Every finding on record at Clyde Nursing Center

Based on observation, interview and record review the facility failed to ensure the resident's had the right to reside and receive services in the facility with accommodation of residents' needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 12 residents(Resident #36, Resident #14, and Resident #32) reviewed for resident rights. The facility failed to ensure Resident #36, Resident #14, and Resident #32's call lights were within reach. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.Findings include: 1. Record review of Resident #36's electronic face sheet, accessed 06/10/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 had diagnoses which included Cerebral Infarction (a stroke caused by blockage in the blood vessel that supplies the brain) and depression. Record review of Resident #36's quarterly MDS assessment, dated 05/27/2026, reflected Resident #36 had a BIMS score of 10, which indicated moderate cognitive impairment. Record review of Resident #36's comprehensive care plan, last revised on 06/08/2026, reflected Resident #10 had impaired vision, communication problem, and potential for falls with intervention of Keep call light in reach in room and bathroom. During an observation on 06/08/2026 at 11:00 AM, revealed Resident #36 was hollering out into the hallway from her bed. The call light was in between the side rail and mattress. Staff assisted the resident but did not move the call light. During an observation and interview on 06/09/2026 at 10:18 AM, revealed Resident #36 was asleep in bed. The call light was stuck between the side rail and mattress. Resident #36 stated her call light was always tied to the bedrail, and she could never find it. She stated she just hollered out when she needed help. 2. Record review of Resident #14's electronic face sheet, accessed 06/10/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #14 had diagnoses which included dementia, anxiety, and depression. Record review of Resident #14's significant change MDS assessment, dated 05/13/2026, reflected Resident #14 had a BIMS score of 00, which indicated severe cognitive impairment. Record review of Resident #14's comprehensive care plan, last revised on 06/08/2026, reflected Resident #10 had impaired vision, communication problem, and exhibits verbally aggressive behaviors and is at risk of not having her needs met in a timely manner with intervention of Keep call light in reach in room and bathroom. During an observation on 06/08/2026 at 11:00 AM, revealed Resident #14 was asleep in bed. A soft touch-call light was hanging behind the bed at the top of the alarm box out of resident's reach. Resident #14 unable to answer questions. During an observation on 06/09/2026 at 10:20 AM, revealed Resident #14 was asleep in bed. A soft touch-call light was hanging behind the bed at the top of the alarm box out of resident's reach. Resident #14 unable to answer questions. During an interview on 06/09/2026 at 10:30 AM, Resident #14's representative stated he expected the call light to be in reach. He stated it upset him that they did not always put it in reach. He stated Resident #36 had a soft touch call light and the staff got annoyed because it was very sensitive and it went off a lot. 3. Record review of Resident #32's electronic face sheet, accessed 06/10/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #32 had diagnoses which included dementia, anxiety, and depression. Record review of Resident #32's significant change MDS assessment, dated 05/13/2026, reflected Resident #14 had a BIMS score of 00, which indicated severe cognitive impairment. Record review of Resident #32's comprehensive care plan, last revised on 06/08/2026, reflected Resident #10 had impaired vision, communication problem, and exhibits verbally aggressive behaviors and is at risk of not having her needs met in a timely manner with intervention of Keep call light in reach in room and bathroom. During an observation on 06/08/2026 at 11:00 AM, revealed Resident #32 was asleep in bed. The call light was stuck between the side rail and mattress. During an observation and interview on 06/09/2026 at 10:20 AM, revealed Resident #32 was asleep in bed. The call light was stuck between the side rail and mattress. Resident #32 stated she didn't know where her call light was. When pointed out the resident was unable to reach it due to the call light being tangled on the side rail and stuck between the mattress and bedrail. During an interview on 06/09/2026 at 4:06 PM, the DON stated his expectation was for residents call light to always be in reach. He stated residents should always be able to call for assistance. He stated not having the call light could lead to falls and residents not getting their needs met. He stated he rounded periodically to ensure that call lights were within reach. During an interview on 06/10/2026 at 2:04 PM, CNA A stated every time she left a resident room, she ensured all safety devices were in place, and the call light was in reach. She stated in reach meant the resident could see it and reach it. She stated residents could not get the help they needed if they could not reach their call light. During an interview on 06/10/2026 at 4:18 PM, the Administrator stated his expectation was for call lights to be within reach and within sight at all times. He stated residents could fall and not get their needs met. He stated he randomly made rounds in the facility to ensure call light placement. Record review of the facility's policy titled Call Light Response, dated 02/10/2021, reflected Process.with each interaction in the resident's room or bathroom, staff will ensure the call light is within reach of resident and secured, as needed.

Based on observation, interview and record review the facility failed to ensure the resident had a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 24 (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) resident rooms and 1 of 1 handicap resident restroom reviewed for resident rights and environmental concerns.1. The facility failed to have water above 100 F in the restroom sink of resident room [ROOM NUMBER] on 06/08/2026.2. The facility failed to have water above 100 F in the handicap restroom sink located on hall 3 on 06/08/2026.3. The facility failed to have water above 100 F in the adjoining restroom for resident room [ROOM NUMBER] and resident room [ROOM NUMBER] on 06/09/2026.These failures could place residents at risk of being uncomfortable and infections from living in an environment that did not function.Findings included:1. Record review of Resident #1's electronic face sheet, dated 06/10/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had a diagnosis which included bacteriuria (bacteria in urine) that was developed during stay. Record review of Resident #1's quarterly MDS assessment, dated 04/01/2026, reflected she had a BIMS score of 12, which indicated moderate cognitive impairment. Resident #1 required supervision with personal hygiene which included washing hands and substantial assistance with toileting hygiene.Record review of Resident #1's comprehensive care plan, dated 05/28/2026, reflected Resident #1 had a UTI with interventions which included resident / caregiver teaching should include good hygiene practices such as females to wipe and cleanse from front to back and clean perineum (region between the genitals and the anus) area well after BM in order to help prevent bacteria in urinary tract.During an observation on 06/09/2026 at 10:20 a.m., there was an adjoining restroom between room [ROOM NUMBER] and room [ROOM NUMBER]. The temperature of the hot water in the restroom sink was 95.5 F using state issued thermometer after the hot water was ran for over one minute. During an interview on 06/10/2026 at 3:23 p.m., Resident #1 stated she would like the water in the bathroom to be hotter. She stated the water had only been warm in the restroom ever since she had resided in the facility. 2. Record review of Resident #40's electronic face sheet, dated 06/11/2026, reflected a [AGE] year-old female who was admitted originally to the facility on [DATE] and readmitted on [DATE]. Resident #40 had a diagnosis which included dementia (loss of memory, thinking, and reasoning skills).Record review of Resident #40's quarterly MDS assessment, dated 04/20/2026, reflected she had a BIMS score of 05, which indicated severe cognitive impairment. Resident #40 needed setup assistance for toileting hygiene and needed supervision assistance for personal hygiene which included washing hands.During an observation on 06/08/2026 at 11:25 a.m., Resident #40 was in room [ROOM NUMBER] lying in the bed next to the window. The restroom connected to room [ROOM NUMBER] had a sink beside the toilet. The hot water in the restroom sink was cool to the touch after letting it run for approximately one minute. During an observation on 06/08/2026 at 4:09 p.m., revealed Resident room [ROOM NUMBER] bathroom sink hot water temperature was 74 F using state issued thermometer after letting it run for over five minutes. During a telephone interview on 06/08/2026 at 2:56 p.m., Resident #40's family member stated she was concerned residents, which included Resident #40, did not have access to hot water, only cold water. Resident #40's family member stated there was not a problem with the water heater in the facility, but the problem was the setting the facility had made for all residents. Resident #40's family member did not state how they knew there was not a problem with the water heater in the facility. During an observation on 06/09/2026 at 4:17 p.m., revealed the Hall 3 handicap residents' restroom sink hot water was cool to the touch. The temperature of the sink's hot water was 88 F using state issued thermometer after letting the hot water run for over one minute. During an interview on 06/10/2026 at 10:55 a.m., the Maint. Director stated the facility had 2 water heaters located on Hall 1 in the facility. He stated during the day the CNAs performed showers, the end of the other two halls resident rooms would not be hot at times. He stated he would rather error on the cool side and not have the water scalding in the resident rooms to prevent burns to the residents. He stated he had difficulty keeping the water warm and had the mixing valve replaced in the past. He stated the mixing valve helped adjust the water temperatures. He stated the facility could not have water above 110 F in the resident rooms per regulations but did not state a level the temperature needed to stay above. He stated he would not mind the water in the sink in the room not being hot if he was a resident in the facility. He stated the CNAs performed showers daily during the week starting at 6 a.m. and kept going until 2 p.m. He stated when he checked the temperatures, and adjusted the water temperatures, he did before or after the showers were completed to get temperatures above 100 F. He stated he did not have any complaints from residents that the water temperature in the rooms was not hot enough. He stated he did not think the residents had any negative effect from the water temperatures being lower than 100 F certain times of the dayDuring an interview on 06/10/2026 at 11:11 a.m., the DON stated a normal person would want hot water in the sink of a bathroom they used to wash their hands. He stated he was not aware of any residents or their representative complaining about water temperatures in the past. He stated the Maint. Director was responsible for ensuring water temperatures were comfortable for the residents. He stated the facility did not have any increased infection spread recently and he kept an infection control tracking system. He stated not having hot water could cause discomfort and was not causing infection spread.During an interview on 06/10/2026 at 11:38 a.m., the ADMN stated he expected for the residents to have access to hot water within the state guidelines of 100 F to 110 F. He stated he was not aware of the Maint. Director was taking weekly temperatures and logging them outside of the residents' shower schedules until today. He stated a reasonable person would want water in their rooms above 95 F in the restroom sink. He stated the facility did not have an attic and the water pipes came out of the water heater room, ran down the halls in pipes, and that could cause the temperature to fluctuate. He stated the facility had a flat roof that did not allow there to be an attic. He stated not having hot water could cause an uncomfortable environment. He stated he had not received any complaints from residents or their representatives about water temperature. Record review of the facility's maintenance care log reflected between 04/13/2026 - 06/03/2026 weekly hot water temperatures documented the hot water in multiple places in the facility including resident rooms was above 100 F.Record review of facility's policy titled Resident Rights, dated 02/23/2026, reflected 8. Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in his or her treatment, his or her treatment including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options he or she preferred for 1 of 2 residents (Resident #40) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #40's bed alarm and chair alarm prior to placing them on the wheelchair of Resident #40. This failure could place residents at risk of unnecessary restriction of their freedom of movement and diminished quality of life. Findings include: Record review of Resident # 40's face sheet, dated 06/09/2026, revealed a [AGE] year-old female who was most recently readmitted to the facility on [DATE]. Resident #40 had the following diagnoses listed: unspecified dementia with mood disturbance (a diagnosis given when a person experiences significant cognitive decline and noticeable emotional changes such as depression, apathy, or anxiety), repeated falls, muscle weakness, unsteadiness on feet, and osteoporosis (a medical condition in which the bones become brittle and fragile). She had a family member listed as her medical and financial power of attorney. Record review of Resident #40's quarterly MDS assessment, dated 03/20/2026, revealed a BIMS score of 05, which indicated she had severely impaired cognition. Resident #40 had one fall since her most recent readmission with no major injuries. The restraints and alarms section reflected, she had a bed alarm and a chair alarm. Record review of Resident # 40's care plan, last revised on 11/12/1015, revealed a focus of: Residents have the potential for falls related to cognitive impairment, Psychoactive drug use, Gait/balance problems, and Fall Risk Score >10 (high fall risk) Goal: The resident will be free of falls through the next review date.Interventions included:Educated by Administrator on using her Call Light. Pressure Sensitive Alarm to wheelchair, recliner, and bed to alert staff to unassisted transfers. Anticipate and meet the resident's needs. Place items frequently used by the resident within easy reach when in the room. Record review of Resident #40's fall risk assessment, dated 03/18/2026, revealed the following documentation: Resident #40 had a history of one to two falls in the last 6 months, she took hypoglycemic medication (to lower blood sugar) and narcotics, within the last 7 days, recalled three out of four of the following; current season, that she was in a nursing home, location of room, staff names/faces, was able to see adequately, was continent of bowel and bladder, had no agitated behavior in the last 7 days, she did not have a drop in blood pressure when lying and standing, and her gait was more unsteady. Based off these answers, it was determined the resident had a low fall risk. Record review of a grievance form, dated 05/25/2026, made by a family member of Resident # 40 on her behalf, stated the following: Family member states that the nurse LVN A always tells [Resident #40] to stay in her bed and she cannot be mobile in her room. The family member wants that nurse not to go back into [Resident #40's] room, and wants the bed alarm removed and Resident #40 to have her walker back in her room. The Facility followed up with two other family members and not the family member who filed the grievance. The follow up stated in part: Family members of the resident discussed the situation on 05/26/2026 with the administrator and the DON. They understand the interventions put into place to prevent falls such as bed alarms and redirecting the residents when necessary. They do not want the LVN A to do it in an unprofessional manner. Record review of the facility incident log since the last survey revealed Resident # 40's last fall was on 08/27/2025. Record review of Resident #40's active physician orders, dated 06/11/2026, revealed the following orders that were initiated on 03/18/2026: Alarm to bed to alert staff of attempts to transfer unassisted due to falls for a diagnosis of unspecified dementia with mood disturbance. Ensure proper placement and functioning. Every shift for resident safety. Alarm to wheelchair to alert staff of attempts to transfer unassisted due to falls for a diagnosis of unspecified dementia with mood disturbance. Record review of Resident # 40's EMR revealed there was no signed consent for a chair or a bed alarm on her chart. During an observation and interview on 06/08/2026 at 4:17 PM, revealed Resident # 40 had a bed alarm on her bed and she was standing up upon entrance to the room. She then turned around and sat back down on her bed. The bed alarm did not sound until she sat down. She stated the bed alarm bothered her when it made noise. During an observation of five videos on 06/09/2026 at 7:57 AM, provided by a family member, revealed Resident # 40 was in her room sitting on her bed. She would get up; the alarm would go off. LVN 1 would go into the resident's room and tell her to get back in her bed. This happened repeatedly. Resident #40 stated Why does that alarm go off? You go on and go to sleep! LVN A stated I can't, because you won't stay in bed she then turned around and left the room. During interview on 6/06/2026 at 4:20 PM, LVN 1 stated Resident #40 had several falls in the past but none recently. She stated she had the bed and chair alarm so she would not fall and possibly hurt herself. She stated the alarm did not restrict the residents movement. She stated the resident got up without assistance anyway. She stated she did not know of any plans to remove the alarm, and no one asked her to remove it. During an interview on 06/10/2026 at 8:30 AM, Resident #40's family member stated at one point Resident #40 was very weak and not eating, but that was several months ago. The family member stated Resident #40 barely moved, and the alarm went off. She stated she felt the alarm restricted Resident #40's movement because she was not allowed to get up and move freely about her room. She stated we want her up, using her walker and walking in her room. She stated she did not like the alarm use and she did not think the administrator would allow them to remove the alarm. She stated she did not remember if she was ever asked for consent before the alarm was placed on Resident # 40. She stated she was told by the Administrator it kept Resident # 40 from falling, and the administrator stated Resident # 40 needed to have therapy before the alarm could be removed. She stated when the administrator told her this, she thought the facility would not allow the alarm to be removed from Resident #40. During an interview on 06/11/2026 at 8:59 AM, the DON stated Resident #40's alarm did not fit the definition of a restraint because it did not prevent her from getting up, it just alerted the staff she needed assistance. He stated he did not think he needed a consent for a bed or chair alarm. He stated he saw a video provided to him by a family member of Resident # 40. During the video LVN 1 checked on Resident #40 and told her to get back in bed. He stated Resident #40 should not be told to get back in bed; she should be assisted or allowed to get up and move about her room with supervision. He stated LVN 1 was inserviced on Professionalism after the family made the grievance and showed him the video. During an interview with the facility administrator on 06/11/2026 at 10:00 AM, he stated he did not consider the bed or chair alarm a restraint. He stated it was an intervention to keep her from falling and it worked. He stated he advised the residents family member that the resident should receive therapy before they removed the alarm. He stated staff should not tell the resident to get back in her bed when the alarm went off. He stated he did not know the family members felt they didn't have a choice in Resident 40's care. He thought they were in agreement. He stated he did not think a consent was needed for the alarm, because it was not a restraint. Record review of the Resident Rights policy provided by the facility, dated 02/23/2016, read in part: The facility will inform the resident both orally and in writing in a language that the resident understands her rights in all rules governing resident conduct and responsibilities during the stay in the facility. Exercise of rights. The resident has the right to exercise his or her rights as a resident of this facility and as a citizen or resident of the United states the resident has the right to be informed and participate in his or her treatment Including the rock can be fully informed in language that he or she can understand of his or her total health status including but not limited to his or her medical condition. To be informed in advance of the character be furnished in the type of caregiver or professional that will furnish the care the right to request refunds and or discontinued treatment to participate in our refused to participate in experimental research and to formulate an advanced directive. Record review of the Sensory Alarm Policy, dated revised 08/06/1018 05/05, read in part It is the policy of this facility to utilize resident alarms in limited circumstances and of coordinates with the residents needs goals and preferences of the resident will be to attain or maintain his or her highest practicable level of physical mental and psychosocial well-being. The use of alarms does not eliminate the need for adequate supervision of the resident identification and addressing resident needs if the alarm is triggered. And you lost for the safe and appropriate use of residential markets including efforts to identify risk evaluation and analyze risk implement interventions to reduce risk and monitor for effectiveness of the interventions and modifying interventions necessary. Considerations or discontinuation of alarms include but are not limited to the behavior symptoms or risk warranting the use of the alarms are no longer present, the risks associated with the use of the alarm outweigh the benefit, evidence of adverse consequences associated with the use of the alarm, and resident family goals and preferences change. There was no policy in regard to a signed consent for a bed or chair alarm.

Based on interview and record review the facility failed to ensure all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for one of 12 residents (Resident #2) reviewed for PASARR. The facility failed to correctly identify Resident #2 as having a mental illness and did not complete a new PASARR Level One Screening. This failure could place residents at risk of not receiving needed services and care.The findings were: Record review of Resident #2's face sheet, accessed 06/10/2026, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses on admission which included Psychotic Disorder with delusions and Major Depressive Disorder, with no diagnosis of dementia. Record review of Resident #2's quarterly MDS assessment, dated 04/15/2026, reflected Resident #2 had a BIMS score of 11, which indicated moderate cognitive impairment. Record review of Resident #2's Comprehensive Care Plan, dated 03/12/2026, reflected the resident had depression and anxiety, and resident used psychotropic drugs. Record review of Resident #2's PASARR Level One Screening Forms, dated 02/03/2025, reflected she did not have a primary diagnosis of dementia. It revealed she was negative for mental illness, intellectual disability, or developmental disability. The form had not been updated. During an interview on 06/10/2026 at 3:40 PM, the MDS coordinator stated the PASARR Level One Screening was completed by another facility prior to admission. She stated since the PASARR Level One Screening showed negative mental illness she did not pursue any further actions. She stated she did not know there were any further steps to be taken. During an interview on 06/10/2026 at 3:56 PM, the RCN stated once the facility learned Resident #2 had a mental illness diagnosis the facility should have completed a new PASARR Level One Screening and followed the steps accordingly. She stated the PASRR Level One Screening would have triggered Resident #2 to have a PASARR Level Two Screening evaluation to determine the need for PASARR services. Record review of the facility's policy titled Preadmission and Screening Resident [NAME] Rules, dated 04/26/2016, reflected Purpose: The purpose of this guideline is to direct the user through the PASRR procedures. Procedure: If negative.If the resident has a qualifying mental illness diagnosis and the nursing facility feels the resident should be positive, they should talk to the referring entity and ask them to correct the PASARR Level One Screening or complete the 1012.

Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food was labeled properly in the refrigerator. The facility failed to ensure food was discarded per manufacture instructions. The facility failed to ensure that staff performed hand hygiene when entered the kitchen. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. The findings included: During an observation on 04/22/25 between 10:10 AM and 10:30 AM, of the kitchen, the DM entered the kitchen from the dining room and failed to perform hand hygiene when he entered the kitchen. The refrigerator contained a container of ham, out of its original container, was not labeled with an item description, open date or a use by date and an open carton of thickened milk with an open date of 04/02/25 and manufacture instructions on the container that stated, Discard if not used within 4 days of opening. During an observation on 04/22/25 at 11:20 AM, the DM entered the kitchen from the dining area and failed to perform hand hygiene. The DM retrieved a scoop from a drawer and handed it to the Cook, prior to performing hand hygiene. During an interview on 04/24/25 at 11:42 AM, the DM stated his expectation was food out of original container, in the refrigerator, should have been labeled with food description and open date. The DM stated the thickened milk should have been discarded per the manufacture recommendations. The DM stated all staff were responsible to check food for freshness, label food with open date, use by date and item description. The DM stated he was responsible to monitor and that he checks items daily. The DM stated residents could have been exposed to foodborne illness if food was not labeled correctly, or if food was not discarded per manufacture recommendations. The DMs stated what led to the failure was that staff had gotten sidetracked. He stated prior to him becoming DM, there had been staff turnover. The DM stated what led to failure of the thickened milk was that the other products had a 7-day discard and he had overlooked it. The DM stated his expectation was that hand hygiene be performed upon entrance into kitchen and when hands became soiled. The DM stated staff had been trained and were responsible to know to perform hand hygiene, and he was responsible for monitoring. The DM stated the effect on residents could have been exposure to foodborne illness. The DM stated what led to failure was there was a lot going on that morning, and he had gotten sidetracked trying to get everything done. During an interview on 04/24/25 at 11:47 AM, the Dietician stated her expectation was that food be labeled with food description and use by date and that if manufacture directions stated to discard after a certain number of days, then the items should have been discarded. The Dietician stated her expectation was that staff wash their hands when entering the kitchen. The Dietician stated failure to wash hands could have caused residents to be exposed to bacteria that could have led to illness. The Dietician stated that the effect on residents if food had gone past use by date or not labeled incorrectly it could have caused food to loose flavor or not being good. The Dietitian stated this could have caused residents to have a loss of satisfaction of their meals. The Dietitian stated it was the responsibility of the DM to ensure food was labeled and discarded correctly. The Dietician stated what led to these failures was lack of proper training, been turnover in dietary managers over the past few months. Record review of the facility's policy titled, Storage of Frozen and Refrigerated Foods dated 10/2017 revealed; Refrigerated products that are opened must be labeled with an opened on date. The use by date is 7 days from when the product was opened, unless there is a manufacturer's use by, expiration or sell by date. For all foods that have a manufacturer use by , sell by or expiration dates this date will be used. Record review of the facility's policy titled, Hand Washing dated 11/2017 revealed: Dietary Staff will wash their hands before starting work and: Upon re-entry into the kitchen.

Based on interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 4 (Resident #5, Resident #9, Resident #18, and Resident #24) of 4 residents reviewed for care plans. The facility failed to ensure care plans specified measurable objectives that could be evaluated or quantified for Resident #5, Resident #9, Resident #18, and Resident #24. This failure could place residents at risk for not receiving care and services individualized to meet their specific physical, mental, and/or emotional needs. Findings included: Review of Resident #5's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of stroke, left side paralysis, anxiety, depression, loss of muscle mass, and difficulty walking. Review of Resident #5's MDS dated [DATE], revealed in Section C - Cognitive Patterns C0500. BIMS Summary Score, Resident #5 scored 15 out of 15 indicating intact cognition. Review of Resident #5's Comprehensive Care Plan revised 01/11/24 revealed the following focus care areas with objectives that were not measurable: Focus: Fragile Skin: [resident] has fragile skin related to the aging process and is at risk for bruising easily and skin tears with an objective of [Resident's] risk for the development of skin tears and bruising will be minimized ., Focus: Cognitive Impairment: [resident] has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to: recent CVA with an objective of [Resident] will have needs met in a timely manner. , Focus: [Resident] has impaired visual function and is at risk for falls, injury, and a decline in functional ability d/t my glaucoma (a group of diseases that damage the nerve in the back of the eye), with an objective of [Resident] will maintain optimal quality of life . , Focus: [Resident] is at risk for the following items and/or diagnosis: Falls with an objective of Staff will be aware of the risks factors and/or diagnosis in POC (Plan of Care)/Kardex (information quick reference used in nursing), Focus: [Resident] has a communication problem related to Hearing deficit with an objective of [Resident} will have needs met in a timely manner ., Focus: I, [resident], have renal (kidney) failure r/t Kidney disease with an objective of I, [resident], will be able to resume normal daily activities of daily living . , Focus: [Resident] has oral/dental health problems broke/carious (decaying) teeth r/t Poor oral hygiene with an objective of [Resident] will tolerate diet . , Focus: [Resident] uses psychotropic medications (antidepressants) related to depression with an objective of [Resident] will maintain the highest level of function possible and not experience a decrease in functional abilities . , Focus: [Resident] is at risk for pain related to: Post CVA - hemiplegia or Hemiparesis Arthritis with an objective of Pain or discomfort will be relieved within a timely manner of receiving pain medications or treatments as ordered by the physician, Focus: I, [resident], have OsteoArthritis (tissue breakdown in the joints) with an objective of I, [resident] will maintain acceptable level of comfort ., Focus: I, [resident], have Hemiplegia (paralysis on one side of the body)/Hemiparesis (complete paralysis of half of the body) d/t my recent Stroke with an objective of I, [resident] will maintain optimal status and quality of life within limitations imposed by Hemiplegia/Hemiparesis ., and Focus: [Resident] has fragile skin related to the aging process and is at risk for bruising easily and skin tears with an objective of [Resident's] risk for the development of skin tears and bruising will be minimized . Review of Resident #9's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of macular degeneration (loss of central vision), anxiety, major depression, post-traumatic stress disorder (disorder that develops after a shocking, scary, or dangerous event), low level of potassium in her blood, low thyroid function, high blood pressure, spondylosis (abnormal wear on the cartilage and bones in the neck and vertebrae), right and left shoulder pain, and heart disease. Review of Resident #9's MDS dated [DATE], revealed in Section C - Cognitive Patterns C0500. BIMS Summary Score Resident #9 scored 14 out of 15 indicating intact cognition. Review of Resident #9's Comprehensive Care Plan revised 02/24/2024, revealed the following focus care areas with objectives that were not measurable: Focus: Resident has impaired visual function and is at risk for falls, injury, and a decline in functional ability r/t her macular degeneration with an objective of Resident will maintain optimal quality of life and not experience a decline in ADL functional abilities or an injury related to vision loss. , Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner with an objective of Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs). The resident will improve current level of function in Bed Mobility, Transfers, Eating, Dressing, Toilet Use and Personal Hygiene, . Resident will be able to: , Focus Resident is on a Regular Diet, NAS and at nutritional & hydration risk related to Anxiety, Depression with an objective of Resident will maintain a normal bowel elimination pattern, Focus: The resident has dentures with an objective of The resident will tolerate diet . , Focus: Resident uses psychotropic medications (antidepressants, antipsychotics, and hypnotics) related to depression, generalized anxiety disorder, Pain management, and hallucinations with an objective of The resident will show decreased episodes of signs and symptoms of depression . , Focus: The resident is on Potassium with an objective of I [Resident], will have electrolyte (minerals in the blood that carry an electrical current) balance restored . , and Focus: Resident has fragile skin elated to the aging process and is at risk for bruising easily and skin tears with an objective of The resident's risk for the development of skin tears and bruising will be minimized . Review of Resident #18's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of Alzheimer's disease, dementia, major depression, hearing loss, heart disease, high blood pressure, atrial fibrillation (upper chambers of the heart beat irregularly), diverticulitis (bulging pouches in the digestive tract), and post-traumatic stress disorder. Review of Resident #18's MDS dated [DATE], revealed in Section C - Cognitive Patterns C0500. BIMS Summary Score Resident #18 scored 14 out of 15 indicating intact cognition. Review of Resident #18's Comprehensive Care Plan revised 02/11/2024, revealed the following focus care areas with objectives that were not measurable: Focus: Resident has impaired cognition and is at risk for a further decline in cognitive and functional abilities related to: Alzheimer's and dementia with objectives of Resident will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained ., and Resident will maintain current level of cognitive function without a decline ., Focus: Resident has a communication problem related to Hearing deficit with an objective of Resident will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained ., Focus: Resident has an ADL Self Care Performance Deficit and is at risk for not having their needs met in a timely manner. Performance deficit is related to Cognitive impairment., Impaired balance/impaired coordination, with an objective of Resident will participate to the best of their ability and maintain current level of functioning with activities of daily living (ADLs) . , Focus: Resident has a behaviors problem as evidenced by: getting in others personal space when she [NAME] they are in the way or her way with an objective of The resident's behavior will not interfere with the delivery of care or services, or result in harm to self or others ., Focus: Resident exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner. Cussing, derogatory comments, and bullying with an objective of Resident's verbal behaviors will not interfere with the delivery of ADL cares by staff . , Focus: Resident is on Mechanical Soft Diet and at nutritional & hydration risk related to Depression with an objective of Resident will maintain a normal bowel elimination pattern., Focus: The resident is edentulous (lacking teeth) and uses dentures with an objective of The resident will tolerate diet ., Focus: Resident uses psychotropic medications (antidepressants, anxiolytics) related to depression with an objective of The resident will show decreased episodes of signs and symptoms of depression . , and Focus: resident is able to effectively communicate the presence of pain and will notify staff when they are in pain. Resident is at risk for pain related to: Accident/Fall, Arthritis with an objective of Resident's pain level will be at or below their acceptable level as verbalized by the resident . Acceptable level of pain: , Review of Resident #24's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with medical diagnoses of epilepsy, bacteria in the urine, itching, history of falls, heart attack, coronary artery disease, high blood pressure, high cholesterol, and heartburn. Review of Resident #24's MDS dated [DATE], revealed in Section C - Cognitive Patterns C0500. BIMS Summary Score Resident #24 scored 15 out of 15 indicating intact cognition. Review of Resident #24's Comprehensive Care Plan revised 01/11/24 revealed the following focus care areas with objectives that were not measurable: Focus: [Resident] has impaired cognition and is at risk for a further decline in cognitive abilities with an objective of [Resident] will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained. , Focus [Resident] is at risk for the following items and/or diagnosis: Behaviors, Falls with an objective of Staff will be aware of the risks factors and/or diagnosis in POC/Kardex, Focus: [Resident] has a communication problem related to her comprehension ability with an objective of [Resident] will have needs met in a timely manner, dignity will be maintained, and current level of functioning will be maintained. , and Focus: [Resident exhibits verbally abusive behaviors at times and is at risk for harm and not having their needs met in a timely manner with an objective of [Resident's] verbal behaviors will not interfere with the delivery of ADL cares by staff. During an interview on 03/06/24 at 11:18 AM, RN A stated if an objective could not be measured there would be no way to determine if an objective was achieved. During an interview on 03/06/24 at 11:34 AM, the DON stated the DON or designee were responsible for monitoring care plans. She stated LVN B was responsible for compiling care plans. The DON explained that all staff work together to identify care focus areas. The DON stated changes on care plans were communicated to direct care staff on the Kardex. She stated acute changes were communicated to staff during daily clinical meetings conducted by the DON, or by posted in-services. The DON stated she or the ADON would come in early to make sure the night staff were informed. She stated objectives on the care plans must be measurable in order to monitor resident's progress or to identify if resident's progress was not occurring. The DON acknowledged the objectives reviewed needed to be reworded. She was unable to state why the objectives were not measurable. She stated the effect of unmeasurable objectives on residents may be if a decline were happening, they would not be able to appropriately address because there was no baseline to compare to. During an interview on 03/06/24 at 12:02 PM, LVN B stated she was responsible for creating care plans. She stated the failure occurred because objectives were computer generated selections and due to time constraints, she did not go through and individualize the objectives. LVN B was not able to state how unmeasurable objectives could affect a resident. LVN B stated restructuring objectives was an option to make the objectives individualized and measurable. Review of the facility policy titled Comprehensive Care Plans dated 02/10/2021 revealed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with 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 resident's comprehensive assessment. 48883

Based observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments for 1 of 2 medication carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure 1 of 2 medication carts were locked when unattended. This failure could place residents at risk of having access to unauthorized medications, wound care and medical supplies leading to possible harm or drug diversions. Findings included: During an observation on 03/04/2024 at 8:55 a.m. an unlocked medication cart was seen on North Hall in between nurses' station and administration offices. There were residents sitting in wheelchair around cart and two residents walking down the North Hall. Inside of treatment cart were one pair of bandage scissors, more than five Nystatin (prescription anti-yeast) powders, and one bottle of Hibicleanse (Antiseptic/Antimicrobial) wash soap. During an interview on 03/04/2024 at 08:55 a.m., the ADON stated that she expected the treatment cart to be locked when unsupervised. She stated that she was unaware of which nurse was responsible for the treatment cart at this time. During an interview on 03/04/2024 at 2:26 p.m., RN A stated that he was not clocked in at the time treatment cart was found unlocked. He stated that after 9:00 a.m., he was responsible for the treatment cart. He stated that he received keys from LVN B after the treatment cart was found unlocked. He stated that the treatment cart should be locked when not supervised. During an interview on 03/04/2024 at 02:27 p.m., LVN B stated she was in the building working as a nurse during the time that treatment cart was found unlocked. She stated that she had not touched the treatment cart during that time. During an interview on 03/04/2024 at 02:29 p.m., the ADMN stated LVN C worked the shift prior to the treatment cart being unlocked. He stated she worked from six o'clock p.m. to six o'clock a.m. The ADMN stated the best way to contact LVN C would be to call her during her work hours and that she would be at work 03/04/2024 at 6 o'clock p.m. During a phone interview on 03/04/2024 at 06:08 p.m., LVN C stated she received treatment cart keys from RN A on 03/03/2024 at six o'clock p.m. LVN C stated she gave treatment cart keys to LVN B when she left at 03/04/2024 at six o'clock a.m. LVN C stated the treatment cart should be locked when unsupervised. LVN B stated treatment cart could have not been locked back when she opened it later in her shift to get out a bandage. She stated it was a busy time and she may have forgotten to lock treatment cart back. She stated it was the nurse's responsibility to lock treatment cart when not supervised. LVN C stated not locking treatment cart could affect residents by allowing resident to have access to items in the treatment cart such as scissors and prescription medications that could cause harm. She stated the ADON and the DON were who were to monitor that treatment carts were locked appropriately by the nurses. During an interview on 03/05/2024 at 11:23 a.m., the DON stated the nurses were responsible for locking both medication and treatment carts. She stated she and the cooperate nurse attempted to find a facility policy on locking treatment carts, and they could not find one. She stated that they used the CDC and CMS guidelines for ensuring treatments and medications were stored appropriately. The DON stated her expectation would be for the treatment cart to be locked when unsupervised. She stated that unlocked treatment cart could affect residents by them having adverse reaction to substances in the cart that could lead to harm. She stated she was unaware of why the treatment cart was unlocked. The DON stated both her and the ADON were responsible for monitoring staff locked carts appropriately. According to the Centers for Medicare and Medicaid Services website https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-36.pdf accessed on 03/06/2024 revealed: Medications and biologicals are accessible only to authorized staff and are locked when not under the direct observation of the authorized staff.

