Every finding on record at Broadmead

Based on a tour of the kitchen, observation, and staff interview, it was determined that the facility staff failed to label stored food items to ensure safety and prevent contamination which could lead to unsafe food and potential illness.The findings include:During the initial tour of the kitchen on 11/17/2025 at 08:00 AM, the following items were found opened and used without any labeling:Walk in Refrigerator #1:1gallon [NAME] sauce w/ red raspberries1gallon sweet baby rays BBQ sauce x2 bottles1 gallon buffalo sauce x 2 bottles1 gallon each of salad dressings; Ranch, Golden Italian and French3 pound Hummus container1 32 oz horse radish containerWalk in Refrigerator #2:1 gallon Mayo1 gallon Harachino sauce 1 gallon pickle chips During an interview with staff # 8 on 11/17/2025 at 08:15 AM, he/she stated that all items that are opened and or used should have had a label with a use by date. Staff # 8 also stated that staff will need to be re-educated on labeling and dating of food items. On 11/19/2025 at 10:12 AM, the Nursing Home Administrator was made aware of the findings in the kitchen and acknowledged the concern.

Based on record review and staff interviews, it was determined that the facility failed to maintain accurate records of staff COVID-19 vaccination status. This deficiency was evident for four (Staff #10, #11, #12, and #13) of the five staff reviewed for COVID-19 vaccinations. The findings include:On 11/19/25 at 11:33 AM, the surveyor reviewed the immunization records for five recently hired staff members who provide direct resident care. The staff reviewed included: Staff #10 and #11 (Hired May 2025), Staff #12 (Hired October 2025), and Staff #13 (Hired August 2025).The review revealed that four out of the five staff did not have records documenting their COVID-19 vaccination status.In an interview with the Infection Preventionist (Staff #5) and the Director of Nursing (DON) on 11/19/25 at 12:18 PM, they confirmed that the facility staff immunization records are managed by Human Resources (HR).During an interview with the HR Director (Staff #16) on 11/19/25 at 1:14 PM, she stated that the facility did not collect data regarding employees' COVID-19 vaccination status.At 1:34 PM on 11/19/25, the DON and Staff #5 presented a spreadsheet detailing facility staff's COVID-19 vaccination status, including dates of initial vaccine, booster, and additional doses. However, the spreadsheet did not contain any data for Staff #10, #11, #12, or #13. The surveyor asked Staff #5 and the DON how the facility monitors and/or offers the COVID-19 vaccine to new staff hires, but they did not provide an answer.On 11/20/25 around 1:00 PM, the surveyor shared the above concerns with the DON, and she validated the deficiency.

Based on a review of the clinical record and staff interviews, it was determined that facility staff failed to properly document the primary decision maker for end-of-life decisions. This deficiency was evident in one (Resident #23) of the five residents reviewed for Advanced Directives during this annual survey.The findings include:The Medical Orders for Life-Sustaining Treatment (MOLST) form ensures that a patient's wishes to receive or decline care are honored. During the admissions process, a practitioner must review the MOLST form.Decision-making capacity is the ability of an individual to make an informed choice about a specific situation, such as medical treatment.On 11/17/25 at 1:12 PM, a review of Resident #23's medical record revealed that the resident's capacity certification was completed by two physicians on 7/21/25 and 7/22/25. Both physicians documented that the resident was not capable of making and communicating decisions regarding medical care.However, the MOLST dated 8/22/25 indicated that the orders were entered as a result of a discussion with and the informed consent of the patient. This contradicts the earlier capacity certifications.In an interview on 11/18/25 at 8:53 AM, the Social Worker ( Staff #3) explained that physicians are supposed to review residents' decision-making capabilities and MOLST based on the resident's health condition, and then Social Workers review them. The surveyor reviewed Resident #23's MOLST and capacity certifications with Staff #3. The staff member acknowledged that two certifications indicated the resident was not capable of making decisions, yet the MOLST was signed by the resident afterward.In an interview with the DON (Director of Nursing) on 11/20/25 around 1:00 PM, the surveyor shared the concern, and the DON validated it.

