Every finding on record at Complete Care at Brackenville LLC

Based on interview, record review, and policy review, the facility failed to thoroughly investigate allegations of abuse for four residents (Resident (R) 59, R88, R97, and R106) out of nine residents reviewed for abuse in a total sample of 40. This failure placed residents at risk of further abuse and a diminished quality of life.Findings include:1. Review of the admission Record, located in the Profile tab of the electronic medical record (EMR), revealed that R59 was admitted to the facility on [DATE] with diagnoses that included hemiplegia/hemiparesis (paralysis on one side of the body) following a cerebral infarct (stroke) and major depressive disorder.Review of the quarterly Minimum Data Set (MDS), located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 02/14/26, revealed R59 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated R59 was cognitive intact.Review of the facility's investigation related to a 08/16/25 report of verbal abuse revealed R59 had slid to the floor when Certified Nurse Aide (CNA) 5 was assisting R59 back to bed. CNA5 called for assistance, and several CNAs came to assist. R59 asked for the Hoyer lift to get up, and CNA2 said he could get himself up. According to the report, R59 became angry and started cursing and told CNA2 to leave his room. CNA2 then told R59 that it wasn't his room; they then began bickering with each other. CNA2 did not leave R59's room until she was told to leave by the Licensed Practical Nurse (LPN) present. The investigation, provided by the facility, did not contain any resident interviews outside of R59.During an interview on 03/04/26 at 3:30 PM, R59 reported that he did not get along with CNA2, and he didn't think many people did. During an interview on 03/05/26 at 10:35 AM, the Director of Nursing (DON) was asked if she had any documentation to show that she had spoken to other residents on the unit and if they had experienced any verbal abuse by CNA2 and what their response was. The DON stated, I don't remember if I interviewed other residents, but if not in the folder, no. I will double check. No other interviews were located.2. Review of the admission Record, located in the Profile tab of the EMR, revealed R88 was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis, hypertension, and peripheral vascular disease.Review of the quarterly MDS, located in the MDS tab of the EMR with an ARD of 02/03/26, revealed R88 had a BIMS score of 14 out of 15, which indicated R88 was cognitively intact.Review of the facility's investigation of a report of verbal abuse on 02/04/26 revealed that R88's roommate was relocated to another room due to the roommate becoming aggressive with R88. On the day the roommate was moved, the roommate's daughter came to R88's room and cursed R88 out. R88 reported the incident to her son, and he reported it to the social worker. The file contained no interviews with other residents outside of R88.During an interview on 03/04/26 at 10:30 AM, R88 reported that she had never been so scared in her life. The lady was so angry, called me a F-ing bitch and said I was going to hell.During an interview on 03/05/26 at 10:35 AM, the DON was asked if she had any documentation to show that she had spoken to other residents on the unit and if they had experienced any verbal abuse by this family member. The DON stated, No. I didn't think it was necessary because this family member always sits at her mother's bedside, and her anger was directed at [R88]. In hindsight I probably should have. 3. Review of R97's admission Record, dated 03/05/26 and found in the EMR under the Profile tab, revealed R97 was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes and epilepsy.Review of R97's quarterly MDS with an ARD of 02/06/25, found in the EMR under the MDS tab, indicated a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R97's Progress Notes, dated 06/18/25 and found in the EMR under the Notes tab, revealed Resident's daughter reported that her mother told her that a male CNA wearing a red shirt was too rough with her and that he was upset with her for having to change her linens.Review of the facility's investigation related to the 06/18/25 report of potential staff to resident abuse revealed an incomplete investigation. Review of the investigation revealed R97 had been interviewed as part of the investigation; however, no additional interviewable residents residing in the same area of the facility and/or with potential knowledge of the incident were interviewed. 4. Review of R106's admission Record, dated 03/05/26 and found in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes and heart disease. The resident was discharged from the facility on 08/03/25.Review of R106's quarterly MDS with an ARD of 05/09/25, found in the EMR under the MDS tab, indicated a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R106's comprehensive record revealed nothing in the progress notes or anywhere else in the record to indicate an allegation of potential abuse.Review of the facility's investigation documentation related to a 07/26/25 allegation of potential abuse by R106 revealed the resident reported a staff member entered her room and told the resident she was a poor excuse for a human being and refused to assist her with changing her brief. The investigation documentation revealed an incomplete investigation into the allegation of abuse. There were no additional residents or staff members interviewed related to the allegation, R106 was not physically and psychosocially assessed related to the allegation in a timely manner, and there was no facility review of the employee record of the staff member accused of being potentially abusive toward R106 as part of the investigationDuring an interview with the Administrator and DON on 03/05/26 at 12:19 PM, both confirmed the investigation into R106's allegation of potential abuse had not been thoroughly investigated (to include a thorough assessment of the resident, additional resident and staff interviews related to the allegation, and a facility review of the accused staff member's employee file). Both stated their expectation was that any allegation of potential abuse should be thoroughly investigated according to facility policy. Review of the facility's policy titled, Abuse, Neglect and Exploitation, reviewed/revised 11/24 revealed, An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. Written procedures for investigations include: . Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.

Based on observation, interviews, record review, review of facility policies, and review of the manufacturer's manual, the facility failed to ensure pressure relieving air mattresses were correctly set according to the manufacturer's guidelines and residents' weights for three of five residents (Residents (R) 5, R48, and R85) reviewed for pressure ulcers out of a total sample of 40 residents. This failure placed residents at risk for skin breakdown, delayed wound healing, pain, infection, and potentially avoidable complications.1. Review of R5's Face Sheet, located in the electronic medical records (EMR) under the Profile tab, revealed an admission date of 10/17/25 with the following diagnoses: myocardial infarction (heart attack) type 2, atypical atrial flutter (heart arrythmia), unspecified dementia, and reflux disease.Review of R5's revised 01/15/26 Care Plan, located in the EMR under the Care Plan tab, revealed [R5] has a pressure ulcer to her sacrum and left buttock. Interventions included following the manufacturer's recommendation for proper function of the air mattress. Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/26, located in the MDS tab in the EMR, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R5 had moderate cognitive impairment. Further review revealed that R5 was admitted with one stage three pressure ulcer and one stage four pressure ulcer.Review of R5's weight, located under the Weight/Vitals tab in the EMR, revealed on 03/03/25 that R5 weighed 115.8 pounds (lbs).Observation on 03/03/26 at 3:46 PM, R5's Proactive Air Mattress weight dial, which could be dialed to weights between 80 and 350 pounds, was set at 80 lbs.Observation on 03/03/26 at 3:55 PM with Certified Nurse Aide (CNA) 4 confirmed R5's pressure relieving mattress was set at 80 lbs.Observation on 03/04/26 at 11:40 AM with the Maintenance Director (MD) 2 confirmed the air mattress was set at 80 lbs. Observation and interview conducted on 03/04/26 at 11:47 AM with Registered Nurse (RN) 1 indicated that nurses checked the air mattresses every shift and ensured the settings were adjusted according to the manufacture's recommendations and the resident's weight to maintain proper inflation and support the healing process. During this same time, RN1 confirmed that R5's air mattress was set at 80 lbs. When updated that R5's current weight was 115 lbs, RN1 stated, The weight is set too low. 2. Review of R48's Face Sheet, located in the EMR under the Profile tab, revealed an admission date of 09/29/24 with the following diagnoses: unspecified cord compression, spinal stenosis, hypertension, and type 2 diabetes. Review of R48's Care Plan, located in the EMR under the Care Plan tab, revision date of 10/13/24, revealed R48 is at risk for skin breakdown related to ambulatory dysfunction and decreased activity, bowel incontinence . The care plan further indicated under interventions that R48 will have a therapeutic mattress. Review of R48's quarterly MDS with an ARD of 10/01/26, located in the EMR under the MDS tab, revealed R48's BIMS score was 14 out of 15, which indicated he was cognitively intact.Interview and observation on 03/02/26 at 2:16 PM revealed R48's air mattress was set at 240 lbs. R48 stated that his current weight was 193 lbs. R48 continued to share that he had been dealing with pressure ulcers and currently had a pressure ulcer on his coccyx. During an interview on 03/04/26 at 1:25 PM, R48 was in his room and stated that a facility staff member was in his room several minutes ago and readjusted his weight setting on the air mattress.Review of a Nutritional Services note, dated 03/05/26 and located in the EMR under the Progress Notes tab, indicated R48 weighed 213 lbs.3. Review of R85's Face Sheet, located in the EMR under the Profile tab, showed an admission date of 08/08/24 with diagnoses including dementia, type 2 diabetes, and adult failure to thrive.Review of R85's MDS with an ARD of 01/15/26, located in the EMR under the MDS tab, revealed he was at high risk for developing pressure ulcers. Review of R85's weight, located under the Weight/Vitals tab in the EMR, revealed on 01/12/26 R85 weight was 99.4 lbs.Interview on 03/04/26 at 11:40 AM with MD2 revealed he did not have the manufacturer's guide for the air mattresses and goes to the products website for guidance. Observation and interview conducted on 03/04/26 at 11:47 AM with RN1 indicated that nurses checked the air mattresses every shift and ensured the settings were adjusted according to the manufacture's recommendations and the resident's weight to maintain proper inflation and support the healing process. During this same time, RN1 went to R85's room and confirmed the resident's air mattress was set too high at 450lbs. During an interview on 03/05/26 at 11:19 AM, the Director of Nursing (DON) confirmed air mattresses should be set as close as possible to the resident's current weight. She shared her expectations that all air mattresses are set at the appropriate weight. Staff should readjust as the resident gains or loses weight to ensure proper healing and to reduce developing new skin issues. Review of facility policy titled Use of Support Surfaces, revised 03/13/23, revealed 'Support surface' refers to specialized mattress . to manage pressure . The policy further revealed, Motor powered devices, or those requiring air, the licensed nurse will check each shift and prn [as needed] for proper functioning and /or inflation . alternating pressure or active support surface is a medical mattress designed to reduce and redistribute pressure on the skin especially for people who spend extended time in bed or have limited mobility . helps prevent and treat bed sores . Under the heading How to set up and use the mattress it directed to Adjust firmness . pumps have a dial based on patient weight . Review of the Proactek, Protect Aire 2000/3000 model provided by the manufacturer at https://proactivemedical.com revealed under the Operating Instructions, Step 6 . Determine the patient's weight and set the control knob to that weight setting on the control unit.

Based on record review, observations, interviews, and review of the facility policies, the facility failed to ensure staff followed enhanced barrier precautions (EBP) and standard nursing precautions while providing care for one of one resident reviewed on EBP (Resident (R) 5). Specifically, a Certified Nurse Aide (CNA) failed to follow personal protective equipment (PPE) guidelines and wear a gown and gloves while performing incontinent care. This failure had the potential to cause further infection to the resident's wounds. Findings include:Review of R5's Face Sheet, located in the electronic medical records (EMR) under the Profile tab, revealed an admission date of 10/17/25, with the following diagnoses: myocardial infarction (heart attack) type 2, atypical atrial flutter (heart arrythmia), unspecified dementia, and reflux disease.Review of R5's Care Plan, revised 01/13/26 and located in the EMR under the Care Plan tab, revealed, [R5] requires enhanced barrier precautions related to (wound, indwelling medical device, infection or colonization with MDRO) It did not specify the reason for EBP but did document a skin opening requiring a dressing.Review of R5's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/17/26, located in the MDS tab in the EMR, revealed R5 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated R5 was moderately cognitively impaired. Further review revealed that R5 was admitted with one stage three pressure ulcer and one stage four pressure ulcer.Observation on 03/03/25 at 3:42 PM revealed an orange sign, Enhanced Barrier Precautions posted on the wall outside of R5's room with a B written in black. The sign read, Stop: Enhanced Barrier Precautions, everyone must wash their hands including before entering and when leaving . wear gloves and a gown for the following high contact resident care activities- changing linens, providing hygiene, changing briefs, and dressing. During this same observation, CNA3 entered the resident's room and proceeded to provide incontinent care without donning a gown or gloves. Once R5's incontinent care was completed, CNA3 exited the room and asked CNA4 to retrieve some clean linen. Interview on 03/03/26 at 3:43 PM, CNA3 confirmed that R5 was on EBP and stated, I should have put on my PPE. She further shared that EBP and Infection Control training was completed annually and as needed. During trainings staff were taught how to properly don and doff PPE along with what PPE was required based on residents' conditions. Interview on 03/03/26 at 3:55 PM with CNA4 confirmed R5 was on EBP.Interview on 03/04/26 at 11:47 AM with Registered Nurse (RN) 1 confirmed R5 was on EBP. RN1 stated all staff are trained on infection control to include how to identify residents on EBP. RN1 shared that the information about residents who are on EBP was listed on the Kardex, a sign posted at the resident's room, and in the EMR.Interview with the Director of Nursing (DON) on 03/05/26 at 11:19 AM revealed staff received infection control and EBP training upon hire, annually, and if needed during specific in-services. She stated she expected all staff to follow the infection control protocol and know how to identify residents on EBP and what PPE to use. Review of the facility's policy titled, Enhanced Barrier Precautions, revised on 02/25/25, revealed Enhanced Barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure accommodation of needs for two of two residents (Resident (R) 71 and R5) in the sample of 40. Specifically, the facility failed to address necessary wheelchair repairs for R71 and did not provide R5 with access to a functioning call light. This created a potential risk for resident injury. Findings include: 1. Review of R71's electronic medical record (EMR) titled Face Sheet, located under the Profile tab, indicated an admission date of 10/25/24 with diagnoses of traumatic brain injury and quadriplegia. Review of R71's EMR titled Care Plan, located under the Care Plan tab, dated 10/28/24, indicated that R71 was at risk for skin integrity due to fragile skin. Review of R71's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/14/25 indicated the staff were unable to determine a Brief Interview for Mental Status (BIMS) score. R71 was dependent on all activities of daily living from staff. During an observation on 03/02/26 at 11:52 AM, R71 was seated in his room in a customized, adapted wheelchair (tilt in space). The resident's bilateral wheelchair arms were cracked. The right-side arm rest had a large peeled opened area which exposed the cushion underneath the upholstery. The left side arm rest had multiple cracks. The concave back, attached to the back of the wheelchair, provided lumbar support. The left side of the concave cushion had an open area, which exposed the cushion underneath the upholstery. During an observation on 03/04/26 at 10:30 AM, R71 was in an activity. The bilateral arm rests were still in disrepair and so was the concave back support. During an interview on 03/04/26 at 12:15 PM, the Maintenance Director (MD) 2 stated that arm rests could be easily replaced on a resident's wheelchair, but he was unsure if he could repair the concave supportive device attached to the back of the resident's wheelchair. During an interview on 03/04/2026 at 3:38 PM, the Director of Nursing (DON) stated that the process was to inform maintenance, who would then repair the resident's wheelchair. The Administrator was present during this interview and stated that R71 owned the wheelchair, or even if the wheelchair was donated, this was considered a medical device, and the facility was not responsible for the repairs of the wheelchair. MD2 stated that there were no work orders in TELS (a web-based work order system). Review of the facility's policy titled Accommodation of Needs dated 03/13/23 indicated, . The facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident, except when the health and safety of the individual or other residents would be endangered . 2. Review of R5's Face Sheet, located in the electronic medical records (EMR) under the Profile tab, revealed an admission date of 10/17/25 with the following diagnoses: myocardial infarction (heart attack) type 2, atypical atrial flutter (heart arrythmia), unspecified dementia, and reflux disease. Review of R5's quarterly MDS with an ARD date of 02/17/26, located in the MDS tab in the EMR, revealed R5 had a BIMS score of 11 out of 15, which indicated R5 had moderate cognitive impairment. Observation and interview on 03/02/26 at 4:43 PM revealed that R5 was visiting with a family friend in her room. During the observation, the call light was noted to be disconnected; the end of the cord that must be inserted into the wall for proper function was not inserted. Both the resident and the family friend confirmed the call light cord was not inserted into the wall. Interview with MD2 on 03/03/25 at 3:02 PM revealed call lights were randomly checked for function weekly. R5's call light system was repaired in 2020 and has had no other issues. Observation on 03/03/26 at 3:46 PM, R5's call light remained disconnected from the wall. Interview and observation on 03/03/26 at 3:55 PM with Certified Nurse Aide (CNA) 4 stated that call lights are used to alert staff that residents need assistance. CNA4 went to R5's room and confirmed the call light was not plugged into the wall. CNA4 proceeded to plug in the call light, which activated the alert sound as well as the light above the door, confirming the system was working properly. Interview and observation on 03/04/25 at 11:40 AM with MD2 confirmed R5's call light was unplugged. MD2 shared that he expected all call lights to remain plugged into the electrical socket. Interview with the Director of Nursing (DON) on 03/05/26 at 11:19 AM stated the expectation that all call lights would remain plugged into the electrical socket and were never unplugged from the wall socket. Review of the facility's policy titled, Call Lights: Accessibility and Timely Response, revised 03/14/23, revealed, 1. All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light . 9. Ensure the call system alerts staff members directly or goes to a centralized staff work area .

Based on record review, staff and resident interviews, and policy review, the facility failed to ensure hearing services were provided for one of one resident (Resident (R) 97 reviewed for vision and hearing services. The facility's failure to ensure the provision of timely hearing services had the potential to negatively impact R97's ability to effectively communicate. A total of 40 residents were reviewed in the sample. Findings include: Review of R97's admission Record, dated 03/05/26 and found in the electronic medical record (EMR) under the Profile tab, revealed R97 was admitted to the facility on [DATE]. The resident's diagnoses included type 2 diabetes and epilepsy.Review of R97's Audiology Consultation Report, dated 09/04/25 and found in the EMR under the Miscellaneous tab, revealed the resident had hearing loss and indicated the resident was in need of, and agreed to, a hearing aid evaluation for an assistive hearing device.Review of R97's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/06/25, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R97's care plan, dated 02/06/26 and found in the EMR under the Care Plan tab, revealed no care plan to address the resident's hearing needs.Review of R97's comprehensive record revealed nothing to indicate a referral had been made for the resident to have a hearing aid evaluation.During an interview with R97 on 03/02/26 at 2:45 PM, she stated she thought hearing aids were supposed to have been ordered in October of 2025, but she still did not have them. She stated she needed the hearing aids to hear appropriately. During an interview with the Social Services Director (SSD) on 03/04/26 at 12:15 PM, she indicated if a resident were having hearing concerns, she would notify the Director of Nursing (DON), and the DON would then generate a referral to obtain the hearing aids. The SSD confirmed she was unable to locate anything in R97's record to indicate follow-up after the 09/04/25 recommendation for R97 to acquire hearing aids. During an interview with the DON on 03/05/26 at 3:00 PM, she stated it was the responsibility of the Social Services Department to generate referrals for hearing and vision services. During an interview with the Administrator on 03/05/26 at 11:11 AM, he confirmed the facility should have followed up with the 09/04/25 recommendation for R97 to be evaluated for hearing aids and stated, Obviously a resident who needs hearing aids should not go six months without them. The facility's Hearing and Vision Services Policy, most recently dated 04/05/23, revealed, It is the policy of this facility that all residents have access to hearing and vision services and receive adaptive equipment as indicated and Employee should refer any identified need for hearing or vision services/appliances to the social worker/social services designee and Once vision or hearing services have been identified, the social worker/social services designee will assist the resident by making appointments and arranging for transportation and Assistive devices to maintain hearing include, but are not limited to, hearing aids and amplifiers.

Based on record review, observations, staff interviews, and facility procedure review, the facility failed to ensure the routine provision of ordered respiratory services for one resident (Resident (R) 89) of two residents reviewed for respiratory services. The facility's failure created the potential for R89 to develop complications related to the ineffective administration of oxygen. A total of 40 residents were reviewed in the sample. Findings include:Review of R89's admission Record, dated 03/05/26 and found in the electronic medical record (EMR) under the Profile tab, revealed R97 was admitted to the facility on [DATE]. The resident's diagnoses included chronic obstructive pulmonary disease (COPD) and pulmonary mycobacterial infection.Review of R89's physicians orders, found in the EMR under the Orders tab, revealed orders, with an original order date of 02/04/26, for the resident to receive oxygen three liters continuously per nasal cannula and for the resident's humidification bottle and oxygen tubing to be changed weekly on Wednesdays on the night shift. Review of R89's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/11/26 and found in the EMR under the MDS tab, indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated the resident was cognitively intact. The assessment indicated R89 was receiving oxygen at the time of the assessment.Review of R89's Medication and Treatment Administration Records (MARs/TARs), found in the EMR under the Orders tab and dated 02/04/26 through 03/05/26, revealed nothing had been documented to indicate the resident's humidification bottle and tubing had been changed on 02/11/26 or 02/25/26 per the physician's orders.During observations on 03/03/26 at 12:29 PM, 1:47 PM, and 3:01 PM and on 03/04/26 at 10: 08 AM, 10:57 AM and 2:39 PM, R89 was observed in bed in her room wearing her oxygen which was running at three liters per minute continuously. There was nothing on the resident's oxygen tubing to indicate the date it had been changed last. In addition, there was no humidification bottle attached to the resident's oxygen compressor.R89 was observed, along with the Interim Unit Manager, Registered Nurse (RN) 1 on 03/04/26 at 2:39 PM. RN1 confirmed there was nothing on R89's oxygen tubing to indicate when the tubing had last been changed, confirmed there was not a humidification bottle attached to the resident's oxygen concentrator as ordered, and confirmed there was nothing in the resident's record to confirm the tubing had been changed. RN1 stated oxygen being delivered at any rate above two liters per minute required humidification.During an interview with the Director of Nursing (DON) on 03/04/26 at 2:44 PM, she confirmed her expectation that all oxygen tubing/equipment was to be changed at least weekly, and this was to be documented on the MAR/TAR. The DON confirmed R89's oxygen should have been humidified.The facility's undated Changing Disposable Humidifier Bottles Procedure revealed, Change humidifier bottles weekly or as per institution infection control policy.The facility's undated Stationary Concentrators Procedure revealed, Oxygen delivery devices and humidifiers should be changed weekly.

Based on record review and interview, it was determined that for one (R5) out of three residents sampled for acceptable standards of clinical practice, the facility failed to ensure that R5's medication was administered according to the physician's order. Findings include:An undated facility document entitled, Rights of Medication Administration, included:Right PersonRight MedicationRight DoseRight TimeRight RouteRight ReasonRight Documentation. 7/14/25 - R5 was admitted to the facility with diagnoses including but not limited to infection of the right lower leg, right heel pressure ulcer, and resistance to multiple antibiotics.7/14/25 6:34 PM - R5's medications included, Daptomycin-sodium chloride intravenous solution, give 800 mg intravenously daily.7/15/25 - R5's clinical record documented a BIMS score of 15, indicating a cognitively intact status.7/21/25 11:00 AM - R5's clinical record documented, .Resident was ordered Daptomycin 800mg IV 1xday, Nurses were administering Daptomycin 850mg IV daily with wrong patient identifiers on IV bag as sent by pharmacy despite not matching order.9/12/25 11:30 AM - During an interview E2 (DON) stated, I received a telephone call from the supervisor on Sunday 7/20/25, that the pharmacy called and said that medication meant for another patient at another facility was delivered to our facility. The supervisor stated that there were two bags of daptomycin 850mg/ml were in the fridge. I told the staff to remove the medication bags from the fridge. The supervisor sent me pictures of the medication bags. I saw that the original name on the bags was crossed out and our patient's name was written on them. I also saw that the dose of medication was different from our resident's order. We identified three nurses involved in the medication error. All three of them were educated and counseled on the rights of medication administration.9/12/25 12:00 PM - During a telephone interview P1 (IV Pharmacist) stated, On 7/15/25, we sent out 3 bags of iv daptomycin to be used for Tuesday, Wednesday and Thursday [for R5]. On 7/18/25, we sent 4 more bags for Friday, Saturday, Sunday and Monday. On Sunday 7/20/25, we received a call from another facility asking for their medications. Our investigation revealed that the courier had inadvertently delivered the 4 bags to the wrong facility. We asked this facility to check and remove the incorrect bags from their fridge. We are working on quality control to prevent this from happening again. 9/12/25 12:30 PM - E2 provided the Surveyor with documentation of counseling for E4 (former weekend RN supervisor) and E5 (former RN.) The Surveyor asked for evidence of counseling for the third nurse involved in the medication error. E2 stated, She said she gave the correct medication, and I have no way of proving that she did not. During an interview, the Surveyor asked E7 (RN) about the medication that was administered to R5 on 7/18/25. E7 stated, I don't remember what he got.9/12/25 12:45 PM - A review of pharmacy medication delivery receipt revealed that four bags of iv daptomycin were prepared to be delivered to the facility on 7/18/25 at 4:28 AM (doses for the next 4 days.) R5's counseling documented medication errors for 7/17/25 and 7/19/25. The surveyor asked E2 if the facility's investigation revealed how many doses of the incorrect medication was administered to R5. E2 stated, We think it was one incorrect dose but there were two remaining bags that were removed from the fridge. A review of R5's medication administration records revealed that iv daptomycin was administered on 7/18/25 and one on 7/19/25.The facility failed to thoroughly investigate the medication error incident to determine exactly how many doses of the incorrect medication was administered and how many nurses were involved in the incident.9/12/25 1:00 PM - During a telephone interview E5 stated, I saw that the medication was labeled with another patient's name, but I thought it would be okay if scratched out that name and put my resident's name on it. I asked the supervisor to initial her name next to mine on the bag. I did not realize that the dosage was incorrect until later when I was told by the DON.9/12/25 1:30 PM - During an interview, the Surveyor asked E2 about the facility's process of accepting medications from the pharmacy. E2 stated, The nurse must sign for any narcotics. If the iv medications must be refrigerated, they are put in the fridge and checked before they are administered. The pills are checked before they are put on the medication carts.The facility failed to ensure that R5's iv medication was administered according to accepted standards of clinical practice.9/12/25 2:30 PM - During an interview, finding was confirmed with E2 (DON). 9/15/25 3:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (RN).

