Every finding on record at North Star Manor

Based on observation, interview and document review, the facility failed to perform hand hygiene during care for 1 of 5 resident (R30) who were observed during cares. Findings include: R30's significant change Minimum Data Set (MDS) dated [DATE], identified R30 had severe cognitive impairment and required substantial/maximal assist with toileting and was always incontinent of bowel and bladder. R30's diagnoses included non-Alzheimer's dementia, and weakness. R30's care plan dated 8/3/26, identified they were incontinent and required their brief be checked and changed every two hours. During an observation on 9/16/26 at 9:30 a.m., nursing assistants (NA)-C and NA-D brought R30 back to her room, sanitized their hands, and assisted her into bed. NA C sanitized their hands again and changed their gloves, and then both NA C and NA D began to check and change R30. They removed R30's pants and brief, and R30 was found to be incontinent of both bowel and bladder. While wearing gloves, NA D asked R30 to roll toward her as NA C cleaned the bowel movement. After completing the initial cleanup, NA C removed the soiled brief; however, while still wearing the same gloves used to clean the bowel movement, NA C placed a clean brief under R30 and continued cleaning her peri area with wipes. NA D then assisted with securing the clean brief. With the same contaminated gloves still on, both NA C and NA D repositioned R30 in bed and covered her so she could take a nap. NA D then removed her gloves and sanitized her hands, and NA C removed her gloves, sanitized her hands, and carried the garbage out of the room. During an interview on 9/16/26 at 9:43 a.m., NA-C stated when caring for resident's and checking and changing them if a resident had BM, they would clean up the BM from the resident and then wash hands and change gloves before finishing drying off resident and placing a new brief under resident to ensure resident remained clean. NA-C said she did not change her gloves at all during the check and change and should have. During an interview on 9/16/26 at 2:53 p.m., the director of nursing (DON) stated hand hygiene was reviewed yearly and when needed. It is expected that nursing and NAs are to change gloves and wash or sanitize their hands when caring for residents and going from dirty to clean, for example, after cleaning up BM. The facility's Hand Hygiene policy dated 3/21/25, identified hand hygiene was to be performed after handling contaminated/dirty items and before handling clean areas.

Based on observation, interview and document review, the facility failed to assess and evaluate wandering behaviors, including entering other residents' rooms and going through personal belongings, for 1 of 3 residents (R13) reviewed for behavioral symptoms.Findings include:R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had severe cognitive impairment and diagnoses that included Alzheimer's disease, dementia and anxiety. R13 exhibited wandering daily. R13 used a bed alarm and a wander/elopement alarm. R13 required set-up/clean-up assistance with eating, was dependent on staff for lower body dressing and footwear and required substantial/maximal assistance for all other care areas.R13's Elopement Eval dated 11/20/25, identified R13 continued to be an elopement risk due to wandering and dementia. R13 had a wander alarm in place, had a history of elopement, and a sign on the assisted living door for R13 to turn around. R13 followed signs and had not tried to leave the facility.R13's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/21/25, identified resident had dual dx of Alzheimer's disease and dementia. R13 wandered throughout facility and had a wander alarm in place.R13's care plan revised 8/10/26, identified R13 had potential to leave the facility. R13 had a wander alarm in place to alert staff if R13 attempted to leave the facility unattended. Staff were directed at: Check wander alarm placement weekly and function monthly. Replace wander alarm yearly and as needed if not functioning correctly. Wander alarm in place.The care plan also identified R13 as at moderate risk for falls related to confusion and R13 was unaware of safety needs. Staff were directed to: Be sure the R13's call light was within reach and encourage R13 to use it for assistance as needed. needs prompt response to all requests for assistance. BED ALARM - ensure the device was in place and functioning. This was to be used at night to alert staff if R13 was up and starting to wander into rooms. Alarm would be off during the day. Ensure that R13 was wearing appropriate footwear black sketcher slip in shoes with the heel that stays up in the back. R13 was able to get these shoes on and off safely. Ensure/provide a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; personal items within reach. Please bring R13 to her room and assist R13 to lay down to rest after breakfast and lunch. Please make sure to take R13's shoes off and put a blanket on R13.Additionally, the care plan identified R13 was incontinent of bowel and bladder. R13 required substantial assistance with toileting, changing of incontinence products and cleaning herself. Staff were directed to: Check and change Every 2 hours during the night, offer toilet at those times and as needed. Toilet every two hours during the day.The care plan also identified R13 had a history of anxiety and have taken medications in the past. R13 had an increase in going into other residents' rooms; even with the door closed and I at times will nap in their beds. R13 had multiple episodes of being up at night and walking in the halls; not sleeping well. Remeron (an antidepressant medication) 7.5 milligrams at bedtime was started on 4/24/26. Staff were directed to: ANTIDEPRESSANT POTENTIAL SIDE EFFECTS: Aggression, agitation, confusion, dissociative experiences, dry mouth, fainting, GI issues, headache, manic or psychotic reactions, palpitations, restlessness, sedation, sensory neuropathy, serotonin syndrome, sexual side effects, suicidal thoughts, sweating, grinding teeth, clenching jaw, tremors, urinary difficulties, vision problems, weight gain/loss. Medications prescribed by provider; Sleep monitoring; TARGET BEHAVIORS: 1. Sleeping in other residents' beds 2. Not sleeping at night. R13's Behavior notes identified the following:On 1/26/26 at 6:55 p.m., wandering into another resident's room. R13 was redirected to her own room. R13 stated how did I do that? Writer assisted R13 to R13's room one door down.On 1/27/26 at 11:07 a.m., R13 was found another resident's room lying in the bed. Writer redirected R13 to R13's room next door and showed R13 the sign on her door stating her name.On 2/9/26 at 1:18 p.m., R13 was laying down in another resident's bed. R13 had been in and out of a few other residents' rooms. R13 was redirected.On 2/9/26 at 5:16 p.m., R13 lay down in other residents' bed, was in and out of a few other residents' rooms. R13 was redirected.On 2/14/26 at 11:47 a.m., R13 was in and out of other residents' room and laying in their beds. R13 was redirected many times.On 2/14/26 at 3:45 p.m., R13 was found in another resident's bed. R13 was assisted to R13's room. 10 minutes later the other resident came out of his room and stated there was a lady in his bed. R13 was again redirected to R13's room.On 2/17/26 at 5:01 p.m., cart nurse reported R13 was found in another resident's room multiple times. The other resident was becoming increasingly agitated and began to yell at R13. Staff put a do not enter banner across the room door frame to deter R13 from entering. R13 was then observed going under the banner into the room. Writer added a picture to the banner that was currently on the assisted living door that had been successful in preventing R13 from going into the assisted living facility. The picture was R13 with a note that said, turn around, do not enter Also added a sign to the side of the other resident's door with [NAME] the pooh and a note that said, your room is this way and pointing in the direction of R13's door. Placed a sign on R13's door with [NAME] the pooh and R13's name. This character was chosen since it was R13's favorite character and familiar to her.On 2/17/26 at 10:27 p.m., R13 entered the same room and lay in bed three times. R13 was redirected.On 2/25/26 at 4:02 p.m., R13 was found wandering into another resident's room.On 2/26/26 at 1:41 p.m., R13 was found in two residents' room lying in beds. R13 was easily redirected. On 3/3/26 at 9:51 a.m., writer found R13 lying in bed in another resident's bed. When writer asked if R13 needed help finding her bed, R13 stated am I in the wrong room again? and shook her head in a disgusted way. When leaving the room, writer and R13 walked right under the sign that stated R13's name and directed R13 do not enter. Writer told R13 that R13 must have walked right under the sign. R13 replied ummmm, yep. R13 was easily redirected and laying in her own bed napping.On 3/5/26 at 9:20 a.m., writer found R13 lying on bed in another resident's room. When asked if R13 wanted to lie down in her own room, R13 stated, I thought I was. Writer redirected R13 to her own room which was the next room on the same side of hallway. R13 stated, I was close. R13 looked at signs on the door and stated, that's me. and I will lay here.On 3/29/26 at 9:00 p.m., R13 was found in another resident's room by that resident. R13 was sleeping in bed. R13 was redirected back to R13's room and bed.On 4/3/26 at 11:45 a.m., R13 was found lying in another resident's bed with her eyes closed. R13 was easily redirected back to R13's room.On 4/4/26 at 1:35 p.m., R13 was found in another resident's room this afternoon. R13 was redirected to R13's room with staff.On 4/4/26 at 6:15 p.m., R13 was found sleeping in another resident's bed and was redirected back to R13's room. R13 had no other attempts this evening. R13 did wander but it was mostly in the hallways. R13 did walk into another resident's room but writer was right behind R13 and redirected R13 out of the room.On 4/5/26 at 6:17 p.m., R13 was wandering into other residents' rooms throughout the day starting around 2:30 p.m. after church services. Nursing assistants reported that R13 was opening closed doors and while cares were being done and R13 walked in without knocking. R13 was redirected back to R13's room but it was not effective and R13 continued to wander. Offered 1:1, snacks but R13 was not interested.On 4/6/26 at 5:18 a.m., R13 slept the first few hours of the night. Since then, R13 was in and out of bed. R13 was found lying in the bed of an empty room. Reminded R13 that she can't go in any doors that were not hers, and that her door says R13's name on it. No further attempts to go to any others' rooms.On 4/6/26 at 6:18 a.m., R13 entered another resident's room while that resident was toileted. R13 was redirected out of the room.On 4/23/26 at 9:55 p.m., R13 was redirected several times throughout the evening shift from other residents' rooms/beds. R13 was easily redirected, however, continued to go in and out of other residents' rooms uninvited. Most of the residents were asking to have their doors shut to keep R13 out.On 4/25/26 at 9:23 a.m., R13 was found sleeping in another resident's bed this morning. R13 was easily redirected back to R13's room where R13 was assisted to lay down in R13's bed.On 4/28/26 at 11:07 a.m., R13 had a long history of walking throughout the facility during waking hours. R13 was a nurse of 40 years practicing in many areas throughout her career. R13 had episodes of going into other residents' rooms but would at times smooth a bedspread or straighten a piece of paper on a table. Throughout the past several weeks this has been changing. R13 was not sleeping well at night; multiple notes indicated R13 was up and ambulated several times during the night. R13 was also going into other residents' room and was found many times to be sleeping in their beds. Some of the residents have stated they would rather R13 did not do that and have asked that their doors remain closed. R13 had no awareness of other residents' personal space and would at times enter a room even if the door was closed. R13 was always easily redirected and had not offered any resistance to moving out of another resident's bed/room. R13 had established care with behavioral health on 2/25/2026; no changes in medications were made at that time per family request. As R13's episodes of going into other residents' rooms increased, R13's family was updated. R13's family reported that R13 used to be prescribed Xanax (an antianxiety medication) and would take very tiny amounts that seemed to be effective in R13's past. R13's family reported that R13 has also taken sertraline (an antidepressant medication) in the past. R13's behavioral health medical provider was updated with new order for Remeron (an antidepressant medication) 7.5mg at bedtime for diagnosis of anxiety. This was started on 4/24/2026 with sleep monitoring. R13 was sleeping through the night since the start of this medication and had no adverse reactions at this time. Verbal consent obtained from R13's family at start of medication. R13's care plan was updated to reflect new medications, new target behaviors of sleeping in other residents' beds and entering other residents' room even with the doors closed and monitoring of signs/symptoms of adverse reactions. On 4/28/26 at 12:30 p.m., Addendum: R13's episodes of lying in other residents' beds had occurred 4-8 times per week since 3/22/26. Several other interventions were attempted prior to medication to prevent her from going into others' rooms including closing their doors, magnetic stop banners across their doors and a banner across her door to remind her at night it is not time to get up; all unsuccessful. As R13 had not been sleeping well prior to the Remeron, it may be R13 needed to lay down in a bed close by to rest before continuing to walk the halls. Monitoring for a decrease in these episodes as R13 slept better through the night. On 4/28/26 at 1:12 p.m., R13 found sleeping in another resident's bed. R13 was redirected back to R13's room and was laying in her own bed at that time.On 4/28/26 at 8:56 p.m., R13 was noted entering another resident's room. R13 entered, turned around and walked out. R13 was redirected from entering the room. R13 stated I was seeing if my brother was in there. Writer talked with R13 about only entering the room with the green around the door. R13 agreed.On 5/21/26 at 10:49 p.m., R13 did not go into any other resident rooms, walked up and down the hallways prior to going to sleep.On 5/24/26 at 7:16 p.m., writer was alerted that R13 was found sleeping in another resident's room after supper. R13 did walk and pleasantly got up when redirected back to R13's room.On 5/26/25 at 9:45 a.m., R13 was found in another resident's room.On 5/26/26 at 8:01 p.m., R13 was found sleeping in another resident's bed today. R13 was easily redirected back to R13's bed. The other resident was upset that R13 was sleeping in her bed.On 6/4/26 at 5:50 a.m., R13 was awake most of the night. Bed alarm was on and R13 was up often during the night. R13 would walk around in R13's room and then lay back down in bed. R13 walked the hallway twice at the beginning of the shift but remained in her room the remainder of the shift.On 7/6/26 at 5:03 p.m., R13 entered different rooms. R13 entered another resident's room but that resident blocked R13 with her walker. The other resident expressed frustration by stating she did not want R13 to lay down in her bed. The other resident was ok if R13 entered the room but not with R13 laying in the bed.On 7/6/26 at 11:10 p.m., R13 was reported to have walked into another resident's room and was stopped by the resident with her walker. R13 attempted to bypass the walker and continue into the room but was again blocked by the other resident and her walker. Staff intervened and redirected R13. The other resident told staff she did not want R13 in her room, that R13 slept in her bed before and did not want it to happen again.On 7/17/26 at 11:55 a.m., R13 was sleeping in another resident's bed. R13 was redirected to go have lunch.On 7/24/26 at 5:28 a.m., Document on sleep habits/pattern weekly every Thursday night shift for sleep pattern. R13 was sleeping well overnight. Per night staff, R13 was refusing to get out of bed to go to the bathroom when encouraged. R13 was a check and change in bed. R13 made no attempts to walk in the hallway and no attempts to go into another resident's room. The few times of bed alarm going off R13 was easily redirected to bathroom and back to bed or if R13 refused bathroom need then was easily redirected to lay back down.On 7/19/26 at 9:40 p.m., staff and writer noted R13 going in and out of other residents' room all evening. Redirection was ineffective. R13 continued the behavior. One resident was lying in bed and started crying. Another resident was angry, started yelling for R13 to get out. Another resident was concerned that R13 was going for a pair of scissors and sewing items. R13 continued to walk the halls, almost tripping multiple times on her feet, with redirection lasting only a few minutes. On 7/19/26 at 11:34 a.m., R13 wandered into another resident's room and talked with the other resident's family.On 7/27/26 at 4:01 p.m., writer was bringing another resident a beverage after bingo (3:40 p.m.) and it was noted that R13 was lying in the other resident's bed. R13 was easily aroused and ambulated with this writer to R13's room and assisted to lie down. The other resident was not upset and just stated She's so sweet I hate to tell her to go, but she probably should.On 7/28/26 at 9:11 a.m., R13 was seen going into multiple rooms down the hallway. Another resident was seen telling R13 to go back to R13's room. R13 was redirected by another staff member back to R13's room where R13 laid down.On 7/28/26 at 6:43 p.m., R13 was sleeping in another resident's bed. Staff redirected R13 to R13's room and assisted with toileting. R13 stated who told when writer was attempting to assist R13. R13 was cooperative with assistance. R13 did not want to lay down in her own bed and moments later R13 was noted back in the other resident's room. R13 was redirected.On 8/17/26 at 6:05 a.m., R13 woke up around 4:00 a.m. and started wandering the hallway. R13 was redirected to R13's room after one wandering for about 5 minutes but came right back out and started walking. R13 was later redirected again by the nursing assistant who dressed R13 for the day. R13 later went back to bed after morning cares were completed around 5:30 a.m.On 8/18/26 at 7:43 p.m., Has the resident had changes in mood? Irritable, anxious, accusatory, isolating, negative statements: WanderingWhat behaviors was the resident showing: restless, anxious, yelling, hitting, etc.? NAWhat were the circumstances prior to the behavior: Resident was wandering throughout the facility.What non-pharm interventions were used to stop the behavior: validation, redirection, snack, etc.? Snack and redirectionDescribe effectiveness of non-pharm interventions: YesDid the resident receive a PRN medication? Med/dose/time administered: NADescribe the effectiveness of the PRN medication: no Nursing Summary: Resident was seen tearing out pages of narcotic record book on East side med cart. Resident was later seen taking items off the med cart. Resident was redirected and given a snack. At this time intervention has been effective.On 8/20/26 at 12:00 p.m., R13 was seen coming out of another resident's room this afternoon. R13 stated I am just walking. Continued walking down the hallway to the common area. Was not seen going into any other resident rooms at this time. On 9/4/26 at 5:08 p.m., R13 was seen multiple times from 1:00 - 5:00 p.m. going into other residents' room [ROOM NUMBER] times. R13 was easily redirected back to the hallway. R13 also redirected for about an hour in her room to eat candy. Another resident was heard telling R13 you can't go in any room you please stay out of there. R13 unfazed by conversation and continued to wander through hallways. During a continuous observation on 9/15/26 at 8:29 a.m., R13 was up, dressed and walking the hallways aimlessly. No staff redirected R13. At 8:32 a.m., R13 stood in another resident's doorway and stared at the other resident before R13 continued walking down the hallway.At 8:32 a.m., R13 entered another resident's room but registered nurse (RN)-D intercepted R13. Let me show you where your room is. RN-B brought R13 to her doorway and pointed at the sign with R13's name on it. What does this say? R13 stated her name. RN-D assisted R13 to walk into her room. Do you want to lie down for a little rest? R13 did not reply. RN-D opened R13's blinds but did not assist R13 to lie down before leaving the room.At 8:34 a.m., R13 left R13's room and went into another resident's room. R13 walked around the room, looked out the window and left the room. R13 then walked down the hallway and looked into every room with an open door.At 8:36 a.m., R13 wandered past the nursing station, to the exit door and turned around. R13 walked past the nail care activity. No staff offered R13 to sit down and participate.At 8:38 a.m., R13 went into another resident's room, turned around and left. R13 continued to wander down the hall. Multiple staff meet R13 and told R13 good morning, but none offered assistance and/or redirection. At 8:44 a.m., R13 went into another resident's room. R13 turned around and left the room. No staff intervened. At 8:45 a.m., R13 went into another resident's room and lay down on the bed setting off the bed alarm. Nursing assistant (NA)-A entered the room and stated, let's go to your room, ok? NA-A assisted R13 to sit on the side of the bed and then walked with R13 to R13's room.At 8:49 a.m., NA-A pointed to R13's bed and pulled back the blankets. R13 lay down in the bed with minimal assistance. NA-A removed R13's shoes and raised the head of the bed to approximately 25 dressed and covered R13 with her blankets. NA-A did not offer toileting to R13. During an interview on 9/15/26 at 8:54 a.m., NA-A stated R13 wandered all the time. Staff tried to redirect R13, if staff were to see R13 looking for a bathroom, staff would take her to the bathroom. or if staff found her in another resident's room, staff took R13 back to R13's room. The other residents did get upset when they found R13 in their rooms but mostly the staff just redirected. During an observation on 9/15/26 at 3:19 p.m., R13 was walking up and down the hallway, circling the dining room loop and then walking back down the hallway. RN-B and NA-E stopped R13 and talked with R13. R13 turned around and walked into R13's room.At 3:22 p.m., NA-E assisted R13 to lie down, NA-E removed R13's shoes. NA-B entered the room but left again for gripper socks. At 3:23 a.m., NA-B returned and put gripper socks on R13. NA-E left the room. NA-B turned off R13's room lights and left the room. R13 was not offered toileting.During an interview on 9/15/26 at 3:27 p.m., NA-B stated R13 walked around a lot. R13 never had a place where R13 routinely went. R13 just walked. R13 would go into other resident rooms. Sometimes, R13 just walked around and left. Sometimes, R13 laid down in the bed. Staff would redirect R13 back to R13's room. Staff had tried taking R13 to the bathroom, giving R13 ice cream or helping R13 to lie down in R13's bed. However, no, NA-B nor NA-E took R13 to the bathroom now. Sometimes it helped and sometimes it didn't. NA-B shrugged and stated R13 really couldn't say what she wanted. R13 didn't talk much and sometimes just didn't answer. Other residents did get upset that R13 was in their rooms. Again, NA-B shrugged and stated staff just redirected R13. At 3:37 p.m., licensed practical nurse (LPN)-B and LPN-C entered R13's room and administered meds to R13. LPN-C asked R13 if she wanted to use the bathroom but LPN-B stated, she was just up. Both LPN-B and LPN-C left the room without taking R13 to the bathroom. At 3:41 p.m., R13's bed alarm sounded. NA-B entered R13's room and R13 was walking around her room. NA-B asked R13 if she wanted to use the bathroom but R13 did not respond. NA-B assisted R13 into the bathroom and assisted R13 to pull down her pants before telling R13 to sit down. R13 stated I don't know and began leaving the bathroom. NA-B told R13 she would help R13. NA-B assisted R13 to stand in front of the toilet, then assisted R13 to sit down. R13 immediately voided. Once R13 started to stand, NA-B gave R13 toilet tissue and R13 completed the task. NA-B used a disposable wipe to ensure R13's skin was clean, pulled up R13's pants and then assisted R13 to lie back down in bed. During an observation on 9/16/26 at 8:57 a.m., R13 was up, dressed and ate breakfast in the dining room. At 9:22 a.m., RN-D sat down at the table with R13 to visit. All other residents have finished eating and returned to their room. At 9:23 a.m., RN-B asked R13 if R13 wanted more breakfast or did R13 have enough? I better. RN-D stated ok but did not get more breakfast for R13. R13 stated usually about good or bad. RN-D told R13 did eat well today and asked if R13 wanted more coffee and if R13 wanted cream or sugar. I do. R13 pointed at her food. RN-D did not get more coffee for R13. RN-D then asked if she could clean up R13's place setting. R13 did not respond.At 9:30 a.m., RN-D removed R13's clothing protector. R13 stood up and started picking up her dishes. RN-D stated that she would take care of it. Then asked if R13 could step away from the table. R13 walked down the hallway. No staff offered to toilet R13 or to assist R13 to lie down in bed as care planned. At 9:44 a.m., R13 had walked a loop of the entire facility and was back in the dining room. R13 stood in front of the tv for approximately 30 seconds before walking to the dining table. R13 then went to the window when the door alarm sounded. NA-E walked with R13 by taking R13's hand and assisted to sit in an easy chair in front of the tv before covering R13 with a blanket. NA-E did not offer toileting or to assist R13 to lie down.At 9:49 a.m., R13 stood up with the blanket bunched in her hands. R13 walked back down the hallway looking at every open door. NA-B and NA-E walked past R13 but did not offer toileting or assist to lie down.At 9:57 a.m., R13 made another loop of the hallway and was back at the easy chair in the dining room. R13 immediately stood back up and started walking again. The administrator met R13 in the hallway and asked if she could take R13's blanket. R13 handed the administrator the blanket and began walking into another resident's room. The administrator asked NA-B to assist R13. NA-B walked with R13 to R13's room.At 10:00 a.m., NA-B assisted R13 to toilet where R13 immediately voided and then assisted R13 to lie down in R13's bed. During an interview on 9/16/26 at 10:13 a.m., trained medication aide (TMA)-A stated R13 walked around. R13 had dementia. TMA-A shrugged and stated R13 might do a little activity or listen. To keep R13 out of other resident rooms, there were stop signs that went across the door. However, there were no stop signs observed in the hallway. During an interview on 9/16/26 at 10:15 a.m., licensed practical nurse (LPN)-A stated R13 was a former nurse so when R13's walking R13 was doing her rounds, just checking on everything. R13 would go into other resident rooms, and staff tried to catch R13 before she did that. Sometimes activities would take R13 or she might sit and watch tv. Staff tried to distract R13.During an interview with RN-B and RN-C on 9/16/26 at 2:44 p.m., RN-C stated staff talked with her R13's family who said if it made R13 happy, let R13 do it. RN-C stated she had watched R13 and wasn't bothering anyone else. Sometimes staff would redirect R13 with ice cream, R13 liked candy, and liked a hand massages. RN-B stated if R13 entered a room multiple times, R13 was looking for a bathroom. RN-B stated that staff had tried stop signs on the rooms R13 frequently went to, R13's room doorframe was painted green, and put signs with R13's name on her door. R13 was a former nurse and staff believed R13 was doing her rounds, checking on people. Some of the other residents invited R13 into their room but other residents were as open to it. We do our best to keep her out of rooms but it was just routine for R13. RN-C stated, at night, staff closed the nursing station fire doors to prevent R13 going to where there was no staff. R13 also had a bed alarm to alert staff to when R13 got up. Every time R13 got up at night, staff took R13 to the bathroom. RN-C stated R13 was a very fast eater and would wander for a bit after meals until the other residents are done. Then staff were able to take R13 to the bathroom and help her lie down. RN-B stated it depended on R13 as well, but most of the time R13 would eat candy in her room and then go to sleep. During an interview on 9/16/26 at 3:10 p.m., the director of nursing (DON) stated staff were expected to assess and care plan interventions for R13's wandering to ensure R13 safety as well as other residents rights.During an interview on 9/16/26 at 3:37 p.m., the administrator stated R13's wandering should be assessed and care planned to ensure R13's safety. The facility policy Elopement/Missing Resident revised 8/2/23, identified the procedure to reduce the risk of elopement. In addition, provide an organized approach to search for if a resident is found to be missing from the facility. However, the policy failed to address resident wandering within the facility.

Based on interview and document review, the facility failed to ensure a gradual dose reduction (GDR) or a clinical justification of a psychotropic medications was documented for 1 of 5 residents (R16) reviewed for unnecessary medication and were taking psychotropic medications. Findings include:R16's significant change Minimum Data Set (MDS) dated [DATE], identified R16 was cognitively intact and had diagnoses that included Alzheimer's disease, dementia, anxiety, restless leg syndrome and type 2 diabetes. R16 used antianxiety medications.R16's Psychotropic Drug Use Care Area Assessment (CAA) dated 8/27/26, identified R16 used Ativan (lorazepam) (an antianxiety medication) daily for anxiety. R16 had recently graduated from hospice and had anxiety regarding end of life. R16 would use her call light for staff assistance but did not wait for staff to arrive. R16's mood was stable and appropriate in conversation. R16's family was highly involved in care. R16's medications were now managed by R16's primary physician. Side effects are monitored by staff. R16 had no behaviors noted. R16's care plan revised 9/9/26, identified R16 was admitted to Hospice 3/5/26; added lorazepam 0.5 milligram (mg) as needed and consent was signed on 3/5/26; scheduled lorazepam 0.5 mg at bedtime and consent was signed on 4/27/26. The care plan identified anti-anxiety medication potential side effects: Anticholinergic symptoms (blurred vision, constipation, dry mouth, urinary retention) increase in behavioral symptoms, increased falls/dizziness, orthostatic BP, sedation/drowsiness and target behaviors: anxiety/restlessness that is not easily re-directed related to end of life. However, the care plan failed to identify potential non-pharmaceutical interventions.R16's Physician order dated 9/3/26, identified the following:On 5/2/26, lorazepam oral tablet 0.5 mg give 0.5 mg by mouth every day related to anxiety disorder.On 9/3/26, lorazepam oral tablet 0.5 mg give 0.5 mg by mouth every 4 hours as needed for anxiety until 10/3/26. Not to be given 2 hours prior to scheduled dose at 11:00 p.m. or 2 hours after. R16's Gradual Dose Reduction Review dated 8/20/26 at 3:02 p.m., identified the following: Medication/Dose/Frequency: Lorazepam 0.5mg by mouth at bedtime. Lorazepam 0.5mg by mouth every 6 hours as needed. Target Behaviors Reviewed: Anxiety/restlessness that is not easily redirected related to end of life. Type of Review: first review since start of lorazepam by hospice.Nursing Summary: R16 had taken one dose of as needed lorazepam in June, none in July or up to this date. R16's mood has been stable. Her weight was increasing; lowest weight was 86 pounds on 3/4/2026; current weight was 115 pounds 8/11/2026. R16 was eating meals in the dining room and conversing with her tablemates and socializing with other residents daily. R16 would be graduating from hospice on 8/20/26. IDT recommended no changes. Is GDR attempt possible at this time? Y/N: N New order/Rationale for no change: R16's medical provider concurred with the above, signed and returned the form.R16's Communication/Visit with Physician dated 9/3/26 at 1:01 p.m., identified R16's medical provider was updated regarding R16's discharge from hospice which she was aware. It was ok for R16 to be seen during rounds on 9/16/26. No concerns at this time, order received to continue with lorazepam 0.5 mg every 4 hours as needed for 30 days for anxiety. However, there was no rationale documented for continued use. During an interview on 9/16/26 at 8:34 a.m., licensed practical nurse (LPN)-A stated orders for lorazepam could only be for a certain number of days and then needed to be reviewed by the medical provider. Staff needed to document R16's condition and behaviors and these were discussed with the medical provider as well before the medication would be renewed. During an interview trained medication aide (TMA)-A and nursing assistant (NA)-F on 9/16/26 at 1:56 p.m., TMA-A stated when R16 was first admitted R16 didn't even want to leave her bed, but R16 had improved and would go to the dining room sometimes. NA-F stated R16 wasn't really into activities but sometimes would go. TMA-A and NA-F stated R16 did not show signs/symptoms of anxiety and neither had ever seen R16 like that.During an interview with registered nurse (RN)-B and RN-C on 9/16/26 at 2:23 p.m., RN-A stated R16 was originally started on lorazepam because R16 was on hospice and a consent had to be signed as well. When it was originally ordered it was for 14 days, then the order was extended further; at most 30 days. During renewal, the amount of use, why it's used or if the resident wanted it was reviewed. Gradual Dose Reductions were done by RN-D.During an interview on 9/16/26 at 2:55 p.m., RN-D stated R16 had a GDR reviewed on 8/20/26 by the interdisciplinary team. At that time, the team was reluctant to change R16's scheduled lorazepam and the as needed dose was overlooked and should have been discontinued because an unneeded psychotropic medication could be a chemical restraint. That's definitely not our goal. During an interview on 9/16/26 at 3:01 p.m., the director of nursing (DON) stated R16 had been on hospice and that was why the prn lorazepam had been overlooked. The DON stated the facility had recently gained a mental health practitioner and psychotropic medication use had skyrocketed but the team had met only once to address it. The facility wanted to find more natural measures to support resident behaviors. R16's as needed lorazepam should have been discontinued and/or documented rationale for continued use. During an interview on 9/16/26 at 3:37 p.m., the administrator stated staff were expected to follow CMS guidelines for as needed psychotropic medications to ensure the rationale and use were appropriate. A psychotropic drug use policy was requested but not received.

