Every finding on record at Rehabilitation & Nursing Center at Everett (The)

Based on observations, record review and interviews, the facility failed to implement personalized care plans for two Residents (#78 and #128) out of a total sample of 34 residents. Specifically:1. For Resident #78, the facility failed to prevent the Resident from having knives at meals.2. For Resident #128, the facility failed to have a fall mat in place. Findings include:1. Resident #78 was admitted to the facility in September 2020 with diagnoses including schizophrenia, bipolar disorder and anxiety.Review of Resident #78's most recent Minimum Data Set (MDS) dated [DATE] had a Brief Interview for Mental Status score of 6 out of a possible 15, which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #78 requires supervision for feeding tasks. Review of Resident #78's physician orders indicated the following orders: May use real utensils while in supervised area at lunch and plastic utensils at breakfast and dinner, every shift for Suicidal ideation with no plan, initiated on 6/30/24.Review of Resident #78's activities of daily living care plan last revised 6/17/25, indicated the following intervention: Eating: I (the Resident) require occasional supervision to use suitable utensils to bring food and/or liquid to my mouth and swallow food and/or liquid once the meal is placed before me. On 8/5/2025 at 8:28 A.M., and 12:10 P.M., Resident #78 was observed eating meals in his/her room with no staff present in the room or in the hallways to supervise. The Resident was provided with regular utensils, including a knife. On 8/6/25 at 8:23 A.M. and at 12:20 P.M., Resident #78 was observed eating meals in his/her room with no staff present in the room or in the hallways to supervise. The Resident was provided with regular utensils, including a knife. Review of Resident #78's care card (a form indicating the level of assistance required and any special equipment a resident may need) indicated the following under the behavior section: Plastic ware only unless supervised. No knife or razor blade in room. During an interview on 8/6/2025 at 12:22 P.M., Certified Nursing Assistant (CNA) #6 said the staff use the care cards to communicate the level of assistance each resident on the unit would require and to add any special equipment needs. CNA #6 said if a resident's status changes, the Assistant Director of Nursing updated the care cards. CNA #6 said Resident #78 is independent with meals and can use regular utensils, including a knife. During an interview on 8/6/2025 at 12:36 P.M., Nurse #5 said Resident #78 has behaviors of threatening to self-harm but that she does not feel these are actual threats and are made to just get attention. Nurse #5 said the knives in the facility are blunt, so the Resident is safe to use them. During an interview on 8/6/2025 at 2:22 P.M., the Assistant Director of Nursing said care cards are in place for all residents to provide communication for the level of care each resident requires. The Assistant Director of Nursing said Resident #78 should not have a knife provided to him/her at meals and all orders and care plans should be followed as written. During an interview on 8/6/25 at 6:54 A.M., the Food Service Director said he was unaware of the physician order that Resident #78 should not have regular utensils or knives provided at meals. During an interview on 8/7/25 at 7:50 A.M., the Director of Nursing said Resident #78 had made a threat of self-harm a while ago and the intervention of not having regular utensils or a knife was put in place at that time. The Director of Nursing said the order and care plan should be followed as written. 2. Resident #128 was admitted to the facility in August 2023 with diagnoses including a stroke. Review of Resident #128's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 15 out of a possible 15 on the Brief Interview for Mental Status which indicates the Resident is cognitively intact. The MDS also indicated Resident #128 is dependent on staff for all self-care and mobility tasks and has adequate vision with corrective lenses. On 8/5/2025 at 8:33 A.M., and at approximately 12:30 P.M., Resident #128 was observed lying in his/her bed. A fall mat was observed folded against the wall at the foot of the bed. Resident #128 said the fall mat is often folded against the wall and is only sometimes placed next to his/her bed. On 8/6/2025 at 8:18 A.M., Resident #128 was observed lying in his/her bed. A fall mat was observed folded against the wall at the foot of the bed. On 8/7/25 at 4:32 A.M., Resident #128 was observed lying in his/her bed. A fall mat was observed folded against the wall at the foot of the bed. Review of Resident #128's fall risk care plan indicated an intervention for a fall mat to be placed next to the bed while the Resident is in bed. During an interview on 8/6/2025 at 12:22 P.M., Certified Nursing Assistant #6 said Resident #128 only needs a fall mat next to his/her bed overnight. During an interview on 8/6/2025 at 12:36 P.M., Nurse #5 said Resident #128 should have a fall mat next to his/her bed as an active fall intervention. During an interview on 8/6/2025 at 2:22 P.M., the Assistant Director of Nursing said Resident #128 fell out of bed a year ago and a new care plan intervention initiated at that time was a fall mat to be placed next to the bed. The Assistant Director of Nursing said the fall mat should be in place next to the bed whenever Resident #128 is lying in bed and care plans should be followed as written. During an interview on 8/7/25 at 7:10 A.M., the Director of Nursing said Resident #128 had fallen out of bed a year ago and a fall mat was placed next to bed as a fall intervention. The Director of Nursing said all care plans should be followed as written, including Resident #128 having a fall mat next to his/her bed while lying in bed.

Based on observations, record review, and interviews the facility to ensure that services provided met professional standards for one Resident (#61), out of 34 sampled residents. Specifically, the facility failed to obtain and implement physician's orders to discontinue Resident #61's CAM boot (medical walking shoe, is a type of orthopedic footwear used to immobilize the foot and ankle after an injury or surgery. It is designed to provide support, stability, and protection to the foot and lower leg during the healing process) and advance his/her weight bearing status after his/her surgical specialty (podiatrist) follow up on 5/19/25. Findings include: Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice, dated as revised April 11, 2018, indicated the following:- Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Resident #61 was admitted to the facility in January 2025 with diagnosis including atherosclerosis of the native arteries (narrowing and blocking blood flow) of the right leg, diabetes mellitus, right foot drop, peripheral vascular disease, and failure to thrive. Review of Resident #61's most recent Minimum Data Set (MDS) assessment, dated 7/25/25, indicated he/she had a severe cognitive impairment evidence by a Brief Interview of Mental Status exam score of 3 of 15. This MDS indicated Resident #61 had an impairment of the lower extremity on one side and Resident #61 required supervision or touching assistance with lower body activities of daily living. Review of Resident #61's active physician's orders included the following:-Non-weight bearing (NWB) to right lower extremity (RLE), dated as initiated 1/29/25.-Use CAM boot when out of bed. Offload Heels while in bed, dated as initiated 4/11/25.On 8/5/25 at 8:09 A.M., the surveyor observed Resident #61 sitting in his/her wheelchair. He/she was bearing weight on his/her right foot, and he/she was wearing sandals. There was no CAM boot in his/her room. On 8/6/25 at 6:47 A.M., the surveyor observed Resident #61 in the bathroom. He/she was sitting in his/her wheelchair, he/she was bearing weight on his/her right foot, and he/she was wearing sandals. There was no CAM boot in his/her room. Review of Resident #61's Surgical Specialties Consultant form, dated 5/19/25, indicated: The post-operative site is healing well, with the tibial corticotomy (surgical incision into the bone) healed beautifully. He/she can transition from the boot to a regular shoe. Review of Resident #61's nursing note, 5/19/25, indicated: Patient returned from his/her appointment today at approximately 1:30 P.M., with new order to discontinue right heel treatment due to wound healing and follow-up appointment at surgical specialties, provider made aware. Review of Resident #61's physical therapy note, dated 6/2/25, indicated: Resident ambulated with rolling walker 50 feet with stand by assist (SBA) weight bearing as tolerated (WBAT) right.Review of Resident #61's, Medication Administration Records, dated between 5/19/25, June 2025, July 2025, and through August 6, 2025, indicated that nursing continued to document that Resident #61 was non-weight bearing.During an interview on 8/6/25 at 11:04 A.M., Certified Nursing Assistant (CNA) #6 said Resident #61 walks on his/her feet, and he/she has no weight bearing restrictions. CNA #6 said that Resident #61 wears sandals and she said she isn't aware that he/she required a CAM boot.During an interview on 8/6/25 at 11:02 A.M., Nurse #5 said that Resident #61 does not use a CAM boot, and she said that Resident #61 is weight bearing as tolerated. During an interview on 8/7/25 at 8:53 A.M., Nurse #4 said that she was the nurse on duty when Resident #61 returned from his/her surgical specialist consult on 5/19/25. Nurse #4 said that she reviewed the consult form and called the Nurse Practitioner with the surgical specialist recommendations. Nurse #4 said she could not remember reading recommendations about Resident #61's weight bearing status or the use of the CAM boot, but Nurse #4 said that if she needed any clarification she would follow up with the surgical specialist consultant for additional information if needed. During an interview on 8/7/25 at 7:57 A.M., the Physical Therapist said that she spoke with the surgical specialist physician, and she was made aware that Resident #61 was weight bearing as tolerated when she worked with the Resident on 6/2/25. During an interview on 8/6/25 at 11:16 A.M., the Assistant Director of Nursing said that Resident #61 went to a follow up appointment back in May of 2025 and his/her CAM boot and weight bearing restrictions were removed. During an interview on 8/7/25 at 5:44 A.M., the Director of Nursing said that the nurse who reviewed Resident #61's consult from 5/19/25 should have updated the physician's orders based on the recommendations.

Based on observation, record review and interview, the facility failed to provide supervision and assistance with meals for two Residents (#56 and #28) out of a total of 34 sampled Residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADL's), dated 9/20/24, indicated the following: -It is The Rehabilitation and Nursing Center at Everett's policy that based on the comprehensive assessment of a resident as outlined in regulatory grouping 483.24, and consistent with the resident's needs and choices, care and services will be provided to maintain their current ADL status. -Care and services for the following ADL's include: Dining-eating, including meals and snacks. -If a resident's ADL status is noted to have a decline, nursing will monitor the resident's status and send a referral to the appropriate department; appropriate department is determined by how the resident is presenting clinically (i.e. if eating difficulty is noted a referral would be made to Speech Therapy). 1. Resident #56 was admitted to the facility in August 2021, with diagnoses including cerebral infarct, hemiplegia and hemiparesis affecting right dominant side, dysarthria (difficulty articulating words), and dysphagia (difficulty swallowing). Review of Resident #56's most recent Minimum Data Set (MDS) assessment, dated 5/2/25, indicated the Resident had a Brief Interview for Mental Status exam score of 14 out of a possible 15, indicating he/she has intact cognition. Further review of the MDS indicated Resident #56 requires supervision or touching assistance for self-feeding. On 8/5/25 at 12:47 P.M., and on 8/6/25 at 8:50 A.M., 9:00 A.M., 9:14 A.M., 12:42 P.M. through 12:52 P.M., and 12:59 P.M., Resident #56 was observed seated upright in his/her bed eating with food spilled on his/her clothing protector. There was no staff observed providing supervision or assistance, and the resident was not visible from the hallway. Record review of Resident #56's ADL care plan on 8/6/25 at 7:00A.M., indicated the following: Eating: I require supervision or touching assistance to use suitable utensils to bring food and or liquid to my mouth and swallow food and or liquid once the meal is placed before me. Last revised 03/18/2025. Review of the Occupational Therapy Discharge summary dated [DATE] indicated Resident #56 requires contact guard assistance for self-feeding Review of the Speech Language Pathology Discharge summary dated [DATE] indicated the following: Min/close supervision. Swallow strategies/Position: To facilitate safety and efficiency. It is recommended the patient use the following strategies and/or maneuvers during oral intake, general swallowing techniques/precautions and alternation of liquid/solids upright posture during meals and upright posture for greater than 30 minutes after meals. During an interview on 8/6/25 at 1:58 P.M., Nurse #1 said we setup Resident #56's meal and he/she likes to feed him/herself and does not require assistance. During an interview on 8/625 at 3:00 P.M., the Director of Nursing said she would expect Resident #56 would be provided with the level of assistance and supervision indicated on his/her care plan for self-feeding. Review of the medical record failed to indicate Resident #56 refused assistance with self-feeding. 2. Resident #28 was admitted to the facility in August 2024 with diagnoses including epileptic seizures, autistic disorder and dysphagia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #28 is severely cognitively impaired as evidenced by a score of five out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #28 required supervision or touching assistance with eating. On 8/5/2025 at 8:08 A.M., the surveyor observed Resident #28 in his/her room eating breakfast. The door was closed and no staff were in the room to provide supervision or assistance. Resident #28 used both hands to pick up a glass of juice. Resident #28's hands were shaking and he/she struggled to drink without spilling. Resident #28 said his/her breakfast was good but did not engage in further conversation. Review of Resident #28's care plans indicated: Resident has an ADL (activities of daily living) and physical mobility deficit RT (related to) activity intolerance, weakness depression and epilepsy, 2/14/25. Interventions: Eating, I require set up/supervision for eating. Review of Resident #28's ADL Guide/Kardex dated 9/11/24 indicated Resident #28 required supervision/assistance with eating. The word occasional was hand written next to the word assistance. On 8/5/2025 at 11:58 A.M., the surveyor observed Resident #28 drinking coffee with both hands, sitting in bed with his/her lunch tray in front of him/her. The door was closed, and no staff were present in the room. Resident #28 said his/her meal was good. During an interview on 8/5/2025 at 12:02 P.M., Certified Nursing Assistant (CNA) #5 said Resident #28 eats his/her meals in his/her room with the door shut. CNA #5 then entered Resident #28's room and asked if he/she had finished eating his/her meal. On 8/6/2025 at 7:58 A.M., the surveyor observed CNA #9 deliver Resident #28's meal and leave the room. No staff remained to provide supervision per his/her plan of care. On 8/6/2025 at 11:58 A.M., the surveyor observed staff attempt to deliver Resident #28's lunch meal, but he/she declined. On 8/7/2025 at 7:57 A.M., the surveyor observed CNA #8 enter Resident #28's room, deliver his/her breakfast meal, and then leave closing the door behind her. CNA #8 then told the surveyor that Resident #28 is set up only for meals. The surveyor then observed Resident #28 in his/her room, sitting up in bed, eating his/her meal. During an interview on 8/7/2025 at 7:59 A.M., CNA #9 said she is assigned to Resident #28 and he/she does not require supervision or assistance with eating. During an interview on 8/7/2025 at 8:02 A.M., Unit Manager #1 said that residents who are care planned for supervision and assistance should not be eating alone in their rooms with the door closed. During an interview on 8/7/2025 at 8:19 A.M., the Director of Nursing (DON) said that Residents who are care planned for supervision and assistance should not be eating alone in their rooms with the door shut. The DON was not aware that Resident #28 was not receiving supervision or assistance per his/her care plan.

Based on observation, record review and interview, the facility failed to provide adequate supervision during the 11:00 P.M. - 7:00 A.M. shift on two of five resident units. Specifically:1. The facility failed to ensure staff were awake and alert on the [NAME] Unit when staff were found asleep and three Residents (#3, #32 and #2) were observed wandering the unit.2. The facility failed to ensure that all assigned staff were consistently awake, alert, and were not simultaneously on their break during the night shift on the Main 1 unit.Findings include:Review of the Employee Handbook, dated 2018, failed to include expectations of staff sleeping while on duty. During the Resident Group Interview on 8/6/2025 at 10:35A.M., two of four participants reported staff sleep on the [NAME] and Main 1 Unit during the overnight shift. One Resident reported that staff hide in the TV room and another said that staff sleep at the nurses station. 1. During an early morning visit on 8/7/25 the following was observed on the [NAME] Unit, (a secured unit which houses residents with behavioral issues and dementia) while three Residents (#3, #2, and #32) were observed awake and wandering: On 8/7/25 at 3:23 A.M., the surveyor entered the [NAME] Unit. Certified Nursing Assistant (CNA) #1 was observed seated in a chair in the hallway with her head resting against the handrail which was padded with a cloth object. CNA #2 was observed asleep in a chair across from the nurses station. His mouth was open, and legs spread. Nurse #2 was observed asleep behind the nurses station with her shoes off and feet elevated. She was leaning back in her chair with her mouth open, and she could be heard snoring. At this time, Resident #3 was observed ambulating up and down the hallway of the unit and he/she greeted the surveyor. a. Resident #3 was admitted to the facility in February 2020 with diagnoses including vascular dementia, delusional disorder and generalized muscle weakness. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #3 is severely cognitively impaired evidenced by a score of five out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #3 has daily behaviors of wandering. Review of Resident #3's fall care plan dated 5/27/25 indicated: Focus: Resident #3 has had actual falls and is at risk for further falls due to his/her poor insight into safety, psychotropic drug use and unsteady gate. He/she does not call for assistance or recognize the call light. Actual fall 11/1/23; 5/23/25 actual fall sustained a minor abrasion on R (right) forehead. Interventions: Will be offered and assisted back to bed when observed to be ambulating late at night. Assist with ambulation (he/she often refuses hands on assist) provide cues for safety and offer periods of rest. The Resident will be offered a chair to sit on when he/she is observed ambulating excessively on the unit. Resident #32 was observed exiting his/her room wrapped in a blanket and paced. b. Resident #32 was admitted to the facility in August 2024 with diagnoses including unspecified dementia, and delusional cognitive communication deficit. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #32 is severely cognitively impaired evidenced by a score of three out of a possible 15 on the Brief Interview of Mental Status Exam (BIMS). The MDS also indicated that Resident #32 has behaviors of rejecting care. Review of Resident #32's fall care plan dated 2/17/25 indicated: Resident is at risk for falls r/t confusion, incontinence, psychoactive drug use, wandering. Resident #2 was observed exiting his/her room and stood in the hallway briefly, then returned to his/her room. c. Resident #2 was admitted to the facility in November 2019 with diagnoses including catatonic schizophrenia and generalized muscle weakness. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #2 is severely cognitively impaired evidenced by a score of seven out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #2 had behaviors of rejecting care. Review of Resident #2's Fall Risk care plan, dated 11/23/21 indicated: Resident #2 is at risk for falls r/t psychoactive drug use, decreased safety awareness, stands for long periods of time. At 3:24 A.M., CNA #1 said that there were three staff on the unit and that Nurse #2 and CNA #2 should not be sleeping. At 3:25 A.M., Resident #3 continued to pace up and down the hallways and CNA #2 and Nurse #2 woke up. Nurse #2 said she, CNA #1, and CNA #2 were the staff on the unit and that the unit consisted of Residents who have dementia and behavioral issues. Nurse #2 said that there are Residents on the unit who are awake and wander all night long. At 3:31 A.M., Resident #3 continued to walk up and down the unit. CNA #2 then got up from the chair he had been asleep on and entered a closet. Resident #3 then walked over and sat on the chair. During an interview at 3:34 A.M., CNA #2 said that he had been asleep when the surveyor arrived and he should not have been. CNA #2 said that there are Residents who wander the unit all night long. The surveyor then observed Resident #32 re-emerge from his/her room wrapped in a blanket and shuffle to the nurses station. At 3:43 A.M., Resident #3 and Resident #32 continued to wander and pace the unit. During an interview at 3:45 A.M., Nurse #2 said she normally works the night shift, and she is not supposed to be sleeping at the nurses station. Nurse #2 said her shoes were off and she was asleep at the nurses station when the surveyor arrived. Nurse #2 said if she feels tired, she will set an alarm and find a room to sleep in. When the surveyor inquired which room she would go to, Nurse #2 then said she would go down to the break room. Nurse #2 said that there are residents who are awake and roam the unit all night long. During an interview on 8/7/2025 at 5:28 A.M., Corporate Nurse #1 and the Director of Nursing (DON) said they were not aware that residents had reported concerns regarding staff sleeping at night. The DON said that one awake CNA cannot provide sufficient supervision to residents on the unit. The DON said that overnight staff should be taking breaks on the unit, but not at the nurses station and there should be more than one person awake and alert to supervise. 2. The following was observed on the Main 1 unit, (a long term care unit), during an early morning visit on 8/7/25: At 3:21 A.M., the surveyor exited the elevator on the Main 1 unit, the surveyor observed Nurse #3 sitting at the nursing station with her head resting on her left palm and her eyes were shut. The surveyor did not observe any other staff members on the Unit. The surveyor made additional rounds on the unit to locate staff. At 3:23 A.M., the surveyor observed CNA #3 down the long hall in a small day room on the Main 1 unit. She was observed laying across the love seat with her eyes shut. The surveyor continued to make rounds on the unit to locate additional staff. At 3:25 A.M., the surveyor again observed Nurse #3 sitting at the desk with her head resting on her left palm with her eyes closed and she appeared asleep. At 3:26 A.M., the surveyor observed CNA #4 sitting in a small day room with a TV set at a loud volume. CNA #4 introduced herself to the surveyor and she began to walk towards the Main 1 unit nursing station with the surveyor. At 3:27 A.M., the surveyor heard the Main 1 unit phone ring, and Nurse #3 appeared startled and opened her eyes, and she answered the phone. The surveyor asked Nurse #3 if there were any staff on break and Nurse #3 said no. The surveyor asked Nurse #3 the location of the any additional staff members on the unit, and she said CNA #3 was down the long hall providing care to a Resident. The surveyor and Nurse #3 walked down the long hall and observed CNA #3 in the long hall in a small day room with her eyes shut laying across the love seat. Nurse #3 then said that CNA #3 must have been on her break. During an interview at 4:26 AM CNA #3 said that she was taking a break and was sleeping in the day room for her break from 3:00 A.M. to 3:30 A.M. CNA #3 said that she is to let the Nurse know when she goes on break and where she will be. CNA #3 said that she made Nurse #3 aware that she was going on break. During an interview at 4:43 A.M., CNA #4 said that on 8/7/25 at 3:26 A.M., she was on her break that was scheduled from 3:00 A.M., to 3:30 A.M., and she was watching TV in the small day room. CNA #4 said that she let Nurse #3 know she was going on break. During an interview at 4:04 A.M., Nurse #3 said that she does not sleep during her shift because she is unable to get comfortable. Nurse #3 once again said that CNA #3 was on his/her break when CNA #3 was observed sleeping. During a follow up interview at 4:49 A.M., Nurse #3 said that there are no assigned break times, and the CNAs are supposed to communicate with her when they are going on break. Nurse #3 said that she was aware CNA #3 was on break, however this contradicted her initial interview. Nurse #3 said that both the CNAs should not be on break at the same time. During an interview on 8/7/25 at 5:32 A.M., the Director of Nursing said that the CNAs should communicate with the Nurse and the CNAs should let the nurse know when they are taking their breaks and they should both not be on break at the same time.

