Every finding on record at Carlyle Senior Care of Kingstree

Based on interview, record review, and facility policy review, the facility failed to ensure residents were encouraged to voice grievances without fear of retaliation and failed to establish and maintain an effective grievance process for 89 of 89 residents reviewed. These deficient practices resulted in a systemic failure of the grievance process and created an environment where residents were discouraged from exercising their right to voice grievances without fear of reprisal.Findings include:Review of the facility's policy titled Grievance Policy revised on 02/01/24, indicated residents have the right to voice grievances without fear of retaliation, grievances may be made verbally or during Resident Council meetings, and all grievances must be documented, investigated, tracked to resolution, and responded to in writing. The policy also states residents may file grievances anonymously.Review of Resident Council (RC) meeting minutes from October 2025 through March 2026, revealed ongoing concerns voiced by residents, including inconsistent provision of evening snacks, excessive call light response times, and delays in receiving care. Specifically, on 11/17/25 and 12/29/25, residents reported not consistently receiving evening snacks. On 02/24/26, multiple residents reported staff did not respond timely to call lights and that they did not receive needed care without long wait times. These concerns were not documented as grievances, were not investigated, and no resolutions or follow-up were documented in subsequent RC meeting minutes. March 2026 RC minutes contained no follow-up to previously identified concerns. There was no documented evidence that RC concerns were tracked, investigated, or resolved.During an interview on 04/08/26 at 3:25 PM, and again at 4:35 PM, the Social Services Director (SSD), who identified herself as the Grievance Official, stated residents are discouraged from filing grievances due to fear of retaliation. The SSD further stated that some grievances are resolved the same day and therefore are not written down or tracked. The SSD confirmed that concerns voiced during Resident Council meetings are not documented as grievances and are not formally investigated or resolved through the grievance process.During the group Resident Council meeting on 04/09/26 at 9:23 AM, residents stated they did not know where to obtain grievance forms and reported there was no grievance box available in the facility. Residents stated grievance forms must be requested from Social Services and are kept in the Social Worker's office. Residents further stated there has never been a grievance box available for submission, and one resident reported, we can't file a grievance without fear of retaliation. Residents also expressed concerns that complaints were not addressed and may be discarded without action. The residents further reported call light response times of up to one hour across all shifts, including weekends and evenings. Residents also reiterated concerns about inconsistent snack availability, including diabetic residents not receiving snacks. These concerns had been previously voiced in RC meetings but were not documented or addressed through the grievance process.During an interview on 04/09/26 at 10:34 AM, the Director of Nursing (DON) and the Corporate Nurse Consultant (CNC) stated residents must request grievance forms from staff and may submit completed forms by placing them under the SSD or DON's door. The DON and the CNC confirmed there is no anonymous grievance submission system in place. The SSD acknowledged there is no current method for residents to file grievances anonymously, despite facility policy allowing anonymous grievances.During an interview on 04/09/26 at 11:36 AM, the Activity Director (AD) stated responses to RC concerns are sometimes written on meeting minutes and shared with departments; however, she acknowledged she had not provided these responses to residents and could not produce documentation of completed resolutions.During an interview on 04/09/26 at 12:31 PM, the DON stated that while RC concerns should be written as grievances, this had not been consistently done for at least the past six months, and documentation of resolutions had not been maintained for approximately one year or longer.During another interview on 04/09/26 at 1:26 PM, the SSD confirmed she is responsible for overseeing all grievances but acknowledged there is no system to address anonymous complaints, and she was unaware of how residents could submit grievances anonymously. The SSD further stated that all concerns, including those voiced in Resident Council meetings (e.g., long wait times and lack of snacks), should be treated as grievances, but confirmed these concerns were not being processed through the grievance system. The SSD also acknowledged residents expressed fear of retaliation.During an interview on 04/09/26 at 1:49 PM, the Administrator stated residents typically bring concerns directly to staff, and issues may be resolved without being documented. The Administrator acknowledged it was unusual that no grievances were recorded and confirmed there was no established system for anonymous grievance submission.

Based on observation, interview, and facility policy review, the facility failed to date, label, and/or cover food products stored in the kitchen. This failure had the potential to create an environment for food-borne illnesses which could affect 89 of 89 residents who consume food prepared from the facility's kitchen.Findings include:Review of the facility's policy titled Date Marking for Food Safety in the section titled Use By Dating Guidelines dated 03/29/24, revealed, . 5. The manufacturer's expiration date, when available, is the use by for unopened items. 6. The manufacturer's instructions for the discarding of open items supersedes the general food storage safe guide. 7. The day of preparation or opening is considered Day 1 when establishing the use by date. 8. Guidelines assume that the food is properly stored, covered, and handled. 9. Guidelines apply regardless of storage location (eg, Kitchen, pantries, etc.) 10. All ready-to-eat, Time/Temperature Control for Safety foods that are to be held for more than 24 hours at a temperature of 41F or less will be labeled and dated with prepared date (Day) and use by Date (no late than Day 7) 11. The Head Cook, or designee, shall be responsible for checking the refrigerator daily for items that are expiring and shall be discarded accordingly. 12 The Dietary Manager, or designee, shall spot check refrigerator weekly for compliance and document accordingly. Corrective action shall be taken as needed.During an observation on 04/07/26 from 10:15 AM to 10:45 AM, with the Dietitian Supervisor (DS), revealed in the main refrigerator were four slices of white bread wrapped in plastic wrap with no label with a date. In the main freezer storage room, waffles were observed in a bag that was open and stored in a cardboard box with no date opened, two racks of pork ribs were in an opened cardboard box opened with no plastic wrap making the ribs exposed to the freezer. Two plastic bags, one with 50 frozen pork sausage links and the other with eight bone in pork chops were opened, resealed with plastic wrap, and no label. During an interview on 04/07/26 at 11:15 AM, the DS confirmed the above observations and stated that bread should be in closed packaging and dated by staff when taken out of the main refrigerator. The DS confirmed that all frozen items once they are opened should be dated by staff. The DS also stated that there has been no schedule for food being checked for dates or expired food.

Based on observation, record review, interview, and facility policy review, the facility failed to provide written documentation of a hospital transfer to Resident (R)5 and to their representative, for 1 of 3 residents reviewed out of a total sample of 24 residents. This failure placed the resident and/or the resident's representative at risk for lack of awareness of rights, including the right to appeal the transfer.Findings include:Review of the facility's policy titled, Transfers and Discharges, dated March 2024 revealed, The resident and/or resident representative are notified in writing of the following information: a. The specific reason for the transfer or discharge; . b. The effective date of the transfer or discharge; . c. The specific location . to which the resident is being transferred or discharged ; . d. An explanation of the residents' rights to appeal the transfer or discharge to the state . f. The bed hold notification . g. The name, address, and telephone number of the Office of the State Long-Term Care Ombudsman.Review of R5's Admissions Record, located under the Admissions tab in the electronic medical record (EMR), revealed R5 was initially admitted to the facility on [DATE], with diagnoses including but not limited to, acute and chronic respiratory failure, paroxysmal atrial fibrillation, dysphagia, oropharyngeal phase, vascular dementia, pressure ulcer stage II of left heel.Review of R5's Nursing Progress Notes, located under the Progress Notes tab in the EMR, revealed the resident was transferred to the hospital on [DATE], related to altered mental status and increased confusion. The resident returned to the facility on [DATE]. There was no documented evidence that a written transfer/discharge notice was provided to the resident or to the resident's representative at the time of transfers or shortly thereafter.During an interview on 04/09/26 at 10:22 AM, the Administrator stated the discharge/transfer notices were generally not scanned into the EMR (electronic medical record) but were kept in an individual resident file located in the office of the admission coordinator. She stated the admission Coordinator was out of the country on vacation. The Administrator stated she searched in the Admissions Coordinator's office, and she could not find a discharge/transfer notification for R5.