Based on interview and document review, the facility failed to investigate, document, and track resolution of a resident grievance regarding resident (R13) entering their room and going through their belongings for 6 of 6 resident (R4, R10, R11, R15, R24, R25) reviewed for grievances.Findings include:R13R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had severe cognitive impairment and diagnoses that included Alzheimer's disease and dementia. R13 exhibited wandering daily. R13 used a bed alarm and a wander/elopement alarm.R13's Cognitive Loss/Dementia Care Area Assessment (CAA) dated 11/21/25, identified R13 had dual dx of Alzheimer's disease and dementia. R13 wandered throughout the facility and had a wander alarm in place.R4R4's annual Minimum Data Set (MDS) dated [DATE], identified R4 was cognitively intact and had diagnoses that included traumatic subdural hemorrhage (a life-threatening collection of blood between the surface of the brain and its outer dural covering, caused by a head injury that tears blood vessels), tension headaches and vertigo.R4's care plan revised 9/9/26, identified R4 was able to make choices in my daily life including activities, food choices, and activities of daily living (ADLS). R4 liked to get up by 7:00 a.m. and preferred to be in bed by 6:30 p.m. R4 liked to watch tv in bed before going to sleep. Staff were directed to encourage R4's choices in clothing, meals and cares. However, the care plan failed to identify R4's preference for R13 to not enter his room.R4's nursing notes failed to identify any notes regarding R13 entering R4's room and/or R4's complaints. During an interview on 9/14/26 at 4:12 p.m., R4 stated well R13 comes in here (R4's room). One time, R4 was in the bathroom and, when 13R4 came out of the bathroom, R13 was lying in R4's bed. R13 can't hear worth a darn so R4 kind of yelled at R13. R4 stated he did not want to do that because he did not want to scare R13 or make R13 fall. The staff heard R4 yelling and came int and got R13 up and took her out of the room. However, R13 had voided urine in R4's bed. After that, R4 watched R13. R13 was really quiet though and would sneak up on R4. Mostly, R13 just stood and looked out the window and R4 made sure R13 stayed out of his bed. R4 stated he had told the staff many times that he didn't like R13 in his room but R13 continued to wander into R4's room. There's nothing they can do about it. R10R10's quarterly MDS dated [DATE], identified R10 had a moderate cognitive impairment and diagnoses that included chronic respiratory failure, heart failure, non-Alzheimer's dementia and anxiety disorder. R10's care plan revised 7/7/26, identified R10 was able to make choices in my daily life including activities, food choices, and ADLS. R10 liked to wake up around 6:00 a.m. and preferred to go to bed by 7:00 p.m. R10 liked to watch television in bed before falling asleep.R10's nursing notes failed to identify any notes regarding R13 entering R10's room and/or R10's complaints.During an interview on 9/16/26 at 12:42 p.m., R10 stated R13 came into R10's room and found R10's bed to crawl in to. I just feel bad for her. I don't complain. I just don't have the nerve. R10 stated she would just go find one of the workers to get R13 out of R10's bed.R11R11's quarterly MDS dated [DATE] identified was R11 was cognitively intact and had diagnoses that included type 2 diabetes. R11's care plan revised 11/20/25, identified R11 was able to make choices in daily life including activities, food choices, and ADLS. R11 did not consistently make appropriate choices such as refusing cares or appointments. R11 preferred not to have staff enter R11's room until after 8:00 a.m. R11 liked to wake up between 8-8:30 a.m. and preferred to go to bed by 9:00 p.m. Staff were directed to encourage R11's choices of clothing, meals and cares. R11's nursing notes failed to identify any notes regarding R13 entering R11's room and/or R11's complaints. During an interview on 9/16/26 at 11:50 a.m., R11 stated R13 wandered into R11's room all the time. If R11 was in her room, R13 would stand in the doorway and stare at R11. If R11 was not in her room, R13 would lay down in R11's bed. Sometimes, R13 would stand in front of the tv. R11 stated she told staff, All the time. Staff did nothing to prevent R13 from wandering into R11's room but would come get R13 after R13 did it. R15R15's quarterly MDS dated [DATE], identified R15 had severe cognitive impairment and diagnoses that included dementia and major depressive disorder.R15's care plan revised 7/7/26, identified R15 was able to make choices in daily life including activities, food choices, and ADLS. R15 preferred to wake up at 7:00 a.m. and liked to go to bed at 7:00 p.m. R11 liked to have her shoes and socks on in the morning. Staff were directed to assist R15 with R15's make-up every morning - R15 liked her eyebrows lined and blush applied. R15's choices in clothing, meals and cares was to be encouraged. R24R24's quarterly MDS dated [DATE], identified R24 had a mild cognitive impairment and diagnoses that included major depressive disorder, Type 2 Diabetes and chronic obstructive pulmonary disease (COPD) (A progressive lung condition that causes long-term damage to the airways and air sacs, making it increasingly hard to breathe.)R24's care plan revised 9/8/26, identified R24 was able to make choices in my daily life including activities, food choices, and ADLS. R24 liked to wake up between 7-7:30 a.m. and preferred to go to bed by 9:00 p.m. Staff were directed to encourage R24's choice in clothing, meals and cares. During an interview on 9/16/26 at 12:20 p.m., R24 stated R13 came into R13's room all the time. R24 stated she couldn't say R13 did anything and that's the sad part. For example, R24 was sitting at her card table and R13 came into R13's room and laid down in R13's bed. She doesn't know any better. R24 stated she did not know what staff did to try to prevent R13 from wandering into R24's room. I've told staff I don't like it, but I think everyone has. Staff did talk to R13's family but R24 did not know what was being talked about. R13 really did not talk and did not understand when spoken to. It's really sad. I love it here and she's the only real problem. It's not that she does anything now, but it's that she could.R25R25's annual MDS dated [DATE], identified R25 was cognitively intact and had diagnoses that included major depressive disorder.R25's care plan revised 7/7/26, identified R25 was able to make choices in daily life including activities, food choices, and ADLS. R25 required extensive physical assistance with emergent situations. R25 liked to be woken up at 8:00 a.m. and preferred to go to bed between 9:30-10pm. Staff were direct to encourage R25's choices in clothing, meals and cares. During an interview on 9/16/26 at 12:32 p.m., R25 stated R13 wandered into R25's room. R25 kept her door shut and R25 had a ribbon that she would place between the door and the door casing when she left the room. This would allow R25 to know if someone had been in her room. However, you could tell when R25 was in the room. R13 would touch and move R25's things or, more often, R13 had laid in R25's bed. R13 had never been violent but R25 had never touched R13 either. R25 stated R13 was a former nurse and many believed R13 was doing rounds and checking on everyone. Oh, everyone knows. If staff saw R13 going into a room, they would try to stop R13. Sometimes though, R13 didn't understand or wouldn't listen and went in anyway. R25 stated it had really got worse in the past 6 months. In the evenings, if R25 was watching tv, R13 would come in and sit down for a few minutes and just look around before leaving. During an interview on 9/15/26 at 8:54 a.m., nursing assistant (NA)-A stated R13 wandered into other resident room all the time. Staff redirected R13 by taking R13 back to R13's room. The other residents did get upset when they found R13 in their room, but mostly the staff just redirected R13.During an interview on 9/15/26 at 3:27 p.m., NA-B stated R13 walked around a lot. R13 never really had a place that she was walking to. R13 just walked. R13 did go into other resident rooms. Sometimes, R13 just walked around the room, turned around and left. Other times, R13 laid down in the bed. Staff redirected R13 out of the room. R13 really couldn't say what she wanted. When asked, sometimes she will answer and sometimes R13 didn't talk. R4 would just tell staff to get R13 out of his room. R15 would get upset. However, R10's room was the room R13 wandered to most often to like down in the bed. R10 would just say to let R13 sleep. NA-B shrugged and stated staff just redirected R13. During an interview on 9/16/26 at 10:13 a.m., trained medication aide (TMA)-A stated R13 walked around. R13 had dementia. TMA-A stated other residents complained about R13 wandering into their rooms and staff put stop signs on the door to prevent R13 from going into the rooms. However, observations failed to identify any stop signs on doors. During an interview on 9/16/26 at 10:15 a.m., licensed practical nurse (LPN)-A stated R13 was a former nurse and when R13 was wandering R13 was doing her rounds. R13 was just checking on everything. R13 would go into other residents' room and staff did try to catch R13 before she did that. R4 understood R13 going into his room but didn't like it. If the door was open, R13 was going to go in. During an interview on 9/16/26 at 2:44 p.m., registered nurse (RN)-B and RN-C stated staff had spoken with R13's daughter who said if it made R13 happy, let R13 do it. RN-B stated she had watched R13 and R13 wasn't bothering anyone else. However, R13 did enter other resident rooms. Staff had tried stop signs on rooms frequently entered, R13's doorframe was painted green, and put a sign on R13's door identifying it as R13's room. R13 was a former nurse and staff believed R13 was doing rounds and checking on people. Some residents invited R13 in and don't mind R13 being there. Some residents were not as open to it. Staff tried their best to keep her out of rooms, but it was R13's routine. During an interview on 9/16/26 at 3:01 p.m., the director of nursing (DON) stated R13 was near and dear to staff's hearts. However, staff were expected to document residents' complaints and attempt to identify a resolution to their concerns and to follow up with the residents. During an interview on 9/16/26 at 3:37 p.m., the administrator stated staff were expected to report resident concerns to the chain of command and, ultimately, the social worker should investigate the concerns, attempt to find a solution and document the concern to track either improvements or worsening. During an interview on 9/15/26 at 8:54 a.m., nursing assistant (NA)-A stated R13 wandered into other resident room all the time. Staff redirected R13 by taking R13 back to R13's room. The other residents did get upset when they found R13 in their room, but mostly the staff just redirected R13.During an interview on 9/15/26 at 3:27 p.m., NA-B stated R13 walked around a lot. R13 never really had a place that she was walking to. R13 just walked. R13 did go into other resident rooms. Sometimes, R13 just walked around the room, turned around and left. Other times, R13 laid down in the bed. Staff redirected R13 out of the room. R13 really couldn't say what she wanted. When asked, sometimes she will answer and sometimes R13 didn't talk. R4 would just tell staff to get R13 out of his room. R15 would get upset. However, R10's room was the room R13 wandered to most often to like down in the bed. R10 would just say to let R13 sleep. NA-B shrugged and stated staff just redirected R13. During an interview on 9/16/26 at 10:13 a.m., trained medication aide (TMA)-A stated R13 walked around. R13 had dementia. TMA-A stated other residents complained about R13 wandering into their rooms and staff put stop signs on the door to prevent R13 from going into the rooms. However, observations failed to identify any stop signs on doors. During an interview on 9/16/26 at 10:15 a.m., licensed practical nurse (LPN)-A stated R13 was a former nurse and when R13 was wandering R13 was doing her rounds. R13 was just checking on everything. R13 would go into other residents' room and staff did try to catch R13 before she did that. R4 understood R13 going into his room but didn't like it. If the door was open, R13 was going to go in. The facility policy Grievance/Concerns revised 7/1/24, identified the following:Grievances may be made by residents or their representatives in writing using the External Grievance/Concern form, or verbally or in writing to any NSM employee or the facility social sorker.Employees should use the Internal Grievance/Concern form when receiving a grievance or concern from a resident or their representative.Once a grievance/concern form is received from a resident or their representative or initiated by an employee, it should be directed to the social worker. External Grievance/Concern forms should be stapled to the Internal Grievance/Concern form prior to submitting to the social worker.After office hours, these forms may be placed in the mailbox outside of the Social Services office.The social worker is responsible for overseeing the grievance process, which will include the following:Receiving and tracking grievances through to their conclusion;Communicating the initial report in IDT;Leading any necessary investigations by the facility;Collaborating with the corresponding department manager on the investigation and resolution;Maintaining the confidentiality of all information associated with grievances (i.e. the identity of the resident for those grievances submitted anonymously);Communicating the resolution in interdisciplinary team (IDT).g. Communicate the resolution to all parties involved;h. Coordinating with state and federal agencies as necessary in light of specific allegations; and as necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated.i. Maintain a copy of all grievance related documents for two years.An investigation will be initiated within 72 hours of receiving a grievance. The investigation may include:A visit with the resident/responsible party to pursue the investigation and establish the validity of the complaint.Interviewing all parties involved in the grievance/concern.Interviewing all parties with information related to the grievance/concern.Providing an update of the progress of the investigation if it exceeds 10 days.The grievance/concern will be documented by employees on the Internal Grievance/Concern form and should include the following information:The name of the resident or responsible party's name, address and phone number,The date the grievance/concern is received,A summary statement of the grievance/concern,Any immediate action taken to resolve the grievance/concernThe steps taken to investigate the grievance,A summary of the pertinent conclusions or findings,A statement as to whether the grievance was substantiated or not,Any corrective action taken or to be taken by the facility as a result of the grievance, the date the resolution was communicated to the reporting individual or responsible party and the format used (ex: in writing, email, phone, in person).8. The form will be reviewed in IDT before a resolution is communicated to the complainant.9. Within 10 days of the filing of the grievance/concern (unless there are extenuating circumstances), the final findings will be provided to the complainant, including the method of complaint resolution and/or plan of action. This communication can be done in writing, by email, over the [NAME] or in person.10. Copies of grievance/concern forms will be reviewed and signed by all appropriate parties and all pertinent related documents will be maintained and secured by the social worker.11. A log will be maintained by the social worker to track, communicate, and identify any consistent trends. This log will be reviewed during QAPI meetings.12. Appropriate corrective action in accordance with state law will be taken if the alleged violation of the resident's rights is confirmed by the facility, or if any outside entity having jurisdiction confirms a violation of any of these residents' rights within its area of responsibility.

Based on observation, interview and document review the facility failed to ensure fluids were provided in a consistency/thickness to meet the needs for 1 of 1 resident (R1) reviewed for liquid consistency. This resulted in an immediate jeopardy for R1 who was served thin liquids, not in accordance with recommendations by the speech language pathologist (SLP).The IJ began on 8/1/26, when facility staff provided R1 with thin liquids despite an order for nectar thickened liquids. The IJ was identified on 8/18/26, the administrator was notified of the immediate jeopardy at 3:00 p.m. on 8/18/26. The immediate jeopardy was removed on 8/2/26, the deficient practice was corrected prior to the start of the survey and was therefore issued at past noncompliance. Findings include: R1's admission Record indicated R1's diagnoses included hemiplegia (paralysis or significant loss of motor function on one side of body)/hemiparesis (weakness on one side of the body), aspiration pneumonia (7/21/26) and dysphasia (difficulty swallowing) (8/11/26).R1's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and indicated he required set up or clean up assistance to eat.R1's care plan dated 7/21/26, indicated pneumonia related to aspiration and indicated he was at risk for aspiration and must be supervised while eating. Intervention dated 7/28/26, indicated nectar thick liquids and no straws.R1's Progress Note dated 7/21/26, indicated R1 returned from clinic appointment with orders to treat for aspiration pneumonia and a referral to SLP due to two episodes of choking while eating.R1's Progress Notes dated 7/25/26, indicated R1 presented with wheezing. Continue with antibiotics for aspiration pneumonia. R1 later presented with labored breathing while in bed and was sent to the emergency department (ED). R1's After Visit Summary dated 7/25/26, indicated he was seen for shortness of breath. Diagnosis indicated aspiration pneumonia of right lower lobe. Orders included Douneb every four hours while awake and continue augmentin until complete.R1's Progress Note dated 7/28/26, indicated R1 had a coughing fit after medication administration. R1 had been cleared by speech for thin liquids but due to coughing, nursing switched to nectar thick liquids. Therapy manager was consulted and confirmed okay to use nectar thick liquids until swallow study could be completed.R1's Progress Note dated 7/28/26, indicated per SLP, R1 to continue nectar thick liquids.R1's Speech Therapy Discharge Summary, dates of service 7/22/26 through 7/29/26, indicated 7/22/26, coughing noted and choking incidents. 7/29/26, discharged due to hospitalization, increased coughing on thin liquids.R1's Progress Notes dated 8/1/26, indicated R1 complained of not feeling well. R1 had not drank more than a sip or two of nectar thick liquids due to dislike of the taste. R1 complained of chills, headache and had vomited. Later R1 woke up flushed and stated he was thirsty. Writer explained purpose of thickened liquids and explained risk of continuing regular liquids. Writer agreed to allow thin liquids with reminder to take slow sips. R1 drank 240 cubic centimeters (cc) of Mountain Dew. Nursing assistant (NA) was present and reminded of importance to keep head up when assisting R1 to use 120-ounce cup without straw.R1's Progress Note dated 8/3/26, indicated R1 was admitted to the hospital for aspiration pneumonia following a clinic appointment.R1's After Visit Summary dated 8/6/26 indicated active hospital problems: acute bronchitis due to other specified organisms, dysphagia and aspiration pneumonia of right lower lobe. Orders included levofloxacin 500 milligram (mg) tablet and prednisone 20 mg tablet. Precaution orders indicated, aspiration precautions continuous. Nectar thick liquids and general diet.R1's Progress Note dated 8/10/26, indicated R1 was seen by SLP. Cognitive testing indicated mild cognitive impairment. SLP continued recommendation for nectar thick liquids.During interview on 8/12/26 at 12:40 p.m., SLP-A stated she received orders to evaluate R1 on 7/21/26 and saw him one time on 7/22/26. R1 was then hospitalized . SLP-A said she had not changed R1's diet on 7/22/26. On 7/28/26, SLP-A received an e-mail indicating R1 had a significant coughing episode on regular liquids and staff asked if SLP-A agreed to downgrade R1 to thickened liquids and she agreed. SLP-A said she saw R1 on 7/29/26 and agreed with the downgrade to nectar thick liquids. SLP-A said the physician wrote orders, but she was able to make recommendations. SLP-A stated clinical signs of aspiration could be immediate or delayed and said there was no way to know the onset date for sure. SLP-A said the risk of thin liquids when not recommended included death resulting from aspiration.During interview on 8/12/26 at 1:32 p.m., registered nurse (RN)-A on 8/2/26, she arrived at the facility and reviewed progress notes from the previous day. RN-A stated she saw a note written by licensed practical nurse (LPN)-A that indicated she had given R1 thin liquids. RN-A said she called LPN-A who told her she did give R1 thin liquids because he did not like the thickened liquids. RN-A said the facility had a process for against medical advice (AMA) and LPN-A did not follow the process.During interview on 8/13/26 at 8:13 a.m., LPN-A stated R1 had a coughing incident prior to 8/1/26 and was treated for aspiration pneumonia. R1's order had been changed to nectar thick liquids. R1 told LPN-A he was not going to drink them. LPN-A said she spoke with RN-A who talked to R1 and offered him different options for thickened liquids. LPN-A said later that evening she was in R1's room with his wife and two NA's. R1 asked for something to drink and was upset they would only give him thick liquids. LPN-A said R1's family member was present and was okay with thin liquids and LPN-A said, that was when I said, at this point I would rather you have fluids than not, you have the right to drink water, no one has the authority to tell me I can't provide it to you. LPN-A said she told R1 the risk of drinking the thin liquids was breathing it in and causing pneumonia. LPN-A said she was aware of the AMA form but did not provide it to R1 or his family member. LPN-A said she did not call a provider prior to or after providing the thin liquids.During interview on 8/13/26 at 1:44 p.m., RN-B said on 8/1/26, LPN-A told RN-B, R1 was not going to drink the thickened liquids and said she educated family. RN-B said LPN-A told her RN-A said R1 could not have the thin liquids. RN-B said she went into R1's room that evening and removed a black mug with thin water and a straw in it. RN-B further stated R1 may not have liked the thick liquids, but he was unlikely to have adamantly refused them.During interview on 8/13/26 at 12:38 p.m., the director of nursing (DON) stated when she talked with LPN-A, she [LPN-A] had other staff giving R1 thin liquids also. The DON said she would have liked LPN-A to have called a physician or herself. The DON said the facility had an AMA form and LPN-A did not follow the process. The DON stated LPN-A had been immediately educated and the facility implemented audits and license nurse competencies.During interview on 8/18/26 at 10:38 a.m., physician assistant (PA)-A stated R1 had an aspiration event a few weeks prior (7/25/26) and the chest x-ray indicated pneumonia. PA-A said he saw R1 on 8/3/26, after he had received the thin liquids and discussed the risk and benefits of waiting for the swallow evaluation before resuming the thin liquids. R1 and his family agreed to continue the thickened liquids. At that visit, R1 had not been feeling well and was hospitalized . PA-A said a scan completed while R1 was hospitalized from [DATE] - 8/6/26 did not show pneumonia but said the pneumonia may have cleared up by the time the scan was completed. PA-A stated if staff had called him prior to giving R1 the thickened liquids, he would have recommended they follow the recommendations of the SLP. PA-A said the risk associated with a resident receiving thin liquids, after receiving a recommendation for thickened liquids, included aspiration pneumonia and death.Facility policy Diet Order, Specialized Diet and Food Consistency, undated, indicated It is the policy of this facility to provide diets as ordered by the attending provider and developed in collaboration with the Registered Dietitian (RD), Speech-Language Pathologist (SLP), Nursing, and Dietary Services. All therapeutic diets and texture modifications will be implemented accurately and consistently to promote safety, prevent complications, and maintain quality of life.The facility implemented the following on 8/2/26, therefore the deficiency is being issued at past non-compliance: LPN-A was immediately educated.Thickened Liquid/diet compliance audits were initiated.Licensed nurse competencies initiated which included: explanation of aspiration risk, identification of thickened consistency, review of physician orders, understanding of refusal process, physician notification process, informed refusal process and resident rights.Education and audits were verified through interview and document review.

Based on observation, interview and document review the facility failed to ensure care planned interventions were implemented for toileting, resulting in a fall for 1 of 3 residents (R1). This resulted in actual harm to R1 when he fell and sustained a pelvic fracture. The facility had implemented actions to prevent recurrence prior to the survey; therefore, the citation was issued at past non-compliance. Findings include:R1's admission Record indicated R1 admitted to the facility 6/26/26. R1's diagnosis included stroke, spinal stenosis, weakness, blindness in one eye and fracture of left pubis (a break in the pubic bone at the front of the pelvis).R1's admission Minimum data Set (MDS) dated [DATE], identified moderate cognitive impairment and indicated R1 did not display behaviors. R1 was dependent on staff for toileting, required partial assistance for transfers and was frequently incontinent of bowel and bladder. R1had falls prior to admission to the facility.R1's Fall Risk Evaluation dated 6/26/26, indicated he was alert and oriented, ambulatory and incontinent. The evaluation identified balance problems while standing and walking. Clinical suggestions indicated nonskid footwear and utilization of a toileting program.R1's care plan dated 6/26/26, indicated he required substantial assistance with activities of daily living and was incontinent of urine. The care plan directed staff to assist with toileting every two hours while awake and at 2:00 a.m. and 5:00 a.m. The care plan identified a risk for falls due to right side weakness from prior stroke and indicated the use of grip soled footwear, call light on left side of bed.Facility incident report dated 7/5/26, indicated on 7/5/26 at 6:55 a.m., R1 was observed on the floor in the prone position (lying flat on stomach) with his head partway out of his doorway, left arm by his head and left arm by his waist. R1 had one leg in his pajama pants, and the other leg was out. No nonskid footwear at time of fall. R1's pants, incontinent brief, shirt and bedding were soiled with urine. Interdisciplinary team (IDT) review indicated video footage from the evening and overnight leading up to R1's fall was reviewed and identified the following: Nursing assistant (NA)-A assisted R1 on 7/4/26 around 8:00 p.m. On 7/4/26 at 11:00 p.m., NA-A entered R1's room and turned off his call light. On 7/5/25, two nurses entered the room briefly twice at approximately 3:40 a.m. and 6:00 a.m. Around 7:00 a.m., R1's room door opened and he was observed to fallR1's Progress Notes indicated the following:7/5/26 at 6:55 a.m., R1 was observed on the floor in the prone position with his head partway out of his doorway, left arm by his head and left arm by his waist. R1 had one leg in his pajama pants, and the other leg was out. No nonskid footwear at time of fall. R1's pants, incontinent brief, shirt and bedding were soiled with urine.7/5/26 at 8:15 a.m., R1 fell earlier in the day. R1 had been incontinent and was headed to the bathroom.7/6/26 at 7:09 a.m., Staff approached R1 as he had been weak, leaning to one side and needed a mechanical stand to transfer. R1 stated he was fine.7/6/26 at 7:31 a.m., R1 was assessed, displayed right side weakness at baseline. R1 reported no pain and stated he felt fine, was just weak.7/6/26 at 11:21 a.m., R1 complained of increased pain to coccyx (tail bone) and increased weakness. R1 was sent to the emergency department (ED) for evaluation.7/6/26 at 4:38 p.m., Root cause of fall indicated R1 had difficulty remembering to call for assistance, safety and judgement to transfer safely. Working with therapy. Transfer status was updated to a mechanical stand and two staff due to weakness and need for more assistance with transfers.7/7/26, R1 returned from the hospital. Weakness had improved but continued to need mechanical stand to transfer. R1 had bruising to right upper arm from previous fall. R1 reported pain all over.7/7/26 at 3:52 p.m., R1 displayed new symptoms during therapy. Reported a headache and rated the pain as 20 out of 10. R1 displayed elevated temperature, increased right side impairment and unable to open right eye or squeeze hand.7/7/26 at 9:01 p.m., R1 returned from the ED with a new diagnosis of pelvic fracture and constipation.During interview on 7/29/26 at 2:44 p.m., physician assistant (PA)-A stated he knew R1 a little bit and said he had been following him prior to being admitted to the facility. PA-A stated the radiology report seemed unclear about the timing of the fracture but said the report indicated the edges of the fracture appeared sharp. PA-A said R1's recent fall likely caused the pelvic fracture.During interview on 7/29/26 at 3:23 pm., the medical director stated he had seen R1 after the initial fall encounter and said, I think we can assume the fall caused the fracture.During interview on 7/29/26 at 3:40 p.m., certified occupational therapy assistant (COTA)-A said following R1's fall he initially had not complained of pain and said when he worked with therapy the next day, he could not stand up at the bars. COTA-A said R1 stated his butt hurt but when asked about the pain level said, what pain? COTA-A said prior to the fall R1 required contact guard assistance and said he had only self-transferred occasionally from his bed to his chair. COTA-A said she was not aware of R1 attempting to self-transfer from his bed.During interview on 7/29/26 at 4:27 p.m., R1 stated he had pain in his arms and legs. R1 said he did not remember what happened the morning he fell but said he thought, the bone should have been healed by now. R1 said staff usually came pretty quick when he pushed his button but said, I think that night was an issue.During interview on 7/30/26 at 11:24 a.m., NA-C stated prior to his fall, R1 only self-transferred once or twice and said he was not, super-impulsive. NA-C said if she had been left wet and not changed it would have made her furious and said she would, definitely try to get out of bed and go change.On 7/30/26 at 11:29 a.m., video footage was viewed with the administrator. The following events were noted on 7/4/26:5:58 p.m., NA-A was observed in the hallway outside R1's room.6:31 p.m., R1 exited his room with his walker. Another NA placed a transfer belt on R1 and brought him back to his room. NA-A entered R1's room and exited after one minute.7:54 NA-B entered R1's room, NA-A entered the room at 7:56 p.m. NA-B left the room at 7:57 p.m. and NA-A exited at 8:00 p.m.8:58 p.m., NA-A entered and exited R1's room within one minute.The following events were noted on 7/5/26:3:47 a.m., NA-A entered R1's room and left after 30 seconds.6:57 a.m., R1 was observed in his doorway with his walker. R1 fell over the walker and landed on the floor. Staff found R1 on the floor at 6:58 a.m.On 7/30/26 at 11:58 a.m., RN-A stated when R1 first admitted to the facility his cognition had been better but had been fluctuating since. RN-A said R1 was incontinent and had been upset with staff waking him, so he set his own toileting schedule for 2:00 a.m. and 5:00 a.m. If R1 was wet at those times, staff should have changed him. R1 was not argumentative or resistive to care. RN-A said R1 did not get up at night to toilet himself. RN-B was present and agreed with RN-A that R1 had not attempted to self-transfer to the toilet at night.During interview on 7/30/26 at 12:45 p.m., NA-A stated she found out about R1's fall four days after it happened. NA-A said each time she went into R1's room he was fine. NA-A said R1 put on his call light once during the night prior to his fall and said he had put his own pajama pants on. NA-A said she went into R1's room more than once that night and said she thought R1 transferred independently and was not aware of his care plan. NA-A said she had received training on where to find the plan of care prior to working with R1.During interview on 7/30/26 at 11:43 a.m., the administrator stated R1's fall was related to NA-A not following care planned interventions for toileting. The administrator stated R1 had been wet from urine and said if that happened to her, she would be disappointed and would want to get up and try to change herself. The administrator said she had received reports from other staff about other residents being found saturated with urine that morning.Facility policy Care Planning dated 9/9/26, indicated all staff are required to review, understand, and follow each resident's current care plan at all times. The care plan serves as the resident's individualized plan of care and provides direction for safe and appropriate care delivery.The past noncompliance began on 7/5/26. The deficient practice was corrected by 7/6/26, after the facility completed a review and added interventions to R1's care plan that included the following: more frequent checks and specific times. The facility continued re-education of staff which was previously started, related to following the care plan and signing off tasks. Interviews with staff from 7/28/26 through 7/30/26, confirmed understanding of reviewing resident care plan before the start of shift for changes. Review of R1's care plan confirmed changes were made.

