 10/12/10 at 10:45 a.m. revealed that she had worked with Resident #1 since the middle of August 2010 and was not aware that the resident needed a chair pad alarm. CNA #2 stated that the ADL sheet did not have that information documented at that time. CNA #2 stated that she had not looked at the ADL sheets daily but had looked at them when she first started to work with Resident #1. CNA #2 stated that the nurse's usually informed the CNAs of any changes for resident care. CNA #2 stated that it was after Resident #1's fall when she was told that to look at the ADL/Kardex daily. CNA #2 stated that she thought the ADL sheet was changed to reflect the alarm after the fall but again stated that she had not looked at the ADL sheet daily prior to the fall. CNA #2 stated that the ADL sheet was signed on the back every shift by the CNAs indicating that the care that was documented on the front of the ADL sheet had been performed. CNA #2 stated that she had not put alarms on Resident #1 prior to her fall when she sustained the head injury. CNA #2 stated that she had gotten Resident #1 up in the wheelchair and taken her to the bathroom because Resident #1 was wet. CNA #2 stated that she went to get the resident's clothes off the bed, which was adjacent to the resident's bathroom, when she heard a noise. CNA #2 stated that she saw Resident #1 on the floor with a knot on her head. CNA #2 stated that Resident #1 was sent to the ER. Interview with CNA #3 on 10/12/10 at 11:00 a.m. revealed that she had taken care of Resident #1 and had not used any alarms prior to the resident's fall with the head injury. CNA #3 stated that the Kardex was initialed on the back for the care that was documented on the front of the Kardex every shift. CNA #3 stated that she had not been told to look at the Kardex daily until after Resident #1's fall. CNA #3 stated that the CNAs are on a permanent list for assigned residents and already knew what care was required. CNA #3 stated that the CNAs relied on the nurse's to let them know of any changes. CNA #3 stated that she looked at the Kardex for new residents. Interview with CNA #4 on 10/12/10 at 2:55 p.m. revealed that she had taken care of Resident #1 a few times and did not recall using an alarm on the wheelchair prior to Resident #1's fall in September 2010. CNA #4 stated that she did not look at the ADL sheets daily until she was told to do so after Resident #1 had the fall. Interview with CNA #5 on 10/12/10 at 3:42 p.m. revealed that she had taken care of Resident #1 prior and after the fall. CNA #5 stated that she was not aware of the resident having an alarm prior to the fall. CNA #5 was asked about signing the ADL sheets and stated: "I know, didn't always look at them but do now." Interview with RN #1 on 10/12/10 at 12:05 p.m. revealed that she had investigated Resident #1's fall after she had gone to theER on [DATE]. RN #1 stated that she did not see a chair pad alarm in the resident's wheelchair and there was not one in the room. RN #1 stated that CNA #2 told her that Resident #1 did not have an alarm. RN #1 stated that when she reviewed the resident's chart that a chair pad alarm was ordered for the resident. RN #1 stated that she had shown CNA #2 the ADL sheet for Resident #1 for the use of the alarm the day of the fall. RN #1 stated that CNA #2 had accused her of altering the sheet. RN #1 stated that any changes made to the ADL sheet should be dated at the time the change was made. RN #2 stated that she told CNAs in the past to check the ADL sheets daily for any changes. RN #1 stated that she couldn't say whether or not it would have made a difference for the alarm to have been in place for Resident #1 or not. RN #1 stated that it was ordered and it should have been used. RN #1 stated that the nurses were supposed to check for functioning of the alarm every shift and document on the MAR. Interview with RN #2, Unit Manager, on 10/12/10 at 9:30 a.m. revealed that she had received the physician's orders [REDACTED]. RN #2 stated that CNA #2 had been working with Resident #1 about two (2) weeks prior to the placement of the alarm and should have known about the order if she had looked at her ADL sheet daily as required. RN #2 stated that the CNAs were told to look at the ADL sheets daily prior to their shift and nurses were supposed to also let the CNAs know of changes. RN #2 stated that the nurse's were supposed to document that they have checked alarms every shift on the MAR. Further interview with RN #2 on 10/12/10 at 12:30 p.m. revealed that she had rewritten the ADL sheet for Resident #1 in September 2010 due to information not being clear. RN #2 stated that when changes were made on the ADL that it should be dated at the time of the change. RN #2 stated that she just failed to date the change when she added the chair pad alarm to Resident #1's wheelchair. Interview with RN #3, Charge Nurse, on 10/12/10 at 1:25 p.m. revealed that she had assessed Resident #1 the day that she fell and hit her head. She stated that Resident #1 was on the floor and had apparently fell against the sink. RN #3 stated that there was a golf ball sized knot on the resident's head. RN #3 stated that she had not heard an alarm prior to entering the resident's room. RN #3 did not recall Resident #1 having an alarm prior