Based on record review and interview, it was determined that for one (R2) out of three residents sampled for care plans, the facility failed to develop a person-centered care plan for the refusal of medications. Findings include:6/27/25 - R2 was admitted to the facility with diagnoses including but not limited to muscle weakness, bladder cancer and ocular myasthenia gravis. R2's admission medications included pyridostigmine bromide oral tablet 60 mg two times a day for the treatment of ocular myasthenia gravis.7/1/25 - R2's clinical records documented a BIMS score of 15, indicating a completely cognitive intact status.6/28/25 - 7/22/25 - R2's clinical records documented twenty-eight (28) episodes of refusal of pyridostigmine bromide tablets out of forty-nine (49) opportunities.9/12/25 11:30 AM - A review of R2's clinical records lacked evidence of a care plan for the refusal of medications.9/12/25 1:00 PM - During an interview, finding was confirmed with E2 (DON).9/15/25 3:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (RN).

Based on record review and interview, it was determined that for one (R5) out of three residents sampled for medication administration, the facility failed to ensure that R5's medication was administered per the physician's order. Findings include:Based on record review and interview, it was determined that for one (R5) out of three residents sampled for medication administration, the facility failed to ensure that R5's medication was administered per the physician's order. Findings include:3/13/23 - A facility documented entitled, Medication Administration, and updated 6/3/24, documented, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.7/14/2025 - R5 was admitted to the facility with diagnoses including but not limited to infection of the right lower leg, right heel pressure ulcer, and resistance to multiple antibiotics.7/14/25 6:34 PM - R5's medications included, Daptomycin-sodium chloride intravenous solution, give 800 mg intravenously daily.7/15/25 - R5's clinical record documented a BIMS score of 15, indicating a cognitively intact status.7/21/25 11:00 AM - R5's clinical record documented, .Resident was ordered Daptomycin 800mg IV 1xday, Nurses were administering Daptomycin 850mg IV daily with wrong patient identifiers on IV bag as sent by pharmacy despite not matching order.9/12/25 11:30 AM - During an interview E2 (DON) stated, I received a telephone call from the supervisor on Saturday, 7/20/25 that the pharmacy called and said that medication meant for another patient at another facility was delivered to our facility. The supervisor stated that there were two bags of daptomycin 850mg/ml were in the fridge and sent me pictures of the medication bags. I saw that the previous name on the bags was crossed out and our patient's name was written on them. We identified three nurses involved in the medication error. All three of them were educated and counseled on the rights of medication administration.9/12/25 12:00 PM - During a telephone interview P1 (IV Pharmacist) stated, On 7/15/25, we sent out 3 bags of iv daptomycin to be used for Tuesday, Wednesday and Thursday [for R5]. On 7/18/25, we sent 4 more bags for Friday, Saturday, Sunday and Monday. On Sunday 7/20/25, we received a call from another facility asking for their medications. Our investigation revealed that the courier had inadvertently delivered the 4 bags to the wrong facility. We asked this facility to check and remove the incorrect bags from their fridge. We are working on quality control to prevent this from happening again. 9/12/25 12:30 PM - E2 provided the surveyor with documentation with counseling for E4 (former weekend supervisor) and E5 (former RN.) The Surveyor asked for evidence of counseling for the third nurse involved in the medication error. E2 stated, She said she gave the correct medication, and I have no way of proving that she did not. During an interview, the Surveyor asked E7 (RN) about the medication that was administered to R5 on the previous day. E7 stated, I don't remember what he got.9/12/25 12:45 PM - A review of pharmacy medication delivery receipt revealed that four bags of iv daptomycin were prepared to be delivered to the facility on 7/18/25 at 4:28 AM (doses for the next 4 days.) R5's counseling documented medication errors for 7/17/25 and 7/19/25. The surveyor asked E2 if the facility's investigation revealed how many doses of the incorrect medication was administered to R5. E2 stated, We think it was one incorrect dose but there were two remaining bags that were removed from the fridge. A review of R5's medication administration record revealed that iv daptomycin was administered on 7/18/25 and one on 7/19/25.9/12/25 1:00 PM - During a telephone interview E5 stated, I saw that the medication was labeled with another patient's name, but I thought it would be okay if scratched out that name and put my resident's name on it. I asked the supervisor to initial her name next to mine on the bag. I did not realize that the dosage was incorrect until later when I was told by the DON.The facility failed to ensure that R5's iv antibiotic medication was administered according to the physician's order when they administered 850mg of daptomycin instead of 800mg for two or three doses. 9/12/25 2:30 PM - During an interview, finding was confirmed with E2 (DON). 9/15/25 3:15 PM - Findings were reviewed during the exit conference with E1 (NHA), E2 (DON) and E3 (RN).

Based on interview and record review, the facility failed to act promptly on the grievances and recommendations of the resident council group for seven of 12 months of resident council minutes reviewed and to the extent practicable, the facility staff failed to revise or develop new policies related to resident rights, life, and care. These failures resulted in resident concerns going unaddressed. Findings include: During a group meeting on 02/12/25 at 3:51 PM with five residents (R), R298, R12, R65, R18, and R57, each resident attending the group meeting was listed on previous month's resident council meeting notes list of attendees. The group of residents indicated they reported the same concerns at every monthly meeting but did not receive an explanation or resolution to their concerns and continued complaints. The group also reported in agreement that the administrator took over in the monthly resident council meeting and was rude to the residents during the meeting. Resident council meeting notes dated March 2024 documented that a resident complained that the towels smell bad and have stains on them when returned from the laundry. No documentation could be provided that the grievance had been addressed or resolved. Residents wanted to know why their grievances and concerns were never addressed or resolved. The Activity Director stated it was out of her hands and that the grievance officer, the Administrator, would let them know. Resident council meeting notes dated May 2024 documented several residents reported the towels smell bad when returned from the laundry. No documentation was provided to indicate the grievance was resolved. Subsequent grievance regarding laundry were reported during the meetings. Resident council meeting notes dated June 2024 documented a grievance that the CNA staff were no longer hanging up clean clothes that returned from the laundry staff that has resulted in piles of clothing on a chair instead of placed in drawers are their closet. No documentation could be provided that indicated the grievance was resolved. Review of resident council meeting notes dated July 2024, voiced complaints of clothing being returned with stains. No documentation was provided to indicate the issue was resolved. Review of resident council meeting notes dated September 2024, documented complaints that resident's towels came back from the laundry looking dirty, smelly, and scratchy. One unnamed resident said she has complained for several months about her toilet leaking under the ring seal, not flushing properly, and running all the time. A complaint regarding the slamming of the kitchen door during council meetings is distracting and would like for ''something to be done.'' A complaint regarding the broken TV in the east dining room and would like for it to be fixed to be used for activities in the dining room. No documentation could be provided that indicated these grievances and concerns had been resolved. Review of resident council meeting notes dated 10/28/24 documented complaints from residents that their laundry is returned with bleach stains and that towels had a bad smell. No evidence was provided of a written response to address the complaints discussed. This grievance was not discussed in subsequent resident council meetings. Resident council meeting notes dated 01/27/25 documented the concerns of the group regarding transportation problems, specifically cancelled appointments due to late pickup/arrivals, and that transportation van staff drop her off outside of the building for medial appointments, and she can't always gain entry to the building with her motorized wheelchair. The resident council meeting minutes documented that the concern had been resolved, however, the grievance officer provided no evidence of a written response to the concerned resident, not identified. During an interview on 02/14/25 at 6:30 PM, the Activity Director stated she was not familiar with the rules, policies, or regulations regarding resident council meetings and/or how to handle grievances in the facility. She said she has been the activity director in the facility for about 5 weeks and was in the process of learning the role and the expectations of the activity program in the facility. She said she was aware that the resident council was a time for residents to have discussions in a safe environment without fear and intimidation. When asked if she thought the resident council currently being facilitated by the facility administrator appeared to be a safe environment for the residents to discuss concerns or issues, she responded that somebody needs to be in there to take notes of the meeting. She said it needed to be a staff member. When asked if she had been invited to the resident council in January 2025. She said that she was not actually invited and that she assumed she was supposed to be there along with the administrator. She said she made notes of the discussions in the January 2025 resident council meeting and was aware of the issues regarding transportation. She said that after the meeting, the notes were kept by the Administrator, and she did not know who was responsible for following up with the residents' concerns and finding a resolution or accommodation to meet the needs of the residents. During an interview on 02/14/25 at 6:45 PM, the Administrator stated he was the grievance officer for the facility and he thought it was his responsibility to facilitate the monthly resident council meetings. He stated that concerns/grievances reported during the resident council meeting were documented and given to the department director to resolve the grievance. He stated he did not follow-up to ensure the grievance has been resolved or that the outcome was communicated to the residents. During an interview on 02/14/25 at 6:58 PM, the Regional Operations Manager said she was not aware the Administrator facilitated the resident council meeting each month for the past 11 months, as indicated on the monthly resident council meeting notes. She stated she would provide training to the Administrator and to the Activity Director regarding her expectations and about the regulations for the monthly resident council meeting. She said that she would ensure staff members could only attend the resident council meeting if they were invited to attend and that her expectation of concerns and grievances discussed in the resident council meeting were documented on a concern/grievance form and formally addressed by department mangers with a written response to the group attendees regarding the process or resolution within three days of the complaint/grievance. Review of the facility policy Resident and Family Grievances, dated 04/05/23, provided by the Administrator, stated it was the policy to support each resident's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The policy documented the administrator was responsible for overseeing the grievance process with prompt efforts to resolve grievances including acknowledgment of the complaint/grievance and actively working toward a resolution, issuing written grievance decisions to the resident, and coordinating with state and federal agencies as necessary in light of specific allegations. The policy stated grievances may be voiced in various forums including verbal complaints to a staff member, written complaint to a staff member or grievance official, written complaint to an outside party, and verbal complaints during resident council meetings, may be filed anonymously. The policy stipulated that the grievance official will keep the resident appropriately appraised of progress towards a resolution of the grievance and in accordance with the resident's right to obtain a written decision regarding his or her grievance.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure call lights were answered timely for one of 38 sample residents (Resident (R) 44) reviewed for staffing. This failure had the potential to put the residents at risk. Findings include: Review of R44's Admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE]. Review of R44's admission Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 11/20/24, revealed R44 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. She was dependent on staff for toileting, bathing, and dressing. During a continuous observation on 02/13/25 from 9:16 AM until 9:54 AM, R44's call light remained on. During this time, Licensed Practical Nurse (LPN) 1 stood by the medication cart from 9:16 AM to approximately 9:35 AM, which was parked by R44's room. Certified Nurse Aide (CNA) 9 walked down the hall and donned personal protective equipment (PPE) and entered another resident's room. R44's call light remained on. At 9:36 AM, CNA8 donned PPE, while standing in front of room [ROOM NUMBER]. She entered room [ROOM NUMBER] at this time and came out of the room at 9:39 AM. While standing near room [ROOM NUMBER], CNA7 said to CNA 8 to let CNA9 know that R44's call light was on. During an interview at 9:46 AM, CNA7 stated CNA9's assignment included R44. He said even though a CNA may be assigned to a section, CNAs would help other CNAs. At 9:50 AM, LPN1 returned to her cart, which remained parked next to R44's room. During the continuous observation, the Activities Director (AD) walked by R44's room twice without answering the call light. At 9:54 AM, two housekeepers stood outside the room, and did not answer the call light. During an observation on 02/13/25 at 9:56 AM, CNA9 and LPN1 entered R44's room and turned off the call light. LPN1 stated a call light should not be left on for 38 minutes. She stated they tried to have call lights answered in less than five minutes. LPN1 stated all staff should answer call lights, even if they could not help the residents, they could get staff who could. CNA9 said he was assigned to R44's room but was helping another resident who had an appointment. CNA9 agreed the call light had been left on for too long. During an interview on 02/13/25 at 10:20 AM, R44 stated it was pretty common that I have to wait for call lights to be answered. She stated this time she needed her phone plugged in. She said while she was waiting, she tried to do it herself, but she almost fell so she had to wait. She stated when she had to wait a long time to get her light answered and she had to go to the bathroom, it really made her angry. During an interview on 02/13/25 at 10:18 AM, Registered Nurse (RN) 3, who was observed sitting at the nurses' station during the continuous observation, approximately four feet from the visual call light monitoring system, stated everyone was responsible for answering lights, even if they could not help the resident, they could pass the message on to the appropriate staff. She stated, we have the intercom system right here, so we know [which resident is calling]. During an interview on 02/14/25 at 4:00 PM, the Director of Nursing (DON) stated call lights should be answered by all staff, even if they could not help the residents, they could get someone who could. She stated if call lights go unanswered for too long, the resident may have an emergency situation which could put the resident at risk. Review of the facility's policy titled, Call Lights: Accessibility and Timely Response, dated 03/14/23, revealed All staff members who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified.

Based on observation, interview, and record review, the facility failed to ensure residents received alternative measures prior to installation of side rails for one of one resident reviewed for side rails (Resident (R) 9) of 38 sampled residents. The lack of alternate side rail measures could lead to potential safety concerns related to bed rail use for residents with bed rails. Findings include: Review of R9's Face Sheet, located in the electronic medical record (EMR) under the Profile tab revealed the resident was readmitted to the facility on [DATE] with diagnoses which included legal blindness and gout. Review of R9's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/14/25 and located in the resident's EMR under the MDS tab, revealed a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated the resident's cognition was severely impaired. Review of R9's Care Plan, dated 06/05/23 and located in the resident's EMR under the Care Plan tab, revealed The resident required assistance and was dependent with ADL [activities of daily living] care related to bed mobility. Interventions in place were 1/4 side rails per physician orders for safety during care and to assist with bed mobility. Review of R9's Bed Rail Evaluation, dated 10/09/23 and located in the EMR under the Assessments tab, revealed no alternates were attempted prior to the placement of the siderails. Further review revealed the outcome for failed alternatives was bedrails requested. During an observation on 02/11/25 at 10:24 AM R9 was lying in the bed with head of bed upright. Side rails in place on both sides of the bed. During an interview on 02/14/25 at 8:18 AM the Director of Rehab (DOR) said therapy had no role in determining if a resident required the use of bed rails. She also stated that therapy did not access R9 for the need of bed rails. During an interview on 02/14/25 at 8:34 AM, the Assistant Director of Nursing (ADON) stated she completed R9's bed rail assessment in July 2024. She stated all residents were assessed on admission for bedrail use and thereafter on a routine basis, but she was unsure how often. She thought every three to six months. She said she was unsure what alternates were attempted prior to using the bedrails and that the family probably requested them to be used for the resident. During an interview on 02/14/25 at 2:31 PM, the Director of Nursing (DON) stated bed rail assessments were completed on admission and that all residents were asked if they wanted bedrails. She stated that it was a resident's right to have the bedrails if they requested them and she did not know that regulation required alternates to be explored prior to their use. Review of the facility's policy titled ''Use of Bed Rails'' revised 03/14/23 revealed it is the policy of the facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails.

Based on interview, record review, document review, and facility policy review, the facility failed to ensure the accurate code status was documented and available for reference for two of 36 sampled residents, (Resident (R)49 and R38). This deficient practice could result in not following the specific residents' wishes documented in the advanced directive. Findings include: Review of R49's Admission record located in the electronic medical record (EMR) under the Profile tab revealed an admitted [DATE]. The Brief Interview for Mental Status (BIMS) assessment, dated [DATE] and located under the Documents tab, revealed R49 scored nine of 15, indicating R49 was moderately cognitively impaired. The documented code status, Full Code, was found in EMR, Resident Profile tab, Face Sheet but no documentation was identified to support the resident's decision. Review of R38s Admission record located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE]. The BIMS assessment, dated [DATE] and located under the Documents tab, revealed R38 scored five of 15, indicating R38 has severe cognitive impairment. R38's documented code status, Full Code, was found in EMR, Resident Profile tab, Face Sheet but no documentation was identified to support the resident's decision. During an interview on [DATE] at 1:49 PM, the Administrator said that he was responsible for acquiring advanced directives for each resident. He stated the facility had been cited in the past for not having advance directives for all residents. He said his plan of correction for the [DATE] survey included educating/asking the residents about their Advance Directives if they had a BIMS score of 13 of 15 or greater, indicating cognitively intact. If the BIMS score is less than 13 of 15, indicating the resident is cognitively impaired, the facility would contact the family. The Administrator said he was responsible for obtaining the Advance Directive from the resident or the family. He stated he had not acquired the advanced directive from the family member of R38 and R49. He said when an advanced directive is not acquired and is not documented in the EMR, the default code status is Full Code, indicating Cardiopulmonary Resuscitation (CPR) would be administered to the resident. During an interview on 02//,d+[DATE] at 2:10 PM, Licensed Practical Nurse (LPN) 2 stated without a code status or advanced directive, CPR would be administered to a resident in an emergency. She stated the Code Status of each resident was located in the EMR, Profile header and defaulted to Full Code if the advanced directive or Do Not Resuscitate (DNR) form was missing from the EMR. A policy was not provided prior to survey exit.

Based on observation, record review, interviews, and facility policy review, the facility failed to determine if one of one resident (Resident (R) 66) was assessed as clinically appropriate to self-administer medications of 38 sample residents. The failure of the facility to leave medications at the bedside unattended prior to an assessment, created an unsafe environment for the residents and other residents in the area. Findings include: Review of the facility's undated policy titled, Resident Self Administration of Medications revealed It is the policy of this facility to support each resident's right to self-administer medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely .11. The care plan must reflect resident self-administration and storage arrangements for such medications. Review of R66's electronic medical record (EMR) undated Admission Record located under the Profile tab, indicated the resident was admitted to the facility on [DATE] with diagnoses of diabetes mellitus, arteriosclerotic heart disease, spinal stenosis, and hypertension. Review of R66's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ADR) of 12/03/24 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident did not demonstrate any upper extremity impairment and required only set up assistance with oral hygiene and eating. Review of R66's EMR Care Plan located under the Care Plan tab, indicated a care plan for the resident to self-administer her medications had not been developed. Review of R66's EMR revealed no assessments were conducted related to self-administration of medications. During an observation on 02/11/25 at 10:09 AM, Licensed Practical Nurse (LPN) 4 walked out of R66's room. The resident's overbed table had two medicine cups. One cup contained approximately eight pills, and the other cup contained approximately 20 cc's (cubic centimeters) of red liquid. The resident was removing the pills and placing them on top of her overbed table. She was able to identify what each pill was as she removed them from the medication cup. She stated that most of the nurses left them for her to take except the agency nurses, they always waited until she took them all before they left. During an interview on 02/11/25 at 10:15 AM, LPN4 stated that the resident liked to take her own medications. LPN4 stated R44 would pour them out, identify them and let them know if anything was missing. She stated she typically did not leave the residents medications; she watched her take them. LPN4 stated R44 just did not like anyone hovering over her. She stated she was not sure if the resident was assessed, or care planned to take her own medications. During an interview on 02/13/25 at 10:44 AM, the Director of Nursing (DON) stated the nurse should have stayed nearby until the resident took all of her medications. DON stated the resident was capable and preferred to take her own medicine. DON stated she did not keep her medication in her room, the nurse had to give it to her.

Based on interview, record review, and review of facility policy, the facility failed to ensure that supervision to prevent accidents for one Resident (R) 297 out of four sampled residents reviewed for accidents. This failure caused actual harm, when R297 sustained a subdural hematoma after a fall when Certified Nursing Assistant (CNA)1 left the resident sitting on the bedside, unattended, while gathering supplies for the resident's personal care. Findings include: Review of a policy provided by the facility titled Fall Prevention Program, dated 09/05/23 indicated .Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.The facility utilizes a standardized risk assessment for determining a resident's fall risk. The risk assessment categories (sic) residents according to low, moderate, or high risk .Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk.Low/Moderate Risk Protocols.Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed .Call light within reach.Adequate lighting.Implement routine rounding schedule.Monitor for changes in resident's cognition, gait, ability to rise/site, and balance. Review of R297's electronic medical record (EMR) titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of Lewy Body (a form of dementia). Review of R297's EMR titled Nursing Admission/ Readmission/Annual/Sig [Significant] Change assessment dated [DATE] indicated the resident scored 14 and was considered to be at moderate risk for falls. Review of R297's EMR titled Care Plan located under the Care Plan tab dated 10/20/22 indicated the resident had impairments in activities of daily living and was totally dependent on one staff member for toileting. The care plan indicated the resident was at risk for falls related to deconditioning and directed the staff to keep the call light within reach for the resident and to anticipate the needs of the resident. The care plan indicated physical therapy (PT) was to assess and treat the resident as needed. The care plan dated 10/24/22 indicated the resident had a diagnosis of Lewy Body and had impaired cognition due to this dementia diagnosis. There were no interventions which identified the unpredictable behaviors associated (poor safety awareness and impulsivity) with the resident with Lewy Body or the Parkinson's related movement (rigidity) associated with Lewy Body and the interventions to prevent falls, and safety risks associated. Review of a document provided by the facility referred to as Kardex (directs the CNA on how to provide resident care), dated 10/20/22 indicated R297's call light was to be within reach, and to follow the facility fall protocol. For bed mobility, the Kardex indicated the resident required extensive assistance of one staff to turn and reposition in bed. Review of R297's EMR titled nursing Progress Notes, dated 10/21/22 indicated the resident was difficult to redirect, had poor safety awareness, and would attempt to get out of her wheelchair/bed unaided. Review of a document provided by the facility titled Physical Therapy [PT] Evaluation & Plan of Care, dated 10/21/22 indicated R297 was moderate assistance for transfers. The PT evaluation indicated the resident's trunk strength moved through full range against gravity and needed slight to moderate assistance. The assessment indicated the resident had symmetrical posture but indicated the resident had impaired gross motor coordination. The PT evaluation provided a section titled Assessment Summary which revealed the resident required skilled PT services to minimize falls, decrease complaints of pain, evaluate need for assistive device. Review of R297's EMR titled admission Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 10/26/22 indicated the resident had a Brief Interview for Mental Status [BIMS] score of four out of 15 which revealed the resident was severely cognitively impaired. The assessment indicated the resident required extensive assistance of two staff members for bed mobility and was totally dependent on two staff for transfers. The assessment revealed the resident had a history of falls without injury prior to her admission. Under the Care Area Assessment the resident triggered for falls and directed the staff to develop a care plan. Review of a document provided by the facility titled Occupational Therapy [OT] dated 11/03/22 indicated R297's goal was to reach/retrieve cones stand by assistance to increase dynamic sitting balance; the precautions identified the resident was a fall risk and had a diagnosis of Lewy Body dementia. Review of a document provided by the facility titled OT, dated 11/04/22 indicated R297 was able to sit upright at edge of bed with supervision. The OT notes indicated the resident had fall precautions for being a fall risk and again identified the resident had a diagnosis of Lewy Body dementia. Review of a document provided by the facility titled Change in Condition Evaluation dated 11/04/23 indicated R297 indicated the resident had an increase in agitation and restlessness during the night shift. The document indicated the resident sustained a fall and sustained a contusion to the scalp which measured approximately four inches with copious amounts of bleeding. The document revealed the resident attempted to get out of bed on her own when the CNA briefly left the room. The resident was found on the floor with her face down and next to her bed. The resident's representative and medical provider were notified. The medical provider ordered the resident to be immediately transferred to the local hospital for evaluation and treatment. Licensed Practical Nurse (LPN)3 completed the note but is no longer employed at the facility. Review of the facility's investigation dated 11/04/22 indicated R297 sustained a fall, and the fall was unwitnessed with injuries. The investigation confirmed the resident sustained a laceration to the left temporal area and was on heparin. The facility investigation confirmed the medical provider ordered R297 to be sent to the hospital. The investigation indicated CNA1 was previously in the resident's room and the resident was on safety monitoring due to increased agitation and the report revealed the resident was alert and oriented times one (the higher the number the more alert the resident was to person, place, surroundings, and time). The investigation indicated a root cause analysis was completed and determined the resident was supervised throughout the day due to her level of confusion and impulsive behaviors secondary to her diagnosis of Lewy Body dementia. The investigation revealed the resident appeared to be getting tired and a CNA took the resident to her room, provided personal care, and toileted the resident. The investigation revealed the resident was then placed into bed by a CNA. The investigation indicated the CNA and a nurse and left the room. During this time the resident attempted to get out of her bed. The CNA returned and the resident refused to lay down in bed. The CNA reported she left the resident sitting on the bed when she left to gather supplies needed to care for the resident. When the CNA returned, approximately five minutes later, she found the resident on the ground and immediately called for assistance. As part of the investigation, the facility indicated therapy deemed the resident safe to sit on the edge of the bed without the need of physical support. However, the above investigation did not include the level of supervision needed to keep R297 safe. Review of a document provided by the facility titled Witness Statement dated 11/04/22 and written by LPN1 indicated she had monitored R297 on her entire shift since the resident made several attempts to get up out of her wheelchair and walk and she was unable to redirect the resident. LPN1 was no longer an employee at the facility. Review of a document provided by the facility titled Witness Statement dated 11/04/22 and written by LPN3 indicated R297 was on safety monitoring during his shift due to an increase in anxiety and restlessness. LPN3 wrote that within a short period of time the resident got up on her own and attempted to walk and was found face down. Review of a document provided by the facility titled Witness Statement dated 11/04/22 indicated CNA1 stated R297 was left sitting on the side of her bed, when she and the nurse walked away. CNA1 indicated she was gone for approximately five minutes and when she returned the resident had fallen. CNA1 stated the resident had on anti-slid socks on. A request was made to the facility to contact CNA1 for an interview, and this was not successful prior to the end of the survey. Review of a document provided by the facility titled CT [computerized tomography] Scan without Contrast, dated 11/05/22 indicated R297 sustained head trauma with moderate to severe subdural hematoma. Review of a type written document provided by the facility untitled and dated 11/16/22 indicated LPN3 wrote a statement which indicated R297 was observed to be highly agitated and restless and was repeatedly attempting to get up from her wheelchair. The statement indicated that staff were concerned for the safety of the resident and every effort was made to provide one on one supervision for her. The statement revealed the resident was left sitting upright on her bed with both feet on the ground when the CNA stepped outside of the room briefly to gather supplies and when the CNA returned the resident had fallen. During an interview on 02/01/24 at 8:40 AM, the Director of Rehabilitation (DOR) stated a resident with a diagnosis of Lewy Body was considered to be at risk for falls. The DOR stated typically there would be interdisciplinary notes or mention of recommendations in the therapy notes, but verified there were none. The DOR stated the resident should not have been left alone by the staff since the resident required supervision. During an interview on 02/01/24 at 11:12 AM, the DON confirmed CNA1 sat R297 on the side of the bed and the resident then fell . The DON stated supervision did not mean to have a staff member's hand on the resident. The DON stated therapy did not meet with the staff to discuss the resident's need for supervision with the diagnosis of Lewy Body. The DON confirmed the resident was left alone when CNA1 left the resident alone to gather supplies to complete the resident's personal care. The DON stated the process was for staff to gather supplies before care was rendered to a resident. The DON stated she did not have access to the remaining hospital records other than the CT scan from 11/04/22. The Regional Clinical Consultant was present during this interview.