Based on observation, interview, and record review the facility failed to establish and maintain an infeciton prevention and control program to help prevent the development and transmission of communicable diseases and infections for 4 of 36 residents (Resident's #1, #2, #3, and #4) reviewed for infection control. Upon learning on 05/18/23 of Resident #1's positive diagnosis of scabies the facility failed to notify the MD until 05/19/23 and start the isolation protocol This failure could place residents at risk for developing rashes and skin irritation resulting in residents scratching. Findings included: Closed Record review of Resident #1's electronic face sheet, dated 5/19/23 revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include Atopic Dermatitis, hypertension, Type 2 Diabetes, and Multiple sclerosis. Record review of Resident #1's Progress notes dated 5/17/23 revealed: Phone call to PoA regarding son we sent to ER due to low blood pressure, low temperature, and coarse lung sounds. When EMS was here, they were unable to obtain a BP. Action: Right lobe rub, left lobe diminished unable to take deep breaths at this time. Grey to white pale in color, cool to touch. Resident is becoming visibly upset and attempting to talk with nurse but unable to communicate clearly for self. During an observation on 5/19/23 at 9:45 AM Resident #1 room was the only room with contact isolation signage and PPE set out. During an interview on 5/22/23 at 11:45 AM Regional RRN-D stated she thought it was psoriasis, but the dermatologist diagnosed Resident #1 with eczema on 8/27/22. She stated that the itching in residents seemed to get much worse after resident showers. She stated she has no idea what is caused the rashes in the facility. She stated that they thought that the issue may be coming from the showers because things seemed to get worse for the residents after their showers. She stated but they really did not know what caused the issue. She stated based off the biopsy results done on 5/15/23 she did believe scabies are in the facility. She stated she was not exactly sure how they got in the facility or how to get rid of them. She stated that there had been an ongoing issue with rashes in the facility for a while now. She stated she is not sure why the DON did not call the Medical Director or any of the resident's primary care physicians after the scabies confirmation. She stated the DON should have put all residents that had an unusual rash on isolation immediately. Record review of Resident #2's electronic face sheet, dated 5/22/23 revealed she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include Folliculitis, Cellulitis, and Muscle Wasting. During an interview on 5/19/2023 at 2:25PM Resident #2 stated she is extremely itchy. She stated her back is the worst part. She stated the itching gets much worse after showering or when she gets hot. During an observation on 5/19/23 at 2:25 PM Resident #2 arms had several small bumps and itch marks. Legs had small bumps and itch marks and back has small bumps. Record review of Resident #3's electronic face sheet, dated 5/22/2023 revealed she was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses to include Cellulitis, Hypertension, and Muscle Weakness. During an interview on 5/19/2023 at 2:45PM Resident #3 stated the itching is bad. She stated she really is not sure what it is. She stated her back is bad. She stated whatever they are doing is not working. She stated that she has been treated by the facility for skin lice out of precaution, but that did nothing for her. She stated she has never been put on isolation because she was told that her rash was associated to her Cellulitis. She stated the rash has been around for a while. She stated it gets bad at night and when she takes her shower. During an observation on 5/19/23 at 2:45 PM Resident #3 skin has bumps and bites down the right arm, a few of the spots were bleeding. Record review of Resident #4's electronic face sheet, dated 5/22/23 revealed she was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses to include Epilepsy, Muscle Weakness, and Muscle wasting. During an interview on 5/19/2023 at 3:15 PM Resident #4 stated she had a rash on her arms and legs. She stated she has no idea how she got it. She stated it does it but not to bad. She stated it get much worse when she gets hot or goes to get her shower. During an interview on 5/19/23 at 2:00 PM DON stated that about 9:30 AM on 5/18/23 she called the hospital and the hospital stated that Resident #1 did have scabies confirmed through the biopsy done on 5/15/23. She stated that somehow the hospital had the results of the biopsy, but she did not. She stated she did not call the medical director or any of the other physicians that have residents in the facility. She stated she did not put up any isolation carts or signage for any other residents. She stated that Resident #1 had isolation up due to being immunocompromised, the isolation was not up due to scabies. She stated the facility was not sure what the resident had, she stated that he was diagnosed with eczema and dermatitis. She stated that there were a few other residents that did have unknown rashes on them in the facility, but she did not think they needed to be isolated because the facility did not believe they were scabies. During an interview on 5/19/2023 at 3:05 PM MD-A stated he never received a call yesterday, 5/18/23 from facility confirming the scabies diagnosis. He stated that with the confirming diagnosis he would have suggested to do a skin assessment of all residents and any resident with a rash should go on isolation. He stated that all residents with rash that went on isolation would prevent the spread of the scabies in the facility if they had not already had spread through the facility. He stated he went to the facility on Saturday 5/20/23 to do a skin assessment of all residents and 6 residents were put on isolation for unknown rash. He stated of the 6 residents only one resident was suspected of scabies but not confirmed. During an observation on 5/22/2023 at 10:45 AM 6 residents now on contact isolation for unknown rash in the facility. During an interview on 5/19/2023 at 3:40 PM NA-B stated she got scabies on 5/7/23 in the facility after giving residents showers all day. She stated she believes that they are all over the facility. She stated that she started not feeling well that night and went to urgent care. She stated the doctor did not scrape test her or anything. She stated that the doctor said it looks like scabies but there is no (tracking). She stated at that point she pulled her shirt down to show the top of her chest to the doctor and there was tracking. She stated the doctor diagnosed her with scabies and did prescribe her scabies medication and it worked within about two days she was feeling better, and the rash was gone, this was all done on 5/7/23. She stated she let the facility know she was diagnosed with scabies. She stated she was allowed to come back to work on 5/8/23 but she did not feel well and wanted to stay out of the facility until the entire rash was gone. She stated she returned to work on 5/17/23. She stated the rash has returned as of today 5/19/23. She stated she believes she is just re-infecting herself each time she goes back to work. During an interview on 5/19/2023 at 3:57 PM RN-C stated that because he was the charge nurse, he has worked every hallway and had worked directly with Resident #1. stated that he went to his doctor on 5/10/23 because he started to have red bumps show up all over his body, primarily armpits, forearms, belly, and inner legs. He stated that due to the suspicion of scabies in the facility he told his doctor. He stated his doctor diagnosed him with scabies and he was prescribed scabies medication. He stated he let the facility know that he was diagnosed with scabies. He stated that no scraping test was done to confirm scabies. He stated he started his medication on 5/10/23 and came back to work on 5/12/23. He stated he is about to do his final treatment as of today 5/19/23. During an phone interview on 5/22/23 at 12:35 PM CNA-E stated she has no idea what is in that building but it is bad. She stated if you do not really work in the shower room or with the residents you will not get the rash. She stated but if you work with residents or in the shower room all day, you are going to get some sort of rash. She stated if you are off for a few days the rash seems to go away but when she comes back to work it comes back. She stated it sucks because the facility has no idea how to prevent it. She stated she was sent home today because she had the rash on her left hand. She stated she did not believe the facility knows how to get rid of the issue and once it is gone how to prevent it. During an interview on 5/22/23 at 2:45 PM AD-F stated she did get the rash. She stated that she can be off a few days, and everything will go away but when she comes back to the facility, she will get the rash again. She stated she did not think the facility really knows what it is. She stated she did believe it is scabies and the facility either did not know how to get rid of them or did not know how to prevent them from coming back once they are gone. Record review of facilities Scabies Guidelines dated 6/11/19 states: The goals of scabies treatment are to: kill the mite. Treat any persons who have been in close contact with the infected person. Prevent scabies from returning. Record review of Facilities Transmission-Based (Isolation) Precautions dated 10/24/22 stated: It is our policy to take appropriate precautions to prevent the transmission of pathogens, based on the pathogens modes of transmission. For training and quick referencing purposes, a summary of precautions is contained at the end of this policy. 8. Contact Precautions. A. intended to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or resident's environment. Type and during of transmission-Based Precautions chart: Scabies-Contact isolation-duration: 24 hours after initiation of treatment. Prevention and Control: Scabies, per CDC guidelines. Scabies mites generally do not survive more than 2 to 3 days away from human skin. Children and adults usually can return to childcare, school, or work the day after treatment. Accessed: 5/22/2023 https://www.cdc.gov/parasites/scabies/prevent.html#:~:text=Scabies%20mites%20generally%20do%20not,work%20the%20day%20after%20treatment.

Based on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 19 residents (Residents #1, #9, #13, #24) reviewed for care plans in that: Resident #1 did not have a care plan in place for oxygen use. Resident #9's fall care plan did not address the use of a bed alarm as an intervention to prevent falls. Resident #13's fall care plan did not address the use of a chair alarm as an intervention to prevent falls. Resident #24's fall care plan did not address the use of a bed alarm as an intervention to prevent falls and there was no care plan in place regarding his right foot ulcer. These failures could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: Resident #1 Review of Resident #1's Admission Record dated 2/8/23 revealed: She was a [AGE] year-old female originally admitted to the facility 2/12/2014 and her most recent admitted was 6/13/22. Her admission diagnoses included Alzheimer's Disease with late onset, recurrent pneumonia, protein-calorie malnutrition, cognitive communication deficit, aphasia, generalized anxiety disorder, GERD, hypertension, STEMI (heart attack), congestive heart failure, history of falls, COPD, convulsions, major depressive disorder. Review of Resident #1's Quarterly MDS dated [DATE], revealed: She had a mental status score of 0 out of 15 indicating severe cognitive impairment. Her oxygen use was not documented in the quarterly MDS assessment. Review of Resident #1' Order Summary dated 2/8/23 revealed the following orders: Change O2 tubing and humidifier bottle every night shift every Thursday for oxygen use ensure that tubing is dated when changed (order date 12/05/22, start date 12/08/22). Monitor O2 saturation. Notify physician if SpO2 falls below 90% every shift (order date 12/05/22, start date 12/05/22). O2 @ 3LPM via NC. Monitor O2 saturation and notify MD if SpO2 falls below 90% as needed for low oxygen blood saturations/wheezing (order date 12/05/22, start date 12/05/22). Record Review of Resident #1's care plan dated 11/08/2022 did not address the use of oxygen. Review of Resident #1's Care Plan, last revised 11/8/22, revealed (in part): Focus - Resident is at risk for respiratory compromise secondary to dx of COPD; Goal - Resident will maintain her current respiratory status during the next 90 days; Interventions - Monitor Resident for SOB, cyanosis, fatigue. Monitor respiratory rate, lung sounds PRN. Resident #9 Review of Resident #9's Admission Record dated 2/9/23 revealed: She was an [AGE] year-old female admitted to the facility 10/05/22 with diagnoses which included vascular dementia, hypertension, cerebral ischemia, pressure ulcer of the sacral region stage 3, pressure ulcer of left heel stage 4, neuralgia and neuritis. Review of Resident #9's Quarterly MDS assessment dated [DATE] revealed: She scored 3 out of 15 on her mental status exam indicating severe cognitive impairment. She had 3 falls reported since the last assessment. Daily use of bed alarm and chair alarm were documented on the quarterly MDS assessment. Review of Resident #9's Order Summary dated 2/9/23 revealed the following orders: Alarming pressure mat to bed to alert staff of attempted unassisted transfers every shift for poor safety awareness related to vascular dementia (order date 2/8/23, start date 2/8/23). Record Review of Resident #9's care plan dated 02/06/2023 did not address bed alarm as an intervention. Resident #13 Review of Resident #13's Admission Record dated 2/9/23 revealed: She was a [AGE] year-old female admitted to the facility 6/28/22 with diagnoses which included dementia, peripheral vascular disease, hypertension, aphasia, Alzheimer's Disease with late onset, major depressive disorder, and insomnia. Review of Resident #13's Quarterly MDS assessment dated [DATE] revealed: She scored 3 out of 15 on her mental status exam indicating severe cognitive impairment. She had no reported falls since the last assessment. Daily use of bed alarm and chair alarm were documented in quarterly MDS assessment. Review of Resident #13's Order Summary dated 2/9/23 revealed the following orders: Alarm to wheelchair to alert staff if resident attempts to get up without assistance d/t lack of safety awareness every shift related to dementia (order date 2/8/23, start date 2/9/23). LAL mattress with bolsters to bed set on comfort setting 1 every shift for skin protection (order date 6/28/22, start date 6/28/22). Low bed with mat every shift (order date 6/28/22, start date 6/28/22). Pressure alarm to bed to alert staff of attempts to transfer unassisted every shift for fall prevention (order date 2/8/23, start date 2/9/23). Record Review of Resident #13's care plan dated 01/17/2023 did not address bed alarm as an intervention. Resident #24 Review of Resident #24's Admission Record dated 2/9/23 revealed: He was an [AGE] year-old male originally admitted to the facility 8/7/20 with the most recent admitted [DATE]. He had diagnoses which included dementia, Type 2 Diabetes Mellitus, non-pressure chronic ulcer of the right foot, benign prostatic hyperplasia, repeated falls, major depressive disorder, hypertension, history of heart attack, and chronic kidney disease stage 3. Review of Resident #24's Quarterly MDS assessment dated [DATE] revealed: He scored 3 out of 15 on his mental status exam indicating sever cognitive impairment. He was a high risk for developing pressure ulcers. He had no unhealed pressure ulcers at the time of the assessment. He had a diabetic foot ulcer at the time of the assessment. He used pressure reducing devices for his chair and bed, and application of ointment /medication for skin and ulcer treatment. Daily use of a bed alarm was documented. Use of a chair alarm was not documented. Review of Resident #24's Order Summary dated 2/9/23 revealed: Admit to this nursing facility under care of Dr. X for wound care, dementia, and atherosclerotic heart disease (order date1/13/23). Alarming pressure mat to bed every shift to alert staff to unassisted transfers poor safety awareness related to dementia, check for function and placement Q shift (order date 1/13/23, start date 1/13/23). Pressure alarm to wheelchair to alert staff of attempts to transfer unassisted due to poor safety awareness ensure proper placement and function every shift for resident safety related to dementia (order date 2/8/23, start date 2/9/23). Prevalon boot to right foot when up to aid in wound healing every shift for wound healing (order date 1/13/23, start date 1/13/23). Tx to right foot ulcer: cleanse wound, and peri wound with normal saline. Apply wound dressing of honey gel, apply secondary wound dressing on silicone bordered foam every dayshift for right foot ulcer (order date 1/13/23, start date 1/13/23). Record Review of Resident #24's care plan dated 01/26/2023 did not address the care of the ulcer/wound on his right foot and Resident #24's care plan dated 01/26/2023 did not address bed alarm as an intervention. Interview on 2/9/23 at 11:35 AM with the Administrator, the DON and Regional Compliance RN, the Administrator stated that MDS nurse was responsible for starting care plans. Regional Compliance RN stated that corporate policy was that the comprehensive care plan was initiated based on the CAAs triggered from the MDS assessment completed by the MDS nurse but once the care plan was started, all clinical staff had access to it in the EMR and was able to update interventions as needed. When asked what should be included on a care plan, the DON stated fall risk, psychotropic medications, diagnoses, pressure ulcer or skin risk, code status, ADLs and interventions for all of the care plan areas. The Regional Compliance RN described fall interventions as things put in place to prevent additional fall occurrences such as bed or chair alarms, fall mats, appropriate footwear. The Administrator stated that falls were part of the facility's quality measures and the missing care plans should have been addressed. The Administrator stated the MDS nurse had been working the night shift to help with staffing shortages and she was unavailable to be interviewed. The DON stated that she was unaware that oxygen use required a care plan of its own, and that having it listed as an intervention for a disease process was sufficient. When asked how staff without access to resident charts knew how to care for resident's oxygen, DON stated they used the Kardex which was populated by the care plan. The DON stated that if the information regarding oxygen parameters and maintenance was not on the care plan it would not be on the Kardex, she then stated she understood that meant the staff would not know how to properly care for the resident. Review of the facility policy Care Plans and CAA (Care Area Assessments) revision date 5/16/2016 revealed in part: Purpose: The purpose of this guide is to ensure that an interdisciplinary (IDT) approach is utilized in addressing the Care Area Triggers (CATs) that were generated by the completion of the Minimum Data Set (MDS) in order to effectively address the Care Area Assessments (CAAs) and ultimately achieve the completion of an effective comprehensive plan of care for each resident. The policy contained no information on what should be included in each resident's care plan and the facility provided no other policies regarding care plans prior to exit.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 40 residents (Resident #12), 1 of 1 treatment carts and 1 of 1 crash carts reviewed for pharmacy services. 1. The facility failed to ensure the Treatment Cart #1 did not include an opened and expired tube of Aspercreme (creme used for joint pain) for Resident #12. 2. There was an opened and expired bottle of Hibiclens (used for cleansing skin of bacteria) and opened and expired bottle of olive oil. (Used for all residents, as needed). 3. The facility failed to ensure the crash cart #1 did not have expired Sodium Chloride. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and worsening of symptoms of diseases. Findings Included: Review of Resident #12's face sheet dated 2/9/23 revealed, a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: Myocardial Infarction (heart attack), Hypertension (high blood pressure), restless leg syndrome (uncomfortable sensation in legs), Polyneuropathy (peripheral nerve damage). Review of Resident #12's care plan dated 01/13/23 stated goal for Resident #12 was that Resident #12 will not have severe pain through the review date, interventions- administer pain medications per MD order. Review of Resident #12's MDS dated [DATE] revealed nothing on pain. Review of Resident #12's physician's orders dated 01/31/22 revealed, Aspercreme Original Creme 10%, to be applied to affected joints topically, as needed for pain. Observation on 02/09/2023 at 08:30 AM, inventory of the treatment cart #1 with the DON revealed one tube of Aspercreme Original Creme 10%-1.25 ounce (expiration date 11/9/22) with Resident #12's name on RX label. Observation on 02/09/2023 at 08:30 AM also revealed the following expired medications (for all residents -standing orders): one 8-ounce bottle of Hibeclens (expiration date 05/22) and a 250ml bottle of olive oil (expiration date 1/23/23). Observation on 02/09/2023 at 09:30 AM revealed four disposable vials of Sodium Chloride on Crash Cart #1 (expired 2022). Interview on 02/09/2023 at 11:30 AM with the DON and ADON, The DON stated that night shift was responsible of checking medication cart for expired/discontinued medications. The ADON stated that she usually does spot checks weekly. The ADON stated that she just checked it last week but failed to look at expiration dates. The DON stated that it was important to check expiration dates because the medications can lose potency and therefore resident does not receive desired effect. The DON stated that expired/discontinued medications are to be removed from medication/treatment carts and placed in the locked closet in her office until the pharmacist comes to facility to destroy. Record review of the facility policy titled Medication Storage dated January 20, 2021, reads in part: Medication carts are routinely inspected for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are removed and destroyed in accordance with the facility policy.

