Every finding on record at Autumn Hills Healthcare Community

Based on record review, interview and review of the facility policy, the facility failed to ensure advance directives were consistent across the medical record. This affected one resident (#7) of five residents reviewed for advance directives. The facility census was 57.Findings include:Review of Resident #7's medical record revealed an admission date of 02/04/26 and diagnoses including syncope and collapse, altered mental status, hypertension, atrial fibrillation, generalized anxiety disorder and vascular dementia with agitation.Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #7 had moderate cognitive impairment.Review of Resident #7's physician's orders revealed an order dated 03/09/26 for an advance directive of Do Not Resuscitate Comfort Care (DNRCC).Review of a nursing progress note dated 02/05/26 at 6:29 P.M. revealed Resident #7 and his son were in agreement with a code status of Do Not Resuscitate Comfort Care Arrest (DNRCCA).Further review of Resident #7's medical record revealed one signed advance directive dated 02/03/26 for a code status of DNRCC and another signed advance directive dated 02/09/26 for a code status of DNRCCA.Review of Resident #7's plan of care dated 02/06/26 revealed he had a code status of DNRCCA.Interview on 04/13/26 at 11:49 A.M. with MDS/Registered Nurse (RN) #200 revealed the nurse doing a resident's admission was responsible for obtaining a resident's advance directive and then management followed up with this process. MDS/RN #200 verified the most current advance directive for Resident #7 was for DNRCCA dated 02/09/26 which did not match the physician's order and confirmed they should have matched.Review of the facility policy, Advance Directives, dated 09/01/21 revealed during the care planning process, the facility will identify, clarify and review with the resident or legal representative whether they desire to make any changes related to the advance directives. Any decision making will be documented in the resident's medical record and communicated to the interdisciplinary team.

Based on observation, interview, and review of the Ohio Department of Health, Department of Agriculture 2019 food code revealed the facility failed to serve food to residents in a sanitary manner to prevent infection. This had the potential to affect 52 residents who receive food from the kitchen. The facility identified two (Resident's #9 and #159) who did not receive food by mouth. The facility census was 54. Findings include: Observation on 05/16/22 at 12:08 P.M. revealed Dietary #325 plating food with no gloves on. Her nails appeared painted. She then stopped serving food and reached on top of her head grabbed her safety goggles and placed them back on her face. No hand hygiene was performed. Dietary #325 then began immediately began plating food again. Interview on 05/16/22 at 12:12 P.M. with Dietary #325 confirmed she was not wearing gloves. She also confirmed her nails were painted. Dietary #325 also confirmed she did touch the top of her head to grab her safety googles and put them on her face and did not wash her hands before serving food again. Interview on 05/16/22 at 12:15 P.M. with Dietary Manager #354 revealed she has instructed her staff not to wear gloves when serving food, just to handle the utensils. Review of Ohio Department of Health, Department of Agriculture 2019 food code - chapter 3717-1-02 reference guide for management and personnel, undated, revealed the facility dietary staff must maintain fingernails (nail polish/artificial nails permitted with intact gloves). The report also stated food employees must properly wash hands after coughing, sneezing, eating, drinking, tissue use, or touching body.

Based on observation, interview, and record review the facility failed to ensure Resident #36 received his meal at the same time as the other residents. This affected one of three residents (Resident's #28, #36 and #49) reviewed for dining. The facility census was 54. Finding include: Review of the medical record revealed Resident #36 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Significant Change Minimum Data Summary (MDS) 3.0 assessment dated [DATE] revealed Resident #36 was moderately cognitively impaired with fluctuating periods of inattention, required supervision and set-up only for eating, had a significant weight loss and an infection to his foot. Review of the care plan dated 04/18/22 revealed a care area for a nutritional problem or potential nutritional problem related to increased calorie/nutrient needs due to system inefficiency related to chronic disease (compromised cardiac function, [CONDITION(S)], type II diabetes), infection healing/repletion needs and a history of artificial weight inflation due to fluid. Interventions included a preference of dining in the south dining room in a specific chair with a tray table or in his room, weight goal of 125 to 135 pounds (lbs.), providing, serving diet as ordered and recording meal intake. Review of the weights for Resident #36 revealed the most recent weight on 05/17/22 of 109.5 lbs., with a body mass index (BMI) of 18.8 and an ideal body weight of 140 to 169 lbs. Observation of lunch on 05/18/22 revealed Resident #36 entered the dining room at 12:04 P.M. All residents, except Resident #36 were served their meal by 12:31 P.M. At 12:33 P.M. servers began placing plates of food covered in foil at the seats where residents had not arrived, including tables near where Resident #36 was sitting. At 12:41 P.M. Dietary Personnel (DP) #344 noticed Resident #36 had not received his meal and provided him a plate of food according to his diet order. Interview on 05/18/22 at 12:45 P.M. with DP #344 revealed she was not aware Resident #36 had not received a meal until she had placed the foil covered meals on tables. She was unable to provide an explanation other than sometimes Resident #36 ate in his room. A tray would be sent to the resident's unit, prior to plates being served in the dining room and returned to the dining room if he was eating in the dining room. Interview on 05/18/22 at 2:13 P.M. with Certified Dietary Manager (CDM) #257 revealed the hall carts were prepared first, as residents came into the dining room. The residents seated closest to the serving area were served first then serving progressed towards the back of the dining room. She verified Resident #36 should have been served prior to the foil covered plates being set out for residents who had not yet arrived in the dining room.

Based on interview, observation, record review, and policy review the facility failed to ensure Resident #26 had fall interventions implemented according to physician orders and/ or care plan. This affected one resident (Resident #26) of four residents (Resident's #26, #36, #37 and #45) reviewed for falls. This had the potential to affect 23 residents (Resident's #4, #12, #16, #18, #19, #24, #26, #27 #29, #31, #33, #35, #36, #37, #38, #45, #47, #49, #52, #53, #55, #158 and #159) at high risk for falls. The facility census was 54. Findings include: Review of the medical record for Resident #26 revealed an admitted [DATE] with diagnoses including [CONDITION(S)], [CONDITION(S)], acute respiratory failure with [CONDITION(S)], diabetes, and muscle weakness. Review of the care plan dated 07/30/21 revealed Resident #26 was at risk for falls related to deconditioning, gait and balance problems, limited mobility, poor decision-making, and history of falls. Interventions included anti-roll back brakes to wheelchair, assist with transfers and ambulation as ordered, Dycem (non-slip material) between wheelchair, cushion, and resident, mat on floor next to bed, and non-skid material to grab bar in bathroom. Review of the facility form labeled Fall Risk Evaluation, dated 03/23/22, and completed by Minimum Data Set (MDS)/ Registered Nurse (RN) #304 revealed Resident #26 was at high risk for falls due to Resident #26 was disoriented, history of falls, chair bound, on medication causing high risk for falls, and had diagnoses including at risk for falls. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had impaired cognition. She required extensive assist of one staff with bed mobility, transfers, and toileting. She was unable to ambulate. Review of the physician order for May 2022 revealed Resident #26 had an order dated 06/22/21 to have a mat on the floor next to her bed while she was in bed. Observation on 05/17/22 at 12:10 P.M. revealed no floor mat was observed in Resident #26's room. Resident #26 was not in her room at the time. The grab bar in Resident #26's bathroom did not have non-skid material on it. Observation on 05/18/22 at 11:02 A.M. of Resident #26 revealed she was in bed with eyes closed, and there was no mat on the floor next to her bed. Resident #26's bathroom continued to be without non-skid material to the bathroom grab bar. Interview on 05/18/22 at 11:07 A.M. with State tested Nursing Assistant (STNA) #323 revealed she was the STNA for Resident #26. STNA #323 verified Resident #26 was in her bed with no floor mat next to her bed. STNA #323 revealed she had never seen Resident #26 with a floor mat and revealed she was not aware this was one of Resident #26's fall interventions. Interview on 05/18/22 at 11:30 A.M. with Licensed Practical Nurse (LPN) #332 revealed she was the nurse for Resident #26 and verified she had assisted Resident #26 to her bed. She verified she had not placed a mat by the side of her bed as she revealed she was not aware this was one of Resident #26's fall interventions and had never seen her with a mat by her bed. LPN #332 verified Resident #26 had a physician order to have a mat to the side of her bed as well as it was a care plan intervention. Interview and observation on 05/18/22 at 4:41 P.M. with the Director of Nursing (DON) verified Resident #26 was care planned to have non-skid material on her grab bar in her bathroom. Observation on 05/18/22 at 4:41 P.M. with the DON verified Resident #26 did not have non-skid material on her grab bar in her bathroom. The DON revealed Resident #26 usually used the bathroom by the nursing station on her unit. Upon observation of the bathroom by the nursing station with the DON also revealed the grab bar did not have non-skid material on the bar. Interview on 05/18/22 at 4:43 P.M. with STNA #340 verified she had never seen non-skid material on Resident #26's bathroom grab bar or on the grab bar in the bathroom by the nursing station. STNA #340 also revealed she had not seen Resident #26 have a mat by her bed and was not aware these were Resident #26's fall interventions per her plan of care and/ or physician order. Review of undated facility policy labeled Fall/ Incident Report Policy revealed the purpose of the policy was to investigate, intervene, prevent, and review falls. The policy revealed the facility would implement an intervention to prevent further incidents. The policy revealed any interventions initiated prior, the falls committee reviewed for effectiveness and either maintained or updated.

