Every finding on record at Palo Alto County Hospital

Based on the Center of Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (January 1- March 31), facility time card records and staff interviews, the facility failed to submit accurate staff data for the PBJ Staffing Data Report. The facility reported a census of 21 residents.Findings include: The PBJ Staffing Data Report run date 7/10/2025 triggered for failure to have licensed nurse coverage 24 hours/day on the following infraction dates: 1/18, 1/24, 1/25, 1/26, 2/6, 2/16, 2/20, 2/23, 3/1, 3/2, 3/9, 3/22 and 3/23. Review of the facility report titled Detailed Hours for the infraction dates reflected the Unit Coordinator/Registered Nurse (RN) covered the nursing shifts on 1/18, 1/24,1/26, 2/6, 2/16, 2/20, 2/23, 3/1, 3/2, and 3/22. Review of facility form titled Employee Timesheet for Staff A, RN revealed Staff A covered a nursing shift on the evening/overnight of 1/24/25. On 7/16/25 at 9:50 AM, the Director of Nursing (DON) reported Staff A's nursing hours were not coded correctly and not reported to PBJ on 1/24/25. She said Staff A normally worked in the 100 hall in the hospital and the job classification was not changed when she picked up the shift.On 7/16/25 at 10:45 AM, the DON verified the Unit Coordinator/RN worked as a charge nurse on 1/18, 1/24,1/26, 2/6, 2/16, 2/20, 2/23, 3/1, 3/2, and 3/22. She reported the nursing hours were not reported to PBJ. On 7/16/25 at 11:13, the DON reported the facility does not have a PBJ policy.

Based on observations, interviews and record review, the facility failed to provide sanitary hand hygiene and appropriate sanitation with laundry. The facility reported a census of 22 residents. Findings include: 1. During an observation on 10/29/19 at 10:12 AM, Staff D, Certified Nurse's Aide (CNA) washed her hands and shut off the sink faucet with bare hands. During an observation on 10/29/19 at 10:27 AM, Staff D washed her hands then shut off the sink faucet with bare hands. During an interview on 10/30/19 at 10:40 AM, the Minimum Data Set (MDS) Nurse, Registered Nurse (RN), stated the staff needed to shut off the water after washing their hands with a paper towel. During an interview on 10/30/19 at 10:58 AM, the Director of Nursing (DON) reported she wasn't sure what the policy stated, she thought it said the sink should be shut off with a paper towel. She wasn't sure if it said that it needed to be clean but the staff should probably use a clean paper towel. The policy labeled, Hand Hygiene, with a revision date of 11/10 stated the purpose was to prevent transmission of infection to patients, visitors, and staff by [MEDICATION NAME] effective hand hygiene principles as stated in the policy. The procedure said to complete handwashing with soap and water by . 1. Wet hands under running water 2. Apply soap from the dispenser and thoroughly distribute it over hands. 3. Vigorously rub hands together, continuing friction over palms, backs of hands, wrists, and between fingers for 15 seconds. 4. Rinse thoroughly under running water. 5. Dry hands with a paper towel. 6. Use a clean, dry paper towel to turn off the faucet. Lever-operated towel dispensers should be activated before beginning hand washing. 2. During a dining room observation on 10/28/19 at 11:45 a.m., observed Staff D, Certified Nurse's Aide (CNA) wash her hands and shut off the sink faucet with bare hands. During a dining room observation on 10/28/19 at 11:52 a.m., observed Staff [NAME] wash her hands and then shut off the sink faucet with bare hands. During a dining room observation on 10/28/19 at 11:53 a.m., observed the Director of Nursing (DON) wash her hands then shut off the sink faucet with bare hands. During an interview on 10/30/19 at 8:26 a.m., the DON and MDS Coordinator stated they would expect all staff to use a clean, dry paper towel to turn the sink off so as not to re-contaminate their hands. The DON provided a copy of the facility's Hand Hygiene policy. 3. An observation on 10/28/19 at 1:25 PM, revealed a washing machine with Clothesline Fresh detergent and Clothesline Fresh fabric softener attached to it. An interview on 10/28/19 at 1:25 PM, Staff C laundry/bath aide stated she does laundry on the days she works. Staff C stated the other shifts do laundry on the days she does not work. Staff C stated she picks the temperature on the whirlpool washing machine that she would use at home when doing residents laundry. Staff C stated she washes residents' clothes together with other residents' clothes. Staff C stated she does loads of wet clothes together and loads of dry clothes together. Staff C stated they rinse soiled clothing in the hopper in the dirty utility room before washing them together with others. Staff C showed the cart on which clean clothes are delivered to the residents' rooms. The cart was open in the front without a cover. The cart had openings between crisscrossed metal that created the sides and the back. Both of the sides of the cart had rods attached to the outsides with clean clothes hanging on the rods. Clean clothes were folded on the shelves inside of the cart. Staff C wheeled the cart out in to the hall and began to deliver clothes to the residents' rooms. In an interview on 10/28/19 at 2:48 PM, the Director of Nursing (DON) and the Maintenance Supervisor both said the clothes were sanitized. The Maintenance Supervisor said the water temperature is set at 110 so it is necessary to use a chemical to sanitize the clothes. He also said the facility as a whole recently changed over to chemical sanitizing of laundry. Upon entering the laundry room, both the DON and the Maintenance Supervisor verified the washing machine did not have a sanitizer hooked up to it. Both acknowledged this was a problem and an infection control issue. The Maintenance Supervisor said he would get on it right away. The DON furthermore verified the cart used to deliver resident clothing should not have clothes hanging on the outside of the cart. Furthermore, the DON stated the clothes on the inside were not covered either, as the front of the cart was completely open and the 3 sides of the cart were partially open related to the holes created by the crisscross pattern of steel. A Resident's Laundry policy dated 7/2006, directed staff to rinse clothing soiled with bodily fluids then immediately place in the washer after all solid particles are removed. These clothes will then be washed again before going into the dryer. The facility provided manufacturer's guidelines for Clothesline Fresh Oxygen Detergent and Clothesline Fresh Fabric Softener. The guidelines did not address sanitizing capabilities. The Clothesline Fresh Fabric Softener guidelines had Discontinued 10/28/19 written on it by the facility. The facility provided manufacturer's guidelines for Clothesline Fresh Fabric Softener/Sanitizer. The guidelines stated at 5 oz per 100 lbs dry laundry this product provides residual self-sanitizing activity that kills 99.9% of bacteria tested (Staphlycoccus aureus and [DIAGNOSES REDACTED] pneumonia). The Clothesline Fresh Fabric Softener/Sanitizer had the date 10/29/19 written on it by the facility. This product has a EPA regulation number. On 10/31/19 at 9:30, the Maintenance Director affirmed the sanitizer was installed to the washer. The facility failed to process and transport linens to prevent the spread of infection.

