Every finding on record at Ashland Health and Rehabilitation

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident's call light was readily accessible for one (1) of 49 residents observed during the initial tour. Resident #22.Findings Include: Review of the facility policy titled Call Light Standard revised 3/19, revealed under, Policy Explanation and Compliance Guidelines: . 5. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. During the initial tour on 4/13/26 at 10:28 AM, Resident #22 was observed lying in bed, which was positioned against the wall on his right side. The call light was not visible or accessible to the resident. Further observation revealed the call light cord was wedged between the wall and the mattress, and the call light device was located on the floor under the bed, rendering it inaccessible to the resident. An interview with Certified Nurse Aide (CNA) #1 on 4/15/26 at 10:18 AM revealed that when staff made rounds to provide care, they were expected to ensure the call light was within the resident's reach. She stated that anything could happen and the resident should always have a way to contact staff for care needs. An interview with the Director of Nursing on 4/15/26 at 11:02 AM confirmed that staff were responsible for ensuring call lights were within reach so residents could summon assistance when needed. Record review of the admission Record revealed the facility admitted Resident #22 on 1/29/24 with medical diagnoses that included Moderate Intellectual Disabilities, Muscle Weakness, and Unsteadiness on Feet. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/27/26 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 12, which indicated Resident #22 was moderately cognitively impaired.

Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to ensure medications were accurately labeled and corresponded with the physician's order for one (1) of three (3) residents observed during medication pass (Resident #47) Findings Include:Review of facility policy titled, Medication Order & Dispensing Variance Protocol dated 03/2026, revealed, .Procedures.1. a. Licensed nursing staff must verify that the medication label, physician's order, and Medication Administration Record (MAR) match prior to each medication administration.3. e. Ensure the physician's order and Medication Administration Record (MAR) are updated in Point Click Care (PCC) to accurately reflect the medication being dispensed and administered.An observation during medication administration on 4/15/2026 at 9:15 AM revealed an order on the electronic Medication Administration Record (EMAR) for Benztropine Mesylate Tablet 1 milligram (mg) with instructions to administer 0.5 mg tablet by mouth two times a day for mood disorder. Licensed Practical Nurse (LPN) #1 retrieved a pharmacy-prepared medication pack labeled Benztropine Mesylate 0.5 mg. LPN #1 acknowledged the discrepancy between the physician's order on the EMAR and the medication label, confirming the orders should match. She stated she did not notice the inconsistency at the time but was aware the resident was to receive 0.5 mg twice daily. During an observation and interview on 4/15/26 at 9:30 AM, the Director of Nursing (DON) confirmed the physician's order did not match the labeled medication, resulting in a discrepancy between the prescribed order and the pharmacy label for Resident #47. The DON revealed nursing staff are responsible for ensuring medication labels correspond with the physician's order and accurately reflect the medication to be administered.Record review of Resident #47's Medication Administration Record revealed an order with a start date of 12/16/2024 for Benztropine Mesylate Tablet 1 MG Give 0.5 tablet by mouth two times a day for mood disorder.Review of Resident #47's pharmacy-prepared medication pack revealed Benztropine Mesylate 0.5 mg.Record review of Resident #47's admission Record revealed the facility admitted the resident on 7/7/2016 with diagnoses including Undifferentiated Schizophrenia, and Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/27/26 revealed under Section C, a Brief Interview for Mental Status (BIMS) summary score of 09 which indicated Resident #47 was moderately cognitively impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan for a resident requiring oral care for one (1) of three (3) sampled residents. Resident #3 Findings Include: Review of the facility policy titled The Care Plan with a revision date of 4/2019 revealed, The Comprehensive Care Plan is completed within seven (7) days after the MDS (minimum data set) is completed . Record review of the Activities of Daily Living (ADL) Care Plan for Resident #3 revealed under, Focus: The resident has an ADL self care performance deficit r/t (related to) Hemiplegia from hx (history) of CVA (Cerebrovascular Accident) affecting left side. Further review revealed the care plan was not developed for oral care. An observation of Resident #3 on 5/07/25 at 8:40 AM revealed she was sitting in her wheelchair in the hallway and was alert but confused and did not answer questions appropriately. Her lower lip was observed as dry and cracked with peeling skin. An observation of Resident #3 on 5/07/25 at 10:05 AM revealed she was lying in bed and her lower lip remained dry and cracked. An interview with Certified Nurse Aide (CNA) #1 on 5/07/25 at 10:35 AM revealed she did not perform oral care on Resident #3. She explained that the resident wore dentures, and she was able to wash them in the sink herself. An interview with Registered Nurse (RN) #1 on 5/07/25 at 10:58 AM confirmed Resident #3's lower lip was dry, irritated, and had peeling skin. An interview with the Administrator (ADM) on 5/07/25 at 12:20 PM confirmed the care plan was not developed for Resident #3 to have oral care and revealed that if it was not developed, the staff would not know to do it. An interview with the Minimum Data Set (MDS) Nurse on 5/07/25 at 12:48 PM revealed the purpose of the care plan was for the staff to know what care to provide for the residents. She confirmed the care plan was not developed for Resident #3 related to oral care and stated, We can't just assume the staff know to do it. Record review of the Admission Record revealed the facility admitted Resident #3 on 2/18/25 with medical diagnoses that included Nontraumatic Intracranial Hemorrhage in the Cortical Hemisphere, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant side, and Encounter for Attention to Gastrostomy. Record review of the Brief Interview for Mental Status (BIMS) Evaluation dated 5/6/25 revealed a summary score of 8, which indicated Resident #3 was moderately cognitively impaired.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide oral care for one (1) of three (3) residents requiring assistance with activities of daily living (ADLs). Resident #3 Findings Include: Review of the facility policy titled Oral Care, with a revision date of 6/2022, revealed under Standard: It is the standard of this facility that every resident will receive oral care at least twice daily, and as needed. Additionally revealed under Process: . 10. Inspect the resident's mouth, teeth and gums for open areas of irritation; notify the supervising nurse immediately of any problems noted or any complaints by the resident. 11. Apply lip balm to the resident's lips and use lemon and glycerin swabs to lubricate the resident's mouth . A telephone interview with a confidential source on 5/06/25 at 1:32 PM revealed Resident #3 was admitted to the facility after suffering a stroke and explained the resident had lost function of the left side of her body. The source revealed that the resident only received hydration through a feeding tube and reported the resident's lips were dry and cracked, and the skin was peeling to the point of bleeding. On 5/07/25 at 8:40 AM an observation of Resident #3 revealed she was sitting in her wheelchair in the hallway, that she was alert but confused and did not answer questions appropriately. Her lower lip was observed to be dry and cracked with peeling skin. On 5/07/25 at 10:05 AM an observation of Resident #3 revealed she was lying in bed and her lower lip remained dry and cracked with peeling skin. An interview with Licensed Practical Nurse (LPN) #1 on 5/07/25 at 10:17 AM revealed she was aware of Resident #3's dry lips and explained that she noticed it last week after a family member reported it. She stated, It was dry and irritated and had started to bleed. She explained it was bleeding, but we thought the family member may have wiped it and caused it to bleed. Furthermore, she revealed she notified the supervisor and knew that lip hydration was provided. LPN #1 confirmed she did not document this information in the notes and was unsure if anything was put into place for the issue. Record review of the Activities of Daily Living Task for Resident #3 revealed there was no task set up for staff to complete oral care/hygiene and apply lip hydration. On 5/07/25 at 10:35 AM an interview with Certified Nurse Aide (CNA) #1 revealed she did not perform oral care on Resident #3. She explained that the resident wore dentures, and she was able to wash them in the sink herself. CNA #1 confirmed she was aware of the resident's dry lips and revealed that she had not applied a moisturizer but explained that she did notify License Practical Nurse (LPN) #1 the previous weekend that her lips were dry and cracked. On 5/07/25 at 10:58 AM an interview with Registered Nurse (RN) #1 revealed they had not initiated any treatment for Resident #3's lower lip and confirmed the lower lip was dry and peeling skin. She revealed that she tried to wash it with a warm wash cloth this morning, and it began bleeding. RN #1 confirmed the resident should have had oral care and a moisturizer applied to her lips and recognized this would be discomforting for the resident. An interview with the Administrator (ADM) on 5/07/25 at 12:20 PM revealed she saw Resident #3's lips yesterday and stopped by the desk and told the staff to do something about it. She confirmed the aide task was not set up to provide oral care, and verbalized it should have been. The ADM explained it was important to have proper oral care and lip moisturizer applied, especially when a resident was receiving nutrition through a feeding tube. Record review of the Admission Record revealed the facility admitted Resident #3 on 2/18/25 with medical diagnoses that included Nontraumatic Intracranial Hemorrhage in the Cortical Hemisphere, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant side, and Encounter for Attention to Gastrostomy. Record review of the Brief Interview for Mental Status (BIMS) Evaluation dated 5/6/25 revealed a summary score of 8, which indicated Resident #3 was moderately cognitively impaired.