Based on observation, record review and interview, the facility failed to provide adaptative equipment during meals for two Residents (#28 and #119) out of a total of 34 sampled residents. Findings include: 1. Resident #28 was admitted to the facility in August 2024 with diagnoses including epileptic seizures, autistic disorder and dysphagia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #28 is severely cognitively impaired evidenced by a score of five out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #28 required supervision or touching assistance with eating. Review of Resident #28's physicians orders indicated: Patient to be provided with weighted utensils and 2 handle overed (SIC) cup with meals, 4/30/25 On 8/5/2025 at 8:08 A.M., the surveyor observed Resident #28 in his/her room eating breakfast. Resident #28's tray included weighted utensils and regular drinking glasses and mugs. Resident #28 used both hands to pick up a glass of juice. Resident #28's hand were shaking and he/she struggled to drink without spilling. Resident #28 said his/her breakfast was good but did not engage in further conversation. On 8/6/2025 at 7:58 A.M., the surveyor observed Certified Nursing Assistant (CNA) deliver Resident #28's breakfast meal. The tray included a plastic fork instead of weighted utensils and did not include two handled cups with covers. Review of Resident #28's meal ticket indicated: weighted utensils, weighted two handle cup with lid. Eats in room. On 8/6/2025 at 11:58 A.M., the surveyor observed Resident #28's lunch tray. The tray included a plastic fork instead of weighted utensils and did not include two handled cups with covers. The surveyor observed staff attempt to deliver Resident #28's lunch tray, but he/she declined. During an interview on 8/7/2025 at 6:53 A.M., the Food Service Director (FSD) said that specialty utensils for residents are indicated on the tray ticket. The FSD said dietary staff are expected to follow the tray ticket and place the correct utensils, cups and plates on the trays. Review of the Adaptive Equipment Tally Report, dated as printed on 8/7/25, indicated Resident #28 requires weighted utensils and a weighted two handle cup with lid. On 8/7/2025 at 7:57 A.M., the surveyor observed CNA #8 deliver Resident #28's breakfast tray which included weighted utensils but did not include two handled cups with lids. During an interview on 8/7/2025 at 8:02 A.M., Unit Manager #1 said the kitchen staff should be following the meal ticket and placing specialty equipment on resident trays. Unit Manager #1 said the team had a meeting yesterday (8/6/25) and that Resident #28 requires weighted utensils and two handled cups with lids with his/her meals. Unit Manager #1 was not aware Resident #28 was not receiving the two handled cups, or that he/she had been served meals with plastic forks instead of weighted utensils. During an interview on 8/7/2025 at 8:19 A.M., the Director of Nursing (DON) said Residents with orders for weighted utensils and handled cups should receive them at meals. The DON was not aware Resident #28 was not receiving the two handled cups, or that he/she had been served meals with plastic forks instead of weighted utensils. 2. Resident #119 was admitted to the facility in March 2009 with diagnoses that include dysphagia and muscle weakness. Review of Resident #119's most recent Minimum Data Set (MDS) Assessment, dated 7/11/25, indicated that the Resident could not participate in the Brief Interview for Mental Status (BIMS) exam and is assessed by staff to have modified independence with cognitive skills for daily decision making. The MDS further indicates that Resident #119 requires supervision/ touching assistance with eating. On 8/5/25 at 9:08 A.M., the surveyor observed Resident #119 alone in his/her room eating breakfast in bed. The Resident had a built- up spoon utensil on his/her tray but did not have a blue mug or divided plate as indicated on his/her meal ticket. On 8/6/25 at 9:00 A.M., the surveyor observed a staff member set up the Resident's tray and exit the room. The Resident was in bed with the meal tray in front of him/her. There was no blue mug or divided plate on the tray. The Resident's coffee was in a regular coffee mug and the meal was served on a lip plate, but not a divided plate. On 8/6/25 at 12:24 P.M. the surveyor observed Resident #119 eating lunch in the dining room. His/her lunch was served on a lip plate, but not a divided plate. Resident #119 did not have a blue mug and his/her beverages were served in a Styrofoam cup with a straw. On 8/7/25 at 9:02 A.M., the surveyor observed Resident #119 eating breakfast in his/her room. The Resident's meal was not served on a divided plate. Review of Resident #119's meal ticket indicated the following: Adapt Equip (Adaptive Equipment): divided plate, built up utensil (spoon) Alerts: allergic to fish, blue mug, finger food Review of Resident #119's active activities of daily living (ADL) care plan indicated the following: EATING: [Resident] requires close supervision/ assist during meals, may have divided plate and built- up spoon for all meals. Review of Nutritional Comprehensive Assessment, dated 1/8/25, indicated the following: Diet order and rational: Reg, fort (fortified) foods, finger foods, PB&J @ L+D (peanut butter and jelly at lunch and dinner). 2 handled cup w/ lid, built up spoon, divided plate. Review of Adaptive Equipment Tally Report dated 8/7/25 provided from the kitchen indicated that Resident #119 requires the following: Built up utensil- spoon, divided plate. During an interview on 8/7/25 at 6:53 A.M., the Food Services Director said that specialty utensils are indicated on the tray ticket and staff are expected to follow the tray ticket and place the correct utensils, plates and other equipment on the trays. He said there is a report they can run and it's on the meal ticket as well. During an interview on 8/7/25 at 9:07 A.M., Unit Manager #3 said that the kitchen should be putting all necessary adaptive equipment on the meal trays. She said that for Resident #119 the divided plate and blue mug should be provided for all meals. Unit Manager #3 said that when nursing staff are passing out meal trays, they should be ensuring that all necessary adaptive equipment is on the tray. During a follow up interview on 8/7/25 at 11:18 A.M., the Food Service Director said that he wasn't sure if they had divided plates in house but would order some if they didn't. He then came back to the surveyor and said they did have some and would ensure that the Resident was receiving it on his/her tray. The Food Service Director further said that the reason the blue mug is not on the adaptive equipment report is because it is written under alerts on the meal ticket but still should be on the Resident's tray. During an interview on 8/7/25 at 11:20 A.M., the Assistant Director of Nurses and Corporate Nurse said that the kitchen should ensure that all adaptive equipment listed as needed for a resident is on their trays, and that they receive it for all meals. They further said that nursing staff should be checking the trays during the meal pass and ensure that all necessary equipment is on the trays.

Based on observation, record review and interview, the facility failed to maintain complete and accurate medical records for three Residents (#25, #78 and #15) out of a total sample of 34 residents. Specifically,1. For Resident #25, the facility failed to accurately document treatment administrations. 2. For Resident #78, the facility failed to accurately document the completion of a physician's order.3. For Resident #15, the facility failed to accurately document the route of medication administration. Findings include:1. Resident #25 was admitted to the facility in October 2013 with diagnoses including peripheral vascular disease and [NAME] insufficiency. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #25 was moderately cognitively impaired evidenced by a score of 11 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS also indicated Resident #25 had behaviors of refusing care. During an interview on 8/5/2025 at 9:57 A.M., the surveyor observed Resident #25's right leg was wrapped and dated 7/24/25. Resident #25 said he/she has edema and staff wrap his/her leg every three days. Review of Resident #25's physician's orders indicated: Wash RLE (right lower extremity) with warm soapy water, rinse and pat dry, wrap legs with unna boot from toes up to top of shin, change every three days, every day shift. On 8/5/2025 at 2:03 P.M., and 8/6/25 at 8:02 A.M. the surveyor observed Resident #25's leg wrap dated 7/24/25. Review of Resident #25's Treatment Administration Records, dated July 2025 and August 2025, indicated Resident #25's leg wrap was changed as ordered. During an interview on 8/6/2025 at 8:14 A.M., Unit Manager #1 said that Resident #25 always refuses treatments, and the staff should be documenting his/her refusals. Unit Manager #1 said staff should not document the treatments to Resident #25's right leg were completed because he/she had refused. 2. Resident #78 was admitted to the facility in September 2020 with diagnoses including schizophrenia, bipolar disorder and anxiety. Review of Resident #78's most recent Minimum Data Set (MDS) dated [DATE] had a Brief Interview for Mental Status score of 6 out of a possible 15, which indicated he/she has severe cognitive impairment. The MDS also indicated Resident #78 requires supervision for feeding tasks. Review of Resident #78's physician orders indicated the following orders: May use real utensils while in supervised area at lunch and plastic utensils at breakfast and dinner, every shift for Suicidal ideation with no plan, initiated on 6/30/24. On 8/5/2025 at 8:28 A.M., and 12:10 P.M., Resident #78 was observed eating meals in his/her room with no staff present in the room or in the hallways to supervise. The Resident was provided with regular utensils, including a knife. On 8/6/25 at 8:23 A.M. and at 12:20 P.M., Resident #78 was observed eating meals in his/her room with no staff present in the room or in the hallways to supervise. The Resident was provided with regular utensils, including a knife. Review of the Treatment Administrative Record for August 2025, indicated the nursing staff had marked the physician's order as complete indicating Resident #78 did not receive knives at the breakfast and lunch meals on 8/5/25 and 8/6/25. During an interview on 8/6/2025 at 12:22 P.M., Certified Nursing Assistant (CNA) #6 said Resident #78 is independent with meals and can use regular utensils, including a knife. During an interview on 8/6/2025 at 12:36 P.M., Nurse #5 said orders should not be signed off as completed if the order was not followed. During an interview on 8/6/2025 at 2:22 P.M., the Assistant Director of Nursing said Resident #78 should not have knives at meals and this order should not have been documented as completed if the Resident did receive knives at the four meals observed. During an interview on 8/7/25 at 7:50 A.M., the Director of Nursing said Resident #78 should not have knives at meals and this order should not have been documented as completed if the Resident did receive knives at the four meals observed. 3. Resident #15 was admitted to the facility in September 2023 with diagnoses that included cerebral infarction and dysphagia. Review of Resident #15's most recent Minimum Data Set (MDS) Assessment, dated 6/13/25, indicated that the Resident was unable to participate in a Brief Interview for Mental Status (BIMS) exam, and was assessed by staff as having severe impairment in cognitive skills and daily decision making. The MDS further indicated the use of a feeding tube. Review of Resident #15's active Physician's orders as of 8/6/25 indicated the following: -NPO (nothing by mouth) diet, NPO texture, NPO consistency, dated 3/25/24. -Aspiration precautions- elevate the head of the bed as tolerated to prevent aspiration, dated 7/8/24. -levETIRAcetam Oral Solution (a seizure medication) 100 mg/ml (milligrams per milliliter) (Levetiracetam), give 7.5 ml by mouth two times a day related to unspecified convulsions; other seizures, dated 9/18/23. -Senna Liquid (a medication to treat/prevent constipation) 8.8 mg/5 ml, give 5 ml by mouth two times daily for constipation, dated 9/8/23. Review of the August 2025 Medication Administration Record indicated that Levetiracetam and Senna were signed off as administered by mouth on 12 out of 12 opportunities. During an interview on 8/6/25 at 8:26 A.M., the surveyor inquired about observing Resident #15 receive medications. Nurse #6 said that she had just finished administering medications to Resident #15. She said that all medications were administered via G-tube (gastrostomy tube) and he/she does not take anything by mouth. Resident #15 was unable to participate in an interview. During an interview on 8/7/25 at 7:01 A.M., Nurse #3 said that Resident #15 has a feeding tube and receives nutrition through bolus feedings. She further said that all medications are administered through the feeding tube, and Resident #15 does not take anything by mouth. During an interview on 8/7/25 at 7:07 A.M., Unit Manager #3 said Resident #15 takes nothing by mouth, including medications. Unit Manager #3 said that medications signed off as being administered by mouth would be inaccurate. During an interview on 8/7/25 8:02 A.M., the Director of Nurses said that for Resident #15, medications signed off as being administered by mouth would be inaccurate. She said nurses should not sign off that medications are being administered by mouth because the Resident is NPO (cannot take anything by mouth). The Director of Nurses said the medications should be ordered to be administered via the Resident's feeding tube.

Based on observation, record review and interview the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Findings include: Review of the facility policy titled Infection Prevention and Control undated, indicated the following: -The Infection Prevention and Control Program includes a comprehensive, total surveillance protocol which is based on the principles of epidemiology. -To provide a systematic method of collecting, consolidating and analyzing data concerning the distribution and determinants of a given disease or event followed by dissemination of that information to those who can improve the outcomes. A. Data Sources. Sources of data for infection surveillance include but are not limited to the following: Clinical record, Microbiology reports, Antibiotic Reports, Radiographic report, Activity logs / 24 hour report, Clinical rounds/staff reports. B. Data Collection and Tabulation: A line listing form is maintained for each unit it is a concise summation of information gathered on the above forms. Potential as well as actual infections are listed on this form. Statistics are kept on a monthly basis; therefore, a new line listing is begun each month. Infections are tabulated according to body site geographic location and type of pathogen. C. Analysis and Interpretation of Data: Infection rates are calculated per unit per body site. Analysis and interpretation includes comparison to previous rates within the facility. E. Procedure Related Process Surveillance: In addition to providing data, procedure related surveillance serves as an educational and training tool for infection control practices. H. Calculation of Nosocomial Rates: Numerator =the number of nosocomial infections that occurred. Denominator the number of patient care days in a specific period of time(month). Review of the facility form titled QAPI Antibiotics for May dated, 5/1/24 to 5/30/24, indicated one diagnosis of C. diff (also known as Clostridium difficile or C. difficile) is a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon) and started on antibiotic therapy. The form failed to indicate any additional details regarding the infection or any control measures taken. Review of the infection control program line listings failed to indicate the monitoring, tracking, and analyzing of infections in the facility. During an interview on 8/28/24 at 9:28 AM., the surveyor asked the Infection Preventionist (IP) to provide her with the facility's line listing. The IP said she has line listings that she reviews at the end of the month, and she will review the clinical dashboard for new antibiotics, but she does not track clinical signs, symptoms or trending of infections because if there were infections present residents would be prescribed antibiotics. The IP said she counts the number antibiotics prescribed but does not evaluate the infections. The IP said she does not obtain reports from the lab on antibiotic use in the facility because if residents are symptomatic the provider will order antibiotics, and the facility does not obtain cultures. The IP said she does not know the monthly infection control rates and said she knows there are a lot of infections in the building if the number of antibiotics prescribed is high at the end of the month. The IP was unable to provide documentation of infection control surveillance, including a system for recording incidents and the corrective actions taken by the facility. During an interview on 8/28/24 at 11:20 A.M. the Director of Nurses (DON) said she expects the facility to follow infection control guidelines for tracking and evaluating infections as well as document surveillance of signs and symptoms of communicable diseases. The DON said the facility should be aware the infection control rates in the facility and should be identifying clusters and monitoring for increases in infections. Refer to F881

Based on record review, policy review and interview, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program. Findings include: Review of the Centers for Disease Control and Prevention (CDC) guidance titled: The Core Elements of Antibiotic Stewardship for Nursing Homes, undated, indicated but was not limited to the following: - The purpose of an antibiotic stewardship program is to improve the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance. - Antibiotic stewardship refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. - The CDC recommends that all nursing homes take steps to improve antibiotic prescribing practices and reduce inappropriate use. - Any action taken to improve antibiotic use is expected to reduce adverse events, prevent emergence of resistance, and lead to better outcomes for residents in this setting. Review of the facility policy titled, Antibiotic Stewardship Program, dated as revised January 2024, indicated the following: -It is the facility's policy to ensure that the use of antibiotics within the facility is done so in a way that optimizes the treatment of infections while striving to reduce adverse events. -Infection preventionist (IP) - will play an elemental role in supporting antibiotic stewardship by utilizing several strategies such as tracking antibiotic use, monitoring adherence to established prescribing standards, and reviewing antibiotic resistance patterns within the facility: -Antibiotic use within the facility including trends of resistance. -Monitoring antibiotic resistance patterns (MRSA (Methicillin-Resistant Staphylococcus Aureus), VRE (Vancomycin-Resistant Enterococci), ESBL (Extended -Spectrum, Beta-Lactamases), CRE (Carbapenem-Resistant Enterobacteriaciae), etc.) -Gather data on the amount of antibiotics prescribed (including number of days prescribed), and the number of residents treated each month. -Monitor the number of residents on antibiotics that did not meet criteria for active infection. -Action Plan: *Assisting in developing and improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection. -Assisting and developing an antibiotic use process (algorithm) for all antibiotics prescribed in the facility promptly clinicians/direct care providers to stop and release the need for, and choice of, an antibiotic when the clinical picture is clearer and more information is available: for example, an antibiotic time out after 48 hrs to review and assess for appropriateness. -Tracking: The IP will be responsible for infection surveillance and MDRO (Multidrug- Resistant Organisms) tracking -See Antibiotic Use Monthly Tracking Form. -The IP will collect and review data such as: -Type of antibiotic ordered, route of administration, antibiotic costs. -Whether appropriate tests such as cultures were obtained before ordering antibiotic(s). -Whether the antibiotic was changed during the course of treatment including testing and documentation explaining the reasons for the change. -Reporting: -The IP will be responsible for the regular reporting of information on antibiotic use and resistance to doctors, nurses, and relevant staff to assist in keeping track and assuring appropriate antibiotic therapy is being utilized, and unnecessary antibiotic use can be decreased. Review of the facility's Antibiotic Use Monthly Tracking Forms failed to contain detailed information as indicate on the form and was missing criteria necessary to monitor the appropriate use of antibiotics. During an interview on 8/28/24 at 9:25 A.M., the surveyor asked the Infection Preventionist (IP) to provide her with the facility's line listing and antibiotic usage audit tool. The IP said she has line listings that she reviews at the end of the month, and she will review the clinical dashboard for new antibiotics, but she does not track clinical signs, symptoms or trending of infections because if there were infections present residents would be prescribed antibiotics. The IP said she counts the number antibiotics prescribed but does not evaluate the infections. The IP said she does not obtain reports from the lab on antibiotic use in the facility because if residents are symptomatic the provider will order antibiotics, and the facility does not obtain cultures. The IP said she does not know the monthly infection control rates and said she knows there are a lot of infections in the building if the number of antibiotics prescribed is high at the end of the month. During an interview on 8/28/24 at 11:13 A.M., the Director of Nurses (DON) said she expects the facility to document and implement the antibiotic stewardship program and follow the requirements for tracking, evaluating and reporting the use of antibiotics and infections. The DON said she expects cultures and labs to be reviewed along with the type and duration of antibiotics prescribed and evaluations should be discussed regarding stopping or continued antibiotics. The DON said the facility should be aware the usage and infection control rates in the facility.

