Every finding on record at Alliance Health at Coleman

Based on observations, interviews, and record reviews, the facility failed to provide trauma-informed care for one Resident (#33) out of a total sample of 17 residents.Specifically, the facility failed to recognize Resident #33's past history of sexual abuse and identify triggers (psychological stimuli that prompt recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening), placing the Resident at risk for re-traumatization. Findings include:Review of the facility policy titled Trauma Informed Care Program effective 11/21/19 and revised 8/1/25, indicated but was not limited to the following:-Policy:>To provide holistic, culturally sensitive, trauma-informed care in accordance with professional standards to our residents who are trauma survivors.>To account for the resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident and optimize psychosocial well-being.-Purpose: To ensure the delivery of care and services, which meet professional standards and are delivered using approaches while are culturally competent, account for individual experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization.-Procedures:>Residents will be screened for past trauma and for signs/symptoms of traumatic stress upon admission, and as needed.>The interdisciplinary team, in collaboration with the resident and with the approved resident's representative(s), will create a culturally sensitive plan of care to help prevent re-traumatization and to optimize quality of life. Individualized resident triggers will be identified as able.-These care plans shall include the identified trigger(s), prevention, intervention, and treatment services that address traumatic stress. Resident #33 was admitted to the facility in July 2024, with diagnoses including vascular Dementia, major depressive disorder, adjustment disorder with mixed anxiety and depressed mood, Parkinson's Disease (a movement disorder of the nervous system), constipation, and restlessness and agitation. Review of Resident #33's active Physician's orders indicated:-Behavioral Health Consult as needed, initiated 7/12/24.-Monitoring for refusal of care, increased anxiety, distressing delusions, and insomnia every shift, initiated 3/27/25. Review of Resident #33's Comprehensive Care Plan initiated 7/12/24, indicated:-Resident's Behavior Symptoms Care Plan relative to socially inappropriate behavior, initiated 8/26/25 and last revised 8/26/25, indicated the Resident exhibited socially inappropriate behavior, as evidenced by exhibiting public display of affection, and intrusive behavior with a particular companion.-Resident's Behavior Symptoms Care Plan relative to verbal abuse, initiated 7/22/24 and last revised 9/8/25, indicated the Resident exhibited verbally abusive behavior and demanding and accusatory behavior towards staff, as evidenced by becoming increasingly restless and agitated with staff surrounding his/her care needs.Further review of the Comprehensive Care Plan failed to indicate any care plan had been developed for trauma-informed care. Review of Resident #33's Trauma Informed Care assessment dated [DATE], indicated the Resident did not have a traumatic experience that had lasting effects on him/her. Review of Resident #33's Behavioral Health Psychiatric Assessment and Progress Note written by the Psychiatric Nurse Practitioner and dated 8/12/24, indicated:-The Resident was seen for his/her initial assessment performed by the Behavioral Health Psychiatric Nurse Practitioner on 8/12/24.-The Resident had a history of sexual abuse as a child. Review of Resident #33's Minimum Data Set (MDS) assessment dated [DATE], indicated:-Resident was moderately cognitively impaired as evidenced by a score of 8 out of a possible 15 on a Brief Interview for Mental Status (BIMS).-Resident had a presence of verbal behavioral symptoms directed toward others (Examples: Threatening others, screaming at others, cursing at others), occurring four to six days during the assessment period.-Resident had a presence of other behavioral symptoms not directed toward others (Examples: Physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming/disruptive sounds.), occurring four to six days during the assessment period.-Resident felt down, depressed, or hopeless over the last two weeks, for two to six days. During an interview on 9/4/25 at 3:16 P.M., Resident #33 was crying and said he/she was sexually abused as a child. Resident #33 said the (unspecified) Doctor gave him/her advice regarding the history of sexual abuse, and the Resident said that he/she would like to speak with a Therapist regarding the history of sexual abuse. During an interview on 9/9/25 at 12:59 P.M., the Psychiatric Nurse Practitioner said it was important to identify whether a resident had a history of trauma so that the resident could be treated appropriately, including being prescribed medications and implementing behavioral interventions. The Psychiatric Nurse Practitioner said that the expectation was that any Behavioral Health notes would be provided to Resident #33's Physician by the facility for review. The Psychiatric Nurse Practitioner said Resident #33 informed her of the Resident's history of sexual abuse and she believed that the Resident disclosed this history during his/her initial assessment. The Psychiatric Nurse Practitioner said she referred the Resident to therapy for further exploration of this history of sexual abuse. During an interview on 9/9/25 at 12:08 P.M., Social Worker (SW) #1 said it was important to screen a resident for a history of trauma in order to develop a care plan that acknowledged the resident's traumatic experience that occurred in the past because that experience may be affecting the resident to this day. SW #1 said that a resident was screened for a history of trauma upon admission and as needed, such as when there was a change in the resident's behavior, if the resident was voicing something, and when there was a change in the resident's mood. SW #1 said it was important to develop and implement a trauma-informed care plan for a resident with a history of trauma to ensure staff were aware of the resident's triggers and other things that may bother the resident. SW #1 said that she would develop a trauma-informed care plan for a resident even if the resident said the trauma occurred, but it was not affecting the resident at that time, as the trauma could resurface at a later time. SW #1 said she was not aware that Resident #33 had a history of sexual abuse. During an interview on 9/9/25 at 2:45 P.M., Unit Manager (UM) #1 said that Behavioral Health Progress Notes were printed by either UM #1 or the Director of Nursing (DON) and were placed in the Provider's (Physician or Nurse Practitioner's) folder for review. UM #1 said that she would update the facility Social Worker when the Psychiatric Nurse Practitioner wrote in the progress note that the facility Social Worker should be updated. UM #1 said the interdisciplinary team was not notified each time there was a Behavioral Health encounter with Resident #33.

Based on observations, interviews, and record reviews, the facility failed to ensure proper treatment was provided to maintain hearing abilities for two Residents (#4 and #18) out of a total sample of 17 residents, increasing the risk of both Residents for impaired communication abilities.Specifically, the facility failed to:1.Follow-up with Resident #4's Physician relative to the Audiologist's recommendation for ear wax removal, so that the Resident's hearing could be adequately assessed when the Resident exhibited decreased responsiveness.2.Obtain a hearing device for Resident #18 when the Audiologist recommended replacement of the right hearing aid, after the Resident's right hearing aid was lost during a hospitalization. Findings include:1.Resident #4 was admitted to the facility in December 2020 with diagnoses including age-related cognitive decline. Review of Resident #4's Physician orders initiated 12/4/20, indicated: Audiology Consult as needed. Review of the Minimum Data Set (MDS) Assessment, dated 12/22/24, indicated Resident #4: -was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15 total possible points. -had adequate hearing abilities without the use of a hearing device. -was able to understand others. Review of Resident #4's Audiological Services Referral Form, signed and dated by the Physician on 1/4/25, indicated: -The Resident exhibited new signs/symptoms requiring Audiological testing. -The new signs/symptoms included family/staff noticed recent decreased patient responsiveness. Review of Resident #4's Audiology Consult, dated 1/21/25, indicated: -The Resident was referred for evaluation due to family/staff noticing recent decreased patient responsiveness. -The Resident had a medical history for hard of hearing. -Clinical findings indicated hearing loss could not be established bilaterally. -A large amount of wax was removed, and deep wax could not be removed. -Unable to complete pure tone testing due to visibly occluded cerumen. -Right ear wax removal needed. -Please contact Physician for wax removal orders. -Plan to re-evaluate patient after wax removal. Review of Resident #4's Nursing Progress Note, dated 1/29/25, indicated: -The Resident was seen by Audiology on 1/21/25. -The Audiologist recommended contacting the Physician for wax removal orders for the Resident's right ears. On 9/3/25 at 8:42 A.M., the surveyor observed Resident #4 sitting in a wheelchair in the hallway, eating breakfast. The surveyor approached the Resident at this time and greeted the Resident whose eyes were open. The Resident did not respond to the surveyor. On 9/3/25 at 9:00 A.M., the surveyor observed a staff member speak to Resident #4 and repetitively ask the Resident if he/she wanted to drink his/her milk. The surveyor observed Resident #4 tell the staff member that he/she could not understand what the staff member was saying. During an interview on 9/4/25 t 3:30 P.M., the Unit Manager (UM) said she reviewed Resident #4's clinical record on 9/4/25 and saw the Audiologist's recommendation for ear wax removal. The UM said that the Audiologist's recommendation had not been followed up on and that orders for ear wax removal had not been obtained. The UM said that facility staff should have obtained orders for ear wax removal the same day of the Audiologist's recommendation in January 2025, so that the Resident's ear wax could be removed and the Resident's hearing could be adequately assessed by the Audiologist. 2. Resident #18 was admitted to the facility in March 2023, with diagnoses including Type 2 diabetes mellitus, hyperlipidemia, and heart failure. Review of Resident #18's active Physician's Orders indicated for the Resident to have an Audiology Consult as needed, initiated 3/9/23. Review of Resident #18's Hearing Deficit Care Plan, initiated 3/20/23 and last revised 6/24/25, indicated the following: -Resident was at risk for impaired communication, social isolation, and injury due to hearing deficit. -Resident was hard of hearing. -Interventions: Resident will use hearing aid, hearing aid will be maintained in working condition, and Resident will be referred to audiology as needed. Review of Resident #18's Audiology Consult Report, dated 2/23/24, indicated the following: -Reason for referral: Family or staff noticed recent decrease in Resident responsiveness. -Resident had history of noise exposure. -Right ear hearing aid: Resident reported lost in the hospital. -Degree of hearing loss: Severe to profound sensorineural hearing loss of right ear. -Ear impressions were made of Resident's ears. -Recommendations for Attending Physician or nursing staff: Hearing aid is recommended to both ears, and Medical Consult needed to obtain medical clearance for hearing aid. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #18: -was cognitively intact as evidenced by a score of 15 out of a possible 15 on a Brief Interview for Mental Status (BIMS). -had minimal difficulty (difficulty in some environments) with use of hearing aids. -understood verbal content with use of hearing aids. During an interview on 9/3/25 at 9:18 A.M., Resident #18 said he/she lost his/her right hearing aid a was a while ago when he/she was in the hospital. Resident #18 said he/she could hear okay unless the speaker was soft spoken. Resident #18 said he/she had difficulty hearing the surveyor as evidenced by the surveyor's need to repeat words and speak loudly enough for the Resident to hear. Resident #18 said he/she had been waiting to see the Audiologist and the staff were aware that he/she was missing his/her hearing aid. Resident #18 said the staff tell him/her month after month that he/she would see the Audiologist the following month. During an interview on 9/9/25 at 9:34 A.M., Unit Manager (UM) #1 said she was not aware the Resident had lost his/her hearing aid in the hospital. During an interview on 9/9/25 at 12:45 P.M., UM #1 said Resident #18 was last seen by the Audiologist on 2/23/24, and the Audiologist recommended replacement of the right hearing aid, requiring completion of a Medical Consult for medical clearance. UM #1 said the facility did not receive the replacement hearing aid as of 9/9/25, and the facility did not follow-up with the Audiologist's office in an attempt to obtain the replacement hearing aid. During an interview on 9/9/25 at 3:18 P.M., UM #1 said she could not locate evidence that the facility completed the Medical Consult and corresponding form required for Resident #18 to receive his/her replacement hearing aid for the right ear.