Based on resident and staff interview, record review, and facility policy review, the facility failed to complete a trauma informed care assessment for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) for one (1) of 53 residents residing in the facility. Resident #45 Findings Include: Review of the facility policy titled Trauma Informed Care with a revision date of 10/22 revealed, Standard: It is the standard of this facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization . Record review of the Admission Record revealed the facility readmitted Resident #45 on 10/02/24 with medical diagnoses that included Post Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder, and Major Depressive Disorder. Record review of the Admission Social History dated 10/03/24 for Resident #45 revealed there was no documentation regarding Post Traumatic Stress Disorder. Record review of the Trauma Screen for Resident #45 dated 11/21/23 revealed, under, 2. Have you ever experienced a type of event that was unusually or especially frightening, horrible, or traumatic? No was answered. Also revealed under, C. War? No and D. Physical, emotional or sexual abuse at any age? No was answered. An interview with Resident #45 on 2/26/25 at 8:50 AM revealed he did suffer from Post Traumatic Stress Disorder and explained that certain things bothered him (triggers). He revealed that he served 4 years in the marines and served in combat. Resident #45 explained he also experienced traumatic events and was mistreated as a child, and was out on his own at the age of 16. He stated that if he does not get enough sleep at night, his anxiety increases and his mood suffers. He admitted that he has had roommates in the past that kept him up at night, which exacerbated his symptoms and confirmed that loud noises and a noisy environment bothered him (triggers). Resident #45 stated that he would love to have more freedom in the facility and explained it was difficult to transition from being at home. An interview with Licensed Practical Nurse (LPN) #1 on 2/26/25 at 8:55 AM revealed she was not aware Resident #45 had any triggers. She stated that the resident had not reported anything to her. An interview with Registered Nurse (RN) #1 on 2/26/25 at 9:02 AM confirmed that Resident #45 did get upset and anxious at times and would pick at his skin. RN #1 revealed when the resident was upset, he would come and tell the staff, and they would talk it out, but admitted that she was not aware of any triggers. An interview with Certified Nurse Aide (CNA) #1 on 2/26/25 at 9:05 AM confirmed that Resident #45 did not like loud noises and explained that the resident gets irritated with a lot of people around in his room. An interview with Social Services (SS) #1 on 2/26/25 at 9:09 AM confirmed that she was aware Resident #45 had Post Traumatic Stress Disorder. She confirmed that her social assessment did not mention the residents' history of combat/military service or traumatic childhood events. She acknowledged that she did not discuss his potential triggers. SS #1 explained that she knew the resident was in the military and voiced that was all she knew, and confirmed she did not make a note of it. She confirmed the residents' trauma assessment should have identified his history and potential triggers so that staff were aware of what things could cause re-traumatization. An interview with the Director of Nursing (DON) on 2/26/25 at 9:18 AM confirmed that the trauma assessment should have reflected his history along with his triggers. She admitted that Resident #45 had some adjustment issues after re-admitting to the facility and confirmed that the resident got nervous and picked at his skin sometimes. An interview with the Administrator (ADM) on 2/26/25 at 9:24 AM confirmed that Resident #45 should have had a trauma screen on admit that accurately reflected his history of trauma and triggers so that staff would know how to care for the resident. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #45 was cognitively intact.