Based on review of the facility policy, record review, observation and interview the facility failed to effectively manage pain for one of one resident (Resident (R) 58) reviewed for pain out of 23 sample residents. The facility failed to order R58's Morphine (an opioid pain medication) in a timely manner, resulting in an escalation of pain levels and decreased oral intake. Findings include: Review of the facility's policy titled Pain Management revised 08/30/24, revealed, 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will . c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences . i. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current treatment regimen. Review of the facility's policy titled Ordering Medications from the Pharmacy, revised 08/10/21, revealed 3. Schedule II controlled substances should be reordered seven (7) days in advance of need. Review of R58's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 12/23/24 revealed R58 was admitted to the facility on [DATE] with diagnoses that include but are not limited to: acquired absence of the right leg above the knee, cardiomyopathy and peripheral vascular disease. R58 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R58 was cognitively intact. Review of R58's Care Plan, revised 03/12/25 revealed Pain: Resident is at risk for alteration in comfort related to weakness, decreased mobility, peripheral arterial occlusion with ischemia to the LLE [lower left extremity] with chronic pain, Rt [right] AKA [above the knee amputation], GERD [gastroesophageal reflux disease], BPH [benign prostatic hyperplasia], Dysphagia and pain Constipation. Amputation was recommended to LLL [lower left leg] but has been declined by the resident. 2/17/25-readmitted to facility, Neurontin & morphine sulfate in place . Interventions included Administer medication as ordered and PRN [as needed] pain meds when non-pharmacological pain interventions are ineffective .Provide alternative comfort measures (relaxation, positioning etc ) prn as ordered, and Report uncontrolled pain to MD [Medical Doctor] as needed. Review of R58's Orders revealed: 02/17/25 Morphine Sulfate Tab ER [extended release] 15 MG [milligrams] by mouth [by mouth] three times a day [TID] for pain. 02/17/25 Gabapentin Cap 400 MG 1 capsule orally two times [BID] a day for pain in legs. 03/03/25 Tylenol Oral Tablet 325 MG (Acetaminophen) 2 tablet by mouth every 6 hours as needed for pain. 3/13/25 Acetaminophen Oral Tablet 325 MG 2 tablet by mouth in the afternoon for Chronic Pain. Review of a medication request located in the Nurse Practitioner's book at the nurse's station, revealed, a request completed on 03/10/25 for R58's morphine ER 15 MG PO three times a day for pain and noted the number on hand as three. On 03/17/25 and 03/22/25 the number on hand was left blank. Review of R58's Pain assessment dated [DATE], revealed R58 occasionally had pain with a Numeric Rating of 3 on a Scale (00-10). R58's pain was managed with Tylenol daily, Gabapentin BID, Morphine TID. Review of R58's Medication Administration Record (MAR) revealed R58's morphine was not administered on 03/21/25 at 2:00 PM, on 03/22/25 and 03/23/25 at 6:00 AM, 2:00 PM, and 10:00 PM, and on 03/24/25 at 6:00 AM. A total of eight doses of morphine were not administered. Review of R58's administration note, dated 03/25/25 revealed Tylenol Oral Tablet 325 MG Give 2 tablet by mouth every 6 hours as needed for pain. Resident c/o [complain of] pain 10/10. During an interview on 03/25/25 at 11:01 AM, R58 stated he had been out of his morphine for five days and suspected the facility ran out. R58 stated his morphine came in yesterday [03/24/25] and it was taking a while for his body to catch up. R58 was asked how it made him feel to be without the morphine and he stated he couldn't describe it, but he couldn't get out of bed or move about in bed because he had a lot of pain. R58 was asked if he was given something else to help with his pain. R58 said Tylenol. R58 was asked if the Tylenol helped and he stated, No, not really, it took a little of the edge off. During an observation and interview on 03/26/25 at 8:34 AM, R58 was observed awake in bed eating breakfast. R58 stated he felt much better now his pain was more controlled. R58 also stated during the time he was without the morphine and in pain he wasn't able to eat. Review of R58's Amount Eaten revealed, on 03/24/25 R58 refused breakfast and lunch. On 03/25/25 R58 ate 26-50 % at breakfast and lunch. R58's usual consumption was 51-100%. During an interview on 03/26/25 at 8:37 AM, Licensed Practical Nurse (LPN) 1 was asked if R58's morphine was out over the weekend. LPN1 stated, Yes. LPN1 stated the prescription was sent to the pharmacy with no response. LPN1 stated, Finally the unit manager called the pharmacy. LPN1 was asked how much time in advance the process needed to be started to refill the morphine. LPN stated they ordered when they saw the morphine getting low, about four days out. LPN1 stated they physically placed the order request in the Nurse Practitioner's (NP) book at the nurse's station and the NP sent it. LPN1 was asked if the prescription for R58's morphine was sent timely and LPN1 stated, No. During an interview on 03/26/25 at 3:09 PM, the Director of Nursing (DON) was asked if she was aware R58 was out of his morphine over the weekend. The DON stated, No, she just became aware. The DON stated she reviewed the medication request book; pharmacy was called, and the NP said she sent it in. The DON went on to say, But it [morphine] didn't come in until we requested it on Monday [03/24/25]. The DON stated it should have come Friday night, 03/21/25. The DON was asked what should be done when the medication didn't come in as planned. The DON stated, Notify the physician. The DON was asked if another pain medication or intervention was utilized in the meantime. The DON stated she would have to check. During an interview on 03/27/25 at 11:20 AM, the NP was asked if she was aware R58 was out of morphine over the weekend. The NP stated, No. The NP stated on 03/21/25, the medication was supposed to be filled and sent to the facility that night. The NP stated R58 informed her 03/24/25 during her visit that the morphine wasn't given. The NP stated the staff on-call should have been notified. The NP checked her computer and confirmed she didn't get notification the on-call staff were called.

Based on review of the facility policy, record reviews and interviews, the facility failed to ensure services were provided to prevent and treat pressure ulcers by not following professional standards of practice to evaluate and document initiating wound assessment and following the wound doctor's care recommendation for four of six residents (Resident (R) 12, R27, R30, and R47) reviewed for pressure ulcers out of a total sample of 23 residents. These failures placed all four residents at risk of pressure ulcers worsening. Findings include: Review of the facility's policy titled, Pressure Injury Prevention and Management, dated 09/30/23, revealed documentation as follows: Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission and weekly. Findings will be documented in the medical record .Assessments of pressure injuries will be performed by a licensed nurse and documented in the electronic charting. 1. Review of R12's Admission Record revealed, R12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including but not limited to: chronic respiratory failure and need for assistance for personal care. Review of R12's Care Plan, revised on 03/26/25, included the following: Potential for alterations in skin integrity related to comorbidities, incontinence, impaired mobility, weakness, and history of pressure ulcers. 02/26/25 - unstageable pressure ulcer to the left medial foot with treatment noted. 03/04/25 - unstageable pressure ulcer left heel with treatment changed. 03/11/25 - treatment changed to left heel and left medial foot. 03/25/25 - treatment changed to left medial foot. Review of R12's Treatment Administration Record (TAR) dated from 01/01/25 to 03/27/25, revealed R12 was receiving wound care orders, that included: Start date 02/26/25, offload heels/ heel protectors two times a day on everyday shift and night shift. May offload heels or apply heel protectors. Start date 03/26/25, wound care to cleanse distal medial foot wound with normal saline. Pat dry. Apply Medi honey and border gauze, do daily. everyday shift. Review of R12's Progress Notes titled VohraProgressNote dated 03/04/25 and 03/25/25, documented three pressure ulcers as follows: a. Site two, UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT, DISTAL, MEDIAL FOOT FULL THICKNESS. The plan of care included recommendations: Cleanse with saline at time of dressing change; Off-Load Wound; Reposition per facility protocol; Pressure Off-Loading Boot. b. Site three, UNSTAGEABLE (DUE TO NECROSIS) OF THE LEFT, MEDIAL FOOT FULL THICKNESS. The plan of care included recommendations: Cleanse with saline at time of dressing change; Off-Load Wound; Reposition per facility protocol; Pressure Off-Loading Boot. c. Site four, UNSTAGEABLE DTI OF THE LEFT HEEL UNDETERMINED THICKNESS The plan of care included recommendations: Cleanse with saline at time of dressing change; Off-Load Wound; Reposition per facility protocol; Pressure Off-Loading Boot. Review of R12's record revealed, no initial wound assessment documentation to include: start date, wound size and wound conditions. Review R12's TAR revealed no documentation that the wound doctor's plan of care recommendations was implemented. During an interview on 03/26/25 at 11:06 AM, the Director of Nursing (DON) stated R12's pressure ulcers' start date was 02/26/25, a Certified Nurse Aide (CNA) verbally reported this to the Infection Preventionist/ Wound Nurse (IP/WN) IP /WN. She said that IP/WN did not document the initial measurements, and the conditions of the pressure wounds in R12's record. 2. Review of R27's Admission Record revealed R27 was admitted to the facility on [DATE] with diagnoses including but not limited to diabetes. Review of R27's Nurse's Note dated 03/05/25 at 1:17 PM, documented, Open area noted to right buttock. TX [treatment] put in place. RP [responsible party] made aware. No s/s [signs and symptoms] of distress noted. Call light is within reach. Review of R27's Progress Notes titled VohraProgressNote dated 03/11/25 included the following: Site two, STAGE 2 PRESSURE WOUND OF THE RIGHT BUTTOCK PARTIAL THICKNESS. Review of R27's Care Plan, revised on 03/24/25, included the following: Stage II pressure ulcer to right buttock with potential for further alterations in skin integrity related to decreased mobility, incontinence, history of healed wounds, comorbidities, and edema. 03/11/25 and stage II pressure ulcer noted to the right buttock with treatment noted. Resolved on 03/22/25. Review of R27's record revealed no initial wound assessment to include: the stage II pressure ulcer's size and wound conditions. During an interview on 03/26/25 at 11:06 AM, The DON stated that a nurse verbally reported the wound to IP/WN and the IP/WN did not document the initial measurements and conditions of the pressure wound in R27's record. 3. Review of R30's Admission Record revealed R30 was admitted to the facility on [DATE] with diagnoses including but not limited to: chronic obstructive pulmonary disease, and pressure-induced deep tissue damage of left heel. Review of R30's Care Plan, revised on 03/26/25 included the following: Existing stage IV to sacrum & Deep Tissue Injury (DTI) left heel with potential for further alternations in skin integrity related to comorbidities, weakness, & impaired mobility, 12/10/24 - Bactrim for fourteen days and cefepime intravenous (IV) for 14 days rated to Methicillin-resistant Staphylococcus aureus (MRSA, a type of staph bacteria resistant the antibiotics) in wound and 12/20/24 - Cefepime IV for fourteen days related to MRSA in wound. Review of R30's Progress Notes titled, VohraProgressNote dated 03/25/25, included the following: Site six, STAGE 4 PRESSURE WOUND SACRUM FULL THICKNESS, wound size 0.4 x 0.7 x 0.3 cm. The plan of care included recommendations: Group-2 Mattress: Continue; Cleanse with saline at time of dressing change; Off-Load Wound; Reposition per facility protocol; Check bed pump q [every] shift to ensure working properly. Review of R30's TAR dated 01/01/25 to 03/26/25 revealed, R30 was receiving wound care by physician's order as follows: Start date 08/06/24, apply heel protectors as tolerated two times a day every day and night shift May offload heels or apply heel protectors. Start 08/14/24, air mattress to bed every shift for aid in wound healing. Check every shift. Start date 03/27/25, wound care for sacral wound, cleanse with wound cleanser. Apply barrier cream on skin directly around the wound. Apply small amount of saline to small piece of Hydrofera Blue, wring out. Tuck in wound and cut off excess. Cover with a dry dressing every day shift, every Tuesday, Thursday, and Saturday, for stage IV pressure ulcer to sacrum. Replace if soiled. Review of R30's record revealed no documentation that the wound doctor's plan of care recommendations was implemented. During an interview on 03/27/25 at 9:53 AM, the DON reviewed R30's record and stated there was no documentation that indicated that the wound doctor's care recommendation was implemented or recorded in R30's record and it should have been implemented, documented in the MAR, and care planned. 4. Review of R47's Admission Record revealed R47 was admitted to the facility on [DATE] with diagnoses including but not limited to: diabetes, stage three pressure ulcer of sacral region, onset date 12/10/25. Review of R47's Care Plan, revised on 03/20/25, included, documentation on 10/28/24 R27 had a stage III pressure ulcer to sacrum. Review of R47's TAR dated 01/01/25 to 03/27/25 revealed that R12 was receiving wound care by physician order as follows: Start date 02/18/25, mattress to bed as tolerated. Check functional every shift. Start 02/21/25, wound care for stage III pressure ulcer to sacrum, clean with wound cleanser, normal saline. Then apply calcium alginate and cover with dry dressing, two times a day on every day and night shift. Review of R47's Progress Notes titled VohraProgressNote dated 10/29/24, included the following: Site seven, STAGE 3 PRESSURE WOUND SACRUM FULL THICKNESS. The plan of care included recommendations: Cleanse with wound cleanser at time of dressing change; Off-Load Wound; Reposition per facility protocol; Turn side to side in bed every 1-2 hours if able; Group-2 Mattress. Review of R47's Progress Notes titled VohraProgressNote dated 02/21/25 and 03/18/25 included the following: Site seven, STAGE 4 PRESSURE WOUND SACRUM FULL THICKNESS Peri Wound Treatment: Zinc ointment apply twice daily and as needed for 30 days. The plan of care included recommendations: Group-2 Mattress: Continue; Cleanse with saline at time of dressing change; Off-Load Wound; Reposition per facility protocol; Turn side to side in bed every 1-2 hours if able; Check bed pump q [every] shift to ensure working properly. Review of R47's record revealed no initial wound assessment was documented to include when the stage III pressure ulcer, now stage IV, began and the initial assessed size. There was no documentation that the treatment order of Zinc ointment twice daily and as needed for 30 days. was given, and if the plan of care recommendation was implemented and what was the pump pressure requirement for the air mattress. During an interview on 03/26/25 at 11:06 AM, the DON stated staff usually verbally reported new wounds to the IP/WN and the IP/WN did not have any documentation of the initial measurements and the condition of the pressure wound. During an interview on 03/27/25, at 9:53 AM, the DON stated a wound assessment would have included size, color, drainage, odors. The DON reviewed R47's record and stated no documentation indicating that the wound doctor's care recommendation was implemented or recorded, and it should have been documented in the MAR, and care planned. During a follow up interview on 03/27/25 at 11:30 AM, the DON stated that the facility's air mattresses were in group two. She said per the manufacturer's manual; the pressure setting would adjust based on the resident's weight. The DON said she would include the pressure setting for air mattress in the monitoring orders in the future.

