Every finding on record at Clinton Place

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents' rights were protected related to meal service for 2 residents out of the 20 sampled residents, (Resident (R)70 and R81).The findings include: Review of the facility policy titled, Resident Rights, dated 01/02/2020, revealed residents had the right to be treated with respect and dignity, including the right to a dignified existence, self-determination, and access to services inside the facility. Observation of the dining service on 08/27/2025 at 11:35 AM, revealed staff were serving the first table with all residents served their meals except R81. Per observation, staff moved to serve residents at the second table before serving R81 the meal. Continued observation revealed all residents at the second table were served their meals except R70 with staff moving to serve another table before R70 received his meal. In interview on 08/27/2025 at 11:40 AM, Certified Nurse Aide (CNA) 1 stated she was aware all residents should be served at one table before moving to serve residents at another table. She reported they had taken the trays from the window that were provided by kitchen staff and believed the kitchen staff had prepared trays according to the meal cards. CNA 1 said she believed the concern was with the meal cards not being in the correct order in the kitchen and that caused the delay in R81's and R70's trays being served. Additionally, she stated staff should follow the guidelines when serving meals to ensure residents were not upset but believed they had corrected the situation as soon as possible. In interview on 08/29/2025 at 9:15 AM, CNA 3 stated she assisted with meal service when needed. She reported every resident had rights in the facility and staff should serve meals to all residents sitting at a table with multiple residents before moving to serve another table. CNA 3 further stated it was important that meal services not exclude residents to ensure their rights were respected and not create unnecessary stress. In an interview on 08/29/2025 at 10:35 AM, the Dietary Manager (DM) stated she was aware all residents should be served at the same table before staff moved to another table. The DM said however, there had been a miscommunication error in the kitchen. She reported R81, who was seated at the first group table served, had ordered food from the alternative menu and she had instructed kitchen staff to put that meal card on the counter, but it had been placed at the bottom of the meal card pile. The DM stated she was responsible for ensuring the meal cards were in order for the groups of residents at each table. She explained she had not been aware until that day, that R70 had also not been served with everyone at the second group table on 08/27/2025. The DM said she understood residents' rights were not respected when that type of thing occurred. She stated when that occurred some residents who were sensitive might feel left out watching others eat while they were not being served. She further stated that was not a normal occurrence and she had apologized to all residents. In interview on 08/29/2025 at 2:30 PM, the Administrator stated her expectations were for staff to serve all residents at one table before moving to another table and that the problem should never have happened. She reported she was aware there had been some confusion with the meal cards being in order due to residents ordering from the alternative lunch food. The Administrator said however, the CNAs who were serving residents' trays should have caught that and corrected the issue immediately. She further stated she did not believe harm had occurred, but the residents involved might have gotten upset and felt they had been forgotten and that was certainly not acceptable.

Based on observation, interview, and facility policy review, the facility failed to store medication in accordance with accepted standards of practice, which had the potential to affect 83 out of 83 facility residents. The findings include: Observation of the facility's Long Hall medication storage room on 08/28/2025 at 9:00 AM revealed seven tablets of Ondansetron (Zofran) 4 milligrams (mg) in a blister pack, not labeled with a resident's name, and with no expiration date on it. Further observation revealed that the Ondansetron was located in a plastic bin containing miscellaneous items, such as a flashlight and a toothpaste tube, stored above the sink. In interview on 08/29/2025 at 10:28 AM, Licensed Practical Nurse (LPN) 2 reported that the pharmacy checked the facility's emergency boxes. The LPN said the night shift nurses were supposed to check for expired medications in the medication rooms. LPN 2 stated the night shift nurses were also to maintain medications by ensuring the medication was labeled and ensure expired medications in the medication room was discarded. The LPN further stated, however, the entire night shift staff were new and were learning the facility's process. In interview on 08/29/2025 at 10:55 AM, the Director of Nursing (DON) reported that the nurses who were on shift were supposed to be checking the medication room for expired and unlabeled medications and maintaining the organization of the rooms. In interview on 08/29/2025 at 2:21 PM, the Administrator stated that medications should be stored in their proper place and that expired medications should be removed.

Based on observation, interview, and review of the facility's policy, the facility failed to store food in accordance with professional standards for food service safety, which had the potential to affect 20 of the facility's 83 residents. The findings include: Review of the facility policy titled, Food Safety Requirements reviewed 06/2025, revealed the facility was to store food in accordance with professional standards for food service safety. Further review revealed refrigerated items should include labeling and dating of the food items, so it was used by its use-by date. Observation of the nutrition refrigerator on the facility's Lighthouse Unit on 08/28/2025 at 9:15 AM, revealed two opened Thickened Water with Lemon containers dated with received dates of 06/17/2025 and 07/08/2025, with no documented opened date. Per observation, additional opened items that were undated, and unlabeled included: a container of Crangrape juice that was half full; a half full container of Electrolit beverage; an opened, uncovered stick of butter; a 12-ounce bottle of Coke, and two water bottles that were half full. Continued observation revealed a ham sandwich and a pimento cheese sandwich that were undated and unlabeled, and a small bowl of pudding covered with plastic wrap that was unlabeled and undated. Further observation revealed a pitcher of lemonade with a preparation date of 08/21/2025 and a use-by date of 08/25/2025. In interview on 08/28/2025 at 9:57 AM, Registered Nurse (RN) 3 stated she thought the facility's policy stated a container could be opened and used for up to two (2) months after being opened. She said different people were responsible for cleaning out the refrigerator, and there was no one in particular assigned to that task. RN 3 further said outdated food or drinks had the potential to cause a food borne illness, and she didn't want anybody to get sick. In interview on 08/29/2025 at 1:35 PM, the Dietary Manager (DM) stated it sounded like the bowl of pudding in the Lighthouse Unit nutrition refrigerator had came off of a resident's meal tray, aa when pudding was sent for a snack, it was sent in pre-packaged containers. She said the nectar liquids were dated with the received date; however, there was not an opened date as required. The DM reported once opened, the nectar liquids were good for seven days according to the printed manufacturer's recommendation on the container. She further stated when the sandwiches were sent out for the unit refrigerators, the tray was dated with the preparation date and the end of use date. In addition, the DM stated there was a potential for food borne illness if food was eaten after the beyond use date. In interview on 08/29/2025 at 1:40 PM, the Director of Operations for the contract dietary company, stated one tray of sandwiches had been misdated for four days. The Director of Operation further stated the sandwiches were good for seven (7) days after prepared. In interview on 08/20/2025 at 1:45 PM, the Director of Nursing (DON) stated food beyond the use-by date should be removed to avoid serving it to residents to avoid causing a resident to become sick. She stated it would be important for items to be labeled and dated to know when to remove items from the refrigerator. In interview on 08/29/2025 at 2:21 PM, the Administrator stated there were risks for using food or drinks past the beyond use date. The Administrator further stated however, she did not know what the risks would be if the food was used past the beyond use date. She also said the beyond use dates were in place to safeguard residents against food borne illnesses.

Based on observation, interview, and review of facility policy, the facility failed to ensure all bathrooms were equipped with call lights at each toilet that was accessible to residents who sustained a fall, and was lying on the floor. The findings include: Review of the facility policy titled, Call Lights: Accessibility and Timely Response reviewed 06/2025, revealed the call system must be accessible to the resident at each toilet and was to be accessible to a resident lying on the floor. Observation on 08/26/2025 at 3:50 PM and on 08/29/2025 at 11:12 AM, revealed the call lights in the bathroom of resident rooms [ROOM NUMBERS] were not equipped with cords to ensure a resident lying in the floor could summon assistance. During interview with the Director of Nursing (DON) on 08/29/2025 at 1:45 PM, she stated call lights were important for the resident to be able to call for help in the bathroom if needed. In interview with the Administrator on 08/29/2025 at 2:21 PM, she stated she was not aware the cords were missing from the call lights (in rooms 119 ad 127).