Based on observation, interview, record review, policy review, and review of the US (United States) Food Code, the facility failed to ensure the kitchen was maintained in a sanitary condition to prevent the potential spread of foodborne illness to 97 out of 99 residents. Specifically, the facility failed to maintain a sanitary kitchen; label, date, and store food properly; use the handwashing sink for handwashing only and ensure a garbage can was in place; ensure equipment was clean; ensure staff followed hand hygiene/glove use standards; and ensure staff had their hair covered. The facility failed to ensure proper infection control practices were maintained for a sugar and a flour container which held scoops previously used by the kitchen staff. The facility failed to ensure Dietary Aide (DA)1 removed his personal disposable cup from a reach in refrigerator which could potentially contaminate food items which were then served to residents. Findings include: US Food Code 2022-- Indicated .Explaining correct procedures for cleaning and sanitizing utensils and food-contact surfaces of equipment.Employees are properly sanitizing cleaned multiuse equipment and utensils before they are reused.an employee shall eat, drink.only in designated areas where the contamination of exposed food, clean equipment, utensils, and linens.During pauses in food preparation or dispensing, food preparation and dispensing utensils shall be stored.In food that is not time/temperature control for safety food with their handles above the top of the food within containers or equipment that can be closed, such as bins of sugar, flour, or cinnamon.refrigerated, ready-to eat, time/temperature control for food safety food is prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 [degrees] C[Celsius] (41 F [Fahrenheit]) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. Review of the Food Preparation policy dated February 2023 revealed, 1. All staff will practice hand washing techniques and glove use. 2. Dining services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. 3. All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use . All staff will use serving utensils appropriately to prevent cross contamination . All refrigerated, ready-to-eat . prepared foods . will be labeled and dated with a prepared date (Day 1) and a use by date (Day 7). Review of the dietary department Staff Attire policy dated October 2023, All staff members will have their hair off the shoulders, confined in a hair net or cap . Review of the Foods Brought by Family/Visitors policy dated October 2019 revealed, Food brought to the facility by visitors and family is permitted . Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food . Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date. 1. During the initial tour conducted on 01/30/24 at 8:30 AM, the Dietary Manager (DM) provided a tour of the kitchen. At 8:35 AM, observed a container of sugar and a container of flour with scoops inserted into both the sugar and the flour. The DM stated this was improper use of scoops to leave them in the containers and it was a potential infection control issue. At 8:36 AM, the DM opened a reach-in refrigerator, and he confirmed the food inside was a meal from the previous night's meal. The following items were observed in separate containers covered with plastic wrap with no date when the items were either served or last date to be used by: peas, chicken, rice, and peas and carrots. Finally, there was a disposable cup, with no lid and filled with a reddish liquid. DA1 stated the juice was his and did not respond when asked why he stored it in a refrigerator that contained food that potentially could be served to residents. The DM confirmed that all the food identified in the refrigerator was undated and should have been dated. 2. During kitchen observations on 02/01/24 from 7:24 AM - 8:28 AM the following concerns were noted: a. There was a piece of pineapple in the handwashing sink. The Regional District Dietary Manager (RDDM) verified the presence of the pineapple, removed it, and stated the handwashing sink should be used for handwashing only and not for food preparation. In addition, there was no garbage can in the proximity of the handwashing sink for disposal of paper towels. The RDDM guided the surveyor to the dish machine room to a garbage can to dispose of the used paper towels. The RDDM verified there should be garbage can in the handwashing sink area. b. The commercial slicer was observed with a large plastic bag covering it. When the bag was removed the back side of the slicing blade had food/grease residue present on the edge of the blade 1/2 inch wide. The RDDM stated the plastic bag covering the slicer indicated the slicer had been cleaned and was ready to be used. The RDDM stated the slicer would need to be cleaned prior to use, verifying the presence of the grease/food residue. c. There were three floor drains in the kitchen. There were deteriorated/missing tiles around each of the three floor drains. The RDDM stated he habitually noted on his monthly inspection reports for the tile around the floor drain in the area between the walk-in refrigerator and freezers. The RDDM verified the condition of the tile floor for all three drains and indicated repair was needed. d. The base board behind the handwashing sink was partially affixed and there was a section of approximately three feet coming away from the wall. A section of approximately three feet of the base board near the door into kitchen from dining room was also not affixed and was coming away from the wall. There was accumulated grime along the baseboard/floor at the dining room/kitchen entrance. e. DA2 was observed in the kitchen with long braids that were not covered with a hair covering. DA2 was observed assisting with tray line during lunch meal service. Only the top of DA2's hair was covered with a hair net. The DM verified DA2's hair was not adequately covered during an interview on 02/01/24 8:38 AM. f. Cook1 was observed to dish up residents' meals for the 600 cart, the 300 cart, and the 200 cart from 8:01 AM - 8:38 AM using a gloved hand to put toast on the plates. There were no utensils present and Cook1 touched multiple other items with the same gloved hand. Cook1 touched plates, bowls, utensils, the counter, etc. with the same gloved hands. The DM stated in an interview on 01/01/24 at 8:38 AM that Cook1 should not be using the same gloves to touch ready to eat food and other items due to the potential for cross contamination. During an observation on 02/01/24 at 6:48 AM, the unit refrigerator in the east side nourishment room was noted with large brown/beige food spills and beverage spills on the shelves and bottom surface of the refrigerator. There were a variety of general snacks, and beverages as well as items for specific residents. There was a croissant sandwich in a box without a name or date. There was chicken with a resident's name noted but no date. The interior of the microwave in the nourishment room was covered with food spills/spatters. 3. Review of the RDDM's monthly Unit Inspection Food Reports for a six-month period preceding the survey revealed similar concerns to those found during the survey: a. Review of the Unit Inspection Food Report dated 08/18/23 revealed unsatisfactory markings for: Floors clean and dry/tiles unbroken in dishwashing area and floors clean and dry/tiles unbroken in walk-ins with a notation floor in between walk-in and doors.; Equipment properly stored when not in use with a notation ensure slicer and mixer detail cleaned after each use and covered when not in use.; Food products are used or discarded by the expiration date with a notation ensure all items labeled and dated, opened items dated for expiration .; and Proper Snack/nourishment refrigerator temperatures are maintained and food items are dated and labeled with a notation inspect daily. b. Review of the Unit Inspection Food Report dated 09/25/23 revealed unsatisfactory markings for: Floors clean and dry/tiles unbroken in dishwashing area and floors clean and dry/tiles unbroken in walk-ins with a notation floor in between walk-ins.; and Foods in the refrigerator/freezer are covered, labeled, dated, and shelved to allow circulation with a notation of, monitor labeling and dating for 100% accuracy.; c. Review of the Unit Inspection Food Report dated 10/22/23 revealed unsatisfactory markings for: Floors clean and dry/tiles unbroken in dishwashing area and floors clean and dry/tiles unbroken in walk-ins with a notation floor in between walk-in and freezer. d. Review of the Unit Inspection Food Report dated 11/29/23 revealed unsatisfactory markings for: Floor clean and dry/tiles unbroken in walk ins with a notation floor between walk-in and freezer.; Foods in the refrigerator/freezer are covered, labeled, dated, and shelved to allow circulation with a notation of, monitor labeling and dating for 100% accuracy.; Snack/nourishment refrigerators on the unit (s) are maintained to prevent the potential for foodborne illness with a notation continue to monitor.; and Proper snack/nourishment refrigerator temperatures are maintained and food items are dated and labeled with a notation continue to monitor. e. Review of the Unit Inspection Food Report dated 12/21/23 revealed unsatisfactory markings for: Floor clean and dry/tiles unbroken in walk ins with a notation floor between walk-in and freezer.; and Foods in the refrigerator/freezer are covered, labeled, dated, and shelved to allow circulation with a notation of, monitor labeling and dating for 100% accuracy. f. Review of the Unit Inspection Food Report dated 01/26/24 revealed unsatisfactory markings for: Food in the refrigerator/freezer are covered, labeled, dated, and shelved to allow circulation with a notation, all prepped items need to be labeled with production and expiration date .; Staff are following . policy for food storage and leftovers with a notation of, storage of partially used items - need to be properly covered and dated with expiration also.; Proper snack/nourishment refrigerator temperatures are maintained and food items are dated and labeled with a notation need to inspect on a daily basis.; and Under Comments a notation read, scoop in pudding container, container not labeled. 4. Review of all the work orders for the kitchen for the past six months showed the deteriorated tiles around the floor drains and baseboard coming away from the wall had not been reported or slated for repair. 5. During an interview on 02/02/24 at 11:37 AM, the Registered Dietitian (RD) stated she completed monthly inspections of the kitchen and had identified a concern with an employee's open beverage in the kitchen. The RD stated utensils should be used for serving toast and not gloved hands due to the potential for cross contamination due to it being a ready to eat food. The RD stated there should be a garbage can designated to be in the handwashing sink area. The RD stated she had identified concerns with the cleanliness of the nourishment rooms; however, the dietary department was not responsible for maintaining/cleaning them. 15406

Based on observation, interview, record review and policy review, the facility failed to ensure there was not more than a 14-hour time span between dinner and breakfast the next day. This failure affected approximately 19 residents out of 99 total residents, who ate in the west dining room. The extended time between dinner and breakfast had not been approved by the resident group. Findings include: Review of the Frequency of Meals policy dated October 2022 revealed, The time between a substantial evening meal and breakfast the following day will not exceed 14 hours, except when a nourishing snack is served at bedtime. Up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span and a nourishing snack is provided. 1. Review of the undated [Name of facility] Meal Service Times provided by the facility and posted on the wall near the dining room revealed a 14-and-a-half-hour gap between dinner and breakfast for residents eating the dining rooms: Breakfast Cart service for hallways begins at 8:00 am Dining room opens at 8:00 am Lunch Cart service for hallways begins at 12:00 PM Dining room service begins at 12:00 PM Dinner Cart service for hallways begins at 5:15 PM Dining rooms open at 5:30 PM 2. Review of the Resident Council May 2023 meeting minutes revealed, Beginning April 3rd, cart service will begin at 5:15 pm. Dining rooms will be served at 5:30 pm. Regulations state that there cannot be more than fourteen hours between dinner and breakfast. The change puts us at fourteen hours and 30 minutes. 3. Review of the undated, [NAME] Dining Room list revealed there were 19 residents who customarily ate their meals in the dining room. 4. During an interview on 02/01/24 at approximately 7:30 AM, the Regional Dietary District Manager (RDDM) stated the 14 and a half hour time lapse between dinner and breakfast the next day applied to residents eating in the dining room. The RDDM stated they had been trying to come up with the best timing for meal service but the timing was tricky. They had tried to serve residents in the dining room breakfast first, but there were late risers and it worked better to serve them after the meal carts which contributed to the longer lapse between dinner and breakfast. During an interview on 02/01/24 at 7:42 AM, the Dietary Manager (DM) stated the dining rooms were served last after the 600 hall, 300 hall, 200 hall, 500 hall, and 100 hall carts. 5. During a meal observation for breakfast on 02/01/24 at 8:56 AM, only two out of the 12 residents in the main dining room had received their meals. There were 10 residents in the main dining room waiting for breakfast. Several of the residents waiting for their meals, including R17 and R50, stated they were hungry. R50 stated breakfast was typically served by 8:45 AM. Observation revealed the last resident was served breakfast at 9:17 AM, making the time span more than 15 hours from dinner the day before. 6. During an interview on 02/02/24 at 12:21 PM, the Activity Director (AD) stated she took minutes at the resident council meetings. She stated a change had been made in the mealtimes and it had been communicated to residents in the resident council meeting (May 2023). The AD stated she was not aware of the resident group approving the time more than 14 hours. During an interview on 02/02/24 at 11:37 AM, the Registered Dietitian (RD) stated the facility had changed the dinner time and previously had changed the breakfast time. She stated the time span between dinner and breakfast should not be more than 14 hours. During an interview on 02/02/24 at 1:54 PM, the Administrator stated the facility had discussed the greater than 14-hour time span between dinner and breakfast with the residents; however, did not get approval from the resident group.

Based on observation, interview, record review and policy review, the facility failed to ensure the food was palatable for four of 22 sampled residents (Resident (R)1, R59, R33, and R65) and residents attending Food Committee meetings. The food was not at a palatable temperature when residents received their meals; condiments were not consistently provided, and food was not flavorful/prepared properly. Findings include: Review of the Food: Quality and Palatability policy dated February 2023 revealed, Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. 1. Resident interviews with R1, R59, R33, and R65 revealed concerns with food palatability: a. During an observation and interview on 01/30/24 at 11:27 AM, R1 was observed with her breakfast tray (scrambled eggs, toast, orange juice) remaining on the overbed table in front of her untouched. R1 stated the eggs were cold when she received them, and she had not eaten them. R1 stated dinner was the worst meal and it usually consisted of sandwiches and stale bread. During an observation on 01/30/24 12:59 PM, R1 was served her lunch which included a hot dog with mustard. When asked if she liked ketchup with her hot dog, R1 stated the only condiment she received was mustard. R1 stated she had her own salt and pepper packets because she did not receive it with meals. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/08/23 in the electronic medical record (EMR) under the MDS tab revealed R1 was moderately impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 11 out of 15 (score of 8 - 12 indicates moderate impairment). b. During an interview on 01/30/24 at 3:37 PM, R59 stated the meat was always overcooked. R59 stated the food was cold when he received his tray in his room. He stated his room was the last one at the end of the hall and he was served last. R59 stated he often asked staff to reheat his meal. Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed Resident (R)59 was admitted to the facility on [DATE]. Review of the quarterly MDS with an ARD of 11/10/23 in the EMR under the MDS tab revealed R59 was intact in cognition with a BIMS score of 15 out of 15. c. During an interview on 01/30/24 at 11:27 AM, R33 stated the, food is lousy, never warm and always cold. Review of the undated Admission Record in the EMR under the Profile tab revealed R33 was admitted to the facility on [DATE]. Review of the admission MDS with an ARD of 12/12/23 in the EMR under the MDS tab revealed R33 had a BIMS score of 14 out of 15 indicating she was cognitively intact. d. During an interview on 01/30/24 at 9:08 AM, R65 stated she had concerns about the food. R65 stated the temperature of the food was a problem and the food was not cooked properly. Review of the Admission Record in the EMR under the Profile tab revealed R65 was admitted to the facility on [DATE]. Review of the quarterly MDS with an ARD of 11/28/23 in the EMR under the MDS tab revealed R65 was cognitively intact with a BIMS score of 13. 2. Review of the Food Committee Meeting Minutes from June 2023 through December 2023 revealed concerns with the food. a. June 2023 Food Committee Meeting Minutes included the following comments: Rolls become soft under the warmer tops. Veggies are cooked too long . b. July 2023 Food Committee Meeting Minutes included to following comments: Several residents stated the kitchen is not using the hot bases to keep the food warm. A resident stated no relish, sugar, applesauce, available . c. Food Committee Meeting Minutes 08/10/23 included the following comments: The food this week was horrible (sic) she received under cooked potato wedges. No lettuce and tomato on her sandwich for dinner . Does not like the angel food cake says its dry and [NAME]. d. Food Committee Notes 11/09/23 included the following comments: Too much moisture in the vegetables. Overcooked vegetables. Residents state the (sic) don't like the coffee. e. Food Committee 12/14/23 minutes included the following comment: Eggs cold. 3. The posted menu in the hallway outside the dining room revealed lunch on 01/30/23 consisted of smothered chicken thigh, whole kernel corn, oven brown potatoes, corn bread, and sliced pears or the alternate of hot dogs on bun, baked beans, and coleslaw. On 01/30/24 at 12:21 PM, staff went into the dining room where residents were sitting and passed out drinks. There were approximately 15 residents in the dining room. Meal service began at 12:26 PM. Meal service was observed continuously through 1:01 PM and none of the residents were served margarine with the corn bread. In addition, the only condiment served with the hot dogs was mustard, except for one resident who specifically asked for ketchup. None of the residents were offered or had salt and pepper available. 4. On 02/01/24 two test trays were evaluated by the Dietary Manager (DM), the Regional Dietary District Manager (RDDM) and the surveyor. The first test tray was a regular diet on the 200-hall meal cart and the second test tray was a pureed diet on the 100-hall meal cart. a. On 02/01/24 at 8:38 AM, staff pushed the 200-hall cart down to the 200 hall. On 02/01/24 at 8:52 AM, all the residents had received their meals. The test tray consisting of scrambled eggs, an apple muffin, and juice was evaluated. The temperature of the scrambled eggs was adequately hot; however, the eggs had an unappealing spongy texture. The DM verified the eggs were cooked in the steamer which contributed to the unusual texture. The cranberry juice was cool at 56 degrees Fahrenheit (F); it was not cold. The DM stated the goal for cold beverages was under 41 degrees. b. On 02/01/24 at 9:05 AM, staff pushed the 100-hall cart down to the 100 hall. On 02/01/24 at 9:34 AM, staff came and removed the last resident's tray. The test tray was evaluated at this time. The test tray consisted of pureed eggs, pureed apple muffin, oatmeal, milk, coffee, and apple juice. The pureed muffin was pasty in texture and salty. The RDDM tasted the pureed muffing and agreed the texture was not right. The RDDM stated the texture became gummy if the bread product was pureed too long. The apple juice was cool but not cold at 59 degrees F and the milk was cool but not cold at 56 degrees F. The coffee was lukewarm and bitter; it was 112 degrees F and the RDDM stated coffee should be between 140 - 160 degrees F. 5. During an interview on 02/02/24 at 11:37 AM the Registered Dietitian (RD) stated she completed meal tray assessment audits. One concern was that residents stated the food was not hot enough. The RD stated a lot of the cold foods (beverages, fruits, puddings) she audited were above temperature and were too warm. The RD stated she had suggested to dietary staff to refrigerate cold foods ahead of time; however, this had not been consistently implemented. The RD stated her audits showed the hot food temperatures had improved but the cold food temperatures were a work in progress. During an interview on 02/02/24 at 4:34 PM the Administrator stated the dietary department had been working on cold food temperatures to ensure foods such as fruit and desserts were cold enough when served to residents. He stated the meal tray audits showed mixed results as far as foods being refrigerated the night before and being sufficiently cold when residents received their meals.

