Every finding on record at Cameron Healthcare Center

Based on observations, review of clinical records, facility documentation, and staff interviews the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases, to help prevent cross-contamination and infections including Covid-19 in regard to, follow CDC (Centers for Disease Control) guidelines for use of PPE (Personal Protective Equipment) and ensure staff donned appropriate personal protective equipment (PPE) prior to wound care for a resident on (Enhanced Barrier Precautions) and provide appropriate wound cere. The facility also failed to ensure the laundry area had bags of trash and dirty laundry in receptacles. These failed practices had the potential to affect every resident currently residing in the facility. Resident identifier:# 2. Facility census: 54. Findings included: a) Resident #2A record review revealed Resident #8 was in Enhanced Barrier Precautions (EBP) due to wound care.On 03/02/26 at 2:00 PM, Licensed Practical Nurse (LPN) #35 with assistance from Nurse Aide (NA) #56 was observed providing wound care on Resident #2's pressure Ulcer without proper PPE. They were only wearing gloves.During continued observation, the surveyor noted that LPN #35 removed packaging from wound supplies and cleaned the wound bed. She then removed additional supplies and placed a clean 4x4 and gauze around the wound without performing hand hygiene.Observation of the EBP sign on the door Resident #2's room revealed a sign titled Enhanced Barrier PrecautionsThe sign stated: Attention: Caregivers, Staff, and Visitors -Wear Gown and Gloves prior to these activities: During high contact resident care activities.- Dressing, bathing/ showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use of a device (i.e. central line, urinary catheters, feeding tube, tracheotomies, ventilators), and wound care: any skin opening requiring a dressing.- Face protection may also be needed if performing activity with risk of splash or spray.-See the care plan for additional information.During an interview, with LPN #35 on 03/02/26 at 2:15 PM, she stated that she should have worn a gown during wound care. She also acknowledged that she should have changed her gloves after touching any dirty area of the wound and before touching any clean areas during the treatment. During the laundry tour on 03/03/26 at approximately 11:30 AM, the surveyor observed bags of trash and bags of dirty laundry on the floor. The laundry receptacles were overflowing with dirty clothing. During the tour the Maintenance Director confirmed that no items should be placed on the floor.

Based on observation, resident interview, staff interview and policy review the facility failed to provide a comfortable home like environment in the communal shower room. This failed practice was a random opportunity for discovery and had the potential to effect more than a limited number of residents during the Long-Term Care Survey Process. Resident identifier: #42. Facility census: 54.Findings Include:a) Communal Shower RoomDuring the initial interview on 03/02/26 at 12:40 PM, Resident #42 stated, The shower room is cold. That is why I wash myself off at the sink a lot of days.An observation on 03/02/26 at 1:00 PM, revealed the shower room felt cool. There was no thermometer in the shower room to get the actual temperature.A further observation of the communal shower room at 1:05 PM, with The Director of Maintenance (DOM), confirmed the room felt cool and noted there was no thermometer to get the actual temperature. The DOM took the room temperature with the water temperature thermometer, which read 71 degrees Fahrenheit. The State Agency (SA) asked if he had a wall thermometer he could place in the room so the actual temperature could be determined.A wall thermometer was placed in the communal shower room by the DOM at approximately 1:10 PMAn observation on 03/02/26 at 2:00 PM with the DOM revealed the actual temperature of the shower room to be 67.7 degrees Fahrenheit. The DOM confirmed the temperature was not comfortable for the shower room.During an interview on 03/02/26 at 2:10 PM, Nursing Assistant (NA) stated, I myself have given one shower in there today. That is the only shower room we use for residents.b) PolicyA review on 03/03/26 at 9:30 PM of the policy titled {Extreme Cold Temperature Protocol}, under policy, reads as follows: It is the policy of this facility to provide resident centered care that meets the psychosocial, physical and emotional needs and concerns of the residents. The purpose of this policy is to provide direction when when internal environmental temperatures drop below the minimum comfort of 71 degrees Fahrenheit

Based on staff interview and record review the facility failed to ensure medical assessments regarding the frequency of falls were completed accurately.This deficiency was identified in one (1) out of two (2) records reviewed. Resident identifier: #6. Facility census: 54. Findings include:a) Resident #6Review of Resident Assessment Instrument (RAI) manual for Minimum Data Sheets (MDS) Section J1800 reads in part, Any falls since admission/entry or reentry or prior assessment, whichever is more recent. Section: J1800 of the MDS, with an Assessment Reference Date (ARD) of 08/18/2025 revealed the MDS registered nurse ( RN) marked the answer as (no) to the question Any falls since admission/entry or reentry or prior assessment, whichever is more recent. Record review revealed Resident #6 had fallen on 05/12/25, 06/07/25, 06/08/25. During an interview on 03/03/26 at around 11:30 AM with MDS RN #27, the RN reviewed observations and reported, I may have missed these, as they should have been answered yes. It could be an error on my end. I will go back and review and return to verify the answer. On 03/03/26 at 12:00PM MDS RN #27 returned and explained that, indeed I missed two, I have modified these to reflect the falls.

Based on resident interview and record review the facility failed to provide Activities of Daily Living (ADL) care to dependent residents during meal times. This failed practice was found true for (1) one of (3) three residents reviewed for ADL care during the Long-Term Care Survey Process. Resident identifier: #11. Facility census: 54.Findings Include:a) Resident #11During the initial interview on 03/02/26 at 12:35 PM, Resident #11 stated, About a week ago, I asked to have my brief changed about 15 minutes before supper and was told by the nurse aide that I would have to wait until after the meal.A record review on 03/04/26 at 9:30 AM, revealed an ADL care plan for Resident #11 that had an intervention that read as follows:Toileting Hygiene: Totally dependent of 1, 1 helper does all the effort. Resident does none of the effort.During the Resident Council meeting with the State Agency (SA) on 03/03/26 at 10:15 AM, The Resident Council as a whole said they are being told they have to wait until after meals to be changed or taken to the restroom.During an interview on 03/04/26 at 12:03 PM, the Director of Nursing (DON) acknowledged that the Resident Council and Resident #11 told the SA staff were not providing ADL care during meal times.

Based on record review and staff interviews, the facility failed to provide care and services in-accordance with professional standard of practice in regards to adverse drug consequence, Adverse consequence is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The resident had not yet experienced side effects from the medication. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #9. Facility census: 54.Findings included:a) Resident #9Adverse consequence is a broad term referring to unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. The resident had not yet experienced side effects from the medication. A review for Unnecessary Medication regarding Resident #9 identified that Acetaminophen was added to the drug allergy list on the admission date of 12/24/25.Continued medical record review revealed an order: Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 650 mg by mouth every four (4) hours as needed for Pain. Order date 02/02/26.A review of Resident #9s medication administration record found Acetaminophen 650 mg was given on 02/20/26, 02/21/26 and 03/04/26.Subsequent review of Resident #9s Medication Regimen Review (MRR) for February 2026 discovered, Acetaminophen was not noted as an Adverse Consequence.On March 4, 2026, at approximately 10:00 AM, the Director of Nursing (DON) verified the Acetaminophen was given to Resident #9 the facility nor the pharmacist identified the potential for adverse consequences regarding the administration of Acetaminophen to Resident #9.

Based on record review and staff interviews Medication Regimen review (MRR) failed to evaluate and report on the potential adverse consequences for a resident to receive a medication in which they had a listed drug allergy. This was true for one (1) of five (5) reviewed for unnecessary medications. Resident identifier #9. Facility census: 55.Findings included:a) Resident #9A review for Unnecessary Medication regarding Resident #9 identified that Acetaminophen was added to the drug allergy list on the admission date of 12/24/25.Continued medical record review revealed an order: Acetaminophen Oral Tablet 325 MG (Acetaminophen): Give 650 mg by mouth every four hours as needed for Pain. Order date: 02/02/26.A review of Resident #9's medication administration record found Acetaminophen 650 mg was given on 02/20/26, 02/21/26 and 03/04/26.Subsequent review of Resident #9's Medication Regimen Review (MRR) for February 2026 revealed that Acetaminophen was not noted as an Adverse Consequence.On 03/04/26 at approximately 10:00 AM, the Director of Nursing (DON) verified that neither the facility nor the Pharmacist identified the potential for adverse consequences when administering Acetaminophen to Resident #9.

Based on record review, facility documentation, and staff interview, the facility failed to protect residents from resident abuse. The facility failed to provide a safe environment for Residents. The deficient practice put five (5) of five (5) Residents at risk for serious injury, serious harm, serious impairment, or death. Resident Identifiers #32, #52, #14, #49, #36, and #24. Facility census: 52. The facility was notified of the Immediate Jeopardy (IJ) at 6:53 PM on 08/13/24. The facility submitted their first abatement plan of correction (POC) at 7:28 PM on 08/13/24. The POC was accepted by the state agency at 7:47 PM on 08/13/22. After observation of the implementation of the abatement POC, the IJ was abated at 3:30 PM on 08/14/24. The IJ started on 08/13/24 and ended on 08/14/24. The facility's approved abatement POC consisted of the following: Correction action for area of concern- - Education to all staff in building at current time with remaining education to all staff 8/14 - education will be on 1:1 process - Resident is 1:1 on 8/13 @ 7:1 - Monitor signs and symptoms of agitation - notify physician immediately with any increased agitation - Utilize medications appropriately - Social Services Supervisor will conduct resident interviews on all residents who are able to be interviewed - Body audits will be completed by licensed nurses to ensure no abuse or neglect - Ad hoc QAPI will be conducted on 8/14 with physician to discuss abatement plan - Additional education will be provided as needed DISCLAIMER: The preliminary findings and subsequent abatement plan are not an admission of wrongdoing, but an acknowledgement of the surveyor's preliminary findings. Findings included: a) Resident to Resident Abuse A record review during the Facility Reported Incident (FRI) surveys found Resident #32 was admitted to the facility on [DATE]. The Brief Interview for Mental Status (BIMS) score was 4 which indicates severe cognitive impairment. On 01/09/24 Resident #32 was noted to be physically aggressive, putting Resident #36 in a head lock. On 02/01/24 Resident #32 was reported to wrap his arm around another Resident #36's neck then placed his head on the back of his neck and squeezed. Continued review found Resident #32 was sent to Laurel Place for behavioral health treatment from 02/23/24 through 03/06/24. Discharge diagnoses from Laurel Place: Major Depressive Disorder, Anxiety Disorder, Dementia with Behavioral Disturbance, Inappropriate Sexual Behavior. Subsequent review found on 03/24/24 Resident #32 grabbed Resident #49 by the right arm, shaking him and stating he was going to kill him. On 4/3/24 Resident #32 grabbed Resident #24's left hand and wrist, squeezed and twisted, causing swelling, bruising and pain to the left wrist. 1:1 intervention -04/04/24 through 04/10/24. 05/16/24 Resident #32 becoming physical aggressive trying to take Resident #14's plate of food. 1:1 intervention -05/17/24 through 05/20/24. A Progress note on 7/23/24 Notified that Resident #32 has been agitated most of the day. He has been going into other residents' rooms with aggressive behaviors. He went into Resident #52's room to begin fighting when Resident #52 pushed Resident #32 to the floor. Resident #32 fell to the floor although continued with aggressive verbiage attempting to attack staff as well as residents. Police were notified to calm the situation although resident continues with outbursts. 1:1 intervention -07/08/24 through 07/12/24. 1:1 intervention -07/23/24 through 07/23/24. During an interview on 08/13/24 about 5:00 PM the Administrator verified all noted incidents. She stated that they have tried everything with Resident #32.

