Every finding on record at Oaknoll Retirement Residence

Based on observation, record review, staff interview, policy review and manufacturer insert review, the facility failed to provide services that met professional standards regarding medication administration for 2 of 2 residents observed (Resident #9 and #25). They did not have their insulin flex pen primed appropriately and the needle was not left under the skin after the insulin was injected for the recommended period of time to ensure the full dose of medication was given. The facility reported a census of 57 residents. Findings include: An observation on 8/26/24 at 7:59 AM, during the Medication Pass Task, revealed Staff A, Registered Nurse, (RN) administered Resident #9's insulin. Staff A, RN obtained the resident's Novolog (insulin) flex pen from the medication cart, put the needle on the tip of the pen and dialed it to 16 units (order was for 14 units plus 2 units of sliding scale for a blood sugar of 175) and proceeded to administer the insulin. Staff A, RN failed to prime the pen with 2 units prior to setting it to 16 units and failed to keep the needle under the skin for a full count of 6 to ensure the full dose was injected before removing. An observation on 8/26/24 at 12:00 PM, during the Medication Pass Task, revealed Staff A, RN administered Resident #25's insulin. Staff A, RN obtained the resident's Novolog (insulin) flex pen from the medication cart, put the needle on the tip of the pen and primed the pen with 1 unit, then dialed it to 3 units as ordered and proceeded to administer the insulin. Staff A, RN failed to prime the pen with 2 units per policy, prior to setting it to 3 units and failed to keep the needle under the skin for a full count of 6 to ensure the full dose was injected before removing. Review of the manufacturer insert for Novolog flex pen revealed the flex pen was to be primed with 2 units of insulin prior to selecting the dose to be administered. It further directed the pen was to be inserted, the dose button pressed down until the dose counter showed 0 and the needle kept in the skin for a slow count to 6 before removing. The insert stated the full dose would not be received unless left in the skin for 6 seconds. Review of the facility provided policy titled Insulin Pen dated 11/7/17 and reviewed on 8/26/24, stated when injecting insulin using an insulin pen, the process was to include priming the insulin pen by dialing 2 units by turning the dose selector clockwise. With the needle pointing up, push the plunger, and watch to see that at least one drop of insulin appears on the tip of the needle. If not, repeat until at least one drop appears. It further stated when injecting the insulin, inject the needle straight at a 90-degree angle to the skin. Fully depress plunger until the dosing numbers count back to zero. While still pressing the plunger, keep the needle in the skin for up to 6-10 seconds and then remove the needle from the skin. In an interview on 8/27/24 at 1:30 PM, the Director of Nursing (DON) stated it was the expectation staff completing insulin injections using a flex pen, follow the policy and procedure of the facility. The DON stated licensed staff had all been re-educated on the appropriate process for flex pen insulin injections.

Based on observation, interview, policy review, and record review the facility failed to ensure neurological assessments were completed for residents with a known history of falls, and failed to ensure residents were safely transported via wheelchair for 6 of 21 residents reviewed for accidents (Residents #4, #8, #16, #21, #48, and #49). The facility reported a census of 57 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident#49 was unable to complete the Brief Interview for Mental Status (BIMS) exam due to short term and long term memory problems, inattention, and an altered level of consciousness. Section J of the MDS, Health Conditions, documented the resident had 2 falls since the prior assessment. The MDS documented the most recent admit to the facility occurred on 10/18/2023. A Care Plan with an admitted [DATE] included the following focus areas: a. Dependence on staff for physical needs related to physical limitations and cognitive challenges (2/23/24), b. Communication problems related to hearing and dementia (10/19/23), i. Intervention: Anticipate and meet needs ii. Intervention: Provide a safe environment c. Potential for falls (10/18/23). i. Intervention: Assist with scheduled check and change ii. Intervention: Assist to common areas when restless iii. Intervention: For no apparent acute injury, determine and address causative factors of the fall iv. Intervention: Monitor and report signs/symptoms of or complaints of discomfort A Health Status Note dated 3/27/24 at 11:37 AM documented Resident #49 was found on the gray mat in front of his bed at 7:30 AM with his legs spread. The resident was incontinent of bowel. A Health Status Note dated 4/3/24 at 3:46 PM documented the resident was found by the nurse sitting on the floor with his legs in front of him, leaning against the closet. The resident denied pain and hitting his head, was assisted to stand, and transferred to his wheelchair. The electronic health record revealed vitals were taken at 11:11 AM on 3/27/24, 11:33 AM on 3/27/24, and 3:50 PM on 4/3/24 by Staff C, Registered Nurse. An Incident Report dated 4/3/24 at 3:30 PM documented the resident had an unwitnessed fall. The resident description indicated he walked towards his walker, lost his balance near the closet, leaned, and slowly went down. Resident #49's mental status was documented as oriented to person, place, and situation. The report listed no environmental, physiological, or predisposing factors. Documentation in the resident's electronic and paper records lacked documentation of neurological monitoring for unwitnessed falls on 3/27/24 or 4/3/24. The most recent neurological assessment sheet in the resident's paper chart was initiated 1/14/24. During an interview on 4/4/24 at 8:30 AM the resident was unable to answer questions from the surveyor regarding his fall 4/3/24. Staff A, Licensed Practical Nurse, on 4/4/24 at 9:04 AM specified the protocol for an unwitnessed fall for a resident with cognitive impairment or a potential injury was to assess for neurological concerns for 24 hours post fall according to a flow sheet. Staff A stated the assessment started with 15-minute checks, progressed to half hour checks, moved to hourly monitoring, and then 4-hour monitoring. She stated no residents were currently being assessed according to this protocol. On 4/4/24 at 11:44 AM the Director of Nursing reported she was not aware of Resident #49's fall on 4/3/24. She stated if there was a question of a head injury neurological checks should be initiated. On 4/4/24 at 11:50 AM the Administrator stated the decision to evaluate after a fall should be more cautious than less. A policy titled Fall Prevention and Investigation Policy, reviewed 1/25/24, documented each resident received care and services in accordance with their individualized level of risk. A fall was defined as an event where an individual unintentionally moved from a higher plane to a lower plane and came to rest on the ground, floor, or other lower level. It could be witnessed, reported, or presumed and could occur anywhere. Number 5(f) indicated general fall protocol was to monitor vital signs according to facility policy. It lacked documentation regarding the extent of assessments required for residents with cognitive impairment or an unwitnessed fall. 2. The Quarterly Minimum Data Set (MDS) for Resident #48 dated 1/31/24 revealed a Brief Interview for Mental Status (BIMS) could not be administered due to short term and long-term memory problems, disorganized thinking, and inattention. The MDS included diagnoses of hypertension and non-Alzheimer's dementia. The MDS documented that a wheelchair was normally used in the last seven days by the resident. The MDS documented that the resident was dependent on staff for putting on and taking off footwear, and lower body dressing. The MDS documented that the resident was dependent on staff to operate the manual wheelchair for the resident. A Care Plan with an admitted [DATE] addressed dependence on staff (7/6/23), impaired cognitive function and impaired thought process (7/6/23), falls (8/10/23), and self-care deficit and impaired mobility (8/10/23). Observation on 04/01/24 at 11:10 AM revealed the following; Staff G, CNA pushed the resident in her wheelchair down the hallway from her room to the dining area without pedals, with the resident holding her feet up off of the ground. Staff G reached the table, then looked down and realized the resident did not have wheelchair pedals. She returned to the resident's room to get them and placed them on the chair. 3. The Annual Minimum Data Set (MDS) assessment for Resident #21 dated 1/10/24 revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) exam due to short term and long term memory problems, inattention, and disorganized thinking. It included a diagnosis of dementia. The MDS documented that a wheelchair was normally used in the last seven days by the resident. The MDS documented that the resident was dependent on staff for putting on and taking off footwear, and lower body dressing. The MDS documented that the resident was dependent on staff to operate the manual wheelchair for the resident. A Care Plan with an admitted [DATE] included focus areas related to impaired mobility (initiated date 4/13/21), dependence on staff for physical needs related to dementia and physical limitations (initiated date 5/4/21), communication deficits related to difficulty with expressing herself (initiated date 4/15/21), and a potential for falls due to poor balance and unsteady gait (initiated date 8/29/22). The Care Plan included the following interventions; a. included scheduled check and change, proper footwear, and monitoring for anxiety related to not being able to propel her wheelchair where she chose. b. The resident needs assistance/escort to activity functions c. The resident can self propel in wheelchair without foot pedals On 4/1/24 at 10:40 AM observed Resident #21 in the common area of the 3rd floor. There was a bag for pedals on the back of her wheelchair. The pedals of her chair were on, and her feet were trapped underneath. She tried to lift her tennis shoes between the pedals without success. The left pedal was at about 80 degrees and the right about 45 degrees from the floor. As she attempted to move, she could not get the momentum in that small foot space to turn the chair without hitting her feet and shins on the pedals. The resident came to a rest with her back to the table she had been sitting at and was unable to move any further. On 4/3/24 at 2:43 PM Staff G, Certified Nursing Assistant (CNA), stated most residents who use wheelchairs have pedals available in their rooms. This resident sometimes needed assistance and sometimes wanted to move on her own. She indicated the resident had a bag on the back of her wheelchair for pedals. She stated some residents need them off so they didn't hit their shins. Staff G stated they are trained by working with other CNAs and they get transfer training. On 4/3/24 at 2:48 PM Staff H, [NAME] Coordinator, stated they educated activity staff about basic wheelchair safety, and CNA staff should know when to use the pedals or leave them off as part of their training with the staff trainer. A document titled CNA Relias Hours Assigned dated 4/1/24 indicated a training called Transferring Safely was assigned 8/14/23. 48888 4. The Quarterly Minimum Data Set (MDS), dated [DATE], documented Resident#4 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated intact cognition. The MDS revealed Resident #4 had impairment to both sides of upper extremities and utilized a wheelchair for mobility. Resident #4 required substantial to maximal amount of staff assistance with transfers and was non ambulatory. The MDS document the resident had diagnoses which included acute osteomyelitis of left ankle and foot, acute lymphangitis of left lower extremity, and osteoarthritis. The MDS documented that the resident normally used a wheelchair for the seven day look back period. The MDS revealed that the resident dependent on a helper to put on and take off footwear, and dress the lower body. The Care Plan, documented a focused care area for impaired mobility with initiated date of 1/25/18. The Care Plan instructed staff to encourage Resident #4 to propel her wheelchair on her own with her feet and to provide assistance as needed. Observation on 04/03/24 at 12:54 PM, revealed Resident#4 pushed by Staff I, Certified Nursing Assistant (CNA), in a wheelchair with no foot pedals in place. Resident #4 held her legs out straight in front of her during transportation from the dining room back to the resident's room. 5. The Quarterly Minimum Data Set (MDS), dated [DATE], documented Resident#8 scored a 4 out 15 for the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Resident #8 utilized a wheelchair for mobility and required dependence on staff for transfers. The MDS documented that the resident had diagnoses which included the following; thyrotoxicosis with thyrotoxic crisis or storm and mild cognitive impairment. The Care Plan, revised 03/25/24, revealed the focused area for impaired mobility with the goal that Resident #8 will not have a decline in self-care ability or ability to transfer and instructed staff to assist/escort Resident #8 to activity functions. On 04/03/24 at 01:18 PM, observed Resident #8 pushed in a wheelchair by staff from the South hall lounge to her room, foot pedals in place, however, feet had not been placed on foot pedals prior to transport. Resident #8's feet pointed downwards and toes skimmed across the floor during transportation. 6. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. Resident #16 utilized a wheelchair for mobility and required partial to moderate amount of staff assistance with transfers and ambulation. Diagnoses included anxiety disorder and restless legs syndrome. The MDS documented that the reside required total assistance with putting on and/or taking off footwear. The Care Plan, revised 02/27/24, revealed a focused area for self care deficit related to impaired mobility with a goal that Resident #16 will continue to be mobile within the facility with an assist of one staff. On 04/03/24 at 10:59 AM, observed Resident #16 in wheelchair without foot pedals, pushed by a shower aide, from the South hall shower room to the South hall medication cart, where staff requested hearing aides from the nurse. A nursing student assisted resident with hearing aides, then pushed Resident #16 from the medication cart to resident's room, Resident #16's feet skimmed just over top of the floor while transported in wheelchair. On 04/03/24 at 11:20 AM, Resident #16 self propelled in wheelchair from room to hallway, Staff I, Certified Nursing Aide (CNA), visited with resident in hallway, latched Resident #16's seatbelt across lap, then assisted Resident #16 back to her room, no foot pedals placed on the wheelchair. 7. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicative of severe cognitive impairment. Diagnoses included: dysphagia (difficulty swallowing) and thyrotoxicosis. The MDS revealed Resident #8 had coughing or choking during meals or when swallowing medication and required a change in the texture of food or liquids during the assessment period. The Care Plan, revised on 03/20/24, revealed a focused care area for impaired swallowing related to dysphagia diagnosis and informed that Resident #8 required fluids thickened to pudding consistency. The Care Plan instructed staff to provide direct supervision of intake and monitor Resident #8's respiratory status. The Speech Therapy Note, dated 02/09/24, revealed the recommendation of Speech Therapist to trial pudding thick liquids between the dates of 02/09/24 and 02/15/24. Nursing staff noted the recommendation on 02/13/24. The Speech Therapy Note, dated 02/12/24, revealed a recommendation to discontinue the free water protocol and instructed for no thin liquids between meals at this time. Recommendation lacked nursing notation. The Nursing Progress Note, dated 03/19/24, revealed Resident #8 had episode of coughing during evening meal that resulted in small emesis and informed that Resident #8 continued to have cough but lung sounds had been clear after episode. The Plan of Care Progress Note, dated 03/27/24, revealed Resident #8 had worked with Speech Therapy due to coughing with meals and had an order for a swallow study to be completed due to dysphagia. The Dietary Department provided a residents diet list, revised on 04/01/24, which informed that Resident #8 required pureed diet with pudding thickened liquids and instructed to serve Resident #8 only with staff present. On 04/01/24 at 12:30 PM, Resident #8 received staff assistance with the lunch meal. Staff provided pureed texture food and pudding thickened liquids. Resident #8 frequently coughed and cleared throat during the meal. On 04/02/24 at 11:28 AM, Staff E, Certified Nursing Assistant (CNA), informed that CNA staff would view diet information kept on a care sheet within each resident's wardrobe. On 04/02/24 at 11:58 AM, observation of two care sheets posted inside Resident #8's wardrobe. The first sheet, titled Resident Information, undated, indicated that Resident #8 required thickened liquids, however lacked information on the thickness required. The second sheet, titled Therapy Recommendation, dated 11/11/22, indicated Resident #8 required minced and moist diet and mildly (nectar) thick liquids with an addendum that informed staff to implement the Frazier Water Protocol, which allowed for thin liquids, between meals. On 04/02/24 at 12:00 PM, Resident #8 had water pitcher located on bedside table with a lid and straw, water inside the pitcher had been of nectar thickness consistency, noted the viscosity of liquid too thin to be given via spoon, as required for pudding thick liquids. On 04/02/24 at 02:00 PM, Staff F, CNA, indicated water pitchers are filled towards the end of each shift and thought Resident #8 had been on nectar thickened liquids, after Staff F checked with Staff A, Licensed Practical Nurse (LPN), informed that Resident #8 had required pudding thickened liquids. On 04/03/24 at 10:00 AM, Staff C, Registered Nurse (RN), reported that Resident #8 had been on honey thickened liquids and stated the medication pass liquids for Resident #8 would be thickened to a honey consistency. Staff C informed that that thickened liquids would be kept in the clean utility refrigerator. Staff C checked the refrigerator, which contained only a bottle of pre-thickened nectar thick water, and informed that if liquids needed to be thicker than nectar consistency, they would add thickening powder to achieve the correct thickness. Staff C, unable to locate thickening powder in the clean utility room or within the medication cart. On 04/03/24 at 10:18 AM, water pitcher located in Resident #8's room again contained water with a thickness less than the required pudding thickness for liquids. On 04/03/24 at 04:25 PM, Dietary Manager informed that the Speech Therapists would send recommendations through the facility's electronic system to nursing and dietary departments and that dietary would update the diet list with new recommendations. The Director of Nursing (DON) informed that when nursing received therapy recommendations, nursing would update the resident's orders. DON notified that therapy recommendations are kept in resident's wardrobes for CNA staff to review and indicated that Restorative Aides are responsible for updating Care Sheets in the wardrobe. The Facility Assessment, titled Oaknoll Retirement Residence Community Assessment Tool 2024, reviewed with leadership on 02/14/24, revealed under Part 2: Services and Care Offered Based on Resident's Needs, the facility would provide nutritional service for individualized dietary requirements.

