Every finding on record at Trend Health and Rehab of Houston

Based on observation, record review, staff interviews, and facility policy review, the facility failed to ensure oxygen was administered in accordance with physician orders for one (1) of 25 residents receiving oxygen. Resident #14Findings Include:Review of the facility policy titled Oxygen Administration Policy revealed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences .1. Oxygen is administered under orders of a physician .Record review of Resident #14's Treatment Administration Record with order date of 4/25/2025, revealed, O2 (oxygen) at 2 (two) liters per nasal cannula continuous every shift related to Chronic Obstructive Pulmonary Disease (COPD), Unspecified.An observation on 5/26/2026 at 12:00 PM revealed Resident #14 sitting in dining room with no oxygen in place or available. On 5/26/2026 at 3:26 PM, Resident #14 was observed lying in bed with oxygen in place by nasal cannula at four (4) liters per minute.On 5/27/2026 at 10:51 AM, Resident #14 was observed lying in bed with oxygen in place by nasal cannula at three (3) and a half liters per minute.An interview on 5/27/2026 at 10:53 AM with Licensed Practical Nurse (LPN) #1 revealed Resident #14 was on continuous oxygen at two (2) liters per minute for COPD. LPN #1 confirmed the oxygen was set at three (3) and a half liter, and the physician order was not followed. She acknowledged the risks of Resident #14 not receiving oxygen as ordered.On 5/27/2026 at 11:35 AM, an interview with the Director of Nursing (DON) confirmed the physician order for oxygen administration was not followed.Record review of admission Record revealed Resident #14 was admitted to facility on 9/01/2022 with medical diagnoses including Chronic Obstructive Pulmonary Disease, Unspecified.Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/27/2026 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 6, which indicated Resident #14 was severely cognitively impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to implement and maintain an effective infection prevention and control program to prevent the transmission of infectious diseases for staff observed performing glucometer disinfection and for oxygen tubing storage (Resident #5) during two (2) of four (4) care areas observed. Findings include: Review of facility policy titled Glucometer Control Monitoring and Cleaning, updated 2/2016, revealed, .The machine will be cleaned before and after each use with a multi-germicidal disinfectant wipe.The glucose monitors are to be cleaned before and after each use with a moist cloth dampened with a multi-germicidal cleaning solution. Review of facility policy titled Nebulizer and Oxygen Tubing Storage Policy updated September 2025, revealed, It is the policy of this facility to decrease the risk of potential and/or direct exposure to infectious diseases, air contaminants, and bacterial exposure. We will provide our residents with the proper storage and cleaning of respiratory equipment. During an observation on 05/27/2026 at 11:48 AM, following a blood glucose check, Licensed Practical Nurse (LPN) #1 wiped the multi-use glucometer with a Sani-Cloth Germicidal Disposable Wipe for several seconds. The glucometer was not maintained in a visibly wet state for the manufacturer's required two-minute contact time before being returned to service. When questioned regarding the disinfection process, LPN #1 stated, I wipe the glucometer down with the wipe for 10-15 seconds and then let it dry for two (2) minutes. During an interview on 05/27/2026 at 11:49 AM, the Infection Control Nurse confirmed the glucometer should be disinfected with Sani-Cloth wipes between residents and remain wet for the required two (2) minute contact time. During an interview on 05/27/2026 at 12:21 PM, the Director of Nursing (DON) confirmed the glucometer should be disinfected after each use with a Sani-Cloth wipe and remain wet for two (2) minutes. Review of the Super Sani-Cloth Product Guide for Sani-Cloth Germicidal Disposable Wipes revealed, Allow surface to remain wet for 2 minutes. Let air dry. Resident #5 During an observation of resident care on 05/27/2026 at 2:24 PM with the Infection Control Nurse it was observed that Resident #5's oxygen (O2) tubing was lying on the floor under a fall mat in the room. During an interview on 05/27/2026 at 2:30 PM with the Infection Control Nurse, she confirmed the oxygen tubing was lying on the floor, and that this would increase his risk for infection. During an interview and observation on 05/27/2026 at 2:45 PM with the Director of Nursing (DON), she verbalized the oxygen tubing should not be on the floor, she removed the tubing from the concentrator and disposed of it. Record review of the Order Summary Report for Resident #5 revealed an order dated 3/11/25 for O2 BNC (bi-prong nasal cannula) at 2 liters per minute as needed for shortness of breath. Record review of admission Record revealed Resident #5 was admitted to facility on 3/11/2022 with medical diagnoses including Cerebral Palsy and Chronic Obstructive Pulmonary Disease. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/06/2026 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 5, indicating Resident #5 was severely cognitively impaired.

Based on record review, staff interview, and facility policy review, the facility failed to accurately complete Section N Medications section of the Minimum Data Set (MDS) assessment for one (1) of 17 residents reviewed for MDS accuracy. Resident #4.Findings Include:Review of the facility policy titled MDS (Minimum Data Set) Assessment dated 5/2006 revealed, Policy It is the policy of this facility to follow the RAI (Resident Assessment Instrument) process as set forth by CMS (Centers for Medicare and Medicaid) protocol .Record review of Resident #4's MDS with an Assessment Reference Date (ARD) of 3/31/26 revealed, under Section N, that during the 7-day look-back period the resident was coded as receiving an antianxiety, antidepressant, hypnotic, and anticoagulant medication.Record review of Resident #4's March 2026 Medication Administration Record revealed the resident did not receive an antianxiety, antidepressant, hypnotic, or anticoagulant medication during the assessment period, confirming the MDS was not accurately completed.An interview with the MDS Nurse on 5/27/26 at 1:45 PM confirmed Resident #4's MDS was incorrect and had been coded in error. She revealed the purpose of an accurate assessment was to ensure the resident's plan of care was developed appropriately so staff could provide the necessary care.Record review of the admission Record revealed the facility admitted Resident #4 on 3/25/26 with medical diagnoses including Metabolic Encephalopathy.Record review of the MDS with an ARD of 3/31/26 revealed, under Section C, a Brief Interview for Mental Status (BIMS) summary score of 11, indicating Resident #4 was moderately cognitively impaired.

Based on record review, staff interview, and facility policy review, the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for one (1) of seven (7) residents reviewed for hospice services. Resident #36Findings include: Review of the facility policy titled MDS Assessment, with a revision date of 5/2006, revealed Policy It is the policy of this facility to follow the RAI (Resident Assessment Instrument) process as set forth by CMS (Centers for Medicare and Medicaid) protocol. Record review revealed Resident #36 was admitted to hospice services on 3/11/25. Review of the resident's MDS assessment record revealed no Significant Change in Status Assessment was completed following hospice admission. During an interview on 5/27/2026 at 3:27 PM, the MDS nurse confirmed a Significant Change in Status Assessment should have been completed when Resident #36 admitted to hospice services and it was not completed.Record review of the admission Record revealed the facility admitted Resident #36 on 12/01/22 with medical diagnoses including Alzheimer's Disease.Record review of the MDS with an Assessment Reference Date (ARD) of 4/16/26 revealed, under Section C, a Brief Interview for Mental Status (BIMS) summary score of 3, indicating Resident #36 was severely cognitively impaired.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure a physician-ordered fluid restriction was followed for one (1) of 16 residents reviewed for hydration. Resident #1 Findings Include: Review of facility policy titled Fluid Restriction revealed, Fluids will be restricted for residents as directed by physician orders.Procedure: 1. Nursing notifies the dietary department when a patient is placed on fluid restriction. 2. Nursing, the Director of Food and Nutrition Services, and the Consultant Dietitian determine the allotment of fluids among meals, medications, etc.4. The type and amount of fluids served from the food and nutrition service department will be noted on the tray card/tray ticket. 5. Water pitchers will not be placed at bedside. 6. Nursing service will document intake and output. Record review of Resident #1's Medication Administration Record with order date of 10/11/2025 revealed, 2000 ml (milliliter) fluid restriction one time a day related to Heart Failure, Unspecified; Edema, Unspecified. On 5/26/2026 at 11:15 AM an observation revealed Resident #1 had significant edema in both lower extremities. A water pitcher was also noted on the bedside table. On 5/27/2026 at 10:59 AM, an interview with Licensed Practical Nurse (LPN) #1 confirmed that Resident #1 was on a 2000 Milliliter (ML) fluid restriction. LPN #1 stated staff does not track the resident's total fluid intake and only documents yes or no on the Medication Administration Record (MAR). LPN #1 also stated Resident #1 is offered fluids from the hydration cart and is provided approximately one-half cup at a time. On 5/27/2026 at 12:12 PM, an observation of Resident #1 in the dining room revealed Resident #1 was served eight (8) oz of milk, four (4) oz of juice, four (4) oz of Mighty Shake, and a personal cup containing an unknown amount of fluid. Review of the meal ticket showed no indication that the resident was on a fluid restriction or the number of fluids allowed with meals.On 5/27/2026 at 2:46 PM, an interview with Registered Nurse (RN) #2 confirmed that Resident #1's 24-hour fluid intake is not documented.On 5/27/2026 at 3:09 PM, an interview with the Dietary Manager revealed Resident #1 received the standard fluid amount of 1500 milliliters for meals. An interview with the Director of Nursing (DON) on 5/28/2026 at 12:15 PM confirmed an order had not been entered for nursing staff to document Resident #1's 24-hour fluid intake on the MAR. The DON acknowledged the risks associated with failing to monitor Resident #1's fluid intake would be fluid volume overload. Record review of admission Record revealed Resident #1 was admitted to facility on 9/02/2025 with diagnoses including Heart Failure, unspecified and Edema, unspecified. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/27/2026 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 6, which indicated Resident #1 was severely cognitively impaired.

Based on resident and staff interviews, record reviews, and facility policy reviews, the facility failed to provide an ongoing activity program designed to meet the needs of each resident for four (4) of 14 residents interviewed during the Resident Council meeting as evidenced by a lack of group activities on weekends. Residents #20, #22, #38 and #39. Findings include: A record review of facility policy titled, Activity Program, dated 1/21/22, revealed, An ongoing program of activities is designed to meet the needs of each resident. Individualized and group activities are provided that: a. Reflect the schedules, choices, and rights of the residents; b. Are offered at hours convenient to the residents, including evenings, holidays, and weekends. Record review of the March 2025 Activity Calendar revealed each Saturday in March INDIVIDUAL PURSUIT was listed as the activity. Church services were listed each Sunday morning with CHECKERS/MOVIES as the 2:00 PM activity each Sunday. Resident #20 During an interview 03/30/25 at 4:50 PM, Resident #20 stated she loved attending group activities, but the facility did not have activities on Saturday's. She admitted that she gets bored on Saturdays and would like there to be activities. An interview with the Administrator on 4/1/25 at 4:00 PM revealed the facility was required to provide daily group activities and other activities that interest the residents even on the weekend. She confirmed the facility failed to provide the residents with activities on Saturday for those residents that choose to attend. During an interview on 4/2/25 at 9:50 AM, the Activity Director confirmed the residents need activities that meet their interests daily and the facility had failed to provide these on Saturdays for a while now. She stated the facility had a family council group that was extremely active and had activities for the residents every Saturday, but the president of that group had a family illness, so she was less involved. Since that time, the family group had fizzled out. She admitted that during the winter months, residents were more confined inside and this could cause them to feel a little stir crazy and bored. Then she added that she provided games and puzzles for the residents to do on their own on the weekend, but there were no scheduled group activities. Record review of Resident #20's Annual Minimum Data Set (MDS) Section F with Assessment Reference Date (ARD) of 9/17/24, revealed the resident's response of very important to the question, How important is it to you to do things with groups of people? To the question, How important is it to you to do your favorite activities, the resident's response was, very important. Record review of Resident #20's Admission Record, revealed the resident was admitted to the facility on [DATE]. Record review of Resident #20's Quarterly MDS Section C with an ARD of 12/4/24, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated the resident was cognitively intact. 46013 Resident #22 During an interview on 3/30/25 at 3:30 PM, Resident #22 revealed weekends are pretty boring here. They got us some games to play, but many folks don't know how to play them, and they just sit and stare at each other. She revealed that on Sundays, someone comes in and does a church service, but we are on our own after that. In an interview on 4/01/25 at 9:37 AM, the Activities Director confirmed that Resident #22 had voiced concerns that she would like to do weekend activities. She revealed she is trying to build the activities department back up and confirmed that there were no organized group activities for the month of March. She revealed it has been quite some time since there have been weekend activities During an interview on 4/01/25 at 10:10 AM, the Administrator confirmed that the family council members used to be very involved in weekend activities, but they haven't been there in a while. Record review of Resident #22's Admission MDS Section F with an ARD of 11/11/24 revealed the resident's response to the question, How important is it to you to do your favorite activities? was, Very important. Record review of Resident #22's Admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Resident #22's MDS Section C with an ARD of 11/11/24, revealed a BIMS of 15 which indicated the resident was cognitively intact. Resident #38 On 03/31/25 at 1:30 PM, an interview with Resident #38, Resident Council President, revealed that they attended monthly Resident Council Meetings and had several residents who attended regularly. She revealed that some of the residents had brought up in the past that there weren't enough activities planned during the week and no activities on the weekends. She revealed that they had preaching on Sunday and that's it. Record review of Resident #38's Admission Record revealed an initial admitted [DATE]. Record review of Resident #38's Quarterly MDS with ARD of 12/09/24 under Section C revealed a BIMS Score of 15 which indicated that she had no cognitive deficits. Resident #39 An interview on 3/30/25 at 3:45 PM, Resident #39 revealed he would love to have something to do on the weekend. He stated that they don't have anything to do on Saturdays, and have a preacher who comes in early Sunday, but after that, we don't have anything to do. Resident #39 stated, I mainly just stay in bed and watch TV or sleep on the weekends. Record review of Resident #39's Annual MDS Section F with ARD of 7/30/24 revealed the resident's response of Very important to the question, How important is it to you to do things with groups of people? To the question, How important is it to you to do your favorite activities? the resident's response was, Very important. Record review of Resident #39's Admission Record revealed the resident was admitted to the facility on [DATE]. Record review of Resident #39's MDS Section C with ARD of 7/30/24 revealed a BIMS score of 8 which indicated the resident had moderate cognitive impairment.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure implementation of infection prevention and control practices to prevent the potential transmission of communicable diseases and infections for two (2) of three (3) resident care areas observed (Resident #1 and Resident #9). Specifically, the facility failed to: 1. Post appropriate transmission-based precautions signage for a resident on contact isolation for Methicillin Resistant Staphylococcus Aureus (MRSA) (Resident #1); and 2. Ensure staff followed Enhanced Barrier Precautions (EBP), including wearing a gown, during the administration of medication via a Percutaneous Endoscopic Gastrostomy (PEG) tube (Resident #9). These failures had the potential to contribute to the transmission of infectious organisms to other residents, staff, and visitors within the facility. The scope/severity for this deficiency was increased to E - pattern. F880 was also cited during the last annual recertification survey. Findings include: A record review of the facility policy titled Enhanced Barrier Precautions, dated 10/23, revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities .(residents with wounds or indwelling medical devices) . c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves . Record review of facility policy titled, Infection Prevention and Control Program, undated, revealed, It is a policy of this facility to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Resident #1 During an interview on 3/30/25 at 5:25 PM, Resident #1 stated he had wounds on his lower legs. A hanging isolation organizer was noted on his door. There was no signage on his door that indicated what type of isolation the resident was in or what type of Personal Protective Equipment (PPE) was needed. During an interview on 3/31/25 at 10:30 AM, the Infection Preventionist/Treatment Nurse stated that Resident #1 had Methicillin Resistant Staphylococcus Aureus (MRSA) in his leg wounds and was on contact isolation for this infection. She stated he was receiving antibiotics and after completing those, a repeat culture would be done. She stated the proper use of PPE helped prevent the spread of an infection. She acknowledged the resident did not have signage on his door to indicate what type of isolation the resident was on or what type of protective equipment needed to be used. An interview with the Administrator on 3/31/25 at 11:40 AM confirmed that Resident #1 was in contact isolation due to MRSA in a wound and signage on or near the resident's door was required. She stated when a resident was placed in contact isolation, the type of precaution and the PPE to be used was required to be placed in a visible area outside of the resident's room. She stated signage was necessary to inform staff and visitors what PPE was needed to help prevent the spread of infection. She confirmed the facility failed to place proper infection control signage on or near a resident's door to identify the type precautions and the appropriate PPE to use. Record review of Resident #1's Order Summary Report revealed an order dated 3/25/25 to Maintain contact precautions due to MRSA infection in lower leg every shift related to bacterial infection. Record review of Resident #1's Admission Record revealed the resident was admitted to the facility on [DATE]. Diagnoses included Bacterial Infection, Non-pressure Chronic Ulcer of left and right lower legs, and Venous Insufficiency. Record review of Resident #1's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/25, revealed a Brief Interview for Mental Status (BIMS) of 10 which indicated the resident had moderate cognitive impairment. 46013 Resident #9 An observation on 4/01/25 at 8:25 AM revealed Licensed Practical Nurse (LPN) #1 administered Resident #9's medications through a PEG tube without wearing a gown for EBP. She confirmed she failed to wear a protective gown and revealed she knows that she should have. She revealed that EBP is supposed to be utilized when providing care to the resident since he has a PEG tube. She revealed we even discussed wearing the gown when I gave him his medications this morning, but I got nervous and forgot to do it. During an interview on 4/01/25 at 2:24 PM, the Interim Director of Nurses (DON) confirmed that the nurse should have worn the PPE when administering his medications through the PEG. She revealed that EBP is implemented to protect the residents and the staff from spreading germs. During an interview on 4/02/25 at 12:06 PM, the Infection Control Nurse revealed that for any residents under EBP, the facility's requirements and expectations are that the staff wear the proper PPE to reduce the possible spread of infections. Record review of Resident #9's Order Summary Report with active orders as of 4/1/25 revealed an order for EBP related to PEG every shift. Record review of Resident #9's Admission Record revealed he was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction and Gastrostomy status.

Based on observations, staff and resident representative interviews, record review, and facility policy review, the facility failed to ensure a dependent resident received appropriate oral care for one (1) of 45 residents residing in the facility. Resident #9. The scope and severity for this citation was increased to E for a repeated citation from the previous annual recertification survey. Findings include: Record review of the facility policy titled ADL (Activities of Daily Living) Care Policy dated 8/23 revealed, It is the policy of this facility to provide appropriate treatment and services in relation to ADL care to residents to ensure all ADL needs are met on a daily basis while attaining or maintaining the residence of highest, practicable, physical, mental, and social well-being. An observation on 3/30/25 at 4:25 PM revealed Resident #9 with a thick white substance inside the corners of his mouth and covering his upper and lower lip. An interview on 3/30/25 at 6:25 PM with Resident #9's Resident Representative (RR) sitting at the bedside, she stated that she visits frequently and usually has to wash his lips and mouth off when she arrives. She revealed she has told the staff about his mouth not getting cleaned. She understands that the staff can't be with him 24 hours a day but thinks they could do better by ensuring he is cleaned up. She revealed she has visited before and found him with white dried secretions on his lips, and that tells her that his sputum stayed on his lips long enough to dry up. During an interview on 4/01/25 at 8:30 AM, Licensed Practical Nurse (LPN) #1 revealed that occasionally at the beginning of shift, the resident will have an white sputum on his mouth and lips. She stated, It doesn't happen all of the time but does occasionally. She revealed that the Certified Nursing Assistants (CNA) are responsible for his ADL care, which includes his mouth care, and that the nurses are also responsible for oral care each shift. In an interview on 4/1/25 at 12:45 PM, with CNA #2, she stated that they clean Resident #9's mouth when they do his ADL care. She admitted that if the staff would clean his mouth each time they checked on him, then that stuff wouldn't dry on his mouth. During an interview on 4/01/25 at 1:45 PM, the Interim Director of Nurses (DON) revealed Resident #9's oral care should be done each shift and more often since he is fed by a feeding tube and probably a mouth breather. She revealed that it is her expectation that each resident is adequately groomed and presentable in appearance. Record review of Resident #9's Admission Record revealed he was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction, Gastrostomy status, and Adult Failure to Thrive.

Based on observations, staff interviews, record reviews, and facility policy reviews, the facility failed to implement a care plan for a resident's Activities of Daily Living (ADL) care for one (1) of 31 resident care plans reviewed. Resident #9. Findings include: Record review of facility policy titled Following the Care Plan Policy dated 1/2011, revealed, It is the policy of this facility to follow a written and approved care plan for each resident. All employees will be trained upon hire and be required to follow the care plan. Record review of the care plan, date initiated 7/16/24, revealed Resident #9 has an ADL self-care performance deficit related to hemiplegia, limited mobility, musculoskeletal impairment, stroke and has contractures to all extremities with associated spasticity. Interventions include oral care every shift. On 3/30/25 at 4:25 PM, an observation revealed Resident #9 with a thick white substance covering his upper and lower lip and sides of his mouth. On 3/30/25 at 6:25 PM, an observation and interview with Resident #9's Representative (RR) revealed she has to clean his mouth every time she visits, which is often. She admitted that she had talked to the staff about it, but it has not improved. On 4/01/25 at 8:30 AM, during an interview, Licensed Practical Nurse (LPN) #1 admitted that she had seen white stuff on Resident # 9's mouth occasionally and had to clean it off. She revealed that it was both the CNAs and the nurse's responsibility to provide oral care to the residents. In an interview on 4/1/25 at 1:35 PM, the Minimum Data Set (MDS) Coordinator revealed the care plans are developed so the staff will know how to take care of each resident's needs. She confirmed that Resident #9's ADL care plan regarding his oral care was not being followed and that the care plan lacked further development for Resident #9's individual needs. During an interview on 4/01/25 at 1:45 PM, the Interim Director of Nurses (DON) revealed Resident #9's oral care should be done more than just each shift since he has a feeding tube and is probably a mouth breather. She revealed the resident's plan of care was not being followed in regard to his oral care, and it should have been. Record review of Resident #9's Admission Record revealed he was admitted to the facility on [DATE] with medical diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction and Gastrostomy status.