Based on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to ensure residents received treatment and care to promote the highest practicable well-being evidenced by inadequate provision/monitoring of care when a resident experienced a voiding issue. This was evident for one (Resident #45) of 14 resident care records reviewed during this annual survey.The findings include:On 11/18/25, at 10:27 AM, the surveyor reviewed system-selected residents' closed records. The review revealed that Resident #45 was discharged from the facility on 9/18/25. A further review of Resident #45's progress notes revealed that the resident reported dark, tea-colored urine on 9/17/25, at 10:30 PM. An additional progress note, written on 9/19/25, at 2:07 AM, stated: Resident left AMA (against medical advice) overnight around 11:30 PM. Reports he/she was not urinating and concerned about the color of urine. [Spouse] was with him/her and took him/her via wheelchair by car with all belongings. They refused to sign the AMA papers and did not want to go by ambulance. Furthermore, there were several progress notes regarding Resident #45's urinary difficulty upon admission.On 11/20/25, at 8:00 AM, the surveyor reviewed Resident #45's discharge summary from the hospital prior to their admission to the facility. The record stated that the resident was hospitalized from [DATE], to 9/12/25. During this stay, the resident had a cystourethroscopy with lithotripsy (a procedure to remove urinary tract stones by using a cystoscope to examine the bladder and urethra). The discharge summary instructed a urology follow-up within 7-10 days after discharge. However, there was no documentation of Resident #45's urology follow-up in the resident's record.During an interview with the Director of Nursing (DON) on 11/20/25, at 10:32 AM, she explained that the urology appointment was originally scheduled for 9/15/25, at 1 PM. The DON added, We contacted the urologist's office and verified that the resident did not attend the appointment. Since there was no documentation, we don't know why. Additionally, the surveyor asked how the facility monitored and/or provided care for Resident #45's voiding issues upon admission, especially after dark urine was noted on 9/17/25. The DON verified that Resident #45's health condition was not monitored and/or appropriate care was not provided.

Based on observation, record review, and staff interview, it was determined that the facility failed to 1) label oxygen tubing with date of change to indicate maintenance of the tubing for proper hygiene and safety, and 2) provide necessary respiratory care services for residents by failing to administer oxygen as prescribed. This was evident for three (Resident #23, #46, and #49) of 3 residents reviewed for respiratory care during this survey.The Findings include: 1) During the screening phase of the survey process on 11/17/25 at 10:30 AM, surveyor observed Resident # 46 and Resident # 49 receiving oxygen through nasal cannula tubing without a label indicating when they were changed. On 11/17/25, record review of resident # 46 noted an order for Oxygen at 2L – 4L/min via nasal cannula every shift for Cardiopulmonary Disorder (COPD). Resident # 49 had an order for Oxygen at 2L/min continuously every shift for Cardiopulmonary Disorder (COPD). On 11/18/25 at 09:30 AM, continued observation was made that the oxygen tubes were not labeled. During an interview with staff # 6, when asked about the nasal cannula tubing for oxygen administration, she/he stated that an order is written for oxygen, and the resident get hooked up to an oxygen tank or an oxygen concentrator, and the nursing staff ensure that the oxygen tubing is changed weekly. When asked if the oxygen tubing should be labeled, staff # 6 stated that the humidifier should be labeled but was unsure about the oxygen tubing. An interview was conducted on 11/18/2025 at 09:51 AM with staff #9. When asked about the nasal cannula tubing for oxygen administration, she/he stated that oxygen was administered continuously through nasal cannula tubing with humidified air and the tubing and the humidifier should be labeled every time that they were changed out. The surveyor requested that staff # 9 verify that Resident # 46 and Resident # 49 oxygen tubing were not labeled. Staff # 9 stated that they should have been labeled. During an interview with the Director of Nursing (DON) on 11/18/25 at approximately 2:00 PM, the surveyor informed her about the concern of the finding regarding the oxygen tubing not labeled with a date of change. The DON stated that the oxygen tubing should have been labeled and acknowledged the concern. 2) During an observation of Resident #23's oxygen tank and tube on 11/18/25 at 7:45 AM, it was noted 3 L (Liters) of oxygen was being administered to the resident through a nasal cannula. However, a review of Resident #23's order showed: 'Oxygen at 4 L/min via Nasal Cannula for SOB (Shortness of Breath).' On 11/18/25 at 7:48 AM, the surveyor asked Licensed Practical Nurse (LPN #2) to verify the amount of oxygen administered to Resident #23. LPN #2 observed the flow meter and confirmed the setting was 3 L/min at the moment. The surveyor asked what the order was for Resident #23. LPN #2 said, Yes, the order is 4 L/min, and then she adjusted the flow meter to 4 L. During an interview with the Director of Nursing (DON) on 11/18/25 at approximately 2:00 PM, the surveyor informed her of the finding regarding Resident #23's oxygen administration dose. The DON acknowledged the concern.

