Every finding on record at Blue Ridge Rehabilitation and Nursing

Based on staff interview, clinical record review, and facility document review, the facility staff failed to inform the physician of a change in condition timely for one of nine residents in the survey sample, (Resident #3). The findings include:The physician was not notified of a change in condition (nausea and vomiting) timely for Resident #3 (R3). Diagnoses for R3 included congestive heart failure, end stage renal disease, chronic obstructive pulmonary disease, metabolic encephalopathy, and acute cystitis without hematuria. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 12/17/25. R3 was assessed with a cognitive score of 11 indicating moderately cognitively impaired. Review of R3's clinical record revealed the following via progress notes: A nurse practitioner note dated 3/23/26 indicated R3 was being seen for nausea and vomiting. The nurse practitioner ordered Zofran for nausea and due to history, ordered urinalysis for possible urinary tract infection (UTI). A nurses assessment note dated 3/24/26 indicated that R3 stated had complained of nausea for the past several days. Prior to the nurse practitioner note dated 3/23/26 there were no notes regarding R3 having nausea and vomiting. The last progress note prior to 3/23/26 was dated 3/18/26 and did not include any concerns with R3. On 5/4/26 at 1:00 p.m. registered nurse (RN #1, nurse that wrote the note on 3/24/26) was interviewed. RN #1 verbalized being on a four-day break and upon returning noticed that R3 was not at baseline and it was reported that by R3 of feeling nauseated and had been vomiting for the past few days. On 5/4/26 at 1:35 p.m. the facilities nurse practitioner (NP) was interviewed. NP verbalized while assessing R3's roommate, R3 had reported not feeling well over the weekend and had had some nausea and vomiting. NP said that there was a basin at R3's bedside containing a small amount of gastric emesis. NP verbalized assessing R3 and ordered an antiemetic and a urinalysis due to a history of UTI. NP said that the staff should have contacted 3rd eye (an outside company) about the change in condition or tried to contact an on-call person to let them know of the change in condition but was unaware of any concerns until speaking with R3. On 5/4/26 at 6:15 p.m. license practical nurse (LPN #1, nurse responsible for documenting a change of condition) was interviewed. LPN #1 verbalized being assigned to R3 on the night shift on 3/22/26. LPN #1 verbalized during report given by the off going 3-11 shift it was reported that R3 had been nauseated and had vomited. LPN #1 verbalized there was no documentation of the change in condition on any of the previous shifts, which prompted LPN#1 to document a change in condition report. A policy titled Notification of Changes read in part: The facility must inform [.] the physician [.] when there is a change requiring such notification. Circumstances requiring notification include: [.] Circumstances that require a need to alter treatment. On 5/5/26 at 2:30 p.m. the above finding was presented to the director of nursing and administrator. No other information was presented prior to exiting the facility on 5/5/26.

Based on staff interviews, facility document review and clinical record review, the facility staff failed to follow professional standards of quality for one of nine residents in the survey sample (Resident #3). The findings include:The facility staff did not document assessments regarding a change in condition for Resident #3 (R3). Diagnoses for R3 included congestive heart failure, end stage renal disease, chronic obstructive pulmonary disease, metabolic encephalopathy, and acute cystitis without hematuria. The most current MDS (minimum data set) was an admission assessment with an ARD (assessment reference date) of 12/17/25. R3 was assessed with a cognitive score of 11 indicating moderately cognitively impaired. Review of R3's clinical record revealed the following via progress notes: A nurse practitioner note dated 3/23/26 indicated R3 was being seen for nausea and vomiting. The nurse practitioner ordered Zofran for nausea and due to history, ordered urinalysis for possible urinary tract infection (UTI). Prior to the nurse practitioner note dated 3/23/26 there were no notes regarding R3 having nausea and vomiting. The last progress note prior to 3/23/26 was dated 3/18/26 and did not include any concerns with R3. A nurses assessment note dated 3/24/26 indicated that R3 stated had complained of nausea for the past several days. On 5/4/26 at 1:00 p.m. registered nurse (RN #1, nurse that wrote the note on 3/24/26) was interviewed. RN #1 verbalized being on a four-day break and upon returning noticed that R3 was not at baseline and it was reported by R3 of feeling nauseated and had been vomiting for the past few days. On 5/4/26 at 1:35 p.m. the facilities nurse practitioner (NP) was interviewed. NP verbalized while assessing R3's roommate (the morning of 3/23/26), R3 had reported not feeling well over the weekend and had had some nausea and vomiting. NP said that there was a basin at R3's bedside containing a small amount of gastric emesis. NP verbalized assessing R3 and ordered an antiemetic and a urinalysis due to R3 having to a history of UTI. NP said that the staff should have contacted 3rd eye (an outside company) about the change in condition or tried to contact an on-call person to let them know of the change in condition but was unaware of any concerns until speaking with R3. NP said that staff seemed aware of the change in condition and were monitoring the concern, however there was no documentation to review regarding the concern. On 5/4/26 at 3:00 p.m. the director of nursing (DON) was interviewed regarding documenting in the clinical record. The DON verbalized that typically documentation (in progress notes) is not done when a resident is not skilled unless there is a concern. On 5/4/26 at 6:15 p.m. license practical nurse (LPN #1, nurse responsible for documenting a change of condition) was interviewed. LPN #1 verbalized being assigned to R3 on the night shift on 3/22/26. LPN #1 verbalized during report given by the off going 3-11 shift it was reported that R3 had been nauseated and had vomited. LPN #1 verbalized doing an assessment on R3 and monitoring throughout the night and did not have any vomiting episodes but was nauseated. LPN #1 said that there was no documentation from the previous shifts although the concern had been verbally reported from one shift to the other and was being monitored and addressed. LPN #1 said that typically there should be documentation in progress notes indicating the status of a resident that has had a change in condition. LPN #1 verbalized that due to the concerns going on with R3 and the day shift nurse (RN #1) coming back from being off, saying R3 was not at her baseline led to the documentation of a change in condition. The facility policy titled Documentation in Medical Record read in part: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. On 5/5/26 at 2:30 p.m. the above finding was presented to the director of nursing and administrator. No other information was presented prior to exiting the facility on 5/5/26.

Based on staff interview, and clinical record review, the facility staff failed to develop and implement a baseline care plan for one Resident (Resident #4) in a survey sample of 5 residents. The findings included: According to the clinical record, diagnoses for Resident #4 (R4) included: Alzheimer's disease, HIV, anxiety disorder, dementia, and malnutrition secondary to disease process. The most current MDS (minimum data set) was a a discharge assessment with an ARD (assessment reference date) of 5/8/24, which assessed R4 with short-term memory problems and severely cognitively impaired. On 5/6/25, a clinical record review was conducted for R4. R4 was admitted to the facility on [DATE]. There was no evidence that an admission assessment had been completed. Review of the comprehensive care plan was noted to have missing interventions for ADL care including bed mobility, dressing, eating, and transfers. On 5/6/25 at 11:00 a.m. the MDS coordinator was interviewed (registered nurse, RN #1). RN #1 reviewed R4's clinical record and verbalized that the admission assessment was missing, explaining that when a new resident is admitted to the facility, the nurses should complete an admission assessment which incorporates the baseline care plan and should be completed within two days. RN #1 reviewed the care plan for R4 and agreed that the baseline care plan was not completed for ADL care. On 5/7/25 at 9:30 a.m., the above information was presented to the director of nursing and administrator. No further information was provided prior to exit conference on 5/7/25.

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to honor resident's food preferences for two residents (Resident #5, R5 and Resident #6, R6) out of a survey sample of 11 residents. The findings included: 1. The facility staff served R5 foods that were listed on the meal ticket as food dislikes. On 12/18/25 at 12:15 p.m., an observation was conducted of the lunch meal. During the observation, the surveyor observed R5's meal ticket. R5 was served carrots, broccoli and cauliflower, and all three of these foods were listed under her food dislikes list on her meal ticket. On 12/18/25 at 12:30 p.m., an interview was conducted with R5. R5 said, I get food I don't like often, and I just leave it on my plate. On 12/19/25 at 9:05 a.m., an interview was conducted with the dietary manager. The dietary manager stated the purpose for the food dislikes on the meal ticket was for dietary to know the resident's preferences and what the resident does not like to eat. The dietary manager said, If food dislikes were carrots, broccoli and cauliflower, they should not have been served and should have been substituted with another vegetable. The servers should go by their meal tickets. 2. The facility staff served R6 foods that was listed on the meal ticket as food dislikes. On 12/18/25 at 12:15 p.m. an observation was conducted of the lunch meal. During the observation, the surveyor observed R6's meal ticket. R6 was served carrots, and this food was listed on her food dislikes list on her meal ticket. On 12/18/25 at 12:35 p.m. an interview was conducted with R6. R6 said, It doesn't matter, nothing will be done about this. On 12/19/25 at 9:05 a.m. an interview was conducted with the dietary manager. The dietary manager stated the purpose for the food dislikes on the meal ticket was for dietary to know the resident's preferences and what the resident does not like to eat. The dietary manager said, I f food dislikes was carrots, they should not have been served the melody and should have been substituted with another vegetable. The servers should go by their meal tickets. On 2/19/25 at 11:00 a.m. a facility documentation review was conducted. The policy titled, Food Preparation Guidelines, read in part, honoring resident preferences, as possible, regarding food and drinks. On 2/19/25 at 11:45 a.m. an end of day meeting was conducted with the administrator and director of nursing. The administrator handed the surveyor an updated preference assessment completed today by the dietary manager for R5 and an education sign in sheet for the dietary department on food preferences completed today. No further information was provided prior to the conclusion of the survey.

Based on observation, clinical record review, staff interview and facility documentation review the facility staff failed to administer oxygen according to physician orders for two residents (Resident#3, R3 and Resident #4, R4) out of a survey sample of 11 residents. The findings included: 1. The facility staff failed to have R3's oxygen concentrator providing the correct number of liters per minute according to the physician's order. On 2/18/25 at 2:50 pm an observation was conducted of R3's oxygen concentrator. The oxygen was set on three liters per minute. On 2/18/25 at 3:00 p.m. a clinical record review was conducted. The physician orders were reviewed. The oxygen order read, Oxygen continuous 2LPM [liters per minute] via NC [nasal cannula]. The treatment administration record was signed off by the registered nurse, RN# 1 (RN1) on 2/18/25. RN1 signed that R3 was receiving oxygen at 2LPM. On 2/18/25 at 3:15 p.m. an interview was conducted with RN1. RN1 was in R3's room and was asked to look at the oxygen concentrator setting. R1 said, It's on 3LPM and should be on 2LPM. R1 adjusted the oxygen concentrator setting to 2LPM. 2. The facility staff failed to have R4's oxygen concentrator providing the correct number of liters per minute according to the physician's order. On 2/18/25 at 2:55 pm an observation was conducted of R4's oxygen concentrator. The oxygen was set on two and half liters per minute. On 2/18/25 at 3:00 p.m. a clinical record review was conducted. The physician orders were reviewed. The oxygen order read in part, .supplemental O2 [oxygen] 2L, if < 92% on 2L may increase to 3L. On 2/18/25 at 3:15 p.m. an interview was conducted with RN1. RN1 was in R4's room and was asked to look at the oxygen concentrator setting. R1 said, It's on 2.5LPM and should be on 2LPM and can have 3 liters if oxygen saturations are less than 92%. R1 adjusted the oxygen concentrator setting to 2LPM. On 2/19/25 at 11:15 a.m., a review of facility documentation was completed. The facility document titled, Oxygen Administration, read in part, .oxygen is administered under orders of a physician. On 2/19/25 at 11:45 a.m., an end of day meeting was conducted with the administrator and director of nursing, and the above concerns were discussed. No further information was provided prior to the conclusion of the survey.

Based on staff interviews, clinical record review, and facility documentation review the facility staff failed to provide notification to the family of a change in condition for one resident (Resident #2, R2) out of a survey sample of 11 residents. The findings included: The facility staff failed to notify the family that R2 was sent to the emergency room. On 2/19/25 at 9:45 a.m. an interview was conducted with licensed practical nurse, LPN#5 (LPN5), unit manager on the A wing. LPN5 stated that it was only one appointment she was aware of that R2 had missed. LPN5 stated that when dialysis sent R2 to the emergency room (ER), they did not let the son know and when the transport company came back to the facility to pick up someone the transport driver let the facility know R2 was transported to the ER from dialysis. LPN5 said, we didn't notify the son when we found out, no one notified the son she was at the emergency room. He found out when he came to take her to an appointment the next day. LPN5 stated that someone from the facility was supposed to notify the son when we found out R2 was at the emergency room. On 2/19/25 at 10:15 a.m. a clinical record review was conducted. A progress note was reviewed that was written on 10/15/25. The progress notes in R2's chart read, [hospital name redacted] called for patient status. Notified that patient has been admitted . On 2/19/25 at 10:45 a.m. a review of the facility documentation was conducted. The facility document titled, Notification of changes, read in part, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, resident's representative when there is a change requiring notification. On 2/19/25 at 11:45 a.m. an end of day meeting was conducted with the administrator and director of nursing, and the above concerns were discussed. No further information was provided prior to the conclusion of the survey.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the flu and pneumonia immunizations to 3 of 5 residents (Resident #80 - R80, Resident #42 -R42, and Resident #70 - R70) sampled for immunizations. The findings included: On 8/27/24, five residents were reviewed for compliance with immunization protocols, as part of the infection control task. During this review, the clinical record of each resident was reviewed. For R80 and R42, the clinical record documented no evidence that either resident had been educated about the vaccines or offered the flu and pneumonia vaccines since admission. There was no documentation for R80 or R42 regarding consent or refusal of the immunization. R70's clinical record had no evidence of being offered the flu vaccine, despite being admitted during the flu season. R70's clinical record revealed that she had received Prevnar 13, but there was no indication that the pneumococcal 23 vaccine was offered. The clincal record reviews revealed that each of the residents had been residing in the facility for at least eight months and that all were residing in the facility during the flu season. On 8/28/24 at 4:32 p.m., an interview was conducted with the facility's infection preventionist (IP). During the interview, the IP reviewed each record and confirmed the lack of documentation regarding the flu and pneumonia immunizations, including education and consents for R80, R42, and R70. The IP said, I don't see anything where it was offered. When asked about the facility's process with regards to immunizations, the IP stated, The floor nurses offer immunizations upon admission, then we can contact the responsible party to see if that is something they want. When asked why immunizations are important, the IP said, To make sure we don't have outbreaks. The facility policy titled, Influenza Vaccination with a review date of 12/1/22, was reviewed. This policy read in part, . 2. Influenza vaccinations will be routinely offered annually from October 1st through March 31st unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine . 8. The resident's medical record will include documentation that the resident and/or the resident's representative was provided education regarding the benefits and potential side effects of immunization, and that the resident received or did not receive the immunization due to medical contraindication or refusal . The facility's policy titled Pneumococcal Vaccine (Series) (revised 12/1/22) documented under procedures, 1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received. 2. Each resident will be offered a pneumococcal immunization unless it is medically contraindicated, or the resident has already been immunized . 3. Prior to offering the pneumococcal immunization, each resident or resident's representative will receive education regarding the benefits and potential side effects of the immunization . On 8/28/24 at approximately 5:30 p.m., the facility administrator, director of nursing, and corporate nurse consultant was made aware of the above findings. The Director of Nursing stepped out to see if she could find any additional information but returned and reported that she had nothing further to provide. No additional information was provided.

Based on resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure two residents (Resident #32-R32 and Resident #249) were free from significant medication errors/omissions, in a survey sample of 31 residents. The findings included: 1. For Resident #32 (R32), the facility staff failed to ensure the resident received antibiotic medication, as ordered by the physician. On 8/26/24 at 7:16 p.m., R32 was interviewed in his room. During the interview, R32 reported that he had osteomyelitis, a serious bone infection, and had been treated for c-diff (clostridioides difficile - an infection of the colon) but had missed a lot of his antibiotic doses .because they don't have the vanc [vancomycin] frequently. On 8/27/24, a clinical record review was conducted. This review revealed a physician order dated 7/20/24 that read, Vancomycin HCl Suspension 50MG/ML Give 2.5 ml by mouth in the morning every 2 day(s) for c diff for 8 Weeks. According to the medication administration record (MAR), R32 was not provided the vancomycin on 8/9/24 and 8/21/24. On 8/9/24, there was a nursing note that indicated the vancomycin was not available, re-ordered. On 6/21/24, there was a physician order written that read, Vancomycin HCl Suspension 50 MG/ML Give 2.5 ml by mouth four times a day for c diff for 14 Days. According to the MAR, R32 missed 12 of the scheduled doses of vancomycin. There was a progress note dated 6/28/24, that indicated that this physician ordered antibiotic was on order and another that read, none available - reordered. There was no indication that the doctor had been called and made aware of the missed doses or given the opportunity to give alternate orders. 2. For Resident #249 (R249), who was an insulin dependent diabetic, the facility staff failed to administer multiple doses of insulin and the physician was not notified of the omitted doses of medication. On 8/26/24 at 6:35 p.m., R249 was interviewed in his room. The resident expressed concern that, they run out of antibiotic often. They say they have to get it through pharmacy. The resident explained that he has an artificial hip joint and is on the antibiotic for that. On 8/27/24, a clinical record review was conducted. This review revealed R249 was receiving antibiotics as ordered with no indication of missed doses. During the record review it was noted that the resident had a physician order for Basaglar Kwik Pen 100 UNIT/ML Solution pen-injector Give 10 unit by mouth in the morning for DM [diabetes mellitus]. According to the MAR, R249 was not given the Basaglar insulin on 8/7/24, 8/12/24-8/15/24. According to the nursing progress notes there was no indication why the dose on 8/7/24 was not administered. There was a nursing note entry on 8/12/24, regarding the Basaglar insulin that read, not available. There was no indication as to why the insulin was not given on 8/13/24-8/15/24. There was another physician order for Humalog Kwik Pen Solution Peninjector100 UNIT/ML (Insulin Lispro (Human)) Inject 8 unit subcutaneously three times a day for DMII, ordered 8/21/24. According to the MAR, R249 missed two does on 8/21/24 and 8/22/24. There was a nursing medication administration note dated 8/22/24 at 9:48 a.m., that read, awaiting arrival. There was no indication that the physician had been called and notified that the medication was not available for administration, nor that a call to the pharmacy had been placed. On 8/27/24 at 2:22 p.m., an interview was conducted with licensed practical nurse # 6 (LPN #6). LPN #6 was asked to explain what the process is if during medication administration she doesn't have a medication available. LPN #6 said, if a medication is not available, I will check the cart, check the cubex [emergency supply of medications], call the doctor to notify them and see if there is a substitution that needs to be done or if it can be held. I call the pharmacy and see when the medicine will get here in a reasonable time and put in a note about it. Following the above interview with LPN #6, the nurse took the surveyor into the medication room and observations were made of the emergency insulin supply. Within the box it was noted that the box was supposed to contain both Humalog/Lispro insulin pen and Basaglar. However, upon opening the box only aspart and levimier was present. LPN #6 said the pharmacy is supposed to restock/change out the box, but she didn't know how often that occurred. LPN #6 also provided the surveyor with a listing of the medications contained in the cubex and it was noted that vancomycin was available only in a 1 gram and 500 mg injectable dose. On 8/28/24 at 3:31 p.m., an interview was conducted with the unit manager. She was made aware of the above findings regarding insulin not being available. The unit manager said, there are times when we don't have insulin. The unit manager again accompanied the surveyor into the medication room and accessed the emergency supply of insulin which revealed only levimier and a 70/30 mix. The pharmacy doesn't change it out very often, we don't have any slips to let them know when they are being pulled, so unless you pull from the cubex or IV box, there is no record of what you are pulling, there are no insulin slips. When asked if she would expect them to check the other unit to see if the medication was available in their box and if not, to let doctor know, the unit manager said, absolutely. On 8/28/24 at 3:35 p.m., an interview was conducted with registered nurse #1 (RN #1), who was working on the other unit. RN #1 was asked to explain what is done if insulin is not available. RN #1 said, we go to refrigerator and look and if not there go to stat box we call the doctor and get a hold order and check blood sugars often. We call pharmacy and beg them to send it to us. RN #1 was asked if they had a local pharmacy they could call as a back up to deliver and she said, no, everything comes out of Maryland. The surveyor was then accompanied into the medication room on that unit and the emergency box of insulin was observed, it was noted that the following insulins were present: Aspart insulin pen, Levemir flex pen, Lispro, Humulin N Kwik pen, Lispro Kwik pen and a multi-dose vial of Humulin R. A review was conducted of the facility policy titled, Unavailable Medications. The policy read in part, 1. The facility maintains a contract with a pharmacy provider to supply the facility with routine, prn [as needed], and emergency medications. 2. A STAT [emergent] supply of commonly used medications is maintained in-house for timely initiation of medications. 3. The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. 4. Medications may be unavailable for a number of reasons. Staff shall take immediate action when it is known that a medication is unavailable: a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. b. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. Obtain alternative treatment orders and/or specific orders for monitoring resident while medication is on hold . 5. If a resident misses a scheduled dose of the medication, staff shall follow procedures for medication errors, including physician/family notification, completion of a medication error report, and monitoring the resident for adverse reactions to omission of the medication. On 8/28/24, during a mid-day meeting, the facility administrator and director of nursing were made aware of the above findings. No additional information was provided.

Based on employee record review, facility document review, and staff interview, the facility staff failed to follow abuse prevention policies regarding pre-employment screening and background checks for 18 of twenty-five records reviewed. The findings include: Twenty-five employee records were reviewed for compliance with the facility's policy for background checks and pre-employment screenings. Of the twenty-five records reviewed, 18 records had no reference checks, 2 licenses were not verified prior to employment; and 6 records documented no sworn statement regarding any criminal history. The list of employee records identified with missing information was provided to the facility's human resource manager (other staff #5) on 8/28/24. On 8/28/24 at 5:04 p.m., the human resource manager (other staff #5) was interviewed about the missing reference checks, license verifications, and criminal history statements. The human resource manager stated, I've reviewed and am not finding any of the missing information. The human resource manager stated the employee records were unorganized with information being difficult to locate. The human resource manager stated the facility required a statement about criminal history, criminal background check, license verification and reference checks for all new employees. The facility's policy titled Background Investigation (revised 10/28/20) documented, Job reference checks, drug screenings, licensure verifications and criminal conviction record checks are conducted on all personnel making application for employment with this company .The facility will not employ individuals who .Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law .Have a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of resident, or misappropriation of resident property . Have a disciplinary action in effect against his or her professional license in a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of resident, or misappropriation of property . This finding was reviewed with the administrator, director of nursing, and regional director of clinical services, during a meeting on 8/28/24 at 7:00 p.m., with no further information provided prior to the end of the survey.

Based on staff interview and clinical record review, the facility failed to ensure preferences were met for showers/bathing for 3 of 31 residents. Resident #'s 71, 57, and 53 did not receive showers on multiple scheduled shower days. The Findings Include: 1. Resident #71 (R71) received one shower between 7/29/24 through 8/27/24. R71's most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 8/5/24 and assessed R71 with a cognitive score of 15 indicating cognitively intact. On an annual MDS dated [DATE] preferences were assessed and indicated that it was very important to choose between tub bath, shower and bed bath. On 8/26/24 at 7:40 PM during an interview with R71, R71 verbalized showers were not being provided twice a week as scheduled and rarely gets a shower anymore and contributed it to staff just not doing their job. R71 said that the staff are providing bed baths, but likes to get in the tub in the evening because it helps her (R71) to relax and sleep. R71's showers schedule was reviewed and indicated R71 was to get showers on Wednesday and Saturday. Review of the ADL (Activities of daily Living) shower report from 7/29/24 through 8/27/24 documented R71 received one shower/tub bath out of 6 opportunities. On 8/27/24 at 4:53 PM license practical nurse (LPN #1, unit manager) was interviewed regarding R71 not getting showers. LPN #1 said that the aides are supposed to be documenting showers on the ADL report and telling the nurse if a resident refused or did not get a shower. LPN #1 then reviewed hand documented shower reports forms for R71 also indicating one shower given to R71 between 7/31/24 and 8/24/24. LPN #1 verbalized we are short staffed on occasion but not to the extent of residents not getting showers. On 8/28/24 at 2:48 PM the above finding was presented to the administrator, director of nursing (DON), and nurse consultant. The DON verbalized awareness to the concern and has been trying to change some things such as using a dedicated shower aide, but the aides are saying, they sometimes can't get to everyone. No other information was presented prior to exit on 8/28/24. 41449 2. For resident #57 (R57), the facility staff failed to accommodate the resident's preference to receive showers twice weekly. On 8/26/24 at approximately 7 p.m., R57 was visited in his room. R57 reported to the surveyor that he was not getting showers. When asked how often he was supposed to get showers, he said twice weekly. On 8/27/24, a clinical record review was conducted of R57's chart. This review revealed that from July 27-August 27, 2024, R57 received five showers, which occurred on 8/1/24, 8/5/24, 8/12/24, 8/16/24, and 8/22/24. According to R57's most recent annual minimum data set (MDS) assessment, with an assessment reference date of 7/4/24, R57 was assessed as having been able to make himself understood. Section F of the MDS, which was preferences for customary routine and activities was not assessed, as indicated by a dash. In section GG, it indicated that R57 required substantial/maximal assistance of facility staff for showers and bathing. On 8/27/24, a review of the facility's grievance log was reviewed. This revealed that on 7/11/24, R57 filed a grievance about not receiving regularly scheduled showers. There were also five other residents that had filed complaints in July about the lack of showers. On 8/27/24, during a group interview conducted with nine residents, they expressed ongoing concerns about the lack of showers. Review of the resident council minutes revealed four meetings in 2024, two in February, once of which was a make-up meeting for January, August and one which had no date. During those meetings residents expressed concerns about the lack of showers. On 8/27/24, a review of the facility's shower assignment sheet was reviewed and revealed that each room within the facility was assigned two shower days per week on first and second shifts. According to the shower schedule, R57's assigned shower days were Monday and Thursdays on the 7am-3 pm shift. During the survey, the survey team observed an adequate quantity of nursing staff available on each of the units and were unable to determine why resident's requests and preferences with regards to showers were not being upheld. On 8/27/24-8/28/24, various staff interviews were conducted with numerous nursing staff, which included but were not limited to licensed practical nurses (LPN #4 and LPN #5), the unit manager (LPN #3), and certified nursing assistants (CNA #6 and CNA #7), all who reported showers were given twice weekly based on the shower assignment. The facility's ADL (activities of daily living) policy was reviewed. It made no mention as to the frequency of showers. It read in part, . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . On 8/27/24 at approximately 1:30 p.m., during a meeting held by the survey team with the facility administrator and director of nursing (DON) the above concerns regarding the lack of resident's preference for showers was discussed. The director of nursing said this had been an area of ongoing concern that they had been working to address but were still having issues with and had not fully resolved. The DON indicated that a lack of staff was not the issue, they just weren't being done. No additional information was provided. 21875 3. Resident #53 did not receive a shower per her preferred frequency of twice per week. Resident #53 (R53) was admitted to the facility with diagnoses that included coronary artery disease, hypertension, diabetes and depression. The minimum data set (MDS) dated [DATE] assessed R53 as cognitively intact and as requiring partial/moderate assistance for showers/bathing. On 8/26/24 at 6:46 p.m., R53 was interviewed about quality of life/care in the facility. When asked about assistance with baths/showers, R53 stated she was not getting two showers per week as she preferred. R53 stated she had been ten days without a shower. R53 stated she preferred a shower to a bed bath, and she knew it was a state requirement for residents to get two showers per week. R53 stated her scheduled shower days were Tuesdays and Fridays. R53 stated she did not know why she was unable to get a shower twice per week. R53's shower records from 7/29/24 through 8/25/24 documented the resident's last shower was on 8/16/24. R53's shower records documented four showers in the last 30 days on 7/30/24, 8/2/24, 8/13/24 and 8/16/24. R53's clinical record documented no evidence the resident was offered and refused showers. R53's plan of care (revised 6/6/24) documented the resident required assistance with activities of daily living due to limited mobility, weakness and history of falls. Interventions to maintain hygiene and activities of daily living included helping with bathing/showering as needed. On 8/28/24 at 8:23 a.m., certified nurses' aide (CNA) #2 caring for R53 was interviewed about showers. CNA #2 stated residents wanting showers were scheduled twice per week and assignments were recorded in a shower book at the nursing desk. CNA #2 stated R53's showers were scheduled for evenings. CNA #2 stated she was not sure why R53 was not getting twice per week showers. On 8/28/24 at 8:49 a.m., the licensed practical nurse unit manager (LPN #1) was interviewed about R53's shower frequency. LPN #1 stated R53 was scheduled to get a shower twice per week during the evening. LPN #1 stated she did not know why R53 was not getting showers twice per week. LPN #1 stated showers given were documented in the activities of daily living records. On 8/28/24 at 2:48 p.m., the director of nursing (DON) was interviewed about R53 not getting showers twice per week as preferred. The DON stated residents were supposed to get showers at least twice per week if desired. The DON stated, I've looked at shower records. They [residents] are not getting them. The DON stated there were enough staff members but that showers were just not getting done. The DON stated she had audited showers in the last two weeks and recognized there was an issue with shower frequency. This finding was reviewed with the administrator, DON and regional director of clinical services during a meeting on 8/28/24 at 2:00 p.m. with no further information presented prior to the end of the survey.

Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide written notice prior to room changes for five of thirty-one residents in the survey sample (Residents #12, #13, #53, #57 and #200). The findings include: 1. No written notice was provided to Resident #53 prior to room changes on 5/10/24 and 7/1/24. Resident #53 (R53) was admitted to the facility with diagnoses that included coronary artery disease, hypertension, diabetes and depression. The minimum data set (MDS) dated [DATE] assessed R53 as cognitively intact. On 8/26/24 at 6:46 p.m., R53 was interviewed about quality of life/care in the facility. R53 stated she had moved rooms twice and had no notice prior to the changes. R53 stated, They just come in and tell you, you are moving. R53 stated she felt her room changes were due to issues with roommates. R53 again stated that she received no verbal or written notice prior to the room/roommate changes. R53's clinical record documented no notification about the room changes on 5/10/24 and 7/1/24. Nursing notes made no mention that the resident changed rooms and/or roommates. On 8/28/24 at 9:53 a.m., the facility's social worker (other staff #4) was interviewed about notification to R53 about room changes. The social worker stated the room changes were due to roommate conflicts. The social worker stated no written notices were provided to R53 prior to the room changes. On 8/28/24 at 2:46 p.m., the administrator was interviewed about room changes without prior notice. The administrator stated residents were supposed to be notified ahead of time regarding room changes and be allowed time to plan for room moves. The facility's policy titled Change of Room or Roommate (revised 12/1/22) documented, .The notice of a change in room or roommate will be provided in writing, in a language and manner the resident and representative understands and will include the reason(s) why the move or change is required . This finding was reviewed with the administrator, DON, and regional director of clinical services, during a meeting on 8/28/24 at 2:00 p.m., with no further information presented prior to the end of the survey. 2. No written notice was provided to Resident #200 prior to room changes on 1/8/24, 2/6/24, and 5/21/24. Resident #200 (R200) was admitted to the facility with diagnoses that included congestive heart failure, hip fracture, neurogenic bladder, diabetes, anxiety and depression. The minimum data set (MDS) dated [DATE] assessed R200 as cognitively intact. R200's closed clinical record documented room changes on 1/8/24, 2/6/24 and 5/21/24. The clinical record documented no written notice to R200 prior to these room changes. There was no written notification provided to the resident indicating the reason for the room changes. On 8/27/24 at 3:22 p.m., R200 was interviewed about notification of room changes. R200 stated he moved rooms three times during his stay at the facility and received no verbal or written notification prior to the room moves. On 8/28/24 at 10:02 a.m., the facility's social worker (other staff #4) was interviewed about written notification to R200 prior to room changes. The social worker stated no written notices were provided to R200 prior to the room changes. The social worker stated she verbally told R200 on 2/5/24 about the room change on 2/6/24. The social worker stated she saw no other notifications to the resident about the room changes. On 8/28/24 at 2:46 p.m., the administrator was interviewed about room changes without notice. The administrator stated residents were supposed to be notified ahead of time regarding room changes and be allowed time to plan for room moves. The facility's policy titled Change of Room or Roommate (revised 12/1/22) documented, .The notice of a change in room or roommate will be provided in writing, in a language and manner the resident and representative understands and will include the reason(s) why the move or change is required . This finding was reviewed with the administrator, DON and regional director of clinical services during a meeting on 8/28/24 at 2:00 p.m. with no further information presented prior to the end of the survey. 41449 3. For resident #57 (R57), the facility failed to provide written notification prior to a room change. On 8/27/24 at 8:08 a.m., an interview was conducted with R57. When asked about a recent room change, R57 said he had a room change to be on isolation. On 8/27/24, a clinical record review was conducted. According to the census tab of R57's chart, he had a room change on 8/13/24. Then on 8/26/24, was moved back to the original room. According to the progress notes an entry was made by the social worker on 8/13/24 at 2:50 p.m., that read, Both myself and DON (Director of Nursing) spoke with [resident's wife's name redacted] about pt [patient] room move and isolation protocol and treatments. There was no indication that the room change had been discussed with the resident prior to the move on 8/13/24 or 8/26/24. There was no evidence that the room change was provided in writing to the resident. 4. For resident #12 (R12), the facility failed to provide written notification prior to a room change. On 8/26/24 at approximately 7 p.m., an interview was conducted with R12. R12 reported that she had been separated from her prior roommate, who she identified as resident #22 (R22), and expressed a desire to room with her again. When asked if she was notified in writing of the change, R12 said, No, nothing was provided in writing. R12 went on to say she was told they were moving her because they were going to do renovations but reports no renovations had taken place. On 8/27/24, a clinical record review was conducted of R12's chart. This review revealed that 6/29/22, R12 was moved into room [ROOM NUMBER], where she remained until she was moved to another unit on 3/8/23. According to the progress notes, an entry was made by the facility administrator on 3/7/23, that read, This writer and director of nursing notified resident this evening of need for a room change so that room renovations can begin. Resident in agreement and is going to begin organizing things for the room move to take place tomorrow, 3/8/23. There was no evidence within the clinical record that a written notice was provided. 5. For resident #13 (R13), the facility failed to provide written notification prior to a room change and failed to address her preference to room with her prior roommate. On 8/27/24 at approximately 11:30 a.m., R13 stopped the surveyor and wanted to express concerns. R13 shared concern that she and her roommate had been split up, in the facility's efforts to make a male room, but says that didn't occur and that she missed her former roommate. R13 reported that they liked being roommates and she, R13 was able to encourage the roommate to attend out of the room activities, which the roommate's family was appreciative of. When asked if R13 received anything in writing about the room change, R13 reported she had not. On 8/27/24 and 8/28/24, a clinical record review was conducted. According to the census tab of R13's chart, she was moved to room [ROOM NUMBER] on 9/15/23. On 2/5/24, she received a new roommate who was being admitted to the facility. They remained roommates until 8/12/24, when both were moved to different rooms, and R13 was moved to a separate unit. Review of the progress notes, assessment tab, and misc. tab of R13's clinical record revealed no information with regards to the room change nor that R13 was given written information about the change. On 8/28/24 at approximately 1:30 p.m., the facility administrator and director of nursing were made aware of the above findings with regards to the lack of written notification for room changes. The concern expressed by R13 and her desire to room with her prior roommate was also discussed. The facility administrator reported that R13's prior roommate had expressed concerns about being roommates and didn't desire to room with R13. The administrator stated that she had statements about this. The survey team asked the administrator to provide any information she had. Following the above meeting, the surveyor went and visited the prior roommate of R13 in her room. When asked about the prior roommate, this resident said that she missed R13. When asked if she would like to be roommates with her again, she said, Yes. No concerns or complaints regarding R13 was shared. On 8/28/24 at approximately 2:30 p.m., the facility administrator provided the survey team with a statement written 8/7/24, by the wound treatment nurse. The statement read in part, This nurse has observed on several occasions during treatment and care, [R13's prior roommate's name redacted] performing task for [R13's name redacted] . This nurse feels that [R13's name redacted] takes advantage of and could potentially cause harm, even unintentionally, towards [roommate's name redacted] . I have attempted to speak with both residents regarding these actions . This nurse feels that is in [sic] the best interest of both residents that they do continue to be roommates. I am concerned that [R13's prior roommate's name redacted] could hurt herself, fall, or have a serious injury. There was no evidence of this within R13's clinical record or that the care plan team had discussed such concerns with the residents and/or resident's family members. There was nothing in the statement that the former roommate had expressed concerns or indicated not wanting to room with R13. On 8/27/24, in the afternoon, an interview was conducted with the facility's social worker (SW). The SW was asked about room changes and reported that they discussed room changes as a team to attempt to determine compatibility. The SW went on to say that she is usually the one that will notify the resident of the room change. When asked if she provides anything in writing regarding the reason for the room change, the SW said no, that that she has never given anything in writing. Review of the facility policy titled Change of Room or Roommate with a review date of 12/1/2022 read in part, . It is the policy of this facility to conduct room changes or roommate assignments when considered to be necessary by the facility and/or when requested by the resident or resident representative .4. Prior to making a room change or roommate assignment, all persons involved in the change/assignment, such as residents and their representatives, will be given advance notice of such a change as is possible. 5. The notice of a change in room or roommate will be provided in writing, in a language and manner the residents and representative understands and will include the reason(s) why the move or change is required No further information was provided.

Based on observation, resident and staff interviews, clinical record reviews, and facility documentation reviews, the facility staff failed to provide activities of daily living (ADL) care to residents who required staff's assistance, for five residents (resident #12- R12, resident #22- R22, resident #57-R57, resident #40-R40, and resident #49-R49), in a survey sample of 31 residents. The findings included: 1. For R12, who was dependent upon facility staff for toileting assistance, the facility staff failed to respond timely to the resident's call light, which resulted in R12 urinating on the floor on one occasion. On 8/26/24 at 6:30 p.m., R12 was observed with her call bell on. R12 was sitting at her doorway waiting for staff to respond. When the certified nursing assistant (CNA) responded, at 6:48 p.m., the CNA noticed a wet spot on the room floor with a towel over it. R12 reported that she had not been able to hold it and had urinated on the floor. The CNA assisted R12 with being cleaned up and put in the bed. On 8/26/24 at 7 pm., the surveyor interviewed R12 in her room. R12 reported that frequently she must wait hours for staff to respond to her call bell. On 8/27/24 at 10:40 a.m., upon the surveyor's arrival on the unit, R12's call bell was observed to be engaged, the light outside of the room was illuminated and an auditory alarm sounding. Numerous staff were observed on the hallway, a nurse performing medication administration, a housekeeper cleaning, and four nursing assistants, who were in and out of rooms on the unit. It was 11:28 a.m., before a staff member responded to R12's room to see what she needed. This was 48 minutes after the surveyor observed the call bell, which was already on when the surveyor made the observation at 10:40 a.m. Following R12 receiving care at 11:28 a.m., the surveyor interviewed R12 in her room. R12 reported she had been waiting for staff to clean her up/provide incontinence care. On 8/27/24, a clinical record review was conducted of R12's chart. R12's most recent minimum data set (an assessment tool) with an assessment reference date of 6/29/24, was reviewed. According to section G of this assessment, R12 required extensive assistance of facility staff for bed mobility, transfers, and toileting. R12 was also coded on this assessment as having had a brief interview for mental status score of 15 out of 15, which indicated she was cognitively intact. According to R12's care plan, she was noted to have a self-care performance deficit Interventions included, but were not limited to, Toilet use: nursing staff to provide assistance as needed, [R12's name redacted] uses a bed pan at times . On 8/27/24 at 2:09 p.m., R12's call bell was again observed engaged. At 2:15 p.m., a nurse entered the room and came out and told certified nursing assistant (CNA) #8 that the resident needed to be cleaned up. CNA #8 was interviewed about call bell responses, and she stated, they should be answered as soon as we can. When asked about R12 having to wait 48 minutes earlier in the day, CNA #8 said, Yeah, that's too long, I don't know what happened, that's a long time, too long. I went and answered another call bell, but I know for them 5 min seems like 5 hours. At 2:20 pm CNA #8 entered R12's room to provide care. 2. For R22, a female resident who had significant facial hair approximately 1 inch long, the facility staff failed to provide assistance to remove the facial hair. On 8/27/24 at 11:25 a.m., during an observation of the nurse administering tube feeding and medication, R22 was observed with a significant amount of facial hair on her chin approximately an inch long. When asked about the facial hair, R22 said, I know, I do [have the facial hairs]. They look terrible and make me look ugly. Can I get them off? LPN #5, the nurse said, Yes, we will get it today. R22 said, That sounds wonderful. That will make me happy, and it will make me feel good. On 8/27/24, a clinical record review was conducted of R22's chart. According to R22's care plan, it noted the resident had a self-care performance deficit and the interventions included, Personal Hygiene/oral care: [R22's name redacted] requires extensive to total assist for grooming and oral care. On 8/28/24 at8:06 a.m., R22 was observed again in bed and the chin/facial hairs were still present. On 8/28/24 at 8:10 a.m., an interview was conducted with LPN #5. When asked when residents are to be shaved, LPN #5 said, I would assume in the shower or whenever they [the staff] have a minute. When asked why R22 had not been shaved when she had requested it yesterday, LPN #5 said, We didn't have time and then she was in therapy by the time we got to her. She scooted off to therapy and we just didn't get back down that way. On 8/28/24 at 8:13 a.m., an interview was conducted with the unit manager. When asked when residents are shaved, the unit manager said, Usually on their shower days, unless they request it in between. None that we have now do it every day. When asked about women with facial hair, the unit manager said, It should be on their shower days. The unit manager was notified that R22 had requested yesterday to be shaved, the unit manager said, It should have been done. Also, she probably changed her mind, She agrees that it needs to be done but often when you go to do the activity, often she doesn't participate. I would have to do some checking to see what transpired. On 8/28/24 at 10:42 a.m., R22 was again observed in bed, with the facial hair still present. On 8/28/24 at 1:30 p.m., during a meeting with the facility administrator and director of nursing, they were made aware of the above findings. On 8/28/24 at approximately 2:30 p.m., the director of nursing reported to the surveyor that R22 was in the activity being held and they would get the resident shaved after the activity. 3. For R57, who had been left unsupervised/unattended sitting on the toilet, had engaged the call bell, and was yelling out for assistance, the facility staff failed to respond timely to assist the resident off the commode. On 8/27/24 at 10:40 a.m., the surveyor arrived on the unit. R57's call bell was engaged at 10:52 a.m., noting that a light was blinking outside of the room and an auditory alarm was sounding in the hallway. R57 could be heard yelling out for help. LPN #5 was observed in the hallway outside of R57's room at the medication cart. Three CNAs were observed on the unit, entering and exiting the utility room, various resident rooms, and up and down the hallway. A housekeeper was also observed on the hallway cleaning. At 11:05 a.m., LPN #5 entered the room and was heard to tell the resident, You don't have to keep yelling, give us a minute. Following the above observation, LPN #5 was approached by the surveyor and asked why R57 was yelling. LPN #5 reported that R57 was sitting on the toilet and waiting for the staff to get him off. At 11:28 a.m., two CNAs were observed to enter R57's room to assist with getting the resident off the commode. On 8/27/24 at 2:09 p.m., an interview was conducted with LPN #5. When asked if residents can be left unassisted and unsupervised on the toilet, LPN#5 said, They can leave him in the bathroom, they were just busy and didn't have to change to get there yet. LPN #5 was asked if she can assist residents with toileting, LPN #5 said, I am able to help out but if I'm on the cart and have narcotics, I can't leave them. When asked if residents should have to wait 36 minutes to be assisted off the toilet, LPN#5 said, I'm agency, so I've only been here a few times, but of course not. Five to ten minutes is reasonable. LPN #5 went on to confirm that they had adequate staffing for the shift and that staff were just busy. According to R57's care plan, the interventions read, Toilet use: Nursing staff to provide assistance as needed. [R57's name redacted] has incontinence and staff assist with changing him . Encourage [R57's name redacted] to use bell to call for assistance . Review of the facility policy titled, Call Lights: Accessibility and Timely Response was conducted. This policy read in part, . 8. All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified . On 8/28/24 at 1:30 p.m., the facility administrator and director of nursing were made aware of the above findings. No additional information was provided. 21875 4. Facility staff failed to cut/trim Resident #40's toenails as required in the plan of care. Resident #40 (R40) was admitted to the facility with diagnoses that included lower leg fracture, atrial fibrillation, heart failure, urinary tract infection and depression. The minimum data set (MDS) dated [DATE] assessed R40 as cognitively intact and as requiring substantial/maximum assistance with personal hygiene. On 8/26/24 at 7:12 p.m., R40 was observed in bed with feet/toenails visible. R40's toenails were thick, yellow, and jagged with several extending approximately 1/8 inch beyond the end of the toes. The left great toenail had layers of brown nail material between the nail surface and the toe. R40 was interviewed at this time about the length and condition of the nails. R40 stated her toenails were too long and needed cutting. R40 stated an aide tried to cut them during a shower but was unable to do it. On 8/27/24 at 4:30 p.m., the certified nurses' aide (CNA #1) caring for R40 was interviewed about the resident's long toenails. CNA #1 stated the resident's nails needed trimming. CNA #1 stated nails were usually trimmed during showers and that she thought R40's showers were scheduled for the day shift. On 8/27/24 at 4:35 p.m., the registered nurse (RN #2) caring for R40 was interviewed about the resident's toenails. RN #2 stated he assessed the resident upon admission and the nails were not in good shape when she arrived at the facility. Accompanied by RN #2 and with the resident's permission, R40's toenails were observed. The nails were thick, jagged, uneven and extended beyond the ends of the toes. RN #2 stated he thought someone had attempted to cut them and he was not sure what options were available to address the nails. R40 stated again at this time that the toenails needed trimming. On 8/28/24 at 8:21 a.m., CNA #2, who was caring for R40, was interviewed about the long toenails. CNA #2 stated she had seen the nails and that they needed trimming. CNA #2 stated that aides were expected to trim nails during showers, if the resident was not diabetic. On 8/28/24 at 8:37 a.m., the director of nursing (DON) was interviewed about R40's toenails. The DON stated R40 was not diabetic and that the aides were expected to cut nails during shower time. The DON stated if the aides had difficulty cutting the nails, nurses was expected to assist with cutting/trimming nails. The DON stated if aides/nurses were unable to trim the nails, podiatry was an option. R40's plan of care (revised 7/12/24) documented the resident required assistance with activities of daily living (ADLs) due to fracture, weakness and difficulty moving. Interventions to maintain ADLs included, .Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse . This finding was reviewed with the administrator, DON, and regional director of clinical services, during a meeting on 8/28/24 at 2:00 p.m., with no further information presented prior to the end of the survey. 49456 5. The facility staff failed to ensure Resident #49's call bell within reach. Resident #49 (R49) was not able to call for assistance. On 8/26/24 a tour of the facility was conducted. During the tour, it was observed that R49's room door was closed, and she was yelling out continuously for someone come help me. When this surveyor entered the room, R49's call bell was on the floor under the bed. On 8/26/24 at 6:45 p.m., an interview was conducted with R49's nurse. The licensed practical nurse, LPN #4 stated, The call bell should not be under the bed but within her reach. LPN #4 (LPN4) indicated that she was going to get an aide to come in and assist R49 with a bath. On 08/26/24 7:30 p.m., an interview was conducted with R49. When asked why she had been yelling, R49 said that she was yelling out for help because I needed someone. R49 then stated, I stink. I need a bath. I smell. On 8/27/24 at 9:00 a.m., an observation was made of R49's call bell, which was again out of her reach. The call bell was laying over the bedside table, where R49 was not able to reach, and was unable to use the call bell to call for assistance. On 8/27/24 at 9:10 a.m. an interview was conducted with LPN #6 (LPN6). LPN6 stated, The call bell should be within her reach to be able to call for assistance if she needs it. On 8/28/24 a clinical record review was conducted. R49's care plan was reviewed and read in part, . [name redacted] has an ADL self-care performance deficit r/t Limited Mobility. The care plan had that R49's ADL (activity of daily living) needs would be provided by staff. On 8/28/24 a clinical record review was conducted. R49's MDS (minimum data set -an assessment tool) with the ARD (assessment reference date) of 5/23/24 documented that R49 was dependent on staff for toileting, bathing, and dressing, while maximal assistance was needed with personal hygiene and oral care On 8/28/24 a facility document was provided and reviewed. The facility policy titled, Call lights: Accessibility and Timely Response, read in part, .all staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light. With each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed. On 8/28/24, during an end of day meeting, the above concerns were discussed with the DON, the administrator, and the nurse consultant. No additional information was provided.

Based on resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections, and failed to respond to a COVID outbreak in accordance with the guidance from the Centers for Disease Prevention and Control (CDC), which involved two residents (Resident #22 and Resident #57) but had the potential to affect numerous residents on 2 of 2 nursing units. The findings included: 1. The facility staff failed to provide care and adhere to infection control practices to include the use of personal protective equipment (PPE) to minimize the spread of multi-drug resistant organisms (MDROs), by implementing enhanced barrier precautions for Resident #22 (R22). On 8/26/24 at approximately 7 p.m., observations were conducted, and it was noted that R22's room had a sign on the door that indicated enhanced barrier precautions. There was a plastic storage hanger also on the door, but it was empty and contained no PPE supplies. A bottle of tube feeding was observed on R22's over bed table (which indicated R22 had a feeding tube), and wound care supplies were noted on the sink area and at the roommate's bedside table. On 8/27/24 at 9:03 a.m., observations were conducted of the breakfast meal being distributed. It was noted that two staff members, certified nursing assistants #6 and #7 (CNA #6 and CNA #7), entered R22's room with breakfast trays. At approximately 9:10 a.m., the two staff persons were observed each sitting at the bedside of the two residents, one of which was R22, feeding the residents. Neither CNA #6 or CNA #7 had any PPE on, no isolation gown or gloves. At this time, the sign was again noted on the door that indicated enhanced barrier precautions and that the storage hanger on the door contained no supplies. On 8/27/24 at approximately 9:20 a.m., an interview was conducted with CNA #6. When asked about the enhanced barrier precautions sign on the room door, CNA #6 said, I don't know because they never told us. So I don't know if it [wearing PPE] is just the nurse when they do her tube feeding or what. On 8/27/24 at approximately 9:30 a.m., an interview was conducted with CNA #9. CNA #9 was asked what the signs on the door that read enhanced barrier precautions meant. CNA #9 said, If stuff is on the door, supposed to put gown and gloves on when enter, but if no supplies on door, I'm not sure what to do. (SIC) On 8/27/24 at 11:25 a.m., the surveyor observed licensed practical nurse #5 (LPN #5) administer medication and bolus tube feeding to R22. It was noted that LPN #5 was wearing gloves during the administration of the medication and the tube feeding, which were both given through the peg tube, but no other PPE had been worn. At this time, it was again noted that the sign on the exterior of the room door indicated enhanced barrier precautions, which indicated facility staff were to wear an isolation gown and gloves when providing any direct resident care. Upon completion of the above observations, LPN #5 was asked about the sign on the door. LPN #5 stated that it was not for R22, it was related to the roommate who had wounds. On 8/27/24, a clinical record review was conducted of R22's chart. This review revealed documentation that R22 had a peg tube and received supplemental nutrition, as well as medications, via the peg tube. There were no physician orders with regards to enhanced barrier precautions. According to the care plan for R22, the activities of daily living focus area had an intervention implemented 4/14/24, that read, Enhanced barrier precautions for direct care. On 8/28/24 at 04:32 p.m., an interview was conducted with the facility's infection preventionist (IP). During the interview, the IP was asked about various levels of isolation. The IP said, Contact Isolation, you have to wash hands, wear a gown, gloves, separate his stuff from everyone else, and on the way-out don and doff [PPE] properly and wash hands again. When asked how that differs from enhanced barrier precautions, the IP said, Enhanced barrier protects the patient from the germs you have, contact protects you from them. They are similar. When asked who is on enhanced barrier precautions, the IP said, Anyone that has a hole they were not born with. The facility policy titled Enhanced Barrier Precautions was reviewed. The policy read in part, . c. Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves . 2 b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status .3. Implementation of Enhanced Barrier Precautions- a. Make gowns and gloves available immediately outside of the resident's room . 2. The facility staff failed to follow transmission-based precautions and wear appropriate personal protective equipment (PPE), while providing direct care to Resident #57. On 8/26/24 at approximately 6:50 p.m., Resident #57 (R57) was interviewed in his room. It was noted that a sign on the door indicated Enhanced Barrier Precautions. R57 had a hospital gown on that left his back exposed, as well as his arms and legs. It was noted that R57 had red lesion-like areas all over his visible body parts, with some that had visible dried blood. When asked about these areas, R57 stated that it was scabies. On 8/27/24, a clinical record review was conducted. This review revealed evidence that R57 did have scabies. According to the active physician order dated 8/13/24, it read, Contact Isolation for Scabies. Resident to be on isolation with all meals, activities, therapy, and all services are provided in room. Staff to utilize contact isolation precautions. According to R57's care plan, which was created on 8/13/24, it read in part, [R57's name redacted] has scabies and is on contact isolation. R57's care plan interventions included: CONTACT ISOLATION: Wear gowns and gloves when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry, instruct family/visitors/caregivers to wear disposable gown and gloves during physical contact with resident. Discard in appropriate receptacle and wash hands before leaving room and Instruct visitors to wear disposable gloves and gown when in residents' room and to wash hands before leaving room. On 8/27/24 at 10:52 a.m., it was observed that R57's call bell was engaged, a light was on and blinking outside of the room, and an auditory alarm was sounding in the hallways. R57 could be heard yelling out for help. At 11:05 a.m., LPN #5 entered the room and was heard to tell the resident You don't have to keep yelling, give us a minute. After exiting the room, LPN #5 was asked why R57 had been yelling. LPN #5 reported that R57 was sitting on the toilet and waiting for the staff to get him off. At 11:28 a.m., two CNA's were observed to enter R57's room to assist with getting the resident off the commode. None of the staff that entered the room had put on any PPE prior to entering the room or during the provision of care. It was again observed that no PPE supplies were present outside R57's room. At 12:07 pm, an interview was conducted with the unit manager, LPN #3, for the unit R57 resided on, Unit 2. When questioned about R57's isolation precautions, LPN#3 stated that R57 had initially tested negative for scabies. LPN#3 stated that it wasn't until the punch biopsy, performed by Dermatology, showed positive results for scabies that his diagnosis was known. LPN#3 then stated that since he was last treated on 8/21/24, that R57 was basically clear from isolation two days later. Later that day, R57 was again observed self propelling his wheelchair in the hallway. No physician order was found that discharged the Contact Isolation precautions. On 8/28/24, in the morning, R57 was again observed out of his room in the hallway around the nursing station. While still in the hallway, it was observed that the unit manager stopped the resident, cleansed an open lesion area on R57's left arm that was bleeding, and applied a band aide, without wearing any PPE. On 8/28/24 at 04:32 p.m., an interview was conducted with the facility's infection preventionist (IP). During the interview the IP was asked about various levels of isolation. The IP said, Contact isolation, you have to wash hands, wear a gown, gloves, separate his stuff from everyone else, and on the way-out don and doff properly [PPE], and wash hands again. Review of the facility policy titled; Transmission-Based Precautions was conducted. The policy read in part, . 3. Contact Precautions- a. Intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment . c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. Donning personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination 3. The facility staff failed to respond to and implement quarantine and testing measures in accordance with CDC (The Centers for Disease Control and Prevention) recommendations to manage COVID-19 during an outbreak. On 8/27/24 at approximately 8 a.m., a sign was observed on the front door that indicated the facility was in an COVID outbreak that began 8/8/24. On 8/28/24 at 4:32 p.m., the surveyor met with the facility's infection preventionist (IP). During the interview, the IP was asked about the COVID outbreak. The IP was unsure how many people had tested positive for COVID and if they had been admitted with COVID or tested positive while a resident. The IP went on to say that the receptionist (Other Employee #8 - OE#8) had tested positive. When asked if she had a line listing that showed the COVID cases, the IP said, No I don't. I just hung myself. I am supposed to do that. I'm still new at this and there is a lot to learn. The IP was asked to explain what they did when OE#8 tested positive. The IP said, We sent her home for five days and housekeeping came and cleaned up front. That must be when we hung the sign, but one person doesn't make an outbreak. She came back and tested on day five and she was negative, so she returned to work. When asked for evidence of OE #8's COVID testing, the IP said that she didn't have it or the details of when OE #8 was tested . When asked if they did contact tracing for broad based testing, the IP said, You are going to think I'm stupid, but what is contact tracing? The surveyor explained contact tracing and then asked again, if anyone else was tested . The IP said, We tested all of the dialysis patients. There was a potential outbreak at dialysis, and they were all negative. When asked to see evidence of the resident testing, the IP said, They were tested on the 9th. I will have to find out where that is. When asked about occurrences of COVID testing, the IP said, We only test if they are symptomatic and we didn't have any. No evidence of any resident testing was provided. When asked if the local health department had been contacted, the IP looked through her emails and provided the surveyor with a copy of email correspondence dated 8/22/24 and 8/26/24. According to this documentation, the IP emailed the local health district's respiratory illness mitigation specialist (RIMS) on 8/22/24, and reported, The employee has returned with no symptoms, we currently have 2 resident who are positive with hospital acquired. One is coming off isolation the 23rd and the other the 26th. The RIMS responded on 8/26/24 and said, The only two cases that I know about tested positive on 8/8/24, which means that isolation would have ended for them around the 18th. Their names are [names redacted]. If there are two more cases with later onsets, please let me know. No other email documentation was provided. Following this document review, one of the two residents noted by the RIMS was identified as Resident #119 (R119). A clinical record review was conducted and revealed that R119 had a readmission to the facility on [DATE], following a fall at the facility and being sent to the emergency room . Review of R119's nursing notes revealed a readmission note dated 8/4/24, that read, admitted from hospital for loss of consciousness, UTI [urinary tract infection] colitis, lactic acidosis, LOC [loss of consciousness] . There was no mention of COVID-19 being diagnosed . On 8/7/24, R119's chart documented a progress note that read, Resident c/o [complained of] sore throat and sudden onset of cough. Oral temperature 102.5F. Resident received PRN Tylenol at 1651 for c/o generalized pain. Contacted the provider on call number and left message requesting return call to this LPN. R119's chart documented another note was entered on 8/7/24 that read, Called and spoke with Dr. [name redacted]. Verbal order received to do a COVID test and monitor and contact MD if any changes and or no improvement of fever. On 8/7/24 at 7:27 p.m., R119's chart documented a nursing note entry which read, COVID test positive. MD notified. Isolation precautions in place. Resident educated on isolation requirements and is in her room. No evidence was found that the facility had conducted any contact tracing to determine if R119 had exposed others to the infection. No evidence was found that broadband testing in response to the COVID outbreak had been conducted. According to the CDC guidance for helthcare settings, titled Infection Control Guidance: SARS-CoV-2, dated 6/24/24, recommendations read in part, .Responding to a newly identified SARS-CoV-2-infected HCP or resident . A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 (Accessed online at https://www.cdc.gov/covid/hcp/infection-control/index.html.) No additional information was provided. 4. The facility staff failed to maintain an infection surveillance/monitoring program. On 8/28/24 at 04:32 p.m., an interview was conducted with the facility's infection preventionist (IP). When asked about infection surveillance, the IP stated that the only line list she had was regarding R57 having scabies. The IP said that she didn't know anything about a line listing until she talked to the health department, and they wanted her to fax them a line listing. When asked about the other two residents who had also been symptomatic with scabies and subsequently treated, the IP said that she was not tracking that because they had not tested positive for scabies. The IP said, The health department only wanted the one confirmed. We will go back and add the others. The IP was also asked about the recent COVID outbreak as a sign was on the front door that indicated as of 8/8/24, the facility was in a COVID outbreak. The IP said that she didn't have any type of listing to indicate who had tested positive, what their symptoms were, or when they had been cleared. A review was performed of the facility policy titled, Infection Prevention Control Program, with a review date of 12/1/22. The policy read in part, . 3. Surveillance: a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual agreement based upon a facility assessment and accepted national standards. b. The infection preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. c. The RNs and LPNs participate in surveillance through assessment of residents and reporting changes in condition to the residents' physicians and management staff, per protocol for notification of changes and in-house reporting of communicable diseases and infections . 5. The facility staff failed to correctly respond to the identified presence of Legionella bacteria within the facility's water system. On 8/28/24 at approximately 4:45 p.m., the survey team met with the facility's maintenance director who oversees the facility's Legionella and water management program. The maintenance director provided the survey team with a book that contained the water management risk assessment and the water flow diagram, which indicated the risk areas identified. Included within the book was a laboratory report dated 12/5/23, which indicated various areas within the facility were tested for the presence of Legionella pnemophila bacteria. The report indicated that .test results less than MPN [most probable number] of 35 do not need treatment. The results showed the presence of Legionella pneumophila in the .shower B wing with a result of 14.6 . ice machine kitchen 58.3 and shower A wing >2272. Also attached was a letter from the company that reported the test results, dated 12/5/23, which was addressed to the maintenance director. The letter read in part, Severe problem areas are 11&12 Ice Machine kitchen & particularly A-Wing Shower. Recommend remove shower heads & aerators throughout building. Soak units in 10% bleach solution for 1 hour then rinse thoroughly . While shower heads & faucets are removed take a bottle brush and dip in 10% chlorine solution containing 10% soap solution such as Simple Green. The soap acts as a spreader sticker so chlorine can do work. Then brush inside pipes to remove any biofilm around opening. Let stand 15 minutes then brush again before rinsing . Ice machine in kitchen needs cleaning. Please request some swabs & jars so that contaminated area can be tested again after decontamination procedure . The maintenance director reported that he cleaned the ice machine in the kitchen, and they replaced the shower head. There was a notation on the bottom of the above letter dated 12/5/23, that indicated cleaned ice machine 12/20/23, replaced shower head 12/22/23. When asked if any cleaning of the aerators and faucets, as well as if any follow-up testing had been done, the maintenance director indicated he was not aware of those recommendations. When the recommendations were pointed out in the letter, the maintenance director said that he hadn't been aware but would do it, now that he knew. Review of the facility policy titled; Legionella Surveillance was performed. The policy read in part, . 1. Legionella surveillance is one component of the facility's water management plans for reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems. 2. In the absence of Legionella infections for a period of at least one year, the facility shall implement primary prevention strategies . 5. Primary prevention strategies: a. Diagnostic testing: b. Investigation for facility source of Legionella, which may include culturing of facility water for Legionella. C. Physical controls . iii. Non-potable water systems shall be routinely cleaned and disinfected ., and D. Temperature controls . On 8/28/24, during an end of day meeting, the facility administrator and director of nursing were made aware of the above findings. No additional information was provided.