Based on observations and staff interview, facility staff failed to provide the housekeeping services necessary to maintain a safe, clean, comfortable, and homelike environment, by not maintaining the water temperature at a comfortable level for residents, and not ensuring that the shower rooms, and residents bathrooms were free of any accumulated dirt, grime, or other substances, and foul odors. Resident Identifiers: #4, #10, and #13. Facility Census:52. The findings included: a) Resident #4: During an interview with Resident #4 on 08/12/24 at 1:22 PM, she stated that the water was always cold when she was given a shower. An inspection of the resident's hand sink revealed no hot water, even after the water was left running for over three minutes. NA #8 confirmed that water temperature was cold. b) Resident #10 During an inspection of Resident #10's bathroom on 08/12/24 at 1:44 PM, a black substance was noted between the floor tiles. NA #8 responded to this surveyor's request and confirmed the black substance. She stated that the floor needed to be cleaned. c) Resident #13 An interview with Resident #13 on 08/12/24 at 2:18 PM, the resident stated that the water was always cold. An inspection of the resident's bathroom revealed a foul, offensive odor. NA #8 confirmed that the bathroom smelled bad, and that it needed to be cleaned. Inspection of the resident's hand sink revealed that no hot water flowed out of the faucet, after the water had been running for at least three minutes. NA #8 confirmed that water temperatures were always cold. She stated that it was a frequent complaint from the residents. d) B-Hallway Shower Room: An inspection of the shower room on B Hallway on 08/12/24, at approximately 2:20 PM revealed two (2) shower benches with a brown substance on their legs. The whirlpool tub contained wheelchair footrests. NA #8 confirmed the observations and explained that the facility was not currently using the whirlpool bath. e) Resident Council A document review revealed a grievance log with complaints about the shower room. 1) On 03/20/24 a Resident Council attendee's complaint stated: Residents don't think shower room is clean enough, and needs to be cleaner and stocked better. 2) On 4/17/24 Residents #18 and #46 complained that the shower room needs to be cleaned better and should have air fresheners. 3) 0n 05/22/24 a Resident Council attendee's complaint stated: Complaints about the shower room not clean enough, and odor. The grievance log further states that these issues were addressed after each complaint. During an interview with the Director of Plant Maintenance (DPM) #13 on 08/12/24 at 2:52 PM, he stated that the facility attempted to maintain hot water temperatures between 105 and 109 degrees Fahrenheit (F). A request for a temperature check of the hot water in Resident #13's room revealed a temperature of 78 degrees Fahrenheit. DPM #13 confirmed that the water temperature was not within the specified range.

Based on observations and staff interviews the facility failed to ensure the facility nursing staff posting was completed for the day shift. This was a random opportunity for discovery during the revisit survey. Facility Census: 53 Findings include: On 10/02/24 at approximately 9:32 AM a surveyor observed the Nursing staffing sheet hung at the end of C - Hall was not completed for the Day shift. During an interview with Licensed Practical Nurse (LPN) #40 confirmed the staffing sheet should have been completed. The LPN stated, I'm doing it now we have been passing meds. An interview with the Director of Nursing (DON) was completed on 10/02/24 at 12:00PM. The interview confirmed the staffing sheet should have been completed at the beginning of day shift. Record review on 10/02/24 of the facility's policy #: NS 1091-01 under Procedure it stated, The facility will post the nurse staffing data daily at the beginning for each shift.

Based on observations and staff interviews the facility failed to ensure the facility nursing staff posting was completed for the day shift. This was a random opportunity for discovery during the revisit survey. Facility Census: 53 Findings include: On 10/02/24 at approximately 9:32 AM a surveyor observed the Nursing staffing sheet hung at the end of C - Hall was not completed for the Day shift. During an interview with Licensed Practical Nurse (LPN) #40 confirmed the staffing sheet should have been completed. The LPN stated, I'm doing it now we have been passing meds. An interview with the Director of Nursing (DON) was completed on 10/02/24 at 12:00PM. The interview confirmed the staffing sheet should have been completed at the beginning of day shift. Record review on 10/02/24 of the facility's policy #: NS 1091-01 under Procedure it stated, The facility will post the nurse staffing data daily at the beginning for each shift.

50801 Based on observation and staff interview, the facility failed to dispose of expired food items. This failed practice had the potential to affect more than a limited number of residents who were served food from the kitchen. Facility census: 52. Findings included: a) Initial Tour of Kitchen During the initial tour of the kitchen, on [DATE] at 11:30 AM, with the Dietary Manager revealed One (1) unopened box of muffin mix found to have an expiration date of [DATE], stamped on the container by the manufacturer. The Dietary Manager stated This should have been thrown out and immediately disposed of muffin mix. Based on observation and staff interview, the facility failed to dispose of expired food items. This failed practice had the potential to affect more than a limited number of residents who are served food from the kitchen. Facility census: 52. Findings included: A) Initial Tour of Kitchen with Dietary Manager My Observations during the initial tour of the kitchen, on [DATE] at 11:30 AM, revealed: One unopened box of muffin mix found to have an expiration date of [DATE], stamped on the container by the manufacturer. The Dietary manager stated: This should have been thrown out and immediately disposed of it

Based on observation, interviews with facility staff, and a review of facility policy and procedures, it was determined that the facility failed to follow acceptable infection control practices that controlled, or prevented, the spread of infection. This practice had the potential to affect all residents that reside in the facility. Facility Census: 52. Findings included: a) Water Management During facility record review of the water management, it was revealed that the facility did not have a Water Management Plan, or a water flow diagram which identified the facility's water systems for which Legionella control measures were needed. No documentation was maintained, or provided, describing facility's control practices to prevent growth of water borne pathogens. b) Laundry Services On 08/14/24 at 2:16 PM an inspection of the soiled laundry room, accompanied by Director of Plant Maintenance (DPM) #13 observed that the door between the soiled laundry room and clean laundry room was held open by a box of detergent. The clean laundry room contained a rack of uncovered clean clothing in close proximity to the open door. The opened door potentially caused contamination of the clean laundry. DPM #13 confirmed that the door should not have been left open. On 08/14/24 at 1:58 PM, during an interview with the DPM #13, revealed that he was unable to locate the facility's water management plan, and water system flow diagram. He mentioned that he had taken measures to control and prevent the growth of opportunistic waterborne pathogens, such as flushing unused water outlets, and shower heads. However, he admitted to having no documentation, or logs, of the measures taken. At approximately 3:48 PM on 08/14/24 DPM #13 submitted a document which stated, I typed this down word for word as I was Instructed. : TYPED AS WRITTEN Hot Water Distribution Water goes underground to main mechanical room via 6-inch water line that feeds the fire suppression sprinklers and then flows through a back flow converter, then branches into 3 hot water heaters. One (tank #3) is located in the main mechanical room that feeds laundry room and kitchen. (Washer 1, washer 2, 3 sinks. C hall sinks, showers, resident restroom, and nurses station restroom. Tank #2 does pantry, ct tub, janitor's closet dump sink, B hall sinks and med room. Cold Water Distribution Enters main mechanical room, same as above and branches to sinks, toilets, ice machines throughout facility and hose bibs outside, then drains to local sewage plant. Facilities must be able to demonstrate their measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program. Water management must be based on nationally accepted standards (e.g., ASHRAE (formerly the American Society of Heating, Refrigerating, and Air Conditioning Engineers), CDC, U.S. Environmental Protection Agency or EPA) and include: o An assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter) could grow and spread; and o Measures to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. Examples of an assessment include a description of the building water systems using text and flow diagrams for identification. Additionally, control measures may include visible inspections, use of disinfectant, and temperature (that may require mixing valves to prevent scalding). Monitoring such controls includes testing protocols for control measures, acceptable ranges, and documenting the results of testing. Water management should also include established ways to intervene when control limits are not met.

Based on record review, and staff interview, the facility failed to report a fall with serious injury to the required agencies within the specified time period. This failed policy had the potential to affect an isolated number of residents that reside in the facility. Resident Identifier: #37. Facility census:52. Findings Included: a) Resident #37 Review of records on 08/13/24 at 11:32 AM revealed a note dated 7/22/2024 at 1:33 AM by Licensed Practical Nurse (LPN) #43. The note stated: Resident fell and hit head in her bathroom large knot and laceration above the left eye. (name) MPOA notified. Telehealth called and gave orders to transfer resident to local hospital. Resident complains of neck pain and some bruising to right hand and left knee. Another note on 7/22/24 at 5:11 AM by LPN #35 stated: Nurse at (local hospital) said resident is being transferred to (area trauma center). She has a laceration to forehead, contusion to (L)chest wall, contusion to face, CT showed cervical fracture. During an interview with the Social Worker on 08/14/24 at 1:58 PM she produced a Facility Reported Incident (FRI) that had been submitted to the Office of Health Facility Licensure and Certification (OHFLAC). Review of the report revealed that the staff had become aware of the fall at 1:23 AM on 07/22/24. The Administrator had been notified of the fall at 7:00 AM on 07/22/24. Further review of the report revealed that no other agencies were notified of the fall, and that the report had been submitted to OHFLAC on 07/22/24 at 11:17 AM. The facility was not in compliance with this requirement because the fall had been reported over six (6) hours after facility had knowledge that a serious injury had occurred, and no notification had been submitted to Adult Protective Services (APS) and Ombudsman.

