Every finding on record at Chaplinwood Nursing Home

Based on observations, staff interviews, and review of the facility's policy titled Labeling and Dating, the facility failed to ensure that expired foods were not available for use. This deficient practice had the potential to place 85 residents who received an oral diet from the kitchen at risk of foodborne illness. Findings include: Review of the facility's policy titled Labeling and Dating, dated April 2024, included, Upon receipt, all items should be inspected and marked with the date it was received into your facility and the date it should be discarded or expired. If the item has a use-by or discard date already printed on it, then you may use this date. During a tour of the kitchen on 6/2/2025 at 9:30 am with the Dietary Manager (DM), the following items were identified: Two jars of grape jelly with an expiration date of 9/25/2024. Two bags of pecan pieces with an expiration date of 4/18/2025. Two bags of chunk light tuna with an expiration date of 5/16/2025. One box of hot cocoa mix with an expiration date of 11/5/2024. Four bags of raspberry gelatin with an expiration date of 4/24/2025. Three bags of cherry gelatin with an expiration date of 4/24/2025. Three bags of strawberry gelatin with an expiration date of 4/24/2025. In an interview on 6/2/2025 at 10:00 am, the Dietary Manager (DM) confirmed the expired food items and stated that expired food items should be discarded on or before the expiration date. In an interview on 6/3/2025 at 11:45 am, Dietary Aide (DA) JJ stated that when staff conducted inventory, they should discard any expired items in storage. In an interview on 6/5/2025 at 8:54 am, the Administrator stated her expectation was for dietary staff to discard food items on or before the expiration date.

Based on observations, staff interviews, and record review, the facility failed to ensure a respiratory therapy mask was properly stored in a manner to prevent contamination for one of 18 residents (R) (R40) receiving respiratory services. This deficient practice had the potential to increase the risks of spreading microorganisms and place R40 at risk for respiratory infections and a diminished quality of life. Findings include: Review of R40's electronic medical record (EMR) revealed diagnoses including, but not limited to, heart failure, unspecified, atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow). Review of R40's Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section GG (Functional Abilities and Goals) documented R40 was dependent for activities of daily living (ADLs). Section O (Special Treatments, Procedures, and Programs) documented that R40 received oxygen therapy while a resident. Review of R40's Care Plan revealed a care area dated 2/25/2025 of altered breathing patters and included the use of a BiPAP as ordered. Review of R40's Resident Consolidated Order revealed an order dated 3/26/2025 for a Bilevel Positive Airway Pressure (BiPAP) [a non-invasive ventilation used to help with breathing] to be applied at bedtime. Observations on 6/2/2025 at 11:53 am and 6/3/2025 at 9:43 am, in R40's room, revealed R40's BiPAP mask lying on top of the machine on the bedside table and not stored in a protective bag. During a concurrent interview and observation on 6/4/2025 at 9:26 am, Registered Nurse (RN) AA confirmed R40's BiPAP mask was not stored in a protective bag and stated the respiratory masks were typically stored in a protective bag. During an interview on 6/4/2025 at 10:22 am, the Director of Nursing (DON) stated that she expected respiratory masks to be stored in a protective bag when not in use.

Based on observations and staff interviews, the facility failed to maintain clean Packaged Terminal Air Conditioner (PTAC) filters or units for two of 12 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) on the 300 Hall. The deficient practice had the potential to place residents residing in the rooms at risk of living in an unsanitary living environment, and a potential for a diminished quality of life. Findings include: Observations on 6/2/2025 at 11:52 am and 6/4/2025 at 9:15 am in room R304 revealed that the PTAC unit filter displayed a thick gray substance. Observations on 6/2/2025 at 11:48 am and 6/4/2025 at 9:15 am in room R303 revealed that the PTAC unit had black substance with debris inside the unit. During a concurrent observation and interview on 6/4/2025 at 9:23 am, the Maintenance Director confirmed that the PTAC unit filter in room [ROOM NUMBER] had a thick gray substance, and the PTAC unit in room [ROOM NUMBER] had a black and gray substance inside the unit. The Maintenance Director stated the units were cleaned monthly. During an interview on 6/4/2025 at 10:25 am, the Administrator stated the maintenance department should check the PTAC filters and units once a month and as needed.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled A Comprehensive Patients' Rights Program, the facility failed to ensure one of 33 sampled residents (R) (R82) choices of care were honored. This deficient practice had the potential to place R82 at risk of unmet needs and a diminished quality of life. Findings include: Review of the facility policy titled A Comprehensive Patients' Rights Program, reviewed date 12/27/2024, revealed the Intent section stated, This intent of this center to have an effective Patients' Rights program that recognizes that meaningful support of Patient's Rights. We believe that all staff should understand the importance of treating patients with care and respect, and honoring patients' rights to make personal choices. We also believe that such a program should include patient, family, and all Associates of the nursing home. Review of R82's electronic medical record (EMR) revealed R82 was admitted on [DATE] with diagnoses including, but not limited to, cerebral infarction, epilepsy, unspecified, intractable, with status epilepticus, delirium due to known physiological condition, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of R82's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 14 (indicating little to no cognitive impairment). Section E (Behaviors) documented no behaviors were exhibited. Review of R82's Physician Orders revealed no orders for medications to aid with sleep. In an interview on 6/2/2025 at 11:45 am, R82 stated he felt he needed a medication to help him sleep at night. He stated he had informed staff, but had not received a sleep aid medication. In an interview on 6/4/2025 at 9:12 am, R82 stated he had not slept well during the previous night. In an interview on 6/4/2025 at 9:39 am, Licensed Practical Nurse (LPN) GG stated that she was familiar with R82's request for a medication to help him sleep. She stated R82 had asked her about obtaining a medication for sleep a few days prior. She confirmed that the provider was not notified because she got busy and forgot. In an interview on 6/4/2025 at 12:08 am, the Assistant Director of Nursing (ADON) stated that she expected the staff to address a resident's request at the time of the request. She further stated that the nurse should have notified the physician of R82's request for a sleep aid medication.

Based on observations, interviews, and record reviews the facility failed to ensure that one resident (R 73) of three residents reviewed for accidents was free from injury during transfer. Actual harm occurred on 7/10/2023 when R 73 sustained a distal tibial fracture after being transferred by two Certified Nursing Aides without the use of a Hoyer lift. Findings include: Review of the electronic medical record (EMR) for R 73 revealed diagnoses that included but were not limited to End stage renal disease, Presence of cardiac pacemaker, Dependence on renal dialysis, Chronic obstructive pulmonary disease, unspecified, Atherosclerotic heart disease of native coronary artery without angina pectoris, Muscle weakness (generalized), Need for assistance with personal care, and endocarditis. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating some impairment to cognition. Further review revealed extensive assistance with two-person physical assistance needed for bed mobility and transfers. Review of Event Initial Note dated 3/29/2023 revealed R 73 was assisted to the floor in the shower room while receiving two-person assistance from the wheelchair to the shower chair. This resulted in a break in skin to the sacrum. A new intervention of using a Hoyer lift for all transfers was put into place. Review of Event Initial Note dated 7/10/2023 revealed R 73 experienced a fall when he was being assisted with a transfer. The intervention that was initiated was to use a Hoyer lift pad. Review of the initial imaging report dated 7/10/2023 for the left ankle had findings of comminuted fracture of the distal femur. Review of the second opinion of the imaging report from 7/10/2023, for the left ankle had findings of comminuted fracture of the distal tibial diaphyseal fracture with anatomic allgnment (sic). During an observation and interview with R 73 on 9/15/2023 at 11:44 am it was reported that Certified Nursing Assistant (CNA) FF was assisting him from his wheelchair to bed when she began to fall backwards taking him with her. R 73 reported that his leg was caught under CNA FF which resulted in a fracture to his left leg and ankle. R 73 reported that prior to this fall sometimes he received two-person assistance and sometimes it was only one person assistance when transferring him. R 73 reported that since the fall the Hoyer lift is used each time. R 73 was observed wearing a boot on his left foot. During an interview with CNA FF on 9/16/2023 at 3:54 pm it was reported that it was her first shift working with R 73 on the day of R 73's fall in July. CNA FF acknowledged that R 73 was a two-person assist with the Hoyer lift for his transfers. However, on the day of the fall, CNA FF reported that R 73 did not have a lift pad under him so she and another CNA (could not remember who) attempted to transfer R 73 from his wheelchair to his bed without the use of the Hoyer lift. During an interview on 9/16/2023 at 5:02 pm with CNA GG who confirmed that she was assisting R 73 on the day of his fall in July and the Hoyer lift was not used for the transfer. CNA GG reported that she was aware that R 73 required the use of the Hoyer lift, but R 73 said that he could stand to transfer. It was further reported that once he stood, he began falling and she was unable to stop the fall. During an interview on 9/17/2023 at 9:10 am with Resident Care Coordinator (RCC) OO who reported that R 73 has a tendency of telling staff that he can walk or is able to pivot. However, staff can utilize the resident Plan of Care (POC) to determine each resident's needs. RCC OO reported that if a resident requires the Hoyer lift, but a lift pad is not under a resident the CNAs should get a pad and place under the resident so that the Hoyer lift can be used. During an interview on 9/17/2023 at 10:51 am with the Administrator and Director of Nursing (DON) the DON reported that when R 73 was found to not have a lift pad under him staff should have consulted the nurse or therapy before trying to transfer R 73 without the Hoyer lift. The Administrator reported that she would have expected the staff to find a lift pad for the resident. The Administrator further reported that if the resident wanted to stand to transfer and not use the lift it is his right.