Based on observation, interview, record review, and policy review the facility failed to maintain the indwelling urinary catheter bag in a manner to prevent urinary tract infection. This affected one (Resident #37) of one resident reviewed for an indwelling urinary catheter. The facility census was 54. Findings include: Review of the medical record for Resident #37 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders for Resident #37 dated 12/16/21 revealed to change the catheter and drainage bags based on clinical indications such as infection, obstruction, or when the closed system was compromised. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had minimal cognitive impairment. Resident #37 required extensive one-staff physical assistance for bed mobility, dressing, and personal hygiene; supervision set-up help only for eating; and extensive two-staff assistance for toilet use. Resident #37 had an indwelling catheter for urine and was occasionally incontinent of bowel. Review of the care plan for Resident #37 dated 04/18/22 revealed she had an indwelling urinary catheter related to obstructive [CONDITION(S)]. Interventions included to position the drainage bag below bladder level and do not let the bag touch the floor and to use special care during transfers and turning to maintain correct bag level and avoid pulling on the tubing. Observation on 05/16/22 at 4:10 P.M. of Resident #37 ambulating herself in her wheelchair down the hallway by the dining room with her urinary catheter drainage bag underneath her chair dragging on the ground. The bag was placed in a blue dignity bag. Observation on 05/17/22 at 10:25 A.M. revealed Resident #37 in her room sleeping in her wheelchair with her urinary catheter drainage bag under chair on the ground. Observation on 05/17/22 at 10:54 A.M. of Resident #37 revealed her ambulating herself in her wheelchair from the activities room with Therapy #371. Her urinary catheter drainage bag was underneath her chair dragging on the ground. Interview on 05/17/22 at 10:54 A.M. with Therapy #371 confirmed Resident #37's urinary catheter drainage bag was dragging on the ground, and she then readjusted her urinary catheter bag to hang off the ground. Interview on 05/19/22 at 7:35 A.M. with State tested Nursing Assistant (STNA) #306 confirmed Resident #37's urinary catheter drainage bag was often touching the ground while she was in her wheelchair due to the wheelchair being so low to the ground. Review of the facility policy titled urinary catheter care, dated 11/14/16, revealed no statement regarding catheter drainage bags being kept off the floor. Review of the facility policy titled indwelling catheter drainage bag dignity bags, undated, revealed no statement regarding catheter drainage bags being kept off the floor.

Based on observation and interview, the facility failed to prepare pureed food to ensure the proper consistency and nutrient density of a serving. This affected nine Residents (#14, #222, #3, #17, #29, #13, #33, #26 and #11) who were prescribed a pureed diet of 67 residents who consumed foods by mouth. The facility census was 68. Findings include: Observation on 09/03/19 at 10:35 [NAME]M. revealed Cook #402 prepared pureed beef teriyaki for lunch on 09/03/19. The cook put the meat, gravy and food thickener into a large food processor and started blending. Then she took out the blades and went to get a spoon for the surveyor to taste, indicating the puree process was complete. The mixture did not appear to be smooth. The mixture was not the proper texture. The concern was verified by Dietary Manager (DM) #401 who told Cook #402 to puree the mixture to the proper texture. Cook #402 poured part of the teriyaki mixture into a smaller food processor/blender and started to process. The mixture was thick, so the cook poured an unmeasured amount of water in and blended. The teriyaki mixture was now of a smooth consistency but was too thin. Cook #402 was going to put more thickener in. DM #401 stopped her. The puree was to be redone. Review of the diet list revealed Residents (#14, #222, #3, #17, #29, #13, #33, #26 and #11) received pureed diets. Interview on 09/03/19 at 10:53 [NAME]M. DM #401 verified the puree was not initially processed to the proper consistency and then was diluted which diluted the flavor and the nutrient density per serving.

Based on record review and interview, the facility failed to ensure an injury of unknown origin was thoroughly investigated as a possible incident of abuse and failed to ensure the injury was reported to the State agency as required. This affected one resident (Resident #86) of one resident reviewed for non-pressure skin areas. Self-reported incidents were reviewed for three additional residents within a facility census of 66. Findings include: Resident #86 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment, required extensive assistance for bed mobility, transfers, toileting and hygiene. The resident was frequently incontinent of bladder. The resident was admitted to the Hospice program on 03/23/16. Record review of the Progress Notes revealed on 02/18/16 at 6:12 A.M. the State tested nurse aide (STNA) alerted the nurse of a discolored bruise to the resident's right lower abdomen. The nurse noted the bruise appeared purple/gray/and blue and measured 13.0 centimeters (cm) long by 3.0 cm. wide with no pain or swelling noted. The nurse noted the resident was not sure when or how the bruise developed. The nurse noted the resident's responsible party was notified and a written note was left for the physician. Record review revealed a physician's orders [REDACTED]. Review of the Skin Tear/Minor Wound Report dated 02/18/16 at 1:00 A.M. revealed the nurse noted the 13 cm. by 3.0 cm purple/gray/blue bruise to the resident's right lower abdomen. The nurse noted the STNA was toileting the resident and had alerted the nurse of the bruise. The nurse signed the form and noted the STNA #30 was interviewed and STNA #30 did not remember the bruise being present on her previous shift. The date or time of her previous shift was not noted and no additional staff were interviewed regarding the bruise. On the right side of the form an unidentified author had noted the resident received Aspirin 81 milligrams three times a week, self-propelled throughout the facility, and they were unable to determine cause of the bruise. An order was written to monitor the bruised area until resolved. The form was signed by the physician on 02/18/16. Four staff members signed the bottom of the form, but did not date when they signed the form. On 04/01/16 at 2:27 P.M. interviewed the Director of Nursing (DON), Licensed Practical Nurse (LPN) #22, and the administrator regarding the Abuse Policy related to injuries of unknown origin. The administrator stated facility staff frequently received education regarding the abuse policies. The administrator and DON stated they did not submit a self-reported incident (SRI) to the State agency and did not conduct any further staff interviews to determine the cause of the bruise which presented as an injury of unknown origin. The DON stated they did review the Skin Tear report on 02/18/16 and they did not think the bruise was reportable, even though it was documented they were unable to determine the cause of the bruise and had not conducted any additional staff interviews. The DON and LPN #22 stated they did not feel it was abuse and that the resident moved around in her chair and leaned to the right. They stated therapy had been working on wheelchair positioning with the resident and that her positioning likely caused the bruise. There was no indication the facility had immediately determined the resident's wheelchair positioning had caused the large bruise and had not documented they had determined that was the cause. The DON stated the nurse did not notify her when the bruise was discovered. Review of the Treatment Record revealed the bruising was not resolved until 03/27/16. Review of the Abuse Policy dated 02/13/13, revealed the staff were inserviced yearly. The policy stated an injury of unknown source was defined as an injury not observed by any person or the resident and the injury is suspicious due to the extent or location of the injury.

Based on record review and interview, the facility failed to ensure the administration of a pneumococcal vaccination was in accordance with acceptable standards of practice and based on physician collaboration and order. This affected one resident (Resident #86) of five residents reviewed for immunizations. Findings include: Resident #86 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment, required extensive assistance for bed mobility, transfers, toileting and hygiene. The resident was frequently incontinent of bladder. The resident was admitted to the Hospice program on 03/23/16. Record review of the signed and dated Group Immunization Pneumonia Immune Consent Form revealed on 01/29/16 the resident's responsible party refused the pneumococcal vaccine and noted the vaccine had previously been administered approximately in 2003. Review of the Medication Record revealed the resident received the [MEDICATION NAME] vaccine on 02/02/16. Review of the physician's orders [REDACTED]. Review of a second Group Immunization Pneumonia Immune Consent Form, revised 2016, noted the resident had received the [MEDICATION NAME] vaccine on 02/02/16. The form was not signed by the responsible party. The Director of Nursing (DON) signed the form and noted the resident was not eligible for Prevnar 13 at this time and will reapproach after 02/02/17. Interview with the director of nursing (DON) on 04/01/16 at 9:35 A.M. verified the nurse had administered the incorrect pneumonia vaccine and the resident had received an unnecessary Pneumovac vaccine. The DON stated she was not aware of the error until the surveyor brought it to her attention at the time of the interview. She stated the nurse had not read or transcribed the physician's orders [REDACTED]. The DON stated the facility had recently updated the pneumonia consent form to reflect the new policy related to administration of the [MEDICATION NAME] 23 and Prevnar-13 vaccinations. The physician's orders [REDACTED].

