Every finding on record at Sainte Anne Extended Healthcare

Based on observation, interviews, and record review, the facility failed to ensure food stored in a unit refrigerator were labeled, dated and discarded properly. Additionally, facility failed to ensure proper food storage for 1 of 1 resident refrigerator that contained undated and unlabeled food.Findings Include:During an observation on 05/20/26 9:05 a.m., the fourth-floor kitchen refrigerator contained the following items: 3 clear sandwich size bags with egg salad sandwiches labeled with room number and undated, 1 small size of uncovered paper bowl of [NAME] tot and a taco wrapped in brown paper from taco [NAME], not labeled and undated. 3 small (2 .25 oz) plastic portion cups, black container, clear covering, holding a creamy and medium consistency substance, not labeled and undated. A medium size (16 oz) food container with a red lid, holding a mixture of ground brown meat, and a reddish liquid labeled with a room number and dated 5/14/26. During an interview on 05/20/26 9:05 a.m., nursing assistant (NA)- A, confirmed food items in the refrigerator were eggs salad sandwiches undated, ranch dressings not labeled and undated, [NAME] tot and a taco from Taco [NAME] not labeled and undated, a medium size food container of goulash dated 5/14/26. NA-A stated dietary staff was responsible for monitoring the kitchen refrigerator daily for proper food labeling, dating, and the removal of outdated food items.During an interview 05/20/26 9:20 a.m., licensed practical nurse (LPN)-A stated, any food item placed in the kitchen refrigerator needed to be dated and labeled, however dietary staff was responsible for monitoring for proper labeling, dating and the removal of outdated food items. During an interview on 05/20/26 at 10:30 a.m., culinary supervisor (CS) stated, dietary staff was responsible for monitoring the refrigerators in the kitchen areas for proper labeling, removal of outdated food items and the task was completed daily. Facility Policy Titled, Safe Food Storage and Handling for Food Brought in, last reviewed August 20219 indicated All food stored in the refrigerator/freezer units should be in covered, seamless containers or otherwise suitably protected with date the product was given to the community for storage, used by date (max of 3 days) name and room number of resident. Containers should be arranged so that free circulation of air is always allowed. Storage of large quantities of food in oversized containers should be avoided.

Based on interview and document review, the facility failed to ensure routine dental services were provided or offered to promote oral hygiene and reduce the risk of complication (i.e., further breakdown, oral pain) for 1 of 1 residents (R29) reviewed for dental hygiene and services. Findings include: R29's quarterly Minimum Data Set, dated [DATE] identified R29 with significantly impaired cognition, and dependent on staff for all cares including oral hygiene. In addition, R29 with diagnoses of neurocognitive disorder with Lewy body (dementia)fibromyalgia, and arthritis.R29's Dental Consult, dated 6/27/24 identified, Multiple broken teeth. Recommend extract any teeth that become symptomatic.R29's care plan with edit date of 4/9/2020 identified, Dental appointments per resident or resident representative preferences.During interview with R29's emergency contact (FM)-B on 5/20/26 at 12:15 p.m., FM-B stated he expected the facility to arrange for routine dental services and could not recall the last time R29 was seen by a dentist. FM-B stated, [R29] did not have many teeth left and wanted her to be seen.During interview with social services (SS)-A on 5/19/26 at 12:57 p.m., SS-A stated the facility arranges a contracted dental service annually for all of the residents and that I believe our infection control preventionist (IP) coordinates it. SS-A stated her department had nothing to do with asking residents or their guardians about routine dental visits.During interview with registered nurse (RN)-A on 5/19/26 at 1:04 p.m., RN-A stated she was the nurse manager for the memory care unit at the facility. RN-A stated she was not involved in asking for or coordinating routine dental visits.During interview with the regional director of clinical services (RC)-C and IP on 5/19/26 at 1:31 p.m., IP stated she sends out an email annually to family members and guardians to ask if they would like to be seen by a dentist for routine care. RC-C stated the facility did not have a process to identify and document refusals or when the last dental visit was done. Both verified that it was possible and likely that residents could get missed for setting up routine dental visits. In addition, both stated R29's EMR lacked evidence of a follow-up dental visit to address possible extraction after the 6/27/24 visit.During interview with director of nursing (DON) on 5/21/26 at 10:04 a.m., DON verified R29's EMR failed to show that she was offered or provided routine dental visits. DON stated, [R29] should be asked and it should be documented but it was not.Facility policy titled Dental Services, reviewed 4/2021, state, Routine and emergency dental services are provided to our residents and All dental services provided are recorded in the resident's medical record.

Based on interview and document review, the facility failed to ensure routine dental services were provided or offered to promote oral hygiene and reduce the risk of complication (i.e., further breakdown, oral pain) for 1 of 1 residents (R9) reviewed for dental hygiene and services.Findings include: R9's annual Minimum Data Set, dated [DATE] identified impaired cognition and required assistance with oral hygiene. In addition, R9 with diagnoses of dementia and anxiety.R9's physician orders dated 7/22/25 state, Optometry, Audiology, Psychology, Dental, and Podiatry consults to evaluate and treat as indicated.R9's care plan dated 1/14/26 identified, need assistance with dental care d/t dementia. I have an upper partial denture.R9's electronic medical record (EMR) lacked evidence of a progress note or referral or provided a consultation for dental services.During observation and interview on 5/18/26 at 2:03 p.m., R9 was sitting in wheelchair in her room on the locked memory care unit. She had intact teeth of upper and lower jaw. R9 stated she did not have dentures and that staff had not asked her about dental appointments. Furthermore, R9 stated she could not recall the last time she visited a dentist.During interview with social services (SS)-A on 5/19/26 at 12:57 p.m., SS-A stated the facility arranges a contracted dental service annually for all of the residents and that I believe our infection control preventionist (IP) coordinates it. SS-A stated her department had nothing to do with asking residents or their guardians about routine dental visits.During interview with registered nurse (RN)-A on 5/19/26 at 1:04 p.m., RN-A stated she was the nurse manager for the memory care unit at the facility. RN-A stated she was not involved in asking for or coordinating routine dental visits.During interview with the regional director of clinical services (RC)-C and IP on 5/19/26 at 1:31 p.m., IP stated she sends out an email annually to family members and guardians to ask if they would like to be seen by a dentist for routine care. RC-C stated the facility did not have a process to identify and document refusals or when the last dental visit was done. Both verified that it was possible and likely that residents could get missed for setting up routine dental visits and R9's EMR failed to identify if she or her guardian were asked to be seen by a dentist.During interview with R9's guardian and power of attorney (FM)-A on 5/19/26 at 12:10 p.m., FM-A stated he was unaware of last time R9 was seen by a dentist.During interview with director of nursing (DON) on 5/21/26 at 10:04 a.m., DON verified R9 EMR failed to show that she was offered or provided routine dental visits. DON stated, [R9] should be asked and it should be documented but it was not.Facility policy titled Dental Services, reviewed 4/2021, state, Routine and emergency dental services are provided to our residents and All dental services provided are recorded in the resident's medical record.

Based on observation, interviews, and record review, the facility failed to ensure once opened, a bottle of tuberculin solution (solution used in intradermal skin tests to detect tuberculosis infection) was labeled in accordance to professional standard (an opened multidose vial of tuberculin PPD must be discarded 30 days after the first puncture). Additionally, the facility failed to ensure 1 of 1 resident's (R32) Lantus (insulin glargine) pen was dated once opened. Findings include: During an observation and interview on 05/18/26 at 2:09 p.m., of the fourth-floor medication refrigerator, a bottle of tuberculin solution approximately three quarters used, a light blue label on the bottle indicated, discard 30 days after opening. Close inspection of the bottle showed no open date. Licensed practical nurse (LPN)-A, present during the observation confirmed, the open bottle of tuberculin solution was not dated once opened and stated, the bottle should not have been in the refrigerator. During an interview on 05/21/26 at 8:44 a.m., registered nurse, case manager (RN)-B stated, tuberculin solution was used for residents on the fourth floor, when needed for floors one, two, three, five and expected an opened bottle of tuberculin solution discarded 30 days after opening. During an observation and interview on 05/20/26 at 9:15 a.m., the fourth floor second medication cart contained a Lantus insulin pen being used for R32. A yellow label on the insulin pen indicated, discard 28 days after opening. LPN-A present during observation confirmed, R32's insulin pen was not dated, and the pen was last used on 5/19/26 at 6 :00 p.m. During an interview on 05/21/26 at 8:48 a.m., RN-B confirmed, Lantus pen was to be dated once opened and discarded 28 days after opening. Facility policy for medication, treatment, and medical supplies storage requested, not received at this time.

Based on observation, interview, and document review, the facility failed to maintain separately locked, permanently affixed compartments for storage of controlled drugs for 4 of 4 observed medication storage areas during a facility wide remodel. Findings include: During an observation and interview on 2/13/25 at 9:08 a.m., licensed practical nurse (LPN)-B identified the current refrigerator used to store medication on the 2nd floor was locked. The locked refrigerator was not affixed to any permanent surface and was in a temporary nurse's station in the open while the facility was in the middle of a remodel. LPN-B identified the medications in the refrigerator contained flu shot, insulin pens, tuberculin, and Ativan (antianxiety). LPN-B stated the nurses are the ones who check the expiration dates and refill the refrigerator. During observation of the 3rd, 4th, and 5th floor medication storage areas, it was found each had the same type of refrigerator located in a temporary nurse's station as found on the 2nd floor. The nursing staff carry a key to the locked refrigerator which was noted to contain some of the same medications noted above. In order to gain access to the area, staff need to walk through a temporary half-height wooden door noted not to lock. behind this half-door is an where the refrigerator is located. Any staff, visitor, or construction worker could have access to this area . During an interview on 2/13/25 at 9:08 a.m., LPN-B stated there is an Emergency Kit located on the 3rd floor, but that was the only double locked medication storage also containing controlled medications. During an interview on 2/13/25 at 10:50 a.m., director of nursing (DON), regional director of nursing (RDON) and administrator was present. The RDON explained the current process for medication storage is to have most medication in the locked carts. The facility has a medication storage refrigerator on each floor behind the temporary nurses' station and a locked cabinet for the emergency kit. Facility policy titled, Controlled Substance Storage dated 4/1/19, included medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with federal, state, and other laws and regulations. The procedure for schedule II medications or higher are stored in a permanently affixed, double -locked compartment separate from all other medications per regulation. Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be kept attached to the inside of the refrigerator.

Based on observation, interview, and record review the facility failed to ensure a dignified dining experience for residents who required assistance with eating. This had the potential to affect all residents in the facility who were dependent on staff for their intake of nutrition. Findings include: During an observation of the main floor dining room on 2/10/25 at 5:08 p.m., nursing staff were standing while feeding residents. The staff would move from table to table to assist different residents and were found to not have engaged with the residents during the meal. During an observation on 2/11/25 at 11:55 a.m., nursing staff were standing during lunch meal and moving from resident to resident. During an observation on 2/12/25 at 12:22 p.m., the 5th floor common area was used for meals. Nursing assistant (NA-C) was assisting residents with their meals while standing. NA-C would call out, out loud asking if the residents needed any assistance. During an interview on 2/12/25 at 12:32 p.m., NA-E explained most of the residents need some sort of assistance during meals and most days there are two NA's available to help assist the residents on 5th floor. NA-E said at times when there is only one NA they may stand to assist the resident to eat. NA-E indicated it's a staff preference if nursing staff choose to stand or sit while helping residents during meals. During an interview on 2/12/25 at 2:04 p.m., the culinary director (CD) stated they have an average of 20-25 residents who eat in the main dining room. Those who do not come to the main dining area use the common area on their floor or receive a tray and eat in their rooms. CD indicated the dietary staff do not assist residents with meals. CD verified staff should not be standing while assisting residents with meals and can be considered a dignity concern. During an observation on 2/13/25 at 8:22 a.m., during breakfast in the main dining room several nursing staff were standing while feeding residents. NA-B, licensed practical nurse (LPN-B) and NA-A were observed not sitting next to the residents who needed assistance with their meal. During an interview on 2/13/2/5 at 9:03 a.m., Regional Director of Nursing (RDON) indicated the expectation during meal times would be to have nursing staff sit at the tables with the residents, assist the resident with food , such as cutting the food up, and offer them the choice of how they would like to consume their meal. RDON verified the facility has several residents who need more assistance with eating and drinking during meals. Nursing staff need to sit in order to provide time and respect to the resident. RDON confirmed nursing staff need to focus on one resident at a time. Facility policy titled Assistance with Meals dated 2018, included nursing staff and associates will serve meals to resident and assist those who require assistance with eating. Residents who cannot feed themselves will be assisted with attention, safety, comfort, and dignity.