Based on observation and staff interview, the facility failed to hold hot food at a temperature high enough to ensure prevention of bacterial pathogen growth. The facility reported a census of 22. Findings include: During an observation on 10/28/19 at 11:45 AM, Staff A, Cook, brought out food stored in stainless steel containers and placed in and on a thick plastic holder on a cart. The carrots did not fit into the plastic holder so they were on top of the other containers and then set on the counter. Staff A took the temperature of each food item. The temperature of the carrots was 165 degrees Fahrenheit (F). The temperature of the chicken was 166 During an observation on 10/28/19 at 12:05 PM, Staff A, took temperatures on all of the food items directly after serving all the residents in the dining room. The temperature of the carrots was 125. The temperature of the chicken was 137. In an interview, during the time of the 10/26/19 12:05 PM observation, Staff A stated she had never taken the temperatures of the food after serving. Staff A stated the carrots and the chicken did not hold a hot enough temperature and it would not be suitable to serve residents if they wanted seconds. In an interview on 10/28/19 at 1:03 PM, Staff B, Registered Dietitian, stated chicken should have been kept at 140 F or above. Staff B stated the carrots should have been 135 F or above. On 10/28/19 at 2:46 PM, Staff B provided a Menu Production Sheet dated 10/28/19. The Dietitian said the menu showed 5 residents received chicken for lunch that day. Staff B stated she was unable to show how many residents received carrots. The facility did not produce a policy regarding holding temperature for food. The FDA 2013 Food Code, deemed that a standard practice in the food service industry is all potentially hazardous hot food must be held for service at a minimum of 135 degrees Fahrenheit. The facility failed to ensure food was held at a high enough temperature.

Based on resident interviews, record review and staff interviews, the facility failed to provide dignity to residents by knocking on the resident's rooms before entering for 2 of 22 residents reviewed (Residents #5 and #3). The facility reported a census of 22. Findings include: 1. The Minimum Data Set (MDS) completed for resident #5 with an Assessment Reference Date (ARD) of 9/11/19 showed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The resident had [DIAGNOSES REDACTED]. During an interview on 10/29/19 at 12:53 PM, the resident reported a man who gave her medicine would walk into her room without knocking, bringing a medicine cup and something else in his other hand. She stated he might not be able to knock but she felt he should knock. She said sometimes when she was in the bathroom with the door open he came in without knocking or when she is walking from the bathroom to her bed. She stated it did not happen too often but it was more than enough. During an interview on 10/30/19 at 10:40 AM, the MDS Nurse, Registered Nurse, stated the staff should knock before entering a resident's room. The policy labeled, Patient and Family Rights, with a revision date of 7/05 stated the patient and family had the right to expect their personal privacy was respected. 2. The MDS completed for resident #3 with an ARD of 8/28/19 showed a BIMS score of 13, indicating intact cognition. The resident had [DIAGNOSES REDACTED]. During an interview on 10/28/19 at 3:21 p.m., the resident reported staff could be better about knocking on his door before coming in. He further stated they would be knocking while walking into his room. There had been times when he would be in using the bathroom and he would come out of the bathroom to find a staff member standing in his room, sometimes with a pill or something. During an interview on 10/29/19 at 2:44 p.m., the Director of Nursing stated she would expect that all staff should knock first and wait for a response before entering a resident's room.

Based on record review and staff interview the facility failed to assure accurate coding of medications on the Minimum Data Set (MDS) assessment tool for 3 of 12 residents reviewed (Resident #10, #13 and #19 ). The facility reported a census of 22 residents. Findings included: 1. Resident #10's 10/11/19 MDS documented the resident received anticoagulant medication 7 days per week. The resident's (MONTH) 2019 Medication Administration Record [REDACTED]. 2. Resident #13's 9/25/19 MDS documented the resident received anticoagulant medication 7 days per week. The resident's (MONTH) 2019 MAR indicated [REDACTED]. 3. Resident #19's 10/23/19 MDS documented the resident received anticoagulant medication 7 days per week. The resident's (MONTH) 2019 MAR indicated [REDACTED]. During interview on 10/30/19 at 2:18 p.m. the MDS Nurse and DON (Director of Nursing) confirmed the MDS had been coded incorrectly for Resident's #10, #13, and #19 who received [MEDICATION NAME] ([MEDICATION NAME]), an antiplatelet medication which is not an anticoagulant. The DON also confirmed [MEDICATION NAME] shouldn't be coded on the MDS as an anticoagulant as it is an antiplatelet medication, a different drug class.

Based on observation,record review, staff and pharmacist interview, the facility failed to store drugs under proper temperature controls. The facility reported a census of 22. Findings include: During observation on 10/28/19 at 12:55 PM, the medication refrigerator at the nursing station registered a temperature of 48 degrees Fahrenheit (F). In an interview during this observation, the Minimum Data Set (MDS) Nurse stated she read the thermometer as 47 degrees F. A review of the refrigerator's temperature log showed the temperature had not been recorded since 10/25/19 and had not yet been recorded on 10/28/19 at 12:55 PM. In an interview on 10/28/19 at 1:20 PM, the MDS Nurse reported she called the pharmacies that the refrigerated medications came from and reported the medications that were in the medication refrigerator. The MDS Nurse stated the medications she reported to the pharmacies included [MEDICATION NAME] (an anti-anxiety medication) as part of a compounded drug and [MEDICATION NAME] (a medication that treats nausea and vomiting). The MDS Nurse stated the pharmacists reported the temperature of 47 degrees F is okay for these meds as the purpose of refrigeration for these mediations is to extend the shelf life only. The Director of Nursing (DON), and the MDS Nurse stated they turned the refrigerator's temperature down. During an observation on 10/28/19 at 2:20 PM, the temperature of the refrigerator registered at 52 degrees Fahrenheit. The refrigerator's door had been opened to check the medication inventory. In a phone interview on 10/28/19 at 3:12 PM, the Pharmacist that had compounded the medication which included [MEDICATION NAME], stated the guidance was to store the compounded drug at 36 F-46 F as that is the range [MEDICATION NAME] is to be stored. She stated 47 F would be out of range. The Pharmacist said the medication may probably still be good. She added technically the medication is out of range. In a telephone interview on 10/28/19 at 3:16 PM, a Pharmacist stated the efficacy of the medications in the medication refrigerator stored at 47 degrees depended on how long the medications were out of temperature storage range. She stated the [MEDICATION NAME] suppository can be stored up to 46 F. In an observation on 10/28/19 at 3:40 PM, the medication refrigerator registered a temperature of 48 F. In an interview at the time of this observation, Staff F, Registered Nurse (RN), verified the temperature was 48 F. Staff F stated she had not opened the refrigerator since she checked the temperature earlier that day at 2:30 PM. Staff F stated the temperature at that time was 52 F. In an interview immediately following this observation and interview, the DON stated she had thought she had turned down the refrigerator but had turned down the freezer instead. The DON stated it had since been turned down. A Refrigerator Use and Check policy dated 7/2005, directed the night nurse to check and record the refrigerator temperatures at the nurse's station.

Based on observation and clinical record review, the facility failed to assure professional standards during medication administration for one of 18 residents reviewed (Resident #10). The facility reported a census of 22 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #10 had [DIAGNOSES REDACTED]. The assessment documented the resident had unspecified skin problems. Resident #10's current physician's orders [REDACTED]. During observation on 8/6/18 at 3:55 PM, Staff A, staff nurse placed the dosage into a plastic cup. Staff A then wiped the mixture onto her gloved finger from the plastic cup and the mixture fell on to the resident's clothing. Staff A scraped the cream off the resident's pants and then rubbed it onto her wrist.