Based on record review and interview, the facility failed to ensure comprehensive assessments and ongoing monitoring was completed for Resident #86 related to an abdominal bruise to determine wound healing. This affected one resident (Resident #86) of one resident reviewed for non pressure skin wounds and one resident (Resident #86) of ten residents reviewed for assessments. Findings include: Resident #86 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment, required extensive assistance for bed mobility, transfers, toileting and hygiene. The resident was frequently incontinent of bladder. The resident was admitted to the Hospice program on 03/23/16. Record review of the progress notes revealed on 02/18/16 at 6:12 A.M. the State tested nursing assistant (STNA) #30 alerted the nurse of a discolored bruise to the resident's right lower abdomen. The nurse noted that during toileting the STNA alerted the nurse of a discolored bruise to the resident's right lower abdomen. The nurse noted the bruise appeared purple/gray/and blue and measured 13.0 centimeters (cm) long by 3.0 cm. wide with no pain or swelling noted. The nurse noted the the resident was not sure when or how the bruise developed. The nurse noted the resident's responsible party was notified and a written note was left for the physician. Record review revealed a physician's orders [REDACTED]. Review of the February and March, 2016 Treatment Record revealed the nurse was to monitor the lower abdominal bruising daily until resolved. Review of the Treatment Record revealed the nurses initialed the treatment was completed daily until 03/27/16, but other than the initial assessment of the bruise on 02/18/16, there was no evidence of any further description of the bruise, including measurements, changes in color or temperature. On 04/01/16 at 2:27 P.M. interviewed the Director of Nursing (DON). She verified there was no additional documentation after 02/18/16 through 03/27/16 that included a description of the abdominal bruise, including measurements, and no evidence the nurse had assessed the bruise to determine if the bruise was healing.

Based on record review and interview, the facility failed to implement the written abuse policy related to reporting and investigating an injury of unknown origin for Resident #86. This affected one resident (Resident #86) of one resident reviewed for non-pressure skin areas. Self-reported incidents were reviewed for three additional residents within a facility census of 66. Findings include: Resident #86 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severe cognitive impairment, required extensive assistance for bed mobility, transfers, toileting and hygiene. The resident was frequently incontinent of bladder. The resident was admitted to the Hospice program on 03/23/16. Record review of the Progress Notes revealed on 02/18/16 at 6:12 A.M. the State tested nurse aide (STNA) alerted the nurse of a discolored bruise to the resident's right lower abdomen. The nurse noted the bruise appeared purple/gray/and blue and measured 13.0 centimeters (cm) long by 3.0 cm. wide with no pain or swelling noted. The nurse noted the resident was not sure when or how the bruise developed. The nurse noted the resident's responsible party was notified and a written note was left for the physician. Record review revealed a physician's orders [REDACTED]. Review of the Skin Tear/Minor Wound Report dated 02/18/16 at 1:00 A.M. revealed the nurse noted the 13 cm. by 3.0 cm purple/gray/blue bruise to the resident's right lower abdomen. The nurse noted the STNA was toileting the resident and had alerted the nurse of the bruise. The nurse signed the form and noted the STNA #30 was interviewed and STNA #30 did not remember the bruise being present on her previous shift. The date or time of her previous shift was not noted and no additional staff were interviewed regarding the bruise. On the right side of the form an unidentified author had noted the resident received Aspirin 81 milligrams three times a week, self-propelled throughout the facilty, and they were unable to determine cause of the bruise. An order was written to monitor the bruised area until resolved. The form was signed by the physician on 02/18/16. Four staff members signed the bottom of the form, but did not date when they signed the form. On 04/01/16 at 2:27 P.M. interviewed the Director of Nursing (DON), Licensed Practical Nurse (LPN) #22, and the administrator regarding the Abuse Policy related to injuries of unknown origin. The administrator stated facility staff frequently received education regarding the abuse policies. The administrator and DON stated they did not submit a self-reported incident (SRI) to the State agency and did not conduct any further staff interviews to determine the cause of the bruise which presented as an injury of unknown origin. The DON stated they did review the Skin Tear report on 02/18/16 and they did not think the bruise was reportable, even though it was documented they were unable to determine the cause of the bruise and had not conducted any additional staff interviews. The DON and LPN #22 stated they did not feel it was abuse and that the resident moved around in her chair and leaned to the right. They stated therapy had been working on wheelchair positioning with the resident and that her positioning likely caused the bruise. There was no indication the facility had immediately determined the resident's wheelchair positioning had caused the large bruise and had not documented they had determined that was the cause. The DON stated the nurse did not notify her when the bruise was discovered. Review of the Treatment Record revealed the bruising was not resolved until 03/27/16. Review of the Abuse Policy dated 02/13/13, revealed the staff were inserviced yearly. The policy stated an injury of unknown source was defined as an injury not observed by any person or the resident and the injury is suspicious due to the extent or location of the injury.

Based on record review, interview and policy review the facility failed to ensure Resident #10's preference for full code status was documented in a consistent and accurate manner in the medical record. This affected one resident (Resident #10) of three residents whose records were reviewed for advanced directives. Findings include: Resident #10 was admitted to the facility 05/29/15 with [DIAGNOSES REDACTED]. Review of Resident #10's medical record revealed a Do Not Resuscitate Identification form. The resident's full name was printed on the form and two boxes were checked. One was labeled DNRCC-Arrest- which stated if this box is checked the DNR (do not resuscitate) Comfort Care Protocol was implemented in the event of a cardiac or respiratory arrest (cessation of heart beat or respirations.) The other box that was checked was labeled Do-Not-Resuscitate-Order and included the statement, My signature below constitutes and confirms a formal order to emergency medical services and other health care personnel that the person identified above is to be treated under the State of Ohio DNR Protocol. I affirm that this order is not contrary to reasonable medical standards or, to the best of my knowledge, contrary to the wishes of the person who is lawfully authorized to make informed medical decisions on the person's behalf. I also affirm that I have documented the grounds for this order in the person's medical record. the form was signed by the facility medical director and dated 06/01/15. On 04/01/16 at 12:00 P.M., interview with Licensed Practical Nurses (LPNs) #20 and #21 revealed they both were familiar with Resident #10. When asked if they knew what to do if the resident experienced a cardiac or respiratory arrest, both said the resident had an order that stated do not resuscitate (DNR.) They both indicated the Do Not Resuscitate (DNR) Identification form, located in the front of the resident's record that was referenced in the previous paragraph. Further review of the resident's record with LPN's #20 and #21, revealed the Interdisciplinary Team (IDT) Meeting notes indicated on three separate dates on 08/20/15, 11/05/15 and 01/14/16 the resident's code status was indicated as full code, meaning every effort was to be made to resuscitate the resident in the event of either a cardiac or respiratory arrest. In addition, the resident's current physician's orders also indicated the resident's status was a full code. Again, both nurses verified they were under the impression that Resident #10 was not to be resuscitated and in the event that he had a cardiac or respiratory arrest they would have verified it with the DNR form and would not have resuscitated the resident. On 04/01/16 at 12:15 P.M., interview with Social Worker (SW) #10 revealed she was familiar with Resident #10 and referred to his daughter, who was his responsible party, by name and indicated the daughter was very involved in care decisions. When asked if she knew what Resident #10's code status was, SW #10 indicated the resident was a full code, which meant every effort would be made to resuscitate him in the event of cardiac or respiratory arrest. SW #10 explained she had discussed that with the resident's daughter and wife and they both agreed they wanted him to be resuscitated. SW#10 continued to explain that Resident #10's code status was reviewed and recorded at each IDT meeting and in her notes as well. Review of the resident's medical record with SW #10 reveled the physician's orders, IDT meeting notes and social worker progress notes did indeed indicate the resident was to be a full code. However, the DNR Identification Form with the resident's full name on it, that was signed by the medical director and dated 06/01/15, had the box checked next to the initials DNRCC-Arrest and indicated a signed Do Not Resuscitate Order. SW #10 was certain the DNR information form was not correct. On 04/01/16 at 2#00 P.M., follow up interview with SW #10 revealed she had immediately contacted Resident #10's daughter and wife and verified with them that they definitely wanted Resident #10 to be a full code. SW#10 also provided Resident #10's initial history and physical documentation that was completed by the medical director on 06/01/15. The form indicated DNRCC with a line through it and full code written next to it. SW #10 explained it was most likely that the medical director initially thought the resident was not to be resuscitated and changed it on the physical exam form, but somehow the DNR form had been erroneously placed in the resident's record. SW #10 the verified the DNR form that had been found in Resident #10's record should not have been there, nursing staff used that form a resource and may have possibly not initiated cardiac or respiratory resuscitation in the event of an arrest Review of the facility policy and procedure relative to advance care planning revealed advanced directives would be discussed with residents and their responsible party upon admission and reviewed periodically thereafter. The resident's choice to be a full code or to not be resuscitated would be documented in the medical record.