Based on resident and staff interview, record review, and facility policy review, the facility failed to develop a resident specific comprehensive care plan that identified trigger specific interventions for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) for one (1) of 19 care plans reviewed. Resident #45 Findings Include: Review of the facility policy titled RAI (Resident Assessment Instrument)/Care Planning Management with a revision date of 4/2019 revealed under, The Care Plan: The Comprehensive Care Plan is completed within seven (7) days after the MDS (Minimum Data Set) is completed and reviewed quarterly thereafter. Review of the facility policy titled Trauma Informed Care with a revision date of 10/2022 revealed under, Policy Explanation and Compliance Guidelines: . 4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professional to develop and implement individualized care plan interventions. 6. The facility will identify triggers, which may re-traumatize residents with a history of trauma. Trigger-specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the residents care plan . Record review of Resident #45's Care Plan Report revealed under, Focus: The resident uses psychotropic medications r/t (related to) anxiety and depression and PTSD (Post Traumatic Stress Disorder). The care plan was not developed for triggers or trigger-specific interventions for PTSD. On 2/26/25 at 8:50 AM, an interview with Resident #45 confirmed that he suffered from Post Traumatic Stress Disorder due to serving in combat and some childhood mistreatment. He admitted that loud noises and other certain things bothered him leading to less sleep, which increased his anxiety. An interview with the Minimum Data Set (MDS) Nurse on 2/26/25 at 9:15 AM confirmed Resident #45's Post Traumatic Stress Disorder (PTSD) care plan was not developed to include trigger specific interventions. She admitted that the staff would not know what the residents' triggers were because they were not listed. On 2/26/25 at 9:24 AM, an interview with the Administrator (ADM) confirmed that Resident #45's care plan should have reflected his history of trauma and been developed so that staff would know how to care for the resident. Record review of the Admission Record revealed the facility readmitted Resident #45 on 10/02/24 with medical diagnoses that included Post Traumatic Stress Disorder (PTSD), Generalized Anxiety Disorder, and Major Depressive Disorder. Record review of the MDS with an Assessment Reference Date (ARD) of 1/13/25 revealed, under section C, a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated Resident #45 was cognitively intact.

Based on observations, record reviews, and facility policy reviews the facility failed to clean and disinfect a multi-use glucometer with the approved disinfecting wipe for two (2) of two (2) medication carts reviewed. Findings Include: Record review of the policy titled, Diabetic Management, dated 04/2019, revealed, Cleaning and disinfecting your EvenCare G2 Meter: .4. To disinfect your meter, clean the meter surface with one of the following disinfecting wipes: Dispatch Hospital Cleaner Disinfectant Towel with Bleach (1 minute). Medline Micro-Kill Disinfecting, Deodorizing, cleaning wipes with Alcohol (30 seconds). Clorox Healthcare Bleach Germicidal and Disinfectant Wipes (1 minute). Medline Micro-Kill Bleach Germicidal Bleach Wipes (2 minutes) . An observation and interview on 11/19/23 at 4:10 PM, with Licensed Practical Nurse (LPN) #4, the LPN used the glucometer to check finger stick blood sugar (FSBS) of a resident and upon return to the B hall medication cart LPN#4 retrieved a pack of 75% alcohol disinfecting wipes and wiped the glucometer with the alcohol wipe for about 15 seconds and laid the glucometer down on a napkin with the wipe still wrapped around the glucometer. An interview with the LPN at this time stated that she usually uses the purple top wipes but there weren't any on her med cart for the last two days and stated, I think we are out of them. I looked for them yesterday and couldn't find any. An observation and interview on 11/19/23 at 4:15 PM, with LPN #3 on A hall med cart revealed that she was out of the purple top wipes as well and stated, I told the Registered Nurse (RN) supervisor to bring me some wipes and he brought me these, holding up a container of 75% alcohol disinfecting wipes. LPN #3 confirmed that she works every other weekend and has not had any purple top wipes on her med cart yesterday or today, but did have some the last time she worked. Interview on 11/19/23 at 4:18 PM, with the CNA Staffing Coordinator confirmed that she ordered supplies and stated, I think they (purple top wipes) are on back order, let me check the supply closet. Observation of the supply closet with CNA staffing coordinator confirmed that there were no purple top wipes in the supply closet. An interview with the Director of Nursing (DON) on 11/19/23 at 4:20 PM, confirmed that she had the disinfecting wipes for the glucometers in her office and that they had just come in and she had placed them in her office, not knowing that the nurses on the med carts were out and that there were none available in the supply closet. The DON confirmed that her office is locked and that weekend staff would not have had access to her office to retrieve the wipes. Record review of in-services transcript for LPN #4 revealed that she had Diabetic Management and Infection Control, on 10/30/23 and LPN #3 completed her in-service titled, Glucometer Disinfection on 10/26/23. An interview with the DON on 11/20/23 at 2:35 PM, confirmed that these three inservices that were attended by LPN #3 and LPN #4 would have taught them that they have to use a germicidal wipe instead of an alcohol wipe on the glucometers. Interview on 11/20/23 at 2:40 PM, with the Nurse Educator confirmed that the in-services titled Glucometer Disinfection and Diabetic Management, is the same in-service and training on how to clean the meter with the appropriate wipe.

Based on observations, staff and resident interviews, record review and facility policy review, the facility failed to identify and properly care plan a restraint for a resident with a chair alarm for one (1) of three (3) residents with a chair alarm reviewed. Resident #23 Findings Include Review of the facility policy titled, Care Planning Management with a revision date of 04/2019 revealed under Process for Completing the .Care Plans .Standard; It is the practice of this facility to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. Objective .#1. To identify resident's individual needs and care requirements, #2. To assure that an interdisciplinary team assesses the emotional, psychosocial, mental, and physical needs of each resident. Care Conference Protocol .After the team reviews the triggered areas of concern, a care plan decision will be made. Problems will be identified and written in an interdisciplinary, CAA (Care Area Assessment) integrated format. Goals will be resident specific, measurable, and realistic. Interventions will be action verb directed and specific to each resident . Record review of Resident #23's care plans revealed there was no restraint care plan. An observation and interview on 11/19/23 at 3:40 PM, revealed Resident #23's had a chair alarm hooked to the back of her wheelchair and was pinned to the back of her shirt. An interview at the same time with Resident #23 revealed that the resident is alert to herself and pleasantly confused on time and place. The resident was asked if she knew what the device was on her wheelchair and she stated, It's a woolly of a thing, it worries me to death. It's supposed to catch me if I'm about to fall. I ask them if I can get it off there and they say no ma'am. An interview on 11/20/23 at 10:30 AM, with Registered Nurse (RN) Minimum Data Set (MDS) nurse confirmed that Resident #23 had a clip alarm on her wheelchair because she kept falling. An interview on 11/20/ 23 at 3:35 PM with RN MDS Nurse revealed the purpose of the care plan was to give a guide to help take care of the resident. She revealed the reason the personal alarm was not care planned as a restraint was because they were not aware that a bed or chair alarm could be a restraint. She acknowledged that a bed or chair alarm could prevent freedom of movement. An interview on 11/21/23 at 8:44 AM with the DON confirmed that they just really did not consider it a restraint, or they would have done things differently. She stated that she understands after reading the regulation that a chair alarm can be considered a restraint and confirmed that it was not care planned. An interview on 11/21/23 at 10:40 AM with RN #2 revealed that the purpose of the care plan was to have person centered developed care provided to the resident. Record review of Resident #23's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus without Complications. Record review of Resident #23's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 02, which indicated the resident is severely cognitively impaired and in Section P that the resident had a chair alarm in use daily.