17281 21382 46592 Based on record review and interviews the facility failed to have sufficient staff on a 24-hour basis to care for residents' needs, as identified through the facility assessment staff-to-resident ratios and the Payroll Based Journal (PBJ) Staffing Data Report supplied from the Centers for Medicare and Medicaid Services (CMS), resident council minutes, and views from the resident group. Additionally, the facility failed to respond in a timely manner to the needs of six residents (R)1, R44, R59, R33, R50, and R89 reviewed out of a total sample of 22. Findings include: Review of the Payroll Based Journal (PBJ) Staffing Data Report for fiscal year quarter four for 2023 [July 2023 through September 2023] and supplied by CMS revealed the facility triggered for excessively low weekend staffing as determined by information submitted by the facility. Review of the Facility Assessment Tool reviewed 07/24/23 and supplied by the facility, revealed the nurse to resident ratios for different shifts to be 1:15 [nurse to resident] for 7:00 AM to 3:00 PM; 1:23 for 3:00 PM to 11:00 PM; and 1:20 for 11:00 PM to 7:00 AM. The indicated Certified Nursing Assistant (CNA) to resident ratios to be 1:8 for 7:00 AM to 3:00 PM; 1:10 for 3:00 PM to 11:00 PM; and 1:20 for 11:00 PM to 7:00 AM. Review of staffing schedules supplied by the facility for July 2023 through September 2023 revealed multiple weekends with different shifts falling below the intended ratios determined by the facility. In an interview on 02/02/24 at 3:20 PM the CNA-Staffing Coordinator (CNA-SC) stated the information submitted to CMS for the fourth quarter was correct. The CNA-SC stated the ratios determined in the facility assessment are the standard for staffing and the facility strives to meet that standard. The CNA-SC stated there were many call-ins during that time. 1. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/08/23 in the electronic medical record (EMR) under the MDS tab revealed R1 was admitted to the facility on [DATE]. Review of the Brief Interview for Mental Status (BIMS) revealed that R1 was moderately impaired in cognition with a score of 11 out of 15. During an interview on 01/30/24 at 11:27 AM, R1 was observed to be lying in bed in a hospital gown. Her breakfast tray remained on the over bed table which was placed over the bed. R1 stated, Today is supposed to be bingo. R1 stated she wanted to go but was dependent on staff to get out of bed, dressed, and into the wheelchair. R1 stated the staff used the Hoyer lift to get her out of bed which required two staff. R1 stated staff left her in bed when she would like to get up early. R1 stated she woke up early and would like to go to breakfast in the dining room. R1 stated staffing was a problem, especially on the weekends. She stated there was, no one around and there was, not enough staff. R1 stated she had been wet at night and not been changed for the whole night. During an interview on 01/30/24 at 12:59 PM, R1 continued to be in bed in her gown and had been served lunch. R1 stated the staff had not gotten her up or bathed her (bed bath). R1 stated she had informed the staff she wanted to get up to go to bingo this afternoon. 2. Review of the undated Admission Record in the EMR under the Profile tab revealed R44 was admitted to the facility on [DATE]. Review of the quarterly MDS with an ARD of 01/08/24 in the EMR under the MDS tab revealed R44 was intact in cognition with BIMS score of 15 out of 15. During an interview on 01/30/24 at 3:09 PM, R44 stated there were not enough staff, especially on the weekends. He stated his essential needs might be met but there were not enough staff to take care of the details. R44 stated he had waited a long time for his call light to be answered on weekends or at night. He stated at night it was quiet, like a [NAME]. R44 stated staff flitted in and out and were busy with other residents. R44 stated he tried to get his incontinence brief changed by 9:45 PM because if he waited longer, the staff might not come and his brief might not be changed. 3. Review of the undated Admission Record in the EMR under the Profile tab revealed R59 was admitted to the facility on [DATE]. Review of the quarterly MDS with an ARD of 11/10/23 in the EMR under the MDS tab revealed R59 was intact in cognition with a BIMS score of 15 out of 15. During an interview on 01/30/24 at 3:37 PM, R59 stated it was hard to get PRN (as needed) pain medication on the evening shift. R59 stated he asked and asked and had to wait for the night nurse to give it to him, indicating there was not enough staff at night. 4. Review of the undated Admission Record in the EMR under the Profile tab revealed R33 was admitted to the facility on [DATE]. Review of the admission MDS with an ARD of 12/12/23 in the EMR under the MDS tab revealed R33 had a BIMS score of 14 out of 15 indicating she was cognitively intact. During an interview on 01/30/24 at 11:27 AM, R33 stated the facility was, short on help. R33 stated when she used her call light there had been times when she waited an hour for it to be answered. R33 stated, Weekends are terrible and nights. R33 stated she needed staff assistance to change her incontinence brief. R33 stated there was a recent incident in which she had urinated three times in her brief before staff came to change her. 5. Review of the undated Admission Record in the EMR under the Profile tab revealed R50 was admitted to the facility on [DATE]. Review of the annual MDS with an ARD of 11/20/23 in the EMR under the MDS tab revealed R50 was intact in cognition with a BIMS of 15 out of 15. During an interview on 01/30/24 at 10:11 AM, R50 stated the agency nurses were not good and they were not familiar with what her needs were. R50 stated there were delays in getting her seizure medications when the facility was short staffed. R50 stated staffing was more problematic on the weekends. Review of the Resident Council Minutes from June 2023 through December 2023 revealed concerns with staffing. a. June 2023 Resident Council Meeting minutes included the following comments: Nursing: Being shorthanded is a problem, the nurse should tell you what medicines that are in your cup if you ask, and you should receive your list of medications upon request, a resident stated she stays wet too long, low pay is causing staff to leave . some of the new CNAs have attitudes when you try to talk to them, new staff need to know their patients issues, CNAs say they will be back and you never see them again . b. August 2023 Resident Council meeting minutes included the following comments: Nursing: Not enough aides on the floor, Nurses come in and are told to go home, several staff have left . Aides are not coming in to pick up trays and beds are not being made. c. October 2023 Resident Council meeting minutes included the following comments: A resident stated she was giving medication and am medication was very late . On weekends the dining rooms are being closed forcing the residents who enjoy eating in the dining rooms to eat in their rooms. d. Resident Council November 2023 meeting minutes included the following comments: The agency CNAs seem to not know their residents and treat several residents as if they were a burden on 3-11 and 11-7 [shifts] . Agency CNAs will not give their name .No back up on 3-11 shift if someone calls out. Call bells ringing too long. 3-11/11-7. e. Resident Council December 2023 meeting minutes included the following comments: Nursing: 3-11/11-7 call bells ringing too long . Weekends are shorthanded . Resident group meeting was held on 1/31/24 at 10:30 AM where eight of nine residents R42, R50, R55, R61, R67, R73, R77, and R78) stated there was not enough CNAs, licensed practical nurses (LPNs), and registered nurses (RNs) working. The residents stated staff would respond to a call light by entering their room, turn off the light, state they would return, leave the room, and never come back. The group stated the weekends, and the night shift were the worst. 5. Review of R89's Face Sheet located in the EMR under the Profile tab, revealed R89 was admitted to the facility on [DATE] with diagnoses that included dementia and Alzheimer's disease. Review of the MDS located in the EMR under the MDS tab with an ARD of 12/13/23, revealed a BIMS score of six out of 15 that indicated R89 had moderate cognitive impairment and required substantial/maximal assistance for dressing the lower body. Observation on 02/01/24 at 6:30 AM revealed R89 was sitting in a wheelchair in the doorway of her room. R89 was dressed in a shirt and a brief with both legs exposed from the upper thigh to the feet. R89 had a pair of slacks in her hand and asked RN2 if she would take the slacks and dry them. RN2 took the slacks, put them in a plastic bag, and put the bag into a hamper in the closet. RN2 when exiting the room, called out to CNA7 to go in and help the resident. Observation on 02/01/24 at 7:20 AM identified R89 was sitting in a wheelchair in the doorway of her room wearing a brief and her entire legs exposed. R89 was heard asking, Are my pants dry, are my pants dry. Observation revealed RN2 was at the medication cart across from R89's room preparing medications and did not provide any assistance to R89. During an interview on 02/01/24 at 7:45 AM, CNA7 stated she was assigned to provide care to 12 residents on the 600 unit on 02/01/24 for the 11:00 PM -7:00 AM shift. CNA7 stated she heard RN2 ask her to help R89, but she was providing care to the other residents on the unit and could not go to help R89. CNA7 stated she told RN2 she was busy providing end of shift care to the other residents and could not assist R89. CNA7 stated, There was no one else to ask for help. Observation on 02/01/24 at 7:50 AM revealed R89 was sitting in a wheelchair in the doorway of her room with only a brief on and her entire legs exposed. Multiple staff were observed to walk by R89's room without intervening. During an interview on 02/01/24 at 8:30 AM, RN2 stated she asked CNA7 to help R89 to put on new slacks. RN2 stated she did not know CNA7 did not assist R89, RN2 stated she asked CNA7 at least twice to provide assistance to R89 but did not know until later that CNA7 was too busy to assist the resident. During an interview on 02/02/24 at 2:15 PM, the Director of Nursing (DON) stated the nurse should help the CNA when they ask for assistance to provide care to residents. The DON stated RN2 should have reported to the Unit Manager when she came on duty at 6:30 AM that she needed help with getting care completed for residents.

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure elopement risks and wander guard assessments were updated to promote dignity for one Resident (R) 301 of two reviewed for elopement risk and wander guard use. The facility failed to ensure Certified Nursing Assistant (CNA)3 closed the privacy curtain while providing personal care to R39. R39's breasts and brief were exposed to public view. Additionally, R89 was not provided an opportunity for dignity when she sat in her wheelchair, while wearing a brief for over an hour. Findings include: 1. Review of a policy provided by the facility titled Resident Alarms dated 03/14/23 indicated, .It is the policy of this facility to utilize residents' alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so that the resident will be able to attain or maintain his or her highest practicable level of physical, mental, and psychosocial well-being.Wander/elopement alarms-includes devices such as bracelets.The facility shall establish and utilize a systemic approach for the safe and appropriate use of resident alarms, including efforts to identify risk; evaluate and analyze risk. Review of R301's electronic medical record (EMR) titled Admission Record, located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of anxiety disorder. Review of R301's EMR titled admission Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 05/01/23 indicated the resident had a Brief Interview for Mental Status [BIMS] score of 15 out of 15 which revealed the resident was cognitively intact. The assessment indicated the resident did not wander. The assessment indicated the resident was able to ambulate with supervision. Review of R301's EMR titled Elopement Evaluation located under the tab Assessments dated 05/02/23 indicated the resident scored a two which revealed the resident was at low risk for elopement. Review of R301's EMR titled Care Plan located under the Care Plan tab failed to include the resident was at risk for elopement and required the use of a Wanderguard. Review of R301's EMR titled nursing Progress Notes, located under Prog [Progress] Notes tab dated 05/02/23 indicated the resident's elopement score was eight. Review of R301's Psychiatric Consultant Note located under Prog Notes dated 05/15/23 indicated the resident had no elopement attempts. Review of R301's nursing Progress Notes located under the Prog Note tab dated 06/02/23 indicated the resident left at 8:20 AM in her own vehicle and later returned at 8:42 AM. The progress notes revealed the resident left the facility without informing the facility. During an interview on 02/01/24 at 11:12 AM, the Director of Nursing (DON) stated the facility did not use consents for the use of a wanderguard. The DON stated the best she could remember was R301 would leave the facility and not inform the staff. The DON stated the resident then agreed to wear the wanderguard device for approximately two weeks. The Regional Clinical Consultant was present during this interview. During an interview on 02/02/24 at 12:42 PM, the Director of Social Services (DSS) stated the resident was not considered an elopement risk but did have her car parked in the facility's parking lot. DSS stated the resident was alert and oriented and could go and do as she pleased. During an interview on 02/02/24 at 1:54 PM, the DON stated the use of the wanderguard should have been placed in the resident's care plan. A request was made to interview the staff member who determined the use of the wanderguard. No staff member was identified by the end of the survey. 2. Review of a document provided by the facility titled Promoting/Maintaining Resident Dignity dated 03/14/23 indicated .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights.Maintain resident privacy. Review of R39's EMR titled Admission Record located under the Profile tab indicated the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. Review of R39's EMR titled Care Plan located under the Care Plan tab dated 12/13/19 indicated the resident was totally dependent on staff for activities of daily living due to her diagnosis of Alzheimer's disease. Review of R39's EMR titled annual MDS with an ARD of 01/23/24 indicated the resident had a BIMS score of six out of 15 which revealed the resident was severely cognitively impaired. An observation was conducted on 02/01/24 at 5:42 AM, CNA3 was observed to provide personal care to R39 and failed to pull the privacy curtain in the semi-private room. R39 had a roommate (R6) who was up in her wheelchair and facing R39 and CNA3 during the provision of care. R39 had her breasts exposed and observed CNA3 place an adult brief on the resident. During an interview on 02/01/24 at 5:45 AM, Registered Nurse (RN)2 who was also the unit manager for the night shift stated her expectation was for the privacy curtain to be pulled between two residents for privacy and dignity reasons. During an interview on 02/01/24 at 6:06 AM, CNA3 confirmed she did not pull the privacy curtain between R39 and R6. During an interview on 02/01/24 at 6:09 AM, the DON stated the reason why there was a privacy curtain in a semi-private room was to be pulled during the provision of care and this would be her expectation as well. 3. Review of the facility policy titled, Promoting/Maintaining Resident Dignity revised on 03/14/23, revealed, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality .Respond to requests for assistance in a timely manner . Review of R89's Face Sheet located in the EMR under the Profile tab, revealed R89 was admitted to the facility on [DATE] with diagnoses that included dementia and Alzheimer's disease. Review of the MDS located in the EMR under the MDS tab with an ARD of 12/13/23 revealed a BIMS score of six out of 15 that indicated R89 had moderate cognitive impairment. This MDS also revealed R89 required substantial/maximal assistance for dressing the lower body. Review of the Care Plan dated 12/21/23, located in the EMR under the Care Plan tab, revealed R89 had a self-care performance deficit related to limited mobility and required moderate assistance of one member of staff to dress. Observation on 02/01/24 at 6:30 AM revealed R89 was sitting in a wheelchair in the doorway of her room. R89 was dressed in a shirt and a brief with both legs exposed from the upper thigh to the feet. R89 had a pair of slacks in her hand and asked RN2 if she would take the slacks and dry them. RN2 took the slacks, put them in a plastic bag, and put the bag into a hamper in the closet. RN2 did not put another pair of slacks on the resident and did not offer to provide coverage to R89's exposed legs. RN2 when exiting the room, called out to CNA7 to go in and help the resident. Observation on 02/01/24 at 7:20 AM identified R89 was sitting in a wheelchair in the doorway of her room wearing a brief and her entire legs exposed. R89 was heard asking, Are my pants dry, are my pants dry? Observation revealed RN2 was at the medication cart across from R89's room preparing medications and did not provide any assistance to R89. During an interview on 02/01/24 at 7:45 AM, CNA7 stated she was assigned to provide care to R89 on 02/01/24 for the 11:00 PM -7:00 AM shift. CNA7 stated she heard RN2 ask her to help R89, but she was providing care to other residents and did not go to help R89. CNA7 stated she told RN2 she was busy and could not help the resident. Observation on 02/01/24 at 7:50 AM revealed R89 was sitting in a wheelchair in the doorway of her room with only a brief on and her entire legs exposed. Multiple staff were observed to walk by R89's room without intervening. During an interview on 02/01/24 at 8:30 AM, RN2 stated she asked CNA7 to help R89 to put on new slacks. RN2 stated she did not know CNA7 did not assist R89 because she was doing a medication pass and was monitoring a resident after a fall. RN2 stated she asked CNA7 at least twice to provide assistance to R89 but did not know until later she did not assist the resident. During an interview on 02/02/24 at 2:15 PM, the DON stated she would expect staff not to leave a resident exposed in a visible area. The DON stated RN2 and the other staff that were on the unit should have stopped and provided assistance to R89. 17281

Based on interview and record review, it was determined that for two (R57 and R352) out of five sampled residents reviewed for pressure ulcer (PU), the facility failed to ensure PU care, treatment and services, consistent with professional standards of practice, were provided to the residents. For R352, a newly admitted resident who was at risk for developing PUs, the facility failed to ensure that R352 received care to prevent a new left heel PU from developing. R352's left heel PU was identified on 6/25/21 by F1 (R352's POA) and subsequently worsened, which required R352 to be evaluated in the emergency room (ER). R352 was admitted to the hospital and diagnosed with a left heel Deep Tissue Injury (DTI), resulting in harm. For R57, the facility failed to assess R57's sacral PU from 5/20/22 - 6/1/22. Findings include: 10/2019 (revision) - The facility's policy and procedure entitled Pressure Ulcers/Skin Breakdown - Clinical Protocol stated: Assessment and Recognition 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Cross refer F655 Review of R352's clinical record revealed: 6/1/21 - R352 was admitted to the facility for wound care and rehabilitation status post [MEDICAL RECORD OR PHYSICIAN ORDER] . 6/1/21 (untimed) - The facility's admission nursing assessment documented: - R352 was alert and oriented to person and place; - no redness, maceration or breakdown of R352's heels were observed; - a Braden assessment documented R352's score was a 14, which documented that she was a moderate risk for developing a pressure ulcer. 6/1/21 (untimed) - The facility's admission Skin Check documented that R352 had skin breakdown, specifically [CONDITION(S)] on her left thigh and buttocks. There were no PUs identified. 6/1/21 (untimed) - The facility's Bed Rail Evaluation documented that R352 was unable to turn and reposition herself. 6/1/21 through 6/8/21 - Review of R352's clinical record revealed that the facility failed to develop a baseline care plan to address her immediate care needs. 6/8/21 - The admission MDS assessment documented that R352 had [CONDITION(S)] and no pressure ulcers, but she was at risk of developing pressure ulcers. The facility checked the following skin treatments: pressure reducing device for chair and bed; turning and repositioning. R352 required extensive assist of one staff person physical assistance for bed mobility. R352 was dependent with two staff person physical assist for transfers. 6/8/21 - R352 had two care plans initiated: 1. Actual skin breakdown related to scold [CONDITION(S)]. Interventions included: -assess site of impaired tissue integrity and its condition; -consult C1 (Wound Care Consultant Physician); -monitor site of impaired tissue integrity daily and prn (as needed) for color changes, redness, swelling, warmth, pain, or other signs of infection; -provide skin tissue care as needed. 2. At risk for skin impairment related to advanced age and decreased mobility. Interventions included: -assist with general hygiene and comfort measures; -encourage to offload (heels off bed to reduce risk of skin breakdown) heels; -monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD (Medical Doctor); -skin will be assessed on a weekly basis on scheduled bath day and document findings on a weekly skin assessment; -report any skin redness/impaired integrity areas to the nurse; -use a draw sheet or lifting device to move resident; -use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Although the 6/8/21 at risk care plan stated to encourage R352 to offload heels, the facility lacked individualized interventions on how nursing staff could assist with offloading the resident's heels as a preventative measure. R352 required extensive assist of one staff person for bed mobility. 6/10/21 at 9:00 AM - A skin check noted no new pressure ulcers. 6/17/21 at 9:00 AM - A skin check noted no new pressure ulcers. 6/19/21 at 4:45 PM - A nurse's note documented that R352's heels were offloaded. 6/24/21 at 1:28 PM - A skin check noted no new pressure ulcers. 6/25/21 at 11:17 AM - The CNA Documentation Survey Report documented that R352 received a scheduled bed bath. 6/25/21 at 8:00 PM - A eINTERACT SBAR Summary for Providers note documented a change in condition . Resident's (POA) reported that she has noticed a blister on resident's left heel . Provider . recommendations: apply skin prep to blister. R352's clinical record lacked evidence of a description/characteristics of R352's left heel blister and surrounding skin and an immediate intervention to offload the resident's heels. 6/26/21 at 10:35 AM - A physical therapy treatment note documented that R352 was seen at the bedside and noticed R352's left heel blister. The therapist documented that she made nursing aware and to offload BLE (bilateral lower extremities) . There was no evidence that an individualized intervention for nursing staff to assist offloading R352's heels was added to the care plan and consistently implemented. 6/26/21 at 4:45 PM - A nursing note documented that R352's had bilateral lower extremity pitting [CONDITION(S)]. Despite facility nursing staff being notified of R352's left heel blister by F1 (R352's POA) during the evening shift of 6/25/21 and then during day shift of 6/26/21 by the physical therapist, the facility failed to do a thorough assessment of R352's left heel blister. 6/28/21 - R352's Occupational Therapy Discharge Evaluation documented that she had no functional improvement while on therapy caseload and remained maximal assistance for bed mobility. 6/28/21 at 11:14 AM - A physical therapy treatment note documented that R352 had a left heel blister and the resident's heels were offloaded. 6/28/21 at 2:50 PM - A progress note by E26 (NP) lacked evidence of an assessment and plan for R352's new left heel blister identified on 6/25/21. 6/29/21 at 9:45 AM - A progress note by E26 (NP) documented that R352 was seen for a left heel blister and the blister now has a darker appearance and is fluid filled. R352 complained of some tenderness when the skin prep is applied . Increased in size overnight. C1 (Wound Care Consultant Physician) following. Monitor and continue with skin prep. 6/29/21 at 11:33 AM - A nurse's note documented Resident was noted with a big blister on her left heel. E14 (Wound Care Consultant Physician) was consulted about the blister and orders were received to send pt (patient) to ED (Emergency Department) for vascular eval (evaluation). E26 (NP) was notified also F1 (R352's POA). 6/29/21 at 5:45 PM - The hospital record documented that R352 had a left ankle/heel blister and consulted WOC (wound, ostomy and continence nurse). 6/29/21 at 6:02 PM - The hospital record documented that R352 had a doppler ultrasound of her legs, groin and ankles. R352's diagnostic results revealed her left lower extremity had full compression and no blood clots. 6/30/21 at 11:31 AM - The hospital record WOC consult documented that R352 had a left heel DTI presenting as ruptured blister with intact roof. DTI may evolve into open wound. Boggy darker discolored area noted over bony prominence. Patient states that she has not been very mobile for the past month . Skin Care Recommendations: Suspend heels with pillow or Heelzup, Inspect bony prominences & under devices at least Q8hr & PRN, Maintain dry and clean skin, Turn and reposition at least Q2H, Limit sitting intervals to a maximum of 2 hours, Patient unable to shift own weight in chair, reposition Q1H, Elevate head of bed <(less than) 30 degrees unless contraindicated, Maintain sling under patient to move & reposition patient, Pillows between knees to prevent skin to skin contact, Elevate legs, Meplix for prevention . R352's clinical record from her admission on 6/1/21 until her discharge to the hospital on 6/29/2 lacked evidence of offloading the heels until after R352 developed a left heel PU on 6/25/21 and lacked evidence of turning and repositioning for ten (10) shifts, specifically eight (8) night shifts and two (2) evening shifts. 7/2/21 - R352 was readmitted to the facility. 7/2/21 at 6:27 PM - A nursing note documented that R352 had an open area on the left heel and heels were inspected. R352's clinical record lacked evidence of further description/characteristics of her left heel PU upon readmission to the facility. In addition, R352's care plan lacked individualized interventions to address the new left heel PU and for facility staff to assist the resident with offloading the heels. 7/3/21 (untimed) - The facility's Skin Integrity Report documented that R352's left heel was an Unstageable PU, measuring 2.0 cm x 3.0 cm x utd with deep purple/maroon surrounding tissue. 7/7/21 at 8:00 PM - A nursing note documented that R352's heels were offloaded. 7/8/21 - A progress note by E26 (NP) documented that when R352 was recently hospitalized , Hematology was consulted, but not Vascular as they felt it was a blister related to DTI. 7/8/21 at 2:23 PM - A nursing note by E3 (ADON) documented that R352 was seen by C1 (Wound Care Consultant Physician). Wound to left heel assessed, per E14 (Wound Care Consultant Physician) wound presents more as acute vascular injury vs. pressure, resident recently hospitalized for blood clot. Wound measures 6.4 x 7.1 x utd (unable to determine) and is 100% intact purple tissue. Continue skin prep and foam dressing as well as to offload. Despite having been diagnosed with a left heel DTI pressure ulcer and a care plan for being at risk of PUs, R352's clinical record from her readmission on 7/2/21 until her discharge on 7/10/21, lacked evidence of nursing staff providing assistance to offload the heels as R352 required extensive assistance of one staff person with bed mobility. 7/25/21 at 10:16 AM - During an interview, E3 (ADON) and the Surveyor reviewed R352's clinical record and the lack of care plan interventions, specifically offloading the resident's heels. E3 was unable to provide evidence of an initial assessment on 6/25/21 when R352's left heel blister was identified. 7/25/21 at 3:20 PM - Finding was reviewed with E1 (NHA) and E2 (DON) during the Exit Conference. 2. The facility policy on pressure ulcer protocol, last updated 10/2019, indicated in the assessment section, The nurse shall describe and document/report the following: full assessment of the pressure sore including location, stage, length, width and depth, presence of exudates or necrotic (dead) tissue. Review of R57's clinical record revealed: 6/24/21- A Braden scale assessment to determine risk of pressure ulcer development was completed that resulted in a score of 16 indicative of mild risk. The clinical record lacked evidence of subsequent Braden scale assessment completions. 6/6/22 - A quarterly MDS assessment documented R57 was at risk for pressure ulcer development and as having a stage three pressure ulcer. An undated care plan for actual skin breakdown, stage three pressure ulcer to the sacrum [tailbone], included the intervention to complete weekly wound assessments. 7/15/22 1:39 PM - The facility provided wound care documentation of assessments of R57's wound from the initial reopening on 5/11/22 - 7/7/22. The wound care documentation lacked evidence of an assessment from 5/20/22 - 6/1/22. During an interview on 7/18/22 at 9:49 AM, E3 (ADON) stated the wounds were expected to be assessed at least weekly. During an interview on 7/18/22 at 10:22 AM, E3 (ADON) confirmed the findings of absent documentation from 5/20/22 - 6/1/22. Findings were reviewed during the exit conference on 7/25/22 at 3:20 PM with E1 (NHA) and E2 (DON).

Based on interviews, record review and review of facility documentation as indicated, it was determined that for one (R18) out of four residents sampled for accidents, the facility failed to ensure that R18, a dependent resident, was transferred using a hoyer lift with the assistance of two staff members on 8/19/21 as per her plan of care and the facility's hoyer lift policy and procedure. As a result of this incident, R18 was diagnosed with a femur fracture on 8/21/21, resulting in harm to the resident. In response to this incident, the facility implemented corrective actions. Based on the facility's corrective actions, interviews of floor staff and confirmation that no further incidents involving hoyer lifts were identified up to and at the time of the current survey, this deficiency was past non-compliance. Findings include: 5/2021 (last revision) - The facility's policy and procedure entitled, Lift, Mechanical (Hoyer), stated, Purpose: To enable two employees to lift and move a resident safely . Procedure: . 9. One employee stays with and guides resident, other employee moves the lift . Cross refer to F609 R18's clinical record revealed: 8/6/15 - R18 was care planned for being totally dependent for Activities of Daily Living (ADL) care. One of the interventions was that the resident required two person assist for transfers. 5/6/20 - R18 had a physician's order for comfort measures only per family request (No labs, IV's, x-rays). 8/2/21 - The quarterly MDS assessment documented R18 with severe cognitive impairment, a diagnosis of dementia and R18 was dependent on two person assist for transfers. 8/20/21 at 7:16 AM - A nursing note documented, This AM resident presents with swollen R (sic) lateral upper thigh; no redness or elevated temp (temperature) noted from area, resident denies pain except for when leg is moved certain positions . 8/20/21 at 12:00 Noon - A nursing note documented that R18's thigh was assessed noting swelling. Resident denied any pain or discomfort. 8/20/21 at 2:00 PM - A nursing note documented that R18's thigh was assessed. The nurse noted swelling and firmness, but no evidence of pain, redness or elevated temperature to the area. R18 denied any pain. 8/21/21 at 6:49 PM - R18's x-ray result revealed an acute fracture of the left femur (thigh bone). 8/21/21 at 10:34 PM - A late entry nursing note documented, On 8/20/21, at the change of shift, 11-7 nurse notified this nurse of the change to resident's (L) (left) thigh. Site noted with edema, no s/s (signs or symptoms) of pain or discomfort noted. No other changes reported throughout the shift. On 8/21/21, 7-3 shift nurse notified this nurse that a change was noted to the site. Upon assessing the site, redness, warmth and a lump was felt. There was evidence of pain r/t (related to) resident's facial expression. This nurse notified the POA . of the change and if it will be ok to X-ray the site. (POA) (sic) to this nurse that she was in the facility on 8/20/21, she did not notice any changes. She said resident was able to lift both legs with no problem. POA ok to obtain X-ray. Spoke to on call NP . order obtained, Hospice also notified and a nurse was requested to come in and evaluate resident. X-ray ordered STAT. (Name) RN from hospice came in to assess resident, new order to start resident on Roxanol PRN, script was faxed to facility by hospice MD. X-ray done, results shows acute fracture of (L) (left) femur. (POA) was notified of result, POA told this nurse not to send resident out to the hospital. This nurse attempted to convince POA to send resident out because the fracture is acute and appeared painful . POA told this nurse to keep resident in the facility and keep her comfortable and administer pain medication as ordered by MD. On call NP (Name) notified of resident's (sic) response and X-ray result. NP told this nurse to honor POA wishes. Hospice also notified of X-ray result and POA's response. PRN Roxanol was administered. 8/23/21 at 11:08 AM - The facility reported R18's injury of unknown source to the State Agency. The facility documented that R18 presented with a change in condition related to swelling noted at right (sic) thigh area with evidence of pain . STAT X-ray . done. Results were femur fracture. Etiology unknown at this time. Investigation has been initiated. The facility failed to report an alleged violation of injury of unknown source to the State Agency within the required two hours after receiving the x-rays results on 8/21/21 at 6:49 PM. The facility conducted a thorough investigation, which included interviewing and obtaining statements from the staff who worked from 8/18/21 to 8/21/21. There was only one staff person's statement that deviated from R18's plan of care, which was a two staff person assist with a hoyer lift transfer: (undated and untimed) - E32 (agency CNA) documented, On 8/19/21, I (E32's name) came in on 3-11 . When I got to R18's (name) room it was about 9 PM. I started to get R18 undressed in the wheelchair. I went out into the hallway to see if I can (sic) get help with the transfer. No one was around so I waited and went in did another resident and came back. No one was still around . Now it's about quarter to 10 PM so I started to set up the transfer using a hoyer lift. Once, I hooked up all four straps I asked R18 was she ok. R18 said yes so I started the transfer . The transfer was over I unhooked the straps . Based on the facility's thorough investigation, they identified that R18 was transferred by one staff member, an agency CNA (E32), using a hoyer lift. R18 was later diagnosed with a significant injury, a femur fracture. In response to R18's investigation, the facility implemented the following corrections: -Immediately reported E32's (agency CNA) actions to her employer and removed her from returning to work in the facility. -On 9/1/21, in-serviced staff and agency CNAs on the facility's Mechanical Lift policy requiring two staff members. -On 9/24/21, updated the agency orientation document where agency CNAs were required to read and sign the attached copy of the facility's Mechanical Lift policy and procedure. The Agency Orientation document emphasized that ALL mechanical lifts require 2 staff members to operate. No exceptions. -Assigned all staff CNAs an educational video that demonstrated how to use the (mechanical) lifts. 7/21/22 at 1:12 PM - During an interview, E2 (DON) confirmed that there have not been any further incidents involving a hoyer lift with other residents since the 8/19/21 incident with R18. Based on review of the facility's corrective measures, interviews with floor staff during the current survey and confirmation of no further incidents occurring with residents involving hoyer lifts since 8/19/21, it was determined that this deficiency was past non-compliance. 7/25/22 at 3:20 PM - Finding was reviewed during the Exit Conference with E1 (NHA) and E2 (DON).