br>Based on observation, interview and record review, the facility failed to ensure privacy during a dressing change. This affected one (Resident #55) of one resident observed during a dressing change. The facility census was 78. Findings include: Observation of a dressing change on 09/15/15 at 2:31 P.M. revealed registered nurse (RN) #6 wheeled Resident #55 to her room. Resident #55 remained in her wheelchair. RN #6 positioned the resident's wheelchair in the middle of the room. The resident's roommate was lying in bed napping. RN #6 did not pull the privacy curtain between the residents. RN #6 lifted Resident #55's shirt, exposing the resident's abdomen to her bra line. A feeding tube was observed entering the resident's abdomen. A dressing was observed around the feeding tube. RN #6 removed the soiled dressing, cleansed the area around the tube and applied a clean dressing. An interview was completed with RN #6 following the observation. RN #6 verified she did not provide privacy for Resident #55 during care because I know they're close roommates. Review of the undated facility policy for a Dressing Change revealed the first two of 21 steps as follows: #1. Inform the resident of the dressing change and explain the procedure. #2. Ensure privacy

Based on observation, interview and record review, the facility failed to ensure Resident #53 was assessed and treated timely for a change in condition with continued pain to the right hip. Actual Harm occurred when the resident had continued pain despite receiving "as needed" pain medication and there was no evidence of medical follow-up for the continued and increased pain in the right hip from 12/29/14 thru 12/31/14. This affected one of one resident reviewed for pain. Findings include: Review of the medical record revealed Resident #53 had several admissions to the facility. The most recent admission was on 09/26/14. Review of the current Activities of Daily Living care plan revealed the resident needed extensive assistance of two persons for transfers and toileting with the use of a wheeled walker. Review of the November 2014 Pain Flow Sheet revealed no evidence of right hip pain. Review of the fall investigation report dated 12/29/14, revealed the resident sustained [REDACTED].M., and complained of right hip pain. Review of the December 2014 Medication Administration Record [REDACTED].M., the resident was given as needed [MEDICATION NAME], a pain medication, 25 milligrams (mg). Review of the December 2014 Pain Flow Sheet revealed the resident complained of right hip pain on 12/30/14 at 7:00 A.M., with an intensity score of 10 out of 10, and then on 12/30/14 at 1:15 P.M., with a score of eight out of 10, and on 12/30/14 at 9:30 P.M., with a score of seven out of 10. The resident was medicated with [MEDICATION NAME] each time. Review of the nursing note dated 12/30/14 at 4:30 P.M., revealed Resident #53 would not get out of bed for dinner because he was in too much pain. The nurse documented she observed the resident's right leg externally rotated but did not notify the doctor, do any further assessments or pass along in report to the next shift nurse. On 12/30/14 at 9:21 A.M., interview with Resident #53 revealed he was currenty in extreme pain in the right hip. The resident stated he had fallen yesterday after pushing the call button for assistance and could not wait any longer so he attempted to self transfer because he did not want to have an incontinence accident. On 12/31/14 at 11:50 A.M., interview with Registered Nurse (RN) #100 verified Resident #53 sustained a fall on 12/29/14 at 7:15 P.M. The resident complained of pain in the right hip after the fall. X-rays were inconclusive and the resident continued to complain of pain. RN #100 verified the nursing note dated 12/30/14 at 4:30 P.M., indicated the resident would not get out of bed for dinner because he was in too much pain, that the resident's right leg was externally rotated but the nurse did not notify the doctor, do any further assessments or pass along in report to the next shift nurse. The facility was not made aware of this until 12/31/14 during the stand up meeting around 9:00 A.M. RN #100 could not remember who informed her of the above. RN #100 verified the resident did not have right hip pain prior to the 12/29/14 fall. RN #100 verified the clinical nurse practitioner was called on 12/31/14, and came to the facility for his routine visits about 9:30 A.M., but RN #100 was not sure if the resident had been seen and verified there had not been any orders written as of yet. RN #100 verified there was no evidence the physician was made aware of the continued pain to see if a stronger pain medication may be helpful for the resident. On 12/31/14 at 1:30 P.M., interview with Resident #53 verified he fell on [DATE] in the evening trying to toilet himself because he pushed his call button for assistance and could not wait any longer on the staff to help him before he had an incontinence accident. The resident stated he was in bed and made it all the way to the doorway of the bathroom before he fell and began to have pain to the right hip. The resident verified he had been in constant pain since the 12/29/14 fall but at times was tired of always having to ask for medications and the nursing saying he had to wait. "Just because I did not always ask did not mean I was not in pain." The resident verified he was in pain and could not move his right leg. On 12/31/14 at 1:45 P.M., interview with State tested Nurse Aide(STNA) #101 verified she and STNA #102 transferred the resident out of bed and into the wheelchair that morning about 7:30 A.M. STNA #101 verified prior to the last couple days the resident was easy to pivot transfer with two people and the use of the wheeled walker. STNA #101 stated that morning the resident could not bear any weight on his left leg and they had to push the bed out from against the wall, stand the resident and have him hold on to the walker, push the bed back against the wall and move the wheelchair behind the resident because he could not pivot or place his left leg on the floor. STNA #101 verified the resident had been complaining of being in a lot of pain the last couple of days and she told the nurse on duty. STNA #101 verified after they transferred the resident this morning she went and told RN #100 before 8:00 A.M. On 12/31/14 at 1:50 P.M., interview with Licensed Practical Nurse (LPN) #103 verified the resident was going to the hospital that afternoon for an evaluation. LPN #103 verified she gave him [MEDICATION NAME] for pain about 9:30 A.M., but had not seen if he was still in pain. On 12/31/14 at 1:55 P.M., interview with RN #100 verified orders had been written that day to send the resident to the emergency room for evaluation. RN #100 verified there was no time on the orders and verified the resident was still in the facility.

Based on observation, interview and record review, the facility failed to notify the physician and oncoming nurse of Resident #53's continued pain to the right hip and change in ability to transfer. This affected one of one resident reviewed for pain. Findings include: Review of the medical record revealed Resident #53 had several admissions to the facility. The most recent admission was on 09/26/14. Review of the current Activities of Daily Living care plan revealed the resident needed extensive assistance of two persons for transfers and toileting with the use of a wheeled walker. Review of the November 2014 Pain Flow Sheet revealed no evidence of right hip pain. Review of the fall investigation report dated 12/29/14 revealed the resident sustained [REDACTED].M. and complained of right hip pain. Review of the December 2014 Medication Administration Record [REDACTED].M., the resident was given as needed [MEDICATION NAME], a pain medication, 25 milligrams (mg). Review of the December 2014 Pain Flow Sheet revealed the resident complained of right hip pain on 12/30/14 at 7:00 A.M. with an intensity score of 10 out of 10, and then on 12/30/14 at 1:15 P.M. with a score of eight out of 10 and on 12/30/14 at 9:30 P.M. with a score of seven out of 10. The resident was medicated with [MEDICATION NAME] each time. Review of the nursing note dated 12/30/14 at 4:30 P.M., revealed Resident #53 would not get out of bed for dinner because he was in too much pain. The nurse documented she observed the resident's right leg externally rotated but did not notify the doctor, do any further assessments or pass along in report to the next shift nurse. On 12/30/14 at 9:21 A.M., interview with Resident #53 revealed he was currenty in extreme pain in the right hip. The resident stated he had fallen yesterday after pushing the call button for assistance and could not wait any longer so he attempted to self transfer because he did not want to have an incontinence accident. On 12/31/14 at 11:50 A.M., interview with Registered Nurse (RN) #100 verified Resident #53 sustained a fall on 12/29/14 at 7:15 P.M. The resident complained of pain in the right hip after the fall. X-rays were inconclusive and the resident continued to complain of pain. RN #100 verified the nursing note dated 12/30/14 at 4:30 P.M., indicated the resident would not get out of bed for dinner because he was in too much pain, that the resident's right leg was externally rotated but the nurse did not notify the doctor, do any further assessments or pass along in report to the next shift nurse. The facility was not made aware of this until 12/31/14 during the stand up meeting around 9:00 A.M. RN #100 could not remember who informed her of the above. RN #100 verified there was no evidence the physician was made aware of the continued pain to see if a stronger pain medication may be helpful for the resident. On 12/31/14 at 1:45 P.M., interview with State tested Nurse Aide(STNA) #101 verified she and STNA #102 transferred the resident out of bed and into the wheelchair that morning about 7:30 A.M. STNA #101 verified prior to the last couple days the resident was easy to pivot transfer with two people and the use of the wheeled walker. STNA #101 stated that morning the resident could not bear any weight on his left leg and they had to push the bed out from against the wall, stand the resident and have him hold on to the walker, push the bed back against the wall and move the wheelchair behind the resident because he could not pivot or place his left leg on the floor. STNA #101 verified the resident had been complaining of being in a lot of pain the last couple of days and she told the nurse on duty. STNA #101 verified after they transferred the resident this morning she went and told RN #100 before 8:00 A.M.