Based on staff interview and record review, the facility failed to accurately complete Section N of an Annual Minimum Data Set (MDS) Assessment for one (1) of 31 resident MDS assessments reviewed. Resident #24. Findings Include: Record review of the facility policy MDS (Minimum Data Set) Assessment revealed, It is the policy of this facility to follow the RAI (Resident Assessment Instrument) process as set forth by CMS (Centers for Medicare and Medicaid Services) protocol. Record review of Resident #24's Annual MDS with an Assessment Reference Date (ARD) of 01/13/25 revealed under Section N - Medications, revealed that a hypnotic medication was coded as Yes, the resident is receiving. Record review of Resident #24's Order Summary Report of active orders as of 01/13/25 revealed the resident did not have an order for a medication with a drug classification of hypnotic. Record review of Resident #24's Medication Administration Record revealed that she did not receive a hypnotic during the seven day look back period from 01/07/25 through 01/13/25. An interview on 04/02/25 at 9:15 AM with Registered Nurse (RN) MDS Coordinator revealed that she was new to the facility and that she was not working there during the time of the last completed MDS Assessment for Resident #24. She confirmed that Resident #24 was not taking a hypnotic and that Section N of Resident #24's Annual MDS with ARD of 01/13/25 was coded inaccurately. RN MDS Coordinator revealed that there was no documentation to reflect that Resident #24 was taking a hypnotic and stated, It's black and white to me, it's either there or it's not. Record review of Resident #24's Admission Record revealed the facility admitted the resident on 09/02/22 with medical diagnoses that included Parkinson's Disease and Major Depressive Disorder. Record review of Resident #24's Annual MDS with ARD of 01/13/25 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 08 which indicated that she had moderate cognitive deficits.

Based on staff interviews and record reviews the facility failed to transmit Minimum Data Set (MDS) Assessments timely for six (6) of 31 residents' MDS assessments reviewed. Residents #15, #16, #19, #30, #34, and #35. Findings include: A review of a typed statement on facility letterhead, and signed by the Administrator on 4/2/25 revealed, It is the policy of (Proper Name of the facility) to follow the RAI (Resident Assessment Instrument) manual, chapter 2, Timeliness of MDS. A record review of the facilities MDS 3.0 Final Validation Report revealed that the following MDS Assessments were submitted late on 3/28/25: Resident #15 last completed and submitted MDS with an Assessment Reference Date of 11/20/24. Resident #16 last completed and submitted MDS with an Assessment Reference Date of 11/25/24. Resident #19 last completed and submitted MDS with an Assessment Reference Date of 11/20/24. Resident #30 last completed and submitted MDS with an Assessment Reference Date of 11/21/24. Resident #34 last completed and submitted MDS with an Assessment Reference Date of 2/12/25. Resident #35 last completed and submitted MDS with an Assessment Reference Date of 2/17/25. In an interview on 4/01/25 at 1:10 PM, the Registered Nurse MDS Coordinator revealed she has only been with the facility for a week and found out when she came into the position that there were a lot of MDS Assessments that were not completed and therefore were very late. Now she is working to get things caught up and completed. In an interview on 4/01/25 at 4:49 PM, the Administrator (ADM) confirmed that she was aware the facility had MDS assessments that were late being submitted. She stated, We knew they were late, our MDS nurse quit, and we knew we were continually getting behind. She revealed the current MDS coordinator has been here for about a week and is working to get things caught up and back on track. She revealed MDS Assessments are very important because they determine the care needed for the residents and ensure payment.

Based on resident and staff interviews, record review and facility policy review, the facility failed to honor a resident bedtime choice for one (1) of 31 sampled residents. Resident #24. Findings Include: Record review of the facility policy Resident Rights revealed 3. Our facility will make every effort to assist each resident in exercising his/her rights to ensure that the resident is always treated with respect, kindness, and dignity An interview on 3/31/25 at 1:00PM with the Administrator (ADM) revealed that on 03/16/25, Registered Nurse (RN) #1 called her and reported that Certified Nursing Assistant (CNA) #1 made Resident #24 go to bed when she didn't want to. The ADM stated that RN #1 reported to her that CNA #1 took Resident #24 to her room from the dining room after the supper meal around 6:00 PM, put Resident #24's gown on and made her go to bed. She also revealed that Resident #24 kept telling her (CNA #1) that she didn't want to go to bed. The ADM reported that Resident #24's roommate, Resident #22 witnessed it, walked up to the nursing desk and reported to RN #1 that CNA #1 told Resident #24 that she was going to bed because she (CNA #1) had things to do. The ADM admitted that it was the residents' right to choose to get up and to go to bed when they wanted to, and Resident #24's choice to stay up longer should have been honored that evening. An interview with Resident #22 on 03/31/25 at 1:40 PM confirmed that she was Resident#24's roommate and a couple of weeks ago, she saw a CNA make Resident #24 go to bed one night after supper. She revealed that she didn't know who the CNA was, but she hadn't been back since that night, and she was glad. Resident #22 revealed that she was in her bed watching television with her privacy curtain pulled about halfway to where she could see what was going on. She confirmed that she heard the CNA say to Resident #24, You're going to bed because I have work to do. She revealed that she heard Resident #24 tell the CNA several times that she was not ready to go to bed. Resident #22 revealed that she got up from her bed and went to the nursing desk and reported to a nurse what happened. An interview on 03/31/25 at 2:35 PM with RN #1 confirmed that around 5:45 PM on 3/16/25 Resident #22 came to the nurse's desk and reported that CNA #1 was mistreating Resident #24 by making her go to bed when she didn't want to. RN #1 revealed that Resident #22 told her that Resident #24 told CNA #1 that she was not ready to go to bed and the CNA told her she was going to bed anyway because she had too much to do. RN #1 revealed that she went to Resident #24's room to check on her and found her sitting on the side of the bed with her gown on. RN #1 revealed that Resident #24 told her that she wanted to stay up longer and visit with friends in the dining room and wasn't ready to go to bed but that CNA #1 made her go to bed. RN #1 revealed that she made sure Resident #24 was safe, offered to put her clothes back on and help her get back up but at that time, she refused. RN #1 revealed that Resident #24 told her that she was sitting in the dining room at a table with other residents and CNA #1 came and pushed her in her wheelchair back to her room and put her to bed, even though she told her she was not ready. RN #1 confirmed that Resident #24's choice to go to bed later that evening should have been honored and this was not okay. An interview on 04/01/25 at 10:20 AM with Resident #24 confirmed that a couple weeks ago, there was an aid who made her go to bed early against her wishes. She revealed that she thought it was around 6:00 PM and she was sitting in her wheelchair at a table in the dining room visiting with friends when the aid came and pushed her back to her room. Resident #24 revealed that she told the aid that she was not ready to go to bed, but the aide told her she was going anyway because she had a lot of work to do. Resident #24 revealed that this was her home, and she wanted to be good to the staff here and she wanted them to be good to her. Resident #24 revealed that it was important to her to make her own decisions about when to go to bed and she wanted to be respected. Resident #24 revealed that the aide did not hurt her, just made her go to bed. She revealed that sometimes she wanted to go to bed early but that was her choice. She revealed that if the aide wasn't going to do right, she didn't need to work there. Resident #24 revealed that she did not know who the aide was and that she hadn't been back to work since that happened. Record review of Resident #24's Admission Record revealed the facility admitted the resident on 09/02/22 with medical diagnoses that included Parkinson's Disease and Depression . Record review of Resident #24's Minimum Data Set (MDS) with an (Assessment Reference Date) (ARD) of 01/13/25 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 8 which indicated that she had moderate cognitive deficits. The review of Section F-Preferences revealed that it was very important to her to choose her own bedtime.

Based on resident and staff interviews, record review and facility policy review, the facility failed to deliver resident mail on Saturdays for five (5) of 31 sampled residents. This has the potential to affect all residents in the facility. Resident #4, Resident #20, Resident #22, Resident #35, and Resident #38. Findings Include: Record review of the facility policy Mail Delivery Policy dated 2/2009 revealed, The mail will be delivered to the resident Monday thru Friday by the Activity Director. If the resident receives mail on Saturday, it will be delivered to the resident by the week-end RN (Registered Nurse) Unit Manager. During a Resident Council Meeting on 03/31/25 at 2:00 PM five of the thirteen residents in attendance revealed that they did not have mail delivered on Saturdays. Resident #38, Resident Council President, revealed that there was no one in the front office on the weekend to pass the mail out to them. Resident #4, Resident #20, Resident #22, and Resident #35 confirmed that the staff handed their mail out during the week and that they did not get mail on Saturdays. An interview on 03/31/25 at 3:40 PM with Registered Nurse (RN) #1, revealed that she worked on the weekends and that she hadn't ever accepted mail on Saturdays. She revealed that the front office was closed on the weekends. RN #1 revealed that if mail was delivered to the facility on Saturdays, she could pass it out to the residents. An interview on 04/01/25 at 9:10 AM with the Director of Nursing (DON), revealed that the mail carrier did not deliver mail to the facility on Saturdays because there was no one in the front office to give it to. She revealed that if the facility had any mail on Saturdays, the mail carrier delivered it the following Monday when they had someone to distribute it to. DON agreed that residents should receive their mail on Saturdays if they had any, and they should not have to wait until the following Monday to get it. On 04/01/25 at 10:00 AM, an interview with the Administrator (ADM) revealed that there had been some inconsistencies with the mail but she was not aware that mail was not delivered on Saturdays. ADM confirmed that it was important for the residents to receive their mail and that it should be passed out on the days the mail ran. Record review of Resident #4's Admission Record revealed an admitted [DATE]. Record review of Resident #4's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 01/27/25 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated that she had no cognitive deficits. Record review of Resident #20's Admission Record revealed an initial admitted [DATE]. Record review of Resident #20's Quarterly MDS with ARD 12/4/24 under Section C revealed a BIMS Score of 15 which indicated that she had no cognitive deficits. Record review of Resident #22's Admission Record revealed an admitted [DATE]. Record review of Resident #22's Quarterly MDS with ARD of 02/06/25 under Section C revealed a BIMS Score of 15 which indicated that she had no cognitive deficits. Record review of Resident #35's Admission Record revealed an admitted [DATE]. Record review of Resident #35's Quarterly MDS with ARD of 11/19/25 under Section C revealed a BIMS Score of 15 which indicated that she had no cognitive deficits. Record review of Resident #38's Admission Record revealed an initial admitted [DATE]. Record review of Resident #38's Quarterly MDS with ARD of 12/09/24 under Section C revealed a BIMS Score of 15 which indicated that she had no cognitive deficits.

Based on observation, staff interview, record review, and facility policy review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for resident(s) with upper body contractures for two (2) of 19 resident assessments reviewed. Resident #34 and #46 Findings include: Record review of facility policy titled Resident Assessment - RAI, dated 6/18/23, revealed, This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences using the resident assessment instrument (RAI) specified by CMS (Centers for Medicare and Medicaid Services) . Resident #34 An observation and interview with Resident #34 on 3/19/24 at 8:20 AM, revealed resident's left hand and fingers were contracted and a gauze dressing was in her palm. She stated it had been like that for a long time and she had a wound in her hand. Record review of Resident #34's MDS with Assessment Reference Date (ARD) of 1/30/24, Section GG revealed the resident had no impairment with range of motion of upper extremities. An interview with MDS Registered Nurse (RN) #1 on 3/20/24 at 3:40 PM, revealed she was the person that completed Resident #34's MDS assessment and made an error by not marking limited range of motion to upper extremity. She stated she was aware of the contracture to the resident's left hand and fingers, but she did not realize that contractures of the hand/fingers would be considered an upper extremity range of motion limitation, so therefore, she failed to code it correctly. She stated she reviewed the RAI and realized she should have marked the limited range of motion for this resident's upper extremities and confirmed she did not enter accurate information in the MDS assessment. During an interview on 3/20/24 at 3:45 PM, the Director of Nursing (DON) revealed the MDS assessment should represent an accurate assessment of the resident's condition at that time. She confirmed the facility failed to code and submit an accurate MDS assessment concerning contractures for Resident #34. Record review of the Physician Orders List for Resident #34 revealed an order dated 12/28/22 for a hand roll to left hand during waking hours as tolerated. Record review of Resident #34's MDS with ARD of 1/30/24, revealed a Brief Interview for Mental Status (BIMS) of 8 which indicated the resident had a moderate cognitive impairment. Record review of Resident #34's Face Sheet revealed she was admitted to the facility on [DATE] with medical diagnoses that include Parkinson's Disease and Abnormalities of gait and mobility. 47874 Resident #46 An observation of Resident #46 on 03/18/2024 at 11:14 AM, revealed him lying in bed awake. The resident was observed with paralysis to the left arm and contractures to the left fingers. Record review of Resident #46's Physician Orders revealed an order dated 7/04/2023, Hand roll to Lt (left) hand during waking hours to prevent further contractures . Record review of the MDS with an ARD of 3/11/2024 revealed, under section GG, functional limitation in Range of Motion - Upper extremity was marked as 0 (zero), which indicated Resident #46's had no impairment. An interview with the MDS #1 on 3/20/2024 at 2:29 PM, revealed she was the person that completed Resident #46's MDS assessment and stated that she made an error by not marking limited range of motion (ROM) for the upper extremity. She revealed that she did not reference the RAI when she completed the assessment, and revealed that she should have. She revealed the MDS did not represent an accurate assessment of the resident. Record review of the Face Sheet revealed the facility admitted Resident #46 on 4/08/2022 with medical diagnosis that included hemiplegia following Cerebral Infarction affecting the left nondominant side, Type 2 Diabetes Mellitus, Seizures, and Depression.

Based on staff interview and record review, the facility failed to complete a Comprehensive Admission Minimum Data Set (MDS) assessment within fourteen days for one (1) of 19 sampled residents Resident #216 Findings Include: Record review of Resident #216's Face Sheet revealed the facility admitted the resident on 2/21/2024. Record review of Resident #216's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/28/2024, revealed under section Z, the date a Registered Nurse (RN) signed the assessment as complete was left blank. It also revealed a status of Open, which indicated the admission assessment had not been completed and closed for transmittal. An interview with the Minimum Data Set (MDS) Nurse #2 on 3/20/2024 at 9:49 AM, confirmed Resident #216's Admission MDS assessment was not completed and should have been completed within 14 days of admission. She revealed she overlooked the assessment and thought it had been completed. She explained the comprehensive assessment must be completed to develop the resident's care plans, which gave the staff a guide of how to care for the resident. An interview with the Director of Nursing (DON) on 3/20/2024 at 3:20 PM, revealed she was not aware that Resident #216's Admission MDS assessment had not been completed. She confirmed the MDS assessments should be completed and submitted per the Resident Assessment Instrument (RAI) guidelines.

Based on observation, resident and staff interview, facility policy review, the facility failed to ensure privacy for a resident as evidenced by a staff member changing a residents brief next to a window with no curtain or blind for one (1) of 57 residents observed for privacy. Resident #35 Findings include: Review of facility policy titled, Resident Rights, with a revision date of 9/22/22 revealed, The resident has the right to a dignified existence .7. Privacy and confidentiality: The resident has a right to personal privacy . An observation on 3/18/24 at 10:35 AM revealed no curtains or blinds on the window in Resident #35's room with the resident's bed situated in front of the window with a view outside of a driveway with a trash dumpster and several parked cars. An interview on 3/18/24 at 1:54 PM, Resident #35 revealed in a slurred speech that she would like curtains on her window and wasn't sure why she didn't have a curtain. An interview on 03/18/24 at 2:30 PM, Certified Nurse Aide (CNA) #3 revealed the resident's window hadn't had a curtain or blind for a while but she was unsure how long it had been off. She revealed we change her briefs and do her peri care while she is standing up, we can't change her while she is in bed because her legs flail around so much. An observation on 03/18/24 at 2:55 PM, CNA #3 entered Resident # 35's room with an incontinence disposable brief in her hand, she pulled the privacy curtain between Resident A and Resident B's bed and was changing Resident #35's brief and administering peri-care in front of the open window that lacked any covering from the outside view. An interview on 03/18/24 at 3:05 PM, the Administrator confirmed there was no blind or curtain on the resident's window and revealed that it should be. She stated she wasn't sure how long it had been like this and confirmed this is a privacy and dignity issue. Record review of Resident #35's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses that included Huntington's disease, Slurred Speech, and Anxiety Disorder. Record review of the quarterly Minimum Data Set with an Assessment Reference Date of 1/20/24 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognitive skills.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to notify a resident's physician of a skin concern for one (1) of 19 sampled residents. Resident #216. Cross Reference F684 Findings Include: Record review of the facility policy titled Notification of Changes with a revision date of 12/20/2022 revealed, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification 3. Circumstances that require a need to alter treatment. This may include: a. New treatment . An observation and interview with Resident #216 on 3/19/2024 at 2:40 PM, revealed the resident sitting in a wheelchair with his head laid over a bedside table. The resident was observed with an excessive thick layer of white buildup with patchy areas of flaking to the entire scalp (all hair) that extended to the ear lobes. The white buildup was also observed in the resident's facial beard that extended to the front of his neck. The resident stated that it did itch at times and revealed that the facility was not performing treatment to the areas. An observation and interview with Licensed Practical Nurse (LPN) #1, on 3/19/2024 at 2:43 PM, confirmed Resident #216's skin concern. She revealed she was not aware of the skin issue and stated the resident was not getting any type of treatment and she was unsure if the physician had been notified, and confirmed he should have been. Record review of Resident #216's Physician Orders revealed there was not a treatment order for his skin concern. Record review of Resident #216's Departmental Notes dated 2/21/2024 through 3/11/2024, revealed the resident had dry skin to the BLE (bilateral lower extremities) with no documentation of his skin concern to the scalp and beard. An interview with Registered Nurse (RN) #1 on 3/20/2024 at 1:40 PM, revealed the staff had not reported any skin issues to her for Resident #216. She stated the physician should have been contacted when the issue was first observed. Record review of the Skin Inspection Report dated 2/28/2024, 3/11/2024, and 3/18/2024 revealed Skin Intact which indicated Resident #216 had no identified skin concern. An interview with LPN #2 on 3/20/2024 at 3:55 PM, revealed she was the person responsible for completing the last two weeks of skin audits on Resident #216. She revealed she did not find any skin concerns on either of the skin audits and stated the resident was lying in bed when she conducted the audits, and she must have overlooked it. An interview with the Director of Nursing (DON) on 3/20/24 at 4:00 PM, confirmed Resident #216's skin concern should have been caught on the weekly skin audits and stated the physician should have been notified for a treatment. Record review of Resident #216's Face Sheet revealed the facility admitted the resident on 2/21/24 with medical diagnoses that included Chronic Systolic (congestive) Heart Failure and Type 2 Diabetes mellitus.

Based on observation, resident and staff interview, record review, and facility policy review the facility failed to honor a resident's preference for end of life Advance Directives for one (1) of 24 residents sampled. Resident #57. Findings include: Record review of facility policy titled, Advance Directive Policy, undated, revealed, This facility recognizes the resident's right under the State Law to accept or refuse medical treatment and to formulate advance directives such as a Living Will, Durable Power of Attorney for Healthcare and decisions regarding resuscitation The facility supports the need for resident's participation in health care decisions and will make every effort to provide the resident and their family with information to enhance decision making capacity and to reasonably assure the ability to make voluntary and informed decisions. Record review of Resident #57's Advance directives/Medical treatment decisions .I do not choose to formulate or issue any Advance Directives at this time. I want efforts made to prolong my life and I want life-sustaining treatment to be provided. Signed by Resident and dated [DATE]. Record review revealed a hospice form for Do-Not-Resuscitate (DNR) signed by daughter and dated [DATE]. Record review of Resident #57's Physician orders for the month of: [DATE] revealed Code Status: Full code. Record review of Resident #57's Physician orders for the month of: [DATE] revealed an order dated [DATE] Code Status: Do Not Resuscitate. An interview on [DATE] at 3:30 PM, with Resident #57 stated, I know I'm on hospice services but if I stop breathing, I want cardiopulmonary resuscitation (CPR). I want to come back. That's what I want. He revealed his daughter signed his hospice paperwork, but he wasn't aware that his code status had changed, and it hadn't been discussed with him. An interview on [DATE] at 4:25 PM, the Admission Liaison Nurse revealed when Resident #57 was admitted to the facility he signed his own Advance Directive paperwork, and his wish was to be a full code meaning he wished to have CPR performed. She confirmed that the resident had a form signed by Resident #57's daughter when he went on hospice services on [DATE], and a physician order for [DATE] for DNR by the hospice physician. She revealed, I don't think his code status was discussed with him when they admitted him to hospice services. She revealed they have no paperwork confirming the daughter is his Power of Attorney (POA) She confirmed it is his right to choose his end-of-life status and it is supposed to be according to his wishes. She revealed she wasn't aware that his end-of-life choice had changed from CPR to DNR. An observation on [DATE] at 4:45 PM, revealed an interview between Resident #57 and the Admission Liaison Nurse in which the nurse explained to the resident his end-of-life choices. The nurse explained the difference between the DNR code status and the Full code status. Resident #57 verbalized understanding of the difference and stated, If you can get my heart to beating, I want you to try, it may not get back to beating but I want you to try. An interview on [DATE] at 2:02 PM, the Administrator confirmed that the resident had completed his own Advance Directive and had chosen a full code status when he was admitted to the facility. She revealed she wasn't aware of the change in his code status when he went on hospice services, and it wasn't communicated through the proper channels, and it should have been. Record review of Resident #57's Face Sheet revealed he was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. Record review of Resident #57's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated the resident has moderate cognitive impairment.

Based on observation, resident and staff interview, and facility policy review, the facility failed to ensure a resident's call light was in reach for one (1) of 57 residents residing in the facility. Resident #4 Findings include: Review of the facility policy titled Call Lights: Accessibility and Timely Response with a revision date of 3/19/2024 revealed, Policy: The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Also revealed under, Policy Explanation and Compliance Guidelines: . 5. Staff will ensure the call light is within reach of resident and secured, as needed. Resident #4 An observation of Resident #4 on 3/18/2024 at 11:16 AM, revealed her lying in bed with a pillow under her left arm with the call light hanging down from the left side of the bed on the floor. An observation and interview on 03/19/2024 at 2:02 PM, revealed Resident #4 hollering for help down the south hallway. The resident was observed sitting in a wheelchair facing a window in her room and stated she needed help and asked, Can you open my chocolate? The call light was hanging down from the left bed rail, which was positioned up against the wall and the resident could not access it. The resident stated she could use the call light to request help if she had it. An observation and interview with Certified Nurse Aide (CNA) #1 on 3/19/2024 at 2:05 PM, revealed she was assigned to Resident # 4 and explained that she brought the resident to her room and got called away to do something else and confirmed that the call light was unreachable and should not be. CNA #1 explained that the purpose of having the call light close by was for the resident to call when she needed help. An interview with the Director of Nursing (DON) on 3/19/2024 at 2:24 PM, confirmed Resident #4's call light should be accessible when the resident was in her room so she could call for assistance when needed. Record review of Resident #4's Face Sheet revealed the facility admitted the resident on 5/10/2016 with medical diagnoses that included Cerebral Infarct, Type 2 Diabetes Mellitus, Epilepsy, and Paranoid Schizophrenia.