Based on record review and interviews, the facility failed to obtain informed consents for psychotropic medications explaining the risks and benefits of treatment, prior to administering psychotropic medication for one Resident (#141) out of a sample of 31 residents. Findings include: Resident #141 was admitted to the facility in July 2024 with diagnoses that included foot drop, chronic non-pressure wounds, peripheral vascular disease. Review of Resident #141's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had severe cognitive impairment. Further review on the MDS indicated he/she received antidepressant medications. Review of Resident #141's physician order, dated 7/19/24, indicated Mirtazapine (antidepressant) 7.5 mg (milligrams). Give 1 tablet by mouth at bedtime related to depression. Review of Resident #141's physician order, dated 7/23/24, indicated Fluoxetine (antidepressant) 10 mg. Give 1 capsule by mouth one time a day for depression. Review of Resident #141's August 2024 Medication Administration Record (MAR), indicated the Resident received Mirtazapine 7.5 mg and Fluoxetine 10 mg daily as ordered. During an interview on 8/28/24 at 7:27 A.M., Unit Manager #1 reviewed Resident #141's medical record with the surveyor. Unit Manager #1 said Resident #141 should have psychotropic consents in place for both Mirtazapine and Fluoxetine but does not. During an interview on 8/28/24 at 8:45 A.M., the Director of Nurses (DON) said the expectation is that nursing obtains consents for psychotropic medications on admission and yearly.

Based on record review and interview the facility failed to ensure the Physician/Nurse Practitioner were notified of recommendations made by a Wound Physician for two Residents (#141 and #53) out of a total sample of 31 residents. Specifically, 1. For Resident #141, the facility failed to ensure the Physician or Nurse Practitioner were notified of recommendations made by the Wound Physician on 8/19/24 and 8/26/24. 2. For Resident #53, the facility failed to ensure the Physician or Nurse Practitioner were notified of recommendations made by Psychiatric Nurse Practitioner. Findings include: 1. Resident #141 was admitted to the facility in July 2024 with diagnoses that included foot drop, chronic non-pressure wounds, peripheral vascular disease. Review of Resident #141's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 3 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating he/she had severe cognitive impairment. The MDS further indicated the Resident has unhealed pressure ulcers and is at risk for developing pressure ulcers. Review of Resident #141's Wound Physician notes, dated 8/19/24 and 8/26/24, indicated left heel full thickness stage 3 pressure wound dressing treatment plan: - Apply Alginate calcium to wound, cover with ABD pad (large pad dressing) apply once daily. Review of Resident #141's active physician order, dated 7/25/24, indicated wash left heel with NS (normal saline), pat dry apply skin prep apply once daily. Review of Resident #141's Wound Physician notes, dated 8/19/24 and 8/26/24, indicated diabetic right heel wound dressing treatment plan: - Apply Santyl (helps debride the wound) to wound and cover ABD pad apply once daily. Review of Resident #141's active physician's order, dated 7/25/24, indicated wash right heel with NS, pat dry apply Betadine apply once daily. Review of Resident #141's August 2024 Treatment Administration Record (TAR), indicated on 8/20/24, 8/21/24, 8/22/24, 8/24/24, 8/25/24, 8/26/24, and 8/27/24 wash left heel with NS, pat dry apply skin prep apply once daily and wash right heel with NS, pat dry apply Betadine apply once daily were signed off as administered. Review of Resident #141's Nurse Practitioner (NP) Note, dated 8/26/24, indicated the Resident was evaluated by the NP. During an interview on 8/28/24 at 7:17 A.M., Unit Manager #1 said the Wound Physician rounds weekly with nursing staff, if the Wound Physician makes recommendations they tell the nursing staff then nursing staff relays the information to the provider in the facility. Unit Manager #1 said the recommendations should have been verbalized to the physician and/or NP here but were not. During an interview on 8/28/24 at 8:54 A.M., Nurse Practitioner #1 said she was unaware that Resident #141 was being seen by the Wound Physician and said she was unaware of the Wound Physician's treatment plans for his/her wounds. 2. Resident #53 was readmitted to the facility in April 2024 with diagnoses that included bipolar disorder, dysphagia and sleep apnea. Review of Resident #53's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating intact cognition. During an interview on 8/26/24 at 8:16 A.M., Resident #53 said he/she has been feeling more depressed lately. Review of Resident #53's psych medication management Nurse Practitioner (NP) note, dated 8/8/24, indicated the Resident reported that his/her mood was labile. Recommended increasing Lamictal to 100 mg daily. Review of Resident #53's physician order, dated 11/28/23, indicated Lamictal (anti-epileptic medication also used for mood stabilization) tablet 25 mg (milligrams) give three tabs (75 mg) daily. Review of Resident #53's NP progress note, dated 8/26/24, indicated Lamictal 25 mg tablet. Take 3 tablets (75 mg) by mouth in the morning. Review of Resident #53's August 2024 Medication Administration Record (MAR), indicated the Resident received Lamictal 75 mg daily as ordered. On 8/28/24 at 7:15 A.M., Unit Manager #1 said nursing will update the Nurse Practitioner that follows the Resident in house of the new psych medication recommendations. Unit Manager #1 said she was unaware that Resident #53 had new medication recommendations made on 8/8/24. On 8/28/24 at 8:52 A.M., Nurse Practitioner #1 said she was unaware of the medication recommendations made by the psych NP on 8/8/24 and said she would expect nursing staff to relay her this information but they did not.

Based on observation, record review and interview the facility failed to ensure the Minimum Data Set assessment (MDS) was accurately coded to reflect the status of two Residents (#71, #21) out of a total sample of 31 residents. Specifically: 1) For Resident #71, the MDS did not accurately assess Resident #71's functional ablities for self-care, specifically for eating and 2) For Resident #21, the facility failed to complete a discharge MDS Assessment when the Resident was discharged from the facility to the hospital. Findings include: 1) Resident #71 was admitted to the facility in February with diagnoses that include but are not limited to cerebral vascular accident, anemia, and malnutrition. Review of the most recent Minimum Data Set assessment dated [DATE] indicated Resident #71 scored a 7 out of 15 on the Brief Interview of Mental Status exam indicating he/she as having a severe cognitive impairment. Further review of the MDS indicated Resident #71 had the following nutritional approaches: feeding tube, mechanically altered diet, and therapeutic diet. Review of Resident #71's physician's orders indicated the following: - Regular diet, Pureed texture, Thin Liquids consistency Diet Active date [DATE]. On [DATE] at 8:52 A.M. Resident #71 was observed in bed with a breakfast tray in front of him/her. On [DATE] at 8:51 A.M., Resident #71 was observed in bed with a breakfast tray in front of him/her holding a bowl of hot cereal and spooning the cereal into his/her mouth. A Certified Nursing Assistant (CNA) was next to Resident #71. During an interview on [DATE] at 12:04 P.M., CNA #3 said the Resident eats his/her meals with someone with him/her due to aspiration. CNA #3 said the Resident does not eat too much but needs supervision to eat. During an interview on [DATE] at 12:08 P.M. Nurse #6 said the Resident takes his/her medication whole with apple sauce. Review of Resident #71's MDS dated [DATE] indicated nutritional approaches as feeding tube, mechanically altered diet and therapeutic diet. The MDS document under functional abilities for eating was documented as 'not applicable' The MDS dated [DATE] indicated under functional abilities for eating was documented as 'not applicable.' Two MDSs failed to accurately assess Resident #71's functional abilities for eating. During an interview on [DATE] at 1:57 P.M., the MDS nurse said she did not know why the MDS was documented as 'not applicable for eating and that Resident #71 is dependent on staff for eating. 45984 2) Review of Resident #21's medical record indicated that the Resident went on hospital leave on [DATE] and did not return to the facility. Review of Resident #21's most recent Minimum Data assessment dated [DATE] indicated a quarterly MDS Assessment was the last completed MDS assessment. The medical record failed to indicate a discharge MDS assessment was completed. Review of Resident #21's nursing progress note dated [DATE] at 10:52 P.M. indicated that the Resident was sent out to the hospital. Review of Resident #21's nursing progress note dated [DATE] at 10:36 A.M. indicated that the Resident had expired in the hospital. During an interview on [DATE] at 1:57 P.M., the MDS Nurse said she is in charge of completing MDS assessments and when a Resident gets discharged from the facility a discharge MDS assessment gets completed. The MDS Coordinator and the surveyor reviewed Resident #21's medical record and she said she did not assess Resident #21 leaving the facility and it must have been forgotten.

Based on observation, policy review and interviews, the facility failed to ensure professional standards of practice were followed for one Resident (#131) out of a total sample of 31 residents. Specifically, the facility failed to ensure nursing staff did not leave medications with Resident #131 while unattended. Findings include: Review of the facility policy titled 'Administration of Medications -General' dated November 2023, indicated the following but not limited to: -Medication may not be left unattended. Keep medications secured in a locked area or in visible control at all times. -Medications are never to be left at resident bedside if a situation occurs which necessitates that nurse must step away from resident prior to administration of all medications, medications must be removed from room and secured in locked medication cart until medications can be administered to resident. -Administers medications to residents via correct route. Offers residents a full glass of beverage. Observes residents to ensure medication consumption. During a medication pass on 8/27/24 at 9:28 A.M., the surveyor observed Nurse #2 prepare and administer medication to Resident #131 including the following medication, MiraLAX 17 grams (medication for constipation) mixed in water. Nurse #2 administered medications and left the cup of MiraLAX mixed in water with the resident. Nurse #2 did not wait to see if the Resident consumed the entire amount. During an interview on 8/27/24 at 1:37 P.M., Nurse #2 said she should have waited until the Resident took all the medications. During an interview on 8/28/24 at 8:43 A.M., the Director of Nursing said nurses are to stay with the residents until all medications are taken and no medications should be left with the residents.

Based on observations, record review and interview, the facility failed to provide activities of daily living for dependent residents for one Resident (#2) out of a total sample of 31 Residents. Specifically, for Resident #2, the facility failed to provide supervision with meals. Findings include: Review of the facility policy titled Activities of Daily Living, dated November 2023, indicated the following: - It is the facility's policy that based on the comprehensive assessment of a resident consistent with the resident's needs and choices, care and services will be provided to maintain their current ADL status. - Care and services for the following ADL's include: Dining - eating, including meals and snacks - Referrals to therapy can be made based on the interdisciplinary team's review of resident's status during scheduled Comprehensive Care Plan Meetings. - Care Plans - All Resident care plans MUST match the Resident Profile care, CNA assignment, Pocket Sheet and DC POC and CNA Accountability sheets with regards to ADLs. Resident #2 was admitted to the facility in July 2007 with diagnoses including dementia, bipolar disorder and Barrett's esophagus. Review of Resident #2's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status score of 5 out of a possible 15 indicating the Resident has severe cognitive impairment. Further review of the MDS indicated the Resident only requires setup assistance with eating. The surveyor made the following observations: - On 8/26/24 at 8:44 A.M., Resident #2 was observed sitting in a wheelchair in his/her room. A staff member entered his/her room with a breakfast tray, set it up and exited the room. Resident #2 was then observed eating a large cut piece of French Toast with no staff present in the room. - On 8/27/24 at 8:33 A.M., Resident #2 was observed sitting in his/her wheelchair in his/her room. A staff member delivered his/her breakfast tray, set up the tray and left the room. No staff were present in the room for supervision or cueing while Resident #2 was eating his/her breakfast. At 8:35 A.M., a staff member delivered Resident #2's roommate's tray and left the room at 8:36 A.M. At 8:39 A.M., a staff member entered Resident #2's room to cut up his/her pancakes and left the room. Resident #2 was observed eating his/her hot cereal with no supervision in his/her room. At 8:50 A.M., Resident #2 was observed to continuously eat his/her breakfast in his/her room without supervision or cueing assistance as needed. -On 8/28/24 at 8:10 A.M., Resident #2 received his/her breakfast tray while laying in his/her bed. At 8:16 A.M., a staff member left the Resident's room, Resident #2 was observed eating his/her breakfast without supervision. At 8:27 A.M., a staff member entered Resident #2's room to take away the Resident's breakfast tray and left the room. Resident #2 was observed drinking from his/her coffee cup with no supervision from staff. Review of Resident #2's self-care deficit: feeding & dysphagia care plan, revised and dated 11/20/23, indicated the following interventions: - Provide meal support per Resident's need. He/she needs supervision for meals & verbal cueing to initiate or continue to intake food due to cognitive impairment/dementia. Review of Resident #2's swallowing care plan related to esophagus impaction reviewed and dated 8/16/24 indicated the following interventions: - All staff to be informed of Resident #2's special dietary and safety needs. - Resident #2 is to eat only with supervision. Monitor for aspiration. Review of Resident #2's nutritional risk care plan revised and dated 4/3/24 indicated the following intervention: - Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Review of Resident #2's Kardex on the electronic medical record indicated the following under the Eating/Nutrition section indicated the following: - Resident #2 is to eat only with supervision. Monitor for aspiration. - Provide meal support per Resident's need. He/she needs supervision for meals & verbal cueing to initiate or continue to intake food due to cognitive impairment/dementia. Review of Resident #2's Kardex with a review date of December 2020 in Certified Nursing Assistant (CNA) assignment binder on the unit indicated the following under the Eating section: - Set-up or clean up assistance Review of Resident #2's CNA ADL assignment sheet for August 2024 indicated that the Resident was documented as receiving setup or clean-up assistance with meals for every day of the month and not supervision with meals. Review of Resident #2's Nurse Practitioner progress note written on 8/9/24 at 2:25 P.M., indicated the following: - Pt. underwent EDG with RFA on 8/8/24: findings showed two esophageal nodules as well as hiatal hernia. - Patient Active Problem List: Esophageal obstruction due to food impaction, aspirations into airway Review of Resident #2's document titled Speech Therapy Discharge Summary dated from 7/26/24 through 8/22/24 indicated the following under the Intake Protocol section: Supervision for Oral Intake = close supervision (recommend set up and close supervision). During an interview on 8/28/24 at 9:25 A.M., CNA #2 said she asks residents what level of assistance they need each day she provides care, CNA #2 also said she uses the kardex to know what level of care each resident need. CNA #2 continued to say when a resident requires supervision with meals they need to be watched at all times while eating. CNA #2 said Resident #2 is able to feed him/herself without supervision, he/she only needs his/her meal tray setup. During an interview on 8/28/24 at 9:38 A.M., Nurse #5 said she speaks with the CNAs about what level of care each resident requires and she refers to the care plans and kardex. Nurse #5 said Resident #2 requires supervision with meals and that supervision means that a staff member needs to be within sight of Resident #2 while he/she is eating. Nurse #5 and the surveyor reviewed Resident #2's care plan and kardex and Nurse #5 said Resident #2 should be supervised at all meals. During an interview on 8/28/24 at 10:58 A.M., the Director of Rehabilitation (DOR) and the surveyor reviewed Resident #2's Speech Therapy Discharge Summary dated from 7/26/24 through 8/22/24. The DOR said given Resident #2's cognitive level of function and swallowing history, he/she needs to be closely supervised while eating. The DOR said close supervision means a staff member needs to be in the room with Resident #2 due to cueing needs and to monitor for aspiration risk. The surveyor shared the observations and the DOR agreed that Resident #2 was not receiving the appropriate supervision during meal times.

Based on observation, record review and interview the facility failed to ensure standards of quality of care were implemented for one Resident (#2), out of a total sample of 31 residents. Specifically, the facility failed to identify a skin injury on the Resident's right forearm. Findings include: Review of the facility's policy subject: Managing Skin Integrity with an effective date of 1/3/2024, indicated the following: It is the policy of the facility to ensure that all residents receive the highest practicable level of quality of care. Nursing, in collaboration with the health care team, will assess and manage skin integrity for all residents throughout their residence in the facility. Focus is on a 'gentle hands' approach when providing care to all residents. Any deterioration in or development of an alteration in skin integrity will be promptly addressed and individualized approaches in accordance with the resident's needs and goals will be implemented. Resident #2 was admitted to the facility in July 2007 with diagnoses including dementia, bipolar disorder and Barrett's esophagus. Review of Resident #2's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated that the Resident had a Brief Interview for Mental Status exam score of 5 out of 15 indicating the Resident as having severe cognitive impairment. During the survey the following observations were made: - On 8/26/24 8:44 A.M., Resident #2 was sitting up in a wheelchair in his/her room with a round approximately quarter sized discoloration with yellowed edges on his/her right forearm. - On 8/26/24 at 3:29 P.M., Resident #2 was in the activity room on another floor and had a round fading discoloration on his/her right forearm. - On 8/27/24 at 8:13 A.M., Resident #2 was up, dressed and in his/her wheelchair. Resident #2's right forearm had a fading round discoloration with yellowing edges. Resident #2 said it was a bruise. Review of Resident #2's medical record indicated the following: - Progress notes dated 7/30/24 through 8/26/24 did not indicate any entry regarding the identification of the skin discoloration consistent with a bruise on Resident #2's right forearm. - A Physician's order dated active 11/8/2021 weekly skin check Monday 3-11 every evening shift every Monday. On 8/27/24 at 7:06 A.M., review of the weekly skin assessment dated [DATE] indicated Resident #2's skin as intact. This assessment conflicts with the observations made on 8/26/24 of Resident #2's discoloration on Resident #2's right forearm. During an interview on 8/27/24 at 2:24 P.M., Certified Nursing Assistant #2 (CNA) said Resident #2 requires care for everything and that she provided bathing dressing this morning. CNA #2 said if skin changes or injuries are seen during care they are reported to the nurse. CNA #2 said Resident #2 moves around in his/her wheelchair and can easily bang his/her arms. During an interview and observation on 8/27/24 at 2:26 P.M., Nurse #6 said the CNA staff report any skin concerns to the nurses. Nurse #6 said residents have weekly skin assessments and anything identified should be on the assessment. Nurse #6 walked into Resident #2's room with the surveyor and saw the circular discolored area on his/her right forearm. Nurse #6 said the area looked old due to the yellow fading edges, was a bruise and a couple days old. Nurse #6 said any skin change/injury on a resident needs an incident report. Nurse #6 said the Resident's bruise should have been noted or reported by staff. During an interview on 8/27/24 at 3:19 P.M., the Assistant Director of Nursing (ADON) said the Nurse on Resident #2's unit just brought the skin injury to her attention. The ADON said it was a bruise on the right forearm, looks to be old, round smaller than quarter, and that Resident #2 had a history of banging his/her arms when he/she moves around the facility. The ADON said staff are to report any skin changes or injuries on a resident.