Based on observations, staff and resident interviews, record review and facility policy review, the facility failed to identify and analyze information obtained from a Minimum Data Set assessment for a chair alarm restraint prior to developing the comprehensive care plan for one (1) of three (3) residents with a chair alarm, Resident #23. Findings include: Review of the typed statement on facility letterhead dated 11/21/23 revealed the facility did not have a policy regarding MDS assessment. The facility uses the current RAI (Resident Assessment Instrument) Manual and was signed by the Administrator. During an observation and interview on 11/19/23 at 3:40 PM, revealed a chair alarm on Resident #23's wheelchair that was pinned to the back of the resident's shirt. This observation revealed the resident propels herself with her feet in the wheelchair. An interview at the same time with Resident #23 revealed that the resident is alert to herself and pleasantly confused on time and place. The resident was asked if she knew what the device was on her wheelchair and she stated, It's a woolly of a thing, it worries me to death. It's supposed to catch me if I'm about to fall. I ask them if I can get it off there and they say no ma'am. During an interview on 11/20/23 at 10:30 AM, with Registered Nurse (RN) Minimum Data Set (MDS) nurse confirmed that Resident #23 had a chair alarm clipped to her shirt that was connect to a box device on her wheelchair because she kept falling. She stated that they do not consider it a restraint because the resident can remove it and we do not code it on the MDS because of that. During an interview on 11/20/23 at 10:40 AM, with the Director of Nurses (DON) and the Nurse Educator confirmed that Resident #23 did have a clip alarm on her wheelchair, and it been on there since her last fall in 8/2023. They confirmed that they do not consider the clip alarm on the wheelchair to be a restraint since the resident can remove it. An observation on 11/20/23 at 11:00 AM revealed Resident #23 stated she did not like the alarm on her chair, that every time she moved it went off, she could not even get her books out of her dresser drawers without it going off. During an interview on 11/20/23 at 3:35 PM with RN MDS Nurse revealed the reason the personal alarm was not care planned as a restraint was because they were not aware that a bed or chair alarm could be a restraint. Record review of Resident #23 care plan titled, The resident is at risk for falls, date initiated 09/02/22, revealed that the care plan does not mention a chair alarm in use. Record review of Resident #23's Fall Evaluation form dated 8/23/23 and 9/1/23 revealed under clinical suggestions that positioning alarms were not indicated. Record review of Resident #23's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus without Complications. Record review of Resident #23's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 02, which indicated the resident is severely cognitively impaired and in Section P that the resident had a chair alarm in use daily.

Based on observation, staff and resident interview, record review and facility policy review the facility failed to prevent a resident from being physically restrained by the sound of a chair alarm for one (1) of three (3) residents with chair alarms reviewed. Resident #23. Findings include: Review of the facility policy titled, Restraint Standards; Physical Restraints with a revision date of 4/2023 revealed under, Physical Restraints Standard .The goal of this facility is to ensure that each resident attains and maintains his/her highest practical level of function and well-being in an environment that limits restraint use to circumstances in which the medical symptoms of the resident warrant the use of the least restrictive restraint. On 11/19/23 at 3:40 PM, an observation and interview revealed a chair alarm on Resident #23's wheelchair that was pinned to the back of her shirt. This observation revealed the resident propels herself with her feet in the wheelchair. During an interview at the same time with Resident #23 revealed that the resident is alert to herself and pleasantly confused on time and place. Resident #23 was asked if she knew what the device was on her wheelchair and she stated, It's a woolly of a thing, it worries me to death. It's supposed to catch me if I'm about to fall. I ask them all the time if I can get it off there and they say no ma'am. An interview on 11/20/23 at 9:00 AM with Certified Nurse Assistant (CNA) #1 confirmed that Resident #23 has a chair alarm clipped to her shirt and connected to a box device on her wheelchair. She stated that she thinks they put it on there because the resident kept falling. She stated that the alarm goes off when she tries to get up or when she moves forward enough in her wheelchair that makes it alarm. She stated that the resident really doesn't like the chair alarm and has complained about wanting it removed. She confirmed that she had told Registered Nurse (RN) #2 about the resident's complaint of wanting the clip alarm removed. An interview on 11/20/23 at 9:05 AM with CNA #2 confirmed that Resident #23 had complained several times about not wanting the clip alarm on her wheelchair. On 11/20/23 at 10:30 AM, an interview with RN Minimum Data Set (MDS) nurse confirmed that Resident #23 had a clip alarm on her wheelchair because she kept falling. She revealed that the Interdisciplinary Team (IDT) team decides who gets a clip alarm when they discuss in the morning standup meetings regarding falls. She stated that they do not consider it a restraint because the resident can remove it. She revealed that when a resident has a fall then a fall risk assessment is completed that indicates the use of a clip alarm. She stated that normally they will leave the alarm on for a couple of months then reevaluate with a high risk fall assessment. She stated she has not heard of any resident's complaining but if they did then they would have to re-evaluate, educate, and possibly do another alternative to the alarm. On 11/20/23 at 10:40 AM, an interview with the Director of Nurses (DON) and Nurse Educator confirmed that Resident #23 did have a clip alarm on her wheelchair and has had it since her last fall in 8/2023. The Nurse Educator revealed that the resident's fall prior to the one in 8/2023 occurred in 4/2023 and the resident did not have any injuries with either fall. She confirmed that they do not necessarily consider the clip alarm on the wheelchair to be a restraint because the resident can remove it. She stated that they usually leave the clip alarm on the resident for 2 months then reevaluate with a high risk fall evaluation again to determine if the resident still needs the alarm. She confirmed that they would normally discuss this reevaluation in the IDT meetings then remove the alarm and see how the resident does. The DON and the nurse educator confirmed that if a resident complained about the clip alarm and did not want it on, then they would need to reevaluate and remove. The DON stated that if the resident complained about the alarm to staff, then they should notify us so we can reevaluate. An observation and interview on 11/20/23 at 11:00 AM, with the DON, Nurse Educator and Resident #23 the resident confirmed that she did not like the alarm on her chair, that every time she moved it went off, she could not even get her books out of her dresser drawers without it going off and buzzing. She stated she knew it was because she had fallen and she may fall tomorrow, but she wanted it taken off. The DON and the Nurse Educator agreed that they would reassess the residents need for the clip alarm. An interview on 11/20/23 at 3:00PM, with the Administrator revealed that she felt like it was a hard call to make whether the residents need a chair alarm or not. She stated that she would consider the residents diagnoses and cognition when determining if a resident needed the alarm due to falls. She agreed that if a resident was complaining about not wanting the alarm, then they should reassess the need. An interview on 11/21/23 at 8:44 AM, with the DON confirmed that she understands that assessing the resident for how they feel about the chair alarm should be part of the assessment for its use. She stated that they just really did not consider it a restraint, or they would have done things differently. She revealed that she understood after reading the regulation that it can be considered a restraint. She revealed that they probably need to have an order for any type of alarm use, document the reason for the use of the alarm and the reevaluation documented along with coding it correctly on the MDS and care planning it correctly also. She confirmed that the resident's fall evaluations dated 8/2023 and 9/2023 did not indicate the use of a chair alarm. Record review of Resident #23's Incident Investigation form dated 8/23/23 revealed the resident had an unwitnessed fall with no injuries. Record review of Resident #23's Fall Evaluation form dated 8/23/23 and 9/1/23 revealed under clinical suggestions that positioning alarms were not indicated. Record review of Resident #23's progress notes revealed there was a note dated 9/14/23 that indicated the resident was being evaluated for a chair clip alarm. This review revealed no other documentation regarding the alarm. Record review of Resident #23's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Type 2 Diabetes Mellitus without Complications. Record review of Resident #23's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/1/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 02, which indicated the resident is severely cognitively impaired and in Section P that the resident had a chair alarm in use at all times.

