Every finding on record at Bayview Nursing & Rehabilitation Center

Based on observations, record review and staff interviews the facility failed to revise the comprehensive care plan to accurately reflect code status and the use of bedrails. This was for 1 of 3 residents (Resident #45) reviewed dementia care, and 2 of 2 residents (Resident #11 and Resident #40) reviewed for the use of bed rails.Findings included: 1. Resident #45 was admitted to the facility on [DATE] with a diagnosis of dementia. A physician's order for Resident #45 dated [DATE] was Do Not Resuscitate. (DNR is the refusal of Cardio-Pulmonary Resuscitation, a lifesaving procedure performed when someone's heartbeat or breathing has stopped). Resident #45's current active comprehensive care plan revealed a focus area desiring Cardio-Pulmonary Resuscitation (CPR). The goal dated last revised on [DATE] was for Resident #45 and her family's wishes for Full Code status (Full Code status involves CPR when someone's heartbeat or breathing has stopped) to be honored through the next review. An intervention was to ensure proper documentation supporting full code status was present in Resident #45's chart. On [DATE] at 8:15 AM an interview with the Minimum Data Set (MDS) Nurse indicated she would have been responsible for ensuring the code status on Resident #45's comprehensive care plan was accurate. She reported a care plan meeting had been arranged with Resident #45 and her family because Resident #45 had been declining. She went on to say there had been paperwork that needed to be signed for a DNR code status. The MDS Nurse stated Resident #45, and her family member had wanted to think about this, so she informed Resident #45's family member to give the paperwork to the Social Worker (SW) when he was finished. She reported she had been aware that all the steps for the completion of the paperwork for a DNR code status had been completed. The MDS Nurse reported this could have been in [DATE], although she could not recall exactly. She stated she should have updated Resident #45's comprehensive care plan immediately when the process including the obtaining of the physician's order for DNR code status was complete, but she missed it. On [DATE] at 9:15 M an interview with the Director of Nursing indicated the MDS Nurse would have been responsible for updating Resident #45's comprehensive care plan to accurately reflect Resident #45's DNR code status. She reported the MDS Nurse should have done this immediately. On [DATE] at 1:09 PM an interview with the Administrator indicated Resident #45's care plan should have been revised to accurately reflect her code status of DNR. 2. Resident #11 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease, chronic kidney disease and heart failure. Review of Resident #11's electronic medical record revealed an assessment titled bed rail assessment dated [DATE] and completed by the Director of Nursing (DON). The assessment revealed Resident #11 used bilateral side rail/assist bars on her bed. A care plan with the latest review date of [DATE] revealed no reference to use of side rails (u-shaped grab bars) for Resident #11. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact. The MDS indicated Resident #11 was dependent on staff for bed mobility and was non-ambulatory. The MDS further revealed Resident #11 had impairment to her lower extremities and no impairment to her upper extremities. The MDS indicated Resident #11's u-shaped grab bars were not used as a restraint. An observation on [DATE] at 11:10 AM revealed Resident #11 lying in bed with bilateral u-shaped grab bars in the raised position. A follow-up observation and interview with Resident #11 was conducted on [DATE] at 1:55 PM. Resident #11 was observed lying in bed with bilateral u-shaped grab bars in the raised position. Resident #11 stated she had the u-shaped grab bars since she was admitted and used them to assist with mobility and positioning in bed. In an interview with the MDS Nurse on [DATE] at 8:32 AM she stated she was responsible for creating and updating care plans. The MDS Nurse was unaware u-shaped grab bars were supposed to be included on a residents comprehensive care plan. In an interview with the Administrator on [DATE] at 8:35 AM she stated she was unaware a residents comprehensive care plan should have included u-shaped grab bars. In an interview with the DON on [DATE] at 8:43 AM she stated she was unaware u-shaped grab bars were to be included on a resident's comprehensive care plan. 3. Resident #40 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease, chronic kidney disease and heart failure. Review of Resident #40's electronic medical record revealed an assessment titled bed rail assessment dated [DATE] and completed by the Director of Nursing (DON). The assessment revealed Resident #40 used bilateral side rail/assist bars (u-shaped grab bars) on her bed. A care plan with the latest review date of [DATE] revealed no reference to use of u-shaped grab bars for Resident #40. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact. The MDS indicated Resident #40 was independent with bed mobility and transfers and was ambulatory with a walker. The MDS further revealed Resident #40 had impairment to both lower extremities and one side of upper extremities. The MDS indicated Resident #40's u-shaped grab bars were not used as a restraint. An observation on [DATE] at 1:10 PM revealed Resident #40 sitting on the side of the bed with bilateral u-shaped grab bars in the raised position. A follow-up observation and interview with Resident #40 was conducted on [DATE] at 2:22 PM. Resident #40 was observed lying in bed with bilateral u-shaped grab bars in the raised position. Resident #40 stated she had the u-shaped grab bars since she was admitted and used them to assist with positioning in bed and to help her stand when getting out of bed. In an interview with the MDS Nurse on [DATE] at 8:32 AM she stated she was responsible for creating and updating care plans. The MDS Nurse was unaware u-shaped grab bars were supposed to be included on a residents comprehensive care plan. In an interview with the Administrator on [DATE] at 8:35 AM she stated she was unaware a residents comprehensive care plan should have included u-shaped grab bars. In an interview with the DON on [DATE] at 8:43 AM she stated she was unaware that u-shaped grab bars were to be included on a resident's comprehensive care plan.