Based on interview and record review the facility failed to provide care and supervision consistent with resident's needs, orders, and care plan to eliminate the risk of an accident during cares for 1 of 3 residents (R1) reviewed for falls. R1 needed increased monitoring for safety due to four previous falls at the facility, strict posterior hip precautions, and was unable to ambulate with nursing staff due to non-weight bearing status of right leg. This resulted in actual harm to R1 when RN-A was aware of the ambulation status, assisted R1 to the bathroom with walker and heard a popping sound during ambulation. This resulted in swelling of R1's right leg and complaints of increased pain. R1 was sent to the hospital for evaluation and required a closed reduction of the right hip related to dislocation. The facility had implemented actions to prevent recurrence prior to the survey on 6/23/26, therefore, the citation was issued at past non-compliance. Findings include:R1's admission Minimal Data Set (MDS) dated [DATE], identified severely impaired cognition without behaviors. R1 required supervision or touching assistance with personal hygiene, partial to moderate assistance for sit to stand, substantial/maximal assistance with toileting hygiene, upper and lower body dressing, lying to sitting on bedside, all transfers, was dependent on staff for shower/bathing, was unable to walk, and used a manual wheelchair for mobility. R1 was occasionally incontinent of bowl and bladder. R1's diagnoses included fractures, non-Alzheimer's dementia, and anxiety. R1 had a surgical wound. R1 used a bed alarm daily.Operative note dated 5/10/26, written by orthopedic surgeon medical doctor (MD)-A identified:Pre-operative diagnoses: right hip pain, right proximal femoral periprosthetic femur fracture (fracture occurring around or near a hip prosthesis) involving the subtrochanteric region (area of the femur that lies just below the junction of the femoral neck and shaft) and diaphysis (the shaft or central part of long bone). Displaced (broken pieces of bone are not aligned properly). Closed (break in bone that does not pierce the skin). Status post right hip replacement. Ground level fall.This patient was going to be admitted to hospital with a 30-pound weight/bearing limit for about 8 weeks; will have posterior hip precautions for the same amount of time.Hospital occupational therapy (OT) treatment note dated 5/13/26 at 2:51 p.m., identified precautions: bed/chair alarm, fall risk, right lower extremity posterior hip (back of the hip) precautions, troch off precautions (no abduction- movement of leg away from the midline of the body), and 30-pound flat foot (able to rest entire foot on the ground while standing). Do not bend past 90 degrees or lift your knee higher than your hip. Do not cross your legs at the knees or ankles. When getting out of bed keep shoulders, knees, and hips in straight line to avoid twisting. R1 required moderate cues to comply with her hip precautions.R1's right hip and pelvis X-ray dated 5/11/26 at 9:52 p.m., identified reason for exam: post op (operative). Findings: osteopenia (lower-than-normal bone density), right hip arthroplasty (joint replacement surgery). Left hip degenerative change. Postoperative changes over the right hip. Impression: right hip arthroplasty without complications.R1's total hip replacement discharge instructions dated 5/14/26, identified:30 pounds weight bearing for the next 8 weeks with posterior hip precautions.When to contact your healthcare provider: if hip pain gets worse, if incision became red, swollen, warm to touch, had increased drainage, or foul-smelling odor, and if you happen to fall and have pain.Weight bearing status: partial- right 30-pound weight bearing.Assistive device: walker /one person.Cognition: Forgetful, poor judgement, poor safety awareness, poor attention/concentration.Pain level: last filed on 5/14/26 at 7:43 a.m., right hip pain 8 out of 10.R1's care plan dated 5/26/26, identified:Bed Alarm. Silent bed alarm due to history of falls while attempting to leave her bed. R1 agreed to the alarm and being safe. Date initiated: 5/14/26.Staff were instructed to place bed alarm on. Date initiated: 5/14/26R1 had cognitive loss/dementia with memory impairment which varied throughout the day. Date initiated: 5/26/26.Staff were directed to use yes or no questions to determine R1's needs, and task segmentation (break tasks into one step at a time) to support short-term memory deficits. Cue, reorient, and supervise as needed. Date initiated: 5/26/26.R1 was extensive assistance with activities of daily living (ADLS) due to decreased mobility related to right hip surgery, and fluctuating cognition. Date initiated: 5/14/26.R1 was unable to ambulate with nursing staff due to her non-weight bearing status of her right leg. Date initiated 5/14/26.Bed mobility: R1 required partial assistance of one staff for turning and repositioning in bed. Date initiated: 5/14/26.Staff were instructed to encourage R1 to use bell to call for assistance.R1 required substantial assistance of two staff for toileting and to move between surfaces. Date initiated: 5/14/26. Date revised 5/26/26,Substantial assistance of one staff. Date revised 5/26/26R1 was at risk for fall due to recent right hip surgery and non-weight bearing with right hip. Date initiated 5/14/26.Silent bed alarm. Date initiated: 5/14/26.Place call light within reach and remind R1 to use it for assistance for safety. Date initiated: 5/14/26.Non-weight bearing on her right leg. Date initiated: 5/14/26. End date 5/18/26.Toe touch bearing at this time with the right leg. Date revised 5/18/26Fall mat added to side of bed and bed at lowest position. Date initiated: 5/18/26.Assist to the recliner in the common area as needed (PRN) for comfort, correct positioning and evaluation of bilateral edema to alleviate edema. Date initiated 5/18/26.Pain related to fracture and post-surgery of the right hip. Date initiated 5/14/26.Reposition R1, pillow support, and/or ice to right hip. Date initiated: 5/14/26.Use pain scale 0 to 10 due to intermittent confusion. Date initiated 5/20/26.R1's Fall Risk assessment dated [DATE] at 8:32 a.m., identified a score of 12 and indicated high risk for falls. R1 was disoriented, had one to two falls in past three months, was chair bound, and continent. Clinical suggestions: rubber-soled shoes or nonskid slippers worn for ambulation, utilizing toileting program and personal/pressure sensor alarms. R1's St. Louis University Mental Status (SLUMS) examination (examination used to detect mild cognition impairment and dementia) dated 5/18/26, identified a score of 14 out of 30 (score of 1 to 20 points indicates dementia).R1's progress notes dated from 5/14/26 through 6/19/26, identified:5/14/26 at 2:10 p.m., [AGE] year-old female admitted from hospital accompanied by husband. Admitting diagnosis was periprosthetic fracture around the internal prosthetic joint (break in the bone that occurs around or very close to an internal prosthetic joint), subsequent encounter. Other diagnoses included anxiety disorder, dementia, irritable bowel syndrome, and anemia. Has some short-term memory impairment with periods of confusion and needs cueing. Has pain in right hip radiating down right leg at 3 out of 10, relieved by pain medications, repositioning, pillow support, or ice. Transfers with assist of two, non-weight bearing on right leg so does not ambulate currently. High risk for falls due to non-weight bearing status of right hip and hip pain.5/14/26 at 10:16 p.m., R1 had been restless and self-transferred from bed several times. Brought out to nurse's station for closer observation.5/16/26 at 11:35 a.m., R1 was witnessed walking down hallway after activities today. Writer was notified and assisted R1 back into wheelchair. Reminded R1 of her fracture, which she did not remember, but did note soreness to right leg, rated pain at 5 out of 10. Chair alarm did not alert as it was not clipped on properly: staff re-educated on proper use. Currently in commons area with chair alarm attached, waiting for lunch.5/17/26 at 1:04 a.m., R1 was found on the floor on her knees by her bed with walker in front of her. She stated she was trying to point to something, I don't know. Ativan (antianxiety medication) was given two hours before fall for restlessness. Earlier, she was assisted to bed for lower extremity elevation for non-pitting edema (fluid swelling that does not leave indentation when pressure is applied to the skin) and color change to RLE (right lower extremity). She was a poor historian. Denied pain and no injuries noted at this time. Provider on call notified and ordered urinalysis to rule out urinary tract infection (UTI).5/18/26 at 9:01 a.m., R1 was significantly more confused later in the day and had poor safety awareness and despite multiple reminders during the day of her weight bearing status on her right leg, she had several episodes of getting up and ambulating independently: sometimes without assistive device, walker or pushing her wheelchair. Her weight bearing status was toe touch.5/18/26 at 10:29 p.m., Late entry. Writer was called to R1's room by NA (nursing assistant) and found resident with head in entry way of the bathroom and feet towards the bed. She denied pain and no BLE (bilateral lower extremity) abnormalities noted. She was more confused on p.m. shift due to diagnosis. Tab alarm was not connected to resident. NA checked on resident two times prior to fall within 30 minutes and tab alarm was on resident.5/22/26 at 9:33 p.m., R1 was found with her walker, ambulating independently down the hallway towards the east end. She did not appear to be weak when walking, redirected to room, and informed her she should have called for assistance to get out of bed and/or go to the bathroom. She voiced understanding and remained confused.5/24/26 at 4:37 a.m., At 3:40 a.m., R1 self-transferred to the chair next to her bed, bed alarm went off. She reported she needed to use the toilet. She complained of right hip rated at 5 out of 10. Flexeril (muscle relaxant) given for discomfort.5/27/26 at 7:19 p.m., R1 was observed falling to the floor in the common area. She landed on her back per staff member observing from a distance. She denied pain and/or discomfort at this time. Notified provider. Chair alarm went off as she fell to the floor. Cord to chair alarm shortened as intervention to alert staff if she attempted to self-transfer.6/3/26 at 5:03 p.m., Care conference identified she participated in skilled therapy: PT/OT (physical therapy/occupational therapy), where she ambulated with front wheeled walker 40 feet with two staff assistance.6/4/26 at 5:51 a.m., R1 was assisted to the restroom this morning. She ambulated with walker and maintained TTWB. A popping sound was heard to the right hip area when she took a step, and she reported some discomfort. Wheelchair was used to assist her back to bed. Right lower extremity swelling was noted. Ice pack applied to site. Numbness and tingling denied, and no discoloration noted.6/4/26 at 5:52 a.m., Writer was walking down the hallway and heard R1 yelling out for help. Writer entered her room and found her with feet on the floor mat and in the process of standing up. [NAME] was beside the bed; wheelchair was on the other side of the room. Due to her standing and not wanting to wait to use bathroom, unable to redirect, writer grabbed the walker. She used the restroom, then was assisted into the wheelchair, brought back to bed and complained of right hip discomfort. She had been having increased pain for a few days6/4/26 at 8:45 a.m., R1 sat in wheelchair leaning to the left to take weight off her right hip. She reported her right hip was very sore but unable to rate her pain. She was assisted to the toilet in her room, able to follow directions of TTWB but was grimacing in pain with every movement. Her right leg had doubled in size of her left and was warm to the touch from toe to knee. She stated her right hip and thigh really hurt. No discoloration noted. Saw provider yesterday who prescribed antibiotics for cellulitis (bacterial skin infection that causes redness, swelling, pain and warmth in the affected skin layers) of the right leg. Called clinic and spoke to his nurse. Asked if an x-ray was warranted.6/4/26 at 6:09 a.m., Received call back from clinic nurse and provider wanted her to be seen at local emergency department (ED). Her right leg remained very swollen and painful. It appeared to be internally rotated, and she was unable to straighten her leg. She was transferred from bed to wheelchair with Hoyer lift and brought over to the ED at 9:25 a.m.6/4/26 at 12:06 p.m., Spoke to registered nurse (RN) at ED. Update received: Her hip prosthesis was dislocated, no fracture to femur. She was being transferred to another hospital for further evaluation and probable surgical intervention.6/6/26 at 12:36 p.m., Called hospital for an update. R1 underwent anesthesia yesterday and they popped her hip back into place. She was a pivot transfer (mobility technique used to move a person limited mobility from one sitting surface to another) with a 30-pound weight-bearing restriction.Email titled Potential Issue with Therapy Notes /RN, dated 6/4/26 at 5:48 p.m., identified:5/28/26, Resident fell the prior night- pain in RLE 5-6/10 with walking. Walked 100-125 feet.5/29/26, Communication from nursing staff reported the patient is no longer allowed in her room by herself due to self-transferring and non-compliance with TTWB, four falls this week.6/1/26, Ambulation with FWW, TTWB to RLE 150 feet. Did she have one step where she did not comply with the TTWB but did not have pain. 6/2/26, Ambulated 175 feet with FWW TTWB. Verbal cues to maintain WB. Reports mild pain.6/3/26, Documented resident was having more pain in right hip and thigh today. Trying to go to the MD. Able to walk only about 15 feet due to pain. Pain reported 10/10 when walking.PT evaluation and plan of treatment dated 5/14/26, R1's baseline ambulation contact guard assistance (CTG) (physical contact to maintain balance and prevent falls, but the patient performs 100% of the physical effort), when allowed to bear weight, of one with FWW (front wheeled walker), not able to attempt due to weight bearing restriction. R1 had history of dementia and had recent hip replacement after a fall that resulted in a subtrochanteric periprosthetic fracture of the right femur. R1 had limited weight bearing status of RLE. Order indicated 30# (pound) weight limit with R1's cognitive deficits. Physical therapist recommended instructing R1 to be TTWB. Precautions: posterior hip precautions. R1 did well following cues to avoid weight bearing on RLE during transfer with FWW though cognitive deficits may be a factor at times with weight bearing. Ambulation was not safe to attempt due to weight bearing status. Transfers: moderate assist ([NAME]) of one with stand pivot transfer using FWW.R1's PT progress reports from 5/28/26 through 6/8/26, identified:5/28/26 at 3:07 p.m., R1 fell again last night and had pain in RLE 5 to 6 out of 10 while walking. Placed alarm back on her after therapy and left in dining room for bingo and coffee.6/1/26, at 3:23 p.m., R1 ambulated with FWW, TTWB to the RLE 100 feet with CGA. R1 had one step where she did not comply with TTWB, did not have any pain to mild pain but with cues did follow through.6/8/26, at 3:41 p.m., PT completed a thorough chart review and completed evaluation: R1 must always have abductor pad in place in bed and wheelchair, wearing right knee immobilizer, avoid hip abduction and monitor. Total hip arthroplasty posterior precautions and troch precautions per hospital notes. In the midafternoon, spouse, asked PT to come in room as abductor pad was not on right and her feet were not on the pedals. PT turned the abductor pad around to make it narrower, and this allowed her feet on the pedals but kept her LE's abducted and updated rehab manager.OT evaluation and plan of treatment dated 5/15/26 at 9:19 a.m., identified referred to therapy as new admission to facility. R1 fell on 5/2/26 and resulted in an open reduction and internal fixation (ORIF), then fell again on 5/9/26, and had surgery for periprosthetic (a broken bone around the components of the total hip replacement) and was TTWB. R1 was limited by cognition. R1 rated her RLE pain at 8 out of 10. Evaluation Summary identified physical/cognitive/psychosocial performance: R1 presented with impairments in balance, dexterity, gross motor coordination, mobility, sensation, strength, attention, follow through, planning, problem solving, self-modification and self-monitoring resulting in limitations and/or participation restrictions in the areas of general tasks and demand, mobility and self-care.R1's OT treatment encounters from 5/28/26 through 6/3/26, identified:5/28/26 at 2:51 p.m., R1 reported increase in right hip pain during ambulation.6/3/26 at 3:30 p.m., R1 required total assistance to raise lower extremity to doff shoes. R1 reported increase in right hip pain incision and had seen MD this afternoon with possible infection.R1's primary provider, medical doctor (MD)-A, progress notes dated 6/2/26, identified R1 had been stable, main issue continued to be her confusion/dementia which resulted in her trying to walk without assistance and had ended in multiple falls. R1 fell four times in the last two months. One of the falls resulted in a refracture of the femur fracture that required ORIF. R1's physical exam identified: slowed behavior, thought process was delusional, impaired cognition and judgement, tenderness and signs of injury present, motor weakness and abnormal gait present.R1's ED notes dated 6/4/26 at 9:34 a.m., [AGE] year-old female presented to emergency room with dementia from LTC (long term care) with complaints of right hip pain. R1 was recovering from a right total hip arthroplasty (RTHA) and seen at clinic yesterday and started on oral antibiotics for incisional infection/cellulitis. Staff stated they heard a pop when moving R1 this morning, noted significant swelling today, worsening redness, and intolerant to any movement to right hip due to pain. Pain was reported per nursing as significantly worse than previously noted. R1's physical exam identified: right lateral incision revealed swelling, tenderness, redness, and pain. No open area or drainage noted. Cellulitis surrounding incision noted. R1 was discharged at 12:25 p.m. and transferred to another hospital via emergency medical services (EMS).R1's CT of right hip dated 6/4/26 at 11:18 a.m., confirmed dislocated right hip prothesis. Femoral ball completely, superiorly dislocated (femoral head migrated upward) from the acetabular cup (prosthetic socket component used in a total hip replacement/arthroplasty). A large indistinct fluid collection ventral (front) from the proximal femur (upper thigh bone) likely from the prior evacuated (previous opening) hip joint space into the proximal thigh musculature (nearby thigh muscles) and maybe hematoma or abscess. Cellulitis laterally.R1's hospital admission history and physical dated 6/4/26 at 5:14 p.m., identified presented with increased pain right hip with fever and redness over wound. R1 had been doing well until yesterday. Pain noted in the right hip, with some redness and swelling. Right thigh is larger than the left. R1 cannot lift the right leg off the bed which she was able to previously. R1 had slight fever yesterday and worsened hip pain today. Hemoglobin 6.8 (normal range 11.2 -15.5 grams/deciliters (gr/dL) and computed tomography (CT) scan (imaging procedure that used specialized x-ray equipment and computers to create detailed cross-sectional images of bones, organs, and soft tissues) results: dislocated right hip prosthesis and large fluid collection ventral side extending inferior from the field of view maybe hematoma or abscess. Cellulitis laterally.Facility incident report filed with State Agency (SA) on 6/4/26 at 12:10 p.m., identified on 6/4/26 at 5:51 a.m., R1 was assisted to bathroom, ambulated with walker, maintained toe touch weight bearing (TTWB) and popping noise was heard to right hip area when R1 took a step. R1 reported some discomfort. Swelling noted to right lower extremity. R1 sat in wheelchair while she ate breakfast, leaned to the left to take weight off right hip and reported right hip was very sore. R1 was assisted to bathroom after breakfast, able to follow directions of toe touch weight bearing on right leg but was grimacing in pain with every movement. R1's right leg had doubled in size of left leg and warm to the touch from toe to knee. R1 sat on toilet, leaned to the left and unable to put weight on her right hip. Provider contacted and informed nurse of the above and asked if an x-ray was warranted. Allegation detail: unexplained injury. Described Injury: dislocated hip and received treatment at hospital.Facility 5-day report submitted on 6/10/26 at 10:55 a.m., identified on 6/4/26 RN-A heard R1 hollering for help. Bed alarm sounded. RN-A stated the walker was closer than the wheelchair and she felt that she could maintain the TTWB status to get her to the bathroom. RN-A was aware of the ambulation status and heard a popping but noted nothing out of the ordinary after R1 returned to bed via wheelchair. R1 was sent to emergency room (ER) to be evaluated, transferred to another hospital on 6/4/26 and returned to facility on 6/5/26. Elements of the care plan were not followed: care plan identified R1 was unable to ambulate with nursing staff due to non-weight bearing status of right leg. Staff assisted R1 to the restroom with the walker maintaining TTWB. The physician order was for 30 pounds weight bearing but therapy utilized toe touch only. The allegation was verified: in combination with increased pain, multiple falls, non-compliance, inability to recall transfer status. There was a hematoma in the capsule postoperatively that may have contributed to the dislocation. Severely low hemoglobin.During an interview on 6/23/26 at 1:07 p.m., with MD-A and the administrator, MD-A verified he had saw R1 on 6/3/26. At that time the right hip was not the issue. R1 dislocated her hip three times while in the facility. MD-A felt the dislocations were related to the initial total hip replacement not being performed correctly. R1 had dementia, never followed instruction, tried to get up by herself, which made it difficult to avoid her self-transferring. MD-A stated the first time R1 dislocated her hip she was sent to the hospital where the hip was placed back in. R1 then dislocated hip again two days later, was sent to the hospital where it was placed it back in. MD-A stated he had not seen any abnormal positioning or concerns of dislocation of R1's leg on 6/3/26. MD-A stated he would have expected staff to follow the recommendations and the care plan on how to transfer R1, TTWB only and no ambulation. When staff heard the popping noises, during the transfer, it would have identified when the dislocation occurred with the right hip and would be extremely painful. MD-A stated R1's hip was repaired improperly. For the most common reasons and with normal activity the hip can pop out with force. MD-A stated a hematoma would not cause R1's hip to dislocate; however, the hematoma would have been caused by the falls she had. MD-A stated R1's hip was dislocated from walking to the bathroom and/or normal activity, but it was not normal for her joint replacement, and not something she was supposed to do without assistance due to her dementia. MD-A indicated R1 basically did things she should not have done due to her dementia.During an interview on 6/23/26 at 12:31 p.m., NA-D stated R1 had dementia, self-transferred, and was a high risk for falls. R1 was a stand pivot with assist of two at first then changed to assist of one, and staff were not to be walking her, no weight was to be placed on her right leg/foot due to the fracture. NA-D stated staff were expected to follow the care plan and/or Kardex located on the computer: keep a close eye on her, prevent her from being left in her room alone, and used bed and chair alarms to let staff know she was trying to self-transfer. NA-D stated she had caught R1 many times in her wheelchair after she had self-transferred, R1 had forgotten about her fractured hip. NA-D stated on 6/4/26 around 6:45 a.m., R1 had to go to the bathroom, NA-D stood her up with a transfer belt to pivot, R1 dragged her right leg, crying and stated it hurt. NA-D stated she informed the staff nurse.During an interview on 6/23/26 at 1:30 p.m., NA-B stated R1 was a high risk for falls and staff used a bed alarm, chair alarm, and had her sit in the commons area to keep a close watch on her. R1 was not to be left alone in her room. NA-B stated there were times when R1 self-transferred in her room. During an interview on 6/23/26 at 2:11 p.m., RN-D stated R1 had dementia, lacked cognition, with impaired balance due to TTWB. R1 was to be transferred with stand pivot with two staff and provided reminders to just touch your toe, to avoid injury or damage to her right hip. RN-D stated on 6/4/26, during breakfast R1 sat in her chair eating, leaned towards her left side like she did not want pressure on her right buttock. RN-D stated in morning report she was made aware R1's hip had made popping noises when she was transferred earlier. R1's right hip appeared swollen, almost like it was half size bigger than the left hip. R1 stated her hip hurt but was unable to identify what type and how much pain she had. RN-D stated R1 had grimaced when transferred to the toilet after breakfast around 8:45 a.m. R1 was sent to ER with a diagnosis of right dislocated hip, then transferred to another hospital, a closed reduction was completed and R1 sent back to facility.During an interview on 6/24/26 at 10:05 a.m., orthopedic surgeon MD-B stated he had completed three of four hip surgeries R1 had. After R1's initial hip repair, R1 had fallen due to dementia, broke her hip a second time due to the quality of the bone was poor. MD-B stated during R1's falls the femoral stem on the implant rotated 30 to 40 degrees, which normally would have been at 10 to 15 degrees. The hip prosthesis continued to dislocate and had to be removed. MD-B stated R1's stem was placed in an anteversion position, rotated towards the front of the body and was not faulty. MD-B stated R1's implant was placed properly, at the correct angle and the angle changed because the bone had not grown to secure it and moved substantially when falling. It was the fall(s) on the hip, especially after surgery that created the problem opposed to the surgical process. This category (age group and decreased cognition) of patients had restrictions on ambulation, and the inability to follow those restrictions made them more vulnerable. The restrictions of 30# weight bearing, avoiding internal rotation of the leg was important to follow to protect the top of the bone and muscles that supported the area where the prosthesis was attached. MD-B stated during the falls and/or not following those restrictions pulled on the part just repaired, and the stem won't heal properly. MD-B stated if there was too much weight placed on the hip/leg the stem will not heal. Most likely it moved after the first fall after admission, due to being new, less healed, and not solid. MD-B stated it takes 6 weeks to 2 months for the implant to cement in and if you continue to have trauma, keep bleeding, kept moving, it will not heal and will continue to dislocate.During an interview on 6/24/26 at 2:00 a.m., RN-A stated R1 was confused, oriented to self only, and high risk for falls. R1 had a total of three or four falls since admission while she tried to self-transfer. RN-A stated R1's interventions in place to help prevent falls included: stand pivot with assist of two staff to keep her safe due to TTWB, decreased cognition, and impulsiveness. RN-A stated on 6/4/26, she was aware R1 required assistance from two staff for transfers, was only to ambulate with therapy, and RN-A should have used the wheelchair to transfer her to the bathroom that day. R1's wheelchair was not close to the bed, R1 already stood up independently, was unable to wait to go to the bathroom, and at that moment RN-A did what she had to do. R1's additional interventions included: bed alarm, chair alarm, and fall mat on both sides on the floor by the bed. RN-A stated on 6/4/26 just before 6:00 a.m., R1 had slight hip pain that day, it did not get worse when she ambulated, she was able to ambulate with RN-A, she followed cues, and was able to maintain TTWB. RN-A stated she watched R1, so that she did not place a lot of weight on her right foot and would hop as she ambulated. RN-A stated she heard a popping noise that came from R1's right hip with every step while she ambulated to the bathroom. RN-A stated she should not have ambulated R1 due to difficulty maintaining TTWB, therapy placed ambulation on hold. RN-A stated she did not think the ambulation affected her hip at all and if she had to do it all over again, she hoped the wheelchair would be closer to the bed so she could complete a pivot transfer instead. RN-A stated she had a walkie on her and could have called another staff member for assistance. RN-A stated staff would be expected to follow the resident care plan to provide most accurate and best care for resident safety. RN-A stated she was unaware of what caused R1's displacement of the hip, she had many falls and self-transfers at the facility and increased pain that could have increased the possibly of displacement. The provider had seen R1 earlier that day prior to the incident. RN-A stated she had received education on 6/5/26, regarding R1's current mobility status and how she should have been transferred.During an interview on 6/24/26 at 2:20 p.m., RN-C stated R1 was confused and seemed to get worse in the evening. R1 was impulsive, had poor memory, needed constant reminders to not self-transfer, and lacked safety awareness. R1's care planned interventions included: appropriate footwear, fall mat, non-weight bearing that was changed to TTWB by therapy, call light, and assist with sitting in recliner in commons area. Staff would be expected to follow the care plan which meant R1 should have ambulated with therapy only due to weight restrictions, TTWB, and pivot transfer only. RN-C stated staff should not ambulated R1, they are not trained therapists, were unable to know if R1 maintained the TTWB restriction and placed her at risk of becoming unsteady, falling, and injuring the right hip.During an interview on 6/24/26 at 2:43 p.m., licensed practical nurse (LPN)-C stated R1 was confused, forgetful, impulsive, and had poor safety awareness. On 5/17/26, R1 was found kneeling on the floor by the side of her bed. LPN-C stated she was unable to recall hearing the alarm go off, was unsure if the bed alarm was used, and the NA could have turned it off, but was unsure. LPN-C stated it would be important for the bed alarm to be used to alert staff R1 had gotten herself up and prevented a fall. LPN-C stated a fall would have placed R1 at risk for hip displacement and/or a hematoma.During an interview on 6/24/26 at 2:55 p.m., LPN-A stated on 5/18/26, R1 had an unwitnessed fall in her room by the bathroom, and the chair alarm was not connected. LPN-A stated the chair alarm was usually clipped to R1's back, R1 may have removed it herself, usure if she could have reached it or remembered it was there. LPN-A stated the NA was asked and indicated she had placed the chair tabs alarm on R1. LPN-A stated that R1's falls could possibly be related to the displacement of her hip, unsteadiness of the hip, and extended the healing process due to trauma.During an interview on 6/24/26 at 4:30 p.m., LPN-B stated R1 was pleasantly confused when she was first admitted and the confusion worsened quickly. R1 attempted to self-transfer many times and lacked safety awareness. LPN-B stated she observed R1 self-transfer and push her wheelchair while she walked behind it independently from the dining room. LPN-B stated she intervened, reminded that R1 assistance for transfers was needed, and R1 stated her right hip was sore. Additionally, R1 was known to self-transfer out of bed on the night shift, taking herself to the bathroom, and staff were aware of the need to keep eyes on her to help prevent a fall.During an

Based on interviews and document review the facility failed to update the care plan and implement care plan interventions for 1 of 3 residents (R1) reviewed for care plan updates and implementation.Findings include:R1's admission Minimal Data Set (MDS) dated [DATE], identified severely impaired cognition without behaviors. R1 required partial to moderate assistance for sit to stand, substantial/maximal assistance with toileting hygiene, lying to sitting on bedside, all transfers, unable to walk, and used a manual wheelchair for mobility. R1's diagnoses included fractures, anemia, non-Alzheimer's dementia, and anxiety. R1 used a bed alarm daily.R1's Fall Risk assessment dated [DATE] at 8:32 a.m., identified a score of 12 and indicated high risk for falls. R1 was disoriented, had one to two falls in past three months, was chair bond, and continent. Clinical suggestions: rubber-soled shoes or nonskid slippers worn for ambulation, utilizing toileting program and personal/pressure sensor alarms.Recliner Use and Potential Physical Restraint Determination completed on 5/18/26, identified purpose of recliner use was behavioral management and fall prevention. R1 made aware of these and agreed to sit in common area for safety monitoring. Care Plan Compliance: recliner use is included in care plan, goal of use is clearly defined (comfort, positioning, etcetera), and care plan updated with changes in condition. Recliner supports clinical goal: positioning/comfort. R1's Falls care plan dated 5/26/26, identified: Silent bed alarm. Date initiated: 5/14/26.Place call light within reach and remind R1 to use it for assistance for safety. Date initiated: 5/14/26.Fall mat to side of bed and bed at lowest position. Date initiated: 5/18/26.Assist to the recliner in the common area as needed (PRN) for comfort, correct positioning and evaluation of bilateral edema to alleviate edema. Date initiated 5/18/26.Anticipate needs due to self-transfers. Date revised: 6/17/26.R1's care plan failed to include the following information: tab alarm as an intervention for falls, direction to keep R1 out of her room as an intervention for falls and recliner in commons area as an intervention for behavior management.During an interview on 6/23/26 at 12:31 p.m., NA-D stated R1 had dementia, self-transferred, and was a high risk for falls. R1 was a stand pivot with assist of two at first then changed to assist of one, and staff were not to be walking her, no weight was to be placed on her right leg/foot due to the fracture. NA-D stated staff were expected to follow the care plan and/or Kardex located on the computer: keep a close eye on her, prevent her from being left in her room alone, and use bed and chair alarms to let staff know she was trying to self-transfer. NA-D stated she had caught R1 many times in her wheelchair after she had self-transferred, R1 had forgotten about her fractured hip.During an interview on 6/23/26 at 1:30 p.m., NA-B stated R1 was a high risk for falls and staff used a bed alarm, chair alarm, and parked her in the commons area to keep a close watch on her. R1 was not to be left in her room alone. NA-B stated there were times when R1 self-transferred in her room while she worked and unable to remember if she attached the chair alarm to R1's clothing 6/11/26. NA-B stated on 5/27/26, she was working, applied the chair alarm to R1's clothing and later heard over the walkie R1 had self-transferred herself in the commons area and fell.During an interview on 6/24/26 at 2:00 a.m., RN-A stated R1 was confused, oriented to self only, and high risk for falls. R1 had a total of three or four falls since admission while she tried to self-transfer. RN-A stated R1's interventions in place to help prevent falls: stand pivot with assist of two staff to keep her safe due to TTWB (toe-touch weight bearing), decreased cognition, and impulsiveness. R1's additional interventions included bed alarm, chair alarm, and fall mat on both sides on the floor by the bed.During an interview on 6/24/26 at 2:20 p.m., RN-C stated R1 was impulsive, poor memory, needed constant reminders to not self-transfer, and lacked safety awareness. R1's interventions included in her care plan: appropriate footwear, fall mat, TTWB, call light, and assist with sitting in recliner in commons area. RN-C stated the chair tabs alarm was not included on the care plan and should have been so the alarm was placed by staff to help prevent falls. Staff would be expected to follow the care plan.During an interview on 6/24/26 at 2:55 p.m., LPN-A stated on 5/18/26, R1 had an unwitnessed fall in her room by the bathroom, and the chair alarm was not connected. LPN-A stated the chair alarm was usually clipped to R1's back, she may have removed it herself but was unsure if she could have reached it or remembered it was there. LPN-A stated the NA was asked and she indicated she had placed the chair tabs alarm on R1. LPN-A stated on 6/11/26, around 6:50 p.m., she had seen R1 before she went on break in her wheelchair with her legs elevated and wedge positioned between her legs. LPN-A went on break and came back at 7:23 p.m. and saw R1 wheeling herself down the hallway with no wedge between her legs, with her feet on the footrests in down position, knees bent. LPN-A stated she was quite surprised when R1 informed her she had taken herself to the bathroom and removed the wedge from between her legs. LPN-A stated R1's chair tabs alarm was not attached to R1's clothing and clipped on the back of the wheelchair instead. LPN-A asked NA about the tab alarm and she admitted she had forgotten to attach it to the resident.During an interview on 6/24/26 at 4:30 p.m., LPN-B stated R1 attempted to self-transfer many times and lacked safety awareness. LPN-B stated there was a time when she observed R1 had self-transferred and pushed the wheelchair while she walked behind it independently from the dining room. Additionally, R1 was known to self-transfer out of bed on the night shift, taking herself to the bathroom, and staff were aware of the need to keep eyes on her to help prevent a fall. R1 started to fall right after admission to the facility, she was not to be left in her room alone so staff could have kept a closer watch on her. LPN-B stated R1's care plan did not include a chair tabs alarm or direction keep resident out of her room to prevent falls. Staff were expected to follow R1's care plan otherwise she would have been placed at risk for a fall or injury to the hip.During an interview on 6/25/26 at 2:00 p.m., director of nursing (DON) stated she expected staff to follow R1's care plan. DON stated staff had constantly reminded R1 she had a fractured leg/hip, had surgery, and restrictions on weight she could have placed on the right foot. DON stated once the chair tabs alarm was in place it should have been added to the care plan, within one hour, so staff would know how to provide care for R1. A tab alarm was used to alert staff when R1 was attempting to transfer herself out of the wheelchair. DON stated the chair tabs alarm should have been placed on her back, out of reach, and the string needed to be shortened. R1 was unable to self-transfer safely, did not know what to do or comprehend what the restrictions were. DON stated contributing factors that led to R1's fall were confusion, infection, anemia, unsteady balance, and possibly pain.Facility policy Care Planning/Interdisciplinary Team dated 6/9/26, identified development of an individualized comprehensive care plan shall be completed for each resident. The interdisciplinary team must review and update the care plan: when there has been a significant change in the resident's condition, the desired outcome is not met, the resident has been readmitted to the facility from a hospital stay and at least quarterly in conjunction with the required quarterly MDS assessment. The care plan serves as the resident's individualized plan of care and provides direction for safe and appropriate care delivery. All staff are required to review, understand, and follow each resident's current care plan at all times. Failure to follow a resident's care plan may result in corrective action, up to and including immediate removal from duty for the remainder of the shift, re-education, competency testing, disciplinary action, termination of employment, and/or the filing of a Vulnerable Adult (VA) report when warranted such as if a resident experienced injury, harm, or potential harm, and an investigation completed. Any instance in which a resident's care plan is not followed must be reported immediately to the charge nurse or supervisor for assessment, follow-up, and documentation.

Based on interview and document review the facility failed to ensure the clinician documented a clinical rationale for the continued dose of a PRN (as needed) medication for 1 of 1 residents reviewed who used PRN Lorazepam (used for the management of anxiety disorders, the short-term relief of symptoms of anxiety or anxiety associated with depression). Findings include: R1's admission Record indicated he admitted to the facility 11/22/23. Diagnosis included depression, psychotic disorder with delusions, pain, weakness, anxiety and Alzheimer's. Facility documents dated 3/15/25, 3/28/25, 4/11/25, indicated verbal orders confirmed by facility staff: Lorazepam oral tablet 0.5 milligrams (mg). Give .5 mg by mouth every eight hours as needed for anxiety. The orders did not include a clinical rationale for continued use of the PRN order. R1's Order Summary Report dated 3/14/25 through 5/31/24, indicated the following orders: - 3/15/25, Lorazepam oral tablet 0.5 mg. Give .5 mg by mouth every eight hours as needed for anxiety. End date 3/25/25. - 3/28/25, Lorazepam oral tablet 0.5 mg. Give .5 mg by mouth every eight hours as needed for anxiety. End date 4/11/25. - 4/11/25, Lorazepam oral tablet 0.5 mg. Give .5 mg by mouth every eight hours as needed for anxiety. End date 4/25/25. - 4/25/25, Lorazepam oral tablet 0.5 mg. Give .5 mg by mouth every eight hours as needed for anxiety. End date 5/9/25. - 5/9/25, Lorazepam oral tablet 0.5 mg. Give .5 mg by mouth every eight hours as needed for anxiety. End date 5/23/25. A facility document titled Psychotropic Medication Gradual Dose Reduction Attempts dated 4/30/25, identified Lorazepam 0.5 mg twice daily and PRN. Target behavior indicated agitation. Nursing summary indicated, mood had been good, eating and sleeping well. Sees psychiatric provider. No issues currently. Is gradual dose reduction possible at this time? the form was checked NO (if NO, clinical rationale must be documented below). The section, Clinical rationale other than listed above, was left blank. The form was signed by the physician on 4/31/25. During interview on 5/15/25 at 10:46 a.m., the director of nursing (DON) stated they had recently had some of the PRN medications drop off so they had developed a process to have the providers write new order on Fridays for the ones that were coming due. The DON indicated she was not aware the provider was required to document a clinical rationale for the ongoing use of PRN medications. Facility Policy Psychotropic Medication Use and Behavioral Monitoring dated 6/17/21, indicated the need to continue PRN orders for psychotropic medications beyond 14 days required that the practitioner document the rationale for the extended order.

Based on observation, interview and document review, the facility failed to ensure soiled and potentially contaminated laundry was sorted in a manner to reduce the risk of cross contamination and spread of infection. This had the potential to affect all 38 residents who utilized laundry services. Findings include: On 6/25/24, a laundry tour was completed with housekeeper (HSK)-A. HSK-A stated dirty laundry from the nursing floor came down to the laundry room in barrels. The resident laundry went into one cart, the facility laundry (such as sheets or soaker pads); and kitchen laundry in another cart. The facility did not send out any of their laundry and all laundry was washed at the facility. If resident or facility laundry were contaminated with urine or feces, the nursing staff were to rinse the laundry items out and put them into a black bag. HSK-A would take the bagged laundry and rip it open over the small wash machine and pre-wash it, before adding it back with the other laundry to be washed. No other laundry was bagged and came down in the dirty barrels loose. There were no gowns observed in the sorting area. - HSK-A put on gloves and sorted the laundry into different carts. After sorting the soiled laundry HSK-A wheeled the cart to the washer and loaded into the washer. HSK-A removed her gloves and washed her hands. HSK-A stated she always put disposable gloves on but had never been instructed to wear a disposable gown to sort the dirty laundry. HSK-A could see how it would be important to wear a personal protective gown over her uniform when sorting the soiled laundry but had never been told to wear one. HSK-A remembered they had worn a protective gown in the past when the facility had residents with COVID or Clostridium difficile (contagious infection). During interview on 6/25/24, at 12:45 p.m. the infection control preventionist stated she was not aware laundry staff were not using personal protective equipment (PPE) to sort soiled laundry and it would be important to wear PPE for the task to avoid contamination of their uniforms. When interviewed on 6/25/24, at 3:00 p.m. the director of nursing (DON) stated she was not aware laundry staff were not utilizing PPE to sort soiled laundry and that would be an infection control issue as there was a possibility for the staff to contaminate their uniforms. The facility Soiled Laundry and Bedding policy dated 7/25/23, identified anyone who handled soiled laundry must wear protective gloves and other protective equipment as needed.

Based on interview and document review, the facility failed to ensure registered nurse hours were submitted accurately on the payroll-based journal. This had the potential to affect all 30 residents residing in the facility. Findings include: The PBJ (payroll-based journal) Staffing Report CASPER Report 1705D FY [fiscal year] Quarter 2 2024 (January 1 - March 31) identified a a trigger for no registered nurse (RN) hours on the following days: 2/24, 3/9, 3/10, 3/17, 3/24 and 3/31. The facility payroll and working scheduled were reviewed for 2/24, 3/9, 3/10, 3/17, 3/24 and 3/31 and there was a RN working for 8 hours consecutively on all 6 days identified on the PBJ report. During interview on 6/27/24, at 9:55 a.m. the administrator confirmed there were RNs scheduled per the requirements on the identified days and was not sure why the PBJ report was inaccurate. She would need to look into it further to identify the reason.

