Every finding on record at Audubon Health and Rehab

Based on observations, interviews, and record reviews, the facility failed to ensure staff wore proper personal protective equipment (PPE) during personal hygiene care for a resident on Enhanced Barrier Precautions (EBP) (an infection control strategy that used gloves and gowns during high-contact resident care to reduce to spread of infection) for 1 (Resident #39) of 8 (Resident# 2, Resident #5, Resident #9, Resident #11, Resident #27, Resident #39, Resident #67, Resident #69) sampled residents who required EBP. Findings:Review of the facility's EBP policy and procedure, dated 01/2023 and revised on 03/2024, revealed, in part, EBP required the use of a gown and gloves for high contact resident care activities such as providing personal hygiene care. Review of the facility's current list of EBP residents revealed, in part, that Resident #39 was currently on EBP. Review of Resident #39's Care Plan revealed, in part, Resident #39 was on EBP related to Resident #39 having an indwelling devices. Observation on 09/15/2025 at 9:35AM revealed an EBP sign on Resident #39's room door indicating staff must wear a gown and gloves when performing high contact resident care activities which included personal hygiene care. Observation on 09/15/2025 at 9:40AM revealed S9Certified Nursing Assistant (CNA) was shaving Resident #39's face without wearing a gown. In an interview on 09/15/2025 at 10:00AM, S9CNA indicated she did not wear a gown while performing hygiene care for Resident #39. S9CNA further indicated she was not aware a gown was required for personal hygiene care for a resident on EBP. In an interview on 09/18/2025 at 11:50AM, S8CNA Supervisor confirmed S9CNA should have worn a gown while performing Resident #39's personal hygiene care. In an interview on 09/18/2025 at 1:10PM, S2Dircetor of Nursing confirmed staff should have worn a gown while performing Resident #39's personal hygiene care.

Based on interviews and record reviews, the facility failed to ensure a resident was included in the discharge planning process for 1 (Resident #8) of 3 (Resident #8, Resident #118, Resident #120) sampled residents investigated for discharge requirements.Findings:Review of the facility's Discharge Transfer and Planning policy, last revised in 08/2025, revealed, in part, discharge planning shall be initiated by the Social Service Director/Designee with anticipated discharges. Further review revealed the discharge plan shall focus on the residents' discharge goals and the preparation of residents to be active partners for post discharge care. Further review reveled the IDT would include regular re-evaluation of residents to identify changes that required modification of the discharge plan. Further review revealed the interdisciplinary team (IDT) would involve the resident and the resident's representative in the development of the discharge plan and address the resident's goals of care and treatment preferences, and the IDT would document that a resident had been asked about their interest in receiving information regarding returning to the community. Review of Resident #8's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/19/2025 revealed, in part, Resident #8 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated Resident #8 was cognitively intact. Further review revealed that only Resident #8's family was included in and participated in the goal setting for Resident #8's discharge planning. Review of Resident #8's Care Plan meeting documentation, dated 06/03/2025, revealed, in part, no documentation Resident #8's discharge planning goals were discussed with Resident #8. Review of Resident #8's Care Plan meeting documentation, dated 08/26/2025, revealed, in part, no documentation Resident #8's discharge planning goals were discussed with Resident #8. Review of Resident #8's Social assessment dated [DATE], revealed, in part, Resident #8's discharge planning was discussed with her family, and it was determined that Resident #8 would remain in the facility. Further review revealed Resident #8 was not documented as included in the above mentioned Social Assessment. Review of Resident #8's Social Assessment, dated 08/19/2025, revealed, in part, Resident #8's discharge planning was discussed with her family, and it was determined that Resident #8 would remain in this facility. Further review revealed Resident #8's family members and not Resident #8 were asked the question Do you want to talk to someone about the possibility of leaving this facility and returning to live and receive services in the community? Further review revealed Resident #8 was not documented as included in the above mentioned Social Assessment. In an interview on 09/15/2025 at 9:38AM, Resident #8 indicated she wanted to be discharged from the facility and wanted to go home. In an interview on 09/16/2025 at 12:06PM, S2Director of Nursing (DON) indicated Resident #8 had spoken to him previously about wanting to go home and her desire to be discharged from the facility. Surveyor gave S2DON the opportunity provide documentation that Resident #8's discharge options were discussed with Resident #8 on 09/16/2025 at 12:08PM. In an interview on 09/16/2025 at 2:19PM, S5Social Services Director (SSD) acknowledged Resident #8's discharge preferences should have been discussed with Resident #8 because Resident #8 had a BIMS of 13. Surveyor gave S5SSD the opportunity to provide documentation that Resident #8's discharge preferences were discussed with Resident #8 and not only Resident #8's family on 09/16/2025 at 2:19PM. In an interview on 09/17/2025 at 9:40AM, S7Licensed Practical Nurse (LPN) indicated Resident #8 had previously expressed to her the desire to go home. In an interview on 09/17/2025 at 10:07AM, S4Admissions Coordinator indicated Resident #8 had indicated to her that she wanted to go home. In an interview on 09/17/2025 at 10:00AM, S5SSD indicated if a resident requested to be discharged to any staff member, the facility's procedure would be to report a discharge request to S5SSD. S5SSD further indicated she was never informed Resident #8 had wanted to be discharged from the facility before the surveyor spoke to her on 09/16/2025, and had she known of Resident #8's desire to be discharged from the facility to home, then a care meeting with Resident #8 and her family would have been set up to assist Resident #8 with discharge planning. S5SSD further indicated it was the facility's policy to discuss discharge plans quarterly with residents. S5SSD also indicated Resident #8's discharged plans were not discussed with Resident #8 during her Quarterly MDS Assessment/Social Assessment on 08/19/2025 and should have been. S5SSD further indicated Resident #8's discharge goals were not discussed with Resident #8 as part of the 08/19/2025 Quarterly MDS Assessment because she was not aware Resident #8's BIMS was 13 at that time. Surveyor gave S5SSD the opportunity to provide documentation to show that Resident #8's discharge planning was conducted with Resident #8 on 09/17/2025 at 10:10AM. In an interview on 09/18/2025 at 12:38PM, S6Assessment Nurse indicated she had not discussed Resident #8's discharge planning goals with Resident #8 during Resident #8's Care Plan meetings. In an interview on 09/17/2025 at 2:15PM, S1Administrator indicated social services should have been notified when Resident #8 requested to be discharged . S1Administrator further indicated Resident #8 should have been included in the discharge planning process.

Based on observations, interviews, and record reviews the facility failed to ensure residents did not have cigarette lighters in their possession and/or rooms for 2 (Resident #32 and Resident #79) of 2 (Resident #32 and Resident #79) sampled residents reviewed for accidents and hazards while smoking. Findings: Review of the facility's Smoking Policies and Regulations dated October 2022 revealed, in part, this policy and procedure was developed to ensure the safety of the residents. Further review revealed cigarette lighters were not permitted in a resident's room and would be kept at the nurses stations. Further review revealed adherence to this policy and procedure would be strictly enforced. Resident #32 Review of the facility's Smoking Task Listing Report dated 09/23/2024 revealed, in part, Resident #32 was identified as an independent smoker. Review of Resident #32's care plan revealed, in part, Resident #32 had a potential for injury related to smoking. Resident #79 Review of the facility's Smoking Task Listing Report dated 09/23/2024 revealed, in part, Resident #79 was identified as an independent smoker. Review of Resident #79's care plan revealed, in part, Resident #79 had a potential for injury related to smoking. In an interview on 09/25/2024 9:45 a.m., S5Licensed Practical Nurse (LPN) indicated she was unsure if residents were allowed to keep cigarette lighters in their possession. In an interview on 09/25/2024 at 9:54 a.m., S6Certified Nursing Assistant (CNA) indicated Resident #32 was allowed to keep her cigarette lighter in her possession. Observation on 09/25/2024 at 10:02 a.m. revealed, in part, Resident #32 was in her room and had a cigarette lighter in the basket of her rolling walker. In an interview on 09/25/2024 at 10:02 a.m., Resident #32 indicated she was allowed to keep her cigarette lighter in her possession and/or room. In an interview on 09/25/2024 at 10:02 a.m., S6CNA confirmed Resident #32 had a cigarette lighter in the basket of her rolling walker and the cigarette lighter was functional. In an interview on 09/25/2024 at 10:10 a.m., S7CNA indicated smokers who were identified as independent smokers were allowed to keep cigarette lighters in their possession. In an interview on 09/25/2024 at 10:22 a.m., S8LPN indicated smokers who were identified as independent smokers were allowed to keep cigarette lighters in their possession. Observation on 09/25/2024 at 10:32 a.m. revealed Resident #79 had a cigarette lighter in his room on top of a small dresser. Further observation revealed Resident #79's cigarette lighter was functional. In an interview on 09/25/2024 at 10:32 a.m., Resident #79 indicated he was an active smoker and he was allowed to keep his cigarette lighter in his possession. In an interview on 09/25/2024 at 10:37 a.m., S2Director of Nursing (DON) indicated he was not aware the facility's smoking policy specified residents were not allowed to keep cigarette lighters in their possession. S2DON further indicated he was not aware cigarette lighters should have been kept at the nurse's station(s). In an interview on 09/25/2024 at 11:05 a.m., S1Administrator confirmed the facility's smoking policy prohibited smokers from keeping cigarette lighters in their possession and the lighters should been kept at the nurse's station(s).

Based on observations and interview the facility failed to ensure clean items in the facility's laundry room were not kept in the contaminated laundry area. Findings: Observation on 09/23/2024 at 4:00 p.m. of the contaminated area in the laundry room, revealed clean mop heads and clean microfiber cleaning cloths were hanging from rods attached to the wall. Observation on 09/24/2024 at 9:10 a.m. of the contaminated area in the laundry room, revealed clean mop heads and clean microfiber cleaning cloths were hanging from rods attached to the wall. In an interview 09/24/2024 at 11:00 a.m., S4Assistant Director of Nursing/Infection Prevention Control Program indicated clean mop heads and clean microfiber cleaning cloths should not be hung to dry in the contaminated area of laundry room.

