Every finding on record at Christian Health Center

Based on observation, interview, record review, and facility policy review. it was determined the facility failed to ensure care plan interventions were implemented for one (1) of twenty (20) sampled residents (Residents #56). Resident #56 was care planned to receive oxygen (O2) at two (2) liters per minute (lpm); however, observations revealed Resident #56's oxygen concentrator was set at 1.5 LPM or 2.5. The findings include: Review of the facility's policy titled, Care Plan, Comprehensive, last revised July 2013, revealed an individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. However, the policy did not address the implementation of care plan interventions. Record review revealed the facility admitted Resident #56 on 10/21/17, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/16/2020, revealed the facility assessed Resident #56's cognition as not intact with a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was not interviewable. Review of Resident #56's Comprehensive Care Plan for [MEDICAL CONDITION], dated 08/09/19, revealed an intervention to provide O2 at two (2) lpm per nasal cannula (n/c), as needed (PRN). However, observations on 03/09/19 at 11:25 AM and 12:34 PM, revealed Resident #56's O2 cannula was in place and O2 was turned on with a reading of 1.5 lpm. Further observations on 03/10/2020 at 8:38 AM and on 03/11/2020 at 8:22 AM, revealed Resident #56's O2 cannula was in place and O2 concentrator was turned on with a reading of 2.5 lpm. Interview with Registered Nurse (RN) #1 on 03/11/2020 at 8:45 AM, revealed Resident #56's O2 was care planned to be on at two (2) lpm. She stated the nurse should check the O2 concentrator at least once per shift to ensure correct setting. RN #1 further revealed staff should follow what is on the resident's care plan while providing daily care. Phone interview with RN #3 on 03/11/20 at 1:39 PM, revealed she could not recall Resident #56's exact order for O2 setting but she recalled checking the O2 concentrator on the morning of 03/10/2020 and again that afternoon before she gave the resident pain medication. She acknowledged care plans should be followed. Interview with the Director of Nursing (DON) on 03/11/19 at 2:46 PM, revealed licensed nurses were responsible for ensuring the care plan were followed related to administering O2.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure two (2) of three (3) residents who were incontinent of bladder in the select sampled of twenty (20) residents received appropriate treatment and services to prevent urinary tract infections to the extent possible (Residents #23 and #66). Observations of incontinent care for Resident #23 and Resident #66 revealed staff failed to follow its policy regarding incontinence care, bladder/perineal care and infection control by contaminating the cleaning process and using improper handwashing techniques. The findings include: Review of the facility policy titled, Incontinence Care, Bladder/Perineal Care, last revised August 2016, revealed the purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Further review of the policy revealed instructions to apply soap or skin cleansing agent to clean washcloth and wash periarea using clean technique, remove the disposable gloves, discarding them into designated container, and to wash hands after pericare has been provided and prior to reposition the covers or touching any other surfaces in patient area. 1. Record review revealed the facility admitted Resident #23 on 11/02/16, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/17/19, revealed the facility assessed Resident #23's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Review of Resident #23's Comprehensive Care Plan for at risk for infection and at risk for injury related to right sided [MEDICAL CONDITION] and has a urinary tract infection dated 11/3/16, revealed an intervention to provide incontinence care after each episode per facility protocol and according to standards of care. Observation of perineal (peri) care on 03/11/2020 at 9:49 AM, for Resident #23 revealed State Registered Nurse Aide (SRNA) #1 soiled her gloves, and placed the dirty washcloth back in the water basin that she used for pericare, then picked up a clean washcloth soaking in the contaminated water, and continued providing peri care. SRNA #1 then proceeded to change the water in the basin, leaving her soiled gloves on. SRNA #1 touched the bedding and turned the resident without changing her soiled gloves. After finishing repositioning Resident #23, SRNA #1 removed her gloves without washing her hands, then picked up the trash and left the room without washing her hands. Interview with SRNA #1 on 03/11/20 at 10:18 AM revealed placing the dirty washcloth in water with clean washcloths was an infection control issue and could contribute to the resident developing an UTI. She stated she should have removed her gloves immediately after they became soiled, and washed her hands. Interview with Registered Nurse (RN) #2 on 03/11/20 at 10:37 AM, revealed placing soiled washcloths back into the water basin and wetting clean washcloths or reusing any washcloths in this water basin would be a cross contamination and infection control issue and may contribute to the development of an UTI. Interview with Director of Nursing (DON) on 03/11/20 at 02:41 PM, revealed CNA's were responsible for pericare and she expected them to use infection control protocols to prevent cross contamination and infection during pericare. The DON stated she expected the CNA's to not put a soiled washcloth back in the water basin after using, to change gloves, empty basin if contaminated, and take soiled gloves off at bedside to ensure proper sanitation and infection control. 2. Record review revealed the facility admitted Resident #66 on 05/22/14 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 02/04/2020, revealed the facility assessed Resident #66's cognition as intact with a BIMS' score of fifteen (15) which indicated the resident was interviewable. Interview with Resident #66 on 03/10/20 at 9:13 AM revealed she has an UTI because staff do not clean him/her often enough, and he/she had been on antibiotics for the last seven (7) days and continues to have symptoms of itching and burning. Review of Resident #66's Comprehensive Care Plan for at risk and has history of actual impaired skin integrity with occasional moisture associated skin damage revealed interventions to check for incontinence every two (2) hours and at night; and, to provide pericare, clean and dry skin if wet or soiled. Observation of Resident #66's pericare on 03/11/2020 at 5:35 PM revealed SRNA #1 failed to use infection control measures when he/she touched the wipes container with soiled gloved hand and used that same soiled glove hand to continue giving pericare to resident. Further observation revealed SRNA #1 did not remove glove after performing pericare and proceeded to touch the resident's linen, bedside dresser, and bedpan, before finally removing the soiled glove. Interview with SRNA #1 on 03/11/20 at 10:16 AM revealed she should have pulled soiled gloves off after touching resident's periarea and before touching the container of wipes and returning to provide pericare. She stated it was the facility's policy and it violated infection control procedure when she touched Resident #66's bed linens, dresser, and bed pan, before taking the soiled glove off. She stated these actions could contribute to UTI's in residents. Interview with RN #2 on 03/11/20 at 10:43 AM, revealed it was a cross contamination and infection control issue for a staff member to use soiled gloved hand to touch wipes container and then retouch resident's peri area with same gloved hand. She stated touching other items such as residents dresser, bed linens and bed pan before removing soiled glove was also an infection control and cross contamination issue and was not an acceptable standard of practice. Interview with DON on 03/11/20 at 02:41 PM, revealed once a staff's gloved hand giving pericare is lifted off the perineal area, it is considered soiled and gloves need to be removed, hands washed, and hands re-gloved before continuing pericare area care and touching any other objects, for example, wipes container, linens, dresser or bed pan. She stated touching any object with soiled glove is an infection control issue and is not standard protocol and that staff has been educated numerous times on facility policy and standards of care. She revealed she expected staff to follow facility policy and standard precautions when providing any care to residents.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide oxygen (O2) therapy according to the physician's orders [REDACTED].#56). Observations on 03/09/2020, 03/10/2020, and 03/11/2020, revealed staff failed to administer O2 at 2 liters per minute (lpm) via nasal cannula (n/c) for Resident #56, as ordered. The findings include: Review of the facility's policy, Oxygen Therapy - Concentrator, last revised 01/23/2012, revealed oxygen therapy is administered only as ordered by a physician or as an emergency intervention until an order can be obtained. The physician's orders [REDACTED].g., cannula, mask, etc. and the rate of flow of oxygen. The policy further revealed before administering oxygen, and while the resident is receiving oxygen therapy, assessments should be completed to include vital signs and to check the oxygen concentration. Record review revealed the facility admitted Resident #56 on 10/21/17, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/16/2020, revealed the facility assessed Resident #56's cognition as not intact with a Brief Interview for Mental Status (BIMS) score of ninety-nine (99), which indicated the resident was not interviewable. Review of Resident #56's Comprehensive Care Plan for [MEDICAL CONDITION], dated 08/09/19, revealed an intervention to provide O2 at two (2) lpm per n/c, as needed. Review of Resident #56's physician's orders [REDACTED].> 90 %, as needed (PRN). Observations on 03/09/19 at 11:25 AM and 12:34 PM, revealed Resident #56's was wearing n/c to nares with O2 turned on and set at 1.5 lpm. Observations on 03/10/2020 at 8:38 AM and on 03/11/2020 at 8:22 AM, revealed Resident #56's was wearing n/c to nares and O2 was turned on and set at 2.5 lpm. Interview with Registered Nurse (RN) #1 on 03/11/2020 at 8:45 AM, revealed Resident #56's O2 was ordered to be on 2 lpm. She stated nurses should check O2 settings at least once per shift to ensure correct settings. RN #1 further revealed staff should follow what is on the resident's care plan and physician's orders [REDACTED].>Phone interview with RN #3 on 03/11/20 at 01:39 PM, revealed she could not recall the exact order for the O2 settings for Resident #56 but she recalled checking the machine and O2 level on the morning of 03/10/2020 and again that afternoon before she gave the resident pain medication. She stated care plans and physician's orders [REDACTED]. She made mention that looking at the setting on the machine can be subjective to person's looking and their position when eyeing it and maybe she should pay more attention to ensure the settings are on the line at the appropriately ordered mark. Interview with the Director of Nursing (DON) on 03/11/19 at 2:46 PM, revealed the licensed nurses were responsible for verifying physician orders [REDACTED]. She stated she expected the nurses to follow physician orders [REDACTED].

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs used in the facility were labeled in accordance with currently accepted professional principles. On 03/09/2020, observation of the medication room refrigerator revealed one (1) vial of [MEDICATION NAME] ([MEDICATION NAME] protein derivative) solution opened and expired. The findings include: Review of the facility's policy titled, Storage and Expiration of Medications, Biological's Syringes, and Needles, last revised 10/31/2016, revealed the facility shall not use outdated drugs or biological's and all such drugs shall be returned to the dispensing pharmacy or destroyed. Observation of the refrigerator in the 100 hall medication room, on 03/09/2020 at 3:36 PM, revealed a vial of [MEDICATION NAME], dated opened on 02/04/2020. However, the medication expired thirty (30) days after opening (03/05/2020); and it was still available for use. Interview with Licensed Practical Nurse (LPN) #1, on 03/09/2020 at PM, revealed the vial of [MEDICATION NAME] should have been discarded because it expired after thirty (30) days. She stated all nursing staff were taught during their orientation to date multi-dose medications and to dispose of expired medications. Interview with the Director of Nursing (DON), on 03/11/2020 at 2:31 PM, revealed she expected the nurses to discard expired medications such as [MEDICATION NAME] because the solution expires thirty days after opening. She stated nursing staff are educated on expiration dates of medications during their orientation upon hire.