Based on observation, resident interview, staff interview, clinical record review and facility documentation review, the facility staff failed to maintain a complete and accurate clinical record for four residents (resident #79-R79, resident #57-R57, resident #32-R32 and resident #93-R93), in a survey sample of 31 residents. The findings included: 1. For Resident #79, the facility staff failed to maintain an accurate clinical record with regards to the changing of oxygen tubing and nebulizer tubing and mask. During initial tour on [DATE] at approximately 6:30 p.m., R79 was visited in her room. It was observed that R79 had a nebulizer on her bedside table. The nebulizer mask was sitting in the top drawer of the bedside table and was open to air. The nebulizer mask and tubing were dated [DATE], as the date it was changed. On [DATE] at 7:09 p.m., an interview was conducted with licensed practical nurse (LPN) #4. LPN #4 was asked about oxygen and nebulizer tubing and the frequency they were changed, LPN #4 said they are to be changed weekly. On [DATE] at 8:31 a.m., R79 was observed with her oxygen tubing and nebulizer tubing stored in a bag. The nebulizer mask that was removed was observed in the trash can at R79's bedside. On [DATE] at 8:33 a.m., an interview was conducted with the unit manager. The unit manager said that oxygen tubing was to be changed weekly and said, this unit is set for Sundays. When asked where it would be documented, the unit manager said, it should be documented on the TAR (treatment administration record) on the night shift. The unit manager then accompanied the surveyor to R79's room and confirmed that the nebulizer had been changed that day [DATE]. The discarded nebulizer mask in the trash was confirmed to be dated [DATE]. On [DATE], a clinical record review was conducted of R79's chart. The physician orders read, Change O2/Nebulizer tubing, humidification bottle (label and date tubing) and bag cover every week every night shift every Thu [Thursday]. The TAR was signed off, to indicate it had been changed [DATE], [DATE], and [DATE], despite it being dated [DATE]. On [DATE] at approximately 1:30 p.m., the above findings were shared during a meeting with the facility administrator and director of nursing. The facility policy titled; Nebulizer Therapy was reviewed. The policy read in part, . 2. Care of the Equipment . h. Change nebulizer tubing once weekly . No additional information was provided. 2. For R57, who was being treated by a dermatologist, the facility failed to maintain a complete and accurate clinical record to include treatment notes from the dermatologist. On [DATE] at approximately 6:50 p.m., R57 was visited in his room. R57 had a hospital gown on that left his back exposed as well as his arms and legs. It was noted that R57 had red lesions areas all over his visible body parts and some had dried blood. R57 was asked about it and reported it was scabies. On [DATE], a clinical record review was conducted. This review revealed multiple entries within the nursing notes that were written by the on-site medical provider that referenced the diagnosis of scabies and being seen by a dermatologist. The most recent entry that noted the scabies diagnosis was dated [DATE]. It read in part, Chief Complaint/Reason for this Visit: Patient who presents today for a medication review and follow-up on scabies treatment. HPI [history and physical information] Relating to this Visit: Patient was diagnosed with scabies by a dermatologist after a second skin scraping, with the first one being negative. Patient has been using permethrin cream, with one dose given last week and the second dose recently administered. They report improvement in itching and a reduction in small areas of excoriation on their arms. However, they still have some affected areas on their bilateral legs and belly. Patient is also taking hydroxyzine three times a day and clobetasol for their skin condition The various sections of the clinical record were reviewed with no information from the dermatologist found. On [DATE] in the mid-morning, the unit manager was interviewed. The unit manager confirmed that R57 had been dealing with the rash for an extended time and the scrapings they did were all negative. Dermatology was consulted and did a biopsy, which confirmed it was scabies. When advised that the surveyor was not able to find any information from the dermatologist, the unit manager reviewed R57's chart and confirmed the information was not present. She stated she would check up front to make sure it just had not been scanned into the record yet. On [DATE] in the afternoon, the unit manager provided the surveyor with notes from the dermatologist. The unit manager confirmed they did not have them at the facility, and she had called the dermatologist, and they faxed the information over. When asked if this information would have been expected to be a part of R57's clinical record she stated yes. 3. For R32, the facility staff failed to maintain a complete clinical record to include information from dialysis regarding dialysis treatment sessions. On [DATE] at approximately 8:15 am. R32 was visited in his room. When asked about communication between the facility and the dialysis center, the resident reported there was a folder that gets sent with him at times, but no one fills out anything. On [DATE] at 8:57 a.m., LPN #5 was asked how they communicate with dialysis and know what has occurred at dialysis. The nurse said there should be a book but was unable to find one. On [DATE] at 9:15 a.m., the unit manager was asked about communication between the facility and dialysis. She stated there is a book that they send back and forth. When asked if she could locate the book for the surveyor, she was not able to. The unit manager reviewed R32's electronic health record and confirmed that no information was within the chart with regards to dialysis visits. On [DATE] at approximately 9:20 a.m., the unit manager provided the surveyor with a dialysis communication book for R32, which she found at the nursing station on the other unit within the facility. According to R32's clinical record and census tab, R32 had been transferred to the current unit on [DATE]. When the surveyor looked at the book, it was full of blank pages, with no information filled in. R32's clinical record had no information with regards to communication between the facility and dialysis, nor any treatment details, medications given while at dialysis, pre and post dialysis weights on a routine basis or any complications encountered during dialysis sessions. On [DATE] at 9:24 a.m., an interview was conducted with the unit manager. When asked if she had looked at the dialysis communication book, she said, I didn't look at it but I'm sure it is not up to date because it was on the other unit. When asked what the purpose of the dialysis communication book is, she said, to monitor how they do while they are there, record their heavy weight and dry weight. They don't write stuff down for us. Review of the dialysis contract executed [DATE], between the facility and the dialysis center was conducted. The contract read in part, . Shared communication between both parties: the care of the resident receiving dialysis services must reflect ongoing communication, coordination and collaboration between the nursing home and the dialysis staff. The communication progress should include how the communication will occur, who is responsible for communicating, and where the communication and response will be documented in the medical record . On [DATE] at 1:30 p.m., during a meeting with the survey team and the facility administrator and director of nursing, the above findings were discussed. No additional information was provided. 4. For resident #32- R32, the facility staff failed to maintain an accurate clinical record with regards to wound treatments being performed as ordered by the physician. On [DATE] at 7:16 p.m., R32 was visited in his room. During the interview, R32 reported, I developed a foot ulcer and went on to say that the facility staff are supposed to change the bandage every other day, but often times they miss treatments. R32 reported it was last changed, day before yesterday. R32 also reported he was scheduled for amputation of a toe on his left foot on [DATE]. On [DATE], a clinical record review was conducted. This review revealed the following physician orders: cleanse left 2nd toe with NS [normal saline] or DWC [dermal wound cleanser], pat dry, apply hydrofera or derma blue and cover with fluff gauze and cleanse left heel with NS or DWC, pat dry, apply hydrofera or derma blue to wound bed, cover with dry dressing. The directions with those two orders read, Every day shift every other day. Documentation within the chart revealed the wounds were vascular in nature and not pressure wounds. According to the treatment administration record (TAR), R32 had received wound treatments to the left toe and heel on [DATE], as indicated by the treatment being signed off. On [DATE] at 9:05 a.m., the surveyor visited R32 who reported, I was waiting for the wound nurse to come yesterday because it was due, but I didn't see anyone. On [DATE] at 9:35 a.m., the unit manager was accompanied by the surveyor to R32's wound to observe the wound. It was noted that the wound had drained through the bandage and onto the bed linen. The dressing on the foot was dated [DATE], which was confirmed by the unit manager. The unit manager said, this had been an ongoing problem of staff not changing his bandage as ordered. The unit manager was told by the surveyor that the resident reported this happens frequently where his dressings are not done as ordered, she said, It does, and as a wound nurse you can't be here 24 hours a day and you expect them to do what they are supposed to do. No additional information was provided. 49456 5. The facility failed to accurately document R93's code status. The nurse practitioner noted R93 as a full code and CPR was to be performed and according to the care plan and physician orders R93 was a do not resuscitate (DNR). On [DATE] a clinical record review was conducted. A DNR was in the clinical record and signed on [DATE] by R93. R93's care plan, that was revised on [DATE] had R93 as a DNR. R93 had a physician's order the code status to be a DNR and was dated [DATE]. The nurse practitioner had a progress note dated [DATE] and it read in part, .Code status, Full Code - attempt CPR {Cardiopulmonary resuscitation}. The nurse practitioner had a progress note dated [DATE] and it read in part, .Code status, Full Code - attempt CPR {Cardiopulmonary resuscitation}. On [DATE] at 2:00 p.m. an interview was conducted with the director of nursing (DON). The DON stated, she does not know why she [nurse practitioner] put that in her notes and she will speak with her. On [DATE] at the end of day meeting the above concerns were discussed with the DON, the administrator and the nurse consultant. No new information was provided.

Based on resident interview, staff interview and clinical record review, the facility staff failed to review and revise the comprehensive care plan for four of thirty-one residents in the survey sample (Residents #32, #39, #57 and #80). The findings include: 1. Resident #80's care plan was not revised to reflect the resident's ability to communicate verbally and without use of a communication board. Resident #80 (R80) was admitted to the facility with diagnoses that included cerebrovascular accident (stroke), hemiplegia, anxiety, depression, hypertension and respiratory failure. The minimum data set (MDS) dated [DATE] assessed R80 as cognitively intact. On 8/27/24 at 1:55 p.m., R80 was interviewed about quality of life/care in the facility. R80 verbally answered the interview questions and responded to conversation without use or need of a communication board. R80's plan of care (revised 5/28/24) documented the resident had aphasia due to cerebral infarction and was nonverbal and uses a dry erase board for communication. Interventions for impaired communication included, .requires dry erase board to communicate. Ensure availability and function of adaptive communication equipment . On 8/28/24 at 8:35 a.m., the licensed practical nurse unit manager (LPN #1) caring for R80 was interviewed about the communication care plan. LPN #1 stated R80 was unable to talk/communication when she was initially admitted . LPN #1 stated R80 was now able to speak and converse without use of the dry erase board. LPN #1 stated R80 had not used the communication board for approximately four months. LPN #1 stated the care plan had not been revised to delete the communication board and indicate the resident was now verbal. This finding was reviewed with the administrator, director of nursing and regional director of clinical services during a meeting on 8/28/24 at 2:00 p.m. with no further information presented prior to the end of the survey. 41449 2. For R57, who fell on [DATE], the facility staff failed to review and revise the care plan to indicate the fall and if any needed revisions were needed to prevent a future fall. On 8/26/24 at approximately 7:30 p.m., R57 was visited in his room. R57 reported he had recently fallen. When asked what the facility had done following the fall to prevent future falls, the resident said he didn't know. On 8/27/24, a clinical record review was conducted. This review revealed a nursing note entry dated 8/13/24, that read, Resident was informed that he needs to move to room [ROOM NUMBER]. CNA reports resident became anxious and agitated and called his wife. Afterwards this nurse was called to resident's room, resident was observed on the floor on his left hip/buttock. Resident reports pain in left hip but also has chronic pain in left hip. MD (medical doctor) [name redacted] notified, new order for hip x-ray. Resident assisted back into his w/c (wheelchair) and moved to room [ROOM NUMBER]. Resident also medicated per order for pain. Staff will continue to monitor. According to R57's care plan, it noted the resident was at risk for falls d/t [due to] impaired mobility and impaired cognition . The most recent intervention for this fall focus area was dated 3/27/24. There was no indication that the care plan had been reviewed or revised following the fall on 8/13/24. According to a fall risk assessment completed on 7/4/24, R57 was identified as having been at high risk for falling. 3. For resident #39 (R39), who had a fall that required a hospital visit, the facility staff failed to review and revise the care plan. On 8/27/24 at 8:14 a.m., R39 was visited in his room. When asked if he had any recent falls, R39 said, he had experienced a couple of falls and I got banged up and all. When asked, what do they do to try to keep you from falling? The resident said, they tell you not to get up too fast. On 8/27/24, a clinical record review was conducted of R39's chart. According to a post- fall review which was locked [indicating complete] on 8/23/24, indicated the resident had an unwitnessed fall on 8/14/24 at 9:30 a.m., and sustained an abrasion to the left side of his forehead. According to section C of this document, which was intervention recommendations it stated, educated pt [patient] on calling for assistance before ambulating and the box 2a. was checked to indicate Indicate all intervention recommendations: 2 a. Care plan revision. According to the nursing notes, an entry dated 8/14/24 at 9:34 a.m., indicated the resident had a fall, the doctor was notified that the resident was requesting to go to the emergency room . On 8/14/24 at 9:59 a.m., another entry was made that indicated the resident was sent to the emergency department for evaluation. According to R39's assessments, a Morse Fall Scale was performed on 7/10/24, which indicated the resident was High Risk for Falling. A care plan indicating R39 was at risk for falls was initiated on 5/9/22. The most recent intervention revision was performed on 1/21/23. The goal that the resident . will not sustain serious injury r/t [related to] falls through the review was revised on 7/19/24. On 8/28/24 at3:46 p.m., the Director of nursing (DON) was made aware of the above findings. The DON reviewed the care plan for R39 and confirmed the findings and indicated the care plan should have been reviewed and revised following the incident. 4. For R32, who weight indicated a 22.6-pound weight loss in one month, the facility staff failed to review and revise the care plan. On 8/26/24, at approximately 6:30 p.m., R32 was visited in his room. R32 reported that he goes to dialysis three times weekly. On 8/27/24, a clinical record review was conducted of R32's chart. According to weights tab of R32's chart, on 7/10/24, the resident's weight had been recorded as 180.4 lbs. The resident's weight on 8/14/24, was recorded as 157.8 lbs. The dialysis communication book was observed, and it was blank, therefore no information was available from dialysis with regards to the weight change. A Quarterly Nutrition Review was within the progress notes and dated 8/13/24. The note read in part, .7/10 [July 10, 2024] 180.4# post dialysis dry weight. BMI 28.3, no weight exception triggered. August weight pending . He is at nutritional risk for sx [side effects] to his previous amputation and dialysis dependence. His PO [by mouth] intake appears adequate a.e.b [as evidenced by] his stable weight and wound healing. Rec: [recommendation] Record an August weight. On 8/19/24, a Weight change note was entered into the progress notes. It read, -10.0% change [ 12.5%, 22.6] Will re-request a post dialysis dry weight for August. His current weight is showing a 22.6#change in a month. This is a severe weight loss if verified . This review revealed that R32 had an order to obtain the dry weight from dialysis every four weeks. However, on 8/13/24, an order was written that read, Weigh one time only for 1 Day - Call dialysis to get a dry weight for August. On 8/14/24, a weight of 157.8 lbs. was recorded. Then on 8/19/24, another order read, Call dialysis to get a post dialysis weight for August one time only for 1 Day. The weight recorded on 8/20/24, noted 157.8 lbs. Review of R32's care plan revealed he had been identified as having potential nutritional problem r/t [related to] therapeutic diet. All the associated interventions were dated 2/13/24. The care plan goal was revised on 8/26/24, and read, [R32's name redacted] will maintain adequate nutritional status as evidenced by maintaining weight with no s/sx [signs or symptoms] of malnutrition, and nutritional needs provided through review date. There was no indication that the care plan was revised to reflect the significant weight loss, nor any interventions were implemented in response to the weight loss. On 8/27/24, attempts were made to interview the care plan coordinator, but the survey team was notified that she was not available nor working during the survey period. On 8/28/24 at 1:30 p.m., the above findings were reviewed with the facility administrator and director of nursing. On 8/28/24 at 3:40 p.m., interviews were conducted with LPN #1 [licensed practical nurse]. LPN #1 reported, If a resident had a fall, it would get put on the care plan the next business day. We talk about them the next morning. On 8/28/24 at 3:43 p.m., an interview was conducted with the director of nursing (DON). When asked about care plan revisions, the DON stated, They should be updated with each change or event. When asked why this is important, the DON said, So that we know what the plan of care is and went on to say, interventions are put in place to reduce the risk of falls or fall related injuries. The facility policy titled, Comprehensive Care Plans was reviewed. The policy did not address revisions when a resident experiences a fall, significant weight change, or other acute change outside of the scheduled assessments. Review of the facility policy titled, Fall Prevention Program was conducted. The policy read in part, A fall is an event in which an individually unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force. The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere . 9. When any resident experiences a fall, the facility will: . e. Review the resident's care plan and update as indicated . No additional information was provided.

Based on staff interview and clinical record review, the facility staff failed to follow physician orders for three of thirty-one residents in the survey sample (Residents #32, #57 and #77). The findings include: 1. For over two months, Resident #77 was not administered the nutritional supplement Pro-stat twice per day as ordered by the physician for treatment of protein-calorie malnutrition. Resident #77 (R77) was admitted to the facility with diagnoses that included congestive heart failure, protein-calorie malnutrition, seizures, dementia, chronic obstructive pulmonary disease, and obstructive uropathy. The minimum data set (MDS) dated [DATE] assessed R77 as cognitively intact. R77's clinical record documented a physician's order dated 2/8/24 for the nutritional supplement Pro-stat 30 milliliters twice per day for management of protein-calorie malnutrition. R77's medication administration record (MAR) documented Pro-stat was not administered as ordered on 3/28/24 through 4/4/24 and from 4/8/24 through 5/30/24. MAR notes on these dates documented the Pro-stat was out of stock, on order, and unavailable for administration. Physician orders were entered on 4/11/24, 4/18/24, 4/25/24, 4/27/24, 5/9/24 and 5/23/24 to hold the Pro-stat as the facility was awaiting delivery. On 8/27/24 at 4:23 p.m., the registered nurse (RN #2) caring for R77 was interviewed about the availability of Pro-stat during April and May (2024). RN #2 stated Pro-stat was now in stock but had been unavailable for a time during April and May. RN #2 stated, We went for a time without it [Pro-stat]. I think they were changing vendors. On 8/28/24 at 8:44 a.m., the licensed practical nurse unit manager (LPN #1) caring for R77 was interviewed about the Pro-stat not administered as ordered. LPN #1 stated she thought there were problems getting the supplement from a different vendor but was not sure why it was not available. On 8/28/24 at 10:56 a.m., the dietary manager (other staff #2) was interviewed about R77 not getting ordered Pro-stat. The dietary manager stated central supply usually ordered supplements that included Pro-stat. The dietary manager stated when a new central supply clerk was in training, she assisted with ordering nutritional items. The dietary manager stated she attempted to order the Pro-stat from her food service supplier, and it was denied by corporate. The dietary manager stated corporate wanted the Pro-stat ordered from the central supply vendor. The dietary manager stated she did not have access to the central supply ordering system so was unable to get the order placed timely. The dietary manager presented a purchase order request dated 5/16/24 for Pro-stat, approved by the administrator on 5/17/24, denial by corporate on 5/17/24 and with instructions to order through the central supply vendor. On 8/28/24 at 11:03 a.m., the administrator was interviewed about the unavailable Pro-stat. The administrator stated there had been a transition in central supply and the supplement was not ordered timely. On 8/28/24 at 11:52 a.m., the director of nursing (DON) was interviewed about R77 not getting Pro-stat as ordered. The DON stated there had been issues with ordering Pro-stat with declined purchase orders due to use of an alternate vendor. The current supply clerk was out of the facility and unavailable for interview during the survey. This finding was reviewed with the administrator, director of nursing and regional director of clinical services during a meeting on 8/28/24 at 2:00 p.m. with no further information presented during the survey. 41449 2. For Resident #57 (R57), the facility staff failed to remove sutures and schedule a follow-up dermatology appointment as ordered by the doctor. On 8/26/24 at approximately 6:50 p.m., R57 was interviewed in his room. R57 had a hospital gown on that left his back exposed as well as his arms and legs. It was noted that R57 had red lesions areas all over his visible body parts and some had dried blood. When asked about this areas, R57 reported that it was scabies. On 8/27/24, a clinical record review was conducted. According to the physician orders, there was an order dated 8/26/24 that read, derm [dermatology] follow up post scabies treatment ASAP [as soon as possible]. According to the progress notes from the on-site medical provider, the most current note was dated 8/26/24. It read in part, Patient who presents today with concerns about stitches and an area of redness on their abdomen. HPI [history and physical information] Relating to this Visit: Patient has recently had a biopsy and was told they had stitches that needed to be removed. However, upon examination, no sutures were found on the patient's shoulder or back Recommended an immediate follow-up with a dermatologist to re-evaluate the need for continued use of clobetasol. The various sections of the clinical record were reviewed with no information from the dermatologist found. On 8/27/24 in the mid-morning, the unit manager was interviewed. The unit manager confirmed that R57 had been dealing with the rash for an extended time and that the scrapings they did were all negative. Dermatology was consulted and did a biopsy, which had confirmed that the rash was scabies. When advised that the surveyor was not able to find any information from the dermatologist, the unit manager reviewed R57's chart and confirmed the information was not present. The unit manager stated she would check up front to make sure it just had not been scanned into the record yet. When asked about any additional dermatology appointments, the unit manager said that she would have to check with the person that schedules appointments but was not aware of any appointments being scheduled. On 8/27/24 in the afternoon, the unit manager provided the surveyor with notes from the dermatologist. The unit manager confirmed that they did not have them at the facility, and that she had called the dermatologist office, who had faxed the information over. When asked if this information would have been expected to be a part of R57's clinical record, the unit manager stated, Yes. Review of the records received from the dermatologist were reviewed. The dermatology note dated 8/7/24, read in part, . biopsy by punch method: location left posterior shoulder . A 8 mm punch biopsy was performed on the left posterior shoulder. Hemostasis was achieved with drysol. Epidermal closure was achieved with 4-0 Ethilon . Patient was provided a home suture removal kit and will remove their sutures at home . Plan: Punch biopsy done today will follow up for results. Patient is having sutures removed at his nursing home facility . The notes indicated the sutures were to be removed in two weeks, which would have been 8/21/24. On 08/28/24 at 8:22 a.m., the surveyor attempted to meet with the transport/appointment clerk but, after being unable to locate them, went to the director of nursing (DON). The DON confirmed that the appointment clerk was not working that day. When asked if R57 had an appointment with dermatology scheduled and how we would find that out, the DON said, Let me double check [while reviewing the electronic health record]. I see where they put the order in for derm follow-up, I saw an order for asap derm follow-up. Let me look through the paperwork up here. The surveyor also stated that no dermatology notes could be located within the chart but had noted that the on-site provider was unable to locate any sutures to remove. On 8/28/24 at 8:40 a.m., the DON and surveyor went to R57's room and asked if they could look for his sutures, to which the resident agreed and reported that the biopsy was taken from his shoulder blade. The area was observed, and one suture was identified. The DON told the resident that she would have the physician assistant look at it today and remove it. On 8/28/24 at approximately 9 a.m., the DON reported that she had called R57's wife, who had said that she was supposed to take resident to dermatology to have sutures removed but wasn't able to get the resident last week. The DON said that she told the wife of the order to follow-up with dermatology, to which the wife had said for the facility to make the appointment, so they will call to have this done. On 8/28/24 at 11:27 a.m., the DON provided the survey team with a physician order that indicated a dermatology appointment had been scheduled for R57 on 9/3/24 at 9:20 a.m. 3. For Resident #32 (R32), the facility staff failed to perform wound care and apply a multi-podus boot, as ordered by the physician. On 8/26/24 at 7:16 p.m., R32 was visited in his room. During the interview, R32 reported, I developed a foot ulcer and went on to say that the facility staff are supposed to change the bandage every other day, but often times they miss treatments. R32 reported it was last changed, day before yesterday. R32 also reported he was scheduled for amputation of a toe on his left foot on 8/29/24. R32 agreed for the surveyor to observe his foot. When the bed linen was lifted it was noted that R32 had a sock on his foot, so the surveyor explained she would need a staff member to assist. On 8/27/24, a clinical record review was conducted. This review revealed the following physician orders: cleanse left 2nd toe with NS [normal saline] or DWC [dermal wound cleanser], pat dry, apply hydrofera or derma blue and cover with fluff gauze and cleanse left heel with NS or DWC, pat dry, apply hydrofera or derma blue to wound bed, cover with dry dressing. The directions with those two orders read, Every day shift every other day. Documentation within the chart revealed the wounds were vascular in nature and not pressure wounds. R32 also had an order that read, PWB [partial weight bearing] to LLE [left lower extremity], may transfer if wearing multi-podus boot to left leg. According to the treatment administration record (TAR), of the 13 occurrences that the treatment was to be provided from 8/1-8/27, only 5 had been signed off as having been conducted. On 8/27/24, the unit manager was made aware that the surveyor wanted to observe R32's foot wound(s). On 8/28/24 at 9:05 a.m., the surveyor interviewed R32 who reported, I was waiting for the wound nurse to come yesterday because it was due, but I didn't see anyone. When questioned further, R32 stated that the wound treatments are frequently not done. On 8/28/24 at approximately 9:15 a.m., the unit manager was notified again that the surveyor wanted to see the resident's wound before he left for dialysis. On 8/28/24 at 9:35 a.m., the unit manager was accompanied by the surveyor to R32's room to observe the wound. It was noted that the wound had drained through the bandage and onto the bed linen. There was no multi podus boot in place. The dressing on the foot was dated 8/24/24, which was confirmed by the unit manager. The unit manager said, This has been an ongoing problem of staff not changing his bandage as ordered. When told by the surveyor that the resident reported this happens frequently where his dressings are not done as ordered, the unit manager said, It does, and as a wound nurse, you can't be here 24 hours a day, and you expect them to do what they are supposed to do. On 8/28/24 at 9:58 a.m., a follow-up interview was conducted with the unit manager. The unit manager was told that the surveyor saw an order for a multi-podus boot but did not see the boot on the resident. The unit manager explained that they don't really use it much because it presses on the area on his toes. The unit manager looked through papers on her desk and provided an order from the wound care specialist that was dated 8/20/24 and read, Please order and provide multi podus boot, patient to wear multi podus boot to protect the left heel especially while in bed, can be removed for ambulating. May wear surgical shoe for ambulating. The unit manager confirmed that the order for multi-podus boot was not correct in the clinical record and this order had not been updated, but she would take care of correcting it. On 8/28/24 at 1:30 p.m., the administrator and director of nursing were made aware of the above findings. No additional information was provided.

Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to provide education and offer the COVID-19 immunization to 4 of 5 residents (Resident #80 - R80, Resident #42 - R42, Resident #60 - R60 and Resident #70 - R70). The facility also failed to provide education to the employee regarding the spike vaccine booster for the 2023-2024 season for 1 of 1 staff sampled (Other Employee #8). The findings included: On 8/27/24, clinical record reviews were conducted of the five residents sampled for immunizations. The findings revealed no evidence of the residents being educated nor offered the COVID-19 2023-2024 spik vaccine. R80 had no immunization information noted, only a PPD tuberculin skin test. R42, had no immunization information noted. R60 and R70 had no information regarding COVID immunization listed. There was no information that the 2023-2024 Spike vaccine was offered, education provided, or that it was declined/refused. On 8/28/24 at 4:32 p.m., an interview was conducted with the facility's infection preventionist (IP). During the interview the IP reviewed and confirmed the above findings with regards to the lack of documentation within the clinical record with regards to COVID immunizations for R80, R42, R60 and R70. The IP said, I don't see anything where it was offered. When asked about the facility's process with regards to immunizations, the IP stated, The floor nurses offer immunizations upon admission, then we can contact the responsible party to see if that is something they want. When asked why immunizations are important, the IP said, To make sure we don't have outbreaks. On 8/28/24 at approximately 5 p.m., the human resources manager (HRM) was asked to pull the COVID immunization information for Other Employee #8 (OE#8). The HRM and administrator were unable to find any information within the employee's file regarding COVID immunization. The administrator had the employee text a photo copy of her COVID immunization card, which indicated that OE#8 had the primary series and one booster dose in October 2022. The facility had no evidence of OE#8 being educated on the COVID immunization or being offered subsequent boosters. The facility policy titled; Coronavirus Prevention and Response with a review date of 7/29/24 was reviewed. This policy read in part, . 9. Vaccination Planning: a. Residents will be assessed for COVID 19 immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented in the medical record, including efforts to determine date of immunization or type of vaccine received. b. Each resident will be offered a COVID 19 immunization unless it is medically contraindicated, or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders. c. Prior to offering the COVID 19 immunization, each resident or the resident's representative will receive education regarding the benefits and potential side effects of the immunization. i. The individual receiving the immunization, or the resident representative, will be provided with a copy of the CDC's current vaccine information statement relative to that vaccine. ii. If necessary, the vaccine information statement will be supplemented with visual presentations or oral explanations to assist vaccine recipients in understanding. d. The resident/representative retains the right to refuse the immunization. A consent form shall be signed prior to the administration of the vaccine and filed in the individual's medical record (see consent form). e. The type of COVID 19 vaccine offered will depend upon and, in accordance with current CDC guidelines and recommendations. f. The resident's medical record shall include documentation that indicates at a minimum, the following: a. The resident or resident's representative was provided education regarding the benefits and potential side effects of the COVID 19 immunization. b. The resident received the COVID 19 immunization or did not receive it due to medical contraindication or refusal. g. For employees, documentation related to COVID 19 immunizations will be maintained in the employee file. Employees will be assessed for COVID 19 status upon hire. All facility staff will be encouraged to get vaccinated against Covid 19 . The FDA (Food and Drug Administration) gives information about the 2023-2024 spike vaccine on their website, accessed at: https://www.fda.gov/vaccines-blood-biologics/coronavirus-covid-19-cber-regulated-biologics/novavax-covid-19-vaccine-adjuvanted. The guidance read, On October 3, 2023, the Food and Drug Administration amended the emergency use authorization (EUA) of Novavax COVID-19 Vaccine, Adjuvanted to include the 2023-2024 formula. The Novavax COVID-19 Vaccine, Adjuvanted, a monovalent vaccine, has been updated to include the spike protein from the SARS-CoV-2 Omicron variant lineage XBB.1.5 (2023-2024 formula). The Novavax COVID-19 Vaccine, Adjuvanted (Original monovalent) is no longer authorized for use in the United States. Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is authorized for use in individuals [AGE] years of age and older as follows: Individuals previously vaccinated with any COVID-19 vaccine: one dose of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) is administered at least 2 months after receipt of the last previous dose of an original monovalent (Original) or bivalent (Original and Omicron BA.4/BA.5) COVID-19 vaccine. Individuals not previously vaccinated with any COVID-19 vaccine: two doses of Novavax COVID-19 Vaccine, Adjuvanted (2023-2024 Formula) are administered three weeks apart . On 8/28/24 at approximately 5:30 p.m., the facility administrator, director of nursing, and corporate nurse consultant were made aware of the above findings. The Director of Nursing stepped out to see if she could find any additional information, but returned and reported she had nothing further to provide. No additional information was provided.