Based on observation, record review and interview, the facility failed to ensure fall interventions were appropriate and/or in place and comprehensive assessments were completed to ensure the resident's safety was maintained. This affected one (Resident #53) of three residents reviewed for falls. Findings include: Review of the medical record revealed Resident #53 had prior admissions to the facility with the most recent admission on 09/26/14. [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was cognitively intact and required total dependence on two or more persons for transfers and extensive assistance of two or more persons for bed mobility. The resident had a history of [REDACTED]. Review of the Fall care plan initiated 10/03/14 revealed the interventions included anticipate and meet the resident's needs, anti skid material to the wheelchair seat to assist in preventing resident from sliding out, ensure call light was within reach, the resident needs prompt response to all requests for assistance, scheduled toileting plan, and transfer with assist of two persons and the wheeled walker. Review of the State tested Nurse Aide (STNA) Kardex report, which stated the individualized needs of each resident, indicated Resident #53 was to have bilateral half side rails up for safety while in bed, resident needed extensive assistance of two persons for transfers and toileting and anti skid material to the seat of the wheelchair. There was no mention of a toileting plan for the resident. 1. Review of the nursing notes dated 12/06/14 at 6:45 P.M., revealed an STNA observed Resident #53 lying on the floor in the room on the right side. The fall had not been witnessed. The resident had no apparent injury. The resident stated, "I slid out of my wheelchair trying to get back into bed." Review of the post fall assessment, not dated, revealed on 12/06/14 the STNA walked past the room and observed Resident #53 lying on his right side in front of his wheelchair. The resident stated he slid out of the wheelchair trying to get back in bed. The new interventions included educated resident again to wait for assistance and will assess for anti roll back device to the wheelchair so it did not move backwards if resident attempted to stand on his own. Review of the nursing note dated 12/07/14 revealed the fall committee met and interview with staff revealed anti-skid material and call light were in place. There were no staff statements available to review. They would assess for an anti-roll back device for the wheelchair to prevent it from rolling back if the resident attempted to stand or transfer on his own. Review of the Confidential Report of Incident form (not a part of the medical record) dated 12/06/14 indicated the call light was within reach but not if it was sounding or not, and that the resident was incontinent but not the last time the resident was toileted. There was no evidence the anti-skid material was in place at the time of the fall. On 12/31/14 at 11:50 A.M., interview with Registered Nurse (RN) #100) verified Resident #53 was at high risk for falls. RN #100 verified there was no documented evidence the interventions were in place at the time of the 12/06/14 fall. RN #100 verified the investigation was not comprehensive and verified if a fall was unwitnessed no statements were obtained from staff. RN #100 verified she was not able to provide documentation of where the resident was in the room at the time of the fall. 2. Review of the nursing notes dated 12/25/14 at 10:30 A.M., revealed Resident #53 was found on the floor at 8:15 A.M., sitting upright, naked and wearing non-skid slippers. The resident had been incontinent of bowel. The call light was activated. Review of the nursing notes dated 12/27/14 revealed the fall committee met and the intervention was to check for an urinary tract infection (UTI) and talk to the resident about not self transferring. The resident did have an UTI and was started on an antibiotic. Review of the post fall assessment (not dated) revealed there was no documented evidence of where the resident was prior to the fall, either the bed or the wheelchair. There was no documented evidence any interventions were in place. On 12/31/14 at 11:50 A.M., interview with RN #100 verified she was not able to state if the resident fell from the bed or the wheelchair. RN #100 verified that effective new interventions could not be put in place if the facility could not determine where the resident fell from. RN #100 verified there were no statements from staff to verify where the resident was prior to the fall. RN #100 verified the resident was alert and oriented but not questioned to attempt to determine how to best keep the resident safe from falls. RN #100 did not know the last time the resident was toileted prior to the fall. 3. Review of Resident #53's nursing notes dated 12/29/14 revealed there was no documented evidence the resident fell on [DATE]. Review of an x-ray report dated 12/29/14 revealed a portable x-ray of the right hip was obtained which revealed no acute fracture or dislocation seen but the pelvic bones were not adequately visualized. Review of the physician orders [REDACTED]. Review of the Confidential Report of Incident dated 12/29/14 revealed the resident was incontinent when found on the floor. Review of the nursing note dated 12/30/14 at 4:05 P.M., revealed the fall committee met and Resident #53 had urinary urgency. A new physicians order was obtained on 12/30/14 for Pyridium 200 milligrams three times a day for three days, to treat the urinary urgency. Review of the nursing notes dated 12/30/14 at 4:30 P.M., revealed the resident declined getting out of bed for dinner because he had too much pain in the right hip. The right leg was noted to be externally rotated. The resident was guarded with the right hip. Review of the nursing notes from 12/29/14 through 12/31/14 revealed there was no other documentation related to the fall and no further documentation of physician notification or assessments of the right leg. On 12/30/14 at 9:21 A.M., interview with Resident #53 revealed he had fallen after pushing the call button for assistance and could not wait any longer so he attempted to self transfer yesterday (12/29/14) because he did not want to have an incontinence accident. On 12/31/14 at 11:50 A.M., interview with RN #100 verified there was no documented evidence in the medical record of Resident #53's fall on 12/29/14. RN #100 verified there was no documented evidence of where the resident was prior to the fall or if any of the fall interventions were in place. RN #100 verified the resident was incontinent but investigation did not determine the last time the resident was toileted or if the call light was activated. RN #100 verified the 12/30/14 nursing note at 4:30 P.M., stated there was external rotation of the right leg and verified there was no evidence the physician was notified and verified the facility was not aware of this until stand up meeting until 12/31/14 about 9:00 A.M. On 12/31/14 at 12:20 P.M., interview with LPN #103, with RN #100 present, verified the Pyridium medication that was ordered as an intervention for Resident #53 on 12/29/14 had not been given to the resident because it had not been sent from the pharmacy. RN #100 verified the pharmacy was in the facility on 12/31/14 but did not send the medication. LPN #103 stated she just called the pharmacy because the medication had not been delivered and the order was faxed on 12/29/14. LPN #103 verified there was no time written on the physician's telephone order. RN #100 verified when an order was faxed the medications were delivered by that evening or the next morning at the latest. RN #100 verified the evening delivery was between 9:00 P.M. and 11:00 P.M. On 12/31/14 at 1:25 P.M., observation of Resident #53's wheelchair with RN #100 verified there were no anti-roll back devices on the wheelchair. On 12/31/14 at 1:30 P.M., interview with Resident #53 verified he could remember each fall in December 2014. He stated the first one he fell out of bed trying to go to the bathroom. He used the call button but staff did not come in time so he tried to toilet himself. The second fall was from out of the wheelchair trying to go to the bathroom and the third fall was from out of bed because he was trying to use the toilet. He said the facility had their own agenda and had to take care of other people and he had to wait. Sometimes he couldn't wait that long and didn't want to have an incontinence accident. He knew he should not transfer himself but it was degrading when he was incontinent. The resident verified he was able to tell when he had to use the toilet. The resident verified he did not have any trouble with transfers with the assistance of two staff prior to the 12/29/14 fall. The resident verified since the fall he could not bear weight on the right leg but staff continued to pivot transfer him and it hurt. He told them but they still pivot transferred him. On 12/31/14 at 1:45 P.M., interview with STNA #101 verified she and STNA #102 transferred the resident out of bed this morning about 7:30 A.M. STNA #101 verified Resident #53 had not had difficulty with pivot transfers until the last couple of days when the resident would not bear weight and was not able to move his leg. STNA #101 verified she informed RN #100 that morning after she transferred the resident out of bed. The resident was in a lot of pain before, during and after the transfer. STNA #101 verified she usually used the wheeled walker and the resident was able to assist with pivot transfer in and out of bed, but this morning he could not bear weight so they sat him on the edge of the bed, pushed the bed out from away from the wall and towards the wheelchair. She placed the walker in front of him, stood him, moved the bed back against the wall and positioned the wheelchair behind him so he did not have to pivot transfer. On 12/31/14 at 1:50 P.M., interview with LPN #103 verified Resident #53 was going to the hospital for evaluation that afternoon. On 12/31/14 at 2:25 P.M., interview with LPN #105 verified there was no documented evidence the resident was assessed to determine when it was best to toilet him, nor was the resident interviewed to attempt to maintain his normal bladder and bowel pattern despite this being a fall intervention.