Based on observation, staff interview, record review, and facility policy review the facility failed to develop comprehensive care plans timely, failed to implement care plans for residents' Activities of Daily Living (ADL) care and position and mobility needs for five (5) of 19 resident careplans reviewed. Residents #1, #13, #26, #46, and #216. Findings include: Record review of facility policy titled Comprehensive Care Plans dated 12/15/22, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Resident #1 Record review of Resident #1's Care Plan with problem onset 09/12/2023, revealed the resident was unable to assist with her care and required total assistance with Activities of Daily Living (ADLs) due to cognitive impairment related to diagnosis of infantile cerebral palsy, and spastic quadriplegia. An intervention listed was oral care every shift with swabs. On 3/18/24 at 11:20 AM, Resident #1 was observed in her wheelchair at the nurses station. Her lips were noted to be covered with a white crusty covering with a white thick secretion noted. An interview on 3/19/24 at 2:40 PM, with the Director of Nursing (DON) confirmed the facility failed to ensure the resident's oral care was done as needed and therefore, the care plan was not followed. An interview with the Minimum Data Set (MDS) Registered Nurse (RN) #1 on 3/20/24 at 4:10 PM, revealed the care plan was to inform the staff of how to take care of the residents. She stated it was a guide for the staff to follow for the needed care of each resident and confirmed this care plan for oral care was not followed. Record review of Resident #1's Face Sheet revealed resident was admitted to the facility on [DATE]. Diagnoses included cerebral palsy, spastic quadriplegic cerebral palsy, convulsions, intellectual disabilities. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/26/24, revealed in Section GG for oral hygiene, this resident was dependent. Review of the Brief Interview for Mental Status (BIMS) score of 0 indicated the resident was severely cognitively impaired. 46013 Resident #13 Record review of the care plan with a problem onset date of 10/23/23, revealed Resident #13 requires total care with ADL needs due to immobility, chronic flexion contractures of all four extremities. An intervention was to provide with oral care every 2 hours and as needed with swabs, wipe his mouth after oral care and apply Vaseline to his lips. An observation on 03/18/24 at 10:45 AM and again at 12:15 PM, of Resident #13 revealed a large amount of thick, white dried substance on his upper and lower lips. An interview on 3/19/24 at 3:15 PM, the DON confirmed Resident #13 not having the proper oral care is not acceptable. She confirmed it is the responsibility of the CNA's on each shift to make sure the resident's lips and oral care are taken care of and the responsibility of the nurses to ensure the scopolamine patch is on to help reduce his oral secretions. An interview on 3/20 at 2:45 PM, MDS Nurse #1 revealed the care plan is developed to ensure staff knows how to take care of the individual needs of each resident. She revealed Resident #13's care plan was developed due to his excessive secretion buildup and for the staff to know he is to receive oral care every two (2) hours and as needed as it is written. She confirmed Resident #13's oral care plan was not being followed and it should have been. Record review of Resident #13's Care Plan with a problem onset date of 10/41/22 revealed I have dysphagia, I am NPO (nothing to eat or drink by mouth), I require PEG (Percutaneous Endoscopic Gastrostomy) tube for all nutrition and hydration, I am at risk for aspiration and other complications due to tube feeding. An intervention listed was PEG tube meds must be given individual. An observation of medication administration via PEG tube on 3/20/24 at 8:45 AM, revealed Licensed Practical Nurse (LPN) #1 crushed six tablet medications together and mixed those with one liquid medication and administered through PEG tube. Interview with the DON on 3/20/24 at 9:50 AM, confirmed that LPN #1 did not follow the physician order or the care plan and give each medication individually. An interview with the MDS RN #1 on 3/20/24 at 4:10 PM, revealed the care plan was to inform the staff of how to take care of the residents. She stated it was a guide for the staff to follow for the needed care of each resident and confirmed this care plan for PEG medication administration was not followed. Record review of Resident #13's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Convulsions, Gastrostomy status, Dysphagia, and Hemiplegia. Record review of MDS with ARD of 1/23/24 revealed a BIMS of 0 score which indicated the resident had severe cognitive impairment. 47874 Resident #26 Record review of Resident #26's Care Plans revealed, Problem Onset: 1/08/2024, I require extensive to total assistance with ADLs Approaches . Nail care to be done weekly on shower days . An observation of Resident #26 on 3/18/2024 at 11:16 AM, revealed her lying in bed with long nails on both hands measuring three-eights (3/8) inch in length. An observation and interview with the DON on 3/19/2024 at 2:25 PM confirmed Resident #26's long nails. An interview with MDS Nurse #1 on 3/20/2024 at 2:26 PM confirmed Resident #26's care plan was not followed for nail care weekly. She revealed the purpose of the care plan was to be able to provide the needed care for the residents. Record review of Resident #26's Face Sheet revealed the facility admitted the resident on 3/30/2022 with medical diagnoses that included Depression, Essential (primary) Hypertension, and Osteoarthritis. Resident #46 Record review of Resident #46's Care Plan with a problem onset date of 3/228/22 revealed, Problem/Need: .contracture to left hand .Approaches . Hand roll to Lt (left) hand during waking hours to prevent further contracture as resident will allow . An observation of Resident #46 on 03/18/2024 at 11:14 AM revealed him lying in bed awake. The resident was observed with paralysis to the left arm and contractures to the left fingers, with no device in use. An observation of Resident #46 on 3/19/2024 at 1:59 PM revealed him sitting in a wheelchair at the nurse's station. No device in place to the left hand. An interview and observation on 3/19/2024 at 2:10 PM with LPN #1 confirmed Resident #46 did not have a left hand roll in use. An interview with MDS Nurse #1 on 3/20/2024 at 2:29 PM confirmed Resident #46's care plan was not followed for applying the left hand roll. Record review of the Face Sheet revealed the facility admitted Resident #46 on 4/08/2022 with medical diagnosis that included Hemiplegia following cerebral infarction affecting the left nondominant side, Type 2 Diabetes Mellitus, Seizures, and Depression. Resident #216 Record review of Resident #216's Face Sheet revealed the facility admitted the resident on 2/21/2024 with medical diagnoses that included Hyperlipidemia, Chronic Systolic (congestive) Heart Failure, Type 2 Diabetes Mellitus, Vitamin D deficiency, and Paroxysmal Atrial Fibrillation. Record review of Resident #216's Electronic Medical Record (EMR) revealed there were not any care plans developed since admission. An interview with MDS Nurse #2 on 3/20/2024 at 9:49 AM, confirmed she had not developed comprehensive care plans for Resident #216. She explained they overlooked completing the admission MDS assessment; therefore, the care plans had not been developed. She revealed the staff would not know how to care for the resident since he did not have care plans. An interview with the DON on 3/20/2024 at 3:20 PM, revealed she was not aware Resident #216 did not have care plans. She revealed without the care plans, the staff would not know how to care for the resident. She confirmed the care plans should be completed within the time frame according to the Resident Assessment Instrument (RAI) guidelines.

Based on policy reviews, interviews, and record reviews the facility failed to implement approaches and interventions related to pain and control pain for one (1) of four (4) residents reviewed for care plans and pain management. Resident #1 Fndings include: Review of the facility policy and procedure titled Abuse Neglect and Exploitation dated 9/19/2022 revealed .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review of a statement on facility letterhead dated 5/16/23 and signed by the Administrator revealed,We do not have a policy on pain management. Record review of the Care Plan for Resident #1 revealed Problem Onset: 11/07/2022 I am at risk for Pain R/T (related to) DX (diagnosis) Chronic Pain Due, Osteoarthritis and Diabetic Neuropathy, Osteoporosis Goal & Target Date: My pain will be controlled by use of PRN (as needed) pain medication and non- pharmac (pharmacological) Approaches: Attempt non-pharmaceutical interventions, observe for sign and symptoms (S/S) adverse reactions . Contact physician as needed, Report any S/S of pain to nurse, Administer my pain medication as ordered, observe for effectiveness and s/e (side effects) of medication, Observe for worsening of resident's pain symptoms and report to physician. On 05/15/23 at 10:00 AM, the Ombudsman reported via a telephone interview that she had received a call from the family of Resident #1 on 03/11/2023. They wanted to issue concerns that the resident had been left sitting in a wheelchair in the dining room for hours after a fall in which the resident stated she thought her right hip was broken and that she was in pain. The family stated that an ambulance should have been called immediately after the fall and that Resident #1 should have been placed in the bed and given pain medications. The Administrator (ADM) revealed during an interview on 05/15/23 at 1:30 PM, that Resident #1 did complain of pain immediately after the fall. The family came to the facility and waited with the resident until the ambulance came to transport her to the emergency room (ER) for evaluation. During an interview on 05/15/23 at 3:00 PM, with Registered Nurse (RN) #2 that was working the first shift and came in at 7:00 AM immediately after Resident #1 had fallen, stated that she did not give any pain medications to Resident #1 on 03/11/23 and stated that she did not witness any pain medications given to the resident on 03/11/23 by the previous nurse who was leaving her shift at 7:00 AM. RN #2 stated that she did not call the physician or the Nurse Practitioner (NP) to obtain orders for pain medications. RN #2 confirmed that the resident did complain of pain, but the pain was mild at 7:00 AM and no orders were obtained for pain medications. The pain scale of 1-10 was used and Resident #1 stated at 7:00 AM that her pain was a 4 on the pain scale. RN #2 stated that she did not assess her pain again after the initial complaint of pain at 7:00 AM. On 05/15/23 at 3:15 PM, in an interview with Licensed Practical Nurse (LPN) #2 who was the medication nurse on first shift on 03/11/23, stated that Res #1 was sitting in her wheelchair in the dining room with two (2) daughters and one (1) son when they asked LPN #2 for some pain medication for Resident #1. LPN #2 stated that the resident was complaining of pain, and she told the family that all that was ordered for Resident #1 was Tylenol and that was all that she could give her. LPN #2 confirmed that she gave the Tylenol to the resident in the dining room while the resident was sitting in her wheelchair and the family watched her give the medication to the resident. LPN #2 stated that she documented that she gave Tylenol in the EMAR (Electronic Medication Administration Record). LPN #2 stated that she gave the resident two (2) 325 milligrams (mg) Tylenol because that was all that she had orders to give. The family expressed that they were tired of waiting and wanted the staff to call 911 and have an ambulance to take the resident to the ER for evaluation and x-ray because the resident was in pain During an interview on 05/15/23 at 3:30 PM, with Certified Nursing Assistant (CNA) #1 revealed that he was walking down the hall at shift change on Saturday morning at approximately a little before 7:00 AM when he passed Resident #1's room and saw her on the floor in front of her dresser. He turned around and went back to check on her and she stated that she had fallen. She stated her leg had given out and it was hurting. CNA #1 stated that he was not assigned to Res #1 that morning, but he immediately went and got the nurse and the CNA assigned to Resident #1. CNA #1, CNA #2, RN #1, and LPN #1 all went into the resident's room, and she told them all that her leg was hurting and that it had given way and she fell to the floor. CNA #1 stated that the right leg did look shorter than the left leg and when the nurse touched her, she stated that it hurt. CNA #1 stated that Resident #1 did verbalize pain to him and to the nurses. I did not see any medications given to Resident #1 after the fall on 03/11/23 at 6:50 AM. The resident did complain of pain in her leg while we were putting her in the wheelchair. On 05/15/23 at 4:10 PM,during an interview with RN #1, revealed that she was serving as the charge nurse on 03/11/23 on the 7:00 PM-7:00 AM shift on the weekends and confirmed Resident #1 did complain of pain and stated, I did not give her any pain medications and I did not obtain an order from the Nurse Practitioner for pain medications and to my knowledge there were no pain assessments documented for her on 3/11/23. In an interview on 05/15/23 at 4:25 PM, with the two (2) daughters of Resident #1 revealed that they along with their brother had all come to the facility to be with their mother after they were notified that she had a fall. Upon arriving at the facility at approximately 7:40 AM on 03/11/23 they found their mother sitting in the dining room in a wheelchair at the breakfast table and she was complaining of pain in her right hip and leg. Resident #1 told the family that she thought her right hip and leg may be broken and she was having pain. The daughter stated that Resident #1 was yelling out in pain as she sat in her wheelchair in the dining room. We asked the nurse if we could have pain medication given to her and the nurse told us she would give her some Tylenol and she left and never came back with the medication. The daughter stated that no pain medications were given to Resident #1 on 03/11/23 at the facility. They did not put her to bed, and they left her in a wheelchair calling out in pain and never gave pain medications. It was hurting her sitting up on that hip in that wheelchair. Interview on 05/16/23 at 10:30 AM, with the Director of Nurses (DON) revealed that the Res #1 should have had her pain assessed and monitored until she left the facility for the ER. We teach this in our employee training, but we have no written training records and no written policies and procedures for the monitoring of pain. We do not have any pain assessments on this resident, and we should have done them. The DON confirmed that the Standing Orders for pain medication of Tylenol was not given after the resident fell . DON confirmed that the MAR had not been documented on 03/11/23 for the administrating of pain medications to Resident #1. The DON confirmed that the resident's care plan was not followed for the pain management as outlined in her care plan. Record review of the facility Resident Incident Report dated 3/11/23 at 06:50 AM, revealed that the incident was Non-Witnessed. Type of Injury: Pain. Narrative of incident and description of injuries: (CNA #1) Reported resident was found sitting on floor in her room. No injuries noted resident has c/o (complaint of) pain to rt. (right) leg. Immediate Actions Taken: Resident was assessed for injuries and assisted up to wheelchair . Pain Scale: 4 Record review of the facility Departmental Notes dated 03/11/23 at 7:14 AM revealed, 0650- (CNA #1) reported to nurse that resident was found sitting on the floor in her room Has c/o (complaint of) pain to Rt (right) leg when touch or moved/lifted. Resident stated, that's the leg I hit when I fell . 0655-Fall with c/o rt. leg pain was reported to FNP- (Family Nurse Practitioner) . 0709-Fall with c/o rt. leg pain .3/11/2023 at 10:46 AM: Late charting for 9:07 AM: Resident had started yelling out in pain . Nursing note dated 3/11/2023 at 1:43 PM : Late charting for 8:20 AM . Resident had started yelling due to pain because she was lying on the affected side Record review of the undated facility Standing Orders revealed Pain: Tylenol 500 mg (milligrams) PO (by mouth) Q (every) 4HRS (hours) PRN (as needed). Notify Provider within 24 hours if pain persists or worsens. The facility did not implement the facility's standing orders for the PRN pain medications of Tylenol 500 mg PO Q 4 HRS PRN. Record review of the Emergency Department report dated 03/11/23 at 1009 revealed: RN/Triage Created: 3/11/23 1009 Last Entry: 1011 EMS (Emergency Medical Services) enroute with a 89 yo (year old) F (female) with fall. Additional Information: Fall, unwitnessed. C/O Right Hip pain 20ga(gauge) IV(intravenous) RAC (right antecubital). 100mcg (micrograms) fentanyl given. Pre-Hospital Care: Patient was not medicated for pain . HPI: Fall: Occurred at 2 hours ago. Fall from standing height onto floor approx.(approximately) 0 feet injuring RLE (right lower extremity) . Chief Complaint: Fall, leg pain HPI: Patient complaining of prior to arrival of the following symptoms: Patient presents the emergency room from nursing home . complaining of right hip leg pain no other evidence of trauma. 3/11/23 at 1151 doctor wrote: Provider Note: I reviewed x-ray finding fracture with family. Patient was given pain medications she has a right femoral neck fracture . Record review of the Face Sheet of Resident #1 revealed that she was admitted to the facility on [DATE] and was discharged on [DATE]. Resident #1 had diagnoses of Type I Diabetes, Alzheimer's Disease, Dementia unspecified severity and Poly osteoarthritis unspecified. Record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 03/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was unable to complete the interview.