Based on observation, interview and document review, the facility failed to replace and maintain oxygen tubing for 2 of 2 residents (R32 and R65) reviewed for respiratory care. Findings include: R32's Minimum Data Set (MDS) assessment, indicated severe cognitive impairment and received supplemental oxygen. R32's order report dated 1/4/2025, indicated diagnoses of primary emphysema (chronic lung condition that causes shortness of breath), respiratory failure, and hypoxemia and R32 active orders instructed staff to deliver continuous oxygen and to titrate (continuously measure and adjust the balance) amount to maintain oxygen saturation above 88%. During an observation on 2/10/25 at 1:44 p.m., R32's oxygen tubing was dirty under the nasal area. This tubing was hooked up to a concentrator with a long extension and tied in a knot with R32's wheelchair sitting on top of the tubing. During an interview on 2/11/25 at 10:45 a.m., licensed practical nurse (LPN-C) explained the process for changing and maintaining oxygen tubing. The current process was a scheduled task during a nursing shift and included changing the tubing weekly, if tubing was visibility dirty, or there were any concerns on tubing integrity. During interview on 2/11/25 at 10:52 a.m., LPN-C verified R32's oxygen tubing was in a knot and should be changed for sanitary reasons. During an interview on 2/11/25 at 11:24 a.m., nursing assistant (NA-B) stated R32 was usually wheeled out of her room with the oxygen tubing still hooked up to the concentrator in resident's room. NA-B was not aware of the process for changing oxygen tubing or why R32 was not hooked up to a portable oxygen tank. R65 R65's MDS indicated severe cognitive impairment and received supplemental oxygen. R65's order report dated 1/16/25, indicated diagnoses of dementia, anxiety, heart failure, hypoxemia, recurrent pneumonia, acute respiratory failure due to hypoxemia, and hypertension. R65's active orders dated 1/20/25, directed staff to deliver continuous oxygen via nasal cannula and to titrate amount to maintain oxygen saturation between 88-92%. Orders further directed staff to deliver continuous oxygen at 2-3 liters per minute via nasal cannula at bedtime, and to titrate amount to keep oxygen sats above 88%. During an observation on 2/11/25 at 12:35 p.m., R65's oxygen tubing was lying beside resident on the floor. R65 was self-propelling in their wheelchair around facility. R65 took their oxygen nasal cannula on and off several times during observation. R65's oxygen tubing was hooked up to a portable oxygen tank and was not labeled when last changed. During an interview on 2/12/25 at 8:54 a.m., RN-A reviewed R65's care plan and orders. RN-A stated R65 rolls self in wheelchair up and down the hallway and was placed on a portable oxygen tank. RN-A explained it would be a concern if R65's oxygen tubing was dirty and not labeled on the portable tank. RN-A stated because R65 moves around facility while taking oxygen tubing on and off as needed, this could potentially lead to infection control concern. During an interview on 2/12/25 at 10:03 a.m., RN-A reviewed R23's plan of care with oxygen tubing. RN-A stated R32 was able to push herself in a wheelchair and move around the room. RN-A confirmed R23 should not have been hooked up to a long extension tube for sanitary and safety concerns. RN-A explained the facility's oxygen policy indicating the oxygen tubing should be changed and labeled weekly. RN-A's expectation was staff should not keep residents on long extension tubing, should change the tubing if it is dirty, and the recommendation would be to place R23 on a portable tank. During an interview on 2/12/25 at 11:41 a.m., infection preventionist (IP) indicated the facility was working on a process of updating the labeling of oxygen tubing. IP reviewed current process as staff chart in the medication administration record (MAR) or treatment administration record (TAR) when they change the tubing. IP stated for residents who have long extension tubing, they should be placed on a portable oxygen tank for sanitary reasons, safety concerns, and it was a standard of care. IP explained if R32's wheelchair was on the oxygen tubing there would be a concern about tubing integrity. IP was aware of R65's habit of taking the oxygen tubing on and off and stated her expectation would be to watch it closely for infection control. During interview on 2/13/25 at 10:46 a.m. director of nursing (DON) and regional director of nursing (RDON) reviewed the current process of changing oxygen tubing and providing a sanitary, clean standard of care. The facility expectation was residents should be placed on portable oxygen tanks with clean tubing. The task should be documented in the MAR or TAR when changed every week and/or changed when other concerns such as tubing integrity or infection prevention needs are met. Facility policy titled Oxygen Therapy dated 2017, includes residents were to be assessed to ensure their respiratory needs are being met. Residents identified in need of oxygen therapy will have interventions and equipment which followed manufacturer recommendations for safe handling, cleaning, humidification, storage, and dispensing, maintenance of equipment and consistent federal, state, and local laws and regulations.

Based on observations, interview, and document review the facility failed to ensure compression stocking were applied as ordered to help with edema of the lower extremities for 1 of 1 resident (R10) reviewed for activity of daily living . Findings include: R10's annual Minimum Data Set (MDS) assessment dated [DATE], included R10 cognitive status was intact and required minimal assistance with activities of daily living. R10's face sheet dated 11/17/23 included diagnoses of disorders of veins, localized edema, essential hypertension, history of acute embolism and thrombosis related to deep veins of bilateral lower extremities, cerebral infarction (stroke or bleeding in the brain), and generalized weakness. R10's medical record included, an order to apply compression stockings daily every a.m. and remove at HS (at night). During an observation on 2/10/25 at 1:15 p.m., R10 was resting in a recliner noted to have edema bilaterally to lower extremities. During an interview on 2/10/25 at 1:31 p.m., R10 said both ankles were swollen, and could not apply the compression stockings themselves and staff do not always put them on in the mornings. R10 stated has asked for assistance to apply the compression stockings, however staff forget to help when getting dressed. During an observation on 2/11/25 at 11:16 a.m. R10 did not have compression stockings on to bilateral extremities. During an interview on 2/11/25 at 11:18 a.m., R10 stated staff did not offer to help put them on and nobody asked about whether they were in place. R10 said the reasons she needed them is due to medical condition and doctor's request. During an interview on 2/11/25 at 12:12 p.m., licensed practical nurse (LPN-C) verified there was a physician's order and staff are supposed to assist R10 in the morning and take them off at night. LPN-C explained R10 usually gets dressed independently and the nursing staff assist R10 as needed. During an interview on 2/12/25 at 2:20 p.m., regional director of nursing (RDON) verified there was a current order for the compression stockings. RDON indicated the expectation were for nursing staff to following through with assisting R10 with compression stockings. A policy on edema/ compression stockings was asked for and not provided.

Based on observation, interview and document review, the facility failed to ensure routine grooming was completed who was dependent on staff for personal cares for 1 of 1 resident (R62), reviewed for activities of daily living (ADL)'s . Findings include: R62's minimum data set (MDS) assessment dated [DATE], indicated mild cognitive impairment and was dependent on facility staff to complete personal hygiene tasks. R62's face sheet included the diagnosis of peripheral autonomic neuropathy (nerve damage), thoracic spondylosis (a condition that affects the middle part of your spine, causing pain, stiffness, and nerve compression), generalized muscle weakness, and hemiplegia ( paralysis of one side of the body) R62's care plan dated 1/24/25 indicated a self-care deficit related to personal hygiene and bathing and required substantial assistance from facility staff. During observation and interview on 2/10/25 5:08 p.m., R62 had facial hair present on the right upper lip and chin. Right upper lip contained a patch of black hairs, and the chin hair contained several medium-length chin hairs and one long hair approximately 1.25 inches in length. R62 stated she does not like the lip or chin hair and would like it removed. During interview on 2/12/25 7:23 a.m., nursing assistant (NA)-F stated nurses on each floor enter the tasks in the task administration record (TAR), this includes things like ADL's, bathing, and hygiene. When NA's start their shift, they get a printout of the care areas to be completed during their shift. NA-F confirmed residents who have facial hair is shaved on bath days. During interview on 2/12/25 7:25 a.m., licensed practical nurse (LPN)-B stated the health unit coordinator enters tasks in the TAR for residents. This could be based on physician orders or nurse direction. Furthermore, registered nurse (RN)-E can enter tasks in the admission care plan and ensures the provider orders are done. If a new care plan or task needs to be ordered, then the floor nurse will enter the task. LPN-B confirmed if the order or care plan isn't entered, then the NA's or other staff don't know they need to complete the task. For hygiene cares, the resident can ask for anything specific or if someone sees they need care then they can enter a task for the cares needed. If she saw a female resident with facial hair, she would discuss the hygiene with the resident then enter an order. During an observation and interview on 2/12/25 8:12 a.m., RN-F stated R62 receives her bath on Thursday's PM shift and this would be when they do hygiene and facial hair removal. RN-F said R62 had a bath last Thursday and confirmed resident has prominent facial hair on upper lip and chin. An undated activities of daily living policy stated residents who are unable to carry out ADL's independently, will receive assistance with hygiene, mobility, elimination, dining, and communication.

Based on observation, interview and record review, the facility failed to appropriately clean resident medical equipment after use and place barrier between resident high touch surface and resident multiuse basket. This had the potential to affect all resdient's who received blood glucose monitoring. In addition, the facility failed to ensure proper use of personal protective equipment (PPE) during cares for 1 of 3 residents (R36) reviewed for enhanced barrier precautions (EBP). Findings include: During medication administration on 2/10/25 at 3:47 p.m. registered nurse (RN)-C set up medications for R35. R35 also required to have a blood sugar checked. RN-C had a basket containing the following: lancets (device to puncture the skin for blood sample), test strips, sharps containers, cotton balls and on top was a glucometer (machine to get results of the blood sample). Once in R35's room RN-C placed the basket on a chair then moved the basket from the chair to the resident tray table with out placing a barrier between the tray table and the basket. After RN-C completed the glucose check RN-C then placed the glucometer on the tray table with out any barrier. When completed RN-C placed the glucometer on the supplies in the basket with out cleaning. At 4:01 p.m. RN-C prepared medications for R3 and had indicated R3 also needed a glucose checked. RN-C had all supplies and medications in hand and ready to enter R3's room when surveyor intervened and asked the nurse to review things prior to going in the room. RN-C placed items back on top of medication cart. RN-C said she should wipe the machine down before using it again. RN-C was looking for the cleaning wipes, surveyor pointed to them on a near by cart. During an observation on 2/10/25 at 4:19 p.m., RN-D prepared insulin for R55. RN-D obtained a basket from a near by treatment cart, containing glucometer, lancet, sharps container and entered R55's room and placed the basket on R55's tray table with out placing a barrier down. RN-D exited the room and placed the glucometer and basket on the treatment cart and walked away. Surveyor asked if there was anything he missed. Surveyor asked if he would normally clean the equipment. RN-D said he forgot. During an email communication dated 2/12/25 at 4:16 p.m., infection preventionist (IP) included the infection tracker and indicated the facility just got out of a Norovirus outbreak. During a phone interview on 2/13/25 at 10:28 a.m., IP indicated the facility uses a shared glucometer for glucose checks and would expect the resident equipment to be cleaned in between residents. There is cleaners on each floor. IP indicated she completed a observation recently and identified a staff not placing a barrier down between the basket and resident tables. IP said a tray table is a high touch surface and should have a barrier if setting something down on it like a basket. IP indicated if staff are not using a barrier there is a potential for spread in the facility. 49893 Resident #36 R36's quarterly Minimum Data Set (MDS) assessment, dated 11/5/24, indicated R36 was cognitively intact and had a g-tube (tube inserted into the stomach used to provide nutrition). R36's diagnoses list includes stroke, gastronomy (hole placed through the skin into the stomach). R36's provider orders included Osmolite 1.5 (brand of liquid nutrition) at 150ml/hr from 9 hours, clean are around gastric tube with wound cleanser or normal saline, apply Calmoseptine (cream to protect the skin), apply split gauze. It also included give meds through gastric tube via liquid form or pill form to be crushed. All medications can be crushed and given together per resident preference. R36's careplan indicated R36 required enhanced barrier precautions (EBP) related to g-tube. Post clear signage on the door or wall outside the resident's room indicating type of precautions and required PPE. Staff to apply gloves and gowns prior to facility-identified high contact care activities, discard PPE in designated locations following activities and sanitize hands after PPE removal. During observation and interview on 2/11/25 at 8:21 a.m. outside R36's room was a sign indicating EBP in addition to a set of drawers containing gowns and gloves. Licensed practical nurse (LPN)-A entered R36's room with a plastic cup containing a colored liquid. LPN-A washed hands and applied gloves. Without donning a gown, LPN A removed dressing from R36's g-tube site and cleaned area with wound wash and a gauze sponge. LPN-A removed gloves, sanitized hands, and applied a new set of gloves. A barrier cream was applied to the skin surrounding the g-tube and a new dressing was applied. LPN-A then administered the colored liquid into the G-tube, flushed the tube with water, removed gloves, and threw away garbage. During an interview, LPN-A stated EBP is important because of exposure due to R36's tube. LPN-A stated gloves were the only requirement for EBP. LPN-A was unaware if the facility provided any specialized training related to EBP. During interview on 2/12/25 at 1:08 p.m., nursing assistant (NA)-A stated staff are required to do yearly online training and in person training regarding EBP. During an interview on 2/12/25 at 1:26 p.m., the infection preventionist (IP) stated appropriate PPE is required for all high contact cares, including administering medications via G-tube, G-tube site care, changing clothing, and bathing for residents on EBP. The IP confirmed gown and gloves should be during R36's dressing change and medication administration. A policy titled Enhanced Barrier Precautions revised 4/1/24, indicated Enhanced Barrier Precautions (EBP) expands the use of Personal Protective Equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated. It also refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. In a grid listing the types of transmission-based precautions and when/how to implement them, the policy indicated Enhanced barrier precautions is implemented for residents with indwelling medical devices, including feeding tubes). Staff are instructed to don gloves and a gown prior to any high contact care activity. High contact care activity included indwelling medical device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator.

