Every finding on record at Prestige Care Center of Fairfield

Based on a facility list of residents who utilized a mechanical lift, policy review, and staff interviews, the facility failed to launder mechanical lift slings according to manufacturer instructions for 11 of 11 residents who utilized mechanical lift slings. The facility reported a census of 54 residents.Findings included:The undated facility List of Hoyer(a type of mechanical lift) Slings, provided to the survey team on 7/1/26, documented 11 residents who utilized a mechanical lift. During a tour of the laundry on 7/1/26 at 10:15 a.m., Staff H Director of Housekeeping stated the facility dried mechanical lift slings in the dryer at a normal heat setting. She stated the facility did not dry them on a lower heat setting and stated this had been the practice since she began at the facility in 2024. Following the interview, Staff H provided a mesh mechanical lift sling and a solid material mechanical lift sling. Both slings had labels affixed to them which directed staff to air dry or tumble dry the slings at a lower temperature. The facility policy Safe Resident Handling/Transfers revised 6/2026, directed staff to launder mechanical slings according to manufacturer's instructions.

Based on observation, facility policy review and staff interview, the facility failed to ensure dietary staff prepared and served food in accordance with safe hygienic practices to prevent cross-contamination of foods for 1 of 1 observation of a meal service. The facility reported a census of 54 residents.Findings include:During an observation on 6/29/2026 at 11:29 AM, Staff R, [NAME] and the Dietary Manager prepared meals. Both staff members wore gloves. Staff R opened a drawer to retrieve a pair of tongs, removed a lid from a steam table container with her gloved hand, and used the tongs to place three chicken-fried steak patties into a blender. Using a 2-ounce spoon, Staff R carried a spoonful of broth from a pan on the stove across the kitchen and added it to the blender. Staff R then reached into a drawer to retrieve a spatula. After pushing the patties further down into the blender, Staff R carried three more spoonfuls of broth across the kitchen, one at a time, to add to the blender. Staff R held her gloved hand under the spoon. Broth spilled into Staff R's gloved hand, and she then poured the spilled broth into the blender. Next, Staff R pureed carrots and mashed potatoes separately. After completing the purees, Staff R removed the lids from the blenders and opened drawers to retrieve spatulas and serving spoons. Staff R then opened a loaf of bread and pulled out three slices of bread using her gloved hand. She placed the bread into a blender with milk and pureed it. Staff R wore the same pair of gloves throughout the entire observation.During an observation on 6/29/26 at 12:04 PM, Staff R, Cook, started lunch meal service. Staff R used her gloved hands to take lids on and off food throughout the meal service. Staff R used tongs and spoons to serve the food. After dishing up food for the sixth resident, Staff R reached into a refrigerator, located behind the steam table, to get out barbeque sauce. Staff R squirted sauce onto a resident's plate and then returned the sauce to the refrigerator. Staff R observed touching a plastic-coated menu located on the top of the steam table with each resident meal plated. During preparing the eighth resident plate, Staff R reached her gloved hand into a loaf of bread, pulled out a slice, and placed it on the plate. Staff R then reached into the refrigerator to get butter patties. Staff R reached into the loaf of bread with her gloved hand to grab a slice of bread for each of the last three residents with a room tray. Staff R wore the same pair of gloves throughout the entire observation.During an interview on 6/30/2026 at 1:33 PM, the Dietary Manager (DM) stated dietary staff needed to wash their hands when going from the dining room to the kitchen, before putting on and after taking off gloves. The DM stated dietary staff needed to change their gloves after touching food, touching their face or any part of their body, after touching surfaces such as opening the refrigerator or opening drawers. Review of the facility's policy, titled Food Safety Requirements for Outside of Vendor Food Source Policy, dated 1/2026, revealed, in part, when preparing food, staff shall take precautions in critical control points in the food preparation process to prevent, reduce, or eliminate potential hazards .Staff shall adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects .Staff shall wash hands according to facility procedures .Staff shall not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure the provision of pneumococcal and/or influenza vaccines and/or obtain informed consents or declinations for the vaccines for 5 of 5 residents reviewed for immunizations(Residents #2, #8, #10, #21, and #23). The facility reported a census of 54 residents.Findings included:1. The Minimum Data Set (MDS) assessment tool dated 5/21/26 lists diagnoses of chronic pain, morbid obesity, and diabetes for Resident #2. The Brief Interview for Mental Status (BIMs) score of 15 out of 15, indicates intact cognition.Review of the electronic health record (EHR) Clinical - Immunizations section revealed Resident #2 refused the pneumococcal vaccine. The EHR lacked documentation that the staff educated the resident or her representative on the risks and benefits of the vaccine, and of the resident's declination. 2. The MDS assessment tool dated 5/15/26 lists diagnoses of heart failure Alzheimer's disease, and non-Alzheimer's dementia for Resident #8. The BIMS score of 6 out of 15, indicates severely impaired cognition. Review of the EHR Clinical - Immunizations section revealed Resident #8 received the Prevnar 20 (a type of pneumococcal vaccine) on 10/28/25. The EHR lacked documentation that the staff educated the resident or her representative of the risks and benefits of the vaccine, and of the resident's consent for the vaccine.3. The MDS assessment tool dated 4/1/26 lists diagnoses of heart failure, abnormal posture, and muscle weakness for Resident #10. The BIMS score of 4 out of 15, indicates intact cognition. Review of Resident #10's EHR Clinical - Immunizations section revealed a lack of documentation to indicate if the resident received or refused the influenza or pneumococcal vaccine. The EHR lacked documentation that the staff educated the resident or his representative on the risks and benefits of the vaccine, and the resident's consent for or declination of the vaccine.4. The MDS assessment tool dated 6/6/26 lists diagnoses of anxiety, depression, and muscle spasms of the back for Resident #21. The BIMS score of 15 out of 15, indicates intact cognition. Review of the EHR Clinical - Immunizations section revealed Resident #21 received the Prevnar 20 vaccine on 10/21/25. The EHR lacked documentation that the staff educated the resident or her representative of the risks and benefits of the vaccine, and the resident's consent for the vaccine.5. The MDS assessment tool dated 3/28/26 lists diagnoses of non-Alzheimer's dementia, depression, and insomnia for Resident #23. The BIMS score of 12 out of 15, indicates moderately impaired cognition.Review of the EHR Clinical - Immunizations section revealed Resident #23's received a PPSV23 (a type of pneumococcal vaccine) on 12/4/19 and PCV13 (a type of pneumococcal vaccine) on 11/28/18. The EHR lacked documentation to indicate if the resident received or declined the most current pneumococcal vaccine (Prevnar 20), and lacked documentation that the staff educated the resident or her representative on the risks and benefits of the vaccine, and the resident's consent for or declination of the vaccine.On 7/1/26 at 12:13 p.m., the Director of Nursing (DON) stated residents should be up to date on their immunizations. The Center for Disease Control and Prevention's (CDC's) Pneumococcal Vaccine Recommendations, dated 2/25/26, retrieved from https://www.cdc.gov/pneumococcal/hcp/vaccine-recommendations/index.html on 7/7/26, stated adults over the age of 65 years or older had the option to receive PCV 20 or 21(types of pneumococcal vaccinations) if they received both PCR13 and PPSV23 over the age of [AGE] years old.The facility policy Influenza Vaccination, revised 10/2025, stated the facility offered residents annual immunization against influenza. Prior to administration, the facility would provide the resident with information regarding the benefits and potential side effects of the vaccine.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure the provision of COVID-19 vaccine for 1 of 5 (Resident #10) residents, and failed to obtain an informed consent or declination for the vaccine for 5 of 5 (Resident #2, Resident #8, Resident #10, Resident #21, and Resident #23) residents reviewed for immunizations The facility reported a census of 54 residents.Findings include: 1. The Minimum Data Set (MDS) assessment tool dated 5/21/26 lists diagnoses of chronic pain, morbid obesity, and diabetes for Resident #2. The Brief Interview for Mental Status (BIMs) score of 15 out of 15, indicates intact cognition.Review of the electronic health record (EHR) Clinical - Immunizations section revealed Resident #2 refused a COVID -19 vaccine. The EHR lacked documentation that staff educated the resident or her representative on the risks and benefits of the vaccine, and of the resident's declination. 2. The MDS assessment tool dated 5/15/26 lists diagnoses of heart failure Alzheimer's disease, and non-Alzheimer's dementia for Resident #8. The BIMS score of 6 out of 15, indicates severely impaired cognition. Review of the EHR Clinical Immunization section revealed Resident #8 received a COVID -19 booster on 1/8/26. The EHR lacked documentation that staff educated the resident or her representative on the risks and benefits of the vaccine, and of the resident's consent. 3. The MDS assessment tool dated 4/1/26 lists diagnoses of heart failure, abnormal posture, and muscle weakness for Resident #10. The BIMS score of 4 out of 15, indicates intact cognition. Review of Resident #10 EHR Clinical Immunization section revealed a lack of documentation to indicate if the resident received or refused a COVID-19 vaccine. The EHR lacked documentation that staff educated the resident or his representative on the risks and benefits of the vaccine, and resident's consent for or declination of the vaccine.4. The MDS assessment tool dated 6/6/26 lists diagnoses of anxiety, depression, and muscle spasms of the back for Resident #21. The BIMS score of 15 out of 15, indicates intact cognition. Review of Resident #21's EHR Clinical Immunization section revealed she received a COVID -19 booster on 1/8/26. The EHR lacked documentation that the staff educated the resident or her representative on the risks and benefits of the vaccine, and the resident's consent. 5. The MDS assessment tool dated 3/28/26 lists diagnoses of non-Alzheimer's dementia, depression, and insomnia for Resident #23. The BIMS score of 12 out of 15, indicates moderately impaired cognition. Review of Resident #23's EHR Clinical Immunization section revealed she received a COVID-19 booster on 1/8/26. The EHR lacked documentation that the staff educated the resident or her representative of the risks and benefits of the vaccine, and the resident's consent. On 7/1/26 at 12:13 p.m., the Director of Nursing (DON) stated residents should be up to date on their immunizations. The facility policy COVID-19 Vaccination, revised 12/2025, stated the facility would minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 by educating and offering residents the COVID-19 vaccine. The facility would provide education regarding the risks, benefits, and potential side effects of the COVID-19 vaccine.The Centers for Disease Control and Prevention's (CDC's) guidance Staying Up to Date with COVID-19 Vaccines retrieved from https://www.cdc.gov/covid/vaccines/stay-up-to-date.htmlz on 7/7/26 stated the CDC recommended a 2025-2026 COVID-19 vaccine for people ages 6 months and older based on individual-based decision-making. The guidance stated protection from the COVID-19 vaccine decreased with time.

Based on observation, clinical record review, facility policy review, resident and staff interview, the facility failed to ensure staff treated residents with dignity and respect for 2 of 18 sampled residents (Residents #13 and Resident #40). The facility reported a census of 54 residents. Findings include: 1.Review of Resident #13's Minimum Data Set (MDS) assessment dated [DATE], revealed intact cognition based on a Brief Interview for Mental Status (BIMS) score of 14 out of 15. Diagnoses included irritable bowel syndrome, and morbid obesity. The MDS indicated an upper body impairment on one side and lower body impairments on both sides. The resident dependent on staff for toileting, hygiene, and transfers, needs partial assistance to roll in bed, and always incontinent of urine and frequently incontinent of bowel. During an observation on 6/29/26 at 2:22 PM, Staff K, Certified Nurse's Aide (CNA), answered the call light for Resident #13. Staff K knocked on the closed room door, entered and shut the door behind herself. At 2: 33 PM, Staff K, CNA, knocked and entered Resident #20's room to assist Staff L, CNA, with a mechanical lift transfer. Both Staff K and Staff L completed the transfer and exited Resident #20's room at 2:48 PM. At 2:48 PM, Staff D, CNA, exited Resident #13's room, shut the door behind him and grabbed a pair of gloves located outside of the room door. During an interview with Staff D, he stated Resident #13 did not have a brief on and that was a problem. Staff D then knocked on Resident #13's door, and after the resident acknowledged him, he entered the room. Upon entering, Resident #13 found to be facing away from the door with her buttocks uncovered and exposed to the open doorway. A strong bowel movement smell present in the room. Staff L, CNA, knocked and entered the room. Staff D came out of Resident #13's room and stated when he initially entered the room he found the resident to have a bare bottom. Staff D got supplies, including wet wipes, a cloth bed chux (type of reusable incontinent pad placed under residents) and bed linens, and then returned to Resident #13's room. Staff D and Staff L exited the resident's room at 2:58 PM. During an interview on 6/29/2026 3:01 PM, Resident #13 identified Staff K, CNA, as the staff who responded to her call light. The resident was unsure if Staff K had assisted her on or off the bed pan. The resident thought she had already had a BM, and had put her call light on to request assistance with getting cleaned up. The resident reported an inability to roll herself in bed without assistance, and stated the first staff had left on her right side facing away from the room door with her bottom bare. The resident reported Staff K couldn't find the supplies she needed and left the room. Resident #13 reported Staff K returned at some point and dropped off a bed chux on her sink counter. Observation revealed a folded cloth bed chux on the resident's counter by her sink. The resident denied being upset, and stated she had been unclear as to why the aide left and did not return promptly. During an interview on 6/29/2026 at 3:06 PM, Staff K, CNA, reported she responded to Resident #13's call light. The resident asked to get off the bedpan. Staff K reported she took the resident off the bedpan, and the resident had not gone to the bathroom yet. Staff K reported the resident did not have the supplies she needed in the room except for briefs. Staff K left to find a bed chux and wet wipes. During the interview, Staff K reported she had still not been able to find the supplies she needed. Staff K reported being unsure if she had left the resident covered or not when she left the room. During an interview on 6/29/2026 at 3:18 PM, Staff D, CNA, stated he walked into Resident #13's room to check on her. He found the resident on her right side, facing away from door with her bottom bare and large amount of BM on the resident and on her bed. Staff D reported the resident told him that she had been waiting for someone to come in and help her. The resident had him where the aide was and then stated the aide told the resident they would come back. During an interview on 6/29/2026 at 3:42 PM, Staff L, CNA, stated when he went to get help to transfer Resident #20, he found Staff K, CNA, by the linen closet. Staff K told him that she was getting a chux for Resident #13's bed, and she would be there to help Staff L after she put the chux in Resident #13's room. Staff L reported Staff K did not say anything about Resident #13 waiting on Staff K for assistance. During an interview on 7/01/2026 at 12:14 PM, the Director of Nursing reported it was acceptable to leave a resident's room to get supplies, but it was not acceptable for staff to leave to help another resident once the CNA had started cares on a resident. 2. The MDS assessment dated [DATE] revealed Resident #40 scored a 15 out of 15 on the BIMS exam, which indicated cognition intact. During an interview on 7/1/26 at 9:31 AM, Staff D, Certified Nurse Aide (CNA) queried on staff interactions with residents and he stated he had heard Staff E, Dietary Aide call Resident #40 a ***ch. Staff D stated Staff E had been upset he needed to remake a plate for the resident. Staff D stated Staff E also told the resident You should know what you wanted. Staff D stated the incident occurred in early June 2026 During an interview on 7/1/26 at 1:21 PM, Staff E, Dietary Aide queried about the incident with Resident #40 and Staff E stated he cussed around Resident #40 but not at her. Staff E asked why he cussed and Staff E stated because he tended to cuss when talking. Staff E queried on what he said and Staff E stated he didn't remember. During an interview 7/1/26 at 2:15 PM, the Administrator queried on the incident dietary staff in the dining room and the Administrator stated she knew something about Staff E getting loud in the dining room and the Administrator had a meeting with the dietary team about appropriate conversations and language. Review of the facility policy titled Resident Rights Policy dated 2/2026 revealed a Policy Explanation and Compliance Guidelines section which directed, in part: All residents will be treated equally regardless of age, race, ethnicity, religion, culture, language, physical or mental disability, socioeconomic status, sex, sexual orientation, or gender identity or expression.

Based on clinical record review, facility policy review, resident and staff interview, the facility failed to ensure staff informed the residents and families of the risks, benefits and side effects of psychotropic medications prior to the administration of those medications for 3 of 3 residents sampled (Residents #54, #7 and #11). The facility reported a census of 54 residents. Findings include: 1. Review of the Minimum Data Set (MDS) Assessment for Resident #54 dated 4/20/26, revealed a Brief Interview for Mental Status (BIMS) score of 2 out of 15, which indicated the resident had a severe cognitive impairment. The MDS listed a primary diagnosis of senile degeneration of the brain. The MDS indicated the resident prescribed antipsychotic and antidepressant medications. Review of Resident #54's Care Plan, last revised 4/20/26, revealed, in part, the following Focus areas and Interventions: a.uses antidepressant medication. 4/9/25 increase in Lexapro. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-depressant drugs being given. b. The resident uses psychotropic medications r/t hallucinations. 1/14/26 new order for Quetiapine bid added to Risperidone started on the 10th (1/10/26). Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of psychotropic medication drugs being given. Review of the Clinical Physician Orders listing, revealed the following psychotropic medication orders: a. quetiapine (generic Seroquel, an antipsychotic) 50 milligrams (mg) tablet, take one-half tablet (25 mg) by mouth twice daily with a 6/5/26 start date. b. lorazepam (an antianxiety) 0.5 mg tablet, take one tablet by mouth twice daily with a 5/14/26 start date. c. risperdone (an antipsychotic) 0.5 mg tablet, take one table by mouth every evening with a 1/9/26 start date. d. bupropion (antidepressant) 300 mg extended length tablet, take one tablet by mouth daily with a 12/31/25 start date. A review of the clinical record lacked signed informed consents for the prescribed psychotropic medications prescribed. Review of a separate folder revealed unsigned and undated consent forms for Resident #54, which included bupropion, risperidone, and Seroquel (quetiapine). During an interview on 7/1/26 at 11:14 AM, the MDS Coordinator stated she is responsible for completing psychotropic medication consent forms with the residents and their representatives. She stated she assumed this responsibility after the last Director of Nursing left. She stated she is behind on getting psychotropic consent forms done. The MDS Coordinator added the previous DON had not been gotten consents signed. The MDS Coordinator explained she had not had time to work on the consents due to covering night shifts for the last couple months. The MDS Coordinator reported she had difficulty getting a hold of the responsible person for Resident #54, and just tried again yesterday (6/30/26). During an interview on 7/1/26 at 11:25 AM, the Administrator reported the previous DON left her position in January 2026. During an interview on 7/01/2026 at 12:27 PM, the DON explained nursing staff should complete psychotropic medication consent forms with the residents and families upon admission if the resident already takes the medication. She added nursing staff must also obtain a consent when initiating psychotropic or if there is a change in dosage. The DON explained the purpose of the psychotropic medication consents forms were to inform the residents and families of the risks, benefits and side effects of the medication so they could make an informed decision. 2. Review of Resident #11's MDS assessment tool dated 6/20/26, revealed a BIMS score of 1 out of 15, indicating a severe cognitive impairment. The list of diagnoses included Alzheimer's disease, anxiety, and depression. The MDS indicated the resident prescribed antipsychotic, antianxiety, and antidepressant medications. Review of the June 2026 Medication Administration Record (MAR) revealed Resident #11 prescribed: a. bupropion 150 mg daily. Start Date: 2/12/26. D/C (discontinue) Date: 6/22/26. b. fluoxetine (an anti-depressant) 20 mg daily. Start Date: 6/14/26. D/C Date: 6/22/26. c. haloperidol (an antipsychotic) 1 mg twice daily. Start Date: 10/30/25. D/C Date: 6/22/26. d. lorazepam 2 mg every 2 hours. Start Date: 6/28/26. D/C Date: 6/29/26. e. olanzapine (an antipsychotic) 5 mg twice daily. Start Date: 5/30/26. D/C Date: 6/22/26. f. quetiapine 100 mg twice daily. Start Date: 5/27/26. D/C Date: 6/22/26. g. risperidone 0.5 mg twice daily. Start Date: 6/16/26. D/C Date: 6/20/26. Review of Resident #11's clinical record lacked signed informed consent forms for the prescribed psychotropic medications. 3. Review of Resident #7's MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated intact cognition. The list of diagnoses included anxiety disorder, depression, schizophrenia, and Post Traumatic Stress Disorder (PTSD). The MDS indicated resident took antipsychotic, antidepressant, and antianxiety medications. The Care Plan revealed the following Focus areas and Interventions: a. Dated 11/25/25, Resident uses antidepressant medications. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of antidepressant drugs being given. b. Dated 6/18/25, Resident uses psychotropic medications. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of psychotropic medication drugs being given. c. Dated 11/19/24, Resident uses anti-anxiety medications. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-anxiety medication drugs being given. Review of the Clinical Physician Orders revealed Resident #7 prescribed: a. trazodone (anti-depressant) 50 mg - take 1/2 tablet by mouth. Start Date: 10/15/25. b. duloxetine HCL (an anti-depressant) 60 mg- give one cap by mouth twice a day. c. clozapine (an antipsychotic) 200 mg- take one tablet by mouth twice daily. Start Date: 5/27/21. d. bupropion tablet 150 mg XL (extended release)- take 1 table by mouth daily. Start Date: 11/25/25. Review of Resident #7's clinical record lacked signed informed consent forms for the prescribed psychotropic medications. During an interview on 6/30/26 at 11:47 AM, Resident #7 stated he never signed consents for his psychotropic medications and the facility really hadn't spoken to him about his psychotropic medications. Review of the facility policy titled Use of Psychotropic Medication revised 5/2026, revealed a Policy statement which declared: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The Policy Explanation and Compliance Guidelines section directed, in part: 5. Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions.

Based on clinical record review, facility policy review, resident representative and staff interviews, the facility failed to notify the family and the physician that 1 of 1 resident (Resident #21) reviewed for notification missed six doses of an anti-anxiety medication scheduled for administration two times daily. The facility reported a census of 54 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The list of diagnoses included anxiety disorder, and the resident prescribed an anti-anxiety medication. Review of the Clinical Physician Orders section in the electronic health record (EHR) revealed an order for Alprazolam tablet 0.5 milligram (mg): take 1 tablet by mouth twice daily for anxiety. Start Date: 5/18/26.Review of the June 2026 Medication Administration Record (MAR) revealed a Resident #21 did not receive the alprazolam on the following dates and times due to the medication being on order: 6/1/26 AM and PM doses, 6/2/26 AM dose, 6/3/26 AM and PM doses, and 6/4/26 AM dose.During an interview on 6/30/26 at 12:54 PM, the Resident #21's resident representative stated Resident #21 had been out of antianxiety medication for 3 days and in the past when the medication stopped in the hospital did not react well and at one point reported seeing bugs crawling on the ceiling. The resident representative stated they were not notified about Resident #21 being out of the medication prior to the resident representative asking.During an interview on 6/30/26 at 5:15 PM, Staff B, Registered Nurse (RN) stated family and the provider need to be notified when a resident did not receive the prescribed medication.During an interview on 7/1/26 at 10:32 AM, Staff O, Nurse Practitioner stated she should of been notified Resident #21 being out of the alprazolam prior to June 4th. During an interview on 7/1/26 at 12:28 PM, the Director of Nursing confirmed the family should have been notified of the missed doses. The DON stated the provider should have also been notified of the medication not coming in to see if a new script needed sent in. Review of the facility policy titled Notification of Changes revised on 3/2025 revealed the a Policy statement which declared: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.The Compliance Guidelines section directed: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification.2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.