Based on observations, interviews and review of clinical records, facility and other documentation, it was determined that for two (R28 and R103) out of 27 Stage 2 sampled residents, the facility failed to ensure that a resident who had an indwelling catheter, had a clinical condition which demonstrated that catheterization was necessary; and a resident who was incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible. For R28, the facility failed to ensure that his clinical condition demonstrated that an indwelling catheter was necessary. The presence of the catheter resulted in a CAUTI (catheter associated urinary tract infection) requiring treatment with antibiotics. For R103, the facility failed to comprehensively assess urinary continence in order to attempt to restore as much normal bladder function as possible. Findings include: The facility's policy entitled Catheter: Urinary - Justification for Use, last revised on 1/2/14, stated, Patients who have urinary catheters will be assessed to determine appropriateness for use based on the following criteria: Indwelling: - [MEDICAL CONDITION] that cannot be treated or corrected medically or surgically, for which alternate therapy is not feasible, and which is characterized by (must have all three): documented post void residual volumes in a range over 200 mls, inability to manage the retention/incontinence with intermittent catheterization, and persistent overflow incontinence, symptomatic infections, and/or renal dysfunction; - Contamination of Stage III or IV wounds with urine which has impeded healing despite appropriate personal care for the incontinence; or - Terminal illness or severe impairment which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain . If patient's situation does not meet any of the criteria, notify physician . to obtain order for catheter removal . 1. R28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 11/4/14 nursing admission assessment, R28 was always continent, used the urinal and voided frequently. 11/4/14 - The incontinence history assessment stated that R28 was aware of the urge to void and when he was wet; leaked urine with physical stress (e.g. cough, laugh, sneeze, lift); and had occasional functional incontinence. 11/11/14 - The admission MDS assessment stated that R28 was independent for daily decision making and occasionally incontinent of urine. 4/20/15 - A physician's orders [REDACTED]. 4/20/15 - R28 was hospitalized from [DATE] to 5/6/15. According to hospital records, R28 underwent a CT scan which revealed mild right hydro[DIAGNOSES REDACTED] without evidence of obstruction. 4/24/15 at 8:55 PM - R28's hospital records revealed that urology was consulted to place a 3-way catheter for continuous bladder irrigation for treatment of [REDACTED]. R28 was diagnosed with [REDACTED]. R28 was also treated for [REDACTED]. 5/4/15 at 2 PM - R28's hospital records revealed a urology follow-up progress note that stated R28 was having difficulty with voiding and [MEDICAL CONDITION] after removal of the 3-way catheter and a new catheter was placed. Since the new catheter was placed, R28 was having persistent hematuria and the plan was for R28 to have a cystoscopy. R28 was discharged from the hospital before a cystoscopy was performed. 5/6/15 - R28 was readmitted to the facility with an indwelling catheter and [DIAGNOSES REDACTED]. 5/6/15 at 10:11 PM - A nurse's note stated that R28 denied urinary incontinence, had [MEDICAL CONDITION] and hematuria while in the hospital and was readmitted with an indwelling catheter with an order to leave the catheter in place until he was seen by the urologist. 5/7/15 - A physician's orders [REDACTED]. 5/7/15 - R28 was care planned for the indwelling catheter due to hydro[DIAGNOSES REDACTED]/acute kidney injury with hematuria and [MEDICAL CONDITION]. The goal was that R28 would have no signs and symptoms of urinary tract infection for 90 days. R28's care plan approaches included: monitor for signs and symptoms of infection and fever and report to physician, monitor urine and report to physician promptly for sediment, blood, odor, cloudy, and assess continued need of catheter. 5/7/15 - R28 was care planned for at risk for complications of infection related to UTI. 5/11/15 at 3:07 PM - A progress note stated to continue the catheter as R28 has urology follow-up appointment. 5/13/15 - A progress note stated that R28 was status [REDACTED]. 5/13/15 - The quarterly MDS assessment stated that R28 was moderate cognitively impaired, had an indwelling catheter, and [DIAGNOSES REDACTED]. 5/29/15 - A progress note stated that R28's UTI was resolved, hydro[DIAGNOSES REDACTED] and AKI was better and continue catheter for [MEDICAL CONDITION] bladder. 6/3/15 at 10:21 AM - A progress note stated that R28 had a catheter for [MEDICAL CONDITION]. 6/10/15 - A urology consultation report stated, Findings: . hospitalized recently for pneumonia. Patient likes to be on catheter because doesn't like to be on diaper. Most probably has [MEDICAL CONDITION] bladder and functional. Diagnosis: [REDACTED]. Consider GU ([MEDICAL CONDITION]) workup if desires to have catheter removed although he still could be functional secondary to [MEDICAL CONDITION]. 6/10/15 at 2:15 PM - A nurse's note stated that R28 was seen by the urologist, ordered to change catheter every month, follow-up as needed and E4 (MD) reviewed the urologist consultation orders. 6/29/15 - A progress note stated that R28 was using PRN Tylenol frequently for chronic pain on his left side even though R28 was receiving [MEDICATION NAME] three times a day for pain. Routine Tylenol was added to R28's daily pain control regimen. 6/29/15 - A physician's orders [REDACTED]. 7/11/15 at 2:47 PM - A nurse's note stated that R28's indwelling catheter was changed. 7/15/15 - A physician's orders [REDACTED]. 7/16/15 at 6:05 AM - A nurse's note stated, resident is still complaining of burning on urination, urine obtained . medicated with Tylenol 650 mg for generalize (sic) pain . urine color is yellow with some odor . TEM (temperature) 98.5. It was unclear from the nursing assessment what burning on urination meant as urine was continuously drained from the bladder through the catheter. 7/16/15 at 1:58 PM - A nurse's note stated that R28's UA result was received, MD was notified and ordered to wait for the C&S. R28 and his POA were notified too. 7/17/15 - R28 was care planned for at risk for complications of infection related to UTI. The goal was the infection will be resolved within 10 days. 7/17/15 at 11:06 AM - A nurse's note stated that while R28's C&S was still pending, his POA requested if the MD could start R28 on an antibiotic. Orders were received to start R28 on [MEDICATION NAME], an antibiotic, for 3 days pending the C&S. R28 received his first [MEDICATION NAME] dose on this shift. 7/17/15 - A physician's orders [REDACTED]. 7/20/15 - R28's urine C&S results were received by the facility which revealed that the current antibiotic ordered was not effective against the organisms identified in the urine culture. 7/20/15 - A physician's orders [REDACTED]. 7/20/15 at 10:36 PM - A nurse's note stated that R28 was diagnosed with [REDACTED]. 7/20/15 at 11:22 PM - A nurse's note stated that R28 had a UTI, complained of slight pain in his penis, cloudy urine was observed during the 3-11 PM shift and the MD and POA were notified. 7/21/15 at 2:04 PM - A nurse's note stated that R28 complained of all over pain including the tip of his penis. 7/21/15 at 10:25 PM - A nurse's note stated that R28's catheter was draining freely with cloudy colored urine and his temperature was 97.9 degrees F. 7/22/15 at 3:02 PM - A nurse's note stated that R28 continued on antibiotic for UTI, temperature was 97 degrees F and he had no complaints of pain when urinating. 7/27/15 - A progress note stated that R28's history of present illness included [MEDICAL CONDITION] bladder with catheter and currently on the antibiotic [MEDICATION NAME] for a UTI. 8/10/15 at 2:47 PM - A nurse's note stated that R28's catheter was changed and blood was observed on the tip of R28's penis. R28 denied pain at the time but told the nurse that he feels pain occasionally when he urinates. R28's record lacked evidence if the nurse's observation of blood and R28's complaint of pain when urinating was communicated to the MD. 8/13/15 - The quarterly MDS assessment stated that R28 was cognitively intact and had an indwelling catheter and [DIAGNOSES REDACTED]. 11/11/15 - The annual MDS assessment stated that R28 was cognitively intact, had an indwelling catheter and [DIAGNOSES REDACTED]. 1/12/16 at 11:32 AM - In an interview, R28 stated that the indwelling catheter was for pure convenience and the catheter hurts. When asked if R28 knew about the risks of an indwelling catheter, such as a CAUTI, R28 did not recall but stated that he had a UTI. R28 also stated that he used to use a urinal but it would spill in his bed. 1/13/16 at 8:39 AM - In an interview, E3 (MD) agreed that a urology follow-up should have occurred. E3 stated that she spoke to R28 about the risks of the indwelling catheter but the conversations were not documented in R28's clinical record. 1/13/16 - A progress note stated that R28 had no signs or symptoms of UTI and he agreed to discontinue the catheter and participate in a voiding trial. 1/13/2016 at 12:43 PM - A nurse's note stated that R28 was seen by the MD and received a new order to discontinue the catheter. 1/13/16 - A physician's orders [REDACTED]. The facility failed to ensure that R28, a resident who had an indwelling catheter, had a clinical condition which demonstrated that catheterization was necessary and resulted in a CAUTI requiring treatment with antibiotics. Findings were reviewed with E1 (NHA) and E2 (DON) on 1/13/15 at approximately 1:30 PM. 2. The facility policy titled Continence Management, last revised 1/2/14, stated The Urinary Incontinence Assessment .and the Three-Day Continence Management Diary .will be completed if the patient is incontinent upon admission or re-admission .Purpose: To provide appropriate treatment and services .restore as much normal elimination function as possible .Practice Standards 1. Identify patient's continence status and need for management by reviewing the nursing assessment. 2. If patient is incontinent: .2.1 Complete Urinary Incontinence Assessment .2.1.1 Address transient causes for incontinence. 2.1.2 Initiate Three-Day Continence Management Diary if incontinence is not resolved . R103 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Nursing Assessment, dated 10/26/15, stated R103 had urinary incontinence and that a toileting program was not currently being used to manage the resident's urinary continence. There was no evidence the Urinary Incontinence Assessment or the Three-Day Continence Management was completed at this time. The facility failed to comprehensively assess R103's urinary incontinence on admission. On 11/2/15 an expanded Nursing Assessment was completed and stated that R103 was frequently incontinent of urine, the incontinence was not of new onset, current toileting methods included use of the bathroom and/or bedpan, and that a trial of a toileting program had not been attempted on admission or since urinary incontinence was noted in this facility. An admission MDS assessment, dated 11/2/15, stated R103's daily decision making skills were moderately impaired (decisions poor; cues/supervision required) and that she required extensive assist of two (2) staff for transfer and toilet use. The 11/2/15 MDS also identified R103 as being frequently incontinent of urine and stated that there was no trial of a toileting program attempted since admission to the facility. On 11/5/15 a care plan was initiated for the problem of incontinence and stated the goal was to have incontinence care needs met by staff. The care plan's interventions lacked any individualized toileting plans. On 12/8/15 a Urinary Incontinence Evaluation was completed. The evaluation stated to initiate a Three-Day Continence Management Diary. The clinical record revealed a Three-Day Continence Management Diary was initiated on 12/9/15. Review of the diary revealed it was incomplete with only one (1) entry on 12/9/15 from 7 AM through 11 PM, and no entries on 12/10/15 from 7 AM through 11 PM. The data was completed for 12/11/15. The facility failed to accurately and fully complete the 3 day diary in order to identify R103's voiding patterns and develop an individualized toileting schedule. During an interview on 1/13/16 at 11:15 AM, E6 (CNA) stated R103 was able to transfer to the toilet with the assist of two (2) staff and that she does on occasion ask to use the bathroom, but is usually already wet. E6 stated that R103 was not on a scheduled toileting plan and she (E6) tries to toilet her regularly. On 1/13/16 at 3:05 PM, E7 (RN/UM) was interviewed. E7 stated that any resident admitted with incontinence should have a urinary incontinence evaluation completed, a 3 day voiding diary completed, and an individualized toileting plan developed based on results of the voiding diary. E7 reviewed the Three-Day Continence Management Diary initiated on 12/9/15, confirmed it was incomplete and stated that when it is completed she is to receive it in her box, review it and sign off on it. E7 stated it apparently was not put in her box because it was never fully completed, someone just put it in the chart. The facility failed to comprehensively assess R103's incontinence, failed to complete a 3-day voiding diary, and failed to develop an individualized toileting plan. The facility failed to provide appropriate care and services to restore as much normal bladder function as possible. On 1/13/16 at 3:25 PM, findings were reviewed with E2 (DON).

Based on record review, observation and interview, it was determined that the facility failed to ensure that 3 residents (R22, R41 and R74) out of 38 stage 2 sampled, received adequate supervision to prevent accidents and that the resident's environment remained as free from accident hazards as was possible. R22, a cognitively impaired and non-compliant resident, was left alone sitting in a recliner where it was not easy to observe him, had an unwitnessed fall from his recliner and sustained a pelvic and hip fracture, bruise on the forehead and skin tear on the right forearm that required hospitalization . R41 sustained fractures of two toes when an unsecured oxygen tank in her room fell on her right foot. R74 who had a urinary tract infection (UTI) had a fall on 7/20/13 when he was lowered to the ground by a family member who was unable to get him into a family car without staff assistance and supervision. Additionally, there was no evidence that R74 was assessed by Physical Therapist (PT) for safe transfer by a family member. Findings include: The facility's policy and procedure entitled, "Resident Safety and Prevention of Accidents" and the Fall Prevention Policy dated 11/30/10 were reviewed. 1. R22 was admitted to the facility with [DIAGNOSES REDACTED]. According to R22's admission Minimum Data Set (MDS) assessment dated [DATE] this resident's cognitive skills for daily decision-making were severely impaired. R22 needed an extensive assistance/total dependence on staff for surface to surface transfers, bed mobility, bathing and all other activities of daily living. R22 was non-ambulatory and confined to the chair. R22 was assessed as a high risk for falls and had several unwitnessed multiple falls (9 falls) from 3/1/13 to 5/14/13 with and without injuries. The facility initiated a care plan on 3/1/13 entitled "High risk for falls related to unaware of safety needs, confusion". The goal stated, "...will not sustain serious injury through the review date (9/26/13)". The care plan interventions included, "I need a safe environment with: floors free from spills and/or clutter; position at night; personal items within reach; ...chair/bed electronic alarm. Ensure the device is in place as needed; ...PT (Physical Therapy) evaluate and treat as ordered or PRN (as necessary); ...Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes." On 3/4/13 and timed 12:30 AM during the 11-7 AM shift, R22 was found kneeling on fall mat holding onto bed with the wheelchair placed next to the fall mat. R22 sustained 5 small abrasions to the 2nd toe of his right foot secondary to bumping the wheelchair with his foot. According to R22, he slipped and fell when he got out of bed to go to the bathroom. R22 removed his night gown to which the tether alarm (pull string alarm) was attached. The wheelchair that was left next to the fall mat created an accident hazard within R22's environment. The falls that occurred on 3/1/13, 3/02/13, 3/4/13, 3/06/13, 3/7/13, 3/15/13 were unwitnessed and appeared to be the result of R22's attempts to get out of bed. R22 was found on the floor/floor mat. Despite of these 6 falls, there was no evidence of Physical Therapy's involvement to evaluate and treat R22 in relation to these falls and in accordance with this resident's care plan. On 3/22/13, the facility revised R22's care plan and included the intervention of "Every 30 minutes checks" and on 4/2/13 initiated the intervention "placing the pressure sensitive alarms under his shoulders (ensure the alarm is attached to the bed-ensure the box is out of the patient's reach)". An incident report dated 4/20/13 stated, "Resident was found on the hallway floor, face down at 9:15 PM. Resident's alarm was ringing. resident sustained [REDACTED]." Review of P2's (attending Physician) History and Physical note dated 04/21/13 revealed that R22 had "right leg pain post fall...Because of the fact that the patient is on a blood thinner medication Coumadin 2 mg (milligram), he was sent to (name of hospital) the Emergency Department for evaluation." In the ER the CAT (Computerized Axial Tomography/uses computer-processed X-Rays to produce detailed pictures or 'slices' of specific areas of the body) scan of the pelvis, revealed that R22 was found to have "multiple pelvic and hip fracture" and was admitted to the hospital. In an interview with E31 (RN) on 8/6/13 at 3:25 PM, she stated that she saw R22 at 9:10 PM on 4/20/13 prior to going to her assigned care area, the 600 hallway unit, sitting upright in a recliner which was parked at the hallway adjacent to the location of the Activity room. E31 also stated that R22 was not visible from the nursing station but audible (alarm could be heard). Although, R22 had a personal alarm to help monitor his activities, this does not eliminate the need for adequate supervision. E31 stated that she was not aware if nurses were present in the nursing station at that time since they were around passing medications to residents on the 400 wing and 500 wing of the unit and E31 was in the 600 wing which was not within view of R22 and/or staff. E31 ran from the 600 hallway toward the resident (R22) when she heard the alarm ringing and found R22 on the floor. On 8/7/13 at approximately 11:00 AM, it was observed that the distance from the door of the Activity Room to the nursing station was approximately 25 feet. Half of the nursing station has a wall that blocked the view of the hallway from the nursing station. Consequently, R22 was left alone sitting upright in a recliner in the hallway without consistent staff supervision. R22, a cognitively impaired resident was placed in an area where it was not easy to observe him. The facility failed to ensure that R22, a cognitively impaired and non-compliant resident, was not left alone sitting in a recliner where it was not easy to observe him in violation of facility policy requiring "cognitively impaired residents to be in an area where it is easy to observe them". This finding was acknowledged by E1 (Administrator) on 8/7/13 at approximately 10:15 AM. Additionally, this was discussed with E1 (Administrator) and E2 (Acting Director of Nursing) on 8/7/13 at approximately 3:00 PM. 2. R41 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of R41's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed R41 was independent with daily decision making. The facility initiated a care plan for R41 on 8/8/12 for Oxygen Therapy with an approach that stated to provide R41 with oxygen via nasal prongs continuously. She uses a concentrator and oxygen tank when ambulating and out of bed. A nurse's note dated 7/12/13 and timed 2:47 PM stated that an oxygen tank fell on the resident's right foot. There was a small hematoma (bruise) at the site. The leg was elevated and ice applied. R41 had a complaint of pain and was medicated with routine pain pills (Tylenol). It was effective. Review of physician's orders [REDACTED]. Review of R41's x-ray report dated 7/12/13 and timed 8:32 PM revealed, fracture involving right fourth and fifth toes. The facility incident report and investigation was reviewed. R41 was interviewed by the facility on 7/12/13 and her statement included, she was in her wheelchair and moved toward the window. There was an oxygen tank standing up unsecured between the radiator and the oxygen concentrator. One of the wheels on the wheelchair hit the oxygen tank, causing it to fall over and onto the arch of her right foot. R41 stated, "I should have reported it to a nurse or somebody then. I feel I'm somewhat to blame, but I feel it shouldn't have been left on the floor". R41 was not hospitalized although x-rays were completed which confirmed a fracture of two toes on her right foot. The facility follow-up report to the state agency dated 7/19/13 was reviewed. This report stated that an unsecured oxygen tank sitting between the resident's oxygen concentrator and the air conditioning unit was accidently bumped by the resident's wheelchair as she was maneuvering in her room. The tank fell on her right foot and caused bruising and swelling. Upon investigation by the facility they were able to determine who left the tank in the resident's room. The nurses aides and therapy department were educated on the safe handling of oxygen tanks. An audit was done of all resident's on oxygen therapy for safe tank placement (secured in holders). Interview on 8/6/13 at 11:15 AM with R41 stated, "The oxygen tank had been in my room for two to three days". The facility failed to properly secure an oxygen tank to reduce an accident hazard for R41 which resulted in fractures to two toes when the unsecured oxygen tank fell on her right foot. Findings were confirmed with E2 (Director of Nursing/DON) on 8/5/13 at 1:00PM. 3. R74 had a fall on 7/20/13 when a family member was taking the resident out. The family member attempted to transfer R74 to the car but was unsuccessful resulting in a fall. The Fall Risk assessment, dated, 7/14/13, stated that R74 had a moderate fall risk. Review of the quarterly Minimum Data Set (MDS) assessment, dated 7/16/13, revealed that R74 had memory issues and required extensive assistance or 2 or more persons to transfer. Additionally, his balance during walking and transfers was unsteady, requiring physical assistance of another person to steady himself. The internal incident report, dated 7/20/13 for R74's fall, had a written statement by E5 (Registered Nurse/RN) in which E5 stated that the root cause (The most basic cause or causes that can reasonably be identified that management has control to fix and, when fixed, will prevent or significantly reduce the likelihood of occurring again.) of the incident was, "Generalized weakness of resident. Family member's lack of training on how to safely transfer persons c (with) impairments (partial or complete loss of or loss of the function of, a body part, organ, or system)." Review of the nurse's note, dated 7/20/13 at 7:43 PM, revealed that R74 was taking an antibiotic for a urinary tract (bladder) infection. During the 7 AM to 3 PM shift, he was to go out with a family member. When the resident began to fall, R74 was lowered to the ground by the family member at 2:15 pm. He denied pain and was transferred back into the wheelchair by physical therapy staff via a hoyer lift ( a mechanical lift used for transfer).The care plan entitled, "At Risk for Falls", developed on 7/21/13 and last revised on 7/30/13, had two goals that the resident's safety will be maintained and that the resident will remain free of injuries from falls. Interventions included: The bed in the lowest position; The bed wheels in the locked position; Educate resident in safety awareness and remind to call for assistance; Ensure adequate lighting; Fall Risk (assessments); Keep the call light and most frequently used items within reach; Maintain room and pathway free of clutter; Remind the resident to use the call light for assistance; Shoes well fitting with non-skid soles.On 7/23/13, R74's physician ordered an ultrasound of the right leg due to edema to rule out a blood clot as well as an x-ray of the right knee and lower leg due to trauma/fall and a history of right knee surgery. The results were negative except to show that R74 had arthritis (Inflammation of a joint, usually accompanied by pain, swelling, and stiffness, and resulting from infection, trauma, degenerative changes). The Physical Therapy (PT) department evaluated R74 on 7/23/13, after his fall due to complaints of pain in the right knee. The evaluation indicated that skilled physical therapy was warranted. A written statement by E33, entitled the "Supervisor Conclusion and Action Plan", dated 7/30/13, stated, ... "The resident was not assisted correctly by family member. They should of asked the family (meaning the family should have asked) for assistance with transferring the resident.On 8/5/13 at 2:40 PM, in an interview, E27 (Certified Nurse Aide/CNA) stated that R74 had a walker since he was able to transfer by standing and turning to sit. However, E27 also stated that when R74 had knee complaints that he was transferred by the standup lift, a mechanical lift. On 8/5/13 at 3:38 PM, in an interview, E28 (RN) stated that the fall on 7/20/13 occurred when R74's family member transferred the resident. The plan was to go out for a ride to take care of some family business. E28 stated that R74 lost his footing during the transfer to the vehicle and was lowered to the ground. E28 stated she was paged and went out along with the therapist to assist. R74 was transferred back to his wheelchair using a hoyer lift (mechanical lift) with three person assisting. On 8/5/13 at 4 PM in an interview, R74 stated that his grandson was going to take him out to see family. When he tried to get into the car, however, his right leg gave out. Since he was only able to hold on with one hand, his right hand, and his family member was not able to hold him, R74 stated that his family member lowered him to the ground. R74 stated that his right leg hurt but was better now. Also, R74 stated that he was having therapy now and that the therapy department was working mostly on his right leg to strengthen it. On 8/7/13 at 10:38 AM, in an interview, E29 (Rehabilitation (therapy) office coordinator) reviewed all of E30's (Physical Therapist) notes from 1/11/12 through 8/7/13. E29 stated that there was no evidence that the facility had the resident, R74, assessed by the PT department with regards to safe transfers by family members to leave the facility with them.On 8/7/13 at 10:47 AM, during an interview with E1 (Administrator) and E2 (Director of Nursing/DON) E30 called and was placed on speaker phone. E30 stated that the incident with R74 occurred (7/20/13) when his family member tried to transfer him to the car and the resident was lowered to the ground next to the car. E30 stated, "I can't tell you if he was assessed (safe transfers by family member) but if so it was not recently. I saw him multiple times getting into the car, I did not do an assessment at those times. If there was any assessment done, it would be in the PT progress notes". E2 then stated to E30 that E29 looked through all of his PT progress notes and there was no assessment. E1 and E2 also acknowledged the findings.The facility failed to ensure that R74 received adequate supervision to prevent accidents when the resident fell on [DATE]. There was no evidence that R74 was assessed for safe transfers by a family member to take the resident out in the car. On 8/7/13 at 10:47 AM, findings were confirmed by E1, E2 and E30.

