Every finding on record at Burleson Nursing and Rehabilitation Center

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food storage, food safety, and nutrition services for 1 of 1 kitchen. The facility failed to ensure food items were labeled and/or dated. This failure could place residents at risk of foodborne illness by being served expired food. Findings Included: Observation on 9/21/2025 at 9:13 AM of the cooler revealed the following:1 sheet cake prepared in the pan sitting on top of boxes uncovered and not dated.1 bag of shredded lettuce sitting on a shelf open and undated. In an interview on 9/21/2025 at 9:13 AM, the DM stated the sheet cake was just cooked this morning, and the staff had placed it in the freezer to cool down and the bag of lettuce was just opened. The DM stated the staff forgot to place a date on it. She said normally anything that is placed in the refrigerator or freezer would be covered and dated. The DM stated it was her responsibility to make sure items was dated and to check the refrigerator and freezer daily. The DM stated not covering items could lead to contamination leading to food borne illness. In an interview on 09/23/2025 1:57 PM, the ADM stated dietary aides and cooks was responsible for covering and dating items that go into the freezer and refrigerator. He stated the dietary manager was responsible for doing daily monitoring of the refrigerator and freezer for expired undated and uncovered items. He stated the ADM does a weekly walk through and inspects the kitchen. He is also responsible for monitoring the kitchen for dated and covered items. He stated consequences for not covering and dating items in the refrigerator could be food borne illness and resident safety. Record review of the facility's food storage policy dated October 01, 2018, reflected the following: Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. Store frozen foods in moisture-proof wrap or containers that are labeled and dated.

Based on observation, interview, and record review the facility did not provide drugs and related services needed by each resident for 1of 1 medication storage rooms and 1 of 3 medication carts (Medication Cart A) reviewed for medication storage. The facility failed to ensure:- expired medication administration supplies was removed from the medication storage room- opened resident medications was dated on the date they were opened. This failure could place residents at risk for ineffective treatments, infections, or not receiving the therapeutic benefit of the medication.Observation on 9/22/25 at 2:45 PM of the E Hall Nurse medication cart revealed the following medications were opened for use and did not have a date indicating when they were opened: 1 Albuterol 90 MCG Inhalers opened and not dated. 1 Albuterol 90 MCG Inhalers opened and not dated. 1 partial bottle labeled Acetic Acid 0.25% opened and not dated. The bottle was also leaking. 1 partial bottle of Hydrogen Peroxide Solution 32 oz opened and not dated. Observation on 9/22/25 at 3:00 PM of the medication storage room revealed the following medication administration supplies were expired: 6 Central line medication catheter dressing kits expired on the following dates:o 4 expired 8/31/25o 2 expired 6/30/25. In an interview on 9/23/25 at 3:11 PM, MA B stated, expired supplies should be discarded properly because they could make residents sick. She stated everyone that goes into the medication room or medication carts was responsible for discarding them. She stated using an expired dressing kit could cause skin problems or infections for the residents. In an interview on 9/23/25 at 3:13 PM, LVN A stated that expired supplies and undated medications should be given to the DON to be destroyed. She stated it is important not to use them after the expiration date, because they could cause allergic reactions or infections. She stated nurses, medication aides, and the DON was responsible for doing this. She stated using a central line dressing kit after it expired could cause an infection. In an interview on 9/23/25 at 3:18 PM, the ADON stated expired supplies, and undated medications should be discarded. She stated this was important because they could lose their effectiveness and for infection control. She stated nurses was responsible for discarding expired items and that she and the DON was responsible for following up on that. She stated an expired central line dressing kit could cause a resident to get an infection. In an interview on 9/23/25 at 3:20 PM, the ADM stated that expired supplies should be disposed. He stated this was important for safety reasons and the nurses, DON, and ADON was responsible for disposing of expired/undated items. He stated using an expired central line dressing kit could cause an infection and that opened Albuterol inhalers should be dated to determine how long they would be good. A record review of facility policy titled, Medication Storage in The Facility, dated June 9, 2025, reflected the following: Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed and disposed of. When the original seal of a manufacturer's container is initially broken, the container will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the container will be 30 days from opening unless regulations require different dates. All expired medications will be removed from active supply and destroyed.

Based on interview and record review, the facility admitted an individual with a positive PL1 without a complete PE and PASRR determination for 1 of 12 residents (Resident #1) reviewed for PASARR services. The facility failed to ensure a PASARR screening was completed correctly for Resident #1. Resident #1 was marked No for mental illness. This deficient practice could place residents at risk for not obtaining the services needed to treat their mental health diagnoses. The findings include:Record review of Resident #1's admission sheet, dated 09/21/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included anxiety (feeling of uneasiness or worry) diagnosed on [DATE], bipolar (extreme mood swings) diagnosed on [DATE] and depression (mood disorder that causes a persistent feeling of sadness) diagnosed on [DATE]. Record review of Resident #1's Quarterly MDS assessment, dated 09/02/2025, revealed Resident #1 had a BIMS score of 14, which indicated intact cognitive response. Resident #1's mood indicators were present which included little interest or pleasure in doing things, feeling down, depressed, or hopeless. The MDS also documented bipolar (extreme mood swings) and depression (mood disorder that causes a persistent feeling of sadness) as active diagnoses. Record review of Resident #1's care plan, dated 06/17/2025, noted the resident used an anti-depressant medication. The goal was Resident #1 Resident will not exhibit signs of drug related side effects or adverse drug reaction. The approach was Assess/record effectiveness of drug treatment. Monitor and report signs of sedation, hypotension (high blood pressure), or anticholinergic symptoms (group of side effects that block the action of the medication). Quantitatively (measure by quantity) and objectively document the resident's mood. Try non-pharmacological interventions before initiating drug therapy. Record review revealed Resident #1's PASARR Level I dated 08/02/2024 revealed that for the question that stated, is there evidence or an indicator this is an individual with a mental illness? was marked as no. During an interview with Resident #1 on 09/23/2025 at 09:33 a.m., Resident #1 said she was diagnosed with her mental disorder a long time ago. She said she had mental illnesses prior to coming to the facility. She said she does take medication for her mental illness, and she sees a phycologist. She also said that she had her own therapist that she was seeing before she entered the facility that she still sees. She said she did not get any other services for her mental health. She said she would like specialized services if she qualified for them. During an interview with SW on 09/23/2025 at 12:37 p.m., revealed that the SW had been trained on PASARR. She said the policy was that the facility had to have a PASARR for all residents before the resident was admitted . She said the hospital or the person doing the referral was responsible for completing a PASARR. She also said if the residents were positive the facility would be sent to LA. She said normally the CCM would ensure accuracy of the PASARR, but the facility did not have a CCM, so she had been ensuring the PASARR's was correct when a resident is admitted . She said she ensures they are correct by looking at the resident's medical records and their diagnosis. She said the process was to get the PASARR to review it, review the resident's medical records, review the diagnosis and if positive then send it to the LA. She said if a resident had a new diagnosis the facility would do a new PASARR, and the resident would be reevaluated by the LA to see if they qualify for specialized services. She said right now the ADM was responsible for submitting a positive PASARR to the LA. She said if the PASARR is not marked correctly the resident could miss services for which they are potentially eligible. She said normally the CCM monitored to ensure all residents had a PASARR, she said right now she thought it was the ADM. She said the PASARR specialist at corporate office would ensure competency of PASARR. She said when the new CCM starts, they would do the training with the PASARR specialist for cooperating office. She said she did not know why Resident #1's PASARR was marked incorrectly. During an interview with the ADM on 09/23/2025 at 12:48 p.m., revealed he had been trained on PASARR. He said the policy was the facility needed a PASARR filled out before a resident was admitted to the facility. He said the hospital or referring party was responsible for completing the PASARR. He said that the CCM was normally responsible for ensuring the PASARRs was correct but until the facility got a new CCM, he was responsible. He said that he had a PIP on PASARR to ensure they was completed correctly and sent to the LA when a resident was positive. He said the PASARR process was to get the PASARR, review the resident's hospital diagnosis list, medical records, and do family interviews to ensure the PASARR is completed correctly. He said usually the CCM was responsible for ensuring that PASARR was referred to the LA when a resident was positive. He said if a resident was positive before admission usually the LA would meet with the resident prior to admission if the PASARR was known to be positive before admission. He said he is responsible for ensuring competency in PASARR. He said he used the HHS learning portal for PASARR and had the SW review it. He said if the PASARR was not done correctly the residents would not get the necessary services they need. He said he did not know why Resident #1's PASARR was marked incorrectly. During an interview with the CPS on 09/23/2025 at 3:17 p.m., revealed that she had been trained on PASARR. She said that the policy was the facility needed a PASARR before a resident was admitted to the facility regardless of payor source. She said normally it would be the CCM who would be responsible for ensuring the PASARR was correct, however the facility did not have one, so the SW and ADM was doing the PASARRs. She said that she helped the facility if they needed it. She said that the facility would look at the resident's clinical records from the hospital and match it up to make sure the PASARR was correct. She said the process was to get the PASARR, review the clinical admission documents and talk to the family about the residents' mental and intellectual disabilities. She said if a resident was diagnosed after admission the facility would review the new diagnosis and see if the resident was positive for mental illness or Intellectual disability and if the resident was not positive at admission the facility would complete a new PASARR level one and then do the PASARR evaluation and submit it to the LA. After submitting to the LA, the LA would set up a meeting to evaluate the residents and see if the residents qualified for specialized services. She said the CCM was responsible for monitoring all residents who had a correct PASARR and then she would double check. She said the facility monitored the PASARRs through a TEAMS channel that had the admissions in an excel file that was reviewed daily. She said that not having the PASARR filled out correctly could affect PASARR specialized services for a resident that might be eligible. She said Resident #1's PASARR was not correct because the hospital did not mark the mental illness. She said she did not know why the previous PASARR coordinator did not catch the mistake. Record review of the PASARR positive resident list provided by the facility on 09/21/2025 revealed Resident #1 was not on the list. Record review of the PASARR Guidelines revised on 7/2023 revealed It is the intent of the facility to meet and abide by all State and Federal regulations that pertain to resident Preadmission and Screening Resident Review (PASARR) Rules. If admission is NOT Exempted Hospital Discharge or Expedited (Self/family/Doctor referral, Psych Hospital, Home, Home with Hospice, Homeless Shelter, Jail): The PL1 is FAXED to LIDDA/LMHA prior to admission The Social Worker/designee monitors the Simple LTC portal for the PE The Social Worker/designee Prints out the PE form, reviews the PE Recommendations with the IDT. PE to be printed and filed in the medical record. IDT will determine if the individual will or will not be admitted to the facility, The Social Worker/designee will Certify on the Simple LTC Portal that the facility can or cannot provide or support the Specialized Services recommended on the PE. The Social Worker/designee will schedule a PCSP Meeting and hold it within 14 days of admitting with the resident, LAR, RN, and LIDDA/LMHA in attendance The Social Worker or designee documents the PCSP Notes in Simple LTC Portal within 3 days of the meeting date. Notes are printed, reviewed by IDT, and filed in resident chart.LIDDA/LMHA will confirm their participation in the PSCP and Specialized Services agreed to within 5 business days of the meeting. Service Coordinator will conduct monthly visits and facilitate the initiation of LIDDA Specialized Services and the coordination of the resident's Specialized Services with the SPT. SPT develops, revises, implements, and monitors a transition plan, as necessary. Facility initiates Specialized Services by submitting requests to DADS within 20 days of PCSP Meeting IDT adds Specialized Service interventions to the Resident's Comprehensive Care Plan; a copy of the care plan is provided to the LIDDA/LMHA. Facility delivers Specialized Services IDT communicates, via the Simple LTC Portal, changes in condition or need for changes to Specialized Services. Important things to remember: Community/self-referrals- must have Pre-admission Screening prior to being admitted .In the event the facility identifies a change in the resident status related to ID/MI the facility will submit a Form 1012 to have the LA/LMHA conduct a PE.

Based on interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission as required for 1 (Resident #1) of 5 residents records reviewed for comprehensive assessments and timing. The facility failed to ensure Resident #1 did not have a completed admission/comprehensive MDS assessment within 14 days following his admission to the facility. This deficient practice could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #1's undated admission record revealed he was an [AGE] year-old male who admitted to the facility on [DATE]. His admitting diagnoses included: surgical aftercare following surgery on the genitourinary system (surgery on the organs in the urinary system), malignant neoplasm of bladder (bladder cancer), altered mental status, diabetes (high blood sugar), chronic kidney disease (gradual loss of kidney function), muscle weakness, high blood pressure, chronic pain, heart disease, and heart failure. Review of Resident #1's MDS summary screen in his EHR on 03/21/25 revealed Resident #1's admission MDS was still in progress. His MDS was last edited on 3/18/25. In an interview on 03/21/25 at 1:19 pm, the RRM stated that the CCM was responsible for completing MDS assessments. She stated she knew about Resident #1's MDS not being completed on time because she was working on it on 3/17/25 with the CCM before the CCM left early that day due to illness. She stated that she was responsible for training the MDSC and that she had already gone over the timelines for assessments with her. Additionally, she stated that the items that still remained for Resident #1's MDS needed to be completed on-site. In an interview on 03/21/25 at 1:28 pm, the ADM stated it was his expectation that MDS assessments be completed on time and that he is aware the admission assessments must be done within 14 calendar days of admission. He stated that the CCM was recently hired into that position, and before being promoted she was a floor nurse. He stated she left early on 3/17/25 due to illness and that might be why the assessment was not completed. He stated that the RRM helps out when needed. The ADM stated he was not sure what a negative outcome to the residents would be for late MDS assessments. During a telephone interview on 3/21/25 at 2:44 pm, the CCM stated that she originally started at the facility in August of 2024 and was promoted in February 2025 to the CCM. She stated she had prior experience in MDS but that was about 4-5 years ago, and she was having to learn all over again. She recalled doing an admission assessment on Resident #1 and did not recall why it was not completed. She stated that the due date would show up for her in the EHR. She further stated that she was trained by the RRM on timeliness, and she was aware of the 14-day timeframe. Review of the CCM's job description dated last revised 4/22/22 reflected under Essential Functions: Manages the RAI Process from resident admission to discharge to maintain clinical compliance and receive appropriate funding from Medicare, Medicaid and Managed Care pay sources. Completes MDS assessments according to the LTC Facility Resident Assessment Instrument 3.0 User's Manual (RAI) in a timely, accurate, documentation-supported and case mix optimized manner. The job description was signed by the CCM on 1/30/25. Review of the CCM Checklist dated last revised 2/01/21 reflected, the CCM completed the MDS Submission/Analyze/Validation training on 1/30/25. Review of the facility's current MDS Completion and Submission Timeframes policy revised July 2017 reflected the following: 1. The Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1 dated last revised October 2024, required OBRA Assessments for the MDS table reflected that the admission (comprehensive) assessment reference date is due no later than the 14th calendar day of the resident's admission (admitted + 13 calendar days).

Based on observation, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter received treatment and services for 1 of 5 residents (Resident #1) reviewed for indwelling urinary catheters. The facility failed to ensure Resident #1's urinary drainage bag tubing and bag were kept from touching and resting on the floor. This deficient practice could affect any resident with an indwelling urinary catheter and place them at risk of developing or increased UTIs. The findings included: Review of Resident #1's undated admission record revealed he was an [AGE] year-old male who admitted to the facility on [DATE]. His admitting diagnoses included: surgical aftercare following surgery on the genitourinary system (surgery on the organs in the urinary system), malignant neoplasm of bladder (bladder cancer), altered mental status, diabetes (high blood sugar), chronic kidney disease (gradual loss of kidney function), muscle weakness, high blood pressure, chronic pain, heart disease, and heart failure. Review of Resident #1's comprehensive care plan, dated 3/06/25, revealed it addressed Resident #1's urinary catheter. No intervention approaches were included to keep the urinary catheter securely in place. No risks or complications were listed. Additionally, the care plan addressed a problem start date of 3/10/25 for I pull off my urostomy and that staff will notify nurse if resident removes urostomy. Observation on 3/21/25 at 10:12 a.m., revealed Resident #1 resting in bed. The Foley Catheter drainage bag and tubing were resting directly on the floor on the right side of his bed. The drainage bag was nearly empty, but the tube closest to Resident #1's midsection had urine in it. The drainage bag was only visible if someone walked into the resident's room. The left side of his bed was against the wall closest to the door. An additional observation on 3/21/25 at 11:05 am, revealed Resident #1 resting in bed with the Foley Catheter bag inside a privacy bag resting directly on the floor on the right side of his bed. The surveyor attempted to obtain an interview with Resident #1, but he preferred to sleep. An interview on 3/21/25 at 1:32 PM with Resident #1's FM revealed that Resident #1 had recently experienced a decline and the FM was devastated they were having to meet with a hospice agency that day. The FM stated that Resident #1 had a urostomy as well as an indwelling catheter and for some reason the urostomy was not adhering to Resident #1's skin very well. The FM also acknowledged awareness of Resident #1 kicking the drainage bag off his bedside during his sleep and expressed a wish for that to be managed by the facility to keep the bag from being on the floor. An interview on 3/21/25 at 2:10 p.m., the DON revealed Resident #1's catheter drainage bag and tubing should not have been touching the floor because the bag and tubing would get contaminated and could cause infections. The DON stated that if the drainage bag was covered by a privacy bag and knocked to the ground staff could place the bag back onto the bed hook, but if the drainage bag is outside of the privacy bag, they would need to replace the drainage bag due to infection control issues. She stated that when colostomy/urostomy/catheter care is performed all supplies needed for the care should be brought into the room so that the staff are not having to leave and get other supplies before the care is completed. When asked if there was anything they could do to keep the catheter bag off the floor she stated she would need to get with the ADM to see what interventions he has used in the past. An interview on 3/21/25 at 11:19 a.m., CNA A revealed she had worked at the facility since August 2024. She stated during catheter care they were trained to make sure the catheter bag was toward the end of the bed when hanging them, and to ensure residents stayed clean by changing their briefs often and cleansing their skin. She stated that Resident #1 tended to kick his catheter bag onto the ground, sometimes he was calm but sometimes had outbursts like taking off all his clothes and talking like he saw people in his room who were not there. She stated the catheter bag was to be hooked onto the bed, not necessarily in a certain place, but just to keep it downward so it can drain/flow right. She stated it was always supposed to be covered with a privacy bag. If a privacy bag was not in there, they would get a new one from the supply room. She did not know if he tended to take his urostomy out or not. She is unsure if he toileted himself to have bowel movements. She stated that he was 1 of 2 residents on his hall and the CNAs rotate who work that hall so she does not have much experience with him but from the few times she had worked with him those were her observations. An interview on 3/21/25 at 12:01 p.m., the ADON revealed Resident #1 was admitted to the facility with a catheter and urostomy. She stated they had to change his catheter bag often, and that he recently had the urostomy placed, but for some reason it would not stick to his skin, and that when he sat himself up, it would come loose. She stated they contacted the doctor to look at it, and the doctor made a visit on 3/20 to observe the area on his skin, and he recommended a different kind of tape be used. She stated they had a urine panel come back on 3/19 but it said it was still pending the results of a UTI. She further stated they had to do frequent monitoring with him regarding the catheter bag, and if a CNA observes the bag on the ground, they were to tell the ADON, and if they found it on the floor, they had to replace it due to infection control procedures. She also stated that the privacy bag should be on there at all times. The ADON stated that there was not any one CNA in particular who had the most experience working with Resident #1 as the CNA's rotated working that hall. Record review of facility policy titled Catheter Care dated 12/2023 indicated: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. 1. Catheter care will be performed every shift and as needed by nursing personnel. 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. 3. Privacy bags will be changed out when soiled, with a catheter change or as needed.

Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 6 residents (Residents #1) reviewed for resident rights in that: The facility failed to ensure Residents #1's call light was within reach on 12/11/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. Findings included: Record review of Resident #1's admission record dated 12/11/24 documented a [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses which included: vascular dementia (a type of dementia where thinking abilities are affected because of reduced blood flow to the brain), generalized anxiety (constantly worrying about everyday things), lack of coordination (not being able to move your body smoothly and precisely, often resulting in clumsiness, stumbling, or jerky movement), and unsteadiness of feet (your feet feel like they are not stable or balanced, making it difficult to walk steadily). Record review of Resident #1's Quarterly MDS assessment, dated 11/02/24, revealed the resident had a BIMS score of 03, which indicated severe impairment. The MDS also revealed Resident #1 was dependent in the area of eating. Resident #1 required substantial/maximal assistance in the areas of oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Record review of Resident #1's care plan, dated 12/11/24, revealed Resident #1 was care planned for a fall r/t dementia and had an intervention of: Keep call light in reach at all times. Observation on 12/11/24 at 10:47 a.m., revealed Resident #1 was lying in bed and call light was placed on a chair out of her reach. Observation on 12/11/24 at 2:04 p.m., revealed Resident #1 was lying in bed and call light was placed on a chair out of her reach. During attempted interview on 12/11/24 at 10:47 a.m., Resident #1 was not able to be interviewed due to her cognitive level. During an interview on 12/11/24 at 11:20 a.m., CNA A stated that CNAs should make rounds at least every two hours. CNA A stated that CNAs should be looking to see if a resident needs assistance, ensuring call lights were within reach, and making sure all residents were comfortable. CNA A stated if a resident's call light was not within reach, then the resident could fall attempting to reach it or the resident would not receive assistance. During an interview on 12/11/24 at 3:30 p.m., the DON stated that anyone that entered the resident's room was responsible for ensuring the call light was within reach. The DON stated the purpose of a call light was for resident to notify staff when they need assistance. The DON stated if a resident's call light was not in reach, then they would not be able to call for assistance. The DON stated her expectation was that all resident's call lights were always within reach and answered timely so the resident can notify staff they need assistance. An interview with the ADM on 12/11/24 at 3:45 p.m., the ADM stated that all resident call lights should be always within reach. The ADM stated that it's everyone's responsibility to ensure call lights are within reach. The ADM stated that the resident needs would not be met promptly if the resident's call light was not within reach. Review of the facility's Answering the Call Light policy, revised March 2021, reflected, Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines . 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections 1 of 1 facility reviewed for infection control. The facility failed to clean and disinfect soiled shower chair in combined shower room A and B. The facility failed to clean and discard soiled wipes left on the floor in shower room C. This failure could place resident at risk of infection transmission. Findings included: Observation on 11/09/2024 at 10:30 AM revealed a combined shower room A and B shower chair had dried bowel movement on the top left seat and inside left corner of the shower chair. Observation on 11/09/2024 at 10:38 AM revealed shower room C had soiled wipes left on the shower room floor. Interview on 11/09/2024 at 11:44 AM with CNA A stated in combined shower room A and B it was dried bowel movement on the shower chair seat. CNA A stated in shower room C it was soiled wipes on the shower room floor. CNA A stated that she did not know who used the shower rooms last and it was expected to clean and disinfect the shower rooms after each use. Interview on 11/09/2024 at 12:23 PM with RN B stated she would not know who used the shower rooms last and did not clean the shower chair or pick up soiled wipes off the floor. RN B stated the expectations were for the CNAs to clean and disinfect the shower rooms after each use and in between residents. RN B stated it was unknown how long the shower chair was soiled or last used. RN B stated once wipes were used it was expected to be discarded in the personal hygiene trash bag ,tied up, and discarded. Interview on 11/09/2024 at 12:30 PM with the ADM stated it was expected for the shower rooms to be cleaned and disinfected after each use. The ADM stated it was unacceptable for the shower chair to be soiled and the soiled wipes to be on the floor of the shower rooms. The ADM stated not cleaning and disinfecting after each use could cause transmission of diseases and infections that may cause illness. Interview on 11/09/2024 at 1:24 PM with CNA C stated it was expected to disinfect and clean showers after each use. CNA C stated she had observed the shower chairs left uncleaned with feces. CNA C stated she could not recall the dates when the showers were left unclean. CNA C stated she would just clean and disinfect the shower room once she noticed it not being cleaned and disinfected. Interview on 11/09/2024 at 1:43 PM with CNA D stated when she would shower residents, she often found feces left on the shower chairs and not being cleaned. CNA D stated she would clean and disinfect the showers and report it to a charge nurse(no specific name given). CNA D stated she was not sure who was not cleaning the shower chairs after each use. CNA D stated it was expected that staff would clean and disinfect the showers after each use. Interview on 11/09/2024 at 2:09 PM with ADON stated it was the staff's responsibility to make sure after each shower use that the shower area was clean. The ADON stated it was expected for the shower rooms to be cleaned and disinfected after each shower use. Interview on 11/09/2024 at 2:40 PM with CNA E stated she gave her resignation to the ADON on 11/08/2024 by email. CNA E stated she could no longer work there because the shower chairs aways had feces left on them and it was not cleaned. CNA E stated she would clean once she noticed but never knew who had left the shower chairs not cleaned. CNA E stated it was expected for the shower rooms to be cleaned after each use. Record review of the facility's Infection Prevention and Control Policy dated July 2024 reflected An infection prevention and control program is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Record review of the facility's Bathrooms Policy dated revised February 2020 Bathrooms, including showers, sinks, commodes, etc, are cleaned and disinfected daily in accordance with out established procedures.

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for the facility's only kitchen reviewed for accidents and hazards. The facility failed to take temperatures of soup during meal service, which resulted with soup being served at 180 degrees. This failure could have placed residents at risk of being burned. Findings included: Record review of Resident #11's FS, downloaded from the Matrix on 10/4/2024, reflected a [AGE] year-old man, born on 09/23/1970, who's admittance date to the facility was on 05/31/2023. He was diagnosed with quadriplegia (which meant paralyzed from the neck down). Record review of Resident #11's Significant Event (Discharge) MDS, dated [DATE], reflected the resident had a BIMS Score of 14. A BIMS Score of 14 indicated the resident had no cognitive impairment. The resident was dependent for eating, which meant the helper provided all the effort of the activity. Interview on 10/1/2024 at 3:55 PM with Resident #11 revealed the food, served from the facility's only kitchen, had a chemical taste. He was worried other residents at the facility tasted it too but were not willing to say anything. Observation and interview on 10/2/2024 at 11:38 AM reflected the facility served Cream of Mushroom soup, as part of a state surveyor requested lunch test tray. The state surveyor was provided with a test tray at 11:38 AM from the facility's only kitchen. Some residents were observed having had soup on their trays, but soup was not provided on the state surveyor requested lunch test tray. A soup was requested from the kitchen, which was poured in a thermal bowl, immediately and directly from the kitchen's steamtable. The thermal bowl was an insulated serving dish meant to keep food warm longer and prevent fast cooling. The steamtable was a metal food serving apparatus designed to use water, and steam, to warm food from underneath to keep food at the minimum temperature of 135 degrees. Having received the Cream of Mushroom Soup, after the meal service and plating had already begun, it was evaluated for temperature. The temperature of the Cream of Mushroom soup was taken at 11:38 AM, with the use of a state issued thermometer, model TP301. The internal temperature of the Cream of Mushroom soup was 180 degrees. The Cream of Mushroom Soup was tasted for patentability, which resulted extreme heat and having burned this state investigators mouth and lips. The facility's SPT had been standing in proximity of the state surveyor having evaluated the lunch tray for temperature. The SPT observed the thermometer's results of 180 degrees and stated 180-degree soup could have burned a resident's tongue, roof of mouth, or cheeks. Interview with the KM, ADM, and the MDSC revealed the soup was 180 degrees. The further delivery of the soup stopped at that moment. The ADM and the MDSC were observed immediately having searched the dining room for effected residents in the facility. The KM stated she checked the temperature of the soup, on the steam table, prior to food service, and the temperature was 172 degrees. Of the foods tasted on the state surveyor test tray, none of the food had a chemical taste. Observations and interview on 10/2/2024 from 11:43 AM reflected the originally served Cream of Mushroom Soup was 160 degrees, interview with the SPT stated 160 degrees could have still caused burns to the mouth; 11:52 AM revealed the soup was 146 degrees; 11:54 AM revealed the soup was 145 degrees; 11:59 AM revealed the soup was 130 degrees. Observation on 10/2/2024 at 12:05 PM observed Resident #9 having requested soup, towards the end of the meal service; observed soup being served. Overheard the resident state the soup was not too hot. Interview on 10/2/2024 at 12:30 PM with KM revealed she, and her staff, immediately stopped serving the soup at 11:38 AM. She stated she added heavy whipping cream, and it had a temperature of 160 degrees at 11:43, but still had not served any more. She stated she continued to add heavy whipping cream until the soup had lowered to a temperature at 140 degrees. Interview and record review on 10/2/2024 at 12:45 PM with the KM revealed the facility had utilized the dial thermometers, which were not instant result thermometers; furthermore, the KM stated she did not wait the entire time to see the true temperature of the soup. She stated she removed the thermometer from the Cream of Mushroom soup, when the dial on the dial thermometer started to slow down, having suggested the soup may have been hotter than 172 degrees. The facility's food temperature chart, for the date of 10/2/2024, indicated the soup temperature was 172 degrees. Interview and record review on 10/2/2024 at 3:00 PM with the ADM revealed he performed a resident safety survey of the census of residents, which was 62 residents. The safe surveys, dated 10/2/2024, reflected the questions: 1. Was the soup at lunch today too hot for you? 2. Did you spill the soup from lunch on you today? * If either question was answered [yes,] resident would have been assessed by a nurse. Review of the safe surveys resulted in 20 residents having received soup on their lunch tray. Of the 20 safe surveys, no resident responded with a [yes] response. Only one resident, Resident #9, responded with a response other than [no.]: Question: Was the soup at lunch today too hot for you? Response: [No. It was warm, real warm but not too hot. It was good.] Question: Did you spill the soup from lunch on you today? Response: [No. I did not.] Observation and interview on 10/2/2024 at 4:55 PM with the KM manager revealed potato soup, sandwiches, and goulash (mixture of beef and macaroni) were being served for dinner. The KM sated the potato soup was cooked on the stove to an internal temperature of 170 degrees. The soup was poured into small sized individual thermal bowls, and she was instructed to monitor and not to serve any soup until it had an internal temperature of 140 degrees. Temperature observations taken, with the facility's own thermometer, of the sandwiches and goulash on the steam table were 145 degrees and 155 degrees, respectively. The steam table had three sections, each controlled by its own low, medium, and elevated temperature dial. A temperature was taken, with the state issued thermometer (sanitized) on an unused [NAME] on the steam table, set at the highest level. The temperature of the water, which produced steam, was 183 degrees. A soup was requested for evaluation at the beginning of meal service. The soup had the temperature taken at 5:05 PM, which resulted in 138 degrees. The soup was tasted for palatability, which resulted with an easily consumable temperature. Interview on 10/4/2024 at 3:26 with the ADON revealed there were parameters for the temperature for safe consumption of foods and beverages. 180-degree liquids consumed would result in burns to the mouth, tongue, and cheeks. Interview and record review on 10/4/2024 at 3:58 PM with the KM revealed the kitchen made sure the steam tables were set to an appropriate temperature and hot foods were not served too hot. She stated they took the temperatures about 10 minutes before meal service started and only checked the temperature the one time. If a resident would have asked for a food item after meal service began, it would have been served but the temperature would not have been taken again. If a resident consumed soup at 180 degrees, it could have scalded the mouth, lips, and tongue. The KM stated the kitchen staff should have checked the food's temperatures more than once during meal service, and thought the steam table, set on high, may have contributed to the 180-degree soup. Record review of the facility's food temperature chart reflected a spot for two annotations of the meals' temperatures. Interview and record review on 10/4/2024 at 4:25 PM with the ADM revealed the facility did not have a policy that indicated food's maximum levels of temperature. The facility's food temperature chart indicated optimum temperatures for entrees was 160-175 degrees. The facility's Food Holding and Service Policy, dated 2018, indicated food should be served at least 135 degrees or greater; adjust the temperature to account for the time the food would have been held prior to the service on the steam table and on the tray carts; take and record temperatures of all hot foods at the beginning, middle, and end of tray service. The ADM expected his dietary manager to follow policy and check the temperatures at the beginning, middle, and the end. A safeguard in place to prevent food from being served too hot was the policy and checks that were supposed to have occurred prior to food having been served. The failure of the facility's only kitchen to prevent service of food out of temperature range, was the kitchen having not checked a state surveyor test tray item like they would have for a resident. Record review of the facility's Hot Beverage Policy, undated, reflected hot beverages should have been served at appropriate temperatures to maintain palatability and reduce the risk of burns. The serving temperature of hot coffee was supposed to be 140 degrees or less. Coffee temperatures were supposed to be monitored to promote resident safety. Record review of the facility's Safety of Hot Liquids Policy, dated October 2021, reflected the potential from burns from hot liquids was considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. Residents with these, or other conditions, may have suffered from accidental burns and related complications stemming from thinner, more fragile skin, which may burn quickly and severely, and take longer to heal. Record review of the facility's incident and accident list, dated 8/1/2024 to 10/2/2024, did not result in the discovery of residents having been injured due to burns from hot coffee or hot food.

