Every finding on record at St Frances NSG & Rehab Center

Based on record review and an interview, the facility failed to ensure a resident's medical record was accurately documented in accordance with accepted professional standards and practices. The facility failed to ensure activities of daily living tasks performed for Resident #2 were accurately documented in the resident's medical record. Findings:Review of an undated policy titled Documentation read in part.The purpose of charting and documentation is to provide:1. A complete account of the resident's care, treatment, response to the care, signs, symptoms, etc. for the continuity of care, treatment decisions, and to support services provided for payment. Review of Resident #2's medical record revealed an initial admit date of 05/06/2024 and a re-entry date of 03/27/2025, with diagnoses that included in part:., Displaced Intertrochanteric Fracture of the Right Femur, Type 2 Diabetes, Severe Protein Calorie Malnutrition, Dementia, Viral Hepatitis C, and Cirrhosis of the Liver. Review of Resident #2's MDS with an ARD of 02/02/2026 revealed Resident #2 had a BIMS score of 6, indicating severe cognitive impairment. Resident #2 required substantial/ maximum assistance with ADLs. On 5/5/2026 at 10:10 a.m., an interview with S11CNA revealed she had worked approximately 4-5 shifts at the facility without being provided login credentials to access residents' medical records. S11CNA stated she was unable to document the ADL care she provided to residents and relied on other CNAs who had not performed the care to complete the documentation in the medical record. S11CNA reported S6LPN/CNASup was aware of the login issues. On 5/5/2026 at 10:19 a.m., an interview with S6LPN/CNASup revealed that the facility had been experiencing ongoing issues with agency staff login credentials. S6LPN/CNASup stated the issue had existed for months and confirmed S1Admin was aware of the problem. S6LPN/CNASup further acknowledged that staff members with login access were documenting care for other staff who did not have login credentials, even though they did not provide care to those specific residents. On 05/05/22026 at 10:32 a.m., an interview with S7LPN confirmed the facility had been experiencing ongoing issues with obtaining login credentials for agency staff. S7LPN reported that staff members with login access were documenting care on behalf of other staff who did not have login credentials. On 05/05/2026 at 11:10 a.m., an interview with S8CNA revealed her login credentials had not functioned for the previous couple months. S8CNA stated she notified S7LPN/CNASup of the issue. S8CNA reported that due to her inability to access the electronic documentation system, other facility staff documented the ADL care she provided to the residents. On 5/6/2026 at 2:48 p.m., an interview with S10CNA revealed she worked full time at the facility and had functioning login credentials. S10CNA confirmed she documented ADL care on 05/04/2026, which she did not personally provide, for an agency CNA who did not have login credentials. S10CNA stated she did not verify whether the care had actually been provided to the residents prior to documenting the care in the medical record. On 05/06/2026 at 4:48 p.m., S3DON acknowledged awareness that facility CNAs were documenting care in the residents' electronic medical records on behalf of agency CNAs who did not have access to the medical record system. Both S2CorporateRN and S3DON confirmed that when the individual documenting care in the medical record did not actually provide the care to the resident, the medical record would not be considered accurate.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety by failing to ensure open food items stored in the pantry and refrigerator were properly sealed and labeled with an open date. This deficient practice had the potential to affect all 44 residents who received meals served from the kitchen. Findings:Review of an undated policy titled Storage: Dry Food read in part.Dry food storage pertains to those foods not likely to support bacterial growth in their normal state.Procedure:2. Keep all containers tightly closed from insects, rodents, and dust. Dry foods can become contaminated, even if they don't need refrigeration. An observation on 05/04/2026 at 9:18 a.m. of the facility pantry and refrigerator revealed the following:1. One package of vanilla wafers was observed open to air.2. One gallon of mayonnaise was observed opened without a date indicating when the item was opened.3. Two plastic cereal containers were labeled with an open date of 04/14/2025.4. One plastic cereal container was labeled with an open date of 11/20/2025.5. One plastic cereal container was labeled with an open date of 02/25/2025. On 05/04/2026 at 09:25 a.m., S5DM stated the cereal was used daily and the plastic containers are refilled frequently. S5DM confirmed the dates listed on the cereal containers were inaccurate and should have been updated when new cereal was added. S5DM further confirmed the package of vanilla wafers was left open to air, but should have been sealed properly. S5DM confirmed the gallon of mayonnaise had been opened and did not contain an opening date, but should have.

Based on observation and interview, the facility failed to ensure the planned menus were followed to meet the nutritional needs of the residents that required mechanically altered diets. The facility failed to provide bread or bread substitute for 2 (#68 and #69) of 2 residents who received mechanically altered diets. Findings:Resident #68Review of Resident #68's Quarterly MDS with an ARD of 03/25/2026 revealed Resident #68 had a BIMS score of 99, indicating an assessment could not be completed. Resident #68 required a mechanically altered diet. Resident #69Review of Resident #69's Quarterly MDS with an ARD of 03/19/2026 revealed Resident had a BIMS score of 9, indicating moderate cognitive impairment. Resident #69 required a mechanically altered diet. On 05/04/2026 at 11:10 a.m., observation of two lunch trays for Resident #68 and #69, who were prescribed mechanical soft diets revealed the following:1. Resident #68, who was prescribed a mechanical soft diet, did not receive cornbread or a substitute for bread with her lunch meal. 2. Resident #69, who was prescribed a mechanical soft diet, did not receive cornbread or a substitute for bread with his lunch meal. On 05/04/2026 at 11:12 a.m., an interview with S5DM revealed residents who received mechanical soft diets were not served cornbread, but instead were to receive an additional scoop of mashed potatoes as a substitute. S5DM observed the lunch meal trays for Resident #68 and Resident #69 and confirmed both residents did not receive cornbread per the planned menu, or the additional mashed potatoes as the substitute, but should have.

Based on observation, interview, and record review, the facility failed to ensure residents who are unable to carry out ADLS (Activities of Daily Living) received the necessary services to maintain grooming for 1 (Resident #64) of 3 residents reviewed for ADL care. The total sample size was 47.Review of facility undated policy titled, Activities of Daily Living (ADLs) revealed in part. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of Resident #64's medical record revealed an admission date of 09/26/1986, with diagnoses that included, in part. Unspecified Vision Loss, Unspecified Intellectual Disabilities, and Communication Deficit.Review of Resident #64's Significant Change MDS with ARD 04/10/2026 revealed the resident had a BIMS score of 4, which indicated severe cognitive impairment. Resident #64 required substantial/maximal assistance with showering/bathing and all personal hygiene/grooming.On 05/04/2026 at 10:18 a.m., observation revealed Resident #64 sitting up in the facility's day room in a wheelchair. Resident observed with facial hair on the bilateral sides of the face, chin, and upper lip. Facial hair observed is more than sparse and approximately as long as a grain of rice. The resident was female and non-interviewible.On 05/05/2026 at 10:02 a.m., observation revealed Resident #64 sitting up in the facility's day room in a wheelchair. Resident observed with facial hair on the bilateral sides of the face, chin, and upper lip. Facial hair is more than sparse and approximately as long as a grain of rice. On 05/05/2026 at 10:45 a.m., observation revealed Resident #64 sitting up in a wheelchair in the facility dining room. Resident observed with full facial hair on the bilateral sides of the face, chin, and upper lip.On 05/05/2026 at 2:14 p.m., observation revealed Resident #64 sitting up in a wheelchair in the facility's day room. Resident observed with full facial hair on the bilateral cheeks, lip, and chin. In an interview on 05/06/2026 at 12:00 p.m., S4CNA confirmed when she arrived to her shift, Resident #64's face was very hairy with thick facial hair, and should have been shaven previously. In an interview on 05/06/2026 at 11:45 a.m., S2CorporateRN confirmed that Resident #64 is a non-interviewible, female resident and that it was unacceptable for Resident #64 to have thick facial hair.

Based on interview and record review, the facility failed to ensure their grievance policy and procedure was followed for 1 (Resident #20) of 1 resident reviewed for missing personal property. The facility failed to initiate a grievance for Resident #20 regarding the reported missing money. Total sample size was 47. Findings:Review of the facility's undated policy titled, Grievances/Complaints read in part.1. Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint to the facility other entity that hears grievances concerning treatment, medical care, behavior of other residents, staff members, theft of property, and other concerns regarding their LTC facility stay without fear of threat or reprisal in any form.4. Upon receipt of a grievance and/or complaint, the grievance official will ensure prompt investigation and resolution of the allegations. Review of Resident #20's medical record revealed an admission date of 09/10/2025, with diagnoses that included, in part.Type 2 Diabetes with Hyperglycemia, Hypertensive Heart Disease with Heart Failure, Hyperlipidemia, Peripheral Vascular Disease, and Dementia. Review of a Quarterly MDS with an ARD of 02/20/2026 revealed Resident #20 had a BIMS score of 15, which indicated intact cognition. Review of the facility grievance logs from November 2025 through April 2026 revealed there were no documented grievances initiated or completed for Resident #20 related to the reported missing money. On 05/04/2026 at 11:23 a.m., an interview with Resident #20 revealed that $220.00 had been stolen from his room approximately two weeks prior. Resident #20 stated he informed S1Admin and S3DON regarding the missing money. Resident #20 further reported he had experienced missing money in the past, which the facility had previously replaced. Resident #20 stated, as of today, he had not been informed of the findings of any investigation related to the most recent complaint and his missing money was not replaced. On 5/6/2026 at 8:55 a.m., an interview with S3DON confirmed she was aware Resident #20 had reported missing money; however, S3DON stated she does not handle missing item investigations and indicated S1Admin was responsible for initiating the grievance and addressing Resident #20's concerns. On 5/6/2026 at 9:03 a.m., an interview with S1Admin revealed he was aware that Resident #20 reported missing money approximately one month prior. S1Admin stated that he replaced Resident #20's money because the missing funds could not be located. S1Admin confirmed that a grievance was not initiated regarding the missing money reported one month prior, but acknowledged that one should have been completed. S1Admin further confirmed he was currently aware of Resident #20's more recent allegation regarding missing money and acknowledged a grievance was not initiated, but should have been.

Based on interview and record review the facility failed to ensure residents received mail on Saturdays. This has the potential to affect all 73 residents residing in the facility. Findings: Review of an undated facility policy on 04/29/2025 at 11:45 a.m. titled, Resident Right to Privacy in Communication revealed the following in part .The facility will honor the resident's right to privacy in written communication including the right to: 1.Send and promptly receive mail that is unopened. 1. The social service designee, or another designated staff member, will ensure each resident receives any mail addressed to that particular resident promptly. On 04/28/2025 at 1:30 p.m., the Resident Council Meeting was conducted and revealed the residents did not receive mail on Saturdays. In an interview on 04/29/2025 at 10:09 a.m., S11 [NAME] Clerk stated her duty as [NAME] Clerk on Saturdays included gathering the facility mail from the mail box located outside the facility. S11 [NAME] Clerk stated she would then lock the facility mail in the medication room companied by the nurse on duty. S11 [NAME] Clerk stated that on Mondays she would notify S6 SSD and S10 BOM of the Saturday mail received. S11 [NAME] Clerk confirmed she does not distribute any facility mail on Saturdays and the mail would not be distributed until Monday by S6 SSD or S10 BOM. In an interview on 04/29/2025 at 10:20 a.m., S6 SSD revealed it is herself and S10 BOM who are responsible for distribution of the facility/resident mail and no other staff handle the facility mail. S6 SSD confirmed any Saturday mail that is received would be stored in a locked area until Monday when herself or S10 BOM are able to sort through the facility mail and distribute it to the residents. In an interview on 04/29/2025 at 10:50 a.m., S1 ADMIN revealed that the facility/resident mail is not distributed on Saturdays or the weekend. S1 ADMIN stated the facility mail received on Saturday would be stored in a safe place until Monday and S6 SSD and S10 BOM would distribute the Saturday mail on Monday. In an interview on 04/30/2025 at 9:47 a.m., Resident #43 revealed his daughter mailed him packages and letters often. Resident #43 stated that if he had received personal mail on a Saturday he would have to wait until Monday to receive it. Resident #43 stated he would like his mail delivered to him when the facility received it because he was aware of his resident rights and had his right mind. In an interview on 04/30/2025 at 10:35 a.m., S10 BOM revealed it is her duty and S6 SSD to sort and distribute facility/resident mail. S10 BOM stated on Mondays she would gather any Saturday mail received and sort through it. S10 BOM confirmed she was aware the resident's mail should be delivered as soon as the facility receives it including Saturdays, but was not. S10 BOM confirmed that since she has been in her role for two years as Business Office Manager, there never was a process for distribution of the resident mail on Saturdays.

Based on observation, record review, and interview the facility failed to ensure residents were free of any significant medication errors for 1 (#29) of 3 (#1, #23, and #29) Residents observed during medication administration, by failing to administer Spironolactone (antihypertensive) medication as ordered. Review of the facility's undated policy titled Medications- Administering on 04/30/2025 at 11:31 a.m. read in part . Medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Observation on 04/29/2025 at 7:54 a.m. revealed S12 LPN performed medication administration for Resident #29. Observation revealed S12 LPN placed 9.5 tablets into medication cup for administration. S12 LPN confirmed count of 9.5 tablets, and then administered the medications to Resident #29. Medications administered to Resident #29 at time of observation included in part . Spironolactone 25mg, 0.5 tablet. Record review revealed Resident #29 was admitted to the facility on [DATE] and had diagnoses that included in part . Hypertensive Heart Disease with Heart Failure, Aphasia Following CVA, and Hemiplegia and Hemiparesis following CVA affecting Right Dominant Side. Review of Resident #29's physician orders read in part . Spironolactone 25mg, 0.5 tablet by mouth daily. Start date 09/03/2024. End date 04/17/2025. Spironolactone 25mg, 1 tablet by mouth daily. Start date of 04/18/2025. Review of Resident #29's 04/2025 EMAR (Electronic Medication Record) revealed in part . Spironolactone 25mg, 0.5 tablet was documented as administered to Resident #29 from 04/01/2025- 04/17/2025. Spironolactone 25mg, 1 tablet was documented as administered to Resident #29 from 04/18/2025- 04/29/2025. Interview on 04/29/2025 at 2:23 p.m. with S12 LPN and observation of Resident #29's medication card on medication cart revealed Resident #29 had Spironolactone 25mg 0.5 tablets on medication cart. S12 LPN confirmed she administered the Spironolactone 25mg 0.5 tablet during medication administration this morning. S12 LPN reviewed Resident #29's current orders on EMAR, and confirmed Resident #29 should have been administered Spironolactone 25mg, 1 tablet. S12 LPN stated there was a change in the dosage of Spironolactone on 04/17/2025. S12 LPN stated the previous order was for Spironolactone 25mg, 0.5 tablet, but the physician increased the dose to 25mg to begin on 04/18/2025. S12 LPN stated when the order was changed, staff should have printed out the order and faxed it to the pharmacy, so that the new dosage could be delivered and placed on the medication cart. S12 LPN confirmed Resident #29 had not been administered Spironolactone 25mg since 04/18/2025, because the new dosage was not available at the facility, and the Resident's medication pack had Spironolactone 0.5 tablet in pack.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #4) of 1 sampled residents reviewed for respiratory care. The facility failed to ensure equipment was properly changed. Findings: Review of Resident 4's medical record revealed an admitted [DATE] with diagnosis that included in part .Chronic Obstructive Pulmonary Disease, Chronic Systolic (Congestive) Heart Failure and Shortness of Breath. Review of Resident #4's active Physician orders revealed the following: Oxygen at 2 Liters per nasal cannula PRN Shortness of Breath Desaturation and or Chest Pain as needed related to Chronic Obstructive Pulmonary Disease. Review of Resident #4's Care Plan with a Target date of 07/31/2025 revealed in part .At risk for respiratory distress related to diagnosis Chronic Obstructive Pulmonary Disease. Oxygen at 2 Liters per nasal cannula PRN Shortness of Breath Desaturation and or Chest Pain with interventions that included change oxygen mask/nebulizer tubing/mask every week and PRN nurse to sign and date bag. Observation and interview on 04/28/2025 at 9:19 a.m. revealed Resident #4's humidifier bottle on his oxygen concentrator had a date of 03/27 (no year was specified). Resident #4 stated he wore his oxygen at night. Observation on 04/29/2025 at 9:04 a.m. revealed Resident #4's humidifier bottle on his oxygen concentrator had a date of 03/27 (no year was specified). Observation and interview with S2 DON and S3 RN on 04/29/2025 at 9:10 a.m. in Resident #4's room revealed his humidifier bottle on his oxygen concentrator had a date of 03/27 (no year was specified). S2 DON confirmed the above date on Resident #4's humidifier bottle. S3 RN stated all oxygen equipment should be changed weekly. S2 DON confirmed Resident #4's humidifier bottle should have been changed weekly but had not.

Based on record review and interview the facility failed to ensure an allegation of physical abuse was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#74) of 25 Sampled Residents. Findings: Review of the facility's undated policy on 04/30/2025 at 11:31 a.m. titled Abuse Prevention and Investigation read in part . Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Review of the medical record for Resident # 74 revealed she was admitted to the facility on [DATE] and discharged from facility on 04/01/2025. Resident #74 had diagnoses that included in part . Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Hypertensive Heart Disease with Heart Failure, Chronic Obstructive Pulmonary Disease, and Cerebral Infarction, unspecified. Review of Resident #74's Quarterly MDS with an ARD of 02/24/25 revealed a BIMS score of 15, which indicated cognition was intact. Review of Resident #74's Departmental Progress Notes revealed in part . 03/25/2025 6:47 p.m. by S14 LPN: Resident #74 reported that she was sitting at the dining room table eating. Resident #11 was pushing a female resident in a wheelchair near Resident #74's chair. Resident #11 hit Resident #74's walker with the female resident's wheelchair. Resident #11 then began hitting Resident #74's walker with a closed fist striking her walker, and her arm several times. Resident #11 was removed from the area. Resident #74 was checked for injuries and bruising, none was noted. Interview on 04/30/2025 11:15 a.m. with S14 LPN revealed she immediately reported the resident to resident altercation that occurred on 03/25/2025 between Resident #11 and Resident #74 to S15 Former DON, and documented the incident on an incident form. Interview on 04/30/2025 11:32 a.m. with S1 Administrator revealed he was responsible for SIMS reporting at the facility. S1 Administrator revealed he recalled being made aware of the resident to resident altercation between Resident #11 and Resident #74. S1 Administrator confirmed he did not complete a SIMS report related to the resident to resident altercation on 03/25/2025. S1 Administrator stated he did not complete a SIMS report because he had been informed via email by an individual at the State Office program desk that facilities were not required to report SIMS for resident to resident altercations, if neglect was not identified, and there was no injury.