Based on record review and interview, the facility failed to ensure the medical record had documentation of Resident #53's fall on 12/29/14. This affected one of three residents reviewed for falls. Findings include: Review of Resident #53's nursing notes dated 12/29/14 revealed there was no documented evidence the resident sustained [REDACTED]. Review of Resident #53's physician orders [REDACTED]. Review of the nursing note dated 12/30/14 at 4:05 P.M., revealed the fall committee met and the resident had urinary urgency. A new physicians order was received on 12/30/14 for [MEDICATION NAME] 200 milligrams three times a day for three days, to treat the increased urge to urinate. Review of the nursing notes dated 12/30/14 at 4:30 P.M., revealed Resident #53 declined getting out of bed for dinner because he had too much pain in the right hip. The right leg was noted to be externally rotated. The resident was guarded with the right hip. Review of the nursing notes from 12/29/14 through 12/31/14 revealed there was no documentation related to the fall and no further documentation of physician notification or assessments of the externally rotated right leg. On 12/31/14 at 11:50 A.M.,interview with Registered Nurse #100 verified there was no documented evidence in the medical record of Resident #53's fall on 12/29/14.

Based on record review, policy review and interview, the facility failed to ensure Residents #53 and #100 were provided a toileting program to ensure the highest practical level of bladder control as possible. This affected two of four residents reviewed for incontinence. Findings include: Review of the facility Bowel and Bladder Function Assessment Policy and Procedure, not dated, revealed the nurse was to initiate the assessment using the bowel and bladder function assessment tool on admission or on change of condition and complete the assessment by the next resident care plan conference. Reassessments were to be done annually. 1. Review of the medical record revealed Resident #53 had prior admissions to the facility with the most recent admission on 09/26/14. [DIAGNOSES REDACTED]. Review of the physicians orders and treatment administration record (TAR) revealed as of 09/27/14, the resident was on a scheduled toileting program upon rising, before and after meals, at bedtime and upon request. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident required extensive assistance of two or more persons for toileting with a mechanical lift, and was frequently incontinent of urine. Review of the MDS 3.0 assessment dated [DATE] revealed the resident required extensive assistance of two or more persons for toileting with pivot transfer, and was frequently incontinent of urine. Review of the current plan of care revealed Resident #53 wore briefs in and out of bed to aid in social continence and was on a scheduled toileting program upon rising, before and after meals, at bedtime and upon request. Staff were to use a mechanical lift for toilet transfers. Review of the Kardex, the sheet used by the state tested nurse aides (STNAs) that listed each resident's individual plan of care for toileting, revealed Resident #53 required extensive assistance for transfers, clothing manager, hygiene and incontinent product changing. The Kardex contained no documentation as to when or how often to toilet the resident. Review of the bowel and bladder pattern for December 2014, with STNA #101 on 12/31/14 at 1:45 P.M., verified the sheet was completed at the end of the shift and it would be hard to be accurate to recall each resident's continency for the shift. STNA #101 verified Resident #53 was not on a toileting program but she tried to toilet all residents every two hours. Review of the bladder documentation dated 12/23/14 revealed the resident was frequently incontinent but aware of need to urinate. On 12/31/14 at 1:30 P.M., interview with Resident #53 stated he needed assistance to be taking to the toilet. The resident stated he knew to push his call button for assistance but sometimes the staff did not come quick enough and he could not wait any longer. "I know I should not transfer myself but it is degrading when I am incontinent." The resident verified he felt the urge when he had to use the toilet and was able to to hold his bladder but not for long periods of time. On 12/31/14 at 2:25 P.M., interview with Licensed Practical Nurse (LPN) #105 verified the facility had three types of toileting plans for residents - scheduled toileting, prompted toileting and check and change. LPN #105 decided which type of program was appropriate for each resident based on staff interviews and the documentation from the STNA's on the bowel and bladder pattern sheet. LPN #105 verified the STNA's completed the paper work at the end of their shift for each resident. LPN #105 verified it would be difficult to remember each resident's continence throughout the day at the end of the shift. On 12/31/14 at 3:00 P.M., interview with LPN #105 verified Resident #53 was on a scheduled toileting program but it was not individualized to determine the best times to assist the resident to ensure he remained as continent as possible. LPN #105 verified the facility had not determined the type of incontinence the resident had or attempted interventions to ensure he remained as continent as possible. 2. Review of the medical record revealed Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS 3.0 assessment dated [DATE] revealed the resident required limited assistance of one person for transfers and toileting, was not on a toileting program and was always continent. Review of the MDS 3.0 assessment dated [DATE] revealed the resident required limited assistance of one person for transfers and toileting and was occasionally incontinent of bladder. Review of the bowel and bladder continence data collection tool dated 10/28/14 revealed Resident #100 was a low restorative potential with occasional incontinence. The resident was aware of the need to urinate. A prompted toileting program for bladder every two hours while aware for safety issues as resident was a fall risk as well as managing occasion incontinence. Review of the current continence plan of care dated 07/30/14 and updated 10/29/14 revealed the resident was on a prompted toileting program every two hours while awake and wore pull ups in and out of bed. Review of the Kardex revealed Resident #100 required limited assistant for transfers. It contained no documentation as to when or how often to toilet the resident. On 12/30/14 at 3:00 P.M., interview with Resident #100 revealed she was able to feel the urge when she had to urinate. The resident stated she could hold it but only for so long. The resident stated she gave the staff a warning by activating the call button but they had to come quick so she did not have an accident. The resident stated she could make it usually but not always because staff did not come in time. The resident stated she was not allowed to toilet herself because she had a fall from trying to toilet herself. On 12/30/14 at 4:30 PM, interview with LPN # 106 verified she toileted Resident #100 that day and she was continent. LPN #106 verified the resident was occasionally incontinent if staff could not get to her in time. The resident had the urge and was able to tell staff when she needed to be toileted. On 12/30/14 at 4:35 P.M., interview with STNA #107 verified Resident #100 was always continent for her but was incontinent at times if staff were not able to get to her fast enough. The resident was able to let them know when she needed to be toileted. Review of the bowel and bladder pattern form with STNA #107 verified the form was completed for each resident at the end of the shift. STNA #107 verified it was difficult to remember what each resident did throughout the day when it was not documented until the end of the shift. STNA #107 verified the resident was not on a toileting program but she tried to toilet the resident every two to three hours. On 12/31/14 at 2:25 P.M., interview with LPN #105 verified she was not able to provide any clinical reason why Resident #100 went from totally continent to occasionally incontinent of bladder. LPN #105 verified the resident would attempt to toilet herself when she felt the urge but then she had a fall and she knew she had to wait on staff for toileting. LPN #105 verified the resident could have been occasionally incontinent because staff could not get to her in time. LPN #105 verified the facility did not attempt to determine the type of incontinence the resident had or attempt interventions to ensure she remained as continent as possible. This deficiency substantiates Complaint Number OH 172.