Based on observation, record review, staff interview, and review of the facility policy 'Patient's Plan of Care' the facility failed to follow the person-centered comprehensive care plan related to using a Hoyer lift for one resident (R) (R73) and related to receiving tube feedings as ordered for two residents (R65 and R8). Actual harm occurred on 7/10/2023 when R73 sustained a distal tibial fracture after being transferred by two Certified Nursing Aides without the use of a Hoyer lift. The sample size was 28. Findings include: 1. Review of the electronic medical record (EMR) for R73 revealed diagnosis that included but not limited to hypertensive heart and chronic kidney disease without heart failure, with stage 5 chronic kidney disease, or end stage renal disease, End stage renal disease, chronic obstructive pulmonary disease, unspecified, muscle weakness (generalized), need for assistance with personal care, and peripheral vascular disease, unspecified. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating some impairment to cognition. Further review revealed extensive assistance with two-person physical assistance needed for bed mobility and transfers. Review of the care plan revealed R73 at risk for falls as evidenced by fall on 3/29/2023 and 7/10/2023. Review of the interventions included (not all inclusive) Hoyer lift for all transfers with an onset date of 3/29/2023. Review of Event Initial Note dated 7/10/2023 revealed R73 experienced a fall when he was being assisted with a transfer. The intervention that was initiated was to use a Hoyer lift pad. During an interview with R73 on 9/15/2023 at 11:44 am it was reported that Certified Nursing Assistant (CNA) FF was assisting him from his wheelchair to bed when she began to fall backwards taking him with her. R73 reported that his leg was caught under CNA FF which resulted in a fracture to his left leg and ankle. R73 reported that prior to this fall sometimes he received two-person assistance and sometimes it was only one person assistance when transferring him. R73 reported that since the fall the Hoyer lift is used each time. During an interview with CNA FF on 9/16/2023 at 3:54 pm it was reported that on the day of R73's fall in July he did not have a lift pad under him so she and another CNA (could not remember who) attempted to transfer R73 from his wheelchair to his bed without the use of the Hoyer lift. During an interview on 9/16/2023 at 5:02 pm with CNA GG who confirmed that she was assisting R73 on the day of his fall in July and the Hoyer lift was not used for the transfer. An interview with the Director of Nursing (DON) on 9/17/2023 at 10:51 am who confirmed the care plan was not followed related to the use of the Hoyer lift for R73 when he fell [DATE]. Cross refer to F689. 38991 2. Review of the 7/6/2023 Quarterly MDS Assessment for R65 revealed a BIMS score of 99 indicating severely impaired cognition, is totally dependent upon staff for all Activities of Daily Living (ADL) with two-person physical assist, has active diagnoses of hyponatremia and is receiving tube feeding. Review of the care plan for R65 revealed she is at risk for altered nutritional status with a review date of 9/12/2023. Interventions include that resident is Nothing by Mouth (NPO). Flush tube with H2O as ordered. Tube feeding with a review date of 9/12/2023. Review of the Physician Orders revealed Auto feeding tube flush 38 milliliters (ml) / hour (hr). Diagnosis (Dx): Gastrostomy status modification date: 8/8/2023. Diabetisource AC 55 ml / hr. May be held for ADL care, therapy, and medication administration. The enteral feeding is not periodic, and the duration of infusion is indefinite. Dx: Gastrostomy status Start Date: 4/8/2023. Observations on 9/15/2023 at 8:31 am and 2:35 pm, and 9/16/2023 at 7:45 am of R65 revealed tube feeding with Diabetisource AC at 55 ml / hr with water flush set at 50 ml every 4 hours. Observation and interview on 9/16/2023 at 8:05 am with Licensed Practical Nurse (LPN) AA, revealed, upon entrance to the room of R65, she confirmed the feeding pump is infusing the flush at 50 ml every 4 hours. Observation and interview on 9/16/2023 at 8:12 am with LPN AA, and Resident Care Coordinator (RCC) BB confirmed the order for the feeding flush for R65 is 38 ml per hour. During this time the RCC stated it is the responsibility of the nurses and herself to ensure feeding pumps are set accurately. Interview on 9/17/2023 at 10:55 am with the DON revealed she confirmed the care plan for R65 and R8 were not implemented by staff and added that they should have been. 39844 3. Review of the Quarterly Minimum Data Set (MDS) for R8 dated 9/6/2023 revealed: Section K-Nutrition: Weight loss indicated not prescribed by Physician, receives nutrition >51% via feeding tube. Review of R8 care plans revealed: At risk for altered nutrition status with intervention that included provide tube feeding and flushes as ordered, and patient will have no signs or symptoms of dehydration through the review period. Review of R8 Physicians orders revealed and order for Diabetisource AC at 55 ml every hour, check every shift, feeding may be held during activities of daily living (ADL) care, therapy, and medication administration. The enteral feeding is not periodic, and the duration of infusion is indefinite. Auto feeding tube flush at 48 ml every hour. Observation on 9/15/2023 at 8:19 am and 1:14 pm, and on 9/16/2023 at 8:10 am revealed R8 gastrostomy tube feeding set infusing at 50 ml per hour and water flush set at 52 ml per hour. Interview on 9/17/2023 at 8:58 am with the DON indicated she would expect the nurses to follow the care plan related to the resident's feeding needs. Further interview on 9/17/2023 at 10:55 am with the DON revealed she confirmed the care plan for R65 and R8 were not implemented by staff and added that they should have been. Cross refer to F693.

Based on observation, interviews, documents, and review of facility policy titled Cleaning and Sanitizing, Storage, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner to prevent cross contamination as evidenced by failing to label and date food items, failing to remove expired items from the cooler, failed to ensure all equipment was not in disrepair, and failing to ensure cleanliness of kitchen and dry food storage shelves for 78 of 81 residents receiving an oral diet. Findings include: Policy: Storage - review [DATE] - Intent It is the intent of this center to store food in a manner that maintains quality and safety. Policy: Cleaning and Sanitizing - review [DATE] - Guideline - Cleaning schedules should be implemented and maintained for all areas of the kitchen. Review of the Quality Assurance Event dated [DATE] identified an issue with compliance in the kitchen which included labeling, dating, and cleaning. Staff not taking ownership of tasks was identified as the root cause of the problem and staff education was provided. During the initial kitchen tour on [DATE] at 7:45 am the following was revealed: 1. The eye wash station leaking. 2. In the walk-in cooler there was a container of thickened tea that had been opened but there was no open date on the item. Directions: After opening, may be kept up to 7 days under refrigeration. 3. There were at least 5 bags of powdered milk that had a use by date of [DATE]. 4. There were seven 16-ounce containers of strawberries with one of the containers having a white substance all over the strawberries. It had a use by date of [DATE]. The Dietary Manager was not at the facility at the time of the tour. During an interview and observation with Certified Dietary Manager (CDM) on [DATE] at 7:53 am the following was observed: 1. In the walk-in cooler there was one opened container of thickened tea that was opened as evidenced by the tabs on top of container being broken. The tea was not labeled or dated with an open date. 2. In the dry food storage area there were 10 five-pound bags of Instant Nonfat Dairy Milk. 3. In dry the food storage area the shelf to the right was noted to have black buildup on the shelves. 4. Condensation was noted on the vents throughout the kitchen. It is noted that the food cart that was being prepared at the time was sitting directly under a vent and there was some dripping onto the empty sups that were sitting up top. 5. Dust was noted to be in the ceiling in the kitchen. 6. There was a black buildup on the can opener. 7. The walls throughout the kitchen were noted to have food splatter. Specifically, near the three-compartment sink, dishwashing area, and wall by the dry food storage area. 8. The light fixtures were noted to have dust buildup on the covers. 9. The eye wash station near the handwashing sink was leaking. During the interview with the CDM on [DATE] at 7:53 am it was reported that she tries to check the cooler daily to remove items that need to be removed. She confirmed that the thickened liquid container was open but not labeled. She reported that the shelves should be checked at least monthly and as needed for cleanliness. She reported that there is a cleaning schedule, and she confirmed the buildup on the wall near the microwave. It was reported that there has not been a deep clean of the kitchen due to challenges related to staffing. The Dietary Manager was unsure of the last time that a deep clean was completed in the kitchen. It was further reported that she was not aware of the eyewash station leaking until it was brought to her attention. During an interview on [DATE] at 6:42 am with the Administrator and CDM it was reported that the issues (label and dating and cleaning) in the kitchen were recognized back in June and were placed in QAPI. On [DATE] the Assistant Food Service Manager was demoted due to not performing job tasks to make sure things were in compliance. It was reported that there has been a lot of staff turnover in the kitchen as well and they are working on that too. It was further reported that the condensation and dust were identified in an audit by the Dietitian a few weeks ago. Review of Daily Cleaning Schedule for [DATE] revealed only one sheet with 10 entries indicating a task was completed. The Weekly Deep Cleaning Schedule for the same month had three entries (delime dish machine and range top burners) to indicate deep cleaning tasks were completed. However, none of the other tasks on the form were completed. Review of Daily Cleaning Schedule and Weekly Deep Cleaning Schedule for [DATE] did not indicate that any tasks had been performed by staff. During a subsequent interview on [DATE] at 10:15 am with the Administrator it was reported that the issues had been identified in the kitchen and the plan started back in June. However, upon review on [DATE] there had not been much progress. It was reported that a staff person was identified as not doing his/her part and a demotion was effective [DATE]. It was acknowledged that there should be daily cleaning and weekly deep cleaning completed but it is not reflected in the cleaning schedules that were provided. The Administrator acknowledged that cleaning in the kitchen had not been done consistently and a meeting is scheduled (with CDM and Maintenance) on [DATE] to determine their next steps.