Based on observation, direct measurement and staff and resident interviews, the facility did not ensure that foods were served at palatable temperatures. The facility reported a census of 22 residents. Findings include: 1. During observation on 8/6/18 at 11:42 AM, staff placed pureed food from a insulated container and brought it to the dining room in front of a resident who could not eat independently. At 11:56 AM a staff member sat to begin assisting the resident to eat. At that time, the food temperatures were as follows: 1. Pureed Enchilada casserole - 99 degrees Fahrenheit (F); 2. Pureed Rice side dish - 98 degrees F; 3. Pureed vegetable - 96 degrees F. On 8/6/18 at 1:40 PM, the Head Cook stated that after staff pureed food, they placed it in bowls of water in a low oven. The food is then placed in front of the residents around 11:40 AM. If there are no staff able to assist, the food can get cold. 2. On 8/7/18 at 11:40 AM the pureed meat, vegetable and potato metal containers were placed on the top of the insulated containers still covered and in a hot water bath. At the time of service to the resident at 11:54 AM the temperatures measured: 1. Pureed green beans with bread - 123 degrees F 2. Pureed baked potato - 121 degrees F. 3. On 8/618 at 2:00 PM, 4 of 4 residents present for the group resident interview reported the food was not always hot.

Based on observation and staff interview the facility failed to assure water mugs refilled in a sanitary manner, and assure staff had no bare hand contact with ready to eat food The facility reported a census of 22 residents. Findings included: During observation on 5/8/17 at 9:14 a.m. Staff B, Certified Nursing Assistant (CNA) brought a water mug from a resident's room (Room 216). She sat the mug on top of a 3 shelf cart next to a pitcher of ice. Two disposable paper cups sat next to the pitcher. The CNA picked up a cup and used it to scoop ice from the pitcher into the resident's water mug. She then set the cup down and took the mug into the resident's room. She proceeded down the hall, room to room, continuing to use the cup to scoop ice into residents' water mugs. During interview on 5/8/17 at 9:31 a.m. when asked why she didn't use a scoop for the ice Staff B stated, Because that's what these are for. and pointed at the disposable cups. The Director of Nursing, also present, stated staff were supposed to take the mugs to the fountain to fill. The DON agreed use of the cups to scoop ice into the mugs was not a sanitary practice. During an observation on 05/09/17 at 7:45 a.m. Staff A Certified Nurtsing Assistant (CNA) handled a residents toast with her bare hands prior to giving him/her a bite. The FDA Food Code 2013 3-301.11 documents food employees may not contact exposed ready to eat food with their bare hands. During an interview on 5/10/17 at 2:15 p.m. the Dietary Supervisor confirmed staff should not handle ready to eat food with their bare hands.

Based on record review and staff interview, the facility failed to notify the physician and family of a change in status for 1 of 9 residents reviewed (Resident #1). The facility reported a census of 22 residents. Findings include: According to the Minimum Data Set (MDS) assessment, dated 04/27/17 Resident #1 demonstrated long and short term memory problems and severely impaired skills for daily decision making. Resident #1 depended on staff for activities of daily living (ADL's) including bed mobility, transfer, dressing, eating and personal hygiene. Resident #1's [DIAGNOSES REDACTED]. The Nutrition Notes dated 2/2/17 documented Resident #1 gradually lost weight as his/her disease progressed. Intakes were slightly down since the previous assessment. Resident #1 relied completely on staff for meals. Resident #1 did not receive supplements, but the dietician felt they may be beneficial to help maintain weight. The dietician recommended 4 ounces Ensure (nectar-thick) at breakfast and supper, and they would continue to monitor. The Nurse's Notes dated 4/12/17 at 1:50 p.m. documented Resident #1's weight and vital signs stable. Family supportive and frequently updated. The Nurse's Notes dated 4/19/17 at 10 a.m. documented Resident #1's weight and vital signs stable, good appetite. Family supportive and updated with status changes. The Nurse's Notes dated 4/26/17 at 9:50 a.m. documented Resident #1's weight and vital signs stable. Family supportive and updated frequently. The Nutrition Notes dated 4/27/17 documented Quarterly review, Resident #1's weight 147 pounds down 21# (a 12.5%, significant loss) in 6 months. After the previous assessment he/she started on Ensure Clear supplement 2 times a day with meals. Intakes are down as well. The dietician recommended increasing Resident #1's supplement to 3 times a day. The clinical record lacked documentation the facility notified the physician or the family of the significant weight loss. During an interview on 5/11/17 at 8:25 a.m. the Director of Nursing (DON) stated they kept family updated on Resident #1, but they had nothing to indicate they notified the physician or family at the time they identified Resident #1's significant weight loss.

The facility failed to assure comprehensive care planning for 1 of 9 residents reviewed (Resident #4). The facility reported a census of 22 residents. Findings included: 1. According to the Minimum Data Set ((MDS) dated [DATE] Resident #4 had [DIAGNOSES REDACTED]. The MDS documented the resident's admitted [DATE]. The Nurse's Notes dated 3/31/17 documented the resident admitted to the facility following surgical repair of a small bowel obstruction. The resident had a mid-line abdominal surgical incision (no measurement). The resident's Care Plan with a revision date of 4/26/17 and a Target Date of 7/20/17 lacked any mention of the abdominal incision. Nurse's notes dated 3/31/17 at 9:40 a.m. documented Resident #4 had 2-3 plus [MEDICAL CONDITION] of both feet and ankles. Nurse's Notes dated 4/1/17 at 10:00 p.m. documented Resident #4 complained of shortness of breath with high anxiety. Staff auscultated crackles in the upper lobes of the resident's lungs had diminished sounds in the lower lobes. The resident had 3 plus [MEDICAL CONDITION] in both lower extremities. Staff took the resident to the Emergency Department. The resident returned at 11:40 p.m. with oxygen at 2 liters per nasal cannula and a new order for [MEDICATION NAME] (a diuretic medication) 40 milligrams (mg.) daily. Review of Resident #4's Care Plan revealed no mention of the resident's fluid retention/[MEDICAL CONDITION]. The Nutritional History And assessment dated [DATE] documented the resident weighed 123 pounds and had a poor appetite. The resident had only been eating an average of 43% of his/her meals. The dietitian noted the resident's usual weight had been 158# but he/she hadn't eaten for 20 days when he/she had the bowel obstruction. The resident's Care Plan lacked any mention of the resident's poor appetite or weight loss. The Medication Administration Record [REDACTED] The Nurse's Notes documented on 4/2/17 at 3:00 p.m. Resident #4 stated he/she felt anxious when trying to sleep. On 4/4/17 at 5:00 a.m. staff documented the resident had the call light on every 1/2 hour to 1 hour. The resident stated he/she couldn't get comfortable in the bed. The resident also said, Now if I could just get my sleep pattern figured out. On 4/25/17 at 4:00 a.m. staff documented in the Nurse's Notes the resident requested something for sleep almost nightly after attempting to sleep. Staff administered [MEDICATION NAME] to decrease the resident's anxiety. Staff documented on 5/5/17 at 6:30 p.m. the resident reported sleeping better since taking the [MEDICATION NAME] at bedtime. The resident's Care Plan lacked any mention of the resident's sleep disturbance. During interview on 5/9/17 at 10:49 a.m. the Director of Nursing confirmed the Care Plan did not address the resident's skin, weight loss, [MEDICAL CONDITION] or sleep problems.