Based on observation, interview, and record review, the facility failed to maintain medical records that are complete and accurately documented for 1 of 3 residents (Resident #240) who were reviewed for documentation of indwelling catheter care. RN A did not document Foley Catheter change for R#240 as required by policy This failure could affect residents who receive catheter care and put them at risk for urinary tract infections. Findings included: Review of Resident #240's electronic face sheet dated 2/09/2023 revealed resident was a [AGE] year-old male and was admitted to the facility on [DATE] with diagnoses of Hemiplegia (paralysis of one side of body) and Hemiparesis (muscle weakness to one side of body) following Cerebral Infarction (stoke)-affecting left non-Dominant side, Obstructive and Reflux Uropathy (urine cannot drain through the urinary tract) and Kidney Failure. Review of Resident #240's admission MDS dated [DATE] revealed a BIMS of 12 making him moderately cognitively intact. He could understand and be understood. He had no other behavior issues, no rejection to care, required one person assistance with ADLs, and admitted with indwelling catheter. Review of Resident #240's comprehensive plan of care dated 01/12/2023 revealed he had an indwelling urinary catheter related to his obstructive uropathy with urine retention, and under interventions .change urinary catheter per routine schedule as ordered by the physician. Review of Resident #240's physician orders dated 01/19/2023 revealed, Change Foley catheter every 5th day of the month and PRN. During an interview on 02/09/2023 at 9:32 AM, Resident #240 stated that his catheter had not been changed since January 5th when he was residing at another SNF. Resident #240 stated that his catheter should have been changed on February 05, 2023, but this had not occurred. Resident #240 stated that he was not experiencing any pelvic pain at this time and stated that yesterday he observed blood-tinged urine draining through catheter tubing into collection bag. Observation on 02/09/2023 at 9:40 AM of Resident #240's Foley catheter system revealed amber colored urine in tubing and collection bag, excessive sediment observed within the drainage tubing, anti-reflux valve (flap that prevents urine back flow into the drainage tubing) and collection bag. Record review for Resident #240 revealed that on 01/05/2023 RN A entered initials on the facility TAR's (Treatment Administration Record) but did not document changing Resident #240's catheter in the Nursing Progress Notes or the Daily Skilled Notes, per facility policy (Foley Catheter Guideline). Review of RN A's nursing progress notes and Daily Skilled Nursing Note (for Resident #240) dated, 02/03/2023 at 11:19 AM, read in part, Resident has catheter Foley catheter patent and draining amber urine Physician was not contacted. Review of RN A's nursing progress notes and Daily Skilled Nursing Note (for Resident #240) dated, 02/05/2023 at 10:44 AM, revealed in part, Resident has catheter Foley catheter is patent and draining yellow cloudy urine with sediment noticeable. During an interview on 02/09/2023 at 10:48 AM, the DON stated that RN A or any nurse working the weekend day shift was to review the TAR's to review for treatments due during their shift. The DON stated that the Med-Aide reviews the MAR's (Medication Administration Record) for medications due during their shift. The DON stated that on 02/05/2023 the RN A was working and was responsible for reviewing the TAR's. The DON stated that there was a Med-Aide working on 02/05/2023 who would be responsible for medication administration. The DON stated that it was her expectation that documentation should be entered into the Nursing Progress Notes and Daily Skilled Notes if a resident has a treatment done (including catheter changes), per facility policy ((Foley Catheter Guideline). The DON stated that this should be completed along with initialing on the TAR's. During an interview on 02/09/2023 at 11:00 AM, RN A stated that he was not able to recall which residents had catheter changes on 02/05/2023. RN A stated that he would have to review the TAR's to see who had catheter changes. During an interview on 02/09/2023 at 11:28 AM, RN A stated that after reviewing TAR's, he determined that two residents were scheduled to have Foley Catheter changes on 02/05/2023. RN A stated that Resident #8 was scheduled to have catheter changed but this had been completed on 02/03/2023, so he did not perform the catheter change. RN A stated that Resident #240 was scheduled for Foley catheter change and stated that he changed Resident #240's Foley catheter. RN stated that he initialed this on the TAR's but did not document in Daily Skilled Note or Nursing Progress Note. RN A asked if he was supposed to document catheter changes in progress notes. Interview on 02/08/23 at 4:09 PM, the Administrator stated that his expectations were that all staff follow facility policies and procedures. Record review of facility policy, Foley Catheter Guideline revised 02/2016, revealed in part, The intent of this policy is to provide guidance for staff caring for residents with urinary catheters and to assist in the prevention of catheter-associated urinary tract infections (CAUTI) The clinical indication for inserting a urinary catheter should be documented in the patient's medical record Catheter care should be provided daily and as necessary Evaluate the color of urine and for urine leaks around the catheter, tubing, or drainage bag Documentation- Physician Orders, Treatment Administration Record, Nurses Progress Notes.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #16) of 2 residents reviewed for wound care, in that: RN B failed to perform sanitary wound care for Resident #16, per facility policy. This failure could place residents with wounds or pressure ulcers at risk for cross contamination and infection. Findings included: Record review of Resident #16's face sheet, dated 02/09/2023, revealed that she was an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16's diagnoses included Dementia (Loss of Memory and Intellectual Functioning), Heart Failure, Colostomy (artificial opening in abdominal wall to allow fecal matter to be removed), Protein-Calorie Malnutrition (Inadequate intake of Proteins/Calories), Contracture of Upper Right Arm (Shortening and Hardening of Muscles, Tendons, or other tissue), Kidney Disease, Contractures of bilateral lower extremities and Muscle Wasting. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #16 had a BIMS score of 3, indicating she had severe cognitive impairment. Resident #16 required total dependence of staff for her activities of daily living. Resident #16 was frequently incontinent of bladder and had a colostomy. Resident #16 had one unstageable pressure injuries presenting as deep tissue injury with pressure reducing device in place for wheelchair and bed. Record review of Resident #16's care plan, dated 01/03/23, revealed in part: Resident #16 has an ADL Self-care deficit due to functional limitations in range of motion and decreased mobility. Resident #16 has a terminal illness and is receiving hospice or palliative care. Resident #16 has the potential for development of a pressure ulcer related to urinary incontinence and impaired mobility with interventions of administer analgesics as needed for discomfort or pain, if necessary to provide pain management prior to dressing changes and repositioning, check frequently for wetness, every two hours and provide incontinence care as needed, weekly skin checks to monitor for redness, pressure sores, open areas, and other changes to skin integrity, pressure reducing devices on bed/chair, including heel pressure reducing device. Record review of Resident #16's physician orders, dated 02/03/23 revealed in part: Apply skin prep to great toe and second toe on Right foot. Cleanse Left lower lateral leg wound with wound cleanser, pat dry, apply Xeroform (Medicated gauze), apply ADB pad (Abdominal Pad used for absorption of discharge from a wound) and wrap with Kerlix (Rolled gauze) every day for wound healing. Cleanse Right heel with wound cleanser, pat dry, apply Triad cream to affected area and cover with padded dressing. Cleanse right lower coccyx (stage 2 pressure ulcer) with wound cleanser, pat dry, apply barrier cream and cover with foam sacral (Area of the first and second vertebrae-lowest part of spine near buttock) dressing. Observation on 02/07/23 at 2:30 PM revealed Resident #16's door had a sign posted Enhanced Barrier Precautions which stated everyone entering room must: Clean hands (including before entering and when leaving room) Wear gloves and gown with High-Contact Care Activities (dressings, bathing, transferring, changing linens, providing hygiene, assisting with toileting, providing care with central lines/urinary catheters/feeding tubes/trach. Put on gloves before entering and discard before exiting room. Put on gown before entering and discard before exiting room. Observation of boxes of gloves and clean disposable gowns hanging on Resident #16's door (under sign). Observation and interview on 02/07/23 at 2:40 PM revealed RN B applied disposable gown and gloves before entering Resident #16's room. No observation (by surveyor) of RN B washing hands or using hand sanitizer prior to applying gloves. RN B placed wound care supplies on Resident # 16's dresser and, placed red bio-hazard trash bag on Resident #16's mattress (at the foot of bed). RN B used scissors to remove old bandage to Resident #16's Left lower lateral leg and placed scissors on top of the red biohazard trash bag (within the interior of bag). RN B then placed dressing (removed from leg) in the red bio-hazard trash bag. RN B changed gloves without washing hands or using hand sanitizer. RN B sprayed wound cleanser on wound and used gauze to wipe off excess exudate/drainage from wound and placed gauze in the red bio-hazard trash bag. RN B opened Xeroform and placed it on Resident #16's leg wound and stated that she did not bring enough Xeroform to cover wound. RN B removed her gloves and left the resident's room to get more Xeroform. RN B did not wash hands, use hand sanitizer and RN B did not remove the disposable gown when exiting the room. RN B returned to Resident #16's room without changing gown and applied a new pair of gloves before entering room without washing hands or using hand sanitizer. RN B applied Xeroform and followed wound care orders. RN B took gloves off and placed them in the red bio-hazard trash bag and applied new pair of gloves without washing hands or using hand sanitizer. RN B took scissors out of the red bio-hazard trash bag and used scissors to remove bandage from Resident 16's Right heel without sanitizing the scissors. RN B placed scissors on Resident #16's blanket (beside red bio-hazard trash bag), removed dressing from the Right heel and placed it in red bio-hazard bag. RN B removed gloves, placed it in red bio-hazard trash bag, and applied a new pair of gloves without washing hands or using hand sanitizer. RN B sprayed wound cleanser on the Right heel, patted dry with gauze and placed gauze in the red bio-hazard trash bag. RN B applied Triad cream to wound of heel and covered wound with padded dressing. RN B removed gloves, placed it in red bio-hazard trash bag, and applied a new pair of gloves without washing hands or using hand sanitizer. RN B removed dressing from right lower coccyx and performed wound care without changing gloves. Resident #16 was repositioned by aide that assisted RN B during wound care. RN B removed gloves and applied new pair of gloves without washing hands or using hand sanitizer and wiped scissors and supplies to be taken out of room with disinfecting wipes. RN B exited room, placed supplies on treatment cart (located by Resident #16's door) and removed disposable gown and gloves and disposed of them in bin (located in hall by Resident #16's door). RN B then documented treatment in computer without observation of hand washing or use of hand sanitizer. RN B pushed treatment cart to next resident's room to perform wound care. RN B used hand sanitizer prior to entering the next resident room and wound care was observed with no issues observed regarding infection control. Interview on 02/08/23 at 11:23 AM, the DON stated that RN B informed DON that she did not perform wound care per policy/procedure (on 02/07/23 prior to ending her shift) and stated this occurred because she was nervous with state staff watching her. The DON stated that her expectations were that all staff should follow facility policies and procedures with all treatments. The DON stated that hands should be washed (or hand sanitizer used) between glove changes. The DON stated she had done hand hygiene, wound care, and infection control in-services with RN B, when they spoke. Interview on 02/08/23 at 11:51 AM, RN C stated that the facility corporate office had put Enhanced Barrier Precautions into effect with all of their facilities to use due to CDC guidance, as a precaution designed to reduce transmission of multidrug-resistant organisms (MDRO's) in nursing homes. Interview on 02/08/23 at 4:09 PM, the Administrator stated that his expectations were that all staff follow facility policies and procedures. Record review of facility policy, Infection Prevention and Control Program revised 10/27/2022, revealed in part: This facility has established and maintains 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 as per accepted national standards and guidelines Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures All staff shall use personal protective equipment (PPE) according to established facility policy. Record review of facility policy, Hand Hygiene revised 02/11/2022, revealed in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR) The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves.

Based on observation, interview and record review, the facility failed to prepare food in accordance with professional standards for food service safety from 1 of 1 facility kitchens as evidenced by: A. Dietary Aide A was eating in the kitchen while preparing resident meal trays. This failure could place 35 residents who reside at the facility and eat meals/snacks prepared and served by the facility's kitchen at risk of contracting a foodborne illness. Findings include: In an interview and observation on 05/29/18 at 07:27 AM Dietary Aide A was observed chewing something in his mouth while in the kitchen preparing resident drinks and prepping food trays. Dietary Aide said he was eating a granola bar. He said he was not supposed to be eating. In an interview on 5/30/18 at 11:40 am, LVN A said all residents eat food prepared from the facility's kitchen. In an interview on 5/30/18 at 9:00 am, Dietary Manager said staff should not be eating while they are in the kitchen. In an interview on 6/1/18 at 6:40 pm, Administrator said staff should not eat while they are in the kitchen. Review of facility Food & Nutrition Services Policy & Procedure Manual policy titled Personal Hygiene, revision date 11/2017 revealed: Policy: Dietary employees will maintain proper food safety practices through proper personal hygiene . Fundamental Information The health and personal hygiene habits of food service workers when not handled properly may potentially cause food contamination. Therefore, it is important to make sure that all food service personnel are properly educated regarding optimal health and hygiene practices . Procedure 6. Eating and gum chewing are not permitted in the dietary department . CMS Form 672 dated 5/29/18 indicated a census of 35.

Based on observation, interview and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 3 errors out of 26 opportunities which resulted in an 11 percent error rate for 3 of 6 (Residents #22, #27 and #34) reviewed for medication errors. 1. LVN A crushed Celecoxib 200mg, [MEDICATION NAME] 25mg, Aspirin 325mg, Cranberry 450mg two tablets, Rivastigmine 4.5mg, Multivitamin with mineral one tab, Oyster Shell Calcium 500mg with 200 IU Vitamin D and Senna Plus one tab and failed to administer all crushed medications to Resident #22 by leaving crushed medications in cup. 2. ADON administered Potassium Chloride ER 10 mEq instead of 20 mEq as ordered to Resident #27 3. LVN A administered [MEDICATION NAME] Ultra eye drops two drops to each eye instead of five drops to each eye to Resident #34 This deficient practice could place 5 residents who receive crushed medications, 13 residents who receive Potassium Chloride and 3 residents who receive [MEDICATION NAME] eye drops at risk of not receiving the intended therapeutic benefit of their medication. The findings: Resident #22 Review of Resident #22's face sheet dated 05/30/18 noted a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following [DIAGNOSES REDACTED]. Review of Resident #22's Quarterly MDS dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment. MDS noted resident #22 did not exhibit signs or symptoms of a possible swallowing disorder. Record review of Resident #22's MAR (Medication Administration Record) for (MONTH) (YEAR) revealed [MEDICATION NAME] 200mg (Celecoxib) one capsule by mouth every 12 hours (order date 1/20/18), [MEDICATION NAME] 25mg one tablet by mouth in the morning (order dated 1/30/18), Aspirin 325mg one tablet in the morning (order date 1/30/18), Cranberry Tablet 450mg two tablets one time a day (order date 1/21/18), [MEDICATION NAME] Capsule (Rivastigmine [MEDICATION NAME]) one capsule by mouth in the morning (order date 1/21/18), Multivitamin with mineral one tab in the morning (order date 1/21/18), Oyster Shell Calcium 500mg with 200 IU Vitamin D (order date 5/1/18) and Senna Plus 8.6-50mg one tab every 12 hours (order date 5/1/18). Review of Resident #22's order summary report printed on 05/30/18 noted order (MONTH) crush crushable meds, open caps and mix with a palatable substance with order date of 1/20/18. Observation on 05/29/18 at 7a.m., LVN A opened [MEDICATION NAME] and [MEDICATION NAME] Capsule and mixed contents with crushed [MEDICATION NAME], Aspirin, Cranberry tablets, Multivitamin with mineral, Oyster Shell Calcium with Vitamin D and Senna Plus. All crushed meds mixed with pudding. LVN A administered medications to resident using wooden spoon. Upon LVN A exiting resident room, medication cup contained medication mixed with pudding. In an interview on 5/29/18 at 7:15 a.m., LVN A said she did not administer all the crushed medication from the cup to Resident #22 and she could not administer the medication remaining in the cup because she placed paper trash in the medication cup and threw the medication cup in the trash. Resident #27 Review of Resident #27's Admission Record dated 5/30/18 noted she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses; [MEDICAL CONDITION] infarction, dysarthria, hypertension, cerebral infarction, dysphagia, [MEDICAL CONDITION], dementia, major [MEDICAL CONDITIONS], gout, [MEDICAL CONDITION] and generalized [MEDICAL CONDITION]. Review of Resident #27's Quarterly MDS (Minimum Data Set) dated 05/03/18 revealed a BIMS score of 12 indicating moderate cognitive impairment. Review of Resident #27's MAR (Medication Administration Record) for (MONTH) (YEAR) revealed Potassium Chloride Extended Release 20 mEq and give one tablet by mouth one time a day (order date 3/29/18). Observation on 05/30/18 at 11:04 a.m., ADON administered Potassium CL ER 10 mEq one tablet to Resident #27. In an interview on 05/31/18 at 3:00 p.m., ADON said she administered one Potassium Chloride 10 mEq to Resident #27 on 05/30/18 and did not notice the MAR stated 20 mEq and the card of Potassium Chloride read 10mEq to give one tablet by mouth once a day with dispense date of 5/19/18. She said she should have administered Potassium CL 20 mEq or two tabs of 10 mEq to Resident #27. Resident #34 Review of Resident #34's Admission Record dated 05/30/18 noted she was a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses; displaced fracture of right femur, [MEDICAL CONDITION], hypertension and gastro-[MEDICAL CONDITION] reflux disease. Review of Resident #34's Admission MDS dated [DATE] revealed a BIMS score of 15 indicating she had no cognitive impairment. Review of Resident #34's MAR (Medication Administration Record) for (MONTH) (YEAR) revealed [MEDICATION NAME] Gel 0.4-0.3% Instill 5 drops in both eyes as needed for dry eyes. Observation on 05/29/18 at 6:50 a.m., LVN A administered [MEDICATION NAME] Eye drops two drops to each eye to Resident #34. In an interview on 5/30/18 at 2:30 p.m., LVN A said she administered [MEDICATION NAME] eye drops two drops to Resident #34. LVN A looked at MAR (Medication Administration Record) for Resident #34 and said she should have administered 5 drops to each eye. In an interview on 05/30/18 at 3:30 p.m., DON said if a nurse received an order to change a dose of medication, they should fax that order to the pharmacy and transcribe that order to the Medication Administration Record. He said the increased dose of Potassium for Resident #27 was not sent to the pharmacy for the change in dosage. He said his expectation was for the nurses to administer medications according to the physician's orders [REDACTED]. If an order was received to change the dose, the nurse could place a sticker on the card indicating a dosage change until the medication was delivered from the pharmacy. He said his expectation was for the nurse to administer all crushed medications to a resident and not leave residue from medication in the cup. In an interview on 06/01/18 at 6:45 p.m., Administrator said her expectation was for medications to be administered as ordered and for the nurse to give all medications especially when medications were crushed. Review of Medication Administration by Facility Personnel (undated) Policy: All medications are to be administered only as prescribed, and only by licensed medical nursing personnel .Procedures: .8. Description of medication pass: .g. Remove the medication packet (s) from the drawer. Compare information on the packet with the medication administration record .verify that all the medications on the packet to be administered that date and time match the MAR (Medication Administration Record).l. administer all medications to the resident, making sure they are taken by the resident. According to a list (undated) provided by the DON on 05/31/18, this deficient practice could place 5 residents who receive crushed medications, 13 residents who receive Potassium Chloride and 3 residents who receive [MEDICATION NAME] eye drops.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of disease and infection for 4 of 4 residents (Resident #'s 9, 10, 11, 137) reviewed for infection control. A. Resident #'s 9 and 10 foley catheter tubing was observed dragging on the floor B. Resident #'s 11 and 137 oxygen concentrator bottles and/or tubing were not dated This deficient practice could place the 4 residents who required oxygen therapy and 4 residents with foley catheters at risk for the development and/or spread of infection and a physical decline in their health. Findings include: RESIDENT #9 Review of Resident #9's face sheet indicated he was a [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #9's quarterly MDS dated [DATE], revealed a BIMS score of 15 indicating an intact cognitive level. The MDS also revealed the resident had an indwelling catheter. Review of Resident #9's Care Plan dated 6/22/17, revised 9/13/17, indicated a focus area of the resident had a urinary catheter and is at risk for urinary tract infections and injury. The interventions listed included to provide urinary catheter care per facility practice. Review of Resident #9's Physician order [REDACTED]. In an observation on 5/29/18 at 9:30 am, Resident #9 was seated in his wheelchair, self-propelling about the facility. His catheter tubing was dragging on the floor and his foot was stepping on it as he moved. RESIDENT #10 Review of Resident #10's face sheet indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #10's Significant Change MDS dated [DATE] revealed a BIMS score of 15 indicating an intact cognitive level. The MDS also revealed the resident had an indwelling catheter. Review of Resident #10's care plan dated 3/19/18 indicated a focus area of the resident had a urinary catheter and was at risk for urinary tract infections and injury. The interventions listed included monitor for pain and discomfort due to the presence of a urinary catheter, change urinary catheter per routine schedule and provide urinary catheter care per facility practice. In an observation on 5/29/18 at 3:11 pm, Resident #10 was seated in her wheelchair propelling herself from the dining room. Her catheter tubing was dragging on the floor. In an interview on 5/31/18 at 3:46 pm, DON said catheter care should be based on physician orders [REDACTED]. He said catheter tubing should not be dragging on the floor and if the tubing is observed dragging on the floor, it should be addressed immediately by staff. DON said CNA's should be attaching the tubing to a Velcro fastener located underneath the resident's wheelchair and nurses should be ensuring devices are in place every shift. In an interview on 6/1/18 at 6:40 pm, Administrator said foley catheter tubing should not be on the floor. RESIDENT #11 Review of Resident #11's Admission record dated 5/28/18 revealed she was an [AGE] year old female admitted to the facility on [DATE] with an original admission date of [DATE] with the following Diagnoses: [REDACTED]. Review of Resident #11's Annual MDS (Minimum Data Set) dated 03/19/18 noted a BIMS (Brief Interview for Mental Status) score of 15, indicating her cognition was intact. The MDS also documented [DIAGNOSES REDACTED]. MDS noted resident received oxygen therapy while a resident of the facility and within the last 14 days. Review of Resident #11's Care Plan dated 05/17/18 noted to administer Oxygen therapy per physician's orders [REDACTED]. Review of Resident #11's Treatment Administration Record dated 5/1/18-5/31/18 revealed to change oxygen tubing and aqua Pak setup every week on Thursdays every night shift with a start date of 12/29/16. This was signed as being changed on 5/3/18 and 5/17/18 but not on 5/10/18 and 5/24/18. Review of Resident #11's Treatment Administration Record dated 5/1/18-5/31/18 revealed to change oxygen tubing and aqua Pak setup every week on Thursdays every night shift with a start date of 5/30/18. This was signed as being changed on 5/30/18. Observation on 05/29/18 at 7:00 a.m., Resident #11's aqua pak dated 05/18/18. No date visible on Resident #11's nasal cannula tubing. Observation on 05/29/18 at 03:04 p.m., Resident #11 with oxygen on using nasal cannula and aqua pak bottle dated 05/18/18 and no date on oxygen tubing (nasal cannula). Resident #11 said she normally wore oxygen at night. RESIDENT #137 Review of Resident #137's admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating no cognitive deficit. Review of Resident #137's Care Plan indicated a focus area of Oxygen: Resident #137 uses oxygen therapy routinely . The interventions listed included: Administer oxygen therapy per physician's orders [REDACTED]. Review of Resident #137's Physician Summary Order dated 5/17/18 revealed an order, with a start date of 5/17/18, to change O2 (oxygen) tubing and humidifier bottle every night shift every Thu (Thursday) for Oxygen use Ensure that tubing is dated when changed. Review of Resident #137's Treatment Administration Record dated 5/1/18-5/31/18 revealed to change oxygen tubing and humidifier bottle every night shift every Thursday for oxygen use Ensure that tubing is dated when changed. Staff initialed completion of task on Thursday, 5/24/18. In an observation on 5/29/18 at 3:19 pm and 5/30/18 at 3:05 pm, Resident #137 was in her room, seated in bed with oxygen on via nasal cannula. The aqua pak bottle and tubing were not dated. In an interview on 5/30/18 at 10:56 am, ADON said oxygen tubing and aqua pak (water) are to be changed weekly by the night shift nurse. She said there was no designated spot to write the date it was changed. She said the date was usually written on the oxygen water bottle. Review of Nursing Policy and Procedure dated 09/12/2014 for Oxygen Administration with policy to describe methods for delivering oxygen to improve tissue oxygenation .Procedure Equipment - .prefilled sterile humidifier bottle, connection tubing, oxygen cannula or mask .Procedure 1. Verify Physician order [REDACTED]. Label bottle with date. Change bottle when empty .Completion of procedure .3. Change disposable parts once a week and label with date (tubing, plastic bag, mask or cannula) .Documentation Treatment Administration Record . Review of facility policy titled, Foley Catheter Guideline revision date 2/2015 revealed: Policy The intent of this policy is to provide guidance for staff caring for residents with urinary catheters and to assist in the prevention of catheter-associated urinary tract infections . Guideline . -Use a secure device to stabilize the catheter, to reduce pulling, involuntary removal of catheter, pain and bladder spasms . -Catheter care should be provided daily and as necessary . In an interview on 5/31/18 at 3:46 pm, DON said 4 residents use oxygen and 4 residents have foley catheters.