Based on resident interview, staff interviews, and facility documentation review, the facility staff failed to maintain adequate funds on-site so that two residents (resident #226 - R226 and resident #53 - R53) had access to their personal funds/trust accounts, which had the potential to affect 41 residents with a trust account. The findings included: 1. For R226, the facility failed to maintain sufficient funds and denied the resident's request to make withdrawals from his account. On 8/27/24 at approximately 8:15 a.m., R226 asked the surveyor to come into his room. R226 reported that he had failed to mention on the prior evening a concern with regards to him having access to his bank account. R226 went on to say that on multiple occasions he had attempted to get money out of his trust account for shopping but had been denied the ability to make withdrawals. R226 went on to say that he could get money previously but now he is told he must make a list of what he wants first or talk to the activities person or is told they don't have the money. On 8/27/24 at 4:22 p.m., an interview was conducted with the business office manager (BOM) (other employee #5). The BOM was asked to explain the process when a resident wants to withdraw funds from their trust account. The BOM explained that she would check to see if they have an account, if they have funds and then will fill out a receipt and give them cash. She said the residents are permitted to withdraw $40 per day. The BOM went on to say, Resident shopping is a different program, the activity director will go around and ask if they want to purchase anything. Those are collectively entered under resident shopping and a check is requested from corporate. Once they approve and send me the check, we cash the check and [activities director's name redacted] gets the cash and list and goes shopping. When asked what the turnaround time is for her to get the check, the BOM said, It varies, depending on what is going on in the building. We just started this process a few weeks ago and I am reinstituting it. We only keep $245 here and we last got that on August 2. We went through that within a week. We have some residents who will withdraw their $40 per day and that doesn't leave much for the others. When asked again for clarification that if a resident requests money for shopping, are they denied that request because there is a process where a check is requested from corporate, the business office manager said, Yes. During the above interview, the BOM was asked about resident's access to funds and where they go to make withdrawals. The BOM said she handles that now, but the position was vacant for eight months. When asked about if a resident's family comes on the weekend and the resident wants to withdraw funds, what is done, the BOM said, They have to get it ahead of time or the family can provide receipts to get reimbursed. The BOM went on to say that she is only at the facility Monday through Friday. The BOM was asked about R226. The BOM said, He does have an account, but I don't have any petty cash on hand right now. We only have $5. I am waiting for it to get replenished. There has been some confusion for him. He said someone was going shopping for him. He kept saying [activities director name redacted] was going shopping, which means resident shopping which is once a month. I explained the procedure is that she would get a list from him, and I thought he was talking about resident shopping. I told him we only have $5, and we just changed banks last week. We got it set up where the administrator can cash checks. The BOM provided the surveyor with a transaction history for R226. Review of this revealed R226 had last had a withdrawal on 7/24/24. On 8/27/24 at 4:45 p.m., an interview was conducted with the activity assistant. The activity assistant was asked about resident shopping and said, I go around and write down a list of what they want, and they give me $40 because that is as much as they can get. A lot of times they will tell me, they didn't get money this week. They don't have any money right now, they switched banks, so no one can get money right now. When asked specifically about R226, the activity assistant said, He is always the short end of the stick somehow. The last 2 shopping trips they ran out of money before he could get any. So I just went on my day off. I've had to buy things for him myself because I felt bad, but I never got reimbursed and I can't afford that. So I can't keep doing that. The activity assistant went on to explain that they were just notified that the process for resident shopping was changing, and they would no longer get money from residents. She explained that they will get a list of what residents want, must go online to get prices for everything, and then they will get a check for everything. The activity assistant explained that this was a new process they were just told about. The BOM stated that a sign was posted in the lobby of when residents could access/withdraw money from the trust account. The lobby was searched, and no posting was noted. At 5:12 p.m., the administrator had the maintenance director put up a sign outside of the BOM's office that indicated banking hours were Monday-Saturday, 7am-7pm. When asked about this, the administrator stated that she had found the sign in the activity's office. When asked how residents will access funds during those hours, the administrator said that the receptionist will keep the money since that is their hours. When asked about this, the BOM confirmed that currently she had the money box, that the receptionist did not have it, and that money is only available Monday-Friday, when they have money to give to residents. On 8/28/24 at 1:30 p.m., during a meeting with the facility administrator and director of nursing, the facility was made aware of the above findings. The facility provided a policy regarding resident trust accounts, but it did not address resident's access to the funds, it only stated the procedures of the business office with regards to trust accounts. No additional information was provided. 21875 2. R53 did not have timely access to money from her personal fund account. Resident #53 (R53) was admitted to the facility with diagnoses that included coronary artery disease, hypertension, diabetes and depression. The minimum data set (MDS) dated [DATE] assessed R53 as cognitively intact. On 8/26/24 at 7:04 p.m., R53 was interviewed about quality of life/care in the facility. R53 stated during this interview that money from her personal fund account at the facility was not always available when requested. R53 stated, You never get it [money] when you ask. R53 stated sometimes it took several days to get money from her account. R53 stated she had asked for money and was told there was not enough cash or nobody was there to issue the money. R53 stated that if she had an outing planned, she asked for the money a week ahead to get it in time. R53's personal fund account documented the resident had available funds with amounts of $50.00 or less provided on 3/21/24 and 6/5/24. On 8/27/24 at 4:55 p.m., the business office manager (other staff #5) was interviewed about R53 having to wait days to access her funds. The business office manager stated she just started work at the facility on 8/1/24 and did not know what the issues were for accessing resident funds prior to that date. The business manager stated as of today (8/27/24) there was $5.00 in the available cash for residents. The business office manager stated the facility recently switched banks and there had been a down time for cashing checks. The business office manager stated, I just don't think we are keeping enough money in the petty cash account. This finding was reviewed with the administrator, director of nursing, and regional director of clinical services, during a meeting on 8/28/24 at 2:00 p.m., with no further information presented prior to the end of the survey.

Based on resident interview, staff interview, and clinical record review, the facility staff failed to provide dignity when moving personal property for one of thirty-one residents in the survey sample (Resident #200). The findings include: Resident #200's personal property/items were moved to another room while the resident was out of the facility at an appointment. There was no advance notice of the room/property move and the resident was not given an opportunity to assist or accompany staff during transfer of personal items to a different room. Resident #200 (R200) was admitted to the facility with diagnoses that included congestive heart failure, hip fracture, neurogenic bladder, diabetes, anxiety and depression. The minimum data set (MDS) dated [DATE] assessed R200 as being cognitively intact. R200's closed clinical record documented a room change on 5/21/24. There was no documentation of a verbal or written notice provided to the resident prior to the 5/21/24 room change. A nursing note dated 5/21/24 at 11:01 a.m. documented a voice message was left for the resident's spouse about a room move. R200's clinical record documented the resident was out of the facility on 5/21/24 for a urology appointment. A nursing note dated 5/21/24 at 4:58 p.m., documented, .returned from urology appointment . A psychology progress note dated 5/27/24 documented that R200 felt the facility should do a better job of communicating with him, in addition to gain his permission before action is taken. Patient does not appreciate his 'pretzels' being misplaced . On 8/27/24 at 3:22 p.m., R200 was interviewed about the personal property/room move on 5/21/24. R200 stated he received no verbal or written notification prior to the room change. R200 stated the room change was done because of his complaints about a roommate. R200 stated he was out of the facility at a doctor's appointment and when he returned, his personal items/property had been moved to another room without his supervision or input. On 8/28/24 at 10:02 a.m., the facility's social worker (other staff #4) was interviewed about R200's property moved without resident notice or input. The social worker stated she thought the room change on 5/21/24 was made because R200 had conflicts and complaints about the roommate. The social worker stated she recalled that on 5/21/24, the resident returned from an outside appointment. The social worker stated the unit manager at that time reported R200 was upset about his items being moved and was especially upset that his pretzels had been discarded. The social worker stated she went to the store and bought R200 a new container of pretzels. The social worker stated she replaced the pretzels twice because the first replacement was not R200's preference. The social worker stated R200 was upset about his property being moved and especially the discarded pretzels. The social worker stated R200 mentioned the discarded pretzels to his psychologist. The social worker stated a voice message was left for the resident's spouse on the day of the move (5/21/24) but that there was no written or verbal notification to R200 prior to the move. The social worker stated she did not know why staff chose to move the resident that day or why the resident's property was moved when he was out of the facility. R200's unit manager on the date of the room change on 5/21/24 was not available for interview as she no longer worked at the facility. On 8/28/24 at 11:26 a.m., the licensed practical nurse unit manager (LPN #3) that cared for R200 was interviewed about the moving of personal property without the resident's consent or supervision. LPN #3 stated she did not recall why R200's personal items were moved while he was an appointment. On 8/28/24 at 11:36 a.m., certified nurses' aide (CNA) #3 that cared for R200 during his stay was interviewed. CNA #3 stated R200 was upset about the room change on 5/21/24. CNA #3 stated R200 complained frequently about the roommate and still complained after the room change. CNA #3 stated R200 was upset that he got moved while he was out of the facility at an appointment. On 8/28/24 at 11:49 a.m., the director of nursing (DON) was interviewed about R200's property handled/moved without the resident's permission or oversight. The DON stated she remembered the resident was moved but did not recall the events of that day (5/21/24). The DON stated R200 was moved due to complaints and issues with the roommate. The DON stated she did not recall the time of day the items were moved. The DON stated, I don't think it [room change] was done with malice. On 8/28/24 at 2:46 p.m., the administrator was interviewed about R200's room change and personal property transfer without notice. The administrator stated it was not the expectation for staff to move personal items without the resident's permission or oversight. The administrator stated residents were supposed to be notified ahead of time and be allowed time to plan for room and/or roommate changes. This finding was reviewed with the administrator, DON and regional director of clinical services during a meeting on 8/28/24 at 2:00 p.m. with no further information presented prior to the end of the survey.

Based on observation, resident interview, staff interview, facility documentation review, and clinical record review the facility staff failed to ensure it was determined clinically appropriate to self-administer medications by the interdisciplinary team for one resident (Resident #79- R79) in a survey sample of 31 Residents. The findings included: For R79, who had Bengay cream, antifungal powder and tums at the bedside, the facility staff had not assessed the resident to determine if it was appropriate for the resident to self-administer medications, failed to obtain physician orders for the medications, and failed to remove the medications. On 8/26/24 at 6:19 p.m., R79 was visited in her room during the initial tour and on the over bed table a tube of Bengay ointment and a container of antifungal powder was observed. While talking to R79, the bedside tabletop drawer was open, and it was easily observed that a bottle of tums was inside. R79 was asked about the Bengay and reported she often has pain and reported the has arthritis. When asked about the Bengay cream, R79 reported she applied it to her right leg and knee several times a day. On 8/26/24 at 7:09 p.m., an interview was conducted with licensed practical nurse (LPN #4). LPN #4 was asked about medication storage. LPN #4 reported that all medications are stored in the medication cart or in the medication room. When asked if that included over the counter medications, she said, yes. When asked if residents were able to keep anything in their room, LPN #4 said, no, unless they have an order that says they can self-administer, but I don't think we have anyone. On 8/27/24 at 8:31 a.m., R79 was visited again in her room. R79's bedside table drawer was observed to be open again and the Bengay, antifungal powder and tums were easily seen. On 8/27/24 at 8:36 a.m., the surveyor met with the unit manager. The unit manager said that all medications are stored in the medication cart for safety reasons. When asked if any residents self-administer medications, the unit manager confirmed no. The unit manager was asked to accompany the surveyor to R79's room. The unit manager confirmed and removed the Bengay, antifungal powder and tums. The unit manager also confirmed that the antifungal cream was a facility supplied item and not brought in by family. When gathering the items R79 told the unit manager she could throw away the tums. The unit manager was asked what she expects staff to do when they see the medications in resident rooms. The unit manager said, staff should be looking when they go in the room, and I expect them to pull them and bring them to me. On 8/27/24, a clinical record review was conducted of R79's chart. This review revealed that on 7/8/24, an order was written for house stock antifungal BID (twice daily) to breast and abdominal folds. There was no physician order for the Bengay or tums. According to R79's care plan, there was no indication that the interdisciplinary team had assessed nor determined R79's ability to self-administer medications. Review of the assessment tab of R79's chart, revealed no assessment for the ability to self-administer medications. On 8/27/24 at approximately 3:20 p.m., the surveyor was provided with a document titled, Medication Self-Administration Safety Screen that had been requested at 8:57 a.m., that morning, for R79. Also provided was an Education In-Service Attendance Record where the unit manager had educated staff that read in part, . when in a resident room, if you see any medications (pills, creams, etc.) on bedside tables, in drawers, etc. remove the items and give to charge nurse or unit manager. Do not leave in room unless previously ordered by physician. Review of the facility policy titled Resident Self-Administration of Medication with a review date of 12/1/22 read in part, 1. Each resident is offered the opportunity to self-administer medications during the routine assessment by the facility's interdisciplinary team. 2. Resident's preference will be documented on the appropriate form and placed in the medical record . On 8/27/24, during an end of day meeting held at approximately 1:30 p.m., the facility administrator and director of nursing were made aware of the above findings. No additional information was provided.

Based on observation, staff interview, group interview, clinical record review, and in the course of a complaint investigation, the facility staff failed to provide supervision during meal time for two of 25 residents in the survey sample. Resident #1 assessed as, Total dependence on staff with one person physical assist for eating, was not supervised during lunch on [DATE], he choked on mashed potatoes and subsequently died (HARM). Resident #22 assessed as, Limited assistance with one person physical assist, was observed eating in his room during the lunchtime meal on [DATE] with no staff present. Findings were: Resident #1 was admitted to the facility with the following diagnoses, including but not limited to: hypertension, dysphagia, anxiety, unspecified intellectual disabilities, feeding difficulties, atrial fibrillation, and heart failure. An annual MDS (minimum data set) with an ARD (assessment reference date) of [DATE] assessed Resident #1 as having problems with both long and short term memory, as well as severely impaired with daily decision making skills. Resident #1 was assessed as a ,d+[DATE] in Section G Functional Status, meaning Total dependence-full staff performance every time during entire 7-day period; One person physical assist. The clinical record was reviewed on [DATE] at approximately 12:00 p.m. The physician orders included an order written [DATE] for Regular Diet .puree texture, Regular/Thin consistency. Double Portions at meals/Fortified Foods. The progress notes section was reviewed and contained the following: [DATE] 19:32 (7:32 p.m.) .Nutrition Review .He has had a change of assistance required at meals, now requiring mostly total dependence from caregivers .MD notes resident has had increased agitation and particularly chewing on non-food items. [DATE] 13:27 (1:27 p.m.) .MDS Note .feeds self after tray setup and needs one on one supervision due to eating too fast and pocketing food . [DATE] 12:13 (p.m.) Behavior Note Toddler like behaviors, pounding on surfaces, chewing on anything he can .Unable to follow direction or focus on tasks, such as eating/swallowing what's in mouth to receive the next bite of food . [DATE] 12:01 (p.m.) Resident started coughing with food intake. Ate 2 bowls of mashed potatoes but had coughing episodes during intake. CNA (certified nursing assistant) states resident would take a bite of food, swallow, cough, then suck/chew on his thumb. Continued cough in between bites of food . [DATE] 07:49 (a.m.) .new order for ST (speech therapy) to eval and treat as indicated. [DATE] 15:30 (3:30 p.m.) .Change in Condition .Nursing observations, evaluation, and recommendations are: staff to observe resident when up in w/c (wheelchair) for behaviors, .ST eval and treat as indicated. [DATE] 16:00 (4:00 p.m.) .While eating breakfast this AM, res had a coughing episode after drinking orange juice. Res able to cough and clear juice. Lungs diminished bilaterally . [DATE] 13:52 (1:52 p.m.) .Late entry for [DATE] Informed of situation where CNA and staffing coordinator saw resident in hallway, gagging, holding onto his wheelchair, face red and eyes watering. Nurse went behind residents chair and rubbed his back and removed paper from his mouth. Noted that paper was a brochure that another resident had given to this resident and place (sic) in his mouth . [DATE] 15:31 (3:31 p.m.) .at 1300 (1:00 p.m.) res observed sitting in front of nurse station chewing exam glove in mouth. Nurse removed glove from res mouth without difficulty. All other objects removed from area near res . [DATE] 16;25 (4:25 p.m.) MDS Note .assisted by staff at meals . [DATE] 12:20 )p.m.) .Change of Condition .Nursing observations, evaluation, and recommendation are: Heimlich performed by nurse and PT (physical therapy) with small amount of mashed potatoes brought up, airway was open, no food observed in oral cavity, 911 dispatched and arrived and called death at 1232, HPD (name of town police department) in facility, obtaining information of incident, per their protocol they contacted Medical Examiner who ordered resident to be sent for Autopsy . The care plan was reviewed. A focus area: ADL (activities of daily living) Self Care Performance Deficit . included the following intervention: Eating: Is able to feed self and requires tray set up and supervision. Needs reminders to slow down while eating and is at risk of choking.' At approximately 1:00 p.m., the administrator was asked if there had been an investigation regarding the choking and subsequent death of Resident #1, and if so to provide it to the survey team. Per the facility investigation and witness statements. Resident #1 was sitting across from the nurse's station eating his lunch. He began to choke on mashed potatoes. Attempts were made to Scoop the food out of his throat. The Heimlich maneuver was performed by nursing staff and a physical therapist with the expulsion of more food. 911 was called and the resident was pronounced on the scene at 12:32 p.m. Per the administrator's follow-up summary/final report, an autopsy was to be done but results were not available at the time of the report ([DATE]) and per the administrator were not available at the time of the survey. The administrator was asked if the CNA who was providing care for Resident #1 was working at the facility. He stated, No. The speech therapist who worked with Resident #1 was interviewed at approximately 1:10 p.m. He was asked if he remembered working with Resident #1. He retrieved his notes and stated, I saw him from [DATE]st until he was discharged on [DATE] .he had reached his highest practical level .I reevaluated him in June. The referral from June was presented. He stated, We got a referral because he had choked on some paper .He was at his baseline then, the staff were feeding him and he was on a puree diet. I recommended that he be appropriately positioned when he was eating. At approximately 1:50 p.m., at the end of a group interview, three residents (Resident #4, Resident #2 and Resident #25, all cognitively intact wanted to discuss the death of Resident #1. Resident #4 (Cognitive score of 15) stated that she lived across the hall from where Resident #1 resided. She stated, He would eat and chew on anything, his blanket, his hands .I could hear him in is room choking sometimes. The day that this happened he was up there at the nurse's station, beside the desk .across from it .the CNA that was with him went to the bathroom or something .she wasn't with him .He was a feeder and she wasn't there when he choked she's not here anymore, they blamed her for him dying .it was terrible the way they did him .nobody should die like that. During a meeting on [DATE] at approximately 2:30 p.m., with the administrator, the DON (director of nursing), the MDS nurse, and the regional nurse consultant, the above information was discussed. LPN (licensed practical nurse) #2 who was responsible for MDS assessments and care planning was asked what it meant when Resident #1 was coded on his MDS as a ,d+[DATE]. She stated, It means he should have someone assisting him with his meals, feeding him, he ate too fast and pocketed food in his mouth. The wording of the care plan was discussed. LPN #2 stated, Maybe I should be more clear with my wording. Staff was supposed to be with him at all times when he was eating. During the meeting it was ascertained that LPN #4 who initiated the Heimlich maneuver on Resident #1 and removed mashed potatoes from his mouth, was not in the facility that day, but would be available for interview on [DATE]. The administrative staff were told that the survey team had significant concerns regarding Resident #1's choking and subsequent death. At approximately 2:45 p.m., the unit where Resident #1 resided was visited. CNA #1 was in the hallway. She was asked if she remembered Resident #1 and if so had she been working the day that he choked. She stated, Yes, I'm the one that saw him first .He was sitting here across from the nurse's station. He was in his wheelchair eating his lunch .I was coming down the hall from the shower room and I saw his sitting there. I looked at him and saw he had too much food in his mouth. I said, '(Name of Resident #1) that's too much food, slow down a little.' Then I turned around to walk away, but I realized he didn't look right. I yelled for (Name of LPN -licensed practical nurse) #4. She came around the nurse's station and started working on him .I ran up the hall and got (Name of PT) to come help us. He came down and helped with the Heimlich maneuver .mashed potatoes were coming out of his mouth. He didn't have a pulse by then .the squad came and he was dead. She was asked if she was the CNA assigned to Resident #1 that day. She stated, No, it was (Name of Other staff #3) .she doesn't work here anymore. She was asked if OS #3 had been with Resident #1 when he choked. She stated, No, she was up the hall. When I saw him choking I looked up the hall and she was coming down the hall with towels and a washcloth. I don't know what she was doing .I don't know if she went to answer a call light or what. CNA #1 was asked if someone was supposed to be with Resident #1 while he was eating. She stated, Yes, he ate way too fast, and put too much food in his mouth. Somebody was supposed to be right beside him the whole time he was eating . She was asked if OS #3 was still working at the facility. She stated, No, they fired her .she wasn't a CNA, she was a TNA, a temporary aid .she never went and took her test like she was supposed to do and then (Name of Resident #1) choked while she was supposed to be taking care of him .she wasn't next to him while he was eating . CNA #3 who worked on the same unit was interviewed at 3:15 p.m. She stated, (Name of OS #3) wasn't where she was supposed to be that day. She was supposed to be with him, assisting him with eating .she more like monitoring him while she did other stuff. LPN #3 was interviewed at approximately 3:30 p.m. She stated, I was working on the other hall and was bringing medicine down here for residents that had moved over here when I got down here I saw what was going on .911 had already been called and they got here pretty quickly. He didn't have a pulse .the police came. It was awful . OS #5, the physical therapist who assisted with the Heimlich maneuver for Resident #1 was interviewed on [DATE] at approximately 4:20 p.m. He was asked what happened. He stated, I was in another resident's room. The CNA (CNA #1) came and got me and said they needed help .when I got to him, (Name) was already gray. I attempted the Heimlich maneuver with him in a seated position .someone was scooping food out of his mouth .it looked like mashed potatoes .the nurses felt and there wasn't a pulse, I didn't feel one either .He was a DNR, so I went back to my resident that I had left. On [DATE] at 10:00 a.m., LPN #4 was interviewed. She was asked about the incident with Resident #1. She stated, It was lunchtime, I was charting at the nurse's station, one of the CNAs (CNA #1) said something was wrong with (Name of Resident #1) .she said he was gurgling and appeared to be choking .I went around the nurse's station to where he was. There was a bowl of mashed potatoes in front of him the aid that called me over there was beside him .I put on gloves and swept his mouth, I didn't get anything. Another nurse (LPN #3) came up and helped me stand him up .we tried to do the Heimlich but didn't get anything .that's when the PT (OS #5) came to help .I don't remember if he got anything up or not\ .I called 911, the squad came and assessed him, I had the DNR (Do not resuscitate) out and they called it. She was asked what type of assistance Resident #1 required with eating. She stated, He could feed himself, but someone was supposed to be with him .he ate too fast. She was asked if an aid or anyone had been with him while he was eating. She stated, I can't say 100 percent if anyone was there or not .I was at the nurse's station charting .I wasn't watching him. At approximately 10:15 a.m., the administrator was asked for a copy of the job description for TNAs working in the facility. He stated, We don't have any now. At approximately 10:30 a.m., a job description for OS #3 was presented. The job description was for a CNA and was signed by OS #3 on [DATE]. The administrator was asked if OS #3 had completed her testing for CNA was she a TNA when she was employed at the facility. He stated, She was a TNA, we don't have a job description for that so she signed this one. A copy of a skills list or competency checklist for OS #3 was requested. The DON presented the requested competency lists for OS #3. The first list was signed off by the former DON on [DATE]. The skills list did not include check off regarding feeding residents. Additionally inservice sign-in sheets were presented, but nothing regarding feeding of residents. A second checklist which the DON stated she had obtained from OS #3. Under the area Nutrition/Hydration the following was listed: Mechanically altered diet/Thickened liquids/Adherence to diet; Passing meal trays/Setup/opening packages for residents who can consume meals independently; Pick up trays; Pass Ice water; Food Storage/Safety The DON was asked where on the checklist it said that OS #3 was competent and had been educated/trained on what to do with a resident such as Resident #1, who was totally dependent on staff for eating and required one person physical assist. She stated, I don't see it on there either. A meal observation was conducted on [DATE] at approximately 11:45 a.m., on the A wing of the facility. Residents identified by the facility as needing assistance with eating were observed. CNA #6 was observed feeding a resident a pureed diet. When she came into the hallway she was interviewed regarding feeding residents or assisting resident who could feed themselves. She stated, If they are feeders I always feed them.CNA #6 was asked if she ever left a resident who could help feed themselves. She stated, No, we are suppose to stay with them . if they try to feed themselves sometimes you don't know how much food is in their mouth. I don't want anybody choking. CNA #7, also observed feeding a resident a puree diet was interviewed. She stated, When they are feeders, even if they can feed themselves a little bit, we are supposed to stay with them. Sometimes they get tired and we have to take over or sometimes they put too much in their mouth. She (referring to the resident she was feeding) just lets me do it. A meeting was held with the administrator, DON, MDS, and the regional Director of Nursing on [DATE] at approximately 12:10 p.m. The Regional Director of Nursing stated, After that incident we did an AD HOC She was asked what that meant. She stated, We identified an issue and put a plan in place to correct it. The plan dated [DATE] was reviewed. The Issue listed was Residents who need feeding assistance and is not being aided with meals this could possible cause harm to the resident. Item(s) for Review: 1. Resident needed staff assistance with meal. 2. Resident given food needing assistance and staff did not assist . There was no expected date of compliance on the plan. The Regional Director of Nursing, and the rest of the administrative staff in the room were told that the plan could not be accepted for past noncompliance, as a current resident had been observed during the survey not receiving feeding assistance per his MDS assessment. Concerns were voiced that per the clinical record, Resident #1 had been identified as having more than one instance of choking. He was identified as eating too fast and pocketing food in his mouth. He was assessed as being totally dependant on staff for feeding, and per staff and resident interviews, facility staff had not been with him at the time that he choked on mashed potatoes and died . They were informed that the information had led the survey team to the identification of harm. No further information was obtained prior to the exit conference on [DATE]. THIS IS A COMPLAINT DEFICIENCY. 2. During the course of a complaint investigation, a list of residents requiring feeding assistance was requested. Resident #22 was on the list and added to the survey sample. Resident #22 was admitted with the following diagnoses including but not limited to: non-[NAME] lymphoma, dementia, AFTT (adult failure to thrive), bipolar disorder, and personal history of transient ischemic attacks. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of [DATE] assessed Resident #22 as moderately impaired with a cognitive summary score of 12. Resident #22 was assessed as a ,d+[DATE] in Section G Functional Status, meaning Limited assistance-resident highly involved in activity; staff provided guided maneuvering of limbs or other non-weight bearing assistance; One person physical assist. On [DATE] at approximately 11:45 a.m., the lunchtime meal was observed on the A wing. Resident #22 was in his room. CNA (certified nursing assistant) #4 took his lunch tray in and placed it on the bedside table that was over his bed. She uncovered his plate, and left the room. Resident #22's tray ticket was observed. Per the tray ticket, Resident #22 was to have beef stroganoff, buttered egg noodles, peas, a dinner roll, cake, and lemonade. There was no beef stroganoff observed over the buttered noodles. CNA #4 was in the hallway passing out additional trays and was asked to look at his tray ticket. She went to the kitchen and retrieved another tray for Resident #22. She served it to him and again left the room. There were no staff members in the room with Resident #22 as he fed himself. The care plan was reviewed at approximately 12:00 p.m. A focus area ADL (activities of daily living) self-care performance deficit r/t (related to) impaired mobility .dementia .CVA (cerebrovascular accident) contained the following intervention: EATING: Assist (Name of Resident #22) at meals with eating. [NAME] can feed self after tray setup at times. A meeting was held with the administrator, DON, MDS, and the regional Director of Nursing on [DATE] at approximately 12:10 p.m. LPN (licensed practical nurse) #2 was asked about Resident #22's MDS assessment and his care plan. She was asked what assistance Resident #22 needed with meals based on his MDS assessment of ,d+[DATE] with eating. She stated, Someone should be with him to provide assistance as he needs it. She was asked if Resident #22 was coded ,d+[DATE] and eating in his room where should staff be located. She stated, They should be in there with him .I should maybe be more clear with my wording on the care plan, I should have updated it when I did the MDS assessment. The administrative team was informed that no one had been in the room with Resident #22 nor was anyone going in and out of the room checking on him. No further information was held prior to the exit conference on [DATE].