Based on observations, interviews, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safely for 3 of 11 residents (Resident #2, Resident #4, and Resident #5) reviewed for dietary services. The facility failed to ensure staff cleaned, or sanitized, their hands prior to meal service delivery. This failure could have placed residents at risk of the spread of infection. Findings included: Resident #2 Record review of Resident #2's FS, downloaded from the Matrix on 10/4/2024, reflected a [AGE] year-old woman, born on 9/14/1949, who's admittance date to the facility was on 4/28/2024. She was diagnosed with major depression (which was a mental condition characterized by depressed mood, loss of pleasure, or interest in life.) Record review of Resident #2's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 14. A BIMS Score of 14 indicated the resident had no cognitive impairment. The resident was independent with eating, which meant the resident completed the activity by herself. Record review of Resident #2's order summary report, downloaded from the Matrix on 10/4/2024, reflected an order, on 7/26/2024, for a regular diet. Record review of Resident #2's CP reflected an area of Problem area for weight loss, started on 8/14/2024, evidenced by refusal of breakfast. The Goal stated the resident would not have significant weight loss. The Approach, started on 8/14/2024, delegated nursing home staff to provide the resident a regular diet. Resident #4 Record review of Resident #4's FS, downloaded from the Matrix on 10/4/2024, reflected a [AGE] year-old woman, born on 3/08/1957, who's admittance date to the facility was on 05/11/2024. She was diagnosed with major depression (which was a mental condition characterized by depressed mood, loss of pleasure, or interest in life.) Record review of Resident #4's Quarterly MDS, dated [DATE] reflected the resident had a BIMS Score of 12. A BIMS Score of 12 indicated the resident had moderate cognitive impairment. The resident was independent with eating, which meant the resident completed the activity by herself. Record review of Resident #4's order summary report, downloaded from the Matrix on 10/4/2024, reflected an order, on 7/11/2024, for a low sodium/regular diet. Record review of Resident #4's CP reflected an area of Problem area for weight loss, started on 8/27/2024, evidenced by her ordered diet. The Goal stated the resident would not have significant weight loss. The Approach, started on 8/27/2024, delegated nursing home staff to provide the resident diet as ordered. Resident #5 Record review of Resident #5's FS, downloaded from the Matrix on 10/4/2024, reflected a [AGE] year-old man, born on 1/05/1963, who's admittance date to the facility was on 2/10/2024. He was diagnosed with Schizophrenia (which was a severe mental disorder having caused hallucination, delusions, and disorganized speech.) Record review of Resident #5's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 10. A BIMS Score of 10 indicated the resident had moderate cognitive impairment. The resident was independent with eating, which meant the resident completed the activity by himself. Record review of Resident #5's order summary report, downloaded from the Matrix on 10/4/2024, reflected an order, on 3/20/2024, for a regular diet. Record review of Resident #5's CP reflected an area of Problem area for failure to thrive, started on 9/20/2024, evidenced by medical diagnosis. The Goal stated the resident would not have exhibit signs of malnutrition. The Approach, started on 9/20/2024, delegated nursing home staff to provide the resident diet as ordered and provide selective menu. Observation on 10/4/2024 at 11:10 AM revealed CNA A having delivered food service tray to Resident #2. She was observed having taken a food tray from the service cart and having entered Resident #2's room without having sanitized her hands. She was observed exiting the resident's room without the lunch tray and did not sanitize her hands. Observation on 10/4/2024 at 11:15 AM revealed CNA A having delivered food service tray to Resident #4. She was observed having taken a food tray from the service cart and having entered Resident #4's room without having sanitized her hands. She was observed exiting the resident's room without the lunch tray and did not sanitize her hands. Observation on 10/4/2024 at 11:18 AM revealed CNA A having delivered food service tray to Resident #5. She was observed having taken a food tray from the service cart and having entered Resident #5's room without having sanitized her hands. She was observed exiting the resident's room without the lunch tray and did not sanitize her hands. Observation and interview on 10/4/2024 at 11:19 AM revealed the MDSC having approached CNA A and having held his face close to her ear. Interview with CNA A revealed the MNDSC reminded her to sanitize her hands before she served a lunch tray. She stated she had not sanitized her hands before she served the three residents listed above. She stated she was trained to sanitize her hands before each meal tray service but did not sanitize her hands until reminded by the MDSC . Interview on 10/4/2024 at 3:05 PM with the ADON revealed staff were supposed to sanitize their hands prior to delivering the resident food to reduce the spread of infection. Hand sanitizing was part of the facility policy. Staff were trained to know how to sanitize their hands. They used the hand washing skill check trainable item on the CNA competency check off sheet. A negative result of a resident ingesting germs could be an illness, having to unnecessarily take medications, or go to the hospital. A safeguard in place to make sure staff were sanitizing their hands in between each meal tray delivery was continued education and on-the-spot corrections. The failure for staff to sanitize their hands prior to serving meals trays falls on management. Interview on 10/4/2024 at 4:19 PM with the ADM revealed staff were trained, per facility policy, to sanitize hands prior to delivering residents their meal trays. Sanitizer dispensers were attached to the walls throughout the facility. The failure to meet the standard of infection control fell upon human error and honest mistakes. Upon request, the ADM was unable to present a policy that addressed hand sanitizing prior to each meal tray delivery . Record review of the facility's Handwashing/Hand Hygiene Policy, undated, reflected all personnel were supposed to follow hand washing and hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Staff were supposed to apply generous amounts of alcohol-based hand sanitizers to the palm of hand and rub together cover all surfaces of hands and fingers until hands were dry. Record review of the 2022 Food Code, Section 2-301; Hands and Arms. Food employees were supposed to keep their hands clean. Employees were supposed to clean their hands immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles.

Based on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections 1 of 1 facility reviewed for infection control. 1. The facility failed to keep stored linens covered. 2. The facility failed to follow EBP (Enhanced Barrier Precaution was an infection control intervention designed to reduce transmission of MDRO that employed targeted gown and glove use during high contact resident care activity) while having provided direct care for Resident #12. This failure could place resident at risk of infection transmission. Findings included: Linens Observation on 10/1/2024 at 6:57 PM revealed a small laundry cart in a facility hallway. The cart had two shelf levels and was made of plastic pipe. The laundry cart had blue meshing that covered the rear, the top, the left, and the right side. The piece of the blue meshing, designed to cover the front of the cart, was folded backwards over the top of the laundry cart. The front opening of the laundry cart was not covered, having exposed the stored linens, towels, and a box of open rubber gloves (size large) to dust, or other soiling agents. Facing the cart, exposed items were brown and blue towels on the lower left, white towels on the lower right, white towels, and white sheets on the upper left, and white linens and a box of open rubber gloves on the upper right. Resident #12 Record review of Resident #12's FS, downloaded from the Matrix on 10/4/2024, reflected an [AGE] year-old man, born on 6/20/1941, who's admittance date to the facility was on 2/10/2024. He was diagnosed with peripheral vascular disease (which was a disease that cause problems with the circulatory function in the extremities) and a bacterial infection. Record review of Resident #12's Quarterly MDS, dated [DATE] reflected the resident had a BIMS Score of 9. A BIMS Score of 9 indicated the resident had moderate cognitive impairment. Record review of Resident #12's order summary report, downloaded from the Matrix on 10/4/2024, reflected an order, on 7/23/2024, for EBP. The resident was ordered Cefepime Reconstitution Solution (antibiotic,) intravenous (inserted into a vein,) starting on 9/17/2024 till 10/4/2024. The resident was ordered Daptomycin (antibiotic,) intravenous starting on 9/13/2024 till 10/3/2024. Record review of Resident #12's CP reflected an area of Problem area for [General], started on 8/20/2024, evidenced by precautions for MDRO acquisition from wound. The Goal stated the resident would not exhibit signs of MDRO. The Approach, started on 8/20/2024, delegated nursing home post a sign on door referring to see a nurse before entering; Staff will wear PPE during high contact activities such as dressing, bathing/showing, transferring, providing hygiene, changing lines, incontinent care, wound care, and device care or use (central line.) Interview and observation on 10/1/2024 at 7:47 PM with Resident #12 revealed an EBP sign on his door. An EBP sign warned staff, and visitors, that the resident required targeted gown and glove use during high contact resident care activity. Resident #12 was in his bed resting comfortably, his head, at the 12 o'clock position, the bed was at a 60-degree angle. The resident had intravenous drugs through a connect line on his right arm, at the 9 o'clock position. During interview, he stated he was hungry and called the nurse's station for a snack. LVN A came to his room, where she was asked for a snack. She was observed leaving to retrieve Resident #12 a snack. Upon her return, she conversed with the resident about how he was doing. She was not wearing gloves; she was observed opening his snack and touching his tray top table. He voiced difficulty with having had enough slack on his call light button cord fully extend to reach his left hand, to the 3 o'clock position. LVN A was observed standing at his right side, at the 10 o'clock position, and was observed, with her bare hands, taking the resident's call light button cord from his left hand. She pulled the resident's covers down from his right midsection to his waist. With both hands, she was observed having attempted to untangle the call light button cord from being looped around the resident' right side support rail. In doing so, LVN A touched the resident's right arm, to get him to raise it. She had to untangle the residents call light button cord from his intravenous antibiotic line. She had to move the intravenous line with her bare hands, reverse loop the call light button cord for its entanglement, and then return the call light button cord to the residents left hand. Once completed the touched the resident's right arm to let him know he could lower it. She moved the resident's covers back to his right-side mid-section. LVN A was observed touching her face after the resident care was provided. Gloves and Protective gear were located outside of the resident's door. Interview on 10/2/2024 at 10:05 AM with LVN B revealed Resident #12 required EBP while having provided resident care in his room. He required EBP because he had an intravenous antibiotics and received wound care on his feet. Having described the observations from 10/1/2024 at 7:47 to LVN B, she stated LNN A staff should have used gloves and PPE to provide the described care. EBP was an intervention used to prevent infections, and keep any present infections at bay or, from worsening. Interview on 10/04/2024 at 3:26 PM with the ADON revealed the facility had a policy in place to address the requirements for residents with EBP and how to safely store linens. Residents on EBP had a sign on the door, to signify the resident had an order for EBP. The facility staff practiced EBP because those residents, who required EBP, were more susceptible to infections and their health could become compromised. In addition to the sign on their door, gowns, gloves, and face shields were available on the floor. As far as linens, the linen carts were supposed to be covered to protect them from dirt and germs. The failure for staff to follow EBP procedures and keep linens protected from dirt and germs fell upon staff oversight and the need for continued education . Interview on 10/4/2024 at 4:19 PM with the ADM revealed staff were trained per facility policy for EBP and safe storage of linens. Residents who required EBP had a sign on the door to say what level of PPE to use for what type of care and contact provided. The intent of the EBP was to stop the spread of infection and the intent of the policy for linens was to make sure they stayed clean. The failure to meet the standard of infection control fell upon human error and honest mistakes. Record review of a Center for Disease Control and Prevention certificate, dated 11/20/2023, indicated the ADM successfully completed the Nursing Home Infection Preventionist Training Course. Record review of the facility's Enhanced Barrier Precautions Policy, undated, indicated an order for EBP would have been obtained for residents with wounds and indwelling medical devices, such as central lines. Enhanced Barrier Precaution was an infection control intervention designed to reduce transmission of MDRO that employed targeted gown and glove use during high contact resident care activity. High-contact resident care activities included device care, or use of central lines. Record review of the facility's Soiled and Bedding Policy, dated April 2020, reflected clean linens were supposed to be protected from dust and soiling during storage to ensure cleanliness.

Based on observations, interviews, and record review, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident for 4 of 62 residents (Resident #1, Resident #2, Resident #6, and Resident #10) reviewed for accommodation of needs. The facility failed to ensure the BCLB, in Resident #1, Resident #2, Resident #6, and Resident #10's was fully accessible for its intended use. This failure could have placed residents at risk of having their needs gone unmet. Findings Included: Resident #1 Record review of Resident #1's FS, downloaded from the Matrix on 10/4/2024, reflected a [AGE] year-old woman, born on 5/10/1951, who's admittance date to the facility was on 7/16/2024. She was diagnosed with Dementia (which was a disease that affected memory, thought, and interfered with daily life.) Record review of Resident #1's Admission MDS, dated [DATE], reflected the Resident #1 had a BIMS Score of 9. A BIMS Score of 9 indicated the resident had moderate cognitive impairment. Resident #1 had no impairment in either upper extremity (shoulder, elbow, wrist, and hand). Resident #1 had impairment on one side of their lower extremities (hip, knee, ankle, and foot). Resident #1 was occasionally incontinent of bladder. Resident #1 was always continent of bowel. Record review of Resident #1's CP reflected an area of Problem area for ADL Functions, started on 7/25/2024 evidenced by toileting, with the assist of 1 person. The Goal stated the resident would not develop skin breakdown related to incontinence. The Approach, started on 7/25/2024, delegated nursing home staff to assist to toilet as needed. Interview and observation on 10/1/2024 at 10:15 AM in the room of Resident #1 revealed her in her room, on the bed. The room was clean, free from clutter, no odors of bowel or urine. Resident alert; orientated to the day, date, and current president. Observations revealed the call light system in Resident #'1 bathroom consisted of a call light box, approximately 6 inches tall and 4 inches wide, attached to the wall. The bottom of the call light box was attached to the wall approximately 28 inches (at its bottom) to 34 inches (at its top) from the floor. The call light box had a thin white cord (BCLS,) about the size of a cooked piece of spaghetti, having extended from the bottom center of the call light box towards the direction of the floor. The top portion of the call light box, top 2 inches, had a reset button. On the bathroom wall, next to the toilet, was metal handrail, approximately 3 feet long, and as wide as a tube of toilet paper. The metal handrail was attached to the wall parallel to the floor at approximately 30 to 32 inches from the floor. The handrail was directly covering 2 inches, 30th inch to the 32nd inch, of the call light box. The BCLS was tied in a knot on the metal handrail, having resulted in a U-shaped loop. Resident #1 stated she had tied the BCLS in the knot around the metal bar because it was easier to push the U-shaped string configuration (the loop) downwards, with her hand and forearm, to call for assistance. From the seated position, and without the knot being tied (the loop), she had difficulty pinching the BCLS with two fingers and pushing the string downwards, because she had no leverage. She had not stated anything to staff. Having learned the BCLS was intended to be used if lying on the floor, she felt she would not have been able to reach it as it was tied in a knot. If she were to fall on the floor, and not have been able to reach the BCLS, she would have been uncomfortable, scared, and helpless. She then felt like she needed an accommodation to be able to use the call light system for both sitting on the toilet or lying on the floor. Interview on 10/1/2024 at 1:21 PM with the ADM revealed the facility had a system in place to identify and correct deficiencies in each resident's room. The practice in place was the use of a visual checklist used when having conducted daily [Angel Rounds.] Angel Round checklists directed staff to check specific items in each resident's room. The Angel Rounds checklists were kept on file if they contained information on needed repairs. The ADM stated it was the ADON's responsibility for the resident's room in question. Upon request, the ADM was unable to provide recent copies of the conducted Angel Rounds. Interview on 10/1/2024 at 1:29 PM with the ADON revealed she was the staff member who performed Angel Rounds for the resident's room in question. She stated she had utilized the Angel Rounds checklist. She stated she did not perform Angel Rounds today, 10/1/2024, yesterday, 9/30/2024. The ADON stated she utilized the Angel Rounds Checklist the last time she performed Angel Rounds, which was sometime last week. She put the Angel Round Checklist on the ADM's desk. Interview on 10/2/2024 at 10:45 AM with the SW revealed she had not previously been informed of a need for an accommodation for Resident #1's call light button. She stated she would speak to Resident #1 and address any accommodation she may have needed. Interview and observation on 10/3/2024 at 11:01 AM with the SW revealed Resident #1 had been moved to a new room. Observations in the bathroom in Resident #1's new room revealed the metal handrail, same as in the description on 10/1/2024 at 10:15 AM, had been raised on one end, and no longer blocked the call light box at the level of 30 to 32 inches from the floor. The metal handrail, having been raised on one end, uncovered a BCLB at the middle section of the call light box, 30 to 32 inches from the floor. The call light box had a button to press, from the seated position, and cord to pull, from lying on the floor. With the assistance of the SW, the BCLB and the BCLS were checked for function and the accommodation resulted with both having worked correctly. Observation and interview on 10/3/2024 at 11:20 AM revealed the ADM and the MNTD having entered Resident #1's new room to have investigated the metal handrail having blocked the BCLB. The ADM stated he would gather a list of rooms in the building where the metal handrail blocked the BCLB of the call light box. Interview on 10/3/2024 at 12:57 PM with the ADM revealed the metal handrails interfered with resident's reaching the BCLB in an isolated number of rooms, which were 10. Record review of highlighted names on the facility's room roster, dated 10/3/2024, designated rooms C1, C3, C4, C5, C6, C7, C8, C9, C10, and E1 all had metal handrails that obstructed the call light system BCLB. He, and the MNTD, had been working to address the concern of inaccessibility. The facility's Call Light Policy was requested. Resident #10 Record review of Resident #10's FS, downloaded from the Matrix on 10/4/2024, reflected a [AGE] year-old woman, born on 9/09/1948, who's admittance date to the facility was on 4/14/2023. She was diagnosed with pain in the right arm and lack of coordination. Record review of Resident #10's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 11. A BIMS Score of 11 indicated the resident had moderate cognitive impairment. Resident #10 had no impairment in either upper extremity (shoulder, elbow, wrist, and hand). The resident had no impairment in either lower extremity (hip, knee, ankle, and foot). The resident utilized a walker for mobility. The resident was independent for toileting hygiene and toilet transfer, which meant the resident completed the activity. The resident was occasionally incontinent of bladder. The resident was occasionally incontinent of bowel. Record review of Resident #10's CP reflected an area of Problem area for falls, started on 9/24/2024, evidenced by weakness. The Goal stated the resident would have remained free from injury. The Approach, started on 9/4/2024, delegated nursing home staff to encourage call light use and always keep the call light within reach. Observation and interview on 10/4/2024 at 10:17 AM with Resident #10 revealed her lying in her bed under her covers. Room was free from odors and clutter. She ambulated with her walker to the restroom and used the toilet on her own. The metal handrail in the bathroom was covering the call light box and the BCLB. She stated the metal handrail posed difficulty having tried to press the BCLB; instead, she had to pinch and push the BCLS downward. Her toilet seat was raised and the angle to having pinched and pushed the BCLS from the sitting position, with her fingertips, was difficult. There was only a 1/2 to 3/4 inch gap between the metal handrail and the BCLB. It was not readily identifiable. To operate the BCLB on the toilet while seated, this investigator had to extend their hand straight out palm facing down, tilt the hand (thumb side down) 90 degrees, lower the hand by raising the elbow, insert the fingertips in the 1/2 to 3/4 inch gap, and feel for the button to press it. Resident #2 Record review of Resident #2's FS, downloaded from the Matrix on 10/4/2024, reflected a [AGE] year-old woman, born on 9/14/1949, who's admittance date to the facility was on 4/28/2024. She was diagnosed with Major Depression (which was a mental condition characterized by depressed mood, loss of pleasure, or interest in life.) Record review of Resident #2's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 14. A BIMS Score of 14 indicated the resident had no cognitive impairment. The resident had no impairment in either upper extremity (shoulder, elbow, wrist, and hand). The resident had no impairment in either lower extremity (hip, knee, ankle, and foot). The resident utilized a walker for mobility. The resident required partial/moderate assistance with toileting and toilet transfer, which meant the helper provided less than half the effort while the resident completed the greater portion of the activity. The resident was occasionally incontinent of bladder. The resident was occasionally incontinent of bowel. Record review of Resident #2's CP reflected an area of Problem area for falls, started on 8/14/2024 evidenced by poor balance. The Goal stated the resident would remain free from injury. The Approach, started on 9/30/2024, delegated nursing home staff to always keep the call light in reach; and a Problem area for call lights, started on 10/2/2024 evidenced by non/compliant use. The Goal stated the resident would have begun to use the call light when she needed assistance. The Approach, started on 10/2/2024, delegated nursing home staff to educate risk versus benefit, make sure call light was in reach, and to respond promptly. Observation and interview on 10/4/2024 at 10:17 AM with Resident #2 revealed her lying in her bed under her covers. Room was free from odors and clutter. She ambulated with her walker to the restroom and used the toilet on her own. The metal handrail in the bathroom was covering the call light box and the BCLB. She stated the metal handrail, which covered the bathroom call button, made pressing BCLB difficult; instead, she had to pull the BCLS downward with her fingers. She stated the angle of having pulled the string from the sitting position was difficult. To operate the BCLB on the toilet while seated, this investigator had to extend their hand straight out palm facing down, tilt the hand (thumb side down) 90 degrees, lower the hand by raising the elbow, insert the fingertips in the 1/2 to 3/4 inch gap, and feel for the button to press it. Resident #6 Record review of Resident #6's FS, downloaded from the Matrix on 10/4/2024, reflected a [AGE] year-old man, born on 6/05/1967, who's admittance date to the facility was on 3/10/2021. He was diagnosed with acquired absence of left leg below knee (which was an amputation of his lower leg,) and lack of coordination. Record review of Resident #6's Quarterly MDS, dated [DATE], reflected the resident had a BIMS Score of 9. A BIMS Score of 9 indicated the resident had moderate cognitive impairment. The resident had no impairment in either upper extremity (shoulder, elbow, wrist, and hand). The resident had no impairment in either lower extremity (hip, knee, ankle, and foot). The resident utilized a wheelchair for mobility. The resident was independent with toileting and toilet transfer, which meant the resident completed the activity. The resident was always continent of bladder. The resident was always continent of bowel. Record review of Resident #6's CP reflected an area of Problem area for transfer self and falls, started on 7/24/2024 evidenced by below/knee amputation. The Goals stated the resident would have safely transferred self independently and remained free from injury. The Approaches, started on 7/4/2024, delegated nursing home staff to have encouraged resident to use the call light and to have kept the call light in reach. Observation on 10/04/2024 at 10:35 AM revealed Resident #6 in his room in his wheelchair. Room was free from odors and clutter. He stated he was able to ambulate with his wheelchair to the restroom and used the toilet on his own. The metal handrail was not blocking the call light box's BCLB. He realized at that time, that the support railing had been removed from his bathroom. There was fresh spackling compound, moist to the touch, in two spaces that were congruent with where the metal handrails were affixed to the wall in the other affected rooms. He stated he did not use the BCLS from inside his bathroom frequently, but remarked the BCLB was inaccessible because the bar was in the way. He stated he could pull the string with ease. Interview on 10/4/2024 at 1:13 PM with the MDSC revealed he was unaware the metal handrails could have impeded a resident's ability to call for help from in the bathroom. The MDSC, having then known about the positioning of the call light box and the metal handrail, stated the call light box was in a bad position on the wall. He stated the position of the metal handrail, which covered the BCLB, was in the most effective placement for the resident safety. The call light systems, in those isolated bathrooms, had not provided their intended function. Resident might not have been able to call from help. The MDSC stated there was a plan in place to address the remaining 8 resident rooms affected. Interview on 10/4/2024 at 1:30 PM with the ADM revealed the handrails, originally having blocked 10 resident BCLBs (corrected having left only 8) were already affixed to the wall when the new the call light system was replaced in 2022. Two had been corrected, that left 8 resident rooms. The old call lights were like a light switch on a wall and a split ring, like that on your car keys, led a string to the floor. The new call light system, with the BCLS and the BCLB, were installed by their local building safety company at the existing power source location on the bathroom wall, behind the metal handrail. The local building safety company did not bring the affected rooms to the attention of the facility administrator. He had never had a complaint from a resident, a health survey, or a LSC survey. The Angel Round checklist, created by the administrator, did not provide the staff instruction to check the resident's bathroom, but the checklist was meant for the staff to check the call button, which protruded from the wall on a long cord. The affected resident rooms, which were 10 then 8, were not viewed as a physical environment problem. The call light box was there and there was a BCLS. The Administrator thought the functionality of the call light system was adequate and the residents simply had the option to push the BCLB or pull the BCLS. Any reason to change the configuration would have been made as a case-by-case basis for the resident. There was no confirmation, from the ADM, of any resident assessment to have ascertained the unincumbered use of the BCLB or BCLS. Even though the ADM stated the change would have only been made on a case by case basis, the facility had already begun to fix the configuration so residents could use both the BCLB and the BCLS. Record review of the facility's Angel Round Checklist, undated, reflected a line item. The line item indicated to make sure the call light was within reach, untangled, with clip present. Record review of the facility's Call Light Policy, dated December 2009, reflected a resident who had disabilities that make use of the facility's communication system inaccessible, alternative auxiliary aids, or services are provided to meet the resident's needs as identified in the resident's assessment or the plan of care. Record review of U.S. Access Board, Guide to the ADA Accessibility Standards, Chapter 6: Toilet Rooms (access/board.gov), viewed on 10/5/2024, indicated side grab bars for toilet rooms must be 33 inches to 36 inches at the top of the gripping surface. Any projecting object must be located at least 12 inches above and at least 1.5 inches from the bottom, and ends, of grab bars, so that the reach and use of grab bars was not impeded. The 1.5-inch clearance between the grab bar and wall was not a minimum but an absolute dimension to prevent entrapment.