Based on observations, interviews, and record review the facility failed to ensure: 1. Staff performed hand hygiene per facility policy during catheter care for 1 (Resident #87) of 2 residents (Resident #30 and Resident #87) investigated for catheters; 2. Staff performed hand hygiene per facility policy while serving meal trays to residents in their rooms; and 3. Staff handled soiled linen in a manner to prevent cross contamination of surfaces when 2 Certified Nursing Assistants (CNAs) (S16CNA and S21CNA) placed soiled linen on the floor for 2 (Resident #44 and Resident #87) of 2 residents observed during perineal care (washing the genital and rectal areas of the body) and 1 CNA(S21CNA) placed items used in a resident's room onto the clean linen cart. Findings: Review of the facility's Hand Hygiene policy revealed, in part, hand hygiene is indicated when entering and exiting a resident's room, before and after procedures, and before and after applying gloves. 1. Observation on 09/26/2023 at 3:50 p.m., revealed S21CNA did not perform hand hygiene before putting on gloves to perform Resident #87's catheter care. Further observation revealed, after performing Resident #87's catheter care and perineal care, S21CNA removed gloves, did not perform hand hygiene, and placed on new gloves before emptying Resident #87's catheter bag. In an interview on 09/27/2023 at 1:25 p.m., S5ADON stated 21CNA should have performed hand hygiene before performing Resident #87's catheter care and before putting on gloves to empty Resident #87's urine from her catheter bag. In an interview on 09/28/2023 at 2:28 p.m., S21CNA stated she should have performed hand hygiene before starting Resident #87's catheter care and before putting on gloves to empty Resident #87 urine from her catheter bag. In an interview on 09/27/2023 at 3:11p.m., S6CNA Supervisor stated 21CNA should have performed hand hygiene before performing Resident #87's catheter care and before putting on gloves to empty Resident #87 urine from her catheter bag. In an interview on 09/27/2023 at 4:52 p.m., S2DON stated that S21CNA should have performed hand hygiene before performing Resident #87's catheter care and should have performed hand hygiene after finishing perineal care, before putting on new gloves and emptying urine from Resident #87's catheter bag. 2. Observation on 09/26/2023 at 12:25 p.m. revealed S12CNA delivered a lunch tray to Resident #37, set up Resident #37's lunch tray, and then exit Resident #37's room and grab Resident #47's lunch tray off of cart without performing hand hygiene. Further observation revealed S12CNA then delivered Resident #47's lunch tray to his room, set up Resident #47's lunch tray, adjusted Resident #47's privacy curtain, exited Resident #47's room, and grabbed Resident #26's lunch tray and place it on top of her cart without performing hand hygiene. Further observation revealed S12CNA delivered Resident #26's lunch tray, exited Resident #26's room, grabbed Resident #6's lunch tray, delivered Resident #6's lunch tray to his room, set up Resident #6's lunch tray, exited Resident #6's room, and grabbed Resident #24's disposable lunch tray without performing hand hygiene, placed Resident #24's lunch tray back down on cart, put on personal protective equipment, and entered Resident #24's room with his disposable lunch tray. In an interview on 09/27/2023 at 12:19 p.m., S12CNA stated she should have performed hand hygiene when she delivered and set up the above resident's lunch trays and did not. In an interview on 09/27/2023 at 12:21 p.m., S6CNA Supervisor stated S12CNA should have performed hand hygiene after exiting a resident's room but before grabbing another resident's tray. In an interview on 09/27/2023 at 4:52 p.m., S2DON stated that CNAs should perform hand hygiene between resident's when delivering and setting up lunch trays. 3. Observation on 09/26/2023 at 3:15 p.m., revealed S16CNA placed a towel and an incontinence pad, on the floor, in the corner of Resident #44's room by the door. In an interview on 09/26/2023 at 3:15 p.m., S16CNA stated that the towel and the incontinence pad on the floor were soiled linen because she had just cleaned Resident #44 from an incontinent bowel movement. Observation on 09/26/2023 at 3:17 p.m., revealed S16CNA performed Resident #44's perineal care. Further observation revealed, when finished with Resident #44's perineal care, S16CNA threw the towel used to perform Resident #44's perineal care on the floor. Observation on 09/26/2023 at 3:50 p.m. revealed S21CNA took a box of gloves and a package of wipes off of the clean linen cart and brought them into Resident #87's room. Further observation revealed S21CNA removed blankets and sheets from Resident #87's bed and threw them on the floor. Further observation revealed, S21CNA removed gloves from the glove box and wipes from the package brought into Resident #87's room without first performing hand hygiene while performing Resident #87's catheter care. Further observation revealed after S21CNA emptied urine from Resident #87's catheter bag, S21CNA removed her gloves, did not perform hand hygiene, grabbed the box of gloves and a pack of wipes from Resident #87's bedside table, left Resident #87's room with the box of gloves and the package of wipes, and placed the box of gloves and the package of wipes onto the clean linen cart in the facility's hallway. In an interview on 09/27/2023 at 12:11 a.m., S16CNA stated she should not have thrown soiled linen on the floor of Resident #44's room. In an interview on 09/27/2023 at 1:25 p.m., S5ADON stated CNAs should not place soiled linen on the floor of the resident's rooms. S5ADON further stated S21CNA should not have placed the box of gloves or the package of wipes used in Resident #87's room back onto the clean linen cart. In an interview on 09/28/2023 at 2:28 p.m., S21CNA stated she should not have thrown Resident #87's blankets onto the floor of her room. In an interview on 09/27/2023 at 3:11p.m., S6CNA Supervisor stated CNAs are not supposed to throw soiled linen on the floor of the resident's rooms. S6CNA Supervisor further stated S21CNA should not have placed the box of gloves or the package of wipes used in Resident #87's room back onto the clean linen cart. In an interview on 09/27/2023 at 4:52 p.m., S2DON stated the facility's CNAs should not have placed soiled linen on the floor of the resident's rooms. S2DON further stated that the box of gloves and the package of wipes should not have been placed back on the clean linen cart after being brought into Resident #87's room.

Based on record reviews, observations, and interviews the facility: 1. Failed to notify a resident's physician of a change in a resident's condition for 3 (Resident #44, Resident #67, and Resident #87) of 25 residents included in the final resident sample; 2. Failed to notify a resident's responsible party of a change in condition for 2 (Resident #44 and Resident #87) of 25 residents included in the final resident sample; and, 3. Failed to notify a resident's hospice agency of a change in condition for 1 (Resident #87) of 25 residents included in the final resident sample. Findings: Review of the facility's Change in Resident Medical Status policy revealed, in part, a facility must immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a need to alter treatment significantly or to commence a new form of treatment. Resident #44 Observation on 09/25/23 at 11:14 a.m. revealed Resident #44's had a border gauze dressing to the top of her right hand with no date or initials on it indicating the last time it was changed. In an interview on 09/26/2023 at 3:16 p.m., Resident #44 stated that the wound to the top of her right hand was new and appeared yesterday, and a treatment nurse had performed wound care on the wound to the top of her right hand yesterday. Observation on 09/26/2023 at 3:16 p.m. revealed Resident #44 had a border gauze dressing to the top of her right hand and it was not dated or not initialed indicating the last time it was changed. Review of Resident #44's Wound assessment dated [DATE] revealed, in part, Resident #44's had a new wound to the top of her right hand that was first assessed on 09/26/2023, and Resident #44's physician and responsible party were notified on 09/26/2023. In a phone interview on 09/27/2023 at 2:40 p.m., Resident #44's responsible party stated that no one had contacted him regarding residents new wound to the top of her right hand. In a phone interview on 09/27/2023 at 2:45 p.m., Resident #44's nurse practitioner stated she was not informed that Resident #44 had a new wound to the top of her right hand. In a phone interview on 09/27/2023 at 2:47 p.m., Resident #44's physician stated he was not informed that Resident #44 had a new wound to the top of her right hand. In an interview on 09/27/2023 at 3:24 p.m., S8Treatment Nurse (TN) stated the staff member who initially found the wound to the top of Resident #44's right hand, should have notified Resident #44's physician and Resident #44's responsible party. S8TN further stated that she should not have documented that she notified Resident #44's responsible party or Resident #44's physician of the new wound to the top of Resident #44's right hand when she had not notified them. In an interview on 09/27/2023 at 3:34 p.m., S7LPN stated the staff member who first found the new wound to the top of Resident #44's right hand was responsible for notifying Resident #44's physician. S7LPN further stated that she did not notify Resident #44's physician until today about the new wound to the top of Resident #44's right hand. In an interview on 09/27/2023 at 4:52 p.m., S2Director of Nursing (DON) stated that whoever found the wound on the top of Resident #44's right hand, should have notified Resident #44's physician and Resident #44's responsible party. S2DON further stated that if S8TN did not notify Resident #44's physician and responsible party of the new wound to the top of Resident #44's right hand, S8TN should not have documented that she did. In an interview on 09/28/2023 at 11:00 a.m., S2DON stated the facility could not provide any documentation that Resident #44's physician or responsible party was notified on 09/25/2023 or 09/26/2023 of the new wound to the top of Resident #44's right hand. Resident #67 Review of Resident #67's care plan revealed, in part, the problems of a potential for injury related to Resident #67 taking Aspirin (a medication that can be used as a blood thinner) and Plavix (a medication that can be used as a blood thinner) with an intervention of observe for presence of active bleeding, hematuria, petechia, bruising, bloody stool, nose bleeds and contact the medical doctor as needed. Review of Resident #67's record revealed, in part, weekly body audits performed on 09/07/2023, 09/14/2023, and 09/21/2023 with documentation of no new skin issues. Review of Resident #67's progress notes for September 2023 revealed, in part, no documentation of bruising to Resident's left upper forearm, or right and left hands. An observation 09/25/2023 at 11:30 a.m. of Resident #67 revealed a hard ball size light purple bruise to the left upper forearm below the elbow. Further observation revealed a dark purple bruising noted across the top of Resident #67's right and left hands. In an interview on 09/27/2023 at 10:30 a.m., S17License Practical Nurse (LPN) stated if any unusual skin issues are noted they should be reported and documented. S17LPN further stated no one informed her of bruising to Resident #67. In an interview on 09/27/2023 at 11:10 a.m., S13Certified Nursing Assistance (CNA) stated she transfers Resident #67. S13CNA further stated she noticed bruising to Resident #67's left upper forearm and hands, but did not report the bruising to anyone. In an interview on 09/28/2023 at 8:30 a.m., S15CNA stated she had noticed the bruising to Resident #67's right and left hand and also, Resident #67's left upper forearm. She stated she did not report the bruising to the nurse. In an interview on 09/28/2023 at 12:30 p.m., S10CNA stated she noticed the large bruise to Resident #67's left forearm and on the top of Resident #67's right and left hands. She stated she had not reported the bruising to the nurse. In an interview on 09/28/2023 at 3:08 p.m., S2Director of Nursing (DON) stated the bruising to Resident #67's left forearm and Resident #67's right and left hands should have been reported. Resident #87 Observation on 09/25/2023 at 10:52 a.m. revealed that Resident #87's urine in her urinary catheter tubing and bag was dark yellow and cloudy. Observation on 09/26/2023 at 9:13 a.m. revealed sediment in Resident #87's urinary catheter bag tubing. Observation on 09/26/2023 at 3:50 p.m. during catheter care, revealed a new pressure injury to Resident #87's left labia. Further observation revealed that when emptying the urine from Resident #87's catheter bag, S22Certified Nursing Assistant (CNA) stated that Resident #87's urine had an odor. Review of Resident #87's Wound assessment dated [DATE] revealed, in part, Resident #87's had a new pressure injury to her left labia. Further review revealed, Resident #87's primary physician and Resident #87's responsible party were notified of the new wound to Resident #87's left labia. In an interview on 09/27/2023 at 11:33 a.m., Resident #87's nurse practitioner stated that Resident #87's primary physician was out of the country, and that she was not notified of Resident #87's new pressure injury to her left labia, the sediment in Resident #87's urine, or of the odor to Resident #87's urine and could not find any documentation that the primary physician's office was notified. In an interview on 09/27/2023 at 2:26 p.m., Resident #87's responsible party stated no one had contacted her regarding the residents new pressure injury to her left labia. In an interview on 09/28/2023 at 2:28 p.m. S21CNA stated she did not notify any nurse of the odor to Resident #87's urine. In an interview on 09/27/2023 at 3:05 p.m., S18RN stated that she had not noted any sediment in Resident #87's urine nor had any CNA informed her that Resident #87 had an odor to her urine. S18RN further stated Resident #87's physician and hospice agency should have been notified of the color and sediment in Resident #87's urine. In an interview on 09/27/2023 at 3:06 p.m., Resident #87's Hospice Nurse stated no one from the facility had contacted Resident #87's hospice agency regarding Resident #87's new pressure injury to her left labia or sediment and odor to Resident #87's urine. In an interview on 09/27/2023 at 3:24 p.m., S8TN stated she did not notify Resident #87's responsible party or hospice agency of the new pressure injury to Resident #87's left labia, and that S7LPN was responsible for notifying Resident #87's physician of the new pressure injury. S8TN further stated she should not have documented that she contacted Resident #87's primary physician and responsible party if she did not. In an interview on 09/27/2023 at 3:34 p.m., S7LPN stated the staff member that first noted a wound was responsible for notifying the resident's physician and responsible party. S7LPN further stated that she thought she had notified Resident #87's physician yesterday, but did not. In an interview on 09/27/2023 at 4:52 p.m., S2DON stated that S8TN should not have documented that she notified Resident #87's physician and responsible party of Resident #87's new left labia pressure injury if S8TN did not notify Resident #87's physician and responsible party of the above wound. 47487