Based on observations, interviews, and record review and policy review, the facility failed to have knowledge of a resident's Advance Directive Code Status, which resulted in three (3) of four (4) nurses failed to verify the correct code status for Resident #5. Full Code status means Cardio-pulmonary Resuscitation (CPR) will be initiated and Do Not Resuscitate (DNR) means CPR will not be initiated. This affected one (1) of 18 residents reviewed for Code Status, Resident #5. Resident #5 had physician orders, Advanced Directive and a Care Plan for a DNR Code Status. Three (3) of four (4) Nurses, on [DATE], stated they would have provided CPR to Resident #5 should he be found without pulse or respiration, by looking at the sticker on the Resident's chart, that documented the resident was a full code status. Findings include: Review of the facility policy titled, Advance Directives, dated 08.2017, revealed: Standard: To respect each resident's right to participate in and/or make his/her treatment decisions. The policy noted that the facility makes every attempt to implement, with the resident and/or resident's family, the healthcare directives in the resident's Advance Directive. Review of the Procedure for DNR Order, provided by the Director of Nursing (DON) on [DATE], as the facility procedure, revealed: On admission or when code status is changed to a DNR: Social Services has the Resident/Responsible Party (RP) sign the Advance Directive (AD). If DNR is selected, the AD is sent to the Physician for signature and then returned to the facility for Medical Records (or designee) to put the order in the computer, place the AD in the medical record, place the sticker on the chart, and update the Code Status book. On [DATE] at approximately 3:45 PM, during record review, it was noted that the inside cover of the medical record chart for Resident #5 had a green sticker that read Full Code. Further review of Resident #5's chart revealed that the resident had a physician's order for DNR and an Advance Directive for DNR, all dated [DATE]. Review of Resident #5's care plan, initiated [DATE], revealed Resident #5 was care planned as a DNR. Review of the Code Status book revealed Resident #5's status was documented DNR, dated [DATE]. During an interview on [DATE] at 4:04 PM, Registered Nurse (RN) #4, Supervisor, was handed Resident #5's closed record. When asked what she would do if she entered Resident #5's room and found the resident with no pulse or respirations, she opened the medical record to the inside cover to the green sticker that documented Full Code and she stated, Resident is a Full Code and I would call Code Blue and initiate CPR. RN #4 did not review any other documentation in Resident #5's medical record. An interview on [DATE] at 4:10 PM, with LPN #3, confirmed that if she walked into Resident#5's room and found the resident with no pulse and no respirations, she would start CPR, after opening the Resident's chart and observing the green sticker inside the chart cover. LPN #3 did not review any other documentation in Resident #5's medical record. During an interview on [DATE] at 4:12 PM, LPN #1 opened Resident #5's medical record and confirmed that if he walked in Resident#5's room and found the resident with no pulse and no respirations, he would call a full code and start CPR. LPN #1 turned only to the front cover of the chart to the green sticker which noted Full Code. LPN #1 did not review any other documentation in Resident #5's medical record. During an interview on [DATE] at 4:20 PM, the Director of Nursing (DON) stated that the nurses should not just look at the sticker to determine code status of a resident, but should check the physician's order and Advance Directive for the code status. The DON acknowledged the Full Code sticker on the inside cover of Resident #5's medical record and peeled it off. The DON stated she knew Resident #5 was a DNR because she had assisted with completion of the Advance Directive. The DON confirmed that it is Medical Record's responsibility to update stickers that label the resident's code status in the chart. The DON confirmed that the DON, Assistant Director of Nursing (ADON) or Nurse Supervisor updated resident status changes if Medical Records is not available. The DON acknowledged the sticker on the inside of the resident's chart was not accurate. The DON confirmed stickers on the chart was part of the facility's verification process of the resident's code status. An interview with the Medical Records LPN on [DATE] at 10:40 AM, revealed that the Social Worker gets the Advance Directive signed, and Medical Records puts the order in the computer, puts the code status in the medical record, places the sticker inside the cover of the chart, and updates the code status book. The Medical Records LPN stated in the event of a code or advance directive status change, Medical Records is responsible to update the chart, reflecting the updates. The Medical Records LPN stated she didn't know if she was there the day the code status changed for Resident #5. She stated, if she was, she Just missed it. An interview with the Administrator (Adm) on [DATE] at 1:30 PM, revealed the DON is responsible for the process for updating resident code status as needed.

Based on observation, staff interview and facility record and policy review, the facility failed to ensure resident's privacy curtains in semi-private rooms afforded full visual privacy. The curtains had open spaces from 48 inches to 60 inches when pulled fully closed. This was observed in 26 of 32 resident bedrooms. Review of the facility's policy titled Resident Rights & Dignity Management (dated 4/2016), revealed staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with resident care and during treatment procedures. During an observational tour of the facility on 7/16/17 from 3:55 PM - 5:15 PM, the following semi-private resident room privacy curtains did not pull fully closed: Room - 200 A and B bed Room - 201 A and B bed Room - 202 A and B bed Room - 203 A and B bed Room - 204 A and B bed Room - 205 A and B bed Room - 206 A and B bed Room - 207 A and B bed Room - 209 A and B bed Room - 210 A and B bed Room - 211 A and B bed Room - 212 A and B bed Room - 213 A and B bed Room - 214 A and B bed Room - 215 A and B bed Room - 216 A and B bed Room - 217 A and B bed Room - 218 A and B bed Room - 219 A and B bed Room - 221 A and B bed Room - 223 A and B bed Room - 224 A and B bed Room - 225 A and B bed Room - 226 A and B bed Room - 227 A and B bed Room - 229 A and B bed During a tour of the semi-private rooms on 7/18/17 at 3:30 PM, the Administrator acknowledged the privacy curtains were not wide enough to fully close in order to provide full visual privacy. In an interview on 7/18/17 at 3:40 PM, the Administrator said new privacy curtains had been up about a month. She said the privacy curtains presently in place are 108 inches wide and that 216 inch wide curtains should have been ordered. She said 216 inch wide privacy curtains were ordered 7/17/17 after staff alerted her that the surveyors were questioning staff about the privacy curtains. The Administrator said the newly ordered privacy curtains were due to arrive 8/16/17.