to the fall. RN #3 stated that the medication nurse's were usually checked the alarms and documented every shift. RN #3 stated that the person who changed the ADL sheets should notify the staff, and the sheet may or may not be dated. Interview with LPN #1 on 10/12/10 at 4:10 p.m. revealed that she did not recall if Resident #1 had an alarm in place prior to the fall. LPN #1 stated that Resident #1 did have an alarm when she returned from the hospital. LPN #1 stated that Resident #1 had a hematoma on her head from the fall. When asked about documenting on the MAR about checking the alarms, LPN #1 stated "I don't recall." LPN #1's initials were documented on the MAR for checking the bed/chair alarms on numerous dates in September 2010 prior to the fall on 9/22/10. Interview with LPN #2 on 10/12/10 at 2:10 p.m. revealed that she did not recall Resident #1 having an alarm prior to the fall with the head injury. LPN #2 stated that Resident #1 got up as she pleased a lot of the time. LPN #1 had documented on the MAR that she had checked the alarm for Resident #1 on 9/15/10. Interview with LPN #3 on 10/12/10 at 4:20 p.m. revealed that she did not recall Resident #1 with an alarm in place the early part of September (2010). LPN #3 stated that she had not been working for the past three (3) weeks and was unaware of Resident #1's fall. When asked about documentation on the MAR about checking Resident #1's alarm, LPN #3 stated that she didn't know for sure but that if she documented it then she had checked it. LPN #3 stated that she was still not sure whether Resident #1 had an alarm, but didn't know why she would have documented it if she didn't. LPN #3 had documented on the MAR that she checked the alarms on Resident #1 on several occasions the first part of September 2010. Interview with Resident #1's family member on 10/12/10 at 3:45 p.m. revealed that alarms had not been consistently used on Resident #1's chair. She did not recall seeing a chair alarm prior to Resident #1's fall on 9/22/10. The family member stated that Resident #1 had been known to remove her the alarms in the past. Interview with the DON on 10/12/10 at 5:50 p.m. revealed that the nurses are supposed to physically check the alarms before documenting on the MAR and if it is not there then they should question someone or check to make sure that the order was still current. The DON was not sure why they would document that it was checked if they didn't really check them. The DON stated that the CNAs should check the ADL sheet/care plan daily before giving care to see if there are any changes and initial the back of the sheet to indicate that they followed the ADL care plan. The DON stated that sometimes they may just get busy and don't pay attention to what they are documenting. The DON stated that the nurses should be supervising to ensure that physician's orders [REDACTED]. Interview with the Administrator on 10/12/10 at 3:10 p.m. revealed that Resident #1's family member had informed her after Resident #1's fall that the alarms had been in place at one time and then they weren't there for awhile. The Administrator stated that she had realized that there was an issue with the alarm after the fall and that staff had been educated and the Unit Managers were checking alarms as now. Further interview with the Administrator on 10/12/10 at 5:00 p.m. revealed that all nurses know to follow the physician's orders [REDACTED]. She stated that there had been inservice in July (2010) after (annual) survey to address following physician orders. The Administrator stated that the nurses were supposed to check the alarms during the medication pass each shift. The Administrator stated that the CNAs are supposed to check alarms every two (2) hours per policy and apparently that was not done for Resident #1. The Administrator stated that they are all saying that the alarm wasn't there for the wheelchair, yet, they were documenting as if the alarm was there. The Administrator stated that there seemed to be a problem with supervision to ensure that the alarm was there and that she had already realized through the investigation that it was a breakdown in communication. Review of the "Audio Alarms Monitoring Policy" with an effective date of 7/1/07 revealed that it was the policy of the facility that Audio Alarms will be monitored as follows: The use of the alarm will be monitored by the CNAs every two hours when rounds are made, by the nurse when medication pass is done, and by other staff when in contact with the residents. The functioning of the alarm and the battery will be monitored by nurses each shift. Documentation: The use of the alarm is documented on the CNAs ADL Care Plan. Monitoring the alarms will be documented on the CNAs ADL Care Plan and monitoring of functioning of alarm and battery will be documented on the MAR. Review of a facility "In-service Addressing Survey Problems June 2010" revealed a section: "Following MD Orders" which read, "All physician's orders [REDACTED]. If the order is unclear, get a clarification order. The order must be clear to everyone." Under the "Supervision of Residents" section: "Any resident on the Falling Star program must be supervised closely to prevent falls. The staff must be aware of the fall risk and increased need for supervision."