Based on observation, record review, and interview, the facility failed to provide appropriate treatment and services related to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) for one Resident (#8), out of 2 applicable residents reviewed for catheter care, out of a total sample of 17 residents.Specifically, for Resident #8, the facility staff failed to obtain Physician orders relative to the Foley (type of indwelling urinary catheter) catheter and balloon size, putting the Resident at risk for indwelling urinary catheter complications. Findings include: Review of the facility policy titled Urinary Catheter Monitoring and Documentation, revised 9/1/16, indicated:-The Charge Nurse will inform the Director of Nursing (DON) and Quality Assurance Department of all residents in the facility who have catheters, any residents who are admitted with catheters and any new orders for catheterization.-The Quality Assurance Department will examine the charts of these residents to make sure it is well documented the catheter is clinically necessary. Review of the facility nursing assessment tool titled, Indwelling Urinary Catheter Screening, dated 8/18/25, indicated:-Order Present (if no order - contact Medical Doctor (MD) to obtain order). Resident #8 was admitted to the facility in August 2025 with diagnoses including retention of urine, BPH with lower urinary tract symptom, obstructive and reflux uropathy, Urinary Tract Infection (UTI), and unspecified Dementia. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #8:-was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. -has an indwelling urinary catheter -was dependent on staff for activities of daily living (ADL's - basic skills such as bathing, dressing, eating, etc.). On 9/3/25 at 7:55 A.M., the surveyor observed Resident #8 lying in bed with a Foley catheter and a urinary drainage bag in a privacy bag in place. Review of Resident #8's September 2025 Physician orders failed to indicate Physician's orders for the appropriate size of the Resident's Foley catheter. Review of Resident #8's September 2025 Care Plan failed to indicate a Foley catheter size or the size of the catheter balloon. Review of the Foley Catheter Assessment completed on 8/18/25, failed to indicate a Foley catheter size or catheter balloon size. On 9/4/25 at 6:49 A.M., the surveyor and Nurse #1 observed Resident #8's Foley catheter. During an interview at the time, Nurse #1 said the Resident's Foley catheter that was in place was size 16 French (Fr) with 10 milliliters (ml) catheter balloon. On 9/4/25 at 7:37 A.M., the surveyor and Nurse #2 reviewed Resident #8's September 2025 Physician's orders. Nurse #2 said there was no order for the size of the Resident's Foley catheter and the size of the catheter balloon. Nurse #2 said the size of the Foley catheter and the size of the catheter balloon was supposed to be part of the Physician's order but was not. During an interview on 9/4/25 at 8:02 A.M., the Unit Manager (UM) said there was no Physician's order for the size of the Foley catheter and the catheter balloon size. The UM said there should have been a Physician's order for the Foley catheter size and the catheter balloon size from the Resident's admission, but there were no Physician orders.

Based on observations, interviews, and record reviews, the facility failed to ensure that two Residents (#35 and #38) out of a total sample of 17 residents were free from physical restraint. Specifically, the facility failed to ensure Resident #35's and #38's wheelchair brakes were not locked when both Residents required the use of a wheelchair for mobility and were attempting to move, resulting in the Resident's freedom of movement or activity being inhibited.Findings include:Review of the facility's policy titled Physical Restraint Policy, undated, indicated the following:-It was the facility's policy that physical restraint would only be utilized when they are required to treat a resident's medical symptoms.-Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. a. Resident #38 was admitted to the facility in January 2025 with diagnoses including Dementia, weakness, and restlessness and agitation. Review of Resident #38's Cognitive Deficit Care Plan, initiated 1/31/25, indicated:-The Resident had Dementia . as evidenced by altered cognition and confusion. -Verbal cues and redirection as needed. Review of Resident #38's Behavior Care Plan, initiated 1/31/25, indicated the Resident exhibited . restlessness and agitation. Review of the Minimum Data Set (MDS) Assessment, dated 7/13/25, indicated Resident #38:-was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of four out of 15 total possible points.-wandered daily.-required the use of a wheelchair. Review of Resident #38's Occupational Therapy (OT) Evaluation, dated 7/21/25, indicated:-was referred for evaluation to assess the Resident's wheelchair positioning and mobility.-One goal was for the Resident to be independent with wheelchair ability in his/her room and on the Unit. Review of Resident #38's OT Treatment Encounter Note, dated 8/22/25, indicated the Resident was able to maneuver his/her wheelchair independently on the Unit with cues for destination. b. Resident #35 was admitted to the facility in February 2025 with diagnoses including Dementia, unsteadiness on feet, restlessness and agitation. Review of Resident #35's Cognitive Deficit Care Pan, initiated 2/11/25, indicated:-The Resident had Dementia . as evidenced by altered cognition and confusion.-Redirection and cueing as needed. Review of Resident #35's Mood State Care Plan, initiated 2/11/25, indicated: [Resident] had an altered mood state or feelings as evidenced by . restlessness and agitation. Review of Resident #35's Communication Care Plan, initiated 2/14/25, indicated:-The Resident had impaired ability to understand language and be understood.-The Resident was unable to make his/her needs known to staff as his/her Dementia continued to progress as anticipated.-Staff to anticipate [Resident's] needs. Review of Resident #35's Physical Therapy (PT) Discharge summary, dated [DATE], indicated:-was able to wheel at least 50 feet and make two turns on level surfaces with supervision or touching assistance while seated in his/her wheelchair.-The Resident's functional status fluctuated due to Dementia. Review of the Resident #35's Minimum Data Set (MDS) Assessment, dated 7/20/25, indicated Resident #35:-was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of one out of 15 total possible points.-required the use of a wheelchair. On 9/4/25 between 8:17 A.M. and 9:03 A.M., the surveyor observed the following in the facility's Small Dining Room during the breakfast meal:-Resident #38 and Resident #35 were both seated in wheelchairs at tables that were positioned in front of the Residents.-Resident #38's and Resident #35's wheelchair brakes were locked.-Resident #38's and Resident #35's wheelchairs were equipped with anti-rollback devices.-Resident #35 used his/her hands to push forcefully against the tabletop repeatedly and grunting while pushing.-Resident #35 looked side to side and said, This is odd, then pushed against and pulled on the table repeatedly.-Resident #38 used his/her feet on the floor, forcefully pushing backward and side to side.-Resident #38 pushed the wheelchair, with his/her brakes locked, approximately 12 inches away from the table, through forceful pushing (backward and side to side) using his/her feet.-The Assistant Director of Nursing (ADON) approached Resident #38 and said, What's the matter? then the ADON unlocked the Resident's wheelchair brakes.-Resident #38 immediately pushed his/her feet on the floor, moving his/her wheelchair backward.-The ADON was observed saying, We're going to serve breakfast.-Resident #38 was observed saying, that will never happen, and the Resident proceeded to propel the wheelchair forward using his/her feet, toward the Small Dining Room exit.-The ADON was observed saying, Okay, and assisted Resident #38 out of the Small Dining Room.-Breakfast was served to Resident #35 and his/her wheelchair brakes remained locked.-A staff member unlocked Resident #35's wheelchair brakes and assisted the Resident out of the Small Dining Room at 9:03 A.M. On 9/4/25 between 10:52 A.M. and 12:20 P.M., the surveyor observed the following on the Resident Unit:-Resident #38 was seated in a wheelchair next to the railing in the hallway across from the Small Dining Room.-The Resident was facing toward the nurses' station.-Both of the Resident's wheelchair brakes were locked and the anti-rollback device was in place on the wheelchair.-Resident #38 placed his/her right hand on the railing and used his/her feet to push backward and side to side, while pulling on the railing.-Resident #38 then used his/her feet to push backward forcefully and the Resident's front wheelchair wheels lifted slightly off the floor and then back down on the floor.-Resident #38 placed his/her left hand on the large left wheel of the wheelchair, then leaned to the left and looked down toward the wheel while his/her right hand remained on the railing. - Resident #38 continued to intermittently push/pull his/her feet against the floor and use his/her hand to pull on the railing.- The surveyor observed that Resident #38's wheelchair remained in the same place in the hallway.During this observation, the surveyor also observed:- Several staff members pass through the hallway where Resident #38 was seated. - Nurse #2 in the hallway at the medication cart with unobstructed view of Resident #38.- The lunch meal cart was observed on the Unit at 12:10 P.M.- Nurse #2 approached Resident #38 and unlocked the Resident's wheelchair brakes at 12:17 P.M.- Nurse #2 then assisted Resident #38 into the Small Dining Room and locked both of the Resident's wheelchair brakes.- The lunch meal tray pass for the Small Dining Room began at 12:20 P.M. During an interview on 9/4/25 at 2:15 P.M. with the ADON and Director of Nursing (DON), the ADON said she had unlocked Resident #38's wheelchair brakes and assisted the Resident out of the Small Dining Room that morning because the Resident did not want to stay in the Smal Dining Room for breakfast. The ADON said locking resident wheelchair brakes was done for safety so that residents would not fall if they tied to get up and also so that they would not run into each other. During this same interview, the DON said resident wheelchair brakes should not be kept in a locked position because residents should be able to move if they want to. The DON said if a resident's wheelchair brakes were left in a locked position and the resident could not move because the brakes were locked, this would be a restraint. The DON said neither Resident #35 nor Resident #38 should have been left with their wheelchair brakes in the locked position. During an interview on 9/4/25 at 3:09 P.M., Nurse #2 said she locked Resident #38's brakes for the lunch meal that day and tat locking resident brakes at meals was a habit and was done for safety. Nurse #2 said that other than during meals, residents should not have their brakes locked by staff and that residents should be free to move. Nurse #2 said neither Resident #35 nor Resident #38 should have been left with their brakes in the locked position and that both Residents sh9uold have been free to move.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services related to activities of daily living (ADL) care for one Resident (#9), out of a total sample of 17 residents.Specifically, for Resident #9, the facility failed to:1. provide assistance to the Resident with applying his/her dentures when the Resident verbalized the need for his/her dentures before the breakfast meal, resulting in the Resident coughing and vomiting during the meal due to inability to chew his/her food.2. assist/encourage the Resident to use his/her back brace when he/she was out of bed.3. ensure that the Resident's hearing aids were in place every morning as required. Findings include: Resident #9 was admitted to the facility in February 2023 with diagnoses including Spinal Stenosis, Low Back Pain, Memory Deficit, and Conductive Hearing Loss. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #9:-was moderately cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. -required assistance from staff for ADL's (basic skills such as bathing, dressing, eating, etc.). Review of Resident #9's September 2025 Physician's orders indicated:-Resident to wear LSO brace (rigid back brace designed to stabilize and support the lower spine) when out of bed. Start date 7/29/25.-Insert bilateral hearing aids in the morning, remove in the evening. Start date 8/18/25. Review of Resident #9's September 2025 Care Plans indicated:1.Vertebral compression, pain management, initiated 5/22/25, interventions included:- -Apply LSO back brace for comfort when out of bed.2. Cognitive Deficits, initiated 2/9/24:-the Resident was alert and oriented.-He/she was his/her own decision maker.-He/she has memory deficit diagnosis and was at risk for further decline in his/her cognitive status.3. Sensory deficit - Hearing deficit- initiated 12/29/24:-Use hearing aid as ordered.4. ADL'S, initiated 3/8/23:-required assistance from one staff member for grooming and dressing. Review of Resident #9's CNA Care Card indicated that the Resident had upper and lower partial dentures. During an interview on 9/3/25 at 7:20 A.M., Resident #9 said the facility staff did not always assist him/her to wear his/her back brace. Resident #9 said he/she was having difficulty hearing without his/her hearing aids. The surveyor observed that the Resident did not have any hearing aids in place and was not wearing a back brace. Resident #9 said he/she has difficulty remembering to perform his/her daily tasks during ADL care. On 9/4/25 at 8:02 A.M., the surveyor observed Certified Nurse Aide (CNA) #1 assist Resident #9, who was seated in a wheelchair, into the dining room for breakfast. The surveyor observed Resident #9 say to CNA #1, Oh I forgot to put my teeth in, and CNA #1 failed to respond to the Resident. The surveyor observed Resident #9 did not have his/her hearing aids in place and back brace on at this time. On 9/4/25 at 8:38 A.M., the surveyor observed Resident #9 coughing and vomiting while seated at the breakfast table. During an interview at the time, Resident #9 said that this occurred because he/she was not wearing his/her dentures. During an interview on 9/4/25 at 8:44 A.M., Nurse #4 said she observed Resident #9 without his/her dentures when the Resident was brought to his/her room after he/she had vomited. Nurse #4 said the CNAs were responsible to ensure Residents had their dentures in after the CNAs provide the Residents with ADL care. Nurse #4 said the Resident should have had his/her dentures in before his/her meal. Nurse #4 further said she only worked two days a week in the facility and was not aware Resident #9 needed his/her hearing aids in the morning. Nurse #4 further said she was not aware Resident #9 needed a back brace when he/she was out of bed. During an interview on 9/4/25 at 904 A.M., the Unit Manager (UM) said the CNAs were expected to perform oral care and provide Residents with their dentures. The UM said Resident #9 should have been provided with his/her dentures, hearing aids and back brace, but was not. During an interview on 9/4/25 at 9:25 A.M., CNA #1 said she was not aware Resident #9 had dentures. CNA #1 said Resident #9 performed his/her own ADL's and she would assist if the Resident asked. CNA #1 said she did not provide Resident #9 with his/her dentures before the breakfast meal.