Based on observation, interview and document review, failed to implement timely transmission based precautions (TBP) and testing according to the Centers for Disease Control (CDC) for 2 of 2 residents (R6, R33, R27) who were displaying COVID-19 symptoms; and the facility failed to conduct COVID-19 outbreak testing was conducted according to CDC guidance for 13 staff (DA-B, C-A, C-B, HSK-A, BUS-A, BUS-B, SS-A, MED-A, NA-J, NA-K, NA-L, NA-M and NA-N) who worked without participating in outbreak testing; and failed to ensure surveillance tracking of infections was completed for staff and residents. This had the potential to affect all residents and staff. Findings include: The Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 5/8/23, identified when performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction ' s public health authority. - A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. - The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. - Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Due to challenges in interpreting the result, testing is generally not recommended for asymptomatic people who have recovered from SARS-CoV-2 infection in the prior 30 days. Testing should be considered for those who have recovered in the prior 31-90 days; however, an antigen test instead of a nucleic acid amplification test (NAAT) is recommended. This is because some people may remain NAAT positive but not be infectious during this period. - In the event of ongoing transmission within a facility that is not controlled with initial interventions, strong consideration should be given to use of Empiric use of Transmission-Based Precautions for residents and work restriction of HCP with higher-risk exposures. In addition, there might be other circumstances for which the jurisdiction ' s public authority recommends these and additional precautions. - If no additional cases are identified during contact tracing or the broad-based testing, no further testing is indicated. Empiric use of Transmission-Based Precautions for residents and work restriction for HCP who met criteria can be discontinued as described in Section 2 and the Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2, respectively. - If additional cases are identified, strong consideration should be given to shifting to the broad-based approach if not already being performed and implementing quarantine for residents in affected areas of the facility. As part of the broad-based approach, testing should continue on affected unit(s) or facility-wide every 3-7 days until there are no new cases for 14 days. If antigen testing is used, more frequent testing (every 3 days), should be considered. The CDC Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 updated 9/23/22, identified HCP with even mild symptoms of COVID-19 should be prioritized for viral testing with nucleic acid or antigen detection assays. When testing a person with symptoms of COVID-19, negative results from at least one viral test indicate that the person most likely does not have an active SARS-CoV-2 infection at the time the sample was collected. If using NAAT (molecular), a single negative test is sufficient in most circumstances. If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining work restrictions and confirming with a second negative NAAT. If using an antigen test, a negative result should be confirmed by either a negative NAAT (molecular) or second negative antigen test taken 48 hours after the first negative test. For HCP who were initially suspected of having COVID-19 but, following evaluation, another diagnosis is suspected or confirmed, return-to-work decisions should be based on their other suspected or confirmed diagnoses. R6's significant change in status Minimum Data Set (MDS) dated [DATE], identified R6 was [AGE] years old and had intact cognition. Diagnoses included diabetes, peripheral vascular disease, and cardiomyopathy. During observation on 9/12/23 at 4:14 p.m. a PPE cart was outside R6's room and a contact precautions sign on the residents door. LPN-F stated R6 was not feeling well and tested positive for COVID-19 earlier that day. R6's nursing progress note dated 9/12/23 at 4:35 p.m., identified R6 complained of weakness, exhaustion and headache. COVID-19 positive. During interview on 9/12/23 at 5:06 p.m., LPN-F stated she recently tested R6 for COVID-19. LPN-F stated she wore a surgical mask, gloves and prescription glasses when she administered the COVID-19 antigen test. LPN-F stated she did not wear a gown, N95 mask or eye protection other than prescription eye glasses. During interview on 9/14/23 at 3:07 p.m., the director of nursing (DON) stated staff are expected to wear full PPE when testing residents for COVID-19. R33's quarterly MDS dated [DATE], identified R33 was [AGE] years old and had a severe cognitive impairment. Diagnoses included atrial fibrillation (irregular heartbeat), hypertension, and anemia. R33's nursing progress notes dated 9/11/23 at 12:50 p.m., identified R33's testing for the facility's COVID-19 outbreak was negative. - On 9/12/23 at 1:24 p.m., R33 was seen during doctor rounds and staff were awaiting orders. The note did not identify R33's symptoms. - On 9/12/23 at 7:42 p.m., staff toileted R33 at 3:00 p.m., and was R33 was weak and shaky. R33 required assist of two persons to transfer to toilet. R33 had loose stools with scant amount of blood due to hemorrhoids. The nurse was updated and the nurse attempted to test for COVID; however, R33 refused by turning head away from staff and stating no. Reassessed R33 at this time. Blood pressure (BP) 168/82, temperature 98.9 degrees Fahrenheit (F), pulse 76, respirations 18, and oxygen saturations 96%. R33's lung sounds were clear throughout with no cough noted. Staff were unable to determine if R33 had other symptoms such as congestion or sore throat. R33 allowed a COVID-19 test be to be completed at 7:30 p.m. which resulted positive. R33 had been in her room that shift. On 9/12/23 at 4:53 p.m., licensed practical nurse (LPN)-F stated R33 was feeling weak, clammy, tired and had diarrhea. LPN-F entered R33's room wearing a surgical face mask, prescription glasses and was carrying a COVID-19 test. LPN-F placed the COVID-19 test kit on the dresser, walked around to the right side of R33's bed, leaned down and reached under R33's right shoulder to physically lift and adjusted the residents head towards the middle of the bed and onto the pillow. LPN-F walked back towards the dresser that was on the left side of the bed. LPN-F put gloves on, picked up the COVID-19 nasal swab, leaned over the left side of the bed and reached across the residents body to insert the swab into R33's nares. State Agency (SA) intervened. LPN-F stopped the testing effort and stated when conducting a COVID-19 test on a resident staff should wear full PPE including a gown, gloves, N95 mask and eye protection other than prescription glasses. LPN-F exited R33's room, threw the unused COVID-19 test into the garbage, used hand sanitizer and went to get another COVID-19 antigen test. LPN-F returned with a new COVID-19 test, donned full PPE, entered residents room, prepped supplies and attempted to swab R33's nares for the test. R33 turned her head down toward the blanket and refused multiple times to have the test administered. LPN-F stood, walked from the bed, threw the unused COVID-19 testing swab in the garbage, removed and disposed of the PPE she had been wearing. During observations on 9/12/23 at 5:20 p.m., R33 was in her room however, there was no sign on R33's door identifying TBP or supplies for TBP outside the door. -at 5:23 p.m. R33's call light was turned on. Nursing assistant (NA)-P and NA-M entered R33's room without putting on personal protective equipment (PPE) (isolation gown, gloves, goggles, and N95 mask). -at 5:26 p.m. NA-P and NA-M exited R33's room and proceeded to help other residents. -at 5:27 p.m. R33's call light was turned on and NA-I entered room without putting on PPE. Then NA-I exited the room and turned the call light off. -at 5:28 p.m. R33's call light was turned on. -at 5:29 p.m. NA-M entered R33's room and did not put PPE on. -at 5:30 p.m. NA-P entered R33's without putting on PPE. -at 5:31 p.m. NA-M exited R33's room and entered two separate units to assist residents to supper. -at 5:32 p.m. NA- exited R33's room and proceeded to assist other residents in the facility. -at 8:01 p.m. R33 was in their room and on TBP. During interview on 9/12/23 at 8:00 p.m., LPN-F stated R33 allowed staff to administer the COVID test and R33 tested positive for COVID-19. R27's annual MDS dated [DATE], identified R27 was [AGE] years old, had severe cognitive impairment. Diagnoses included Alzheimer's disease, hypertension, and anxiety. R27's nursing progress note dated 9/11/23 at 12:49 p.m., identified R27's testing for the facility's COVID-19 outbreak was negative. During observation on 9/12/23, at 4:44 p.m. R27 was wheeling around in the common area with other residents around. R27 was not on TBP. During an interview on 9/13/23 at 4:30 p.m., the DON stated she identified R27 had symptoms of a cough and runny nose on 9/10/23, was tested with an antigen test which resulted as negative. R27 was again tested on [DATE]. R27 was not placed into isolation due to symptoms until a confirmatory test was collected after 48 hours on 9/12/23. R27's medical record nor the infection prevention surveillance logs identified this. The DON stated she expected staff to notify the IP of all possible infections and also expected the tracking and tending of all infections to prevent possible transmission. R27's medical record lacked information related to the signs and symptoms of potential COVID-19 infection. The facility Infection Surveillance log for September 2023, identified the onset date, resident name and room number, infection site, symptoms/signs, test culture pathogen, diagnosis and antibiotic order/physician-provider. The data included R29's COVID-19 diagnosis; however, the log did not include R6, R33, nor R27 for COVID-19. During an interview on 9/13/23 at 11:22 a.m. RN-A and LPN-B stated whenever a resident exhibited any sign/symptom of illness they would complete an assessment, an overall check. Does the resident have a fever and/or cough? LPN-B stated at that time they would also collect a COVID-19 antigen test. If the test was negative, staff might call the provider and also enter a nursing progress note. LPN-B nor RN-A stated they would notify the IP or the DON if the test was negative. RN-A stated she would never place a symptomatic resident who had tested negative for COVID-19 into isolation because that would be unwarranted nor was a confirmatory test required. RN-A stated R33 was tested on [DATE], due to being symptomatic, was not placed into isolation, was seen by the provider, but tested positive the evening of 9/12/23. At that time, R33 was placed into isolation because she was confirmed positive for COVID-19. During an interview on 9/14/23 at 12:48 p.m., the IP stated she normally attended the Interdisciplinary Team Meeting (IDT) and was informed of possible infections. Upon review of the September Infection Surveillance log, the IP stated it was up to date until the evening of 9/12/23. The IP did not usually put all symptoms on the tracking log because some things would resolve without treatment. STAFF ILLNESS: During an interview on 9/13/23 at 1:13 p.m., NA-D stated on 9/12/23, NA-D felt hot/cold, just not feeling well. NA-D tested at home and was negative for COVID-19. NA-D told the nurses during report she tested negative on 9/12/23, at home then tested in the facility on 9/13/23, with an antigen test. If NA-D had continuing symptoms NA-D would have stayed home but tested negative so came to work as usual. Staff only needed to stay home if they tested positive. NA-D received an email that would pop up on her phone telling her when to test. Staff used to test twice a week, but she really did not know anymore. The facility's infection preventionist (IP) had not told the staff yet when they were supposed to test again but would probably tell them later in the week. NA-D could not say who she reported to her symptoms and test to. NA-D illness symptoms and home test were not listed on the September staff illness log. During an interview on 9/13/23 at 1:15 p.m., LPN-B stated she found out she needed to wear a mask in the facility when she had arrived to work on 9/12/23, and someone told LPN-B there was COVID-19 in the building and everyone had to test. That morning on 9/13/23, the IP told everyone over the walkie-talkie to test again. LPN-B stated she did not work at the facility often and just knew she had to test every time she worked. During an interview on 9/13/23 at 1:17 p.m., DA-A stated staff had to test and wear a surgical mask in the building because there was COVID-19. DA-A stated he thought staff had to test twice a week but was not really sure. Staff received an email and the nurses gave verbal reminders too. During an interview on 9/13/23 at 1:18 p.m., RN-A stated she found out she needed to test for COVID-19 while she was in morning report with the other staff. Staff used to come to work early and they had to know their results before starting work, but that morning RN-A just went to the nurses' station to test. Outbreak testing used to be twice a week but she would test whenever she was told to. During an interview on 9/13/23 at 10:40 a.m., the facility IP stated staff had to follow the facility's call-in procedure. All staff had to report to the charge nurse. The charge nurse filled out an absence form and then gave the form to the IP because she did payroll duties as well. The absence form was for any type of absence, [NAME], etc. The charge nurse gave the form to the department supervisor who signs the form and forwards it to the IP. At that time, the IP would do a follow up with the staff member. Most supervisors emailed the IP to let her know and she would look at her email Monday through Friday between 8:00 a.m. and 3:00 p.m. when she was in the facility. For example, if she received an email at 4:00 p.m. on Friday, the IP would not read that email until Monday morning. For immediate weekend or after hour concerns, the staff should send a text to the IP; however, it really depended on the supervisor and/or department because not all departments worked weekends or aft/er hours. The nurses should collect all the data they needed /and go forward with whatever option they thought was best for them. Nursing did not call the IP with any questions because there was an on-call RN as well. - The facility utilized COVID-19 antigen tests on the staff and residents. Staff would come to the IP office and swab themselves, then the IP would complete the rest of the test. Any staff member would always have access to a test. If the IP was working, staff would swab and test themselves, then record the results on the testing sheets. The IP collected the sheets every day. Additionally, staff were able to test at home with an over-the-counter test. - NA-A reported symptoms in the afternoon on 9/9/23. NA-A worked that day and also worked 9/8/23. NA-A's family member who lived with NA-A tested positive so NA-A wore a surgical mask on 9/8/23 and 9/9/23. NA-A reported to the nurses station, tested positive and was sent home. Because 9/9/23, was a Saturday, nursing emailed the IP. - On 9/11/23, the IP put signs on the doors identifying the facility was in outbreak status and conducted whole house testing with the residents and staff in the building because it was too difficult to identify potential high risk exposures. However, there were additional staff positive COVID-19 cases. LPN-A tested positive at home on 9/10/23. LPN-A tested positive at home on 9/10/23. Trained medication assistant (TMA)-A reported sneezing and tired on 9/10/23. She worked 9/9/23, 9/10/23 and 9/11/23. On 9/11/23, TMA-A was tested at the facility, was positive, and was sent home. LPN-C tested positive at home as well on 9/10/23. LPN-C last worked in the facility on 9/8/23; however, the absence form did not identify symptoms or when symptoms started. - All staff who worked tested because they knew to test; however, the IP did not go back through the testing log to verify all staff tested . New testing guidance was distributed in August 2023, but she had not reviewed the guidance and would need to look it up. On 9/11/23, IP sent an email to everyone telling them to test prior to work and to wear a mask. Staff were able to test any time during their shift. If they started work at 7:00 a.m., they could test at 10:00 a.m. The IP kept all the Staff Testing: BinaxNOW COVID-19 Ag Card lists in a binder in her office and also kept a running list. The IP told the department managers to remind their staff; however the IP did not review schedules to verify all staff tested . Since 9/11/23, the IP was unaware of any staff who had not tested . At the end of the outbreak, the IP would review the working list and put together an email for all the managers. The IP would do this whenever the IP had time. COVID-19 testing during an outbreak was important to ensure asymptomatic staff were not carrying the COVID-19 virus because it could lead to transmission to other staff and residents. The facility Staff Testing: BinaxNOW COVID-19 Antigen (Ag) Cards identified the following: - On 9/9/23, NA-A tested positive. - On 9/10/23, the following tested negative: LPN-E, trained medication assistant (TMA)-A, and NA-E. The following tested positive: TMA-A. - On 9/11/23, the following tested negative: LPN-A, LPN-D, LPN-E, NA-E, NA-F, and NA-G. - On 9/12/23, the following tested negative: registered nurse (RN)-B, LPN-B, and NA-H. - On 9/13/23, the following tested negative: NA-F and NA-I The facility staff illness log for September 2023, identified the following: - On 9/9/23, NA-A complained of a headache and chills. NA-A had an exposure to COVID-19 at home and had tested negative on 9/8/23. The cautionary measures were stay out of work. The log did not identify what type of test was conducted, when NA-A had worked in the facility and/or any potential high risk exposures. - 9/11/23, licensed practical nurse (LPN)-A complained of a headache and congestion and tested positive for COVID-19 at home. The cautionary measures were stay out of work. The log did not identify what type of test was conducted, when LPN-A had worked in the facility and/or any potential high risk exposures. - On 9/12/23, NA-B complained of congestion and fatigue. NA-B had reported a negative COVID-19 test was done at home on 9/11/23 and 9/12/23. The cautionary measures were stay out of work. The log did not identify what type of test was conducted, when LPN-A had worked in the facility and/or any potential high risk exposures. - On 9/13/23, NA-C complained of cough. NA-C tested negative for COVID-19 on 9/12/23. The log did not identify what type of test was conducted, when LPN-A had worked in the facility and/or any potential high risk exposures. The staff log failed to identify LPN-B nor TMA-A's illnesses or positive COVID-19 tests The facility provided staff testing log and the staff schedules for 9/11/23, 9/12/23 and 9/13/23, identified the following staff worked without participating in outbreak testing prior to their shift: - dietary aide (DA)-B worked on 9/12/23 and did not test. - cook (C)-A worked 9/12/23 and 9/13/23 and did not test. - C-B worked 9/12/23 and did not test. - housekeeper (HSK)-A worked 9/12/23 and 9/13/23 and did not test. - business office (BUS)-A worked on 9/11/23, 9/12/23, and 9/13/23 and did not test. - BUS-B worked 9/11/23, 9/12/23, and 9/13/23 and did not test. - social services (SS)-A worked 9/11/23, 9/12/23, and 9/13/23 and did not test. - medical records (MED)-A worked 9/12/23 and 9/13/23 and did not test. - NA-J worked 9/11/23 and did not test. - NA-K worked 9/11/23 and did not test. - NA-L worked 9/11/23 and did not test. - NA-M worked 9/11/23 and did not test. - NA-N worked 9/12/23 and 9/13/23 and did not test. During an interview on 9/14/23 at 1:30 p.m., director of nursing (DON) stated she expected staff to notify the IP nurse of all possible infection symptoms and also for all infection symptoms to be tracked to prevent possible transmission of communicable disease. The facility policy Staff Mass Testing for COVID-19 revised 2/21/22, identified testing completed at the facility would be at no cost to the staff. In the event of this pandemic, the facility would mandate testing for all staff. COVID testing could be done by RT-PCR (NAAT) or by antigen test. The policy lacked to identify when a symptomatic staff member should report symptoms and test, when to stay out of the facility, when a confirmatory test should be collected, nor frequency of outbreak testing. The facility policy Resident Mass Testing for COVID-19 revised 12/15/22, identified COVID testing could be done by RT-PCR or antigen testing. Residents that had not consented would be clearly indicated and no resident would be restrained or forced to complete the test. Residents who refused would be educated about the current COVID status in the facility and about proper PPE use for residents. The resident would be monitored for any COVID symptoms and placed under transmission based precautions if any symptoms arose. However, the policy did not direct staff to collect confirmatory tests for symptomatic residents who had tested negative nor directed staff to place symptomatic residents into isolation until a confirmatory test could be collected in a timely manner. 40948 42075

Based on observation, interview and record review the facility failed to administer physician's order as written for 1 of 3 (R2) residents reviewed for steroid inhalation which resulted in a diagnosis of oral thrush. Findings include: R2's significant change Minimum data set (MDS) dated [DATE], identified intact cognition with no behaviors. R2's diagnoses included chronic obstructive pulmonary disease (COPD), and respiratory failure. R2's care plan dated 4/5/23, identified R2 had respiratory/pulmonary concerns with COPD. Staff were instructed to give aerosol or bronchodilators as ordered, monitor for any side effects and effectiveness, and shortness of breath on exertion. R2's PHYSICIAN ORDER summary dated 8/10/23, identified: -Order date 4/1/23, identified oxygen at 2 liters (L) per nasal cannula as needed (PRN) to keep oxygen saturation level above 90% related to COPD. -Order date 7/25/23, DuoNeb solution 0.5/2.5 mg/ml (ipratropium/albuterol) one vial inhale orally via nebulizer every four hours as needed for shortness of breath and difficulty breathing related to COPD. -Order date 6/28/23, Ipratropium-Albuterol inhalation solution 0.5/2.5 mg/ml one dose inhale orally four times a day related to COPD. Rinse mouth after each nebulizer. -Order date 3/24/23, and discontinued 7/27/23, Budesonide inhalation suspension 0.5 mg/2 ml one inhalation orally two times a day for shortness of breath or wheezing. Rinse mouth after nebulizer treatment. -Order date 5/27/23, held from 6/20/23, through 7/1/23, and discontinued 7/25/23, Spiriva inhalation, aerosol solution 2.5 mcg two puffs inhale orally one time a day for asthma related to COPD. Review of R2's progress note on 6/27/23 at 4:40 p.m. R2 returned from NVHC visit with NP for follow up on COPD and R2 requested cough syrup for coughing. New orders identified: 1. Nystatin 5 ml four times a day for 10 days (for diagnosis of thrush) 2. Duo Nebs as previously order four times a day. 3. Rinse mouth after each nebulizer to prevent thrush. 4. Augmentin 875 mg twice a day times 10 days. 5. Prednisone 40 mg daily times five doses. R2's electronic medication administration record (EMAR) dated 6/1/23, through 6/27/23, indicated staff did not sign off indicating R2 rinsed mouth after administration of Budesonide (steroid) nebulizer treatment prior to diagnosis of thrush. During an observation and interview on 8/8/23 at 3:24 p.m. licensed practical nurse (LPN)-A sanitized hands, removed DuoNeb inhalant medication from box, completed checks with electronic medication administration record (EMAR), locked medication cart and computer screen, and entered R2's room. LPN-A checked R2's oxygen level 92%, applied gloves and prepared medication. LPN-A handed the nebulizer tube container to R2, instructed her to place mouthpiece in her mouth, turned nebulizer machine on, and said, I will be back in seven minutes and exited the room. At approximately 3:35 p.m. an unidentified staff requested assistance from LPN-A and walked down the hallway. R2 completed the nebulizer treatment, turned off nebulizer machine, and placed the tubing and mouthpiece onto the bedside table. At approximately 3:45 p.m. surveyor entered R2's room asked if she had anything to drink and R2 stated no, but now that you mentioned that I should have rinsed out my mouth after that nebulizer treatment. R2 took a sip of water, swished it around in her mouth and spit the water into the garbage can. R2 then stated, I think that is what I am supposed to do so the sores in my mouth do not come back. During a follow-up interview on 8/9/23 at 1:40 p.m. RN-A stated staff were expected to enter on R2's EMAR whether she rinsed her mouth or not after the nebulizer treatment was completed to prevent thrush. RN-D also verified when an X mark was entered on the EMAR she was unsure of what that meant. Review of R2's EMAR lacked evidence nursing staff documented R2's mouth rinse following her nebulizer treatments from June 1st, 2023 through survey exit. During an interview on 8/9/23 at 11:00 a.m. RN-B stated it was important to have R2 rinse after her nebulizer treatments as oral thrush was usually caused by a steroid inhalation medication and lack of rinsing the mouth afterwards. During an interview on 8/9/23 at 11:30 a.m. R2 sat in wheelchair in her room. R2 stated she had just finished her nebulizer treatment and turned off the machine. R2 also stated she had rinsed her mouth with water and spit it into the garbage can. R2 indicated the nurse must have gotten busy. R2 stated she had gotten thrush in her mouth and still had an awful taste in there, not sure if all the sores were gone yet. R2 indicated she needed reminders from staff to rinse her mouth after the breathing treatment and as did not always remember to do it. During a telephone interview on 8/9/23 at 1:07 p.m. nurse practitioner (NP) verified she had seen R2 on 6/27/23, in the Emergency Department (ED) due to increased breathing. NP indicated during that visit, R2 was diagnosed with thrush on soft palate, placed on Nystatin (used to treat yeast infections in the mouth) most likely caused by steroid inhalation (Pulmicort) and lack of rinsing her mouth out with water after the treatments. During a telephone interview on 8/9/23 at 1:25 p.m. pharmacist (P)-A stated anytime a resident received a steroid nebulizer treatment such as Budesonide (Pulmicort) nursing should have ensured R2 rinsed out her mouth to prevent thrush. During an interview on 8/9/23 at 2:30 p.m. trained medication assistant (TMA)-A stated R2's memory was fair but would be unable to remember to rinse her mouth out after her nebulizer treatment without reminders from staff. During an interview on 8/9/23 at 3:11 p.m. RN-C stated R2 was pretty much orientated but most likely could not remember to rinse mouth out with water after her nebulizer treatment and needed reminders. RN-C stated staff were expected to remind R2 to rinse her mouth out after the nebulizer treatments to help prevent thrush. During an interview on 8/9/23 at 4:30 p.m. director of nursing (DON) verified when an order was placed in PCC there were options to choose an add on (such as rinse mouth) and that add on was not completed when the steroid inhalant was placed on R2's EMAR. DON stated nursing staffed required cueing to rinse R2's mouth and that should have been recognized sooner. DON indicted the nurse on the medication cart were expected to have followed the recommendations regarding steroid inhalations to have prevented oral thrush. DON verified from 6/1/23, through 6/26/23, R2's medication administration record did not show mouth washes were completed and it was certainly possible that the lack of rinsing out R2's mouth increased her chance of getting thrush. DON stated if it was not documented as completed, it was not done. Facility policy titled Adverse Consequences and Medication Errors dated 8/15/21, revealed a medication error was defined as the preparation or administration of drugs which was not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of professionals providing services. An adverse consequence was defined as an unpleasant symptom or even that was due to or associated with a medication such as side effect. Facility policy titled Order Entry dated 6/28/23, revealed to ensure safe delivery of medications and treatments and prevent medication errors a nurse would be expected to add New Orders Checklist sticker to the original order and the following steps completed: a. Enter order into PCC then print. b. Order faxed to pharmacy if applicable. c. A second licensed nurse would have been required to verify the order was entered properly and initial the sticker. The second licensed nurse would also be expected to have placed the order in East/West file folder for the third check by night shift licensed nurse.

Based on interview and document review, the facility failed to implement their policy to ensure adequate resident protection and a thorough investigation following an allegation of abuse for 1 of 2 residents (R1) reviewed for abuse. Findings include: R1's annual Minimum Data Set, dated dated dated [DATE], identified intact cognition. R1's care plan dated 12/15/22, identified a self care deficit related to diagnosis of hypertensive encephalopathy and a history of transient ischemic attacks. A report to the state agency (SA) dated 12/29/22, indicated an incident occurred during a conversation between a facility staff member and R1, on 12/29/22, at 5:00 p.m. regarding R1's blood pressure. R1 stated trained medication aide (TMA)-A was upset and frustrated the other day. R1 stated TMA-A was yelling at her about all of her medication changes. R1 stated TMA-A handed her medications during the interaction and R1 said she would not take the medications until her blood pressure was checked. R1 said TMA-A was set off and grabbed the pill cup out of her hand. The report indicated R1 showed the staff member her hand. The staff member noted a couple of scratches to R1's left pinky finger. A facility investigation report dated 1/5/23, indicated the director of nursing (DON) met with R1 regarding the concern. R1 stated she had gone to see her physician earlier in the week and he had changed her medications again. R1 said she woke up on Wednesday and had breakfast in her room as usual and sometime after breakfast she felt dizzy and had a pain up her neck. R1 stated she did not report it as she thought it would pass. R1 said TMA-A came to her room around 11:00 a.m. with a plastic medication cup. R1 told TMA-A she felt dizzy and asked if she should have her blood pressure checked before taking her pills. R1 said she thought that had upset TMA-A who asked her to take the pills first to which R1 replied No, I don't want to take them without knowing my blood pressure. R1 stated TMA-A grabbed the cup out of her hand and said she felt a scratch on her finger at the time but did not think much of it until later. The report indicated R1 had two bruises on her fingers and a scratch. The report also indicated R1 stated as TMA-A was leaving her room she stopped in the doorway and said, If you saw a real doctor you would have a pill that worked without all these med changes every day. The report indicated R1 had two bruises on her fingers and a scratch. During interview on 1/5/23, at 2:20 p.m. TMA-A stated, I think this lady, I don't think she likes me. TMA-A stated she was concerned as R1 was her resident and said the scratch, the bruising, I would never do anything like that. TMA-A stated she had long nails and indicated that may have caused the scratch. TMA-A stated she brought the medications to R1 and she did not want to take them. TMA-A said we were both frustrated. TMA-A said she took the cup from R1 and had another staff give the medications. TMA-A stated she did not remember saying anything about the physician except they had changed the medications again. TMA-A stated after the incident she had worked with R1 the next day then was moved to the other unit. TMA-A stated the Friday after was her day off and said she got a phone call and was told she could not work on R1's wing and could not be around her but she continued to work with other residents. During interview on 1/5/23, at 4:51 p.m. R1 stated she had trouble with her blood pressure and had gone to her physician quite a bit. R1 stated the day before the incident she had been to the clinic and the physician changed her medication and the time it was given. R1 stated TMA-A brought her two pills and she asked to have her blood pressure taken because she had been dizzy. R1 said she told TMA-A she was not going to take the pills without checking her blood pressure because she was afraid her blood pressure would bottom out. R1 stated TMA-A grabbed the cup, she ripped it out of my hand and said she got a cut and some bruising. R1 said she wasn't going to say anything and said, I've heard her holler before. R1 stated after TMA-A ripped the cup out of her hand she stopped in the doorway and said, you could go to a real doctor and maybe something could get resolved and said she had never seen anyone with medication changes so many times. R1 stated she could see TMA-A was mad and said she had an angry look on her face. R1 stated it made her feel terrible. R1 further stated, I do feel like I was abused by her and I am afraid of her. She will probably come and say something to me like it's my fault. On 1/6/23, at 11:54 a.m. the administrator, DON and Social worker (SW) were interviewed. The DON stated a staff member had reported to her the conversation between R1 and TMA-A. The DON said initially R1 could not recall what day it had occurred but remembered TMA-A had been upset and talking with a raised voice. The DON said she went to R1's room and met with her and R1 shared the allegation with her. The DON stated R1 had a pinpoint mark on her finger and said it looked like a blood blister. The DON said the underside of R1's ring finger had faint blue bruising and some faint discoloration on the middle finger. The DON stated we feel there was a misunderstanding between [R1] and [TMA-A]. R1 thought [TMA-A] was upset with her. The DON said in reality [TMA-A] was worried and concerned about [R1]. The DON stated she did not feel TMA-A's behavior was appropriate and had written up an action plan to review with TMA-A, however, this had not been done yet. The DON stated she felt part of the problem was R1 and TMA-A had known each other for so long they treated each other more as friends instead of a professional relationship. The DON stated when she spoke with R1 she proposed they move TMA-A to the other unit. When asked if other residents had been interviewed for potential concerns the DON sated they had not talked to any other residents because they felt it was an isolated incident and did not feel other residents would have been harmed or affected. The DON said they had a conversation with TMA-A prior to her next shift but said she did not go into all the details. The DON said TMA-A was told she could not go to the east unit where R1 resided and could not have any interaction with R1. The DON said the hug in the dining room was brought to their attention the following Monday and she and the administrator had a conversation with TMA-A to discuss. The DON further stated TMA-A had not received any education but they planned to meet with her to present the corrective action plan and planned to have the staff development coordinator present education. The SW stated the immediate interventions was to not have TMA-A work with R1 and said R1 and her family was comfortable with that. The DON stated we truly did not feel suspension of [TMA-A] was warranted because we did not feel the other residents were at risk. A facility policy Reporting Mistreatment of Vulnerable Adults dated 7/11/22, indicated all residents have the right to be free form abuse, neglect, misappropriation of property and exploitation. The policy indicated the facility will follow all state and federal regulations for abuse prevention and protection of vulnerable adults. The policy further indicated for reports made alleging a facility employee as a perpetrator, appropriate action will be taken to protect the resident, up to and including removing the employee from the schedule pending the results of the internal investigation.

Based on interview and document review the facility failed to ensure 1 of 3 residents (R3) reviewed remained free from a significant medication error when Lorazepam (class of drugs known as benzodiazepines which act on the brain and nerves) was administered to R3 eight times the prescribed dose. Findings include: R3's quarterly Minimum Data Set identified severe cognitive impairment and indicated dependence on staff to complete activities of daily living. R3's care plan dated 12/28/22, identified a risk for pain and directed staff to administer medications as prescribed. R3's physician Order Summary Report dated 12/27/22, indicated Lorazepam oral tablet 0.5 mg. Place and dissolve 0.5 mg buccaly (in or near the cheek area) every four hours as needed for anxiety/restlessness and Lorazepam oral tablet 0.5 mg. Place and dissolve 0.5 mg buccaly every four hours for anxiety/restlessness. R3's Individual Narcotic Record indicated name of drug and dose: Lorazepam 0.5 mg. The record indicated on 12/27/22, at 8:54 a.m. LPN-A administered 1 tablet (.5 mg) of Lorazepam. An entry dated 12/27/22, with no time documented indicated LPN-A administered nine tablets (4.5 mg) of Lorazepam. A facility Medication/ Treatment Error Report dated 12/27/22, indicated medication as ordered: Lorazepam 0.5 milligrams (mg). Description of error: gave 4.5 mg. Staff member responsible was identified as LPN-A. The report indicated LPN-A verified the order but still heard it wrong and indicated staff to ask/inform prescriber that order needed to be written prior to dispensing. During interview on 1/5/23, at 3:10 p.m. the director of nursing (DON) stated the medication error occurred because LPN-A took a verbal order prior to the actual order being put into the system. The DON stated when she met with LPN-A she found out the hospice nurse had assessed R3 and gave a verbal order to administer Lorazepam because R3 was uncomfortable. The DON stated LPN-A repeated the dose back to the hospice nurse, then went to the registered nurse (RN) to clarify. The DON stated LPN-A was supposed to give Lorazepam 0.5 mg but gave 4.5 mg. The DON further stated she was still in the process of completing her investigation into the medication error but told LPN-A he needed to get written orders prior to administering medications. The DON stated she had not yet come up with a plan to proceed. On 1/5/23, at 4:22 p.m. RN-A stated she had completed the medication error form. RN-A stated the hospice nurse notified the physician who had responded I am not going to say it's okay because that's not what I ordered. RN-A said they were told to hold the next to doses and monitor R3 for side effects like sleepiness, breathing, stuff like that. RN-A stated she remembered the error because it was so significant but did not remember specific details because it had been awhile. RN-A stated she felt part of the problem was that LPN-A was a new nurse so he probably wouldn't have noticed the 4.5 mg was a high dose. During interview on 1/6/23, at 11:10 a.m. the hospice nurse practitioner (NP) stated she had been made aware of the error and had instructed staff to hold scheduled doses of Lorazepam until 8:00 p.m. and monitor R3. The NP stated I would say it was a fairly significant medication error and said she normally did not prescribe more than 2 mg. During interview on 1/6/23, at 12:44 p.m. the consulting pharmacists (CP) stated the potential side effects of the medication error included central nervous system depression, lethargy, and could increase the risk for falling. The CP stated the nurse should have clarified the order as it was outside the usual parameters for Lorazepam. A facility policy Adverse Consequences and Medication Errors dated 8/15/21, indicated the DON evaluates medication usage in order to prevent and detect adverse consequences and related problems such as adverse drug reactions and side effects. In the event of a significant medication-related error, immediate action is taken as necessary to protect the resident's safety and welfare. Data and errors will be complied and presented to the quality assurance and performance improvement committee on a monthly or quarterly basis.