Based on observations, interviews, and record review the facility failed to ensure proper infection control techniques were practiced to prevent urinary tract infection for 2 (Resident #44 and Resident #87) of 2 residents observed for perineal care (washing the genital and rectal areas of the body). Findings: Review of the facility's Perineal Care policy revealed, in part, when providing perineal care to a female resident the genital area should be washed moving from front to back, while using a clean portion of a wash-cloth or pre-moistened wash wipe for each stroke. Resident #44 Observation on 09/26/2023 at 3:17 p.m., revealed, S16Certified Nursing Assistant (CNA) performed incontinence care by wiping Resident #44's rectal area forward into Resident #44's vaginal and urethral area (wiping back to front) three times. Further observation revealed a visible streak of brown was noted on the towel after S16CNA wiped from Resident #44 from back to front. In an interview on 09/27/2023 at 12:11 a.m., S16CNA stated that she should not have wiped Resident #44 from back to front when she performed perineal care. In an interview on 09/27/2023 at 1:25 p.m., S5Assistant Director of Nursing (ADON) stated S16CNA should have wiped Resident #44 from her vaginal and urethral area back to her rectal area (wiping front to back). In an interview on 09/27/2023 at 3:11 p.m., S6CNA Supervisor stated that S16CNA should not have wiped Resident #44 from back to front. In an interview on 09/27/2023 at 4:52 p.m., S2Director of Nursing (DON) stated that S16CNA should not have wiped Resident #44 from back to front. Resident #87 Observation on 09/26/2023 at 3:50 p.m., revealed S21CNA performed Resident #87's perineal care by wiping Resident #87's right and left labia in a down and up (wiping back to front and front to back) motion with the same corner of a wet towel repeatedly. Further observation revealed, S21CNA drained Resident #87's catheter, and allowed the catheter drainage valve to touch the floor while she went to dispose of urine. Further observation revealed upon S21CNA's return, she placed the drainage valve back into its holder on the catheter bag without cleaning the drainage valve. In an interview on 09/27/2023 at 1:25 p.m., S5ADON stated CNAs should not be wiping resident's in a back to front motion when performing perineal care. In an interview on 09/28/2023 at 2:28 p.m., S21CNA stated that she should not have used the same corner of the towel or wiped in a back to front motion when performing Resident #87's perineal care. S21CNA further stated that she should not have let the drainage valve of Resident #87's catheter bag touch the floor and confirmed that she did let the drainage valve of Resident #87's catheter bag touch the floor. In an interview on 09/27/2023 at 3:11p.m., S6CNA Supervisor stated 21CNA should have used different corners of the towel when performing Resident #87's perineal care and S21CNA should not have wiped Resident #87 in a down and up motion when performing perineal care. S6CNA supervisor further stated S21CNA should not have let the drainage valve to Resident #87's catheter bag touch the floor. In an interview on 09/27/2023 at 4:52 p.m., S2DON stated that S21CNA should not have wiped Resident #87 in a down and up motion and should not have let the drainage valve of Resident #87's catheter bag touch the floor.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident's careplan was updated following the residents attempt to exit the facility for 1 (Resident #102) of 3 (Resident #88, Resident #94, and Resident #102) residents investigated for dementia care. Review of Resident #102's medical record revealed, in part, an admitted [DATE] with a readmitted [DATE] with a diagnosis of Vascular Dementia with Mood Disturbance. Review of Resident #102's Quarterly Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 07/19/2023 revealed, in part, Resident #102's Brief Interview for Mental Status Score was 3 which indicated Resident #102 had severe cognitive impairment. Review of Resident #102's Comprehensive Care Plan, with a start date of 08/29/2022, revealed, in part, Resident #102 had a history of wandering and moved around a lot in her wheelchair. Review of Resident #102's nurse's notes revealed, in part, a nurse's note with a date of 09/11/2023 and time of 9:56 a.m. that read is was a late entry for 09/10/2023. Review revealed, Resident #102 rolled herself to the front door of the facility and was trying to get out. Further review revealed, Resident #102 was able to hold the door on her own and had to be continuously redirected all day. In an interview on 09/28/2023 at 1:47 p.m., S4Careplan stated she is responsible for Resident #102's careplan. S4Careplan stated she was not informed Resident #102 had attempted to exit out of the front door of the facility. S4Careplan further stated when Resident #102 attempted to exit out of the front door of the facility on 09/10/2023, an elopement risk assessment should have been performed and her careplan should have been updated to reflect new interventions. In an interview on 09/28/20023 at 3:45 p.m. S2DON confirmed Resident #102 should have been reassessed and had her careplan updated to reflect new interventions put in to place for Resident #102's wandering. There was no documented evidence and the facility failed to present any documented evidence that Resident #102's careplan was revised and updated after Resident #102 attempted to exit out of the front door of the facility on 09/10/2023.

Based on interviews and record reviews, the facility failed to ensure a resident with a new diagnosis of unspecified psychosis was referred to the appropriate state agency for a Preadmission Screening and Resident Review (PASARR) Level II evaluation as required for 1 (Resident #47) of 2 (Resident #47 and Resident #18) sampled residents reviewed for PASARR. Findings: Resident #47 Review of Resident #47's medical record revealed, in part, Resident #47 was admitted to the facility on [DATE]. Review of Resident #47's Level 1 Pre-Admission Screening and Resident Review dated 10/16/2021 revealed, in part, Resident #47 was not diagnosed with a mental illness. Review of Resident #47's medical records revealed, in part, Resident #47 received a new mental illness diagnoses of unspecified psychosis and depression on 03/21/2023. Review of Resident #47's Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/23/2023 revealed, in part, Resident #47 had an active diagnoses of psychotic disorder and depression. Review of Resident #47's medical record revealed, in part, Resident #47 was not evaluated for a Level II PASARR after receiving a new mental illness diagnosis of unspecified psychosis on 03/21/2023. In an interview on 09/27/2023 at 9:30 a.m., S19MDS verified Resident #47 was diagnosed with a mental illness of unspecified psychosis on 03/21/2023. In an interview on 09/27/2023 at 9:35 a.m., S20Social Worker (SW) stated she was not made aware when Resident #47 received a mental illness diagnosis and did not know it was required to have residents with a new mental illness diagnosis evaluated for a Level II PASARR until 09/19/2023. S20SW further stated Resident #47 should have been referred to the appropriate state-designated agency for a Level II PASARR after receiving a mental illness diagnosis on 03/21/2023. In an interview on 09/27/2023 at 9:40 a.m., S2Director of Nursing stated the facility did not have a system in place for submitting residents with a new mental health diagnosis for evaluation to the appropriate state-designated agency for Level II PASARR evaluation.

Based on observations, interviews and record review the facility failed to ensure an adaptive call bell was available for a resident with limited range of motion in her hands for 1 (Resident #44) of 30 initial pool residents reviewed for call bell use. Findings: Review of Resident #44's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/04/2023 revealed, in part, Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #44 was cognitively intact, and Resident #44 was totally dependent and required two person physical assistance for bed mobility, transfer, and toilet use. Review of Resident #44's care plan revealed, in part, Resident #44 had functional limited range in her hands related to bilateral hand contractures. Further review revealed, a goal of Resident #44 will be free of injury and complications with interventions that included placing a call light within reach, assisting with ADLs as needed, and providing assistive/supportive devices. Observation on 09/25/23 at 11:14 a.m. revealed Resident #44's had limited range of motion in both hands. In an interview on 09/25/2023 at 11:14 a.m., Resident #44 stated she is unable to use the call bell in her room, and she has to holler for assistance when needed. Resident #44 further stated she did not like having to holler for assistance, and wished she had another way to call for assistance. In an interview on 09/28/2023 at 9:09 a.m., S11Certified Nursing Assistant (CNA) stated Resident #44's hands were contracted and she could not use the call bell. S11CNA further stated that Resident #44 had to scream out for assistance when she needed it by yelling help or calling the CNA's names. S11CNA further stated Resident #44 should not have to holler out for assistance, and Resident #44 should have an adaptive call bell that allowed her to use the call bell system independently. In an interview on 09/28/2023 at 9:10 a.m. S16CNA stated she thinks the resident should be given one of the flat pad-like call bells, because she could use that to call for assistance instead of having to holler for help. In an interview on 09/28/2023 at 9:13 a.m. S18Registerd Nurse (RN) stated Resident #44 had dexterity issues in her hands and had to holler for assistance. Observation on 09/28/2023 at 9:28 a.m. revealed S18RN tested to see if Resident #44 could use the call bell in her room. Further observation revealed that Resident #44 was unable to press the call bell button. In an interview on 09/28/2023 at 9:28 a.m., S18RN confirmed Resident #44 was unable to use her call bell in her room. In an interview on 09/28/2023 at 11:00 a.m., S2Director of Nursing (DON) stated that facility should have accommodated Resident #44's need for an adaptive call bell, and Resident #44 should not have to holler for assistance.