Based on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for the 1 of 15 residents (Resident #12) reviewed for a safe and comfortable environment. The facility failed to report maintenance issues to the MNTD and make repairs to a broken toilet seat in Resident #1's bathroom. This failure could have placed the residents at risk of falling from skin breakdown or falling from the toilet. Findings Included: Record review of Resident #1's FS, downloaded from the Matrix on 10/4/2024, reflected a [AGE] year/old woman, born on 5/10/1951, who's admittance date to the facility was on 7/16/2024. She was diagnosed with dementia (which was a disease that affected memory, thought, and interfered with daily life.) Record review of Resident #1's Admission MDS, dated [DATE], reflected the resident had a BIMS Score of 9. A BIMS Score of 9 indicated the resident had moderate cognitive impairment. The resident had no impairment in either upper extremity (shoulder, elbow, wrist, and hand). The resident had impairment on one side of their lower extremities (hip, knee, ankle, and foot). The resident was occasionally incontinent of bladder. The resident was always continent of bowel. Record review of Resident #1's CP reflected an area of Problem area for ADL Functions, started on 7/25/2024 evidenced by toileting, with the assist of 1 person. The Goal stated the resident would not develop skin breakdown related to incontinence. The Approach, started on 7/25/2024, delegated nursing home staff to assist to toilet as needed. Interview and observation on 10/1/2024 at 10:15 AM in the room of Resident #1 revealed her in her room, on the bed. The room was clean, free from clutter, no odors of bowel or urine. Resident alert; orientated to the day and date; current president. Resident #1 complained about the toilet lid, and that it had broken in August, and it took about a week to fix. It was fixed up until a week ago, 9/22/2024, when it became loose; it came off for good 2 days ago, 9/29/2024. The toilet seat was observed removed and resting up against the wall under the bathroom sink. The back of Resident #1's toilet, where the seat was supposed to have been attached, had two grey protruding plastic attachments (male connectors), which were about 1/2 inch high and the diameter of a quarter. The loose toilet seat had two connections on its underside (female connectors) underneath the spot where a sitting resident's upper buttock would have been. Having used to toilet in its current state of repair, use caused discomfort on her upper left and right buttock area. She stated she told her nurse about the broken seat. The nurse stated she would put in a work order. Interview on 10/1/2024 at 11:25 AM with LVN C revealed staff were able to submit work orders for broken items through the maintenance QR code submittal process. Staff simply scanned a QR code (a small picture on a piece of paper made up of dots and dashed, shaped like a square, that directed the user to a centralized computer program) at the nurse's station and wrote a description of the broken item. The MNTD received the alerts . Interview and observation on 10/1/2024 at 1:04 PM with the MNTD revealed there was a QR code system, with TELS (an internet based technology for building maintenance records) to report maintenance issues. The staff scanned a QR code, located at the nurse's station, and described the error by having written a brief description. The MNTD read the workorder on the computer and fixed the issue; safety repairs took priority. Observation at the nurse's station revealed an 8 inch by 10 inch piece of paper with a maintenance request QR code. The MNTD printed out the work orders that were made, or in progress. Record review of list did not reveal a work order had been entered for the broken toilet seat in Resident #1's bathroom. The MNTD stated management, and department heads, conducted daily rounds of the facility and rooms, to identify maintenance needs. The process was called Angel Rounds (management room visits to check their condition.) Interview on 10/1/2024 at 1:21 PM with the ADM revealed each Angel Round covered a specific area of the facility. Angel Round checklists were kept on file if they contained information on needed repairs. The ADM stated the ADON was assigned the specific area. Upon request, the ADM was not able to produce a completed Angel Round checklists. Interview and observations on 10/1/2024 at 1:29 PM with the ADON revealed she was a staff member who performed Angel Rounds at the facility. Observations revealed the ADON walking with this state investigator and pointing out the rooms she checked. The ADON pointed at Resident #1's Room. She did not perform Angel Rounds today, 10/1/2024, yesterday, 9/30/2024, and did not recall further. The ADON stated she utilized the Angel Rounds Checklist the last time she performed Angel Rounds, which was sometime last week. She put the Angel Round Checklist on the ADM's desk . Observations on 10/1/2024 at 1:53 PM revealed Resident #1's toilet lid still broken off. Interview and observation on 10/1/2024 at 8:00 PM with Resident #1 revealed she told staff earlier in the day, 10/1/2024, about the toilet seat and it was fixed. Observations revealed the toilet seat was connected to the toilet. She was happy and stated the plastic pieces that stuck up from the toilet were not pressing up against her skin like before. Interview on 10/4/21024 with the ADM at 2:20 PM revealed the facility used a QR code to report maintenance issues to the MNTD. He expected his staff to report the work, per policy, so the MNTD could make the repair. A system in place to catch maintenance issues was Anger Rounds, which specifically talked about the toilet functioning correctly. He was not aware that the resident had experienced discomfort while having utilized the toilet, due to the 1/2 inch raised; quarter in diameter raised plastic attachments pressing into her skin. The failure to identify the broken toilet seat fell upon the ADM for not following up and having ensured the Angel Rounds were performed correctly . Record review of the facility's Maintenance Service Policy, dated November 2021, reflected the MNTD was responsible for having maintained the building, the grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel included having maintained plumbing fixtures. Record review of the Direct Supply's TELS work order list, dated 10/1/2024 and signed by the MNTD, reflected open and in-progress work orders. Review of the work order list did not reveal a work order for Resident #1's toilet seat repair. Record review of the facility's Angel Round's Checklist, undated, indicated staff were supposed to check for sink and toilets to have been in good repair.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure that the cucumbers in the facility's refrigerator, were placed in a sealed container according to guidelines. The facility failed to ensure that the dented cans were removed and separated from the other canned food. The facility failed to ensure that the dust on the air filters and air vents in the kitchen were cleaned. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. Findings Included: Observation of the kitchen on 08/13/2024 at 9:05 AM, revealed that inside the large refrigerator were 6 cucumbers in a box on a shelf. They were not in a sealed container and were not dated. In the dry storage area, there were 2 dented cans of Vegan Salad Sliced Beets on the shelf with the other canned goods. There were 7 air vents in the kitchen that were dusty including 2 air vents above the food preparation area. There was 1 air vent above the dishwashing area that had a considerable amount of dust on the exposed air filter. In an interview with [NAME] F on 08/14/2024 at 1:30 PM, she stated that she was responsible for storing the canned goods in the dry pantry area. She stated that she did not observe the 2 dented cans of Vegan Salad Sliced Beets on the shelf when she was restocking the canned goods. She stated that the dented cans are to be placed in a separate area for the dented cans. She stated that a resident possibly ingesting foods from a dented can could cause the resident to become sick and ill. In an interview with [NAME] G on 08/14/2024 at 1:37 PM, she stated that she had been told by someone that it was okay to keep the vegetables in the box in the refrigerator. She could not recall who told her the information but stated that she would correct the error and place the 6 cucumbers in a sealed container and label and date the container. She stated that the risk of the 6 cucumbers being in the refrigerator in an open box on the shelf could be cross-contamination and could lead to air-borne illnesses for the residents. In an interview with the Maintenance Director on 08/15/2024 at 1:42 PM, he stated that the general cleaning of the kitchen would be the responsibility of the staff in the kitchen including the cleaning of the air filters and air vents. He stated that he did not have a cleaning log that recorded the cleaning and sanitization of the air filters and air vents in the kitchen. He stated that the risk of the dust being on the air filters and air vents in the kitchen above the food preparation and dishwashing areas could be that the dust from the air filters and vents could land on the food that the residents eat and can make them sick. In an interview with the Dietary Manager on 08/15/2024 at 1:55 PM in the presence of the Maintenance Director, she stated that the Maintenance Director was responsible for the cleaning of the air vents in the kitchen. She stated that it was her responsibility to ensure that the air vents and air filters in the kitchen remained free of any dust. She stated that her staff can also notify her if the air filters and air vents needed to be cleaned and then she would notify the Maintenance Director to request for the air filters and air vents in the kitchen to be cleaned and sanitized. She stated that the kitchen did not have a log or schedule for cleaning the air vents in the kitchen. She stated that it is the responsibility of everyone in the kitchen to ensure that there are not any dented cans in the dry storage area with the other canned goods. She stated that she has a routine of checking the dry storage area to ensure that everything is labeled, dated and that there were not any dented cans on the shelf with the other canned goods. She stated that she was absent from work the day before and had not checked the dry storage area upon her return. She stated that the 6 cucumbers in the open box in the refrigerator should be placed in a sealed container and labeled and dated. She stated that the risks for there being dust on air filters and vents, the 6 cucumbers in the open box in the refrigerator, and the dented cans being stored with the other canned goods could be cross-contamination, dust getting in the food that is prepared for the residents and has the potential for air-borne illnesses for the residents who eat food that is prepared in the kitchen by staff. Interview with the Maintenance Director on 08/15/2024 at 2:06 PM, he stated that the cleaning of the air vents in the kitchen are his responsibility. He stated that if the air vents needed to be painted, they would be his responsibility as well. He stated that the air vent above the dishwashing area does not have a vent cover and is designed to have an exposed air filter. He reported that the changing of the air filter is his responsibility and the air vents and air filters should be cleaned at least twice a month. In an interview with the Administrator on 08/15/2024 at 4:55 PM, he stated that the Dietary Manager is responsible for overseeing the staff in the kitchen. He stated that the cleaning of the air vents is the responsibility of the Maintenance Director, but it is the responsibility of the staff in the kitchen to notify the Maintenance Director to clean the air vents in the kitchen. He stated that the dented cans should be separated from the other cans in the kitchen to prevent the risk of sickness and illness of the residents in the facility. The Administrator stated that the vegetables in the kitchen should be stored in a sealed container and labeled and dated to prevent the risk of sickness and illness of the residents or anyone that eats food that comes from the kitchen. Record review of the facility's undated policy, Kitchen Sanitization and Cleaning Schedules, revealed All surfaces, including floors, walls, storage shelves, prep tables, trash cans, and all food contact surfaces must be routinely cleaned and sanitized. Ceilings, vents, light fixtures, pipes, and any other potentially contaminated surface will be cleaned as needed. All equipment must be thoroughly washed and sanitized between uses, in different food preparation tasks and anytime contamination occurs or is suspected. Food and Storage Sanitation .Dented or otherwise damaged cans will not be used. Once identified, dented cans should be stored in a separate area of the storeroom to be returned to vendor or discarded. Record review of the facility's August 2024 Weekly Cleaning Schedule revealed that there were not any cleaning schedule entries that included the cleaning the air vents in the kitchen. Record review of the facility's August 2024 Weekly Cleaning Schedule revealed that in the Item column there was a handwritten entry All Vents. In the Responsible Party column, there was a handwritten entry, All Staff. The Week 1 and Week 2 columns were empty and Week 3 column, there was a handwritten entry with 2 staff members initials, [Cook F and [NAME] G] Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observation, interview, and record review the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for 1 of 8 residents (Resident #18) reviewed for ADLs. The facility failed to ensure Resident #18 received a bed bath as scheduled and upon request and failed to assist her out of bed when she requested to attend a Resident Council meeting. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are import in their life and decrease their quality of life. Findings included: Record review of Resident #18's Face Sheet dated 8/14/24 revealed she was a [AGE] year-old female readmitted to the facility on [DATE]. Record review of Resident #18's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 15 indicating she was cognitively intact. She was completely dependent on staff for bed to chair transfers and required maximal assistance for bathing. Her diagnoses included hypertension (high blood pressure), diabetes, anxiety and depression. Record review of Resident #18's Care Plan revealed an entry dated 7/8/24 that reflected: she required extensive assistance with 2 people for transfers, and extensive assistance by 1 person for personal hygiene. Goal: Will maintain a sense of dignity by being clean, dry, odor free and well-groomed over next 90 days. Approaches included, .2) Staff will give -shower, shave, oral, hair, nail care per schedule and prn . 3) Assist with dress according to climate, monitor appearance .5) Assist with transfer as needed . During an observation and interview on 8/13/24 (Tuesday) at 12:35 PM, Resident #18 was observed sitting up in her bed eating lunch. Resident #18 stated she sometimes felt like staff did not want to do their jobs. She stated, This last Saturday (08/10/24) I asked for a bed bath 4 times. The first time she said, 'Oh ok, let me finish with this other person and I'll be right back' and she never came. I called again, she said, 'Oh ok, I'll be right back'. It happened 4 times then she left. The last call was around 10:00 PM. The night aide came and said, 'we don't do baths at night' and left. Resident #18 stated she had an outing planned with her family the next day and really wanted to be bathed before she left. She stated it took a while on Sunday, but they finally bathed her before she left. She stated her bath days were Tuesday, Thursday, and Saturday in the evening. She was unable to recall the name of the Aide. Resident #18 stated, This past Tuesday, they came around and informed me there was a Resident meeting at l1:00 AM. I told the Aide at 10:00 AM I wanted to go. I missed the last meeting because I couldn't get help. I waited and called; they never got me up. I just watched the clock, 11:00, 11:15, 11:30-nothing. I want to tell them not to even tell me they are happening if I can't go. What's the point in telling me if you won't help me get up and go? It made me feel like I'm not worth it, like I'm not worth their time. Why even tell me if you won't get me up? Resident #18 stated she required a mechanical lift for transfers to her chair as she was unable to use her legs. Resident #18 stated she had complained to facility management about the incidents and thought she had told the DON. She did not know whether they had addressed her issue. In an interview on 8/14/24 at 1:07 PM, CNA A stated she had worked the 6:00 AM to 2:00 PM shift and had worked at the facility for two months. She stated she regularly worked with Resident #18 and had worked the previous week. CNA A stated she did not recall Resident #18 asking to get up for the Resident Council meeting or being asked to get her up. She stated Resident #18 usually wanted to get up after lunch for therapy. In an interview on 8/15/24 at 7:45 AM, Resident #18 stated she had not heard anymore from facility management and had also missed her scheduled bath on 8/13/24. She stated she had not received a bath since Sunday, 8/11/24. She stated she asked the Aide twice on 8/13/24 for her bath and was told she did not have enough help and was working two halls that day. She could not recall the name of the aide. She stated she was not offered a bath on 8/14/24 either. Resident #18 stated she prefers evening baths because she gets up daily for rehab after lunch and that takes a while. She stated, I guess we'll see if I get one tonight. She stated she has had so many problems and just wanted them addressed. In an interview on 8/15/24 at 8:03 AM, CNA B stated she cared for Resident #18 and had been assigned to her hall on 8/13/24. She stated she knew Resident #18 got up after lunch for rehab and was due for a bath that evening. When asked about her scheduled bath for Tuesday 8/13/24, CNA B stated she did not know why she did not do it. She stated they were down an aide that evening, but she should have done it. She stated they usually had enough staff to care for the residents and even had shower aides most of the time. She stated the risk for not getting bathed was you don't feel very good if you're not clean. CNA B did not recall whether she worked with Resident #18 the day of the last Resident Council meeting but stated residents had a right to get up whenever they wanted. During an interview on 8/15/24 at 8:42 AM, the Activity Director stated she had worked at the facility for 3 years but had just taken over as the Activity Director on 8/1/24. She stated there was a Resident Council meeting on 8/9/24. She stated she lets all the residents know on the day before and the day of Resident Council meetings by going room to room and handing out a paper letting them know the date and time of the meeting. She stated, if a resident was dependent and said they wanted to go, she would check with them and let the nursing staff know they would need assistance. She stated she would verbally alert the staff and offer to assist with resident transfers because she was a CNA and could help. She stated she also placed a paper with a list of dependent residents who expressed interest in attending the Resident Council meetings in a binder at the nurse's station that contained the staff schedule. The Activity Director stated she recalled telling Resident #18 about the meeting on 8/9/24 and recalled her saying she wanted to get up and go. The Activity Director stated she recalled making an aide aware but could not recall the name of the aide. She stated she did not assist with transfers that day because the meeting was in the morning and there was little time. She stated she noticed Resident #18 was not at the meeting but did not know what had happened. She stated residents often changed their minds about attending at the time of the meeting. She stated she thought she recalled Resident #18 complaining about missing the meeting and believed she had reported it to the Administrator but was not certain. She stated Resident #18 was the only one unable to attend that day. She stated the risk of failing to assist residents to meetings or other activities was emotional distress. She stated, If no one will get them up when they want to, can make them feel like, 'is it me, is it the staff?', if you don't communicate, they can think anything. The Activity Director stated she usually kept a copy of the lists provided and would look for the list used for the last Resident Council meeting. No list was located prior to the exit conference. In an interview on 8/15/24 at 9:30 AM, the ADON stated she had worked on 8/11/24 and recalled Resident #18 complaining that she had missed her bath on 8/10/24. She stated Resident #18 was upset because she had family coming and wanted her bath. She stated the aide was CNA C who told her Resident #18 had refused her bath 8/10/24. The ADON stated she did not follow up with Resident #18 to ask if she had, in fact, refused her bath because she was upset and they took care of her bath for her. She stated she had completed a grievance form on the matter. The ADON stated CNA C had resigned and no longer worked for the facility. She was not aware Resident #18 also missed her bath on 8/13/24 or the previous Resident Council meeting. The ADON stated risks for residents missing baths and activities included social and skin breakdowns, mental health decline and a spectrum of breakdowns. During an interview on 8/15/24 at 10:26 AM, the DON stated they had received complaints about missed baths and showers over a month ago and had added a shower aide to the schedule to assist with completions. She stated the shower aides provided a list at the end of the day of completed showers they were using to track. She stated the shower aides did not provide bed baths, but the assigned CNAs completed them . The DON stated she had heard from the ADON that Resident #18 had missed a bath over the weekend and the ADON had taken care of it. She stated Resident #18 had her and the Administrator's personal phone numbers to call if she had any concerns. She stated she was unaware Resident #18 had missed her bath again on 8/13/24. The DON stated they did have a shower aide that day but had to suspend her and send her home when they received a complaint about her which may have contributed to the situation. She checked her phone and stated she had not received any complaints. The DON stated she did not know about Resident #18 missing the Resident Council meeting the previous week. She stated Resident #18 had a history of not wanting to get out of bed and they had had a meeting with her about it, so she was disappointed to hear they did not get her up when she wanted to. She stated the risk of not getting residents bathed or out of bed as desired was it could diminish their dignity. During an interview on 8/15/24 at 12:14 PM, LVN D stated she worked the 6:00 AM to 2:00 PM shift and regularly cared for Resident #18. She stated she recalled the resident complaining to her after she missed the last Resident Council meeting. She stated she had complained after the fact. LVN D stated she was aware of the list provided by the Activity Director of residents who needed assistance to go to an activity and checked it daily. She could not recall whether she had noted Resident #18's name on the list for that day. LVN D stated she would typically assist with transferring residents out of bed when needed. She stated she attempted to find the aide to determine why she had not gotten her out of bed but did not recall who the aide was or what she was told on that day. LVN D stated Resident #18 had complained to her previously about missing baths but could not recall when it was but stated it had not been the current week. She stated Resident #18 received her baths on the evening shift. She stated the nurses were responsible for ensuring the baths were completed and were told in report when they were completed. She stated she had not heard anything about her missing any baths that week. She stated the risk to residents when not receiving baths or transfers as requested included pressure ulcers, poor hygiene, not having their voices heard, and depression. On 8/15/24 at 3:24 PM, an attempt to reach CNA C via telephone was unsuccessful. A voicemail message was left. No return call was received prior to facility exit. In an interview on 8/15/24 at 3:42 PM, LVN E stated she worked the 2:00 PM to 10:00 PM shift and regularly cared for Resident #18. She stated Resident #18 usually received bed baths on her shift and the aides reported to her when the baths were given. She stated her last bath should have been this week and she was not aware Resident #18 had missed her scheduled bath on 8/13/24. She stated Resident #18 did not complain to her about it. She denied asking her or the aide whether her bath had been done. LVN E stated the risk of missing baths was loss of dignity. LVN E stated she, herself, would not want to be around anyone if she missed a shower. She stated this was the resident's home and they deserved good treatment. During an interview on 8/15/24 at 3:48 PM, the Administrator stated he was very familiar with Resident #18, and she had his cellphone number to call or text with any complaints. He checked his phone and stated the last call he received had been in July and was related to staff taking too long to answer her call light. He stated he was away from the facility at that time but sent a staff member to check on her and had re-educated the staff about customer service after the incident. He stated she had made him aware of missing the Resident Council meeting. He stated he had been assisting another facility that day and came back and made evening rounds which was when she told him. He stated he told her he would personally ensure it did not happen again and would transfer her himself if needed. The Administrator stated he was not aware that had been the second time it had happened. He stated he did not know about the missed baths that had occurred on Saturday or Tuesday. The Administrator stated the risks to residents in these instances included decreased emotional status and pressure sores. He stated they generally followed up on resident complaints during QA meetings. He stated, with Resident #18, they were focused on ensuring she had been getting up for therapy, which had improved. Record review of the facility's policy titled, Resident Self Determination and Participation dated, Revised February 2021 reflected: Policy Statement: Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. Policy Interpretation and Implementation: 1. Each resident is allowed to choose activities, and schedule health care and healthcare providers, that are consistent with his or her interests, values, assessments and plans of care, including: a. daily routine, such as sleeping and waking, eating, exercise and bathing schedules. b. personal care needs, such as bathing methods, grooming styles and dress; . e. activities, hobbies, and interests . 2. In order to facilitate resident choices, the administration and staff: . b. gather information about the residents' personal preferences on initial assessment and periodically thereafter, and document these preferences in the medical record; c. include information gathered about the resident's preferences in the care planning process; and d. document and communicate any medical conditions or limitations that may inhibit or interfere with participation in preferred activities. 3. Residents are encouraged to make choices about aspects of their lives in the facility, including: . b. organizing and participating in resident groups; . 4. Residents are provided assistance as needed to engage in their preferred activities on a routine basis .

Based on interviews and record review, the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 8 residents (Resident #18) reviewed for self-determination. The facility failed to ensure Resident #18 received a bed bath as scheduled and upon request and failed to assist her out of bed when she requested to attend a Resident Council meeting. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are import in their life and decrease their quality of life. Findings included: Record review of Resident #18's Face Sheet dated 8/14/24 revealed she was a [AGE] year-old female readmitted to the facility on [DATE]. Record review of Resident #18's Quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 15 indicating she was cognitively intact. She was completely dependent on staff for bed to chair transfers and required maximal assistance for bathing. Her diagnoses included hypertension (high blood pressure), diabetes, anxiety and depression. Record review of Resident #18's Care Plan revealed an entry dated 7/8/24 that reflected: she required extensive assistance with 2 people for transfers, and extensive assistance by 1 person for personal hygiene. Goal: Will maintain a sense of dignity by being clean, dry, odor free and well-groomed over next 90 days. Approaches included, .2) Staff will give -shower, shave, oral, hair, nail care per schedule and prn . 3) Assist with dress according to climate, monitor appearance .5) Assist with transfer as needed . During an observation and interview on 8/13/24 (Tuesday) at 12:35 PM, Resident #18 was observed sitting up in her bed eating lunch. Resident #18 stated she sometimes felt like staff did not want to do their jobs. She stated, This last Saturday (08/10/24) I asked for a bed bath 4 times. The first time she said, 'Oh ok, let me finish with this other person and I'll be right back' and she never came. I called again, she said, 'Oh ok, I'll be right back'. It happened 4 times then she left. The last call was around 10:00 PM. The night aide came and said, 'we don't do baths at night' and left. Resident #18 stated she had an outing planned with her family the next day and really wanted to be bathed before she left. She stated it took a while on Sunday, but they finally bathed her before she left. She stated her bath days were Tuesday, Thursday, and Saturday in the evening. She was unable to recall the name of the Aide. Resident #18 stated, This past Tuesday, they came around and informed me there was a Resident meeting at l1:00 AM. I told the Aide at 10:00 AM I wanted to go. I missed the last meeting because I couldn't get help. I waited and called; they never got me up. I just watched the clock, 11:00, 11:15, 11:30-nothing. I want to tell them not to even tell me they are happening if I can't go. What's the point in telling me if you won't help me get up and go? It made me feel like I'm not worth it, like I'm not worth their time. Why even tell me if you won't get me up? Resident #18 stated she required a mechanical lift for transfers to her chair as she was unable to use her legs. Resident #18 stated she had complained to facility management about the incidents and thought she had told the DON. She did not know whether they had addressed her issue. In an interview on 8/14/24 at 1:07 PM, CNA A stated she had worked the 6:00 AM to 2:00 PM shift and had worked at the facility for two months. She stated she regularly worked with Resident #18 and had worked the previous week. CNA A stated she did not recall Resident #18 asking to get up for the Resident Council meeting or being asked to get her up. She stated Resident #18 usually wanted to get up after lunch for therapy. In an interview on 8/15/24 at 7:45 AM, Resident #18 stated she had not heard anymore from facility management and had also missed her scheduled bath on 8/13/24. She stated she had not received a bath since Sunday, 8/11/24. She stated she asked the Aide twice on 8/13/24 for her bath and was told she did not have enough help and was working two halls that day. She could not recall the name of the aide. She stated she was not offered a bath on 8/14/24 either. Resident #18 stated she prefers evening baths because she gets up daily for rehab after lunch and that takes a while. She stated, I guess we'll see if I get one tonight. She stated she has had so many problems and just wanted them addressed. In an interview on 8/15/24 at 8:03 AM, CNA B stated she cared for Resident #18 and had been assigned to her hall on 8/13/24. She stated she knew Resident #18 got up after lunch for rehab and was due for a bath that evening. When asked about her scheduled bath for Tuesday 8/13/24, CNA B stated she did not know why she did not do it. She stated they were down an aide that evening, but she should have done it. She stated they usually had enough staff to care for the residents and even had shower aides most of the time. She stated the risk for not getting bathed was you don't feel very good if you're not clean. CNA B did not recall whether she worked with Resident #18 the day of the last Resident Council meeting but stated residents had a right to get up whenever they wanted. During an interview on 8/15/24 at 8:42 AM, the Activity Director stated she had worked at the facility for 3 years but had just taken over as the Activity Director on 8/1/24. She stated there was a Resident Council meeting on 8/9/24. She stated she lets all the residents know on the day before and the day of Resident Council meetings by going room to room and handing out a paper letting them know the date and time of the meeting. She stated, if a resident was dependent and said they wanted to go, she would check with them and let the nursing staff know they would need assistance. She stated she would verbally alert the staff and offer to assist with resident transfers because she was a CNA and could help. She stated she also placed a paper with a list of dependent residents who expressed interest in attending the Resident Council meetings in a binder at the nurse's station that contained the staff schedule. The Activity Director stated she recalled telling Resident #18 about the meeting on 8/9/24 and recalled her saying she wanted to get up and go. The Activity Director stated she recalled making an aide aware but could not recall the name of the aide. She stated she did not assist with transfers that day because the meeting was in the morning and there was little time. She stated she noticed Resident #18 was not at the meeting but did not know what had happened. She stated residents often changed their minds about attending at the time of the meeting. She stated she thought she recalled Resident #18 complaining about missing the meeting and believed she had reported it to the Administrator but was not certain. She stated Resident #18 was the only one unable to attend that day. She stated the risk of failing to assist residents to meetings or other activities was emotional distress. She stated, If no one will get them up when they want to, can make them feel like, 'is it me, is it the staff?', if you don't communicate, they can think anything. The Activity Director stated she usually kept a copy of the lists provided and would look for the list used for the last Resident Council meeting. No list was located prior to the exit conference. In an interview on 8/15/24 at 9:30 AM, the ADON stated she had worked on 8/11/24 and recalled Resident #18 complaining that she had missed her bath on 8/10/24. She stated Resident #18 was upset because she had family coming and wanted her bath. She stated the aide was CNA C who told her Resident #18 had refused her bath 8/10/24. The ADON stated she did not follow up with Resident #18 to ask if she had, in fact, refused her bath because she was upset and they took care of her bath for her. She stated she had completed a grievance form on the matter. The ADON stated CNA C had resigned and no longer worked for the facility. She was not aware Resident #18 also missed her bath on 8/13/24 or the previous Resident Council meeting. The ADON stated risks for residents missing baths and activities included social and skin breakdowns, mental health decline and a spectrum of breakdowns. During an interview on 8/15/24 at 10:26 AM, the DON stated they had received complaints about missed baths and showers over a month ago and had added a shower aide to the schedule to assist with completions. She stated the shower aides provided a list at the end of the day of completed showers they were using to track. She stated the shower aides did not provide bed baths, but the assigned CNAs completed them . The DON stated she had heard from the ADON that Resident #18 had missed a bath over the weekend and the ADON had taken care of it. She stated Resident #18 had her and the Administrator's personal phone numbers to call if she had any concerns. She stated she was unaware Resident #18 had missed her bath again on 8/13/24. The DON stated they did have a shower aide that day but had to suspend her and send her home when they received a complaint about her which may have contributed to the situation. She checked her phone and stated she had not received any complaints. The DON stated she did not know about Resident #18 missing the Resident Council meeting the previous week. She stated Resident #18 had a history of not wanting to get out of bed and they had had a meeting with her about it, so she was disappointed to hear they did not get her up when she wanted to. She stated the risk of not getting residents bathed or out of bed as desired was it could diminish their dignity. During an interview on 8/15/24 at 12:14 PM, LVN D stated she worked the 6:00 AM to 2:00 PM shift and regularly cared for Resident #18. She stated she recalled the resident complaining to her after she missed the last Resident Council meeting. She stated she had complained after the fact. LVN D stated she was aware of the list provided by the Activity Director of residents who needed assistance to go to an activity and checked it daily. She could not recall whether she had noted Resident #18's name on the list for that day. LVN D stated she would typically assist with transferring residents out of bed when needed. She stated she attempted to find the aide to determine why she had not gotten her out of bed but did not recall who the aide was or what she was told on that day. LVN D stated Resident #18 had complained to her previously about missing baths but could not recall when it was but stated it had not been the current week. She stated Resident #18 received her baths on the evening shift. She stated the nurses were responsible for ensuring the baths were completed and were told in report when they were completed. She stated she had not heard anything about her missing any baths that week. She stated the risk to residents when not receiving baths or transfers as requested included pressure ulcers, poor hygiene, not having their voices heard, and depression. On 8/15/24 at 3:24 PM, an attempt to reach CNA C via telephone was unsuccessful. A voicemail message was left. No return call was received prior to facility exit. In an interview on 8/15/24 at 3:42 PM, LVN E stated she worked the 2:00 PM to 10:00 PM shift and regularly cared for Resident #18. She stated Resident #18 usually received bed baths on her shift and the aides reported to her when the baths were given. She stated her last bath should have been this week and she was not aware Resident #18 had missed her scheduled bath on 8/13/24. She stated Resident #18 did not complain to her about it. She denied asking her or the aide whether her bath had been done. LVN E stated the risk of missing baths was loss of dignity. LVN E stated she, herself, would not want to be around anyone if she missed a shower. She stated this was the resident's home and they deserved good treatment. During an interview on 8/15/24 at 3:48 PM, the Administrator stated he was very familiar with Resident #18, and she had his cellphone number to call or text with any complaints. He checked his phone and stated the last call he received had been in July and was related to staff taking too long to answer her call light. He stated he was away from the facility at that time but sent a staff member to check on her and had re-educated the staff about customer service after the incident. He stated she had made him aware of missing the Resident Council meeting. He stated he had been assisting another facility that day and came back and made evening rounds which was when she told him. He stated he told her he would personally ensure it did not happen again and would transfer her himself if needed. The Administrator stated he was not aware that had been the second time it had happened. He stated he did not know about the missed baths that had occurred on Saturday or Tuesday. The Administrator stated the risks to residents in these instances included decreased emotional status and pressure sores. He stated they generally followed up on resident complaints during QA meetings. He stated, with Resident #18, they were focused on ensuring she had been getting up for therapy, which had improved. Record review of the facility's policy titled, Resident Self Determination and Participation dated, Revised February 2021 reflected: Policy Statement: Our facility respects and promotes the right of each resident to exercise his or her autonomy regarding what the resident considers to be important facets of his or her life. Policy Interpretation and Implementation: 1. Each resident is allowed to choose activities, and schedule health care and healthcare providers, that are consistent with his or her interests, values, assessments and plans of care, including: a. daily routine, such as sleeping and waking, eating, exercise and bathing schedules. b. personal care needs, such as bathing methods, grooming styles and dress; . e. activities, hobbies, and interests . 2. In order to facilitate resident choices, the administration and staff: . b. gather information about the residents' personal preferences on initial assessment and periodically thereafter, and document these preferences in the medical record; c. include information gathered about the resident's preferences in the care planning process; and d. document and communicate any medical conditions or limitations that may inhibit or interfere with participation in preferred activities. 3. Residents are encouraged to make choices about aspects of their lives in the facility, including: . b. organizing and participating in resident groups; . 4. Residents are provided assistance as needed to engage in their preferred activities on a routine basis .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 1 (Hall B) of 6 halls, 1 of 1 nurses' station and 1 of 1 dining room. The facility failed to ensure Hall B, nurses' station and the dining room were free from flies. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life. Findings included: Observation of Hall B on 07/11/23 10:20 AM, Resident #14 had flies circling in his room and landing on his personal items. Observation of Hall B on 07/11/23 10:44 AM, Resident #57 had flies circling in his room and landing on his personal items. Resident #57 stated staff spray a chemical for the flies but does not seem to help. He stated he does not like them but got used to them already. Observation and interview of Hall B on 07/11/23 at 10:46 AM, there were several flies on Resident #21 while he was in bed. Resident #21 stated flies were a major issue and it has gotten worse since summer started. Resident #21 stated he had informed staff but all they do is say Sorry about that. Observation of Hall B on 07/11/23 11:07 AM, Resident #16 had flies circling in his room and landing on his personal items Observation on 07/11/23 11:35 AM, there were a few flies sitting on some of the dining tables where residents were sitting at and flying around residents' plates. Record review of facility pest control binder revealed the following: 06/7/23 - Location (Hall/Room/Area) B5, B6, B7, B8 - Issues Flies, 07/11 - Location (Hall/Room/Area) B6. Interview during a confidential group meeting on 07/12/23 at 2:00 PM, eight out of twelve residents revealed concerns regarding flies. Residents stated they have seen pest control company spraying chemicals; however, it did not seem to help. During the meeting there was residents observed with fly swatters on their wheelchairs. Observation on 07/13/23 during the times of 10:00 AM - 3:00 PM, there were several flies observed around the nurses' station. The staff were observed brushing the flies off. Interview on 07/13/23 at 10:50 AM with Nurse Aide E revealed she had been working at the facility for 5 months. She stated at the beginning of this summer they have had a constant issue with flies. She stated it was worse when summer started and had gotten better. She stated she has had residents complain about flies, but it seemed like they have gotten used to them that they did not complain as much. She stated she would report the concerns to the Administrator and Maintenance Supervisor. She stated she was not sure if pest control had come by. She stated they had fly swatters to kill them. Interview on 07/13/23 at 11:00 AM with the Pest Control Technicain revealed at the facility today (07/13/23) to complete the facility's monthly pest control visit. He stated last month monthly visit was on 06/08/23, and the facility had concerns regarding flies. He stated when he entered the facility the first thing he did was review the pest control binder to review if the facility had any concerns. He stated they treated the entire building first and if the facility had a concern regarding a specific room, they would treat that room after the building had been completed. He stated pest control also came when the facility had an emergency, such as when they were at the facility on 07/11/23 to treat flies. He stated that treatment should still be active. Interview on 07/13/23 at 1:12 PM with Housekeeper F revealed she had been working at the facility since April 2023. She stated she was assigned to A, B, C, D Hall. She stated she has had residents complain about flies. She stated the worst hall was B Hall. She stated she killed about 20-30 flies a day. She stated she did not know what attracted them. She stated she cleaned the rooms every day and at times twice mostly on B Hall. She stated when a resident reported a complaint regarding pest, she reported it on the maintenance pest control log. She stated Maintenance was responsible for following up on the complaints. She stated pest control had been at the facility; however, she dod not think the treatment they were applying was working because they still had flies. She stated it had gotten worse since summer started. Interview on 07/13/23 at 4:23 PM with the Maintenance Supervisor revealed he has had complaints regarding flies. He stated it was worse when summer started; however, it had gotten better. He stated pest control had been at the facility for their monthly visits and on 07/11/23 for an emergency visit to treat flies. He stated pest control applied a treatment powder and sprayed outdoor and indoor. He stated about two months ago they ordered fly lights on Halls B, C, D. They still had an outstanding order for the other Halls A, F, E. He stated he did his rounds and would kill any that he observed. He stated they called pest control on Tuesday due to the number of flies they observed. The Maintenance Supervisor stated other than being a pest control issue the risk would be residents being annoyed by them. Interview on 07/13/23 at 4:35 PM with the Administrator revealed flies had been a constant issue. He stated this year had been worse than others. The Administrator stated since May 2023 they have had monthly services with an additional service to treat the flies. The Administrator stated they treated it as best as they were able; however, pest control could not enter the resident rooms with residents inside and some residents did not want to leave their rooms. He stated housekeeping went inside the room twice a day to clean the rooms. He stated the heaviest halls with flies were Hall B and D due to the door leading outside. The Administrator stated the risk would be infection control in the environment. Review of the facility's Pest Control policy, revised dated [NAME] 2008, reflected: Our facility shall maintain an effective pest control program. 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents .6. Maintenance services assist, when appropriate and necessary, in providing pest control service .