Based on observation, interview, record review, and review of the facility's policies/procedures, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for six (6) of twenty-eight (28) sampled residents (Residents #1, #9, #23, #56, #85, and #94). Observation during the survey revealed Registered Nurse (RN) #1 removed medication from a package with her bare hands and put the medication on top of the medication cart prior to administration. Also, during a PEG Tube medication pass, RN #1 did not wash her hands prior to donning gloves. The plunger (of the syringe) used to administer the PEG Tube medication was on the Resident #85's bare stomach, and she proceeded to use the plunger. In addition, observation of Resident #1's wound care, on 12/12/18, revealed RN #1 failed to provide infection control measures before, during, and after wound care. Furthermore, the facility failed to ensure proper perineal care was provided for Resident #94. The findings include: Review of the facility's policy and procedure, titled Infection Control Policy, last revised (MONTH) (YEAR), revealed the goals of the Infection Control Program were to provide a safe, sanitary and comfortable environment and to help prevent development and transmission of disease and infection. 1. Record review revealed the facility admitted Resident #85 on 04/11/05 with [DIAGNOSES REDACTED]. Observation, on 12/12/18 at 8:15 AM, revealed the resident was in bed awake, and was alert and oriented. Interview with the resident revealed he/she had no concerns at this time. Observation of Resident #85's medication administration, on 12/12/18 at 8:15 AM, revealed RN #1 prepared medications for administration via a PEG Tube and laid the pills on top of the medication cart. She transferred the pills from the package to the medication cup with her bare hands, dropped one (1) package of medication in the side disposal bin of the medication cart, and took the medication out and administered medication through the resident's PEG Tube without washing her hands, or donning gloves. Further observation revealed she laid the plunger of the syringe, used to administer the medications, on the resident's bare abdomen. Interview with RN #1, on 12/13/18 at 8:49 AM, revealed she put the pill in her bare hand, and stated this was what they do all the time. She stated it could be an infection control issue laying the plunger on the resident's stomach, when administering the PEG Tube medications. Interview with the Director of Nursing (DON), on 12/13/18 at 9:00 AM, revealed her expectations were that the nurse should wash his or her hands before administering medications, and dispose of medications that were on top of the medication cart. She stated if the pill became contaminated in any way, dispose of it and pull a new pill. She also stated not to take any pill out of the package with his or her bare hands, use proper infection control practices during administration of tube medications, and not let the syringe touch the resident. Interview with the Assistant Director of Nursing (ADON)/Staff Development Coordinator (SDC)/Infection Control (IC) Nurse, and Unit Manager (UM) of Unit 100, on 12/13/18 at 8:35 AM, revealed infection control was part of the scheduled inservices. She revealed when an issue was identified, the staff received education related to the deficient practice. She stated new employees received infection control education during orientation and inservice education was provided several times throughout the year. She stated the big inservice was held in (MONTH) for all staff. She revealed it was her expectation the nurse would not lay a pill on top of the medication cart, or remove the pill from the package with her bare hands. She stated she expected the nurse to wash his or her hands before donning gloves to administer tube medications. Interview with the Administrator, on 12/13/18 at 9:00 AM, revealed her expectation was infection control procedures would be followed by everyone, and not following the process would not be tolerated. 2. Review of the facility policy, Wound Care, dated (MONTH) 1998 and updated (MONTH) (YEAR), revealed this procedure may involve potential and/or direct exposure to blood, body fluids, infectious diseases, air contaminants, and hazardous chemicals. The procedure is to provide guidelines for the care of wounds to promote healing. Protective barriers include handwashing, gloves, gown, designated waste disposal, mask goggles and face shield. Equipment needed included gloves, dressing material, disposable cloths, antiseptic as order and personal protective equipment. Steps include: 1. Wash your hands thoroughly before beginning the procedure. 2. Assemble the equipment and supplies necessary to perform the procedure. Date and initial all bottles and jars upon opening. Wipe all nozzles, foil packets, bottle tops, etc., with alcohol pledget before opening. 3. Proceed to the resident's room with the equipment and supplies. 4. Knock before entering the room. 5. Identify yourself and ask the resident's permission to perform the procedure. 6. Explain the procedure. 7. Close the door. 8. Pull the cubicle curtain around the bed for privacy. 9. Use disposable cloth to establish clean field. Place clean field on resident's over bed table. If table is soiled, wipe with clean towel. All items for reuse must be placed back on the clean field after use. 10. Place all items to be used during procedure on the clean field. 11. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 12. Put on exam glove. Loosen tape and remove dressing. 13. Pull glove over dressing and discard into appropriate receptacle. Wash hands. 14. Wear exam gloves for holding gauze to catheter irrigation solutions that are poured directly over the wound. 15. Wear sterile gloves for new or deep wound, wounds which bleed, when physically touching the wound, or holding a moist surface over the wound. 16. Dress wound. Mark tape with initials, time, and date and apply to dressing. 17. Be certain all clean items are on clean field. 18. Place barrier cloth and soiled items into designated container. Remove gloves and discard into designated container. Wash your hands. 19. Use clean field saturated with alcohol to wipe over bed table. 20. Wipe items with alcohol as indicated, (i.e., outside of containers that were touched by unclean hands, scissor blades etc.). 21. Wash your hands. Record review revealed the facility admitted Resident #1 on 03/26/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 11/23/18, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was interviewable. Review of Section M, for skin conditions, revealed the resident had one (1) stage two (2) pressure ulcer. Review of the Physician's order, dated 12/04/18, revealed cleanse with Normal Saline (NS), pat dry, and apply a small polymen shape dressing to the open wound. Review of the care plan for skin integrity, pressure ulcer to pelvic region stage two (2) active status, revealed impaired skin will show no signs of infection through next review, goal date 02/20/18, and treatment per Physician's orders. Observation of wound care for Resident #1, on 12/12/18 at 11:47 AM, provided by RN #1, revealed she sanitized her hands with hand gel at the nurse's station, prior to entering Resident #1's room. She knocked on the door, repositioned the bed, repositioned Resident #1 over on his/her side, removed a pillow from the resident's back, placed the pillow at the top of the bed, and laid wound care supplies on top of the resident's pillow. She then pulled the privacy curtain, unattached the resident's brief, and applied gloves on both hands, without washing her hands. The RN removed the resident's soiled dressing, and laid the soiled dressing on the resident's cloth pad. She removed the right glove after removing the soiled dressing, applied a new glove obtained from the resident's pillow, without washing her hands. She applied a new glove to the right hand, washed the resident's wound area with NS and opened a dressing package, applied a new dressing to an area on his/her buttocks after applying the dressing to the coccyx area, all done with the same gloves. She picked up the soiled bandage supplies with her gloved right hand and repositioned the resident. She placed a pillow under the resident's back side with the same dirty glove, placed the same cloth pad back under the resident, removed her gloves, and wadded up the soiled supplies in her bare hand. She left the room, and used a hand gel out of a dispenser outside of the resident's room. Interview with RN #1, on 12/12/18 at 12:15 PM, revealed there was nothing she would have done differently regarding the care she provided for Resident #1. She stated, people are obsessed with washing their hands and changing their gloves. She revealed she had used hand gel at the nurse's station prior to entering the resident's room, and did not feel the need to wash her hands prior to providing actual care for the resident. She did not feel the need to wash her hands after leaving the room, because there was hand gel out in the hall that can be used after leaving the room. She did not see a problem with placing the soiled dressing and supplies on the resident's personal bedding, and did not feel the need to use a bag for the soiled dressings. She stated there was no need to wash her hands between glove changes, because this was not a sterile procedure, it was just a simple dressing change. Further interview revealed she did not think there was any infection control concerns regarding the dressing change for Resident #1. Interview with the SDC, on 12/13/18 at 8:34 PM, revealed it was her expectation that all staff practice infection control measures, such as washing hands and wearing gloves prior to dressing changes, placing a bag at the foot of the bed for soiled dressings or linens, removing gloves, and washing hands prior, during and after providing wound care. She stated it was basic nursing infection control practice we all learned in nursing school. However, it sounds like some staff have become lax regarding infection control concerns. Interview with the DON, on 12/13/18 at 8:22 AM, revealed it was her expectation as the DON, that nurses were expected to wash their hands prior to providing care, and during care as needed, between changing gloves, any time the gloves become soiled, and always prior to leaving the room. In addition, all soiled items/linen were to be bagged prior to leaving the room. Staff should prepare a clean work area with a barrier, and never use the residents' bedding as a work area. She stated all these issues would be an infection control concern. She stated It's a nursing standard of practice, basic Nursing 101, and ultimately my responsibility to ensure staff follow the infection control policy. 3. Review of the facility's Standards of Practice titled Mosby's Textbook for Nursing Assistants, undated, revealed the following under the Female Perineal section: Wash hands, put on gloves, fill a wash basin with warm water and put the basin on the over bed table, remove any wet or soiled incontinence products, remove and discard gloves, practice hand hygiene, put on clean gloves, wet the washcloths, perform perineal care. Under post procedure section: Remove and discard gloves, practice hand hygiene, put on clean gloves, provide clean and dry linens and incontinence products as needed. Record Review revealed the facility admitted Resident #94 to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of fifteen (15), indicating the resident was cognizant. Further review of the MDS revealed he/she was always incontinent of urine and frequently incontinent of bowel. Observation of perineal care by Certified Nurse Aide (CNA) #4, on 12/12/18 at 10:30 AM, revealed the CNA took wet washcloths, put them in a dry towel, put the towel with washcloths on the over bed table, and proceeded to do perineal care for Resident #94. After completing care, the CNA touched the divider curtain with contaminated hands, got a clean brief from a dresser drawer, put the brief on the resident with the same contaminated gloves, pulled the resident's gown down, touched the siderail with the same gloves, put a dirty brief in the garbage bag, and then took the contaminated gloves off. Interview with CNA #4, on 12/12/18 at 10:45 AM, revealed she had been a CNA for twenty (20) years and stated she did not know she needed to change gloves after doing perineal care, before touching items in the room or the resident's gown, siderail or clean brief. She further stated she could see how not changing her gloves would be an infection control issue. Interview with Resident #94, on 12/11/18 at 12:02 PM, revealed he/she had a Urinary Tract Infection [MEDICAL CONDITION] at the present time and was on antibiotics. Review of the Physician's orders revealed the resident was ordered [MEDICATION NAME] (Antibiotic specific for UTI's) one hundred (100) milligrams (mg) starting on 12/09/18 for seven (7) days. Review of the Comprehensive Care Plan revealed the resident was care planned for Risk for Infection, initiated 03/01/17, related to a history of UTI's with interventions to monitor for signs/symptoms of UTI. Also, he/she was care planned for Impaired Skin Integrity related to incontinence, initiated on 03/01/17, with interventions to check for incontinence every two (2) hours and as needed, change if wet/soiled, and use pads/briefs to manage incontinence. Interview with CNA #1, on 12/13/18 at 2:42 PM, revealed she had worked at the facility for three (3) years. She stated for perineal care, she used a different washcloth for each area, washed front to back, changed gloves as soon as she was done with perineal/incontinent care, as this would be an infection control issue to be touching things in the room with the dirty gloves on. Interview with CNA #5, on 12/13/18 at 2:50 PM, revealed she had worked at the facility for twenty-one (21) years. She stated with perineal care/incontinent care, the CNAs checked the residents every two (2) hours, knocked on the door before entering the room, washed hands, put on gloves, washed from front to back, and take gloves off after doing perineal care. She stated it would be an infection control issue to touch things in the room or on the resident's bed with dirty gloves. Interview with the ADON/SDC, on 12/13/18 at 8:34 AM, revealed it was her expectation that staff change gloves or wash their hands after doing perineal/incontinent care, before touching anything in the resident's room. She further stated her plan was to do in-services on infection control, and was in the process of doing some in-services now. Interview with the DON, on 12/13/18 at 8:21 AM, revealed her expectation was staff would wash their hands before and after care, remove gloves after doing perineal/incontinent care and wash his or her hands, not touch any items on the resident's bed, or in the room with contaminated gloves. 4. Review of the facility's policy, Wound Care, dated 12/1998 and updated 08/2016, revealed the purpose is to provide guidelines for the care of wounds to promote healing. Steps in the procedure include wash hands thoroughly before beginning the procedure. Assemble the equipment and supplies necessary to perform the procedure. Wipe all nozzles, foil packets, bottle tops, etc., with alcohol pledget before opening. Use disposable cloth to establish clean the field. Clean table prior to placing the barrier. Remove old dressing with gloves and wash hands. Don sterile gloves to place new dressing after cleaning wound. Wash your hands after dressing applied. Record review revealed the facility admitted Resident #23 on 08/23/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed a BIMS score of fifteen (15), which revealed the resident was cognitively intact and interviewable. Observation of RN #1, on 12/11/18 at 9:45 AM, revealed she performed a finger stick blood sugar on Resident #23 without the use of gloves. Interview with RN #1, on 12/11/18 at 10:45 AM, regarding performing finger sticks without gloves, revealed it would probably be a good idea to use gloves. Interview with Resident #23, on 12/13/18 at 2:47 PM, revealed most nurses used gloves, but some did not. He/she revealed he/she wanted the staff to use gloves so the nurses did not give him/her any bad germs. 