Based on observations and interviews the facility failed to ensure a homelike environment as evidenced by slow draining sinks, missing paint from walls and bathrooms, holes in walls, dust buildup in vents, loose sink, brown staining in ceiling, staining on floors, stained privacy curtain, rust on base of overbed table, and missing privacy curtain on one (200 hall) of four halls. Findings include: Observations on 9/15/2023 revealed the following: 1. At 9:26 am in the bathroom of room [ROOM NUMBER] there was a loose sink, panel behind toilet loose with hole showing, dust buildup in vents, and stains in ceiling upon walking in the room. 2. At 9:39 am in room [ROOM NUMBER] behind bed A there was a hole in the wall, staining on privacy curtain for Bed B, and staining on floor at head of bed B. 3. At 11:33 am in room [ROOM NUMBER] there was no privacy curtain for bed A, missing paint from walls in bathroom, dust buildup in vent in bathroom, and buildup on floor at head of bed A. 4. At 12:12 pm in room [ROOM NUMBER] there was missing paint from wall in bathroom, scuff marks throughout the room and bathroom, rusty on over toilet frame, stained privacy curtain for Bed A, and a slow draining sink in the bathroom. 5. At 12:19 pm in room [ROOM NUMBER] the over bed table had rust on the base, slow draining sink in the bathroom, missing paint on wall in bathroom, and buildup on floor in corners of room. During an interview and observation on 9/17/2023 at 9:33 am with Certified Nursing Assistant (CNA) CC and CNA DD, CNA DD confirmed that she was assigned to resident in room [ROOM NUMBER] A. CNA CC and CNA DD both acknowledged the missing privacy curtain for Bed A and reported that the issue should be reported to Maintenance. An environmental tour was conducted on 9/17/2023 at 9:37 am with the Administrator and the Maintenance Director and the following was confirmed: 1. In room [ROOM NUMBER] the over bed table had rust on the base, slow draining sink, missing paint on wall in bathroom, staining on floor in corners of room. 2. In room [ROOM NUMBER] there was missing paint from wall in bathroom, scuff marks throughout room and bathroom, rust on over toilet frame, stained privacy curtain Bed A, and slow draining sink in bathroom. 3. In room [ROOM NUMBER] behind bed A hole in the wall. staining on privacy curtain bed B, staining on floor at head of bed B. 4. In room [ROOM NUMBER], there was no privacy curtain for bed A, missing paint from walls in bathroom, dust buildup in vent in bathroom, and buildup on floor at head of bed A. 5. In the bathroom of room [ROOM NUMBER], loose sink, panel behind toilet loose with hole showing, dust buildup in vents, and stains in ceiling upon entry into room. Patient care was being provided and unable to confirm staining on privacy curtain and staining on floor at the head of Bed A and Bed B. During an interview with the Administrator and Maintenance Director at end of the environmental tour on 9/17/2023 at 9:55 am revealed the Floor tech is responsible for replacing privacy curtains. It was explained that whoever finds a missing or stained privacy curtain should notify the Floor Tech. The Administrator reported that she is acting as the Housekeeping Supervisor due to not having one staffed at this time. There is not a log of tasks for the changing of privacy curtains by the Floor Tech. The Maintenance Director reported that he has been aware of the sink in room [ROOM NUMBER] for about a week. He further reported that he was made aware of the hole in the wall in room [ROOM NUMBER] yesterday. The Administrator reported that the overall environment was in QAPI and on 5/31/2023 developed a plan to address findings at that time. However, the items identified during the environmental tour were not a part of their areas identified to be addressed. Both the Maintenance Director and the Administrator reported that they were not aware of the staining in room [ROOM NUMBER] until the tour today. The Maintenance Director reported that the items identified during the tour are not a part of his monthly tasks but everyone in the building has access to work orders so that they can be addressed. The Administrator reported that everyone can place a work order in the system when an issue has been identified.

Based on observations, interviews, record review, and review of facility policy titled Abuse Prohibition the facility failed to ensure two residents (R57 and R41) of 81 residents were free from verbal abuse by staff. Findings include: Review of policy titled Abuse Prohibition, with a review date of 12/20/2022 revealed the following: Intent: It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. We believe that each patient has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. The purpose of these identified procedures is to assure that we are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of mistreatment, neglect, abuse or misappropriation of any patient and/or their property. The procedures herein established standards of practice for protection of patients and for identification and prevention of abuse. 1. Review of the electronic medical record (EMR) for R57 revealed diagnosis that included but not limited to Malignant neoplasm of colon, unspecified hearing loss, unspecified ear, difficulty in walking, not elsewhere classified, and unspecified lack of coordination, Review of Facility documents revealed: Facility Incident Report Form dated 5/24/2023 submitted for staff to resident abuse and the alleged perpetrator being a Dietary Aide (II). The Dietary Aide was suspended pending the investigation. Review of a written statement (not signed or dated) revealed R57 was sitting near double doors near kitchen when the Dietary Aide came out of the kitchen with the food cart yelling at resident. It is reported that the staff member grabbed R57 by the arm causing skin tears and bruising to his left arm. R57 notified Administrator to call police but she had already called. Once present R57 gave a statement to press charges against the Dietary Aide. Witness statement dated 5/24/2023 at 6 pm by Licensed Practical Nurse (LPN) HH revealed R#57 was sitting in the hallway and the Dietary Aide was trying to get around the resident but resident would not move. Dietary Aide attempted to move the resident and R#57 became argumentative and combative (Swinging his arms in a hitting way). The Dietary Aide then grabbed the resident's arms and held them both down towards the resident and he then grabbed his cart and proceeded to move the cart. The cart then bumped R#57's arm, R#57 was continuing to swing his arms in the air, and this resulted in his skin tear and bruises to arms. Review of another undated witness statement revealed that Dietary Aide was heard cursing at R57 and R57 was cursing back. Review of undated statement from Dietary Aide who reported that he asked R57 to move out of hallway, but he did not move. Dietary Aide then reported that R57 became combative, but he did not touch the resident. He reported that the resident began to yell out and the nurse came up the hallway to get R57 and he continued down the hall to deliver the trays. Review of an Initial Note dated 5/24/2023 revealed that R57 received a skin tear after having an altercation with a Food Service Worker. The document continued to reveal that R57 was fighting with a worker as the food cart was passing him in the hallway. The writer reported that she only heard the commotion but did not see the events leading up to the time in which she arrived. During an interview on 9/15/2023 at 12:12 pm with R57, resident presented hard of hearing but had a notepad at bedside for people to write out their questions. The interview was conducted with R57 responding to typed questions. R57 denied having any problems with staff or other residents and he denied being fearful of anyone. R57 did not voice any concerns regarding the care he is currently receiving. 2. Review of the EMR for R41 revealed diagnosis that included but not limited to Type 2 diabetes mellitus with unspecified complications, Major depressive disorder, recurrent, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, need for assistance with personal care, complete traumatic amputation at knee level, and right lower leg, sequela. Review of Facility Incident Report Form - dated 7/2/2023 for staff to resident abuse - Agency Nurse name not listed on this document. There were multiple witness statements that included hearing R41 and the Agency Registered Nurse (JJ) involved in a verbal altercation. During an interview on 9/15/2023 at 9:33 am R41 reported that nurses at the facility talk bad to her, and she specifically reported that she had an incident in which an Agency Nurse cursed me out. During a subsequent interview with R41 on 9/16/2023 at 9:00 am R41 reported that there was an incident in May in which a nurse cursed at her so the police were called. R41 further reported that she thinks the facility got rid of that nurse because she has not seen her again. During an interview on 9/16/2023 at 4:15 pm with the Administrator and Director of Nursing (DON) confirmed that verbal abuse was substantiated by staff towards R41 and R57. It was reported that after every facility reported incident (FRI) education is provided to staff. DON confirmed that the agency nurse involved in the incident with R41 last day working at the facility was on 7/2/2023. The Administrator provided a separation notice for the Dietary Aide involved in the incident with R57, with 5/24/2023 being the last day of employment. The reason for separation was Company Rule violation Abuse. During an interview with the DON on 9/17/2023 at 7:25 am it was reported that the staffing agency is provided a copy of education related to abuse whenever it is provided to facility staff, and it is the agency's responsibility to educate their staff. She further reported that the facility does not receive any confirmation from the agency that the education was provided. Lastly, the DON reported that abuse education has not been provided to agency staff upon working at the facility because the agency should be providing the education.

Based on observation, record review, staff interview, and review of the facility policy 'Enteral Nutrition Management', the facility failed to provide enteral nutrition and hydration according to physician orders for two of four residents (R) (R65 and R8) receiving tube feeding in the facility. Findings include: 1. Review of the facility policy 'Enteral Nutrition Management' with a review date of 12/30/2022 revealed it is the intent of this center to provide nutritionally complete enteral or parenteral feedings, as ordered by the physician, for the nourishment of patients who are unable to meet estimated nutritional needs orally. Review of the 7/6/2023 Quarterly Minimum Data Set (MDS) Assessment for R65 revealed a BIMS score of 99 indicating severely impaired cognition, no behaviors, is totally dependent upon staff for all Activities of Daily Living (ADL) with two-person physical assist, has active diagnoses of hyponatremia, anxiety, Diabetes Mellitus (DM), is receiving tube feeding, and receives an antipsychotic, antidepressant, antibiotic, and insulin injections 7/7 days. Review of the Physician orders revealed Auto feeding tube flush 38 milliliters (ml) / hour (hr). Diagnosis (Dx): Gastrostomy status modification date: 8/8/2023. Diabetisource AC 55 ml / hr. May be held for ADL (activities of daily living) care, therapy, and medication administration. The enteral feeding is not periodic, and the duration of infusion is indefinite. Dx: Gastrostomy status Start Date: 4/8/2023. Observation on 9/15/2023 at 8:31 am revealed R65 in bed with eyes closed. Bed noted in lowest position. Tube feeding infusing of Diabetisource AC at 55 ml / hr with water flush set at 50 ml every 4 hours. Bag of water is also hanging. Bags are observed labeled using the labels that came with bags and are dated with start time and initials of staff who hung feeding and water. Head of bed is at 35 degrees. Observation on 9/15/2023 at 2:35 pm of R65 resting in bed. Tube feeding continues infusing at 55 ml/hr. Water set on pump continues to infuse at 50 ml every 4 hours. Observation on 9/16/2023 at 7:45 am of R65 revealed she was in bed with eyes closed. Tube feeding infusing at 55 ml per hour and flush infusing at 50 ml every 4 hours. Head of bed up at 30 degrees. R65's mouth was open and appeared moist. Lips were observed to be moist. Observation and interview on 9/16/2023 at 8:05 am with Licensed Practical Nurse (LPN) LPN AA, revealed, upon entrance to the room of R65, she confirmed the feeding pump is infusing the flush at 50 ml every 4 hours. During observation and interview on 9/16/2023 at 8:12 am with LPN AA, and Resident Care Coordinator (RCC) BB, they confirmed the order for the feeding flush for R65 is 38 ml per hour. During this time the RCC stated it is the responsibility of the nurses and herself to ensure feeding pumps are set accurately. Observation and interview on 9/16/2023 at 8:15 am with LPN AA revealed she entered the room of R65 and changed the settings to the correct settings for the feeding flush per the physician order. During this time, she revealed that because the flush was not infusing as ordered R65 was not receiving enough fluid and that R65 had the potential to become dehydrated. Interview on 9/16/2023 at 10:15 am with the DON revealed it is the responsibility of the nurses to ensure the tube feedings are set on the pump accurately per the physician orders. She revealed the orders are on the Medication Administration Record (MAR) and are to be checked and signed off that the rates are correct two times daily, morning and night. She revealed that the settings on the feeding pump being incorrect for R65 put her at risk for dehydration. 39844 2. Review of R8 diagnoses include but not limited to dementia with behaviors, dysphagia, and Alzheimer's disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C-Cognition: BIMS score of 99 indicating severe cognitive deficit. Section G-Functional Status: Extensive assistance with bed mobility; total dependence with dressing, eating, personal hygiene and bathing. Section K-Nutrition: Weight loss indicated not prescribed by Physician, receives nutrition >51% via feeding tube. Review of R8's Physicians Orders revealed and order for Diabetisource AC at 55 milliliters (ML) every hour, check every shift, feeding may be held during activities of daily living (ADL) care, therapy, and medication administration. The enteral feeding is not periodic, and the duration of infusion is indefinite. Auto feeding tube flush at 48 ML every hour. Resident may have pureed food and nectar thick liquids upon request during the day. Observation on 9/15/2023 at 8:19 am and 1:14 pm revealed R8 gastrostomy tube feeding set infusing at 50 ml per hour and water flush set at 52 ml per hour. Observation on 9/16/2023 at 8:10 am revealed R8 in bed, bed low position and head of bed elevated. Gastrostomy tube feeding set infusing at 50 ml per hour, bag and water flush set at 52 ml per hour. Interview on 9/16/2023 at 8:29 am with Resident Care Coordinator (RCC) BB revealed feeding pump set at the correct settings. She indicated she just checked it and she reset it according to the order. She indicated it should be checked by the nurse every shift and by the nurse who changes the feeding out at night. Interview on 9/16/2023 at 8:35 am with Licensed Practical Nurse (LPN) AA revealed she checks the feeding pump during her shift. Interview on 9/17/2023 at 8:58 am with the Director of Nursing (DON) indicated she would expect the nurses to check the feeding pump settings every shift and when hanging a new bottle and follow the Physician's Orders. She indicated that not following the recommended settings could contribute to weight loss or dehydration. She indicated the resident has had weight loss but currently her weight is stable. The Registered Dietician was unavailable for interview.