Based on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for two (Residents #4 and Residents #44) of five residents reviewed for dignity. The facility failed to promote both Resident #4 and Resident #44's dignity by not covering their catheter urinary collection bag with a privacy bag. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Review of Resident 4's MDS quarterly assessment, dated 06/07/23, revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4's diagnoses which included urinary tract infection, neuromuscular dysfunction of bladder (urinary bladder problems due to disease or injury of the central nervous system), resistance to multiple antibiotics, hyperlipidemia (blood has too many fats) polyneuropathy (affect nerves throughout the body). The assessment reflected the resident's cognitive was intact, with a BIMS score of 13. Resident #4's functional status with toileting is extensive assistance with one-person physical assistance. Resident #4 bowel and bladder indicated an indwelling catheter (including suprapubic catheter). Review of Resident #4's care plan, dated 07/10/23, reflected: Resident #4 required a suprapubic catheter related to neurogenic bladder. The resident will have suprapubic catheter care managed appropriately. Approach start date 06/14/23 included avoid obstructions in the drainage, do not allow tubing or any part of the drainage system to touch the floor, position bag below level of bladder, Store collection bag inside a protective dignity pouch. Observation and interview on 07/11/23 at 10:54 AM revealed Resident #4 in his room in bed. The resident had a catheter bag hanging on the right side of his bed facing the door. Resident #4's urinary collection bag was not in a privacy bag; urine was visible inside the collection bag. Resident #4 stated he was not sure if there was a privacy bag over his collection bag, but there should be a blue one. Resident #4 stated the collection bag was usually always placed on the right side of the bed facing the door, so it was embarrassing to know the collection bag was not covered. Interview on 07/11/23 at 2:23 PM with CNA C revealed she did assist Resident #4 this morning with draining his catheter; however, she forgot to ensure he had a privacy bag. CNA C stated she realized he did not have a privacy bag after the DON asked her why it was not covered. According to CNA C, not having a privacy bag put residents at risk of dignity issues. CNA C stated it was the responsibility of the nursing staff to ensure residents with catheters had a privacy bag at all times. Review of Resident 44's MDS quarterly assessment, dated 04/23/23, revealed the resident was a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #44's diagnoses included urinary tract infection, infection, and inflammatory reaction due to indwelling urethral catheter, neuromuscular dysfunction of bladder (urinary bladder problems due to disease or injury of the central nervous system). The assessment reflected the resident's cognitive was intact, with a BIMS score of 15. Resident #4's functional status with toileting is extensive assistance with one-person physical assistance. Resident #4 bowel and bladder indicated an indwelling catheter (including suprapubic catheter). Review of Resident #44's care plan, dated 07/10/23, reflected: Resident #44 required an indwelling urinary catheter related to neurogenic bladder. Resident will have catheter care managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma. Approach start date 04/2423 included observe for leakage, change catheter bag every month, do not allow tubing or any part of the drainage system to touch the floor, position bag below level of bladder, provide catheter care every shift, use a catheter strap. Observation on 07/11/23 at 11:41 AM revealed Resident #44 observed resident in his wheelchair in the hallway entering the dining area for lunch. The resident had a catheter urinary bag which was not covered by a privacy bag. The urinary catheter bag had urine inside. Observed resident to continue to get his meal tray. There were several residents in the dining area eating lunch. During interview on 07/11/23 at 2:30 PM with Resident #44 revealed while in the dining room, CNA D put on a privacy bag to cover his catheter during lunch. According to Resident #44, he did not have a problem with the catheter not being covered; however, someone else could be bothered by it and it could bother others. Resident #44 stated he did not want to make others feel uncomfortable. Resident #44 stated he usually used his manual wheelchair which had a privacy bag, due to the change to the electric chair may have prompted the missing privacy bag so he felt he needed to alert CNA D. Interview on 07/12/23 at 9:32 AM with CNA D revealed she assisted Resident #44 out of bed and into his electric chair on yesterday morning (07/11/23). CNA D stated while in the dining room, Resident #44 mentioned to her that there was not a privacy bag covering his catheter bag. CNA D stated she then went to grab a privacy bag to place over the catheter. CNA D stated not having a privacy bag put Resident #4 at risk of affecting his dignity. CNA D stated, I would not want anyone seeing my pee so I don't think he would want that for himself CNA D stated the nursing staff were responsible for ensuring the privacy bag was on at all times. Interview on 07/13/23 at 1:22 PM with LVN B revealed she worked Hall F with Resident #4 and Resident #44. LVN B stated neither Resident #4 or Resident #44's urine collection bag had a privacy cover. She stated it was facility protocol to have urinary collection bags covered at all times. LVN B stated it was the responsibility of all staff, especially aides and nurses, to ensure bags were covered. LVN A stated she had completed training regarding privacy bags and noted urine collection bags should be covered to ensure the resident's privacy and to prevent infections. Interview on 07/13/23 at 2:10 PM with the DON revealed a urinary collection catheter bag should always be covered. She stated all staff were responsible for ensuring the urinary collection catheter bags were covered. She stated the negative outcome of the collection bag not being covered was that it could affect the resident's dignity and the resident's right to privacy. Review of the facility's policy titled Dignity revised February 2021, reflected the following: .Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents, for example: a. Helping the resident to keep urinary catheter bags covered

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 2 residents (Resident #20) reviewed for tube feeding. LVN A failed to check placement of Resident #20's g-tube (a tube going into the stomach through the abdomen to administer medications and liquid nutrition) placement prior to flushing with water and administered bolus feeding. LVN A did not flush g-tube with the correct amount of water before and after bolus feeding. Facility failed to follow physician order for Resident #20 when cleaning enteral stoma site by not applying gauze dressing. This deficient practice could place residents who require enteral feedings at risk for weight loss, dehydration, metabolic abnormalities, and hospitalization s. Findings included: Record review of Resident #20's Face Sheet, dated 07/13/23, revealed Resident #20 was an [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia oropharyngeal phase (difficulty swallowing) and gastrostomy status (surgical opening into the stomach). Record review of Resident #20's quarterly MDS Assessment, dated 06/26/23, revealed Resident #20 had a BIMS score of 09, which indicated cognition was moderately impaired. Resident #20's MDS Assessment Section K revealed nutritional approach was feeding tube. Record review of Resident #20's Care Plan, dated 04/24/23, revealed the following: Feeding tube: Enteral feedings related to CVA, Inability to swallow PO and brain tumor. Goal: [I] will maintain adequate parameters of nutrition through tube feedings as evidence by stable weight and labs within normal limits. Approach: Administer water flushes per MD order. Administer tube feeding formula per MD order. Check placement of tube prior to each addition of feeding, fluids, or medication. Cleanse peg tube site with soap and water. Dehydration/Fluid Maintenance: At risk of dehydration related to diuretic therapy, meds, swallowing problems (NPO status), tube feeding. Goal: [I] will be free of s/s of dehydration. Approach: Encourage fluids frequently. Feeding tube: At risk of aspiration due to resident needing feeding tube. Goal: Airway will be clear to prevent no aspiration over the next 90 days. Approach: Check tube placement, by auscultation, before each feeding and med administration. Check gastric residual as ordered. Monitor ostomy site and report irritation or breakdown. Record review of Resident #20's physician order dated 01/17/23, revealed an order for: Enteral Stoma Site Care: (With Dressing - Routine) Clean with Normal Saline. Pat dry. Apply split gauze dressing. Once a day. Record review of Resident #20's physician order dated 01/17/2023, revealed an order for: Enteral Stoma Site Care: (With Dressing - PRN) Clean with Normal Saline. Pat dry. Apply split gauze dressing. Record review of Resident #20's physician order dated 06/13/2023, revealed an order for: Enteral Feeding Bolus Administration: Jevity 1.5, Bolus 237ML 6 times per day via gravity. Total Bolus in 24 Hours: 1,185ML Total Kcal per Day: 1775Kcal. Record review of Resident #20's physician order dated 06/13/2023, revealed an order for: Enteral Free Water: Administer bolus (100) ML of Water before and after administration of enteral feeding 6 times per day. Observation and interview on 07/11/23 at 12:14 PM of Resident#20 sitting in the facility common area. Resident #20 stated he was doing well. Resident stated he had a g-tube and had already had his feeding. He stated his g-tube did not bother him or hurt him. Resident #20 pulled his shirt up and stated he did not have any redness or signs of infection. There was no observation of a dressing around the g-tube. Observation on 07/12/23 at 12:17 PM revealed LVN A prepping to provide Resident #20 his bolus feeding. LVN A reviewed Resident #20 treatment screen and stated Resident #20 would be receiving one can of Jevity 1.5 Bolus and 100 ml of water before and after feeding. Observed LVN A grab the formula can and an empty clear 5 oz cup. LVN A entered the resident's room without her stethoscope. Observed LVN A add water to the cup. She checked for the g-tube for gastric content residual but did not check for placement of the g-tube. The g-tube was flushed with approximately 10 -15ml of water before the bolus administration. LVN A then provided Resident #20's formula via gravity and flushed with approximately 20 - 30ml of water via gravity. Observed cup to still be half full of water. Interview on 07/12/23 12:50 PM with LVN A revealed she had been working for the facility for a couple of months. She stated she had been Resident #20 nurse since working here and she was the nurse assigned to Resident #20 today (07/12/23). LVN A stated she reviewed Resident #20 order's before entering the room, and stated resident had an order for 100ml of water before and after feeding. LVN A stated the syringe she used can hold 60 cc of fluids. LVN A stated if Resident #20 needed 100ml of water she should have provided Resident #20 with 60 cc and then another 40 cc of water. LVN A stated she failed to provide Resident #20 with his full 100ml of water before and after his bolus feeding. LVN A stated she normally would provide the correct amount; however, she was nervous and forgot. LVN A stated the risk of not providing Resident #20 with his water fluids could cause dehydration and g-tube to get clogged. LVN A stated she cleaned the g-tube site daily. LVN A stated she was not aware that the order states to apply slip gauze dressing. LVN A stated since Resident #20 g-tube site had no signs or symptoms of irritation she did not need to apply gauze, she stated she was looking at the PRN orders. She stated the risk of not applying a dressing could cause an infection. LVN A stated she failed to follow physician order regarding applying a gauze dressing. LVN A stated there are two ways for checking placement of the g-tube. She stated one way of checking placement would be checking for residual and if residual comes out the g-tube is in place. Second way of checking would be by using a stethoscope and inserting a little air inside the g-tube. LVN A stated when she checked Resident #20 g-tube there was no residual. When asked how she checked for placement, LVN A stated she should have used a stethoscope but failed to do so. LVN A stated the risk of not checking placement could cause aspiration or g-tube to be clogged. Interview on 07/13/23 at 2:59 PM with the ADON revealed her expectations are for her nurses to follow physician orders and policy. The ADON stated prior to nurses entering a resident room, nurses should check physician orders and prepare supplies. She stated each nurse should have a measuring cup for water. Nurses should check for placement by using a stethoscope, then check for residual and then flush with water depending on the order, continue with bolus feeding via gravity and then flush again. The ADON stated if any of the nurses failed to follow physician orders could cause dehydration and tube can get clogged. The ADON stated residents with g-tube have two orders; one is for cleaning the g-tube site and applying a dressing daily and the other order was PRN in case the dressing comes off or is soiled the nurses can change them. She stated the risk of not following physician order could cause an infection around the g-tube placement. Interview on 07/13/2023 at 3:19 PM with the DON revealed she just started working at the facility 3 weeks ago. She stated she had not provided any in-services to her nurses regarding g-tubes and has not observed her nurses provide bolus feedings yet. The DON stated her expectations are for her nurses to follow physician orders. She stated residents with g-tube have two orders; one is for cleaning the g-tube site and applying a dressing daily and the other order was PRN in case the dressing comes off or is soiled the nurses can change the dressing accordingly. The DON stated it was the ADON and herself responsibility to ensure their staff are following physician orders. The DON stated risk of not following orders could cause dehydration, and skin irritation. Record review of the facility policy Enteral Nutrition revised date November 2018 reflected the following: .11. The nurses confirms that orders for enteral nutrition are complete. A. the enteral nutrition product; b. delivery site (tip placement); c. the specific enteral access device; d. administration method (continuous, bolus, intermittent). 12). The provider will consider the need for supplemental orders, including: a. confirmation of tube placement; e. head of bed elevation; g. checks for gastric residual volume (GRV). 14). Staff caring for resident with feeding tubes are trained to how to recognize and report complications associated with insertion and /or use of a feeding tube, such as: a. spiration; b. tube misplacement or migration; c. skin breakdown around insertion site; f. clogging of the tube

Based on observation, interview, and record review, the facility failed to pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for one (C Hall cart) of three nurse medication carts reviewed for medication storage. LVN A failed to remove expired medications for Resident #14 from the nurse medication cart for the C Hall cart. This failure placed residents at risk of receiving medications that failed to deliver their full effectiveness. Findings included: Observation on 07/12/23 at 12:50 PM of nurse medication cart on C Hall revealed two Fluconazole inhalers , labeled for Resident #14, had expired on 05/31/23. Interview on 07/12/23 at 12:52 PM LVN A stated she had administered Resident #14's Fluconazole that morning. She stated she did not notice the medication was expired. She stated the risk of giving an expired medication included the resident not receiving the full effects intended by the physician. Interview on 07/12/23 at 1:00 PM the DON stated she expected the nurses to check their medications for expiration dates before they administer them. The DON stated the nurses were responsible for re-stocking their carts and checking for expired medications before making their rounds. She stated the risk of giving a resident expired medications was the resident not receiving the therapeutic effects of the medication. Review of Resident #14's July 2023 MAR revealed Fluconazole was not on the list of medications. Review of Resident #14's physician orders revealed Fluconazole had been discontinued on 05/01/23. Interview on 07/12/23 at 2:20 PM Resident #14 was confused, he could not recall if he had taken an inhaler in the morning. He stated he was not feeling short of breath. Interview on 07/13/23 at 10:00 AM with LVN A revealed she must have misunderstood what the surveyor was asking her on 07/12/23 about administering the Fluconazole. She stated she just had the medication on her cart but had not administered it. LVN A stated the nurses were responsible for checking their carts and removing expired or discontinued medications. She stated she did not know why the Fluconazole was still on the cart when it had been discontinued over two months ago. Interview on 07/13/23 at 11:03 AM with the DON revealed she had followed-up with all the nurses on 07/12/23 and checked all the medication carts for expired medications. The DON stated she did not know why LVN A had stated she had given the Fluconazole because if it was not on the MAR she would not have been triggered to give it. Review of the facility's Administering Medications policy and procedure, dated April 2019, reflected: .12. The expiration/beyond use date on the medication label is checked prior to administering

Based on interview and record review, the facility failed to have evidence that all alleged violations are thoroughly investigated for two (Resident #30 and Resident #41) of two residents reviewed for resident-to-resident sexual abuse. The facility did not investigate a reported Resident-to Resident allegation of sexual abuse made on 03/28/2022 by Resident #31, (alleged victim), involving his roommate (Resident #40, alleged perpetrator) performing oral sex on him. These failures could place the 61 residents in the facility at risk of not receiving thorough investigations of reported allegations of abuse. Findings included: In an interview with LBSW conducted on 05/18/22 at 09:04 AM, she said on 03/28/2022 Resident # 31 came to her office and alleged that his roommate, Resident # 40, went to his bed during the night and performed an oral sexual act on him. She said she immediately reported the allegation to the administrator. She did not document anything about the allegation Resident #31 had made and shrugged her shoulders in response to why she did not document anything in either residents' charts. She said she would go look and see what was documented about the allegation. She returned and said she could not find any documentation in either of the resident's medical records about the sexual allegation made on 03/28/2022. She said Resident #40 was bedbound and could not get out of bed to go over to Resident #31's bed. She had called and spoke with Resident #31's family member on 02/07/2022, and the sister said the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #31's electronic medical record reflected 54- year-old was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #31's Care Plan, dated 04/06/2022, revealed a care plan for a history of making false allegations of a sexual nature. Record review of Resident #31's electronic medical chart from 03/26/2022 to 03/30/2022, revealed no documentation of the alleged allegation. Record review of Resident #31's electronic medical chart revealed no documentation of the facility notifying his responsible party, sister, of the allegations made on 03/28/2022. Record review of Resident #31's electronic medical chart revealed no documentation of the facility notifying the medical director of the allegations made on 03/28/2022. Record review of Resident #31's Progress Notes revealed on 03/27/2022 at 9:54PM he was in bed. On 03/28/2022 at 10:30PM, a weekly skin assessment was performed noting dryness on his right leg, and on 03/29/2022 at 1:59PM, Resident #31 did not display distress from sexual allegations. There was no other documentation in the progress notes for 03/27/2022, 03/28/2022, or 03/29/2022. Record review of Resident #31's Event Report dated 03/28/2022, reflected the resident reported an allegation of sexual abuse to a staff member. Treatment provided was an assessment, no type of assessment was noted. Resident #31 was not confused or disoriented. Actions taken by the facility included his care plan was updated and the alleged perpetrator was moved into another room. Record review of Resident #31's Trauma Based assessment, dated 04/06/2022, revealed no harm had occurred to the resident from the allegation made on 03/28/2022. Record review of Resident # 40's electronic health record an [AGE] year-old male admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He ambulated with a wheelchair, had adequate hearing and vision, and required assistance with activities of daily living. Record review of Resident #40's Comprehensive resident assessment and care screening form, (Admission MDS Assessment), dated 02/28/2022, revealed he had minimum difficulty hearing, clear speech and clear comprehension. His BIMS, (brief interview of mental status), score was 12 out of 15 indicating mild cognitive impairment. He had signs of depression, feeling down, depressed, or hopeless for several days, trouble falling or staying asleep and feeling tired nearly every day, and half of the days he felt bad about himself. He exhibited no behaviors. In section GG, Functional Abilities and goals, his admission performance was documented as needing Partial or moderate assistance, (the helper does less than half the effort such as helper lifts, holds, or supports trunk or limbs, but provides less than half the effort), with eating, oral hygiene, rolling from a lying on back to left and right side and returning to lying on back on the bed, the ability to move from sitting on side of bed to lying flat on the bed, the ability to move from lying on the back to sitting on the side of the bed feet flat on the floor and with no back support, the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed, and the ability to get on and off the commode. He needed substantial/maximal assistance (where the helper does more than half the effort) with bathing/showering his self, upper and lower body dressing and required supervision or touching assistance, (where the helper provides verbal cues and or touching, steadying, or contact guard assistance as the completed the activity) with transferring to and from a bed to a chair or wheelchair and the ability to wheel at least 150 feet. Record review of Resident #40's quarterly assessment dated [DATE] revealed he received therapy services from 02/23/2022 through 04/15/2022, he had minimum difficulty hearing, clear speech and clear comprehension. His BIMS score was a 13 out of 15 and he had feelings of being depressed and feeling tired several days. No behaviors were documented, and he was independent, (no help or staff oversite at any time), with wheelchair locomotion. Record review of Resident #40's Care Plans revealed no care plan associated with the allegation of sexual abuse made against him on 03/28/2022 and no care plans for behaviors. Record review of Resident #40's electronic medical chart from 03/26/2022 to 03/30/2022, revealed no documentation of the alleged allegation. Record review of Resident #40's electronic medical chart from 03/26/2022 to 03/30/2022, revealed no documentation of the facility notifying his responsible party, spouse, of the allegations made on 03/28/2022. Record review of Resident #40's electronic medical chart revealed no documentation of the facility notifying the medical director of the allegations made against the resident on 03/28/2022. Record review of Resident #40's electronic medical chart from 03/26/2022 through 03/30/2022, did not have any progress notes regarding the allegation of sexual abuse against his roommate in his chart. Record review of Review of Resident #40's Focused Observation documentation revealed no documentation for date of 03/28/2022. Record review of Resident #40's electronic medical chart from 03/26/2022 through 03/30/2022, did not have an event report. Record review of Resident #40's electronic medical chart from 03/26/2022 through 03/30/2022, did not have an assessment for 03/28/2022 In an interview on 05/18/22 at 12:01 PM, the administrator said he completed the investigation by reaching out to the corporate office for instructions and interviewing both residents. He told the LBSW to start safe interviews with other residents in the facility. He said the nurse, he did not give a name and explained he meant someone in the nursing department, told him they had spoken with the power of attorneys of both residents, Resident #31 and #40 and had notified the doctor. He said nursing should have documented on the resident's event report, each resident having one completed. He said he reviewed and updated Resident #31's care plan. For Resident #40, he said a report was completed by a nurse and the alleged perpetrator was moved into another room with another resident. He explained the allegation Resident #31 made against Resident #40 was a false allegation because Resident #40 could not get up on his own to wheel himself to Resident #31's side of the room. He said Resident #40 was not witnessed to be in bed, but since the allegation happened at night, Resident #40 should have been in bed. In response to the person responsible for notifying the MD and responsible parties of each resident involved in the reported allegation, he said the nurse was responsible. A trauma-based assessment was completed on Resident #31, but the administrator was not able to determine or conclude as to where or what may have attributed to the resident making the allegation. In response to the question why Resident #31, the alleged victim, was the resident investigated instead of the perpetrator, the administrator said Resident #40 did not have a history of the allegation and was immediately moved to another room with another resident. The resident he moved in with was coherent, and Resident #40 had no similar history of events. He said Resident #40's spouse denied the allegation and she loved the new roommate. He said on 02/07/2022, Resident #31's sister notified them the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 05/18/22 at 12:50 PM with the CCO, he said Resident #40 did not have any documentation or event report in his chart. He said the conclusion that Resident #31 made a false accusation against Resident #40 was based on Resident #31's history of making false accusations and Resident #40's inability to get out of his bed by himself. He pointed out the incident was not witnessed, and Resident #40 should have been in bed even though no one saw him at the time the event supposedly occurred. He said there was no documentation about the abuse allegation, notifications, incident or event reports, or findings related to the allegation in the alleged perpetrators chart, Resident #40, because the alleged perpetrator was not part of the facility's investigation . In an interview on 05/18/22 at 01:17 PM, the CCO handed a written statement dated 03/28/2022, and said the statement was taken by the ADON from a CNA saying she had never seen Resident #40 out of bed on her shift. The CNA documentation, revealed another CNA had cared or Resident #40 during the shift of the alleged event. The CCO took the statement back. In an interview on 05/19/2022 at 09:11 AM with the CCM, he said he is responsible for resident care plans. In response to why Resident #31 was care planned on 04/06/2022 for a history of sexual allegations, he said he heard about the allegation made by Resident #31 in that Resident #40 had walked/rolled over to his roommates' bed and performed oral sex on him. He said Resident #40 required total assistance with all his ADL's and could not have walked or wheeled himself to the other side of the room and had been in his bed when the allegation supposedly occurred. In an interview on 05/18/22 at 01:47 PM, LVN said she had worked 6am-10pm on Sunday, March 28, 2022 and was Resident #40's nurse on the day the sexual misconduct supposedly occurred. She said she had not been interviewed about the allegation made and during this interview was the first time she was asked about the allegation or resident involved. Resident #40 was up in his wheelchair most of her shift, but it was so long ago she could not remember what time the resident had gone to bed. In a telephone interview on 05/18/22 at 10:14 AM, Resident #40's family member said she had not been notified about the allegation of sexual abuse made against Resident #40 on 03/28/2022. Sheraised her voice then said there was no way Resident #40 would do such a thing. She repeatedly asked why she was not notified of the allegation made and said (the Facility) they told her the reason Resident #40 had to move to another room was because of something Resident #31 had done but did not tell her what Resident #31 had done . In an interview with the ADON on 05/18/22 at 01:58 PM, she said on 05/18/2022 she was asked to gather information about the allegation of sexual abuse that was made on 03/28/2022. She said she was not part of the investigation at the time the allegation was made. In an interview on 05/18/22 at 02:19 PM with the CCO, he said an investigation was not been done on Resident #40, the alleged perpetrator, because the resident could not have done it. When asked, he responded the facility did not follow the facility policy and procedure for investigating allegations of abuse. He said Resident #40 was moved to another room with another resident because he did not believe the allegation happened. He explained if an allegation would have been made against a staff person, the employee would be sent home pending the investigation results to prevent the alleged perpetrator from access to any other resident but in a resident sexual abuse allegation, the procedure was different, and investigations of abuse allegations varied based on the involved persons. He said the staff working with Resident #31 and Resident #40 were not interviewed, and the policy was not followed because they investigated the victim instead of the perpetrator to determine if the allegation really occurred or not. He said the nurse, he did not provide a name or identifying information, had been interviewed by someone, not named, or identified, and said she did not know anything about the allegations. He gave an example and said if the surveyor said someone stole money from them, he would investigate the surveyor to determine if the allegation happened or not, not the person who was reported to have stolen the surveyor's money. He said he investigates backwards, starting with the person making the allegation to determine if the allegation really occurred. In an interview with the Medical Director on 05/19/22 at 09:28 AM, he said the previous ADON spoke with him about one allegation of one resident touching another. He did not remember who the residents were. He said he did not remember the details and did not know if he had been told about more than one sexual abuse allegation made by Resident #31. He said he did not know about any other allegation of sexual abuse dealing with Resident #31. He said sometimes the facility just calls him or speaks with his Nurse Practitioner. Record review of The facility Abuse Prevention Program, dated June 2021, reflected Policy Statements including all reports of resident abuse, neglect, exploitation, misappropriation of resident property, shall be . and thoroughly investigated by Center management. Findings of abuse investigations will also be reported. As part of the resident abuse prevention program, the administration will: Identify and assess all possible incidents of abuse The Administrator or designee will assign the investigation to an appropriate individual and will keep the resident and their representative informed of the progress of the investigation. The role of the investigator will, at a minimum: a. Review the completed documentation forms b. Review the residents medical record to determine events leading up to the incident c. Interview the person reporting the incident d. Interview any witnesses e. Interview the resident f. Interview the resident Attending Physician as needed to determine the resident current level of cognitive function . g. Interview staff members on all shifts who have had contact with thee resident during the period of the alleged incident h. Interview . Family members Upon conclusion of the investigation, the investigator will record the result of the investigation on approved documentation forms and provide the completed documentation to the Administrator During abuse investigations, residents will be protected from harm by the following measures: c. If the alleged abuse involves another resident, the accused residents' representative and Attending Physician will be informed of the alleged abuse incident and that there may be restrictions on the accused residents' ability to visit other resident rooms unattended. Review of the facility Resident Census 05/17/2022, revealed 61 residents in the facility.