Based on observation, record review, interviews, and facility policy review it was determined that the facility failed to provide quality of care related to skin impairment and Activities of Daily Living for one of 33 sampled residents. (Resident #45 (R45)). On 07/15/2023 at 12:44 AM, nursing observed small white insects approximately 3 cm [centimeters] in size what appeared to look like small worms, in creases of resident's wound beds on both lower extremities. The resident had a temp of 101.6 and was complaining of chills and sweats. Resident 45 was sent to the emergency room for evaluation. Additionally, staff documented on 06/01/2024 and 06/02/2024 the resident had white particles on her outer thigh area of BLE (bilateral extremities), in the resident abdominal folds, and inner creases of BLE. In an interview with R45 on 06/24/2024 at 2:28 PM, she stated that she has had maggots on her legs at least two (2) times, but only went to the hospital for them once. R45 stated she had lots of flies in her room sometimes. The findings include: Review of the facility's policy titled, Resident Rights, revised 03/18/2024, revealed the resident had the right to a dignified existence, and 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 and safety of the resident or other residents. Review of the facility's policy titled, Activities of Daily Living (ADLs), revised 08/09/2023, revealed the facility will ensure a resident's abilities in Activities of Daily Living (ADLs) do not deteriorate unless deterioration was unavoidable. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Record review revealed the facility admitted Resident 45 on 12/16/2020 with diagnoses to include [NAME]-[NAME] Syndrome, Lymphedema, and Unspecified Intellectual Disabilities. Review of Resident #45's Quarterly Minimum Data Set assessment dated [DATE] revealed Resident #45 was assessed to have a Brief Interview for Mental Status (BIMS) Score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Observation of the facility on 06/23/2024 at 6:10 PM, revealed four (4) flies swarming on the 200 Hall and Dining Room area. On 06/24/2024 at 2:28 PM, observation revealed three (3) flies in R45's room and one (1) on the resident's bed. On 06/25/2024 at 10:00 AM, observation revealed three (3) flies swarming on the 200 Hall of the facility. Observation on 06/26/2024 at 1:27 PM, revealed several flies in R45's room with three (3) flies resting on the Resident's thigh area. Also, five (5) additional flies were noted swarming over the resident's bed. Further observation revealed nursing staff waving their hands to shoo the flies away. Observation on 06/27/2024 at 1:42 PM revealed flies in R45's room with one fly on the resident's face and one fly on the left side of the resident's neck. During an interview with R45 at this time, she stated that she did not like the flies on her and that they made her feel bad. Review of Resident 45's (R45) care plan revised 06/09/2023, revealed the facility care planned the resident for nutritional problems r/t [NAME]-[NAME] Syndrome which results in her not feeling full; morbid obesity with weight greater than 500 lbs; and weight gain since admission. Further review revealed R45 frequently refused to allow weight to be obtained. MD aware, with interventions to include CCHO Controlled Carbohydrate diet with HS (night time) snack, Dietary to provide low calorie dense food/snacks between meals upon resident's request, Educate/encourage family to bring resident healthy snacks instead of candy, chips, sugary drinks. Provide and serve diet as ordered. Regular Diet with thin liquids. Resident 45's last weight was 640 lbs on 06/11/2024. Review of Resident 45's shower schedule revealed the resident was scheduled on Mondays and Thursdays during dayshift for baths. Review of Activities of Daily Living (ADLs) documentation revealed Resident 45 was given a complete bed bath on 07/14/2023 by State Registered Nurse Aide #6 (SRNA6). Review of the Nursing Progress Note dated 07/15/2023 at 12:44 AM revealed the nurse was summoned to the resident's room. Further review revealed the nurse observed small white insects approximately 3 cm [centimeters] in size what appeared to look like small worms, in creases of resident's wound beds on both lower extremities. Nurse notified the DON [Director of Nursing], DON stated that she would contact the wound care nurse to get new orders. Resident had a temp of 101.6. Resident was complaining of chills and sweats. Nurse contacted on call services. The doctor on call gave order to send resident to ER. RP notified and arrived at the facility to escort resident to ER. Resident left facility via ambulance at approx 0030. Review of hospital records revealed a Skin Assessment documented by the emergency room Physician on 07/15/2023 at 2:01 AM revealed multiple areas of wetness especially noted in all of the resident's skin folds due to her weight. There was one maggot noted along the right side of the resident's body. Review of the facility's document titled, Pest Sighting Log, revealed twenty (20) flies were found and killed at the 200 Hall nurse's station and ten (10) flies were found and killed in R45's room on 05/21/2024 at 9:00 AM, also, ten (10) flies were found and killed in the same room on 06/01/2024 at 10:00 AM. Review of the Nursing Progress Note, dated 06/01/2024 at 11:45 AM, revealed the nurse was summoned by staff to R45's room r/t SRNA seeing white particles on the resident's outer right thigh. Further nursing assessment revealed white particles were noted coming out of the outer thigh area of BLE (bilateral extremities), in the resident abdominal folds, and inner creases of BLE. Review of the Nursing Progress Note, dated 06/02/2024 at 2:55 PM revealed, Complete bed bath given today x 4 staff members. [NAME] particles continue to right outer thigh area. None noted to abdominal folds or left thigh. Dakins and triad cream continues. In an interview with R45 on 06/24/2024 at 2:28 PM, she stated that she has had maggots on her legs at least two (2) times, but only went to the hospital for them once. R45 stated she had lots of flies in her room sometimes. In an interview with R45's mother on 06/25/2024 at 9:43 AM, she stated she felt that the facility was not providing quality care for the resident. She stated R45 called her and told her that she had laid and waited for someone to come and change her for hours and that it was mainly afternoon staff. She stated they use the resident's size and instances of care refusal as an excuse to not take care of her. She further stated R45 had had maggots on her at least twice that she knew of. She stated she got a call from a nurse around midnight on 07/15/2023 and the nurse reported she found maggots on R45 and was sending her to the hospital. She stated she met the resident at the hospital and the hospital emergency room (ER) staff informed her that they also had to clean maggots off the resident. She stated the Director of Nursing (DON) had told her they were working on a plan to get rid of the flies in the facility, but no one had followed up with her in regards to it. She further stated R45 had recently called her crying and scared stating, She is afraid those bugs might come back. In an interview with State Registered Nurse Aide (SRNA) #1 on 06/25/2024 at 1:00 PM, she stated that she was doing rounds with another SRNA. She stated when she turned R45 over, she saw something white fall onto her gloved hand. She stated she started wiping the resident and observed small, white, rice-like objects falling from the resident and noted they were moving. She stated they were generally all over the bed and crawling out from Resident 45's skin. She stated she told the other SRNA that she was going to go get the nurse, and she left and came back with the nurse who assessed the resident and stated they looked like maggots. During further interview, she stated that they cleaned R45 up and called the DON who advised them against documenting the incident, and to wait and get direction from her because she needed to find out what to do about it. SRNA #1 stated she recalled seeing flies in R45's room. She stated approximately two weeks after the incident she was called into the Administrator's office and blamed by the Administrator for R45 getting the maggots. She stated the administrator stated to her that she was not doing her job because R45 did not get a bath. SRNA1 stated that was the first time she had worked with R45 in over three weeks because she was working the Memory Care Unit and not on the hall where R45 resided so it was not possible for her to have provided care to this resident. She stated she resigned from the facility after her meeting with Administrator. In an interview SRNA6 on 06/26/2024 at 2:45 PM, she stated she assisted staff with care and provided a bed bath for R45 on 07/14/2023. She stated there were always flies present in R45's room. She stated she had seen maggots on the resident's bed but not on her. In an interview with Licensed Practical Nurse (LPN) #1 on 06/25/2024 at 11:35 AM, she stated that she observed the maggots on R45 on 07/15/2023. She stated it was her first time working at the facility as she was a new employee. She stated SRNA #1 came and requested her to come to R45's room. She stated she assessed resident and noted maggots were falling out of R45's folds and creases in her legs, and abdomen. She stated she called the Director of Nursing (DON) and the DON advised her to just treat the resident with some Dankins solution (a type of hypochlorite solution used to clean wounds). She stated the DON told her that this had happened to the resident before. She stated the DON informed her not to chart the incident, but LPN #1 stated she knew that was wrong and documented her findings. She notified the Physician on call who gave orders to send R45 to the hospital. In an interview with Registered Nurse (RN) #4 on 06/27/2024 at 2:10 PM, she stated on 06/01/2024 she was summoned to R45's room by the SRNAs regarding possible maggot sightings on the resident. She stated she observed white particles noted coming out of the outer thigh area of the resident's Bilateral Lower Extremities (BLE), in the resident's abdominal folds, and the resident's inner creases. She stated the white particles appeared to be maggots to her but she was told by her DON that since she was not pest control that she cannot say what she though it was and was advised by the DON to document her findings as white particles instead of maggots. She stated she tried to keep R45 clean and dry and apply treatments as ordered to reduce the skin issues. She further stated that it would be a great idea for R45 to get more baths per week, but the facility just did not have the man power to do so. In an interview with the Director of Nursing on 06/27/2024 at 1:20 PM, she stated if a resident has skin breakdown and wound care recommended they increase the number of baths a resident received they would do so. The DON stated that in her opinion R45 was on a great bathing schedule as it was. During further interview the DON stated the nursing staff were very well trained to care for this resident and provide them with a complete bed bath. She further stated R45 has a history of refusing care because she has a preference of which staff members provided her care. In a second interview with the Director of Nursing on 06/28/2024 at 12:48 PM, she stated she received a call from the nurse around 9-10 at night, the nurse informed her that she saw white things on R45' legs. The DON stated she told the nurse to call the on call physician who gave orders to send Resident #45 to the hospital. She further stated within this month RN # 4 called her and informed her that she saw them again and she advised her to call the medical director and he ordered treatments for resident. She stated she just told staff to document the facts, and state what they saw. In an interview with the Medical Director (MD) on 06/27/2024 at 3:33 PM, he stated the On Call Doctor gave the order for R45 to go out the ER. He stated that R45 had had them at least twice that he was aware of. The MD stated the Root Cause of the problem was the flies in the facility. In an interview with the Administrator on 06/28/2024 at 1:23 PM, She stated the DON contacted her and she instructed them to call the on call physician services who ordered R45 to go out to the hospital. She stated she followed up with the family in regards to the situation. During the interview, she stated she maintained an open line of communication for them to talk with her about any concerns. She stated that they have pest control come monthly, placed fly lights in residents' rooms, fly swatters, air blowers, and tried to keep the windows shut. She stated she had to educate R45 on keeping the windows shut. She stated the resident was her own person and would tell you what she wanted and could be very non-compliant and resistant to care.

Based on observation, interviews, record review, and review of the facility's policy it was determined the facility failed to maintain an effective pest control program to ensure it was free of pests. All 81 residents had the potential to be affected. On 07/15/2023, 06/01/2024, and 06/02/2024, Resident (R) 45 was found to have maggots in her skin folds and bilateral lower extremity wound beds. Observation on 06/27/2024 at 1:42 PM revealed flies in R45's room with one fly on the resident's face and one fly on the left side of the resident's neck. Refer to F684. The findings include: Review of the facility's policy titled, Resident Rights, revised 03/18/2024, revealed the resident had a right to a safe, clean, comfortable and home like environment. Review of the facility's policy titled, Pest Control, revised 03/23/2024, revealed the facility shall maintain an effective, on-going pest control program that ensures the building is kept free of insects and rodents. Review of the facility's policy titled, Maintenance Service, revised 09/20/2023, revealed maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. Review of the facility's Pest Control Monthly Service Report's dated 01/24/2024 at 11:30 AM, 02/22/2024 at 11:30 AM, 03/28/2024 at 12:35 PM, 04/24/2024 at 12:00 PM, 05/23/2024 at 1:40 PM, and 06/21/2024 at 12:20 PM, revealed the pest control company treated the facility's exterior perimeter and points of entry. Further review service reports revealed it was for general services, but did not list the specific type of treatment provided. Review of the facility's document titled, Pest Sighting Log, not dated, revealed on 05/21/2024 at 9:00 AM, twenty flies were found and killed at the 200 Hall nurse's station and ten flies were found and killed in R45's room. On 05/27/2024 at 10:00 AM twelve flies were found in the employee breakroom and bathroom but only four were killed. On 06/01/2024 at 10:00 AM, ten flies were found and killed in R45's room. On 06/01/2024 at 11:00 AM, 15 flies were found and killed at the 200 Hall Nurse Station. On 06/01/2024 at 1:00 PM 10 flies were found and killed in the room of Resident (R) 63. On 06/01/2024 at 7:00 AM, 10 flies were found and killed in R4's room . On 06/02/2024 at 2:00 PM, 10 flies were found and killed at the Nurse Station on 200 Hall. On 06/02/2024 at 6:00 PM, eight flies were found and killed in the room of R37. On 06/02/2024 at 6:00 PM, four flies were found and killed in the room of R63. On 06/09/2024 at 10:45 AM, three flies were found and killed in the room of R53. On 06/23/2024 at 6:10 PM, observation revealed four flies swarming on the 200 Hall and dining room area. On 06/23/2024 at 6:23 PM, observation revealed four flies swarming in Resident (R) 37's room and one fly landing on resident's arm and another one landing on the resident's bed. On 06/24/2024 at 2:28 PM, observation revealed three flies in R45's room and one (1) on the resident's bed. On 06/25/2024 at 10:00 AM, observation revealed three flies swarming on the 200 Hall of the facility. Observation on 06/26/2024 at 1:27 PM revealed flies in R45's room with three (3) flies resting near the resident's thigh. Also, five (5) additional flies were noted swarming over the resident's bed. Nursing staff was observed to be waving their hands to shoo the flies away. On 06/26/2024 at 1:40 PM, observation revealed four (4) flies swarming around Hall 200 and in and out of multiple residents' rooms. During an interview with State Registered Nurse Aide (SRNA) 4, at this time, she stated the flies were a problem all over the facility. Observation on 06/27/2024 at 1:42 PM revealed flies in R45's room with one fly on the resident's face and one fly on the left side of the resident's neck. During an interview with R45, at this time, she stated that she did not like the flies on her and that they made her feel bad. Record review revealed the facility admitted R45 on 12/16/2020 with diagnoses to include [NAME]-[NAME] Syndrome, Lymphedema, and Unspecified Intellectual Disabilities. Review of R45's Quarterly Minimum Data Set Assessment with an Assessment Reference Date (ARD) of 04/08/2024 revealed the facility assessed R45 to have a Brief Interview for Mental Status (BIMS) Score of fourteen (14) out of fifteen (15). This score indicated the resident was cognitively intact. In an interview with R45 on 06/24/2024 at 2:28 PM, she stated that she has had lots of flies in her room at times, and had maggots on her legs at least two (2) times. In an interview with SRNA6 on 06/26/2024 at 2:45 PM, she stated she has seen numerous flies throughout the facility and that they seem to be a persistent problem. During an interview with SRNA4 on 06/26/2024 at 1:40 PM, she stated the flies were a problem all over the facility. In an interview with Registered Nurse (RN) 4 on 06/27/2024 at 2:10 PM, she stated they have logged pest sightings on the pest control logbook that was located at the nurse's station. She stated they also reported the fly problem to Maintenance and they appeared to have been working on it. She stated the facility gave out fly swatters, and put up pest control light stations to try and combat the flies. RN4 stated she couldn't recall when these measures were put in place. She stated she felt there was more the facility could do to help get rid of the flies. She stated she last saw pest control at the facility about a month ago. The State Survey Agency (SSA) surveyor contacted the facility's Pest Control Company on 06/25/2024 at 9:40 AM and on 06/27/2024 at 3:55 PM, with no response or return call. In an interview with the facility's Maintenance Director on 06/27/2024 at 3:17 PM, he stated he had been the maintenance director since 09/2023. He stated that the current pest control company had always been the pest control provider and there had not been any considerations made by him or administration to seek other pest control companies. He stated that the current company was doing ok. He stated this year had been a rough year for pest control in general, and ever since spring hit this year the pest control became an issue. He further stated they had not located a point of entry for the flies. The Maintenance Director further stated he provided fly swatters, and made sure the windows were screened. In an interview with the Administrator on 06/28/2024 at 1:23 PM, she stated that they have pest control come monthly. She stated they had also, placed fly lights in R45's room, given out fly swatters, placed air blowers over some of the exit doors, and tried to keep the windows shut. The Administrator stated she had to educate R45 on keeping the windows shut. She stated she had no issues with the current pest control company and thought they had been the best company thus far. The Administrator stated she felt that they had done the best they could to control the flies in the facility. She stated they were working on adding more blowers to the outside to help control them and keep them away from the entrances. The Administrator further stated it was difficult because they were out in the middle of fields and located next to a creek bed, where the pests just tend to be in abundance.