Based on observations, record review, staff and resident interviews the facility failed to assess entrapment risk and failed to attempt alternatives prior to siderail use for 2 of 2 residents (Resident #11, Resident #40) reviewed for side rails. Findings included: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease, chronic kidney disease and heart failure. Review of Resident #11's electronic medical record revealed an assessment titled bed rail assessment dated [DATE] and completed by the Director of Nursing (DON). The assessment revealed Resident #11 used bilateral side rail/assist bars (u-shaped grab bars) on her bed. The bed rail assessment noted that Resident #11 used the u-shaped grab bars as an enabler to promote independence and that she expressed desire to have the u-shaped grab bar. The bed rail assessment did not include an entrapment risk evaluation or if any alternatives were attempted before installation of the u-shaped grab bars. A care plan with the latest review date of 8/22/25 revealed no reference to use of u-shaped grab bars for Resident #11. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 was cognitively intact. The MDS indicated Resident #11 was dependent on staff for bed mobility and was non-ambulatory. The MDS further revealed Resident #11 had impairment to her lower extremities. The MDS indicated Resident #11's u-shaped grab bars were not used as a restraint. An observation on 11/17/25 at 11:10 AM revealed Resident #11 lying in bed with u-shaped grab bars in the raised position. The bars were white, metal and about 8 inches wide x 16 inches tall. They were attached to the frame of the bed. A follow-up observation and interview with Resident #11 was conducted on 11/18/25 at 1:55 PM. Resident #11 was observed lying in bed with bilateral u-shaped grab bars in the raised position. Resident #11 stated she had the u-shaped grab bars since she was admitted and used them to assist with positioning in bed. In an interview with the DON on 11/18/25 at 2:30 PM she stated she was the staff member who conducted Resident #11's side rail assessment on 5/30/25 and that the facility referred to them as u-shaped grab bars. The DON revealed that staff did not conduct an entrapment risk assessment or attempt alternative interventions before using side rails. The DON further stated she was unaware that alternatives needed to be tried and documented and that an entrapment risk evaluation needed to be conducted before using u-shaped grab bars. The DON indicated that the MDS Nurse often conducted the quarterly side rail assessments. In an interview with the MDS Nurse on 11/18/25 at 2:40 PM she stated she often conducted quarterly side rail assessments for the use of the u-shaped grab bars. The MDS Nurse further stated she was unaware an entrapment risk evaluation needed to be conducted and alternatives to u-shaped grab bars needed to be tried and documented. In an interview with the Administrator on 11/18/25 at 3:46 PM she stated that the therapy department assessed residents for entrapment risk when using the u-shaped grab bars when they did their bed mobility evaluation. An interview was conducted with the Rehabilitation Manager on 11/18/25 at 3:54 PM. She stated therapy did not conduct entrapment risk evaluations. The Rehabilitation Manager further stated that when therapy conducted an evaluation regarding bed mobility and they felt the resident could use side rails to help, they would verbally inform that residents charge Nurse and Maintenance to have the side rails put on the bed if they don't already have them. In a follow-up interview with the Administrator on 11/18/25 at 4:02 PM, she indicated nursing staff used the side rail assessment tool that the corporate clinical team provided to the facility. The Administrator stated she was unaware that an entrapment risk evaluation needed to be done and that alternatives needed to be tried and documented before the use of u-shaped grab bars. 2. Resident #40 was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease, chronic kidney disease and heart failure. Review of Resident #40's electronic medical record revealed an assessment title bed rail assessment dated [DATE] and completed by the Director of Nursing (DON). The assessment revealed Resident #40 used bilateral side rail/assist bars (u-shaped grab bars) on her bed. The bed rail assessment noted that Resident #11 used the u-shaped grab bars as an enabler to promote independence and that she expressed desire to have the u-shaped grab bar. The bed rail assessment did not include an entrapment risk evaluation or if any alternatives were attempted before installation of the u-shaped grab bars. A care plan with the latest review date of 10/17/25 revealed no reference to use of u-shaped grab bars for Resident #40. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact. The MDS indicated Resident #40 was independent with bed mobility and transfers and was ambulatory with a walker. The MDS further revealed Resident #40 had impairment to both lower extremities and one side of upper extremities. The MDS indicated Resident #40's u-shaped grab bars were not used as a restraint. An observation on 11/17/25 at 1:10 PM revealed Resident #40 sitting on the side of the bed with u-shaped grab bars in the raised position. The bars were white, metal and about 8 inches wide x 16 inches tall. They were attached to the frame of the bed. A follow-up observation and interview with Resident #40 was conducted on 11/18/25 at 2:22 PM. Resident #40 was observed lying in bed with u-shaped grab bars in the raised position. Resident #40 stated she had the u-shaped grab bars since she was admitted and used them to assist with positioning in bed and to help her stand when getting out of bed. In an interview with the DON on 11/18/25 at 2:30 PM she stated she was the staff member who conducted Resident #11's side rail assessment on 5/30/25 and that the facility referred to them as u-shaped grab bars. The DON revealed that staff did not conduct an entrapment risk assessment or attempt alternative interventions before using side rails. The DON further stated she was unaware that alternatives needed to be tried and documented and that an entrapment risk evaluation needed to be conducted before using u-shaped grab bars. The DON indicated that the MDS Nurse often conducted the quarterly side rail assessments. In an interview with the MDS Nurse on 11/18/25 at 2:40 PM she stated she often conducted quarterly side rail assessments for the use of the u-shaped grab bars. The MDS Nurse further stated she was unaware an entrapment risk evaluation needed to be conducted and alternatives to u-shaped grab bars needed to be tried and documented. In an interview with the Administrator on 11/18/25 at 3:46 PM she stated that the therapy department assessed residents for entrapment risk when using the u-shaped grab bars when they did their bed mobility evaluation. An interview was conducted with the Rehabilitation Manager on 11/18/25 at 3:54 PM. She stated therapy did not conduct entrapment risk evaluations. The Rehabilitation Manager further stated that when therapy conducted an evaluation regarding bed mobility and they felt the resident could use side rails to help, they would verbally inform that residents charge Nurse and Maintenance to have the side rails put on the bed if they don't already have them. In a follow-up interview with the Administrator on 11/18/25 at 4:02 PM, she indicated nursing staff used the side rail assessment tool that the corporate clinical team provided to the facility. The Administrator stated she was unaware that an entrapment risk evaluation needed to be done and that alternatives needed to be tried and documented before the use of u-shaped grab bars.

Based on observations, record reviews, and staff interviews, the facility failed to provide a dignified dining experience by standing over a resident while providing feeding assistance for 1 of 1 resident reviewed for dignity (Resident #28). Findings included: Resident #28 was admitted to the facility on [DATE]. A review of Resident #28's quarterly Minimum Data Set, dated dated dated [DATE] indicated she had severe cognitive impairment and required extensive assistance for most activities of daily living. On 3/06/22 at 12:34 PM an observation was made of Nurse Aide (NA) #1 standing at Resident #28's bedside while feeding the resident her lunch. The resident's head of bed was in an upright position and the NA stood above the resident's eye level during the dining experience. There was no chair in the room available for the NA to use. An interview on 3/06/22 at 2:56 PM with NA #1 revealed she stated she did not sit down to feed the residents because it was hard to reach them. She stated she was trained to sit down and feed the residents but had not done so. An interview on 3/08/22 at 3:15 PM with the Director of Nursing revealed she was unaware that NA #1 had provided feeding assistance to Resident #28 standing up. She stated she should have sat down and did not know why she had not done so. An interview on 3/08/22 at 1:48 PM with the Administrator revealed she expected the staff to sit down when providing feeding assistance to the residents and she did not know why NA #1 had not done so.

Based on record reviews, staff and physician interviews, the facility failed to ensure Physician visits were performed every sixty days as required for 1 of 2 residents reviewed for physician services (Resident #16). Findings included: Resident #16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #16's quarterly Minimum Data Set, dated dated dated [DATE] indicated she had severe cognitive impairment and required limited assistance for most activities of daily living. Review of progress notes revealed that notes were written, signed, and dated by the NP for several consecutive visits with the most recent one dated 12/31/21. No documentation was found to indicate that the attending physician had visited and examined the resident since 9/22/21. An interview on 3/07/22 at 2:17 PM with the Medical Records Clerk revealed she was responsible for providing the physician with a list of residents who needed to be seen for routine visits. She stated she had not put Resident #16 on the physician's list for her to be seen. She stated she had just overlooked Resident #16 on her list and she should have been seen by the physician in January 2022. An interview on 3/09/22 at 9:45 AM with the physician revealed he saw the facility residents for routine visits based on a list provided by the Medical Records Clerk. An interview on 3/08/22 at 1:47 PM with the Administrator revealed she expected the facility to follow the regulation for physician visits.

Based on record review and staff and family interviews and Physician interview he facility failed to provide a dressing change treatment as ordered by the physician to an opened blister on the shin for 1 of 3 residents reviewed for wound care. (Resident #13) Findings included: Resident #13 was admitted to the facility on [DATE]. His active [DIAGNOSES REDACTED]. Resident #13 ' s minimum data set assessment dated [DATE] revealed he was assessed as severely cognitively impaired. Resident #13 had no skin issues at that time. Resident #13 ' s care plan dated 9/30/19 revealed he was care planned to be at risk for skin breakdown. The interventions included to administer treatments per orders. Resident #13 ' s orders revealed on 9/17/19 he was ordered to have the open blister to his right lower shin cleansed with normal saline, patted dry, moistened [MEDICATION NAME] AG applied, and covered with Allevyn every other day until healed. Resident #13 ' s (MONTH) 2019 treatment administration record (TAR) revealed on 9/19/19 the treatment to his right lower shin was performed as ordered, but on 9/21/19 the TAR reflected the resident did not have his dressing changed as ordered. During an interview on 10/8/19 at 11:55 AM Resident #13 ' s family member stated on 9/21/19 Resident #13 was supposed to have his dressing changed and the dressing still had a date of 9/19/19. She stated family spoke to Nurse #1 who informed the family there were no supplies available to perform the dressing change. During an interview on 10/9/19 at 8:04 AM Nurse #1 stated she worked with Resident #13 on 9/21/19 and there were no supplies for his dressing change in the treatment cart and in the large supply storage room. She stated she was not aware of a smaller supplies storage area that could be accessed by the wound care nurse, but she did not believe she would have been able to get in to that room even if she had known about it because no one in the facility that Saturday had the key. The nurse further stated she informed the family at the bedside that the wound treatment was not done for this reason. The nurse concluded she did not notify the physician or do anything further with the dressing because it was clean and dry and dated 9/19/19. During an interview on 10/9/19 at 9:42 AM Physician #1 stated if a resident had a dressing change ordered and the supplies were not available to the nurse, the nurse should either notify her or the on call physician or nurse practitioner to inform them of the situation and see if there could be an alternative they could implement until the supplies were available again. She further stated she was not aware of the missed dressing change for Resident #13. During an interview on 10/9/19 at 10:27 AM the Director of Nursing stated for Resident #13 on 9/21/19 the first thing Nurse #1 should have done was call the physician or on call physician and gotten an alternative dressing order to perform the dressing change due that day until the supplies were available again. She further stated the second thing Nurse #1 could have done was to call her as the Director of Nursing to receive guidance on what could be done to perform the dressing change as ordered. The Director of Nursing stated she would have come to the facility to give her access to the smaller supply closet which the nurse was unaware of at that time and she could have educated her.