Based on observations, interviews, and record review the facility failed to ensure S3Treatment Nurse (TN) performed hand hygiene per facility policy when S3TN performed wound care. This deficient practice was identified for 2 (Resident #3 and Resident #5) of 5 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5) residents reviewed for wound care. Findings: Review of the facility's Dressing Change Policy and Procedure revealed, in part, hand hygiene is to be performed before wound care procedures. Further review revealed, in part, gloves are to be removed and hand hygiene performed after removing old dressings, after cleansing and measuring wounds, and before applying any creams or new dressings. Resident #3 Observation on 03/14/2023 at 11:12 a.m., revealed S3TN cleaning an incontinence episode for Resident #3 and changing Resident #3's incontinence pad. S3TN then removed her gloves and put on new gloves without performing hand hygiene. S3TN proceeded to clean Resident #3's pressure injury with normal saline and gauze, but was unable to continue pressure injury wound care when Resident #3 began to have an incontinent bowel movement. S3TN exited Resident #3's room to get more supplies. Observation on 03/14/2023 at 11:23 a.m., revealed S3TN returned to Resident #3's room and applied gloves, cleaned Resident #3's from an incontinent bowel movement, removed her gloves, and then placed on new gloves without performing hand hygiene. S3TN then proceeded to clean Resident #3's pressure injury again with normal saline, applied barrier cream to Resident #3, and applied new dressing to Resident #3's pressure ulcer without changing her gloves or performing hand hygiene between each step. In an interview on 03/14/2023 at 2:04 p.m., S3TN stated she should have performed hand hygiene between providing incontinence care to Resident #3 and cleaning Resident #3's pressure injury. S3TN further stated she should have changed her gloves and performed hand hygiene between cleaning Resident #3's pressure injury, applying barrier cream to Resident #3, and applying dressing to Resident #3's pressure injury. In an interview on 03/16/2023 12:40 p.m., S2Assistant Director of Nursing (ADON) stated S3TN should have performed hand hygiene before performing Resident #3's pressure injury wound care, and S3TN should have performed hand hygiene and changed gloves between cleansing Resident #3's pressure injury, applying barrier cream to Resident #3, and applying new dressing to Resident #3's pressure injury. In an interview on 03/16/2023 at 12:48 p.m., S1Quality Improvement (QI) Nurse stated S3TN should have performed hand hygiene before starting Resident #3's wound care, and S3TN should have performed hand hygiene and changed gloves between cleaning Resident #3's pressure injury, applying barrier cream to Resident #3, and applying dressing to Resident #3's pressure injury. Resident #5 Observation on 03/14/2023 at 1:45 p.m., revealed S3TN applied gloves, removed dressing to Resident #5's left hand skin tear and Resident #5's left forearm skin tear, removed her gloves, and then applied new gloves without performing hand hygiene. S3TN then cleaned Resident #5's left hand skin tear and Resident #5's left forearm skin tear with normal saline and gauze, and then patted Resident #5's left hand skin tear and Resident #5's left forearm skin tear dry with gauze. Further observation revealed, S3TN did not perform hand hygiene or change gloves before she applied new dressings to Resident #5's left hand skin tear and Resident #5's left forearm skin tear. In an interview on 03/14/2023 at 2:04 p.m., S3TN stated she should have performed hand hygiene between removing old dressings from Resident #5's left hand skin tear and Resident #5's left forearm skin tear, and cleaning Resident #5's left hand skin tear and Resident #5's left forearm skin tear. S3TN further stated she should have performed hand hygiene and changed her gloves after cleaning Resident #5's left hand skin tear and Resident #5's left forearm skin tear before applying new dressings to Resident #5's left hand skin tear and Resident #5's left forearm skin tear. In an interview on 03/16/2023 12:40 p.m., S2Assistant Director of Nursing (ADON) stated S3TN should have performed hand hygiene between removing old dressing to Resident #5's left hand skin tear and Resident #5's left forearm skin tear and cleansing Resident #5's left hand skin tear and Resident #5's left forearm skin tear. S2ADON further stated S3TN should have performed hand hygiene and changed her gloves between cleansing Resident #5's left hand skin tear and Resident #5's left forearm skin tear, and applying new dressing to Resident #5's left hand skin tear and Resident #5's left forearm skin tear. In an interview on 03/16/2023 at 12:48 p.m., S1Quality Improvement (QI) Nurse stated S3TN should have performed hand hygiene after removing dressing to Resident #5's left hand skin tear and Resident #5's left forearm skin tear before she cleaned Resident #5's left hand skin tear and Resident #5's left forearm skin tear. S1QI Nurse further stated that S3TN should have changed her gloves between cleaning Resident #5's left hand skin tear and Resident #5's left forearm skin tear and applying new dressing to Resident #5's left hand skin tear and Resident #5's left forearm skin tear.

Based on observation, interview and record review the facility failed to shave and provide nail care for 1 (Resident #109) of 3 residents reviewed for Activity of Daily Living (ADL) Assistance in a total sample of 26 residents reviewed in the investigation stage. This deficient practice had the potential to affect any of the 132 residents who resided in the facility as per the facility's Resident Census and Conditions of Residents Form (CMS- Form 672). Findings: Resident #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #109's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 02/06/2020 revealed, in part, cognitive skills for daily decision making were severely impaired and the client never and/or rarely made decisions. Further review of Resident #109's MDS revealed, in part, Resident #109 was totally dependent on one staff member for personal hygiene. Review of Resident #109's Care Plan revealed, in part, he was dependent with ADLs. Observation of Resident #109 on 03/02/2020 at 11:40am revealed he was lying in bed with facial hair and nails on both hands that were extended beyond the fingertips with an unidentified brown colored substance under the nails. Observation of Resident #109 on 03/05/2020 at 9:00am revealed he was lying in bed with facial hair and nails on both hands that were extended beyond the fingertips with an unidentified brown colored substance under the nails. In an interview on 03/05/2020 at 9:00am, S2Certified Nursing Assistant (CNA) observed Resident #109 with the surveyor and stated Resident #109 had not been shaved and confirmed his nails were extended beyond the fingertips and confirmed the presence of an unidentified brown colored substance under the nails. S2CNA stated the shower aides were responsible for shaving residents and the activity staff was responsible for nail care for all non-diabetic residents. S2CNA stated Resident #109 typically had a shaved face and did not typically wear a facial beard. In an interview on 03/05/2020 at 9:05am, S1Director Of Nursing (DON) confirmed Resident #109's nails were extended beyond the fingertips and confirmed the presence of an unknown brown substance under the nails. S1DON confirmed Resident #109 was not a diabetic and stated the activity staff was responsible for the completion of nail care and the shower aides were responsible for shaving residents on shower days. S1DON confirmed Resident #109 had a facial beard. In an interview on 03/05/2020 at 9:07am, S3 Shower Aide stated she was responsible to shower and shave Resident #109. S3ShowerAide stated she had not shaved Resident #109 because she just did not get to it. S3ShowerAide confirmed Resident #109 should be shaved and not have a facial beard. In an interview on 03/05/2020 at 9:13am, S4 Registered Nurse (RN)/Assessment Nurse stated it was the responsibility of the shower aide to shave Resident #109 and it was the activity staff responsibility to perform nail care for any non-diabetic residents. S4 RN /AssessmentNurse further stated that if a resident had a preference to have a beard rather than be shaved then it would be addressed in the residents care plan. S4RN /Assessment Nurse reviewed Resident #109's care plan and confirmed there was not a documented preference for a beard. In an interview on 03/05/2020 at 9:51am, S5 Activity Director stated the activity staff completed nail care for non-diabetic residents and they documented the task in the computer. S5 Activity Director stated she reviewed Resident #109's activity documentation from 12/21/19 to 03/05/2020 and there was no documented evidence nail care had been provided.