Based on interview and document review, the facility failed to follow a care planned intervention to prevent or reduce the risk of falls for 1 of 3 residents (R1) reviewed for falls. This resulted in actual harm when R1 fell and sustained a right fibular fracture which required an emergency room (ER) visit. The facility implemented immediate corrective action, so the deficient practice was issued at past non-compliance. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had severely impaired cognition and diagnoses of dementia, fracture of upper and lower end of right fibula, anxiety disorder and depression. Further identified R1 required 2-person extensive assist with bed mobility, transfers, and toileting. R1 had one fall with injury and two falls with major injury. R1's fall Care Area Assessment (CAA) dated 5/28/24, identified R1's was at risk for falls due to R1 received physician ordered anti-depressant medications. R1 has had one fall during this assessment period. Nursing staff assisted R1 with activities of daily living (ADL)'s as needed according to facility policy. R1 was at risk for fall related injury. No referrals at this time, will proceed to care plan with goal to have no fall related injuries. R1's care plan dated 7/1/24, identified R1 was at risk for falls due to generalized muscle weakness, use of high-risk psychotropic medications, and cognitive impairment. An intervention directed staff will wake and assist R1 to bathroom every day at 11:00 p.m., and 4:00 a.m. Additional intervention dated 8/9/24 identified night light to be used at all times due to R1 keeping the lights off and shades shut most of the time. R1's progress note dated 8/9/24, identified R1 had a fall at 7:15 a.m., R1 was calling out for help and found sitting on the floor in front of her bed. R1's room was dark at the time of the fall with the lights off and the shades pulled down. R1 stated she was on her way back from the bathroom and had attempted to get back into bed when she fell . No injury noted. R1's Fall Event Report, dated 8/9/24 identified R1 had an unwitnessed fall and was coming back from the bathroom and getting into bed. On 8/9/24 at 10:40 p.m., R1 had no complaints of pain, did have a night light placed in her room in the am and R1 commented she liked it. R1's progress note dated 8/12/24, identified R1 was heard yelling for help on the night shift around 1:10 a.m., R1 was discovered in her room lying on the floor on her right side. R1 had complaints of severe lower extremity pain, primarily on her right lower extremity (RLE) but upon focused assessment had more difficulty moving her left lower extremity (LLE). R1 was alert and oriented and stated that she hit her head, and a lump was noted to the back of her head. Family member (FM)-A was contacted due to R1 reports of severe pain and was agreeable to emergency transport to hospital for further assessment. R1 was transported from the facility to the hospital around 2:50 a.m. for further assessment. R1's Event report dated 8/12/24, included the aforementioned information pertaining to R1's fall. Additionally noted R1 was unsure what she was doing prior to fall but verbalized needing to use the restroom. R1's progress note dated 8/12/24 at 7:04 a.m., identified a call was received from the hospital indicating R1 will be sent back via ambulance with a right fibular fracture, proximal to R1's ankle. A Facility Investigation, completed 8/15/24, IDT team reviewed fall on 8/12/24 that occurred at 1:10 a.m. Fall was not witnessed, and staff were alerted to fall by resident calling out in pain. R1 was located lying on the floor next to her bed and could not state what she was doing but did verbalize needing to use the restroom. R1 had not been offered toileting at 11:00 p.m. by NA-A as the care plan stated and R1 was not checked on at midnight by NA-A during rounding. Interventions were to remove pillow top mattress, switch rooms so R1 could be closer to center of unit and not at end of hall so staff could see her more frequently. Toileting changed to every 2-3 hours. [NAME] light was added as R1 stated she was confused by the red button call light. Care plan updated to have transfers with assist of two and ceiling track. Physical therapy (PT) and occupational therapy (OT) was ordered by provider. Family approved of interventions. Care plan, group sheets, and communication book updated. R1 had an appointment with certified nurse practitioner (CNP)-A to review falls in one week and review pain management on 8/13/24. Education was provided to NA-A regarding care plan stating resident was to be toileted at 11:00 p.m., as this did not occur and of the importance of visualizing resident during rounds. NA-A last day of employment was 8/16/24 as separation of employment. During a phone interview on 11/4/24 at 2:48 p.m., NA-A stated she remembered the night R1 fell and stated she was very busy that night and did not make it into R1's room at 11:00 p.m., to toilet her, also stated she did not get to R1 on rounds at 12:00 a.m. NA-A stated she was on a different floor when R1 fell on [DATE]. NA-A stated someone at that facility did educate her about the importance of following the residents care plan and the importance of rounding timely. During a phone interview on 11/4/24 at 2:56 p.m., licensed practical nurse (LPN)-A stated she was the nurse that worked the floor the night R1 fell . LPN-A stated it was her first time working at the facility and had been walking to another residents room to give some medications when she heard R1 calling for help. LPN-A stated she asked another nurse for help due to being unfamiliar with R1 and R1 ended up being sent to the ER and came back with a fractured lower right leg. LPN-A stated R1 was in a lot of pain, and she had not been in R1's room prior to the fall. During an interview on 11/4/24 at 2:13 p.m., registered nurse (RN)-A indicated R1 fell on [DATE] at 1:10 a.m., due to needing to use the bathroom which resulted in a trip to the ER and a fractured right fibula. RN-A indicated nursing assistant (NA)-A did not offer toileting at 11:00 p.m. per R1's plan of care and this could have prevented the fall. NA-A was educated on the importance of following the care plan. RN-A stated we review falls in interdisciplinary Team (IDT) meeting Monday through Friday, we will look at all of the information documented to ensure a root cause, appropriate interventions are in place and to ensure the care plan was being followed. RN-A stated on Wednesdays we review all falls for the week to ensure the interventions we put in place remain appropriate, if not we may remove intervention and add a new one. During an interview on 11/4/24 at 3:08 p.m., director of nursing (DON) and regional nurse consultant (RNC)-A reviewed R1's facility fall investigation and identified a comprehensive fall investigation was completed to include a summary of events, interviews, resident assessment, description of immediate resident protections, notifications, causal and/or contributing factors, and an overall detailed summary. DON and RNC-A indicated on 8/12/24, R1's care plan for toileting was not followed resulting in a fall with a fracture. DON and RNC-A indicated education was completed with NA-A on the importance of following the care plan and the importance of rounding timely along with expectations. DON and RNC-A indicated all falls are reviewed Monday through Friday to ensure interventions are in place and to ensure the care plan was followed. DON and RNC-A further indicated they meet every Wednesday to ensure all fall interventions are appropriate. The deficient practice was corrected on 8/15/24, after the facility implemented a plan that included the following actions: R1 was immediately assessed and fall protocols were followed. Upon R1's change in pain and mobility status, R1 was transferred to the ED. Facility investigation was coordinated with interviews of staff and R1, along with care plan review. NA-A was provided verbal coaching and education after it was determined she failed to follow R1's plan of care. The facility reviewed falls at IDT Monday through Friday to ensure the care plan was followed for each fall and reviewed all falls weekly on Wednesdays to ensure current prevention interventions that were in place were effective. The facility was free of additional falls after 8/15/24 related to failure to follow plan of care. The corrective actions were verified through documentation review and staff interviews. Facility policy, Comprehensive Assessments and Care Planning, revised 9/27/23, identified a purpose to provide a comprehensive person-centered interdisciplinary care assessment of the resident's condition, in order to develop consistent quality care that will attain or maintain the highest practicable physical, mental, and psychological functioning possible, a facility must make a comprehensive assessment of a resident's needs, using the RAI specified by the State .11. All person-centered care plan interventions will be implemented by qualified personnel. Interventions may be communicated through the electronic health record, resident profile, assignment sheets, and/or verbal communication . Facility policy, Integrated Fall Management, reviewed 9/2023, identified the Purpose: Fall risk assessment, identification, and implementation of appropriate interventions as necessary, to maintain resident safety, prevent falls and reduce further injury from falls. Residents with risk for falling will have interventions implemented through the resident centered care plan.

Based on observation, interview, and document review the facility failed to ensure proper hand hygiene during personal cares and wound care for 1 of 1 resident (R3) observed for infection control practices. Finding include: R3's face sheet identified diagnoses that included chronic heart failure, dementia with behavioral disturbances, and difficulty walking, R3's quarterly minimum data set (MDS) dated [DATE], identified R3 was usually understood and sometimes understands with verbal and nonverbal expressions, had severe cognitive impairment, and was dependent on staff for assistance with most to all dressing and grooming activities. R3's infection care plan dated 5/6/24, identified R3 required enhanced barrier precautions and staff are to apply gloves and gowns prior to facility-identified high-contact care activities, discard personal protective equipment (PPE) is designated location following activities and sanitize hands after PPE removal. R3's skin care plan dated 1/11/24, identified pressure area to left heel to be documented on and measured weeky to follow treatment orders. Skin care plan dated 3/18/24 identified pressure area to right buttocks to be documented and measured weekly and to follow treatment orders. During an observation on 5/14/24 at 1:42 p.m., licensed practical nurse (LPN)-A and LPN-B assisted R3 with incontinent care before providing wound care on heel and coccyx wound. LPN-A applied gloves and removed old dressing on heel, noted that LPN-A's gown was not tied behind her neck which caused the gown to fall down her arms which required LPN-A to adjust the gown numerous times while providing cares. With gloved hands, LPN-A removed removed the old wound dressing, cleansed R3's wound, and then applied barrier cream. LPN-A then removed gloves, cleansed hands in the residents bathroom with soap and water, and proceeded to put on new dressing with no gloves on. LPN-A stated, I don't use gloves to apply new bandages as it will stick to my gloves when I try to apply it to the wound. LPN-A and LPN-B proceed to the bathroom to wash hands and apply gloves. LPN-A and LPN-B positioned R3 on her side. R3 was incontinent of stool, LPN-A used a wipe to remove stool from R3's bottom and LPN-B removed the soiled brief. LPN-A and LPN-B put the clean brief on.Neither LPN-A nor LPN-A changed their gloves and performed hand hygiene prior to putting on the new brief. During an interview on 5/14/24 at 2:07 p.m., LPN-A stated she knew she was supposed to change gloves and sanitize or wash hands after removing old dressing and putting on new dressing. LPN-A explained she should have tied her gown but when she ties the gown it pulls her hair. Further, LPN-A stated she did not put on new gloves or sanitize her hands properly because the dressings stick to her gloves. During an interview on 5/14/24 at 2:08 p.m., LPN-B stated she had not removed her old gloves before putting new brief in place and touching other items, but knew that she was supposed to. LPN-B was unable to articulate why she had not competed proper hand hygiene during R3's cares. During an interview on 5/15/24 at 2:35 p.m., with the executive director (ED) and regional director of clinical services-South region expected staff to perform hand hygiene according to the facility policy and procedure. Facility Policy titled Hand Hygiene, revised 9/2023, indicated, Hand hygiene simply means cleaning hands using either handwashing (washing hands with soap and water), or antiseptic hand rub (i.e. alcohol-based hand sanitizer, including foam or gel). Times to Perform Hand Hygiene are, but not limited to: When arriving for work, When hands are visibly soiled wash hands with soap and water, Before and after direct resident contact Before and after performing any invasive procedure (e.g. fingerstick blood sample), Before and after entering isolation precaution setting, Before and after eating or handling food - wash hands with soap and water, Before and after assisting a resident with meals - wash hands with soap and water, Before and after assisting a resident with personal cares, Before and after handling peripheral vascular catheters and other invasive devices, Before and after inserting indwelling catheters, Before and after changing a dressing, Upon and after coming in contact with a resident's intact skin, such as when taking vitals or after assisting with lifting, After personal use of the restroom - wash hands with soap and water Before and after assisting a resident with toileting - wash hands with soap and water, After blowing or wiping nose After contact with a resident's mucous membranes and body fluids or excretions, After handling soiled or used linens, dressing, bedpans, catheters and urinals, After handling soiled equipment or utensils, After performing your personal hygiene - wash hands with soap and water, After removing gloves or aprons When work day is completed.