Based on observation, interview and record review, the facility failed to ensure the residents and/or responsible representative had the right to participate in the development of his or her care plan for 4 of 12 residents (Resident #2, #12, # 21 and #35) reviewed for comprehensive care plan, in that: Residents #2, #12, #21 and #35 or the resident's representatives were not invited to participate in the residents' care plan conferences. This failure could affect 35 residents by placing them at risk for a loss of independence, psychosocial well-being and the opportunity to participate in the planning of their care. Findings include: Resident #2 Review of Resident #2's Admission Record dated 06/01/18 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses; dementia, mood disorder, [MEDICAL CONDITION] with delusions, history of falls, hypertension, [MEDICAL CONDITION], dysphagia, difficulty in walking and complete atrioventricular block with presence of pacemaker. Review of Resident #2's Admission MDS dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 9 indicating moderate cognitive impairment. MDS noted resident #2 had clear speech and makes self-understood and usually understands others. MDS noted resident participated in assessment and goal setting but guardian or legally authorized representative did not participate in assessment. Review of Care Plan Acknowledgement Form - Resident/Representative form for Resident #2 dated 11/08/17 noted My signature below specifies that I have discussed/viewed the plan of care and was given the opportunity to ask questions and state my preferences in my care and goals of care. Type of care plan: Other and Admission Care Plan. Reason for discussion or viewing of the care plan: Other: Care plan review. Date 11/08/17 Signature (s) of resident, representative or other was blank (no resident or family signature) Signature of facility representative: MDS nurse, Activity Director, Dietary Director and Director of Rehab. Review of Care Plan Acknowledgement Form - Resident/Representative form for Resident #2 dated 02/20/18 noted My signature below specifies that I have discussed/viewed the plan of care and was given the opportunity to ask questions and state my preferences in my care and goals of care. Type of care plan: Other and Quarterly Care Plan. Reason for discussion or viewing of the care plan: Other: Blank. Date 02/20/18 Signature (s) of resident, representative or other was blank (no resident or family signature) Signature of facility representative: MDS nurse, Activity Director, Dietary Director and Director of Rehab In an interview on 06/01/18 at 2:28 p.m., Resident #2 said he didn't know what a care plan meeting was about. Resident #12 Review of Resident #12's Admission Record dated 06/01/18 revealed she was an [AGE] year old female admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITION] and [MEDICAL CONDITION] following cerebral infarction, [MEDICAL CONDITION], major [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], dysarthria, Dysphagia, [MEDICAL CONDITION], asthma, arthritis, contracture of muscle right hand and right lower leg and cognitive communication deficit. Review of Resident #12's Annual MDS dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 3 indicating severe cognitive impairment. Resident was noted to have clear speech, makes self-understood and usually had the ability to understand others. MDS noted resident #12 participated in assessment but no family or significant other participate in assessment. Review of Resident #12's Care plan dated 04/20/18 noted Resident #12 had a communication problem related to a stroke. Interventions include: anticipate and meet needs, encourage resident to continue stating thoughts even if resident was having difficulty. Care plan for activities dated 04/20/18 noted Resident #12 was dependent on staff for cognitive stimulation, activity attendance and social interaction related to cognitive impairment and was at risk for isolation. Interventions include: Encourage ongoing family involvement. Invite the resident's family to attend special events, activities and meals. Review of Care Plan Acknowledgement Form - Resident/Representative form for Resident #12 dated 12/05/17 noted My signature below specifies that I have discussed the plan of care and was given the opportunity to ask questions and state my preferences in my care and goals of care. Type of care plan: Other and continue current plan of care. Reason for discussion or viewing of the care plan: Other: Quarterly. Date 12/05/17 Signature (s) of resident, representative or other had line drawn through section. Signature of facility representative: MDS nurse, Activity Director, Dietary Director, Director of Rehab Review of Care Plan Acknowledgement Form - Resident/Representative form for Resident #12 dated 4/3/18 noted My signature below specifies that I have discussed the plan of care and was given the opportunity to ask questions and state my preferences in my care and goals of care. Type of care plan: Other and continue current plan of care. Reason for discussion or viewing of the care plan: Other: Quarterly. Date 4/3/18 Signature (s) of resident, representative or other had line drawn through section. Signature of facility representative: MDS nurse, Activity Director, Dietary Director and Director of Rehab In an interview on 05/31/18 at 4:12 p.m., Power of attorney of resident #12 said he had not been notified based on his knowledge by mail, email or phone for a care plan meeting at the facility for his mom until today when he received a letter inviting him to a meeting regarding Resident #12. He said he had not attended a care plan meeting at the facility for Resident #12 since her admission. Resident #21 Review of Resident #21's Admission Record dated 6/1/18 revealed she was an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITIONS], major [MEDICAL CONDITION], diabetes mellitus and cerebral [MEDICAL CONDITION]. Review of Resident #21's Admission MDS dated [DATE] revealed a BIMS score of 3 indicating severe cognitive impairment. MDS noted resident #21 had adequate hearing, clear speech, usually makes self-understood and usually understands others. Her vision was noted to be moderately impaired. Resident #21 was not noted to have behavioral symptoms or rejection of care. MDS noted Resident #21 participated in assessment but no family or significant other participated in assessment. Review of Resident #21's Care plan dated 11/06/17 noted she had a communication problem related to her cognitive impairment. Interventions include: anticipate and meet needs. Care plan dated 11/06/17 noted Resident #21 was dependent on staff for cognitive stimulation, activity attendance and social interaction related to cognitive impairment and was at risk for isolation. Interventions include: Encourage ongoing family involvement. Invite the resident's family to attend special events, activities, meals. Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Review of Care Plan Acknowledgement Form - Resident/Representative form for Resident #21 dated 12/08/17 noted My signature below specifies that I have discussed/viewed the plan of care and was given the opportunity to ask questions and state my preferences in my care and goals of care. Type of care plan: Other and continue current plan of care. Reason for discussion or viewing of the care plan: Other: Quarterly. Date 12/08/17 Signature (s) of resident, representative or other had line drawn through section. (no resident or family signature) Signature of facility representative: MDS nurse, Activity Director, Dietary Director Review of Care Plan Acknowledgement Form - Resident/Representative form for Resident #21 dated 4/6/18 noted My signature below specifies that I have discussed/viewed the plan of care and was given the opportunity to ask questions and state my preferences in my care and goals of care. Type of care plan: Other and continue current plan of care. Reason for discussion or viewing of the care plan: Other: Quarterly. Date 4/6/18 Signature (s) of resident, representative or other had line drawn through section. (no resident or family signature) Signature of facility representative: MDS nurse, Activity Director, Dietary Director In an interview on 05/31/18 at 4:31p.m., with Resident #21's responsible party, she said she visited the facility weekly and talked to staff frequently. She said Resident #21 received Hospice services. She said she could not recall receiving a letter in the mail or an email regarding a care plan meeting to discuss Resident #21's care or attended a meeting to discuss her care. Resident #35 Record review of Resident #35's Admission record revealed an [AGE] year-old male admitted on [DATE] with the following diagnoses; dysphagia, cerebral infarct, [MEDICAL CONDITIONS] disease, [MEDICAL CONDITION] and [MEDICAL CONDITION] left side, hypertension, [MEDICAL CONDITIONS], gastrostomy, [MEDICAL CONDITION] reflux, cognitive communication deficit, dysarthria, [MEDICAL CONDITION] disorder, lack of coordination, muscle wasting and atrophy, contracture left lower leg, contracture left thigh, mood disorder with major depressive episodes, type II diabetes, [MEDICAL CONDITION], coronary angioplasty implant and graft, heart failure, major [MEDICAL CONDITION], attention deficit post cerebral infarct, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Record review of MDS (minimum data set) dated 10/21/17 revealed a BIMS (Brief Interview for Mental Status test) score of 4 indicating severe cognitive impairment. Review of Care Plan Acknowledgement Form - Resident/Representative form for Resident #35 dated 05/11/18 noted My signature below specifies that I have discussed the plan of care and was given the opportunity to ask questions and state my preferences in my care and goals of care. Type of care plan: Other and review current plan of care. Reason for discussion or viewing of the care plan: Other: Quarterly. Date 05/11/18 Signature (s) of resident, representative or other was blank. (no resident or family signature) Signature of facility representative: MDS nurse, Activity Director, Dietary Director and Director of Rehab. In an interview on 06/01/18 at 2:50 p.m., responsible party for Resident #35 said he had not received notification verbally or in the mail regarding a care plan meeting for Resident #35. He said he did not remember being asked to attend a care plan meeting. In an interview on 06/01/18 at 10:30 a.m., MDS nurse said she was responsible for notifying families and residents of date and time of care plan meetings. She said she doesn't have copies of letters notifying families of care plan meetings. She said she had no proof anyone was invited. She said she invited the family and residents unless the resident was their own responsible party and didn't want family invited. In an interview on 06/01/18 at 6:45 p.m., Administrator said her expectation was family/responsible party and residents to be notified by letter of date and time of care plan meetings. She said the facility should keep a copy of the letter sent inviting family/responsible party and resident to care plan meeting. Review of facility Care Plan Guidelines, origination date 1/21/15, revision date 5/6/16, revealed: Guideline It is the intent of Advanced Health Care Solutions to meet and abide by all State and Federal regulations that pertain to resident care plans and subsequent Care Area Assessments (CAAs) completion. Purpose The purpose of this guide is to ensure that an interdisciplinary (IDT) approach is utilized in addressing the Care Area Triggers (CATs) that were generated by the completion of the Minimum Data Set (MDS) in order to effectively address the Care Area Assessments (CAAs) and ultimately achieve the completion of an effective comprehensive plan of care for each resident. Procedure . Care Plan Meetings 1. Meetings will be conducted within 21 days of admission to the facility and at least quarterly thereafter . 2. The meetings will be scheduled by the Social Worker, or designee following the schedule above . 3. The Social Worker, or designee, will send out invitation letters to the resident, family member, responsible party as well as any other entity that may be required to attend including but not limited to hospice representative, local authority from PASSR program, physician, appointed guardian etc. 4. The Social Worker will use the facilities designated form for documentation by IDT of meeting. Form to be filed in the resident's chart. According to facility resident list report dated 05/29/18, the facility had a census of 35 residents.

Based on interview and record review, the facility failed to electronically transmit within 14 days an accurate and complete resident's MDS data to the CMS system for discharge for 1 (Resident #1) of 1 resident reviewed for transmittal requirements. This failure could affect 11 residents who were discharged in the last 3 months by not ensuring resident specific payment and quality monitoring. Findings include: Review of Resident #1's Admission record dated 12/5/17 revealed a [AGE] year-old female initially admitted to the facility on [DATE] and admitted on [DATE] with the following diagnoses; acute and chronic [MEDICAL CONDITIONS], diabetes mellitus, major [MEDICAL CONDITION], sleep apnea, [MEDICAL CONDITIONS], asthma and gastro-[MEDICAL CONDITION] reflux disease. Review of Resident #1's 5-day MDS dated [DATE] noted assessment was the first assessment since the most recent admission/entry or reentry. Type of assessment was noted to be an unplanned discharge assessment with return not anticipated. Discharge Status was noted to be acute hospital. Resident was noted to have a Medicare-covered stay from 12/05/17-12/10/17. Review of Resident #1's physician orders [REDACTED]. In an interview on 06/01/18 at 5:20 p.m., DON said Resident #1 was transported to Hospital A and did not return to the facility. He said his expectation was for MDS nurse to submit information according to CMS RAI instructions. Review of Resident #1's MDS (Minimum Data Set) Summary dated 12/10/17 noted Medicare 5 day/DRNA (Discharge return not anticipated)/End of PPS Part A Stay completed. In an interview on 06/01/18 at 5:15 p.m., MDS (Minimum Data Set) nurse said she submitted a Discharge with Return not anticipated MDS to Managed Care but failed to check a box that would submit it to CMS. She said she sent the MDS to Resident #1's Managed Care Insurance. MDS nurse said she was to follow CMS' RAI instructions when completing MDS for residents. Review of CMS's RAI Version 3.0 Manual dated (MONTH) (YEAR) Page 5-4 noted Submission Time Frame for MDS Records Discharge Assessment to be submitted MDS Assessment Completion Date: Date of the RN (Registered Nurse) assessment coordinator's signature, indicating that the MDS assessment is complete plus 14 days. In an interview on 06/01/18 at 6:45 p.m., Administrator said her expectation was for the MDS nurse to complete MDS (Minimum Data Set) utilizing CMS (Centers for Medicare/Medicaid Services) guidelines per the RAI (Resident assessment instrument) manual. In a list provided by the Administrator on 06/01/18 noted 11 residents were discharged from the facility in the past 3 months.