Based on record review, and resident and staff interviews, it was determined that the facility staff failed to treat residents with respect and dignity, and to allow the residents the right to exercise his or her rights as a resident of the facility. This finding was true for one (1) of two (2) residents reviewed for the dignity care area during the survey. Resident Identifier #4. Facility Census: 52. Findings Included: a) Resident #4 During an interview on 08/12/24 at 2:57 PM, Resident #4 stated that she prefers to use a bedpan when voiding. Resident is non-ambulatory. Her diagnoses include fibromyalgia, acute and chronic respiratory failure, muscle wasting and atrophy of right and left upper arms, generalized muscle weakness, and morbid obesity. Resident is on oxygen, and requires substantial assistance, including the use of a lift for transfers. Resident stated that when Nurse Aide (NA) #53 was on duty, he refused her request for a bedpan, stating You call for a bedpan more than anyone else in the facility. Instead, NA #53 insists that resident use the bedside commode. Resident stated that it takes time for the staff to assist her to the bedside commode, and that by then she has usually voided into her brief. She further stated that the lift causes her pain due to her fibromyalgia. A review of resident's care plan reveals a note that states Toilet transfer: Totally dependent of 2 = 2 or more helpers do all the effort. Resident does none of the effort. Date Initiated: 02/18/24. Another note in the care plan states: Resident is incontinent of urine. Resident will remain free of skin break down due to incontinence. Date Initiated: 05/30/23 Revision on: 04/24/24. During an interview with the Director of Nursing (DON) #52 on 08/13/24 at 1:52 PM she stated that NA #53 was not available for interview because he worked at the facility on a part time basis. She further stated that it was possible that NA #53's refusal to offer resident a bedpan at her request was because getting Resident #4 out of bed would allow her to more fully void her bladder. Resident #4 was not given the opportunity to exercise her right to make a choice in the provision of her care. 50801 F Tag 550 Based on observation and staff interview, the facility failed to have the ombudsman information posted easily assessable to residents. This failed practice had the potential to affect more than a limited number of residents who are not tall enough or in wheel chairs Facility census: 52. Findings include: A) Resident Council Meeting During a resident council meeting on 08/14/24 at 9:30 AM, the residents stated they were aware of their rights and knew where the ombudsmen phone number was, but they did stated the board is not low enough for them to read it. They went on to state the board is too high for them to get the number with out asking for assistance. On 8/14/2024 at approximately11:35 AM, the Social Worker confirmed the Board for resident rights and ombudsman information was too high for the residents in wheel chairs to read.

Based on record review and staff interview, the facility failed to ensure that the resident's Pre-Admission Screening (PAS) reflected pre-admission diagnoses for one (1) of one (1) residents reviewed for the category of PASARR (Pre-Admission Screening and Record Review), during the Long-Term Care Survey process. Resident identifier: #39. Facility census: 52. Findings included: a) Resident #39 A record review, completed on 08/13/24 at 7:30 PM, revealed Resident #39 had been admitted to the facility on [DATE] with an admitting diagnosis of Major Depressive Disorder. The admitting PASARR, dated 12/09/21, did not identify Resident #39 had a major depressive disorder on Section III, Question 30 of the PAS. A continued record review also revealed there was never a new PAS completed that revealed resident's major depressive disorder diagnosis in order to address whether or not specialized services were needed. During an interview on 08/14/24 at 9:45 AM, the Social Worker acknowledged the admitting PAS failed to identify resident's major depressive disorder diagnosis and that there was never a new PAS completed that revealed resident's major depressive disorder diagnoses. The Social Worker then stated she would complete a new PASARR for Resident #39 to reflect the major depressive disorder diagnosis.

Based on record review and staff interview, the facility failed to ensure residents who experienced weight loss of five (5) pounds or more were re-weighed to verify weight was correct. This was true for one (1) of one (1) resident's reviewed under the nutrition pathway during the Long-Term Care Survey Process. Resident Identifier: #38. Facility census: 52. Findings included: a) Resident #38 A record review, completed on 08/13/24 at 2:02 PM, revealed there was a physician order for resident to have weekly weights. The review also revealed the following weights for Resident #38: -On 02/12/2024 at 1:01 PM, Resident weighed 90.0 Lbs. -On 02/21/2024 at 2:38 PM, Resident weighed 81.4 Lbs. -On 03/01/2024 at 9:10 AM, Resident weighed 81.0 Lbs. A review of the facility's Resident Height and Weight policy, completed on 08/13/24 at 2:33 PM, revealed the following guidelines for obtaining a resident's weight: --Compare weight to previous weight obtained. If a variance of 5 pounds or more is noted, Reweigh resident to verify weight. --Documentation: In EHR (Electronic Health Record) During an interview on 08/14/24 at 11:23 AM, the Director of Nursing (DON) acknowledged a reweigh had not been recorded in the electronic medical record after staff weighed Resident #38 on 02/021/24 and there was a weight loss of 8.6 lbs. The DON stated she would review the dietician's notes and follow-up with surveyor if she found any documentation about resident being reweighed. No further information was provided prior to surveyor's exit from the building.

Based on observation and staff interview, the facility failed to have the Ombudsman information posted that was easily accessible for residents. This failed practice had the potential to affect more than a limited number of residents who are not tall enough or in wheel chairs. Facility census: 52. Findings included: a) Resident Council Meeting During a Resident Council meeting on 08/14/24 at 9:30 AM, the residents stated they were aware of their rights and knew where the Ombudsmen phone number was located. They further stated that the board was not low enough for them to read it. They went on to state that the board is too high for them to get the number without asking for assistance. On 8/14/2024 at approximately 11:35 AM, the Social Worker confirmed the Board for resident rights and Ombudsman information was too high for the residents in wheel chairs to read.

Based on resident council minutes review, resident interviews, review of the facility's grievance log, and staff interview, the facility failed to consider the voiced concerns of residents in resident council as grievances. The facility failed to act promptly to investigate resident grievances. This had the potential to affect an unlimited amount of residents living in the facility. Facility census: 53. Findings included: a) Resident Council Minutes A review of resident council minutes was conducted on 10/11/11/22 at 11:00 AM. The following concerns/grievances were reported: 12/21/21 Resident Council --Residents would like to know who their aide is first thing in the morning. 01/18/22 Resident Council --It was noted under Old Business, [The Administrator's First Name] is going to address resident concern of knowing who their nurse aide is at the beginning of the shift. 03/24/22 Resident Council: --Shower room is not clean. there is a black substance on the right hand side in every stall. 04/28/22 Resident Council: --Showers continue to have mold, not cleaned enough. --Water pressure and temp issues in shower room. 05/19/22 Resident Council: --Curtains in shower room have poo [feces] on them and need washed. --Water pressure issue in bathroom. 06/16/22 Resident Council: --Water pressure is still an issue - not enough pressure. 07/21/22 Resident Council: --Would like to know who Aides are for the day. b) Resident Council Meeting / Resident Interviews On 10/11/22 at 1:3O PM, a Resident Council Meeting was held. Residents stated they do not feel the facility acts promptly on concerns/grievances. There are numerous things that have been addressed previously that remain unresolved and no feedback has been shared with the residents. Items that were still unresolved were: --Residents have requested to know who their aides are with each shift change --Cleanliness of shower room has been brought up multiple times in various resident council meetings. This is still an unresolved issue. --Water pressure in the shower room sometimes ends up only being a trickle. Residents feel water may be being pulled over to washing machines or kitchen equipment. c) Review of Facility Grievance Log A review of the facility grievance log, completed on 10/11/22 at 2:40 PM, did not find the concerns/grievances listed in the resident council minutes documented. Nor was there any evidence the facility had responded to the resident concerns in a meaningful way. d) Interview with Social Services Supervisor During an interview, on 10/12/22 at 1:45 PM, the Social Services Supervisor acknowledged the residents had repeatedly reported concerns about the cleanliness facility's shower room as well as the lack of water pressure. The Social Service Supervisor confirmed being the facility's Grievance Officer. She also stated she had spoken to another surveyor who was going to cite the shower room under lack of homelike environment due to the condition it was in upon entrance to the facility for the long-term care survey process. The Social Service Supervisor also stated she knew the residents requests to be be told who their assigned aide is each shift had been a lingering issue that remains unresolved at this time.

Based on resident interview, observation and staff interview, the facility failed to maintain a clean and safe shower room. This is true for one of one shower room utilized by all residents. Resident census: 53. Findings include: a) Resident interviews On 10/10/22 at 9:40 AM Resident (R) #28 complained the facility's only shower room was moldy and unclean. R #28 stated the shower chair and walls are moldy. The shower is not cleaned between residents and stool increments are left on the floor. Staff push the wheel chair through the stool and make no attempts to clean the wheel chair afterwards. At 10:00 AM on 10/10/22 R #13 voiced concerns related to the shower room being moldy and dirty and not cleaned between residents. On 10/10/22 at 1:14 PM, R #3 reported the shower room needed repaired and was not cleaned between residents. R #3 stated her wheel chair was wheeled though stool left on the floor and dirty bed side commodes are reused for other residents in the shower room. b) Observations On 10/10/22 at 12:00 PM an observation of the facility's only shower room with Nurse Aide (NA) #18 revealed the following: --a musty odor throughout the room NA #18 confirmed the odor was present --water puddles on the floor --uneven side tables with missing legs in each shower stall. NA#18 reported they are used for toiletries --one shower chair with black dirty legs and a mold like substance on the inner side of the chair leg. --cracked tiles and missing grout on the walls in multiple areas --mold like substance on the floor and wall edges and shower corners --cracked and missing tile around the floor drain --two soiled bedside commodes one with dried stool over the seat --shower bed table with multiple cracked areas - NA#18 reported this is the only shower bed in the facility and is used for R#12 On 10/10/22 at 12:05 PM Registered Nurse (RN) #4 viewed the shower room with this surveyor and confirmed there is only one shower room in the facility. RN #4 agreed with the above findings and stated she would notify housekeeping immediately. RN #4 stated the shower room is to be cleaned between residents and soiled bedside commodes should not be sitting in the shower room.