Based on observation, interview, and facility policy review, the facility failed to maintain secure medication storage when 1 of 3 medication carts remained unlocked without staff supervision and further failed to keep schedule 4 medication (lorazepam concentrate solution) under double lock for 2 of 3 medication storage rooms observed. The facility reported a census of 57 residents. Findings include: On 04/01/24 at 02:14 PM, observation of the medication cart, located on South hallway, with the lock out in an unlocked position and keys hanging from the lock. The medication cart left unattended with four visitors and three residents sitting in the area, various ancillary staff also passed through the hallway. One ambulatory resident wandered in the hallway and attempted to open a locked room near the medication cart. Two Certified Nursing Aides (CNAs) sat around the corner, out of eyesight of the medication cart. At 02:23 PM, after nine minutes of continuous observation, Staff A, Licensed Practical Nurse (LPN), exited room [ROOM NUMBER], returned to South hall medication cart, removed the keys from the cart and pushed the lock in a locked position. On 04/02/24 at 12:04 PM, continuous observation of the South hall medication cart left unlocked and unattended. Four South hallway residents remained in their rooms during this time and various staff passed through the area. At 12:09 PM, Staff A, LPN returned to medication cart, grabbed trash, and again failed to lock the medication cart before leaving it unattended to go to clean utility room. At 12:11 PM, Staff A, returned to medication cart, locked cart, and went into chart room. On 04/03/24 at 10:05 AM, Staff B, LPN, provided a tour of North hall medication storage room. A medication refrigerator, kept inside this medication room, contained an open bottle of liquid lorazepam concentrate medication, classified as a Schedule 4 controlled substance due to potential for abuse and addition. The medication refrigerator lacked an additional locking system to limit access to the schedule 4 medication. Staff B, explained that there had not been a lock on the medication refrigerator as the medication storage room itself is kept locked. On 04/03/24 at 10:20 AM, Staff C, Registered Nurse (RN), provided a tour of South hall mediation storage room. An additional medication refrigerator, kept inside this medication room, contained an open bottle of liquid lorazepam concentrate medication. Staff C informed that this medication would be destroyed due to resident's recent passing and confirmed that no additional locking system had been kept on this medication refrigerator. On 04/03/24 at 04:25 PM, the Director of Nursing (DON), confirmed that medication storage rooms lacked an additional locking system on refrigerators containing Schedule 4 controlled substance (lorazepam concentrate solution) and would check into this requirement. In an E-mail sent from DON, dated 04/03/24 at 06:49 PM, revealed that the facility now had all liquid lorazepam under double lock system. This medication stored in a lock box inside the medication refrigerator within the medication storage room. The facility policy, titled Medication Storage, revised 02/09/24, revealed the expectation that all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) and instructed that medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. The Medication Storage policy additionally informed that Schedule 2 drugs and back up stock of Schedule 3, 4, and 5 medications are stored under double-lock and key.

Based on observation, interview, and record review the facility lacked documentation regarding behavioral triggers related to the use of psychotropic medication. The facility failed to implement a comprehensive Care Plan that included documentation identifying behavioral triggers to meet the resident's medical, mental and psychosocial needs prior to the administration of unnecessary medications for two of four residents reviewed for unnecessary medications (Resident #33) and (Resident #36). The facility reported a census of 57 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #33 dated 3/6/24 revealed the resident had severely impaired cognitive skills for daily decision making. Per the MDS, Resident #33 diagnosis included Alzheimer's disease and depression. The Care Plan revised 3/6/2024 documented a focus area of Psychotropic Drug Use: Zoloft as ordered every day, Trazadone as ordered, Risperidone. Interventions included: Alter environmental meet needs, document behaviors as noted et monitoring, Monitor Aims every quarter and as needed, monitor for et report SE of medication as noted, provide distractions per resident needs et preferences. The Care Plan did not document specific behaviors or triggers associated with behaviors. The Physician Order dated 4/3/2024 documented Risperidone TAB 0.5MG 1 TAB PO every morning related to Dementia is other diseases classified elsewhere, unspecified severity The Physician Order dated 12/13/2023 documented Trazadone Tab 50MG 1/2 Tablet (25MG) 1/2 Tablet (25MG) PO every morning and bedtime related to Alzheimer's disease, Unspecified The Physician Order dated 11/30/2022 documented Sertraline Tab 100MG one tab PO every morning related to Depression, Unspecified Review of Resident #33's Medication Administration Record (MAR) documented the resident received Trazadone Tab 50MG 1/2 Tablet (25MG) every morning and bedtime and Sertraline Tab 100MG I tab PO every morning during the review period of April 1, 2024 through April 8, 2024 as prescribed. The resident received Risperidone TAB 0.5MG every morning during the period of April 4, 2024 through April 8, 2024. The Behavior Monitoring document dated 3/10/2024 to 4/8/2024 documented the resident displayed the following behavioral symptoms; Wandering on 3/27,3/29, 4/2,4/3,4/7 Kicking/Hitting on 4/3 Grabbing on 3/29, 4/3 Abusive language and threatening behavior on 4/3 The care plan lacked potential interventions for these behaviors or potential triggers. Review of Progress Notes dated 3/13/24 at 9:03 documented the resident remains alert and oriented to self and familiar people, but with challenges related to expressing self and needs due to dementia disease progression. Resident at times appears agitated and becomes frustrated when unable to express himself. Staff continue to find ways to support resident and anticipate needs. Resident's dementia related behaviors continue to be managed with assistance from geri-psych provider and primary care provider (PCP). The care plan lacked documentation of these or other behavioral triggers. 2. The Minimum Data Set (MDS) assessment dated [DATE], for Resident #36 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. The MDS documented the resident received antidepressant medication on 7 out of 7 days of the assessment reference period. Resident #36 is diagnosed with congestive heart failure, type 2 diabetes and unspecified mood disorder. The MDS did not document any behavior concerns. The Care Plan dated 6/23/2023 and revised on 2/19/2024 documented a focus area of Psychotropic Drug Use related to the diagnosis of Depression with the following interventions: a. Administer Wellbutrin, Cymbalta as ordered every day. Monitor et report side effects (SE's) as noted. Symptoms of anxiety. b. Alter environment to meet needs c. Monitor and (et) document behavior et mood changes as noted et monitoring d. Monitor et report complaints of (c/o) or s/sx of nerve pain of lower extremities as noted e. Monitor for et report SE of medication as noted f. Provide distractions per resident needs et preferences g. Provide pharmacy eval every month, Medical Doctor (MD) every 2 months for continued drug use The Care Plan lacked documentation of specific triggers and associated behaviors to support the need for psychotropic drug use. The Physician Order dated 6/30/2023 documented, Bupropion Hydrochloride (HCL) Extra Long (XL) (antidepressant) 300MG TAB 1 TAB PO every morning, related to depression, unspecified The Physician Order dated 6/30/2023 documented, Duloxetine Delayed Release (DR) (antidepressant) 30MG 1 CAP PO every (Q)AM **Take with 60MG to equal 90MG related to major depressive disorder The Physician Order dated 6/30/2023 documented, Duloxetine HCL DR 60MG 1 CAP PO QAM **Take with 30MG to equal 90MG related to major depressive disorder Review of Resident #36's Medication Administration Record (MAR) documented the resident received Duloxetine DR 30MG, Duloxetine HCL DR 60MG and Bupropion HCL XL 300MG TAB each morning during the review period of April 1, 2024 through April 8, 2024 as prescribed. The Behavior Monitoring document dated 3/23/2024 to 4/4/2024 documented the resident did not display any behavior symptoms. 4/4/2024 at approximately 12:30 PM, the Administrator reported for Psychotropic medications the whole team is involved. The facility focus is on medication reviews and gradual dose reductions (GDR) completed timely. The facility charts by exception so they would not chart unless there was some sort of behavior. Staff members are provided with a lot of education regarding documentation of behaviors and interventions. The facility utilizes non-pharmacological interventions such as music therapy, massage, redirection and distraction. Staff members know resident triggers because they know their residents. Staff members are assigned to designated areas so they are familiar with their residents. Resident #36 has not displayed behaviors. The facility policy titled Medication Regimen Review, dated 11/7/2017 and revised 6/1/2023, included each residents' drug regimen remains free of unnecessary drugs. An unnecessary drug is any drug when used: In excessive doses, including duplicate therapy. For excessive duration. Without adequate monitoring. Without adequate indications for its use. In the presence of adverse consequences which indicate the dose should be reduced or discontinued.