Based on clinical record review, facility policy review and staff interviews, the facility failed to report an allegation of abuse to the State Agency for 1 of 1 resident reviewed for abuse (Resident #40). The facility reported a census of 54 residents. Findings include: Review of Resident #40's Minimum Data Set assessment dated [DATE], revealed a Brief Scale for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. During an interview on 7/1/26 at 9:31 AM, Staff D, Certified Nurse Aide (CNA) queried on staff interactions with residents and he stated he had heard Staff E, Dietary Aide call Resident #40 a ***ch. Staff D stated Staff E had been upset he needed to remake a plate for the resident. Staff D stated Staff E also told the resident You should know what you wanted. Staff D stated the incident occurred in early June 2026. When queried on reporting the incident, Staff D stated he did not report the incident and thought Staff G, Certified Medication Assistant (CMA).Review of facility reported incidents on the State Agency database revealed no reports regarding Staff E, Dietary Aide and Resident #40. During an interview on 7/1/26 at 9:58 AM, Resident #40 queried if she had any dietary staff speak to her in an undignified way and Resident #40 stated no, she loved dietary and thought the facility had a great dietary team. During an interview on 7/1/26 at 1:02 PM, Staff F, Registered Nurse (RN), queried on the incident with Resident #40 and Staff F stated she went to the dining room and an aide told Staff F that Staff E was rude to Resident #40. Staff F stated she talked to Staff E and Staff E told her that Resident #40 was rude to him, and Staff E explained he got upset and cussed in front of the resident. Staff F stated she did not remember what was said, but recalled it not appropriate. Staff F asked if the incident had been reported and Staff F stated she did not report it, but thought another staff did.At 1:12 Staff F, RN contacted the State Agency to clarify that she had talked to Resident #40 also. She added she didn't contact the Administrator because as charge nurse she handled the situation. Staff F stated she did not know if the incident was reportable or not, and added it did not happen again so her approach worked. During an interview on 7/1/26 at 1:27 PM, Staff G, Certified Medication Aide (CMA) queried on the incident with Resident #40 and Staff E, Dietary Aide. Staff G stated Staff E told Resident #40 she didn't have to be such a dick. Staff G stated she asked the nurses on duty to come to the unit and while waiting for them to arrive, Staff E continued to be belligerent and used the f word. Staff G said she told Staff E to leave and he went into the kitchen. Staff G stated she did not report the situation to the Administrator because she thought the nurses would report it. Staff G stated a few days later she thought about the incident and thought she should have reported it to the Administrator or the Director of Nursing.During an interview 7/1/26 at 2:15 PM, the Administrator queried on the incident with a Staff E, Dietary Staff and Resident #40 and she stated she knew something about him getting loud in the dining room and she held a meeting with the dietary team about appropriate conversations and language. The Administrator stated at that time she did not know what specifically Staff E had said to Resident #40, and if she had known she would have suspended him and reported the incident.Review of the facility policy titled Abuse, Neglect, and Exploitation revised 1/2025 revealed a Policy statement which declared: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The Definitions sections defined Alleged Violation as a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property.The Policy Explanation and Compliance Guidelines section directed, in part:1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

Based on clinical record review, facility policy review and staff interviews, the facility failed to conduct a thorough investigation of an allegation of abuse for 1 of 1 resident (Resident #40) reviewed for abuse. The facility reported a census of 54 residents. Findings include:Review of Resident #40's Minimum Data Set assessment dated [DATE], revealed a Brief Scale for Mental Status (BIMS) score of 15 out of 15 indicating intact cognition. During an interview on 7/1/26 at 9:31 AM, Staff D, Certified Nurse Aide (CNA) queried on staff interactions with residents stated he had overheard Staff E, Dietary Aide call Resident #40 a ***ch. Staff D stated Staff E had been upset he needed to remake a plate for the resident. Staff D stated Staff E also told the resident You should know what you wanted. Staff D stated the incident occurred in early June 2026. When queried on reporting the incident, Staff D stated he did not report the incident and thought another staff reported the incident to the Administrator. During an interview on 7/1/26 at 2:15 PM, the Administrator stated she did know about Staff E, Dietary Aide being loud in the dining room with Resident #40. She stated she talked to the Dietary Staff about interactions with residents. She stated if she had known at the time what specifically was said by Staff E she would have reported the incident to the State Agency, and started an investigation.Review of the facility policy titled Abuse, Neglect, and Exploitation revised 1/2025 revealed a Policy statement which declared: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The Policy Explanation and Compliance Guidelines section directed, in part:V. Investigation of Alleged Abuse, Neglect and ExploitationA. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur.B. Written procedures for investigations include:1. Identifying staff responsible for the investigation;2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence);3. Investigating different types of alleged violations;4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations;5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and6. Providing complete and thorough documentation of the investigation.

Based on clinical record review, policy review, and staff interview, the facility failed to provide bed hold notices for 2 of 3 residents (Resident #10 and Resident #60) reviewed for hospitalizations. The facility reported a census of 54 residents. Findings include: 1. The Minimum Data Set (MDS) assessment tool, dated 4/1/26, listed diagnoses for Resident #10 which included insomnia, muscle weakness, and heart failure. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 14 out of 15, indicating intact cognition. A 6/13/26 Activities Note stated the resident had a fall and transferred to the hospital. A 6/15/26 Health Status Note stated the resident returned to the facility.The resident's clinical record lacked documentation of bed hold information relayed to the resident or the resident's representative upon transfer to the hospital. 2. The MDS assessment tool, dated 3/4/26, listed diagnoses for Resident #60 which included heart failure, anxiety disorder, and depression. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition. The resident's clinical record lacked documentation of bed hold information relayed to the resident or the resident's representative upon transfer to the hospital. On 7/1/26 at 12:13 p.m., the Director of Nursing (DON) stated she could not locate bed hold notifications provided to the above residents. She stated the nurse usually verbally explained the bed hold information to the resident upon discharge and the social worker obtained a signature the next day. The facility policy Bed Hold Notice revised 2/2025, directed the facility would provide written information to the resident and/or the resident's representative regarding bed hold practices at the time of a hospital transfer.

Based on observation, record review, staff interviews, and the facility policy, the facility failed to identify and assess a non pressure skin wound for 1 of 2 residents (Resident #1) reviewed for wounds. The facility reported a census of 54 residents. Findings include: Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of a 13 out of 15 on the exam, indicating intact cognition. The list of diagnoses included hemiplegia/hemiparesis. The MDS indicated Resident #1 required substantial/maximal assistance to change position from sit to lying, sit to stand, and chair/bed-to-chair transfer, and at risk for pressure ulcers. The MDS indicated Resident #1 admitted with no pre-existing pressure ulcers, venous/arterial ulcers, surgical, or diabetic wounds. admission date listed as 6/1/26 from a short-term hospital stay. Review of Resident #1 Care Plan dated 6/16/26 revealed a Focus area to address the resident has potential for actual impairment to skin integrity.During an interview on 6/29/26 at 10:01 AM, Resident #1 stated she had a wound on her right hip. Resident #1 stated she didn't know how it happened and staff noticed it and said they would get cream for it, but didn't. Resident #1 described the area to be about the size of a quarter. Review of Weekly Skin Reviews in the electronic health record (EHR) revealed:a. On 6/5/26 at 10:32 PM: Skin Condition: No boxes checked. (Choices - Skin intact, Dry, Rash, Skin tears, Blisters, Bruise, Open area. The Other section documented: No changes.b. On 6/12/26 at 3:22 PM: Skin Condition: Skin intact checked. c. On 6/19/26 at 9:57 AM: Skin Condition: Skin intact checked. d. On 6/26/26 at 11:12 PM: Skin Condition: Skin intact checkedDuring an interview on 6/30/26 at 1:27 PM, Resident #1 stated she didn't remember nursing doing skin checks or who noticed the wound on her hip. Resident #1 stated she didn't realize she had the wound until staff pointed it out to her. During an interview on 6/30/26 at 1:47 PM, Staff U, Certified Nurse Aide (CNA) stated she remembered Resident #1 having a patch on her hip when she came in.During an observation on 7/1/26 at 10:07 AM, Resident #1 lowered her incontinence brief to reveal her right upper hip. There was a slightly reddened area with a flat dark brown/black center with peeling skin along the edges.During an interview on 7/1/26 at 10:07 AM, Staff S, Licensed Practical Nurse (LPN) observed Resident #1 wound and stated it appeared like eschar tissue and something that had been there awhile.During an interview on 7/1/26 at 10:25 AM, Staff O, Nurse Practitioner queried on Resident #1 wound and Staff O stated she measured it and it was 1.5 centimeters (cm) x 2.1 cm. Staff O stated Resident #1 noticed it a couple of days ago and Staff O thought the wound was a shear injury. Staff O confirmed staff should have noticed it and notified Staff O of the wound.During an interview on 7/1/26 at 12:42 PM, the Director of Nursing (DON) queried on Resident #1 skin condition and the DON stated it was a communication issue and the DON didn't know who found it first, but the facility would be discussing it at the all training. The DON confirmed the wound should have been reported to the nurse and a risk management needed to be completed. Review of the facility policy titled Skin Assessment revised on 6/2026 revealed a Policy statement which declared: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment.The Policy Explanation and Compliance Guidelines directed, in part:1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment should also be performed upon any change in condition or identification of new wound(s) (i.e., pressure injury, no pressure injuries, diabetic ulcers, skin tears, etc.).

Based on record review, staff interviews, and the facility policy, the facility failed to complete pre and post dialysis assessments 1 of 1 resident (Resident #5) review for dialysis. The facility reported a census of 54 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The list of diagnoses included end stage renal disease (ESRD). The MDS indicated resident received hemodialysis while a resident. Review of Resident #5 Care Plan dated 5/1/26 revealed a Focus area to address [name of redacted, Resident #5] is at risk for complication related to receiving dialysis for diagnosis of ESRD. Interventions initiated on 5/1/26 included, in part:a. Observe for clinical signs of infection at shunt site-redness, hardness, swelling, pain, or pus-like drainage.b. Notify MD and dialysis for s/s of infection;c. Observe for hypotension: Dizzy or light headed with a feeling of passing out. Instruct me to lie down with my head lower than my arms and legs, if possible. Notify my MD if symptoms persist.d. Observe/document edemaReview of the electronic health record (EHR) revealeda. Pre Dialysis Assessments not found for 5/8/26; 5/13/26; 5/18/26; 5/22/26; 5/29/26; 6/1/26; 6/3/26; 6/10/26; and 6/22/26. b. Post Dialysis Assessments not found on 5/22/26 and 6/10/26. During an interview on 6/30/26 at 4:31 PM, Staff A, Licensed Practical Nurse (LPN) queried on the pre and post dialysis assessments and Staff A stated the assessments needed to be completed each time Resident #5 went to dialysis. During an interview on 7/1/26 at 12:05 PM, Staff C, LPN queried on the pre and post dialysis assessments and Staff C stated yes, they complete them and were supposed to check the bruit, thrill, vitals, and weight. Staff C stated the expectation was to complete the assessments every time a resident went to dialysis. During an interview on 7/1/26 at 12:34 PM, the Director of Nursing (DON) queried on the pre and post assessments for Resident #5 and the DON stated the facility just hired a lot of nurses for second shift. The DON asked what should happen and the DON stated when the resident came back from dialysis the vitals, weights, and fistula needed checked and before the resident went to dialysis the fistula needed checked. The DON confirmed the pre and post assessments needed to be completed when residents received dialysis services. Review of the facility policy titled Hemodialysis updated on 4/2024 revealed a Policy statement which declared: The facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the residents goals and preferences, to meet the special medical, nursing, mental and psychosocial needs of resident receiving hemodialysis. The Compliance Guidelines directed, in part: 3. The facility will monitor for and identify changes in the resident's behavior that may impact the safe administration of dialysis before and after treatment and will inform the attending practitioner and dialysis facility of the changes. The nurse will ensure that the dialysis access site (e.g. AV shunt or graft) is checked before and after dialysis treatments and every shift for patency by auscultating for a bruit and palpating for a thrill.

Based on record review and staff interviews, and the facility policy, the facility failed to perform annual evaluations for 2 of 3 certified nursing assistants reviewed for performance reviews. The facility reported a census of 54 residents. Findings include: 1. Per an email from the Administrator on 6/30/26 at 11:18 AM, Staff D, Certified Nursing Assistant (CNA) had a date of hire of 4/24/25. A review of Staff D's employee file found no annual evaluation. 2. Per an email from the Administrator on 6/30/26 at 11:18 AM, Staff I, CNA had a date of hire of 4/17/25. A review of Staff I's employee file found no annual evaluation.During an interview on 6/30/26 at 4:53 PM, the Administrator stated the facility confirmed annual evaluations had not been completed for Staff D or Staff I. The Administrator stated the evaluations were missed during a transition of Director of Nursing (DON) personnel. During an interview on 7/1/26 at 12:44 PM, the DON explained the Human Resource department gives the DON a list of staff annual evaluations that are due, and it is the DON who is responsible for completing the reviews. Review of the facility policy titled Competency Evaluation dated 5/2024 revealed a Policy statement which declared: It is the policy of this facility to evaluate each employee to assure appropriate competencies and skills for performing his or her job and to meet the needs of facility residents.The Policy Explanation and Compliance Guidelines section directed, in part: Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure the provision of a routine medication for 1 of 7 residents reviewed for medications (Resident #9). The facility reported a census of 54 residents.Findings included:The Minimum Data Set(MDS) assessment tool, dated 4/23/26, listed diagnoses for Resident #9 which included heart failure, obesity, and high blood pressure. The MDS listed a Brief Interview for Mental Status(BIMS) score as 15 out of15, indicating intact cognition. A 7/11/25 Nursing Note listed a new order for fluticasone (a nasal spray used to reduce inflammation) 50 micrograms (mcg) 2 sprays daily in the morning.A 7/12/25 Nursing Note stated the medication was unavailable. A 9/20/25 eMar (electronic Medication Administration Record) note stated the medication was not in the facility.Progress Notes on the following dates stated the medication was on order: 2/7/26, 2/8/26, 2/9/26, 2/10/26, 4/14/26, 5/16/26.A 6/26/26 eMar note stated the medication could not be located. On 7/1/26 at 12:13 p.m., the Director of Nursing (DON) stated fluticasone was located in the carts and there were 2 extra bottles in the building.The facility policy Medication Reordering, dated 4/19, stated the facility would accurately and safely provide pharmaceutical services including the provision of routine medications. The policy directed staff to reorder medications if less than 6 doses remained.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to ensure a medication error rate less than 5 percent when a medication administration observation resulted in a 7 percent error rate. The facility reported a census of 54 residents.Findings included: 1. The Minimum Data Set (MDS) assessment tool, dated 4/4/26, list of diagnoses for Resident #42 included anxiety, depression, and muscle weakness. The Brief Interview for Mental Status (BIMS) score of 8 out of 15, indicates a moderate cognitive impairment. The June 2026 Medication Administration Record (MAR) for Resident #42 listed a 2/2/26 order for sucralfate (an oral medication used to coat the stomach in order to prevent ulcers) 1 gram, 1 tablet by mouth twice daily. The order directed staff to make this into a slurry (a semi-liquid mixture of solids suspended in a liquid, usually water) and administer 1 hour prior to meals. During an observation on 6/29/26 at 3:02 p.m., Staff J Licensed Practical Nurse (LPN), administered Resident #42, 1 gram of sucralfate in a tablet form with water without making a slurry. The facility Meal Serving Times schedule listed a dinner time of 5:45 p.m. for Resident #42's unit. On 7/1/26 at 12:13 p.m., the Director of Nursing (DON) stated staff should follow orders and give sucralfate within an hour of eating. She stated Resident #42's unit did not eat until 6:00 p.m. 2. Review of the Clinical Physician Orders listing for Resident #21 revealed, in part, the following orders: a. Senna Plus 8.6-50 mg tablet, take two tablets by mouth twice daily for constipation with a start date of 5/18/26. b. Lidocaine Patch Pad 4 percent, apply one patch topically and change daily (apply at 8:00 AM and remove at 8:00 PM). During an observation on 6/29/26 starting at 10:40 a.m., Staff M, Registered Nurse (RN), set up medications to administer to Resident #21. Medications placed into a pill cup included Senna Plus 8.6-50 mg, one tablet. Staff M reported she was looking for the Lidocaine patches for Resident #21, and was unable to find them. Staff M reported she had to order more Lidocaine patches from the pharmacy, and the pharmacy would not deliver the patches until later that evening. At 10:51 a.m., Staff M administered medications to Resident #21 which failed to include two Senna Plus tablets. Review of the June 2026 MAR revealed Staff M, RN, documented a 9 for the 6/29/26 Lidocaine patch. The MAR Chart Code indicated a 9 = Other/See Nurses Notes. Review of progress notes revealed a noted entered on 6/29/26 titled E-MAR Medication Administration which documented Lidocaine 4 percent patch was on order. Review of the facility policy, titled Medication Reordering, dated 6/2026, revealed, in part, the facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident .Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner .Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permitting.

Based on clinical record review, facility policy review, provider and staff interviews, the facility failed to reorder a medication and utilize the emergency pharmacy stock in an effort to prevent a resident from missing six doses of an anti-anxiety medication for 1 of 11 residents (Resident #21) reviewed for medication administration. The facility reported a census of 54 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The list of diagnoses included anxiety disorder, and the resident prescribed an anti-anxiety medication. Review of Resident #21's Care Plan dated 3/18/26, revealed a Focus area to address [name redacted, Resident #21] uses anti-anxiety medications r/t (related to) anxiety disorder. 3/17/26 GDR (Gradual dose reductions) declined for Alprazolam- [name redacted, Resident #21] refuses to try because she has taken this medication for so long. Interventions include, in part: Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness every shift. Revised: 9/10/25. Review of the Clinical Physician Orders section in the electronic health record (EHR) revealed an order for Alprazolam tablet 0.5 milligram (mg): take 1 tablet by mouth twice daily for anxiety. Start Date: 5/18/26Review of the June 2026 Medication Administration Record (MAR) revealed a Chart Code which indicated a 9 = Other/See Nurses Notes. A 9 documented on the June 2026 MAR on the following days:a. On 6/1/26 during the 1000-1200 (10 AM to 12 PM) and 1500-1700 (3 PM to 5 PM) scheduled times. 1. A Nursing Note entered on 6/1/26 at 1:26 PM documented: on order.b. On 6/2/26 during the 1000-1200 scheduled time.1. A Nursing Note entered on 6/2/26 at 1:07 PM documented: on order.c. On 6/3/26 during the [PHONE NUMBER] and 1500-1700 scheduled times. 1. A Nursing Note entered on 6/3/26 at 11:19 AM documented: out of medication;2. And a Nursing Note entered at 6:57 PM documented: on order. d. On 6/4/26 during the 1000-1200 scheduled time. 1. A Nursing Note entered on 6/4/26 at 10:41 AM documented: on order. During an interview on 6/30/26 at 1:06 PM, Resident #21 stated there had been an issue with her medications running out and she had to wait 3 or 4 days before receiving it. During an interview on 6/30/26 at 5:15 PM, Staff B, Registered Nurse (RN) queried on Resident #21 being out of her alprazolam and Staff B stated she tells the Certified Medication Aides to let Staff B know when there are 5-7 days left on the cards so Staff B can order it. Staff B stated the nurse needed to notify the provider if the medication didn't come in. During an interview on 7/1/26 at 10:32 AM, Staff O, Nurse Practitioner queried on Resident #21 alprazolam and Staff O stated she placed an order on 4/28/26 for 5 refills and then put in another order on 6/4/26 for 60 tablets. Staff O stated the facility asked for refills from the pharmacy and typically contacted her if they didn't receive it in 2-3 days. Staff O stated staff would request a refill 4 to 5 days prior to running out of the medication.During an interview on 7/1/26 10:47 AM, Staff P, CMA queried on Resident #21 alprazolam and Staff P stated Resident #21 was out of the alprazolam for a couple of days. Staff P stated if she was not able to order on the computer, Staff P would take the reorder sticker off the card and fax it to the pharmacy. During an interview on 7/1/26 at 11:08 AM, Staff Q, Pharmacy Technician queried on when the last refill request received for an alprazolam refill for Resident #21 and Staff Q stated he didn't see any requested for refills between 4/28/26 and 6/4/26. Staff Q stated the pharmacy might not have received the request if a fax or email did not go through. Staff Q queried if the 4/28 order was current prior to the new order on 6/4 for Resident #21 medications and Staff Q stated yes, the order was current until September 2026. During an interview on 7/1/26 at 12:01 PM, Staff C, Licensed Practical Nurse (LPN) queried on Resident #21 alprazolam order and Staff C wasn't sure why it didn't come in. Staff C confirmed Resident #21 not receiving the medication for multiple doses was little excessive. During an interview on 7/1/26 at 12:28 PM, the Director of Nursing (DON) queried on Resident #21 not receiving the alprazolam for multiple doses and the DON stated she remembered the pharmacy not sending it and needing a new order. The DON stated she thought the medication was in their emergency stock medication. The DON stated she would have checked the emergency stock and pulled from there and called the pharmacy to see why the pharmacy didn't send it. The facility policy titled Reordering Medication Policy revised 6/2026, revealed a Policy statement which declared: It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. The Policy Explanation and Compliance Guidelines section directed, in part:1. The facility will utilize a systematic approach to provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident.2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner.3. Each time a nurse is administering medications and observes (6) or less doses left of one kind, that nurse will reorder the medication, time permitting.

Based on observation, clinical record review, facility policy review, resident and staff interviews, the facility failed to ensure that dietary staff served meals that met the therapeutic needs (Resident #18) and preferences (Resident #49) for 2 of 5 residents reviewed for diet orders. The facility reported a census of 54 residents.Findings include: 1.Review of the Minimum Data Set (MDS) Assessment for Resident #18, dated 5/1/2026, revealed a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating a severe cognitive impairment. The list of diagnoses included diabetes, aphasia (difficulty swallowing) and morbid obesity. The MDS identified Resident #18 as dependent on staff for eating, and the received a mechanically altered, and therapeutic diet. Review of Resident 18's Care Plan dated 5/1/2026, revealed a Focus area to address [name redacted, Resident #18] has a potential nutritional problem of weight fluctuations r/t advanced age, current cognitive status, and need for mechanically altered diet w/full feeding assistance. Interventions included, in part: Provide, serve diet as ordered. Res (resident) to receive small portions and double protein to promote weight loss per provider.Review of the Clinical Physician Orders revealed an order for Regular diet, *Pureed texture, thin consistency, small portions, double protein. Start Date: 5/15/2024.During an observation on 6/29/2026 that started at 11:29 AM, Staff R, Cook, prepared two servings of pureed food items for one resident with a puree diet order (Resident #18). Review of the Week 2 menu revealed the noon meal to consist of: country fried steak, mashed potatoes, cream gravy, honey buttered carrots, bread/[NAME](erine), banana berry cup and milk. Staff R placed three (three servings) country fried steak patties into a blender with beef broth and pureed the mixture. The Dietary Manager then split the 3 servings of protein between two resident plates, placing 1.5 servings on each resident's plate. The Dietary Manager reported Resident #18 had a puree diet order with double serving of protein. Staff R, [NAME] also prepared three servings each of pureed carrots, mashed potatoes, and bread and divided the servings between the two residents. Resident #18 received 1.5 servings of each food item. At 12:04 PM, Staff R, Cook, started the lunch meal service. Staff R sent out a divided plate with pureed food for Resident #18. At 12:32 PM, Resident #18 noted to have eaten 100 percent of the lunch meal. 2. Review of the MDS Assessment for Resident #49, dated 4/3/2026, revealed a BIMS score of 0 out of 15, indicating a severe cognitive impairment. The list of diagnoses included stroke, chronic respiratory failure and malnutrition. The MDS identified Resident #39 dependent on staff for eating and required a mechanically altered diet. Review of Resident #49 Care Plan dated 4/3/2026, revealed, a Focus area to address [name redacted, Resident #49] is at nutritional risk as diet is mechanically altered/therapeutic diet and thickened liquids as ordered.Interventions included, in part: Provide diet as ordered and record intake. Staff to provide feeding assistance. Review of the Clinical Physician Orders revealed an order for General diet, mechanical soft texture, nectar consistency for pleasure diet per resident's request. Start Date: 4/4/25.Review of a Nurse Practitioner Progress Note dated 10/14/25 revealed in part: Plan: Dysphagia following cerebral infarction: Continues on mechanical soft diet despite speech therapy recommendations of pureed food. Is now taking pills orally with applesauce per speech therapy recommendations, no episodes of choking, difficulties taking meds noted. Review of a physician's progress note, dated 10/14/2025, revealed, in part, a plan for dysphagia treatment following cerebral infarction .continues on mechanical soft diet despite speech therapy recommendations of pureed food. Review of a progress note, titled RD (Registered Dietician) Q (quarterly) review, dated 6/29/2026, revealed, in part, .Weight shows no sig changes over past 30 (days)/180D (days). Reg ([NAME]) Mechanical soft, nectar thick diet continues with good po (oral) intakes noted .Continue current POC (plan of care).During an observation on 6/28/2026 at 12:28 PM, Resident #49 served her lunch with consisted in part of whole barbeque pork rib patty. Staff V, Certified Nursing Assistant (CNA) cut up the rib patty and started to feed Resident #49. The resident ate 3 to 4 bites of meat, and then refused to eat any more meat. During an observation on 6/29/2026 at 12:04 PM, Staff R, [NAME] during the lunch meal served Resident #49 a whole chicken fried steak patty. At 12:32 PM, Resident #49 noted to not have eaten the patty. During an interview on 6/29/2026 at 12:35 PM, Resident #49 communicated she did not ask for meat to be serviced whole, and wanted it to be ground into small pieces. During an interview on 6/30/2026 at 1:33 PM, the Dietary Manager (CM) stated Resident #18 received 1.5 servings of protein instead of two servings, and confirmed the resident received an extra half serving instead of small portion for carrots, potatoes and bread. The DM explained he had sent out mechanical soft food to Resident #49 in the past, and the resident had sent it back and requested regular instead of ground meat. Review of the facility's policy, titled Therapeutic Diet Orders, 11/2025, revealed, in part, the facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences.