Based on review of the facility policy, record review, observation, and interviews, the facility failed to document bruising for one of two residents (Resident (R)11) reviewed for quality of care of 23 sample residents. This failure could have caused a missed opportunity to distinguish accidents from inflicted injuries. Findings include: Review of the facility's policy titled, Skin Assessment revised 09/30/24, revealed A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition . h. Note any skin conditions such as redness, bruising . Documentation of skin assessment . b. Document observations (e.g., skin conditions). Review of R11's annual Minimum Data Set (MDS) with an Assessment reference date (ARD) date of 02/03/25, revealed R11 had an admitted [DATE] and a BIMS score of 11 out of 15, indicating R11's cognition was moderately impaired. R11 received an antiplatelet medication, and had diagnoses of heart failure, diabetes mellitus, and stroke. Review of R11's Orders revealed the following: 08/21/24 Clopidogrel Bisulfate (an antiplatelet medication) 75 MG [milligrams] 1 tablet [tab] by mouth [PO] one time a day. 08/21/24 Aspirin (an antiplatelet medication) Tab 325 MG 1 tablet by mouth one time a day. With instructions to observe closely for significant side effects including .bruising . every shift and to document: Y[yes] if side effects noted and notify MD if indicated; N[no] if no side effects noted. Document side effects observed in progress note. Review of R11's March 2025 Medication Administration Record (MAR) revealed, monitoring of anticoagulant side effects such as bruising documented with an N or 0 for 03/01/25 through 03/26/25 indicating no side effects were present. Review of R11's Skin Only Evaluations dated 03/03/25 and 03/18/25, revealed no current skin issues noted. Review of R11's Progress Notes, dated 01/10/25 through 03/25/25, revealed no documentation of bruising. During an observation and interview on 03/25/25 at 11:10 AM, R11 was awake in bed dressed in a night gown. Several purple bruises were noted on both of R11's forearms. R11 was asked about her bruises. R11 stated she didn't know how she got them, and it was concerning her. R11 stated she was not mistreated, and the bruises were not painful. R11 then revealed more bruises on her right neck and shoulder. R11 stated she didn't remember bumping anything. During an interview on 03/26/25 at 1:26 PM, Licensed Practical Nurse (LPN) 1 was asked about R11's bruises. LPN1 stated she was aware of R11's bruises, but she wasn't sure why R11 had them as she wasn't receiving an anticoagulant medication. During an interview on 03/26/25 at 1:56 PM, the DON was asked why R11 had bruises and why the section of the March 2025 MAR included 0 or N indicating no side effects were present. The DON stated she didn't know but R11 was out of the facility last weekend. The DON stated R11 had bumps things on her way to the bathroom and that sometimes causes bruises. The DON confirmed the MAR section for documenting side effects and the skin assessment were noted as none present. During an interview on 03/27/25 at 11:23 AM, the Nurse Practitioner (NP) was asked about R11's bruises. The NP stated she found out about R11's bruises on Monday, 03/24/25 and they looked like purpura. The NP stated she documented the bruises but didn't always tell the staff. The NP was asked what her expectation was for staff in documenting bruises. The NP stated, it depends on the bruise. 52323

Based on review of facility policy, record reviews and interviews, the facility failed to ensure an allegation of physical abuse towards Resident (R)1 was reported within the 2 hour time frame, for 1 of 1 residents reviewed for abuse. Findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, revised on 10/24/22, documents, It is the policy of this facility to provide protections for health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. law enforcement when applicable) within specified timeframe's: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. Review of R1's Face Sheet revealed the facility admitted R1 with diagnoses, including, but not limited to: dementia with behavior disturbance, Alzheimer's Disease and major depressive disorder. Review of the Facility Reportable, revealed the date of the alleged abuse occurred on 09/15/24 at 6:38 AM, in which R1 reported that a Certified Nursing Assistant (CNA)1 drug her to the floor from her bed, and had beat her in order to get her to allow the CNA to bathe her. Further review of the reportable revealed, the actual allegation of physical abuse was made on 09/12/24, when the nurses leaving their shift and were at the nurses station giving report to the oncoming nurses. CNA1 came out of R1's room to report the incident to the nurse, when the bath was finished. The nurses did not report the incident to the Administrator in the required timeframe and the Administrator did not submit the allegation of physical abuse in the required timeframe. Review of a Witness Statement dated 09/16/24, CNA1 stated, The resident was walking around soiled, and I suggested that we get cleaned, the resident agreed and went into her room to get cleaned, she did not get combative and let me get her cleaned up, after we were done, she began to allege that I beat her on her hip, nurses were changing shift and notified. A body assessment was done and nothing was found. (Happened of [sic] 2nd shift 9/12/24). Review of R1's Progress Note dated 09/14/24 at 11:15 PM, documented, Resident's son [name] reported to this writer that resident said she was dragged off the bed onto the floor and forced to take a bath. Body audit complete. No bruising noted. No signs of injury at this time. Resident states She dragged me on the floor and beat me to take a bath. Resident states she has pain all over and rates it a 6/10 on pain scale. Resident currently on scheduled tylenol for management of pain. Incident reported to unit manager and on-call phone. Reported to physician. Resident currently laying in bed resting. No acute distress noted. Will continue to monitor for signs of injury. During an interview on 12/03/24 at 11:05 AM, CNA1 stated, The resident agreed to a bath, and then when I got finished giving her a bath, she started yelling, that I had beat her an drug her to the shower. I would never hurt any of the residents. I went immediately to get the nurse. During an interview on 12/03/24 at 12:30 PM, the Administrator confirmed the allegation of physical abuse occurred on 09/12/24. During an interview on 12/03/24 at 12:45 PM, the Registered (RN) Unit Manager stated we were at the nurses desk giving report to the oncoming nurses when CNA1 came out of the resident's room and said that the resident alleged that she had been beat by the CNA. The RN Unit Manager stated that the incident should have been reported within 2 hours to the State Agency, and immediately to the Administrator.