Based on observation, interview and record review, it was determined the facility failed to provide adequate supervision and assistance devices to prevent accidents for one (Resident #5) of four residents reviewed for falls. 1. The facility failed to train staff about Resident #5's lap tray, which attached to her wheelchair to assist with leaning forward. 2. Staff failed to report Resident #5's malfunctioning lap tray and continued to place the tray on the resident's wheelchair. 3. Staff failed to develop other interventions when the resident had multiple falls related to the use of the lap tray. These failures resulted in Resident #5 sustaining lacerations, contusions, skin tears and a facial fracture. These failures could affect the 83 residents, identified by the facility, who needed staff assistance with transfers, by placing them at risk for falls and injuries including fractures, pain and decreased quality of life. Findings included: Resident #5's Face Sheet dated 04/16/13 reflected an initial admission date of [DATE] and a readmission date of [DATE]. Resident #5's most recent MDS assessment, dated 04/30/13, included [DIAGNOSES REDACTED]. The MDS assessment reflected the resident had limited range of motion in her upper and lower extremities, her cognitive skills for daily decision-making were severely impaired, she never/rarely made decisions, she used a wheelchair for mobility and she required extensive assistance of one person with transfers. Resident #5's Care Plan, dated 01/13/09 with a revision date of 05/01/13, reflected the resident was at risk for falls related to generalized weakness, impaired balance and a history of falls. The Care Plan's Interventions included providing a clutter free environment and addressing specific causes of risk for falls to eliminate the cause. The most recent Fall Risk Assessments for Resident #5 were dated 08/16/12 and 04/10/13 and the scores were 14 and 16 respectively. According to the instructions on the form, residents with scores of 10 or greater should be considered at high risk for potential falls, and a prevention protocol should be initiated immediately and documented on the care plan. Resident #5's Care Plan dated 01/09/13 and revised on 05/01/13 reflected to discontinue the lap tray and initiate a lap buddy. An observation on 05/14/13 at 9:25 AM revealed Resident #5 sitting in a standard wheelchair in her room with a lap buddy (a type of cushion with foam padding and a vinyl covering, which fits snugly between the resident and the wheelchair, to provide upper torso support and to prevent forward leaning) attached to the front of the wheelchair. She had a fading bruise to her right cheek. At this time, LVN A stated the resident was confused, incontinent of bowel and bladder, had a history of [REDACTED]. A facility I/R dated 03/01/13 reflected Resident #5 had an unwitnessed fall in the dining room at 11:25 AM. According to the report, the three-quarter lap tray on the front of the resident's wheelchair "fell apart." There was no specific information regarding how the tray broke or what part of the tray was broken. This I/R reflected the incident could have been prevented if equipment/safety devices had been checked. Resident #5 had an X-ray of the pelvis, but no injury was identified. The report further reflected immediate actions implemented to prevent a recurrence of the incident were to assess the resident for injury. Nurse's Notes dated 03/01/13 and timed 11:25 AM reflected Resident #5 "slid" out of her wheelchair while listening to music in the dining room. The note further reflected the resident was confused and unable to verbalize how the fall occurred. The resident was assessed during this time with old bruising to the right side of the face and multiple bruising to the right arm. This note also reflected Resident #5 was sitting in the wheelchair with a personal alarm and the three-quarter lap tray attached to the wheelchair after the fall. Review of the resident's entire clinical record revealed there was no review or revision of the care plan to address this fall. An interview with LVN I on 05/16/13 at 10:43 AM revealed she was the charge nurse on duty on 03/01/13 when Resident #5 fell from the wheelchair. The LVN stated the resident used a lap tray because the resident leaned and rocked forward in the wheelchair. According to LVN I, she was summoned to the dining room and the lap tray was on the floor. She stated she was thinking the lap tray fell apart. The nurse further stated she was not familiar with the lap trays and did not know how they "worked." LVN I revealed Resident #5 was assisted back into the wheelchair and the lap tray was put back on the front of the wheelchair. During this interview, LVN I stated she did not know if Resident #5 had received a new lap tray or if the lap tray had been repaired. Resident #5's Care Plan, dated 01/13/09 with a revision date of 05/01/1,3 did not reflect the use of a lap tray or personal alarm. A facility I/R dated 03/14/13 reflected Resident #5 fell in the dining room at 5:30 PM. According to the report, the wheelchair lap tray "slid" off the front of the wheelchair. The second page of the report reflected the lap buddy was removed, while the resident was at the dining table and the resident fell . This report did not reflect if the personal alarm was in use, in place, sounding or functional at the time of this fall. The I/R incorrectly reflected the resident did not have a history of sliding out of the wheelchair and therefore the incident could not have been prevented. The report further reflected immediate actions implemented to prevent a recurrence of the incident were to leave the lap buddy on during mealtimes. An interview with the Acting DON (who was previously the facility's corporate nurse consultant) on 05/16/13 at 12:03 PM revealed the I/R dated 03/14/13 incorrectly reflected Resident #5 was using a lap buddy. The Acting DON stated the resident was still using the lap tray during the fall on 03/14/13. Nurse's Notes dated 03/14/13 and timed 7:00 PM reflected Resident #5 sustained no injuries during the fall on 03/14/13 at 5:30 PM. According to this note the resident was assisted up and back into her wheelchair and the lap tray was again applied to the front of the wheelchair. Review of the resident's entire clinical record revealed there was no review or revision of the care plan to address this fall. An interview with LVN H on 05/16/13 at 10:31 AM revealed she was the charge nurse on duty on 03/14/13 when Resident #5 fell from the wheelchair. The LVN stated she was informed by a CNA the resident's lap tray slid off the wheelchair and the resident slid to the floor. According to LVN H, the resident was assisted back into the wheelchair and the lap tray was replaced on the front of the wheelchair. LVN H revealed the tray was applied by sliding it on and sliding it off. When queried during this time about the lap tray being functional on 03/14/13, LVN H replied, "I think so. No one really showed me how to use it." She stated she "really" did not know how the lap tray "worked." An I/R dated 04/10/13 reflected Resident #5 had an un-witnessed fall in the dining room at 12:00 PM and sustained cuts, lacerations and skin tears. According to the report, the personal alarm was in place. However, the resident was able to remove the lap tray and fell face down onto the floor in the dining room. Nurse's Notes dated 04/10/13 and timed 5:45 PM reflected Resident #5 was found lying face down on the dining room floor. According to the Notes, her arms were tucked under her body, her upper lip was lacerated and there were skin tears to her left hand. The paramedics were notified and Resident #5 was transferred to the emergency room for evaluation. Nurse's Notes dated 04/10/13 and timed 6:15 PM reflected the resident returned from the hospital with internal and external sutures to the upper lip and orders for antibiotic treatment for [REDACTED]. Review of the resident's entire clinical record revealed there was no revision of the care plan to address this fall. An interview with CNA G on 05/16/13 at 10:31 AM revealed she was on duty on 04/10/13 when Resident #5 fell from the wheelchair. According to CNA G, she did not witness the fall, but had repeatedly replaced the lap tray on 04/10/13 because it kept "sliding off." CNA G stated the lap tray was supposed to "click" when it was placed on the wheelchair, but it never clicked during the times she had to replace it. CNA G revealed she did not receive any training on the lap tray, but knew it should "click." CNA G stated there were times when the lap tray would not "click" and she would assist the resident from the wheelchair onto the bed. When asked if she reported to anyone that the tray was not "clicking," CNA G replied, "No." An interview with LVN I on 05/16/13 at 11:00 a.m. revealed she was the charge nurse on duty on 04/10/13 when Resident #5 fell from the wheelchair. The LVN stated CNA G informed her the lap tray on Resident #5's wheelchair would sometimes slide off. LVN I revealed she had informed the previous DON of this when the resident fell on [DATE] and on 04/10/13. According to LVN I on 03/01/13 and on 04/10/13, the CNAs were to complete "some type" of form on the computer to notify maintenance the lap tray was broken. LVN I revealed, "I guess because nothing seems to have been done concerning the broken tray, (Resident #5) fell and ended up on the floor twice when I was her nurse." Nurse's Notes dated 04/14/13 and timed 2:00 PM reflected Resident #5 experienced another fall in the dining room on 04/14/13 at 10:45 AM. According to the Notes, the resident fell out of the wheelchair and sustained a large contusion to the right eyebrow and right cheek. The resident complained of right arm and leg pain and skin tears were on her left knee and right lower leg. The Notes reflected Resident #5 was transported to the hospital for evaluation. Nurse's Notes dated 04/15/13 and timed 11:00 PM reflected Resident#5 returned from the emergency room to the facility on [DATE] at 9:30 PM with a diagnosed fracture to her jawbone and a peri-orbital contusion (around the orbit of the eye). The note also reflected she had scattered bruising to her arms, chest and upper torso, redness/inflammation to the right knee, deep bruising to the right eye and a laceration to the upper lip with visible sutures. Incident witness account forms dated 04/14/13 reflected CNAs F and G were entering the dining room when Resident #5 fell from her wheelchair. Resident #5's Care Plan was revised on 05/01/13 and reflected to discontinue the lap tray and initiate a lap buddy. An interview with the Acting DON on 05/16/13 at 9:55 AM revealed she was unable to locate an I/R related to the resident's fall on 04/14/13. During this time, she confirmed there had been no I/R completed to address the fall on 04/14/13. An interview with CNA F on 05/16/13 at 10:01 AM revealed she and CNA G discovered Resident #5 on the floor of the dining room on 04/14/13. The CNA stated the lap tray had "come off" the wheelchair and the resident had fallen forward and hit her head "really hard on the floor." She further stated she was returning from lunch, when she entered the dining room and observed Resident #5 on the floor. The resident's arm was tucked under her body and there was a lot of blood on the floor. CNA F stated the resident had a laceration that went through the entire lip. According to CNA F, she picked the lap tray up from the floor after the fall and saw there were parts missing. The CNA stated the spacer required to secure the lap tray to the wheelchair was missing. CNA F stated she was familiar with how the lap tray worked and the parts the tray required. CNA F revealed Resident #5 had a tendency to rock back and forth and lean forward in the wheelchair. She stated the lap tray was used to keep the resident safe. CNA F revealed if the spacer was missing the tray would not work properly. She stated she was not sure if maintenance was informed of the broken lap tray. She also revealed LVN I was aware the tray was broken and not functioning properly. An interview with CNA G on 05/16/13 at 10:31 AM revealed she and CNA F returned from lunch on 04/14/13 and witnessed Resident #5 "coming out" of the lap tray and fall onto the floor of the dining room. The CNA stated she and CNA F were unable to reach the resident before the resident "smacked" the floor. According to CNA G, there was no staff in the dining room when the resident fell . CNA G revealed she assumed the lap tray was to prevent Resident #5 from falling because the resident leaned and rocked in the wheelchair. A documented time line related to Resident #5's falls on 03/01/13, 03/14/13, 04/10/13 and 04/14/13 was provided by the Acting DON on 05/16/13. According to the time line documentation, the intervention to address the resident's fall on 03/01/13 was the lap tray was repaired. An interview with the facility's only MD on 05/16/13 at 11:02 AM revealed he was responsible for wheelchair repairs. The MD stated in January 2013 he did recall securing a clamp and tightening the left side of the wheelchair (armrest) where the lap tray "slides in." The MD did not recall receiving a work order for any other repairs to Resident #5's lap tray including replacing or working on the spacer. The MD further stated if he had known the lap tray was broken, he would have repaired it right away. An interview with CNA G on 05/16/13 at 11:45 AM revealed she was unable to recall if she reported Resident #5's broken lap tray to the MD. She stated she did not generate a work order in the computer, but was unable to recall if she had verbally informed the MD. A subsequent interview on 05/16/13 at 11:51 AM with the MD in the presence of the Administrator and the Acting DON revealed he was able to recall tightening the spacer on Resident #5's wheelchair on 03/01/13. The time line reflected the intervention to address the resident's fall on 03/14/13 was the lap tray would no longer be removed during mealtimes. The time line reflected the intervention to address the fall on 04/10/13, was a therapy screen was requested for positioning. No therapy screen was provided, and review of Resident #5's entire clinical record revealed there was no therapy screen related to the fall on 04/10/13. According to the documented time line, after the fall on 04/14/13, therapy was initiated on 04/17/13 and a tilt-in-space wheelchair with a lap buddy was provided for Resident #5. Resident #5's Care Plan did not reflect the tilt-in-wheelchair. (Note: Observation on 05/14/13 at 9:25 AM revealed the resident was sitting in a standard wheelchair with a lap buddy. The time line also reflected the lap tray was discontinued and the lap buddy was put in place on 05/01/13. The resident's care plan was dated revised as on 05/01/13 and reflected the lap tray was discontinued and the lap buddy was initiated. During an interview on 05/16/13 at 10:01 AM, CNA F stated after Resident #5 returned from the hospital on [DATE], the lap tray was on the resident's wheelchair. She stated she was instructed to place a lap buddy on Resident #5's wheelchair. CNA F revealed she retrieved a new lap buddy and applied it to the resident's wheelchair. CNA F was unable to recall the exact date, but stated she was sure it was after the fall on 04/14/13. During this interview she stated she knew the MD did not repair the lap tray because she had observed it with missing parts. An interview with CNA J on 05/16/13 at 2:20 PM revealed she worked in Central Supply. She stated she provided nursing staff with the lap buddy for Resident #5 on 05/01/13. She stated she recalled requesting the physician's orders [REDACTED]. A physician's telephone order dated 05/01/13 reflected the lap buddy was ordered on [DATE] to reduce falls due to Resident #5 leaning forward. An interview conducted with the Acting DON (who was previously the facility's nurse consultant) on 05/16/13 at 12:03 PM revealed when she was informed of Resident #5's fall on 03/14/13 she was initially told the resident slid down and out of the wheelchair, then during her investigation she was told the lap tray had been removed and a CNA was sitting at the table with the resident. She stated she instructed staff to conduct a meeting and "come up" with another intervention. The Acting DON further stated if she was going to remove the lap tray, she would have a CNA sitting right beside the resident. Additionally, she stated there had been no one to investigate the incident on 03/14/13 because there was no DON. During this time the Acting DON was asked what other interventions were implemented for Resident #5, and she replied the lap tray was the device in use during the time of the resident's falls. At this time, the Acting DON reviewed the resident's care plan and confirmed there had been no revision of the resident's care plan in an effort to prevent further falls/injury. Resident #5 was observed on 05/17/13 at 11:50 AM sitting in a tilt-in-space wheelchair with a lap buddy attached to the front of the chair. The Acting DON was present during this observation and stated this was the chair she had wanted and that had been discussed for the resident's use in the patient at risk meeting on 04/17/13. The Acting DON stated the wheelchair was not provided because therapy had not addressed her request for the tilt-in-space wheelchair. An interview with the Rehab Director on 05/17/13 at 12:00 PM revealed after Resident #5's second fall on 04/14/13, a therapy evaluation determined the tilt-in-space wheelchair would be the best for the resident. The Rehab Director stated therapy made the recommendation, but nursing staff was responsible for implementing it if they agreed, not the therapy department. The facility's P/P, titled Falls Potential and Risk Reduction Protocol, was provided by the Acting DON on 05/16/13 and identified as current. The first two pages of the three-and-a-quarter page document were dated revised July 2007. The final pages were dated revised December 2011. According to the facility's P/P, the facility was to assess residents for the potential for falls and identify factors that might contribute to falls. The facility would address those factors identified in order to reduce the risk for falls. The P/P reflected the resident's care plan would address special needs and/or risk factors identified on the Resident Risk Assessment Profile. The circumstances surrounding past falls would be reviewed. The care plan would address if the resident required increased attention at peak times of the day, or if the resident had other unmet needs. The P/P further reflected the resident's care plan should be updated after a fall to address the most recent cause of the fall. The section related to potential considerations for fall risk reflected after a fall, assistive devices would be re-evaluated for appropriateness and an assessment would be conducted for an alternative assistive device if necessary. An interview with the MDS Coordinator on 05/22/13 at 10:30 AM revealed there was only one resident in the facility utilizing a lap tray during the survey process from 05/14/13 through 05/17/13. The Form CMS-672, Resident Census and Conditions of Residents, dated signed by the Acting DON on 05/14/13 reflected 83 residents required staff assistance with transfers.

Based on observation, interview and record review, the facility failed to ensure adequate supervision and assistance devices were provided to prevent an accident for one (Resident #1) of five residents, reviewed with lap trays, a merri walker and/or lap buddies, from the potential of falling. Resident #1, who was a known fall risk, fell on [DATE], because the lap tray was not fully secured to the Tilt-in-Space wheelchair. On 07/24/13, the surveyor and the ADON were able to easily remove Resident #1's lap tray from the Tilt-in-space wheelchair. The facility still needed to in-service 24 of 50 CNAs and six of 23 licensed staff employed by the facility on the Tilt-in-Space wheelchair and lap tray attachment. These failures to ensure facility staff used approaches designed to prevent Resident #1 from falling and were securely attaching the lap tray to the Tilt-in-Space wheelchair could affect the five residents with lap trays, merri walkers and/or lap buddies at risk for falls, which put them at risk for falling, resulting in skin tears, bruising, fractures, subdural hematoma and even death. Findings included: The MDS assessment dated [DATE] for Resident #1, an 80 -year-old female, reflected she was admitted on [DATE]. Resident #1 was severely impaired cognitively and never/rarely made a decision. Resident #1 was totally dependent on staff for ADLs and the resident was not ambulatory. The MDS assessment reflected Resident #1 had fallen two or more times prior to the current assessment, and one was with a major injury. Resident #1's [DIAGNOSES REDACTED]. Resident #1's current CNA Care Card (undated) reflected: "Comments: Monitor lap try for proper safety placement (every) shift. High Risk for falls," and Reviewed: wheelchair with lap tray Fall Risk. Note: A CNA Care Card is made for every resident and addresses specific care needs. Care Plan dated 01/13/09, most recent update was 05/02/13 with no new approaches or interventions. Problem: Resident #1 has cognitive deficits as evidenced by confusion, disorientation and memory recall deficits. Decision-making ability severely impaired. Rarely/never able to make self understood and rarely/never able to understand others. Resident #1's Plan of Care originally dated 01/13/13 reflected: "Problem: at risk for falls. Related to Generalized Weakness, Impaired Balance, History of Personal Falls, Poor posture noted. Resident leans forward while seated in her wheelchair." Goal: Will have no falls for 90 days. Approaches included: Chair alarm to wheelchair. Check for function and placement every shift. Three-quarter tray to wheelchair to reduce risk for fall due to leaning forward in wheelchair. Resident #1's Plan of Care for being at risk for falls was updated on 04/10/13: Resident #1 fell and sustained a laceration to her lip. The only updated approach included: Sent to ER for evaluation and treatment related lip laceration. This was identified as healed on 04/22/13. Resident #1's Fall Risk assessment dated [DATE] reflected a total score of 16 and was at High Risk for falls. The assessment reflected a total score of 10 or above represented High Risk Resident #1's Plan of Care for being at risk for falls was updated again on 04/14/13: Resident #1 fell in the dining room, sustained a facial fracture with a right eyebrow and cheek contusion, and right arm and leg pain. New approaches included: On 04/14/13, the resident was sent to the ER for evaluation and to monitor complications of facial fracture. Resident #1's Occupational Therapy Plan of Care dated 04/14/13 reflected, "Fracture Right Maxilla, peri orbital contusion from fall on 04/10/13 and 04/14/13." Resident #1's Plan of Care for being at risk for falls was updated again on 05/01/13 with the following approach: On 05/01/13, discontinued the 3/4 tray as ordered; Start lap buddy to wheelchair to reduce risk of falls related to leaning forward in w/c. Release every two hours and prn. Resident #1's Plan of Care for being at risk for falls was updated again on 05/15/13 with the following approach: On 05/15/13, Tilt and Space wheelchair with tray. Resident #1's consolidated physician orders [REDACTED].`13 to be in the Tilt in Space wheelchair for safety and positioning with a lap buddy for safety. Facility In-services dated 05/16/13, 05/17/13, and 05/21/13 following the order for the use of the Tilt-in-Space did not address any instruction in the use of the wheelchair with the lap tray. The in-services conducted at that time addressed thoroughly investigating incidents/injuries and injuries of unknown origin, a conclusion and documenting interventions to put into place to place to prevent reoccurrence. The in-services also included notification of broken equipment, resident concerns, and fall risk management. Resident#1's Occupational Therapy treatment note dated 06/03/13 reflected, "Nursing staff reported difficulty with positioning in tilt-in-Space wheelchair over the weekend." Discussed and educated with CNA G. "Will continue to educate nursing staff." Resident #1's Plan of Care for being at risk for falls was updated again on 07/06/13 with the following approach: "Fall from Geri-chair." (Note: identification of a fall, not an intervention.) The Plan of Care for Resident #1 being at risk for falls, which was copied from the resident's clinical record and reviewed on 07/24/13, did not address the resident's fall on 07/06/13 with any interventions. The facility's Incident Report for Resident #1 dated 07/06/13 reflected the following: Incident Description: "Fall sitting in Geri-Chair (no injury)." Intervention/Correction Action/Supervision Follow-up: If known, what caused this injury/incident: "Chair tray not securely engaged." Could this injury/incident have been prevented? "Yes." if yes, how? "staff educated on properly placing the tray." On 07/24/13, review of the Facility Incident Report Log revealed Resident #1's fall on 07/06/13 was not found in the log dated from 07/01/13 to 07/24/13. Resident #1's Nurses Note dated 07/06/13 at 5 p.m. reflected the resident was "in dining room slid from Geri-Chair, no injuries, no bruising, neuro)neurological checks intact, no sign and symptoms of pain." Resident #1's Occupational Therapy Plan of Care dated 07/07/13 reflected, "[AGE] year old female presented to therapy due to a fall on 07/06/13... a result of equipment malfunction resulting in no injury." On 07/24/13 at 3:08 p.m., during an interview with the Maintenance Supervisor, the surveyor reviewed the work order form #1065 for a Tilt-n-Space wheelchair dated 07/08/13 at 1:39 PM. The form's Section Description reflected: In-service conducted with CNA staff on proper locking tray and demonstrated correct procedure. (This in-service was following the fall on 07/06/13.) The surveyor asked the Maintenance Supervisor what in-services had he done with staff on lap trays and chairs? The Maintenance Supervisor stated, "On 07/08/13, Tilt-in-Space in-service with all three shifts... The corporate nurse called and wanted an in-service on the locking procedure of the tray,,, I brought two CNAs on hall F, 6-2 (shift), and I showed the locking system of the tray and the arm." The surveyor asked who the two CNAs and the others were. The Maintenance Supervisor stated, "(CNAs B, D, E, and F)." The surveyor asked about the sign-in sheet for the in-services. The Maintenance Supervisor stated, "I turned it in to the corporate nurse, and that (sign-in sheet) is one we can't find... That is the work order there (indicating the form) that tells what was done." On 07/24/13 at 2:15 p.m., during an interview with CNA B, the surveyor asked if she had worked on 07/06/13 with Resident #1. CNA B stated, "Yes. We got her up, put her in the chair, pushed her back (in the chair). Put on the lap tray, we pushed it (the lap tray) back, and tried our best to lock it, but we did the best we could." The surveyor asked CNA B who assisted her with Resident #1. CNA B stated, "Agency nurse. I asked the agency nurse to take (Resident #1) to the dining room and pull her up to the feeder table." The surveyor asked CNA B if she was able to lock the lap tray to the wheelchair when it was put on the resident's wheelchair. CNA B responded, "We had a hard time locking it. We have to be careful, because she (Resident #1) moves forward and pushes it (the lap tray) off. She is a fall risk." The surveyor asked CNA B if she had a problem with the lap tray. CNA B stated, "Yes. I was on one side, and she (agency nurse) was on the other." The surveyor asked whether anyone else helped with attaching the lap tray to the wheelchair. CNA B stated, "No. I told the agency nurse to turn on the (chair) alarm." The surveyor asked if the "agency nurse" took Resident #1 to the dining room, and CNA B stated, "Yes." The surveyor asked CNA B if she knew what happened with Resident #1. CNA B answered, "Yes. She fell ." The surveyor asked CNA B if she knew why Resident #1 fell . CNA B stated, "I think she pushed the lap tray off, and she was not against the table (in the dining room)." The surveyor asked whether CNA B or the "agency nurse" checked if the lap tray was locked before taking her to the dining room. CNA B said, "No." On 07/24/13 at 9:20 a.m. the surveyor, who was accompanied by the facility's only ADON, observed Resident #1 on initial rounds sitting in her Tilt-in-Space wheelchair in her room with a lap tray on the wheelchair. Resident #1 was sitting in an upright position with her abdomen against the lap tray. The surveyor looked at the lap tray to see if it had been securely attached to the Tilt-in-Space wheelchair. The surveyor was able to simply pick up and remove the lap tray from the Tilt-in-Space wheelchair. The surveyor handed the lap tray to the ADON. The ADON replaced the lap tray onto the Tilt-in-Space wheelchair and stepped away. The surveyor asked the ADON to attempt to pull the lap tray from the Tilt-in-Space wheelchair by pulling on the tray. The ADON was able to remove the lap tray from the Tilt-in-Space wheelchair without difficulty and or unlatching the lap tray from the Tilt-in-Space wheelchair. The ADON replaced the lap tray onto the Tilt-in-Space wheelchair. After replacing the lap tray on the Tilt-in-Space wheelchair, she checked the tray for being securely attached. The ADON was able to remove the lap tray from the Tilt-in-Space wheelchair. The surveyor asked the ADON what would have occurred if Resident #1 had leaned forward against the lap tray. The ADON stated, "She (Resident #1) would have fallen out forward." The ADON successfully applied the lap tray the second time and when tested , it did not come off. The surveyor asked the ADON who had gotten the resident up in the wheelchair that morning. The ADON stated it was the night shift. She said, "We have trained and trained on this." On 07/24/13 at 2:40 p.m., during a telephone interview with CNA C, the surveyor asked if she worked the night shift, which started on 07/23/13 and ended on 07/24/13 "this morning," and did she assist with getting Resident #1 out of bed. CNA C stated, "Yes. Me and (CNA G). We got her (Resident #1) up, washed face and hands, combed her hair, put on the lap tray, pushed it back and hooked it." The surveyor asked how the CNA checked the lap tray for being secure on the wheelchair. CNA C stated, "Oh yes. We pulled on it when we locked it " On 07/24/13 at 10:00 a.m., the Administrator provided to the surveyor a list of the facility's staff. The Administrator stated the staff, who were highlighted, had received an in-service on Resident #1's Tilt-In-Space wheelchair with the lap tray. Review of the untitled list of employees provided by the Administrator revealed the facility had 23 licensed staff and 50 CNAs. Twenty-four of 50 CNAs still needed the in-service. Of 23 licensed staff, six still needed to be in-serviced. On 07/24/13 at 10:33 a.m., Resident #1 was observed in a therapy session with the Physical Therapist Resident #1 sitting in the Tilt-in-Space wheelchair with lap tray. On 07/24/13 at 10:33 a.m., the facility's Therapy Director was interviewed. The surveyor asked if Resident #1 required the Tilt-In-Space wheelchair with a lap tray. The Therapy Director responded, "If she (Resident #1 ) does not have this chair and tray, she is strong enough to bring herself forward and lean over." The surveyor asked whether Resident #1 was strong enough to lean forward and fall over. The Therapy Director stated, "Yes." On 07/24/13 at 11:45 a.m. Resident #1 was observed in the dining room sitting in Tilt-in-Space wheelchair. The lap tray was secure. The facility's Census List dated 07/24/13 was identified by the facility by highlighting with the five residents with lap trays, a merri walker and/or lap buddies.