Based on observation, interview and document review the facility failed to provide appropriate care in a timely manner to prevent a decline in condition for 1 of 1 residents (R32) when R32 continued to experience prolonged nausea and decline lasting more than three weeks causing harm. As a result, R32 was sent to the emergency department (ED) and admitted to the intensive care unit (ICU) after the facility failed to ensure the provider was fully appraised of R32's signs and symptoms. Findings include: R32's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R32 was admitted to the facility on [DATE] after a right knee fracture, had moderate cognitive impairment and was dependent on staff for toileting, bathing, personal hygiene, transfers, and locomotion. During an interview on 12/11/23 at 3:59 p.m., R32 stated she had not seen a physician in person since she had started feeling sick, stating she was nauseated all the time and was not able to eat much due to her nausea. R32 stated she was able to tolerate the pain from her fracture but could not live with this nausea. During an interview and observation on 12/13/23 at 10:40 a.m., R32 stated she just wanted to get better but did not want to go to the hospital. Stating she continued to feel nauseated all the time. R32 was pale in color. R32's progress notes indicated the following: 11/21/23 R32 complained of being nauseated with little appetite, stating she felt like spitting up. 11/23/23 R32 tested positive for COVID. The nurse practitioner (NP) was updated and started R32 on Mirtazapine for appetite stimulant. 11/27/23 R32's nausea was continuing. R32 stated, I can't eat if I'm always nauseated. 11/28/23 R32 had a spell in the bathroom where her colored turned pale, her head lowered and she came back around after a few seconds. It was also documented R32 had 2 loose stools, black in color. R32 stated not right now when offered to be sent to the hospital. 11/29/23 the nursing assistant (NA) found R32 to be unresponsive while changing her brief. The nurse was called to the room and found R32 with brownish liquid coming from her mouth. R32 did not respond when the nurse called her name or shook her. When R32 came around she was asked if she wanted to be seen in the emergency department and refused. 11/29/23 R32 had a loose, blackish stool and was noted to have a spot of darkened blood on her gown. R32's daughter in law was updated on the small spell in the bathroom on 11/28/23. 11/30/23 a referral for hospice was made and R32 continued to have loose black stools. The note indicated the medical director (MD) would be updated on the hospice consult. 12/2/23 R32's appetite remained poor, R32 stated I'm so sick to my stomach, I can't eat, The note indicated R32 was having a difficult time taking medications. 12/3/23 R32 had complaints of nausea. R32 became tearful when she was too weak to transfer on her own. 12/4/23 R32 stated she was nauseated, had a difficult time taking medications and did not eat any breakfast. 12/4/23 R32's weight was declining due to R32 refusing most meals and was being followed by the registered dietician (RD). 12/5/23 R32 continued to state feeling sick to my stomach and did not eat any breakfast. 12/6/23 R32 continued to have multiple loose stools, stating I can't eat if I am nauseated all the time. The nurse practitioner (NP) was informed and gave an order for as needed (PRN) Zofran (an antiemetic that can prevent nausea and vomiting). 12/7/23 R32 received an order from the provider for occupational therapy for lymphatic treatment and massage due to new swelling of her lower extremities. 12/8/23 the MD was updated about R32 having bleeding gums. R32 continued to have slight nausea. 12/8/23 the MD ordered labs to be obtain to include BMP and CBC with differentials due to concerns with bleeding gums. 12/8/23 R32's platelets within normal limits (WNL) and do not indicate a bleeding concern. R32 continued to have nausea and loose stools. 12/9/23 R32 had a negative COVID test and was removed from COVID isolation. 12/11/23 R32 became upset she was feeling so rotten all the time and had no breakfast. R32 was documented as being pale in color. 12/11/23 R32 continued with nutritional decline and significant weight loss. The RD met with R32 who stated she can't keep anything down due to her ongoing nausea. 12/11/23 R32 had complaints of nausea and diarrhea. R32 had two stools that shift and had two spells of passing out while being transferred to the toilet. It was documented with both episodes she became flaccid and during the second episodes had difficulty holding her head up. 12/12/23 R32's daughter in law was updated regarding the evening shift toilet episodes and R32 continued to not eat and remain nauseated even after Zofran was given. R32 was noted to have four loose stools that shift. 12/13/23 it was documented R32 had a spell of unresponsiveness at 4:00 a.m. While being transferred R32 had explosive, loose, dark stool stating she felt sick, holding her mouth as if to vomit. R32 progressively became unresponsive, bowing her head. Progress note included, R32 had flaccid, arms barely supporting her weight on the sling. On coming shift was updated. 12/13/23 R32 refused breakfast and when R32 attempted to sit on the side of the bed she stated she needed to lay back down and was pale and nauseated. B/P was 67/45 while up and 92/60 when laying back down. R32 stated, why do I feel so sick? Medications were held and supervisor was updated. 12/13/23 the NP decided R32 should be sent to the hospital for evaluation. R32 was okay with going to the hospital if they could get her to feel better. 12/13/23 R32 was in the ICU with a potential GI bleed. R32's family refused diagnostic testing for confirmed GI bleed but okayed R32 receiving a blood transfusion for low hemoglobin. R32's electronic medical record (EMR) indicated R32 had a face-to-face provider visit twice since admission. On 10/26/23 the MD saw R32 for her admission visit and on 11/22/23 the NP saw R32 for a routine visit. R32's Active Orders list indicated the following medication orders: amlodipine 2.5 milligrams (mg) daily (a high blood pressure medication), adjusted on 12/12/23; lisinopril 5mg daily (a high blood pressure medication), adjusted on 12/12/23; ferrous sulfate 325 mg daily (iron supplement), dated 11/1/23; Eliquis 5mg twice a day (a blood thinner medication), dated 10/9/23; and Zofran 4 mg every eight hours PRN for nausea and vomiting. R32's care plan lacked interventions to address R32's frequent and continued nausea and diarrhea described as loose and black in color. During an interview on 12/13/23 at 2:58 p.m., the rehab social worker (SW) stated she reached out to the hospice social worker after the hospice meeting on 11/30/23, who stated family was waiting on an x-ray scheduled for 12/4/23 to decide if they wanted to continue with therapy or pursue hospice. The SW was unsure if staff had followed up with family after the x-ray on 12/4/23. R32's EMR lacked evidence the family had been re-approached about hospice care versus continuing with therapy after the x-ray on 12/4/23. R32's Physical Therapy Treatment Encounter Note, dated 11/28/23, indicated physical therapy (PT) entered R32's bathroom, R32's head was hanging down and she was not responding to verbal or tactile cues. R32 began saying a few words after several minutes but was not responding appropriately. Session ended due to patient medical condition. R32's Physical Therapy Treatment Encounter Note, dated 12/11/23, indicated R32 was complaining of an upset stomach after sitting on the edge of the bed. The note indicated R32 was receiving nausea meds but was unsure if they were helping. R32 stated she wanted to get better but was unable to continue with the therapy session due to an upset stomach. R32's Physical Therapy Treatment Encounter Note, dated 12/13/23, indicated R32 had complaints of feeling like she was going to pass out when sitting on the edge of the bed. The note indicated R32 was still not eating or drinking daily due to nausea and had been taking nausea medicine daily without a notable difference. Therapy session was stopped due to R32's medical condition. During an interview on 12/13/23 at approximately 9 a.m., occupational therapist (OT)-A stated she had an order to see R32 for lymphedema treatment due to increased swelling in her lower extremities. OT-A stated due to R32's low blood pressure and continued nausea she would not be medically stable enough for lymphedema treatments. During an interview on 12/13/23 at 9:15 a.m., NA-A stated R32 was often nauseated and weak, stating they just want us to use the bed pan and push fluids. During an interview on 12/13/23 at 10:15 a.m., licensed practical nurse (LPN)-D stated she would not update the provider if there was a concern with a resident or a change in condition, as she would let the charge nurse know, even on the weekends. LPN-D stated R32 hadn't been good lately and has been sick on and off for a few weeks. LPN-D confirmed utilizing R32's PRN Zofran the past couple of days, stating it was not working. During an interview on 12/13/23 at 11:30 a.m., the assisted director of nursing (ADON) stated R32 came to the facility for rehab due to a knee fracture and did not have a good appetite since admission and would make statements she was ready to go to heaven. During review of the EMR, the ADON confirmed R32 had not seen a provider since 11/22/23 but on 11/1/23 labs were drawn and an iron supplement was started, 11/23/23 Mirtazapine was started as an appetite stimulant, 12/6/23 Zofran was started (14 days after first unset of nausea), 12/7/23 orders were received for occupational therapy, 12/8/23 labs were completed and on 12/11/23 blood pressure medications were adjusted. The ADON was unaware R32's unresponsive episodes started on 11/28/23 and was under the impression the first episode was early that morning. The ADON stated she would like to be updated on R32's unresponsive episodes but it was unrealistic to know about them all and she expected the nurses to update the providers on any change in condition. The ADON was also not aware the Zofran was ineffective for R32 stating, apparently it is not working if she is still nauseated. The ADON stated they had recommended hospice, but the family was still undecided on hospice versus continuing to treat with therapy. During an interview on 12/13/23 at approximately 2:00 p.m., the NP stated she sent R32 to the hospital due to her low blood pressure. The NP stated she aware of R32's unresponsive episode early that morning but was unaware they started back at the end of November, stating she would like to be made aware of every episode but not necessarily the same day they happened. Further, the NP was unaware of the uncontrolled nausea, stating she had initiated the Zofran but was not aware it was not working. The NP did confirm she was aware of the black tarry stool, stating since R32 was on iron it was hard to tell if it was related to her low blood pressure readings. (Black stool is often a sign of gastrointestinal bleeding, but not always. Certain medications and supplements, such as iron, may turn stool black.) During an interview on 12/14/23 at 10:19 a.m., the medical director (MD) stated she met R32 for her initial visit on 10/26 and that was the only time she met with R32. The MD stated R32 came to the facility with a knee fracture and history of dementia. She was doing therapy but not participating well. The MD stated she was aware of R32's poor appetite and had started mirtazapine for an appetite stimulant. She was aware R32 was started on Zofran for nausea and had started cutting back on some medications on 12/12/23. The MD further stated R32 would be a good candidate for hospice. The MD stated she was not personally aware of R32's multiple unresponsive episodes, the episodes of loose, black stools, the brown liquid found coming from R32's mouth or that her nausea remained uncontrolled. The MD stated she was notified of possible bleeding gums, which was why she had ordered labs on 12/8 but not of the brown liquid coming from R32's mouth while unresponsive or the loose black stool. The MD further stated she would want to be made aware of these episodes but not necessarily the day they occurred, stating she did not believe she had a full picture of R32's condition, stating multiple providers were made aware of different situations making it difficult to see the full picture, as many of these signs and symptoms indicate a potential GI bleed. The MD stated she would have approached R32's care different had she been aware, starting a proton pump inhibitor (a class of medications that cause a profound and prolonged reduction of stomach acid production), more routine hemoglobin checks, more intensive interventions for her nausea and a more forward conversation about goals of care with R32 and her family to appropriately address R32 with either treatment focused interventions or comfort care. The MD stated R32's hemoglobin went from 11.3 to 9.6 this morning, stating she would suspect a GI bleed until it was ruled out, stating the only way to conclusively tell would through an endoscopy (a flexible instrument inserted through the mouth or rectum to view the inside of the GI tract). During an interview on 12/14/23 the director of nursing (DON) stated R32 had been addressed at their interdisciplinary team (IDT) meetings and she would have expected the nurses to take care of it. The DON stated she did not want R32 back to the facility without a clear plan of either treatment or comfort focused care. A facility policy titled Change in Condition, reviewed 10/2/23, indicated when a significant change in the resident's physical, mental or psychosocial status is identified by the license nurse, or when there is a need to alter treatment significantly. The licensed nurse consults with attending provider or the medical director.

Based on observation, interview and document review, the facility failed to ensure medications were labeled appropriately with open dates. In addition, the facility failed to remove expired medications for 6 of 82 residents (R76, R29, R34, R16, R39) whose medications were observed during medication storage. Findings include: During the medication storage tour on the second floor on 12/13/23 at 2:11 p.m., with trained medication aide (TMA)-B there were medications with no open dates and medications/items past the expiration date as listed below: -lantus insulin for R29 with no open date -29 hydrogen peroxide wipes manufacturer's expiration date of 11/9/22 -copper tone sun screen with manufacturer's expiration date of 11/2020 -equate sport sun screen with manufacturer's expiration date of 11/2020 -mineral oil with manufacturer's expiration date of 12/5/22 On 12/13/22 at 2:15 p.m., registered nurse (RN)-A stated medication carts should be checked monthly for expired medications. RN-A stated this was important to ensure residents did not receive medications which had expired. During the medication storage tour on the third floor on 12/13/23 at 2:34 p.m., with licensed practical nurse (LPN)-A antacid tablets with manufacturer's expiration date of 9/2023 were found in the medication cart. During the medication storage tour on the fifth floor on 12/14/23 at 10:06 a.m., with LPN-E there were medications with no open dates and medications/items past the expiration date listed below: - albuterol inhaler for R34 expiration date of 10/2022 -aspirin 81 milligrams (mg) expiration date of 1/2023 -glycerin eye drops for R16 expiration date of 7/2023 -naphocon-a-sol eye drops for R16 expiration date of 9/15/22 -albuterol inhaler for R39 expiration date of 9/18/23 On 12/14/23 at approximately 10:15 a.m., LPN-E stated it was important to have a process in place to make sure staff were not administering expired medications to residents. During the medication storage tour on the fourth floor on 12/14/23 at 10:27 a.m., with LPN-D dorzolamide timolol eye drops for R76 were found with an expiration date of 7/2023. On 12/14/23 at 9:29 a.m., consultant pharmacist (CP) stated staff should be checking medications in the carts on a regular basis to ensure there were no outdated medications. On 12/14/23 at 10:53 a.m., the director of nursing (DON) stated the staff should be completing cart audits monthly. The DON stated the purpose was to ensure residents were not given outdated medications as they could have lost their effectiveness. Medication Storage in the Facility dated 4/1/19, included-directed the staff to do the following: E. The nurse will check the expiration date before administering it. F. No expired medication will be administered to a resident. G. All expired medications will be removed from the active supply and be destroyed in the facility, regardless of the amount remaining. The medication will be destroyed in the usual manner.

Based on observation, interview and document review, the facility failed to ensure narcotics were counted in a manner to detect potential diversion at shift change for 2 of 7 medication carts reviewed. Findings include: On 12/12/23 at 2:50 p.m., licensed practical nurse (LPN)-B on-coming staff and LPN-C off-going staff counted narcotics in two carts. LPN-B unlocked the drawer and would call out the group number and the page number. LPN-C would look for the page number in the narcotic book and LPN-B would say how many pills or milliliters (ml) if it was a bottle with liquid. LPN-C would confirm the number or ml was correct. The index page and/or paging through each page was not used to ensure all medications were accounted for. LPN-B stated the on-coming staff was in the drawer and the off-going staff was looking in the book. On 12/12/23 at 2:58 p.m., LPN-B stated unless they looked at each page in the book they would not know if a card or bottle was missing. LPN-B verified they did not review each page and not all medications had been signed into the index page of the narcotic book. On 12/12/23 at 3:02 p.m., registered nurse (RN)-A stated the process was to use the index page to sign in all narcotics. In addition, RN-A stated staff needed to use the index page to count narcotics at shift change would to ensure all medications were accounted for. RN-A verified the index pages had medications not signed into the book, three of 40 were not signed into book one, seven of 40 were not signed into book two, two of 40 were not signed into book four, and four of 12 were not signed into book five. On 12/12/23 at 3:15 p.m., RN-B stated the process for the narcotic count would be to check each page to ensure all medications were accounted for and correct. RN-B stated staff should be signing all narcotics into the book using the index page and filling out the information on the corresponding page. On 12/12/23 at 3:21 p.m., the assistant director of nursing (ADON) verified the books had missing entries for narcotics on the index pages of the narcotic books. The ADON verified when staff complete the narcotic count at shift change they should be counting from the book (checking each page) to ensure each medication is accounted for. On 12/12/23 at 3:34 p.m., the director of nursing (DON) verified it was best practice to sign each narcotic into the index page and fill in the information on the corresponding page. The DON verified staff should look at each page to ensure all narcotics were counted and accounted for to prevent diversion. On 12/14/23 at 9:31 a.m., the consultant pharmacist (CP) verified staff should count narcotics from the book to ensure no medications were missing from the cart. Medication Ordering And Receiving From Pharmacy dated 4/1/19, directed staff to do the following: Controlled substance inventory sheets are completed, if necessary , and filed appropriately. A hard-bound log book is utilized to track the controlled substance from delivery to disposition.