Based on interview, observation and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 5 of 12 residents (#35, #15, #34, #12, #10) reviewed for activities. This deficient practice could affect 35 residents by not providing activities to promote socialization and prevent boredom. Findings include: Record review revealed resident #35 is [AGE] year-old man, last admission on 10/21/17. His [DIAGNOSES REDACTED]. Record review of Resident #35's care plan dated, 'Revised on 9/11/17', revealed he was to be 'provided activities that are compatible with the resident's physical and mental capabilities and known interests and preferences'. Record review of daily activity log, dated (MONTH) (YEAR), for resident #35 included TV, listening to radio and conversation. No other activities were documented. Record review of MDS (minimum data set) dated 10/21/17 revealed, BIMS (Brief Interview for Mental Status test) score of 4 indicated he was mentally severely impaired. Interview on 6/1/18 at 10:10 am, through an interpreter, he said he would like to go to some activities outside of his room. He had no idea what that might be, just outside of his room. Observation on 6/1/18 at 10:10 am, he was up in his wheelchair sitting near the nurses' station, not talking to anyone. Sitting and watching people go by. Record review of the (MONTH) and (MONTH) Activities Calendar revealed multiple opportunities to engage were listed on the calendar, he did not participate. No refusals noted. Record review of facesheet dated 5/2018 resident #15 was a [AGE] year-old female, last admitted was 10/21/14. Her [DIAGNOSES REDACTED]. Record review of MDS dated [DATE] revealed her BIMS score was 15, indicating she was cognitively intact and able to make choices. Record review of resident #15's care plan revised on 1/24/18 revealed activities goal was for her to remain independent and choose activities in which she would like to participate. The interventions include getting to know other residents, activities of interest for the resident, posting of activity calendar, materials for individual activities and the right to refuse. Resident's preferences are listed under interventions she enjoys getting her nails done, watching TV, spends most of her time in her room, has meals in the dining room. Record review of the daily activity log for (MONTH) and (MONTH) indicated resident #15 watches TV and talks to people and nothing else was marked for either month. In an interview on 6/1/18 at 10:30 AM with resident #15 revealed she preferred to stay in her room with her roommate. She said she liked it when they have matinee movies and popcorn. Resident #15 denied being offered 'in room' activities. She does not participate in any other activities offered. Record Review of Resident #34's Admission Record dated 5/30/18 noted a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses; displaced fracture of right femur, abnormalities of gait and mobility, lack of coordination, [MEDICAL CONDITION], hypertension, gastro-[MEDICAL CONDITION] reflux disease and arthritis. Review of Resident #34's Admission MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. Resident was noted to have no overall presence of behavioral symptoms. MDS noted during interview for activity preferences the following activities were very important: books, newspapers, magazines to read, listen to music, be around animals such as pets, keep up with the news, go outside to get fresh air when weather is good, participate in religious activities or practices and do things with groups of people. Review of Activity Evaluation (undated) but listed date of admission of 5/3/18 noted Resident #34 had a current interest in the following activities: cards, games, crafts/arts/hobbies, exercise/walking/jogging, sports, music, reading/audio books, writing, baking/cooking, computer, spiritual/religious activities, trips/shopping, spending time outdoors, walking/wheeling outdoors, watching TV/radio, watching movies, gardening/plants, talking/conversing, helping others/volunteer work, parties/social events, keeping up with the news and community outings. Resident #34 would prefer to participate in scheduled activities in the morning and afternoon. Review of Resident #34's Care plan initiated on 05/04/18 and revised on 05/30/18 noted she is independent in making activity choices and attending activities of preference. Stays busy with hobbies, reading, or fixed daily routine. Goal was Resident #34 would remain independent in activity choices and participation through next review date. Interventions include to assist with arranging community activities, arrange transportation, establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary, Resident #34's preferred activities are: playing cards, bingo, exercise, reading and listening to music, enjoys being social and attending social gatherings such as parties, games, and just visiting with other residents, spending time outside when the weather is nice. Provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility, provide the resident with materials for individual activities as desired. Review of Resident #34's (MONTH) (YEAR) Individual Resident activities noted on Sunday spiritual/religious, music and groups/organizations are completed. Resident #34 participated in games with no type listed every Monday, Wednesday and Friday from 05/07/18-05/30/18. Other activities marked daily from 5/4/18-5/31/18 include reads, views television, talking/conversing/visits other residents. Review of (MONTH) (YEAR) activity calendar noted Bingo scheduled on Monday, Wednesday and Friday at 10 a.m., movie and popcorn scheduled on 05/09/18, 05/18/18 and 05/23/18, Dollar Tree shopping scheduled on 05/09/18 and park walking on 05/24/18. In an interview on 05/30/18 at 10:15 a.m., Resident #34 said activities do not occur as listed on the activity calendar. She said the schedule was just for looks. She said residents do not have access to dominoes or games. She said if the residents had access to games, there was not a place to play them. She said it would be nice to go outside and visit with families and other residents. She said if you set on the front porch of the facility, there is no way to see the park because of all the cars parked in their view. She said she would enjoy going shopping outside the facility. She said the facility only had a couple of movies and denied the facility having movie and popcorn activities. She said the residents at the facility do not have direct access to movies, puzzles, games or dominoes to play. Resident #34 said she would like to have adult coloring book or puzzle/word search books, but none are available to the residents. She said the residents feel socially isolated in the facility as there are no outside activities held for residents. She said staff had not informed her of puzzles, games, movies, dominoes, etc. being available for resident use. She said she was unaware of a closet in the hallway with activity supplies for residents. In an interview on 05/31/18 at 1:15 p.m., Resident #34 said the band that was scheduled to come on Monday nights had only been to the facility on ce since her admission on 5/3/18. She said a book cart would be nice for the residents to have a variety of books to choose from. She said she had not seen any games since her admission on 5/3/18. She said the facility had a 1000-piece puzzle, but it was too hard for most of the residents, so it would be nice to have easy puzzles with less pieces. She said puzzle books, word search books or adult coloring books would be nice for residents to have access to. Review of Resident #12's Admission Record dated 06/01/18 revealed an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses; [MEDICAL CONDITIONS] following cerebral infarction, [MEDICAL CONDITION], major [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], dysphagia, [MEDICAL CONDITION], asthma, contracture of muscle right hand and right lower leg and generalized muscle weakness. Review of Resident #12's Annual MDS dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 3 indicating severe cognitive impairment. MDS revealed it was very important for Resident #12 to be around animals such as pets, go outside to get fresh air when the weather was good, religious services or practices and somewhat important to keep up with the news. The MDS also noted her vision to be impaired and corrective lenses to be worn, she was totally dependent on two staff to physically assist with transfers and totally dependent of one staff to physically assist with locomotion off unit (e.g. areas set aside for dining, activities or treatments). Review of Resident #12's care plan for activities dated 04/20/18 noted she was dependent on staff for cognitive stimulation, activity attendance and social interaction related to cognitive impairment and was at risk for isolation. Goal for Resident #12 was she would attend/participate in activities of choice 3-5 times weekly. Interventions include: assist/escort the resident to activity functions, .establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary, introduce the resident to residents with similar background, interests and encourage/facilitate interaction, invite the resident to scheduled activities, .provide a program of activities that was of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility, .provide the resident with assistance as needed during the activity, .when the resident chooses not to participate in organized activities, turn on TV or music in room to provide sensory stimulation. Observation on 05/29/18 at 01:16 pm., Resident #12 sitting up in wheelchair in hallway. Neatly dressed and groomed. Resident was sitting in hallway outside of her room. No TV or radio was in Resident #12's side of her bedroom. Resident #12's roommate has a TV on her side of the room, but she keeps privacy curtain pulled and Resident #12 cannot see the TV from her bed. Record Review of Resident #12's (MONTH) (YEAR) Individual Resident Activities noted on 05/29/18 resident's activity included views TV. In an interview with CNA A staff said Resident #12 was usually only up in wheelchair for meals. She said resident does not have a TV in her room and there was no TV in the dining room. She said the resident will sometimes sit in the lobby after breakfast. She said resident was normally either in her bed or her wheelchair. CNA A said Resident #12 would usually sit in the lobby after meals and watch TV otherwise she did not participate in activities to her knowledge. Review of Resident #10's face sheet indicated she was a [AGE] year-old female who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #10's Significant Change MDS dated [DATE] revealed a BIMS score of 15 indicating an intact cognitive level. MDS also revealed in an interview for activity preferences, Resident #10 said it was very important for her to to be around animals such as pets, keep up with the news, do things with groups of people and participate in religious services or practices and it was somewhat important for her to do her favorite activities. Review of Resident #10's Care Plan revealed a focus area for activities dated 5/2/17 that the resident is independent in making activity choices and attending activities of preference. The goal noted the resident will remain independent in activity choices and participation through next review date. Interventions included: provide a program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility, provide the resident with materials for individual activities as desired and the resident's preferred activities are: the resident enjoys being outside when the weather is nice, resident enjoys taking her smoke breaks and visiting with her peers, she enjoys watching television and attending some social events such as birthday parties and musicals. Review of Resident #10's Activity Evaluation dated 2/27/18 conducted by Activity Director, indicated on the resident preference interview, it was very important for resident to have books, newspapers and magazines to read, to be around animals such as pets, keep up with the news, do things with groups of people, do her favorite activity, get fresh air when the weather was good and participate in religious services and practices. The evaluation indicated the resident's current interests included: cards, games, crafts/arts/hobbies, exercise, sports, music, baking/cooking, spiritual/religious activities, trips/shopping, spending time outdoors, walking/wheeling outdoors, watching TV/radio, watching movies, gardening/plants, talking/conversing, parties/social events and keeping up with the news. The preferred activity setting is noted at the resident's own room in the morning or afternoon. In an interview on 5/30/18 at 9:47 am, when asked about activities, Resident #10 said she would like to go on an outing to a store like Dollar General/Family Dollar/Dollar Tree and look around at the offerings and do some shopping. In an observation on 5/29/18 at 3:11 pm, Resident #10 was seated in her wheelchair propelling herself from the dining room after participating in the birthday party activity. Observation on 05/30/18 at 3:30 p.m. revealed an unlocked, unlabeled, closet that contained activity supplies. The closet was not accessible to residents due to being built up at the bottom and requiring staff/residents to step up into the closet. The closet contained boxes and bins unlabeled with contents such as puzzles, dominoes, puzzle books, etc. In an interview on 6/1/18 at 3:02 p.m., Activity Director said she completed an activity evaluation upon admission and with a significant change. She said she does make an entry into the resident's progress notes quarterly. She said the residents who attend the monthly resident council meeting choose activities for the month or for special holidays. She said there were on average 4-7 residents who attend monthly resident council meetings and they tell her what they want to do as far as activities. She said she will then incorporate their preferences into the activity calendar. She said she tells residents when the council meeting is and invites them to attend. Activity director said she offers resident to speak with her one on one if they don't attend the resident council meeting. She said she works 8 am to 5 pm, Monday thru Friday. She said CNA's do the activities after 5:00 pm and on weekends. She said if it was a special activity or event (Superbowl, Easter), she would come up on the weekend and do that activity. The Activity Director said she documents on the individual resident activities sheets for activities that occurred Monday through Sunday. She said she talks with random residents to see what they did over the weekend and documents on the individual resident activities sheet. For one on one activities with a resident or in-room activities, the activity director said it depends on who the resident is and what they like to do as to what she will offer as an activity. She said she had an individual resident activities sheet on her clipboard for Resident #34 and had not yet filed it in the book with other resident's activity sheets. In an interview on 06/01/18 at 5:15p.m., CNA B she said the CNA's are responsible for completing activities on weekends with residents. She said they do whatever was listed on the activity calendar. She said if an outside activity was planned, it will depend on the weather if it was done. She said if the weather doesn't permit the activity, she offered an alternate activity. She said she did not document anywhere who participated in activities on the weekend. She said the documentation was completed by the Activity Director. She said she did not document or make a list of residents who participated in activities over the weekend. She was not sure how the Activity Director obtained the information as to who participated in activities over the weekend. She said the residents can ask for supplies such as cards, dominoes, etc. they may want to do activities in the evening or on the weekend. She said the activity closet in the hallway across from the dining room was unlocked and staff had access to supplies as needed. In an interview on 06/01/18 at 6:45 p.m., Administrator said based on the activity assessment, activities should be put on the calendar based on the consensus of the residents. She said the Activity Director should reach out to residents even if only one resident wants to do an activity. She said CNA's can help with activities. She said residents who cannot do group activities should receive one-on-one assistance for activities. Administrator said one-on-one, or in-room, activities should consist of something more than talking with the resident. She said a bin was available with games in the activity closet. She said the activity closet was not labeled for residents to know where activity supplies were located. Administrator said residents should have access to activities after hours and not have to ask CNA's for activity items. CMS Form 672 dated 5/29/18 indicated a census of 35.