Based on observation, medical record review, and interview with facility staff, it was determined that the facility failed to ensure that the environment of resident care was maintained in a manner that minimized the potential spread of infection, evidenced by an oxygen tube lying on the floor in a resident's room. This was evident for one (Resident #23) of two residents observed for oxygen therapy during this annual survey.The findings include:During the initial tour of the facility on 11/17/25 at approximately 10:00 AM, it was observed that Resident #23's oxygen tank was in the bathroom of his/her room, and the oxygen tube was lying on the floor from the tank to the resident's bed.The second observation, on 11/18/25 at 7:45 AM, noted that Resident #23's oxygen tube was still lying on the floor from the bathroom to the bed.In an interview with a Licensed Practical Nurse (LPN #2) on 11/18/25 at 7:45 AM, she stated that the facility's nurses manage residents' oxygen, including the tank, tube, and humidifier. The surveyor asked to observe Resident #23's oxygen tube. LPN #2 verified that the tube was lying on the floor and she said, It's not supposed to be touching the floor, but the resident kept it on the floor because of a behavior issue. We have documented this.On 11/18/25 at 8:20 AM, the surveyor reviewed Resident #23's progress note. The review revealed that there were several documentations regarding the resident's behavior, such as removing oxygen tubing and a lack of safety awareness. However, there was no documentation regarding the oxygen tube placed on the floor.During an interview with the Director of Nursing (DON) on 11/18/25 at approximately 2:00 PM, the surveyor asked about managing the oxygen tube. She verified that the tube should not be placed on the floor due to infection prevention. The surveyor shared the above concern, and the DON acknowledged the concern.

Based on medical record review, and staff interview it was determined the facility failed to ensure residents received medications in accordance with professional standards of practice. This was evident for 1 resident (#10) out of 17 residents reviewed during the survey. The findings include the following: Review of Resident #10's medical record on 03/20/2024 at 09:30 AM revealed that the resident was discharged from the hospital and admitted to the facility on [DATE]. On the hospital discharge summary, it stated that Resident (#10) was to be given medication, Cefdinir, twice a day for 9 days as a course of antibiotic therapy and Resident (#10) was to begin Cefdinir on 02/21/2024. Review of facility investigation on 03/20/2024 at 11:00 AM revealed that Resident (#10) did not receive Cefdinir until 02/26/2024 and therefore missed 11 doses of this medication. During the interview with the Director of Nursing (#2) on 03/20/24 at 11:15 AM he/she confirmed the medication error and findings in the facility investigation. All concerns were shared with the Administration Team at the time of exit on 3/21/24 at 2:00 PM.

Based on medical record review and staff interviews, it was determined that Pharmacy continued to prepackage a medication for Resident (# 29) after the medication was placed on hold. This occurred for 1 of 4 residents observed during the medication pass. The findings include: During observation of a medication pass on 3/20/24 at 9:00am with LPN (Licensed Practical Nurse) (Staff # 11) revealed that Resident #29 had Lasix 40mg in his/her prepackaged medications dated 3/20/24. Staff #11 stated, Lasix is in the package to be administered however, I know the medication is on hold. Review of the medical record on 3/20/24 at 11:30am revealed the medication was placed on hold on 3/15/24 at 9:30am. During an interview with the DON (Staff #2) on 3/20/24 at 1:30pm, she stated medications are delivered to the facility every 2 days for each resident and the Lasix should not have been in the package with Resident #29's medications. During a follow up interview on 3/20/24 at 2:15pm, the DON stated she spoke with pharmacy and the medication was being removed. All concerns were shared with the Administration Team at the time of exit on 3/21/24 at 2:00 PM.