Based on observation, interview, and document review, the facility failed to ensure communal vital signs machine was disinfected between resident use for 2 of 2 residents (R61, R71) observed to have vital signs checked conducted without proper disinfection of the machine. This practice had the potential to affect all 26 of 26 resident residing on the floor. Findings include: On 12/14/23 at 7:49 a.m., licensed practical nurse (LPN)-A was observed to enter R71's room with the communal vital sign machine. LPN-A proceeded to take vital signs for R71 and exited her room. LPN-A was not observed to disinfect the vital sign machine. There were no disinfecting wipes observed on the vital sign machine. The vital sign machine was left in the hallway, while LPN-A stopped and talked to another staff. On 12/14/23 at 7:51 a.m., LPN-A was observed entering R61's room with the communal vital sign machine that had not been disinfected. LPN-A proceeded to take vital signs for R61. Upon exiting the room, the communal vital sign machine was placed by the nursing station, by the scale without being disinfected. During interview with LPN-A, on 12/14/23 at 8:05 a.m., they stated that they had taken numerous residents vital signs this morning. They stated it is expected to disinfect the vital sign machine between each resident, the importance of this as it helps stop the spread of viruses and verified, they had a recent outbreak of COVID. They verified they had not disinfected the vital sign machine between any of the vital signs they took this morning or upon completion of taking vital signs for the morning. During interview with infection preventionist (IP), she stated it is the expectation any equipment used for more than one resident is to be disinfected between residents. She stated all staff have been trained on this on hire, annually and on-going. She stated it is important to disinfect equipment between residents to stop the transmission of disease. During interview with director of nursing (DON) on 12/14/23 at 11:25 a.m., stated it is the expectation all equipment is disinfected between resident, supplies are readily available to staff, education and training is provided to all staff. She stated the importance of disinfecting equipment as it stops transmission of viruses. A facility policy titled, Resident Care Equipment, dated June 2017 was provided. The policy indicates that each community will protect against indirect transmission, which is the transfer of an infectious agent through a contaminated intermediate object, through decontamination for an object rendering it safe to use. The policy indicates a procedure to follow for disinfecting equipment.

Based on interview and document review, the facility failed to implement the current standards of vaccinations regarding pneumonia for 4 of 5 residents (R13, R17, R31, and R72) over [AGE] years old whose vaccinations histories were reviewed. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/15/2023, identified various tables when each (or all) of the pneumococcal vaccinations should be obtained. This identified when an adult over [AGE] years old had received the complete series (i.e., PPSV23 and PCV13; see below) then the patient and provider may choose to administer Pneumococcal 20-valent Conjugate Vaccine (PCV20) for patients who had received Pneumococcal 13-valent Conjugate Vaccine (PCV13) at any age and Pneumococcal Polysaccharide Vaccine 23 (PPSV23) at or after [AGE] years old. R13's facility immunization record, dated 12/12/23, indicated she was [AGE] years old. The record indicated she received a PCV13 on 6/4/2013 followed by the PPSV23 on 9/15/2015. A copy of the MIIC (Minnesota Immunization Information Connection) report, provided 12/14/23, indicated PPSV23 was administered 11/1/2009 and 11/20/2009 also. There was no evidence in the electronic medical record or MIIC report that R13 was provided education, offered, or received PCV20 following the PCV13 and PPSV23 series. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. R17's facility immunization record, dated 12/12/23, indicated she was [AGE] years old. The record indicated she received a PPSV23 on 10/11/2012 followed by the PCV13 on 3/3/2016. A copy of the MIIC (Minnesota Immunization Information Connection) report, provided 12/14/23, indicated PPSV23 was administered 6/4/1998 and 10/11/2012 also. There was no evidence in the electronic medical record or MIIC report that R17 was provided education, offered, or received PCV20 following the PCV13 and PPSV23 series. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. R31's facility immunization record, dated 12/12/23, indicated he was [AGE] years old. The record indicated he received a PPSV23 on 10/7/2014 followed by the PCV13 on 12/8/2016. A copy of the MIIC (Minnesota Immunization Information Connection) report, provided 12/14/23, indicated PPSV23 was administered 9/6/11 and PCV13 on 1/18/17 also. There was no evidence in the electronic medical record or MIIC report that R17 was provided education, offered, or received PCV20 following the PCV13 and PPSV23 series. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. R72's facility immunization record, dated 12/12/23, indicated she was [AGE] years old. The record indicated she received a PPSV23 on 12/2/2000 followed by the PCV13 on 6/25/15. There was no evidence in the electronic medical record or MIIC report that R72 was provided education, offered, or received PCV20 following the PCV13 and PPSV23 series. The record lacked evidence of shared clinical decision making with the physician for PCV20 at least 5 years after the last pneumococcal dose. During an interview with infection preventionist (IP), on 12/13/23 at 12:52 p.m., she indicated immunizations are verified upon admission. She indicated immunizations are verified through MIIC (Minnesota Immunization Information Connection), Epic (electronic health record system) and will ask residents/families and consents are obtained. IP stated she is using the current CDC recommendations from March 2023. IP verified R13, R17, R31 and R72's pneumococcal immunizations as listed above. IP verified they had not been offered or provided education on PCV20. IP stated they have focused on administering influenza immunizations, then COVID immunizations. The next phase is to administer RSV (respiratory syncytial virus) vaccine and then will review pneumococcal vaccines. IP stated they do not have a date or a definite plan in place for administering or hosting an immunization clinic for RSV. At this time, there is no time frame on when the pneumococcal vaccines will be offered and reviewed. During interview with director of nursing (DON), on 12/14/23 at 1:23 p.m., she indicated IP keeps the records for immunizations and it is everyone's responsibility to ensure residents are up-to date on immunizations. She stated the pharmacist assists with this. She stated they have access to MIIC to help review records. During interview with medical director (MD), on 12/14/23 at 11:32 a.m., she stated flu, COVID and RSV are priority immunizations. She indicated she feels technically residents are up to date on pneumococcal immunizations. She did verify according to the guidelines from CDC, there is a PPSV20 which should be offered. She stated she does not know of any plans, at this time, for administering the RSV vaccine to residents. MD verified she has not had any discussions with any residents regarding the pneumococcal immunizations. A facility policy titled Pneumococcal Vaccines for Residents with a review date of 2/7/22 was provided. Policy indicated: it is the policy of BHS communities to provide education and administration of the PPSV23 and PCV13 to the residents of the facility according to CDC recommendations. CDC now recommends pneumococcal conjugate vaccine PCV15 or PVC20 for Adults who have NEVER received a prior pneumococcal conjugate vaccine PCV13 if they are [AGE] years or older and have certain chronic medical conditions or other risk factors. For adults who have only received PCV13 but not PPSV23, CDC recommends vaccine providers give PPSV23 as previously recommended. One reference indicated is CDC updated guidance - MMWR 1/28/22.

Based on interview and document review the facility failed to ensure a resident's code status was consistent across the Electronic Medical Record (EMR) and paper chart for one of 10 residents (R46) reviewed for advanced directives. Finding include: R46's Face Sheet, indicated R46 was admitted to the facility on [DATE] with a primary diagnosis of hemiplegia and hemiparesis following a cerebral infarction affecting her left, non-dominant, side. The banner at the top of R46's face sheet further indicated R46's code status was do not resuscitate (DNR)/ do not intubate (DNI). R46 physician order, dated [DATE], indicted R46's code status was DNR/DNI. R46's Provider Order for Life-Sustaining Treatment (POLST), dated and signed by R46 on [DATE], indicated R46 would like cardiopulmonary resuscitation (CPR) if she had no pulse and/or was not breathing and would like full treatment to include intubation, advanced airway interventions and mechanical ventilation as indicated. R46's Health Care Directive, dated and signed by R46 on [DATE], indicated R46 would like CPR attempted if her heart or breathing stopped, based on her current state of health. A Care Conference Progress Note, dated [DATE], indicated R46 had changed her mind on her code status and wished to be DNR. During observation [DATE] at 2:00 p.m., R46's paper chart behind the nursing station contained R46's face sheet as the first page, indicating R46 was DNR/DNI. Directly behind R46's face sheet was R46's Health Care Directive which indicated R46 was full code and would like to be resuscitated. During an interview on [DATE] at 2:23 p.m., licensed practical nurse (LPN)-D stated she would use the Banner in the EMR to know a resident's code status and stated R46's code status was DNR/DNI. During an interview on [DATE] at 3 p.m., nurse manager and registered nurse (RN)-A stated the best place to look for a resident's code status was the Banner in the EMR as that was the most accurate information. During an interview on [DATE] at 10:40 a.m., nurse manager and RN-A stated they used a checklist to indicate what documents to send with a resident when then needed to go to the hospital. Among those documents to send to the hospital with the resident was the POLST and physician orders. RN-A confirmed these documents for R46 would contain conflicting information with the orders stating DNR and the POLST stating full code. During an interview on [DATE] at 12:10 p.m., the director of nursing (DON) stated she would expect the information on code status to match, acknowledging there was conflicting information in R46's chart. A facility policy on code status and advanced care planning was reviewed.

Based on interview and document review the facility failed to fully and accurately complete the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) (Form CMS-10055) for two of three residents (R13 and R64) reviewed for beneficiary notices. Findings include: The SNFABN contains a section with three options for the resident or resident representative to select. Option One indicates the resident would like the care listed above and recognizes payment responsibility but would like Medicare to be billed for an official decision on payment, Option Two indicates the resident would like the care listed above and recognizes payment responsibility but does not want Medicare billed and Option Three indicates the resident does not want the care listed above. R13's face sheet, indicated R13 was admitted to the facility on [DATE] with a primary diagnosis of senile degeneration of the brain. R13's Progress Note, dated 6/21/23, indicated R13's skilled services would be ending on 6/23/23 with financial liability beginning on the following date. The progress note detailed a phone conversation with R13's daughter regarding the SNFABN but failed to identify what option R13 would like for her care. R64 face sheet, indicated R64 was admitted to the facility on [DATE] with a primary diagnosis of encounter for orthopedic aftercare following surgical amputation. R64's SNFABN, dated 11/14/23, indicated R64's skilled services would be ending on 11/16/23 with financial liability beginning on 11/17/23. The form was signed by R64 on 11/14/23 but did not indicate which option he wanted for his care. During an interview on 12/13/23 at 9:57 a.m., licensed practical nurse (LPN)-F stated her process was to issue the SNFABN regardless of whether a resident discharging from Medicare A was discharging to the community or the facility. LPN-F stated it was the resident's and/or the resident representative's decision on which of the three options listed on the SNFABN to select. LPN-F stated R13's representative should have been followed up with to obtain the signed SNFABN and to determine which option they would like for R13's care. LPN-F further stated R64 should have been followed up with to determine which option he would like for his care on the SNFABN as he was cognitively intact to make the decision on his own. During an interview on 12/14/23 at 12:10 p.m., the director of nursing stated she would expect an option to be selected on the SNFABN and for the residents who did not have an option selected to be followed up with. A facility policy titled Beneficiary Notices, revised on 11/2017, indicated the facility would provide beneficiary notices according to Medicare guideline.

Based on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 6.9 % with two errors out of 30 opportunities for error involving 2 of 6 residents (R73, R61)who were observed during the medication pass. Findings include: R73's annual Minimum Data Set (MDS) assessment dated [DATE], identified R73 was severely cognitively impaired and had diagnoses which included cancer, diabetes mellitus, dementia, and depression. R73's Physician Order Report identified R73 had orders as follows: -10/9/23, Humalog insulin 100 units per milliliter (ml) 17 units subcutaneously once a day between 11:00 a.m. and 1:00 p.m. On 12/12/23 at 12:18 p.m., during an observation licensed practical nurse (LPN)-A prepared Humalog insulin for R73 by scrubbing the hub of the pen, placing a disposable needle on the pen and priming the needle by dialing two units and wasting the insulin. LPN-A then dialed up 17 units of insulin and proceeded to R73's room. -at 12:22 p.m., LPN-A was stopped and asked about the open date for the insulin pen. LPN-A looked at the pen again and was unable to locate an open date. LPN-A said insulin was good for 28 days after opening and because she could not locate an open date she should not give the insulin she prepared and should discard the pen and get a new pen. LPN-A then removed a new insulin pen for R73 and scrubbed the hub, wasted two units of insulin and dialed up 17 units of insulin and then proceeded to R73's room and administered the insulin from the new pen. On 12/12/23 at 12:30 p.m., during an interview LPN-A stated the importance of dating insulin pens was to ensure the insulin was not used past 28 days to ensure the insulin would still be effective. R61's quarterly MDS assessment dated [DATE], indicated R61 was cognitively intact and had diagnoses which included cerebrovascular accident (stroke), hypertension, and hemiplegia and hemiparesis (loss of strength or paralysis on one side of the body). R61's Physician Order Report identified R61 had orders as follows: -5/31/23, refresh relieva one drop ophthalmic eye twice a day morning and bedtime med pass On 12/13/23 at 8:26 a.m., during an observation trained medication aide (TMA)-A was preparing medications for R61. TMA-A picked up a bottle of refresh tears with an open date of 10/23/23, and an expiration date of 3/2026. TMA-A stated she was not sure if the eye drops were for both eyes or just one eye. TMA-A asked LPN-A what to do and was told to place one drop in both eyes. TMA-A had R61 tip their head back and placed a drop in each eye. On 12/14/23 at 9:26 a.m. the consultant pharmacist (CP) stated the staff should have checked the order for clarification and if the details were missing they should have held the eye drops until they received that clarification. On 12/14/23 at 10:49 a.m., the director of nursing (DON) stated if an insulin pen was not dated the staff should have done one of two things. One would be to throw the insulin pen away, the second would be to check the send date from the pharmacy and if it was within the 28 days the pen could be dated as opened on the send date and use the pen up to the 28 days. In addition, the DON stated if the route for eye drops was not specified in the order (for example right eye, left eye, or both eyes) the staff should not administer the eye drops until the order was clarified. Preparation and General Guidelines dated 4/1/19 Medication Administration directed staff to follow the five rights of medication administration, right resident, right drug, right dose, right route, and right time. In addition, the policy directed staff to check the medications for the five rights at 3 steps in the process: when they selected the medication, when the medication was removed from the container and again after the dose was prepared and the medication was being being put away.