Based on observation, interview and record review, the facility failed to post on a daily basis the required nurse staffing information that included the actual hours worked by licensed and unlicensed nursing staff for three days.Specifically, the facility failed post the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift that should also reflect any staff absences on that shift due to call-outs and illness. Findings include: The surveyor observed that nurse staffing information was posted in the resident dining area on the following days:-9/3/25-9/4/25-9/5/25 Review of the nursing staffing information posted on 9/3/25, 9/4/25 and 9/5/25 indicated the name of the facility, the date, the census and the number of CNAs and LPN/RN working on each shift. The posted nurse staffing information was observed as follows:-DAY (7:00 A.M. to 3:00 P.M.) RN/LPN 3, CNA 5-EVENING (3:00 P.M. to 11:00 P.M.) RN/LPN 2, CNA 4-NIGHT (11:00 P.M. to 7:00 A.M.) RN/LPN 2, CNA 2Further review of the nurse staffing information postings failed to indicate the actual hours worked by licensed and unlicensed nursing staff. During an interview on 9/5/25 at 12:37 P.M., the Payroll Personnel (PP) responsible for posting the staffing information said she was unaware of any additional information that was needed on the posted nursing staff information. During an interview on 9/5/25 at 2:25 P.M., the Executive Director (ED) said she was unaware of any additional information that was needed on the posted nursing staff information. The ED said the actual working hours were not posted on the daily nurse staffing information. The ED said she would work with the Director of Nursing (DON) to update the nurse staffing posting to include all the necessary information.

Based on policy review, observation, and interview, the facility failed to ensure medications were appropriately stored in two out of two medication carts. Specifically, the facility staff failed to store topical medications separately from oral medications. Findings include: Review of the facility's policy, titled Medication Storage in the Facility, dated 2017, indicated the following: -Procedure: Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, etc. 1. During an observation of the East Medication Cart, on 4/14/23 at 8:45 A.M., with Nurse #2, the surveyor observed a small basket in the top drawer of the cart that had multiple individual packets of Hydrocortisone cream (steroid for external use), several packets of lubricant (used to insert suppositories), and several packets of thickener (oral agent used to thicken liquids). All of these items were stored together in the same basket. Nurse #2 said she did not know the items could not be stored together. 2. During an observation of the West Medication Cart, on 4/14/23 at 10:43 A.M., with Nurse #3, the surveyor observed the following items, stored together in the bottom drawer of the medication cart: one open tube of Dicflonec gel (external gel used for arthritis), one open tube of Silvadene cream 1% (external cream used to prevent wound infections), packets of skin preparation (used to create a barrier on the skin to prevent irritation), one open bottle of sodium chloride tablets (oral use), and one open bottle of Ocuvite (vitamin) tablets. Nurse #3 said all of the creams and gels should be stored in the treatment cart, not the medication cart, and they should not have been stored together.

Based on record review and interview, the facility failed to ensure one Resident (#6) out of a total sample of 13 residents was free of a significant medication error. Specifically, facility staff failed to implement necessary action when Heparin (blood thinning medication used to prevent the development of blood clots) that was ordered by the Physician to be administered every 12 hours, was omitted from the Resident's medication administration, resulting in a missed dose and increasing the risk for development of blood clots. Findings include: Review of facility's Medication Policy titled Preparation and General Guidelines, dated 2017, indicated: - Medications are administered in accordance with written guidelines of the Prescriber. - The Charge Nurse reports equipment and supply deficiencies to the Director of Nursing (DON). - If a medication is withheld, refused, or not available, the Physician is notified. - Nursing documents the notification and Physician's response. Resident #6 was admitted to the facility in April 2021 with a diagnosis of unilateral (one sided) primary Osteoarthritis (condition where flexible tissue at the ends of bones gradually wears down and worsens over time) of the left hip. Review of the clinical record indicated the Resident was hospitalized following a fall at the facility on 4/5/23 where he/she sustained a left hip fracture and required hospitalization to repair the hip. Further review of the clinical record indicated the Resident returned to the facility on [DATE]. Review of the Hospital Discharge Summary, dated 4/9/23, indicated the following: - The Resident had a diagnosis of Atrial Fibrillation (A-fib: irregular, often rapid heart rate that causes poor blood flow and a potential for blood clots). - The Resident received one dose of Heparin 5,000 units, subcutaneously (injected in the fatty tissue, just under the skin) at 8:38 A.M. on 4/9/23. Review of a Nurse's Note, dated 4/9/23 and completed at 3:31 P.M., indicated Resident #6 returned to the facility from the hospital and all medication orders were reviewed with the Physician. Further review of the Note indicated to add Heparin 5,000 units every 12 hours. Review of the Physician's order, dated 4/9/23, indicated: Heparin (porcine) 5,000 unit/ml (milliliters) injection solution, inject one ml (5,000 unit) by subcutaneous (inject in the fatty tissue, just under the skin) route every 12 hours, every day at 8:00 A.M. and 8:00 P.M. Review of the April 2023 Medication Administration Record (MAR) indicated the ordered 8:00 P.M. dose of Heparin was not administered to Resident #6 on 4/9/23 because it was not available to be administered. Further review of the MAR indicated the Resident did not receive Heparin until the next scheduled 8:00 A.M. dose was administered on 4/10/23. Review of the clinical record indicated no evidence the Physician had been contacted relative to Heparin not being available for administration to Resident #6 or for alternate care instructions when Heparin was identified as unavailable to be administered. During an interview on 4/19/23 at 10:42 A.M., Nurse #5 said Heparin was ordered for Resident #6 as a blood thinner to prevent blood clots, and the ordered 8:00 P.M. dose of Heparin was not administered to the Resident on 4/9/23 because it was not available. Nurse #5 said the Heparin had been ordered through the Pharmacy, but it had not been delivered to the facility in time to be administered to Resident #6 for the scheduled 8:00 P.M. dose. Nurse #5 then said the Heparin was delivered to the facility somewhere around 4:00 A.M. to 5:00 A.M. the next morning (4/10/23). Nurse #5 said he could not recall whether the Physician was contacted for alternate care instructions when it was identified that the Heparin was not available. During an interview on 4/19/23 at 10:59 A.M., the Director of Nursing (DON) said if an ordered medication was not available for a resident, facility staff were expected to contact the Pharmacy and check the facility's emergency medicine supply, and if a vital medication was not available, staff were also required to notify the Physician that the medication could not be administered as ordered and to obtain alternate care instructions. The DON said Heparin was considered a vital medication and was not stocked in the facility's emergency medication supply. When asked whether the DON was made aware that no Heparin was available for Resident #6's scheduled 8:00 P.M. dose on 4/9/23, she said staff do not call her every time something like this occurs. The DON then said the Unit Manager (UM) was the Nurse that verified Resident #6's medication orders with the Physician when the Resident returned from the hospital on 4/9/23, so she would be able to speak to accessibility of Heparin for Resident #6 when he/she returned from the hospital. During an interview on 4/19/23 at 11:01 A.M., the UM said she verified Resident #6's medication orders with the Physician when the Resident returned from the hospital on 4/9/23. The UM said that since the Resident had already been at the facility, all of his/her medications were available for administration. The UM then said the only medication that may not have been available would have been Heparin, but this was stocked in the facility's emergency medication supply, so the Resident would not have missed his/her 8:00 P.M. dose on 4/9/23 while awaiting the Pharmacy delivery of the medication. The UM then reviewed the list of medications stored in the emergency medicine supply and said Heparin was not a medication that was stored in the facility's emergency medication supply, so it would not have been available for Resident #6 at 8:00 P.M. on 4/9/23. The UM said staff who worked the evening shift on 4/9/23 would have been required to call the Physician when they noticed the Heparin was not available to be administered and obtain alternate care instructions. She also said staff would have been required to document their contact with the Physician and whether new orders were obtained for alternate care instructions.