Based on observation, staff interview and policy review the facility failed to ensure the outside trash receptacles/garbage dumpsters were kept covered in a manner to prevent potential access by pests, animals and rodents. This affected the facility's sanitation for one (1) of two (2) dumpsters maintained by the facility. Findings include: A review of the facility's policy entitled, Sanitary Conditions of the Dining Service Department, not dated, documented as follows: Garbage Disposal: Garbage is removed from food preparation area as quickly as possible. Outdoor trash receptacles are kept covered at all times. During the initial observation of the facility on 09/20/16 at 8:05 AM, two (2) garbage dumpsters were observed adjacent to the front parking area of the facility. The receptacle on the right was observed to have trash bags stacked above the rim of the container with the lid open. During an observation on 09/21/16 at 8:10 AM, the housekeeping (HK) staff # 1 was observed to place a trash bag in the dumpster without closing the lid. Additional trash bags were observed above the rim of the dumpster with the lid open. During an interview on 09/22/16 at 12:15 PM, the HK Staff #1 confirmed taking garbage out to the dumpster on 09/21/16. She said the garbage included trash from the facility and resident's rooms. She said the lid was left open because the dumpster was too full and the lid would not come down. During an interview on 09/22/16 at 11:30 AM, the Dietary Manager (DM) said dietary department staff takes garbage to the dumpsters in front of the facility. She said the garbage included food scraps and boxes. The DM said maintenance usually cleans around the dumpsters. An observation of the dumpsters on 09/22/16 at 11:35, with the Maintenance Director, revealed the dumpster lid of one dumpster was open and trash bags were visible above the rim of the receptacle. The Maintenance Director stated that leaving the dumpster lid open allowed possible access to the garbage by animals and pests and the dumpster needed emptying.

Based on observation and staff interview, the facility failed to maintain a clean, comfortable, and homelike environment as evidenced by black stains bleeding through the wall paint in the hallways, giving a dirty, and unclean appearance, and discolored ceramic tile shower stalls for two of three (2 of 3) days of survey. Findings include: On, 07/27/15 at 10:00 AM, observations during the initial environment tour with Licensed Practical Nurse (LPN) #1, revealed the walls in the hallway underneath the handrail was painted brown with black specks bleeding through. The wall had a rough texture where the black specks were. An interview with on, 07/27/15 at 10:00 AM, revealed the Maintenance Supervisor stated, There was carpet on the walls and it was removed. The black spots and spotting on the walls is most likely glue that bled through the paint. It looks like the walls weren't primed prior to painting them. Interview on, 07/27/15 at 3:00 PM, revealed the Administrator stated, The wall was painted after carpet was removed. I'm not sure exactly why it looks like it does. The Administrator agreed it was in need of repair. The surveyor asked the Administrator for a policy regarding care of the environment and was informed by the Administrator the facility did not have a policy regarding environment. Observation of the shower room on, 07/29/15 at 8:55 AM, with the Maintenance Supervisor revealed 2 (two) ceramic tile shower stalls with an area 8 (eight) inches high from the floor, with a rust/cream colored film along the entire perimeter of the shower walls. One shower wall contained an area adjacent to the shower curtain with black coffee ground appearing spots. During an interview on, 07/29/15 at 8:55 AM, the Maintenance Supervisor confirmed the shower stall film, and black stains. He stated the black spots appeared to be mold. He stated the eight (8) inch area around the parameter of the showers was where a leak was repaired. He also stated the eight (8)-inch film around the parameter at the bottom of the shower was a mixture of glue and grout from the repair. During an interview on, 07/29/15 at 10:15 AM, Maintenance staff #2 confirmed the condition of the shower stall. He stated the house keeping staff was responsible for cleaning the stalls after every resident shower, and deep cleaning weekly. He stated the house cleaning staff more than likely thought the black stains were part of the wall. During an interview on, 07/29/15 at 09:42 AM, the Facility Administrator acknowledged the problems with the shower stalls. She stated the facility has a new maintenance person, and the previous maintenance person had repaired the stall in his own way.

Based on record review, staff interview and facility policy review the facility failed to have the required essential staff present for 2 of 3 quarterly quality assurance meetings. Review of quarterly quality assurance (QA) meeting sign in sheets for meeting held on 01/30/14, 03/20/14, 06/26/14, 07/25/14 and 08/14/14 did not have the medical director or physician designee present. Interview with the Director of Nursing and the Administrator on 09/04/14 at 11:20 AM confirmed that the QA meetings did not have the medical director present and stated, "Didn't realize he wasn't here". Review of facility policy titled Quality Improvement Committee stated, "Must include the Director of Nurses, a physician designated by the facility, and at least three other members of the facility staff".

Based on observation, staff interview, pharmacy manufactures' recommendations review the facility failed to store drugs according to manufactures' recommendations for one (1) of one (1) medication room. Observation on 09/03/14 at 11:20 AM of medication room refrigerator observed 2 containers of Xalatan 0.005% eye drops with opened dates of 07/09/14 and 06/02/14. Interview on 09/03/14 at 11:20 AM with Registered Nurse (RN) #1 during tour of medication room stated, "All of us are responsible for it". RN #1 confirmed that 2 containers of medicated eye drops should have been discarded and stated, "28 days from opening it". Interview on 09/04/14 at 9:05 AM with facility Pharmacist stated, "When opened and administered, they should be discarded after 6 weeks". Interview with the Director of Nursing on 09/04/14 at 10:15 AM stated, "We didn't know, we thought they were good until the expiration date, but we have since discarded them". Review of Pharmacy Manufactures' recommendations for storage and use of Xalatan 0.005% eye drops stated, "Once a bottle is opened for use, it may be stored for up to 6 weeks".

