**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, for one Resident (#22) of 28 sampled residents , the facility failed to develop and implement a baseline care plan that includes instructions needed to provide effective and person-centered care for him/her, resulting in a fall, requiring nine stitches to his/her right ear. Findings include: Resident #22 was admitted to the facility in January 2023 with diagnosis including dementia, and depression. Review of his/her most recent Minimum Data Set (MDS) dated [DATE] indicated that he/she is severely cognitively impaired and requires extensive 1-person physical assist with ambulation, transfer, bed mobility and toilet use. Review of the facility policy titled comprehensive person-centered care plan-baseline care plan, dated 12/12/22 indicated: -The Baseline Care Plan must be developed and implemented within 48 hours of a resident's admission (both new admissions and re-admissions). The baseline care plan must include the instructions and healthcare information necessary to properly care for a resident including, but not limited to the following: -initial goals based on admission orders. -physician orders. -dietary order -therapy services -social services -PASARR recommendations, if applicable. -The baseline care plan must reflect the resident's stated goals and objectives and include interventions that address his or her current needs. It must be based on the admission orders, information about the resident available from the transferring provider and discussion with the resident and resident representative, if applicable. Because the baseline care plan documents the interim approaches for meeting the resident's immediate needs, professional standards of quality care would dictate that it must also reflect changes to approaches, as necessary, resulting from significant changes in condition or needs, occurring prior to development of the comprehensive care plan. Facility staff must implement interventions to assist the resident to achieve care plan goals and objectives. Review of the nurse progress notes dated 1/24/23 indicated that Resident #22 was found in the social service office across from the day room. Resident #22 was lying on the floor next to a table and had a cut/laceration on his/her right ear. Resident #22 was transferred to the Emergency Department for further evaluation. Resident #22 returned from the hospital on the same day with nine stitches on his/her right ear. Review of Resident #22's admission falls risk assessment indicated the following: -history of falls within the last 6 months. Resident #22 had fallen 1-2 times. -total incontinence with bladder and bowel. -unable to independently come to a standing position. -uses and assistive devices (cane/walker) Review of the record indicated that a baseline care plan was created on 1/20/23. Further review of the baseline care plan failed to address Resident #22's risk for falls within 48 hours of admission. During an interview with Nurse #5, on 1/25/23 at 10:20 A.M., she told the surveyor that Resident #22 fell and obtained laceration on his/her right ear 4 days after admission. She told the surveyor that Resident #22 was assessed and identified as high fall risk during the admission. She acknowledged that the fall care plan and interventions for Resident #22 were not initiated until Resident #22's fall on 1/24/23.

Based on observation, record review and interview the facility failed to ensure standards of quality of care for 2 Residents (#18 and #44), out of a total sample of 28 residents. Specifically, 1). for Resident #18 the colonoscopy preparation instructions were not followed, resulting in the procedure not occurring as planned and Resident #18 requiring hospitalization for dehydration and 2). for Resident #44 A. to ensure daily treatment to his/her right second toe was provided in accordance with the physician's orders, resulting in failure to monitor the wound for changes, pain, signs and symptoms of infection. Further, the treatment that was provided included a dressing which was not indicated by the physician's order potentially resulting in keeping the area moist and not dry. B. failed to identify, report, monitor and obtain treatment orders for an area on Resident #44's right third toe, which was observed as an area of black scabbed skin consistent with eschar (dark scab of dead skin.) and C. failed to identify an area on the base of the right great toe that had a dressing and protective bandage applied, with no order or treatment plan for monitoring the area, or plan to provide a treatment or dressing. Findings include: 1. For Resident #18, the facility failed to ensure that hospital recommendations for his/her colonoscopy bowel preparation were done in accordance with professional standards of practice. Resident #18 was transferred to the emergency department due to dehydration caused by the facility's failure to ensure his/her colonoscopy preparation was followed as recommended. Resident #18 was admitted to the facility in October 2021 with diagnoses