Based on observation, interview, and record review, the facility failed to ensure each resident received the necessary care and services to maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for five (Residents #1, #2, #3, #4, and #5) of 13 residents reviewed for assessments and timely treatment and 59 (Residents #1, #2, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60 and #61) of 92 residents randomly reviewed for a Flu Immunization. 1) Resident #2 had not received the flu vaccine and her status was not monitored and her deteriorating respiratory status was not identified until rounds were conducted by the surveyor and the DON. Following surveyor intervention, the resident was admitted to the hospital with [REDACTED]. 2) Resident #3's continued decline on 01/24/13 was not acted upon timely and she was not sent/admitted to the hospital for evaluation until 01/25/13. Resident #3's status following her return to the facility on [DATE] from the hospital was not monitored from 01/31/13 to 02/05/13 even though she was still receiving antibiotic therapy. 3) Resident #4's status was not assessed at all from 01/24/13 to 01/29/13 while she was receiving antibiotic therapy and prior to her hospitalization on [DATE]. 4) Resident #5's respiratory status was not monitored from 02/02/13 to 02/06/13 even though she had been administered [MEDICATION NAME] to treat her flu symptoms. 5) Resident #1's left leg left a trail of fluid on the floor when being transported in her wheelchair on 02/03/13 and 02/04/13. She also had swelling of the left lower leg. Following surveyor intervention, the physician was notified, and the resident was admitted to the hospital with [REDACTED]. 6) The facility failed to ensure there was enough flu vaccine to vaccinate all the facility's residents and those staff who needed/wanted the vacine. Fifty-nine residents were identified as not receiving or being offered the flu vaccine. 7) The facility failed to have information available to provide the following: a) which residents had received the flu vaccine, b) which residents had been offered the flu vaccine and refused, c) which residents had not received the flu vaccine, and d) which residents would be prioritized to receive the flu vaccine first. The facility's failure to ensure the 59 residents had received the flu vaccine placed them at risk for developing the flu at it's fullest potentcy instead of providing resistance so if they developed the flu, it would not be as harsh. This could result in the residents developing pneumonia, requiring respiratory treatments and the use of oxygen, and the potential for hospitalization . These failures to ensure adequate assessments and monitoring of residents' conditions could affect the facility's 92 residents and placed them at risk for: 1) not being adequately assessed, 2) having a change of condition or deteriorating health status go unrecognized, 3) the physician to be unaware of the residents' status, 4) not receiving needed treatment, and 5) being exposed to respiratory infections and/or the flu; which could result in a change in condition, respiratory distress, deteriorating health status and potentially require emergency help and/or hospitalization , or result in death. Findings included: 1) Upon entering the facility on 02/01/13 at 8:30 AM, the Administrator and DON both stated to the surveyor, "We bet we know why you are here. We have not completed giving our residents the flu injection this year." The Administrator stated the facility QA meeting had been held on 01/23/13. At that time, the problem of not having offered/administered the flu vaccine to residents and staff and not currently having enough doses of the flu vaccine to offer to the residents and/or staff was discussed at the QA meeting. The Administrator and DON stated an audit was completed on 01/29/13 of residents, who needed to be offered/administered the flu vaccine. However, she was unable to identify which residents had the flu vaccine and stated, "Residents go in and out. It's hard to tell who got them." A request for the list of residents identified as not having had the flu vaccine on 01/29/13 was requested from the DON at that time. When it was reviewed by the survey team, the list was not concise enough to determine identification of the residents and/or the number of residents, who needed the flu vaccine. When asked why the DON had not gotten physician orders [REDACTED]. The DON stated she had attempted to purchase the flu vaccine from their contracted pharmacy and other local pharmacies, but due to regulations, they were unable to purchase the flu vaccine. When asked whether the facility's corporate office had been notified of the facility's inability to find the flu vaccine for the residents, the DON said, "No." The surveyor then suggested the DON and/or the Administrator should notify the facilty's corporate office to request assistance with procuring the needed flu vaccine. When the Administrator and DON were asked if the facility had identified residents at risk for contracting the flu and/or residents who were ambulatory about the facility, both the Administrator and the DON replied, "No." On 02/01/13 at approximately 1:50 PM, the DON reported to the surveyor she had contacted the facility's Corporate Nurse, who was going to bring 65 doses of the flu vaccine to the facility. On 02/01/13 at approximately 2:30 PM, the Corporate Nurse arrived at the facility with 65 doses of the flu vaccine and other licensed nurses from sister facilities. The Corporate Nurse reviewed the list provided to the surveyor, which identified the residents needing the flu vaccine. The Corporate Nurse then told the surveyor there would be another audit conducted to more accurately determine how many residents needed the flu shot because the list provided to the surveyor was incomplete and disorganized. An additional audit was conducted by the DON, the Staff Development Coordinator, and Medical Records personnel on 02/01/13, which identified 59 residents, who were in need of the flu vaccine. At 6:00 PM on 02/01/13, the surveyor was provided with the results of the second audit, which was conducted by the DON, the Staff Development Coordinator and Medical Records personnel. The list identified 59 residents, who had not been offered and/or administered the flu vaccine. The list included: Residents #1, #2, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60 and #61. 2) Resident #2's MDS assessment dated [DATE] reflected the resident, an [AGE] year-old female and non smoker, was admitted to the facility originally on 10/07/10 and re-admitted on [DATE]. The MDS assessment reflected the resident required extensive assistance with transfers, dresssing, toileting, personal hygiene and bathing. The MDS assessment further reflected Resident #2 was incontinent of both bladder and bowel. [DIAGNOSES REDACTED]. Resident #2's History and Physical (H & P) dated 12/29/12 reflected further Diagnoses: [REDACTED]. Resident #2's care plan dated 01/10/13 reflected the following problems were identified: UTI, Dehydration (being given a diuretic), Falls, Risk for Contractures, Polypharmacy, Diabetes Mellitus (DM), ADLs, Cognition/Decision-Making, Skin, Anxiety, Pain and the resident's resistance to being provided care. Review of Resident #2's Immunization Record revealed she had the Pneumonia Vaccine on 07/27/11. The most recent administration of Flu vaccine was documented as administered on 10/28/10. During an interview on 02/02/13 at 6:00 PM, the DON and the Administrator had identified Resident #2 as not being offered the Flu Vaccine in 2012 or 2013. Nurses Notes dated 01/22/13 at 2:00 AM were as follows: "Resident in bed, eyes open, respirations even and unlabored. Noted with increased cough and congestion. New order for CXR (chest x-ray) to rule out pneumonia from Dr. ___." Resident #2's Physician order [REDACTED]. The result of the chest x-ray dated 01/22/13 indicated Resident #2 had pneumonia. The next entry on the Nurses Note was not until 01/28/13 at 3:00 AM (six days later). It was documented Resident #2 complained of a cough, which was treated with [MEDICATION NAME] DM. Further, "Resident in bed, eyes closed, respirations even and unlabored." The resident's vital signs were B/P 142/66, pulse 74, respirations 18, temperature 98.4 degrees F and O2 Sat. (saturation) 98%. Resident #2's Nurses Notes continued on 01/28/13 at 3:00 PM, "N/O (new order) [MEDICATION NAME] and [MEDICATION NAME] 0.83% via nebulizer Q (every) 6 hours. Will monitor." Resident #2's Physician orders [REDACTED]. Resident #2's next Nurses Note was dated 01/30/13 at 5:00 PM (two days later), which reflected "[MEDICATION NAME] mg 1 PO (by mouth) BID X 10 days Right middle lobe infiltrate." The same day at 9:00 PM: "Crackles, congestion noted in both lungs. O2 on at 2.5 LPM (liters per minute) via NC (nasal cannula). B/P 130/65, pulse 56, respirations 20, temperature 98.9 (degrees F), O2 Sat. 95%." Resident #2's physician orders [REDACTED]. The 01/30/13 chest x-ray results for Resident #2 were "Marked right lobe infiltrate. The findings are new since 1/22/2013." Resident #2's Physicians Progress Notes dated 01/31/13 had a [DIAGNOSES REDACTED]. Resident #2's Nurses Notes dated 01/31/13 at 6:00 PM indicated "Resident has coarse breath sounds. B/P 131/91, pulse 65, respirations 22, temperature 98.6, O2 Sat. 94%... with O2 Sats at 94% with O2. Resident's appetite is poor, but takes PO fluids when offered. Total care given D/T (due to) debility." Nurses Notes dated 02/01/13 at 3:00 AM for Resident #2 revealed an O2 Sat. at 93% while she was receiving O2. Resident #2 was observed during rounds at 12:15 PM on 02/02/13 by the surveyor, who was accompanied by the DON. Resident #2's breath sounds were coarse, moist sounding, and rattly, which were audible from the bedside without the need for a stethoscope. The resident was lethargic, drowsy to almost nonresponsive, had on oxygen (O2) continuously via nasal cannula, and was receiving oral care from the CNA. When asked how she felt, Resident #2 replied with much difficulty, "Not well." The surveyor asked if the DON knew what Resident #2's vital signs were, whether she had a fever and what her O2 saturation level was. The DON stated she did not know but would find out. Resident #2's vital signs were then taken at approximately 12:20 PM. The DON stated Resident #2 had a fever of 101.8 degrees F and her O2 Sat level was 91% (normal is 95 - 100%). At that time, the DON and LVN A determined the physician would be contacted for orders to send the resident to the hospital. Interview with LVN A on 02/05/13 at 10:45 AM revealed when asked if residents were routinely assessed, she replied, "We routinely assess vital signs on Medicare residents. I assess the lungs of residents on nebulizer treatments. When asked if she assessed residents with a cough or congestion, she stated, "No. They all usually have [MEDICAL CONDITIONS] and are smokers. They wheeze all the time anyway." The Third Party Discharge Planning Report dated 02/05/13 reflected Resident #2's hospital admitted was 02/01/13 with the following identified from her assessment: Altered Mental Status, Pneumonia, [MEDICAL CONDITION], Leukocytosis, [MEDICAL CONDITIONS], Type II DM, Hypertension and Elevated Brain Natriuretic Peptide (BNP) Level. The same Report indicated Resident #2's chest x-ray at 1:02 PM on 02/02/13 indicated "Right-sided pleural effusion and infiltrate." A Consultation dated 02/03/13 reflected Resident #2 underwent a thoracentesis (surgical puncture of a needle to drain the [MEDICATION NAME] cavity) to remove 100 ml of green purulent material from her lungs. A CT scan dated 02/03/13 confirmed a (right-sided) posterior basilar effusion. Surgery will not be an intervention per the family's request. According to the Third Party Discharge Planning Report dated 02/05/13, inpatient hospital treatment included: [MEDICATION NAME] Q 4 hours; the following antibiotics: [MEDICATION NAME] 500 mg Q 24 hours IVPB (Intravenous Piggyback), [MEDICATION NAME] 900 mg TID (three times daily) IVPB, [MEDICATION NAME] 500 mg Q 8 hours IVPB, [MEDICATION NAME] 3.375 G (grams) Q 6 hours IVPB, [MEDICATION NAME] 1 G Q 12 hours IVPB, and the flu vaccination - [MEDICATION NAME] 0.5 ml IM (intramuscular). The plan was when and if the resident was able, she would return to the facility on hospice. 3) Resident #3's hospital H & P dated 01/25/13 reflected the resident was admitted to the facility in July 2012. Resident #3's MDS assessment dated [DATE] reflected the resident, an [AGE] year-old female, was admitted with [DIAGNOSES REDACTED]. The MDS assessment reflected the resident required assistance with transfers and ADLs. Resident #3's care plan dated 12/20/12 reflected the following problems were identified: UTI, Falls, Cognitive Impairment, Mood, ALDs, Communication, Incontinence, Skin, Safety Awareness and Anti-Anxiety Medications. Review of Resident #3's Nurses Notes dated 01/24/13 at 1:00 PM revealed the resident had a temperature of 101.8 degrees F, which was treated with Tylenol 325 mg, and the physician was notified. Orders received were to monitor the resident and to repeat the resident's temperature. At 2:00 PM, the Nurses Notes reflected the resident's vital signs were: B/P 119/64, pulse 78, respirations 18 and temperature 98.2 degrees F. "Pt (patient) alert and responsive." Nurses Notes dated 01/24/13 at 9:00 PM (seven hours later) reflected Resident #3 was "afebrile (does not have a fever), unable to fully awaken for PM meds Will cont (continue) to monitor." The next entry on Resident #3's Nurses Notes was on 01/25/13 at 6:00 AM: "pt in bed very lethargic, pt unable talk Temp at this time 101.8 (degrees F), report from previous shift, said pt have fever 102. Tylenol 325 mg given pt able to take this med. MD notified, awaiting for return call V/S (vital signs) B/P 96/50 (previous BP was 119/64), pulse 93 (previous pulse was 78), respiratory 18." There was no O2 Sat. documented. At 8:00 AM, when the resident was rechecked, "pt. at this time very lethargic, Altered mental status noted pt not responding, skin very warm to touch. Temp at this time 102.8, A second call to Dr. ___, who said to send pt to ER for further evaluation." Resident #3's Physicians Order dated 01/25/13 indicated "Transfer to nearest ER secondary 1. Fever + 101.8 - 102.5 for 2 days. 2. Change in Altered Mental status, 3. Pt very lethargic and non responsive." Another physician's orders [REDACTED]. Resident #3 arrived at a local hospital with the following admission Diagnoses: [REDACTED]. According to the Hospital Progress Notes dated 01/30/13, inpatient hospital treatment included: [MEDICATION NAME] Q 4 hours and the following antibiotics: [MEDICATION NAME] 3.375 G Q 8 hours IVPB and [MEDICATION NAME] 750 mg Q 24 hours IVPB. The plan was for Resident #3 to return to the Nursing Facility on IVPB [MEDICATION NAME] and [MEDICATION NAME]. Resident #3's re-admission note dated 01/30/13 at 8:45 PM/9:30 PM reflected the resident's Foley catheter had been discontinued at the hospital prior to discharge and the resident had not voided that shift. Observation of Resident #3 during rounds at 8:20 AM on 02/03/13 revealed she was in bed asleep. At that time, the DON stated Resident #3 had recently returned from the hospital with a [DIAGNOSES REDACTED]. Per a review of Resident #3's Nurses Notes on 02/05/13, the most recent documentation was dated 01/31/13 at 3:30 AM, which reflected the resident was still on antibiotics for her upper respiratory infection) with no adverse reaction and no shortness of breath noted. Her respirations were equal and unlabored. Resident #3 denied pain or discomfort and voided without difficulty. However, there was no documentation for five days (three shifts per day) on a resident with a [DIAGNOSES REDACTED]. On 02/06/13 at approximately 2:00 PM, the DON was asked if there was any evidence of an assessment or resident evaluation from 01/31/13 through 02/05/13 for Resident #3. The DON responded, "It is what it is, and I can't do anything about it now." 4) The MDS assessment dated [DATE] for Resident #4, a [AGE] year-old female, reflected she was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected the resident required extensive assistance with her ADLs and was occasionally incontinent of urine. Resident #4's care plan reflected the following problems were identified: Pacemaker, ADLs, Diabetes Mellitus, Falls, Dehydration, Skin with [MEDICAL CONDITION], Left Above the Knee Amputation, and Right [MEDICAL CONDITIONS], Nine or More Medications, Hypertension, [MEDICAL CONDITION] and Pain. Resident #4 was observed during rounds at 8:20 AM on 02/03/13 and was found in bed asleep. (She was Resident #3's roommate.) The DON, who had accompanied the surveyor, reported Resident #4 was on antibiotic therapy for an Upper Respiratory Infection. "She (Resident #4) is just not feeling up to par." Review of Resident #4's Immunization Record revealed the Pneumonia Vaccine was given in 2009. The Flu Vaccine section indicated the resident's last Flu vaccine was given on 11/15/11 per the resident's family member. Resident #4's Nurses Notes dated 01/20/13 at 7:30 PM reflected the resident was on [MEDICATION NAME] and [MEDICATION NAME] for a cough and respiratory congestion without improvement. Review of Resident #4's entire clinical record and Nurses Notes dated from 01/24/13 through 01/29/13 (four days) revealed no evidence of any assessment or evaluation of Resident #4's respiratory status prior to her hospitalization on [DATE] and while she received antibiotic therapy. Review of the Nurses Notes dated 01/21/13 revealed Resident #4 was sent to the hospital per family request for coughing, respiratory congestion, and nausea/vomiting. The 01/29/13 CXR's results dated 01/30/13 indicated: "Suspicious for pneumonia. Follow-up recommended to document resolution." Resident #4' Nurses Notes dated 01/30/13 at 2:00 PM reflected the resident was currently being treated for [REDACTED]. Review of the Nurses Notes dated 01/31/13 revealed Resident #4 was sent to the hospital again per family request for coughing, respiratory congestion, and nausea/vomiting. The hospital H & P dated 01/31/13 reflected Resident #4 was admitted to the hospital on [DATE] with a chief complaint of vomiting and weakness. The H & P reflected she had not been able to eat much or keep food or medications down. The H & P further reflected she had been coughing, had no fever and the chest x-ray in ER reflected Pneumonia. The H & P's assessment indicated the following: Pneumonia, Hypokalemia and Weakness. The hospital CXR results dated 01/31/13 reflected: "New small right pleural effusion with right basilar atelectasis versus infiltrate." On 02/06/13 at approximately 2:00 PM, the DON was asked if there was any evidence of an assessment or resident evaluation for Resident #4 between 01/24/13 and 01/29/13. The DON stated, "It is what it is." 5) Resident #5's MDS assessment dated [DATE] reflected the resident, an [AGE] year-old female, was admitted to the facility on [DATE] and re-admitted on [DATE]. The MDS assessment indicated the resident was independent with her ADLs and only required assistance with her bath and personal hygiene. Resident #5's H & P dated 07/28/12 included the following Diagnoses: [REDACTED]. The care plan dated 12/04/12 reflected Resident #5 was identified with the following problems: Upper Respiratory Infection, Nutrition, Dehydration, Falls, Skin, Multiple Medications, Cancer of the Colon, Pain, Forgetfulness, ADLs, [MEDICAL CONDITION] and Smoking. The Physicians Progress Notes dated 12/27/12 reflected Resident #5 was assessed by the physician to have had yellowish sputum for seven days. At that time, the physician diagnosed an acute exacerbation of [MEDICAL CONDITION]. A report was faxed to Resident #5's physician on 01/30/13 at 2:05 PM, which reflected the resident "c/o (complains of) diarrhea, hot/sweaty, cough (with) mucous, tired. States she is afraid she is getting the flu." A physician order [REDACTED]. On 01/31/13, the Physician's Progress Note for Resident #5 reflected the physician assessed the resident with continued yellow sputum, shortness of breath, and her bilateral breath sounds were decreased. The physician then diagnosed her with [MEDICAL CONDITION] with an Upper Respiratory Infection. Review of Resident #5's Nurses Notes dated 02/02/13 at 9:00 AM revealed, "Resident c/o not feeling well Temp. 96.2." The physician was notified and given the results of the 02/01/13 CXR (left lower lobe atelectasis, no infiltrate or congestion, new findings since 12/28/12). The Notes reflected: "No new orders at this time, will continue to monitor." Review of Resident #5's entire clinical record including Nurses Notes on 02/05/13 revealed no evidence of the resident's status being monitored since the last Nurses Notes dated 02/02/13 at 9:00 AM. On 02/06/13 at approximately 2:00 PM, the DON was asked if there was any evidence of an assessment or resident evaluation for Resident #5 between 02/02/13 and 02/05/13. The DON stated, "It is what it is." Resident #5 was observed during rounds on 02/02/13 at 1:00 PM. She was lying in her bed and had a productive cough of greenish sputum. Resident #5's breath sounds were coarse, moist sounding, and rattly. The resident's breath sounds were audible from the bedside without using a stethoscope. When asked how she felt, she replied, "I feel bad." At that time, Resident #5 and her roommate, Resident #62, were asked if they had received any type of instructions by the facility staff on how not to spread infection since Resident #5 had an Upper Respiratory Infection. Both replied, "No." Resident #62 stated, "I'm just going to pull the curtain and stay on my side. I don't want this stuff." 6) The MDS assessment dated [DATE] for Resident #1, a [AGE] year-old female, reflected she was admitted to the facility on [DATE]. The MDS assessment reflected the resident had both vision and hearing impairment, disruptive behaviors, wandered, required extensived assistance with ADLs including ambulation, and no problems were identified with her skin. [DIAGNOSES REDACTED]. Resident #1 had a Care Plan dated 10/08/12 for a "Draining wound left lateral leg." Review of Resident #1's "Daily/Weekly/Monthly Body Audit and Hydration Report" (skin sheet) revealed two comments written in January 2013. On 01/04/13, Resident #1's skin was warm and dry to touch; and both lower legs were swollen. On 01/23/13, both of Resident #1's legs were swollen with the left leg "weeping. The note reflected the physician was notified on 01/23/13. Resident #1's "Daily/Weekly/Monthly Body Audit and Hydration Report" for 02/01/13 reflected: The resident's skin was warm and dry to touch. Bruising and old age spots were observed on both arms and hands. There were brownish discolored areas on the back of Resident #1's left left leg with 4+ [MEDICAL CONDITION] "weeping." The resident was encouraged to elevate her legs. On 02/03/13 at approximately 1:00 PM, the surveyor observed a wet trail of fluid in the middle of the hallway, which went from Resident's #1's room down the hall and around the Nursing Station. The continuous trail of fluid was approximately three inches wide. On 02/03/13 at approximately 1:30 PM, the fluid was observed to have dried on the floor, which had not been cleaned. On 02/04/13 at 12:15 PM, a continuous, wet trail of fluid was again observed from Resident #1's room, down the hall, curving around the Nursing Station and into the Dining Room. At that time, Resident #1 was observed being wheeled by an unknown CNA from the Dining Room. The CNA was asked what the wet trail was. She stated it was drainage from the resident's foot. She said that was why she had to bring Resident #1 back to her room. The CNA stated the resident's leg was weeping, and her dressing needed to be changed. The surveyor verified with the CNA the wet trail of fluid on the floor was drainage from Resident #1's leg. The CNA stated, "Yes." At that time, Resident #1 was observed to have Ace bandage wraps from her knees to toes on both legs. The left leg wrap was observed to be draining a clear fluid, which had soaked through the Ace bandage wraps. Again on 02/04/13 at 12:30 PM, the fluid, which had drained from Resident #1's leg, was observed to have dried on the floor, which had not been cleaned. The above observation was brought to the attention of the Corparate Nurse on 02/04/13 at approximately 3:00 PM. She stated she would follow-up on Resident #1 and the disinfecting of the floor. Review of Resident #1's MAR for January 2013 and February 2013 revealed the application and removal of Resident #1's Ace bandages was to be documented every shift as TED Hose applied/removed and to apply a dry dressing on the left lower leg, effective 01/28/13. Review of the resident's MARs revealed it was initialed as being done only daily. Review of Resident #1's Nurses Notes from January and February 2013 revealed no documentation in regard to the dressings on Resident #1's legs, the drainage and/or assessment. The only Nurses Note written in February 2013 was on 02/04/13 at 6:00 PM. "...leg noted draining water, MD notified said to send pt to hospital, so that the leg will be checked...." Resident #1's Transfer and Referral Record dated 02/04/13 reflected the resident was transferred to a local hospital on [DATE] for "Pt noted with both feet swollen, both feet also draining water." Resident #1's hospital H & P dated 02/04/13 reflected [DIAGNOSES REDACTED]. 7) On 02/05/13, The Administrator and the DON provided a list of items, which they had implemented or planned to implement to correct problems being identified. It included: Effective 02/01/13, the 59 residents' physicians were to be contacted by the licensed nurses in order to obtain orders to administer the flu vaccination to the residents. Orders received from the residents' physicians included to vaccinate the residents only if they had no signs or symptoms of a respiratory infection and were not currently on antibiotics. The Administrator, DON, Social Worker and Staff Development Coordinator were to contact the residents' respective responsible parties for consent to give the flu vaccine for those residents not capable of giving consent effective 02/02/13. The DON will contact those residents' physicians whose family/responsible parties were not able to be contacted to receive an additional order to administer the vaccine, effective 02/02/13. Residents who were not currently receiving antibiotics and did not have signs/symptoms of a respiratory infection and had not previously received the flu vaccine were to be administered the flu vaccine by licensed nurses beginning on 02/01/13 and completed by 02/02/13. New residents admitted to the facility after 02/02/13 will receive the flu vaccine within 72 hours of admission with physician orders [REDACTED]. This will be monitored by the DON. Residents assessed with [REDACTED]. If residents choose to leave their rooms, they will be provided with face masks to wear in common areas, effective 02/02/13. Housekeeping staff are utilizing disinfectant on a daily basis to wipe down handrails, door knobs and other items, which can be contaminated, effective 02/01/13. A staff in-service was initiated by a licensed nurse on 02/01/13 and will be completed by 02/04/13 addressing the Prevention of the Spread of Infection including: notification to the nurse of any changes in the resident condition and staff who have an elevated temperature with coughing and congestion will be asked to stay home until fever free. The Administrator was verifying residents had consented to the administration of the flu vaccine and to ensure documenation of the flu vaccine was placed in the Resident Immunization Binder effective 02/01/13. Residents currently receiving antibiotics will have their respective physicians notified by the charge nurse when the antibiotics are completed and obtain orders to administer the flu vaccine, effective 02/02/13. The DON, the ADON, and the Staff Development Coordinator will audit new admission charts for adherence to the administration of the flu vaccine on the first business day after admission to ensure compliance weekly for four weeks and then monthly for three months effective 02/02/13. Ongoing, residents' vaccination records will be audited monthly by the DON and reported to the Quality Assurance Committee. The DON will be responsible for ensuring vaccinations are administered as indicated effective 02/02/13. The Medical Director was notified of the SQC upon his arrival to the facility on [DATE] by the Medical Records Nurse and reviewed the action plan related to flu vaccines not being administered; no further interventions indicated. The DON will report compliance to the Quality Assurance Committee monthly for three months starting 02/20/13, effective 02/02/13. Review of the clinical records of the facility's 59 residents, who had not received the flu vaccine, revealed physician's orders [REDACTED]. This was completed o

Based on observation, interview, and record review, the Administrator and the DON failed to ensure the facility was administered in a manner, which enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for five (Residents #1, #2, #3, #4, and #5) of 13 residents reviewed for assessments and timely treatment and 59 (Residents #1, #2, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60 and #61) of 92 residents randomly reviewed for a Flu Immunization. A) The Administrator failed to: 1) supervise the DON to ensure the DON ensured licensed nursing staff were competent in resident assessment and timely treatment of [REDACTED]. 2) supervise the DON to ensure nursing staff administered flu vaccine timely, 3) ensure facility-specific policies and procedures were developed and in place for resident assessment, 4) ensure the current facility policy and procedure was implemented for the administration of flu vaccine. B) The DON failed to: 1) supervise licensed nursing staff to ensure residents were assessed appropriately and timely when exhibiting signs and symptoms of infection. 2) ensure licensed nursing staff were knowledgeable and trained in assessment skills and documentation of their assessment. 3) ensure a facility-specific policy/procedure was in place for assessment of residents. These failures resulted in the following: 1) Resident #2 had not received the flu vaccine and her status was not monitored and her deteriorating respiratory status was not identified until rounds were conducted by the surveyor and the DON. Following surveyor intervention, the resident was admitted to the hospital with [REDACTED]. 2) Resident #3's continued decline on 01/24/13 was not acted upon timely and she was not sent/admitted to the hospital for evaluation until 01/25/13. Resident #3's status following her return to the facility on [DATE] from the hospital was not monitored from 01/31/13 to 02/05/13 even though she was still receiving antibiotic therapy. 3) Resident #4's status was not assessed at all from 01/24/13 to 01/29/13 while she was receiving antibiotic therapy and prior to her hospitalization on [DATE]. 4) Resident #5's respiratory status was not monitored from 02/02/13 to 02/06/13 even though she had been administered [MEDICATION NAME] to treat her flu symptoms. 5) Resident #1's left leg left a trail of fluid on the floor when being transported in her wheelchair on 02/03/13 and 02/04/13. She also had swelling of the left lower leg. Following surveyor intervention, the physician was notified, and the resident was admitted to the hospital with [REDACTED]. 6) The facility failed to ensure there was enough flu vaccine to vaccinate all the facility's residents and those staff who needed/wanted the vacine. Fifty-nine residents were identified as not receiving or being offered the flu vaccine. 7) The facility failed to have information available to provide the following: a) which residents had received the flu vaccine, b) which residents had been offered the flu vaccine and refused, c) which residents had not received the flu vaccine, and d) which residents would be prioritized to receive the flu vaccine first. The facility's failure to ensure the 59 residents had received the flu vaccine placed them at risk for developing the flu at it's fullest potentcy instead of providing resistance so if they developed the flu, it would not be as harsh. This could result in the residents developing pneumonia, requiring respiratory treatments and the use of oxygen, and the potential for hospitalization . These failures to ensure adequate assessments and monitoring of residents' conditions could affect the facility's 92 residents and placed them at risk for: 1) not being adequately assessed, 2) having a change of condition or deteriorating health status go unrecognized, 3) the physician to be unaware of the residents' status, 4) not receiving needed treatment, and 5) being exposed to respiratory infections and/or the flu; which could result in a change in condition, respiratory distress, deteriorating health status and potentially require emergency help and/or hospitalization , or result in death. Findings included: 1) Upon entering the facility on 02/01/13 at 8:30 AM, the Administrator and DON both stated to the surveyor, "We bet we know why you are here. We have not completed giving our residents the flu injection this year." The Administrator stated the facility QA meeting had been held on 01/23/13. At that time, the problem of not having offered/administered the flu vaccine to residents and staff and not currently having enough doses of the flu vaccine to offer to the residents and/or staff was discussed at the QA meeting. The Administrator and DON stated an audit was completed on 01/29/13 of residents, who needed to be offered/administered the flu vaccine. However, she was unable to identify which residents had the flu vaccine and stated, "Residents go in and out. It's hard to tell who got them." A request for the list of residents identified as not having had the flu vaccine on 01/29/13 was requested from the DON at that time. When it was reviewed by the survey team, the list was not concise enough to determine identification of the residents and/or the number of residents, who needed the flu vaccine. When asked why the DON had not gotten physician orders [REDACTED]. The DON stated she had attempted to purchase the flu vaccine from their contracted pharmacy and other local pharmacies, but due to regulations, they were unable to purchase the flu vaccine. When asked whether the facility's corporate office had been notified of the facility's inability to find the flu vaccine for the residents, the DON said, "No." The surveyor then suggested the DON and/or the Administrator should notify the facilty's corporate office to request assistance with procuring the needed flu vaccine. When the Administrator and DON were asked if the facility had identified residents at risk for contracting the flu and/or residents who were ambulatory about the facility, both the Administrator and the DON replied, "No." On 02/01/13 at approximately 1:50 PM, the DON reported to the surveyor she had contacted the facility's Corporate Nurse, who was going to bring 65 doses of the flu vaccine to the facility. On 02/01/13 at approximately 2:30 PM, the Corporate Nurse arrived at the facility with 65 doses of the flu vaccine and other licensed nurses from sister facilities. The Corporate Nurse reviewed the list provided to the surveyor, which identified the residents needing the flu vaccine. The Corporate Nurse then told the surveyor there would be another audit conducted to more accurately determine how many residents needed the flu shot because the list provided to the surveyor was incomplete and disorganized. An additional audit was conducted by the DON, the Staff Development Coordinator, and Medical Records personnel on 02/01/13, which identified 59 residents, who were in need of the flu vaccine. At 6:00 PM on 02/01/13, the surveyor was provided with the results of the second audit, which was conducted by the DON, the Staff Development Coordinator and Medical Records personnel. The list identified 59 residents, who had not been offered and/or administered the flu vaccine. The list included: Residents #1, #2, #4, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60 and #61. 2) Resident #2's MDS assessment dated [DATE] reflected the resident, an [AGE] year-old female and non smoker, was admitted to the facility originally on 10/07/10 and re-admitted on [DATE]. The MDS assessment reflected the resident required extensive assistance with transfers, dresssing, toileting, personal hygiene and bathing. The MDS assessment further reflected Resident #2 was incontinent of both bladder and bowel. [DIAGNOSES REDACTED]. Resident #2's History and Physical (H & P) dated 12/29/12 reflected further Diagnoses: [REDACTED]. Resident #2's care plan dated 01/10/13 reflected the following problems were identified: UTI, Dehydration (being given a diuretic), Falls, Risk for Contractures, Polypharmacy, Diabetes Mellitus (DM), ADLs, Cognition/Decision-Making, Skin, Anxiety, Pain and the resident's resistance to being provided care. Review of Resident #2's Immunization Record revealed she had the Pneumonia Vaccine on 07/27/11. The most recent administration of Flu vaccine was documented as administered on 10/28/10. During an interview on 02/02/13 at 6:00 PM, the DON and the Administrator had identified Resident #2 as not being offered the Flu Vaccine in 2012 or 2013. Nurses Notes dated 01/22/13 at 2:00 AM were as follows: "Resident in bed, eyes open, respirations even and unlabored. Noted with increased cough and congestion. New order for CXR (chest x-ray) to rule out pneumonia from Dr. ___." Resident #2's Physician order [REDACTED]. The result of the chest x-ray dated 01/22/13 indicated Resident #2 had pneumonia. The next entry on the Nurses Note was not until 01/28/13 at 3:00 AM (six days later). It was documented Resident #2 complained of a cough, which was treated with [MEDICATION NAME] DM. Further, "Resident in bed, eyes closed, respirations even and unlabored." The resident's vital signs were B/P 142/66, pulse 74, respirations 18, temperature 98.4 degrees F and O2 Sat. (saturation) 98%. Resident #2's Nurses Notes continued on 01/28/13 at 3:00 PM, "N/O (new order) [MEDICATION NAME] and [MEDICATION NAME] 0.83% via nebulizer Q (every) 6 hours. Will monitor." Resident #2's Physician orders [REDACTED]. Resident #2's next Nurses Note was dated 01/30/13 at 5:00 PM (two days later), which reflected "[MEDICATION NAME] mg 1 PO (by mouth) BID X 10 days Right middle lobe infiltrate." The same day at 9:00 PM: "Crackles, congestion noted in both lungs. O2 on at 2.5 LPM (liters per minute) via NC (nasal cannula). B/P 130/65, pulse 56, respirations 20, temperature 98.9 (degrees F), O2 Sat. 95%." Resident #2's physician orders [REDACTED]. The 01/30/13 chest x-ray results for Resident #2 were "Marked right lobe infiltrate. The findings are new since 1/22/2013." Resident #2's Physicians Progress Notes dated 01/31/13 had a [DIAGNOSES REDACTED]. Resident #2's Nurses Notes dated 01/31/13 at 6:00 PM indicated "Resident has coarse breath sounds. B/P 131/91, pulse 65, respirations 22, temperature 98.6, O2 Sat. 94%... with O2 Sats at 94% with O2. Resident's appetite is poor, but takes PO fluids when offered. Total care given D/T (due to) debility." Nurses Notes dated 02/01/13 at 3:00 AM for Resident #2 revealed an O2 Sat. at 93% while she was receiving O2. Resident #2 was observed during rounds at 12:15 PM on 02/02/13 by the surveyor, who was accompanied by the DON. Resident #2's breath sounds were coarse, moist sounding, and rattly, which were audible from the bedside without the need for a stethoscope. The resident was lethargic, drowsy to almost nonresponsive, had on oxygen (O2) continuously via nasal cannula, and was receiving oral care from the CNA. When asked how she felt, Resident #2 replied with much difficulty, "Not well." The surveyor asked if the DON knew what Resident #2's vital signs were, whether she had a fever and what her O2 saturation level was. The DON stated she did not know but would find out. Resident #2's vital signs were then taken at approximately 12:20 PM. The DON stated Resident #2 had a fever of 101.8 degrees F and her O2 Sat level was 91% (normal is 95 - 100%). At that time, the DON and LVN A determined the physician would be contacted for orders to send the resident to the hospital. Interview with LVN A on 02/05/13 at 10:45 AM revealed when asked if residents were routinely assessed, she replied, "We routinely assess vital signs on Medicare residents. I assess the lungs of residents on nebulizer treatments. When asked if she assessed residents with a cough or congestion, she stated, "No. They all usually have [MEDICAL CONDITIONS] and are smokers. They wheeze all the time anyway." The Third Party Discharge Planning Report dated 02/05/13 reflected Resident #2's hospital admitted was 02/01/13 with the following identified from her assessment: Altered Mental Status, Pneumonia, [MEDICAL CONDITION], Leukocytosis, [MEDICAL CONDITIONS], Type II DM, Hypertension and Elevated Brain Natriuretic Peptide (BNP) Level. The same Report indicated Resident #2's chest x-ray at 1:02 PM on 02/02/13 indicated "Right-sided pleural effusion and infiltrate." A Consultation dated 02/03/13 reflected Resident #2 underwent a thoracentesis (surgical puncture of a needle to drain the [MEDICATION NAME] cavity) to remove 100 ml of green purulent material from her lungs. A CT scan dated 02/03/13 confirmed a (right-sided) posterior basilar effusion. Surgery will not be an intervention per the family's request. According to the Third Party Discharge Planning Report dated 02/05/13, inpatient hospital treatment included: [MEDICATION NAME] Q 4 hours; the following antibiotics: [MEDICATION NAME] 500 mg Q 24 hours IVPB (Intravenous Piggyback), [MEDICATION NAME] 900 mg TID (three times daily) IVPB, [MEDICATION NAME] 500 mg Q 8 hours IVPB, [MEDICATION NAME] 3.375 G (grams) Q 6 hours IVPB, [MEDICATION NAME] 1 G Q 12 hours IVPB, and the flu vaccination - [MEDICATION NAME] 0.5 ml IM (intramuscular). The plan was when and if the resident was able, she would return to the facility on hospice. 3) Resident #3's hospital H & P dated 01/25/13 reflected the resident was admitted to the facility in July 2012. Resident #3's MDS assessment dated [DATE] reflected the resident, an [AGE] year-old female, was admitted with [DIAGNOSES REDACTED]. The MDS assessment reflected the resident required assistance with transfers and ADLs. Resident #3's care plan dated 12/20/12 reflected the following problems were identified: UTI, Falls, Cognitive Impairment, Mood, ALDs, Communication, Incontinence, Skin, Safety Awareness and Anti-Anxiety Medications. Review of Resident #3's Nurses Notes dated 01/24/13 at 1:00 PM revealed the resident had a temperature of 101.8 degrees F, which was treated with Tylenol 325 mg, and the physician was notified. Orders received were to monitor the resident and to repeat the resident's temperature. At 2:00 PM, the Nurses Notes reflected the resident's vital signs were: B/P 119/64, pulse 78, respirations 18 and temperature 98.2 degrees F. "Pt (patient) alert and responsive." Nurses Notes dated 01/24/13 at 9:00 PM (seven hours later) reflected Resident #3 was "afebrile (does not have a fever), unable to fully awaken for PM meds Will cont (continue) to monitor." The next entry on Resident #3's Nurses Notes was on 01/25/13 at 6:00 AM: "pt in bed very lethargic, pt unable talk Temp at this time 101.8 (degrees F), report from previous shift, said pt have fever 102. Tylenol 325 mg given pt able to take this med. MD notified, awaiting for return call V/S (vital signs) B/P 96/50 (previous BP was 119/64), pulse 93 (previous pulse was 78), respiratory 18." There was no O2 Sat. documented. At 8:00 AM, when the resident was rechecked, "pt. at this time very lethargic, Altered mental status noted pt not responding, skin very warm to touch. Temp at this time 102.8, A second call to Dr. ___, who said to send pt to ER for further evaluation." Resident #3's Physicians Order dated 01/25/13 indicated "Transfer to nearest ER secondary 1. Fever + 101.8 - 102.5 for 2 days. 2. Change in Altered Mental status, 3. Pt very lethargic and non responsive." Another physician's orders [REDACTED]. Resident #3 arrived at a local hospital with the following admission Diagnoses: [REDACTED]. According to the Hospital Progress Notes dated 01/30/13, inpatient hospital treatment included: [MEDICATION NAME] Q 4 hours and the following antibiotics: [MEDICATION NAME] 3.375 G Q 8 hours IVPB and [MEDICATION NAME] 750 mg Q 24 hours IVPB. The plan was for Resident #3 to return to the Nursing Facility on IVPB [MEDICATION NAME] and [MEDICATION NAME]. Resident #3's re-admission note dated 01/30/13 at 8:45 PM/9:30 PM reflected the resident's Foley catheter had been discontinued at the hospital prior to discharge and the resident had not voided that shift. Observation of Resident #3 during rounds at 8:20 AM on 02/03/13 revealed she was in bed asleep. At that time, the DON stated Resident #3 had recently returned from the hospital with a [DIAGNOSES REDACTED]. Per a review of Resident #3's Nurses Notes on 02/05/13, the most recent documentation was dated 01/31/13 at 3:30 AM, which reflected the resident was still on antibiotics for her upper respiratory infection) with no adverse reaction and no shortness of breath noted. Her respirations were equal and unlabored. Resident #3 denied pain or discomfort and voided without difficulty. However, there was no documentation for five days (three shifts per day) on a resident with a [DIAGNOSES REDACTED]. On 02/06/13 at approximately 2:00 PM, the DON was asked if there was any evidence of an assessment or resident evaluation from 01/31/13 through 02/05/13 for Resident #3. The DON responded, "It is what it is, and I can't do anything about it now." 4) The MDS assessment dated [DATE] for Resident #4, a [AGE] year-old female, reflected she was admitted to the facility on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected the resident required extensive assistance with her ADLs and was occasionally incontinent of urine. Resident #4's care plan reflected the following problems were identified: Pacemaker, ADLs, Diabetes Mellitus, Falls, Dehydration, Skin with [MEDICAL CONDITION], Left Above the Knee Amputation, and Right [MEDICAL CONDITIONS], Nine or More Medications, Hypertension, [MEDICAL CONDITION] and Pain. Resident #4 was observed during rounds at 8:20 AM on 02/03/13 and was found in bed asleep. (She was Resident #3's roommate.) The DON, who had accompanied the surveyor, reported Resident #4 was on antibiotic therapy for an Upper Respiratory Infection. "She (Resident #4) is just not feeling up to par." Review of Resident #4's Immunization Record revealed the Pneumonia Vaccine was given in 2009. The Flu Vaccine section indicated the resident's last Flu vaccine was given on 11/15/11 per the resident's family member. Resident #4's Nurses Notes dated 01/20/13 at 7:30 PM reflected the resident was on [MEDICATION NAME] and [MEDICATION NAME] for a cough and respiratory congestion without improvement. Review of Resident #4's entire clinical record and Nurses Notes dated from 01/24/13 through 01/29/13 (four days) revealed no evidence of any assessment or evaluation of Resident #4's respiratory status prior to her hospitalization on [DATE] and while she received antibiotic therapy. Review of the Nurses Notes dated 01/21/13 revealed Resident #4 was sent to the hospital per family request for coughing, respiratory congestion, and nausea/vomiting. The 01/29/13 CXR's results dated 01/30/13 indicated: "Suspicious for pneumonia. Follow-up recommended to document resolution." Resident #4' Nurses Notes dated 01/30/13 at 2:00 PM reflected the resident was currently being treated for [REDACTED]. Review of the Nurses Notes dated 01/31/13 revealed Resident #4 was sent to the hospital again per family request for coughing, respiratory congestion, and nausea/vomiting. The hospital H & P dated 01/31/13 reflected Resident #4 was admitted to the hospital on [DATE] with a chief complaint of vomiting and weakness. The H & P reflected she had not been able to eat much or keep food or medications down. The H & P further reflected she had been coughing, had no fever and the chest x-ray in ER reflected Pneumonia. The H & P's assessment indicated the following: Pneumonia, Hypokalemia and Weakness. The hospital CXR results dated 01/31/13 reflected: "New small right pleural effusion with right basilar atelectasis versus infiltrate." On 02/06/13 at approximately 2:00 PM, the DON was asked if there was any evidence of an assessment or resident evaluation for Resident #4 between 01/24/13 and 01/29/13. The DON stated, "It is what it is." 5) Resident #5's MDS assessment dated [DATE] reflected the resident, an [AGE] year-old female, was admitted to the facility on [DATE] and re-admitted on [DATE]. The MDS assessment indicated the resident was independent with her ADLs and only required assistance with her bath and personal hygiene. Resident #5's H & P dated 07/28/12 included the following Diagnoses: [REDACTED]. The care plan dated 12/04/12 reflected Resident #5 was identified with the following problems: Upper Respiratory Infection, Nutrition, Dehydration, Falls, Skin, Multiple Medications, Cancer of the Colon, Pain, Forgetfulness, ADLs, [MEDICAL CONDITION] and Smoking. The Physicians Progress Notes dated 12/27/12 reflected Resident #5 was assessed by the physician to have had yellowish sputum for seven days. At that time, the physician diagnosed an acute exacerbation of [MEDICAL CONDITION]. A report was faxed to Resident #5's physician on 01/30/13 at 2:05 PM, which reflected the resident "c/o (complains of) diarrhea, hot/sweaty, cough (with) mucous, tired. States she is afraid she is getting the flu." A physician order [REDACTED]. On 01/31/13, the Physician's Progress Note for Resident #5 reflected the physician assessed the resident with continued yellow sputum, shortness of breath, and her bilateral breath sounds were decreased. The physician then diagnosed her with [MEDICAL CONDITION] with an Upper Respiratory Infection. Review of Resident #5's Nurses Notes dated 02/02/13 at 9:00 AM revealed, "Resident c/o not feeling well Temp. 96.2." The physician was notified and given the results of the 02/01/13 CXR (left lower lobe atelectasis, no infiltrate or congestion, new findings since 12/28/12). The Notes reflected: "No new orders at this time, will continue to monitor." Review of Resident #5's entire clinical record including Nurses Notes on 02/05/13 revealed no evidence of the resident's status being monitored since the last Nurses Notes dated 02/02/13 at 9:00 AM. On 02/06/13 at approximately 2:00 PM, the DON was asked if there was any evidence of an assessment or resident evaluation for Resident #5 between 02/02/13 and 02/05/13. The DON stated, "It is what it is." Resident #5 was observed during rounds on 02/02/13 at 1:00 PM. She was lying in her bed and had a productive cough of greenish sputum. Resident #5's breath sounds were coarse, moist sounding, and rattly. The resident's breath sounds were audible from the bedside without using a stethoscope. When asked how she felt, she replied, "I feel bad." At that time, Resident #5 and her roommate, Resident #62, were asked if they had received any type of instructions by the facility staff on how not to spread infection since Resident #5 had an Upper Respiratory Infection. Both replied, "No." Resident #62 stated, "I'm just going to pull the curtain and stay on my side. I don't want this stuff." 6) The MDS assessment dated [DATE] for Resident #1, a [AGE] year-old female, reflected she was admitted to the facility on [DATE]. The MDS assessment reflected the resident had both vision and hearing impairment, disruptive behaviors, wandered, required extensived assistance with ADLs including ambulation, and no problems were identified with her skin. [DIAGNOSES REDACTED]. Resident #1 had a Care Plan dated 10/08/12 for a "Draining wound left lateral leg." Review of Resident #1's "Daily/Weekly/Monthly Body Audit and Hydration Report" (skin sheet) revealed two comments written in January 2013. On 01/04/13, Resident #1's skin was warm and dry to touch; and both lower legs were swollen. On 01/23/13, both of Resident #1's legs were swollen with the left leg "weeping. The note reflected the physician was notified on 01/23/13. Resident #1's "Daily/Weekly/Monthly Body Audit and Hydration Report" for 02/01/13 reflected: The resident's skin was warm and dry to touch. Bruising and old age spots were observed on both arms and hands. There were brownish discolored areas on the back of Resident #1's left left leg with 4+ [MEDICAL CONDITION] "weeping." The resident was encouraged to elevate her legs. On 02/03/13 at approximately 1:00 PM, the surveyor observed a wet trail of fluid in the middle of the hallway, which went from Resident's #1's room down the hall and around the Nursing Station. The continuous trail of fluid was approximately three inches wide. On 02/03/13 at approximately 1:30 PM, the fluid was observed to have dried on the floor, which had not been cleaned. On 02/04/13 at 12:15 PM, a continuous, wet trail of fluid was again observed from Resident #1's room, down the hall, curving around the Nursing Station and into the Dining Room. At that time, Resident #1 was observed being wheeled by an unknown CNA from the Dining Room. The CNA was asked what the wet trail was. She stated it was drainage from the resident's foot. She said that was why she had to bring Resident #1 back to her room. The CNA stated the resident's leg was weeping, and her dressing needed to be changed. The surveyor verified with the CNA the wet trail of fluid on the floor was drainage from Resident #1's leg. The CNA stated, "Yes." At that time, Resident #1 was observed to have Ace bandage wraps from her knees to toes on both legs. The left leg wrap was observed to be draining a clear fluid, which had soaked through the Ace bandage wraps. Again on 02/04/13 at 12:30 PM, the fluid, which had drained from Resident #1's leg, was observed to have dried on the floor, which had not been cleaned. The above observation was brought to the attention of the Corparate Nurse on 02/04/13 at approximately 3:00 PM. She stated she would follow-up on Resident #1 and the disinfecting of the floor. Review of Resident #1's MAR for January 2013 and February 2013 revealed the application and removal of Resident #1's Ace bandages was to be documented every shift as TED Hose applied/removed and to apply a dry dressing on the left lower leg, effective 01/28/13. Review of the resident's MARs revealed it was initialed as being done only daily. Review of Resident #1's Nurses Notes from January and February 2013 revealed no documentation in regard to the dressings on Resident #1's legs, the drainage and/or assessment. The only Nurses Note written in February 2013 was on 02/04/13 at 6:00 PM. "...leg noted draining water, MD notified said to send pt to hospital, so that the leg will be checked...." Resident #1's Transfer and Referral Record dated 02/04/13 reflected the resident was transferred to a local hospital on [DATE] for "Pt noted with both feet swollen, both feet also draining water." Resident #1's hospital H & P dated 02/04/13 reflected [DIAGNOSES REDACTED]. 7) On 02/05/13, The Administrator and the DON provided a list of items, which they had implemented or planned to implement to correct problems being identified. It included: Effective 02/01/13, the 59 residents' physicians were to be contacted by the licensed nurses in order to obtain orders to administer the flu vaccination to the residents. Orders received from the residents' physicians included to vaccinate the residents only if they had no signs or symptoms of a respiratory infection and were not currently on antibiotics. The Administrator, DON, Social Worker and Staff Development Coordinator were to contact the residents' respective responsible parties for consent to give the flu vaccine for those residents not capable of giving consent effective 02/02/13. The DON will contact those residents' physicians whose family/responsible parties were not able to be contacted to receive an additional order to administer the vaccine, effective 02/02/13. Residents who were not currently receiving antibiotics and did not have signs/symptoms of a respiratory infection and had not previously received the flu vaccine were to be administered the flu vaccine by licensed nurses beginning on 02/01/13 and completed by 02/02/13. New residents admitted to the facility after 02/02/13 will receive the flu vaccine within 72 hours of admission with physician orders [REDACTED]. This will be monitored by the DON. Residents assessed with [REDACTED]. If residents choose to leave their rooms, they will be provided with face masks to wear in common areas, effective 02/02/13. Housekeeping staff are utilizing disinfectant on a daily basis to wipe down handrails, door knobs and other items, which can be contaminated, effective 02/01/13. A staff in-service was initiated by a licensed nurse on 02/01/13 and will be completed by 02/04/13 addressing the Prevention of the Spread of Infection including: notification to the nurse of any changes in the resident condition and staff who have an elevated temperature with coughing and congestion will be asked to stay home until fever free. The Administrator was verifying residents had consented to the administration of the flu vaccine and to ensure documenation of the flu vaccine was placed in the Resident Immunization Binder effective 02/01/13. Residents currently receiving antibiotics will have their respective physicians notified by the charge nurse when the antibiotics are completed and obtain orders to administer the flu vaccine, effective 02/02/13. The DON, the ADON, and the Staff Development Coordinator will audit new admission charts for adherence to the administration of the flu vaccine on the first business day after admission to ensure compliance weekly for four weeks and then monthly for three