Based on interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of three (3) resident was free from a significant medication error (Resident #1). Resident #1 was admitted with a Hospital Discharge Order for [MEDICATION(S)] (anti-psychotic) 234 milligrams (mg) intramuscularly (IM) every thirty (30) days, however; the facility nurse failed to transcribe the medication to the facility Physician Order and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in the resident having an increase in behaviors. The Findings include: Review of the facility policy titled, Reconciliation of Medications on Admission revealed, the purpose of this procedure is to ensure medication safety by accurately accounting for the residents medications, routes and dosages upon admission and readmission. Under General Guidelines 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care. 2. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosage and routes, during the admission/transfer process. Under steps in the procedure 6. If there is a discrepancy or conflict in medications, dose, route or frequency, determine the most appropriated action to resolve the discrepancy. For example: a. Contact the nurse from the referring facility, b. contact the physician from the referring facility. d. contact the residents primary physician in the community. e. contact the residents secondary physician(s) in the community. g. contact the admitting and /or Attending physician. further review of the policy revealed on 05/01/2020, the following was written on the policy revealed the following was written on the policy by the Director of Nurse (DON): 9. two nurses are to check and verify medications and PCC orders, print admit plan of service (POS) with three signatures. Review of the facility policy titled Adverse Consequences and Medication Errors, last revised April 2014 revealed: . 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physicians orders, manufacturer specifications, or accepted professional standards and principles of the professional providing service. 6. Examples of medications error include: a. Omission - a drug is ordered but not administered. Review of the facility policy titled, Administering Medications last revised December 2012 revealed medications shall be administered in a safe and timely manner, as prescribed.3. Medications must be administered in accordance with the orders, including any required time frame. Record review revealed, the facility admitted Resident #1 on 02/25/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment, dated 03/02/2020 revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of (11) which indicated the resident was interviewable. Review of the Hospital Discharge Summary dated 02/25/2020 revealed [MEDICATION(S)] 234 milligrams (mg) intramuscularly (IM) last given on 02/17/2020; next injection due in thirty (30) days. Review of Resident #1's hospital discharge medication list, dated 02/25/2020 at 3:30 PM revealed This is a list of medications that you should continue taking. with [MEDICATION(S)] (trade name: [MEDICATION(S)]) 234 MG IM every thirty days every month (Q month) to take (RX) instructions: next dose due 03/17/2020 listed. Further review at the end of the discharge medications was a written statement of This is the list of the medications for you to take upon discharge from the hospital. Be sure to follow this list and do not take any additional prescription medication not on this list without first discussing it with your doctor. Call your doctor if there are any issues with your medication. Review of the Physician Orders dated 02/25/2020, March 2020, and April 2020 revealed there was no order for [MEDICATION(S)] IM Injections. Review of the February, March, and April 2020 Medication Administration Records (MAR's) revealed, no [MEDICATION(S)] IM Injection listed to be administered. Review of the Nursing Progress Notes dated 04/23/2020 revealed Resident #1 was sent to the hospital on 04/23/2020 due to being unresponsive and was admitted with [CONDITION(S)] and [CONDITION(S)]. Review of Nursing Progress Notes written by the Director of Nursing (DON), dated 04/29/2020 at 12:21 PM, revealed there was a medication error identified because the hospital called asking when the resident's last [MEDICATION(S)] IM was administered. Review of a Medication Error Report dated 04/29/2020 at 12:17 PM completed by the DON, revealed the hospital called and asked if Resident #1 had received his/her [MEDICATION(S)] shot. The Report showed the Discharge Orders dated 02/28/2020 were reviewed per two nurses, and it was noted to have [MEDICATION(S)] IM injection on medication list and the Medical Doctor (MD) notified. Further review of the report under Other Information, revealed Nurse admitting resident had question in regards to ordered medication and forgot to follow through with MD. Review of the Hospital Discharge Summary, revealed Resident #1 was hospitalized from 05/01/2020 to 05/07/2020 due to increased confusion, delusional thinking, agitation and inability to contract for safety. The resident had progressively worsen behaviors at the nursing home prior to this admission. Further review of the summary revealed Resident #1's [CONDITION(S)] medications were assessed, it was noted that the Resident had not received his/her [MEDICATION(S)] injection the last two (2) months so this medication was administered, and the Resident responded well to the medicaton and symptoms improved. Next dose due on 05/30/2020. Interview with Registered Nurse (RN) #1 on 08/13/2020 at 2:54 PM revealed, there was a med error for Resident #1 related to his/her [MEDICATION(S)] injection. She stated she thought Resident #1 had to have approval for the injection and thought they were waiting on approval for the injection to come in. Interview with Resident #1's Psychiatric Physician on 08/13/2020 at 1:41 PM revealed, he was notified Resident #1 did not receive his/her [MEDICATION(S)] IM injection for two (2) months. He stated the facility failing to administer Resident #1's [MEDICATION(S)] IM injection would make a big difference in Resident #1's behavior due to [MEDICATION(S)] being an anti-psychotic medication and Resident #1 needed it. He stated it was good Resident #1 was taking the oral form of [MEDICATION(S)] now until the [MEDICATION(S)] IM injection could be obtained. Interview with the Director of Nursing (DON) on 08/13/2020 at 2:24 PM revealed, Resident #1 was admitted to the facility on [DATE] from another facility. The DON stated Resident #1 had orders for [MEDICATION(S)] IM injection to be given monthly on the admission/discharge orders and normally the Interdisciplinary Team (IDT) and the Nurses reviews the admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She revealed the discharge orders are used to compare to the facility orders that are put in the computer on admission and staff were also encouraged to have a peer check their orders. She stated RN #1 admitted Resident #1 and believed they just missed the [MEDICATION(S)] IM injection because it was at the top of the orders which made staff believe it was a stopped medication. She revealed Resident #1 received the [MEDICATION(S)] IM injection prior to admission in February 2020 but missed the March injection and received April's injection at the end of April while in the hospital; however, the April injection was due on 04/13/2020. She stated Resident #1 was put on the oral form of [MEDICATION(S)] at the end of May 2020. The facility implemented the following actions to correct the deficient practice: 1. RN #1 was disciplined and educated on Medications Reconciliation Policy and Admission and Re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. A Medication Error Report was completed on 04/29/2020 at 12:17 PM by the DON. 3. Clinical Meeting and Risk Meeting was held on 05/01/2020 to check all orders. of new admits. Staff went through and checked all orders with the hospital orders to ensure all orders were carried through and on MAR Medical Records, Assistant Director of Nursing (ADON), DON, MDS RN, Staff RN, and the Staffing Development Coordinator (SDC) attended the meeting 4. Education on the Admission/Re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The procedure was as follows: 1. All medications are to be placed into (PCC) Point Click Care upon admit. 2. Two nurses are then to go over the medication orders to ensure accuracy in PCC. 3. The admit (POS) is to be printed with three signature lines: Two lines to be signed by admitting nurse, the other line for verifying nurse and third line is for MD signature. 4. The clinical (IDT) will go over the admit orders for accuracy the next working business day. The policy was to ensure double checking what is on the hospital discharge summary/orders to make sure they match what's in the computer (PCC) 5. Audits were conducted daily on Admission/Re-Admissions to ensure orders were correct, matched the hospital discharge/admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 6. Resident #1 was started on Oral [MEDICATION(S)] tablet Extended release twenty four (24) hour nine (9) milligram (mg) ([MEDICATION(S)] ER) 9 mg by mouth one time a day on 05/30/2020. The State Survey Agency validated the corrective action taken by the facility as follows: 1. Interview with the DON on 08/14/2020 at 3:42 PM revealed RN #1 was educated on 05/01/2020 on the Medication Reconciliation of Medications Policy and on Admission and Re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with RN #1 on 08/13/2020 at 2:54 PM revealed she received disciplinary action and education related to Medication Reconciliation Policy and orders. 2. Review of a Medication Error Report dated 04/29/2020 at 12:17 PM revealed Resident #1 did not receive [MEDICATION(S)] injections for two months due to the nurse having a question in regards to the ordered medication and she forgot to follow through with MD. 3. Review of the clinical Meeting and Risk Meeting dated 05/01/2020 revealed the staff attending went through and checked all orders with the hospital orders to ensure all orders were carried through and on MAR. 4. Review of Education dated 05/01/2020 and sign in sheet dated 05/15/2020 revealed all Administrative and Staff Nurses were educated on the Medication Reconciliation Policy and Admission/Re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interviews on 08/13/2020 with RN #1 at 2:54 PM and Licensed Practical Nurse (LPN) #5 on 08/13/2020 at 11:35 AM; and on 08/14/2020 with the Clinical Educator at 8:50 AM, LPN #2 at 9:29 AM, LPN #3 at 9:31 AM, and LPN #1 at 9:35 AM, revealed they were educated on Reconciliation of Medications and Admission and Re-admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 5. A review of the audit sheets dated 05/04/2020 through 07/30/2020 revealed dates/names of new admits: with orders checked with discharge paperwork to ensure all physician orders carried through. Interview with the DON on 08/14/2020 at 3:42 PM revealed staff reviewed every admit from 05/01/2020 through 08/01/2020. Orders check already on the the audits they do, a management checklist. The DON stated she wrote it in the policy on 05/01/2020 for two (2) Nurses are to check and verify medications and (PCC) orders, print admit (POS) with three signatures to include the admitting nurse, the verifying nurse and the physician. That is what they were educated on and all was completed by 05/15/2020. Interview with the Administrator on 08/14/2020 at 10:40 AM revealed, Resident #1 error reported as a medication error. Performance Improvement Plan started, made the notifications to the Physicians and Guardianship. Education done to all Nurses on policy Medication Reconciliation and placed in the (QAPI) Quality Assurance Performance Improvement plan. The policy, education on Medication Reconciliation put in place to double check orders from the hospital to ensure the orders are correct 6. Review of Hospital record and May 2020 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was started on Oral [MEDICATION(S)] tablet Extended release twenty four (24) hour nine (9) milligram (mg) ([MEDICATION(S)] ER) by mouth one time a day on 05/30/2020 due to not being able to obtain IM [MEDICATION(S)] through Veterans Administration.