Based on observation, interview, and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, for 1 of 7 residents (Resident #4) reviewed for quality of care. On [DATE] Resident #4 was lowered to the ground while being provided care by one staff. There was no thorough assessment conducted after a CNA reported to the DON that Resident #4 could not bear weight on [DATE]. On [DATE] Resident #4 showed signs and symptoms of pain to her knee, and no thorough assessment was conducted. On Saturday [DATE] at 2:00 a.m. the physician was notified by LVN E via fax that two large purple bruises were found on Resident #4 ' s right leg (Labor Day Weekend). At 5:30 a.m. on [DATE] the leg was swollen, and the physician was notified. Resident #4 was diagnosed with [REDACTED]. The resident's family chose palliative care and Resident #4 died on [DATE]. On [DATE] an Immediate Jeopardy (IJ) was identified and the AD was notified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could affect 27 residents, and could place them at risk for not being adequately assessed and treated for [REDACTED]. The findings included: Closed record review of Resident #4's undated face sheet revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #4's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) could not be conducted. The staff assessment of Resident #4's mental status indicated she had short and long term memory problems and severely impaired cognitive functioning. Her assessment under functional status for transfers indicated total dependence with the support of two+ person physical assist with dressing and bathing assessed as total dependence with support of one person physical assist. Review of MDS Kardex report dated [DATE] for Resident #4 revealed she was not steady during transitions/walking, when moving from seated to standing; moving on and off toilet; and surface-to-surface transfer. She was listed as total dependence, two+ persons physical assist for transfers. Review of Resident #4's Care Plan for Falls dated [DATE], updated on [DATE], [DATE] and [DATE], revealed the resident was a high risk for falls and the Plan of Care (POC) to be continued. Resident #4 ' s Rehab/Mobility Care Plan indicated extensive assistance of two staff needed for transfers due to decreased mobility and poor safety awareness. Rehab/Mobility Care plan also indicated resident is extensive time one assist most of the time. Occasionally she will start hitting at staff so two person assist is needed. Occasionally she will sleep (drowsy) a lot and will not assist with transfers so assist of two persons is needed. Resident #4 will receive assistance appropriate to mobility status and to encourage self mobility as tolerated by resident. The Care Plan for Rehab/Mobility and Functional ADL's (Activities of Daily Living) dated [DATE], with updates on [DATE], [DATE] and [DATE] revealed Resident #4 was an extensive assist for toileting, dressing, eating and personal hygiene, an extensive assist times 2 for transfers, a total assist for bathing with staff to bathe the resident and total dependence for bed mobility. Record Review of Resident #4's fall risk assessment dated [DATE] with updates on [DATE], [DATE] and [DATE] revealed a score of 13 for each date. The assessment form states, A score of 10 or higher may represent high risk. Record review of Nurse's Progress Note/Summary dated [DATE] revealed Resident #4 was noted to be unsteady in her balance and lifted manually for transfers. Record review of referral to Physical Therapy for evaluation and plan of treatment dated [DATE] revealed Resident #4's current referral to physical therapy was due to decline in functional mobility causing decrease in strength, decrease in transfers, reduced balance, reduced functional activity tolerance, decrease in functional mobility, reduced static and dynamic balance, decreased coordination and increased need for assistance from others placing patient at risk for falls, further decline in function, decreased participation with functional tasks and increased dependency upon caregivers. Impressions noted by the therapist reflect .Patient was reported by nursing to have decline in functional mobility patient shows anxiety performing mobility task thus making patient a high risk for fall. Record review of [DATE] Assessment Summary Impression completed by Physical Therapy for Resident #4 revealed a report by nursing the resident had a decline in functional mobility and showed anxiety performing mobility tasks thus making resident a high risk for fall. Recommendations based on [DATE] referral revealed Resident #4 was dependent for basic mobility of sit to stand, chair or bed to chair transfer and toilet transfer. Resident #4 was totally dependent without attempts to initiate transfers and gait. Record review of the facility's Incident Report QA/CQI Log for month ending ,[DATE] lists the fall for Resident #4 on [DATE] (untimed) and under contributing factors was noted Res. (Resident) quit standing during assist transfer-lowered to floor. Record review of Resident #4's Interdisciplinary Post-Fall Assessment, dated [DATE], revealed the description of the fall as: Resident was lowered to knees then onto (R) side and then back with legs outstretched after leaning into CNA (E) while CNA (E) was adjusting stuck brief during dressing her post shower. The probable cause for this fall based on review and investigation: Res. (Resident) pushed into CNA (E) while CNA (E) adjusting brief causing loss of balance of both-CNA (E) lowered res. to floor to prevent fall. .does the current plan of care for this resident clearly indicate the level of assistance the resident requires? Yes is the box checked with an explanation: Dependent-Extensive ,[DATE] person depending on Res. performance. Recommendations from review by team (also record in resident medical record) Isolated incident-to prevent hard fall. Continue POC. Record review of the SBAR (Situation Background Appearance Review) Communication Form, undated, related to the incident involving Resident #4 revealed the change in condition observed was resident was lowered to knees onto floor (after) shower in shower room. The form indicated the situation occurred on [DATE]. The SBAR indicated the resident did not display any signs of pain or distress, had full range of motion, did not display any bruising, and did not display common signs of a fracture. The SBAR indicated Physician A was notified at 4:00 PM on [DATE] and recommended for the facility to continue to monitor. The SBAR was signed by ADON. An additional update was added to Resident #4 ' s Care Plan for Falls on [DATE] to reflect the incident when the resident had been lowered to the floor via staff to prevent a hard fall-isolated incident with a note to continue the Plan of Care. Review of Medication Administration Record [REDACTED]. pain. The medication had not been administered on [DATE] or [DATE]. Record review of Nurses Medication Notes within the MAR indicated [REDACTED]. At 10:00 a.m. ADON documented in the Results section of the notes zero signs/symptoms of pain discomfort, sitting up in wheelchair. The resident was given Tylenol, 325 milligrams, two tablets by mouth on [DATE] at 5:30 am by LVN E due to guarding of right lower extremity. Record review of Resident #4's Nurse's Notes revealed the following entries: [DATE] 9:00 a.m. Pt. (patient) exhibiting (decreased) ability (with) functional transfers + (and) mobility. Occasionally not bearing wt (weight). (Decreased) ADL (activities of daily living) participation + requires (increased) staff assistance (with) repositioning to reduce pressure points + skin breakdown Signed by LVN B [DATE] 7:20 a.m. Cont. (continue) with PT/ OT (occupational therapy) services + requires staff assist (with) all ADL's + transfers . Signed by LVN B (No entries in the nurse's notes regarding Resident #4 being lowered to the floor in the shower room on [DATE] through [DATE] at 4:00 PM) In an interview on [DATE] at 9:50 a.m., DON said nurses are supposed to document every shift for 72 hours post fall for delayed injury. (No entries in the nurse's notes between [DATE] at 4:00 PM and [DATE] at 10:00 AM) In an interview on [DATE] at 9:30 a.m., ADON said the expectation was for nurses to document incidents like Resident 4's on alert charting and the 24 hour nurses report so nurses will know to assess for any changes on every shift for 72 hours. [DATE] 4:00 p.m. Resident (up) in wheelchair awake alert oriented x (times) 1. (No) delayed injury or bruising r/t (related to) s/p (status [REDACTED]. (No) s/s (signs or symptoms) pain/discomfort. Personal alarm on et (and) working. Signed by ADON [DATE] 10:00 a.m. Cont (Continue) (with) PT/OT (and) requires staff assist (with) all ADL's (and) transfers. Unable to make her needs known verbally. PT reports to this nurse that during therapy resident was grimacing when Biofreeze applied to her knee. No s/s pain presently. Signed by LVN B [DATE] 2:00 a.m. (Saturday of Labor Day weekend) CNA reports finding a bruise to Res (resident) Right leg assessment reveals an 11 x 7 cm (centimeter) dark purple bruise to her posterior calf. Also a 6 x 6 cm light purple bruise to (right) popliteal area. (No) s/s pain or discomfort noted. Res singing (and) talking during assessment. (No) s/s pain or discomfort noted to RLE (right lower extremity). Res moving ext (extremity). Pedal, femoral (and) popliteal pulses present. Physician A notified of bruises via fax. R/P (responsible party) will be notified in AM D/T (due to) this late hour. Signed by LVN E [DATE] 3:15 a.m. Bruising remains to RLE (with) no s/s pain or distress. Singing/talking (at) intervals per norm (normal). Will monitor. Signed by LVN E [DATE] 5:30 AM Res noted (with) 3 (plus) [MEDICAL CONDITION] to (right) thigh and 2 (plus) [MEDICAL CONDITION] to (right) calf. Bruising spreading to lateral thigh (and) knee, dark purple in color. Res guarding RLE. Pulses remain positive v/s (vital signs) ,[DATE], 82, 20, 96.7 SPO2 (oxygen saturation) 90 % on RA (room air). Physician A notified (at)6:15 AM. Order received to transport to ER(emergency room ) for eval (evaluation) (and) tx (treatment). R/P notified of res cond (condition) (and) transport to ER. PRN (as needed) APAP ([MEDICATION NAME]) 650 mg (milligram) given. Signed by LVN E [DATE] 6:20 AM EMS (Emergency Medical Services) called (and) en route to facility. Signed by LVN E [DATE] 6:40 AM Res leaves facility for ER via ambulance. Condition stable. Report called in to ER. Signed by LVN E According to Biofreeze.com <http://www.Biofreeze.com> Biofreeze is a topical [MEDICATION NAME] that uses the cooling effect of menthol, a natural pain reliever, to soothe minor muscle and joint pain. http://www.biofreeze.com/how-biofreeze-works (accessed [DATE]) According to medlineplus.gov [MEDICATION NAME] is used to relieve mild to moderate pain from headaches, muscle aches, . and to reduce fever. [MEDICATION NAME] may also be used to relieve the pain of [MEDICAL CONDITION] (arthritis caused by the breakdown of the lining of the joints). <http://medlineplus.gov/druginfo/meds> (accessed [DATE]) Hospital records Record review of orthopedic surgical consultation with Physician B dated [DATE] for Resident #4 indicates X-rays taken of the right knee and femur noted a periprosthetic [MEDICAL CONDITION] femur with some distal bone still attached to the femoral prosthesis and displacement. Options for treatment were discussed with Resident #4's family. They included managing the fracture non-operatively with a knee immobilizer with the unlikelihood the fracture would heal or an open reduction and internal fixation of the periprosthetic fracture. The later would require a surgical fixation with a high complication rate, necessity for further surgery, including the possibility of amputation. It is noted should the family decide for the surgery, Resident #4 would require transfusion to a more acceptable hematocrit level. Record review of physician progress notes [REDACTED].#4 and their decision was for Resident #4's comfort to be a priority for care and requested a referral to hospice. Record review of Resident #4's records from a local hospital revealed Resident #4 was transferred from the facility in which she was assessed in the emergency roiagnom on [DATE] at 7:26 AM. Her [DIAGNOSES REDACTED]. X-ray report revealed a comminuted fracture involving the distal femur, proximal to the knee arthroplasty. Resident #4 was subsequently admitted to the inpatient hospice unit until being transferred to a long-term care facility. Resident #4 died on [DATE]. According to the Mayo Clinic: A broken leg (leg fracture) is a break or crack in one of the bones in your leg. Common causes include falls . In all cases, prompt [DIAGNOSES REDACTED]. A broken thighbone (femur) - the strongest bone in your body - usually is obvious because it takes so much force to break. Signs and symptoms of a broken leg may include: Severe pain, which may worsen with movement, swelling, tenderness, bruising, obvious deformity or shortening of the affected leg and inability to walk. Delays in [DIAGNOSES REDACTED]. Fractures of the thighbone are severe, potentially life-threatening injuries http://www.mayoclinic.org/diseases-conditions/broken-leg/basics/symptoms/con- 562 (accessed [DATE]) In an interview on [DATE] at 5:35 p.m., CNA E said on [DATE] she transferred Resident #4 by herself from bed to wheelchair. In the shower room she transferred Resident #4 alone from wheelchair to shower chair using stand pivot transfer. After shower, CNA E said she stood Resident #4 up to pull brief up when the brief caught between Resident #4 ' s legs. She said Resident #4 starting leaning forward. CNA E said she lowered Resident #4 to the ground on her knees. CNA E said she starting yelling for help. CNA E laid Resident #4 to her side then to her back. CNA E said once resident #4 was laid on her back she was okay. CNA E said DON entered the shower room. ADON entered the shower room to assess resident. CNA E said she, DON and ADON lifted resident up to wheelchair after the assessment. CNA E said she did not normally work the hall resident #4 resided on. She said she looked in the CNA assignment binder at the nurses station for amount of assistance needed to transfer resident. CNA E said she had worked at the facility for one year and has always transferred Resident #4 by herself. Record review of CNA Assignment Sheet dated [DATE] revealed Resident #4 to be transfer assist times ,[DATE] also noted at risk of fall . In an interview on [DATE] at 5:40 p.m., CNA E stated Resident #4 started yelling when CNA was lowering her to her knees on the floor in the shower. She also stated she had transferred the resident by herself prior to incident on [DATE]. In an interview on [DATE] at 9:50 a.m., DON said on [DATE] she was in her office when she heard a noise in the shower area. She said she went to the shower area where she observed CNA E lowering Resident #4 to the floor. She said she asked ADON to assess Resident #4. After assessing her, they transferred resident to wheelchair. DON said Resident could move both arms and legs and nothing appeared abnormal. Resident #4 did not display any signs of pain, redness or swelling. DON said CNA E reported Resident #4 was standing for her to pull up brief and then couldn 't stand so she lowered her to the floor. DON said Resident #4 could normally transfer with assist of ,[DATE] staff and other days she CNA walk on her own. DON said Resident #4's fall should have been written on the nursing alert log for nurses to know to document. DON said nurses are supposed to document every shift for 72 hours for delayed injury. DON said on Thursday ([DATE]) at supper, CNA D reported to her Resident #4 did not help as much as normal when she transferred her. DON said she assessed Resident #4 and she could move her legs and nothing abnormal was noted. DON said she did not document in nurse's note her assessment of Resident #4. In an interview on [DATE] at 09:30 a.m., ADON said DON requested she assess Resident #4 in shower before she was moved. She said nothing appeared wrong, no indication of pain or discomfort. ADON said CNA E said she lowered Resident #4 to the floor on her knees. ADON said she saw Resident on [DATE], [DATE] and [DATE] and nothing abnormal noted. ADON said she helped CNA G transfer Resident #4 in shower on [DATE]. She helped CNA G dress resident and did not notice any swelling or redness. She did not note any signs of pain or discomfort and heard no moaning. She said Resident could require ,[DATE] staff for transfers. She said she has transferred her on many occasions by herself out of bed and to bed. She said on [DATE] that LVN B reported to her that PT A reported Resident #4 may be in discomfort. She said the expectation was for nurses to put incidents like Resident #4 ' s on [DATE] on alert charting and the 24 hour nurses report so nurses will document any changes on every shift for 72 hours. In an interview on [DATE] at 6:25 p.m., LVN E said around 2am on [DATE] CNA J reported Resident #4 had bruising to posterior right calf near knee with some bruising to back of knee. She said Resident #4 was moving her legs. LVN E said she instructed CNA J to check on Resident #4 regularly. LVN E said at first Resident #4 had no complaints of pain. She said CNA J checked on Resident #4 about every hour and around 5:,[DATE]:30 a.m., Resident #4 was guarding her right leg. LVN E said nothing out of the ordinary happened to Resident #4. LVN E said she reported bruising to ADON soon after she found it. She did not notify physician Phy A until ,[DATE] minutes before Resident #4 was transferred to the emergency room . LVN E said around 5:,[DATE]:15 a.m., she realized something was not right but Resident #4 had recently received a new wheelchair and thought the wheelchair may have caused the bruising. LVN E said her assessment of Resident #4 didn' t scream fracture to her. LVN E said she was not aware Resident #4 had a fall in the shower in late August. She said resident #4 was normally a two person transfer. She said Resident #4 could bear weight and sometimes would walk with assistance of two staff using a gait belt. In an interview on [DATE] at 6:47 p.m., CNA J said during rounds on [DATE] at 9 p.m. and 11:15 p.m. resident #4 was dry. She said on [DATE] at 2 a.m., she checked Resident #4 and she was wet. She pulled the covers off and turned her on her side. She could see bruise from knee to calf area. She ran to get nurse to see her. LVN E came to see her and instructed CNA J to leave resident in bed in am and not get her up as usual. She changed Resident #4's brief. She said Resident #4 did not appear in pain. She was singing but when she turned her on her side she said ouch . She said she checked on her every hour because the bruise was so large from knee to calf on back of leg. She was not sure of the measurements as the nurse had measured the bruise. She said she always transferred Resident #4 with two people not using a gait belt. She said Resident #4 could occasionally stand if not too tired. In an interview on [DATE] at 8:35 a.m., CNA D said one evening after evening meal she noticed Resident #4 ' s pants to be wet. She put Resident #4 to bed, changed her brief and clothing. She said she did not see any bruising at that time. She said Resident #4 was her normal self. She said an aide told her Resident #4 collapsed in the shower a couple of days before. CNA D said she did not want to bear weight on [DATE] when she put her to bed. She said after incident in shower, Resident #4 was different. She said she was not bearing weight. She notified CNA E who said she noticed it also. CNA D said she notified DON that Resident #4 did not bear weight and all the aides talked about it. CNA D said she transferred Resident #4 all the time by herself and on [DATE], she transferred her without use of gait belt. She said Resident #4 did not moan or grimace as if in pain. She said one day between fall on [DATE] and [DATE], she was pushing Resident #4 in wheelchair to dining room when she noted Resident to make a moaning sound and grabbed her leg. CNA D said she notified DON (on [DATE]). She said Resident #4 on a good day could transfer with one staff but after fall couldn't help transfer at all and could not bear weight. She said on [DATE], she did not see any bruising or signs of pain during check and change. In an interview on [DATE] at 9:13 a.m., LVN B said PT A reported to her on [DATE] that Resident #4 was moaning when she applied Biofreeze to her knee. LVN B said Resident #4 seemed comfortable at that time, she looked at her and she was not flinching. She could not remember which knee or leg but she looked at both and saw nothing unusual. She straightened both legs out, no wincing or signs of pain, redness, bruising or swelling noted. She said resident #4 kept her eyes closed all the time and was nonverbal but could moan. She said she was not aware of the incident on [DATE] in the shower in which Resident #4 was lowered to the floor. In an interview on [DATE] at 4:18 p.m., CNA A stated since the incident on [DATE], Resident #4 would display little signs of pain and/or grimacing, her mood seemed different, she was not singing as often as she usually did and she made little grunts when placed in a chair or bed. CNA A shared she had transferred Resident #4 by herself prior to the incident on [DATE]. In an interview on [DATE] at 2:20 p.m., CNA D stated after the incident on [DATE], she transferred Resident #4 alone and the resident displayed signs of pain and/or grimacing while in the dining room. CNA D said she reported this to DON. In an interview on [DATE] at 9:50 a.m., DON said around the evening meal on [DATE], she assessed resident #4 at request of CNA D due to Resident #4 not assisting as much with transfer. DON said she assessed the Resident, observed she could move her legs and looked at her knees and nothing looked abnormal. DON said she did not document the assessment in nurse's notes. She did not observe a transfer. In an interview on [DATE] at 2:24 p.m., CNA I stated Resident #4 was more difficult to transfer and was not assisting as much after the incident on [DATE] but did not report this to anyone. In an interview on [DATE] at 5:00 p.m., CNA G said she was assigned to shower Resident #4 on [DATE]. She said three staff assisted Resident #4 from wheelchair to shower chair. She said Resident #4 was bearing weight on both legs at that time. She said during the shower she did not observe any swelling or bruising. She said Resident #4 did not display any signs of pain. She said two staff assisted Resident #4 from shower chair to wheelchair. In an interview on [DATE] at 8:50 a.m., PT A said Resident #4 was totally dependent on two staff for transfers. She said Resident #4 had moments when she could help with transfer. She said Physical Therapy recommended Resident #4 have 2 staff for transfers, showering/bathing and attempting to dress. PT A said she was not aware resident had an incident in the shower on [DATE] in which she was lowered to the floor. She said she was not at work on [DATE] and [DATE]. PT A said she worked with Resident #4 on [DATE] and [DATE]. On [DATE] she worked with Resident #4 on range of motion and rolling over in bed. PT A said on [DATE], Resident #4 was up in wheelchair in therapy room for therapy. She had knee pain with range of motion and winced so PT A massaged right knee and applied Biofreeze. PT A said she noticed right knee was a little warm to touch with some swelling but no bruising to her right knee. She said Resident had arthritic knees. She said she attempted to stand Resident #4 up but she winced. PT A transported Resident #4 in a wheelchair to LVN B and notified her of her findings. She said LVN B checked her. She said Resident #4 could not tell you verbally if something was wrong but could tell you by facial expressions or moaning. In an interview on [DATE] at 8:53 a.m., Director of Rehab (DOR) said Resident #4 needed 2 staff to transfer for safety prior to incident on [DATE]. She said Resident #4 could do more to assist at times than others. She said in her opinion, one person could not dress her or stand her. She said she learned of the incident in the shower a couple days after incident. She said she did receive a screening form due to fall in shower but it did not specify an injury. She said she worked with Resident #4 on [DATE] and [DATE] for occupational therapy. She said she did not transfer her those days. She said Resident #4 did use upper body bicycle. She said she did not have physical therapy on [DATE] or [DATE] due to new Physical Therapist Assistant that was not familiar with resident. In an interview on [DATE] at 10:16 a.m., AD said her expectation for a resident with a fall was for follow-up every shift for 72 hours but she realized nurses did not put the fall on the follow-up alert charting so documentation did not occur. She said when a nurse received a report of a resident fall, they should assess the resident and chart the assessment in the nurses notes. She said Resident #4 had a right total knee replacement in the past and the break was right above the knee prosthesis. In an interview on [DATE] at 1:03 p.m., DOR said nursing with input of Rehab determined amount of assistance needed for resident transfers. She said on admission or with a change in status she would recommend type of transfer for resident. She said nurses would use their judgment on amount of assistance a resident needed for transfers. An Immediate Jeopardy (IJ) was identified and the AD was notified on [DATE] at 3:50 p.m. In an interview on [DATE] at 6:28 p.m., AD said the facility policy regarding falls and documentation is for fall protocol to be followed to assess resident for 72 hours for delayed injury and to document change of condition for 72 hours. She said if a resident had a change in condition, the IDT (Interdisciplinary Team) would meet and review resident to make necessary changes. She said she evaluates policies and procedures to ensure the effectiveness of facility processes thru the Quality Assurance committee. She said staff was in-serviced on falls and documentation. Her expectation of staff regarding a resident fall was to follow the fall protocol and report the fall to supervisor. AD said the Immediate Jeopardy came about due to lack of documentation. The system failed to make sure incident report filled out and documentation to monitor for delayed injury occurred. The injury to Resident #4 was the biggest reason for the immediate jeopardy. AD said she was aware of incident in which Resident #4 fell but was not aware of there being no follow-up documentation by nurses. AD said she has a consultant staff, nurse, pharmacist that are available to help her and staff to monitor systems. In an interview on [DATE] at 4:05 p.m., AD said on [DATE] DON was responsible for updating CNA assignment sheet to ensure information was correct for each resident. RN A is now responsible for ensuring CNA assignment sheet is correct. AD said the CNA assignment sheet is updated daily and left at nursing station. If a resident had a significant change, the CNA assignment sheet would be updated and information given to staff. AD said she monitors staff to ensure transfers are done correctly by onsite competency testing. She said if an incident occurred with a transfer, she could send staff to Physical Therapist for training. She said transfer training was completed in May. If she sees a trend with transfers, she would discuss in Quality Assurance meeting and put a plan in place and in-service staff. AD said she does not monitor nurse alert sheet or 24 hour nursing report to ensure Information is recorded. The RN and ADON would look at the nurse alert sheet and 24 hour nursing report daily to verify information against incident/accident reports. She said the DON and ADON are responsible for ensuring nursing alert sheet and 24 hour log is current for incidents and documentation is completed. She said her expectation was for nurses to document their assessments. She said her expectation for nurses to monitor and document after an incident for 72 hours would include what they see with that resident, a change in condition or what is going on. She said if a resident suffered a fall she would expect the nurse to follow the protocol and note anything out of the norm for that resident, change in transfer status, pain or delayed injury. She said the CNA assignment sheet did not match the nursing care plans because nurses didn ' t adjust care plan to what was needed. MDS (Minimum Data Set) captures during a timeframe and MDS and Care plan should match. AD said the reason the nursing documentation was not completed on Resident #4 per fall protocol was because ADON failed to put her on alert charting therefore other shifts didn ' t know to document. Her expectation of staff transferring residents is a safe transfer at all times. Staff are never to put residents at risk. AD said the reason we continue to observe issues with transfer of residents is because there are so many steps to remember. She said she would continue to monitor and have physical therapy monitor. She will retrain staff as needed on transfers. AD said currently Physical Therapy, ADON, RN continue to monitor staff transferring residents. AD said if a CNA observes a change in condition for a resident and reports that change to the nurse, she expects that nurse to assess the resident, call the physician, check for change in condition and chart assessment. AD said the DON is responsible for monitoring licensed staff. AD said she does track and trend in Quality Assurance and with infection control log. In an interview on [DATE] at 6:10 p.m., DON said there is no policy on transfers but the facility does have a policy to address falls. She said documentation is standard nursing documentation; fall log and follow interact charting. DON said her expectation if for transfers to be safe with no falls and if a fall occurred, document it as it occurs. She said staff has been in-serviced multiple times on transfers, falls and documentation. She said in-services had been completed for transfers and falls since the last resident admission on [DATE]. DON said she felt