Based on observation, record review, and interview the facility failed to provide care and services that met professional standards of quality by failing to ensure Physician's Orders were implemented. The facility failed to ensure supplements were administered as ordered for 1 (Resident #22). Total sample 25. Findings: Review of Resident # 22's Clinical Record revealed an admitted [DATE] with diagnosis which included: Fracture of Unspecified part of the Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Dementia; Anxiety; Protein Calorie Malnutrition; Vitamin Deficiency; Hyperlipidemia; Depression; Psychotic Disorder with Delusions d/t known Psychological Condition; Delusions; Alzheimer's Disease. Review of Resident # 22's Significant Change MDS with ARD of 03/02/2025 revealed a BIMS summary score not conducted due to Resident # 22 was rarely/never understood. Resident #22 required extensive assistance for bed mobility, transfers, eating, and toileting. Review of Resident # 22's Care Plan with a revision date of 04/17/2025 revealed in part .Provide and serve diet and supplements as ordered. Review of Resident # 22's 04/2025 Physician's Orders revealed in part . NSOT (No Salt on Tray) Diet, Regular Texture, Regular/Thin Consistency, ADD PBJ (Peanut Butter and Jelly) with all meals. Review of Resident # 22's Clinical Document titled Change in Diet dated for 03/07/2025 revealed in part . Add PBJ with all meals. Observation on 04/28/2025 at 11:35 a.m. revealed Resident #22 did not receive PBJ with lunch. Observation on 04/29/2025 at 11:18 a.m. revealed Resident #22 did not receive PBJ with lunch. Interview with S7 CNA revealed Resident # 22 had not received PBJ with meals on multiple occasions when S7 CNA assisted Resident # 22 with feeding. Interview with S16 DM on 04/29/2025 at 11:48 a.m. confirmed Resident #22's diet order and diet slip included PBJ with all meals dated 03/07/2025. S16 DM confirmed Resident # 22 should have received PBJ with all meals. Interview with S2 DON on 4/29/2025 at 11:59 a.m. confirmed Resident # 22 should have received a peanut butter and jelly sandwich with all meals.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5%. The facility failed to: 1. Follow the manufacturer's instructions of Do Not Crush for a medication administered to Resident #23; and 2. Administer a medication as ordered for Resident #29. A total of 36 opportunities were observed for the 3 Residents (#1, #23, and #29) observed during medication administration, which included 2 medication errors for a medication error rate of 5.56%. Findings: Review of the facility's undated policy titled Medications- Administering on 04/30/2025 at 11:31 a.m. read in part . Medications shall be administered in a safe and timely manner, and as prescribed. The individual administering the medication must check the label 3 times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Resident #23 Observation on 04/29/2025 at 7:57 a.m. revealed S12 LPN performed medication administration for Resident#23. Observation revealed S12 LPN placed 3.5 tablets into medication cup for administration. S12 LPN confirmed count of 3.5 tablets. S12 LPN then crushed all medications, and administered the medications to Resident #23. Medications administered to Resident #23 at time of observation included in part . Slo-Mag 71.5-119mg OTC (Over the counter) 2 tablets. Observation on 04/29/2025 at 8:02 a.m. of the Slo Mag OTC bottle used for medication administration for Resident #23 read do not crush. S12 LPN reviewed the medication bottle used and revealed she was unaware the medication should not be crushed. S12 LPN confirmed medications labeled do not crush, should not be. Interview on 04/29/2025 at 10:05 a.m. with S2 DON confirmed medications labeled do not crush, should not be. Resident #29 Observation on 04/29/2025 at 7:54 a.m. revealed S12 LPN performed medication administration for Resident #29. Observation revealed S12 LPN placed 9.5 tablets into medication cup for administration. S12 LPN confirmed count of 9.5 tablets, and then administered the medications to Resident #29. Medications administered to Resident #29 at time of observation included in part . Spironolactone 25mg, 0.5 tablet. Record review revealed Resident #29 was admitted to the facility on [DATE] and had diagnoses that included in part . Hypertensive Heart Disease with Heart Failure, Aphasia Following CVA, and Hemiplegia and Hemiparesis following CVA affecting Right Dominant Side. Review of Resident #29's physician orders read in part . Spironolactone 25mg, 0.5 tablet by mouth daily. Start date 09/03/2024. End date 04/17/2025. Spironolactone 25mg, 1 tablet by mouth daily. Start date of 04/18/2025. Review of Resident #29's 04/2025 EMAR (Electronic Medication Record) revealed in part . Spironolactone 25mg, 0.5 tablet was documented as administered to Resident #29 from 04/01/2025- 04/17/2025. Spironolactone 25mg, 1 tablet was documented as administered to Resident #29 from 04/18/2025- 04/29/2025. Interview on 04/29/2025 at 2:23 p.m. with S12 LPN and observation of Resident #29's medication card on medication cart revealed Resident #29 had Spironolactone 25mg 0.5 tablets on medication cart. S12 LPN confirmed she administered the Spironolactone 25mg 0.5 tablet during medication administration this morning. S12 LPN reviewed Resident #29's current orders on EMAR, and confirmed Resident #29 should have been administered Spironolactone 25mg, 1 tablet. S12 LPN stated there was a change in the dosage of Spironolactone on 04/17/2025. S12 LPN stated the previous order was for Spironolactone 25mg, 0.5 tablet, but the physician increased the dose to 25mg to begin on 04/18/2025. S12 LPN stated when the order was changed, staff should have printed out the order and faxed it to the pharmacy, so that the new dosage could be delivered and placed on the medication cart. S12 LPN confirmed Resident #29 had not been administered Spironolactone 25mg since 04/18/2025, because the new dosage was not available at the facility.

Based on observation and interview the facility failed to ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident # 22) of 4 (Resident #9, Resident #22, Resident #43, and Resident #225) sampled Residents reviewed for dignity in a total sample size of 25. The facility failed to ensure S7 CNA did not stand while feeding Resident #22 during meal service. Findings: Review of Resident # 22's Clinical Record revealed an admitted [DATE] with diagnoses that included: Fracture of Unspecified part of the Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Dementia; Anxiety; Protein Calorie Malnutrition; Vitamin deficiency; Hyperlipidemia; Depression; Psychotic Disorder with Delusions d/t know Psychological Condition; Delusions; Alzheimer's disease. Review of Resident # 22's Care Plan with a revision date of 04/17/2025 revealed a potential for Malnutrition with interventions that included in part . Resident to be fed meals per staff. Observation and interview on 04/29/2025 at 11:18 a.m. revealed S7 CNA standing while feeding Resident #22. S7 CNA confirmed that she should not have been standing while feeding Resident #22. Interview on 04/29/2025 at 1:01 p.m. with S2 DON confirmed that S7 CNA should not have been standing while feeding Resident # 22.

Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #9) resident of 25 sampled residents. The facility failed to ensure Resident #9's care plan for Psychotropic drugs: Risperdal, Buspirone, and Trazodone was developed and/or initiated. Findings: Review of a facility's undated policy on 04/30/2025 at 1:18 p.m. titled, Care Plan-Comprehensive revealed the following in part . 11. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Review of a facility's undated policy on 04/30/2025 at 1:18 p.m. titled, Care Plans-Preliminary revealed the following in part .A preliminary plan of care to meet the resident's immediate needs shall be developed for each resident. The preliminary care plan consists of all nurse assessments, notes, face sheets, MARS, TARS, CNA care plans/flow sheets and Physician orders. Review of Resident #9's medical record revealed a re-admitted [DATE], with diagnoses that included in part . Rheumatoid Arthritis with Rheumatoid Factor; Bipolar Disorder; Major Depressive Disorder, Single Episode; Pain; and Anxiety Disorder. Review of Resident #9's Quarterly MDS with an ARD of 06/24/2025 revealed a BIMS score of 12, which indicated moderate cognitive impairment. Resident #9 received antipsychotic, antianxiety, and antidepressant medications. Review of Resident #9's 04/2025 physician orders revealed in part . 03/11/2025: Risperdone 0.5mg-give 1 tablet orally one time a day related to Bipolar Disorder. Target behaviors: increased agitation, complaints of feeling lonely and tearful. 03/12/2025: Risperdone 0.25mg-give 1 tablet by mouth one time a day. Target behaviors: yelling, isolation, paranoia related to Bipolar Disorder. 01/10/2025: Buspirone Hydrochloride (HCl) 15mg-give one tablet by mouth three times a day related to Anxiety Disorder. 09/03/2024: Trazodone Hydrochloride (HCl) 50mg-give one tablet orally at bedtime related to Major Depressive Disorder. Target behaviors: withdrawn, tearful, self-isolative. Review of Resident #9's care plan with a review date of 07/31/2025 revealed in part . Focus: Diagnosis: Depression. Prescribed Cymbalta 90mg. Target behaviors withdrawn, tearful, and self-isolative. Date initiated: 10/29/2024. Interventions: Administer anti-depressant medication as ordered; Assess for adverse side effects, document, and report. Date initiated: 10/29/2024. Further review revealed a care plan was not developed and/or initiated for Psychotropic drugs Risperdone 0.5mg, Risperdone 0.25mg, Buspirone HCl 15mg, and Trazodone HCl 50mg for Resident #9. In an interview and record review on 04/29/2025 at 11:58 a.m., S4 MDS LPN revealed she is responsible for developing and updating care plans. S4 MDS LPN confirmed she developed/initiated Resident #9's Psychotropic Drug care plan on 04/29/2025, which included the drugs Risperdone 0.5mg, Risperdone 0.25mg, Buspirone HCl 15mg, and Trazodone HCl 50mg. In an interview on 04/29/2025 at 1:52 p.m., S2 DON confirmed the Psychotropic drugs Risperdone 0.5mg, Risperdone 0.25mg, Buspirone HCl 15mg, and Trazodone HCl 50mg should have been developed and/or initiated on Resident #9's care plan prior to 04/29/2025, but had not.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection for 2 (Resident #7 and Resident #22) sampled residents by failing to: 1. Ensure staff wore PPE for Resident #7 who was on Enhanced Barrier Precautions; and 2. Ensure staff did not blow on Resident #22's food to cool it while feeding her. Findings: Resident #22 Review of Resident # 22's Clinical Record revealed an admitted [DATE] with diagnoses which included: Fracture of Unspecified part of the Neck of Left Femur, Subsequent Encounter for Closed Fracture with Routine Healing; Hypertensive Heart Disease without Heart Failure; Dementia; Anxiety; Protein Calorie Malnutrition; Vitamin deficiency; Hyperlipidemia; Overactive Bladder; Depression; Psychotic Disorder with Delusions d/t known Psychological Condition; Delusions; Alzheimer's Disease. Review of Resident # 22's Care Plan with a revision date of 04/17/2025 revealed a potential for Malnutrition with interventions that included in part . resident to be fed meals per staff. Observation on 04/18/2025 at 11:18 a.m. revealed S7 CNA had put food on Resident #22's spoon and then blew on it to cool it. S7 CNA then put the food in Resident #22's mouth. S7 CNA confirmed she should not have blown on Resident #22's food to cool it while feeding her. Interview on 04/29/2025 at 1:01 p.m. with S2 DON confirmed that S7 CNA should not have blown on Resident #22's food to cool it while feeding her. 51503 Resident #7 Review of a facility policy titled, Enhanced Barrier Precautions dated 01/2025 revealed the following in part .Enhanced Barrier Precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with an multidrug-resistant organisms (MDRO) as well as those at increased risk of MDRO acquisition (residents with wounds or indwelling medical devices). 48. High-contact resident care activities include: a. dressing; b. bathing; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use: central lines, urinary catheters, feeding tubes, tracheostomy tubes; h. wound care: any skin opening requiring a dressing. Review of Resident #7's medical record revealed a re-admitted [DATE], with diagnoses that included in part . Open Wound of Abdominal Wall, Unspecified Quadrant with Penetration into the Peritoneal Cavity, and Type 2 Diabetes Mellitus without Complications. Review of Resident #7's Quarterly and State Optional MDS with an ARD of 02/18/2025 revealed a BIMS score of 15, which indicated intact cognition. Resident #7 required total dependence with two person assist for transfers and extensive assistance with two person assist for bed mobility and toileting. Review of Resident #7's current physician orders revealed in part .08/15/2022 (start date): Enhanced Barrier Precautions related to Abdomen (ABD) wound. Review of Resident #7's care plan with an initiated date of 02/21/2025 revealed in part .Focus: Enhanced Barrier Precautions related to abdomen (ABD) wound. Intervention: Enhanced Barrier Precautions related to abdomen (ABD) wound. Maintain universal precautions when providing resident care. On 04/30/2025 at 10:00 a.m., observed S8 CNA and S9 CNA enter Resident #7's bedroom with the mechanical Hoyer lift and close the bedroom door. Observed the Enhanced Barrier Precaution signage taped to Resident #7's door in two different places for viewing. Observed the personal protective equipment (PPE) storage placed over the resident's door with disposable gowns and gloves in the storage caddy. Observed no evidence of gown usage by S8 CNA and S9 CNA upon entrance of the resident's room. In an interview on 04/30/2025 at 10:09 a.m., S8 CNA and S9 CNA both revealed they had provided a transfer from geri-chair to bed and a brief change for Resident #7. S8 CNA and S9 CNA both confirmed they only wore gloves during the transfer and brief change. S8 CNA and S9 CNA confirmed they were aware of the Enhanced Barrier Precaution signage on the resident's door and confirmed they should have worn a gown during Resident #7's transfer and brief change. In an interview on 04/30/2025 at 10:13 a.m., S2 DON revealed any resident on Enhanced Barrier Precautions required all the CNAs and nursing staff to wear gown and gloves during their transfer or brief change. S2 DON confirmed the CNAs should have worn a gown and gloves during the transfer and brief change of Resident #7, but did not.

Based on interview and record review, the facility failed to include the Medical Director or his designee and Director of Nursing in the Quality Assessment and Assurance (QAA) committee quarterly meeting, as required. The facility's total census was 73. Findings: Review of an undated facility policy titled, Quality Assessment and Assurance revealed the following in part .1. The Committee will be made up of, at a minimum, the Director of Nursing; the Medical Director or his designee, and at least three (3) other members of the facility staff, at least one of whom must be the administrator, owner, a board member or other individual in a leadership role; and the infection preventionist officer. Review of the facility's documented quarterly Quality Assurance (QA) meeting held on 04/24/2025 revealed S1 ADMIN and eight (8) other leadership personnel in attendance. There was no documentation of the Medical Director nor the Director of Nursing in attendance of the QA meeting held on 04/24/2025. In an interview on 04/30/2025 at 1:17 p.m., S1 ADMIN revealed S5 Corp RN was the designated interim facility DON on 04/24/2025. S1 ADMIN confirmed the Medical Director nor the interim DON, S5 Corp RN, were present at the last quarterly QA meeting held on 04/24/2025, but should have been.

Based on observation, interview, and record review the facility failed to ensure that a resident received adequate supervision to prevent incidents and accidents. The facility failed to ensure a resident received supervision while smoking for 1 (Resident #178) of 1 resident reviewed for smoking. Findings: Review of the facility's undated policy on 04/29/2025 at 10:20 a.m. titled Smoking Policy read in part . Residents who smoke will be assessed for safety awareness and for willingness and ability to follow the facility's safety rules for smoking upon admission, and thereafter as needed but at least quarterly. A standardized form will be used and incorporated into the care planning process. Residents who are assessed as not being able to smoke safely will not be allowed to smoke without supervision. If a resident exhibits dangerous behaviors with smoking paraphernalia such as smoking in non-designated areas, smoking in room, using lighter to start fire of any kind, giving or loaning lighter to other residents, the resident will be considered unsafe to maintain smoking paraphernalia and it will be maintained for them at the nurse's station or other specified location. Review of Resident #178's medical record revealed he was admitted to facility on 03/01/2024 and had diagnoses that included in part Generalized Anxiety Disorder, Chronic Obstructive Pulmonary Disease, End Stage Renal Disease, and Depression. Record review of Resident #178's Quarterly MDS with ARD of 03/12/2025 reveled Resident #178 had a BIMS of 15, and was a current tobacco user. Record review of Resident #178's Smoking Safety assessment dated [DATE] revealed Resident #178 was determined to be an unsafe smoker. Resident #178 did not demonstrate that he only smoked in designated areas. Resident #178 did not demonstrate that he would avoid giving cigarettes or smoking paraphernalia to other residents who may be unsafe, or lit cigarettes for them. Review of Resident #178's Care plan revealed description of: Unsafe Smoker. Requires supervision while smoking. Monitor for any safety issues and report immediately. Cigarettes and lighter kept at nurse's station. History of smoking in undesignated smoking areas. Interview on 04/29/2025 at 9:42 a.m. with Resident #178 revealed he was allowed to come out and smoke whenever he wanted, and was able to hold his cigarettes and lighter on himself. Observation on 04/29/2025 at 9:44 a.m. revealed Resident #178 was seated on a bench on the front smoking patio of the facility without staff present. Resident #178 was observed removing a pack of cigarettes and a lighter from his pocket, and lit a cigarette without difficulty. Observation on 04/29/2025 at 9:50 a.m. revealed Resident #178 got up from the bench and ambulated to the front door of the facility with his lit cigarette in hand, and then flicked the lit cigarette on the ground by the front door. Resident #178 did not distinguish or place the cigarette within the ash tray located on the patio. Observation on 04/29/2025 at 9:54 a.m. of the front patio area with S13 RN revealed she observed the lit cigarette that Resident #178 had thrown on the ground near the front door. Interview with S13 RN revealed Resident #178 was an unsafe smoker, and had been educated on placing cigarettes in the ashtray. S13 RN stated he often does what he wants to do. S13 RN stated Resident #178 was considered an unsafe smoker due to him smoking in his room, and places he was not supposed to. S13 RN revealed residents who are unsafe smokers were to be observed by staff when smoking, and go out at designated times. S13 RN stated she did not know Resident #178 was back from dialysis, and confirmed he should not have been outside smoking without supervision.