Based on record review and staff interviews the facility failed to maintain accurate medical record documentation for 1 of 1 resident reviewed for communicating information to receiving health care provider. (Resident # 3). The findings included: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The five-day minimum data set ((MDS) dated [DATE] indicated Resident #3 had moderately impaired cognition. On [DATE] at 4:35 PM a telephone interview was conducted with Nurse #1 who stated she had called Emergency Medical Services (EMS) to send Resident #3 to the hospital for an acute emergency. She further stated sent the face sheet and physician orders [REDACTED].#3. Resident #3 died enroute to the hospital. Nurse #1 indicated the hospital called her at the facility after the unnamed resident's family arrived at the hospital and informed the hospital the unnamed resident was not their relative. Nurse #1 realized she had sent the wrong resident's paperwork and faxed the correct information to the hospital. On [DATE] at 12:16 PM an interview was conducted with the Director of Nursing (DON) who stated Nurse #1 had given EMS the paperwork for another unnamed resident and the correct paperwork was faxed to the hospital as soon as the error was found. She further stated it was her expectation that the correct paperwork would be sent with the resident when they left the facility and the staff should double check to ensure accuracy. On [DATE] at 2:03 PM an interview was conducted with the Administrator who stated Nurse #1 had called her as soon as the paperwork error had been discovered. She further stated Nurse #1 had been counseled about this error and it should not have happened.

Based on record review and staff interviews, the facility failed to code Minimum data Set (MDS) section E for physical and verbal behaviors for 1 of 1 sampled resident (Resident # 57) and Failed to code MDS Section I for [DIAGNOSES REDACTED].# 31). Findings Included: 1-Record review indicated Resident # 57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident # 57 was severely cognitively impaired, required extensive assist with bed mobility, transfer, dressing and personal hygiene. The MDS did not code behavioral symptoms section E to indicate Resident # 57 behaviors for the month of (MONTH) (YEAR). A review of Resident # 57's Care Plan dated 10/9/2018 revealed the facility had developed a comprehensive Care Plan which was resident centered with measurable goals and comprehensive interventions including: Requires extensive to total dependence from staff with Activity of Daily Living (ADL) care due to [DIAGNOSES REDACTED]. Review of the Behavioral monitoring sheet for the Month of (MONTH) (YEAR) revealed the resident exhibited following behaviors: Grabbing others, pushing others, kicking others, scratching others and hitting others. An interview with the MDS nurse was conducted on 11/7/2018 at 1:56 pm. During this interview she revealed she completed the quarterly assessment for Resident # 57. The MDS nurse stated she did not code the behavioral symptoms because she had already coded behavioral symptoms in the admission MDS. An interview with the Director of Nursing (DON) was completed on 11/7/2018 at 2:09 pm. During this interview she stated she expected the MDS to be coded correctly. 2- Record review indicated Resident # 31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Pharmacy review dated 7/31/2018 revealed the resident was taking [MEDICATION NAME] medication for mood disorder (Depression) diagnosis. Review of Resident # 31 care plan reviewed 8/14/2018 indicated the resident was at risk for adverse reaction due to use of antidepressant medication ([MEDICATION NAME]). She has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident # 31 cognition was intact , required extensive assist with bed mobility, transfer, dressing and personal hygiene. The MDS did not code Depression as a [DIAGNOSES REDACTED]. An interview with the MDS nurse was conducted on 11/7/2018 at 1:56 pm. During this interview she revealed she completed the quarterly assessment for Resident # 31. The MDS nurse stated she did not code the depression [DIAGNOSES REDACTED]. An interview with the Director of Nursing (DON) was completed on 11/7/2018 at 2:09 pm. During this interview she stated she expected the MDS to be coded correctly.

Based on observation, resident, staff, and Physician Assistant interviews, and record review the facility failed to provide scheduled pain medication as ordered by the physician for 1 of 1 residents (#29). A record review revealed Resident #29 was readmitted to the facility on [DATE]. His documented [DIAGNOSES REDACTED]. The Quarterly Minimum (MDS) data set [DATE] revealed he had moderately impaired cognition, required one person physical assistance with activities of daily living, and used a wheelchair for mobility. It also documented that he was on a scheduled pain medication regimen. A record review of his care plan dated 09/01/17 revealed that Resident #29 was at risk for alteration in comfort with the following interventions documented: 1. Monitor and document pain level every shift and as needed 2. Assist with turning and repositioning for comfort 3. Administer pain medication as ordered 4. Monitor effectiveness of pain medication; if ineffective notify physician A review of the October 2017 Medication Administration Record [REDACTED] 1. [MEDICATION NAME] Sodium (Aleve) 220 mg by mouth at breakfast and supper 2. Tylenol 325 mg by mouth (2) tabs every six hours An additional record review of the MAR indicated [REDACTED]. In an interview conducted on 10/09/17 at 3:06 PM with Resident #29 and a family member he stated that he was in pain because he had not received his Aleve. He said morning Nurse #2 told him the facility was out of Aleve. The family member reported she had asked again at 2:00 PM on 10/09/17 and Nurse #2 told her the facility was out of Aleve. In an interview conducted on 10/10/17 at 1:55 PM with Nurse #2 she revealed that the facility had been out of Aleve. She said she had worked second shift on 10/08/17 and then worked again on day shift on 10/09/17 passing medications on Resident #29's hall both shifts. She stated that Resident #29 was out of the facility on 10/08/17 at supper time and did not return until around 9:00 PM. Nurse #2 stated because she did not administer Resident #29's medications at supper time on 10/08/17, she was unable to state if the facility was out [MEDICATION NAME] that day but did notice on the morning of 10/09/17 that [MEDICATION NAME] was empty. She stated she did not offer Resident #29 an alternate pain medication and had not contacted the physician regarding the missed doses of Aleve. She revealed that the Director of Nursing went to a local store on 10/09/17 in the afternoon and [MEDICATION NAME] Resident #29 had received his scheduled dose [MEDICATION NAME] 5:00 PM on 10/09/17. In an interview conducted with the Director of Nursing on 10/10/17 at 11:05 AM she revealed it was her expectation that if a nurse discovered she did not have a medication to administer the nurse would call the pharmacy for medication replacement. She stated if it was known that there would be a delay in delivery, she would expect the nurse to contact the physician to notify him of the medication omission or to get an alternative order. She would also expect the nurse to notify the responsible party. In a telephone interview with the Physician's Assistant on 10/12/2017 at 11:23 AM, she stated if a resident was out of a medication she expected the facility to let her know and to also call the pharmacy to get the medication into the facility. She said there was no excuse for this resident to run out [MEDICATION NAME] he had been on it for at least the year since she has been servicing this facility. She reported the resident had severe arthritis and needed the medication. She said this was the first she had heard that the resident had missed doses [MEDICATION NAME] she had been in the facility on Tuesday (10/10/17). She expected the nurses to let her know when any medication was not given and she revealed she had not been notified. She said the nurses who had been dispensing the medication should have known it was about to run out and should have had it reordered so that it was available to the resident.