Based on clinical record review, review of hospital documents, review of facility policy and procedure, and staff interview, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice to maintain the highest level of practicable well being, for one of 24 residents in the survey sample (Resident # 83). Facility staff failed to monitor blood sugars according to facility hypoglycemic protocol, failed to contact the physician according to facility hypoglycemic protocol and physician orders, and failed to seek emergency help in a timely manner. There was a delay of approximately four hours in sending the resident to the hospital for evaluation and treatment after a second hypoglycemic event within 24 hours. This resulted in harm to the resident who was hospitalized . The findings were: Resident # 83 was admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set, a Significant Change with an Assessment Reference Date of 2/6/19, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 13 out of 15. Review of Resident # 83's Electronic Health Record (EHR) revealed the following Progress (Nurses) Notes entry dated 1/21/2019 at 1523 (3:23 p.m.), Pt. (Patient) lethargic and diaphoretic, was gurgling some, was not talking, (Name of Physician's Assistant) aware. He ordered d5 ns (5% [MEDICATION NAME] in normal saline) at 100 cc/hr (cubic centimeters per hour) times (to equal) 1 liter. This was started at 1355 (1:55 p.m.). Blood sugar was 36. [MEDICATION NAME] given in mouth as well. Pox (pulse ox) 96% on 3 liters (of oxygen). (Name of Physician's Assistant) stated to put it on 3 liters this am. She started becoming more awake. Blood sugar was 36 at 1345 (1:45 p.m.). Blood sugar was up to 63 at 1410 (2:10 p.m.). Not gurgling anymore at 1530 (3:30 p.m.). No respiratory distress noted. (NOTE: [MEDICATION NAME] is an oral gel that delivers 15 grams of pure glucose ([MEDICATION NAME]) for rapid response to [DIAGNOSES REDACTED]. Ref. MooreMedical (McKesson).com.) Also in the resident's EHR was a Telephone Order dated 1/21/19 at 10:35 a.m., that included the following, D5 1/2 NS (5 1/2 % [MEDICATION NAME] in normal saline) at 100 cc/r per IV (intravenous)/clysis x (times) 2 L (liters) for AKI (Acute Kidney Injury/Failure). (NOTE: Clysis is the introduction of large amounts of fluid into the body, usually by [MEDICATION NAME] injection. Ref. Langenscheidt's Merriam-Webster Medical Dictionary, Copyright 2002, page 124.) At 3:00 p.m. on 3/6/19, RN # 2 (Registered Nurse), who wrote the 1/21/19 Progress (Nurses) Notes entry, was interviewed. RN # 2 was first asked why [MEDICATION NAME] would be given to someone who was .lethargic and diaphoretic, was gurgling some, was not talking. RN # 2 said, We put it under her tongue and in her cheek. She was not totally out of it. We encouraged her to swallow and she could. RN # 2 was then asked if the order for the order for the IV was written at 10:35 a.m., why was it not started until 1:55 p.m., approximately 3 hours and 20 minutes later. RN # 2 questioned the timing of the IV order and said she didn't think the time was right. RN # 2 then said, If I wrote that time (meaning 1355 or 1:55 p.m.), then that was when it (the IV) was started. Asked if the IV supplies were readily available, RN # 2 said they were all in the medication storage room. An order on Resident #83's (MONTH) Medication Administration Record [REDACTED]< (less than) 60 or > (greater than) 500, two times a day for glucose monitoring. The times for checking blood sugar were documented at 9:00 a.m. and 9:00 p.m. on the MAR. On 1/21/2019, Resident #83's blood sugar was documented as 67 at 9:00 p.m. Resident # 83's EHR contained the following Progress (Nurses) Notes entry related to her hypoglycemic event, dated 1/22/2019 at 0336 (3:36 a.m.). Resident continued with shakes. BS (Blood Sugar) 28. Given med pass X (times) 2, given half a sandwich, given oral [MEDICATION NAME]. BS rechecked and 49. On call MD called, order for D5 1/2 NS ordered. BS rechecked after IV running for 2 hours and BS still at 49. Resident pulled IV out. Nursing judgement made to send resident out to (name of hospital). At approximately 11:50 a.m. on 3/7/19, the survey team met with the Administrator, Director of Nursing (DON), and the Corporate Nurse Consultant. At that time, the surveyor requested the DON to make a timeline of Resident # 83's hypoglycemic episode, starting with the Progress (Nurses) Notes dated 1/21/2019 through 1/22/2019. At 2:40 p.m. on 3/7/19, the DON provided the requested timeline. Together, the surveyor and the DON reviewed the timeline, which noted the resident's BS at 9:00 a.m. on 1/21/19 was 108. The timeline confirmed the 1/21/19 Telephone Order time of 10:35 a.m., but it did not include the IV order. The DON agreed the IV order was on the Telephone Order. Continuing, the timeline noted, After lunch, resident presented diaphoretic, BS 36, PA (Physician's Assistant) aware, D5 1/2 NS ordered at 100 cc/hr for 1 liter, O2 (oxygen) via NC (Nasal Canula) increased to 3 liters. IV started at 1355 (1:55 p.m.). At 1410 (2:10 p.m.) BS 63. Asked if IV supplies were available, the DON stated they were in the Medication Storage Room. When asked why it took so long for the IV to be started, the DON said, It should not have taken 3 hours. Moving on to the events of 1/22/19, the timeline noted, .MD notified and order for D5 1/2 NS ordered (IV was started approximately 0130 {1:30 a.m.)) BS rechecked after IV running for 2 hours and BS was 49, resident pulled IV out, and resident was sent to ED (Emergency Department). Based on a start time of 1:30 a.m., and a run time of two hours, the surveyor and DON agreed that the IV would have finished at approximately 3:30 a.m. A review of the ED Provider Notes from the hospital placed the resident's hospital arrival time at 7:54 a.m. on 1/22/19. Asked how far away from the facility, time wise, was the hospital, the DON said, About 10 minutes. The DON and surveyor agreed on another 15 to 20 minutes to get the resident ready and loaded into the ambulance, which placed the time the resident left the facility at approximately 7:30 a.m. Asked why approximately four hours lapsed between the time Resident # 83's IV finished and the time she was sent to the hospital, the DON had no explanation. Asked about physician involvement in the decision to send the resident to the hospital, the DON indicated that apparently there was none since the resident was sent out based on nursing judgement. On 3/6/19, the surveyor requested and was provided with the facility's protocol to address [DIAGNOSES REDACTED]. Under the Procedure portion of the protocol the following was noted at Item 6c. Check blood glucose every 15 minutes, until blood sugar is over 70 mg/dl (milligrams per deciliter). If blood sugar continues to fall after 15 minutes or continues to be below 70 mg/dl after 30 minutes, call physician. Item 10 of the protocol documented, Continue to monitor blood sugars, if the resident has not improved within 20 minutes from initial treatment or the resident's condition worsens, or passes out from [DIAGNOSES REDACTED]: a. Contact the physician b. Follow any new orders c. DO NOT inject insulin d. DO NOT give food or fluids e. Inject [MEDICATION NAME], if ordered f. Call for Emergency help The :Documentation Guidelines included the following: 1. Date and time of event 2. Resident's response, as related to the procedure, a. Resident's signs and symptoms, b. Frequency and results of blood testing, c. And change in medication administration, d. Type, time, and amount of oral intake, e. Resident's response to treatment. 2. Date and time of physician notification. The DON was asked if the 15 minute Blood Sugar checks were done according to the protocol on 1/21/19 and 1/22/19. The DON said she talked to staff and .they said they did them, but they did not document them. The DON also noted there was no documentation of what happened between 3:30 a.m. and 7:30 a.m. on 1/22/19. There was also no documentation to indicate the physician was called on 1/21/19 when the resident's Blood Sugar failed to rise above 70 mg/dl, or on 1/22/19 when her Blood Sugar failed to rise after two hours of an IV. There was no documentation of the resident's signs and symptoms between the Progress (Nurses) Notes of 1/21/19 at 3:23 p.m. and 1/22/19 at 3:36 a.m. There was no documentation indicating the physician was called prior to the resident being send to the hospital based on nursing judgement. The American Diabetes Association classification of [DIAGNOSES REDACTED] defines a Level 2 [DIAGNOSES REDACTED] as .a blood glucose concentration < 54 mg/dL (3.0 mmol/L), which .is the threshold at which neuroglycopenic symptoms begin to occur and requires immediate action to resolve the hypoglycemic event. A Level 3 event is defined as .a severe event characterized by altered mental status and/or physical functioning that requires assistance from another person for recovery .Level 3 [DIAGNOSES REDACTED] may be recognized or unrecognized and can progress to loss of consciousness, [MEDICAL CONDITION], coma, or death. It is reversed by administration of rapid-acting glucose or glycogen. [DIAGNOSES REDACTED] can cause acute harm to the person with diabetes .A large cohort study suggested that among older adults with type 2 diabetes, a history of level 3 [DIAGNOSES REDACTED] was associated with a greater risk of dementia. Ref. American Diabetes Association Standards of Medical Care in Diabetes - 2019, page S67. Resident # 83's hypoglycemic episode was discussed during a meeting at 4:15 p.m. on 3/7/19 that included the Administrator, Director of Nursing, Corporate Nurse Consultant, and the survey team.

Based on observation, staff interview, family interview and clinical record review, the facility staff failed to ensure one of 24 residents maintained acceptable parameters of nutritional status, Resident #70. Resident #70 had a weight loss of 6.12 % in three months and a significant weight loss of 10.20% in six months. Resident #70 was unable to feed herself, and facility staff did not offer assistance at meal time per Resident #70's care plan. This was identified as harm by the survey team. Findings were: Resident #70 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Dysphagia, Type II Diabetes Mellitus, Major [MEDICAL CONDITION], Hypertension, Anxiety, and Progressive Supranuclear [DIAGNOSES REDACTED] ([COND] Syndrome). The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 01/29/2019. Resident #70 was assessed as cognitively intact with a summary score of 15. In Section G: Functional Status, Resident #70 was coded as 0/1 for eating, indicating she was independent with eating and needed set up only for her meals. On 03/05/2019, Resident #70 was observed sitting in a chair in her room. Her husband was in the room and he was feeding her lunch. An interview was conducted with both Resident #70 and her husband. Resident #70's speech was very slow, halting and deliberate. Her husband stated, She has difficulty talking. The husband stated, She doesn't eat if I'm not here. He was asked what that meant. He stated, She can't feed herself .she can't get the food to her mouth .I've told them she does okay with finger foods, but she can't pick up those peas on her tray. He handed the spoon to Resident #70 and stated, Honey, try to feed yourself a little bit. Resident #70 took the spoon and attempted to scoop up peas on her plate. She pushed the peas all around on her plate before getting one or two on her spoon. She attempted to put the spoon to her mouth, but either it had no food on it, or dropped the peas before getting them to her mouth. Her husband was asked who assisted her when he was not at the facility. He stated, Nobody does .I've been sick myself and haven't been in as much .she's lost some weight. The care plan was reviewed on 03/05/2019 at approximately 4:30 p.m., and contained the following information: Focus: ADL (activities of daily living) self-care performance deficit Interventions: EATING: (Name) is able to feed self after tray set up. If (Name) is dropping food or getting tired, staff to feed her. 10/16/18: (Name) needs lids and straws for all cups and for all meals. Requires set up for straws for coffee cups. Plate guard for all meals. Date initiated: 06/12/2018 .Revision on: 10/16/2018. On 03/06/2019 at approximately 8:45 a.m., Resident #70 was observed lying in bed. Her breakfast tray had been picked up. Her CNA (certified nursing assistant) was located and interviewed regarding Resident #70's intake at breakfast. CNA #1 stated, I think she just needs set up only .I don't think she needs any assistance .I didn't put her tray in there this morning, or pick it up .maybe (name) did. CNA #1 went down the hall and spoke with three other staff members, none of which had been in Resident #70's room. CNA #2 was coming down the hallway. CNA #1 asked her if she had picked up or set up Resident #70's tray. She stated, Yes, I put straws in her cups .She drank about 240 cc of fluid and ate about 25%. CNA #2 was asked if she had offered to assist Resident #70 with eating. She stated, No. The CNAs were asked who delivered and picked up trays. CNA #1 stated, We work together .we all deliver and pick them up .then we write on a piece of paper at the nurse's station how much they eat. The clinical record was reviewed. The following weights (in pounds) were documented: 06/04/2018: 154 (standing) 06/05/2018: 157 (mechanical lift) 06/09/2018: 152 06/24/2018: 153 07/05/2018: 149 (standing) 07/18/2018: 148 07/25/2018: 147 08/08/2018: 148 09/06/2018: 147 10/05/2018: 145 11/05/2018: 143 12/06/2018: 138 01/04/2019: 134 01/13/2019: 134 01/19/2019: 137 01/27/2019: 136 02/02/2019: 133 02/09/2019: 134 02/16/2019: 136 02/23/2019: 135 03/02/2019: 132 From 09/06/2019 until 12/06/2018 (3 months) Resident #70 lost 9 pounds, 6.12% in three months and from 09/06/2018 until 03/02/2019 (6 months) Resident #70 lost 15 pounds, a significant loss of 10.20%. The MDS nurse, RN (registered nurse) #1 was interviewed at approximately 11:00 a.m. Observed in the clinical record was an MDS assessment that was in progress but had not been completed. The functional ability section G was completed on the MDS and Resident #70 was coded as a 4/2 for eating, indicating she needed extensive assistance of 1. RN #1 stated, That populates from within the system .we make changes to it as we finalize it. The observations of Resident #70 eating and the interview with her husband were discussed. At approximately 1:00 p.m., RN #1 came to the conference room and stated, I contacted Resident #70's RP (responsible party) and I updated her care plan. She presented an updated care plan that contained the previous mentioned interventions and the addition of the following: 03/06/2019 (Name) is able to feed herself finger foods, anything she can hold in her hand. (Name) needs assist with foods that require using a utensil to eat. She needs to be fed slowly. The above information was discussed during an end of the day meeting on 03/06/2019 with the administrator, the DON (director of nursing) and the corporate nurse consultant. The DON stated that Resident #70 had recently had speech therapy. On 03/07/2019 at approximately 9:00 a.m., Resident #70 was observed lying in bed. She was asked if she had eaten her breakfast. She slowly stated, No. She was asked if anyone had assisted her with breakfast. She slowly responded, No. She was asked if she was hungry. She slowly answered, Yes. A nurse in the hallway was asked who the CNA assigned to Resident #70 was. She stated, (Name of CNA #3) there she is, coming around the corner. CNA #3 was observed coming down the hallway, she was wearing a coat, talking on a cell phone, and carrying a small white plastic bag. She went into an office on the unit and shut the door. This surveyor knocked on the door and asked to speak with the CNA when available. CNA #3 was asked if she was caring for Resident #70. CNA #3 asked, What room is that? CNA #3 was told the room number. She asked, A bed or B bed? She was told which bed. She stated, Yeah, she's mine. CNA #3 was asked how much breakfast Resident #70 had eaten that morning. She stated, I didn't do her .I think (name of CNA #4) did. CNA #3 was asked what that meant. She stated, We all hand out the trays and pick them up, you don't always do your own rooms .We can look at the intake sheet and see how much she ate. CNA #3 went to the nurse's station looked at a piece of paper and stated, She refused breakfast, but she drank 360 cc, CNA #3 was asked who wrote that down. She stated, I guess (CNA #4) did. CNA #3 was asked if she had gotten report on Resident #70. She stated, We make rounds and they tell us if anything has changed. CNA #3 was asked if she was aware that Resident #70's care plan stated that if she was dropping food or getting tired while eating that staff were to assist her. She stated, No, I didn't know that. CNA #3 was asked if she had reviewed Resident #70's care plan. She stated, No. She was asked if that was something she normally did. She stated, I do it when I get time .I try to do it before I give them care .I've taken care of her before I just didn't know that .I think somebody should have told me that in report. CNA # 4 was located. She was asked if she had given Resident #70 her tray or picked it up. She stated, No, (name of CNA #3) did. CNA #4 and this surveyor located CNA #3. CNA #4 and CNA #3 had a discussion about which one of them had gotten Resident #70's tray. They were both asked if either of them had offered to assist Resident #70 with her food or if Resident #70 had stated that she didn't want breakfast. Both stated, No. Information was presented on 03/07/2019 regarding speech therapy services received by Resident #70 from (MONTH) through (MONTH) of 2019. Review of the evaluation included the following goals: Patient will increase use of breath support and control strategies up to 70% accuracy during production of words increase speech intelligibility; Patient will articulate words with 60% intelligibility using over-articulation, breath support and control, environmental modifications and pacing in order to improve functional communication skills; Patient will communicate yes/no responses using non-speech generating AAC system with moderate cueing. At approximately 9:25 a.m., the speech therapist who worked with Resident #70 was interviewed. He was asked if he had observed Resident #70 eat while she was receiving speech therapy services. He stated, No I was in there to facilitate her ability to communicate .her communication board had been misplaced so I was consulted to work with her on ways to communicate. On 03/07/2019 at approximately 10:00 a.m., observed in the clinical record was an Angel Care Welcome Survey. The survey was dated 6/4/2018. One of the questions was: How had the food been? Resident #70's response was She can't feed (her)self. The DON was asked what the Angel Care Welcome Survey was; she stated a survey done a few days after a resident's admission to the facility to see how things were going. The information regarding Resident #70 not being able to feed herself was pointed out to the DON. The RD (registered dietitian) was interviewed on 03/07/2019 at approximately 10:30 a.m., regarding Resident #70. She was asked if she was aware of Resident #70's weight loss. She stated, Yes, I saw her this month (March) because she has been referred to Hospice so I did a significant change assessment .I also saw her in (MONTH) for her quarterly assessment .I increased her supplements then, and we are still doing weekly weights. The RD was asked if she had watched Resident #70 eat. She stated, The PA (physician's assistant) was in there when I saw her last so, no I didn't. She was asked if she had watched Resident #70 eat in (MONTH) when she did her quarterly assessment. She stated, No, I didn't .I really can't be here to watch everyone eat .I have watched her in the past but not either of those times. The observations of Resident #70 eating and the interview with her husband were discussed with the RD. The RD stated, We discuss her weight meeting every week, I've increased her supplements and I am going to liberalize her diet more. A note written on 03/07/2019 at 9:59 a.m., by the unit manager, was observed in the clinical record at approximately 11:45 a.m. The note contained the following: Res (resident) noted with dysphagia and overall decline with ADL's. Res states that she is not able to feed self, res is able to consume liquid by self with no assistance. Staff assisted with eating this day and res noted with difficulty. This nurse followed up with Hospice to have someone come to assess these concerns and assist with any changes that may be needed . The unit manager was interviewed at approximately 12:00 p.m. and was asked about the note written that morning. She stated, Yes, I noticed that she had refused breakfast this morning so I got her another tray and had the CNA try to feed her. The unit manager was asked if she was aware that Resident #70's care plan contained interventions for staff to feed her if she was becoming tired or dropping food and most recently updated to include that staff assist her with food requiring utensils and for staff to feed her slowly. The unit manager stated, No, I was not aware of any of that being on her care plan. On 03/07/2019 at approximately 12:45 p.m., a meeting was held with the DON, the administrator and the corporate nurse consultant. The above information was discussed, The corporate nurse consultant stated, She had an occupational therapy consult in (MONTH) (2018) and she was able to feed herself then. The Occupational therapy notes from (MONTH) (YEAR) were presented. Under the section Functional Skills Assessment .the area Self Feeding was marked Self Feeding=Supervised (A). The occupational therapist that completed the eval was interviewed on 03/07/2019 at approximately 2:35 p.m. He was asked what the A stood for in his notes. He stated, Assist. He was asked what that meant in regards to Resident #70 eating. He stated, Assist means that might need cueing .move her plate or cup over to her if it gets pushed away, that type of thing. An end of survey meeting was held with the administrator, the DON and the corporate nurse consultant. The above information was discussed. Concerns at the level of harm were voiced due to the fact that the facility staff had not provided assistance to Resident #70 at meal time, nor were the staff aware that Resident #70 required assistance per her care plan. The RD nor the speech therapist had observed Resident #70 eating, and the CNA staff while working as a team on the unit to get trays out to residents and picked back up in a timely manner had not assured that the CNA setting up or picking up her tray had offered assistance with eating. No further information was obtained prior to the exit conference on 03/07/2019.

Based on staff interview, clinical record review and in the course of a complaint investigation, facility staff failed to prevent one of 24 residents from an accident, resulting in harm for Resident #360. Facility staff failed to put appropriate fall precautions in place for Resident #360, resulting in this resident falling, fracturing her pelvis in multiple places and rupturing her bladder. Findings included: Resident #360 was originally admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident #360 was not in the facility at the time of survey. The most recent MDS (minimum data set) was a Re-entry (5-day assessment) with an ARD (assessment reference date) of 11/20/16. Resident #360 was assessed as severely impaired in her cognitive status with a total cognitive score of seven (7) out of 15. Resident #360's closed record was reviewed on 03/29/18 at 9:00 a.m. During this review seven Fall Risk assessments were completed on Resident #360. Every Fall Risk assessment indicated Resident #360 was High Risk for Falls except the assessment dated [DATE]. The High Risk for Falls assessments were dated 10/19/16, 11/03/16, 11/10/16, 11/13/16, 12/13/16, and 12/20/16. Section G - Functional Status of the MDS dated [DATE] included Resident #360 required, Extensive assistance, One person physical assist, in Bed mobility, Transfer, Walk in room, Walk in corridor, Locomotion on unit, Locomotion off unit. Section G - Functional Status of the MDS dated [DATE] included Resident #360 required, Limited assistance, One person physical assist, in Bed mobility, Walk in room, Walk in corridor and required Extensive assistance, One person physical assist, in Transfer, Locomotion on unit, Locomotion off unit. Progress notes were reviewed on 03/29/18 at approximately 10:00 a.m. and revealed the following documentation: LPN (licensed practical nurse) note dated 10/20/16, pt (sic) is pleasantly confused, and is not alert enough to observe fall precautions. she (sic) is a great fall risk and continues to be in and out of bed and walking around with the support of staff or assistive devices . LPN note dated 11/4/16, pt (sic) continues on skilled services PT/OT (physical therapy/occupational therapy) . LPN note dated 11/5/16, .Participated with therapy this shift. 1 assist, ambulatory with w/c (wheelchair) . LPN note dated 11/6/16, pt (sic) continues to participate with therapy services .ambulates with a wheelchair for unsteady gait . LPN note dated 11/9/16, Day two post witnessed fall without c/o (complaints of) pain . LPN note dated 11/11/16, .impulsive and needs ques and redirection .mobile with self propelled wheelchair . LPN note dated 11/17/16, .unstedy (sic) gait, self propels wheelchair with direction . Wound Care Nurse note dated 11/21/16, .extensive assist for .transfers, and bed mobility .propels self in w/c on and off the unit . LPN note dated 11/23/16, .confused a lot and needs redirection . LPN note dated 11/24/16, .alert but confused most of the time. needs (sic) prompting to voice needs and use call light .self propels wheelchair. needs (sic) ques and prompting for safety . Incident/Accident Note dated 12/10/16 at 7:21 a.m., CNA (certified nursing assistant) heard a thud and when she went into the room resident was on the floor. On her back and c/o pain in her pelvic bone region .Resident's roommate stated she told her not to get up but she was already getting up at that time .Will ask day shift to notify POA (power of attorney) and MD (medical doctor). We have initiated to monitor resident q30min (every 30 minutes). LPN note dated 12/10/16 at 1:00 p.m., Received the resident this morning and was informed that she had a fall at 06:40 hours (6:40 a.m.) on 12/10/16. Resident received all morning medication from me but complained of left hip pain ad lef (sic) leg pain while having her morning care. Resident was medicated this morning with 650mg (milligrams) OTC (over the counter) Tylenol per listed PRN (as needed) order. Resident had no relief and physician was contacted for appropriate steps. Per Dr. (doctor) (Name) resident needs to be sent out and have f/u (follow/up) xray and full work up for left leg pain, left hip pain and check forpossible (sic) fracture. Resident also has some vaginal spotting and nurse has been informed to keep a [MEDICAL CONDITION] eye on the area as it may subside. If vaginal bleeding increases or gets worse resident will need GYN (gynecology) appointment . LPN note dated 12/12/16, Resident was admitted to (hospital initials) for pelvic fx (fracture) and ruptured bladder. LPN note dated 12/18/16, Resident roommate called for help, CNA's entered room to find resident lying on L (left) side on the floor beside her bed. Bed pillow was partially out of place . LPN note dated 12/23/16, Resident's CNA notified this nurse to come to resident's room. The nurse observed that resident had no respirations and there is no radial or carotid pulse noted . A Physical Therapy Screening note dated 11/08/16 included the following: 1. Type of Screen c. Fall/Occurrence Review .17. Comments: pt fell yesterday, 11/7/16, taking herself to the bathroom. pt. reported, along with nrsg. no injuries. (sic) Resident #360's CCP (comprehensive care plan) was reviewed and included the following regarding mobility and falls: .Transfer: requires assistance by (1) staff to move between surfaces. Created on: 11/07/2016 .At risk for falls r/t poor safety awareness. Fall on: 11/8/16, 12/10/16, 12/18/16 .Bed pressure alarm to decrease fall risk. Created on: 11/08/2016 .Low bed with fall mat to decrease fall risk. Created on: 12/20/2016 Be sure The (sic) resident's call light is within reach and encourage the resident to use it for assistance if needed. The resident needs prompt response to all requests for assistance. Created on: 10/23/2016 .Ensure that (Name) is wearing appropriate footwear when ambulating or mobilizing in w/c as needed . Resident #360 c/o chest pain on 11/12/16 and was sent out to the ER. She returned to the facility on [DATE]. Readmission orders [REDACTED]. Upon her readmission Resident #360's bed alarm and low bed with fall mat was not reordered and was not included on her CCP. No fall precautions were in place at the time of Resident #360's fall on 12/10/16 resulting in multiple pelvic fractures and a ruptured bladder. Again Resident #360 was readmitted to the facility from the hospital and no fall precautions were put in place until she managed to roll out of bed on 12/18/16. Fall precautions were still not added until 12/20/16. Incident reports for the three falls were reviewed on 03/29/18 at approximately 11:00 a.m. The incident report for the fall on 11/7/16 included Resident #360 was up in her room, unassisted, was wearing regular socks, was not using an assistive device and no alarms were present. The use of a bed alarm was initiated. The incident report for the fall on 12/10/16 included Resident #360 complained of pubic pain, was up in her room unassisted, was wearing regular socks, was not using an assistive device and no alarms were in use. Every 30 minute checks were initiated. The incident report for the fall on 12/18/16 included Resident #360 slid out of bed after displacing her bolster pillow with her legs. A low bed and floor mat were initiated. An Admission H&P (history and physical) dated 12/10/2016 from the local hospital included: .2. Multiple pelvic fractures - pain control 3. Hematuria with bladder rupture .Chief Complaint: Fall Patient sent in from (nursing home name) after fall this morning and pain with minimal movement . CT Pelvis w/o Contrast (Cat Scan of pelvis without contrast) .dated 12/10/2016 .Impression: 1. Evidence of combined intraperitoneal and extraperitoneal bladder rupture. 2. Multiple pelvic fractures including a parasymphyseal left superior pubic ramus fracture, comminuted left inferior pubic ramus fracture, left sacral ala fracture, and intra-articular [MEDICAL CONDITION] posterior ilium extending to the SI joint . The Administrator and Interim DON (director of nursing) were informed of the above findings during a meeting with the survey team on 03/29/18 at approximately 2:30 p.m. The DON was asked about no alarm sounding after the fall on 12/10/16, why no fall precautions were in place on the CCP and why the resident was not sent out until 1:00 p.m. The DON stated, I will need to look at her record and I will get back with you. At approximately 3:30 p.m. the DON entered the conference room and stated, We did education to the nurses on updating the care plans when needed awhile ago. I am not sure why she wasn't sent out until later in the day. I know they called the physician when she fell and he told them to watch her every 30 minutes. I also know after the Tylenol did not relieve her pain. The day shift nurse called the doctor and received an order to send the resident to the ER (emergency room ). No further information was received by the survey team prior to the exit conference on 03/29/18.