5. Record review revealed the facility admitted Resident #9 on 02/16/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS, dated [DATE], revealed a BIMS score of ten (10), which indicated the resident was moderately cognitively impaired; however, upon interview, the resident was able to give only one (1) word answers. Observation of wound care for Resident #9, on 12/12/18 at 1:37 PM, revealed a Stage IV wound to the coccyx. Observation revealed a grape fruit sized affected area including the coccyx and upper buttocks bilaterally. An egg size opened wound was noted on the coccyx with a straw size open area, with tunneling of 1.5 centimeters (cm) around the upper edge of the wound. The nurse opened a barrier and placed it on the over bed table without cleaning the table, then laid her supplies onto the barrier, which included spray wound cleaner, sterile 4x4s, a pair of sterile gloves and paper tape. She proceeded to put on non-sterile gloves and removed the dirty dressing, folding her dirty dressing into her gloves as she removed them. She then went to the bathroom and washed her hands. She came back, put on sterile gloves, then opened the dressings. She removed her scissors from her pocket and an alcohol wipe to clean the scissors. Further observation revealed she did not clean her scissors, and placed barrier on prior to the dressing change. She cleansed the wound bed with wound cleanser and used q-tips to cleanse the undermining area. She then packed the undermining area with silverseal dressing and covered with a 4x4 dressing and paper tape. She told the resident she was done. The nurse rolled up the dressings and barrier, and placed them in the trash. She removed her gloves and left the room. Further observation revealed the resident's roommate was in the bathroom and the nurse could not wash her hands. The nurse stopped outside the room and used a hand cleanser. She took the dirty bags of soiled trash to the trash receptacle bare handed. Interview with the nurse revealed she should have cleaned the over bed table prior to putting the barrier down and should have removed her scissors from her pocket, cleaned them, and placed them on the barrier, prior to the start of the wound care. She revealed she should have cleaned the over bed table after the dressing change was completed, donned gloves after removal of soiled gloves, and washed her hands. She stated, before picking up soiled trash, she should put on non-sterile gloves. Further interview revealed she placed the resident at risk for infection by not following the care plan/orders as written for clean technique. 6. Record review revealed the facility admitted Resident #56 on 09/21/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS revealed a BIMS score of fifteen (15), which indicated the resident was cognitively intact and interviewable. Interview with RN #2, on 12/12/18 at 3:06 PM, revealed the resident had multiple issues with his/her catheter leaking and had been changed a total of six (6) times in the last two (2) months. Further interview with RN #2 revealed the resident was sent to see a urologist for the same thing, who ordered for the catheter to be irrigated with 100 milliliters (ml) of normal saline, since the resident had an increased amount of sediment in his/her bladder. Observation during the provision of catheter care revealed the nurse did not clean the over bed table prior to placing supplies on the table. Further observation revealed she did not clean the over bed table after removing the used supplies. Additional interview with RN #2 revealed she should have cleaned the table prior to placing the barrier on the table and after using the over bed table. Interview with the ADON/SDC, on 12/13/18 at 8:33 AM, revealed she was the Infection Control nurse and had scheduled education for infection control for (MONTH) this year. In-services were mandatory and wound care was talked about in orientation. She also revealed she worked two (2) days a week as the wound care nurse. She expected hand washing prior to doing peri care, after peri care was completed, and before touching any resident's clothing, curtain, call light, etc. Also, she stated she expected staff to remove gloves and wash hands prior to carrying soiled linen or trash, and they should not touch door knobs prior to removing gloves or washing hands. Interview with the DON, on 12/13/18 at 8:22 AM, regarding infection control issues revealed she expected nurses to wash their hands according to the policy in place. They also should knock on the door and announce who they are and wait for the resident to ask them to come in. She stated they should wash their hands prior to peri care, remove gloves, wash hands, and not wear soiled gloves out of the room. She stated, during wound care, they should clean the over bed table, put down a barrier and clean the over bed table after care. She also revealed ultimately it is my responsibility to make sure the nurses are following infection control policies.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for two (2) of twenty-eight (28) sampled residents (Residents #55 and #57). Review of the Comprehensive Care Plan revealed the care plan had not been revised after falls events. The findings include: Review of the facility's policy Care Plans, Comprehensive revealed an individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's Comprehensive Care Plan has been designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, build on the resident's strengths, reflect treatment goals and objectives in measurable outcomes, aid in preventing or reducing declines in the resident's functional status and/or functional levels, and enhance the optimal functioning of the resident by focusing on rehabilitative program. Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly and more frequently if warranted by a change in the resident's condition. 1. Record review revealed the facility admitted Resident #55 on 08/08/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/29/18, revealed the resident had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. Further review of the MDS assessment, Section G, revealed the resident required extensive assist of two (2) for transfers and ambulation; however, did not occur during the assessment period. Review of the Comprehensive Care Plan, dated 08/08/18, revealed the resident was at risk for injury related to a history of falls with a left (L) ankle injury, related to Alzheimer's Dementia with confusion, disorientation, memory problems, decreased safety awareness, weakness, and was currently non-ambulatory. Further review of the care plan revealed a revision on 11/12/18 after a fall; however, further record review revealed the care plan had not been revised after falls which occurred on 11/18/18 and 11/25/18, according to the Post Event Evaluation/Assessments. 2. Record review revealed the facility admitted Resident #57 on 10/03/18 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment, dated 11/21/18, revealed he/she had a BIMS score of twelve (12), which indicated the resident was interviewable. Review of Section G of the MDS assessment revealed the resident required extensive assist of two (2) for transfers and ambulation, however, did not occur during the assessment period. Review of the Comprehensive Care Plan, revised 10/16/18, revealed he/she was care planned for injury related to history of falls. Review of the Nursing Progress Notes, dated 10/19/18, 10/25/18, and 11/18/18, revealed the resident had falls with injuries. Further review of the Comprehensive Care Plan revealed no revisions were made after each of the resident's falls. Interview with the Regional Nurse Consultant (RNC), on 12/13/18 at 9:05 AM, revealed whoever identified the concern would be responsible for revision of the care plan to reflect the most current updated interventions for the identified problem areas. Interview with the Director of Nursing (DON), on 12/13/18 at 8:22 AM, revealed the Comprehensive Care Plans should be followed as written.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure a resident who displays or is diagnosed with [REDACTED].#34, #55, and #67). The findings include: Review of facility's policy titled, Behavioral Health Services Policy, last updated 11/11/17, revealed It is the policy of the facility that each resident must receive and the facility must provide the necessary behavioral health care and services and medically-related social services to attain or maintain the highest practical physical, mental and psychosocial well-being, in accordance with the comprehensive assessment (483.20) and plan of care. The facility will provide sufficient staff to provide direct services to residents with the appropriate skills sets to provide nursing related services. The Interdisciplinary team will utilize information from the PASARR process as well as to complete a comprehensive assessment of resident's needs, strengths, goals, life history and preferences using the Resident Assessment Instrument (RAI) specified by the Center for Medicare/Medicaid (CMS). 1. Record review revealed the facility admitted Resident #34 on 11/23/12 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 09/27/18, revealed the facility assessed Resident #34's cognition as intact with a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated the resident was inteviewable. Review of Section I, revealed the resident had an active [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plans and Certified Nurse Aide (CNA) care sheets, revealed no documented evidence a Dementia care plan had been developed. Observation, on 12/11/18 at 9:20 AM, 12:39 PM, and 3:40 PM, and, on 12/12/18 at 9:00 AM, revealed Resident #34 was lying in bed. Interview with Resident #34, on 12/13/18 at 9:00 AM, revealed she/he did not want to get up out of bed, and preferred watching television. 2. Record review revealed the facility admitted Resident #67 on 03/29/18, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 11/20/18, revealed the facility had assessed Resident #67's cognition as severely impaired with a BIMS score of three (3), which indicated the resident was non-inteviewable. Review of Section I, revealed he/she had an active [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plans and CNA care sheets revealed no documented evidence a Dementia care plan had been developed. Observation, on 12/13/18 at 11:00 AM and 2:10 PM, revealed Resident #67 was lying in the bed, eyes closed, covered with a blanket pulled up to his/her shoulders. Interviews, on 12/13/18 at 12:20 PM, 12:29 PM, and 12:37 PM, respectively, with CNA #1, CNA #2 and CNA #3, revealed there was no specific guidance on the nurse aide care guide when providing care for a resident who had a [DIAGNOSES REDACTED]. The CNAs stated they provided the basic care needs to all residents just the same, but it would be nice if the nurse aide care guide gave some specifics or ideas on how to care for a resident who had Dementia or Alzheimer's. They stated they just guessed and did the best they could. Interview with the MDS Coordinator, on 12/13/18 at 2:14 PM, revealed Social Services was responsible for Developing the Dementia care plans. She stated, when reviewing Resident #34's and Resident 67's care plan, she did not see a specific care plan that addressed Dementia or [MEDICAL CONDITION]. She revealed it was ultimately the responsibility of the MDS department to ensure a care plan was developed. Further interview revealed when reviewing the nurse aide care guides for the residents with a [DIAGNOSES REDACTED]. She stated the nurse aide care guide only addressed the basic care needs of the residents. Interview with the Assistant Director of Nursing (ADON), on 12/13/18 at 3:15 PM, revealed she would have expected a comprehensive care plan to have been developed for a resident with the [DIAGNOSES REDACTED]. Further interview revealed she and the Unit Manager (UM) from each unit created the nurse aide care guides, based on physician's orders [REDACTED]. She further stated, the CNA care guide sheets need to be more specific related to providing care for Dementia residents for our CNAs, as they provide the bulk of the care for our residents. Interview with the Regional Nurse Consultant (RNC), on 12/13/18 at 1:09 PM, revealed when reviewing Resident #34's and Resident 67's care plans, she did not see an individual care plan that addressed a [DIAGNOSES REDACTED]. She stated Social Services was responsible for developing the Dementia care plan and the previous Social Service Director (SSD) would have been responsible for creating the care plan; however, she is no longer with this facility, and our new person just started today. She further stated, It's sad, but I am owning our mistakes, and care plans need to be specific on how to provide care for a resident with Dementia. She further revealed the new SSD started today, and she will be training her specifically, and will ensure she is aware to develop a care plan for all residents with the [DIAGNOSES REDACTED]. 3. Record review revealed the facility admitted Resident #55, on 08/08/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 10/29/18, revealed the resident had a BIMS score of four (4), which indicated the resident was not interviewable. Review of the Comprehensive Care Plan, dated 08/08/18, revealed the resident was care planned for risk for injury related to a history of falls with a left (L) ankle injury related to Alzheimer's Dementia with confusion, disorientation, memory problems, decreased safety awareness, weakness, and currently non-ambulatory. Further review revealed care plan interventions included Remind resident to call for assistance before getting out of bed and to use transfer assist devices, staff to provide verbal or tactile cues for safety measures, staff to explain room arrangement, and staff to encourage slow transitional changes in position. Interview with the RNC, on 12/13/18 at 9:05 AM, revealed the care plans were updated in the MyUnity database and should reflect the most current update/interventions for the identified problem areas. Interview with the Director of Nursing (DON), on 12/13/18 at 8:22 AM, revealed the Comprehensive Care Plans should provide appropriate interventions for residents with Dementia.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents, for one (1) of twenty-eight (28) sampled residents (Resident #38). Observations during the survey revealed the resident's call light was not accessible to him/her. The findings include: Review of the facility's policy/procedure, titled Call Light System, revised 12/11/18, revealed each resident would be provided with a functional call light system within his/her reach. Explanation on how to use the call light would be provided to the resident if necessary. Record review revealed the facility admitted Resident #38 on 09/20/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 10/08/18, revealed the resident had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident was interviewable. Further review of the MDS revealed he/she required extensive to total assist for activities of daily living (ADLs). Review of the Comprehensive Care Plan, dated 10/12/18, revealed place call light within easy reach of resident. Observation, on 12/12/18 at 9:00 AM, revealed Resident #38 was moaning with facial grimacing, and was restless in the bed. Further observation revealed the call light was not in his/her reach and he/she was unable to call for assistance. Observation, on 12/13/18 at 3:15 PM, revealed his/her call light was clipped to his/her bed above the resident's left shoulder. Further observation revealed the resident was unable to reach the call light after several attempts were made by the resident. When asked by the surveyor if he/she could reach his/her call light, the resident shook his/her head no. Interview with Certified Nurse Aide (CNA) #6, on 12/13/18 at 1:30 PM, revealed she was suppose to check the call light every thirty (30) minutes; however, she was unsure what the facility policy stated, related to checking call lights. She stated she had been trained to check call light placement. Interview with CNA #7, on 12/13/18 at 1:45 PM, revealed she had been trained to check call lights, and to ensure the resident's call light was in reach. Interview with the Director of Nursing (DON), on 12/13/18 at 8:22 AM, revealed her expectations were that all residents had access to the call light, and rounds were to be made by the staff every two (2) hours to ensure the call lights were in reach. She stated it was everyone's responsibility to ensure the call lights were accessible to the residents.