Based on observation, staff interviews and record review, the facility failed to disinfect the glucometer between resident uses according to manufacturer's recommendations for 1 of 2 resident's observed for glucometer checks (Resident #54). Findings included: Review of the facility's policy and procedure on cleaning glucometers last reviewed 8/18/11 revealed that the glucometers were to be cleaned per manufacturer's instructions. Review of the facility's glucometer user instruction manual revised 11/2012 revealed the glucometer was to be cleansed with a commercially available registered disinfectant detergent or germicide wipe. To use a wipe, the instructions were to follow the product label instructions of the wipe to disinfect the glucometer. Review of the directions on the germicidal wipes used by the facility for cleaning glucometers on 10/11/17 at 12:01 PM revealed the surface to be cleaned was to remain visibly, thoroughly wet for a full four minutes, using additional wipes if needed to assure continuous four minutes of wet contact time. The surface was then to be let air dry. During observation on 10/11/17 at 12:04 PM, Nurse #1 was observed to check Resident #69's blood sugar level with a glucometer. After checking this resident's blood sugar, she then wiped the glucometer for approximately seven seconds with the facility's germicidal wipe and placed it on her cart to air dry at 12:08 PM. At 12:10 PM the glucometer was observed to be dry. At 12:18 PM Nurse #1 used the same glucometer to check Resident #54's blood sugar. During an interview on 10/11/2017 at 12:20 PM, Nurse #1 stated the policy and procedure for using glucometers at the facility was to use the germicidal wipe to give one swipe on the front, one swipe on the back and three swipes across the top, bottom, and sides of the glucometer. She further stated she always used this technique before and after each resident. During an interview on 10/11/17 at 2:02 PM, the Infection Control Nurse stated it was her expectation the nursing staff would follow the manufacturer's directions when cleaning the glucometers and stated the glucometer should have remained visibly wet for four minutes. During an interview on 10/11/17 at 2:13 PM, the Director of Nursing stated she did not know there was a time limit for cleaning glucometers, but they just needed to be cleaned with a bleach wipe and let it dry before and after each use. She then stated the glucometer should have remained wet for a minute. After reading the label on the wipes used by the facility she stated it was her expectation the nurse would leave the surface of the glucometer visibly wet for four minutes before letting it air dry per the directions on the germicidal wipes label.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment Committee (QA) failed to maintain implemented procedures and monitor the interventions the committee put into place in January 2017. This was for a deficiency which was originally cited in January 2017 on a federal monitoring survey and was cited again on the current recertification and complaint investigation survey. The deficiency was in the area of infection control. The continued failure of the facility during two federal surveys of record demonstrate a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referenced to: F441: Based on observation, staff interview and record review the facility failed to disinfect the glucometer between resident uses according to manufacturer's recommendations for 1 of 2 resident's observed for glucometer checks (Resident #54). Infection Control (F441) was originally cited on the federal monitoring survey on January 13, 2017 for failure to properly handle intravaneous tubing to prevent risk of cross contamination. During an interview with the Clinical Coordinator on 10/12/17 at 11:30 AM she stated the QA committeed had completed a QA project but it was not related to infection control. During an inteview with the the Administrator on 10/12/17 at 11:40 AM she reported the QA Commitee met monthly to discuss and monitor numerous topics. The members who attended included the DON along with more than 3 members of the management team. She stated the physician attended quarterly and provided a signature sheet to confirm attendence at the last quarterly meeting.

br>Based on observation, record review, family and staff interviews the facility failed to maintain a wheelchair and privacy curtain in a clean and sanitary condition in 1 of (Ocean side) 4 halls. The findings included. During an interview on 11/17/15 at 2:50 PM a family member stated that Resident # 32 ' s wheel chair was dirty. On 11/17/15 at 2:55 PM Resident # 32 ' s wheel chair was observed to be dirty with dust and food particles on the cushion and side bars of the wheel chair. On 11/18/15 at 10:49 AM Resident # 32 ' s wheel chair was observed to be dirty with dust and food particles on the cushion and side bars of the wheel chair. A third observation on 11/19/15 at 8:50 AM Resident # 32 ' s wheel chair was observed to be dirty with dust and food particles on the cushion and side bars of the wheel chair. In an interview on 11/18/15 at 11:37 AM the Maintenance Man stated that on the first Monday of the month, one hall is selected and all wheelchairs on that hall are deep cleaned with the pressure washer. In an interview with Nursing Assistant # 1 (NA) on 11/19/15 at 8:55 AM she stated that maintenance cleaned the wheel chairs on a regular basis. She stated that staff verbally tell maintenance of any wheelchair that is dirty and they would clean it. In an interview with NA # 2 on 11/19/15 at 9:12 AM she stated that if she saw a dirty wheelchair she would tell nursing staff and nursing would inform maintenance the wheel chair needed to be cleaned. During an interview with the Administrator on 11/19/15 at 9:43 AM she stated that the maintenance department does one hall a week for power washing the wheel chairs and also as needed. She indicated that once a month every wheelchair was pressure washed. During an interview with the Director of Nursing on 11/19/15 at 10 AM he stated that he expected all wheelchairs were pressure washed once a month and staff to wipe off any spills on a wheel chair. 2. On 11/16/15 at 11:27 AM Resident #55's privacy curtain was observed to have dried brown streaks. The Resident was residing in the room. The Head of Housekeeping stated in an interview on 11/18/15 at 4:30 PM the resident's privacy curtains are cleaned if noted to be soiled or dirty by the staff. He further stated there is not a set privacy curtain cleaning schedule. On 11/18/15 at 4:35 PM an observation was made with the Head of Housekeeping of Resident #55's privacy curtain. Dried brown substance was noted to be on the privacy curtain. In an interview with the Head of Housekeeping he stated the curtain needed to be taken down and replaced with a clean curtain. On 11/18/15 at 5:18 PM Resident #55's room was noted to have a clean privacy curtain in place. The Administrator stated in an interview on 11/19/15 at 12:43 PM that the housekeeping staff needed to clean all privacy curtains twice a year and as needed if soiled or dirty.