Based on observation, record review and interview the facility failed to a) develop a care plan for the assessed risk for developing a pressure ulcer/injury and b) failed to implement the physician's order for prevalon boots (a heel protector) for one Resident (#79) out of a total sample of 31 residents. Findings include: Review of the facility's policy titled Subject: Pressure Ulcer Preventions and Management, with an effective date 1/3/2024 indicated the following: It is the policy of the facility to assess all resident for the risk of pressure injuries and to have an appropriate interdisciplinary preventive care plan implemented when indicated. Procedure: 3. When a resident is identified as at risk for development of a pressure injury, the licensed nurse/unit manager will initiate a care plan that recognizes the resident's needs and goals and addresses the same with individualized interventions that are consistent with recognized standards of practice. Resident #79 was admitted to the facility in November 2023 with diagnoses that include but are not limited to chronic obstructive pulmonary disease, type 2 diabetes mellitus, mild protein-calorie malnutrition, and partial traumatic amputation on right foot. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #79 scored a 13 out of 15 on the Brief Interview for Mental Status exam indicating he/she is cognitively intact, requires partial/moderate assistance from staff on bathing, dressing and transfers, and is at risk for developing pressure ulcers. Review of the Norton Scale for Predicting Pressure Ulcer conducted for Resident #79 on 11/27/23 score of 9, 2/26/24 score of 8, and 5/28/24 score of 10, all indicated Resident #79 as being at high risk for developing a pressure ulcer/injury. A score of 10 or below places the resident at risk for developing a pressure ulcer. a) Review of the comprehensive MDS dated [DATE] indicated a Care Area Assessment note: Care Plan considerations: (Resident #79) Dependent to Extensive assist with ADLs/Mobility. Skin intact. Always incontinent; Prompt incontinent care needed. Weekly skin assessments. Pressure relief devices. Pressure Ulcer/Injury will be addressed in the care plan. Review of the documented care plans failed to indicate a person-centered care plan with an individualized goal and interventions for the risk of developing pressure ulcers was developed. During an interview on 8/27/24 at 2:05 P.M., the Minimum Data Set nurse said if an area for care triggers with the decision to proceed with a care plan, the care plan with the specific focus the focus should be developed. The MDS nurse said Resident #79 should have a care plan for the risk of developing pressure ulcer/injury. b) On 8/26/24 8:46 A.M., Resident #79 was observed in bed, wearing a nasal cannula in his/her nose administering oxygen, and eating his/her breakfast. Resident #79 said he/she needs help with bathing and dressing. Review of Resident #79's medical record indicated the following: *A physician's order: Prevalon boots while in bed at bedtime, dated 12/28/24 *A physician's order dated 12/28/24 skin prep to dry eschar on right heal (sic). Apply BID (two times a day) and prn (as needed). During an interview on 8/26/24 at 12:12 P.M., Resident #79 said he/she did not have any boots that he/she wears to bed and that he/she did not have any issues with his/her heels. On 8/27/24 at 7:49 A.M., Resident #79 was observed in bed. Resident #79's heels were directly on the mattress and he/she was not wearing prevalon boots. There were no prevalon boots observed in the Resident's room. During an interview on 8/27/24 at 2:41 P.M., Certified Nursing Assistant (CNA) #3 said she works days, and that Resident #79 is in bed when she starts her shift and does not have or use boots or any pillows for his/her heels. During an interview on 8/27/24 at 2:50 P.M., Nurse #6 said Resident #79 has a pink dryness on his/her right heel which is treated with skin prep. Nurse #6 reviewed the MAR and said there is an order for the prevalon boots which he/she is supposed to be wearing at night. Nurse #6 went with the surveyor to Resident #79's room and was unable to locate the prevalon boots. On 8/27/24 at 3:30 P.M., the Assistant Director of Nursing said her recollection is that Resident #79 had broken skin at one point and the prevalon boots were for preventative measures. The ADON said typically the use of the prevelon boots is documented on the Treatment Administration Record (TAR) and not the MAR, but she would expect that they are implemented per the physician's order.

Based on observations, interviews, policy review, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice for one Resident (#48) out of a total sample of 31 residents. Specifically for Resident #48, the facility failed to ensure his/her oxygen concentrator air filter was in place. Findings include: Review of the facility policy titles Oxygen Therapy, dated 1/3/24, indicated Maintenance of Concentrator: - Filters will be washed in warm soapy water weekly. - Filters should be dried thoroughly before being reinstalled. Resident #48 was admitted to the facility in July 2024 with diagnoses that included sepsis, pneumonia, acute respiratory failure with hypoxia and chronic obstructive pulmonary disease. Review of Resident #48's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored 15 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident is cognitively intact. Further review of the MDS indicated he/she is receiving oxygen therapy. Review of Resident #48's physician orders, dated 7/26/24, indicated change 02 (oxygen) tubing and clean filter every week. On 8/26/24 at 8:06 A.M., the surveyor observed Resident #48 in bed receiving oxygen via nasal cannula, the oxygen concentrator did not have an air filter in place. On 8/27/24 at 7:43 A.M., the surveyor observed Resident #48 in bed receiving oxygen via nasal cannula, the oxygen concentrator did not have an air filter in place. During an interview on 8/28/24 at 7:28 A.M., Unit Manager #1 said the oxygen concentrator should have an air filter in place because if the air filter is not in place it puts the resident at risk for an infection. During an interview on 8/28/24 at 11:28 A.M., the Director of Nurses (DON) said she expects air filters to be in place at all times on the oxygen concentrator machines.

Based on observations, record reviews, policy reviews and interviews, the facility failed to ensure it was free from a medication error rate of five percent or greater. One out of four nurses observed made two errors in 40 opportunities on one unit resulting in a medication error rate of 5%. These errors impacted one Resident (#53), out of four residents observed. Findings include: Review of the facility policy titled 'Administering of Medications-General' dated, November 2023, indicated the following but not limited to: -It is the facility's policy that medications will be administered to residents in a timely and accurate manner by a licensed nurse or physician. -Nurse compares the medication names, strength, and dosage schedule on the medication administration record against the prescription label. Always check three times prior to administration. -Review physician's orders and compares against medication administration record. 1. During a medication pass on 8/27/24 at 9:44 A.M., the surveyor observed Nurse #1 prepare and administer including the following medications for Resident #53: -Vitamin D3 5000 units one cap by mouth. -Calcium 600 milligram with 400 units of vitamin D. Review of the Resident #53's current physician orders indicated the following medication orders: -Cholecalciferol tablet 1000 unit. Give one tablet by mouth one time a day for osteoporosis. -Calcium carbonate 600 milligrams. Give one tablet by mouth one time a day for osteoporosis. During an interview on 8/27/24 at 1:38 P.M., Nurse #1 said she substitutes medication with whatever she has on hand which the Resident ended up receiving 4400 units extra of vitamin D. She further said she administered the wrong dosages. During an interview on 8/28/24 at 8:38 A.M., the Director of Nursing said if medication is not available the nurse would call the physician and get a substitute for what is on hand. Nurses should not substitute medications without a physician order.

Based on observation, policy review and interview, the facility failed to ensure nursing staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, 1. The facility failed to properly secure the medication cart on one of four units 2. The facility failed to properly secure the medication room on one of four units Findings include: Review of the facility policy titled Maintenance of Medications, dated 11/8/23, indicated Only authorized licensed personnel are to have access to the keys and the medications. Medication carts must be locked at all times when not in use, including during medication passes when the nurse steps away from the cart. 1. On 8/26/24 at 7:48 A.M. and 12:38 P.M., the surveyor observed the medication cart on the [NAME] 1 Unit unlocked and unsupervised. No staff were at the medication cart. During an interview on 8/28/24 at 7:30 A.M., Unit Manager #1 said the medication cart should be locked if a nurse is not present at it. During an interview on 8/28/24 at 8:44 A.M., the Director of Nurses (DON) said she expects nursing to keep their medication carts locked unless they are present at the cart. 2. On 8/26/24 from 8:02 A.M. to 8:32 A.M., the medication room on the Main 1 Unit was unlocked and unsupervised. No staff were present in the medication room or at the nurses station. On 8/27/24 from 8:18 A.M. to 8:55 A.M., the medication room on the Main 1 Unit was unlocked and unsupervised. No staff were present in the medication room or at the nurses station. During an interview and observation on 8/27/24 at 8:56 A.M., Nurse #2 said the medication room is unlocked at the present time and should not be. Nurse #2 said the medication room should always be locked unless a nurse is present in the room. During an interview on 8/28/24 at 7:30 A.M., Unit Manager #1 said the medication room should be locked at all times unless a nurse is in the room obtaining supplies. During an interview on 8/28/24 at 8:44 A.M., the Director of Nurses (DON) said she expects nursing to keep their medication rooms locked unless they are present in the in the medication room.

Based on observations, record reviews and interviews, the facility failed to obtain dental services for one Resident (#87) out of a total sample of 31 Residents. Findings include: Review of the facility policy titled Dental Services/Dentures, dated November 2023, indicated the following: -Routine and emergency dental services are available to meet the resident's oral health services in accordance with the residents' assessment and plan of care. -Social services representatives with assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. -If dentures are damaged or lost, residents will be referred for dental services within 3 days. If the referral is not made within 3 days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting dental services, and the reason for the delay. Resident #87 was admitted to the facility in March 2024 with diagnoses including dementia, dysphagia (difficulty swallowing), adult failure to thrive, hyperlipidemia, diabetes mellitus, and anxiety. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #87 has a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, indicating he/she has intact cognition. The MDS also indicated Resident #87 requires extensive assistance from staff for all functional tasks. Review of the Nutritional Comprehensive Assessment, dated 3/18/24, indicated that Resident #87 is a nutritional risk related to advanced age, FTT (failure to thrive), dysphagia, HLD (hyperlipidemia), T2DM (Type 2 Diabetes Mellitus), Dementia with potential for changes in appetite and weight. Review of the Activities of Daily Living care plan dated 3/14/24, indicated the following: -Set up for oral care; Resident #87 has upper/lower dentures refer to dental services if needed. Review of physician order dated 3/14/24, indicated the following: -Dental evaluation and treat as indicated. Review of the clinical record failed to indicate that Resident #87 was offered dental services with the facility's contracted dental service on admission and there was no signed consent or declination form on file. Review of the clinical record does not indicate that Resident #87 was seen by a contract or outside service for oral evaluation since admission. Review of the Activities of Daily Living care plan dated 3/14/24, indicated the following: -Set up for oral care; [NAME] has upper/lower dentures refer to dental services if needed. During an interview on 8/26/23 at 9:26 A.M., Resident #87 said he/she had dentures but lost them prior to admission and has been asking to see a dentist to obtain new dentures since admission. Resident #87 said he/she told multiple staff that he/she needs new dentures but has not been to the dentist. Resident #87 was observed to have no teeth and no dentures in his/her mouth. During an interview on 8/28/23 at 7:58 P.M., the Unit Manager said appointments are made for residents and residents are added to the list if they need or request to be seen by the dentist and residents or families will notify staff if they want to be seen. The Unit Manager said Resident #87 has not received an oral evaluation and does not have a signed consent for dental services on file but should have been offered dental services on admission and should have been seen by the dentist. The Unit Manager said physician orders and nutritional recommendations should be followed within 48 hours and that Resident #87 should have been added to the list for dental evaluation to replace his/her dentures. During an interview on 8/28/24 at 8:44 A.M., the Director of Nurses (DON) said Resident #87 should have been offered dental services for dental evaluation and should have been seen by the dentist to follow up with new dentures.

Based on record review and interview, the facility failed to ensure one Resident (#76) was free from a significant medication error, out of a total sample of 25 residents. Specifically, Resident #76 was administered insulin (medication used to treat elevated blood sugars) when his/her physician's order indicated for the insulin to be held. Findings include: Review of the facility policy titled, Administering Medications, dated April 2021, indicated medications are administered in a safe and timely manner, and as prescribed. 9. The following information is checked/ verified for each resident prior to administering medications: b. vital signs Resident #76 was admitted to the facility in January 2020 with diagnoses including dementia, anxiety and diabetes. Review of the Minimum Data Set (MDS) assessment, dated 8/11/23, indicated Resident #76 received insulin injections over the last 7 days. Review of the plan of care related to diabetes, dated as revised 11/9/21, indicated diabetes medication as ordered by doctor. Review of the physician's order, dated 10/12/21, indicated the following: NovoLOG 100 units/ milliliter solution, inject 12 units subcutaneously with meals related to diabetes HOLD FOR BLOOD SUGAR LESS THAN 150. Review of the Medication Administration Record, dated August 2023, indicated nursing administered Resident #67's physician's ordered NovoLOG insulin on the following dates: - 8/4/23 at 7:30 A.M., Blood Sugar 131 - 8/15/23 at 1130 A.M., Blood Sugar 146 - 8/16/23 at 5:30 P.M., Blood Sugar 90 - 8/22/23 at 7:30 A.M., Blood Sugar 137 - 8/26/23 at 7:30 A.M., Blood Sugar 114 - 8/26/23 at 5:30 P.M., Blood Sugar 145 - 8/27/23 at 5:30 P.M., Blood Sugar 132 On 8/30/23 at 1:14 P.M., Unit Manager #1 and the surveyor reviewed the medication administration record, dated August 2023, Unit Manager #1 said that Resident #76 should not have received his/her physician's order insulin. During an interview on 8/31/23 at 8:42 A.M., the Director of Nursing said Resident #76 should not have received his/her physician's order insulin

Based on an observation made on 9/13/17, and interviews, the Facility failed to protect 1 of 24 Residents (Resident #17) from verbal and physical abuse. Findings include: Resident #17 was admitted to the Facility in 7/2015 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE], indicated the Resident had moderate cognitive impairment and required the assist of one staff for activities of daily living. The Resident was incontinent of bladder and occasionally incontinent of bowel. The Resident had a Guardian and a Roger's monitor for the administration of antipsychotic medications. Review of the medical record indicated the Resident's behaviors included paranoia, delusions, yelling out and resisting care. The Resident preferred to remain in her/his own room and had two other roommates. Review of the Facility policy titled Abuse Prohibition dated 7/25/14, indicated that it is the policy of the rehabilitation and nursing center to assure an environment free of abuse, neglect, mistreatment and misappropriation of resident property. Residents must not be subjected to abuse by anyone. This is included, but not limited to facility staff, other residents, consultants, volunteers, staff of contracted agencies, family members, legal guardians, friends or other individuals. On 9/13/17, at 11:40 A.M., the Surveyor heard a resident yelling loudly - You're hurting me! You're hurting me! repeatedly. Upon entering the room, the Surveyor observed Resident #17 standing in the bathroom, with the door wide open, completely unclothed and having her/his buttocks area vigorously cleaned by Certified Nursing Assistant (CNA) #7. CNA #7 was speaking to Resident #17 in a tone that was terse, frustrated and at times, exasperated. CNA #7 was heard telling the Resident to just be nice, I'm not hurting you!, this is ridiculous! and then called the Resident an[***] . The Resident continued to yell loudly you're hurting me! and another CNA, (CNA #4), entered the room and offered to help. As the two CNA's continued to wash and dress Resident #17, the Surveyor remained in the room and continued to observe the Resident to ensure safety. CNA #7 continued to speak to Resident #17 in an exasperated tone and said Oh goodness several times. Once CNA #7 realized the Surveyor was in the room, CNA#7 said, You know I love you, you must have me confused with someone else. Following the incident, the Director of Social Services met with the Resident at 12:28 P.M. and documented that overall, the Resident reported she was doing ok. Review of the medical record indicated that UM#3 conducted a skin assessment on 9/13/17, after the incident and documented the presence of a new scratch of left side of rib. UM#3 documented that the Resident had no knowledge of how the scratch occurred secondary to dementia. UM#3 documented that the Nurse Practitioner and Medical Director were notified of the incident. The Resident's Guardian was also notified. On 9/14/17, at 8:35 A.M., the Surveyor observed Resident #17's scratch on the left upper rib cage with UM#3 present. The scratch was still present, but no longer reddened. The Resident had no idea how the scratch occurred. The Nurse Practitioner was interviewed on 9/14/17, at 9:55 A.M. the Nurse Practitioner said that she was informed of the incident. Although Resident #17 was unable to be interviewed by the Surveyor due to Resident #17's cognitive deficits, the Reasonable Person Concepts presumes that an unimpaired person would experience mental anguish from being sworn at and spoken to in a harsh manner by a caregiver and discomfort from a scratch to the body. The Roommate of Resident #17, Resident #15, was interviewed on 9/15/17, at 9:15 A.M. Resident #15 said that staff pushes Resident #17 around when they change his/her brief. Please see F225.