Based on record review, facility policy review, and interviews, the facility failed to ensure residents who were identified as having a newly evident or possible serious mental disorder were referred for a Level II pre-admission screening and resident review (PASARR). This affected 1 (Resident (R)59) of 2 residents reviewed for PASARR. Findings include: A review of the facility's policy titled, PASARR Coordination effective 11/28/2016, revealed, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to the maximum extent practicable to avoid duplicative testing and effort. Policy Explanation and Compliance Guidelines: 1. All individuals with a mental disorder or intellectual disability who apply for admission to this facility will be screened in accordance with the State's Medicaid rules for screening. The policy further revealed, 6. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review. 1. A review of R59's Facesheet revealed the facility admitted the resident on 06/09/2020 with a diagnosis of anxiety disorder and the resident was diagnosed with psychosis on 12/28/2021. A review of R59's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/06/2023, revealed R59 had a Brief Interview of Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. The MDS also indicated the R59 was not currently considered by the state Level II PASARR process to have a serious mental and/or intellectual disability or a related condition. However, according to the MDS, R59 had a diagnosis of a psychotic disorder. A review of R59's active Care Plan(s), with a start date of 12/14/2022, revealed R59 was at risk for side effects of psychotropic medication use (Risperdal) related to diagnoses of dementia with behaviors and psychosis. A review of R59's Level I PASARR screening, dated 06/09/2020, revealed the resident had a diagnosis of anxiety. The screening revealed the resident did not have a diagnosis of mental illness and had no history of psychiatric hospitalization within the previous two years. According to the PASARR, no further action was needed. During an interview on 05/25/2023 at 8:34 AM, the Social Service Director stated the Admission Coordinator was responsible for residents' PASARR screenings. During an interview on 05/25/2023 at 8:40 AM, the Admission Coordinator (AC) indicated she completed the Level I PASARR screening for R59 dated 06/09/2020. The AC indicated that she revaluated and completed a new Level I PASARR when a resident developed a mental disorder after being admitted . She stated nursing staff made her aware of residents who developed a new mental disorder and she also reviewed physician notes. The AC indicated she also completed an audit on all PASARRs every quarter but had not caught R59's new diagnosis. She indicated she was not aware the resident was diagnosed with psychosis on 12/28/2021 and had not completed a new Level I PASARR. She said a new Level I screening should have been completed when the resident received the new mental diagnosis. The Admission Coordinator stated the negative outcome if a new Level I screening was not completed when the resident developed a new mental diagnosis after admission was they possibly may not receive more specialized care and services for their mental disorder. During an interview on 05/25/2023 at 12:26 PM, the Director of Nursing (DON) stated she was not too familiar with the PASARR process but indicated that every person, before they were admitted , needed to have a Level I PASARR. She stated if the resident had a serious mental disorder or intellectual disability, they may need a Level II screening. The DON stated the AC was responsible for the PASARRs at the facility. The DON stated she was not aware if a resident required a new Level I PASARR if they developed a new mental disorder diagnosis after they were admitted . She also indicated she was not aware of the importance of the PASARRs being accurate and complete prior to this survey. During an interview on 05/25/2023 at 12:43 PM, the Administrator stated the facility must have a PASARR when residents were admitted to the facility. She indicated a Level II PASARR meant they had certain diagnoses that warranted the Level II screen. The Administrator stated if there was a change in a specific diagnosis after admission, a new Level I screen may have to be completed. She indicated the Admission Coordinator was responsible for making sure the PASARRs were accurate and complete. She indicated her expectation was that PASARRs were completed timely and accurately. She also indicated the importance of the PASARR was to see if the resident may require more advanced services. After reviewing R59's PASARR dated 06/09/2020, the Administrator indicated a new Level I screen should have been completed to ensure the resident received all the necessary care and services for their mental disorder diagnosis. 42883

Based on observations, interviews, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health for 1 (Resident (R)77) of 3 residents reviewed for non-pressure skin conditions. Specifically, staff identified that R77 had a crusted area to the right great toenail bed on 05/19/2023 and the facility failed to provide treatment and monitoring to the area from 05/19/2023 through 05/24/2023. Findings include: A review of a Facesheet revealed the facility admitted R77 on 10/24/2022 with diagnoses that included but was not limited to; paraplegia, iron deficiency, essential hypertension, pressure ulcer, and type 2 diabetes. A review of R77's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/24/2023, indicated R77 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The MDS also indicated R77 required extensive assistance of one person assistance with bed mobility and toileting and was totally dependent on two people for transfers. The MDS indicated the resident was independent with set-up assistance only with eating. A review of R77's Care Plan, initiated on 10/24/2022, revealed the resident was at risk for alterations in skin integrity related to incontinence, history of pressure sores, and paraplegia resulting in impaired mobility. Interventions directed staff to monitor skin with weekly body audits for signs and symptoms of alteration in skin integrity and notify the wound nurse and practitioner as indicated. Further review revealed an intervention initiated on 05/24/2023 related to a draining area to the right great toe that was likely an ingrown toenail. An interview on 05/23/2023 at 12:16 PM with R77 revealed R77 had an open area on his/her right big toe. The resident said it was oozing and staff were not cleaning it or providing treatment for it. R77 said he/she was unable to clean it themself. The resident stated the area was not covered and the staff told the resident they would need to wait to see the foot doctor when the foot doctor came to the facility again. An observation on 05/23/2023 at 12:25 PM of R77's right great toe revealed an area of dry crusted drainage from the cuticle area to the tip of the toe covering the left side of the nail bed. There was slight swelling noted at the cuticle area with a small (approximately 1/32 inch) open area with no active drainage noted. A review of Departmental Notes revealed a nurses note, dated 05/19/2023 at 8:02 AM and documented by Registered Nurse (RN)10, that indicated R77 was noted with a crusted area to the lateral aspect of the right great toenail bed. A review of Departmental Notes revealed a nurses note, dated 05/23/2023 at 4:13 PM and documented by RN11, that indicated R77 had complaints about issues with toenails on the right foot. The note further indicated R77 would follow-up with the podiatrist on 05/30/2023. An interview on 05/24/2023 at 1:00 PM with RN10 revealed the facility's process when there was a new skin condition was to first identify what type of wound or skin issue it was and inform the treatment nurse. RN10 said she did notify the oncoming shift of the concern with R77's toe that was identified on 05/19/2023, and she was sure she informed the treatment nurse as well. RN10 stated she did not document the notification. RN10 said the concern with R77's toe also should have been documented on the communication log and she thought she may have documented it there, but she could not be certain. RN10 stated she was not aware of any complaints by R77 about the resident's right toe prior to it being identified on 05/19/2023, while completing a skin audit. RN10 stated she did not notify the physician and had not seen the resident's right great toe since 05/19/2023. An interview on 05/24/2023 at 2:24 PM with RN11, who was the treatment nurse, revealed she was aware there was an issue with R77's right great toe. She said a night shift nurse informed her on 05/19/2023 that R77 had an area to the right great toe. RN11 said she saw R77 on 05/19/2023 but she did not document that. She stated when she assessed the resident on 05/19/2023, she did not think the resident needed any treatment at that time. RN11 said there was not any drainage or crust on the right great toe at that time, but she did not document that assessment. RN11 said she assessed R77's right great toe again on 05/23/2023 and she documented there was a change at that time due to the area having some crust/dried drainage. However, she did not put in a treatment at that time and indicated the resident would be seen on the next rounds for podiatry on 05/30/2023. RN11 stated she had not notified the physician of the area on the right great toe. She also stated it should have been noted on the communication log on 05/19/2023 when it was first discovered, but she did not check the communication log to ensure there was documentation related to the issue with R77's right great toe. RN11 stated any information the physician needed to be aware of about a resident was documented on the communication log and it was checked daily by the nurse practitioner. RN11 stated the nurse practitioner signed the book to indicate they had followed up and the unit manager would review those daily to ensure there was a signature by each entry. A review of the Communication Log on 05/24/2023 at 2:48 PM revealed no evidence of documentation related to R77's right great toe on 05/19/2023 or 05/23/2023. An interview with RN11 during an observation of R77's right great toe on 05/24/2023 at 2:52 PM revealed, RN11 stated the resident had drainage to the top of the toe at the nail bed and the foot had some edema (swelling). The RN stated she cleaned the area today when the wound doctor looked at it on rounds and stated there was some dried drainage to the area before it was cleaned. RN11 stated this was the first time the area had been cleaned since it was identified on 05/19/2023. An interview on 05/25/2023 at 11:09 AM with the Medical Director (MD) revealed any new skin conditions should be reported to the nurse practitioner (NP) during work hours or on call after work hours. The MD stated if it was not an emergency it was okay for staff to inform the NP first thing the next morning. The MD stated if it was a new wound or skin tear, staff would have the wound team assess the area first. An interview on 05/25/2023 at 11:57 AM with Nurse Practitioner (NP)12 revealed if there was a change in condition and she was in the building staff could verbally tell her or write it in the communication book. The NP stated she would expect for staff to make her aware of any residents change in condition within a 24-hour period. The NP stated she was not aware of the area to R77's right great toe until 05/24/2023. The NP stated any delay in care that was below the resident's level of sensation due to paraplegia put R77 at a high risk for losing the toe. The NP stated it was concerning that she was not informed about the new area to the right great toe for five days. An interview on 05/25/2023 at 12:08 PM with the Wound Physician (WP) revealed she saw R77 on 05/24/2023 related to a diabetic wound on the resident's calf that she was treating. She stated she was not made aware of the wound on the right great toe until they were doing wound rounds on 05/24/2023. An interview on 05/25/2023 at 12:07 PM with the Director of Nursing (DON) revealed any new skin conditions, whether it was a skin tear or breakdown, should have a treatment initiated when it was first identified. The DON said that most nurses would notify the wound nurse who would assess and either continue the treatment in place or change the treatment and notify the physician. The DON stated most of the time staff would put it in the communication log or inform the treatment nurse. The DON said that all orders were reviewed daily and thats was how they would become aware of any new skin condition; by reviewing the treatment order. The DON said she was aware of the issue on R77's right great toe after RN11 told her on 05/23/2023 or 05/24/2023. The DON said she did not assess the resident at that time because she trusted that RN11 made the right decision. The DON said RN11 did not put any treatment in place at that time because she did not think it needed one and that RN11 thought it looked like an ingrown toenail and would wait and let podiatry look at it. However, the DON said a treatment should have been put in place on 05/19/2023 when the area was first identified. The DON stated the area being left untreated could have caused the resident to become septic, or the toe to become infected and it put the resident at risk for amputation of the toe because R77 was high risk due to having diabetes and being a paraplegic. The DON stated the nurse who identified it on 05/19/2023 should have put it on the communication log to ensure the nurse practitioner was made aware the following day. An interview on 05/25/2023 at 12:41 PM with the Administrator revealed when staff identify any new skin condition, it should be communicated on the communication log and staff should ensure the oncoming shift was aware of the issue and what treatment was put into place. The Administrator stated four to five days was too long to wait for treatment to be put into place for R77.