Based on record review, observation, and interviews the facility failed to ensure the Care Plan was comprehensively reviewed, revised, or followed for 1 of 3 residents (Resident #35) reviewed for nutrition and for 1 of 3 residents (Resident #42) reviewed for behavioral health. The facility reported a census of 57 residents. Findings include: 1. The Annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #35 listed diagnoses of coronary artery disease, gastroesophageal reflux disease, and hypokalemia (low potassium). The MDS documented 3/2/23 as the residents most recent admitted . The MDS indicated the resident needed set up or clean up assistance with eating. The resident was unable to complete the Brief Interview for Mental Status (BIMS) exam due to short term and long term memory problems, inattention, and disorganized thinking. The resident's Care Plan printed at 12:43 PM on 4/2/24 with an admitted [DATE] included focus areas for altered nutrition (revised 3/20/23), Potential for Dehydration (initiated 5/10/21), and self-care deficits (3/16/23). Interventions for nutrition included: a. Labs as ordered (5/10/21) b. Assistance with and encourage intake as needed (5/10/21) c. Cater to food preferences as able (5/10/21) d. Quarterly and PRN dietician consults (5/10/21) e. Documentation of meal intake (5/10/21) f. Educate/encourage healthy food choices (5/10/21) g. Offer snacks between meals (5/10/21) h. Offer substitutions (5/10/21) i. Provide assistive devices as needed (5/10/21) j. Provide diet as ordered (5/10/21) k. Provide banana at breakfast (11/15/23) l. Provide favorite food to encourage intake (5/10/21) m. Provide juice supplement at med pass BID (twice per day)(created 11/15/23) n. Provide meal/tray set up (5/10/21) o. Provide meal in room per resident preference (3/20/23) p. Provide supplement at meals (4/17/23) q. Family provided snacks in her room (3/20/23) r. Weight monthly or as registered dietician recommended (5/10/21) A Dietician Note in the paper chart, (without time documentation) and dated 2/7/24, documented a 2 pound weight loss in one month, 8 pounds since the last assessment, and 12 pounds in 6 months. The note documented the resident met and continued care plan goal related to maintaining weight. The weight loss was unplanned. A Communication with Physician (Progress Note) dated 2/7/24 at 1:52 PM indicated the facility communicated with the physician regarding weight loss and documented the resident was unable to understand the importance of nutrition. The Care Plan lacked additional interventions or intervention modifications. A Plan of Care Note dated 2/9/24 at 11:53 AM indicated the note was from 1/30/24 and lacked documentation regarding nutrition. A Order Note dated 2/9/24 at 4:43 PM indicated an order was received to change the supplement. The Care Plan lacked additional interventions or intervention modifications. On 4/1/24 at 12:18 PM observation revealed the resident guided from her room by staff to eat her meal in the dining area. Her shirt was loose on her torso and her pants appeared baggy. She remained at the table for the full meal. On 4/2/24 at 8:18 AM observation revealed a staff enter resident's room and ask if she wanted breakfast. The resident declined. At 9:01 AM staff provided her with a tray. Staff left her room immediately. With continued observation until 10:15 AM staff did not enter the room to assist or encourage the resident to eat or drink, per direction on the Care Plan for nursing staff. On 4/4/24 at 12:38 PM the Dietary Manager stated the resident's weight on 3/18/24 was incorrect due to issues with the scale and resident compliance requiring an updated weight. He reported the new weight for 4/2/24 as 112.8. Weight was reassessed as follows: a. 1 month - 109.4 on 3/5/24 to 112.8 on 4/2/24, up 3.11% b. 3 months - 114.6 on 1/1/24 to 112.8 on 4/2/24, down 1.57% c. 6 months - 126.6 on 10/4/23 to 112.8 on 4/2/24, weight down 10.9% 13 of the 18 nutrition care plan interventions were created during a prior admission. The Care Plan lacked triggers, behaviors, and/or resident specific interventions that addressed the resident's 10.9% weight loss over 6 months. On 4/3/24 at 2:43 PM Staff G, Certified Nurses Assistant (CNA) reported the resident's weight fluctuated, the family used to bring snacks but not as much now. On 4/3/24 at 2:48 PM Staff H, [NAME] Coordinator stated the resident had an irregular sleep pattern, some days she slept more during the day and was up at night. Staff H did not know what she ate then, but reported sometimes the kitchen premade sandwiches. On 4/4/24 at 1:06 PM Staff B, Licensed Practical Nurse, reported she was aware of the weight loss. She confirmed the increase in nutritional drinks and stated they tried finger foods. The resident did not have a meal routine and where she ate varied. 2. The Quarterly Minimum Data Set (MDS) assessment for Resident #42 dated 1/31/24 revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS) exam due to short term and long term memory problems, inattention, and disorganized thinking. The MDS documented the resident had the diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The resident's Care Plan, documented a focus area with initiated date 10/26/22 as follows; psychotropic drug use to include Sertraline, Trazadone, and Mirtazapine. The Care Plan Interventions included the following; a. monitor for side effects, provide distractions, and to administer medication as ordered. The Care Plan identified the following focus area dated 11/3/22; the potential to develop a psychosocial well-being problem related to dementia process, [NAME] admission, and worry. The Care Plan interventions dated 11/3/22 included the following; a. give the resident time to answer questions and verbalize feelings b. consult with pastoral care, social services, and psych services as needed c. encourage participation from resident who depends on others to make own decisions d. facilitate connections with friends e. provide opportunities to participate in care. A Progress Note dated 2/26/24 at 9:47 AM documented social services assisted with a referral to a behavioral health provider due to increased anxiety, restlessness, and fearfulness. The Care Plan lacked documentation of triggers, new diagnoses, and resident specific behaviors with associated interventions. A Progress Note titled Order Note dated 3/11/24 at 1:49 PM documented a Telehealth visit with social services and the [NAME] Coordinator present, with new order to increase Mirtazapine (medication for depression). A document titled Psychiatry Intake Note dated 3/11/24 from 8:00 AM - 9:00 AM documented a new diagnoses of generalized anxiety disorder and dementia, unspecified type, severe, with anxiety. Suggested interventions included encourage participation in activities that promote brain engagement and socialization, warm washcloths, and lavender essential oil for comfort. (These were not added to the resident's Care Plan or included in a progress note.) Resident #42's diagnosis report lacked documentation of resident's new mental health diagnoses as of 4/2/24 at 2:29 PM. The Medication Administration Record documented the resident started Risperidone 3/28/24. The associated diagnosis did not match the diagnosis in the Psychiatry Intake Note. The progress notes lacked documentation of this order. The resident's Care Plan lacked documentation of triggers, new diagnoses, and resident specific behaviors with associated interventions. An interview on 4/3/24 at 2:48 PM with the [NAME] Coordinator confirmed the resident participated in the Telehealth appointment. She stated the resident was very anxious, they worked on his medication, and they tried music, headphones, and 1:1 reading as interventions. On 4/4/24 at 1:06 PM Staff B, Licensed Practical Nurse (LPN) reported the Assistant Director of Nursing addressed their Care Plan updates. Staff B, LPN stated changes and updates for Care Plans were communicated at meetings, by email, or in person. On 4/4/24 at 11:44 AM the Director of Nursing stated that Care Plans were updated in up to 7 days.

Based on observation, record review, and interviews the facility failed to complete a baseline Care Plan within the first 48 hours of admission that addressed resident goals and services for 1 of 5 residents reviewed (Resident #48). The facility reported a census of 57. Findings include: The Quarterly Minimum Data Set (MDS) for Resident #48 dated 1/31/24 revealed a Brief Interview for Mental Status (BIMS) could not be administered due to short term and long-term memory problems, disorganized thinking, and inattention. The MDS included diagnoses of hypertension, non-Alzheimer's dementia, and depressive episode. The MDS documented that the resident's most recent admit was 6/27/23. A Care Plan printed 4/3/24 at 2:35 PM included the revision history and documented an admitted [DATE]. A focus area for advance directives was initiated 6/27/23. Focus areas which addressed dependence on staff, and impaired cognitive function and impaired thought process, were added 7/6/23. Focus areas for dehydration and altered nutrition were added 7/10/23. Additional focus areas covered incontinence and impaired skin integrity, falls, and self-care deficit and impaired mobility which were added 8/10/23. Progress notes failed to document development of the Plan of Care or that one was discussed with or offered/provided to the resident's power of attorney within 48 hours of admission. On 4/4/24 at 9:13 AM observation revealed facility paper charts for this resident's home were located in an office on the second floor. The resident resided on the 3rd floor. Resident #48's chart did not contain a baseline care plan. On 4/4/24 at 8:39 AM Staff D, Social Worker, indicated there were two Care Plan Coordinators, and each department provided them with information for completion. On 4/4/24 at 11:44 AM the Director of Nursing confirmed nursing was not responsible for care plans. The MDS Coordinator and ADON (Assistant Director of Nursing) both completed them with assistance from her as needed. On 4/4/24 at 1:06 PM Staff B, Licensed Practical Nurse stated she spoke to the ADON about care plans. She did not know why Resident #48's baseline Care Plan was not completed.

Based on interview, clinical record review, and facility policy review the facility failed to document an agreement and collaboration between the facility and hospice. The facility failed to document a plan to coordinate hospice care and ensure the Care Plan documents, a description of care and services provided by the hospice provider and the facility for two of two residents reviewed for Hospice (Resident #12, #107). The facility reported a census of 57 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident # 12 dated 3/20/2024 revealed the resident had moderately impaired cognitive skills for daily decision making. The MDS documented Resident #12 had diagnoses which include Parkinson's Disease and Progressive Neurological Conditions. The MDS lacked documentation regarding the resident was on Hospice Care. The Care Plan dated 6/12/2019 and revised on 3/20/24 failed to document Hospice Certification and Plan of Care for Resident #12. A Pharmacist Note dated 12/27/2023 at 9:22 a.m. documented Resident #12 is now enrolled in Hospice. 2. The Admission Minimum Data Set (MDS) assessment for Resident #107 dated 3/25/2024 revealed the resident had mildly impaired cognitive skills for daily decision making. The MDS documented Resident #107 had diagnoses which includes Medically Complex Conditions including Atrial Fibrillation or Other Dysrhythmias and Adult Failure to Thrive. The MDS documented the resident was on Hospice Care. Admission Summary 3/14/2024 at 3:23 p.m. documented as follows; Res brought via wheel chair to health center with assist. Stand by assist transfer to recliner which resident sleeps in, bedside commode. Does not use bed. Hospice Care, DNA, Do not hospitalize, comfort foods. No known allergies, alert and oriented times three, occasional hallucinates, hospice to provide comfort meds. Resident deemed nondesional, Durable Power of Attorney sister enacted. Strong urine odor, resident refused, blood pressure, labs or urinalysis. During an interview on 4/4/2024 at approximately 12:30 PM the facility Administrator was queried regarding a physician orders for residents. The Administrator advised it is her expectation that a medical order for hospice would be in the resident's file. When asked specially about orders for the two identified residents the Administrator advised with both of the identified residents the facility did not initiate hospice and therefore would not have anything to do with the doctor. If a resident's family initiates hospice or the resident is admitted on hospice I think it would be weird to insert ourselves. Upon request, the Administrator was able to obtain a copy of the Hospice Certification and Plan of Care from the hospice provider for resident #12 and resident #107. 4/4/2024 Upon request, Administrative staff provided Interdisciplinary Communication for both residents which they advised is only accessible by the DON and Social Worker. During an interview 4/4/2024 at 2:10 PM The facility Administrator and the Director of Nursing (DON), advised if there were new orders for medication, treatment or symptom management that would be documented. When queried both administrative staff members advised that information would be documented in the hospice notes entered by the agency hospice provider via Interdisciplinary Communication entered by the hospice worker. When further queried, the Administrator and the DON advised they believe the only facility staff to have access to the Interdisciplinary Communication is the DON and the facility Social Worker. The Facility Policy dated 2/26/2024 titled, Agreement For Hospice Care For Skilled Nursing Facility and Nursing Facility Residents documented, Article 1 Responsibilities of Hospice Section 1.2 (a) Hospice Provider will furnish Facility with a copy of the Hospice Provider Plan of Care after the Resident's admission to Hospice Provider and will identity the services to be furnished by Facility and the services to be provided by Hospice Provider.