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 7 (Residents #3, 4, 6) residents reviewed for assistance with transfers. 1) Resident #4 was lowered to floor in shower after being assisted by one staff to stand to be dressed. Resident #4 was assessed on [DATE] to require extensive assistance of two staff for transfers. Resident #4 was diagnosed with [REDACTED]. The resident's family chose palliative care and Resident #4 died on [DATE]. 2) Resident #3 was lowered to floor in shower after being assisted by one staff to stand. Resident #3 was assessed on [DATE] to require total assistance of two staff for transfers. 3) Resident #6 was transferred with assistance of two staff and gait belt from wheelchair to bed and during transfer resident's feet did not touch the floor. Resident #6 was assessed on [DATE] to require total assistance of two staff for transfers. On [DATE] an Immediate Jeopardy (IJ) was identified. AD was notified. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of Actual harm that is not Immediate Jeopardy and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place 27 residents at risk of not being transferred correctly and could lead to a fall and injury. Findings Include: Resident #4 Record review of Resident #4 Admission Record revealed she was a 91year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #4's quarterly Minimum Data Set ((MDS) dated [DATE] revealed an interview for Brief Mental Status (BIMS) score of 0, indicating resident is rarely or never understood. Her assessment under functional status for transfers indicated total dependence with the support of two+ person physical assist; dressing and bathing were assessed as total dependence with support of one person physical assist. Record Review of Resident #4's fall risk assessment dated [DATE] with updates on [DATE], [DATE] and [DATE] revealed a score of 13 for each date. The assessment form states, A score of 10 or higher may represent high risk. Review of Resident #4's Care Plan for Falls dated [DATE], updated on [DATE], [DATE] and [DATE], revealed the resident was a high risk for falls and the Plan of Care (POC) to be continued. Resident #4's Rehab/Mobility Care Plan indicated extensive assistance of two staff needed for transfers due to decreased mobility and poor safety awareness. Rehab/Mobility Care plan also indicated resident is extensive time one assist most of the time. Occasionally she will start hitting at staff so two person assist is needed. Occasionally she will sleep (drowsy) a lot and will not assist with transfers so assist of two persons is needed. Resident #4 will receive assistance appropriate to mobility status and to encourage self mobility as tolerated by resident. The Care Plan for Rehab/Mobility and Functional ADL's (Activities of Daily Living) dated [DATE], with updates on [DATE], [DATE] and [DATE] revealed Resident #4 was an extensive assist for toileting, dressing, eating and personal hygiene, an extensive assist times 2 for transfers, a total assist for bathing with staff to bathe the resident and total dependence for bed mobility. An additional update was added to Resident #4 ' s Care Plan for Falls on [DATE] to reflect the incident when the resident had been lowered to the floor via staff to prevent a hard fall-isolated incident with a note to continue the Plan of Care. Review of MDS Kardex report dated [DATE] for Resident #4 revealed she was not steady during transitions/walking when moving from seated to standing; moving on and off toilet; and surface-to-surface transfer. She was listed as total dependence, two+ persons physical assist for transfers. Review of Nurse's Progress Note/Summary dated [DATE] revealed Resident #4 was noted to be unsteady in her balance and lifted manually for transfers. Review of Physical Therapy Evaluation and Plan of Treatment Referral dated [DATE] revealed Resident #4's current referral to physical therapy was due to decline in functional mobility causing decrease in strength, decrease in transfers, reduced balance, reduced functional activity tolerance, decrease in functional mobility, reduced static and dynamic balance, decreased coordination and increased need for assistance from others placing patient at risk for falls, further decline in function, decreased participation with functional tasks and increased dependency upon caregivers. Impressions noted by the therapist reflect .Patient was reported by nursing to have decline in functional mobility patient shows anxiety performing mobility task thus making patient a high risk for fall. Review of Physical Therapy Evaluation and Plan of Treatment dated [DATE] revealed Resident #4 was referred to Physical Therapy due to decline in functional mobility causing decrease in strength, decrease in transfers, reduced balance, reduced functional activity tolerance, decrease in functional mobility ., decreased coordination and increased need for assistance from others placing patient at risk for falls, further decline in function, decreased participation with functional tasks and increased dependency upon caregivers. Resident #4 was dependent for basic mobility of sit to stand, chair or bed to chair transfer and toilet transfer. Resident #4 was totally dependent without attempts to initiate transfers and gait. Assessment Summary Impression for Resident #4 revealed nursing reported she had a decline in functional mobility and shows anxiety performing mobility task thus making resident a high risk for fall. In an interview on [DATE] at 8:50 a.m., PT A said Resident #4 was totally dependent on two staff for transfers. She said Resident #4 had moments when she could help with transfer. She said Physical Therapy recommended Resident #4 have 2 staff for transfers, showering/bathing and attempting to dress. PT A said she was not aware resident had an incident in the shower on [DATE] in which she was lowered to the floor. She said she was not at work on [DATE] and [DATE]. PT A said she worked with Resident #4 on [DATE] and [DATE]. On [DATE] she worked with Resident #4 on range of motion and rolling over in bed. PT A said on [DATE], Resident #4 was up in wheelchair in therapy room for therapy. She had knee pain with range of motion and winced so PT A massaged right knee and applied Biofreeze. PT A said she noticed right knee was a little warm to touch with some swelling but no bruising to her right knee. She said Resident had arthritic knees. She said she attempted to stand Resident #4 up but she winced. PT A transported Resident #4 in a wheelchair to LVN B and notified her of her findings. She said LVN B checked her. She said Resident #4 could not tell you verbally if something was wrong but could tell you by facial expressions or moaning. In an interview on [DATE] at 8:53 a.m., DOR said Resident #4 needs 2 staff to transfer for safety. She said Resident #4 could do more at times than others and could help at times. She said in her opinion, one person could not dress her or stand her with one person. She said she learned of the incident in the shower a couple days after incident. She said she did receive a screening form due to fall in shower but it did not specify an injury. She said she worked with Resident #4 on ,[DATE] and [DATE] for occupational therapy. She said she did not transfer her those days. She said Resident #4 did use upper body bicycle. She said she did not have physical therapy on [DATE] or [DATE] due to new Physical Therapist Assistant that was not familiar with resident. In an interview on [DATE] at 10:16 a.m., AD said her expectation for a resident with a fall was for follow-up every shift for 72 hours but she realized nurses did not put the fall on the follow-up alert charting so documentation did not occur. She said when a nurse received a report of a resident fall, they should assess the resident and chart the assessment in the nurses notes. She said Resident #4 had a right total knee replacement in the past and the break was right above the knee prosthesis. In an interview on [DATE] at 1:03 p.m., DOR said nursing with input of Rehab determined amount of assistance needed for resident transfers. She said on admission or with a change in status she would recommend type of transfer for resident. She said nurses would use their judgment on amount of assistance a resident needed for transfers. An Immediate Jeopardy (IJ) was identified and the AD was notified on [DATE] at 3:50 p.m In an interview on [DATE] at 6:28 p.m., AD said the facility policy regarding falls and documentation is for fall protocol to be followed to assess resident for 72 hours for delayed injury and to document change of condition for 72 hours. She said if a resident had a change in condition, the IDT (Interdisciplinary Team) would meet and review resident to make necessary changes. She said she evaluates policies and procedures to ensure the effectiveness of facility processes thru the Quality Assurance committee. She said staff was in-serviced on falls and documentation. Her expectation of staff regarding a resident fall was to follow the fall protocol and report the fall to supervisor. AD said the Immediate Jeopardy came about due to lack of documentation. The system failed to make sure incident report filled out and documentation to monitor for delayed injury occurred. The injury to Resident #4 was the biggest reason for the immediate jeopardy. AD said she was aware of incident in which Resident #4 fell but was not aware of there being no follow-up documentation by nurses. AD said she has a consultant staff, nurse, pharmacist that are available to help her and staff to monitor systems. In an interview on [DATE] at 4:05 p.m., AD said on [DATE] DON was responsible for updating CNA assignment sheet to ensure information was correct for each resident. RN A is now responsible for ensuring CNA assignment sheet is correct. AD said the CNA assignment sheet is updated daily and left at nursing station. If a resident had a significant change, the CNA assignment sheet would be updated and information given to staff. AD said she monitors staff to ensure transfers are done correctly by onsite competency testing. She said if an incident occurred with a transfer, she could send staff to Physical Therapist for training. She said transfer training was completed in May. If she sees a trend with transfers, she would discuss in Quality Assurance meeting and put a plan in place and in-service staff. She said the CNA assignment sheet did not match the nursing care plans because nurses didn ' t adjust care plan to what was needed. MDS (Minimum Data Set) captures during a timeframe and MDS and Care plan should match. Her expectation of staff transferring residents is a safe transfer at all times. Staff are never to put residents at risk. AD said the reason we continue to observe issues with transfer of residents is because there are so many steps to remember. She said she would continue to monitor and have physical therapy monitor. She will retrain staff as needed on transfers. AD said currently Physical Therapy, ADON, RN continue to monitor staff transferring residents. In an interview on [DATE] at 6:10 p.m., DON said there is no policy on transfers but the facility does have a policy to address falls. DON said her expectation if for transfers to be safe with no falls and if a fall occurred, document it as it occurs. She said staff has been in-serviced multiple times on transfers, falls and documentation. She said in-services had been completed for transfers and falls since the last resident admission on [DATE]. DON said she felt the immediate jeopardy occurred because she failed to ensure documentation was done. She didn't feel harm occurred. She felt the fracture was related to resident #4's [DIAGNOSES REDACTED]. Record review of the facility's Incident Report QA/CQI Log for month ending ,[DATE] lists the fall for Resident #4 on [DATE] and listed under contributing factors is noted Res. (Resident) quit standing during assist transfer-lowered to floor. Review of the Situation Background Assessment & Recommendation (SBAR) communication form dated [DATE], reporting the incident of [DATE] involving Resident #4 revealed .resident was lowered to knees on to floor post shower in shower room . Resident was lowered to knees on floor by CNA post shower during transfer . Record Review of Incident/Accident Report dated [DATE] revealed Resident #4 was being dressed after shower and as CNA attempted to pull brief up it stuck. As CNA attempted to unstick it, resident leaned into CNA, so CNA lowered her to her knees, then onto right side then flat on back with legs out to keep both from falling. No apparent injury. Isolated incident to prevent hard fall - continue current plan of care. Phy A was notified at 4:00 p.m. on [DATE]. Review of Interdisciplinary Post-Fall assessment dated [DATE] reveals the description of the fall as: Resident was lowered to knees then onto (R) side and then back with legs outstretched after leaning into CNA while CNA was adjusting stuck brief during dressing her post shower. The probable cause for this fall based on review and investigation: Res. (Resident) pushed into CNA while CNA adjusting brief causing loss of balance of both-CNA lowered res. (resident) to floor to prevent fall. .does the current plan of care for this resident clearly indicate the level of assistance the resident requires? Yes is the box checked with an explanation: Dependent-Extensive ,[DATE] person depending on Res. performance. Recommendations from review by team (also record in resident medical record) Isolated incident-to prevent hard fall. Continue POC. Record review of Nurse's Notes for Resident #4 revealed an entry on [DATE] at 9:00 am reporting the patient exhibiting decreased ability with functional transfers and mobility. Occasionally not bearing weight, decrease in Activities of Daily Living (ADL's) participation and requires increased staff assistance with repositioning to reduce pressure points and skin breakdown. The next entry in Nurse's Notes for Resident #4 was on [DATE] at 7:20 am revealed patient continues with physical and occupational therapy and requires staff assist with all ADL's and transfers. Rarely attempts to feed herself, turn and repositioned every 2 hours to avoid pressure areas. Signed by LVN B (No entries in the nurse's notes regarding Resident #4 being lowered to the floor in the shower room on [DATE] through [DATE] at 4:00 PM) [DATE] 5:30 AM Res noted (with) 3 (plus) edema to (right) thigh and 2 (plus) edema to (right) calf. Bruising spreading to lateral thigh (and) knee, dark purple in color. Res guarding RLE. Pulses remain positive v/s (vital signs) ,[DATE], 82, 20, 96.7 SPO2 (oxygen saturation) 90 % on RA (room air). Physician A notified (at)6:15 AM. Order received to transport to ER(emergency room ) for eval (evaluation) (and) tx (treatment). R/P notified of res cond (condition) (and) transport to ER. PRN (as needed) APAP (Acetaminophen) 650 mg (milligram) given. Signed by LVN E Review of medical records obtained from the hospital Resident #4 was transferred from the facility. She was assessed in the emergency roiagnom on [DATE] at 7:26 am. Her [DIAGNOSES REDACTED]. X-ray report revealed a comminuted fracture involving the distal femur, proximal to the knee arthroplasty. Resident #4 was subsequently admitted to the inpatient hospice unit until being transferred to a local long-term care facility. Resident #4 died on [DATE]. In an interview on [DATE] at 2:33 p.m., DON said Resident #4 has been transferred by 1 person including herself and transferred fine so her coding of ,[DATE] on CNA assignment sheet was correct. In an interview on [DATE] at 4:18 pm, CNA A stated since the incident on [DATE], Resident #4 would display little signs of pain and/or grimacing, her mood seemed different, she was not singing as often as she usually did and she made little grunts when placed in a chair or bed. CNA A shared she had transferred Resident #4 by herself. In an interview on [DATE] at 5:40 pm, CNA E stated Resident #4 started yelling when CNA was lowering her to her knees on the floor in the shower. She also stated she had transferred the resident by herself prior to fall on [DATE]. In an interview on [DATE] at 2:20 pm, CNA D reported she had transferred Resident #4 by herself and Resident #4 displayed signs of pain and/or grimacing one day in the dining room after the incident on [DATE]. CNA D states she told DON about the resident. In an interview on [DATE] at 9:50 a.m., DON said around the evening meal on [DATE], she assessed resident #4 at request of CNA D due to Resident #4 not assisting as much with transfer. DON said she assessed the Resident, observed she could move her legs and looked at her knees and nothing looked abnormal. DON said she did not document the assessment in nurse's notes. Resident #3 Record Review of Resident #3's Admission Record dated [DATE] revealed she was a [AGE] year old female admitted with the following diagnoses; unspecified disorder of adult personality and behavior, [DIAGNOSES REDACTED], acute upper respiratory infection, anemia, [DIAGNOSES REDACTED], dementia, major depressive disorder, generalized anxiety disorder, seizures, essential hypertension, atrial fibrillation, congestive heart failure, cerebrovascular disease, cognitive deficits, dysphagia and [DIAGNOSES REDACTED]. Record Review of Resident #3 ' s MDS (Minimum Data Set) dated [DATE] revealed in Section C for cognitive status a BIMS (Brief Interview of Mental Status) score of 2 indicating severe cognitive impairment. Section G revealed resident #3 required extensive assistance (resident involved in activity, staff provides weight bearing support) of two plus person physical assist with transfers. Section J revealed resident has had falls since admission or since prior assessment with two or more falls with no injury. Record Review of Resident #3 ' s Fall Risk assessment dated [DATE] revealed score of 17. A score of 10 or higher may represent high risk for falls. Record Review of Resident #3 ' s Functional ADL ' s (Activities of Daily Living)/Mobility Care plan dated [DATE] revealed resident required extensive assistance of two staff for transfers. On [DATE] the Functional ADL ' s/Mobility Care plan was reviewed by RN A and note to continue Plan of Care, See Kardex. On [DATE], Resident #3 ' s Functional ADL ' s/Mobility care plan was re-evaluated to hoyer lift with 2 staff to be utilized for transfers. Record Review of Resident #3 ' s MDS (Minimum Data Set) Kardex report dated [DATE] revealed resident required extensive assistance of two plus persons physical assist with transfers. Resident was not steady during transitions/walking when moving from seated to standing, moving on an off toilet and surface-to-surface transfers. Record Review of Resident #3 ' s Fall Risk assessment dated [DATE] revealed score of 14. A score of 10 or higher may represent high risk. Record Review of Resident #3 ' s Fall Plan of care dated [DATE] reviewed on [DATE] with note to continue plan of care. On [DATE], a note was written on Fall Plan of Care revealed resident was standing in shower room for pants to be pulled up, decided to sit down, CNA (Certified Nurse Aide) eased resident to floor - resident behavior. On [DATE], a note was written that inservice for CNA ' s on shower safety - resident behaviors - continue therapy. On [DATE], a note was written on care plan if resident became aggressive during stand to transfer - slapping and hitting staff. Balance lost and sat on lap of a CNA. On [DATE], a note was written that staff was inserviced on aggressive behaviors and transfer reviewed and Therapy referral. Record Review of Resident #3 ' s Nurse ' s Notes dated [DATE] at 0930 revealed Resident was holding the side rail in the shower room, slowly started sliding down, CNA D assisted resident slowly to the floor. No signs/symptoms of pain, no bruising noted at that time. Fax sent to MD. Record Review of Resident #3 ' s Nurse ' s Notes dated [DATE] at 1620 revealed staff was attempting to transfer patient from bed to wheelchair when she became combative and refused to stand sliding off the bed. While CNA C held her then he eased her to his lap on the floor. LVN B assessed patient from head to toe with no injury noted Resident was returned to wheelchair with staff x 3. Record Review of Incident/Accident Report dated [DATE] revealed Staff was attempting to transfer Resident #3 from bed to wheelchair and became combative. Resident #3 refused to stand and slid from bed while CNA held her and eased her to his lap on the floor. Witnesses to incident were CNA C and CNA E. Record Review of Resident #3 ' s Interdisciplinary post fall assessment for falls on [DATE] and [DATE] revealed the current plan of care for this resident clearly indicated the resident was unsteady with transfers and assistance was required for all activities of daily living except ambulation which resident cannot do. The current plan of care for this resident indicates the level of assistance the resident required as ,[DATE] persons. In an interview on [DATE] at 6:20 p.m., CNA C said on [DATE] he and CNA E attempted to transfer Resident #3 from bed to her wheelchair. Resident #3 attempted to bite CNA E and refused to stand so CNA C lowered her to the floor on his legs. CNA C said Resident #3 was listed as a one person transfer but he didn ' t feel like he could transfer her alone. Observation on [DATE] at 4:47 p.m., Resident #3 was transferred from bed to chair by CNA A and CNA B using Joerns Hoyer Presence 500 lift. Sling was placed under Resident #3 leaving approximately one foot of sling above top of resident ' s head resulting in bottom of sling having insufficient amount under buttocks for support during transfer. Record Review of Resident #3 ' s Nurse ' s Progress note/Summary dated [DATE], [DATE] and [DATE] revealed resident #3 was lifted manually for transfers. Record Review of CNA Assignment Sheet dated [DATE] revealed Resident #3 required ,[DATE] assistance with transfers. Record Review of CNA Assignment Sheet dated [DATE] revealed Resident #3 required hoyer lift with 2 staff for transfers. Record Review of CNA Assignment Sheet dated [DATE] revealed Resident #3 required hoyer lift with 2 staff for transfers. Observation on [DATE] at 4:30 p.m., Resident #3 was transferred from wheelchair to bed by CNA F and CNA G using gait belt and assistance of two staff. Resident #6 Record Review of Resident #6 ' s Admission Record undated revealed she was a [AGE] year old female admitted with the following diagnoses; diabetes, hypertension, pain, muscle wasting and atrophy, lack of coordination, osteoporosis, abnormalities of gait mobility, dementia, adult failure to thrive, major depressive disorder, muscle weakness, impulse disorder and vitamin deficiency. Record Review of Resident #6 ' s Quarterly MDS (Minimum Data Set) dated [DATE] revealed in Section C for cognitive status a BIMS (Brief Interview of Mental Status) score of 2 indicating severe cognitive impairment. Section G revealed resident #6 was totally dependent of two plus staff for transfers. Section J revealed resident had no falls since admission or since prior assessment. Record Review of Resident #6 ' s MDS kardex report dated [DATE] revealed resident was totally dependent of two plus person ' s physical assistance for transfers. Resident was not steady during transitions/walking, moving from seated to standing, moving on and off toilet and surface to surface transfers. Record Review of Resident #6 ' s Functional ADL ' s (activities of daily living) /Mobility Patient care plan dated [DATE] revealed Resident #6 is total assist of two staff for transfers. On [DATE], noted to continue plan of care and see Kardex. On [DATE], Functional ADL ' s/Mobility updated to transfers by Hoyer times 2 staff. Record Review of Resident #6 ' s Osteoporosis Patient Care Plan dated [DATE] revealed use of two staff for transfers. Patient Care Plan is reviewed on [DATE] with note to continue plan of care. Observation on [DATE] at 4:39 p.m., Resident #6 was transferred from bed to wheelchair by CNA A and CNA K with use of gait belt. Two staff with use of gait belt stood resident up without resident #6 feet being on floor. Observation on [DATE] at 1:05 p.m., Resident #6 was transferred from wheelchair to bed by CNA H and CNA I with use of gait belt. Two staff with use of gait belt stood resident up without resident #6 feet being on floor. Staff lifted resident from wheelchair to bed. Resident was not given opportunity to put feet on floor during transfer. PT A was present during transfer. In an interview with PT A on [DATE] at 1:05 p.m., she said based on her observation of transfer by two staff and use of gait belt that one staff could not safely transfer resident #6 as listed on CNA assignment sheet. Observation on [DATE] at 5:00 p.m., Resident #6 was transferred from bed to wheelchair by CNA B and CNA E using Hoyer lift. No concerns noted with transfer technique. Record Review of Fall Risk assessment dated [DATE] revealed resident is at high risk of falls with a score of 10. A score of 10 or higher may represent high risk for falls. Record Review of Resident #6 ' s Nurse ' s Progress Note/Summaries dated [DATE], [DATE] and [DATE] revealed resident #6 required a mechanical lift for transfers. Record Review of CNA assignment sheet dated [DATE] revealed Resident #6 required ,[DATE] staff for transfers. In an interview on [DATE] at 2:33 p.m., DON said CNA assignment sheet should reflect Resident #6 requires 2 person assist because MDS states 2 person, Care plan states 2 person and she just made a mistake. She updates CNA assignment sheet as needed. Record Review of CNA assignment sheet dated [DATE] revealed Resident #6 required Hoyer lift with two staff for transfers. Record Review of CNA assignment sheet dated [DATE] revealed Resident #6 required Hoyer lift with two staff for transfers. Record review of the facilities Transfers of Residents Policy and Procedure origination dated ,[DATE], states: Transfers are defined as the act of moving a resident from one surface such as from the bed to the wheelchair or from the wheelchair to the toilet. The goal was to ensure the safety of the resident when moving from one place to another, to prevent injuries to the resident, to prevent injuries to staff member assisting the resident . Procedure · Always use good body mechanics · . · Let the resident know what you are planning to do and ask him/her to help. · . · Use a gait belt around the resident to protect both the resident and yourself, unless contraindicated · Put shoes or non-slip slippers on the resident · . · Ensure resident has a good base support at the feet . Record review of the facilities Fall Management System, Nursing Policy and Procedure Manual origination date ,[DATE], revision date ,[DATE], states: Policy It was the policy of this facility that each resident will be assessed to determine his/her risk for falls, and a plan of care implemented based on the resident's assessed needs. Fundamental Information A fall occurs when there was an unintentional coming to rest on the floor, ground, or other lower level but not as a result of an overwhelming external force . An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, was considered a fall. A fall without injury was still a fall. A fall was often the result of cumulative risk from both intrinsic (resident-related) and extrinsic (environmental) factors. .The following are examples of common intrinsic risk factors: Gait and balance disorders; Confusion; Incontinence; Seizure Disorder; Depression; Previous falls; Certain medication classes such as: .antipsychotics, .antidepressants, .the use of five or more medications. Procedure A. Identifying residents at risk for falls . 2. The facility will also utilize the Minimum Data Set (MDS) and Care Area Assessments (CAA) to assist in identifying resident's risk for falls. The MDS and CAAs are to be completed according to the Federal Guidelines. 3. Analysis of Assessment and Implementation of Preventative Measures 1. Residents that score 10 or above per the Fall Risk Assessment, may represent HIGH RISK for falls. 2. The identifying factors will be provided to staff, and the individualized resident care plan will be developed with appropriate goals and interventions utilizing the Fall Management Plan of Care Form. In an interview on [DATE] at 1:03 p.m., DOR said nursing with input of Rehab determined amount of assistance needed for resident transfers. She said on admission or with a change in status she would recommend type of transfer for resident. She said nurses would also use their judgement on amount of assistance a resident needed for transfers. In an interview on [DATE] at 10:16 a.m., Administrator said CNA ' s know how to transfer a resident based on the CNA assignment sheet. In an interview on [DATE] at 1:17 p.m., DON said she updates CNA assignment sheet as changes occur such as on admission or changes in condition. DON said she and MDS nurse makes CNA assignment sheet based on MDS information. In an interview on [DATE] at 3:40 p.m., DON said on [DATE], she was responsible for ensuring the CNA assignment sheet was current. She said at this point, RN A will be responsible for ensuring CNA assignment sheet is current. She said she failed to ensure the CNA assignment sheet was current. She said it was updated to what they thought but wasn ' t updated to what the MDS (Minimum Data Set) showed. She said she didn ' t want to take away from what the resident could do. She said she should have had the Physical Therapist assess the resident. DON said a CNA assignment sheet will be put out daily with each CNA ' s name on it at the time clock and new employees will be oriented. DON said if a change needed to be made to the CNA assignment sheet, she would notify employees immediately. DON said she ensured transfers are done correctly because she makes rounds at least twice a day; she completes monitoring tools and assists with transfers. DON said the reason the CNA assignment sheet did not match care plans was due to residents can change and the care plans are based on last MDS (Minimum Data Set) and the facility could use the greater number in coding. She said ultimately she was responsible. DON said her expectation for staff transferring residents was to do it safely for resident and themselves. She said she watched transfers and staff did fine. DON said she, the ADON and Physical Therapist monitors staff to ensure transfers are done correctly. DON said if a CNA observes a change in condition for resident and reports to nurse, she expects the nurse to assess the resident and notify her and physician. S