Based on interview and record review, it was determined the facility failed to ensure a copy of the notice of transfer/discharge was sent to a representative of the Office of the State Long-Term Care Ombudsman, for one (1) of twenty-eight (28) sampled residents (Resident #97). Resident #97 was transferred to the local hospital on [DATE]; however, the facility failed to send notification of the transfer/discharge to the Ombudsman. The findings include: Interview with the Director of Clinical Operations (DCO), on 12/13/18 at 2:40 PM, revealed the facility did not have a policy related to Ombudsman notification. Record review revealed the facility admitted Resident #97 on 09/21/16 with [DIAGNOSES REDACTED]. Further record review revealed the resident required immediate transfer to the local hospital on [DATE] with a [DIAGNOSES REDACTED]. Further record review revealed the facility readmitted the resident on 12/08/18. Additional record review revealed no documented evidence that a copy of the transfer/discharge notice was sent to the Ombudsman. Interview with the Assistant Social Services Director (SSD), on 12/13/18 at 1:30 PM, revealed the former SSD left in (MONTH) (YEAR), and she had not completed any Ombudsman notifications, as she was unaware she had to do so. She stated the former SSD was responsible for training her and did not tell her about notifying the Ombudsman about resident transfer/discharge. Interview with the Director of Nursing (DON), on 12/13/18 at 2:30 PM, revealed she expected Social Services to know to contact the Ombudsman about transfers/discharges, and expected Social Services to do so. Interview with the DCO, on 12/13/18 at 2:40 PM, revealed she knew the Assistant SSD was educated on notification of the Ombudsman, as she conducted the training on 12/12/16, with power points. She stated there was also a meeting two (2) days later, to review all of the information.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure it developed and implemented a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for one (1) of twenty-eight (28) sampled residents (Resident #55), related to not revising the care plan after falls nor developing a person centered care plan. The findings include: Review of the facility's policy Care Plans, Comprehensive revealed an individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. Each resident's Comprehensive Care Plan has been designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, build on the resident's strengths, reflect treatment goals and objectives in measurable outcomes, aid in preventing or reducing declines in the resident's functional status and/or functional levels, and enhance the optimal functioning of the resident by focusing on rehabilitative program. Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly and more frequently if warranted by a change in the resident's condition. Record review revealed the facility admitted Resident #55 on 08/08/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 10/29/18, revealed the resident had a Brief Interview for Mental Status (BIMS) score of four (4), which indicated the resident was not interviewable. Further review of the MDS assessment, Section G, revealed the resident required extensive assist of two (2) for transfers and ambulation; however, did not occur during the assessment period. Review of the Comprehensive Care Plan, dated 08/08/18, revealed the resident was at risk for injury related to a history of falls with a left (L) ankle injury, related to Alzheimer's Dementia with confusion, disorientation, memory problems, decreased safety awareness, weakness, and was currently non-ambulatory. Review of the care plan revealed a revision on 11/12/18 after a fall; however, further record review revealed the care plan had not been revised after falls which occurred on 11/18/18 and 11/25/18, according to the Post Event Evaluation/Assessments. Interview with the Regional Nurse Consultant (RNC), on 12/13/18 at 9:05 AM, revealed whoever identified the concern would be responsible for revision of the care plan to reflect the most current updated interventions for the identified problem areas. Interview with the Director of Nursing (DON), on 12/13/18 at 8:22 AM, revealed the Comprehensive Care Plans should be followed as written.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to promote dignity for three (3) of (3) sampled residents, (Residents #1, #2, #3). The facility failed to answer their call lights in a timely manner and failed to meet personal care needs of the residents. The findings include: Review of the facility policy titled, Dignity, revised 09/15/17, revealed care should be provided in a manner that maintains or enhances a resident's dignity; staff should honor a resident's request for toileting regardless of the time or activity in which the staff member was involved in. Record review revealed the facility admitted Resident #1 on 09/17/15 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 12/28/17, revealed the facility assessed Resident #1's cognition as intact with a Brief Inventory of Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Further review of the MDS revealed the facility assessed Resident #1's bowel and bladder elimination at three (3), which indicated the resident is always incontinent. Interview with Resident #1 about incontinent care, on 06/14/18 at 6:30 PM, revealed Resident #1 stated, I normally wait as long as an hour or more this time of the evening because of supper; they (staff) won't change me until after they get everybody fed and supper trays collected. I always go after supper, when I call to be changed, they (staff) tell me I have to wait until supper is over. Resident #1 also stated, it's embarrassing to have to lay here with my brief soiled, and my roommate and I have to smell it. 2. Record review revealed the facility admitted Resident #2 on 05/22 14 with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment, dated 12/15/17, revealed the facility assessed Resident #2's cognition as intact with a BIMS score of thirteen (13) which indicated the resident was interviewable. Further review of the MDS, revealed the facility assessed Resident #2's bowel and bladder elimination at three (3), which indicated the resident is always incontinent. Interview with Resident #2, on 03/16/18 at 11:15 AM, revealed he/she was incontinent of bowel and bladder. Resident #2 stated, I can push my bell (call light) when I soil and/or wet my diaper (brief), and it may take hours for them (staff) to come change me. Sometimes they (staff) will reach around the door and cut my call light off and still don't see what I need, which is really worse during the evening and night. I'm surprised my butt don't have a sore on it, sometimes I lay so long without being changed; it's not a good feeling to lay in poop, especially when you have to depend on someone else to get it off of you. Resident #2 revealed he/she has voiced his/her concerns to the Director of Nursing (DON) however, he/she did not remember the date. 3. Record review revealed the facility admitted Resident #3 on 11/11/16 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 02/15/18, revealed the facility assessed Resident #3's cognition as intact with a BIMS score of fourteen (14) which indicated the resident was interviewable. Further review of the MDS, revealed the facility assessed Resident #3's bowel elimination at three (3) which indicated the resident is always incontinent; and bladder elimination assessed at one (1) which indicates the resident is occasionally incontinent. Interview with Resident #3, on 03/16/18 at 11:30 AM, revealed he/she has laid wet from urinary incontinence for over an hour. Resident #3 stated, I turn on the call light and they (staff) reach around the door and turn the call light off. I was embarrassed and ashamed, it made me mad. I do not require a lot of help, but they (staff) make you feel like they do not have time, they let you know when they do not have help. Interview with the Complainant, on 03/14/18 at 2:55 PM, revealed staff do not attend to the residents toileting needs during meal times. The Complainant stated he/she had discussed this concern with the DON but did not remember the date. Further interview revealed the Complainant stated, although I have discussed the concerns with the DON, nothing changed. Interview with Certified Nurse Aide (CNA) #1, on 03/14/18 at 4:30 PM, revealed supper meal time on 300 Wing is a busy time; most of the residents require some help with their care, and there is only two (2) CNA's. CNA #1 stated she has failed to toilet residents during meal time. She revealed resident's care should be given when requested and they should not have to wait. Interview with CNA #2, on 03/14/18 at 7:00 PM, revealed call lights are not always answered timely during supper meal on 300 Wing. CNA #2 stated, we (staff) do not toilet residents during meal time, once we (staff) start with the meal, we do not stop feeding to toilet residents. CNA #2 revealed she would expect staff to be able to provide care to the residents in a timely manner. Interview with CNA #5, on 03/15/18 at 2:45 PM, revealed when providing care to residents she has noticed dry, urine stained linen, and/or dry feces which indicated the resident care was not provided in a timely manner. CNA #5 stated she has answered call lights and was told by residents, I have been waiting as long as an hour to be changed. CNA #5 stated, I would expect for the resident to receive care when requested. I know it is the responsibility of us (staff) to make sure the patient care needs are met and to maintain their (residents) dignity. Interview with CNA #6, on 03/15/18 at 2:35 PM, revealed she have answered call lights and the resident has stated, I have been waiting on someone to come forever. CNA #6 stated it is the responsibility of all staff to ensure resident care needs are met and dignity maintained. Interview with Licensed Practical Nurse (LPN) #1, on 03/14/18 at 7:10 PM, revealed it was difficult for two (2) CNA's to answer call lights and toilet residents during meal time. LPN #1 stated she expected resident care to be provided when requested at all times. Interview with Registered Nurse (RN) #1, on 03/15/18 at 2:15 PM, revealed it is the responsibility of all staff to answer call lights and ensure resident care needs are met. RN #1 stated, what ever the resident care need may be, I would expect staff to make all effort to meet the need. RN #1 revealed staff is expected to ensure all residents dignity and care needs are met. Interview with the Director of Nursing (DON), on 03/16/17 at 11:55 AM, revealed she expected staff to answer call lights in a timely manner. The DON stated the staff should not turn off a resident's call light until care need is met and she would expect residents toileting needs to be provided if requested, at all times, meal time included. The DON revealed she expected the resident's dignity to be maintained as care needs are met.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents, (Resident #2), was free of an accident hazard related to the use of a mechanical lift which resulted in the resident obtaining a bruise to the left breast. The Director of Nursing (DON) and Registered Nurse (RN) #1 identified a bruise to Resident #2's breast and the resident stated the bruise was sustained while being transferred with the lift. However, further record review and interview revealed no incident report or investigation was completed to try ensure no further harm would come to the resident related to the use of the lift. The findings include: Review of the facility policy titled, Incident/Accident, not dated, revealed it is the policy of the facility to keep residents environment as free from accident hazard as possible. Assess the resident for signs of injury, provide first aid as applicable to physical exam findings, complete the Incident/Accident Investigation Form with root cause analysis of the incident, and route to the Administrator for signature and review. Record review revealed the facility admitted Resident #2 on 05/22 14 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set, assessment, dated 12/15/17, revealed the facility assessed Resident #2's cognition as intact with a Brief Interview of Mental Status (BIMS) score of thirteen (13) which indicated the resident was interviewable. Further review of the MDS, revealed the facility assessed Resident #2's transfer needs as three (3/3) which indicated the resident required extensive assistance of two (2) or more persons. Observation of Resident #2's left breast and interview with Resident #2, on 03/16/18 at 11:15 AM, revealed purple and blue discoloration of the outer left breast extending underneath. Resident #2 stated, they (staff) were using the lift to get me up and when they put the harness (lift sleeve) underneath me there was not enough room between the sling and the machine and my breast got pinched. Review of Resident #2's Nurses Notes, dated 03/01/18 to 03/16/18, revealed there was no documentation related to the bruising of the resident's left breast and no documented evidence an investigation was completed to determine if the lift was safe for the resident. Interview with Registered Nurse (RN) #1, on 03/16/18 at 4:20 PM, revealed she assessed Resident #2's left breast as instructed by the DON and discovered the left breast was greatly bruised. RN #1 stated she failed to document her assessment, complete an incident report, initiate an investigation and/or implement interventions to attempt to prevent reoccurrence. Interview with the Director of Nursing (DON), on 03/16/18 at 4:05 PM, revealed she was informed by Resident #2 his/her left breast was sore. The DON stated she looked at the resident's breast and noted the bruising. The DON revealed she reported the bruise to the nurse on unit (RN #1), and told RN #1 to assess the area and document. The DON revealed she would expect the nurse to assess the bruising, document characteristics, and notify the resident's physician and family. The DON stated she would not expect an investigation to be done because the resident knew what caused the bruise.

Based on observation, interview, record review and facility policy, it was determined the facility failed to provide services related to incontinent care to meet professional standards of quality for one (1) of twenty-one (21) sampled residents (Resident #10). Observation on 10/12/17 revealed Certified Nurse Aide (CNA) #1 failed to follow professional standards of quality when she provided incontinent care and cleansed the resident perineal area wiping from the rectum to urinary meatus. The findings include: Review of the Mosby's Medical, Nursing, and Allied Health Dictionary, Sixth Edition revealed perineal care, a cleansing procedure prescribed for cleansing the perineum is done after elimination and as a routine part of hygiene care using clean technique. The cleansing [MEDICAL CONDITION] always move from the vulva toward the anus and from the midline out. After each stroke, the disposable washcloth is discarded, and a new one is used for the next stroke. Record review revealed the facility admitted Resident #10 on 12/11/09 with [DIAGNOSES REDACTED]. Observation of incontinent care for Resident #10 on 10/12/17 at 10:45 AM by CNA #1 and Licensed Practical Nurse (LPN) #1, revealed CNA #1 used a washcloth to clean the resident's perineal area wiping from back to front (anus to vulva) instead of according to the professional standards of wiping from front to back (vulva to anus). Further observation revealed she also rinsed the resident's perineal area wiping from back to front. Interview with CNA #1, on 10/12/17 at 12:55 PM revealed she performed incontinent care the way she had been taught and did not notice she was cleaning from back to front. She stated cleaning from back to front could contaminate and may cause a Urinary Tract Infection. She revealed she would clean from front to back for female residents. Interview with LPN #1 on 10/12/17 at 10:48 AM revealed she noted the CNA #1 cleaning from back to front and revealed the proper cleaning technique was from front to back. Interview with Assistant Director of Nursing on 10/12/17 at 10:50 AM revealed she expected staff to use proper technique when providing incontinent care and staff should clean female residents perineal area from front to back.

Based on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to follow the care plan related to administering a supplement to promote healing of a facility acquired pressure ulcer for one (1) of twenty-one (21) sampled residents, (Resident #5). Observation on 10/10/17 at 9:45 AM revealed Certified Medication Aide (CMA) #1 failed to ensure Resident #5 had taken his/her wound healing supplement (identified as Prostat AWC) per the plan of care. The Supplement was left on Resident #5's breakfast tray for the resident to self administer after finishing his/her breakfast meal. The findings include: Review of the facility's policy and procedure, CARE PLANNING, not dated, revealed it is the policy of the facility to develop and implement a Comprehensive Person Centered Care Plan for each resident, reflecting the resident's medical, nursing, mental, and psychological needs. The Comprehensive Care Plan must include; The services that are being provided for the resident/elder. Care and services provided or arranged by facility staff on the Comprehensive Care Plan must meet professional standards of quality by qualified persons. Record review revealed the facility admitted Resident #5 on 04/09/13 with [DIAGNOSES REDACTED]. Review of the Clinical Progress Notes, dated 06/29/17, revealed the resident developed a facility acquired Stage II pressure ulcer to his/her coccyx. Review of Resident #5's Comprehensive Care Plan for risk for impaired skin integrity, not dated, revealed an intervention to provide Prostat AWC 30 ml twice a day for wound healing. However, observation on 10/10/17 at 9:45 AM, revealed thirty (30) milliliters (ml) of brown colored liquid (Prostat) in a medicine cup on Resident #5's breakfast tray with no staff present to ensure the resident drank the supplement. Interview with Certified Medication Aide (CMA) #1, on 10/10/17 at 10:05 AM, revealed she did not know if Resident #5 was care planned to self administer Supplements. CMA #1 stated, the resident can give it to him/herself. CMA #1 revealed she did not supervise the consumption of the ordered Supplement to ensure the care plan was followed. Interview with Licensed Practical Nurse (LPN) #1, on 10/10/17 at 10:10 AM, revealed Resident #5 had not been care planned to self administer his/her own Supplements and/or medications and the staff should not leave the supplement at the resident's bedside expecting the resident to self administer. Interview with the Interim Director of Nursing (IDON), on 10/10/17 at 2:00 PM, revealed the staff should follow the care plan and administer the Prostat to Resident #5. She stated Resident #5 was not care planned to self administer his/her own Supplements.