Based on interview and document review the facility failed to ensure 1 of 1 residents (R1) were treated with dignity and respect when a facility staff member aggressively took a cup from a residents hand, causing unintentional, minor injury and made a verbal statement to R1 causing R1 to feel bad about herself. Findings include: R1's annual Minimum Data Set, dated dated dated [DATE], identified intact cognition. R1's care plan dated 12/15/22, identified a self care deficit related to diagnosis of hypertensive encephalopathy and a history of transient ischemic attacks. A report to the state agency (SA) dated 12/29/22, indicated an incident occurred during a conversation between a facility staff member and R1, on 12/29/22, at 5:00 p.m. regarding R1's blood pressure. R1 stated trained medication aide (TMA)-A was upset and frustrated the other day. R1 stated TMA-A was yelling at her about all of her medication changes. R1 stated TMA-A handed her medications during the interaction and R1 said she would not take the medications until her blood pressure was checked. R1 said TMA-A was set off and grabbed the pill cup out of her hand. The report indicated R1 showed the staff member her hand. The staff member noted a couple of scratches to R1's left pinky finger. A facility investigation report dated 1/5/23, indicated the director of nursing (DON) met with R1 regarding the concern. R1 stated she had gone to see her physician earlier in the week and he had changed her medications again. R1 said she woke up on Wednesday and had breakfast in her room as usual and sometime after breakfast she felt dizzy and had a pain up her neck. R1 stated she did not report it as she thought it would pass. R1 said TMA-A came to her room around 11:00 a.m. with a plastic medication cup. R1 told TMA-A she felt dizzy and asked if she should have her blood pressure checked before taking her pills. R1 said she thought that had upset TMA-A who asked her to take the pills first to which R1 replied No, I don't want to take them without knowing my blood pressure. R1 stated TMA-A grabbed the cup out of her hand and said she felt a scratch on her finger at the time but did not think much of it until later. The report indicated R1 had two bruises on her fingers and a scratch. The report also indicated R1 stated as TMA-A was leaving her room she stopped in the doorway and said, If you saw a real doctor you would have a pill that worked without all these med changes every day. During interview on 1/5/23, at 2:20 p.m. TMA-A stated, I think this lady, I don't think she likes me. TMA-A stated she was concerned as R1 was her resident and said the scratch, the bruising, I would never do anything like that. TMA-A stated she had long nails and indicated that may have caused the scratch unintentionally. TMA-A stated she brought the medications to R1 and she did not want to take them. TMA-A said we were both frustrated. TMA-A said she took the cup from R1 and had another staff give the medications. TMA-A stated she did not remember saying anything about the physician except they had changed the medications again. During interview on 1/5/23, at 4:51 p.m. R1 stated she had trouble with her blood pressure and had gone to her physician quite a bit. R1 stated the day before the incident she had been to the clinic and the physician changed her medication and the time it was given. R1 stated TMA-A brought her two pills and she asked to have her blood pressure taken because she had been dizzy. R1 said she told TMA-A she was not going to take the pills without checking her blood pressure because she was afraid her blood pressure would bottom out. R1 stated TMA-A grabbed the cup, she ripped it out of my hand and said she got a cut and some bruising. R1 said she wasn't going to say anything and said, I've heard her holler before. R1 stated after TMA-A ripped the cup out of her hand she stopped in the doorway and said, you could go to a real doctor and maybe something could get resolved and said she had never seen anyone with medication changes so many times. R1 stated she could see TMA-A was mad and said she had an angry look on her face. R1 stated it made her feel terrible. R1 further stated, I do feel like I was abused by her and I am afraid of her. She will probably come and say something to me like it's my fault. On 1/6/23, at 11:54 a.m. the administrator, DON and Social worker (SW) were interviewed. The DON stated a staff member had reported to her the conversation between R1 and TMA-A. The DON said initially R1 could not recall what day it had occurred but remembered TMA-A had been upset and talking with a raised voice. The DON said she went to R1's room and met with her and R1 shared the story with her. The DON stated R1 had a pinpoint mark on her finger and said it looked like a blood blister. The DON said the underside of R1's ring finger had faint blue bruising and some faint discoloration on the middle finger. The DON stated we feel there was a misunderstanding between [R1] and [TMA-A]. R1 thought [TMA-A] was upset with her. The DON said in reality [TMA-A] was worried and concerned about [R1]. The DON stated she did not feel TMA-A's behavior was appropriate and had written up an action plan and planned to review it with TMA-A. The DON further stated TMA-A had not received any education but they planned to meet with her to present the corrective action plan and planned to have the staff development coordinator present education. At the time of survey, TMA-A had not received any education related to resident dignity and respect, resident rights or abuse training to ensure immediate correction. A facility policy Reporting Mistreatment of Vulnerable Adults dated 7/11/22, indicated all residents have the right to be free form abuse, neglect, misappropriation of property and exploitation. The policy indicated the facility will follow all state and federal regulations for abuse prevention and protection of vulnerable adults.

Based on observation, interview and document review, the facility failed to ensure voiced grievances concerning call lights were addressed and resolved to satisfaction for 2 of 2 residents (R1 and R3) who reported dissatisfaction with extended wait times for call lights to be answered or call light access. Findings include: R1's Admission Record indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/15/22, at 11:41 am. R1 was observed seated in a wheelchair in her room. R1 was not utilizing oxygen, however, there was an oxygen concentrator in the corner of the room. R1 stated she did not need to use oxygen all of the time, only when she was short of breath. R1 stated when she felt short of breath, she felt anxious like I will pass out. When queried if the staff members answered her call light timely, R1 stated call light response time was dependent upon which staff members were working. Sometimes the staff would respond timely, other times it would take a long time. R1 did not define a long time. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Progress Note (nurses note) dated 6/5/22, (**note FM-A reported the concern occurred on 6/4/22, however documentation identified the incident occurred on 6/5/22) indicated R1 had expressed concerns of shortness of breath. R1's oxygen saturation was 85% and the staff members had applied oxygen via nasal cannula. R1's oxygen saturation increased to 97% after 15 minutes. On 6/15/22, at 11:04 a.m. FM-A stated on 6/4/22, R1 was short of breath and the facility did not respond to her call light timely. FM-A stated the facility did not have enough staff to care for the residents and that was affecting their ability to answer call lights. FM-A stated he had attempted to talk to the facility staff members about his concerns but did not feel they had addressed his concern. On 6/15/22, at 4:42 p.m. the director of nurses (DON) stated the morning of 6/9/22, she had been notified FM-A had expressed a concern related to timely call light response to an unidentified facility staff member on the evening of 6/8/22. The DON stated the facility was actively conducting an internal investigation. The DON stated the licensed social worker (LSW-A) should follow up with FM-A. The DON confirmed she had not discussed the concern with FM-A. R3's Admission Record indicated a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Care Area Assessment (CAA) dated 7/21 revealed self-care performance deficit related to [CONDITION(S)] in both eyes, weakness, and mobility impairment. On 6/15/22, at 2:30 p.m. R3 was observed seated in a recliner in her room with oxygen on. R3 was a blind alert resident. R3 stated the staff members did not always respond to her call light timely and sometimes she was unable to reach her call light. R3 stated she needed to have her call light because she could not see things around her and needed assistance to find items she wanted. At 2:45 p.m. FM-B entered R3's room. FM-B stated he visited the facility 1-2 times per week and in a span of two weeks, he had found R3 without a call light within her reach. FM-B stated he had talked to the DON regarding his concern about R3 not being able to reach her call light. FM-B had informed the facility he was going to report the facility to the State Agency. FM-B stated the DON had informed him; she would report the concern to the State Agency. FM-B stated he had not had any further conversations with the facility regarding R3 not being able to reach her call light and was unaware of any action taken by the facility to resolve his concerns. Review of a Nursing Home Incident Report (NHIR) dated 5/26/22, revealed the facility had reported R3 was in her room for 46 minutes without her call light within reach on 5/26/22. R3's progress note dated 5/26/22, at 5:40 p.m. indicated FM-B had expressed concern to the facility related to R3 not having an accessible call light. R3's progress noted dated 5/26/22, at 6:15 p.m. indicated the DON had informed FM-B a report had been submitted to the State Agency. R3's progress notes from 5/2722 - 6/16/22 lacked further documentation related to the concern related to call light access or follow up with FM-B. On 6/15/22, at 3:10 p.m. LSW-A stated the facility had reviewed the hallway video surveillance and had identified the staff member responsible for R3 on 5/26/22. They had provided education to all staff members on the importance of ensuring call lights were within reach for all residents who were able to use them and completed call light audits to ensure compliance with call light response. When asked if LSW-A had followed up with the family member who had expressed the concern, LSW-A stated she was unaware of who FM-B was and therefore had not followed up with him. The facility Grievance Policy dated 5/23/22, indicated all residents receiving services at the facility had the right to voice grievances to the facilities grievance officer without fear of discrimination or reprisal. The policy identified the facility grievance officer by name as LSW-A. Any grievance could be submitted verbally or in writing. The policy directed the grievance officer to: - Be responsible for overseeing the grievance process. -Receive and track grievances through to their conclusion. -Lead any necessary investigation by the facility. -Maintain the confidentiality of all information associated with the grievance. -Issue written grievances decisions to the resident. -Coordinate with the State and federal agencies as necessary in light of specific allegation; and as necessary, taking immediate action to prevent further potential violation of any resident right while the alleged violation was investigation. -Investigation of the grievance were to be started 72 hours after the grievance was filled. -Grievance will be documented on the Grievance Report. -Grievance Reports were to be reviewed by the administrator before it is provided to the complainant. -Within 10 days of filing of the grievances, the final findings were to be provided to the complainant in writing, including the method of complaint resolution and/or plan of action. The results of the finding of the investigation were to be reviewed with the complaint in person by request. On 6/15/22, at 4:27 p.m. LSW-A stated she had been at the facility for five months and the facility had not received any type of formal grievances. LSW-A confirmed FM-B's concern regarding R3's call light being with reach was a complaint. The facility had submitted the concern to the State Agency and a follow up report had been submitted within 5 days which identified the facility had responded to the complaint by providing education to the staff and completion of call light audits. LSW-A reviewed the facility grievance policy and stated she was unaware of her responsibly follow up with the complainant and to maintain documentation. At 5:10 p.m. nursing assistant (NA)-D stated if a family member or a resident had a concern, she would report the concern to the charge nurse. The nurses were then to take care of the concern. At 5:21 p.m. licensed practical nurse (LPN)-C stated if a resident or family member had a concern, she would try to resolve the concern on her own. If it was a concern for a different department, she would notify the appropriate department. If she was not able to resolve the concern, she would notify the DON or administrator. At 5:30 p.m. NA-B stated any concerns expressed by a resident or family member would be reported to the charge nurse or the DON. On 6/16/22 at 7:15 a.m. LPN-B stated if a resident or a family member expressed a concern, she would direct them to report the concern to the facility administrator. At 7:23 a.m. registered nurse (RN)-A stated if a resident or family member expressed a concern, she would report the concern to the administrator or the DON. At 8:48 a.m. the administrator stated any concern/grievance identified by a resident or family member could be reported to the facility either verbally or in writing. The facility staff were then to investigate and process the concern until an acceptable resolution could be reached to satisfy both the complainant and the facility. LSW-A was to lead the investigations and ensure the facility had a system for tracking and documenting all grievances. The administrator confirmed FM-A had expressed multiple concerns over the past few years and she was aware of FM-B's concern due to call lights. The administrator stated she had reviewed the facility video surveillance for 6/4/22 and 6/5/22. R1's call light had been one for one minute not 30 minutes as reported. R3's concern related to not having her call light within reach had been reported to the State Agency. However, she was unaware the facility did not have a current system to track and document the grievances brought forward by residents or family members. She was also unaware the facility staff had not been following up with the complainants after a grievance had been expressed as directed by the facility policy.

Based on observation, interview and document review the facility failed to ensure timely repositioning to promote healing and prevent further pressure ulcer development for 1 of 1 residents (R25) reviewed for pressure ulcers. Findings include: R25's quarterly minimum data set (MDS) dated [DATE], identified R25 had severe cognitive impairment and required assist of two staff for turning and repositioning. R25 was at risk for pressure ulcers and used a pressure reducing mattress, a pressure reducing wheelchair cushion, and was on a turning/repositioning program. R25's Tissue Tolerance - V4 assessment dated [DATE], identified R25 had a dark red blanchable area of skin on the coccyx/buttocks and was scheduled to be turned/repositioned every two hours. R25's care plan dated 5/25/22, identified R25 was unable to independently sit up in bed, move extremities, ambulate or participate in any activities of daily living (ADL's). R25 was at risk for pressure ulcers due to a [CONDITION(S)]. The care plan directed staff to turn, reposition and apply barrier cream to R25's bottom every two hours and as needed. Continuous observation was conducted on 5/24/22, at 7:17 a.m. through 10:31 a.m. R25 was lying flat on his back. The head of the bed was elevated at approximately 25-30 degrees. R25 remained in the same position and no staff entered R25's room for a total of 2 hours and 53 minutes. During interview on 5/24/22, at 10:31 a.m. registered nurse (RN)-B stated staff repositioned R25 the morning of 5/24/22, around 6:40 a.m. and was not aware of if R25 was repositioned since 6:40 a.m. RN-B stated R25 should be repositioned every 2 hours. -At 10:35 a.m. R25 was repositioned by RN-B. During interview on 5/24/22, at 2:15 p.m. nursing assistant (NA)-A and NA-B stated they assisted R25 with repositioning the morning of 5/24/22, at approximately 6:30 a.m. and then again after lunch at approximately 12:45 p.m. NA-A and NA-B stated they had not repositioned R25 between 6:30 a.m. and 12:45 p.m. NA-A and NA-B stated R25 was supposed to be repositioned every 2 hours and as needed. - At 2:44 p.m. RN-A stated R25 should be repositioned every 2 hours as the care plan directs. RN-A stated R25 was at high risk for pressure ulcers and was not appropriate to wait nearly 3 hours to be repositioned. The facilities Repositioning policy revised 7/20/21, identified repositioning as an effective intervention for preventing skin breakdown, promoting circulation, providing pressure relief and was critical for an immobile or dependent resident. The policy further identified staff were to comprehensively assess the resident, develop a plan of care, document the plan on the resident's care plan, monitor/re-evaluate and report any changes to the supervisor.

Based on observation, interview, and document review the facility failed to maintain respiratory equipment per manufacturer's recommentation for 1 of 1 resident (R24) who required a bilevel positive airway pressure ([CONDITION(S)]- a type of ventilator that is used to treat sleep apnea) Finding include, R24's significant change Minimum Data Set (MDS) dated [DATE], identified R24 had no cognitive impairment. R24's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's Respiratory assessment dated [DATE], identified R24 used the [CONDITION(S)] daily. The nurse's aide care sheet dated 5/23/22, R24 had a [CONDITION(S)], and they were to check care plan for instruction or frequency for cleaning of the [CONDITION(S)]. R24's care plan 5/25/22, lacked instruction or frequency for cleaning of the [CONDITION(S)]. R24's medical record lack lacked instruction or frequency for cleaning of the [CONDITION(S)]. During an interview on 5/22/22, at 2:57 p.m. R24 stated she wore the [CONDITION(S)] every night and was unsure if the staff have ever cleaned it. R24 was observed on 5/24/22, at 9:03 a.m. and on 5/25/22, at 9:31 a.m. in bed with the [CONDITION(S)] on and running. During an interview on 5/25/22, at 9:33 a.m. nursing assistant (NA)-C stated she had not cleaned R24's [CONDITION(S)] and did not know how often it would need to be cleaned. During an interview on 5/25/22, at 9:37 a.m. licensed practical nurse (LPN)-A stated she believed the [CONDITION(S)] was on a schedule for cleaning once a week and would be completed and documented by the NA's. During an interview on 5/25/22, at 9:55 a.m. NA-D stated she thought the [CONDITION(S)] was cleaned monthly but was unsure. Instructions for cleaning would be on the NA point of care assignments (aide care sheet). She stated she had cleaned it once after resident was first admitted . During an interview on 5/25/22, at 10:31 a.m. NA-F she had not cleaned R24's [CONDITION(S)] and was unaware of how often it would need to be cleaned. During an interview on 5/25/22, at 10:36 a.m. LPN-A came back and clarified the [CONDITION(S)]'s were to be cleaned daily by the NA's on the evening shift and would be documented in point of care documentation. During an interview on 5/25/22, at 10:54 a.m. NA-G stated [CONDITION(S)]'s were to be cleaned daily on the evening shift and charted in the point of care. During an interview on 5/25/22, at 2:15 p.m. the director of nursing (DON) stated the regular procedure for residents who come in with a [CONDITION(S)] or a [CONDITION(S)] was to be cleaned daily and placed on the point of care charting and it would be the NA's responsibility. There were no instructions or frequency for cleaning R24's [CONDITION(S)] and would have expected it to be in the point of care. She was unsure if the [CONDITION(S)] had been cleaned because there was no documentation. The manufacturer's instructions for the [CONDITION(S)] identified mask and tubing was to be cleaned at a minimum of twice a week, or to follow facility policy. The facility's [CONDITION(S)]/[CONDITION(S)] Support policy dated 2/10/21, identified [CONDITION(S)] masks, nasal pillows, short tubing, and humidifiers are to be cleaned daily by placing in warm soapy water and soaking/agitating for 3-5 minutes. Would need to rinse with warm water and let air dry. The rest of the equipment for the [CONDITION(S)] was to be cleaned weekly.

Based on interview and document review, the facility failed to ensure an allegation of abuse was immediately reported to the State Agency (SA) for 1 of 3 residents (R1) reviewed for potential abuse. Findings include: R1's quarterly minimum data set (MDS) dated [DATE], identified R1 was cognitively intact and required supervision with transfers and toileting. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nursing Home Incident Reporting- Incident Report Summary 1 submitted to the SA on 11/2/21, at 12:58 p.m. identified an allegation of potential staff to resident physical abuse with potential for emotional or mental abuse. The report identified the date and time of the incident as 11/1/21, at 4:00 a.m.; however, the incident description identified R1's family member (FM-A) reported the allegation to the director of nursing (DON) on 10/28/21. Further, The facility internal investigation notes dated 10/26/21, identified the director of nursing (DON) received an e-mail from FM-A regarding a concern of alleged staff to resident abuse during cares. The DON replied to FM-A on 10/26/21, and indicated the facility would investigate the concern. The DON forwarded the e-mail chain to social worker designee (SS)-A on 10/26/21. During interview on 11/5/21, at 12:58 p.m. the DON stated the DON, administrator and SS-A met and discussed the concern and decided SS-A would submit the report to the SA. The next morning the DON searched the reported incident and could not find it. The DON stated SS-A thought she had 24 hours to report the incident and didn't think it needed to be reported immediately. The DON stated R1's alleged abuse should have been reported immediately The Reporting of Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . If an employee has knowledge of potential abuse it would be reported immediatly to their supervisor, who would then report to the administrator. Immediately: means as soon as possible, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on observation, interview and document review, the facility failed to ensure residents were free from ongoing abuse when repeat allegations were made against 1 of 1 resident (R2), who had increasingly agitated and aggressive behaviors towards others, and who had been observed by staff hitting and pushing other residents. This had the potential to affect all 38 residents who resided in the facility as well as visitors and staff. This failure resulted in an immediate jeopardy (IJ) due to the facility's failure to immediately implement interventions in order to protect residents from future abuse and injury. The IJ began on 3/26/19, at 5:32 p.m. when the director of nursing (DON), administrator, and social worker (SW) initially received a report of R2 walking into R21's room and punching R21 with a closed fist on the right side of the face, and the right shoulder/upper chest area. Although the administrator, DON and SW were aware of R2's history of aggressive and physically abusive behaviors towards others, they failed to identify and implement immediate interventions to protect residents from future occurrences, and failed to develop interventions to protect R2 from potential retaliation by other residents. The administrator and DON were notified of the IJ at 4:30 p.m. on 3/27/19. The IJ was removed on 3/29/19, at 11:53 a.m. but noncompliance remained at the scope and severity of Level G, actual harm that is not immediate jeopardy. The findings include: A Nursing Home Incident Reporting form submitted by the facility 3/26/19, at 6:48 p.m. indicated R21 had alleged R2 wandered into her room and punched her. The report indicated on 3/26/19, at 4:30 p.m. R21 was in her room seated in her wheelchair when R2 wandered into her room, and without speaking to R21 punched R21 on the right side of her face, shoulder and upper check with a closed fist. The report indicated R21 began yelling help me, help me, and staff came in and intervened directing R2 to exit R21's room. The report did not identify whether an injury occurred. The facility's Abuse Prevention Program revised (MONTH) (YEAR), indicated the facility would identify and assess all incidents of abuse, protect the resident during abuse investigations, implement changes to prevent future occurrences of abuse, and involve the resident council in monitoring and evaluating the facility's abuse prevention program. R2's [DIAGNOSES REDACTED]. R2's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R2 required the assist of one with dressing and personal hygiene, assist of two for toileting, and was independent with other activities of daily living (ADLs) including ambulation. The MDS also indicated R2 exhibited physical behaviors directed toward others, wandering, and rejection of cares 1-3 days during the MDS assessment period. R2's significant change MDS assessment dated [DATE], indicated R2 exhibited physical and verbal behaviors, rejection of care 1-3 days, and wandering 4-6 days during the MDS assessment period. The MDS indicated the behaviors placed R2 at risk of physical injury, and significantly interfered with his care and participation in activities and social participation. The MDS indicated R2's behaviors also put others at significant risk for physical injury, significant intrusion of privacy and activities of others, and significantly disrupted care and/or the living environment. The MDS also indicated R2's wandering significantly intruded on the privacy and activities of others, and indicated R2's current behavior status, care rejection or wandering had worsened. R2's Mood State Care Area Assessment (CAA) dated 5/31/18, indicated R2's PHQ-9 (patient health questionnaire-9) (assesses degree of depression severity) scores had changed by 2 points in the direction of increased depression. The CAA further indicated R2 did not attempt to answer the assessment questions and did not appear to recognize questions evidenced by R2 having looked blank or staring into space. The CAA also indicated R2's previous [DIAGNOSES REDACTED]. was possibly progressing to the next stage or level and during the month of (MONTH) (YEAR), there was an increase in behaviors such as: wandering, attempting to strike out with an actual tap on another male resident. The CAA also indicated R2's present mood state was completely opposite of what R2's previous lifestyle and mood state was which was very difficult for family. R2's Behavioral Symptoms CAA dated 5/31/18, indicated in (MONTH) (YEAR), R2's behaviors of wandering, striking out, aggression towards other residents, toileting in inappropriate areas and having difficulty expressing himself led to increased frustration, and irritation had increased. The CAA further indicated during the assessment period, R2 had started being more impulsive with his behaviors such as raising his fists and going into other resident's room which posed a possible threat to other residents as well as for R2 if there was retaliation. The CAA indicated R2 required 1:1 guidance in a calm, quiet manner in order to redirect R2. R2's [MEDICAL CONDITION] Drug Use CAA dated 5/31/18, indicated R2 was on psychopharmacological medication related to advanced stage dementia as evidenced by symptoms of anxiety, restlessness, physical aggression, elopement attempts, and increased confusion. In addition, the CAA indicated R2 also used antidepressant medications for mild depression. The CAA indicated a pharmacy consultant would review new medications on a routine basis and provide medication reduction direction. R2 was started on [MEDICAL CONDITION] and antianxiety drugs 5/24/18, to help manage and treat aggressive behaviors due to the aforementioned symptoms. R2's goal was to demonstrate cooperative behaviors and optimal level of psychosocial well-being without side effects to the medications. R2's Activities CAA dated 5/31/18, indicated R2 did not understand verbal directions and would become frustrated because he could not find the words he wanted to say. The CAA also indicated R2 could become aggressive toward staff or other residents. R2 was unable to stay seated for a period of time, but would stay for live music entertainment. The CAA also indicated R2 used to like looking at hunting pictures in his room, and would sweep the floor for a period of time but did not show interest in any activity R2 had enjoyed in the past. R2's care plan dated 1/24/19, indicated R2 had a potential for increase in disruptive behaviors related to [MEDICAL CONDITION] with progressive cognitive deficits evidenced by wandering, [MEDICAL CONDITION], and elopement attempts. The care plan indicated R2 would often pace or be up in room, and would sometimes be in the hallway and enter other resident rooms which could frighten other residents. The care plan directed staff to intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert R2's attention with activities such as sweeping, and remove R2 from the situation and take to alternate location as needed. The care plan further directed staff if R2 resisted, to retreat if possible and re-approach at a later time; to keep disruptive noise to a minimum because carts and other loud noises and voices triggered anxiety and agitation for R2; and to not wake R2 for a shower in the evening; staff were to place magnetic door barriers on some of the other resident's room doorways which R2 more frequently entered without permission, and to monitor for effectiveness, and to remind R2 that it was not his room by stating It's a lady's room. Review of incident reports and R2's Progress Notes revealed the following related to R2's aggressive behaviors/resident to resident altercations: Incident #1: On 1/17/18, at 4:00 p.m. R4 was found on floor of his room and R4's wheelchair was next to him, laying its side. R4 said a man came out of another room, grabbed him by the throat and threw him down. R4 could not remember who it was at that moment. A few seconds later, R4 pointed at R2 and stated That's him, get him away from me. The incident was reported to the Minnesota Department of Health (MDH). R4 was sent for evaluation of his hip and wrist which identified a right hip bruise but no fractures. The incident record indicated the incident was an alleged random resident to resident allegation that was not confirmed, and no outward signs of aggression or injury were noted by the alleged perpetrator (AP). Further the report indicated both residents were diagnosed with [REDACTED]. Incident #2: On 5/24/18, at 6:45 a.m. an unidentified nursing assistant (NA) was wheeling R10 down the hall to obtain a weight. R2 exited another resident's room, approached R10 and shoved him from behind. No injury. The incident was reported to MDH. Interventions indicated the staff intervened properly and no change to the policy was necessary. A second incident report dated 5/24/18, (Incident #3) indicated at 11:30 a.m. R2 nudged R10 in the back with his fist in the hallway. The incident was reported to the MDH. The subsequent intervention indicated R2 would eat in the East dining area because it was quieter and had less commotion and stimulation. In addition, R2 was restarted on [MEDICATION NAME], a [MEDICAL CONDITION] medication, 5/24/18. Incident #4: On 6/7/18, at 6:00 p.m. registered nurse (RN) progress note (PN) indicated R2 had been in another resident's room (other resident only identified as PP) and that R2 demonstrated anxiety. The PN indicated the other resident had stated, When I told him to leave, he came over and shook his fist at me. The other resident was described as visibly upset. The PN indicated R2 was directed out of the room with minimal difficulty and R2 was walked back to his room, with staff explaining to R2 he was not allowed in other residents' rooms unless invited. The note indicated R2 became less anxious at that time and pulled the writer into a nice hug. This incident was not reported to the MDH. Incident #5: On 6/25/18 at 9:21 p.m. a progress note documented by a licensed practical nurse (LPN) indicated R2 had pushed the staff in shoulder twice. The PN indicated when staff left the room, R2 came out of his room and shoved R15 in the left shoulder. R15 was moved due to R2 getting agitated when walking by him. Review of notes later the same evening, indicated the facility social worker and administrator came to the facility, but by that time R2 had calmed down. The incident was not reported to MDH. No new new interventions were identified. A typed employee report related to R2's actions on 6/25/18, submitted to administrator, indicated at about 9:30 p.m. a staff person guided R2 to his room, and that R2 hit her (the staff) and whacked R15 once in the hall, and again when R15 came around the corner from the dining hall area. The PN indicated R2 began shoving R15's chair and pressing him to the wall until the writer got between the two of them and asked R15 to go away from R2. At 10:00 p.m. a visitor was making his way out of the facility when he commented on R2 roaming in the building, because R2 was roaming the west end at that point. The reporter walked with the visitor to the west end of the building to investigate because the reporter was worried that R2 would lash out again. By the time the reporter and the visitor made it to the west end, R2 instantly snapped at the visitor. The reporter indicated he stood between the two and asked the visitor to make his way out while R2 remained behind him. R2 had a pen in his hand, was showing clear frustration, and was again showing annoyance toward staff. Moments later R15 was again shoved and pressed by R2 with no reason at all. The reporter stood in between the two, making sure R15 would not be hurt in the situation. The reporter identified seven physical incidents had occurred within in a two hour time period. The reporter indicated solutions needed to be made for this behavior because the support of the facility workers was thinning and the safety of everyone was slowly dissolving due to the these issues. Incident #6: On 9/4/18, at 10:55 a.m. a registered nurse's (RN) Progress note indicated R2 was in the hallway while an unidentified NA was pushing R15 in a wheelchair. The NA asked R2 to step out of the way and R2 proceeded to punch R15 in the arm, then punched the NA. The progress note indicated R15 had complained it hurt. This incident was not reported to MDH. Incident #7: On 9/14/18, at 6:00 a.m. NA was wheeling R15 toward the tub room. Without warning, R2 started hitting R15 in the face. R15 was placed in the tub room to separate him from R2. Scratches were noted to R15's cheek measuring 1.5 x 0.1 cm and left neck measuring 0.6 x 0.1 cm. The incident was reported to the MDH. Interventions were identified as: Fax communication to the physician dated 9/14/18, at 1:50 p.m. indicating the physician commented R2 would need either a change in facility or a medication to sedate R2. After discussion with the physician and R2's family, R2 was started on [MEDICATION NAME] (an antidepressant). Staff separated the residents and observed R2 for further behaviors. R2 was redirected to a calm environment. A Progress Note dated 3/8/19, at 11:32 p.m. indicated a CMA (certified medication aide) was passing medications (meds) next to the the med cart when R2 slapped the CMA on the arm. The CMA immediately moved away from R2 and R2 came at her again, following her into R15's room hitting and punching her. The CMA guided R2 out of the room and closed the door. R2 proceeded to go across the hall into R30's room. R30 was in bed watching TV (television). The CMA called for help over the walkie system and staff responded immediately and assisted to remove R2 from the situation. The DON, administrator, R2's son and the on-call medical provider were notified. an order for [REDACTED]. Incident #8: Review of an incident documented 3/26/19, at 4:30 p.m. indicated R2 wandered into R21's room, did not speak to R21, and punched R21 with a closed fist on the right side of her face, shoulder and upper chest at which time. The report indicated R21 began yelling help me, help me so staff intervened and encouraged R2 to leave R21's room. The report did not indicate if an injury had occurred. Further, the documentation indicated the Behavior Committee met at 8:45 p.m. that day to discuss the incidentt. Causal factors identified indicated the incident had occurred during a sun downing (a neurological phenomenon associated with increased confusion and restlessness in patients with [MEDICAL CONDITION] or some form of dementia, occurring in the evening when the sun is setting) period of the day. Interventions indicated the event would be reviewed and options discussed, including possible medication changes, at the QAPI (Quality Assurance and Performance Improvement) meeting the following day. The documentation also indicated the social worker (SW) had ensured R2's son and daughter-in-law had been informed of the incident, the SW reported it to MDH, and that there had been a discussion with another facility's SW regarding R2's possible transfer to that facility. However, the other facility would not accept R2 stating they had wandering residents and did not feel they could provide adequate care for R2's behaviors. Per R2's son's request, the SW emailed a release of information form to them so they could access R2's medical record and also a list of other facilities that may be an option for placement for R2. A CMA progress note from 10:41 p.m. that day indicated R2 was lying in his bed awake and had stated, I don't want to be here. At the time of the incident, no new interventions were implemented in order to protect R21 or other residents from future abuse, or to protect R2 from potential injury. On 3/26/19, from 1:33 p.m. until 3:31 p.m. continuous observations were made. -At 1:33 p.m. R2 was wandering the administration hallway, looked into the activity room several times during which the activity staff invited him in but, R2 remained at the doorway and continued on walking the hallways. Shortly thereafter, R2 returned to the activity area and entered the room. R2 sat down on a rolling office chair, near the door. Two female residents seated at a table in the middle of the room were putting on disposable gloves in preparation for a baking activity. The female residents were visiting with each other but did not acknowledge R2. R2 sat looking out the window and did not pay attention to the other residents. No staff were in attendance. -At 1:38 p.m. an alarm sounded down the hallway. R2 turned his head to the sound, made facial grimaces, but did not stand up. The other residents continued visiting. No staff were in the room. -At 1:42 p.m. activity aide (AA)-A entered the room with a box of large disposable gloves. AA-A did not acknowledge R2's presence however, asked the other residents if they had read the recipe for the baking activity. After reading the recipe, AA-A noticed R2 was sleeping in the rolling office chair and proceeded to wake R2 and ask R2 to sit in a different chair. R2 stood up and walked to the center of the room, stood there and returned to the doorway. -At 1:44 p.m. R2 sat down in a stationary chair placed by AA-A near the door. No one was talking to R2. R2 remained seated in the chair as AA-A was talking with the other residents as they arrived to the activity, but did not include R2 in the conversation. -At 1:49 p.m. R2 continued to sit by door and had fallen asleep. -At 1:52 p.m. The baking activity had begun. R2 continued to sleep in the chair near the door. -At 1:59 p.m. R2 woke up and looked around room. No staff or residents acknowledged R2. R2 closed his eyes and fell back to sleep. -At 2:07 p.m. R2 continued to sleep in the chair by the door. AA-A left the room to get more supplies from the kitchen leaving no staff in the room. -At 2:10 p.m. AA-A returned with the supplies. R2 continued to sleep by the door. -At 2:14 p.m. while attempting to wheel herself out of the activity room, R21 bumped/ran over R2's right foot. AA-A pulled R21 back into the room and explained to R21 that R2 had a sore foot. R21 apologized and stated she did not know R21 had a sore foot and didn't mean to bump it. R2 woke up, stared at R21 but did not speak or make movement. -At 2:17 p.m. R21 left the room while paying close attention to R2's feet. Staff did not assist R21. R2 looked around the room. Staff did not attempt to include R2 in any part of the activity or conversations. -At 2:21 p.m. R2 continued to sit by the door. AA-A did not attempt to include R2 in the activity. -At 2:23 p.m. R2 stood up suddenly and left the room. -At 2:24 p.m. R2 was wandering aimlessly down the hallway adjusting his clothing as he walked. -At 2:26 p.m. R2 was in the east dining room standing next to the dining table. R2 continued to adjust his clothing. Staff greeted R2 by saying hi but did not offer R2 a snack or assistance to the toilet. -At 2:27 p.m. R6 motioned R2 over to him. R6 told R2 to sit down at his table because he could watch people coming or going. R6 shook R2's hand and said, You're not going to hurt me now are you? R2 let go of R6's hand. R6 again encouraged R2 to sit down because it was only 3:30 p.m. and not time for supper. -At 2:28 p.m. R2 lifted the lid on R6's walker basket at which time R6 told R2 there was nothing in the basket and proceeded to show R2 a blanket. Shortly thereafter, R2 wandered away from R6. -At 2:29 p.m. R2 remained in the dining room looking out the window and the dining room exit door which led to the clinic. R2 did not attempt to open door. -At 2:30 p.m. R6 again encouraged R2 to sit down at the table and said staff would be bringing goodies out any time. The staff present in the room at the time, did not acknowledge the conversation. Shortly thereafter, nursing assistant (NA)-F walked into the dining room while wheeling another resident across the room to the clinic doorway when R2 yelled HEY! and pointed at NA-F. NA-F greeted R2 and jokingly asked R2 what have I've done now? R2 did not speak, but smiled widely and walked with NA-F as she wheeled the other resident to the clinic. As NA-F went through the door, trained medication aide (TMA)-B stood by door while it shut to ensure R2 did not follow. R6 again encouraged R2 to sit down at the table. R2 shook R6's hand again but continued to watch the door for NA-F's return. -At 2:35 p.m. R2 walked to a dining table, pulled a chair out and sat down. R2 continued to watch the doorway for NA-F. -At 2:42 p.m. the SW entered the east dining area. R2 stood up and went to SW. SW stated to R2 she was looking for something for another resident to do. R2 followed the SW across the room and began picking up the weights that SW had given to the other resident. R2 put the weights back down on the table and wandered away. R2 attempted to talk, but was nonsensical. -At 2:44 p.m. R2 wandered down the hallway following the SW out of the dining room. R2 looked into each resident room as he wandered by and entered his own room after reading his name on the doorplate. R2 was in his room momentarily, turned around and exited it. R2 proceeded to wander down the administration hallway looking into each room, but continued on. -At 2:47 p.m. R2 wandered back to the activity room where he met the SW in hallway. R2 followed her to her office, but did not enter. The SW talked briefly with R2 and left him standing in the hallway. -At 2:49 p.m. the DON approached R2, shook his hand, and asked R2 to follow her. The DON brought R2 to an activity. However, R2 followed the DON out of the activity and into the business office and remained in the office with the door partially shut until 3:31 p.m. At no time during the constant observation was R2 offered toileting, a snack, beverage or a diversional activity. On 3/27/19, at 7:07 a.m. R2 was observed in bed sleeping with his room lights off and the door partially shut. -At 7:12 a.m. NA-A began assisting R2 with morning cares. NA-A provided R2 with verbal and visual cues throughout the cares. R2 was able to participate in part of the tasks with NA-A completing. NA-A used simple statements and a calm voice. R2 exhibited no agitation or aggression. - At 7:29 a.m. NA-A obtained R2's shaver, handed it to R2 and asked him if he would like to shave, however, R2 handed the shaver back to NA-A and NA-A began shaving R2. R2 started laughing, looked at the surveyor, and stated I think she's going to take my nose! NA-A stopped shaving R2 and asked R2 if that was enough. R2 nodded his head. NA-A proceeded to assist R2 brush his teeth and provided verbal and visual cues. -At 7:33 a.m. NA-A offered R2 breakfast. R2 appeared confused and stated Where to? NA-A explained she would take R2 to the dining room with her. R2 stated Oh yea? and smiled brightly. NA-A assisted R2 to the east dining room for the breakfast meal. -At 7:40 a.m. R2 had not been served breakfast yet and left the dining room. R2 wandered up to med cart at end of the 400 wing, stood next to licensed practical nurse (LPN)-A momentarily and turned around to go back to the dining room. On 3/27/19, at 8:01 a.m. R2 was observed to wander aimlessly in the 400 wing hallway. The staff were in the same vicinity as R2, however continued with their daily tasks. On 3/27/19, at 8:09 a.m. R21 confirmed R2 had came into her room on the afternoon of 3/26/19, and punched her in the face. R21 stated R2 had never entered her room before. R21 proceeded to maneuver herself and the surveyor into the same placement she and R2 were in when R2 punched her. R21 stated she was sitting in her wheelchair in front of the TV watching a program when R2 entered her room, stood along side of her, did not say anything to her and punched her. R21 stated she knew R2 wandered about and because she had previously worked at this nursing home, she knew those types of people. However, R21 stated she did not know R2 hit people and added, He just started hitting me in the face. R21 stated she had yelled out for help and the staff had come right away and removed R2 from her room. At the time of the conversation with R21, she removed her glasses which revealed a faint bruise on her right cheekbone/temple area. R21 stated her cheek hurt when he punched her and it continued to hurt a little yet today but was not bad. When R21 was asked what she would do if R2 came into her room again, R21 hesitated and stated she would ask for help. When asked how she would feel if R2 entered her room again, R1's facial expression became drawn and concerned. R21 stated it would make her feel nervous, and maybe a little scared. R21 stated the facility had not said anything to her about how they would protect her or other residents from R2 in the future. On 3/27/19, at 8:34 a.m., R37 stated R2 wandered into her room. R37 stated although sometimes effective, at times the red Do Not Enter banner draped across the doorway at eye level did not help in keeping R2 out On 3/27/19 at 9:05 a.m., R33 stated R2 did not wander into her room often as she kept her door partially closed most of the time so R2 could not see her which helped in keeping him out. R33 stated when she had company, R2 liked to come in her room and see the people. R33 stated last summer, her son had to hold the door shut so R2 could not get in. R33 thought R2 was going to break the door down because he kept pushing on it. R33 did not talk to R2 as she did not want to encourage him, however, about a month ago, R2 did walk into her room and when she told R2 he could not be in here, R2 shook his fist at her. Two NAs came by and escorted him out of her room. She stated she would put her call light on, but a nurse was not always handy. R33 stated she was not afraid of R2 rather, she did not like him coming into her room. R33 added, a stop sign banner across her room door had been tried in the past however R2 just took it down. R33 also had a stop sign on the door but that did not help either as R2 went where he wanted to. R33 stated she had not observed R2 strike anyone but felt he could if someone resisted him too much because that was when he got upset or mad. R33 stated she just did not talk to R2. On 3/27/19 at 9:21 a.m., R30 stated he was afraid of R2 so he had asked for his room door to be shut for privacy. R30 stated R2 was unpredictable and did what R2 wanted at all times of the day. R30 stated R2 had swung at him on 3/8/19, but did not hit him. R30 further stated I do know if he ever gets close enough to me to swing at me again, I'm swinging first. R30 stated the Do Not Enter banner draped across his room door did not help keep R2 out of his room because R2 would just take them down. On 3/27/19 at 9:11 a.m., R10 stated R2 wandered into his room several times, stating R2 would just walk in, stand by the end of the bed and then walk back out. R10 also stated R2 had not struck out at him but added, I am leery of him. On 3/27/19 at 3:25 p.m., NA-G stated she normally worked the 6 a.m. - 6 p.m. shift. NA-G stated R2 exhibited behaviors of aggression such as attacking staff unprovoked and general agitation. NA-G also stated R2 would get a mad - irritated look and staff would stay away from R2. NA-G stated R2 would grab the staff's hands or hit staff on the head and back and had tried to choke a staff person awhile back. NA-G stated the staff generally tried to leave and re-approach R2 later or have a different aide re-approach. NA-G also stated if a staff person brought in another staff to assist, it would only irritate R2 more. NA-G stated the staff tried the best they could to keep an eye on R2. NA-G stated some residents had a red banner across their room doorways to prevent R2 from wandering in, but R2 would sometimes duck under the banner and entry other resident's rooms anyways. NA-G further stated a lot of times, staff could keep a good eye on R2 or R2 would stay in his room, but other times R2 put other residents at risk due to his behaviors. NA-G confirmed there were residents who did not want R2 in their rooms but NA-G was not aware of any of the residents being afraid of him. NA-G stated the other residents would do all they could do to avoid R2. NA-G stated the only warning of R2's aggression was his facial expression because it would become cold and mean like, but there were other times when there were no warnings at all and it did not matter what time of day it was. NA-G stated she believed R2's behaviors had worsened over the course of time and stated they occurred almost daily. NA-G proceeded to state she thought the facility was staffed pretty good, but that she thought R2 should have a staff person assigned only to him. On 3/27/19 at 3:37 p.m., LPN-B stated she worked mostly day shifts and did not work with R2 a whole lot. LPN-B stated the Do Not Enter door banners helped only to a point as R2 would go underneath them. LPN-B stated she had heard that R2 had hurt others and knew the other residents avoided him. LPN-B stated R2 exhibited no warning signs prior to his aggressive episodes, and stated the facility had four staff working but due to R2's behaviors, she did not feel four staff was enough. On 3/27/19 at 3:52 p.m., registered nurse (RN)-E confirmed R2 wandered the hallways, would go in and out of other resident rooms, and would sometimes get agitated with redirection. RN-E stated R2 would come up behind other residents and staff and begin to violently hit, slap, and grab their upper arms. RN-E stated R2 had hurt other residents by punching them. RN-E stated staff would use a calm voice and try to distract R2. RN-E stated keeping a constant eye on R2 worked the best but did not feel the facility had enough staff to provide 1:1 observation of R2 in order to keep R2 and the other residents safe. RN-E stated, After being punched by (R2), (R21) complained of a headache. RN-E believed R2's behaviors were escalating but did not think they occurred daily. RN-E stated R2 was exhibiting less and less warning signs and more escalating behaviors, I wish there was more we could do but we don't have the staff. RN-E confirmed there were residents who were fearful of R2 and recalled an incident when R10 had just moved into the facilty and R2 jumped in front of him and started punching him. RN-E stated if the staff could intervene early, it could help, but other times R2 would become aggressive towards the staff instead. On 3/27/19 at 3:29 p.m., LPN-A stated she usually worked a 6 a.m. to 6:30 p.m. shift. LPN-A verified R2 wandered all the time and other residents were afraid of him. LPN-A stated R2's mood could turn on a dime and had no triggers/warning signs. LPN-A stated R2 had hit another resident a while ago and there was another incident where R2 had just left a room and another resident was found in the room lying on the floor with his wheelchair tipped over. LPN-A stated the resident who was tipped over was scared to have R2 around. LPN-A confirmed R2's behaviors had worsened and if the staff noticed R2 getting agitated, they would redirect him to a table and give him a cup of coffee. LPN-A stated she used to give R2 bolts, a puzzle, or other busy things to distract him, but he no longer understood what to do with them, or how to use them. On 3/27/19 at 3:38 p.m., NA-C stated she usually worked on 2 p.m.-10:30 p.m. shift. NA-C stated R2 was always doing his own thing, and stated staff would try to keep an eye on him because some of the residents were afraid of him. NA-C confirmed R2 had pushed and hit another resident and stated s