Based on record review and staff, resident and physician interviews the facility failed to obtain orders for pain medication for adequate pain control for 1 of 1 residents reviewed for pain (Resident #69). The findings included: Resident #69 had a [DIAGNOSES REDACTED]. When the resident arrived at Facility A, the resident did not want to stay there and requested to be transferred to Facility B. The resident was admitted to Facility B around 2:30PM on 6/26/15. The admission nurse ' s note dated 6/26/15 at 4:11 PM, written by Nurse #2 (7AM-3PM shift) revealed the resident was admitted to the unit at 2:30 PM, was alert and oriented and could make her needs known. The note revealed the resident rated her hip pain as a 1 on a scale of 1-10 with 10 being the worst. The Admission Care Plan dated 6/26/15 included the monitoring of pain. A pain evaluation sheet dated 6/26/15 included information that the resident had a [DIAGNOSES REDACTED]. The form noted the resident had frequent pain and rated her pain as 5 being the worst it would get and 1 as being the best it would get on a 0-10 pain scale (0 being no pain and 10 being the worst pain imagined). The resident described the pain as aching, throbbing and sharp. There was a section on the form titled Relief of Pain. The section contained the following questions: What is the resident ' s acceptable pain level? Is the resident on a scheduled pain regimen? If yes, pain medication(s) in use. Does the resident receive a PRN (as needed) medication? If yes, pain medication(s) in use. Is pain medication effective? This section of the form was not filled out. The pain evaluation sheet revealed pain management intervention was necessary. A nurse ' s note dated 6/26/15 at 6:50 PM revealed the admission orders [REDACTED]. Review of the hospital discharge orders dated 6/26/15 revealed no orders for pain medication and there were no orders for pain medication on the written physician's order [REDACTED]. A nurse ' s note dated 6/26/15 at 10:53 PM noted no signs or symptoms of distress but did not specifically address the resident ' s pain. A nurse ' s note dated 6/27/15 at 9:47 AM, late entry for 11-7 shift revealed the resident denied any pain. A nurse ' s note dated 6/27/15 at 10:04 AM by Nurse #3 noted the resident was alert and verbal but the note did not address pain. Review of the resident ' s Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. A nurse ' s note dated 6/27/15 at 11:32 PM by Nurse #4 noted the resident complained of pain not relieved by PRN (as needed) Tylenol every 6 hours. The note revealed the nurse called the on call medical provider at 10:00 PM and received an order for [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A note on the MAR indicated [REDACTED]. A nurse ' s note dated 6/28/15 at 2:40 AM by Nurse #5 read: Complaints of pain verbalized, partial relief obtained from current prescribed medication, needs follow-up for verification of [MEDICATION NAME]. A nurse ' s note written by Nurse #2 (7AM-3PM shift) dated 6/28/15 at 10:27 AM revealed no complaints of pain this shift. There were no additional nurse ' s notes documented for the 7AM-3PM shift. A nurse ' s note written by Nurse #4 on 6/28/15 at 11:13 PM revealed no information regarding resident ' s pain status on the 3 PM to 11 PM shift. The note revealed the resident was very anxious throughout the end of the shift and was currently asleep. Review of the physician's order [REDACTED]. A nurse ' s note dated 6/29/15 at 3:32AM by Nurse #5 read: Complaints of pain verbalized, partial relief obtained from current prescribed medication, continues to need follow-up for verification of [MEDICATION NAME]. Complaints of nausea and received [MEDICATION NAME] by mouth per standing order. A nurse ' s note dated 6/29/15 at 6:59AM by Nurse #5 revealed the resident had some relief of nausea from the medication and requested to see the physician today regarding needs. A nurse ' s note dated 6/29/15 at 1:00PM by Nurse #2 revealed the physician saw the resident and wrote orders for [MEDICATION NAME], a narcotic medication given for pain, [MEDICATION NAME] for sleep, [MEDICATION NAME] for muscle spasms and [MEDICATION NAME] for inflammation. Review of the physician's order [REDACTED]. Nurse #5 (11PM-7AM shift) stated in an interview on 11/17/15 at 3:54AM she gave the resident the ordered pain medication and the resident went to sleep. The Nurse stated when the resident was awake she would say the pain medication helped but still had some discomfort but was able to sleep. The Nurse stated the resident had no moaning or groaning or signs of pain. The Nurse stated she called the pharmacy about the resident ' s pain medication but they did not have an order and she reported to the day shift they needed to find out the status of the resident ' s pain medication. Nurse #2 (7AM-3PM) stated in an interview on 11/18/15 at 7:19AM that she was the nurse who admitted the resident and worked with her over the weekend (6/27-28/15). The Nurse stated she could not remember whether the resident had a prescription for pain medication. The Nurse stated if a resident did not have pain medication they call the physician and get an order. The Nurse stated if they have an order, they have back up pain medications they can give until the resident ' s pain medication arrives from the pharmacy. The Nurse was observed to read her nurse ' s notes and stated it looked like the resident did not complain of pain during her shift over the weekend. On 11/18/15 at 3:35PM the facility ' s Medical Director stated in an interview the medical provider on call could have given a 72 hour emergency order for pain medication. The Physician stated their call center recorded all phone calls between the facility and the on call medical provider and was able to have the call e-mailed to her computer and played the call made by Nurse #4 on 6/27/15 at 10:47PM. Nurse #4 was heard to tell the provider she had a resident that had hip surgery on 6/23/15 and the resident had been given Tylenol per their standing orders and the Tylenol was not doing her pain justice. The Nurse was heard to ask the provider if they could [MEDICATION NAME] the Tylenol. The provider asked the nurse several questions about the resident ' s history and then [MEDICATION NAME] every 6 hours as needed for pain. (Review of the physician's order [REDACTED]. The Medical Director stated though the nurse suggested Advil, the provider should have known [MEDICATION NAME] not strong enough for pain after having hip surgery. On 11/19/15 at 7:45AM, Nurse #3 stated when they get a new admission the nurse calls the facility physician to verify the orders sent with the resident to the facility. The Nurse stated she verified the orders sent with the resident and did not recall having a conversation with the physician regarding pain medication for the resident. On 11/19/15 at 8:46AM, Resident #69 stated in an interview she was discharged to another facility and due to conditions in the facility could not stay there. The Resident stated she called another nursing home and was told they had a bed. The Resident stated she called a friend to drive her and that due to the [MEDICATION NAME] she received prior to discharge from the hospital, she was able to maneuver and get in her friend ' s car. The Resident stated the staff at the first nursing home could not find her prescriptions and told her to go ahead and they would fax the information to the new facility. The Resident stated she had a high pain tolerance but on Sunday (6/28/15) she had increased pain and [MEDICATION NAME] help but did not relieve her pain. The Resident stated she was given something for nausea that helped her to sleep. The Resident stated she called her Surgeon on Monday (6/29/15) regarding pain medication and was told the facility staff could have called them for orders for pain medication as they always had someone on call. On 11/19/15 at 9:50AM Nurse #4 stated in an interview she was not sure why she asked the medical provider [MEDICATION NAME] the resident ' s pain. The Nurse stated she did not recall taking the order [MEDICATION NAME] what was going on when she wrote the order [MEDICATION NAME] instead of 400mg. The Director of Nursing (DON) stated in an interview on 11/19/15 at 10:43 AM that Nurse #4 told the medical provider the resident had hip surgery on 6/23/15 and felt like the provider should have known the resident would need more [MEDICATION NAME] pain. The DON acknowledged the nurse did not write the order correctly. On 11/19/15 at 11:57AM the Administrator stated in an interview that Nurse #4 made the initiative to call the medical provider and the provider should have known what kind of medication a resident with new hip surgery needed. The Administrator stated the nurse should not suggest to the doctor what medication to order but should discuss the level of the resident ' s pain. The Administrator stated she felt the resident ' s pain was covered satisfactorily.

Based on observations, staff interviews and record review, the facility failed to provide adequate incontinence care for 1 of 1 sampled residents dependent on staff for Activities of Daily Living (Resident #51) by failing to use soap and water during care. Findings included: Resident # 51 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/28/15 Comprehensive Minimum Data Set (MDS) indicated Resident #51 had severely impaired cognitive skills for daily decision making. The MDS also revealed the Resident required extensive assistance of staff for toileting and personal hygiene, was always incontinent of bowel and had an indwelling urinary catheter. The Care Area Assessment (CAA) dated 9/28/15 for Activity of Daily Living (ADL) and urinary catheter documented the Resident required extensive assistance with all ADL ' s and wore adult briefs for protection and containment. The care plan dated 9/29/15 documented the Resident was not able to take care of his own needs and the staff were to provide incontinent and personal hygiene care as needed. On 11/18/15 at 10:10 AM Nurse #6 was observed to give incontinence care to Resident #51. Nurse #6 removed a moderate amount of soft brown stool with toilet paper, cleansed the rectal area only with water soaked toilet paper, and patted the area dry. A clean brief was applied. Nurse #6 stated in an interview on 11/18/2015 10:48:39 AM Resident #51 was incontinent of stool and she should have cleaned the rectal area and then entire perianal area with soap and water and not just used toilet paper to clean the resident. In an interview with the Director of Nursing (DON) and Administrator on 11/18/2015 3:14 PM, the DON stated when a resident was incontinent of stool he expected the staff to remove the bulk of the stool with toilet tissue, to clean the perirectal area with soap and water, rinse the area, pat dry and apply protective cream if ordered. He further stated all employees have been in-serviced on incontinence care.

br>Based on observations and staff interviews the facility failed to maintain kitchen equipment in a clean and sanitary manner to prevent food borne illness by failing to clean a steam table shelf. The findings included: During an observation of the kitchen on 11/17/15 at 4:46 PM the steam table was observed. Observations made underneath the five foot shelf revealed it was covered with dried dark food particles. During a second observation of the steam table on 11/18/15 at 3:42 PM the underside of the steam table shelf was again observed to be covered with dried dark food particles. During a third observation of the steam table on 11/19/15 at 10:28 AM the underside of the steam table shelf was again observed to be covered with dried dark food particles. In an interview with the Dietary Manager on 11/19/15 at 10:33AM he revealed that he had been hired two weeks ago and was currently in the process of reviewing the cleaning schedule. He stated that they had not identified the steam table shelf as not being clean but that staff would clean it immediately.