Based on observation, interview, record review, and review of the facility's policy and procedures, it was determined the facility failed to ensure a resident with a pressure ulcer received the necessary treatment and services to promote healing for one (1) of twenty one (21) sampled residents, (Resident #5). Observation on 10/10/17 revealed a wound healing supplement, (identified as Prostat AWC), was noted at Resident #5's bedside for the resident to self administer after eating the breakfast meal with no staff present to supervise the resident's consumption of the supplement per facility policy. The findings include: Review of the facility's policy and procedures titled,PRESSURE ULCER PREVENTION not dated, revealed it is the policy of the facility to identify clinical conditions that are primary risk factors for developing pressure ulcers that may include but are not limited too: Malnutrition/dehydration, whether secondary to poor appetite or another disease process that places the resident at risk for poor healing. Review of the facility's policy, SUPPLEMENTS, last revised 01/23/12, revealed supplements include a rotation of products that meet the minimum criteria of two-hundred (200) calories and six (6) grams of protein per serving or more. Procedural steps include: deliver the supplements to the residents and supervise the consumption. Record review revealed the facility admitted Resident #5 on 04/09/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 07/20/17, revealed the facility assessed Resident #5's cognition as intact with a Brief Inventory of Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Review of the Clinical Progress Notes, dated 06/29/17, revealed the resident developed a facility acquired Stage II pressure ulcer to his/her coccyx. Review of Resident #5's Physician Orders, dated 06/29/17, revealed an order for [REDACTED]. Review of Resident #5's Comprehensive Care Plan for risk for impaired skin integrity, hot dated, revealed an intervention to provide Prostat AWC 30 ml twice a day for wound healing. Observation on 10/10/17 at 9:45 AM, revealed thirty (30) milliliters (ml) of brown colored liquid in a medicine cup on Resident #5's breakfast tray. Interview with Resident #5, on 10/10/17 at 9:45 AM, revealed the liquid was for him/her to take after eating the breakfast meal. Further interview revealed Resident #5 stated, it's for the sore on my backside. Observation of a wound assessment of Resident #5's stage II pressure ulcer to coccyx , on 10/12/17 at 10:00 AM, revealed a red area measuring (1.7) centimeters (cm) in length and (2.1) cm in width, non blanchable, with skin surrounding wound, pink and blanches. Interview with Certified Medication Aide (CMA) #1, on 10/10/17 at 10:05 AM, revealed the brown liquid left on Resident #5's dietary tray was Prostat AWC. CMA #1 stated, the resident can give it to herself and the Prostat AWC was ordered to promote wound healing. CMA #1 was unable to say whether Resident #5 had consumed the Prostat AWC and stated, let me go see if he/she took it. Further interview revealed CMA #1 failed to supervise the consumption of the ordered Supplement. Interview with Licensed Practical Nurse (LPN) #1, on 10/10/17 at 10:10 AM, revealed Prostat AWC should not be left at a resident's bedside expecting the resident to self administer. LPN #1 stated Resident #5 had not been assessed to self administer his/her own Supplements and/or medications. Interview with the Interim Director of Nursing (IDON), on 10/10/17 at 2:00 PM, revealed Prostat is administered by staff performing medication administration. The IDON stated Resident #5 was not assessed to self administer his/her Supplements. The IDON further the staff administering the Supplement should ensure it is consumed and not leave it with the resident expecting a resident to take it.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (1) of twenty-one (21) sampled residents (Resident #10). Observation of peri-care for Resident #10, on 10/12/17 revealed Certified Nurse Aide (CNA) #1 wiped from the back of buttocks toward the front while providing peri-care instead of front to back per facility policy. The findings include: Review of the facility policy titled, Incontinence Care, Bladder/Perineal Care, last updated August 2016, revealed the purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Step #16 - revealed to use a wet washcloth and apply soap or skin cleansing agent, wash perineal area, wiping from front to back, separate labia and wash area downward from front to back, and continue to wash the perineum moving outward to and including thighs, alternating from side to side, and using downward [MEDICAL CONDITION]. Wash the rectal area thoroughly, wiping from the base of the labia and extending over the buttocks. Record review revealed the facility admitted Resident #10 on 12/11/09 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment, dated 07/25/17, revealed the facility assessed Resident #10's cognition as intact with a Brief Interview of Mental Status (BIMS) score of twelve (12) which indicated the resident was interviewable. Review of the Comprehensive Care Plan for Self Care Deficit related to weakness, limited range of motion to upper extremities, limited mobility, arthritis and history of pain to bilateral shoulders, dated 11/10/13, revealed an interventions for extensive assist with most Activities of Daily Living and incontinence care as needed. Review of Resident #10's Urine Cultures revealed the resident had a urinary tract infection on 09/28/17 with a growth of Citrobacter Freundii; on 09/06/17, with a growth of Escherichia Coli; on 06/30/17, with a growth of Proteus Mirabillis; and on 06/14/17, with a growth of Escherichia Coli. Observation of incontinent care for Resident 10 by CNA #1 and Licensed Practical Nurse (LPN) #1, on 10/12/17 at 10:45 AM, revealed CNA #1 cleaned the residents perineal area using a washcloth wiping from back to front from the rectum toward the urinary meatus. She also rinsed using a washcloth from back to front. Interview with CNA #1, on 10/12/17 at 12:55 PM, revealed she had performed incontinent care the way she had been taught and did not notice she was cleaning from back to front. She stated she understood cleaning from back to front could contaminate and may cause a Urinary Tract Infection. She further revealed she should clean from front to back for female residents. Interview with LPN #1, on 10/12/17 at 10:48 AM, revealed she noted that CNA #1 was cleaning the resident's perineal area from back to front. She stated the proper cleaning technique was from front to back. Interview with Assistant Director of Nursing (ADON), on 10/12/17 at 10:50 AM, revealed she expected staff to follow the policy and procedure for incontinent care and for staff to clean a female resident from front to back, not back to front.

Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure two (2) of three (3) sampled residents received adequate supervision to prevent accidents. Resident #1's cognition was assessed as severely impaired and was assessed and care planned for behaviors of getting up without assistance. However, on 04/25/17, Resident #1 was transported in a wheelchair by the local transit system to the appointment without an escort or family member. The nurse failed to write family or escort next to the resident's name on the calendar to ensure the resident would have supervision to and from the appointment; and, at the physician's office per facility policy. The transit system was late picking the resident up to return to the facility which resulted in Resident #1 falling asleep in the wheel chair and could have potentially fallen out of the wheelchair. In addition, the facility failed to enter all information on the appointment calendar for Resident #2 to ensure adequate supervision would be provided for transport to his/her appointment. The findings include: Review of the policy titled, Resident Appointment Process, last revised 01/14/14, revealed resident appointments are to be recorded in the Lab Calendar on the date of the appointment. The nurse receiving/making the appointment will call family to see if they need transportation or if the family will be transporting the resident. If transportation is needed, a call to set up transport and record transport company and time of pickup. Ask family if they will be accompanying the resident to the appointment. If the family is accompanying the resident, write FAMILY next to the appointment in the calendar. If the family is not accompanying the resident, write ESCORT next to the appointment and notify scheduling for a Certified Nurse Aide (CNA) to be scheduled to go to the appointment. The night shift will check the calendar for the next day and print the clinical information for the appointment. Day shift nurse will check the calendar for appointments to have the resident ready for the pick-up time recorded. 1. Record review revealed the facility admitted Resident #1 on 03/24/17 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 04/28/17, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Further review of the MDS assessment revealed Resident #1 did not ambulate, required a wheelchair, and occasionally had behavior of attempting to get up without assistance. Review of the Comprehensive Care Plan for at risk for falls related to impaired balance, history of fall, and the [DIAGNOSES REDACTED]. Review of the Lab Calendar for the date of the Physician's appointment revealed there had been an appointment card attached but the DON removed the card to verify it had come from the doctor's office and was delivered by a family member. There was no documentation as to whether the resident required an escort per the facility policy. Interview with Registered Nurse (RN) #2, on 06/02/17 at 8:00 AM, revealed the son had taken Resident #1 to the first visit in his vehicle, then came back and gave the DON the follow-up appointment card. She stated there was nothing written beside the appointment time that indicated if a family member would be present or if needed an escort per the facility policy, but she knew the family always went with him/her or met the transit van at the Physician's office. She revealed she felt it was safe to let Resident #1 ride in the van without supervision because the resident was fine as he/she had been working puzzles, and she felt it was safe. She stated if she felt it to be unsafe, she would have notified the DON. Interview with the Nephrology Receptionist, on 06/02/17 at 9:30 AM, revealed she remembered someone was supposed to pick up the resident but didn't remember what the problem was. She stated the resident had seen the Nephrologist on 04/11/17, and had given the son an appointment time card for the follow-up appointment. She revealed the resident was very sleepy and was falling asleep in the chair. She stated she became very concerned when no one arrived to pick him/her up so she called the daughter-in-law. She further stated she also remembered her and the transit driver commenting on how small the wheelchair was prior to wheeling him/her into the transit van. Interview with Resident #1's guardian/daughter-in-law, on 06/02/17 at 10:10 AM, revealed if the family had known about the appointment, they would have taken him/her, as they always went with him/her. The Guardian stated the physician's office receptionist said she called her when she noticed there was no one to pick the resident up after the appointment and because she became very nervous because Resident #1 had fallen asleep and she was afraid he/she may fall out of the chair. The Guardian revealed she ran over to the Physician's office to find the resident slumped over in a little bitty wheelchair, about to come out of it. She further revealed the transit system was late because of a blocked roadway and when the transit system got there, the driver helped her get Resident #1 into the van. She stated she rode with him/her to hold him/her up. She revealed they may have made the appointment but the time had changed and they were not made aware of it. Interview with the Director of Nursing (DON) on 05/31/17 at 4:00 PM revealed it was the family that had made the doctor's appointment, and they always met him/her at the doctors office, but didn't that time. She stated the physician's office was calling the wrong transit system so the resident ended up sitting at the office for a while. She stated the office never called the facility so they were not aware. 2. Record review revealed the facility admitted Resident #2 on 01/10/17, and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 01/17/17, revealed the facility assessed Resident #2's cognition to be intact with a BIMS score of thirteen (13), which indicated the resident was interviewable. Further review of the MDS assessment, revealed the resident used a wheel chair for mobility, needed assist of one (1) with ambulation in the room, and rarely ambulated in the hall way. Review of the Comprehensive Care Plan, dated 06/02/17, revealed Resident #2's was assessed to have a self care deficit related to right sided hemiparesis, weakness, decreased mobility, and non-ambulatory, and is a transfer with a mechanical lift with the assist of two (2). Review of the facility Lab Calendar revealed Resident #1 had an appointment at the wound clinic on 06/02/17; however, there was documentation stating if a family member or escort would be accompanying the resident per facility policy. Interview with License Practical Nurse (LPN) #1 on 06/02/17 at 10:15 AM revealed Resident #2 always goes out with a family member due to him/her being unable to go out alone. Interview with RN #1, on 06/02/17 at 2:30 PM, revealed nursing staff check the calendar every Friday for upcoming appointments, call and remind the family, and ensure if the resident needs to be accompanied it is written on the calendar. Interview with the Administrator and the DON, on 06/02/17 at 3:00 PM, revealed they identified the problem after the incident with Resident #1 and felt they had already corrected the problem by having nursing to check the calendar every Friday. When surveyor pointed out there was nothing written next to Resident #2's appointment on the calendar, the DON stated Resident #2's sister always wants to take the resident to his/her doctor appointments due to she feels it would be unsafe for him/her to go alone. She further stated since Resident #2 had a BIMS score of thirteen (13) it would be his/her right to refuse if he/she decided he/she did not want someone to accompany him/her to the doctor.