including hypertension, depression, and anxiety disorder. Review of the Minimum Data Set (MDS) assessment, dated 3/16/23, indicated that the Resident scored a 15 out of possible 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated that Resident #18 was cognitively intact. During an interview on 5/23/23 at 8:00 A.M., Resident #18 said that on 5/16/23 he/she was scheduled for an outpatient colonoscopy procedure, but he/she was transferred to the emergency department due to low blood pressure and a change in mental status. Resident #18 said that he/she was dehydrated due to inappropriate administration of his/her colonoscopy prep. Resident #18 said that he/she received the bowel preparation kit for four straight days (5/13/23 through 5/16/23). Resident #18 told said that he/she spent two days at the hospital receiving IV (intravenous) fluids and his/her blood pressure was monitored until it was stabilized. Review of Resident #18's medical record indicated the Resident had been scheduled to have a colonoscopy (an exam to check for irritated tissues, polyps or cancer in the large intestine and rectum) on 5/16/23 at 12:00 P.M. Further review of Resident #18's medical record indicated recommendations for the Resident's colonoscopy bowel prep including the following: -Three days before the colonoscopy: begin a low-residue diet. -The day before the colonoscopy: -Begin a clear liquid diet as soon as you wake up. Be sure to drink plenty of clear liquids throughout the day. -At 7:00 P.M., give suprep bowel prep kit (an osmotic laxative used for cleansing the colon as preparation for colonoscopy) dose #1: must complete step 1 to 4 before going to bed. -Step 1: pour 6-ounce bottle of suprep liquid into a mixing container. -Step 2: add cool drinking water to 16-ounce line on the container and mix. -Step 3: drink all the liquid in the container. -Step 4: drink two more 16-ounce containers of clear liquid over the next hour. -The day of colonoscopy: -6 hours before the schedule procedure time: -suprep dose #2: drink the second 6-ounce bottle of suprep, following the same 4 steps as last night. Review of Resident #18's physician's orders indicated the following: -An order dated 5/10/23 for suprep bowel prep kit oral solution 17.5-3.13-1.6 GM/177 ml (sodium sulfate-potassium sulfate-magnesium sulfate), give 6-ounce of suprep bowel oral solution (177 ml), mix with cold water on 5/13/23. -An order dated 5/10/23 for suprep bowel kit oral solutions 17.5-3.13-1.6 GM/177 ml (sodium sulfate-potassium sulfate-magnesium sulfate), give 16-ounce of suprep bowel oral solution (473 ml), mix with cold water on 5/14/23. -an order to give stat (immediately/without delay) suprep bowel kit oral solutions 17.5-3.13-1.6 GM/177 ml (sodium sulfate-potassium sulfate-magnesium sulfate, give 32-ounce of suprep bowel oral solution (946 ml), mix with cold water. Review of the May 2023 Electronic Medication Administration Record (EMAR) indicated the following. -On 5/13/23 at 7:00 P.M., Resident #18 received 6-ounces of suprep bowel oral solution, mixed with cold water. -On 5/14/23 at 10:00 A.M., Resident #18 received 16-ounces of suprep bowel oral solution, mixed with cold water. -On 5/15/23 10:17 P.M., Resident #18 received 32-ounces of suprep bowel oral solution, mixed with cold water. On 5/23/23 at 1:42 P.M., Nurse Practitioner (NP) #1 was interviewed via telephone. She said she was aware of Resident #18's colonoscopy and preparation. She said she would follow whatever the recommendations were as far as colonoscopy prep. The surveyor reviewed the physician's order for colonoscopy prep with NP #1 and she said she wrote an order for suprep bowel oral solutions to start on 5/13/23 and 5/14/23 and a stat order 5/15/23 through 5/16/23. She said she was aware that Resident #18 was transferred to a hospital emergency department for evaluation and treatment on the day of his/her colonoscopy, but she was not aware that Resident #18's dehydration was caused by the colonoscopy prep. On 5/23/23 at 1:54 P.M., Unit Manager (UM)#1 was interviewed, and she said she reviewed and carried out the NP order for suprep bowel oral solution from 5/13/23 through 5/15/23. She said Resident #18 received the suprep bowel solution kit on 5/13/23, 5/14/23, 5/15/23, and 5/16/23. During a follow up interview on 5/24/23 at 8:05 A.M., Resident #18 said he/she spent most of his/her time using the bathroom and that a few times he/she did not make it to the toilet. Resident #18 said he/she felt shaky and dizzy from 5/14/23 through the day of his/her colonoscopy procedure. Resident #18 said on 5/16/23, the day of his/her colonoscopy, the nurse gave him/her another suprep bowel oral solution at 6:00 A.M. Review of Resident #18's hospital report dated 5/16/23 indicated Resident #18 was scheduled for an outpatient colonoscopy but was referred to the emergency department due to abnormal laboratory results and was diagnosed with an acute kidney injury due to dehydration caused by the colonoscopy prep. Resident #18 received albumin (used to treat low blood volume) intravenously (IV) at the hospital. On 5/24/23 at 1:27 P.M., NP #1 was interviewed via telephone. She said she was not the NP on call the weekend of 5/13/23 and 5/14/23. She said she was not aware Resident #18 had a complaint of dizziness and being shaky while on call for the weekend of 5/13/23 and 5/14/23. She said the report that she received from the nurses at the facility was that Resident #18 was taking fluids well. On 5/26/23 at 10:25 A.M., Nurse #4 was interviewed via telephone. Nurse #4 said she worked on 5/15/23 during the evening, 3:00 P.M.