Based on observation, clinical record review, facility policy review, and staff interview, the facility failed to ensure staff performed hand hygiene during glove changes to prevent the potential spread of infection for 1 of 3 residents observed for wound care treatment (Resident #20). The facility reported a census of 54 residents. Findings include: Review of Resident #20's Minimum Data Set (MDS) assessment tool dated 4/24/26 lists diagnoses of multiple sclerosis, heart failure and peripheral vascular disease. Review of the electronic health record (EHR) an IDT (interdisciplinary team) Note dated 6/25/26 at 11:56 AM revealed, in part: IDT met to review resident's non-pressure skin issue. Resident currently has non-pressure skin issue to right great toe.Review of the EHR revealed a Physician Order for Triple Antibiotic Ointment and Optifoam Gentle 3 dressing applied once daily to the right great toe.During an observation on 6/30/26 at 9:39 AM, Staff O, Advanced Registered Nurse Practitioner (ARNP), and Staff N, Infection Preventionist (IP)/Licensed Practical Nurse (LPN), sanitized their hands and set up supplies to perform wound care on Resident #20's right great toe. Staff O, ARNP, and Staff N, IP/LPN, donned gloves. Staff O, ARNP, uncovered the resident's legs and removed the soft bilateral boots, socks, and tubigrips (a type of soft skin covering) from the resident's lower legs and feet. Staff O then removed the wound dressing covering the resident's right great toe. The dressing contained deep red bloody drainage, and red blood covered the wound site. Staff O, ARNP, removed her gloves, failed to perform hand hygiene, and donned a new pair of gloves. Staff O cleaned the wound using 4x4 gauze and Vashe Wound Wash. Staff O applied antibiotic ointment to the wound bed. Staff O removed her gloves, skipped hand hygiene, and donned a new pair of gloves. Staff O measured the wound, covered it with a small foam dressing, and applied Aquaphor cream to the right lower leg. Staff O removed her gloves, skipped hand hygiene, and donned a new pair of gloves. Staff O applied Aquaphor cream to Resident #20's left lower leg. Staff O removed her gloves and failed to perform hand hygiene before donning a glove on her left hand only. She then pushed hair out of her face with her right hand and opened and closed a drawer of the resident's nightstand to obtain a clean pair of tubigrips. Staff O asked Staff N, IP/LPN, to get her another glove. Staff O donned a glove on her right hand. Staff O failed to perform hand hygiene after removing gloves and prior to donning gloves. Staff O applied a tubigrip cover to the resident's left lower leg. Staff N, IP/LPN, applied a tubigrip on the resident's right lower leg, applied soft bilateral boots, removed her gloves, and washed her hands. Staff O, ARNP, picked up the resident's dirty breakfast dishes with her gloved hands, exited the room, took the dishes to the unit kitchenette, removed her gloves, and washed her hands During an interview on 6/30/26 at 3:46 PM, Staff N, IP/LPN, stated hand hygiene should be done before starting wound care and with every glove change. Staff N reported gloved hands should be changed after the removal of a wound dressing, after cleaning the wound and after applying the wound treatment/dressing. During an interview on 7/1/26 at 9:31 AM, Staff O, ARNP, stated she knew that she forgot to perform hand hygiene with glove changes while performing wound care on Resident #20 during the observation on 6/30/26.On 7/01/2026 at 12:24 PM, during an interview, the Director of Nursing, (DON), stated staff should be performing hand hygiene with every glove change.Review of the facility policy, titled Hand Hygiene, dated 12/2025, revealed, in part, Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

3. The MDS assessment tool, dated 5/12/25, listed diagnoses for Resident #13 which included Alzheimer's disease, non-Alzheimer's dementia, and Parkinson's disease(a disorder which caused tremors and difficult mobility). The MDS listed her cognition as severely impaired. A 2/15/25 Care Plan entry stated the resident was at risk for falls related to confusion. On 6/3/25 at 9:56 AM, Resident #13 sat in a shower chair in her room. The door was open and no staff were within sight of her. At 10:12 AM Staff A Registered Nurse(RN) and Staff R Certified Nursing Assistant(CNA) walked by the resident's room and Staff A asked Staff R if she just finished the resident's shower. Staff R said no she had been done. Staff R closed the resident's door and they both walked away. The resident remained in her shower chair until 10:36 AM At 10:36 AM Staff R stated she was not sure what time she completed the resident's shower but stated she required 2 staff members for the transfer and the other staff were at the other end of the hall. At 10:40 AM Staff R and Staff F transferred the resident to bed with a mechanical lift. They assisted her to roll over onto her right side and her right rear leg had red indentations spanning across the back of her thigh. On 6/10/25 at 10:55 AM, Staff Q, Certified Medication Aide(CMA) stated she would not leave a resident in her shower chair. She stated after showers she tried to lay them down as quickly as possible and to get them off their bottoms. On 6/10/25 at 11:12 AM, Staff R, CNA stated normally on the [NAME] Unit there were 3 aides staffed. She stated on the day that Resident #13 was in her shower chair, there were only 2 aides staffed on the floor and there was not enough staff to help the resident. She stated if the facility was fully staffed, there were no problems taking care of the residents but stated they were not always fully staffed. She stated depending on what was going on, residents have waited up to 30 minutes for staff to respond to their call lights. On 6/10/25 at 11:52 AM, Staff A, RN stated she would not want a resident in the shower chair for an extended period of time. On 6/11/25 at 12:26 PM, The DON stated staff should not leave residents in a shower chair alone. 4. The MDS assessment tool, dated 5/10/25, listed diagnoses for Resident #21 which included abnormalities of gait and mobility, abnormal posture, and adult failure to thrive. The MDS stated the resident had a fall without injury during the review period and listed her BIMS score as 5 out of 15, indicating severely impaired cognition. A 5/4/23 Care Plan entry stated the resident was at risk for falls related to gait and balance problems. A 5/15/25 1:08 PM Incident Note stated staff reported another resident(Resident #15) knocked the resident down in a wheelchair. The resident had a large hematoma(a collection of blood due to injury) to the back of her head and complained of a headache. A 5/15/25 2:07 PM Nursing Note stated the resident had a fall in the hallway and transferred to the ER. A 5/15/25 4:05 PM Nursing Note stated the resident returned from the ER with no new orders. A 5/27/25 Provider Note stated the resident walked in the hallway when another resident came by in the wheelchair and knocked her over . This caused her to fall and hit her head and she sustained a large hematoma on the base of her head. The resident tried ice packs but this did not help with the pain. The provider added Tramadol(a narcotic pain reliever) to the resident's medications. 5. The MDS assessment tool, dated 3/25/25, listed diagnoses for Resident #15 which included hemiplegia (one-sided paralysis), morbid obesity, and history of traumatic brain injury. The MDS listed the resident's BIMS score as 8 out of 15, indicating moderately impaired cognition. A 8/18/24 Nursing Note stated when the resident left the dining room, he rolled himself out of his wheelchair backwards and did not seem to care that he ran into others. He almost knocked two people out of their chairs trying to leave the room. When staff asked him to be careful, he grunted and did this anyway. His peers started to complain that he was going to hurt someone. A 12/5/24 Care Plan entry stated the resident used a wheelchair for locomotion and propelled the wheelchair backwards and staff needed to intervene and push him safely to destinations. A 5/15/25 Behavior Note stated the resident propelled down the hallway in his wheelchair towards his room and another resident went in the opposite direction. Resident #15 ran into the other resident and caused to her fall and hit her head on the floor. The CNA(who witnessed the incident) stated it looked intentional. A 5/15/25 Care Plan entry stated staff educated him on spatial awareness [NAME] the wheelchair and would assist the resident with wheelchair mobility until therapy evaluated him for safely. The Care Plan lacked additional wheelchair safety interventions to ensure the resident and others were safe. On 6/10/25 at 10:55 a.m., Staff Q, CMA stated on the day of the incident with Resident #15 and Resident #21, she pushed Resident #15 out into the hallway. He went full speed in his wheelchair and Resident #21 walked out of the bird room. Staff Q stated he was going full speed and she told him to be careful. Resident #15 ran into the side of Resident #21's walker. She stated she did not know if he ran into her on purpose but thought he did because she saw him in the past be verbally mean to her. She stated though that she did not know for sure if he ran into her on purpose or if he was just going too fast. On 6/11/25 at 12:26 p.m. the DON stated if staff thought the resident was unsafe in a wheelchair, there should be interventions. She stated currently they had an intervention in place that staff would assist him to and from meals. Review of the Facility Policy titled Accidents and Supervision, dated 4/2019 and last revised 6/2025, revealed the following per the Identification of Hazards and Risks Section: All staff (e.g., professional, administrative, maintenance, etc.) are to be involved in observing and identifying potential hazards in the environment, while taking into consideration the unique characteristics and abilities of each resident .The facility should make a reasonable effort to identify the hazards and risk factors for each resident. Based on observation, interview, and record review, the facility failed to ensure safe transfer via mechanical lift, and failed to ensure adequate supervision when a resident known to exhibit unsafe tendencies in their wheelchair knocked another resident down for 3 of 10 residents reviewed for accidents (Resident #15, Resident #21, Resident #32). Resident #32 fell from mechanical lift sling, resulting in a hematoma with abrasion to the resident's posterior head. Resident #21 ran into Resident #15's walker with their wheelchair, Resident #15 fell, and sustained a hematoma to the back of the head. Resident #15 did not receive received adequate supervision when the resident was left alone in their room in a shower chair. The facility also failed to ensure oxygen tanks were secured during transport. The facility reported a census of 59 residents. Findings include: 1. Review of the Minimum Data Set (MDS) assessment dated [DATE] for Resident #32 revealed the resident was rarely to never understood. Per this assessment, the resident was dependent for chair/bed-to-chair transfer. The Care Plan dated 11/27/24 revealed, [Resident #32] has an ADL (activities of daily living) self-care performance deficit r/t (related to) Aggressive Behavior, Dementia. The Intervention dated 11/27/24 revealed, TRANSFER: Mechanical Lift Hoyer with 2 staff assistance and use large sling. The Care Plan dated 11/14/24, revised on 5/7/25, revealed the following: [Resident #32] is risk for falls r/t (related to) dementia, Gait/balance problems, Poor communication/comprehension. The Intervention dated 5/7/25 revealed, 5/7/25 sling malfunctioned and sling removed from service. The Progress Note dated 5/7/25 at 7:19 AM authored by Staff B, Registered Nurse (RN) revealed, During Hoyer lift transfer with this RN and CNA (Certified Nursing Assistant) [Name Redacted] res slid out of Hoyer sling to floor. Landed on upper back and bumped his head on the floor. Assessed for injury, hematoma with abrasion on posterior head. VS (vital signs) obtained. Lifted from floor with 2 staff and sat in his w/c (wheelchair). abrasion cleansed with wound wash. No active bleeding .Intervention remove new Hoyer sling for no further use. Neuros initiated. The Progress Note dated 5/7/25 at 9:45 AM revealed, IDT (interdisciplinary team) met to review resident's witnessed fall. Staff were transferring in hoyer, resident was secure in Hoyer checked by both staff members upon transferring to wheelchair resident jerked while in sling and fell landing on back of head. Abrasion noted on the back of head. Neuros initiated and vitals stable. resident denies any pain. No other injuries noted. New Intervention: Hoyer sling removed. On 6/04/25 at 10:41 AM, Staff B, RN queried about the resident's fall from the lift, and explained the following: Per Staff B, had just received a new [mechanical lift] sling, transferred resident up, and normally [mechanical lift] sling as lifted was to a seated position. Staff B explained it was almost like the kind of sling for bed to bed transfer, explained didn't even seem right, and was brand new sling that never used before. Staff B explained she pulled the [mechanical lift] back, and the other staff member at the wheelchair. Per Staff B, as soon as moved [resident], normally knees would bend, and resident's legs were straight out. Staff B explained the resident slid from the [mechanical lift] onto the floor, and bumped head on the floor. Staff B explained called [former Administrator], made former Administrator lay in the sling, put her in the sling, response was couldn't use that sling, and was taken away and said couldn't use it. Staff B, RN queried what kind of sling it was, responded was green in color, and Staff B couldn't tell the manufacturer's name on it. Staff B explained she ran the [mechanical lift] when happened. Per Staff B, she felt horrible, and further explained the problem was fixed immediately. Staff B acknowledged when raised resident up, was flat. When queried if had used the sling for anyone else, Staff B responded no. When queried if the resident got hurt, Staff B responded had bump to the back of head. On 6/4/25 at 11:49 AM, Staff C, Certified Nursing Assistant (CNA) explained the following about the incident: Per Staff C, she was getting the resident up and ready for the day, and noticed the resident had a different sling. Staff C explained she went and looked for a different sling, and it was a bed to bed transfer sling instead of a bed to chair sling. Per Staff C, she noticed the sling used laid the resident more flat. Staff C explained she called the nurse into assist with the transfer, and as were lifting the resident up Staff C said, It looks like he's going to fall/ Should I put him back down? Staff C explained she told this to [Staff B], the nurse at the time, and Staff B responded, No, that's just how he looks in the sling. Staff C explained continued with with the transfer. Per Staff C,CNA as soon as pulled the resident out from over the bed, the resident slid out from the back of the sling and landed on the floor. When queried what hit the floor, Staff C responded the head. When queried how the resident responded, Staff C explained resident said a quiet Ow. Staff C explained the resident didn't talk much in general, and other than that, didn't say anything. Per Staff C, the resident was conscious the whole time, the nurse stayed with the resident, and confirmed Staff B was present the whole time for the transfer. When queried if she had transferred the resident before this incident, Staff C, CNA acknowledged she had. When queried what type of sling was used for resident before the incident, Staff C explained sling with 4 corners that had hooks on them, blue, green, and purple. Per Staff C, CNA the sling used (at time of incident) had hooks on the side of the sling instead of the top corner. Staff C explained the sling used wasn't very secure, and further explained she would not use it again if had to. When queried where the sling used had come from, Staff C responded had run out of slings, maintenance contacted, and from what understood found somewhere around the building. Per Staff C, this sling present when Staff C got there in the morning, she queried Staff B where the sling had come from, and response provided was on previous day, had to ask maintenance to find one. Per Staff C, she'd only used the slings before with the 4 corners, and those had worked perfectly fine. When queried what made Staff C, CNA feel the resident was going to fall, Staff C responded as she lifted the resident, saw [resident's] legs a smidge too high, and as lifted [resident] up, his head kept going down instead of coming up above hips like should be. Per Staff C, had Staff B report it to the Administrator, Administrator came up, explained put Administrator up in sling to demonstrate what happened. Review of the [Facility Name] Post Fall Skin assessment dated [DATE] revealed the resident had new redness, new skin tears, and new bruise. The Post Fall Skin Assessment further revealed the following: due to fall; hematoma with abrasion, bruising to posterior head. On 6/3/25 at 11:51 AM, two staff assisted Resident #32 with transfer from bed to wheelchair. The sling used was blue in color, and had a purple binding. The sling connected to the mechanical lift via loops at the top and bottom of the sling. The resident was raised up in the sling, then transferred from bed to wheelchair. Observation on 6/4/25 at 12:46 PM revealed Resident #32 in a wheelchair in the dining room of the area where the resident resided. The resident had a sling present underneath them in their wheelchair. The sling was blue in color, with purple binding around the edges of the sling. On 6/11/25 at 1:59 PM, the facility's Director of Nursing (DON) queried what staff should do if had concern when started to raise resident in lift, and responded to lower the resident back down, and assess the equipment. 2. Observation on 6/3/25 at 9:47 AM on the [NAME] area of the facility revealed Staff A, Licensed Practical Nurse (LPN), walked down the hall with an oxygen tank, then set the oxygen tank down hard on the floor. The oxygen tank not observed in a holder. Observation on 6/3/25 at 9:51 AM on the [NAME] area of the facility revealed Staff A carried an oxygen tank down the hallway without a holder. Observation further revealed Staff A stood in the hallway and held the tank with one hand. Observation on 6/10/25 at 9:38 AM revealed Staff A, LPN walked out by the nursing desk and held an oxygen tank in her hand. Staff A set the tank down on the floor. The tank stood upright behind the nursing desk and was not in a holder. Staff A worked with the tank, and could hear air flow out of the tank. On 6/11/25 at 1:57 PM, the facility's Director of Nursing (DON) queried about previous observations, and responded it should be on wheels, should be carried, and definitely should be in an appropriate handler if going down the hall. The DON explained she would do education. Review of the Facility Policy titled Oxygen Safety, dated 4/2019 and last revised 4/2025, revealed the following: Protect cylinders from damage by not storing in locations where heavy objects may strike them or fall on them, or where they can be tipped over by foot traffic or door movement.

Based on observation, clinical record review, policy review, and staff and resident interviews, the facility failed to administer medications within the timeframe directed by the manufacturer/pharmacist for 3 of 8 residents (Resident #31, #41, #53) reviewed for medications, and failed to follow professional standards of medication administration by ensuring the same staff member set up medications as who administered them for 1 of 8 residents reviewed for medication administration (Resident #52). The facility reported a census of 59 residents. Findings: 1. Review of the Minimum Data Set (MDS) assessment tool, dated 5/10/25, revealed a list of diagnoses for Resident #31 which included diabetes (a disease which causes abnormalities in blood sugars), heart failure, and morbid obesity. The Brief Interview for Mental Status (BIMS) score as 15 out of 15, indicating intact cognition. Review of the Care Plan, dated 3/15/23 revealed a Focus area to address diabetes, with an Intervention to administer diabetes medications as ordered. The June 2025 Medication Administration Record (MAR) listed a 5/20/25 order for insulin apart (a type of insulin, an injectable medication used to lower blood sugar) 24 units three times daily. The Insulin Aspart Injection Patient Information, retrieved from https://www.novo-pi.com/insulinaspart.pdf on 6/16/25, directed to eat a meal within 5-10 minutes after the administration of the dose. During an observation on 6/4/25 at 11:38 AM, Staff A, Registered Nurse (RN) administered 24 units of insulin aspart to Resident #31. Observation following this administration revealed the resident did not receive a meal or ingest any snacks as of 12:05 PM, At 12:05 p.m., the Staff A stated she had a window of 30 minutes for him to eat. At 12:09 PM, Staff F Certified Nursing Assistant (CNA) offered the resident a snack. 2. Review of the MDS assessment tool, dated 3/25/25, revealed a list of diagnoses for Resident #52 which included hemiplegia (one-sided paralysis), dysphagia (difficulty swallowing), and chronic pain syndrome. The MDS assessed the resident at risk for development of a pressure ulcer, with no unhealed ulcers at the time of the assessment. The MDS listed the resident's BIMS score as 0 out of 15, which indicated a severe cognitive impairment. Review of Resident #52's June 2025 MAR revealed the following medication orders: a. A 12/4/24 order for lorazepam (an anti-anxiety medications) 0.25 milliliter(ml) [0.5 milligrams(mg)] via G-tube (a gastrostomy tube, which is a tube inserted directly into the stomach via a surgical opening in the abdomen used to instill medications, nutrition and hydration) twice daily b. A 5/20/25 order for oxycodone (a narcotic pain medication) 0.5 ml (10 mg) via G-tube three times daily c. A 4/11/25 order for Peg 3350 [NAME] (polyethylene glycol powder - a type of laxative) 17 grams into 4-8 ounces of liquid via g-tube twice daily d. A 11/18/24 order baclofen (a muscle relaxant) 10 mg per G-tube three times daily e. A 11/19/24 order for gabapentin (a pain medication) 6 ml (300 mg) three times daily. Review of the June MAR revealed an entry on 6/4/24 at 2:00 PM for the above medications initialed by Staff X Certified Medication Assistant's (CMA) with a check mark to indicate the administration of the medications. During an interview on 6/4/25 at 2:23 PM, Staff A, RN stated Staff X, CMA set up the medications she would administer via g-tube to Resident #52. Staff X held a cup of liquid and said he utilized tap water to mix with the medications. Staff A stated the medications in the cup were the resident's lorazepam, oxycodone, PEG 3350, baclofen, and gabapentin. Staff A then took the medications from Staff X, went to the resident's room, and administered the medications via G-tube. Staff A stated sometimes the CMA set the medications up and sometimes she did. She stated she observed the CMA set up the medications. During an interview on 6/11/25 at 8:26 AM, Staff H, CMA stated he would not set up medications for the nurse to administer. 3. Review of the MDS assessment tool, dated 3/1/25, revealed a list of diagnoses for Resident #41 which included diabetes, heart failure, and anxiety. The BIMS score as 12 out of 15, indicated a moderate cognitive impairment. Review of the June 2025 MAR revealed an order for levothyroxine (a medication used to treat thyroid disorder) 137 micrograms daily scheduled at 6:00 AM, Start Date: 2/7/25. Per the MAR all other morning medications scheduled at either 7:00 AM. or 8:00 AM. During an interview on 6/3/25 at 12:58 PM, Resident #41 stated she was supposed to get her thyroid medication an hour before other medications but received it with two other pills. During an interview on 6/10/25 at 9:46 AM, Staff P, RN stated staff should administer levothyroxine by itself. During an interview on 6/10/25 at 11:52 AM, Staff A, RN stated the night shift nurses were supposed to administer the levothyroxine but there were times when they did not do that and the day shift administered them with other medications. During a phone interview on 6/11/25 at 11:23 AM, Staff V, Pharmacist stated levothyroxine was definitely intended to be given by itself so there was no difference in metabolism. He stated when they set up medications for facilities, they created a separate medication time for that medication. During an interview on 6/11/25 at 12:26 PM, the Director of Nursing (DON) stated nurses should administer rapid acting insulin within 15 minutes of the time the resident would eat. She stated CMAs should not set up medications for the nurse. The DON stated staff should administer levothyroxine between 5:00 AM and 6:00 AM 4. Review of the MDS assessment, dated 3/31/25, revealed Resident #53 had a BIMS score of 5 out of 15, which indicated severe cognitive impairment. The list of diagnoses included: dysphagia and traumatic brain injury. The MDS indicated Resident #53 required a G-tube for medications, and 51% of total calorie intake. Review of the Care Plan, dated 4/04/24, revealed a Focus area to address Resident #53 potential for alteration in neurological status related to traumatic brain injury. Interventions included, in part: Give medications as ordered. Monitor/document for side effects and effectiveness. The Care Plan also included a Focus area to address the requirement of a tube feeding r/t dysphagia. Review of the June 2025 MAR revealed the following medications scheduled for the 7:00 AM medication pass: 1. Osmolite 1.2 liquid to be given four times a day. Scheduled times 7:00 AM, 11:00 AM, 2:00 PM, and 8:00 PM. 2. Baclofen 20 mg to be given three times a day. Scheduled times 7:00 AM, 2:00 PM, and 8:00 PM. 3. Escitalopram 10 mg to be given daily at 7:00 AM. 4. Folic Acid 1000 mcg (micrograms) to be given daily at 7:00 AM. 5. Gabapentin 600 mg to be given three times a day. Scheduled times 7:00 AM, 2:00 PM, and 8:00 PM. 6. Senna 8.6mg to be given daily at 7:00 AM. 7. Sentry (multivitamin) tablet to be given daily at 7:00 AM. During an observation on 6/04/25 at 9:29 AM, Staff N, Licensed Practical Nurse (LPN), administered the following medications (crushed and through the G-tube) scheduled for 7:00 AM: baclofen 20 mg, escitalopram 10 mg, folic acid 1000 mcg, gabapentin 600 mg, senna 8.6 mg, and sentry multivitamin tablet. During the observation, Staff N noted to have flushed Resident #53's G-tube with 100 milliliters (mL) of water before and after administration of Osmolite 390 mL. During an interview 6/10/25 at 10:31 AM, Staff Q, CMA, reported that facility protocol instructed staff to give medications within an hour before or an hour after scheduled administration time and explained that the electronic MAR would indicate if a medication was late by change in color. During an interview on 6/10/25 at 2:58 PM, Staff K, LPN reported that facility protocol instructed staff to give medications within an hour before and an hour after the scheduled administration time. Staff K stated if a medication was given late there would be concern that the next scheduled dose would be given too soon. During an interview on 6/11/25 at 2:52 PM, the DON stated the expectation is for nursing staff to give medications within an hour before or after the scheduled time. The DON confirmed 9:30 AM would be considered late for scheduled 7:00 AM medication time. Review of facility policy Medication Administration, dated 4/2025, revealed a Compliance Guideline #12. Compare medication source with the Medication Administration Record to verify resident name, medication name, form, dose, route, and time. The policy instructed for medication to be administered within 60 minutes prior to or after scheduled time unless otherwise ordered by physician