Based on facility policy reviews, interviews, and record reviews the facility neglected to properly assess Resident #1 and manage pain after a fall with injury and delay of treatment for one (1) of four (4) residents reviewed for falls. Resident #1 Finding include: Review of the facility policy and procedure titled Abuse Neglect and Exploitation dated 9/19/2022 revealed .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . The facility provided on letterhead dated 5/16/23 a statement that read: We do not have a policy on lifting after a fall. signed by the facility Administrator (ADM). Record review of the facility policy Fall Prevention Program dated 11/10/2022 revealed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . 9. When any resident experiences a fall, the facility will: : a. Assess the resident. b. Complete a post -fall assessment. c. Complete an incident report. D. Notify physician and family f. Document all assessments and actions During a telephone interview on 05/15/23 at 10:00 AM, with the Ombudsman revealed that she had received a call from the family of Resident #1 on 03/11/2023. The family reported concerns of neglect and reported that the facility did not timely call for an ambulance to transport their mother to be evaluated and treated. The family did not think that the Resident should have been put in a wheelchair and taken to the dining room to eat breakfast while in pain and possibly with a fracture. The family stated that they had to insist that the facility call 911 after resident had been left sitting in a wheelchair in the dining room for hours after a fall in which the resident stated she thought her right hip was broken and that she was in pain. The family stated that an ambulance should have been called immediately after the fall and that Resident #1 should have been placed in the bed and given pain medications. In an interview on 03/15/23 at 1:30 P.M. with the Administrator (ADM) revealed that Resident #1 was severely cognitively impaired and had a Brief Interview for Mental Status (BIMS) score of 2 or 3. ADM stated that the resident was verbal and ambulatory without assistance and was able to verbalize to the staff that she had lost her balance and her leg gave way as she was standing at her dresser, and she fell to the floor. ADM stated that Resident #1 did complain of pain immediately after the fall and the staff called the family to report the fall and the family came to the facility and waited with the resident until the ambulance came to transport her to the emergency room (ER) for evaluation. The ADM stated that there was no local hospital near the facility and that there was no local ambulance service in the town where the facility was located. The ADM revealed that the town had a contract with neighboring towns ambulance services and the closest ambulance service was approximately 30 miles away and the closest ER for treatment of injuries was approximately 30 miles away. The ADM confirmed that the ambulance had to come from approximately 30 miles away to transport the resident to an ER which was another 30 or more miles away from the facility. The ADM revealed that the incident of the fall of Resident #1 occurred on 03/11/23 at approximately 7:00 AM during the change of shifts on a Saturday morning. Resident #1 did have an un-witnessed fall which resulted in a broken hip. Res #1 had hip surgery and spent three (3) nights in the hospital prior to her return to the facility on [DATE]. In an interview on 05/15/23 at 3:00 PM, with Registered Nurse (RN #2) who works the first shift on weekends 7:00 AM-7:00 PM, stated that she did not give any pain medications to Resident #1 on 03/11/23. RN #2 stated that she did not witness any pain medications given to Res #1 on 03/11/23 and RN #2 did not call the physician or the nurse practitioner (NP) to obtain orders for pain medications. RN #2 stated that the family came to the facility early on that Saturday morning of 03/11/23 shortly after they were contacted that the resident had fallen which was approximately 6:45 AM. The family (3-4 people) were at the facility with the resident, and they were upset that an ambulance had not been called to transport Resident #1. The on-call x-ray technician had been called to come do a bed-side portable x-ray, but she had not answered her phone and a voicemail message was left on her phone. At approximately 9:30 AM the x-ray technician called back to the facility, but the ambulance had been called to transport Res #1 to the ER for x-ray and evaluation. Res #1 did complain of pain, but the pain was mild at 7:00 AM and no orders were obtained for pain medications. The pain scale of 1-10 was used and Res #1 stated at 7:00 AM that her pain was a 4 on the pain scale. RN #2 stated that she did not reassess her pain after the initial complaint of pain at 7:00 AM. The ambulance was not called until approximately 9:00 AM on 03/11/23 after the family had requested that 911 be called. It took the ambulance approximately 20 minutes to arrive at the facility. The ambulance left the facility with Res #1 at approximately 9:32 AM. During an interview on 05/15/23 at 3:15 PM, with Licensed Practical Nurse (LPN) #2 she revealed she was the medication nurse on the 7 AM - 7 PM shift on 03/11/23. LPN#2 stated that the resident was sitting in her wheelchair in the dining room with two (2) daughters and one (1) son when they asked LPN #2 for some pain medication for Res #1. LPN#2 stated that she told the family that the only thing that was ordered for Res #1 was Tylenol and that was all that she could give Res #1. LPN #2 stated that Res #1 was complaining of pain and that she gave the Tylenol to Res #1 in the dining room while she sat in her wheelchair. LPN #2 stated that she documented the giving of the Tylenol in the EMAR (electronic Medication Administration Record). LPN #2 stated that she gave Res #1 two (2) 325 mg Tylenol because that was all that she had orders to give. LPN #2 stated that the family was insisting that the staff call an ambulance to transport Res #1 to the ER for an x-ray. LPN #2 stated that she had been told that the x-ray technician that was on call had not answered and the facility had left a message on the voicemail for a bedside x-ray. The family expressed that they were tired of waiting on the on-call x-ray technician to respond. The family wanted the staff to call 911 and have an ambulance to take Res #1 to the ER for evaluation and x-ray. An interview on 05/15/23 at 3:30 PM, with Certified Nursing Assistant (CNA) #1 revealed that he was walking down the hall at shift change on Saturday morning at approximately a little before 7:00 AM when he passed Res #1's room and saw her on the floor in front of her dresser. He turned around and went back to check on Res #1 and she stated that she had fallen, and her leg had given out and it was hurting. CNA #1 stated that he was not assigned to Res #1 that morning, but he immediately went and got the nurse and the CNA assigned to Res #1. CNA #1 and CNA #2, RN #1 and LPN #1 all went into Resident #1's room, and she told them all that her leg was hurting and that it had given way and she fell to the floor. CNA #1 stated that the right leg did look shorter than the left leg and when the nurse touched her, she stated that it hurt. CNA #1 stated that the resident did verbalize pain to him and to the nurses. He said the Charge Nurse (RN#1) told us to pick up Res #1 off the floor and place her in her wheelchair and push her to the dining room for breakfast. I did not see any medications given to Res #1 after the fall on 03/11/23 at 6:50 AM. I left the facility at 7:00 AM on 3/11/23. We physically picked the resident up off of the floor and placed her in a wheelchair at the request of the charge nurse RN #1 and took her to the dining room. CNA #1 confirmed that Resident #1 did complain of pain while we were putting her in the wheelchair. We did not use a lift to pick the resident up off the floor. In an interview on 05/15/23 at 4:10 PM, with RN #1 stated that she was the charge nurse on 03/11/23 on the 7:00 PM-7:00 AM shift. She confirmed that they picked up Res #1 off the floor and did not use a lift. They put Resident #1 in a wheelchair and took her to the dining room so there would be eyes on her. I did not want to leave her (Res #1) alone in her room after the fall because I thought that there was too much going on during shift change and she may try to get up again if she was left alone. Things were very busy at the change of shift. RN#1 confirmed that the resident sat in a wheelchair in the dining room at the breakfast table. Her family was contacted, and 3-4 family members came to the facility to be with her at approximately 7:45 AM. RN#1 stated that Resident #1 did complain of pain and stated, I did not give her any pain medications and I did not obtain an order from the NP for any pain medications. RN#1 stated, To my knowledge there were no pain assessments documented for the resident on 3/11/23. In an interview on 05/15/23 at 4:25 PM, with the two (2) daughters of Resident #1 revealed that they along with their brother had all come to the facility to be with their mother after they were notified that she had a fall. Upon arriving at the facility at approximately 7:40 AM on 03/11/23, they found her sitting in the dining room in a wheelchair at the breakfast table and she was complaining of pain in her right hip and leg. The nurse told the children that they were going to get an x-ray but that the clinic did not open until 10:00 AM and they were waiting for the x-ray person to arrive at the clinic to get the x-ray at that time. Resident #1 told the family that she thought her right hip and leg may be broken and she was having pain. The daughter stated that she was yelling out in pain as she sat in her wheelchair, and we all thought that she should be in her bed lying down and not sitting up. She was asking us to please put her in the bed. We asked the nurse if we could have pain medication given to her and the nurse told us she would give her some Tylenol and she left and never came back with the medication. The daughter confirmed no pain medications were given to Res #1 on 03/11/23 at the facility while the family was there. We asked if we could put her in her bed and the nurse told us she needed to sit up and wait for the x-ray. We waited until after 9:00 AM and nothing was done for our mother so we asked if they could call 911 and have her sent to for x-ray and evaluation. We all were not happy with how little consideration the staff gave her and they did not put her to bed. They left her in a wheelchair crying out in pain and never gave her any pain medications. We do not want to get anyone in trouble, but we do not think that any resident should be treated with such disregard. We want proper procedures to be executed for all residents and no one deserved to be treated like they treated our mother. We finally took her to her room, and we put her to bed where she was requesting to be placed. It was hurting her sitting up on that hip in that wheelchair. When we got to the ER, we found that our mother had a broken right hip, and she went to surgery the next day. We also do not feel that the facility gave us an explanation of how the entire incident occurred. The facility did nothing to address her pain after the fall. She should never be placed in a wheelchair to sit on a broken hip. During an interview on 05/16/23 at 10:30 AM, with the Director of Nurses (DON) revealed that Resident #1 should not have been physically picked up off the floor and placed in a wheelchair. She should have been placed in bed and assessed. The DON stated that Resident #1 should have been put in the bed and her pain should have been assessed and monitored until she left the facility for the ER. We teach this in our employee training, but we have no written training records and no written policies and procedures for the monitoring of pain. We do not have any pain assessments on this resident, and we should have done them. The DON confirmed that the Standing Orders for pain medication of Tylenol was not given after Resident #1 fell and confirmed that the Medication Administration Record (MAR) had not been documented on 03/11/23 for the administrating of pain medications to Resident #1. On 05/16/23 at 12:20 PM, in an interview with the NP she revealed that she does not recall the details of the incident with Resident #1 on 03/11/23 but she does remember that she was asked if they could get a bed side portable x-ray ordered. NP stated that this was early on a Saturday morning when she was called, and she does not have any notes from the call, so she does not recall the details. The details of Resident #1's pain were not relayed to the NP by the facility staff, and she confirmed that the Standing Orders should have been implemented and the nurses at the facility could have called for an ambulance or for additional orders as soon as the fall occurred. On 05/16/23 at 2:30 PM, an interview with CNA #2, revealed that she was assigned to Res #1 on the third shift on 03/11/23. She was on her way out of the facility when she was notified that one of her assigned residents had fallen. Upon entering the room there were two (2) nurses and another CNA (CNA #1) in the room with Res #1 on the floor. The nurse told them to pick up the resident and put her in the wheelchair and take her to the dining room to eat breakfast. CNA #2 did not witness the fall of Res #1 and she did not witness any pain assessments or pain medications given to Res #1. Record review of the facility Resident Incident Report dated 3/11/23 at 06:50 AM, revealed that the incident was Non-Witnessed Type of Injury: Pain. Narrative of incident and description of injuries: (CNA #1) Reported resident was found sitting on floor in her room. No injuries noted resident has c/o (complaint of) pain to rt. (right) leg. Immediate Actions Taken: Resident was assessed for injuries and assisted up to wheelchair . Pain Scale: 4 .Family notified, and Nurse Practitioner notified 3/11/23. Exam by Physician: No. Taken to Hospital: No. Report prepared by RN#1. Record review of the facility Departmental Notes dated 03/11/23 at 7:14 AM revealed, 0650- (CNA #1) reported to nurse that resident was found sitting on the floor in her room. Resident reported that she did fall, she stated My Leg gave out, resident was assessed for injuries. Has c/o (complaint of) pain to Rt (right) leg when touch or moved/lifted. Resident stated, that's the leg I hit when I fell . 0655-Fall with c/o rt. leg pain was reported to FNP- (Family Nurse Practitioner) Order was obtained for x-ray of RT/hip/leg. 0709-Fall with c/o rt. leg pain was reported to son -he was informed that x-ray was ordered. Nurses note signed by the third shift Charge Nurse (RN #1). The nursing note 3/11/23 9:32 AM Leaving via ambulance to ER for eval and treatment. Signed by the first shift Charge Nurse (RN #2). 3/11/2023 9:50 AM Called report to ER. Signed by (RN#2). The nursing note dated 3/11/2023 at 10:46 AM read: Late charting for 9:07 AM: Resident had started yelling out in pain, radiology not available at this time. Family agreed that this nurse should call 911. Called FNP and received order to call (EMS) Emergency Management Services. Signed by (RN #2). Nursing note dated 3/11/2023 at 1:43 PM Late charting for 8:20 AM: Resident sitting up in wheelchair in the dining room and has eaten breakfast with her family. Family then transported resident back to her room in her wheelchair. Asked by her son and CNA if she should go to bed. This nurse advised against putting her back to bed due to resident needed an x-ray of her right hip, right femur and right knee. Came back to check on resident later and family member had put her in bed. Resident had started yelling due to pain because she was lying on the affected side. This nurse then called FNP to get order to send resident to the ER. Signed by RN#2. Record review of the Electronic Medication Administration Record (eMAR) for March 2023 revealed no documentation that Resident #1 had not been given pain medications on 03/11/23 including Tylenol from the Standing Orders. Record review of the undated facility Standing Orders revealed Pain: Tylenol 500 mg (milligrams) PO (by mouth) Q (every) 4HRS (hours) PRN (as needed). Notify Provider within 24 hours if pain persists or worsens. The facility did not implement the facility's standing orders for the PRN pain medications of Tylenol 500 mg PO Q 4 HRS PRN. Record review of the Emergency Department report dated 03/11/23 at 1009 revealed: RN/Triage Created: 3/11/23 1009 Last Entry: 1011 EMS (Emergency Medical Services) enroute with a 89 yo (year old) F (female) with fall. Additional Information: Fall, unwitnessed. C/O Right Hip pain. Denies LOC (loss of consciousness), no blood thinners. Alert but confused. 20ga(gauge) IV(intravenous) RAC (right antecubital). 100mcg (micrograms) fentanyl given. FSBG( Fingerstick blood glucose) 203. Emergency Alert: Alert Called: Pre-Hospital Care: Patient was not medicated for pain . HPI: Fall: Occurred at 2 hours ago. Fall from standing height onto floor approx.(approximately) 0 feet injuring RLE (right lower extremity) . Chief Complaint: Fall, leg pain HPI: Patient complaining of prior to arrival of the following symptoms: Patient presents the emergency room from nursing home and apparently an unwitnessed fall confused at baseline with dementia but complaining of right hip leg pain no other evidence of trauma. 3/11/23 at 1151 doctor wrote: Provider Note: I reviewed x-ray finding fracture with family. Patient was given pain medications she has a right femoral neck fracture I consulted orthopedics. Patient will be admitted to the hospital service . Record review of the Face Sheet of Resident #1 revealed that she was admitted to the facility on [DATE] and was discharged on [DATE]. Resident #1 had diagnoses of Type I Diabetes, Alzheimer's Disease, Dementia unspecified severity and Poly osteoarthritis unspecified. Record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 03/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was unable to complete the interview. The record review of the nursing notes for 03/11/2023 documented that Res #1 was found on the floor of her room at 6:50 AM and she complained of pain upon discovery at 6:50 AM and Resident was yelling out in pain at 9:07 AM. The record review of the nursing notes revealed that the nursing staff did not address Res #1's pain upon her first complaint at 6:55 AM or assess and address Res #1's pain at 9:07 AM when she began yelling out in pain. There was no written documentation that the facility staff had given Res #1 Tylenol as per the facility's Standing Physician's Orders. The facility did not assess or provide pain management for Res #1's voiced pain from 0650-9:32 AM which was a minimum of two (2) hours and 42 minutes prior to leaving in the ambulance to travel 30 plus miles away to the emergency room (ER). The facility neglected to obtain an order for pain management for Res #1. The record review also revealed that the facility nursing staff placed Res #1 in a wheelchair to sit rather than place her in the bed for assessment and there was no pain management issued for Res #1. The record review documented that Res #1 was voicing pain for over two hours, and the staff did not obtain orders for pain management. The record review of the ER reports dated 3/11/23 confirmed that (Res #1) was not medicated or given pain medications prior to leaving the nursing home for evaluation at the ER. The ER reported that Resident #1 was complaining of right hip and leg pain at the nursing home following the unwitnessed fall. The ER report confirmed that the resident had a fracture of the right hip and leg and that pain medications were given.

Based on facility policy reviews, interviews, and record reviews the facility failed to treat pain for Resident #1 after a fall with vocalization of pain. The facility did not assess or provide pain management for the resident after voiced pain from 6:50-9:32 AM which was a minimum of two (2) hours and 42 minutes prior to leaving in the ambulance to travel 30 plus miles away to the emergency room (ER). Resident #1 was one (1) of four (4) residents reviewed for pain management. Findings include: Review of the facility policy and procedure titled Abuse Neglect and Exploitation dated 9/19/2022 revealed .Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress . Record review of a typed statement on letterhead dated 5/16/23 and signed by the Administrator (ADM) revealed, We do not have a policy on pain management. Record review of the facility policy Fall Prevention Program dated 11/10/2022 revealed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls . 9. When any resident experiences a fall, the facility will: : a. Assess the resident. b. Complete a post -fall assessment. c. Complete an incident report. D. Notify physician and family f. Document all assessments and actions Interview on 05/15/23 at 10:00 AM, with the Ombudsman via telephone revealed that she had received a call from the family of Resident #1 on 03/11/2023. The family reported that they wanted to issue concerns of neglect and report that the facility did not timely call for an ambulance to transport the resident to be evaluated and treated. The family did not think that the Resident should have been put in a wheelchair and taken to the dining room to eat breakfast while in pain and possibly with a fracture. The family stated that they had to insist that the facility call 911 after the resident had been left sitting in a wheelchair in the dining room for hours after a fall in which the resident stated she thought her right hip was broken and that she was in pain. The family stated that an ambulance should have been called immediately after the fall and that Resident #1 should have been placed in the bed and given pain medications. Interview on 05/15/23 at 1:30 PM, with the ADM stated that Resident #1 was severely cognitively impaired and had a Brief Interview for Mental Status( BIMS) score of two (2) or three (3). ADM stated that the resident was verbal and ambulatory without assistance. She was able to verbalize to the staff that she had lost her balance and her leg gave away as she was standing at her dresser, and she fell to the floor. The ADM stated that Resident #1 did complain of pain immediately after the fall. The staff called the family to report the fall and the family came to the facility and waited with the resident until the ambulance came to transport her to the emergency room (ER) for evaluation. The ADM confirmed that there was no local hospital or local ambulance service near the facility. The ADM confirmed that the town had a contract with the neighboring town for ambulance services and the closest ambulance service was approximately 30 miles away and the closest ER for treatment of injuries was approximately 30 miles away. The ADM confirmed that the incident of the fall for Resident #1 occurred on 03/11/23 at approximately 7:00 AM during the change of shifts on a Saturday morning. Resident #1 did have an un-witnessed fall which resulted in a femoral fracture of the hip and that the resident had hip surgery at the hospital on 03/12/23. Resident #1 spent three (3) nights in the hospital prior to her return to the facility on [DATE]. Interview on 05/15/23 at 3:00 PM, with Registered Nurse (RN) #2 that was working the first shift and came in at 7:00 AM immediately after Resident #1 had fallen, stated that she did not give any pain medications to Resident #1 on 03/11/23 and stated that she did not witness any pain medications given to the resident on 03/11/23 by the previous nurse who was leaving her shift at 7:00 AM. RN #2 stated that she did not call the physician or the Nurse Practitioner (NP) to obtain orders for pain medications. RN #2 stated that the family came to the facility early on that Saturday morning of 03/11/23 shortly after they were contacted that Resident #1 had fallen at approximately 6:45 AM. The on-call x-ray technician had been called to come do a bedside portable x-ray. At approximately 9:30 AM the x-ray technician called back to the facility, but the ambulance had been called to transport the resident to the ER for x-ray and evaluation. RN #2 confirmed that the resident did complain of pain, but the pain was mild at 7:00 AM and no orders were obtained for pain medications. The pain scale of 1-10 was used and Resident #1 stated at 7:00 AM that her pain was a 4 on the pain scale. RN #2 stated that she did not assess her pain again after the initial complaint of pain at 7:00 AM. Interview on 05/15/23 at 3:15 PM, with Licensed Practical Nurse (LPN) #2 who was the medication nurse on first shift for 03/11/23. LPN #2 stated that Res #1 was sitting in her wheelchair in the dining room with two (2) daughters and one (1) son when they asked LPN #2 for some pain medication for Resident #1. LPN #2 stated that the resident was complaining of pain, and she told the family that all that was ordered for Resident #1 was Tylenol and that was all that she could give her. LPN #2 confirmed that she gave the Tylenol to the resident in the dining room while the resident was sitting in her wheelchair and the family watched her give the medication to the resident. LPN #2 stated that she documented that she gave Tylenol in the EMAR (Electronic Medication Administration Record). LPN #2 stated that she gave the resident two (2) 325 milligrams (mg) Tylenol because that was all that she had orders to give. LPN #2 stated that the family was insisting that the staff call an ambulance to transport Resident #1 to the ER for an x-ray. LPN #2 confirmed that she had been told that the x-ray technician that was on call had not answered and the facility had left a message on the voicemail for a bedside portable x-ray but that they had not arrived at the facility yet at this point. The family expressed that they were tired of waiting on the on-call x-ray technician to respond and wanted the staff to call 911 and have an ambulance to take the resident to the ER for evaluation and x-ray because the resident was in pain. Interview on 05/15/23 at 3:30 PM, with Certified Nursing Assistant (CNA) #1 revealed that he was walking down the hall at shift change on Saturday morning at approximately a little before 7:00 AM when he passed Resident #1's room and saw her on the floor in front of her dresser. He turned around and went back to check on her and she stated that she had fallen. She stated her leg had given out and it was hurting. CNA #1 stated that he was not assigned to Res #1 that morning, but he immediately went and got the nurse and the CNA assigned to Resident #1. CNA #1, CNA #2, RN #1, and LPN #1 all went into the resident's room, and she told them all that her leg was hurting and that it had given way and she fell to the floor. CNA #1 stated that the right leg did look shorter than the left leg and when the nurse touched her, she stated that it hurt. CNA #1 stated that Resident #1 did verbalize pain to him and to the nurses. The Charge Nurse told us to pick the resident up off the floor and place her in her wheelchair and push her to the dining room for breakfast. I did not see any medications given to Resident #1 after the fall on 03/11/23 at 6:50 AM. I left the facility at 7:00 AM on 3/11/23 and I have not worked at the facility since 03/24/23. We physically picked the resident up off the floor and placed her in a wheelchair at the request of the charge nurse RN #1 and the resident did complain of pain in her leg while we were putting her in the wheelchair. CNA #1 confirmed that they did not use a lift to pick her up off the floor. Interview on 05/15/23 at 4:10 PM, with RN #1 revealed that she was serving as the charge nurse on 03/11/23 on the 7:00 PM-7:00 AM shift on the weekends and confirmed that they picked Resident #1 up off the floor and did not use a lift. They put Resident #1 in a wheelchair and took her to the dining room so there would be eyes on her. I did not want to leave her (Res #1) alone in her room after the fall because I thought that there was too much going on during shift change and she may try to get up again if she was left alone. Things were very busy at the change of shift. RN #1 confirmed that the resident sat in a wheelchair in the dining room at the breakfast table and her family was contacted and they came to the facility to be with the resident at approximately 7:45 AM. Resident #1 did complain of pain and stated, I did not give her any pain medications and I did not obtain an order from the Nurse Practitioner for pain medications. An order was placed for an in-house x-ray. The neurological assessments were completed by the first shift nurse (RN#2) and to my knowledge there were no pain assessments documented for her on 3/11/23. Interview on 05/15/23 at 4:25 PM, with the two (2) daughters of Resident #1 revealed that they along with their brother had all come to the facility to be with their mother after they were notified that she had a fall. Upon arriving at the facility at approximately 7:40 AM on 03/11/23 they found their mother sitting in the dining room in a wheelchair at the breakfast table and she was complaining of pain in her right hip and leg. The nurse told us that they were going to get an x-ray but that the clinic did not open until 10:00 AM and they were waiting for the x-ray person to arrive to get the x-ray at that time. Resident #1 told the family that she thought her right hip and leg may be broken and she was having pain. The daughter stated that Resident #1 was yelling out in pain as she sat in her wheelchair in the dining room. We all thought that she should be in her bed lying down and not sitting up and she was asking us to please put her in the bed. We asked the nurse if we could have pain medication given to her and the nurse told us she would give her some Tylenol and she left and never came back with the medication. The daughter stated that no pain medications were given to Resident #1 on 03/11/23 at the facility. We asked if we could put her in her bed and the nurse told us she needed to sit up and wait for the portable x-ray. We waited until after 9:00 AM and nothing was done for our mother, so we asked if they could call 911 and have her sent to the hospital for x-ray and evaluation. We all were not happy with how little consideration the staff gave our mother. They did not put her to bed, and they left her in a wheelchair calling out in pain and never gave pain medications. We do not want to get anyone in trouble, but we do not think that any resident should be treated with such disregard. We want proper procedures to be executed for all residents and no one deserves to be treated like they treated our mother. We finally took our mother to her room, and we put her to bed where she was requesting to be placed. It was hurting her sitting up on that hip in that wheelchair. When we got to the ER, we found that she had a broken right hip, and she went to surgery the next day on a Sunday. We also do not feel that the facility gave us an explanation of how the entire incident occurred. The facility neglected to properly care for her after the fall and they should never place her in a wheelchair to sit on a broken hip. Interview on 05/16/23 at 10:30 AM, with the Director of Nurses (DON) revealed that Res #1 should not have been bodily picked up off the floor and placed in a wheelchair. DON stated that the Res #1 should have been put in the bed and her pain should have been assessed and monitored until she left the facility for the ER. We teach this in our employee training, but we have no written training records and no written policies and procedures for the monitoring of pain. We do not have any pain assessments on this resident and we should have done them. The DON confirmed that the Standing Orders for pain medication for Tylenol was not given after the resident fell . The DON confirmed that the MAR had not been documented on 03/11/23 for the administration of pain medications to Resident #1. Interview on 05/16/23 at 12:20 PM, with the NP revealed that she does not recall the details of the incident with the resident on 03/11/23 but she does remember that she was asked if they could get a bed side portable x-ray ordered because the resident had fell . The NP stated that this was early on a Saturday morning when she was called, and she does not have any notes from the call, so she does not recall the details. The NP confirmed that the facility did not let her know that the resident was in pain, or she would have given them an order to treat the pain. The NP stated that the Standing Orders should have been implemented and the nurses at the facility could have called for an ambulance or for additional orders as soon as the fall occurred. Interview on 05/16/23 at 2:30 PM with CNA #2, revealed that she was assigned to the resident on the third shift (11-7) on 03/11/23. She stated that she was on her way out of the facility when she was notified that one of her assigned residents had fallen. Upon entering the room there were (2) nurses and CNA #1 in the room with Resident#1 and she was on the floor. The nurse told them to pick up the resident and put her in the wheelchair and take her to the dining room to eat breakfast. CNA #2 did not witness the fall of Resident #1 and she did not witness any pain assessments or pain medications given to resident. CNA #2 stated that she had never had a resident to fall during her shift prior to this fall on 3/11/23. CNA #2 stated that a lift should be used for picking the resident up after a fall, but they picked her up according to the charge nurse's (RN #1) instructions. Record review of the facility Resident Incident Report dated 3/11/23 at 06:50 AM, revealed that the incident was Non-Witnessed Type of Injury: Pain. Narrative of incident and description of injuries: (CNA #1) Reported resident was found sitting on floor in her room. No injuries noted resident has c/o (complaint of) pain to rt. (right) leg. Immediate Actions Taken: Resident was assessed for injuries and assisted up to wheelchair . Pain Scale: 4 .Family notified, and Nurse Practitioner notified 3/11/23. Exam by Physician: No. Taken to Hospital: No. Report prepared by RN#1. Record review of the facility Departmental Notes dated 03/11/23 at 7:14 AM revealed, 0650- (CNA #1) reported to nurse that resident was found sitting on the floor in her room. Resident reported that she did fall, she stated My Leg gave out, resident was assessed for injuries. Has c/o (complaint of) pain to Rt (right) leg when touch or moved/lifted. Resident stated, that's the leg I hit when I fell . 0655-Fall with c/o rt. leg pain was reported to FNP- (Family Nurse Practitioner) Order was obtained for x-ray of RT/hip/leg. 0709-Fall with c/o rt. leg pain was reported to son -he was informed that x-ray was ordered. Nurses note signed by the third shift Charge Nurse (RN #1). The nursing note 3/11/23 9:32 AM Leaving via ambulance to ER for eval and treatment. Signed by the first shift Charge Nurse (RN #2). 3/11/2023 9:50 AM Called report to ER. Signed by (RN#2). The nursing note dated 3/11/2023 at 10:46 AM read: Late charting for 9:07 AM: Resident had started yelling out in pain, radiology not available at this time. Family agreed that this nurse should call 911. Called FNP and received order to call (EMS) Emergency Management Services. Signed by (RN #2). Nursing note dated 3/11/2023 at 1:43 PM Late charting for 8:20 AM: Resident sitting up in wheelchair in the dining room and has eaten breakfast with her family. Family then transported resident back to her room in her wheelchair. Asked by her son and CNA if she should go to bed. This nurse advised against putting her back to bed due to resident needed an x-ray of her right hip, right femur and right knee. Came back to check on resident later and family member had put her in bed. Resident had started yelling due to pain because she was lying on the affected side. This nurse then called FNP to get order to send resident to the ER. Signed by RN#2. Record review of the Electronic Medication Administration Record (eMAR) for March 2023 revealed no documentation that Resident #1 had not been given pain medications on 03/11/23 including Tylenol from the Standing Orders. Record review of the undated facility Standing Orders revealed Pain: Tylenol 500 mg (milligrams) PO (by mouth) Q (every) 4HRS (hours) PRN (as needed). Notify Provider within 24 hours if pain persists or worsens. The facility did not implement the facility's standing orders for the PRN pain medications of Tylenol 500 mg PO Q 4 HRS PRN. Record review of the Emergency Department report dated 03/11/23 at 1009 revealed: RN/Triage Created: 3/11/23 1009 Last Entry: 1011 EMS (Emergency Medical Services) enroute with a 89 yo (year old) F (female) with fall. Additional Information: Fall, unwitnessed. C/O Right Hip pain. Denies LOC (loss of consciousness), no blood thinners. Alert but confused. 20ga(gauge) IV(intravenous) RAC (right antecubital). 100mcg (micrograms) fentanyl given. FSBG( Fingerstick blood glucose) 203. Emergency Alert: Alert Called: Pre-Hospital Care: Patient was not medicated for pain . HPI: Fall: Occurred at 2 hours ago. Fall from standing height onto floor approx.(approximately) 0 feet injuring RLE (right lower extremity) . Chief Complaint: Fall, leg pain HPI: Patient complaining of prior to arrival of the following symptoms: Patient presents the emergency room from nursing home and apparently an unwitnessed fall confused at baseline with dementia but complaining of right hip leg pain no other evidence of trauma. 3/11/23 at 1151 doctor wrote: Provider Note: I reviewed x-ray finding fracture with family. Patient was given pain medications she has a right femoral neck fracture I consulted orthopedics. Patient will be admitted to the hospital service . Record review of the Face Sheet of Resident #1 revealed that she was admitted to the facility on [DATE] and was discharged on [DATE]. Resident #1 had diagnoses of Type I Diabetes, Alzheimer's Disease, Dementia unspecified severity and Poly osteoarthritis unspecified. Record review of the Minimum Data Set with an Assessment Reference Date (ARD) of 03/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was unable to complete the interview.