Based on observation, interview, and document review, the facility failed to comprehensively assess, thoroughly investigate causal factors and implement interventions in order to minimize the risk of falls and injury for 1 of 1 resident (R23) who had repeated falls with serious injuries which required medical intervention. This resulted in an immediate jeopardy situation for R23. Findings include: The Immediate Jeopardy (IJ) began on 11/7/16, related to the facility's failure to complete a comprehensive assessment to determine causal factors and implement interventions for R23 who had sustained significant injuries from two falls which occurred on 10/30/16, and another fall on 11/7/16. The lack of assessment placed R23 at significant risk for serious injury and/or death. The facility administrator and director of nursing (DON) were notified of the IJ on 11/10/16, at 4:00 p.m. which began on 11/7/16, when R23 had fallen and the facility failed to complete a comprehensive assessment of causal factors related to R23's continued falls, in a effort to implement interventions to minimize the risk of R23's risk for further falls. The IJ was removed on 11/15/16, at 3:27 p.m. however, non-compliance remained at a scope and severity level of G, which indicated actual harm for R23 due to a hematoma and epistaxis sustained during a fall which required medical assessment and interventions. R23's [DIAGNOSES REDACTED]. R23's progress note (PN) dated 8/16, at 8:01 p.m. indicated R23 was admitted from the hospital following surgical repair of a fractured right hip as a result of a fall while at home. R23 was deaf and utilized a white communication board to communicate. R23 did speak, however, was sometimes difficult to understand due to whisper tone speech. R23 was pleasant and alert to person and place. R23 was able to verbalize need to use the bathroom. R23 was currently non weight bearing and would be transferred with staff assist and use of a mechanical lift as directed by physical therapy due to R23 consistently putting weight on restricted right leg with attempted to transfer. Immobilize/brace noted on right leg. R23's admission Minimum Data Set ((MDS) dated [DATE], indicated R23 had a history of [REDACTED]. The MDS also indicated R23 required extensive assistance with activities of daily living (ADLs), was incontinent of urine, was not on a toileting program and received anti-anxiety and diuretic medications which could increase fall risk. R23's Falls Care Area Assessment (CAA) dated 9/9/16, indicated R23 had difficulty maintaining sitting balance and impaired balance during transition. R23's Cognitive Loss/Dementia CAA dated 9/9/16, indicated R23 had decreased ability to make self understood, had pain, hearing or vision impairment. R23 was non verbal and communicated to staff via a white board. R23's Physical Therapy Evaluation and Plan of Treatment form dated 9/30/16, indicated R23 was a fall risk, was completely deaf, had fair sitting balance and poor standing balance, poor safety awareness and did not follow through with weight bearing restrictions. R23's care plan dated 10/25/16, indicated R23 had limited physical mobility related to a right femur fracture and weakness and required partial weight bearing to right leg only and one staff assistance with mobility and weight bearing support. R23 utilized a wheelchair for locomotion and required cueing and guidance. R23 had confusion, impaired balance, limited mobility, limited range of motion and musculoskeletal impairment which required extensive staff assist for bathing, bed mobility, dressing, toileting, personal hygiene and stand by assistance of one staff with front wheeled walker and gait belt for transfers. R23 had bladder incontinence with a history of urinary tract infections and staff were directed to encourage R23 to drink more fluids during morning and afternoon hours and limit fluid in the evening/night, she utilized an incontinent product and staff were to check R23 before and after meals, before and after activities, during the night at least at midnight and 4:00 a.m. R23 would also use the bedpan. The care plan also indicated R23 had a hip fracture following a fall which required surgical repair. Staff were directed to monitor for sign and symptoms of complications, infection, unrelieved pain, and pneumonia. Staff were also directed to reposition R23 as necessary, prevent 90 degree flexion, monitor use of adaptive devices, monitor pain and limb swelling and or skin changes. R23 had an actual fall with no injury related to a history of falls, poor balance, post surgical status and unsteady gait. The care plan indicated R23 was to have a physical therapy (PT) consult for strength and mobility, a motion sensor alarm in room to be on when R23 was in bed to alert staff of any movement, to educate/instruct R23 not to bend over to pick up dropped items and to encourage use of grabber bar or to ask for assistance. Staff were to modify environment in order to maximize safety with bed on lowest position and body pillows on both sides of her while in bed. Staff were also to observe for any sign of injury and check range of motion at the time of a fall. R23's Visual Bedside Kardex Report dated 11/9/16, (tool nursing assistants use to direct care), indicated R23 was partial weight bearing to right leg, and required the assistance of one staff person for all mobility, transfers, repositioning, toileting, dressing and grooming. The document indicated R23 was to have her bed in lowest position, utilize raised edge mattress on her bed, and body pillows on each side of her in bed when in bed for her safety. R23's Falls Tool dated 8/26/16, indicated R23 had one or more falls in last three months, R23 was at high risk for falls due to recent falls, mobility and transfer problems related to muscle weakness, impaired balance, weight bearing ability changes, pain and took high risk medications. R23 also had cognitive risk factors which included restlessness, reduced insight, impulsiveness and a difficult time following instructions. Fall action plan was to refer R23 to therapy and update R23's care plan. Fall incidents: 1. R23's undated Investigation form indicated R23 fell on [DATE], at 10:40 a.m. R23 attempted to self transfer and was found on the floor in the doorway of her bathroom. The report indicated R23 had previous injuries from circumstances of this type over the last 30 days, was incontinent of bowel, was not wearing glasses, and had no injuries. Fall interventions included neuro checks, adding a motion sensor alarm to her bed, and update R23's care plan. R23 had anti-anxiety, anti-coagulant, diuretic, cardiovascular medications and a laxative within 8 hours of the fall. R23's care plan was amended to include motion sensor. The administrator and DON signed the form 9/13/16. R23's PN dated 9/3/16, at 11:02 a.m. indicated R23 was found lying on the floor in her room, in front of her wheelchair in between the bathroom and living area of room. R23 denied pain. No injuries. R23 was assisted into bed via a mechanical lift. Once in bed, R23 was incontinent of bowel and stated she needed to use the bathroom. R23 was wearing shoes at the time of the incident. Call bell was within R23's reach. R23's Fall Scene Huddle Worksheet (FSHW) dated 9/4/16, at 10:40 a.m. indicated questions 1-7 were to be completed at the time of the fall, during the Fall Huddle. The sheet indicated R23 was found on the floor in her room. R23 had slid out or fell from the wheelchair when attempting to self transfer. A diagram of the location of the fall was included. R23's mobility was identified as bed bound, she had shoes on, she had orientation to room/new admission and was incontinent of bowel. Medications received within the last eight hours identified and neuro checks were initiated. Potential root cause of the fall was identified as resident attempting to self transfer. R23 had no injuries. 2. R23's PN dated 9/6/16, at 5:51 a.m. indicated R23's motion sensor was alarming, along with another resident's sensor alarm. Staff chose to answer other alarm first. When entered R23's room, R23 was found lying on the floor. R23 was assisted off the floor. Neuro checks started. No injuries. A subsequent PN at 1:37 p.m. by occupational therapy (OT) indicated R23 had a fall earlier after putting on light. R23 had been rubbing knee and reporting pain. R23's Falls Tool dated 9/6/16, indicated R23 was at medium risk for falls due to recent falls, mobility and transfer problems, impaired balance, restlessness, impaired sleep patterns, cognitive status and took high risk medications. Fall action plan section was blank. R23's Investigation form dated 9/6/16, indicated at 4:00 a.m. R23 was found on the floor in her room. The form indicated this was a repeat incident, R23 had previous injuries or circumstances of this type in the last 30 days. R23 had just been toileted 15 minutes prior to being found on the floor. R23's motion sensor had gone off multiple times throughout the night. Another resident's motion sensor and R23's sensor sounded at the same time. Staff member went to answer the other residents sensor first then responded to R23's. R23's bed was in low position. The corrective action implemented was for R23 to have bed in low position when in it. The administrator and the DON both signed the form on 9/13/16. R23's FSHW dated 9/6/16, indicated R23 was found on the floor, had been attempting to self transfer, had been assisted by staff 15 minutes prior, motion sensor was alarming. R23 was not wearing glasses and was restless. A picture of the scene was drawn. R23 was alert to person and place prior to and after the falls. Potential root cause of the fall was possible anxiety. No injuries sustained. The Fall Scene Investigation Report form which included root cause analysis was blank. 3. R23's PN note dated 9/11/16, at 9:32 a.m. indicated R23 had been found on the floor in room beside left side of bed, lying on stomach. Bed in lowest position. No injuries noted. R23 indicated non verbally she did not have any pain or injuries. R23 was assisted back to bed. All reasonable persons were notified. R23's Falls Tool dated 9/11/16, indicated R23 was at high risk for falls due to recent falls, mobility and transfer problems, impaired balance, weight bearing changes, took high risk medications and moderately impaired cognition. The tool further identified R23 had cognitive risk factors which included reduced insight, impulsiveness and a difficulty following instructions and unsafe use of equipment including alarms. The Action Plan section was blank. R23's Investigation form indicated on 9/11/16, an incident occurred at 8:00 a.m. R23 was found on the floor next to her bed on her stomach, R23 was not wearing her glasses, personal alarms were working and R23 was incontinent of urine. The report indicted this was a repeat incident and R23 had previous injuries or circumstances over the last 30 days, and R23 had rolled out of her bed before. The report also identified R23 was deaf, rarely vocalized and used her call light. R23 had no injuries. Fall interventions included neuro checks, resident and employee education, and body pillows on each side of R23 when she was in bed was implemented. R23 had anti-anxiety, anti-coagulant, diuretic, anti-depressant medications and a laxative within eight hours of the fall. The report was signed by the administrator and DON on 9/13/16. A second Investigation report on 9/11/16, at 4:10 p.m. indicated R23 had a repeat incident of trying to self transfer which was not investigated until 9/13/16. R23 was restless with multiple falls. Sensor device in place to detect movement, body pillows utilized. R23 inconsistent with call light use. A raised edge mattress was added to R23's bed and R23 along with staff and family were educated by nursing. R23 was alert to person and place and forgetful prior to and after the fall. Neuro checks were initiated. R23 had sustained a bruise/hematoma from the fall. Both the administrator and director of nurses signed this form on 9/13/16. The undated FSHW indicated R23 was found on the floor in her room. was nonverbal and was last assisted by staff one hour prior. R23's alarms was working, she was not wearing glasses and was incontinent of urine. A description of the scene was drawn on the form. R23 was alert prior to and after the fall. The Comments section indicated this is a repeat incident. Medication administered in the last 8 hours indicated. Neuro checks initiated. No injury. 4. R23's PN dated 10/20/16, at 5:23 p.m. indicated R23's motion sensor was sounding. Upon entering R23's room, R23 was found sitting on the floor next to her bed. No injuries. R23 was assisted back into bed. R23's Falls Tool dated 10/20/16, indicated R23 was at medium risk for falls due to recent falls, mobility and transfer problems, difficulty seeing objects, impaired balance, weight bearing changes, and took high risk medications. The tool further identified R23 had cognitive risk factors which included, confusion, poor memory, difficulty following instructions and forgot to use the call light and assistive devices. The Action Plan section indicated R23 would be referred to therapy. This was not a new interventions as R23 was currently receiving therapy services. R23's Investigation form dated 10/20/16, at 3:20 p.m. indicated R23 was found on the floor next to her bed. The report indicated R23 did not call for help, and attempted to transfer herself, lost her balance, and her walker tipped over. The report further indicated this was a repeat incident with previous injuries or circumstances over the last 31-180 days. The report identified R23 had difficulties seeing objects, had no injuries, and personal alarms were working. Fall interventions included neuro checks and R23 was re-educated on using call light for help, and reminded R23 she needed assistance for transfers. The continence area of the report was left blank. R23 had received narcotic and diuretic medication within eight hours of the fall. Both the administrator and DON signed this form 10/27/16. R23's FSHW dated 10/20/16, at 5:30 p.m. indicated R23 was found on floor in own room after attempting a self transfer. R23 has difficulty seeing objects, lost balance, walker tipped over and fall alarms were working. A description of the scene was drawn. R23 was alert and oriented to person, place and time, was forgetful prior to and after the fall. meds administered identified. No injury. Neuro checks initiated. 5. R23's Investigation form dated 10/27/16, at 8:10 a.m. indicated R23 was seated in the wheelchair and witnessed to reach towards her shoe or the floor (unknown) and fell in the dining room. The report further indicated this was a repeat incident with previous injuries or circumstances over the last 30 days. The report identified R23's hand was a little sore. The vision and continence areas of the report was left blank. Fall interventions were R23 was re-educated on calling or asking for assistance, self-releasing seat belt was added to her wheelchair and R23 educated on use and R23 was able to release seat belt. R23 had received diuretic medication within eight hours of the fall. Although the report indicated a seat belt was installed on R23's wheelchair, it was later revealed the seat belt was not applied until she returned from the hospital on [DATE], because the facility had to order a belt in which it had finally been delivered. This form was signed by the DON on 11/2/16, and the administrator on 11/3/16. R23's FSHW dated 10/27/16, at 8:10 a.m. indicated R23 was in the dining room, reaching, and was lowered to the floor. No injuries. The scene of the incident was drawn on the form. R23 was alert and oriented to person, place and time prior to and after the fall. Medication used identified. R23 complained hand was a little sore, hurts a little. Staff to monitor mobility. R23's PN dated 10/27/16, at 9:49 a.m. by physical therapy indicated R23 had fallen out of her wheelchair in the dining room. R23 had been reaching and leaned too far forward. R23 reported right hand pain at 4 of 10 on a 0-10 scale (10 worst pain). Pain was noted most increased over the 2nd metacarpal area and tender to touch. R23's right knee also continues to have pain. This was reported to nursing. R23 to be seen on physician rounds. Pain created limitations to R23's therapy session. A subsequent PN written by OT at 11:34 a.m. indicated R23 had fallen earlier. R23 was noted to have guarded use of her right thumb and right lower extremity. Wheelchair mobility decreased due to R23 declining to use right hand and foot to propel the wheelchair. 6. R23's PN dated 10/30/16, at 8:30 a.m. indicated R23 was found sitting on the floor of the 100-hallway on her buttocks. R23 was assisted back into the wheelchair via a mechanical lift. R23 was noted to be holding her right shoulder and had a large hematoma to her forehead. R23 denied pain but Tylenol had been previously given at 7:00 a.m. R23 was sent the emergency department (ED) for evaluation. A subsequent PN at 11:39 a.m. indicated R23 returned from the ED with no new orders. R23 had a CT of the head which showed no acute intracranial pathology and a CT of the spine which was also negative. The ED recommended facility staff continue to monitor R23's neurological status and frontal hematoma for skin breakdown and for R23 to follow up with the ED on 10/31/16, as R23 received an X-factor A inhibitor (anticoagulant medication). R23's Investigation form dated 10/30/16, indicated at 9:30 a.m. R23 was found on the floor in the hallway after she had slipped or tripped and she attempted to transfer herself or ambulate. The report indicated this was a repeat incident with previous injuries or circumstances over the last 30 days. The report further identified R23 had no injuries, and R23's wheelchair brakes were not locked. The vision and continence areas of the report was left blank, and did not identify R23's personal alarms were working. Fall interventions included R23 was re-educated on the importance of asking for help, and was re-educated that she needed assistance with all transfers. R23 had received diuretic, cardiovascular and narcotic medications, and a laxative within eight hours of the fall. Both the DON and administrator signed the form 10/31/16. R23's FSHW dated 10/30/16, at 9:50 a.m. indicated R23 was found on the floor in the hallway and had slit or fell out of wheelchair. R23 had slipped and wheelchair brakes were unlocked. A diagram of the scene was drawn. R23 was alert to person and forgetful. Medications administered within previous eight hours identified. No injury. The Comments section indicated R23 does not ask for help and attempted to ambulate and transfer self. A second Investigation form dated 10/30/16, at 5:00 p.m. indicated R23 was leaning too far forward in her chair and fell . R23 was to have a self releasing seat belt installed and R23 was to be reeducated. The Results of Investigation section indicated R23 was reeducated to not lean so far forward and to ask for assistance. Seat belt added to wheelchair. Demonstrated and educated R23 on use. R23 demonstrated understanding by releasing seat belt per self. Staff will continue to monitor weekly. The DON signed the form on 11/2/16, and the administrator on 11/3/16. Although the form indicated a seat belt was added to R23's wheelchair, further investigation revealed a seat belt had been ordered and had not been delivered to the facility and applied to R23's wheelchair until 10/31/16. 7. R23's PN dated 10/30/16, at 5:15 p.m. indicated R23 was found on the floor in the dining room lying on her right side with a heavy bloody nose from both nostrils. R23 denied pain. R23 was assisted into a dining room chair via a mechanical lift. However, R23's nose continued to bleed. R23 was removed from the dining area. A subsequent PN titled Late Entry at 6:30 p.m. indicated R23 fell at 4:45 p.m. and sustained a bloody nose. R23 was assisted into a dining chair however continued to head bob and bleed through her nose. R23 was returned to her room and assisted into bed. R23 was given an antianxiety medication to settle her. At this time, R23 was found in her bed with with large amounts of blood on her pillow and her nose clotted with blood. R23's blood pressure was 87/54. The on call physician was notified and R23 was taken back to the ED for evaluation. A subsequent note indicated R23 was admitted to the hospital for observation of a head injury and possible urinary tract infection. R23's bleeding had ceased and she was receiving fluids. An earlier CT revealed a hematoma but no hemorrhaging on the brain. R23's FSHW dated 10/30/16, at 6:00 p.m. indicated R23 slid or fell from wheelchair and was found on the floor in the dining room. R23's wheelchair brakes were unlocked. A diagram of the scene was drawn. R23 was alert but forgetful. Medications used within last eight hours were indicated. R23 had a bloody nose. The Comments sections indicated therapy to reevaluate R23's wheelchair for a possible smaller one. R23's Falls Tool dated 10/30/16, indicated R23 was at medium risk for falls due to recent falls, mobility and transfer problems, impaired balance, and took high risk medications. The tool further identified R23 had cognitive risk factors which included, poor memory, impulsive, difficulty following instructions, forgot to use the call light or assistive devices, and received high risk medications. The Action Plan listed was to refer R23 to therapy, however, R23 was currently receiving therapy services. R23's Falls Tool dated 10/31/16, indicated R23 was at low risk (despite being identified as high risk previously) for falls due to recent falls, and took high risk medications. The tool further identified R23 forgot to use the call light or assistive devices, and was incontinent. The Fall Action plan was to refer R23 to therapy. R23's PN dated 10/31/16, at 11:58 a.m. by physical therapy indicated R23 was admitted to the hospital for observation after having two falls with closed head injury and significant bloody nose. R23's PN dated 10/31/16, at 3:38 p.m. indicated R23 had a fall the day prior and sustained a bloody nose and did hit her head. R23 had a large lump on her forehead and was seen in the ED/hospitalized . The physician evaluated R23's medications and discontinued a few. R23 is currently resting in bed. Nose is still bleeding lightly. Gauze provided and call light within R23's reach. 8. R23's Falls Tool dated 11/7/16, indicated R23 was at medium risk for falls due to recent falls, mobility and transfer problems, difficulty seeing objects, not wearing her glasses, impaired balance, and took high risk medications. The tool further indicated R23 had cognitive risk factors which included poor memory, impulsiveness, and was unsafe to use equipment. The Action Plan was to refer R23 to therapy. R23's Investigation form dated 11/7/16, at 8:15 a.m. indicated R23 was found on the floor in her bathroom in front of the toilet and sink. The report indicated R23 did not call for assistance, and transferred herself. The report further indicated this was a repeat incident with previous injuries or circumstances over the last 30 days. The report identified R23 was not wearing her glasses, did not identify if R23's personal alarms were sounding and the continence area of the report was left blank. The report indicated R23 had no injuries, and fall intervention was to re-educate R23. R23 had diuretic medication within eight hours of the fall. The Results of Investigation section was blank. The signature section of the form was also blank. R23's record lacked documentation of a fall investigation in order to determine causal factors and interventions to be implemented. R23's PN dated 11/7/16, at 10:13 a.m. by physical therapy indicated R23 had a fall in the bathroom with self transferring. She was found on the bathroom floor. R23 stated she had pain in her right knee rated a 5 out of 10. R23's hands appear sore as well as R23 keeps rubbing them together. R23 was agreeable to therapy. R23 was educated on importance of asking for assistance when going to the bathroom. R23 was unaware of poor safety. R23's PN dated 11/7/16, at 12:27 p.m. written by OT indicated OT and nursing both responded to R23's wheelchair alarm and found R23 attempting to self transfer from the wheelchair to the bed. Nursing informed OT of R23's fall that morning. R23's FSHW dated 11/7/16, at 3:30 p.m. indicated R23 was found on the bathroom floor, had attempted self transfer, was not wearing glasses and had slipped. A diagram of the scene was drawn. R23 was alert to person and place and was forgetful. Medication given within previous eight hours identified. No injury and no pain. The Comments section indicated R23 did not use call light and self transferred. No further information identified. On 11/7/16, at 5:31 p.m. R23 was observed in the dining room, seated in her wheelchair. The brakes were off while at the table and R23 had a self-releasing seat belt fastened around her with the alarm unit attached to the left side of the wheelchair. R23 had a large purple bruise over her right eye which extended down the right side of her nose. R23 also had a large purple goose egg on her right forehead. On 11/8/16, at 10:14 a.m. R23 was observed in bed, asleep. She had only one body pillow positioned behind her. R23's room was dark, her bedroom door was 3/4 closed, bilateral grab bars were noted on the bed frame, bed was in lowest position, a four wedge mattress was on her bed, the audio alarm was on, her wheelchair was next to the bed, and walker was in the corner of the room across from her bed. On 11/08/16, at 1:33 p.m. R23 was observed in bed, asleep. One body pillow laid vertically above her head. R23 had no body pillows on either side of her. R23's bedroom door was 3/4 closed, her bed was in lowest position, had bilateral grab bars, four wedge bed mattress, sensor alarm was on, wheelchair was next to bed, and walker in the corner of the room across from her bed. During this observation, R23's audio alarm sounded. The human resources and quality assurance coordinator (HR/QA) walked into R23's room, and immediately walked out to the nurses station and turned R23's audio alarm off. -At 2:07 p.m. R23's sensor alarm sounded, health information management (HIM) was observed to go into R23's room, immediately walk out and went directly to the nurses station and turned R23's alarm off. -At 2:25 p.m. R23's sensor alarm sounded. Nursing assistant (NA)-H was observed to enter R23's room and immediately exit walking directly to the nurses station. On NA-H's way to the nurses station, resident assistant (RA)-A was heard to call out from outside the nurses station to NA-H, Did she roll over? NA-H stated, Yes, and walked over and turned R23's alarm off. -At 2:56 p.m. R23's sensor alarm was sounding. Registered nurse (RN)-B came out of her office which was next to the nurses station. RN-B had witnessed the surveyor exit R23's room and immediately turned the alarm off at the nurses station. RN-B did not go to R23's to check on her. -At 3:31 p.m. R23's sensor alarm sounded. Licensed practical nurse (LPN)-B entered R23's room and turned on R23's call light and immediately walked out of R23's room towards the nurses station and loudly stated to RA-A, can you help her? RA-A replied, Yes, LPN-B proceeded to turn off R23's alarm. RA-A entered R23's room and closed the door. On 11/09/16, at 7:30 a.m. R23's motion alarm sounded. R23 was observed in bed on her left side, pulling up covers. One body pillow was noted on the floor, her bed was in lowest position, four wedge mattress on bed, bilateral grab bars, walker in corner of room across from her bed, and her wheelchair was by her bed. -At 7:33 a.m. R23 was observed seated on the edge of her bed, in her night gown. R23's wheelchair was near with the brakes on. LPN-B applied R23's rubber soled slippers, applied a gait belt. R23 slowly rocked back slightly, paused for a second, and pushed herself slowly up with both of her hands while LPN-B lifted her up with gait belt and assisted R23 into her wheelchair. R23 kept both of her knees bent during the transfer, was hunched/leaned over and leaned forward, was unsteady and did not stand up straight. R23 favored her left leg during the transfer. Once in the chair, LPN-B pointed to R23's left brake handle and R23 pulled the long handle and released it. R23 sat with her head down while LPN-B released her right wheelchair brake. R23 slowly scooted herself back twice in her wheelchair, and pulled the right half of her self-releasing seat belt around her right side while LPN-B pulled the left side strap of her seatbelt Velcro the belt straps together. R23's failed to identify the use of the self releasing seat belt. -At 7:39 a.m. NA-H was observed to enter R23's bedroom and LPN-B exited. R23 was assisted into the bathroom. -At 7:48 R23 was observed standing up in front of the toilet while facing the doorway. R23 had both hands on the wheelchair handles and was stretched over the wheelchair seat. R23's legs were bent at her knees. NA-H held on to R23's gait belt and applied a clean brief and then assisted her into the wheelchair. R23 was unsteady and required NA-H to hold onto her and guide her into the wheelchair during the transfer. Following the observation, NA-H verified R23 was at a high risk for falls and required staff assistance with all ADLs. NA-H stated he was not sure what R23's cognition was because R23 was unable to speak and that got in the way. NA-H stated R23 transferred pretty well, however, staff have had to stop her from self-transferring. R23 moved quickly and did not wait for staff. He stated R23 unfortunately always thought about sleep and was also confused sometimes as to why her seatbelt was on. He stated R23's fall interventions were her seat belt and wall alarm. He stated he did not know of any other interventions to prevent R23 from falling. NA-H stated the last time R23 self transferred was on 11/7/16, in which R23 must have fallen when she got off the toilet because there was stool in the toilet bowl and the water was running in the bathroom. He stated he found her on the floor in her bathroom that morning at about 8:00 a.m. with her back against the wall under the towel rack and her legs were out by the toilet and no alarms were sounding. NA-H stated he called the nurse in because he was worried about the bump on her head and he did not know if that fall had caused the bump or another fall had. NA-H pulled R23's small white communication board from a bag in the back of R23's wheelchair and wrote time to eat on it for R23 to read. -At 7:58 a.m. R23 was observed self propelling her wheelchair slowly down the hallway towards the dining room. R23's self releasing seat belt on and fastened correctly. R23 used both arms, and her left leg and foot to propel herself. R23 grabbed the right side hallway rail and pulled herself along until the railing ended and she found her seat at the dining room table. R23 was not supervised by staff as she self propelled from her room to the dining room. On 11/09/16, at 8:53 a.m. physical therapist (PT) was observed to ambulate with R23 in the hallway outside of R23's room. PT applied a gait belt and lifted/assisted R23 to stand up. R23 was stooped over and both legs remained bent at the knee. R23 took small, slow steps. and appeared to favor her left leg. PT held on to R23's gait belt with her left hand, and pushed R