Based on resident interview, record review, and staff interview, the facility failed to make a reasonable accommodation for a resident's room temperature preference as it related to his Chronic Obstructive Pulmonary Disease (COPD) and Anxiety diagnoses. Resident identifier #22. Facility census: 53. Findings included: a) Resident #22 During an interview, on 10/10/22 at 10:42 AM, Resident #22 stated he has breathing issues from his COPD diagnosis. Resident went on to say he would prefer to have his room at a cooler temperature than 71 degrees Fahrenheit. Any time he tries to address the fact that he finds it harder to breathe when the room is not cool, resident reports he is told the room must stay at 71 degrees Fahrenheit with no exceptions. Resident #22 stated he feels mistreated and unheard. When asked to explain his reasoning for a cooler temperature, Resident #22 listed the following concerns: --I feel like I can't catch my breath if the room gets too warm for me. It makes breathing harder. --I experience higher levels of anxiety. --I don't rest as well throughout the night. --I feel like my COPD and Anxiety point to the fact that I have a medical disability and a reasonable accommodation should be made for me. A medical record review was completed on 10/11/22 at 7:00 PM. Resident #206's care plan did not reflect any details about resident's preference for a cooler room, if any alternative interventions had been offered, if a roommate change had been discussed in order to pair resident with someone else who may prefer a cooler room temperature, etc. However, there was documentation reflecting resident had a roommate change on the following dates: --12/07/21 --01/26/22 --08/08/22 --08/18/22 --10/05/22 During an interview, on 10/12/22 at 1:32 PM, the Social Services Supervisor and Registered Nurse Assessment Coordinator were interviewed. The facility could provide no evidence it has attempted to work with Resident #22 to accommodate his preference for a cooler room temperature. Both employees agreed that reasonable accommodation of resident needs and preferences could mean efforts to individualize a resident's physical environment.

Based on interview, observation and record review, the facility failed to ensure Resident #21 had the right to to self-determination, reassessment of mental capacity, make her own medical decisions and the ability to freely associate with persons of her choosing who reside outside of the facility. These failures cause Resident #21 to experience actual psychosocial harm. --The facility the Medical Power of Attorney and other family members to restrict Resident #21's visitation with a family member with whom she had previously resided and had a special bond. This desision was made based on statements that could not be corroborated that the resident was upset when the restricted family member left after a visit. There was no documentation to support this claim, however, the facility failed to protect the resident from the over reach by the MPOA. --The facility failed to ensure a physician reassessed capacity once it was clear her cognition had significantly improved. --The facility failed to ensure the resident was able to make her own decisions when she clearly showed improvement and tested as mentally and cognitively intact, while permitting the family and MPOA to inappropriately make decisions on the resident's behalf. --The facility failed to ensure legal representatives take into consideration the expressed wishes of the protected person. --The faciliy failed to protect the resident from unnecessary and invasive medical procedure when the resident's mental status results showed she had capacity. The facility used a straight catheter to drug test the resident. The results were positive only for medication prescribed and given by the facility. The resident was not told of the reason for the test and the lab order gave false reason for the order. These practices caused Resident #21 to suffer psychosocial harm. She experienced feelings of being stuck at the facility, feelings of no one listening to her, and feelings of depression related to not being able to visit with her resitricted family member. This was true for one (1) of 15 sample residents. Resident identifier: #21. Facility census: 50 Findings included: a) Resident #21 A resident interview, on [DATE] at 11:00 AM, revealed Resident #21 expressed the feelings of contiuous and extreme distress and being upset over a family member being restricted from visiting. Resident #21 stated, there was a meeting with the Administrator and her Medical Power of Attorney (MPOA) and she was told she lacked capacity and could not see her [restricted family member] anymore. Resident stated she responded to this by saying, It will make me more upset by not getting to see [the restricted family member]. Resident #21 stated the MPOA with facility agreement told me I get too upset when the restricted family member leaves, the also tell me I lack capacity, so I do not have a choice on who can visit me. Resident #21 revealed her current medications controlled her depression and she did not feel she is any more upset when the restricted family member leaves than when any other family members visits and leaves. The resident expressed this was a normal reaction to being stuck in the facility and seeing family leave after a visit. A record review, on [DATE] at 8:45 PM, revealed a Physician Determination of Capacity with a date of [DATE]. The record stated Resident #21 demonstrated incapacity for a duration long term, nature [CONDITION(S)] with a cause stroke. Upon further record review, on [DATE] at 10:30 PM, revealed a Mini Mental Status Exam (MMSE) and Minimum Data Set (MDS). The mental status information was as followed: -- A Minimimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 00. The resident was unable to answer questions due to a recent stroke. -- A MMSE with effective date [DATE] revealed a score of 31 which indicted 100% accuracy in all areas of the test which included: Time Orientation, Place Orientation, Short Term Memory, Spatial Abstract, Memory Recall Recognition, Follow Direction-Verbal, Follow Direction- Hearing, Follow Direction- Reading, Follow Direction- Writing and Follow Directions- Copying with interlocking geometric shapes. -- A MDS dated [DATE] revealed a BIMS of 15. -- A MDS dated [DATE] revealed a BIMS of 15. The DON stated that the medical director had dismissed all the MDS BIMS scores and the Mini Mental Status Exam (MMSE) in the last six (6) months because the Doctor did not like those assessments and evaluations. The DON stated the Doctor preferred and goes by a mental exam that requires resident's ability to interlock hexagon shapes. (Mini Mental Status Exam dated [DATE] revealed Resident successfully copied a design and interlocked geometric shapes on the mini mental exam.) The DON stated the Doctor was currently away on vacation and was unavailable for interview. The DON and Administrator were unable to provide any physician notes related to the improvement of Resident #21's mental health status. The DON and Administrator were unable to provide any further assessments which were conducted based on Resident #21's significant mental status improvement. The facility could not show any evidence they attempted to get the physician to reassess the resident's capacity or that they sought a second professional to re-assess capacity. A staff interview with the MDS Coordinator, on [DATE] at 4:35 PM, revealed the BIMS was completed on Resident # 21 on [DATE] and [DATE] where Resident #21 did answer all questions appropriately. MDS coordinator confirmed Resident #21 was non-verbal when admitted on [DATE] which made her BIMS a 00 upon admission. The MDS Coordinator revealed, Resident #21 was assessed on the next MDS on [DATE] and she made a significant improvement and answered all questions appropriately. The MDS Coordinator stated, although Resident #21 answered all BIMS correctly, the family said Resident #21 is not always free from confusion and the family does not think Resident #21 can manage at home therefore cannot have capacity. The facility continued to fail the resident by discrediting the mental status assessments and the resident's observed cognitive improvements by permitting the family to have a non-clinical say in her capacity. These same family members work at the facility and have had significant influence in keeping their mother listed as incapacitated and living at the facility, despite the resident's wishes. A record review, on [DATE] at 9:00 PM, revealed several social service progress notes. The social services progress notes revealed: -- A Social Services Progress Note dated [DATE] revealed, Conference including Administrator, Director of Nursing (DON), Minimum Data Set (MDS) Coordinator, (name of Staff), Social Worker, (name of family member #1), MPOA, and via phone (name of family member #2) and (name of family member #3). Family members voiced concern the interactions between resident and the restricted family member may be causing emotional distress for resident. PR agreed that this may be causing depression and emotional anguish. PR placed restrictions on visitation for [restricted family member] and additionally for family member #4, (name of friend #1), (name of friend #2), (name of friend #3), and (name of friend #4), who may try and contact resident for (restricted family member). It should be noted the resident's medical record showed no adverse behaviors when visitors left visiting with Resident #21. -- A Social Services Progress Note dated [DATE] revealed, Spoke with a visitor of resident, (relationship of restricted visitor). Restricted family member stated that she felt the resident could return home. Educated (restricted family member) on protective health information and explained that she could not make medical decisions for the resident. Restricted family member stated that she would be contacting a lawyer and resident's doctor. -- An Addendum Progress Note dated [DATE] revealed, Spoke with Doctor regarding our concerns for the resident, staff has noticed that residents behaviors have also changed since visitation started, after talking with Doctor and obtaining order and talking to the resident MPOA we have decided to obtain a urine on the resident before visitation and ,d+[DATE] hours after visitation to rule out any type of drug use and drugs being brought into the facility for her from an outside source. -- A Social Services Progress Note dated [DATE] revealed, Received an anonymous phone call stating that this individual was asked to bring in Tic Tacs. States they wanted her to bring them from PA from resident relatives. Individual stated she would get her some at the gas station and the family members stated no that they had to be these tic tacs. POA is concerned about visitors possibly bringing resident in non-prescribed medications or substances. It should be noted the facility had no documented evidence to show the resident's behavior changed during and after visitation to suggest the use of drugs not prescribed by the facility. Further record review, on [DATE] at 9:30 PM, revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional orders for a Urine Drug screen was available. It should be noted the order did not state the urine screening was to rule out the use of illicit drugs being given to the resident from outside the facility. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . As of [DATE] the order was changed to Oxycodone 5 mg at bedtime. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional record review, on [DATE] at 10:00 PM, revealed two (2) Laboratory /Diagnostic Notes. The progress notes are as followed: -- Laboratory Diagnostic Note dated [DATE] stated, Urine Drug Screen was obtained via straight catheterization resident tolerated well. No documentation available that Resident was informed as to why urine was taken. -- Laboratory Diagnostic Note dated [DATE] stated, Urine Drug Screen was obtained at this time, resident tolerated well, MPOA aware. Further record review, on [DATE] at 10:15 PM, revealed two (2) Laboratory Diagnostic Results. The progress notes are as followed: -- Laboratory Diagnostic Result note dated [DATE] stated, Summary of results received: Oxycodone. -- Laboratory Diagnostic Result noted dated [DATE] stated, Summary of results received: Oxycodone. Resident #21 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No other drugs were found in the urine drug screens. A record review of the current care plan, on [DATE] at 8:45 AM, revealed Resident #21 received antidepressant medication [MEDICATION(S)] for depression with an intervention that stated, encourage family and friends to visit. A review of facility documentation, on [DATE] at 9:00 AM, revealed the Visitor Daily Monitoring Form for Covid-19 Screening. The form revealed Resident #21's restricted family member visited on [DATE] at 1:29 PM and on [DATE] at 10:05 AM. A resident interview, on [DATE] at 10:10 AM, revealed the restricted family member was a close relative of her late husband who died in [DATE]. Resident # 21 stated she and late husband lived with the restricted family member and husband twice in the past. Once the restricted family member and husband moved in with Resident #21 and husband when they needed help. Resident #21 stated, then she and her husband moved in with the restricted family member and husband to help them and lived with restricted family member for a good while before she had her stroke. Resident # 21 stated the desire was to be discharged from the facility with a plan to go back and live with the restricted family member. Resident # 21 revealed a concern, she informed the MPOA of the need to update and complete head of household paperwork on the apartment she and her restricted family member shared but MPOA replied, Mom forget that place you live here now. Resident # 21 stated she was not happy in the facility and had spoken with family member #2 who confirmed she would fight to get conservator/guardianship because Resident #21 felt as though the MPOA only wanted to keep her in the facility because the MPOA worked in the facility. Resident # 21 expressed the feeling of being stuck in the facility. Resident # 21 asked Surveyor, wouldn't you feel depressed if you felt like you were stuck, and no one listened to you. Resident # 21 stated her discharge plan was to be discharged back into the apartment where she was head of household with her restricted family member. Resident #21 stated, the use of public transportation and her late husband's electric wheelchair would allow her to go back and forth to future appointments. Resident #21 stated, I know public transportation is handicap accessible cause my late husband used public transportation and it was accommodating to wheelchairs. An additional resident interview on [DATE] at 11:30 AM revealed the concern about getting help regarding the restriction of her family member from visiting and expressed missing her restricted family member. Resident # 21 frowned inquisitively and replied, Not that I know of, that is all they told me. Surveyor asked Resident #21 when blood work or urine samples are taken if staff inform her of why the tests were being done? Resident #21 replied, No, I just figured they were routine. Further record review, on [DATE] at 12:00 PM, revealed no additional progress notes related to mental anguish or negative behavior exhibited by Resident #21. There were no behavior flow sheets available in the electronic medical record. discharged and completed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional progress notes or physician notes in the electronic medical record revealed the significant change in psychosocial improvement. There was no evidence the resident exhibited symptoms or behaviors that indicated suspicious drug use. A review of an outside resource psychiatric evaluation conducted on [DATE] revealed no history of prior illicit drug use. A staff Interview with the Administrator and Director of Nursing (DON) on [DATE] at 3:15 PM, revealed no behavior sheets available for the dates when the restricted family member visited on [DATE] and [DATE] because the facility was not monitoring behaviors for Resident #21. The DON stated she did not personally see any behavior changes that would cause visitation to be discontinued for the restricted family member but the decision was based on family wishes and family observations. The DON recalled, this resident would call the MPOA and (other family member) and yell at them for keeping her in the facility but not because the restricted family member had visited. The Administrator revealed only one (1) physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator confirmed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . DON confirmed, the two (2) drug screens were really conducted based on the Social Service Progress Note dated [DATE] which indicated an anonymous phone call to the facility asking about bringing tic tacs to Resident #21 but not related to the reasons given on the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A family interview with the MPOA and other family member, on [DATE] at 5:43 PM, revealed Resident #21 may not return to live with her restricted family member as they have reason to believe the person did not make Resident #21 go to a follow up doctor's appointment which caused Resident #21 to have a stroke. MPOA and another family member stated after the stroke occurred an ambulance was not called until a half hour later for Resident #21 when the restricted family member and late husband realized something was wrong. MPOA revealed Resident #21's current unrestricted visitors included: MPOA and three other family members. MPOA and another family member stated, we need to do what is best for her whether she agrees or not. These failures cause Resident #21 to experience actual psychosocial harm. --The facility the Medical Power of Attorney and other family members to restrict Resident #21's visitation with a family member with whom she had previously resided and had a special bond. This desision was made based on statements that could not be corroborated that the resident was upset when the restricted family member left after a visit. There was no documentation to support this claim, however, the facility failed to protect the resident from the over reach by the MPOA. --The facility failed to ensure a physician reassessed capacity once it was clear her cognition had significantly improved. --The facility failed to ensure the resident was able to make her own decisions when she clearly showed improvement and tested as mentally and cognitively intact, while permitting the family and MPOA to inappropriately make decisions on the resident's behalf. --The facility failed to ensure legal representatives take into consideration the expressed wishes of the protected person. --The faciliy failed to protect the resident from unnecessary and invasive medical procedure when the resident's mental status results showed she had capacity. The facility used a straight catheter to drug test the resident. The results were positive only for medication prescribed and given by the facility. The resident was not told of the reason for the test and the lab order gave false reason for the order. These practices caused Resident #21 to suffer psychosocial harm. She experienced feelings of being stuck at the facility, feelings of no one listening to her, and feelings of depression related to not being able to visit with her resitricted family member.