Based on observations, record review and the facility failed to updated the Care Plan for 2 out of 5 residents reviewed (Resident #15 and #26). The facility reported a census of 52 residents. Findings Include: 1. The Minimum Data Set (MDS) Assessment for Resident #15 dated 7/28/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS further listed the Resident with a Brief Interview for Mental Status (BIMS) as a 5 indicating severely impaired cognition. The Care Plan for Resident # 15 dated 7/28/21, failed to identify the resident on a blood thinning medication and failed to direct staff to monitor for adverse effects of the medication. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 8/04/21 at 08:56 AM, Resident #15 walked independently with his walker on the South hall. 2. The Minimum Data Set (MDS) Assessment for Resident #26 dated 6/10/21, included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected the resident with short and long term memory problems and severe difficulty in daily decision making skills. The Care Plan for Resident #26 dated 3/2/21, identified the resident is at risk for alteration in psychosocial well being related to restriction on visitation due to Coronavirus Disease 2019 (COVID-19). The Care Plan directed staff to monitor for psychosocial changes, observe and report changes in mental status/mood due to situational stressors, provide increased opportunity for 1-1 staff interaction as needed, and provide opportunity for expression of feelings related to situational stressors The Behavior Note dated 5/17/2021 at 3:07 PM, read Resident #26 observed by male Certified Nurses Aid (CNA) holding a fork to his neck. CNA approached, Res stated I just want to die. CNA able to pull the Resident's hand away from neck. Res. Had 2 small areas noted where fork punctured skin and 2 small drops of blood noted. The note continued the Resident reported he felt sad that he is not with his family. The note documented the resident's wife also stated the resident historically walked several miles per day to release his emotions and he hasn't been able to walk to this extent since admission. Staff provided 1:1 until appointment the next day. The Care Plan Note dated 6/1/2021 at 1:47 PM, read the Resident continued on [MEDICATION(S)] (antidepressant) since admission. The Physician discontinued the [MEDICATION(S)] (antidepressant) after the incident and scheduled an appointment with Geriatric Psych. The note continued Resident #26's anxiety increased during evening hours, the resident's wife and children calmed the resident down. Behavior Note 6/27/2021 at 3:43 PM, read Resident # 26 is distressed through most of morning. The resident became very upset about word finding issues. Through conversation, Resident # 26 indicated he had not spoken to any family members in at least 5 days. The resident stated, If my life is going to be like this, I just want to kill myself. I used to be a physician and I know how it goes. I just can't do this. Another statement resident made was, Everyone (meaning staff) is running around taking care of a lot of people. I am not a bad person. I have never punched anyone. I don't know why everyone is mad at me. The note continued to reflect the resident yelled at Certified Nurses Aid (CNA) with stern eyes, She told you hello! The Physician's Telephone Order dated 7/3/21, directed [MEDICATION(S)] (antidepressant) 50 milligrams (mg) daily, and trazadone (antidepressant) 12.5 mg to 25 mg three times daily as needed for breakthrough anxiety. The order further read continue trazadone 25 mg nightly for sleep. The Care Plan revision dated 8/2/2, failed to address the resident use of an antidepressant medication and failed to address behaviors identified in the Progress Notes of suicidal thoughts. Observation on 8/04/21 at 12:40 PM, Resident #26 sat in the dining room at the table eating with another resident. Interview on 8/4/21 at 2:08 PM, Staff I, Restorative Aid, reported staff know how to take care for a resident by what is in the Care Plan. Staff I stated with Resident #26 they alert each other when he is up on the move for elopement risk. Staff I continued to state Resident #26 reported he had some dark thoughts we watch for. Interview on 8/09/21 at 3:03 PM, Staff G, Care Plan Coordinator, reported a medication is addressed on the Care Plan as an intervention, to provide medication per order. Staff G stated she expected the nurses to know what side effects to monitor for. Interview on 8/09/21 at 4:05 PM, Staff H Social Services, reported she puts a note in the progress notes, but Care Plan Coordinator is in charge of the Care Plan. Staff H stated she reaches out to family, and resident's, and puts a note in the chart, but doesn't do anything with the Care Plan. Interview on 8/09/21 at 4:09 PM, the Assistant Director of Nursing (ADON) confirmed the Care Plan should address a resident wanting to hurt them self. Interview on 8/10/21 at 11:15 AM, the Director of Nursing (DON) reported her execution is the nurses know, or look up the side effects of a medication in a drug book for what to monitor for. The DON revealed her expectation is all the staff who complete the Care Plan, update the Care Plan. Interview on 8/10/21 at 11:18 AM, the Administrator reported her expectation is the Care Plan addresses a resident's comments of self harm. The policy titled Comprehensive Care Plans dated 9/30/2020, directed at point # 5- the Comprehensive Care Plan will be reviewed and reviewed by the Interdisciplinary Team after comprehensive and Quarterly MDS Assessment. Point # 6- included Alternative intervention will be documented as needed.

Based on record review, observation, and staff interview the facility failed to ensure identified areas of skin impairment with unknown etiology were thoroughly investigated for 1 of 1 resident reviewed for injuries of unknown origin (Resident #23). The facility reported a census of 52 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 rarely to never understood, had severely impaired cognition, and had a short term and long term memory problem. The Progress Note dated 5/11/2021 at 8:45 AM documented, Skin/Wound Note: Certified Nursing Assistant (CNA) alerted this Nurse of skin tear to Left forearm (LFA); unknown etiology. Cleansed 4.5 linear skin tear to LFA with normal saline (NS) and covered with non-stick [MEDICATION(S)] et roll gauze. An Incident Report form was not received which addressed this injury. The Incident Report dated 6/20/21 at 12:15 AM revealed, Assisted resident into bed about 30 minutes later. At approximately 3:00 AM, the CNA notified nurse that the resident was bleeding from her shin. Resident still in bed but had her legs hanging off the side of the bed. Upon assessment the resident had an open wound on her right shin about 4 centimeters (cm) in diameter. Skin over the wound had completely come off, when looking around noticed the flap of skin sitting on resident's foot. It is unclear how the resident injured herself as she was still in bed and had not fallen out of bed. The corresponding Incident Note dated 6/20/21 at 6:42 AM did not provide additional information about Resident #23's right shin wound. The Progress Note dated 7/18/2021 at 3:03 PM documented, Skin/Wound Note: CNA alerted this Nurse of blood on the bed sheet with source noted to be an open triangular 1.5 cm x 3.0 cm skin tear to the upper right posterior thigh region; etiology unknown. Family notified, Medical Doctor faxed. This Progress Note had been authored by Staff B, Licensed Practical Nurse (LPN). An Incident Report form was not received from the facility which addressed this injury. Observation on 8/02/21 at 10:25 AM revealed Resident #23 was seated in a high back wheelchair. The resident stated, Did I have my dinner? In an interview on 8/04/21 at 11:16 AM, Staff B, LPN was queried as to the identity of the CNA who had alerted them of the resident's injury on 7/18/21. Staff B was not able to recall. Staff B explained if it was not determined how the event occurred then the etiology would be unknown. Staff B further explained they would notify the physician. When queried as to when they would notify the facility Administrator of an injury of unknown origin, Staff B explained the process would occur internally and would be completed in the computer somewhere. In an interview on 8/05/21 at 9:37 AM, Staff A, Registered Nurse (RN), was queried as to the process followed when an injury of unknown origin had been discovered. Staff A explained they would first assess the wound, determine if it was bleeding or not, and would assess the current condition. Staff A explained they would radio for help, tell others to bring supplies, obtain vitals, and would ask the resident if they were having any pain. Then after the resident was situated, they would get the resident back to their room, would complete a full skin assessment, would determine if there was any bleeding, and would further evaluate. The resident would be asked if they had any pain, dizziness, if they were light headed, and had nausea, and then if everything was ok the resident would be positioned where they would like to be in the resident room. Per Staff A they would document, would fill out an Incident Report and Health Status Note. They would evaluate if the resident hit their head, and if that was the case, then neurological evaluations would begin. Staff A explained this would be included in the Health Status Note. The physician would be faxed about the situation to see if there were any new orders, and the family notification would be completed. Per Staff A one of the Administrators would be notified of the new injury via call if they were present or via email if they were not present at the facility, if it was very severe they would be called at home and informed of the situation. On 8/05/21 at 11:39 AM, the Director of Nursing (DON) was queried as to the process nursing staff followed if a resident was found with an injury of unknown origin. The DON explained it would depend on the injury, the injury would be treated first, and the cause would try to be determined. When queried who staff should tell in this situation, the DON responded the information would be passed through report. The DON further explained they would be notified if someone had a fall or more of a major injury, and staff were not asked to notify every time there was a skin tear. The DON acknowledged if there was a brand new injury without a determined cause an Incident Report should be completed. Per the DON, staff would reach out to herself or the Assistant Director of Nursing (ADON). The DON was queried as to the location of additional information for injuries of unknown origin, and explained information would be in the Nurses Note or Incident Report. The DON explained the ADON reviewed the Incident Reports, and the DON reviewed the 24 hour reports and 72 hour reports. On 8/10/21 at 12:00 PM, the facility Administrator was queried regarding injuries of unknown origin, and explained staff would tell their nurse, the nurse would assess the injury and notify the nurse on call or the DON, and the nurse on call would notify the DON and she would call the Administrator. The Administrator acknowledged the nurse on call or the Director of Nursing should be notified with any injury of unknown origin. The Administrator acknowledged they could not speak specifically to the events, but staff may thought they had known where they had come from. A facility policy was requested pertaining to injuries of unknown origin. The DON returned and explained there was no specific policy for injury of unknown origin. Review of the facility's Abuse, Neglect and Exploitation policy dated 11/28/16 revealed the following definition of injuries of unknown source: an injury should be classified as an injury of unknown source when BOTH of the following conditions are met: the source of the injury was not observed by any person or the source of the injury could not be explained by the resident: AND the injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incidence of injuries over time.