CI MS # *****After Administrative Review with CMS, the Scope and Severity of this deficiency was amended to a J level. ****** Based on review of facility policy, review of staffing assignment sheets, staff posting from 7/01/18 to 7/30/18, and Staff interviews, the facility failed to employ and ensure that sufficient direct care staff are available to meet resident needs. The staffing issue had been addressed through the Quality Assurance Committee repeatedly from (YEAR), due to two (2) citations from the State Agency, on Annual and Complaint Surveys. The lack of sufficient staff had the potential to affect care and supervision for 56 of 56 residents currently in the facility. Staffing had a direct effect on Resident #1, who exited the facility on 7/21/18, unsupervised, after multiple attempts to exit the facility. Staff were not available to redirect the resident from the front door. Findings Include: The facility policy and procedure titled, Nursing Service Staffing Pattern dated 7/25/02, and reviewed 5/10/18, by the Director of Nursing (DON), documented: The staffing pattern for the facility is as follows: One (1) Registered Nurse (RN) to serve as DON One (1) RN charge nurse on 7-3 shift One (1) RN/LPN (Licensed Practical Nurse) as Medical Records (MR) Nurse One (1) LPN or RN charge nurse on 3-11 shift One (1) RN charge nurse on 11-7 shift One (1) or two (2) LPN's on 11-7 shift with RN available if needed Two (2) LPN's 7-3 and two (2) LPN's 3-11 shift Seven (7) CNAs 7-3 shift each day Six (6) CNAs 3-11 shift each day (Added: 5-6 CNAs on 3-11) Four (4) CNAs 11-7 shift each day An extra CNA may be called to work upon the approval of the Director of Nurses if the safety or increased need of residents warrants extra help. (Added: All staffing is based on the census of the facility.) The policy noted: Sufficient nursing personnel shall be assigned and on duty to assure safe and effective nursing care so that at least the following conditions are met: 1. Residents are provided with safe and efficient nursing care. 2. Residents receive appropriate nursing intervention in response to physical and behavioral/emotional conditions. 3. Residents receive all treatments, medications and diets as prescribed. 4. Residents are provided with rehabilitative and supportive nursing care as needed. 5. Residents are provided with proper care with regards to immobilization . 6. Residents are kept comfortable, clean, neat, well groomed, protected from accident, injury, infection, and receive assistance as needed with daily hygiene. 7. The resident's family is involved in the training for residents self care as appropriate. The policy noted: Staffing is based on a written plan that considers the needs of the resident population in determining the composition of nursing staff. In order to provide 24 hour nursing coverage, provisions are made for relief personnel during vacation periods, sick leave and emergencies, by using part time personnel for call in. Review of the annual survey of 7/18/17, revealed the facility was cited for failure to meet staffing requirements for four (4) of 14 days. Review of a complaint survey of 5/15/18, revealed the facility failed to meet staffing requirements for three (3) of the five (5) days reviewed in a 14 day period. Review of the staffing assignment sheets and interview with the DON on 7/30/18 at 7:53 AM, revealed there were actually 22 of 28 days reviewed from 7/01/18 to 7/28/18, that she didn't have five (5) CNAs on the 7-3 and/or 3-11 shifts. She stated the facility also used Agency nurses and CNAs and she still couldn't meet the staffing numbers. She further revealed she had multiple CNA and Nursing positions open to fill and she didn't always have three (3) CNAs on the 11-7 shift. Eight (8) days were specifically reviewed and revealed the following: 7/06/18- 1st and 2nd shift only had four (4) CNAs who worked and normally five (5) are scheduled. 7/09/18 - 1st shift only had three (3) CNAs working 7/16/18- 2nd shift had three (3) CNAs working 7/18/18 - 1st shift had two (2) CNAs working (1:27 ratio) 7/22/18 - 1st and 2nd shift had three (3) CNAs on each shift (1:18 ratio) 7/24/18 - 1st shift four (4) CNAs worked (1:13.5 ratio) 7/25/18 - 1st shift four (4) CNAs worked 7/27/18- 3rd shift two (2) CNAs worked The DON was asked if these dates there were staff shortages. She replied, Yes. She stated that she normally scheduled five (5) CNAs for 1st and 2nd shift, and three (3) CNAs for 3rd shift. She stated that she had been unable to even give staff days off for vacation, and even with the Agency staff, there was still not enough help to meet the staffing numbers. Review of a facility report, faxed to the State Agency on 7/26/18, revealed Resident #1 eloped from the facility on 7/21/18 at 8:58 AM, and was located by local citizens, 100 yards from the facility at a local service station. The resident had been asking to go to the beauty shop that morning and had been looking out the front door. The resident had been redirected from the door. The facility report concluded that there had been visitors at the facility and as they exited, the resident exited the door prior to the door shutting and locking. Documentation included a handwritten note, signed by RN #1 on 7/21/18, noting that Resident #1 had gone to the front door multiple times attempting to get out and was redirected. The RN documented that both LPNs were doing medication pass and she was making arrangements for getting another resident an X-ray. She documented that everyone was away from the desk when the Coroner called, asking if there was anyone missing from the facility; there was an older lady walking down the road. Review of staffing sheets revealed on 7/21/18, there was one (1) RN, two (2) LPNs and four (4) CNAs for 56 residents on the day shift when Resident #1 eloped. The Person Per Day (PPD) for 7/21/18 was 2.510. The minimum state requirement is 2.80 PPD. Review of the facility Quality Assurance/Performance Improvement (QA/PI) Committee Meeting and topics discussed revealed for 4/19/18, (discussion related to staffing- several open positions), 5/21/18 (survey Complaint related to low staffing), 7/03/18 (Staffing number of open positions to fill), and 7/23/18 (Resident Elopement, Staffing number of positions open to fill). On 7/28/18, three (3) alert and oriented residents were interviewed in confidence. During these interviews, they revealed that the previous night there were only two (2) CNAs to try to meet their needs. They reported that staffing is frequently short and the residents needed a lot of care. Multiple confidential staff interviews, from 7/28/18 to 7/30/18, revealed that all shifts were frequently short of CNAs and that most of the facility staff were actively seeking employment elsewhere. On 8/02/18 around 3:30 PM, the Chief Executive Officer (CEO)/Hospital Administrator, who also manages the facility, was interviewed regarding his involvement in the nursing home facility and assistance with meeting the nursing home staffing needs. He revealed he didn't attend the nursing home Quality Assurance (QA) meetings. When asked how the he assisted with the staffing shortages he further revealed that there had been ads placed in the local paper, hospital job site, and the state nursing home site. When stressing that the nursing home had been repeatedly cited for staffing shortages, he stated that he felt that the problems were not just related to the salary. The Human Resources Director of the hospital was interviewed, with the CEO/Hospital Administration present at this time, and she confirmed she ran ads in the local paper (weekly) for two (2) weeks from 05/31/17 to 06/13/17, which was two ads, and that the hospital job site and nursing home site had ads. When asked on 8/03/18 at 9:12 AM, what she'd done more recently, she replied there were four (4) potential employees she was waiting on background checks. She confirmed she had not listed any ads in papers outside the small community and that she was relisting the ad in the local paper, which was a weekly paper. The lack of involvement in the nursing home QA, assistance in determining the reason for staff hiring and retention, and putting additional emphasis/interventions in place by the Hospital Administrator, rendered the nursing home ineffective in providing sufficient nursing staff to fully meet the needs of the residents served.

CI MS Based on observation, interview, record review and policy review, the facility failed to initiate and implement a plan of care for one (1) of eight (8) residents reviewed, Resident #1. Resident #1 was admitted to the Behavioral Health Unit for refusing medications and attempts to leave the facility. Upon return to the facility, on 6/13/18, staff did not re-assess the resident's elopement risk and ensure a plan of care was developed and implemented to prevent elopement (leaving the facility unsupervised). Resident #1 left the faciity on [DATE], without supervision and staff knowledge, and was two/tenths (2/10) of a mile from the facility, which is located on a busy main highway, when seen by local citizens and returned to the facility. The failure to develop and implement a care plan for Resident #1, a demented resident who had prior attempts to leave the facility, placed this and other residents at risk for elopement in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ), which began on 7/21/18, when Resident #1 left the facility unsupervised and without staff knowledge. On 7/31/18 at 1:30 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 08/02/18, in which the facility alleged removal of the IJ on 8/3/18. The SA validated the A[NAME] on 08/03/18, and determined the IJ was removed prior to exit. Therefore the scope and severity for 42 CFR(s) 483.21 (b)(1)-Comprehensive Care Plans, F656, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the policy for Care Plans, undated, revealed: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Review of Resident #1's care plan revealed no plan of care for the resident's risk of wandering and/or elopement when re-admitted to the facility on [DATE]. Review of Resident #1's care plan, initiated 3/29/17, and resolved on 4/5/17, revealed the resident was at risk for elopement for episodes of wanting to go home and episodes of increased confusion when she had infections. Review of physician's orders [REDACTED]. Review of a History and Physical (H&P) from the Behavioral Health Unit (BHU), dated 5/30/18, revealed Resident #1 was admitted due to becoming somewhat combative, uncooperative, refusing medications, and trying to leave the nursing home. A note, documented on 6/11/18, revealed that the resident roamed about the unit looking for her husband and That little girl. Review of the Discharge (D/C) Summary, dated 6/13/18, revealed Resident #1's chief complaint included: Referred from (facility) with reports of refusing medications, finger sticks and constantly attempting to elope from the facility; also runs away from staff. Review of Resident #1's medical record revealed no documented assessment or care plan for the resident's risk of elopement upon return to the facility on [DATE]. Review of a facility investigative report, faxed to the State Agency on 7/26/18, revealed Resident #1 had eloped from the facility on 7/21/18 at 8:58 AM, and was seen by visitors/local Coroner 100 yards from the facility at a local service station. The resident was returned to the facility unharmed and an arm band and Wandergard transmitter were applied. The resident had been asking to go to the beauty shop that morning and had been looking out the front door. The resident had been redirected from the door. The facility report concluded that there had been visitors at the facility and as they exited, the resident went out the door before it completely shut and locked, allowing the resident to exit the facility. The report documented the reporter was unaware of prior attempts to leave the facility. Interview with RN #2 on 8/18/18 at 1:30 PM, revealed that she readmitted Resident #1 on 6/13/18 and did not do an elopement assessment or updated the care plan at that time, she thought the DON had done it. She stated that she was part time agency staff and this was probably the first re-admission she had done. She stated that she didn't know all of the assessments to do, but has since been told of all, including the risk assessment for wandering and elopement. RN #1 stated she was unaware of Resident #1's elopement attempts prior to going to the BHU and had not looked at the H&P or D/C summary; had only looked at the orders upon re-admission. RN #1 stated she did not initiated or update Resident #1's care plan for wandering/elopement. Post exit telephone interview with the Director of Nursing (DON) on 8/17/18 at 10:30 AM, and the Assistant DON on 8/17/18 at 11:20 AM, revealed that a re-assessment should have been done for Resident #1 for the risk of elopement and a care plan initiated upon re-admission to the facility on [DATE], according to the BHU H&P and D/C Summary. Both the DON and ADON were unaware that Resident #1 had exit seeking behaviors when sent to the BHU; they both thought the admission was for refusing medications. The DON stated that every time a resident was readmitted , an assessment should be done for an elopement risk along with all of the other assessments, and care planned as appropriate. The facility's Acceptable Allegation of Compliance included: 1. On (MONTH) 21, (YEAR), at approximately 8:30 AM, Resident #1 walked unsupervised to a local convenient store, approximately 100 yards from the facility. Two (2) women and the local Coroner recognized Resident #1, called the facility at 8:58 AM, and spoke with Registered Nurse (RN) #1. Resident #1 was returned to facility at 9:00 AM, by Woman #1 in her vehicle. Resident #1 has a [DIAGNOSES REDACTED]. Resident's last Brief interview for Mental Status (BIMS) score was unable to be determined by the Social Worker on (MONTH) 6, (YEAR), due to cognitive impairment. 2. After facility was called by the Coroner on (MONTH) 21, (YEAR) at 8:58 AM, RN #1 printed a census and did a head count of all residents. Facility census was 56. Fifty five residents in house with one (1) bed hold that was in local hospital. All other 54 residents were accounted for by RN #1. A resident that was identified as an elopement risk and has a wanderguard bracelet was assessed for placement and function without any issues. 3. Resident #1 was assessed by RN #1 at 9:30 AM, on (MONTH) 21, (YEAR), with no injury noted. Vital Signs were obtained by RN #1 and were within normal limits. RN #1 visually monitored Resident #1 on (MONTH) 21, (YEAR) every 15 minutes from 9:30 AM until 11:30 AM, and every 30 minutes from 11:30 AM until 3:30 PM, and documented in nurse's notes. 4. Director Of Nurses (DON) was notified (MONTH) 21, (YEAR) at 9:10 AM, of Resident #1's elopement by RN #1 stating ,I had my first resident leave to go to beauty shop but I got her right back in. DON understood from RN #1 that resident attempted to go to beauty shop in facility and was redirected back through hall corridor doors by RN #1. It was approximately 12:00 PM, when RN #1 reported to DON that Resident#1 walked approximately 100 yards to a store off of the facility grounds unsupervised. 5. Administrator was notified by DON of Resident #1 leaving to go to beauty shop at 9:12 AM on (MONTH) 21, (YEAR). Administrator was notified of Resident #1 leaving facility grounds unsupervised at 12:15 PM, on (MONTH) 21, (YEAR), by the DON. 6. An elopement risk assessment was completed on Resident #1 on (MONTH) 21,2018 at 1:30 PM, by the DON, and Resident #1 was assessed as being a risk for elopement. A wander guard bracelet was placed on Resident #1 (MONTH) 21, (YEAR), by the DON at 3:30 PM. Resident #1 was previously deemed an elopement risk on (MONTH) 26, 2014, after exiting the facility unsupervised. An Elopement risk assessment performed by DON on (MONTH) 4, (YEAR), deemed Resident #1 was not an elopement risk and the wander guard bracelet was taken off Resident #1. 7. DON arrived at facility on (MONTH) 21, (YEAR) at 1:00 PM, and checked Function ability of all four (4) exit doors with no problems noted. 8. An Elopement Risk Assessment was performed on all Residents (MONTH) 21, (YEAR) at approximately 2:00 PM, by the DON, and Resident #1 was identified as the only new at risk resident. Another resident, previously identified as an elopement risk, had on a functioning wander guard bracelet. Both residents' risk for elopement care plans were reviewed by the DON and Resident #1's Care Plan was updated to reflect the elopement on (MONTH) 21, (YEAR), and the intervention of the wander guard bracelet was implemented and carried out by the DON and the other resident, who previously identified as an elopement risk, care plan was reviewed without any issues noted. Residents with Wander guards are monitored each shift for placement of wander guard and daily for function of wander guard by the Shift Supervisor and the Medication Cart Nurse and is documented in the transmitter log and the Electronic Treatment Administration Record (ETAR). 9. The Elopement Policy and Prevention In-service was begun on (MONTH) 21, (YEAR), at approximately 2:45 PM, by the DON. This policy defines elopement, identifies common triggers, lists ways to keep your residents from leaving the facility and defines what to do if a Resident is missing. Total number of staff in-serviced on (MONTH) 21, (YEAR), was 12. One (1) Registered Nurse, four (4) Licensed Practical Nurses, and seven (7) Certified Nurse's Assistants. The remaining 45 staff members included Therapy, Dietary, Housekeeping, and Maintenance were in-serviced thru (MONTH) 2, (YEAR), by the DON and Department Manager. No staff will be allowed to work unless in-serviced. 10. Quality Assurance Committee (QA) was held (MONTH) 23, (YEAR) at 8:30 AM. The Medical Director, Administrator, Director of Nurses, Assistant Director of Nurses, Unit Supervisor, Social Services Coordinator, and MDS Supervisor were in attendance. The Elopement of Resident #1, on (MONTH) 21, (YEAR), Staffing, Updated Care plans, Elopement Policy, Elopement Drills and 100 percent of elopement assessments performed were discussed. No further recommendations were recommended at this time. 11. Elopement Drills were performed on all three (3) shifts on (MONTH) 23, (YEAR), by the DON and the Social Worker, beginning at 1:19 PM. All staff responded appropriately. 12. Signs stating, Attention Visitors, when exiting the facility use caution to only exit with members of your party, were placed on all four (4) facility exit doors on (MONTH) 30, (YEAR) at 2:00 PM, by the DON. 13. The Attorney General's Office was notified by E-Mail on (MONTH) 21, (YEAR) at 3:14 PM, and The State Office of Licensure and Certification was notified on (MONTH) 26, (YEAR) at 7:27 AM, by phone and fax, by the DON about Resident #1's Elopement. 14. Facility alleges all corrective actions to remove the Immediate Jeopardy (IJ) were completed on (MONTH) 2, (YEAR), and the IJ was removed as of (MONTH) 3, (YEAR). Validation of Allegation of Compliance included: 1. Based on record review and interview, the State Agency (SA) validated that on (MONTH) 21, (YEAR) at approximately 8:30 AM, Resident #1 walked unsupervised to a local convenient store that is approximately 100 yards from the facility, or two tenthss (2/10) of a mile. Interview validated that two (2) women and the local Coroner recognized the Resident, called the facility at 8:58 AM, and spoke with Registered Nurse (RN) #1. Resident #1 was then returned to the facility at 9:00 AM, by Woman #1, in her personal vehicle. Record review and interview validated that Resident #1 has a [DIAGNOSES REDACTED]. Her last Brief interview of Mental Status (BIMS) was unable to be determined by the Social Worker on 12/6/17, due to cognitive impairment. 2. Record review and interview by the SA validated that after the facility was notified by the Coroner on 7/21/18 at 8:58 AM, regarding the location of Resident #1, RN #1 did a head count of all residents. The census was 56. Fifty five Residents were in house with one (1) bed hold. All 54 residents were accounted for by RN #1. A resident that was identified as an elopement risk and has a wanderguard bracelet was assessed for placement and function without any issues noted. 3. The SA validated through record review and interview that Resident #1 was assessed by RN #1 at 9:30 AM on 7/21/18, with no injuries noted. Vital signs were within normal limits. RN #1 then visually monitored Resident #1 on 7/21/18 every 15 minutes from 9:30 AM to 11:30 AM, then every 30 minutes from 11:30 AM to 3:30 PM and documented in the nurse's notes. 4. The SA validated through interview and record review that the Director of Nurses (DON) was notified on 7/21/18 at 9:10 AM, of Resident #1's elopement by RN #1 stating I had my first resident leave to go to beauty shop but I got her right back in. The DON understood from RN #1 that the resident attempted to go to the beauty shop in the facility and had been redirected back through the hall corridor door by RN #1. It was approximately 12:00 PM when RN #1 reported to the DON that Resident #1 walked approximately 100 yards to a store off of the facility grounds unsupervised. 5. The SA validated through record review and interview that the Administrator was notified, by the DON, of Resident #1 leaving to go to the beauty shop at 9:12 AM on 7/21/18. The Administrator was notified of Resident #1 leaving the facility grounds unsupervised at 12:15 PM on 7/21/18, by the DON. 6. Through interview and record review, the SA validated that an elopement risk assessment was completed on Resident #1 on 7/21/18 at 1:30 PM, by the DON, and was assessed as an elopement risk. A wander guard bracelet was then placed on Resident #1 on 7/21/18, by the DON, at 3:30 PM. Resident #1 had previously been deemed an elopement risk on 12/26/14, after exiting the facility unsupervised. An elopement risk assessment performed by the DON on 4/4/17, deemed Resident #1 was not an elopement risk and her wanderguard bracelet was removed at that time. 7. The SA validated through record review and interview that the DON arrived to the facility on [DATE] at 1:00 PM, and checked the function ability of all four (4) exit doors with no problems noted. 8. The SA validated through record review, observation, and interview that an elopement risk assessment was performed on all residents on 7/21/18 at approximately 2:00 PM, by the DON, and Resident #1 was identified as the only new resident at risk. Another resident, previously identified as an elopement risk, had on a functioning wander guard bracelet. Both residents risk for elopement care plans were reviewed by the DON and Resident #1's care plan was updated to reflect the 7/21/18 elopement and the intervention of the wander guard bracelet was implemented and carried out by the DON. The other resident's care plan was reviewed without any issues noted. Residents with Wander guards are monitored each shift for placement of wander guard and daily for function of the wander guard by the Shift supervisor and the medication cart nurse and is documented in the transmitter log and the Electronic Treatment Administration Record (ETAR). 9. The SA validated through interview and record review that an Elopement Policy and Prevention In-service began on 7/21/18 at approximately 2:45 PM, by the DON. This policy defined elopement, identified common triggers, lists way to keep residents from leaving the facility and defines what to do if a resident is missing. The total number of staff inserviced on 7/21/18 was 12, which included one (1) Registered Nurse, four (4) Licensed Practical Nurses and seven (7) Certified Nurses Assistants. The remaining 45 staff members included Therapy, Dietary, Housekeeping and Maintenance were inserviced through 8/2/18, by the DON and Department Managers. No staff were allowed to work unless inserviced. The SA validated through interview of four (4) Certified Nurses Aide and one (1) Agency Certified Nurses Aide, one (1) Licensed Practical Nurse, one (1) Registered Nurse Agency, one (1) Therapist, one (1) Maintenance, one (1) Housekeeping and one (1) Dietary employee. 10. The SA validated through record review, sign in sheet review, and interview that a Quality Assurance committee (QA) meeting was held 7/23/18 at 8:30 AM. The Medical Director, Administrator, Director of Nurses, Assistant Director of Nurses, Unit Supervisor, Social Services Coordinator and MDS supervisor were in attendance. The elopement of Resident #1 on 7/21/18, staffing, updated care plans, elopement policy, elopement drills, and 100 percent of elopement assessments that hd been performed were discussed. No further recommendations were made at that time. 11. Through record review and interviews, the SA validated that elopement drills were performed on all three (3) shifts on 7/23/18, by the DON and the Social Worker, beginning at 1:19 PM, and all staff responded appropriately. 12. The SA validated through interviews and observation, signs stating Attention Visitors, when exiting the facility use caution to only exit with member of your party were placed on all four (4) exit doors on 7/30/18 at 2:00 PM, by the DON. 13. The SA validated through interview and record review, the Attorney General's Office was notified by Email on 7/21/18, and the State Office of Licensure and Certification was notified on 7/26/18, by phone and fax, by the DON, about Resident #1's elopement. 14. The SA validated through interview and record review that the facility's corrective actions to be remove the Immediate Jeopardy (IJ) were completed on 8/2/18, and the IJ was removed as of 8/3/18.