Based on observation, record review, interviews, and review of facility policy, it was determined that the facility failed to maintain acceptable parameters of nutritional status such as body weight for one (R78) out of 38 Stage II sampled residents. R78 had a 6.15% (percent) severe weight (wt) loss within one month after admission to the facility. Findings include: The facility's policy entitled, "Nutrition Standards", last reviewed and updated on 12/21/12, had the purpose, "...To ensure the nutritional needs of the resident are assessed and interventions are implemented as needed". Standards included, "Each resident is weighed within 24 hours of admission or re-admission, and then weekly for the next four weeks ... Any resident who has a weight variance of +/- (more than or less than) 3 pounds from the previous weight will be re-weighed within 72 hours to verify the weight change ..." R78, a [AGE] year old, was admitted to the facility on [DATE] following surgical repair of a left [MEDICAL CONDITION]. According to the weights on the facility's computerized program, R78's admission weight (wt) on 6/20/13 was 130 pounds. The admission "Nutrition Assessment", dated 6/23/13, noted R78's diet as regular. R78's usual body weight was listed as between 130 to 140 pounds. E9 (Registered Dietician) noted, "Diet order...appropriate; Will need to add nutrition supplement to help provide additional kcal (calories) /protein for wt maintenance/repletion (A state of being fully supplied.); Nutritional dx (diagnosis): Inadequate po (oral), amount of food; Nutritional goals: improve wt back closer to usual body wt range - 130-140# (pounds); Maintain po intake average > (greater than) 50% (percent); skin intake; adequate hydration; improve surgical wound site; provide nutrition supplement." On 6/24/13, R78 was weighed at 125 pounds; a 5 pound weight loss in 4 days. There was no evidence that the resident was re-weighed within 72 hours as per the facility's policy. The Care Plan, developed on 6/26/13 and last revised on 7/18/13, noted a nutrition and/or potential nutrition problem related to significant weight loss; inadequate oral intake; and, a surgical wound site from a surgical repair of a [MEDICAL CONDITION]. The care plan goals included: Maintain average oral intake greater than 50%; Improve surgical wound site; Improve weight back closer to usual body weight of 130-140 pounds. Interventions included: Provide nutritional supplement of Resource twice a day; Provide, serve diet as ordered. Monitor oral intake and record each meal; Weigh weekly for the first month, then monthly and assess weight changes and report to physician as needed. Review of the admission "Minimum Data Set" (MDS) assessment, dated 6/27/13, revealed that R 78 was an alert and oriented resident who had lost weight and was not on a physician/doctor prescribed weight loss program. On 6/28/13: E9 (Registered Dietician) wrote a nutrition note at 11:19 AM stating that meal consumption was fair (51-75%) and that the plan was to order a nutritional supplement twice a day. R78's physician ordered Resource twice a day. E9 wrote a nutrition note at 12:31 PM stating that the pharmacy could not process the order due to R78's allergy to one of the ingredients. E9 spoke to the resident who agreed to a milkshake supplement at dinner time. On 7/1/13, R78's weight was 126 pounds. On 7/2/13: A nutrition note written by E9 at 12:30 PM stated that P1 (Nurse Practitioner) was notified of the resident allergy but ordered the Resource 2 times per day anyway and discontinued the milkshake. Review of the physician orders for R78 revealed that the facility failed to write the verbal order for Resource and they failed to write to discontinue the milkshakes. There were no physician orders written for R78 on 7/2/13. On 7/8/13, R78's weight was 124 pounds. On 7/8/13, R78's progress note stated that the resident had mild swelling in the left ankle but, "Not enough to give diuretics" (Medications used to rid the body of extra fluid). On 7/15/13, R78's weight was 123 pounds. On 7/17/13, a physician's order was written to discontinue the vanilla milkshake on the dinner tray, to add Resource twice a day and that nursing had spoken with the P1 on 7/2/13 regarding allowing the supplement despite an allergy to [MEDICATION NAME]. On 7/18/13 8:40 AM, E9 noted in the nutritional notes, "...Wt (weight) decrease over past 30 days which triggers as significant. (actually is a severe weight loss) Some of weight loss may be fluid related - noted w LLE (Left lower leg) but do feel r/t (related to) inadequate intake. During initial Nutritional Assessment on 6/28 resident expressed that she hadn't been very hungry, which started during her hospital stay, and po (oral) intake on Regular diet has been averaging 64%. Discussed w (with) resident at initial visit the idea of adding a nutritional supplement: Resource 2.0 and resident was agreeable. Nsg (Nursing) reported to RD (Registered Dietician) that based upon allergy to [MEDICATION NAME] this product could not be ordered so RD changed order to Vanilla Milkshakes, but then next morning Nsg spoke with NP (Nurse Practitioner) and verbalized that the Resource could be given to resident - resident had Boost (similar product) in hospital with no reaction. This verbal order was never written in chart and RD yesterday wrote to allow for supplement ... " On 7/22/13, R78's weight was 122 pounds. R78 had lost 8 pounds since admission, a severe weight loss of 6.15% in one month from 6/20/13 to 7/22/13. On 8/2/13 at 8:38 AM, an observation of R78's breakfast tray was made and revealed that the resident had a meal ticket that stated she was on a regular diet. R78 had eaten eggs and potatoes and drank juice but did not eat hot cereal or drink any milk. On 8/2/13 at 8:40 AM, in an interview, E26 (Certified Nurse Aide/CNA), stated that the resident's intake varied. For breakfast today she ate 75%. E26 further stated that if the resident ate well for breakfast then she would eat less for lunch and vice a versa. On 8/5/13 at 12:45 PM, in an interview, R78 stated that she had a fall, broke her left hip and had surgery with 2 pins placed in the hip .R78 stated that she still has no appetite and that she did lose weight. R78 further stated that she did take Resource but when she gets it right before a meal especially at dinner then she is too full to eat dinner. R78 was observed and had no lower leg swelling. On 8/5/13 at 1:55 PM, in an interview, P1 stated that when she gets a call or is asked for supplement she will give the okay for the order. She reviewed the order of 7/17/13 which noted that nursing spoke with her on 7/2/13 regarding allowing the supplement despite the allergy to [MEDICATION NAME]. P1 confirmed the findings that she gave the verbal order on 7/2/13 for Resource. On 8/5/13 at 3 PM, in an interview, E9 confirmed the findings that the facility failed to provide Resource twice a day for the 15 days. E9 stated that additional factors related to R78's severe weight loss included, "Advanced age, not wanting to eat and not wanting to try other things". On 8/6/13 at 8AM, an observation was made of R78 in her room, seated in a wheel chair with her feet on the foot rests. There was no [MEDICAL CONDITION] observed in her legs. The resident had her breakfast tray and was just beginning to eat it. The meal ticket again stated that R78 was on a regular diet. On 8/6/13, at approximately 9:00 AM, the resident had eaten 100% of her breakfast meal. Review of the June 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the July 2013 MAR indicated [REDACTED]. Further review revealed that R78 did not receive Resource for the period of 7/2/13 PM through 7/17/13 PM despite a verbal order given on 7/2/13. R78 did not receive the supplement for 15 days or 30 missed administrations. The facility failed to ensure that R78 maintained acceptable parameters of nutritional status, such as body weight when she had a severe weight loss in one month after admission to the facility. In an interview with E1 (Administrator) and E2 (Director of Nursing) on 8/6/13 at 10:20 AM, they acknowledged the severe weight loss. E1 and E2 confirmed that the order for Resource was not written on 7/2/13 and that the facility failed to administer the supplement twice a day for 15 days. In addition, E2 confirmed that R78 did not receive the ordered milkshakes from 6/28/13 - 7/17/13.

Based on observation, record review, interview, and review of facility policy and procedure, it was determined that the facility failed to maintain acceptable parameters of nutritional status such as body weight for one (R7) out of seven (7) residents sampled. The facility failed to monitor R7's oral intake, failed to reassess the interventions and failed to identify a weight loss on 10/1/13. Findings include: The facility policy entitled "Nutrition Standards," updated September, 2013 stated, "...2. Residents are weighed monthly unless the team determines a different schedule based on assessment...3. Any resident who has a weight variance of +/- (plus/minus) 5 percent (%) from the previous weight will be re-weighed within 24 hours to verify the weight change....9. Residents are assessed and reviewed by the nutritional risk committee when they meet one or more of the following criteria: Weight change of 5 percent (%) in 30 days, 7.5% in 90 days, 10% in 180 days; Trending weight loss (Insidious weight loss) or gain, even if desired...10. The weight report is printed at least monthly and reviewed by the RD (Registered Dietitian). The RCM (Resident Care Manager/Unit Manager) reviews weights monthly to identify residents with gradual or significant weight change trends and refers to the Nutrition at Risk Committee..." R7 was admitted to the facility in 2011 with [DIAGNOSES REDACTED]. The 9/12/13 Minimum Data Set (MDS) assessment stated R7 had short and long term memory problems and was moderately impaired (decisions poor; cues/supervision required) for daily decision making skills. This same MDS stated that R7 required supervision (oversight, encouragement or cueing) and setup (cutting of food, opening containers, etc.) help only when eating. A care plan for "The resident has nutrition problem and/or potential nutrition problem r/t (related to) prior h/o (history of) decreased intake..." was initiated by the facility on 2/22/13. The goals of this care plan included, "The resident will improve po (by mouth) intake > (greater than) 50% of meals daily" and "The resident's weight will remain stable without any significant weight changes, Goal to keep weight within 115-127# (pounds)." Interventions included: monitor for supplementation if weight continues to drop and oral intake not showing signs of improvement; provide/serve diet as ordered and monitor intake and record q (every) meal; Weigh monthly and analyze for weight loss/gain - assess changes and report to physician as needed. Review of the monthly physician order [REDACTED]. R7 was receiving a regular diet (no changes to consistency/no restrictions). The electronic record revealed that on 9/3/13, R7 weighed 136.7 pounds (lbs). A progress note, dated 9/24/13 and timed 1:52 PM, completed by E4 (Registered Dietitian) stated, "Nsg (nursing) reports resident throwing meal trays in the trash and concerned with po intake. Documented po intake for the past week 48% which shows a decrease from the last quarterly review on 9/12 (2013) which reported average intake of 73%. Current weight 136.7# does fall above goal weight range and noted with increase of 10 lbs. over the past year...Will continue to monitor behavior, po intake and weights and ask Nsg staff to remove food trays once she has finished her meal." There were no new interventions implemented at this time when it was noted that R7's meal intakes had declined. Calculation of R7's meal intakes (entered into an electronic record by Certified Nurse's Aides/CNAs) from 9/24/13 through 9/30/13 revealed an average intake of 50%, a decline from the above noted 73% on 9/12/13. Review of the electronic record revealed that R7's weight on 10/1/13 was 130.3 lbs, signifying a weight loss of 6.4 lbs in one (1) month (28 days) or 4.68%. The facility did not complete a re-weight at this time, as their policy stated that weight changes of 5% required a re-weight for verification. The clinical record lacked evidence that anyone had identified or addressed this 6.4 lbs. weight loss. On 10/9/13, the facility implemented a new policy entitled, "Weight and Nutrition Monitoring." This policy stated "Any resident who has a weight variance of 5 pounds (as opposed to the previous policy stating 5%) from the previous weight will be re-weighed within 24 hours to verify the weight change. Calculations of R7's meal intakes from 10/1/13 through 10/23/13 revealed an average intake of approximately 43% (42.9%). This was below the care plan's goal for R7 to consume greater than 50% of her meals daily. Although the CNAs were documenting the daily meal intakes, there was no evidence that the facility was monitoring and analyzing these intakes in order to identify declines and to implement new interventions in an attempt to prevent further weight loss. Despite E4's 9/24/13 progress note that R7's intakes had declined below her desired goal of greater than 50% at meals, there was no evidence that monitoring and analysis was occurring. The facility failed to monitor R7 for the need for supplementation when the resident's weight and meal consumption declined. R7 was observed on 10/24/13, during breakfast from 8:30 AM through 8:55 AM, feeding herself in her room. R7 consumed approximately 25% of her meal. Although staff had delivered and setup the meal, no staff were observed coming into the room to monitor R7's intake or to encourage or cue her to eat. On 10/24/13, R7 was observed at 12:12 PM feeding herself lunch in her room. R7 consumed approximately 25% of this meal. During an interview with E6 (Certified Nurse's Aide) on 10/24/13 at approximately 12:30 PM, E6 stated that R7 used to take her tray and throw everything into the trash but now she is eating "some." E6 stated that they had tried taking her into the dining room to eat but she wouldn't stay. On 10/25/13, R7 was again observed during the morning meal from 8:30 AM through 8:56 AM in her room. E7 (Certified Nurse's Aide) was observed setting up the meal and encouraging R7 to drink and eat. E7 stated to this surveyor that "we need to step away 'cause she won't eat if you are near her." R7 was observed from the hallway feeding herself and consumed approximately 50% of the meal. At 8:56 AM, E7 was observed going into R7's room to check on her. Although staff were setting up R7 for her meals and she was able to feed herself independently, there was a lack of consistent supervision and/or cueing during the meals. During an interview with E3 (Unit Manager) on 10/25/13 at 1:35 PM, E3 stated that the same CNA is assigned to complete all the weights in the facility. E3 stated that the monthly and weekly weights are reviewed by the Registered Dietitian (E4). Upon this surveyor's voiced concern over R7's weight loss of 6.4 lbs. on 10/1/13, E3 requested staff to obtain a weight on R7. On 10/25/13, R7 was weighed on the stand up scale (same scale used previously) and weighed 127.7 lbs. This was an additional 2.6 lbs. weight loss for a total loss of 9 lbs.(a 6.58% loss) since 9/3/13 which was approximately seven and one half weeks. On 10/25/13 orders were written for R7 to receive a Magic Cup (dietary supplement) at lunch and dinner and to have weekly weights starting 10/28/13. On 10/28/13, R7's weight was 126.4 lbs, signifying an additional 1.3 lbs loss since 10/25/13 and a total of 10.3 lbs (or a severe loss of 7.5%) since 9/3/13. Review of the Medication Administration Record [REDACTED]. During an interview on 10/28/13 at 1:30 PM, E1 (Administrator) stated that R7 did not trigger as a significant weight loss (5% or greater) when the 10/1/13 monthly weights were completed and that it would have been identified when the November monthly weights were done. An interview with E2 (Acting Director of Nursing) on 10/28/13 at approximately 2:10 PM revealed that when the new nutrition policy was implemented on 10/9/13, it was given to the facility Unit Managers and it was hung at the nursing stations for staff to read. E2 stated that an inservice had not been conducted since they had just had an inservice on the previous policy. Staff were expected to read the new policy. On 10/28/13 at 3 PM, an interview was conducted with E4 (Registered Dietitian). E4 stated she was now conducting additional audits of significant weight losses as part of the facility's plan of correction for the biannual survey of 8/7/13. E4 stated that electronic program used in the facility only identified significant weight loss/gain of 5% in 30 days and 10% in 6 months. E4 stated that based on this report she will chart progress notes and develop interventions as indicated. She stated that since R7 did not have a 5% weight loss on 10/1/13, she did not trigger for a review. E4 acknowledged that she did not review all the monthly weights and that she was not aware of R7's 6.4 lbs weight loss on 10/1/13. E4 was asked, that with the knowledge of R7's decreased intakes, as per her 9/24/13 progress note, if she had known of the 6.4 lb. weight loss on 10/1/13, (despite it not triggering a significant weight loss), would she have done anything about it? E4 stated that she probably at least would have ordered weekly weights to monitor. The facility failed to consistently monitor and analyze meal intake records for R7, failed to identify a continuing decline in intakes, failed to identify an initial weight loss of 6.4 lbs. in one month and failed to implement timely interventions in an attempt to avoid further weight loss.