Based on observation, record review and staff interviews, the facility failed to investigate root cause of residents falls, and implement targeted interventions to reduce reoccurrence of falls, for two of seven residents investigated for falls. (Resident #23 and #47). The facility reported a resident census of 52. Findings Include: 1. The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident#47 had diagnoses including [CONDITION(S)], anxiety disorder, cognitive communication deficit, dementia, and [CONDITION(S)] disorder. The MDS revealed the resident scored a 4 out 15 for Brief Interview for Mental Status, which is severely impaired skills with daily decision making. The MDS documented that the resident required limited assistance of one staff for transfers, walking, toilet use, and personal hygiene. The MDS documented that the resident had a history of two falls in the last three months without injury. Upon review of the Incident Reports for the time period 2/19/21 to 7/24/21 the resident had ten falls, all of which were located in her room. Four of the ten Incident Reports documented that the resident fell between 10:00 p.m. and 11:30 p.m. Five of the ten falls described the resident as being on the floor near the bed. The Care Plan included one intervention for the time period reviewed, with the initiated date of 6/8/21 that directed staff as follows; gait belt, walker and assist of two with transfers. The Care Plan and the Incident reports lacked targeted interventions to help prevent the reoccurrence of falls for the resident. Incident Note 6/17/21 with time of 2:15 p.m. documented that the resident had frequent safety checks in place. The Care Plan lacked this as an intervention. The Morse Fall Scales dated 1/12/21, 4/19/21, and 7/07/21 documented the score of 90. The Instructions documented as follows; Fall Risk is based upon fall risk factors and it is more than a total score. Determine fall risk factors and target interventions to reduce risks. Complete on admission, quarterly, at change of condition, and after a fall. On 8/02/21 at 10:26 a.m. the resident laid in bed with soft music playing, two small upper side rails had been up towards the head of the bed, and call light in reach of the resident. On 8/04/21 at 12:20 p.m. the resident asleep in her bed, two small upper side rails up on bed towards the head of the bed, and call light within reach of the resident. On 8/04/21 at 2:35 p.m. the resident asleep in her bed small bedrails up on bed towards the head of the bed, with bed in lower position. On 8/9/21 at 2:10 p.m., the Assistant Director of Nursing (ADON) reported that interventions that would help the resident are talking with people, but the resident does get angry when people are in her room at times, but does enjoy visits from a dog. On 8/09/21 at 3:03 p.m. Staff I, Restorative Aide reported that the resident had a low bed, and floor mats in place for fall prevention. Upon review of the Care Plan it lacked documentation of an intervention for a low bed, and floor mats. Review of the Care Plan interventions did not address all of the falls during the time period reviewed. The clinical record lacked a thorough resident centered investigation to assist in reducing the reoccurrence of falls for the resident. During an interview on 8/10/21 at 12:19 p.m., the Director of Nursing (DON) reported that she agreed that the Care plan team needs to work on communication as well as assessing the falls better, and working on interventions. The Comprehensive Care Plan Policy dated 9/30/20 directed staff to review and revise with the Interdisciplinary Team after each Comprehensive and Quarterly MDS Assessment, and alternative interventions will be documented as needed. 2. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 rarely to never understood, had severely impaired cognition, and had short term and long term memory problems. The MDS also revealed Resident #23 required the extensive assistance of two plus persons physical assist for bed mobility, required limited assistance of one person physical assist for transfers, had two or more falls since admission or prior assessment with no injury, and had two or more falls since admission or prior assessment with injury (except major). A MORSE FALL SCALE Quarterly assessment dated [DATE] identified Resident #23 at high risk for falling and scored an 80.0 on the assessment. It was noted a high risk score was categorized as 45 or higher. Review of thirteen Incident Reports for Resident #23 documented thirteen falls between 3/2/21 and 7/26/21. Incident reports documented eleven unwitnessed incidents and two witnessed incidents for the time period. Six incidents had occurred in the South Hall per the reports, and seven incidents had occurred in the resident's room. Dates of the incidents were as follows: 3/2/21 (two incidents), 3/23/21, 4/30/21, 5/6/21, 5/7/21, 6/7/21, 6/12/21 (two incidents), 6/16/21, 6/20/21, 7/12/21, and 7/26/21. The Care Plan for Resident #23 dated 4/16/19 revealed the following: a. Resident has potential For Falls, Poor Balance. b. Altered Comfort. c. Altered Sleep. The Care Plan also included the following five interventions added in 2021: a. Gait belt assist x 1, no walker, use bed rail and arm rests of chair for transfers (initiated 2/24/21, revised 5/27/21), wheelchair to toilet, use grab bar, assist x 1. b. Assist x 1 for hygiene and clothing management (initiated 2/24/21, revised 5/27/21). c. Administer analgesics as ordered/needed. APAP (initiated 4/14/21, revised 4/19/21). d. Keep wheelchair next to bed with brakes locked (initiated 5/27/21). e. Provide elevated sided pressure relieving mattress (initiated 6/17/21). Review of the Care Plan interventions failed to address all of Resident #23's falls during the time period. The Incident Report dated 3/2/21 at 11:00 AM documented an unwitnessed event occurred in the resident room. The Incident Description documented: Hope Dining Room staff member alerted this Nurse that the resident scooting on floor at entrance of her room. Her wheelchair noted to be within reach and the resident stated, I'm hungry. The Incident Report dated 3/2/21 at 12:20 PM, revealed an unwitnessed event occurred in the South Hall. The Incident Description documented: Certified Nursing Assistant (CNA) alerted this Nurse that the resident was lying down on her left side at the foot of a nearby wheelchair. The Incident Report dated 3/23/21 at 10:00 AM, revealed an unwitnessed event occurred in the resident room. The Incident Description documented: resident noted to be awake and scooting outside of her room, stating she was hungry. The Incident Report dated 4/30/21 at 5:19 PM, revealed an unwitnessed event occurred in the South Hall. The Incident Description documented: Around 4:50 PM, CNAs heard a loud noise while in another resident's room. Came out by South Hall tables and noted the resident lying supine on the floor. They notified this nurse immediately. Blood noted to be pooling from a wound to the back of the resident's head. The Incident Report dated 5/6/21 at 5:18 PM, documented an unwitnessed event occurred in the resident's room. The Incident Description documented: Around 4:50 PM, a CNA reported that the resident was on the floor/mat beside her bed. The nurse arrived to note the resident lying supine with her head up between the side table and bed, while the rest of her body was on the mat beside the bed. The Incident Report dated 5/7/21 at 1:15 PM, documented an unwitnessed event occurred in the resident's room. The Incident Description documented: Resident seen on the mat on the floor next to her bed by CNA. Called the nurse. The Incident Report dated 6/7/21 at 6:58 AM, revealed an unwitnessed event occurred in the South Hall. The Incident Description documented: Staff walked past resident's room and seen that she was out of bed and staff assisted resident back into bed. The Incident Report dated 6/12/21 at 2:56 AM, documented an unwitnessed event took place in the resident room. The Incident Description documented: Nurse was performing rounds after getting report, was checking on resident when seen her bed was empty, the nurse walked into the resident's room and noted the resident sitting on floor. Staff assisted resident into a wheelchair and brought her out to the commons area. A Behavior Note dated 6/12/21 at 8:50 AM, documented: Resident awake and active this a.m. attempting to get in and out of bed, in and out of her wheelchair. 1:1 provided as much as possible. Resident noted spitting, hitting, kicking nursing. staff with cares and medication pass. The Incident Report dated 6/12/21 at 9:45 AM, documented a witnessed fall in the South Hall. The Incident Description documented: Nurse caught the resident while she self-transferred out of her wheelchair in the South Common Area; called for help. The resident noted restless and stated wanting to go home. The Behavior Note dated 6/15/21 at 11:26 PM, documented: Resident noted to have increased agitation and restlessness. Frequently attempting to get out of bed or her wheelchair when up. She ate some food and took her medications, but was notably combative with staff (attempting to hit, kick, bite, etc.). After getting some rest the resident's combativeness decreased somewhat, but she remained combative when staff would attempt to prevent her from standing/self-transferring from her wheelchair. Resident is currently sitting up in her wheelchair quietly near south hall tables. The Incident Note dated 6/16/21 at 2:15 AM, documented: Resident in reclaim chair sleeping, when nurse heard the resident call for help. Nurse turned head and saw resident lying on the floor in the South Hall. Nurse went to help resident and saw resident head and hair had blood. Nurse called nurse on North Hall for help. The Incident Report dated 6/16/21 at 2:15 AM, documented a witnessed fall in the South Hall. The Incident Description documented: At around 2:15 AM, call from South Hall Nurse needing help cause resident had fallen out of her chair and hit her head on the floor. North Nurse went over to South and saw resident sitting up on floor with blood smears on the floor from back of resident's head. Assessed back of resident's head and what appeared to be a laceration that would potentially require sutures or staples. South nurse and South CNA stayed with resident and held pressure to back of head. The Incident Report dated 6/20/21 at 12:15 AM, documented an unwitnessed event in the South Hall. The Incident Description documented: CNA called nurse to South Hall tables for assistance. Upon returning the resident laying on the floor next to table with wheelchair beside her. The resident had a small laceration to the left side of her forehead approximately 2 cm in length with some discoloration surrounding it. The laceration bleeding and bled back into resident's hair. No other injuries noted, assisted the resident back into the wheelchair with CNA assist. Resident required constant 1:1 attention throughout the shift. The Incident Report dated 7/12/21 at 2:20 PM, documented an unwitnessed event in the resident room. The Incident Description documented: Nurse summoned to room and the resident noted to be scooting on the floor off bedside floormat. With 2 assist and use of soft gait belt returned resident to safety of her wheelchair, then brought out into South Common Area to monitor. The Health Status Note dated 7/26/21 at 3:25 PM, documented: Afebrile and somewhat restless at times, but for most part, the resident rested in her wheelchair and recliner this shift out in the South Common Area to provide 1:1/ close monitoring. Housekeeper noted resident sitting on wheelchair pedals. The Incident Report dated 7/26/21 at 3:26 PM, revealed an unwitnessed event in the resident room. The Incident Description documented: Housekeeper noted there resident sitting on the wheelchair pedals. Assist of two staff with use of soft gait belt back into safety of wheelchair and no injuries observed. Observation on 8/02/21 at 10:25 AM, revealed Resident #23 was seated in a high back wheelchair. Resident #23 stated, Did I have my dinner? On 8/04/21 at 1:13 PM, Staff C, Certified Nursing Assistant (CNA), was queried in regard to Resident #23, and explained the resident moved a lot up and down in the bed and the wheelchair. Staff C explained they tried to keep someone with the resident at all times. Per Staff C the resident was not able to use the call light and had days and nights mixed up. Staff C explained everyone assisted as staff were busy, and nurses and Recreation Aides assisted with as much time as they could. On 8/04/21 at 1:31 PM, Staff D, CNA, was queried in regard to Resident #23. Staff D explained the resident could understand the staff if they were within six inches of her ear. Staff D was queried whether the resident liked to get up and down, and responded that she had witnessed this approximately twenty minutes ago. Staff D further explained the resident would stand up to reach for anything if it was on the table within reaching distance. On 8/04/21 at 4:41 PM, Staff E, Registered Nurse (RN), was queried in regard to Resident #23 and explained, in part, the resident was very frequently confused and often restless which could lead to Resident #23 being combative at times. Staff E explained Resident #23 may be calmed down by going for walks around the unit and often when the resident's children came it calmed the resident. On 8/09/21 at 2:10 PM, the facility's Assistant Director of Nursing (ADON) was queried as to how they became aware of falls, and responded this was communicated via email or when they read report. The ADON explained they read report every day and reviewed resident Progress Notes. Next, the ADON would make sure the Incident Report was filled out completely, and would also follow to see if there were any injuries or skin issues. The Incident Report would usually be closed out, and nurses would usually get ahold of the doctor if there were any skin issues. After that, skin would be followed weekly and the ADON further explained there should be charting daily if there was a treatment. The treatment would be completed until the area was healed. The ADON was queried as to interventions implemented post fall to prevent reoccurrences, acknowledged staff were involved in the process, and further explained this would be reviewed every 90 days with the Care Plan review or if there was another issue or something which required follow up. The ADON was queried as to next step followed if the intervention was not working, explained the intervention would be changed, and communication would occur with the doctor to obtain their thoughts. The ADON was queried as to whether they looked for patterns with falls, and acknowledged they were always looking for patterns. On 8/09/21 at 2:23 PM, the facility's ADON was further queried about participation in the Falls Meeting, explained they were not in on the Fall Meeting, and further explained usually it was someone else and two Restorative Aides. The ADON explained they were not the person that did all the fall interventions, and identified the individual responsible as Staff G (Care Plan Coordinator). The ADON identified Staff G as responsible for fall interventions and identifying trends. Per the ADON if a new intervention was implemented the ADON would add it to the plan of care, otherwise a discussion would occur. The ADON explained interventions attempted before a fall would usually be documented, and usually in the Nurses Notes it would be documented what had been tried or what interventions were attempted prior to administering medication. The ADON was queried about interventions for Resident #23, and explained one to one supervision with someone walking and/or sitting with the resident had been effective. The ADON further explained there were Recreation Aides that would walk with the resident, sit with her, and whoever had time would assist. The ADON acknowledged with one to one supervision for Resident #23 the resident would still display behaviors, however the resident was less likely to fall out of the chair. On 8/09/21 at 2:50 PM, Staff G, Care Plan Coordinator was queried about their involvement in the falls process. Staff G explained they completed care plans for skilled residents. Per Staff G, the ADON would go through the incident reports every month as they occurred, and when the ADON saw that a resident had fallen then they would review the incident report. Staff G explained they (Staff G) would review the fall incident reports at the end of the month, and a discussion would occur with restorative staff to try to brainstorm interventions. Staff G explained they would look to see what the nurses and the ADON had already put in place, and stated that for some people no matter what you do it did not seem to help much. Staff G was queried if each fall would have a new intervention on the plan of care, and acknowledged that it would depend. Staff G acknowledged sometimes it got to the point where there was nothing else that could be thought of to do. Staff G explained the ADON would probably put new information on the plan of care, unless if was an intervention implemented by Staff G and Restorative Aides. If the intervention had been implemented by Staff G and the Restorative Aides, then Staff G acknowledged she would probably put it on the plan of care. Staff G was queried regarding Resident #23's falls, and the staff member explained most falls were related to the resident crawling out of bed. When queried about trends in the resident's falls, Staff G explained as the resident's cognition got worse, the resident got very very restless. Staff G further explained Resident #23 would want to go to bed, the resident would be assisted to lay down, and it would not be two minutes until the resident wanted to get up. Per Staff G Resident #23 required a lot of one to one (supervision) as the resident progressed with the disease process. On 8/09/21 at 3:03 PM, Staff I, Restorative Aide was queried in regard to fall meetings, and acknowledged the frequency of the meeting was once per month. Staff I explained themselves, the ADON, Staff G, Staff J, Restorative Aide, and sometimes the DON would go through all falls that had happened in the last quarter and they would brainstorm interventions. Staff I was queried if an intervention would be implemented for each fall, and responded They sure try. I would say yes. Staff I was queried about Resident #23's falls, and explained when the resident was on the floor it was considered a fall. Staff I explained the resident would slide, and when the resident was assisted to bed and she did not want to be there the resident would squirm right out of the bed to the hall. Per Staff I the resident was checked more frequently than a lot of other people. Staff I further queried as to which interventions were particularly effective in preventing additional falls for the resident, and explained they could not honestly say other than putting the resident's bed on the floor. The facility policy titled Accidents and Incidents-Investigating and Reporting last revised 1/14/21 documented: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Director of Health Services and the Administrator. The policy further explained, the Nurse Supervisor/Charge Nurse and/or the Department Director or Supervisor shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident form for visitors, employees, venders, etc For residents document the following in Power chart on the Post Fall Assessment: a. The date and time the accident or incident took place. b. The nature of the injury/illness (e.g., fall, incidents of injury etc.). c. The circumstances surrounding the accident or incident. d. Where the accident or incident took place. e. The name(s) of witnesses and their accounts of the accident or incident. f. The injured person's account of the accident or incident. g. The time the injured person's Attending Physician was notified. h. The date/time the injured person's family was notified and by whom. i. The condition of the injured person, including his/her vial signs. j. The disposition of the injured (i.e., transferred to hospital, put to bed, sent home, returned to work, etc.). k. Any corrective action taken. l. Follow-up information. m. Other pertinent data as necessary or required. n. The signature and title of the person completing the report.