Based on interview, record review, and facility policy review, the facility must develop and implement a Comprehensive, person-centered care plan for each resident, consistent with the resident rights that includes 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) resident, in the selected sample of four (4) residents (Resident #1). The facility failed to follow the Comprehensive Care Plan by ensuring Resident #1's bed sensor alarm was in working order at all times and placed where the resident could not reach it. The resident fell two (2) times on 02/09/2020 and one (1) time on 02/12/2020, requiring hospitalization for a subdural hematoma, left clavicle fracture and left scapular fracture with numerous skin tears and bruising. The findings include: Review of the facility policy titled, Comprehensive Assessment and the Care Delivery Process, last revised December, 2017, revealed comprehensive assessments will be conducted to assist in developing person-centered care plans. Decision making leads to a person-centered plan of care, including selection and implementation of interventions based on the assessment and information analysis. Periodic monitoring to review progress and adjust treatment as well as overall care and services as necessary. Record review revealed the facility admitted Resident #1 on 04/20/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of ten (10), indicating the resident was moderately cognitively impaired. Further review of the MDS revealed he/she required supervision of one (1) person to walk in the room. Balance during walking revealed the resident was not steady and unable to stabilize without human assist. Review of the Comprehensive Care Plan, dated 01/29/19, revealed the resident was at Risk for Falls related to gait/balance, and poor safety awareness due to fluctuating cognition. Interventions included to place a sensor alarm where the resident cannot reach it, and a pressure alarm to the bed, initiated on 07/20/19. 1. Review of the Nurse's Notes, dated 02/09/2020 at 8:58 AM, revealed the nurse was called into the room by a Certified Nurse Aide (CNA) due to him/her having slid out of bed on to the floor. She revealed his/her bed was raised and he/she did not have non-skid socks in place. There was no documented evidence that the alarm sounded. The resident was assessed with [REDACTED]. Interview with Licensed Practical Nurse (LPN) #4, on 02/18/2020 at 1:55 PM, revealed she had been Resident #1's nurse on 02/09/2020 that morning, at the time the resident fell . She revealed she was called into the room and found the resident sitting on the floor leaning against the bed. She revealed he/she had a small abrasion to the mid-back with no other injuries. She revealed the bed alarm was not sounding and found it had been turned off, and stated the resident had been trying to get to the bathroom at the time. She remembered several times explaining to him/her that the facility used the alarm to keep him/her from falling. Interview with CNA #2, on 02/19/2020 at 10:22 AM, revealed she had provided care for the resident on the date of 02/09/2020 on day shift. She revealed she had been in the resident's room a short time prior to the fall to change him/her. She went in the room to take the breakfast tray and found the resident sitting on the floor. She revealed he/she had apparently slid out of bed trying to get up. She revealed the resident did not have on nonskid socks. She also revealed there was no bed alarm alarming and did not recall seeing a bed alarm on the bed. She revealed she utilized the Kardex for each resident's care. Review of the POS [REDACTED]. The intervention was to keep the bed in low position and use gripper socks at all times. 2. Review of the Nurse's Notes, dated 02/09/2020 at 9:20 PM, revealed the nurse was called to room by a CNA and observed him/her lying face down beside the bed and night stand. He/she had a laceration to the left brow; his/her glasses were broken and had a skin tear to the left elbow. Emergency Medical Services (EMS) was notified for transfer to the local hospital at 10:45 PM. Review of a second (2nd) Nurse's Note, dated 02/09/2020 at 9:38 PM, revealed he/she was wearing non-skid socks; however, the bed alarm had not sounded, and it appeared the resident had possibly removed the alarm battery. Interview with LPN #1, on 02/20/2020 at 10:36 AM, revealed she was passing medications on 02/09/2020 on night shift at approximately 11:20 PM, when she was called into the room by a CNA, and found the resident lying on the floor. He/she complained of hurting all over, and was sent to the hospital for an evaluation. She revealed the bed alarm was not working, and believed that the resident had turned it off. She revealed she had not made rounds on him/her since coming on shift at 7:00 PM. She stated almost four and one half (4 1/2) hours had lapsed prior to her seeing him/her for the first time on that date, and she didn't make rounds first thing. She stated she would usually start her med pass and assess the residents as she got to them. She further revealed she didn't see anything wrong with waiting until medication pass to see the resident for the first time during the shift. She revealed she checked bed alarms at the time she was in the room giving medications. Interview with CNA #3, on 02/19/2020 at 10:33 AM, revealed she was providing care for the resident when he/she returned from the emergency room (ER) visit on 02/09/2020. She revealed on the morning of 02/10/2020, he/she complained of being extremely sore and hurting all over. She revealed he/she used the bed positioning buttons and raised the head of the bed up and down. He/she was confused at times and made comments about someone being in the room that wasn't there. She stated she was aware of the resident's care needs as written in the Comprehensive Care Plan and the CNA Kardex. 3. Review of the Nurse's Notes, dated 02/12/2020 at 8:00 AM, revealed the nurse was called to the room by a CNA and observed him/her on the floor, on his/her right side at the foot of the bed by the bathroom. Review of the Nurse's Notes revealed there was a laceration to his/her forehead and a skin tear to the right arm. Review of the hospital records revealed the resident had a subdural hematoma, a left clavicle fracture and multiple skin tears, bruising and abrasions. The resident was transferred to a higher level of care facility and treated for [REDACTED]. Interview with LPN #4, on 02/18/2020 at 1:55 PM, revealed she was his/her nurse on 02/12/2020. She revealed the bed alarm had sounded earlier that morning and she had went into the room and found the resident trying to get up. She revealed he/she used the call light if he/she needed something; however, if he/she was delusional, he/she tried to get out of bed by himself/herself. When she was called into the room after the fall, she noted the alarm was not sounding. Further checks revealed the alarm had been turned off. She revealed she thought the resident had turned the alarm off since he/she had turned it off in the past. She also revealed she did not know what to do to keep the resident from tampering with the alarm. She stated we have tried to hide it in the past but (he/she) finds it. She further revealed the resident could move the bed up and down and also raised the head of the bed up and down by himself/herself. She stated the Comprehensive Care Plan was written as a plan of care for each resident and I am to follow it as written. Interview with CNA #1, on 02/19/2020 at 9:40 AM, revealed she had taken care of him/her on 02/12/2020. She revealed she usually took someone in the room with her if the resident was agitated or confused. She revealed she checked and changed the resident at 6:15 AM. The next time she saw the resident, she was taking the breakfast tray into the room. She found him/her lying on the floor with puddles of blood surrounding him/her. The bed alarm was not sounding. He/she was lying close to the bathroom door. When she asked the resident what he/she was doing, he/she revealed was trying to get to his/her son. She further revealed the resident had taken the bed alarm apart. She revealed she was also aware of the resident's care needs as the Care Plan was available to view and go by for resident's care, and was to follow the plan of care accordingly. Review of the POS [REDACTED]. Also, possible medical cause of [MEDICAL CONDITION] Fibrillation or Trans Ischemic Attack (TIA). Intervention was to take hypo-static blood pressures for three (3) days and have the Medical Doctor review his/her medications after return from the hospital. Interview with the Clinical Educator, on 02/19/2020 at 3:41 PM, revealed she expected all nurses to do their rounds at the beginning of each shift. Alarms should be checked to ensure they worked properly. She revealed education had been provided for nurses and CNA's regarding making rounds and checking alarms. She stated she had educated staff on using the Comprehensive Care Plan and Kardex for resident care. Interview with the Director of Nursing (DON), on 02/20/2020 at 9:00 AM, revealed she had action plans for falls, bed and chair alarms. She revealed the facility was not equipped to do fifteen (15) minute checks on any resident unless it was an elopement. She stated the Interdisciplinary Team (IDT) went over all the falls and put interventions in place. She revealed there were alarm covers on order to try and keep the resident from turning the alarm off and taking it apart. She revealed nursing staff, when coming on shift, should make rounds on all residents, then start medication pass if needed. She stated she further expected all staff to follow the comprehensive care plan and CNA care plans as written.

Based on interview, record review, and facility policy review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents related to multiple falls for one (1) resident, in the selected sample of four (4) residents (Resident #1). The facility assessed and care planned Resident #1 to have a pressure alarm to the bed and to offer toileting frequently; however, the resident had three (3) unwitnessed falls, and with each fall the bed alarm did not sound, two (2) falls on 02/09/2020 and one (1) fall on 02/12/2020. The falls resulted in a [MEDICAL CONDITION] with a subdural hematoma, a left scapular fracture, left clavicular fracture with multiple bruising and skin tears. The resident was admitted to the hospital for pain control and wound/fracture care. The findings include: 1. Review of the facility policy, Accidents and Incidents - Investigating and Reporting, date reviewed 05/18/19, revealed the policy statement was, All accidents or incidents involving residents, employees, visitors vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The facility is to be in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. 2. Review of the facility policy, Falls - Clinical Protocol, revised September 2012, and reviewed 03/26/19, revealed the nurse shall assess and document/report the following: vital signs, recent injury, especially fracture or head injury, musculoskeletal function, observe for change in normal range of motion, weight bearing, etc., change in cognition or level of consciousness, neurological status, pain, frequency and number of falls since last Physician visit, precipitating factors, details on how fall occurred, all current medications and all active diagnoses. Based on the preceding assessment, the staff and Physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. 3. Review of the facility policy, Falls Management Program Guidelines, dated 12/01/18, revealed the purpose is to maintain a hazard free environment, mitigate fall risk factors and implement preventative measure. The facility recognizes even the most vigilant efforts may not prevent all falls and injuries. In those cases, intensive efforts will be directed toward minimizing or preventing injury. Record review revealed the facility admitted Resident #1 on 04/20/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of ten (10), indicating the resident was moderately cognitively impaired. Further review of the MDS revealed he/she required supervision of one (1) person to walk in the room. Balance during walking revealed the resident was not steady and unable to stabilize without human assist. Review of the Comprehensive Care Plan for Activities of Daily Living (ADL's) self-care performance deficit related to Alzheimer's, dated 04/12/19, revealed the resident required one (1) assist for transfer, and he/she was to use a call light for assistance. Review of the Certified Nurse Aide (CNA) Kardex, undated, revealed Resident #1 required an assist of one (1) staff for transfers. Review of the Physical Therapy Evaluation and Plan of Treatment, dated 02/04/2020, revealed the functional mobility assessment regarding gait on level services of total dependence. Further, the resident must have supervision/touching assistance when using a wheel device, such as a walker or rolator. 1. Review of Resident #1's Fall Risk Assessment, dated 02/09/2020 at 8:58 AM, revealed a score of 65, which indicated the resident was at high risk for falls. Review of the Nurse's Notes, dated 02/09/2020 at 8:58 AM, revealed the nurse was called into the room by a Certified Nurse Aide (CNA) due to him/her having slid out of bed on to the floor. She revealed his/her bed was raised and he/she did not have non-skid socks in place. There was no documented evidence that the alarm sounded. The resident was assessed with [REDACTED]. Review of the POS [REDACTED]. The intervention was to keep the bed in low position and use gripper socks at all times. Interview with Certified Nurse Aide (CNA) #2, on 02/19/2020 at 10:22 AM, revealed she had provided care for the resident on the date of 02/09/2020 on day shift. She revealed she had been in the resident's room a short time prior to the fall to change him/her. She went in the room to take the breakfast tray and found the resident sitting on the floor. She revealed he/she had apparently slid out of bed trying to get up. She revealed the resident did not have on nonskid socks. She also revealed there was no bed alarm alarming and did not recall seeing a bed alarm on the bed. Interview with Licensed Practical Nurse (LPN) #4, on 02/18/2020 at 1:55 PM, revealed she had been Resident #1's nurse on 02/09/2020 that morning, at the time the resident fell . She revealed she was called into the room and found the resident sitting on the floor leaning against the bed. She revealed he/she had a small abrasion to the mid-back with no other injuries. She revealed the bed alarm was not sounding and found it had been turned off, and stated the resident had been trying to get to the bathroom at the time. 2. Review of Resident #1's Fall Risk Assessment, on 02/09/2020 at 11:31 PM, revealed a score of 90, which revealed he/she was at high risk for falls. Review of the Nurse's Notes, dated 02/09/2020 at 9:20 PM, revealed the nurse was called to room by a CNA and observed him/her lying face down beside the bed and night stand. He/she had a laceration to the left brow; his/her glasses were broken and had a skin tear to the left elbow. Emergency Medical Services (EMS) was notified for transfer to the local hospital at 10:45 PM. Review of a second (2nd) Nurse's Note, dated 02/09/2020 at 9:38 PM, revealed he/she was wearing non-skid socks; however, the bed alarm had not sounded, and it appeared the resident had possibly removed the alarm battery. Review of the POS [REDACTED]. Intervention was to put grip strips on floor by bed. Interview with LPN #1, on 02/20/2020 at 10:36 AM, revealed she was passing medications on 02/09/2020 on night shift at approximately 11:20 PM, when she was called into the room by a CNA, and found the resident lying on the floor. He/she complained of hurting all over, and was sent to the hospital for an evaluation. She revealed the bed alarm was not working, and believed that the resident had turned it off. She revealed she had not made rounds on him/her since coming on shift at 7:00 PM. She stated almost four and one half (4 1/2) hours had lapsed prior to her seeing him/her for the first time on that date, and she didn't make rounds first thing. She stated she would usually start her med pass and assess the residents as she got to them. She further revealed she didn't see anything wrong with waiting until medication pass to see the resident for the first time during the shift. She revealed she checked bed alarms at the time she was in the room giving medications. Interview with CNA #3, on 02/19/2020 at 10:33 AM, revealed she was providing care for the resident when he/she returned from the emergency room (ER) visit on 02/09/2020. She revealed on the morning of 02/10/2020, he/she complained of being extremely sore and hurting all over. She revealed he/she used the bed positioning buttons and raised the head of the bed up and down. He/she was confused at times and made comments about someone being in the room that wasn't there. Review of the ER records revealed, on 02/10/2020, Resident #1 had a left scapular fracture. Further review revealed the laceration to the left eyebrow was closed, and the resident was transferred back to the facility. 3. Review of Resident #1's Fall Risk Assessment, on 02/12/2020 at 8:00 AM, revealed a score of 75, which revealed he/she was at high risk for falls. Review of the Nurse's Notes, dated 02/12/2020 at 8:00 AM, revealed the nurse was called to the room by a CNA and observed him/her on the floor, on his/her right side at the foot of the bed by the bathroom. Review of the Nurse's Notes revealed there was a laceration to his/her forehead and a skin tear to the right arm. Review of the hospital records revealed the resident had a subdural hematoma, a left clavicle fracture and multiple skin tears, bruising and abrasions. The resident was transferred to a higher level of care facility and treated for [REDACTED]. Review of the POS [REDACTED]. Also, possible medical cause of [MEDICAL CONDITION] Fibrillation or Trans Ischemic Attack (TIA). Intervention was to take hypo-static blood pressures for three (3) days and have the Medical Doctor review his/her medications after return from the hospital. Interview with LPN #4, on 02/18/2020 at 1:55 PM, revealed she was his/her nurse on 02/12/2020. She revealed the bed alarm had sounded earlier that morning and she had went into the room and found the resident trying to get up. She revealed he/she used the call light if he/she needed something; however, if he/she was delusional, he/she tried to get out of bed by himself/herself. When she was called into the room after the fall, she noted the alarm was not sounding. Further checks revealed the alarm had been turned off. She revealed she thought the resident had turned the alarm off since he/she had turned it off in the past. She also revealed she did not know what to do to keep the resident from tampering with the alarm. She stated we have tried to hide it in the past but (he/she) finds it. She further revealed the resident could move the bed up and down and also raised the head of the bed up and down by himself/herself. Interview with CNA #1, on 02/19/2020 at 9:40 AM, revealed she had taken care of the resident on 02/12/2020. She revealed she usually took someone in the room with her if he/she was agitated or confused. She revealed she checked and changed the resident at 6:15 AM on 02/12/2020. The next time she saw the resident, she was taking the breakfast tray into the room. She found him/her lying on the floor with puddles of blood surrounding him/her, lying close to the bathroom door, and the bed alarm was not sounding. When she asked the resident what he/she was doing, he/she revealed he/she was trying to get to his/her son. She further revealed the resident had taken the bed alarm apart. Interview with Resident #1's Physician, on 02/19/2020 at 2:22 PM, revealed he was aware of the resident's falls and felt like the facility had done everything to prevent the falls. However, he expected the bed alarms to work properly. Interview with the Clinical Educator, on 02/19/2020 at 3:41 PM, revealed she expected all nurses to do their rounds at the beginning of each shift. Alarms should be checked to ensure they worked properly. She revealed education had been provided for nurses and CNA's regarding making rounds and checking alarms. Interview with the Assistant Director of Nursing (ADON), on 02/20/2020 at 4:10 PM, revealed she expected nursing staff and CNA's to make rounds to check alarms, and they should start at the beginning of the shift. Interview with the Director of Nursing (DON), on 02/20/2020 at 9:00 AM, revealed she had action plans for falls, bed and chair alarms. She revealed the facility was not equipped to do fifteen (15) minute checks on any resident unless it was an elopement. She stated the Interdisciplinary Team (IDT) went over all the falls and put interventions in place. She revealed there were alarm covers on order to try and keep the resident from turning the alarm off and taking it apart. She revealed nursing staff, when coming on shift, should make rounds on all residents, then start medication pass if needed.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the services provided by the facility as outlined in the Comprehensive Care Plan must meet professional standards of quality related to administration of medications according to professional standards of practice for one (1) resident, in the selected sample of three (3) residents (Resident #5). Observation of a medication pass, on 02/18/2020, revealed Licensed Practical Nurse (LPN) #3 removed and recorded medication as given, while handing the medication off to LPN #4 to administer to Resident #5. The findings include: Review of the facility policy, Administering Medications reviewed 05/14/19, revealed medications shall be administered in a safe and timely manner and as prescribed. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medication. The individual administering the medication must initial the resident's Medication Administration Record [REDACTED]. Record review the facility admitted Resident #5 on 03/31/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15), which revealed he/she was cognitively intact and interviewable. Observation, on 02/18/2020 at 9:00 AM, upon entering the building while completing a short tour, this surveyor observed LPN #3 remove medications from the medication cart and proceed to sign off the medications. She then handed the medications to LPN #4, and LPN #4 proceeded into Resident #5's room. Interview with LPN #3, on 02/18/2020 at 9:10 AM, revealed she had given the medications to LPN #4 to administer to Resident #5. She revealed she was behind on giving medications and did not want to be late. She revealed she had done this before in the past. She revealed she knew she was not suppose to do it, but she wanted to catch up. She revealed she did not have enough time to administer all the morning medications prior to having to go to the dining area to be a licensed staff to help, if needed. Review of employee time revealed LPN #3 was habitually late. Interview with LPN #4, on 02/18/2020 at 1:55 PM, in regard to administering medications that another nurse pulled and signed off on, revealed there was not enough nurses to get all the medications passed in time. She revealed you have to come in early to complete them; however, review of employee time revealed LPN #4 was always habitually late. She revealed she was not suppose to give medications pulled by another nurse and signed off by the other nurse; however, she gave them. Interview with the Clinical Educator, on 02/18/2020 at 3:26 PM, revealed staff nurses were educated upon hire and yearly, regarding medication administration. She revealed there was also a test that must be passed prior to administering medications. She further revealed, even if a nurse was standing next to a nurse who was pulling medications, the nurse who actually pulled medication still gave the medication. She expected whomever pulled the medication, to give the medication and sign off, no exceptions. She revealed medication administration was a basic nursing task taught in nursing school. Interview with the Director of Nursing (DON), on 02/19/2020 at 11:39 AM, revealed she expected staff nurses to give only medications they pulled from the medication cart, with no exceptions. She further revealed LPN #3 had only been on time three (3) times in the last three months.