Based on observation, interview and document review, the facility failed to comprehensively assess 1 of 4 residents (R10) at risk of falls and failed to effectively implement interventions in order to minimize the risk for further falls and /or serious injury or death resulting in an immediate jeopardy (IJ) situation for R10. In addition, R10 sustained actual harm by sustaining hematomas to the scalp following 4 separate falls. The immediate jeopardy began on February 6, 2014, due to the facility's systemic failure to comprehensively assess the falls and implement appropriate interventions to prevent/minimize further falls, injury and / or death. The administrator and the interim director of nursing (DON) were notified on 2/6/14, at 12:55 p.m. of the IJ. The IJ was removed on 2/7/14, at 2:20 p.m., however, non-compliance remained at a scope and severity level of G, which indicated actual harm for R10 due to a scalp hematoma sustained during a fall which required medical interventions. Findings include: R10 was identified by the facility as high risk for falls related to cognitive impairment, impaired gait and mobility, history of falls and unpredictable behaviors. However, the facility failed to comprehensively assess R10's risk factors related to falls which would include possible causal factors related to attempts at unsafe independent transfers. R10's Face Sheet dated 1/8/14, indicated R10's [DIAGNOSES REDACTED]. R10's significant change Minimum Data Set ((MDS) dated [DATE], indicated R10 was dependent upon staff for activities of daily living. The MDS also indicated R10 had sustained two or more falls without injury and two or more falls with injury during the assessment period. The Falls Care Area Assessment (CAA) dated 9/17/13, identified R10 at high risk for falls related to increased confusion and agitation. R10 had received antianxiety and antidepressant medications and R10 had increased wandering within the facility. The CAA also indicated R10 had sustained a decline in activities of daily living which indicated R10 required more assistance with cares. However, the CAA failed to comprehensively assess for causal factors and risks for falls. R10's quarterly MDS dated [DATE], indicated R10 had severe cognitive impairment and required extensive assist of one staff for transfers, toilet use and bed mobility. The MDS also indicated R10 was non-ambulatory and totally dependent upon staff for locomotion on and off of the unit. In addition, the MDS indicated R10 had sustained two or more falls without injury, and two or more falls with injury, during the assessment period. However, the facility failed to comprehensively assess for causal factors and risks related to falls. R10's plan of care (POC) dated 1/6/14, indicated R10 had mobility impairment related to senile dementia, osteoarthrosis, dizziness and jerky movements. The POC directed staff to ambulate R10 with a four wheeled walker, ensure R10 wore appropriate foot wear at all times, provide a non skid mat at the bedside, maintain chair alarm to wheelchair and recliner, anti- roll back devices on wheelchair, monitor for signs and symptoms of physical illness and report to the physician as needed. On 2/3/14, continual observations were made from 4:00 p.m. to 8:00 p.m. At 4:00 p.m. R10 was observed sleeping. At 5:45 p.m. R10 was observed in the wheelchair and assisted into the dining room for the evening meal. R10 did not waken for the meal, therefore, was observed to be assisted from the dining room and assisted into a recliner at the nurses station. R10 was observed to remain in the recliner the remainder of the evening. On 2/4/14, at 8:00 a.m. until 10:30 a.m. R10 was continually observed to remain in bed, asleep. From 12:30 p.m. until 3:00 p.m. R10 was observed seated in a recliner near the nurses station, sleeping. At 3:10 p.m. nursing assistant (NA)-K and registered nurse (RN)-A was observed to transfer R10 from the recliner into a wheelchair and assisted R10 to the bathroom. R10 was observed to stand with verbal cues and bear own weight without difficulty. On 2/5/14, from 7:00 a.m. until 9:30 a.m. R10 was observed asleep in bed. At 9:30 a.m. R10 was served breakfast at the nurses station. At 10:30 a.m. R10 was observed to independently wheel self on the nursing unit. At no time during observations did R10 attempt to stand independently or display behaviors which could potentially be disruptive to others. Review of R10's Incident Reports revealed the following: - On 7/26/13, at 2:30 p.m. R10 fell while ambulating independently. No injury was noted. The post fall investigation dated 7/26/13, indicated R10 had alarms in place, was able to transfer self and was receiving antianxiety medications. The Falls Data Collection (FDC) tool completed on 7/26/13, indicated R10 was at high risk for falls. There were no changes made to R10's POC. - On 8/2/13, at 9:30 p.m. R10 stood independently from a recliner resulting in a fall. No injury was sustained. The FDC dated 8/2/13, identified R10 at high risk for falls. The investigation indicated R10 had increased behaviors. The FDC was not completed and there were no changes made to the POC. - On 8/5/13, at 9:30 p.m. R10 was found sitting on the floor in front of an enclosed framed walker. No injuries were noted. The post fall investigation indicated R10 had been agitated and was given medications to decrease behaviors. The report also included, "Behaviors continued at intervals until resident finally succumbed to sleep." The FDC was not completed. There were no changes made to the POC. - On 8/9/13, at 9:00 p.m. R10 was observed to stand independently and fall backwards. R10 hit head on the floor causing a bruise to the right cheek and complaints of left hip and right elbow pain. A raised red area was also noted on the spine. The post fall investigation indicated R10 required one to one staffing. The investigation indicated: "Not able to provide constant 1:1 (one to one) staffing plan. Keep resident in close proximity when agitated or be sure she is safe, leave her to calm and re-approach." The FDC was not completed. There were no changes made to the POC. - On 8/16/13, at 8:05 p.m. R10 fell . No injuries were noted. The post fall investigation identified R10 as having increased agitation and staff were unable to calm here. One to one staff care was unavailable and the resident refused medication to help her relax. The FDC was not completed. There were no changes made to the POC. - On 8/19/13, at 7:35 p.m. R10 fell in the hallway. No injuries were noted. The post fall investigation identified R10's behaviors as anxiety, agitation, wandering and abusive behaviors which were not reduced after medication administration. Staff had attempted interventions of folding towels, snacks etc. but the interventions had only been successful for a short period of time. The FDC was not complete. There were no changes made to the POC. - On 8/20/13, at 6:30 p.m. R10 was found on the floor next to the bed. R10 was noted to have hit the right side of forehead and was sent to the emergency room for evaluation. The post fall investigation identified R10 as having a history of independent ambulation. The FDC identified R10 at high risk for falls. There were no changes made to the POC. - On 8/27/13, at 4:50 p.m. R10 fell from the wheelchair resulting in a 3 centimeter (cm.) red raised area to the left side of head. The post fall investigation repeated the incident report. The FDC tool identified R10 as being at high risk for falls. No changes to the POC were identified. physician's orders [REDACTED]. Review of R10's Clinic Referral form dated 8/29/13, indicated R10 was seen in the clinic, received a CT scan of head and had 10 cubic centimeters (cc) of fluid removed from a scalp hematoma. No change was noted in the POC. - On 9/30/13, at 7:45 p.m. R10 had slid out of the wheelchair. No injury was noted. The post fall investigation indicated R10 did not realize when she was in danger, or when staff are trying to assist her. An FDC tool dated 8/27/13, indicated R10 was at high risk of falls. There were no changes to the POC. - On 10/4/13, at 8:30 a.m. R10 was found on the floor between the bed and recliner. No injuries were noted. The post fall investigation repeated the incident but did not identify the root cause of the fall. The FDC tool dated 10/4/13, identified R10 at high risk for falls. No changes were made to the POC. - On 10/4/13, at 9:45 p.m. R10 had attempted to self transfer from the wheelchair resulting in a fall. No injuries were noted. The post fall investigation identified R10 as having increased anxiety and restlessness. The results of the investigation directed the staff to assist R10 to ambulate. No change in the POC. - On 11/5/13, at 1:30 am. R10 was found on the floor next to her bed. No injuries were noted. The post fall investigation indicated "no investigation need." The FDC tool dated 11/5/13, identified R10 at high risk for falls. There were no changes to the POC. - On 11/22/13, at 5:40 p.m. R10 was found on the floor in front of her bed. No apparent injury. The post fall investigation repeated the results of the incident. The FDC was not completed. There were no changes to the POC. - On 11/23/13, 10:40 a.m. R10 was found on the floor next to the bed. No apparent injury. The post fall investigation repeated the results of the incident. The FDC was not completed. There were no changes to the POC. - On 12/2/3, at 7:15 p.m. R10 attempted to ambulate independently, fell and hit the right side of her forehead which resulted in a 3 cm bruise. R10 received a cold compress to the area. The post fall investigation indicated R10 required one to one constant monitoring. The FDC was not completed and there were no changes to the POC. - On 12/20/13, at 9:10 p.m. R10 slid from a recliner onto the floor. No apparent injury. The investigation from the fall could not be located. The FDC was not completed and there were no changes to the POC. - On 1/12/14, at 4:00 .p.m. R10 was found on the floor in front of the wheelchair. R10 complained of back pain. The post fall investigation indicated R10 had a history of [REDACTED]. In addition, the investigation indicated staff were to provide continuous monitoring to ensure R10's safety. There were no changes to the POC. - On 1/24/14, at 8:00 p.m. R10 was found on the floor in another resident's room. No injuries were noted. The post fall investigation included staff direction to monitor the resident and redirect when necessary. The FDC tool was not completed, and there were no changes to the POC. R10's clinical record lacked a comprehensive assessment of falls in order to determine the root cause of the falls in an attempt to modify the environment / situation in an attempt to minimize further falls. R10's Interdisciplinary Progress Notes (nurses' notes) included multiple entries of R10 displaying behaviors such as swearing, yelling, "increased restlessness" and wandering. A note dated 2/4/14, at 10:00 p.m. described R10 as compulsive, combative, swearing and as being forgetful of limitations. In addition, the note read: "Staff tried to prevent her from fall PRN (as needed) Xanax (antianxiety medication) was given at 23:00 (11:00 p.m.) She was calmer sitting in recliner." On 2/4/13, at 1:20 p.m. nursing assistant (NA)-G stated R10 was combative and would kick, hit and disrobe in public. NA-G stated R10 was resistive with cares and would frequently attempt to stand on her own. On 2/5/14, at 12:41 p.m. the interim director of nursing (DON) reviewed R10's falls. The DON stated prior to her employment at the facility, the facility had not been identifying the circumstances prior to falls, nor had they attempted to determine the root cause of resident falls. The DON verified the facility did not have a system to monitor each individual to identity a pattern of falls. She confirmed R10 had a pattern of falls. On 2/5/14, at 1:44 p.m. RN-A stated following a fall, staff were supposed to monitor the resident for any signs of injury, monitor the resident's vitals and were to discuss the fall at the regular management meetings. On 2/5/13, at 1:50 p.m. licensed practical nurse (LPN)- B stated following a fall, the resident was to be checked for injury and have vital signs monitored. LPN-B stated staff were to add things such as bed and chair alarms, fall mats by the bed and ensure the resident had appropriate gripper socks. She stated she could not think of any other interventions to attempt which would be appropriate at the time of a fall. On 2/5/13, at 2:25 p.m. the DON confirmed the facility did not have a system to determine the root cause of the falls and had not developed interventions to prevent/minimize falls for R10. She added the facility did not have an established falls committee at this time which could also monitor for a pattern of falls. The DON stated staff are aware of the whereabouts of R10 at all times, utilized chair and bed alarms for R10, had mats in place next to R10's and staff were encouraged to toilet R10 more frequently in an attempt to prevent falls. On 2/5/14, at 4:24 p.m. health information specialist (HIM)-A stated R10 attempted to stand independently several times a day. HIM-A stated staff tried to find different tasks for R10 to do such as puzzle books or folding towels, but R10 had not always responded well to redirection. On 2/5/14, at 4:25 p.m. NA-B stated R10 was not cooperative with staff and attempted to walk on her own. At the same time, NA-D stated R10 exhibited behaviors such a swearing at the top of her lungs, hitting and scratching at staff members. She stated R10 had the ability to walk with staff, but frequently attempted to walk independently which resulted in falls. On 2/5/14, at 4:27 p.m. NA-C stated R10 displayed behaviors and did not respond to redirection. NA-C stated she frequently worked the overnight shift and stated R10 frequently slept until about midnight and then would be awake from 1 a.m. to 3 a.m. looking for her family members. NA-C stated, "We try to keep her safe, but there are only three staff at night." NA-C stated when R10 was seated in a wheelchair, she would attempt to stand by herself. On 2/5/14, at 4;33 p.m. NA-A stated R10 frequently tried to stand up alone. She stated R10 had recently attempted to stand on the evening shift of 2/3/14. NA-A stated R10 did not realize she was not steady on her feet and unable to walk by herself. On 2/5/14, at 4:30 p.m. housekeeper (HSK)-A stated R10 frequently attempted to get out of her chair. She stated when this happened, she stayed with R10 to ensure she did not attempt to stand until nursing staff could assist her. On 2/5/14, at 4:30 p.m.. RN-A stated staff were to approach R10 in a calm manner and attempt to redirect R10 with food or other activities. She explained staff were also to approach R10 from the front and avoid startling her. RN-A verified R10 attempted self transfers and utilized chair and bed alarms to alert staff when she attempted to stand. On 2/5/14, at 4:35 p.m. dietary aide (DA)-A stated R10 occasionally attempted to stand up from the dining room table by herself and staff had to redirect her. A facility policy dated 11/2002, and updated on 11/2013, directed staff to complete the Falls Data Collection Tool and compare the results with the data previous colleted. The policy also directed staff to look for differences that my indicate a change in the resident's risk for falls. It also directed staff to use the tool to explore risk factors and to assist in planning for resident safety. The policy directed staff to update the comprehensive POC and to monitor the resident's condition and the effectiveness of the interventions put in place to prevent further falls. The policy's attachment A- titled Suggested Care Plan Approaches for Fall Prevention reviewed on 9/2010, which had multiple examples aimed at assisting in implementing interventions which may be appropriate for a resident with falls. The potential approaches identified included: monitoring for medication side effects which could include: poor balance, confusion, agitation, drowsiness, weakness, dizziness, and multiple other side effects. The IJ that began on 2/6/14, was removed on 2/7/14 at 2:20 p.m. when the facility completed a comprehensive assessment and had R10 evaluated by physical and occupational therapy. A physical therapy (PT) plan was established in which R10 would receive PT for two weeks in order to develop a safe walking program for continued restorative nursing. R10 received a different wheelchair and seat cushion. In addition, laboratory levels were drawn for medical evaluation. R10's POC was updated to include a low bed with a frame not higher than six inches from the floor, a reduction in environmental hazards and a monitoring plan for psychotropic medications was also established. All staff members were educated on how to interact with residents with dementia and how to work with aggressive behaviors and an "At Risk" committee was formed to monitor residents sustaining falls.

Based on interview and document review, the facility failed to ensure residents were protected from mistreatment, abuse and neglect, and failed to ensure allegations were thoroughly investigated and immediately reported to the administrator and State agency (SA) as required for 3 of 20 alert residents (R43, R2, and R63) interviewed who reported allegations of staff-to-resident mistreatment/abuse/neglect; and for 1 of 1 resident (R13) who was allegedly mistreated/abused by a nurse. The failure to implement abuse prevention plans to protect residents from abuse constituted an immediate jeopardy (IJ) for R43, R2, R63 and R13, who were alleged to have received rough handling during bathing assistance or abuse/mistreatment/neglect during cares. This had the potential to effect all 56 residents who resided in the facility. The failure to implement an abuse prevention plan which instructed staff on how to protect residents in the facility against potential abuse and neglect, constituted an immediate jeopardy (IJ) for R43, R2, R63 and R13, who were alleged to have been mistreated/abused/neglected. The systemic failure to protect, report and thoroughly investigate incidents of potential mistreatment/abuse/neglect, the lack of employee knowledge on how to report allegations of mistreatment/abuse/neglect and the systemic breakdown of internal reporting to administrative staff, constituted an IJ for all 56 residents who resided in the facility. The administrator and director of nursing (DON) were notified on 5/22/13 at 5:08 p.m., of the immediate jeopardy to the health and safety of all 56 residents who resided in the facility, at a widespread level (L). The facility initiated an IJ removal plan which included review of the abuse prevention plan and training of all staff, on each shift, prior to any direct resident contact. The facility also interviewed all alert residents who resided in the facility to determine if further potential abuse was present. The residents were also informed of who alleged abuse was to be reported to. In addition, direct care staff, licensed nursing staff and nursing supervisors/managers were interviewed and were able to explain their responsibilities for identification of alleged abuse, internal reporting, resident protection, investigation and external reporting as defined in the facility's abuse prevention plan. The IJ was removed on 5/24/13 at 11:10 a.m., but noncompliance remained at the lower scope and severity of an E level which is no actual harm with the potential for more than minimal harm, at a pattern. Findings include: Review of the facility's Abuse and Neglect policy dated 6/12, revealed staff were directed to protect residents from abuse, immediately report any allegations of abuse or neglect to the administrator and other officials in accordance with state law and thoroughly investigate allegations of abuse. R43, R2 and R63 reported concerns of mistreatment/abuse/neglect by nursing assistant (NA)-N and NA-M. R43, R2 and R63 indicated they had reported their concerns to facility employees. The facility employee(s) failed to internally report the allegations to the administrative staff and the facility's abuse prohibition policy was not followed. R43's [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] indicated R43 had intact cognition and required extensive staff assistance for activities of daily living (ADLs). During interview on 5/20/13 at 4:48 p.m., R43 stated the bath aide was "too rough" during bathing. R43 also insisted other NAs knew the bath aide handled the residents roughly during baths. R2's annual MDS dated [DATE] identified her as being alert and oriented. During interview on 5/21/13 at 2:35 p.m., R2 stated she had concerns with NA-N. She stated NA-N was no longer working at the facility, but in the past, had worked as a night NA. R2 stated that when NA-N did work at the facility, she made her feel like she was not to put her call light on during the night because NA-N would snap at R2 whenever she did used her call light. R2 indicated she had reported the incidents to other staff members and learned that other residents had expressed the same concerns. Upon inquiry as to when R2 reported the concerns, or to which staff member she made the report, R2 was unable to recall, but insisted facility staff were aware of her concerns. Review of an incident report dated 2/17/13 revealed R2 had received a skin tear on her right shin during a bath. At that time, NA-M was identified as the staff member who had given the bath. The incident report indicated NA-M had received education and was "reminded... to be more gentle." A nurses note dated 4/22/13, identified R2 as having received a 2.5 centimeter (cm) x 1.5 cm skin tear on her right shin while getting up for her bath. R2 received first aide for the treatment of [REDACTED]. The facility did not fill out an incident report regarding the skin tear. R63's quarterly MDS dated [DATE] identified him as alert and orientated. During interview on 5/21/13 at 3:04 p.m., R63 reported that his bath aide was "pretty rough." R63 stated NA-M was his bath aide and she was a strong person with lots of power behind her. He explained that while receiving baths, NA-M moved his legs too fast, which caused him pain. He stated, "It's just her way." R63 indicated that he had talked with other residents, "the guys," and they too thought NA-M was rough with them while they were receiving baths. R63 added that he had reported his concerns regarding NA-M to an unidentified NA. R63 revealed that the second NA had agreed with him, that NA-M was rough during cares. R63 was not aware of the concern being reported to any other staff member or administration. Registered nurse (RN)-A reported concerns of potential staff-to-resident mistreatment during cares for R13, related to a pattern of increased behaviors displayed after cares completed by licensed practical nurse (LPN)-B. RN-A failed to internally report the allegations to the administrative staff and the facility's abuse prohibition policy was not followed. R13's [DIAGNOSES REDACTED]. The significant change MDS dated [DATE] indicated R13 had severe cognitive impairment and required extensive assistance from staff for all ADL's. During interview on 5/22/13 at 7:29 a.m., RN-A revealed that there had been reports of R13's behavior being "out of control" when LPN-B worked with her. RN-A verified that LPN-B worked only on night shifts. RN-A stated there had been a couple of residents, including R13, that were observed as upset, agitated and striking out at others whenever LPN-B finished providing cares for them. RN-A verified these behaviors were uncharacteristic for those residents. RN-A also stated that comments made by LPN-B about the residents, led her to believe LPN-B was not being gentle or kind with the residents. As an example of one of the comments, RN-A mimicked, "No one will spit on me." Employee interviews and a family interview revealed a systemic breakdown of internal reporting for incidents of potential mistreatment/abuse/neglect to administrative staff and a lack of employee knowledge on how to report allegations of mistreatment/abuse/neglect. On 5/21/13 at 1:59 p.m., NA-A verified R43 and R2 had voiced ongoing complaints of NA-M's physical roughness during their baths for the past several months. In addition, NA-A stated R2 had received multiple skin injuries on the shins during her bath. NA-A added, NA-M had a habit of grabbing the residents' arms "too roughly" which caused skin tears. NA-A verified she had not reported the complaints or injuries to the charge nurse or the DON and did not know if the facility administration had ever been informed. In addition, NA-A indicated "all" the NAs had talked amongst themselves about NA-M's "rough mishandling" of the residents, which occurred in the bath area and also while providing personal cares, but had never reported the concerns to the DON or charge nurse. During interview on 5/21/13 at 2:40 p.m., NA-D verified R2 had reported that NA-M was "a little rough" during baths. NA-D also verified R2 had received skin tears during her bath. NA-D stated she was unsure whether the DON or charge nurse had been informed of the resident complaints or injuries. However, NA-D stated she was sure the nurses were aware of the complaints and injuries, but was unaware if they had ever followed up on them. NA-D stated the NAs had expressed concerns as to whether or not some of the facility nurses followed up on any of their reports. During a continued interview on 5/22/13 at 7:29 a.m., RN-A indicated she was aware that staff were supposed to report their suspicions of abuse and resident complaints/injuries to the DON; however, RN-A verified she had never reported these complaints to administrative staff. RN-A stated it would not have been effective to inform the DON, as many reports "fell on deaf ears," based on her knowledge of reports that had been made in the past. RN-A verified that according to reports she had received from R43, along with other resident complaints, there were "lots" of incidents of physical, "rough handling" and "a lot" of skin tears that occurred during resident baths. RN-A stated NA-M was not a gentle person and her rough handling of the residents occurred "every day." RN-A also stated the residents had been complaining to her of these concerns for several years now. On 5/22/13 at 7:40 a.m., NA-F verified she was aware that R2 had made complaints about NA-N. She stated R2 had complained that NA-N was rough with her while rolling her over in bed. NA-F verified NA-N was no longer working at the facility. During a family interview on 5/22/13 at 8:05 a.m., family member (FM)-A stated that she did not feel the DON responded to her concerns and/or complaints regarding resident cares in the facility. On 5/22/13 at 8:32 a.m., RN-D stated that NA-M was a long term employee who had an "attitude" and came across as "gruff," but had "a heart of gold." RN-D stated if any of the residents had a complaint about NA-M she would take the concerns "with a grain of salt." She also stated that if any residents had a legitimate concern about a staff member, the concern was to be investigated according to the facility's policy. She stated she had not received any complaints about NA-M but reported NA-N had been let go from the facility following an investigation related to an alleged abuse concern. On 5/22/13 at 10:00 a.m., the DON stated the facility had "zero tolerance" for alleged abuse. She stated "anything and everything" regarding abuse or neglect was reported to the SA immediately. She stated that any time a staff member received reports of alleged mistreatment/abuse/neglect she was to be notified immediately. DON verified NA-N had been terminated due to alleged abuse. She stated LPN-B had a tendency to be a bit bossy toward her co-workers, but she had not had any complaints related to LPN-B with R13 or any other residents. On 5/22/13 at 10:02 a.m., the licensed social worker (LSW) revealed that on occasion she was involved with concerns regarding abuse allegations; however, at the time of interview, she was unaware of any current investigations or concerns regarding abuse. The LSW added that typically nursing staff issues were reported to and handled by the DON for investigation and review. The administrator was interviewed regarding the facility's abuse reporting system on 5/22/13 at 10:04 a.m., during which he established that if there were any vulnerable adult issues, the facility staff were to report the concern immediately to the DON or the licensed social worker LSW, who were then to notify the administrator immediately. The administrator stated that an initial report was then made to the SA. The administrator stated he was not sure if the SA had to be notified immediately, but stated he knew that a completed internal investigation was required to be reported to the SA after five working days. The administrator verified that he expected all of the facility staff to report rough treatment and further stated that yearly education regarding abuse and reporting requirements was provided to all employees. The administrator established that the front-line staff were to immediately report concerns of mistreatment/abuse/neglect to their supervisor or a nurse on the floor so the DON or LSW could address the issue. The administrator stated that employees were told to follow the concept, "If it makes you feel uncomfortable," or "If it doesn't seem right," report the situation. Upon inquiry into monitoring of staff burn-out, the administrator replied, "I can't say that we monitor the staff for burn out." The administrator stated he expected staff to report to the management team if they were feeling burnt-out. The administrator added, because they were such a small facility, the facility would pick up on behavior changes of the staff and would therefore be able to identify burn-out. The administrator concluded the interview by stating he needed to "brush up" on what the facility abuse policy included. He stated that he counted on the DON and LSW for compliance with reporting requirements. On 5/22/13 at 10:13 a.m., RN-F verified that all allegations of abuse were to be reported immediately. RN-F added that substantial allegations were to be reported to the registry. RN-F verified she oversaw staff education on abuse. Education was conducted upon hire and annually through an on-line program, or RN-F did one-on-one training upon request of the DON when issues arose. RN-F reported she had not been asked to follow up with any retraining of staff, related to abuse. RN-F also stated the facility had a process for conducting performance improvement plans for staff concerns. She explained the performance improvement plans became part of the alleged employee's personnel file, although RN-F was unaware of any performance improvement plans having been submitted to her. During follow-up interview on 5/22/13 at 1:00 p.m., the DON reported that concerns of skin tears received during bath time had been identified within the facility and the appropriate employee(s) had been verbally re-educated. The DON stated she had not identified the skin tears during bath time as a pattern of potentially "rough" care during baths, and reported that she did not have documented evidence that re-education was provided with regards to skin tears or rough treatment during baths. During follow-up interview on 5/22/13 at 3:59 p.m., the administrator verified he was unaware of the resident complaints and staff suspicions of mistreatment/abuse/neglect indicated above. On 5/22/13, at 9:30 a.m. the personal records of NA-N, NA-M and LPN-B were reviewed. NA-N was hired on 4/5/11. On 6/20/11, a disciplinary action record revealed NA-N had received a written warning from the DON, regarding raising her voice to a resident, telling an unidentified resident to stop yelling and not asking the resident if she required any assistance. On 5/12/13, NA-N was terminated from the facility after removing an alert resident's urinal and tying that resident's call light under the bed to ensure they did not call for assistance during the night. NA-M was hired on 9/30/02. The most recent performance evaluation completed on 9/26/11 identified a goal for NA-M to act more professional on the job and to be "more patient." The personnel record lacked evidence of further education or evaluations since the 9/26/11 evaluation. LPN-B was hired on 1/8/13. The personnel record lacked evidence of any type of correctional education. Additional interviews with facility administration revealed a systematic failure to report the incidents of mistreatment/abuse/neglect to the SA and a systematic failure to thoroughly investigate incidents of potential mistreatment/abuse/neglect. On 5/22/13 at 5:08 p.m., the administrator and DON were notified of IJ related concerns to R43, R2, R63 and R13. In addition, NA-M and LPN-B were identified as currently employed staff members who were alleged to have perpetrated the mistreatment/abuse/neglect. On 5/23/13 at 2:45 p.m., the administrator confirmed LPN-B had worked the night shift on 5/22/13, as the acting supervisor. In addition, he confirmed incidents involving the four resident's identified in the IJ had not been reported to the state agency as directed by the facility's policy. On 5/24/13 at 11:18 a.m., the DON confirmed the allegations of mistreatment/abuse/neglect for R43, R2, R63 and R13 had not been reported to the state agency in accordance with the facility policy.