Based on observation, record review and staff interview, the facility failed to discard expired medication in 4 of 5 medication carts, failed to store medications in a refrigerator in 2 of 5 medication carts and failed to date a medication in 1 of 5 medication carts. The findings included: The facility 's policy on storage of medication handed by the administrator on 12/11/14 was reviewed. The policy indicated no outdated medication will be in the facility for use. The policy also indicated to store unopened insulin bottles inside the medication room refrigerator. Lantus insulin, Novolog and Humalog insulin will be discarded after 28 days from the date opened. The policy further indicated Advair Diskus (treatment for [REDACTED]. The manufacturer's specification for Advair Diskus read " discard Advair Diskus 30 days after opening the foil pouch. " The manufacturer 's specification for Florajen Acidophilus is to refrigerate for maximum freshness and effectiveness. 1. On 12/10/14 at 3:25 PM, the Ocean hall 1 medication cart was observed. A bottle of Vi-Daily liquid medication was observed with an expiration date of 05/14. Interview with the nurse #1 revealed the medication should have been discarded. 2. On 12/10/14 at 3:27 PM, the Ocean hall 1 medication cart was observed. A Bisacodyl suppository was observed with an expiration date of 11/14. Interview with the nurse #1 revealed the medication should have been discarded. 3. On 12/10/14 at 3:35 PM, the Ocean hall 2 medication cart was observed. A Novolog Flexpen was opened on 10/10/14. Interview with the nurse #1 revealed the medication expired and should have been discarded. 4. On 12/10/14 at 3:55 PM, the Lake hall medication cart was observed. A box of Hemoccult single slide was observed with expiration date of 06/14. Interview with nurse #2 revealed the box should have been removed from the medication cart. 5. On 12/10/14 at 3:58 PM, the Lake hall medication cart was observed. Two Lantus insulin pens were opened on 10/06/14 and 10/18/14 respectively. Interview with nurse #2 revealed the insulin should have been removed and discarded. 6. On 12/10/14 at 3:28 PM, the Ocean hall 2 was observed. There were 5 Lantus insulin pens unopened were in the medication cart. The label from the package read to store in a refrigerator until opening. Interview with nurse #1 revealed the Lantus insulin pens should have been placed in the medication room refrigerator. 7. On 12/10/14 at 3:57 PM, the Lake hall medication cart was observed. One bottle of Florajen Acidophilus was in the medication cart. The label in the package read to have the medication stored in a refrigerator. Interview with nurse #2 revealed she was not aware the bottle was in the medication cart. 8. On 12/10/14 at 4:03PM, the Bay hall medication cart was observed. A used Advair Diskus was seen with no date of opening. The Advair Diskus was sent to the facility on [DATE]. Nurse #2 was interviewed and stated the medication should have been dated when opened. The Director of Nursing (DON) was interviewed on 12/11/2014 9:30:58 AM. She stated the nurses were expected to check the medication carts and medication rooms daily. She further stated the nurses were expected to discard expired medications, store medications in refrigerator that needed controlled temperature and to write date of medications that needed date of opening.

Based on observation, staff interview and record review, the facility failed to ensure that one of three residents who required assistance with feeding was fed at the same time as other residents in the dining room (Resident #23). Resident #23 was admitted [DATE] with a [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] noted Resident #23 to be severely impaired for cognition, and needed extensive assistance for eating with the physical assistance of one person. The Care Area Assessment indicated that the resident needed attention to nutritional status, and this area went to care plan. On 12/8/14 at 12:38 PM, an observation was made of a staff member serving Resident #23 his plate of food. Two other staff members were observed feeding two other residents at the same table at this time. Upon finishing feeding one of the two residents at the table, one of the staff members began to feed Resident #23 at 1:10 PM. On 12/10/14 at 3:11 PM, in an interview, the Director of Nursing (DON) stated that her expectations were that Resident #23 would be fed at the same time as the other residents at the table.