Based on interview on record review, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for 1 (#2) of 4 (#1, #2, #3, and #4) residents reviewed for elopement. The Administration failed to have an effective system in place to respond when Resident #2, who was assessed to be at risk for elopement, eloped from the facility on 10/26/2024 at 1:55 a.m. The likelihood continued for the remaining 3 residents (#1, #3 and #4), who were assessed as being at risk for elopement. This deficient practice resulted in an immediate jeopardy situation on 10/26/2024 at 1:55 a.m., when Resident #2, who was moderately impaired cognitively, had a history of exit seeking behaviors, had been identified as a high elopement risk, and wore a wanderguard bracelet, exited the facility through the front door without staff knowledge. The alarm sounded and S6 LPN walked outside to investigate why the alarm had sounded; however, S6 LPN did not alert facility staff to immediately perform a census check on all residents in the facility when no resident was seen outside the building, because she stated she was unaware that she should have. Facility staff became knowledgeable of Resident #2's elopement when Resident #2's family member notified the facility at 2:13 a.m., that Resident #2 had walked through a residential area to her home, which was 0.3 miles away from the facility. The family member returned Resident #2 to the facility on [DATE] at 2:18 a.m. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Cross reference F689 Review of the facility's Elopement Risk-Resident Policy (no original policy date document), on 11/06/2024, with a revision date of 10/28/2024, read in part . The facility will make every attempt to provide adequate supervision to all Residents. However, even when all precautions are taken, a resident who is independently mobile may be able to leave the facility grounds without being observed by the staff. 1. Residents are assessed upon admission and at least quarterly for potential elopement risk. 2. If a resident is found to be at risk, the facility will closely monitor the resident's locations and document a visual check at least every 2 hours, in addition the resident may be provided with a security soft bracelet that will identify him or her as a resident of the facility in the event the resident becomes lost. 3. The facility may maintain a locking door system whereby an at-risk resident would wear a safety device that activates a door alarm. 4. At the direction of the Administrator, the facility may post, in an inconspicuous yet known to staff location, a list of residents who need to be watched closely for potential elopement. This watch list would also be available in the nurse's stations. Attempted Elopement 1. If the alarm sounds for a wanderguard system, nursing staff is to immediately check entrance where alarm is sounding. If no resident is seen, census checks are to be done immediately on all residents in the building. Review of the facility undated policy on 11/06/2024, titled Elopement - Missing Residents policy, read in part . As soon as a resident is determined to be missing, the charge nurse will immediately do the following: 1. Assign all available staff to systematically search the entire premises, both inside and outside, patient rooms, bathrooms, closets, kitchen, lobby, and offices. 2. Notify the Administrator and /or Director of Nursing. 3. Assign staff to search around the facility a radius of one mile during the first 30 minutes. This should include a search by vehicle and on foot. When the resident is located, contact an ambulance if injuries are apparent, or if the resident has been exposed to extreme heat or cold weather. Otherwise, return the resident to the facility where the charge nurse will: 1. Examine the resident and provide first aide or request medical attention as needed. 2. Complete and file an incident report; and 3. Document the incident in the resident's medical record. 4. Documentation must be concise and reflect the actual facts as they relate to the incident including: a. Times b. Persons contacted c. Condition of resident upon return to the facility d. Physician notified e. Physician orders f. Treatment indicated g. Any other pertinent information Observation facility's video footage on 11/06/2024 at 12:30 p.m., revealed on 10/26/2024, S6 LPN was observed sitting at the nurse's station at 1:54 a.m. S6 LPN was observed sitting at the nurse's station with her head down at 1:54 a.m. At 1:55 a.m., Resident #2 was seen walking past the nurse's station, approached the front door, pushed on the door, it opened and she exited the facility. At 1:55:55 a.m., S6 LPN was seen walking to the front door of the facility after hearing the alarm sound. S6 LPN walked out the front door, looked around, reentered the facility and reset the door code. At 2:13:45 a.m., S6 LPN received a telephone call from Resident #2's family member, that Resident #2 was at her home. At 2:18 a.m., Resident #2 was returned to the facility by her family member. Interview with S6 LPN on 11/06/2024 a 9:35 a.m., revealed she worked on 10/26/2024, the night Resident #2 eloped from the facility. S6 LPN revealed she heard the alarm sound at the front door; approached the door and did not see anyone. She walked outside and looked around, did not see anyone and walked back into the facility. She reset the alarm and sat back down at the nurse's station. S6 LPN stated she received a phone call from Resident #2's granddaughter around 2:00 a.m., that Resident #2 left the facility and walked to her home. S6 LPN stated she notified S7 LPN, S1 Administrator and S2 DON that Resident #2 had eloped from the facility. S6 LPN stated Resident #2's granddaughter retuned her to the facility, and staff began a census check on all residents in the building. S6 LPN stated she did not conduct a census check on all residents once she was unable to identify why the alarm system sounded at 1:55 a.m., because she thought it was a staff member, or another resident with the door code that may have set off the alarm. Interview with S1 Administrator on 11/06/2024 at 10:11 a.m. revealed he was notified by the facility of the elopement, and arrived at the facility around 2:30 a.m. on 10/26/2024. S1 Administrator stated he and S8 Maintenance Supervisor checked all doors, alarm systems, and wander guards in the facility. He stated they noticed there was a malfunction with the tension bar on the closure of the front door, and fixed the issues at that time. Interview with S2 DON on 11/06/2024 at 11:22 a.m. revealed she was notified of the elopement after the incident occurred on 10/26/2024, and notified staff to conduct a facility wide census check at that time. S2 DON confirmed that a census check should have been initiated immediately when staff were unable to identify why the alarm sounded on 10/26/2024 at 1:55 a.m., but had not been done. S2 DON stated the nurse should have been aware that a census check should have been done. S2 DON revealed she initiated an in-service for all staff on 10/26/2024, that was completed on 10/29/2024, on the elopement policy and to ensure that anytime the alarm sounds with an unidentifiable cause, that a census check must be conducted for all residents. On 11/06/2024 at 1:40 p.m., the Administrator gave the surveyors a copy of their Elopement Risk- Resident Policy (no original policy date), with the following revision: The facility is to initiate a census check on all residents in the building if the alarm sounds, and no resident is seen. The revision date was documented as 10/28/2024. Interview with S6 LPN on 11/06/24 1:45 p.m. revealed she was unaware that she should have done a census check on all residents after the alarms sounded, and she was unable to verify the cause. S6 LPN stated she was in-serviced on this after the incident occurred. The facility has implemented the following actions to correct the deficient practice: 1. Census check completed for all residents. 2. Resident #2 was immediately assessed and placed on a 24 hour, 1:1 supervision after returning to the facility on [DATE] at 2:18 a.m. After the 24 hour 1:1 supervision, Resident #2 was placed on Q15 minute census check that are currently still being provided. 3. S1 Administrator fixed the malfunction of the tension bar in the closer of the front door. 4. Daily monitoring initiated on all exit doors, alarm systems, and wander guards on 10/26/2024. 5. The elopement policy was reviewed and revised. A facility wide in-serviced was initiated on 10/26/2024 and completed on 10/29/2024 for all staff, to ensure that anytime the alarm sounds with an unidentifiable cause, that a census check must be conducted for all residents. 6. Elopement Risk evaluation was conducted on all residents with wanderguards in the facility on 10/26/2024, and determined that 5 residents were at risk for elopement. 7. Daily monitoring tool for high elopement risk residents was initiated on 10/26/2024. 8. The alarm system company serviced the alarm system with no issues found. 9. QA on elopement was initiated on 10/26/2024, and is reviewed daily with morning QA meeting to discuss any new incidents or new exit seeking behaviors in residents. As of 10/29/2024 and once the above interventions were all implemented, the past noncompliance was considered to be corrected.

Based on observation, interview and record review, the facility failed to ensure Resident #2, who had been assessed to be at high risk for elopement, received adequate supervision to prevent the resident from eloping from the facility, for 1 (#2) of 4 (#1, #2, #3, and #4) residents reviewed for elopement. Findings: This deficient practice resulted in an immediate jeopardy situation on 10/26/2024 at 1:55 a.m., when Resident #2, who was moderately impaired cognitively, had a history of exit seeking behaviors, had been identified as a high elopement risk, and wore a wanderguard bracelet, exited the facility through the front door without staff knowledge. The alarm sounded and S6 LPN walked outside to investigate why the alarm had sounded; however, S6 LPN did not alert facility staff to immediately perform a census check on all residents in the facility when no resident was observed outside the building. Facility staff became knowledgeable of Resident #2's elopement when a family member notified the facility at 2:13 a.m. Resident #2 had walked from the facility and through a residential area to a family members' home, which was 0.3 miles away from the facility. The family member returned Resident #2 to the facility on [DATE] at 2:18 a.m. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility policy on 11/06/2024 with a revision date of 10/28/2024, and titled Elopement Risk- Resident, read in part .the Facility will make every attempt to provide adequate supervision to all Residents. However, even when all precautions are taken, a resident who is independently mobile may be able to leave the facility grounds without being observed by the staff. 1. Residents are assessed upon admission and at least quarterly for potential elopement risk. 2. If a resident is found to be at risk, the facility will closely monitor the resident's locations and document a visual check at least every 2 hours, in addition the resident may be provided with a security soft bracelet that will identify him or her as a resident of the facility in the event the resident becomes lost. 3. The facility may maintain a locking door system whereby an at-risk resident would wear a safety device that activates a door alarm. 4. At the direction of the Administrator, the facility may post, in an inconspicuous yet known to staff location, a list of residents who need to be watched closely for potential elopement. This watch list would also be available in the nurse's stations. Attempted Elopement 4. If the alarm sounds for a wanderguard system, nursing staff is to immediately check entrance where alarm is sounding. If no resident is seen, census checks are to be done immediately on all residents in the building. Review of the facility undated policy on 11/06/2024, titled Elopement - Missing Residents policy, read in part . As soon as a resident is determined to be missing, the charge nurse will immediately do the following: 1. Assign all available staff to systematically search the entire premises, both inside and outside, patient rooms, bathrooms, closets, kitchen, lobby, and offices. 2. Notify the Administrator and /or Director of Nursing. 3. Assign staff to search around the facility a radius of one mile during the first 30 minutes. This should include a search by vehicle and on foot. Review of Resident #2's medical record revealed an admitted [DATE], with diagnoses that included, in part . Alzheimer's Disease, Unspecified Dementia, and Schizophrenia. Review of Resident #2's Admission MDS with an ARD of 08/22/2024, revealed a BIMS score of 12, indicating moderate cognitive impairment. The MDS revealed Resident #2 required no mobility devices, and was able to independently walk 150 feet. Review of Resident #2's 08/2024 Physician's Orders revealed in part . 08/27/2024 - Left ankle wanderguard worn at all times, with Q1 hour census checks related to elopement risk. Review of Resident #2's Care plan with a start date of 08/14/2024, read in part .Elopement: At risk for elopement due to a history of wandering. Interventions: Q1 hour census checks. Left ankle wanderguard at all times. Review of Resident #2's Risk of Elopement Evaluation dated 08/22/2024, revealed Resident #2 ambulated per self, and had a history of elopement attempts at home. Intervention included: frequent monitoring with Q1 hour visual checks, and left ankle wanderguard. During an interview with Resident #2 on 11/04/2024 at 9:45 a.m., she stated she remembered that she left the facility via the front door on 10/26/2024, and stated that was the first time she ever attempted to leave the facility. Observation of the facility's video footage on 11/06/2024 at 12:30 p.m., revealed on 10/26/2024, S6 LPN was observed sitting at the nurse's station with her head down at 1:54 a.m. At 1:55 a.m., Resident #2 was seen walking past the nurse's station, approached the front door, pushed on the door, it opened and she exited the facility. At 1:55:55 a.m., S6 LPN was seen walking to the front door of the facility after hearing the alarm sound. S6 LPN walked out the front door, looked around, reentered the facility and reset the door code. At 2:13:45 a.m., S6 LPN received a telephone call from Resident #2's family member, stating Resident #2 was at her home. At 2:18 a.m., Resident #2 was returned to the facility by her family member. Interview with S6 LPN on 11/06/2024 a 9:35 a.m., revealed she worked on 10/26/2024, the night Resident #2 eloped from the facility. S6 LPN revealed she heard the alarm sound at the front door; approached the door and did not see anyone. She walked outside and looked around, did not see anyone and walked back into the facility. She reset the alarm and sat back down at the nurse's station. S6 LPN stated she received a phone call from Resident #2's granddaughter around 2:00 a.m., notifying her that Resident #2 had left the facility and walked to her home. S6 LPN stated she notified S7 LPN, S1 Administrator and S2 DON that Resident #2 had eloped from the facility. S6 LPN stated Resident #2's granddaughter returned her to the facility, and staff began a census check on all residents in the building. S6 LPN stated she did not conduct a census check on all residents once she was unable to identify why the alarm system sounded at 1:55 a.m., because she thought it was a staff member, or another resident with the door code that may have set off the alarm. Interview with S7 LPN on 11/06/2024 at 10:00 a.m., revealed she cared for Resident #2 on 10/26/2024 when the elopement occurred. S7 LPN revealed she last saw Resident #2 asleep in bed at 1:30 a.m., then was notified by S6 LPN that Resident #2 had left the building and was found at a family member's home nearby. S7 LPN stated all staff immediately initiated a census checks on all residents after Resident #2 returned to the facility. S7 PLN stated once Resident #2 was returned to the facility, Resident #2 was placed on 1:1 supervision, and a body audit was conducted with no issues. Interview with S1 Administrator on 11/06/2024 at 10:11 a.m. revealed he was notified by the facility of the elopement, and arrived at the facility around 2:30 a.m. on 10/26/2024. S1 Administrator stated he and S8 Maintenance Supervisor checked all doors, alarm systems, and wander guards in the facility. He stated they noticed there was a malfunction with the tension bar on the closure of the front door, and fixed the issues at that time. Interview with S2 DON on 11/06/2024 at 11:22 a.m. revealed she was notified of the elopement after the incident occurred on 10/26/2024, and notified staff to conduct a facility wide census check at that time. S2 DON confirmed that a census check should have been initiated immediately when staff were unable to identify why the alarm sounded on 10/26/2024 at 1:55 a.m., but had not been done. S2 DON revealed she initiated an in-service for all staff on 10/26/2024, that was completed on 10/29/2024 on the elopement policy and to ensure that anytime the alarm sounds with an unidentifiable cause, that a census check must be conducted for all residents. The facility has implemented the following actions to correct the deficient practice: 1. Census check completed for all residents. 2. Resident #2 was immediately assessed and placed on a 24 hour, 1:1 supervision after returning to the facility on [DATE] at 2:18 a.m. After the 24 hour 1:1 supervision, Resident #2 was placed on Q15 minute census check that are currently still being provided. 3. S1 Administrator fixed the malfunction of the tension bar in the closer of the front door. 4. Daily monitoring initiated on all exit doors, alarm systems, and wanderguards on 10/26/2024. 5. The elopement policy was reviewed and revised on 10/28/2024. A facility wide in-serviced was initiated on 10/26/2024 and completed on 10/29/2024 for all staff, to ensure that anytime the alarm sounds with an unidentifiable cause, that a census check must be conducted for all residents. 6. Elopement Risk evaluation was conducted on all residents with wanderguards in the facility on 10/26/2024, and determined that 5 residents were at risk for elopement. 7. Daily monitoring tool for high elopement risk residents was initiated on 10/26/2024. 8. The alarm system company serviced the alarm system with no issues found 9. QA on elopement was initiated on 10/26/2024, and is reviewed daily with morning QA meeting to discuss any new incidents or new exit seeking behaviors in residents. As of 10/29/2024, and once the above interventions were all implemented, the past noncompliance was considered to be corrected.

Based on record review and interview the facility failed to ensure an injury of unknown source was reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency for 1 (#1) of 4 (#1, #2, #3, and #4) sampled residents reviewed for abuse. Findings: Review of the facility's undated policy on 11/04/2024 at 4:00 p.m. titled Abuse Prevention and Investigation read in part . The facility has implemented abuse prevention including 7 key components which are: Employee Screening, Training, Prevention, Identification, Investigations, Protection of residents during investigations, and Response and Reporting of incidents of suspected & actual abuse, according to current federal and state laws and regulations. 16. Reporting: a. All alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately, but not later than 2 hours after the allegation is made if the alleged violation involves abuse, or results in serious bodily injury OR within 24 hours if the alleged violation does not involve abuse and does not result in serious bodily injury to the administrator of the facility and to other officials including the state survey agency and adult protective services in accordance with state law through established procedures. 22. The appropriate State Agency will be notified per regulations for any abuse, suspected abuse, injury of unknown origin using the State- Mandated Protocol for Reporting. Review of the medical record for Resident #1 revealed she was admitted to the facility on [DATE] with diagnoses that included: Osteoporosis, Magnesium Deficiency, Displaced Fracture of Shaft of Left Clavicle (06/30/2021), Muscle Wasting and Atrophy, Dietary Calcium Deficiency, Generalized Muscle Weakness, Unspecified Dementia, Major Depressive Disorder, Anxiety, and Schizoaffective Disorder. Review of Resident #1's Quarterly MDS with an ARD of 08/14/2024 revealed a BIMS score of 99, which indicated the resident was not able to participate in interview. The MDS revealed Resident #1 was dependent on staff for eating, oral hygiene, toileting, showering/bathing, dressing, and personal hygiene. Review of Resident #1's Departmental Progress Notes revealed in part . 10/23/2024 10:31 a.m. by S3 Treatment Nurse: Informed by S5 CNA that Resident had skin tear to right elbow area measuring 5 cm x 2 cm, with small amount of bleeding noted. Cleansed with normal saline, triple antibiotic ointment applied, and covered. Bruising noted to right upper arm with blue and yellow discoloration. Facial grimaces noted upon assessing. S4 NP made aware, new orders given to x-ray right arm. 10/23/2024 2:03 p.m. by S3 Treatment Nurse: Portable x-ray obtained as ordered. Results of x-ray revealed right humerus fracture and osteopenia. S4 NP made aware of results, and ordered to send to orthopedist. Appointment scheduled for tomorrow at 9:30 a.m. RP also made aware of results and of appointment. Informed her that an investigation was on going as to what happened, she verbalized understanding. Interview on 11/04/2024 at 1:00 p.m. with S2 DON revealed on 10/23/2024 she was notified by S3 Treatment Nurse that Resident #1 obtained a skin tear to right upper arm with bruising. S2 DON stated S3 Treatment Nurse notified S4 NP, and S4 NP ordered an x-ray. S2 DON stated the X-ray resulted as a Right Humeral Fracture. S2 DON stated the facility began an investigation immediately due to injury of unknown origin and Resident #1 was not able to state the cause. S2 DON stated the facility ultimately could not determine how the injury occurred. Interview on 11/06/2024 at 3:40 p.m. with S1 Administrator revealed he was responsible for reporting incidents into the Statewide Incident Management System. S1 Administrator confirmed according to policy he should have reported the incident regarding Resident #1's injury of unknown origin, that resulted in a serious bodily injury, within 2 hours of becoming aware, but had not.

Based on observation and interview, the facility failed to ensure medications were stored and labeled properly in accordance with currently accepted professional principles on 1 (Hall A) of 2 (Hall A and Hall B) medication carts and 1 of 1 medication storage rooms. Findings: Review of the facility policy titled: Medications-Storage, revealed in part The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. Observation on 02/07/2024 at 9:00 a.m. of the Hall A medication cart accompanied by S15 LPN revealed the second drawer of the medication cart contained 3 loose pills and the bottom drawer of the medication cart contained an opened 100ct box of 28G safety lancets with an expiration date of 02/01/2024. Findings confirmed with S15 LPN at the time of observation. S15 LPN revealed it was the responsibility of all nurses to ensure carts were kept clean and free of loose pills and to check dates on boxes. Observation on 02/07/2024 at 9:30 a.m. of the facility medication storage room revealed the following items on shelves for use: 5 (30ct) boxes of Ipratropium Bromide and Albuterol Sulfate inhalation 0.5mg/3mg solutions. Expiration dates noted as 11/2023 on 2 boxes, 07/2023 on 2 boxes, and 1 box expired on 05/2023. 1 (30ct) box of Ipratropium Bromide 0.02% inhalation solution with an expiration date of 01/2024. 1 (40ct) box of Guaifenesin Extended Release 600mg tablets with an expiration date of 01/2024. 4 Fluticasone Propionate & Salmetrol inhalation disk. Expiration dates noted as 04/2023 on 3 disk and 01/2023 on the other disk. 1 Symbicort 160/4.5 inhaler with an expiration date 06/2022. Interview on 02/07/2024 at 9:56 a.m. with S1 DON confirmed the medication room findings. S1 DON stated expired medications should have been removed from shelves and placed in the appropriate bins for disposal and had not been.