Based on observation, record review and staff interviews the facility failed to follow care plan interventions for 1 of 9 residents reviewed (Resident #9). The facility reported a census of 22 residents. Findings included: According to the Minimum Data Set ((MDS) dated [DATE] Resident #9 had moderately impaired cognitive function and required extensive assistance of staff for transfers and ambulation. The Incident/Falls Checklists documented Resident #9 experienced falls on 10/10/16, 11/29/16, 2/17/17 and was lowered to floor by staff on 3/15/17 and 5/5/17. The resident's Care Plan identified the resident had limited physical mobility with a history of falls related to balance issues. The Care Plan initiated a Tabs alarm and a chair pad alarm when the resident sat in the recliner on 2/17/17. The Care Plan directed staff to apply a Tabs alarm and a pressure alarm in bed beginning on 4/19/17. On 5/10/17 at 12:42 p.m. observation revealed the resident seated on the toilet in his/her bathroom with his/her feet/lower legs strapped to the base of the EZ Stand lift and the lift belt around the resident's waist and attached to the lift. Observation revealed no staff in the room. At 12:53 p.m. Staff C, Certified Nursing Assistant entered to assist the resident from the toilet. A clip alarm attached to the handrail had the string and clip hanging down, not attached to the resident. When asked about the alarm Staff C stated it need not be attached if the resident remained attached to the lift. When interviewed on 5/10/17 the Director of Nursing stated residents who used alarms should not be left unattended on the toilet without alarms even if attached to the EZ stand.

Based on observation, record review and staff interview the facility failed to provide incontinence care in a manner to prevent infection for 1 of 4 incontinent residents reviewed (Resident #6). The facility reported a census of 22 residents. Findings included According to the Minimum Data Set (MDS) assessments dated 7/22/16, 12/16/16 and 3/2/17 Resident #6 required extensive to total assistance with toileting and had frequent urinary incontinence. An (untitled) Hospital Report documented the resident admitted on [DATE] with a [DIAGNOSES REDACTED]. coli)[MEDICAL CONDITION] and UTI (urinary tract infection). An 8/13/16 and 4/22/17 Urine Culture documented the resident had E.coli urinary infection. During an observation on 5/9/17 at 10:57 a.m. Staff A Certified Nursing Assistant (CNA) provided peri care after Resident #6 toileted. Staff A wiped both groins, then reached through the resident's legs from behind, wiping from the genital and urinary meatus area through the anal/rectal area multiple times without changing the side of the cloth. During an interview on 5/10/17 at 10 a.m. the Infection Control Coordinator stated if staff wiped the rectal area they should not wipe the area of the urinary meats with the same cloth. Doing so could result in E-coli contamination and infection. The facility policy for Skills: Perineal Care effective August 2013 directed to use a clean washcloth or perineal wipe, and wipe from the perineum to the rectum (front to back). Repeat the process using a new washcloth or perineal wipe.

Based on record review, and staff interview the facility failed to follow care plan interventions to prevent falls for 1 of 9 residents reviewed (Resident #9). The facility reported a census of 22 residents. Findings included: 1. According to the Minimum Data Set ((MDS) dated [DATE] Resident #9 had moderately impaired cognitive function and required extensive assistance of staff for transfers and ambulation. The Incident/Falls Checklists documented Resident #9 experienced falls on 10/10/16, 11/29/16, and 2/17/17. Nurse's Notes dated 3/15/17 at 6:55 a.m. documented staff lowered Resident #9 to the floor when the resident's knees buckled while ambulating with staff. Staff documented the interventions put in place to help prevent a re-occurrence included using an EZ Stand (mechanical lift) for transfers or assisting the resident with 2 staff. Nurse's Notes dated 5/5/17 at 530 a.m. documented while assisting the resident to the bathroom with a walker the resident became weak and staff lowered the resident to his/her knees. During interview on 5/10/17 at 9:49 a.m. the Director of Nursing (DON) stated the incident on 5/5/17 occurred when one staff assisted the resident alone, instead of 2 as the care plan directed. On 5/10/17 at 12:42 p.m. observation revealed the resident seated on the toilet in his/her bathroom with his/her feet/lower legs strapped to the base of the EZ Stand lift and the lift belt around the resident's waist and attached to the lift. Observation revealed no staff in the room. At 12:53 p.m. Staff C, Certified Nursing Assistant entered to assist the resident from the toilet. A clip alarm attached to the handrail had the string and clip hanging down, not attached to the resident. When asked about the alarm Staff C stated it need not be attached if the resident remained attached to the lift. When interviewed on 5/10/17 the Director of Nursing stated residents who used alarms should not be left unattended on the toilet without alarms even if attached to the EZ stand.

Based on observation, record review, and staff interview the facility failed to provide dietary supplements as recommended for 1 of 1 residents identified with weight loss (Resident #1). The facility reported a census of 22 residents. Findings include: According to the Minimum Data Set (MDS) assessment, dated 04/27/17, Resident #1 demonstrated long and short term memory impairment and severely impaired skills for daily decision making. Resident #1 depended on staff for activities of daily living (ADL's) including bed mobility, transfer, dressing, eating and personal hygiene. Resident #1's [DIAGNOSES REDACTED]. The MDS indicated Resident #1 had not had a weight loss of 5% in 1 month or 10% in 6 months. The current Care Plan revised 2/5/17 identified Resident #1 with the potential for decreased intakes related to progressive dementia. The interventions included to consult with the physician if signs if increased intolerance to oral intake, and address possibility of a swallow evaluation . If weight loss greater than 5% in 30 days, consider supplement at snack times. Resident #1 required staff to feed his/her meals, snacks, liquids. Small portions per family request related to weight gain. Stop feeding when/if began coughing at meals. An undated sticky note on the care plan, signed by the dietician, directed to please increase supplement to 3 times a day (although the care plan failed to identify resident on supplements). The Nutrition Notes dated 8/25/16 at 10:30 a.m. documented Resident #1's family did not want him/her to gain more weight and requested Resident #1 receive small portions. The Nutrition Notes dated 2/2/17 documented Resident #1 gradually lost weight as his/her disease progressed. Intakes were slightly down since the previous assessment. Resident #1 relied completely on staff for meals. Resident #1 did not receive supplements, but the dietician felt they may be beneficial to help maintain weight. The dietician recommended 4 ounces ensure (nectar-thick) at breakfast and supper, and they would continue to monitor. The Nurse's Notes dated 4/12/17 at 1:50 p.m. documented Resident #1's weight and vital signs stable. Family supportive and frequently updated. The Nurse's Notes dated 4/19/17 at 10 a.m. documented Resident #1's weight and vital signs stable, good appetite. Family supportive and updated with status changes. The Nurse's Notes dated 4/26/17 at 9:50 a.m. documented Resident #1's weight and vital signs stable. Family supportive and updated frequently. The Nutrition Notes dated 4/27/17 documented Resident #1's weight down 21# (a 12.5%, significant loss) in 6 months. After the previous assessment he/she started on Ensure Clear supplement 2 times a day with meals. She recommended increasing Resident #1's supplement to 3 times a day. The clinical record lacked any documentation of the administration of the supplement as recommended. The Monthly Appetite Log for February, March, April and to present in May documented in a footnote to record fluid in cc's (30 cc's equaled 1 ounce), but showed staff documented the percentage of fluids Resident #1 took. The log failed to identify if Resident #1 received a dietary supplement or how much he/she took if he/she did. During an interview on 5/9/17 at 8:30 a.m. the Director of Nursing (DON) stated she did not know if Resident #1 had a supplement, she would ask dietary. At 9:10 a.m. the DON stated dietary might send the supplement with meals. She said (if on a supplement) they do not document how much of the supplement is taken. The amount would be included in the total (fluid) intake. A form provided by dietary documented resident room, name and diet care plan. The form documented Resident #1 to have 1 box Ensure Clear with breakfast, dinner and supper. During an observation on 5/9/17 at 11:48 a.m. Staff B Certified Nursing Assistant (CNA) stated Resident #1's meal consisted of pureed fruit/apricots, dessert, corn, potato casserole, meat, milk, and cranberry juice. Resident #1 did not have Ensure clear. Dietary staff left the dining room without leaving Resident #1 a supplement. During an observation on 5/10/17 at 11:43 a.m. dietary staff served Resident #1 pureed foods and cranberry juice and milk. At 11:55 a.m. dietary staff left the dining room without leaving Resident #1 a supplement. During an interview on 5/11/17 at 8:25 a.m. the DON stated she did not know if they were aware of the recommendation for the increased supplement.