Based on record review, and interview, the facility failed to provide Physician notification on status changes for three Residents (#18, #6 and #8) out of a total sample of 13 residents. Specifically, 1. For Resident #18, the facility staff failed to notify the Physician of an abnormal high finger stick blood sugar level (FSBS: a measurement of sugar in the blood) result. 2. For Resident #6, the facility staff failed to notify the Physician that one dose of Heparin (blood thinning medication used to prevent blood clots) was not administered as ordered. 3. For Resident #8, the facility staff failed to report the presence of pressure ulcers noted on admission to the Physician, delaying care and treatment. Findings include: 1. Resident #18 was admitted to the facility in September 2022 with a diagnosis of Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). Review of the American Diabetes Association Blood Glucose Testing and Monitoring guidelines, copyright 1995-2023 indicated target ranges for blood glucose levels to be 80-130 mg/dl. Review of the current Physician's orders, last renewed 3/30/2023, indicated an order for monitoring FSBS (Finger Stick Blood Sugar) BID (two times daily) at 7:30 A.M. and 4:30 P.M. No result parameters were included in the Physician's order for FSBS monitoring prior to the surveyor interview with the Director of Nurses (DON). Review of the April 2023 Medication Administration Record (MAR) for Resident #18 indicated a FSBS level of 509 mg/dl documented for 4/17/23 at 4:30 PM. Review of the progress notes for April 2023 showed no evidence that the Physician was notified of Resident #18's FSBS result of 509 mg/dl. During an interview on 4/18/23 at 3:18 P.M., with Nurse #1 and the DON, Nurse #1 said she did not notify the Physician of the Resident's FSBS level of 509 mg/dl on 4/17/23 because there were no parameters included with the FSBS monitoring order. The DON said that when the Physician writes an order for FSBS monitoring the order usually contains parameters for when the Physician should be notified. She said that Resident #18 did not have a FSBS monitoring order that included parameters for when to notify the Physician but that the Physician should still be notified if an FSBS result is abnormal. She also said a FSBS level of 509 mg/dl was an abnormally high result and the Physician should have been notified but that was not done. 42761 2. Resident #6 was admitted to the facility in April 2021 with a diagnosis of unilateral (one sided) primary Osteoarthritis (condition where flexible tissue at the ends of bones gradually wears down and worsens over time) of the left hip. Review of the facility's Medication Policy, titled Preparation and General Guidelines, dated 2017, indicated: - Medications are administered in accordance with written orders of the Prescriber. - If a vital medication is not available, the Physician is notified and Nursing documents the Physician's response. Review of Resident #6's clinical record indicated the Resident was hospitalized after falling at the facility on 4/5/23 where he/she sustained a left hip fracture and required hospitalization to repair the hip. Further review of the clinical record indicated the Resident returned to the facility on [DATE]. Review of the Hospital Discharge Summary, dated 4/9/23, indicated the following: - The Resident had a diagnosis of Atrial Fibrillation (A-fib: irregular, often rapid heart rate that causes poor blood flow and a potential for blood clots). - The Resident received one dose of Heparin 5,000 units, subcutaneously (injected in the fatty tissue, just under the skin) at 8:38 A.M., on 4/9/23. Review of a Nurse's note, dated 4/9/23 and completed at 3:31 P.M., indicated Resident #6 returned to the facility from the hospital and all medication orders were reviewed with the Physician. Further review of the note indicated to add Heparin 5,000 units every 12 hours. Review of a Physician's order, dated 4/9/23, indicated: Heparin (porcine) 5,000 unit/milliliter (ml) injection solution, inject one ml (5,000 unit) by subcutaneous (inject in the fatty tissue, just under the skin) route every 12 hours, every day at 8:00 A.M. and 8:00 P.M. Review of the April 2023 Medication Administration Record (MAR) indicated the ordered 8:00 P.M. dose of Heparin was not administered to Resident #6 on 4/9/23. Further review of the MAR indicated the medication was not available. Review of the clinical record indicated no evidence that facility staff notified the Physician that the 8:00 P.M. dose of Heparin had not been administered to Resident #6 as ordered on 4/9/23. During an interview on 4/19/23 at 10:42 A.M., Nurse #5 said Heparin was ordered for Resident #6 as a blood thinner to prevent blood clots. Nurse #5 said Resident #6 did not receive the evening dose of Heparin on 4/9/23 as ordered because it was not available in the facility. Nurse #5 also said he could not recall whether the Physician was notified that the scheduled 8:00 P.M. dose of Heparin was not administered as ordered to the Resident on 4/9/23. During an interview on 4/19/23 at 10:59 A.M., the Director of Nursing (DON) said if a Physician ordered vital medication was not available for administration, staff were required to notify the Physician that the medication could not be administered as ordered and to obtain alternate care instructions. The DON said Heparin was considered a vital medication. The DON said Heparin was not stocked in the facility's emergency medication supply and if it was unavailable to be administered, the Nurse would be required to notify the Physician. The DON then said the Unit Manager (UM) was the Nurse that verified Resident #6's medication orders with the Physician when the Resident returned from the hospital on 4/9/23, so she would be able to speak to accessibility of Heparin for Resident #6 when he/she returned from the hospital. During an interview on 4/19/23 at 11:01 A.M., the UM said she verified Resident #6's medication orders with the Physician when the Resident returned from the hospital on 4/9/23. The UM said that since the Resident had already been at the facility, all of his/her medications were available and there were no ordered medications that would not have been available for administration to Resident #6. The UM then said the only medication that may not have been available was Heparin, but this was stocked in the facility's emergency medication supply, so the Resident would not have missed his/her 8:00 P.M. dose on 4/9/23 while awaiting the Pharmacy delivery of the medication. The UM then reviewed the list of medications stored in the emergency medication supply and said Heparin was not a medication that was stored in the facility's emergency medication supply, so it was not available for Resident #6 at 8:00 P.M. on 4/9/23. The UM said she did not notify the Physician that Heparin was not available for Resident #6 because she thought it was stored in the emergency medication supply. The UM further said the Nurse who identified that Heparin was not available for administration to Resident #6 should have notified the Physician, as required, and documented the Physician's response in the clinical record. Please Refer to F760. 42712 3. Resident #8 was admitted to the facility in December 2022 with diagnoses including Arthritis and mild cognitive impairment. Review of the facility policy, titled Skin at Risk Treatment Protocol, revised 10/8/2015, indicated that residents at risk for breakdown will be identified on admission, and the Physician must be notified to initiate a specific treatment plan. Review of the Nursing Admission assessment dated [DATE] indicated the Resident had Stage II (partial thickness skin loss) open areas of the coccyx (base of the spine, also known as the tailbone) - no measurement given, excoriated (scraped and abraded) skin on the groins and a Deep Tissue Injury (DTI - purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from injuries and shear) 3.4 x 1.4 centimeters on the left foot. Review of the admission History and Physical, dated 12/30/2022, indicated the exam was a telehealth visit conducted and the skin assessment indicated edema (swelling) of the lower extremities, no lesions, no rash. Review of the December 2022 Physician's orders indicated no evidence of treatments ordered for the impacted skin areas identified on admission. Review of the December 2022 Medication Administration Record (MAR) and the Treatment Administration Record (TAR) indicated no documented treatments administered to the left and right buttocks and to the left foot. Review of the Nursing Progress Note, dated 1/3/2023 at 12:45 P.M., indicated the Resident was seen by the Wound Nurse, and that the Physician was notified of the Stage II pressure areas on the right (1 x 1 x 0.1 centimeters) and left (1 x 4 x 0.1 centimeters) buttocks, and an open area on the left foot (2 x 3 x 0.1 centimeters). Review of the January 2023 Treatment Administration Record (TAR) indicated no documented evidence that treatments were administered to the left and right buttocks and the left foot until 1/3/23 when the following treatments were provided: -Apply Calmoseptine (an ointment used to protect and heal skin irritations) to right and left buttocks area twice a day until healed, start date 1/3/23. -Wash open area on top of left foot with normal saline, pat dry, apply Bacitracin and dressing daily until healed, start date 1/3/23. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was at risk for the development of pressure ulcers, and had an unhealed Stage II pressure ulcer, one unstageable (depth unable to be determined due to dead skin cells and or drainage) Deep Tissue Injury and Moisture Associated Skin Damage (MASD), used a pressure reducing device for the bed and chair, and received pressure ulcer care. During an interview on 4/18/23 at 3:18 P.M., with the Assistant Director of Nursing (ADON), the ADON said when a resident was admitted , a full assessment was completed and if there were any skin issues of concern, a call would be placed to the Physician and orders obtained for the care and services of those areas. The ADON said the progress note dated 1/3/23 indicated that the Physician was updated regarding the wounds present and treatments were ordered. The ADON further said, that based on her preliminary review of the record, there was no documented evidence that the Physician was notified, and that treatment was initiated upon the resident's admission. During a subsequent interview on 4/18/23 at 4:23 P.M., the ADON said, after further review of the clinical record, that no additional documentation was found regarding Physician notification or wound treatments ordered for the pressure areas present upon admission until 1/3/2023.