Based on observation, record review, staff interview and facility policy review, the facility failed to provide services to promote healing of a pressure ulcer for one (1) of two (2) residents reviewed with pressure ulcers (Resident #1). Findings include: Resident # 1 Record review revealed Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date 06/19/13, revealed a Brief Interview for Mental Status score of 15, which indicated Resident #1 was cognitively intact. Observation during the initial tour on 8/27/13 at 11:15 a.m. revealed Resident #1 was lying in his bed, alert and oriented to person place and time. Both arms were contracted with slight movement to both hands. Interview with Licensed Practical Nurse (LPN) #1 on 08/27/13 11:15 a.m. confirmed that Resident #1 had a Stage 4 wound to coccyx area that developed on 05/08/13. LPN #1 stated, "It seems like its stalled, it's not getting better, but it's not getting worse either, but I just don't know what to do with it anymore." LPN #1 confirmed that Resident #1 did not have labs ordered to monitor [MEDICATION NAME] levels and also confirmed Resident #1 received a multivitamin daily, and confirmed that Resident #1 did not have an order to receive protein supplements daily. Interview with Registered Dietician (RD) on 08/29/13 at 12:20 p.m. confirmed that she visits residents every week and had not been given Resident #1's information to review for dietary recommendations. The RD confirmed that she reviews any new admissions and residents who are considered high risk. The RD stated, "I have no way of knowing if someone has a wound unless the DON (Director of Nursing) or the wound nurse tells me. I just got his name last week to look at his intake, so I'll be looking at him today for the first time." Interview with Director of Nursing (DON) on 08/29/13 at 4:00 p.m. confirmed that she has not assessed the wound weekly as facility policy stated. The DON stated, "I'm not, I haven't since I've been in this position." The DON confirmed that she had been in this position for about a month. Interview with the facility's Medical Director on 08/29/13 at 5:55 p.m. revealed, "This ulcer had developed on his back then he had drainage from the anal area. I didn't feel he needed a dietary consult." The Medical Director confirmed that he has not ordered any labs to check Resident #1's nutritional status. The Medical Director confirmed that he visits Resident #1 every other month and Nurse Practitioner visits other months. Review of the [MEDICAL CONDITION] Risk Assessment, dated 06/08/13, revealed a score of 4, which indicated that Resident #1 was at risk for [MEDICAL CONDITION] if the score is higher than 10, but the area was marked indicated [MEDICATION NAME] lab values were within normal limits. The Medical Doctor and Treatment Nurse confirmed that labs were not being monitored that would show if Resident #1 was at risk for [MEDICAL CONDITION], so risk score was not accurate. Resident #1's care plan revealed, "Facility will follow policy and procedure for prevention and treatment of [REDACTED]. Review of the facility's policy entitled "Skin Care Policy", dated 2010, noted, "The purpose is the prevention and management of wounds and to provide consistent care of the integumentary system with an interdisciplinary approach including but not limited to Nursing Service, Therapy and Dietary. The timely identification and documentation of potential risks, implementation of preventive measure, consistent wound care and tracking of the progress of all wounds until healed are essential components of the policy. All residents will be assessed for risk on admission, readmission, quarterly, and with change of condition. Residents found to be at risk should be reviewed for the following: Recent [MEDICATION NAME] level, Weekly Weights, Care Plan update, especially preventive care. Residents at risk will receive an evaluation by Dietitian or Dietary Manager within 72 hours of "risk determination" to include: Assessment of nutritional/hydration status, Pre-[MEDICATION NAME] or [MEDICATION NAME] levels, Determination of caloric, fluid and protein needs. The Physician will personally assess residents with Stage III, Stage IV and non-stageable wounds on at least a monthly basis and as needed. The Director of Nursing will assess all residents with Stage III, Stage IV and non-stageable wounds on at least a weekly basis."

Based on record review, staff and resident interview and facility policy review, the facility failed to address resident grievances concerning physician and physician designee visits for eight (8) of eight (8) residents during group interview (Resident #7, Resident #14, Unsampled Residents A, B, C, D, E and F). Findings include: Unsampled Resident A Record review revealed Unsampled Resident A was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Unsampled Resident A's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/29/13, revealed a Brief Interview for Mental Status score of 15, indicated Unsampled Resident A was cognitively intact. Unsampled Resident B Record review revealed Unsampled Resident B was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Unsampled Resident B's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/12/13, revealed a Brief Interview for Mental Status score of 15, which indicated Unsampled Resident B was cognitively intact. Unsampled Resident C Record review revealed Unsampled Resident C was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Unsampled Resident C's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/06/13 and a Brief Interview for Mental Status score of 15, which indicated Unsampled Resident C was cognitively intact. Unsampled Resident D Record review revealed Unsampled Resident D was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Unsampled Resident D's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/13 and a Brief Interview for Mental Status score of 4, which indicated Unsampled Resident D's cognitive status was severely impaired. Unsampled Resident E Record review revealed Unsampled Resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Unsampled Resident E's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/15/13 and a Brief Interview for Mental Status score of 2, which indicated Unsampled Resident E's cognitive status was severely impaired. Unsampled Resident F Record review revealed Unsampled Resident F was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Unsampled Resident F's Minimum Data Set (MDS) with an ARD date of 8/22/13, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicated Unsampled Resident F was cognitively intact. Resident #7 Record review revealed Resident #7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #7's Minimum Data Set (MDS) with an Assessment Reference Date dated of 6/17/13, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #7 was cognitively intact. Resident #14 Record review revealed Resident #14 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #14's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/1/13, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated that Resident #14 was cognitively intact. Interview on 8/27/13 at 2:00 p.m. with resident's in the group meeting revealed Resident #7 and Unsampled Resident C both stated that "There is a doctor that comes at like 2:00 a.m. or 3:00 a.m. in the morning, but if you aren't awake, you don't get to see him." Resident #7 confirmed that this is something that has been reported to staff previously. All residents in attendance agreed that they feel that they do not see a physician regularly and do not have an opportunity to speak with a physician when rounding so early in the morning. Review of Resident Council meeting minutes with the permission of council president, revealed that on October 30, 2012 - Residents stated that they didn't see the Dr. (doctor) enough that he peeps in and out." On February 26, 2013, documentation from the Resident Council Meeting revealed, "Resident wanted to know who the doctor was that comes to the facility around 4 (4:00) a.m." Review of the follow up documentation to Resident Council meetings entitled, "Concern Form", dated 10/30/12, documented, Residents stated that they did not see the MD (Medical Doctor) enough. Investigation/Findings: LPN (Name of Licensed Practical Nurse) and SW (name of Social Worker) met (with) residents at 3:15 p.m. in the dining room discussed MD visits. Explained to residents (name of Medical Director #1), was always on call if not here and they could see the DR (doctor) of there (their) choice and that he is contacted (with) any concern of a resident care. Explained to residents if they had an issue between visits would could contact (name of Medical Director #1)." This document signed by Social Worker #1. Review of "Concern Form" dated 2/26/13 revealed, (name of Unsampled Resident C) didn't see the dr (doctor) enough. Documentation on this form further revealed, Social Services spoke with resident about how often the dr (doctor) visits and that if she needed to see a dr (doctor) before his visit we would make sure she would see one. This document signed by Social Worker #1. Review of facility provided documentation of physician and physician designees visit schedule to facility revealed that Medical Director #1 visits facility in January, March, May, July, September, and November, and begins rounds on Friday at 8:00 a.m. and continues until around noon. The Family Nurse Practitioner #1 visits in February, April, June, August, October, and December, and divides the visits during the month seeing 10-15 per visit arriving approximately at 3:00 a.m. until 5:00 a.m. Interview with the Social Worker #1, Director of Nursing (DON), Administrator and the Minimum Data Set Nurse #1 on 8/29/13 at 4:07 p.m., revealed the DON confirmed that the Family Nurse Practitioner (FNP) #1 made rounds with nursing staff between three 3:00 a.m. until 5:00 a.m. in the morning and will complete assessments with residents at that time. Social Worker #1 confirmed speaking with residents concerning how often Medical Director #1 visits facility and how he can be reached, but did not address the concerns with the Family Nurse Practitioner #1 visits. The Administrator confirmed that she was aware of Family Nurse Practitioner #1 making rounds between 3:00 a.m. until 5:00 a.m. in the morning, prior to going to his clinic. The Administrator stated that she had spoken with the Medical Director #1 about coming more, last month (July 2013). The Administrator confirmed that Family Nurse Practitioner #1 awakens the residents to perform assessments. The Administrator stated, "I mean he has been doing this for like four years now." The Administrator confirmed that she had not addressed this concern with the Resident Council members. Interview with Medical Director #1 on 8/29/13 at 5:55 p.m. revealed the Medical Director #1 stated he recalled that Administrator spoke with him about two months ago maybe, concerning visiting facility more. The Medical Director #1 stated that he was not aware of Family Nurse Practitioner #1 visiting facility during the hours of 3:00 a.m. until 5:00 a.m., and was not aware of resident's complaints concerning this. Medical Director #1 stated, "I will speak with (name of FNP #1) about that." The Medical Director stated that this was too early to visit residents. Review of the facility's policy entitled, "Grievances (Concerns)", reviewed 2010, revealed, "It is the policy of this facility to encourage and assist residents in filing grievances. 3. Upon receipt of a written grievance, the appropriate department head will investigate the allegations set forth and will be organized by the Administrator. The Administrator will distribute the concern for follow-up to the appropriate staff person for review."