Based on observation, record review and staff interview, the facility failed to assure residents had gradual dose reduction attempted to reduce [MEDICAL CONDITION] medications for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 22 residents. Findings include: According to the Minimum Data Set (MDS) assessment, dated 04/27/17, Resident #1 demonstrated long and short term memory impairment and severely impaired skills for daily decision making. Resident #1 depended on staff for activities of daily living (ADL's) including bed mobility, transfer, dressing, eating and personal hygiene. Resident #1's [DIAGNOSES REDACTED]. A Medication Review Report dated 3/20/17 showed Resident #1 had physician orders [REDACTED]. Psychoactive Medication Quarterly Evaluations dated 2/3/17 and 5/1/17 documented Resident #1 took Haloperidal 1 mg 2 times a day and Trazadone 25 mg every day. The evaluation documented the behavior warranting the use of the medication as a history of aggressive and disruptive behaviors. The comments included Resident #1's behaviors were controlled. He/she occasionally hollered out with cares. He/she needed total assist with all cares and ADL's. The Behavior Monthly Flowsheets for May, June, July, August, September, October, November, and December 2016, and January, February, March, and April 2017 lacked documentation of Resident #1 having any behaviors. The Progress Notes dated 5/1/17 at 7:53 a.m. documented Resident #1 would open eyes when spoken to, did not appear to recognize family, unable to express him/herself, and was immobile. Resident #1 continued to take [MEDICAL CONDITION] medications as ordered. He/she occasionally, randomly hollered out. The current Care Plan revised 2/5/17 identified Resident #1 used antipsychotic medication ([MEDICATION NAME] 1 mg 2 times a day, and Trazadone 25 mg every day) related to dementia with aggressive behavior and agitation, with the goal for Resident #1 to be calm and cooperative with cares and meals. The interventions included to administer medications as ordered by the physician, monitor/document side effects and effectiveness, physician and pharmacy to review per their routine. A pharmacy letter dated 2/23/17 notified the physician the use of central nervous system (CNS) medication a potential concern to state regulators. Please review Resident #1's CNS medications to determine future use. For Trazadone the physician documented effective dose, no change. For [MEDICATION NAME] the physician responded effective, stable. The response failed to provide a rationale for why a dose reduction would be contraindicated. During observation on 5/8/17 at 11:53 a.m. staff assisted Resident #1 with the noon meal. Resident #1 sat calmly in the geri-chair. During an observation on 5/9/17 at 6:45 a.m. staff wheeled Resident #1 near the nurse's station. Resident #1 sat quietly. At 7:30 a.m. staff wheeled Resident #1 to the dining room. At 7:52 a.m. staff assisted Resident #1 with breakfast. Resident #1 remained calm. At 8:50 a.m. staff wheeled Resident #1 to his/her room and used the total mechanical lift to transfer from the geri-chair to the bed. Resident #1 remained calm. At 10:48 a.m. Staff B Certified Nursing Assistant (CNA) performed pericare, and Staff B and Staff C CNA transferred Resident #1 from the bed to the geri-chair with the mechanical lift. Resident #1 remained calm. During an interview on 5/9/17 at 8:30 a.m. the Director of Nursing (DON) stated Resident #1's medications had not changed for a long time. She stated Resident #1 had behaviors, probably years ago. She noted they had not documented any behaviors since the previous survey (a year previous).