Based on interview, observation and record review, the facility failed to ensure Resident #21 had the right to to self-determination and the ability to freely associate with persons of her choosing who reside outside of the facility. These failures cause Resident #21 to experience actual psychosocial harm. --The facility the Medical Power of Attorney and other family members to restrict Resident #21's visitation with a family member with whom she had previously resided and had a special bond. This desision was made based on statements that could not be corroborated that the resident was upset when the restricted family member left after a visit. There was no documentation to support this claim, however, the facility failed to protect the resident from the over reach by the MPOA. --The facility failed to ensure a physician reassessed capacity once it was clear her cognition had significantly improved. --The facility failed to ensure the resident was able to make her own decisions when she clearly showed improvement and tested as mentally and cognitively intact, while permitting the family and MPOA to inappropriately make decisions on the resident's behalf. --The facility failed to ensure legal representatives take into consideration the expressed wishes of the protected person. These practices caused Resident #21 to suffer psychosocial harm. She experienced feelings of being stuck at the facility, feelings of no one listening to her, and feelings of depression related to not being able to visit with her resitricted family member. This was true for one (1) of 15 sample residents. Resident identifier: #21. Facility census: 50 Findings included: a) Resident #21 A resident interview, on [DATE] at 11:00 AM, revealed Resident #21 expressed the feelings of contiuous and extreme distress and being upset over a family member being restricted from visiting. Resident #21 stated, there was a meeting with the Administrator and her Medical Power of Attorney (MPOA) and she was told she lacked capacity and could not see her [restricted family member] anymore. Resident stated she responded to this by saying, It will make me more upset by not getting to see [the restricted family member]. Resident #21 stated the MPOA with facility agreement told me I get too upset when the restricted family member leaves, the also tell me I lack capacity, so I do not have a choice on who can visit me. Resident #21 revealed her current medications controlled her depression and she did not feel she is any more upset when the restricted family member leaves than when any other family members visits and leaves. The resident expressed this was a normal reaction to being stuck in the facility and seeing family leave after a visit. A record review, on [DATE] at 8:45 PM, revealed a Physician Determination of Capacity with a date of [DATE]. The record stated Resident #21 demonstrated incapacity for a duration long term, nature [CONDITION(S)] with a cause stroke. Upon further record review, on [DATE] at 10:30 PM, revealed a Mini Mental Status Exam (MMSE) and Minimum Data Set (MDS). The mental status information was as followed: -- A Minimimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 00. The resident was unable to answer questions due to a recent stroke. -- A MMSE with effective date [DATE] revealed a score of 31 which indicted 100% accuracy in all areas of the test which included: Time Orientation, Place Orientation, Short Term Memory, Spatial Abstract, Memory Recall Recognition, Follow Direction-Verbal, Follow Direction- Hearing, Follow Direction- Reading, Follow Direction- Writing and Follow Directions- Copying with interlocking geometric shapes. -- A MDS dated [DATE] revealed a BIMS of 15. -- A MDS dated [DATE] revealed a BIMS of 15. The DON stated that the medical director had dismissed all the MDS BIMS scores and the Mini Mental Status Exam (MMSE) in the last six (6) months because the Doctor did not like those assessments and evaluations. The DON stated the Doctor preferred and goes by a mental exam that requires resident's ability to interlock hexagon shapes. (Mini Mental Status Exam dated [DATE] revealed Resident successfully copied a design and interlocked geometric shapes on the mini mental exam.) The DON stated the Doctor was currently away on vacation and was unavailable for interview. The DON and Administrator were unable to provide any physician notes related to the improvement of Resident #21's mental health status. The DON and Administrator were unable to provide any further assessments which were conducted based on Resident #21's significant mental status improvement. The facility could not show any evidence they attempted to get the physician to reassess the resident's capacity or that they sought a second professional to re-assess capacity. A staff interview with the MDS Coordinator, on [DATE] at 4:35 PM, revealed the BIMS was completed on Resident # 21 on [DATE] and [DATE] where Resident #21 did answer all questions appropriately. MDS coordinator confirmed Resident #21 was non-verbal when admitted on [DATE] which made her BIMS a 00 upon admission. The MDS Coordinator revealed, Resident #21 was assessed on the next MDS on [DATE] and she made a significant improvement and answered all questions appropriately. The MDS Coordinator stated, although Resident #21 answered all BIMS correctly, the family said Resident #21 is not always free from confusion and the family does not think Resident #21 can manage at home therefore cannot have capacity. The facility continued to fail the resident by discrediting the mental status assessments and the resident's observed cognitive improvements by permitting the family to have a non-clinical say in her capacity. These same family members work at the facility and have had significant influence in keeping their mother listed as incapacitated and living at the facility, despite the resident's wishes. A record review, on [DATE] at 9:00 PM, revealed several social service progress notes. The social services progress notes revealed: -- A Social Services Progress Note dated [DATE] revealed, Conference including Administrator, Director of Nursing (DON), Minimum Data Set (MDS) Coordinator, (name of Staff), Social Worker, (name of family member #1), MPOA, and via phone (name of family member #2) and (name of family member #3). Family members voiced concern the interactions between resident and the restricted family member may be causing emotional distress for resident. PR agreed that this may be causing depression and emotional anguish. PR placed restrictions on visitation for [restricted family member] and additionally for family member #4, (name of friend #1), (name of friend #2), (name of friend #3), and (name of friend #4), who may try and contact resident for (restricted family member). It should be noted the resident's medical record showed no adverse behaviors when visitors left visiting with Resident #21. -- A Social Services Progress Note dated [DATE] revealed, Spoke with a visitor of resident, (relationship of restricted visitor). Restricted family member stated that she felt the resident could return home. Educated (restricted family member) on protective health information and explained that she could not make medical decisions for the resident. Restricted family member stated that she would be contacting a lawyer and resident's doctor. A record review of the current care plan, on [DATE] at 8:45 AM, revealed Resident #21 received antidepressant medication [MEDICATION(S)] for depression with an intervention that stated, encourage family and friends to visit. A review of facility documentation, on [DATE] at 9:00 AM, revealed the Visitor Daily Monitoring Form for Covid-19 Screening. The form revealed Resident #21's restricted family member visited on [DATE] at 1:29 PM and on [DATE] at 10:05 AM. A resident interview, on [DATE] at 10:10 AM, revealed the restricted family member was a close relative of her late husband who died in [DATE]. Resident # 21 stated she and late husband lived with the restricted family member and husband twice in the past. Once the restricted family member and husband moved in with Resident #21 and husband when they needed help. Resident #21 stated, then she and her husband moved in with the restricted family member and husband to help them and lived with restricted family member for a good while before she had her stroke. Resident # 21 stated the desire was to be discharged from the facility with a plan to go back and live with the restricted family member. Resident # 21 revealed a concern, she informed the MPOA of the need to update and complete head of household paperwork on the apartment she and her restricted family member shared but MPOA replied, Mom forget that place you live here now. Resident # 21 stated she was not happy in the facility and had spoken with family member #2 who confirmed she would fight to get conservator/guardianship because Resident #21 felt as though the MPOA only wanted to keep her in the facility because the MPOA worked in the facility. Resident # 21 expressed the feeling of being stuck in the facility. Resident # 21 asked Surveyor, wouldn't you feel depressed if you felt like you were stuck, and no one listened to you. Resident # 21 stated her discharge plan was to be discharged back into the apartment where she was head of household with her restricted family member. Resident #21 stated, the use of public transportation and her late husband's electric wheelchair would allow her to go back and forth to future appointments. Resident #21 stated, I know public transportation is handicap accessible cause my late husband used public transportation and it was accommodating to wheelchairs. An additional resident interview on [DATE] at 11:30 AM revealed the concern about getting help regarding the restriction of her family member from visiting and expressed missing her restricted family member. Resident # 21 frowned inquisitively and replied, Not that I know of, that is all they told me. Further record review, on [DATE] at 12:00 PM, revealed no additional progress notes related to mental anguish or negative behavior exhibited by Resident #21. There were no behavior flow sheets available in the electronic medical record. discharged and completed physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional progress notes or physician notes in the electronic medical record revealed the significant change in psychosocial improvement. There was no evidence the resident exhibited symptoms or behaviors that indicated suspicious drug use. A review of an outside resource psychiatric evaluation conducted on [DATE] revealed no history of prior illicit drug use. A staff Interview with the Administrator and Director of Nursing (DON) on [DATE] at 3:15 PM, revealed no behavior sheets available for the dates when the restricted family member visited on [DATE] and [DATE] because the facility was not monitoring behaviors for Resident #21. The DON stated she did not personally see any behavior changes that would cause visitation to be discontinued for the restricted family member but the decision was based on family wishes and family observations. The DON recalled, this resident would call the MPOA and (other family member) and yell at them for keeping her in the facility but not because the restricted family member had visited. A family interview with the MPOA and other family member, on [DATE] at 5:43 PM, revealed Resident #21 may not return to live with her restricted family member as they have reason to believe the person did not make Resident #21 go to a follow up doctor's appointment which caused Resident #21 to have a stroke. MPOA and another family member stated after the stroke occurred an ambulance was not called until a half hour later for Resident #21 when the restricted family member and late husband realized something was wrong. MPOA revealed Resident #21's current unrestricted visitors included: MPOA and three other family members. MPOA and another family member stated, we need to do what is best for her whether she agrees or not. These failures cause Resident #21 to experience actual psychosocial harm. --The facility the Medical Power of Attorney and other family members to restrict Resident #21's visitation with a family member with whom she had previously resided and had a special bond. This desision was made based on statements that could not be corroborated that the resident was upset when the restricted family member left after a visit. There was no documentation to support this claim, however, the facility failed to protect the resident from the over reach by the MPOA. --The facility failed to ensure a physician reassessed capacity once it was clear her cognition had significantly improved. --The facility failed to ensure the resident was able to make her own decisions when she clearly showed improvement and tested as mentally and cognitively intact, while permitting the family and MPOA to inappropriately make decisions on the resident's behalf. --The facility failed to ensure legal representatives take into consideration the expressed wishes of the protected person. These practices caused Resident #21 to suffer psychosocial harm. She experienced feelings of being stuck at the facility, feelings of no one listening to her, and feelings of depression related to not being able to visit with her resitricted family member.