Based on observation, interview, and record review, the facility failed to provide assistive devices for one Resident (#17) out of a total sample of 13 total residents, to aid in preventing an injury/accident. Specifically, the facility failed to ensure its staff provided leg rests on a wheelchair to support the Resident's legs during transport, resulting in the Resident's right foot getting caught under the wheelchair while the chair was being pushed by staff. Findings include: Resident #17 was admitted to the facility in April 2019 with a diagnosis of Dementia. Review of Resident #17's Activities of Daily Living (ADLs) and Mobility Care Plan, dated 11/8/22 and reviewed 1/31/23, included the following: - The Resident was able to self propel short distances in his/her wheelchair with staff cueing and direction. - Do not use foot pedals on chair, it prevents self-ambulation in the wheelchair. Review of the Resident's Cognitive Deficit Care Plan, dated 1/26/23, indicated the following: - Gain the Resident's attention prior to hands-on care. - Explain in simple terms what to expect, give the Resident time to process. On 4/14/23 at 10:34 A.M., the surveyor observed Resident #17 seated in an alcove by a resident room, facing the hallway. Resident #17 was seated in a wheelchair with his/her feet resting on the floor. At this time, CNA #2 walked in front of the Resident, around his/her wheelchair, then behind the wheelchair and grasped the wheelchair handle. CNA #2 then told the Resident she was going to assist the Resident to his/her room as she began to push the wheelchair forward and turn right into the hallway. As the CNA was pushing the wheelchair, Resident #17's right foot caught on the rug, his/her knee flexed, and the lower part of his/her leg and foot got caught under the wheelchair. Resident #17 gasped, the CNA stopped pushing the wheelchair and told the Resident to pick his/her feet up. During an interview on 4/14/23 at 11:15 A.M., CNA #2 said some residents did not use leg rests on their wheelchairs because they self-propelled. CNA #2 said if staff needed to assist these residents with transport in their wheelchairs, they would instruct them to pick up their feet, and if they were unable, then an additional staff member would assist them to hold their feet up during transport. CNA #2 said Resident #17 did not use leg rests because he/she self-propelled the wheelchair throughout the Unit. CNA #2 said she had assisted Resident #17 to his/her room earlier to provide personal care and the Resident's right leg got caught under the wheelchair because he/she did not lift his/her feet when the CNA began to assist with transport. During an interview on 4/14/23 at 2:06 P.M., the Director of Nursing (DON) said all residents who had wheelchairs were provided with leg rests for transport. The DON said residents who self-propelled their wheelchairs would not use the leg rests when mobilizing on their own, but if staff assisted with transport, the staff were required to put the leg rests on the residents' wheelchairs. The DON also said Resident #17 self-propelled his/her wheelchair on the unit and that if staff approached him/her and gave him/her their hand, he/she would usually self-propel with their direction. The DON said since staff transported the Resident to his/her room that morning, they should have put the leg rests on the chair prior to transport, as required, to avoid a potential accident/injury. The DON then said the Resident had leg rests provided for him/her for this purpose and asked the Unit Manager (UM) to show the surveyor where the leg rests were kept. During an observation and interview on 4/14/23 at 2:11 P.M., the UM said all residents on the Unit who required wheelchairs were provided with leg rests. She said staff were required to put leg rests on residents' chairs when they assisted residents with transport. The UM said Resident #17 self-propelled in the wheelchair, but he/she had leg rests provided when staff needed to transport him/her in the wheelchair and that the leg rests were stored in the Resident's closet. The UM also said she witnessed the Resident's right leg get caught under his/her wheelchair during transport in the morning and that staff should have provided the Resident with leg rests to prevent that from happening. At this time, the UM opened the Resident's closet and located one right-sided leg rest, but was unable to locate the left- sided leg rest. The UM then said she did not know where the left-sided leg rest was but that it should have been in the Resident's closet and that she would need to locate the left-sided leg rest.

Based on observation, interview, record review, and policy review, the facility failed to ensure its staff provided timely pain management interventions for one Resident (#6) out of a total sample of 13 Residents. Specifically, the facility staff failed to respond to the Resident calls for assistance and provide Physician ordered scheduled pain medication in a timely manner. Findings include: Review of the facility's policy, titled Preparation and General guidelines: Equipment and Supplies for Administering Medications, dated 2017, indicated that medications were to be administered within 60 minutes of scheduled time . Resident #6 was admitted to the facility in April 2021 with a diagnosis of unilateral (one sided) primary Osteoarthritis (condition where flexible tissue at the ends of bones gradually wears down and worsens over time) of the left hip. Review of the clinical record indicated Resident #6 was hospitalized after falling at the facility on 4/5/23 where he/she sustained a left hip fracture and required hospitalization to repair the hip. Further review of the clinical record indicated the Resident returned to the facility on [DATE]. Review of the active Physician's orders indicated the following: -Acetaminophen 500 milligrams (mg) tablet, give two tablets (1000 mg) by oral route three times per day, every day at 8:00 A.M. -Tramadol (narcotic medication used to treatmoderate to severe pain) 50 mg tablet, give one tablet by oral route every eight hours as needed, dated 3/30/23 -Tramadol 50mg tablet, give one tablet by oral route daily, every day at 8:00 A.M., dated 4/12/23 On 4/14/23, between 9:07 A.M. and 9:12 A.M., the surveyor observed Resident #6 in bed in his/her room. The Resident called out, Help me, it hurts repetitively while the surveyor was in the hallway outside the Resident's room. The surveyor observed staff members in the area outside of the Resident's room, walking through the hallway, and no staff members responded to the Resident's call for help. On 4/14/23 at 9:12 A.M., the surveyor observed Rehabilitation Staff #1 enter the Resident's room and close the door. On 4/14/23 at 9:18 A.M., Rehabilitation Staff #1 exited Resident #6's room. During an interview on 4/14/23 at 9:18 A.M., Rehabilitation Staff #1 said he/she entered Resident #6's room that morning to notify him/her of the day's therapy schedule. Rehabilitation Staff #1 said the Resident was in pain, so she helped the Resident reposition in bed, but the Resident was still having pain. Rehabilitation Staff #1 then said she was going to alert the Nurse that the Resident was in pain. On 4/14/23 at 9:26 A.M., the surveyor observed Nurse #3 enter Resident #6's room with a medicine cup in her hand. During an interview on 4/14/23 at 9:33 A.M., Nurse #3 said medications were required to be administered to residents within one hour before and one hour after the scheduled administration time. Nurse #3 said Resident #6 had slept through the night and did not request any pain medication, so she expected the Resident would be uncomfortable that morning. Nurse #3 said Resident #6's pain level was nine out of 10 on the numeric pain scale when she administered his/her pain medication at 9:26 A.M. and that she had given the Resident scheduled extra strength Tylenol (Acetaminophen) and a PRN (as needed) Tramadol at that time. The surveyor then reviewed Resident #6's medication orders with Nurse #3. Nurse #3 said she was not aware Resident #3 had a scheduled order for Tramadol to be administered at 8:00 A.M. and she was out of compliance with providing the Resident's scheduled 8:00 A.M. pain medication.

Based on record review, observation, and interview, the facility and its staff failed to ensure that the medication pass had an error rate of less than 5%. Two out of two nurses observed failed to administer medications as ordered, for two out of seven Residents (#22 and #15) observed. The medication error rate was calculated at 10.34 % with 29 opportunities for error. Findings include: 1. On [DATE] at 4:09 P.M., the surveyor observed Nurse #1 prepare the following medication (along with other prescribed medications) for Resident #22: -Celecoxib (antidepressant) 100 milligrams (mg), the expiration date observed on the medication card was [DATE]. During an interview on [DATE] at 4:14 P.M., the surveyor intervened prior to Nurse #1 administering the medication. The surveyor asked Nurse #1 what her process was for medication administration. Nurse #1 said she checked the Resident for identification, then checked the Physician order against the medication card, and checked the expiration date. When Nurse #1 checked the medication card for a second time, she said the medication had expired in [DATE]. Nurse #1 then removed the Celecoxib capsule from the cup of medications and disposed of it. 2. On [DATE] at 7:50 A.M., the surveyor observed Nurse #2 administer the following medications (along with other prescribed medications) to Resident #15. -Miralax (laxative) 17 grams (gm) powder in 4 ounces of water -Prednisolone Acetate 1% eye drop, suspension, one drop to the right eye. Nurse #2 did not shake the vial prior to administering the medication. Review of the label on the vial of Prednisolone Acetate 1% eye drop suspension, indicated to shake well prior to administration. Review of the [DATE] Physician's orders indicated the following: -Miralax 17 gm powder in 8 ounces of water, juice, soda, coffee or tea by oral route once daily. During an interview on [DATE] at 8:05 A.M., Nurse #2 said she thought the vial of eye drops shook as she walked holding the medications into the Resident's room. During an interview on [DATE] at 8:45 A.M., Nurse #2 said that she filled the cup of water with the Miralax as high as it could go. When the surveyor asked how big the cup was, Nurse #2 said it was a 4 ounce cup. Nurse #2 and the surveyor reviewed the Physician's orders for Resident #15 and Nurse #2 said she should have mixed 8 ounces of water or juice and not 4 ounces, when she prepared the Miralax.

Based on records reviewed and interviews for one of three sampled residents (Resident #1), who required extensive assistance of two staff members for all transfers, the Facility failed to ensure staff implemented and followed interventions from his/her plan of care, when on 10/01/21 during the evening shift, Certified Nurse Aide (CNA) #3 transferred Resident #1 into bed without another staff person to help. Resident #1 was observed, at the end of the shift, to have bruises to his/her left forehead and left hip, an x-ray was taken which revealed a left hip fracture and he/she was transferred to the Hospital Emergency Department and admitted . Findings Include: Review of the Facility Report submitted to the Department of Public Health (DPH) via the Health Care Facility Reporting System (HCFRS), dated 10/06/21, indicated that, on 10/01/21 at 11:00 P.M., Resident #1 was observed to have bruises on his/her left hip and left side of his/her head. The Report indicated that x-rays revealed a non-displaced left intertrochanteric fracture (type of hip fracture). The Report indicated that, during the Facility Investigation, the Director of Nursing and the Assistant Director of Nursing met with CNA #3, who had provided care for Resident #1 on 10/01/21. The Report indicated that CNA #3 told them that Resident #1 did not fall, that nothing abnormal occurred and the evening was uneventful. The Report indicated that after staff were interviewed, statements reviewed, and CNA #3 demonstrated how she transferred Resident #1 from his/her wheelchair into bed on 10/01/21, the Facility concluded that Resident #1's injury was the result of a difficult transfer into bed and that as he/she was being transferred he/she bumped the side rail, which was in the lower position, during the transfer. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated that diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS indicated that Resident #1 required extensive assistance of two staff members with all transfers. Review of Resident #1's Activity of Daily Living (ADL) Function and Mobility Care Plan, dated as effective 09/22/21, indicated that he/she had experienced a decline with transfers and mobility and indicated that he/she required the assistance of two staff members with the use of a gait belt for transfers. Review of the Incident Report, dated 10/01/21, indicated that, at 11:00 P.M., Resident #1 was observed with a 2.2 centimeter (cm) by 6.2 cm bruise on his/her left forehead and a 4.5 cm by 5.0 cm bruise on his/her left hip. Review of the Nurse's Note, dated 10/02/21, indicated that Resident #1's Physician was notified about his/her bruises, an order was obtained for a left hip x-ray and the Radiology Company was contacted. The Note indicated that Resident #1 denied pain when asked, but later complained of pain when his/her left leg was touched, so his/her Physician was called to obtain an order to send him/her to the Hospital Emergency Department for evaluation. The Note indicated that when Resident #1's (activated) Health Care Agent (HCA) was notified of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurse's Note, dated 10/02/21 and timed at 2:51 P.M., indicated that a call was placed to the Radiology Company to follow-up on the x-ray and to obtain an estimated time of arrival. Review of the Nurse's Note, dated 10/02/21 and timed at 6:54 P.M., indicated that Resident #1 was alert, verbal, had no complaints of pain, and had bruises on his/her left forehead and left hip. Review of the Radiology Report, dated 10/02/21, indicated that x-ray results revealed a intertrochanteric fracture of Resident #1's left hip. Review of the Nurse's Note, dated 10/03/21, indicated that Resident #1's Physician was notified and an order was obtained to transfer him/her to the Hospital Emergency Department. Review of the Hospital Discharge Summary, dated 10/07/21, indicated Resident #1 was admitted to the Hospital on 10/03/21 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on 10/26/21 at 2:09 P.M., CNA #3 said Resident #1 required assistance of two staff members for transfers. CNA #3 said that, on 10/01/21 during the 3:00 P.M. to 11:00 P.M. shift, Resident #1 was on her assignment and said after she showered him/her, she brought him/her back to his/her room, positioned his/her wheelchair beside the bed, and locked the wheelchair. CNA #3 said she started to leave Resident #1's room to look for someone to help her transfer him/her into bed but looked back and observed that he/she was seated at the edge of his/her wheelchair rocking herself/himself. CNA #3 said she did not want Resident #1 to fall so she transferred him/her into bed without assistance. CNA #3 said she did not know why did not call out for help, or press the call light for assistance, or bring Resident #1 with her to look for another staff member for assistance. CNA #3 said when she transferred Resident #1 she put her arms under Resident #1's arms, lifted him/her up and put him/her into the bed. CNA #3 said was unsure if Resident #1's feet ever touched the ground when she lifted him/her from the wheelchair and said although she was unsure, she thought Resident #1 could have bumped the side rail of the bed, which was lowered and to the side of the bed. During an interview on 10/26/21 at 3:27 P.M., the Director of Nursing (DON) said Resident #1 required the assistance of two staff members for transfers and said Care Plan interventions are established to provide safety for Residents and for staff. The DON said CNA #3 demonstrated how she transferred Resident #1 alone and had CNA #3 transfer her (DON) into bed as she had transferred Resident #1. The DON said she made herself dead weight and because CNA #3 transferred her alone, during the transfer demonstration, CNA #3 bumped her (DON) into and over the side rail. The DON said if CNA #3 was afraid someone would fall, she should stay with them, stand next to them, called for help, or take them into the hall to look for assistance.