Based on record reviews and interviews with facility staff, it was determined that the facility failed to address a pharmacy recommendation in a timely manner. This was evident for 1 (Resident #20) of 5 residents reviewed for unnecessary medications. The findings include: On 3/19/24 at 5:07 PM, record review of Resident #20's medical record revealed the following pharmacist recommendation dated 1/25/24, Please consider discontinuing PRN artificial tears and melatonin for no use in > 6 months. Furthermore, the document titled Letter to Physician, noting the response of the pharmacist's Recommendation and Medical Regimen Review (MRR) date of 1/25/24, contained a handwritten response of done. On 3/19/24 at 5:10 PM, record review of physician's orders in the electronic health record (EHR), revealed Resident #20 was ordered Artificial Tears Ophthalmic Ointment 83-15 % (White Petrolatum-Mineral Oil); Instill 1 application in both eyes every 24 hours as needed for Dry Eyes and Melatonin Oral Tablet 3 MG (Melatonin); Give 1 tablet by mouth every 24 hours as needed for Insomnia Give at bedtime. Both medications were ordered on 7/6/23. The discontinuation date listed in the physician's orders section of the EHR for both medications was 2/26/24. On 3/20/24 at 11:57 AM, further record review of Resident #20's medical record revealed the exact same pharmacy recommendation from January 2024 that was dated 2/24/24 stating, Please consider discontinuing PRN artificial tears and melatonin for no use in > 6 months. In addition, the aforementioned recommendation was listed on a document titled, Consultant Pharmacist's Medication Regimen Review Active Recommendations Lacking a Final Response, also dated 2/24/24. Furthermore, the document titled Letter to Physician, noting the response of the pharmacist's Recommendation and Medical Regimen Review (MRR) date of 2/24/24, contained a signature from the Medical Director #5, and a date of 2/26/24 with the Agree box checked. On 3/20/24 at 12:01 PM, in an interview with the Director of Nursing (DON), she stated the process for Medication Regimen Review (MRR) was as follows: the pharmacist sends the recommendations to the DON who sends them to the appropriate discipline. The pharmacist recommendations on the skilled unit are addressed within 24 hours and the pharmacist recommendations on the long term care unit are addressed before the next MRR. On 3/21/24 at 9:57AM in an interview with Staff #3 (who during January and February 2024 held the title of Interim DON), spoke with Medical Director #5 and stated that she received the MRR via email, and Staff #12 was to address it for her, but did not. When the exact same recommendation from January 2024, showed up again on the February 2024 MRR, Medical Director #5 discontinued the medications at that time. The following concerns were shared with the Administration Team at the time of exit on 3/21/24 at 2:00 PM.

Based on observation and staff interview, it was determined the facility failed to store food in accordance with professional standards for food safety. The findings include: An initial tour of the facility Kitchen was completed on [DATE] at 08:10 AM with Staff (#8) and the following items were found to be missing an expiration date on the product: 1) Two cans of black-eyed peas 2) Two boxes of classic salt 3) Several spice containers that included ground ginger 4) Two containers of avocado smash During the tour interview on [DATE] at 08:25 AM with Staff (#8), he/she stated that the above items did not have an expiration date on them and he/she would check on these items to be sure that they were able to be used and not expired.

Based on medical record review and interview, it was determined the facility staff failed to notify the responsible party for Resident (#34) of an increase in medication and obtain consent for that increase. This was evident for 1 of 5 residents selected for review of unnecessary medications during the survey process. The findings include: Medical record review for Resident #34 revealed the resident was seen by psychiatric nurse practitioner on 4/10/19. At that time, it was ordered: increase [MEDICATION NAME] to 15 milligrams by mouth at hour of sleep if OK with family. [MEDICATION NAME] is used to treat depression and anxiety. It works by helping to restore the balance of a certain natural substance (serotonin) in the brain. Further record review revealed the order for the [MEDICATION NAME] was written and initiated for Resident #34; however, the facility staff failed to notify the resident's family of the increase in the [MEDICATION NAME] and obtain consent for the medication increase. Interview with the social worker on 4/19/19 at 11:20 AM revealed the facility staff failed to notify the family of Resident #34 of an increase in medication and obtain for consent for that increase. Interview with the Director of Nursing on 4/19/19 at 1:30 PM confirmed the facility staff failed to notify the responsible party for Resident #34 for an increase in medication and obtain consent for that increase prior to initiation of that increase of [MEDICATION NAME].

Based on medical record review and interview, it was determined the facility staff failed to address and notify the physician of results of an abnormal blood sugar level for Resident (#24). This was evident for 1 of 27 residents selected for review during the annual survey process. The findings include: Resident #24 was admitted to the facility with diabetes which requires the body's blood sugar levels to be controlled by medications. A blood sugar level below 60 requires more sugar to be given to the resident and if above 300 requires extra medications to be given to lower the level. On 1/19/19 Resident #24's physician ordered the nursing staff to notify him/her if the blood sugar levels dropped below 60 or greater than 500. On 4/8/19 at 9 PM Resident #24's blood sugar level was documented on the medication administration as 534 and on 4/9/19 at 7 AM the level was 588. Interview with the Assistant Director of Nursing on 4/19/19 at 10:30 AM confirmed that on 4/8/19 at 9PM, and 4/9/19, the nursing staff did not document on the Medication Administration Record, [REDACTED].