Based on records reviewed, interviews and observations for 2 of 3 sampled residents (Resident #1 and Resident #4) the Facility failed to ensure adequate supervision to prevent an elopement on 7/12/17 for Resident #1 and failed to ensure the environment was free from accident hazards to prevent a burn injury sustained by Resident #4. In addition razor blades were left unattended in a resident bathroom located on a locked unit with residents who had [DIAGNOSES REDACTED]. On 7/12/2017, Resident #1, who resided on a locked unit and who had a known history of elopement, was noted to be missing from the Facility and unable to be located. As of the date of Survey, 7/24/17, Resident #1 has not been found. - In addition on 7/12/17, following Resident #1's elopement, the exit door leading to the outside loading bay was able to be opened without entering the assigned security code. As of 7/17/17, The Facility had not changed the security codes to the elevator leading to the locked unit or to exit doors and a contracted service had not been contacted to assess the code pad on the exit door leading to the loading bay. Staff interviewed said the exit door to the loading bay sometimes could be pushed open without entering the security code and, at other times, they needed to enter the security code. Findings include: 1. The Hospital Psychiatric Discharge Summary, dated 4/24/17, indicated Resident #1 was brought to the emergency room under section 12 for threatening behaviors and poor self care. The Summary indicated Resident #1 had a history of [REDACTED]. The Summary indicated Resident #1 was prescribed Haldol and Zyprexa (antipsychotic medications), he/she was re-directable when prompted, and agreed to voluntary discharge to the Facility where he/she promised to take his/her medications and would not attempt to elope. The Elopement Risk Assessment, dated 4/25/17, indicated Resident #1 was identified at high risk for potential elopement, was alert and ambulatory, and had eloped from another Facility in the past. The Care Plan, dated 4/25/17, indicated Resident #1 was at risk for elopement due to a history of elopement, and staff were to encourage participation in an appropriate activity to minimize potential wandering while meeting the need for social/cognitive stimulation, and maintain consistent staff and routines as possible. The Health Care Proxy Activation Form, dated 4/27/17, indicated Resident #1 lacked the capacity to make or communicate health care decisions due to paranoid schizophrenia. Surveyor #1 interviewed Physician #1 at 1:12 P.M. on 7/19/17. Physician #1 said Resident #1 had scattered judgement with poor thought process, was very anxious, compulsive, was unable to make safe decisions and regularly paced up and down the unit. Surveyor #1 interviewed the Health Care Agent (HCA) at 2:40 P.M. on 7/19/17. The HCA said she had been involved in Resident #1's care for many years due to Resident #1's long history of mental illness and non-compliance with medications. The HCA said that prior to Resident #1's most recent hospitalization , Resident #1 had been homeless for approximately 1 year after eloping from another Facility, and had gone without any medications leading to increased paranoia placing him/her at risk to self and to others. The HCA said Resident #1 was unable to make safe decisions, unable to care for him/herself and was admitted to the Facility's Locked Unit for medication management. The Interdisciplinary Team meeting notes, dated 5/17/17, indicated Resident #1's elopement risk was discussed and it was determined that Resident #1 required a secure unit for his/her safety and well-being, and although alert and oriented times 3 at baseline, he/she was confused at times with alteration in cognitive status due to Schizophrenia. The Notes indicated Resident #1 had an activated HCP, length of stay at the Facility was uncertain due to frequent functional status changes, and it was not clear if Resident #1 would be able to function independently. Review of Resident #1's medical record indicated there were no nurse progress notes documented between 5/1/17 and 7/11/17. A physician progress notes [REDACTED].#1 missed his/her friends and apartment, and did not enjoy the people or activities at the Facility. A Nurse Progress Note, dated 7/12/17, indicated Resident #1 was observed at 4:15 P.M. in the hallway next to the elevator waiting to go smoking break. At 5:05 P.M. staff were unable to locate Resident #1, a Code Yellow (emergency alert) was called, a search of the Facility and outside grounds were initiated, and the Police Department was notified that Resident #1 was missing. The Supervisors 24 Hour Report, dated 7/12/17, indicated the entrance/exit door by the kitchen area needs to be fixed because as you push the door it opens without entering the secret code. Surveyor #1 interviewed Certified Nurse Assistant (CNA) #1 at 4:23 P.M. on 7/17/17. CNA #1 said she rode the elevator to the locked unit with Resident #1 after he/she had finished smoking and Resident #1 exited the elevator and walked towards his/her room. CNA #1 said to the best of her recollection this was sometime around 3:45 P.M. CNA #1 said she saw Resident #1 a short time later, at approximately 4.20 P.M. pacing up and down the unit, with a cup in his/her hand. Surveyor #1 interviewed Nurse #4 at 9:05 A.M. on 7/20/17. Nurse #4 said Resident #1 normally approached her at her medication cart after he/she returned from smoking break, requesting his/her medications. Nurse #4 said that on the afternoon of 7/12/17, Resident #1 did not approach her, which was very unusual, and at approximately 5:00 P.M. as other staff were passing out supper in the dining room, she went to Resident #1's room to look for him/her. Nurse #4 said Resident #1, who normally ate supper in his/her room, was not there. Nurse #4 said she went to the dining room and asked other staff if they knew where Resident #1 was and when everyone responded no, a Code Yellow was called, a search was initiated inside and on the grounds of the Facility, and the Police were notified that Resident #1 was missing. Surveyor #1 interviewed the Director of Nurses (DON) at 3:30 P.M. on 7/17/17 and throughout the day on 7/18/17. The DON said that while she was not certain how Resident #1 left the Facility unnoticed by staff, it was her assumption that Resident #1 got in the elevator unnoticed after the supper time meal truck was delivered and exited via the door to the loading bay. The DON said the Police have been unable to find Resident #1. The meal truck delivery schedule indicated the first meal truck is delivered to the locked unit at 4:40 P.M. Surveyor #1 interviewed Dietary Aide # 2 at 4:15 P.M. Dietary Aide #2 said he took the first truck to the locked unit at approximately 4:50 P.M. on 7/12/17. Dietary Aide #2 said as he stepped off the elevator he saw a number of residents standing around close to the elevator door. Dietary Aide #2 said he did not know Resident #1 or what he/she looked like, and could not say for certain Resident #1 was among the group of resident's next to the elevator door. Dietary Aide #2 said as he pushed the truck towards the nurse's station the elevator door closed behind him and he did not know if anyone got on the elevator. The HCA said when she visited Resident #1 maybe 2 or 3 weeks before Resident #1 eloped from the Facility, she had asked a nurse to let her on to the elevator to go off the unit. The HCA said the Nurse, who was sitting at the nurse's station, verbally give her the code and she, the HCA, then entered the code and got on the elevator. The HCA said Resident #1 and other residents were in the area at the time and it was very possible Resident #1 overheard the code and was able to enter the code to the elevator without staff noticing. The HCA said Resident #1 has no access to prescribed antipsychotic medications outside of the Facility and is very vulnerable, and at risk for harm to self or others when off his/her medications. Surveyor #1 interviewed Nurse #1 at 5:33 PM on 7/17/17 and at 3:40 P.M. on 7/18/17. Nurse #1 said that while she was searching the ground floor with a Police Officer, the Officer pushed on the exit door leading to the loading bay and the door opened without entering the security code. Surveyor #1 interviewed the Nurse Supervisor at 5:22 P.M. on 7/17/17 and at 12:35 P.M. on 7/18/17. The Nurse Supervisor said he checked the door to the loading bay after Nurse #1 told him the Police officer was able to open the door without entering the code. The Nurse Supervisor said the door frame to the loading bay door was broken and he was able to open the door without entering the code. Surveyor #1 toured the Facility with the Director of Maintenance at 10:35 A.M. on 7/18/17. The Director of Maintenance said the only security camera in the Facility, which was located at the front entrance, was broken. The Director of Maintenance said that the security code to the front entrance door was changed monthly but all other codes, including the elevator code to the locked unit and exit doors at the back of the building leading to the outside, were changed only as needed and had not been changed after Resident #1 eloped from the Facility on 7/12/17. While the Director of Maintenance did enter security codes to open exit doors leading to the outside, the Director of Maintenance said that the code on one of the two doors leading to the parking garage, which lead directly on to the street, could not be changed as the code pad was overloaded. The Director of Maintenance said he tightened the frame on the door leading to the loading bay but did not replace the code pad or reset the code as this was an unalarmed door with a lot of heavy traffic from vendors. The Director of Maintenance said he had started to check that door more frequently as there had been a lot of complaints that it was not always shut properly, sometimes it would open without entering the code and at other times would only open when the code was entered. The Director of Maintenance said that he checked that doors and codes were functioning properly on average of once a week. Review of Door Audit records provided by the Maintenance Director to Surveyor #1 indicated that audits included; date of check completed, if doors close, if code works, any comments or plan, and date of repair. Although documentation indicated that between 5/1/17 and 7/17/17 audits were conducted at least once a week, there was no documentation to support or indicate that doors were closed and codes were working and functioning properly. Surveyor #1 interviewed Resident #1's roommate at 11:10 A.M. on 7/18/17. The roommate said that although she did not see Resident #1 leave on 7/12/17, Resident #1 told her he/she was going to leave because his/her parents where away on a trip and he/she was afraid someone would break into their house. The roommate said no-one had asked her any questions about Resident #1 and said she had not shared this information with anyone prior to speaking to Surveyor #1. Surveyor #1 shared this information regarding Resident #1 with the Social Worker who then contacted the Police Department to do a wellness check. At 1:47 P.M. on 7/18/17 Surveyor #1 and the DON exited the elevator to the locked unit at which time the elevator alarm sounded active by a wanderguard on Resident #3 who was assessed at risk for elopement and was sitting by the elevator door. Surveyor #1 and DON remained at the elevator in order to prevent Resident #3 from entering the elevator. Staff were observed walking by the elevator and ignoring the sounding alarm. After a period of 3 minutes a male person, without a name badge approached and said he was new to the Facility and did not know the code but would find someone to help. He then approached a second male staff member, later identified as CNA #3, who was kneeling on the floor with his back to the elevator speaking to a resident. CNA #3 approached the elevator, turned off the alarm and said he was assigned to work the 3:00 P.M. to 11:00 P.M. shift but had come in early to help move new furniture which was delivered to the Facility earlier that day and was not directly assigned to care for residents at that time. At 1:55 P.M. the DON said to Surveyor #1 that the staff observed passing the elevator and ignoring the alarm were house-keeping staff. The DON said that 1 nurse and 2 CNA's were on lunch break, and the third CNA was supervising the resident smoke break in the assigned area in the garage, leaving only 1 nurse on the Unit at that time who had been in the bathroom and had not heard the elevator/wanderguard alarm sound. At 4:00 P.M. on 7/18/17 the Social Worker told Surveyor #1 that Police had contacted her and said they did a drive by of Resident #1's parents' house, there were no signs of anyone in the house at that time and no-one had answered the door. 2. Surveyor #2 interviewed Resident #4 at 2:49 P.M. on 7/24/2017. Resident #4 said he/she had asked a female staff member to heat his/her cup of coffee. Resident #4 said he/she took the cup of coffee from the female staff member, after she heated it, and proceeded to self-propel his/her wheelchair back to his/her room. Resident #4 said he/she bumped into the door of his/her room and spilled the coffee onto his/her left hand. Resident #4 said the coffee was too hot, or words to that effect, and he/she did not tell staff about the incident until the next day. Surveyor #2 interviewed Housekeeper #1, with interpreting assistance of the Housekeeping Supervisor at the request of Housekeeper #1, at 3:36 P.M. on 7/24/17. Housekeeper #1, who worked on Resident #4's unit on 7/20/17 and had been identified by the Facility as the staff person who heated Resident #4's coffee, said she did not remember heating a coffee, or any liquid, for any resident. Housekeeper #2 said she had never been educated by the Facility about heating liquids for residents and had not received any education about heating liquids as of the date of Survey, 7/24/17. Surveyor #2 interviewed the Director of Nurses (DON) at 4:05 P.M. on 7/24/17. The DON said Resident #4 informed the nursing staff on 7/21/17, he/she had spilled hot coffee on his/her person the day before, 7/20/17, after a housekeeper had heated his/her coffee which resulted in a burn to his/her left hand. A physician progress notes [REDACTED].#4 was assessed and noted to have redness on his/her left hand with a blister between his/her thumb and finger with skin opening and complaints of hand pain and swelling. The physician progress notes [REDACTED]. Physician order [REDACTED].#4 was prescribed dressing changes to his/her left hand, oral and topical antibiotics. Nurse Progress notes, dated 7/21/2017, indicated Resident #4 reported to the nursing staff he/she had spilled coffee on his/her left hand the day prior (7/20/2017). The Nurse Progress notes indicated Resident #4 was assessed and his/her left hand was noted to be edematous (swollen), with a pink, broken blister between his/her thumb and first digit. The Nurse Progress Note indicated the Physician and Nurse Practitioner (NP) were notified, NP assessed Resident #4 and new orders for oral and topical antibiotics were ordered for Resident #4 The Facility Investigation documentation, provided to Surveyor #2 on 7/24/17, indicated Resident #4 reported, on 7/21/17, he/she had sustained a burn injury which had occurred the day before when he/she spilled coffee on his/her person after the coffee had been heated by a housekeeper. The Facility Investigation documentation, which included Educational In-service Records dated 7/21/17, indicated staff were educated by the Facility on 7/21/17 that only nursing staff is to reheat resident's foods or liquids. The Educational In-service Records indicated Housekeeper #1 had not been provided with this education. 3. Surveyor #2 toured the Plunkett Nursing Unit, a secured unit with residents who had known cognitive impairment and [DIAGNOSES REDACTED].M. on 7/24/17. During this tour Surveyor #2 observed 2 shaving razors, with exposed razor blades, sitting on a sink in a hallway bathroom, across from room 208 and identified as a common bathroom for resident use. Surveyor #2 observed the toilet to be not flushed with yellow, urine smelling liquid and two candy wrappers in the toilet. Surveyor #2 interviewed the Social Worker at 8:20 A.M. on 7/24/17 on the Plunkett Nursing Unit. The Social Worker was shown Surveyor #2's observations of the resident bathroom located in the hallway across from room 208. The Social Worker said this bathroom was a common bathroom for use by any resident on the unit. The Social Worker said the unit was a secure unit with residents with known behavioral issues and psychiatric [DIAGNOSES REDACTED]. Surveyor #2 observed Nurse #5, at approximately 8:25 A.M. on 7/24/17, remove the razor blades from the bathroom on Plunkett unit and dispose of them in a sharps container located on a medication cart. Surveyor #2 informed the Administrator at 8:45 A.M. on 7/24/17 of the observations made in the bathroom on the Plunkett Nursing Unit. The Administrator accompanied Surveyor #2 to this bathroom and noted the contents inside of the toilet still contained yellow, urine smelling liquid and two candy wrappers.

Based on interviews and records reviewed, for 1 out of 3 sampled residents (Resident #1), the Facility failed to ensure laboratory blood tests were completed, as ordered by the Physician, which resulted in Resident #1 experiencing a significant change in status and being transferred to the Hospital. On 6/6/17 Resident #1 suffered a [MEDICAL CONDITION] and a cut to his/her left eyebrow, he/she was transferred to the Hospital for evaluation and treatment, where it was determined Resident #1 had a critically low blood sodium level and was admitted for treatment. Findings include: The Mayo Foundation for Medical Education and Research, dated 2017, indicated sodium plays a key role in the body. It helps maintain normal blood pressure, supports the work of nerves and muscles, and regulates the body's fluid balance. A normal sodium level is between 135 and 145 milliequivalents per liter (mEq/L) of sodium. [MEDICAL CONDITION] occurs when the sodium in your blood falls below 135 mEq/L. One of the causes of [MEDICAL CONDITION] is drinking too much water. Because you lose sodium through sweat, drinking too much water can dilute the sodium content of your blood. The Research indicated the signs and symptoms of [MEDICAL CONDITION] may include nausea, vomiting, headache, confusion, and [MEDICAL CONDITION]. The Policy titled Critical Test Values, revised 01/19/10, indicated the Facility would be responsible for obtaining laboratory test values from their laboratory service. The Facility's Laboratory Instructions Test Request protocol, located in the laboratory book on the unit, indicated, staff would place the laboratory test request forms under the correct numerical tab which correlated with the date the test was to be performed. Resident #1 was admitted to the Facility 11/1/16, [DIAGNOSES REDACTED]. A Laboratory Standing Order Form, dated 5/19/17, indicated, Resident #1 was to have a Basic Metabolic Panel (BMP) blood test performed every Monday, Wednesday, and Friday, which included Resident #1's blood sodium level. A Medication Administration Record (MAR) for Resident #1, dated 6/2017, indicated, BMP blood test every Monday, Wednesday, and Friday, monitor sodium levels and report low sodium level to the Medical Doctor immediately. The MAR indicated Resident #1's BMP was scheduled to be obtained on 6/2/17 and 6/5/17, however there were no initials by nurses to confirm the laboratory tests were obtained on those days, and the Facility was unable to provide documentation to support Resident #1's BMPs were obtained. Two Incident Reports, both dated 6/6/17, indicated Resident #1's BMP had not been obtained on 6/2/17 and 6/5/17, as ordered by the Physician and intended to monitor his/her sodium level. A Nurse Progress Note, dated 6/6/17, indicated, Resident #1 was found, on his/her bed, lethargic, with a cut on his/her left eyebrow, and having [MEDICAL CONDITION] activity. The note indicated, Resident #1 was transferred to the emergency room . A Hospital Discharge Summary, dated 6/10/17, indicated Resident #1 was admitted to the Hospital 6/6/17 with [DIAGNOSES REDACTED]. An Incident Review report, dated 6/28/17 and signed by the Director of Nurses, indicated Nurse #1 was assigned to Resident #1 on 6/2/17. The Surveyor interviewed Nurse #1 at 4:13 P.M., on 7/13/17. Nurse #1 said he could not recall if Resident #1's laboratory tests were ordered or obtained for 6/2/17. Nurse #1 said as the nurse assigned to Resident #1 he was responsible to ensure that blood laboratory tests were performed, and if not, he would call the Physician to obtain orders for the blood laboratory tests to be performed immediately. An Incident Review report, dated 6/28/17 and signed by the Director of Nurses, indicated Nurse #2 was assigned to Resident #1 on 6/5/17. The Surveyor interviewed Nurse #2 at 4:46 P.M., on 7/13/17. Nurse #2 said he could not recall if Resident #1's laboratory tests were ordered or obtained for 6/5/17 The Surveyor interviewed Unit Manager #1 at 11:13 A.M., on 7/10/17. Unit Manager #1 said the laboratory paperwork slips were supposed to be filed under the corresponding days of the month in the laboratory book. Unit Manager #1 said she worked on 6/1/17, and had forgotten to file the monthly laboratory slips in the laboratory book, and did not return to work after that day. The Surveyor interviewed the Director of Nurses at 8:50 A.M., and throughout the day on 7/10/17. The Director of Nurses said the laboratory test forms should have been filed in the laboratory book on the unit, and the nurses assigned to Resident #1 should have noticed the order on the MAR and checked to ensure the laboratory tests had been performed.

Based on record review and interview for one of four sampled residents (Resident #1), the Facility failed to implement Resident #1's Care Plan for Elopement Risk. At approximately 2:55 P.M., Resident #1 climbed through an unsecured dining room window in the building's secure unit. Resident #1 landed on the ground and sustained a non-displaced medial malleolus fracture (ankle fracture). Resident #1's Care Plan for Elopement Risk required that he/she not leave the Facility unattended and ancillary staff would be aware of Resident #1's risk for elopement. Findings include: Resident #1's Psychiatric Assessment, dated 2/4/16, indicated a [DIAGNOSES REDACTED]. Resident #1's Elopement Risk Assessment, dated 2/4/16, indicated he/she was at risk for elopement. Resident #1's Plan of Care for Elopement Risk, dated 2/5/16, indicated he/she had a history of [REDACTED].#1 would not leave the Facility unattended and ancillary staff would be aware of Resident #1's risk for elopement. The Surveyor interviewed the Unit Manager at 10:30 A.M. on 2/23/16. The Unit Manager said that Resident #1 was placed on the Facility's locked unit because he/she had eloped from a hospital a couple of times. The Unit Manager said that Resident #1 talked every day about wanting to leave the Facility and he/she was considered an elopement risk. The Unit Manager said that at approximately 2:55 P.M. on 2/16/16, she asked Maintenance Staff #1 to fix a [MEDICATION NAME] which was supposed to block the dining room window from opening beyond six inches. The Unit Manager said that Maintenance Staff #1 left the dining room to get the tools he needed for the job. The Unit Manager said she also left the dining room and returned to the nursing station. The Unit Manager said that approximately one minute after leaving the dining room an overhead page indicated that Resident #1 had eloped from the building. The Surveyor interviewed Maintenance Staff #1 at 11:15 A.M. on 2/23/16 and again at 2:12 P.M. on 2/25/16. Maintenance Staff #1 said that at approximately 2:15 P.M. on 2/16/16, he was on Resident #1's unit, next to the nursing station, and he saw the Unit Manager on the telephone behind the nursing station beginning to page his name. Maintenance Person #1 said he interrupted the Unit Manager to let her know he was here. Maintenance Staff #1 said that the Unit Manager handed him a window [MEDICATION NAME] and brought him down to the dining room and asked if he could drill the window [MEDICATION NAME] back into the window track. Maintenance Staff #1 said there was no [MEDICATION NAME] in the window track. Maintenance Staff #1 said he left the dining room to go to his workshop to get a drill and find screws for the [MEDICATION NAME]. Maintenance Staff #1 said that approximately 2 minutes later he returned to the dining room with a drill and screws. Maintenance Staff #1 said he noticed that the window was wide open and when he walked over to it he looked out and saw a resident standing next to the Facility's perimeter fence. Maintenance Staff #1 said he did not know Resident #1, or that he/she was at risk for elopement. Maintenance Staff #1 said the Facility had not provided an in-service or other means of communication or education to inform him of who was at risk for elopement. Maintenance Staff #1 said he assumed that everyone on the secured unit was at risk for elopement and those with a wanderguard were especially at-risk for elopement. The Unit Manager said that after the incident she asked Resident #1 if he/she escaped from the building through the window and Resident #1 replied, You bet your ass I did. Resident #1's nurse's note, dated 2/16/16, indicated an X-ray report determined Resident #1 had a non-displaced medial malleolus fracture (ankle fracture).