Based on records reviewed and interviews for one of three sampled residents (Resident #1) who required extensive assistance of two staff members for all transfers, the Facility failed to ensure Resident #1 was provided the necessary level of assistance to maintain his/her safety, when on 10/01/21, Certified Nurse Aide (CNA) #3 transferred him/her into bed without the assistance of another staff member. Resident #1 was observed, at the end of the shift, to have bruises to his/her left forehead and left hip, an x-ray was taken which revealed a left hip fracture and he/she was transferred to the Hospital Emergency Department and admitted . Findings Include: The Facility Policy titled Transfers and Lifts, dated 01/07/00, indicated the Facility will ensure that all staff members are instructed in safe transfer and lifting techniques. The Policy indicated to know the resident's needs and that the resident's Care Plan should be very explicit on exactly how the resident is to be transferred and/or lifted. Review of the Facility Report submitted to the Department of Public Health (DPH) via the Health Care Facility Reporting System (HCFRS), dated 10/06/21, indicated that, on 10/01/21 at 11:00 P.M., Resident #1 was observed to have bruises on his/her left hip and left side of his/her head. The Report indicated that x-rays revealed a non-displaced left intertrochanteric fracture (type of hip fracture). The Report indicated that, during the Facility Investigation, the Director of Nursing and the Assistant Director of Nursing met with CNA #3, who had provided care for Resident #1 on 10/01/21. The Report indicated that CNA #3 said Resident #1 did not fall, that nothing abnormal occurred and the evening was uneventful. The Report indicated that after staff were interviewed, statements reviewed, and CNA #3 demonstrated how she transferred Resident #1 from his/her wheelchair into bed on 10/01/21, the Facility concluded that Resident #1's injury was the result of a difficult transfer into bed and that as he/she was being transferred he/she bumped the side rail, which was in the lower position, during the transfer. Review of Resident #1's Annual Minimum Data Set (MDS), dated [DATE], indicated that diagnoses included dementia, abnormality of gait and mobility, arthritis, and muscle weakness. The MDS indicated that Resident #1 required extensive assistance of two staff members with transfers. Review of Resident #1's Activity of Daily Living (ADL) Function and Mobility Care Plan, dated as effective 09/22/21, indicated that he/she had experienced a decline with transfers and mobility and indicated that he/she required extensive assistance of two staff members with the use of a gait belt for transfers. Review of the Incident Report, dated 10/01/21, indicated that, at 11:00 P.M., Resident #1 was observed with a 2.2 centimeter (cm) by 6.2 cm bruise on his/her left forehead and a 4.5 cm by 5.0 cm bruise on his/her left hip. Review of the Nurse's Note, dated 10/02/21, indicated that Resident #1's Physician was notified about his/her bruises, an order was obtained for a left hip x-ray and the Radiology Company was contacted. The Nurse's Note indicated that Resident #1 denied pain when asked, but later complained of pain when his/her left leg was touched, so his/her Physician was called to obtain an order to send him/her to the Hospital emergency room for evaluation. The Nurse's Note indicated that when Resident #1's (activated) Health Care Agent (HCA) was notified of the new Physician's Order to transfer Resident #1 to the Hospital Emergency Department, the HCA requested that the x-ray taken be obtained in the Facility. Review of the Nurse's Note, dated 10/02/21 and timed at 2:51 P.M., indicated that a call was placed to the Radiology Company to follow-up on the x-ray and to obtain an estimated time of arrival. Review of the Nurse's Note, dated 10/02/21 and timed at 6:54 P.M., indicated that Resident #1 was alert, verbal, had no complaints of pain, and had bruises on his/her left forehead and left hip. Review of the Radiology Report, dated 10/02/21, indicated that x-ray results revealed a intertrochanteric fracture of Resident #1's left hip. Review of the Nurse's Note, dated 10/03/21 indicated that Resident #1's Physician was notified, an order was obtained to transfer him/her to the Hospital Emergency Department. Review of the Hospital Discharge Summary, dated 10/07/21, indicated Resident #1 was admitted to the Hospital on 10/03/21 with a diagnosis of a left hip fracture. During an interview on 10/26/21 at 2:09 P.M., CNA #3 said Resident #1 was on her assignment on the 3:00 P.M. to 11:00 P.M. shift on 10/01/21, and when she brought him/her back to his/her room she showered him/her, she positioned Resident #1's wheelchair beside the bed in order to transfer him/her into bed and locked the wheelchair. CNA #3 said she was aware that Resident #1 required assistance from two staff members for transfers but said when she started to leave the room, she looked back at Resident #1, saw that he/she was seated at the edge of his/her wheelchair rocking herself/himself, said she did not want Resident #1 to fall so she transferred him/her into bed without assistance. CNA #3 said she did not know why did not call for help, bring Resident #1 with her to look for assistance, or use the call light for staff assistance rather than transferring Resident #1 alone. CNA #3 said when she transferred Resident #1 without assistance, she put her arms under Resident #1's arms, lifted him/her and put him/her into the bed. CNA #3 said was unsure if Resident #1's feet ever touched the ground when she lifted him/her from the wheelchair and said although she did not see him/her, she thought Resident #1 could have bumped the side rail of the bed, which was lowered and to the side of the bed. During an interview on 10/26/21 at 3:27 P.M., the Director of Nursing (DON) said she met with CNA #3 and had her demonstrate on herself (DON) how she transferred Resident #1 into bed and said as CNA #3 transferred her alone, she bumped her into and over the side rail. The DON said Resident #1 required the assistance of two staff members for transfers. The DON said if CNA #3 was afraid a resident would fall, she should stay with them, stand next to them, call for help, or take him/her out into the hall to look for assistance.

Based on observation and interview, the facility failed to maintain an infection prevention and control program relative to the use of personal protective equipment (PPE) and disinfecting medical equipment, designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases, infections and/or COVID-19. Findings include: Review of Center for Disease Control and Prevention (CDC) website: Interim Infection Prevention and Control Recommendations for HCP During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 7/15/20, indicated the following relative to environmental infection control; -All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instruction and facility policies. Review of the CDC website for Hand Hygiene in Healthcare Settings, undated, indicate the following; Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: -Immediately before touching a patient. -After touching a patient or the patient's immediate environment. -After contact with blood, body fluids, or contaminated surfaces. -Immediately after glove removal. Review of the facility's Clean, Disinfect, Deodorize Equipment Policy, date issued 3/2020, indicated the following: During an infectious outbreak, it is the policy of Coleman House to wipe clean all equipment used on ill residents with bleach Sani-wipes after each use as per manufacturer's directions. During an interview on 7/29/20 at 7:15 A.M., the Assistant Director of Nurses (ADNS) said the facility had no COVID-19 positive residents or staff at this time. She said staff testing is done every 2 weeks as their last round of testing did not indicated any COVID-19 positive staff. She said the census was currently 38, which included 3 new admissions under 14 days of quarantine. During a tour of the facility's west and east side units on 7/29/20 between 7:35 A.M. and 8:30 A.M , the following were observed; -Certified Nursing Assistant (CNA) #1 was observed in room [ROOM NUMBER] at the side of the resident of bed B. She was wearing a surgical mask, disposable gown and gloves. As she neared the entrance to the room, she doffed the gloves and gown, preformed hand hygiene and exited the room pushing a mechanical lift. CNA #1 placed the lift in the hallway. CNA #1 said the resident in bed B was COVID-19 negative and the resident in bed A was COVID-19 recovered. -CNA #2 was also in the same room at the resident's side. She was adjusting the bedside table in front of the resident. The PPE she was wearing was a surgical mask. -CNA #1 donned a disposable gown and gloves and entered room [ROOM NUMBER] while pushing the mechanical lift. Nurse #1 said both residents in this room were COVID-19 negative. CNA #1 was observed leaving room [ROOM NUMBER] pushing the mechanical lift. She left the lift in the hallway and moved onto caring for other residents on the unit. -CNA #2 was observed leaving the room [ROOM NUMBER] with her surgical mask down off her nose, exposing her nostrils. The mask remained this way while she continued to assist residents on the unit. She was observed touching and adjusting the mask with her hand, after staff requested she move it up to cover her nose fully. She did not perform hand hygiene and change her facemask after adjusting it. -CNA #3 was observed entering room [ROOM NUMBER] to provide a breakfast meal tray. He did not perform hand hygiene when leaving the room before moving onto providing other resident's their meals. The resident in room [ROOM NUMBER] was under quarantine. -CNA #1 entered room [ROOM NUMBER] and set up and assist the resident in bed A with their breakfast tray. The PPE she was wearing was a surgical mask. Staff said the resident in bed A was COVID-19 negative. None of the staff were wearing protective eyewear while assisting COVID-19 negative residents in their rooms. The mechanical lift was not disinfected after use of either resident. During an interview on 7/29/20 at 10:35 A.M., the surveyor reviewed the concerns with the Administrator, the Director of Nurses (DON) and the ADNS. The Administrator and DON said staff should have been wear goggles for care of negative and quarantined residents. The DON said the mechanical lift should have been cleaned with disinfectant wipes after each resident use. All of them said a facemask should fully cover the mouth and nose while worn, and staff should perform hand hygiene after all tasks, care and/or when touching potentially contaminated surfaces.