Based on medical record review and staff interview it was determined the facility staff failed to document accurate assessments for Resident (# 33) and Resident (# 39) on the MDS. This was evident for 2 of 26 residents selected for review during the investigation stage of the survey process. The findings include the following: The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use and Treatments and procedures. At the end of the MDS assessment the interdisciplinary team develops the plan of care for the resident to obtain the optimal care for the resident. 1. Review of Resident #33 MDS, with an ARD of 11/23/17, was inaccurate. Section N 0410, Medications Received (C), antidepressant coded that the resident did not received for 7 days. Review of Resident # 33 November 2017 Medication Administration Record [REDACTED]. 2. Review of Resident #39 quarterly MDS, with an ARD of 11/30/17, was inaccurate. Section P 0200, Alarms (E), Wander/elopement alarm coded that the resident did not have an alarm for the 7 days. Review of Resident # 39 November 2017 Treatment Administration Record (TAR) documented that the resident had the wander/elopement alarm during the lookback period. Interview with the DON on 12/20/17 at 10:30 am confirmed the facility staff failed to accurately code the MDS for Resident # 33 and Resident # 39 assessment.

Based on medical record review and staff interview, it was determined that the facility staff failed to obtain laboratory blood tests as recommended by the Consultant Pharmacist for a resident (#34). This was evident for 1 of 26 residents selected for review during the investigation stage of the survey process. The findings include: Medical record review of Resident #34 revealed on 11/17/17 the Consultant Pharmacist completed a Medication Regimen Review and recommended the Resident have a BMP (Basic Metabolic Panel) and a Vitamin D level. The BMP is done to evaluate: kidney function, blood acid/base balance and blood sugar levels. The Vitamin D level is to evaluate if there is a Vitamin D level deficiency. Vitamin D deficiency has been linked to a host of illnesses and conditions, from [MEDICAL CONDITION] and diabetes to certain types [MEDICAL CONDITION]. On 11/21/17 the Resident's physician agreed with the Consultant Pharmacist's recommendation. Further record review revealed that the facility staff failed to obtain the laboratory blood tests as recommended by the Consultant Pharmacist. After surveyor intervention the laboratory blood tests were obtained on 12/20/17. Interview with the Director of Nursing on 12/21/17 at 8:00 AM confirmed the facility staff failed to obtain laboratory blood tests as recommended by the Consultant Pharmacist.

Based on medical record review and interview with facility staff, it was determined that the facility failed to maintain accurate medical records related to orders and behavior monitoring. This was evident for 2 of the 26 residents (#355 and #39) reviewed in the second stage of the survey process. Findings include: 1. Based on staff interview and review of the medical record it was determined that the facility failed to obtain an order for [REDACTED]. Review of the medical record on 12/19/17 at 10:15 AM revealed that on 12/11/17 Resident #355 was sent to the emergency room for evaluation following three episodes of Hematuria (Blood in the urine) within two days. Resident #355 returned to the facility later in the day on 12/11/17 with a foley catheter in place. Further review of the medical record on 12/19/17 revealed that there was no physician's order written for the care and management of the foley catheter. In an interview on 12/19/17 at 10:42 AM the unit nurse supervisor was made aware of this concern and asked if there was any additional orders or hospital discharge summary available. Following review of Resident #355's chart the unit nurse supervisor confirmed that the order had not been written for the foley care and no additional documentation was presented through the remainder of the survey. At that time the unit nurse supervisor called Resident #355's physician and obtained a verbal order for foley care and management. 2. A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. Medical record review for Resident # 39 revealed a Psychoactive Medication Monthly Flow record, which target behavioral symptoms such as disruptive behavior, physically abusive and wondering. The facility staff documented that the Resident did not display any behavioral symptoms from 12/01/17 thru 12/19/17 on the flow record. Further review of the Resident's # 39 medical record reveal documentation regarding his/her behavior in the Progress notes on 12/4, 12/11, 12/14, and 12/19/2017 that the resident had disruptive target behavior. Interview with the Director of Nursing on 12/19/17 at 1:30 PM confirmed the facility staff failed to maintain the medical record in the most complete and accurate form for Resident #39.

Based on clinical record review and staff interview it was determined that the facility staff failed to ensure an ophthalmology consult was obtained as requested by a resident (#31). This was true for 1 of 26 residents selected for review during the investigation stage of the survey process. The findings include: A review of Resident #31's clinical record revealed that the resident told the Hospice nurse on 5/1/17 that he/she wanted to see an ophthalmologist. There was no evidence in the clinical record that the ophthalmology consultation was obtained. Staff #1 was interviewed on 12/21/17 at 11:25 AM. She confirmed the consultation was not obtained. She stated that the hospice nurse did not tell the facility nursing staff that the resident requested to see an ophthalmologist and that nursing staff missed the hospice nursing note. She stated that primary physician was called after surveyor intervention and the physician spoke with the resident.