Based on observation, record review and interview, it was determined that the facility failed to ensure that three (R7, R2 and R6) out of seven (7) sampled residents received the necessary care and services to attain or maintain the highest practical physical, well-being, in accordance with the comprehensive assessment and plan of care. The facility failed to thoroughly assess R7 when R7 complained of right leg pain and experienced a change in color of his right leg and the facility failed to ensure staff took appropriate immediate action to provide R7 with the care and services required by this emergency. Staff failed to identify the immediacy of the situation. Three hours after R7 experienced a change in condition he was sent to the hospital at which time he was found to have blood clots ([MEDICAL CONDITION] - [MEDICAL CONDITION] in both legs requiring amputation of the right leg above the knee due to lack of circulation. For R2, the facility failed to recognize the onset of slurred speech and left sided weakness as signs and symptoms of possible stroke. R2 was not sent to the hospital until 2 hours after the onset of symptoms. For R6, the facility failed to administer R6's [MEDICATION NAME] (used for pain) according to the physician's orders [REDACTED]. On 1/30/13, R6 incorrectly received a total of five doses of [MEDICATION NAME] instead of the three (3) as ordered. Findings include: 1. R7 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. An admission MDS (minimum data set) assessment, dated 2/26/13, revealed that R7 required one person extensive assist with activities of daily living (except eating) and that he was independent for daily decision-making. R7 was able to make his own decisions regarding medical care. A care plan entitled skin at risk due to decreased mobility, dated 2/19/13, included an intervention to turn and reposition every 2 hours. A care plan developed on 3/7/13 for diabetes included the intervention to wash feet daily with mild soap and water and dry thoroughly. Facility Policy and Procedure dated 2/20/11 and revised 3/11/13 entitled, "Change of Condition Standards" stated, "2.The licensed nurse evaluates the change of condition and determines the course of action based on standard of practice. 3.The physician is notified immediately, by phone (voice to voice), if the condition change warrants immediate medical attention...5. Licensed staff may initiate transport of a resident via "911" to the ER (emergency room ) without a physicians order if it is deemed emergent...the MD (physician) will be notified after the transfer." A pre-operative Cardiology Report for placement of [MEDICAL TREATMENT] access, dated 3/15/13, revealed that R7 was diagnosed with [REDACTED]. On 3/16/13 R7 was sent to the emergency room (ER) for evaluation and subsequently was admitted to the hospital. R7 returned to the facility on [DATE] with orders to receive aspirin EC ([MEDICATION NAME] coated) 81 mg (milligram) every day and [MEDICATION NAME] XL (extended release for high blood pressure) 50 mg every day added to his medications. A review of the nursing re-admission assessment, dated 3/19/13, revealed, that it failed to include an assessment for any pulses in the lower extremities e.g. popliteal (behind knee) or pedal (foot) pulses. A nurse's note, dated 3/26/13, stated that there was redness to R7's right inner ankle and that there was +1 [MEDICAL CONDITION] (swelling) to both extremities and they were elevated. Review of the doctor communication book lacked evidence that R7's physician was notified of the red ankle with +1 [MEDICAL CONDITION] as noted in the nurse's note on 3/26/13 A nurse's note, dated 3/27/13, stated that R7 returned from the hospital after having [MEDICAL TREATMENT] access placed in arm. R7 complained of pain in his arm and was given Tylenol 650 mg at 7:00 PM. A nurse's note, dated 3/30/13 and timed 9:00 PM, stated that during care, R7 was noted to have bleeding from his penis and R7 stated, that he was having pain in his right leg. A call was placed to E10 (nurse practitioner). There was no evidence to indicate the NP was notified of R7's leg pain or that the staff observed or checked for pulses in the right leg. A physician's orders [REDACTED]. A nurse's note, dated 3/31/13 and timed 2:35 AM, stated that a certified nurse aide ( E17-CNA) alerted E12 (RN) that R7's had a red rash on his right knee. R7's right leg was noted to have reddish purple mottling from the knee down. The leg was extremely cold to touch. There was no pedal pulse on the right foot, and a weak popliteal on the right leg that was barely palpable. The left popliteal and pedal pulses were weak and the left leg was warm to touch with no mottling. VS (vital signs) 118/69, 96.4, 102, 18. At 11:30 PM NP (E10 nurse practitioner) called and alerted of situation, E10 stated to call R7's family to ask if they wanted him sent out. R7's nephew was contacted and stated that the resident should make the decision if alert and oriented to situation. Patient was not able to move toes on right foot. Patient discussed situation with E12 (RN) and agreed he wanted to go to the hospital. 911 called, patient transferred to hospital ER, awaiting update. The facility 24 hour shift report revealed that R7 was transported to theER on [DATE] at 2:45 AM. This was approximately 3 hours from the time that E17 (CNA) notified E12 (RN)of the redness noted in R7's right leg, and 29and 3/4 hours after the facility first documented the resident complaint of pain in the right leg. The hospital ER Assessment Sheet, dated 3/31/13, stated..."resident arrived at 3:07 AM, assumed care of pt (patient) from EMS (emergency medical services) ALS (advanced life support). Pt sent from LTC (long term care) facility for cold and numb RLE (right lower extremity) times 2 days and increasing. Negative pulses RLE. RLE cold and blue in color with mottled appearance". The hospital H&P (history and physical) dated 3/31/13, stated, "...Assessment and Plan: 1. Limb ischemia (death to tissues), R (right) more than left leg. On the R side he appears to have critical limb with ischemia". The Intake and Interdisciplinary Record, dated 3/31/13, stated,..."Chief Complaint: right leg cold with no feeling times few days. No pedal pulse". ER Physician Record-Lower Extremity, dated 3/31/13, stated, ..."Onset/Duration - Cool right extremity. Negative pulse 2 days ago. Pt leg became cool 2 days ago, NH (nursing home) sent pt in today". Attending ER Physician note dated 3/31/13, stated..."Presenting with cool pulseless extremity times 2 days". Vascular (blood vessel)Surgery Progress note, dated 4/1/13 stated, "No acute issues. Leg unchanged at baseline...3) Needs plan: leg does not seem viable (alive), possible amputation". Review of R7's ADL (activity of daily living) flow sheets revealed that the daily skin checks were signed off as completed by CNA's and yet there was no documentation concerning the change in the right leg of R7 on March 30 & 31, 2013. Review of R7's MAR (medication administration record) for 3/27/13 revealed that no Tylenol was signed off as being given per nurse's note on 3/27/13. E11 (R7's physician) was interviewed on 4/4/13 at 12:00 PM. E11 stated that a [MEDICAL CONDITION] ([MEDICAL CONDITION] - blood clot) "can happen very quickly, I'm talking a matter of hours". E11 stated, "I do expect someone who has leg pain with [MEDICAL CONDITION] for them to call me and let me know or put it in the book". E16 (RN 3-11PM shift) was interviewed on 4/3/13 at 10:15 AM. E16 stated that the resident complained of arm pain on 3/27/13, the day the [MEDICAL TREATMENT] access was placed in R7's arm. E16 checked him at 10:30 PM. E16 stated she gave R7 Tylenol and that he had bruises on his arms. E16 stated that she did a full assessment on R7, but does not remember anything about his lower extremities. E18 (CNA 3-11 PM shift) was interviewed on 4/4/13 at 1:10 PM. E18 stated that, on 3/30/13 between 7-8 PM, she went in to perform care on R7 and he complained that his leg was hurting. R7 stated "ouch" when she turned him. E18 went and got E6 (LPN). E18 stated that E6 touched R7 on the leg, but did not feel his foot. E18 stated that R7's right upper leg was red. E6 (LPN 3-11 PM shift) was interviewed on 4/2/13 at 3:10 PM. E6 stated that she did not give R7 anything for pain on 3/30/13 when R7 stated that he had pain in the right leg because he did not have an order for [REDACTED]. E6 stated that she did not see the order. E6 stated that R7 kept saying that he did not feel good. When E6 was asked if R7 had complaint of leg pain before, E6 stated no. E6 did state that she told the doctor of the right leg pain when she notified her of the bleeding from his penis. E10 (nurse practitioner) was interviewed on 4/5/13 at 11:25 AM. E10 stated, that she was called about R7 on 3/30/13 and E6 (nurse) stated that the resident had blood tinged urine. E10 gave an order to hold the aspirin for 3 days and get a UA and C&S. They called me back and stated they could not get any urine and wanted an order to straight cath (tube to obtain urine) R7. E10 stated that at no time did the facility mention anything about R7's leg. E10 stated, "If they did I would have given them an order for [REDACTED]. E12 (nurse 11-7 AM shift) was interviewed on 4/3/13 at 10:25 AM. E12 stated that the 24 hour shift report for 3/30/13 stated that R7 had an episode of a large amount of bleeding from his penis. There was an order to hold aspirin for 3 days and get UA and C&S. E12 stated that R7 does not urinate a lot because he is on [MEDICAL TREATMENT]. Also in the report it stated that R7 had complaint of right knee pain. At approximately 11:45 PM, E17 (CNA) came to E12 and stated that R7 has a red rash on his right knee. E12 went and looked at the leg and stated,"I did not know exactly what I was looking at. I felt the knee and leg and it was cold. The redness was around the knee and creeping down the leg". R7's physician was called. It took 30 minutes for the physician to call back. E12 stated that she worked as a psychiatric nurse and "You don't experience the same situations in Psych as here". E2 (Director of Nursing) was interviewed on 4/5/13 at 10:35 AM. E2 stated that she found out that the staff was trying to get permission from the nephew, then from R7, to send R7 to the hospital. E2 (Director of Nursing) stated, "They should have just sent him (R7) out". E2 acknowledged and confirmed the findings. R7 was transferred to the hospital at 2:45 AM, 3 hours after resident was found to have mottling of right leg and no pedal pulses. Subsequently, R7's right leg had to be amputated. 2. R2 was admitted to the facility in 2009. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 11/7/12, revealed that R2 required one person extensive assist with activities of daily living (except eating). R2 had clear speech, was understood and she understood others. A care plan entitled decreased cardiac output, revised 11/12/12 included potential for heart failure, respiratory distress (breathing difficulties). Interventions included: monitor for decreased peripheral pulses (arms and legs), arrhythmia's (irregular heart beat), fatigue, rales (abnormal breath sounds), dyspnea (difficulty breathing), changes in mental status, cool clammy skin, and [MEDICAL CONDITION]. Review of an on-line article (last updated 3/20/13) from the National Institute of Neurological Disorders and Stroke entitled, "Know Stroke, Know the Signs, Act in Time" stated, ..." The window of opportunity to start treating stroke patients is three hours, but to be evaluated and receive treatment, patients need to get to the hospital within 60 minutes" (http://www.ninds.nih.gov/disorders/stroke/knowstroke.htm). Facility Policy and Procedure dated 2/20/11 and revised 3/11/13 entitled, "Change of Condition Standards" stated, "2.The licensed nurse evaluates the change of condition and determines the course of action based on standard of practice. 3.The physician is notified immediately, by phone (voice to voice), if the condition change warrants immediate medical attention...5. Licensed staff may initiate transport of a resident via "911" to the ER (emergency room ) without a physicians order if it is deemed emergent...the MD (physician) will be notified after the transfer". A nurse's note, dated 12/25/12 at 3:40 PM, stated R2 was found in the TV room and when E6 (LPN) tried to talk to her, R2 tried to respond but E6 could not understand what she was saying. Left hand weakness was noted and R2 was not able to turn her head to the right side. There was no evidence that the supervisor was made aware of R2's change in condition. A nurse's note, dated 12/25/12 and timed 4:50 PM, stated E20 (physician) was paged by E6 (nurse), awaiting call back. This was one (1) hour and 10 minutes after R2 was first noted to have left hand weakness and unclear speech. R2's daughter was called and message was left. Daughter called back after 10 minutes and was made aware of R2's condition. A nurse's note dated 12/25/12 at 5:10 PM, stated R2's daughter called, message left. The daughter called back after 10 minutes and was made aware of R2's condition. R2 was now on oxygen, pulse ox (oxygen level in the blood) of 86% (desired level is 92-100%). R2's daughter stated to send R2 to the hospital. R2 was sent to the hospital at 5:30 PM, approximately 2 hours after presenting with left hand weakness and unclear speech. A nurse's note, dated 12/25/12 at 10:30PM, stated E20 was paged with still no response. E21 (medical director) was called at this time. E21 gave OK for order to send R2 to hospital and was informed that R2 had been sent to the hospital. R2's facility History and Physical, dated 12/31/12, stated that on 12/25/12 R2 was found to be less responsive and transferred to hospital, where an MRI (magnetic resonance imaging) revealed left temporal (side of brain)[MEDICAL CONDITION]([MEDICAL CONDITION] - stroke). During an interview with R2's daughter on 3/28/13 at 11:20 AM she stated that she visits her mother at least once a week and that on 12/25/12 at 3:00PM when she was there she noticed that R2 was "not right". R2 was in the activity lounge and when her daughter approached her she found R2 talking "gibberish". R2's daughter stated that she told E5 (LPN) of her concern that R2 may have had a stroke. R2's daughter stated that E5 did nothing for R2, just looked at her. E5 stated to R2's daughter that "they would keep an eye on her". R2's daughter then went to the nurse's desk and told someone (does not remember who) that her mother was not right. The daughter stated, she thought staff were going to have a doctor look at her mother and she left the facility. During an interview with E6 (nurse) on 3/28/13 at 3:10 PM, she stated that R2's daughter and E5 came to her and stated that something was wrong with the R2. E6 went into the dayroom and looked at R2 and she could tell that something was not right. E6 asked E5 if she called the doctor and E5 stated "No". E6 asked E5 if she got vitals (blood pressure, pulse, heart rate and temperature) and E5 stated that she got R2's blood pressure. E6 then went back to her hall to give meds. E6 stated she still felt something was wrong and went back and told E5 to get R2's pulse ox which was 86% on room air. E6 then put oxygen on R2 and called the daughter because E20 (physician) had not returned the page and asked the daughter for permission to send the resident to hospital. E6 stated it was approximately 2 hours from the time R2's daughter stated that she felt something was wrong and when R2 was transported to the hospital. During an interview with E7 (certified nurse's aide) on 3/28/13 at 3:35 PM, he stated that R2 was leaning to the left side in her wheelchair and E7 repositioned her and she continued to lean to the left. E7 asked the nurse if he could put her to bed but she said no that they were going to call the doctor. E7 stated that he knew something was wrong with R2. E7 did not see R2's daughter there at that time. In an interview with E5 (LPN) on 4/1/13 at 12:15 PM she stated, R2's daughter came to her around 3:30 PM on 12/25/12 and said something is wrong with R2's speech. E5 stated that she looked at R2 and that she was her normal self. E5 stated she told R2's daughter that we will keep an eye on her. When R2 was noted to appear different than her normal self the facility failed to ensure staff assessed her ability to move both arms, speak clearly, and to smile. R2 was not assessed by staff. Thirty minutes later E7 (CNA) came to put R2 in bed for a nap. At that time E6 (LPN) came and stated that R2 doesn't look right. E5 (LPN) stated that the E21(medical director) was calling about another resident and E5 (LPN) told the medical director about R2's condition and that E20 (physician) had not returned his page. The medical director stated to call E20 (physician) one more time which E5 (LPN) did and still did not get a response. A facility Occupational Therapy (OT) Initial Evaluation dated 12/31/12, stated R2 was hosptalized on [DATE] and was diagnosed with [REDACTED]. A Speech Therapy Initial Evaluation dated 1/3/13, stated R2's verbal expression is severely impaired. Reason for referral was for new onset dysphagia (difficulty swallowing) and [MEDICAL CONDITION] (difficulty speaking) secondary [MEDICAL CONDITION] 12/25/12. Observation of R2 on 3/27/13 at 11:05 AM revealed, R2 sitting in a wheelchair in her room. R2 was unable to converse with this surveyor. R2 could only make grunting noises and yelled "mom, mom". R2's left arm and hand were noted to be limp. Observation of R2 on 4/1/13 at 8:30 AM in the restorative dining room revealed, R2 was being assisted by E13 (nurse) to eat breakfast. R2 was noted not to be able to use her left arm and hand. E2 (Director of Nursing) was interviewed on 4/5/13 at 11:30 AM and the findings were acknowledged and confirmed. The facility failed to thoroughly assess R2 when she first exhibited difficulty in speech and left sided weakness. The facility failed to ensure R2 received the care and services needed when there was a failure to identify the signs and symptoms of a stroke. 3. R6 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment, dated 1/26/13, revealed that R6 required supervision and set up only for all ADL's (activities of daily living) except for bathing. R6 had a BIMS (brief interview for mental status) score of 12 which indicated that R6 was moderately impaired for decision making. A care plan for, "I am experiencing pain related to chronic back pain", last revised on 7/30/12 included interventions: administer pain medications as ordered, see MAR (medication administration record) ...Monitor for potential side effects of pain medication, monitor resident frequently for pain control ...notify physician/nursing of any concerns. A facility Policy and Procedure entitled Medication Error and Adverse Drug Reaction Reporting dated 2009 stated, "1.6.2 Policy - Medication errors and adverse drug reactions are assessed, documented, and reported as appropriate to the resident's attending physician, the Quality Assurance Committee and the pharmacy. Definitions - Medication Error/Discrepancy: An incorrect medication prescribed, dispensed, or administered to a resident; an omission of a vital medication due to a prescribing, dispensing, or administering error; medication administered to an individual with a documented history of allergy to the medication....e. The following information is documented (in the resident's medical record) and/or on the medication error report...3) Name of physician and time notified". A physician's orders [REDACTED]. On 1/29/13, a physician's orders [REDACTED]. R6's MAR (medication administration record) revealed that on 1/30/13, R6 received [MEDICATION NAME] 100mg PO at 8 AM, 9 AM, 2 PM, 5 PM and 8 PM. The facility failed to clarify and if directed discontinue the 1/29/13 [MEDICATION NAME] order when a new order was written on 1/30/13. Consequently, R6 received a total of five (5) doses instead of three (3) as ordered. E3 (Assistant Director of Nursing) was interviewed on 3/27/13 at 11:40 AM, and acknowledged and confirmed findings.

Based on record review, observation and interview, it was determined that the facility failed to ensure that one (1) resident (R8) who was incontinent of bladder received appropriate treatment and services to restore as much normal bladder function as possible and received appropriate treatment and services to prevent urinary tract infection [MEDICAL CONDITION]. R8 was assessed as continent of bladder upon admission. CNA ADL tracking forms dated 1/2012 and 2/2012 documented episodes of incontinence. There was no documented evidence of completion of a re assessment/evaluation such as a voiding trial per facility policy. R8 was assessed as continent of bladder upon admission. CNA ADL Tracking forms dated1/2012 and 2/20/12 documented episodes of incontinence indicating a decline in continency. There was no documented evidence of completion of a re-assessment/re-evaluation such as voiding trial per facility policy. Findings include: The facility's policy entitled, "Standards for Urinary Assessment" to ensure a quality assessment and treatment for [REDACTED]. R8 was admitted in the facility on 12/05/2011 with [DIAGNOSES REDACTED]. According to R8's admission Minimum Data Set (MDS) assessment dated [DATE], her BIMs (Brief Interview for Mental Status) score was 9 out of 15 (cognition was moderately impaired; cues/supervision is required). R8 needed extensive assistance of one person for bed mobility, transfer, dressing, toilet use, hygiene and bathing. R8 had limited range of motion on both upper and lower extremities. R8 was coded as being continent of bladder and bowel. An admission Urinary Continence Evaluation (undated) indicated that R8 was continent of bladder and therefore no assessment of voiding patterns was initiated. The facility established a care plan, dated 12/21/11 on " Potential for incontinence related to: impaired mobility, diminished balance, ROM, activity intolerance, weakness." The care plan goals were "Resident will be/remain continent at all times, through next review" and "Resident will have no complications related to incontinence through next review (3/21/12)." The interventions included: Check resident every two hours and PRN (as necessary), and assist with toileting as needed, Provide urinal/bedpan/bedside commode, assist to bathroom PRN, as indicated, Provide peri-care after each incontinent episode if any occur, Monitor for signs/symptoms of urinary tract infection, Assist resident to toilet PRN or per resident's request, Refer to Physical therapy and/or Occupational therapy as indicated, Notify physician of any concerns as indicated, Discuss with resident the triggers of stress incontinence such as coughing, sneezing, and laughing, Maintain pathway to toilet that is free of obstacles, This care plan identified that R8 was "continent." A "Urinary Incontinence Assessment" was done on 1/27/12 which indicated that R8 was continent and that this resident can typically hold urine "Q 3-4 hours" and that "Toileting per resident's request" was the current intervention. However, review of R8's CNA (Certified Nursing Aide) ADL's Tracking Form revealed that this resident showed beginning signs of incontinence: For example: 01/2012 CNA's ADLs Tracking form documented that R8 was incontinent of bladder 6 times on the 3-11 PM shift. 02/2012 CNA's ADLs Tracking form documented that R8 was incontinent of bladder 27 times on the 3-11 PM shift; 5 times on the 11-7 AM shift. 03/2012 CNA's ADLs Tracking form documented that R8 was incontinent of bladder 13 times on the 7-3 shift; 4 times on the 11-7 AM shift out of 22 days. There was no documented evidence of a re-assessment/re-evaluation such as a three day voiding trial/observation per the facility's policy in order to identify this resident's voiding patterns, to establish a toileting program, and to maintain R8's bladder continency and prevent urinary tract infections. Subsequently, according to R8's quarterly review Minimum Data Set (MDS) assessment dated [DATE], R8's Urinary Continence indicated that this resident was assessed as frequently incontinent (coded 2). R8's urinary continency declined from code 0/always continent to Code2/frequently incontinent. In addition, R8 showed signs and symptoms of increased confusion, complained of burning during urination, attempted to get out of bed multiple times without assistance, was combative with aggressive behaviors, non-compliant with use of the call bell, was forgetful and had 3 unwitnessed falls with minor injuries. R8's urine culture results collected on 02/08/12 and 02/19/12 showed positive urinary tract infection (organism- Escherichia Coli >100,000 CFU/ml) and was treated with the antibiotic [MEDICATION NAME]. R8's Blood Work results were as follows: normal range 2/7/12 BUN 43 H 8-20 mg/dl creatinine 1.4 H 0.4-1.1mg/dl 2/13/12 BUN 47 H creatinine 1.3 H 2/22/12 BUN 52 H creatinine 1.4 H 3/05/12 BUN 43 H Creatinine 1.2 H These findings were discussed with E1 (Administrator) and E2 (Director of Nursing) on 3/26/12.