Based on observation, interview, and record review, it was determined the facility failed to implement written policies and procedures that prohibit neglect of residents for one (Resident #14) of ten residents reviewed for neglect. Staff failed to keep Resident #14's fall mat, bed alarm, and chair alarm in place. The former DON removed the devices on 06/19/12 and Resident #14, who was assessed at high risk for falls, fell on [DATE]. PT/OT failed to evaluate and treat Resident #14's hand, which was bruised after her fall on 06/25/12, after an order was written on 07/19/12, until surveyor intervention on 08/01/12. These failures resulted in Resident #14's substantial bruising to her left hand, right hand, both arms, right side of her face and a reopened skin tear to her left elbow and pain. These failures could affect the 18 residents, who were identified with falls, by placing them at risk for falls, injuries, pain, fear, and a decreased quality of life. Findings included: Resident #14's Face Sheet, dated 08/03/12, reflected the resident was a [AGE] year-old female who was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #14's Care Plan, dated 11/11/11 reflected, "Potential for injuries from falls due to history of falls...Resident will remain safe and evidenced by no injuries from falls for the next 3 months. 2/11/12 5/12 Assess cause and pattern of previous falls and act upon resolvable factors. PT/OT evaluation as indicated and ordered. Encourage resident to call for assistance when unsteady or transferring ...Staff to assure resident receives assistance when needed ...Monitor for safety with ambulation; tends to lean backwards when walking ...BED AND CHAIR ALARM 10/27/11 (handwritten on Care Plan) Wedge cushion Abductor device between knees while up in w/c. Pillow between knees at NOC while in bed...." The Care Plan reflected it was reviewed on 02/10/12 by RN N and to continue the plan for three more months. Resident #14's Nurse's Note, dated 02/10/12 and signed by RN K, reflected the resident needed a low bed with a mat next to her bed. Resident #14's Fall Risk Assessment, dated 02/10/12 and signed by RN K, reflected 0 to 21 was low risk for falls, 22 to 42 was medium risk of falls, and over 42 was high risk for falls. The Assessment reflected Resident #14's total score was 66 which indicated she was at high risk for falls. Resident #14's MDS assessment with an assessment reference date of 05/30/12 reflected her vision was highly impaired, her short and long-term memory was impaired, and cognitive skills for daily decision-making were severely impaired. The assessment also reflected she needed extensive assistance of two or more persons for transfers, she did not ambulate in the last seven days, and she needed the assistance of two or more persons for toileting. Further review of the MDS assessment revealed Resident #14 used a wheelchair for mobility, she was unsteady and only able to stabilize with staff assistance when "Moving from seated to standing position" and "Surface-to-surface transfer," and she was incontinent of bowel and bladder. Resident #14's MDS assessment reflected no recent falls and she had range of motion impairment on one side of her upper extremities. Resident #14's Fall Risk Assessment, dated 05/30/12, reflected a score of 57 which indicated she was at high risk for falls. Resident #14's June 2012 physician's orders [REDACTED]. Resident #14's Nurse's Notes, dated 06/19/12 at 10:00 AM and signed by the former DON, reflected, "...Resident reviewed as fall risk and team decided bed & chair alarm were no longer needed as resident is less active." The Note also reflected Resident #14's family member was notified and understood. An interview with the former DON, on 08/04/12 at 12:30 PM, revealed he removed residents' bed and chair alarms and fall mats, because they did not have standing orders to have them. He stated assessments were completed on the residents prior to the removal of the safety devices and were in the residents' clinical records. Resident #14's clinical record did not reflect a Fall Risk assessment dated after 05/30/12. An interview with CNA J, on 06/27/12 at 10:10 AM, revealed Resident #14's bed alarm and fall mat were removed by the former DON. CNA J stated the former DON said the resident did not need the alarm or the mat. An interview with LVN G, on 07/31/12 at 10:04 AM, revealed the facility had fall mats, alarms, and low beds. LVN G stated the fall mats were for residents who fell out of bed, rolled out of bed, or climbed out of bed. She stated fall mats and bed alarms were removed by the former DON. LVN G stated the former DON told the CNAs to remove the fall mats and bed alarms from residents who had not fallen for a while. She stated the CNAs notified her of what they were doing. LVN G stated Resident #14 was a resident who had a fall mat and bed alarm removed. Resident #14's Physician's Telephone Order, dated 06/19/12, reflected to discontinue the resident's bed alarm and chair alarm. The order was signed by Resident #14's physician and the facility's former DON. An interview with Resident #14's Physician, on 08/03/12 at approximately 2:27 PM, revealed he was not aware the bed and chair alarms and fall mat were removed from Resident #14 and other residents who needed them. He stated he would not have had the safety devices from residents who were assessed as high risk for falls. Resident #14's Physician stated the former DON did not inform him of the removal of the safety devices for Resident #14 and other residents. The facility's Incident Report, dated 06/25/12, reflected Resident #14 fell on that date at 2:45 PM and sustained bruising and a skin tear. The Incident Report also reflected she was found lying face down on the floor next to her bed and she could not say what happened. The Incident Report reflected the nurse assessed Resident #14 with bruising to left hand, right hand, both arms, right side of her face and a reopened skin tear to her left elbow. The Incident Report reflected the resident was last seen at approximately 2:40 PM in her bed and she appeared to be sleeping. An interview with CNA I, on 06/27/12 at 4:52 PM, revealed she heard a thump and then saw Resident #14 on the floor in her room, on her stomach. She stated there was no mat on the floor, but Resident #14 had a floor mat a week or so prior to this fall. CNA I stated a week ago floor mats and alarms for the beds and chairs were removed. She said Resident #14 was a high fall risk resident, and the resident had fallen out of bed onto the mat previously. An interview with CNA H, on 06/27/12 at 3:04 PM, revealed the former DON went through residents' clinical records and gave the CNAs a list for their halls and told them to pull the bed alarms, chair alarms, and floor mats. CNA H stated the former DON had them remove the items from residents who did not have a physician's orders [REDACTED]. She said Resident #14 fell after the former DON had the safety devices removed. She said Resident #14 had a bed alarm and a mat before the fall. Further review of the facility's Incident Report dated 06/25/12 revealed an Investigation of the Incident which reflected a chair/bed alarm was not in use and the floor was dry. The section Intervention/Corrective Action/Supervisor Follow Up reflected neglect was not suspected or alleged. The Report reflected, "Resident attempted to get OOB. Has not fallen in months." The Report also reflected, "What was done during or immediately after this incident to protect the resident from further injury or risk of injury, and to prevent recurrences of this incident? bed alarm & mats put in place. Monitor, assess." An observation of Resident #14, on 07/31/12 at 9:34 AM, revealed she was lying on her back, her legs were bent at the knees, and she was asleep. A single 1/4 side rail at the head of the bed (away from the wall) was in the up position. A floor mat was not under or next to her bed or in the room at that time. There was not a bed alarm on the bed at this time. Her wheelchair was next to her bed. An observation of Resident #14, on 08/01/12 at 10:00 AM, revealed she was in her room in her wheelchair with a lap buddy in place. There was not a fall mat in the room. An observation of Resident #14, on 08/02/12 at 2:05 PM, revealed she was lying on her back in bed with the ? side rail (at the head of her bed and away from the wall) in the up position. There was not a fall mat in her room. Resident #14's Nurse's Notes dated 06/25/12 at 2:45 PM reflected, "...Res rolled OOB & fell on floor face down. Sustained multiple bruises to BUE & reopened old skin tear to (L) (left) elbow. Sustained Substantial bruising to ? side of face/under ? eye...." Resident #14's Facsimile Transmittal Sheet, dated 07/18/12, reflected LVN F informed the resident's Physician, "Res still c/o pain to ? (hand) which was significantly bruised from fall on 6-25-12. May we get x-rays? (There is moderate swelling noted.)" An interview with LVN F on 08/01/12 at 10:36 PM revealed Resident #14's hand was half closed and there was space between her fingers and her palms, when she fell . Resident #14's Physician's Telephone Order, dated 07/19/12, reflected to x-ray the resident's right hand. Another Physician's Telephone Order dated 07/19/12 reflected Therapy to evaluate and treat as indicated. Resident #14's Nurse's Notes, dated 07/19/12 at 2:00 PM, reflected the resident's right hand was swollen with signs and symptoms of a contracture. The Notes also reflected an x-ray was taken and awaiting the results. The Notes reflected Therapy was to evaluate and treat as indicated. An interview with the LVN G, on 08/02/12 at 11:25 AM, revealed she never noticed Resident #14's right hand before she was told Resident #14's hand was swollen. She stated she was the nurse who wrote the Physician's Telephone Order, dated 07/19/12, for Resident #14 to be evaluated and treated by Physical Therapy. LVN G stated she put one copy of the order in the PT box and the other copy of the order in the Medical Records box. Resident #14's Radiology Report, dated 07/19/12, reflected, "The hand is contracted with poor visualization of the fingers...There is mild widening of the scapholunate Interval, suggestive for ligamentous injury, which may be either chronic-[MEDICAL CONDITION] or acute-posttraumatic...Conclusion: Grossly intact right hand as described with scapholunate dissociation (separation of two wrist bones, scaphoid and lunate)." An interview with the Director of Therapy, on 08/01/12 at 1:46 PM, revealed he did not receive a physician's orders [REDACTED]. He stated Resident #14 was not evaluated by PT or OT. The Director of Therapy stated he was not notified in the daily Stand-Up meetings, held with facility managers, of the order for Resident #14 to be evaluated and treated by PT. He stated the DON was supposed to notify PT/OT/ST of physician's orders [REDACTED]. An interview with the Director of Therapy, on 08/02/12 at approximately 2:20 PM, revealed ideally he would see residents within 24 hours of having received a physician's orders [REDACTED]. An interview with the ADM, on 08/01/12 at 2:00 PM, revealed when accidents or incidents occurred within the facility they were to be documented on the 24 Report and discussed in the next morning's Stand Up meeting. She stated the Stand Up meeting attendees were the facility managers, including the Director of Therapy and the DON. The ADM stated she did not recall anything significant brought up in a Stand Up meeting regarding Resident #14's fall. She stated she did not know what happened to Resident #14 after the fall, or was told about any injuries she sustained. An observation, on 08/01/12 at 3:40 PM, revealed the Director of Therapy wheeling Resident #14 into the Therapy Department to evaluate and treat, which was the first time since the physician's orders [REDACTED]. An interview with the OT, on 08/01/12 at 4:20 PM, revealed she evaluated Resident #14 with the Director of Therapy for range of motion, strength, and transfers. She stated contractures had developed to Resident #14's hands, she had leg weakness, and had pain in her right index finger (Resident #14 said "ouch" on evaluation to open her hand.) An interview was conducted with the Director of Therapy and the OT, on 08/01/12 at 4:25 PM. The Director of Therapy stated upon evaluation of Resident #14's right hand, she had pain with extension of her right index finger (the resident said "ouch" when it was extended.) He stated Resident #14 was weak in her trunk and bilateral extremities, could not follow simple step commands, lost her balance after 15 seconds of standing, required maximum assistance for transfers, and required moderate assistance transitioning from a sitting to a standing position. The Director of Therapy stated he placed resting hand splints on Resident #14's hands. They stated the right hand splint was placed due to her palm showing signs of maceration (softening.) He revealed OT would monitor and adjust the hand splints. The Director of Therapy stated Resident #14's hands were tightly clenched and splints helped to prevent further contractures of her hands and to hold her hands in an appropriate position for increased range of motion. He revealed Resident #14's therapy plan would include: increasing her arm strength, increasing her potential for transfers, and transfer training to maximize her function. He stated Resident #14 was at high risk for falls, was not able to follow commands, and was not able to verbalize understanding. The Director of Therapy stated he was not aware of how long her right hand was clenched. He rated her right hand pain at nine, on a one to 10 pain scale rating with one being the least pain and 10 being the worst pain due to Resident #14 saying "ouch" during the evaluation. The OT stated Resident #14 would benefit from the splint by decreasing skin breakdown to her right palm, promoting proper positioning, and improving pain control. She rated Resident #14's right hand pain at a five using the same scale due to the placement of the resting hand splint on her hand. Both the Director of Therapy and OT contributed Resident #14's pain to her clenched right fist which caused her right hand joints to be in a maximum end range position and under maximum force, which ultimately caused maximum joint stress to her right hand (i.e. prolonged tension/stress to Resident #14's right hand ligaments/tendons caused her pain). They stated they would be managing the resident's right hand pain with electrical stimulation to increase blood flow and increase range of motion, and ultrasound (deep heat) to relax the ligaments/tendons/muscles of her right hand. The Director of Therapy apologized for having missed the physician order [REDACTED]. Resident #14's PT Plan of Care for Resident #14 dated, 08/01/12 at 10:00 PM, included the following: a. Onset Date: 07/19/12 b. Reason for Referral: Resident #14 had a fall on 07/19/12 and PT/OT asked to evaluate the resident to ensure she has the appropriate equipment and strength to prevent further falls c. Previous Therapy: no previous history of therapy d. Precautions: falls e. Underlying impairments included: oriented to self only, severely impaired safety awareness f. Current level of function included: required maximum assistance for transfers to/from bed/chair, was unable to maintain balance without moderate/maximum support, pain scale of nine out of 10 to right index finger with activity. g. Requires skilled services to focus on: PT evaluation, diathermy treatment, electrical stimulation (attended), ultrasound, therapeutic exercise, neuromuscular reeducation, gait training, massage, manual therapy, therapeutic activities, and electrical stimulation (unattended) Resident #14's OT Plan of Care, dated 08/01/12 at 5:39 PM, included the following: a. Onset Date: 07/19/12 b. Reason for Referral: potential for injury due to fall c. Previous Therapy: possible PT/OT in 2009 d. Precautions: falls e. Underlying impairments included: oriented to self only, required cues/redirection for safety on multiple occasions during the evaluation, severely impaired gross/fine motor control on all extremities, severely impaired proprioception (awareness of position of body), and severely impaired visual/perceptual memory. f. Current level of function included: requires maximum assistance for transfers, and a pain scale of nine out of 10 to arms. g. Requires skilled services to focus on: OT evaluation, diathermy treatment, electrical stimulation (constant attendance), ultrasound, therapeutic exercise, neuromuscular reeducation, massage, manual therapy, therapeutic activities, sensory integrative techniques, self-care/home management training, and electrical stimulation (unattended.) The facility's Abuse and Neglect Prevention Policy, revised July 2010 reflected: resident has the right to be free from mistreatment, neglect...by anyone...' "It is the policy of this facility that each Neglect' means the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being...The facility shall...identify, correct, and intervene in situations in which abuse, neglect...is more likely to occur...Ongoing prevention of abuse, neglect...will be directed by the Abuse Coordinator (Administrator or designee)...." The facility's Roster/Sample Matrix, CMS-802, provided to the surveyors on 08/01/12 reflected 18 residents had falls.