Based on medical record review and interview with staff it was determined that the facility failed to accurately assess the residents' status on the quarterly Minimum Data Set (MDS) assessments regarding the residents' 1) activities of daily living (ADL) ability related to bed mobility and toileting, 2) activities of daily living related to bed mobility and transfers, and 3) diagnoses. This was evident for 3 (#20, #22, and #77) out of the 25 residents reviewed in the stage 2 sample.The findings included:The Minimum Data Set (MDS) is a multi-disciplinary tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. 1. Surveyor observed Resident #20 on 11/30/16 during the initial tour of the facility and again on 12/1/16 prior to the resident leaving for a dental appointment. The resident observed independently ambulating off the unit escorted by facility staff. Review of the medical record including the MDS on 12/5/16 at 4:00 PM for Resident #20 revealed coding for section 'G' functional ability. Under bed mobility and toileting, a change from the admission assessment on 7/6/16 to the residents quarterly assessment on 9/30/16 was noted from independent ability, to requiring supervision for those tasks.Interview with the facility MDS coordinator and the DON (Director of Nursing) at 4:38 PM on 12/5/16, revealed that they were unaware of any significant change that had occurred with the resident that would require an increase in staff support for those areas of ADL's. Review of the GNA documentation for the look back period for 9/30/16 did not reveal any documentation that the resident had an increase in staff required support. The findings were reviewed with the MDS coordinator in the presence of the Administrator on 12/5/16 at 5:15 PM. The MDS coordinator stated that, with the resident's increase in supervisory needs in other areas of ADL care, she may have assumed s/he also needed an increase in the level of support in the above identified areas. 2. On 12/05/16 at 4:04 PM, medical record review revealed that resident #22 showed a change in bed mobility between the previous MDS Quarterly review assessment on 06/28/16 and the most recent Annual assessment on 09/22/16. The resident's status was noted to change from requiring total dependence to extensive assistance. During the same assessments there was also a change in transfers from extensive assistance to total assistance and a change in eating self- performance from limited assistance to extensive assistance.Interview with the facility's MDS coordinator and the DON (Director of Nursing) on 12/05/16 at 4:38 PM revealed that the MDS coordinator's assessments was based on information that was obtained from the nurses' and GNAs' documentation, POC (point of care) documenation, and personal observations. In addition they were unaware of any significant change that had occurred with this resident that would require a change in staff support for those areas of ADL's. Moreover regarding bed mobility, the DON stated that the resident has always required a Hoyer lift which are for residents that are totally dependent. The MDS coordinator acknowledged that she did not address the changes noted and did not perform a significant change comprehensive assessment. 3a. Resident #77 was admitted with [DIAGNOSES REDACTED]. Review of the physician's progress note dated 8/2/16 revealed the notation that the resident had progressive cognitive impairment affecting his/her ability to carry out his/her Activities of Daily Living. The physician further noted the new onset of Dementia. Review of the MDS Assessment completed on 10/25/16 revealed that facility staff failed to enter in Section I (Active Diagnoses) the [DIAGNOSES REDACTED]. The findings were confirmed with the MDS Coordinator on 12/5/16 at approximately 3:15 PM.3b. Review of Resident #77's MDS Assessments completed on 7/28/16 and 10/25/16 revealed facility staff entered in Section I (Active Diagnoses) the [DIAGNOSES REDACTED]. Symptoms can include overflow incontinence, frequency, urgency, and retention. Risk of serious complications (e.g., recurrent infection and backward flow of urine) is high.Review of Resident #77's admission MDS assessment completed on 7/28/16 revealed the facility staff coded the resident in Section H Urinary Continence H0300 as a 0 (always incontinent). Review of the Quarterly MDS assessment completed on 10/25/16 revealed the facility staff coded the resident as a 1 (occasionally incontinent- less than 7 episodes of incontinence) indicating a potential decline in urinary continence.The Minimum Data Set (MDS) is a comprehensive multi-disciplinary tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. The daily charting completed by nursing assistants regarding bladder function revealed that between the period of 10/19/16 and 10/25/16 the resident was noted to be continent 17 of 21 shifts, incontinent 1 of 21 shifts and unknown due to lack of documentation on 2 of 21 shifts. In interview with the surveyor on 12/5/15 at 2:20 PM the Director of Nursing (DON) revealed the facility does not conduct bowel and bladder assessments. When the surveyor inquired about the origin of the diagnosis, [MEDICAL CONDITION] bladder, the DON stated he/she was unsure. At the time of exit facility staff could not provide information regarding the origin of this diagnosis.The care plan that addressed urinary incontinence did not note the [DIAGNOSES REDACTED].