Based on interview and record the facility failed to ensure physician ordered wound care treatments were administered in accordance with professional standards of practice for 10 (#2, #5, #6, #7, #9, #10, #11, #12, #13, and #14) of 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 and #14) sampled resident who received wound care. The deficient practice resulted in an Immediate Jeopardy situation on [DATE] when S3RN/DON allowed S10CNA to perform complex wound care for Residents #2 and #5, PEG tube care for Residents #9, #10, #11, #12, #13 and #14, and treatment to skin tears for Resident #7. As of [DATE], the facility has failed to re-educate/retrain staff regarding respective job responsibilities/duties. The facility Administrator was notified of the Immediate Jeopardy situation on [DATE] at 5:35 p.m. The Immediate Jeopardy situation was removed on [DATE] at 3:58 p.m. when the facility submitted the following plan of removal, and the surveyor determined through observation, interview and record review that the plan of removal was being implemented, which included: All wound care would be performed by licensed nurses. When all staff were in-serviced and tested on ensuring that only qualified, licensed staff performed wound care and were knowledgeable of who to report to immediately if any staff performed tasks outside their scope of practice. Training was completed on [DATE] at 11:00 a.m. Any staff who has not received the in-service or testing will be trained and tested prior to working their shift. The DON was counseled and discipline on [DATE]. The Administrator or designee will monitor, beginning [DATE], at least 8 residents per week for 8 weeks to ensure that wound care was provided only by qualified, licensed staff. As of [DATE], if 100% compliance has not been established, monitoring will continue for 4 more weeks. This process will occur until 100% compliance is achieved. Audit reports will be submitted to the Administrator and will be reviewed by the QAPI committee on [DATE] and new interventions will be implemented as needed. The Administrator, or corporate designee, will also monitor the actions of the facility DON. This will occur daily, and for a period of 8 weeks. Monitoring will began on [DATE] and will conclude on [DATE]. This deficient practice continues at a scope and severity of more than minimum harm for all 13 residents who required wound care treatments. Findings: Review of the facility's Skin Program, Pressure Ulcers and Other Wounds policy and procedures revealed the following Care of Residents with Wounds (Pressure and Non-pressure related): If a resident does develop a reddened area or wound, the licensed nurse will implement the following interventions Obtain treatment order from physician if needed or implement the facility's protocol if appropriate. Review of a facility investigation of a wound care incident that began on [DATE] revealed S8LPN/MDS reported to S1 ADM at the end of the day, rumors of CNAs performing wound care treatments. Wound care documentation was checked and confirmed that S3RN/DON signed that she had completed the wound care for Wednesday [DATE] and Thursday [DATE]. On Friday [DATE], S9CNA Supervisor reported to S1ADM that multiple CNAs were concerned that S10 CNA was performing wound care on residents. After the treatment cart was discovered parked outside of Resident #7's room, S11SSD walked down the hall to inspect who was using the treatment cart. Upon entering the resident's room, S11SSD observed S10 CNA and the hospice CNA to be giving the resident a bath. S11SSD asked who was using the treatment cart and S10CNA stated that she was doing wound care per S3 DON's instructions. S11SSD informed S10 CNA that she should not be performing wound care and S10CNA had the right to refuse to do so. S11 SSD informed S1 ADM of her encounter with S10CNA. S1ADM then spoke with S10CNA and S9CNA Supervisor regarding S10CNA performing wound care. S10 CNA revealed she had done all the wound treatments per ordered by S3RN/DON for the past 3 days ([DATE], [DATE] and [DATE]). S10CNA revealed she was unaware that she was not supposed to be performing wound care, but was doing what she was ordered to do by S3RN/DON. Further review of the facility Investigation Report revealed the following: On [DATE], S1 ADM and S2Corporate ADM met with S3RN/DON. The report revealed S3RN/DON stated that she did not give S10CNA (missed a word) to perform wound care treatments. S3 RN/DON stated that she asked S10CNA to assist with wound care, and S10CNA must have taken it upon herself to do the wound care. S3RN/DON stated she found out about S10CNA doing the wound care after it was done and chose not to do anything about it. S3RN/DON stated S10CNA did not do all the wound care in the building and that it only occurred one day. The Investigation Report revealed S3RN/DON was suspended immediately and RN coverage was ensured during her absence. S7Treatment Nurse/LPN was instructed to assess all wounds to ensure no harm was done, and to be aggressive/deliberate with wound care. Review of an Employee Warning Report dated [DATE], and signed by S1ADM revealed Carelessness and Violation of company policies and procedures were checked for Type of Violation. The Supervisor's/Employer's Statement revealed S3RN/DON allowed CNA to perform wound care on residents. Unacceptable action. Suspension for 1 week ([DATE] to [DATE]) was checked as the action to be taken. The report revealed that failure to improve would result in dismissal. Interview with S12CNA on [DATE] at 10:08 a.m. revealed she worked the 7:00 a.m. - 3:00 p.m. shift. S12CNA stated that on Friday [DATE], she was getting ready to take her break and went down the hall to let S10 CNA know. S12CNA stated she opened the door to Resident #2's room and saw S10CNA and the hospice CNA cleaning the wound on Resident #2's stomach. S12CNA revealed she closed the door, and once S10CNA came out of the room, she approached her and told her she should not be doing wound care on residents and that was the nurse's job. S12CNA stated that S10CNA said that she didn't know that she couldn't do wound care, and would not do it anymore. S12CNA stated she reported this to S9CNA Supervisor that same day. She stated she had not been in-serviced on the subject of CNAs performing wound care after this incident. Interview with S9CNA Supervisor on [DATE] at 10:18 a.m. revealed she was off on [DATE], and returned to work on [DATE]. S9CNA Supervisor stated on the morning of [DATE], S12CNA approached her to ask if anyone had contacted the State to get approval for CNAs to perform wound care. S9CNA Supervisor stated that she was informed by S12CNA, that S10CNA performed wound care on residents after being directed by S3RN/DON to do so. S12CNA informed S9CNA Supervisor that she reported the incident to S8LPN. S9CNA Supervisor stated she informed S1ADM, who told her that he was aware of it and looking into the situation. S9CNA Supervisor stated that after the incident, she did not attend any in-services on the subject. Interview with S3RN/DON on [DATE] at 12:22 p.m. revealed on [DATE] she had taken the treatment cart down to Resident #5's room, got his supplies ready, and placed kerlix and other supplies on the top of the treatment cart while S10CNA and the Hospice CNA were bathing the resident. S3RN/DON stated she told them to call her when they were ready. However when she went back down to the room, they stated they had already done the wound care. S3RN/DON stated that CNAs do not have the scope to do wound treatments and she did not ask them to do the treatments. S3RN/DON stated she had initialed the TARS for all wound care residents on [DATE], [DATE], and [DATE] because she didn't want any holes or blanks on it. S3RN/DON stated she did not report or reprimand them because she was overwhelmed, swamped, and had just received a call that she was going to have to work the night shift, and was trying to get things done. S3RN/DON stated she was going to do Resident #2's wound care after S10CNA and the Hospice CNA bathed her, but they never came to get her. S3RN/DON stated she went down later to Resident #2's room and asked her about her wound care, and the Resident #2 stated that it had already been done. S3RN/DON stated didn't ask the resident who did it, and confirmed she signed Resident #2's TARs indicating she had performed the wound care without finding out who did it, or if it had in fact been done. Further interview with S3RN/DON revealed weekly wound assessments were done on Thursdays. Interview with S1ADM on [DATE] at 1:00 p.m. revealed on the evening of [DATE], S8LPN reported to him about rumors that CNAs were performing wound care. S1ADM stated on [DATE], S9CNA Supervisor came to him and stated S12CNA had reported it to her. S1ADM revealed he called S2 Corporate ADM and got him involved, pulled records and interviewed CNAs. Originally, S3 RN/DON admitted she allowed S10CNA to do all the wound care on [DATE]; however, S3RN/DON then stated that she only asked S10CNA to assist her with wound care, and that S10CNA took the liberty to do it on her own. S1ADM stated they came to the decision that they thought the DON disregarded the policy for nurses to do treatments. S1ADM revealed they suspended S3RN/DON for a week and verbally counseled S10CNA because she was just following the DON's orders. S1ADM confirmed there had been no in-services with staff on following their scope of practice, or reporting staff if asked to do something outside their scope of practice. Interview with S10CNA on [DATE] at 11:00 a.m. revealed she worked on [DATE], [DATE] and [DATE]. S10 CNA stated when she came to work on [DATE], she was told by S3RN/DON that she was assigned to do wound care that day. S10CNA stated that she had assisted the nurses in turning and holding things in position while they performed wound care, but had never performed it by herself. She stated she did not question S3 RN/DON because she had been promoted to CNA supervisor and thought that it was part of her job. S10CNA stated on [DATE] she and the Hospice CNA were providing ADL care to Resident #5, and S3RN/DON came to the resident's room and asked if they were ready to do the wound care on him. She stated she told her that they had just started on his bath and that it was going to take a while. S10CNA stated S3RN/DON stated well just go ahead and do the wound care and that she would leave the cart unlocked, because she couldn't give her the keys. S10CNA stated she did not do any of the treatments using a TAR or MD orders, but off of memory from watching it being done by other staff. S10CNA stated on [DATE] and [DATE] she went and got the treatment cart, which was already unlocked, and completed wound treatments on a total of 11 residents each day except on [DATE]. S10CNA stated she completed wound care for Residents #2 and #5 on [DATE], and was called to Resident #4's room to do wound care. While standing at the treatment cart outside Resident #4's, S11 SD came down the hall told her that she was not supposed to be doing wound care. S10CNA stated she told S11SSD that she was just doing what S3RN/DON had told her to do. She stated S11SSD told her that she could not do it and to tell the DON no. S10CNA stated that she did not know she could not do wound care. S10CNA revealed she did not do any further treatments that day. S10CNA stated right after that, S1ADM called her into his office and asked her what she was doing. She stated she explained to him that S3RN/DON had asked her to do wound care on [DATE], ,d+[DATE] and [DATE], because she did not have time, and there was no treatment nurse working those days and the other LPNs refused to do the wound care. S10CNA revealed S1ADM and S2 Corporate ADM told her not to do it anymore. Interview with S8LPN on [DATE] at 1:45 p.m. revealed on [DATE] at approximately 2:00 p.m. she was called to Resident #7's room by CNAs S13CNA and S14CNA. S8LPN stated when she arrived to the room the CNAs were reporting a bruise that they had found during wound care. She asked the CNA's who was doing the wound care and they told her S10CNA was doing the wound care for the resident who had wound care ordered and had given them supplies to finish Resident #7's wound care up. S8LPN stated she saw the wound supplies in the resident's room. S8LPN revealed she spoke to S10CNA but did not ask her if she was doing treatments or who told her to do treatments, because I just really didn't want to know. S8LPN revealed she reported to S1ADM on [DATE] at approximately 3:00 p.m. of a rumor that S10CNA was performing wound care. Interview with the Hospice CNA on [DATE] at 9:40 a.m. revealed she had two residents at the NH, Residents #2 and #5. The Hospice CNA stated on [DATE], she and S10CNA were giving Resident #5 a bed bath, when S3RN/DON opened the door and asked if they were ready to do the wound care, and they both stated no. The Hospice CNA stated S10CNA went to the door and told S3RN/DON that it would be a little while because they had just gotten started. The Hospice CNA stated she heard S3RN/DON tell S10CNA to just go ahead and do the wound care while there. The Hospice CNA stated S10CNA performed the wound care as instructed by S3RN/DON. The Hospice CNA stated S10CNA also performed Resident #2's wound care when she was assisting with the bath. Further interview with the Hospice CNA revealed that when she came into the facility on either [DATE] or [DATE], she stopped by S3RN/DON's office and asked who was doing wound care that day, and S3RN/DON stated S10CNA would be doing wound care. Interview with S10CNA on [DATE] at 11:45 a.m. revealed she performed PEG tube care to the following residents on [DATE], [DATE], and [DATE]: Residents #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14. S10CNA stated she removed the old gauze, used wound cleaner to clean the area, put on a new split gauze, and taped the top and bottom. Interview with S3RN/DON on [DATE] at 12:45 p.m. confirmed that she asked S10CNA on [DATE] to assist her with wound care; however, the CNA took it upon herself to perform all wound care. S3RN/DON confirmed that S10CNA performed wound care on [DATE], [DATE] and [DATE], but was not instructed to do so. S3RN/DON confirmed she signed the TARS indicating she had performed the wound care herself on all 3 days, should not have documented she performed it when she didn't. S3RN/DON she did not reprimand the CNA for performing the wound care. Resident #2 Review of Resident #2's Face sheet revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Significant Change MDS with an ARD of [DATE] revealed Resident #2 was coded as having a BIMS of 7 (moderate cognitive impairment). The MDS further revealed Resident #2 required 2+ persons physical assistance for bed mobility, dressing, toilet use, and personal hygiene, had no ROM Impairments bilaterally, and was coded to have an open lesion other than ulcers, rashes, and cuts. Review of Resident #2's Plan of Care with a problem onset date of [DATE] revealed the problem I have an open lesion to my lower abdomen - Dx: Panniculitis. MD aware - non-healing due to obesity. Care Plan interventions included: wound care as ordered by physician, weekly evaluation of wound healing, monitor for changes in skin status that may indicate worsening of open lesion, and notify the physician. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR for ,d+[DATE] revealed an abdominal wound treatment to cleanse the wound with normal saline, apply Calcium Alginate Rope, and cover with super absorbent pad daily until healed, was signed off as performed by S3 RN/DON on [DATE], [DATE] and [DATE]. Observation on [DATE] at 8:55 a.m. of wound care for Resident #2 that was performed by S7LPN and assisted by S10CNA and a Hospice CNA, revealed Resident #2 had a large open area to her lower abdomen. Resident #2 is obese and her abdomen had to be picked up/lifted in order to visualize and perform wound care of the full area. The open area was observed to be beefy red in color with sero-sanguenous drainage. There was a towel that contained red drainage draped over the area prior to S7LPN Treatment Nurse performing wound care. The open area measured approximately 10 inches wide by 5 inches long. Resident #2 stated she was not in pain. S7LPN Treatment Nurse cleaned the area with wound cleanser, patted dry, applied Calcium Alginate, covered with gauze, and then covered with a dry dressing. Observation of Resident #2 on [DATE] at 9:58 a.m. revealed her lying in bed. Interview with Resident #2 at that time revealed she has resided at the facility for [AGE] years and has received wound care to her abdomen every day since admission. Resident #2 stated that either S3 RN/DON, S5RN or S7LPN Treatment Nurse performed the wound care. She stated a CNA has never done wound care on her without a nurse present. She stated she knew whether a staff was a LPN or CNA. Interview with S10CNA on [DATE] at 11:00 a.m. revealed she has been a CNA since 2019, and has worked at the facility for 2 years. She stated she is CNA Supervisor on the weekends. S10CNA stated she performed wound care for all residents who required wound care and PEG Tube care on [DATE], [DATE] and [DATE]. S10CNA stated she did not know that she could not do wound care. She stated [DATE] was the first time she ever did the actual wound care herself. S10CNA She stated that on [DATE], S3 RN/DON came to her around 3:00 p.m. and asked if she would help with wound care on [DATE], and she said yes. S10CNA stated she thought she was going to assist like she had done in the past; however, S3RN/DON told her to go ahead and do wound care on all the residents on [DATE], and to let her know when it was completed so she could chart it as being done. S10CNA stated she performed wound care on several residents including Resident #2. On [DATE], S3RN/DON told her that she was over wound care again that day, and again to let her know when she finished so she could chart it. S10CNA stated she performed wound care on all residents that required wound care on that day, and when she got to Resident #2, she needed a medication called blonde hair, because that's what the medication looked like. S10CNA stated she did not know the official name for it. S10CNA stated S3RN/DON got the medication for her and handed it to her to apply to Resident #2's abdominal wound. S10CNA further stated that she performed wound care to Resident#2's abdomen again on Friday [DATE]. Resident #5 Review of Resident #5's medical record revealed his admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Significant Change Assessment with an ARD of [DATE] revealed a BIMS score of 3, indicative of severe cognitive impairment. Resident #5 required extensive assistance with two plus persons for bed mobility, dressing, toileting and personal hygiene; extensive assistance with one person for eating; required total dependence with two plus person assist for transfers and bathing; required total dependence with one person assist for locomotion on/off unit. The MDS further revealed Resident #5 had no ROM limitation with no impairment to upper and lower extremities. Resident #5 had an indwelling catheter and always incontinent of bowels. Resident #5's skin conditions included pressure ulcers treated with pressure reducing device for bed and chair, turning/ repositioning, nutrition/ hydration, pressure ulcer care, application of dressings, applying ointments/medications and dressings to feet. Review of Resident #5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] [DATE] - Left outer ankle, left buttock, left inner buttock, right buttock, right shoulder, Cleanse with normal saline, apply Medi honey with dry dressing daily until healed. [DATE] - Cleanse wound to mid back with wound cleanser, wet to dry dressing, pack tunnel with [MEDICATION(S)] soaked gauze, and cover with dry dressing daily until healed. [DATE] - Cleanse right scapula, right inner leg, and right inner lower leg with wound cleanser, apply Medi honey, dry dressing daily until healed. [DATE] - Cleanse left hip Pressure wound with wound cleanser, triple antibiotic ointment, dry dressing daily until healed. [DATE] - Cleanse blister to left mid outer foot, left lower outer foot and left inner foot with wound cleanser, paint with [MEDICATION(S)] daily [DATE] - Right heel- paint with [MEDICATION(S)], wrap with [MEDICATION(S)] daily until healed. Review of Resident #5's TARS for February 2022 revealed S3RN/DON signed off wound care treatments as performed by S3RN/DON on the specific dates of [DATE], [DATE] and [DATE]. Review of Resident #5's Care Plan with a problem onset date of [DATE], and a goal target date of [DATE] revealed resident #5 is at risk for PU related to limited mobility, fragile skin, incontinence and history of skin breakdown. Further review revealed resident #5 with PU Stage 2 to right buttocks, and unstageable wounds to right heel inner lateral, right ankle, right rear shoulder, left baby toe, left inner foot, left heel, right hip, right lateral foot, left groin perineal area, left outer ankle, sacrum, left lower outer foot, mid upper back right side of spine, right heel and left buttocks. Interventions for CNA included repositioning every 2 hours, assess skin daily with routine care, bilateral heel protectors at all times with heels floating. Interventions for wound nurse included to refer to wound specialist/clinic for evaluation, perform wound care as ordered, assess wound healing weekly, assess changes in skin status that indicate worsening of pressure ulcer and to notify physician. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #5's Discharge Summary revealed Resident #5 expired on [DATE] at 9:40 p.m. Resident #6 Review of Resident #6's Face Sheet revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's Quarterly MDS with an ARD of [DATE] revealed a BIMS of 7 (severe cognitively impairment). Functional Status revealed the resident required extensive 2 + persons physical assistance for bed mobility, transfers, toileting, extensive assist of 1 + persons for dressing and eating, and personal hygiene. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #6's TAR for ,d+[DATE] revealed a treatment to cleanse skin shear to left lower extremity with wound cleanser, apply collagen, then cover daily, and to cleanse shear to lateral side of left lower extremity with wound cleanser and apply topical antibiotic ointment, then cover daily at 6:30 a.m. Further review revealed the wound care was signed off as completed on [DATE], [DATE] and [DATE] by S3 RN/DON. Resident #7 Review of Resident #7's Face Sheet revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's Quarterly MDS with an ARD of [DATE] revealed a BIMS of 3 (severe cognitively impairment). Functional Status revealed the resident required extensive 2 + persons physical assistance for bed mobility, transfers, dressing, toileting, and personal hygiene, and moderate assist of 1 + persons for eating. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's TAR for ,d+[DATE] revealed a treatment to cleanse scabbed areas to left forearm with wound cleanser and paint with [MEDICATION(S)] daily until resolved over daily at 6:30 a.m. Further review revealed the wound care was signed off as completed on [DATE], [DATE] and [DATE] by S3 RN/DON. Resident #9 Review of Resident #9's Face Sheet revealed an admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Quarterly MDS with an ARD of [DATE] revealed a BIMS of 6 (severe cognitively impairment). Functional Status revealed the resident required extensive 2 + persons physical assistance for bed mobility, dressing, toileting and hygiene, total dependence upon 2= persons for transfers, and extensive assistance of 1 person for eating. Review of Resident #9's Care Plan revealed a problem of Pressure Ulcers: At risk due to limited mobility, incontinent, Q 2 hour turn Schedule - Category Skin. The Care start date was [DATE]. Intervention: Peg tube care as ordered - Role - Wound Nurse. Start date [DATE]. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's TAR for ,d+[DATE] revealed a treatment to change Peg split gauze Q day at 6:30 a.m. Further review revealed the dressing change was signed off as completed on [DATE], [DATE] and [DATE] by S3 RN/DON. Resident #10 Resident of Resident #10's Face Sheet revealed she was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Quarterly MDS with an ARD of [DATE] revealed a BIMS of 3 (severely impaired cognitively). The MDS further revealed Resident #10 required extensive physical assistance of 2+ persons for bed mobility, dressing, toilet use and hygiene; extensive assistance of 1 person for eating; and was totally dependent upon 2+ persons for transfers. The MDS revealed Resident #10 had no ROM impairments bilaterally; and was coded for skin tear with the application of a non-surgical dressing, and [MEDICATION(S)] feeding. Review of the Plan of Care revealed a problem of Pressure Ulcers: at risk r/t Immobility, Incontinence, Q2H turn schedule with a start date of [DATE]. Interventions included: perform wound care as ordered - Role -Wound Nurse, and apply [MEDICATION(S)] cream to Rt Abd and groin QD until resolved r/t dx: fungal infection - Role - Wound Nurse. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR for ,d+[DATE] revealed treatments to cleanse PEG site with NS, apply split gauze daily, and Apply [MEDICATION(S)] Cream to the Rt Abd and Groin daily until resolved, was signed as completed by S3RN/DON on [DATE], [DATE], and [DATE]. The treatment to cleanse area to ABD with WC QD until healed was signed as completed by S3RN/DON on [DATE] and [DATE]. Resident #11 Review of Resident #11's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Resident #11's Annual MDS with an ARD of [DATE] revealed a BIMS of 99 (unable to complete interview); require 2+ persons physical assistance for bed mobility, dressing, toilet use and hygiene; totally dependent upon 1 person for physical assistance with eating, totally dependent on 2 persons assistance for transfers; and ROM Limitation on 1 side for upper and lower extremities. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Care Plan revealed in part a DX of Malnutrition - continues on Glucerna 1.5 bolus 1 can TID, and DX of [CONDITION(S)], with a start date of [DATE]. Intervention include: PEG site treatment QD, and PRN per soilage - Role - Wound Nurse. Review of the TAR for ,d+[DATE] revealed a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The TAR revealed the treatment was signed off as performed by S3RN/DON on [DATE], [DATE] and [DATE]. Resident #12 Review of Resident #12's medical record revealed admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident # 12's Quarterly MDS with ARD [DATE] revealed a BIMS score of 00, indicating severe cognitive impairment. Resident required extensive assistance with two person assist for bed mobility, dressing, toileting and personal hygiene, required total dependence with two-person assist for transfers, required total dependence with one person assist for bathing, locomotion on unit and eating and ROM limitations without impairment to extremities. Resident had a peg feeding tube. Review of Resident # 12's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #12's MARS/TARS for February and [DATE] revealed administration of medications and treatments were performed, such as Peg tube treatment, temperature and placement checks and keeping the head of bed elevated. Review of Resident #12's TARS for [DATE], [DATE] and [DATE] treatment to Cleanse Peg with normal saline and apply split gauze every day initialed by S3 RN/DON. Review of Resident #12's Care plan with target date [DATE] revealed the resident was at risk for skin breakdown related to incontinent and immobility and at risk for malnutrition. The resident was also care planned for Peg tube feedings: NPO with continuous [MEDICATION(S)] at 50ml/hour with 60ml/hour of automatic water flush continuous per Kangaroo pump with the head of the bed elevated to prevent aspiration. Peg site was to be cleansed with normal saline, pat dry and apply gauze every day dependent upon staff for feedings and care of Peg with appropriate goals and interventions implemented. Resident #13 Revi [TRUNCATED]