CI MS # Based on observations, record review, interviews, and policy review, the facility failed to assess, monitor, and increase supervision, for one (1) of eight (8) sampled residents, Resident #1, to prevent the resident from leaving the facility without supervision. This was evidenced by Resident #1, a demented resident, left the faciity on [DATE], without supervision, and was observed at a local convenience store/gas station approximately two/tenths (2/10) of a mile from the facility on a busy major street. Resident #1 had a history of [REDACTED]. Resident #1 had a prior Wandergard that was discontinued. She had a [DIAGNOSES REDACTED]. Resident #1 was admitted to the Behavior Health Unit (BHU) on 5/30/18 and discharged back to the facility on [DATE], with documented behaviors, on the History and Physical and Discharge Summary, of wanting to go home and attempts of elopement from the facility. The staff failed to re-assess Resident #1's wander/elopement risk upon return. On 7/21/18, Resident #1 attempted, and stated multiple times, she was going to the beauty shop (to leave), and had to be redirected away from the front lobby by staff. Failures of the facility to help prevent accidents and ensure supervision included: 1. Failure to have sufficient staff to monitor entrance/exit at the front door to ensure this confused wandering resident, who no longer had a Wanderguard bracelet, who had been trying to exit the doors that morning, did not exit the building. 2. Failure to have a system in place to alert and notify visitors coming into the facility that there were wandering residents and that visitors needed to ensure no one went out without staff knowledge and that the door completely closed prior to walking away. 3. Failure to have operational policies/procedures that included specific instructions as to the full completion of the elopement assessment tool with guidance/parameters as to when a wanderguard bracelet will be removed for someone with cognitive impairment and/or actual elopement history. 4. Failure to have a sufficient number of wanderguard bracelets available in the event one was needed for resident use. 5. Failure to re-assess a resident for wandering/elopement risk after re-admission to the facility. The facility's failure to have systems in place to assess, re-assess, and supervise residents with a known history of elopement, placed this and other residents at risk for elopement in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) that began on 7/21/18, when Resident #1 left the facility unsupervised and without staff knowledge. Resident #1 was seen approximately two/tenths (2/10) of a mile from the facility by people who notified facility staff of Resident #1's whereabouts. On 7/31/18 at 1:30 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 08/02/18, in which the facility alleged removal of the IJ on 8/3/18. The SA validated the A[NAME] on 08/03/18, and determined the IJ was removed prior to exit. Therefore the scope and severity for 42 CFR(s) 483.25(d)(2)-Accidents, F689, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Elopement Policy, undated, documented the definition of elopement: Elopement is considered to be when a resident confused or oriented attempts to leave the facility and is successful in his or her attempt. The policy documented Reminders: If the resident actually elopes and cannot be located, follow missing resident policy. If a resident is attempting to leave the facility, a monitoring log can be used as a means to document the times and number of occurrences per shift. Consider requesting a medical review of system. The facility policy titled, Wandering Residents, with a revision date of 3/11/14, documented: The facility staff shall identify residents with actual or potential wandering residents by using an interdisciplinary team evaluation process. The behavior will be marked on the Minimum Data Set (MDS) and addressed in the care plan. Residents who have been identified as wanderers will wear an ankle bracelet (Wandergard) 24 hours a day. The personnel must be aware at all times that this is always a danger and be alert for any residents who are prone to wander. Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 currently had a [DIAGNOSES REDACTED]. The most recent Minimum Data Assessment (MDS), with an Assessment Reference Date (ARD) of 5/29/18, revealed Resident #1 was unable to complete the Brief Interview for Mental Status (BIMS). Staff assessment identified Resident #1 with moderately impaired-decisions poor, cues and supervision required, with memory problems both long and short term. Resident #1 was also identified with hearing impairment. Review of a facility report, faxed to the State Agency on 7/26/18, revealed an investigation for Resident #1's elopement. Resident #1 eloped from the facility on 7/21/18 at 8:58 AM, and was located by local citizens, 100 yards from the facility at a local service station. The resident was returned to the facility unharmed and an arm band and Wandergard transmitter were applied. The resident had been asking to go to the beauty shop that morning and had been looking out the front door. The resident had been redirected from the door. The facility report concluded that there had been visitors at the facility and as they exited, the resident was at the door before it shut completely and locked, allowing the resident to push the door open and exit the facility. The report documented the reporter was unaware of prior attempts to leave the facility. Documentation included a handwritten note, signed by RN #1 on 7/21/18, noting that Resident #1 had gone to the front door and bumped it, causing an alarm, after being told she could not go to the beauty shop. The door alarmed again and staff told her to come back. The RN documented that both LPNs were doing medication pass and she was making arrangements for getting another resident an X-ray. Everyone was away from the desk. The Coroner called, asking if there was anyone missing from the facility, there was an older lady walking down the road. RN #1 documented she went to get Resident #1, but two (2) ladies returned the resident to the facility. Review of the Nurse's Notes for Resident #1, revealed a note dated 7/21/18 at 10:32 AM. Documentation included: Charting for 9:15 AM: Resident eloped when the front door was open. She walked down to the (name) station and two (2) ladies picked her up and returned her to the facility. This nurse left to go get her. The Coroner reported seeing her out. She was unharmed and said she was going to the hairdresser. Full assessment with no injuries. Review of Resident #1's record revealed no monitoring log to document times and number of attempts of Resident #1 to leave, and /or increase frequency of monitoring the resident, to ensure supervision and oversight. Review of the weather report, documented from weather.com, revealed a temperature of 92 degrees and sunny, for 7/21/18. Observation on 7/28/18 at 7:00 AM, of the area where Resident #1 was located in relation to the facility, was approximately two/tenths (2/10) of a mile. The resident could have cut across the parking lot of a local motel/restaurant, through a vacant lot that was grassy with some gravel, to the gas station. The other route would have been to go the main highway, then to the gas station on the highway. This area is paved and a busy main street of the city. Observations on 07/28/18 at 3:00 PM, and 7/29/18 at 2:50 PM, revealed there were no signs posted on the outside or inside of the exit doors to notify visitors of the facility not to let anyone outside behind them, or to be aware of wandering residents. In an interview, on 7/28/18 at 8:08 AM, Registered Nurse (RN) #1 revealed Resident #1 had been redirected away from the front door multiple times that morning. She stated that Resident #1 kept saying she was going to the beauty shop; this was around 8:00 AM. RN #1 stated she had left the front desk to put an Intravenous (IV) line in another resident and no one was available at the front desk. She stated when she returned to the desk, she received a call from the Coroner, around 9:00 AM, reporting the resident was at the local gas station. RN #1 stated, In our investigation, we could only determine that (Resident #1) must have walked out the door behind someone. She further revealed they had no idea the resident had eloped until receiving the phone call. RN #1 stated the resident had been known to leave the facility before. RN #1 stated that Resident #1 didn't have a Wandergard until the day she left (7/21/18). RN #1 stated that she was hanging an IV, the two (2) medication nurses were giving medications and the CNAs were giving baths, so no one was at the desk to watch the front door (to redirect the resident if needed). Interview with Woman #1, on 8/2/18 at 10:45 AM, revealed she saw Resident #1 walking down the side of the road (7/21/18) between the convenience store and another store. She stated there was some traffic on the road. She stated Resident #1 got into her car and she drove her to the facility; no injury. She stated that no one from the facility knew she was gone, but they knew she shouldn't be outside, because the nurse told her this was the first one that had gotten away from her. Interview with the Director of Nursing (DON) on 7/28/18 at 7:50 AM, revealed Resident #1 could have been in danger leaving the facility unsupervised due to hearing difficulties and being on Highway 8 (busy road). Interview with LPN #1 on 7/28/18 at 7:00 AM, revealed Resident #1 had gotten out of the facility on 7/21/18, had gotten to the gas station and was about to hitch a ride. She stated that Resident #1 didn't have a Wandergard until that day. Interview with LPN #2 on 7/28/18 at 8:45 AM, revealed she was working on 7/21/18, and Resident #1 kept saying she was going home and had attempted twice to get out. LPN #2 stated the resident would stop and go watch television with other residents, then the next thing she knew the Coroner was calling saying she'd gotten out. She stated that two (2) ladies brought the resident back to the facility. LPN #2 stated there were multiple visitors at the facility and they were very busy (on 7/21/18). Interview with CNA #1 on 7/28/18 at 8:58 AM, revealed she was told around 9:00 AM, by RN #1, that Resident #1 had gotten out of the building. She stated that she had been giving showers during that time. She stated that you had to watch Resident #1 because she likes to follow family out the front door. CNA #1 stated they were often short-staffed. Interview with CNA #2 on 7/28/18 at 9:10 AM, revealed she worked on day shift 7/21/18, and had heard after the fact that Resident #1 had gotten out of the building and had gone to the (gas station). She stated they were often short staffed. CNA #2 stated there were supposed to be five (5) CNAs working on day shift and that day (7/21/18), and she thought there were only three (3). CNA #2 stated she had been bathing other residents when she learned that Resident #1 had left the facility. Interview with CNA #3 on 7/28/18 at 9:15 AM, revealed that she had been assigned to Resident #1 on 7/21/18, and took her breakfast. She stated, We kept a check on her. CNA #3 stated she was giving baths that morning and someone told her that Resident #1 kept asking to open the door. She stated she thought someone came in and the resident went out. CNA #3 was unaware of Resident #1 going out the door prior. Interview with CNA #4 on 7/29/18 at 9:45 AM, revealed that Resident #1 had eloped from the facility several years prior. She stated that the resident always goes behind family toward the front door when they leave and staff knows we really have to watch her. She stated that the daughter didn't want the Wandergard taken off because of the past history. During survey, 7/28/18-8/2/18, multiple observations of Resident #1 were observed walking around in her room and up and down the hallway. She had a Wandergard on her right ankle. Attempts were made to interview Resident #1 during survey, however she was very confused. Review of Resident #1's Elopement Assessment form, dated 10/23/14, 12/1/14, and 2/24/15, revealed a score of 7. Documentation on the assessment included: With a score of 10 or higher the resident should be considered a high risk for elopement and an appropriate preventative plan of care should be established. Under the section: Explain Occurrences: Has wandergard to right ankle due to frequently talking of going home with risk of elopement. This was not dated. Review of the medical record for Resident #1 revealed on 12/26/14, the resident had an order for [REDACTED].#1 had actually eloped on 12/26/14, prior to the wanderguard placement. The Wandergard was discontinued on 4/5/17, per physician's orders [REDACTED]. Review of Resident #1's care plan, initiated 3/29/17, and resolved on 4/5/17, revealed the resident was at risk for elopement for episodes of wanting to go home and episodes of increased confusion when she has infections. (Resident #1 was being treated for [REDACTED]. The facility had prior knowledge, per this care plan, that the resident had increased confusion during infection, which put her at greater risk for elopement.) The Resident Elopement Risk Assessment Tool for Resident #1, dated 3/7/18, 5/17/18, and 7/21/18, was reviewed with the DON on 07/28/18 at 9:40 AM. The Risk Assessment had been completed with a score of 9 for each assessment date from (MONTH) to (MONTH) (YEAR). The statements at the bottom of the page included: Based on your knowledge, has the Resident had occurrences of leaving residence/premises without supervision? If yes, approximate number of times. Explain occurrences. These statements were left blank, unanswered. The DON stated that she had worked in the facility since (YEAR), and she was unaware that Resident #1had a previous elopement in 2014. She stated if she had known about the elopement, they wouldn't have removed the Wandergard from the resident. She further stated that Wanderguard bracelets are usually removed from demented residents when they become bedfast/non-ambulatory. When asked if there was a written procedure to follow in completing the Resident Elopement Assessment Form, the DON stated not to her knowledge. When asked about the significance of the two (2) statements below the assessment piece, she was unsure if it would impact the decision to continue or add a Wanderguard bracelet. She confirmed the sections were blank. Review of a History and Physical from the Behavioral Health Unit (BHU), dated 5/30/18, revealed Resident #1 was admitted due to becoming somewhat combative, uncooperative, refusing medications and trying to leave the nursing home. A note, documented 6/11/18, revealed that the resident roams about the unit looking for her husband and That little girl. Review of the Discharge Summary, dated 6/13/18, revealed Resident #1's chief complaint included: Referred from (facility) with reports of refusing medications, finger sticks and constantly attempting to elope from the facility; also runs away from staff. Review of a Nurse's Note, dated 5/30/18 at 2:35 PM, revealed: (Physician) called for resident to transfer to Geri-Psyche (BHU) due to resident refusing medications and trying to go home. Paperwork and orders faxed to Geri-Psyche unit. Family notified and agrees. Review of Resident #1's medical record revealed there was no documented assessment or care plan for the resident's risk of elopement, upon return to the facility on [DATE]. Post exit telephone interview with the Director of Nursing (DON) on 8/17/18 at 10:30 AM, and the Assistant DON on 8/17/18 at 11:20 AM, revealed that when residents return from a BHU or hospital, that a re-assessment should be done for the risk of elopement. Both agreed that Resident #1 should have been assessed and care planned for the risk of elopement according to the BHU Discharge Summary, documenting the resident's behavior for attempts of elopement. The DON stated a Wandergard should have been applied when Resident #1 returned on 6/13/18. Both the DON and ADON were unaware that Resident #1 had exit seeking behaviors as a reason the resident was sent to the hospital, they both stated they thought the reason for the BHU admission was for refusing medications. During the interview, on 7/28/18 at 9:40 AM, the DON was asked why another resident's (Resident #2) wanderguard was discontinued on 7/21/18, with orders for every hour visual checks, and then orders were written to reapply the Wanderguard on 7/27/18. She revealed she didn't have any wanderguard bracelets she could find in the building on 7/21/18, so she removed the Wandergard bracelet from Resident #2 to put on Resident #1, until more Wanderguard bracelets came in. When asked the number of wandering residents, the DON stated that Resident #2 was the only one until Resident #1 left on 07/21/18, and a new resident (Resident #3) was admitted on [DATE], and a wanderguard was applied. Resident #1's daughter was interviewed on 7/28/18 at 12:05 PM. She revealed her mom had gotten out of the facility before and wore a wanderguard bracelet. When asked about the Wanderguard bracelet removal, she stated They just took it off. I wanted them to leave it on. She stated that Resident #1 had no safety awareness because she couldn't hear well and had memory problems. The Physician, who signed the discontinue order for the wanderguard bracelet on 4/5/17, for Resident #1, was interviewed on 7/29/18 at 12:50 PM. He revealed he gave an order to discontinue the Wanderguard after it was discussed with him. He further stated that he didn't know the resident had a past elopement incident. The Medical Director, Resident #1's Physician, was interviewed on 7/30/18 at 8:45 AM. He stated that Resident #1 had become more confused and evidently, due to the incident of elopement, maybe it hadn't been good to remove the Wanderguard bracelet. He stated she'd had the Wandergard before because she'd had a history of [REDACTED]. He stated he was aware of staffing issues and that they could use more staff, and there would be a continued problem until the facility pays nursing enough to keep down turnover. Resident #1's ability to leave the facility unsupervised correlates to insufficient staff to increase the monitoring of the resident's whereabouts after she made repeated attempts to leave. Staff had been redirecting the resident away from the front lobby/door on 7/21/18, then left the front door unattended. Resident #1 eloped without staff knowledge and was observed walking to a nearby gas station/convenience store, which is situated on a busy highway. Review of the staff posting and assignment sheets for 07/21/18, revealed one (1) RN, two (2) LPNs and four (4) CNAs were on duty for the day shift and the census was 56. For the 24 hours, staff included 140.58 hours of nursing, which totaled 2.51 patients per day (ppd). The minimum requirement is 2.80 ppd. The facility's Acceptable Allegation of Compliance included: 1. On (MONTH) 21, (YEAR), at approximately 8:30 AM, Resident #1 walked unsupervised to a local convenient store, approximately 100 yards from the facility. Two (2) women and the local Coroner recognized Resident #1, called the facility at 8:58 AM, and spoke with Registered Nurse (RN) #1. Resident #1 was returned to facility at 9:00 AM, by Woman #1 in her vehicle. Resident #1 has a [DIAGNOSES REDACTED]. Resident's last Brief interview for Mental Status (BIMS) score was unable to be determined by the Social Worker on (MONTH) 6, (YEAR), due to cognitive impairment. 2. After facility was called by the Coroner on (MONTH) 21, (YEAR) at 8:58 AM, RN #1 printed a census and did a head count of all residents. Facility census was 56. Fifty five residents in house with one (1) bed hold that was in local hospital. All other 54 residents were accounted for by RN #1. A resident that was identified as an elopement risk and has a wanderguard bracelet was assessed for placement and function without any issues. 3. Resident #1 was assessed by RN #1 at 9:30 AM, on (MONTH) 21, (YEAR), with no injury noted. Vital Signs were obtained by RN #1 and were within normal limits. RN #1 visually monitored Resident #1 on (MONTH) 21, (YEAR) every 15 minutes from 9:30 AM until 11:30 AM, and every 30 minutes from 11:30 AM until 3:30 PM, and documented in nurse's notes. 4. Director Of Nurses (DON) was notified (MONTH) 21, (YEAR) at 9:10 AM, of Resident #1's elopement by RN #1 stating ,I had my first resident leave to go to beauty shop but I got her right back in. DON understood from RN #1 that resident attempted to go to beauty shop in facility and was redirected back through hall corridor doors by RN #1. It was approximately 12:00 PM, when RN #1 reported to DON that Resident#1 walked approximately 100 yards to a store off of the facility grounds unsupervised. 5. Administrator was notified by DON of Resident #1 leaving to go to beauty shop at 9:12 AM on (MONTH) 21, (YEAR). Administrator was notified of Resident #1 leaving facility grounds unsupervised at 12:15 PM, on (MONTH) 21, (YEAR), by the DON. 6. An elopement risk assessment was completed on Resident #1 on (MONTH) 21,2018 at 1:30 PM, by the DON, and Resident #1 was assessed as being a risk for elopement. A wander guard bracelet was placed on Resident #1 (MONTH) 21, (YEAR), by the DON at 3:30 PM. Resident #1 was previously deemed an elopement risk on (MONTH) 26, 2014, after exiting the facility unsupervised. An Elopement risk assessment performed by DON on (MONTH) 4, (YEAR), deemed Resident #1 was not an elopement risk and the wander guard bracelet was taken off Resident #1. 7. DON arrived at facility on (MONTH) 21, (YEAR) at 1:00 PM, and checked Function ability of all four (4) exit doors with no problems noted. 8. An Elopement Risk Assessment was performed on all Residents (MONTH) 21, (YEAR) at approximately 2:00 PM, by the DON, and Resident #1 was identified as the only new at risk resident. Another resident, previously identified as an elopement risk, had on a functioning wander guard bracelet. Both residents' risk for elopement care plans were reviewed by the DON and Resident #1's Care Plan was updated to reflect the elopement on (MONTH) 21, (YEAR), and the intervention of the wander guard bracelet was implemented and carried out by the DON and the other resident, who previously identified as an elopement risk, care plan was reviewed without any issues noted. Residents with Wander guards are monitored each shift for placement of wander guard and daily for function of wander guard by the Shift Supervisor and the Medication Cart Nurse and is documented in the transmitter log and the Electronic Treatment Administration Record (ETAR). 9. The Elopement Policy and Prevention In-service was begun on (MONTH) 21, (YEAR), at approximately 2:45 PM, by the DON. This policy defines elopement, identifies common triggers, lists ways to keep your residents from leaving the facility and defines what to do if a Resident is missing. Total number of staff in-serviced on (MONTH) 21, (YEAR), was 12. One (1) Registered Nurse, four (4) Licensed Practical Nurses, and seven (7) Certified Nurse's Assistants. The remaining 45 staff members included Therapy, Dietary, Housekeeping, and Maintenance were in-serviced thru (MONTH) 2, (YEAR), by the DON and Department Manager. No staff will be allowed to work unless in-serviced. 10. Quality Assurance Committee (QA) was held (MONTH) 23, (YEAR) at 8:30 AM. The Medical Director, Administrator, Director of Nurses, Assistant Director of Nurses, Unit Supervisor, Social Services Coordinator, and MDS Supervisor were in attendance. The Elopement of Resident #1, on (MONTH) 21, (YEAR), Staffing, Updated Care plans, Elopement Policy, Elopement Drills and 100 percent of elopement assessments performed were discussed. No further recommendations were recommended at this time. 11. Elopement Drills were performed on all three (3) shifts on (MONTH) 23, (YEAR), by the DON and the Social Worker, beginning at 1:19 PM. All staff responded appropriately. 12. Signs stating, Attention Visitors, when exiting the facility use caution to only exit with members of your party, were placed on all four (4) facility exit doors on (MONTH) 30, (YEAR) at 2:00 PM, by the DON. 13. The Attorney General's Office was notified by E-Mail on (MONTH) 21, (YEAR) at 3:14 PM, and The State Office of Licensure and Certification was notified on (MONTH) 26, (YEAR) at 7:27 AM, by phone and fax, by the DON about Resident #1's Elopement. 14. Facility alleges all corrective actions to remove the Immediate Jeopardy (IJ) were completed on (MONTH) 2, (YEAR), and the IJ was removed as of (MONTH) 3, (YEAR). Validation of Allegation of Compliance included: 1. Based on record review and interview, the State Agency (SA) validated that on (MONTH) 21, (YEAR) at approximately 8:30 AM, Resident #1 walked unsupervised to a local convenient store that is approximately 100 yards from the facility, or two tenthss (2/10) of a mile. Interview validated that two (2) women and the local Coroner recognized the Resident, called the facility at 8:58 AM, and spoke with Registered Nurse (RN) #1. Resident #1 was then returned to the facility at 9:00 AM, by Woman #1, in her personal vehicle. Record review and interview validated that Resident #1 has a [DIAGNOSES REDACTED]. Her last Brief interview of Mental Status (BIMS) was unable to be determined by the Social Worker on 12/6/17, due to cognitive impairment. 2. Record review and interview by the SA validated that after the facility was notified by the Coroner on 7/21/18 at 8:58 AM, regarding the location of Resident #1, RN #1 did a head count of all residents. The census was 56. Fifty five Residents were in house with one (1) bed hold. All 54 residents were accounted for by RN #1. A resident that was identified as an elopement risk and has a wanderguard bracelet was assessed for placement and function without any issues noted. 3. The SA validated through record review and interview that Resident #1 was assessed by RN #1 at 9:30 AM on 7/21/18, with no injuries noted. Vital signs were within normal limits. RN #1 then visually monitored Resident #1 on 7/21/18 every 15 minutes from 9:30 AM to 11:30 AM, then every 30 minutes from 11:30 AM to 3:30 PM and documented in the nurse's notes. 4. The SA validated through interview and record review that the Director of Nurses (DON) was notified on 7/21/18 at 9:10 AM, of Resident #1's elopement by RN #1 stating I had my first resident leave to go to beauty shop but I got her right back in. The DON understood from RN #1 that the resident attempted to go to the beauty shop in the facility and had been redirected back through the hall corridor door by RN #1. It was approximately 12:00 PM when RN #1 reported to the DON that Resident #1 walked approximately 100 yards to a store off of the facility grounds unsupervised. 5. The SA validated through record review and interview that the Administrator was notified, by the DON, of Resident #1 leaving to go to the beauty shop at 9:12 AM on 7/21/18. The Administrator was notified of Resident #1 leaving the facility grounds unsupervised at 12:15 PM on 7/21/18, by the DON. 6. Through interview and record review, the SA validated that an elopement risk assessment was completed on Resident #1 on 7/21/18 at 1:30 PM, by the DON, and was assessed as an elopement risk. A wander guard bracelet was then placed on Resident #1 on 7/21/18, by the DON, at 3:30 PM. Resident #1 had previously been deemed an elopement risk on 12/26/14, after exiting the facility unsupervised. An elopement risk assessment performed by the DON on 4/4/17, deemed Resident #1 was not an elopement risk and her wanderguard bracelet was removed at that time. 7. The SA validated through record review and interview that the DON arrived to the facility on [DATE] at 1:00 PM, and checked the function ability of all four (4) exit doors with no problems noted. 8. The SA validated through record review, observation, and interview that an elopement risk assessment was performed on all residents on 7/21/18 at approximately 2:00 PM, by the DON, and Resident #1 was identified as the only new resident at risk. Another resident, previously identified as an elopement risk, had on a functioning wander guard bracelet. Both residents risk for elopement care plans were reviewed by the DON and Resident #1's care plan was updated to reflect the 7/21/18 elopement and the intervention of the wander guard bracelet was implemented and carried out by the DON. The other resident's care plan was reviewed without any issues noted. Residents with Wander guards are monitored each shift for placement of wander guard and daily for function of the wander guard by the Shift supervisor and the medication cart nurse and is documented in the transmitter log and the Electronic Treatment Administration Record (ETAR). 9. The SA validated through interview and record review that an Elopement Policy and Prevention In-service began on 7/21/18 at approximately 2:45 PM, by the DON. This policy defined elopement, identified common triggers, lists way to keep residents from leaving the facility and defines what to do if a resident is missing. The total number of staff inserviced on 7/21/18 was 12, which included one (1) Registered Nurse, four (4) Licensed Practical Nurses and seven (7) Certified Nurses Assistants. The remaining 45 staff members included Therapy, Dietary, Housekeeping and Maintenance were inserviced through 8/2/18, by the DON and Department Managers. No staff were allowed to work unless inserviced. The SA validated through interview of four (4) Certified Nurses Aide and one (1) Agency Certified Nurses Aide, one (1) Licensed Practical Nurse, one (1) Registered Nurse Agency, one (1) Therapist, one (1) Maintenance, one (1) Housekeeping and one (1) Dietary employee. 10. The SA validated through record review, sign in sheet review, and interview that a Quality Assurance committee (QA) meeting was held 7/23/18 at 8:30 AM. The Medical Director, Administrator, Director of Nurses, Assistant Director of Nurses, Unit Supervisor, Social Services Coordinator and MDS supervisor were in attendance. The elopement of Resident #1 on 7/21/18, staffing, updated care plans, elopement policy, elopement drills, and 100 percent of elopement assessments that hd been performed were discussed. No further recommendations were made at that time. 11. Through record review and interviews, the SA validated that elopement drills were performed on all three (3) shifts on 7/23/18, by the DON and the Social Worker, beginning at 1:19 PM, and all staff responded appropriately. 12. The SA validated through interviews and observation, signs stating Attention Visitors, when exiting the facility use caution to only exit with member of your party were placed on all four (4) exit doors on 7/30/18 at 2:00 PM, by the DON. 13. The SA validated through interview and record review, the Attorney General's Office was notified by Email on 7/21/18, and the State Office of Licensure and Certification was not