Based on observations, interviews, and facility policies review titled Preventive Maintenance Schedules, and Physical Plant Maintenance, the facility failed ensure that the facility was maintained in a clean, safe, and sanitary condition on two of three halls observed. Specifically, the facility failed to ensure that used bath basin were properly labeled and stored in five residents' rooms on 300-Hall (room 302, 306, 308, 310, and 312), and one resident room on 200-Hall (room 220). The facility also failed to ensure residents rooms were in good repair for rooms 306 and 308 which had water noted on the bathroom floor from a water leak that was not addressed. Findings include: On 5/24/22 at 9:42 a.m. observation of room 312 bathroom revealed bath basin on back of toilet unlabeled with unlabeled urinal inside. On 5/25/22 at 8:56 a.m. second observation of room 312 bathroom revealed bath basin on back of toilet urinal hanging on towel rack unlabeled. On 5/24/22 at 9:45 a.m. observation of room 310 revealed base board in room on the floor, bath basin in bathroom unlabeled sitting on the floor by the toilet. Wall behind sink under vanity mirror has missing paint with dry wall showing, as well as wall on A side of the room. On 5/25/22 at 8:48 a.m. second observation of room 310 revealed base board lying on the floor off wall going into bathroom. Wall behind sink under vanity mirror has missing paint with dry wall showing, as well as wall on A side of the room. On 5/24/22 at 10:00 a.m. observation room of room 306 revealed water on the floor in front of bathroom door, paint on the bathroom wall is peeling away, bath basin sitting on the back of the toilet unlabeled, urinal hanging on towel rack in the bathroom. On 5/25/22 at 8:53 a.m. second observation room 306 revealed water on the floor white towel noted soaking up residual, bath basin on back of toilet unlabeled, paint on bathroom wall by toilet peeling away. Black substance noted on the wall of bathroom in the corner. On 5/24/22 at 10:12 a.m. observation of room 308 revealed water on the floor in front of bathroom door. On 5/25/22 at 8:49 a.m. second observation of room 308 revealed water on the floor in front of bathroom door, brown smeared substance on wall by the toilet in bathroom paint peeling off the wall to the right of bathroom. On 5/24/22 at 10:26 a.m. observation of base board in room 302 revealed bathroom has peeling paint, base board lining under drawers is peeling off and lying on the floor, bath basin in bathroom unlabeled and sitting in the sink and on the back of toilet. On 5/25/22 at 8:58 a.m. second observation of room 302 revealed bathroom has peeling paint, base board under drawers is peeling off and lying in the floor, three bath basins noted in bathroom one in the sink, one on the back of the toilet, one on the floor on white stand, all basins were unlabeled. On 5/24/22 at 10:34 a.m. observation of room 220 revealed toilet seat sitting on the floor against the wall of the bathroom, bath basin stacked one in another unlabeled. On 5/25/22 at 9:03 a.m. second observation of room 220 revealed toilet seat sitting on the floor against the wall of the bathroom, urinal on towel rack unlabeled, bath basin on back of toilet unlabeled. On 5/25/22 at 9:41 a.m. interview with Housekeeper AA revealed that staff member was not aware of a maintenance logbook to log any repairs that need to be addressed, staff member stated that they usually just verbally let the Maintenance Director know of any repairs that are observed. On 5/25/22 at 10:04 a.m., environmental rounds conducted with Administrator and RN Regional Nurse Consultant due to Maintenance Director and Environmental Services Director out on leave. During conducted rounds all previous environmental observations were confirmed during rounding. On 5/25/22 at 11:11 a.m., interview with Administrator revealed there was only one Maintenance staff member for the facility. All maintenance requests are documented in the TELs system that only the administrative staff and the charge nurses have access to. Further interview also revealed that Administrator was not aware of the needed repairs that were observed during environmental rounds. Continued interview also revealed that if there are any needed repairs for the facility the maintenance staff from their sister facility will come over fix any issues that need to be addressed. During interview it was also disclosed that it is the Administrators expectation that the facility be kept clean and in good repair. Review of facility policy titled Physical Plant Maintenance dated 12/4/21 revealed under intent: it is the intent of this center that all areas of the building, grounds, and equipment be maintained and properly serviced. Under guideline: the following functions should be by plant operations but are not limited to: Maintaining the building and equipment in compliance with manufacturer recommendations, current federal, state, and local laws, regulations, and guidelines: Maintaining the building in good repair and free from hazards; providing routinely scheduled maintenance service to areas; and others that may become necessary or appropriate. Review of facility policy titled Preventive Maintenance Schedules dated 12/4/21 revealed under intent: It is the intent of this center that preventive maintenance schedules be developed and implemented to assure that the building and equipment are maintained in a safe and operable manner.

Based on observation, record review, and staff interview, the facility failed to ensure the medication error rate was less than five per cent (5%). A total number of 35 medication opportunities were observed, and there were three errors for two of four residents (R) (R#54) and (R#72) by two of three certified medication aides (CMA) observed giving medications, for an error rate of 8.57%. Findings include: On 5/25/22 at 7:07 a.m., Certified Medication Aide (CMA) FF was observed giving R#54 her morning medications. Observation revealed that medicines given included Aspirin 81 mg (milligrams) chewable 1 tablet, Cranberry Extract 450 mg 1 tablet, Loratadine 10 mg 1 tablet, Vitamin C 500 mg 1 tablet, Vitamin D3 25 mg 5 tablets, [MEDICATION(S)] 5 mg 1 tablet, [MEDICATION(S)] 100 mg 1 tablet, [MEDICATION(S)] HCL 10 mg 1 tablet, [MEDICATION(S)] 50 mg 1 tablet, and [MEDICATION(S)] HCL 37.5 mg 1 tablet. After all of the resident's morning medications had been prepared, CMA FF counted the number of pills in the cup, and verified during interview that what she prepared was all of the medications R#54 received for that time of day. Review of R #54's May physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During the medication observation with CMA FF on 5/25/22 at 7:07 a.m., CMA FF verified that she administered ASA 81 mg chewable 1 tablet. On 5/25/22 at 7:22 a.m. during medication observation surveyor observed CMA BB administer the following medications to R#72; [MEDICATION(S)] 75 mg 1 tablet, [MEDICATION(S)] 12.5 mg 1 tablet, [MEDICATION(S)] 10 mg 1 tablet, [MEDICATION(S)] 25 mg 1 tablet, Potassium Chloride 10 meq 1 tablet and [MEDICATION(S)] HCL 25 mg 1 tablet. Surveyor observed CMA BB remove 2 [MEDICATION(S)] Inhalers from the mediation cart for administration for R#72. CMA BB asked resident to rinse her mouth with water before and after the administration of the [MEDICATION(S)] Inhaler. CMA BB then attempted to administer the second inhaler ([MEDICATION(S)]); surveyor intervened and asked CMA BB to step outside with both inhalers. CMA BB verified that the second inhaler was another [MEDICATION(S)] inhaler and not the scheduled [MEDICATION(S)] inhaler. CMA BB stated, I got mixed up. Review of R#74's electronic medication record revealed that resident has an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . CMA BB verified she did not administer the scheduled medication. Review of facility's policy titled Pharmacy Services Medication Administration General dated 2019 reads medications are administered as prescribed, in accordance with good nursing principles.

Based on observation, interviews and review of facility policy titled Transmission-Based Precautions (TBP), the facility failed to ensure proper disposal of contaminated Personal Protective Equipment (PPE), for one of two residents (R) (#24) on TBP. Specifically, the facility failed to ensure that biohazard container was available for staff use. Findings include: Review of the clinical record revealed R#24 was admitted to the facility on [DATE]. On 5/14/22, R#24 was discovered to have shingles and was started on [MEDICATION(S)] 1 gram daily for five days and placed on isolation. Observation on 5/25/22 at 9:56 a.m. revealed Certified Nursing Assistant (CNA) BB exiting R#24's room with used PPE in hand and placed it in soiled trash cart located on the hall. Continued observation on 5/25/22 at 10:06 a.m. revealed no biohazard container in residents' room. Interview with Director of Nursing (DON) on 5/25/22 at 10:08 a.m. confirmed that there was not a biohazard container in the resident's room. The expectation is that if the biohazard container is not available in the residents' room, to place the used PPE in the trash can in the room until a container can be replaced. On 5/25/22 at 10:15 a.m. interview with CNA BB revealed that the PPE was taken off in the room and placed in the container in the hall because there was not a biohazard container in the room and there was not a trash bag in the trash can in the room to use as well. Continued interview also revealed that it is usually housekeeping that would make sure that the containers are in the rooms. Interview with Administrator on 5/25/22 at 12:07 p.m. revealed that there should be a biohazard container in each residents' room that is on infection precautions. It is the responsibility of all that enters that room to ensure that the proper disposal containers are in the room for staff use. Staff should not be taking dirty linen or used PPE from a room on precautions out in the hall and mixing it with other laundry. The expectation is that all infection control precautions be followed. Review of facility policy titled Transmission-Based Precautions dated 12/4/21 under contact precautions revealed to remove gown and observe hygiene before leaving the patient care environment.