Based on observation, record review, staff interview and facility policy review the facility failed to accurately assess and evaluate one (1) of two (2) residents for restraint reduction (Resident #3). Findings include: Resident #3 Record review revealed Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 99, which indicated that Resident #3 was not able to complete the interview. Observation during the initial tour of the facility on 08/27/13 at 11:00 a.m. revealed Resident #3 was in the hallway by nurse's station seated in a Broda chair with her head slumped down, asleep, with bilateral vinyl leg straps secured across the upper thighs of both legs. Interview during initial tour on 08/27/13 revealed Licensed Practical Nurse (LPN) #1 stated, "(Name Resident #3) is not interviewable. She took care of her disabled son and she was wandering in the facility and falling a lot so we started using that chair. She doesn't try to get up much in the last couple of months, she just sleeps. She probably would be fine without it (restraint) now." Review of Resident #3's Care Plan on 08/28/13 revealed, "The resident uses, physical restraints (thigh straps in broda chair) r/t (related to) Confusion, Injury and repeated falls to prevent unassisted transfers. Evaluate the resident's restraint use (quarterly): Evaluate/record continuing risks/benefits of restraint, alternatives to restraint, need for ongoing use, reason for restraint use. PT (Physical Therapy) and OT (Occupational Therapy) to eval (evaluate) for least restrictive device. Date initiated: 03/01/13." Review of Resident #3's medical record revealed there were no quarterly assessments to show alternatives to restraints and Physical Therapy and Occupational Therapy evaluations for the least restrictive devices. Interview with Director of Rehabilitation Therapy on 08/28/13 at 4:15 p.m. revealed, "I don't have any assessments on her. They (the nurses) had asked me to look at her because she was falling a lot. I made a recommendation that if they were going to use the thigh straps that she would need monitoring, but that's up to them (nurses)." Record review revealed an order summary, dated 03/01/13, for "OT (Occupational Therapy) Recommendation for use of Broda Chair thigh straps to assist with positioning and for postural control of resident when up in Broda Chair. Pt (patient) will require regular intervals of monitoring for safety purposes." Review of the facility's policy entitled "Physical Restraints", dated 2010, documented, "It is the policy of this facility that each resident will attain and maintain his/her highest practical level of function and well-being in an environment that limits restraint use to circumstances in which the medical symptoms of the resident warrants the use of the least restrictive restraint. Procedure 1. All residents will be evaluated for safety needs on admission, with change in cognition, and with any significant change in condition as noted on the MDS (Minimum Data Set) using the Resident Fall Risk Assessment. Interventions designed to promote safety and/or minimize the risk of injury will be implemented as needed. 5. All residents who have a restraint shall be evaluated at least quarterly and with any significant change in condition, for the potential to reduce or eliminate the restraint."

Based on group interview, staff interview and policy review, the facility failed to ensure that mail was delivered on Saturdays.This was for ten (10) of ten (10) resident's attending the group meeting. Findings include: Interview with 10 of 10 residents in the group meeting on 9/19/11 at 3:00 p.m. revealed that they did not get mail on Saturdays. Interview on 9/20/11 at 2:45 p.m. with the Activity Director revealed that the post office does not deliver mail to the facility on Saturdays. The facility has a box at the post office and mail was placed in the box on Saturdays. The Activity Director stated that she worked some weekends; but, she was not provided with a key or granted permission to get the mail from the post office box. Interview on 9/20/11 at 2:48 p.m. with the Administrator revealed that she was not aware that residents were not getting mail on Saturdays. The Administrator confirmed that the Activity Director had not been granted access to the post office box to obtain mail to be delivered to residents on Saturdays and stated that a new procedure will be put into place to ensure that residents received mail on Saturdays. Review of the " Resident Mail Delivery and Distribution " policy, dated 2010, noted: "The facility will develop a system to delivery (deliver) and distribute resident mail in accordance with privacy and confidentiality regulations in order to provide each resident with a means of writing, sending and receiving unopened mail ...2. All resident mail is delivered unopened and postmarked (for outgoing mail) within 24 hours ... "