Based on interview and record review, the facility failed to ensure resident received adequate supervision to prevent a cognitively impaired resident from leaving the facility and wandering out into the community for 1 (#3) of 5 residents (#1, #2, #3, #4, and #5) residents reviewed. This deficient practice resulted in an Immediate Jeopardy on 01/05/2020 at 6:48pm for Resident #3 when he eloped from the facility. On 01/05/2020 at 11:53pm, facility staff received a phone call from someone in the community who notified them that there was a man walking by the red light at a busy intersection. The resident had not been seen by staff and staff was not aware that the resident had left the facility until receiving the phone call which revealed a resident standing at a busy intersection. The nurse alerted other staff members, exited the facility, and found Resident #3 away from the facility at a busy intersection. Resident #3 was returned to the facility on [DATE] at 12:00am. The facility implemented corrective actions which were completed prior to the State Agency's completion of its investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the record revealed Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/2019 revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated he was severely cognitively impaired. Further review in Section P, Restraints, revealed Resident #3 used no alarms. Review of the record revealed a care plan was developed which identified Resident #3 with an altered thought process related to impaired memory and decision making. This problem was identified on 04/13/2017 upon admission. Some approaches included, in part, reality orientation during waking hours, and contact the family and/or physician as needed. Further review of the record revealed a care plan was developed which identified Resident #3 as at risk for elopement related to a history of elopement (wandering off grounds). This problem was identified on 01/06/2020, after Resident #3 eloped from the facility. Some approaches included, in part, place security bracelet, check placement every shift, and observe wander-guard function daily. A next goal date was set for 03/24/2020. Review of Resident #3's nurse's notes entry dated 04/13/2017 revealed, in part, Resident #3 was admitted to the facility. Resident #3 was able to ambulate with an unsteady gait. A wander-guard was applied due to the resident's short term memory loss and not accepting admission. Review of Resident #3's Nurse Data Collection Screening dated 01/24/2018 revealed, in part, Resident #3 was assessed as not at risk for elopement. Wander-guard was deemed unnecessary and was discontinued on this day. Review of Resident #3's Nurse Data Collection Screening dated 12/17/2019 revealed Resident #3 did not have wandering behaviors, and was not at risk for elopement. Review of Resident #3's nurse's notes entry dated 01/06/2020 at 4:18am revealed, in part, at 11:50pm, S3Licensed Practical Nurse (LPN) was making rounds after report was received. Upon entering Resident #3's room, it was noted he was not in his room. S3LPN returned to the nurse's desk to check the sign out book and computer to see if Resident #3 was out of the facility. The facility phone rang and a lady on the phone voiced I'm not sure if this is a patient from ya'll facility, but there is a man that is walking by the red light across from a local pharmacy. S3LPN alerted staff and ran down the hall outside. An outgoing nurse, S6LPN, voiced she was going to get her car. When S3LPN made it outside, she looked toward the direction of the pharmacy, and did not see anyone. S3LPN walked further and called out Resident #3's name. S3LPN noticed someone stopped and was looking around. The person took a few more steps and S3LPN shouted Resident #3's name again. The person stopped and looked around again. S6LPN reached Resident #3 in her car first, and S3LPN reached him shortly thereafter. When staff reached Resident #3, Resident #3 was placed in S6LPN's personal vehicle, and transported back to the facility. Review of the facility's incident report revealed the following time lines: 1845 (6:45pm) - Resident exited the facility, walked on the front porch, and walked off of the front porch to the left. 1846 (6:46pm) - Resident was noted walking in front of hall a, walking away 1847 (6:47pm) - Resident was walking in the front yard near the swing. 1848 (6:48pm) - Resident continued to walk on the sidewalk, towards the patio a, but never enters the patio a. 2353 (11:53pm) - floor nurse, S3LPN, was seen running down hall a and exited the building. Further review of the incident report revealed it was initiated on 01/06/2020 at 12:00am. In an interview on 02/17/2020 at 2:05pm, S4CNA stated on 01/05/2020, when he went to put Resident #3's roommate to bed on 01/05/2020, he noted that Resident #3 was not in his room. S4CNA was unable to recall the time he put Resident #3's roommate to bed. S4CNA figured the resident was either in the bathroom, or in the TV room. S4CNA stated it never occurred to him that the resident may have eloped. S4CNA confirmed the last time he saw Resident #3 was in the dining room at supper time between 5:30pm and 6:00pm. S4CNA confirmed his shift ended at 10:00pm. S4CNA stated he did not check the sign out log, and confirmed he did not notify the nurse on duty that Resident #3 was not in his room. S4CNA further confirmed he did not check on the resident every 2 hours as required. In a telephone interview on 02/17/2020 at 2:24pm, S5LPN stated she was the evening nurse on 01/05/2020 for Resident #3. S5LPN confirmed she did not check on the resident every 2 hours, and had no idea the resident eloped from the facility. In a telephone interview on 02/17/2020 at 09:44am, S3LPN confirmed she was the nurse who worked on the 01/05/2020 night shift, and was Resident #3's assigned nurse. S3LPN stated her shift started on 01/05/2020 at 11:00pm, and ended on 01/06/2020 at 7:00am. After receiving report from the outgoing shift, S3LPN stated she started to make her rounds. When she entered Resident #3's room, she noted that his bed was made, and he was not in his room. She asked his roommate if he knew where the resident was, and the roommate stated Resident #3 was with his family member, not in the facility. S3LPN checked the computer and the sign out log, and Resident #3 was not signed out. S3LPN stated she was picking up the phone to call Resident #3's evening nurse, S5LPN, when the phone rang. The person on the other end of the phone informed her that there was an elderly man walking near the red light near a local pharmacy. S3LPN stated she immediately hung up the phone, and knew this was Resident #3. She ran down the hall yelling for the CN[NAME] She ran to the Wing a exit door to look out and did not see the resident. She exited the door further into the facility parking lot, and saw a dark shadow. She yelled Resident #3's name, the figure stopped and looked around, and then continued to walk. She began to run and yelled his name again. He stopped in his tracks. S3LPN stated she was almost hit by a car which was turning by the intersection. S3LPN stated the outgoing nurse, S6LPN, ran to get her car when S3LPN alerted the staff the resident was not in the building. S6LPN reached Resident #3 in her car first, then S3LPN reached them both. Resident #3 was then transported back to the facility in S6LPN's personal vehicle. Resident #3 was assessed with [REDACTED].#3 eloped from the facility. S3LPN confirmed she did not notify facility administration of Resident #3's elopement until they returned to work on the morning of 01/06/2020, after 7:00am. S3LPN further confirmed she did not immediately notify Resident #3's physician of the elopement. A joint interview was conducted on 02/18/2020 at 11:15am with S1Administrator and S2Director of Nurses (DON). S1Administrator and S2DON confirmed Resident #3 eloped from the facility on 01/05/2020 and was missing until 01/06/2020 at 12:00am when he was returned to the facility. S1Administrator confirmed the video surveillance of the incident was no longer available to view as it was not archived or copied. Both confirmed S4CNA failed to check on the resident every 2 hours as required. Both confirmed S5LPN did not know Resident #3 was not in the facility during her assigned shift. Both confirmed S3LPN failed to notify administrative staff immediately of a resident's elopement. Both confirmed the intersection was busy, and the end result could have been tragic. Throughout the survey from 02/17/2020 through 02/18/2020, random interviews with staff were conducted. Staff members were questioned in regards to observations of residents and if they knew what to do if a resident was unable to be located. All staff questioned stated they received in-service training on making rounds at least every 2 hours on all residents, and on the immediate notification to the Administrator and/or DON of any resident found off of the facility property. The facility has implemented the following actions to correct the deficient practice effective 01/06/2020 at 07:30am. 1. Resident #3 incurred no injury as a result of his elopement from the facility. He was assessed for and found appropriate for initiation of a wander guard/security bracelet. His care plan was revised to reflect this change in his plan of care. 2. Six (6) residents with an elopement risk had their wander guard/security bracelets placement verified and function verified on 01/06/2020. Active Census on the date of occurrence was 135. 3. Measures implemented to prevent recurrence include: Administrator and Director of Nursing were notified 01/06/2020. Incident Report completed by staff nurse indicated the event and notification of the Physician and Resident Representative on 01/06/2020. S4CNA received an Employee Warning Report for failure to round on resident every two hours. Administrator reset all exit doors 01/06/2020 to lock at 5:30pm rather than 7:00pm. In-serviced on every 2 hour rounds by CNAs, and immediate notification of the Administrator or designee of any resident found off of facility property. Involved staff were educated via the facility Employee Education Request Administrative (AD) -347. Investigation and Reporting initiated per State Incident Management System (SIMS), including but not limited to initiation of a Corrective Action Plan, direct visualization of facility video surveillance footage, and all staff present at the time of the incident were contacted for statements/interviews by the Administrator and DON. Nurse's notes from the previous day or weekend were reviewed daily to identify any non-compliance or issues that may warrant immediate notification of the Administrator or designee. 4. Monitoring of compliance included the following: a. Video surveillance is randomly reviewed 3 times a week by the Administrator, DON and/or Assistant Director of Nursing (ADON) to monitor that rounds are being completed by CNAs and nurse. This is done for 3 weeks and randomly thereafter. b. DON/designee interviewed cognitively appropriate residents by asking if rounds are being made by CNAs and nurses for 3 weeks and randomly thereafter. c. Wander guard / security bracelets are verified every shift with function test done daily. d. The Assessment Nurses reviewed the potential for elopement on all residents and will continue during each resident's quarterly assessment. Upon identification of elopement risk whether verbal or physical attempts, the residents are reassessed and proper interventions implemented. e. Nurse's notes from the previous day or weekend are reviewed Monday - Friday to identify any non-compliance or issues that may warrant immediate notification of the Administrator or designee. f. Continued in-servicing of Direct Care staff to ensure compliance with the aforementioned protocol. Direct Care Staff will not provide patient care until training is complete with new hires having required training during orientation. g. The Quality Assurance (QA) committee will review the aforementioned plan of correction and modify as needed by the QA team. 5. Completion Date 2/6/2020

Based on observation, interview, and record review, the facility failed to implement a care plan for a resident on fluid restrictions as evidenced by failing to follow physician's orders [REDACTED].#26) of 2 sampled residents reviewed for hydration, in a total investigation stage sample of 47. The total facility census was 140 as documented on the Resident Census and Conditions of Residents Form CMS-672. Findings: Review of the record revealed Resident #26 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #26's (MONTH) 2019 physician's orders [REDACTED]. Review of Resident #26's record revealed a care plan was developed which identified a problem for 1000ml fluid restriction. Some approaches included, in part, 1000ml fluid restriction, and encourage diet and fluid restriction compliance. Review of Resident #26's nursing documentation in completed care revealed nursing documentation of fluid intake. Review of Resident #26's completed care tasks from 02/15/19 through 03/13/19 revealed, in part, documentation of fluids offered every two hours, and accepted, with only one refusal on 02/16/19 at 05:28am. Further review revealed no documentation of accurate intake of amount of fluids consumed by Resident #26. Observation on 03/11/19 at 06:40am revealed Resident #26 had a small cup of unthicken, clear liquid, half full at his bedside. In interview at this time Resident #26 stated he was given the cup of unthicken water to take with his morning medications. In an interview on 03/11/19 at 09:30am, S2 Licensed Practical Nurse (LPN) stated Resident #26 should not have a cup of water at his bedside. In an interview on 03/13/19 at 09:52am S4 Certified Nursing Assistant (CNA) stated she only documented if Resident #26 accepted or refused liquids. S4 CNA confirmed she was unaware that Resident #26 was on fluid restrictions. In an interview on 03/13/19 at 10:04am S5 CNA stated Resident #26 was offered thicken liquids every 2 hours. S5 CNA further stated she documented only whether fluids were accepted or refused. S5 CNA confirmed she did not document how much was consumed. S5 CNA confirmed she was unaware that Resident #26 was on fluid restriction. In an interview on 03/13/19 at 10:10am, S2 LPN stated Resident #26 was on fluid restriction of 1000ml daily. S2 LPN confirmed she was unaware of CNAs offering fluids to Resident #26 every 2 hours. S2 LPN confirmed the CNAs should not be offering fluids every 2 hours to Resident #26. In an interview on 03/13/19 at 10:15am, S1 Director of Nursing (DON) was informed of the above findings and had no additional documentation to present.

Based on record review, observation and interview the facility failed to provide the ordered gastrostomy tube feeding formula for 1 (Resident #54) of 47 residents reviewed in the investigative stage. This deficient practice had the potential to affect any of the 7 residents who resided in the facility and received gastrostomy tube feedings as documented on the facility's Resident Census and Conditions of Residents Form CMS-672. Findings: Review of Resident #54's record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. (An artificial external opening into the stomach for nutritional support.) Review of Resident #54's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/10/19 revealed, in part, the resident had a feeding tube and received a therapeutic diet. Review of Resident #54's (MONTH) 2019 Physician order [REDACTED]. Review of Resident #54's Care Plan dated 10/19/18 revealed, in part, the resident had a feeding tube for nutritional intake. A documented approach included, in part, [MEDICATION NAME] 2.0 at 35cc per hour via gastrostomy tube per pump for 24 hours a day. Review of Resident #54's Registered Dietician Nutrition assessment dated [DATE] revealed, in part, tube feeding [MEDICATION NAME] 2.0 at 35cc per hour via gastrostomy tube per pump for 24 hours a day. Observation of Resident #54 on 03/12/19 at 7:10am revealed Fibersource HN (a tube feeding formula) was infused at 35cc per pump. Further observation revealed the Fibersource HN was dated 03/12/19 at 3:45am. The pump revealed 690cc of Fibersource HN had been infused per the pump reading. Observation of Resident #54 on 03/12/19 at 9:55am revealed Fibersource HN was infused at 35cc per pump. The pump revealed 774cc of Fibersource HN had been infused per the pump reading. In an interview on 03/12/19 at 10:00am S2 Licensed Practical Nurse (LPN) stated Resident #54 had an order for [REDACTED].#54's room accompanied by the surveyor and confirmed Fibersource HN was infused at 35cc per the pump. S2 LPN confirmed Fibersource HN was not the ordered formula for Resident #54. S2 LPN further stated when a new bag of formula was hung the pump was reset to zero; therefore, the amount indicated on the pump as infused would have been the amount of the incorrect formula the resident received. In an interview on 03/12/19 at 10:20am S1 Director of Nursing (DON) stated the nurse was responsible to ensure the correct formula was provided to the resident. S1 DON confirmed the current order for Resident #54 was [MEDICATION NAME] 2.0 at 35cc per hour per pump.