Based on observation, staff and family interview, and clinical record review, the facility failed to provide adequate nursing supervision for one of two residents identified as an elopement risk reviewed (Resident #1). An elopement is defined as a resident who has impaired decision-making skills leaves the facility without the knowledge or authorization of staff. This constituted immediate jeopardy to Resident #1's health and safety. The facility reported a census of 21 residents. Findings include: According to the Minimum Data Set (MDS) assessment tool dated 9/21/16, Resident #1 had a [DIAGNOSES REDACTED]. The MDS documented the resident was independent for activities of daily living such as transfers, mobility, and ambulation (walking) in their room, but required supervision with ambulation off the unit at times, and occasionally rejected care. Documentation of a physician's visit, dated 8/22/16 (prior to the resident's admission), revealed Resident #1's family planned to transfer him/her to a nursing home due to wandering and concerns that he/she may leave the building (unattended). The Care Plan, dated 9/8/16, identified the resident as at risk for elopement related to progressive dementia. The Care Plan documented Resident #1's spouse resided in the adjoining facility. The Care Plan directed staff to: a. Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television or a book. b. Monitor the resident's location at all times. Document wandering behavior and attempted diversion interventions in the behavior log. Provide stand by assistance for direction when the resident is in the hall. c. Place a movable barrier before the Willow Ridge entrance for distraction. Review of the Fall Risk assessment dated [DATE] identified the resident scored a 10 on the assessment scale. A score of 10 or above represented a high risk for falling. The Nurse's Notes revealed the following documentation: a. On 8/29/16 at 10:00 a.m., Resident #1 was admitted to the facility. The Director of Nursing (DON) documented staff applied a wanderguard bracelet to the resident's person upon admission due to elopement potential as the resident was familiar with the facility. Resident #1 resided in an adjoining facility prior to long term care placement. b. On 8/29/16 at 3:30 p.m., a wanderguard was applied to the resident's right ankle. c. On 8/30/16 at 1:50 p.m., Resident #1 pushed through the locked doors and entered Willow Ridge. The door alarm sounded and staff redirected the resident to the facility, although Resident #1 wanted to leave. d. On 9/1/16 at 1:45 p.m., staff observed Resident #1 holding framed family photos wrapped in newspaper at the Willow Ridge door. The resident was adamant that he/she wanted to return to the old apartment. Staff redirected the resident ten minutes later and unpacked the photos. e. On 9/2/16 at 10:00 a.m., the resident made numerous attempts to leave the facility and was not easily redirected. Staff notified the family, physician and DON. f. On 9/3/16 at 4:30 a.m., the resident looked down the hall and asked about the entrance to Willow Ridge. g. On 9/3/16 at 3:00 p.m., Resident #1 became restless. The resident searched for his/her spouse and wanted to leave the facility. Interventions to redirect the resident were not successful and Resident #1 became agitated and pushed staff to the side. Staff redirected the resident with a snack, but he/she continued to pace the halls to the exits with frequent redirection. h. On 9/6/16 at 4:15 p.m., Resident #1 exited the facility thru the Willow Ridge doors. The wanderguard alarm did not sound and did not lock. Staff followed the resident into Willow Ridge, however they were not able to redirect him/her. The resident exited the Willow Ridge elevator, went down the stairwell and entered his/her spouse's apartment. The resident's spouse returned with the resident and staff to the facility. As Resident #1 entered the facility, the wanderguard alarm sounded. i. On 9/9/16 at 2:35 p.m., Resident #1 stated he/she was going to his/her spouse's apartment. The resident packed belongings and donned his/her coat. Staff redirected the resident to the lounge area near the nurse's station. At 3:30 p.m., the Willow Ridge door alarm sounded. Staff responded and discovered Resident #1 at the door with a housekeeper. Staff redirected the resident to his/her room. j. On 9/10/16 at 1:00 p.m., the resident wandered throughout the facility most of the day and constantly looked for his/her spouse. The resident was not easily redirected. k. On 9/16/16 at 3:45 p.m., Resident #1 walked to the door and looked out the windows. Staff attempted to redirect the resident to the common area, however he/she was determined to leave and informed staff he/she was leaving. Staff frequently observed the resident to ensure the resident remained in the common area. l. On 9/16/16 at 4:00 p.m., staff responded to the door alarm, observed Resident #1 and redirected him/her to the common area. While staff provided assistance to other residents, the door alarm sounded again. Staff responded, discovered Resident #1 at a door, and redirected him/her to the common area. m. On 9/16/16 at an undocumented time, the Nurse's Notes revealed while staff assisted residents to the dining room for the evening meal, they observed Resident #1 in the public bathroom near the Willow Ridge door. Staff continued to provide assistance to residents then realized Resident #1 was missing. Staff J, certified nursing assistant (CNA), went to Willow Ridge to look for the resident. Staff K, registered nurse (RN) and the DON looked in the facility. An unknown female in a car returned Resident #1 to Willow Ridge. Documentation revealed the wanderguard alarm did not sound when Resident #1 exited the facility, but did sound when the resident returned to the facility. n. Resident #1 was transferred from the facility on 9/21/16. Maintenance work orders dated 8/31/16 at 1:50 p.m. revealed nursing staff reported to the maintenance Department a concern; the wanderguard alarm did not sound as Resident #1 exited the facility and entered Willow Ridge. Maintenance work orders dated 9/1/16 at 7:15 a.m. revealed nursing staff reported the wanderguard alarm did not sound when Resident #1 ambulated to the Willow Ridge doors. Information from a safety meeting dated 9/2/16 revealed documentation of interventions to implement to ensure Resident #1 did not exit the facility: Provide hospital staff with a photo and description of Resident #1 in the event he/she wandered, and placement of a yellow barrier (construction barrier) to deter the resident from entering Willow Ridge. On 11/18/16 at 5:32 p.m., Resident #1's family member stated staff notified him Resident #1 escaped the facility, but was returned. The family member stated Resident #1 informed him he/she observed a couple exit the facility and a car picked them up. The resident did the same. Resident #1 informed the family member he/she went to the big building with all the cars by the school to watch all the people. Someone informed him/her it was Homecoming. Resident #1 visited with a spectator while away and requested a ride to Willow Ridge. Upon return to Willow Ridge, Resident #1's spouse and Staff J were waiting. Resident #1's family member was unaware who gave the resident a ride. The family member stated the resident's story made sense because while he/she resided at Willow Ridge, he/she frequently commented on all the cars and activity at the school and enjoyed watching. The resident's family member stated he was not sure how the resident exited the facility without the alarm sounding as the family member had seen the alarm sound/door lock before when the resident took him near an exit door. When the alarm sounded, Resident #1 had assured their family member it was ok and staff would turn it off. Staff interviews contained the following reports: a. On 11/18/16 at 10:33 a.m. Staff J, CNA, stated on 9/16/16 at the beginning of the shift, the DON informed her the Willow Ridge wanderguard alarm did not always sound and directed her to keep a watchful eye on Resident #1. Staff J stated Resident #1 knew his/her spouse resided at Willow Ridge and attempted to exit the facility from the time he/she was admitted . The resident learned if he/she got too close to certain doors the wanderguard would sound. On 9/16/16, Staff J observed Resident #1 near the Willow Ridge door and intervened before the resident was near the exit. She redirected Resident #1 to the lounge area across from the nurses station for closer observation. She then proceeded to assist residents. Staff J was not certain whether or not the nurse was at the nurses station at this time. Resident #1 continued to try to exit the facility as staff assisted other residents to the dining room for the evening meal. Staff J stated at approximately 5:20-5:30 p.m. she observed Resident #1 in the public bathroom near the Willow Ridge exit. She directed the resident to the dining room for dinner, then proceeded to provide assistance to another resident. When she returned to the dining room, staff noticed Resident #1 was missing. Staff J did not hear the wanderguard alarm sound. Staff J went to Willow Ridge to search for Resident #1. The resident was not located in his/her spouse's apartment. Staff J reported at approximately 5:45 p.m., an unknown female drove Resident #1 to Willow Ridge entrance and stated the resident was near the high school football field. The resident informed Staff J he/she went to Willow Ridge and exited the facility thru the door on the Willow Ridge side of the facility (east side). Staff J assisted Resident #1 back to the facility. Upon entering the facility thru the Willow Ridge door the wanderguard alarm sounded. Staff J stated it was a busy shift and it was Staff K's first shift by herself. The DON had worked as an aide that shift and also assisted Staff K. b. On 11/17/16 at 3:45 p.m. Staff K, licensed practical nurse (LPN), stated 9/16/16 was her first shift alone. At approximately 3:00 p.m. staff responded to the Willow Ridge wanderguard alarm. Resident #1 attempted to exit the facility through Willow Ridge exit. She brought Resident #1 back into the facility. Resident #1 stated he/she was leaving. Staff kept a close eye on the resident. Staff K last observed Resident #1 in the dining room. Staff K, Staff J and the DON continued to provide transfer assistance to residents. At approximately 5:30 p.m. Staff K observed the public bathroom door open and Resident #1 missing. Staff K reported the wanderguard alarm did not sound when Resident #1 exited the facility. Staff K searched the facility and Staff J went to Willow Ridge to look for the resident. At approximately 5:45 p.m. someone returned Resident #1 to Willow Ridge. Staff K stated after the elopement, the facility put a rush on getting the alarms fixed, and someone informed her they were waiting for quotes. She was aware the Willow Ridge wanderguard alarm did not always alarm when Resident #1 was near the exit door. c. On 11/17/16 at 1:45 p.m. Staff E, registered nurse (RN), stated Resident #1 was difficult to redirect when he/she decided to leave the facility and the Willow Ridge door alarm did not always sound when the resident was near. She reported the concern to maintenance staff. Staff E recalled once Resident #1 read the sign and knew if he/she held the door for 15 seconds, the door would open. The alarm did not sound. Staff followed the resident to the elevator in Willow Ridge, where they were able to guide him/her back to the facility. Staff E reported the concern to maintenance staff. d. On 11/17/16 at 2:55 p.m. Staff H, LPN, stated Resident #1 mentioned leaving the facility and could redirect him/her at times. If redirection was not effective, she kept a very close eye on the resident. Resident #1 knew he/she lived at Willow Ridge. Staff H always intervened and redirected the resident if she noticed the resident walking toward Willow Ridge. Interventions used included placing the resident in the commons area near the nurses station and provide activities. f. On 11/18/16 at 3:09 p.m. Staff P, LPN, stated Resident #1 was very determined to exit. The resident had dementia but could figure out how to try to exit when staff were not in the halls. Staff P intervened before the resident was near the exit doors. She was aware of an instance prior to the elopement that the wanderguard alarm near the Willow Ridge entrance did not sound. Staff P reported the concern. She attended a Senior Leader meeting and worked with a team to develop interventions to ensure safety. She stated they provided a photo of Resident #1 with information to notify the facility if observed wandering. They also placed a barrier in front of the Willow Ridge entrance in attempt to stop Resident #1. Resident #1 quickly learned how to move the barrier. Staff P recalled once Resident #1 attempted to sell her his/her room at the facility because the resident thought if the room was no longer available he/she could leave. The resident showed Staff P his/her room and highlighted various aspects of comfort and location. The resident then opened his/her closet and was surprised his/her personal items were present as he/she packed daily. h. On 10/27/16 at 5:35 p.m. Staff B, CNA, stated she was aware the wanderguard system had problems since last summer. Every once in awhile she found a resident near the exit door and the alarm did not sound so she notified the charge nurse. She stated maintenance attempted to repair the system several times. At this time, Staff B demonstrated the alarm function by opening the door. A magnetic alarm above the door sounded once, staff responded. Documentation of door alarm checks for the month of September, 2016 revealed the door alarm checks began 9/30/16. During an interview on 10/27/16 at 5:40 p.m., the Director of Nursing (DON) stated on 9/16/16 Resident #1 exited the facility without a staff member. The DON reported prior to admission to the facility, Resident #1 resided with his/her spouse at an independent living facility, Willow Ridge. The DON also reported the resident admitted to the facility for approximately 3 weeks prior to the elopement; Willow Ridge is connected to the facility by a door that was alarmed with a wanderguard alarm system. Because all are connected, Willow Ridge tenants walk through the nursing facility to get to the hospital or physician's office. The DON stated Resident #1 had considered Willow Ridge home. The DON stated on 9/16/16 at (approximately 5:30 p.m.) staff discovered Resident #1 was missing. Staff J, certified nursing assistant (CNA), searched Willow Ridge while the DON and Staff K, licensed practical nurse (LPN), searched the facility. The DON stated she received a call from Staff J who stated an unknown community member discovered Resident #1 near the local high school and drove him/her to Willow Ridge. Staff J met Resident #1 at the south entrance of Willow Ridge. The DON stated Resident #1 expressed a desire to go home prior to the elopement. The DON reported at the time of the elopement, Resident #1 had been wearing a new wanderguard bracelet with an expiration date in 2017. The DON stated the wanderguard alarm did not sound when the resident exited the facility, however the alarm did sound upon the resident's return to the facility. After the resident was returned to the facility, the DON reported interventions such as utilization of a personal alarm and an alarmed floor mat were implemented to alert staff when Resident #1 exited his/her room. The facility also added an additional security alarm to the door on 9/30/16 to alert staff if someone left the facility as a temporary measure until the door system can be updated. During an observation on 10/27/16 at 6:08 p.m., the DON explained how the door alarm had functioned: The wanderguard system was triggered by a wanderguard bracelet worn by residents identified at risk for elopement. The resident wore the device that alarmed/locked exit doors when the resident came near. The alarm sounded to alert staff that a resident who wore a wanderguard bracelet is near an exit door. On 11/22/16 at 11:48 a.m., the Director of Nursing (DON) confirmed the wanderguard door alarm did not consistently sound prior to Resident #1's elopement and the concern had been reported to maintenance staff. The facility abated the immediate jeopardy on 9/16/16 when they implemented the following: 1. The facility checked the resident every thirty minutes. 2. The facility applied an alarm to the resident's door that sounded when the resident opened the door, and put a mat alarm on the floor outside the door that sounded when the resident walked out of his/her room. Additionally, the next day the staff noted the resident learned how to step over the door mat and disarm the alarm attached to his/her doorway. The facility immediately initiated constant supervision by staff or family until the resident was transferred on 9/21/16.