Based on observation, facility policy review and staff interview, facility failed to serve food under sanitary conditions in order to reduce the risk of food-borne illness during two of two meals observed. The facility census was 43 residents. Findings include: 1. Observation on 5/29/18 at 11:58 a.m., revealed Staff A, cook, assigned to serve the noon meal, that included preparing items to order. Staff A washed his hands and donned a glove on the left hand, but touched multiple surfaces including meal tickets, serving utensils, skillet handle, tomato container lid, counter surfaces and used the gloved hand to take a tomato slice out of the container and unwrapped a package of cheese to remove a cheese slice. Staff A discarded the glove but failed to wash his hands after removing the glove and donning another glove. Staff A used the gloved hand to take 2 slices of bread from the package and prepare a ham salad sandwich and took pickle slices out of the container with the gloved hand. Staff A discarded the glove but failed to wash his hands after removing it and prior to donning a new glove. Staff A used the gloved hand to take a cheese slice from a package of cheese and a raw hamburger patty from a container. He used the gloved hand to put the lid back on the container and then discarded the glove, but failed to wash his hands prior to donning another glove. Staff A used the gloved hand to take a hamburger bun out of a package and placed it cut side down on the grill. Staff A used the gloved hand to place leaf lettuce, tomato slices and pickles on 2 plates and took a cheese slice, from a package of cheese, for a grilled cheese sandwich. He removed the glove, but failed to wash his hands prior to donning a new glove, and used the gloved hand to position the bun, from the grill, on a plate, place cheese on the hamburger and place the top bun. 2. Observation during the breakfast service on 5/30/18 at 7:30 a.m., revealed Staff A assigned to serve the resident's breakfast meal, that included preparing items to order. During observation Staff A placed bread in the toaster twice with bare hand. Staff A donned a glove 5 times, during the observation period and failed to wash his hands prior to donning and removing each glove. Staff A touched a variety of surfaces including menu tickets, counter tops, utensil handles, pan handles, phone receiver, freezer door handle, box of english muffins and lids to some cold table items. During the observation period, Staff A handled ready-to-eat food with gloved hands including 4 slices of toast, 1 english muffin, 5 slices of cooked bacon, 1 cheese slice and held a pancake and sausage to cut up. Observation at 8:20 a.m., revealed Staff B, dietary aide washed her hands and donned gloves and proceeded to work with chopped lettuce. Staff B placed a large container of lettuce on the counter and began removing lids from multiple individual bowls of lettuce and emptied them into a large container. Staff B continued with the gloved hands and obtained another container and filled it with lettuce, using the gloved hands to guide lettuce into the container. She also used her gloved hands to pat dry diced tomatoes and green peppers with a paper towel and picked up the tomatoes and peppers with the gloved hands and put on top of the container of lettuce. In addition to touching the various containers/lids, she touched the counter surface and uniform pants with the gloved hands as she was handling the lettuce and salad ingredients. During an interview on 5/30/18, at 3:40 p.m., the Director of Dining Services and Registered Dietitian, reported dietary staff are trained on appropriate glove use upon hire and annually. The Director of Dining Services explained all dining service staff are assigned an on-line training module titled Safe Food Handling upon hire and annually which covers a variety of topics, including handwashing and proper glove use, this is also covered in an annual skills fair. He reported staff are trained how to remove glove correctly, wash their hands prior to donning and after removing gloves and use for a single task only. The Director of Dining Services and Registered Dietitian acknowledged staff should not touch multiple surfaces and then touch ready to eat food. Review of a facility policy titled Handwashing and Glove Usage Guidelines-Dining Employees, reviewed 2/1/2017, identified handwashing and glove usage is necessary to prevent the spread of bacteria that may cause foodborne illnesses and directed dietary employees to wash hands before and after using gloves and to change gloves after an interruption in the task occurs (such as taking a phone call) and after handling raw meat. The 2013 Food Code, published by the Food and Drug Administration and considered a standard of practice for the food service industry requires single-use gloves be used for only one task, such as working with ready-to-eat food and used for no other purpose and discarded when damaged or soiled or when interruptions occur in the operation and food employees must wash their hands before donning gloves to initiate a task that involves working with food.

Based on observation, interviews and record review, the facility failed to serve 3 out of 3 residents the pureed diet according to the menu. The facility reported a census of 51 residents. Findings included: The noon meal menu for 3/14/17, directed staff to serve residents on General Puree diets a #6 scoop of the smoked beef brisket. The General diet menu for 3/14/17, directed staff to serve 3 ounces of smoked beef brisket. During an interview on 3/14/17 at 10:51 a.m., Staff A, Cook, reported adding 12, 3-ounce servings of the smoked beef brisket to the blender. One pureed serving for the Assisted Living, 3 serving for the Oaknoll Health Center and 8 ground for the Oaknoll Health Center. Staff A reported guesstimating serving sizes with using the tips and ends. During an observation on 3/14/17 at 10:51 a.m., Staff A ground the meat. Staff A scooped out 8 servings with a green # 12 scoop leaving 4 servings in the blender. During an observation on 3/14/17 at 10:53 a.m., Staff A added an unmeasured amount of broth/gravy to the blender and blended to a pureed consistency. Staff A proceeded to scoop 3 scoops with a #10 scoop size, into the steam table pan for the 3 residents with a pureed diet. Staff A failed to measure the end volume after pureeing. During an interview on 3/14/17 at 10:59 a.m., Staff A reported not using the correct scoop size to dish up the 3 servings from the blender into the serving pan. Staff A stated needing to use a #12 scoop at meal time. Staff A continued to report the Dietitian's directions for what scoop sizes to use from the with meal services is taped to the refrigerator by the serving table. During an observation on 3/14/17 at 11:00 a.m., after Staff A removed the 3 #10 scoops for the pureed resident's diet at the Health Center Staff A removed 1 more serving for the Assisted Living resident. The blender contained an addition 1.5 cups of pureed meat. Staff A directed to the Dining Service Director to throw away. During an interview on 3/14/17 at 11:02 a.m., the Dining Service Director voiced no concern with the puree process. It is completed like the Dietitian directed. During an observation on 3/14/16 between 11:48- 12:15 p.m., Staff A served 3 #12 scoops of the pureed beef brisket. At 12:23 p.m. Staff A measured out 1/3 of a #12 scoop left over in the pan. The paper taped to the side of the refrigerator untitled and undated directed: Pureed plain meat and fish-#12 dipper Pureed potato/pasta/rice-#10 dipper Pureed vegetable-#10 dipper Ground plain meat and fish #12 dipper Regular potato/pasta/rice #8 dipper 1/2 portion potato/pasta/rice #16 dipper Regular vegetable-#10 dipper. During an interview on 3/14/17 at 3:16 p.m., the Dietitian reported coming up with the scoop sizes to use by pureeing chicken, beef and pork several times and deciding a #12 scoop generally is the correct portion for meat and doing the same to come up with the needed scoop sizing for vegetables, fruit, deserts. The Dietitian reported knowledge of the Simplified diet, but this works. During an interview on 3/16/17 at 8:38 a.m., the Dining Service Director looked at the menu for 3/14/17 and indicated a lack of understanding the directions to serve a #6 scoop the pureed smoked beef when the Dietitian's directions sheet reads Pureed plain meat and fish-#12 dipper. The Dietitian provided the undated Process used to determine dipper (scoop) sizes for pureed foods: In order to standardize the dipper sizes for plain meats, fish, vegetables and starches, I went through the puree process of counting the number of portion pureed, adding small increments of liquid until the desired consistency was archived. I made the determined the correct dipper that would give me the number of servings that I started with. I did this 5-6 times with all food groups until it was consistent the dipper size. If the amount was between two dipper sizes then I went with the larger ounce dipper (smaller dipper #) The facility provided the Simplified Diet Manual Twelfth edition, which directed on page 51 the method for determine the portion sizes of consistency altered foods that included the following: 1. Measure out desired number of servings into container for pureeing. Puree the food. Add any necessary thickener or liquid to obtain desired consistency. 2. Measure the volume of the food after it has been pureed. 3. Divide the total volume of the food by the original number of portions. This is the new portion size.

Based on observation and staff interview, the facility failed to maintain a clean and sanitary food preparation area. The facility census was 47 residents. Findings include: 1. During initial dietary tour on 3/8/16 at 9:00 a.m., observation revealed Staff A, cook was cooking breakfast. Observation revealed two vents and two panel lights directly above the food preparation area had a darkened black substance and visible dust. 2. During lunch observation on 3/8/16 at 11:00 a.m., Staff A, cook was obtaining the temperature of resident food items to be served during the lunch meal. Observation revealed the two vents and two panel lights directly above the food preparation area in the kitchen continued to have a darkened black substance and visible dust. During interview on 3/8/16 at 12:10 p.m., the Food Service Director acknowledged the vents over the cooking surface could be cleaned. During interview on 3/8/16 at 12:20 p.m., the dietician acknowledged the vents and lights over the food preparation area needed cleaned.

Based on observation, alarm response time report review, resident and staff interviews, the facility failed to answer resident call lights in a timely manner in order to meet four of six resident needs. The facility census was 46 residents. Findings include: 1. During group interview conducted on 5/17/15 at 2:00 p.m., four of six residents reported concerns regarding staff's response in responding to call lights timely. One resident reported waiting up to 30 minutes and another resident reported waiting 20 minutes for staff to respond. Residents reported the longest wait times occurred during meal times, in the morning when wanting to get up and in evening when wanting to go to bed. One resident reported staff told the resident to only pull the call light cord one time and they would assist the resident when they could. Resident Council Minutes dated 3/16/15 and 4/21/15, documented resident's expressed several comments regarding call light response time and had to wait awhile for call lights to be answered. Review of the Alarm Response Time Report dated 5/15 to 5/17/2015, revealed the following: On 5/15/15, twelve episodes occurred in which the duration was between 16 to 45 minutes for call light response. Three episodes occurred during 6 a.m. -2 p.m. shift Seven episodes occurred during 2 p.m. - 10 p.m. shift Two episodes occurred during 10 p.m. - 6 a.m. shift On 5/16/15, five episodes occurred in which the duration was between 16 to 30 minutes for call light response. Two episodes occurred during 6 a.m. - 2 p.m. shift, One episode occurred during 2 p.m.-10 p.m. shift Two episodes occurred during 10 p.m. - 6 a.m. shift On 5/17/15, three episodes occurred in which the duration was between 18 to 19 minutes for call light response. One episode occurred during 6 a.m. - 2 p.m. shift Two episodes occurred during 2 p.m. - 10 p.m. shift During interview on 5/20/15 at 7:58 a.m., the minimum data set, MDS Coordinator reported the call light report included residents on the North and South hallway. During interview on 5/20/15 at 11:45 a.m., the Health Coordinator reported call lights are expected to be answered within 10 minutes. On 5/20/15 at 12:20 p.m., the health coordinator reviewed the nursing communication cards for each resident who resided in the North and South Hallway. During the month of May, only 1 call light had to be changed out due to malfunction (room [ROOM NUMBER]-Bed 2). The health coordinator reported when a call light had been activated, a page goes out to the certified nurse aide assigned to the resident, after 3 minutes, a page goes out to the hall team and after 7 minutes, a page goes out to the entire team in the North and South hall.

Based on observation, dietary menu review and staff interview, the facility failed to ensure hot food remained at or above 135 degree Fahrenheit (F), failed to ensure resident food items were properly labeled, failed to ensure kitchen equipment was properly sanitized before use. The facility census was 46 residents. Findings include: 1. During observation on 5/18/15 at 10:57 a.m., Staff H, dietary staff placed three sugar cookies into a metal container and poured whole milk into the container. Staff H used a Waring hand blender and blended the cookie and milk contents together. Staff H removed the hand blender from the metal container and placed the blender in the sink. Observation revealed the blade and blade guard of the hand blender touched the bottom of the sink. Staff H added food thickener to the metal container and took the hand blender from the sink and placed it into the metal container and blended the contents together. After checking the consistency of the pureed sugar cookie, Staff H used water to rinse off the blender and stood the blender on the counter. During interview on 5/19/15 at 9:45 a.m., the Dietary Manager stated the sink by the coffee and juice dispenser was used by staff to obtain water or wash utensils off, but was not used as a handwashing sink. The Dietary Manager stated when staff used the hand blender it would be expected for staff to use another container to place blender in if staff had to sit the mixer down during food preparation. 2. Dietary menu review revealed the Monday lunch menu included: a. Quiche- 1 serving b. Alternate meat entrée - 6 ounce c. Carrot raisin salad or Cinnamon applesauce - 1 serving d. Fruit plate (cantaloupe, honeydew, and pineapple) - 1 serving e. Assorted cookie - 1 serving During observation 5/18/15 at 10:47 a.m., Staff F, Dietary Cook, prepared pureed quiche and fruit. At 11:33 a.m., observation revealed Staff F check the temperature of the pureed quiche to be 195 degrees Fahrenheit (F) prior to beginning food service. At 12:35 p.m., after the last plate was served, Staff F checked temperatures of the pureed Quiche to be 126.3 degrees F. During interview on 5/20/15 at 11:20 a.m., the dietary manager reported food temperatures were expected to be between 135-140 degrees F. when hot foods were served. 3. During tour on 5/17/15 at 10:25 a.m., the Hope Dining Room had two containers of Hormel Magic cup desserts with a Use by date 11/25/15 but no thaw date listed on the container. Observation of the fourth floor kitchen revealed one 10 pound (lb) bag R & F pasta and one 10 lb. bag tricolor Barilla pasta packages open, but no open date indicated on package. One box of onions and one box of yams in a box on the floor. Observation revealed no lid on the bulk container of brown rice and a white scoop lying in a bulk container of corn meal. Observation revealed four unwrapped, frozen hamburger patties on the top shelf. On 5/19/15 at 8:05 a.m., the North Hall kitchenette refrigerator contained seven 8 ounce cartons of Hormel mighty shakes with a use by date 5/7/16 , and 2 magic cups with use by date 11/25/15 but did not have a thaw date listed on the cartons. During interview on 5/18/15 at 8:58 a.m., the Dietary Manager reported mighty shakes and magic cups were removed from freezer and placed in refrigerator to thaw. They go by the use by date on carton, but do not date cartons when taken from the freezer to thaw. On the unit, when staff obtain a mighty shake or magic cup, staff are expected to write a date when the carton is opened. On 5/18/15 at 1:25 p.m., the Dietary Manager agreed bulk food needed to be covered and scoops should not to be stored inside canisters or containers. The Hormel Health Labs spreadsheet revised on 2/21/2006, revealed the shelf life of mighty shakes is 1 year when kept frozen and 14 days when product thawed or refrigerated; The shelf life of magic cups is 1 year when kept frozen and only 5 days when product thawed or refrigerated.