Based on record review, observation and staff interviews, the facility failed to follow the manufacturer's instruction for placement of a bed alarm device for a resident admitted with a fall history from home, so that staff could hear and respond to the sound for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). Findings included: According to the manufacturer's directions for use for the bed alarm device titled "Direct Supply Attendant Pressure Pad" instructs one "1) Place monitor out of reach of the resident. Suitable mounting locations may include: back of headboard, back of wheelchair, wall or under the bed and 2) the weight of some cushions can reduce the effectiveness of the alarm." The hospital discharge summary dated 7/31/14 revealed Resident #1 fell at home while going to the bathroom because she became weak and fell down. A CAT (Computerized Axial Tomography) scan of the brain without contrast showed no acute abnormalities were seen. Resident #1 was admitted into the facility on [DATE]. Cumulative [DIAGNOSES REDACTED]. A review of the nurse's note dated 8/1/14 read "Bed/chair alarm placed at family's request." The 24 hour report/change of condition report dated 8/1/14 reflected a bed/chair alarm was implemented. A review of the telephone order dated 8/4/14 revealed a neurological consult for confusion and cognitive changes. The care plan (CP) completed on 8/9/14 revealed the resident was at risk for injury due to impaired thought process with interventions which in part read "Provide consistent care giver on all shifts, keep resident environment free of clutter and safety hazards, call light within reach at all times in room and bathroom." The CP further indicated Resident #1 required staff assistance with activities of daily living (ADL) with risk for further decline due to recent acute hospitalization . At risk for falls was indicated as an identified problem on 8/9/14 due to inability to perform ADLs independently secondary to a recent acute hospitalization . Approaches to prevent falls read "Assist with one staff member for all ambulation, monitor for changes in condition that may warrant increased supervision/assistance and notify the physician." The care plan did not reflect a bed alarm device. A review of the kardex (undated) did not reflect a bed alarm device or instruction regarding its use. The Care Area Assessment completed 8/9/14 listed falls as an identified problem. The root cause related to previous fall history was not specifically indicated. At risk for injurious falls was listed as analysis of findings, with care plan consideration for therapy as ordered and as needed. The falls narrative note referenced the ADL note which read "Per medical records, resident requires extensive assistance, at further risk for ADL decline with therapy as ordered and as needed." The 14 day admission Minimum Data Set (MDS) completed on 8/14/14 indicated Resident #1's cognitive pattern was severely impaired. No behavior or rejection of care was indicated. Extensive assistance with bed mobility and transfers of two persons was required. Balance was indicated as not steady (only able to stabilize with staff assistance) with transition and walking. Range of motion was impaired on one side to both the upper and lower extremities. Mobility devices included a walker and wheelchair. No falls were indicated prior to or since admission. Weight was indicated as 176 pounds. A review of the neurological consult completed on 8/22/14 revealed Resident #1 was admitted into the nursing facility for rehabilitation for sub-acute care. It was further indicated the resident was evaluated for memory impairment. Further assessment indicated the resident could walk 60 feet with assistance, had never been a physical person, had fallen at home due to nocturia (excessive urination at night), getting up in the middle of the night, fatigued easily, but is better. Balance was listed as impaired, abnormal gait, very weak legs and left arm weak. The plan included rehab (walk short distances several times daily), brace for leg and wrist drop and a revisit in one month. The resident was assessed to be deconditioning. A review of the weekly skin assessment completed on 8/2, 8/9 and 8/23/14 revealed no concerns or bruising to the head. The 30 day MDS completed on 8/26/14 indicated Resident #1 cognitive pattern was moderately impaired. No behavior or rejection of care was listed. Extensive assistance with bed mobility and transfers of one person was indicated. Balance was indicated as not steady (only able to stabilize with staff assistance). No falls were indicated prior to or since admission. Weight was indicated as 175 pounds. A review of the nurse's notes (NN) written by Nurse #1 revealed on 9/5/14 at 3:47 am "Resident alert and able to make most needs known. Assistance with ADLs (activities of daily living) and transfers, left side weakness, call light in place and alarm in place in bed (specific location not indicated)." At 8:53 am NN in part read "Had checked on resident at 5:30 am and the resident in bed with eyes closed and her door opened at that time. Went back at 6:00 am to administer her morning meds and found resident on the floor with laceration on back of head. Her bed alarm was under her pillow going off and her door was closed when I got back. I called 911, on call doctor and her family. Resident complained of her head hurting and her back hurting. Went out via stretcher via 911 at 7:00 am." A review of the nurse notes from admission to discharge revealed Resident #1 was at times confused, required redirection, left side weakness and required assistance from the facility staff with ADLs and transfers. The notes did not reflect the resident attempted to place the bed alarm under the pillow or an attempt to get out of the bed to close the door to the room unassisted. A review of Nurse #1's written statement dated 9/5/14 read "6:00 am resident was on floor with blood behind her head. Had her lay still, kept her awake and talking, called 911, physician and family. 911 came about 7:00 am by stretcher." A review of the Emergency Medical Services (EMS) narrative report dated 9/5/14 revealed a dispatch to the nursing facility, "Upon entry arrival at the facility patient was observed lying next to the bed, patient states she slid off the bed, patient has a contusion (bruise) to the back of her head, patient denies any other injury, c-collar applied (neck brace,) loaded and transported without change, (name of hospital) called and report given." A review of the hospital emergency department pre-arrival summary notes dated 9/5/14 at 7:30 am revealed Resident #1 presented to the emergency room due to a fall/head pain. Chief complaint read "Pt (patient) slid off her bed around 6 am this morning per staff at (name of nursing facility). Pt noted with small laceration and swelling to back of head. Pt complains of left elbow pain. Poor historian and unable to tell the nurse of morning events." A CT of the brain revealed "1) left side subdural hematoma (a severe acute head injury in which blood fills the brain rapidly, compressing or squeezing brain tissue) largest diameter is 15.8 millimeter. Due to underlying atrophy (degeneration) there is very little mass effect, 2) Intraventricular hemorrhage (bleeding in the brain) with blood noted in the posterior horn of the right lateral ventricle: impression: chronic degenerative changes. No acute findings. X-ray of left elbow revealed no radiographic evidence of acute injury. Patient was reevaluated resting comfortable no changes in signs or symptoms. She'll be transferred to (name of medical center) for continuation of care and treatment." A review of the staff in-service completed 9/10/14 at 2:30 pm, 3:30 pm and 11:00 pm read "All staff: ensure that all residents' doors stay open when they are not receiving patient care. If a patient insists on the door being closed - care plan, falls - review of proper documentation." The in-service did not reflect education provided to the staff related to proper placement of bed alarms so that staff could hear and respond to the sound. A review of the death certificate dated 9/22/14 read "1) Immediate cause of death: consequences of closed head injury and 2) Underlying cause: fall on 9/5/14 (date of injury), 3) Manner of death: accident." On 10/21/14 at 3:55 pm, in an interview, the administrator revealed she had discussed with Nurse #1 on 9/5/14 related to the resident being found on the floor. The administrator indicated Nurse #1 informed her she had just checked on the resident at 5:30 am and the resident was fine. She (Nurse #1) informed her (administrator) she had suspected in previous times the resident had attempted to get up and close the door by herself prior to the incident, however she had not seen the resident actually do so. The administrator indicated further discussion with Nurse #1 revealed she did not hear the alarm sounding until she actually opened the resident door to administer medications at 6:00 am, and the resident was observed on the floor. The administrator stated as an intervention to prevent re-occurrence the staff was in-serviced (educated) to leave the residents door opened. The administrator stated she and the Staff Development Coordinator (SDC) completed the in-services on 9/10/14 as a result of Resident #1's fall. On 10/22/14 at 5:40 am, in an interview, NA (Nursing Assistant) #1 accompanied by the Director of Nursing (DON) acknowledged she (NA #1) was the primary NA for Resident #1 on 9/5/14 (date of fall) from 11 pm - 7 am. She stated she last observed the resident at 4:00 am during care rounds. She added the resident would at times attempt to get out of the bed unassisted by herself and needed reminders to ring the call bell for assistance. NA #1 stated she had never observed the resident attempting to close the door or to put the bed alarm device under the pillow. NA #1 stated at times she placed the resident's bed alarm (sounding device part) out of sight of the resident so she could not see it at the top of the pillow on the bed mattress, however she did not recall placing the alarm device underneath the pillow. NA #1 stated the type of alarm was one the resident laid on. She further indicated she did not recall if she (NA #1) closed the door, as this was against facility standards. NA #1 stated she had access to the resident Kardex and verified at 6:06 am, through computer access at the nursing station, she had access to review the plan of care for the residents. NA #1 did not elaborate where she place the bed alarm on the day Resident #1 was observed on the floor, or if she had notified a licensed nurse of the resident attempts to get up out of bed unassisted. On 10/22/14 at 6:10 am, in an interview, Nurse #1 accompanied by the DON and administrator acknowledged the incident (fall) witness statement dated 9/5/14 was her written statement, however did not indicate the exact location she observed the bed alarm device on 9/5/14 at 3:47 am or if she noticed the placement of the alarm device at 5:30 am. Nurse #1 indicated she did not hear the bed alarm sounding until she entered the resident's room at 6:00 am to administer meds and observed the resident on the floor beside the bed and noticed the alarm was located underneath the pillow and sounding. She stated she had never observed the resident attempting to place the bed alarm underneath the pillow, trying to get out of the bed unassisted or attempt to close her door independently. Nurse #1 denied placing the bed alarm sounding device underneath the pillow. On 10/22/14 at 9:16 am, in an interview, Nurse #2 accompanied by the administrator and DON stated she (Nurse #2) was responsible for the development of residents' care plans and the MDS. She stated she was not aware the staff was using a bed alarm device as a safety intervention for Resident #1, therefore the care plan and Kardex did not reflect such an intervention or guidance to the nursing staff or nursing assistants for usage. She indicated she was aware Resident #1 was at risk for falls on admission. Nurse #2 stated she expected if the staff implemented such as intervention as a bed alarm, he or she also needed to complete an interdisciplinary form, so communication is conveyed in the standup meeting and the care plan could have been updated. Nurse #2 stated basic interventions were implemented for the resident initially which did not include a bed alarm due to the resident did not score a 10 (high risk) or above for fall risk. She stated a bed alarm would not have been implemented for a fall score of 9. Nurse #2 concluded there was no facility legend for the fall assessment to be reviewed to reveal what a score of 9 would indicate; just it was not considered high risk. On 10/22/14 at 9:34 am, in an interview, the SDC accompanied by the DON and administrator indicated she (SDC) became aware Resident #1 was at risk for falls on admission. She also stated she was aware the resident had a fall on 9/5/14, which included knowledge the bed alarm device was located under the resident's pillow and the door closed. The SDC concluded she was present in the stand-up meeting on 9/5/14, when the team discussed the fall and the events surrounding the fall, however she did not in-service licensed nurses or nursing assistants related to ensuring bed alarms were not located under residents' pillow to minimized falls or so that staff could hear and respond to the sound. On 10/22/14 at 9:50 am, an observation was made with the DON, SDC and administrator with a similar bed alarm on the hallway (empty room) where Resident #1 resided. The bed alarm sounding device was placed under the pillow and the door to the room was shut and the sound of the alarm could be heard with a muffled sound 38 feet away with the door shut. Upon returning to the room and opening the door the sound became louder and when the SDC removed the pillow the sound became significantly louder and apparent to one. On 10/22/14 at 12:00 pm, in an interview, the DON accompanied by the administrator stated she (DON) expected the bed alarm to have been placed according to the manufacturer's instructions so the alarm device could reach its full capacity when alarming and in-services for licensed nurses and nursing assistants to have been initiated on 9/5/14 (date of the fall), and the resident's care plan to reflect a bed alarm prior to the fall due to the resident was assessed at risk for falls on admission. The administrator added the 24 hour report/change in condition report is brought to each morning stand up meeting for discussion and Nurse #2 was present in the meeting held on 8/1/14.