Based on record review and staff interview, the facility failed to care plan [MEDICAL CONDITION] medications for 3 of 5 residents receiving [MEDICAL CONDITION] medications (Residents #1, #8, and #9). The facility reported a census of 21 residents. Findings include: 1. The annual Minimum Data Set (MDS) assessment tool, dated 2/19/16, identified Resident #1 with a Brief Interview for Mental Status score of 11, indicating moderately impaired cognition. A score of 13 to 15 indicated intact cognition. The MDS revealed the resident received an antidepressant medication 7 days in the previous 7 day look back period. Review of the CAA (Care Area Assessment) Summary of the MDS revealed [MEDICAL CONDITION] Drug Use triggered and the decision made to care plan. The Psychiatric Drug Use CAA Worksheet dated 2/19/16, indicated the facility planned to develop a care plan for symptom relief or palliative measures. The April 2016 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] (antidepressant medication) 10 mg. (milligrams) daily related to screening for depression. The resident's care plan with goal dates of 5/2016 lacked documentation the resident had any type of mood disorder and lacked documentation the resident received an antidepressant. The care plan had no plan that identified goals, interventions, and potential side effects related to the administration of [MEDICATION NAME]. During an interview 4/6/16 at 1:30 p.m., the MDS Coordinator verified the resident's care plan lacked documentation the resident received an antidepressant. 2. The quarterly Minimum Data Set (MDS) assessment, dated 3/18/16, identified Resident #8 with severely impaired cognition and behaviors included delusions, physical symptoms directed toward others, care rejection, and wandering. The MDS revealed the resident's [DIAGNOSES REDACTED]. The April 2016 MAR indicated [REDACTED]. daily for senile dementia and [MEDICATION NAME] (antipsychotic medication) 0.5 mg. twice daily for unspecified dementia without behavior disturbances. The resident's care plan with goal dates of 6/2016 identified the resident had cognitive impairment and impaired thought processes related to dementia. The same care plan identified the resident with a potential for falls related to dementia and an intervention revealed the pharmacy consultant planned to evaluate medications (start date 2/4/14). The care plan lacked documentation the resident received [MEDICATION NAME] and [MEDICATION NAME] and a plan that identified goals, interventions, and potential side effects related to the administration of the medications. During an interview 4/6/16 at 1:30 p.m., the MDS Coordinator verified the resident's care plan lacked documentation the resident received any [MEDICAL CONDITION] medications. 3. The 2/5/16 MDS assessment tool identified Resident #9 with severely impaired cognition, without behaviors, and lacked documentation the resident had any neurological, psychiatric, or mood diagnoses. The MDS revealed the resident received an antidepressant medication 7 days in the previous 7 day look back period. The MDS lacked documentation the resident received an antipsychotic medication. A Psychoactive Medication Quarterly Evaluation Second Quarter sheet, dated 11/20/15, revealed the resident received [MEDICATION NAME] (antipsychotic medication) and [MEDICATION NAME] (antidepressant medication). The April 2016 MAR indicated [REDACTED]. daily for irritability with behaviors (start date 9/3/15). The resident's care plan with goal dates of 5/16 lacked documentation the resident had any type of psychiatric, neurological, or mood disorder and lacked documentation the resident received [MEDICATION NAME] and [MEDICATION NAME]. The care plan lacked a plan that identified goals, interventions, and potential side effects related to the administration of the medications. During an interview 4/6/16 at 1:30 p.m., the MDS Coordinator verified the resident's care plan lacked documentation the resident received any [MEDICAL CONDITION] medications.