Based on observations, interview, and policy review, the facility staff failed to wear all required personal protective equipment when on the Coronavirus (COVID) 19 unit. This failure had the potential to affect all 16 residents, with confirmed or suspected [DIAGNOSES REDACTED].#1, #2, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17). Findings Include: 1. Review of facility policy titled: Novel Coronavirus Prevention and Response, Approval and Effective date: 3/26/2020, revealed the facility would respond promptly upon suspicion of illness associated with a Novel Coronavirus in efforts to identify, treat and prevent the spread of [MEDICAL CONDITION]. The definition per the facility policy was: COVID-19 is a new respiratory disease caused by a novel (new) Coronavirus that is spread person-to-person, mainly between people who are within six (6) feet of one another through respiratory droplets produced when an infected person coughs or sneezes. According to the policy, the Infection Preventionist would assess facility risk associated with COVID -19 through surveillance activities of emerging diseases in the community and illness present in the facility. The facility procedure when COVID-19 was suspected was: Implement standard, contact and airborne precautions (droplet precautions if no airborne isolation room available). Wear gloves, gowns, goggles/face shields and masks (respirators) upon entering room and when caring for the resident. 2. Review of Facility's Training, dated 4/2020, revealed annual training for infection control including proper (PPE) personal protective equipment was completed by all staff members. 3. Observation on 6/16/2020 at 9:00 a.m. on the COVID-19 isolation unit, revealed, Unit Charge License Practical Nurse (LPN) #3 was observed exiting a resident's room without the required N95 or surgical mask. The nurse was observed to have on a cloth mask. The nurse wore the rest of the required PPE in accordance with the policy. Interview on 6/16/2020 at approximately 9:06 a.m. with License Practical Nurse (LPN) #3, revealed he/she was responsible for administering medications to all 16 residents on the COVID-19 unit. When queried about required personal protective equipment, the LPN stated he/she received training but decided to wear her own mask today. 4. Observation on 6/16/2020 at approximately 9:47 a.m. revealed Certified Nursing Assistant (CNA) #4 exited a resident's room on the COVID-19 isolation unit without the required face shield or goggles. The CNA wore the rest of the required PPE in accordance with the policy. Interview on 6/16/2020 at 9:48 a.m. with CNA #4, revealed I received training on the use of wearing the required personal protective equipment, but I don't like to wear the shield or the googles because they make me hot and fog up. 5. Interview on 6/16/2020 at approximately 11:00 a.m. with Director of Nursing/Infection Control Nurse, revealed all staff members had been trained on how to use the proper personal protective equipment on the COVID-19 unit. He/she stated, all staff received annual training related to infection control in February of this year and that his/her expectation was for all staff to wear the required personal protective (PPE) equipment upon entering any resident's room, especially on the COVID-19 unit.

Based on interview and review of state guidance, the facility failed to ensure the meal service operations were under the direction of a qualified food service supervisor. One of one staff reviewed for Certified Dietary Manager qualifcations. The findings included: During an interview on 08/19/19 at approximately 10:40 AM with the Dietary Manager (DM), s/he said there is no Certified Dietary Manager (CDM) employed and that s/he currently holds a ServSafe Certification dated 6/26/17 - 6/26/2022, and is studying to become a Certified Dietary Manager. The DM said the Registered Dietitian (RD) comes to the facility every week for at least a day, and is available by phone or fax for any concerns or new admissions. During an interview with the Administrator on 08/22/19 at approximately 11:00 AM, he/she verified that the facility does not employ a full-time Certified Dietary Manager and that the Dietary Manager is currently studying to become Certified. The Administrator said that a Registered Dietitian is available for consults and comes to the facility every week at least 8 hours, but is on call for the DM every day. The Dietary Manager is working to complete the requirements for the course and to take the test to become a CDM. The Administrator stated the Dietary Manager is in school currently to become certified and is working with the RD. The facility provided a copy of an agreement, signed by the RD, to precept the DM. A review of The R.61-17, Standard for Licensing Nursing Homes, Bureau of Health Facilities Licensing, South [NAME]ina Department of Health and Environmental Control, Section 1400. Meal Service 1405. Meal Service Staff, page 52 states, 1405 [NAME] The meal service operations shall be under the direction of a dietitian or qualified food service supervisor who shall be responsible for supervising the meal service staff, planning, preparation, and serving of food and the maintenance of proper records. A staff member shall be designated by the name or position, to act in the absence of this person. (II)

Based on observations, interviews and review of the facility policy titled, Laundry and Bedding, Soiled, the facility failed to ensure soiled linen was bagged at point of use and then placed in the soiled linen bins in the hallways, on the units, for transport to the laundry department during 1 of 1 observations of transporting soiled linen. The findings included: An observation on 8/22/2019 at approximately 10:40 AM during the soiled linen pick up on the halls by laundry worker #1 revealed bins that were randomly placed in the hallways, between resident rooms, with soiled linen placed in them. The bins had a large plastic bag but no bags to indicate soiled linen was placed in bags in the resident room before placing it in the bins. During an interview on 8/22/2019 at approximately 10:50 AM, during the sorting process in the laundry room, with Laundry Worker #1 and #2 confirmed the soiled linen was not bagged in the resident's room prior to placing it in the bins randomly placed in the hallway on all units. Review on 8/22/2019 at approximately 11:00 AM of the facility policy titled, Laundry and Bedding, Soiled, states under policy statement, Soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. Number 2 under, Policy Interpretation and Implementation, states, Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the locations of use.

Based on record review, interview and review of the facility policy titled, Bill of Rights for Residents in LTC (Long Term Care) Facilities, the facility failed to ensure Resident #80 was afforded the right to make his/her own decision to receive the Influenza and the Pneumonia vaccines for 1 of 5 residents reviewed for immunizations. The findings included: The facility admitted Resident #80 on 11/13/2018 with [DIAGNOSES REDACTED]. Review on 8/22/2019 at approximately 12:15 PM of the medical record for Resident #80 revealed a flu and pneumonia consent signed by the Personal Representative for Resident #80 and not the resident. Further review on 8/22/2019 ay approximately 12:20 PM of the medical record for Resident #80 revealed a physician statement that verified that Resident #80 was able to make his/her own health care decisions. During an interview on 8/22/2019 at approximately 12:30 PM with the DON (Director of Nursing) confirmed the personal representative for Resident #80 had made the decision for the Flu and Pneumonia vaccines. Review on 8/22/2019 at approximately 12:45 PM of the facility policy titled, Bill of Rights for Residents in LTC Facilities, states under number 11. The resident has a right to be fully informed in advance about care and treatment and any changes in that care or treatment that may affect the resident's well being. Number 32 states, The resident has a right to choose activities, schedules and health care consistent with his or her interest, assessments, and plans of care.

Based on observation and interview the facility failed to ensure proper storage condition for food substances. An employee's personal item was found in direct contact with a decaffeinated coffee filter pack. The freezer contained a gallon pitcher, with a substance unlableled and dated 08/11/19. Based on observation of 1 of 1 kitchen The findings included: During the initial tour of the kitchen on 08/19/19 at approximately 10:45 AM, the freezer contained a gallon pitcher, covered with tin foil, approximately 1/3 full of a frozen mix that was light tan and thick consistency, without a label. It was dated 8/11/19. The Dietary Manager (DM) removed it and discarded it in the trash stating, It was a milkshake and should have been discarded after 3 days. Continuing the initial kitchen tour on 08/19/19 at approximately 10:50 AM, a bag of pre-made decaffeinated coffee and filter combination was observed open. Inside the bag and directly on/in a coffee filter, was a personal cell phone of one of the kitchen employees. The DM removed the phone and discarded the bag of coffee imbedded filters into the garbage and stated, That should never happen. In an interview on 8/19/19 at 10:51 AM, the Dietary Aide stated, I just threw my phone up on the counter and it landed in there.

Based on record review and interview, the facility failed to ensure Resident #2 received appropriate care according to the current plan of care. Resident #2's care plan was not followed related to a physician ordered air mattress.(1 of 3 reviewed for pressure ulcer) The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on [DATE] revealed physician's orders [REDACTED]. Review of the current care plan related to skin breakdown revealed an approach for an air mattress to bed. Observation of Resident #2 on 8/22/17 at 12:52 PM and on 8/24/17 at 10:00 AM revealed an air mattress was not located on the bed. During an interview with Registered Nurse #1 on 8/24/17 at approximately 11:30 AM, he/she stated the air mattress had malfunctioned and confirmed an air mattress was not on Resident #2's bed at the time of the pressure ulcer treatment observation.

Based on record review, observation and interview, the facility failed to implement measures to prevent pressure ulcers from becoming worse for 1 of 3 residents reviewed for pressure ulcers. Resident #2 did not have an ordered air mattress. The findings included: The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Record review on [DATE] revealed Resident #2 had a Stage II pressure ulcer of the sacrum and unstageable pressure ulcers to the left and right heel. Review of the wound care orders dated 6/15/17 revealed Resident #2 was to have an air mattress. Observation of Resident #2 on 8/22/17 at 12:52 PM and on 8/24/17 at 10:00 AM revealed an air mattress was not located on the bed. During an interview with Registered Nurse #1 on 8/24/17 at approximately 11:30 AM, he/she stated the air mattress had malfunctioned and confirmed an air mattress was not on Resident #2's bed at the time of the pressure ulcer treatment observation.