-11:00 P.M. shift and was the nurse providing care for Resident #18. Nurse #4 said she gave suprep bowel oral solution for Resident #18 around 10:00 P.M. On 5/26/23 at 12:24 P.M., Nurse #8 was interviewed via telephone. Nurse #8 said she worked on 5/15/23 during the 11:00 P.M.-7:00 A.M. overnight shift and was the nurse providing care for Resident #18. Nurse #8 said she gave suprep bowel oral solution for Resident #18 around 6:00 A.M. on 5/16/23. The facility failed to follow recommendations for colonoscopy prep for Resident #18, resulting in the Resident receiving an excessive amount of the preparation solution and developing an acute kidney injury with dehydration requiring an acute transfer and intravenous fluids and medications.2. Resident #44 was admitted to the facility in March 2023, with diagnoses that include but are not limited to cerebral infarction, depression, dependence on renal dialysis, end stage renal disease, chronic obstructive pulmonary disease, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene (dead tissue caused by lack of blood supply). Review of the facility's policy, titled Skin Management Program, Skin Assessment and Surveillance, not dated indicated, in part, the following: To minimize the development of pressure ulcers through the systemic and regular inspection of the resident's skin, and to ensure early detection and intervention for all skin problems. 2. Residents will undergo a weekly body check by the licensed nurses. The facility will utilize the weekly body check form. 3. Certified Nursing Assistants will inspect the skin of each resident during care and whenever skin care is provided and report to the license nurse of the following changes in skin condition but not limited to: Redness, inflammation or swelling, skin breaks, cracks or blisters, discoloration, pain and tenderness, 4. Licensed Nurses will respond to reports of skin problems and assess the resident's skin as soon as possible. 5. If an area is identified, the physician will be notified, and a treatment will be obtained. 11. Licensed Nurses on the units shall monitor the completion of preventative and restorative measures and routines. Review of the Minimum Data Set (MDS), with an Assessment Reference Date of 3/15/23 indicated Resident #44 scored a 15 out of 15 on the Brief Interview for Mental Status Exam indicating intact cognition, required extensive assistance with daily care including bed mobility, bathing, dressing and hygiene. Further review of the MDS identified Resident #44 as having diabetic foot ulcer(s). Review of Resident #44's medical record indicated the following: *N Adv Skilled Evaluations dated: 3/11/23, 3/12//23, 3/15/23, 3/19/23, 3/23/23, 3/25/23, 3/27/23, 4/4/23, 4/17/23 all indicated skin issue location #1 Right toe, diabetic foot ulcer, the skin note is blank with no further documentation of description of the skin issue (wound), odor, tunneling, undermining, treatment schedule or status of the wound. *Mass-Skin check-weekly dated 4/24/23, is skin intact? no. Findings of skin check right toe: Second dorsal toe: necrotic (dead tissue.). Treatments Wash right second dorsal toe-clean with wound cleaner, pat dry, apply iodine (a topical treatment used to treat and prevent infection,) skin prep. *N ADV Skilled Evaluation dated 4/27/23 indicated skin issue location #1 right toe, skin issue #1, other skin issue, description Necrosis, wound odor: No, tunneling: No, Undermining: No, treatment schedule: daily, status: no change. *Mass-Skin check-weekly dated 5/16/23, is skin intact? no. Findings of skin check: site and description not filled in and left blank. Treatments Wash right second dorsal toe-clean with wound cleaner, pat dry, apply iodine skin prep. *A care plan, focus: Resident has Diabetes Mellites, dated 3/11/23 with interventions dated 3/11/23, Check all of body for breaks in skin and treat promptly as order by the doctor. *Review of Resident #44's physician's order summary report indicated the following: Diabetic Foot Care, every evening shift for monitoring dated 3/9/23. *A Nurse Practitioner progress note dated 3/13/23 which did not include an assessment or plan related to the right necrotic dorsal toe. *A Physician's progress note dated 3/30/23 which did not indicate any assessment/nor addressed Resident #44's right necrotic dorsal toe. *A Podiatrist visit progress note dated 4/11/23 indicated podiatric diagnosis (es) right 2nd toe dry gangrene: type 2 Diabetes Mellitus with peripheral. Circ. Disorders, onychomycosis: peripheral Neuropathy. Recommend New Orders: Yes, right 2nd toe dry gangrene, please keep the area dry and clean daily betadine painting is recommended. Please monitor for any signs of infection or converting to wet gangrene, consult vascular surgeon for appropriate treatment. Review of the Physician's orders indicated the following: -Wash Right second dorsal toe-Clean with wound cleaner, pat dry, apply iodine skin prep. Every day shift for arterial wound, dated 3/10/23. During an interview on 5/23/23 at 10:15 A.M., Resident #44 was observed resting in bed wearing yellow antiskid socks with protective boots on both feet. Resident #44 said he/she had a dressing on his/her right foot that was done over a week ago, and since then no one has taken his/her sock off to look at it. Resident #44 said he/she had pain in his/her right foot and has a black toe on his/her right foot. Resident #44 said he/she had an upcoming appointment for his/her toe in June. During an interview on 5/23/23 at 3:44 P.M., Nurse #2 (who worked the day shift) said she had not done the treatment for Resident #44 yet. The surveyor asked Resident #44, and he/she agreed the surveyors could be present for the treatment. On 5/23/23 at 4:39 P.M., the treatment was observed by the surveyors. Nurse #2 and Nurse #3 were present and completed the treatment. The following was observed: -The yellow slipper sock was removed from Resident #44's right foot. -Resident #44 grimaced and said it hurt. -A gauze bandage was around Resident #44's foot, covering his/her toes. -Tape on the dressing was dated 5/11/23 with initials VC. This was 13 days prior to the observation. -Nurse #3 removed the dressing, which had dark colored stain/drainage on it. -Resident #44's foot was scaley and dry, with flakes of skin landing on the blue protective boot holding his/her foot up. -Right black second toe: - - was black/with a buildup of gold coloring and a small white patch located over the black dead tissue. - - bottom had clear fluid on the edge at the bottom of the toe wound. - - wound was observed to be lifting toward the bottom of the black second toe wound. - Right third toe: -A dark scabbed area was observed (no identified and no treatment ordered). Right great toe: -A quarter inch foam dressing was observed, held in place by a blue bandage beneath the right great toe. -Nurse #3 cleaned the second black toe with wound cleaner and patted it with iodine. -Nurse #2 placed a pad on the second black toe and used gauze to wrap Resident #44's toes and foot (not indicated on the physician's order to use a dressing.) -No treatment was provided for the black area on the third toe. During an interview with Nurse #2 and Nurse #3 on 5/23/23 at the conclusion of Resident #44's treatment, Nurse #2 said Resident #44 was admitted with gangrene of the right second toe. Nurse #2 said the dressing that was removed was dated 5/11/23 and acknowledged the dressing change was to be completed daily. Nurse #3 said they do not always have a third nurse and sometimes treatments do not get done. Nurse #3 said this was her first-time providing treatment of Resident #44's toe. Nurse #2 said she did not know if the wound/gangrene toe looked different or had changed. Further, Nurse #2 and Nurse #3 said they did not know about the dressing that was at the base of Resident #44's right great toe and Resident #44's only treatment was for his/her right second toe. Neither Nurse #2 nor Nurse #3 acknowledged the black area on Resident #44's third toe. Review of Resident #44's medical record did not indicate an order for a treatment or dressing to the area below Resident #44's right great toe. The medical record including progress notes, skin assessments and care plans failed to indicate any documentation of why there was a dressing, what the dressing was treating, or a plan to remove the treatment with a dressing. During a telephone interview on 5/23/23 at 5:20 P.M. the Physician said Resident #44 had the necrotic toe for longer than a year. The Physician said it was a dead toe with gangrene due to Resident #44's poor vascular condition. The surveyor informed the Physician that the dressing that was removed on 5/23/23 was dated 5/11/23. The Physician said the treatment should have been completed as ordered. The Physician said it would be speculation but due to the treatment not being done, along with no monitoring of the dead toe there would be a natural progression that could result in auto necrosis. During subsequent telephone interviews on 5/24/23 at 3:35 P.M., and 5/25/23 at 12:45 P.M., the Physician said he may have last seen Resident #44's right second toe on 3/30/23 and he did not document about the condition of the right toe in his progress note. He said he determined a vascular consult was missed in January and one is set up for June. The Physician said the right toe should be left open to air with no dressing applied. He said the dressing left on would make the area less dry. The Physician said he saw Resident #44's right toe last night, (5/24/23), after removing