Based on record review and interview the facility failed to provide appropriate treatment and services to prevent urinary tract infections by failing to obtain an order to irrigate an indwelling foley catheter and failing to notify the physician of a change in status related to an indwelling foley catheter for 1 (Resident #112) of 47 residents reviewed in the investigative stage. This deficient practice had the potential to affect any of the 4 residents who resided in the facility and had an indwelling foley catheter as documented on the facility's Resident Census and Conditions of Residents Form CMS-672. Findings: Resident # 112 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #112's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/27/18 revealed, in part, he had medically complex conditions which included, in part, a UTI in the last 30 days. Review of Resident #112's Care Plan revealed, in part, history of UTI and Indwelling Catheter with a documented approach to notify the physician of any complications. Review of Resident #112's Nurses Notes dated 10/11/18 at 6:46pm revealed, in part, admitted to the facility following a hospitalized from [DATE] through 10/11/18 for treatment of [REDACTED].#112's record revealed he was admitted to the facility with an order for [REDACTED].) Review of Resident #112's record revealed he was hospitalized on two occasions since his admission for a UTI. Review of Resident #112's Nurses notes dated 12/28/18 at 7:18pm revealed, in part, a verbal telephone order was received for antibiotics due to a UTI. Review of Resident #112 Nurses Notes dated 02/22/19 at 3:09pm revealed, in part, a late entry for 12:00pm, blood and heavy sediment noted to GU ([MEDICAL CONDITION]) tubing (the tube that drains the urine from the bladder to the collection device) from foley catheter. Further review of Resident #112's Nurses Notes revealed the physician was called and a message was left with the nurse. Review of Resident #112's Nurses Notes dated 02/22/19 at 10:18pm revealed, in part, the foley catheter was irrigated. Further review revealed, in part, catheter now drained golden yellow urine with noted cloudiness. Physician notified of purulent drainage (a thick and milky discharge) noted from meatus. (The meatus is the point where urine exits the urethra.) Awaiting response from the physician. Review of Resident #112's Skilled Nursing Facility (SNF) Documentation record dated 02/23/19 revealed, in part, catheter patent and intact with cloudy urine. Review of Resident #112's SNF Documentation record dated 02/24/19 revealed, in part, catheter patent and intact with cloudy urine. Review of Resident #112's Nurses Notes dated 02/25/19 at 11:30am revealed, in part, received fax from physician to collect CBC (complete blood count) and UA (urinalysis) with C & S (culture and sensitivity) due to blood noted in stool and sediment and blood noted to urine on 02/22/19. Further review of the record revealed a urine sample was collected and a moderate amount of sediment remained in the urine. Review of Resident #112's UA results revealed the sample was collected on 02/25/19 at 12:35pm and revealed seven abnormal findings which included, in part, bacteria present, yellow cloudy urine, a large amount of blood present, positive for [MEDICATION NAME] ([MEDICATION NAME] in urine may be a sign of a UTI), large amounts of leukocytes (an enzyme present in white blood cells), Red Blood Cell Count of 5-9 (normal results are 0-2), and a White Blood Cell Count of 100+ (normal results are 0-5). Review of Resident #112's Nurses Notes dated 02/26/19 at 1:13pm revealed the UA results were called and faxed to the physician office. Review of Resident #112's Physicians Telephone Order dated 02/26/19 at 4:15pm revealed, in part,[MEDICATION NAME] tablet take one tablet by mouth twice per day for seven days was ordered for a UTI. In an interview on 03/13/19 at 2:25pm S2 Licensed Practical Nurse (LPN) stated nurses either call or fax the physician when a change was noted with a resident. S2 LPN stated she called Resident #112's physician on 2/22/19. S2 LPN further stated on 02/25/19 she received a fax from Resident #112's physician with an order to collect a UA with C & S and a CBC. In an interview on 03/13/19 at 3:25pm S3 LPN stated on 02/22/19 she noted Resident #112 had bloody urine and she irrigated Resident #112's foley catheter. S3 LPN stated she did not obtain an order prior to the catheter irrigation. S3 LPN stated she sent a fax to the physician office after hours when she assessed purulent drainage from Resident #112's meatus. S3 LPN confirmed she did not speak to the physician nor did she get a faxed reply from the physician regarding Resident #112's status. In an interview on 03/13/19 at 3:50pm S1 Director of Nursing (DON) stated an order should be obtained for a catheter irrigation. S1 DON further stated the physician should be contacted for changes in condition and if a response was not received the information should be communicated at shift change for further action to be taken by the nursing staff. S1 DON confirmed there was no documented evidence the physician was notified of Resident #112's status on 02/23/19 or 02/24/19.