CI MS # Based on observation, review of staff schedules, review of Quality Assurance (QA) reports/policy, review of prior citations, and Staff interviews, the facility failed to implement an appropriate plan of action to correct identified deficiencies with meeting the minimum staffing requirements through their Quality Assurance Performance Improvement (QAPI) committee. The facility failed to effectively employ and ensure sufficient direct care staff were available to meet the resident needs. The staffing issue had been addressed through the QA Committee repeatedly from (YEAR), due to two (2) citations from the State Agency on Annual and Complaint Surveys. The lack of an effective QA process to ensure sufficient staff to meet the needs of residents, had the potential to affect 56 of 56 residents currently in the facility, especially Resident #1, a demented resident, who exited the facility unsupervised, on 7/21/18. The facility's failure to ensure an effective QAPI process to identify and implement measures to provide sufficient staff to take care of resident needs placed all residents, especially Resident #1 and other residents who needed increased supervision, in a situation that was likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ), which began on 7/21/18, when Resident #1 left the facility unsupervised, after being redirected from the exit door multiple times that day, and was located approximately two/tenths (2/10) of a mile from the facility. The facility failed to have sufficient staff to increase supervision of Resident #1, to redirect and prevent her from exiting the facility unsupervised. On 7/31/18 at 1:30 PM, the SA notified the facility's Administrator of the IJ and SQC. The facility submitted an acceptable Allegation of Compliance (A[NAME]) on 8/02/18, in which the facility alleged removal of the IJ on 8/3/18. The SA validated the A[NAME] on 8/03/18, and determined the IJ was removed prior to exit. Therefore the scope and severity for 42 CFR(s) 483.75(g)(2)-Quality Assessment and Assurance, F867, was lowered from a J to a scope and severity of a D, while the facility developed a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Review of the Quality Assurance Performance Improvement Plan policy of the local Hospital, who manages the nursing home, failed to address how the hospital administration will assist the nursing home when issues are identified through the nursing home QA. The objective of the QAPI plan is to preserve the quality of patient care, enhance appropriate utilization of resources, and to reduce or eliminate unnecessary risks and hazards within the facility. The facility policy and procedure titled, Nursing Service Staffing Pattern dated 7/25/02, and reviewed 5/10/18, by the Director of Nursing (DON), documented the following: Sufficient nursing personnel shall be assigned and on duty to assure safe and effective nursing care so that at least the following conditions are met: 1. Residents are provided with safe and efficient nursing care. 2. Residents receive appropriate nursing intervention in response to physical and behavioral/emotional conditions. The policy noted: Staffing is based on written plan that considers the needs of the resident population in determining the composition of nursing staff. In order to provide 24 hour nursing coverage, provisions are made for relief personnel during vacation periods, sick leave and emergencies, by using part time personnel for call in. Review of the annual survey results of 7/18/17, revealed the facility was cited for failure to meet staffing requirements for four (4) of 14 days. The facility's plan of correction (P[NAME]) revealed the Director of Nursing (DON) or Assistant Director of Nursing (ADON) would check daily and ensure staffing was adequate and job postings ran in the local paper and on the facility website. Review of a complaint survey of 5/15/18, revealed the facility failed to meet staffing requirements for three (3) of the five (5) days reviewed in a 14 day period. The P[NAME] included job postings on the facility website, in the local paper, and contract staff utilized. Another corrective action included the off-going shift to stay over if staffing was not met and other clinical administrative staff to assist with staffing. The DON/ADON was to check staffing daily to ensure requirements were met. Both P[NAME]s indicated that results of the monitoring would be included in the QA meeting for further recommendations. Review of the staffing for the current survey revealed the facility continued to have insufficient required staff to meet the needs of the residents. Review of the staffing for 7/21/18, revealed the facility did not meet minimum requirements of staff to meet the needs of the residents, which included increased supervision for Resident #1, who left the facility unsupervised, and was located approximately two/tenths (2/10) of a mile from the facility. There was one (1) RN, two (2) LPNs and four (4) CNAs, per review/validation of the assignment sheet, for 56 residents. The Person Per Day (PPD) ratio for 7/21/18 was 2.51 PPD. The minimum state requirement is 2.80 PPD. The facility failed to provide documented evidence of further recommendations from QA meetings related to staffing. Review of the facility's QAPI Committee Meetings and topics discussed for 4/19/18, revealed a discussion related to staffing- several open positions: RNs-three (3), LPNs-four (4) and CNAs-six (6). On 5/21/18, topics included a survey Complaint related to low staffing. Open positions included two (2) full time 3-11 LPNs, six (6) 7-3 CNAs, and two (2) 3-11 CNAs. On 7/03/18 topics included open positions of one (1) RN Charge Nurse for 7-3, two (2) RN Charge Nurses for 3-11, six (6) 7-3 CNAs, two (2) 3-11 CNAs, and one (1) 11-7 CNA. On 7/23/18, topics included-Resident Elopement and Staffing open positions of six (6) 7-3 CNAs, four (4) 3-11 CNAs, two (2) 11-7 CNAs, two (2) RN Supervisors, two (2) LPNs and one (1) Wound Nurse. The recommendations for the QA included an increase in pay (with no mention of action). The Action Team Assignment included: Continue to use Agency to provide staffing needs and run openings in the paper and on facility site. There was no alteration or different plans recommended to have sufficient staff to meet the requirements and needs of the residents. On 8/02/18 around 3:30 PM, the Chief Executive Officer (CEO)/Hospital Administrator was interviewed regarding his involvement in the nursing home QA and assistance with meeting the nursing home staffing needs. The local hospital also manages the nursing home facility. He revealed he was not involved, and he didn't attend the nursing home QA meetings. When asked how he assisted with the staffing shortages, he stated there had been ads placed in the local paper, hospital job site, and the state nursing home site. When asked about the repeated citations of the nursing home for staffing shortages, he stated that he felt that the problems were not related to the salary only. The Human Resources Director of the hospital was interviewed with the CEO/Hospital Administration at this time and she confirmed she had ran ads for staff in the local weekly paper for two (2) weeks from 05/31/17 to 06/13/17, and had ads on the hospital job site and nursing home site. When asked on 8/03/18 at 9:12 AM, what she'd done more recently, she confirmed she had not listed any ads in papers outside the small community and that she was relisting the ad in the local paper. The lack of involvement in the nursing home QA and assistance in determining the reason for staff hiring and retention by the Hospital Administration, who managed the nursing home, rendered the nursing home QA ineffective in providing resolution to the nursing and Certified Nursing Assistant (CNA) shortage. The facility's Acceptable Allegation of Compliance included: 1. On (MONTH) 21, (YEAR), at approximately 8:30 AM, Resident #1 walked unsupervised to a local convenient store, approximately 100 yards from the facility. Two (2) women and the local Coroner recognized Resident #1, called the facility at 8:58 AM, and spoke with Registered Nurse (RN) #1. Resident #1 was returned to facility at 9:00 AM, by Woman #1 in her vehicle. Resident #1 has a [DIAGNOSES REDACTED]. Resident's last Brief interview for Mental Status (BIMS) score was unable to be determined by the Social Worker on (MONTH) 6, (YEAR), due to cognitive impairment. 2. After facility was called by the Coroner on (MONTH) 21, (YEAR) at 8:58 AM, RN #1 printed a census and did a head count of all residents. Facility census was 56. Fifty five residents in house with one (1) bed hold that was in local hospital. All other 54 residents were accounted for by RN #1. A resident that was identified as an elopement risk and has a wanderguard bracelet was assessed for placement and function without any issues. 3. Resident #1 was assessed by RN #1 at 9:30 AM, on (MONTH) 21, (YEAR), with no injury noted. Vital Signs were obtained by RN #1 and were within normal limits. RN #1 visually monitored Resident #1 on (MONTH) 21, (YEAR) every 15 minutes from 9:30 AM until 11:30 AM, and every 30 minutes from 11:30 AM until 3:30 PM, and documented in nurse's notes. 4. Director Of Nurses (DON) was notified (MONTH) 21, (YEAR) at 9:10 AM, of Resident #1's elopement by RN #1 stating ,I had my first resident leave to go to beauty shop but I got her right back in. DON understood from RN #1 that resident attempted to go to beauty shop in facility and was redirected back through hall corridor doors by RN #1. It was approximately 12:00 PM, when RN #1 reported to DON that Resident#1 walked approximately 100 yards to a store off of the facility grounds unsupervised. 5. Administrator was notified by DON of Resident #1 leaving to go to beauty shop at 9:12 AM on (MONTH) 21, (YEAR). Administrator was notified of Resident #1 leaving facility grounds unsupervised at 12:15 PM, on (MONTH) 21, (YEAR), by the DON. 6. An elopement risk assessment was completed on Resident #1 on (MONTH) 21,2018 at 1:30 PM, by the DON, and Resident #1 was assessed as being a risk for elopement. A wander guard bracelet was placed on Resident #1 (MONTH) 21, (YEAR), by the DON at 3:30 PM. Resident #1 was previously deemed an elopement risk on (MONTH) 26, 2014, after exiting the facility unsupervised. An Elopement risk assessment performed by DON on (MONTH) 4, (YEAR), deemed Resident #1 was not an elopement risk and the wander guard bracelet was taken off Resident #1. 7. DON arrived at facility on (MONTH) 21, (YEAR) at 1:00 PM, and checked Function ability of all four (4) exit doors with no problems noted. 8. An Elopement Risk Assessment was performed on all Residents (MONTH) 21, (YEAR) at approximately 2:00 PM, by the DON, and Resident #1 was identified as the only new at risk resident. Another resident, previously identified as an elopement risk, had on a functioning wander guard bracelet. Both residents' risk for elopement care plans were reviewed by the DON and Resident #1's Care Plan was updated to reflect the elopement on (MONTH) 21, (YEAR), and the intervention of the wander guard bracelet was implemented and carried out by the DON and the other resident, who previously identified as an elopement risk, care plan was reviewed without any issues noted. Residents with Wander guards are monitored each shift for placement of wander guard and daily for function of wander guard by the Shift Supervisor and the Medication Cart Nurse and is documented in the transmitter log and the Electronic Treatment Administration Record (ETAR). 9. The Elopement Policy and Prevention In-service was begun on (MONTH) 21, (YEAR), at approximately 2:45 PM, by the DON. This policy defines elopement, identifies common triggers, lists ways to keep your residents from leaving the facility and defines what to do if a Resident is missing. Total number of staff in-serviced on (MONTH) 21, (YEAR), was 12. One (1) Registered Nurse, four (4) Licensed Practical Nurses, and seven (7) Certified Nurse's Assistants. The remaining 45 staff members included Therapy, Dietary, Housekeeping, and Maintenance were in-serviced thru (MONTH) 2, (YEAR), by the DON and Department Manager. No staff will be allowed to work unless in-serviced. 10. Quality Assurance Committee (QA) was held (MONTH) 23, (YEAR) at 8:30 AM. The Medical Director, Administrator, Director of Nurses, Assistant Director of Nurses, Unit Supervisor, Social Services Coordinator, and MDS Supervisor were in attendance. The Elopement of Resident #1, on (MONTH) 21, (YEAR), Staffing, Updated Care plans, Elopement Policy, Elopement Drills and 100 percent of elopement assessments performed were discussed. No further recommendations were recommended at this time. 11. Elopement Drills were performed on all three (3) shifts on (MONTH) 23, (YEAR), by the DON and the Social Worker, beginning at 1:19 PM. All staff responded appropriately. 12. Signs stating, Attention Visitors, when exiting the facility use caution to only exit with members of your party, were placed on all four (4) facility exit doors on (MONTH) 30, (YEAR) at 2:00 PM, by the DON. 13. The Attorney General's Office was notified by E-Mail on (MONTH) 21, (YEAR) at 3:14 PM, and The State Office of Licensure and Certification was notified on (MONTH) 26, (YEAR) at 7:27 AM, by phone and fax, by the DON about Resident #1's Elopement. 14. Facility alleges all corrective actions to remove the Immediate Jeopardy (IJ) were completed on (MONTH) 2, (YEAR), and the IJ was removed as of (MONTH) 3, (YEAR). Validation of Allegation of Compliance included: 1. Based on record review and interview, the State Agency (SA) validated that on (MONTH) 21, (YEAR) at approximately 8:30 AM, Resident #1 walked unsupervised to a local convenient store that is approximately 100 yards from the facility, or two tenthss (2/10) of a mile. Interview validated that two (2) women and the local Coroner recognized the Resident, called the facility at 8:58 AM, and spoke with Registered Nurse (RN) #1. Resident #1 was then returned to the facility at 9:00 AM, by Woman #1, in her personal vehicle. Record review and interview validated that Resident #1 has a [DIAGNOSES REDACTED]. Her last Brief interview of Mental Status (BIMS) was unable to be determined by the Social Worker on 12/6/17, due to cognitive impairment. 2. Record review and interview by the SA validated that after the facility was notified by the Coroner on 7/21/18 at 8:58 AM, regarding the location of Resident #1, RN #1 did a head count of all residents. The census was 56. Fifty five Residents were in house with one (1) bed hold. All 54 residents were accounted for by RN #1. A resident that was identified as an elopement risk and has a wanderguard bracelet was assessed for placement and function without any issues noted. 3. The SA validated through record review and interview that Resident #1 was assessed by RN #1 at 9:30 AM on 7/21/18, with no injuries noted. Vital signs were within normal limits. RN #1 then visually monitored Resident #1 on 7/21/18 every 15 minutes from 9:30 AM to 11:30 AM, then every 30 minutes from 11:30 AM to 3:30 PM and documented in the nurse's notes. 4. The SA validated through interview and record review that the Director of Nurses (DON) was notified on 7/21/18 at 9:10 AM, of Resident #1's elopement by RN #1 stating I had my first resident leave to go to beauty shop but I got her right back in. The DON understood from RN #1 that the resident attempted to go to the beauty shop in the facility and had been redirected back through the hall corridor door by RN #1. It was approximately 12:00 PM when RN #1 reported to the DON that Resident #1 walked approximately 100 yards to a store off of the facility grounds unsupervised. 5. The SA validated through record review and interview that the Administrator was notified, by the DON, of Resident #1 leaving to go to the beauty shop at 9:12 AM on 7/21/18. The Administrator was notified of Resident #1 leaving the facility grounds unsupervised at 12:15 PM on 7/21/18, by the DON. 6. Through interview and record review, the SA validated that an elopement risk assessment was completed on Resident #1 on 7/21/18 at 1:30 PM, by the DON, and was assessed as an elopement risk. A wander guard bracelet was then placed on Resident #1 on 7/21/18, by the DON, at 3:30 PM. Resident #1 had previously been deemed an elopement risk on 12/26/14, after exiting the facility unsupervised. An elopement risk assessment performed by the DON on 4/4/17, deemed Resident #1 was not an elopement risk and her wanderguard bracelet was removed at that time. 7. The SA validated through record review and interview that the DON arrived to the facility on [DATE] at 1:00 PM, and checked the function ability of all four (4) exit doors with no problems noted. 8. The SA validated through record review, observation, and interview that an elopement risk assessment was performed on all residents on 7/21/18 at approximately 2:00 PM, by the DON, and Resident #1 was identified as the only new resident at risk. Another resident, previously identified as an elopement risk, had on a functioning wander guard bracelet. Both residents risk for elopement care plans were reviewed by the DON and Resident #1's care plan was updated to reflect the 7/21/18 elopement and the intervention of the wander guard bracelet was implemented and carried out by the DON. The other resident's care plan was reviewed without any issues noted. Residents with Wander guards are monitored each shift for placement of wander guard and daily for function of the wander guard by the Shift supervisor and the medication cart nurse and is documented in the transmitter log and the Electronic Treatment Administration Record (ETAR). 9. The SA validated through interview and record review that an Elopement Policy and Prevention In-service began on 7/21/18 at approximately 2:45 PM, by the DON. This policy defined elopement, identified common triggers, lists way to keep residents from leaving the facility and defines what to do if a resident is missing. The total number of staff inserviced on 7/21/18 was 12, which included one (1) Registered Nurse, four (4) Licensed Practical Nurses and seven (7) Certified Nurses Assistants. The remaining 45 staff members included Therapy, Dietary, Housekeeping and Maintenance were inserviced through 8/2/18, by the DON and Department Managers. No staff were allowed to work unless inserviced. The SA validated through interview of four (4) Certified Nurses Aide and one (1) Agency Certified Nurses Aide, one (1) Licensed Practical Nurse, one (1) Registered Nurse Agency, one (1) Therapist, one (1) Maintenance, one (1) Housekeeping and one (1) Dietary employee. 10. The SA validated through record review, sign in sheet review, and interview that a Quality Assurance committee (QA) meeting was held 7/23/18 at 8:30 AM. The Medical Director, Administrator, Director of Nurses, Assistant Director of Nurses, Unit Supervisor, Social Services Coordinator and MDS supervisor were in attendance. The elopement of Resident #1 on 7/21/18, staffing, updated care plans, elopement policy, elopement drills, and 100 percent of elopement assessments that hd been performed were discussed. No further recommendations were made at that time. 11. Through record review and interviews, the SA validated that elopement drills were performed on all three (3) shifts on 7/23/18, by the DON and the Social Worker, beginning at 1:19 PM, and all staff responded appropriately. 12. The SA validated through interviews and observation, signs stating Attention Visitors, when exiting the facility use caution to only exit with member of your party were placed on all four (4) exit doors on 7/30/18 at 2:00 PM, by the DON. 13. The SA validated through interview and record review, the Attorney General's Office was notified by Email on 7/21/18, and the State Office of Licensure and Certification was notified on 7/26/18, by phone and fax, by the DON, about Resident #1's elopement. 14. The SA validated through interview and record review that the facility's corrective actions to be remove the Immediate Jeopardy (IJ) were completed on 8/2/18, and the IJ was removed as of 8/3/18.