Based on observations, interview and review of the facility policy titled, Food Storage, the facility failed to ensure open and partially used foods were labeled and dated with an open date, and outdated frozen foods were removed from storage. The findings included: An observation during initial tour on 2/27/2017 at approximately 11:00 AM revealed in the freezer 1 frozen pork chop dated 6/2016. A pack of partially used pork chops dated 12/21. The freezer contained frozen pancakes dated 2/2016. The freezer also contained biscuits opened with no date. The Certified Dietary Manager (CDM) confirmed the findings on 2/27/2017 at approximately 11:00 AM. Review of the facility policy titled, Food Storage, on 2/27/2017 at approximately 2:00 PM states under #15, C. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. On 2/27/17 during initial tour of the nutrition kitchen on the Avonlea Unit revealed (2) 60 fluid ounce containers of Orange Juice with no open date and (1) 46 fluid ounce thickened water with no open date. At the time of the observation, the Unit Manager of the Avonlea Unit confirmed the findings. During an interview with the Nurse Consultant on 3/2/17 at 12:42 PM, he/she stated the Infection Control Nurse was responsible for checking the nutrition kitchens every morning. Review of the facility policy concerning left-overs revealed the following: All leftover foods must be properly covered, dated, labeled and stored under refrigeration.

Based on record review and interview the facility failed to provide an ongoing program of activities designed to meet in accordance with the comprehensive assessment, the interest, and the physical, mental, and psychosocial well being of Resident #33 for 1 of 3 residents reviewed for Activities. The findings included: The facility admitted Resident #33 with [DIAGNOSES REDACTED]. Review on 2/28/2017 at approximately 4:49 PM of the medical record for Resident #33 revealed 1 to 1 activity attendance sheets from readmission of 9/16/2016 until 2/28/2017. There were no activity attendance sheets for the month of September. The next attendance sheets were for 2 days in October which were 10/12/16, 10/18/2016. November activity attendance sheets included 11/7/2016, 11/18/2016 no other activities were documented as offered for the month of November. December activity attendance sheets included 12/2/2016, 12/14/2016 and 12/29/2016. January activity sheets were for 1/17/2017, 1/18/2017, 1/26/2017, 1/27/2016 and 1/31/2017. February activity attendance sheets for 1 to 1 activities were documented on 2/1/2017, 2/13/2017, 2/17/2017, 2/23/2017 and 2/28/2017. No other activities group nor 1 to 1 activities were documented for Resident #33. During an interview on 3/1/2017 at approximately 5:00 PM with the Activity Director he/she stated, we try to do 1 to 1 activities all during the week. This resident is able to be up out of bed in in group activities, but no one gets him/her up. No documentation could be found in the medical record for Resident #33 to ensure he/she has been in group activities of his/her choice since admission in September 2016. Review on 3/2/2017 at approximately 10:04 AM of the Minimum Data Set (MDS) assessment for Resident #33 dated 1/2/2017 section F0500 titled, Interview for Activity Preferences, reads when asked, A. How important is it to you to have books, newspapers, and magazines to read? it is coded with a 1 as very important. B asked, How important is it to you to listen to music you like? and is coded with a 1 for very important. D reads, How important is it to you to keep up with the news. D is coded as very important. E. asks, How important is it to you to do things with groups of people? E is coded as very important. F asks, How important is it to you to do your favorite activities? F is coded as very important. G asks, How important is it to you to go outside to get fresh air when the weather is good? G is coded as very important. And H. asks, How important is it to you to participate in religious services or practices'? H is coded with a 1 as very important. No documentation could be found in Resident #33's medical record to ensure he/she had be offered and or afforded the opportunity to participate in his/her activity preferences.

Based on record review and interview the facility failed to provide care and services to meet the needs of Resident #61 who receives [MEDICAL TREATMENT] for 1 of 1 resident reviewed for [MEDICAL TREATMENT]. The thrill and bruit were not assessed as ordered by the physician for the month of January. The findings included: The facility admitted Resident #61 with [DIAGNOSES REDACTED]. Review on 3/1/2017 at approximately 11:15 AM of the physician's orders [REDACTED]. Further review on 3/1/2017 at approximately 11:20 AM of the treatment records for December 2016, January 2017 and February 2017 revealed no documentation for the month of January 2017 to ensure the Thrill and Bruit were assessed per the physician's orders [REDACTED].>During an interview on 3/1/2017 at approximately 11:30 AM with the Director of Nursing (DON) confirmed that the Thrill and Bruit were not assessed as ordered for the month of January 2017.

Based on record reviews, interview and review of the facility policy titled, Physician Visits, the facility failed to ensure Resident #61 was seen by the Optometrist during his/her visit to the facility for 1 of 3 residents reviewed for vision. The findings included: The facility admitted Resident #61 with [DIAGNOSES REDACTED]. Review on 2/28/2017 at approximately 2:25 PM of the medical record for Resident #61 revealed an order for [REDACTED]. Further review of the medical record on 2/28/2017 at approximately 2:25 PM revealed a list of residents to be seen by the eye doctor on 2/2/2017 during a routine visit to the facility. The list included Resident #61 but he/she was marked out as not seen on 2/2/2017. Review on 2/28/2017 at approximately 2:40 PM of the nurses notes dated 2/2/2017 revealed Resident #61 went out of the facility at 12:30 PM for [MEDICAL TREATMENT] and returned on 2/2/2017 at 5:00 PM. During an interview on 3/1/2017 at approximately 9:00 AM with the Director of Nursing (DON) confirmed that Resident #61 had not been seen as scheduled by the eye doctor on 2/2/2017. When asked what time the eye doctor was in the facility to see residents the DON stated he/she is always here around 9:00 AM to start seeing residents. The DON knew Resident #61 was to go to [MEDICAL TREATMENT] on 2/2/2017 and could have been seen before going to [MEDICAL TREATMENT]. The DON stated that the resident would have to be seen the next time the physician came into the facility. The DON agreed that residents that cannot ambulate or get themselves to the eye appointments rely on staff to ensure they are seen in a timely manner. The DON also agreed that Resident #61 had ample time to be seen by the eye doctor before leaving the facility to go to [MEDICAL TREATMENT]. The DON went on to say that by the time Resident #61 returned from [MEDICAL TREATMENT] the eye doctor had already left for the day. And the eye doctor usually comes to the facility to see residents every 6 months. Review on 3/1/2017 at approximately 9:25 PM of the facility policy titled, Physician Visits, reads under, Policy Explanation and Compliance Guidelines, reads 1. The Licensed Nurse should: a. Track due dates of physician visits. b. Residents are placed on a list for physician to see and notified of the upcoming visit, and i. reads, Inform the Director of Nursing when a physician visit does not occur within the required timeframes. (Note: If a resident on the list was not seen, such as, out of the facility for another appointment, out with family, etc, and nothing acute was occurring with the resident, the resident will be placed on the recurring list for next physician visit.) Resident #61 has a [DIAGNOSES REDACTED].