Based on record review, observation, and staff interview, the facility failed to provide nutritional care and services to ensure the maintenance of acceptable parameters of nutritional status, to the extent possible, for (1) of one (1) resident who received nutrition through a combination of tube feedings and food by mouth. The resident's feeding tube malfunctioned and the facility failed to ensure timely replacement. In addition, during this time, the resident's food intake and weights were not monitored to ensure interventions were established and/or implemented to prevent avoidable weight losses. Resident identifier: #33. Facility Census: 50. Findings include: a) Resident #33 On 10/27/15, at approximately 3:20 p.m., review of the resident's medical record found the most recent annual minimum data set (MDS) assessment, dated 08/14/15, identified Resident #33 had severe cognitive impairment and was totally dependent upon staff for all activities of daily living, including eating and drinking. Additionally, the MDS documented the resident received tube feedings and a mechanically altered therapeutic diet. According to the MDS, Resident #33 received 51% or more of his nutrition through tube feedings. The vital sign/weight record, dated 09/02/15, documented the resident's weight as 169.4 pounds. The dietitian's note, dated 09/04/15, stated Resident #33 received nocturnal tube feedings of 1000 cc (cubic centimeters) of [MEDICATION NAME] 1.5 at 100 cc/hour. Additionally, he received 150 cc of water before and after feedings as well as 145 cc six (6) times per day. Resident #33 received a protein supplement (Promod) 45 cc every day. He was provided a no-concentrated sweet pureed diet with honey thick liquids during meals. The dietitian further documented weight fluctuations when oral intake increased. The most recent tube feeding care plan, with an admission date of [DATE], revealed a goal for no significant weight change through the review date. Interventions included to: 1. See the physician orders [REDACTED]. 2. Provide and serve no-concentrated sweets diet, honey thick fluids 3. Spoon feed the resident all food/drink. Additionally, the care plan stated the registered dietitian was to: 1. Evaluate the resident monthly and when ever necessary (PRN) 2. Monitor the nutritional status, caloric intake, and make recommendations for changes to tube feeding as needed. Continued review of the medical record, on 10/27/15 at 8:25 a.m., revealed a progress note dated 09/28/15, stating Resident #33 was transferred to the local hospital due to the percutaneous endoscopic gastrostomy (PEG) tube no longer functioning. Interview with the DON on 10/28/15 at 10:38 a.m., revealed the PEG tube blew and was no longer working; therefore, Resident #33 was transferred to the hospital. The progress notes indicated Resident #33 was in the hospital until 10/01/15. The progress note dated 10/01/15, revealed Resident #33 was sent back to the facility with a new PEG tube. The note further stated Resident #33 was not administered food or medication while in the hospital; only intravenous fluids. At 8:10 p.m. on 10/01/15, the progress note documented, Nurse found PEG tube displaced, lying in bed beside of resident. The physician was notified the PEG tube was out and ordered arrangements be made in the morning for the resident to be seen by the [MEDICATION NAME] in the emergency room to reinsert the PEG tube. The progress note dated 10/02/15 at 12:10 p.m. revealed the physician was in the facility and was notified of the resident's 10/07/15 appointment with the [MEDICATION NAME]. The note further documented the physician was made aware that Resident #33 was not eating and was pocketing his food. Review of the progress notes, on 10/27/15 at 1:30 p.m., revealed on 10/06/15; a speech evaluation due to dysphagia (difficulty with swallowing) was ordered. Review of the SLP evaluation and plan of treatment dated 10/06/15 revealed Resident #33 had severe swallowing abilities and was holding foods. The recommendations included a pureed diet, honey-thick fluids, and close supervision. The progress note dated 10/06/15 documented the physician was in and reviewed the speech therapy recommendations. The resident's note by the physician dated 10/06/15 confirmed the resident had many problems with the PEG tube. The physician documented she was going to notify the [MEDICATION NAME] as, This really needs to be addressed on a semi-urgent basis and I feel there has been a slow response to our requests for an evaluation. On 10/07/15, the progress note stated the new appointment with the [MEDICATION NAME] was 10/15/15. The progress note dated 10/07/15 documented the physician was notified and ordered staff to watch intake and outputs and if the resident became dehydrated to call for orders. During an interview with Clinical Care Supervisor #2, on 10/28/15 at 9:07 a.m , she stated the [MEDICATION NAME] refused to insert the PEG tube until the resident was seen in the hospital. The new appointment was scheduled for 10/15/15. The vital sign/weight record dated 10/08/15 revealed Resident #33's weight was 158.8 pounds, indicating a severe weight loss of 6.3% in 30 days. A progress note, dated 10/08/15, indicated the resident was discussed at the weight and nutrition meeting due to a 10.6 pound weight loss in 1 month and consumption of less than 26% of meals and 900 cc of fluids. The note stated the physician was notified and no new orders were received. The note did not indicate the dietitian was notified. An interview was conducted with Dietary Services Supervisor #23 on 10/27/15 at 4:47 p.m., regarding the significant weight loss. She verified Resident #33 was discussed at the weight and nutrition meeting on 10/08/15. She provided the progress note regarding the meeting and verified there were no new physician orders. She stated Clinical Care Supervisor #2 would be aware of additional interventions. During an interview with Clinical Care Supervisor #2, on 10/28/15 at 9:07 a.m., she stated interventions implemented while the PEG tube was out included: offering food every shift, starting a nutritional supplement (magic cup) three (3) times a day, and ordering a speech therapy evaluation. On 10/28/15 at 10:38 a.m., the meal percentages from 10/01/15 through 10/14/15 were reviewed with the DON. During this period, Resident #33 consumed between 5% and 60% of the meals for 26 of 40 shifts. There was no consumption on four (4)shifts and nine (9) meal refusals. The DON stated it was hit or miss when it came to oral consumption. She stated staff should have re-weighed the resident according to the policy since there was greater than 5 pound weight loss. Additionally, she stated she would have expected the resident to receive a nutritional supplement such as [MEDICATION NAME] and increase the number of feedings. On 10/28/15 at 12:00 p.m., review of the Weighing and Measuring the Resident Policy, revised on 07/01/06, revealed staff were to re-weigh the resident if there was a change of five (5) 5 pounds, and to report the change. Additionally, review of the Nutritional Assessment and Documentation Operations policy, effective 03/01/14, indicated the consultant dietitian should review and assess residents experiencing a significant weight change of 5% in 30 days. There was no evidence the dietitian was notified of the significant weight loss. On 10/28/15 at 12:15 p.m., the Dietitian Review Notes, dated 10/22/15 were reviewed. The notes did not mention the significant weight loss. The note stated to continue the tube feedings, oral intake had improved to three (3) meals of varied amounts when the tube was out, and the resident received Magic Cup three (3) times per day. There were no new recommendations. On 10/28/15 at 7:38 a.m., the weight record revealed the resident was weighed on 10/27/15. Resident #33's current weight was 144.7 pounds. This was a loss of 14.1, representing a severe weight loss of 8.88% in 19 days. An observation was made of Resident #33 being fed by Licensed Practical Nurse (LPN) #7 on 10/28/15 at 12:35 p.m. The resident was totally dependent and was being spoonfed. During an interview with LPN #7, at the time of the observation, she verified Resident #33 consumed 1/2 of the Magic Cup and ate a few bites of pureed potatoes and squash. She stated there were no choking episodes and no swallowing difficulty. Corporate Dietitian #67 was interviewed on 10/28/15 at 12:48 p.m. She stated she evaluated Resident #33 and made significant recommendations to the tube feeding schedule and medications for Resident #33 to address the weight loss. Review of the Dietitian Review Notes, dated 10/28/15, revealed Resident #33 was to receive tube feedings for 20 hours/day. Additionally she recommended the administration of Vitamin C and Zinc Sulfate.