Based on staff interview, resident interview, clinical record review and facility document review, the facility staff failed 1) to provide supervision during toileting as a result, the resident sustained [REDACTED].#11 and 2) a call bell was within reach and accessible for use for one of 24 residents in the survey sample, Resident #11 and 3) the facility staff failed to perform quarterly smoking assessments for one of 24 residents in the survey sample, Resident #9. 1. Resident #11 was assessed on 10/13/15 and 11/10/15 for a toileting program and was deemed a good candidate for both assessments; the facility failed to implement the scheduled toileting program to provide assistance to the resident during toileting, Resident #11 sustained a fractured hip during a self transfer without assistance while on the toilet on 11/27/15. 2. Resident #11 was observed on 2/3/16 and 2/4/16 in the room with the call bell out of reach and not accessible for use. 3. Resident #9's smoking assessments were not performed quarterly to ensure safety while smoking. The findings include: Resident #11 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/29/16 was a 60 day assessment. The resident was assessed as being an 8 (moderately impaired in decision-making skills) for cognitive impairments. Prior to the fall on 11/27/2015, Resident # 11's MDS (Minimum Data Set) with and Assessment Reference Date (ARD) of 11/13/15 coded the resident as having short-term memory impairments. The resident was assessed as needing extensive assistance of one person, physical assist, for transfers and toilet use. Under Balance During Transitions and Walking, the resident was assessed as being unsteady and only able to stabilize with the assistance of staff for moving on and off the toilet and surface to surface transfers (between the bed and chair or wheelchair) On 2/2/16 at approximately 2:00 p.m., Resident #11's electronic clinical record was reviewed to include the following: Resident #11 sustained twelve (12) documented falls prior to the fall and fracture on 11/27/15, of the twelve (12) falls five (5) were related to going to the bathroom unassisted from 9/3/15 through 11/27/15 (*** denote falls related to the bathroom). The falls were reviewed in the electronic nursing notes as follows: Nursing Notes: *** 9/3/15 14:42 (2:42 p.m.) Resident was walking out of bathroom using walker as residents room mate was sitting in room in wheelchair. Resident stated her walker go caught in wheelchair and she lost her balance and fell against wall and slide down the wall . ***9/8/15 09:02 Late Entry for 9/4/15: Pt (patient) educated on safety and awareness of surroundings. Encouraged to ask for assistance when room cluttered or roommate things need arranged/straightened up. Pt stated Ok upon completion of education . 9/14/15 20:26 (8:26 p.m.) Res (resident) was disoriented this evening. She wandered in to the room across the hall. Called a friend on the phone and misstated many details. She passed the phone to me and I spoke to her friend. The friend said she has been call almost everyday with confused conversation. I told her I would document the situation (sic). 9/17/15 11:15 Resident is supervision with ADL's (activities of daily living) and transfers .Resident has some confusion . *** 9/26/15 22:40 (10:40 p.m.) This nurse was at med (medication) cart in front of residents room. Observed resident walking from bathroom to sink she was attempting to sit in w/c (wheel chair). She was only wearing socks and w/c was unlocked she slid out onto bottom .Educated resident to ring call bell and slip resistance socks were put on her. 10/1/15 13:33 Weekly Summary; Resident is continent of bowel and bladder. Resident is alert and oriented with confusion . *** 10/3/15 21:16 (9:16 p.m.) Res (resident) fell in her bathroom unwitnessed. Res report she went to the restroom to have a BM (bowel movement). Somehow a small smear of fecal matter gat (sic) on the floor just in front of the toilet. She said is was her job to clean it if she made the mess (sic). She said I couldn't just leave it. She was found on the floor sitting, (CNA (certified nursing assistant) named) was the first to find her in the restroom She got to her feet with the assist of two CNA and myself . 10/9/15 22:13 (10:13 p.m.) The roommate of the res (resident) called for help. I found This resident on the floor near the end of her bed and in between her wheel chair. She reported that she was trying to move from the bed to her WC (wheel chair) and she slipped out of the seat and on to the floor. The seat custion (sic) was turn sideways and one of her shoes was on the seat. After a timeout 2 (CNA's (certified nursing assistants named) and myself got her to her feet. She was very unstable .Two times following the fall I was called to the her room. Once for attempting to use her room-mates bed and the second time she was laying across her bed with her leg far off the bed (sic). 10/14/15 03:47 a.m. Resident is PD (post day) 1 unwitnessed fall w/o (without) injury . 10/22/15 17:31 (5:31 p.m.) At 1005 (10:05) resident was being assisted by this writer in walking in her room as she was using her walker when she losed (sic) her balance and fell back on her coccyx. With help of other staff members she was assisted off the and helped into her bed . 11/2/15 03:17 a.m. 0055: Residents room-mate yelled out HELP. This nurse went to the room & observed resident was laying face down on the floor beside her bed. CNA and nurse assisted resident onto her bed after this nurse assessed her .She stated that she was checking on her room-mate & when she went to sit in her wheelchair she slid off of it (due to having clutter on the seat). She forgot that she had put the items in/on her wheelchair . *** 11/7/15 07:37 a.m. CNA heard a noise at 0430 (4:30 a.m.), while resident was sitting on toilet and went into room, REsident was sitting on floor. Stated that she was reaching for the string on the wall .(sic). 11/26/15 14:16 (2:16 p.m.) Weekly Summary Resident is continent of bowel and bladder. Resident is alert and oriented with confusion .Resident requires one assist with transfer, toilet needs, bathing, grooming, and bed mobility . *** 11/27/15 20:58 (8:58 p.m.) Resident was transferring from wheel chair to toilet and fell to bathroom floor - landed on left hip - experiencing pain and has deformity of hip with internal rotation of left leg - (Physician named) gave order to transport to (hospital named) . *** 11/27/15 21:13 (9:13 p.m.) Resident states she stood in the bathroom to transfer to toilet and slipped - (Physician named) in house and assessed- ordered resident sent to ER (emergency room ). Hospital History and Physical: admitted : 11/27/15 .Chief Complaint: status [REDACTED]. She came into the Emergency Department for evaluation and x-ray showed a femoral fracture. Orthopedics was consulted, recommended hospitalist admission before plans for surgery tomorrow . Discharge Summary: discharge date : 12/4/15 .Discharge Diagnoses: [REDACTED]. [DIAGNOSES REDACTED] secondary to urinary tract infection .Discharge Instructions: (Resident named) presented from (Nursing facility named) after experiencing a fall. Unfortunately, patient sustained a left femoral fracture. Patient underwent an intramedullary nail on 11/28/15. Patient had developed a urinary tract infection with [DIAGNOSES REDACTED]. At this point, her [DIAGNOSES REDACTED] has resolved and she continues to receive antibiotics as above to treat urinary tract infection. Patient will require 3 more days of Ceftin as prescribed .Hospital Course: .Patient underwent fixation of the left femur IV via cephalomedullary nail without any acute complications. During the hospitalization , patient had become anemic after the procedure and had received 1 unit of packed red blood cells with hemoglobin remaining stable between 10 to 11. Patient's mentation was slow to improve. Patient had developed a fever and white count had continued to rise after the procedure. Further workup demonstrated evidence of urinary tract infection. Patient was growing greater than 100,000 colony-forming units of E.coli. (Escherichia coli). Patient was started on Rocephin and the following day, her mentation had improved. Unfortunately, during the hospitalization , patient also developed mild fluid overload, resulting in diastolic congestive heart failure exacerbation. The patient was diuresed with IV (intravenous) Lasix and was weaned off oxygen. By 12/4/15, patient had returned to her baseline . Fall Risk Tool Effective Date 11/10/15 .Score 7 Category: High Risk for Falls A Care Plan and Kardex updated on 12/4/15 was reviewed, the care plan nor the Kardex addressed a toileting program for the resident from the time the resident was deemed a good candidate on 11/10/15 through 2/4/15. The Fall Care Plan and Kardex was reviewed as follows: Fall Precaution: Date Initiated: 7/9/15 .Revision on: 1/19/16 Focus: (Resident named) is at risk for falls r/t (related to) debility, OA (osteoarthritis) macular degeneration. 9/3 15, 9/26, 10/3, 10/9, 10/13, 10/22, 11/2, 11/7, 11/27, 12/5/15, 12/19/15, 12/21. 2016 Falls: 1/8, 1/16 . Goal: Will not have a fall with injury through next review date . Interventions: 11/30/15 IDT (interdisciplinary team) to eval for intervention when she returns from hospital. 12/9/15 (Resident named) wheelchair was reviewed for modalities and appropriate. 1/21/16 Alarm to wheelchair. 9/28/15 Anti-rollbacks to w/c to decrease risk of falls. 7/9/15 Anticipate and meet needs. 10/12/15 Dycem to wheelchair seat to decrease risk of falls. 1/8/16 Dycem on top of personal cushion to decrease risk of falls. 9/4/15 Educate (Resident named to be aware of surroundings and to call for assistance if she cannot navigate around the room to decrease risk of falls. 7/9/15 Ensure (Resident named) has appropriate footwear is in when ambulating or mobilizing in w/c. 12/15/15 Frequent checks to decrease risk of falls. 7/9/15 Gentle reminders not to get up unassisted. 10/23/15 Staff ed (educated) to let (Resident named) rest a few minutes before getting her from sitting to standing to decrease risk of falls. 11/2/15 Staff ed (educated) to make sure (Resident named) has on non skid socks on feet to decrease risk of falls. 11/2/15 Staff ed (educated) to remove clutter from wheelchair. 11/7/15 Staff ed (educated) to stay in the room while (Resident named) is in the bathroom. Cognitive Function Care Plan: Date initiated: 7/16/15 Focus: (Resident named) has impaired cognitive function r/t (related to) short-term memory loss. Interventions: Keep (Resident named) routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion . ADL (activities of daily living) Self Performance Care Plan: Date initiated: 7/9/15 .Revision on: 8/11/15. Focus: (Resident named) an ADL Self Care Performance Deficit r/t (related to) debility .OA (osteoarthritis) and macular degeneration. Interventions: Transfer: (Resident named) requires extensive assist of 2 persons NWB (non-weight bearing) with transferring. Toilet Use: (Resident named) requires extensive assist of 1-2 person for toileting, incontinence care and changing briefs . The care plan did not address a toileting program or interventions for the resident. On 2/3/16 at approximately 9:30 p.m., the director of nursing was interviewed regarding the investigation for the fall that occurred on 11/27/15, the director of nursing stated, I have it in my office, I will bring it to you. On 2/3/16 at approximately 10:30 a.m., the director of nursing presented the Unusual Occurrence Report to this Surveyor, the report was reviewed to include the following: Date and Time of Occurrence: 11/27/15 at 20:30 (8:30 p.m.) . Summary: Found on the floor (unwitnessed) Location: Bathroom . Factors: Resident lost balance Type and location of injury: Pain with movement left hip joint or leg. Raised bony area in the middle of left buttock after getting in bed . What was resident doing or just prior to fall? Attempting self transfer . Key Question: Ask resident: What were you attempting to do? Stated going to bathroom and tripped on something .If unable to answer, what did resident roommate state happened: Roommate alerted staff of fall . Gait devices at time of fall? None . What type of assistance was resident receiving at the time: Alone. Footwear at time of fall: The section was blank, no answer documented . Alarm being used at time of fall? No . Time last toileted, catheter emptied, or checked for continence status: This section was left blank, no answer documented . How did fall occur? Next to transfer surface was checked . What appears to be the root cause of the fall? Resident attempting to transfer self from w/c to toilet and fell on (R) hip (CP-care plan) update. 11/30/15 Unusual occurrence committee meeting: Resident attempting to transfer self from w/c to toilet and fell on (R) hip Roommate alerted staff. Resident stated she tripped no obstacle seen. Day #2 D/C'd to (hospital named) . 1. Witness Statements: (CNA named) documented Walking towards (Resident's roommate named) room and (Resident's roommate named) told (Resident's roommate named) told me that someone had fallen in her room. (CNA named) and I walked in her room and (Resident named) was on the floor in her bathroom. She said that (Resident's roommate named) told her to get out of the bathroom and (Resident named) tried to but that's when she fell . 2. CNA named documented: When entering their room she was sitting on the bathroom floor (I heard her yelling from the room down the hall. On 2/3/16 at approximately 3:17 p.m. during the end of the day meeting with the administrative staff, the above findings were presented for clarification. The Director of Nursing stated, She, the resident, is impulsive occasionally and does not ring or call for assistance and she will get up on her own. She is definitely one of our fall risk that we talk about. On 2/3/16 at approximately 3:45 p.m., the CNA that was named on the Unusual Occurrence report was interviewed regarding the above mentioned fall and fracture. The CNA, who will be identified as CNA #1 stated, I do not recall working that day but Director of Nursing, said I wrote a statement. I remember the day after and her recovery, which was awful, she suffered but she is a tough cookie (sic). When interviewed and asked if the resident ring for assistance prior to attempting to ambulate or transfer to the toilet, CNA #1 stated, she will ring or her roommate will ring, sometimes she will try to get up on her own but we will catch her and ask her what she is doing or her roommate will get help. She is good about that. On 2/3/16 at approximately 3:50 p.m., Resident #11's roommate Minimum Data Set (MDS) with an Assessment Reference Date of 8/25/15 and 11/7/15 was reviewed for cognitive status; Section C: Cognitive Patterns (C 0500) on 8/25/15, the resident was a 14 (fourteen) (independent in decision-making skills) on 11/17/15, the resident was assessed as being a 7 (seven) (moderately impaired in decision-making skills). On 2/3/16 at approximately 3:50 p.m., Resident #11's roommate was interviewed regarding the fall on 11/27/15. The roommate stated, I know she fell in the bathroom (pointing towards the bathroom). I rang the call bell for her, she always say she can't find hers so I rang mine for her, I always do that when she says that. The day she, (Resident named) went in the bathroom I rang the bell and we waited but no one came so she took herself to the bathroom and that's when she fell . On 2/3/16 at approximately 7: 22 p.m., the charge nurse, who was a registered nurse and will be identified as RN #1 was interviewed regarding the fall on 11/27/15, RN #1 stated, Normally we kept an eye on her because she was is able to stand and transfer with someone watching and supporting her for balance and to make sure she didn't wobble. She, the resident, was educated to ring the call bell in case she needed help. I was giving meds (medicines) around the corner. I do not recall a call bell and I am not sure if someone cut it off, I honestly did not think to ask that question. When I heard the CNA holler, I went in there and she was laying on her side, the right side I believe. I did a head to toe assessment, she was complaining of mild pain, there was no deformity and nothing looking like a big issue. I got her vital signs and she was transferred to her wheel chair. She started complaining of mild pain but there was still no deformity so we moved her to the bed and I rechecked her; she was complaining a little more of pain and that's when I noted the mild deformity so I stopped the process and went out and called 911. After I did that, I went back in the room and made sure her pulses were present and that she was comfortable (sic). On 2/4/16 at approximately 9:30 a.m., the director of nursing was made aware of the interviews obtained regarding the fall on 11/27/15. On 2/4/16 at approximately 9:45 a.m., the Director of Nursing stated, I re-interviewed Resident #11's roommate her BIMS (brief interview for mental status) is a seven (7). I am not sure if she remembered. The Director of Nursing was made aware that the resident repeated a lot of the information that was written in the Unusual Occurrence Report without looking at the report or without any coercion from this Surveyor. The director of nursing was also made aware that the BIMS score on the MDS was based on a seven day look back period, which could change depending on what is going on with the resident. No further information was provided during the course of the Survey regarding the resident not having a toileting program in place to assist with toileting to decrease the risk of falls, while attempting to transfer herself to and from the bathroom. On 2/3/16 at approximately 10:30 a.m. a bowel and bladder assessment was reviewed in the electronic clinical record to include the following: Bowel and Bladder (B&B) Eval (evaluation) Tool Effective Date 10/13/15 and 11/10/15 .Score 3 Category: Good candidate for retraining program . On 2/3/16 at approximately 11:36 a.m., the unit manager, who was a licensed practical nurse and will be identified as LPN #3 was interviewed regarding the location of the B&B documents for the resident. LPN #3 stated, (Resident named) would take herself to the bathroom due to dementia and she would forget to ask. She did not have a pattern noted to continue the bowel and bladder program. I did a three day bowel and bladder schedule on her. When asked what a three day bowel and bladder schedule was, LPN #3 stated, It is a tool to determine if the resident needed to be on a scheduling program. (Resident named) did not have a set time of going to the bathroom. We did it for breakfast, lunch and dinner. LPN #3 was interviewed and asked of the location of the three day schedule. LPN #3 stated, I gave them to them to (Director of Nurses) named. This Surveyor accompanied LPN #3 to the office where the DON was located, LPN #3 retrieved some forms from the DON and looked through the entire stack of papers. LPN #3 turned to this Surveyor and stated, It's not in this stack, maybe it's in her soft chart, I will check with (Medical Records staff named). This Surveyor accompanied LPN #3 and the Medical Records personnel, who will be identified as Other Staff (OS #5) to another office located on the B wing. LPN #3 and OS #5 looked through the records in its entirety, for Resident #11. Upon completion of looking through the soft chart and notebooks, LPN #3 and OS #5 stated, I don't have anything for her. On 2/3/16 at approximately 12:48 p.m., LPN #3 entered the conference room and in the presence of other Surveyors stated to this Surveyor, I reviewed (Resident named) notes from her stay here before and after the fracture. I had her confused with another resident. A three day bowel and bladder schedule was not done. She, the resident, was able to ring for assistance to go to the bathroom, she did not have a scheduled toileting program done. When interviewed and asked of the reason the resident was not assisted to the bathroom for the toileting program, LPN #3 stated, I don't know, I can't answer that. On 2/4/16 at approximately 10:40 a.m., the wound nurse, who was a licensed practical nurse and will be identified as LPN #1 and the director of nursing was interviewed regarding the location of the B&B logs in the electronic clinical records, LPN #1 stated, If they, the B&B records, are in there, they would be under Tasks. This Surveyor asked LPN #1 and the DON for assistance in locating the B&B records in the electronic clinical record. LPN #1 pulled up the B&B assessment for 11/10/15 and stated, It should be under the resolved tab, if we did a bowel and bladder program for her and if it did not work it will show up red. LPN #1 pulled up the resolved tab in the electronic records, the tab did not show red. LPN #1 stated, We did not do one for her. When interviewed and asked why Resident #11 did not have a B&B program initiated, Both, LPN#1 and the DON stated, I have to investigate. On 2/4/16 at approximately 11:15 a.m., the DON stated, The bowel and bladder assessment in the computer say she is a good candidate for the program and it is staff's job to follow up if she is not a good candidate and write a note in the computer, that's the piece that is missing. She, Resident #11, is a good candidate and moving forward she will be on a bowel and bladder program. No further information was presented during the course of the survey as to why Resident #11 was not provided a bowel and bladder program after being assessed as a good candidate for the program. 2. Resident #11 was observed on 2/3/16 and 2/4/16 in the room with the call bell out of reach and not accessible for use. Resident #11 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/29/16 was a 60 day assessment. The resident was assessed as being an 8 (moderately impaired in decision-making skills) for cognitive impairments. On 2/3/16 at approximately 2:00 p.m., a Kardex dated 12/4/15 was reviewed in the electronic clinical record to include the following: Transferring Transfer: Resident named requires extensive assist of 2 persons NWB (non-weight bearing) with transferring . Bed Mobility Bed Mobility: Resident named requires extensive assist of 2 person to turn and position . Fall precaution .Educate Resident named to be aware of surroundings and to call for assistance if she cannot navigate around the room to decrease risk of falls . On 2/3/16 at approximately 2:50 p.m., Resident #11 was observed in her room sitting in her wheelchair facing the doorway; the call bell was observed behind the resident and wrapped tightly around the railing of the bed. Resident #11 was interviewed and asked if she knew where her call bell was located. Resident #11 attempted to position herself in the wheelchair, but to no avail, to reach the call bell that was located behind her and around the railing of the bed. Resident #11 then stated, I can't get it. On 2/3/16 at approximately 2:55 p.m., the medication nurse, who was a licensed practical nurse and will be identified as LPN #4, was called to the resident's room to observe the call bell. LPN #4 observed the call bell wrapped tightly around the railing of the bed and inaccessible to Resident #11. LPN #4 asked Resident #11 if she could get to the call bell, Resident #11 attempted to pull the cord of the call bell to free it from the railing of the bed, again to no avail. LPN #4 stated, That's a problem, and unwrapped the call bell from around the railing of the bed and placed it on the bed within reach of the resident. LPN #4 turned to this Surveyor and stated, It's fixed now. On 2/3/16 at approximately 3:17 p.m., the administrative staff were made aware of the above findings. On 2/4/16 at approximately 11:08 a.m., Resident #11 was observed sitting in the room in the wheelchair at the foot of the bed; the call bell was observed wrapped around the railing of the bed and not accessible to the resident. This Surveyor interviewed and asked Resident #11 the location of the call bell, Resident #11 stated, I don't know where it is. Resident #11 looked towards the bed and stated, There it is, pointing to the side rail on the bed, where the call bell was wrapped. On 2/4/16 at approximately 11:10 a.m., the medication nurse, who was a licensed practical nurse and will be identified as LPN #7 was called to the room to observe the call bell around the railing of the bed and Resident #11 sitting at the foot of her bed, and the call bell not in reach. LPN #7 removed the call bell from around the railing of the bed, placed it on the end of the bed next to the resident and stated, Is this better? LPN #7 was interviewed at this time and asked who was the staff person assigned to the resident, LPN #7 stated, CNA (certified nursing assistant named) has her for today. During the time of the interview with LPN #7, CNA #6 entered the room. On 2/4/16 at approximately 11:10 a.m., CNA #6 was interviewed regarding the placement of the resident in relation to the call bell. CNA #6 stated, I wasn't finished in this room. I have to make up this, pointing to Resident #11's roommate's bed. CNA #6 was interviewed and asked if she was finished providing care and services to Resident #11, CNA #6 stated, Yes. When asked why Resident #11's call bell was not accessible to her for use, upon completion of her care and services, CNA #6 stated, I don't know. On 2/4/16 at approximately 11:15 a.m., the director of nursing was made aware of the above findings. On 2/4/16 at approximately 1:46 p.m., the director of nursing stated to this Surveyor, After we talked, I went down and talked to (Resident named) she was sitting beside her bed and her call bell was in reach. I asked her preference for the call bell and she stated, When I am in bed, around my siderail. When I am out of bed and in my wheel chair, on my bed and at eye level. I did a sweep of who put the call bell around the rail and out of reach, no one owned up to it, but it will be put on her care plan going forward her preference for her call bell placement (sic). 3. Facility staff failed to assess Resident #9 quarterly for smoking safety. Resident #9 went a period of seven months without having a smoking assessment completed. Resident #9 was originally admitted to the facility on [DATE] and readmitted [DATE] with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 10/01/2015. Resident #9 was assessed with [REDACTED]. Findings included: During the EMR (electronic medical review) on 02/03/2016 at approximately 7:45 a.m., Resident #9's comprehensive care plan was reviewed. Included in his smoking care plan was an intervention that stated, .Smoking assessment will be done quarterly and PRN (as needed) to determine safety while smoking. Date initiated: 01/24/2015 . Three smoking assessments were located in Resident #9's EMR. These assessments were dated 01/24/2015, 09/18/2015 and 12/01/2015. A copy of the facility's smoking policy was received from the Admissions Coordinator at approximately 11:00 a.m. The policy, Smoking Protocol Approved 5-2014 . included, .4. Smoking assessments will be done as part of the admission process, quarterly, or when reassessment is indicated . The DON (director of nursing) was interviewed during an end of day meeting with the Administrator and the survey team on 02/03/2016 at approximately 3:30 p.m. He stated, I will look into it and get back with you. On 02/04/2015 at approximately 9:40 a.m. the DON entered the conference room and stated, Regarding (Name) Resident #9's smoking assessment. We identified a problem in August and decided to do assessments when his MDS is due. A smoking assessment was completed for this resident on 09/18/2015. This resident went a period of seven months without having a smoking assessment completed. No further information was received by the survey team prior to the exit conference on 02/04/2015.

Based on staff interview, clinical record review and facility document review, the facility staff failed to provide a toileting program for one (1) of 24 residents in the survey sample, Resident #11. Resident #11 did not have a scheduled toileting program initiated after being accessed as a good candidate for one. Resident #11 was originally admitted to the facility on [DATE] and readmitted on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/29/16 was a 60 day assessment. The resident was assessed as being an 8 (moderately impaired in decision-making skills) for cognitive impairments. Section G: (Functional Status) I Toilet Use-how the resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter, and adjusts clothes. Do not include emptying of bedpan, urinal, bedside commode, catheter bag or ostomy bag. Resident #11 was assessed as a 3/2 requiring extensive assistance of one person physical assist. On 2/2/16 at approximately 2:00 p.m., Resident #11's electronic clinical record was reviewed to include the following: Bowel and Bladder (B&B) Eval (evaluation) Tool Effective Date 10/13/15 and 11/10/15 .Score 3 Category: Good candidate for retraining program . A Care Plan and Kardex updated on 12/4/15 was reviewed, the care plan nor did the Kardex address a toileting program for the resident. On 2/3/16 at approximately 11:36 a.m., the unit manager, who was a licensed practical nurse and will be identified as LPN #3 was interviewed regarding the location of the B&B documents for the resident. LPN #3 stated, (Resident named) would take herself to the bathroom due to dementia and she would forget to ask. She did not have a pattern noted to continue the bowel and bladder program. I did a day bowel and bladder schedule on her. When asked what a three day bowel and bladder schedule was, LPN #3 stated, It is a tool to determine if the resident need to be on a scheduling program. (Resident named) did not have a set time of going to the bathroom. We did it for breakfast, lunch and dinner. However, on 2/3/16 at approximately 12:48 p.m., LPN #3 entered the conference room and in the presence of other Surveyors stated to this Surveyor, A three day bowel and bladder schedule was not done. She, the resident, was able to ring for assistance to go to the bathroom, she did not have a scheduled toileting program done. When interviewed and asked of the reason the resident was not assisted to the bathroom for the toileting program, LPN #3 stated, I don't know, I can't answer that. On 2/4/16 at approximately 10:40 a.m., the wound nurse, who was a licensed practical nurse and will be identified as LPN #1 and the director of nursing was interviewed regarding the location of the B&B logs in the electronic clinical records, LPN #1 stated, If they, the B&B records, are in there, they would be under Tasks. This Surveyor asked LPN #1 and the DON for assistance in locating the B&B records in the electronic clinical record. LPN #1 pulled up the B&B assessment for 11/10/15 and stated, It should be under the resolved tab, if we did a bowel and bladder program for her and if it did not work it will show up red. LPN #1 pulled up the resolved tab in the electronic records, the tab did not show red. LPN #1 stated, We did not do one for her. When interviewed and asked why Resident #11 did not have a B&B program initiated, Both, LPN#1 and the DON stated, I have to investigate. On 2/4/16 at approximately 11:15 a.m., the DON stated, The bowel and bladder assessment in the computer say she is a good candidate for the program and it is staff's job to follow up if she is not a good candidate and write a note in the computer, that's the piece that is missing. She, Resident #11, is a good candidate and moving forward she will be on a bowel and bladder program. No further information was presented during the course of the survey as to why Resident #11 was not provided a bowel and bladder program after being assessed as a good candidate for the program.