Based on observation, resident and staff interviews and record review, the facility failed to assess the circumstances surrounding falls so that effective interventions could be implemented for one of three residents sampled (Res.#142). The facility also failed to ensure a safe water temperature in 3 of 4 residents' rooms (rooms #10, #14, #31) where the temperature exceeded 116 Farenheit. Findings included: Resident #142 was admitted [DATE] with [DIAGNOSES REDACTED]. The admission 5 day Minimum Data Set (MDS), dated [DATE] noted Res. #142 was cognitively intact, and was extensive assistance for all Activities of Daily Living (ADLs), with the physical assistance of one person. A review of the admission Care Area Assessment (CAA) dated 9/5/13 noted Res. #142 had a recent fall without injury, but was at risk for injurious falls, and that a care plan would be developed, and was signed by the MDS coordinator and dated 9/5/13. Care plan dated 9/7/13 noted a focus of requiring assistance for ADL care secondary to resident ' s general debility/decline. The goal was that the resident would become independent with ADLs by next review. Approaches included: allow the resident rest breaks between tasks, physical or occupational therapy as ordered, one person to assist the resident with toileting/transfers every day and as needed. A review of the care plan noted no care plan for falls. A review of the falls incident reports for Resident #142 revealed that there were falls on: 9/20/13 An unobserved fall in the resident ' s bathroom, the resident was encouraged to ask for assistance. 10/12/13 The resident fell in his room while trying to transfer from bed to the wheelchair. Resident stated that he slipped. Urinal offered to keep at bedside and encouraged to call for assistance. 10/18/13 The resident fell in the bathroom and requested to go to the emergency room . It was determined in the emergency room that Res. #142 had a sprained knee. Facility offered the resident a bed/chair alarm, which he refused. The resident continues to transfer self to toilet without assistance. 10/23/13 A fall in the resident bathroom occurred when the resident was on the commode, trying to transfer to the wheelchair and fell . The bathroom was assessed and report noted that assist bar was on appropriate side (unaffected side). A second rail could not be added due to the structure of the bathroom. 10/26/13 The resident was attempting to transfer himself from the bed to the wheelchair, slipped on the call bell cord and fell on his bottom. All cords were removed from the floor. 10/28/13 The resident was found on the floor of his room. The resident stated that the wheel chair went out from under him. No injuries noted. Facility will offer a bed/chair alarm. Remind the resident to lock brakes. The resident was placed on a list for psych services on 11/11/13, for any recommendations related to erratic moods and frequent falls. On 11/14/13 at 9:30 AM, in an interview, Res.#142 stated that he sometimes has to wait for help to the bathroom, because it is hard for him to maneuver in the bathroom in his wheelchair. His right side is his "good" side and the grab bar is on the right, but on the other side of the toilet. He states that sometimes he can not wait to go to the toilet and he goes into the bathroom himself. Res. #142 stated that the Nurse Aide (NA) came into his room and told him that sometimes he would have to wait for someone to help him. Res. #142 stated that he asked the NA " Ma ' am, do you want me to go in my pants? " Res. #142 has had 6 falls since Sept. 20, and he stated that he had another fall yesterday, and hit his shoulder. On 11/14/13 at 10:00 AM, in an interview, Nurse #1 stated that Res. #142 did fall on 11/13/13 and an x-ray was taken of his shoulder. A review of the x-ray report revealed that there were no fractures or damage to the shoulder. On 11/14/2013 at 11:00 AM in an interview, the MDS nurse stated that falls are assessed and discussed in the accidents/incidents meetings that are held weekly. On 11/14/13 at 2:10 PM, the Director of Nursing (DON) stated that since Res. #142 is cognitively intact, he can make decisions about whether to try and transfer himself or not. The DON stated that the facility does encourage Res. #142 to call for assistance. 2. Record review of a facility policy entitled "Water Temperatures Patient Care Areas" dated 3/5/2003 indicated under policy statement "Water temperatures in hand sinks or bathtubs will be maintained at levels that will not scald or harm residents." The policy also indicated "To be acceptable, this reading should be between 100 and 116 degrees F (Farenheit). If the reading is not between 100 and 116 degrees F, all staff should be notified immediately and no hot water should be used in patient care areas until the temperature has been corrected. It will be the responsibility of the Administrator and Director of Nursing to notify oncoming staff of any problems related to water temperatures. After any problem with maintaining proper water temperatures is corrected, water temperatures will be taken and recorded every two (2) hours for the next 24 hours to ensure the problem has been corrected." A temperature observation with the Maintenance Director (MD) on 11/13/13 at 2:07pm on three separate resident halls, revealed the following room water temperatures in the residents' bathroom sinks with a calibrated thermometer: (Prior to sink water temperature checks, the MD placed the metal shaft of the thermometer into an ice bath and calibrated it to 32F. After the thermometer was calibrated to 32F, the MD placed the calibrated thermometer metal shaft into an empty cup, and placed the cup containing the thermometer into each of the resident's sink running hot water until the thermometer read its maximum temperature.) Rm 14 - 120F Rm 10 - 120F Rm 31 - 120F In an interview with the MD on 11/13/13 at 2:20 pm, the MD stated he documented in a log weekly water temperatures in resident rooms. The MD stated a new mixing valve was installed on 10/1/13. The mercury thermometer above the new mixing valve read 128F. When asked if the water was too hot, the Maintenance Director stated "yes, the water is too hot, it should be 110F-116F." In an interview with the Executive Director on 11/13/13 at 2:26 pm, the Director stated "if the water temperature is too high, we would adjust the water temperature until it was within range, and then we would stop the showers until the temperatures were back within safe range."

Based on observations, record review, and staff interview, the facility failed to ensure a privacy bag was utilized for 1 of 6 residents with a urinary catheter. Findings include: 1. Resident # 25 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment of 1/2/12 indicated Resident # 25 had severe cognitive deficits and required all aspects of care rendered by staff. Observations on 10/15/12 at 3:06 PM revealed Resident # 25 lying in bed. The urinary catheter bag was attached to the bedframe on the side of the bed facing the door of the room. The uncovered catheter bag contained urine and was visible from the hall. Observations on 10/15/12 at 5:11 PM revealed Resident # 25 being assisted from the bed to a wheelchair by Nursing Assistant (NA) # 1. When Resident # 25 was seated, NA # 1 placed the urinary catheter bag into a privacy bag hanging from the back of the wheelchair. NA # 1 stated a privacy bag was not used unless a resident was in a wheelchair. During an interview on 10/18/12 at 2:42 PM with the Administrator and the Director of Nursing (DON), the Administrator stated there was usually a privacy bag on both sides of the bed as well as on a wheelchair for a resident with a urinary catheter. The Administrator stated the catheter bag should be in a privacy bag whether the resident was in or out of bed. During the interview, the DON stated that utilizing a privacy bag was included in the instructions to staff on care of a catheter. The DON stated the expectation was for the urinary catheter bag to be covered. During an interview on 10/18/12 at 3:05 PM, the Staff Development Coordinator (SDC) stated that during orientation, new nursing assistants were instructed in dignity related to the use of privacy bags to cover urinary catheter bags whether the resident was in or out of bed.

Based on record review and family and staff interviews, the facility failed to notify the responsible party when a resident was moved to a different room, for one of one resident (Resident #2). Findings include: Resident #2 was admitted [DATE] with a [DIAGNOSES REDACTED]. She needed extensive assistance with all Activities of Daily Living (ADLs). A review of the nurse notes revealed that on 9/2/12 Resident #2 was moved to a different room because of a medical condition. This move occurred on the 3PM to 11PM shift. . On 10/16/2012 at 9:30 AM, in a family interview, Resident #2's Responsible Party (RP) stated that the facility moved the resident into a different room due to a medical condition, and that she was not notified. In an interview on 10/18/12 at 9:00 AM the Social Worker stated that she was the person who would go over the admission packet with the families, and explained that if there was a room change the RP must be notified. She stated that if a resident was moved in the middle of the night, the facility may wait until the next day and notify the RP, but otherwise the RP would be notified the same day. She stated that her expectation would be that the nurse would also chart that the RP was notified. The Social Worker stated that she was aware that the RP was not notified and that the RP came into the facility and spoke to the nurse. On 10/18/12 at10:45 AM, in an interview, the Director of Nursing (DON) stated her expectation was that the nurse should notify the RP and chart that she notified the RP. The DON also stated that the RP may not be notified until morning, but that it should be charted. She also stated that the nurse should notify the family. On 10/18/12 at 11:40 AM, Nurse #1 stated that the floor nurse who was assigned to that resident would be responsible for notifying the responsible party.