Based on record review, observation, facility policy review, and staff interview, the facility failed to provide a safe environment and/or adequate supervision to prevent falls for three (3) of thirty-two (32) Stage II sample residents, one (1) of whom sustained injuries requiring medical intervention. Resident #66, whose cognitive status was severely impaired and who had been assessed as having unsteady gait, was identified as being at high risk for falls. She sustained twelve (12) falls in the facility since her admission on 02/09/11, two (2) resulting in injuries requiring medical attention, with no evidence of root cause analysis of the falls (which was identified as an intervention in her falls care plan) and no revisions made to her care plan to promote her safety. Resident #43 sustained seven (7) falls between the middle of July 2011 and the beginning of October 2011, with no consistent, documented evidence that the facility's falls and fall risk policy was being followed (which was to include a re-evaluation of interventions after each fall) or that all recommended measures to minimize falls had been implemented (e.g., the application of a non-slip material to the resident's chair). Resident #54 sustained one (1) fall in September 2011, with no evidence that the facility's falls and fall risk policy was followed after the fall occurred. Resident identifiers: #66, #43, and #54. Facility census: 55. Findings include: a) Resident #66 1. A review of the clinical record revealed Resident #66 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She was assessed on admission as being at high risk for falls due to wandering and altered safety awareness. - 2. Review of the resident's comprehensive admission minimum data set (MDS) with an assessment reference date (ARD) of 02/18/11 found these responses to the following questions related to falls (J1700 and J1800): - "Did the resident have a fall any time in the last month prior to admission?" - No - "Did the resident have a fall any time in the last 2-6 months prior to admission?" - No - "Did the resident have any fractures related to a fall in the 6 months prior to admission?" - No - "Has the resident had any falls since admission or the prior assessment .., whichever is more recent?" - Yes According to the assessor, the resident one (1) fall since admission or the prior assessment, for which no injury was sustained. - Review of the results of the brief interview for mental status (BIMS) completed as part of the 02/18/11 MDS found the resident scored "04" out of "15", indicating the resident's cognitive status was severely impaired (C0500). As part of the BIMS, the resident was asked to recall three (3) words that had been said to her earlier in the interview (C0400); she was unable to recall two (2) of the words and was only able to recall the third word with cuing. (Review of the resident's most recent quarterly MDS with an ARD of 07/28/11 found her BIMS score was "06" out of "15", again indicating her cognitive status was severely impaired (C0500). As part of this BIMS, she was able to recall one (1) word with no cuing and one (1) word with cuing and was not able to recall the third word.) - Review of the assessment of her functional status completed as part of the 02/18/11 MDS found her balance (G0300) when moving from a seated position to a standing position was not steady and she was only able to stabilize with human assistance; her balance while walking and while turning around and facing the opposite direction while walking was not steady but she was able to stabilize without human assistance. - According to the care area assessment (CAA) worksheet associated with the above MDS, dated [DATE] (quoted as typed), under the heading "Analysis of Findings" for "Nature of the problem / condition": "Resident had a fall 2/13 beside her bed, unsteady on feet, received scheduled xanax for anxiety progress notes, observation, physician's orders [REDACTED]." - 3. Her comprehensive admission care plan included the following problem statement: "(Resident #66) is High risk for falls r/t wandering." (initiated on 02/14/11) Interventions to promote Resident #66's safety with respect to her risk of falling (all of which were initiated on 02/14/11) included (quoted as typed): "HIGH FALL RISK: Anticipate and meet patient's needs. Provide a safe environment for the patient by observing the condition of his/her room every shift and correcting any identified issues. PT (physical therapy) evaluate and treat prn (as needed). Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate patient / family / IDT (interdisciplinary team) as to cause." (These were the same routine interventions found on all the records records reviewed for falls during the survey, and there were no interventions that reflected the unique needs of the individual residents.) - Additional problem statements (P) and their associated interventions (I) included (quoted as typed): P - "(Resident #66) has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) Dementia / occassional aggressive behaviors." (initiated on 02/14/11) I - "1/2 side rails up on both sides of bed to enhance bed mobility and transfer ability TRANSFER: Independent. DRESSING: Assist of 1. Wears Glasses. TOILET USE: Independent. TOILETING SCHEDULE: ... PERSONAL HYGIENE/ORAL CARE: Assist of 1. BATHING: Assist of 1." (all initiated 02/17/11) P - "Patient is at risk for elopement due to Hx (history) of elopements from home, increased confusion." (initiated on 02/09/11) I - "Secure Care Alarm to right ankle at all times. Check alarm device every shift to ensure functionality. Allow patient to wander freely within safe and secure environment. Involve patient in 1:1 (one-on-one) recreational activities. Encourage socialization with other appropriate residents. Encourage family support / involvement." (all initiated on 02/09/11) - 4. Her admission orders [REDACTED]. Following her admission to the facility on [DATE], Resident #66 sustained falls on the following dates, as documented in her progress notes (quoted as typed): - 02/13/11 at 7:20 p.m. - "Resident was found sitting beside of foot of bed on buttocks. ..." - 02/20/11 at 8:20 a.m. - "found sitting on floor beside bed in room (number), merriwalker in hallway ..." - 02/24/11 at 3:27 p.m. - "fall, found on the floor beside merry-walker sitting, leaning up against the ..." - 02/27/11 at 2:00 p.m. - "resident observed sitting on buttocks beside of bed ..." - 03/02/11 at 9:09 p.m. "resident sat down on floor from merry walker ..." - 03/06/11 at 11:47 a.m. - "resident was found on floor in room (number) on buttocks in front of merry walker. ..." - 04/08/11 at 7:50 p.m. - "Nursing assistants reports to me resident was on floor beside of bed ..." - 07/29/11 at 3:45 p.m. - "CNA (certified nursing assistant) walking down B hall, observed resident sitting on floor beside bed ... Hematoma 6cm x 6cm x 3cm protrusion observed to left forehead ..." - 07/29/11 at 10:39 p.m. - "Fall out of bed with no apparent injury. ..." - 08/27/11 at 3:58 a.m. - "... Resident found lying on back on floor.Denies hitting head. ..." - 10/02/11 at 7:10 a.m. - "patient found on floor lying on rt (right) side in front of lt (left) side of bed, 1cm laceration and 2cm laceration rt side of rt eyebrow and 3cm hematoma under lacerations. ..." - 10/03/11 at 12:52 a.m. - "Fall this morning ..." The resident sustained [REDACTED]. [REDACTED]. - 5. The resident was observed at 2:30 p.m. on 09/26/11, walking aimlessly in the hallway, asking staff members if they would help her find her cane. A nurse (Employee #56) led her back to her room and got her quad cane for her. The resident was observed again on 09/27/11, 09/28/11, and 09/29/11, walking about either with or without her cane. She would ask about it, and staff would get it for her. Sometimes she would carry the cane with her while she walked, and sometimes she would use it for support. - 6. Although the initial (and still active) care plan stated that all falls were to be reviewed and evaluated to identify root cause(s) with resulting changes made to the care plan, there was no evidence in the record (nursing notes, progress notes, incident reports, CAA Worksheets, care plans, etc.) to reflect this was being done. The care plan for falls remained, on 10/05/11, exactly as it was at its initiation. There had been no revisions to the care plan (to include use of the quad cane) and/or any evidence that additional / different interventions had been attempted in an effort to promote the resident's safety even after she sustained falls with injuries requiring medical intervention. - 7. The director of nurses (DON - Employee #74), when asked at 11:00 a.m. on 10/04/11 if the resident's falls were being reviewed, stated they always talked about them, but she acknowledged, after reviewing Resident #66's medical record, that there had been no revisions to the care plan and no documentation reflecting an effort to identify causal or contributing factors to the falls. She had no answer when asked when and why the use of the cane was started. - 8. A review of the physical therapy (PT) evaluation and notes from 02/10/11 through her discharge from PT services on 04/08/11 found that, although she had improved and had less "ataxia" with her gait, she did not meet her rehabilitation goals. She continued a second course of therapy from 04/09/11 through 04/22/11, and at discharge was noted to have "less unsteadiness". A review of subsequent therapy screens dated 07/15/11, 08/01/11, and 08/30/11 failed to find any proposed interventions or comments except for recommending the use of a bed alarm on 08/30/11, which was not adopted. There was also no evidence that therapy staff had assessed the resident for or instructed her in the use of a quad cane. This was verified by the physical therapist (Employee #76) at 9:30 a.m. on 10/05/11. - 9. During an interview with Employee #75 (the nurse who was responsible for developing the care plans) at 11:15 a.m. on 10/05/11, she acknowledged there had been no entries into the care plan regarding the use of the quad cane and no revisions to the care plan interventions after any of the falls. When asked about the lack of individuality in the care plan addressing Resident #66's falls, she stated that, usually after they know the resident better, they address individual needs, but she acknowledged this had not occurred for Resident #66. - 10. During an interview with the administrator (Employee #73) at 1:00 p.m. on 10/04/11, he reported that the fall on 10/02/11 had been reviewed and was attributed to the resident's receiving a newly prescribed pain medication, which was discontinued. When asked about any previous actions, his only remark was that they had the resident screened by physical therapy after the falls and they had