Based on administrative and medical record review, staff and resident interview it was determined the facility failed to conduct a thorough investigation of an allegation of abuse by Resident #14 who maintained he/she was told by Staff #4 and Staff #5 that he/she could only call for help once every 2 hours. This was evident for 1 of 5 residents identified during a review of facility reported incidents.The findings include: Surveyor review of a facility reported incident (#MD 168) on 12/2/16 revealed an allegation by Resident #14 that Staff #4 and Staff #5 told him/her that he/she could not ring the call bell more than once in a 2 hour period. The resident reported this to facility staff on 6/2/16.Review of the Admission MDS Assessment completed on 10/31/16 revealed the facility entered a BIMS score of 14 out of 15 in Section C Cognitive Patterns. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive understanding. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. The Minimum Data Set (MDS) is a comprehensive multi-disciplinarian tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed.During an interview with the surveyor on 12/1/16 at 12:05 PM, the resident stated he/she was unclear about why he/she was told that he/she was only allowed to use the call light once every 2 hours. The resident then stated he/she was uncomfortable talking about the incident.During an interview with the Director of Nursing (DON) on 12/2/16 at 11:41 AM, the Surveyor inquired of the DON if other residents were interviewed to determine if they had the same or a similar experience. The DON stated other residents were interviewed but confirmed the responses were not documented. At this time the Administrator and DON stated the two employees were terminated because the care they provided was inconsistent with the values of the facility. The Administrator further stated Resident #14 does use the call bell frequently and it is necessary to be patient with him/her. Review of the resident's care plans failed to reveal interventions to address this concern.The investigative documentation presented at the time of the survey also failed to include statements from the alleged perpetrators, and a specific rationale for the termination of the employees when it was concluded the abuse was unsubstantiated.