a dressing. He said he observed a natural lifting at the proximal edge that could be the natural progression of the eschar (dead tissue.) He said the toe should be left open to air after the iodine is painted on the toe. The Physician said he did not change the treatment but may consider changing the treatment based on the lifting at the base of toe but will wait until after a wound consultation is completed. The Physician said he did see the area on the third right toe last evening (5/24/23.) The Physician said it was eschar and could have been there in the past or possible new onset to due chronic ischemia and the beginning of a new dry gangrene. He said he reviewed an image taken at the hospital dated 4/8/23 which indicated the presence of the lesion on the right third toe. The Physician said he was not made aware by facility staff, nor was there a treatment for the area on Resident #44's right third toe. Regarding the treatment observed under the great right toe, the Physician said he speculates the podiatrist may have shaved the side of Resident #44's right foot and put a duoderm dressing on for protection. The Physician said he reviewed the area on 5/24/23 and there was a pink circular area under the dressing. The physician said he was not aware that the dressing was there and that there was no order to monitor the area or to provide any treatment. Review of the podiatrist treatment note dated 4/11/23 did not indicate any treatment to the area below the right greater toe. Orthopedic exam indicated bunion deformity none. During an interview on 5/25/23 at 8:05 A.M., the Regional Corporate Nurse said she was made aware that the dressing to Resident #44's right toe was not completed as ordered and this was disappointing. Regional Nurse reviewed the photo of Resident $44's right foot, that revealed the dark area on the right third toe and the dressing to the right side under his/her right great toe. She acknowledged the area on the right third toe and said it would need to be reviewed. Regional Cooperate Nurse said the area below the great toes looked to be a bunion protector and should have an order and a care plan in place. During an interview on 5/24/23 at 4:30 P.M., Resident #44 said he/she had pain in his/her right toes from neuropathy and said he/she has had increased pain in the last 3 weeks.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed ensure residents identified as being at risk for falls received adequate supervision and revision of care plan interventions as needed to prevent falls, resulting in falls with injury for 2 Residents (#125 and #88) out of a total of 28 sampled Residents. Findings include: Review of the facility's Fall Prevention policy, revised 11/21/21 indicated: Policy: A fall prevention plan will be initiated on all Residents who are at risk for falling. Each Resident will be assessed for risk factors and predisposition. Process: 2. A fall risk assessment will be completed and Residents scoring at risk for falls will have the following interventions. 3. Interventions will be documented on the Residents' care plan and on the CNA (Certified Nurses Aide) care card. the Care plan process will be initiated with individualized interventions and will be reviewed and revised as needed. *If a fall occurs and investigation will be initiated at the time of the incident to determine probable cause and implement further interventions to prevent reoccurrence. After a fall: Update the resident's care plan with new interventions. Communicate interventions to staff caring for this Resident. 1. Resident #125 was admitted to the facility in September 2022 with diagnosis including dementia, chronic obstructive pulmonary disease and anxiety. Review of Resident #125 Minimum Data Set, dated [DATE] indicated he/she scored 10 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating he/she is moderately cognitively impaired. Further review of the MDS indicated Resident #125 requires physical assistance of 1 person with bathing, dressing and ambulation. On 5/23/23 at 9:26 A.M., the surveyor observed Resident #125 laying in bed. Resident #125 was thin/frail, confused and his/her call light string was tied to a handbell. Review of Resident #125's care plans indicated: Focus: Resident has ADL (actives of daily living) self-care performance deficit and physical mobility r/t (due to) activity intolerance, confusion, dementia, 9/28/22. Interventions: Ambulation: Resident requires staff supervision to walk and as necessary. Educate and encourage resident to use assistive devices as needed to provide increased function and safety. Focus: Resident at risk for falls due to confusion, 9/28/22. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The Resident needs prompt response to all requests for assistance, 9/28/22. Review of Resident #125's fall incident report dated 10/8/22 indicated that at 5:25 P.M., Resident #125 was yelling for help and was found by staff seated on the floor next to his/her bed. The incident report indicated: Resident confused, did not give clear information on what he/she was attempting to do. Interventions implemented in response to the fall included: Encourage use of walking device, remind resident to request assist with transfers and ambulation. The interventions implemented to prevent reoccurrence were interventions already in place effective 9/28/22. Additionally, reminders for Resident #125's would be ineffective due to his/her cognition. Review of Resident #125's fall incident report dated 10/13/22 indicated that at 8:00 P.M., the nurse on the unit responded to a commotion and found Resident #125 on the floor next to his/her bed yelling that he/she had fallen. Resident #125 was sent to the hospital and diagnosed with a fractured left wrist, pubic bone fracture and sacral fracture. During an interview with the Director of Nursing on 5/24/23 she said that after a Resident falls, the expectation is for his/her care plan to be updated with new interventions. She said that education and reminders are not appropriate interventions for Residents with dementia. 2. For Resident #88, who was identified as high risk for falls, the facility failed to develop appropriate interventions to prevent fall. Record review indicated Resident #88 had 2 falls since admission, with one resulting in an injury. Resident #88 was admitted to the facility in 2/2023 with diagnoses including fracture of unspecified part of neck of right femur, dementia and repeated falls. The Minimum Data Set (MDS) dated [DATE], indicated Resident #88 scored a 0 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating Resident #88 had severely impaired cognition. In addition, the MDS indicated Resident #88 needed extensive assistance for transfers, bed mobility and locomotion. Resident #88 also had a fall with a fracture prior to admission. Review of a care plan developed initiated on 2/24/23 for falls r/t (related to confusion, deconditioning, gait/balance problems and unaware of safety needs included the following interventions: - Anticipate and meet the resident's needs. - Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. - Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. A fall risk assessment conducted on 3/9/23 indicated Resident #88 was identified as high risk for falls. Record review indicated on 3/9/23 at 1:00 P.M., Resident #88 had an unwitnessed fall in his/her room. Per the nurse's note, Resident #88 was observed on the floor in front of his/her wheelchair with the right leg caught on the leg rest. Resident #88 complained of pain to the right hip and right pelvis. The Nurse Practitioner was notified and ordered an X-ray. The X-ray revealed a dislocated right hip prosthesis. Resident #88 was transferred to the hospital for an evaluation and was diagnosed with a right hip dislocation and osteoporosis. Resident #88 underwent closed reduction surgery (Closed reduction is a procedure to set (reduce) a broken bone without cutting the skin open. The broken bone is put back in place, which allows it to grow back together in better alignment). Review of the facility's investigation indicated Resident #88 was last seen approximately 25 minutes prior to the fall in his/her room. Resident #88's roommate's husband stated Resident #88 tried to get up from the wheelchair and fell. Resident #88 returned to the facility on 3/13/23. The fall care plan was updated on 3/13/23 to include the following intervention: - WBAT to RLE (weight bearing as tolerated to right lower extremity). There were no interventions developed to provide supervision to prevent further falls for Resident #88. Record review indicated on 5/19/23 at around 2:35 P.M., Resident #88 had another unwitnessed fall. Review of the nurses' notes indicated Resident #88's roommate stated Resident #88 fell from the wheelchair. Resident #88 was found on the floor in his/her room lying in front of the wheelchair. Resident #88 was assessed for injuries, no apparent injuries were noted. The fall care plan was updated to include the following: - PT consult. Resident will be put back to bed for a nap after lunch. - Provide activities that promote exercise and strength building where possible. There were no interventions put in place to provide supervision to prevent further falls for Resident #88. On 5/23/23 at 8:30 A.M., Resident #88's door to his/her room was closed. Resident #88 was observed in bed sleeping. At 10:30 A.M., the door to Resident #88's room was closed. Resident #88 was in the room sitting in his/her wheelchair. On 5/24/23 at 8:45 A.M., Resident #88's door to his/her room was again closed. Resident #88 was in bed eating breakfast. Certified Nursing Assistant (CNA) #4 was interviewed at that time and stated the door was always closed and she was not sure why it was closed. During an interview with the Director of Nursing on 5/25/23 at 3:00 P.M., she stated reminding a resident with dementia to use a call light and to educate about safety are not effective.