Based on clinical record review, staff interview, and facility policy review the facility failed to follow physician orders for warfarin administration, also known as Coumadin, after one of three residents (Resident #3) had an elevated International Normalized Ratio (INR) lab result of 6.7 on 1/17/25. Previous to this INR result, Resident #3 had an order for warfarin 5.5 mg daily, with a goal of a therapeutic INR range of 2.5 to 3.5. After an INR result of 6.7, a physician order was given to hold Resident #3's warfarin dose on 1/17/25, and starting on 1/18/25 decrease the daily dose from 5.5mg to 5.0mg daily. The Medication Administrator Record (MAR) documented a 5.5mg dose of warfarin administered to Resident #3 on 1/17/25, and 5.5 mg warfarin doses administered on 1/18/25, 1/19/25, and 1/20/25. On 1/21/25, Resident #3 had a repeat INR test with a result of 12.4. Resident #3 admitted to the hospital on 1/21/25 with pneumonia, urinary tract infection and INR of 13. The resident treated with Vitamin K (antidote to warfarin) in the hospital. This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident. The facility reported a census of 65 residents. Findings include: The State Agency informed the facility of the IJ on 2/12/25 at 3:15 PM. The IJ began on 1/17/25, when the resident administered warfarin following INR of 6.7. Facility staff removed the IJ on 2/13/25 at 3:47 PM through the following actions: a. Policy/procedure review/revision by the DON (Director of Nursing)/designee. b. Licensed nurse education on facility policies regarding high-risk medication, anticoagulants, transcribing physician's orders, and notifying the physician when lab values not in the therapeutic range, and re-education on putting in appropriate hold orders. c. Licensed nurse education on appropriate transcription of putting medication on hold. d. Corrective action/one to one education with licensed nurse/Certified Medication Aide identified in deficient practice. The scope and severity lowered from a J to a G at the time of the survey after ensuring the facility implemented education. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 9 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicted the resident had moderately impaired cognition. Per this assessment, the resident took anticoagulant medication. Review of Medical Diagnoses for Resident #3 included dementia, chronic atrial fibrillation unspecified, and presence of prosthetic heart valve. Review of the Care Plan dated 7/22/24 revealed, [Resident #3] is on anticoagulant therapy r/t (related to) Atrial fibrillation, history of CVA (cerebrovascular accident). The intervention dated 7/31/24 revealed, Administer anticoagulant medications as ordered by the physician. The Physician Order dated start date 12/12/24 revealed, warfarin tab 1mg (milligram) with directions to take 1/2 tab (0.5mg) by mouth at bedtime *add to 5mg tablet to make 5.5mg dose*. The Physician Order dated start date 12/12/24 revealed, warfarin tab 5mg with directions to take 1 tablet by mouth daily *add to 0.5mg tablet to make 5.5mg dose*. Review of Hold Orders dated 1/17/25 by Staff D, Licensed Practical Nurse (LPN) revealed the following: warfarin 5mg put on hold on 1/17/25 from 8:27 AM to 8:00 PM, for 0 days due to PT/INR was too high, and warfarin 1mg with instructions to give half tab (0.5mg) put on hold on 1/17/25 from 8:29 AM to 8:00 PM, for 0 days, due to PT/INR too high. Review of the resident's lab results collected 1/7/25 at 7:03 AM, verified on 1/7/25 at 7:12 AM revealed the resident's INR was 3.4. The Provider Note dated 1/14/25 revealed, Patient has atrial fibrillation, anticoagulated with warfarin 5.5mg daily, tolerates well. INR goal 2.5 to 3.5 with a history of mechanical mitral valve. Review of the resident's lab results collected 1/14/25 at 6:15 AM, verified on 1/14/24 at 6:47 AM revealed the resident's INR was 7.3. The Telephone/Verbal Order Form dated 1/14/25 revealed the following: a. Hold warfarin x1 dose b. Recheck INR this upcoming Thursday c. Change INR from weekly to twice weekly. Review of the resident's lab results collected 1/17/25 at 7:24 AM, verified on 1/17/25 at 8:14 AM, revealed the resident's INR was 6.7. The Nursing Note dated 1/17/25 at 8:16 AM revealed, Lab called with critical value INR 6.7; PT (Prothrombin Time) 62.4; provider notified. The Nursing Note dated 1/17/25 at 8:22 AM revealed, New orders received from [Name Redacted], ARNP (Advanced Registered Nurse Practitioner) to hold coumadin on 1-17-25 and change to 5mg daily starting on 1-18-25. Review of the resident's MAR dated January 2025 revealed Resident #3 was administered 5.5mg of warfarin on 1/17/25, and revealed Resident #3 received 5.5mg of warfarin on 1/18/25, 1/19/25, and 1/20/25. Review of the resident's lab results collected 1/21/25 at 6:57 AM, verified on 1/21/25 at 7:27 AM, revealed the resident's INR was 12.4. The Nursing Note dated 1/21/25 at 6:36 AM revealed, [Name Redacted] lab was here this a.m. concerned resident was having some altered mental status change. Assessment completed, Resident vitals B/P (blood pressure) 151/80, P (pulse) 114, RR (respiratory rate) 20, O2 (oxygen) 94% T (temperature) 96.8. He is in a pleasant mood, Alert only to self. PT/INR drawn this a.m. Protime is 119.8, INR 12.4. New order received by [Name Redacted] ARNP (Advanced Registered Nurse Practitioner) to transfer resident out to ED (emergency department) for evaluation. Call placed to 911 at 8:08 a.m Report called to [Name Redacted] ED at 8:29 a.m. Notified [family member, name redacted] POA (Power of Attorney). resident was confused and unable to sign bed hold. Notified [Name Redacted] DON (Director of Nursing). Resident transferred to ED at 8:38 a.m. via [Name Redacted] ambulance. Review of the ED Provider Note dated 1/21/25 at 3:10 PM revealed, Patient presents with altered mental status. Pt has altered mental status with elevated INR LTC (long term care) reports 12.4 EMS (Emergency Medical Services) reports 11 pt (patient) is aware of town not building unaware of time oriented to self last known well 2100 (9:00 PM) last night EMS reports had been holding coumadin often due to INR values no recent falls noted hx (history) of heel ulcer and dementia confusion note baseline and demeanor is laughing smiling also not his normal hx UTI (urinary tract infection) noted no Vitamin K administered no hx diabetes. The Hospital Notes further documented, [age-redacted] year-old-male from the nursing home was sent with elevated INR. Patient has no complaints. Patient was Coumadin for atrial fibrillation. Patient was no bleeding no other issues. Continued review of the resident's hospital records dated 1/21/25 revealed, in part, the following per the Impression section: Sepsis with septic shock, likely secondary to hypotension and hypothermia secondary to pneumonia. Patient found to have a supratheraputic INR, was given Vitamin K. Will hold Coumadin at this time .Super therapeutic INR. Vitamin K administered. Recheck in am if no bleeding will not transfuse ffp (frozen fresh plasma) for now. Goal with 2-3. Review of Hospital Records revealed a Progress Note dated 1/22/25 at 12:53 PM by an ARNP which revealed, Chief Complaint: F/U (follow up) septic shock .INR 7.3 after giving vitamin k 5mg x1 in the ER. Review of Recent Results (from the past 24 hours) included as part of the Progress Note revealed the following highest values of PT/INR in the Recent Results section: PT of 125.6 and INR 13.0. On 2/11/25 at 1:19 PM, Staff A, Certified Medication Aide (CMA) queried if only nurses gave Coumadin, and responded believed both did (CMA and nurse). Per Staff A, if medication held she would be told and would also be on the MAR. Per Staff A, report was given in the morning. When queried what it would mean if there was a check on the MAR, Staff A meant, we gave it. On 2/11/25 at 3:15 PM, Staff B, CMA, who had signed out Resident #3's Coumadin doses on 1/17/25 with a check mark, queried about Coumadin administration at facility. Staff B acknowledged both CMAs and nurses gave Coumadin if scheduled. When queried how she knew how much to give, Staff B responded on the MAR told you. When queried how she would know if on hold, Staff B responded would say on hold on the MAR, and usually the card turned backwards. Per Staff B, would not show yellow, and would say on hold. When queried what the check on the MAR indicated, Staff B could not explain. On 2/11/25 at 3:21 PM, Staff C, Licensed Practical Nurse (LPN) explained the following about when resident sent out: Lab came to draw that morning, probably PT/INR but Staff C not sure because he (Resident #3) was getting other labs drawn, resident was very confused, and pupils were super dilated. Per Staff C, the resident's vital signs weren't normal for him, went in and changed him, was talking, super confused, was in wheelchair and kept trying to go the dining room and wanted to eat breakfast. Staff C explained as got to talk to him the resident was not acting right, and explained she got a hold of the doctor who said to send him out, and kept him. When queried if the resident was on Coumadin, Staff C acknowledged he was, said it depended on the week, and a lot of weeks changed order, and further explained had to hold the order. Per Staff C, critical labs were an ongoing thing, several days held the coumadin, and explained everything did was not working. When queried who put in Coumadin orders at the facility, Staff C responded pharmacy, and further explained pharmacy put in all orders unless it was a hold. Per Staff C, lab would call a critical, and Staff C or whoever at facility would call the doctor, doctor would say whatever tell to do. Staff C explained could physically go in and hold the medication, and further explained what she did was put an H on the card so the medication aide knew to hold it, and in the computer could put it as a hold. Staff C explained she could not change the order, and if dosage change would have to refax to pharmacy, pharmacy put it in, and then Staff C would confirm the order. When queried if pharmacy could put in hold orders, Staff C responded they could hold it, and facility could always fax for them to hold, [facility] confirm it, and could send to pharmacy or put on hold [at facility level]. Staff C explained she would put H on the card so the medication aide knew, would go into the actual order and update, would go into the order page, hit the arrow down, explained there were different options, and would put the hold on that day. Per Staff C, then [resident] would start the new orders the next day. When queried if she needed to pick times if holding medication, Staff C showed how, if a one time hold order, she could put hold date. When held for one day, the screen showed the date range auto-populated to the next day for end date. Staff C further explained, in part, if on hold staff would not have the option to even click it, and whoever passing pills following MAR literally couldn't click gave it as not existent to push. On 2/11/25 at 4:06 PM, Staff D, Licensed Practical Nurse (LPN) explained generally if had a Coumadin order, would send to the pharmacy and they would put the order in, and explained would need to go in and discontinue old order and confirm the new order. Per Staff D, pharmacy put in all of the orders with the exception of wounds and labs and such, which [facility] could do. Per Staff D, pharmacy put in all the medications, and as the nurse would have to go in and confirm or discontinue for them to appear on the MAR or TAR (Treatment Administration Record). Staff D explained on previous instance had tried to send a hold order to the pharmacy, and the pharmacy sent it back and said the nurse had to put the hold order in. During the telephone interview with Staff D, Staff D was read the note they input for Resident #3 on 1/17/25 at 8:22 AM. Per Staff D, she remembered telling the CMA not to give the Coumadin, and acknowledged she remembered that order. When queried as to the identity of the CMA, Staff D explained she believed it was Staff B. When queried about a hold order in that instance, Staff D explained she could not tell that had ever put in a hold order, was not one hundred percent on how, and explained that was why she had sent hers to the pharmacy. When queried if she needed to select the number of days if put in a hold order, Staff D responded she thought so, she thought could go in and it would ask you, and she was not one hundred percent sure because she did not do a lot of hold orders. When queried if she had received education on how to hold order, Staff D denied. Staff D explained the nurse would have to talk to the CMA before could get into the medication cart, and acknowledged on the 17th (1/17/25), she (Staff D) would not have put a physical notation on the card. On 2/12/25 at 10:15 AM the facility's Director of Nursing (DON) queried about Coumadin orders at the facility, and explained the following: When received order from the physician, would fax to pharmacy, and pharmacy would enter the orders into [facility electronic health record system redacted]. Per the DON, nurses would go back and confirm it. When queried about hold orders, the DON explained nursing staff could hold per physician order and let the pharmacy know. The DON explained with any other dosage change, med change would fax the orders to pharmacy. The DON explained the following about hold orders: Per the DON, would go into [facility electronic health record system redacted], would look under order, and could put update/hold so could hold the medication, and nurses could go ahead and do that if had the order. When queried if staff needed for enter the number of days holding the drug, the DON responded yeah. When queried as to the process to hold one dose, the DON explained would have to put in the specific date and time, ensure time is correct, and acknowledged would need to put 1 day in the day spot. When queried about the process for telephone orders, the DON explained the facility had verbal order forms, would go ahead and fill those out, and would fax to pharmacy. Per the DON, would also depend on what kind of order it was, as the facility could enter lab orders. Per the DON, pharmacy could be involved in the hold process as well, and the DON further explained would send to pharmacy when holding, as was kind of like a double check. The DON queried what a check on the MAR would mean, and responded the medication administered or signed off. The DON explained the facility had several educations with nurses and medication aides, acknowledged included the process for holding, acknowledged H to be present on the bubble pack (medication package), and explained the facility would usually turn that card around on the cart. The DON acknowledged the medication aide would have the only set of keys to the cart, and so staff would have to find the medication aide to put an H (on card) and to flip the card. When queried about Coumadin concerns for Resident #3, explained his had been all over the place for quite awhile, explained the resident's body had been failing for the past two to three months, and seemed to have gotten more out of whack. The DON acknowledged not aware of Coumadin hold concerns for resident. When queried if the resident received the medication on 1/17/25, the DON responded from what she could see, yes, said it could have been accidentally charted, and explained she saw it was checked off. When queried about the resident's MAR for 1/18-1/20/25, DON acknowledged saw 5mg and then 0.5 mg. When queried if aware of concern or new information, the DON responded new information. Per the DON, any new order would have been faxed to pharmacy, facility could do hold orders, and most of the time was pharmacy. On 2/12/25 at 11:05 AM, the DON explained the following about the resident's medication to be held on 1/17/25: Per the DON, tracked down the nurse who put the hold order in, explained had been passed to the medication aide and was still popping up, and staff didn't put in the correct code because didn't give it. Per the DON, Staff D had put an H and turned the med around. On 2/12/25 at 12:28 PM, Staff E, Pharmacy Technician interviewed, explained the facility was on [electronic health record system redacted], and was pharmacy initiated. Per Staff E, the pharmacy did not manage hold orders and that was a task the facility would have to implement on their end. Staff E explained the following process for a scheduled Coumadin order: For a dose change, would submit the dose change as well as INR too, and pharmacy would make that as soon as received fax. Staff E explained the following about being pharmacy initiated: The pharmacy would manage entry of all pharmacy orders on the EMAR (electronic medication administration record). Per Staff E, the last scheduled Coumadin orders pharmacy had for resident were 5.5mg dose, received 5mg and 1mg dose (to take half of the 1), to get to 5.5 dose. Per Staff E, those faxes were last sent in December. On 2/12/25 at 12:44 PM, Staff F, Nurse Practitioner (NP) queried about Resident #3. Staff F acknowledged she managed resident's Coumadin at the facility, and explained if was the most difficult Coumadin had to manage. Per Staff F, INR went up and down, and [resident] was very sensitive to any inflammatory infectious process. Staff F explained any time the resident was unwell it would set off his INR really badly. Per Staff F, any little thing physically would make the INR abnormal. The Facility Policy titled Anticoagulants, dated 4/2019 and revised 1/2025, revealed the following: 1. Anticoagulants shall be prescribed by a physician or other authorized practitioner with clear indications for use. Examples include prevention and treatment of deep vein thrombosis, pulmonary embolism, atrial fibrillation with embolization, stroke or management of myocardial infarction. 2. Target symptoms (i.e. lab values) and goals for use (i.e. prevention or treatment) of anticoagulants shall be documented in the resident's medical record. Duration of use shall be appropriate to the resident's condition and indication for use.