Based on interview, record review, and facility policy review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices that will meet each resident's physical, mental, and psychosocial needs for one (1) resident, in the selected sample of three (3) residents (Resident #1). Review of medical records found no documented evidence that Resident #1's alarm had been checked at the beginning of the shift or during the shift by Licensed Practical Nurse (LPN) #1. Resident #1 had three (3) falls from 02/09/2020 to 02/12/2020 which resulted in injuries and required hospitalization . Additionally, the fall on 02/09/2020 at 9:15 PM, happened during LPN #1's shift. The findings include: Review of the facility Job Description for Charge Nurse (LPN or RN) revealed the charge nurse would provide direct nursing care to the residents and supervise the day to day nursing activities performed by nursing assistants. Such supervision must be in accordance with current Federal, State, and Local standards, guidelines, and regulations that govern our facility and as may also be required by the Director of Nursing to maintain the highest degree of quality care at all times. Essential duties and responsibilities include to confirm that all nursing personnel assigned to the charge nurse comply with the written policies and procedures established by the facility. Perform routine charting duties as required and in accordance with established charting and documentation policies and procedures. Promptly respond to call lights and assist with other resident needs. Job requirements include strong attention to detail and accuracy, excellent organizational skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity. Record review revealed the facility admitted Resident #1 on 04/20/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of ten (10), which revealed the resident was moderately cognitively impaired. Further review of the MDS revealed the resident required supervision of one (1) person to walk in the room. Balance during walking revealed the resident was not steady and unable to stabilize without human assist. Review of the Comprehensive Care Plan for resident at Risk for Falls with a goal of resident will not sustain serious injury through the review initiated 01/29/19, revealed an intervention to place a sensor alarm where the resident cannot reach it, initiated 10/10/19, and a pressure alarm to the bed, initiated 07/20/19. Review of the February 2020 Physician order [REDACTED]. Review of the Treatment Administration Record (TAR) , date February 2020, revealed there were no alarm checks documented from 02/01/2020 to 02/18/2020. Interview with LPN #1, on 02/20/2020 at 10:36 AM, revealed when she came on shift on 02/09/2020 she did not check on the resident since she checked alarms and gave medication at the same time. She denied doing any resident assessments when she began her shift. She revealed she routinely went straight to the medication cart and started the medication pass, instead of assessments of residents. She revealed she was not aware the bed alarm checks were to be documented on the TARs. She revealed she had been educated on the alarms recently, but could not recall the date. Interview with the Clinical Educator, on 02/19/2020 at 3:41 PM, revealed all Charge Nurses should have documentation and do their rounds when they come and go to ensure the alarms worked. She revealed she had three (3) big nursing meetings about putting orders in, and audits on new orders, which should reflect the alarm checks. She also revealed she had educated the Certified Nurse Aides (CNA's) regarding making rounds and checking alarms. Interview with Director of Nursing (DON), on 02/19/2020 at 11:39 AM, revealed she had completed an audit in January 2020 and it revealed the nurses had not been documenting their checks for bed alarms. She further revealed she expected Charge Nurses to make rounds on all residents upon the start of the shift, and also document findings. She expected all staff to follow Physician Orders, Comprehensive Care Plans and all Charge Nurse duties to be carried out, no exceptions.

Based on observation, interview, record review, and facility policy review, the facility must 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. Standard and transmission-based precautions are to be followed to prevent spread of infections, for one (1) of three (3) sampled residents (Resident #4). During observation of medication administration, on 02/19/2020, eye drops were administered to Resident #4 by nursing staff without using standard precautions of gloving, on two (2) different occasions. The findings include: 1. Review of the facility policy, Personal Protective Equipment-Using Gloves revealed the purpose is to guide the use of gloves. Objectives included to prevent the spread of infection, to protect wounds from contaminating, to protect hands from potentially infectious material and prevent exposure [MEDICAL CONDITION](AIDS) and [MEDICAL CONDITION] (HBV) viruses from blood and body fluids. Use gloves when touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin. Wash hands prior to donning gloves. After task completed, remove gloves and wash hands. 2. Review of the facility policy, Instillation of Eye Drops, provided guidelines for instillation of eye drops to treat medical conditions, eye infections and dry eyes. Steps include to wash and dry hands thoroughly. Put on gloves. Lower eyelid down. Drop medication into mid lower eyelid. Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Record review revealed the facility admitted Resident #4's on 12/12/16 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status Score (BIMS) of 15, which indicated the resident was cognitively intact and interviewable. Review of Physician Orders, dated February 2020, revealed an order for [REDACTED]. Observation, on 02/19/2020 at 12:13 PM, revealed Licensed Practical Nurse (LPN) #2 instilled eye drops to Resident #4 without donning gloves. Also, observation on 02/19/2020 at 3:10 PM, revealed LPN #2 again instilled drops into Resident #4's eyes without donning gloves. Interview with LPN #2, on 02/19/2020 at 3:25 PM, revealed he does not use gloves when doing eye drops. He revealed he sanitized his hands and thought that was enough. He further revealed he could understand wearing gloves if he or the resident had an infectious disease. Interview with the Clinical Educator, on 02/19/2020 at 3:41 PM, revealed she expected all nurses to use gloves when giving eye drops or anything that would come in contact with mucus membranes, blood or body fluids. Interview with the Director of Nursing (DON), on 02/19/2020 at 4:10 PM, revealed she expected all nursing staff to follow the facility policy regarding administration of eye drops and personal protective equipment. She revealed it was not acceptable for nursing staff to give eye drops without gloves under no circumstances.

Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure one (1) of three (3) sampled residents' right to be free from neglect. Resident #1 asked to be changed due to being wet, and Certified Nurse Aide (CNA) #1 neglected the resident when she refused to change the resident, The findings include: Review of the facility's policy titled, Abuse and Neglect-Clinical Protocol, last revised July 2017, revealed Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Record review revealed the facility admitted Resident #1, on 07/24/19, with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change Minimum Data Set (MDS) Assessment, dated 09/26/19, revealed the facility assessed Resident #1's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was interviewable. Further review of the MDS assessment, Section G-Activities of Daily Living (ADL's) revealed Resident #1 required extensive assistance of two (2) staff for toileting needs. Review of the facility's initial report dated 12/25/19, revealed Resident #1 reported Certified Nurse Aide (CNA) #1 refused to change him/her and stated, No you son of a [***] , I've changed you more than anyone else in the building, I'm going to have them put a catheter in you. Resident #1 restated he/she needed to be changed, and CNA #1 continued to argue for a bit. Resident #1 further stated he/she called CNA #1 a [***] . Review of the facility five (5) day final report, dated 01/02/2020, revealed through investigation, observation, multiple interviews, and record reviews; the facility was unable to substantiate verbal abuse as the resident did not exhibit signs/symptoms of emotional distress related specifically to the alleged incident and there were no witnesses that were able to verify that it did occur; however, the facility concluded the behavior in general was very unprofessional and did not meet the facility's standard of culture. CNA #1 was terminated as of 01/02/2020. Interview with Resident #1 on 01/06/2020 at 2:19 PM, revealed on 12/25/19 he/she asked CNA #1 to change him/her because he/she was wet. Resident #1 stated CNA #1 said she had changed him/her several times already and was not going to change him/her again. Resident #1 revealed he had to wait until second shift cam in to be changed. In addition, Resident #1 revealed he/she became upset with CNA #1 after she called him/her a son of a [***] and refused to change him/her, so he/she called CNA #1 a [***] . The resident also stated CNA #1 stated she was going to tell staff to put a catheter in him. Resident #1 stated he/she felt humiliated and angry. Interview with CNA #1 on 01/07/2020 at 12:50 PM, revealed she had worked as an aide in the facility for six (6) years. She stated on 12/25/19 she had changed Resident #1 after lunch and shortly after he/she was yelling at her to change him/her again during the last round at approximately 12:00 PM. CNA #1 stated she asked the resident to wait a minute but Resident #1 came into the hallway and called her a [***] and she told him/her, she did not have to listen to this and walked away. Interview with Unsampled Resident A on 01/07/2020 at 12:05 PM, revealed he/she overheard Resident #1 and CNA #1 arguing outside in the hallway. He/she stated, I heard her tell him/her she wasn't going to change him/her right now. Unsampled Resident #4 could not recall if CNA #1 had called Resident #1 a name, or told the resident she was going to have staff put in a catheter Interview with CNA #2 on 01/07/2020 at 12:35 PM, revealed she worked second shift (2-11 PM), on 12/25/2019. She stated Resident #1 told her CNA #1 had called him/her a son of a [***] and had refused to change him/her. CNA #2 stated she assisted Resident #1, however, Resident #1 was not excessively wet, but sometimes dribbles urine on himself/herself. Interview with the Director of Nursing (DON), on 01/07/2020 at 1:53 PM, revealed CNA #1 was suspended once the Administrator was made aware of the allegation and was terminated shortly after. The DON stated she felt the aide acted unprofessionally but did not consider the incident verbal abuse. She further stated the aide may have been short with the resident but should not have denied the resident care. Interview with the Administrator, on 01/07/2020 at 2:10 PM, revealed CNA #1 was suspended pending the investigation outcome and was terminated due to unprofessional behavior. She stated Resident #1 had not mentioned not being changed during the investigation; however, review of the facility self report revealed the resident stated CNA #1 refused to provide care.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene for one (1) of three (3) sampled residents (Resident #1). Resident #1 requested to be changed due to being wet on 12/25/19; however, Certified Nurse Aide (CNA) #1 refused to change the resident. The findings include: Interview with the Director of Nursing (DON) on 01/07/2020 at 1:53 PM, revealed the facility did not have a specific policy related to Activities of Daily Living (ADL). She further stated the facility follows state and federal regulations related to resident ADL care. Record review revealed the facility admitted Resident #1, on 07/24/19, with [DIAGNOSES REDACTED]. Review of Resident #1's Significant Change in status Minimum Data Set (MDS) Assessment, dated 09/26/19, revealed the facility assessed Resident #1 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), which indicated the resident was interviewable. Further review of the MDS Assessment, dated 09/26/19, Section G-Activities of Daily Living (ADL's) revealed Resident #1 required extensive assistance of two (2) staff for toileting needs Review of Resident #1's Comprehensive Care Plan for limited physical mobility related to Neurological deficits, dated 11/07/19, the resident was incontinent of bladder and required assistance of one (1) staff member for toileting. Interview with Resident #1 on 01/06/2020 at 2:19 PM, revealed on 12/25/19 he/she asked CNA #1 to change him/her because he/she was wet. Resident #1 stated CNA #1 said she had changed him/her several times already and was not going to do so. Resident #1 stated he/she became upset with CNA #1 after she called him/her a son of a [***] and refused to change him/her. Resident #1 stated he/she then called CNA #1 a [***] and had to wait until second shift staff to come in to be changed (approximately two (2) hours). Resident #1 further stated he/she felt humiliated and angry. Interview with CNA #1 on 01/07/2020 at 12:50 PM, revealed she had worked as an aide in the facility for six (6) years. She stated on 12/25/19 she had changed Resident #1 after lunch (approximately 12:00 PM) and shortly after the resident was yelling at her to change him/her again during the last round (approximate time 12:00 PM, after lunch). CNA #1 stated she asked the resident to wait a minute but Resident #1 came into the hallway and called her a [***] and she told him/her she did not have to listen to this and walked away. Interview with Unsampled Resident #4 on 01/07/2020 12:05 PM, revealed he/she overheard Resident #1 and CNA #1 arguing outside in the hallway. He/she stated, I heard her tell him/her she wasn't going to change him/her right now. Interview with CNA #2 on 01/07/2020 at 12:35 PM, revealed she worked second shift 2-11 PM, on 12/25/2019. She stated Resident #1 told her CNA #1 had called him/her a son of a [***] and had refused to change him/her. CNA #2 stated she assisted Resident #1, however, Resident #1 was not excessively wet, but sometimes dribbles urine on himself/herself. Interview with the DON, on 01/07/2020 at 1:53 PM, revealed CNA #1 was suspended once the Administrator was made aware of the allegation and was terminated shortly after. The DON stated the aide may have been short with the resident but should not have denied the resident care. Interview with the Administrator, on 01/07/2020 at 2:10 PM, revealed CNA #1 was suspended, then terminated due to unprofessional behavior. She stated Resident #1 had not mentioned not being changed during the investigation.

Based on interview, record review and facility policy review, it was determined the facility failed to ensure Medical records, were complete and accurately documented for one (1) of three (3) sampled residents (Resident #1). Staff failed to document Resident #1's meal intake for twenty-two (22)meals in June 2019. The findings include: Review of facility policy titled, Charting and Documentation, last revised July 2017, revealed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record shall facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 1. Documentation in the medical record may be electronic, manual, or a combination. 2. The following information is to be documented in the residents medical record: a. Objective observations b. Medications administered c. Treatments or services performed d. Changes in the resident's condition e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in he care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. Record review revealed the facility readmitted Resident #1 on 12/10/18, with [DIAGNOSES REDACTED]. Review of Resident #1's Nutrition-Meals and Fluids intake flow sheet for June 2019, revealed a total of twenty-two (22) meals were not recorded during this month. Interviews on 07/11/19 with Certified Nurse Aide (CNA) #1 at 2:26 PM, and CNA #2 at 3:04 PM, revealed Resident #1's family visits daily and feeds him/her most meals. CNA's #1 and #2 stated they should have documented the resident's meal intake and not left the form blank. Interview with the Registered Dietitian (RD) on 07/11/19 at 11:10 AM, revealed she would expect the nurse aides to record the residents meal consumption's daily. She stated she reviews the residents meal consumption records in order to make an accurate nutritional assessment and initiate appropriate interventions to address weight loss. Interview with the Director of Nursing (DON) on 07/12/19 at 1:35 PM, revealed the aides are expected to document resident's meal intakes daily. She further stated the documentation is important in order to evaluate and assess a residents nutritional needs