Based on observation, record reviews and staff interviews the facility failed to implement a comprehensive person-centered care plan for 2 (Resident #103 & Resident #137) of 28 resident records reviewed as evidenced by: 1. Failing to administer medications as ordered for a resident who received [MEDICAL TREATMENT] services (Resident #103); and 2. Failing to apply gripper socks for a resident with a history of falls (Resident # 137). This deficient practice had the potential to effect any of the 141 residents residing at the facility according to the facility's Resident Census and Conditions of Residents. Findings: Resident #103 Resident # 103 was admitted to the facility on [DATE] with diagnoses, in part, [MEDICAL CONDITION], Stage 5 (Dependent on [MEDICAL TREATMENT]),[MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease), Dysarthria, [MEDICAL CONDITION], Diabetes, [MEDICAL CONDITIONS] and [MEDICAL CONDITIONS]. Review of the (MONTH) (YEAR) Physicians Orders revealed, in part, [MEDICATION NAME] ( a medication used to lower the amount of phosphorus in the blood of patients receiving kidney [MEDICAL TREATMENT]) 800mg TID (three times per day) to be administered at 9:00am, 1:00pm and 5:00pm. Review of the facility policy titled Drug Administration and Documentation revealed, in part, for electronic medication administration (EMAR), any medication not administered is indicated by an N in the block with a note of explanation as to why medication was not administered. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] 04/03/18 at 1:00pm. Review of the Administration note dated 04/03/18 at 2:33pm revealed, in part, [MEDICATION NAME] 800mg tablet not administered due to resident not available. Review of the (MONTH) (YEAR) MAR indicated [REDACTED] 03/03/18 at 1:00pm; 03/10/18 at 1:00pm; 03/13/18 at 1:00pm and 5:00pm; 03/15/18 at 1:00pm; 03/17/18 at 1:00pm; 03/20/18 at 1:00pm; 03/27/18 at 1:00pm; 03/29/18 at 1:00pm. Review of the administration notes dated 03/03/18, 03/10/18, 03/13/18, 03/15/18, 03/17/18, 03/20/18, 03/27/18 and 03/29/18 revealed, in part, [MEDICATION NAME] 800mg tablet not administered due to resident not available. Review of the (MONTH) (YEAR) MAR indicated [REDACTED] 02/03/18 at 1:00pm; 02/06/18 at 1:00pm; 02/07/18 at 1:00pm; 02/08/18 at 1:00pm; 02/10/18 at 1:00pm; 02/12/18 at 5:00pm; 02/15/18 at 1:00pm and 5:00pm 02/17/18 at 1:00pm; 02/23/18 at 5:00pm; 02/24/18 at 1:00pm; 02/27/18 at 1:00pm and 5:00pm. Review of the administration notes dated 02/03/18, 02/06/18, 02/07/18, 02/08/18, 02/10/18, 02/12/18, 02/15/18, 02/17/18, 02/23/18, 02/24/18 and 02/27/18 revealed, in part, [MEDICATION NAME] 800mg tablet not administered due to resident not available. Review of Resident #103's Care Plan revealed, in part, resident has a [DIAGNOSES REDACTED]. Documented interventions include, in part, administer medications as ordered and notify MD of any complications. In interview on 04/04/18 at 9:41am S4/Licensed Practical Nurse (LPN) stated Resident # 103 goes to [MEDICAL TREATMENT] every Tuesday, Thursday and Saturday. She stated that she has been holding the [MEDICATION NAME] that is scheduled during [MEDICAL TREATMENT] hours. She further stated the physician had not been notified regarding the dosage of [MEDICATION NAME] being held. In interview on 04/04/18 at 10:30am S2/Registered Nurse (RN) Director of Nursing (DON) confirmed the medication ([MEDICATION NAME]) was not given on multiple occasions in February, (MONTH) and (MONTH) (YEAR). In interview on 04/05/18 10:54 am S2/RN DON stated that failure to implement the care plan was not identified and a Quality Assurance (QA) program was not put into place to address the issue. Resident #137 Resident # 137 was re-admitted to the facility on [DATE] following a hospitalization for a fractured neck of the femur (leg bone) with other diagnoses, in part, [MEDICAL CONDITION] (paralysis) of right dominant side, and history of a stroke. Review of the MDS dated [DATE] revealed in part, Resident #137 was assessed as having a history of falls. Review of the MDS (Minimal Data Set) dated 03/08/18 revealed in part, Resident #137 was assessed as having poor decision making abilities, required extensive assistance with transfers and bed mobility. Review of the facility incident log dated 01/2018 to 04/2018 revealed Resident #137 had falls on the following dates: 01/17/18; 02/03/18; 02/17/18; 02/21/18; 03/31/18. Review of nursing notes dated 01/17/18 revealed Resident #137 had a fall in the dining room. Review of nursing notes dated 02/04/18 (late entry) revealed Resident #137 had an unobserved fall on 02/03/18 in his bedroom. Further review revealed Resident #137 complained of left leg pain, was unable to extend his left leg and was admitted to the hospital with [REDACTED]. Review of nursing notes dated 02/17/18 revealed Resident #137 had an unobserved fall in his bedroom/bathroom. Review of nursing notes dated 02/21/18 revealed Resident #137 had an unobserved fall and was found on the floor in the unit's dayroom on his buttocks in front of his wheelchair. When asked what happened, Resident # 137 stated he slipped. Review of nursing notes dated 03/31/18 Resident #137 had an unobserved fall and was found on floor near the visitor restroom on the hall he resides. Review of Resident #137's Care plan with a goal date of 05/22/18 revealed in part, the resident has muscle weakness and was at risk for falls related to right sided paralysis. Documented interventions include, in part, ensure resident has gripper socks on at all times. Observation on 04/02/18 at 11:04am revealed Resident #137 was in a High back wheel chair and wearing regular white crew socks with no gripper treads present on the socks. Observation on 04/03/18 at 10:00am revealed Resident #137 was in a high back wheelchair and wearing regular white crew socks with no gripper treads present on the socks. In Interview on 04/04/18 at 11:13am S5/CNA (Certified Nursing Assistant) stated she wasn't aware of Resident #137 having a history of falls. When asked if she places anything on Resident #137 to prevent him from falling she stated they placed socks with treads on him. When the surveyor pointed to another resident with green gripper socks on and asked if Resident #137 wore socks like those, S5/CNA said yes. When asked if she had cared for Resident #137 on 04/03/18 S5/CNA stated yes. When asked if Resident #137 was wearing gripper socks on 04/03/18 and if she had placed gripper socks on Resident #137 on 04/03/18, S5/CNA stated Resident #137 wasn't wearing gripper socks during the time she cared for Resident #137 on 04/03/18 because Resident #137 didn't have any gripper socks at that time. Further stated gripper socks were just distributed on 04/04/18 and Resident #137 didn't have any gripper socks prior to that. In interview on 04/05/18 at 10:44am when informed Resident #137's careplan stated he was to have gripper socks on at all times, when informed Resident #137 was observed on 2 separate days as not having gripper socks on, and when informed facility staff stated they had not placed gripper socks on Resident #137 because he had none until 04/04/18, S1/Administrator, S2/ RN DON, and S3/ADON stated they would look into Resident #137 not having gripper socks on as observed and get back to the surveyor because gripper socks are readily available and Resident #137 should have had them on. No additional evidence was provided by S1/A Based on Resident #137 Resident # 137 was re-admitted to the facility on [DATE] following hospitalization for fractured femur with the diagnoses, in part, of Fractured neck of femur, unspecified sequelae of cerbral infarction, [MEDICAL CONDITION] of right dominant side, [MEDICAL CONDITION], Anorexia, dysarthria following cerebral infarction. Review of MDS dated [DATE] revealed in part, a BIMS of 99 (unable to complete interview with moderately impaired decision making poor), requires extensive assistance with eating, transfers, and bed mobility. Further review revealed assessed as swallowing disorder -holds food in cheeks or mouth, difficulty in swallowing, has had weight loss, on mechanically altered diet, at risk for developing PU but none present, received therapy. Review of MDS dated 2/22/18 revealed in part, assessed as having falls. Accidents: Review of incident log dated 1/2018 to 4/2018 revealed Resident # 137 with falls/incidents on 1/6/18 (other); 1/17/18; 2/3/18; 2/17/18; 2/21/18; 3/31/18. Review of Fall risk assessment dated [DATE] revealed Resident # 137 assessed as high risk for falls with a score of 15 (higher than 7=high risk). Review nursing note dated 1/6/18 revealed Resident # 137 found on floor in unit lobby by janitor. Able to perform active ROM, without difficulty, no c/o pain. Nods head that hit head-no abrasions, bruises, cuts. RP and MD aware. Review of nursing notes dated 1/8/18 revealed Resident # 137 propels self to and from dining room. Review of nursing notes dated 1/9/18 revealed video surveillance observed by DON with Resident # 137 taking self out of wheelchair on 1/6/18 and laying himself down on floor. No fall. Review of nursing notes dated 1/17/18 revealed Resident # 137 in dining room picking up bib while in w/c and rolled over to floor, didn't hit head. Video surveillance reviewed by DON and resident didn't hit head. Review of nursing notes dated 2/4/18 as a late entry of 2/3/18 10:30pm revealed Resident found on floor mat at bedside kneeling facing bed on knees. C/O back pain and given [MEDICATION NAME] after pointing to back. No bleeding, no guarding. Bed in low position. floor mat present. Review of nursing notes dated 2/4/18 revealed Resident # 137 assessed as diaphoretic, shakes head yes when asked if feeling bad, crying with c/o pain to left leg . Unable to extend left leg. Pain medication given. Temp 100.9. RP and MD aware. To send to ER for evaluation. admitted to hospital with [MEDICAL CONDITION]. Review of nursing notes dated 2/9/18 Resident # 137 returned to facility from hospital. Review of nursing notes dated 2/14/18 revealed mechanical lift used to transfer resident from bed to w/c. Review of nursing notes revealed Resident #137 Had fall on 2/3/18; went toER on [DATE] due to increased left leg pain. Review of nursing notes dated 2/17/18 revealed Resident # 137 found lying on floor to left side next to bed on mat and resident didn't know what he was trying to do. C/O leg discomfort to left leg. Increased supervision. MD and RP aware. Review of nursing notes dated 2/21/18 revealed Resident # 137 found on floor in dayroom on buttocks in front of w/c. When asked what happened, Resident # 137 stated slipped. MD and RP aware. Review of nursing notes dated 2/21/18 revealed Resident # 137 with w/c with pads to apply under legs and non slip w/c cushion. Review of nursing notes dated 2/27/18 to MD for [MEDICAL CONDITION] F/U. Review of nursing notes dated 3/31/18 Resident # 137 found on floor near visitor restroom on C long hall. Couldn't answer what he was trying to do. Denies pain. RP and MD aware. Review of completed care dated 4/2/18 revealed documented yes gripper socks on at all times at 10:04am, 9:59pm;12:37am and further review on 4/3/18 documented times as being on 10:33am, 9:43pm, 10:23pm that gripper socks were on. Review of C Long hall unit schedule for week of 4/2/18 revealed in part Lavette, CNA and Dora Tilford, CNA was on day shift on 4/2/18; Erica, CNA and Dora Tilford, CNA were on 4/3/18 and 4/4/18 day shift. Review of Therapy services screening revealed screenings done after falls on 1/9/18, 1/19/18, therapy started upon discharge from hospital 2/9/18, screen on 2/20/18, 2/23/18, and 4/3/18. Review of Care plan with goal date of 5/22/18 revealed in part, resident careplanned for muscle weakness (OT to treat 6x/wk); dx. of [MEDICAL CONDITION] (ST to treat 6x/wk); at risk for falls r/t right sided [MEDICAL CONDITION] ( measures inclusive of ensure resident has gripper socks on at all times. In Interview on 04/04/18 11:13 AM Erica Poindexter, CNA stated she assists with transfers, bed bath at times, diaper change, he generally eats well but when I first started about a month ago when I stated he wasn't eating too well, he usually eats on own, cueing at times. I wasn't aware of Resident #137 with falls, but we would put floor mats down and he has them, his bed is low, he doesn't try to get out of the chair. When asked if she places anything on Resident #137 to prevent him from falling she stated they put socks with treads on him. When pointing to another resident with green gripper socks on and when asked if he wears socks like those, Erica said yes. When asked if Resident #137 had them on yesterday, Erica stated Resident #137 didn't have them yesterday but he does have them on today. He is suppose to wear them everyday. I think they have them on him, and told the surveyor she could ask the nurse but they were just giving them all out today and he didn't have any prior to that. When asked how she finds out about new measures to implement for her residents or measures to discontinue, Erica stated she asked the nurse what was going on with the resident when her shift started and that is when she got In information regarding if there are changes with the resident or new measures to take place. In Interview on 04/04/18 11:55 AM Buffy Solar, LPN stated we have tried many things to prevent him from falling changed chair to highback, no slip cushion, attempted leg rests, fall mat, gripper socks he should be on all the time, he'll take them off while in bed. CNAs should know what to do by what is on completed care charting, every begin of shift we have verbal report. Further stated we have gotten scans, changed meds, changed supplements, has been at feeding table, had swallowing test, we have tried so many things. She stated RP is probably going to be in favor of PEG but he is now eating better. In interview on 04/04/18 03:19 PM Emily Bonvillain, PT/Rehab Director stated Resident # 137 he has been on services in past but has met max potential, would be noncompliant, combative, and is hit or miss when it comes to his cognitive status. I am part of careplanning meetings and we have tried numerous measures to keep him from falling, nursing consults me-in high back chair to provide more support. ST did follow him due in part to loss of weight and he was discharged with meeting max potential. Not getting anywhere with him with all therapies and we discharged . He was not compliant. In interview on 04/05/18 10:44 AM Tanya Blanchard,ADON, Robbie Leblanc, DON, and Lance LeBon, ADM stated, when informed that Resident # 137 's careplan stated he was to wear gripper socks at all times and he was observed on 4/2/18 and 4/3/18 with no gripper socks on but white socks on, and staff informing the surveyor she had not put gripper socks on Resident #137 on 4/3/18 because he had none, stated they would look into it because gripper socks are readily available and he should have had them on. Observation on 04/02/18 11:04 AM revealed a fall mat at Resident #137's bedside. Further observation revealed Resident #137 is in a High back chair and wearing white socks on with no slip resistant treads. Observation on 4/3/18 at 10:00 am revealed Residnet #137 in unit dayroom, sitting in high back wheelchair with plain white socks on with no gripper treads. Observation on 04/04/18 09:34 AM revealed Resident # 137 sitting in chair unit lobby with green gripper socks on. Review o f documentation for falls revealed facility updated careplan with each fall, therapy screened with each fall, implemented new measures with each fall, but did not implement measures (gripper socks). Citation cited. Nutrition: Record review revealed Resident # 137 with a weight of 165 on 11/8/17 and 146 on 3/27/18 for a 11.52% weight change in past 6 months. Further review revealed weight on 3/6/18 was 144. 2# weight gain in 1 month. Review of MAR indicated [REDACTED]. (MONTH) reveals 50% to 100% and no refusals. Review of nursing notes dated 2/14/18 revealed Resident # 137 assessed to pocket food and medications in mouth. Further review revealed sits at feeding table, encouraged by staff. Review of nursing notes dated 2/15/18 revealed Resident # 137 eating 50% or higher at feeding table. Review of nursing notes dated 2/16/18 revealed Resident # 137 eating less since return from hospital. Did take house supplement with no issues. Review of nursing notes dated 2/16/18 revealed being fed by staff at feeding assistance table. Review of nursing notes dated 2/18/18 revealed Resident # 137 eating 25% or less, trying mechanical soft and pureed diets. Review of nursing notes dated 2/19/18 revealed Resident # 137 continued with poor appetite. Supplement taken=25% Review of nursing notes dated 2/20/18 revealed with poor appetite. Family brought food from out and resident refused to eat. Refused supplement. Review of nursing notes dated 2/21/18 revealed low intake of dinner. Review of nursing notes dated 2/23/18 revealed refusing meals, lack of appetite. Review of dietician notes dated 2/28/18 revealed recommendation to increase HS to 6 oz TID. MD and RP aware Review of nursing notes dated 2/28/18 revealed continues to refuse meals. Resident nods yes when asked if hurts or hard to swallow. MD aware and ordered swallow study. Review of nursing notes dated 3/2/18 revealed continues with poor appetite and when asked if anything hurts, points to stomach. Non abdominal distention, normal BMs. NP aware. New orders for labs, U/A, CAT scan of head and abd with contrast. Review of nursing notes dated 3/5/18 revealed RP awrae of poor appetite and wt loss. RP states she has tried to get him to eat, has brought food from home, PEG tube discussed and RP will consider if appetite doesn't improve. Review of nursing notes dated 3/7/18 revealed family wants to wait on PEG until results of CT scans, swallow study. Review of nursing notes dated 3/7/18 revealed CT showed presence of gall stones and surgery consult needed. Noted with fever and chills. NP states if worse, send to ER. Review of nursing notes dated 3/8/18 revealed appointment with surgeon on 3/9/18. Review of nursing notes dated 3/8/18 revealed [MEDICATION NAME] given per rectum for constipation. Review of nursing notes dated 3/9/18 revealed Surgeon recommended PEG. RP wants to wait for swallow study results. Review of nursing notes dated 3/13/18 revealed refusing meals. Review of nursing notes dated 3/22/18 out for swallow study. Ate 100% of Ensure pudding upon return. Order to start [MEDICATION NAME] 10cc and d/c [MEDICATION NAME]. Review of nursing notes dated 3/28/18-swallow study revealed no choking or aspiration id'd. Review of completed care dated 12/2017 to 4/2018 revealed in part, % of meals consumed in 12/2017 ranged 75-100%; 1/2018 ranged 50-100% with majority of 100%; 2/2018 0-75% with continued decline noted after 2/9/18; 3/2018 0-100% with majority of 25%; 4/2018 with majority 25%. Review of Weights dated 1/1/18 to 4/4/18 revealed weights obtained weekly beginning 2/9/18 (164.5). Weight on 2/19/18 was 158. Weight on 2/27/18 was 150. Weight on 3/6/18 was 144 and weights on 3/12 and 3/20 were 142. Review of MARs dated 3/2018 and 4/2018 revealed [MEDICATION NAME] documented as given as ordered and supplement documented as given and taken as ordered with exception of 8 times of resident refusal in 3/2018. Review of medical record reveals labs are being monitored regularly and as needed. Last draw date revealed 3/5/18 and results faxed to MD. Review of MD orders dated 4/2018 revealed resident to have NSOT/Mechanical soft no fatty or fried foods, 6 oz house supplement TID, [MEDICATION NAME] 40mg/1ml susp give 10cc po daily, routine labs every 6 mo. Review of Care plan with goal date of 5/22/18 revealed in part, resident careplanned for dx. of [MEDICAL CONDITION] (ST to treat 6x/wk); needs assistance with eating(verbal cues, assist with meals); has dx of anorexia(administer meds, diet as orderd, monitor weight monthly, encourage to eat); therapeutic diet with compromised nutritional status, refusing meals, holds food in mouth, significant weight loss, requires cueing, trying to drink food that requires utensils, Review of therapy notes revealed services PT/ST/OT started on 2/11/18 through 3/30/18. Met max potential. In interview on 4/3/18 at 10:30am Buffy, LPN stated Resident # 137 is getting better with intake and feels a [MEDICAL CONDITION] experienced while in hospital for fx femur but has no definitive dx. of [MEDICAL CONDITION]. Further stated they took him off [MEDICATION NAME] and started [MEDICATION NAME] which seems to be working better (on since 3/23/18) Interview on 04/04/18 11:13 AM Erica CNA stated she assitss with transfers, bed bath at times, diaper change, he generally eats well but when I first started about a month ago when I stated he wasn't eating too well, he usually eats on own, cueing at times. I wasn't aware of falls, but we would put floor mats down and he has them, his bed is low, he doesn't try to get out of chair. He dind't have them yesterday but he does have them on today. He is suppose to wear them everyday. I think they have themher youe can ask nurse but they wer just giving them all out yesterday. He takes snacks. I ask what is going on with the resident when my shift starts and that is when I get information regarding if there are changes with the resident or new measures to take place. Interview on 04/04/18 11:55 AM Buffy Solar, LPN stated we have tried many things to prevent him from falling changed chair to highback, no slip cushion, attempted leg rests, fall mat, gripper socks he should be on all the time, he'll take them off while in bed. CNAs should know what to do by what is on completed care charting, every begin of shift we have verbal report. Further stated we have gotten scans, changed meds, changed supplements, has been at feeding table, had swallowing test, we have tried so many things. She stated RP is probably going to be in favor of PEG but he is now eating better. Observation on 4/2/18 at noon meal revealed ate about 25% of meal and staff stated breakfast meal is best meal for Resident # 137 and he didn't want to eat anymore. Assisted with set up. Observation on 04/04/18 07:52 AM revealed Resident # 137 sitting in dining room feeding self breakfast, drinking coffee on own. Observation on 04/04/18 12:14 PM revealed Resident # 137 feeding self noon meal as ordered at feeding assistance table. Actively eating gumbo and potato salad. Ate 25%. Through record review, interview and observation, revealed Resident # 137 with significant weight loss with major decrease in appetite noted after hospitalization [DATE]. Further revealed numerous measures implemented by facility with Resident # 137 refusing some of interventions, family involved, MDs involved, dietician involved, higher level testings completed. Weight loss unavoidable. Accidents