Based on observation, record review, and staff, resident responsible party and State Climatologist interviews, the facility failed to ensure resident safety and prevent a resident's elopement, when they failed to identify a resident's change in condition and actions that placed the resident at high risk for elopement, for 1 of 9 resident records reviewed (Resident #8). Resident #8 eloped from the facility and 0.7 miles away from the facility when located by staff approximately 20 to 25 minutes after he was last observed at the main entrance door. The facility reported a census of 68 residents. Findings include: The Admission Minimum Data Set (MDS) Assessment tool dated 8/23/23 revealed Resident #8 admitted to the facility 8/16/23 with diagnoses that included acute cholelethiasis (gal stones), Parkinson's disease and altered mental status. The MDS documented that the resident scored 9 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated severe cognitive impairment. The MDS indicated that the resident required extensive assistance of at least 1 staff for turning or repositioning in bed, transfer to and from bed, ambulation, personal hygiene and dressing, and total dependence on staff for toileting and bathing. The MDS revealed the resident received Hospice care and services while at the facility. The Elopement Assessment, dated 8/16/23 on the Admission Assessment completed by Staff A, current Director of Nursing (DON), revealed the following indicators selected: 1. Is the resident cognitively impaired with poor decision making skills? a. Yes (1 point) 2. Does the resident have a diagnosis of dementia, Alzheimer's, OBS, Schizophrenia, delusions, hallucinations, bipolar disorder? b. No (0 points) 3. Does the resident ambulate independently with or without the use of assistive device including w/c? b. No (0 points) 4. Is the resident having difficulties accepting facility placement? b. No (0 points) 5. Does the resident have a history of elopement at home or other facility? b. No (0 points) 6. Does the resident wander aimlessly? b. No (0 points) 7. Does the resident express a desire to go home? b. No (0 points) 8. Does the resident wander expressing a desire to locate a family member? b. No (0 points) 9. Is the resident cognitively impaired and has been observed standing at the exit door waiting for someone to let them out? b. No (0 points) A SCORE OF 5 OR MORE IS CONSIDERED TO BE AT RISK FOR ELOPEMENT 1. Is the resident's Elopement Risk Score 5 or greater? b. No The facility's Self-Reported Incident, dated 10/3/23, documented the resident exited his upstairs unit, when alarm went off he silenced the alarm. He got on elevator, went to 1st floor and exited outside through the employee exit. Found at a gas station, brought back into building by staff. The resident was transferred to another long-term care facility with a locked unit on 10/6/23. Observations throughout the investigation revealed: 1. On 10/25/23 at 10:15 a.m. The gas station where staff later found the resident was located 0.7 miles from the facility. 2. On 10/30/23 between 4:26 p.m. and 4:55 p.m the Surveyor walked 0.7 miles outdoors in 16 minutes at a leisurely pace, and 12 minutes and 45 seconds at a brisk pace. 3. On 10/24/23 at 3:36 p.m. the resident's electronic record did not contain a photo of the resident, common in electronic records and used for identification purposes. 4. On 10/25/23 at 2:09 p.m. a set of double doors at the entrance/exit of the Bonnifield unit located on the 2nd floor, where the resident resided, had an alarm that sounded if the door was opened without the code entered on the security key code pad located by the doors. Similarly, 3 exit doors located on first floor, the main floor, also were equipped with key code pads where security codes were entered for the doors to open without sounding an alarm. The main entrance front doors, similar to sliding pocket doors, normally did not open unless the security code was entered on the key pad, although they could be pried open manually without much effort. The Employee Entrance door and the other exit door alarmed if opened without the security code entered on the key pad. The following problems were included on the resident's Nursing Care Plan: 1. An Activity of Daily Living (ADL) Assistance problem, related to 1 staff assistance required for bed mobility, transfer, dressing, toileting, personal hygiene and bathing, initiated 8/27/23, interventions also implemented 8/27/23, directed the staff as follows; a. Dress and change resident as needed. b. The resident requires 1 staff assist with transfer/ambulation, please use a gait belt. c. If the resident is incontinent of bowel and bladder please check every 2 hours and as needed, and provide incontinence care. d. Observe for hygiene needs and render as needed each shift and as needed. 2. An Elopement Risk/Wanderer related to Impaired Safety Awareness problem, initiated 10/3/23, included the following interventions also initiated on 10/3/23: a. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. b. Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. c. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures and memory boxes. Nursing Progress Notes revealed the following entries: 8/21/2023 at 2:25 p.m., Staff B, Licensed Practical Nurse (LPN) stated resident has been approaching double doors asking people for rides to the square for the entertainment. Redirects temporarily. Kept trying to take fan and walk away. 8/28/2023 at 9:40 p.m., Staff C, Registered Nurse (RN) stated resident was calm,cooperative this whole shift, has been up and down several times, but no behaviors to noted. 8/30/2023 at 1:22 p.m., Staff C, RN, stated resident calm and cooperative, did have a lot of pacing this morning. 9/26/2023 at 12:45 p.m., Staff D, LPN, stated resident pacing back and fourth in the hall this shift, going into other residents rooms, talking as if he is going to New York, he is leaving, he doesn't know where he should go. Resident has been redirected back to his room. 10/1/2023 at 2:20 p.m., Staff E, LPN, stated resident has been pacing up and down per usual. 10/2/2023 at 4:10 p.m., Staff E, LPN, stated resident has been pacing back and fourth this shift, no aggressive behaviors. 10/3/2023 at 6:59 a.m., Staff E, LPN, stated front door alarm was sounding, as I was walked toward the door Staff F, Hospitality Aide notified me she just saw the resident down in the lobby and unsure if he was supposed to be down there. I ran out the door and down to the lobby, resident was no longer in the lobby. I searched the first floor, saw Staff G, Maintenance, and he gave me a walkie-talkie. Staff G announced we had a lost sheep and needed assistance locating him on the walkie-talkie. Returned to Bonnifield to search all rooms, [NAME] reported he was not there. After Bonnifield search completed, [NAME] unit staff verified they had not located the resident. The back hall, laundry, third floor, and basement were all searched by this nurse, Staff G and Staff H, Certified Nursing Assistant (CNA). The facility Administrator was notified the resident could not be found at 7:12 a.m. The Administrator called back and said the resident was at a gas station and Staff G, Maintenance, was sent to get the resident. Resident was assisted back to facility at 7:29 a.m accompanied by Staff I, Scheduler. Skin assessment was completed and no new skin alterations observed. Resident had no complaints of pain or discomfort. Resident reported he wanted to leave and find civilization. An Elopement Risk Assessment, completed 10/3/23 at 11:55 a.m. by Staff A, current DON, revealed the following indicators: Select the answer that most represents the residents status. 1. Mobility a. Confined to bed or chair (cannot self-propel) (0 pts.) b. Mobile with device (able to self-propel walker, wheelchair, merrywalker, etc.) (2 pts.) c. Ambulatory (2 pts.) (C selected) If resident is confined to bed or chair and is unable to self-propel - STOP - Resident Not At Risk Select the answer that most represents the residents status. 2. Placement Perception a. Verbalizes desire or plan to leave the facility unauthorized/unsupervised (10 pts.) (A selected) b. Resident is resistant to Long Term Care Placement (5 pts.) c. No verbal expressions to leave facility (0 pts.) If resident has verbalized to leave facility and is ambulatory or can self-propel - STOP - Resident At Risk 3. Predisposing Disease - Dementia, OBS, Alzheimer's, Depression, Mental Illness, Expressive Language Deficits, Substance Abuse, End of Life a. None presents (0 pts.) b. One or more presents (2 pts.) (B selected) 4. Mental Status a. Alert & oriented (1 pt.) b. Cognitively impaired (decreased safety awareness, disturbances in judgement, wanderer) (3 pts.) (B selected) 5. Medications (including psychoactives) a. None present (0 pts.) b. 1 medication (1 pt.) c. 2 or more medications (3 pts.) (C selected) 6. Length of Stay a. Over 120 days without elopement incident (0 pts.) b. 30-120 days since admission (1 pt.) (B selected) c. New admission (<30 days) (2 pts.) d. Any time frame with elopement attempt (3 pts.) 7. History of Elopement within past 6 months (walk away attempts from home, other facility, current facility) H a. No history of elopement (0 pts.) (A selected) b. One or two episodes (3 pts.) c. Three or more episodes (4 pts.) B. SCORING 21 points, that placed the resident At Risk for elopement. SCORING: AT RISK - 12 points or higher LOW RISK 0-11 points The facility's Elopement and Wandering Residents policy, implemented 4/2019, last updated 10/2023, directed the following: 1. This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. 2. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. 3. The facility is equipped with door locks/alarms to help avoid elopements. 4. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 5. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 6. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering: a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. 7. Procedure for Locating Missing Resident: a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g. internal alert code). b. The designated facility staff will look for the resident. c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office. d. DON or designee shall notify the physician and family member or legal representative. e. Police will be given a description and information about the resident; include any photos. f. All parties will be notified of the outcome once the resident is located. g. Appropriate reporting requirements to the State Survey agency shall be conducted. The resident ' s electronic medical record did not contain a photo of the resident. The facility ' s Elopement/Resident Wandering policy directs that the Police Department be notified and provided with resident photos and description if the resident is not located on the facility ' s property. The facility did not notify the Police Department of the resident ' s elopement and wouldn ' t have had a photo immediately available to provide to the Police; that would have been a critical factor to quickly locate a missing resident for those not familiar with the missing person. The resident was at the facility from 8/16/23 through 10/6/23, and it is unclear why there was not a photo of the resident at the time of his elopement. Staff interviews revealed: Staff J, Dietary Manager, interviewed 10/25/23 at 10:37 a.m., stated on 10/3/23, she was in the kitchen cooking with other dietary staff, around 7:05 a.m. she heard an overhead page for Lost Sheep, which meant there was a missing resident. One dietary staff remained in the kitchen and the rest left to assist with the search throughout the building. They couldn't find him in the building so some staff went outside to look for him. She got in her car and started going up and down the side streets around the facility, and found him standing outside a gas station, she thought it was around 7:15 a.m. or 7:16 a.m. She pulled over to him, the resident said he was trying to find his daughter, and said No when she asked him if he wanted to return to the facility. She called the Administrator when she found him, then went into the gas station with him and bought him a cup of coffee. Staff G, Maintenance and Staff I, Scheduler came to the gas station then and the resident agreed to return to the facility with Staff G. The door alarm might have been going off at the time, she didn't know for sure as it can be difficult to hear that when in the kitchen. Staff K, CNA, assigned to the Bonnifield unit on the 10/3/23 day shift, interviewed at 11:16 a.m. on 10/25/23, stated the resident ambulated independently, on the morning of 10/3/23 she saw the resident hanging around the dining room on the unit around 6 a.m. when she got there, that was normal for him, he was there for a while, then he said he was going to his room, she thought it was before 7 a.m. At that time, she was in the process of morning cares, got residents up and dressed for breakfast, in resident rooms with the doors closed for cares and didn't hear any alarm sounding that morning. She was informed by the nurse on the unit the resident was missing, and that's when everyone started looking for him. Staff F, Hospitality Aide, assigned to the Bonnifield unit on the 10/3/23 day shift, interviewed on 10/25/23 at 11:36 a.m., stated on 10/3/23 she went down to 1st floor for something, when she was on her way back upstairs, she thought around 7 a.m., she saw the resident standing by the front door/main entrance of the facility. She couldn't understand what he said as he spoke, wasn't sure if he could be off the Bonnifield unit so she went straight upstairs and asked the nurse, Staff E, LPN, if the resident could be downstairs and she said no. They both went downstairs then, 1 on the elevator and the other took the stairs so they wouldn't miss him. They couldn't find him on 1st floor, they looked throughout the area and in all the rooms, then they called the code overhead lost sheep and all staff started looking for him then. They brought him back to the facility within the hour, not sure of the time. Staff E, LPN, assigned to the Bonnifield unit on the 10/3/23 day shift, interviewed 10/25/23 at 11:46 a.m., stated on 10/3/23 she saw the resident first thing in the morning, 6 a.m., he was in his room, then he paced between the dining room and his room, which was normal for him. She went into a resident's room at approximately 6:45 a.m., for cares that normally took between 15 and 20 minutes and the resident's door remained open as she provided the care. When she left that resident's room she did not hear the alarms until she got to the Nurse's Station area, approximately 40 feet closer to the exit doors from where she had been. She headed to the exit doors, Staff F, the Hospitality Aide came through the door and said the resident was down in the lobby. She thought Staff F saw the resident by the front door at 6:58 a.m. or around then. They both went to the 1st floor lobby and couldn't find him anywhere, she saw Staff G, Maintenance, coming in from the Employee Entrance, and the alarm was sounding from that entrance. She asked him if he had seen the resident, he had not, he called Lost Sheep overhead, she called the Administrator, per her memory it was 7:12 a.m. and reported he was missing, then she went to the basement with Staff G, they searched the entire basement and couldn't find him. She went back to Bonnifield, the [NAME] unit reported they had not found him, the [NAME] unit as well, then she went to the 3rd Floor with Staff H, CNA, to search and they couldn't find him there. At that point people were outside looking for him. She got a call from the Administrator after that, not sure of the time, who said staff found him at a gas station. When the resident returned, he knew exactly what he was doing, after he got back he went down the hall towards the exit again, looked over his shoulder to make sure nobody watched him, she tried to follow at a distance so he wouldn't see her, he passed a resident's room who called out at him Where are you going?, then he stopped and turned around, they had staff assigned to him 1 to 1 after he returned. Staff E described the experience as upsetting and very stressful. Staff G, Maintenance, interviewed 10/25/23 at 1:44 p.m., stated on 10/3/23, he arrived to the facility just before 7 a.m., parked by the Employee Entrance, didn't see anyone in the area when he arrived, when he got to the door, no alarm sounded as he approached the door. There is a button outside of the facility that you push to silence the alarm on the door, you then have 30 seconds to get through the door and the door shut without sounding an alarm, it takes longer than 30 seconds, the alarm will sound. Once inside the door, he saw Staff E, the nurse, she was by the kitchen doors and said an aide saw the resident by the front entrance but he wasn't there now. He grabbed a walkie-talkie, put it on channel 5, started looking for him, they had searched throughout the building and couldn't find him. He got in his vehicle then and drove away from the facility looking for him. He got a call from the Administrator at 7:21 a.m., she told him Staff J, Dietary Manager, found him at the gas station and directed him to go over there. When he got to the gas station the resident was calm but said he wasn't going back to the facility. He talked with him for a while, he was outside, Staff I, Scheduler pulled in then and she was able to get the resident to agree to get in his vehicle and return to the facility. He didn't know what door the resident got out of, it made more sense to him that he left through the main entrance front door when someone came in through that entrance. 10/31/23 at 10:16 a.m., Staff I, Scheduler, stated on 10/3/23, she was at home getting ready for work when she got a call from the Administrator who told her the resident was at the gas station and asked her to go there and assist. When she got to the gas station Staff J, Dietary Manager and Staff G, Maintenance were there, the resident stood outside by the gas pumps with a cup of coffee, said he wanted cookies and didn't want to return to the facility. He was dressed in jeans, a long sleeved shirt and a longer sleeved shirt over that, and shoes. He said he wanted coffee and wanted to go for a walk as to why he was at the gas station. They were able to get him in Staff G's vehicle for his return to the facility, and once returned, she was then assigned as 1 to 1 with him for supervision that day. The Administrator, interviewed 10/25/23 at 2:37 p.m., stated on 10/3/23 she received a call from Staff E, LPN, who said the resident was missing, she was already on her way to work at the time, 5 minutes away from the facility and didn't call the police. As she arrived at work, she got a call from Staff J, Dietary Manager, who said she'd found him at the gas station. The Administrator then called Staff G, Maintenance, and directed him to the gas station to assist with the resident. The Administrator could not explain why the facility did not have a photo of the resident. 10/31/23 at 9:18 a.m., Iowa's State Climatologist stated the weather in Fairfield, Iowa on 10/3/23 was as follows: Sunrise at 7:06 a.m. The temperature between 7 a.m. and 8 a.m. was 64 to 66 degrees Fahrenheit, with 64 to 68 percent relative humidity. The winds were out of the south at 7 miles per hour. The visibility was 4 to 7 miles, low visibility with haze was reported at Fairfield. Normal visibility on a clear day without obstructions is 10 miles. The resident's responsible party and Power of Attorney (POA), interviewed on 10/26/23 at 11:41 a.m., stated the resident thought it was funny that he could get out of the facility and made all the staff look for him. When asked how they thought he was able to get out of the facility, the POA stated the resident watched people and probably saw the code they entered, and he also had a regular visitor that might have told him what the exit code was, he somehow knew the exit code and that is how he got out of the building.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to create and implement fall interventions based on root cause analysis of previous falls for 3 of 3 residents reviewed for falls(Residents #2, #3, and #5) and failed to ensure the proper disposal of a needle for 1 of 1 needle-related incident reviewed. The facility reported a census of 64 residents. Findings Include: 1. The Minimum Data Set(MDS) assessment tool, dated 3/13/23, listed diagnoses for Resident #2 which included stoke, hip fracture, and a history of falling. The MDS documented the resident required limited assistance of 1 staff for transfers, walking, dressing, toilet use, and personal hygiene, and extensive assistance of 1 staff for bathing. The MDS listed the resident's Brief Interview for Mental Status(BIMS) score as 10 out of 15, indicating moderately impaired cognition. Care Plan entries, dated 11/11/20, stated the resident was at risk for falls and directed staff to anticipate the resident's needs, follow facility fall protocol, and assist the resident with her glasses and hearing aides. A 3/17/23 untitled incident report stated staff found the resident sitting on her floor with her back against the bed frame. The resident stated she was trying to sit up and slid off the bed. The Care Plan lacked documentation of an intervention implemented following the resident's 3/17/23 fall. A 4/5/23 Nursing Note stated the resident walked to meals and back with her walker. A 4/15/23 untitled incident report stated staff heard a noise from the resident's room and the resident was lying on her left side in the doorway of her bathroom. The resident self-transferred to the bathroom and did not call for help with her call light. The resident stated she tripped. A 4/15/23 hospital History and Physical stated the resident admitted to the emergency room after a fall and stated she was using her walker to get from the bathroom when she tripped and fell . An X-ray revealed a left hip fracture. The resident was not a surgical candidate. The 4/21/23 MDS documented the resident depended completely on 2 staff for transfers. During an observation on 5/2/23 at 1:28 p.m., Staff B Certified Nursing Assistant(CNA) and Staff F CNA transferred the resident from her wheelchair to her bed using a mechanical lift. 2. The MDS assessment tool, dated 3/14/23, listed diagnoses for Resident #3 which included diabetes, weakness, and abnormalities of gait and mobility. The MDS stated the resident required limited assistance of 1 staff for bed mobility, transfers, and walking, extensive assistance of 1 staff for dressing, depended completely on 1 staff for personal hygiene and bathing, and depended completely on 2 staff for toilet use. The MDS listed the resident's BIMS score as 5 out of 15, indicating severely impaired cognition. A 6/1/22 Un-witnessed Fall report stated staff found the resident sitting in front of the door in hallway. The resident tried to sit down and missed the chair. 6/2/22 Care Plan entries stated the resident was non-compliant with waiting for help and self transferred on her own. Staff educated the resident on the use of the call light. Staff directed to dress and change the resident as needed, utilize 1 staff and a gait belt for ambulation, and determine and address causative factors of the fall. A 7/28/22 Witnessed Fall report stated the resident fell in the doorway and she transferred to the ER for evaluation. A 10/6/22 Un-witnessed Fall report stated staff found the resident's sitting on the floor in front of the bed and she stated she attempted to go to the bathroom. An 11/22/22 Un-witnessed Fall report stated staff found the resident's sitting on the floor and she said she lost her balance while attempting to go to the bathroom. A 12/25/22 Un-witnessed Fall report stated staff heard the resident fall and she laid on her right side in the hallway. A 1/12/23 Witnessed Fall report stated the resident got up from the dining room table and landed on her buttocks. A 3/14/23 Un-witnessed Fall report stated staff heard a noise from the resident's room and found her sitting in front of the bed. The resident stated she was walking to her room after breakfast. A 3/23/23 Witnessed Fall report stated the resident sat on the seat of her wheeled walker, backed up, and fell sideways. The resident transferred to the ER for evaluation. A 3/26/23 hospital Progress Note stated the resident had a right hip fracture which required operative fixation(surgery). A 3/29/23 Care Plan entry stated the resident had a right hip fracture and directed staff to ensure call light in reach. A 4/5/23 Un-witnessed Fall report stated staff found the resident sitting on her buttocks near her bed. The resident's transferred to the ER. A 4/12/23 Un-witnessed Fall report stated staff heard the resident yelling and found her up against the closet. A 4/28/23 Un-witnessed Fall report stated a nurse was outside of the resident's room and she laid on her right side, head at the door facing the room. The resident transferred to the ER with possible fractures of her right hand/fingers. A 4/28/23 untitled radiology report documented the resident had fractures of the 3rd, 4th, and 5th fingers of her right hand. 5/4/23 Care Plan entries directed staff to anticipate the resident's needs, encourage the call light, and utilize appropriate foot wear. The Care Plan lacked further interventions prior to 5/4/23 related to the resident's previous falls and the resident's clinical record lacked documentation of a root cause analysis of each fall in order to prevent further falls. 3. The 1/27/23 MDS listed diagnoses for Resident #5 which included syncope(fainting) and collapse, hemiplegia(one-sided paralysis), and traumatic brain injury. The MDS stated the resident required supervision assistance of 1 staff for transfers and walking, limited assistance of 1 staff for bed mobility, and extensive assistance of 1 staff for dressing, toilet use, personal hygiene, and bathing. The MDS listed the resident's BIMS score as 6 out of 15, indicating severely impaired cognition. A 1/13/22 Care Plan entry directed staff to keep the call light in reach and anticipate needs. A 4/24/22 Care Plan entry directed staff to provide space when agitated. An 8/12/22 Un-witnessed Fall report stated staff heard a bang come from the resident's room and found the resident on his back on the floor at the end of his bed. The resident stated he fell getting out of the recliner and sustained a bruise to the right knee and an abrasion to the forehead. A 9/1/22 Witnessed Fall report stated the resident walked around the corner, lost his balance, leaned against the wall, slid to the floor, and landed on his left side. A 10/3/22 Witnessed Fall report stated the resident was on the floor of his room sitting on his buttocks with his legs crossed. A staff member stated the resident was agitated and yelling and started to turn around to leave, fell backward, and hit his back against the wall. A 10/7/22 Un-witnessed Fall report stated staff found the resident on the left side of his bed on his left side. The resident was screaming my back, my back. Staff assessed the resident and assisted him back to bed. A 3/17/23 Witnessed Fall report stated the resident walked in the dining room, unsteadily, stumbled, fell to the floor on his right side and hit his head on the floor. The resident had severe pain in the right elbow and was unable to move his right arm. A 3/17/23 8:09 a.m. Nursing Progress Note stated the physician ordered and x-ray of the right elbow, chest, and back. A 3/17/23 12:23 p.m. Nursing Progress Note stated the resident's had increased pain in the right shoulder, elbow, and mid back. The facility received an order to transfer the resident to the ER for evaluation. A 3/17/23 5:52 p.m. Nursing Progress Note stated the resident returned to the facility and had a fracture of the right elbow. A 3/18/23 6:06 a.m. Nursing Note stated the resident had significant pain after his fall yesterday. A 3/18/23 12:20 p.m. Medication Administration Note stated the resident screaming out in pain. A 3/18/23 12:34 p.m. Nursing Note stated the resident complained of severe pain, yelled out, sobbed, and was unable to move. A 3/18/23 2:39 p.m. Nursing Note stated the resident's pain was unrelieved by medication and the facility received an order to transfer the resident to the ER for evaluation. A 3/18/23 4:56 p.m. Nursing Note stated the resident admitted to the hospital for refracture of the T12(thoracic 12-a bone in the spine) and multiple right rib fractures. A 3/23/23 Medication Administration Note stated the hospital notified the facility on 3/22/23 that the resident passed away. The Care Plan lacked further interventions related to the above falls and the resident's clinical record lacked documentation of a root cause analysis of each fall in order to prevent further falls. 4. On 5/8/23 at 10:34 a.m., Staff H Licensed Practical Nurse(LPN) stated a Certified Nursing Assistant(CNA) brought her a needle which she found in the bathroom between 130-132. On 5/8/23 at 11:20 a.m. Staff G CNA stated she found a syringe in the bathroom joining rooms [ROOM NUMBERS]. She stated the nurse had her write a report about it. On 5/9/23 at 8:08 a.m., the Director of Nursing(DON) stated after a fall, the she expected staff to notify the physician and family and implement an immediate intervention. She stated every fall should have an intervention. She stated staff should place all needles in the sharps container. The facility policy Accidents and Supervision reviewed 4/2023, stated the facility would utilize specific interventions to attempt to reduce a resident's risks from hazard in the environment. During an interview on 5/9/23 at 3:30 p.m., the Provisional Administrator stated the facility did not have a policy specific to the discarding of needles.

Based on clinical record review, policy review, and staff interview, the facility failed to create and carry out care plan interventions for a resident with wandering and aggressive behaviors. This failure lead to a resident to verbalize expressions of non-self-limiting expressions of fear. for 1 of 1 resident reviewed for behavioral health (Resident #7). The facility reported a census of 64 residents. Findings Include: 1. The 1/15/23 Minimum Data Set(MDS) assessment tool, dated 1/15/23, listed diagnoses for Resident #7 which included non-traumatic brain dysfunction, early onset Alzheimer's disease, and non-Alzheimer's dementia. The MDS stated the resident had hallucinations and delusions and listed the resident's cognition as severely impaired. In an interview on 5/4/23 at 9:27 a.m., Resident #6 stated Resident #7 came into her room and grabbed her hand and then jerked her again and she screamed for help. She stated the resident got really mad and she screamed for help and tried to get to the door. She stated Resident #7 was enraged and stated the incident frightened her. A 2/1/21 Behavior Note stated the Resident#7 entered Resident #14's room and shoved her hard against her room door causing her lower back to hit the latch. Resident #14 was crying and very upset for quite a while. A 2/7/21 Behavior Note stated the resident wandered around the unit and became aggressive with redirection. The resident walked into another resident's room and urinated on her bed. A 5/8/21 Health Status Note stated the resident wandered into another resident's room and drank from her water pitcher. A 5/24/21 Behavior Note stated the resident wandered and required redirection to keep him out of other resident rooms and stated the resident became upset and drew back his fist at the nurse. A 6/27/21 Behavior Note stated the resident wandered and required redirection away from other resident rooms. A 7/23/21 Behavior Note stated staff found the resident lying on the bed in the room directly across from the resident's room. The resident had feces on the bed spread and his shirt and his hands were completely full of feces. After 10 minutes the resident returned to his own room. A 7/23/21 Behavior Note stated during the time the resident was in another resident's room with feces in his hands, the female resident whose room the resident was in sat in her lounge chair. A 12/20/22 Nursing Note stated a female resident alerted her call light and screamed no, no and when staff arrived the Resident#7 was in the hallway looking at her. The facility policy Behavioral Health Services, revised 12/2022, stated the resident would receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning. The policy stated the services would be person-centered and reflect the resident's goals for care. A 3/16/23 Incident Note stated another resident passed by and Resident #7 made several remarks and seemed greatly agitated. The resident at some time got up and went into another resident's room. Resident #6's Nursing Note, dated 3/16/23 at 5:00 p.m. stated Resident #6 informed the nurse that she sat with her back to the door when suddenly from behind, hands were around her neck and her bib was pulled off. The resident's right arm was pulled of the arm rest and her right leg was pushed off the footholder. The note stated Resident #6 was crying and repeating the ordeal. The facility notified the police. A 3/16/23 9:47 p.m. Nursing Note stated the facility received orders to increase Seroquel (an antipsychotic) back to 100 milligrams(mg) twice daily, administer an extra 100 mg of Seroquel now, and administer Ativan (an anti-anxiety medication) three times daily as needed for breakthrough anxiety for 14 days. The Care Plan did not address the resident's history of physical altercations with other residents or his history of entering other resident rooms and lacked interventions prior to 3/17/23 directed at preventing the resident from entering other resident rooms. Care Plan entries, dated 3/17/23 stated the resident had the potential to be physically aggressive and stated the resident would not harm self or others. The entries directed staff to administer medications as ordered and monitor for effectiveness, monitor and report signs of resident posing a danger to self and others, attempt to bring the resident back to his room which could be a comfort zone, allow resident to meditate alone and attempt cares later when calm, intervene before agitation escalated if possible, guide away from the source of distress, remove other residents from his area, and guide resident away from other resident's rooms. A 3/18/23 Nursing Note stated the Resident#7 was in another resident's room looking down at the occupant and when staff attempted to encourage him to walk out he grabbed the staff member and started shaking her. A 3/19/23 9:44 a.m. Nursing Note stated the resident was in and out of resident rooms. A 3/19/23 2:04 p.m. Nursing Note stated the resident was in and out of other resident rooms and laid on random beds during the lunch meal even though 15 minute checks were ongoing. The note stated it was not possible to keep track of the resident. A 3/22/23 physician's Rounding Note stated on 3/16/23, the resident entered another resident's room and grabbed and shook her. On 5/4/23 at 12:00 p.m., the Provisional Administrator stated that a history of resident altercations should be included on the care plan. She stated after the incident, they put a stop sign on Resident #6's door but stated there was not one present before. She stated that everyone on his side of the hallway had stop signs to deter him from going in other resident's rooms. She stated Resident #6 did not have a stop sign and stated to her knowledge the resident did not go into rooms without stop signs until the situation with Resident #6. When queried as to how the resident was prevented from going into rooms without stop signs, she stated she would check with the Director of Nursing for guidance. On 5/9/23 at 8:08 a.m. the Director of Nursing stated the facility offered stop signs to residents. When she started at the facility she was told the resident occasionally wandered and they offered stop signs to prevent him from going in other rooms. She stated she did not know the specifics about his wandering. She stated prior to the incident with Resident #6, there had not been any concern.