carried out their recommendations. -- b) Resident #43 Record review revealed Resident #43 was a [AGE] year old woman who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her comprehensive admission MDS with an ARD of 01/11/11, when reviewed on 10/03/11 at 2:00 p.m., found her BIMS score was "03" out of "15", indicating severe cognitive impairment with no ability to recall three (3) words said to her earlier in the interview (C0500 and C0400). She required the extensive physical assistance of one (1) person to transfer between surfaces and the limited assistance of one (1) person with ambulation and locomotion (G0110). Her balance when moving from a seated to standing position and when transferring between surfaces was not steady but she was able to stabilize herself without human assistance; her balance when walking, turning around, and moving on and off the toilet was not steady and she was not able to stabilize herself without human assistance (G0300). She also used a cane / crutch and a wheelchair as mobility devices (G0600). She had sustained a fall in the last month prior to her admission to the facility (J1700), and she had one (1) fall since admission with no injury (J1900) - Review of her care plan revealed the following problem statement, which was initiated on 01/04/11 (quoted as typed): "(Resident #43) is High risk for falls r/t impaired safety awareness, Confusion , Wandering, Hx of frequent falls." The goal associated with this problem was: "Patient will not sustain serious injury from falls through 12/21/11." (This goal was initiated on 01/19/11.) Interventions to be implemented to accomplish this goal were: "HIGH FALL RISK: Anticipate and meet patient's needs. Provide a safe environment for the patient by observing the condition of his/her room every shift and correcting any identified issues. PT prn (as needed)." All of these interventions were initiated on 01/04/11. Subsequent revisions to the care plan found the following additional interventions: - Added on 04/15/11 - "Low bed at all times and fall mat to both sides of bed." - Added on 09/27/11 - "FALL RISK: Alarm to bed at all times to alert staff of patient attempts to transfer unassisted. Bed in lowest position except when providing care." - Added on 09/27/11 - "FALL RISK: Alarm to chair when not in merrywalker, at all times to alert staff of patient attempts to transfer unassisted." (All of these interventions were found in place through daily observations during the survey event.) - Review of incident reports, on 10/04/11, found Resident #43 had sustained falls on 07/17/11, 08/03/11, 08/12/11, 09/05/11, 09/10/11, 09/29/11, and 10/02/11. Beginning in September 2011, interdisciplinary team (IDT) notes were found to be included at end of the incident reports. The IDT note on the report for the 09/05/11 fall, which was dated 09/06/11, simply recapitulated verbatim a statement of what had happened: "Resident sitting in merry walker when she fell asleep and fell on to strap and then onto floor when staff was assisting her back up into merry walker." The IDT note on the report for the 09/10/11 fall, which was 09/13/11, simply recapitulated the current interventions already in place prior to this fall. The IDT note on the report for the 09/29/11 fall, which was dated 10/03/11, discussed the continued use of the Merrywalker (typed as written): "IDT reviewed incident report evaluated use of merry walker weighed benefits, safety and risks, the benefits out weight the risks due to the merry walker allowing for independent mobility. resident has poor memory and does (not) remember other assistive devices such as a cane or walker." - Review of fall assessments in the resident's electronic medical record (EMR), on 10/04/11 at 1:00 p.m., found graphs of assessment scores containing the legend "fall risk assessments trigger therapy screen". During an interview with the administrator on 10/04/11 at 2:00 p.m., when asked to explain this process, he stated that therapy screens were done after every fall assessment, except for annual assessments. Copies were requested of completed therapy screens for Resident #43 following each of the falls under review (07/17/11, 08/03/11, 08/12/11, 09/05/11, 09/10/11, 09/29/11, and 10/02/11.) On 10/04/11 at 3:10 p.m., the administrator provided the PT screen completed on 09/07/11 for the 09/05/11 fall and the PT screen completed on 10/03/11 for the 09/29/11 fall. He stated Resident #43 was still an active therapy client on 07/17/11. For the remaining falls that occurred on 08/03/11, 08/12/11, and 09/10/11, there was no evidence that therapy screens were ever completed. - The facility's policy and procedure for falls was requested. A policy titled "Falls and Fall Risk, Managing" (revised 07/01/06) was provided at 3:40 p.m. on 10/04/11. The policy stated, under the heading "Monitoring Subsequent Falls and Fall Risk": "1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. "2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. "3. If a resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. "4. The staff and/or physician will document the basis for conclusions that specific irreversible factors exist that continue to present a risk for falling or injury due to falls." - A review of Resident #43's physician orders, on 10/04/11 at 3:50 p.m., found the resident was ordered Seroquel 12.5 mg once daily beginning on 06/20/11. This was an increase from the previous dosage of 6.25 mg daily. The current care plan described side effects of Seroquel as dizziness, headaches, and seizures. There is no evidence of any consideration given to possible impact of the psychoactive medication increase on the resident's falls found in the assessments or the care plan. - When reviewed on 10/05/11 at 9:00 a.m., the PT screen completed on 09/07/11, for the fall of 09/05/11, was found to contain a recommendation to use of Dycem (a non-slip material) in the resident's room chair to prevent her from sliding out, as she had on 09/05/11. This intervention was not found in Resident #43's care plan, and it was not found on the daily care instructions for nursing assistants (the resident's Kardex). The DON, when asked about the use of Dycem as a safety measure for Resident #43 on 10/05/11 at 11:40 a.m., stated that Dycem was used on her chair when she is in it. The nursing assistant assigned to provide care for Resident #43 (Employee #46) was interviewed at 11:45 a.m. on 10/05/11. When asked if there was non-skid material to be applied to Resident #43's room chair when she was in it, Employee #46 replied that there was not. An interview was conducted with the administrator on 10/05/11 at 9:35 a.m., during which he voiced understanding that there was not consistent, documented evidence that the facility's falls and fall risk policy was being followed or that all recommended measures to minimize falls had been implemented. -- c) Resident #54 Record review revealed Resident #54 was a [AGE] year old woman who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Observations throughout the survey found Resident #54 travelling throughout the facility in her wheelchair. - An abbreviated quarterly MDS with an ARD of 03/03/11, when reviewed on 10/03/11 at 1:30 p.m., revealed Resident #54's cognitive skills for dialing decision making were moderately impaired (C1000), with short-term and long-term memory problems (C0700 and C0800). She walked independently in her room, but she did not walk in the corridor at all during the assessment reference period. Her balance while moving from a seated to standing position, walking, and turning around was not steady, but she was able to stabilize without human assistance (G0300). She used a wheelchair as a mobility device, and she moved independently on the unit with set-up help only and off the unit with the assistance of one (1) person. As of 03/03/11, she had no falls since her prior MDS. A comprehensive annual MDS, with an ARD of 05/26/11, revealed no changes had occurred in her cognitive status since the previous MDS. She walked in her room and in the corridor only once or twice during the assessment period, and when walking in her room she received the assistance of one (1) person. Her balance while walking and turning around was not steady, but she was able to stabilize without human assistance (G0300). She used a wheelchair as a mobility device, and she moved on the unit and off the unit with supervision by one (1) person. As of 05/26/11, she had no falls since her prior MDS. An abbreviated quarterly MDS, with an ARD of 08/25/11, revealed no changes had occurred in her cognitive status since the previous MDS. She walked independently in her room, but she did not walk in the corridor at all during the assessment reference period. She used a wheelchair as a mobility device, and she moved on the unit and off the unit with supervision and set-up help. As of 08/25/11, she had no falls since her prior MDS. - Resident #54's current care plan, when reviewed on 10/03/11 at 1:40 p.m., was found to contain a focus area for "High risk for falls r/t (related to) hx (history) of falls, impaired safety awareness, cognitive deficits." This problem statement was initiated on 03/07/11. The stated goal for this focus area was that the resident would "not sustain serious injury from falls through 11/30/11". The only two (2) interventions were to be implemented to accomplish the goal were: "HIGH FALL RISK: anticipate and meet patient's needs. Provide a safe environment for the patient by observing the condition of her room every shift and correcting any identified issues." These interventions, which were also initiated on 03/07/11, were not specific to this resident's needs and were found in the care plans of other residents reviewed for falls. - During an interview with a licensed practical nurse (LPN - Employee #23) on 09/27/11 at 12:19 p.m., she stated the resident had a fall on 09/02/11. - An incident report recording this fall, when reviewed at 1:00 p.m. on 10/03/11, stated the resident was found in a shower stall on the floor with her wheelchair in front of her on the morning of 09/02/11. A note at the end of the report, dated 09/06/11, stated (typed as written): "IDT (interdisciplinary team) review report referral made to PT for screening resident transfers independently." - Further record review found no evidence that the PT screen, which had been requested by the IDT following the fall of 09/02/11, had been completed. During an interview with the administrator at 10:40 a.m. on 10/04/11, a PT screen dated 08/10/11 was provided, which stated: "... at this time pt (patient) does not need skilled therapy." The administrator confirmed the facility failed to act upon the recommendation by the IDT for another therapy screening of Resident #54 in an effort to prevent further falls. .