Based on interview and document review, the facility failed to ensure residents were protected from mistreatment, abuse and neglect, and failed to ensure allegations were thoroughly investigated and immediately reported to the administrator and State agency (SA) as required for 3 of 20 alert residents (R43, R2, and R63) interviewed who reported allegations of staff-to-resident mistreatment/abuse/neglect; and for 1 of 1 resident (R13) who was allegedly mistreated/abused by a nurse. The failure to implement abuse prevention plans to protect residents from abuse constituted an immediate jeopardy (IJ) for R43, R2, R63 and R13, who were alleged to have received rough handling during bathing assistance or abuse/mistreatment/neglect during cares. The administrator and director of nursing (DON) were notified on 5/22/13 at 5:08 p.m., of the immediate jeopardy related to the failure to protect residents from abuse and mistreatment for [REDACTED]. The facility initiated an IJ removal plan which included review of the abuse prevention plan and training of all staff, on each shift, prior to any direct resident contact. The facility also interviewed all alert residents who resided in the facility to determine if further potential abuse was present, and the residents were informed of who alleged abuse was to be reported to. In addition, direct care staff, licensed nursing staff, and nursing supervisors/managers, were interviewed and were able to explain their responsibilities for identification of alleged abuse including: internal reporting, resident protection, investigation and external reporting as defined in the facility's abuse prevention plan. The IJ was removed on 5/24/13 at 11:10 a.m., but noncompliance remained at the lower scope and severity of an E level which is no actual harm with the potential for more than minimal harm, at a pattern. Findings include: R43, R2 and R63 reported concerns of mistreatment/abuse/neglect by nursing assistant (NA)-N and NA-M. R43, R2 and R63 indicated they had reported their concerns to facility employees. The facility employee(s) failed to internally report the allegations to the administrative staff and the facility's abuse prohibition policy was not followed. R43 [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE], indicated R43 had intact cognition and required extensive staff assistance for activities of daily living (ADLs). During interview on 5/20/13 at 4:48 p.m., R43 stated the bath aide was "too rough" during bathing. R43 also insisted other NAs knew the bath aide handled residents roughly during baths. R2's annual MDS dated [DATE] identified her as being alert and oriented. During interview on 5/21/13 at 2:35 p.m., R2 stated she had concerns with NA-N. She stated NA-N was no longer working at the facility, but in the past, had worked as a night NA. R2 stated that when NA-N did work at the facility, she made her feel like she was not to put her call light on during the night because NA-N would snap at R2 whenever she did use her call light. R2 indicated she had reported the incidents to other staff members and had learned that other residents had expressed the same concerns. Upon inquiry as to when R2 reported the concerns, or to which staff member she made the report, R2 was unable to recall, but insisted facility staff were aware of her concerns. Review of an incident report dated 2/17/13, revealed R2 had received a skin tear on her right shin during a bath. At that time, NA-M was identified as the staff member who had given the bath. The incident report indicated NA-M had received education and had been "reminded... to be more gentle." A nurse's note dated 4/22/13, identified R2 as having received a 2.5 centimeter (cm) x 1.5 cm skin tear on her right shin while getting up for her bath. According to the note, R2 had received first aide for the treatment of [REDACTED]. The facility had not filled out an incident report regarding the skin tear. R63's quarterly MDS dated [DATE], identified him as alert and orientated. During interview on 5/21/13 at 3:04 p.m., R63 reported that his bath aide was "pretty rough." R63 stated NA-M was his bath aide and she was a strong person with lots of power behind her. He explained that while receiving baths, NA-M moved his legs too fast, which caused him pain. He stated, "It's just her way." R63 indicated that he had talked with other residents, "the guys," and they too thought NA-M was rough with them while they were receiving baths. R63 added that he had reported his concerns regarding NA-M to an unidentified NA. R63 revealed that the second NA had agreed with him, that NA-M was rough during cares. R63 was not aware of the concern being reported to any other staff member or administration. Registered nurse (RN)-A reported concerns of potential staff-to-resident mistreatment during cares for R13, related to a pattern of increased behaviors displayed after cares completed by licensed practical nurse (LPN)-B. RN-A failed to internally report the allegations to the administrative staff and the facility's abuse prohibition policy was not followed. R13's [DIAGNOSES REDACTED]. The significant change MDS dated [DATE], indicated R13 had severe cognitive impairment and required extensive assistance from staff for all ADL's. During interview on 5/22/13 at 7:29 a.m., RN-A revealed that there had been reports of R13's behavior being "out of control" when LPN-B worked with her. RN-A verified that LPN-B worked only on the night shift. RN-A stated there had been a couple of residents, including R13, that were observed as upset, agitated and striking out at others whenever LPN-B finished providing cares for them. RN-A verified these behaviors were uncharacteristic for those residents. RN-A also stated that comments made by LPN-B about the residents, led her to believe LPN-B was not being gentle or kind with the residents. As an example of one of the comments, RN-A mimicked, "No one will spit on me." Employee interviews and a family interview revealed a systemic breakdown of internal reporting for incidents of potential mistreatment/abuse/neglect to administrative staff and a lack of employee knowledge on how to report allegations of mistreatment/abuse/neglect. On 5/21/13 at 1:59 p.m., NA-A verified R43 and R2 had voiced ongoing complaints of NA-M's physical roughness during their baths for the past several months. In addition, NA-A stated R2 had received multiple skin injuries on the shins during her baths. NA-A stated, NA-M had a habit of grabbing the residents' arms "too roughly" which caused skin tears. NA-A verified she had not reported the complaints or injuries to the charge nurse or the director of nursing (DON), and did not know if the facility administration had ever been informed. In addition, NA-A indicated "all" the NAs had talked amongst themselves about NA-M's "rough mishandling" of the residents, which occurred in the bath area and also while providing personal cares, but stated NA-A stated she had never reported the concerns to the DON or charge nurse as did not feel it made any difference. During interview on 5/21/13 at 2:40 p.m., NA-D verified R2 had reported that NA-M was "a little rough" during baths. NA-D also verified R2 had received skin tears during her bath. NA-D stated she was unsure whether the DON or charge nurse had been informed of the resident complaints or injuries. However, NA-D stated she was sure the nurses were aware of the complaints and injuries, but was unaware if they had ever followed up on them. NA-D stated the NAs had expressed concerns as to whether or not some of the facility nurses followed up on any of their reports. During a continued interview on 5/22/13 at 7:29 a.m., RN-A indicated she was aware that staff were supposed to report their suspicions of abuse and resident complaints/injuries to the DON; however, RN-A verified she had never reported these complaints to administrative staff. RN-A stated it would not have been effective to inform the DON, as many reports "fell on deaf ears," based on her knowledge of reports that had been made in the past. RN-A verified that according to reports she had received from R43, along with other resident complaints, there were "lots" of incidents of physical, "rough handling" and "a lot" of skin tears that occurred during resident baths. RN-A stated NA-M was not a gentle person and her rough handling of the residents occurred "every day." RN-A also stated the residents had been complaining to her of these concerns for several years now. On 5/22/13 at 7:40 a.m., NA-F verified she was aware that R2 had made complaints about NA-N. She stated R2 had complained that NA-N was rough with her while rolling her over in bed. NA-F verified NA-N was no longer working at the facility. During a family interview on 5/22/13 at 8:05 a.m., family member (FM)-A stated that she did not feel the DON responded to her concerns and/or complaints regarding resident cares in the facility. On 5/22/13 at 8:32 a.m., RN-D stated that NA-M was a long term employee who had an "attitude" and came across as "gruff," but had "heart of gold." RN-D stated if any of the residents had a complaint about NA-M she would take the concerns "with a grain of salt." She also stated that if any residents had a legitimate concern about a staff member, the concern was to be investigated according to the facility's policy. RN-D stated she had not received any complaints about NA-M but reported NA-N had been let go from the facility following an investigation related to an alleged abuse concern. On 5/22/13 at 10:00 a.m., the DON was interviewed. The DON stated the facility had "zero tolerance" policy for alleged abuse. She stated, "anything and everything" regarding abuse or neglect was reported to the SA immediately. She stated that any time a staff member received reports of alleged mistreatment/abuse/neglect she was to be notified immediately. The DON verified NA-N had been terminated due to alleged abuse. The DON also stated LPN-B had a tendency to be a bit bossy toward her co-workers, but she had not received any complaints related to LPN-B with R13 or any other residents. On 5/22/13 at 10:02 a.m., the licensed social worker (LSW) stated that on occasion she was involved with concerns regarding abuse allegations; however at the time of interview, she stated she was unaware of any current investigations or concerns regarding abuse. The LSW added that typically nursing staff issues were reported to and handled by the DON for investigation and review. The administrator was interviewed regarding the facility's abuse reporting system on 5/22/13 at 10:04 a.m., during which he established that if there were any vulnerable adult issues, the facility staff were to report the concerns immediately to the DON or licensed social worker (LSW), who were then to notify the administrator immediately. The administrator stated an initial report was then to be made to the SA. The administrator stated he was not sure if the SA had to be notified immediately, but stated he knew that a completed internal investigation was required to be reported to the SA after five working days. In addition, the administrator verified that he expected all of the facility staff to report rough treatment, and further stated that yearly education regarding abuse and reporting requirements was provided to all employees. The administrator established that the front-line staff were to immediately report concerns of mistreatment/abuse/neglect to their supervisor or a nurse on the floor so the DON or LSW could address the issue. The administrator stated that employees were told to follow the concept, "If it makes you feel uncomfortable," or "If it doesn't seem right," report the situation. Upon inquiry into monitoring of staff burn-out, the administrator replied, "I can't say that we monitor the staff for burn out." The administrator stated that he expected the staff to report to the management team if they were feeling burnt-out and added that because they were such a small facility, the facility would pick up on behavior changes of any staff and would therefore be able to identify burn-out. The administrator concluded the interview by stating that he needed to "brush up" on what the facility abuse policy included. He stated that he counted on the DON and LSW for compliance with reporting requirements. On 5/22/13 at 10:13 a.m., RN-F verified that all allegations of abuse were to be reported immediately. RN-F added that substantial allegations were to be reported to the registry. RN-F verified she oversaw staff education on abuse. Education was conducted upon hire and annually through an on-line program, or RN-F did one-on-one training upon request of DON when issues arose. RN-F reported she had not been asked to follow up with any retraining of staff, related to abuse. RN-F also stated the facility had a process for conducting performance improvement plans for staff concerns. The performance improvement plans became part of the alleged employee's personnel file, although RN-F was unaware of any performance improvement plans having been submitted to her. During follow-up interview on 5/22/13 at 1:00 p.m., the DON reported that concerns of skin tears received during bath time had been identified within the facility and the appropriate employee(s) had been verbally re-educated. The DON stated she had not identified the skin tears during bath time as a pattern of potentially "rough" care during baths, and reported that she did not have documented evidence that re-education had been provided with regards to skin tears or rough treatment during baths. During a follow-up interview on 5/22/13 at 3:59 p.m., the administrator verified he was unaware of the resident complaints and staff suspicions of mistreatment/abuse/neglect indicated above. On 5/22/13, at 9:30 a.m. the personal records of NA-N, NA-M and LPN-B were reviewed. NA-N was hired on 4/5/11. On 6/20/11, a disciplinary action record revealed NA-N had received a written warning from the DON, regarding raising her voice to a resident, telling an unidentified resident to stop yelling and not asking the resident if she required any assistance. On 5/12/13, NA-N was terminated from the facility after removing an alert resident's urinal and tying that resident's call light under the bed to ensure they did not call for assistance during the night. NA-M was hired on 9/30/02. The most recent performance evaluation completed on 9/26/11 identified a goal for NA-M to act more professional on the job and to be "more patient." The personnel record lacked evidence of further education or evaluations since the 9/26/11 evaluation. LPN-B was hired on 1/8/13. The personnel record lacked evidence of any type of correctional education. Additional interviews with facility administration revealed a systematic failure to report the incidents of mistreatment/abuse/neglect to the SA and a systematic failure to thoroughly investigate incidents of potential mistreatment/abuse/neglect. On 5/22/13 at 5:08 p.m., the administrator and DON were notified of IJ related concerns to R43, R2, R63 and R13. In addition NA-M and LPN-B were identified as the currently employed staff members who were alleged to have perpetrated the mistreatment/abuse/neglect. On 5/23/13 at 2:45 p.m., the administrator confirmed LPN-B had worked the night shift on 5/22/13, as the acting supervisor. In addition, he confirmed incidents involving the four residents identified in the IJ had not been reported to the state agency as directed by the facility's policy. On 5/24/13 at 11:18 a.m., the DON confirmed the allegations of mistreatment/abuse/neglect for R43, R2, R63 and R13 had not been reported to the state agency in accordance with the facility's policy. Review of the facility's Abuse and Neglect policy dated 6/12, revealed staff were directed to protect residents from abuse, immediately report any allegations of abuse or neglect to the administrator and other officials in accordance with state law, and thoroughly investigate allegations of abuse.

Based on observation, interview, and document review, the facility failed to ensure adequate reassessment, supervision, and appropriate interventions had been implemented to minimize the risk of further falls and accidents for 2 of 3 residents (R29, R40) reviewed for falls. R29 had sustained actual harm related to a fall on 1/1/12. Findings include: R29 had sustained multiple falls without adequate reassessment of causal factors and the implementation of possible alternative and appropriate interventions related to identified failures of current interventions. R29 sustained harm following a fall on 1/1/12, related to R29's disablement of a current fall intervention that rendered it ineffective. The fall resulted in harm related to a left 5th fractured finger and a hematoma and laceration sustained to the temple aspect of the left orbit (the bone cavity that contains the eyeball) that required sutures and additional treatment. R29 was diagnosed with [REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], indicated R29 had severe cognitive impairment, required extensive assist with bed mobility, transfers, ambulation, and toileting. R29 was also identified with unsteady balance at times. The MDS indicated R29 had sustained 2 or more falls with no injuries and one fall with injury since the prior assessment period. The 6/15/11, Fall Care Area Assessment (CAA) indicated R29 was unable to remember to ask for assistance and was unsteady on feet when transferring. The CAA indicated R29 used a wheelchair. The Fall Data Collection Tool form dated 1/1/12, 12/2/11, 11/14/11, and 11/13/11, indicated R29 was identified at high risk for falls. The 12/12/11, plan of care (POC) indicated R29 required assist of one staff to ambulate to and from meals and to and from the bathroom with a front wheeled walker and the use of a transfer belt. The POC indicated if R29 was restless staff should take her for a walk. The POC indicated R29 required extensive assist with toileting and for staff to toilet R29 every two hours. The POC indicated R29 had a clip alarm on the wheelchair and when in bed. Staff were to place the clip alarm where R29 was unable to remove it. R29 was to wear rubber soled shoes when up and had a wheelchair with anti-rollback device applied. An incident report identified R29 had fallen on 1/4/11, at 4:15 p.m. R29's roommate reported R29 had slipped off her chair while self transferring from the recliner to stand. No injury was identified. The incident reports identified R29's multiple falls since April 2011: -4/8/11, at 11:00 a.m., R29 sat down between the beds in her room and reported she had gotten dizzy. R29's roommate saw her sit down. R29 sustained a 1 cm. bruise to her left lateral outer side of her hand. Staff positioned R29's wheelchair so the pedals were out of R29's walking area. - 5/5/11, at 9:30 a.m., R29 was found in the dining room on the floor laying on her right side after a self transfer from the wheelchair. The report indicated R29 went to her knees with intentions to lie down on the floor and had indicted she was tired. No new interventions were implemented. -5/21/11, at 7:00 p.m., R29 was found on the floor in another resident's room sitting on her buttocks. The report indicated R29 had fallen from bed and had stated she hurt her back, but no injury was identified. No new interventions were identified. Further incident reports identified: - 5/30/11, at 4:10 a.m., R29 was found sitting on the floor next to her roommate's bed. No injury was identified. The report also indicated R29 had fallen on 5/21/11, and was unsteady on feet. A clip alarm while in bed and wheelchair was implemented. -6/9/11, at 2:20 a.m., R29 was found in her room on the floor sitting on her buttocks between the beds. R29 sustained a golf size bruise to her left hand and had pain in her ankle/foot. Staff were to check brief and toilet R29 every 2 hours with stand by assist. - 7/4/11, at 12:45 p.m., R29 was found on the floor in the dining room lying on her left side. No injuries were identified. R29's clip alarm had not been on the wheelchair. Staff placed the alarm on the wheelchair. -8/12/11, at 6:30 p.m., R29 was found sitting on her buttocks on the floor in the dining room. The chair alarm was not sounding and R29 had been identified to have removed the clip alarm. No injuries were noted. Staff placed the clip alarm back on R29. No new interventions put in place. -8/12/11, at 7:30 p.m., R29 was found on the floor in her room sitting on her buttocks at the end of her bed. The report indicated R29's alarm had not sounded due to R29's removal of the alarm. No injuries were noted. The report indicated, "Clip alarm put on for 2nd time, 2nd fall in one hour. Each time clip alarm had been removed." No new interventions were implemented. -9/13/11, at 6:45 a.m., R29 was found sitting on her buttocks on the floor by her bed. No injuries were noted. The alarm had sounded. Staff were instructed to answer alarms promptly. -9/14/11, at 8:30 p.m., R29 was found on her buttocks on the floor of the hallway outside of her room. The report indicated the clip alarm did not sound as R29 had removed it. No injuries were noted. Staff were directed to place the clip alarm to an area that R29 could not see or get at easily and to respond quickly to the alarm. -9/23/11, at 9:30 p.m., R29 was found in her room on the floor on her buttocks against the bed. R29's personal alarm had sounded. R29's brief was noted to be wet. The report indicated R29 was getting up to the bathroom and lost her balance. No injuries were noted. No new interventions were put in place. -10/6/11, at 2:45 p.m., R29 was found in the dining room on the floor sitting on her buttocks. The report indicated R29 was witnessed to stand up, stumble, and fall on her right side. No injuries were noted. Staff shortened the cord on R29's tab alarm so it would sound sooner when she stood up. -10/9/11, at 10:50 a.m., R29 was found sitting on her buttocks on the dining room floor. The alarm had not sounded. The clip alarm was attached but the knot on the cord came undone and the clip magnet remained on alarm. R29 complained of pain-burning in her left wrist. Staff re-tied the string on the clip alarm were to make sure it would not untie again. R29's son suggested an anti-roll back system for her wheelchair. -10/14/11, at 8:00 p.m., R29 was found lying on the floor on her right side next to her wheelchair in the dining room. R29 had unclipped the alarm from her shirt. No injuries were noted. No new interventions were identified. - 10/19/11, at 8:50 a.m., R29 was found in her room on the floor, lying on her left hip. The report indicated R29's personal alarm had sounded. The report indicated R29 had gotten out of bed and attempted to walk to the hallway. R29 complained of generalized pain that resolved on its own. Staff placed non-skid mats beside R29's bed. The report indicated staff questioned whether R29 could be moved closer to the nursing station. A note dated 10/20/11, on the report indicated R29's son "has been very resistive to room changes." On 10/25/11, an occupational therapy (OT) evaluation was completed related to R29's balance issues and frequent falls. A wheelchair evaluation was also completed and R29's room was assessed and set up for safety. In addition, OT recommended for R29 to walk to and from meals. The 10/25/11, OT note indicated a functional maintenance plan (FMP) was developed to increase R29's mobility with a front wheeled walker for nursing staff to implement. A new wheelchair equipped with an anti-roll device was ordered. The 12/17/11, OT note indicated R29's new wheelchair had arrived and she was discharged from OT services. Further incident reports revealed: -11/3/11, at 1:20 p.m., R29 was observed by OT staff to stand up from the wheelchair in the dining room, lose her balance, and fall to the floor on her left side. The alarm had sounded. No injury was noted. OT ordered R29 a new wheelchair. The report indicated staff were utilizing a toileting schedule, monitoring medications, OT and PT (physical therapy) evals, and would now be placing R29 on a more consistent ambulation schedule to try decrease self standing attempts. The interdisciplinary progress note dated 11/7/11, indicated medications had been reviewed with the physician visit on 10/31/11, with no changes made. -11/13/11 at 9:00 p.m., R29 was found sitting in front of her wheelchair in the dining room. R29's personal alarm had not sounded. No injury was noted. Staff replaced the clip alarm with another unit. -11/14/11 at 5:55 a.m., R29 was found on the floor sitting up against her bed. The report indicated R29's personal alarm had sounded. R29 sustained a bruise on her left back and reported her buttocks hurt. No new intervention was put in place. - 12/2/11, at 11:00 p.m., R29 was found on the floor laying on the right side in the dining room. The alarm was sounding. The report indicated R29 was sleeping in the recliner, was restless and staff were not able to hear her bed alarm with the door being closed due to flu. No injuries. The note also indicated the director of nursing had worked with therapy on R29's room arrangement, mats on floor, and low bed and alarms. The incident reports identified multiple falls with a pattern of R29's removal of alarm devices that rendered the device ineffective on 8/12/11, at 6:30 p.m., and 7:30 p.m., and on 9/14/11, and 10/14/11. However, the facility failed to implement any new interventions related to the finding. The interdisciplinary (IDT) assessments and summary reviews identified a "comprehensive fall assessment" was completed on 9/26/11, 10/26/11, and 12/12/11. However, the assessments failed to identify the failure of the clip alarm device related to R29's removal of it and 4 resultant falls on 8/12/11, 9/14/11, and 10/14/11. In addition, although polypharmacy of central nervous system depressants were identified, no changes had been attempted in medications. Further, although R29 was identified to attempt toileting several times during identified falls, no changes in the resident's toileting plan were attempted. The incident report dated 1/1/12, indicated at 9:30 p.m., R29 was found in her room lying on the floor on the left side inside the doorway to her room. R29's personal alarm system was identified to not sound as R29 had removed the alarm and had ambulated self towards the hall doorway. The report indicated staff heard R29's fall impact and responded. The report indicated staff applied pressure to a bleeding laceration on R29's head and attempted to calm R29 until the ambulance arrived at 9:45 p.m. to take R29 to the emergency room (ER). The RN documented staff were unable do an assessment/evaluation due to R29 hitting and kicking. The report indicated three staff were required to restrict the head laceration's bleeding and R29's movements. The RN documented, "Has alarms on bed and wheelchair." No new interventions were implemented. The IDT progress note dated 1/2/11, at 11:30 p.m. indicated R29 returned to the facility with a pressure bandage, steri strips, and dermabond on the laceration. The IDT progress note dated 1/2/11, at 11:55 a.m. indicated R29 had removed the dressing and steri strips and had her fingers in the open laceration and was sent back to the ER for sutures. The Clinic Referral sheet (For visits to Doctor or Hospital Outpatient) dated 1/1/12, (no time) identified R29 had sustained [DIAGNOSES REDACTED]. R29 was also identified to have sustained an orbital contusion/ecchymosis/hematoma (bruising and localized collection of blood) to the skull and facial bone. A head CT scan was completed and additional neuro checks ordered. R29's blood pressure was noted to be elevated. The laceration was treated with dermabond and steristrips for closure. Staff were directed to also remove the steri strips in 14 days, monitor for infection, and apply ice every 3-4 hours as needed. In addition, the physician noted R29 was receiving polypharmacy including Risperdal, Zoloft, Ativan, and Tramodol, and staff should contact R29's primary provider re: considering a dose reduction. The Clinic Referral dated 1/2/12, indicated R29 had required suture repair of the 4.75 cm deep laceration in the temporal aspect of the left orbit. In addition, a contusion with ecchymosis was noted on the left 5th finger. Augmentin 500mg (an antibiotic) was ordered every 8 hours for 7 days and daily wound checks along with cold compresses to the left orbit and left 5th finger. The Imaging Report from the ER dated 1/2/12, identified a small fracture of the left 5th finger. The physician noted on the report treatment to include a finger tip immobilizer splint for 4-6 weeks. The Interdisciplinary Assessments and Summary Reviews note dated 1/9/12, identified an additional comprehensive fall assessment. The note identified R29 had unclipped her bed alarm prior to the fall on 1/1/12. The note documented R29 was now sleeping in the recliner in the dining area if restless and that a pad alarm was on her bed that she could not remove. Although the note identified polypharmacy again, no potential changes to be considered were identified. No further falls were identified for R29. On 1/31/12, at 2:30 p.m. R29 was observed sitting in the dining room, in a soft chair with a sensor pad alarm on. On 2/1/12, at 8:00 a.m. R29 was observed sitting in her wheelchair with a sensor alarm in place. R29 was using her feet to wheel herself in the hallway. On 2/1/12, at 12:30 p.m. nursing assistant (NA)-B stated she worked from 2:00 a.m. to 2:00 p.m. She stated R29 would start out in bed and often would get restless. NA-B indicated R29 would be transferred to the recliner in the dining room. At 1:30 p.m. NA-D stated R29 was able to take the clip alarm off and often would do that. At 2:30 p.m. the rehab aide, NA-C, stated R29 got very restless at night and staff would take her to the dining room and have her sleep in the soft chair with the clip alarm. At 3:00 p.m. NA-D stated R29's mood varied and staff assisted her into bed at night. NA-D indicated R29 often wanted to get up and would be transferred to the recliner chair in the dining room. NA-D stated R29 was very unsteady during stand transfers. At 3:40 p.m. registered nurse (RN)-A reviewed the Interdisciplinary Assessments and Summary Reviews note dated 1/9/12. The note indicated a sensor pad alarm had been placed on R29's bed as a new fall intervention. At this time, both RN-A and licensed practical nurse (LPN)-A stated they were not aware of the sensor pad on R29's bed or wheelchair. RN-A verified the care plan did not address the sensor alarm device and only identified a clip alarm for the bed and wheelchair. At 4:00 p.m. a bed sensor pad and clip alarm were both noted to be on R29's bed. At 4:10 p.m. NA-E indicated she worked evenings and stated R29 used both a sensor pad alarm and a clip alarm on her bed. NA-E stated R29 often would get anxious and she would be placed in the soft chair in the dining room. On 2/2/12, at 9:15 a.m. NA-B indicated she worked day shifts and stated she thought it had been 3 or 4 months since R29 had been able to walk with her front wheeled walker. At that time, NA-B showed the surveyor her hand held palm pilot that showed R29's ambulation plan. The plan directed for R29 to ambulate to and from dining room and to and from the bathroom. The plan was listed as "information" and the NAs did not document on R29's ambulation. At 9:20 a.m. RN-A stated R29's ambulation POC was correct. RN-A verified the NA hand held palm pilots identified R29's ambulation plan as "information" and NAs were not able to document on R29's FMP ambulation status on the palm pilot. RN-A stated the health information manager (HIM) who had transferred the FMP into the care plan did not set up a place where NAs could document on the palm pilot. RN-A added she would have changed that so NAs could document on R29's ambulation. RN-A verified OT had been working with R29 in November and December 2011, and at that time R29 was able to ambulate 150 feet. On 2/2/12, at 12:30 p.m. RN-A stated they review falls during interdisciplinary team (IDT) meetings, but did not document any of what was discussed in R29's record. RN-A verified the 11/28/11, quarterly MDS lacked a comprehensive fall assessment. The 9/2010, "Prevention and Management of Falls Practice Guidelines" policy indicated ongoing evaluation of a resident's level of function was required. Residents who sustained a decline in physical function may be at increased risk for falls. These residents should be further evaluated by restorative nursing and referred to skilled therapy. R40's assessed fall interventions had not been implemented in an attempt to minimize further falls. R40 was diagnosed with [REDACTED]. The annual MDS dated [DATE], identified R40 had severe cognitive impairment. The Fall CAA dated 4/6/11, identified R40 had no history of falls in the past year, although required assistance with transfers due to impaired balance. The quarterly MDS dated [DATE], identified the resident with severe cognitive impairment. The falls data collection tool dated 12/1/11, identified R40 at high risk for falls. The current plan of care (POC) dated 5/10/10, identified R40 required extensive assistance from 1-2 staff and a walker for transfers, and if lethargic a mechanical lift could be used. Fall interventions included to apply a clip alarm for safety on the wheelchair and a concave mattress to prevent falls. The incident reports identified: -On 5/27/11, at 3:50 p.m. R40 fell on to the floor from the bed and landed on the roommate's mat. The intervention was to apply a clip alarm when in bed. -On 8/2/11, at 5:30 a.m. R40 slipped out of bed, and the clip alarm was not attached to the resident. The intervention was to remind all staff about the clip alarm. -On 8/18/11, at 7:50 p.m. R40 was found lying on his right side on the floor out of his wheelchair. R40 had returned from dialysis earlier and after supper became increasingly agitated and confused. Staff had placed the resident by the nurses station and he fell out of the wheelchair before staff could get to him. The resident was taken to the emergency room . He sustained a nose laceration and required sutures. The intervention was to keep him closer to the nurses station. -On 10/1/11, at 10:30 a.m. R40 stood up from his wheelchair and fell and hit his head on the floor. The resident had neurological checks completed and required no medical attention. The intervention was to apply a clip alarm to the wheelchair. -On 10/17/11, at 4:00 a.m. R40 was found on the floor on his left side with left forearm caught between the grab bar and mattress. The intervention was to remove the grab bars from the bed. The interventions was to apply a concave mattress to the bed. -On 10/28/11, at 7:40 a.m. R40 was found on the floor. His call light was on, however, the clip alarm was not attached to the resident. The intervention was to try and anticipate the resident needs more quickly, and add body pillows in the bed for positioning. -On 11/12/11, at 5:15 p.m. the nurse observed R40 sliding off the bed onto his left side on the floor. The intervention was to remind the resident to call for help, a mat was placed on the floor, the bed alarm was added, and the low bed. -On 12/1/11, at 6:55 p.m. the nursing assistant (NA) found R40 lying on the mattress on the floor. The bed clip alarm and the body pillows had not been placed. The intervention was to remind the NAs to apply the clip alarm, and check on the resident more often. -On 12/4/11, at 2:30 p.m. R40 rolled out of bed and landed on his right side on the long body pillow and floor mat. The bed alarm sounded. The interventions were to continue with the low bed, mats on floor, clip alarm, body pillows, position resident in middle of bed and check on resident frequently per the care plan. No further falls were documented. On 2/1/12, at 8:00 a.m. R40 was observed asleep on his right side in bed. The bed clip alarm was attached to the back of his sweatshirt. The alarm box was lying on the upper right side of the mattress not affixed to any surface. At 8:19 a.m. NA-K and NA-G transferred R40 to the wheelchair. The wheelchair clip alarm was not placed on the resident. At 8:33 a.m. R40 was observed at the breakfast table being fed by NA-G and the wheelchair alarm was still not placed. At 9:37 a.m. R40 was in bed asleep on his left side. The clip alarm was attached to his shirt. The alarm box was positioned in the right upper corner of the mattress not affixed to any surface. On 2/2/12, at 7:26 a.m. R40 was observed on his right side in bed. The clip alarm was attached to his shirt. The alarm box was lying at the top of the mattress not affixed to any surface. At 8:07 a.m. R40 was observed up in his wheelchair and the clip alarm was not placed on the resident. At 8:37 a.m. R40t was being fed at the breakfast table by NA-G and the clip alarm was still not on the resident. On 2/2/12, at 9:09 a.m. NA-G stated R40 has used the clip alarm in bed for about 6 months. She stated they used to keep the box attached to the grab bar on the bed. She added there was no grab bar now, and no one had thought about affixing it to the head board. NA-G stated all the other residents have the boxes Velcroed to the grab bars. NA-G stated, " I don't think he is supposed to use the clip alarm on the wheelchair." She stated, " We can't put the alarm on the wheelchair because there is no Velcro to attach it to." She added her hand held (HH) device which contained R40's POC did not address the use of the clip alarm in bed or wheelchair. NA-G stated R40 only used a mat on the floor on the left side of the bed. NA-G verified the (HH) device did not address the use of the mat on the floor either. At 9:45 a.m. the director of nursing (DON) stated on 8/18/11, R40 was agitated when he came back from dialysis. She stated the nurse was standing right by him when he fell straight out of the wheelchair. At 11:07 a.m. the DON stated the clip alarm was added to wheelchair on 10/1/11. The DON stated she talked to the 2 NAs that were working on 10/28/11,when the resident fell and they stated the alarms were working. The DON stated they were not sure if R40 removed the alarm, or if just his moving around in the bed caused the alarm to come off. The DON stated when R40 fell on [DATE], the intervention was for staff to check on the resident frequently. In addition, the DON stated she reviewed every fall with the administrator and social services to see if any further interventions were needed. At 11:25 a.m. the DON stated since 10/1/11, the staff should use the clip alarm on the wheelchair as directed on the POC. She stated there was "absolutely" no reason for not getting the box alarm on the wheelchair. The DON stated the alarm box should be attached to the top of the bed. She added, "We want the alarm to go off when he sits up." She stated the box should be affixed to the headboard with a metal device. The DON verified the POC was not followed regarding the wheelchair and bed alarm. The DON stated they do a falls data collection tool, change the POC, and make a copy of the POC so that the information gets onto the HH device. The current plan of care (POC) dated 5/10/10, identified the fall interventions of applying a clip alarm for safety on the wheelchair and a concave mattress to prevent falls. However, the responsible party identified on the care plan read NRG which stands for nursing. The DON stated if the care plan does not state HH behind it does not get on the HH device for the NAs. The DON stated either the staff wrote NRG verses HH, or it was not put in the computer correctly. The DON verified the care plan was lacking fall interventions which included the clip alarm on when in bed, the mat on the floor, body pillows, low bed, and to check on the resident frequently. The DON stated these items should also be on the care plan. The DON added if it does not go to the HH device, the staff do not read the entire care plan and would not know the interventions. At 2:02 p.m. the DON stated she had put a plastic holder on R40's headboard to hold the alarm box. In addition, she put a basket on the wheelchair to hold the alarm box.

Based on observation, interview, and document review, the facility failed to provide ambulation services to prevent a decline in function for 1 of 1 resident (R29) in the sample who had a decline in ambulation. This practice caused actual harm for R29 related to the loss of the ability to ambulate. Findings include: R29's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE], identified R29 had severe cognitive impairment, required extensive assist from staff to walk in room and transfer, and used a wheelchair. The 6/15/11, Fall Care Area Assessment (CAA) indicated R29 was unsteady on feet when transferring and used a wheelchair. The 10/25/11, occupational therapy (OT) evaluation and plan of treatment indicated R29 was evaluated due to balance issues, frequent falls, and difficulty in wheelchair positioning. The 11/3/11, OT note indicated R29 ambulated 150 feet. The 11/3/11, and the 12/17/11, Functional Maintenance Program (FMP) sheet indicated R29 required assist of one staff and front wheeled walker to and from meals and to and from bathroom. The FMP indicated R29 was to be offered opportunities to walk throughout the day. The 12/21/11, OT discharge note indicated it was important for staff to carry out the FMP frequently. The plan of care (POC) dated 12/12/11, directed staff to transfer R29 with assist of one staff and ambulate with assist of one staff to and from meals and to and from bathroom with a front wheeled walker and gait belt. On 2/1/12, at 7:15 a.m., R29 was observed to be wheeled into the dining room in her wheelchair. On 2/2/12, at 7:00 a.m., R29 was sitting in her wheelchair at the dining table. On 2/1/12, at 3:00 p.m., nursing assistant (NA)-D stated R29 was assisted with transfers and evening staff did not walk her. NA-D added R29 was very unsteady when standing. On 2/1/12, at 3:10 p.m. registered nurse (RN)-C stated according to R29's POC, she was to be on a functional maintenance program (FMP) for ambulation. However, no documentation was noted in the Rehab section of the medical record. RN-C stated the rehab department would have the documentation. On 2/1/12, at 4:10 p.m. NA-E stated that she did not walk R29 on evenings and that she only transferred R29 from the wheelchair to bed and added R29 was very stiff. On 2/2/12, at 7:10 a.m. NA-F stated she could not recall R29 being able go for a walk because she always ached and was stiff. At 7:15 a.m. NA-B stated she had assisted NA-A with transferring R29 that morning and had a hard time transferring R29 because she ached and was stiff. At 8:15 a.m. NA (rehab aide)-C stated R29 was no longer being seen by the rehab department. NA-C stated R29 used to be seen, however, had been discharged more than 6 months ago because R29 would often refuse services and was walking by herself a lot on the unit at that time. At 9:15 a.m. NA-B indicated she worked day shifts and stated she thought it had been 3 or 4 months since R29 had been able to walk with her front wheeled walker. At that time, NA-B showed the surveyor her hand held palm pilot that showed R29's ambulation plan. The plan directed for R29 to ambulate to and from dining room and to and from the bathroom. The plan was listed as "information" and the NAs did not document on R29's ambulation. At 9:20 a.m. RN-A stated R29's ambulation POC was correct. RN-A verified the NA hand held palm pilots identified R29's ambulation plan as "information" and NAs were not able to document on R29's FMP ambulation status on the palm pilot. RN-A stated the health information manager (HIM) who had transferred the FMP into the care plan did not set up a place where NAs could document on the palm pilot. RN-A added she would have changed that so NAs could document on R29's ambulation. RN-A verified OT had been working with R29 in November and December 2011, and at that time R29 was able to ambulate 150 feet. At that time, the 4/20/11, POC was reviewed with RN-A. The POC indicated rehab nursing was seeing R29 three times a week, however, the documentation did not state how far R29 was to ambulate. The Rehab Nursing sheets during the month of May 2011, indicated R29 was able to ambulate 180-280 feet. The May 2011, note indicated R29's FMP was discontinued due to refusals and that R29 walking with staff on the unit. At 9:40 a.m., RN-B, the rehab coordinator stated R29 was not capable of ambulating as indicated per the POC on most days. Documentation related to R29's decline in ambulation status was lacking in the medical record. At 11:10 a.m. NA-A was unable to find R29's front wheeled walker on the unit so another was used. At 11:15 a.m. RN-B and NA-A attempted to ambulate R29, however, she refused. Then NA-A wheeled R29 into the bathroom. NA-A asked R29 if she could stand and R29 stated, "No." NA-A and RN-B transferred R29 onto the toilet. At 11:25 a.m. RN-B stated R29 had declined physically. She stated she did not have any way of knowing that the NAs were not ambulating R29, because they had not documented on R29's ambulation. RN-B stated R29's decline in ambulation had not been assessed or documented in the medical record. RN-B stated physical therapy would be contacted to evaluate R29's ambulation status. The 2/2005, Restorative Nursing Care policy indicated each resident would receive restorative nursing care to the extent possible, based on individual strengths, needs, and problems as defined in nursing assessments. The goal of restorative nursing care was to attain and maintain the maximum possible independence for each resident. The 1/09, Ambulation of Resident policy indicated staff were to document the resident's ambulation on facility forms. The 9/2010, Prevention and Management of Falls Practice Guidelines policy indicated ongoing evaluation of a resident's level of function was required. Residents who sustained a decline in physical function may be at increased risk for falls. Those residents should be further evaluated by restorative nursing and referred to skilled therapy.