Based on observation, interview and record review, the facility failed to ensure housekeeping staff used a cleaning and disinfection product according to the manufacturer's instruction for use and one Certified Nurse Aide (CNA) failed to don personal protective equipment (PPE) prior to entering the room of a resident on transmission-based precautions. Findings include: 1. In an interview on 2/15/21 at 10:48 a.m., Housekeeper (Hskpr) II responded to the question of what product was used on high touch areas stating/showing a container of Clorox Bleach Germicidal wipes and PDI Super Sani Cloth (purple top) wipes. When asked what the contact or wet time was, Hskpr II held up the bleach product and stated, It stays wet about 2 minutes. Observation of Hskpr II at 10:50:35 seconds a.m. on 2/15/21 showed her removing two PDI Sani Cloth wipes from the canister and wipe down the handrail outside of room [ROOM NUMBER]; asked about the contact or wet time of the PDI wipes, Hskpr II stated supposed to stay wet about ten minutes. At 10:51:35 seconds a.m., asked if the handrail was still wet, Hskpr II touched the rail and pronounced that it was dry. Review of the PDI Super Sani Cloth wipes label showed: Directions for use . To disinfect and deodorize: To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) minutes. Let air dry In an interview on 2/15/21 at 7:26 PM, the Infection Preventionist confirmed the wet time of the area cleaned was not according to the manufacture instruction for use (MIFU). 2. Observation of the meal tray pass on 2/15/21 at 1:15 p.m. showed Certified Nurse Aide (CNA) HH, wearing face mask and eye protection, exited room [ROOM NUMBER], use hand sanitizer, pulled a tray from the tray cart and entered into room [ROOM NUMBER] without donning a gown and gloves. room [ROOM NUMBER] had transmission-based precaution sign on the door and a door hanger bag had PPE available; and exited the room using hand sanitizer. At 1:18 p.m., the call light above the door of room [ROOM NUMBER] went on, and CNA HH knocked and entered the room without donning (putting on) any PPE stating she needed a cup of coffee for the resident. At 1:22 p.m., CNA HH went to the door of room [ROOM NUMBER] with coffee, stopped and donned PPE. When asked why no PPE prior to now, CNA HH responded I accidently didn't think about it. knocked and entered the room. Review of the facility policy titled Emergency Preparedness Response: Guidelines for Influx of People with Infections (sic) Disease, revised 7/24/20 showed: High-COVlD19 is Suspected or Confirmed in Your Center . Personal Protective Equipment (PPE) 1. Ensure signs appropriate signs for transmission-based precautions are placed in required areas 2. Ensure that an associate is assigned to inventory and stock PPE carts per shift' 3.Universal use of N95 masks should be implemented. Strategies to optimize PPE can be completed using guidance from CDC. 4. Universal use of face shields or goggles for all HCP (healthcare personnel) should be used per guidance of CDC. 5. When supply shortage exists, please refer to CDC guidance for maximizing use of personal protective equipment (PPE). In an interview on 2/15/21 at 7:27 p.m., the Infection Preventionist confirmed room [ROOM NUMBER] was on transmission-based precautions and staff should have worn PPE.

Based on record review and resident/staff interviews, the facility failed to offer a choice of a shower and bathing schedule for one of three residents (R#1) residing on the COVID/isolation unit. Findings include: Review of the face sheet revealed R#1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of R#1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had a Brief Interview for Mental status (BIMS) score of 12 (indicates the resident is cognitively intact). During an initial interview conducted on 9/22/2020 at 2:30 p.m., R#1 revealed he wants a shower but was told that he could not get a shower because of COVID, and they told him there was not a shower room on the COVID unit. R#1 further stated he has not had a shower or offered a shower since he has been on the COVID unit. Review of Progress Notes dated 8/29/2020 revealed R#1 tested positive for COVID-19 and was moved to the isolation unit, and family notified. On 9/23/2020 at 4:00 p.m. a request for the facility's bathing schedule and policy was requested from the Director of Nursing (DON). The DON stated they do not have a bathing policy. The undated resident shower preference sheet created by the Social Service Director (SSD) was provided. Review of undated resident shower preference sheet revealed resident R#1 preferred showers in the mornings. An interview on 9/22/2020 at 2:15 p.m. with Certified Nursing Assistant (CNA) EE revealed the residents on the COVID and observation unit can get a shower if they ask for one, but no one has asked for a shower. An interview with Licensed Practical Nurse (LPN) AA on 9/22/2020 at 3:42 p.m., revealed that the facility does 12 hour shifts on the COVID unit, and there are five residents on the COVID unit, and three residents on the observation unit. LPN AA stated that when COVID first started they were taking residents to the shower but now they get bed baths. LPN AA stated if a resident requested a shower, they could get a shower if they have on their mask. LPN AA further stated that she has been out for a couple of weeks, and since she has been back no resident has requested or received a shower on the COVID/observation unit. Interview with CNA BB on 9/22/2020 at 4:52 p.m., revealed showers are given when requested by the resident, and a basin, soap, and a wash rag is provided. CNA BB stated she has two residents that can bathe themselves. CNA BB also stated no one has requested a shower. The shower schedule is on Maple unit, the non COVID unit. During an interview with SSD on 9/23/2020 at 11:00 a.m., revealed when she returned from leave in June 2020, she asked if the residents on the COVID unit received showers. SSD stated she went around to each resident and interviewed every single resident in the building to see if they wanted a shower in the morning or evening, and asked them what their shower preference was and updated the resident shower preference sheet and gave it to the Assistant Director of Nursing (ADON) who is no longer here. SSD further stated since June she has not updated the shower schedule. SSD stated the residents on the COVID, and isolation unit should be getting a shower if they want one. During an interview with Wound Care Nurse (WCN) on 9/23/2020 at 11:52 a.m., she stated she feels there is enough staff to take care of the residents. WCN stated when she first came back residents were not receiving showers. WCN stated they were getting bed baths. WCN stated she brought it up to the Administrator and the ADON in the morning meeting. WCN stated she was concerned about infection control but, after it was discussed, it was determined that they could go to the shower as long as they had a mask on and housekeeping sanitized the shower in between residents. During an interview with Environmental Service Manager (ESM) on 9/23/2020 at 12:12 p.m., she stated as far as she knows the residents on the COVID unit are receiving a shower. Protocol for COVID is after each resident uses the shower, housekeeping will go in and clean it. She does not have a log documenting when the showers are cleaned, but they clean the showers about five or six times a day. During an interview with the DON on 9/23/2020 at 4:00 p.m., she stated the facility identified a problem with the shower schedule in June 2020. DON stated they were considering a shower team, and they are in the process of revamping the shower schedule again. DON stated the SSD did an audit of who wanted what and when. Further interview on 9/24/2020 at 4:00 p.m. with the DON revealed R#1 likes to take a shower. She stated sometimes he will try and go to the shower by himself and we have to stop him from going in there because we have to make sure no one is in there and make sure it has been cleaned. The Resident Summary of Bath document printed 9/24/2020 shows the type of bath taken. The DON did a further review of the CNA bathing tasks and verbally confirmed that there was no documentation or evidence that R#1 had received a shower from 8/1/20 through 9/24/20.

Based on record review and staff interviews, the facility failed to follow the Physician order [REDACTED].#1). Findings include: Review of the face sheet revealed R#1 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of R#1's quarterly Minimum Data Set ((MDS) dated [DATE], revealed he had a Brief Interview for Mental status (BIMS) score of 12 (indicates the resident is cognitively intact). Review of the Patient Summary for the [MEDICAL CONDITION] Associates dated 8/4/2020 revealed an order written [REDACTED]. Review of the Medication Administration Record (MAR) dated August 2020 revealed no evidence that the order was transcribed to the (MAR) and no evidence that the medication was ordered or given. An interview with Licensed Practical Nurse (LPN) AA on 9/22/2020 at 3:42 p.m. revealed when a resident returns from an appointment with an order, the nurse will check the orders to see if they are currently on the medication. The nurse should put the order into the electronic MAR and notify the resident. LPN AA stated the nurse should follow up with Resident Care Coordinator (RCC) about pending orders or prescriptions in the morning. R#1 was seen by the pulmonologist on 9/23/2020. Physician order [REDACTED].