Based on medical and administrative record review, and staff and family interview, it was determined the facility failed to clarify in the medical record the level of supervision required for a functionally and cognitively impaired resident (Resident #61) who experienced a fall and sustained a [MEDICAL CONDITION] maxillary (located in the cheekbones) sinus. This was evident for 1 of 5 residents identified during a review of facility reported incidents.The findings include:Resident #61 was admitted to the facility with [DIAGNOSES REDACTED]. A contracture is a shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints.The care plan that addressed falls was initiated 9/28/15 to include the following interventions: place call light within reach and encourage resident to use it; proper footwear to be worn during transfers-non skid socks when not in shoes; and place personal items within reach. A Fall Risk assessment dated on 7/1/16 revealed the resident was determined to be a low risk for falls with a score of 4 and his/her gait balance was noted to be normal.The Quarterly MDS assessment completed on 7/11/16 revealed the facility entered a BIMS score of 5 out of 15 in Section C Cognitive Patterns. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive understanding. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment. The Minimum Data Set (MDS) is a comprehensive multi-disciplinary tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. Review of the Quarterly MDS assessments dated 7/11/16 and 10/5/16 revealed facility staff coded the resident in Section G Functional Status G0110 Activities of Daily Living Assistance C - walk in the room, D- walk in the corridor, E-locomotion on the unit and F-locomotion off the unit as a 1 (requires supervision/oversight); and in section G0300 Balance During Transfers and Walking A- moving from a seated to standing position as a 0 (steady at all times) and B- walking, as not steady but able to stabilize without human assistance. A nursing progress note dated 8/4/16 at 14:03 reported the resident was walking with a companion when he/she tripped on a laundry cart and fell in the hallway.A physical therapy assessment summary dated 9/26/16 reported the resident presented with increasing unsteadiness with walking, due to worsening posture, resulting in several falls. The summary also included the following statement, .Pt (patient) has sustained a functional regression as compared to previous level of function from last discharge from PT (physical therapy). A physical therapy encounter note dated 9/28/16 reported the resident was engaged for gait training with a rollator (a type of walker with a built-in seat, which allows the user to stop and rest when needed). The therapist documented that the resident remained resistant to the idea of using a rollator and was very unsafe walking without it, frequently reaching out to walls for balance. The medical record did not contain a care plan that addressed care refusal.A Fall Risk assessment dated [DATE] revealed a score of 9, medium risk, and the resident was noted to have balance problems while standing, walking, and jerking or unstable when making turns. Further review of Resident #61's medical record revealed an additional BIMS score assessment was completed on 10/5/16, and provided a score of 7 out of 15 (severe cognitive impairment). A nursing progress note dated 10/31/16 at 6:29 AM noted the resident reported that while ambulating to the bathroom at 5:30 AM he/she lost his/her balance and fell resulting in pain to the left rib area. Review of Resident #61's physician orders [REDACTED]. [MEDICATION NAME] is a diuretic which has the potential to increase urinary urgency and frequency thereby increasing the need for more frequent toileting.Further review of the falls care plan revealed that the care plan was updated on 10/31/16, however it did not clearly state the interventions being utilized for use with this resident. For example, while the care plan noted the resident utilized a rollator, it did not provide instructions to staff on how or if any specific instructions were needed, such as reminding the resident to use the rollator. Surveyor review of a facility reported incident (MD 571) revealed Resident #61 experienced a fall on 11/25/16 and sustained a [MEDICAL CONDITION] maxillary sinus. Updates to Resident #61's care plan on 11/28/16, after the fall with an injury included: 1) make sure the resident wears the call pendant at all times, 2) escort the resident to the dining room for all meals, 3) monitor for pain and offer toileting every 2 hours and as needed while awake for 1 week, and 4) medication review. A nursing progress note dated 11/29/16 at 10:58 PM reported the resident was alert and confused and was found sitting on the floor in the bathroom. The resident reported falling on his/her legs when he/she attempted to get off the toilet.On 12/5/16 at 2:55 PM the surveyor attempted to interview the resident regarding the fall. The resident was alert and facial bruising was still evident, due to the fall. The resident stated she/he did not remember falling and denied needing assistance with ambulation. During an interview with the surveyor on 12/5/16 at 3:00 PM the Director of Nursing stated the resident was placed on hourly observation after the fall on 11/25/16. In interview with the surveyor on 12/5/16 at 3:15 PM, the Administrator stated the resident is independent and does not want assistance. Surveyor also discussed the changes in the resident's functional status and the lack of adjustments to the resident's care plan, including the level of supervision.

Based on administrative and medical record review, staff and resident interviews it was determined the facility failed to honor Resident #77's preference to have female caregivers when a male nursing assistant showered the resident on 9/6/16. This was evident for 1 of 5 residents identified during a review of facility reported incidents.The findings include:Medical record review on 12/5/16 revealed a Resident's Care Guide with a start date of 7/22/16, that noted the resident did not want a male care giver. Surveyor review of an incident (#MD 583) revealed a concern that, during the week of 9/5/16, Resident #77 was given a shower by Staff #1, a male nursing assistant. The Resident reported to his/her family member that this was inappropriate and reported to the Social Worker and Director of Nursing that he/she felt violated. Resident #77 was admitted to the nursing home in July 2016 with [DIAGNOSES REDACTED]. The Admission MDS assessment completed on 7/28/16 revealed the facility entered a BIMS score of 3 out of 15 in Section C Cognitive Patterns and a score of 8/15 on the Quarterly assessment completed on 10/25/16. Brief Interview for Mental Status (BIMS) is an assessment that assists staff in determining a resident's cognitive understanding. A score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment.The Minimum Data Set (MDS) is a comprehensive multi-disciplinarian tool that allows many facets of the resident's care (cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few) to be addressed. In interview with the surveyor on 12/1/16 at 12:45 PM the resident recalled the incident and stated the staff member (Staff #1) was, misinformed as it was not appropriate to have a male caring for a female.During an interview with the surveyor on 12/5/16 at 2:35 PM, the Director of Nursing stated that residents are not queried about their preferences to have male versus female staff provide care. He/she stated Resident #77's preference is now noted in the Resident's Care Guide which is used by nursing assistants as a guideline for residents' care.In interview with the surveyor on 12/5/16 at 2:45 PM, Staff #2 reiterated that residents were not asked about preferences of male versus female caregivers during the admission process but once a preference is expressed the resident's choice is honored. Review of the resident s Activities of Daily Living (ADLs) care plan, initiated on 9/1/16, failed to reveal the resident's preference despite an intervention that stated staff would discuss ADL preferences with the resident and family. ADLs refer to daily self-care activities such as bathing, grooming and dressing.