Based on record review and interview for one of four sampled residents (Resident #1), the Facility failed to supervise and prevent Resident #1 from climbing out of an unsecured second floor window from the building's secured unit. At approximately 2:55 P.M., on 2/16/16, staff noticed that the window stopper to the secured unit's dining room window was detached and in the process of the repair staff left Resident #1 without supervision in the room. Resident #1 climbed out of the unsecured window and landed on the ground and sustained a non-displaced medial malleolus fracture (ankle fracture). Resident #1 was at risk for elopement. Findings include: Resident #1's Elopement Risk Assessment, dated 2/4/16, indicated he/she was at risk for elopement. Resident #1's Plan of Care for Elopement Risk, dated 2/5/16, indicated he/she had a history of [REDACTED].#1 would not leave the Facility unattended and ancillary staff would be aware of Resident #1's risk for elopement. The Surveyor interviewed the Unit Manager at 10:30 A.M. on 2/23/16. The Unit Manager said that Resident #1 was placed on the Facility's locked unit because he/she had eloped from a hospital a couple of times. The Unit Manager said that Resident #1 talked every day about wanting to leave the Facility and he/she was considered an elopement risk. The Unit Manager said that at approximately 2:55 P.M. on 2/16/16, a Visitor approached her at the nursing station and told her that Resident #1 was in the dining room and angry. The Unit Manager said she entered the dining room and observed Resident #1 sitting in a chair, drinking coffee and he/she appeared calm. The Unit Manager said another resident in the room told her that Resident #1 threw a bag out the window. The Unit Manager said she looked out the window and saw a plastic bag, of what appeared to be clothing, on the ground. The Unit Manager said the window only opened about six inches. The Unit Manager said she asked Resident #1 what was the matter and Resident #1 shrugged his/her shoulders, and appeared calm. The Unit Manager said she asked Maintenance Staff #1 to fix the stopper which blocked the dining room window from opening beyond six inches. The Unit Manager said that Maintenance Staff #1 left the dining room to get the tools he needed for the job. The Unit Manager said she also left the dining room and returned to the nursing station. The Unit Manager said that approximately one minute after leaving the dinging room an overhead page indicated that Resident #1 had eloped from the building. The Surveyor interviewed Maintenance Staff #1 at 11:15 A.M. on 2/23/16. Maintenance Staff #1 said that during the afternoon on 2/16/16, he was on Resident #1's unit, next to the nursing station, and he saw the Unit Manager speaking on the telephone and beginning to page his name. Maintenance Staff #1 said he interrupted the Unit Manager to let her know he was here. Maintenance Staff #1 said that the Unit Manager handed him a window stopper and brought him down to the dining room and asked if he could drill the window stopper back into the window track. Maintenance Staff #1 said there was no stopper in the window track. Maintenance Staff #1 said there were two holes in the window stopper for screws, but there were no screws in the stopper and no screws on the floor near the window or on the window track. Maintenance Staff #1 said he left the dining room to go to his workshop to get a drill and find screws for the stopper. Maintenance Staff #1 said that approximately 2 minutes later he returned to the dining room with a drill and screws. Maintenance Staff #1 said he noticed that the window was wide open and when he walked over to it he looked out and saw a resident standing next to the Facility's perimeter fence. The Surveyor re-interviewed Maintenance Staff #1 at 2:12 P.M. on 2/25/16, and he remained consistent with his account of the incident. The Unit Manager told the Surveyor that after the incident she asked Resident #1 if he/she escaped from the building through the window and Resident #1 replied, You bet your ass I did. Resident #1's nurse's note, dated 2/16/16, indicated an X-ray report determined Resident #1 had a non-displaced medial malleolus fracture (ankle fracture).

Based on record review and interviews for one of three samples residents (Resident #1), the Facility failed to ensure the Guardian was provided crucial information before consenting to Resident #1 leaving the Facility with Family Member #1, who had previously abandoned Resident #1 while on leave in January 2013. On 5/29/13, the Facility staff allowed Resident #1 to leave the Facility again with Family Member #1 and he/she was not assisted back to the Facility by Family Member #1, and his/her whereabouts was unknown to the Facility for more than 48 hours. As reasonable person would experience emotional harm as a result of being abandoned and without shelter, medications, and nourishment. Findings include: The physician orders, dated 5/1/13 to 5/31/13, indicated Resident #1's [DIAGNOSES REDACTED]. The Letter of Guardianship for an Incapacitated Person Form, dated 7/17/12, indicated Resident #1 had a permanent Guardian. The Guardianship form indicated Resident #1 was determined to be incapacitated; the powers and duties of the Guardian were not limited; and the admission of Resident #1 to a nursing facility was in the best interest of Resident #1. The nurse's note, dated 1/27/13, indicated Resident #1 was alert and oriented and ambulated with a walker. The note indicated Resident #1 was signed out by Family Member #1 at 9:00 A.M. on 1/27/13. The note indicated at 5:00 P.M. on 1/27/13, Family Member #1 was seen leaving the Facility. The note indicated it was assumed that Family Member #1 brought Resident #1 back to the Facility, but at 6:00 P.M., it was determined Resident #1 could not be located. The note indicated Family Member #1 informed Facility staff he left Resident #1 alone and in a train station. The nurse's note, dated 1/28/13, indicated Resident #1 returned to the Facility and informed the staff he/she and Family Member #1 got into an argument while on leave and Family Member #1 left Resident #1 in a train station. The note indicated Resident #1 asked a police officer for assistance to return to the Facility. The quarterly Minimum Date Set (MDS) assessment, dated 5/2/13, indicated Resident #1 scored 14 out of 15 on the brief interview for mental status (BIMS); had disorganized thinking, which fluctuated; and presented with symptoms of feeling down, depressed, or hopeless during the assessment period. The social worker note, dated 5/23/13, indicated the interdisciplinary team discussed the risks and benefits of Resident #1 having independent privileges and determined Resident #1 was physically capable for independent leave of absences. The team indicated the risks and benefits would be discussed with Resident #1's Guardian who will have the responsibility of approving or declining Resident #1's request. The Surveyor interviewed the Unit Manager on 6/4/13. The Unit Manager said on 5/29/13 at approximately 11:40 A.M., Resident #1 and Family Member #1 approached the nurses' station and informed her they planned to leave the Facility to do complete errands. Family Member #1 they did not provide any specific information regarding anticipated length of time away from the Facility, but told her he thought they would be away from the Facility all day. The social worker progress note, dated 5/29/13, indicated Social Worker #1 and the Guardian discussed Resident #1 going out with Family Member #1 to visit family and do errands, and gave verbal consent to the family outings. There was no documentation to indicate the Guardian was aware of the circumstances surrounding Family Member #1 and Resident #1's previous outing in January 2013, or that Family Member #1 was the same person who previously abandoned Resident #1 while on a social leave of absence. The Resident Sign Out Log Entry, dated 5/29/13, indicated Family Member #1 documented in the log that he left the Facility with Resident #1 at 11:40 A.M., with an anticipated return of 8:00 P.M. on the same day. The log indicated the destination was a different city than where the Facility was located; and included a cellular telephone number for Family Member #1. The nurse's note, dated 5/29/13, indicated Resident #1 left the Facility at 11:40 A.M. with Family Member #1. The nurse's note, dated 5/29/13, indicated at 4:30 P.M., Family Member #1 called the Facility and spoke with Nurse #1 and told Nurse #1 he called 911 for Resident #1 while on the leave, because Resident #1 complained of not feeling well, but Family Member #1 said he left Resident #1 before the ambulance arrived. The note indicated that at 10:30 P.M. on 5/29/13, the police informed Nurse #1 that the person who took Resident #1 out of the Facility was not a family member of Resident #1 and the name being used by Family Member #1 was false. The Surveyor interviewed Social Worker #1 at 5:32 P.M. on 5/31/13 and at 1:35 P.M. on 6/4/13. Social Worker #1 said she was Resident #1's Social Worker, and Resident #1 had poor insight, short-term memory deficits, and a history of [MEDICAL CONDITION] and as a result, had a court appointed Guardian. Social Worker #1 said since Resident #1's admission to the Facility, Resident #1 was very unhappy. Social Worker #1 said because of Resident #1's being unhappy, they tried to work with Resident #1 to allow Resident #1 to have more independence. Social Worker #1 said on 5/29/13, Resident #1's family member came to take Resident #1 out of the Facility on social leave of absence. Social Worker #1 said Resident #1 left with Family Member #1 on 5/29/13, but never returned him/her to the Facility but instead, left Resident #1 in another city, but did not disclose the location of where he last was with Resident #1. Social Worker #1 said the last time Resident #1 left the Facility with Family Member #1 was in January 2013, and Family Member #1 left Resident #1 unsupervised and did not return him/her to the Facility. Social Worker #1 said at the time, Resident #1 asked a police office for assistance and was transferred to the hospital for an evaluation before returning to the Facility. Social Worker #1 said upon Resident #1's return, Social Worker #1 said she talked with Resident #1. Social Worker #1 said Resident #1 told her that while on leave, Family Member #1 asked Resident #1 for money and they ended up in a fight, and Family Member #1 left Resident #1 (without ensuring his/her safe return to the Facility). Social Worker #1 said after the January 2013 incident, Resident #1 was not allowed to leave the Facility. Social Worker #1 said some time prior to 5/29/13, the team at the Facility decided they wanted to try to allow Resident #1 more community access with structure, and Social Worker #1 spoke with Resident #1's Guardian regarding the team's decision. Social Worker #1 said Resident #1 was determined by physical therapy to be able to safely walk to a local store and back. There was no documentation to indicate Resident #1 was assessed to determine his/her ability to manage public transportation or elicit assistance should he require it when on a leave of absence from the Facility. There was no indication Resident #1 had the physical, mental, or financial means to utilize public transportation to get back to the Facility should Family Member #1 abandoned Resident #1 and did not ensure Resident #1's safe return to the Facility. Social Worker #1 said she discussed with the Guardian the risks and benefits of Resident #1 being allowed to leave and Resident #1's Guardian consented to Resident #1 leaving the Facility with Family Member #1, but this conversation occurred at approximately 3:30 P.M. to 4:00 P.M. on 5/29/13, which was after Resident #1 already was allowed to leave the Facility with Resident #1. Social Worker #1 said she was not sure whether the Guardian was aware at the time she gave consent that Family Member #1 was the same family member who in January 2013, abandoned Resident #1 in another city. Social Worker #1 said she did not have a conversation with the Guardian regarding the details and events of Resident #1's last leave with Family Member #1. Social Worker #1 said she was informed by the Unit Manager that Resident #1 left with Family Member #1, after Resident #1 was already out of the Facility. The Surveyor interviewed the Physician at 6:35 P.M. on 5/31/13. The Physician said gave an order for [REDACTED]. The Physician said he would rely on the facility staff to have determined this prior to allowing any resident, including Resident #1 leave. The Physician said he was not aware that Family Member #1 was the same person who abandoned Resident #1 in January and had no prior knowledge of that event. The Physician said Family Member #1 clearly demonstrated to the Facility in January 2013 that he was not a responsible person and therefore, should never had been allowed to take Resident #1 out of the Facility on a leave. The Physician said one time abandoning Resident #1 was more than enough, and there should never have been a second time. The Physician said he would have expected the Facility staff share the information about the January 2013 incident, with whoever gave the order for Resident #1 to leave with a responsible person. The Surveyor interviewed Nurse #1 at 7:05 P.M. on 5/31/13 and Nurse #2 in person at 7:30 P.M. on 5/31/13. Nurse #1 and Nurse #2 said they worked the afternoon Resident #1 left the Facility with Family Member #1. Nurse #1 said at approximately 4:30 P.M., Family Member #1 called her and informed her that he left Resident #1 after calling 911 because Resident #1 was unable to stand while on leave. Nurse #1 said Family Member #1 informed her that at the time of the call, Resident #1 was being transported in an ambulance to the hospital. Nurse #1 said the Physician was present and she informed the Physician. Nurse #1 said Family Member #2 told her that he was on a bus and did not know where Resident #1 was being taken. Nurse #1 and Nurse #2 said as of 5/31/13, Resident #1's whereabouts remained unknown. The Surveyor interviewed the Director of Nurses (DON) at 7:50 P.M. on 5/31/13. The DON said she was informed Resident #1 wanted to leave with Family Member #1. The DON was asked by the Surveyor what defined a "responsible person" and the DON responded, words to the effect of, "the Guardian would choose who was considered responsible." The DON said she never spoke with the Guardian about Resident #1 being allowed to leave the Facility with Family Member #1, but said Social Worker #1 informed the Guardian. The Surveyor interviewed Resident #1's Guardian at 5:23 P.M. on 6/3/13. The Guardian said she had no knowledge of Resident #1 being taken out of the Facility on 1/27/13 or that Resident #1 was left in a train station while on leave with Family Member #1. The Guardian said she recalled one occasion when Resident #1 left the Facility and asked for assistance from a police officer to return, but she did not know Family Member #1 was involved. The Guardian said she did not know that while on leave from the Facility in January 2013, Family Member #1 asked Resident #1 for money, fought with Resident #1, and left Resident #1 alone. The Guardian said the first learned of the January 2013 incident during the interview with the Surveyor on 6/3/13. The Guardian said that at 3:59 P.M. on 5/29/13 she spoke with Social Worker #1 who asked her if Resident #1 could leave the Facility with Family Member #1. The Guardian said she was informed by Social Worker #1 that Family Member #1 came to the Facility to visit Resident #1, prior to the request to be able to leave with Family Member #1 and Social Worker #1 gave the Guardian no indication of any previous concerns. The Guardian said the first thing she asks a Facility before giving consent for a leave, is whether the person asking to take the resident in known to the staff, and that staff obtain the person's telephone number, address, cellular number, destination, and obtain a time-table regarding when they will return. The Guardian said normally she established parameters for a resident to be able to leave and spoke with Social Worker #1 about parameters for Resident #1 to be able to leave. The Guardian said she was not informed at the time of her conversation with Social Worker #1, that Resident #1 was already out of the Facility on a leave of absence. The Guardian said she would not have given consent for Resident #1 to leave the Facility at all, let alone with Family Member #1, had she been aware of the details regarding the January 2013 leave. See F 323.

Based on record review and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1's was Guardian informed of significant incidents involving Resident #1. On 1/27/13 Family Member #1 took Resident #1, a resident with dementia, out for a social leave, and during the leave left Resident #1 in a train station alone. The Facility did not notify the Guardian on 5/29/13, when Family Member took Resident #1 out for another social leave, until four hours after Resident #1 was gone from the Facility. During the second leave, Family Member #1 left Resident #1 and Resident #1's whereabouts remained unknown for more than 48 hours. In addiction, the Physician was not immediately informed of resident #1 being abandoned by Family Member #1 while on a leave on 5/29/13 and that as of 5/31/13, his/her whereabouts remained unknown. Findings include: The physician orders, dated 5/1/13 to 5/31/13, indicated Resident #1's [DIAGNOSES REDACTED]. The Letter of Guardianship for an Incapacitated Person Form, dated 7/17/12, indicated Resident #1 had a permanent Guardian. The Guardianship form indicated Resident #1 was determined to be incapacitated; the powers and duties of the Guardian were not limited; and the admission of Resident #1 to a nursing facility was in the best interest of Resident #1. The nurse's note, dated 1/27/13, indicated Resident #1 was alert and oriented and ambulated with a walker. The note indicated Resident #1 was signed out by Family Member #1 at 9:00 A.M., and at 5:00 P.M., Family Member #1 was observed leaving the Facility, but at 6:00 P.M., it was determined Resident #1 could not be located. The note indicated Family Member #1 informed Facility staff he left Resident #1 alone and in a train station. The nurse's note, dated 1/28/13, indicated Resident #1 returned to the Facility and informed the staff he/she and Family Member #1 got into an argument while on leave and Family Member #1 left Resident #1 in a train station. The note indicated Resident #1 asked a police officer for assistance to return to the Facility. The quarterly Minimum Date Set (MDS) assessment, dated 5/2/13, indicated Resident #1 scored 14 out of 15 on the brief interview for mental status (BIMS); had disorganized thinking, which fluctuated; and presented with symptoms of feeling down, depressed, or hopeless during the assessment period. The social worker note, dated 5/23/13, indicated the interdisciplinary team discussed the risks and benefits of Resident #1 having independent privileges and Resident #1 was physically capable for independent leave of absences. The team indicated the risks and benefits would be discussed with Resident #1's Guardian who will have the responsibility of approving or declining Resident #1's request. The Surveyor interviewed the Unit Manager on 6/4/13. The Unit Manager said on 5/29/13 at approximately 11:40 A.M., Resident #1 and Family Member #1 approached the nurses' station and informed her they planned to leave the Facility to do errands. Family Member #1 they did not provide any specific information regarding anticipated length of time away from the Facility, but told her he thought they would be away from the Facility all day. The Unit Manager said she did not speak with the Guardian to obtain approval for Resident #1 to leave with Family Member #1 on 5/29/13. The Resident Sign Out Log Entry, dated 5/29/13, indicated Family Member #1 documented in the log that he left the Facility with Resident #1 at 11:40 A.M., with an anticipated return of 8:00 P.M. on the same day. The log indicated the destination was a different city than where the Facility was located; and included a cellular telephone number for Family Member #1. The nurse's note, dated 5/29/13, indicated Resident #1 left the Facility at 11:40 A.M. with Family Member #1 and at 2:30 P.M., Family Member #1 was called and informed the nurse Resident #1 was okay and they would be out for awhile longer. The nurse's note, dated 5/29/13, indicated at 4:30 P.M., Family Member #1 called the Facility and spoke with Nurse #1. The note indicated Family Member #1 told Nurse #1 he called 911 for Resident #1 while on the leave, because Resident #1 complained of not feeling well. The note indicated Family Member #1 said he left Resident #1 before the ambulance arrived. The note indicated the nursing staff contacted local hospitals, spoke on more than one occasion with Family Member #1, and contacted the police. The Surveyor interviewed Social Worker #1 at 5:32 P.M. on 5/31/13 and at 1:35 P.M. on 6/4/13. Social Worker #1 said she was Resident #1's Social Worker, and Resident #1 had poor insight, short-term memory deficits, and a history of [MEDICAL CONDITION] and as a result, had a court appointed Guardian. Social Worker #1 said on 5/29/13, Resident #1's family member came to take Resident #1 out of the Facility on social leave of absence. Social Worker #1 said she discussed with the Guardian the risks and benefits of Resident #1 being allowed to leave and Resident #1's Guardian consented to Resident #1 leaving the Facility with Family Member #1, but this conversation occurred at approximately 3:30 to 4:00 P.M. on 5/29/13, which was after Resident #1 already was allowed to leave the Facility with Resident #1. Social Worker #1 said she did not inform the Guardian that Resident #1 was already on the leave at the time of the call. Social Worker #1 said Unit Manager #1 told her she did not call the Guardian to obtain the Guardian's consent prior to Resident #1 leaving the Facility with Family Member #1. The Surveyor interviewed the Physician at 6:35 P.M. on 5/31/13. The Physician said he was not aware that Family Member #1 was the same Family Member who abandoned Resident #1 in January and had no prior knowledge of the event. The Physician said Family Member #1 clearly demonstrated to the Facility in January 2013 that he was not a responsible person and therefore, should never had been allowed to take Resident #1 out of the Facility on a leave. The Physician said he would have expected the Facility staff share the information about the January 2013 incident, when calling to obtain an order for [REDACTED]. The Surveyor interviewed the Director of Nurses (DON) at 7:50 P.M. on 5/31/13. The DON said she never spoke with the Guardian about Resident #1 being allowed to leave the Facility with Family Member #1, but said Social Worker #1 informed the Guardian. The Surveyor interviewed Resident #1's Guardian at 5:23 P.M. on 6/3/13. The Guardian said she maintained telephone call logs of all calls received by her office. The Guardian said review of the telephone call logs for January 2013, indicated she received a call at 7:05 P.M. on 1/27/13, which indicated, "calling about one of your guardians." The Guardian said the name of the facility, the person calling, and the resident involved was not included in the message. The Guardian said she had no knowledge of Resident #1 being taken out of the Facility on 1/27/13 or that Resident #1 was left in a train station while on leave with Family Member #1. The Guardian said she recalled one occasion when Resident #1 left the Facility and asked for assistance from a police officer to return, but she did not know Family Member #1 was involved. The Guardian said she did not know that while on leave from the Facility in January 2013, Family Member #1 asked Resident #1 for money, fought with Resident #1, and left Resident #1. The Guardian said the first learned of the January 2013 incident during the interview with the Surveyor on 6/3/13. The Guardian said that at 3:59 P.M. on 5/29/13, she spoke with Social Worker #1 who asked her if Resident #1 could leave the Facility with Family Member #1. She was not informed at the time that Resident #1 was already out of the Facility on a leave of absence. The Guardian said the first time she learned that Resident #1 did not return to the Facility with Family Member #1 was through a voice mail message left at 12:52 P.M. on 5/30/13. The Guardian said on 5/31/13 at 10:30 P.M. she was informed Resident #1 returned to the Facility. The Guardian said she was not informed that Resident #1 returned appearing intoxicated or his/her condition upon returning to the Facility or that Resident #1 was transferred to two different hospitals t to be evaluated. See F 323.