Based on observation, record review and staff interviews, the facility failed to address the random wandering of one resident (Resident #29) and failed to prevent a fall which resulted in a fracture for one resident (Resident #65). The facility reported a census of 64 residents. Findings included: 1. The Minimum Data Set, dated dated dated identified Resident #29 as severely cognitively impaired with a BIMS of 0 and with the following diagnoses: Hypertension, Renal Insufficiency and diabetes Mellitus. It also identified the resident required extensive staff assistance with bed mobility, toileting and bathing and totally dependent on staff for personal hygiene. A review of the undated care plan did not identify the resident with the problem of risk of elopement. During an observation on 3/14/23 at 7:43 AM, the resident self-propelled in her wheelchair out through side door and the alarm sounded. She had pushed herself out through the first door and hand her hand on the safety bar of the second door which led immediately outside. The surveyor had to flag down staff to assist the resident. Staff B, RN, nurse and Staff C, CNA came down immediately. Staff C then pushed the resident back to her room in her wheelchair. In an interview on 3/15/23 at 11:00 AM, Staff C, CNA reported yesterday was the first time she had seen the resident trying to go outside. She did not think there had been anything care planned to keep her from going outside and did not think she had a wandergard (a bracelet worn to set off alarms if the resident attempts to elope) On 3/15/23 at 11:32 AM, Staff H, CNA reported she had witnessed her twice, yesterday attempting to go out the door and it happened and before that she saw her last month trying to go out the side door by the dining room. She does not have a wandergard. She did not know if this had been addressed on the care plan. In an interview on 3/15/23 at 1:00 PM, Staff B, RN reported she had not been aware if the resident tried to elope prior to the other day when she tried to go out. She had not worked that floor very long, noted the resident did not have a wandergard and would expect to have the issue to be addressed on the care plan. In an interview on 3/15/23 at 1:15 PM, Staff D, LPN reported the last time she tried to go out the side door a few months ago. And after the surveyor caught her going out that side door by the dining, later on that day, she tried to go out the other exit door on the other end of the hallway. In an interview on 3/15/23 1:31 PM, Staff I, CNA reported she had not been aware of any other time she had tried to go outside, she does not have a wandergard and all the doors to that unit are alarmed so it will sound when residents try to go outside. In an interview on 3/16/23 7:15 AM, the director of nursing (DON) reported she had not been aware of any other incidents of her trying to elope until just the other day. She did not know if anything had been been care planned for her, however, would expect it to be addressed on the care plan. A review of the facility policy titled: Elopement and Wandering Residents dated January 2023 had documentation of the following: Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. a. The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. b. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering aa. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. bb. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. cc. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. dd. Adequate supervision will be provided to help prevent accidents or elopements. ee. Charge nurses and unit managers will monitor the implementation of interventions, response to interventions, and document accordingly. ff. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. 46873 2. The Minimum Data Set (MDS) of Resident #65, dated 1/10/2023 identified a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderate cognitive impairment. The MDS revealed the resident required limited physical assistance of 1 staff for transferring, walking and toileting. The MDS coded the use of a walker. The Care Plan of Resident #65, closed on 2/27/23, revealed an undated revised/canceled intervention stating the resident required the assistance of 1 staff member using a gait belt for transfers and ambulation. The most current intervention, canceled 2/27/23, stated Resident #65 required the assistance of 2 staff members using a hoyer lift for transfers. An undated document titled Performance Improvement Project Fall Prevention Program directed staff to complete a Fall Risk Assessment upon facility admission. The incomplete facility admission, started 12/19/22, revealed the resident to have a fall score greater than 10 on her Morse Fall Assessment, indicating the resident to be at risk for falls. The Progress Note dated 2/18/23 at 6:30 a.m. documented that a nurse had been called by two Certified Nurses Aides (CNA's) to the residents room at 6:10 a.m., and pulled back the residents covers which revealed, the residents right ankle swollen and twisted. The physician had been notified as well as the family. The nurse completed an assessment, and the resident sent out by ambulance. Prior progress notes prior to the observation on 2/18/23 at 6:30 a.m. lacked any documentation of a fall, or injury. The Progress Note dated 2/18/23 at 9:55 am documented Resident #65 was diagnosed with a fractured right ankle at the emergency room with dislocation of the tibia/fibula (two long leg bones connecting the knee and the ankle). The hospital had to reduce (realigned the bones) the fracture. The Progress Note dated 2/18/23 at 4:21 pm document Resident #65 returned to the facility with orders/diagnoses of: 1. Non weight bearing 2. OCL right lower leg (osteochondral lesion, damage to the cartilage and the talus bone of the ankle joint) 3. Displaced right ankle fracture was reduced, also proximal fibula fracture 4. Hospice cares (family had previously requested a hospice consult before ankle injury) 5. Keep right leg elevated on pillows 6. Resume prior medications and be seen by primary care provider. The Progress Note dated 2/18/23 at 7:51 pm documented multiple bruises found on resident during skin check which included the following; 1. light bruising noted to right hip measuring 3 centimeters (cm's) by 2 cm's 2. Posterior left leg measuring 10cm's by 9cm's 3. lower left side dark purple bruise measuring 22cm's by 14 cm's 4. Left hip noted with dark purple bruise measuring 22cm's by 12cm's 5. Massive dark purple bruising noted coming up out of cast on right lower extremity and around the leg. The Progress Note dated 2/18/23 at 8:22 pm documented the resident's family member was called and notified of the resident's bruises and the family member stated the resident had fallen in the bathroom the prior day with himself and a CNA. The Progress Note dated 2/19/23 at 3:32 am documented that the resident had continued on antibiotics for follow up for sepsis (an infection that spreads throughout the body). The synopsis of the incident per the Facility internal investigation revealed between 5:00 and 5:30 pm on February 17th, 2023 a family member of Resident #65 independently ambulated and transferred the resident to the toilet in her bathroom. A CNA responded to the call light being on and witnessed the family member in the bathroom attempting to assist the resident onto the toilet. The CNA assisted the family member, the resident became unsteady and stopped bearing weight and the CNA as well as the family member assisted Resident #65 to the floor in front of the toilet. The synopsis further stated the CNA notified the family member that additional assistance was needed and the family member declined assistance. The synopsis then next stated the resident was sitting on the toilet. No information was given indicating how the resident went from the floor to the toilet. The synopsis continued that the CNA got assistance from a second staff member and they then ambulated the resident from the toilet to the wheelchair. The synopsis further documented the resident was then taken to the evening meal by the family member and the family member continued his visit throughout the evening and continued to independently ambulate and transfer the resident. When the resident was put in bed for the night, the resident complained of pain in her right leg. Upon assessment by the nurse, the nurse found no swelling, rotation or deformity and the resident denied pain as long as her leg was not being held. The written statement by Staff D, LPN stated on the evening of 2/17/23 the family member of Resident #65 requested assistance for the resident to use the restroom. Staff D asked Staff Q, CNA to assist. Staff Q reported to Staff D a short time later that Resident #65 had fallen in the bathroom. Per the written statement, Staff D asked Staff Q for more details and Staff D understood that Resident #65 had been lowered to the toilet during the transfer. The written statement by Staff Q, CNA stated on the evening of 2/17/23, she went to assist Resident #65 to use the restroom and as she entered the room, the resident was all ready in the restroom with her family member. The resident was standing and did not have her oxygen on or her walker with her. Staff Q went to assist and Resident #65 stated she was experiencing pain in her knee and then fell instantly. Staff Q, along with the family member assisted the resident off the floor and onto the toilet. Staff Q provided oxygen to the resident and informed the family member she would get the nurse for an assessment. The family member denied needing the nurse's assistance but the CNA reported the fall to the nurse anyway. The statement read that the family member continued to transfer the resident throughout the shift after the fall. The written statement by Staff H, CNA stated that she was not a witness to the fall. She assisted the resident after the fall transfer from the toilet. She also assisted the resident transfer from the wheelchair to the bed. On 3/14/23 at 4:27 pm, a family member of Resident #65 stated on the night of the fall he had rang the call light for the resident needed to use the restroom. He stated a CNA answered the call light and he and the CNA assisted the resident to the restroom. The family member stated they both had their hands on her and she only needed to take a step or two but her leg gave way and she slumped to the floor. He stated she did not appear to have been hurt. The family member stated he and the CNA together lifted the resident to the toilet and then another CNA came to assist and they transferred her to the wheelchair and then into bed. He stated he left a few minutes after that and he was not present the rest of the night for any more times she went to the restroom. On 3/14/23 at 4:39 pm Staff D, LPN stated she was passing medications and her med cart was right outside the room of Resident #65 on the evening of 2/17/23. She stated a family member was present and she heard him state something about the resident using the restroom. She stated she told the family member she would send a CNA in. A short time later the CNA reported to her the resident had fallen in the bathroom. She stated when she questioned the CNA for further details, her understanding was the resident had stumbled and was lowered to the toilet. Staff D reported she did not consider this a fall. She stated the CNA did not inform her the resident had fallen to the floor. She voiced a gait belt should always be used for every resident transfer. She also said a resident should never be moved after a fall until being assessed by a nurse. She reported at the time of speaking to the family member prior to the fall, Resident #65 had been sitting in her recliner. She stated she had never personally witnessed the family member transferring the resident. She said the family member stayed until 8:00 or 9:00 pm that evening and after the resident was in bed, he reported to her the resident was complaining of pain. She then assessed the resident. The family member was holding onto the resident's leg and the resident was hollering ouch. Staff D did not note anything out of the ordinary, no swelling or anything. She asked the family member to let go of the resident's leg and when he did so, the resident then denied pain. On 3/15/23 at 7:26 am, the Director of Nursing (DON) stated if a resident falls when a CNA is with him or her, the expectation is for the CNA to first make sure the resident is safe and then get assistance. The resident should not be moved or transferred until a nurse comes in to assess the resident first, regardless of if there are any apparent injuries or not. She stated this is part of new employee orientation. On 3/17/23 at 4:58 PM Staff Q, CNA stated on the evening of 2/17/23, she responded to the call light of Resident #65. She stated when she entered the room, the resident was all ready in the bathroom with a family member. She said the resident was not wearing her oxygen but her walker was in the bathroom. She stated she went to assist and held the resident by her center of gravity and the resident called out that her knee hurt and she then just fell to the floor with no warning. Staff Q stated she informed the family member that she needed to inform the nurse of the fall and he stated no and was starting to pick the resident up. Staff Q stated she assisted him as he was picking the resident up anyway. Once we got her to the toilet I was able to get another CNA (Staff H) to help and we transferred her to the wheelchair. Staff Q stated she then reported the fall to Staff D, LPN and Staff D responded ok. Staff Q stated she worked throughout the entire night shift as well and Resident #65 had no complaints of pain throughout the night. Staff Q stated she did not use a gait belt because the facility does not have enough gait belts to provide for each resident room or for each staff member. She stated when a gait belt is needed, she has to go search for one. On 3/20/23 at 11:14 AM Staff H, CNA stated she did not witness the fall of Resident #65 on 2/17/23. She stated she was asked to assist transfer the resident from the toilet to the wheelchair after the fall. She stated she used a gaitbelt during this transfer. She said after the resident was in the wheelchair, her family member took her to the dining hall and returned with her to her room after supper. She stated she and Staff Q assisted the resident into bed. She stated the family member offered his assistance but she responded to him they did not need assitance. She stated the family member has often offered to help during transfers but she always has told him no. She stated she has never witnessed the family member transferring the resident on his own. A documented titled Fall Prevention program, revision date November 2017 directs a near miss is when a resident would have fallen if someone else had not caught the resident from doing so. A near miss should be considered a fall. The document further directs When any resident experiences a fall, the facility will: a. Assess the resident. b. Complete a post-fall assessment. c. Complete an incident report. d. Notify physician and family. e. Review the resident 's care plan and update as indicated. f. Document all assessments and actions. g. Obtain witness statements in the case of injury.

Based on observation, interview, and record review, the facility failed to ensure a resident received only medications prescribed to him for one of one resident reviewed for significant medication errors and failed to ensure a resident remained free from a significant medication error during medication administration for one of three residents reviewed for the medication administration task (Resident #11, Resident #21). The facility reported a census of 64 residents. Findings include: 1. The Quarterly Minimum Data Set (MDS) assessment for Resident #11 dated 1/17/23 documented the resident scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam which indicated the resident was cognitively intact. Review of the Potential Medication Error Investigation dated 10/17/22 provided by the facility documented, in part, At approximately 0945 Charge Nurse on [NAME] Avenue [Staff D] LPN (Licensed Practical Nurse) who was training [Staff E] LPN reported to D.O.N. (Director of Nursing) that resident [Resident #11] was being sent to [hospital] for a change in condition. [Staff D] reported [Resident #11] was his usual self at breakfast, upon return to his room he began demonstrating neurological changes, signs of lethargy, changes in speech pattern .While awaiting the ambulance [Staff D] and [Staff E] determined [Resident #11] potentially received another residents' medications. Certified Medication Aide [Staff A] was the CMA assigned to [NAME] Avenue for the medication pass on this day [Staff D] and [Staff E] found [Resident #11's] medication cup with his medications in a cup sitting at the bedside of another resident, [Resident #43]. These pills had not been taken. Upon further investigation the medication card for Resident #43 had the medications punched out of the card, the medications had been signed out, the medications were not found anywhere. The section of Potential Medication Error Investigation which documented an interview with Staff A documented, in part, She reported she stopped at [Resident #11's] room because he was asking about his medications. She stated she got his medications ready to be given to him. She reported [Resident #11] usually looks at his medications prior to taking them. She was unable to recall whether he looked at his medications this time. When asked about leaving the medication cup with pills at the bedside of [Resident #43] [Staff A] reports she is unable to recall whether [Resident #43] was in his room when she sat the pills on the night stand. When questioned about the practice of leaving medications at the bedside and not observing resident take pills [Staff A] responded everyone does it. The section of the Potential Medication Error Investigation that documented an interview with Staff D documented, in part, While [Staff A] was gone a nurse [NAME] <sic> reported to [Staff D] that [Resident #11] was not acting like himself. Resident was slurring words, was pale in color, and incontinent of urine After [Resident #11] was sent to the ER resident [Resident #43] reported to [Staff A] that he did not believe the pills sitting on his bedside stand were his. [Staff D] checked the medication cards and the pills sitting at [Resident #43's] bedside were [Resident #11's] medications. The section of the Potential Medication Error Investigation that documented an interview with Staff E documented, in part, During one of [Staff A's] absences from the facility it was discovered [Resident #11's] medications were found in [Resident #43's] room sitting on the bedside table in a medication cup. Upon investigation it was determined [Resident #11] had not received his morning medications although his medication pack for this day had the medications removed from the card and were signed out. The medications in the medication cup at [Resident #43's] bedside were determined to belong to [Resident #11]. The medication card for [Resident #11] had the medications removed and were signed out and matched the pills in the medication cup at [Resident #43's] bedside. Review of a statement written by Staff A dated 10/18/22, no time present, documented, in part, I stopped at [Resident #11's] room he was asking about his medication so I got his medicine ready to be given to him. The Late Entry Nursing Progress Note dated 10/18/22 at 9:35 AM documented, Assessment on resident at this time. Vitals were BP (blood pressure)-130/78,R (respirations)- 20, T (temperature)-98.1, SPO2-98%, P (pulse)-78. Resident responding to questions but speech very slurred. Eyes not tracking. Having a hard time with forming complete sentences or thoughts. Called 911 at this time to evaluate at ER (emergency room ). The Nursing Progress Note dated 10/18/22 at 9:35 AM documented, in part, Bath aid came to nurses station to express concern of change of condition. Nursing assessment completed and found that resident was given wrong medications. Sent to ER for evaluation. Review of hospital documentation dated 10/18/22 documented, [Resident #11] is a [age] y.o. (year old) who is being admitted through the emergency room for altered mental status Today he was brought to the emergency room for altered mental status. Unfortunately the patient was given the wrong medications and received clonazepam 1.5 milligrams, gabapentin 400 milligrams ,Cymbalta 60 milligrams, and baclofen. The patient does take baclofen daily. He was found to be drowsy and only responsive to painful stimulation. He was given Romazicon in the ED (emergency department) with minimal improvement. The patient is now being admitted for further observation. Hospital documentation also revealed, Was found that he was given another residents medications and brought to the emergency room for further evaluation. Secondary to his continued altered mental status he is being admitted for observation and he is high risk for aspiration. On 3/13/23 at 4:09 PM, Resident #11 had been observed in his room in bed. When Resident #11 had been queried about going to the hospital, Resident #11 explained he had been given medications that were not his and were the wrong stuff, and explained he had had a pretty bad reaction. On 3/15/23 at 11:49 AM, Staff E, Licensed Practical Nurse (LPN), had been queried about when Resident #11 had gone out. Per Resident #11, when the resident had gone out she had been training with Staff D, LPN. Per Staff E, she remembered Staff D said the resident was not acting right/normal, an assessment had been done, and it had been said the resident was being sent out. Staff E explained she did not see the resident before he went out. On 3/15/23 at 4:38 PM, Staff D had been queried about the situation. Staff D explained she realized the resident did not come back from breakfast and had still been in the dining room which was unusual. Staff D explained the resident was unconscious, and did not respond at all. Staff D explained the resident had been breathing. Per Staff D, the resident was taken back to his room, vitals were completed, and the doctor and 911 were called. Per Staff D, they got the resident out as quickly as they had found him. Staff D explained the resident across the hall rang and had had cup of pills they said weren't theirs. Per Staff D, those had been Resident #11's pills. Staff D explained they got to thinking, looked at the other resident who didn't get his medications but were popped out, and considered the possibility. On 3/16/23 at 11:06 AM, the Director of Nursing (DON) explained that it had been determined [Staff A] had given the wrong medications. When queried about expectations, the DON explained the EMAR (electronic medication administration record) was supposed to be checked with the card, and if there were questions the nurse was to be asked. The DON acknowledged staff were to make sure it had been the right medication, dose, and resident. When queried if Staff A had stayed with the resident when he took the medications, the DON acknowledged she did not believe so and acknowledged the staff member should have done so. 2. The MDS assessment dated [DATE] revealed Resident #21 scored 9 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had moderately impaired cognition. Per this assessment the resident had a diagnosis of Diabetes Mellitus. The Physician Order dated 1/4/23 documented NovoLOG Solution (Insulin Aspart) with directions to inject 2 units subcutaneously before meals related to Type 2 Diabetes Mellitus without complications .hold if blood sugar is <100 (less than 100). Review of the Blood Sugar Summary present in the resident's electronic health record revealed on 3/16/23 at 11:49 AM, Resident #21's blood sugar had been documented as 68.0 mg/dL (milligram per deciliter) On 3/16/23 at 11:41 AM, Staff B, Registered Nurse (RN), had been observed to prepare an Insulin Aspart Pen 100 units/milliliter to the 2 unit mark on the pen for Resident #21 and also took the resident's blood sugar. Staff B had not been observed to prime the pen prior to dialing the number of units for insulin administration. Staff B said the resident's blood sugar had been 68. Staff B administered the insulin to the resident. Review of the resident's Medication Administration Record (MAR) for 3/16/23 documented the insulin had been marked as administered. On 3/16/23 at 4:02 PM, the facility's Director of Nursing (DON) acknowledged if there were parameters staff were to follow them, and if the did not follow them staff were to contact the doctor or the Nurse Practitioner, whoever was on call. The Facility Policy titled Medication Administration dated 4/19 and revised 1/23 documented, 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form. dose, route, and time 14. Administer medication as ordered in accordance with manufacturer specifications.