Based on observations, clinical record review, interview and review of other facility documents, it was determined that the facility failed to ensure that four (R2, R5, R7 and R8) out of nine (9) sampled residents received adequate supervision to prevent accidents. R2 and R7 failed to receive adequate supervision as per their plan of care which resulted in falls with lacerations. One of R2's fall resulted in transfer to the emergency room and 3 sutures to the forehead and 4 staples to the top of the head. R7 also required sutures to a laceration in the hospital. R8 had physical factors/[DIAGNOSES REDACTED]. The facility failed to re-assess/evaluate/analyze the effectiveness of R8's use of the call bell as related to these physical factors and failed to modify the intervention as necessary to provide adequate supervision to toilet, prevent falls and UTI (urinary tract infection). The facility failed to provide adequate supervision for R5 when staff left him alone against care plan interventions to have one staff walk with him at all times when he was walking his dog. Additionally, the facility failed to monitor two (2) (SSR1 and SSR2) resident's Wanderguards for usage and functionality. Findings include: The facility policy entitled "Fall Prevention" states, "...Procedure Nursing Actions in the Event of a Resident Fall...8. Update care plan with intervention(s) to minimize potential for further falls...Interventions to consider for the Prevention of Falls 10. Answer call lights immediately...25. Do not leave confused, agitated residents alone in open social areas. 26. Do not leave resident in the Nurses Station area unattended. 36. Provide social activity, interaction for distraction for the agitated cognitively impaired resident. 37. Place sleepless cognitively impaired residents in an area where it is easy to observe them and provide food, interaction or medicate as necessary and return to bed when appropriate..." 1. R7 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 11/22/11 admission orders [REDACTED]. On 11/23/11 an order was written for R7 to have bilateral fall mats placed when in bed. An 11/26/11 order stated to discontinue use of the walker pending further physical therapy evaluation. A care plan for Fall Risk was developed on 11/23/11 and included the interventions "educate resident in safety awareness as indicated, remind resident to call when needing assistance, make sure that all staff members are aware that resident is at high risk for falls, chair alarm, bed in lowest position, padded floor next to bed bilateral, bed alarm. On 11/30/11 a care plan for non-compliance with safety was developed and stated that R7 had cognitive impairment and refuses to use call bell and walker and wear geri sleeves. The 11/29/11 admission Minimum Data Set (MDS) assessment stated R7's cognitive skills were severely impaired and he required extensive assist of one staff person for bed mobility, transfers, walking in the room, dressing, hygiene, and toilet use. The Care Area Assessment (CAA) Summary triggered for falls and was checked to proceed with care planning for this area. The CAA Review Report, dated 11/29/11 stated the resident was alert and oriented x 2-3 (person, place and time) with periods of confusion, agitation, short and long term memory loss and also an elopement risk, has attempted to leave the building wearing wanderguard. On 12/19/11, R7 was sent to the emergency room (ER) for a change in condition and was subsequently admitted to the hospital with [REDACTED]. Prior orders for the use of bed and chair alarms, wanderguard, fall mats, geri sleeves and fall precautions were all resumed. A nurse's note and facility incident report, dated 1/13/12, stated that at 2:40 PM, R7 was found on the fall mat next to his bed and he stated that he was transferring himself to bed. There were no injuries sustained. The facility's "Incident Report Conclusion & Action Plan" listed under Intervention(s) to prevent this from happening again stated "Consult Activities-(increase) activities, supervision, Physical Therapy evaluation, continue with pressure alarms (bed + chair) and fall mats." Review of the clinical record revealed that R7 was currently on the PT (physical therapy) and OT (occupational therapy) workload. An incident report, dated 1/14/12 and timed 10:00 AM stated that R7 slid out of his wheelchair as he reached over and tried to pick something up from the floor. A written statement, dated 1/14/12 and completed by E16 (activities assistant) stated that while she was doing exercises with a group of residents she saw R7 trying to pick something up from the floor. E16 wrote that there was nothing on the floor and he fell sideways and she was unable to reach him in time. Review of the corresponding nurse's note revealed that R7 sustained 2 skin tears to the left arm as a result of the fall. The Incident Report Conclusion & Action Plan, dated 1/16/12 stated under interventions to prevent re-occurrence to continue with alarms and fall mats, increase supervision and monitoring and increase activities. The report also stated that the care plan was revised. Review of the fall risk care plan revealed that on 1/14/12 the interventions were updated to include "PT eval" and "increase activities." A second incident report, dated 1/14/12, but timed 4:00 PM stated R7 fell as he was attempting to get up from his wheelchair, hit his head and sustained a laceration to the forehead and re-injured a skin tear on the left elbow sustained from the fall that had occurred earlier that day. A written statement completed by E17 (CNA) stated they witnessed the resident getting up and falling and they reached over to stop him but it was too late. R7 was sent to the ER for evaluation and returned several hours later. A nurse's note dated 1/15/12 and timed 8:28 AM stated the resident had returned from the ER at approximately 12:40 AM and that "two small (2) lacerations on the forehead appear to have been closed using adhesive." The clinical record revealed that a "Therapy Communication" was completed on 1/14/12 from nursing and placed in the therapy mailbox. The communication sheet stated "(patient) fell 3 times in 24 hours-please reassess for options." Although therapy notes indicated that therapy staff were working with R7 and that he had poor safety awareness, gait abnormality and required verbal cues, there was no evidence that the problem of the falls was addressed. Review of nurse's notes, dated 1/16/12 and 1/17/12 written by the 11 AM to 7 AM shift, stated R7 was up and out of bed several times straightening his bed sheets and checking side table drawers. The notes stated the resident was brought out into the hall and/or TV room. A nurse's note dated 1/19/12 and timed 4:15 AM stated, "Call by CNA pt found sitting on floor in hallway outside (room number), forehead with quarter size abrasion bleeding and previous laceration below it bleeding pt c/o (complained of) left thigh leg pain, pt able to move all extremities freely...4:30 AM...pt to be sent to ER..." An incident report, dated 1/19/12 and timed 4:30 AM stated the fall was unwitnessed and R7 was last seen by a CNA in the hallway in his wheelchair, but does not state at what time he was last seen. An written incident statement, dated 1/19/12 stated "...on floor in front of his w/c in hallway tether alarm still attached to w/c not attached to pt clothing, pt has hx (history of) removing his alarms..." The facility failed to provide adequate supervision for R7 in an attempt to prevent an accident and failed to consider an alternative to the tether alarm if R7 had a history of [REDACTED]. R7 was sent to theER on [DATE] and subsequently admitted to the hospital with [REDACTED]. pt fell resulting in head trauma (laceration) received call from cards (cardiology)...re: no need for cardiac w/u (work up)." R7 returned to the facility on [DATE] with sutures in place (unclear how many). Review of the clinical record revealed that on 1/23/12 the physician ordered Risperdal (anti psychotic used for behavioral symptoms associated with dementia in elderly) and ordered a psychiatric consult which was completed on 1/24/12. A nurse's note, dated 1/31/12 and timed 10:00 PM, stated she was called to the room by a CNA where the resident was found sitting on the floor next to his wheelchair with a skin tear on his left upper forearm outer aspect. An incident report stated that R7 was last seen in the hallway and that the fall was unwitnessed. The Incident Report Conclusion & Action Plan again stated the resident required increased supervision, increased activity level and continue pressure alarms. The facility again failed to provide adequate supervision. R7 was last seen in the hallway but then found in his room sitting on the floor with a skin tear. A nurse's note, dated 2/24/12, timed 11:30 AM and completed by E14 (nurse) stated, "1015-chair alarm sounding this RN entered room noted pt sitting in wheelchair watching TV faceing (sic) window in room. Chair alarm teather (sic) re-attached. Patient sitting quietly watching TV. This RN exited room walked to nurse's station, seconds later chair alarm sounds this RN enters room observes pt sitting on floor now facing the bedroom door. Observed pt with 3 lacerations to forehead...Patient alert and responsive...MD notified gave order to send pt to Christiana ER for eval...Patient consistently confused and disoriented to place and time. Hx of falls from chair and bed with prior head injuries. Patient non-compliant with safety precautions...At time of fall patient had call bell in reach clipped to chair. patient last toileted at approx 0930 per CNA post breakfast. Breaks (sic) to wheelchair were locked." R7 was sent out to the ER and returned to the facility later that same day with sutures on the forehead. The facility failed to provide adequate supervision for R7 when he was left alone in his room unsupervised, fell and sustained harm. On 3/26/12 at 11:45 AM, R7 was observed seated in a wheelchair next to the biohazard room directly across from the lounge. There were no staff present in the lounge and there were no staff observed anywhere up or down the hall. Although 3 staff were present in the nurse's station, 2 charting and one answering the telephone and performing various other tasks, R7 was not visible to them due to where he was placed. During an interview with E14 (nurse) on 3/26/12, E14 stated "supervision would mean within view of staff." E14 acknowledged that on 2/24/12, R7 was alone in his room unsupervised, when he could have been in an activity in the lounge supervised by facility staff. The facility failed to follow the plan of care to increase supervision and monitoring and to increase activities in order to attempt to prevent accidents from falls. Findings were reviewed and acknowledged by E1 (Administrator) and E2 (Director of Nursing) on 3/26/12. 2. R2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 12/6/11 admission nurse's note, R2 was admitted from the hospital with a [DIAGNOSES REDACTED]. The facility Fall Risk Assessment, dated 12/6/11 scored R2 equal to 24 with a score of seven (7) or greater being high risk. The clinical record revealed that upon admission and through 12/13/11, R2 had 24 hour 1:1 aides. After 12/13/11 1:1 aides were present from 8:00 PM to 8:00 AM until 3/20/11, at which time they were discontinued. On 12/7/11, the facility developed a care plan for the problem Fall Risk potential for injury related to unsteady gait, cognitive deficits, impaired safety awareness, weakness, impaired mobility, balance problem and risky behaviors. The goal of the care plan was for R2 to remain free from injuries related to falls. Interventions included "remind resident to call when needing assistance, keep call light and most frequently used personal items within reach, assess medications for contributing factors as indicated, toilet resident per request, chair alarm, bed in lowest position, padded floor next to bed bilateral, bed alarm." A physician's orders [REDACTED]. R2 was discontinued from skilled therapy services on 1/4/12 due to "achieved MAX (maximum) Rehab potential." A physician's orders [REDACTED]. R2 was evaluated by the psychiatric nurse practitioner on 12/13/11 and was seen periodically thereafter. The 12/13/11 admission Minimum Data Set (MDS) assessment stated R2 was cognitively intact and required extensive assist of one staff person for bed mobility, transfer, walk in room and corridor, dressing and toilet use. Review of the clinical record and facility incident reports revealed that R2 had multiple falls from 12/13/11 through 3/11/12. Review of the clinical record and facility incident reports revealed that between 12/13/11 and 12/22/11, R2 had a total of four (4) falls. Two of the falls were witnessed by staff, two were not. Skin tears were sustained during two (2) of the falls. A nurse's note, dated 12/29/11 and timed 10:00 AM stated that R2 did not have a 1:1 sitter on the 11 PM-7 AM shift. "Noncompliant with call bell use. OOB (out of bed) to BR (bathroom) alone at midnight...Writer observed resident holding bed alarm button to prevent alarm sounding while resident standing up from bed...call bell within reach." Between 12/29/11 and 1/9/12, the clinical record revealed that R2 had seven (7) falls, three (3) witnessed, four (4) unwitnessed. R2 sustained a skin tear during one (1) of these falls. Written staff statements for six (6) of these falls stated that they responded to an alarm sounding. Review of facility incident reports revealed that on 12/14/11 and 12/16/11 a "Therapy Communication" form was completed regarding R2's falls. Although R2 was receiving skilled therapy at this time there was no evidence that therapy assessed the falls or communicated with nursing regarding the frequent falls. On 1/3/12 a physician's orders [REDACTED]. There was no evidence of any significant findings pertaining to the blood pressure and heart rate. A Consult Request from the consultant Pharmacist, dated 1/10/12 stated a review of R2's medications was completed. The recommendations included "...4.) Abnormal Gait-cause/add to impaired coordination and fall risk? PT therapy to help restore/improve balance, etc..." There was no evidence that additional skilled therapy services were provided. A "Conclusion & Action Plan" dated 1/12/12 stated "Resident knows how to silence and disconnect alarms. Noncompliant with call bell use...Resident is A&O (alert and oriented), likely wants to maintain independence. he has been educated several times on safety awareness and call bell use. Resident will remain on Q 1 Hour checks and 1:1 supervision 8PM-8AM. Staff will continue with frequent reminders for call bell use and safety awareness." Review of the clinical record revealed that mid-January 2012, R2 began receiving Restorative ambulation services from the Restorative Aide 5 days a week. A nurse's note, dated 1/15/12 and timed 8:38 AM stated "elopement attempt at 0130 this morning. Exit alarm alerted staff...Writer observed resident in hallway standing in front of w/c pushing on exit door. resident stated he wanted to get his car. (Name) sitter present @ nurse's arrival in hallway. Unable to determine if sitter with resident during attempt. resident has gotten past sitter before..." Review of the clinical record revealed that between 1/19/12 and 1/27/12, R2 had 3 additional falls. Two (2) falls were witnessed (one by staff, the other by another resident's family member). R2 sustained a small scrape to his lower left back during one of these falls. The facility's Incident Report Conclusion & Action Plan, dated 1/19/12 stated under interventions "(increase) supervision; alarms in place; continue with 1 on 1 sitter." A Conclusion & Action Plan, dated 1/24/12 stated "continue with 1-1 supervision and monitoring; (increase) activities." Review of a physician's progress note, dated 1/24/12, stated the resident was confused, still impulsive and that a repeat blood ammonia level would be ordered due to alcoholic [DIAGNOSES REDACTED] (a syndrome of global brain dysfunction, can be caused by many different illnesses). The condition can cause increased confusion. The medication Lactulose was started on 1/24/12 to bring down blood ammonia levels. A nurse's note, dated 1/27/12 and timed 3:00 PM stated "This nurse responded to an alarm that went on for a while then off. This nurse found patient sitting on his w/c with blood oozing from his left arm...Sent to hospital for Eval..." R2 returned from the hospital later on the evening shift with 14 staples in the left elbow. According to the incident report the resident stated he fell and hit the door hinge and then got up into his w/c. According to the Conclusion & Action Plan, dated 1/28/12, a family visitor had just left him at 3:00 PM and by 3:05 PM R2 was on the floor. This Action Plan also stated "Pt does better if on CVO (continuous visual observation) @ all times." Review of the care plan revealed that on 1/28/12 the fall risk plan was updated to include the intervention "increase supervision." The Incident Report, dated 1/28/12 revealed that a Therapy Communication form was completed and sent to therapy regarding the fall. There was no evidence that therapy re-evaluated R2. According to an incident report, dated 1/28/12 and timed 12:00 PM, R2 was at the front of the nurse's station for supervision, when he stood up and fell on his knee and the nurse could not get to him in time. There was no injury sustained. A nurse's note, dated 1/30/12 and timed 4:00 PM stated "Resident eloped out of the facility through the 500 hall exit door and fell on the grass outside. Resident opened exit door, alarm sounded and proceeded to walk outside. Resident grabbed the handicap post in the parking lot and sat on the ground..." The incident report, dated 2/5/12 and timed 6:45 AM included a CNA's written statement that she was in the room next door when she heard the alarm. Upon arrival found R2 standing up next to his bed so she went to grab him and he started going down so she eased him to the floor. The corresponding nurse's note stated that the sitter had left at 6 AM due to a family emergency. There was no supervision of the resident at this time. A 2/8/12 incident report stated R2 was seated in his w/c in front of the nurse's station (at 2:00 PM), when the nurse walking down the hall witnessed him stand up and immediately fall to the floor and land on his left knee. According to the Falls Investigation Report there was a lack of supervision of the resident and only 2 staff were present on the unit at the time. Between 2/12/12 and 3/3/12, R2 had an additional five (5) falls; four (4) witnessed, one (1) unwitnessed. There were no injuries sustained. A nurse's note dated 3/8/12 and timed 6:15 PM stated "Pt sitting on side of bed eating dinner & stood up & fell to floor. He sustained 2 skin tears one on forehead & one on scalp...to ER..." A subsequent nurse's note dated 3/9/12 and timed 1:15 AM stated R2 returned from the ER with 3 sutures to the forehead and 4 staples to the top left side of his head. There was no evidence that R2 was being supervised by staff at the time of the fall. Between 3/9/12 and 3/11/12, R2 had an additional two (2) falls. One of these falls was witnessed by another resident across the hall and one a nurse saw the resident stand and fall. R2 was observed on 3/20/12 at 10:35 AM seated in his w/c in his room with a tether alarm clipped to his shirt. R2 was scooting himself around in his w/c in his room barefoot. The resident was asked if he participated in any activities and he stated that he wasn't interested. On 3/20/12 at 2:30 PM R2 was observed self propelling himself to the nurse's station. On 3/21/12 at 3:00 PM, R2 was seen in the TV lounge, staff were present in the room. On 3/22/12 at 9:00 AM R2 was observed lying on his bed with his call bell in reach. There was no staff within view. At 2:40 PM on 3/22/12, R2 was observed seated in his w/c in his room with his eyes closed and head resting on the wall next to the bathroom door. Again he was not within view of staff. On 3/26/12 at approximately 12:30 PM, R2 was observed in the hallway seated in his w/c. R2 was observed trying to return to his room but was then redirected by staff to remain in the hallway within view of the nurse's station. The facility failed to provide adequate supervision for R2, who was known not to utilize a call bell, known at times to disconnect his alarms and have impulsive behaviors. The falls which occurred on 1/27/12 and 3/8/12 both resulted in injuries and harm to the resident. During both of these falls, R2 was alone in his room unsupervised. Additionally, despite several therapy communication forms being completed, there was no evidence that therapy re-evaluated R2 after the falls. On 3/26/12 R2 was interviewed. When asked if he calls for help from staff by using the call bell he stated not always because he has to wait a long time. Review of the facility's computerized call bell response time from 1/1/12 through 3/25/12 revealed that out of 34 calls made from R2's bed, 16 of them took greater than 2 minutes to be responded to. Additionally, seven of these calls took greater than 5 minutes response time. None of these increased call bell response times coincided with the falls that resulted in injuries to R2. During an interview with E1 (Administrator) and E2 (Director of Nursing) on 3/26/12, it was acknowledged that there had been problems with the therapy department and getting them to reevaluate residents when communicated to by nursing. E2 stated that as of 2/12 a different therapy service had come in and was providing services. 3. R8 had [DIAGNOSES REDACTED]. The X-ray result of 12/6/11 indicated that R8 had moderate DJD of the right shoulder. According to R8's admission Minimum Data Set (MDS) assessment, dated 12/10/11, R8's cognitive skills for daily decision-making were moderately impaired; cues/supervision required. R8 needed extensive assistance of one person with all ADLs (Activities of daily living). R8 used the wheelchair for mobility. Additionally, R8's problems included impaired physical mobility related to right shoulder and left hip pain, limited range of motion, unsteady gait and shuffling, and arthritis (osteoarthritis). R8 was assessed on 12/5/11 as a high risk for falls due to history of falls, ambulated with problems and with devices, always needs physical support, bilateral lower extremities and right shoulder pain. The facility initiated a care plan on 12/5/11 entitled Fall Risk, "Potential for Injury related to: unsteady gait, shuffling, weakness, impaired mobility, balance problem, history of falls, unable to ambulate without assistance, unable to transfer without assistance." The interventions included: "Remind resident to call when needing assistance and Instruct resident to sit on side of bed for one minute before standing as appropriate 'Stay with her,' Keep call light and most frequently used items within reach." Review of R8's record revealed the following sequence of events: a. A nurse's note, dated 1/29/12 stated, "Resident was found on the floor next to bed by CNA this evening at 17:30 (5:30 PM)....resident was a little confused about calling for help prior to toileting...Some bruising noted on back at left shoulder blade measuring 5.0 x 4.0 cm...re-educate resident about calling for help". The "Incident Report" results of investigation, dated 2/2/12 indicated that this fall was related to toileting. "Resident fell out of wheelchair while attempting to go to the bathroom. Resident usually calls when toileting is needed. Resident seemed to be recently declined in mental status and forgot to call". The care plan was revised on 1/31/12 to include the intervention "1 hour check Resident" by nursing. However, review of the CNAs ADL flow sheet and Nursing's TAR (Treatment Administration Record) failed to indicate evidence of the 1 hour check of R8 by nursing staff. b. Nurse's note, dated 2/4/12 stated :...CNAs showed this nurse a large purple bruise 9.5 x 5 cm on the resident's L. scapula. Resident stated that she fell , however, no such incident has been recently reported to this nurse. The care plan was revised on 2/7/12 to include the intervention "Bed/Chair exit alarms." c. 2/18/12 Nurse's note stated "Resident fall unwitnessed 2225 (10:25 PM). Answers questions with some confusion and obeys commands....received order for UA, C+S (urinalysis and urine culture and sensitivity) to rule out UTI (urinary tract infection) RE: changed mental status, weakness, cloudy urine over several days... Fall alarms/precautions were and are continuously in place and checked". Review of the Incident Report's results of investigation dated 2/18/12 stated "root cause of this fall, weakness/confusion-possible UTI. No injury was noted". R8 had experienced three (3) falls within 2 months of stay in the facility and sustained bruising on back at left shoulder blade measuring 5.0 x 4.0 cm and large purple bruise 9.5 x 5 cm on the resident's left scapula (left upper back). This finding was discussed with E2 (DON) and E1 (Nursing Home Administrator) on 3/26/12. 4. R5 had [DIAGNOSES REDACTED]. The facility initiated a care plan on 2/1/11 (last quarterly reviewed on 12/15/11) entitled "Wandering and/or elopement risk" as evidenced by History of attempts to leave facility unattended, impaired safety awareness and history of Non compliance with safety procedures. The care plan interventions included "Likes going outside to ambulate without staff. Document each episode. The interventions on the care plan included that R5 was to ambulate outside only with staff member accompanying him", The activity care plan documented that R5 required caring for his dog in regular walks. The interventions indicated that resident required structured and supervised walking activities. In his cognitive deficit care plan for dementia, the plan indicated that staff was to follow the same routine with resident ' s care each day, as much as possible. Review of facility's incident report dated 10/2/11 indicated that at approximately 10:30 AM, R5 had left the facility with E3 (Security Guard) to walk R5 ' s dog and refused to go back to the facility when requested by E3. Subsequent documentation revealed that the staff (E3) returned to the facility to get assistance for R5, and that R5 continued to walk his normal path off the premises with his dog alone and into the neighborhood behind the facility. In an interview with E3 on 3/21/12 at 8:00 AM, she confirmed she walked R5 on the premises and was told she could not leave the premises to walk the resident. She stated that R5 was very upset, R5 refused to return with her to the facility, and R5 wanted to continue to walk his normal path with his dog. E3 stated that she returned to the facility, as she was the security guard for the facility, and left the resident to walk alone with his dog. She stated she returned to get assistance for the resident and observed from the facility as E4 (Manager on Duty, MOD) and E5 (Maintenance Staff) went after the resident to get him to return to the facility. In an interview with E4 on 3/21/12, she revealed that she was the MOD on 10/2/11 when the resident wandered beyond the facility ground. She stated that Activities Department was responsible for walking with the resident to walk his dog and that she was the one that usually walked R5 off the premises; but that day she could not walk him as she was in charge of the facility. She stated that other activity staff were not available to walk the resident either. She stated that R5 managed to walk off far and that she and E5, went after the resident. She stated E5 managed to get resident back to the facility. She confirmed that leaving him alone had the potential for injury to this resident. E4 did not understand why E3 did not call from a cell and stay with the resident. She confirmed this finding. 5. Observation of SSR1 on 3/20/12 at 11:10 AM with E6 (Nurse) revealed a Wander Guard band (or bracelet) on SSR1 ' s right ankle (with an expiration of 1/2013). Observation of SSR1 on 3/21/12 at 2:25 PM revealed the resident had a Wander Guard band on the right ankle. In an interview with E7 (Nurse Supervisor) on 3/20/12 at 11:00 AM, she stated that an elopement/exit seeking/wandering assessments are completed that identifies the residents elopement risk to determine that a Wander Guard was required. She stated that they developed a care plan for residents requiring a Wander Guard. After they determined a Wander Guard was required for a resident, they placed the Wander Guard bracelet on the resident. She stated that they did shift checks of the Wander Guard each shift and documented in the TAR. They checked to see if resident had the bracelet, bracelet was not too tight, and bracelet was working. She also stated that the Wander Guard for SSR1 was requested by the family. However SSR1 ' s March 2012 Treatment Administration Record (TAR) failed to show staff documentation that all three shifts signed for Wander Guard bracelet as checked. 6. Observation of SSR2 on 3/20/12 at 1:21 PM revealed a Wander Guard band (or bracelet) on SSR2 ' s right ankle (with an expiration of 9/2012). Review of the Treatment Record and the Medication Record lacked evidence, or instructions, to check for the wander guard (presence and functionality) daily and at each shift. Resident was observed wearing her Wander Guard on 3/20/12 and 3/21/12. In an interview with E8 (Nurse) on 3/21/12 at 2:35 PM, she revealed that she did check for presence and checked functionality only when resident passed by the alarmed door outfront but that she was not doing it each time. E6 (Nurse) on 3/21/12 indicated that she took the residents to the alarmed door to test the Wander Guard for functionality. When asked if she did it at third shift when residents were sleeping, she said she did not test then. In an interview with E9 (Unit Manager) for one unit (400/500/600) on 3/21/12, he stated that they should have documented in the MAR/TAR staff checks of the wanderguard's functionality on every shift's check. E9 (Unit Manager) confirmed this finding. A resident list indicating residents using Wander Guards bracelets with serial numbers, expirations dates, or inspections done by the maintenance staff, was not available. The only door that was activated by the Wander Guard was the front door. All the other facility doors that had alarms supported by batteries would activate when opened by anybody with or without Wander Guard bracelets. The batteries on these doors were inspected each month based on record review. E2 and E10 (Maintenance director) on 3/23/12 confirmed these findings.

Based on record review, interview, review of other facility documentation and hospital records, it was determined that the facility failed to ensure that one (1) resident (R10) out of 14 sampled received adequate supervision and assistance device to prevent accidents. R10 was left in her room, unsupervised while sitting in a wheelchair. R10 fell (was found on the floor) and sustained a laceration on her forehead that required sending her to the hospital ER where she had sutures inserted. Findings include: 1. R10 had [DIAGNOSES REDACTED]. According to R10 ' s Minimum Data Set (MDS) assessment dated [DATE] her cognitive skills for daily decision-making were " moderately impaired-decisions poor, cues/supervision required " and had a short and long term memory problem. R10 needed extensive assistance of staff for all activities of daily living (ADLs). R10 was assessed as a high risk for falls. The facility initiated R10' s care plan dated 1/27/10 on the problem of Fall risk: Potential for Injury related to unsteady gait, cognitive deficits, impaired mobility and history of falls. The interventions included " Remind resident to call when needing assistance, Keep call light and most frequently used items within reach, shoes non-fitting with non-slip soles and gripper socks prn (when necessary) " . A nurse's note dated 02/03/11, R10 was taken to the hospital emergency room (ER) for left sided weakness on her face, arm and leg and with difficulty speaking. R10 was diagnosed with [REDACTED]. R10 returned to the facility on [DATE]. A nurse's note dated 2/14/11 stated that at 9:45 AM, R10 was found on the floor in front of her wheelchair by E25 (Nun's name) who happened to walk into this resident's room. R10 sustained an abrasion on her left face and was taken to the hospital ER for evaluation and treatment. R10 returned to the facility in the afternoon of the same day. The facility revised R10's care plan for Fall Risk and added the interventions " Make sure she is out of room when she is in her w/c (wheelchair) or supervised " . The intervention " Bed and Chair alarms at all times " was also added per physician's order [REDACTED]. According to a written statement by E23 on 3/07/11 at 10:40 AM, R10 was found face down on the floor in front of her wheelchair by E23 (unit clerk/CNA). Also there was blood found on the floor. R10 was left in her room, unsupervised and fell out of her wheelchair. R10 sustained right forehead laceration and was sent to the hospital ER for treatment and evaluation. R10 was re-admitted to the facility on [DATE] with " 5-6 sutures to right forehead and hematoma at top of the head " . On 3/9/11 the physician ordered a " Rock and go chair ( a manual wheelchair with sling seat and back rocking mechanism) for positioning/comfort " for R10 in place of the regular wheelchair. R10 was transferred to another facility on 3/23/11 per family ' s request. During an interview with E1 (Administrator) on 5/13/11 at approximately 1:30 PM, E1 confirmed these findings.

Based on record review, interviews and observations it was determined that the facility failed to ensure that emergency policies and procedures were available to staff and that staff was knowledgeable and competent in performing emergency procedures. A facility physician who was present when staff attempted to perform CPR (Cardiopulmonary Resuscitation) on [DATE] notified management regarding the knowledge deficit of staff . However mock codes as suggested by the physician were not begun until [DATE]. Forty (40) out of 93 (43%) residents in the facility were listed as full codes and had the potential to sustain harm if emergency procedure were not performed promptly and correctly. Additionally the facility failed to have a system in place to consistently identify a resident's code status and lacked the ability to identify the presence of trained and competent staff to deal with emergency situations on each shift. The facility failed to provide the necessary care and services to maintain the highest practicable physical well being for residents who required CPR and/or those who had the potential for being a code candidate. Findings include: Review of the facility's policy and procedure manual revealed that there was no facility policy and procedure for performing emergency procedures or for CPR/AED (Automatic External Defibrillator) use. On [DATE], during an interview with E3 (ADON), she stated that when there is not a specific policy, that staff have been directed to refer to the Lippincott Manual of Nursing Practice, 9th edition. During an interview on [DATE], E2 (DON) confirmed that there was no facility written policy and procedure for performing emergency procedures or for CPR/AED use. On [DATE], E2 provided a copy of a memorandum for CPR procedure that he stated he developed on [DATE] after the surveyor brought this to his attention. On [DATE], the facility provided the surveyor with a list of residents and their code status. There were 40 out of 93 residents listed as full codes. However, interview and record review revealed inconsistencies regarding the code status. 1. On [DATE], R1 coded and even though CPR was started by E4 (LPN), there was confusion as to R1 ' s code status. On [DATE], during an interview E5 (RN house supervisor) stated that she was unsure of the code status because R1 had hospice services so she placed a telephone call to R1 ' s family and to hospice services prior to calling 911. On [DATE], during an interview E4 stated that she failed to use the AED (Automatic External Defibrillator) because, " I didn ' t think to use it " . E5 returned to R1 ' s room but did not address the lack of utilization of the AED. 2. On [DATE], random record review revealed that R2 had a signed a DNR consent form dated [DATE]. There was no condition alert sheet and no DNR Sticker on the outside of R2 ' s record. The Physician order [REDACTED]. That resulted in R2 having a full code status. On [DATE], the facility provided a list of code status ' for the residents and R2 was listed as " DNR " (Do Not Resuscitate). 3. On [DATE], random record review revealed that R3 had a signed DNR consent form dated [DATE]. R3 had a DNR sticker on the condition alert sheet and the outside of R3 ' s record. However, the ,[DATE] POS stated, " Discontinue all previous orders " and there was no code status documented on this POS. Additionally, the ,[DATE] and ,[DATE] POS ' failed to list R3 ' s code status. That resulted in R3 having a full code status. However, on [DATE], the facility provided a list of code status ' for the residents and R3 was listed as " DNR " . 4. On [DATE], random record review revealed that R4 had a signed DNR consent form dated [DATE]. R4 had a DNR sticker on the condition alert sheet. The ,[DATE] POS stated, " Discontinue all previous orders " and there was no code status documented on this POS. Additionally, the ,[DATE] and ,[DATE] POS ' failed to list R4 ' s code status. That resulted in R4 having a full code status. On [DATE], the facility provided a list of code status ' for the residents and R4 was listed as " DNR " . On [DATE], E2 provided a list, " Current CPR Nursing Staff " which contained nurses and aides (CNAs) for a total of 85 nursing staff. Copies of current CPR cards were provided for 17 out of 85 staff. Review of the list had 2 staff listed as needing CPR training and one listing the card as lost. On [DATE], during an interview, E2 was asked about the remaining staff as to their CPR status. E2 replied that the E6 (staff development) was tasked to get all CPR current for nursing staff. E2 also stated that he had no proof of the remaining staff 's current CPR status in the facility. He stated that the Human Resource (HR) department is located at (name) Hospital. Therefore there was no proof for the nursing staff beyond what he already provided. He stated that E3 ' s (ADON) CPR certification expired on ,[DATE]. He additionally, stated that he would try to obtain further documentation from the HR department or directly from the nursing staff. On [DATE] during an interview, E2 stated that since personnel files were inaccessible to the facility he was unable to confirm if there was at least one staff person with current CPR certification per shift daily. On [DATE], staff interviews regarding CPR and AED usage revealed the following: - E7 (CNA) did not know location of AED; - E8 (LPN) thought that there was an AED on each crash cart when in reality the facility has only one AED; - E5 (RN supervisor) did not know when AED was to be initiated but thought within the first 5 to 10 minutes and did not know where to apply AED pads. On [DATE], staff interviews regarding CPR and AED usage revealed the following: - E9 (CNA) did not know when AED was to be initiated, thought it was after 5 sets of compressions and breaths; - E10 (RN supervisor) did not know correct # of breaths to give and did not know correct placement of AED pads; - E11 (CNA) did not know where AED was located or when AED was to be initiated and did not know CPR ratio of breaths to compressions; - E12 (LPN) did not know CPR ratio of breaths to compressions. On [DATE], during an interview, E13 (Physician) stated that staff summoned her during an actual code on R5 on [DATE]. E13 stated that staff had incorrectly placed CPR board under R5 ' s hips, staff did not know where the ambu bag was and did not initially have the correct mask for oxygen administration. E13 stated that she addressed her concerns to E2 by [DATE] and suggested mock codes be done to inservice staff. There were no mock codes performed in the facility until [DATE] when the surveyor addressed ongoing concerns with E3. On [DATE], E2 stated that he was not sure if an incident report was forwarded to the state for R1 ' s code on [DATE]. However, E2 acknowledged that from the morning stand up meeting on [DATE] he became aware that the paramedics had concerns about the staff ' s emergency and CPR/AED response. E2 stated that he did not do any investigation regarding the emergency procedure and CPR performed by staff when the paramedics expressed concerns. He acknowledged that he did not mandate an inservice/retraining for the RN ' s involved in the code. He stated that he talked them through it but did not require any demonstration of CPR/AED. Three out of the three mock codes done between [DATE] and [DATE] (one code per shift) revealed that the facility failed to demonstrate competency in emergency procedures. The mock codes revealed that the facility had multiple issues including: - RNs failed to take charge of the code - No CPR board was placed prior to CPR initiation; - Incorrect number of compressions done - Failure to turn on the AED and improper placement of the AED pads; - Staff had to be prompted to initiate AED on one mock code; - Slow response to overhead code page; - Bag/Mask not used and no oxygen connections. On [DATE] at 3:15 PM, E1 and E2 were informed that immediate jeopardy was identified on [DATE] due to the potential for harm related to the facility failures in ensuring the competency of staff in the provision of emergency procedures. E1 and E2 acknowledged the facility's system failures.