Based on 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 (Resident #1). Staff failed to document Resident #1's meal intakes twenty-two (22) times in June 2019 so the Registered Dietician would be able to make an accurate nutritional assessment and initiate appropriate interventions to address weight loss. The findings include: Review of the facility policy titled, Weight Assessment and Intervention, last revised September 2008, revealed the interdisciplinary team will strive to prevent, monitor, and intervene for unstable weight loss for residents. Further review of the policy revealed assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the appropriate calorie, protein, and other nutrient needs compared with the residents current intake. Interventions for undesirable weight loss shall be based on careful consideration of nutrition and hydration needs of the resident. Record review revealed the facility readmitted Resident #1 on 12/10/18, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 06/27/19, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of six (6), which indicated the resident was not interviewable. Review of Resident #1's Comprehensive Care Plan dated 03/14/19, revealed the resident has expected weight loss related to metastatic [MEDICAL CONDITION], with a resident goal of consuming fifty (50) percent, two (2) or three (3) meals per day. Further review of the care plan revealed interventions to include monitor and evaluate any weight loss, and to monitor and record food intake at each meal. Review of the Nutrition Progress Note dated 05/28/19, revealed a weight loss of thirteen (13) percent in the last three (3) months and no significant weight loss for the last month. Further review of the note revealed intake per nursing varied between twenty-five and seventy-five percent (25-75 %) of meals. Review of Resident #1's Nutrition-Meals and Fluids intake flow sheet for June 2019, revealed a total of twenty-two (22) meals were not recorded during this month. Interview with Certified Nurse Aide (CNA) #1 on 07/11/19 at 2:26 PM, revealed she provided care to Resident #1 multiple shifts during the month of June 2019. She stated Resident #1's family visits daily and feeds him/her most meals. CNA #1 revealed she did not document Resident #1's meals because she was not sure how much Resident #1 had eaten because his/her meal tray had already been picked up. She further stated documentation should be completed daily and staff may work over to complete their charting if needed. Interview with CNA #2 on 07/11/19 at 3:04 PM, revealed she had provided care to Resident #1 during June 2019 and may have gotten busy and did not ask Resident #1's family about his/her meal intake. She stated she should have followed through and documented the resident's meals because it should be done before she leaves and not left blank. Interview with the Registered Dietitian (RD) on 07/11/19 at 11:10 AM, revealed she reviews the residents meal consumption records in order to make an accurate nutritional assessment and initiate appropriate interventions to address weight loss. The RD further stated she would expect the nurse aides to record the residents meal consumption's daily. Interview with the Director of Nursing (DON) on 07/12/19 at 1:35 PM, revealed the aides are expected to document residents' meal intakes daily. She stated the documentation is important in order to evaluate and assess a residents nutritional needs.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the infection prevention and control program to address scabies was effective for five (5) of five (5) residents who acquired scabies (Residents #1, #2, #3, #4, and #5). The facility identified Resident #3 with a possible case of crusted scabies with treatment provided. On 03/20/19 the facility identified Resident #5 had crusted scabies and called the local Epidemiologist for recommendations, however, the facility failed to follow the recommendations to treat all staff and residents who had contact with the resident in the last two (2) months. On 03/27/19, the facility identified Resident #1 also had scabies and called the local Epidemiologist for recommendations; however, the facility failed to follow the recommendations to treat all residents and staff due to the facility's long history of rashes. The findings include: Review of facility policy titled, Scabies Identification, Treatment and Environmental Cleaning Level III, last revised August 2016 revealed the purpose of this procedure was to treat residents infected with and sensitized to Sarcoptes scabiei and to prevent the spread of scabies to other residents and staff. Secondary bacterial skin infections may result from untreated scabies. Incubation period can be two to six (2-6) weeks before onset of itching for persons with no previous exposure. Persons who previously have been infested develop more rapid symptoms, 1-4 days after re-exposure. Scabies is spread by skin-to-skin contact with the infected area, or through contact with bedding, clothing privacy curtains and some furniture. Failure to identify positive scrapings does not necessarily exclude the diagnosis. It is difficult to obtain a positive scraping because only one (1) or two (2) mites may cause multiple [MEDICAL CONDITION] so often [DIAGNOSES REDACTED]. Further review revealed during an outbreak among residents/personnel, the ICN or Committee will coordinate interdepartmental planning to facilitate a rapid and effective treatment program. Control of an epidemic depends on treating all residents at risk; use of Ivermectin PO (Per Os) should be considered during widespread outbreak and or when treatment with a topical medication is unsuccessful Environmental Control: Crusted/Atypical Scabies: maintain precautions until treatment is complete and/or resident is determined (by dermatologist/PCP) to be scabies free. Review of CDC guidelines Parasites-Control, not dated revealed a scabies outbreak that transmission has been occurring within the institution for several weeks to months-thus increasing the likelihood that some infested staff or patients may have had time to spread scabies elsewhere in the community, including to other facilities. Control measures for a single case of non-crusted scabies should consist of heightened surveillance for early detection of new cases, proper use of infection control measures when handling patients (e.g. avoidance of direct skin to skin contact, handwashing, etc.), conformation of the [DIAGNOSES REDACTED]. In addition, the guidelines indicated measures to control scabies in an institution depends on factors such as whether any of the cases are crusted (Norwegian) scabies. Because it is highly transmissible, crusted scabies requires rapid and aggressive detection, diagnosis, infection control, and treatment measures to prevent and control spread. The local health department should be notified of any outbreak that may have community implications, including possible spread by patients or staff to other institutions. Control measures for multiple cases of non-crusted scabies should consist of [MEDICATION NAME] treatment of [REDACTED]. Unrecognized crusted scabies often is the source of institutional outbreaks of scabies. Infection control personnel and dermatologists should be involved as soon as scabies suspected in an institution; all staff, volunteers, and visitors who may have been exposed to a patient with crusted scabies should be identified and treated. All potentially exposed patients, staff, visitors, and family members should be treated at the same time to prevent re-exposure. Remember that symptoms of scabies can take weeks to appear the first time a person is infested; however, the person can still spread scabies during this asymptomatic period. Review of information provided by Epidemiologist revealed to prevent the spread of scabies the persons with symptoms should be checked and treated by their doctor as quickly as possible, and household members and other persons with skin-to-skin contact should be preventively treated. 1. Record review revealed the facility admitted Resident #3 on 05/13/14 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE] revealed the facility assessed Resident #3's cognition as intact with a BIMS score of fifteen (15) which indicated the resident was interviewable. Review of Resident #3's Progress Notes revealed on 01/26/19 to apply [MEDICATION NAME] Cream 0.1% apply to rash on back, shoulders, topically every (12) twelve hours as needed for rash. On 2/20/19, Resident #3 complained specifically about his/her hands and held hands up to staff and said look at my hands. The DON assessed hands and believes could possibly be [REDACTED] with contact isolation precautions initiated. The POA and Physician notified and awaiting reply. On 02/21/19, physician replied stating he would assess resident rash when he does rounds this week. On 02/22/19, Resident #3 placed on isolation precautions related to possible [REDACTED]. [MEDICATION NAME] body lotion applied as ordered to reduce itching with dermatologist visit scheduled for 02/25/19. Review of a Rash Timeline provided by the Infection Control Nurse on 05/14/19 revealed Resident #3 with dermatologist appointment on 02/25/19 with prescription of Ivermectin, [MEDICATION NAME] cream and [MEDICATION NAME] cream. Further review of the timeline revealed documentation on 02/26/19 that [MEDICATION NAME] cream was applied to Resident #3 and left on for (8) eight hours then showered and room was deep cleaned and all items washed or bagged. Review of Nursing Progress Note dated 03/23/19 revealed the resident with rash and barrier cream to skin. Review of Hospital Record and emergency room Note dated 03/23/19 revealed Resident #3 to be placed on Hospice related to acute kidney failure with [MEDICAL CONDITION] and septic shock. Further review of the resident's record revealed the resident passed away on 03/27/19. 2. Record review revealed the facility admitted Resident #5 on 05/31/17 with [DIAGNOSES REDACTED]. Review of Quarterly MDS assessment, dated 01/27/19 revealed the facility assessed Resident #5's cognition as severely impaired with a BIMS score of seven (7) which indicated the resident was not interviewable. Review of Nursing Progress Notes dated 03/20/19 revealed Advanced Registered Nurse Practitioner (ARNP) to see Resident #5's hands; with order for [MEDICATION NAME] cream and Ivermectin by mouth. Review of March 2019 MAR indicated [REDACTED].) by mouth, one time only for scabies for one day for day #1, day #2, day #8, and day #9; and, [MEDICATION NAME] Cream 2%, apply to hands bilateral topically (BID) two times a day for itching X (4) four weeks to rash on bilateral hands; all with a start date on 03/21/19. Review of Resident #5's March 2019 MAR indicated [REDACTED]. Review of a Rash Timeline provided by the Infection Control Nurse on 05/14/19 revealed on 03/20/19, Resident #5 was diagnosed with [REDACTED]. On 03/21/19, a call was made to the local Epidemiologist and she was made aware of Resident #5's [DIAGNOSES REDACTED]. The Epidemiologist was asked for further instructions and she advised the Infection Control Nurse the treatment of [REDACTED]. The Corporate Consulting Nurse (CNC) was notified and waiting for advisement from CNC. However, interview with Infection Control Nurse on 05/14/19 at 3:20 PM and on 05/16/19 at 10:06 AM revealed regional looked into it and decided the facility was not going to follow the recommendations by the health department epidemiologist. 3. Record review revealed the facility readmitted Resident #1 on 06/15/18 with [DIAGNOSES REDACTED].#1's cognition as intact with a Brief Interview of Mental Status (BIMS) score of fourteen (14) which indicated the resident was interviewable. Review of a Dermatologist Report dated 03/27/19 revealed Resident #1 with scabies of abdomen, arms, legs, back and positive for mites; with instruction for process of bedding, clothes to be done initially and followed up with same procedure in one week for treatment of [REDACTED]. Review of Dermatology Encounter dated 03/27/19 revealed resident to be treated with Ivermectin tablets 100 milligrams (mg) X (14) fourteen days. Review of March 2019 Medication Administration Record [REDACTED] Further review of the Rash Timeline, revealed Resident #1 was diagnosed with [REDACTED]. On 03/27/19, the CNC was notified of new scabies [DIAGNOSES REDACTED]. On 03/27/19 at 2:15 PM, a call was made to local epidemiologist at health department for further instructions after identifying Resident #1 was diagnosed with [REDACTED]. However, interview with the Infection Control Nurse on 05/14/19 at 3:20 PM and on 05/16/19 at 10:06 AM revealed regional looked into it and decided the facility was not going to follow the recommendations by the health department epidemiologist. In addition, interview with the Director of Nursling (DON) on 05/14/19 at 2:12 PM and 5:15 PM, and on 05/16/19 at 10:29 AM revealed the Infection Control Nurse discussed the recommendations with her, the CNC, and the Administrator and the CNC said to follow facility policy and procedure and they did follow their policies. Review of Skin assessment dated [DATE] revealed Resident #1 with existing rash and treatment in progress with improvement. 4. Record review revealed the facility admitted Resident #2 on 05/16/17 with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment, dated 04/01/19 revealed the facility assessed Resident #2's cognition as severely impaired with a BIMS score of six (6) which indicated the resident was not interviewable. Review of Progress Notes dated 04/02/19, 04/03/19, and 04/15/19 revealed Resident #3 was treated with [MEDICATION NAME] allergy tablets give (1) one tablet every six (6) hours q6h as needed (PRN) for itching, CereVe lotion every AM and evening especially to bilateral arms for [MEDICAL CONDITION], and [MEDICATION NAME] cream to rash. Review of Resident #2's Weekly Skin assessment dated [DATE] revealed the resident had a rash to upper trunk, shoulders abdominal area and bilateral arms with treatment in progress. Review of a Rash Timeline provided by the Infection Control Nurse on 05/14/19 revealed on 05/01/19, Resident #2 complained of itching with [MEDICATION NAME] lotion prescribed and no rash present. On 05/12/19, [MEDICATION NAME] IM and [MEDICATION NAME] cream and contact isolation ordered for Resident #2. On 05/13/19, [MEDICATION NAME] cream was applied to Resident #2. Observation on 05/14/19 at 7:43 PM of Resident #2 revealed Resident #2 scratching abdomen and stating this is itching me to death. 5. Record review revealed the facility admitted Resident #4 on 04/17/18 with [DIAGNOSES REDACTED]. Review of Quarterly MDS assessment, dated 03/18/19 revealed the facility assessed Resident #4's cognition as intact with a BIMS score of fifteen (15) which indicated the resident as interviewable. Review of Order Listing Report dated 05/15/19 revealed Resident #4 to have order for [MEDICATION NAME] Cream 5% apply to neck down to toes topically every day shift for rash until 05/28/19. Observation on 05/13-16/19 revealed Resident #4 was on contact precautions on 05/13-16/19. Interview on 05/14/19 at 10:01 AM with Resident #4 revealed he/she was still breaking out and still itching. Review of handwritten list provided by DON on 05/15/19 revealed Resident #4 with light rash on abdominal area. Review of a Rash Timeline provided by the Infection Control Nurse on 05/14/19 revealed on 05/12/19, Resident #4 was ordered [MEDICATION NAME] cream and contact isolation. On 05/13/19, [MEDICATION NAME] cream was applied to Resident #4. Interview with Certified Nurse Aide (CNA) #7 on 05/14/19 at 12:30 PM revealed they had been told the residents had [MEDICAL CONDITION] and the staff kept asking and was wondering why the rashes keep spreading. CNA #7 stated they do not understand if it is [MEDICAL CONDITION], why it keeps spreading. Interview with Licensed Practical Nurse (LPN) #2 on 05/13/19 at 7:54 PM and 05/15/19 at 8:58 AM revealed some staff saw their primary care physician (PCP) but were unable to afford the treatment and the facility will not pay for treatment of [REDACTED].#2 stated Resident #2 and Resident #4 had bad rashes with no orders for scrapings or appointments to see dermatologist and Resident #1 was a confirmed case of scabies and was given oral medication. LPN #2 also revealed Resident #3 and Resident #5 had scabies with Resident #3 putting him/herself in isolation, and having the rash a month or more before the cream was given to the resident. LPN #2 stated Resident #5's hands were crusted and broken open with the Resident #5 eaten alive. Interview with LPN #3 on 05/14/19 at 12:35 PM revealed Resident #2 and Resident #4 had no scrapings but were being treated for [REDACTED]. Interview with RN #1 on 05/13/19 at 7:38 PM revealed there had been scabies in the facility and everyone in the facility had not been treated. RN #1 stated management had been informed but management stated that corporate did not want to treat everyone. Interview with Infection Control Nurse on 05/14/19 at 3:20 PM and on 05/16/19 at 10:06 AM revealed the timeline was the only documentation she had related to the rashes of the residents. She stated she called the local health department for advisement on what to do for the scabies, and told the DON what she was told and the information was sent to regional. She revealed regional looked into it and decided the facility was not going to follow the recommendations by the health department epidemiologist. Additionally, the Infection Control Nurse stated Resident #2 and Resident #4 had not been to a dermatologist but ARNP #1 had treated them with the [MEDICATION NAME] cream but the cream was not doing it and the rash was not going away. Interview with Advanced Registered Nurse Practitioner (ARNP) #1 on 05/15/19 at 11:00 AM revealed the Physician/Medical Director and ARNP #2 had treated Resident #5 for [REDACTED] and Resident #1, #2 and #4 for scabies; but she did not think Resident #2 and Resident #4 had scabies. Additionally, ARNP #1 stated she did not know if Resident #3 had scabies, and she did not know if she could diagnose scabies. Interview with ARNP #2 on 05/16/19 at 12:11 PM revealed she did not have any documentation with her or did not remember the date, but she assessed Resident #5's rash and by using resources that were up to date and pictures, her and the Physician/Medical Director agreed with a [DIAGNOSES REDACTED].#2 stated Resident #5's hands were crusted and splitting open with a little dry blood in the cracks and the nurse had informed her the crusting had erupted quickly. ARNP #2 revealed she does not keep up with treatment for [REDACTED]. Interview with Pharmacist #1 on 05/16/19 at 9:10 AM revealed any one in direct contact with scabies or in room with someone that had scabies, or close contact; he felt would be at risk of getting scabies and would recommend treatment. Interview on 05/14/19 at 9:36 AM with Epidemiologist revealed she had received three (3) complaints concerning scabies from the facility. The Epidemiologist stated some Registered Nurses (RN's) and CNA's now have scabies and the facility is not treating everyone in building just treating one person at a time and keep stating it is [MEDICAL CONDITION] but this has been going on for more than a year. Additionally, the Epidemiologist revealed she thinks the owners are determining how to address the scabies in the facility. The Epidemiologist further stated the Center for Disease Control (CDC) guidelines and the communicable disease guidelines protocol is if 2 or more persons are determined to be infected--then the entire facility needs prescription for treatment. The Epidemiologist stated the infection control nurse had called her, and nurses have reached out anonymously with concerns over the scabies. Interview with the Director of Nursing (DON) on 05/14/19 at 2:12 PM and 5:15 PM, and on 05/16/19 at 10:29 AM revealed the Infection Control Nurse called the health department concerning the scabies and obtained their recommendations and then discussed the recommendations with her, the CNC, and the Administrator. The DON stated she said something to the CNC about the residents and scabies and she was told to follow facility policy and procedure and they did follow their policies. The DON further revealed they had not had any recent outbreaks of rashes until Resident #2 broke out and he/she was put in isolation until treated and 24 hours after treatment. She stated the treatment course and action was dependent on the physician. The DON stated the physician had started treatment in March 2019 prescribing [MEDICATION NAME] (a cream that is utilized in the treatment of [REDACTED]. Interview with Physician/Medical Director, on 05/15/19 at 12:30 PM and 4:04 PM revealed a couple of residents were sent to the dermatologist and diagnosed with [REDACTED]. He stated other residents were being treated as precautionary and not confirmed cases. He revealed he did not think the rashes looked like scabies, he thought the rashes looked like contact [MEDICAL CONDITION], and they do not send everyone that has a rash to the dermatologist. When asked how the rest of the facility was being treated, he stated depends--he could not give a blanket statement on how to treat the whole facility; if resident in room all the time they may only treat the resident and roommate. He stated if a resident has been diagnosed with [REDACTED]. He further revealed there were only two (2) cases of confirmed scabies and the others are contact [MEDICAL CONDITION]. Interview on 05/15/19 at 3:45 PM with Corporate Nurse Consult (CNC) revealed she did remember being told of a conversation with epidemiologist at the health department. She stated she probably did have a discussion about the scabies but does not recall. She revealed it was no longer recommended by the CDC to treat every one [MEDICATION NAME], and she left that up to the DON and the Administrator because they were talking to Physician/Medical Director about orders, but she was not in on the discussion. The CNC further revealed two months later and having dealt with scabies she would want to see scrapings and the Physician/Medical Director may just be treating [MEDICATION NAME]. The CNC stated the facility only had tow (2) confirmed cases of scabies and the others were only confirmed rashes. The CNC revealed she did not necessarily agree with the recommendation of the health department. Interview on 05/15/19 at 4:18 PM with the Administrator revealed she was not aware of the suggestion of the health department and if she had been she would have followed it.