Based on observation, interview and record review, the facility failed to ensure Resident #24 did not receive an increase in psychoactive medications without a need for them. This affected one of five residents reviewed for unnecessary medications. Findings include: Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognitive ability, and identified no documented concerns with mood or behaviors. Review of the current plan of care revealed the resident had impaired cognitive function and thought processes due to dementia and history of agitation with behavioral disturbances. The interventions included do not give the resident a time frame for anything because that agitated the resident, review medications and document changes in cognitive function. The care plan for agitation with dementia and anxiety disorder, included the interventions of monitor and record mood to determine if problems were related to external causes such as medications, treatments and concerns. The care plan for [MEDICAL CONDITION] medications for dementia with behavioral disturbances, anxiety and depression, included interventions of administer medications as ordered, consult pharmacy and physician to consider dosage reduction when clinically appropriate, monitor and record occurrence of the target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, and repeat voicing about times and schedules, and monitor and record side effects and adverse reactions to psychoactive medications. Review of the December 2014 monthly physicians orders revealed the following medications were ordered: a. [MEDICATION NAME], an antipyschotic medication, 25 milligrams (mg) three times a day initiated on 10/19/13 for dementia. [DIAGNOSES REDACTED]. b. [MEDICATION NAME], an antidepressant, was increased to 15 mg on 06/26/13 and increased to 20 mg daily on 04/02/14 for depression. c. [MEDICATION NAME], an anti anxiety medication, was continued at 0.5mg twice a day on 06/26/13 for anxiety. d. [MEDICATION NAME], an anti anxiety medication, was ordered at 0.5 mg as needed prior to January 2014 and was increased to 1.0 mg every 12 hours as needed on 05/05/14. Review of the psychiatrist note dated 06/26/13 revealed increased [MEDICATION NAME] to 15 mg. The resident had a history of [REDACTED]. Review of the psychiatrist note dated 10/09/13 revealed increased [MEDICATION NAME] to 25 mg three times a day for [MEDICAL CONDITION]. Resident on multiple [MEDICAL CONDITION] medications. Resident continued to be anxious but cooperative and paranoid. No aggressive behaviors observed. Review of the psychiatrist note dated 11/13/13 revealed resident continued to exhibit symptoms of delusions and anxiety from the delusional thoughts. No aggressive behaviors observed. Review of the social service note dated 01/24/14 revealed the resident still gets upset with baths but staff offers much encouragement to make it a pleasant experience. Review of the Behavior Intervention Monthly Flow Record for January 2014 revealed the resident's behaviors were an increase in asking questions and increase in anxiety. The increase in questions occurred five days in the month. The as needed [MEDICATION NAME] was given two days of the month for anxiety. Review of the psychiatrist note dated 02/05/14 revealed the resident was a little more anxious, was on a lot of psychiatric medication, and discussed behavioral intervention probably the best option for this resident. The reason for not reducing medications was resident at high risk of deterioration. Review of the Behavior Intervention Monthly Flow Record for February 2014 revealed the increase in asking questions occurred four times during the month. Medications for an increase in anxiety were given five times in the month. Review of the Behavior Intervention Monthly Flow Record for March 2014 revealed as needed [MEDICATION NAME] was given five of the seven times the resident was noted to have an increase in anxiety. Review of the psychiatric note dated 04/02/14 revealed resident was actually doing considerably well with intermittent agitation. Resident continued to be irritable and [MEDICATION NAME] was increased to 20 mg a day. Review of the social service note dated 04/17/14 revealed the resident's daughter was present during the plan of care meeting and was pleased with the resident's care. The daughter felt the resident was settled and well taken cared for at the facility. Review of the Behavior Intervention Monthly Flow Record for April 2014 revealed the resident had two episodes of increase in asking questions. She received [MEDICATION NAME] one time and exhibited an increased in anxiety twice during the month. Review of an edit note dated 04/25/14 revealed according to staff interview, the resident continued to be anxious over scheduling of eye drops, going to meals and bathing. These behaviors occurred almost daily. Review of the Behavior Intervention Monthly Flow Record for May 2014 revealed the resident had four episodes of increased anxiety and [MEDICATION NAME] was given three of the times. Review of the pharmacy note to the attending physician or prescriber dated 05/23/14 revealed the resident had received [MEDICATION NAME] 25 mg three times a day since late 2013 and may be due for a dose reduction attempt. The physician checked the box and signed the form on 06/24/14 that stated she disagreed but no further documentation was provided and there was no documented evidence a gradual dose reduction was attempted. Review of the psychiatric note dated 05/27/14 revealed the resident continued to be anxious and confused but no aggressive behaviors observed. The resident used the as needed [MEDICATION NAME] with improvement in symptoms. If severe agitation two tablets could be used resulting in one mg [MEDICATION NAME] as needed. The reason for not reducing medication was the resident was at high risk of deterioration. Review of the Behavior Intervention Monthly Flow Record dated June 2014 revealed the resident had two days with increased questions and six days with increased anxiety. Three of those six days Resident #24 received [MEDICATION NAME]. Review of the Behavior Intervention Monthly Flow Record dated July 2014 revealed the resident had two days with increased questions and five days with increased anxiety. Four of the five days Resident #24 received [MEDICATION NAME]. Review of the social service note dated 07/17/14 revealed the resident did tolerate change well. Review of the Behavior Intervention Monthly Flow Record dated August 2014 revealed the resident had one day of increased anxiety and [MEDICATION NAME] was given. Review of the nursing notes from 08/27/14 through 09/09/14 revealed there was no documented evidence the resident exhibited any behaviors. Review of the nursing note dated 09/10/14 at 11:15 A.M., revealed the resident exhibited an increase in anxiety, repeating questions over and over. Redirection was unsuccessfully several times. [MEDICATION NAME] one mg was given. The resident was tested and found positive for UTI and started on an antibiotic. Review of the psychiatric note dated 09/30/14 revealed resident continued to be anxious but manageable. Reason for not reducing medication was resident at high risk of deterioration. Review of the Behavior Intervention Monthly Flow Record dated September 2014 revealed the resident had three days of increased questions and three days of increased anxiety and one of the days (09/04/14) [MEDICATION NAME] was given. Review of the medication administrator record (MAR) for September 2014 revealed as needed [MEDICATION NAME] was given two days (09/04/14 and 09/10/14). Review of the social service note dated 10/09/14 revealed there were no concerns noted with the resident. Review of the nursing notes dated 10/31/14 revealed new orders received to change the [DIAGNOSES REDACTED]. Review of the Behavior Intervention Monthly Flow Record dated October 2014 revealed the resident had one episode of increased anxiety and no [MEDICATION NAME] was given. Review of the MAR for October 2014 revealed [MEDICATION NAME] was given on 10/03/14 there was no documented evidence to support the use of the [MEDICATION NAME]. Review of the Behavior Intervention Monthly Flow Record dated November 2014 revealed the resident had two episode of increased questions and one episode of increased anxiety and no [MEDICATION NAME] was given. Review of the nursing notes dated 12/16/14 at 11:30 P.M., revealed on 12/15/14 the resident experience increased anxiety and shortness of breath. [MEDICATION NAME] was given. Review of the nursing notes dated 12/18/14, revealed the resident was tested and found to have a UTI and was started on an antibiotic. Review of the Behavior Intervention Monthly Flow Record for December 2014 revealed the resident had two episodes of increased questions and four episodes of increased anxiety where [MEDICATION NAME] was given on three of the days. On 12/30/14 at 2:55 P.M., Resident #24 was observed in the wheelchair in her room looking out the window. The resident was not exhibiting any behaviors. Attempted interview revealed the resident was very hard of hearing. On 12/30/14 at 4:00 P.M., interview with the director of nursing (DON) verified the resident had a continued increase in psychoactive medications despite no documented evidence for the need in the increase in medications. The DON verified the resident had been on [MEDICATION NAME] since 2013 and there was no documented attempts to reduce the medication despite the pharmacy recommendation to do so in May 2014. The DON verified the original [DIAGNOSES REDACTED]. The DON verified the resident's increase in anxiety and questions was mostly on bath days and when the resident needed to have eye drops. The DON was not able to provide any documented interventions on how the facility addressed the resident's anxiety on bath days or for the use of the eye drops. The DON verified the plan of care did not address this nor was there documentation in the medical record. On 12/30/14 at 4:30 P.M., the resident was observed slowly self propelling in the hall by the nurses station. The resident was not exhibiting any behaviors. The resident asked the activities person if she could paint her nails. On 12/31/14 at 9:20 A.M., the state tested nurse aide (STNA) was wheeling the resident back into her room. The STNA asked the resident if the surveyor could talk to her and the resident stated, "I just want to go to bed right now." The resident was not exhibiting any behaviors. On 12/31/14 at 9:22 A.M., interview with STNA #101 and STNA #108 verified Resident #24 was never mean or aggressive, and rarely got upset. When she did, it was like a fake cry and when they talk with her she was better. The resident never yelled. Each day was different with her. Some days she was more tired and other days more awake. On 12/31/14 at 11:00 A.M., interview with Registered Nurse #100 verified she did rounds with the doctors and verified there had not been an attempt to decrease the resident's psychoactive medications including the [MEDICATION NAME] since the resident started the medications.

Based on document review and interview, the facility failed to ensure the fire drills were conducted at varied times. This had the potential to affect the 75 residents residing in the facility. Findings include: Review of the 2014 fire drill records revealed the following: First shift second quarter was conducted on 04/23/14 at 9:15 A.M. First shift third quarter was conducted on 08/26/14 at 9:50 A.M. First shift fourth quarter was conducted on 11/20/14 at 9:50 A.M. Second shift first quarter was conducted on 02/25/14 at 2:50 P.M. Second shift fourth quarter was conducted on12/02/14 at 2:50 P.M. On 12/31/14 at 11:00 A.M., interview with Maintenance Director #1 verified the above.