Based on observation and interview the facility failed to store and prepare to serve food in a sanitary manner by: 1.) failing to ensure all food stored in the refrigerator was dated and labeled; 2.) failing to ensure food in the storage room when opened was dated and labeled; 3.) failing to ensure the coffee cups in the main dining area were clean and free of debris. This failed practice had the potential to affect all residents who had food prepared by the facility's kitchen and who eat or drink by mouth. The facility census was 132 as documented on the facility's Resident Census and Conditions of Residents form. Findings: Review of the facility's Food Sanitation/ Infection Control policy revealed in part, food that is removed from its original container must be properly identified, and must indicate the use by and/or expiration date. All foods must be clearly marked with the name of the item and should indicate when received or use by date or expiration date. Observation during the initial kitchen tour with S4/Cook on 6/6/2016 06:45AM revealed in the refrigerator 6 plates of lettuce with plastic wrap covering the plates, a container holding 20 small plastic cups with tops identified as salad dressing by the S4/Cook, 4 slices of meat in a plastic zipped bag identified by the cook as turkey, and 2 pans of meat with a plastic cover identified as bacon strips all which were not labeled or dated. In interview on 6/6/2016 at 06:50AM, S4/Cook, agreed the foods in the refrigerator should be dated and labeled. Observation of the Storage Room located in the kitchen on 6/6/16 at 7:00AM with S4/Cook revealed a plastic package of cookies sitting on the table not in the original box identified by S4/Cook as vanilla wafers without a date or label. S4/Cook agreed the cookies should be dated and labeled. In interview on 6/6/2016 at 10:30AM, S3/Dietary Manager agreed all foods in the refrigerator and the storage room should be labeled and dated. Observation of the coffee station in the dining room next to kitchen on 06/06/16 at 08:06AM revealed 6 light colored plastic coffee cups turned upside down on a plastic tray at the coffee station. Further observation revealed one of the cups had reddish pink lipstick residue on one side of the rim of the cup, one cup had a small brown piece of debris on the outside of the cup, four of the six cups had what appeared to be debris stuck on the inside sides of the cups and the plastic tray on which the cups were placed upside down (rim side down) had 3 small pieces of brown debris on it. In interview on 06/06/16 at 08:05AM, Resident #17 stated the plastic coffee cups at the coffee station are always dirty. Observation on 06/07/16 at 11:30AM revealed 3 trays of coffee cups stacked on top of each other at the coffee station and each tray contained 12 cups. All 24 cups were inspected and 9 of the cups were found to have small unidentified particles in the cups. The particles ranged in color from light brown to black. In interview on 06/07/16 at 11:55AM, S1/Administrator stated that the coffee cups are run through the dishwashing machine and should be inspected and rewashed if debris is found. S1/Administrator observed the 9 coffee cups and agreed the 9 cups observed had small unidentified particles in the cup and was not sure if it was food particles, or debris from the dishwasher. S1/Administrator further stated all dishes should be inspected and cleaned properly prior to the resident use.

br>Based on interview and record review the facility failed to ensure the resident's responsible party was immediately notified when there was a change in physical status by failing to notify a resident's responsible party after the resident developed skin tears and a laceration. This deficient practice was identified for 1 (Resident #3) of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) sampled residents but had the potential to affect any of the 136 residents who may have a change in condition as documented on the facility's Resident Census and Conditions of Residents CMS Form-672. Findings: Review of Resident #3 ' s wound assessment report dated 08/07/15 revealed a new skin tear to left lateral shin measuring 4.0 x 4.0 x 0.10 centimeters with no documentation that Resident #3 ' s responsible party was notified. Review of Resident #3 ' s wound assessment report dated 09/29/15 new skin tear to right and left lateral shin was documented on the wound assessment report. Review of documentation revealed the measurements of the new right lateral skin tear measured 1.5 x 2.0 x 0.10 centimeters and the left lateral skin tear measured 1.0 x 1.0 x 0.10 centimeters. Review of documentation revealed Resident #3 ' s responsible party was not notified of new skin tears. Review of Resident #3 ' s wound assessment report dated 10/05/15 revealed a laceration wound to left inner shin measuring 2.0 x 8.0 x 0.10 centimeters. Review of documentation revealed Resident #3's responible party was not notified of the laceration wound to the left inner shin. In interview on 10/14/15 at 2:30pm S3/Treatment Nurse indicated when she came to work on 10/05/15 to do her monthly body audit on Resident #3; she noticed the dressing to Resident #3 ' s leg. S3/Treatment Nurse indicated the injury occurred over the weekend on 10/03/15. S3/Treatment Nurse indicated if she finds a new wound or if it ' s a pressure wound then S3/Treatment Nurse would call the responsible party, but if it ' s a skin tear or any other change in condition, the floor nurse would call the responsible party to notify of the change in condition. Review of nurse ' s notes dated August 2015 and September 2015 revealed no documentation that the responsible party was notified of Resident #3 ' s skin tears. Review of nurse ' s notes dated 10/03/15 revealed no documentation that the responsible party was notified of the new wound to Resident #3 ' s left inner shin. In interview on 10/15/15 at 12:25pm S1/Administrator indicated that the responsible party should have been notified of Resident #3 ' s skin tears and laceration. S1/Administrator confirmed that he could not find documentation that the responsible party was immediately notified of Resident #3 ' s skin tears that occurred in August and September or the new wound to Resident #3 ' s left shin area that occurred on 10/03/15. In interview on 10/15/15 at 10:20am S2/DON indicated when there is a change in a resident ' s condition or if a resident develops a skin tear, the responsible party should be notified at that time. S2/DON reviewed documentation in Resident #3 ' s record and confirmed there was no documentation that the responsible party was notified of Resident #3 ' s skin tears or new wound to left shin area prior to 10/05/15.

Based on record review and interview the facility failed to ensure the plan of care was revised for 1 (Resident #40) of 3 (Resident # 22, Resident #40, and Resident #51) Stage 2 sampled residents reviewed for Accidents in a total Stage 2 sample of 37. This deficient practice had the potential to affect any of the 134 residents residing at the facility as documented on the facility's Census and Conditions of Residents form. Findings: Review of Resident #40's Fall Risk Screening form dated 1/15/15 revealed Resident #40 had a fall in the last 6 months and was at high risk for falls. Review of Resident #40's current Care Plan revealed Resident #40 was care planned for a potential for injury related to falls. Review of Resident #40's Nurse's Notes revealed Resident #40 experienced a fall on 4/15/15. Further review of Resident #40's current Care Plan revealed no documented evidence of any revision after the fall on 4/15/15 in an attempt to prevent further falls. In an interview on 5/15/15 at 10:50am S2/ADON indicated after each resident fall, the resident's care plan should be revised with a new intervention. In an interview on 5/15/15 at 09:30am S1/DON indicated the facility's fall process was to revise each care plan with each resident fall to prevent further falls.