Based on staff interviews and review of policy titled Patient's Plan of Care, the facility failed to implement the care plan for two residents (R#52 and R#56) related to falls; failed to implement the care plan for one resident (R#11) related to administrating medications as ordered, and the facility failed to follow the care plan for five residents (R#15, R#81, R#21, R#59 and R#83) regarding monitoring of side effects for [MEDICAL CONDITION] medications of 38 sampled residents. This deficient practice caused actual harm to R#52 who experienced a right distal fracture sustained from a fall. Findings include: Review of the facility policy titled Patient's Plan of Care revealed under the section on page one, bullet C titled Interventions that the interventions should be instructions for care that were easily understood by staff and the interventions were to be carried out by staff. 1. Review of the medical record for R#52 revealed the following Diagnosis: [REDACTED]. Review of Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) of 15, indicating no cognitive impairment; required extensive assistance from two persons for bed mobility; was dependent on staff for transfers; was non-ambulatory; and was totally dependent on two-person assistance for toileting. Review of the resident's care plan revealed that the resident had an Activities of Daily Living (ADL) self-care deficit related to the [DIAGNOSES REDACTED]. Continued review revealed that the resident had a stoma with an intervention to provide appropriate level of assistance to maintain patient safety which was initiated on 10/3/18. Further review revealed a high risk to falls due to being immobile and interventions included assisting with ADLs as needed, assist with toileting as needed, and will keep most frequently used personal items and call light in reach. Resident also had impaired physical mobility due to [MEDICAL CONDITION] and required extensive assist to turn and reposition per the care plan that was initiated on 3/6/18. Review of Event Initial Note dated 9/14/18 revealed that 5:45 a.m. that resident was on the floor on knees while hanging on to the assist rails with both hands. It was reported by staff that care was being provided to resident and resident was too close to the edge of bed and when rolled to her right side she fell out of bed. Further review of the Event Note revealed the intervention was instructing staff to move resident to the center of the bed before rolling to make sure that lower extremities are not close to edge of bed. An interview with Administrator and Nurse Consultant QQ on 6/13/19 at 9:24 a.m. revealed that each were able to pull up the information that is found in the Certified Nursing Assistant (CNA) hand-held electronic device related to care for R#52. The handheld device revealed that the physical functioning for bed mobility requires extensive assistance requiring two people to assist R#52. The Administrator reported that at the time of the fall for R#52, this information was available to CNA but not followed The Administrator revealed the bed mobility requirements for R#52 is two persons. Cross refer to F689 2. Review of the medical record for R#56 revealed the following Diagnosis: [REDACTED]. Review of Quarterly MDS assessment dated [DATE] revealed that resident had severe cognitive impairment; required extensive assistance from two persons for bed mobility; was dependent on staff for transfers, dressing and toileting which required two or more people for assistance; not steady when moving from seated to standing position, impairment on one side for both upper and lower extremities, incontinent of both bowel and bladder, and there were no previous falls identified. Review of the resident's care plan revealed that the resident had an Activities of Daily Living (ADL) care plan related to [MEDICAL CONDITIONS] as evidenced by right sided weakness and poor safety awareness with an intervention of out of bed as tolerated in wheelchair and use of Hoyer lift for transfers (onset date of 4/8/19). Continued review revealed a fall risk assessment with interventions of assistance with ADLs as needed, bed in low position, and specialty chair usage. Resident also has impaired physical mobility care plan as evidenced by decreased range of motion (ROM) in ankles, knees, and hip and interventions that included therapy to screen and/or evaluate as need and provide appropriate level of assistance to promote safety of resident. Review of Event Initial Note dated 4/5/19 revealed that at 3:20 p.m. the resident slid from bed while the CNA attempted to adjust the straps on the stand-up lift. As the result of the fall resident had a small wound, the size of a pin hole, with minor bleeding to the left hip. Further review of the form revealed an intervention of using the Hoyer lift instead of the stand-up lift was added. During interview with the Administrator and Nurse Consultant QQ on 6/13/19 at 9:44 a.m., revealed that the information that is provided in the hand-held device for the CNAs is driven by the information that is coded by MDS related to physical functioning. Review of the information in the hand-held electronic devices for R#56 revealed: the last update for physical functioning was on 8/13/18; sit to stand lift on 8/16/18 and was last revised on 4/8/19 with the sling Hoyer being added on 4/8/19 and two people to assist when Hoyer used. Cross refer F689 3. During a resident interview on 6/10/19 at 11:35 a.m. with R#11, the resident revealed that she was not always receiving her medication. She stated that it included the following medications, her blood pressure medication, the medicine for her nebulizer, and her Breo diskus. Review of the Physician Orders revealed an order for [REDACTED]. [MEDICATION NAME] 600 mg tablet, extended release one tablet by mouth two times per day. A review of the care plan revealed that the resident was at risk for respiratory changes related to [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Sets dated 3/11/19 revealed a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. During an interview on 6/12/19 at 1:55 p.m. with LPN II confirmed that the resident's Breo-Ellipta inhaler was not given on 6/9/19, 6/10/19, 6/11/19, or 6/12/19. Interview on 6/12/19 at 4:36 p.m. with the Assistant Director of Nursing (ADON) revealed that it would be her expectation for the physician's order to be followed or a new order obtained. An interview on 6/13/19 at 9:10 a.m. with the ADON confirmed that the Breo-Ellipta was not given on 6/9/19, 6/10/19, 6/11/19, or 6/12/19. Cross reference to F684 4. Review of the clinical record for R#15 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident's care plan initiated 3/29/18 revealed resident was at risk for [MEDICAL CONDITION] drug use. Interventions to care include administer medications as ordered, assess for fall risk, observe for side effects of medications, assess for non-drug interactions, consult with Physician or Pharmacy for medication review, document episodes of refusing care, monitor behaviors as indicated. Review of Physician Orders for R#15 dated 6/13/19 revealed an order for [REDACTED]. Review of the behavior monitoring record dated 4/1/19 through 6/12/19 revealed behavior monitoring of side effects had not been consistently documented on day shift seven (7) times during 4/2019, nine (9) times during 5/2019 and one (1) time during 6/2019. No documented side effects for night shift 13 times during 4/2019, 22 times during 5/2019 and five (5) times during 6/2019. Cross refer to F757 5. Review of the clinical record for R#81 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan initiated 4/15/19 revealed resident was at risk for [MEDICAL CONDITION] drug use. Interventions to care include administer medications as ordered, assess for fall risk, observe for side effects of medications, consult with Physician or Pharmacy for medication review, monitor behaviors as indicated. Review of Physician Orders for R#81 dated 6/13/19 revealed an order for [REDACTED]. Review of the behavior monitoring record dated 4/15/19 through 6/12/19 revealed behavior monitoring of side effects had not been consistently documented on day shift five (5) times during 4/2019, nine (9) times during 5/2019 and three (3) time during 6/2019. No documented side effects for night shift seven (7) times during 4/2019, 22 times during 5/2019 and nine (9) times during 6/2019. cross refer to F757 6. Review of the clinical record for R#21 revealed she was admitted to the facility on [DATE] and has the [DIAGNOSES REDACTED]. Review of Physician Orders for R#21 dated 6/13/19 revealed an order for [REDACTED]. Review of resident's care plan initiated 4/12/19 revealed resident was at risk for [MEDICAL CONDITION] drug use. Interventions to care include administer medications as ordered, monitor behavior as indicated, notify physician as indicated, and observe for possible side effects. Review of the behavior monitoring record dated 4/1/19 through 6/12/19 revealed behavior monitoring side effects had not been consistently documented on day shift seven (7) times during 4/2019, nine (9) times during 5/2019 and one (1) time during 6/2019. No documented side effects for night shift 13 times during 4/2019, 22 times during 5/2019, and five (5) times during 6/2019. Cross refer to F757 7. Review of the clinical record for R#59 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident's care plan initiated 4/3/19 revealed resident was at risk for [MEDICAL CONDITION] drug use. Interventions to care include administer medications as ordered, assess for fall risk, observe for side effects of medications, monitor behavior as indicated, notify Physician as indicated. Review of the Physician Orders for R#59 dated 4/18/19 revealed an order for [REDACTED]. A review of documentation for medication side effects 4/3/19 through 6/13/19 revealed documentation for medication side effects had not been consistently documented on day shift 18 times during 4/2019 and 24 times during 5/2019. There is missing documentation for medication side effect on the night shift 17 times in 4/2019, 32 times in 5/2019, and four (4) times in 6/2019. cross refer to F757 8. Review of the clinical record for R#83 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of resident's care plan dated 1/13/16 revealed resident was at risk for [MEDICAL CONDITION] drug use, related to [MEDICAL CONDITION]. Interventions to care include administer medications as ordered, observe for side effects and behavior as indicated. Review of Physician Orders for R#83 dated 6/13/19 revealed an order for [REDACTED].>Review of the record for medication side effects dated 4/3/19 through 6/13/19 revealed medication side effects had not been documented consistently as follows:, on day shift 10 times in 4/2019 and 32 times in 5/2019. There is missing documentation for medication side effects on the night shift 25 times in 4/2019, 44 times in 5/2019, and six (6) times in 6/2019. Cross refer to F757