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) sampled residents maintained acceptable parameters of nutritional status such as body weight, unless clinical conditions demonstrate this is not possible (Resident #1). On 04/06/17, Resident #1 was care planned for nutritional supplements as ordered and on 04/13/17, the Registered Dietician (RD) identified Resident #1 to have a weight loss of fifteen (15) pounds in twenty (20) days (since admission) and recommended the resident receive Two Cal 90 millimeters (ml) two times a day (BID). The Physician signed off on the recommendation on 04/14/17. However, the facility failed to provide the resident with the nutritional supplement for fourteen (14) days after it was ordered. Resident #1's weight dropped an additional twelve (12) pounds during that fourteen (14) day period. The findings include: Review of the facility policy titled Consult Recommendations, not dated, revealed to send all consult recommendations to the Primary Care Provider (PCP) when received via their choice of notification mode. Responses from the PCP when received should be transmitted in the Electronic Medical Record (EMR) if it results in a new order. For new orders see Prescription Medication Order for guidance if needed. Responses that decline the recommendation shall be noted and sent to Medical records to be scanned the residents's EMR. Notify the Resident, and the Resident's responsible party of any new orders received. Review of facility policy titled Medication Orders, dated 03/02/15, revealed under documentation of the medication order states for each medication order, the pharmacy shall request in the resident's medical record, the date, time, and signature of the person receiving the order. The order is recorded on the physician order sheet or the telephone order sheet if it is a verbal order, and then on the MAR or Treatment Administration Record (TAR). If the facility uses electronic records, the facility will follow their policy and procedure for entering information into the electronic record system to record on the Physician orders, telephone orders, MAR and/or TAR. Review of the Policy titled Prescribe Medication Order, not dated, revealed orders received in any form, verbal, telephone or written are to be transcribed into the EMR by the receiving Nurse, open the Resident's EMR. Clinical/Orders/ and a medication/treatment/lab/other, enter the medication and dosage in the search box, choose the appropriate item (Medication, Lab, treatment) as ordered, add [DIAGNOSES REDACTED]. Record review revealed the facility admitted Resident #1 on 03/24/17 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 04/28/17, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of four (4) which indicated the resident was not interviewable. Review of the Comprehensive Care Plan, dated 04/06/17, for at risk for Alteration in nutrition/hydration related to Adult Failure to Thrive, Dementia, advanced age, [MEDICAL CONDITION] and multiple medications. The goal was for the resident's nutrition status to be maintained over the next ninety (90) days, weight will remain stable or increase, and will show no signs and symptoms of dehydration. Interventions were to allow adequate time to eat; provide cues and encouragement; feed remaining food items, if needed; monitor food intake at each meal, document percentage eaten; offer water with each medication pass, open all containers, provide special utensil as needed, monitor weight, provide nutritional supplements as ordered, and diet as ordered. Review of the Dietary Nutrition Fourteen (14) Day Review, dated 04/13/17, revealed Resident #1's weight to be one hundred and seventy-nine.four (179.4) lbs which was a fifteen (15) lb weight loss in twenty (20) days (since admission). At this time, a recommendation was made to discontinue health shakes BID and add 90 milliliters (ml) of Two Cal, twice a day to aid in weight stabilization. Further review of this review revealed the recommendation was signed off by the Physician on 04/14/17. Review of the May 2017 Medication Notes (medication administration record) revealed Two Cal HN ninety (90) millimeters (ml) was added on 04/28/17 to be given at the breakfast and evening meal. Review of the Nutrition Thirty (30) day Review/Change of Status Assessment, dated 04/27/17, revealed Resident #1 weighed one-hundred and sixty-seven.two (167.2) lbs, which was an additional twelve (12) pounds for a total of a twenty-seven (27) lb. weight loss in thirty-four (34) days. It further revealed, the resident now had an unstagable pressure wound to the left lower posterior heel, the right lower posterior heel, and the right lower ankle. Labs revealed the residents [MEDICATION NAME] level to be three (3.0) grams per deciliter (dgd) (normal: 3.5 to 5.5). Further review of the assessment revealed a recommendation for Two Cal HN BID was made on 04/13/17, the order was signed and scanned on 04/14/17, but was not noted on the April 2017 Medication Administration Record (MAR), so the resident had not received the Two Cal BID for thirteen (13) days. Ensure was added three times a day (TID) and the Director of Nursing (DON) was notified of the omission of the two Cal at that time. Review of the Physician Orders, dated 04/28/17, revealed to give Resident #1's Two Cal ninety (90) ml. The recommendation was made on 04/13/17. Ensure one (1) can three times a day (TID). Interview with the RD, on 06/02/17 at 12:30 PM, revealed she assesses a resident, and if they have wounds or weight loss then she will make a recommendation for the proper supplement. She stated when Resident #1 developed wounds, she recommended Prostat and when the resident was identified to have weight loss, Two-Cal was recommended. The RD revealed she completed and signed the dietary form recommending the supplement and then placed it on the physician's clip board. She stated after that the order was given to nursing and after the order is approved by the physician, it is scanned. She revealed during the 04/27/17 thirty (30) day review, she checked to see if the order was followed through with and noted it had been signed and scanned but not placed on the April 2017 MAR. She stated she then brought it to the attention of the Director of Nursing (DON) and the order was added to the MAR on 04/28/17. Interview with Registered Nurse (RN) #1, on 06/02/17 at 2:30 PM, revealed it is the responsibility of the nurse that takes off an order to put it on the MAR, both nursing and dietary. Interview with the Director of Nursing (DON), on 06/02/17 at 3:00 PM, revealed when the order for the Two Cal was entered in the computer, it was put in on the wrong resident's MAR. The DON stated RN #1 realized the mistake and discontinued it off the MAR, but failed to put it on Resident #1's MAR. She further stated she expected all orders be added to the right resident's MAR, and due to the fast pace of the transitional unit, the staff need to look closely and slow down to avoid errors. She also sated she expected staff to follow the resident care plan. Interview with the Administrator, on 06/02/17 at 3:15 PM, revealed she expected no orders to be missed' and for the nurse to check for any new orders every shift. She also stated she expected the nurses to follow the resident's care plan.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide care in accordance with the resident's written plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned to provide nutitional supplements as ordered and an order was received to administer Two Cal (nutritional supplement) two (2) times a day; however, the facility failed to administer the resident the supplement as care planned. The findings include: Review of the policy titled Care Plan, Comprehensive, last revised July 2013, revealed an individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. The facility's Care Planning/Interdisiplinary Team, in coordination with the resident, his/her family or representative, develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Each resident's Comprehensive Care Plan has been designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, build on the resident's strengths, reflect treatment goals and objectives in measurable outcomes; identify the professional services that are responsible for each element of care, aid in preventing or reducing declines in the resident's functional status and/orfunctional levels, and enhance the optimal functioning of the resident by focusing on a rehabilitative program. Record review revealed the facility admitted Resident #1 on 03/24/17 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for at risk for Alteration in nutrition/hydration, dated 04/06/17, with an intervention to provide nutritional supplements as ordered. Review of a Nutrition fourteen (14) day Assessment, dated 04/13/17, revealed the Physician signed off on the Dietician's recommendation for Two Cal HN two times a day (BID); however, review of the Nutrition thirty (30) day Review/Change of Status Assessment, dated 04/27/17, revealed the Dietician had identified the order had not been added to Resident #1's April 2017 Medication Administration Record [REDACTED]. The Dietician made the Director of Nursing aware of the omission. Further review revealed the resident had lost an addition thwelve (12) pounds during this time frame. Review of the May 2017 Medication Notes revealed the Two Cal HN ninety (90) ml's was added on 04/28/1; to be given at the breakfast and evening meal. Interview with the RD, on 06/02/17 at 12:30 PM, revealed she completed and signed dietary form recommending the supplement and then placed it on the physician's clip board. She stated after that the order was given to nursing and after the order is approved by the physician, it is scanned. She revealed during the 04/27/17 thirty (30) day review, she checked to see if the order was followed through with and noted it had been signed and scanned but not placed on the April 2017 MAR. She stated she then brought it to the attention of the Director of Nursing (DON) and the order was added to the MAR indicated [REDACTED] Interview by the DON and the Administrator on 06/02/17 at 3:00 PM revealed they expected the staff to be followed.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide services in accordance with the written plan of care for one (1) of three (3) sampled residents (Resident #1). Resident #1 was care planned to receive oxygen (O2) at two (2) liters per minute (LPM) however, Certified Nurse Aide (CNA) #1 failed to ensure the resident's oxygen was available for use while giving the resident a shower. Resident #1 became short of breath and anxious in the shower room with his/her saturation level dropping and the resident was sent to the emergency room . The findings include: Review of on facility policy titled, Daily Work Assignment, dated March 2016, revealeds all nursing services personnel shall follow daily work assignments and perform assigned duties in accordance with professional standards of practice and facility policy. Work assignments are prepared from the resident's care plan by the Nurse Supervisor or Charge Nurse and must be reviewed at the beginning of each shift for possible revisions and CNA'S are expected to carry out their daily assignments in a professional manner and in accordance with established nursing procedures. Record review revealed the facility admitted Resident #1 on 11/08/16, had a stay in the hospital related to rectal bleeding and was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 12/02/16, revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview for Mental Status (BIM) score of eleven (11) which indicated the resident was interviewable. Review of the CNA Care Plan, dated 12/12/16, revealed to administer O2 at two (2) LPM. Review of a Nurse's Notes, dated 12/12/16 at 11:00 AM; interviews on 12/15/16 with CNA #1 at 11:20 AM and Registered Nurse (RN) #1 at 11:40 AM; and, interviews on 12/16/16 at 11:05 with CNA #3 and at 12:10 PM with CNA #4 revealed Resident #1 became short of breath and anxious in the shower room after receiving his/her shower without his/her oxygen on 12/12/16. The resident was taken back to his/he room and placed back on oxygen and the resident was sent to the emergency room . Further interview with CNA #1 on 12/15/16 at 11:20 AM, revealed Resident #1 was care planned to receive O2 at 2 LPM. She stated she did not normally care for Resident #1 but on 12/12/16, she removed Resident #1's oxygen to take the resident to the shower. She revealed she did not know if the resident needed oxygen while in the shower or not and did not ask the nurse if the resident needed the O2 in the shower. She revealed she felt since the resident was alert and did not ask for the O2, it would be all right to leave it in the room. Interview with CNA #2, on 12/16/16 at 10:00 AM, revealed she normally provided care for Resident #1. She stated Resident #1 Resident #1 would decide if he/she wanted O2 while in the shower and usually did not, but she would always ask him/her during the shower if he/she was having any trouble breathing. She revealed she would always take a portable unit to the shower as needed. Interview with the Assistant Director of Nursing (ADON), on 12/16/16 at 12:30 PM, revealed she felt that CNA #1 should have checked with the nurse concerning the O2 before giving the shower since she was not familiar with the resident's care and the CNA care plan stated O2 at 2 LPM per NC. She further stated the CNA'S learn in orientation, and are inserviced frequently on always checking and following their care plan before giving resident care and if there was any questions to always ask the charge nurse. Interview with the Director of Nursing (DON) on 12/16/16 at 12:35 PM revealed she expected all CNA'S to always follow the resident care plan and consult the nurse with any questions.