Based on observation and interview, the facility failed to ensure urinary drainage bags were maintained in a dignified manner for Residents #123 and #37. This affected two of three residents reviewed for Foley catheters. There were 6 residents in the facility with indwelling Foley catheters. The facility census was 84. Findings include: 1. Resident #123 was admitted to the facility on [DATE] after a recent motorcycle accident. The resident was admitted with [DIAGNOSES REDACTED]. Resident #123 was utilizing an indwelling Foley catheter (a type of bladder catheter). Resident #123 was observed on 09/11/13 at 8:52 A.M. in bed. The resident's Foley catheter and urine drainage bag was not covered. The resident's urine was visible to anyone in the hall or entering the room. An interview with the director of nursing (DON) on 09/12/13 at 11:30 A.M. confirmed privacy bags are not used to cover the urinary drainage bags when resident's are in their rooms. The DON verified Resident #123's drainage bag was visible from the hallway. The DON indicated nursing assistants were taught to only apply privacy bags when the resident's were out of their rooms. The DON verified visitors entering resident rooms would also be able to see the urinary drainage bags. 2. Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was utilizing an indwelling Foley catheter. Resident #37 was observed on 09/10/13 at 4:19 P.M. and on 09/11/13 at 9:40 A.M. lying in bed with his urinary drainage bag uncovered and without a privacy bag. An interview with the DON on 09/12/13 at 11:30 A.M confirmed privacy bags were not used to cover the urinary drainage bags when the resident is in their room. The DON indicated nursing assistants were taught to only apply privacy bags when the resident's were out of their rooms. The DON verified that visitors entering resident rooms would also be able to see the urinary drainage bags and may be visible from the hallway.

Based on observation, interview and record review, the facility failed to provide a planned intervention of a bed alarm to prevent Resident #29's fall and fractured hip. The facility failed to properly label chemicals, and failed to remove dryer lint from clothes dryers to limit the fire hazard potential. This affected one resident with falls (#29) of nine sampled residents with falls, of 21 residents with falls or fractures, and 31 ambulatory residents. The facility census was 70. Findings include: 1. Resident #29 was admitted to the facility in 2009 and had current [DIAGNOSES REDACTED]. Resident #29 was assessed to be at high risk for falls including on 09/20/10. The resident had a history of [REDACTED]. A nurse's note dated 12/13/10 at 5:45 A.M., indicated the nurse was called to Resident #29's room and found the resident on the floor next to her bed complaining of leg pain. A later note by the same nurse indicated that the resident was diagnosed with [REDACTED]. A review of the facility investigation documents regarding the fall revealed that Resident #29 had been found on the floor by an unnamed state tested nurse aide (STNA) who had called the nurse into the room. The investigation listed "intervention presently in place to prevent falls" including a bed sensor, chair alarm and to ambulate with two staff. Another document labeled Investigation Report indicated that the director of nursing (DON) had spoken to the resident's STNA that night and the resident's bed sensor alarm did not sound at the time of the incident. On 04/14/11 at 11:45 A.M., the DON verified that Resident #29's bed sensor alarm did not sound at the time of the fall on 12/13/10. 2. On 04/12/11 at 3:00 P.M., Licensed Practical Nurse (LPN) #6 and STNA #7 were interviewed in the bathroom at the end of the south hallway. They indicated the bathroom was used by residents. The bathroom contained a five gallon bucket on the floor with a worn label showing only the word "soap" in its title line. STNA #7 indicated the bucket contained an ice melting compound used on the driveway outside the nearby doorway. The staff lifted the bucket's lid to show it had white pellets in it. 3. On 04/14/11 at 8:15 A.M., the surveyor toured the laundry area with the maintenance director. The three large dryers were in use. Laundry Staff #11 and the maintenance director stopped the machines to view the lint traps. All three lint traps had a heavy coating of white lint. Laundry Staff #11 said she started her day at 5:00 A.M. and the traps were to be cleaned three times on her shift starting at 6:00 A.M., but she had not cleaned the traps that day.

Based on observation, interview and record review, the facility failed to provide ordered skin barrier ointments as needed and appropriate incontinence care, which resulted in the formation of a pressure ulcer on the hip of Resident #5. The facility failed to provide appropriate treatment for [REDACTED].#40) of five sampled residents with pressure ulcers. Five residents in the facility had pressure ulcers. Findings include: 1. Resident #5 was admitted to the facility in 2010 and had [DIAGNOSES REDACTED]. The resident's history of pressure ulcers included a surgical skin graft and flap closure to the right buttock just prior to admission. The resident's Minimum Data Set (MDS) 3.0 assessment dated [DATE], indicated he had severe cognitive deficits and was not able to communicate or take part in his own care. The resident had two Stage II pressure ulcers on his coccyx. Resident #5 was assessed to be at high risk for skin breakdown since admission, including the most recent skin assessment dated [DATE]. The resident's care plan for skin included pressure reducing devices, turning and positioning. A wound clinic note dated 04/04/11, indicated Resident #5 received treatment for [REDACTED]. The note indicated that the resident's coccyx and sacral area were excoriated and the treatment for [REDACTED]. On 04/12/11 at 2:30 P.M., Resident #5 was observed during a wound treatment. Licensed Practical Nurse (LPN) #6 performed the wound care and was assisted by State tested Nurse Aide (STNA) #7. At the beginning of the treatment, STNA #7 noted the resident was incontinent of liquid stool and provided hygiene. The STNA said the resident was frequently incontinent of liquid stool. She said she did not apply any medicated cream or lotions to the resident's skin after incontinence care, and that the nurse was the one that did that. Following the incontinence care, the surveyor noted a new pressure ulcer on the resident's right hip area. The nurse verified the new area and indicated she would notify the wound nurse and the wound clinic. The new area measured 1.0 centimeter (cm) by 2.0 cm by 0.1 cm deep, and was an abraded area with a bright red bleeding center. The nurse did not provide a treatment to the wound at that time. On 04/13/11 at 10:40 A.M., LPN #1 indicated she put a call in to the wound clinic regarding Resident #5's new pressure ulcer but had not received a call back. The nurse verified no treatment had been started for the new pressure ulcer. She verified that she did not apply any cream or lotion to the resident's skin after incontinence care. On 04/13/11 at 10:45 A.M., Resident #5 was observed with the wound nurse, Registered Nurse (RN) #3. The resident's new pressure area on the right hip was dry and had a small dry red line at its center. The resident was incontinent of liquid stool and had reddened buttocks. On 04/13/11 at 2:40 P.M., Resident #5 was observed during incontinence care. The resident had liquid stool. STNAs #7 and #8 cleaned the resident with disposable wipes. The last wipe used had stool on it and STNA #7 wiped the resident's new right hip pressure area with it. The resident's buttocks were reddened and no cream or ointment was applied. 2. Resident #40 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] revealed the resident was moderately impaired in cognition for decision making and was an extensive assistance by two staff members for bed mobility and transferring. The MDS assessment revealed the resident was a high risk for the development of pressure sores. The resident's weight was 211 pounds. The resident was admitted with 28 staples in place to her right hip. Physician orders [REDACTED]. The resident was non weight bearing to the right leg. Resident #40's interim plan of care dated 03/14/11 revealed under the area of Skin/Musculoskeletal to turn and reposition the resident every two hours, pressure relieving mattress, cushion to wheel chair, positioning side rails and transfers with extensive assistance. The interim plan of care revealed the resident had a "left spongy heel". A plan of care for Impaired Skin Integrity dated 03/22/11 included interventions to turn and reposition the resident every two hours and as needed. On 04/12/11 between 8:45 A.M. and 10:00 A.M., Resident #40 was observed lying in her bed, positioned on her back with the head of the bed elevated. The resident's eyes were closed. At 11:30 A.M., the resident was lying in bed, on her back with the head of the bed elevated. During observation of Resident #40's buttock area on 04/14/11 at 10:30 A.M., LPN #4 wiped an overbed table with a sanitizing cloth and placed supplies onto the table, including a handful of 4 inch by 4 inch gauze dressings and a handful of gloves. She removed a marker from her pocket, wrote her initials and date on a [MEDICATION NAME] dressing and put on a pair of gloves. LPN #4 did not wash her hands before putting on the gloves. The nurse was assisted by STNA #6 to roll the resident onto her right side. A [MEDICATION NAME] dressing ([MEDICATION NAME]) was scrunched up on the resident's mid buttock area. The dressing was not dated. LPN #4 removed the dressing, took off her gloves and without washing her hands, she put on new gloves from the overbed table. The wound was a circular open area with thick yellow and white substance covering the entire inside of the wound and a white colored edge. Her skin all around the wound was bright red. LPN #4 squirted a normal saline solution onto the wound and patted it dry. After patting the area dry, she wiped from the buttock area around the wound and then directly over the open wound area, re-contaminating the open wound area. She took off the gloves and without washing her hands, put on another pair of gloves and measured the open wound area. The wound measured 2.0 cm by 1.1 cm and 0.2 deep. LPN #4 measured the entire red, excoriated area around the open wound as 12.0 cm by 10 cm. She placed a new [MEDICATION NAME] dressing over the wound, removed her gloves and washed her hands. On 04/14/11 at 11:00 A.M., LPN #4 verified that she had not cleaned Resident #40's open wound appropriately and had not changed her gloves after the gloves were dirtied.