On the days of the survey, based on record review and interviews, the facility failed to review and revise care plans for changes in the residents' condition for 2 of 11 sampled residents reviewed for care plans. The care plan was not updated for Resident #2 who had multiple falls with injuries. The care plan for Resident #5 was not updated related to a sustained injury. The findings included: The facility admitted Resident #2 on 9/24/10 with [DIAGNOSES REDACTED]. During a review of the Plan of Care (POC) on 12/6/11 at 12:05AM, a fall was documented on 12/4/2011 with a head injury. Further review of the POC revealed 6 additional falls between 11/2/11 and 12/4/11. After investigation of the Nurse's Notes, Physician's Telephone Orders, Incident/Accident Reports, Plan of Care, and lab results, the information gathered on Resident #2 showed evidence of 18 falls with 5 head injuries from 11/6/10 to 12/4/11. A review of these incidents revealed that the facility failed to update the POC for 16 incidents to prevent recurrence and minimize injury as follows: -The Incident/Accident Report dated 11/9/10 stated "Resident lying on floor with large amount of bleeding from back of residents head, apparent laceration" and the EMS (Emergency Management System) was called to the facility. The POC stated that a sensor pad alarm was placed on the bed on 10/19/10. There was no documentation on the POC that a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 12/25/10 documented that the Resident stated, "I slid off the bed while taking my shoe off." The POC indicated that the sensor pad should have been in place. The Physician's Telephone Orders dated 11/1/10 noted "Per family request D/C (Discontinue) low bed". The intervention on the Incident/Accident Report was "Resident education-continue to monitor". Per the Resident Assessment Instrument (RAI) Manual's definition for daily decision making, the resident's ability for daily decision making includes: "using awareness of one's own strength and limitations to regulate the day's events (e.g., asks for help when necessary) acknowledging the need to use appropriate assistive equipment as necessary such as a walker", requiring the assist of one for transfers etc. Review of the Minimum Data Set ((MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was a "2", with a score of 0-7 indicative of severe impairment. There was no documentation on the POC that a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 1/1/11 stated "Resident got up, walked to doorway, started scratching her back on door frame and sat on floor". The documentation on the Incident/Accident Report stated that a pad alarm was on the bed. The intervention on the Incident/Accident Report was to "Educate the resident and to check foot wear". The Nurse's Notes of 1/1/11 and 1/2/11 stated resident was "confused", "gets agitated with staff", and "talks to self" which makes it difficult to "educate the resident". There was no documented evidence on the POC that a new and appropriate intervention was implemented to prevent further falls/injury. The POC dated 10/18/10 already had an approach of "Be sure resident wears protective footwear". -There were two Incident/Accident Reports dated for 1/8/11, one at 10:40AM and the second one at 11:40AM. The first Incident/Accident Report stated "Resident on floor in room beside her bed on knees, resident states I can't get up". There was no evidence of an intervention in place at the time of the fall, although the POC indicated that alarms were to be in place on the bed and wheel/chair. There was no documentation that the alarm was sounding. There was documentation on the Incident/Accident Report that orthostatic blood pressures were to be completed. A Physician's Telephone Orders dated 1/12/11 stated to complete "orthostatic blood pressures lying, sitting and standing, 6AM, 9AM and 4PM", which was four days after the falls. There was no evidence provided of any changes made to the POC as a result of the blood pressure monitoring. A Therapy Weekly Progress Report documented that the Occupational Therapy (OT) was discontinued on 1/8/11. There was no evidence on the POC that a new intervention was implemented to prevent further falls/injury. The second Incident/Accident Report dated 1/8/11 at 11:40AM documented the "CNA (Certified Nursing Assistant) reported that when she walked in resident's room to assist her resident was ambulating in room bent slightly over resident stated "help me" then resident fell ". There was no reference to alarms on this report either. The intervention on the Incident/Accident Report was to send the resident to the ER and complete orthostatic blood pressures. There was no evidence on the POC that a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 1/17/11 stated "Resident sitting on the floor beside the bed". There was no documentation of any intervention in place at the time of the fall. The POC continued the bed and chair alarms, but there was no reference to them being in place or sounding. The intervention on the Incident/Accident Report was to send resident to the "ER". Review of the Nurse's Notes did not show evidence of the resident being sent to ER until 1/21/11 after another fall. There was no documentation on the POC that a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 1/21/11 stated "Resident was heard yelling for help, noticed resident on floor and blood coming from left side of head". The POC continued the bed and chair alarms, but there was no reference to them being in place or sounding. The intervention on the Incident/Accident Report following the fall was to place a low bed in the resident's room. The Physician's Telephone Orders dated 1/25/11 documented an order for [REDACTED]. There was no documentation on the POC that a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 2/22/11 stated "resident stated got up from chair to cut on heater and turned around too fast and slid down". The POC continued the bed alarms, chair alarms and a low bed, but there was no reference to them being in place or sounding. The intervention on the Incident/Accident Report was to "monitor for proper foot wear". The POC of 10/18/10 already stated to "Encourage to wear protective footwear". There was no documentation of the POC that a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 4/4/11 stated "Resident noted sitting on floor by side of her bed in upright position, noted to have a small amount of blood on back of head". The intervention on the Incident/Accident Report was to send the resident to the "ER" and to "complete a med(ication) review". Meanwhile, no new interventions were implemented to prevent further falls/injury. The POC continued the bed alarms, chair alarms and a low bed, but there was no reference to them being in place or sounding. There was no documentation of the POC that a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 5/9/11 stated "Resident got up from chair in dining room and was walking around, resident fell and hit right side of head on the floor". The POC continued the bed alarms, chair alarms and a low bed, but there was no reference to them being in place or sounding. The intervention on the Incident/Accident Report was to send the resident to the "ER" and to "complete a med review". There was no documented evidence on the Incident/Accident Report that a new intervention was implemented to prevent further falls/injury. A Physical Therapy order was requested and therapy was implemented for ambulation, transfers, and balance. The POC was not updated with this information, nor did it document a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 11/2/11 stated "The resident was found on the floor". Resident stated "I slipped walking back from the bathroom". The intervention on the Incident/Accident Report stated "Request for Physical Therapy (PT) and to encourage proper footwear". The POC stated that the low bed and sensor pad were D/C'd on 8/10/11 and the tab alarm was D/C'd on 9/19/11. The POC dated 10/18/10 stated to "Encourage to wear protective footwear". Review of the resident's MDS dated [DATE] stated the BIMS score was a "9". A score of 8-12 indicated moderate impairment. There was no documentation on the POC that a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 11/12/11 stated "Resident was sitting up on side of bed and slid to floor on her bottom". The intervention on the Incident/Accident Report was to "Encourage resident to wear proper foot wear". The same intervention as for the 11/2/11 fall. The 10/18/10 POC included to "Encourage to wear protective footwear" plus a previous approach of anti-skid strips. There was no documentation on the POC that a new intervention was implemented to prevent further falls/injury. As above, the MDS dated [DATE] noted the resident as having a moderately impaired cognitive status. -The Incident/Accident Report dated 11/13/11 stated "While attempting to sit back down on bed, resident missed the bed and slid to the floor on her bottom". The documentation of intervention in place prior to the fall was anti-skid strips on the floor next to her bed which were in place as of 11/6/10. The intervention on the Incident/Accident Report was to "Encourage resident to check distance to bed before attempting to sit down". As above, the MDS dated [DATE] noted the resident as having a moderately impaired cognitive status. There was no evidence on the POC that a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 11/20/11 stated "Resident noted on floor in bathroom by CNA, sitting upright by toilet". There was no documentation of any interventions in place at the time of the fall, except for the anti-skid strips per the POC. The intervention on the Incident/Accident Report was to "move res(ident) closer to nur(sing) station". The POC and Social Service notes stated that the resident was moved closer to the nurse's station on 11/22/11. The change in the resident's room occurred two days after the fall". -The Incident/Accident Report dated 11/30/11 stated "called to room by housekeeper, resident laying on floor. Resident stated she was trying to get in bed and fell ". There was no documentation of any interventions in place prior to the fall except for anti-skid strips. The intervention on the Incident/Accident Report was "encouraged resident to call for help and use her walker". As above, the MDS dated [DATE] noted the resident as having a moderately impaired cognitive status. There was no evidence on the POC that a new intervention was implemented to prevent further falls/injury. 12/6/11 at 12:45PM with the Director Of Nursing (DON), she confirmed that the resident had numerous falls in the last year. The DON stated that the resident had two types of name brand sneakers purchased and tried on the resident and that the resident did not like either brand. During an interview on 12/7/11 at 10:10AM the information found on the Incident/Accident Reports, Nurse's Notes and POC's was reviewed and the DON acknowledged that information appeared to be missing. She then referred the surveyor to the MDS Coordinator. During an interview on 12/7/11 at 10:15AM with the MDS Coordinator, she reviewed the falls and POC, she verified that the POC had not been updated on 1/8/11, 2/22/11, 4/4/11, and 5/9/11. During an interview on 12/7/11 at 02:00PM, the MDS Coordinator and the Consultant provided written information on how they addressed the prevention of further falls and/or how they were minimizing potential injuries for Resident #2. No additional information was provided that had not already been reviewed. Review of the current physician's orders [REDACTED]. Initial observation of the resident in her room revealed that the bed was not placed against the wall in the semi-private room. Observations on 12/6/11 during Initial Tour, at 11:40AM, and at 12:40PM revealed that the bed was placed in the center of the resident's half of the room. At 5:00PM, staff provided a low bed and placed it against the wall as had been previously ordered. The POC did not contain this information. The facility admitted Resident #5 on 12-22-09 with [DIAGNOSES REDACTED]. Record review on 12-06-11 at approximately 11:15 AM of the Nurse's Notes dated 11-29-11 at 4:15 PM revealed staff found Resident #5 in bed with a laceration to the top of the frontal area of the skull with active bleeding noted (injury of unknown origin). Resident #5 subsequently had been transported to the hospital for sutures. Record review on 12-06-11 of the Care Plan dated 10-05-11 revealed the Care Plan had not been updated to reflect the need for the addition of safety measures for Resident #5 related to the injury of unknown origin. Review on 12-07-11 of the Resident Activities of Daily Living (ADL) Care Plan located on the inside of Resident #5's closet door revealed the ADL Care Plan had not been updated to reflect the need for safety measures for Resident #5. During an interview on 12-07-11 with Licensed Practical Nurse (LPN) #2, she revealed the Nursing Manager of the nursing unit would update the ADL Care Plan as needed when changes occurred.