Based on record review and interviews for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 left the Facility with a responsible person. In January 2013, Resident #1, who had a Guardian and [DIAGNOSES REDACTED].#1. The Facility allowed Resident #1 to leave the Facility again with Family Member #1 and was again not assisted back to the Facility by Family Member #1, and his/her whereabouts was unknown to the Facility for more than 48 hours. As reasonable person would experience emotional harm as a result of being abandoned and without shelter, medications, and nourishment. The Guardian was not informed of the January 2013 with Family Member and was notified four hours after Resident #1 left the Facility with Family Member #2. The Physician said Resident #1 had an order to leave the Facility with a responsible person, but would not consider Family Member #1 a responsible person. Findings include: The physician orders, dated 5/1/13 to 5/31/13, indicated Resident #1's [DIAGNOSES REDACTED]. The Letter of Guardianship for an Incapacitated Person Form, dated 7/17/12, indicated Resident #1 had a permanent Guardian. The Guardianship form indicated Resident #1 was determined to be incapacitated; the powers and duties of the Guardian were not limited; and the admission of Resident #1 to a nursing facility was in the best interest of Resident #1. The nurse's note, dated 1/27/13, indicated Resident #1 was alert and oriented and ambulated with a walker. The note indicated Resident #1 was signed out by Family Member #1 at 9:00 A.M., and later at 5:00 P.M., Family Member #1 was seen leaving the Facility. The note indicated it was assumed that Family Member #1 brought Resident #1 back to the Facility, but at 6:00 P.M., it was determined Resident #1 could not be located. The note indicated Family Member #1 informed Facility staff he left Resident #1 alone and in a train station. The nurse's note, dated 1/28/13, indicated Resident #1 returned to the Facility and informed the staff he/she and Family Member #1 got into an argument while on leave and Family Member #1 left Resident #1 in a train station. The note indicated Resident #1 asked a police officer for assistance to return to the Facility. The note indicated Family Member #1 was not contacted regarding the incident because the Facility did not have a contact number for Family Member #1. The physician telephone order, dated 1/28/13, indicated Resident #1 was not to have any leave of absence privileges and his/her plan of care was updated to include the use of wanderguard device at all times. The quarterly Minimum Date Set (MDS) assessment, dated 5/2/13, indicated Resident #1 scored 14 out of 15 on the brief interview for mental status (BIMS); had disorganized thinking, which fluctuated; and presented with symptoms of feeling down, depressed, or hopeless during the assessment period. The social worker progress note, dated 5/13/13, indicated Resident #1 requested independent privileges outside of the Facility, which included being able to go to a store. The social worker progress note, dated 5/14/13, indicated Resident #1's Guardian consented to Resident #1 beginning the community assessment process. The outpatient rehabilitation evaluation, dated 5/21/13, indicated Resident #1 was referred to determine Resident #1's safety outdoors and his/her ability to walk to the convenience store and back, and to assess Resident #1's balance and endurance. The evaluation indicated Resident #1 ambulated with SC (straight cane) independently; had a steady gait on uneven sidewalks, curbs, and crossing street and entering and exiting the store. The evaluation indicated Resident #1 was functionally capable of safely walking to and from the Facility to the convenient store and back, which was located on the same street as the Facility. The physician's telephone order, dated 5/22/13, indicated Resident #1 may have a leave of absence with a responsible person. The social worker note, dated 5/23/13, indicated the interdisciplinary team discussed the risks and benefits of Resident #1 having independent privileges and Resident #1 was physically for independent leave of absences. The team indicated the risks and benefits would be discussed with Resident #1's Guardian who will have the responsibility of approving or declining Resident #1's request. The Surveyor interviewed the Unit Manager at 2:12 P.M. on 6/4/13. The Unit Manager said Resident #1 moved to her unit the end of April 2013 or May 2013. The Unit Manager said she obtained the 5/22/13 order for Resident #1 to leave the Facility with a responsible person. The Unit Manager said a family member who left a resident on a previous leave of absence would not be someone she would consider as being a responsible person and therefore would be unable to take a resident out of the Facility. The Unit Manager said that at the time she spoke with the Physician to obtain the order for the social leave on 5/22/13, she did not inform or have a conversation with, the Physician regarding Family Member #1 or issues with a previous leave of absence with Family Member #1 (the 1/27/13 incident), because she was not aware of the incident until after 5/29/13, when Resident #1 did not return to the Facility. The Unit Manager said on 5/29/13 at approximately 11:40 A.M., Resident #1 and Family Member #1 approached the nurses' station and informed her they planned to leave the Facility to do errands, which included going to the bank and drug store. Family Member #1 did not provide to the staff any specific information regarding anticipated length of time away from the Facility, but told the Unit Manager he thought they would be away from the Facility all day. The Unit Manager said she did not speak with the Guardian to obtain approval for Resident #1 to leave with Family Member #1 on 5/29/13. The Unit Manager said Social Worker #1 told her, during previous conversations with the Unit Manager, Resident #1's Guardian approved for Resident #1 to have social leave of absences from the Facility, with Family Member #1. The social worker progress note, dated 5/29/13, indicated Social Worker #1 and the Guardian discussed the risks and benefits associated with leave of absences and the Guardian approved for Resident #1 to go out independently. The note indicated Social Worker #1 and the Guardian discussed limitations that would help structure Resident #1's outings and make them more purposeful while minimizing risks (eg. Two hour intervals, etc). The note indicated Social Worker #1 and the Guardian discussed Resident #1 going out with Family Member #1 to visit family and do errands, and gave verbal consent to the family outings. There was no documentation to indicate any discussions with Resident #1's Guardian, regarding the circumstances surrounding Family Member #1 and Resident #1's previous outing in January 2013, and that Family Member #1 was the same person who abandoned Resident #1 while on an outing. The Resident Sign Out Log Entry, dated 5/29/13, indicated Family Member #1 documented in the log that he left the Facility with Resident #1 at 11:40 A.M., with an anticipated return of 8:00 P.M. on the same day. The log indicated the destination was a different city than where the Facility was located; and included a cellular telephone number for Family Member #1. The nurse's note, dated 5/29/13, indicated Resident #1 left the Facility at 11:40 A.M. with Family Member #1 and at 2:30 P.M., Family Member #1 was called and informed the nurse Resident #1 was okay and they would be out for awhile longer. The nurse's note, dated 5/29/13, indicated at 4:30 P.M., Family Member #1 called the Facility and spoke with Nurse #1. The note indicated Family Member #1 told Nurse #1 he called 911 for Resident #1 while on the leave, because Resident #1 complained of not feeling well. The note indicated Family Member #1 said he left Resident #1 before the ambulance arrived because he had to, "jump on the bus." The note indicated the nursing staff contacted local hospitals, spoke on more than one occasion with Family Member #1, and contacted the police. The note indicated that at 10:30 P.M. on 5/29/13, the police informed Nurse #1 that the person who took Resident #1 out of the Facility was not a family member of Resident #1 and the name being used by Family Member #1 was false. The Surveyor interviewed Social Worker #1 at 5:32 P.M. on 5/31/13 and at 1:35 P.M. on 6/4/13. Social Worker #1 said she was Resident #1's Social Worker, and Resident #1 had poor insight, short-term memory deficits, and a history of alcohol abuse and as a result, had a court appointed Guardian. Social Worker #1 said since Resident #1's admission to the Facility, Resident #1 was very unhappy. Social Worker #1 said because of Resident #1's being unhappy, the team tried to work with Resident #1 to allow Resident #1 to have more independence. Social Worker #1 said on 5/29/13, Resident #1's family member came to take Resident #1 out of the Facility on a social leave of absence. Social Worker #1 said the nurses informed her that, Family Member #1 told the nurses he planned to take Resident #1 to obtain a birth certificate and visit Resident #1's sister. Social Worker #1 said she did not have any conversations with Family Member #1 prior to Resident #1 leaving on 5/29/13. Social Worker #1 said Resident #1 left with Family Member #1 on 5/29/13, but never returned him/her to the Facility. Social Worker #1 said the nurses told her Family Member #1 called Nurse #1 and told her that while out, Resident #1 had difficulty walking. Social Worker #1 said Family Member #1 activated emergency medical services EMS, by calling 911, but did not remain with Resident #1 because he had to, words to the effect of, "catch a bus," and left Resident #1 in a public area in another city, but did not disclose the location of where he last was with Resident #1. Social Worker #1 said the last time Resident #1 left the Facility with Family Member #1 was in January 2013, and Family Member #1 left Resident #1 unsupervised and did not return him/her to the Facility. Social Worker #1 said at the time, Resident #1 asked a police office for assistance and was transferred to the hospital for an evaluation before returning to the Facility. Social Worker #1 said upon Resident #1's return Social Worker #1 said she talked with Resident #1. Social Worker #1 said Resident #1 told her that while on leave, Family Member #1 asked Resident #1 for money and they ended up in a fight, and Family Member #1 left Resident #1 (without ensuring his/her safe return to the Facility). Social Worker #1 said she did not speak with Family Member #1 about leaving Resident #1 alone and unsupervised when he last took Resident #1 out of the Facility in January 2013. Social Worker #1 said after the January 2013 incident, Resident #1 was not allowed to leave the Facility. Social Worker #1 said prior to 5/29/13, the team at the Facility decided they wanted to try to allow Resident #1 more community access with structure, and Social Worker #1 spoke with Resident #1's Guardian regarding the team's decision. Social Worker #1 said Resident #1 was determined by physical therapy to be able to safely walk to a local store and back. There was no documentation to indicate Resident #1 was assessed to determine his/her ability to manage public transportation or elicit assistance should he require it when on a leave of absence from the Facility. There was no indication Resident #1 had the physical, mental, or financial means to utilize public transportation to get back to the Facility should Family Member #1 abandoned Resident #1 and did not ensure Resident #1's safe return to the Facility. Social Worker #1 said she discussed with the Guardian the risks and benefits of Resident #1 being allowed to leave the Facility and Resident #1's Guardian consented to Resident #1 leaving the Facility with Family Member #1, but this conversation occurred at approximately 3:30 P.M. to 4:00 P.M. on 5/29/13, which was after Resident #1 already was allowed to leave the Facility with Family Member #1. Social Worker #1 said she was not certain the Guardian was aware at the time she gave consent, that Family Member #1 was the same family member who in January 2013, abandoned Resident #1 in another city. Social Worker #1 said she did not have a conversation with the Guardian regarding the details and events of Resident #1 last leave with Family Member #1. Social Worker #1 said she was informed by the Unit Manager that Resident #1 left with Family Member #1, after Resident #1 was already out of the Facility. Social Worker #1 said she thought the Unit Manager did not know Resident #1 had a Guardian, but the Guardian needed to provide consent prior to Resident #1 being allowed to leave the Facility. Social Worker #1 said she did not know whether any education was provided to Family Member #1 regarding how to supervise Resident #1 while out on leave. Social Worker #1 said when asked by the Surveyor how she determined Family Member #1 to be considered a responsible person, Social Worker #1 responded words to the effect of Resident #1, "wanted to be with him." The Surveyor interviewed the Physician at 6:35 P.M. on 5/31/13. The Physician said he was not aware that as of 5/31/13, staff did not know where Resident #1 was or that Resident #1 did not return from a leave of absence. The Physician said he was at the Facility the afternoon of 5/29/13, and was informed by the nurses that Resident #1 fell while out on a leave of absence and was taken by ambulance to a hospital. The Physician said the first time he learned of Resident #1 being abandoned and that his/her whereabouts was unknown was while speaking with the Surveyor. The Physician said he was the Facility's Medical Director and Resident #1's Physician, and should have been informed immediately. The Physician said gave an order for [REDACTED]. The Physician said the Facility staff had the opportunity to determine whether someone was reliable or gave indication they were not reliable and should not be allowed to take a resident from the facility. The Physician said he would rely on the facility staff to have determined this prior to letting any resident, including Resident #1 leave. The Physician said he was not aware that Family Member #1 was the same person who abandoned Resident #1 in January and he had no prior knowledge of the event. The Physician said Family Member #1 clearly demonstrated to the Facility in January 2013 he was not a responsible person and therefore, should never had been allowed to take Resident #1 out of the Facility on a leave. The Physician said one time abandoning Resident #1 was enough, and there should never have been a second time. The Physician said he would have expected the Facility staff share the information about the January 2013 incident, with whoever gave the order for Resident #1 to leave with a responsible person. The Surveyor interviewed Nurse #1 at 7:05 P.M. on 5/31/13 and Nurse #2 in person at 7:30 P.M. on 5/31/13. Nurse #1 and Nurse #2 said they worked the afternoon Resident #1 left the Facility with Family Member #1. Nurse #1 said at approximately 4:30 P.M., Family Member #1 called her and informed her that he left Resident #1 after calling 911 because Resident #1 was unable to stand while on leave. Nurse #1 said Family Member #1 informed her that at the time of the call, Resident #1 was being transported in an ambulance to the hospital. Nurse #1 said the Physician was present and she informed the Physician. Nurse #1 said Family Member #1 told her that he was on a bus and did not know where Resident #1 was being taken. Nurse #1 and Nurse #2 said they called local hospitals and the police and had more than one conversation with Family Member #1 the afternoon of 5/29/13, and Family Member #1 was not consistent regarding the details of what occurred with Resident #1 while on leave and where Resident #1 was when last seen by Family Member #1. Nurse #1 and Nurse #2 said as of 5/31/13, Resident #1's whereabouts remained unknown. Nurse #1 and Nurse #2 said they never called the Physician to update him or any other physician that they were provided misinformation from Family Member #1 regarding Resident #1 and that Resident #1's whereabouts on 5/29/13 was not know. The Surveyor interviewed the Director of Nurses (DON) at 7:50 P.M. on 5/31/13. The DON said she was informed Resident #1 wanted to leave with Family Member #1. The DON said a "responsible person" was defined as a person who, words to the effect of, "the Guardian would choose who was considered responsible." The DON said she never spoke with the Guardian about Resident #1 being allowed to leave the Facility with Family Member #1, but said Social Worker #1 informed the Guardian. The Surveyor interviewed Family Member #1 at 6:23 P.M. on 5/31/13. Family Member #1 said he and Resident #1 took a bus to go to Resident #1's bank, where Resident #1 withdrew 300.00 from the bank. Family Member #1 said he and Resident #1 got on a second bus to obtain Resident #1's birth certificate, and planned to get a third bus to visit Resident #1's sister. Family Member #1 said between getting the birth certificate and going to visit Resident #1's sister, Resident #1 was unable to stand and Family Member #1 called 911. Family Member #1 said he did not remain with Resident #1 while waiting for the ambulance but rather, took a bus back to the Facility to obtain his bicycle which he left at the Facility. Family Member #1 told the Surveyor Resident #1 used Family Member #1 to take him/her out and get drunk; and was not able to tell Resident #1 what to do because Resident #1 did not listen to him. The Surveyor interviewed Resident #1's Guardian at 5:23 P.M. on 6/3/13. The Guardian said she maintained telephone call logs of all calls received by her office. The Guardian said review of the telephone call logs for January 2013, indicated she received a call at 7:05 P.M. on 1/27/13, which indicated, "calling about one of your guardians." The Guardian said the name of the facility, the person calling, and the resident involved was not included in the message. The Guardian said she was the Guardian for five residents at the Facility, and the call log notes indicated she was only aware the call originated from the Facility because she reviewed the caller ID. The Guardian said she had no knowledge of Resident #1 being taken out of the Facility on 1/27/13 or that Resident #1 was left in a train station while on leave with Family Member #1. The Guardian said she recalled one occasion when Resident #1 left the Facility and asked for assistance from a police officer to return, but she did not know Family Member #1 was involved. The Guardian said she did not know that while on leave from the Facility in January 2013, Family Member #1 asked Resident #1 for money, fought with Resident #1, and left Resident #1 alone. The Guardian said the first learned of the January 2013 incident during the interview the Surveyor on 6/3/13. The Guardian said that at 3:59 P.M. on 5/29/13 she spoke with Social Worker #1 who asked her if Resident #1 could leave the Facility with Family Member #1. The Guardian said she informed by Social Worker #1 that Family Member #1 came to the Facility to visit Resident #1, prior to the request to be able to leave the Facility with Family Member #1 and Social Worker #1 gave the Guardian no indication of any previous concerns. The Guardian said the first thing she asked a Facility before giving consent for a leave, is whether the person asking to take the resident is known to the staff, and that staff obtain the person's telephone number, address, cellular number, destination, and obtain a time-table regarding when they will return. The Guardian said normally she established parameters for a resident to be able to leave and spoke with Social Worker #1 about parameters for Resident #1 to be able to leave. The Guardian said she was not informed at the time of the call, Resident #1 was already out of the Facility on a leave of absence. The Guardian said she would not have given consent for Resident #1 to leave the Facility at all, let alone with Family Member #1, had she been aware of the details regarding the January 2013 social leave of absence. The Guardian said the first time she learned that Resident #1 did not return to the Facility with Family Member #1 was through a voice mail message left at 12:52 P.M. on 5/30/13. The Guardian said on 5/31/13 at 10:30 P.M. she was informed Resident #1 returned to the Facility. The Guardian said she was not informed that Resident #1 returned appearing intoxicated or his/her condition upon returning to the Facility or that Resident #1 was transferred to two different hospitals to be evaluated. The Guardian said she called the Facility at 7:09 A.M. on 6/1/13, and the nurse said Resident #1 returned to the Facility, but was unable to provide any information to the Guardian. The Guardian said the nurse informed her the Director of Nurses (DON) would call her back, but as of 6/3/13, had not been provided any additional information from the Facility.