Based on interview, record review, and review of the facility's policy/procedures, it was determined the facility failed to provide the necessary care and services related to assessments, providing pain medication and sending a resident to the hosptial to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for one (1) of five (5) sampled residents (Resident #2). Resident #2 sustained a fall on 03/17/16 at approximately 2:00 AM. Licensed Practical Nurse (LPN) #3 assessed the resident and identified the resident was having pain to the left thigh and the physician was notified with an order to obtain an x-ray. However, Resident #2 was transferred to his/her recliner and left in the recliner from 2:00 AM until approximately 7:30 AM in pain, soaked in urine and sitting on his/her [MEDICAL CONDITION]. LPN #3 failed to assess the resident's pain throughout the night, failed to administer as needed pain medication as ordered and failed to ensure the resident was able to receive incontinent care. In addition, at approximately 7:00 AM, the dayshift CNAs reported to the nurses that Resident #2 was grimacing in pain, soaked in urine, left hip was swollen and left foot was turned outward; however, the LPNs did not come to assess the resident and no medication was administered for the pain. The facility failed assess the resident's pain and administered pain medication for approximately eight (8) hours. The nurses failed to call EMS until 9:35 AM to transport the resident to the hospital. The resident was diagnosed with [REDACTED]. The resident was hospitalized and required surgical intervention. The findings include: Review of the facility's procedure for a Quick and Easy Head to Toe Physical Assessment, revealed the assessment should be completed on Admission and with any change in condition. The licensed staff should observe for any signs of distress (complaints of pain and facial grimacing) and level of consciousness; and, assess the head, neck, chest, and perform passive range of motion (PROM) on all extremities to note any pain or resistance to PROM. Review of the facility policy and procedure titled, Pain, dated 02/25/15, revealed it is the policy of the facility to achieve a consistent level of comfort while maintaining as much function as possible for each resident identified with pain, through ongoing assessment, a monitoring system and specific plan of care. Further review revealed staff should use a pain scale when the resident describes his/her pain and amount of pain relief. Use a pain scale of 1-10 and a visual face indicating degrees of happy or unhappy can be tried with residents that do not understand the numerical scale. Record review revealed the facility readmitted Resident #2 on 03/21/16 with [DIAGNOSES REDACTED]. with late onset, Dementia with Behavioral Disturbances, Generalized [MEDICAL CONDITION], and Disorder of Bone Density and Structure multiple sites. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/27/16, revealed the facility assessed Resident #2's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of two (2), which indicated the resident was not interviewable. Review of the Clinical Note Report, dated 03/17/16 at 8:29 AM, revealed Certified Nurse Aide (CNA) #4 entered Resident #2's room when bed alarm sounding, witnessed the resident's walker getting away from the resident and the resident fell to the floor. Licensed Practical Nurse (LPN) #3 assessed the resident and identified skin tears to the second finger on left hand, left wrist, left elbow, and forehead over left eyebrow. The areas were cleaned with steri-strips applied. No other visible injuries were noted. The resident complained of pain of left upper thigh. Neuro checks were started. The Physician was called at 2:45 AM with voice message left. Medical Director notified and orders received to obtain x-ray of left thigh. Further review of the record revealed there was no evidence the resident's pain was assessed throughout the night. In addition, review of the March 2016 Medication Administration Record [REDACTED]{2} tablets) every four (4) hours PRN for pain. However, there was no documented evidence Resident #2 was administered any medication for pain from the time he/she fell at approximately 2:00 AM until he/she left for the hospital at approximately 9:55 AM (approximately eight {8} hours) on 03/17/16. Review of the Neurological assessment dated [DATE], revealed the nurse conducted neuro-checks every fifteen (15) minutes times four (4) (2:15 AM, 2:30 AM, 2:45 AM and 3:00 AM), every thirty (30) minutes times two (2) (3:30 AM and 4:00 AM) and every hour times two (2) (5:00 AM and 6:00 AM). However, further review revealed the nurse had documented the resident ' s motor function was present in the upper extremities but she documented she was unable to check the motor function of the resident's lower extremities at every check. Review of a Clinical Note Report dated 03/17/16 at 9:44 AM, revealed the resident's physician was called with an order received to send out to ER for treatment and Emergency Medical Services (EMS) arrived at 10:00 AM to transport the resident. Review of the EMS Prehospital Report, dated 03/17/16 revealed EMS arrived at the facility at 9:39 AM. Resident #2 was found lying in bed in room and staff stated the resident had fallen earlier and they had placed the resident back in bed. The resident was complaining of left hip pain and an assessment identified the resident's left hip was swollen and tender to touch. The left leg was rotated out and shortened. The resident winced in pain upon touching left extremity and stated his/her leg hurt. While in route to hospital resident was administered [MEDICATION NAME] (narcotic pain medication) 25 micrograms (mcg) intravenously but resident was still wincing and complaining of pain so anther 25 mcg of [MEDICATION NAME] was administered IV with improved results. Further Review of the POS [REDACTED]. The resident was hospitalized and required surgical intervention. Interview with CNA #4, on 08/03/16 at 8:26 AM and on 08/05/16 at 11:45 AM, revealed she entered Resident #2's room due to the bed alarm sounding, she saw the resident falling, and the resident grabbed for the walker when he/she fell . She stated she had to leave the resident to go get LPN #3 as the nurse was on another hall because the nurse covers two (2) halls. She revealed the nurse thought she had a [MEDICAL CONDITION] and they transferred the resident from the floor to the recliner. The resident was in pain and his/her hands and fingers were swollen, after the fall. She stated she did not know if the resident's foot was rotated outward or not. Further interview on 08/09/16 at 3:10 PM, revealed the resident did not void after put back in the recliner and she did rounds every two (2) hours but did not check on the resident during her last round at about 6:00 AM. She also stated she did not see the nurse go back into the room that night but CNA #3 went into the resident's room with her one (1) time that night and they noticed the left foot was turned outward. Interview with CNA #3, on 08/08/16 at 3:20 PM, revealed she was in the break room when Resident #2 fell . She stated when she came back from break she went to the resident's room, the resident was in the recliner, and she and CNA #4 cleaned the injuries from the fall. She stated she did not remember seeing any injuries to the resident's hips but did remember seeing bruises to the resident's fingers and over left eye. Interview with CNA #3, on 08/09/16 at 3:40 PM, revealed the last round she made with CNA #4 was at 4:00 AM and they applied the alarm to the resident. She stated they did not want to move the resident but when they put the alarm under the resident the resident did grimace and the resident left hand and hip were swollen. She stated they reported the resident's condition to the nurse and she saw the nurse go into the resident's room. Interview with LPN #3, on 06/17/16 at 8:45 AM, revealed she was covering two (2) halls the night Resident #2 fell and broke his/her hip. She stated CNA #4 came and notified her that Resident #2 had fallen, the resident was bleeding, and had a bump over his/her left eye. She revealed they got the resident up off the floor, she started neuro checks, the resident denied pain, and a head to toe assessment was completed. She stated she did not identify any rotation to the resident's leg, no asymmetry to the lower extremities and the resident had no pain when range of motion was checked. She stated she tried to call the physician and did not get an answer so she called the Medical Director and received an order to obtain an x-ray. She revealed she did not get an x-ray at the facility as the resident was not in pain and no pain medication was administered; however, review of the clinical note dated 03/17/15 at 8:29 AM revealed she documented the resident complained of left thigh pain and the physician was notified and an order was received for an x-ray. She stated she did not feel the resident needed to go to the emergency room (ER). She further revealed the dayshift CNAs reported the resident's left hip was swollen when they made their first rounds. Interview with CNA #1, on 08/05/16 at 10:30 AM, revealed when she came in on dayshift on 03/17/16 she received report from CNA #4 and was made aware Resident #2 had fallen and they thought the resident's hip was fractured. She stated when she made her first round at approximately 7:00 AM she identified Resident #2 was sitting up in the recliner and soaked with urine. She revealed the resident's left hip was swollen and the left foot extended outward. She stated she reported this to LPN #1 (dayshift nurse) but she did not come and assess the resident. She further stated that LPN #3 was at the desk and the LPN stated, Well if left hip is broke it was not broke last night when she fell . She revealed she knew something was wrong when the resident was sitting up in the recliner and the resident was moving trying to get repositioned, had facial grimacing, was crying and she could tell the resident was in a lot of pain. She stated CNA #4 stated she and CNA #3 could not figure out how to get the resident back in bed because they did not know how to move him/her. Further interview revealed her and CNA #12 asked the Physical Therapy Assistant to look at the resident. Interview with CNA #12, on 08/08/16 at 3:00 PM, revealed she was assigned to Resident #2 for the dayshift on 03/17/16 (post fall). She stated she saw Resident #2 sitting up in recliner and CNA #4 reported the resident had fallen during the night, had a bump over left eye and a skin tear on his/her right hand. She revealed CNA #4 also stated that Resident #2 was going to have an x-ray of his/her hip that morning. She stated she started cleaning Resident #2 up in the recliner, and when she pulled back the sheet the resident groaned in pain and stated, Don ' t touch that leg, it hurts. She revealed at that time she noticed the left foot was turned outward. She revealed she reported this information to LPN #3 and LPN #1 and she was told a report was being filled out at this time but the nurses did not come and assess the resident. Further interview with CNA #12 revealed her and CNA #1 asked the Physical Therapy Assistant to look at the resident. Interview with LPN #1, on 08/08/16 at 2:35 PM, revealed the 11PM-7AM nurse was still at the facility when she arrived at the facility on 08/17/16 at approximately 6:45 AM. She stated she did not receive report before she started her shift and did not do a walking round. She revealed the CNAs stated Resident #2 had fallen during the night and when she saw Resident #2 a little after 7:00 AM; the resident's face was banged up . She stated she did not remember anyone reporting the resident might have a [MEDICAL CONDITION]. She revealed she did not assess the resident when the CNAs reported the resident was complaining of pain and had a swollen left hip because other disciplines were caring for the resident and LPN #3 was still at the facility providing care so she felt the resident was receiving care. She revealed when LPN #3 did give her report she stated the resident had skin tears, had hit forehead, and arms, and complained of left leg pain. She stated LPN #3 did not say the resident could have a [MEDICAL CONDITION]. Interview with the Physical Therapy Assistant, on 08/05/16 at 12:50 PM, revealed CNA #1 and #12 asked her to assess the resident at approximately 7:30-7:45 AM. She stated when she looked at the resident's left thigh it was greatly swollen and he/she grimaced when she barely moved the leg. She revealed she asked CNA #1, #12 and two (2) other therapy staff to transfer the resident from the recliner to the bed where she could better assess the resident. She revealed she then realized the resident hip was broken once she got the resident laid out flat because the lower extremities were not symmetrical, the left leg was shorter, and the left foot had outward rotation. She stated the resident did not show any outward grimacing or pain once back in the bed. She further revealed the resident was saturated in urine and the CNAs reported they could not figure out how to change the resident in the recliner. Interview with Assistant Director of Nursing (ADON), on 08/05/16 at 4:20 PM, revealed she arrived at the facility at approximately 7:30 AM on 03/17/16. She stated LPN #3 reported that Resident #2 had fallen during the night, LPN #3 had called mobile x-ray, and they were coming to do an x-ray. She revealed she did not go to the resident's room but immediately got on the phone and around 8:00 AM was able to contact Resident #2's Physician and obtained an order to send the resident to the ER. Interview with the Medical Director, on 08/08/16 at 3:25 PM, revealed she remembered the nurse thought it was a significant injury when they called her to intervene but she did not remember the details. She stated if the resident was comfortable and was in bed then the resident could have waited a few hours for the x-ray and she may have told the nurse to wait until the morning. She revealed if the nurse thought it was a fracture she could have sent the resident to the ER but even if it was a fracture and the resident was comfortable then there was no harm in waiting for the x-ray.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to review/revise the Comprehensive Care Plan with interventions that were appropriate to the resident's cognition and that addressed the root cause of falls for one (1) of five (5) sampled residents (Resident #2). Resident #2 was care planned to ensure call light was in place even though the facility had assessed the resident's cognition to be severely impaired. Resident #2 sustained falls on 01/27/16, 02/11/16, and 03/17/16, and the facility determined the root cause of the falls was the resident attempting to ambulate without assistance and the resident falling with alarm in place/sounding. However, the facility failed to develop interventions that addressed the root cause of the falls. The Falls Committee developed interventions to ensure the resident's walker was by the bed even though he/she was unable to make decisions and to toilet the resident prior to bedtime and at last round at night. However, the facility failed to revise the Comprehensive Care Plan to include these interventions so staff would be aware. After the fall on 03/17/16, the resident was sent to the hospital and diagnosed with [REDACTED]. The resident was hospitalized and required surgical intervention. The findings include: Review of the facility's policy and procedure, Care Plans, Comprehensive, last revised July 2013, revealed an individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychosocial needs is developed for each resident. The Care/Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a Comprehensive Care Plan for each resident that identifies the highest level of functioning the resident may be expected to attain. Review of the facility's policy and procedure, Fall Prevention, last revised May 2015, revealed new intervention(s) should be added to aid in avoiding future falls. Care plan changes, and new interventions should be revised and communicated. Record review revealed the facility readmitted Resident #2 on 03/21/16 with [DIAGNOSES REDACTED]. with late onset, Dementia with Behavioral Disturbances, Generalized [MEDICAL CONDITION], and Disorder of Bone Density and Structure multiple sites. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/27/16, revealed the facility assessed Resident #2's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of two (2), which indicated the resident was not able to make his/her own decisions and required one (1) staff physical assistance with transfers. Review of Resident #2's Comprehensive Care Plan for Risk for Injury/Falls, not dated, revealed to transfer and ambulate with assistance of one (1) person and a rolling walker, to use appropriate footwear with non-skid soles and to place the call bell/light within easy reach even though the facility assessed the resident's cognition as severely impaired. In addition, there was an intervention for chair and bed alarms for safety; however, observation on 06/15/16 at 1:40 PM revealed Resident #2's room was the last room on the hall and the furthest from the nursing station. Review of the facility's Post Fall Investigations, dated 01/27/16, 02/11/16, and 03/17/16, revealed Resident #2 sustained falls in his/her room on each of these dates. The facility determined the root cause of the falls was unassisted transfers from the bed. The facility initiated an intervention to place a rolling walker by bed after the first fall even though the resident's cognition was severely impaired and to obtain a three (3) day voiding pattern/assess for toileting after the second fall. Review of Resident #2's Three (3) Day Voiding Pattern/assessment, dated 02/12/16 through 02/14/16, revealed it was determined on 02/19/16 to initiate a toileting plan to ensure the resident was toileted at bedtime and last round of night. However, further review of the Comprehensive Care Plan revealed the care plan was not revised to place the rolling walker by bed at night and to toilet the resident at bedtime and last round at night so staff would be aware. In addition, the facility failed to address the resident getting up out of bed without assistance when they identified staff were unable to respond in time to prevent the falls when the alarm sounded. Further Review of the POS [REDACTED]. The resident was hospitalized and required surgical intervention. Interview with Licensed Practical Nurse (LPN) #1, on 06/16/16 at 11:30 AM, revealed the Fall Committee members were responsible to initiate interventions to prevent further falls. She revealed the Falls Committee members determined the interventions to implement, and the Unit Manager (UM), MDS Coordinator, or the Nurse then added the interventions. Further interview revealed Resident #2 was cognitively impaired and unable to remember to use his/her rolling walker or the call bell/light, even though frequent prompts/reminders were utilized. Interview with the Unit Manager (UM), on 08/03/16 at 10:15 AM, revealed as a member of the Falls Committee it is hard to determine appropriate interventions for Resident #2 with a BIMS score of two (2). She stated an alarm would be an appropriate intervention for Resident #2 although the alarm will not keep the resident from falling it will alert staff of Resident #2's attempt to transfer. Interview with the Director of Nursing (DON), on 06/21/16 at 5:00 PM, revealed she expected the resident's care plan to be revised with any change in a resident's condition if it was determined interventions needed to be added or deleted. Further interview revealed the DON felt the interventions were appropriate and attainable for the resident; however, the care plan interventions were unsuccessful. Further interview with the DON, on 08/03/16 at 3:15 PM, revealed the DON and/or the Administrator notifies the facility's Therapy Department after each fall and the Falls Committee reviews information and causative factor of fall and determines the root cause as a committee. She stated the ongoing interventions are assessed, and that interventions are revised and/or new interventions implemented if determined by the Falls Committee. She revealed a Post Fall Committee Recommendation is given to the Nurse or Unit Manager and added to the resident's Comprehensive Care Plan.