Based on interview and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, by failing to ensure wound care was performed in accordance with professional standards of practice for 10 (#2, #5, #6, #7, #9, #10, #11, #12, #13 and #14) of 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, 312, #13 and #14) sampled residents. This deficient practice resulted in an Immediate Jeopardy situation on 02/16/2022 when S3RN/DON allowed S10CNA to perform complex wound care for Residents #2 and #5, PEG Tube care for Residents #9, #10, #11, #12, #13 and #14, and treatment to skin tears for Resident #7. The S1 ADM failed to take immediate preventive action when he became knowledgeable of this situation on 02/17/2022 at approximately 3:00 p.m., and S10CNA performed wound care again on 02/18/2022. As of 03/14/2022, the facility has failed to re-educate/retrain staff regarding respective job responsibilities/duties. The facility's Administrator was notified of the Immediate Jeopardy situation on 03/11/2022 at 5:35 p.m. The Immediate Jeopardy situation was removed on 03/14/2022 at 3:58 p.m. when the facility submitted the following plan of removal, and the surveyor determined through observation, interview and record review that the plan of removal was being implemented, which included: All wound care would be performed by licensed nurses. When all staff were in-serviced and tested on ensuring that only qualified, licensed staff performed wound care and were knowledgeable of who to report to immediately if any staff performed tasks outside their scope of practice. Training was completed on 03/14/2022 at 11:00 a.m. Any staff who has not received the in-service or testing will be trained and tested prior to working their shift. The DON was counseled and discipline on 02/21/2022. The Administrator or designee will monitor, beginning 03/14/2022, at least 8 residents per week for 8 weeks to ensure that wound care was provided only by qualified, licensed staff. As of 05/06/2022, if 100% compliance has not been established, monitoring will continue for 4 more weeks. This process will occur until 100% compliance is achieved. Audit reports will be submitted to the Administrator and will be reviewed by the QAPI committee on 05/06/2022 and new interventions will be implemented as needed. The Administrator, or corporate designee, will also monitor the actions of the facility DON. This will occur daily, and for a period of 8 weeks. Monitoring will began on 03/14/2022 and will conclude on 05/06/2022. This deficient practice continues at a scope and severity of more than minimum harm for all 13 residents who required wound care treatments. Findings: Cross Reference to F684. Interview with S3RN/DON on 03/10/2022 at 12:22 p.m. revealed on 02/16/2022 she had taken the treatment cart down to Resident #5's room, got his supplies ready, and placed kerlix and other supplies on the top of the treatment cart while S10CNA and the Hospice CNA were bathing the resident. S3RN/DON stated she told them to call her when they were ready. However when she went back down to the room, they stated they had already done the wound care. S3RN/DON stated that CNAs do not have the scope to do wound treatments and she did not ask them to do the treatments. S3RN/DON stated had initialed the TARS for all wound care residents on 02/16/2022, 02/17/2022, and 02/18/2022 because she didn't want any holes or blanks on it. S3RN/DON stated she did not report or reprimand them because she was overwhelmed, swamped, and had just received a call that she was going to have to work the night shift, and was trying to get things done. S3RN/DON stated she was going to do Resident #2's wound care after S10CNA and the Hospice CNA bathed her, but they never came to get her. S3RN/DON stated she went down later to Resident #2's room and asked her about her wound care, and the Resident #2 stated that it had already been done. S3RN/DON stated didn't ask the resident who did it, and confirmed she signed Resident #2's TARs indicating she had performed the wound care without finding out who did it, or if it had in fact been done. Further interview with S3RN/DON revealed weekly wound assessments were done on Thursdays. Interview with S1ADM on 03/10/2022 at 1:00 p.m. revealed on the evening of 02/17/2022, S8LPN reported to him about rumors that CNAs were performing wound care. S1ADM stated on 02/18/2022, S9CNA Supervisor came to him and stated S12CNA had reported it to her. S1ADM revealed he called S2 Corporate ADM and got him involved, pulled records and interviewed CNAs. Originally, S3 RN/DON admitted she allowed S10CNA to do all the wound care on 02/17/2022; however, S3RN/DON then stated that she only asked S10CNA to assist her with wound care, and that S10CNA took the liberty to do it on her own. S1ADM stated they came to the decision that they thought the DON disregarded the policy for nurses to do treatments. S1ADM revealed they suspended S3RN/DON for a week and verbally counseled S10CNA because she was just following the DON's orders. S1ADM confirmed there had been no in-services with staff on following their scope of practice, or reporting staff if asked to do something outside their scope of practice. Interview with S10CNA on 03/11/2022 at 11:00 a.m. revealed she worked on 2/16/2022, 02/17/2022 and 02/18/2022. S10 CNA stated when she came to work on 02/16/2022, she was told by S3RN/DON that she was assigned to do wound care that day. S10CNA stated that she had assisted the nurses in turning and holding things in position while they performed wound care, but had never performed it by herself. She stated she did not question S3 RN/DON because she had been promoted to CNA supervisor and thought that it was part of her job. S10CNA stated on 02/16/2022 she and the Hospice CNA were providing ADL care to Resident #5, and S3RN/DON came to the resident's room and asked if they were ready to do the wound care on him. She stated she told her that they had just started on his bath and that it was going to take a while. S10CNA stated S3RN/DON stated well just go ahead and do the wound care and that she would leave the cart unlocked, because she couldn't give her the keys. S10CNA stated she did not do any of the treatments using a TAR or MD orders, but off of memory from watching it being done by other staff. S10CNA stated on 02/17/2022 and 02/18/2022 she went and got the treatment cart, which was already unlocked, and completed wound treatments on a total of 11 residents each day except on 02/18/2022. S10CNA stated she completed wound care for Residents #2 and #5 on 02/18/2022, and was called to Resident #4's room to do wound care. While standing at the treatment cart outside Resident #4's, S11 SSD came down the hall told her that she was not supposed to be doing wound care. S10CNA stated she told S11SSD that she was just doing what S3RN/DON had told her to do. She stated S11SSD told her that she could not do it and to tell the DON no. S10CNA stated that she did not know she could not do wound care. S10CNA revealed she did not do any further treatments that day. S10CNA stated right after that, S1ADM called her into his office and asked her what she was doing. She stated she explained to him that S3RN/DON had asked her to do wound care on 02/16/2022, 0217/2022 and 02/18/2022, because she did not have time, and there was no treatment nurse working those days and the other LPNs refused to do the wound care. S10CNA revealed S1ADM and S2 Corporate ADM told her not to do it anymore. Interview with S10CNA on 03/11/2022 at 11:45 a.m. revealed she performed PEG Tube care to the following residents on 02/16/2022, 02/17/2022, and 02/18/2022: Residents #9, Resident #10, Resident #11, Resident #12, Resident #13, and Resident #14. S10CNA stated she removed the old gauze, used wound cleaner to clean the area, put on a new split gauze, and taped the top and bottom. Interview with S3RN/DON on 03/16/2022 at 12:45 p.m. revealed that she asked S10CNA on 02/16/2022 to assist her with wound care; however, the CNA took it upon herself to perform all wound care. S3RN/DON confirmed that S10CNA performed wound care on 02/16/2022, 02/17/2022 and 02/18/2022. S3RN/DON confirmed she signed the TARS indicating she had performed the wound care herself on all 3 days, and should not have documented she performed it when she didn't. S3RN/DON she did not reprimand the CNA for performing the wound care.

Based on record review and interview, the facility failed to ensure the services provided or arranged by the facility were provided by qualified persons in accordance with a resident's written plan of care, as evidenced by failing to ensure that a resident who had been assessed by the facility to be at high risk for falls, and had a history of [REDACTED].#4) of 5 sampled residents reviewed (#1, #2, #3, #4, #5). The facility failed to: 1. Follow the resident's plan of care and ensure non-skid socks were applied to the resident's feet. This facility failure placed the resident in an actual harm situation. Resident #4 was admitted to the facility on [DATE], and assessed by the facility on 8/26/14 to be at "High Risk" for falls with a fall risk score of "13". Review of the Fall Risk Assessment form reflected, if the total score on the form was greater than 10, the resident should be considered at HIGH RISK for potential falls. The resident sustained [REDACTED]. The resident was reassessed on 10/15/14, and was determined by the facility to have a fall risk score of "17". Review of the resident's most recent MDS dated [DATE] with an ARD of 10/15/14 reflected the resident was assessed to have unsteady balance while walking. According to the Departmental Notes the resident got out of bed on 11/1/14 in an attempt to go to the bathroom, and experienced a fall. The resident was observed to have on regular socks, and no shoes at the time of the fall. As a result of the fall on 11/1/14, the resident sustained [REDACTED]. According to the Resident Census and Conditions of Residents form provided by the facility and dated 11/14/14, the facility's total census was 71 residents. Findings: Review of the Admission Facesheet reflected resident #4 was initially admitted to facility on 8/21/14. The Admission Facesheet reflected the resident had the following dxs: Pain in Limb; [MEDICAL CONDITION]; [MEDICAL CONDITION]; Mycotic Arthritis; [MEDICAL CONDITION]; [MEDICAL CONDITION]; [MEDICAL CONDITION] Fibrillation; [MEDICAL CONDITION]; [MEDICAL CONDITION]; and Generalized Pain. Review of the facility's Incident Logs for September 2014 to November 2014 reflected the following for resident #4: 10/1/14 at 6:15 p.m. - Fall; no head injury. No injury apparent. Fall occurred in resident's room. Disposition reflected "in-house treatment." 11/1/14 at 9:00 p.m. - Fall with head injury; no apparent injury. Fall occurred in resident's room. Disposition reflected the resident was placed on observation. Review of the current Quarterly MDS assessment for resident #4 dated 10/27/14, with an ARD of 10/15/14 reflected the resident had unsteady balance while moving from a seated to standing position, walking, turning around while walking, moving on and off the toilet, and during surface-to-surface transfers. The assessment reflected the resident required the extensive assistance of 1 person physically for dressing, limited assistance of one person physically for transfers, and extensive assistance of 2 plus persons physically for walking. Further review of the assessment reflected the resident required limited assistance of 1 person physically for toilet use and personal hygiene, and that the resident had sustained 1 fall since admit/re-entry/prior assessment. Review of the resident's Fall Risk Assessment forms revealed the following: 8/26/14 - Alert and oriented; hx 1-2 falls past 3 months (at hospital); chairbound; vision adequate; balance problem while standing and while walking; use of assistive device; total score of "13" reflecting resident at high risk for falls. 10/15/14 - Intermittent confusion; 1-2 falls past 3 months; chairbound; balance problem while standing and while walking; use of assistive device; total score of " 17 " reflecting resident at high risk for falls. Review of the Departmental Notes from August 2014 to November 2014 reflected a note dated 10/1/14 at 11:20 p.m. that the nurse was called to resident ' s room by a CNA at 6:15 p.m. The resident was found sitting on her buttocks next to the a/c unit in her bedroom. The entry reflected the resident got OOB without assistance, and that her call light was within reach. The entry reflected the CNA stated she had just left out of the resident's room after changing her, and when she passed back by the resident's room, she noticed her standing by the a/c unit. As the CNA was entering the resident's room, she (resident #4) slipped and fell . The note reflected the resident was assessed, denied hitting her head or having pain, and was assisted back to bed. Further review of the entry reflected the nurse educated the resident to call for assistance when needed, and she voiced understanding. Non-skid socks were applied to the resident's feet, and the nurse ensured the resident's bed alarm was in place and functioning. Further review of the Departmental Notes reflected that on 11/2/14 at 9:08 a.m. a late entry was made for 11/1/14 at 9:00 p.m. that reflected S3 LPN was called to resident #4's room. The entry reflected the resident was noted lying on the floor on her back in the entrance of her room. When questioned, the resident stated she was trying to use the restroom. The entry reflected the resident was assessed, was wearing non-skid socks, and had no shoes on. Further review reflected the resident was incontinent of bowel and bladder and wore adult briefs. The note further reflected the resident hit her head during the fall and c/o generalized pain. Weakness was noted. The resident had been administered her scheduled pain medication prior to the fall. The resident was assessed for injuries, vital signs obtained, and assisted up x 3 staff. The entry reflected the resident's physician and RP were notified and made aware. Review of the Resident Incident Reports for resident #4 reflected the following: Investigation for 10/5/14 at 3:56 p.m. for fall occurring 10/1/14 at 6:15 p.m.: Resident sitting on buttock next to a/c unit in bedroom. Got OOB without assistance; call light was in reach. Assessed; denied pain. Assisted to standing x 2 staff, then back to bed. RP, DON, and MD notified. Educated resident to call for help when assistance needed; voiced understanding. Educated staff to keep close eye on resident. Further review of the form reflected the resident's bedrails were down and the bed was down. In-house tx. Review of the Incident Followup dated 10/2/14 at 3:31 p.m. for the 10/1/14 fall reflected the resident was up in a w/c. No pain or discomfort voiced. No new injury. Safety measures in place and maintained. Sign placed above bed for bed pad alarm and siderails up x 2. Further review reflected that on 10/3/14 the documentation reflected Safety QA monitoring tool in effect; resident's RP called and all safety measures in place. DON spoke with resident to call for assist to avoid injury. Investigation for 11/6/14 at 3:10 p.m. for fall occurring 11/1/14 at 9:00 p.m.: Called to room, noted resident lying on floor on her back, in the entrance to her room. Stated she was trying to use the restroom. Upon assessment noted she was wearing non-skid socks and had no shoes on. Incontinent; wears adult diapers. Hit head, c/o generalized pain; scheduled pain pill given prior to fall. No apparent injuries. The documentation reflected the resident was assisted to stand x 3 persons; neurological checks were initiated. Further review of the form reflected the MD was notified on 11/1/14 at 9:00 p.m., and the family was notified on 11/1/14 at 9:10 p.m. Disposition reflected the resident was observed. The documentation reflected the bed height was adjustable, and the resident was alert and oriented x 2. Review of the Incident Follow-up documentation dated 11/3/14 at 2:04 p.m. for 11/1/14 at 9:00 p.m. fall reflected the resident was currently admitted to the hospital for left hip fx pending sx. The documentation reflected the investigation of the fall was in progress; room inspected for fall hazards, and family contacted by nursing. Further review of the incident Follow-up documentation reflected that on 11/3/14 the facility's investigation determined that the resident suffered a left hip and left wrist fx as a result of her fall on 11/1/14, and that appropriate nursing interventions were in place. Review of the facility's Investigation Follow-up documentation dated 11/3/14 reflected resident #4 sustained a fall on 11/1/14 at 9:00 p.m. Past interventions were non-skid socks, bed alarm, and high risk fall monitoring. The documentation reflected under "Recommendations/New Interventions" that the bed alarm would be changed from a short pad to long pad and possible wall alarm when resident returns, multi-team care plan w/family to discuss resident ' s status and her impulse control; not calling for assistance, and inservice the nursing staff on the fall assessment protocol. Review of resident #4's current plan of care with a goal date of 12/10/14 reflected a problem onset of 8/21/14 for Potential for falls r/t [MEDICAL CONDITION] and antihypertensive medication use, requires assistance with ADLs, hx of fall with fx, confusion, poor safety awareness, use of diuretics, use of narcotic pain medications, and does not always call for assist with transfers. Further review of the problem onset reflected the resident experienced falls on 10/1/14 and 11/1/14. Review of the facility's interventions reflected the facility staff was to assure that proper fitting/non-skid shoes were worn for ambulation. The interventions reflected that on 9/26/14 a bed alarm was initiated to be in place at all times while the resident was in bed, and on 10/1/14 non-skid socks were applied as an intervention. Review of the Departmental Notes for November 2014 reflected S3 LPN made the following entries: 10/1/14 at 6:15 p.m. - Fall; no head injury. No injury apparent. Fall occurred in resident's room. Disposition reflected in-house treatment. 11/1/14 at 9:00 p.m. - Fall with head injury; no apparent injury. Fall occurred in resident's room. Disposition reflected the resident was place on observation. Further review of the November 2014 Departmental Notes reflected S4 LPN noted on 11/2/14 at 7:09 p.m. that at 4:30 p.m. she called the hospital and was notified that resident #4 was admitted with [DIAGNOSES REDACTED]. Interview on 11/17/14 at 1:50 p.m. with S3 LPN revealed she was the nurse on duty the evening of 11/1/14, when resident #4 experienced a fall. S3 LPN stated she was on another hall when she heard S5 CNA call a "Code Green". She stated "Code Green" meant someone had fallen. S3 LPN stated when she arrived, the resident was observed lying on her back in the doorway of her room. S3 LPN stated the resident was assessed and c/o generalized pain, was assisted to stand, and was placed back in bed. She stated the resident had on regular socks and they did not have any grip on them. Interview on 11/17/18 at 2:10 p.m. with S6 CNA revealed she worked on the evening of 11/1/14 when resident #4 fell . She stated S5 CNA called a "Code Green" and she went to the room to assist. She stated after the nurse assessed the resident, the staff (including herself) attempted to get the resident up off of the floor, but her socks were slippery. She stated the resident had on regular socks; not non-skid socks. S6 CNA stated the resident stated she was trying to go to the bathroom. Interview on 11/17/14 at 2:30 p.m. with S7 LPN revealed she worked on the evening of 11/1/14 when resident #4 experienced a fall. She stated she was not assigned to the resident and was on another hall passing medications when S8 CNA came and got her, telling her there was a "Code Green". S7 LPN stated when she arrived on the hall, the resident was lying in the doorway of her room with her legs in the room and her upper body in the hallway. S7 LPN stated the resident was responsive and stated she was trying to go to the bathroom. S7 LPN stated the resident had on regular white socks, and stated the socks resident #4 had on were not non-skid socks. Interview on 11/17/14 at 3:00 p.m. with S5 CNA revealed she was one of the CNAs assigned to work with the resident on the evening of 11/1/14. S5 CNA stated she had just left the hall to go to the bathroom. As she was returning to the hall she heard someone hollering for help, and noticed resident #4 lying on the floor. S5 CNA stated she called a "Code Green", which meant someone had fallen. S5 CNA stated the resident had no shoes on, and had on regular socks; not non-skid socks. Interview on 11/18/14 at 11:15 a.m. with S8 CNA revealed she was one of the CNAs assigned to care for resident #4 on the evening of 11/1/14 when she experienced a fall. S8 CNA stated she did not witness the resident fall, but had just checked on the resident, to see if she needed anything. S5 CNA stated she left the hall to take her 15 minute break, and not long after that she heard someone scream. When she went to check it out, she observed resident #4 lying in the doorway of her room. S5 CNA stated the resident said she had to go to the bathroom when questioned about what she was trying to do. S8 CNA stated the resident had on socks, but she could not recall what type of socks. S8 CNA further stated the resident was able to use her call light to ask for assistance, but was confused at times. Interview on 11/18/14 at 11:45 a.m. with resident #R1 (resident #4 ' s roommate) revealed she was in the room at the time of the resident ' s fall on 11/1/14. #R1 stated she saw the resident getting out of bed and asked her several times to let her call for the staff to come help her. Further interview with #R1 revealed the whole incident happened so fast, and that by the time she pressed the call light the resident had fallen. #R1 stated resident #4 had on regular socks and that they were not the non-skid type. Further interview on 11/18/14 at 1:13 p.m. with S3 LPN revealed she again confirmed resident #4 did not have on non-skid socks at the time of her fall on 11/1/14, as documented on the Resident Incident Report dated 11/6/14 at 3:10 p.m. and in the Departmental Notes dated 11/2/14 at 9:08 a.m., but had on regular socks. When asked to confirm her documentation regarding the resident wearing non-skid socks, as documented on the Resident Incident Report dated 11/6/14 at 3:10 p.m. and in the Departmental Notes dated 11/2/14 at 9:08 a.m., S3 LPN stated her meaning was that the resident had on "socks without the rubber on the bottom". S3 LPN further stated she was not aware of whether or not the resident's care plan reflected she was to have on non-skid socks as an intervention for fall prevention. S3 LPN stated she did, however educate the resident after her fall on the importance of wearing non-skid socks, but that she did not put them on her, and she was not certain if the CNAs put non-skid socks on the resident after she (S3 LPN) educated her (resident #4). S3 LPN confirmed it would have been the staff's responsibility to ensure that the resident had on non-skid socks if she was care planned to have them on for fall prevention. Further interview with S3 LPN revealed she stated she ensured measures for prevention were in place for the resident through every hour monitoring and documentation on the eMAR. She confirmed the eMAR did not reflect a monitor for ensuring the resident wore non-skid socks as an intervention for prevention of falls. Further interview on 11/18/14 at 1:15 p.m. with S8 CNA revealed she was not aware of whether or not resident #4 was to have on non-skid socks for fall prevention. S8 CNA stated she was only aware that the resident was to have her siderails up, and a bed alarm on her bed. Further interview on 11/18/14 at 1:31 p.m. with S5 CNA revealed they are made aware of changes to resident's care needs during "Huddle" meeting, report from the nurses, and inservices. S5 CNA stated there was never mention of the resident having on non-skid socks as an intervention for fall prevention, and she did not know if the resident was suppose to have them on or not. Interview on 11/18/14 at 1:41 p.m. with S4 LPN revealed she worked with resident #4 on the morning of 11/1/14 prior to her fall that evening. S4 LPN stated the resident remained in bed during her entire shift, and she was not sure if she had non-skid socks on during that time. S4 LPN confirmed resident #4 was at risk for fall due to her history of falls. S4 LPN stated interventions for fall prevention for the resident included a bed alarm and every hour monitoring of her environment. S4 LPN stated she was not aware of the resident having an intervention for the use of non-skid socks in her plan of care. S4 LPN stated the resident normally used to the call light to call for assistance, but did experience periods of confusion. Interview on 11/18/14 at 2:01 p.m. with S9 CNA revealed she was one of the CNAs assigned to work with the resident on the 7:00 a.m. to 3:00 p.m. shift on 11/1/14. S9 CNA stated she did not work with the resident on a regular basis, but when she did, the resident never got up. S9 CNA stated the resident was checked on more than usual due to her being at risk for falls. S9 CNA stated she was not aware of the resident having an intervention to wear non-skid socks for fall prevention. Interview on 11/18/14 at 2:25 p.m. with S10 CNA revealed she was one of the CNAs assigned to work with resident #4 on the 7:00 a.m. to 3:00 p.m. shift on 11/1/14. S10 CNA confirmed the resident was at risk for falls. S10 CNA stated her preventative interventions included a bed alarm, every one hour checks, siderails up bilaterally, and her call bell was to be within her reach at all times. S9 CNA stated the resident had non-skid socks in her drawer, and the CNAs were responsible for putting them on her. S9 CNA stated that the resident would wear them sometimes, and sometimes she wouldn't; it was her (resident #4's) choice. S9 CNA stated she was not aware of the non-skid socks being an intervention on the resident's plan of care for fall prevention.