Based on observation, interview and review of Physicians' Orders, 2 of 3 Nurses (#1 and #2), failed to ensure that the Medication Pass had an error rate of less than 5%, affecting 2 of 4 residents (#8 and #15). The error rate was calculated at 34% with 29 opportunities for error and 10 errors observed. Findings include: 1. On 12/26/18, the Surveyor observed Nurse #2 during the 8:00 A.M. medication pass for Resident #8. The nurses are required to administer medications either one hour prior to or one hour after the physician's orders [REDACTED].M. (one hour and 50 minutes after the ordered time of 8:00 A.M.: - [MEDICATION NAME] (medication for excessive salivary secretions) 1 milligram (mg) by mouth (po) three times daily at 8:00 A.M., 12:00 P.M., and 4:00 P.M. - [MEDICATION NAME] (hormone) 0.025 mg/24 hours weekly on Wednesday. This medication was inadvertently missed during the medication pass until the Surveyor brought it to Nurse #1's attention at 11:30 A.M. that it had been missed. - [MEDICATION NAME] (for constipation) 100 mg. 2 tablets po twice daily at 8:00 A.M. and 4:00 P.M. - Senna (for constipation) 8.6 mg 2 tablets po twice daily at 8:00 A.M. and 4:00 P.M. - [MEDICATION NAME] (medication for nerve pain and neuropathies) 100 mg po twice daily at 8:00 A.M. and 8:00 P.M. - [MEDICATION NAME] solution (for constipation) 30 milliliters (ml) po twice daily at 8:00 A.M. and 4:00 P.M. - [MEDICATION NAME] ([MEDICAL CONDITION] medication) 25 mg-100 mg tablet, give 2 tablets po four times daily at 7:30 A.M., 11:30 A.M.; 4:30 A.M. and 8:00 P.M. This medication was administrated almost 2 hours late. 2. On 12/26/18 at 10:05 A.M., the Surveyor observed Nurse #1 during the 8:00 A.M. medication pass for Resident #15. The following medications were administered at 10:05 A.M. (2 hours and 5 minutes after the ordered time of 8:00 A.M.): - Tylenol (pain relieving medication) 500 mg, give 2 tablets po three times daily at 8:00 A.M., 2:00 P.M. and 8:00 P.M. - [MEDICATION NAME] (antidepressant medication) 50 mg po twice daily at 8:00 A.M. and 5:00 P.M. - [MEDICATION NAME] (blood pressure medication) 25 mg po twice daily at 8:00 A.M. and 4:00 P.M. On 12/26/18 at 10:15 A.M., Nurse #1 and #2 said that the medication pass is most often late due to stopping during meals as well as the volume of medications. Please refer to F760.

Based on observation, interview, and record review the facility staff failed to follow the facility policy for obtaining consent for the use of a physical restraint for 2 residents (#15 and #37) out of 16 sampled residents. Findings include: Review of the facility's undated Physical Restraint Policy indicated the following: .If the resident, family member, or legal representative agrees to the use of a restraint in writing, then the device may be used for a specific period of time for which the restraint has been determined to treat the medical symptom. 1. Resident #37 was admitted to the facility in 8/2018 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/18/18, indicated the resident had severe cognitive impairment as evidenced by a score of 1 out of 15 on the Brief Interview for Mental Status (BIMS), used a trunk restraint daily, and had an invoked Health Care Proxy (HCP). Review of the 12/2018 physician's orders [REDACTED]. On 12/27/18 at 9:09 A.M., the Resident was observed to be seated in a reclined Broda chair in the small activity room with a velcro alarm belt attached around the waist. During an interview on 12/27/18 at 9:51 A.M., with the Director of Nurses (DON) and MDS Nurse, the DON stated to be honest they didn't get written consent from the resident's representatives. 2. Resident #15 was admitted to the facility in 10/2018 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 10/22/18, indicated the resident had severe cognitive impairment as evidenced by a score of 2 out of 15 on the BIMS, used a trunk restraint when out of bed less than daily and had an invoked HCP. Review of the 12/2018 physician's orders [REDACTED]. On 12/26/18 at 11:10 A.M., the Resident was observed to be seated in a reclined Broda chair in the activity room watching television with a velcro belt attached loosely around the waist. During an interview on 12/27/18 at 10:16 A.M., the surveyor asked the DON if this resident had a consent for the use of the restraint. The surveyor and DON reviewed the clinical record and were unable to locate a consent form. No other documentation was provided throughout the remainder of the survey that indicated the risks of a restraint were reviewed and consent obtained from the resident's representatives for either of the above stated residents.

Based on observation and interview, facility staff failed to ensure clean and safe storage of drugs and biologicals including labeling of medications when opened. Findings include: On [DATE] at 3:00 P.M., the Surveyor inspected medication cart #1 with Nurse #3. The top drawer of the cart had medications/supplies which were either not dated when opened (per policy) or were expired: - Blood Glucose test strips were not dated when opened. Manufacturer's directions for use are to use within 6 months after opening or before the expiration date if not opened. - [MEDICATION NAME] eye solution 0.01% was not dated when opened. - [MEDICATION NAME] eye solution was not dated when opened. -[MEDICATION NAME] solution, 3 drops left ear twice daily for 2 days. The order was dated [DATE]. The solution was in the medication cart in a plastic bag with light brown dried exudate on the front of the bag. (order had expired) - [MEDICATION NAME] (inhalation medication) for a nebulizer. The order was dated and received [DATE] to be used twice daily for 7 days. (order expired [DATE]) The top and front of the medication cart had areas of caked on debris that was left after medication passes. The top drawer of the medication cart had a copious amount of various loose pills and cardboard tabs from the medication cards on the bottom of the drawer. On the bottom of the locked narcotic box was a large amount of the cardboard tabs from the cards, also heaped in the back of the drawer. The middle drawer had a red sticky substance spilled in the drawer with bottles of liquid medication sticking to it. During interview on [DATE] at 3:20 P.M., Nurse #3 said that he would take care of it right away.

Based on interview and record review the facility staff failed to provide 3 beneficiaries, (resident's #5, #24, and #44), with an Advanced Beneficiary Notice (ABN) at the termination of skilled Medicare Part A benefits as required, to advise the beneficiary of his/her potential liability for payment. Findings include: Review of the Notice of Medicare Non-Coverage letters for 3 residents #5, #24, and #44 who remained in the facility after their skilled Medicare benefit had been terminated, indicated ABNs had not been provided to the residents or their representatives. During an interview on 12/27/18 at 3:47 P.M., the Administrator said the ABNs were not done for any of the three residents and they should have been.

Based on observation record review and interview the facility staff failed to obtain consent and assess risk for entrapment for 9 residents ( #1, #2, #4, #5, #6, #7, #8, #9, and #11) out of a total of 12 sampled residents. Examples and findings include: 1. For Resident #1 facility staff failed to obtain informed consent for the use/application of siderails. The facility also failed to ensure that the safety of the siderails was assessed for the risk of entrapment. Resident #1 was admitted to the facility 7/2016 with multiple [DIAGNOSES REDACTED]. Review of the care plan for risk of alteration in skin indicated that '1/4' siderails were up when the resident was in bed. Review of the clinical record did not indicate that informed consent was obtained by the resident or responsible party for the use of siderails, nor was there any safety assessment completed for the risk of entrapment, as required. Observation of the resident's bed on 9/20/17, indicated bilateral 1/2 siderails were in place. 2. For Resident #2 facility staff failed to obtain informed consent for the use/application of siderails. The facility also failed to ensure that the safety of the siderails were assess for the risk of entrapment. Resident #2 was admitted to the facility 5/2017, with [DIAGNOSES REDACTED]. Review of the care plan for fall risk indicated the resident used 2 1/4 siderails in bed to aid in self positioning. Review of the clinical record did not indicate that informed consent was obtained by the resident or responsible party for the use of siderails, nor was there any safety assessment completed for the risk of entrapment, as required. Observation of the residents bed on 9/19/17, indicated bilateral 1/2 siderails were in place. 3. For Resident #8 facility staff failed to obtain informed consent for the use/application of siderails. The facility also failed to ensure that the safety of the siderails were assess for the risk of entrapment. Resident #8 was admitted to the facility 7/2011 with multiple [DIAGNOSES REDACTED]. Review of the current Physician orders indicated an order dated 8/2/17 for the resident to have padded 1/2 siderails when in bed. Review of the clinical record did not indicate that informed consent was obtained by the resident or responsible party for the use of siderails, nor was there any safety assessment completed for the risk of entrapment, as required. Observation of the resident on 9/20/17 at 2:10 P.M., in bed with the head of the bed elevated 30 degrees and bilateral padded 1/2 siderails up. 4. For Resident #4, the facility staff failed to obtain informed consent for the use/application of side rails. The facility also failed to ensure that the safety of the side rails were assessed for entrapment. Resident #4 was admitted to the facility in 12/2015 with [DIAGNOSES REDACTED]. Review of the 7/2017 Monthly Physician Orders did not indicate an order for [REDACTED]. Review of the clinical record did not indicate that informed consent was obtained by the resident and/or responsible party for the use of the side rails, nor was there any safety assessment completed for risk assessment, as required. During an observation on 9/19/17 at 2:10 P.M., the resident was awake and resting in bed. A bed alarm was noted on the bed. The call light was within resident's reach. There were 2 half side rails in the up position. 5. For Resident #6, the facility staff failed to obtain informed consent for the use/application of side rails. The facility also failed to ensure that the safety of the side rails were assessed for entrapment. Resident #6 was admitted to the facility in 9/2015 with [DIAGNOSES REDACTED]. Review of the 9/2017 Monthly Physician Orders did not indicate an order for [REDACTED]. Review of the clinical record did not indicate that informed consent was obtained by the resident and/or responsible party for the use of side rails, nor was there any safety assessment completed for risk assessment as required. During an observation on 9/20/17 at 7:20 A.M., the resident was resting in bed with eyes closed. The call light was within reach. There were 2 half side raised in the up position. 6. For Resident #7, the facility staff failed to obtain informed consent for the use/application of side rails. The facility also failed to ensure that the safety of the side rails were assessed for entrapment. Resident #7 was admitted to the facility in 4/2017 with [DIAGNOSES REDACTED]. Review of the 8/2017 Monthly Physician Orders did not indicate an order for [REDACTED]. Review of the clinical record did not indicate that informed consent was obtained by the resident and/or responsible party for the use of the side rails, nor was there any safety assessment completed for risk assessment, as required. During an observation on 9/19/17 at 1:30 P.M., the resident was resting in bed with eyes closed. The radio was playing. The call light was within reach. There were 2 half side rails in the up position. During an interview with the Director of Nurses (DON) on 9/20/17 at 10:10 A.M. and at she said the facility staff did not get informed consent or complete resident specific safety entrapment risk assessment prior to the use of siderails because they were unaware that it was required. During a follow up interview with the DON on 9/20/17 at 1:00 P.M., she said that the facility used 1/2 siderails not 1/4 siderails and they did not have a policy for siderail use.