Based on record review, staff and resident interviews, and review of policy titled Fall Management and Using a Portable Lifting Machine the facility failed to provide care by two staff members, for R#52, who fell from bed, resulting in actual harm due to fracture of her right distal femur. The facility also failed to provide a consistent process to track and follow up on falls for two of four residents (R) #56 and #15 who have experienced falls. Findings include: 1. Review of the medical record for R#52 revealed the resident was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) of 15, indicating no cognitive impairment; required extensive assistance from two persons for bed mobility; was dependent on staff for transfers; was non-ambulatory; and was totally dependent on two-person assistance for toileting. Review of the resident's care plan revealed that the resident had an Activities of Daily Living (ADL) self-care deficit related to the [DIAGNOSES REDACTED]. Continued review revealed that the resident had a stoma with an intervention to provide appropriate level of assistance to maintain patient safety which was initiated on 10/3/18. Review of the incontinence care plan revealed an intervention to provide appropriate level of assistance to maintain patient safety. Further review revealed a high risk to falls due to being immobile and interventions included assisting with ADLs as needed, assist with toileting as needed, and will keep most frequently used personal items and call light in reach. Resident also had impaired physical mobility due to [MEDICAL CONDITION] and required extensive assist to turn and reposition per the care plan that was initiated on 3/6/18. Review of an Event Initial Note dated 9/14/18 revealed that at 5:45 a.m. the resident was on the floor on knees while hanging on to the assist rails with both hands. The resident was assisted to the floor on her back. The staff member (not identified) stated the resident landed on her knees after rolling off the bed. It was further reported by staff that care was being provided to resident and resident was too close to the edge of bed and when rolled to her right side she fell out of bed. Further review of the event note revealed the intervention was instructing staff to move resident to the center of the bed before rolling to make sure that lower extremities are not close to edge of bed. It was also documented that the staff member was responsible for the incident and education was provided. The event note did not reveal staff involved or evidence of an investigation of the fall and there was no documentation of the education provided to staff involved. The report revealed that the Physician and family were notified of the resident's fall. The Physician ordered bilateral knee x-ray to be completed. Record review of the onsite x-ray dated 9/14/18 revealed Findings: Acute Comminuted fracture distal femur just above the knee. Osteoporotic changes. The results were called to the Physician's on-call Nurse Practitioner with an order to send the resident to the emergency room (ER) for evaluation. Record review of the hospital ER report revealed an x-ray report dated 9/14/18 impression: Traumatic Acute Closed fracture involving the supracondylar region of the distal femur. Osteopenia noted. Recommendation: Right knee immobilizer and follow up with Orthopedic clinic on Tuesday. Review of the Orthopedic clinic progress notes dated 9/27/18 revealed Assessment: Comminuted right distal femur fracture, patient to wear right knee immobilizer, continue non-weight bearing, follow up with Orthopedic clinic in four weeks. Review of the resident's physician progress notes [REDACTED]. An interview with R#52 on 6/12/19 at 8:45 a.m. revealed that she could not remember the last name of the Certified Nursing Assistant (CNA) who was assisting her at the time of her fall on 9/14/18. The resident reported that the CNA was assisting, by herself, with a brief change and when the draw sheet was lifted to help her roll to her right side that she slid off the bed. The resident further revealed that since the fall, most of the time, there are two staff present when providing care for her. An interview on 6/12/19 at 8:35 a.m. with CNA PP revealed that the CNAs utilize a handheld electronic device which indicates what care and services are needed for R#52. Upon reviewing the handheld device for R#52, it showed that two persons are required for assistance with transfers and a Hoyer lift is to be used. An interview with the Administrator on 6/12/19 at 12:42 p.m. revealed that CNA LL was the CNA providing care at the time of the fall for R#52. An interview with the Administrator and the Director of Nursing (DON) on 6/12/19 at 5:39 p.m. revealed that once a fall takes place, the initial report begins the process for documenting. He reported that the charge nurse is responsible for documenting the actual event related to what was going on at the time of the event. They further revealed that each fall is discussed in the morning meeting with the Interdisciplinary Team. The Administrator further revealed that interventions should be initiated after falls and if additional interventions are needed, the DON is responsible for entering. The Administrator reported that the facility had identified that there were issues related to documentation of falls and there had been efforts in place for better follow up. The Administrator revealed that a complete investigation of the fall was not completed and therefore the fall was not included on the falls log. The Administrator revealed that he was aware of what happened during the fall for R#52 and confirmed that only one CNA was providing care. The DON reported that there should be three days of follow up documented after each fall although was not completed for this fall. An interview conducted on 6/13/19 at 6:21 a.m. revealed that CNA LL confirmed that she was the only CNA working with R#52 at the time of the fall on 9/14/18. CNA LL reported that it was her understanding, before the fall, that R#52 only required one person for bed mobility and ADL care. She revealed that the CNA's use a handheld device to inform them of the type of care needed for each resident and how much help is needed. She further revealed that after the fall the resident required two people to assist for care. CNA LL reported receiving a verbal reprimand and being informed to always have two people when assisting resident but denies receiving any training or education. CNA LL further reported that she continued to work with the resident for a month before she was instructed that she could no longer provide care for R#52. An interview on 6/12/19 at 9:01 a.m. with the Administrator revealed that after the fall on 9/14/18 an investigation was conducted but the information was not written down. Interview with the Administrator and Nurse Consultant QQ on 6/13/19 at 9:24 a.m. related to how CNAs identify what needs are required for residents. The Administrator and Nurse Consultant each able to pull up the information that is found in the CNA hand-held electronic device related to care for R#52. It revealed that the physical functioning for bed mobility requires extensive assistance requiring two people to assist R#52. The Administrator reported that at the time of the fall for resident, this information was available to CNA LL but not follow and therefore the CNA was written up. A post survey telephone interview on 6/25/19 at 11:05 a.m. with the Administrator revealed that the paper admission nursing assessment for R#52, conducted 2/17/17, did not include the number of staff needed for bed mobility or transfer. He further revealed that the facility went to an electronic medical record system in 1/2018 and all current residents were re-assessed for the electronic medical record (EMR) which included the number of staff needed for transfers and what type of transfer should be used for each resident. The Administrator further revealed that the Electrical/Mechanical Lift Skills Check-off form is used upon hire to confirm that the CNAs knew how to use the lifts although the number of staff needed is contained in the handheld electronic devices that all CNA's use for documenting and reference of care needed/given to each resident. He further revealed that CNA LL, who was caring for R#52 when she fell from bed, was reprimanded and re-educated for not following the assessment in the handheld device resulting the resident fall and fracture. 2. Review of the facility Using a Portable Lifting Machine policy revealed that the patient's plan of care or nurse's clinical judgement should direct if a lift should be used, which type lift is appropriate, and the amount of support required staff should receive educational and complete skills check-off prior to use of lifting equipment. Review of the medical record for R#56 revealed the following Diagnosis: [REDACTED]. Review of Quarterly MDS assessment dated [DATE] revealed that resident had severe cognitive impairment; required extensive assistance from two persons for bed mobility; was dependent on staff for transfers, dressing and toileting which required two or more people for assistance; not steady when moving from seated to standing position, impairment on one side for both upper and lower extremities, incontinent of both bowel and bladder, and there were no previous falls identified. Review of the resident's care plan revealed that the resident had an Activities of Daily Living (ADL) care plan related [MEDICAL CONDITION] evidenced by right sided weakness and poor safety awareness with an intervention of out of bed as tolerated in wheelchair and use of Hoyer lift for transfers (onset date of 4/8/19). Continued review revealed a fall risk assessment with interventions of assistance with ADLs as needed, bed in low position, and specialty chair usage. Resident also has impaired physical mobility care plan as evidenced by decreased range of motion (ROM) in ankles, knees, and hip and interventions that included therapy to screen and/or evaluate as need and provide appropriate level of assistance to promote safety of resident. Review of Event Initial Note dated 4/5/19 revealed that at 3:20 p.m. resident slid from bed while the CNA attempted to adjust the straps on the stand-up lift. As the result of the fall resident had a small wound the size of a pin hole with minor bleeding to the left hip. Further review revealed an intervention of using the Hoyer lift instead of the stand-up lift was added. The event note did not reveal the names of involved staff. Review of the event follow up notes revealed that there was no documentation on each shift for three days following the fall. An interview on 6/12/19 at 4:27 p.m. with Licensed Practical Nurse (LPN) NN revealed that she did not remember all of the details of the fall for R#56 but remembered that the fall was related to the CNA trying to get the resident in the lift. LPN NN could not remember the name of the CNA but reported there was only one CNA assisting the resident and using the lift at the time of the fall. Interview on 6/13/19 at 8:20 a.m. with the Administrator, DON, Nurse Consultant BB and Nurse Consultant QQ identified that CNA MM was involved with the fall for R# 56. An interview with the Administrator and Nurse Consultant QQ on 6/13/19 at 9:44 a.m. revealed that the information that is provided in the hand-held device for the CNAs, is driven by the information that is assessed by the MDS related to physical functioning. Review of the information in the hand-held electronic devices for R#56 revealed: the last update for physical functioning was on 8/13/18; sit to stand lift on 8/16/18 and was last revised on 4/8/19 with the sling Hoyer being added on 4/8/19 and two people needed to aid with care. An interview on 6/13/19 at 2:54 p.m. with CNA MM revealed that she was transferring the R#56 and resident slid off the edge of the bed. CNA MM reported that typically two people assisted resident whenever the stand-up lift was being used, but acknowledged that the day of the fall, she was assisting the resident alone. CNA MM reported that after the fall she does not remember any in-services about use of the lifts but revealed that she was informed that there must be two people present when using lifts. CNA MM reported that she was trained to use lift by another CNA. Review of the facility Falls Management policy revealed that all residents would be assessed for fall risks falls would be presented in the morning interdisciplinary meeting to ensure proper actions have been taken and documentation is accurate and complete the resident's care plan would be reviewed and revised the event management report to be entered in the event database for tracking and trending the resident would be assessed at least every shift for 72 hours or until the patient is stable and document assessment findings in the resident's medical record. 3. Review of the clinical record for R#15 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, indicating no cognitive impairment. Section G revealed total dependence for bed mobility and transfers with two plus persons. Review of R#15 initial Nursing Admission Assessment completed on 10/26/16, revealed on page three (3) section Activities of Daily Living (ADL) transfer-indicated dependent; page four (4) patient's level of mobility functioning on admission revealed the resident was dependent with the assistance of two or more staff for chair/bed to chair transfer. Review of the resident's care plan initiated 12/14/18 revealed resident was at risk for impaired physical mobility. Interventions to care include provide appropriate level of assistance to promote safety of resident. Review of Event Initial Note dated 4/27/19 at 1:10 p.m. revealed that resident was assisted out of bed by two (2) certified nursing assistants (CNA's) with a stand-up lift and resident slid out of lift to floor. The event note did not indicate which staff members were involved, or any interventions that were implemented as result of the fall. An interview on 6/12/19 at 9:01 a.m. with the Administrator revealed that the only documentation the facility does for falls is in the electronic medical record (EMR), which is the Event Initial Note. He stated the facility does an investigation for each incident/fall but does not do any type of documentation on paper or in the EMR to show what happened, which staff were involved, the root cause of incident or interventions that were put in place. He further stated the Event Initial Note should trigger the 72-hour follow-up in the EMR. He further stated once the 72-hour follow-up is completed, the incident transfers over to fall/incident log. He verified that R#15 did not have any follow-up documentation to her fall on 4/27/19. He further stated that because the facility did not complete the 72-hour follow-up, the incident/fall did not get transferred to the fall/incident log. An interview on 6/12/19 at 9:33 a.m. with Certified Nursing Assistant (CNA) CC revealed that he remembered when R#15 fell in (MONTH) 2019. He revealed that CNA EE came to get him to help her with R#15, when her foot slipped off the sit to stand lift. He stated that when he entered the room, resident was on the lift, with her feet on the floor, and the sling was around her armpits. He further stated that he and CNA EE lowered the resident to the floor, to aid in getting her back in the bed. An interview on 6/12/19 at 1:24 p.m. with CNA DD, stated that she has received training on the use of the sit to stand lift and the Hoyer lift and that she had a skills check-off on the demonstration of the lift. CNA DD demonstrated from the handheld device which indicated that R#15 required two (2) plus persons for transfers. A telephone interview on 6/12/19 at 1:36 p.m. with CNA EE revealed that she remembered the incident and fall for R#15 with the lift. She revealed that she gets the resident up by herself using the sit to stand lift, because resident is afraid of the Hoyer lift. She stated that she was getting the resident out of bed by herself on 4/27/19, using the sit to stand lift, when the residents right foot slipped off the footrest of the sit to stand lift. She further revealed that she left the resident hanging from the lift, with the harness under her armpits, while she went to get help from CNA CC. She further revealed that they lowered resident to the floor and used the Hoyer lift to place resident back in the bed. Review of the in-service training dated 10/9/18 related to transfers and bed mobility and transfers using mechanical lifts, revealed that CNA EE attended both trainings. Review of the Electrical/Mechanical Lift Skills Check-Off for CNA EE, revealed she had return demonstration on 4/11/19, checked off by Licensed Nursing staff. Interview on 6/12/19 at 4:04 p.m. with the Administrator revealed that they discuss all falls in the morning stand up meetings. They discuss interventions that have been placed and whether they are appropriate. He stated that the Director of Nursing (DON) is the responsible for doing the follow-up to the fall and then she passes it on to him to do a final follow-up. He stated there is no documentation to reflect the facility staff investigated the fall, determined the root cause or any statements from staff or approved interventions. He verified that R#15 fall from 4/27/19 was not indicated on the fall/incident log for the past nine months. An interview on 6/13/19 at 2:48 p.m. with Nurse Consultants BB and QQ along with the DON revealed that the admitting nurse decides if a lift is needed for the resident and which type of lift is to be used after the admission assessment. There is no re-evaluation process unless a resident has a tremendous decline, and then a referral would be made for therapy to evaluate and that evaluation could consist of an appropriate lift to use. A post survey interview with the Administrator on 6/25/19 at 11:13 a.m. revealed that the facility does not have a lift policy although the facility refers to the lift manufacture's recommendation. He revealed that the facility has always used two person when a lift is utilized for transfer of a resident and that on the CNA's handheld device it specifies what type of lift should be used and that two persons are needed.