Based on record review and interview, the facility failed to ensure a resident received adequate supervision and assistance devices to prevent accidents, as evidenced by failing to ensure the resident had on non-skid socks to prevent falls for 1 (#4) of 5 sampled residents reviewed (#1, #2, #3, #4, #5). The facility failed to: 1. Supervise and monitor resident #4 to ensure the resident wore non-skid socks after sustaining a fall on 10/1/14. This facility failure placed the resident in an actual harm situation. Resident #4 was admitted to the facility on [DATE], and assessed by the facility on 8/26/14 to be at "High Risk" for falls with a fall risk score of "13". Review of the Fall Risk Assessment form reflected, if the total score on the form was greater than 10, the resident should be considered at HIGH RISK for potential falls. The resident sustained [REDACTED]. The resident was reassessed on 10/15/14, and was determined by the facility to have a fall risk score of "17". Review of the resident's most recent MDS dated [DATE] with an ARD of 10/15/14 reflected the resident was assessed to have unsteady balance while walking. According to the Departmental Notes the resident got out of bed on 11/1/14 in an attempt to go to the bathroom, and experienced a fall. The resident was observed to have on regular socks, and no shoes at the time of the fall. As a result of the fall on 11/1/14, the resident sustained [REDACTED]. According to the Resident Census and Conditions of Residents form provided by the facility and dated 11/14/14, the facility's total census was 71 residents. Findings: Review of the Admission Facesheet reflected resident #4 was initially admitted to facility on 8/21/14. The Admission Facesheet reflected the resident had the following dxs: Pain in Limb; Presenile Depression; CHF; Mycotic Arthritis; Edema; [DIAGNOSES REDACTED]; Atrial Fibrillation; Depressive Disorder; Osteoarthritis; and Generalized Pain. Review of the facility's Incident Logs for September 2014 to November 2014 reflected the following for resident #4: 10/1/14 at 6:15 p.m. - Fall; no head injury. No injury apparent. Fall occurred in resident's room. Disposition reflected "in-house treatment." 11/1/14 at 9:00 p.m. - Fall with head injury; no apparent injury. Fall occurred in resident's room. Disposition reflected the resident was placed on observation. Review of the current Quarterly MDS assessment for resident #4 dated 10/27/14, with an ARD of 10/15/14 reflected the resident had unsteady balance while moving from a seated to standing position, walking, turning around while walking, moving on and off the toilet, and during surface-to-surface transfers. The assessment reflected the resident required the extensive assistance of 1 person physically for dressing, limited assistance of one person physically for transfers, and extensive assistance of 2 plus persons physically for walking. Further review of the assessment reflected the resident required limited assistance of 1 person physically for toilet use and personal hygiene, and that the resident had sustained 1 fall since admit/re-entry/prior assessment. Review of the resident's Fall Risk Assessment forms revealed the following: 8/26/14 - Alert and oriented; hx 1-2 falls past 3 months (at hospital); chairbound; vision adequate; balance problem while standing and while walking; use of assistive device; total score of "13" reflecting resident at high risk for falls. 10/15/14 - Intermittent confusion; 1-2 falls past 3 months; chairbound; balance problem while standing and while walking; use of assistive device; total score of "17" reflecting resident at high risk for falls. Review of the Departmental Notes from August 2014 to November 2014 reflected a note dated 10/1/14 at 11:20 p.m. that the nurse was called to resident's room by a CNA at 6:15 p.m. The resident was found sitting on her buttocks next to the a/c unit in her bedroom. The entry reflected the resident got OOB without assistance, and that her call light was within reach. The entry reflected the CNA stated she had just left out of the resident's room after changing her, and when she passed back by the resident's room, she noticed her standing by the a/c unit. As the CNA was entering the resident's room, she (resident #4) slipped and fell . The note reflected the resident was assessed, denied hitting her head or having pain, and was assisted back to bed. Further review of the entry reflected the nurse educated the resident to call for assistance when needed, and she voiced understanding. Non-skid socks were applied to the resident's feet, and the nurse ensured the resident's bed alarm was in place and functioning. Further review of the Departmental Notes reflected that on 11/2/14 at 9:08 a.m. a late entry was made for 11/1/14 at 9:00 p.m. that reflected S3 LPN was called to resident #4's room. The entry reflected the resident was noted lying on the floor on her back in the entrance of her room. When questioned, the resident stated she was trying to use the restroom. The entry reflected the resident was assessed, was wearing non-skid socks, and had no shoes on. Further review reflected the resident was incontinent of bowel and bladder and wore adult briefs. The note further reflected the resident hit her head during the fall and c/o generalized pain. Weakness was noted. The resident had been administered her scheduled pain medication prior to the fall. The resident was assessed for injuries, vital signs obtained, and assisted up x 3 staff. The entry reflected the resident's physician and RP were notified and made aware. Review of the Resident Incident Reports for resident #4 reflected the following: Investigation for 10/5/14 at 3:56 p.m. for fall occurring 10/1/14 at 6:15 p.m.: Resident sitting on buttock next to a/c unit in bedroom. Got OOB without assistance; call light was in reach. Assessed; denied pain. Assisted to standing x 2 staff, then back to bed. RP, DON, and MD notified. Educated resident to call for help when assistance needed; voiced understanding. Educated staff to keep close eye on resident. Further review of the form reflected the resident's bedrails were down and the bed was down. In-house tx. Review of the Incident Followup dated 10/2/14 at 3:31 p.m. for the 10/1/14 fall reflected the resident was up in a w/c. No pain or discomfort voiced. No new injury. Safety measures in place and maintained. Sign placed above bed for bed pad alarm and siderails up x 2. Further review reflected that on 10/3/14 the documentation reflected Safety QA monitoring tool in effect; resident's RP called and all safety measures in place. DON spoke with resident to call for assist to avoid injury. Investigation for 11/6/14 at 3:10 p.m. for fall occurring 11/1/14 at 9:00 p.m.: Called to room, noted resident lying on floor on her back, in the entrance to her room. Stated she was trying to use the restroom. Upon assessment noted she was wearing non-skid socks and had no shoes on. Incontinent; wears adult diapers. Hit head, c/o generalized pain; scheduled pain pill given prior to fall. No apparent injuries. The documentation reflected the resident was assisted to stand x 3 persons; neurological checks were initiated. Further review of the form reflected the MD was notified on 11/1/14 at 9:00 p.m., and the family was notified on 11/1/14 at 9:10 p.m. Disposition reflected the resident was observed. The documentation reflected the bed height was adjustable, and the resident was alert and oriented x 2. Review of the Incident Follow-up documentation dated 11/3/14 at 2:04 p.m. for 11/1/14 at 9:00 p.m. fall reflected the resident was currently admitted to the hospital for left hip fx pending sx. The documentation reflected the investigation of the fall was in progress; room inspected for fall hazards, and family contacted by nursing. Further review of the incident Follow-up documentation reflected that on 11/3/14 the facility's investigation determined that the resident suffered a left hip and left wrist fx as a result of her fall on 11/1/14, and that appropriate nursing interventions were in place. Review of the facility's Investigation Follow-up documentation dated 11/3/14 reflected resident #4 sustained a fall on 11/1/14 at 9:00 p.m. Past interventions were non-skid socks, bed alarm, and high risk fall monitoring. The documentation reflected under "Recommendations/New Interventions" that the bed alarm would be changed from a short pad to long pad and possible wall alarm when resident returns, multi-team care plan w/family to discuss resident ' s status and her impulse control; not calling for assistance, and inservice the nursing staff on the fall assessment protocol. Review of resident #4's current plan of care with a goal date of 12/10/14 reflected a problem onset of 8/21/14 for Potential for falls r/t psychotropic and antihypertensive medication use, requires assistance with ADLs, hx of fall with fx, confusion, poor safety awareness, use of diuretics, use of narcotic pain medications, and does not always call for assist with transfers. Further review of the problem onset reflected the resident experienced falls on 10/1/14 and 11/1/14. Review of the facility's interventions reflected the facility staff was to assure that proper fitting/non-skid shoes were worn for ambulation. The interventions reflected that on 9/26/14 a bed alarm was initiated to be in place at all times while the resident was in bed, and on 10/1/14 non-skid socks were applied as an intervention. Review of the Departmental Notes for November 2014 reflected S3 LPN made the following entries: 10/1/14 at 6:15 p.m. - Fall; no head injury. No injury apparent. Fall occurred in resident's room. Disposition reflected in-house treatment. 11/1/14 at 9:00 p.m. - Fall with head injury; no apparent injury. Fall occurred in resident's room. Disposition reflected the resident was place on observation. Further review of the November 2014 Departmental Notes reflected S4 LPN noted on 11/2/14 at 7:09 p.m. that at 4:30 p.m. she called the hospital and was notified that resident #4 was admitted with [DIAGNOSES REDACTED]. Interview on 11/17/14 at 1:50 p.m. with S3 LPN revealed she was the nurse on duty the evening of 11/1/14, when resident #4 experienced a fall. S3 LPN stated she was on another hall when she heard S5 CNA call a "Code Green". She stated "Code Green" meant someone had fallen. S3 LPN stated when she arrived, the resident was observed lying on her back in the doorway of her room. S3 LPN stated the resident was assessed and c/o generalized pain, was assisted to stand, and was placed back in bed. She stated the resident had on regular socks and they did not have any grip on them. Interview on 11/17/18 at 2:10 p.m. with S6 CNA revealed she worked on the evening of 11/1/14 when resident #4 fell . She stated S5 CNA called a "Code Green" and she went to the room to assist. She stated after the nurse assessed the resident, the staff (including herself) attempted to get the resident up off of the floor, but her socks were slippery. She stated the resident had on regular socks; not non-skid socks. S6 CNA stated the resident stated she was trying to go to the bathroom. Interview on 11/17/14 at 2:30 p.m. with S7 LPN revealed she worked on the evening of 11/1/14 when resident #4 experienced a fall. She stated she was not assigned to the resident and was on another hall passing medications when S8 CNA came and got her, telling her there was a "Code Green". S7 LPN stated when she arrived on the hall, the resident was lying in the doorway of her room with her legs in the room and her upper body in the hallway. S7 LPN stated the resident was responsive and stated she was trying to go to the bathroom. S7 LPN stated the resident had on regular white socks, and stated the socks resident #4 had on were not non-skid socks. Interview on 11/17/14 at 3:00 p.m. with S5 CNA revealed she was one of the CNAs assigned to work with the resident on the evening of 11/1/14. S5 CNA stated she had just left the hall to go to the bathroom. As she was returning to the hall she heard someone hollering for help, and noticed resident #4 lying on the floor. S5 CNA stated she called a "Code Green", which meant someone had fallen. S5 CNA stated the resident had no shoes on, and had on regular socks; not non-skid socks. Interview on 11/18/14 at 11:15 a.m. with S8 CNA revealed she was one of the CNAs assigned to care for resident #4 on the evening of 11/1/14 when she experienced a fall. S8 CNA stated she did not witness the resident fall, but had just checked on the resident, to see if she needed anything. S5 CNA stated she left the hall to take her 15 minute break, and not long after that she heard someone scream. When she went to check it out, she observed resident #4 lying in the doorway of her room. S5 CNA stated the resident said she had to go to the bathroom when questioned about what she was trying to do. S8 CNA stated the resident had on socks, but she could not recall what type of socks. S8 CNA further stated the resident was able to use her call light to ask for assistance, but was confused at times. Interview on 11/18/14 at 11:45 a.m. with resident #R1 (resident #4 ' s roommate) revealed she was in the room at the time of the resident ' s fall on 11/1/14. #R1 stated she saw the resident getting out of bed and asked her several times to let her call for the staff to come help her. Further interview with #R1 revealed the whole incident happened so fast, and that by the time she pressed the call light the resident had fallen. #R1 stated resident #4 had on regular socks and that they were not the non-skid type. Further interview on 11/18/14 at 1:13 p.m. with S3 LPN revealed she again confirmed resident #4 did not have on non-skid socks at the time of her fall on 11/1/14, as documented on the Resident Incident Report dated 11/6/14 at 3:10 p.m. and in the Departmental Notes dated 11/2/14 at 9:08 a.m., but had on regular socks. When asked to confirm her documentation regarding the resident wearing non-skid socks, as documented on the Resident Incident Report dated 11/6/14 at 3:10 p.m. and in the Departmental Notes dated 11/2/14 at 9:08 a.m., S3 LPN stated her meaning was that the resident had on "socks without the rubber on the bottom". S3 LPN further stated she was not aware of whether or not the resident's care plan reflected she was to have on non-skid socks as an intervention for fall prevention. S3 LPN stated she did, however educate the resident after her fall on the importance of wearing non-skid socks, but that she did not put them on her, and she was not certain if the CNAs put non-skid socks on the resident after she (S3 LPN) educated her (resident #4). S3 LPN confirmed it would have been the staff's responsibility to ensure that the resident had on non-skid socks if she was care planned to have them on for fall prevention. Further interview with S3 LPN revealed she stated she ensured measures for prevention were in place for the resident through every hour monitoring and documentation on the eMAR. She confirmed the eMAR did not reflect a monitor for ensuring the resident wore non-skid socks as an intervention for prevention of falls. Further interview on 11/18/14 at 1:15 p.m. with S8 CNA revealed she was not aware of whether or not resident #4 was to have on non-skid socks for fall prevention. S8 CNA stated she was only aware that the resident was to have her siderails up, and a bed alarm on her bed. Further interview on 11/18/14 at 1:31 p.m. with S5 CNA revealed they are made aware of changes to resident's care needs during "Huddle" meeting, report from the nurses, and inservices. S5 CNA stated there was never mention of the resident having on non-skid socks as an intervention for fall prevention, and she did not know if the resident was suppose to have them on or not. Interview on 11/18/14 at 1:41 p.m. with S4 LPN revealed she worked with resident #4 on the morning of 11/1/14 prior to her fall that evening. S4 LPN stated the resident remained in bed during her entire shift, and she was not sure if she had non-skid socks on during that time. S4 LPN confirmed resident #4 was at risk for fall due to her history of falls. S4 LPN stated interventions for fall prevention for the resident included a bed alarm and every hour monitoring of her environment. S4 LPN stated she was not aware of the resident having an intervention for the use of non-skid socks in her plan of care. S4 LPN stated the resident normally used to the call light to call for assistance, but did experience periods of confusion. Interview on 11/18/14 at 2:01 p.m. with S9 CNA revealed she was one of the CNAs assigned to work with the resident on the 7:00 a.m. to 3:00 p.m. shift on 11/1/14. S9 CNA stated she did not work with the resident on a regular basis, but when she did, the resident never got up. S9 CNA stated the resident was checked on more than usual due to her being at risk for falls. S9 CNA stated she was not aware of the resident having an intervention to wear non-skid socks for fall prevention. Interview on 11/18/14 at 2:25 p.m. with S10 CNA revealed she was one of the CNAs assigned to work with resident #4 on the 7:00 a.m. to 3:00 p.m. shift on 11/1/14. S10 CNA confirmed the resident was at risk for falls. S10 CNA stated her preventative interventions included a bed alarm, every one hour checks, siderails up bilaterally, and her call bell was to be within her reach at all times. S9 CNA stated the resident had non-skid socks in her drawer, and the CNAs were responsible for putting them on her. S9 CNA stated that the resident would wear them sometimes, and sometimes she wouldn't; it was her (resident #4's) choice. S9 CNA stated she was not aware of the non-skid socks being an intervention on the resident's plan of care for fall prevention.