Based on observation, interview and document review, the facility failed to identify an increased risk of elopement for 1 of 3 (R1) residents equipped with security safety alarm devices (aka. wander guard) who exited the building through unalarmed exit doors. The facility's failure resulted in an Immediate Jeopardy (IJ) when R1 exited the building unnoticed through unsecured doors. This practice had the potential to affect other residents who had wander guard system devices in place at the time of survey for 2 of 2 residents (R3 and R4). The IJ began on 6/5/21, at 08:41 a.m. when R1 exited the 4th floor and into a stairwell through an unsecured exit door to the main floor and walked around the building outdoors to a nearby church with out being noticed. The facility administrator and director of nursing (DON) were notified of the IJ on 6/11/21, at 09:19 a.m. The IJ was removed on 6/11/21, at 4:37 p.m. but noncompliance remained at the lower scope and severity level of D - isolated, scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: R1's admission Minimum Data Set (MDS) assessment dated [DATE], indicated severe cognitive impairment, rejection of cares daily, wandering 1-3 days, required extensive assist of 1 with dressing and transfers, limited assist of 1 with all other activities of daily living, and used a cane/walker for mobility. R1's care plan dated 3/30/21, included: at risk for elopement as evident by history of attempts to leave facility unattended, wander aimlessly, impaired safety awareness and disoriented to place with interventions to check wander guard placement right wrist and function every shift, document incidents of wandering, encourage activities, structured daily routine, distract from wandering by offering diversions, and provide safe place to wander. R1's facility reported incident to State agency dated 6/5/21 at 10:11 a.m. indicated facility received call from receptionist stating that R1 was said to be found at [name] church and wander guard in place was working before time of incident. R1's progress note dated 6/5/21, at 10:38 a.m. included, writer received a call from receptionist stating that they got a call from the [Name] Church stating R1 was found to be over there and they took R1 to the lake and also got him a new shaver from [MEDICATION(S)]; R1 returned to Saint Anne's Extended Healthcare on to 4th floor at 9:45 a.m.; R1 did not have any injuries and stated he was going to go and get himself a new shaver; writer educated R1 on the importance of safety and how he shouldn't leave the building alone; wander guard is working and he set the alarms off on the main entrance and 5th floor elevators; for an intervention resident was moved up to 5th floor for his safety; resident was okay with the move and understood the reasoning behind it; writer contacted his emergency contact and updated him about the move and the incident and emergency contact thanked writer for the update; DON was updated and made aware of the situation and had made the decision to transfer resident to 5th floor for safety reasons. During observation and interview on 6/10/21, at 9:15 a.m. R1's room prior to the elopement was directly across from the 4th floor stairwell. There was a piece of paper on the door that read [the code to exit]. DON stated on the main floor the inside sliding door and lower floor where staff enter were locked and have had wander guard alarms in place. DON stated the main entrance sliding doors that exits to outside does not include the wander guard alarm. DON indicated they believed R1 went down four flights of stairs and walked out the main door that did not have an alarm unnoticed. DON stated R1 wander guard was implemented 3/23/21 after observing R1 wandering the halls. Review of R1's Progress notes from 3/19/21 to 6/4/21 revealed the following: -3/19/2021, at 9:43 p.m. R1 had been up and down the halls several times transferring himself; staff assisted him and sat 1:1 with him; R1 then packed his bag and insisted he was leaving and put on his coat but was then agreeable to sit down and eat a snack first; writer called his friend to let him talk to him but unfortunately this did not calm R1; staff ambulated up and down hall again with R1 and then stated he wanted to watch TV. -3/23/2021, at 2:30 a.m. R1 was observed walking around the corner from the North stairwell door and stated he heard someone at the door and needed to check; and door alarm was not sounding and it appeared he did not attempt to open the door. -3/23/2021, at 8:09 p.m. wander guard was placed on R1 right wrist to alert staff if he were to exit the building; R1 has wandered down the hall towards exit doors as well as speaking of getting on the elevator and going shopping; wander guard will be checked each shift for performance and functionality and documented in the treatment administration record. R1's record lacked an updated elopement risk assessment being completed after attempts, verbal comments of wanting to leave or the placement of the wander guard. -3/24/2021, at 1:53 p.m. R1 came to elevator and hit button; Housekeeping staff noted him attempting to open door on stairwell unsuccessfully then went towards elevator; R1 stated he was going to go home and get his shaver; redirected out to solarium to monitor; R1 returned to room and remained to have everything packed up and ready to go. -3/27/2021, 3:33 p.m., included an observation of R1 getting onto the elevator with his coat on and bags packed; writer quickly intervened. R1 became very upset with writer and stormed out of the elevator towards stairwell. and noted the stop sign so turned around and stormed past elevator, pushed divider roughly out of the way and turned around returning to elevator; R1 angry with staff stating we were keeping him against his will . -3/29/2021, at 8:57 p.m. reception called and R1 had taken elevator down to first floor then went down to ground floor but was brought back to 4th floor by staff; R1 was initially resistive to returning to unit but was eventually cooperative; R1 had packed suitcase and had brought this with him; R1 was later noticed standing by elevator with suitcase; R1 stated he wanted to leave but he was redirected back to his room. -6/03/2021, at 2:06 p.m. the social worker was on 1st floor for another matter and observed R1 arrive with restorative staff from the elevator; restorative staff stated she found R1 on the 2nd floor and had stated he was going to the chapel; restorative staff rode elevator to 1st floor with R1; no church service and R1 stated he wanted to go outside for a walk; social worker walked with R1 and receptionist contacted 4th floor staff to come get R1. -6/03/2021, at 4:31 p.m. R1 was attempting to get on the elevator to get to the car; R1 stated his razor was in his car. -6/04/2021, at 4:55 p.m. R1 became more agitated and had his bag packed and was trying to get on elevator to get to his car; 3 staff assisted to redirect; R1 then moved towards the staircase in which he was not able to put code for door to open; R1 then told staff he would return to his room and call someone to help and shortly after the nurse received a call from receptionist stating R1 had called 911 asking for help and they wanted to make sure everything was ok. During an observation and interview on 6/10/21 at 10:06 a.m., R1 had no recollection of leaving the facility and going to the church next door to get his razor. R1 thought he had only lived at the facility for about a week and stated he needs someone with him in order to go outside now. During an interview on 6/10/21 at 10:17 a.m., DON stated there had not been other incidents of elopement from facility for other residents. DON stated elopement assessment should be completed upon admission, quarterly, and yearly. DON stated the team discusses behavior concerns daily including if wandering or elopement for residents. During an interview on 6/10/21 at 10:33 a.m., registered nurse (RN)-B stated R1 had made statements of wanting to go to church which was on the main floor. RN-B stated the wander guard was implemented due to the statements and staff were to escort R1 off floor using elevator to attend church or other activities. RN-B stated there was not a wander guard alarm system at elevator on 4th floor and only one at main entrance and lower floor entrance. During an interview on 6/10/21, at 10:54 a.m. LPN-B stated she was working day of R1's elopement. LPN-B said staff received a phone call from one of the local churches letting them know R1 was there. LPN-B stated staff did not know he was missing until the church staff notified facility that R1 was there with them. LPN-B stated R1 had his wander guard on and was uncertain if it sounded when he left the building. LPN-B said R1 had taken the elevator before and was monitored frequently. LPN-B stated she was not aware of any other elopements for R1 and others in the facility. LPN-B stated R1 was moved to secure unit on 5th floor upon return to facility. During an interview on 6/10/21, at 11:08 a.m., NA-A stated R1 was independent in room? and staff would check on him. NA-A stated R1 had used elevator a couple months ago and was found on main floor but had not attempted to leave the building at that time. NA-A stated R1 was now on the secure unit on 5th floor. NA-A stated no other residents had attempted to elope. During an interview on 6/10/21, at 12:09 p.m., RN-C stated he worked 4th floor day of incident and had last noticed R1 around 9 a.m. near the solarium. RN-C received a phone call around 9:20 a.m. from the receptionist stating R1 was found at the next door church. RN-C stated he was not aware R1 had gone missing. RN-C stated no alarms had sounded but did sound when R1 returned into building. RN-C stated he notified the DON and emergency contact. RN-C stated R1 likely took the elevator down to main level when he left the building. RN-C stated the elevators on 4th floor do not have wander guard alarms. RN-C stated R1 was independent and had not been exit seeking and was easily directed. RN-C stated there had not been any other incidents of elopement for R1 or others. RN-C stated R1 was moved to secure unit on 5th floor upon return to facility. During an interview on 6/10/21, at 12:20 p.m., Social worker (SW)-A stated an elopement risk assessment was completed upon admission for R1 on 3/17/21 and had not had another elopement risk assessment completed since that time. SW-A stated R1 would pack his bags and sit in the solarium and began to wander more so the facility implemented a wander guard band for R1. SW-A stated on 6/3/21, she saw R1 exit off elevator with a restorative staff and R1 had indicated he wanted to go to church but at that time there was no church services. SW-A stated R1 then wanted to go outside so she took him outside and had the receptionist call for staff to come and take him back to 4th floor. SW-A stated the restorative aide had stated she found R1 on the 2nd floor and brought him down to the 1st floor. SW-A stated his wander guard did alarm when taking R1 through main doors to outside. SW-A stated there was discussion with therapeutic recreation to increase time with residents in general, but no additional interventions implemented at that time. SW-A stated all doors to stairwells had codes to enter and there was a wander guard alarm system on the main floor doors and lower-level back entrance. SW-A stated 2nd and 5th floor have wander guard alarm systems at the elevator but not on 3rd or 4th floor. SW-A stated R1 was moved to the secure unit on 5th floor and remains there on 30-minute checks. SW-A stated no one really knew how R1 left the 4th floor, whether it was the stairwell or the elevator, but assumed he took the elevator. SW-A stated the facility cameras showed R1 exiting building at 8:41 a.m. though RN-C stated R1 was last seen on floor around 9:00 a.m. SW-A stated they had not been able to discuss the incident with the person who found R1. SW-A stated the person notified the facility around 9:30 a.m. and stated they were taking R1 to nearby [MEDICATION(S)] to purchase a razor as R1 was requesting a razor. SW-A stated R1 was returned to the facility at 9:45 a.m. SW-A further stated R4 was moved to 4th floor from 5th floor, due to an incident not relating to elopement, but continued to have the wander guard in place and had not attempted to leave the unit. SW-A stated staff would not know if R4 exited floor using elevator, but if attempted to leave the building the wander guard alarm would alarm. During an interview with the DON and administrator on 6/10/21 at 2:05 p.m., DON stated R1 was not reassessed for elopement since first implemented 3/17/21. DON stated R1 had not been assessed to determine if R1 knew the current year or if R1 would be able to enter the code to the exit door to the stairwell on the 4th floor. DON stated R1 had exited 4th floor using elevator before but had never attempted to leave the facility. DON stated she thought the residents who required the wander guard placement had been reassessed and should have been. DON stated the social worker completed the elopement assessments and stated any new admissions with elopement risk would ideally be admitted to the secure unit on 5th floor. The administrator stated she reviewed the facility cameras and R1 exit the building through the stairwell exit then out of building at 8:41 a.m. and was last seen on camera on east side of building at 8:44 a.m. The administrator stated the elevator camera on main floor did not show R1 exiting the elevator at any time prior to the exit in the stairwell leaving them to believe R1 had taken the stairs from 4th floor or took elevator to bottom floor and entered stairwell from bottom floor and climbed the stairs to the exit door at main level in the stairwell. The administrator stated the camera times were accurate. DON stated the stairwell on main floor and bottom floor was used by staff. DON stated she was alerted by staff at 9:23 a.m. of the notification that R1 was found at the church next door. The administrator stated the third and fourth floors do not have wander guard alarms yet and verified the facility had one resident on each floor who required the use of the wander guard. During an interview on 6/10/21 at 2:33 p.m., environmental director (ED)-A stated he felt the current wander guard alarm system was obsolete and the facility had checked into a new system in the past to add alarms in other areas of the building. ED-A stated he had not recently requested quotes from other companies for updating the system. ED-A confirmed the stairwell exit on main floor was not alarmed currently and could be accessed from main floor or bottom floor without code. ED-A stated on main floor from the vestibule entering the stairwell the doors are locked but if your coming from inside the stairwell into the vestibule to exit to the outside, the door in not locked or alarmed. During an interview on 6/10/21 at 2:43 p.m., the church staff-A stated no one is usually at the church on Saturdays but due to an event some staff were present that day. The church staff-A could not verify the time R1 had shown up and stated the [person] who was with R1 was currently on vacation. The church staff-A indicated the [person] took R1 with him to the event location and that a parishioner called the facility to notify they took R1 to [MEDICATION(S)] to get a razor R1 was insisting. The church staff-A then stated the parishioner returned R1 to the facility. The church staff-A stated there were a couple of police officers in area that the staff alerted them indicating if the facility reports R1 missing they have him and will be bringing him back. During an interview on 6/10/21 at 3:00 pm., the DON stated they were currently in the process of reviewing and completing elopement assessments of all residents with wander guards and would be finished by 6/11/21. In the process of having those residents with wander guards on 2nd, 3rd and 4th floors screened to see if they can read the sign and know what year it is to enter it into the keypad and get out into the stairwells. Our plan was to reach out to Advanced Wireless and get a new wander guard system with that company as the current company is obsolete. The DON also stated the other residents with wander guards had not attempted to leave the facility. During an observation and interview on 6/11/21 at 2:35 p.m., ED-A was observed placing a stop sign across exit door on main floor in stairwell and installing an alarm system that would alert staff if the door is opened any time. ED-A stated he will also be installing the same alarm on the east exit door from building. The immediate jeopardy that began on 6/5/21, was removed on 6/11/21, when the facility secured unalarmed doors, supplied documentation and educated all staff on missing residents, elopement, wander guard alarms and dementia, but the noncompliance remained at the lower scope and severity level of D - isolated, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility failed to identity an elopement risk and reassess residents who exhibited signs of elopement and continued use of wander guards. Facility policy Potential for Elopement dated 3/26/08 and reviewed 6/10/21 included the use of wander guard is a safe alternative that alerts staff if a resident leaves a unit or the facility where a wander guard alarm system is in place. The procedure included: provide a safe environment for residents who are exit seeking and ensure that they are in secure location to maintain safety without leaving the facility through identifying residents at risk of elopement upon admission, quarterly, annually and with significant change in condition and through applying wander guard bracelet for residents that exhibit exit seeking tendencies and that have the ability to leave the facility; processes implemented include identification of hazards including residents risk of potentially eloping in the residents current environment, evaluation and analysis of hazards and risks if resident makes attempts to elope or makes verbal statements they want to leave, implementation of individualized resident centered interventions such as adequate supervision and monitoring for triggers related to attempting to elope, monitoring for effectiveness of interventions, behavior tracking related to attempts to leave building, testing the wander guard each shift, notification alarms will only sound on 5th and 2nd floor, the main entrance, and ground floor entrance, if a resident on a floor other than 5th or 2nd has a wander guard further supervision will need to be implemented to assure resident does not leave the unit or all attempts will be made to move the resident to the secure unit if room is available.