On the days of the survey, based on observation, interviews and record reviews, the facility failed to provide supervision and/or assistive devices and/or interventions to minimize injury for one of three sampled residents reviewed for falls. The staff failed to implement appropriate interventions in a timely manner for Resident #2 to prevent her from receiving further/repeated injuries related to falls. The findings included: Cross refer to F 280 as it relates to the failure of the facility to develop and implement appropriate interventions to prevent falls with injuries. The facility admitted Resident #2 on 9/24/10 with [DIAGNOSES REDACTED]. Record review on 12/6/11 at 9:55AM, of Resident # 2's the Nurse's Notes, Physician's Telephone Orders, Incident/Accident Reports, Plan of Care, and lab results showed evidence of 18 falls with 5 head injuries from 11/6/10 to 12/4/11. A review of these incidents revealed that the facility failed to implement appropriate and timely interventions in 17 incidents to prevent recurrence and minimize injury as follows: -The Incident/Accident Report dated 11/9/10 stated "Resident lying on floor with large amount of bleeding from back of residents head, apparent laceration" and the EMS (Emergency Management System) was called to the facility. There was no documentation of an intervention in place prior to the fall. The Plan of Care (POC) stated that a sensor pad alarm was placed on the bed on 10/19/10. The Incident/Accident Report did not state that the sensor pad was in place and/or alarming. The intervention on the Incident/Accident Report stated to send the resident to the ER (emergency room ) and to "Cont(inue) tabs alarm". There was no documented evidence on the Incident/Accident Report, Nurse's Notes or on the POC that a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 12/25/10 documented that the Resident stated, "I slid off the bed while taking my shoe off." There was no documentation of an intervention in place at the time of the fall. The POC indicated that the sensor pad should have been in place. However, the Incident/Accident Report did not note that it was in place or alarming at the time of the fall. The Physician's Telephone Orders dated 11/1/10 noted "Per family request D/C (Discontinue) low bed". The intervention on the Incident/Accident Report was "Resident education-continue to monitor". Per the Resident Assessment Instrument (RAI) Manual's definition for daily decision making, the resident's ability for daily decision making includes: "using awareness of one's own strength and limitations to regulate the day's events (e.g., asks for help when necessary) acknowledging the need to use appropriate assistive equipment as necessary such as a walker", requiring the assist of one for transfers etc. Review of the Minimum Data Set ((MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was a "2", with a score of 0-7 indicative of severe impairment. -The Incident/Accident Report dated 1/1/11 stated "Resident got up, walked to doorway, started scratching her back on door frame and sat on floor". The documentation on the Incident/Accident Report stated that a pad alarm was on the bed but did not state if the pad alarm was sounding. The intervention on the Incident/Accident Report was to "Educate the resident and to check foot wear". The Nurse's Notes of 1/1/11 and 1/2/11 stated resident was "confused", "gets agitated with staff", and "talks to self" which makes it difficult to "educate the resident". There was no documented evidence on the Incident/Accident Report, Nurse's Notes or on the POC that a new and appropriate intervention was implemented to prevent further falls/injury. The POC dated 10/18/10 already had an approach of "Be sure resident wears protective footwear". -There were two Incident/Accident Reports dated for 1/8/11, one at 10:40AM and the second one at 11:40AM. The first Incident/Accident Report stated "Resident on floor in room beside her bed on knees, resident states I can't get up". There was no evidence of an intervention in place at the time of the fall, although the POC indicated that alarms were to be in place on the bed and wheel/chair but there was no documentation that the alarm was sounding. There was documentation on the Incident/Accident Report that orthostatic blood pressures were to be completed. A Physician's Telephone Orders dated 1/12/11 stated to complete "orthostatic blood pressures lying, sitting and standing, 6AM, 9AM and 4PM", which was four days after the falls. There was no evidence provided of any changes made to the POC as a result of the blood pressure monitoring. A Therapy Weekly Progress Report documented that the Occupational Therapy (OT) was discontinued on 1/8/11. There was no evidence on the Incident/Accident Report, Nurse's Notes or in the POC that a new intervention was implemented to prevent further falls/injury. The second Incident/Accident Report dated 1/8/11 at 11:40AM documented the "CNA (Certified Nursing Assistant) reported that when she walked in resident's room to assist her resident was ambulating in room bent slightly over resident stated "help me" then resident fell ". There was no reference to alarms on this report either. The intervention on the Incident/Accident Report was to send the resident to the ER and complete orthostatic blood pressures. There was no evidence on the Incident/Accident Report, Nurse's Notes or in the POC that a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 1/17/11 stated "Resident sitting on the floor beside the bed". There was no documentation of any intervention in place at the time of the fall. The POC continued the bed and chair alarms, but there was no reference to them being in place or sounding. The intervention on the Incident/Accident Report was to send resident to the "ER". Review of the Nurse's Notes did not show evidence of the resident being sent to ER until 1/21/11 after another fall. There was no documentation on the Incident/Accident Report, Nurse's Notes or in the POC that a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 1/21/11 stated "Resident was heard yelling for help, noticed resident on floor and blood coming from left side of head". There was no documentation of an intervention in place at the time of the fall. The POC continued the bed and chair alarms, but there was no reference to them being in place or sounding. The intervention on the Incident/Accident Report following the fall was to place a low bed in the resident's room. Documentation in the Nurse's Notes stated that the resident returned from the ER at 4:10PM. The Physician's Telephone Orders dated 1/25/11 documented an order for [REDACTED]. Review of the POC revealed no entry for the date of this fall and indicated that there was a previous intervention of 12/25/10 for the low bed which had not been D/C'd. -The Incident/Accident Report dated 2/22/11 stated "resident stated got up from chair to cut on heater and turned around too fast and slid down". There was no documentation of an intervention in place prior to the fall. The POC continued the bed alarms, chair alarms and a low bed, but there was no reference to them being in place or sounding. The intervention on the Incident/Accident Report was to "monitor for proper foot wear". No new interventions were implemented. The POC of 10/18/10 already stated to "Encourage to wear protective footwear". -The Incident/Accident Report dated 4/4/11 stated "Resident noted sitting on floor by side of her bed in upright position, noted to have a small amount of blood on back of head". There was no documentation of an intervention in place prior to the fall. The intervention on the Incident/Accident Report was to send the resident to the "ER" and to "complete a med(ication) review". Meanwhile, no new interventions were implemented to prevent further falls/injury. The POC continued the bed alarms, chair alarms and a low bed, but there was no reference to them being in place or sounding. Nurse's Notes for 4/4/11 were requested, which the facility failed to provide. A med review was completed and the resident's Xanax dose was decreased. -The Incident/Accident Report dated 5/9/11 stated "Resident got up from chair in dining room and was walking around, resident fell and hit right side of head on the floor". There was no documentation of any interventions in place at the time of the fall. The POC continued the bed alarms, chair alarms and a low bed, but there was no reference to them being in place or sounding. The intervention on the Incident/Accident Report was to send the resident to the "ER" and to "complete a med review". There was no documented evidence on the Incident/Accident Report that a new intervention was implemented to prevent further falls/injury. A copy of the Nurse's Notes for 5/9/11 was requested, but the facility failed to provide them. A Physical Therapy order was requested and therapy was implemented for ambulation, transfers, and balance. The POC was not updated with this information. -The Incident/Accident Report dated 11/2/11 stated "The resident was found on the floor". Resident stated "I slipped walking back from the bathroom". There was no documentation of an intervention in place prior to the fall. The intervention on the Incident/Accident Report stated "Request for Physical Therapy (PT) and to encourage proper footwear". There was no documented evidence on the Incident/Accident Report or in the Nurse's Notes that a new intervention was implemented to prevent further falls/injury. The POC stated that the low bed and sensor pad were D/C'd on 8/10/11 and the tab alarm was D/C'd on 9/19/11. The POC dated 10/18/10 stated to "Encourage to wear protective footwear". Review of the resident's MDS dated [DATE] stated the BIMS score was a "9". A score of 8-12 indicated moderate impairment. -The Incident/Accident Report dated 11/12/11 stated "Resident was sitting up on side of bed and slid to floor on her bottom". There was no documentation of an intervention in place at the time of the fall. The intervention on the Incident/Accident Report was to "Encourage resident to wear proper foot wear", the same intervention as for the 11/2/11 fall. The 10/18/10 POC included to "Encourage to wear protective footwear" plus a previous approach of anti-skid strips. There was no documentation on the Incident/Accident Report, Nurse's Notes or on the POC that a new intervention was implemented to prevent further falls/injury. As above, the MDS dated [DATE] noted the resident as having a moderately impaired cognitive status. -The Incident/Accident Report dated 11/13/11 stated "While attempting to sit back down on bed, resident missed the bed and slid to the floor on her bottom". The documentation of intervention in place prior to the fall was anti-skid strips on the floor next to her bed which were in place as of 11/6/10. The intervention on the Incident/Accident Report was to "Encourage resident to check distance to bed before attempting to sit down". As above, the MDS dated [DATE] noted the resident as having a moderately impaired cognitive status. There was no evidence on the Incident/Accident Report, Nurse's Notes or on the POC that a new intervention was implemented to prevent further falls/injury. -The Incident/Accident Report dated 11/20/11 stated "Resident noted on floor in bathroom by CNA, sitting upright by toilet". There was no documentation of any interventions in place at the time of the fall, except for the strips per the POC. The intervention on the Incident/Accident Report was to "move res(ident) closer to nur(sing) station". The POC and Social Service notes stated that the resident was moved closer to the nurse's station on 11/22/11. The change in the resident's room occurred two days after the fall". -The Incident/Accident Report dated 11/30/11 stated "called to room by housekeeper, resident laying on floor. Resident stated she was trying to get in bed and fell ". There was no documentation of any interventions in place prior to the fall except for anti-skid strips. The intervention on the Incident/Accident Report was "encouraged resident to call for help and use her walker". As above, the MDS dated [DATE] noted the resident as having a moderately impaired cognitive status. There was no evidence on the Incident/Accident Report, Nurse's Notes or on the POC that a new intervention was implemented to prevent further falls/injury. -Review of the POC revealed an incident/fall that occurred on 12/1/11 for which no Incident/Accident Report had been provided. The POC stated "fell getting (of) (sic.) from bed, between bed & (and) wall. C/O (complaint of) hip pain, sent to ER for eval(uation)". The interventions added to the POC dated 12/2/11 included a tabs alarm in wheel/chair until a sensor pad was available. As there was no Incident/Accident Report available for review, it was unable to be determined due to lack of information. -The Incident/Accident Report dated 12/4/11 stated "Noted on floor in dayroom, lying flat on her stomach, face flat to floor on her R(ight) side, blood noted on floor with active bleeding. Per res(ident), fell out of her w/c (wheelchair) &(and) hit floor". The intervention on the Incident/Accident Report stated "Sent to ER-CT(Cat Scan) done @ (at) hosp(ital)-cont(inue) with alarms to bed/chair". Resident was transported to ER. There was no mention of any interventions in place at the time of the fall, though there was a POC in place for a tabs alarm in the wheel/chair and no documentation stated the alarm sounded. The intervention on the Incident/Accident Report was "Sent to ER and to continue with alarms to bed/chair". The POC dated 12/5/11 stated a "Sensor pad to w/c (wheelchair) and change transfer assistance to one + (plus), continue physical therapy". During an interview on 12/6/11 at 12:45PM with the Director Of Nursing (DON), she confirmed that the resident had numerous falls in the last year. The DON stated that the resident had two types of name brand sneakers purchased and tried on the resident and that the resident did not like either brand. During an interview on 12/7/11 at 10:10AM the information found on the Incident/Accident Reports, Nurse's Notes and POC's was reviewed and the DON acknowledged that information appeared to be missing. She then referred the surveyor to the MDS Coordinator. During an interview on 12/7/11 at 02:00PM, the MDS Coordinator and the Consultant provided written information on how they addressed the prevention of further falls and/or how they were minimizing potential injuries for Resident #2. No additional information was provided that had not already been reviewed. Review of the current physician's orders [REDACTED]. Initial observation of the resident in her room revealed that the bed was not placed against the wall in the semi-private room. Observations on 12/6/11 during Initial Tour, at 11:40AM, and at 12:40PM revealed that the bed was placed in the center of the resident's half of the room. At 5:00PM, staff provided a low bed and placed it against the wall as had been previously ordered.