Based on record review, staff interviews and policy review titled Pharmacy Services [MEDICAL CONDITION] Medications the facility failed to consistently document monitoring of side effects for behaviors for five of seven residents (R#15, R#81, R#59, R#83, R#21), who were receiving [MEDICAL CONDITION] medications. Findings include: Review of the policy titled Pharmacy Services [MEDICAL CONDITION] Medications, updated (MONTH) (YEAR), revealed the intent is patients who receive antipsychotic, sedative, hypnotic, antidepressant or any other medication prescribed to modify behavior (such as antiepileptic medications and [MEDICATION NAME]) are evaluated to determine the effectiveness of the medication for the identified problems. Guideline 2. Monitoring of [MEDICAL CONDITION] Medications when [MEDICAL CONDITION] therapy is initiated, the patient is monitored quantitatively and qualitatively to determine the effectiveness of the medication and the presence of side effects. Review of Consultant Pharmacist review for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) 2019, (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019 revealed Special notes: watch for holes on the behavior and side effect monitoring across all units-this is a widespread problem. 1. Review of the clinical record for R#15 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, indicating no cognitive impairment. Section D revealed feeling down, depressed or hopeless; trouble falling or staying asleep; feeling tired or having little energy; poor appetite or overeating; feeling bad about self. Section [NAME] revealed other behavior symptoms not directed towards others. Review of resident's care plan initiated 3/29/18 revealed resident was at risk for [MEDICAL CONDITION] drug use. Interventions to care include administer medications as ordered, assess for fall risk, observe for side effects of medications, assess for non-drug interactions, consult with Physician or Pharmacy for medication review, document episodes of refusing care, monitor behaviors as indicated. Review of Physician order [REDACTED]. Review of the behavior monitoring record dated 4/1/19 through 6/12/19 revealed behavior monitoring of side effects had not been consistently documented on day shift seven (7) times during 4/2019, nine (9) times during 5/2019 and one (1) time during 6/2019. No documented side effects for night shift 13 times during 4/2019, 22 times during 5/2019 and five (5) times during 6/2019. 2. Review of the clinical record for R#81 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 8, indicating moderate cognitive impairment. Section D revealed no moods exhibited and Section [NAME] revealed no behaviors exhibited. Review of the resident's care plan initiated 4/15/19 revealed resident was at risk for [MEDICAL CONDITION] drug use. Interventions to care include administer medications as ordered, assess for fall risk, observe for side effects of medications, consult with Physician or Pharmacy for medication review, monitor behaviors as indicated. Review of Physician order [REDACTED]. Review of the behavior monitoring record dated 4/15/19 through 6/12/19 revealed behavior monitoring of side effects had not been consistently documented on day shift five (5) times during 4/2019, nine (9) times during 5/2019 and three (3) time during 6/2019. No documented side effects for night shift seven (7) times during 4/2019, 22 times during 5/2019 and nine (9) times during 6/2019. Interview on 6/12/19 at 4:33 p.m. with Licensed Practical Nurse (LPN) AA revealed that part of her responsibilities as the nurse is to give medications and documentation. She stated that she does behavior monitoring once per shift on residents who are receiving [MEDICAL CONDITION] medications. She further stated that she reports to the Director of Nursing if residents exhibit behaviors that are unusual for them. Interview on 6/13/19 at 8:46 a.m. with Director of Nursing (DON) revealed that she had previously identified an issue with incomplete documentation for behavior monitoring but stated she cannot remember when she identified it. She stated she gets alerts from the Electronic Medical Record (EMR) system for incomplete data entry but stated that the system does not identify whether all fields have been completed. She stated her expectation is that nurses document behavior monitoring and side effects of medications every shift. Interview on 6/13/19 at 8:50 a.m. with Nurse Consultant BB stated that the EMR identifies when nurses document zero for episodes, but it does not identify that boxes are left blank. She further stated that the previous process was not effective, and therefore would need to be re-evaluated. Interview on 6/13/19 at 12:05 p.m. with the Administrator revealed his expectation is for documentation related to behaviors and medication side effects include consistency of documentation every shift and every day. 3. Review of the clinical record for R#59 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The residents Quarterly Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, indicating mild cognitive impairment. Section D revealed no moods exhibited and section [NAME] revealed no behaviors documented. Review of resident's care plan initiated 4/3/19 revealed resident was at risk for [MEDICAL CONDITION] drug use. Interventions to care include administer medications as ordered, assess for fall risk, observe for side effects of medications, monitor behavior as indicated, notify Physician as indicated. Review of the Physician order [REDACTED]. A review of documentation for medication side effects 4/3/19 through 6/13/19 revealed documentation for medication side effects had not been consistently documented on day shift 18 times during 4/2019 and 24 times during 5/2019. There is missing documentation for medication side effect on the night shift 17 times in 4/2019, 32 times in 5/2019, and four (4) times in 6/2019. 4. Review of the clinical record for R#83 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The residents most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not conducted, indicating a cognitive level of severely impaired. Section D revealed no moods exhibited and section [NAME] revealed physical behavioral symptoms directed toward others occurred four (4) to six (6) days but less than daily, verbal behavior directed toward others occurred one (1) to three (3) days, other behavior symptoms not directed toward others occurred four (4) to six (6) days, but less than daily. Review of resident's care plan dated 1/13/16 revealed resident was at risk for [MEDICAL CONDITION] drug use, related to [MEDICAL CONDITION]. Interventions to care include administer medications as ordered, observe for side effects and behavior as indicated. Review of Physician order [REDACTED]. Review of the record for medication side effects dated 4/3/19 through 6/13/19 revealed medication side effects had not been documented consistently, on day shift 10 times in 4/2019 and 32 times in 5/2019. There is missing documentation for medication side effects on the night shift 25 times in 4/2019, 44 times in 5/2019, and six (6) times in 6/2019. 5. Review of the clinical record for R#21 revealed she was admitted to the facility on [DATE] and has the [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, indicating no cognitive impairment. Section D revealed feeling down, depressed or hopeless; trouble falling or staying asleep; feeling tired or having little energy; poor appetite or overeating; feeling bad about self. Section [NAME] revealed other behavior symptoms not directed towards others. Review of resident's care plan initiated 4/12/19 revealed resident was at risk for [MEDICAL CONDITION] drug use. Interventions to care include administer medications as ordered, assess for fall risk, assess for non-drug interventions, document episodes of refusing requested care, monitor behavior as indicated, notify physician as indicated, and observe for possible side effects. Review of Physician order [REDACTED]. Review of the behavior monitoring record dated 4/1/19 through 6/12/19 revealed behavior monitoring side effects had not been consistently documented on day shift seven (7) times during 4/2019, nine (9) times during 5/2019 and one (1) time during 6/2019. No documented side effects for night shift 13 times during 4/2019, 22 times during 5/2019, and five (5) times during 6/2019.

Based on record review, resident interview, staff interview, and review of policies titled Pharmacy Services and Medication Unavailable for Administration, the facility failed to ensure that one resident (R#11), of 38 sampled residents, received medication as ordered by the Physician. Findings include: Review of the facility policy titled Pharmacy Services documented that the intent of the policy was to obtain medications in a timely manner for proper administration to the patient. Under item three on page one, the policy revealed that medication that must be reordered by the nurse included medications that were not in a tablet form or a capsule (for example, inhalers, and creams). A review of the facility policy titled Medication Unavailable for Administration documented that the provider pharmacy may assist in obtaining the medication from a back-up pharmacy, if available or may send the medication by STAT delivery. The policy also documented that any time a medication was not available the nurse would notify the prescriber and obtain a hold until medication available from pharmacy order, a discontinuation order or a change order. An interview with R#11 on 6/10/19 at 11:35 a.m. revealed that she was not always receiving her medication. She stated that it included the following medications, her blood pressure medication, the medicine for her nebulizer, and her Breo diskus. She stated that this had happened several times. She stated that she had reported it but couldn't give a specific name of who she reported the problem. Review of the Physician Orders revealed an order for [REDACTED]. [MEDICATION NAME] 600 mg tablet, extended release one tablet by mouth two times per day and [MEDICATION NAME] (Tylenol) 625 mg extended release twice daily. A review of the care plan revealed that the resident was at risk for respiratory changes related to [DIAGNOSES REDACTED]. A review of the Quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. An interview on 6/12/19 at 10:15 a.m. with Licensed Practical Nurse (LPN) HH revealed that the green O on the Medication Administration Record [REDACTED]. She stated that if you hover over the X or O the name of the nurse was documented. A second interview with the resident on 6/12/19 at 10:30 a.m. revealed that she was told that she did not receive all her medicine last night. Review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. There were two doses of Tylenol (both doses were documented as not given by LPN II) documented as not being given at 8:00 a.m. on 5/1/19 and 5/6/19. Both missed doses of medication documented that the medication was on order. One dose of [MEDICATION NAME] 600 mg (documented as not given by LPN II) was not given on 5/4/19 at 8:00 a.m. and the MAR indicated [REDACTED] An interview on 6/12/19 at 1:55 p.m. with LPN II revealed that when the resident's Breo-Ellipta ran out he called the pharmacy on Monday. He was told that it was too soon to refill the inhaler. He stated that he was told they would send it on Wednesday. LPN II called the pharmacy during the interview and they confirmed that the inhaler would be at the facility this evening. When asked why it ran out he said that he did not know. He confirmed that the medicine was not given on 6/9/19, 6/10/19, 6/11/19, or 6/12/19. An interview on 6/12/19 at 4:35 p.m. with the Assistant Director of Nursing (ADON) revealed that the process for reordering medication included clicking a button on the electronic MAR indicated [REDACTED]. She stated that the nurses were responsible for reordering medications and/or of notifying the Physician that it couldn't be refilled, if it was too soon for refill. She stated that if it was too soon for the medication to be refilled, her expectation was that the nurse would notify the Physician and clarify how the Physician wanted it handled. The ADON revealed that she could not explain why R#11 went four days without her inhaler. An interview with the ADON on 6/13/19 at 9:10 a.m. confirmed that the Breo-Ellipta was not given on 6/9/19, 6/10/19, 6/11/19, or 6/12/19. She stated that after investigation, she found the reason why the resident did not receive her medication as ordered was the policy for reordering medication was not followed.