Based on observation, interview and document review, the facility failed to complete comprehensive fall assessments to determine effective interventions, consistently implement current interventions and provide supervision for 1 of 4 residents (R40) who had a history of [REDACTED]. This deficient practice resulted in an immediate jeopardy (IJ) and substandard quality of care for R40 who sustained a compression fracture requiring medical evaluation and treatment after multiple falls and continued to be at high risk for significant injury from falls. In addition, the facility also failed to assess causal factors of falls, and implement appropriate interventions to decrease the risk for subsequent falls 1 of 4 residents (R75) who had falls which did not result in I[NAME] The facility also failed to assess, and enforce appropriate interventions for smoking safety for 1 of 1 residents (R2) assessed for smoking. The IJ began on 4/26/19, when R40's fell while self transferring resulting in a compression fracture. The facility failed to complete a comprehensive fall assessment, analyze previous falls for patterns and implement interventions to limit the incidence of self transfers resulting in falls. On 9/19/19, at 2:19 p.m. the administrator and director of nursing (DON) were notified of the IJ for R40. The IJ was removed on 9/20/19, at 3:22 p.m.; however, non compliance remained at an isolated scope and severity which indicated actual harm that was not IJ (Level G). Findings include: R40's Minimum Data Set ((MDS) dated [DATE], identified R40 had severe cognitive impairment and required extensive assistance with bed mobility, transfers, dressing, toileting, locomotion on and off the unit. [DIAGNOSES REDACTED]. R40 was frequently (7 or more episodes of incontinence, but at least one episode of continent voiding) incontinent of urine. The MDS identified R40 had falls since her prior assessment dated [DATE]. R40 had 1 fall without injury and 1 fall with a major injury. The MDS identified R40 was receiving antidepressant, diuretic and opioid medications. R40's Falls Care Area assessment dated [DATE], identified R40 had a history of [REDACTED]. R40 was unsteady and required extensive assistance with walking and transfers. R40 used a wheelchair for long distances. R40 had a history of [REDACTED]. R40 was alert , pleasant, cooperative and had significant cognitive impairment. Family identified R40 spent about 20 hours a day in bed and liked to be alone and quiet. R40 was at risk for falls and fall related injuries. A care plan would be developed and interventions included were: ensure resident remained safe in her environment; remind her to call when needing assistance; staff were to ensure the call light was available and keep personal items within reach; ensure room was free of clutter and ensure gripper socks were on at all times. No referrals were made. R40's care plan last reviewed 9/6/19, identified R40 was at risk for falls related to gait and balance impairment, muscle weakness, use of an assistive device of a walker and wheelchair and use of high risk medication. Interventions included the following: R40 liked to fiddle with electronics, keep the alarm controller out of reach so R40 did not disassemble or turn off; do not leave alone in the bathroom; leave door open when R40 was in her room, as she allowed; remind R40 to use the call light; bed alarm while in bed; paddy (soft touch) call light, check and change brief or ask to use the toilet (a frequency was not identified); encourage R40 to come out of her room for meals; check on R40 routinely (a time frequency was not identified); keep call light and other items within reach, remind R40 when staff were in the room to use the call light for assistance and not to get up on her own. Leave a call , don't fall sign in R40's room where she could see it; ensure R40 was wearing non skid slippers or shoes when out of bed, provide proper fitting footwear. R40 often refused to wear gripper socks and preferred to be barefoot; keep room clutter free and provide adequate lighting. Further, the activities of daily living care plan identified for staff to assist with toileting upon rising, before and after meals and at bedtime. On 9/17/19, at 2:17 p.m. R40 was observed lying in bed barefoot. R40's wheelchair was positioned at a 45 degree angle near the bed. The wheelchair had the left brake on, but the right brake was not on. R40 stated she transferred herself to bed and removed her shoes. On 9/18/19, from 10:24 a.m. until 2:31 p.m. R40 was continuously observed and the following was identified: - At 10:24 a.m. R40's bedroom door was shut and R40 was lying in bed with her legs near the edge of the bed, with the paddy call light within reach inside a pouch attached to the grab bar. R40's wheelchair was near the edge of the bed; however neither brakes were locked. A black pair of shoes were on the floor near the wheelchair. R40's wheelchair had no automatic locking mechanisms. There were no call don't fall signs in R40's room. R40 had two small lamps on in the room. R40 had a pressure alarming devise on the bed. The alarm mechanism was located behind the headboard, near the top. The alarm was unplugged and not functioning. R40 stated she unplugged the alarm, because it was noisy and it bothered her when she was trying to sleep. R40 demonstrated how she could reach behind the headboard and disassemble the alarm. Further, R40 closed her door because she did not like the noise in the hallway. R40 stated she had falls but could not recall if she had any injury or the circumstances following the falls. R40 stated she takes herself to the bathroom and was not sure how often staff checked on her or what they assisted her with. She shook her head at the call light and stated I can't remember everything. She didn't mind if the staff assisted, but did not remember to use the call light for help. - From 10:30 a.m. until 10:44 a.m. multiple staff had walked past R40's closed bedroom door and no one opened it to check on R40. - At 10:44 a.m. Volunteer (V)-A knocked, opened the door and brought R40 some ice water. R40 was in the same position. V-A shut R40's door after exiting the room. - From 10:44 a.m. until 11:36 a.m. multiple staff had walked past R40's closed bedroom door and no one opened it to check on R40. - At 11:36 a.m. R40 opened her bedroom door from the inside and exited her room via wheelchair and went to the day area and sat at the table. R40 had tan colored shoes on both feet. The alarm on her bed did not sound, as it continued to be disassembled. A pair of black shoes remained on the floor near R40 bed. There were no staff in the room to assist with transferring R40 from the bed to the wheelchair, or offer toileting assistance. - At 11:55 a.m. an unidentified staff member gave R40 a puzzle to work until lunch arrived. - From 12:20 p.m. until 1:30 p.m. R40 ate lunch in the day area with staff supervising the area. At 1:15 p.m. R40 went over to another table and worked on a puzzle. Staff did not offer to take R40 to the bathroom. R40's bed alarm remained disassembled and not functioning. - At 2:15 p.m. R40 wheeled herself back to her room, turned around in the wheelchair and shut the door. R40 went over to the side of the bed locked the right wheelchair brake, but did not lock the left brake. Removed her shoes, used her left hand to grab the grab bar on the side of the bed and stood up, the wheelchair moved back to the left, and laid on the bed. R40 was not centered in the bed and it took her several minutes, moving back and forth, to be able to get her legs into bed. - At 2:31 p.m. nursing assistant (NA)-I knocked on R40's closed door and asked if she wanted a snack. R40 declined. NA-I did not offer to to get R40 in a more centered, safer position on on the bed. NA-I did not enter R40's room and check on the alarm or offer R40 bathroom assistance. NA-I then shut the door, without R40 requesting the door to be shut. On 9/18/19, at 2:38 p.m. NA-I stated R40 was a high risk for falls and received a fracture in her back from a previous fall. The only change that was made after R40 fractured her back was placing a bed alarm on R40's bed to alert staff, when R40 was self transferring. R40 self transferred several times a day. R40 frequently unhooked the alarm and pulled the wires out of the alarm. The staff were supposed to keep R40's door open so they could keep a closer eye on R40, but R40 did not like her door open and would get out of bed just to shut the door, she told staff it was too noisy. Other fall interventions R40 had were to keep her wheelchair near her bed with the brakes locked, check on her routinely and check and change her brief and they moved her to a room closer to the nursing station. NA-I stated routinely was every two hours, no different from other residents and the staff tried to check and change R40's brief every couple of hours, or assist her to the bathroom. R40 was frequently incontinent of urine. The nurses were aware R40 did not like her door open and disassembled the fall alarm, but no further instructions were provided to staff on what to do. R40 would read the call don't fall signs and then throw them away. The nursing assistants are told through report about a residents fall interventions and they also had a care sheet to reference. NA-I entered R40's room and stated R40 did not have any call don't fall signs in her room, the alarm was unplugged and both wheelchair brakes were not locked. NA-I plugged in the bed alarm and reminded R40 to use the call light if she needed anything. NA-I then left the room and shut the door. When interviewed on 9/18/19, at 2:50 p.m. NA-J stated R40 self transferred a lot, and occasionally used her call light. R40 was checked on every 2 hours just like all the other residents. R40 frequently unplugged her fall alarm. R40 also did not like her bedroom door left open, because she liked her independence. It was hard to prevent her from self transferring when she unplugged her alarm and the door was closed. R40 was receptive to cares and allowed the staff to assist with cares. NA-J stated she knew from working with R40, as soon as she was done eating dinner she would take herself to her room and try and toilet herself. So when NA-J was working as soon as R40 finished dinner she would take her to the bathroom and get her ready for bed so she would not attempt to complete those tasks on her own. When R40 was toileted right after dinner she was dry and would void on the toilet. NA-J was not aware of any other interventions to prevent R40 from falling. Further, the staff needed to be better at figuring out her schedule and intervening prior to her doing things on her own. A nurse had never asked NA-J what R40's schedule was or what works and what doesn't work to prevent falls. During interview on 9/18/19, at 3:00 p.m. NA-K stated R40 was a high fall risk and frequently self transferred and rarely used her call light. R40 did not remember to use the call light for help. NA-K did not work frequently but when he noticed her door was shut he would peak in and check on her; although, they were instructed to check on her every 2 hours. NA-K indicated he had not checked on her since his shift started at 2:30 p.m. R40's cares needed to be anticipated and he tried to toilet her prior to dinner if she had not done it herself. NA-K was not sure on her evening routine and what time she liked to come out for dinner, so staff could intervene prior to her self transferring. Staff were to remind R40 to use her call light prior to leaving the room. NA-K was not aware of any other fall interventions attempted or current. R40's Group 1 nursing assistant care sheet dated 7/15/19, identified R40 was at high risk for falls and directed staff to encourage R40 to come out for meals. No further fall interventions were identified. The toileting section identified R40 was incontinent of urine and to toilet at 3:00 a.m., no further toileting direction was provided. R40's progress notes identified the following: 4/26/19, R40 fell when she self transferred to close the window and did not utilize wheel. Did not utilize wheelchair. Declined to be seen by a physician. R40 was reminded to use call light and use staff assistance for transferring. 4/26/19, R40 complaining of back pain from fall and self transferred four times that shift. 4/27/19, R40 was self transferring to the bathroom and had complaints of lower back hurting. 4/28/19, R40 was self transferring, reminders provided to use the call light. R40 agreed to be seen in the emergency room . R40 returned with [DIAGNOSES REDACTED]. Antibiotics were prescribed and an increase in pain medication was prescribed. 5/11/19, R40 had a fall and the bed alarm was not in place. The two prior shifts had found the alarm dysfunctional and the alarm box for the bed alarm was at the nursing station prior when day shift had arrived. The information about the alarm box was passed on through report. 5/16/19, R40 was seen by the physician and reviewed fall history with options. Review of documents did identifiy what options were mentioned in the progress note and the care plan was not updated. 5/18/19, R40 continued to try and self transfer and remove the bed alarm. Staff was able to intervene. 6/23/19, R40 disassembled the bed alarm on two separate occasions. 7/23/19, R40 dismantled the bed alarm and stated she was tired of the alarm going off. R40 was transferring several times that shift. 8/14/19, R40's bed alarms found with cords torn from it. Work orders placed. R40 was self transferring that shift. 8/23/19, R40 self transferred after disassembling the bed alarm. The bed alarms was found in her wheelchair by her dresser. Reminded resident to use the call light and not disassemble the bed alarm. 9/2/19, R40 had a fall, the bed alarm was not sounding. R40 had unplugged her bed alarm. 9/3/19, R40 continued to self transfer and take apart the bed alarm. 9/4/19, R40's bed alarm was sounding, when staff approached R40 was attempting to remove the alarm wiring. The bed alarm was placed out of R40's reach. 9/13/19, Staff had been finding bed alarm unplugged and hidden at times. 