Based on observation, clinical record review, policy review, resident interview, and staff interview, the facility failed to carry out assessments and interventions in order to prevent the development and/or worsening of a facility acquired pressure ulcer for 3 of 3 residents reviewed for pressure ulcers (Residents #1, #2, and #3). The failures resulted in Immediate Jeopardy to the health, safety, and security of the residents. The facility reported a census of 69 residents. Findings include: 1. The MDS (Minimum Data Set) assessment tool, dated 8/18/21, stated the resident had MASD (Moisture Associated Skin Damage-incontinence-associated [CONDITION(S)]/inflammation of the skin). The MDS assessment tool, dated 11/18/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident completely depended on 1 staff for eating and personal hygiene, and completely depended on 2 staff for bed mobility, transfers, dressing, toilet use, and bathing. The MDS listed the resident's BIMS (Brief Interview for Mental Status) score as 8 out of 15, indicating moderately impaired cognition and stated the resident had MASD and was at risk for developing pressure ulcers. The 2/12/21 Nursing Admission Assessment section for skin was blank and contained no information. The December 2021 TAR (Treatment Administration Record) listed a 3/12/21 order for Baza Protect Cream (a moisture barrier cream), apply to left gluteal fold topically every day and evening shift related to personal history of diseases of the skin and subcutaneous (below the top layer of the skin) tissue. It listed a discontinue date of 12/1/21. An 8/8/21 Nursing Note stated the resident continued to have skin breakdown on his buttocks and staff repositioned him every 2 hours. The Braden Scale for Predicting Pressure Sore Risk, dated 9/5/21, stated the resident was at risk for the development of pressure ulcers. The facility lacked documentation of a skin assessment done for the gluteal fold or buttocks from 3/12/21-12/1/21. A Nursing Note, dated 12/1/21 at 6:34 p.m., stated the physician saw the resident and ordered the following: 1. Discontinue current treatments to the skin of the buttocks. 2. Cleanse buttocks/perineum 4 x daily with warm soapy water, rinse well, pat dry, apply [MEDICATION(S)] (a cream used to treat skin concerns) liberally. 3. Egg crate mattress or air mattress to bed. 4. Roho cushion (used to relieve pressure) in chair. 5. Turn side to side every 2 hours when in bed, avoid supine (back lying) position. 6. Not to be up in chair for periods greater than 60 minutes. The note contained no assessment of the skin and did not indicate the reason the physician saw the resident and initiated new orders. A review of the resident's clinical record revealed staff did not complete a skin assessment on 12/1/21. A 12/1/21 ARNP (Advanced Registered Nurse Practitioner) Note stated the resident had diffuse redness, discoloration, sloughing (shedding) tissue and multiple areas of sheared tissue across the buttocks and coccygeal(tailbone) area. The note directed staff to cleanse the area three times per day with water and /or soapy water, apply barrier cream with [MEDICATION(S)], provide a Roho cushion when in the chair and an air mattress to the bed, and turn every 2 hours. A 12/6/2021 10:15 a.m. Nursing Note stated the resident had a decline in health status and was not eating or drinking. The facility called the provider who sent the resident to the ER. The note did not include an assessment or description of the resident's skin. A 12/6/21 4:37 p.m. Nursing Note stated the resident admitted to the hospital with an elevated WBC (white blood cell) count. A 12/6/21 hospital History and Physical listed a 12/6/21 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The note stated the resident had a midline large gluteal skin sore and had a low pressure mattress and directed staff to get air to the skin and keep the resident off of it. The note stated the wound had black coloration at the superficial (occurring on the surface) ulcer level with odor. The resident took antibiotics and had a WBC count of 12.4/uL(microliter) with normal range defined as 3.7-9.3/uL. The document stated the resident was unable to feed himself. A 12/12/21 Hospital Note listed the 12/7/21 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . It stated the resident's wound culture was positive for proteus mirabilis and staph aureus(types of bacteria). It stated the resident's blood culture grew staph epi(a type of bacteria), a probable skin contaminant. It directed staff to complete meticulous perineal care. A 12/13/21 Nursing Note stated the resident readmitted to the facility from the hospital with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had an open wound on the coccyx 10.5 cm (centimeters) x 14 cm x 3 cm (length x width x depth) with a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A 12/13/21 Wound Weekly Observation Tool stated the resident had a coccyx pressure wound, acquired 12/1/21, and the resident had an air mattress and was on a turning and repositioning routine. The tool documented the wound had a large amount of purulent (referring to pus) drainage and measured 105 mm (millimeters) x 14 mm x 3 mm. A 12/16/21 4:11 p.m. Nursing Note stated the resident had a coccyx wound and staff turned him side to side and avoided the supine position. The note stated the resident required assistance to feed himself. The resident's Care Plan as of 12/20/21 did not address the resident's current skin issues or list interventions to treat and prevent skin issues. The 12/20/21 Daily Assignment Sheet for [NAME] (the unit Resident #1 resided) listed the following staff members assigned for the 1st shift: Staff A, Staff D, Staff C, Staff B, and Staff F. Observations on 12/20/21 revealed the following: 8:30 a.m. The resident's door closed. 9:05 a.m. Staff C CNA (Certified Nursing Assistant) entered the resident's room with a Styrofoam container of breakfast. The resident was in bed on his back. Staff C did not offer to assist the resident with eating. 9:17 a.m. Staff B Nurse Aide brought the resident a small container of chocolate Mighty Shake (a nutritional supplement). The resident was on his back with the head of his bed elevated less than 30 degrees. The resident's over bed table was not above him but over on the left side of the bed. The resident's Styrofoam breakfast container was on the table, not in reach of the resident. Staff B handed the resident the Mighty Shake and the resident's hands shook when he took it from her. Staff B did not offer to assist the resident to eat or drink any further. 11:19 a.m. Staff G Activities Staff entered several rooms in the hall to pass out Christmas cards and gifts. She did not enter Resident #1's room. 11:58 a.m. Staff A RN (Registered Nurse) went into the resident's room with a medication cup. She stated to the resident oh did you spill your milk? The resident's unopened Styrofoam breakfast container was still on the table. Staff A exited the room at 12:01 p.m. and stated to Staff C that she needed some help. There was an area approximately 1 foot in diameter on the floor which appeared to be the resident's chocolate shake. The resident was on his back and was shaky. Staff E CNA entered the room and Staff C and Staff E rolled the resident over onto his left side. Staff C asked Staff E if there were cloths in the room and Staff E stated she did not know and did not know who worked with the resident this morning or last night. Staff C and E rolled the resident over onto his left side and the resident had a large wound on his coccyx area which appeared to have depth to it. Yellow and dark brown drainage seeped from the wound and the wound had a foul odor. The pad and the fitted sheet under the resident had an area approximately 2 feet in diameter stained with a dark brown substance. Staff A RN re-entered the room and removed packing from the wound which was covered with brown and red drainage and had a foul odor. Staff A cleansed the area with [MEDICATION(S)] (an iodine solution) and inserted new packing into the area. The resident also had an open area on the lower right buttock. After the dressing change, there was a scant amount of blood under the resident's buttocks on a paper pad. After the cares, the surveyor asked Staff C to open the resident's breakfast container. Staff C opened it and she said he did not eat anything. The food appeared untouched. Staff C stated she last worked with him 2 weeks ago and thought he fed himself. Staff C and Staff E stated they did not assist the resident earlier in the day. Staff E stated Staff D CNA and Staff B worked with the resident and Staff F CNA did showers. Before leaving the room, Staff C gave the resident a drink of water and he was very shaky and struggled to hold onto the water container. The resident appeared to take a small drink of water. Staff C stated the resident drank some of his Mighty Shake and that the chocolate milk on the floor had been there when she delivered his breakfast that morning. She stated it looked like he drank approximately half of his Mighty Shake carton. The resident had a urinary catheter and the bag contained approximately 200 ml( milliliters) of dark brown urine. The resident had an air mattress on the bed which was dialed to the firmest setting and was set on static. The surveyor stood in the hallway from 8:30 a.m. and no staff entered the resident's room from 9:17 a.m. until 11:58 a.m. and staff did not reposition the resident or provide hygiene assistance for the resident from 8:30 a.m.-11:58 a.m. Aside from possibly a sip of Mighty Shake and the sip of water Staff C gave the resident, the surveyor did not see staff assist the resident to drink during this time frame. 12:55 p.m. The resident laid in bed on his left side with the head of his bed at a 45 degree angle. The resident's tray table was on the left side of his bed and he attempted to reach the food on his tray but was not in position to do so. The food was not within a comfortable reach of the resident and it did not appear he ate more than a couple of bites. During an observation on 12/21/21 at 11:15 a.m., Staff A changed the resident's dressing and Staff H LPN Facility Wound Nurse measured the coccyx wound as 9.8 cm x 7.4 cm with tunneling at a depth of 1.5 cm at the position of 10:00. She measured the depth of the center of the wound as 4.7 cm. Staff H then measured an open area with a red wound bed on the right lower buttocks as 6.6 cm x 3.2 cm. During the cares, Staff H stated the wound was getting progressively worse every day. The surveyor asked Staff H about the air mattress setting and she stated Hospice set it up and she didn't know what setting the machine should be set on. She stated it could be a little less firm. The resident's POC (Point of Care) Response History for the question record fluid intake revealed the following: Entries on 12/20/21 at 1:28 p.m., 1:54 p.m., and 7:44 p.m. documented the resident drank 0-25%. The resident's POC Response History for the question record meal intake documented the resident ate 0-25% at 1:28 p m, 1:54 p.m., and 7:44 p.m. The Panacea Direct Air Element Mattress Owner Manual stated the Alternate/Static Switch selected between alternate pressure mode and static pressure mode. With alternate pressure mode, alternating air cells are partially deflated and inflated, avoiding prolonged pressure on any single point beneath the patient or resident to help prevent pressure ulcers. With static pressure mode, all of the air cells are equally inflated. (Retrieved on 12/27/21 from https://content.directsupplycdn.com/ 6316E230D1337F533F9421A0A7F44C30BD08C5F1 F496F2D2F2D17B62A8157DB5). During an interview on 12/20/21 at 1:00 p.m., Staff F CNA stated she did showers today and did not assist Resident #1. During an interview on 12/20/21 at 1:05 p.m., Staff D CNA stated she did not care for Resident #1 today. She stated Staff C and B cared for him. During an interview on 12/20/21 at 1:07 p.m., Staff B stated she did not take care of Resident #1 today. During an interview on 12/20/21 at 2:20 p.m., Staff H LPN (Licensed Practical Nurse) stated she had Staff I ARNP see the resident on 12/1/21. Staff H stated she thought the wound looked like a Kennedy ulcer (a dark sore that developed rapidly during the final stages of a person's life). She stated Staff I ordered [MEDICATION(S)] 4 times per day and stated 4 days later the wound looked worse and they admitted him to the emergency room (on 12/6/21). She stated she did not complete any measurements on 12/1/21 when the ARNP saw the resident. She stated the facility treated his bottom for a while. He had redness and sloughing. She stated on 12/1/21, the area was closed and Staff I ordered an egg crate. She stated prior to 12/1/21, the resident's buttocks were red, irritated, and macerated(breakdown of skin resulting from prolonged exposure to moisture). She stated it had been like that for a while and she had no skin assessments prior to 12/1/21 as she only completed skin assessments for pressure wounds, surgical wounds, and skin tears. She stated the nurses only do skin assessments if the resident had a current skin issue or if they were skilled. She stated the facility did not complete skin assessments routinely on all residents. During a telephone interview on 12/21/21 at 8:33 a.m., Staff J RN stated Resident #1 did not reposition himself. She stated the resident had a decline and required the assistance of staff to eat. She stated she expected staff to turn him at a minimum of every 2 hours. The surveyor asked Staff J what staff should do if the resident had dark colored urine and she stated he had a water pitcher within reach but stated she did not know if he could get it himself currently. During an interview on 12/21/21 at 8:49 a.m., Staff K LPN stated she first saw Resident #1's coccyx wound about 3 weeks to 1 month ago. She stated they received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated it was good sized when she first saw it. She stated prior to this during the last 6 months, the resident's bottom was red. She stated staff should turn the resident at least every 2 hours. During a telephone interview on 12/21/21 at 9:11 a.m., Staff I ARNP stated she was not aware the resident had any skin problems until 12/1/21. She stated considering the resident was incontinent she would expect staff to assess skin areas every time they cleansed him. She stated when she saw the wound on 12/1/21, it was an area of purplish discoloration and no open areas or ulcers were present. During an interview on 12/21/21 10:45 a.m., Staff B Nurse Aide stated there was no spilled chocolate milk on the floor when she delivered his chocolate milk on 12/20/21. During an interview on 12/21/21 at 11:36 a.m., Staff A RN stated when they first noticed the area on Resident #1's coccyx, it was purple and reddish with no open areas. She stated the ARNP ordered a cushion and [MEDICATION(S)] cream. She stated the area looked totally different than it currently looked. She stated staff should turn the resident every 2 hours at least and should check on him every time they pass the room for safety reasons. She stated on 12/20/21, the Hospice Aide came in early in the morning to give him a bed bath but she didn't know what time. She stated his urine was dark and they encouraged fluids. She stated today the resident attempted to eat himself but needed help and stated if staff helped him, she thought the resident would eat more. She stated the resident lying on his side was a handicap to eat. With regard to skin assessments, she stated if the aides report a problem to the nurses, they completed an assessment but there was no system to complete regular assessments on all residents. During an interview on 12/21/21 at 11:53 a.m., Staff F CNA stated Resident #1's wound looked totally different now than it used to. She stated it used to have redness but it was not open. She stated if staff talked to the resident, he allowed repositioning. She stated she thought staff should turn Resident #1 every 1 hour. During an interview on 12/21/21 at 12:37 p.m. Staff H stated staff should reposition and change the resident Resident #1 every 2 hours and anytime he was soiled. She stated if a resident refused cares or feeding assistance, they should attempt 3 times. She stated they should sit the resident up to eat and attempt to feed him. She stated if the resident's urine was dark, staff should offer fluids as the resident would drink Mighty Shakes. She stated there was probably no family notification of the resident's red bottom. She stated with regard to the Care Plans, the interim DON(Director of Nursing) was attempting to get them made up after the former DON left her position. She stated she was made aware last night that staff did not assist another resident with eating assistance for lunch on 12/20/21 in addition to Resident #1. She stated she reprimanded the aides regarding this. During a telephone interview on 12/22/21 at 11:50 a.m., Staff L Home Health Aide, stated on 12/20/21 she thought she arrived to give Resident #1 a bed bath a little after 7:00 a.m. and left a little before 8:00 a.m. She stated she definitely did not care for the resident after 8:00 a.m. During an interview on 12/22/21 at approximately 2:00 p.m., the Dietary Supervisor showed the surveyor the size of Mighty Shake Resident #1 received and it contained 117 ml (milliliters) 2. The MDS assessment tool, dated 10/28/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident required limited assistance of 1 staff for bed mobility, transfers, walking, dressing, and personal hygiene and required extensive assistance of 1 staff for toilet use and bathing. The MDS listed the resident's BIMS (Brief Interview for Mental Status) score as 15 out of 15, indicating intact cognition and stated the resident had 1 Stage 2 pressure ulcer (defined as partial thickness loss of dermis(skin) presenting as a shallow open ulcer with a red or pink wound bed). A 12/15/21 Wound-Weekly Observation Tool stated the resident had a Stage 4 pressure ulcer (an ulcer extending into the deep tissues) in the intergluteal crease acquired on 9/9/21 which measured 5 mm x 5 mm. The December 2021 TAR listed a 12/1/21 order for Calcium Alginate-Silver Pad (a type of wound dressing), apply to intergluteal crease daily. The Braden Scale for Predicting Pressure Sore Risk stated the resident was at moderate risk for the development of pressure ulcers. During an observation on 12/21/21 at 10:40 a.m., the resident stood from her recliner and Staff A RN measured an open area with a pink wound bed in between the resident's buttock as 0.5 cm x 0.5 cm. Staff A cleansed with NS(Normal Saline) and applied Calcium Alginate. The resident's recliner did not have a cushion in it. During the following observations, the resident sat in her recliner: 12/20/21 at 9:03 a.m. and 9:10 a.m. During an observation/interview on 12/21/21 at 10:40 a.m., the resident sat in her recliner and stated no one offered her a cushion for her recliner. As of 12/20/21, the resident's Care Plan did not address the resident's pressure ulcer or include interventions in place to treat the area. 3. The MDS assessment tool, dated 12/9/21, listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS stated the resident required limited assistance of 1 staff for eating, extensive assistance of 1 staff for personal hygiene and dressing, extensive assistance of 2 staff for bed mobility and transfers, depended completely on 1 staff for bathing, and depended completely on 2 staff for toilet use. The MDS listed the resident's BIMS score as 15 out of 15, indicating intact cognition and stated the resident had 1 Stage 2 pressure ulcer(affecting the top layer of the skin). An 11/24/21 Nursing Note stated the resident admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A 12/2/21 Nursing note stated the resident returned to the facility from the hospital. A 12/2/21 Admission Nursing Assessment documented the resident had bruising to the lower legs but did not state the resident had impairment of the coccyx. A 12/8/21 Nursing Note stated the resident had a new treatment order for the coccyx. The December 2021 TAR listed a 12/9/21 order for Santyl Ointment (used to treat wounds) apply to coccyx every evening shift for coccyx wound. A 12/11/21 Nursing Note stated the resident complained of her buttocks hurting. A 12/16/21 Wound Weekly Observation Tool, stated the resident had a coccyx pressure ulcer acquired 12/8/21 which was a Stage 1 measuring 5.2 cm x 6.1 cm with no depth. The facility lacked any further assessments of the wound from the 12/8/21 order note until 12/16/21. A 12/20/21 Nursing Note stated the resident complained of buttock pain. The resident's Care Plan as of 12/20/21 did not address the resident's pressure ulcer or include interventions to treat and prevent worsening of the ulcer. During an observation on 12/20/21 at 3:55 p.m. Staff A rolled the resident over on the right side and the resident had a wound on the coccyx with a red wound bed which appeared to have some depth. Staff A measured the wound as 5 cm x 4.5 cm x 2.5 cm depth. The resident stated to the surveyor that the area was not getting better. Staff A applied Santyl ointment to the area and covered it. The facility policy Dressings, Dry/Clean, revised 2013, directed staff to document a wound's appearance, wound bed, edges, presence of drainage, and size. The facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised March 2014 , directed nurses to conduct full assessment of pressure sores including location, stage, size and presence of exudates and necrotic(dead) tissue. The policy stated the physician would help identify medical interventions related to wound management. The facility policy Pressure Ulcer Risk Assessment, revised [DATE], stated staff would perform routine skin inspections with daily care and nurses would conduct skin assessments at lest weekly to identify changes. The facility policy Prevention of Pressure Ulcers, revised September 2013, directed staff to implement preventative interventions including position changes, special mattresses, provision of personal hygiene assistance to remove bacteria and promote comfort, and ensuring the resident drinks plenty of fluids and eats a well-balanced diet. During an interview on 12/21/21 at 12:37 p.m. Staff H stated she did not have any measurements for Resident #3 in the computer and had a small scrap piece of paper with her which she stated had measurements she took of the resident's coccyx wound on 12/17/21. She stated the measurements were 5.2 cm x 6.1 cm x .04 cm. When the surveyor stated the depth during the observation on 12/20/21 was 2.5 cm, Staff H agreed the wound was getting worse. She stated she did not know anything about the area until 12/17/21 and did not know when staff discovered it. She stated if it was not discovered upon admission from the hospital, she probably did get the wound at the facility. She stated it was difficult for her to work the floor and complete wound assessments. During an interview on 12/28/21 at 11:02 a.m. the interim DON (Director of Nursing) stated she triggered skin assessment observations in the computer for every single resident. Last Wednesday staff completed them on everyone. Staff should completed them every week. She audited them and staff completed them. She stated they now had a way to track this. She expected assessments for MASD as well. For Res #2 she expected her to have a cushion for pressure relief. She stated she disciplined staff regarding the events with Resident #1 on 12/20/21. The facility was notified of the Immediate Jeopardy and given the IJ template on 12/21/21 at 4:15 PM. The facility corrected the immediate jeopardy on 12/22/21 by providing education to staff on wound care and assessments, repositioning, hydration/nutrition and incontinence cares. Care plans were updated and skin assessments completed. At time of exit the scope and severity was lowered to a D after verification staff had implemented their policies and procedures.

Based on observation, record review, and interview, the facility failed to provide adequate supervision to protect one (1) of five (5) residents from hazards during transfers. Resident #3 fell and sustained a hip fracture on 10/22/16. Record review revealed Resident #3 ' s care plan called for one staff assistance for transfers with a gait belt and walker. Staff interview revealed the resident ' s walker had been left in his/her room at the time of the fall; and staff had transferred the resident prior to the fall without a walker. The facility reported a census of 61 residents. Findings include: 1. According to the Minimum Data Set (MDS) assessment tool, dated 8/18/16, Resident #3 had [DIAGNOSES REDACTED]. The MDS documented the resident required limited assistance of 1 staff for eating and extensive assistance of 1 staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. The MDS documented the resident did not walk during the MDS review period and listed the resident as not steady and only able to stabilize with staff assistance while moving from seated to standing position, walking, turning around and facing the opposite direction while walking, moving on and off toilet, and surface-to-surface transfers. The MDS documented the resident had 2 falls resulting in no injury since the last assessment and normally used a walker and a wheelchair. The resident's care plan stated the resident was at risk for falling related to prior falls and impaired mobility and included the following interventions implemented prior to the resident's 10/22/16 fall: Resident #3 will transfer/ambulate with assist of 1 using a gaitbelt and walker while minimizing the risk for falls, initiated 8/15/16, revised 10/10/16. a. Keep personal items and frequently used items within reach. Date initiated 8/15/16 b. Provide toileting assistance before and after meals, at bedtime, and as needed. Date initiated 8/15/16 c. Wheeled walker in reach. Date initiated 8/29/16. d. Transfer/ambulate with assistance of 1 (staff) using gaitbelt and walker 10/10/16 (revised date). Facility incident reports listed the following previous falls for the resident between the dates of 8/13/16-10/22/16: a. 8/13/16 Staff found the resident sitting on the floor. No injury noted. b. 8/15/16 Staff found the resident sitting on the floor. No injury noted. c. 8/25/16 Staff found the resident sitting on the floor by the bed. No injury noted. d. 8/25/16 The resident's spouse witnessed the resident slide out of the recliner. No injury noted. e. 8/26/16 Staff found the resident sitting on a fall mat on the floor by the bed. No injury noted. f. 9/13/16 Staff found the resident seated on the floor mat in the room. The resident complained of right leg pain and went to the emergency room . Hospital emergency department notes, dated 9/14/16(the day after a fall), stated the resident complained of right leg/hip pain after slipping off bed and landing on a thick floor mat. Radiology reports revealed no evidence of a fracture or dislocation. Fall 10/11/16 Facility incident reports listed the following previous fall for the resident: g. 10/11/16 Staff found the resident on the floor. No injury noted. The Progress Notes dated 10/11/16 at 7:30 a.m. documented Resident #3 was found on the floor on his/her left side by his/her bed by the staff. The night staff stated she was unaware the resident had floor mat. The nurse informed the night staff the reason for the floor mats intervention needed to be in place at all times when the resident had been in bed. Facility incident reports listed the following previous fall for the resident: h. 10/21/16 Staff witnessed the resident get up from a chair and fall and hit head. No injury noted. A fall risk assessment, dated 10/21/16, listed the following fall risks for Resident #3: a. a fall in the last 30 days b. a fall in the last 31-180 days c. complaints of dizziness or unsteadiness in the past 30 days d. anti-anxiety medications e. anti-depressant medications f. diuretic medications(medications which increase the need to urinate) g. anti-hypertensive/cardiovascular(blood pressure/heart) medications h. visual impairment i. required assistance with toileting Fall 10/22/16: According to a facility incident report, dated 10/22/16 at 9:20 a.m., Staff C, Agency nurse documented Resident #3 was sitting in the TV room and she observed him/her standing and attempting to walk. The Agency staff documented before she could get to the resident and the resident lost his/her balance and resident fell backwards. The resident had pain in the right hip about an hour later upon reassessment and the facility transferred the resident to the emergency room . The incident report did not included any information about a walker/wheelchair air nearby. The facility incident report dated 10/22/16 revealed inconsistency of a witnessed fall, however Staff A indicated during her interview, Staff C had been with her in another resident ' s room when they heard Resident #3 ' s fall; and they both exited the other resident ' s room together. The Progress notes written by Staff C (Agency nurse), dated 10/22/16 at 1:26 p.m., documented the following: Resident #3 had been sitting on the chair in the lounge after breakfast and was seen standing up attempting to ambulate at about 9:20. The Agency nurse documented he went to help Resident #3 resident sit back down on the chair but the resident lost balance and fell on to the right side. The Agency nurse documented he informed the Supervisor (Staff B). The resident complained of pain in the right hip about an hour later and the facility transferred the resident to the emergency room . Interviews: During the investigation, the surveyor attempted to call Staff C, Agency nurse multiples times listed below without success: on 11/2/16 at 12:42 p.m., (left a message to return a call); on 11/2/16 at 2:28 p.m., and 11/3/16 at 8: 17 a.m During an interview on 11/2/16 at 2:16 p.m., Staff A CNA (Certified Nursing Assistant) stated on 10/22/16, she and the nurse (Staff C, Agency nurse) were in another resident's room when they heard a sound. Staff A reported they both went out to the lounge and she saw Resident #3 lying on the floor, on his/her right side trying to get up. She stated she assisted the resident earlier that morning and took the resident to the bathroom, then to breakfast. She stated the resident tried to get up multiple times during breakfast so she took him/her for a walk using the hand over hand method and a gait belt. She stated she did not utilize a walker because this was hard for the resident. After the walk, she asked the resident if he/she wanted to go to the bathroom and the resident declined so she took him/her to the recliner. She stated the walker was not in the lounge near the resident but was in the resident's room. Staff C stated to her, there needed to be more supervision in this area as there were 4-5 people who needed supervision and there was a call in that day and they were not typically staffed. During an interview on 11/3/16 at 8:59 a.m., Staff B RN (Registered Nurse) stated in the resident's area, there were 3-4 residents who needed supervision. Staff B stated staffing was challenging and the difference that day was they didn ' t have a float. During an interview on 11/3/16 at 11:05 a.m., Staff B stated she had been on the resident's unit the day of the fall but was not in the area at the time of the fall. She stated there was not a float that day so she helped out as she could. She stated as a rule, a staff member usually watched the sitting area/lounge because some of the residents were impulsive and could get up. During an interview on 11/3/16 at 10:37 a.m., the Director of Nursing stated the resident was to have his/her walker beside him/her when in the lounge and the resident should be toileted before and after meals. The DON reported the resident was care planned for mat beside his/her bed. She stated when he/she was restless, the staff promoted toileting and she would expect staff to encourage him/her if he/she said no to going to the bathroom. She stated the resident's area was normally staffed with 1 nurse, 1 CNA, and 1 float(CNA). She stated on 10/22/16, the area lacked the float CNA. The staffing assignment sheet for the resident's area on the day shift(6-2) of 10/22/16 listed 1 charge nurse, aide #1, and aide #2(float). The document indicated aide #1 called in for the shift and the float aide filled in aide #1's position. The form did not show a replacement for the float aide. During an interview on 11/3/16 at 11:00 a.m., the Activities Director stated she had a short 10 minute 1:1 visit with the resident after breakfast on 10/22/16 around 9:00 a.m. in the lounge area. She stated she did not remember seeing any other staff in the lounge or dining room area when she left the resident after the 1:1 but stated staff members were in the halls helping other residents. The emergency department notes dated 10/22/16 documented the resident had arrived via ambulance with complaints of fall and right hip pain & knee pain. The hip x-ray dated 10/22/16 documented the resident had a slightly comminuted intertrochanteric right femoral fracture. There is a slight angulation between the femoral neck and femoral shaft with several small avulse fracture fragments. A hospital visit summary, dated 10/22/16, listed a [DIAGNOSES REDACTED]. Progress notes, dated 10/25/16, stated the resident returned to the facility from the hospital During an observation on 11/2/16 at 1:41 p.m., the resident sat in a recliner in the lounge area. The resident's walker was about 1 foot from the resident and had a sign on it.

Based on clinical record review, facility policy, resident and staff interviews, the facility failed to ensure 1 of 5 residents remained free of resident to resident abuse. The facility reported a census of 61 residents. Findings included: 1. The admission Minimum Data Set (MDS,) assessment dated [DATE] documented Resident #2 with a BIMS (Brief Interview for Mental Status) of 3 which indicated severely impaired ability for daily decision making. The MDS indicated difficulty focusing attention and disorganized thinking. The MDS indicated the resident required extensive staff assistance for all activities of daily living. Resident #2 [DIAGNOSES REDACTED]. A care plan initiated 08/25/16 identified the resident as a wanderer, propels self in wheelchair to other's rooms. Resident #2 care plan revealed he/she disoriented to place, with impaired safety awareness and significantly intrudes on the privacy or activities of others. The staff were instructed to ask the resident to leave if found in another's room, distract the resident from wandering by offering diversions. The care plan identified the resident had patterns of wandering and for staff to provide structured activities and placing signs on doors. An Incident Report dated 8/24/16 at 10:40 a.m. revealed another resident became aggressive with Resident #2 and threatened to slap him/her and pushed him/her out of his/her room. An Incident Report dated 09/04/16 at 7:05 p.m. noted Registered Nurse (RN) witnessed Resident #2 in hallway being hit by another resident (Resident #3) at the end of the hallway with a flyswatter repeatedly. The RN separated the two residents. The incident report indicated Resident #2 received two skin tears to the right forearm measuring 1.2 centimeters and 1.5 centimeters. 2. The admission Minimum Data Set (MDS,) assessment dated [DATE] documented Resident #3 with a BIMS (Brief Interview for Mental Status) of 15, which indicated intact cognition for daily decision making skills. The MDS indicated Resident #3 independent for activities of daily living. Resident #3 [DIAGNOSES REDACTED]. A care plan with a target date of 09/19/16 did not address the incident from 09/04/16 where Resident #3 struck Resident #2 with a flyswatter causing skin tear injuries to Resident #2. On 09/19/16 at 1:00 p.m. Staff A, RN stated she had been the nurse on the hallway and had been attending to another resident when she note Resident #2 propelling self up and down the hallway. Stated she had to remove the resident from another resident's room and redirected the resident. She stated by the time she made it back up the hallway, Resident #2 had wheeled self down to the end of the hall outside of Resident #3's room. Staff A stated she observed Resident #3 hitting Resident #2 with a flyswatter. She stated she intervened and redirected Resident #3 back into his/her room, then assessed Resident #2 for injury. Staff A stated Resident #2 had two lacerations on the lateral part of the right arm like the resident had placed the arm up to defend self from the hit. Staff A stated she called the facility Administrator and the resident ' s family. Staff A stated that Resident #3 did not say why he/she had hit Resident #2 except that Resident #2 did not belong down here. Staff A states she did not witness Resident #2 going into Resident #3's room, stated Resident #3 had been in the hall when she witnessed the altercation. Staff A stated she thinks that Resident #2 had been in the other resident's room on prior occasions but not on this day/shift. On 09/19/16 at 10:50 a.m. Staff B, CNA stated she had been working on the hallway but had been in another resident's room when the incident occurred. She stated she had seen Resident #2 in self propelling in the hallway and noticed marks and broken skin on the resident's arm. Staff B stated Resident #2 told her She/He hit me. Staff B stated the charge nurse had witnessed the altercation so she and the nurse went to talk with Resident #3 regarding the incident. Staff B stated Resident #3 told her this is their private property and could do whatever he/she wanted to. Staff B stated she told Resident #3 if another resident came into his/her room, he/she should put on the call light to summon help from the staff. On 09/20/16 at 11:00 a.m. Resident #3 when asked if remembered having an altercation with Resident #2, the resident stated she/he had been using a flyswatter to kill flies in his/her room when Resident #2 came into the room, and would not leave. Resident #3 stated she/he just smacked the other resident a couple of times on the arm with the flyswatter. When asked why he/she did not put the call light on to summon staff for assistance, Resident #3 stated just didn't think about doing that. The resident stated that would not do that again but would call the staff for help. Resident #3 stated the other resident had been in his/her room several times and had gotten tired of it. Resident #3 stated they should have better control of people. Resident #3 stated she/he had to move from her/his other room and moved upstairs but does like the new room better because no one comes into the room without knocking first. On 09/20/16 at 10:40 a.m. Resident #2 had been observed sitting in a wheelchair watching people in the hallway. The resident self-propelled from the bedroom door starting down the hallway. The charge nurse asked the resident to come with her, the resident turned the wheelchair around and propelled self toward the nurse. Review of the Abuse and Neglect policy and procedure with an issues date of 08/2016 instructed staff the purpose of the policy is that the resident has a right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion, to ensure the residents are treated with dignity and care, free from abuse and neglect and to take swift and immediate action to investigate and adjudicate alleged resident abuse and neglect. The policy noted that the resident must not be subjected to abuse by anyone, including facility staff, other residents, consultants, volunteers, staff or other agencies serving the individual, family members, legal guardians or other individuals. Point #11of the policy indicated Resident to resident physical contact that occurs, which includes but is not limited to where residents are hit, slapped, pinched or kicked and results in physical harm, pain or mental anguish is considered resident to resident abuse. Resident to resident sexual harassment, sexual coercion, or sexual assault is also considered abuse. The facility will presume that instances of abuse cause physical harm, or pain or mental anguish with cognitive and/or physical impairments which may result in a resident unable to communicate physical harm, pain or mental anguish, in the evidence to the contrary.