Based on record review and interview the facility failed to ensure services provided met professional standards of quality for 1 of 6 sampled residents (#3). The facility failed to: 1. assess the resident for pain from 2/8/12 when he was diagnosed with [REDACTED]. The facility also failed to assess the resident for pain after his return from the hospital on [DATE]. 2. ensure the resident was free from chemical restraints by failing to implement non-medicinal interventions to assist in relieving pain and anxiety prior to the administration of chemical restraints. 3. ensure the resident was free from unnecessary drug use by failing to perform a complete accurate assessment of the residents symptoms, and attempt non- pharmacological interventions prior to the administration of psychoactive medications. 4. ensure the physician was notified of a resident's behaviors of crying out for help and slapping his legs. 5. ensure the resident was assessed and treated for [REDACTED]. The resident was administered chemical restraints when yelling and crying out from 2/28/12 through 3/1/12, and was not administered his prescribed narcotic pain medication. Resident #3 was placed in Immediate Jeopardy on 2/8/12 at 12:00 p.m. when the the x-ray report of the resident's left thigh revealed there were "greater trochanteric fragment" noted. The resident was administered chemical restraints ([MEDICATION NAME] and /or [MEDICATION NAME]) when he began to yell out for help and hit and slap his legs. He was diagnosed with [REDACTED]. This resulted in the resident experiencing pain without interventions and in the resident receiving [MEDICATION NAME] and [MEDICATION NAME] ([MEDICAL CONDITION] medications) prior to implementing non-pharmacological interventions. The Immediate Jeopardy ended for resident #3 on 2/23/12 when he was admitted to the hospital for surgery. It resumed on 2/28/12 when the resident returned from the hospital after surgery to repair the [MEDICAL CONDITION]. He was again administered [MEDICATION NAME] and/or [MEDICATION NAME] due to his agitation and continuous crying out, and was not assessed for pain nor was he administered his prescribed narcotic pain medication. The IJ was removed when the resident was transferred to the hospital on [DATE]. Findings: The provider failed to provide services according to professional standards of quality as stated by the Louisiana State Board of Practical Nursing, Section 961 of Chapter 11, Louisiana Revised Statutes of 1950, The "practice of practical nursing" means the performance for compensation of any acts....in the care, treatment, or observation of the ill, injured, or infirm and for the maintenance of the health of others and the promotion of health care, including the administration of medications and treatments.... Review of resident #3's record revealed he was a [AGE] year old male who had [DIAGNOSES REDACTED]. He also resided on the facility's locked Alzheimer's Unit prior to his recent hospitalization . Further review of the record revealed an order dated 9/1/11 for [MEDICATION NAME] 0.5 mg po every 4 hours as needed for agitation and an order dated 9/4/11 for [MEDICATION NAME] 1 mg/[MEDICATION NAME] 5 mg. IM every 4 hours as needed for agitation and [MEDICAL CONDITION]. The record also reflected a physician's orders [REDACTED]. to be administered twice daily for [MEDICAL CONDITION]. Further review of the record revealed the resident fell on [DATE]. No apparent injuries were noted at that time. The nurses' notes dated 2/7/12 at 10 p.m. revealed the resident was yelling "help me" and slapping his legs. At 10:30 p.m. he was given [MEDICATION NAME] 0.5 mg orally for the behaviors. There was no documentation of an assessment of the resident. At 11:30 p.m. he continued to yell for help, and he was given [MEDICATION NAME] 5 mg. and [MEDICATION NAME] 1 mg. IM. Review of the Chemical Restraint Flow sheet revealed the injection on 2/7/12 was given for increased agitation, yelling out and because the oral [MEDICATION NAME] was not effective. Review of the Behavior Intervention Monthly Flow Record revealed on 2/7/12 there were no behaviors documented. There was no documentation of any further assessments to determine why the resident was yelling for help and slapping his legs, and no documentation of interventions attempted prior to the administration of [MEDICAL CONDITION] medications. The nurses' notes further reflected results an x-ray of of the resident's left thigh were received at 12:00 p.m. on 2/8/12. The x-ray results reflected fragments to left trochanter. The physician was notified and a CT scan of the left hip was ordered. There was no documentation of an assessment from 2/8/12 to 2/12/12. Results of the CT scan which was done on 2/13/12, revealed there was a transtrochanteric [MEDICAL CONDITION] hip. The results of the scan were reported to the physician on 2/13/12 at 2:14 p.m. by the CT technician. An order was written on 2/17/12 on the CT results page, "schedule appointment with Dr", (orthopedic specialist). The resident did not see the specialist until 2/23/12 at which time he was transferred to the hospital for surgical intervention of his [MEDICAL CONDITION]. Review of the PRN Medication Sheet revealed that Tylenol 650 mg. was administered at 12:45 p.m. prior to going out for the CT scan. There was no documentation of an assessment from 2/12/12 to 2/18/12 when the nurse was called to the residents room at 12:07 a.m. by the CNA. He was found lying on the floor in supine position. A small skin tear was noted to his right elbow. Further review of the nurses' notes revealed on 2/18/12 at 1:40 a.m., [MEDICATION NAME] 0.5 mg. was given orally due to the resident "yelling continuously". The nurses' notes reflected the resident was was yelling out continuously from 11:15 p.m. to 11:45 p.m. on 2/17/12 and again from 12:40 a.m. to 1:40 a.m. on 2/18/12. Review of the Behavior Intervention Monthly Flow Record for February 2012 revealed no documentation of interventions done prior to the medication administration and no assessment of the resident for medical reasons/pain. There was no documentation to reflect the physician had been consulted. The record did not reflect any assessment of the resident's pain from 2/19/12 to 2/22/12. Review of the MAR revealed that on 2/22/12, a prn dose of [MEDICATION NAME] 0.5 mg po was given, but there was no documentation in the record of the reason for the administration of the [MEDICAL CONDITION] medication and no prior interventions were documented. There was no assessment of the resident for possible reasons of his behaviors. Review of the MAR reflected on 2/23/12 a prn dose of [MEDICATION NAME] 0.5 mg po was given. Review of the Chemical Restraint Flow Sheet for 2/23/12 reflected the medication was given at 12:05 a.m. for "yelling and slapping his thighs and buttocks". There was no documentation in the record of any further assessment of the resident and no interventions attempted prior to administering the [MEDICAL CONDITION] medication. The resident was seen by an orthopedic specialist on 2/23/12 and was sent to the hospital for surgical repair (ORIF) of the left [MEDICAL CONDITION]. He returned to the facility on [DATE] at 4:35 p.m. with a [DIAGNOSES REDACTED]. An order was noted for [MEDICATION NAME] 7.5 mg (a narcotic [MEDICATION NAME]) to be given every 4 hours as needed for pain. Review of the record revealed that at 9:00 p.m. on 2/28/12, the resident was given a prn dose of [MEDICATION NAME] 0.5 mg for agitation. There was no documentation of any further assessment of the cause of his agitation, no assessment of his pain level, and no interventions attempted prior to administering the [MEDICATION NAME]. Review of the Chemical Restraint Flow sheet dated 2/29/12 revealed the resident was administered a prn dose [MEDICATION NAME] 0.5 mg. orally at 2:00 a.m. for continuous crying out. There was no documentation of any prior interventions attempted, or an assessment of the residents' pain or the cause of his crying out. Review of the MAR and nurses' notes for February 2012 revealed the post-op medication ordered for pain had never been administered to the resident. Further review of the record revealed a Chemical Restraint Flow sheet dated 2/29/12 at 4:15 p.m. which revealed a prn dose of [MEDICATION NAME] 1 mg and [MEDICATION NAME] 5 mg were administered IM for "danger to self, continuously crying out". Review of the nurses' notes for that date and time revealed the resident was crying continuously, was hollering and agitated. There was no documentation of an assessment of the resident's pain or administration of his pain medication, and no documentation of interventions attempted prior to administration of the psychoactive medications. Interview with S6 CNA on 3/5/12 at 2:00 p.m. revealed she had frequently worked with the resident. She stated that he appeared to be in pain prior to going to the hospital for his surgery. She further stated he would yell out for help and hit his legs, and that she would notify the nurse when he did that. She also stated his mobility had decreased a lot during that time. Interview with S4 CNA on 3/5/12 at 2:10 p.m. revealed the resident had a history of [REDACTED]. She stated he would yell out for help and he looked as if he were in pain. She stated he had pretty much stopped walking around during that time. Review of the Pain Assessment and Management policy revealed that all residents have the right to have an assessment of and treatment of [REDACTED]. Interview with the S1DON on 3/6/12 at 11:20 a.m. confirmed there was no documentation that complete assessments of the resident were done to determine why he was yelling and crying out for help or slapping his legs, even after the [DIAGNOSES REDACTED]. She stated the resident had a [DIAGNOSES REDACTED]. She further stated more complete assessments should have been done prior to the administration of the [MEDICATION NAME] and/or [MEDICATION NAME].

Based on record review and interview the facility failed to maintain a residents highest practicable physical, mental and psychosocial well-being for 1 of 6 sampled residents (#3). The facility failed to : 1. assess the resident for pain from 2/8/12 when he was diagnosed with [REDACTED]. The facility also failed to assess the resident for pain after his return from the hospital on [DATE]. 2. ensure the resident was free from chemical restraints by failing to implement non-medicinal interventions to assist in relieving pain and anxiety prior to the administration of chemical restraints. 3. ensure the resident was free from unnecessary drug use by failing to perform a complete accurate assessment of the residents symptoms, and attempt non- pharmacological interventions prior to the administration of psychoactive medications. 4. ensure the physician was notified of a resident's behaviors of crying out for help and slapping his legs. 5. ensure the resident was assessed and treated for [REDACTED]. The resident was administered chemical restraints when yelling and crying out from 2/28/12 through 3/1/12, and was not administered his prescribed narcotic pain medication. Resident #3 was placed in Immediate Jeopardy on 2/8/12 at 12:00 p.m. when the the x-ray report of the resident's left thigh revealed there were "greater trochanteric fragment" noted. The resident was administered chemical restraints ([MEDICATION NAME] and /or [MEDICATION NAME]) when he began to yell out for help and hit and slap his legs. He was diagnosed with [REDACTED]. This resulted in the resident experiencing pain without interventions and in the resident receiving [MEDICATION NAME] and [MEDICATION NAME] ([MEDICAL CONDITION] medications) prior to implementing non-pharmacological interventions. The Immediate Jeopardy ended for resident #3 on 2/23/12 when he was admitted to the hospital for surgery. It resumed on 2/28/12 when the resident returned from the hospital after surgery to repair the [MEDICAL CONDITION]. He was again administered [MEDICATION NAME] and/or [MEDICATION NAME] due to his agitation and continuous crying out, and was not assessed for pain nor was he administered his prescribed narcotic pain medication. The IJ was removed when the resident was transferred to the hospital on [DATE]. Findings: Review of resident #3's record revealed he was a [AGE] year old male who had [DIAGNOSES REDACTED]. He also resided on the facility's locked Alzheimer's Unit prior to his recent hospitalization . Further review of the record revealed an order dated 9/1/11 for [MEDICATION NAME] 0.5 mg po every 4 hours as needed for agitation and an order dated 9/4/11 for [MEDICATION NAME] 1 mg/[MEDICATION NAME] 5 mg. IM every 4 hours as needed for agitation and [MEDICAL CONDITION]. The record also reflected a physician's orders [REDACTED]. to be administered twice daily for [MEDICAL CONDITION]. Further review of the record revealed the resident fell on [DATE]. No apparent injuries were noted at that time. The nurses' notes dated 2/7/12 at 10 p.m. revealed the resident was yelling "help me" and slapping his legs. At 10:30 p.m. he was given [MEDICATION NAME] 0.5 mg orally for the behaviors. There was no documentation of an assessment of the resident. At 11:30 p.m. he continued to yell for help, and he was given [MEDICATION NAME] 5 mg. and [MEDICATION NAME] 1 mg. IM. Review of the Chemical Restraint Flow sheet revealed the injection on 2/7/12 was given for increased agitation, yelling out and because the oral [MEDICATION NAME] was not effective. Review of the Behavior Intervention Monthly Flow Record revealed on 2/7/12 there were no behaviors documented. There was no documentation of any further assessments to determine why the resident was yelling for help and slapping his legs, and no documentation of interventions attempted prior to the administration of [MEDICAL CONDITION] medications. The nurses' notes further reflected results an x-ray of of the resident's left thigh were received at 12:00 p.m. on 2/8/12. The x-ray results reflected fragments to left trochanter. The physician was notified and a CT scan of the left hip was ordered. There was no documentation of an assessment from 2/8/12 to 2/12/12. Results of the CT scan which was done on 2/13/12, revealed there was a transtrochanteric [MEDICAL CONDITION] hip. The results of the scan were reported to the physician on 2/13/12 at 2:14 p.m. by the CT technician. An order was written on 2/17/12 on the CT results page, "schedule appointment with Dr", (orthopedic specialist). The resident did not see the specialist until 2/23/12 at which time he was transferred to the hospital for surgical intervention of his [MEDICAL CONDITION]. Review of the PRN Medication Sheet revealed that Tylenol 650 mg. was administered at 12:45 p.m. prior to going out for the CT scan. There was no documentation of an assessment from 2/12/12 to 2/18/12 when the nurse was called to the residents room at 12:07 a.m. by the CNA. He was found lying on the floor in supine position. A small skin tear was noted to his right elbow. Further review of the nurses' notes revealed on 2/18/12 at 1:40 a.m., [MEDICATION NAME] 0.5 mg. was given orally due to the resident "yelling continuously". The nurses' notes reflected the resident was was yelling out continuously from 11:15 p.m. to 11:45 p.m. on 2/17/12 and again from 12:40 a.m. to 1:40 a.m. on 2/18/12. Review of the Behavior Intervention Monthly Flow Record for February 2012 revealed no documentation of interventions done prior to the medication administration and no assessment of the resident for medical reasons/pain. There was no documentation to reflect the physician had been consulted. The record did not reflect any assessment of the resident's pain from 2/19/12 to 2/22/12. Review of the MAR revealed that on 2/22/12, a prn dose of [MEDICATION NAME] 0.5 mg po was given, but there was no documentation in the record of the reason for the administration of the [MEDICAL CONDITION] medication and no prior interventions were documented. There was no assessment of the resident for possible reasons of his behaviors. Review of the MAR reflected on 2/23/12 a prn dose of [MEDICATION NAME] 0.5 mg po was given. Review of the Chemical Restraint Flow Sheet for 2/23/12 reflected the medication was given at 12:05 a.m. for "yelling and slapping his thighs and buttocks". There was no documentation in the record of any further assessment of the resident and no interventions attempted prior to administering the [MEDICAL CONDITION] medication. The resident was seen by an orthopedic specialist on 2/23/12 and was sent to the hospital for surgical repair (ORIF) of the left [MEDICAL CONDITION]. He returned to the facility on [DATE] at 4:35 p.m. with a [DIAGNOSES REDACTED]. An order was noted for [MEDICATION NAME] 7.5 mg (a narcotic [MEDICATION NAME]) to be given every 4 hours as needed for pain. Review of the record revealed that at 9:00 p.m. on 2/28/12, the resident was given a prn dose of [MEDICATION NAME] 0.5 mg for agitation. There was no documentation of any further assessment of the cause of his agitation, no assessment of his pain level, and no interventions attempted prior to administering the [MEDICATION NAME]. Review of the Chemical Restraint Flow sheet dated 2/29/12 revealed the resident was administered a prn dose [MEDICATION NAME] 0.5 mg. orally at 2:00 a.m. for continuous crying out. There was no documentation of any prior interventions attempted, or an assessment of the residents' pain or the cause of his crying out. Review of the MAR and nurses' notes for February 2012 revealed the post-op medication ordered for pain had never been administered to the resident. Further review of the record revealed a Chemical Restraint Flow sheet dated 2/29/12 at 4:15 p.m. which revealed a prn dose of [MEDICATION NAME] 1 mg and [MEDICATION NAME] 5 mg were administered IM for "danger to self, continuously crying out". Review of the nurses' notes for that date and time revealed the resident was crying continuously, was hollering and agitated. There was no documentation of an assessment of the resident's pain or administration of his pain medication, and no documentation of interventions attempted prior to administration of the psychoactive medications. Interview with S6 CNA on 3/5/12 at 2:00 p.m. revealed she had frequently worked with the resident. She stated that he appeared to be in pain prior to going to the hospital for his surgery. She further stated he would yell out for help and hit his legs, and that she would notify the nurse when he did that. She also stated his mobility had decreased a lot during that time. Interview with S4 CNA on 3/5/12 at 2:10 p.m. revealed the resident had a history of [REDACTED]. She stated he would yell out for help and he looked as if he were in pain. She stated he had pretty much stopped walking around during that time. Review of the Pain Assessment and Management policy revealed that all residents have the right to have an assessment of and treatment of [REDACTED]. Interview with the S1DON on 3/6/12 at 11:20 a.m. confirmed there was no documentation that complete assessments of the resident were done to determine why he was yelling and crying out for help or slapping his legs, even after the [DIAGNOSES REDACTED]. She stated the resident had a [DIAGNOSES REDACTED]. She further stated more complete assessments should have been done prior to the administration of the [MEDICATION NAME] and/or [MEDICATION NAME].