Based on interview, record review, and review of the Kentucky Board of Nursing (KBN) Advisory Opinion Statement (AOS) #14, it was determined the facility failed to implement the care plan for pain for one (1) of five (5) sampled residents. Resident #2 had physician's orders [REDACTED]. On 03/17/16 at 2:00AM, Resident #2 sustained a fall, which resulted in pain to the resident's left thigh. The resident showed signs of pain with grimacing when moved, stating Don't touch that leg, it hurts, and crying from 2:00 AM through 9:58 AM (approximately eight {8} hours) when Emergency Medical Services staff administered pain medication during transport to hospital; however, licensed staff failed to administer pain medication to address the resident pain indicators. The resident sustained [REDACTED]. The resident was hospitalized and required surgical intervention. The findings include: Review of the KBN AOS #14 Patient Care Orders, last revised October 2010, revealed licensed staff should administer medication and treatment as prescribed by the Physician or Advanced Practice Registered Nurse including administering medication in the prescribed dosage, route and frequency. Record review revealed the facility readmitted Resident #2 on 03/21/16 with [DIAGNOSES REDACTED]. with late onset, Dementia with Behavioral Disturbances, Generalized [MEDICAL CONDITION], and Disorder of Bone Density and Structure multiple sites. Review of the March 2016 physician's orders [REDACTED].{2} tablets) every four (4) hours PRN for pain. Review of the Clinical Note Report dated 03/17/16 at 8:29 AM, and Fall Investigation, dated 03/17/17 at 2:00 AM, revealed Resident #4 fell in his/her room and was assessed by Licensed Practical Nurse (LPN) #3 to have skin tears to the second finger on left hand, left wrist, left elbow, and forehead over left eyebrow; and had complaints of pain of left upper thigh. The Medical Director notified and orders received to obtain x-ray of left thigh. Interviews with Certified Nurse Aide (CNA) #4 on 08/03/16 at 8:26 AM and CNA #3, on 08/08/16 at 3:20 PM, revealed Resident #2 was placed in his/her recliner after the fall. CNA #4 stated the resident complained of pain at the time of the fall and both CNAs stated the resident grimaced in pain when they attempted to place an alarm under the resident in the recliner at 4:00 AM. The CNAs stated they reported the resident's pain to LPN #3 and she went into the resident's room. CNA #4 and CNA #3 stated the resident remained in the recliner all night because they were did not know how to move the resident with his/her injury. Interviews with CNA #1, on 08/05/16 at 10:30 AM and interview with CNA #12 (dayshift CNAs), on 08/08/16 at 3:00 PM, revealed they saw Resident #2 at approximately 7:00 AM sitting in his/her recliner. The CNAs stated the resident's left hip was swollen and the left foot was extended outward. CNA #12 stated when she pulled back the sheet to clean the resident up the resident groaned in pain and stated, Don't touch that leg, it hurts. The CNAs stated they reported the resident's condition to LPN #3 and LPN #1 and the nurses did not come and assess the resident. CNA #1 stated she knew something was wrong when the resident was sitting up in the recliner and the resident was moving trying to get repositioned, had facial grimacing, was crying and she could tell the resident was in a lot of pain. Interview with LPN #3, on 06/17/16 at 8:45 AM, revealed after Resident #2's fall on 03/17/16, her, and the CNAs transferred the resident from the floor to the recliner, the resident denied pain, and a head to toe assessment was completed. She stated she did not identify any rotation to the resident's leg, no asymmetry to the lower extremities and the resident had no pain when range of motion was checked. She stated she tried to call the physician and did not get an answer so she called the Medical Director and received an order to obtain an x-ray. She revealed she did not get an x-ray at the facility as the resident was not in pain and no pain medication was administered; however, review of the clinical note dated 03/17/15 at 8:29 AM revealed she documented the resident complained of left thigh pain. Interview with LPN #1, on 08/08/16 at 2:35 PM, revealed she did not receive report before she started her dayshift on 03/17/16 and did not do a walking round. She stated she did not remember anyone reporting the resident might have a [MEDICAL CONDITION] and she did not assess the resident when the CNAs reported the resident was complaining of pain and had a swollen left hip. She revealed other disciplines were caring for the resident and LPN #3 was still at the facility providing care so she felt the resident was receiving care. Interview with the Physical Therapy Assistant, on 08/05/16 at 12:50 PM, revealed CNA #1 and #12 asked her to assess the resident at approximately 7:30-7:45 AM. She stated when she looked at the resident's left thigh it was greatly swollen and he/she grimaced when she barely moved the leg. She revealed she asked CNA #1, #12 and two (2) other therapy staff to transfer the resident from the recliner to the bed where she could better assess the resident. She revealed the resident was saturated with urine and she then realized the resident hip was broken once she got the resident laid out flat because the lower extremities were not symmetrical, the left leg was shorter, and the left foot had outward rotation. However, review of the March 2016 Medication Administration Record [REDACTED]{8} hours) on 03/17/16. Review of a Clinical Note Report, dated 03/17/16 at 9:44 AM, revealed the resident's physician was called with an order received to send out to ER for treatment and Emergency Medical Services (EMS) arrived at 10:00 AM to transport the resident. Review of the EMS Prehospital Report, dated 03/17/16 revealed EMS arrived at the facility at 9:39 AM. Resident #2 was found lying in bed in room and staff stated the resident had fallen earlier and they had placed the resident back in bed. The resident was complaining of left hip pain and an assessment identified the resident's left hip was swollen and tender to touch. The left leg was rotated out and shortened. The resident winced in pain upon touching left extremity and stated his/her leg hurt. While in route to hospital resident was administered [MEDICATION NAME] (narcotic pain medication) 25 micrograms (mcg) intravenously but resident was still wincing and complaining of pain so anther 25 mcg of [MEDICATION NAME] was administered IV with improved results. Review of the POS [REDACTED]. The resident was hospitalized and required surgical intervention. Interview with Assistant Director of Nursing (ADON), on 08/05/16 at 4:20 PM, revealed she arrived at the facility at approximately 7:30 AM on 03/17/16. She stated LPN #3 reported that Resident #2 had fallen during the night, LPN #3 had called mobile x-ray, and they were coming to do an x-ray. She revealed she did not go to the resident's room but immediately got on the phone and around 8:00 AM was able to contact Resident #2's Physician and obtained an order to send the resident to the ER. She stated she expected staff to follow the physician's orders [REDACTED].

Based on observation, interview, record review, and review of the facility's policy and procedure, it was determined the facility failed to ensure one (1) of five (5) sampled residents received adequate supervision and assistive devices to prevent accidents. Resident #2 had falls on 01/27/16, 02/11/16 and 03/17/16. Prior to the falls the resident was care planned to ensure call light in place; however, the resident's cognition was severely impaired and bed/chair alarms were in place. The facility determined the root cause of each fall was the resident attempting to transfer/ambulate without calling for assistance and the alarm was in place/sounding with each fall. However, the facility failed to ensure adequate supervision was in place to address the resident falling before staff could get to the resident when the alarm sounded. In addition, the interventions put in place at the time of the first and second fall (walker by bed and toilet before bedtime and during last round) were not recorded on the Comprehensive/Certified Nurse Aide (CNA) Care Plan to ensure staff were aware. Resident #2 sustained a fracture of the left femur (thigh) and a fracture of the third (3rd) metacarpal (finger) bone in his/her left hand with the fall on 03/17/16. The resident was hospitalized with a left femur fracture, which required surgical intervention. The findings include: Review of the facility's policy and procedure, Fall Prevention, last revised May 2015, revealed it was the facility's policy through assessment and interventions to provide supervision and assistance to residents in an effort to avoid falls and minimize injury that may result from a resident falling. Further review of the procedure revealed new intervention(s) should be added to aid in avoiding future falls. Care plan changes, and new interventions should be revised and communicated. Record review revealed the facility readmitted Resident #2 on 03/21/16 with [DIAGNOSES REDACTED]. with late onset, Dementia with Behavioral Disturbances, Generalized Osteoarthritis, and Disorder of Bone Density and Structure multiple sites. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/27/16, revealed the facility assessed Resident #2's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of two (2), which indicated the resident was not able to make his/her own decisions and was not interviewable. Additionally, review of the MDS revealed the facility assessed Resident #2 to require one (1) staff physical assistance with transfers. Review of Resident #2's Comprehensive Care Plan for Risk for Injury/Falls, not dated, revealed for the resident to transfer and ambulate with assistance of one (1) person and a rolling walker, chair and bed alarms for safety, use appropriate footwear with non-skid soles. In addition, there was an intervention to place the call bell/light within easy reach although the resident's cognition was severely impaired. Review of the facility's Post Fall Investigation, dated 01/27/16, revealed Resident #2 sustained a fall on 01/27/16, which resulted in no injuries. The facility determined the root cause of the fall was an unassisted transfer from the bed, and the alarm was sounding. Further review revealed the Falls Committee initiated an intervention to place a walker next to the resident's bed even though the resident ' s cognition was severely impaired. In addition, there was no intervention to address the resident's ability to get up without staff assistance in his/her room and staff not being able to respond before the resident would fall. Review of the facility's Post Fall Investigation, dated 02/11/16, revealed Resident #2 sustained a fall, which resulted in skin tears to the resident's left shin, right lateral leg, and right side of forehead; and a small bump to right forehead. The facility determined the root cause of the fall was an unassisted transfer from the bed to go to the restroom, and the alarm was sounding. Further review revealed the facility initiated interventions to obtain a three (3) day voiding pattern/toileting assessment. Review of Resident #2's Three (3) Day Voiding Pattern, dated 02/12/16 through 02/14/16 revealed a toileting plan was initiated to ensure the resident was toileted at bedtime and last round at night; however, there was no evidence the Comprehensive/CNA Care Plan was updated to include the interventions so staff was aware. In addition, there was still no intervention to address the resident's ability to get up without staff assistance in his/her room and staff not being able to respond before the resident would fall. Review of the facility's Post Fall Investigation, dated 03/17/16, revealed Resident #2 sustained a fall on 03/17/16 at 2:15 AM and the facility determined the root cause of the fall was the resident attempted to transfer and ambulate to the bathroom without calling for assistance, and the alarm was sounding. Further review of the resident's Comprehensive Care Plan revealed there still was no interventions added to the care plan when the resident returned to the facility on [DATE] to address the resident getting up out of bed without assistance and staff not being able to respond before the resident would fall. Interview with CNA #4, on 08/03/16 at 8:26 AM, revealed when she entered Resident #2's room when the bed alarm was sounding, the resident was falling and the resident grabbed for the walker when she fell . Further review of the Post Fall Investigation, dated 03/17/16, revealed the resident was transferred to the local Hospital emergency room (ER), and it was determined the resident sustained [REDACTED]. The resident was hospitalized and required surgical intervention. Observation, on 06/16/16 at 4:50 PM, revealed when CNA #5 prompted Resident #2 to use the rolling walker and the call light, CNA #5 had to be physically assist the resident to use the rolling walker and call light, as the resident did not seem to understand the CNA's directions. Interview with Resident #2's Power of Attorney (POA) and Health Care Surrogate, on 06/16/16 at 12:20 PM, revealed when Resident #2 needs to toilet or becomes incontinent that she would transfer/ambulate without assistance. She stated facility staff was aware of the resident's history of unassisted transfers and the facility assessed the resident as a high falls risk related the resident's history of falls, impaired cognition, and impaired safety awareness. The POA revealed consistent toileting every two (2) hours during the night would decrease the resident's fall risk. Interview with CNA #4, on 06/21/16 at 2:35 PM, revealed Resident #2's gait was unsteady at times and he/she should not transfer without the assistance of staff, as the resident was assessed as a falls risk. CNA #4 stated the resident would forget to use the rolling walker, even when the rolling walker was within his/her reach. Further interview revealed Resident #2 would not wear non-skid footwear (socks) while in bed. Interview with CNA #6, on 08/02/16 at 4:40 PM, revealed Resident #2 would not use the call bell/light and does not always remember to use his/her walker although the walker was placed at bedside and call bell/light was in reach. Interview with CNA #7, on 08/02/16 on 4:40 PM, revealed Resident #2's care planned to wear skid proof socks while in bed but the resident does not always keep skid proof socks on. She stated Resident #2 requires increased supervision although the resident was not care planned for this intervention. Interview with Licensed Practical Nurse (LPN) #3, on 08/03/16 at 8:06 AM, revealed Resident #2's care plan interventions of call bell/light within reach and walker beside bed were not effective for the resident. She stated Resident #2 ambulated without his/her walker if staff was not available. Further interview revealed because of Resident #2's severely impaired cognition and decreased safety awareness, the resident was not capable of identifying the necessity of using the call bell. Interview with the Unit Manager (UM), on 08/03/16 at 10:15 AM, revealed as a member of the Falls Committee it is hard to determine appropriate interventions for Resident #2 with a BIMS score of two (2). She stated an alarm was an appropriate intervention for Resident #2 although the alarm will not keep the resident from falling it will alert staff of Resident #2's attempt to transfer. Interview with the Director of Nursing (DON), on 06/21/16 at 5:00 PM, revealed she felt the interventions were appropriate and attainable for the resident; however, the care plan interventions were unsuccessful.