Based on observation and clinical record review, the facility failed to ensure two of two resident observed during personal cares received complete peri care. (Resident #5 & #6) The facility census was 46 residents. Findings include: 1. The Medication Administration Record [REDACTED]. The minimum data set (MDS) assessment dated [DATE], documented the resident as incontinent of bowel and bladder and required extensive assistance with personal hygiene needs. The plan of care dated 4/28/15, documented a problem with urinary incontinence with interventions that included promote hydration, proper cleansing, check and change routinely, toilet as needed, support skin care and assist with incontinence cares. Observation on 5/18/15 at 7:45 a.m., revealed Staff A, certified nurse aide, CNA provided incontinent care to the residents Observation revealed Staff A cleansed the residents left and right groin area and perineal area. With the resident turned to their right side Staff A cleansed the residents right and left inner aspects of the buttocks and rectum. Staff A failed to cleanse the residents left outer buttock or left hip of urine residue and the residents right buttock and right hip before application of a new undergarment. 2. The MDS assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident as incontinent of bowel and bladder and dependent on staff for the personal hygiene needs. The plan of care dated 2/27/15, documented a problem of altered elimination of bowel and bladder with approaches that included provide check and change program before and after meals, at hour of sleep and as needed, change incontinent pads and peri care with each incontinence. Observation on 5/18/15 at 10:00 a.m., revealed Staff B, CNA and Staff C, CNA provided incontinency care for the resident. Observation revealed Staff B cleansed the residents left and right groin area and peri area. With the resident positioned on their left side Staff B, cleansed the residents left and right inner buttocks. Staff failed to cleanse the residents right buttock, right hip, left buttock and left hip prior to placing a new brief in place.

Based on observation, clinical record review and facility policy review, the facility failed to complete catheter care after an incontinent episode for one of one residents that had a Foley catheter in place. (Resident #2) The facility census was 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #2 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance with bed mobility and toilet use. The care plan included a problem of self care deficit related to stroke and [MEDICAL CONDITION] (paralysis on one side of body). The problem included an intervention for catheter care twice a day and as needed to be completed by the certified nurse aide, CNA. During observation of morning cares on 5/18/2015 at 7:20 a.m., Staff D, CNA and Staff E, CNA, removed the resident's incontinence brief . Staff D cleansed the resident's groin front to back on both sides using disposable wipes. Staff D cleansed across the front of the residents groin and penis using a disposable wipe. A Foley catheter observed draining yellow urine. Staff D and Staff E rolled the resident to left side as Staff D cleansed the resident's bottom between the buttocks using disposable wipes. Staff failed to perform Foley catheter care. A facility policy titled Urinary Catheter Care, revised September 2005, revealed if a resident had a catheter, the meatus should be washed first, then the glans using circular [MEDICAL CONDITION] from meatus outward, changing the position of the washcloth with each cleansing stroke. The area then rinsed with warm water. The catheter should be cleansed from the insertion site to approximately four inches outward.

Based on observation, clinical record review, facility policy review and staff interview, the facility failed to demonstrate complete incontinency care for 2 of 4 of residents observed during personal cares. (Resident #5 & #6) The facility census was 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #5 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident as dependent for bed mobility and toilet use and was incontinent of bowel and bladder. During observation on 3/25/14 at 9:43 a.m., Staff B, certified nurse aide, CNA and Staff C, CNA assisted the resident after an incontinence episode. Staff B cleansed the resident's front groin folds and genital area, rolled the resident to the left and cleansed the residents rectal area. Staff B placed a depend under the resident and rolled the resident to the right to wrap the depend around the resident. Staff B failed to cleanse the resident's outer hips and the right buttock that had contact with urine residue. 2. The MDS assessment dated [DATE], documented Resident #6 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident required extensive assistance with bed mobility and toilet use and was incontinent of urine and bowel. During observation on 3/26/14 at 4:45 p.m., Staff A, CNA assisted the resident to the toilet. Staff A stated the resident was incontinent of urine and had a bowel movement in the toilet. Staff A assisted the resident to stand and wiped the residents buttocks with disposable wipes two times. Staff A did not cleanse the resident's front groin folds or genital area that had come into contact with urine residue. The Incontinent/Perineal policy revised November 2005 instructed staff to cleanse the perineum moving inside outward to include the thighs, alternating side to side, and using downward [MEDICAL CONDITION]. Wash the rectal area thoroughly wiping from the base of the genitals and extending over the buttocks.

Based on observation, clinical record review, facility policy review, staff and resident interviews, the facility failed to provide privacy during a procedure for 1 of 7 residents observed (Resident #1). The facility census was 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], identified Resident #1 had [DIAGNOSES REDACTED]. The MDS documented the resident required extensive assistance with bed mobility, transfers, toilet use and personal hygiene and required intermittent catheterization. The MDS documented the resident had memory problems with modified independence with decision making abilities regarding tasks of daily life. During initial tour of the facility Staff F, registered nurse, RN stated the resident had intact cognition and was interviewable but needed time to answer questions due to [MEDICAL CONDITION]. During observation on 3/25/12 at 2:22 p.m. the surveyor asked permission to observe the nurse demonstrate the catheterization procedure. The resident gave permission and had full knowledge the surveyor observed the procedure. Staff D, RN donned clean gloves and placed a towel between the resident's legs under the genitals. After prepping the the genitals and inserting the catheter and allowing the urine to flow into the urinal, the resident attempted to place his/her hands over the genital region to cover the area. Staff D told the resident to keep their hands off the region. At 2:30 p.m., the resident remained exposed and the urine continued to drain into the urinal. At 2:37 p.m., the resident's spouse opened the door to the hallway while the resident continued to be exposed. People stood outside in the hallway. At 2:40 p.m., Staff D put a depends brief and pants on to the residents knee area, placed a gait around the residents waist and assisted the resident to sit on the side of the bed. Observation revealed the resident pulled their shirt down in an attempt to cover their penis. Staff D put on the residents shoes and raised the bed before standing the resident up and then pulled the brief and pants up covering the residents genital area. The resident was exposed from 2:22 p.m. until 2:40 p.m. During interview on 3/25/14 at 2:45 p.m., the resident stated he/she was embarrassed because there was a stranger in the room and would have liked to be covered up. The resident stated the nurse usually kept him/her uncovered during the procedure but understood because it was a sterile procedure. The Intermittent Catheterization Policy revised September 2005 instructed the staff to fold the covers down to the foot of the bed. Place a sheet across the resident's chest. Avoid unnecessary exposure of the resident's body during the procedure.

Based on clinical record review, facility policy review and staff interview, the facility failed to complete ongoing skin assessment as policy directed for one resident reviewed with a pressure area (Resident #4). The facility census was 46 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE], documented Resident #4 had [DIAGNOSES REDACTED]. The MDS assessment documented the resident as fully dependent on staff for bed mobility, transfers, personal hygiene and toilet use. The MDS documented the resident as at risk for developing pressure ulcers. The Braden Scale for predicting pressure sore risk dated 1/29/14, documented a score of 12 indicating the resident as at high risk of developing pressure ulcers. The care plan dated 2/6/14, listed a potential for impaired skin integrity with interventions to provide a bariatric bed with an air mattress, padding on elbows and feet, monitor and report skin impairment and to encourage to lie down or reposition in the wheelchair. Nurse notes dated 9/18/13, documented an open area on the residents gluteal cleft that measured 1.5 by 2.5 centimeters (cm). No further assessment was documented. Nurse notes dated 10/18/13, documented an open area to the residents ankle that measured .3 by .5 cm. Nurse notes dated During interview on 3/26/14 at 3:05 p.m., Staff F, registered nurse, stated the facility had no formal system to track the pressure areas and did not complete weekly assessments. The Pressure Ulcer Risk Assessment revised March 2005, instructed staff to implement a skin sheet for the pressure area and assess the presence of developing ulcers on a weekly assessment.

Based on record review, observations and staff and family interviews the facility failed to appropriately supervise one of four residents reviewed (Resident #1,) and failed to ensure interventions determined to keep the resident safe were implemented as directed by the resident ' s care plan. The facility reported a census of 43 residents. Resident #1 had a high risk for falls and experienced multiple falls(4) within a two week period while living at the facility. The plan of care directed staff to not leave the resident alone while in the bathroom. The Occupational Therapist and Physical Therapist directed staff of the need to stay with the resident. A sign was posted in the bathroom. On 6/15/2012, the resident sat on the toilet unattended. The staff member stayed in the resident ' s room but left the resident unattended in the bathroom. The staff member heard a bump and saw the resident on the floor. The resident had a cerebral contusion and a laceration on the lower back area. The family transferred the resident to another facility. Findings include: 1. Resident #1 had an admission MDS (Minimum Data Set) assessment with a reference date of 6/7/2012. The MDS revealed Resident #1 had no cognitive impairments but required extensive assistance of two staff to ambulate and transfer from one surface to another and to use the toilet. The MDS reflected the resident required staff to balance and stabilize while moving on and off the toilet and moving from a seated to standing position, and had two falls since the prior assessment with no injury. The MDS dated [DATE] revealed Resident #1 transferred and used the toilet with extensive assistance of one staff, and had [DIAGNOSES REDACTED]. The CNA (Certified Nursing Assistant) Care Plan Flow Sheet for June, 2012 documented Resident #1 ambulated with PT (Physical Therapy) only and had a pad alarm on at all times when unattended. This had been initiated on 06/04/2012. The Resident Care Plan dated 06/13/2012 identified Resident #1 had a problem with self care deficit related to a recent CVA (stroke). The care plan directed staff to provide therapy, provide assistance of one staff to toilet, assure pad alarm is on at all times when unattended every day, do not leave alone in room when resident is on toilet or in wheel chair, assure alarm is on in bed and recliner, do not leave unattended in wheel chair, do not use silky pajamas, assure Dycem is in recliner seat and provide low bed. On 6/11/2012, the physician signed an order for [REDACTED]. The MARS and TARS (Medication and Treatment Administration Record) did not identify the resident used alarms. The Fall Risk assessment dated [DATE] revealed Resident #1 had a high risk for falls with a score of 10. A total score of 10 or above represented high risk. The Occupational Therapy Recommendation dated 06/08/2012 instructed staff to not leave Resident #1 unattended in the wheel chair or propped up in a recliner. Physical Therapy Recommendation dated 06/01/2012 directed staff to transfer Resident #1 with the assistance of two staff and a gait belt and do not leave unattended on the toilet, and do not leave unattended in the wheel chair. Physical Therapy Recommendation dated 06/05/2012 directed staff to transfer Resident #1 with the assistance of one staff and a gait belt, do not leave unattended while seated on the toilet with the transfer of one staff and do not leave unattended. Other: Do Not leave unattended in wheel chair or on toilet. The Resident Accident/Incident Reports revealed Resident #1 had the fallowing falls: a. On 06/03/2012 at 11:00 p.m., staff found the resident on the floor at bedside. Staff applied a bed alarm and provided frequent checks. b. On 06/04/2012 at 12:45 p.m., staff found the resident on the floor next to the recliner. The resident reported he/she slid from the chair. Staff applied blue Dycem and a pad alarm to the recliner. c. On 06/08/2012 at 5:45 a.m., staff responded to the resident ' s call for help and found the resident sitting next to the bed with legs outstretched. The pad alarm malfunctioned and failed to sound. The staff replaced the alarm. d. On 06/15/2012 at 7:50 a.m., staff assisted the resident to the toilet and staff then left the bathroom, but remained present in the resident's room. The resident attempted to self transfer from the toilet to the wheel chair and fell hitting head with legs outstretched. The Hospital Discharge Summary dated 06/20/2012, revealed the resident was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. On 07/09/2012 at 12:30 p.m., the Director of Health Services was interviewed and reported the resident ' s MARS and TARS included alarms, and nurses check them every shift. The Administrator stated the CNA's check the alarms during rounds and sign off on them on the resident flow sheets. On 06/28/2012 at 2:00 p.m. and 07/10/2012 at 11:00 a.m., the DON (Director of Nursing) reported Resident #1 got off the toilet and fell sustaining a low back laceration, brain contusion and no brain bleed. The family decided to move the resident to another facility. During the resident's two week stay, the resident experienced four falls. Staff A (CNA) assisted the resident to the bathroom, remained in the resident's room, and the resident stood and fell , probably hitting his/her back on the foot pedal. Staff A left the bathroom door open and the resident stood without warning. Staff are not allowed to leave the resident's room. Physical and Occupational therapists evaluate residents and place recommendations in front of the CNA charting book. The CNA's complete ADL flow sheets daily and have team sheets containing resident information. The staff are required to remain in resident rooms if they have an alarm. The physical therapist recommended staff not leave the resident unattended. Resident #1 had restless legs and trunk balance issues. On 07/10/2012 at 8:10 a.m., Staff H (Occupational Therapist) was interviewed and reported telling staff to not leave Resident #1 unattended due to issues with sliding, scooting and getting up on his/her own. Recommendations are placed in the CNA charting and communication book and placed in the resident's room. On 7/10/2012 at 8:30 a.m., Staff I (Physical Therapist) reported on 6/1/2012, therapy recommended staff transferred Resident #1 with the assistance of two and on 6/5/2012 they recommended staff transfer him/her with the assistance of one and added: "Do not leave unattended in wheel chair or on toilet". Recommendations are placed in the CNA book, and they are responsible to read it. The resident had poor insight into the illness and had impulsive behaviors. On 07/10/2012 at 9:10 a.m., Staff J ( PTA (Physical Therapy Aide) was interviewed and reported placing the therapy recommendation dated 06/05/2012 in Resident #1's room on the closet door and in the CNA communication book. On 07/09/2012 at 2:30 p.m., Staff A, CNA reported working on 06/15/2012 after a 3 week vacation. Staff B, RN (Registered Nurse) informed Staff A Resident #1 transferred with the assistance of one and had a CVA (stroke). Staff A assisted the resident out of bed and to the toilet and remained in the room, making the bed. Staff A heard a bump and saw the resident on the floor. Staff A reported leaving the bathroom door open with the resident within view, however failed to witness the fall. Staff A denied knowledge of prior falls and the need to remain in the bathroom with the resident. Staff A did not read the recommendation in the CNA book. During rounds with the night shift, he/she learned the resident slept all night. Staff A did not read the therapy recommendation sign in the resident's room. On 07/09/2012 at 12:00 p.m., Staff F (CNA) reported residents with alarms need to remain within view and reach. On 07/10/2012 at 11:00, Staff L (CNA) reported resident's with alarms need to remain within view and reach and staff need to stay with them. Therapy posts special precautions and instructions in resident rooms, and in the CNA chart book. On 07/10/2012 at 8:05 a.m. the family member of Resident #1 was interviewed and reported the resident resided at the facility for 16 days, had frequent falls and sustained an injury which required stitches. The family member voiced the staff assisted the resident to the toilet and then would leave the resident unattended. The family member stated on 2 separate occasions, she had observed staff walking down the hall and leaving loved one sitting on the toilet unsupervised. The family member reported the concerns to the staff and to the therapy department. Although there were signs posted in the bathroom for staff not to leave unattended, the staff continued to do this.