Based on observation, record review, and interviews with staff, family and hospital personnel, the facility failed to provide adequate supervision for one of six reviewed residents (Resident #4) when staff neglected to safely secure the resident with a seatbelt when accompanying the resident in a hospital-provided van. The resident fell out of the wheelchair enroute to an appointment and fractured his/her knee. The facility census was 44 residents. Findings include: Resident #4 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set assessment (MDS) assessment, with an assessment reference date of 9/21/11, revealed the resident was non-ambulatory due to hemiparesis (weakness on one side of the body related to the resident's CVA), and required two staff members using a mechanical lift to be transferred from one surface to another. The resident used a staff-propelled geriatric chair for mobility around the facility. The resident scored 15 on the MDS Brief Interview of Mental Status which is the highest possible score representing intact cognition. The resident's care plan, dated 9/27/11, directed staff to transfer the resident with a Hoyer lift (mechanical lift) and two staff members and that the resident required a staff-propelled gerichair for mobility. Nurse's notes and a facility incident report, both dated 9/27/11, revealed the facility received a phone call at 11:08 a.m. from Staff A, facility ward clerk and CNA, stating the resident had slid out of the wheelchair while being transported by the hospital van to a physician's appointment. The documentation revealed the van transported the resident and Staff A to the emergency room (ER) where hospital staff assisted Staff A in lifting Resident #4 back into the wheelchair. The resident was then propelled to his/her doctor's office in an adjoining building. A written statement dated 9/29/11 by Staff A, as well as an interview on 10/3/11 at 1:30 p.m., revealed the resident had been loaded into the hospital van by the van driver (an employee of the hospital) who secured the wheelchair wheels with straps welded onto the van. A seatbelt was not used to secure the resident into the wheelchair. The resident was going to a doctor's appointment and, per facility policy, was accompanied by Staff A. The van had another passenger to pick up on route to the doctor's office so Staff A sat in the front seat with the van driver instead of on the usual bench seat between the wheelchair and the front seat. Staff A did not recall if she or the van driver used seatbelts enroute to the hospital. The second passenger was picked up and seated on the bench seat without a seat belt. As the van was driving along a flat road Resident #4 called out, "I think I am slipping." The van driver started to pull over and the resident said, "I slipped out of my chair." Once the van stopped, Staff A and the van driver went to the back of the van and observed the resident sitting on the floor with his/her left leg laying against a silver railing. Staff A stated she and the van driver were unable to lift the resident back into the wheelchair so, Staff A sat in the wheelchair, supporting the resident's back, while the van driver drove to the hospital. emergency room (ER) staff assisted with positioning the resident back into the chair and the resident was propelled to the doctor's office next door. The doctor ordered an x-ray of the resident's left knee in response to the resident's complaints of pain. Staff A stated she had accompanied approximately 10-20 residents in the van at other times and did not recall seeing residents in wheelchairs use seatbelts to secure them into the wheelchairs. Findings of the X-ray report, dated 9/27/11, revealed the resident had a "large knee joint effusion" (the escape of a fluid from anatomical vessels by rupture) and a probable subtle fracture at the medial joint margin." The radiologist recommended the resident have a cat scan (CT) for more definitive evaluation of the left knee. The resident refused the CT scan. Nurse's notes dated 9/27/11 stated the resident returned to the facility at 1:30 p.m. and staff applied a knee brace to stabilize the resident's fracture. The physician ordered the resident wear the brace 23 1/2 hours per day for 8-12 weeks. The resident complained of severe pain and the physician, upon notification from facility staff, ordered Dilaudid (a potent Schedule II narcotic pain reliever), 2 milligrams by mouth every 6 hours, as needed for pain. Medication administration records for October 2011 revealed the resident received the Dilaudid 10 times between October 1-5, 2011. Interviews with multiple staff members revealed the facility did not have a written policy for transporting resident by the hospital van or the SECO transit van (van operated by a non-profit community action group). Staff C stated in an interview on 10/4/11 at 10:02 a.m. that she had accompanied residents in the past and that the van driver would secure the wheelchair in the van, and didn't recall ever seeing a seat belt or shoulder strap used to secure a resident into the wheelchair. Staff E stated in an interview on 10/4/11 at 11:20 a.m. she had not accompanied a resident on either van but if she did she would make sure the resident was belted into their seat. During an interview on 10/4/11 at 6:30 p.m., Staff D stated she accompanied Resident #14 on the hospital van after Resident #4's incident and insisted the van driver use the seatbelt to secure the resident. Staff D stated she was told at work by co-workers that residents needed to be seatbelted into their wheelchairs from now on. A telephone interview with the administrator and the Director of Nurses (DON) on 10/3/11 at 11:00 p.m. revealed the facility did not have a policy on transporting residents in vehicles off the premises of the facility. It was an unwritten policy that a staff member or a family member accompany the resident when being transported in the hospital van. The DON stated she did not know the hospital van had seatbelts and she believed securing residents for transporting was the responsibility of the van driver. She stated after the incident, staff was told to always use a seatbelt when accompanying a resident in either vehicle. On 9/28/11 a Facility Complaint Investigation Report form was filled out by the administrator to be submitted to the Department of Inspections and Appeals. Review of this handwritten form disclosed the corrective action taken by the facility after the 9/27/11 incident in the van which was: Staff to ensure all residents secured with a fastened seatbelt when riding in the hospital van. During an observation on 10/4/11 at 12:50 p.m., Staff E propelled Resident #15 (with a BIMS score of 13 which indicated intact cognition) in his/her wheelchair outside the facility to the waiting hospital van. The van driver used the electric lift to raise the resident and the wheelchair up into the back of the van. The van driver secured the wheelchair to the van but did not place a seatbelt on the resident. There was confusion as to who would accompany the resident and the daughter-in-law stated she would go with the resident in the van. The staff member did not request that the resident be secured with a seatbelt. The van drove off with the resident and his/her daughter-in-law. During interviews on 10/4/11 at 11:50 p.m. and again at 4:30 p.m., the van driver stated he always secured the wheelchairs in the back of the van with straps. He did not always use the seatbelt and stated he would only use the van's seatbelt if he felt the resident was impaired cognitively. He stated sometimes the facility staff would inform him if a resident was not cognitivel intact and sometimes he used his own judgement. He stated the overall responsibility of the resident during transport belonged to the facility. He stated, "If the resident wasn't their responsibility, why would they send a staff member to supervise the resident?" An interview with Resident #4 on 10/4/11 at 10:15 a.m. revealed he/she was placed in a wheelchair on top with a Hoyer sling (cloth sling used with mechanical lift to raise resident) underneath him/her for transport to the physician's office. The resident stated he/she usually sat a geriatric chair which had a taller back then a wheelchair and thicker padding. The resident stated he/she was not used to sitting in a wheelchair. The resident stated that after the other passenger was picked up and the van was moving again, he/she felt him/herself sliding out of the chair and verbalized that out loud. The resident said before he/she realized it, he/she was "down on the floor and my knee hurt." The resident was not sure what he/she hit his/her knee on. The resident stated he/she did not ask for a seatbelt but "if I had, maybe I would not have slipped off (the chair)." The resident also stated that his/her knee hurts very badly especially when he/she has to move it.

Based on observation, clinical record review, and staff interviews, the facility failed to use safe techniques when transferring 2 residents (Resident #1 and Resident #2) and failed to effectively assess and implement interventions intended to prevent falls for Resident #7. The standard sample was 10 residents and census of the facility was 36 residents. Findings included: 1. The Minimum Data Set (MDS) assessment, with an assessment reference date of 07/20/11, documented Resident #1 with severely impaired cognition. The MDS indicated the resident exhibited verbal, and other behaviors, directed at others. The MDS indicated the resident required total assistance of two staff for transfers. The MDS indicate the resident did not ambulate and utilized a wheelchair for mobility. The MDS indicated the resident as totally dependent on staff for toileting and for personal hygiene. The MDS indicated the resident could not stabilize balance without human assistance. The MDS documented the resident with [DIAGNOSES REDACTED]. A fall risk assessment dated [DATE], documented the resident with a score of 12, which indicated the resident as at high risk for falls. Observation on 08/02/11 at 9:35 a.m. revealed Staff F and Staff H enter the resident's room to help the resident with routine toilet use. The resident had been seated in a high-backed wheelchair with a pommel cushion. Staff F placed a gaitbelt around the resident's waist as Staff H removed the wheelchair pedals from the wheelchair. Staff F propelled the wheelchair into the bathroom, and without locking the wheelchair wheels, assisted the resident to stand and pivot turn onto the toilet. Staff H pushed the wheelchair back out of the bathroom. After the resident completed toileting, staff assisted the resident to stand by pulling up on the gait belt and by placing their bent arms under the resident's arms (at the axillary). The resident stood in the knee bent position with the staff holding him/her under the axilla with arms bent up. Staff proceeded to cue the resident to stand straight but the resident continued to have bent knees as the staff provided incontinency care in the appropriate manner. Because the resident appeared to be having difficulty standing, staff lowered him/her back onto the stool and pulled clean clothing over the legs. Staff assisted the resident to stand again and pulled the clothing over his/her lower body and again assisted the resident back onto the stool as Staff H obtained the wheelchair and propelled it back into the bathroom. Staff assisted the resident to stand and pivot turn back into the chair with the staff supporting the resident's weight by holding him/her up with the gaitbelt and under his/her arms. Staff F propelled the resident out of the bathroom and over to the recliner. After locking the wheelchair's wheels, Staff F assisted the resident to stand again by lifting on the gaitbelt and under the resident's arms. Staff pivot turned the resident and sat him/her on the edge of the recliner. Staff then picked the resident up under the arms and legs to adjust his/her position into the recliner. On 08/04/11 at 10:00 a.m., Staff E stated the resident had been able to bear weight and at times was able to ambulate with assistance. She agreed that lifting the resident under the arms and with the gaitbelt was not a good practice and could have caused injury to the resident. 2. The MDS, with an assessment reference date of 05/06/11, documented Resident #2 with no cognitive impairment. The MDS indicated the resident required limited assistance of one staff for transfers and ambulation in the room, but required a wheelchair for mobility. The MDS indicated the resident to be independent for personal hygiene. The MDS indicated the resident had an open lesion on the foot. Observation on 08/02/11 at 2:15 p.m. revealed Staff F and Staff G enter the resident's room after the resident requested assistance to go to the bathroom. The resident had been sitting in a wheelchair. Staff F placed a gaitbelt around the resident's waist and placed a walker in front of the resident. Staff F assisted the resident to stand and ambulate to the bathroom. Staff F pulled the resident's clothing down. The resident had a soiled incontinence brief. After assisting the resident to sit on the toilet, Staff F removed the soiled brief. Staff prepared washcloths and after assisting the resident to stand using the gaitbelt and walker, provided incontinency care. Staff G propelled the wheelchair back to the bathroom doorway as Staff F provided the pericare. The resident stated "I feel like I am going to fall" several times, holding onto the walker, and bending at the knees. Staff G placed her hands on the gaitbelt and under the resident's arms holding him/her up as Staff F completed the pericare. After Staff F removed her gloves, she placed her arm under the resident's arm and grabbed the gaitbelt. The staff then lifted the resident with the gaitbelt and arms and sat him/her on the edge of the wheelchair. The Surveyor assisted the staff to reposition the resident back into the wheelchair to keep the resident from sliding onto the floor. On 08/04/11 at 10:00 a.m., Staff E agreed that the staff did not have control of the situation, but stated the resident usually did his/her own personal cares and wanted to be as independent as possible. 3. The MDS, with an assessment reference date of 06/29/11, indicated Resident #7 had memory problems and moderately impaired daily decision making abilities. The MDS documented the resident exhibited periods of inattention and disorganized thinking, exhibited aggressive verbal and physical behaviors to others, and wandering behaviors. The MDS indicated the resident required extensive assistance of two staff for transfers and ambulation, toileting and personal hygiene. The MDS documented the resident as frequently incontinent of bowel and bladder. The MDS indicated the resident could not stabilize balance without human assistance and exhibited functional limitations of range of motion to one side of the body. The MDS documented the resident had history two or more falls since last assessment period. The MDS documented the resident with [DIAGNOSES REDACTED]. The resident's care plan, with a review date of 10/15/11, informed staff the resident got up without assistance. The care plan indicated the resident required assistance of one to ambulate with a wheeled walker but would not always ambulate with staff. The care plan instructed staff to keep the resident's bed at the lowest level, and place a fall mat on the floor beside the resident's bed. An elopement risk document, dated 06/29/1, indicated the resident had attempted to elope from the facility and exhibited wandering behaviors. The fall risk assessment dated [DATE] scored the resident at a 19 which indicted the resident as at high risk for falling. The resident's last physical therapy evaluation on 06/16/11 indicated the resident as alert to self only with poor safety awareness. The physical therapy report recommended the resident have moderate assistance of 2 staff during transfers and when transitioning from sitting to standing. The resident's clinical record revealed the resident had fallen at least twenty (20) times from 01/09/11 to 06/15/11. These included: 1. On 01/09/11 at 3:00 p.m., staff found the resident on the floor at the side of the bed with his/her right arm caught in the side rail. The resident had no apparent injuries. Interventions: Observe for side effects of new medication ordered. 2. On 01/12/11 at 5:00 p.m., the resident fell between the wheelchair pedals when he/she attempted to stand up and ambulate. The resident had no apparent injuries. Intervention: Question if medication was causing issues. 3. On 01/13/11 at 6:25 a.m., staff responded to the resident's pressure alarm sounds and found the resident on the floor with no apparent injuries. Intervention: Look into getting medications discontinued. 4. On 01/15/11 at 9:30 p.m., Staff C.N.A. observed resident getting self up from unlocked wheelchair. The resident lost his/her balance and started to fall. C.N.A caught resident and lowered him/her to the floor. The resident had no apparent injuries. Intervention: Monitor the resident for illness. 5. On 01/24/11 at 1:45 p.m., staff found the resident on the floor at the west door when personal and wanderguard alarms sounded. The resident had attempted to elope; the resident became combative with staff. Interventions: Requested an as needed antianxiety medication. 6. On 01/30/11 at 4:15 p.m., staff responded to a sounding pressure alarm and found the resident on the floor; he/she had slid off the bed onto the floor when trying to get self up from bed. The resident had no apparent injuries. by self. Interventions: Place fall mat on floor beside bed when resident was in bed. 7. On 02/12/11 at 5:50 p.m., staff found resident on fall mat after attempting to get self out of bed. The alarm had been sounding. The resident apparently struck head on wheelchair, and sustained a 2.5 by 2.5 centimeter reddened area (to the head). Interventions: review toileting schedule. 8. On 02/19/11 at 9:30 p.m., staff found the resident on the floor mat beside the bed with the alarm sounding. No apparent injury. Intervention: Re-evaluate for urinary tract infection. 9. On 02/21/11 at 9:45 a.m., staff found the resident on the floor under the wheelchair with the pressure alarm sounding. Staff noted two reddened areas on the resident's right back; No other injuries noted. Intervention: Staff education. 10. On 02/27/11 at 8:55 p.m., a staff C.N.A., sitting at the nurse's desk, heard an alarm sounding and saw the resident standing. As the resident attempted to sit in the wheelchair, the C.N.A. attempted to catch him/her as the resident landed on the floor. No apparent injuries noted. Interventions: Direct resident to an activity when restless. 11. On 03/11/11 at 8:10 p.m., staff found the resident on the floor leaning against the bed with the alarm sounding. The fall mat was folded in half; the resident sustained [REDACTED]. Interventions: Staff took the resident to the bathroom; he/she needed to have a bowel movement. 12. On 03/13/11 at 5:30 a.m., staff found the resident on the floor mat with atrash can between his/her legs and the alarm was sounding. Staff noted the resident had a skin tear to the left elbow. Interventions: Re-educated staff to lay resident on floor mat when he/she exhibited increased agitation or anxiety. 13. On 03/21/11 at 7:15 p.m., staff responded to the resident's alarm sounding. The resident had apparently stood up and fallen, resulting in a skin tear to the resident's left inner arm. Interventions: Resident treated for [REDACTED]. 14. On 03/22/11 at 10:30 a.m., staff found the resident lying on the left side of the fall mat. A pressure alarm had sounded and the resident had been incontinent of bowel. The resident complained of left sided discomfort. Intervention: As above. 15. On 03/30/11 at 3:20 a.m., staff found the resident sitting on the floor in between the wheelchair pedals. The personal alarm had been sounding; the resident had been incontinent of bowel. Interventions: Toilet resident right after lunch. 16. On 05/10/11 at 8:20 p.m., staff found the resident on the floor mat beside the resident's bed. Interventions: Be aware that resident had multiple medications changed and observe resident for changes in mood, behaviors, and functioning. 17. On 06/04/11 at 1:05 p.m., a staff C.N.A. propelled the resident sitting in a wheelchair down the hallway with the footpedals on. The resident abruptly moved his/her right foot off the pedal and fell forward out of the chair. The staff was unable to catch the resident. No injury noted. Intervention: Staff education. 18. On 06/06/11 at 6:30 a.m., staff responded to the resident's personal alarm sounding and found the resident sitting on the floor mat, incontinent of urine. Intervention: Staff education and check resident's urine for urinary tract infection. 19. On 06/12/11 at 10:00 a.m., the resident leaned over in his/her wheelchair and toppled to the floor. The resident's eyeglasses hit forehead above the right eye and resulted in a laceration that required sutures. Interventions: Personal alarms and pressure alarms in place, staff education, antibiotics changed for a urinary tract infection and physical therapy evaluation. 20. On 06/15/11 at 2:10 p.m., staff found the resident on the bathroom floor. The water was running and the resident's dentures were in the sink. The resident complained of bilateral thigh pain and right shoulder pain. Interventions: Continue to have the resident work with physical therapy. On 08/04/11 at 10:00 a.m., Staff E stated she felt many of the resident's falls were related to the antipsychotic medication, Zyprexa the resident took and to the resident's frequent urinary tract infections. When asked what interventions had been tried to prevent the resident's frequent falls, Staff E stated they had placed alarms on the resident.

The following deficiency relates to incident -I. Based on record review and interviews, the facility failed to follow physician's order for transfers and failed to assess and provide timely interventions for Resident # 1. The standard sample consisted of three residents and the facility reported its census as 34 residents. Findings include: 1. The Minimum Data Set (MDS) with an assessment reference date of 6/23/11 indicated Resident #1 with short and long term memory deficits and severely impaired cognitive skills for daily decision making. Resident #1 required total dependence with physical assist of two staff with bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene and bathing. Resident #1 was incontinent of bladder and frequently incontinent of bowel. Resident #1's [DIAGNOSES REDACTED]. Nursing Home admission orders [REDACTED]. Orders noted by Staff F on 3/9/11. Nursing Home admission orders [REDACTED]. Orders noted by Staff E. Resident #1's plan of care dated 3/22/11 indicated a problem in which Resident #1 did not ambulate and an approach which included "Transfer with hoyer lift and 2(staff) assist". In an interview on 7/14/11 at 4:25 p.m. Staff I (CNA) indicated when Resident #1 returned from the hospital he/she was a hoyer lift. Resident #1 was having problems going to the bathroom, so we tried to use the EZ stand to transfer him/her onto the commode. Staff I noted "we only used it for a couple days because he/she was complaining of more pain". In an interview on 7/14/11 at 5:13 p.m. Staff G (CNA) indicated Resident #1 was a hoyer lift only after returning from the hospital, however there was a time the facility did a "trial" using the EZ stand. After the first time the aides saw Resident #1 could not sustain his/her weight and was immediately put back on hoyer lift only. In an interview on 7/14/11 at 11:13 a.m. Staff J (CNA) indicated Resident #1 has always been a hoyer lift since she has worked at the facility. However there was a few times in which nursing staff felt Resident #1 was strong enough to use a sara lift to transfer. Staff J noted she had never known Resident #1 to be in pain or discomfort during these transfers. Staff J indicated on 6/18/11 she transferred Resident #1 using the sara lift and Resident #1 stood incredibly well and was weight bearing without complaint of pain. In an interview on 7/14/11 at 12:05 p.m. Staff D (RN) indicated Resident #1 had significantly improved after returning from hospitalization . The only concern was trouble with constipation. Facility staff discussed and nursing judgment made to try allowing Resident #1 to use an EZ stand lift to transfer on and off the commode. Nurse's notes dated 6/16/11 at 1:30 p.m. written by Staff A indicated Resident #1 complained of knee pain while being provided cares. When followed up on later, Resident #1 denied on-going pain. Nurse's notes dated 6/16/11 at 9:45 p.m. written by Staff B indicated Resident #1 continued to complain of right knee pain. Resident #1 indicated he/she does not know why it hurts. Area warm to the touch and appears swollen. Nurse's notes dated 6/17/11 written by Staff A indicated new order for mobile x-ray of Resident #1 right knee. Progress note dated 6/17/11 and initialed by the physician indicated Resident #1 was complaining of right knee pain with some change in the contour of the knee compared to the left knee. Plan to get a portable x-ray to see if there is anything acute. The physician noted that it is more than likely related to arthritis and is old. Physicians Order Sheet and Progress Notes dated 6/17/11 indicated an order for [REDACTED]. Nurse's notes covering the weekend of 6/18/11 and 6/19/11 make no mention any pain, discomfort or changes associated with Resident #1's right knee. Nurse's notes dated 6/20/11 at 8:00 a.m. written by Staff D indicated she received a phone call from the mobile x-ray service and scheduled Resident #1's x-ray at 9:30 a.m. X-rays taken at 9:15 a.m. Nurse's notes dated 6/20/11 at 12:20 p.m. written by Staff E indicated results received from x-ray and forwarded to physician. Radiology report dated 6/20/11 regarding Resident #1's right knee x-rays indicated "Severe [MEDICAL CONDITION] change right knee with distal right femoral diaphyseal metaphyseal fracture with some impaction and mild displacement at the fracture site". In an interview on 7/13/11 at 2:55 p.m. Staff A (Registered Nurse) indicated that on Friday, 6/17/11 at around 11:00 a.m. she received an order for [REDACTED]. Staff A scheduled the x-ray for Resident #1 for Monday, 6/20/11. Staff A indicated she did not recall speaking to the physician directly, but thought she notified his office and left a message of the delay. In an interview on 7/25/11 at 1:27 p.m. Resident #1's physician stated he saw Resident #1 on 6/17/11 and ordered a portable x-ray of his/her right knee. The physician stated he believed the knee pain was associated with arthritis since there was no reported falls or incident. The physician indicated he was not aware that the x-ray was delayed until Monday (6/20/11) and indicated he should have been notified of the delay. The physician stated he was not aware that Resident #1 was being transferred using an EZ stand per nurses judgment and noted Resident #1 was to be a hoyer lift only. The physician indicated he should have been consulted regarding the change in transfer. In an interview on 7/13/11 at 2:22 p.m. Staff E (DON) indicated that following Resident #1's discovered right knee fracture, she spoke with nursing staff to question how the fracture may have occurred and in doing so discovered nursing staff had approved Resident #1 to be pivot transferred. In an interview on 7/14/11 at 11:04 a.m. Staff H (CNA) indicated Resident #1 was a hoyer lift and was not aware of any transfers made without using the hoyer lift. In an interview on 7/14/11 at 12:30 p.m. Staff F (RN) indicated she knew Resident #1 was being transferred safely using the sara lift onto the toilet, on a few occasions, when Resident #1 had constipation. The record lacked any documentation the physician approved the nursing staff's decision to transfer the resident with an EZ stand or a physician orders or consultation with the physician for physical therapy evaluation prior to using the EZ stand.