Based on interview and record review, the facility staff failed to follow the plan of care for fall prevention for 1 resident (#7) in a total sample of 11 residents. Findings include: For Resident #7, the facility staff failed to follow the plan of care for fall prevention relative to the use of a gait belt and an alarmed Velcro seatbelt. Resident #7 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 3/13/16, indicated the resident had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 4 of 15, required limited assistance for transfers, ambulation and toileting and had [DIAGNOSES REDACTED]. Review of the care plan for falls, effective 3/14/16, indicated the resident was high risk for falls due to impulsiveness, poor safety awareness and advanced [MEDICAL CONDITION]. One intervention was to use a Velcro alarm self release seat belt while in chair. In addition, the resident was to transfer with assistance of one using a gait belt. Review of a Resident Incident/Accident Report, dated 5/12/16 at 2:00 P.M., indicated a Certified Nurses' Aide (CNA) was transferring the resident from the wheelchair to bed. The resident's leg buckled. The CNA called for the assistance of an additional CNA to help the resident into bed. The resident sustained [REDACTED]. The report indicated a gait belt had not been used for the transfer as care planned. Review of a Resident Incident/Accident Report, dated 5/13/16 at 5:45 P.M., a visitor reported that a resident had fallen. The resident was found in his/her room on the left side, bleeding from an area below the left eyebrow. The Velcro seat belt alarm was not sounding. The resident was sent to the hospital for treatment. Further, the report indicated that the resident had been placed into a reclining chair after being toileted, the Velcro seatbelt applied, but the alarm not activated as care planned. Review of the Hospital emergency room Department Record, dated 5/13/16, indicated the resident had a mechanical fall resulting in a laceration above the left eye requiring five sutures, left shoulder ecchymosis (bruising) and bruising and tenderness of the left index and middle fingers. During an interview on 7/5/16 at 4:00 P.M. with the Director of Nurses and the MDS Nurse, they said the care plan to prevent falls had not been followed regarding the use of the gait belt for transfers, or for the use of the alarmed Velcro seatbelt. See F323

Based on interview and record review, the facility staff failed to provide adequate interventions to prevent falls for 1 resident (#7), of 7 applicable residents reviewed for falls, in a total sample of 11 residents. Findings include: For Resident #7, the facility staff failed to correctly implement the use of a gait belt and an alarmed Velcro seatbelt as part of the resident's fall prevention care plan. Review of the facility policy for Fall Prevention, revised 9/15/08, indicated that contributing factors to falls included the [DIAGNOSES REDACTED]. In addition, all residents at high risk of falls would have the following instituted: -Use pressure alarms and/or tab alarms as indicated, -Place resident in an area of greater supervision when out of bed. Resident #7 was admitted to the facility in 4/2014 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 3/13/16, indicated the resident had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 4 of 15, required limited assistance for transfers, ambulation and toileting and had [DIAGNOSES REDACTED]. Review of the care plan for falls, effective 3/14/16, indicated the resident was high risk for falls due to impulsiveness, poor safety awareness and advanced Parkinson's disease. One intervention was to use a Velcro alarm self release seat belt while in chair. In addition, the resident was to transfer with assistance of one using a gait belt. Review of a Resident Incident/Accident Report, dated 5/12/16 at 2:00 P.M., indicated a Certified Nurses' Aide (CNA) was transferring the resident from the wheelchair to bed. The resident's leg buckled. The CNA called for the assistance of an additional CNA to help the resident into bed. The resident sustained [REDACTED]. The report indicated a gait belt had not been used for the transfer. Review of a Resident Incident/Accident Report, dated 5/13/16 at 5:45 P.M., a visitor reported that a resident had fallen. The resident was found in his/her room on the left side, bleeding from an area below the left eyebrow. The Velcro seat belt alarm was not sounding. The resident was sent to the hospital for treatment. Further, the report stated that the resident had been placed into a reclining chair after being toileted, the Velcro seatbelt applied, but the alarm not activated. Review of the Hospital emergency room Department Record, dated 5/13/16, indicated the resident had a mechanical fall resulting in a laceration above the left eye requiring five sutures, left shoulder ecchymosis (bruising) and bruising and tenderness of the left index and middle fingers. Review of the Quarterly MDS Assessment, dated 6/5/16, indicated the resident had severe cognitive impairment, required extensive assistance with transfers, ambulation and toileting, and had two falls with injuries. During an interview on 7/5/16 at 4:00 P.M. with the Director of Nurses and the MDS Nurse, they said the care plan to prevent falls had not been followed regarding the use of the gait belt for transfers, or for the use of the alarmed Velcro seatbelt. In addition, they said maintenance had checked the alarm the next day to ensure it was not faulty.

Based on record review and interview, the facility failed for 1 of 2 sampled residents (Resident #1) to clearly indicate in Resident #1's plan of care that Resident #1 was not to be left alone in the bathroom, and on 1/20/12, Certified Nurse Aide #1 left Resident #1, who was at a high risk for falls and used a bed and chair alarm, alone in the bathroom, Resident #1 got up from the toilet alone, attempted to ambulate and fell , sustaining a fractured left humerus. The findings include: The face sheet indicated that Resident #1 was admitted to the Facility in 11/11 with [DIAGNOSES REDACTED]. The Certified Nurse Aide (CNA) care card indicated that Resident #1 used alarms both in and out of bed and was at risk for falls. The page 2 referral, dated 11/8/11, indicated that Resident #1 ambulated with a rolling walker and supervision with reminders because he/she exhibited poor safety awareness and was a high fall risk. The care plan, dated 11/8/11, developed to address Resident #1's risk for falls, included the following interventions: use pressure alarms in and out of bed, if resident is noted to be restless during the night attempt to toilet resident and assist to common area as needed. The fall risk assessment, dated 11/15/11, indicated Resident #1 scored 16. According to the scale used, a score if 10 or greater indicated a high fall risk. The admission Minimum Data Set (MDS) assessment, dated 11/20/11, indicated Resident #1 scored 6 out of 15 on a cognitive rating scale which indicated cognitive impairment. The nurse's note, dated 1/20/12, at 3:34 A.M., indicated that Resident #1's alarm sounded, CNA #1 found Resident #1 in the bathroom, CNA #1 left Resident #1 in the bathroom to get incontinence supplies and Resident #1 fell . The note indicated Resident #1 complained of pain in the left arm/shoulder. During an interview with Certified Nurse Aide (CNA) #1 on 2/28/12 at 10:00 A.M. CNA #1 said that on 1/20/12 at approximately 2:00 A.M. he heard Resident #1's alarm sound and went to Resident #1's room. CNA #1 said that Resident #1 was in the bathroom. CNA #1 said that he left Resident #1 in the bathroom and went back to doing rounds with CNA #2. CNA #1 said that CNA #2 told him that Resident #1 was safe to leave in the bathroom. CNA #1 said that he and CNA #2 were down the hall when they heard Resident #1 fall in the bathroom. CNA #1 said that if a resident has a bed alarm, that resident is not safe to ambulate independently. During an interview with CNA #2 on 2/21/12 at 9:00 A.M., CNA #2 said that CNA #1 worked at the Facility for over 2 years, at least 2 to 3 times a week and was familiar with the unit and Resident #1, as well as the procedure relative to fall risk. CNA #2 said that she and CNA #1 were doing resident care rounds when she heard an alarm sound. CNA #2 said that she told CNA #1 to go and check the alarm. CNA #2 said that CNA #1 went to check the alarm and when he returned he told her that the alarm was Resident #1 who needed to go to the bathroom. CNA #2 said that CNA #1 did not tell her that he left Resident #1 in the bathroom alone. CNA #2 said that a short time later, they heard a loud crash and went to investigate. CNA #2 said that when she and CNA #1 got to Resident #1's room, Resident #1 was on the floor by the bathroom door and was complaining of pain in the left shoulder. CNA #2 said that CNA #1 left Resident #1 on the toilet, alone when he answered Resident #1's alarm, and Resident #1 fell . During an interview with Nurse #1 on 2/15/12 at 1:40 P.M., Nurse #1 said that on 1/20/12, she heard Resident #1's alarm sound. Nurse #1 said that a short time later she heard a crash and went to Resident #1's room where she found Resident #1 lying on the floor on his/her left side. Nurse #1 said that she assessed Resident #1, notified the physician and transferred Resident #1 to the Hospital for evaluation and treatment. Nurse #1 said that CNA #1 told her that he answered Resident #1's alarm, found Resident #1 in the bathroom, and went to get a clean incontinence pad. Nurse #1 said that CNA #1 (an agency staff) said CNA #2 (Facility staff) told him that it was alright to leave Resident #1 alone in the bathroom. Nurse #1 said that CNA #2 knew Resident #1 could not be left alone and would never tell anyone that he/she could be left alone. Nurse #1 said she asked CNA #2 if she said that and CNA #2 said no. Nurse #1 said that CNA #1 had worked on the unit previously. Nurse #1 said that any resident using an alarm is not to be left alone in the bathroom. During an interview with the Supervisor on 2/15/12 at 1:15 P.M., the Supervisor said that there is a list of residents using alarms on the unit and the alarms are checked at the beginning of each shift by CNA's. The Supervisor said that it is an unwritten policy that any resident using any type of alarm device, is not to be left alone in the bathroom. The Supervisor said that CNA #1 was from the agency and Facility staff instructs the agency staff relative to the needs of the residents on the unit. The Supervisor said that CNA #1 worked at the Facility on previous occasions. The Supervisor said that CNA #1 used poor judgment when he left Resident #1 alone in the bathroom. The Supervisor said the Facility staff received re-education relative to alarm safety and fall prevention, following this incident. During an interview with the Director of Nursing (DON) on 2/21/12 at 8:30 A.M., the DON said that it is the practice of the Facility that if a resident uses an alarm, that resident should not be left alone in the bathroom. The DON said that the information relative to a resident's alarm use is located on the CNA care card and is given to agency CNAs during change of shift report. The DON said that CNA #1 was familiar with the Facility because he had worked there prior to the incident. The DON said that since this incident, CNA #1 is not allowed to work at the Facility. During an interview with the MDS Coordinator on 2/15/12 at 2:40 P.M., the MDS Coordinator said it is an unwritten policy not to leave a resident alone in the bathroom if the resident requires the use of an alarm for safety. During an interview with the Unit Manager on 2/15/12, at 12:30 P.M., the Unit Manager said Resident #1 used a rolling walker with assistance to ambulate and was unsteady on his/her feet. The Unit Manager said that if a resident uses an alarm, that resident is not to be left alone in the bathroom.