9/18/19, R40 standing in her room unplugging the bed alarm. R40 stated I don't want it. R40's quarterly Fall Risk (Acuity)- Balance and Functional Limitation ROM (range of motion) 10-17 were completed on 1/24/19, 4/11/19, 7/11/19, and identified R40 was at a high risk for falls. All three assessments identified R40 was at higher risk for falls related to an unsteady gait, blood pressure and diuretic medications and a drop in blood pressure when going from a seated to a standing position. The assessments did not identify what interventions were implemented to reduce falls and instructed to continue the current care plan. R40's quarterly alarm assessment dated [DATE], identified R40 had a bed alarm placed. She had a significant history of falls. She had fallen six times in the past four months on: 5/11/19, 4/26/19, 4/14/19, 3/23/19, 3/03/19, 2/27/19. The fall on 4/26/19, resulted in a significant injury. Since placement of the alarm she had fallen once. The bed alarm was found to be non-functional by evening shift and night shift. Staff was alerted several times a day by R40 attempting to self transfer out of bed. This has given staff adequate time to attend to R40's needs before she self transfers. She had a private room and the alarm was not causing disturbances to other residents. She was spontaneous and will not call staff for assistance. The alarm in place had been effective at preventing falls. R40's PT (physical therapy) Patient Discharge Instruction dated 7/17/19, identified R40 had refused the last seven session and significant improvement in strength and mobility did not occur. Will be discontinuing services due to refusals. PT recommended continued assistance from staff for safe transfers. R40 required verbal and tactile cues for safe mobility and assistance. R40 had a decreased safety awareness. Facility staff were updated. R40's fall reports from (MONTH) (YEAR), until (MONTH) 2019, identified R40 had over 20 falls since admission to the facility. The fall documention included Safety Events- Fall reports, Falls Post Fall Assessment and romp (and internal system for nurse supervisor evaluation) report which identified the following: - (MONTH) (YEAR), R40 fell 6 times on: 11/7/18, at 2:50 a.m., 11/8/18, at 3:26 a.m., 11/15/18, at 8:00 p.m., 11/21/18, 7:13 p.m., 11/22/18, at 6:11 p.m., and 11/29/18, at 3:15 p.m. All falls occurred in R40's room, unwitnessed and while attempting to self transfer. There was no evidence blood sugars and orthostatic blood pressures were taken to assess for medical changes. One fall identified R40 was trying to close the shades on her window and one fall identified toileting needs. Interventions included were have physical and occupational therapy assess, perimeter mattress and offer toileting at least once a night. Reasons for the falls were identified by the facility as cognition related however, there was no comprehensive assessment identifying causes of the falls. There was no evidence the facility addressed an identified pattern of R40 falling while attempting to self- transfer in her room, nor was there evidence that R40 was evaluated for the need for increased assistance with activities of daily living (ADL's) or schedule changes. - (MONTH) (YEAR), R40 fell 9 times on 12/2/18, at 10:25 p.m., 12/5/18, at 12:00 a.m. 12/6/18, at 3:38 a.m., 12/8/18, at 1:00 a.m. and 5:45 PM., 12/16/18, at 2:00 a.m., 12/20/18, at 2:18 p.m., 12/29/18, at 2:58 am. and 12/30/18, at 9:39 a.m. All falls occurred in R40's room, unwitnessed and while R40 was self transferring. There was no evidence blood sugars and orthostatic blood pressures were taken to assess for medical changes. R40 did receive some bruising from the falls. Interventions included were a reduction in antidepressant and pain medication, asked for restorative nursing program that R40 refused, eat in dining room, working on moving room closer to the nursing station, added toileting at 3:00 a.m. The romp assessments identified R40 continued to transfer on her own, there was no assessment identifying why implemented interventions would prevent future falling. Reasons for the falls were identified by the facility as cognition related however, there was no comprehensive assessment identifying causes of the falls. There was no evidence the facility addressed an identified pattern of R40 falling while attempting to self- transfer in her room, nor was there evidence that R40 was evaluated for the need for increased assistance with ADL's or schedule changes. - (MONTH) 2019, R40 fell 3 times and had falls on: 1/4/19, at 2:45 a.m., 1/10/19, at 6:00 a.m. and 1/30/19, at 2:04 p.m. All falls occurred in R40's room, were unwitnessed and self transferring. There were not injuries. The 1/4/19, fall R40 stated she did not remember what she was doing. The 1/10/19, fall R40 stated she tripped coming from the bathroom. The 1/30/19, fall R40 stated she tried to transfer to bed to lay down. All three falls identified R40 self transferred. There was no evidence blood sugars and orthostatic blood pressures were taken to assess for medical changes. The fall on 1/30/19, was the only fall where immediate interventions were initiated, this was use call don't fall signs. R40 was moved to a room closer to the nursing station. The romp assessments identified R40 continued to transfer on her own, but there were no new interventions developed to limit self transferring. Reasons for the falls were identified by the facility as cognition related however, there was no comprehensive assessment identifying causes of the falls. There was no evidence the facility addressed an identified pattern of R40 falling while attempting to self- transfer in her room, nor was there evidence that R40 was evaluated for the need for increased assistance with ADL's or schedule changes. - (MONTH) 2019, R40 fell 2 times and had falls on 2/8/19, at 12:15 p.m. and 2/27/19, at 12:30 p.m. All falls occurred in R40's room, were unwitnessed and was self transferring. There was no injury from the 2/8/19, fall. On 2/27/19, R40 received a bruise to the back of left calf, which measured 4.5 centimeters (cm) x 3 cm. She also had a skin tear on the back left knee which measured 1 cm x 0.5 cm. First aid was initiated. There was no evidence blood sugars and orthostatic blood pressures were taken to assess for medical changes. There were no immediate interventions implemented to prevent falls. The romp report from 2/8/19, identified the resident was messing around with her wheelchair and fell , an intervention to have the wheelchair at bedside with the brakes locked was added. The romp report for 2/27/19, identified R40 was going to the bathroom. The bed was in a high position and the controllers to the bed were on the floor. A specific intervention was not identified, but the report identified increased monitoring of the resident. The report did not identify frequency or when the increased monitoring needed to occur. The romp assessments identified R40 continued to transfer on her own, but there were no new interventions developed to limit self transferring. Reasons for the falls were identified by the facility as cognition related however, there was no comprehensive assessment identifying causes of the falls. There was no evidence the facility addressed an identified pattern of R40 falling while attempting to self- transfer in her room, nor was there evidence that R40 was evaluated for the need for increased assistance with ADL's or schedule changes. - (MONTH) 2019, R40 fell 2 times and had falls on 3/3/19, at 2:08 a.m. and 3/23/19, at 9:49 a.m.: . All falls occurred in R40's room, were unwitnessed and with no injury. Both falls occurred when the resident self transferred to the bathroom. There was no evidence blood sugars and orthostatic blood pressures were taken to assess for medical changes. There were no immediate interventions implemented to prevent further falls. The romp report identified an intervention of bring R40 to the common area when restless. Upon reviewed of the historical care plan from 10/28/18, through 9/6/19, the intervention was not added to the care plan. No further interventions were intimated. Reasons for the falls were identified by the facility as cognition related however, there was no comprehensive assessment identifying causes of the falls. There was no evidence the facility addressed an identified pattern of R40 falling while attempting to self- transfer in her room, nor was there evidence that R40 was evaluated for the need for increased assistance with ADL's or schedule changes. - (MONTH) 2019, R40 had 2 falls falls on 4/17/19, at 2:15 p.m. and 4/26/19, at 10:13 a.m. All falls occurred in R40's room when R40 transferred. The fall on 4/14/19, R40 was self transferring to the bathroom. No injury was identified. No new interventions were implemented. R40 then fell on [DATE], while attempting to close her bedroom window. R40 received an injury of a compression fracture. Following that fall a bed alarm was placed upon return from the emergency roiagnom on [DATE]. There was no evidence blood sugars and orthostatic blood pressures were taken to assess for medical changes. No further interventions were intimated. Reasons for the falls were identified by the facility as cognition related however, there was no comprehensive assessment identifying causes of the falls. There was no evidence the facility addressed an identified pattern of R40 falling while attempting to self- transfer in her room, nor was there evidence that R40 was evaluated for the need for increased assistance with ADL's or schedule changes. - R40's Report of Root Cause Analysis Incidental Findings Action Plan dated 5/6/19, regarding the 4/26/19, fall identified the root cause analysis was completed because R40 had a fall with a fracture. The care plan needed to be updated, because R40 had 23 falls in 6 months and there were many interventions. Several interventions were found to be ineffective and removed from care plan. There was documentation she did not like gripper socks and preferred to be barefoot. This can be concerning because she was diabetic. The lipped mattress was removed as most falls occurred from bed and may be contributing to falls; although resident was not found right next to the bed for most of the falls. The root cause analysis did not identify all R40's falls had been reviewed for patterns, or identify causative factors for falling. - R40's corresponding emergency department note dated 4/28/19, identified R40 arrived via ambulance. The nursing home report identified R40 fell two days prior and developed worsening back pain unrelieved by current pain management regime. The fall was described as slipped to the ground level in the bathroom. R40 stated she had pain and there was no pain when she did not move and was holding still. R40 did not remember the fall. family stated R40 had memory issues, but had not been formally diagnosed with [REDACTED]. There was a 6 centimeter (cm) purple bruise in the upper [MEDICATION NAME] area extending down to the lumbar region of R40's back. Images and labs were obtained. [DIAGNOSES REDACTED]. It may be due to trauma or due to a weakening of the vertebra) , urinary tract infection and accidental fall. Antibiotics and pain medications were prescribed and R40 was discharged back to the facility. R40's [DIAGNOSES REDACTED]. - (MONTH) 2019, R40 a fall on 5/22/19, at 11:24 a.m. which occurred in R40's room by her dresser and did not know what she was doing. The alarm was not in place as it was non-functional and found by the prior shift. R40 received an abrasion and bruising to the right side and it measured 4 cm x 4 cm. No immediate intervention was implemented. There was no evidence blood sugars and orthostatic blood pressures were taken to assess for medical changes. Reasons for the falls were identified by the facility as cognition related however, there was no comprehensive assessment identifying causes of the falls. There was no evidence the facility addressed an identified patterns of R40 falling while attempting to self- transfer in her room, nor was there evidence that R40 was evaluated for the need for increased assistance with ADL's or schedule changes. - (MONTH) 2019, R40 1 had fall on 9/2/19, at 9:41 a.m. The fall occurred in R40's room and she was self transferring. There was no injury. There was no evidence blood sugars and orthostatic blood pressures were taken to assess for medical changes. Immediate interventions were to keep door open and frequent checks. These intervention were already care planned and frequency of checks did not identify how frequent. Reasons for the falls were identified by the facility as cognition related however, there was no comprehensive assessment identifying causes of the falls. There was no evidence the facility addressed an identified pattern of R40 falling while attempting to self- transfer in her room, nor was there evidence that R40 was evaluated for the need for increased assistance with ADL's or schedule changes. R40's quarterly Bowel/Bladder Retraining Potential assessments completed on 1/27/19, 4/15/19 and 7/15/19, identified R40 was frequently incontinent of urine. The assessment had an area inquiring if a toileting program had been attempted. The area was not marked on all three assessments. Further, all three assessment contained the same evaluation summary of: R40 was able to use her call light, but was often spontaneous to use the bathroom. R40 was not always aware if she had to urinate related to declining cognition. Staff toilet R40 upon rising, before and after meals; at bedtime and when she requested. The assessments lacked an evaluation of bladder patterns to assist staff in resident specific toileting times to help reduce R40 risk for falls. R40's historical care plan from 10/28/18, through 9/6/19, identified discontinued fall interventions. These interventions consisted of: 15 minute checks from 12/20/18, though 1/19/19; cognitive testing as ordered from 12/5/18, though 5/7/19; complete orthostatic blood pressures as ordered and provide results to the provider from 12/5/18, through 5/7/19; restorative nursing program from 12/5/18, through 5/7/19; Position height so feet are flat on the floor and knees were at 90 degrees when seated at the edge of the bed from 11/15/18, though 5/7/19; Physical and occupational therapy evaluation and treat as ordered from 11/15/18, through 5/7/19; bed in low position from 10/30/18, through 11/5/18; Remind resident to seek assistance before transferring from 4/26/19, through 5/7/19; and Have chair at bedside while in bed from 2/8/19, through 5/7/19. The care plan identified the fall goal was discontinued, it was resolved or no reason was identified for the removal of the interventions. The medical record and fall reports did not identify why the interventions were discontinued or what the outcome of the intervention was. Although, R40 went from (MONTH) 2019, until (MONTH) 2019, without falling there was no evidence the falls were comprehensively assessed to review current fall interventions for effectiveness; and determine potential causative factors (aside from cognitive impairment) in order to develop and implement appropriate interventions to prevent future falls. There were multiple progress notes regarding self transferring and removing the bed alarm. R40 continued to self transfer without new interventions implemented, placing R40 at significant risk for falling again and receiving a significant injury. When interviewed on 9/18/19, at 3:10 p.m. licensed practical nurse (LPN)-E stated when a resident fell the nurse assessed for injury, took pulse, temperature, blood pressure and respirations and made notifications to the family and provider. The nurse intimated event charting, completed a progress note, completed a paper fall checklist and completed a post fall observation. The nurse on duty was supposed to look at the situation and implement a temporary intervention i.e call light in reach, remind to use call light, gripper socks. The point of an immediate intervention was to prevent further falls until the nursing supervisor had time to review the fall, so obvious things needed to be looked at. R40 had numerous falls while residing in the facility. LPN-E was aware R40 had a bed alarm and her door should be open. R40 became upset when staff shut the door. She had personally caught her self transferring numerous times as well as disassembling the bed alarm. R40 did not remember to use the call light so reminders to use the call light were not effective. LPN-E stated she noticed R40 really disliked noise and when it became loud in the day area she would become anxious and head to her room and shut her door. After the nurse completed all required fall paperwork it was forwarded to the nursing supervisor and they were supposed to review the fall and come up with appropriate interventions to help prevent new falls. We could be better at fall prevention for R40. On 9/19/19, at 9:21 a.m. nursing supervisor registered nurse (RN)-C stated the floor nurse filled out the Safety Events- Fall reports, Falls Post Fall Assessment following the fall. The paperwork usually took around three days to complete. Then she usually completed the romp assessment and implemented a new intervention. The nurses also filled out a p