Based on clinical record review and staff interview, the facility staff failed, for five of 24 residents in the survey sample (Residents # 4, 5, 6, 17 and 20), to thoroughly assess the nature and location of each individual resident's pain, and failed to attempt the implementation of non-pharmacological interventions to address the resident's pain; and failed, for one of 24 residents (Resident # 15), to follow physician's orders [REDACTED]. The findings include: 1. Facility staff failed to thoroughly assess the nature and location of resident # 4's pain, and failed to attempt non-pharmacological interventions to address the resident's pain. Resident # 4 in the survey sample, a [AGE] year-old female, was originally admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. According to an Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/23/15, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 2 out of 15. According to the most recent Quarterly MDS, with an ARD of 1/19/16, the resident was assessed under Section C (Cognitive Patterns) as being severely cognitively impaired, with a Summary Score of 3 out of 15. Review of Resident # 4's care plan, updated on 1/23/16, revealed the following problem, At risk for alteration in comfort, DX (diagnosis) of arthritis, chronic pain, [MEDICAL CONDITION]. The goal for the problem was, Will alert staff to the need for pain medication through next review date. The following was included as an approach to the stated problem, Offer diversional activities. Resident # 4 had the following order, dated 10/23/14, for pain medication: [MEDICATION NAME] 5 mg (milligrams) tablet, 1 by mouth every 3 hours PRN (as needed) for pain. Review of Resident # 4's Electronic Medication Administration Record [REDACTED]. Review of the Progress (Nurses) Notes for the month of January revealed that of 11 entries devoted to the administration the PRN [MEDICATION NAME], none listed the location and nature of the pain, and no diversional activities (non-pharmacological interventions) to address Resident # 4's pain were identified. Resident # 4's care plan, updated on 1/26/16, included the following problem, At risk for alteration in comfort related to dx of [MEDICAL CONDITIONS]. The goal for the problem was, Will have pain/discomfort recognized and controlled by next review. The following was included as an approach to the stated problem, Obtain resident's rating of pain scale face/verbal description and document. At 9:55 a.m. on 2/3/16, LPN # X (Licensed Practical Nurse), who was familiar with the resident, was interviewed regarding the documentation of PRN medication administration. After reviewing the Progress (Nurses) Notes in Resident # 4's electronic record, LPN # X said, Our practice is to document where the pain is. LPN # 4 also agreed that there was no documentation of non-pharmacological interventions to address Resident # 4's pain. The findings were reviewed during an end of day meeting on 2/3/16 that included the survey team, Administrator, Director of Nursing (DON), and Human Resources Director. 2. Facility staff failed to thoroughly assess the nature and location of resident # 6's pain, and failed to attempt non-pharmacological interventions to address the resident's pain. Resident # 6 in the survey sample, a [AGE] year-old female, was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. According to a Significant Change MDS, with an ARD of 11/19/15, the resident was assessed under Section C (Cognitive Patterns) as having no short term memory problems, but having long term memory problems with moderately impaired daily decision making skills. Resident # 6's care plan, updated on 1/26/16, included the following problem, At risk for alteration in comfort related to dx of [MEDICAL CONDITIONS]. The goal for the problem was, Will have pain/discomfort recognized and controlled by next review. The following was included as an approach to the stated problem, Offer diversional activities. Resident # 6 had the following order, dated 1/8/16, for pain medication: [MEDICATION NAME] tablet, give 2 tablets orally every 4 hours as needed (PRN) for pain/fever not to exceed 3250 mg/24 hours. Review of Resident # 6's EMAR revealed she received the PRN [MEDICATION NAME] once on eight different days in the month of January 2016. Review of the Progress (Nurses) Notes for the month of January revealed that of the eight entries devoted to the administration the PRN [MEDICATION NAME], seven of the entries failed to identify the location and nature of the pain, and no diversional activities (non-pharmacological interventions) to address Resident # 6 pain were identified. The findings were reviewed during an end of day meeting on 2/3/16 that included the survey team, Administrator, DON, and Human Resources Director. 3. Facility staff failed to thoroughly assess the nature and location of resident # 17's pain, and failed to attempt non-pharmacological interventions to address the resident's pain. Resident # 17 in the survey sample, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Initial MDS, with an ARD of 12/19/15, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 14 out of 15. Resident # 17 had the following orders, dated 12/12/15, for pain medication: [MEDICATION NAME] tablet 50 mg. Give 1 tablet by mouth every 4 hours as needed for pain 4 - 6 on pain scale. [MEDICATION NAME] tablet 50 mg. Give 2 tablets by mouth every 4 hours as needed for pain 7 - 10 on pain scale. On 12/22/15, both pain medication orders were amended to include the following notation: **NTE (Not To Exceed) 8 tabs/24 hours** Review of Resident # 17's EMAR revealed the as needed [MEDICATION NAME] tablet 50 mg. Give 1 tablet . was administered four times during the month of December 2015. Review of the EMAR also revealed the as needed [MEDICATION NAME] tablet 50 mg. Give 2 tablets . was administered five times during the month of December 2015. Review of the Progress (Nurses) Notes for the month of December 2015 revealed that three of four entries devoted to the administration the as needed 1 tablet of [MEDICATION NAME], and all five of the entries devoted the administration of 2 tablets of [MEDICATION NAME] consisted of a repeat of either the one tablet or two tablet [MEDICATION NAME] order. There was no assessment of the nature or location of the pain, and no non-pharmacological interventions to address the resident's pain were identified. The findings were reviewed during a meeting on 2/4/16 that included the survey team, Administrator, DON, and Human Resources Director. 4. Facility staff failed to thoroughly assess the nature and location of resident # 20's pain, and failed to attempt non-pharmacological interventions to address the resident's pain. Resident # 20 in the survey sample, a [AGE] year-old male, was admitted to the facility on [DATE], and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. According to the most recent MDS, a Quarterly, with an ARD of 1/19/16, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 11 out of 15. Resident # 20 had the following orders, dated 7/14/15, for pain medication: [MEDICATION NAME] tablet 5 mg. Give 10 mg by mouth every 4 hours as needed for pain 6 - 10. [MEDICATION NAME] tablet 5 mg. Give 5 mg by mouth every 4 hours as needed for pain 1 - 5. Review of Resident # 20's EMAR for the month of January 2016, revealed the resident received 10 mg of as needed [MEDICATION NAME] 15 times, and received 5 mg of as needed [MEDICATION NAME] five times. Review of the Progress (Nurses) Notes for the month of January 2016 revealed that out of a total of 20 entries devoted to the administration of the as needed 5 mg [MEDICATION NAME] and the 10 mg [MEDICATION NAME], 12 entries lacked an assessment of the nature or location of the resident's pain, and there were no non-pharmacological interventions to address the resident's pain identified in any of the 20 entries. The findings were reviewed during a meeting on 2/4/16 that included the survey team, Administrator, DON, and Human Resources Director. 5. Resident #5 was administered as needed (prn) pain medication almost daily without a comprehensive assessment of the resident's pain, attempts to determine the source of pain and without prior attempts at non-pharmacological interventions to minimize pain. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #5 with short and long-term memory problems and modified independent cognitive skills. Resident #5's clinical record documented a current physician's orders [REDACTED]. Resident #5's Medication Administration Record [REDACTED]. The resident was administered 36 doses of [MEDICATION NAME] 5-325 two tablets; 14 doses of [MEDICATION NAME] 5-325 mg one tablet; one dose of Tylenol 650 mg. Thirty-six doses of pain medication were administered to Resident #5 in January 2016 with no documented location of the resident's pain or any associated assessment of why the pain medication was administered. The clinical record only documented the location of the resident's pain for 15 doses of as needed pain medication as follows. 1/2/16 - headache 1/4/16 - crying out 1/5/16 - left ear pain and lower back pain 1/5/16 - headache 1/6/16 - lower back and bilateral hip discomfort 1/8/16 - lower back pain 1/10/16 - back pain 1/15/16 - bilateral lower legs hurting 1/16/16 - lower back and bilateral lower leg pain 1/17/16 - back pain 1/19/16 - lower back pain 1/15/16 - headache 1/24/16 - bilateral lower leg pain 1/23/16 - lower back pain 1/26/16 - head/back pain The clinical record documented no attempts of any non-pharmacological interventions prior to the administration of the as needed pain medicines or attempts to determine the source of the resident's pain. On four dates (1/2/16, 1/16/16, 1/19/16, 1/27/16) one tablet of [MEDICATION NAME] 5-325 mg was administered for pain rated as 2 or 3 when Tylenol 650 mg was ordered for pain rated as 1 to 3. There was no documentation of why the [MEDICATION NAME] was administered instead of Tylenol. The resident's care plan (revised 1/12/16) stated the resident had discomfort due to a [DIAGNOSES REDACTED]. The care plan included no problems, goals and/or interventions specifically related to back pain, leg pain, headache, earache or leg pain. A pharmacist note dated 1/26/16 documented, Assess increased use of prn [MEDICATION NAME] and prn [MEDICATION NAME]. A nurse practitioner progress note dated 1/15/16 documented the resident denied pain but made no mention of the almost daily use of pain medication. On 2/3/16 at 9:20 a.m. the licensed practical nurse (LPN #6) that routinely administered medications to Resident #5 was interviewed about the resident's pain. LPN #6 stated the resident sometimes complained of back and leg pain. LPN #6 stated the resident had recently been treated for [REDACTED].#6 stated she documented a pain rating on the MAR indicated [REDACTED]. Concerning non-pharmacological interventions for pain, LPN #6 stated the resident usually went to the morning activities. On 2/3/16 at 9:30 a.m. the licensed practical nurse (LPN #5) unit manager was interviewed about pain medication administered without documented assessments and of any non-drug interventions attempt prior to or with the medication. LPN #5 stated nurses were supposed to be entering a note when they signed off the MAR for as needed medications. LPN #5 stated, We can reposition her (Resident #5) and she does like music. LPN #5 stated music kind of soothes her (Resident #5). LPN #5 stated the resident had experienced pain associated with a recent ear infection. When asked if music or repositioning was implemented prior to or with the pain medications, LPN #5 stated she did not see any documentation regarding those interventions. After reviewing Resident #5's clinical record LPN #5 stated there needed to be more documentation about giving prn medicines. When asked about an individualized care plan regarding the resident's pain, LPN #5 stated the MDS coordinators were responsible for care plans. On 2/3/16 at 10:50 a.m. the certified nurses' aide (CNA #4) that routinely cared for Resident #5 was interviewed about the resident's pain and any interventions to minimize pain. CNA #4 stated Resident #5 was frequently fidgety, would call out for help and ask to get out of bed. CNA #4 stated usually when the resident was assisted to her wheelchair and out of the room she calmed down. CNA #4 stated the resident liked music. Regarding pain, CNA #4 stated, She's (Resident #5) not complained of pain to me. The Drug Information Handbook for Nursing 13th edition on page 602 describes [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME]) as an [MEDICATION NAME] combination opiod used for the relief of moderate to severe pain. This reference states [MEDICATION NAME] is a High alert medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes which have a heightened risk of causing significant patient harm when used in error. (1) These findings were reviewed with the administrator and director of nursing during a meeting on 2/3/16 at 3:15 p.m. (1) Turkoski, Beatrice B., Brenda R. Lance and Elizabeth A. Tomsik. Drug Information Handbook for Nursing. Hudson, Ohio: Lexi-Comp, 2011. 6. The facility staff failed to follow physician orders [REDACTED].# 15. Resident # 15 was ordered 1500 ml (milliliter) of fluid per day. Resident # 15 was admitted to the facility 1/19/16 with [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was the admission assessment dated [DATE]. Resident # 15 was coded with moderate impairment in cognition with a total summary score of 12 out of 15. The electronic medical record (EMR) was reviewed 2/4/16. A physician order [REDACTED]. The eMAR (electronic medication administration record) was reviewed for daily totals. Nursing began documenting shift amounts of fluids on 1/20/16; the daily totals varied from 360 ml to 1450 ml. The task section of the EMR was then reviewed, and CNA (certified nursing assistant) documentation revealed fluid amounts of 720 ml to 1540 ml. The CNA documentation did not begin until 1/22/16. The daily totals for nursing and CNA documentation was then reconciled, and revealed from 1/22/16 through 2/3/16 eleven days the daily totals exceeded 1500 ml. On 2/4/16 at 9:40 a.m. RN (registered nurse) # 2, a weekend supervisor, was asked about the documentation for the fluid restriction. RN # 2 stated Nursing uses his cup for measuring out the total ml for the day; whatever ml per shift he's allowed, that's what's put in the cup. The CNA's record their fluids as well. RN # 2 was then made aware of the above findings, and asked if nursing staff and CNA's communicated about the fluid amounts. RN # 2 stated I'll have to research that and let you know. I'm not sure why that is either. On 2/4/16 at 10:00 a.m. LPN (licensed practical nurse) # 5, who was the day shift supervisor, and RN # 2 were interviewed about the fluid restriction and the documentation. This surveyor shared the daily amounts as documented from nursing and CNA's: 1/22/16 = 3210 1/23/16 = 2500 1/24/16= 2770 1/26/16 = 1700 1/27/16 = 1880 1/28/16 = 1690 1/29/16 = 2020 1/31/16 = 1800 2/1/16 = 2050 2/2/16 = 1630 2/3/16 = 2260 LPN # 5 then reviewed the documentation, and stated It appears the CNA's are recording the dietary fluids and nursing is recording the fluids they give . I'm not sure anyone is looking at the daily totals. LPN # 5 was then asked if the physician order [REDACTED]. LPN # 5 stated That's a good question. The administrator, DON (director of nursing), and administrator in training were informed of the above findings during a meeting with facility staff 2/4/16 beginning at 2:05 p.m. No further information was provided prior to the exit conference.

Based on observation, staff interview, resident interview, clinical record review and facility document review, the facility staff failed to provide supervision and devices for transfers resulting in major accidents with injuries for 5 of 24 residents in the survey sample, Residents #7, 10, 12, 13, and 18; the facility staff also failed to provide safety devices for the prevention of accidents and injuries for one of 24 resident in the survey sample, Resident #6. The facility was identifed as having SUBSTANDARD QUALITY OF CARE. 1. Resident #12 was not provided assistance for toileting. After ringing the call bell as staff instructed, Resident #12 self transferred to the toilet and as a result, Resident #12 fell and sustained an orbital fracture. This resulted in harm. 2. Resident #18 was not provided assistance for toileting, Resident #18 was care planned for mechanical aid for transfers, Resident #18 got up unassisted, which resulted in a fall with head trauma and sustained a laceration, which required the resident being transferred to the local hospital and later airlifted to another hospital for further evaluation. This resulted in harm. 3. The facility staff failed to provide ongoing supervision to prevent an accident with injury to Resident #10, a resident known to be a high fall risk and with a history of falls. This resulted in harm. 4. The facility staff improperly transferred Resident 13, which resulted in a right fibula fracture. This resulted in harm. 5. The facility staff failed to implement interventions after a fall with major injury on 12/3/14 for Resident #7 after a physical therapy assessment (performed because of 12/3/14 fall) determined a decline in balance and transfers for the resident. The resident had a second fall on 12/20/14 with another major injury. This resulted in harm. 6. The facility staff failed to implement w/c (wheel chair) leg rests and dycem to Resident # 6's w/c for safety and the prevention of falls. The findings include: 1. Resident #12 was not provided assistance for toileting. After ringing the call bell as staff instructed, Resident #12 self transferred to the toilet and as a result, Resident #12 fell and sustained an orbital fracture. This resulted in harm. Resident #12 was admitted to the facility on [DATE] with, but not limited to, the following Diagnoses: [REDACTED]. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/9/14 was an annual assessment. The resident was assessed as a 15 for cognitive skills. Section G "Functional Status" for Transfers was 2/2, limited assistance of one person...Toilet use was 2/2, limited assistance of one person...G0300 Balance During Transitions and Walking: A. (2) moving from seated to standing position; not steady, only able to stabilize with staff assistance...B. (2) Walking (with assistive device if used)...C. (2) Turning around and facing the opposite direction while walking...D. (2) Moving on and off toilet...E. (2) Surface-to-surface transfer (transfer between bed and chair or wheelchair)." The MDS with an ARD of 8/19/14, which was prior to the fall and fracture, the above areas were as follows: Transfers was 3/2 extensive assistance of one person...Toilet use was 2/2, limited assistance of one person...G0300 Balance During Transitions and Walking: A. (2)...B. (1) not steady, but able to stabilize without staff assistance...C. (1)...D. (2)...E. (2)." (Underline added) On 1/7/15 at approximately 2:30 p.m., Resident #12's electronic medical record (EMR) was reviewed to include the following nurse's notes: "8/12/14 0350 (3:50 a.m.) cna answered BR (bathroom) callbell and found resident sitting on floor in front of toilet. denies pain. assisted to standing position with 2 assist. assisted to toilet where resident urinated. urine on floor of BR. stated "i was taking my briefs off and started urinating and slipped in it(sic)..." "8/12/14 14:23 (2:23 p.m.) Resident named was screened by OT (occupational therapy) due to (reason), Request from Nursing. The following areas were reviewed for changes:...Toileting, Decline...Cognition, No change. Safety / Judgement, Decline (sic)..." "8/19/14 16:51 (4:51 p.m.) (Resident named) was assessed to determine if they were a candidate for a toileting program. (Resident named) score was a 3.0 which makes him/her a Good candidate for retraining program candidate for a toileting schedule..." The clinical record and the EMR was reviewed for the location of the Bowel and Bladder retraining log, neither of the records had the logs in them for review. "8/19/14 16:52 (4:52 p.m.) had a falls risk evaluation completed with a score of 5.0, putting resident at a Low Risk for Falls risk for falls (sic)..." "9/29/14 06:35 (6:35 a.m.) Late Entry...Pt (Patient) Observed on floor. Water on floor. Empty cup on table. Pt yelling that "she fell " Pt's head in bathroom face down her body laying on walker, feet towards bed. large amt of blood under her head. Pt could MAE (move all extremities) A (alert) and O (oriented) X 3 First-aid administered. Physician's named called order received to send to local hospital ED (sic)..." "9/29/14 14:01 (2:01 p.m.) Resident returned to facility shortly after 1300 (1:00 p.m.) on stretcher...Resident noted to have a right orbital fracture..." An Emergency Department report was reviewed to include: "Date of service: 9/29/14...Diagnosis: [REDACTED]." On 1/7/15 at approximately 2:45 p.m., the "Fall Risk Assessment" prior to the falls on 8/12/14 and 9/29/14 were reviewed to include the following: 3/12/14 Score (8) "Moderate Risk" for falls 8/19/14 Score (5) "Low Risk" for falls Further review of the "Fall Risk Assessment for 8/19/14 revealed that the information was incorrect and the resident Fall risk score, according to the categories on the assessment, (scoring scale: 0-4 = LOW, 5-9 = MODERATE, 10 or above =HIGH RISK. In addition interventions MUST be initiated, i.e., bed/chair alarm, low bed, etc.) placed the resident at a "Moderate Risk" for falls and the appropriate interventions should have been initiated for safety. A Falls care plan (CP) updated on 10/9/14 was reviewed to include the following: "Focus...Resident named is a risk for falls r/t previous falls, decreased mobility, psychotropic medication use...Interventions: Educate resident/family/caregivers about safety reminders and what to do if a fall occurs...Gentle reminders not to get up unassisted...Keep bed in transfer position at all times...date initiated 1/25/13. Non skid Shelf liner placed on resident named overbed table to decrease the risk of water cup falling over and spilling on floor so resident named doesn't slip and fall in water...9/29/14...U/A and Urine C&S ordered to check on dysuria which is why she voided on fall and fell , to decrease fall risk (sic)... date initiated 8/13/14." The care plan did not address alarms to bed/chair or the resident having a low bed as indicated on the "Fall Risk" assessment. On 1/7/15 at approximately 5:00 p.m., the administrator, director of nursing and the regional clinical consultant were made aware of the concerns related to the resident falling and receiving an orbital fracture during an unassisted transfer to the bathroom. When the administrative staff was interviewed as a group by the Survey team regarding alarms or fall interventions for the residents who frequently get up unassisted and fall, the DON stated, "We do not have alarms. A lot of times they, the residents, are already on the floor by the time the alarm sounds and we get to them. We found that the alarms excites them so we did a reduction to get away from using them." On 1/8/15 at approximately 9:16 a.m., the rehabilitation director, who was a licensed physical therapy assistant and will be identified as Other Staff (OS) #3 was interviewed regarding the resident's mobility and transfer status. OS #3 stated that the resident was screened by the "physical therapist" and that she would "need to get back to me with that information." On 1/8/15 at approximately 9:20 a.m., the Physical Therapist, who will be identified as OS #2 was interviewed regarding Resident #12's transfers and ambulation. OS #2 stated that the resident was "fair minus, minimal assist, and poor plus, moderate assist for moving around, side stepping and turning around." OS #2 further stated that the resident was "not safe to do anything, although she, the resident, tries to walk on her walker." OS #2 was interviewed regarding the documentation in the clinical record indicating, from therapy, that the resident was "No change." OS #2 stated, "When the resident fell in August and again in September the resident's status was unchanged in the areas of standing, walking and getting in the chair." OS #2 further stated that the resident "needed someone with her at all times due to poor safety awareness." On 1/8/15 at approximately 9:50 a.m. during the meeting with the Survey team the director of nursing (DON) stated that the facility did away with alarms for the residents by doing an "alarm reduction in July 2013." The DON stated that "alarms were removed from residents that had no falls for 60 days or longer and the residents were "tracked to determine if alarms were needed." The DON was interviewed and asked if the falls had decreased since the alarms were eliminated; the DON stated, "No, they, the falls increased some months." On 1/8/15 at approximately 2:05 p.m., a certified nursing assistant (CNA), who routinely cares for Resident #12 and will be identified as CNA #3 was interviewed regarding the resident's compliance with ringing the call bell for assistance prior to getting up unassisted. CNA #3 stated, "She, the resident, is alert and oriented; she will ring for assistance before she gets up. She, the resident, does not get up until help arrives. She had a fall once and we informed her to ring for assistance and she does." CNA #3 further stated, "Once she get up in the morning and gets dressed she is out of the room for the rest of the day." On 1/8/15 at aproximately 2:07 p.m., Resident #12's room was observed, the bed was not low to the floor, there were no alarms or fall mats present. The Resident's walker was located at the door close to the bathroom and the resident was not in the room. CNA #3 was standing at the doorway of another Resident's room. When asked of the whereabouts of Resident #12, CNA #3 stated, "She is probably at activities." On 1/8/15 at approximately 2:10 p.m., the unit manager, where the resident resided, a registered nurse, who will be identified as RN #3 was interviewed regarding the Bowel and Bladder protocol for Resident #12, since the two falls occurred while the resident was attempting to toilet and the B&B assessments coded the resident as a "Good candidate for retraining program candidate for a toileting schedule..." RN #3 stated that the residents are "not on a scheduled Bowel and Bladder program, it is a standard of practice that the residents are toileted every two hours." RN #3 was asked about the location of the documentation showing where Resident #12 was offered or assisted to the bathroom every two hours. RN #3 stated that the CNA's document the information in the computer. A copy was requested of the documentation and a copy of the investigation. On 1/8/15 at approximately 2:45 p.m., this Surveyor was provided the information for the Resident #12's bowel and bladder provided by the CNA's. The documentation for September 2014 was reviewed to include that on 9/29/14, the day the resident sustained [REDACTED]. RN #3 was made aware of the times documented on the form for toileting. RN #3 was interviewed in regards to the statement that the residents were "offered toileting every two hours as a standard of practice." RN #12 stated that the CNA's were probably rounding or in the room with someone else and had not checked on the resident." When interviewed regarding the times for rounds, RN #3 stated, "they, the CNA's round every two hours, they get here at eleven (11:00 p.m.) and every two hours after that so one, three and five are the times they round." On 1/8/15 at approximately 2:50 p.m., the "Unusual Occurrence Incident Report" was reviewed to include the following: "Fall description details: 3. Fall Summary: Found on the floor (unwitnessed)...4. Fall location: Resident room...5. What was the resident doing or just prior to fall? Ambulating...6. What type of assistance was resident receiving at time of fall? Assisted per care plan. (Care plan initiated on 1/25/13 indicated the resident required limited assistance of 1 person for toileting and supervision of one person for transfers). Post Fall Report...Contributing Factors (circle all that apply). Areas circled were...impaired vision, impaired balance and weakness...CNA Report for Falls...Type of fall...Observed on floor...Care prior to fall...Visually observed 9/29/14 Time 7:30...Toileted 9/29/14 Time 6:00, then crossed out and 6:30 was documented..." Clinical record documented that the resident was found on the floor at 6:35 a.m., last toileting documented on the CNA Bowel and Bladder form was 2:53 a.m. On 1/8/15 at approximately 2:55 p.m., Resident #12 was interviewed regarding the falls. Resident #12 stated, "I fell when I went to the bathroom, both times I was going to the bathroom and fell ." Resident #12 was asked if she rang the call bell prior to getting up out of the bed. Resident #12 stated, "I rang my call bell, the staff took too long coming, I got up, tripped over my walker and fell in the floor. I must have spilled some water or something because the next thing I know, I was in the floor. When interviewed and asked how long was the call bell ringing, Resident #12 stated, "sometimes I have to wait an hour to an hour and a half. I can't hold my water that long so I get up and go. Sometimes you are told you have to wait because it's not your turn. One time a man, no name given, told me to do what I had to do but if I got up and fell on e more time he was going to take my walker away from me." Resident #12 was asked the name of "the man." Resident #12 smiled and stated, "I don't know his name he is no longer here." On 1/8/15 at approximately 3:32 p.m., the Minimum Data Set (MDS)Coordinator and the director of nursing (DON) were made aware of the above findings. No further information was provided during the course of the survey regarding the resident not being assisted to the bathroom after ringing the call bell, which resulted in a fall with right orbital fracture. 2. Resident #18 was not provided assistance for toileting, Resident #18 was care planned for mechanical aid for transfers, Resident #18 got up unassisted, which resulted in a fall with head trauma and sustained a laceration, which required the resident be transferred to the local hospital and later airlifted to another hospital for further evaluation. This resulted in harm. Resident #18 was admitted to the facility on [DATE], with but not limited to, the following Diagnoses: [REDACTED]. The MDS Assessment was incomplete as the resident was a recent admit. A Nursing Admission/Readmitted d 1/2/15 assessed the resident as being oriented to time, place and person. On 1/8/15 at approximately 10:00 a.m., Resident #18's electronic medical record (EMR) was reviewed to include the following nurse's notes: "1/7/15 04:34 (4:34 a.m.) Nurse & CNA's heard a loud boom sound come from the back hall. As we went searching for where it came from we found the resident in the bathroom of her room on the floor laying flat on her back with blood coming from the back of her head. as this Nurse went to turn/lift residents head to see exactly where it was coming from the blood was coming out uncontrollably faster. Pressure was applied and 911 was called...She stated that she slipped on water as she went to use the bathroom, however, the floor was dry. There was no clutter or anything on the floor that she could've slipped on (sic)..." "1/7/15 14:37 (2:37 p.m.) Resident admitted to hospital named. Unable to obtain diagnosis. NHA (nursing home administrator) and DON (director of nursing) notified." 1/6/15 Fall Risk Data collection Tool: Resident named had a falls risk evaluation completed with a score of 6.0, putting the resident at a Low Risk for Falls risk for falls. Cognitive status is noted to be Mild/Moderate Impairment..." On 1/8/15 at approximately 10:10 a.m., upon review of the Fall Risk Assessment, and according to the scoring; the "Fall Risk Assessment for Resident #18 was incorrect and the resident Fall risk score, according to the categories on the assessment, (scoring scale: 0-4 = LOW, 5-9 = MODERATE, 10 or above =HIGH RISK. In addition interventions MUST be initiated, i.e., bed/chair alarm, low bed, etc.) placed the resident at a "Moderate Risk" for falls and the appropriate interventions should have been initiated for safety. An interim Care plan dated 1/2/15 was reviewed to include the following: Resident is at risk for falls R/T recent hospitalization ...Fall Risk Score 6...Interventions...Complete Fall Risk Screen on admission, place call bell within easy reach, Assist for toileting & transfers PRN (as needed/necessary) and Keep environment safe." A Visual /Bedside Kardex Report (tool the CNA's use to provide care to the residents and are initiated on admission) dated 1/21/15 was reviewed to include the following: Transferring: *Transfer: requires Mechanical Aid (specify: Sling, Sit to Stand) for transfers...Bed Mobility: *Bed Mobility requires (Specify Supervision, cueing, weight bearing assistance, lifter sheet, trapeze) to turn and position..." An Admission Progress Note was documented to include the following: "1/2/15...Functional Status: Resident transfers, One person assist (guidance or light touch), N/A. Ambulation, Walker, Ambulation with assist x 1 and walker. Mobility, Wheelchair (propels self), N/A. A Physical Therapy Screen dated 1/3/15 was reviewed to include the following: Type of Screen: request review from Nursing...Balance: Decline...Transfers: Decline...Bed Mobility: Decline...Ambulation: Decline...17. Comments: Patient has decline in functional status and needs skilled PT services to address those declines..." On 1/8/15 at approximately 9:25 a.m., the Physical Therapist, who will be identified as OS #2 was interviewed regarding Resident #18's transfers and ambulation. OS #2 stated that the resident was "minimal assist for bed mobility and transfers, meaning she needs contact guard assist for ambulation. She can walk about 200 feet with a front wheeled walker with two to three rest breaks." When interviewed and asked if the resident was safe to ambulate independently for toileting, OS #2 stated, "No, she needed someone with her for toileting." OS #2 further stated that the Resident, "according to her, the resident's, daughter, she, the resident, was moderately independent until she experienced a decline in her cognitive status, which was causing her to fall to a decrease in balance." OS #2 stated we were working with her to improve balance, mobility and safety awareness but she was not to the point where she was safe to transfer on her own. We only had her for a short time." On 1/8/15 at approximately 2:00 p.m., the nurse, who was a licensed practical nurse and will be identified as LPN #7 was interviewed regarding Resident #18's fall and the Kardex initiated for the resident on admission. LPN #7 reviewed the Kardex and when asked if the Kardex was active and in place for the resident during her stay at the facility, LPN #7 stated, "Yes." LPN #7 was made aware that the Kardex indicated that the resident was coded for transfers as needing a "Mechanical Aid," LPN #7 stated, "Yes, that's correct." LPN #7 further stated that the resident was "confused at times and must have gotten up to go to the bathroom and fell ." When asked if the resident rang for assistance, LPN #7 stated, "I am not sure if she rang the call bell. I was not here; it happened on eleven to seven shift." On 1/8/15 at approximately 2:15 p.m., the unit manager, where the resident resided, a registered nurse, who will be identified as RN #3 was interviewed regarding the Bowel and Bladder protocol for Resident #18, since the fall occurred while the resident was attempting to toilet and the B&B assessments coded the resident as a "Good candidate for retraining program candidate for a toileting schedule..." RN #3 stated, "it's the same as Resident named (Resident #12) they are not on a scheduled Bowel and Bladder program, it is a standard of practice that the residents are toileted every two hours." RN #3 was asked about the location of the documentation showing where Resident #18 was offered or assisted to the bathroom every two hours. RN #3 pulled a copy of the Resident's Bowel and Bladder schedule, documented by the CNA's, up in the computer. The document revealed that the last time Resident #18 was offered and/or assisted to the toilet was at 2:52 a.m. RN #3 was interviewed and asked if there was more documentation elsewhere indicating that the resident was offered or assisted to the toilet past 2:52 a.m., RN #3 stated, "No the CNA's document in the electronic records. I know it looks weird but I am sure she offered again." No further information was provided regarding the resident being offered or assisted with toileting at other times during the 11-7 (third) shift. On 1/8/15 at approximately 3:15 p.m., Resident #18's room was observed, the bed was not in a low position, there were no fall mats or alarms noted in the room. Resident #18 was not in the room due to hospitalization from the fall on 1/7/15. On 1/8/15 at approximately 3:30 p.m., the director of nursing and the Minimum Data Set (MDS) coordinator were made aware of the above findings. The DON and the MDS Coordinator were interviewed in reference to the Fall Risk Assessment being inaccurate and how would the staff know what interventions or if the interventions implemented were correct, if the fall assessment was inaccurate. The DON stated, "You don't know. I see what you are saying." The DON was asked if an investigation had been initiated regarding the fall. This Surveyor was provided the investigation to review only, no copies of the investigation were allowed per the MDS coordinator and the DON. The investigation was reviewed to include the following: "1/7/15 Unattended fall...Time 4:20 a.m... Time last toileted or catheter emptied...AM was marked but a time was not documented...CNA Report for Falls...Time of fall 4:30 a.m... Care Prior to fall: Visually observed 1/7/15 4:15 a.m....Toileted 1/7/15 4:15 a.m... On 1/8/15 at approximately 4:55 p.m., the MDS Coordinator was interviewed regarding obtaining medical records from the hospital named, where the resident was admitted , for review. The MDS Coordinator was interviewed at this time regarding the Kardex that was in place for the resident. The MDS Coordinator reviewed the Kardex and stated, "We do an interim care plan (CP) on admission until we do an assessment then we do a full care plan." The MDS Coordinator was made aware that the resident had a CP, other than the interim CP, that was initiated on 1/5/15 and had the same interventions as the Kardex that was initiated for the resident on 1/2/15. The MDS Coordinator stated, "When we do a care plan, the areas from the Kardex are pulled over onto the care plan." The MDS Coordinator reviewed the Kardex and stated, "I am not sure why that triggered, mechanical aid for transfers, that's not a good choice but yes, that's what the CNA's go by. The MDS Coordinator was made aware that when the resident fell and sustained a laceration to the back of her head, she was up ambulating unassisted and not being transferred by mechanical aid as indicated on the Kardex. On 1/8/15 at approximately 5:10 p.m. the hospital report for Resident #18 was reviewed to include the following: CT Brain Head WO (without) Cont (contrast)...History: Fall, laceration...Impression(s) 1. Intracranial hemorrhage as described. There is a right parafalcine small subdural hematoma and there is also probably a parenchymal punctuate hemorrhage in the right frontal lobe. Significant right posterior scalp hematoma without evidence of skull fracture..." On 1/8/15 at approximately 6:05 p.m., the administrator, director of nursing and the regional clinical consultant were made aware of the above findings. 3. The facility staff failed to provide ongoing supervision to prevent an accident with major injury to Resident #10, a resident known to be a high fall risk and with a history of falls. The facility staff also failed to ensure that fall interventions contained on her comprehensive care plan and her Kardex care plan were implemented and in place at the time of the survey. This resulted in harm. Resident #10 was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 11/18/2014. Resident #10 was assessed as having a cognitive summary score of "09", indicating moderate impairment with her cognitive status. On 01/06/2015 at approximately 2:00 p.m., Resident #10 was observed sitting on the right side of her bed dangling her legs. Her mattress was a concave mattress. She was wearing a dress/gown and knee high stockings. The clinical record was reviewed beginning on 01/06/2015 at approximately 3:00 p.m. Observed on the comprehensive care plan were numerous interventions regarding fall prevention for Resident #10. These interventions included but were not limited to: "Bright colored cloth to put on seat of recliner to aid in (Resident #10's name) seeing seat of chair; Concave mattress; Drinking cup with lid to decrease risk of spilling liquids on the floor; Dycem to wheelchair to decrease fall risks, Dycem under her cushion to prevent her from sliding out; Encourage/provide use of nonslip shoes/socks for ambulation and transfers; Ensure w/c (wheelchair) is at bedside and locked so (name of Resident #10) will use it to hold on to when she is in bed and gets up to decrease fall risk; Left side of bed against wall; Recliner pushed up against the bathroom door so it won't slide when she goes to sit down in it, to decrease risk of falls; regular w/c with antirollbacks; Nonskid strips on right side of bed in front of BSC (bedside commode); Staff to check resident around 0100 (1:00 a.m.). This surveyor returned to Resident #10's room at approximately 4:00 p.m. Resident #10 was still sitting on the side of the right side of her bed but had laid down on her right side and was asleep. This surveyor looked around the room for the interventions listed on the comprehensive care plan. The recliner in the room was not against the bathroom door and did not have a bright colored cloth on the seat; her wheelchair was not at her bedside and there was no Dycem present on the wheelchair seat; the left side of her bed was not against the wall, instead the head of the bed was to the wall; nonskid strips were on the left side of the bed; there was no BSC in the room; and Resident #10 was wearing knee high stockings, not the nonslip shoes/socks that were care planned. Another surveyor was called into the room to compare the interventions on the care plan with what was seen in the room. She was in agreement that the interventions were not in place. On 01/07/2015, at approximately 8:00 a.m., Resident #10 was observed sitting up in her wheelchair at her bedside. She was feeding herself breakfast. The wheelchair cushion was lying in the recliner beside her and was not in place. Resident #10 was wearing shoes. None of the other missing interventions from the previous day's observation were in place. At approximately 8:30 a.m., review of the clinical record continued. The progress note section was reviewed. A total of 39 falls were documented from 03/09/2014 through 12/25/2014. This included documentation of a fall on 07/16/2014 at 3:15 a.m.: "At 0315 resident was observed by her assigned CNA (certified nursing assistant) standing in the doorway of the TV room unassisted but holding on to the rail with her right hand. As the CNA walked towards resident to assist her the resident turned as if to go back in the TV room, bumped into the door frame, lost her balance and fell . The CNA was unable to get to her before impact. Resident c/o her right upper arm hurting. She denied any other pain or discomfort. No injuries, skin tears, or abrasions observed upon assessment. Her LOC (level of consciousness) and ROM (range of motion) continues to be WNL (within normal limits). The CNA and I assisted resident back to her room/bed and she is now resting quietly with eyes closed..." Resident #10 began complaining of right arm pain and was sent to the emergency room . An X-ray report dated 07/16/2014 stated, "Comminuted impacted displaced fracture of the proximal humerus, questionable fracture of the distal right humerus versus proximal right ulna." Section G "Functional Status" of the MDS in place at the time of the fall (ARD 06/24/2014) assessed Resident #10 as follows: "G0300 Balance During Transitions and Walking: Not steady, Only Able to stabilize with staff assistance, Turning around: Not steady, Only Able to stabilize with staff assistance." Prior to the fall on 07/16/2014, Resident #10 had seven documented falls: "03/09/2014 At 0140 (1:40 a.m.) upon bending down to pick a comb off the floor, resident fell to her knees; 03/22/2014 at 0130 (1:30 a.m.) res walked out of room to nurse's station lost balance trying to reach out for desk fell backwards hitting head; 03/23/2014 0125 (1:25 a.m.) Resident was seen on floor in her room by the floor tech (who was working across the hall) and notified writer and CNA. Resident unable to tell us what actually happened due to moderate confusion/dementia tonight. Writer and CNA assisted resident back to bed after being assessed. ROM is good and wnl. Resident c/o left knee pain and stated it was already hurting before she fell ...; 05/19/2014 Resident up in wheelchair sitting in hallway by medicine cart. When getting out of wheelchair, stumbled over feet and fell on buttocks...; 06/11/2014 at 0325 (3:25 a.m.) resident yelled out for a nurse. Her assigned CNA and I went to her room and observed her sitting on the floor at bedside in front of bedside commode. When asked what happened resident denied falling. She stated that she sat on the floor after getting off the BSC. Her underwear wasn't down and there was no evidence of her having used the commode...; 06/11/2014 0525 (5:25 a.m.) resident came out of her room asking for a nail clipper to cut her nail...as I was looking in my drawer for a nail clipper resident lost her balance and fell backwards...there was a resident sitting in a wheelchair behind her and the back of residents left shoulder hit the foot rail of the wheelchair upon falling...; 06/18/2014 At 1730 (5:30 p.m.) LPN (licensed practical nurse) observed resident with both hands on the railing squatting in hallway. Resident stated, "I have to pee"...helped resident stand up..." Review of the care plan in place at the time of the falls from 03/09/2014 until the time of the fall with fracture on 07/16/2014 showed one new intervention put in place to address Resident #10's falls. The new intervention was implemented