Based on staff interview, record review and facility policy review, the facility failed to follow a care plan that indicated the care that was to be provided to Resident #1 who required the use of a full body lift for one (1) of three (3) care plans reviewed. Findings Include: Review of facility policy titled Care Plan and dated August 2006, revealed, the nurse uses the care plan to complete the Certified Nursing Assistant (CNA)'s daily/weekly work assignments and/or flow sheets. All staff are to follow the resident's care plan. Review of the Activity of Daily Living (ADL) check sheet dated January 2016 and documented by the Certified Nursing Assistant (CNA)'s revealed: Resident #1 required two (2) or more(staff) physical assistance with transfers. Review of Resident #1's care plan with initiation date of 04/24/15 and current through 03/28/16 revealed, Total mechanical lift required for all transfers. Always use two (2) assist with all lifts. Interview with CNA #1 on 02/04/16 at 4:40 PM confirmed that there is an ADL care guide for Resident #1 to indicate the type of lift that is required and how many staff members are required to use the full body lift. CNA#1 stated, she had an ADL care guide for Resident #1 and that it indicated to use two (2) people. CNA #1 further stated that she got in too big of a hurry to get the resident back into bed due to her shift coming to an end. She also stated that she did not ask for help with Resident #1's transfer. Interview with Social Services (SS) #1 on 02/05/16 at 11:50 AM confirmed that Resident #1 had a care plan for the full body lift with two (2) people to assist, prior to the injury. SS#1 confirmed that she helped to investigate this incident and that she reviewed the care plan on 01/23/16 and the facility held a care plan meeting to review Resident #1's care plan and SS#1 confirmed that the care plan was not followed by CNA #1 and that she did not utilize two (2) staff members while transferring the resident from her Geri chair to the bed using the full body lift alone. Resident #1 was admitted into the facility on [DATE] with diagnoses, which included [MEDICAL CONDITION] and Arthritis. The most recent Minimum Data Set (MDS) with Assessment Reference Date of 12/28/15 revealed Resident #1 had severe cognitive impairment.

Based on observation, staff interviews, record review and facility policy review, the facility failed to prevent an accident for Resident #1 who was assessed for a full body lift with assistance of two (2) persons and was transferred by one staff member that resulted in an injury for Resident #1. One (1) of three (3) residents were reviewed for lifts. Findings Include: Facility policy titled Mechanical Lift and Sling dated 08/24/06, and reviewed on 01/27/16, revealed: It is required that two (2) assistants be used for ALL lifting preparation, transferring from and transferring to procedures. Review of the user manual for Invacare Reliant 600 Portable Patient Lift dated 2011, revealed, Lifting the Patient: Invacare recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures. Review of a Nursing Departmental Note dated, 01/23/16 at 2:30 PM, revealed Resident #1 was being transferred from her Geri Chair to the bed via total lift, the lift pad was not hooked properly, and the resident fell out of the lift pad hitting her right leg on the floor. Resident #1 had a deep laceration with adipose tissue exposed across the right lower leg shin and blood was observed running from her right lower leg into her sock. The foot was noted to be unstable. Rolled towels were placed over and around the laceration for splinting support until the ambulance could arrive. Resident #1 was grimacing in pain and guarding the right leg. When ambulance personnel arrived, they administered pain medications intravenously and had to splint the right foot further before transport to the hospital. Initial written statement from Certified Nursing Assistant (CNA) #1 on 01/23/16, who was transferring Resident #1 without assistance, stated, I was getting her up with the lift and one of the straps had come out of the ring and she fell out of the lift on her leg. Initial written statement from Registered Nurse (RN) #1 on 01/23/16 revealed, Once the resident left the facility by ambulance, I personally checked the function of the total lift involved before it was used again, and it was functioning properly. Initial written statement from the Director of Nursing (DON) on 01/23/16 revealed that CNA #1 was attempting to transfer Resident #1 with the mechanical full body lift without assistance. It appeared that Resident #1 had sustained a fracture to her right lower leg as a result of falling from the lift. All lifts were inspected and all lifts were functioning properly. Record review revealed Resident #1 had an initial Lift/Transfer Assessment dated 07/13/15 that indicated the use of a total lift with a two-person assist required. Record review of the hospital admission history and physical dated 01/23/16 revealed, The patient was apparently being moved at the nursing facility when she was dropped. She was found to have an open distal tibia and fibula fractures. On examination of her right leg, she has a very large open laceration over the anterior aspect of her leg approximately 6 to 8 centimeters in length proximal to the ankle joint. This needs to be addressed surgically and also to stabilize her fractures. Activity of Daily Living check sheet dated January 2016 and utilized by the CNA's revealed, Transfers, two or more physical assist. CNA in-service dated 10/21/15 revealed all lift transfers require 2 person assist. The same document revealed that CNA #1 attended and signed the in-service. Interview with CNA #1 on 02/04/16 at 4:40 PM stated, I couldn't find anyone to help me. I know I was wrong. CNA #1 stated that the rest of the staff were in rooms assisting other residents, because when she looked out into the hallway she didn't see anyone to help her transfer Resident #1. CNA #1 confirmed that she just got in too big of a hurry because it was the end of her shift and she wanted to get the resident back into the bed. CNA #1 stated, she had not told anybody she needed help and almost had Resident #1 to the bed in the lift and she slid out of the lift sling and fell on the floor and landed on her leg. CNA said she yelled for help. CNA #1 further stated she knew she wasn't going to be able to keep her job after the incident with Resident #1. Interview with RN #1 on 02/04/16 at 6:15 PM confirmed she heard CNA #1 yelling and screaming from the room of Resident #1. RN #1 arrived in the resident's room and observed her on the floor with blood on her sock and on the floor. The blood was running from the resident's right lower leg into her sock. RN #1 stabilized her leg and we called for the ambulance. CNA #1 was crying, very upset, and was repeating, This is my fault, I did this. RN #1 confirmed that she asked CNA #1 why she did not get help to transfer Resident #1 using the full body lift and she was repeatedly apologizing and stated that she was just trying to get her work done because it was the end of her shift and she just wanted to get her back in the bed. RN #1 confirmed that she immediately checked the full body lift after the resident left the facility by ambulance. The lift, lift pad, and the lift mechanism was working properly. Interview with the DON on 02/04/16 at 4:30 PM confirmed that in-services were provided on 05/28/15 and again on 10/21/15 regarding the full body lifts and that all staff are required to utilize two (2) staff members for transfers to prevent injuries. The DON also confirmed that they follow the manufacturer's recommendations for the Invacare 600 full body lift and it recommended two (2) people for transfers. The DON confirmed that CNA #1 was immediately suspended pending the investigation and was terminated on 01/26/16 because she did not follow the protocol with the full body lift. Resident #1 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Mininum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/28/15 revealed that Resident #1 had severe cognitive impairment.

Based on observation, record review, interview and policy review the facility failed to follow the plan of care to ensure a resident had two person assist during a transfer with a sit to stand lift for one of nine sampled residents transferred by lifts. The failure of the facility to follow the resident's care plan resulted in the resident suffering a dislocated shoulder on 08/06/14. (Resident # 7) Findings include: A review of the facility's policy entitled "Total Care Plan Policy", updated 04/15/09, documented "It is the policy of this facility that the Interdisciplinary care plan will be done as follows: Identify problems that affect the resident and his/her care needs. Address areas identified on the MDS (Minimum Data Set) and RAP's (Resident Assessment Protocols). Identify the interventions related to the specific problems." A review of Resident #7's "Selected Care Plan," revised 02/13/14, documented "RISK FOR FALLS. Approaches included: MANUAL LIFT 1-2 FOR TRANSFERS OR MAY USE STANDUP LIFT WITH 2 ASSIST TO TOILET." A review of an investigation, provided by the facility on 08/06/14, concluded on 08/04/14 at 1:30 PM, Resident #7 was being assisted in the shower, using a sit to stand lift, by CNA (Certified Nursing Assistant) #3. CNA #3 failed to follow facility's policy and procedure of using two assist during lift transfer. During the transfer the resident's legs started to give and the resident could not hold herself up with her arms. The CNA reported she attempted to lower the lift hand bars but the remote on the lift would not go down. The investigation revealed the resident had to be manually removed from the lift to the floor. As a result of the facility's failure to have two person assist with transfer per policy and care plan the resident suffered a dislocation of the left shoulder. During initial tour on 08/06/14 at 8:45 AM, Resident #7 was observed lying in bed with a sling on the left arm and shoulder. During an interview on 08/08/14 at 1:00 PM with RN #3, responsible for care planning, she affirmed Resident #7's was care planned for two person assist with the use of the stand up lift. During an interview on 08/08/14 at 1:20 PM the Administrator acknowledged Resident # 7 was care planned to have two person assist with the stand up lift. The Administrator also affirmed that on 08/04/14 Resident #7 was being transferred with a sit to stand lift with one staff present. The administrator affirmed that as a result of the facility's failure to follow the care plan of two person assist with the lift, the resident suffered a dislocated shoulder, which required a trip to the emergency room .

Based on observation, record review, staff interview, facility report and policy review the facility failed to ensure adequate supervision of two staff while utilizing a sit to stand lift and failed to ensure the remote for a mechanical lift was maintained in a manner to prevent a malfunction in the operation of the lift for one (1) of nine (9) sampled residents reviewed for transfers with lifts. The lack of two person assist and the malfunction of the lift remote on 08/04/14 resulted in Resident #7 suffering a dislocated shoulder while being transferred with the lift. (Resident #7) Findings include: A review of information on the Standup and transport slings, provided by the facility documented "WARNING, Invacare recommends that two (2) assistants be used for ALL lifting preparation, transferring from and transferring to procedures." A review of an "Accident/Incident Investigation" provided by the facility revealed on 08/04/14 Resident #7 was being transferred in the shower room by a Certified Nurses Assistant (CNA) #3 with a sit to stand lift when the lift malfunctioned. The resident was manually removed from the lift. As a result the resident suffered a dislocated shoulder and was transferred to the emergency room . A review of the "Resident Incident Follow-up Report", dated 08/04/14, documented, "Lift taken off hall for Maintenance to fix. CNA suppose (supposed) to have assist when using lift. Only one CNA (symbol for with) pt (patient) using lift." A review of the "Nurse's Notes," dated 08/04/14, documented, "13:30 (1:30 PM) Called to shower room. Pt (patient) is lying in floor on her back. Pts left arm is above her head. Pt unable to move her left arm. Pts L (symbol for left) shoulder appears to be turned upward. CNAs stated pt was slipping from sit to stand lift and CNA eased pt to the floor." The entry was signed by Registered Nurse (RN) #2. A review of the hospital "history and physical examination [REDACTED]. Somehow her left arm became dislocated, with obvious deformity and she was in marked distress, with her arm over her head. In the emergency room , x-rays were taken showing anteroinferior dislocation of the left shoulder. After she was given 1 mg (milligram) of Dilaudid and .05 of Ativan intravenously, the shoulder was able to be reduced with moderate difficulty. During initial tour on 08/06/14 at 8:45 AM Resident #7 was observed lying in bed with a swathe and sling on the left arm and shoulder. An attempt was made to interview CNA #3, but was unable to contact the CNA by phone. During an interview on 08/07/14 at 4:00 PM, CNA #2 said she was at the nurse's station on 08/04/14 at about 1:00 PM when the Emergency light came on in the shower room. She said CNA #3 was standing outside the door and asked her to come to the shower room. CNA #2 said Resident #7 was up in the sit to stand lift with her arms in an upward way. She said another CNA came into the shower after her and used her pen to mash the emergency button on the lift. The CNA said they eased Resident #7 down on the floor and ran to get the nurse. CNA #2 said the remote of the lift would go up and then would not come down. She said maintenance comes from hospital and the remote would work for 2 or 3 days. CNA #2 said two people are required to use lift. She acknowledged that there was not two staff in the shower with Resident #7. During an interview on 08/07/14 at 8:35 AM, CNA #4 said she had trouble with pressing the remote on the lift. It would not work. She said the batteries were changed and it works for a while. During an interview on 08/07/14 at 8:10 AM, CNA #5 said sometimes the remotes did not work properly with the lifts. The batteries would go dead. During an interview on 08/07/14 at 2:35 PM, RN #3 said staff had voiced concerns about the lift batteries not staying charged. She said maintenance from the hospital had been over several times to fix the remotes. The maintenance service was provided by the attached hospital maintenance department. Monthly maintenance logs were provided by the department and reviewed. During an interview on 08/08/14 at 1:20 PM, the Administrator acknowledged on 08/04/14, Resident #7 was transferred with a sit to stand lift with one staff present. The Administrator affirmed Resident #7 had to be sent out to the hospital with a dislocated shoulder. The facility admitted Resident #7 to the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of 05/14/14 identified Resident #7 with a BIMS (Brief Interview for Mental Status) Score of three (3) or cognitively impaired. The resident required extensive assistance to total dependence on staff for all Activities of Daily Living (ADLs.)

Based on observation, record review, staff interview and policy review the facility failed to prevent a accident with injury for one (1) of three (3) residents reviewed for falls with injuries and one (1) of one (1) residents in the facility with a floor mat alarm (Resident #10). Findings include: Record review revealed that Resident #10 was admitted to the facility the facility on 6/24/99 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 4, which indicated that Resident #10's cognitive status was severely impaired. Review of Resident #10's physician's orders [REDACTED]." Review of the nurse's notes for 3/3/12 at 1:15 p.m. noted: "Called to pt's (patient's) room. Pt had attempted to get into her bed. Pt had unbuckled her self release alarm belt, attempted get into her bed unassisted, found pt laying on her back parallel to her bed, writer asked pt does she have any pain, writer touch both hips, pt complained of pain to left and right hips, ... assisted to bed, no redness, no bruising, no open wounds, no skin tears at this time." Review of the Diagnostic Imaging Report for 3/3/12 at 2:04 p.m. from a local hospital noted: "Indeterminate fracture of the left hip." Review of the Occurrence Report for Resident #10, dated 3/3/12 at 1:15 p.m., noted: "Found on floor lying on her back parallel to bed. Res (resident) unbuckled self release alarm belt which alert staff- alarm on floor mat sounded also. Res c/o (complained of) pains to the L (left) & (and) R (right) hips upon assessment. Sent to ER (emergency room ) per MD (Medical Doctor) - Res had just been cautioned not to go to (her) room by several staff inclusion (including) nurse. Res was in dining room (at a) table with wheelchair locked previously." Review of the QA (Quality Assurance) Investigation for Resident #10's fall with fracture on 3/3/12 noted: " ... As a result of this incident, the nurse aide who failed to use the floor mat with alarm has been terminated due to failure to carry out her job duties and responsibilities. A new policy has been implemented for use of any audio alarming devices. The policy includes that nurse aides are to check all assigned residents with audio alarm devices to ensure that the alarm is in place and functioning properly ... The audio alarm checks for placement and function have been added to the nurse aide's ADL records and the nurse's daily treatment sheets. All staff has been directed as to what protocol to follow if an audio alarm is identified not being in place and not functioning properly. A mandatory in-service was held with all employees to present and review the new audio alarm device policy. It was reviewed in detail of what is expected and what the consequences would be if failure to do so was determined. The 11 to 7 nurse aide who was assigned this resident has been counseled regarding the audio alarm mat not being in place when the 7-3 nurse aide came on duty. A personnel action has been issued for this 11-7 nurse aide ..." Interview, via telephone, on 7/13/12 at 11:15 a.m. with Certified Nurse Aide (CNA) #1 revealed, "I usually worked the 3-11 (p.m.) shift PRN (as needed by the facility); On 3/3/12 I was assigned to work the 7-3 shift with (name of Resident #10). There was no floor mat alarm on the side of (name of Resident #10)'s bed during the beginning of the shift and I assisted the resident to the wheelchair. I was thinking the floor mat alarm was placed on the side of (name of Resident #10)'s bed during the night shift only; (name of Resident #10) was left in the dining room with the wheelchair locked and the self release seat belt alarm in placed when I went on my lunch break; I made Registered Nurse (RN) #1 (the charge nurse) and CNA #2 aware that I was leaving for lunch at approximately 12:30 p.m. with CNA #6. CNA #2 was assigned to monitor the dining room during the lunch meal. RN #1 was also, in the dining room; I was not aware that Resident #10 was able to unbuckle the seat belt alarm. I was told by CNA #2 that Resident #10 had a fall after returning from lunch break; (name of Resident #10) was in the bed and transferred to the local hospital by 2 staff person; I was not in-serviced on (name of Resident#10)'s floor mat alarm. " Interview on 7/13/12 at 11:30 a.m. with Certified Nurse Aide (CNA) #3 revealed, "I heard CNA #2 yelling for help approximately 12:30 p.m. (name of Resident #10) was on the floor and no alarm was sounding. They (staff) may have cut the alarm off. (Name of Registered Nurse #1) okayed us to place (name of Resident #10) back to bed. I am not aware of an in-service on the floor mat alarm before this incident. Interview on 7/13/12 at 11:45 a.m. with Certified Nurse Aide #2 revealed, "I was assigned to monitor the dining during the lunch meal. I did not see (name of Resident #10) leaving the dining room after the lunch meal. I was picking up meal trays from Hall #3 (Rooms 421 - 425) and heard Unsampled Resident B (Resident #10's roommate) yelling around 1:00 p.m. Usually we can hear the floor mat alarm go off when she rolls over it in the wheelchair. I got the nurse and we assisted (name of Resident #10) back to bed after being checked out by the nurse. We had to body lift her back to bed. I told CNA #1 about (name of Resident #10) fall after she returned from lunch. The floor mat alarm and the chair alarm failed to alarm/sound. I checked the floor mat alarm and it failed to alarm after I stepped on it. The battery may have been down. We were in-serviced on the floor mat alarm by the Director of Nurses after the incident. (Name of Resident #10) was part on the floor mat alarm and part on the floor. (Name of Resident #10) was able to un-buckle the self release belt alarm. I am not sure of hearing the chair alarm." Interview on 7/12/12 at 12:10 p.m. with Certified Nurse Aide (CNA) #4 revealed, "Around 12:30 p.m., I was told (name of Resident #10) had fallen and CNA #1 was gone to lunch. I was assigned to work hall #1. We can hear the alarm going off if it was working; I was not in-serviced on (name of Resident #10) ' s floor mat alarm until after the incident." Interview on 7/13/12 at 2:15 p.m. with Licensed Practical Nurse #2 revealed, "I worked the 11 to 7 shift on 3/2/12. I have to push the floor mat alarm under the bed to keep from stepping on the mat during the 5:00 a.m. medication pass. I pull it back out when I finish giving (name of Resident #10)'s medication. (Name of Resident #10) usually sleeps all night. I am not sure what time she gets up. Usually I think she is up at 7:00 a.m. I was not in-serviced on the floor mat alarm before the incident on 3/3/12." Record review revealed there was no documented evidence that the facility in-serviced the staff on the floor mat alarm before the incident on 3/3/12, and there was no documented evidence that the facility had a monitoring system in place to ensure that the floor mat alarm was functioning properly. Interview with the Director of Nurses on 7/13/12 at 12:25 p.m. revealed a monitoring system was put in placed on 3/13/12. A facility policy was developed to address the Audio Alarm Device on 3/15/12 and the staff in-service was started on 3/15/12 on the new policy and the floor mat alarm. Interview on 7/13/12 at 3:40 p.m. with Licensed Practical Nurse #5 revealed, "I work the 7 to 3 shift on 3/3/12 on A Hall. I was gone to lunch during (name of Resident #10)'s fall. I was told about the fall after returning from lunch. I was in-serviced after the incident." Interview, via telephone, on 7/13/12 at 4:00 p.m. with (name of Resident #10)'s physician revealed that he was made aware by the Administrator of the facility ' s policy changes, in-service and monitoring system being put in place after (name of Resident #10)'s falls on 3/3/12.