Based on observation, interview, and record review, it was determined the facility failed to provide assistance devices to prevent accidents for for one (Resident #14) of ten residents reviewed for falls. Staff failed to keep Resident #14's fall mat, bed alarm, and chair alarm in place to prevent falls. The former DON removed the devices on 06/19/12 and Resident #14, who was assessed at high risk for falls, fell on [DATE]. Staff failed to place a floor mat next to Resident #14's bed, as indicated by the Incident Report as an intervention, after her fall on 06/25/12. These failures resulted in Resident #14's substantial bruising to her left hand, right hand, both arms, right side of her face and a reopened skin tear to her left elbow. These failures could affect the 18 residents, who were identified with falls, by placing them at risk for falls, injuries, pain, fear, and a decreased quality of life. Findings included: Resident #14's Face Sheet, dated 08/03/12, reflected the resident was a [AGE] year-old female who was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #14's Care Plan, dated 11/11/11 reflected, "Potential for injuries from falls due to history of falls...Resident will remain safe and evidenced by no injuries from falls for the next 3 months. 2/11/12 5/12 Assess cause and pattern of previous falls and act upon resolvable factors. PT/OT evaluation as indicated and ordered. Encourage resident to call for assistance when unsteady or transferring ...Staff to assure resident receives assistance when needed ...Monitor for safety with ambulation; tends to lean backwards when walking ...BED AND CHAIR ALARM 10/27/11 (handwritten on Care Plan) Wedge cushion Abductor device between knees while up in w/c. Pillow between knees at NOC while in bed...." The Care Plan reflected it was reviewed on 02/10/12 by RN N and to continue the plan for three more months. Resident #14's Nurse's Note, dated 02/10/12 and signed by RN K, reflected the resident needed a low bed with a mat next to her bed. Resident #14's Fall Risk Assessment, dated 02/10/12 and signed by RN K, reflected 0 to 21 was low risk for falls, 22 to 42 was medium risk of falls, and over 42 was high risk for falls. The Assessment reflected Resident #14's total score was 66 which indicated she was at high risk for falls. Resident #14's MDS assessment with an assessment reference date of 05/30/12 reflected her vision was highly impaired, her short and long-term memory was impaired, and cognitive skills for daily decision-making were severely impaired. The assessment also reflected she needed extensive assistance of two or more persons for transfers, she did not ambulate in the last seven days, and she needed the assistance of two or more persons for toileting. Further review of the MDS assessment revealed Resident #14 used a wheelchair for mobility, she was unsteady and only able to stabilize with staff assistance when "Moving from seated to standing position" and "Surface-to-surface transfer," and she was incontinent of bowel and bladder. Resident #14's MDS assessment reflected no recent falls. Resident #14's Fall Risk Assessment, dated 05/30/12, reflected a score of 57 which indicated she was at high risk for falls. Resident #14's June 2012 physician's orders [REDACTED]. Resident #14's Nurse's Notes, dated 06/19/12 at 10:00 AM and signed by the former DON, reflected, "...Resident reviewed as fall risk and team decided bed & chair alarm were no longer needed as resident is less active." The Note also reflected Resident #14's family member was notified and understood. An interview with the former DON, on 08/04/12 at 12:30 PM, revealed he removed residents' bed and chair alarms and fall mats, because they did not have standing orders to have them. He stated assessments were completed on the residents prior to the removal of the safety devices and were in the residents' clinical records. Resident #14's clinical record did not reflect a Fall Risk assessment dated after 05/30/12. An interview with CNA J, on 06/27/12 at 10:10 AM, revealed Resident #14's bed alarm and fall mat were removed by the former DON. CNA J stated the former DON said the resident did not need the alarm or the mat. An interview with LVN G, on 07/31/12 at 10:04 AM, revealed the facility had fall mats, alarms, and low beds. LVN G stated the fall mats were for residents who fell out of bed, rolled out of bed, or climbed out of bed. She stated fall mats and bed alarms were removed by the former DON. LVN G stated the former DON told the CNAs to remove the fall mats and bed alarms from residents who had not fallen for a while. She stated the CNAs notified her of what they were doing. LVN G stated Resident #14 was a resident who had a fall mat and bed alarm removed. Resident #14's Physician's Telephone Order, dated 06/19/12, reflected to discontinue the resident's bed alarm and chair alarm. The order was signed by Resident #14's physician and the facility's former DON. An interview with Resident #14's Physician, on 08/03/12 at approximately 2:27 PM, revealed he was not aware the bed and chair alarms and fall mat were removed from Resident #14 and other residents who needed them. He stated he would not have had the safety devices from residents who were assessed as high risk for falls. Resident #14's Physician stated the former DON did not inform him of the removal of the safety devices for Resident #14 and other residents. The facility's Incident Report, dated 06/25/12, reflected Resident #14 fell on that date at 2:45 PM and sustained bruising and a skin tear. The Incident Report also reflected she was found lying face down on the floor next to her bed and she could not say what happened. The Incident Report reflected the nurse assessed Resident #14 with bruising to left hand, right hand, both arms, right side of her face and a reopened skin tear to her left elbow. The Incident Report reflected the resident was last seen at approximately 2:40 PM in her bed and she appeared to be sleeping. An interview with CNA I, on 06/27/12 at 4:52 PM, revealed she heard a thump and then saw Resident #14 on the floor in her room, on her stomach. She stated there was no mat on the floor, but Resident #14 had a floor mat a week or so prior to this fall. CNA I stated a week ago floor mats and alarms for the beds and chairs were removed. She said Resident #14 was a high fall risk resident, and the resident had fallen out of bed onto the mat previously. An interview with CNA H, on 06/27/12 at 3:04 PM, revealed the former DON went through residents' clinical records and gave the CNAs a list for their halls and told them to pull the bed alarms, chair alarms, and floor mats. CNA H stated the former DON had them remove the items from residents who did not have a physician's orders [REDACTED]. She said Resident #14 fell after the former DON had the safety devices removed. She said Resident #14 had a bed alarm and a mat before the fall. Resident #14's Nurse's Notes dated 06/25/12 at 2:45 PM reflected, "...Res rolled OOB & fell on floor face down. Sustained multiple bruises to BUE & reopened old skin tear to (L) (left) elbow. Sustained Substantial bruising to ? side of face/under ? eye...." Further review of the facility's Incident Report dated 06/25/12 revealed an Investigation of the Incident which reflected a chair/bed alarm was not in use and the floor was dry. The section Intervention/Corrective Action/Supervisor Follow Up reflected neglect was not suspected or alleged. The Report reflected, "Resident attempted to get OOB. Has not fallen in months." The Report also reflected, "What was done during or immediately after this incident to protect the resident from further injury or risk of injury, and to prevent recurrences of this incident? bed alarm & mats put in place. Monitor, assess." An observation of Resident #14, on 07/31/12 at 9:34 AM, revealed she was lying on her back, her legs were bent at the knees, and she was asleep. A single 1/4 side rail at the head of the bed (away from the wall) was in the up position. A floor mat was not under or next to her bed or in the room at that time. There was not a bed alarm on the bed at this time. Her wheelchair was next to her bed. An observation of Resident #14, on 08/01/12 at 10:00 AM, revealed she was in her room in her wheelchair with a lap buddy in place. There was not a fall mat in the room. An observation of Resident #14, on 08/02/12 at 2:05 PM, revealed she was lying on her back in bed with the ? side rail (at the head of her bed and away from the wall) in the up position. There was not a fall mat in her room. The facility's Roster/Sample Matrix, CMS-802, provided to the surveyors on 08/01/12 reflected 18 residents had falls.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and/or assistance devices to prevent accidents for one (Resident #14) of six residents and for five (Residents #15, #16, #17, #18 and #19) of six residents, who used oxygen, and were reviewed for smoking safety. 1. Resident #14 was smoking in the smoking area, sitting in a wheelchair, which had an oxygen tank attached to it. The resident had the nasal cannula in place with the tubing connected to the oxygen tank. Resident #14's family member, who was smoking, had turned the oxygen off at the oxygen tank. 2. A CNA, LVN and the Maintenance Supervisor did not intervene and remove the oxygen tank and tubing from the area. 3. The Staff Development Coordinator instructed staff how to turn off the oxygen on the tank, check the tubing for flow of oxygen and replace the cannula to the resident's face and allow the resident to smoke. The Staff Development Coordinator was unaware of any safety concerns with Resident #14. 4. CNAs T and U would only turn the oxygen off when a resident wanted to smoke and had an oxygen tank attached to the resident's wheelchair, which was providing oxygen. 5. The Cognitive Performance Scale and Smoking Assessments to determine a resident's need for assistance/supervision with smoking was incomplete and calculated incorrectly for Resident #14. An Immediate Jeopardy (IJ) was identified on 04/11/2012. While the IJ was removed on 04/13/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy" because the facility was still implementing and monitoring the Plan of Removal. These failures could affect the 16 residents, including Resident #14, who smoked, and placed them at risk for flash fires and burns resulting in an immediate need for medical treatment. NON-IMMEDIATE JEOPARDY 6. The Cognitive Performance Scale and Smoking Assessments to determine a resident's need for assistance/supervision with smoking were incomplete and calculated incorrectly for Residents #15, #16, #17, #18 and #19. These failures could affect Residents #15, #16, #17, #18 and #19 and the other ten residents identified as smokers and placed them at risk for not receiving the necessary supervision, assistance and assistance devices to ensure they smoked safely, which placed them at risk for the potential of burns and injury. Findings included: Based on administrative review, it was determined the facility had an Immediate Jeopardy (IJ) in the area of Quality of Care, which was identified on 04/11/12 and removed on 04/13/12. 1) Review of Resident #14's Significant Change MDS assessment dated [DATE] revealed an admission date of [DATE]. Resident #14's [DIAGNOSES REDACTED]. Further review revealed Resident #14 was unable to complete the BIMS interview and the cognitive patterns indicated a short term memory problem. Her cognitive skills for daily decision making were assessed as modified independence with some difficulty in new situations only. Resident #14's care plan dated 02/03/12 reflected the resident needed supervision during smoking. The approach for the supervision indicated the resident must be assessed prior to smoking for : a. Alertness, absence of confusion and if physically able to smoke safely. b. Is to wear a smoking apron if at all drowsy. c. Resident is to practice safe smoking precautions. d. Resident is to only smoke in designated smoking area. Review of Resident #14's smoking assessment and Cognitive Performance Scale dated 02/15/12 revealed the assessment of the resident's ability to make herself understood and the assessment of her short-term memory was wrong and not marked in the correct place on the form. The Cognitive Performance Scale had no totals marked, which were necessary to complete the Cognitive Performance Interpretation. The Cognitive Performance Interpretation had been left blank and there had been no determination of the Nursing Intervention needed for smoking until 04/11/12. The Nursing Intervention circled on 04/11/12 was identified as Potential Smoke Risk, which was incorrect due to the resident's cognitive status. On 04/12/12 at approximately 10:30 a.m., the Corporate Nurse reviewed the instructions for use of the two-part assessment, which included Cognitive Performance Scale and Cognitive Performance Interpretation to determine the Nursing Intervention needed when the resident wanted to smoke. According to the Corporate Nurse, the scores from the Cognitive Performance Scale were used in the second part "Cognitive Performance Interpretation" (algorithm) to determine the resident's ability to smoke and need for supervision/assistance. Review of the Cognitive Performance Scales conducted on 04/11/12 for Resident #14 revealed the facility staff had incorrectly documented the resident's information. The Corporate Nurse confirmed the assessment was not accurate and would be redone. On 04/12/12 at 11:00 a.m., LVN C was interviewed and asked how to score the Cognitive Performance Scale, which was on the Initial Assessment. LVN C replied, "I've not ever used that form." When asked who completed the Initial Assessment on admission, LVN C said, "Whoever admits the resident." When asked if she had ever admitted a resident, LVN C said, "Yes, but if I don't get through, the next shift finishes it." LVN C demonstrated she did not know how to complete the Cognitive Performance Scale. On 04/11/12 at 1:00 p.m., during environmental rounds with the Maintenance Director in the smoking area, which was a patio outside the C and D hall dining room, Resident #14 was observed in the smoking area at a table sitting in a wheelchair and smoking. Attached to the wheelchair was an oxygen cylinder, which was connected to oxygen tubing with a nasal cannula, which was in place on the resident's face and attached to her nose. A family member was present and smoking with Resident #14, who stated the oxygen was turned off. Further observation in the smoking area revealed an unidentified LVN and an unidentified CNA stopped and talked to Resident #14, but did not react to the oxygen tank in the smoking area in any manner. The Maintenance Director walked by Resident #14 twice and did not take notice of the oxygen. At that time, the Administrator was summoned to the area. The Administrator immediately identified the oxygen tank as a hazard and approached the resident, removed the oxygen cylinder and tubing from Resident #14's wheelchair. After removing the oxygen tank from the smoking area, the Administrator returned to Resident #4 and her family member and explained the hazard of having oxygen in the smoking area. Resident #14 was interviewed on 04/11/12 at 3:12 PM. When questioned about having an oxygen tank attached to her wheelchair, she stated when staff took her outside, they just turn the oxygen off. Resident #14 stated, "I've got to have O2 to make it to the smoking area." 2) On 04/11/12 at 2:00 p.m., the SDC stated she trained new hires during orientation about smoking and oxygen use, but the training was not documented. She stated she just "throws it in there" because of an incident, which occurred at another facility in the past. The SDC stated there was no annual training for staff in regard to smoking and/or oxygen use. She stated there was only Resident #14 came to the designated smoking area with her oxygen tank. The SDC stated she was not aware of any safety concerns with Resident #14's smoking. In addition, she stated she did not know if Resident #14's family was aware of the safety issues involved with smoking in the presence of oxygen. As the SDC, she stated she trained staff to turn off the oxygen from the tank, remove the nasal cannula to check for oxygen coming through the tubing, and then replace the cannula after it had been determined there was no oxygen flow and then allow the resident to go to the smoking area to smoke with the oxygen tank still attached to the wheelchair. The SDC stated these were the same procedures she followed. On 04/11/12 at 6:00 p.m., the surveyor informed the Administrator, the Corporate VP and the Corporate RN, the SDC was training staff to turn off the oxygen, check the tubing, and to leave the oxygen tank on the resident's wheelchair for residents with oxygen wanting to smoke. When they were asked if all staff were being trained, they assured the surveyor all staff were to receive training. 3) On 04/11/12 at 2:00 PM, CNA N was interviewed in regard to Resident #14 smoking. CNA N stated the residents were allowed two cigarettes during Smoking Breaks, but the residents can request cigarettes and smoke all day long if there was a family member to supervise. CNA N stated when she took residents with oxygen tanks outside to smoke, they could not take their oxygen tank along . The CNA stated Resident #14 always tried to get CNA N to take her outside with the oxygen on her wheelchair and just turn the oxygen off, but she (CNA N) would take the oxygen tank off the wheelchair. CNA N stated Resident #14's family member took Resident #14 outside to smoke, and she questioned whether he had any education/training in regard to smoking and oxygen. 4) The following staff were interviewed on 04/11/12 between 1:00 p.m. and 3:30 p.m. regarding residents being able to bring oxygen tanks with them to the facility's approved smoking area: a) CNA T indicated residents with oxygen must only turn the cylinder to the off position on the oxygen tank to enter the smoking area. b) CNA U responded residents with oxygen tanks must only turn the oxygen to the off position to enter the smoking area. c) The Maintenance Director was also interviewed in regard to Resident #14's oxygen tank with tubing and the nasal cannula in place on the resident. The Maintenance Director stated this was a nursing issue. 5) Review of the facility's current Oxygen Storage and Handling policy dated July 2007, indicated oxygen should not be stored near an open flame. NO SMOKING signs were to be placed at rooms where oxygen was in use. The facility's current policy for Oxygen Therapy, dated as revised July 2007, reflected the following: "Policy: To administer oxygen when indicated to provide adequate gas exchanges. A physician's orders [REDACTED].e., nasal cannula, mask, etc.). Purpose: To administer oxygen for improved tissue perfusion in specific medical conditions. Equipment: 1. Oxygen cylinder on stand or Oxygen Concentrator ...3. Oxygen signs 4. Nasal cannula, or mask and tubing... Key Steps: 1. Assess the resident's condition... 2. Explain the procedure to the resident that includes the type of equipment to be used. 3. Check the resident's room to make sure it's safe for oxygen administration. ...post a NO SMOKING sign in or near the resident's room. ...5. Monitor the resident's response to oxygen therapy. ...Check the resident frequently.... Review of the facility's current Smoking Policy (revised August 2011) given upon admission to residents/family members revealed all residents who smoked would be supervised. The policy did not specify who would supervise. In addition, the policy reflected all family members would be made aware of the facility smoking policy, and it was posted for review. The facility's Smoking Policy/Procedure, dated as revised July 2010, reflected the following: "It shall be the policy of this facility to provide a smoke free environment. No smoking will be allowed in the facility by our residents, staff or guests. Our facility is a non-smoking facility. Due to inherent safety risks, no unsupervised smoking is allowed to occur. Designated smoking areas for residents and staff will be provided outside the facility. Each resident who is admitted to this facility that chooses to smoke will be assessed by the assessment coordinator using the cognitive performance scale to determine if they are a safe smoker or a non-safe smoker. Family members will be made aware of the facility smoking policy during the admission process. Employees will be inserviced on our non-smoking policy and the location of the approved designated areas outside the building during the orientation process. Care plans will reflect support of the non-safe smokers decisions. Screening of smokers will be done upon admission, quarterly and annually to assure safety for each resident. Residents may be placed on a smoking schedule supervised by staff if the assessment determines it necessary. No smoking materials are allowed on any residents' person. Smoking materials will be kept in a locked area. The policy is posted for review. The Quality Assurance sub committee, Environment of Care, reviews adherence to the smoking policy. Failure to comply with the facility's smoking policy includes but is not limited to: - Smoking paraphernalia kept in resident's room (cigarettes, cigars, lighters, etc.); - Smoking unsupervised. Any violation of the above policy will result in a 30 day notice of discharge." Observation on 04/11/12 of the posted smoking policy, which was dated 07/30/04 and on the posting board, revealed it did not match the policy identified as being given at admission. 6) An Immediate Jeopardy (IJ) was identified at 3:30 p.m. on 04/11/12. The facility Administrator and support staff were notified at that time. A plan of removal was requested for the IJ. 7) The facility's Plan of Removal was accepted at 2:30 p.m. on 04/12/2012. The Plan of Removal reflected: The facility concern: Resident #14 was observed actively smoking with family supervision in the presence of an oxygen container. The risk to residents is limited to those that smoke. It does contain certain fire risks that without proper management or supervision all residents have the potential to be harmed. The facility took the following actions: a. The oxygen tank was immediately removed from Resident #14, who was in immediate risk. This was performed by the Administrator on 04/11/12. b. Residents and families were educated about risks related to oxygen in the presence of fire and cigarette smoking. This was performed by the LVN-Medical Records and Human Resources on 04/11/12. c. Staff in-serviced on identification of risks related to smoking and oxygen containers in the same location. This was performed by the LVN-Staff Development Coordinator, Berryman Fire Equipment and RN-Corporate Nurse. d. NO OXYGEN BEYOND THIS POINT signage was posted in the smoking area, beauty salon and laundry. Laminated signs posted as weather fast signs have been ordered. This was performed by the Maintenance Director. Temporary signs were posted 04/11/12, and the permanent signs were ordered 04/12/12. e. Care plans for smokers are updated now and quarterly to reflect risk related to smoking and oxygen use. This was performed by RN-MDS 1 and RN-MDS 2 on 04/11/12. f. A fire extinguisher was added to the smoking area. This was performed by Berryman Fire Equipment on 04/11/12. g. Sign in log sheet for smoking aide to visualize all smokers and sign that there is no oxygen in the smoking area at the time of smoke breaks. This is to be performed by the CNA assigned as the Smoking Aide. A Smoking Log was started 04/11/12. h. Families wishing to take residents outside to smoke during non-smoking times will check with nursing staff to visualize no oxygen is attached to the resident. This will be performed by the on-duty charge nurse. An in-service to start the procedure was completed on 04/11/12. i. All smokers were assessed for safety using the cognitive performance scale. This was performed by nursing staff and completed 04/11/12. 8) Review of in-services provided by the facility revealed: a. The Fire Safety In-service dated 04/11/12 was conducted by Berryman Fire. The facility had 12 of the on-duty staff in attendance. Training was ongoing with staff during normal duty hours. b. The Oxygen and Smoking Times In-service dated 04/11/12 was conducted by the Administrator and the Corporate Regional VP. The facility had 18 staff members in attendance. Training was ongoing with staff during normal duty hours. c. The No Oxygen Tanks in Smoking Area or Beauty Salon In-service dated 04/11/12 was conducted by the Administrator, the Corporate Regional VP,the Staff Development Coordinator and the Maintenance Director. There were five staff in attendance and six attempted phone interviews with family members. d. The Smoking Policy in-service dated 04/11/12 was conducted by facility staff. The facility contacted family members to discuss oxygen in the smoking area. The list indicated six family members had been contacted and advised. e. The facility provided an updated Resident Smoking Assessment form that included reviewing residents at admission, quarterly, annually and for a change of condition. The assessment also included information about the physical state of the resident. f. Systematic changes by the facility: 1) Staff will be in-serviced upon hire about fire precautions to include safety in handling residents with oxygen and who also smoke. 2) Families/Residents will be educated during the admission process about fire safety and the use of oxygen. g. Monitoring system by the facility: The Smoking Aide will verify that no one will be outside with oxygen tanks during smoking times and will sign the smoking log as verification. The log will be in the smoking box. 9) Resident #14's Cognitive Performance Scale dated 04/12/12 and completed by the DON revealed it had been conducted according to the instructions and included the nursing intervention for smoking. On 04/11/12, a care plan dated 02/03/12 for "Full Code Status" was modified to reflect "smoke risk" with the approach of "no O2 cylinders will be allowed on the patio at smoking time." 10) On 04/12/12 at 1:30 p.m., the residents were observed during the smoke break in the smoking area. No oxygen tanks/paraphernalia was observed in the designated smoking area. An unidentified CNA was supervising. Observation on 04/12/12 at 1:50 p.m. and on 04/13/12 at 9:30 a.m. of Resident #17 revealed no problems were apparent in regard to safety of the resident while smoking or other residents in the smoking area. The residents were being supervised by an unidentified CNA. Observation on 04/12/12 at 4:00 p.m. and 04/13/12 at 9:30 a.m. revealed Resident #15 was wearing a smoking apron and was supervised while smoking. Resident #18 was observed smoking on 04/12/12 at 1:50 p.m. sitting outside in the approved smoking area smoking without any problems noted. Resident #18 was sitting in a wheelchair and had full control of his upper body. On 04/13/12 at 9:30 a.m., Resident #18 was observed smoking in the smoking area and being supervised by an unidentified CNA. The resident was awake and alert and no problem was observed with the resident's safety while smoking. 11) On 04/13/12 at 3:15 p.m., LVN A was interviewed in regard to filling out the Cognitive Performance Scale, which was used to determine the amount of supervision/guidance a resident required when smoking. She stated she really just learned how to fill the form out "last night" (04/12/12) from another LVN, who was working and a new resident was being admitted . LVN A was able to accurately explain to the surveyor how the form was filled out. 12) On 04/13/12 at 4:03 PM, the DON was interviewed in regard to the Resident Smoking assessment dated [DATE], whether it was the current smoking assessment to be used and if the Cognitive Performance Scale was to be used with the Resident Smoking Assessment. The DON then went to the Administrator's office to verify information included with the smoking assessment was to be used with every new resident. The DON immediately returned and said the Resident Smoking Assessment was to be used in conjunction with the Cognitive Performance Scale with any new resident admitted to the facility. 13) On 04/24/12 at 2:55 p.m., the Administrator was contacted via telephone by the Region 3 Regulatory Services Division's Assistant Regional Director and the Enforcement Coordinator. At that time, the Administrator was informed the IJ, which was identified on 04/11/12 was assessed as a Quality of Care issue, and the IJ was removed on 04/13/12. 14) While the IJ was removed on 04/13/12, the facility remained out of compliance at a scope of "pattern" and a severity level of "no actual harm with the potential for more than minimal harm that is not immediate jeopardy" because the facility was still implementing and monitoring the Plan of Removal. 15) At the entrance conference on 04/11/12, the facility was asked to identify residents who smoked in the facility as well as residents on oxygen. Residents #14, #15, #16, #17, #18 and #19 were identified as being smokers, who also received oxygen therapy. The facility further identified a total of 16 residents in the facility, who smoked. NON-IMMEDIATE JEOPARDY FINDINGS: 16) On 04/12/12 at approximately 10:30 a.m., the Corporate Nurse reviewed the instructions for use of the two-part assessment, which included Cognitive Performance Scale and Cognitive Performance Interpretation to determine the Nursing Intervention needed when the resident wanted to smoke. According to the Corporate Nurse, the scores from the Cognitive Performance Scale were used in the second part "Cognitive Performance Interpretation" (algorithm) to determine the resident's ability to smoke and need for supervision/assistance. 17) Resident #15's current quarterly MDS assessment dated [DATE] reflected the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #15 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #15's Care Plan dated 09/07/11 reflected the resident must wear a smoking apron to smoke and required supervision with smoking. Review of Resident #15's Cognitive Performance Scale dated 11/17/11 revealed the form was not filled out per the instructions and had "mild cognitive impairment" circled. 18) Review of Resident #16's MDS assessment dated [DATE] revealed she was originally admitted to the facility on [DATE] and readmitted on [DATE]. The MDS assessment reflected Resident #16's [DIAGNOSES REDACTED]. Further review of the MDS assessment revealed Resident #16 was able to complete the BIMS with a score of 14, which indicated she was cognitively intact. The MDS assessment further identified Resident #16 as using oxygen on an as needed basis. On 04/12/12 at 1:37 p.m. in interview, Resident #16 stated, "I put my oxygen on at night. I don't use it during the day. I don't go out and smoke every time, just once in a while." Review of Resident #16's Cognitive Performance Scale on the Initial Nursing assessment dated [DATE] revealed it had not been completed. Additionally, the second portion "Cognitive Performance Interpretation" (algorithm) was not completed. Further review of the Cognitive Performance Scale for Resident #16 revealed there was no physical assessment of the resident's ability to smoke. Resident #16's Cognitive Performance Scale dated 04/12/12 and completed by the DON reflected it had been conducted according to the instructions and included the nursing intervention for smoking. 19) Resident #17's Quarterly MDS assessment dated [DATE], reflected the resident had a BIMS score of 15, which indicated the resident was cognitively intact. The MDS assessment reflected active [DIAGNOSES REDACTED]. The MDS assessment also reflected the resident received oxygen therapy and experienced shortness of breath and/or trouble breathing with exertion and lying flat. Review of Resident #17's Cognitive Performance Scale dated 02/08/12, and completed by LVN A, revealed the form was not filled out per the instructions, and had "mild cognitive impairment" circled. There was no Nursing Intervention circled in regard to the resident's smoking. In an interview with LVN A, on 04/13/12 at 3:15 p.m., she stated she did not know how to fill out the Cognitive Performance Scale when she did the one on Resident #17 on 02/08/12. She stated she just learned how to fill it out on 04/12/12, during an admission, when another nurse showed her how. Review of the Cognitive Performance Scale for Resident #17, dated 04/11/12, and completed by the DON, revealed the form was not filled out per the instructions, and had "mild cognitive impairment" circled. Review of Resident #17's Cognitive Performance Scale dated 04/12/12 and completed by the DON revealed it was conducted according to the instructions, revealed the resident had mild cognitive impairment and had modified smoking privileges. In an interview with the DON, on 04/13/12 at 12:30 p.m., she stated she incorrectly filled out Resident #17's Cognitive Performance Scale dated 04/11/12. 20) Review of Resident #18's MDS assessment dated [DATE] revealed a BIMS score of 15, which indicated the resident was cognitively intact. The MDS assessment reflected the resident was receiving oxygen therapy and the resident experienced shortness of breath and/or trouble breathing with exertion. Resident #18's Cognitive Performance Scale dated 09/21/11, and completed by the DON revealed the form was not filled out per the instructions, and had "no cognitive impairment" circled. However, the Nursing Intervention for Smoking identified Resident #18 as a "Potential Smoke Risk." Review of the Cognitive Performance Scale dated 04/11/12 for Resident #18 and completed by the DON revealed the form was not filled out per the instructions, and had "mild cognitive impairment" circled. On 04/12/12 at approximately 10:30 a.m., the Corporate Nurse reviewed Resident #18's Cognitive Performance Scales conducted on 04/11/12, which revealed facility staff had incorrectly documented the resident's information. The Corporate Nurse confirmed the assessment was not accurate and would be redone. Review of the corrected facility Cognitive Performance Scale for Resident #18, dated 04/12/12, and completed by the DON, revealed a score of three, which indicated mild cognitive impairment and modified smoking privileges. In an interview with the DON, on 04/13/12 at 12:30 p.m., she stated she incorrectly filled out Resident #18's Cognitive Performance Scales dated 09/21/11 and 04/11/12. 21) Resident #19's current quarterly MDS assessment dated [DATE] reflected the resident was admitted to the facility on [DATE] with diagnose including: Hypertension, [DIAGNOSES REDACTED], Depression, Asthma, Rheumatoid Arthritis, [DIAGNOSES REDACTED], Neuropathy, and Osteoporosis. Resident #19 had a BIMS score of 15 which indicated the resident was cognitively intact. Review of the facility's Cognitive Performance Scale for Resident #19, dated 08/09/10 revealed it had not been filled out.

Based on observation, interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical well-being for one (Resident #1) of four sampled residents reviewed for accidents. Resident #1 cut her legs while shaving on 08/27/11. The physician was not notified and orders for treatment were not received until 08/29/11, when the treatment nurse noticed Resident #1's legs were red and queried the resident about them. an order for [REDACTED]. The physician was not notified. There was no change in the treatment orders, and treatments were not provided on two weekends. When the antibiotic was finished on 09/04/11, the physician was not notified, and there was no reordering of an antibiotic. The resident made requests for the physician to look at her legs, but this did not occur. Resident #1 had a family member take her to a pharmacy and when she showed her legs to the pharmacist for a recommendation for treatment, the pharmacist told her to go to the hospital. Resident #1 went to the hospital ER, where she was admitted for treatment of [REDACTED]. These failures affected Resident #1 resulting in her admission to the hospital for treatment of [REDACTED]. These failures could affect the facilty's 101 residents, placing them at risk for the development of infection, resulting in pain, and the need for medical treatment in the hospital. Findings included: 1) Resident #1 was a [AGE] year-old female re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was identified as "interviewable" on a list provided by the Administrator on 09/29/11. 2) Resident #1's Progress Notes reflected the following entry dated 08/27/11 at 12 AM: "I arrived in ____ (Resident #1)'s room for her scheduled meds and she was in the bathroom. I asked the aide to assist her. When she came out she had scratches on both shins, she said she cut herself shaving. I cleaned the wounds and applied TAO. She said she was ok and lain (sic) down to go to sleep." The progress note was signed by RN B. Review of 24 Hour Report logs dated 08/28/11 and 08/29/11 revealed entries had been included for the night shift for Resident #1 and reflected "cut leg shaving." Interview with RN B on 09/29/11 at 5:20 PM revealed he did not complete the Incident/Accident form and follow the facility policy on Incident/Accidents regarding the cuts on Resident #1's legs on 08/27/11. RN B stated, "I was brand new and didn't know (facility policy and procedures)." He was not able to recall if he received training on Incident and Accident reporting. "If they did, it (training) wasn't real thorough, not trying to shoot the blame on anyone." He recalled the night of the incident with Resident #1. "She had (paper) tissue stuck to her leg. She told me she cut her legs shaving. I sat her down, took the tissue off, cleaned the wounds, put triple antibiotic ointment on, she said she was fine. Then I gave her scheduled medications. It was around midnight (12:00AM). I was working the 11-7 shift." He did not recall Resident #1 complaining of pain at the time of the incident or any time after the incident. When asked to describe if he noticed any changes to Resident #1's legs, he stated, "...wounds were healing properly, no signs of infection; it looked like she was coming along, no complaints of pain or anything." Review of a Personnel Action form dated 09/13/11 revealed RN B had been written up for failing to report the incident regarding Resident #1 on 08/27/11 to the appropriate individuals, including the resident's family and physician. He did not have any other disciplinary actions in the file. 3) The next Progress Note entry was dated 08/30/11 and reflected: "Rec'd (received) order from ____ Hospice for resident to receive [MEDICATION NAME] (antibiotic) 500 mg PO TID X (times) 7 days for wound infection ID (initial dose) given this AM." Further review of Resident #1's progress notes revealed no entries describing Resident #1's wounds. Resident #1's physician's orders [REDACTED]. Review of Resident #1's September 2011 MAR indicated [REDACTED]. Further review of the resident's September 2011 MAR indicated [REDACTED]. Resident #1's physician's orders [REDACTED]." Review of Resident #1's treatment record for September 2011 revealed an order written [REDACTED]. There was no change in the treatment provided to Resident #1's legs. The treatment record reflected no treatment was given on 09/03/11 (Saturday), 09/04/11 (Sunday), 09/10/11 (Saturday) and 09/11/11 (Sunday) for a total of four missed treatments. 4) Resident #1's Daily/Weekly/Monthly Body Audit and Hydration Reports for August 2011 and September 2011 reflected the following entries made by LPN D: 08/28/11 "Areas Bilat (bilateral) legs d/t (due to) resident shaving herself " 09/01/11 and 09/02/11 "NC" (no change) 09/05/11 "Skin W/D to touch. Open areas bilat LE's (lower extremities) from shaving. BLE's red and [MEDICAL CONDITION]" 09/06/11- 09/09/11 "NC" 09/10/11 and 9/11/11 blank Interview with LPN D on 10/03/11 at 11:10 AM revealed she was the wound nurse at the facility and had been caring for Resident #1's wounds. When queried how she found out about Resident #1's wounds, LPN D stated she was sitting outside the facility with Resident #1 on 08/29/11 and noticed her legs looked red beneath her pants. She stated she asked Resident #1 what had happened to her legs and was told about the shaving incident. LPN D stated she normally received a skin sheet from the nurses when a treatment was needed but she had not received anything regarding Resident #1. She stated she began doing dressing changes and notified Resident #1's nurse. When queried as to whether she filled out an incident report, LPN D stated the nurses did the incident reports and she did the treatments. When queried about her entry on 09/05/11 reflecting Resident #1's legs were red and [MEDICAL CONDITION], LPN D stated, "Yes, but they were always red. That's how I spotted them under her pants. On Friday, (09/09/11) the open places were scabbed and dry. She never asked me to see a doctor. I saw her every day and changed her dressing. She may have told a nurse." 5) Interview with Resident #1 on 09/29/11 at 10:30 AM revealed on 08/27/11 she had cut both her legs with a razor she brought to the facility from home. She stated they "weren't bad at first," but "then got worse and worse." Resident #1 stated the wounds started leaking yellow fluid. Resident #1 stated she asked the nursing staff several times to see a physician but was never seen by a physician. She was unable to identify whom she asked. She added the nurses knew they (the wounds) were bad, because they (nursing staff) were cleaning them and putting bandages on them. When queried about an antibiotic order, Resident #1 stated she was told the doctor put her on an antibiotic, but it did not work. Resident #1 stated she called her son to take her to the pharmacy so she could get something herself. While at the pharmacy that day, she showed the pharmacist her legs and asked for a recommendation. She stated the pharmacist told her to go straight to the ER. When queried what time she left the facility, Resident #1 stated it was around dinnertime, and "You can see what time I signed out." Resident #1 denied returning to the facility before going to the ER and denied receiving her evening medications from the facility that day. Obsservation at that time of Resident #1's legs revealed they had healed and were without signs/symptoms of infection. 6) Resident #1's family member was interviewed by telephone on 09/30/11 at 3:40 PM. The family member stated while they were at theER on [DATE], the nurse there told them they had received Resident #1's September 2011 MAR by fax from the facility. 7) Review of the Facility's sign-out book located at the nurse's station revealed Resident #1 had signed herself out of the facility on 09/11/11 at 5:30 PM. Resident #1 had signed herself out on another resident's form by mistake. 8) Review of ER hospital records revealed Resident #1 was admitted to theER on [DATE] at 7:10 PM. Review of hospital records revealed an Admission History and Physical (H&P) dated 09/11/11. The Physical examination on the H&P reflected, "EXTREMITIES: 2+ [MEDICAL CONDITION] and [DIAGNOSES REDACTED]tous from below the knee up to the ankle and with serous discharge with [MEDICATION NAME], papular, and vesicular [MEDICAL CONDITION] in bilateral lower extremities (swelling caused by fluid, reddened skin with flat red areas, raised red bumps and fluid filled bumps on both her lower legs). ASSESSMENT: reflected 1. Bilateral lower extremity [MEDICAL CONDITION]. 2. Rule out contact [MEDICAL CONDITION] ____ (Resident #1) was discharged from the hospital on [DATE]...." 9) Resident #1's MAR for September 2011 reflected the resident's [MEDICATION NAME] (antibiotic) 300 mg to be administered every eight hours was not signed as administered for the following scheduled doses: 09/23/11, all doses, and 09/24/11 at 1:00 AM, 09/26/11-09/30/11 all 5:00 PM doses. 10) The facility's current Accident and Incidents Policy, revised July 2010, reflected "all accidents, incidents or unusual occurrences involving a resident, visitor or employee will be documented and reported to meet all the regulatory requirements." Definitions reflected: 1. Accident "Any unexpected or unintentional incident or chain of events, which may or may not result in injury or illness to a resident..." 2. Unusual Occurrence or Event "a. Any event not consistent with routine resident care; b. An event or happening involving a resident or visitor with unintended, undesirable or unexpected results or outcomes. Procedure included: 1. Reporting "a. Regardless of how minor an accident incident may be, it must be reported to the department supervisor... c. The DON must be informed of all accidents or incidents." 3. Medical Attention The ADON, Supervisor or the charge nurse shall: a. Examine all accident/incident victim. b. Inform the physician of the accident or incident c. Follow up charting shall occur every shift for the 72 hours following the incident or accident...." 11) The CMS Form 672, Resident Census and conditions of Residents, dated 09/29/11 and signed by RN C reflected a census of 101 residents.