Based on record review, observation, and staff interviews, the facility failed to follow professional standards for medication administration for 1 of 7 residents observed (Resident #8). The facility reported a census of 21 residents. Findings include: 1. The Minimum Data Set (MDS) assessment, dated 3/18/16, identified Resident #8 was admitted to the facility 1/22/14 and had severely impaired cognition. The MDS identified the resident with [DIAGNOSES REDACTED]. The April 2016 Medication Administration Record [REDACTED] During an observation 4/5/16 at 7:00 a.m., Staff A, Licensed Practical Nurse (LPN) verified the resident's [MEDICATION NAME] dose on the MAR. Staff A removed the [MEDICATION NAME] pen from the refrigerator in the medication room, attached the needle to the insulin pen, and selected 27 units on the [MEDICATION NAME] pen. Staff A failed to perform the safety test by clearing the needle with 2 units of [MEDICATION NAME] before she administered the [MEDICATION NAME] at 7:05 a.m. The resident winced and yelled out that the injection hurt. During an interview 4/5/16 at 7:02 a.m. Staff A stated she had never cleared the [MEDICATION NAME] pen with 2 units of insulin before administering. During an interview 4/5/16 at 9:10 a.m., Staff A reviewed and verified the [MEDICATION NAME] Instruction Leaflet, revised in July 2015. The instruction leaflet directed the following: a. Perform a safety test by turning the pen to 2 units, hold the pen upwards, tap the insulin reservoir to remove air bubbles, press the injection button all the way, and make sure insulin comes out of the needle tip. The instructions stated the safety test ensures the pen in correct working order and an accurate dose administered. b. The pen storage instructions directed staff to remove the [MEDICATION NAME] pen from the refrigerator 1 to 2 hours before administration and that cold insulin causes more pain when injected. The instructions directed the [MEDICATION NAME] can be stored at room temperature up to 86 degrees Fahrenheit after opened and to dispose the pen after 28 days of use if not empty. During an interview 4/6/16 at 9:30 a.m., the MDS Coordinator stated she had cleared the [MEDICATION NAME] pen needle with 1 unit of insulin and the resident had received [MEDICATION NAME] since admission to the facility on [DATE].

Based on observation, clinical record review and staff interview the facility failed to ensure the services provided by the facility must be provided by qualified persons in accordance with each residents plan of care for 1 of 9 residents reviewed, (Resident #2). The facility reported a census of 21 residents. Findings include: According to the Minimum Data Set with assessment reference date of 3/4/16, Resident #2 had severely impaired cognitive skills for daily decision making and totally dependent on staf for transfers, toileting and had not ambulated. The resident had [DIAGNOSES REDACTED]. Resident #2's Care Plan included a focus, initiated 1/20/14, of the resident at risk for falls related to confusion, psychoactive drug use and gait/balance problems. Interventions included an EZ Stand (mechanical lift) for all transfers and toileting, monitor the resident to insure he/she does not unbuckle self from lift while in use, initiated on 6/10/15. On 10/5/15 intervention added use prime snap with tab alarm. A Physical Therapy Progress Note dated 2/4/16 indicated Resident #2 primarily transfers with assist of two or EZ Stand. The EZ Stand is always used in the bathroom. Resident #2's Nurse Notes dated 4/3/16 at 6:30 p.m. showed the resident slide to floor in the bathroom while transferring to the wheelchair from toilet. Noted a 5 inch by 1 inch abrasion in right mid-back area, no drainage noted. Aide stated she had turned her back for a brief second to dispose pad when the resident attempted to stand and slid to the floor. Neuro's intact. The resident denied pain and can move all four extremities without difficulty. Encouraged resident to wait before transferring self. The Incident Investigation dated 4/3/16 included investigation done by the Director of Nursing, (DON). The DON received a phone call from Staff B, Registered Nurse (RN) to notify her Resident #2 had fallen in the bathroom. Staff B stated Staff C, Certified Nursing Assistant (CNA), was yelling help when Staff B went in and the resident had fallen to the floor according to Staff C. Staff B assisted Staff C and the resident was assisted into the wheelchair safely with no injury. The DON spoke with Staff C who voiced she had not used the EZ Stand as care plan stated it is to be used in the bathroom. Staff C stated she transferred the resident to the chair, turned her back to put clothes in a bin, when Resident #2 attempted to pull self up by the grab bars. The brakes were not locked and the wheelchair rolled out from under him/her. Staff C saw the resident begin to fall and tried to assist him/her to the floor. During interview on 4/5/16 at 12:45 p.m. The DON stated she had completed the investigation of Resident #2's fall on 4/3/16. The DON stated staff had not used the EZ Stand for transfer as directed in the care plan and the staff member will be receiving a written warning and is aware of it. During observation on 4/4/16 at 2:40 p.m. Staff D, CNA, went to Resident #2 to assist to the toilet. The resident was sitting in a recliner across from nurse's station with a prime snap tab alarm in place. Staff D had brought the EZ Stand to assist with transfer to the wheelchair. Staff D unhooked the prime snap tab alarm and transferred the resident with EZ Stand to the wheelchair. Staff D did not hook the prime snap tab alarm to the resident. Staff D took the EZ Stand around the corner and down the hall to the residents room to use to transfer the resident from the wheelchair to the toilet. When Staff D came back to the resident she hooked the prime clip alarm to the resident and stated, I guess I should have put that on him/her before.