Based on staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to ensure four of 32 residents in the survey sample were free from abuse; Residents # 1, # 14, # 25, and # 26. 1. The facility staff failed to manage inappropriate, sexual behaviors exhibited by Resident # 1 toward female residents and toward staff that provided care to the resident on a daily basis. The facility failed to protect female residents, specifically Residents # 14, 25, and 26 from physical and verbal sexual abuse by Resident # 1. The sexual behaviors were identified as a problem by facility staff after Resident # 1 was admitted to the facility in 2008 and the behaviors have continued up to present. The facility staff failed to protect other residents within the facility, as well as Resident # 1 from abuse. 2. The facility staff failed to protect Resident # 14 from sexual abuse by Resident # 1. 3. The facility staff failed to protect Resident # 25 from sexual abuse by Resident # 1. 4. The facility staff failed to protect Resident # 1 from verbal sexual abuse by a staff member. 5. The facility staff failed to protect Resident # 26 from sexual abuse by Resident # 1. Findings include: 1. Resident # 1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED].(urinary tract infections). The most recent full MDS (minimum data set) assessment (3.0) was a significant change assessment, which was dated 10/19/10. Under section G. Functional Status, Resident #1 was coded as 1/1 for locomotion both on and off the unit (supervision-oversight only, encouragement or cueing/ set-up help only). He was coded as having no limitations with range of motion and using a wheelchair as his mobility device. The cognitive status on this MDS was incomplete and could not be used. The previous full MDS for Resident # 1 was an annual assessment dated [DATE], which assessed the resident as having short term memory impairment only and as having modified independence in daily decision making skills. A quarterly MDS assessment dated [DATE] was reviewed for comparison. This MDS assessed Resident # 1 as having short and long term memory impairment and having moderate impairment in daily decision making skills. On 01/18/11 at approximately 1:30 p.m. an initial tour of the facility was conducted in the presence of the ADON (assistant director of nursing), also known as RN (Registered Nurse) #4. While touring the facility on the A-wing, RN # 4 provided a brief description of each resident as each room was approached. Upon reaching Resident # 1's room, RN # 4 shared information regarding Resident # 1. RN # 4 stated that the resident had "overt sexual behaviors" and that the resident was being seen by behavioral health. RN # 4 also voiced that the resident attempts to grab female residents by reaching out and that he exhibits the same type of behavior with staff. When RN # 4 was asked if the resident was alert and oriented, RN # 4 Stated, "Let's put it this way, does he know what he's doing? Yea, he does." RN # 4 went on to say that, "he cycles...", is seen by "behavioral health...last seen about 2 1/2 to 3 months ago." On 1/19/11 at 8:25 a.m., Resident #1 was observed propelling down the hall in his wheelchair. During clinical record review on 01/19/11 at approximately 9:00 a.m. nursing notes were reviewed. It was documented that Resident # 1 had multiple episodes of abusive, sexually inappropriate behaviors (both verbal and physical) toward females residents, as well as staff providing care. Nursing notes, as well as all documentation thinned from the clinical record was requested from staff regarding Resident # 1's inappropriate, unpredictable sexual behaviors since the last survey (01/05/2010 - 01/07/2010). The current clinical record and the thinned records for Resident # 1 were then reviewed and the following entries were documented regarding the behaviors exhibited by Resident # 1: ? 02/16/10-Sick Visit Note-"...This resident has had serious and persistent problems with [MEDICAL CONDITION] over the past months...He is very frequently inappropriately touching female resident's...signature of physician." ? 02/23/10-Sick Visit Note-"...asked by nurse and the family to evaluate and adjust medications if possible for this resident...we have gone up on his medications to help reduce his inappropriate sexual behaviors...His inappropriate sexual behaviors were very frequently directed towards female residents in the facility and they were often offended or bothered by his frequent touching or inappropriate comments...signature of physician." ? 03/07/10-1345 (1:45 p.m.)-(NN)-"This resident went into his room after lunch and begin (sic) cursing & (and) yelling /c (with) his roommate & threatening to knock his damn (sic) head off...moved this resident to # X-X...signature of nurse." ? 03/09/10-Recertification Visit-"...Staff notes continued inappropriate sexual behavior recently moved him to another room so he was not across from another male resident whom he thought was having a sexual relationship with women who visited him. Became aggressive toward other resident labs & meds reviewed...signature of physician." ? 03/11/10-2125 (9:25 p.m.)-(NN) (Nursing Note)-"...verbally abusive to staff & shaking his fist...signature of nurse." ? 03/14/10-1310 (1:10 p.m.)-(NN)-"...this am making inappropriate comments to former roommate...signature of nurse." ? 04/13/10-11:30 a.m. (NN)-"Res observed in hallway rubbing another female res. left lower leg, attempted to re-direct, res again reached down to rub res. leg...heard a res. yell out "get away from her," res. (another facility resident) stated that Mr. (name of Resident # 1) grabbed a different female res. breast. Res. was assisted to the Social Services office to speak /c (with) social worker for 1:1 redirection...signature of RN # 1.. On 01/19/11 at approximately 5:15 p.m., the administrator and DON were made aware of concerns regarding Resident # 1. At this time, any and all documentation regarding Resident # 1 was requested. The administrator and DON were interviewed at this time regarding interventions the facility had in place to protect other residents in the facility from Resident # 1's sexually inappropriate behaviors. The DON stated that, we (the facility) "watch very closely", and "we did 15 minute checks for days", and voiced that they (the facility) "had done those the last time their was an incident" with Resident # 1. The DON also voiced the staff had "moved" (a female resident who was sexually targeted by Resident # 1) and that medication adjustments have been made for Resident # 1. At this time, documentation was also requested regarding any 1:1 supervision and/or 15 minute checks, in addition to the facility's policy on abuse/neglect. On 01/20/11 at approximately 8:15 a.m. the DON presented the requested documentation regarding Resident # 1. This information was reviewed and revealed the following: An unusual occurrence (UO) incident report regarding the incidents' on 04/13/10 for Resident # 1. The UO documented two separate incidents that involved two different residents. Under the "Actions taken to prevent potential reoccurrence (referrals, change in toileting schedule)" section it was documented: "1:1 supervision/MD (physician) to review meds...signature of RN # 1 (person making report), DON (director of nursing), the administrator, and the medical director." Further review revealed the following: ? 04/14/10-Social Worker Note-"...on 04/13/10 res involved X (times) 2 res/res touching two female res 1 X res/res redirected/reported 2 X res/res SS (social services) spent 1:1 X (time) /c (with) res explaining the fault res agree states he will keep his hands to self. APS made aware MD to review meds...signature of SW. ? 04/15/10-1100 (11:00 a.m.) (NN)-"Aide (name of CNA) reported that she was sitting resident on the side of the bed when he took his hand & grabbed her behind (sic)...signature of Nurse Practitioner." ? 04/16/10-2300 (11:00 p.m.) (NN)-"...being verbally abusive to roommate...signature of nurse." ? 04/19/10-2300 (11:00) (NN)-"...was moved to room XX d/t (due to) verbally abusive behaviors...signature of nurse." ? 04/28/10-Recertification Visit: "...inappropriate touching of women, inappropriate behaviors...Believe he is best to stay at present meds, present doses...signature of physician." ? 05/04/10-PSYCHOLOGICAL EVALUATION-"...Annual review...related to sexually inappropriate behaviors...Mr. (name of Resident # 1) has been referred for sexually inappropriate behaviors since his admission. His behaviors are such that he has been observed to pursue residents who are unable to protect themselves-He is aware when others are watching him & he sneaks about...Treating physician may wish to consider which behaviors are more tolerable, sexual gropping (sic) of residents and staff or sleepiness...Mr. (name of Resident # 1) is very aware of which residents to pursue-He has been observed to do this by undersigned...signature of clinical psychologist." ? 05/18/10 Sick Visit-"...continues to be sexually aggressive and inappropriate with female residents at the facility and also with female staff. After he has been redirected on his A-wing unit, repeatedly, he now goes to B-wing unit to try to find women. He says there are not enough women on A-wing anymore...gets around and in (sic) his wheelchair...In discussion about this with him in his room, he points to an apparently 16-[AGE] year old girl on his bulletin board and says that she is his girlfriend and that "they will not let me be with her"...We will continue to use behavioral techniques as we have been doing including redirection and avoiding exposure to female residents...signature of physician." The clinical record was reviewed at this time for "behavioral techniques" used by staff to address/manage the inappropriate sexual behaviors by Resident # 1. No documentation regarding "behavioral techniques" could be located within the clinical record. It was documented in the nursing notes that Resident # 1 had refused medications on the following days: Feb. 22, March 8th, 11th, May 12th, June 10th, and the 16th. It was also documented that Resident # 1 became combative with staff on 06/09/10 and on 06/10/10. ? 08/06/10-Recertification Visit-"...Continue close observation of his interactions with female staff and residents...Still observed...to be approaching female residents...signature of physician." ? 08/09/11-Social Worker Note-"...Res requires much redirection secondary to boundaries...signature of SW." ? 08/10/10-1100 (11:00 a.m.) (NN)-"...socially inapprop....Redirection needed freq. (frequently)...signature of nurse." ? 08/17/10-1140 (11:40 a.m.) (NN)-"... increased sexual behaviors touch staff inap. (inappropriately)...inap. statements...signature of nurse." ? 08/18/10-Physician's Progress Note-"...increasing sexually inappropriate behavior toward staff. Touching & inappropriate comments...signature of physician." ? 09/14/10-11:00 a.m. (NN)-"...increased behaviors, grabbing @ (at) CNA's between their legs not easily re-directed....signature of nurse." ? 09/16/10-physician progress notes [REDACTED]. This has been a problem in the past with both staff and residents...Will simply have staff use behavioral measures to control...signature of physician." It was documented in the nursing notes that Resident # 1 refused medications on the following days: August 11th, September 27th, 28th, 30th, and on October 3rd, 4th, and the 6th. ? 09/21/10-Sick Visit-"...severe problems with his [MEDICAL CONDITION] doses of medications...without great success...trying to balance reducing his [MEDICAL CONDITION] without causing oversedation...signature of physician." ? 10/03/10-1400 (2:00 p.m.) (NN)-"...Sexually inappropriate with staff telling one CNA she had nice breasts...asking to feel them and pointing to another CNA's breasts and asked if he would get in trouble if he grabbed them...Visitor reported seeing this resident force his hands between the legs of a woman in room XX (Resident # 14)...signature of nurse." A UO (unusual occurrence) was reviewed at this time for Resident # 1 regarding the incident on 10/03/10. The UO documented: "Visitor reported witnessing this resident force his hand between the legs of the resident...(Resident # 14)...Actions taken to prevent potential for reoccurrence (referrals, change in toileting schedule): redirected resident, q (every) 15 min (minute) checks...signature of nurse (person making the report and nurse assigned to this resident at time of incident), the CNA (assigned to care for resident at time of incident), the administrator, DON, and the medical director." ? 10/04/10-11:00 a.m. (NN)-"IDT (interdisciplinary team) meeting held. Resident receiving q 15 min. visual checks to determine location...signature of RN # 4." ? 10/04/10-1100 (11:00 a.m.) (NN)-"...He is searching for female residents that he can put his hands on. This morning he wheeled himself into a female patient's room where she was alone. Staff stopped him before he could grope her. Showing deviant behavior...signature of nurse." ? 10/05/10-1600 (4:00 p.m.) (NN)-"CNA going by room XXX (Resident # 14's room) found this resident (Resident # 1) with hands under sheets-CNA removed ... denied going into room or touching female inappropriately...signature of nurse." ? 10/05/10-1710 (5:10 p.m.) (NN)-"...order for appt. with CBHS (initials of psychological clinic) ASAP...signature of DON. ? 10/05/10-Recertification Note: "...Still inappropriate sexual activity with female residents. We tried to decrease meds due to oversedation but as soon as not sedated, starts up again with problem behaviors. Very difficult situation! No single solution...signature of physician." A nursing note was observed, dated 10/05/10 that documented 15 minute checks were initiated at 4:15 p.m. and continued until 5:00 p.m.; Resident # 1 was observed 1:1 from 5:00 p.m. until 6:00 p.m., at 6:15 p.m. the resident was put in bed and remained there until the next day (10/06/10). The CBHS report dated 10/06/10 and timed 4:09 p.m. documented: "...history of ongoing sexually inappropriate behaviors; sexually aggressive and inappropriate with both female residents at the facility as well as female staff...approaching female residents, making inappropriate comments. According to accompanying staff, this has been an ongoing issue for an extended period of time. According to documentation, patient will even leave his wing to visit the alternative wing due to lack on (sic) females on his wing...poor insight why he cannot pursue females, even apparently females who are under [AGE] years of age (photo of 16-[AGE] year old female on bulletin board)...has previously been seen at our practice for similar past behaviors...becomes drowsy on higher doses of [MEDICATION NAME] which makes it more difficult to manage his behaviors through psychopharmacology (psychiatric medications)....PLAN: ...#4. Start gabatril...#6. RTC (return to clinic) in 2 weeks for followup. Next appointment: 2 week(s), or sooner if indicated. It was documented that Resident # 1 returned to the facility following the above appointment on 10/06/10 at 5:00 p.m. It was documented that 15 min. checks were in effect from 5:00 p.m. through 6:30 p.m., the resident was then put in bed at 6:45 p.m. and remained until the following day (10/07/10). On 10/07/10 it was documented that Resident # 1 was on 15 minute checks until 11:00 a.m., at which time it was documented that the resident was up in his chair in his room. A nursing note was observed dated 10/07/10 and timed 2:00 p.m. that documented: "...He had to be reminded once not to enter another residents room...signature of nurse." It was documented in the nursing notes that Resident # 1 refused medication on the following days: October 6th, 7th, 8th, 9th, 10th, 11th, 13th, 15th, 16th, 23rd, 26th, 27th, and 28th. ? 10/12/10-(1:00 p.m.)-"...Resident attempting to touch CNA appropriately (sic) during...care, making inappropriate comments regarding genitals...signature of nurse." ? 10/13/10-(11:20 a.m.)-"...He had been moved away from another resident...signature of nurse." ? 10/14/10-(2:00 p.m.)-"...had to be removed from vacinity (sic) of female patient twice this shift. Also another resident scolded him for going to (sic) close to female resident...signature of nurse." ? 10/15/10-(Quarterly Note)-"...able to propel self...cont. (continues) with inappropriate sexual behaviors towards female res, needs frequent/daily redirection ...signature of nurse." ? 10/26/10-(9:30 p.m.)-"...combative with HS (bedtime) care...signature of nurse." ? 10/26/10-Sick Visit-"...seeing because of refusal to take medications...signature of physician." It was further documented in the nurse's notes that Resident # 1 refused medications on November the 1st, 2nd, 3rd, 4th, 6th, 7th, 8th, and 9th. It was also documented that Resident # 1 was "threatening to hit staff" on 11/3/10 and was documented to be combative with staff on 11/05/10. On 11/05/10 (12:58 p.m.), Resident # 1 was seen by CBHS again. This visit was 2 weeks past the recommended follow-up, which was recommended on the 10/06/10 visit. The report documented: "...more pleasant, angers quickly and easily and symptoms of irritability are inconsistent with typical self... Medication Compliance: YES...Next appointment: 4 week(s), or sooner if indicated." Resident # 1 was not compliant with his medication as evidenced by the nursing documentation. A "Recertification Visit" dated 12/03/10 was observed and documented: "...Complaints of: "Don't give me more pills!!'...now on [MEDICATION NAME] for behaviors...signature of physician." A CBHS visit dated 12/03/10 (timed 12:34 p.m.) documented: "Controlled at visit...angers quickly and easily and symptoms of irritability are inconsistent with typical self...Medication Compliance: YES...Next appointment: 3 week(s), or sooner... Again, Resident # 1 was not compliant with his medications as evidenced by the nursing documentation. A document titled, "Report of Consultation" dated 12/03/10 for Resident # 1 was observed. A section just below the title, "Report Requested Regarding" included: Documentation of presence or absence of sexually inappropriate behavior...signature of Nurse Practitioner-dated 12/05/10." The lower portion of this document titled, "REPORT" included: "Findings: 12/05/10-1240 Received notes from facility No documentation of sexually inappropriate behaviors since addition of [MEDICATION NAME]. However, staff who accompany pt are reporting sexually inappropriate & aggressive behaviors Will need facility to clarify P (Plan): Seek clarification of behavior from facility continue meds for now RTC (Return To Clinic) 3 wks (weeks)...12/05/10 1240 signature of psych." Nursing notes from December 2010 up to present (January 24, 2011) were observed and documented the following: ? 12/04/10 (2:00 p.m.)-"...CNA reported...he tried to touch them inappropriately...speaks loudly to them "you like this, don't you"...CNA's are able to protect themselves from his advances, thus they have not been reporting behavior....signature of nurse." ? 12/14/10 (1:00 p.m.)-"2 more CNA's confirm that pt is sexually inappropriate with them verbally & physically....signature of nurse." ? 12/16/10-0745 (7:45 a.m.)-"Despite 2 CNA's present during pt's (patients) shower, he grabbed shower aid's pubic area...signature of nurse." ? 01/06/11-1710 (5:10 p.m.)-"Observed res. lean forward...Reach out and place his R (right) hand between Res # [MEDICATION NAME] (Resident # 14's) legs...3-11 supervisor and charge nurse notified of above...signature of RN # 1." ? 01/06/11-1715 (5:15 p.m)-"q (every) 15 min (minute) checks initiated for behaviors while out of bed." ? 01/07/11-0250 (2:50 a.m.)-"...threatened to hit staff...signature of nurse." ? 01/11/11 0405 (4:05 a.m.)-"...Inappropriate with CNA (certified nursing assistant) X (times) 1. Put hand on CNA's hip...inappropriate behaviors towards CNA's (grabbing @ (at) them, cursing, inappropriate)...Res. able to propel w/c (wheelchair)...signature of nurse." ? 01/14/11-1000 (10:00 a.m.)-"...Resident made inappropriate sexual statements to CNA's. Resident tried to grab CNA in genital area, however aide jumped back before he could grab her...Charge nurse advised...signature of nurse." ? 01/15/11-1400 (2:00 p.m.)-"Nurse had to intervene to prevent pt's sexually inappropriate behavior /c (with) 2 different female residents in the hallway. He had attempted to touch the woman but was stopped as he was reaching for them. (2 different residents)...signature of nurse." The MAR (medication administration records) for December 2011 and January 2011 were reviewed; Resident # 1 was documented to have refused medications on the following days in December: 2nd, 10th, 16th, 17th, 20th, 25th, 26th, 27th, and 28th. Resident # 1 refused medications in January on the 2nd, 3rd, 5th, 6th, 8th, 10th, 11th, 12th, 13th, 14th, 15th, 16th, 17th, and 18th. The comprehensive care plan for Resident # 1 was reviewed at this time. The care plan, (dated 10/22/10 as creation date) documented: "Care Plan Problem List...# 3. Long term care resident/Behaviors...FOCUS: Mr. (name of Resident # 1) is a long term care resident at this facility that wanders into others space. At times, Mr. (name of Resident # 1) requires redirection and becomes angry with staff...noted in the past to become verbally and physically aggressive...hx (history) of inappropriate sexual behaviors towards female residents...noted to resist medical regimen...INTERVENTIONS: refer...to CSC as needed...MD to eval...medications as needed...SS will meet with (Resident # 1) as needed, along with RP (responsible party)...Refer (Resident # 1) to any community resources as needed...Provide activities of choice for (Resident # 1)." A hand written update was listed under the interventions section and was dated 11/8 (2010), which documented: "MD aware of res refusing meds-initials of RN # 1." Another hand written entry was observed under the intervention section (this entry had a line drawn through it), which documented: "Res placed on q (every) 15 min checks til (sic) res was placed in bed r/t (related to) inappropriate touching of female res-initials of RN # 1." The last hand written entry under the intervention section documented: "1/13 Complete-initials of RN # 1." These were the only documented interventions regarding Resident # 1's inappropriate, unpredictable sexual behaviors. No "behavioral techniques" or "behavioral measures" could be located within the clinical record or in the resident's comprehensive care plan to address the unpredictable, inappropriate sexual behaviors exhibited by Resident # 1. CNA # 2 was interviewed on 01/19/11 at 2:15 p.m. regarding the Resident # 1's behaviors. CNA # 2 stated, "...Says rude things-sexual, I always ask him not to-if he grabs...he doesn't talk to other residents will try to grab them...we have put "blocks" on the door of the person he is going after...we will move him and ask him not to." When asked if it helps, CNA # 2 voiced "Not really." CNA # 12 was interviewed on 01/19/11 at 2:45 p.m. regarding Resident # 1's behaviors. CNA # 12 stated that, "It's awful...well the other day we took three people in to do care." When asked what helps with these types of behaviors, CNA # 12 voiced, "nothing really." On 01/19/11 at approximately 5:15 p.m. in an end of day meeting with the survey team, the administrator and DON were informed of concerns regarding Resident # 1. The DON and administrator were asked what interventions were in place to protect female residents from Resident # 1. The DON voiced that he (Resident # 1) is watched very closely, every 15 minute checks for days, did it last time we had and incident, moved the resident he was seeking (Resident # 14)...watch him very closely, adjust meds-he's been very sedated. The administrator and DON voiced allegations of abuse of any kind should be reported initially to the charge nurse and then up the chain of command. The DON was asked if Resident # 1 went for his follow up appointment as recommended by the psychology specialist on 12/05/10 for the resident to be seen back in 3 weeks. The DON stated that she did not think so and voiced that she had given me all the requested documentation, but would double check. No further information was provided regarding interventions to keep female residents safe or any additional information on Resident # 1's recommended follow-up visit. On 01/20 11 at 12:10 p.m., the Medical Director (administrative staff #4) was interviewed via speaker phone in a meeting with the survey team regarding Resident # 1's inappropriate sexual behaviors. The Medical Director voiced that this was "certainly a priority" for the facility and the facility was in a difficult situation trying to "balance" care. He further voiced that they (the facility) were "walking a fine line" and that he (the medical director) didn't know of any actual harm. When the Medical Director was asked what interventions are in place to protect the other residents in the facility, he (the medical director) verbalized, "15 minute checks, looking and seeing where he (Resident # 1) is and kept in his room or away from others." The Medical Director was then asked to elaborate on "behavioral measures" and "behavioral techniques" that had been documented in the progress notes under plan; the medical director then voiced "redirection, 15 minute checks after an incident and to involve the POA (Power of Attorney) and SW (social worker). It was pointed out that according to documentation, none of these "behavioral measures/techniques" had been effective in managing Resident # 1's sexually inappropriate behavior or protecting other residents in the facility from these sexually abusive behaviors. The medical director was asked about the incident between Resident # 1 and Resident # 14 on October 5th. The medical director stated that, "I think that sounds familiar." The medical director was asked if Resident # 14 was assessed, he stated, "I don't know of any report of any noticeable harm." The medical director was then asked if he would expect the resident to be assessed for any type of injury or abuse. The medical director then stated, if there is harm. This surveyor then commented on the ability to determine abuse or neglect if a resident isn't assessed and if a thorough investigation isn't conducted. The facility's policy on abuse and neglect was reviewed and documented the following: ? POLICY: It is the policy of this facility that all residents have the right to be free from abuse that includes but is not limited to verbal, sexual and mental abuse, corporal punishment and involuntary seclusion by facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. Abuse also includes those practices and omissions, neglect and misappropriation of resident property that left unchecked, lead to abuse... ? Sexual Abuse includes but is not limited to sexual assault, sexual coercion, and sexual harassment... ? This facility prohibits...abuse of residents...although we cannot guarantee that a resident will not be abused we can only assure that the facility will take steps necessary to prevent abuse. Such steps...are not limited to, ...staff education, and on ongoing inservices of resident's rights, monitoring and investigation of incidents and accidents... ? 1. If a staff member witnesses any inappropriate behavior defined as Abuse per policy, that staff member must take immediate and prompt action to stop that behavior. 2. Physically assess the involved resident for injuries... ? Follow Local and State guideline for reporting and always report to State Survey and certification agency. ? Follow Federal Guidelines for Reporting...Report immediately via fax, to appropriate agency. a) Immediately means as soon as possible but ought not exceed 24 hours after discovery of the incident... ? 6. The facility will thoroughly investigate and document each alleged violation and will prevent further potential abuse while the investigation is in progress... ? Identify and care plan staff interventions to prevent occurrences regarding those residents with needs and behaviors which might lead to conflict or neglect... ? ...A thorough internal investigation should include, but is not limited to: Examine the alleged victim promptly and documenting findings...Protecting the alleged victim from further abuse... ? ABUSE...This presumes that instances of abuse of all residents, even those in a coma... At approximately 1:30 p.m. on 01/20/2011, the survey team discussed and reviewed the findings regarding Resident # 1 and the concern for other residents safety within the facility related to the unpredictable, sexually inappropriate behaviors and the facility's lack of/inconsistent interventions. Resident # 1's sexually inappropriate behaviors were unmanaged with re-direction and medication. The facility's administrator, DON, and vice president of operations (administrative staff # 3) were notified of the findings on 01/20/11 at 2:00 p.m. The administrator, DON and vice president of operations presented the survey team with a plan on 01/20/11 at 4:37 p.m. The plan included, but was not limited to: immediate 1:1 observation, and an emergency discharge in planning from the facility to RMH (initials of acute care hospital) emergency room for a psychiatric evaluation. RN # 1 was interviewed on 01/21/11 at 9:00 a.m. regarding Resident # 1's comprehensive care plan in relation to his sexually inappropriate behaviors towards female residents and staff. RN # 1 voiced that the care plan was current and it was done in October 2010 and that she would check with the social worker regarding any other interventions that might not be listed on the care plan. At 9:30 a.m. on 01/21/11, RN # 1 returned and voiced the only other specific intervention was for the Resident # 1 to have 2 staff members for assistance, which happened on 12/14/10. This intervention was not documented on the care plan. RN #1 went on to say that if there was something else, it "didn't get communicated." When asked about updating the care plan with incidents that had occurred specifically related to his behaviors, RN # 1 voiced that "none of these were wrote up as occurrences"...as far as updates, if we talk about an incident-may come up with interventions. RN # 1 stated, "I don't know of anything else..." At 10:00 a.m. on 01/21/11, the SW was interviewed regarding Resident # 1's behaviors and the role of the SW regarding such. The SW stated, "I don't have much documentation regarding where I faxed the referral...yesterday when this arose I called outside resources." On 01/24/11 at 10:50 a.m. the administrator and DON were again interviewed in a meeting with the survey team regarding the expected process of reporting suspected or actually abuse. The administrator voiced that all allegations of abuse should be reported, as outlined in the facility's abuse policy and go up the chain of command. No further information was provided prior to the exit conference on 01/24/11 at 4:00 p.m. 2. The facility staff failed to protect Resi