Based on observation, record review and staff interviews, the facility failed to provide appropriate treatment and services to restore as much normal bladder function as possible for 2 of 9 Residents who were incontinent (#5 and #18) out of a sample of 25 Residents. Findings include: 1. For Resident #18, the facility failed to ensure that a new bladder assessment was conducted when a decline in bladder status occurred. Review of the facility's current "Continence Management" Policy on 3/1/12, indicated that "A urinary incontinence assessment will be completed if the resident is incontinent upon admission or re-admission and with a change in condition." Resident #18 was readmitted from the hospital to the facility on [DATE]. [DIAGNOSES REDACTED]. At that time, the 12/6/11 incontinence assessment indicated that the resident was continent of bladder and bowel. On 3/1/12, review of the quarterly Minimum Data Set ((MDS) dated [DATE], identified the resident as having cognitive impairment, was independent with transfer and required supervision with ambulation. The resident was identified as continent of bowel and bladder. Further review of the significant change MDS dated [DATE], continued to identify cognitive impairment with a functional decline in activities of daily living (ADLs). The resident was now coded as frequently incontinent of bowel and bladder. The Care Area Assessments (CAAs) for Urinary Incontinence indicate that due to a change in cognitive status, the resident is now incontinent of both bladder and bowel, but does still have periods of continence. A problem for bladder and bowel elimination related to incontinence dated 2/1/12, was added to the care plan which included the following intervention: complete a bladder and bowel assessment. There was no assessment completed which addressed the resident's decline in continence status. Unit Manager #1 when interviewed on 3/1/12 at 2:00 P.M., stated that Resident #18 is incontinent of bladder and bowel. Unit Manager #1 further stated that an assessment had not been conducted following a change in continence status, to determine if bladder and bowel function could be restored and to identify appropriate interventions to accomplish this. 2. For Resident #5, the facility failed to conduct a bladder evaluation and patterning, and provide treatment and services, in order to restore as much bladder function as possible. Resident #5 was admitted to the nursing facility with [DIAGNOSES REDACTED]. Review of the medical record, on 2/28/12, indicated that the last bladder assessment had been conducted on 2/28/11 and the Resident was documented as having no incontinence with risk factors. The risk factors included the use of [MEDICATION NAME] (a diuretic medication) and a [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set (MDS), dated [DATE], documented the Resident as having long and short term memory losses and as moderately impaired in daily decision making. The Resident required the extensive assistance of two persons for transfers and required total care for bathing and hygiene. The Resident was documented as always incontinent of bladder and bowel. A Quarterly MDS Assessment, dated 1/24/12, continued to document Resident #5 as always incontinent of bladder and bowel. Review of the facility's current "Continence Management" Policy on 3/1/12, indicated that "A urinary incontinence assessment will be completed if the resident is incontinent upon admission or re-admission and with a change in condition." Unit Manager #1 was interviewed on 3/2/12 at 3:00 P.M. Unit Manager #1 stated that Resident #5 is incontinent of bladder. Unit Manager #1 stated that Resident #5 had been hospitalized from [DATE] through 4/13/11 and returned to the nursing facility with bladder incontinence and that prior to the hospitalization had been continent of bladder. Unit Manager #1 further stated that a bladder assessment was not conducted upon the Resident's return to the nursing facility, and a bladder assessment was never done to determine if bladder function could have been restored.

Based on observation, record review and staff interview, a.) The facility failed to provide adequate supervision and effective interventions to prevent repeated falls/fractures, for 1 of 7 residents (#10) identified with falls. b.) The facility also failed to provide adequate supervision and protective devices to prevent accidents while smoking for 2 of 7 residents (#17 and #18) who smoked, in a total sample of 25 residents. Findings include: a.) FALLS/FRACTURES: 1. Resident #10 sustained a total of 17 repeated falls from April 2011 through February 2012, which included 3 major injuries (fractures). The facility failed to provide adequate supervision and the assistance of two staff members per the Resident's plan of care, in order to prevent two separate falls which resulted in two fractures. Resident #10 was admitted on [DATE], to the nursing facility with [DIAGNOSES REDACTED]. Current [DIAGNOSES REDACTED]. On 2/27/12, the first day of survey, during the initial report/tour, Resident #10 was identified by Unit Manager #5 as having had multiple falls, some with injury. In addition, the resident had behavioral issues and was known to be non-compliant with follow through interventions such as ringing the call bell when assistance was needed. Review of the clinical record on 2/28/12, including nurses' notes, Minimum Data Sets (MDS), care plans and corresponding falls incident reports and investigations, indicated the following: * Review of the interdisciplinary care plans on 2/28/12, for this resident, indicated that since 6/2010, the Activities of Daily Living Care Plan included "two persons at all times" for bathing, dressing and grooming. * On 4/26/11 at 6:55 A.M., the resident was found on his/her left side on the floor beside the bed after self-transferring from wheelchair. The resident had refused to go to bed for the night. No injury was identified. The resident was re-educated to go to bed every night. Described as "non-compliant" on the Falls investigation as he/she often slept in his/her wheelchair instead of bed. The falls care plan was updated on 4/27/11 to include the following: Goal: Resident will have no falls with injury times 90 days. Interventions: * Assist with transfer when needed. * Provide verbal cues for safety and sequencing when needed. * Provide verbal cues for proper pacing and energy conservation techniques. * Maintain a clutter-free environment in the resident's room. * When the resident is in bed, place all necessary personal items within reach. * Monitor for toileting needs. * Encourage resident to attend all activities that maximize their full potential while meeting their need to socialize. * Fall risk assessment per protocol. * Monitor carefully for any side effects/adverse effects of medications that may increase risk of falls. * Implement the following safety precautions: Non-skid footwear; Remind to ask for assistance. * Walker at all times. * Wheelchair for long distances. * On 5/23/11 at 9:00 P.M., a noise was heard in the resident's room. The resident was observed on the floor in prone position on the left side of the bed. The resident was sleeping and fell from the bed. Resident stated that his/her stocking had slipped and he/she slid to the floor. No injury identified. Non-skid strips were placed on the floor. Review of the 6/2/11 annual MDS on 2/28/12, indicated that the resident was alert and oriented having demonstrated multiple behaviors and utilized psychoactive medications including anti-psychoactive, anti-anxiety and anti-depressant medications. The resident also utilized scheduled and as needed (PRN) pain medication. The resident required limited assistance for transfer, ambulation and dressing, was continent of bowel and bladder and has had falls. * On 6/17/11 at 11:30 P.M., the resident was found sitting on floor; slid off the bed. No injury identified. The resident was reminded to call for assistance. A mat was placed on the floor. * On 7/5/11 at 5:15 A.M., the resident was observed lying on his/ her left side in front of bed/wheelchair, fell when attempting to self-transfer. Investigation documentation indicated that the left wheelchair brake lock was broken but had not been reported. (There was no documentation to indicate how long the brake was broken.) No injury was identified. The left brake was fixed. The resident was cautioned to call for assistance and lock the wheelchair. * On 7/18/11 at 1:30 A.M., the resident was on the edge of the bed trying to move closer to the head of the bed and slid to the floor. Documentation of the falls investigation indicates that the resident is non-compliant with asking for assistance. Half siderails were implemented to assist with transfers while in bed. The resident was encouraged to go to bed at 10:00 P.M. An x-ray report of 7/18/11, triggered by left rib cage bruising, indicated: "There are healing midaxillary line fractures of the 5th, 6th and 7th ribs and possibly 4th and 8th, as well. These findings are new since 4/18/11." The radiologist documentation reported that rib fractures do not have to be accompanied by bruising. The accuracy depends on the angle of the view. There were 4 previous falls since 4/18/11 with no fracture reported. * On 7/29/11, following an allegation that a certified nursing assistant (CNA) was short with the resident and denied assistance, the facility implemented two caregivers when providing care at all times. This intervention was documented on the CNA care plan. This intervention had originally been care planned for in 6/2010 on the ADL care plan which was documented: "Two persons at all times." * On 8/1/11 at 1:45 P.M., a falls report/investigation documented that the resident was sitting on the shower chair and reached to get a bottle of hair conditioner which caused the resident to slide out of the shower chair. The seat to the shower chair became loose. The CNA who was present in the room, did not see the fall but heard it. The resident complained of right wrist, right shoulder and tailbone pain. The resident was sent to the hospital and returned on 8/3/11 with fractured 8th and 9th left ribs. The care plan was revised to provide physical assistance in the shower if the resident allows. The shower chair was discarded and replaced. The above indicated that there was only one CNA present during the shower, not two as initiated on 7/29/11. It is not clear how the CNA heard the fall but did not see it, if the CNA was in the room as documented in the falls investigation. It was indicated during interview with the resident on 2/28/12 at 11:00 A.M., that the shower chair was already broken before the CNA assisted the resident into it and the CNA used the shower chair anyway. Further review of the clinical record on 2/28/12, indicated that there was no evidence that the care plan had been reassessed and the resident continued to fall. * On 8/6/11 at 7:30 P.M., the resident was self-transferring from bed to the wheelchair and slid in a water spill on the floor. No injury identified. The resident was reminded to call for assistance. Bed and chair alarms were initiated. * On 8/15/11 at 12:30 A.M., the resident slipped out of the wheelchair trying to put something away in a box. The alarm sounded. The resident was re-educated to call for assistance. Hand bell initiated. * On 9/27/11 (no time documented), the resident was with a CNA in the shower room on a shower chair being assisted with a shower. The resident's feet were wrapped in plastic to keep the bilateral lower extremity dressings intact which made it very slippery when the resident put her feet down on a wet floor. The CNA stated that the brakes to the shower chair were unlocked in order to move the resident out of the shower. The resident stated that the CNA asked the resident to stand up which the CNA denied. The resident stood up and slipped, tried to sit back down but the chair moved away. The resident fell on his/her left side. The resident complained of left wrist and left hip pain and was transported to the hospital and diagnosed with [REDACTED]. The resident returned with a cast on left lower arm. The CNA assignment was changed. The resident was reminded not to stand while in the shower chair without assistance. The above indicated there was only one CNA assisting the resident with a shower, not two as care planned on 6/2010 and again on 7/29/11. Further review on 2/28/12 after two fractures, there was no evidence that the care plan had been reassessed to develop and implement effective interventions. The resident's known non-compliance with follow-through with calling for assistance was not addressed and the resident continued to fall. * On 11/1/11 at 1:00 A.M., the resident was found on the floor after sliding out of the wheelchair secondary to not locking the brake. No injury was identified. The resident was not compliant with ringing the bell or asking for assistance. The resident again was cautioned to call for assistance. * On 11/3/11 (no time documented on the incident report) The report indicated that ice fell and the resident fell when trying to pick it up off the floor. There was no further documentation regarding this incident. Review of the 12/1/11 quarterly MDS on 2/28/12, indicated that the resident was alert and oriented, demonstrated multiple behaviors and utilized psychoactive medications including anti-psychoactive, anti-anxiety and anti-depressant medications. The resident also utilized scheduled and as needed (PRN) pain medication. The resident required limited assistance for transfer, ambulation, dressing, hygiene and bathing; was continent of bowel and bladder and has had falls. * On 12/19/11 at 3:00 A.M., the resident continues to refuse to call for assistance and was found on his/her buttocks. No injury was identified. No new intervention. The investigative information indicated that all interventions were in place. There was no further documentation regarding this incident. * On 12/31/11 at 8:40 A.M., a CNA found the resident on his/her right side on the floor in his/her room with the wheelchair locked. No injury was identified. The investigative information indicated that all interventions were in place. There was no further documentation regarding this incident except to remind the resident to sit in the wheelchair properly. * On 1/17/12 at 5:35 A.M., the resident was trying to wheel self to the bathroom when the resident slid out of the wheelchair. The alarm was sounding. The resident complained of bilateral lower extremity pain and was medicated. * On 2/8/12 at 11:50 P.M., the resident was found on the floor when a staff member was passing by the room. The resident stated that he/she slipped and fell . No injury was identified. A new intervention was added to the care plan: assist with ambulation using rolling walker with staff following with wheelchair behind the resident. There was no documentation as to whether the alarm was being utilized or functioning. * On 2/17/12 at 3:55 A.M., the resident was found on the floor on his/her back after rolling out of bed. No injury was identified. There was no documentation as to whether the alarm was being utilized or functioning. * On 2/26/12 at 10:00 P.M., when a CNA was checking on the resident, he/she was found on his/her knees after falling, with his/her face in the bed, sleeping. No injury was identified. The intervention put in place was: when the resident refuses to go to bed at 10:00 P.M., staff is to check and offer the resident assistance to get into bed every 15 minutes thereafter. Observation of the resident on 2/28/12, in the small sitting room on the unit, revealed the resident entering the room in a wheelchair. Without speaking, the resident transferred his/herself to another wheelchair with a backpack attached. The resident stated, "I don't know why they (staff) take my wheelchair out of the room with my backpack and put it in here. I have to go and get it and wheel it back to my room." When asked why it is removed from the resident's room, the resident replied, "They (staff) do not want me to use it at night." It was not clear why staff would remove the resident's chair but leave the roommate's wheelchair in the room which was also accessible to the resident. Even though the resident continued to fall 8 additional times after the second fracture, Unit Manager #5 on 3/1/12 at 10:00 A.M., was unable to provide evidence that the falls had been reassessed to identify the causal factor contributing to the multiple falls. Unit Manager #5 stated, "This resident is very difficult. We do the best we can." The facility failed to develop and implement effective interventions and provide appropriate supervision to prevent repeated falls and injury. The facility failed to address this resident's non-compliant behavior and not rely on the resident to initiate a call for assistance. The facility also failed to provide 2 caregivers at all times per the plan of care. Two of the 17 falls on 8/1/11 and 9/27/11 resulted in rib fractures and a left wrist fracture respectively. b.) SMOKING: 2. For Resident #17, the facility failed to provide adequate supervision and a smoking apron per resident assessment in order to ensure safe smoking. Resident #17 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) which was a quarterly dated 2/9/12, was reviewed on 3/5/12. It identified the resident as being cognitively impaired, verbally abusive, requiring assistance with transfer, dressing, hygiene and bathing, supervision with ambulation and set up for meals. The resident was identified as being always incontinent of bowel and bladder and received antipsychotic and antidepressant medications. The current smoking care plan in place on 3/5/12, which was initiated on 11/10/11, identified the resident as having spastic movements which could cause trauma, requiring supervision and a smoking apron when smoking. The most current Assessment for Smoking dated 2/1/12, which was was reviewed on 3/5/12, indicated that: * The resident had short term memory loss and impaired decision-making. * The resident was not able to grasp a cigarette and hold safely. * The resident was not able to move hand to mouth in steady, smooth movement. * The resident was not able to demonstrate ability to safely light a cigarette. * The resident was not able to dispose of smoking material/ashes safely. * The resident was not able to enter and exit through the doorway independently and needs an escort for ambulation and wheelchair mobility. * The resident was not able to recognize needs and summon assistance. * The resident was not able to demonstrate access and use of smoking apron. * The resident was not able to demonstrate proper use of a fire blanket. After review of the 2/1/12 Smoking Assessment by the IDT team, the resident was identified as requiring supervision and a smoking apron secondary to spastic arm movements. Observation of the the smoking area on 2/29/12, revealed a ratio of 2 facility staff to 19 residents. Observation of the resident on 2/29/12 at 1:30 P.M., revealed that the resident was seated in the smoking area, hand shaking and ashes flying, landing on the resident's lap and clothing. The resident was not wearing a smoking apron. Interview with the Activity Director on 3/1/12 at 1:15 P.M., stated that the resident should be wearing a smoking apron. Observation of the the resident on 3/1/12 at 1:30 P.M. and 3/5/12 at 1:45 P.M., revealed that the resident was not utilizing a smoking apron as assessed and care planned. On 3/1/12 and 3/5/12, the resident's hand continued to shake, ashes continued to fly landing on the resident's clothing. The resident was not seated by a smoking oasis, nor were ash trays available for ashes and to extinguish cigarettes. The resident was observed throwing the smoked cigarette on the ground. The facility failed to ensure safety when smoking by providing and utilizing a smoking apron for this at risk resident. The facility also failed to provide ash trays to collect ashes and extinguish cigarettes. 3. For Resident #18, the facility failed to provide adequate supervision and a smoking apron worn correctly in order to ensure safe smoking. Resident #18 was originally admitted on [DATE] and re-admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review, on 3/1/12, of the significant change MDS dated [DATE], identified the resident was cognitively impaired with a functional decline in activities of daily living (ADLs). The resident received anti-depressant and anti-psychotic medications. The current smoking care plan in place on 3/1/12 which was initiated on 10/2010, identified the resident as a supervised smoker. The most current Assessment for Smoking dated 2/1/12, was reviewed on 3/1/12. It indicated that: * The resident had short term memory loss and impaired decision-making. * The resident was not able to demonstrate ability to safely light a cigarette. * The resident was not able to dispose of smoking material/ashes safely. * The resident was not able to enter and exit through the doorway independently. However, the second page was the page where the Interdisciplinary Team analyzed and developed conclusions and interventions. This page was blank, therefore, incomplete. Observation of the the smoking area on 2/29/12, revealed a ratio of 2 facility staff to 19 residents. Observation of the resident on 2/29/12 at 1:30 P.M., revealed that the resident was seated in the smoking area, hand shaking and ashes flying, landing on the resident's lap and clothing. The resident was not wearing a smoking apron as care planned. The Activity Director when interviewed on 3/1/12 at 1:15 P.M., stated that the resident should be wearing a smoking apron. Observation of the the resident on 3/1/12 at 1:30 P.M., revealed that as his/her had continue to shake while holding the cigarette. The resident was observed to drop a lighted cigarette into the crook of the resident's arm. When the Activity Director tried to assist the resident, he/she dropped it again. As the resident had a smoking apron folded on his/her lap, it did not protect the resident from a potential fire, had the resident not been assisted by the Activity Director. On 3/5/12 at 1:45 P.M., the resident had a smoking apron folded on his/her lap. The apron was worn incorrectly and was not over the resident's head covering the chest area, the resident's lap with the resident's arm under the apron resting on his/her lap. As on 2/29/12, the resident's hand continued to shake, ashes continued to fly, landing on the apron when it was on the resident's lap. They also landed on the resident's clothing when the apron had slipped to the ground. The resident was not seated by a smoking oasis, nor were ash trays available for ashes and to extinguish cigarettes. The resident was observed throwing the smoked cigarettes on the ground. The facility failed to ensure safety when smoking, by providing and utilizing smoking aprons appropriately. The facility also failed to provide ash trays to collect ashes and extinguish cigarettes. Please see F 514.