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews for one of three sampled residents (Resident #1) was assessed by Nursing to be at increased risk for elopement, and required a wander guard bracelet, the facility failed to ensure that in an effort to maintain Resident #1's safety to prevent an incident of elopement, that staff implemented and followed facility policy and procedures when responding to a sounding alarm. On 10/20/22 at approximately 5:30 A.M., Resident #1, eloped from the facility unbeknownst to staff, and was found by the Police at approximately 7:00 A.M., wandering down the street, dressed in pajamas and slippers, the temperature was in the high 30's, he/she was shivering, and transported to the Hospital Emergency Department for evaluation. Findings Include: The Facility's Policy, Door Alarm Responses, dated as revised on 07/28/22, indicated the purpose of the Door Alarm Response is to ensure and maintain resident safety and to prevent resident elopement from the facility. The Policy indicated staff must identify the cause of the sounding alarm. The Policy indicated when staff respond to door alarms, staff must immediately do the following; - assess surrounding location for the cause of the alarm activation, - notify the supervisor if unable to identify the cause, - the supervisor will notify nursing units staff to immediately complete a head count of all residents to determine if a resident is missing, - and in the event a resident is determined to be missing, a Code White will be announced. The Policy indicated staff to notify the Administrator and Director of Nursing immediately and proceed with the Facility's Elopement Policy. Resident #1 was admitted to the facility in July 2022 with diagnoses which include: Temporal Neurocognitive Disorder (frontal lobe dementia), anxiety disorder, altered mental status, cognitive communication deficit, abnormal gait and mobility and muscle weakness. Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 10/13/22, indicated he/she had severe cognitive impairment. Resident #1's Plan of Care for Falls, dated as initiated on 10/28/21, (reviewed and renewed with the quarterly MDS in 10/2022) indicated Resident #1 was at a risk of falls due to diagnosis of frontal lobe dementia with decreased safety awareness and history of wandering in the facility. Resident #1's Plan of Care for Wandering, dated as revised on 10/28/21, (reviewed and renewed with the quarterly MDS in 10/2022) indicated Resident #1 was an elopement risk and wandered related to his/her frontal lobe dementia. The Care Plan indicated interventions related to Wandering included Resident #1 will be supervised when off of the unit. Resident #1's Plan of Care for Activities of Daily Living - Ambulation, dated as initiated on 11/04/21 (reviewed and renewed with the quarterly MDS in 10/2022), indicated Resident #1 required continual supervision and staff to escort him/her to his/her destination. Review of the Facility Incident Report, dated 10/20/22, indicated that Resident #1 eloped approximately at 5:30 A.M., (on 10/20/22) was found by Police at approximately 7:30 A.M., and was transferred to the hospital. Review of the Facility's Investigation Report, dated 10/26/22, indicated the Facility was contacted by the local Police of Resident #1's elopement. The Report indicated that at approximately 5:30 A.M., one of the facility's door alarm sounded, Nurse #1 checked the unit doorways and stairwell staircases. The Report indicated Nurse #1 turned off the sounding alarms when he did not see any residents. The Report further indicated Nurse #1 did not follow Facility's Policy and Procedures, did not activate the Code White (Elopement Emergency Response Code) in order to identify a missing resident. The Report indicated Nurse #1 did not follow up with staff to ensure all residents were accounted and on the unit. The Report indicated that Nurse #1 shut off the sounding door alarm without properly investigating the cause of the sounding alarm. Review of the Police Report, dated 10/20/22, indicated Resident #1 was found by Police Officers at approximately 7:00 A.M., walking down the street in his/her pajamas, shaking and shivering profusely as the temperature outside was in the high 30's at that time. The Report indicated Resident #1 was wearing a thin long sleeve shirt, pajama pants and slippers. The Report indicated Resident #1 had snot coming out of his/her nose that appeared to be frozen to his/her face, he/she appeared to be in a semi-catatonic state and initially presented as non-verbal. The Report indicated that Resident #1 was transported to the local hospital. During an interview on 11/21/22 at 11:27 A.M., Nurse #1 said on 10/20/22 approximately 5:45 A.M., he heard an alarm sounding. Nurse #1 said he checked the elevator and proceeded to the two exits where he heard the sounding alarm coming from. Nurse #1 said he was unable to see any residents in the area, so he turned off the alarm manually on the second floor unit. Nurse #1 said an alarm was still sounding so he proceeded down the exit door stairwell (leading to the first floor) and said the exit door leading to the outside of the facility alarm was sounding. Nurse #1 said he turned off the external exit door sounding alarm and entered the first floor through the internal door, looked out the window on the first floor and did not see any residents outside. Nurse #1 said he informed Certified Nurse Aide (CNA) #1 and CNA #2 to check the residents on the unit. Nurse #1 said he did not call Code White, did not step outside the exit alarming door to see if a resident was outside and did not follow up with the CNA's to ensure all the residents were on the unit. Nurse #1 said he was unaware Resident #1 was missing until the Police called the facility to let them know Resident #1 was found and had been transported to the hospital. During an interview on 11/21/22 at 10:55 A.M., Certified Nurse Aide (CNA) #1 said on 10/20/22 Resident #1 was sleeping when she entered his/her room at 5:00 A.M. CNA #1 said she had been providing care to residents and she did not hear the sounding alarm. CNA #1 denied that Nurse #1 asked her to check to ensure all the residents were accounted on the unit. CNA #1 said she completed her rounds with CNA #2 and left the facility at 7:00 A.M. During an interview on 11/21/22 at 6:20 P.M., Certified Nurse Aide (CNA) #2 said on 10/20/22 Resident #1 was sleeping when she entered his/her room at 5:00 A.M. CNA #2 said she had been providing care to residents and she did not hear the sounding alarm. CNA #1 denied that Nurse #1 asked her to check to ensure all the residents were accounted on the unit. CNA #2 said she completed her rounds with CNA #1 and left the facility at 7:00 A.M. During an interview on 11/16/22 at 5:21 P.M., the Director of Nursing (DON) said on 10/20/22 Resident #1 exited the facility from a staircase exit doorway and was later found by the local Police. The DON said Nurse #1 did not follow the Elopement Policy and Procedures. The DON said Nurse #1 did not call Code [NAME] and turned off the alarms prior to accounting all the residents were on the unit. The DON said Nurse #1 did not follow up with CNA #1 and CNA #2 to ensure that they completed the resident head count on the unit. The DON said her expectation is that Nursing staff are able to recognize an elopement and not being notified by the local Police of the facility's elopement. The DON said staff are expected to follow the Facility's Policies and Procedures. On 11/16/22, the Facility presented the Surveyor with a plan of correction that addressed the areas of concern identified in this survey; the Plan of Correction provided is as follows: A) Resident #1 was re-admitted to the facility on [DATE] and was placed on frequent checks on all shifts for 24 hours. Resident #1 continues to wear his/her wanderguard bracelet and Resident #1's Plan of Care was updated. B) On 10/20/22, all residents at risk for elopement were reviewed to ensure the following were completed; proper placement and functioning of all wander guards, completion of the Elopement Risk Assessment, updating Plan of Care and the Elopement Book, Physician Wander Guard Orders and the Physician Orders were documented on the resident's Treatment Administration Record (TAR). C) On 10/20/22 and 10/21/22, the Administrator audited all facility Maglocks to ensure the doors opened properly, had correct signage, the emergency door released after 15 seconds, exit signs illuminated and had an audible alarm. All systems were deemed to be fully functional. D) On 10/20/22, 10/27/22, 11/03/22, 11/10/22, 11/11/22, the Nursing Management Team conducted audits to ensure the following were completed; Physician Wander Guard Orders, the Wander guard had proper placement and functioning, residents supervised on and off of the unit and residents Plan of Care were completed and updated. E) On 10/20/22 the Nursing Management Team conducted Educational In-services for all staff on the Facility's Elopement Prevention and Procedure Policy. The staff education included the following; the Elopement Binders located at each Nurses Station and the Front Reception desk, provide supervision to any resident at risk for Elopement when off the unit, outside door entrance alarms sounding need to be investigated before shutting off any alarm, Elopement Assessment/Evaluations are completed on admission/quarterly and change of condition and Wander guard placement/functioning properly on resident's at risk for elopement. F) On 10/20/22, 10/21/22, 10/25/22, 10/26/22, 11/03/22 and 11/10/22, the Nursing Management Team conducted Code [NAME] Drills in the facility. G) Weekly Audits and Code [NAME] Drills were conducted 10/20/22 through 11/15/22 by Nursing Management Team. H) On 11/04/22, the Elopement Root Cause Analysis, results of the Weekly Audits, and Code [NAME] Drills were discussed at the Quality Assurance & Performance Improvement (QAPI) committee meeting. I) Monthly Audits and Code [NAME] Drills will be conducted by Nursing Management Team until the spring of 2023. Results of these audits will be brought to QAPI committee meetings by the Nursing Management Team. J) The Administrator/and or designee are responsible for overall compliance.