Based on observation, interview, and facility policy review, it was determined the facility failed to ensure food was stored in accordance with professional standards for food service safety. Kitchen observation on 03/26/19, revealed ice build-up on a shelf below the fan and an area of the floor of the walk-in freezer. Review of the Census and Condition, dated 03/26/19, revealed sixty-five (65) of sixty-seven (67) residents received their food from the kitchen. The findings include: Review of facility document titled, Food Storage/Safety Checklist, not dated, revealed freezer unit shelving and floors should be clean and free from ice build-up. Review of the facility document titled, Repair Requisition, dated 03/12/19, revealed a work order related to ice on the freezer floor was requested by the Dietary Manager. Observation of the walk-in freezer on 03/26/19 at 11:40 AM, revealed there was a ice build-up on a shelf below the fan and an area of the floor of the walk-in freezer. Interview with Dietary Manager on 03/26/19 at 11:50 AM, revealed she had completed a work order for the issue and the maintenance man was aware. She stated the freezer temperatures were checked daily and were within normal range. The Dietary Manager further stated she would expect the freezer to be free of frozen condensation and the issue to be resolved, as the ice build-up could be a potential fall hazard to employees and the freezer should be maintained in proper working order. Post-survey interview with the Maintenance Man on 04/12/19 at 8:47 AM, revealed he had chipped the ice away in the walk-in freezer on 03/12/19, and checked the functioning of the defrost light indicator and found no issues elsewhere. He stated the Dietary Manager made him aware again on 03/26/19 and after consulting with someone found there was a second breaker for the defrost light behind the freezer that had tripped and there was no light to indicate defrost mode.

Based on interview, and record review, it was determined the facility failed to notify the representative of one (1) of twenty-three (23) sampled residents of a medication change (Resident #45). On 03/02/19, an order was written to discontinue Resident #45's [MEDICATION NAME]; however, staff failed to notify Resident #45's representative. The findings include: Interview with the Director of Nursing (DON) on 03/29/19 at 10:12 AM, revealed the facility did not have a specific policy related to notification/change in condition but follows state and federal guidelines. Record review revealed the facility admitted Resident #45 on 08/31/17, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Sets (MDS) assessment, dated 01/25/19 revealed the facility assessed Resident #45's cognition as intact with a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated the resident was interviewable. Further review of the record revealed the resident had a legal family guardian. Review of Resident #45's Progress Notes dated 03/02/19 at 9:14 PM, revealed the Director of Nursing (DON) documented new order received to discontinue [MEDICATION NAME] due to pharmacy recommendation. Review of physician's orders [REDACTED]. However, further review of the Progress Notes, dated 03/02/19, revealed there was no documented evidence Resident #45's family was made aware of the medication change. Interview with Resident #45's Responsible Party on 03/22/19 at 3:21 PM, revealed she did not know the resident's [MEDICATION NAME] had been stopped until she spoke with staff at the Geriatric-Psych Unit on 03/13/19, and viewed the nursing homes list of medications. She stated she was very upset she was not notified of the medication changes due to the residents multiple psych and depression diagnoses. Interview with the Director of Nursing (DON) on 03/29/19 at 10:12 AM, revealed she was responsible for notifying residents' responsible parties of medication changes. The DON stated Resident #45's [MEDICATION NAME] was discontinued and she called Resident #45's responsible party but could not remember if she left a message. She further stated she failed to document the notification. Interview with the Administrator on 03/29/19 at 4:30 PM, revealed she would have expected nursing to notify the resident's responsible party of any medication changes.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0 User's Manual, it was determined the facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment for three (3) of twenty-three (23) sampled residents (Residents #5, #36, and #43). Resident #36 had a decline in activities of daily living (ADL's), bowel and bladder continence, cognition, and a significant weight loss from 10/28/18 to 01/24/19; Resident #43 had a decline in four (4) areas of ADL's; and, Resident #5 had an Improvement in three (3) areas of ADL's. However, further review of the residents' MDS assessments revealed a significant change in condition was not identified and a Significant Change MDS assessment was not completed per the RAI 3.0 Users Manual. The findings include: Interview with the MDS Coordinator, on 03/27/19 at 4:58 PM, revealed the facility does not have a policy for completion of MDS assessments; however, the RAI 3.0 User's Manual was used as reference when completing MDS assessments. Review of the RAI 3.0 User's Manual, Version 1.16, October, 2019, revealed a significant change is a major decline or improvement in a resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; impacts more than one area of the resident's health status; and requires interdisciplinary review and/or revision of the care plan. MDS assessments are not required for minor or temporary variations in resident status - in these cases, the resident's condition is expected to return to baseline within two (2) weeks. However, staff must note these transient changes in the resident's status in the resident's record and implement necessary assessment, care planning, and clinical interventions, even though an MDS assessment is not required. 1. Record review revealed the facility admitted Resident #36 on 03/20/18 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], Section C, Cognitive Pattern, Item C0500 revealed Resident #36 had a BIMS score of Fourteen (14) indicating intact cognition. Review of Section G, Functional Status, Items G0110 A, B, and I revealed the resident required limited assist of one (1) staff (coded 2/2) for bed mobility and toileting; and supervision with stand-by assist (coded 1/1) for transfers. Review of Section H, Bladder and Bowel, Item H0300, revealed the resident was occasionally incontinent of urine; and Item H0400 revealed he/she was always continent of bowel. Additional review of the MDS, Section K, Swallowing/Nutritional Status, Item K0200B, revealed the Resident weighed 221 pounds. Review of the Quarterly MDS assessment dated [DATE], Section C, Cognitive Pattern, Item C0500 revealed Resident #36 had a BIMS score of ninety-nine (99) indicating severely impaired cognition. Review of Section G, Functional Status, Items G0110 A, B, and I, revealed the resident required extensive assistance of two (2) staff (coded 3/3) with bed mobility and toileting, a decline from previous coded 2/2; and limited assistance of one (1) staff (Coded 2/2) for transfers, a decline from previous coded 1/1. Review of Section H, Bladder and Bowel, Item H0300, revealed the resident was frequently incontinent of bowel and bladder, a decline in continence. Additional review of the MDS, Section K, Swallowing/Nutritional Status, Item K0200B, revealed a dash - with no weight recorded. However, review of the Weights summary revealed the resident weighed 181 pounds on 01/30/19, down eighteen percent (18%) since the previous MDS assessment. However, further review of Resident #26's MDS assessments revealed there was no Significant Change MDS assessment completed per the RAI manual. Review of the Care Plan Conference Summary dated 01/17/19 revealed there was no documented evidence that a significant change in condition was discussed during the meeting. Interview with Physical Therapy Assistant (PTA) on 03/27/19 at 1:22 PM revealed when the therapy department received the referral for Resident #36 on 01/19/19, Resident #36 had declined in physical abilities, standing, ambulation, and poor safety awareness. The PTA stated the resident transfers were a struggle for the resident. He further revealed the decline was due to the resident's increased weakness. Interview with Occupational Therapist (OT) on 03/27/19 at 1:34 PM revealed Resident #36 was referred to OT after a hospitalization on [DATE]. OT stated prior to hospitalization , the resident required stand-by assistance to minimal assistance with ADL's, however after hospitalization , the resident required moderate to maximum assistance. The OT further revealed the resident was not able to make much progress due to lack of cooperation and extreme lethargy and was discharged from OT services on 02/15/19. Interviews with the MDS Coordinator on 03/27/19 at 4:58 PM and on 03/28/19 at 12:26 PM revealed completion of MDS assessments was her responsibility. She stated if there was a change in more than two (2) areas, she should initiate a significant change in condition assessment within a fourteen (14) day period of that change. The MDS Coordinator stated it was a team effort to identify a resident's decline or improvement. She stated the Interdisciplinary Team (IDT) met each day to discuss residents' conditions. The MDS Coordinator stated the system usually prompts the coordinator if there is a decline in an area, but the system did not alert for this resident's decline. She stated she did not realize the resident had a decline and no one had alerted the IDT of changes. Additionally, the MDS Coordinator stated the resident fluctuates in ADL ability and bowel and bladder, however, there was no documented evidence of the fluctuations. She further revealed the significant decline in the resident's condition was over-looked and was not initiated as it should have been. Interview with the Director of Nursing (DON) on 03/27/19 at 2:46 PM and on 03/28/19 at 8:33 AM revealed a Significant Change in Condition assessment should have been initiated for Resident #36 due to decline. She stated she should have recognized a change/decline in the resident and brought the MDS Coordinator's attention to it. She revealed she does not know exactly what the facility's process was, for a resident decline, at this time. The DON further stated the MDS Coordinator should have recognized a decline when the care plan was updated with the MDS Assessment information and should have followed policy to follow up. 2. Record review, revealed the facility admitted Resident #5 on 12/06/16 with [DIAGNOSES REDACTED]. Review of an Annual MDS assessment, dated 09/16/18 revealed section G showed Resident #5's ADL's were coded as Bed mobility: 3/2 Transfer: 3/2 Eating: 2/2 Toileting: 3/2. Further review revealed the quarterly MDS completed on 12/13/18 section G showed Resident #5's ADL's were coded as Bed mobility: 2/2 Transfer: 2/2 Eating: 2/2 Toileting: 2/2. The records showed Resident #5's ADL's improved as the resident went from requiring extensive assistance to only requiring limited assistance in the three (3) care areas of Bed mobility , Transferring and Toileting; however, review of Resident #5's MDS assessments revealed there was no documented evidence a significant change MDS was completed per the RAI manual. Review of a Quarterly MDS assessment, dated 02/02/19, revealed the facility assessed Resident #5's cognition as intact, with a BIMS score of fifteen (15), which indicated the resident was interviewable. Interview with MDS Coordinator on 03/29/19 at 9:12 AM revealed she was not aware Resident #5 had an improvement. The MDS Coordinator stated the person who completed the MDS on 12/13/18 no longer was employed by the facility and . The MDS Coordinator stated she did not observe there was an improvement in Resident #5's ADL's and she did not investigate to see why there was an improvement. The MDS Coordinator revealed if she did observe an improvement she would have completed a Significant change Assessment. The MDS Coordinator stated she is still learning their new system and she has more to learn regarding the alerts the systems provides in regards to completing changes. 3. Record review revealed the facility admitted Resident #43 on 02/18/13 with [DIAGNOSES REDACTED]. Review of Quarterly MDS assessment, dated 03/01/19, revealed the facility assessed Resident #43's cognition as moderately impaired with a BIMS score of eleven (11), which indicated the resident was not interviewable. Review of the Admission MDS completed on 12/17/18 section G showed Resident #43's ADL's were coded as Bed Mobility: 1/2, Transfer: 1/2, Eating: 1/1, and Toileting: 1/2. Further review revealed the Quarterly MDS completed on 03/01/19 section G showed Resident #43's ADL's were coded as Bed Mobility: 3/3, Transfer: 3/3, Eating: 3/2, Toileting: 3/3. The records showed that Resident #43 went from only requiring supervision to requiring extensive assistance in the all four (4) areas of Bed Mobility, Transfer, Eating and Toileting; however, further review of the resident's MDS assessments revealed there was no documented evidence a Significant Change MDS assessment was completed per the RAI manual. Interview with MDS Coordinator on 03/29/19 at 09:50 AM revealed she believed a significant change assessment should have been completed based on Resident #43's decline. The MDS Coordinator stated there was an expected decline in Resident #43 ADL's. The MDS Coordinator stated staff were are not aggressively treating any of Resident #43's declines and they were not trying to restore any areas of decline as they were just providing comfort measures. Interview with the Director of Nursing (DON) on 03/29/19 at 3:45 PM revealed a Significant Change in Condition assessment should have been initiated for Resident #5 and Resident #43 due to the improvement and decline. The DON stated she should have recognized a change either in improvement or decline in the residents and brought it to the MDS Coordinator's attention. The DON further stated the MDS Coordinator should have recognized that an improvement or decline occurred and completed a Significant Change Assessment.