Based on observation, record review, staff and family interviews and facility policy/procedures, the facility failed to provide adequate supervision to prevent an elopement for one of four residents reviewed. (Resident #1). The facility reported a census of 46 residents and reported 9 residents with wandering behaviors, an elopement risk and wore Wander Guard bracelets. Findings include: 1. According to the Admitting Report face sheet, Resident #1 had an admitted to the facility on [DATE]. The quarterly MDS (Minimum Data Set) assessment with a reference date of 11/18/2010 indicated Resident #1 sometimes understood others and sometimes had the ability to make self understood. The BIMS (Brief Interview for Mental Status) revealed a summary score of 00 indicating the resident could not complete the test. The MDS revealed the resident transferred and ambulated independently with no help or oversight from staff, and had [DIAGNOSES REDACTED]. The Resident Care Plan, signed on 11/29/2010, indicated Resident #1 had potential for injury related to attempts to leave the Health Center unattended with a start date of 05/26/2010. The approaches directed staff to encourage ambulation every day, assure environment free of fall hazards, assure Wander Guard on the resident every day, check the Wander Guard with box at night, provide personal alarm on door at night to alert staff resident is leaving room at night, reorient the resident not to self remove the Wander Guard device every day as needed and provide frequent location checks every day. The physician's orders [REDACTED]. The December Treatment Record documented staff initialed and checked the Resident ' s Wander Guard every shift on 12/17/2010 and 12/18/2010. The record added verification of checking the Wander Guard with the box every shift beginning 12/22/2010. According to the record, staff changed the wrist Wander Guard on 12/18/2010 and the ankle Wander Guard on 11/19/2010. The Resident Accident/Incident Report dated 12/18/2010 at 10:00 a.m. reflected Resident #1 exited the health care facility. The alarms did not sound. The Wander Guard to the ankle worked properly. Wander Guard to the wrist did not work properly. The staff changed the Wander Guard to the resident ' s wrist. The Incident Report indicated a neighbor observed the resident at the corner of Michael and Benton Streets (approximately 1/2 mile from the facility). The resident wore no coat, but had a clothing protector and dinner napkin wrapped in each hand. The neighbor returned the resident to the facility and also accompanied by a police officer. Staff gave the resident a warm cup of coffee and a blanket. The resident had a temperature of 97.6 degrees Fahrenheit. The Incident Report identified the facility checked the Wander Guard door alarms and the South Hall Dining Room door. The South Hall dining room door failed to respond to the Wander Guard bracelet located on the ankle. The report indicated twenty four hours later, a second Wander Guard box, ankle height, was added to the South Door. The facility staff set the doors to activate at wrist or ankle. The staff discontinued the 15 minute checks. The Nurse's Notes dated 12/18/2010 at 10:00 a.m. documented Resident #1 exited the facility and observed outside on the corner of Michael and Benton Street. A citizen brought the resident back to the health center and staff offered the resident a warm cup of coffee. Staff notified the director of nursing (DON). Staff checked all doors with a Wander Guard bracelet at ankle height. Three doors failed to respond to the Wander Guard on the ankle. Staff notified maintenance and the executive director. The outside temperature registered 14 degrees. Staff implemented 15 minute checks. The Nurse's Notes on 09/12/2010 at 12:00 noon indicated Resident #1 exited the facility and staff brought him/her inside and found the Wander Guard failed to work. Staff replaced the Wander Guard. The Nurse's Notes on 09/22/2010 at 7:30 a.m. indicated Resident #1 exited the health center and staff found him/her exiting the third floor to the outside. Staff heard the alarm sound but no knowledge of who answered the alarm. The December Care Plan Flow Sheet revealed staff checked Resident #1's Wander Guard every day and checked it with the box (battery check) every night from December 1 - 21, 2010. The Elopement Risk assessment dated [DATE] documented Resident #1 had a Wander Guard and staff provided frequent checks and occupied the resident. A quarterly assessment with a reference date of 11/18/2010 documented the resident wandered and left the health center unattended two times that quarter. (09/12 and 09/22/2010). The facility Wandering, Unsafe Resident Policy included: Statement: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Policy Interpretation and Implementation: 1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at risk individuals for potentially correctable risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is at risk for elopement or other safety issues. 4. A Wander Guard bracelet/anklet will be placed on individuals deemed at risk for wandering. This Wander Guard shall sound an alarm when the resident wearing one approaches or attempts to leave via an activated exit door. 5. In the event of an alarm sounding, staff will check the Wander Guard alarm system panel of information regarding the sounding exit. Staff will then go to the alarming exit, locate the resident that is setting off the alarm, and ensure their safety within the facility. If no resident is seen immediately, a census will be taken and a search initiated, if appropriate. 6. Wander Guards will be checked for placement and functioning every day. Wander Guards will be changed every 90 days per manufacturer's recommendations. 7. Nursing staff will document circumstances related to unsafe actions, including wandering, by a resident. 8. Staff will notify the Administrator and Director immediately and will institute appropriate measure (including searching) for any resident who is discovered to be missing from the unit or facility. The First Q and Wander Guard User Instructions included: Warning: Before using the Wander Guard systems read and follow these instructions carefully. Failure to do so could result in injury or death to a person in your care. No device is a substitute for proper nursing care. If you have any questions concerning the operation or use of the signaling device call Customer Service. Test the device before using. Thereafter, test the device daily and record the results in the resident's record. Do not use more than one signaling device on a resident. Two signaling devices, if brought very close together, may not be received by the door monitor and the alarm will not sound. Band attachment instructions: Warning: The Wander Guard and First signaling devices are designed to be worn on a wrist, but can also be placed on an ankle if your system consists of Wander Guard E monitors only. If you have a mix of Wander Guard E, D, and/or 202 monitors, you must contact Wander Guard Technical Service for further instructions before using ankle or other alternate placement. On 12/22/2010 at 2:45 p.m. Staff A, maintenance, verified the facility had Wander Guard D, system. A phone conversation with Wander Guard technical support at 2:50 p.m. reported the antenna would have to be lowered for the "D" model for use with the ankle bracelet. The "D" series is designed to be used with either the ankle or the wrist, not both. Therefore, all resident bracelets needed to be placed on the ankle or the wrist. The "E" series is designed to use with both ankle and wrist placement. At 2:15 the Administrator and Director of Nursing reported staff put wrist bracelets on and initiated 15 minute checks for Resident #1 and Resident #2 to ensure the wrist bracelets remained on. On 12/29/2010 at 12:20 p.m., Staff A reported residents had wrist bracelets on and they received two quotes on replacing the "D" monitors with "E" monitors and should be installed in a couple of weeks. Observation of the Wander Guard monitors on 12/22/2010 revealed the South dining room exit door to the stairwell had two monitors; one at wrist height and one at ankle height. Staff A tested both monitors and both sounded. The remaining exit doors Wander Guard monitors all functioned when tested . During an interview on 12/22/2010 at 11:15 a.m., Staff B, maintenance reported Resident #1 exited through the South stairwell door, went up to level three and from there went outside. Staff checked Resident #1's ankle Wander Guard on each of the doors and that was the only door that did not activate, therefore staff placed a monitor at ankle height. During a phone interview on 12/29/2010 at 10:40 a.m., Staff C, RN (Registered Nurse), reported working the night shift on 12/17/2010 and checked the resident ' s wrist and ankle Wander Guard bracelets with the battery tester. The ankle bracelet functioned, however the wrist bracelet failed to function when tested around 5:00 a.m. Staff C did not change the bracelet and did not report the bracelet did not work. Staff C initialed the treatment sheet indicating the resident ' s Wander Guard functioned. Staff C reported he/she assumed if one worked, that would be enough. Staff C stated had planned to change the wrist bracelet prior to leaving, but had forgotten. During an interview on 12/22/2010 at 12:50 p.m., Staff D, LPN (Licensed Practical Nurse), reported working on 12/18/2010 and last saw Resident #1 at 9:20-9:30 a.m. in the dining room and had just finished breakfast. At approximately 10:00 a.m. Staff D received a call from the facility receptionist who said someone was bringing Resident #1 back to the facility. When the resident returned he/she wore slacks, shoes, three shirts and a neck napkin. Staff D stated had not heard any Wander Guard door alarms sound when Resident #1 exited the facility. Staff D stated no staff reported to Staff D that they heard door alarms sound. Staff D put a Wander Guard bracelet in his/her sock and checked all the doors. The South door alarm failed to sound when Staff D walked through. Staff D checked Resident #1 ' s Wander Guard bracelets with the test box and it revealed only the ankle bracelet functioned correctly. The battery test box failed to light up when Staff D checked the wrist Wander Guard bracelet. Staff D indicated staff last changed Resident #1's wrist and ankle Wander Guard bracelets on 11/19/2010, and they have a 90 life span. Resident #1 received no injury from the elopement and staff notified the physician and family. During an interview on 12/29/2010 at 11:30 a.m. The ADON (Assistant Director of Nursing) said Resident #1 exited the facility last September. The investigation showed a dietary staff person turned the alarm off. The dietary staff person no longer worked at the facility. The facility changed the code and only maintenance and nursing staff were made aware of the code. During an interview on 12/22/2010 at 2:30 p.m., the DON (Director of Nursing) indicated on 12/18/2010 he/she received a call from Staff D who said a neighbor returned Resident #1 to the facility at approximately 10:00 a.m. The Wander Guard alarm failed to sound and the wrist Wander Guard bracelet did not function, but the ankle bracelet did function. Staff A, maintenance came to the facility, checked the doors and found the South door did not activate when tested with the ankle bracelet on. Staff A installed another monitor at a lower height and staff instituted fifteen minute checks. The DON stated Resident #1 had a history of [REDACTED]. Last September the resident exited the facility and an apartment resident observed and returned the resident. At that time the Wander Guard did not activate and the pendants were change. On another occasion, the resident exited the facility, the alarms functioned and staff searched for the resident. An apartment resident returned the resident. Resident #1 has resided at the facility for a long time and familiar with the surroundings and some of the apartment residents. During a phone interview on 01/04/2011 at 10:45 a.m., Staff E, CNA reported working the day shift on Saturday, December 18, 2010. Staff E stated she/he assisted Resident #1 in the morning to get up and dressed, and walked the resident to the dining room at approximately 7:30 a.m. The resident wore a turtle neck, sweater, shoes and slacks. Staff E recalled the resident wore an ankle bracelet but not sure if the resident wore a wrist bracelet. Resident #1 typically stayed in the dining room for a long time and then would return to own room. Staff E did not hear an alarm sound and around 10:00 a.m. the nurse told Staff E the police would return the resident to the facility. The resident had previously attempted to exit the facility while Staff E worked, however, the alarms always sounded and staff stopped the resident from elopement. At the time of the complaint investigation, the violation was coded at " J " , Immediate and Serious Jeopardy Level. By 12/18/2010 the facility had implemented measures that adequately addressed the jeopardy by attaching wrist bracelets to residents that wore ankle bracelets and performed every 15 minute checks. The scope and severity level was lowered to a " D " . The facility obtained bids for an " E " Wander Guard system. The facility continued to need to: ? Monitor operations and effectiveness of the new Wander guard system, ? Continue to frequently monitor wandering residents.