Based on observation, record review and interview, the facility failed to ensure that the physician was consulted with and provided an accurate description of a resident's behaviors of yelling, crying out for help and slapping his legs after x-ray findings reflected left thigh "greater trochanteric fragment" and a CT scan impression reflected a left [MEDICAL CONDITION] for 1 of 6 sampled residents (#3). The resident was administered prn chemical restraints multiple times. The facility failed to: 1. consult with the residents physician when the resident yelled out for help and slapped at his legs from 2/8/12, when an x-ray of the left thigh reflected "greater trochanteric fragment" until 2/23/12, when he was admitted to the hospital for surgery to repair a fractured left hip. 2. ensure the resident was free from chemical restraints by failing to consult with the physician when the resident exhibited behaviors of crying out for help and slapping his legs after an x-ray of the left thigh reflected "greater trochanteric fragment", and after the CT scan reflected a left [MEDICAL CONDITION] on 2/13/12. 3. ensure the resident was free from unnecessary drug use by failing to perform a complete accurate assessment of the residents symptoms and notify the physician of the assessment. Resident #3 was placed in Immediate Jeopardy on 2/8/12 at 12:00 p.m. when the the x-ray report of the resident's left thigh revealed there were "greater trochanteric fragment" noted. The resident was administered chemical restraints ([MEDICATION NAME] and /or [MEDICATION NAME]) when he began to yell out for help and hit and slap his legs. He was diagnosed with [REDACTED]. This resulted in the resident experiencing pain without interventions and in the resident receiving [MEDICATION NAME] and [MEDICATION NAME] ([MEDICAL CONDITION] medications/chemical restraints) prior to implementing non-pharmacological interventions. The physician was not notified of the residents behavior's and of the multiple use of chemical restraints. The Immediate Jeopardy ended for resident #3 on 2/23/12 when he was admitted to the hospital for surgery. The facility also failed to promptly notify the physician and resident's responsible party of an incident resulting in injuries for a resident (#1). There was a total sample of 6 residents in a total census of 80 residents. Findings: 1. Review of resident #3's record revealed he was a [AGE] year old male who had [DIAGNOSES REDACTED]. He also resided on the facility's locked Alzheimer's Unit prior to his recent hospitalization . Further review of the record revealed an order dated 9/1/11 for [MEDICATION NAME] 0.5 mg po every 4 hours as needed for agitation and an order dated 9/4/11 for [MEDICATION NAME] 1 mg/[MEDICATION NAME] 5 mg. IM every 4 hours as needed for agitation and [MEDICAL CONDITION]. The record also reflected a physician's orders [REDACTED]. to be administered twice daily for [MEDICAL CONDITION]. Further review of the record revealed the resident fell on [DATE]. No apparent injuries were noted at that time. The nurses' notes dated 2/7/12 at 10 p.m. revealed the resident was yelling "help me" and slapping his legs. At 10:30 p.m. he was given [MEDICATION NAME] 0.5 mg orally for the behaviors. There was no documentation of an assessment of the resident. At 11:30 p.m. he continued to yell for help, and he was given [MEDICATION NAME] 5 mg. and [MEDICATION NAME] 1 mg. IM. Review of the Chemical Restraint Flow sheet revealed the injection on 2/7/12 was given for increased agitation, yelling out and because the oral [MEDICATION NAME] was not effective. Review of the Behavior Intervention Monthly Flow Record revealed on 2/7/12 there were no behaviors documented. There was no documentation of any further assessments to determine why the resident was yelling for help and slapping his legs, and no documentation of interventions attempted prior to the administration of [MEDICAL CONDITION] medications. The nurses' notes further reflected results an x-ray of of the resident's left thigh were received at 12:00 p.m. on 2/8/12. The x-ray results reflected fragments to left trochanter. The physician was notified and a CT scan of the left hip was ordered. There was no documentation of an assessment from 2/8/12 to 2/12/12. Results of the CT scan which was done on 2/13/12, revealed there was a transtrochanteric [MEDICAL CONDITION] hip. The results of the scan were reported to the physician on 2/13/12 at 2:14 p.m. by the CT technician. An order was written on 2/17/12 on the CT results page, "schedule appointment with Dr", (orthopedic specialist). The resident did not see the specialist until 2/23/12 at which time he was transferred to the hospital for surgical intervention of his [MEDICAL CONDITION]. Review of the PRN Medication Sheet revealed that Tylenol 650 mg. was administered at 12:45 p.m. prior to going out for the CT scan. There was no documentation of an assessment from 2/12/12 to 2/18/12 when the nurse was called to the residents room at 12:07 a.m. by the CNA. He was found lying on the floor in supine position. A small skin tear was noted to his right elbow. Further review of the nurses' notes revealed on 2/18/12 at 1:40 a.m., [MEDICATION NAME] 0.5 mg. was given orally due to the resident "yelling continuously". The nurses' notes reflected the resident was was yelling out continuously from 11:15 p.m. to 11:45 p.m. on 2/17/12 and again from 12:40 a.m. to 1:40 a.m. on 2/18/12. Review of the Behavior Intervention Monthly Flow Record for February 2012 revealed no documentation of interventions done prior to the medication administration and no assessment of the resident for medical reasons/pain. There was no documentation to reflect the physician had been consulted. The record did not reflect any assessment of the resident's pain from 2/19/12 to 2/22/12. Review of the MAR revealed that on 2/22/12, a prn dose of [MEDICATION NAME] 0.5 mg po was given, but there was no documentation in the record of the reason for the administration of the [MEDICAL CONDITION] medication and no prior interventions were documented. There was no assessment of the resident for possible reasons of his behaviors. Review of the MAR reflected on 2/23/12 a prn dose of [MEDICATION NAME] 0.5 mg po was given. Review of the Chemical Restraint Flow Sheet for 2/23/12 reflected the medication was given at 12:05 a.m. for "yelling and slapping his thighs and buttocks". There was no documentation in the record of any further assessment of the resident and no interventions attempted prior to administering the [MEDICAL CONDITION] medication. The resident was seen by an orthopedic specialist on 2/23/12 and was sent to the hospital for surgical repair (ORIF) of the left [MEDICAL CONDITION]. He returned to the facility on [DATE] at 4:35 p.m. with a [DIAGNOSES REDACTED]. An order was noted for [MEDICATION NAME] 7.5 mg (a narcotic [MEDICATION NAME]) to be given every 4 hours as needed for pain. Review of the record revealed that at 9:00 p.m. on 2/28/12, the resident was given a prn dose of [MEDICATION NAME] 0.5 mg for agitation. There was no documentation of any further assessment of the cause of his agitation, no assessment of his pain level, and no interventions attempted prior to administering the [MEDICATION NAME]. Review of the Chemical Restraint Flow sheet dated 2/29/12 revealed the resident was administered a prn dose [MEDICATION NAME] 0.5 mg. orally at 2:00 a.m. for continuous crying out. There was no documentation of any prior interventions attempted, or an assessment of the residents' pain or the cause of his crying out. Review of the MAR and nurses' notes for February 2012 revealed the post-op medication ordered for pain had never been administered to the resident. Further review of the record revealed a Chemical Restraint Flow sheet dated 2/29/12 at 4:15 p.m. which revealed a prn dose of [MEDICATION NAME] 1 mg and [MEDICATION NAME] 5 mg were administered IM for "danger to self, continuously crying out". Review of the nurses' notes for that date and time revealed the resident was crying continuously, was hollering and agitated. There was no documentation of an assessment of the resident's pain or administration of his pain medication, and no documentation of interventions attempted prior to administration of the psychoactive medications. Interview with S6 CNA on 3/5/12 at 2:00 p.m. revealed she had frequently worked with the resident. She stated that he appeared to be in pain prior to going to the hospital for his surgery. She further stated he would yell out for help and hit his legs, and that she would notify the nurse when he did that. She also stated his mobility had decreased a lot during that time. Interview with S4 CNA on 3/5/12 at 2:10 p.m. revealed the resident had a history of [REDACTED]. She stated he would yell out for help and he looked as if he were in pain. She stated he had pretty much stopped walking around during that time. Review of the Pain Assessment and Management policy revealed that all residents have the right to have an assessment of and treatment of [REDACTED]. Interview with the S1DON on 3/6/12 at 11:20 a.m. confirmed there was no documentation that complete assessments of the resident were done to determine why he was yelling and crying out for help or slapping his legs, even after the [DIAGNOSES REDACTED]. She stated the resident had a [DIAGNOSES REDACTED]. She further stated more complete assessments should have been done prior to the administration of the [MEDICATION NAME] and/or [MEDICATION NAME]. 2. Review of resident #1's nurse's note dated 3/5/2012 at 6:30 a.m. reflected that upon doing an accucheck for the resident on 3/5/2012, the LPN had noted bruising of the 4th and 5th finger of the right hand with purple bruising and a fading bruise across the top of the right hand with swelling. The documentation further reflected: Unknown cause of right hand bruising and swelling; however, upon inquiring, S3CNA said may have been from him grabbing the shower head out of her hand Friday (3/2/2012) and swinging it back and forth hitting one hand and then the other. Observation of the resident on 3/6/2012 at 10:30 a.m. revealed the resident was in the Alzheimer's unit day room and his right hand was swollen and bruised. The resident's left arm above the wrist area had purple/ red and some yellow/green bruising on it with several cuts noted in the bruising. Review of the nurses' note for March 2012 revealed there were no entries for 3/2/2012, 3/3/2012 or 3/4/2012 to reflect the physician and family had been notified of the incident. Review of the resident's plan of care with a problem onset date of 1/18/2012 reflected that the resident had a potential for alteration in mood/behaviors related to [MEDICAL CONDITION] and combative behaviors with staff at times. Approaches included to monitor and document behavior every shift and report negative behavior to the physician. Request to the S1DON on 3/6/2012 at 10:35 a.m. for information related to the incident reflected that she had not been aware of the incident until 3/5/2012 at 6:30 a.m. She confirmed the family and physician had not been consulted with after the 3/2/2012 incident until 3/5/2012. Interview on 3/6/2012 at 10:33 a.m. with the S3CNA who was assigned to the resident revealed she had reported the 3/2/2012 incident to S8LPN and S9LPN on 3/2/2012.

Based on observation, record review, and interview the facility failed to ensure accurate, complete assessments were done on each resident by failing to assess a resident's behaviors of crying out for help, agitation and slapping his legs following a [DIAGNOSES REDACTED]. The facility also failed to perform an accurate, comprehensive assessment of the resident after he returned to the facility following an ORIF of the left hip. The resident was administered chemical restraints without an assessment or prior interventions. Resident #3 was placed in Immediate Jeopardy on 2/8/12 at 12:00 p.m. when the the x-ray report of the resident's left thigh revealed there were "greater trochanteric fragments" noted. The resident was administered chemical restraints ([MEDICATION NAME] and /or [MEDICATION NAME]) when he began to yell out for help and hit and slap his legs. He was diagnosed with [REDACTED]. This resulted in the resident experiencing pain without interventions and in the resident receiving [MEDICATION NAME] and [MEDICATION NAME] ([MEDICAL CONDITION] medications) prior to implementing non-pharmacological interventions. The Immediate Jeopardy ended for resident #3 on 2/23/12 when he was admitted to the hospital for surgery. It resumed on 2/28/12 when the resident returned from the hospital after surgery to repair the [MEDICAL CONDITION]. He was again administered [MEDICATION NAME] and/or [MEDICATION NAME] due to his agitation and continuous crying out, and was not assessed for pain nor was he administered his prescribed narcotic pain medication. The IJ was removed when the resident was transferred to the hospital on [DATE]. The facility also failed to assess a resident after an incident resulting in bruises and cuts to his left arm and bruising and swelling to his right hand for 1 of 6 sampled residents (#1). Findings: 1. Review of resident #3's record revealed he had [DIAGNOSES REDACTED]. He had been residing on the locked Alzheimer's Unit of the facility. Further review of the record revealed orders dated 9/1/11 for [MEDICATION NAME] 0.5 mg po every 4 hours as needed for agitation and orders dated 9/4/11 for [MEDICATION NAME] 1 mg/[MEDICATION NAME] 5 mg. IM every 4 hours as needed for agitation and [MEDICAL CONDITION]. Further review of the record revealed the resident fell on [DATE]. No apparent injuries were noted at that time. The nurse's notes dated 2/7/12 at 10 p.m. revealed the resident was yelling "help me" and slapping his legs. At 10:30 p.m. he was given [MEDICATION NAME] 0.5 mg orally for the behaviors. There was no documentation of an assessment of the resident. At 11:30 p.m. on 2/7/12, he continued to yell for help, and he was given [MEDICATION NAME] 5 mg. and [MEDICATION NAME] 1 mg. IM. Review of the Chemical Restraint Flow sheet revealed the injection on 2/7/12 was given for increased agitation, yelling out, and because the oral [MEDICATION NAME] had not been effective. Review of the Behavior Intervention Monthly Flow Record revealed on 2/7/12 there were no behaviors documented, and none were documented prior to administering the medications. There was no documentation of any further assessments to determine why the resident was yelling for help and slapping his legs. The nurse's notes further reflected results an x-ray of of the resident's left thigh were received at 12:00 p.m. on 2/8/12. The x-ray results reflected fragments to his left trochanter. The physician was notified and a CT scan of the left hip was ordered. There was no documentation of an assessment from 2/8/12 to 2/12/12. Results of the CT scan which was done on 2/13/12 revealed there was a transtrochanteric [MEDICAL CONDITION] hip. The results of the scan were reported to the physician on 2/13/12 at 2:14 p.m. by the CT technician. An order was written on 2/17/12 on the bottom of the CT results page, "Schedule an appointment with the Dr. (orthopedic specialist)". The resident did not see the specialist until 2/23/12 at which time he was transferred to the hospital for surgical intervention of his [MEDICAL CONDITION]. Review of the PRN medication sheet revealed Tylenol 650 mg. was administered at 12:45 p.m. prior to going out for the CT scan. There was no documentation of an assessment from 2/12/12 to 2/18/12 when the nurse was called to the resident's room at 12:07 a.m. by the CNA. He was found lying on the floor in supine position. A small skin tear was noted to his right elbow. Further review of the nurse's notes revealed on 2/18/12 at 1:40 a.m. [MEDICATION NAME] 0.5 mg. was given orally due to the resident "yelling continuously". The nurse's notes reflected the resident was was yelling out continuously from 11:15 p.m. to 11:45 p.m. on 2/17/12 and again from 12:40 a.m. to 1:40 a.m. on 2/18/12. Review of the Behavior Intervention Monthly Flow Record for February 2012 revealed no documentation of interventions done prior to the medication administration and no assessment of the resident for medical reasons/pain. The record did not reflect any assessment of the resident's pain from 2/19/12 to 2/22/12. Review of the MAR revealed on 2/22/12, a prn dose of [MEDICATION NAME] 0.5mg po was given, but there was no documentation in the record of the reason for the administration of the [MEDICAL CONDITION] medication and no prior interventions were documented. There was no assessment of the resident for possible reasons of the behaviors he exhibited. Review of the MAR reflected that on 2/23/12 a prn dose of [MEDICATION NAME] 0.5 mg po was given. Review of the Chemical restraint flow sheet for 2/23/12 reflected the medication was given at 12:05 a.m. for "yelling and slapping his thighs and buttocks". There was no documentation in the record of any further assessment of the resident or interventions attempted prior to the [MEDICATION NAME] dose. The resident was seen by the orthopedic specialist in his office on 2/23/12 and was sent to the hospital for surgical repair (ORIF) of the left [MEDICAL CONDITION]. He returned to the facility from the hospital on [DATE] at 4:35 p.m. with a [DIAGNOSES REDACTED]. An order was noted for [MEDICATION NAME] 7.5 mg (a narcotic [MEDICATION NAME]) to be given every 4 hours as needed for pain. Review of the record revealed that at 9:00 p.m. on 2/28/12, the resident was given a prn dose of [MEDICATION NAME] 0.5 mg for agitation. There was no documentation of further assessments of the cause of his agitation, no assessment of his pain level and no attempted interventions prior to administering the [MEDICATION NAME]. On 2/29/12, review of a Chemical Restraint Flow Sheet revealed the resident was administered a prn dose [MEDICATION NAME] 0.5 mg orally at 2:00 a.m. for continuous crying out. There was no documentation of prior interventions attempted, or an assessment of the resident's pain or the cause of his crying out. Review of the MAR and nurse's notes for February 2012 revealed the post-op medication ordered for pain, [MEDICATION NAME], had not been administered. Further review of the record revealed a Chemical Restraint Flow Sheet dated 2/29/12 at 4:15 p.m. which revealed a prn dose of [MEDICATION NAME] 1 mg and [MEDICATION NAME] 5 mg were administered IM for "danger to self, continuously crying out". Review of the nurse's notes for that date and time revealed no documentation of interventions had been attempted prior to the administration of the psychoactive medications. Interview with S6 CNA on 3/5/12 at 2:00 p.m. revealed the resident appeared to be in pain prior to going to the hospital for his surgery. She further stated he would yell out for help and hit his legs, and confirmed that she had notified the nurse when he did that. She also stated his mobility had decreased a lot during that time. Interview with S4 CNA on 3/5/12 at 2:10 p.m. revealed the resident had a history of [REDACTED]. She reported he would yell out for help and he looked as if he were in pain. She stated he had pretty much stopped walking during that time. Interview with the S1DON on 3/6/12 at 11:20 a.m. confirmed there was no documentation that complete assessments of the resident had been done to determine why he was yelling, crying out for help or slapping his legs. She further confirmed the physician was not called about the resident's crying out for help and slapping his legs. She stated the resident had a [DIAGNOSES REDACTED]. She further stated more complete assessments should have been done prior to the administration of the [MEDICATION NAME] and/or [MEDICATION NAME]. 2. Observation of resident #1 on 3/5/12 at 12:05 p.m. revealed he was in the Alzheimer's Unit and was lying in bed with his body and head covered by a sheet. The surveyor could not view the resident's arms. Observation of the resident on 3/6/12 at 10:30 a.m. revealed the resident was in the Alzheimer's unit day room and his right hand was swollen and bruised. The resident's left arm above the wrist area had purple/red and some yellow/green bruising on it with several scabbed cuts noted in the bruising. Interview on 3/6/12 at 10:33 a.m. with the S3CNA who was assigned to the resident revealed she had taken the resident to the shower on 3/2/12 and he had grabbed the shower nozzle out of her hand and had injured himself on the right hand and left arm by hitting himself repeatedly with the nozzle. S3CNA stated she reported the incident to S8LPN and S9LPN on 3/2/2012. Review of the nurse's note for March 2012 revealed there was no assessment of the resident's right hand and left arm on 3/2/12, 3/3/12 or 3/4/12. Review of a nurse's note dated 3/5/12 at 6:30 a.m. reflected that upon doing an accucheck for the resident on 3/5/12, the LPN had noted bruising of the 4th and 5th fingers of the right hand with purple bruising and a fading bruise across the top of the right hand with swelling. The documentation further reflected: "Unknown cause of right hand bruising and swelling"; however, upon inquiring, S3CNA said it may have been from him grabbing the shower head out of her hand Friday (3/2/12) and swinging it back and forth hitting one hand and then the other. There was no assessment of the cuts and bruising on the resident's left arm. Interview with the S1DON on 3/6/12 at 10:35 a.m. confirmed an assessment had not been done of the resident's right hand and left arm on 3/2/12, 3/3/12, and 3/4/12. S1DON further confirmed there was no assessment of the resident's left arm.